diff --git "a/data/extracting_subclaim/subset_testset/extracted_subclaims_multiclinsum_test_en_2500_3000.json" "b/data/extracting_subclaim/subset_testset/extracted_subclaims_multiclinsum_test_en_2500_3000.json" new file mode 100644--- /dev/null +++ "b/data/extracting_subclaim/subset_testset/extracted_subclaims_multiclinsum_test_en_2500_3000.json" @@ -0,0 +1,33242 @@ +[ + { + "id": "multiclinsum_test_1182_en.txt", + "fulltext": "A 49-year-old male presented to the emergency department at Bascom Palmer Eye Institute complaining of right eye pain and decreased vision about 17 h after being struck in the eye with a tree branch. On examination, he was noted to have a 1.5-mm corneal laceration with fibrin in the anterior chamber and signs of traumatic cataract with posterior synechiae and pigment on the anterior lens capsule. No signs of endophthalmitis were noted on B-scan. The laceration was repaired, and the patient was treated prophylactically with intravitreal ceftazidime 2.25 mg, vancomycin 1 mg, and voriconazole 50 μg. Aqueous humor cultures for fungi and bacteria were negative, and B-scan was unremarkable at initial follow-up.\nAfter an initially uncomplicated postoperative course, the patient returned 26 days later with pain and an elevated intraocular pressure (IOP) of 45 mm Hg. On B-scan, there were mobile subhyaloid and vitreous opacities indicative of endophthalmitis . The patient underwent pars plana lensectomy and vitrectomy with 1,000 cSt silicone oil injection, peripheral iridectomy, and administration of intravitreal vancomycin 1 mg, ceftazidime 2.25 mg, and voriconazole 100 μg. The lens capsule was left in place. The undiluted intraoperative vitreous sample demonstrated Gram-variable bacilli which were later identified as O. turbata.\nThe immediate post-treatment course was uncomplicated. However, 1 month later, the patient returned with decreased vision and an acutely-elevated IOP of 55 mm Hg. The patient underwent silicone oil removal.\nThe course was again stable for another 2 months until the patient presented with worsening eye pain and inflammation with an IOP of 45 mm Hg, keratic precipitates, and 4+ anterior chamber cell. B-scan demonstrated dense vitreous opacities with multiple focal hyperechoic foci and peripheral membrane formation. Ultrasound biomicroscopy revealed diffuse anterior chamber opacities and retained lens capsule adherent to the posterior iris . Intravitreal vancomycin 1 mg and ceftazidime 2.25 mg were administered. Anterior chamber paracentesis was performed, culture of which revealed no fungal or bacterial growth. B-scan about 1 month later revealed new vitreous opacities and inferior membranes. The patient was suspected to have chronic endophthalmitis and subsequently underwent pars plana vitrectomy and total capsulectomy with administration of intravitreal vancomycin 1 mg, ceftazidime 2.25 mg, and voriconazole 100 μg. Anterior chamber fluid cultures were ultimately negative, and no further organisms were identified in the lens capsule on pathology. The patient had sustained mixed mechanism chronic IOP elevation and eventually underwent glaucoma drainage implant surgery. The final aphakic best corrected visual acuity was 20/80 and IOP was 19 mm Hg. There have been no reactivations of inflammation or infection for 1 year after the last surgery .", + "fulltext_subclaims": [ + "The patient was a 49-year-old male.", + "He presented to the emergency department at Bascom Palmer Eye Institute.", + "He complained of right eye pain and decreased vision.", + "The symptoms began about 17 h after being struck in the eye with a tree branch.", + "On examination, he had a 1.5-mm corneal laceration.", + "There was fibrin in the anterior chamber.", + "Signs of traumatic cataract were noted.", + "Posterior synechiae were present.", + "Pigment was on the anterior lens capsule.", + "No signs of endophthalmitis were noted on B-scan.", + "The laceration was repaired.", + "The patient was treated prophylactically with intravitreal ceftazidime 2.25 mg.", + "The patient was treated prophylactically with intravitreal vancomycin 1 mg.", + "The patient was treated prophylactically with intravitreal voriconazole 50 μg.", + "Aqueous humor cultures for fungi and bacteria were negative.", + "B-scan was unremarkable at initial follow-up.", + "The patient returned 26 days later with pain.", + "The intraocular pressure was 45 mm Hg.", + "B-scan showed mobile subhyaloid and vitreous opacities indicative of endophthalmitis.", + "The patient underwent pars plana lensectomy and vitrectomy.", + "The patient received 1,000 cSt silicone oil injection.", + "A peripheral iridectomy was performed.", + "Intravitreal vancomycin 1 mg was administered.", + "Intravitreal ceftazidime 2.25 mg was administered.", + "Intravitreal voriconazole 100 μg was administered.", + "The lens capsule was left in place.", + "The undiluted intraoperative vitreous sample demonstrated Gram-variable bacilli.", + "The bacilli were later identified as O. turbata.", + "The immediate post-treatment course was uncomplicated.", + "The patient returned 1 month later with decreased vision.", + "The intraocular pressure was 55 mm Hg.", + "The patient underwent silicone oil removal.", + "The course was stable for another 2 months.", + "The patient presented with worsening eye pain and inflammation.", + "The intraocular pressure was 45 mm Hg.", + "Keratic precipitates were present.", + "There was 4+ anterior chamber cell.", + "B-scan showed dense vitreous opacities with multiple focal hyperechoic foci.", + "Peripheral membrane formation was noted.", + "Ultrasound biomicroscopy revealed diffuse anterior chamber opacities.", + "Retained lens capsule adherent to the posterior iris was noted.", + "Intravitreal vancomycin 1 mg was administered.", + "Intravitreal ceftazidime 2.25 mg was administered.", + "Anterior chamber paracentesis was performed.", + "Culture of the anterior chamber fluid revealed no fungal or bacterial growth.", + "B-scan about 1 month later showed new vitreous opacities.", + "Inferior membranes were noted.", + "The patient was suspected to have chronic endophthalmitis.", + "The patient underwent pars plana vitrectomy and total capsulectomy.", + "Intravitreal vancomycin 1 mg was administered.", + "Intravitreal ceftazidime 2.25 mg was administered.", + "Intravitreal voriconazole 100 μg was administered.", + "Anterior chamber fluid cultures were ultimately negative.", + "No further organisms were identified in the lens capsule on pathology.", + "The patient had sustained mixed mechanism chronic IOP elevation.", + "The patient underwent glaucoma drainage implant surgery.", + "The final aphakic best corrected visual acuity was 20/80.", + "The intraocular pressure was 19 mm Hg.", + "There have been no reactivations of inflammation or infection for 1 year after the last surgery." + ], + "summary": "A patient presented with chronic endophthalmitis that occurred after ocular trauma with organic material and Oerskovia turbata was eventually isolated. After a prolonged treatment course, including two pars plana vitrectomies and total capsulectomy, the patient achieved 20/80 visual acuity at 1-year follow-up.", + "summary_subclaims": [ + "A patient presented with chronic endophthalmitis.", + "The chronic endophthalmitis occurred after ocular trauma with organic material.", + "Oerskovia turbata was eventually isolated.", + "The patient received a prolonged treatment course.", + "The treatment included two pars plana vitrectomies.", + "The treatment included total capsulectomy.", + "The patient achieved 20/80 visual acuity at 1-year follow-up." + ] + }, + { + "id": "multiclinsum_test_2856_en.txt", + "fulltext": "A 70-year-old female with a history of three years of right shoulder pain presented with limitation in both active and passive ranges of motion. Upon physical examination, Jobe's test and Hawkins test both showed positive results, indicating dysfunction of the rotator cuff and impingement in the shoulder joint, respectively. Plain radiograph showed joint space narrowing with bone deformity, sclerotic change, and subchondral cyst formation in the glenohumeral joint; the patient was thus diagnosed as advanced osteoarthritis. MRI evaluation revealed an approximately 1 cm tear in the rotator cuff, specifically in the supraspinatus muscle on its articular side, as well as tendinosis and subtle muscular signal change in distal subscapularis . The patient underwent an anatomic shoulder arthroplasty considering the functional deltoid muscle.\nThe deltopectoral approach was used for the surgery. Upon blunt dissection to the subdeltoid and subacromial spaces, a superior portion of the pectoralis major muscle was released. The subscapularis tendon was released from its insertion site followed by capsulotomy. A distinct muscular structure was found at the anterior-inferior aspect of the glenoid rim , which was not determined as part of the glenoid labrum. This muscle was carefully tagged and dissected near its origin site to allow glenoid reaming. A routine anatomic total shoulder arthroplasty was carried out afterwards. The muscle was repaired along with the SM. No major complications were found. The patient was discharged at seven days postoperation.", + "fulltext_subclaims": [ + "The patient is a 70-year-old female.", + "The patient has a history of three years of right shoulder pain.", + "The patient has limitation in both active and passive ranges of motion.", + "Jobe's test showed a positive result.", + "Hawkins test showed a positive result.", + "Plain radiograph showed joint space narrowing in the glenohumeral joint.", + "Plain radiograph showed bone deformity in the glenohumeral joint.", + "Plain radiograph showed sclerotic change in the glenohumeral joint.", + "Plain radiograph showed subchondral cyst formation in the glenohumeral joint.", + "The patient was diagnosed as having advanced osteoarthritis.", + "MRI revealed an approximately 1 cm tear in the rotator cuff.", + "The tear was specifically in the supraspinatus muscle on its articular side.", + "MRI showed tendinosis in the distal subscapularis.", + "MRI showed subtle muscular signal change in the distal subscapularis.", + "The patient underwent anatomic shoulder arthroplasty.", + "The deltopectoral approach was used for the surgery.", + "A superior portion of the pectoralis major muscle was released.", + "The subscapularis tendon was released from its insertion site.", + "A routine anatomic total shoulder arthroplasty was carried out.", + "The muscle was repaired along with the SM.", + "No major complications were found." + ], + "summary": "We report a patient with osteoarthritis of the shoulder joint who underwent reverse shoulder arthroplasty and showed anatomical variation in the subscapularis muscle (SM). A variation of the rotator cuff originating from the anteroinferior aspect of the glenoid was separated from the SM by a septum and was named infraglenoid muscle (IGM).", + "summary_subclaims": [ + "The patient had osteoarthritis of the shoulder joint.", + "The patient underwent reverse shoulder arthroplasty.", + "The patient showed anatomical variation in the subscapularis muscle.", + "A variation of the rotator cuff originated from the anteroinferior aspect of the glenoid.", + "The variation was separated from the subscapularis muscle by a septum.", + "The variation was named infraglenoid muscle." + ] + }, + { + "id": "multiclinsum_test_2554_en.txt", + "fulltext": "A man in his early 40s with no past medical history presented with a mild headache that had persisted for two days. He was diagnosed with a SAH that corresponded to the World Federation of Neurosurgical Societies Grade I. Computed tomography angiography (CTA) revealed a bilateral VADA . We confirmed that the left VADA ruptured by hematoma localization on images. Therefore, the left VADA was surgically trapped via a left lateral suboccipital approach on admission. Fresh bleeding was found under adventitia of the left VADA, consistent with a rupture. The posterior inferior cerebellar artery (PICA) was not involved in the VADA. Therefore, we performed proximal clipping distal to the PICA. The trapping was completed without any intraoperative complications. Follow-up CTA revealed left PICA and obliteration of the left VADA on postoperative day 2 . However, on postoperative day 11, follow-up CTA revealed asymptomatic enlargement of the contralateral VADA . The perforating arteries from the distal part of the right VADA to the medulla oblongata, fetal-type posterior communicating arteries (PCOMs), and hypoplastic precommunicating segment of both the posterior cerebral arteries (P1) were revealed on digital subtraction angiography . We planned proximal clipping of the right VADA with a right superficial temporal artery (STA)–superior cerebellar artery (SCA) bypass on postoperative day 17. The right STA–SCA bypass was performed first using a subtemporal approach [ and ]. Ultrasonic pulse Doppler velocimeter intraoperatively detected a graft flow rate of 25 mL/min. Proximal clipping distal to the PICA was performed after completion of the STA–SCA bypass . Parts of the proximal VADA vessel walls were thin, indicating a high risk of rupture. Although the VADAs extended up to the vertebral junction, neither of the VADAs was a continuous lesion. We found perforating arteries in the right VADA . Ultrasonic pulse Doppler and indocyanine green imaging revealed a PICA, and the perforating arteries from the VADA were preserved. Motor and somatosensory evoked potentials and auditory brainstem response remained stable throughout the surgery. The bilateral VADA was obliterated, and the patent STA–SCA bypass flow was observed using CTA . No infarction was observed on postoperative magnetic resonance imaging. The patient had an uneventful postoperative course and was discharged about a month after rehabilitation. He received a modified Rankin scale score of 0 at both the 1-year and 6-month follow-up assessments.", + "fulltext_subclaims": [ + "A man in his early 40s with no past medical history presented with a mild headache that had persisted for two days.", + "He was diagnosed with a SAH that corresponded to the World Federation of Neurosurgical Societies Grade I.", + "Computed tomography angiography (CTA) revealed a bilateral VADA.", + "The left VADA ruptured by hematoma localization on images.", + "The left VADA was surgically trapped via a left lateral suboccipital approach on admission.", + "Fresh bleeding was found under adventitia of the left VADA, consistent with a rupture.", + "The posterior inferior cerebellar artery (PICA) was not involved in the VADA.", + "Proximal clipping distal to the PICA was performed.", + "The trapping was completed without any intraoperative complications.", + "Follow-up CTA revealed left PICA and obliteration of the left VADA on postoperative day 2.", + "On postoperative day 11, follow-up CTA revealed asymptomatic enlargement of the contralateral VADA.", + "The perforating arteries from the distal part of the right VADA to the medulla oblongata were revealed on digital subtraction angiography.", + "Fetal-type posterior communicating arteries (PCOMs) were revealed on digital subtraction angiography.", + "Hypoplastic precommunicating segment of both the posterior cerebral arteries (P1) were revealed on digital subtraction angiography.", + "We planned proximal clipping of the right VADA with a right superficial temporal artery (STA)–superior cerebellar artery (SCA) bypass on postoperative day 17.", + "The right STA–SCA bypass was performed first using a subtemporal approach.", + "Ultrasonic pulse Doppler velocimeter intraoperatively detected a graft flow rate of 25 mL/min.", + "Proximal clipping distal to the PICA was performed after completion of the STA–SCA bypass.", + "Parts of the proximal VADA vessel walls were thin, indicating a high risk of rupture.", + "The VADAs extended up to the vertebral junction.", + "Neither of the VADAs was a continuous lesion.", + "We found perforating arteries in the right VADA.", + "Ultrasonic pulse Doppler and indocyanine green imaging revealed a PICA.", + "The perforating arteries from the VADA were preserved.", + "Motor and somatosensory evoked potentials and auditory brainstem response remained stable throughout the surgery.", + "The bilateral VADA was obliterated.", + "The patent STA–SCA bypass flow was observed using CTA.", + "No infarction was observed on postoperative magnetic resonance imaging.", + "The patient had an uneventful postoperative course and was discharged about a month after rehabilitation.", + "He received a modified Rankin scale score of 0 at both the 1-year and 6-month follow-up assessments." + ], + "summary": "A Japanese man in his 40s presented with bilateral VADA with subarachnoid hemorrhage. He had only mild headaches without any other neurological deficits. Subsequently, the ruptured left VADA was surgically trapped. However, on postoperative day 11, the contralateral VADA enlarged. The right VADA was then proximally clipped via a lateral suboccipital approach. Furthermore, a superficial temporal artery-superior cerebellar artery bypass was performed through a subtemporal approach in advance to preserve cerebral flow in the posterior circulation. The bilateral VADA was obliterated, and the patient had an uneventful postoperative course during the 1-year and 6-month follow-up period.", + "summary_subclaims": [ + "The patient was a Japanese man in his 40s.", + "He had bilateral VADA with subarachnoid hemorrhage.", + "He had only mild headaches.", + "He had no other neurological deficits.", + "The ruptured left VADA was surgically trapped.", + "On postoperative day 11, the contralateral VADA enlarged.", + "The right VADA was proximally clipped via a lateral suboccipital approach.", + "A superficial temporal artery-superior cerebellar artery bypass was performed through a subtemporal approach.", + "The bypass was performed in advance to preserve cerebral flow in the posterior circulation.", + "The bilateral VADA was obliterated.", + "The patient had an uneventful postoperative course.", + "The follow-up period was 1 year and 6 months." + ] + }, + { + "id": "multiclinsum_test_475_en.txt", + "fulltext": "A 54-year-old Caucasian woman, without any relevant medical history and no gynecological aftercare, was admitted to our hospital emergency room with dyspnea that had progressed over 10 days and was worsening. Upon admission, we noted blood oxygen saturation of 89%, tachycardia (125 beats per minute) and hyperthermia (38.9°C). Her blood pressure was 120/80 mmHg. Electrocardiography showed sinus tachycardia and echocardiography revealed severe pericardial effusion with a swinging heart. An emergency subxiphoid incision with pericardial drainage was performed through a pericardial window, which permitted draining of 700 mL of bloody fluid and a pericardial biopsy. Cytological examination of the fluid revealed atypical cells, and the biopsy specimen showed tumor emboli suggestive of adenocarcinoma. Immunostaining indicated elevated levels of tumor marker, cytokeratin 7 (CK7). Her blood concentrations of carbohydrate antigen (CA) 125 and CA 15.3 were 4667 IU/L and 451 IU/L, respectively, suggesting ovarian malignancy.\nWhen stabilized, our patient was transferred to our department for further investigations. A gynecological examination only found a large uterus. A physical examination of her cervix was normal. An ultrasound examination showed uterine myomatosis, but no endometrial abnormality. Her ovaries were not seen. Magnetic resonance imaging (MRI) showed a 35 mm cervical lesion indicative of an endocervical tumor . A thoracic tomodensitometry and liver ultrasound were normal. Exploratory laparoscopy found normal ovaries, with no ascites, but diffuse peritoneal lesions suggestive of carcinosis. A bilateral adnexectomy and multiple peritoneal biopsies were performed. Endocervical curettage revealed necrotic tumor tissue. Cervical biopsies were performed. Histological examination showed a poorly differentiated micropapillary adenocarcinoma of her cervix with peritoneal and ovarian involvement . Immunostaining showed that the tumor cells were strongly positive for CA 125, Kit-ligand-1, Ki67, and CK7. Three weeks after this surgical procedure, intravenous chemotherapy with carboplatin and paclitaxel was initiated. Our patient's progression was unfavorable; three days after the first course of chemotherapy she was admitted to our intensive care unit and given thrombolytic therapy for severe pulmonary embolism with no sign of pericardial effusion recurrence. She died due to heart failure after three days in a context of severe pulmonary arterial hypertension.", + "fulltext_subclaims": [ + "The patient was a 54-year-old Caucasian woman.", + "She had no relevant medical history.", + "She had no gynecological aftercare.", + "She was admitted with dyspnea that had progressed over 10 days.", + "Her blood oxygen saturation was 89%.", + "Her heart rate was 125 beats per minute.", + "Her temperature was 38.9°C.", + "Her blood pressure was 120/80 mmHg.", + "Electrocardiography showed sinus tachycardia.", + "Echocardiography revealed severe pericardial effusion with a swinging heart.", + "An emergency subxiphoid incision with pericardial drainage was performed.", + "A pericardial window was created.", + "700 mL of bloody fluid was drained.", + "A pericardial biopsy was performed.", + "Cytological examination of the fluid revealed atypical cells.", + "The biopsy specimen showed tumor emboli suggestive of adenocarcinoma.", + "Immunostaining indicated elevated levels of tumor marker, cytokeratin 7 (CK7).", + "Her blood concentration of carbohydrate antigen (CA) 125 was 4667 IU/L.", + "Her blood concentration of CA 15.3 was 451 IU/L.", + "These findings suggested ovarian malignancy.", + "A gynecological examination found a large uterus.", + "A physical examination of her cervix was normal.", + "An ultrasound examination showed uterine myomatosis.", + "An ultrasound examination showed no endometrial abnormality.", + "Her ovaries were not seen.", + "Magnetic resonance imaging showed a 35 mm cervical lesion indicative of an endocervical tumor.", + "Thoracic tomodensitometry was normal.", + "Liver ultrasound was normal.", + "Exploratory laparoscopy found normal ovaries.", + "Exploratory laparoscopy found no ascites.", + "Exploratory laparoscopy found diffuse peritoneal lesions suggestive of carcinosis.", + "A bilateral adnexectomy was performed.", + "Multiple peritoneal biopsies were performed.", + "Endocervical curettage revealed necrotic tumor tissue.", + "Cervical biopsies were performed.", + "Histological examination showed a poorly differentiated micropapillary adenocarcinoma of her cervix.", + "The histological examination showed peritoneal and ovarian involvement.", + "Immunostaining showed that the tumor cells were strongly positive for CA 125.", + "Immunostaining showed that the tumor cells were strongly positive for Kit-ligand-1.", + "Immunostaining showed that the tumor cells were strongly positive for Ki67.", + "Immunostaining showed that the tumor cells were strongly positive for CK7.", + "Three weeks after the surgical procedure, intravenous chemotherapy with carboplatin and paclitaxel was initiated.", + "Three days after the first course of chemotherapy, she was admitted to the intensive care unit.", + "She was given thrombolytic therapy for severe pulmonary embolism.", + "There was no sign of pericardial effusion recurrence.", + "She died due to heart failure.", + "Her death occurred after three days in the context of severe pulmonary arterial hypertension." + ], + "summary": "A 54-year-old Caucasian woman, without any relevant medical history and no gynecological aftercare, was admitted to our hospital emergency room with severe dyspnea. Echocardiography revealed severe pericardial effusion with a swinging heart. An emergency pericardial drainage was performed through a pericardial window, which permitted the draining of 700 mL of bloody fluid and a pericardial biopsy. Cytological examination of the fluid revealed atypical cells, and the biopsy specimen showed tumor emboli suggestive of adenocarcinoma. Magnetic resonance imaging showed a 35 mm cervical lesion indicative of an endocervical tumor. Exploratory laparoscopy revealed diffuse peritoneal lesions and histological examination of cervical curettage showed a poorly differentiated micropapillary adenocarcinoma of the cervix.", + "summary_subclaims": [ + "The patient is a 54-year-old Caucasian woman.", + "The patient had no relevant medical history.", + "The patient had no gynecological aftercare.", + "The patient was admitted to the hospital emergency room with severe dyspnea.", + "Echocardiography revealed severe pericardial effusion with a swinging heart.", + "An emergency pericardial drainage was performed through a pericardial window.", + "The pericardial drainage permitted the draining of 700 mL of bloody fluid.", + "A pericardial biopsy was performed.", + "Cytological examination of the fluid revealed atypical cells.", + "The biopsy specimen showed tumor emboli suggestive of adenocarcinoma.", + "Magnetic resonance imaging showed a 35 mm cervical lesion indicative of an endocervical tumor.", + "Exploratory laparoscopy revealed diffuse peritoneal lesions.", + "Histological examination of cervical curettage showed a poorly differentiated micropapillary adenocarcinoma of the cervix." + ] + }, + { + "id": "multiclinsum_test_1026_en.txt", + "fulltext": "A 62-year-old Caucasian man presented with symptoms of cough, fever, myalgia and chills. Symptoms had begun 6 days prior to admission. He had tested positive for SARS-CoV-2 by Xpert Xpress SaRS-CoV-2 (Cepheid, Dx System Version 4.8) three days after symptom onset. His past medical history was unremarkable except for hyperlipidemia treated with atorvastatin 40 mg daily. No allergies were reported, the patient did not smoke, drink alcohol or use illicit substances. Kidney function was normal on admission.\nComputed tomography (CT) scan of the chest, abdomen and pelvis excluded pulmonary emboli and showed diffuse bilateral ground-glass infiltrates of the lungs with associated lymphadenopathy, moderate pleural effusions, normal-sized and -shaped kidneys with adequate perfusion and without cortical defects.\nTwo days after admission the patient required intubation due to acute respiratory distress syndrome (ARDS). He was managed with prone positioning and was initiated on hydroxychloroquine after exclusion of glucose-6-phosphate dehydrogenase (G6PD) deficiency. Antibiotic therapy with amoxicillin-clavulanate was given empirically assuming bacterial superinfection of viral pneumonia. His clinical condition worsened with the development of atrial fibrillation, AKI, paralytic ileus, hemolytic anemia and a maculopapular rash on the trunk and lower extremities.\nThe chronologic sequence of medications and clinical events are highlighted in Fig. . Laboratory results are shown in Table . Details of affected organ systems, diagnostics and therapies are listed in Table .\nA maculo-papular skin rash developed on day 7 after admission. Severe AKI with oliguria (AKIN 3), consecutive fluid overload and metabolic acidosis necessitated initiation of continuous veno-venous hemodiafiltration (CVVHDF) on day 9. Peak creatinine was 519 umol/L, urinalysis showed minimal proteinuria and microscopic hematuria. Proteinuria subsequently increased significantly and microscopic hematuria persisted, urine leucocytes were persistently within the normal range. .\nSeveral days after initiation of CVVHDF (on day 24) the patient developed severe microangiopathic hemolytic anemia, Coombs negative, which was transfusion dependent. Serologic screening was negative for HIV, hepatitis B and C virus infection; anti-nuclear antibodies, anti-DNA antibodies, anti-neutrophil cytoplasmic antibodies, anti-cardiolipin antibodies and complement levels were normal. Eosinophils were initially not significantly elevated. There was no evidence of urinary obstruction or rhabdomyolysis. Echocardiogram showed preserved cardiac function.\nDifferential diagnosis of the AKI included acute tubular injury (ATI) due to hemodynamic instability; sepsis-associated AKI; ATI with pigmented tubular casts as a consequence of hemolysis; thrombotic microangiopathy - given the ongoing severe hemolysis with schistocytes on peripheral smear (despite lack of overt thrombocytopenia); collapsing glomerulopathy - given the large rise in proteinuria,; and acute interstitial nephritis associated with antibiotics - given concurrent skin rash, although peripheral eosinophilia and leucocyturia were not marked. In the absence of improvement of kidney function a transcutaneous renal biopsy was performed while the patient was proned in ICU, 32 days after admission.\nLight microscopy revealed 34 mostly normal glomeruli. Few glomeruli were mildly congested, without thrombi. There was diffuse interstitial edema and focal infiltrates with lymphocytes, histiocytes, rare plasma cells, neutrophils and eosinophils. Multiple non-caseating granulomas mostly consisting of lymphocytes and epithelioid histiocytes were present. There was very mild tubulitis with rare lymphocytes in the tubular epithelium. Many tubules had a dilated lumen, flattened epithelium and loss of brush border. Some had fine, isometric vacuolization of the cytoplasm. Rare lumina contained finely granular, mostly eosinophilic and very rare brownish casts only partially positive for hemoglobin in a few tubules. Some peritubular capillaries contained mononuclear cells, but no erythrocyte aggregation. There was mild arteriolar hyalinosis and arteriosclerosis, but no thrombi or vasculitis. Immunhistochemistry showed only trace IgM, Kappa and Lambda in the mesangium. IgG, IgA, C3 and C1q were negative in the glomeruli. Electron microscopy revealed myelin figures in the cytoplasm of a few parietal epithelia. No definite viral particles were detected.\nThe biopsy was consistent with granulomatous tubulointerstitial nephritis, acute tubular injury and regeneration. There was no evidence of renal thrombotic microangiopathy, collapsing glomerulopathy or vasculitis.\nMycobacterium tuberculosis infection as excluded and confirmed by negative cultures of urine and tracheal secretions. Serology for Sjogren’s Syndrome was negative. Sarcoidosis was considered clinically unlikely, despite thoracic lymphadenopathy which was interpreted as consistent with severe SARS Cov2 pneumonia. The ionized calcium levels were normal or low during the ICU stay. Angiotensin converting enzyme and Interleukin-2 levels were however not measured. The biopsy findings could not explain the proteinuria, which was interpreted as a consequence of kidney injury and profound inflammation associated with SARS Cov2 infection.\nGiven that a medication reaction was a potential cause for kidney biopsy findings as well as for the rash and the hemolysis, a multidisciplinary decision was taken to stop ß-lactams, amiodarone and pantoprazole and to begin methylprednisolone 60 mg daily on day 37 . 47 days after admission urine output began to improve and CVVHDF was discontinued. The hemolysis resolved, the skin rash improved.\nOn transfer to neurorehabilitation 48 days after admission, the patient was tetraparetic due to critical illness polyneuropathy but alert and able to follow simple commands, he had tracheostomy in place and was breathing spontaneously with little support. The course of rehabilitation showed progressive improvement of kidney function . The estimated GFR two months post-discharge was 43 ml/min/1,73 m2 suggesting a likely transition to chronic kidney disease.", + "fulltext_subclaims": [ + "The patient was a 62-year-old Caucasian man.", + "He presented with cough, fever, myalgia, and chills.", + "Symptoms had begun 6 days prior to admission.", + "He had tested positive for SARS-CoV-2 by Xpert Xpress SARS-CoV-2 three days after symptom onset.", + "His past medical history was unremarkable except for hyperlipidemia treated with atorvastatin 40 mg daily.", + "No allergies were reported.", + "The patient did not smoke, drink alcohol, or use illicit substances.", + "Kidney function was normal on admission.", + "CT scan showed diffuse bilateral ground-glass infiltrates of the lungs.", + "CT scan showed associated lymphadenopathy.", + "CT scan showed moderate pleural effusions.", + "CT scan showed normal-sized and -shaped kidneys with adequate perfusion and without cortical defects.", + "Two days after admission, the patient required intubation due to acute respiratory distress syndrome.", + "He was managed with prone positioning.", + "He was initiated on hydroxychloroquine after exclusion of G6PD deficiency.", + "Antibiotic therapy with amoxicillin-clavulanate was given empirically.", + "The clinical condition worsened with the development of atrial fibrillation.", + "The clinical condition worsened with the development of AKI.", + "The clinical condition worsened with the development of paralytic ileus.", + "The clinical condition worsened with the development of hemolytic anemia.", + "A maculopapular rash on the trunk and lower extremities developed.", + "A maculo-papular skin rash developed on day 7 after admission.", + "Severe AKI with oliguria necessitated initiation of CVVHDF on day 9.", + "Peak creatinine was 519 umol/L.", + "Urinalysis showed minimal proteinuria and microscopic hematuria.", + "Proteinuria subsequently increased significantly.", + "Microscopic hematuria persisted.", + "Urine leucocytes were persistently within the normal range.", + "Severe microangiopathic hemolytic anemia developed on day 24.", + "The hemolytic anemia was Coombs negative.", + "The hemolytic anemia was transfusion dependent.", + "Serologic screening was negative for HIV, hepatitis B, and C virus infection.", + "Anti-nuclear antibodies, anti-DNA antibodies, anti-neutrophil cytoplasmic antibodies, anti-cardiolipin antibodies, and complement levels were normal.", + "Eosinophils were initially not significantly elevated.", + "There was no evidence of urinary obstruction or rhabdomyolysis.", + "Echocardiogram showed preserved cardiac function.", + "Differential diagnosis included acute tubular injury due to hemodynamic instability.", + "Differential diagnosis included sepsis-associated AKI.", + "Differential diagnosis included ATI with pigmented tubular casts due to hemolysis.", + "Differential diagnosis included thrombotic microangiopathy.", + "Differential diagnosis included collapsing glomerulopathy.", + "Differential diagnosis included acute interstitial nephritis associated with antibiotics.", + "A transcutaneous renal biopsy was performed 32 days after admission.", + "Light microscopy revealed 34 mostly normal glomeruli.", + "Few glomeruli were mildly congested, without thrombi.", + "There was diffuse interstitial edema and focal infiltrates.", + "Multiple non-caseating granulomas were present.", + "There was very mild tubulitis with rare lymphocytes in the tubular epithelium.", + "Many tubules had a dilated lumen, flattened epithelium, and loss of brush border.", + "Some tubules had fine, isometric vacuolization of the cytoplasm.", + "Rare lumina contained finely granular, mostly eosinophilic and very rare brownish casts.", + "Some peritubular capillaries contained mononuclear cells, but no erythrocyte aggregation.", + "There was mild arteriolar hyalinosis and arteriosclerosis, but no thrombi or vasculitis.", + "Immunohistochemistry showed only trace IgM, Kappa, and Lambda in the mesangium.", + "IgG, IgA, C3, and C1q were negative in the glomeruli.", + "Electron microscopy revealed myelin figures in the cytoplasm of a few parietal epithelia.", + "No definite viral particles were detected.", + "The biopsy was consistent with granulomatous tubulointerstitial nephritis.", + "The biopsy was consistent with acute tubular injury and regeneration.", + "There was no evidence of renal thrombotic microangiopathy.", + "There was no evidence of collapsing glomerulopathy.", + "There was no evidence of vasculitis.", + "Mycobacterium tuberculosis infection was excluded.", + "Sarcoidosis was considered clinically unlikely.", + "The biopsy findings could not explain the proteinuria.", + "A multidisciplinary decision was taken to stop ß-lactams, amiodarone, and pantoprazole.", + "Methylprednisolone 60 mg daily was begun on day 37.", + "Urine output began to improve 47 days after admission.", + "CVVHDF was discontinued.", + "The hemolysis resolved.", + "The skin rash improved.", + "On transfer to neurorehabilitation 48 days after admission, the patient was tetraparetic due to critical illness polyneuropathy.", + "The patient had a tracheostomy in place and was breathing spontaneously with little support.", + "The estimated GFR two months post-discharge was 43 ml/min/1.73 m2.", + "The estimated GFR suggested a likely transition to chronic kidney disease." + ], + "summary": "The patient presented here was positive for SARS-CoV-2, had severe acute respiratory distress syndrome and multi-organ failure. Within days of admission to the intensive care unit he developed oliguric acute kidney failure requiring dialysis. Acute kidney injury developed in the setting of hemodynamic instability, sepsis and a maculopapular rash. Over the ensuing days the patient also developed transfusion-requiring severe hemolysis which was Coombs negative. Schistocytes were present on the peripheral smear. Given the broad differential diagnoses for acute kidney injury, a kidney biopsy was performed and revealed granulomatous tubulo-interstitial nephritis with some acute tubular injury. Based on the biopsy findings, a decision was taken to adjust medications and initiate corticosteroids for presumed medication-induced interstitial nephritis, hemolysis and maculo-papular rash. The kidney function and hemolysis improved over the subsequent days and the patient was discharged to a rehabilitation facility, no-longer required dialysis.", + "summary_subclaims": [ + "The patient was positive for SARS-CoV-2.", + "The patient had severe acute respiratory distress syndrome.", + "The patient had multi-organ failure.", + "The patient developed oliguric acute kidney failure requiring dialysis.", + "Acute kidney injury developed in the setting of hemodynamic instability.", + "Acute kidney injury developed in the setting of sepsis.", + "Acute kidney injury developed in the setting of a maculopapular rash.", + "The patient developed transfusion-requiring severe hemolysis.", + "The hemolysis was Coombs negative.", + "Schistocytes were present on the peripheral smear.", + "A kidney biopsy was performed.", + "The kidney biopsy revealed granulomatous tubulo-interstitial nephritis.", + "The kidney biopsy revealed some acute tubular injury.", + "A decision was taken to adjust medications.", + "A decision was taken to initiate corticosteroids.", + "The corticosteroids were for presumed medication-induced interstitial nephritis.", + "The corticosteroids were for presumed hemolysis.", + "The corticosteroids were for presumed maculo-papular rash.", + "The kidney function improved over the subsequent days.", + "The hemolysis improved over the subsequent days.", + "The patient was discharged to a rehabilitation facility.", + "The patient no longer required dialysis." + ] + }, + { + "id": "multiclinsum_test_1692_en.txt", + "fulltext": "A one-month-old girl of African origin was admitted to the local emergency pediatric unit for high fever, trilineage blood cytopenia and hepatosplenomegaly. Natural killer cells analysis showed a lack of perforin expression. The diagnosis of hemophagocytic lymphohistiocytosis (HLH) was confirmed by Next Generation Sequencing (NGS) analysis on peripheral blood DNA, showing the presence of genomic variants c.50delT and c.1130G>A in PRF1 gene, both heterozygous. NM_005041 (PRF1): c.[50delT1130G>A], p.[Leu17ArgfsTer34Cys377Tyr]. These variants, both homozygous and compound heterozygous, are described as related to HLH., The patient started treatment with dexamethasone and cyclosporine, followed by emapalumab, a monoclonal antibody anti-interferon gamma. She underwent HLA-matched unrelated donor HSCT at the age of 6 months (HLA-A, DRB1, permissive DPB1 allele mismatches). Conditioning regimen: busulfan (3×3,2 mg/kg/day), fludarabine (3×50 mg/m2/day), thiotepa (2×5 mg/kg/day) and rabbit antithymocyte globulin (ATG GenzymeTM) (3×4,5 mg/kg/day). The patient received 4.14×108/kg bone marrow total nucleated cells and 7.37×106/kg of CD34+ cells. GVHD prophylaxis was based on cyclophosphamide (2×50 mg/kg) and cyclosporine and low dose of prednisone (0,4 mg/kg/die). The pre-engraftment period was complicated by Pseudomonas aeruginosa sepsis (day + 10) and right lobar pneumonia (day +13). The engraftment occurred at day +16 with no sign of aGVHD. Therapy with ciclosporin was interrupted three months after HSCT, and she started therapy with tacrolimus. The prednisone given as GVHD prophylaxis was interrupted at month +7 post-HSCT. Full donor chimerism was found at day +50 and confirmed at month +8 post-HSCT. At 17 months the child was admitted to the hospital for lack of appetite, elevated liver enzymes with alanine aminotransferase (ALT) 850 U/L and aspartate aminotransferase (AST) 499 U/L (normal value 5–45), and polypnea. Presuming GVHD-related symptoms, she was treated with methylprednisolone at the dose of 2 mg/kg/die with no clinical improvement. The child rapidly developed respiratory failure that required mechanical ventilation. An extensive diagnostic work-up was performed: blood analysis revealed an increased value of creatine kinase (CK) of 13830 U/L (normal value 25–190), creatine kinase (CK)-MB 555 ng/L (normal value < 6) and troponin of 2601 ng/L (normal value < 45); tacrolimus through blood level was in range; immunoglobulin levels were normal whilst the peripheral blood lymphocyte subpopulations showed an increase in the content of B-lymphocytes (2544,34 cells/ul, normal value 123–349); echocardiography showed a normal biventricular function; electroencephalography (EEG) revealed no abnormality; serological test and polymerase chain reaction (PCR) assay revealed no evidence of recent parvovirus B19, Adenovirus, Enterovirus, Cytomegalovirus, Human herpesvirus 6, Human immunodeficiency virus, hepatitis B virus, hepatitis C virus or Epstein-Barr virus infection; cerebrospinal fluid (CSF) findings resulted negative for bacterial and viral infections; electromyography (EMG) showed a normal pattern of the motor unit action potential (MUAP) waveform with normal values of F wave and only sporadic myopathic MUAPs were found; an extensive screen for autoantibodies related to autoimmune and neuromuscular disease was negative. In suspicion of a GVHD-related myositis, a biopsy from vastus lateralis muscle was performed showing necrotic and degenerating muscle fibres, basophilic regenerating fibres and inflammatory infiltrates predominantly around vessels .\nInflammatory cells were predominantly composed of CD3+ CD8+ T cells; some CD4+ T cells and a few CD68+ macrophages, CD20+ B cells and CD57+ natural killer cells were observed; only rare CD 138+ cells were present .\nThese findings indicated immune-mediated polymyositis; therefore the immunosuppression treatment was potentiated with methylprednisolone 30 mg/kg for three days, rituximab (105 mg/m2 once weekly for four doses); tacrolimus was replaced with sirolimus because of its potential neurotoxicity. In the following days the clinical conditions of the child improved, with a decrease in CK, CK-MB, AST, ALT and troponin values; she was weaned from mechanical ventilation after 25 days. In the following weeks the girl presented a progressive clinical improvement with complete normalisation of the neuromuscular disease in about two months. The girl was treated with sirolimus (ongoing), and low dose of prednisone (0,2 mg/kg/die) gradually tapered off over nine months. Currently, after 15 months, the girl is asymptomatic in very good general conditions without any neuromuscular alteration. The values of CK-MB, AST, ALT and troponin are average while CK persists slightly abnormal (1.5 times above the normal upper range).", + "fulltext_subclaims": [ + "A one-month-old girl of African origin was admitted to the local emergency pediatric unit for high fever, trilineage blood cytopenia and hepatosplenomegaly.", + "Natural killer cells analysis showed a lack of perforin expression.", + "The diagnosis of hemophagocytic lymphohistiocytosis (HLH) was confirmed by Next Generation Sequencing (NGS) analysis on peripheral blood DNA.", + "NGS analysis showed the presence of genomic variants c.50delT and c.1130G>A in PRF1 gene, both heterozygous.", + "NM_005041 (PRF1): c.[50delT1130G>A], p.[Leu17ArgfsTer34Cys377Tyr].", + "These variants, both homozygous and compound heterozygous, are described as related to HLH.", + "The patient started treatment with dexamethasone and cyclosporine, followed by emapalumab, a monoclonal antibody anti-interferon gamma.", + "She underwent HLA-matched unrelated donor HSCT at the age of 6 months (HLA-A, DRB1, permissive DPB1 allele mismatches).", + "Conditioning regimen: busulfan (3×3,2 mg/kg/day), fludarabine (3×50 mg/m2/day), thiotepa (2×5 mg/kg/day) and rabbit antithymocyte globulin (ATG GenzymeTM) (3×4,5 mg/kg/day).", + "The patient received 4.14×108/kg bone marrow total nucleated cells and 7.37×106/kg of CD34+ cells.", + "GVHD prophylaxis was based on cyclophosphamide (2×50 mg/kg) and cyclosporine and low dose of prednisone (0,4 mg/kg/die).", + "The pre-engraftment period was complicated by Pseudomonas aeruginosa sepsis (day + 10) and right lobar pneumonia (day +13).", + "The engraftment occurred at day +16 with no sign of aGVHD.", + "Therapy with ciclosporin was interrupted three months after HSCT, and she started therapy with tacrolimus.", + "The prednisone given as GVHD prophylaxis was interrupted at month +7 post-HSCT.", + "Full donor chimerism was found at day +50 and confirmed at month +8 post-HSCT.", + "At 17 months the child was admitted to the hospital for lack of appetite, elevated liver enzymes with alanine aminotransferase (ALT) 850 U/L and aspartate aminotransferase (AST) 499 U/L.", + "Presuming GVHD-related symptoms, she was treated with methylprednisolone at the dose of 2 mg/kg/die with no clinical improvement.", + "The child rapidly developed respiratory failure that required mechanical ventilation.", + "An extensive diagnostic work-up was performed.", + "Blood analysis revealed an increased value of creatine kinase (CK) of 13830 U/L.", + "Creatine kinase (CK)-MB 555 ng/L.", + "Troponin of 2601 ng/L.", + "Tacrolimus through blood level was in range.", + "Immunoglobulin levels were normal.", + "The peripheral blood lymphocyte subpopulations showed an increase in the content of B-lymphocytes (2544,34 cells/ul).", + "Echocardiography showed a normal biventricular function.", + "Electroencephalography (EEG) revealed no abnormality.", + "Serological test and polymerase chain reaction (PCR) assay revealed no evidence of recent parvovirus B19, Adenovirus, Enterovirus, Cytomegalovirus, Human herpesvirus 6, Human immunodeficiency virus, hepatitis B virus, hepatitis C virus or Epstein-Barr virus infection.", + "Cerebrospinal fluid (CSF) findings resulted negative for bacterial and viral infections.", + "Electromyography (EMG) showed a normal pattern of the motor unit action potential (MUAP) waveform with normal values of F wave and only sporadic myopathic MUAPs were found.", + "An extensive screen for autoantibodies related to autoimmune and neuromuscular disease was negative.", + "A biopsy from vastus lateralis muscle was performed.", + "The biopsy showed necrotic and degenerating muscle fibres, basophilic regenerating fibres and inflammatory infiltrates predominantly around vessels.", + "Inflammatory cells were predominantly composed of CD3+ CD8+ T cells.", + "Some CD4+ T cells and a few CD68+ macrophages, CD20+ B cells and CD57+ natural killer cells were observed.", + "Only rare CD 138+ cells were present.", + "These findings indicated immune-mediated polymyositis.", + "The immunosuppression treatment was potentiated with methylprednisolone 30 mg/kg for three days, rituximab (105 mg/m2 once weekly for four doses).", + "Tacrolimus was replaced with sirolimus because of its potential neurotoxicity.", + "In the following days the clinical conditions of the child improved, with a decrease in CK, CK-MB, AST, ALT and troponin values.", + "She was weaned from mechanical ventilation after 25 days.", + "In the following weeks the girl presented a progressive clinical improvement with complete normalisation of the neuromuscular disease in about two months.", + "The girl was treated with sirolimus (ongoing), and low dose of prednisone (0,2 mg/kg/die) gradually tapered off over nine months.", + "Currently, after 15 months, the girl is asymptomatic in very good general conditions without any neuromuscular alteration.", + "The values of CK-MB, AST, ALT and troponin are average while CK persists slightly abnormal (1.5 times above the normal upper range)." + ], + "summary": "We report a case of a 17-months-old child affected by hemophagocytic lymphohistiocytosis who underwent a matched unrelated donor haematopoietic stem cell transplantation (HSCT). She developed severe cGVHD-related polymyositis that was successfully treated with high-dose steroid therapy, rituximab and sirolimus.", + "summary_subclaims": [ + "The patient was a 17-months-old child.", + "The patient was affected by hemophagocytic lymphohistiocytosis.", + "The patient underwent a matched unrelated donor haematopoietic stem cell transplantation.", + "The patient developed severe cGVHD-related polymyositis.", + "The patient was treated with high-dose steroid therapy.", + "The patient was treated with rituximab.", + "The patient was treated with sirolimus.", + "The treatment was successful." + ] + }, + { + "id": "multiclinsum_test_2584_en.txt", + "fulltext": "A 56-year-old man was referred to our hospital with a 6-month history of abdominal distension and discomfort (A). He had a medical history of schizophrenia. His abdomen was markedly distended, and severe edema was present in both lower limbs. He had no symptoms of gastrointestinal obstruction. Neurological examination findings were normal. He had slight anemia (hemoglobin of 10.5 g/dl), and other laboratory data were within normal limits. A computed tomography (CT) scan demonstrated a 30- × 18- × 30-cm giant mass located between the stomach and transverse colon. It included a large cyst and solid component that showed enhancement (B). The main feeder artery for the tumor seemed to be the right gastric artery. Magnetic resonance imaging (MRI) also showed a huge heterogeneous soft tissue mass. The solid component showed high signal intensity on T2-weighted imaging and diffusion-weighted imaging (C, D). Upper and lower endoscopy was not performed because the patient declined. CT-guided biopsy was not performed to avoid dissemination. Our preoperative differential diagnoses were sarcoma with a mucinous component, gastrointestinal stromal tumor, lymphangioma, and mesenteric cyst. A histological diagnosis was not obtained preoperatively, and the tumor was too large to identify its boundary with the surrounding organs by radiological examination. We expected that the tumor was arising from the stomach, transverse colon, or mesenterium.\nWe decided to perform surgery because the tumor showed the tendency to grow. During laparotomy, we identified a huge encapsulated tumor. The tumor occupied most of the pelvic cavity, but the caudal side of the tumor had no adhesions with pelvic organs. We gradually dissected along the capsule and moved the tumor outside the body (A). Finally, we found that the tumor was adhered to the stomach and transverse colon. We resected the distal stomach and 15 cm of the transverse colon with the tumor. Reconstruction was performed using Billroth-I anastomosis for the stomach and end-to-end anastomosis for the colon. We identified the resection margin of the tumor, and we did not perform intraoperative histological examination or lymph node dissection because no enlarged lymph nodes or disseminated nodules were found. The tumor was completely removed. The postoperative course was uneventful, and the patient was discharged on postoperative day 17.\nMacroscopic examination revealed a 38- × 20- × 19-cm tumor weighing 13,000 g (B). No abnormalities were found on the intraluminal surface of the stomach or transverse colon wall. On histological examination, the tumor was composed mainly of short spindle and vacuolated cells, including lipoblasts and mature adipocytes, with a myxomatous matrix. The main mass was located in the abdominal cavity, but the tumor base was broadly adhered to the gastric wall and seemingly grew from the gastric submucosa, suggesting that the tumor had likely arisen from the stomach . The transverse colon was intact. Immunohistochemically, the tumor cells were negative for smooth muscle actin, c-kit, and MDM2. These features were consistent with myxoid liposarcoma. The patient was still doing well 2 years postoperatively.", + "fulltext_subclaims": [ + "The patient was a 56-year-old man.", + "He had a 6-month history of abdominal distension and discomfort.", + "He had a medical history of schizophrenia.", + "His abdomen was markedly distended.", + "Severe edema was present in both lower limbs.", + "He had no symptoms of gastrointestinal obstruction.", + "Neurological examination findings were normal.", + "He had slight anemia with a hemoglobin of 10.5 g/dl.", + "A CT scan demonstrated a 30- × 18- × 30-cm giant mass located between the stomach and transverse colon.", + "The mass included a large cyst and solid component that showed enhancement.", + "The main feeder artery for the tumor seemed to be the right gastric artery.", + "MRI showed a huge heterogeneous soft tissue mass.", + "The solid component showed high signal intensity on T2-weighted imaging.", + "The solid component showed high signal intensity on diffusion-weighted imaging.", + "Upper and lower endoscopy was not performed because the patient declined.", + "CT-guided biopsy was not performed to avoid dissemination.", + "The preoperative differential diagnoses included sarcoma with a mucinous component, gastrointestinal stromal tumor, lymphangioma, and mesenteric cyst.", + "A histological diagnosis was not obtained preoperatively.", + "The tumor was too large to identify its boundary with the surrounding organs by radiological examination.", + "The tumor was expected to be arising from the stomach, transverse colon, or mesenterium.", + "Surgery was decided because the tumor showed the tendency to grow.", + "During laparotomy, a huge encapsulated tumor was identified.", + "The tumor occupied most of the pelvic cavity.", + "The caudal side of the tumor had no adhesions with pelvic organs.", + "The tumor was gradually dissected along the capsule and moved outside the body.", + "The tumor was adhered to the stomach and transverse colon.", + "The distal stomach and 15 cm of the transverse colon were resected with the tumor.", + "Reconstruction was performed using Billroth-I anastomosis for the stomach.", + "Reconstruction was performed using end-to-end anastomosis for the colon.", + "The resection margin of the tumor was identified.", + "Intraoperative histological examination was not performed.", + "Lymph node dissection was not performed.", + "No enlarged lymph nodes or disseminated nodules were found.", + "The tumor was completely removed.", + "The postoperative course was uneventful.", + "The patient was discharged on postoperative day 17.", + "Macroscopic examination revealed a 38- × 20- × 19-cm tumor weighing 13,000 g.", + "No abnormalities were found on the intraluminal surface of the stomach or transverse colon wall.", + "The tumor was composed mainly of short spindle and vacuolated cells, including lipoblasts and mature adipocytes, with a myxomatous matrix.", + "The main mass was located in the abdominal cavity.", + "The tumor base was broadly adhered to the gastric wall.", + "The tumor seemed to grow from the gastric submucosa.", + "The tumor was likely to have arisen from the stomach.", + "The transverse colon was intact.", + "The tumor cells were negative for smooth muscle actin.", + "The tumor cells were negative for c-kit.", + "The tumor cells were negative for MDM2.", + "These features were consistent with myxoid liposarcoma.", + "The patient was still doing well 2 years postoperatively." + ], + "summary": "A 56-year-old man was referred to our hospital with abdominal distension and discomfort. A computed tomography scan showed a huge mass located between the stomach and transverse colon. The preliminary differential diagnoses were sarcoma with a mucinous component, gastrointestinal stromal tumor, lymphangioma, and mesenteric cyst. Upper and lower endoscopy was not performed because the patient declined. The patient underwent surgical resection, and the tumor was completely removed. Macroscopic examination revealed a 39-×26-×20-cm tumor weighing 13,000g. On histological examination, the tumor was diagnosed as a myxoid liposarcoma in the gastric submucosa. The patient was still doing well 2 years postoperatively.", + "summary_subclaims": [ + "A 56-year-old man was referred to our hospital with abdominal distension and discomfort.", + "A computed tomography scan showed a huge mass located between the stomach and transverse colon.", + "The preliminary differential diagnoses were sarcoma with a mucinous component, gastrointestinal stromal tumor, lymphangioma, and mesenteric cyst.", + "Upper and lower endoscopy was not performed because the patient declined.", + "The patient underwent surgical resection.", + "The tumor was completely removed.", + "Macroscopic examination revealed a 39-×26-×20-cm tumor weighing 13,000g.", + "On histological examination, the tumor was diagnosed as a myxoid liposarcoma in the gastric submucosa.", + "The patient was still doing well 2 years postoperatively." + ] + }, + { + "id": "multiclinsum_test_2028_en.txt", + "fulltext": "A 64-year-old man visited our eye clinic with a two-day history of decreased visual acuity in his right eye. The patient presented with a medical history of hypertension and diabetes mellitus. He stated that his vision had gradually worsened in recent days.\nAt the initial visit, his best-corrected visual acuity was 20/125 in the right eye and 20/25 in the left eye, and intraocular pressures were 18 mmHg and 13 mmHg, respectively. Slit-lamp examination demonstrated mild hyperemia and keratic precipitates. The eye also showed inflammation in the anterior chamber and anterior vitreous, which was scored as grade 2+ and grade 1+ according to the Standardization of Uveitis Nomenclature Working Group guidelines . Fundus examination of the right eye showed multiple and diffuse white-yellowish infiltrations combined with retinal dot hemorrhages in the peripheral retina . The left eye was completely normal. Ultra-wide-field fluorescence angiography showed obstructive retinal arteritis with peripheral non-perfusion and late leakage from the retinal vessels in the right eye .\nThe patient was hospitalized for further evaluation and appropriate management. Basic laboratory test and serology study were performed. The serological tests were positive for HSV type 1 immunoglobulin G (IgG), VZV IgG, Epstein-Barr virus viral capsid antigen IgG, and Toxoplasma-specific IgG antibodies. Anterior chamber paracentesis and PCR analysis of the aqueous humor have been performed. VZV DNA was identified in the aqueous humor. But, DNA for HSV-1, HSV-2, and cytomegalovirus was not detected. Given the impression of VZV associated ARN, treatment was started with intravenous acyclovir (1200 mg three times a day). Oral prednisolone (1 mg/kg/day) was also started 24 h after systemic acyclovir treatment.\nAfter 3 days of the above treatment, slit-lamp examination revealed 3+ cells in the anterior chamber, 2+ cells in the anterior vitreous, and increased vitreous opacity (grade 2) in the right eye. On the fundus examination, the multiple whitish infiltrations were increased and newly developed vitreous and peripapillary hemorrhages were detected in the right eye . At that time, the patient had symptoms of headache. T2-weighted MRIs of the brain performed to find the cause of the atypical ARN demonstrated a sub-acute or old hemorrhagic infarction in the right occipital lobe, and contrast-enhancing lesions in the right basal ganglia . The spinal tapping was performed in the department of neurology in our hospital at the time when the patient complained of headache, and intracranial pressure was 31 mmHg. This suggests that the possibility of Terson’s syndrome due to suddenly increased intracranial pressure in this case .\nIn view of the patient’s clinical features, immune status, and brain images, he was diagnosed as having VZV-mediated ARN with Terson’s syndrome. On day 5 of the admission, the patient’s visual acuity was reduced to counting fingers at 50 cm in the right eye. Retinal infiltration and vitreous hemorrhage were increased. Therefore, we started intravitreal injections of ganciclovir (2 mg/0.5 mL). After 5 intravitreal injections (from the 5 to 15 day of the admission), the multiple white-yellowish infiltrative lesions and retinal dot hemorrhages were decreased, and visual acuity increased to 20/800 in the right eye. The vitreous and peripapillary hemorrhages were also markedly decreased compared with the initial status of the ARN. After 20 days of intravenous antiviral therapy, the patient was discharged on oral valacyclovir, 1000 mg twice a day, combined with an oral prednisolone (tapering dose, 0.5 m/kg/day). After 5 intravitreal ganciclovir injections over a period of 8 months, there was no recurrence in the patient’s right eye, in which his visual acuity had improved to 20/60 . The contralateral eye remained normal.", + "fulltext_subclaims": [ + "The patient is a 64-year-old man.", + "The patient visited the eye clinic with a two-day history of decreased visual acuity in his right eye.", + "The patient has a medical history of hypertension.", + "The patient has a medical history of diabetes mellitus.", + "The patient stated that his vision had gradually worsened in recent days.", + "At the initial visit, best-corrected visual acuity was 20/125 in the right eye.", + "At the initial visit, best-corrected visual acuity was 20/25 in the left eye.", + "Intraocular pressure was 18 mmHg in the right eye.", + "Intraocular pressure was 13 mmHg in the left eye.", + "Slit-lamp examination demonstrated mild hyperemia in the right eye.", + "Slit-lamp examination demonstrated keratic precipitates in the right eye.", + "The right eye showed inflammation in the anterior chamber.", + "The right eye showed inflammation in the anterior vitreous.", + "The anterior chamber inflammation was scored as grade 2+.", + "The anterior vitreous inflammation was scored as grade 1+.", + "Fundus examination showed multiple and diffuse white-yellowish infiltrations in the right eye.", + "Fundus examination showed retinal dot hemorrhages in the peripheral retina of the right eye.", + "The left eye was completely normal.", + "Ultra-wide-field fluorescence angiography showed obstructive retinal arteritis in the right eye.", + "Ultra-wide-field fluorescence angiography showed peripheral non-perfusion in the right eye.", + "Ultra-wide-field fluorescence angiography showed late leakage from the retinal vessels in the right eye.", + "The patient was hospitalized.", + "Basic laboratory tests were performed.", + "Serology studies were performed.", + "Serological tests were positive for HSV type 1 IgG.", + "Serological tests were positive for VZV IgG.", + "Serological tests were positive for Epstein-Barr virus viral capsid antigen IgG.", + "Serological tests were positive for Toxoplasma-specific IgG antibodies.", + "Anterior chamber paracentesis was performed.", + "PCR analysis of the aqueous humor was performed.", + "VZV DNA was identified in the aqueous humor.", + "HSV-1 DNA was not detected in the aqueous humor.", + "HSV-2 DNA was not detected in the aqueous humor.", + "Cytomegalovirus DNA was not detected in the aqueous humor.", + "Treatment was started with intravenous acyclovir (1200 mg three times a day).", + "Oral prednisolone (1 mg/kg/day) was started 24 h after systemic acyclovir treatment.", + "After 3 days of treatment, slit-lamp examination revealed 3+ cells in the anterior chamber of the right eye.", + "After 3 days of treatment, slit-lamp examination revealed 2+ cells in the anterior vitreous of the right eye.", + "After 3 days of treatment, increased vitreous opacity (grade 2) was noted in the right eye.", + "On fundus examination, multiple whitish infiltrations were increased in the right eye.", + "Newly developed vitreous and peripapillary hemorrhages were detected in the right eye.", + "The patient had symptoms of headache.", + "T2-weighted MRIs of the brain showed a sub-acute or old hemorrhagic infarction in the right occipital lobe.", + "T2-weighted MRIs showed contrast-enhancing lesions in the right basal ganglia.", + "Spinal tapping was performed when the patient complained of headache.", + "Intracranial pressure was 31 mmHg.", + "This suggests the possibility of Terson’s syndrome due to suddenly increased intracranial pressure.", + "The patient was diagnosed as having VZV-mediated ARN with Terson’s syndrome.", + "On day 5 of admission, visual acuity was reduced to counting fingers at 50 cm in the right eye.", + "Retinal infiltration and vitreous hemorrhage were increased.", + "Intravitreal injections of ganciclovir (2 mg/0.5 mL) were started.", + "After 5 intravitreal injections, multiple white-yellowish infiltrative lesions and retinal dot hemorrhages were decreased.", + "After 5 intravitreal injections, visual acuity increased to 20/800 in the right eye.", + "The vitreous and peripapillary hemorrhages were markedly decreased.", + "After 20 days of intravenous antiviral therapy, the patient was discharged.", + "The patient was discharged on oral valacyclovir, 1000 mg twice a day.", + "The patient was discharged on oral prednisolone with a tapering dose of 0.5 mg/kg/day.", + "After 5 intravitreal ganciclovir injections over 8 months, there was no recurrence in the right eye.", + "Visual acuity improved to 20/60 in the right eye.", + "The contralateral eye remained normal." + ], + "summary": "A 64-year-old man visited our eye clinic with a complaint of decreased visual acuity in his right eye. At the initial visit, his best corrected visual acuity was 20/125 in the right eye. Slit-lamp examination demonstrated mild hyperemia, keratic precipitates, and anterior chamber inflammatory reaction. Fundus examination revealed multiple diffuse white-yellowish infiltrations in the peripheral retina combined with dot hemorrhages. Ultra-wide-field fluorescence angiography showed obstructive arteritis with peripheral non-perfusion and leakage from the retinal vessels. As a result of the PCR analysis, varicella zoster virus DNA was identified in the aqueous humor. Under the diagnosis with VZV-mediated ARN, we started with intravenous acyclovir and oral prednisolone. After 3 days of the above treatment, the anterior chamber inflammation and vitreous opacity were increased. On fundus examination, multiple whitish infiltrations were increased. In addition, newly developed vitreous and peripapillary hemorrhages were detected. On the T2 brain magnetic resonance imaging (MRI) demonstrated a sub-acute or old hemorrhagic infarction in the right occipital lobe, and contrast-enhancing lesions in the right basal ganglia. The spinal tapping was performed in the department of neurology in our hospital at the time when the patient complained of headache, and intracranial pressure was 31 mmHg. Under the diagnosis of ARN with Terson's syndrome, we started intravitreal ganciclovir (2 mg/0.5 ml) injections. After 5 intravitreal ganciclovir injections over a period of 8 months, the diffuse whitish infiltrating retinal lesions combined with dot hemorrhage were decreased. The vitreous and peripapillary hemorrhage was significantly reduced. There was no recurrence in the patient's right eye, in which his visual acuity had improved to 20/60.", + "summary_subclaims": [ + "A 64-year-old man visited our eye clinic with a complaint of decreased visual acuity in his right eye.", + "At the initial visit, his best corrected visual acuity was 20/125 in the right eye.", + "Slit-lamp examination demonstrated mild hyperemia.", + "Slit-lamp examination demonstrated keratic precipitates.", + "Slit-lamp examination demonstrated anterior chamber inflammatory reaction.", + "Fundus examination revealed multiple diffuse white-yellowish infiltrations in the peripheral retina.", + "Fundus examination revealed dot hemorrhages.", + "Ultra-wide-field fluorescence angiography showed obstructive arteritis.", + "Ultra-wide-field fluorescence angiography showed peripheral non-perfusion.", + "Ultra-wide-field fluorescence angiography showed leakage from the retinal vessels.", + "PCR analysis identified varicella zoster virus DNA in the aqueous humor.", + "The diagnosis was VZV-mediated ARN.", + "Intravenous acyclovir was started.", + "Oral prednisolone was started.", + "After 3 days of treatment, the anterior chamber inflammation and vitreous opacity were increased.", + "Fundus examination showed multiple whitish infiltrations were increased.", + "Newly developed vitreous and peripapillary hemorrhages were detected.", + "T2 brain MRI demonstrated a sub-acute or old hemorrhagic infarction in the right occipital lobe.", + "T2 brain MRI showed contrast-enhancing lesions in the right basal ganglia.", + "Spinal tapping was performed at the time when the patient complained of headache.", + "Intracranial pressure was 31 mmHg.", + "The diagnosis was ARN with Terson's syndrome.", + "Intravitreal ganciclovir (2 mg/0.5 ml) injections were started.", + "After 5 intravitreal ganciclovir injections over a period of 8 months, the diffuse whitish infiltrating retinal lesions combined with dot hemorrhage were decreased.", + "The vitreous and peripapillary hemorrhage was significantly reduced.", + "There was no recurrence in the patient's right eye.", + "The patient's visual acuity had improved to 20/60." + ] + }, + { + "id": "multiclinsum_test_2717_en.txt", + "fulltext": "A 61-year-old obese male underwent laparoscopic partial nephrectomy due to an incidental tumor in the left kidney that was found during a work-up for hypertension. Microscopic examination of the tumor revealed that this was a chromophobe renal cell carcinoma. After one year of surveillance, a routine follow-up evaluation revealed a tumor in the left seminal vesicle. Magnetic resonance imaging (MRI) showed a well-circumscribed heterogeneous solid tumor in the left seminal vesicle measuring 32 mm across its largest dimension, with well-defined cleavage planes with the rectum and bladder walls . The patient then underwent laparoscopic surgical excision of the left seminal vesicle.\nGrossly, the seminal vesicle measured 6 x 3 x 2 cm, and the cut surface showed a solid, well-circumscribed, brownish and smooth nodule measuring 30 mm across its largest dimension. The surgical margins were free from tumor. Microscopic examination of the tumor disclosed well-defined nests of cuboidal cells separated by vascular fibrous septa without evidence of vascular invasion, mitotic figures or necrosis. Gland-like structures were identified focally. The individual tumor cells had a large central nucleus and small to medium-sized nucleoli, and granular eosinophilic cytoplasm .\nThe diagnostic possibilities at this point included metastasis of the previous chromophobe renal cell carcinoma, adenocarcinoma of the seminal vesicle and paraganglioma. Immunohistochemical characterization was used for the differential diagnosis (antibodies summarized in ). The tumor cells were immunoreactive for chromogranin and synaptophysin . At the periphery of the tumor nests, S100 protein-positive cells were identified, probably corresponding to sustentacular cells, in the absence of tumor keratin expression . Absence of immunoreactivity for keratins (AE1/AE3, CK7 and CK8/18) ruled out the hypothesis of primary or metastatic carcinoma, and supported the diagnosis of seminal vesicle paraganglioma. The Ki-67 labeling index was less than 2%. VHL and SDHB mutations were investigated using genomic DNA extracted from paraffin-embedded tumor sections (both from the seminal vesicle tumor and from the chromophobe renal cell carcinoma). No genetic alterations were found either in the VHL or in the SDHB genes.\nThorough imaging analysis showed that there was no tumor elsewhere, which therefore reinforced the diagnosis of primary seminal vesicle paraganglioma. The patient is still alive after 14 months of follow-up and his blood pressure is under control.", + "fulltext_subclaims": [ + "The patient is a 61-year-old obese male.", + "The patient underwent laparoscopic partial nephrectomy.", + "The tumor was found incidentally during a work-up for hypertension.", + "The tumor was located in the left kidney.", + "Microscopic examination of the tumor revealed chromophobe renal cell carcinoma.", + "After one year of surveillance, a tumor was found in the left seminal vesicle.", + "MRI showed a well-circumscribed heterogeneous solid tumor in the left seminal vesicle.", + "The tumor measured 32 mm across its largest dimension.", + "The tumor had well-defined cleavage planes with the rectum and bladder walls.", + "The patient underwent laparoscopic surgical excision of the left seminal vesicle.", + "Grossly, the seminal vesicle measured 6 x 3 x 2 cm.", + "The cut surface showed a solid, well-circumscribed, brownish and smooth nodule.", + "The nodule measured 30 mm across its largest dimension.", + "The surgical margins were free from tumor.", + "Microscopic examination disclosed well-defined nests of cuboidal cells.", + "The nests were separated by vascular fibrous septa.", + "There was no evidence of vascular invasion.", + "There were no mitotic figures.", + "There was no necrosis.", + "Gland-like structures were identified focally.", + "The tumor cells had a large central nucleus.", + "The tumor cells had small to medium-sized nucleoli.", + "The tumor cells had granular eosinophilic cytoplasm.", + "The diagnostic possibilities included metastasis of the previous chromophobe renal cell carcinoma.", + "The diagnostic possibilities included adenocarcinoma of the seminal vesicle.", + "The diagnostic possibilities included paraganglioma.", + "Immunohistochemical characterization was used for the differential diagnosis.", + "The tumor cells were immunoreactive for chromogranin.", + "The tumor cells were immunoreactive for synaptophysin.", + "S100 protein-positive cells were identified at the periphery of the tumor nests.", + "The tumor cells did not express keratins (AE1/AE3, CK7 and CK8/18).", + "The absence of keratin immunoreactivity ruled out the hypothesis of primary or metastatic carcinoma.", + "The diagnosis was supported as seminal vesicle paraganglioma.", + "The Ki-67 labeling index was less than 2%.", + "VHL and SDHB mutations were investigated using genomic DNA.", + "No genetic alterations were found in the VHL gene.", + "No genetic alterations were found in the SDHB gene.", + "Thorough imaging analysis showed no tumor elsewhere.", + "The diagnosis was reinforced as primary seminal vesicle paraganglioma.", + "The patient is still alive after 14 months of follow-up.", + "The patient's blood pressure is under control." + ], + "summary": "This report describes, for the first time to the best of our knowledge, a primary paraganglioma of the seminal vesicle occurring in a 61-year-old male. The patient presented persistent arterial hypertension and a previous diagnosis of chromophobe renal cell carcinoma. It was hypothesized that the seminal vesicle tumor could be a metastasis from the chromophobe renal cell carcinoma. Immunohistochemical characterization revealed expression of synaptophysin and chromogranin in tumor cell nests and peripheral S100 protein expression in sustentacular cells. Succinate dehydrogenase A and B-related (SDHA and SDHB) expression was present in both tumors.", + "summary_subclaims": [ + "This report describes, for the first time to the best of our knowledge, a primary paraganglioma of the seminal vesicle occurring in a 61-year-old male.", + "The patient presented persistent arterial hypertension.", + "The patient had a previous diagnosis of chromophobe renal cell carcinoma.", + "It was hypothesized that the seminal vesicle tumor could be a metastasis from the chromophobe renal cell carcinoma.", + "Immunohistochemical characterization revealed expression of synaptophysin and chromogranin in tumor cell nests.", + "Immunohistochemical characterization revealed peripheral S100 protein expression in sustentacular cells.", + "Succinate dehydrogenase A and B-related (SDHA and SDHB) expression was present in both tumors." + ] + }, + { + "id": "multiclinsum_test_3078_en.txt", + "fulltext": "Clinical information\nThe patient, female, 57 years old. In September 2021, lung tumors were found during the examination in The First Affiliated Hospital of Dalian Medical University. The chief complaint was chest pain and fatigue for half a year. For further treatment, the outpatient department was admitted to the hospital on the grounds of “lung shadow.” The patient’s mental state is good, appetite is reasonable, sleep is good, and weight has no significant change. Based on MSCT plain scan of the chest, partial solid nodules appeared in the posterior segment of the upper lobe of the patient’s right lung (21 mm * 13 mm), with signs of lobulation, burrs, pleural indentation, and vacuole. Multiple small nodules in both lungs. Blood test: neutrophils↑, lymphocytes↓. The patient underwent surgical treatment and part of lung tissue was removed. Pathology revealed invasive adenocarcinoma in the upper lobe of the right lung, and no metastasis in the parbronchial lymph nodes.\n\nTCM therapy\nIn November 2022, when the patient returned to the doctor, it was found that there were ground glass nodules in the upper lobe of the left lung, about 18 mm * 9 mm, indicating the recurrence of the primary cancer. The patient refused a second surgical treatment. The symptoms were fatigue, pale tongue, white fur, and weak pulse. TCM syndrome is Qi and blood deficiency, the treatment principle is tonifying Qi and blood, attacking evil, and removing blood stasis. The Chinese medicine prescription is as follows: Shashen (Adenophora stricta) 20 g, Baihe (Lilium brownii) 20 g, Dangshen (Codonopsis pilosula) 20 g, Chuanbeimu (Sichuan fritillary bulb) 15 g, Baihuasheshecao (Hedyotis diffusa Willd) 15 g, Jiegeng (Platycodon grandiflorus) 20 g, Maidong (Ophiopogon japonicus) 20 g, Sangbaipi (Mulberry root bark) 15 g, Shudi (Rehmannia glutinosa) 10 g, Danggui (Chinese angelica) 8 g, Fuling (Poria cocos) 20 g, Guiban (tortoiseshell) 8 g, Biejia (Carapax trionycis) 8 g, Gouqizi (Lycium chinense) 15 g, Niuxi (radix achyranthis bidentatae) 15 g, Muli (Concha Ostreae) 20 g. One dose per day, totaling 180 mL, twice a day in the morning and evening, half an hour after meals, lasting 1.5 months.\n\nTreatment outcomes\nAfter that, the patient took Chinese medicine and had a semiannual physical examination. In January 2024, The CT examination revealed a recurrent tumor shrinkage of about 7 × 9 mm, which was undoubtedly amazing. Blood routine examination was normal, liver and kidney function was normal. The patient had no signs of fatigue or wasting, and diet, bowel movements and sleep were normal. It shows that the treatment plan of traditional Chinese medicine is correct and the medication is symptomatic.\n\nFrom 2021 to 2024, the patient underwent a follow-up examination of the lung tissue, and CT showed that the size of the lung masses changed, indicating that the lung tumors became significantly smaller during treatment after lung CT examination. The level of carcino-embryonic antigen tends to be normal. For this patient, the lung cancer recurred after surgery and could not tolerate another operation, so she sought Chinese medicine treatment. And achieved the expected desired efficacy. Before TCM treatment, the CT showed that dense shadows and cord foci could be seen in the hilar area of the lung. Ground glass nodules were observed in the upper lobe of the left lung. There are small nodules in both lungs and multiple small lymph nodes in the mediastinum. After treatment, the image showed that the lung texture became clearer and the nodules shrinked. Calcification shadow and cord foci lessened or even disappeared. The author believes that this treatment plan is worth promoting.", + "fulltext_subclaims": [ + "The patient is a 57-year-old female.", + "Lung tumors were found in September 2021 during the examination at The First Affiliated Hospital of Dalian Medical University.", + "The chief complaint was chest pain and fatigue for half a year.", + "The patient was admitted to the hospital on the grounds of 'lung shadow.'", + "The patient’s mental state is good.", + "The patient’s appetite is reasonable.", + "The patient’s sleep is good.", + "The patient’s weight has no significant change.", + "Based on MSCT plain scan of the chest, partial solid nodules appeared in the posterior segment of the upper lobe of the patient’s right lung (21 mm * 13 mm).", + "The nodules showed signs of lobulation, burrs, pleural indentation, and vacuole.", + "Multiple small nodules were present in both lungs.", + "Blood test showed neutrophils↑.", + "Blood test showed lymphocytes↓.", + "The patient underwent surgical treatment and part of lung tissue was removed.", + "Pathology revealed invasive adenocarcinoma in the upper lobe of the right lung.", + "No metastasis was found in the parbronchial lymph nodes.", + "In November 2022, ground glass nodules were found in the upper lobe of the left lung, about 18 mm * 9 mm.", + "The patient refused a second surgical treatment.", + "The symptoms were fatigue, pale tongue, white fur, and weak pulse.", + "The TCM syndrome was diagnosed as Qi and blood deficiency.", + "The treatment principle was tonifying Qi and blood, attacking evil, and removing blood stasis.", + "The Chinese medicine prescription included Shashen (Adenophora stricta) 20 g.", + "The Chinese medicine prescription included Baihe (Lilium brownii) 20 g.", + "The Chinese medicine prescription included Dangshen (Codonopsis pilosula) 20 g.", + "The Chinese medicine prescription included Chuanbeimu (Sichuan fritillary bulb) 15 g.", + "The Chinese medicine prescription included Baihuasheshecao (Hedyotis diffusa Willd) 15 g.", + "The Chinese medicine prescription included Jiegeng (Platycodon grandiflorus) 20 g.", + "The Chinese medicine prescription included Maidong (Ophiopogon japonicus) 20 g.", + "The Chinese medicine prescription included Sangbaipi (Mulberry root bark) 15 g.", + "The Chinese medicine prescription included Shudi (Rehmannia glutinosa) 10 g.", + "The Chinese medicine prescription included Danggui (Chinese angelica) 8 g.", + "The Chinese medicine prescription included Fuling (Poria cocos) 20 g.", + "The Chinese medicine prescription included Guiban (tortoiseshell) 8 g.", + "The Chinese medicine prescription included Biejia (Carapax trionycis) 8 g.", + "The Chinese medicine prescription included Gouqizi (Lycium chinense) 15 g.", + "The Chinese medicine prescription included Niuxi (radix achyranthis bidentatae) 15 g.", + "The Chinese medicine prescription included Muli (Concha Ostreae) 20 g.", + "The prescription was taken one dose per day, totaling 180 mL, twice a day in the morning and evening.", + "The medication was taken half an hour after meals.", + "The medication was taken for 1.5 months.", + "In January 2024, CT examination revealed a recurrent tumor shrinkage of about 7 × 9 mm.", + "Blood routine examination was normal.", + "Liver and kidney function was normal.", + "The patient had no signs of fatigue or wasting.", + "The patient’s diet, bowel movements, and sleep were normal.", + "The treatment plan of traditional Chinese medicine is correct and the medication is symptomatic.", + "From 2021 to 2024, the patient underwent follow-up examination of the lung tissue.", + "CT showed that the size of the lung masses changed.", + "The lung tumors became significantly smaller during treatment after lung CT examination.", + "The level of carcino-embryonic antigen tends to be normal.", + "The lung cancer recurred after surgery.", + "The patient could not tolerate another operation.", + "The patient sought Chinese medicine treatment.", + "The treatment achieved the expected desired efficacy.", + "Before TCM treatment, CT showed dense shadows and cord foci in the hilar area of the lung.", + "Ground glass nodules were observed in the upper lobe of the left lung.", + "There were small nodules in both lungs.", + "There were multiple small lymph nodes in the mediastinum.", + "After treatment, the image showed that the lung texture became clearer.", + "The nodules shrank.", + "Calcification shadow and cord foci lessened or even disappeared.", + "The author believes that this treatment plan is worth promoting." + ], + "summary": "Patient concerns: Patients with lung tumors, which had been surgically removed in the past. This time, the tumor occurred again, and the patient could not tolerate another surgical treatment. Other targeted treatments are not available due to financial and body constraints.\n\nDiagnoses: The case was diagnosed as invasive adenocarcinoma of the upper lobe of the right lung.\n\nInterventions: The patient received early surgical treatment, and then changed to traditional Chinese medicine (TCM) decoction treatment. The treatment principle of Chinese medicine is mainly to tonify healthy Qi and blood, enhancing the immunity of the body.\n\nOutcomes: After nearly 2 years of TCM decoction treatment, the recurrent tumor has shrunk significantly. No discomfort such as fatigue, fever or weight loss. During this period, the patient did not receive western medical treatment such as surgery and chemotherapy, which did not affect normal life. It also proves that Chinese medicine is effective.", + "summary_subclaims": [ + "The patient had lung tumors surgically removed in the past.", + "The tumor occurred again.", + "The patient could not tolerate another surgical treatment.", + "Other targeted treatments are not available due to financial and body constraints.", + "The case was diagnosed as invasive adenocarcinoma of the upper lobe of the right lung.", + "The patient received early surgical treatment.", + "The patient changed to traditional Chinese medicine (TCM) decoction treatment.", + "The treatment principle of Chinese medicine is mainly to tonify healthy Qi and blood.", + "The treatment principle of Chinese medicine is to enhance the immunity of the body.", + "After nearly 2 years of TCM decoction treatment, the recurrent tumor has shrunk significantly.", + "The patient did not experience fatigue.", + "The patient did not experience fever.", + "The patient did not experience weight loss.", + "During this period, the patient did not receive western medical treatment such as surgery and chemotherapy.", + "It did not affect normal life.", + "It also proves that Chinese medicine is effective." + ] + }, + { + "id": "multiclinsum_test_115_en.txt", + "fulltext": "A 26-day-old boy was referred from a peripheral hospital with a right-sided incarcerated congenital inguinal hernia. The referring pediatrician told his father that he has a palpable testis in his right inguinal canal but no palpable testis on the left side. Apart from a clinically evident right irreducible hernia and empty both hemiscrota, the rest of the examination was unremarkable. After initial resuscitation with intravenous fluids and antibiotics, an urgent operation was undertaken. On inguinal exploration, the hernia sac was found to contain a viable cecum and small bowel loops. After reduction of the contents to the peritoneal cavity, the right testis was found in the inguinal canal. However, a second testis was unexpectedly delivered through the deep inguinal ring. Both testes have independent spermatic cords, i.e. two separate sets of vas deferens and testicular vessels on either side of a T- shaped structure resembling an infantile uterus and fallopian tube . Because of the shortness of the spermatic cord and the vague nature of this anomaly for the operating surgeon, only a biopsy was taken from both testes and all the structures were returned back to the peritoneal cavity followed by herniotomy.\nPostoperative pathology showed normal testicular tissue bilaterally with absent ovarian structures. Karyotyping was done for the patient and revealed a normal 46XY male karyotype. Diagnostic laparoscopy was performed at the age of 6 months, which showed a closed left internal ring on the left side and a widely open internal ring on the right side. In addition, the left sided testis and spermatic cord were found joining their counterparts on the right side through the rudimentary uterus close to the right internal ring. The rudimentary uterus as well as the fallopian tubes were partially excised. Peritoneal dissection was made to gain extra length for both spermatic cords. Orchiopexy was done, with each testis fixed into its corresponding hemiscrotum. The patient had an uneventful recovery. Throughout the 6-month follow-up period, the size and the blood flow of both testes were normal as evaluated by Doppler ultrasound.", + "fulltext_subclaims": [ + "A 26-day-old boy was referred with a right-sided incarcerated congenital inguinal hernia.", + "The referring pediatrician told his father that he has a palpable testis in his right inguinal canal.", + "The referring pediatrician told his father that he has no palpable testis on the left side.", + "The rest of the examination was unremarkable.", + "An urgent operation was undertaken.", + "On inguinal exploration, the hernia sac was found to contain a viable cecum and small bowel loops.", + "After reduction of the contents to the peritoneal cavity, the right testis was found in the inguinal canal.", + "A second testis was unexpectedly delivered through the deep inguinal ring.", + "Both testes have independent spermatic cords.", + "Both testes have two separate sets of vas deferens and testicular vessels on either side of a T-shaped structure resembling an infantile uterus and fallopian tube.", + "Only a biopsy was taken from both testes.", + "All the structures were returned back to the peritoneal cavity followed by herniotomy.", + "Postoperative pathology showed normal testicular tissue bilaterally.", + "Postoperative pathology showed absent ovarian structures.", + "Karyotyping was done for the patient.", + "Karyotyping revealed a normal 46XY male karyotype.", + "Diagnostic laparoscopy was performed at the age of 6 months.", + "Diagnostic laparoscopy showed a closed left internal ring on the left side.", + "Diagnostic laparoscopy showed a widely open internal ring on the right side.", + "The left sided testis and spermatic cord were found joining their counterparts on the right side through the rudimentary uterus close to the right internal ring.", + "The rudimentary uterus as well as the fallopian tubes were partially excised.", + "Peritoneal dissection was made to gain extra length for both spermatic cords.", + "Orchiopexy was done.", + "Each testis was fixed into its corresponding hemiscrotum.", + "The patient had an uneventful recovery.", + "Throughout the 6-month follow-up period, the size and the blood flow of both testes were normal as evaluated by Doppler ultrasound." + ], + "summary": "We present a case of TTE accompanied by persistent Müllerian duct structures (PMDS) that had been discovered incidentally during inguinal exploration of a 26-day-old boy who presented with an incarcerated congenital inguinal hernia on the right side and left cryptochidism on the left side. The pathogenesis, approach and proposed management of TTE are discussed.", + "summary_subclaims": [ + "We present a case of TTE accompanied by persistent Müllerian duct structures (PMDS).", + "The case was discovered incidentally during inguinal exploration of a 26-day-old boy.", + "The boy presented with an incarcerated congenital inguinal hernia on the right side.", + "The boy had left cryptochidism on the left side.", + "The pathogenesis, approach and proposed management of TTE are discussed." + ] + }, + { + "id": "multiclinsum_test_1360_en.txt", + "fulltext": "A 61-year-old male with a history of recurrent falls and a previous left proximal humerus ORIF procedure in January 2022 following a fall on December 26, 2021, presented to an external hospital in June 2023 after experiencing a ground-level fall. On arrival, the patient was unable to raise his left arm due to severe pain. He was promptly splinted and referred for a higher level of care. The patient underwent an evaluation 3 days later, and radiographs were taken, revealing a peri-implant fracture located below the previously implanted plate at the level of the proximal humerus .\nOn clinical examination, the patient remained incapable of actively using his arm. However, he exhibited intact neurovascular function, showed no signs of infection, and displayed well-healed wound sites from the previous ORIF procedure. The patient’s pertinent medical history includes being HIV-positive, actively receiving antiretroviral therapy, former tobacco use, and reportedly abstaining from alcohol consumption for the past 2 years.\nThe patient was thoroughly informed about the available treatment options, associated risks, and benefits. He expressed a preference for wide-awake local anesthesia surgery over non-operative management and GA. The patient desired surgery but wished to avoid hospital admission, thus opting for wide-awake local anesthesia to prevent the need for GA. The patient admittedly also wanted a more affordable surgery. The patient was consented and booked for surgery.\nWide Awake Local Anesthesia Humerus Technique.\nThe patient was positioned supine with their arm well-supported, and manipulation was avoided until the patient received adequate anesthetic. First, to manage pain, 15 mg of ketorolac was initially administered intramuscularly. Next, the surgical assistant prepared the local anesthetic solution by combining 25 mL of lidocaine with adrenaline and 10 ml of bicarbonate, diluting the mixture to 200 mL with normal saline. The solution was then gently administered systematically, with an initial entry point in the upper arm anteriorly, followed by circumferential injections around the upper arm, along the planned anterolateral incision line (taking into account any previous scars), and into deep subcutaneous tissues approximately 8–10 cm above and below the fracture site. The periosteum and bone around the fracture site and incision line were also adequately anesthetized. The surgeon waited for 20 min between the initial injection and the first incision to allow the local anesthetic sufficient time to take effect. During the initial incision, the patient was monitored by asking for feedback, and they reported not feeling the incision. The patient’s comfort and anesthesia adequacy were actively monitored throughout the procedure, with additional local anesthetic administered as needed.\nAn incision was made through the patient’s previous scar. Meticulously, the soft-tissue envelope was exposed and retracted until the plate and fracture were adequately visualized. The previous plate and hardware were then removed, and the fracture was reduced using a new plate and screws. Since no intraoperative imaging is presently available at the hospital, the reduction and internal fixation were carried out solely under direct visualization, depending on the expertise of the surgeon.\nThe incision was then closed, and the patient’s neurovascular status was assessed by having the patient flex and extend his elbow as well as his wrist and digits. The total duration of the procedure was 85 min though from incision to close was only 65 min accounting for the 20-min window for the anesthetic to take effect. The patient received appropriate care and instructions postoperatively, ensuring a successful and pain-free surgical experience. The patient followed up in the clinic 4 weeks later, having no issues with a well-healed wound . Radiographs were also obtained at that time . The patient was instructed to begin physical therapy at that time. The patient was seen in the clinic at 8 weeks and 12 weeks postoperatively and was once again found to have no issues, he was progressing appropriately with his physical therapy.", + "fulltext_subclaims": [ + "The patient is a 61-year-old male.", + "The patient has a history of recurrent falls.", + "The patient had a previous left proximal humerus ORIF procedure in January 2022.", + "The ORIF procedure was performed following a fall on December 26, 2021.", + "The patient presented to an external hospital in June 2023 after a ground-level fall.", + "On arrival, the patient was unable to raise his left arm due to severe pain.", + "The patient was promptly splinted.", + "The patient was referred for a higher level of care.", + "Radiographs revealed a peri-implant fracture located below the previously implanted plate.", + "The fracture was at the level of the proximal humerus.", + "The patient remained incapable of actively using his arm.", + "The patient exhibited intact neurovascular function.", + "The patient showed no signs of infection.", + "The patient’s wound sites from the previous ORIF procedure were well-healed.", + "The patient is HIV-positive.", + "The patient is actively receiving antiretroviral therapy.", + "The patient is a former tobacco user.", + "The patient reported abstaining from alcohol consumption for the past 2 years.", + "The patient was informed about the available treatment options.", + "The patient expressed a preference for wide-awake local anesthesia surgery.", + "The patient opted for wide-awake local anesthesia over non-operative management and GA.", + "The patient desired surgery but wished to avoid hospital admission.", + "The patient opted for wide-awake local anesthesia to prevent the need for GA.", + "The patient admitted to wanting a more affordable surgery.", + "The patient was consented and booked for surgery.", + "The Wide Awake Local Anesthesia Humerus Technique was used.", + "The patient was positioned supine with their arm well-supported.", + "15 mg of ketorolac was initially administered intramuscularly.", + "The surgical assistant prepared the local anesthetic solution by combining 25 mL of lidocaine with adrenaline and 10 ml of bicarbonate.", + "The solution was diluted to 200 mL with normal saline.", + "The solution was administered systematically.", + "The initial entry point was in the upper arm anteriorly.", + "Circumferential injections were made around the upper arm.", + "Injections were made along the planned anterolateral incision line.", + "Injections were made into deep subcutaneous tissues approximately 8–10 cm above and below the fracture site.", + "The periosteum and bone around the fracture site and incision line were adequately anesthetized.", + "The surgeon waited for 20 min between the initial injection and the first incision.", + "During the initial incision, the patient was monitored by asking for feedback.", + "The patient reported not feeling the incision.", + "The patient’s comfort and anesthesia adequacy were actively monitored throughout the procedure.", + "Additional local anesthetic was administered as needed.", + "An incision was made through the patient’s previous scar.", + "The soft-tissue envelope was exposed and retracted until the plate and fracture were adequately visualized.", + "The previous plate and hardware were removed.", + "The fracture was reduced using a new plate and screws.", + "The reduction and internal fixation were carried out solely under direct visualization.", + "The incision was closed.", + "The patient’s neurovascular status was assessed by having the patient flex and extend his elbow, wrist, and digits.", + "The total duration of the procedure was 85 min.", + "The duration from incision to close was 65 min.", + "The 20-min window for the anesthetic to take effect was accounted for.", + "The patient received appropriate care and instructions postoperatively.", + "The patient had a successful and pain-free surgical experience.", + "The patient followed up in the clinic 4 weeks later.", + "The patient had no issues at the 4-week follow-up.", + "The patient’s wound was well-healed at the 4-week follow-up.", + "Radiographs were obtained at the 4-week follow-up.", + "The patient was instructed to begin physical therapy at the 4-week follow-up.", + "The patient was seen in the clinic at 8 weeks postoperatively.", + "The patient was found to have no issues at the 8-week follow-up.", + "The patient was progressing appropriately with physical therapy at the 8-week follow-up.", + "The patient was seen in the clinic at 12 weeks postoperatively.", + "The patient was found to have no issues at the 12-week follow-up.", + "The patient was progressing appropriately with physical therapy at the 12-week follow-up." + ], + "summary": "The subject of this study is a 61-year-old HIV-positive male with a history of recurrent falls, seeking treatment for a peri-implant proximal humerus fracture. Electing the wide-awake local anesthesia option due to financial constraints, the patient underwent a successful surgery. The technique employed involved precise administration of local anesthetic, facilitating fracture reduction, and plate replacement. Notably, the emphasis was placed on active patient participation during intraoperative assessment.", + "summary_subclaims": [ + "The subject of this study is a 61-year-old HIV-positive male.", + "The patient has a history of recurrent falls.", + "The patient sought treatment for a peri-implant proximal humerus fracture.", + "The patient elected the wide-awake local anesthesia option due to financial constraints.", + "The patient underwent a successful surgery.", + "The technique employed involved precise administration of local anesthetic.", + "The technique facilitated fracture reduction.", + "The technique included plate replacement.", + "The emphasis was placed on active patient participation during intraoperative assessment." + ] + }, + { + "id": "multiclinsum_test_834_en.txt", + "fulltext": "A 46-year-old man with no remarkable past medical history was brought to the emergency department of the University Clinical Hospital in Wrocław. As reported by the emergency medical service physician, the man was found lying under a park bench. He was obtunded, reported nausea and vomiting, but denied any chest pain. The physician noted anisocoria (left > right).\nThe initial electrocardiogram (ECG) recorded at 04:04 PM showed sinus bradycardia with a rate of 55 beats per minute (bpm), first degree atrioventricular block, widened QRS complexes, and ST elevation in leads II, III, aVF, and V3–V6 . Suspicion of an acute coronary syndrome (ACS) was raised. Within 5 min, ventricular tachycardia developed , followed by torsade de pointes with a rate of 150 bpm . At 04:28 PM, cardiac arrest due to bradycardia/asystole occurred. Sinus rhythm returned after a short application of external cardiac massage. While the patient was in the emergency department, basic and advanced life support was initiated several times (with 1 mg adrenalin injection three times) due to cardiac arrest caused by bradycardia and asystole. Intravenous dopamine infusion was started and access to the right jugular vein was obtained. Emergency coronary angiography showed no significant coronary lesions. A consulting neurologist ordered computed tomography of the brain which also showed no significant abnormalities.\nAbnormal laboratory test results included elevated levels of dimer D (1.19 μg/mL), gamma-glutamyl transpeptidase (119 U/L), aspartate transaminase (238 U/L), alanine transaminase (172 U/L), urea (68 mg/dL), creatinine (1.40 mg/dL), plasma glucose (323 mg/dL), and hypokalemia (3.3 mmol/L). Troponin I level was normal. Arterial blood gases showed metabolic acidosis.\nOn admission to the Intensive Cardiac Care Unit, the patient was severely ill, sedated with midazolam and fentanyl, intubated, ventilated, and treated with intravenous dopamine infusion. Bedside echocardiography showed dilated vena cava inferior (28 mm) without respiratory variability, paradoxical interventricular septal motion (D-sign), and impaired left ventricular systolic function with an ejection fraction of 40 %. Pulmonary embolism was suspected and pulmonary computed angiotomography was performed which showed no evidence of embolism.\nAt 11:05 PM, cardiac arrest due to pulseless electrical activity occurred and resuscitation was started immediately. ECG showed recurrent torsade de pointes, requiring several defibrillations and administration of magnesium and antiarrhythmic drugs, and periods of bradycardia. The overall duration of resuscitation attempts was 1.5 h. The patient was treated with intravenous dopamine (200 μg/50 mL 0.9 % NaCl, rate 15 mL/h), norepinephrine (8 mg/50 mL 0.9 % NaCl, rate 30 mL/h), and dobutamine (250 μg/50 mL 0.9 % NaCl, rate 5 mL/h) infusions and adrenaline in boluses (6 × 1 mg during resuscitation) followed by infusion (2 mg/50 mL 0.9 % NaCl, rate 10 mL/h) beginning at 02:30 AM. The patient also received amiodarone, lidocaine, bicarbonates, and intravenous fluids (1000 mL 0.9 % NaCl, yielding 2700 mL of urine). Due to ineffective antiarrhythmic drug therapy and bradycardia, a transvenous pacing lead was inserted, allowing effective pacing and resolution of shock.\nDespite treatment with amiodarone, magnesium, and lidocaine, correction of electrolyte disturbance, and several dozens of defibrillation attempts, the arrhythmia underlying cardiac arrest persisted. Only after overdrive pacing was established using a transvenous pacing lead could arrhythmia be controlled and the patient’s condition stabilized.\nAs the underlying cause of the patient’s clinical condition remained unknown, the patient’s family was contacted. The family reported that 2–3 weeks before admission to the Department of Cardiology, the patient was consulted by a psychiatrist due to a suspected suicide attempt. He had numerous financial debts resulting from his addiction to internet gambling. The toxicology screen and serum digoxin assay on admission were negative. The family was asked to search for any toxic substances among the patient’s personal belongings at home and work. A decoction of unknown origin was found in the patient’s work locker and his mobile phone’s internet history included websites discussing toxic plants, including yew (Taxus baccata). Due to a suspicion of Taxus baccata intoxication (bradycardia leading to asystole, vomiting, orange-pink color of urine), the decoction and patient’s blood sample were sent to the Department of Pharmaceutical Biology and Botany for biochemical analysis.\nFresh leaves (needles) (20 g) of T. baccata were harvested from two different locations. The first sample was from the vicinity of where the suicide attempt took place (yew1) and the second one was from the certified collection of the Wroclaw Medical University Botanical Garden where T. baccata is cultivated (yew2). The voucher specimens of the two plant samples are stored in the herbarium of the Botanical Garden.\nAll material was ultra-sonicated (IS-36 ultrasonic bath, Intersonic, Poland) in 200 mL of ethanol (analytical grade, 95 %) for 30 min and soaked for 16 h overnight. The crude extract was filtered, the solvent evaporated, and the residue was reconstituted with 80 mL 1 N HCl and extracted with 80 mL dichloromethane. The aqueous phase was alkalized with ammonia solution (25 %) and extracted with 240 mL dichloromethane (3 × 80 mL). The organic phases were pooled and the solvent evaporated, yielding 80 mg of a white residue (0.4 % of the fresh mass of yew leaves). A methanolic solution of this residue was diluted with mobile phases A and B (50:50, v/v) for further analysis.\nTwo mL of the patient’s blood serum sample obtained from the coronary care unit were precipitated by adding 2 mL of acetonitrile, followed by centrifugation at 6000 g for 7 min. The supernatant was then purified by the solid phase extraction method using octadecyl silica bed cartridges (Supelco, USA). All analyzed samples were filtered with a 0.45 μm membrane filter (PTFE, Carl Roth, Germany) before injection into the ultra fast liquid chromatography (UFLC) system.\nThe UFLC system consisted of an LC-30ADXR pump, a DGU-20A3 degasser, a SIL-20AXR autosampler, a CTO-10ASVP column heater, and a CBM-20A system controller (Shimadzu Ltd. Japan). Chromatographic separations were performed on a Kinetex C18 100A column (2.1 mm × 100 mm, 2.6 μ) with a security guard column (Phenomenex, U.S.A.).\nThe mobile phase was composed of acetonitrile-water with 0.1 % (v/v) formic acid. A gradient program was employed with the mobile phase, combining solvent A (water) and solvent B (acetonitrile) with 0.1 % formic acid as follows: 80 % A (0–0.5 min), 80–40 % A (0.5–7 min), 40–20 % A (7–12 min), 20–5 % A (12–15 min), 5–0 % A (15–16 min), 0 % A (16–17 min), 0–80 % A (17–18 min), 80 % A (18–22 min).\nThe flow rate was 0.3 mL/min and the injection volume was 1 μL. The column and sample temperatures were maintained at 35 and 4 °C, respectively. All data acquisition and peak integration were performed using LabSolution (5.53 SP2) from Shimadzu Ltd.\nMass spectrometric detection was performed on a Shimadzu LCMS-8030 with an electrospray ionization (ESI). The analytes were determined in the positive ionization mode and quantified by multiple-reaction monitoring (MRM) mode. The parameters and conditions were optimized as follows: capillary voltage of 4.5 kV, desolvation line (DL) temperature of 250 °C, heat block temperature of 400 °C, and nebulizing gas flow and drying gas flow of 3 L/min and 15 L/min, respectively.\nQualitative confirmation was achieved using UFLC MS/MS analysis with MRM . The obtained spectra were compared to the literature data [, ].\nThe main substance of taxine origin identified in the blood sample (serum) was 3,5-DMP, the aglycone of taxicatine (3,5-dimethoxyphenol glucoside), which is an ingredient of yew leaves. This compound was suggested by Musshof et al. as a convenient marker of poisoning with Taxus baccata leaves. We observed this compound in both yew1 and yew2 samples. Other toxins including taxine A, 2-deacetyltaxine, monoacetyltaxin, taxine B (isotaxine B), monohydroxydiacetyltaxine, triacetyltaxin, and monohydroxytriacetyltaxine were also detected. We did not detect paclitaxel (Taxol A), deacetyltaxol, 10-(DAT), deacetylbaccatin III 10-(DAB) in any of the analyzed samples. These compounds are frequently listed as yew constituents. However, they may not have been extracted from our plant material with the method used.\nNonetheless, the liquid chromatography tandem mass spectrometry (LC-MS/MS) method was useful for fast and reliable detection of yew toxin residues in the blood sample.\nThe main taxine ingredients are presented in Table .", + "fulltext_subclaims": [ + "The patient was a 46-year-old man with no remarkable past medical history.", + "The man was found lying under a park bench.", + "The emergency medical service physician reported that the man was obtunded.", + "The physician noted anisocoria (left > right).", + "The initial ECG showed sinus bradycardia with a rate of 55 bpm.", + "The ECG showed first degree atrioventricular block.", + "The ECG showed widened QRS complexes.", + "The ECG showed ST elevation in leads II, III, aVF, and V3–V6.", + "Suspicion of an acute coronary syndrome was raised.", + "Ventricular tachycardia developed within 5 min.", + "Torsade de pointes with a rate of 150 bpm occurred.", + "At 04:28 PM, cardiac arrest due to bradycardia/asystole occurred.", + "Sinus rhythm returned after a short application of external cardiac massage.", + "Basic and advanced life support was initiated several times due to cardiac arrest.", + "Intravenous dopamine infusion was started.", + "Access to the right jugular vein was obtained.", + "Emergency coronary angiography showed no significant coronary lesions.", + "Computed tomography of the brain showed no significant abnormalities.", + "D-dimer level was 1.19 μg/mL.", + "Gamma-glutamyl transpeptidase level was 119 U/L.", + "Aspartate transaminase level was 238 U/L.", + "Alanine transaminase level was 172 U/L.", + "Urea level was 68 mg/dL.", + "Creatinine level was 1.40 mg/dL.", + "Plasma glucose level was 323 mg/dL.", + "Potassium level was 3.3 mmol/L.", + "Troponin I level was normal.", + "Arterial blood gases showed metabolic acidosis.", + "The patient was intubated and ventilated.", + "Bedside echocardiography showed dilated vena cava inferior (28 mm) without respiratory variability.", + "Bedside echocardiography showed paradoxical interventricular septal motion (D-sign).", + "Left ventricular ejection fraction was 40%.", + "Pulmonary computed angiotomography showed no evidence of embolism.", + "At 11:05 PM, cardiac arrest due to pulseless electrical activity occurred.", + "ECG showed recurrent torsade de pointes.", + "The patient received intravenous dopamine, norepinephrine, and dobutamine infusions.", + "The patient received adrenaline boluses (6 × 1 mg) during resuscitation.", + "The patient received amiodarone, lidocaine, bicarbonates, and intravenous fluids.", + "A transvenous pacing lead was inserted.", + "Overdrive pacing using a transvenous pacing lead controlled the arrhythmia.", + "The patient’s family reported a suspected suicide attempt 2–3 weeks before admission.", + "The toxicology screen on admission was negative.", + "A decoction of unknown origin was found in the patient’s work locker.", + "The patient’s mobile phone history included websites discussing toxic plants, including yew.", + "A suspicion of Taxus baccata intoxication was raised.", + "The decoction and blood sample were sent for biochemical analysis.", + "Fresh leaves of T. baccata were harvested from two locations.", + "The voucher specimens of the two plant samples are stored in the herbarium.", + "The leaves were ultra-sonicated in ethanol for 30 min.", + "The crude extract was filtered and the solvent evaporated.", + "The residue was reconstituted with 1 N HCl and extracted with dichloromethane.", + "The aqueous phase was alkalized with ammonia solution and extracted with dichloromethane.", + "The organic phases were pooled and the solvent evaporated.", + "The patient’s blood serum was precipitated with acetonitrile.", + "The supernatant was purified by solid phase extraction.", + "The UFLC system used an LC-30ADXR pump, DGU-20A3 degasser, and other components.", + "Chromatographic separations were performed on a Kinetex C18 100A column.", + "The mobile phase was composed of acetonitrile-water with 0.1% formic acid.", + "A gradient program was employed with the mobile phase.", + "The flow rate was 0.3 mL/min and the injection volume was 1 μL.", + "Mass spectrometric detection was performed on a Shimadzu LCMS-8030 with ESI.", + "The analytes were determined in the positive ionization mode.", + "The main substance identified in the blood sample was 3,5-DMP.", + "3,5-DMP is the aglycone of taxicatine.", + "3,5-DMP was observed in both yew1 and yew2 samples.", + "Taxine A, 2-deacetyltaxine, and other toxins were detected.", + "Paclitaxel, deacetyltaxol, and other compounds were not detected.", + "The LC-MS/MS method was useful for detecting yew toxin residues." + ], + "summary": "In this report we describe a suicide case study and an ad hoc developed fast method of detection and quantitation of 3,5-dimethoxyphenol - the main taxane metabolite in the blood plasma from the patient as well as the determination of major taxine components in the plant material (Taxus baccata). At present, there is no reasonable alternative for mass spectrometry that could match its high sensitivity and accuracy, and Multiple Reaction Monitoring could be adequate and useful mass spectrometry technique in analyzing and identification of plants material compounds that cause severe poisoning in humans. In the reported case, intensive cardiac care together with the astuteness of the treating physicians not only saved the patient's life, but also allowed for his complete recovery and return to work.", + "summary_subclaims": [ + "This report describes a suicide case study.", + "An ad hoc developed fast method of detection and quantitation of 3,5-dimethoxyphenol was used.", + "3,5-dimethoxyphenol is the main taxane metabolite.", + "The method was used in the blood plasma from the patient.", + "The determination of major taxine components in the plant material (Taxus baccata) was performed.", + "There is no reasonable alternative for mass spectrometry that could match its high sensitivity and accuracy.", + "Multiple Reaction Monitoring could be adequate and useful mass spectrometry technique.", + "Multiple Reaction Monitoring is used in analyzing and identification of plant material compounds.", + "Plant material compounds can cause severe poisoning in humans.", + "Intensive cardiac care was provided in the reported case.", + "The astuteness of the treating physicians saved the patient's life.", + "The patient's complete recovery and return to work were achieved." + ] + }, + { + "id": "multiclinsum_test_478_en.txt", + "fulltext": "We present the case of an 84 years old male presenting with dyspnea (NYHA III) and fatigue, hypotension (88/50 mmHg), tachycardia (97 bpm), and fever (38.4 °Celsius) to our emergency department fulfilling 2 of 4 criteria for SIRS . Clinical examination was significant for discrete bibasal pulmonary rales and a 2/6 systolic murmur, in agreement with a preexisting, moderate mitral valve insufficiency. Initial laboratory findings showed substantially elevated C-reactive protein (CRP) (84 mg/l) and serum creatinine (159 μmol/l).\nRecent medical history was significant for ST-elevation myocardial infarction (STEMI) 15 days prior to the current presentation with successful percutaneous coronary intervention and implantation of two drug eluting stents in the proximal right coronary artery. Other relevant comorbidities included pre-existing coronary artery disease, arterial hypertension and hypercholesterolemia. His current medication included aspirin, ticagrelor, nebivolol, olmesartan, rosuvastatin and pantoprazol, with ticagrelor initiated 15 days ago. He had no history of allergies.\nEmpirical antibiotic treatment with ceftriaxone was initiated in the emergency department due to suspected severe sepsis after blood and urine culture sampling. Extensive infectious disease work-up including blood cultures, a respiratory panel for the comprehensive detection of respiratory disease-causing viruses and bacteria, HIV testing, and imaging studies (CT-scan of the chest, abdominal ultrasound, transthoracic and transoesophageal echocardiography) did not reveal an infectious cause of SIRS.\nSymptoms (dyspnea and fatigue), signs (fever), and laboratory signs (CRP) of SIRS persisted despite 6 days of intravenous antibiotic treatment . Further, Dressler-Syndrome was considered as a differential diagnosis. However, lack of a pericardial rub, leukocytosis, pericardial effusion, or clinical and laboratory response to preemptive treatment with ibuprofen rendered it very unlikely.\nAfter broad, unrevealing diagnostic work-up ticagrelor was suspected as the causative agent of persistent SIRS due to recent initiation and no other change in drug treatment. Accordingly, ticagrelor was discontinued at day seven and replaced by clopidogrel. No other drug was changed during the hospital stay. This was followed by a rapid improvement in symptoms as well as clinical and laboratory signs of SIRS. In clinical follow-up 2 weeks and 1 year after discharge the patient remained asymptomatic and well.", + "fulltext_subclaims": [ + "The patient is an 84 years old male.", + "The patient presented with dyspnea (NYHA III).", + "The patient had hypotension (88/50 mmHg).", + "The patient had tachycardia (97 bpm).", + "The patient had fever (38.4 °Celsius).", + "The patient fulfilled 2 of 4 criteria for SIRS.", + "Clinical examination showed discrete bibasal pulmonary rales.", + "The patient had a 2/6 systolic murmur.", + "The patient had preexisting, moderate mitral valve insufficiency.", + "Initial laboratory findings showed elevated C-reactive protein (CRP) (84 mg/l).", + "Initial laboratory findings showed elevated serum creatinine (159 μmol/l).", + "The patient had a recent STEMI 15 days prior to the current presentation.", + "The patient had successful percutaneous coronary intervention.", + "The patient had implantation of two drug eluting stents in the proximal right coronary artery.", + "The patient's current medication included ticagrelor.", + "Ticagrelor was initiated 15 days ago.", + "Empirical antibiotic treatment with ceftriaxone was initiated in the emergency department.", + "Extensive infectious disease work-up did not reveal an infectious cause of SIRS.", + "Symptoms of SIRS persisted despite 6 days of intravenous antibiotic treatment.", + "Dressler-Syndrome was considered as a differential diagnosis.", + "Lack of a pericardial rub, leukocytosis, pericardial effusion, or clinical and laboratory response to ibuprofen rendered Dressler-Syndrome very unlikely.", + "Ticagrelor was suspected as the causative agent of persistent SIRS.", + "Ticagrelor was discontinued at day seven.", + "Ticagrelor was replaced by clopidogrel.", + "This was followed by a rapid improvement in symptoms.", + "This was followed by a rapid improvement in clinical and laboratory signs of SIRS.", + "In clinical follow-up 2 weeks after discharge the patient remained asymptomatic.", + "In clinical follow-up 1 year after discharge the patient remained well." + ], + "summary": "We report the case of an 84 years old patient presenting with SIRS subsequent to initiation of ticagrelor after implantation of two drug eluting stents. A broad diagnostic work-up for alternative causes and therapeutic measures were unrevealing. Discontinuation of the agent was followed by rapid improvement in clinical and laboratory signs of SIRS.", + "summary_subclaims": [ + "The patient was an 84 years old individual.", + "The patient presented with SIRS.", + "The SIRS occurred after initiation of ticagrelor.", + "Ticagrelor was started after implantation of two drug eluting stents.", + "A broad diagnostic work-up for alternative causes was unrevealing.", + "Therapeutic measures were unrevealing.", + "Discontinuation of ticagrelor was followed by rapid improvement in clinical signs of SIRS.", + "Discontinuation of ticagrelor was followed by rapid improvement in laboratory signs of SIRS." + ] + }, + { + "id": "multiclinsum_test_3180_en.txt", + "fulltext": "Female patient, 43 years old, with uterine diffuse large B-cell lymphoma, stage IIIB, undergoing hysterectomy followed by chemotherapy (QT) and radiotherapy (RT). As a background, she had a diagnosis of chronic renal disease in renal replacement therapy (TSR), due to bilateral ureterohydronephrosis by uterine primary disease. Pre-QT echocardiogram with concentric left ventricular hypertrophy (HVE) and preserved left ventricular ejection fraction (FEVE) (66%).\n\nThe patient underwent eight cycles of the R-CHOP (Rituximab, Cyclophosphamide, Doxorubicin, Vincristine) treatment schedule. Due to refractoriness to the primary treatment, she underwent rescue therapy with the R-ICE (Mesna, Ifosfamide, Etoposide, Carboplatin) schedule for four cycles, but she was intolerant to Carboplatin. The treatment was switched to GEMOX (Oxaliplatin, Gencitabine) and was completed after four cycles. She then underwent 28 sessions of RT and has not shown signs of oncological recurrence since then.\n\nTwo years after the start of the QT, she was admitted with a picture of heart failure (IC). A new echocardiogram showed a FEVE of 35%. Myocardial perfusion scintigraphy showed a reduction in the FEVE (37%) by gated SPECT and transient hypoperfusion in the apical and inferoseptal walls of the left ventricle (LV). A cineangiocoronariography did not show epicardial coronary artery disease.\n\nSince then, there have been four hospitalizations for decompensated HF, the last one a year ago. Cardiac MRI (CMR) showed a LVEF of 39% and non-ischaemic late enhancement in the inferior left wall of the LV.\n\nThe patient is currently stable on Carvedilol 25 mg/day, Losartan 100 mg/day and Furosemide 40 mg/day. The diagnosis of cardiotoxicity (CTX) was considered the most likely etiology of the HF with reduced LVEF (HFrEF).\n\nEvolution of Cardiological Imaging Exams\nDue to the evolution of the case, the cardiac imaging exams were allocated chronologically, for a better understanding. A decrease in the LVEF was observed in the echocardiogram performed at the time of the diagnosis of HF. This LVEF had a recovery in 2019, with new decreases in the following echocardiograms, as well as in the MUGA.\n\nIn a retrospective evaluation of myocardial uptake of fluorodeoxyglucose-fluorine-18 (18F-FDG) by positron emission tomography, coupled with computed tomography (PET/CT), an increase in uptake was observed from the first examination, performed after the initiation of QT. The standard uptake value (SUV) remained elevated in subsequent examinations, reaching its highest value in the last examination.\n", + "fulltext_subclaims": [ + "The patient is a 43-year-old woman.", + "She has uterine diffuse large B-cell lymphoma, stage IIIB.", + "She underwent a hysterectomy followed by chemotherapy and radiotherapy.", + "She had a diagnosis of chronic renal disease in renal replacement therapy.", + "The renal disease was due to bilateral ureterohydronephrosis by uterine primary disease.", + "A pre-chemotherapy echocardiogram showed concentric left ventricular hypertrophy.", + "The pre-chemotherapy echocardiogram showed a preserved left ventricular ejection fraction of 66%.", + "She received eight cycles of R-CHOP chemotherapy.", + "She underwent four cycles of R-ICE rescue therapy.", + "She was intolerant to Carboplatin.", + "She received four cycles of GEMOX chemotherapy.", + "She underwent 28 sessions of radiotherapy.", + "She has not shown signs of oncological recurrence.", + "Two years after the start of chemotherapy, she was admitted with heart failure.", + "A new echocardiogram showed a left ventricular ejection fraction of 35%.", + "Myocardial perfusion scintigraphy showed a reduction in the left ventricular ejection fraction to 37%.", + "Cineangiocoronariography did not show epicardial coronary artery disease.", + "She has had four hospitalizations for decompensated heart failure.", + "Cardiac MRI showed a left ventricular ejection fraction of 39%.", + "Cardiac MRI showed non-ischaemic late enhancement in the inferior left wall of the left ventricle.", + "The diagnosis of cardiotoxicity was considered the most likely etiology of the heart failure with reduced left ventricular ejection fraction.", + "A retrospective evaluation of myocardial uptake of 18F-FDG by PET/CT showed an increase in uptake from the first examination.", + "The standard uptake value remained elevated in subsequent PET/CT examinations.", + "The standard uptake value reached its highest value in the last PET/CT examination." + ], + "summary": "Female, 43 years old, with uterine lymphoma, underwent hysterectomy, three chemotherapy regimens (QT), successively, and radiotherapy. She presented episodes of acute heart failure two years after QT. An echocardiogram showed a reduction in the ejection fraction of the left ventricle (FEVE). A retrospective analysis of the 18F-FDG PET/CT observed an elevation of myocardial uptake in all examinations during oncological follow-up. Despite the oncological remission, the patient developed IC with reduced FEVE. During the QT, there was a diffuse and significant increase in myocardial uptake of 18F-FDG, which preceded the fall of cardiac performance, and seemed to reflect metabolic changes in cardiomyocytes related to CTX.\n", + "summary_subclaims": [ + "The patient is a 43-year-old woman with uterine lymphoma.", + "She underwent hysterectomy.", + "She received three chemotherapy regimens successively.", + "She received radiotherapy.", + "She presented episodes of acute heart failure two years after chemotherapy.", + "An echocardiogram showed a reduction in the ejection fraction of the left ventricle.", + "A retrospective analysis of the 18F-FDG PET/CT observed an elevation of myocardial uptake in all examinations during oncological follow-up.", + "The patient developed ischemic cardiomyopathy with reduced ejection fraction despite oncological remission.", + "During chemotherapy, there was a diffuse and significant increase in myocardial uptake of 18F-FDG.", + "The increase in myocardial uptake of 18F-FDG during chemotherapy preceded the fall of cardiac performance.", + "The increase in myocardial uptake of 18F-FDG during chemotherapy seemed to reflect metabolic changes in cardiomyocytes related to chemotherapy." + ] + }, + { + "id": "multiclinsum_test_2203_en.txt", + "fulltext": "We present a case of a 55-year-old Caucasian man with a past medical history significant for Chronic Lymphocytic Leukemia (CLL) and Melanoma, diagnosed in 2006 and 2008 respectively, who presented to our Cancer Center complaining of a one-day history of persistent fevers and chills. The patient was visiting from out of state and was concerned about a potential infection. He had completed his 4th cycle of chlorambucil (40 mg per square meter, given orally every 28 days) for his CLL two weeks prior. The patient was status post surgical excision for a stage IIIA melanoma discovered in the left axilla with no further adjuvant treatment. He was scheduled to travel extensively over the course of the proceeding month and requested an additional course of antibiotics.\nOn review of systems, he noted progressive fatigue and anorexia. He had started a prescription for levofloxacin prior to the clinic visit. The patient had no known drug allergies. The patient denied any tobacco or alcohol use. He was employed in an office setting. There was no pertinent family history. The patient had a temperature of 38 degrees Celsius. Physical exam was remarkable for an enlarged spleen, approximately 3 finger-breadths below the costal margin. Laboratory parameters revealed a white blood cell count of 21,500 (normal 4500-11,000/mm3), a hemoglobin of 10.8 g/dl (normal 11-15 g/dl), and a platelet count of 170,000 (normal 150,000-400,000/mm3). His absolute neutrophil count (ANC) was 430 (normal 1,500 to 8,000/mm3). Further a quantitative immunoglobulin panel was consistent with hypogammaglobulinemia: IgG level was 309 L (normal 562-1585 mg/dl), IgM 9.0 L (normal 30-246 mg/dl), and IgA was 10 L (normal 72-372 mg/dl).\nThe patient was subsequently admitted to our hospital for evaluation and treatment of febrile neutropenia. We elected to administer 30 grams of IVIG (0.4 g/kg) as a means of enhancing his immunity in the context of recent exposure to chemotherapy and his hypogammaglobulinemia. The patient had previously tolerated multiple infusions of IVIG without any adverse reactions. We premedicated the patient with acetaminophen, hydrocortisone, and benadryl. Approximately 12 hours following the IVIG infusion, the patient began to complain of headaches, shortness of breath with accompanying chest pain, and weakness of his bilateral upper and lower extremities.\nA complete cardiac and neurologic assessment was immediately initiated. The patient was found to have a myocardial infarction with a troponin elevation of 15.2 ng/ml and 13.3 ng/ml (normal 0.00-0.15 ng/ml) for the first two sets of his cardiac enzymes respectively, with a clearance of the enzymes by his third set. The EKG revealed ST-T wave changes consistent with myocardial ischemia in the inferior and anterolateral regions. An echocardiogram was consistent with a mural thrombus visualized in the left ventricular apex. There was mild global left ventricular hypokinesis, with inferior and inferolateral wall motion abnormalities consistent with myocardial infarction. In addition, an MRI of the brain delineated evolving cerebral infarcts seen within the left posterior MCA distribution , bilateral high parietal loops , and bilateral occipital lobes . There was no evidence of significant mass effect or hemorrhagic transformation.\nFurthermore, the patient began to experience a change in his mental status. A Neurology consult was obtained and the assessment attributed his waxing and waning consciousness to the continued watershed infarcts that were present. Nevertheless an EEG study was performed which delineated periodic lateralized epileptiform discharges consistent with seizure like activity. The patient was subsequently placed on intravenous levetiracetam with no improvement in his mental status. Shortly thereafter he had increasing respiratory requirements, and the decision was made to forgo intubation at the request of the family secondary to the patient's pre-determined request to never be placed on a ventilator.", + "fulltext_subclaims": [ + "The patient is a 55-year-old Caucasian man.", + "The patient has a past medical history of Chronic Lymphocytic Leukemia (CLL).", + "The patient has a past medical history of Melanoma.", + "The patient's CLL was diagnosed in 2006.", + "The patient's Melanoma was diagnosed in 2008.", + "The patient presented to the Cancer Center with a one-day history of persistent fevers and chills.", + "The patient was visiting from out of state.", + "The patient had completed his 4th cycle of chlorambucil two weeks prior.", + "The chlorambucil dose was 40 mg per square meter, given orally every 28 days.", + "The patient was status post surgical excision for a stage IIIA melanoma.", + "The melanoma was discovered in the left axilla.", + "The patient had no further adjuvant treatment for melanoma.", + "The patient had started a prescription for levofloxacin prior to the clinic visit.", + "The patient had no known drug allergies.", + "The patient had a temperature of 38 degrees Celsius.", + "The physical exam was remarkable for an enlarged spleen, approximately 3 finger-breadths below the costal margin.", + "The white blood cell count was 21,500 (normal 4500-11,000/mm3).", + "The hemoglobin was 10.8 g/dl (normal 11-15 g/dl).", + "The platelet count was 170,000 (normal 150,000-400,000/mm3).", + "The absolute neutrophil count (ANC) was 430 (normal 1,500 to 8,000/mm3).", + "The IgG level was 309 L (normal 562-1585 mg/dl).", + "The IgM level was 9.0 L (normal 30-246 mg/dl).", + "The IgA level was 10 L (normal 72-372 mg/dl).", + "The patient was admitted to the hospital for evaluation and treatment of febrile neutropenia.", + "The patient was administered 30 grams of IVIG (0.4 g/kg).", + "The IVIG was administered as a means of enhancing his immunity.", + "The patient had previously tolerated multiple infusions of IVIG without any adverse reactions.", + "The patient was premedicated with acetaminophen, hydrocortisone, and benadryl.", + "Approximately 12 hours following the IVIG infusion, the patient began to complain of headaches.", + "Approximately 12 hours following the IVIG infusion, the patient began to complain of shortness of breath.", + "Approximately 12 hours following the IVIG infusion, the patient began to complain of chest pain.", + "Approximately 12 hours following the IVIG infusion, the patient began to complain of weakness of his bilateral upper and lower extremities.", + "The patient was found to have a myocardial infarction.", + "The first troponin level was 15.2 ng/ml (normal 0.00-0.15 ng/ml).", + "The second troponin level was 13.3 ng/ml (normal 0.00-0.15 ng/ml).", + "The EKG revealed ST-T wave changes consistent with myocardial ischemia in the inferior and anterolateral regions.", + "An echocardiogram was consistent with a mural thrombus visualized in the left ventricular apex.", + "There was mild global left ventricular hypokinesis.", + "There were inferior and inferolateral wall motion abnormalities consistent with myocardial infarction.", + "An MRI of the brain delineated evolving cerebral infarcts seen within the left posterior MCA distribution.", + "An MRI of the brain delineated evolving cerebral infarcts seen within bilateral high parietal loops.", + "An MRI of the brain delineated evolving cerebral infarcts seen within bilateral occipital lobes.", + "There was no evidence of significant mass effect.", + "There was no evidence of hemorrhagic transformation.", + "The patient began to experience a change in his mental status.", + "A Neurology consult was obtained.", + "The Neurology consult attributed the waxing and waning consciousness to the continued watershed infarcts.", + "An EEG study was performed.", + "The EEG study delineated periodic lateralized epileptiform discharges consistent with seizure like activity.", + "The patient was placed on intravenous levetiracetam.", + "There was no improvement in the patient's mental status.", + "The patient had increasing respiratory requirements.", + "The decision was made to forgo intubation.", + "The family requested to forgo intubation.", + "The patient had a pre-determined request to never be placed on a ventilator." + ], + "summary": "We present a 55-year-old Caucasian man with CLL who presented to our clinic with neutropenic fevers following a cycle of chemotherapy. Laboratory parameters revealed hypogammaglobulinemia prompting IVIG administration. Shortly thereafter, he developed a massive cascade of thromboembolic phenomena precipitating his demise.", + "summary_subclaims": [ + "The patient is a 55-year-old Caucasian man.", + "The patient has chronic lymphocytic leukemia.", + "The patient presented with neutropenic fevers.", + "The neutropenic fevers occurred following a cycle of chemotherapy.", + "Laboratory parameters revealed hypogammaglobulinemia.", + "Intravenous immunoglobulin was administered.", + "The patient developed a massive cascade of thromboembolic phenomena.", + "The thromboembolic phenomena precipitated the patient's demise." + ] + }, + { + "id": "multiclinsum_test_347_en.txt", + "fulltext": "A 28-year-old female visited a local hospital for preconception care in June 2019 because spontaneous abortion previously occurred at the 8th gestational week in February 2019. Hashimoto’s thyroiditis and subclinical hypothyroidism were found, and euthyrox was prescribed (25 µg/day). Sex hormones were also tested on the 22nd day of the cycle for irregular menstruation (cycle ranged from 31 to 51 days), and the results were abnormal with no evidence of dominant follicle or ovulation .\nThen she was referred to the reproductive endocrinology outpatient department of a tertiary teaching hospital for further diagnosis. Menarche occurred at 12 years of age. Physical examination showed a well-developed woman with normal breast size and no signs of hyperandrogenism or insulin resistance. Serum testosterone, androstenedione, and adrenal androgen levels were normal. The pelvic ultrasound on the 4th day of the spontaneous cycle showed a normal uterus size with an endometrium measured at 6 mm. The antral follicle count per ovary was > 20, and a cyst (1.6 × 1.3 × 2.2 cm) beside the left ovary was observed. Serum antimullerian hormone (AMH) was 8.33 ng/mL. Polycystic ovary syndrome was primarily diagnosed based on ovulatory dysfunction and polycystic ovarian morphology after excluding other etiologies. Oral contraceptives containing drospirenone and ethinylestradiol were prescribed for 3 cycles.\nAfter stopping oral contraceptives, the early follicular phase serum estradiol levels persistently increased to between 527 and 642 pg/mL (normal range in follicle phase, 19.5-144.2 pg/mL) during the next 10 months, as illustrated in Table . All estradiol measurements were obtained from the same laboratory, using the same competitive chemiluminescent immunoassay (CLIA, Siemens ADVIA CENTAUR). The patient was further referred to the oncology department. However, the levels of other tumor biomarkers were negative (CA-125 6.8, CA-199 6.9, CEA 0.7, β-HCG 2, a-fetoprotein < 1.3). Radiologic assessment by abdominal and pelvic computed tomography was negative for any significant adrenal or adnexal masses, except for a cyst next to the left ovary. Moreover, any form of hormonal substance or dietary supplement was absent by reviewing the dietary diary. Findings on physical examination were completely normal, with no spider angiomas, telangiectasia, palmar erythema, breast tenderness or varicose veins.\nOn the basis of persistent elevated estradiol and the cystic lesion beside the ovary, a granulosa cell tumor of the ovary was suspected. Laparoscopy surgery was performed, but a left mesosalpinx cyst and benign pathological results were found.\nThe source of increased estradiol was still unclear after screening for 11 months. The patient was then suggested to monitor the follicle growth by ultrasound and attempt pregnancy. Surprisingly, the follicle would grow slowly and eventually ovulate. An appropriate rise in estradiol was observed with follicle growth (1067.8 pg/mL when the follicle was 1.5 cm in diameter).\nThere were discrepancies between the serum estradiol level and the clinical picture (follicle growth and normal follicle stimulating hormone). We suspected a case of falsely elevated estradiol levels. The comparison of samples drawn on the same day (14th day of spontaneous cycle), showed our laboratory and the reference laboratory estradiol values to be 619 pg/mL (Siemens ADVIA CENTAUR) and 60 pg/mL (Beckman, DxI 800), respectively. The latter values of estradiol were in concordance with the clinical situation. Thus, falsely increased estradiol was confirmed, and it resulted from analytic interference. Further treatments, including induced ovulation by using letrozole, ultrasound monitoring and intercourse guidance, were scheduled for her urgent pregnancy demand. Successful clinical pregnancy was achieved after six months of therapy. The patient has given birth a healthy baby on 13th March 2022, and she is satisfied with the treatment.", + "fulltext_subclaims": [ + "The patient is a 28-year-old female.", + "She visited a local hospital for preconception care in June 2019.", + "She had a spontaneous abortion at the 8th gestational week in February 2019.", + "Hashimoto’s thyroiditis and subclinical hypothyroidism were found.", + "Euthyrox was prescribed at 25 µg/day.", + "Sex hormones were tested on the 22nd day of the cycle.", + "The menstrual cycle ranged from 31 to 51 days.", + "The sex hormone test results were abnormal with no evidence of dominant follicle or ovulation.", + "She was referred to the reproductive endocrinology outpatient department of a tertiary teaching hospital.", + "Menarche occurred at 12 years of age.", + "Physical examination showed a well-developed woman with normal breast size.", + "There were no signs of hyperandrogenism or insulin resistance.", + "Serum testosterone, androstenedione, and adrenal androgen levels were normal.", + "Pelvic ultrasound on the 4th day of the spontaneous cycle showed a normal uterus size.", + "The endometrium measured 6 mm.", + "The antral follicle count per ovary was > 20.", + "A cyst (1.6 × 1.3 × 2.2 cm) beside the left ovary was observed.", + "Serum antimullerian hormone (AMH) was 8.33 ng/mL.", + "Polycystic ovary syndrome was primarily diagnosed.", + "Oral contraceptives containing drospirenone and ethinylestradiol were prescribed for 3 cycles.", + "After stopping oral contraceptives, early follicular phase serum estradiol levels persistently increased to between 527 and 642 pg/mL.", + "The estradiol measurements were obtained from the same laboratory using the same competitive chemiluminescent immunoassay (CLIA, Siemens ADVIA CENTAUR).", + "The patient was referred to the oncology department.", + "Other tumor biomarkers were negative (CA-125 6.8, CA-199 6.9, CEA 0.7, β-HCG 2, a-fetoprotein < 1.3).", + "Radiologic assessment by abdominal and pelvic computed tomography was negative for any significant adrenal or adnexal masses.", + "A cyst next to the left ovary was observed.", + "No hormonal substance or dietary supplement was present.", + "Findings on physical examination were completely normal.", + "A granulosa cell tumor of the ovary was suspected.", + "Laparoscopy surgery was performed.", + "A left mesosalpinx cyst and benign pathological results were found.", + "The source of increased estradiol was still unclear after screening for 11 months.", + "The patient was suggested to monitor follicle growth by ultrasound and attempt pregnancy.", + "The follicle would grow slowly and eventually ovulate.", + "An appropriate rise in estradiol was observed with follicle growth (1067.8 pg/mL when the follicle was 1.5 cm in diameter).", + "There were discrepancies between the serum estradiol level and the clinical picture.", + "Falsely increased estradiol was suspected.", + "The comparison of samples drawn on the same day showed estradiol values of 619 pg/mL (Siemens ADVIA CENTAUR) and 60 pg/mL (Beckman, DxI 800).", + "The latter estradiol values were in concordance with the clinical situation.", + "Falsely increased estradiol was confirmed.", + "It resulted from analytic interference.", + "Further treatments, including induced ovulation by using letrozole, ultrasound monitoring, and intercourse guidance, were scheduled.", + "Successful clinical pregnancy was achieved after six months of therapy.", + "The patient gave birth to a healthy baby on 13th March 2022.", + "She is satisfied with the treatment." + ], + "summary": "A 28-year-old female with pregnancy demand was diagnosed with polycystic ovary syndrome, Hashimoto's thyroiditis and subclinical hypothyroidism. She was found to have persistently elevated levels of serum estradiol in the early follicular phase (between 527 and 642 pg/mL). Screening workup was performed for nearly 11 months to find the causes. Serum tumor biomarkers were normal. Abdominal and pelvic computed tomography were negative for adrenal or adnexal masses. A left mesosalpinx cyst and benign pathological results were achieved by laparoscopic surgery. Hormonal substances and dietary supplements were absent, as determined by dietary records. Ultrasound confirmed follicles could grow slowly and eventually ovulate. Falsely elevated estradiol levels were suspected due to the discrepancy among high estradiol levels, follicle growth and normal gonadotropin levels. Immunological interference by heterophile antibody was finally verified by two competitive chemiluminescent immunoassay platforms (estradiol levels in the early follicle phase: 619 pg/mL, Siemens ADVIA CENTAUR and 60 pg/mL, Beckman, DxI 800). Successful clinical pregnancy was eventually achieved by combining induced ovulation, ultrasound monitoring and intercourse guidance.", + "summary_subclaims": [ + "The patient is a 28-year-old female with pregnancy demand.", + "She was diagnosed with polycystic ovary syndrome.", + "She was diagnosed with Hashimoto's thyroiditis.", + "She had subclinical hypothyroidism.", + "She had persistently elevated levels of serum estradiol in the early follicular phase.", + "Serum estradiol levels ranged between 527 and 642 pg/mL.", + "A screening workup was performed for nearly 11 months.", + "Serum tumor biomarkers were normal.", + "Abdominal and pelvic computed tomography were negative for adrenal or adnexal masses.", + "A left mesosalpinx cyst was found.", + "Benign pathological results were achieved by laparoscopic surgery.", + "Hormonal substances were absent.", + "Dietary supplements were absent.", + "Ultrasound confirmed follicles could grow slowly.", + "Follicles eventually ovulated.", + "Falsely elevated estradiol levels were suspected.", + "Immunological interference by heterophile antibody was finally verified.", + "Estradiol levels were 619 pg/mL on the Siemens ADVIA CENTAUR platform.", + "Estradiol levels were 60 pg/mL on the Beckman DxI 800 platform.", + "Successful clinical pregnancy was eventually achieved." + ] + }, + { + "id": "multiclinsum_test_1211_en.txt", + "fulltext": "A previously healthy 24-year-old male (A) presented at the emergency department (ED) with chest pain and diarrhoea. The chest pain began 2 h prior to hospital admission and was described as a constant light chest pressure without correlation to breathing or body position. 3 days earlier, the patient and a friend had had chicken in a restaurant before boarding a flight to Sweden. One hour after arrival in Sweden the patient experienced sudden abdominal pain, chills and diarrhoea. During the following three days the patient had 6 diarrhoeas per day, mucous but no visible blood. The patient was diagnosed with C jejuni gastroenteritis after stool culture at a primary care facility, no antibiotics were given. Upon admission to the ED the abdominal pain had subsided, the patient was afebrile (37 °C or 98.6 °F) but still experiencing diarrhoea. Upon examination the patient had normal circulatory and respiratory parameters. Heart auscultation: regular rhythm (RR), no murmurs or extra sounds. Lung and abdominal examinations were normal. Laboratory examinations showed C-reactive protein (CRP) at 89.1 (normal range <10 mg/L), leukocyte count (LC) at 11.3 (normal range 4-12 × 109/L) and high-sensitive Troponin T (hsTnT) at 108 (normal range <14 ng/L) ECG showed regular sinus rhythm, 64/min and general 1 mm ST-elevation . The patient was treated with Brufen 200 mg (tid), Omeprazol 20 mg (qd) and Loperamid 2 mg and admitted to a cardiac care unit (CCU) for cardiac monitoring.\nDuring the following 4 days the hsTnT reached a maximum value of 504 and then dropped to 46. Stool culture confirmed the diagnosis of C jejuni. Blood cultures were negative. Transthoracic echocardiogram (TTE) showed normal right and left ventricle function, ejection fraction (EF) 60–65 %, normal valvular structure and function, no hypokinesia or pericardial effusion. After on day the ECG-changes had resolved. The patient was started on ciprofloxacin but developed urticarial rashes and severe itching and the treatment was discontinued. The chest pain subsided after 2 days and the patient left the hospital after 4 days. The patient was given a 10 day prescription of Azithromycin 500 mg (qd) upon hospital release. The diagnosis was determined to be C jejuni-associated perimyocarditis (CPM). At follow-up visit 4 weeks after discharge the patient was without complaints, physical examination was normal and both ECG and TTE were normal.", + "fulltext_subclaims": [ + "A previously healthy 24-year-old male presented at the emergency department with chest pain and diarrhoea.", + "The chest pain began 2 h prior to hospital admission.", + "The chest pain was described as a constant light chest pressure.", + "The chest pain was without correlation to breathing or body position.", + "3 days earlier, the patient and a friend had had chicken in a restaurant before boarding a flight to Sweden.", + "One hour after arrival in Sweden the patient experienced sudden abdominal pain, chills and diarrhoea.", + "During the following three days the patient had 6 diarrhoeas per day.", + "The patient had mucous but no visible blood in the stool.", + "The patient was diagnosed with C jejuni gastroenteritis after stool culture at a primary care facility.", + "No antibiotics were given at the primary care facility.", + "Upon admission to the ED the abdominal pain had subsided.", + "The patient was afebrile (37 °C or 98.6 °F) upon admission.", + "The patient was still experiencing diarrhoea upon admission.", + "Heart auscultation showed regular rhythm, no murmurs or extra sounds.", + "Laboratory examinations showed C-reactive protein at 89.1 mg/L.", + "Laboratory examinations showed leukocyte count at 11.3 × 109/L.", + "Laboratory examinations showed high-sensitive Troponin T at 108 ng/L.", + "ECG showed regular sinus rhythm, 64/min.", + "ECG showed general 1 mm ST-elevation.", + "The patient was treated with Brufen 200 mg (tid).", + "The patient was treated with Omeprazol 20 mg (qd).", + "The patient was treated with Loperamid 2 mg.", + "The patient was admitted to a cardiac care unit for cardiac monitoring.", + "During the following 4 days the hsTnT reached a maximum value of 504.", + "Stool culture confirmed the diagnosis of C jejuni.", + "Blood cultures were negative.", + "Transthoracic echocardiogram showed normal right and left ventricle function.", + "Transthoracic echocardiogram showed ejection fraction 60–65 %.", + "Transthoracic echocardiogram showed normal valvular structure and function.", + "Transthoracic echocardiogram showed no hypokinesia or pericardial effusion.", + "After one day the ECG-changes had resolved.", + "The patient was started on ciprofloxacin.", + "The patient developed urticarial rashes and severe itching.", + "The treatment with ciprofloxacin was discontinued.", + "The chest pain subsided after 2 days.", + "The patient left the hospital after 4 days.", + "The patient was given a 10 day prescription of Azithromycin 500 mg (qd) upon hospital release.", + "The diagnosis was determined to be C jejuni-associated perimyocarditis.", + "At follow-up visit 4 weeks after discharge the patient was without complaints.", + "At follow-up visit 4 weeks after discharge physical examination was normal.", + "At follow-up visit 4 weeks after discharge both ECG and TTE were normal." + ], + "summary": "A previously healthy 24-yo male (A) presented at the Emergency Department(ED) with recent onset of chest pain and a 3-day history of abdominal pain, fever and diarrhoea. The symptoms began within a few hours of returning from a tourist visit to a central European capital. Vital signs were stable, the Electrocardiogram(ECG) showed generalized ST-elevation, laboratory testing showed increased levels of C-reactive protein(CRP) and high-sensitive Troponin T(hsTnT). Transthoracic echocardiogram (TTE) was normal, stool cultures were positive for C Jejuni and blood cultures were negative. Two days after patient A was admitted to the ED his travel companion (B), also a previously healthy male (23-yo), presented at the same ED with almost identical symptoms: chest pain precipitated by a few days of abdominal pain, fever and diarrhoea. Patient B declared that he and patient A had ingested chicken prior to returning from their tourist trip. Laboratory tests showed elevated CRP and hsTnT but the ECG and TTE were normal. In both cases, the diagnosis of C jejuni-associated perimyocarditis was set based on the typical presentation and positive stool cultures with identical strains. Both patients were given antibiotics, rapidly improved and were fully recovered at 6-week follow up.", + "summary_subclaims": [ + "A previously healthy 24-yo male presented at the Emergency Department with recent onset of chest pain and a 3-day history of abdominal pain, fever and diarrhoea.", + "The symptoms began within a few hours of returning from a tourist visit to a central European capital.", + "Vital signs were stable.", + "The Electrocardiogram showed generalized ST-elevation.", + "Laboratory testing showed increased levels of C-reactive protein and high-sensitive Troponin T.", + "Transthoracic echocardiogram was normal.", + "Stool cultures were positive for C Jejuni.", + "Blood cultures were negative.", + "Two days after patient A was admitted to the ED his travel companion, also a previously healthy male, presented at the same ED with almost identical symptoms.", + "Patient B declared that he and patient A had ingested chicken prior to returning from their tourist trip.", + "Laboratory tests showed elevated CRP and hsTnT.", + "The ECG and TTE were normal.", + "In both cases, the diagnosis of C jejuni-associated perimyocarditis was set based on the typical presentation and positive stool cultures with identical strains.", + "Both patients were given antibiotics.", + "Both patients rapidly improved and were fully recovered at 6-week follow up." + ] + }, + { + "id": "multiclinsum_test_1646_en.txt", + "fulltext": "A 68-year-old man presented with acute-onset cognitive and memory disturbance 10 days before admission. He experienced disorientation and had a score of 12 points on the mini-mental state examination (MMSE). He had no headache, nausea, or visual disturbance, including a visual field defect. Endocrinological examinations revealed hyponatremia (119 mEq/L), serum hypo-osmolality (242 mOsm/L), urinal hyper-osmolality (475 mOsm/L), presence of serum antidiuretic hormone (1.6 pg/mL), continued renal excretion of sodium (93.6 meq/L), normal adrenocortical function, absence of clinical evidence of volume depletion, absence of other causes of hyponatremia, and correction of hyponatremia with fluid restriction, which met the criteria of SIADH. Computed tomography (CT) indicated a high-density mass located in the third ventricle that caused left unilateral hydrocephalus due to obstruction of the foramen Monroe . Intraventricular hemorrhage was not apparent. On magnetic resonance imaging (MRI), the tumor showed high intensity in both T1-weighted images (T1WIs) and T2-weighted images (T2WIs), low intensity in susceptibility-weighted images (SWIs), and a low intensity peripheral rim in T2WIs, suggesting subacute intralesional hemorrhage. The mass was not enhanced with gadolinium. Cerebral angiography revealed no mass stains.\nThe mass was removed via a basal interhemispheric translamina terminalis approach . An old hematoma was suctioned after incision of the capsule. The mass adhered tightly to the left hypothalamus, which was supposed to the origin and was well circumscribed from the surroundings. We carefully separated the mass from the left hypothalamus and completely excised the mass. Histopathological examination indicated that the specimen was composed of variant vessels, hematomas, and hemosiderin according to hematoxylin-eosin staining . Elastica van Gieson staining showed thin blood vessel walls containing endothelium as well as a collagenous adventitia. CD34-immunoreactivity was identified in the endothelial-like cells. The histopathological diagnosis was CCM.\nHyponatremia and serum hypo-osmolality improved (Na: 137 meq/L, serum osmolarity: 279 mOsm/L) without fluid restriction 7 days postoperatively. Diabetes insipidus did not appear. Postoperative T1WIs showed that the mass was completely excised and that the left unilateral hydrocephalus improved . However, disorientation and memory disturbance did not recover after the operation, and he was transferred to another hospital for rehabilitation of higher brain function. His MMSE score improved to 21 points, and he could perform indoor activities of daily living, however, he could not resume work at 1 year after the operation.", + "fulltext_subclaims": [ + "The patient was a 68-year-old man.", + "He presented with acute-onset cognitive and memory disturbance 10 days before admission.", + "He experienced disorientation.", + "He had a score of 12 points on the mini-mental state examination (MMSE).", + "He had no headache.", + "He had no nausea.", + "He had no visual disturbance.", + "He had no visual field defect.", + "Endocrinological examinations revealed hyponatremia (119 mEq/L).", + "Endocrinological examinations revealed serum hypo-osmolality (242 mOsm/L).", + "Endocrinological examinations revealed urinal hyper-osmolality (475 mOsm/L).", + "Endocrinological examinations revealed presence of serum antidiuretic hormone (1.6 pg/mL).", + "Endocrinological examinations revealed continued renal excretion of sodium (93.6 meq/L).", + "Endocrinological examinations revealed normal adrenocortical function.", + "Endocrinological examinations revealed absence of clinical evidence of volume depletion.", + "Endocrinological examinations revealed absence of other causes of hyponatremia.", + "Hyponatremia was corrected with fluid restriction.", + "The criteria of SIADH were met.", + "Computed tomography (CT) indicated a high-density mass located in the third ventricle.", + "The mass caused left unilateral hydrocephalus due to obstruction of the foramen Monroe.", + "Intraventricular hemorrhage was not apparent.", + "On magnetic resonance imaging (MRI), the tumor showed high intensity in both T1-weighted images (T1WIs) and T2-weighted images (T2WIs).", + "On MRI, the tumor showed low intensity in susceptibility-weighted images (SWIs).", + "On MRI, the tumor showed a low intensity peripheral rim in T2WIs.", + "The tumor showed subacute intralesional hemorrhage.", + "The mass was not enhanced with gadolinium.", + "Cerebral angiography revealed no mass stains.", + "The mass was removed via a basal interhemispheric translamina terminalis approach.", + "An old hematoma was suctioned after incision of the capsule.", + "The mass adhered tightly to the left hypothalamus.", + "The mass was well circumscribed from the surroundings.", + "The mass was completely excised.", + "Histopathological examination indicated the specimen was composed of variant vessels, hematomas, and hemosiderin.", + "Elastica van Gieson staining showed thin blood vessel walls containing endothelium as well as a collagenous adventitia.", + "CD34-immunoreactivity was identified in the endothelial-like cells.", + "The histopathological diagnosis was CCM.", + "Hyponatremia and serum hypo-osmolality improved (Na: 137 meq/L, serum osmolarity: 279 mOsm/L) without fluid restriction 7 days postoperatively.", + "Diabetes insipidus did not appear.", + "Postoperative T1WIs showed that the mass was completely excised.", + "Postoperative T1WIs showed that the left unilateral hydrocephalus improved.", + "Disorientation and memory disturbance did not recover after the operation.", + "The patient was transferred to another hospital for rehabilitation of higher brain function.", + "His MMSE score improved to 21 points.", + "He could perform indoor activities of daily living.", + "He could not resume work at 1 year after the operation." + ], + "summary": "A 68-year-old man presented with acute-onset cognitive and memory disturbance. Endocrinological examinations revealed hyponatremia due to SIADH. Computed tomography indicated a high-density mass in the third ventricle that caused left unilateral hydrocephalus due to obstruction of the foramen Monroe. On magnetic resonance imaging, the mass showed high intensity in both T1 and T2-weighted images and low intensity in susceptibility-weighted images, suggesting subacute intralesional hemorrhage. We completely excised the mass via a basal interhemispheric translamina terminalis approach. Intraoperatively, the mass adhered tightly to the left hypothalamus, which was supposed to the origin and was well circumscribed from the surroundings. The histopathological diagnosis was CCM, and his SIADH improved after the operation.", + "summary_subclaims": [ + "The patient is a 68-year-old man.", + "He presented with acute-onset cognitive and memory disturbance.", + "Endocrinological examinations revealed hyponatremia due to SIADH.", + "Computed tomography indicated a high-density mass in the third ventricle.", + "The mass caused left unilateral hydrocephalus due to obstruction of the foramen Monroe.", + "On magnetic resonance imaging, the mass showed high intensity in both T1 and T2-weighted images.", + "The mass showed low intensity in susceptibility-weighted images.", + "The mass was completely excised via a basal interhemispheric translamina terminalis approach.", + "Intraoperatively, the mass adhered tightly to the left hypothalamus.", + "The histopathological diagnosis was CCM.", + "His SIADH improved after the operation." + ] + }, + { + "id": "multiclinsum_test_2317_en.txt", + "fulltext": "A 52-year-old male, with a history of heart transplantation, presented to the emergency department (ED) with the abrupt onset of upper and lower lip edema, without concurrent respiratory symptoms. The patient had no known allergies to medications or foods and had been on a long-term daily regimen of lisinopril 5 mg. Sirolimus 1 mg daily was introduced 20 days prior as part of a renal-sparing immunosuppressive protocol. Upon ED admission, the patient’s vital signs were stable with a blood pressure of 139/83 mmHg, a pulse rate of 88 beats/min, a respiratory rate of 20, and a pulse oximetry reading of 98%. The patient exhibited no signs of difficulty swallowing. Clinical examination revealed significant edema affecting both the upper and lower lips . A prompt diagnosis of angioedema was established, and treatment was initiated with intravenous methylprednisolone (125 mg), famotidine (20 mg), and diphenhydramine (50 mg). Subsequently, both lisinopril and sirolimus were discontinued. The patient’s ability to tolerate a clear liquid diet improved, and he was successfully transitioned to a soft diet. He was subsequently discharged with a prescription for oral antihistamines, demonstrating sustained improvement in the following days .", + "fulltext_subclaims": [ + "The patient is a 52-year-old male.", + "The patient has a history of heart transplantation.", + "The patient presented to the emergency department with the abrupt onset of upper and lower lip edema.", + "The patient had no concurrent respiratory symptoms.", + "The patient had no known allergies to medications or foods.", + "The patient had been on a long-term daily regimen of lisinopril 5 mg.", + "Sirolimus 1 mg daily was introduced 20 days prior.", + "Sirolimus was introduced as part of a renal-sparing immunosuppressive protocol.", + "Upon ED admission, the patient’s blood pressure was 139/83 mmHg.", + "The patient exhibited no signs of difficulty swallowing.", + "Clinical examination revealed significant edema affecting both the upper and lower lips.", + "A prompt diagnosis of angioedema was established.", + "Treatment was initiated with intravenous methylprednisolone (125 mg).", + "Treatment was initiated with intravenous famotidine (20 mg).", + "Treatment was initiated with intravenous diphenhydramine (50 mg).", + "Both lisinopril and sirolimus were discontinued.", + "The patient’s ability to tolerate a clear liquid diet improved.", + "The patient was successfully transitioned to a soft diet.", + "The patient was discharged with a prescription for oral antihistamines.", + "The patient demonstrated sustained improvement in the following days." + ], + "summary": "A 52-year-old male with a history of heart transplant developed severe upper and lower lip edema. The patient had been on Lisinopril without any adverse events. However, sirolimus was recently added to his drug regimen. Sirolimus potentiated angioedema was suspected.", + "summary_subclaims": [ + "The patient is a 52-year-old male.", + "The patient has a history of heart transplant.", + "The patient developed severe upper and lower lip edema.", + "The patient had been on Lisinopril without any adverse events.", + "Sirolimus was recently added to his drug regimen.", + "Sirolimus potentiated angioedema was suspected." + ] + }, + { + "id": "multiclinsum_test_640_en.txt", + "fulltext": "A 24 years old male arrived to our outpatient department complaining of right-sided otalgia and hearing loss for 8 years, no history of otorreah, vertigo or dizziness. He had a history of right-sided chronic suppurative otitis media with a history of two operations at the same side, which were right side atticotomy combined with tympanoplasty in 2002 and right side tympanoplasty in 2007. Examination showed dull, intact tympanic membrane. Tuning fork showed mild conductive hearing loss. The rest of the examination was within normal.\nAudio-tympanogram showed mild conductive hearing loss in the right side and type B tympanogram. A computed tomography (CT) scan showed opacification of the right middle ear and mastoid as shown in . Patient was admitted to the hospital and all pre-operative hematological, biochemical and serological investigations were within normal. Patient underwent exploratory right tympanatomy combined with right cortical mastoidectomy. Tissue specimens were sent for histopathology and comprehensive microbiology for aerobic, anaerobic, fungal and acid-fast bacillus cultures.\nHistopathology showed acute and chronic inflammation with diffuse fibrosis. Acid-fast bacillus staining was negative and all microbiological cultures failed to grow any organisms. A Grocott-Gomori’s methenamine silver-nitrate stain (GMS stain) showed branching bacterial filaments as seen in , allowing the diagnosis of actinomycosis to be established.\nPatient had a history of Penicillin allergy. Consultations for both infectious diseases and allergy/immunology specialties were obtained to determine an optimal management strategy. He was started on Augmentin 1g and Doxycycline 200mg/day. Then, discharged in a stable condition on same medications with regular outpatient clinic appointments. During regular follow-up visits in outpatient clinic till up to date patient has no complaint, tympanic membrane looked normal. CT was done showed normal right middle ear and mastoid opacification as shown in .", + "fulltext_subclaims": [ + "The patient is a 24 years old male.", + "The patient complained of right-sided otalgia.", + "The patient complained of hearing loss for 8 years.", + "The patient had no history of otorreah.", + "The patient had no history of vertigo.", + "The patient had no history of dizziness.", + "The patient had a history of right-sided chronic suppurative otitis media.", + "The patient had a history of two operations on the right side.", + "The first operation was right side atticotomy combined with tympanoplasty in 2002.", + "The second operation was right side tympanoplasty in 2007.", + "Examination showed dull, intact tympanic membrane.", + "Tuning fork showed mild conductive hearing loss.", + "The rest of the examination was within normal.", + "Audio-tympanogram showed mild conductive hearing loss in the right side.", + "A computed tomography (CT) scan showed opacification of the right middle ear.", + "A computed tomography (CT) scan showed opacification of the right mastoid.", + "All pre-operative hematological, biochemical and serological investigations were within normal.", + "The patient underwent exploratory right tympanatomy.", + "The patient underwent right cortical mastoidectomy.", + "Tissue specimens were sent for histopathology.", + "Tissue specimens were sent for comprehensive microbiology for aerobic cultures.", + "Tissue specimens were sent for comprehensive microbiology for anaerobic cultures.", + "Tissue specimens were sent for comprehensive microbiology for fungal cultures.", + "Tissue specimens were sent for comprehensive microbiology for acid-fast bacillus cultures.", + "Histopathology showed acute and chronic inflammation.", + "Histopathology showed diffuse fibrosis.", + "Acid-fast bacillus staining was negative.", + "All microbiological cultures failed to grow any organisms.", + "A Grocott-Gomori’s methenamine silver-nitrate stain showed branching bacterial filaments.", + "The diagnosis of actinomycosis was established.", + "The patient had a history of Penicillin allergy.", + "Consultations for both infectious diseases and allergy/immunology specialties were obtained.", + "The patient was started on Augmentin 1g.", + "The patient was started on Doxycycline 200mg/day.", + "The patient was discharged in a stable condition.", + "The patient was discharged on Augmentin 1g.", + "The patient was discharged on Doxycycline 200mg/day.", + "During regular follow-up visits, the patient has no complaint.", + "The tympanic membrane looked normal during follow-up visits.", + "A CT scan showed normal right middle ear.", + "A CT scan showed right mastoid opacification." + ], + "summary": "We presented A 24 years old male arrived to our outpatient department complaining of right-sided otalgia and hearing loss for 8 years, no history of otorreah, vertigo or dizziness. He had a history of right-sided chronic suppurative otitis media with a history of two operations at the same side. This report suggests that actinomycosis , although it is rare, it could occurs in middle ear. It should be considered as one of the differential for chronic suppurative otitis media patients with no improvement on medical treatment.", + "summary_subclaims": [ + "A 24 years old male arrived to our outpatient department complaining of right-sided otalgia and hearing loss for 8 years", + "He had a history of right-sided chronic suppurative otitis media with a history of two operations at the same side", + "This report suggests that actinomycosis, although it is rare, it could occurs in middle ear", + "It should be considered as one of the differential for chronic suppurative otitis media patients with no improvement on medical treatment" + ] + }, + { + "id": "multiclinsum_test_529_en.txt", + "fulltext": "A 48-year-old woman (III-8, a sister of the proband from this HLRCC family) underwent abdominal ultrasonography annually at a local clinic after 2007, and presented with a left renal mass detected by an ultrasonography and was introduced to our hospital in March 2013 (Additional file : Figure S1).\nShe had undergone enucleation myomectomy for uterine leiomyomatosis at the age of 29 years at another hospital, while hysterectomy had been performed for recurrence large uterine leiomyomatosis at the age of 39 years at other hospital. In 2007 (when she was 40), her sister was diagnosed with HLRCC having a novel FH mutation at 241,671,938 bp (C574T) by direct sequencing of the FH gene from leukocyte DNA. Her sister subsequently died of HLRC-associated advanced renal cancer. In 2007, sequencing of DNA extracted from blood cells of this patient confirmed that she also had the same FH mutation as her sister . After 2007, we recommended that 13 members of this family with the FH mutation should receive active surveillance by annual imaging (abdominal plain computed tomography (CT) or ultrasonography) at a convenient clinic .\nLaboratory tests revealed moderate anemia (hemoglobin: 9.3 g/dl) and elevation of serum C-reactive protein (CRP: 3.19, normal < 0.3 mg/dl). Karnofsky performance status (KPS) was 100 %. Plain CT scans obtained at our hospital showed a left renal tumor with a diameter of 7 cm and involvement of multiple regional para-aortic lymph nodes, but no distant metastases (cT3aN1M0) . Positron emission tomography (PET) showed fluorine-18-deoxyglucose (FDG) accumulation in the renal tumor and the metastatic lymph node and the maximum standardized uptake value (SUVmax) was 15.3 and 7.5, respectively .\nHer risk classification for renal cancer was intermediate risk according to the Memorial Sloan-Kettering Cancer Center (MSKCC) criteria. However, the prognosis of patients with HLRCC-associated renal cancer, in particular those with extrarenal involvement, is extremely poor. Furthermore, her tumors showed a different imaging pattern from that of typical clear cell RCC (Additional file : Figure S1), and the histology of the renal cancers in her relatives was non-clear cell RCC (undifferentiated RCC in her mother, pRCC2 in both her sister and maternal cousin). Thus, the tumor of this patient seemed likely to be non-clear cell carcinoma, but we did not perform needle biopsy to avoid dissemination of cancer cells.\nIn order to decrease the tumor burden and improve the feasibility of surgery, we selected preoperative treatment with a multi-targeted tyrosine kinase inhibitor (TKI). In comparison to first-generation TKIs targeting the VEGFR, axitinib is a potent second-generation inhibitor of VEGFRs with a higher affinity for tyrosine kinase and achieves stronger inhibition of kinase activity with fewer adverse effects such as thrombocytopenia. Additionally, first-generation inhibitors block other targets, such as PDGF receptors (PDGFR), KIT (cluster of differentiation 117: CD117), b-rapidly accelerated fibrosarcoma (RAF), and Fms-like tyrosine kinase 3 (FLT-3), which are not substantially inhibited by axitinib. These off-target activities might contribute to the adverse effects of the first-generation inhibitors, suggesting that more specific inhibitors of VEGFR such as axitinib might have an enhanced therapeutic window. We recently successfully treated a patient who had a large right RCC showing sarcomatoid differentiation that directly invaded the duodenum and inferior vena cava with regional lymph node involvement. In this patient, radical right nephrectomy, cavotomy with thrombectomy, and pancreatoduodenectomy were successfully performed after administration of axitinib as first-line neoadjuvant therapy without severe toxicity .\nWe selected axitinib as preoperative molecular-targeting therapy to decrease the tumor size before surgery with good tolerability. Administration of axitinib starting at 5 mg/day was scheduled for four to six weeks before radical surgery involving left nephrectomy and extended retroperitoneal lymph node dissection (para-aortic and aorto-caval nodes). After 1 week, the dose of axitinib was increased to 14 mg/day. After four weeks of total dose of axitinib of 329 mg (5 mg/day for continuous 7 days and 14 mg/day for following continuous 21 days), there were no apparent adverse events of > grade 3, excluding headache and hypertension (systolic blood pressure > 200 mmHg). Tumor shrinkage and a decrease of SUVmax were observed . Subsequently, we successfully carried out radical left nephrectomy and extended retroperitoneal lymph node dissection (para-aortic and aorto-caval nodes). Macroscopically, the tumor was an invasive whitish-yellowish mass with partial necrosis. Pathological examination confirmed pRCC2 with Fuhrman grade 3 differentiation (pT3apN1M0). The pathological effect of axitinib was grade 2 (i.e., two-thirds necrosis of the tumor). The patient has been receiving axitinib at 5 mg/day in the manner of one cycle of one week (5 days on - 2 days off) as adjuvant therapy for 33 months, and remains well with no evidence of recurrence at 33 months after the operation.", + "fulltext_subclaims": [ + "The patient is a 48-year-old woman.", + "She is a sister of the proband from this HLRCC family.", + "She underwent abdominal ultrasonography annually at a local clinic after 2007.", + "She presented with a left renal mass detected by an ultrasonography.", + "She was introduced to our hospital in March 2013.", + "She had undergone enucleation myomectomy for uterine leiomyomatosis at the age of 29 years at another hospital.", + "Hysterectomy had been performed for recurrence large uterine leiomyomatosis at the age of 39 years at other hospital.", + "In 2007, her sister was diagnosed with HLRCC having a novel FH mutation at 241,671,938 bp (C574T) by direct sequencing of the FH gene from leukocyte DNA.", + "Her sister subsequently died of HLRC-associated advanced renal cancer.", + "In 2007, sequencing of DNA extracted from blood cells of this patient confirmed that she also had the same FH mutation as her sister.", + "After 2007, we recommended that 13 members of this family with the FH mutation should receive active surveillance by annual imaging.", + "Plain CT scans obtained at our hospital showed a left renal tumor with a diameter of 7 cm.", + "Plain CT scans showed involvement of multiple regional para-aortic lymph nodes.", + "Plain CT scans showed no distant metastases.", + "The tumor was classified as cT3aN1M0.", + "Positron emission tomography (PET) showed fluorine-18-deoxyglucose (FDG) accumulation in the renal tumor.", + "The maximum standardized uptake value (SUVmax) was 15.3 in the renal tumor.", + "The SUVmax was 7.5 in the metastatic lymph node.", + "Her risk classification for renal cancer was intermediate risk according to the MSKCC criteria.", + "The prognosis of patients with HLRCC-associated renal cancer, in particular those with extrarenal involvement, is extremely poor.", + "Her tumors showed a different imaging pattern from that of typical clear cell RCC.", + "The histology of the renal cancers in her relatives was non-clear cell RCC.", + "The tumor of this patient seemed likely to be non-clear cell carcinoma.", + "We did not perform needle biopsy to avoid dissemination of cancer cells.", + "We selected preoperative treatment with a multi-targeted tyrosine kinase inhibitor (TKI).", + "Axitinib is a potent second-generation inhibitor of VEGFRs.", + "Axitinib achieves stronger inhibition of kinase activity with fewer adverse effects such as thrombocytopenia.", + "First-generation inhibitors block other targets, such as PDGF receptors (PDGFR), KIT, b-RAF, and FLT-3.", + "These off-target activities might contribute to the adverse effects of the first-generation inhibitors.", + "More specific inhibitors of VEGFR such as axitinib might have an enhanced therapeutic window.", + "We recently successfully treated a patient who had a large right RCC showing sarcomatoid differentiation.", + "Radical right nephrectomy, cavotomy with thrombectomy, and pancreatoduodenectomy were successfully performed after administration of axitinib as first-line neoadjuvant therapy.", + "We selected axitinib as preoperative molecular-targeting therapy.", + "Administration of axitinib starting at 5 mg/day was scheduled for four to six weeks before radical surgery.", + "After 1 week, the dose of axitinib was increased to 14 mg/day.", + "After four weeks of total dose of axitinib of 329 mg, there were no apparent adverse events of > grade 3.", + "Tumor shrinkage and a decrease of SUVmax were observed.", + "We successfully carried out radical left nephrectomy.", + "We successfully carried out extended retroperitoneal lymph node dissection.", + "Pathological examination confirmed pRCC2 with Fuhrman grade 3 differentiation.", + "The pathological effect of axitinib was grade 2.", + "The patient has been receiving axitinib at 5 mg/day in the manner of one cycle of one week (5 days on - 2 days off) as adjuvant therapy.", + "The patient remains well with no evidence of recurrence at 33 months after the operation." + ], + "summary": "We recommended that 13 at-risk individuals from a family with HLRCC should receive active surveillance for early detection of renal cancer. A 48-year-old woman with a left renal tumor and involvement of multiple regional lymph nodes with high accumulation of fluorine-18-deoxyglucose on positron emission tomography was treated with axitinib as a neoadjuvant therapy. Preoperative axitinib induced the shrinkage of the tumor with decreased fluorine-18-deoxyglucose accumulation. Resected samples showed two thirds tumor tissue necrosis as well as high expression of serine/threonine kinase Akt and low expression of nuclear factor E2-related factor 2 (Nrf2) which activates anti-oxidant response and protects against oxidative stress in viable cancer cells. Targeted next-generation sequencing revealed that FH mutation and loss of the second allele were completely identical between blood and tumor samples, suggesting that FH mutation plays a direct role in FH-deficient RCC. She has remained well after radical operation for over 33 months.", + "summary_subclaims": [ + "We recommended that 13 at-risk individuals from a family with HLRCC should receive active surveillance for early detection of renal cancer.", + "A 48-year-old woman with a left renal tumor and involvement of multiple regional lymph nodes with high accumulation of fluorine-18-deoxyglucose on positron emission tomography was treated with axitinib as a neoadjuvant therapy.", + "Preoperative axitinib induced the shrinkage of the tumor with decreased fluorine-18-deoxyglucose accumulation.", + "Resected samples showed two thirds tumor tissue necrosis.", + "Resected samples showed high expression of serine/threonine kinase Akt.", + "Resected samples showed low expression of nuclear factor E2-related factor 2 (Nrf2).", + "Targeted next-generation sequencing revealed that FH mutation and loss of the second allele were completely identical between blood and tumor samples.", + "FH mutation plays a direct role in FH-deficient RCC.", + "She has remained well after radical operation for over 33 months." + ] + }, + { + "id": "multiclinsum_test_2882_en.txt", + "fulltext": "A 29-year-old woman presented to our clinic complaining of a six-day loss of visual acuity in her left eye.\nThe patient’s symptoms began a month ago, with a decrease in the visual acuity of the left eye, which had worsened over the last six days. Recently, the patient had eaten a great deal of fried food, and she had poor blood glucose control. No other diabetic complications were observed.\nThe patient had had type 2 diabetes mellitus for two years almost certainly because of poor diet and lack of exercise. The patient had been treated for diabetic retinopathy and followed up at our hospital.\nThe patient had diabetes for two years and denied any diagnoses of family history. The patient had normal menstruation.\nThe physical examination was normal.\nThe results of the laboratory examinations revealed the following: total cholesterol (CHO) level of 13.98 mmol/L (3.6–6.5); triglyceride (TG) 20.55 mmol/L (0–1.71); high density lipoprotein (HDL) 0.75 mmol/L (0.83–1.96); low density lipoprotein (LDL) 6.91 mmol/L (0–3.36); apolipoprotein-A1 0.64 g/L (1.0–1.6); apolipoprotein-B 0.49 g/L (0.6–1.1); total protein 85.8 g/L (65–85); fasting blood glucose 10.89 mmol/L (3.9–6.1) ; glycosylated hemoglobin 12% (4.5–6.3); hemoglobin 216 g/L (115–150); mean corpuscular hemoglobin (MCH) 46.2 pg (27–34); MCH concentration 548 g/L (316–354); erythrocyte sedimentation rate 40 mm/h (0–20); and blood uric acid 424 μmol/L (140–340). Normal reference values are shown in parentheses after the results. The results of other blood routine tests for C-reactive protein 4.45 mg/L (0–10), liver function, kidney function, electrolytes, and homocysteine were normal. A B ultrasound of bile, pancreas, and spleen, an electrocardiogram, and a computed tomography of chest showed normal results. The B ultrasound showed that the patient had fatty liver.\nFundus color images (Kowa, Nonmyd 7, Kowa, Japan) showed a pink–white color of the fundus, arteries, and veins. Arteries and veins could not be distinguished by color, only by the caliber of the vessels . The fundus of the left eye was covered by vitreous blood. Only the optic disk could be seen .\nInfrared images (Heidelberg Spectralis, Heidelberg Engineering, Heidelberg, Germany) showed hyperinfrared reflection of arteries and veins, unlike the hypoinfrared reflection of the normal fundus. Arteries and veins could not be distinguished by infrared reflection .\nOptical coherence tomography (OCT) (Heidelberg Engineering, Heidelberg, Germany) showed numerous high point-like reflections in the retinal section, which corresponded to different caliber blood vessel sections . The big vessels in the choroid showed medium reflections, unlike the low reflections of normal choroid vessels. Careful observations were required to detect the great choroidal vessels .\nFundus fluorescein angiography (FFA) (Heidelberg Spectralis, Heidelberg Engineering, Heidelberg, Germany) showed no significant difference in retinal filling time and fundus fluorescence between the patient’s hypertriglyceridemia condition and a normal blood lipid condition .\nThe patient also underwent optical coherence tomography angiography (OCTA) (Avanti RTVue XR100-2, Optovue Inc, Fremont, CA, United States). The retinal blood flow showed decreased vascular density in the macular area consistent with the fundus fluorescein angiography, which was caused by diabetic retinopathy .", + "fulltext_subclaims": [ + "The patient is a 29-year-old woman.", + "The patient presented with a six-day loss of visual acuity in her left eye.", + "The patient’s symptoms began a month ago with a decrease in the visual acuity of the left eye.", + "The patient had eaten a great deal of fried food recently.", + "The patient had poor blood glucose control.", + "No other diabetic complications were observed.", + "The patient had had type 2 diabetes mellitus for two years.", + "The patient had been treated for diabetic retinopathy.", + "The patient had diabetes for two years.", + "The patient denied any diagnoses of family history.", + "The patient had normal menstruation.", + "The physical examination was normal.", + "The total cholesterol level was 13.98 mmol/L.", + "The triglyceride level was 20.55 mmol/L.", + "The high density lipoprotein level was 0.75 mmol/L.", + "The low density lipoprotein level was 6.91 mmol/L.", + "The apolipoprotein-A1 level was 0.64 g/L.", + "The apolipoprotein-B level was 0.49 g/L.", + "The total protein level was 85.8 g/L.", + "The fasting blood glucose level was 10.89 mmol/L.", + "The glycosylated hemoglobin level was 12%.", + "The hemoglobin level was 216 g/L.", + "The mean corpuscular hemoglobin was 46.2 pg.", + "The erythrocyte sedimentation rate was 40 mm/h.", + "The blood uric acid level was 424 μmol/L.", + "The B ultrasound showed that the patient had fatty liver.", + "Fundus color images showed a pink–white color of the fundus, arteries, and veins.", + "Arteries and veins could not be distinguished by color, only by the caliber of the vessels.", + "The fundus of the left eye was covered by vitreous blood.", + "Only the optic disk could be seen.", + "Infrared images showed hyperinfrared reflection of arteries and veins.", + "Arteries and veins could not be distinguished by infrared reflection.", + "Optical coherence tomography showed numerous high point-like reflections in the retinal section.", + "The big vessels in the choroid showed medium reflections.", + "Fundus fluorescein angiography showed no significant difference in retinal filling time and fundus fluorescence between the patient’s hypertriglyceridemia condition and a normal blood lipid condition.", + "The patient underwent optical coherence tomography angiography.", + "The retinal blood flow showed decreased vascular density in the macular area consistent with the fundus fluorescein angiography.", + "The decreased vascular density was caused by diabetic retinopathy." + ], + "summary": "A 29-year-old woman with type 2 diabetes presented to our clinic complaining of a six-day loss of visual acuity in the left eye. The fundus color images showed typical LR: Arteries and veins were the same pink-white color. Infrared images showed hyperinfrared reflections of the arteries and veins. Optical coherence tomography (OCT) showed numerous high point-like reflections in the retinal section, corresponding to different calibers of blood vessel sections. Medium reflections were seen in the big vessels of the choroid. Fundus fluorescein angiography (FFA) and optical coherence tomography angiography (OCTA) showed no significant changes. Laboratory examination found a total cholesterol level of 13.98 mmol/L, triglyceride 20.55 mmol/L, which confirmed the diagnosis of LR. After treatment to lower blood lipids and control blood glucose, the fundus imaging showed that the blood lipids in the patient had returned to normal.", + "summary_subclaims": [ + "The patient is a 29-year-old woman with type 2 diabetes.", + "She presented with a six-day loss of visual acuity in the left eye.", + "Fundus color images showed typical LR.", + "Arteries and veins were the same pink-white color.", + "Infrared images showed hyperinfrared reflections of the arteries and veins.", + "OCT showed numerous high point-like reflections in the retinal section.", + "The high point-like reflections corresponded to different calibers of blood vessel sections.", + "Medium reflections were seen in the big vessels of the choroid.", + "FFA showed no significant changes.", + "OCTA showed no significant changes.", + "Laboratory examination found a total cholesterol level of 13.98 mmol/L.", + "Triglyceride level was 20.55 mmol/L.", + "The diagnosis of LR was confirmed.", + "Treatment included lowering blood lipids and controlling blood glucose.", + "Fundus imaging showed that the blood lipids in the patient had returned to normal." + ] + }, + { + "id": "multiclinsum_test_2287_en.txt", + "fulltext": "A 69-year-old man visited our hospital with a complaint of acute onset abdominal pain 3 years previously. Laboratory investigation revealed that his serum amylase level was high, and computed tomography (CT) revealed fluid collection around the pancreas and a pseudocyst . He was diagnosed with acute pancreatitis without gallstones. He had no history of diabetes or any other medical conditions. The smoking history was 20 cigarettes/day for about 50 years, and the drinking history was about 500 ml of beer about 2 times a week. Magnetic resonance cholangiopancreatography (MRCP) revealed a pseudocyst without an intraductal papillary mucinous neoplasm (IPMN) . The patient was discharged, and CT recorded 1 year after discharge revealed shrinkage of the pseudocyst with slightly dilated distal pancreas duct . He developed acute pancreatitis 1 year previously. Subsequently, acute pancreatitis recurred three times. Endoscopic retrograde cholangiopancreatography (ERCP) revealed no stenosis or dilatation of the pancreatic duct at that time , and repeated pancreatic juice cytology showed no evidence of malignancy. Endoscopic ultrasound (EUS) was performed; however, no mass lesion was found in the distal pancreatic parenchyma. Acute pancreatitis recurred again this year, and CT revealed fluid retention around the tail of the pancreas and the splenic hilum, and a pseudoaneurysm of the splenic artery . Therefore, abdominal angiography and transcatheter arterial embolization was performed .\nThe possibility of pancreatic cancer could not be completely ruled out for causing repeated episodes of distally localized pancreatitis, and to treat secondary splenic artery aneurysm; therefore, surgical resection was planned after full-informed consent .\nThe tumor markers 2 months prior to surgery were within the normal range as follow; carcinoembryonic antigen 4.5 ng/mL, carbohydrate antigen 19–97 U/mL, and Duke pancreatic monoclonal antigen type 2 25 U/mL. Laparoscopy-assisted distal pancreatectomy was performed, with an operation time of 293 min, and a blood loss of 200 mL . The pancreas was resected on the left side of the portal vein. Preoperative examination revealed no findings suspicious of malignancy and considering the severe inflammatory changes due to repeated pancreatitis, D1 lymph node dissection was performed without rapid intraoperative pathology of pancreatic stump. A single tufted cyst 25 mm in size was found in the tail of the pancreas and a coil embolus was found in the dilated splenic artery; a part of the blood vessel wall was ruptured, and the coil embolus was exposed in the cyst . Pathological examination revealed a non-invasive cancer component in the specimen, i.e., carcinoma in situ . No lymph node metastasis was detected, and PanIN with carcinoma in situ was finally diagnosed.\nThe patient recovered satisfactorily and was discharged on postoperative day 10. The pancreatitis did not recur after surgery and there was no recurrence of pancreatic cancer; the patient still has regular follow-ups at our hospital.", + "fulltext_subclaims": [ + "The patient is a 69-year-old man.", + "He visited the hospital with a complaint of acute onset abdominal pain 3 years previously.", + "His serum amylase level was high.", + "Computed tomography revealed fluid collection around the pancreas.", + "Computed tomography revealed a pseudocyst.", + "He was diagnosed with acute pancreatitis without gallstones.", + "He had no history of diabetes.", + "He had no history of any other medical conditions.", + "He smoked 20 cigarettes/day for about 50 years.", + "He drank about 500 ml of beer about 2 times a week.", + "Magnetic resonance cholangiopancreatography revealed a pseudocyst.", + "Magnetic resonance cholangiopancreatography revealed no intraductal papillary mucinous neoplasm.", + "CT recorded 1 year after discharge revealed shrinkage of the pseudocyst.", + "CT recorded 1 year after discharge revealed slightly dilated distal pancreas duct.", + "He developed acute pancreatitis 1 year previously.", + "Acute pancreatitis recurred three times.", + "Endoscopic retrograde cholangiopancreatography revealed no stenosis or dilatation of the pancreatic duct.", + "Repeated pancreatic juice cytology showed no evidence of malignancy.", + "Endoscopic ultrasound was performed.", + "No mass lesion was found in the distal pancreatic parenchyma.", + "Acute pancreatitis recurred again this year.", + "CT revealed fluid retention around the tail of the pancreas.", + "CT revealed fluid retention around the splenic hilum.", + "CT revealed a pseudoaneurysm of the splenic artery.", + "Abdominal angiography and transcatheter arterial embolization was performed.", + "The possibility of pancreatic cancer could not be completely ruled out.", + "Surgical resection was planned after full-informed consent.", + "The tumor markers 2 months prior to surgery were within the normal range.", + "Carcinoembryonic antigen was 4.5 ng/mL.", + "Carbohydrate antigen 19–9 was 7 U/mL.", + "Duke pancreatic monoclonal antigen type 2 was 25 U/mL.", + "Laparoscopy-assisted distal pancreatectomy was performed.", + "The operation time was 293 min.", + "The blood loss was 200 mL.", + "The pancreas was resected on the left side of the portal vein.", + "Preoperative examination revealed no findings suspicious of malignancy.", + "D1 lymph node dissection was performed.", + "A single tufted cyst 25 mm in size was found in the tail of the pancreas.", + "A coil embolus was found in the dilated splenic artery.", + "A part of the blood vessel wall was ruptured.", + "The coil embolus was exposed in the cyst.", + "Pathological examination revealed a non-invasive cancer component in the specimen.", + "No lymph node metastasis was detected.", + "PanIN with carcinoma in situ was finally diagnosed.", + "The patient was discharged on postoperative day 10.", + "The pancreatitis did not recur after surgery.", + "There was no recurrence of pancreatic cancer.", + "The patient still has regular follow-ups at our hospital." + ], + "summary": "A 69-year-old man was referred to our hospital with severe abdominal pain, and serial imaging studies showed acute distally localized pancreatitis with a pseudocyst. Although he had successful conservative medical treatment followed by discharge from the hospital, he was re-admitted with severe abdominal pain for recurrent distal pancreatitis with splenic artery aneurysm followed by its rupture. No pancreas mass was detected by imaging studies including endoscopic ultrasound and cytologic studies of the pancreas juice did not show any malignant cells, although slight dilatation of distal pancreas duct was observed only in the initial computed tomography. Because of the episodes of repeated distally localized pancreatitis caused by possible pancreatic ductal neoplasm, we planned and performed laparoscopy-assisted distal pancreatectomy after full-informed consent. Pathological examination revealed pancreatic intraepithelial neoplasia (PanIN) with carcinoma in situ in the distal main pancreas duct. The post-surgical course of the patient was uneventful and he was discharged 10 days after surgery from recurrent disease for over a year.", + "summary_subclaims": [ + "A 69-year-old man was referred to our hospital with severe abdominal pain.", + "Serial imaging studies showed acute distally localized pancreatitis with a pseudocyst.", + "He had successful conservative medical treatment followed by discharge from the hospital.", + "He was re-admitted with severe abdominal pain for recurrent distal pancreatitis with splenic artery aneurysm followed by its rupture.", + "No pancreas mass was detected by imaging studies including endoscopic ultrasound.", + "Cytologic studies of the pancreas juice did not show any malignant cells.", + "Slight dilatation of distal pancreas duct was observed only in the initial computed tomography.", + "We planned and performed laparoscopy-assisted distal pancreatectomy after full-informed consent.", + "Pathological examination revealed pancreatic intraepithelial neoplasia (PanIN) with carcinoma in situ in the distal main pancreas duct.", + "The post-surgical course of the patient was uneventful.", + "He was discharged 10 days after surgery.", + "He was discharged from recurrent disease for over a year." + ] + }, + { + "id": "multiclinsum_test_1197_en.txt", + "fulltext": "A 38-year-old illiterate housewife from rural southeast Mexico, with bilateral urolithiasis attended a urology consultation at a highly specialized public hospital in Yucatan Mexico, as she had had a fever between 38 ℃ and 40 ℃ for the previous 2 d, accompanied by severe pain in the right flank irradiating to the ipsilateral suprapubic region and reported changes in frequency and quality of urination.\nShe was admitted for in-hospital care, and abdominal computerized axial tomography was performed, along with blood and urine tests, including cultures. Tomography indicated the presence of gas in the right kidney indicating EPN Huang IV and confirmed the presence of a nonfunctional left kidney . Blood culture was unremarkable, while urine culture reported S. fonticola as a single pathogen, sensitive to most antibiotics but resistant to trimethoprim and nitrofurantoin.\nAntecedents included that she debuted with symptomatic bilateral urinary lithiasis in 2015, and she was diagnosed with chronic kidney disease Class Kidney Diseases Global Outcomes 3A that same year. Left renal exclusion was confirmed using radiotracer mercaptoacetyltriglycine gammagraphy.\nIn 2016 and 2017 second look percutaneous nephrolithotomy was performed, finding right ureteral stenosis due to lithiasis; JJ catheters were temporarily placed in the right kidney and removed after treatment.\nFever and right flank pain irradiating to the ipsilateral suprapubic region persisted.\nDiabetes and hypertension had been ruled out at every hospitalization, as the patient only registered normal values of fasting glucose and blood pressure. The patient was treated with piperacillin/ tazobactam; a combined endoscopic intrarenal surgery was performed to place a metallic catheter and to treat with percutaneous drainage. After 3 d of antibiotic, she became afebrile. The gas presence due to anaerobic bacteria reduced according to imaging, and a new culture was performed on day 4, which was reported negative. Her white blood cell count improved markedly. However, after 8 d her fever relapsed, and new studies were performed, finding Pseudomonas aeruginosa as a single pathogen in her urine culture along with an increase in neutrophils and white blood cell count in general. She was therefore treated with meropenem .\nAfter 10 d of treatment, with tomographic and laboratory evidence for the resolution of the acute signs and symptoms, she was discharged.", + "fulltext_subclaims": [ + "The patient is a 38-year-old illiterate housewife from rural southeast Mexico.", + "She has bilateral urolithiasis.", + "She attended a urology consultation at a highly specialized public hospital in Yucatan Mexico.", + "She had had a fever between 38 ℃ and 40 ℃ for the previous 2 d.", + "She had severe pain in the right flank irradiating to the ipsilateral suprapubic region.", + "She reported changes in frequency and quality of urination.", + "She was admitted for in-hospital care.", + "Abdominal computerized axial tomography was performed.", + "Blood and urine tests, including cultures, were performed.", + "Tomography indicated the presence of gas in the right kidney indicating EPN Huang IV.", + "Tomography confirmed the presence of a nonfunctional left kidney.", + "Blood culture was unremarkable.", + "Urine culture reported S. fonticola as a single pathogen.", + "S. fonticola was sensitive to most antibiotics.", + "S. fonticola was resistant to trimethoprim and nitrofurantoin.", + "She debuted with symptomatic bilateral urinary lithiasis in 2015.", + "She was diagnosed with chronic kidney disease Class Kidney Diseases Global Outcomes 3A in 2015.", + "Left renal exclusion was confirmed using radiotracer mercaptoacetyltriglycine gammagraphy.", + "In 2016 and 2017, second look percutaneous nephrolithotomy was performed.", + "Right ureteral stenosis due to lithiasis was found during the 2016 and 2017 procedures.", + "JJ catheters were temporarily placed in the right kidney and removed after treatment.", + "Fever and right flank pain irradiating to the ipsilateral suprapubic region persisted.", + "Diabetes and hypertension had been ruled out at every hospitalization.", + "The patient only registered normal values of fasting glucose and blood pressure.", + "The patient was treated with piperacillin/tazobactam.", + "A combined endoscopic intrarenal surgery was performed to place a metallic catheter and to treat with percutaneous drainage.", + "After 3 d of antibiotic, she became afebrile.", + "The gas presence due to anaerobic bacteria reduced according to imaging.", + "A new culture was performed on day 4, which was reported negative.", + "Her white blood cell count improved markedly.", + "After 8 d, her fever relapsed.", + "New studies were performed, finding Pseudomonas aeruginosa as a single pathogen in her urine culture.", + "There was an increase in neutrophils and white blood cell count in general.", + "She was therefore treated with meropenem.", + "After 10 d of treatment, with tomographic and laboratory evidence for the resolution of the acute signs and symptoms, she was discharged." + ], + "summary": "A 38-year-old female presented with fever, severe pain in the right flank and changes in urinary habits. She was admitted, and emphysematous pyelonephritis was confirmed by an abdominal computerized tomography and urine cultures; the latter showed Serratia fonticola as a single pathogen. After 3 d of being treated with piperacillin/tazobactam and percutaneous drainage she became afebrile, and the gas presence reduced.", + "summary_subclaims": [ + "The patient is a 38-year-old female.", + "The patient presented with fever.", + "The patient had severe pain in the right flank.", + "The patient had changes in urinary habits.", + "Emphysematous pyelonephritis was confirmed by an abdominal computerized tomography.", + "Urine cultures showed Serratia fonticola as a single pathogen.", + "The patient was treated with piperacillin/tazobactam.", + "The patient received percutaneous drainage.", + "After 3 d of treatment, the patient became afebrile.", + "After 3 d of treatment, the gas presence reduced." + ] + }, + { + "id": "multiclinsum_test_868_en.txt", + "fulltext": "The patient is a 67-year-old male who underwent surgical mitral repair and tricuspid annuloplasty due to severe mitral regurgitation (MR) and moderate tricuspid regurgitation. The procedure involved the use of a 36 mm Edwards Physio annuloplasty ring (Edwards Lifesciences, Irvine, CA, USA). Three months ago, the patient was admitted to our department with fatigue, chest tightness, and exertional dyspnea (New York Heart Association functional class IV). Echocardiography showed recurrent severe MR (volume = 36.0 mL; Vmax = 167 cm/s), and maximum transvalvular gradients were 13 mmHg. The left ventricle was dilated and showed a systolic ejection fraction of 46%.\nA multidisciplinary cardiac team performed a meticulous evaluation of his transesophageal echocardiography (TEE) scans and computed tomography angiography scans and obtained the informed consent after having discussed all available treatment methods. Since the patient was highly symptomatic and at very high risk of secondary thoracotomy surgery, it was decided to perform the TMViR due to the possibility of the need for a high-risk surgical reoperation (based on Society of Thoracic Surgery score, 11.192%; European System for Cardiac Operative Risk Evaluation Score II, 8.3%) (A–E). Meanwhile, a patient-specific3D-printed model was created using computed tomography angiography data. The image data, in Digital Imaging and Communications in Medicine format, were collected and processed using Materialise Mimics 21.0 software (Materialise, Leuven, Belgium). The software was used to segment the images and export them in the Standard Tessellation Language (STL) format. Post-processing of the STL files was performed using Materialise 3-Matic software (Leuven, Belgium, version 14.0). The final STL files were then imported into a Polyjet 850 multimaterial full-color 3D printer (Stratasys, Inc., Eden Prairie, MN, USA). The printer utilized materials with different flexibilities to accurately represent the structural characteristics of different parts, such as the annuloplasty ring and myocardial tissue (F–H). Then, the procedures were simulated during the bench test. After its release, the unfolded bioprosthetic valve was observed clearly. The information obtained was used to evaluate and prognosticate major perioperative complications. Because the area of a 36 mm Physio ring was 7.0 cm2, and in addition, because the ring was D-shaped and semirigid and had a high risk of complications for the transcatheter aortic valve-in-ring concept, we decided to implant the Mi-thos system (I) via a transapical approach.\nThe procedure was conducted with the patient under general anesthesia and mechanical ventilation. Intraoperative guidance was provided using fluoroscopic images and TEE. A 4 cm left anterior mini-thoracotomy incision was made to access the puncture point at the apex of the left ventricle. Puncture and cannulation were carried out using 6F sheaths on both the right femoral artery and vein. Subsequently, a temporary pacemaker electrode was carefully inserted into the right ventricle through the vein sheath. At the same time, a 6F pigtail catheter was advanced from the right femoral artery to the left ventricle. We successfully obtained standard apical access and secured the entry site using a hexagonal suture. To optimize visibility of both the left ventricle and atrium, we made adjustments to achieve a cranial right-anterior-oblique angulation. Ventriculograms were performed to evaluate the MR and to assess the shape of the left ventricle and the mitral annuloplasty ring. Based on the preoperative assessment and simulation conducted using the patient-specific3D-printed model (A–C), the assembly of a 33 mm Mi-thos bioprosthesis onto the delivery system was performed in vitro. To begin the procedure, an apical puncture was made, and a 6 Fr sheath was inserted. A 6F pigtail catheter, along with a J-tipped 0.035-inch guide wire, was then guided across the mitral surgical ring and into the left atrium. Following this, a 260 cm Lunderquist super stiff wire (Cook Medical Inc., Bloomington, IN, USA) was then used for exchange. The delivery system was inserted over the Lunderquist guide wire and advanced in a retrograde manner across the mitral annuloplasty ring via the transapical approach, ultimately reaching the left atrium. By retracting the outer sheath of the delivery system, the atrial skirt, which was specifically designed to fit the D-shaped mitral annulus, was released. It completely covered the mitral annulus and the annuloplasty ring, guided by TEE and fluoroscopy, while the ventricular portion of the device remained partially confined to the sheath. After confirming the position and alignment of the Mi-thos valve, the entire system was retracted and properly seated on the mitral annuloplasty ring. Subsequently, under rapid pacing at a rate of 140 per minute, the ventricular portion of the bioprosthesis was released and securely anchored to the native MV using secure barbs.\nImmediately ventriculograms confirmed the excellent position and shape of the Mi-thos valve, with no evidence of transvalvular regurgitation, paravalvular leak (PVL), or left ventricular outflow tract obstruction (LVOTO) (the area of the neo-left ventricular outflow tract was 374.6 cm2). The valve’s position and function were further assessed using TEE, which indicated a mean pressure gradient of 3 mmHg (D–I, ). Subsequently, the delivery system was carefully removed through the apex incision, and hemostasis was achieved using the apical strings that were previously placed. After closing the incision, the patient was successfully weaned off the ventilator and transferred to the cardiac intensive care unit. The postoperative recovery was smooth, and the patient was discharged in good clinical condition 5 days after the operation. At the time of discharge, the transthoracic echocardiogram examination confirmed the excellent position and function of the valve. Additionally, there was no evidence of any significant transvalvular or paravalvular regurgitation, as well as no LVOTO, and the maximum and mean gradients were measured at 6 mmHg and 2 mmHg, respectively. The patient’s symptoms had improved (NYHA functional class II).", + "fulltext_subclaims": [ + "The patient is a 67-year-old male.", + "The patient underwent surgical mitral repair and tricuspid annuloplasty.", + "The procedure involved the use of a 36 mm Edwards Physio annuloplasty ring.", + "Three months ago, the patient was admitted with fatigue, chest tightness, and exertional dyspnea.", + "Echocardiography showed recurrent severe MR (volume = 36.0 mL; Vmax = 167 cm/s).", + "The left ventricle was dilated and showed a systolic ejection fraction of 46%.", + "A multidisciplinary cardiac team performed a meticulous evaluation of TEE scans and computed tomography angiography scans.", + "The patient was at very high risk of secondary thoracotomy surgery.", + "It was decided to perform the TMViR due to the possibility of the need for a high-risk surgical reoperation.", + "A patient-specific 3D-printed model was created using computed tomography angiography data.", + "The image data were collected and processed using Materialise Mimics 21.0 software.", + "The software was used to segment the images and export them in STL format.", + "Post-processing of the STL files was performed using Materialise 3-Matic software.", + "The final STL files were imported into a Polyjet 850 multimaterial full-color 3D printer.", + "The printer utilized materials with different flexibilities to accurately represent the structural characteristics of different parts.", + "The procedures were simulated during the bench test.", + "The information obtained was used to evaluate and prognosticate major perioperative complications.", + "The area of a 36 mm Physio ring was 7.0 cm2.", + "The ring was D-shaped and semirigid.", + "The ring had a high risk of complications for the transcatheter aortic valve-in-ring concept.", + "We decided to implant the Mi-thos system via a transapical approach.", + "The procedure was conducted with the patient under general anesthesia and mechanical ventilation.", + "Intraoperative guidance was provided using fluoroscopic images and TEE.", + "A 4 cm left anterior mini-thoracotomy incision was made.", + "Puncture and cannulation were carried out using 6F sheaths on both the right femoral artery and vein.", + "A temporary pacemaker electrode was inserted into the right ventricle.", + "A 6F pigtail catheter was advanced from the right femoral artery to the left ventricle.", + "Standard apical access was obtained.", + "The entry site was secured using a hexagonal suture.", + "Adjustments were made to achieve a cranial right-anterior-oblique angulation.", + "Ventriculograms were performed to evaluate the MR and assess the shape of the left ventricle and the mitral annuloplasty ring.", + "The assembly of a 33 mm Mi-thos bioprosthesis onto the delivery system was performed in vitro.", + "An apical puncture was made, and a 6 Fr sheath was inserted.", + "A 6F pigtail catheter and a J-tipped 0.035-inch guide wire were guided across the mitral surgical ring and into the left atrium.", + "A 260 cm Lunderquist super stiff wire was used for exchange.", + "The delivery system was inserted over the Lunderquist guide wire and advanced in a retrograde manner across the mitral annuloplasty ring via the transapical approach.", + "The atrial skirt was released and completely covered the mitral annulus and the annuloplasty ring.", + "The ventricular portion of the device remained partially confined to the sheath.", + "The position and alignment of the Mi-thos valve were confirmed.", + "The entire system was retracted and properly seated on the mitral annuloplasty ring.", + "The ventricular portion of the bioprosthesis was released and securely anchored to the native MV using secure barbs.", + "Ventriculograms confirmed the excellent position and shape of the Mi-thos valve.", + "There was no evidence of transvalvular regurgitation, paravalvular leak, or left ventricular outflow tract obstruction.", + "The area of the neo-left ventricular outflow tract was 374.6 cm2.", + "TEE indicated a mean pressure gradient of 3 mmHg.", + "The delivery system was removed through the apex incision.", + "Hemostasis was achieved using the apical strings.", + "The patient was successfully weaned off the ventilator.", + "The patient was transferred to the cardiac intensive care unit.", + "The postoperative recovery was smooth.", + "The patient was discharged in good clinical condition 5 days after the operation.", + "The transthoracic echocardiogram confirmed the excellent position and function of the valve.", + "There was no evidence of any significant transvalvular or paravalvular regurgitation.", + "The maximum and mean gradients were measured at 6 mmHg and 2 mmHg, respectively.", + "The patient’s symptoms had improved (NYHA functional class II)." + ], + "summary": "We describe the case of a 67-year-old male patient who underwent surgical mitral concomitant tricuspid annuloplasty repair 7 years ago who developed recurrent severe MR (New York Heart Association functional class IV). To avoid a high-risk surgical reoperation, we chose to perform a TMViR using an innovative dedicated device-the Mi-thos system-via a transapical approach. A patient-specific, 3-dimensional printed model was used to guide the procedure to avoid potential challenges. The procedure was performed successfully, and the patient exhibited symptomatic improvement.", + "summary_subclaims": [ + "The patient was a 67-year-old male.", + "The patient had undergone surgical mitral concomitant tricuspid annuloplasty repair 7 years ago.", + "The patient developed recurrent severe MR.", + "The patient was in New York Heart Association functional class IV.", + "A high-risk surgical reoperation was avoided.", + "A TMViR was performed using the Mi-thos system.", + "The Mi-thos system is an innovative dedicated device.", + "The procedure was performed via a transapical approach.", + "A patient-specific, 3-dimensional printed model was used to guide the procedure.", + "The procedure was performed successfully.", + "The patient exhibited symptomatic improvement." + ] + }, + { + "id": "multiclinsum_test_2399_en.txt", + "fulltext": "A 35-year-old-male patient presented with sudden loss of vision associated with periorbital swelling in both eyes (OU). He had systemic complaints of fever and pedal edema. The patient was already undergoing treatment for membranoproliferative glomerulnephritis, and for the previous seven months was taking oral prednisone (pg. mg/day) and Angiotensin converting enzyme inhibitor. Ocular examination revealed visual acuity of light perception (LP) with inaccurate ray projection in OU.\nSlit lamp biomicroscopic examination revealed 2+ cells in anterior chamber and pigments over the anterior lens surface in OU. Fundus examination revealed hazy media along with retinal detachment in the inferotemporal area in OU. Sub-retinal exudates, intraretinal hemorrhages along with dilated veins and narrowed arteries were visible. Intraocular pressure (IOP) was 16 mmHg in OU. The patient had blood pressure of 160/100 mmHg and bradycardia. Hence, the initial diagnosis was hypertension related exudative retinal detachment, although both atypical central serous chorioretinopathy and Vogt-Koyanagi Harada syndrome were also considered in differential diagnosis. After receiving a nephrologist's opinion, the patient was stabilized with an injection of hydrocortisone 200 mg OD, frusemide 40 mg OD, cefixime 200 mg BD along with amlodipine 5 mg OD as a hypertensive drug.\nAfter two days, the patient developed generalized hypotony, a staggering gait, truncal ataxia, and buccal and proximal weakness with decreased plantar reflexes. After neurology consultation, a pontomedullary lesion or cytomegalovirus meningitis was considered as an initial cause. A cerebrospinal fluid tap was performed to rule out meningitis; the results were normal. Magnetic resonance imaging (MRI) of the brain [Figure and ] showed multiple cystic-enhancing lesions over both cerebral hemispheres, suggestive of tuberculomas or neurocysticercosis.\nThe patient was started on anti-tubercular treatment (ATT) along with oral steroids. Four days after starting ATT, the patient had a generalized tonic-clonic seizure. A contrast MRI showed disseminated parenchymal lesions. At the beginning of anti-epileptic treatment, patient showed signs of improvement over the next two weeks; however after this period the patient started worsening. The patient had restricted abduction, sluggishly reacting pupils, 3+ cells in the anterior chamber OU with IOP of 66 and 52 mmHg in the right and left eyes, respectively. Fundus examination revealed increased exudates, increased height of retinal detachment and vitreous cells OU. A diagnosis of disseminated toxoplasma or malignancy was considered. Analysis of an aqueous tap via polymerase chain reaction (PCR) was negative for malignant cells, tuberculosis, cytomegalovirus (CMV), herpes simplex virus (HSV), varicella zoster virus (VZV), and toxoplasma.\nAn Ahmed glaucoma valve was implanted in the left eye subsequent to failure of IOP control with maximum medical therapy. Postoperatively, the left eye was stony hard with severe conjunctival chemosis and a shallow anterior chamber .\nDue to suspicion of metastatic endophthalmitis, five weeks after initial presentation, a vitreous biopsy was performed through pars plana vitrectomy. Intravitreal vancomycin (1 mg/0.1 ml), ceftazidime (2.5 mg/0.1 ml), and voriconazole (1 mg/0.1 ml) were instilled at the end of the procedure and the patient was started on fortified cefazolin 5% and tobramycin 1.4% every hour and Natamycin 5% (every six hours) for presumptive fungal endophthalmitis. All tissue sample smears and cultures that were tested for bacterial and fungal organisms were negative.\nSubsequently, the patient had no LP along with severe conjunctival chemosis, exposure keratopathy, and conjunctival abscesses. Cerebrospinal fluid was negative for CMV and Cryptococcus sp. Blood tests were negative for HIV and TORCH (Toxoplasma gondii, other viruses [HIV, measles, and so on), rubella [German measles]), CMV, and herpes simplex. Blood culture showed no evidence of bacterial and fungal organism growth. A bone marrow biopsy was performed to rule out blood cell malignancy but results were normal.\nDue to the progressive worsening of patients' systemic status and severe cachexia, a repeat MRI of the brain was done, and revealed a large right parieto-occipital mass lesion [Figure and ]. The orbital region showed bilateral globe deformities, intraocular hemorrhages, and extraocular soft-tissue inflammation [Figure and ].\nA multiloculated intracerebral abscess was drained, and a brain biopsy was performed, revealing the presence of the Nocardia organism along with granulomatous reactions [Figure –]. The patient was administered intravenous imipenem for two weeks, amikacin for four weeks, and later, oral cotrimoxazole and trimethoprim. However, the patient had no LP in both eyes despite anti-nocardial treatment, probably because of delayed diagnosis and severity of involvement. Although the patient improved systemically over next two weeks, he subsequently developed phthisis of both eyes.", + "fulltext_subclaims": [ + "A 35-year-old-male patient presented with sudden loss of vision associated with periorbital swelling in both eyes.", + "He had systemic complaints of fever and pedal edema.", + "The patient was already undergoing treatment for membranoproliferative glomerulonephritis.", + "For the previous seven months, he was taking oral prednisone (pg. mg/day) and an Angiotensin converting enzyme inhibitor.", + "Ocular examination revealed visual acuity of light perception with inaccurate ray projection in both eyes.", + "Slit lamp biomicroscopic examination revealed 2+ cells in anterior chamber and pigments over the anterior lens surface in both eyes.", + "Fundus examination revealed hazy media along with retinal detachment in the inferotemporal area in both eyes.", + "Sub-retinal exudates, intraretinal hemorrhages along with dilated veins and narrowed arteries were visible.", + "Intraocular pressure was 16 mmHg in both eyes.", + "The patient had blood pressure of 160/100 mmHg and bradycardia.", + "The initial diagnosis was hypertension related exudative retinal detachment.", + "Both atypical central serous chorioretinopathy and Vogt-Koyanagi Harada syndrome were also considered in differential diagnosis.", + "After receiving a nephrologist's opinion, the patient was stabilized with an injection of hydrocortisone 200 mg OD.", + "The patient was started on frusemide 40 mg OD.", + "The patient was started on cefixime 200 mg BD.", + "The patient was started on amlodipine 5 mg OD as a hypertensive drug.", + "After two days, the patient developed generalized hypotony.", + "The patient developed a staggering gait, truncal ataxia, and buccal and proximal weakness.", + "The patient had decreased plantar reflexes.", + "A cerebrospinal fluid tap was performed to rule out meningitis; the results were normal.", + "Magnetic resonance imaging of the brain showed multiple cystic-enhancing lesions over both cerebral hemispheres.", + "The MRI findings were suggestive of tuberculomas or neurocysticercosis.", + "The patient was started on anti-tubercular treatment along with oral steroids.", + "Four days after starting ATT, the patient had a generalized tonic-clonic seizure.", + "A contrast MRI showed disseminated parenchymal lesions.", + "At the beginning of anti-epileptic treatment, the patient showed signs of improvement over the next two weeks.", + "After this period, the patient started worsening.", + "The patient had restricted abduction, sluggishly reacting pupils, 3+ cells in the anterior chamber in both eyes.", + "Intraocular pressure was 66 mmHg in the right eye and 52 mmHg in the left eye.", + "Fundus examination revealed increased exudates, increased height of retinal detachment and vitreous cells in both eyes.", + "A diagnosis of disseminated toxoplasma or malignancy was considered.", + "Analysis of an aqueous tap via polymerase chain reaction was negative for malignant cells.", + "The aqueous tap PCR was negative for tuberculosis, cytomegalovirus, herpes simplex virus, varicella zoster virus, and toxoplasma.", + "An Ahmed glaucoma valve was implanted in the left eye subsequent to failure of IOP control with maximum medical therapy.", + "Postoperatively, the left eye was stony hard with severe conjunctival chemosis and a shallow anterior chamber.", + "Due to suspicion of metastatic endophthalmitis, five weeks after initial presentation, a vitreous biopsy was performed through pars plana vitrectomy.", + "Intravitreal vancomycin (1 mg/0.1 ml), ceftazidime (2.5 mg/0.1 ml), and voriconazole (1 mg/0.1 ml) were instilled at the end of the procedure.", + "The patient was started on fortified cefazolin 5% and tobramycin 1.4% every hour.", + "The patient was started on Natamycin 5% every six hours.", + "All tissue sample smears and cultures that were tested for bacterial and fungal organisms were negative.", + "The patient had no light perception along with severe conjunctival chemosis, exposure keratopathy, and conjunctival abscesses.", + "Cerebrospinal fluid was negative for CMV and Cryptococcus sp.", + "Blood tests were negative for HIV and TORCH.", + "Blood culture showed no evidence of bacterial and fungal organism growth.", + "A bone marrow biopsy was performed to rule out blood cell malignancy but results were normal.", + "A repeat MRI of the brain revealed a large right parieto-occipital mass lesion.", + "The orbital region showed bilateral globe deformities, intraocular hemorrhages, and extraocular soft-tissue inflammation.", + "A multiloculated intracerebral abscess was drained, and a brain biopsy was performed.", + "The brain biopsy revealed the presence of the Nocardia organism along with granulomatous reactions.", + "The patient was administered intravenous imipenem for two weeks.", + "The patient was administered amikacin for four weeks.", + "The patient was later administered oral cotrimoxazole and trimethoprim.", + "The patient had no light perception in both eyes despite anti-nocardial treatment.", + "The patient probably had no light perception because of delayed diagnosis and severity of involvement.", + "The patient improved systemically over the next two weeks.", + "The patient subsequently developed phthisis of both eyes." + ], + "summary": "A 35-year-old man with a history of long-term, prescribed oral steroid use for membranoproliferative glomerulonephritis presented with profound bilateral vision loss. Patient's diagnosis of bilateral endogenous nocardial endophthalmitis was delayed. Nocardia was finally isolated from a brain biopsy after a repeat magnetic resonance imaging revealed a brain abscess. With anti-nocardia therapy, patient improved systemically, but the visual outcome was poor, with no light perception in both eyes.", + "summary_subclaims": [ + "The patient is a 35-year-old man.", + "The patient has a history of long-term, prescribed oral steroid use.", + "The patient's oral steroids were for membranoproliferative glomerulonephritis.", + "The patient presented with profound bilateral vision loss.", + "The patient's diagnosis of bilateral endogenous nocardial endophthalmitis was delayed.", + "Nocardia was finally isolated from a brain biopsy.", + "A repeat magnetic resonance imaging revealed a brain abscess.", + "With anti-nocardia therapy, the patient improved systemically.", + "The patient's visual outcome was poor.", + "The patient had no light perception in both eyes." + ] + }, + { + "id": "multiclinsum_test_3026_en.txt", + "fulltext": "A 42-year-old woman with a stable partner who consulted for a painful swelling in the genital area. On medical examination, the presence of an abscess in the Bartholin gland was confirmed, which was drained; the purulent material from the puncture was sent for culture. The patient was treated empirically with azithromycin 1 g on the first day and then 500 mg/day for 5 days. The sample was seeded on blood agar, chocolate agar and thioglycolate broth. It was incubated for 24 h at 37 °C in an atmosphere with 5% CO2. Gram staining of the purulent material was performed. Identification was performed by VITEK®2 with VITEK®2 NH cards.\nThe sample from the abscess and the isolate were sent to the STD Service of the National Institute of Infectious Diseases (INEI)-ANLIS \"Dr. Carlos G. Malbrán\" for confirmation of genus and species. In addition, the presence of Chlamydia trachomatis, Mycoplasma genitalium, Mycoplasma hominis and Ureaplasma spp. was investigated in the sample from the abscess by the polymerase chain reaction (PCR) technique. Confirmation of genus and species from the isolate and the determination of the capsular group were performed by PCR. For molecular characterisation and subtyping, the sequentiotype (ST) and the clonal complex (CC) were determined by the technique of multi-locus sequencing (MLST). The antigenic profile was studied by amplification and sequencing of the genes encoding PorA (porin A), fHbp (factor H binding protein), NHBA (heparin binding antigen) and NadA (Neisseria adhesion protein)9. The analysis of the sequences obtained for the assignment of peptide allelic variants was performed in the PubMLST database.\nIn addition, the antimicrobial service of INEI-ANLIS determined the minimum inhibitory concentration (MIC) by dilution in agar of the following antibiotics: penicillin, ampicillin, ceftriaxone, rifampicin, ciprofloxacin, chloramphenicol, tetracycline and azithromycin. The methodology established by the Clinical and Laboratory Standards Institute (CLSI) was followed.\nThe patient was swabbed oropharyngeally, urethrally and endocervically for the search of colonisation by N. meningitidis by PCR and culture. It was not possible to obtain swabs from her sexual partner. All samples were sent to the ETS service of INEI-ANLIS.\nGram staining of the purulent material showed a large inflammatory reaction and Gram negative diplococci. After 24 hours, the colonies in the solid media were bright, greyish and larger than the N. gonorrhoeae colonies. The colonies were tested for superoxol and oxidase and were both positive. Identification with VITEK® 2 NH cards showed N. meningitidis (97%). The identification of the isolate was confirmed by the ETS service of INEI-ANLIS by testing the use of carbohydrates (glucose, maltose, lactose and sucrose) and mass spectrometry (MALDI-TOF MS, Bruker, Daltonics). The PCR technique from the sample was positive for N. meningitidis and M. hominis and negative for C. trachomatis, M. genitalium and Ureaplasma spp.\nThe isolate was identified as belonging to capsular group B (NmB), ST-35 (CC-35), and its outer membrane protein profile consisted of PorA 22-1,14; NHBA 21 and fHbp 16 (Novartis family 2). The gene encoding the NadA protein was not detected.\nThe antibiotic susceptibility of the isolate was intermediate to penicillin (MIC: 0.12 μg/ml) and ampicillin (MIC: 0.25 μg/ml) and sensitive to ceftriaxone (MIC: 0.0005 μg/ml), rifampicin (MIC: ≤ 0.004 μg/ml), ciprofloxacin (MIC: 0.015 μg/ml), chloramphenicol (MIC: 1 μg/ml), tetracycline (MIC: 0.12 μg/ml) and azithromycin (MIC: 0.12 μg/ml).\nWith N. meningitidis confirmed as the infectious agent of bartholinitis, the antibiotic was changed to ceftriaxone. The PCR technique and cultures of the patient's oropharyngeal, urethral, and endocervical swabs were negative for N. meningitidis.\n", + "fulltext_subclaims": [ + "A 42-year-old woman with a stable partner consulted for a painful swelling in the genital area.", + "On medical examination, the presence of an abscess in the Bartholin gland was confirmed.", + "The abscess was drained.", + "The purulent material from the puncture was sent for culture.", + "The patient was treated empirically with azithromycin 1 g on the first day.", + "The patient was treated with azithromycin 500 mg/day for 5 days.", + "The sample was seeded on blood agar.", + "The sample was seeded on chocolate agar.", + "The sample was seeded on thioglycolate broth.", + "It was incubated for 24 h at 37 °C in an atmosphere with 5% CO2.", + "Gram staining of the purulent material was performed.", + "Identification was performed by VITEK®2 with VITEK®2 NH cards.", + "The sample from the abscess and the isolate were sent to the STD Service of the National Institute of Infectious Diseases (INEI)-ANLIS 'Dr. Carlos G. Malbrán' for confirmation of genus and species.", + "The presence of Chlamydia trachomatis was investigated in the sample from the abscess by the polymerase chain reaction (PCR) technique.", + "The presence of Mycoplasma genitalium was investigated in the sample from the abscess by the polymerase chain reaction (PCR) technique.", + "The presence of Mycoplasma hominis was investigated in the sample from the abscess by the polymerase chain reaction (PCR) technique.", + "The presence of Ureaplasma spp. was investigated in the sample from the abscess by the polymerase chain reaction (PCR) technique.", + "Confirmation of genus and species from the isolate was performed by PCR.", + "The determination of the capsular group was performed by PCR.", + "For molecular characterisation and subtyping, the sequentiotype (ST) was determined by the technique of multi-locus sequencing (MLST).", + "For molecular characterisation and subtyping, the clonal complex (CC) was determined by the technique of multi-locus sequencing (MLST).", + "The antigenic profile was studied by amplification and sequencing of the genes encoding PorA (porin A), fHbp (factor H binding protein), NHBA (heparin binding antigen) and NadA (Neisseria adhesion protein).", + "The analysis of the sequences obtained for the assignment of peptide allelic variants was performed in the PubMLST database.", + "The antimicrobial service of INEI-ANLIS determined the minimum inhibitory concentration (MIC) by dilution in agar of the following antibiotics: penicillin, ampicillin, ceftriaxone, rifampicin, ciprofloxacin, chloramphenicol, tetracycline and azithromycin.", + "The methodology established by the Clinical and Laboratory Standards Institute (CLSI) was followed.", + "The patient was swabbed oropharyngeally for the search of colonisation by N. meningitidis by PCR and culture.", + "The patient was swabbed urethrally for the search of colonisation by N. meningitidis by PCR and culture.", + "The patient was swabbed endocervically for the search of colonisation by N. meningitidis by PCR and culture.", + "It was not possible to obtain swabs from her sexual partner.", + "All samples were sent to the ETS service of INEI-ANLIS.", + "Gram staining of the purulent material showed a large inflammatory reaction and Gram negative diplococci.", + "After 24 hours, the colonies in the solid media were bright, greyish and larger than the N. gonorrhoeae colonies.", + "The colonies were tested for superoxol and oxidase and were both positive.", + "Identification with VITEK® 2 NH cards showed N. meningitidis (97%).", + "The identification of the isolate was confirmed by the ETS service of INEI-ANLIS by testing the use of carbohydrates (glucose, maltose, lactose and sucrose) and mass spectrometry (MALDI-TOF MS, Bruker, Daltonics).", + "The PCR technique from the sample was positive for N. meningitidis.", + "The PCR technique from the sample was positive for M. hominis.", + "The PCR technique from the sample was negative for C. trachomatis.", + "The PCR technique from the sample was negative for M. genitalium.", + "The PCR technique from the sample was negative for Ureaplasma spp.", + "The isolate was identified as belonging to capsular group B (NmB).", + "The isolate was identified as ST-35.", + "The isolate was identified as CC-35.", + "The outer membrane protein profile of the isolate consisted of PorA 22-1,14.", + "The outer membrane protein profile of the isolate consisted of NHBA 21.", + "The outer membrane protein profile of the isolate consisted of fHbp 16 (Novartis family 2).", + "The gene encoding the NadA protein was not detected.", + "The antibiotic susceptibility of the isolate was intermediate to penicillin (MIC: 0.12 μg/ml).", + "The antibiotic susceptibility of the isolate was intermediate to ampicillin (MIC: 0.25 μg/ml).", + "The antibiotic susceptibility of the isolate was sensitive to ceftriaxone (MIC: 0.0005 μg/ml).", + "The antibiotic susceptibility of the isolate was sensitive to rifampicin (MIC: ≤ 0.004 μg/ml).", + "The antibiotic susceptibility of the isolate was sensitive to ciprofloxacin (MIC: 0.015 μg/ml).", + "The antibiotic susceptibility of the isolate was sensitive to chloramphenicol (MIC: 1 μg/ml).", + "The antibiotic susceptibility of the isolate was sensitive to tetracycline (MIC: 0.12 μg/ml).", + "The antibiotic susceptibility of the isolate was sensitive to azithromycin (MIC: 0.12 μg/ml).", + "With N. meningitidis confirmed as the infectious agent of bartholinitis, the antibiotic was changed to ceftriaxone.", + "The PCR technique and cultures of the patient's oropharyngeal swabs were negative for N. meningitidis.", + "The PCR technique and cultures of the patient's urethral swabs were negative for N. meningitidis.", + "The PCR technique and cultures of the patient's endocervical swabs were negative for N. meningitidis." + ], + "summary": "We report a 42-year-old heterosexual woman with an abscess of the Bartholin's gland caused by Neisseria meningitidis, which was isolated by culture and identified by VITEK®2. Molecular characterisation and subtyping was performed by sequencing the sequotipe and clonal complex. Antigenic profile was studied by amplification and sequencing of the genes encoding PorA, fHbp, NHBA and NadA and antimicrobial profile was studied by MIC. Molecular diagnosis allows to confirm N. meningitidis as the causative agent of bartholinitis.\n", + "summary_subclaims": [ + "The patient is a 42-year-old heterosexual woman.", + "The patient had an abscess of the Bartholin's gland.", + "Neisseria meningitidis was isolated by culture.", + "Neisseria meningitidis was identified by VITEK®2.", + "Molecular characterisation and subtyping was performed by sequencing the sequotipe and clonal complex.", + "Antigenic profile was studied by amplification and sequencing of the genes encoding PorA, fHbp, NHBA and NadA.", + "Antimicrobial profile was studied by MIC.", + "Molecular diagnosis allows to confirm N. meningitidis as the causative agent of bartholinitis." + ] + }, + { + "id": "multiclinsum_test_216_en.txt", + "fulltext": "A case of tuberculosis of the cervix presenting as cervical carcinoma is being reported for its rarity.\nA 26-year-old P2L2 Indian lady, housewife by occupation, presented with chief complaints of pain abdomen, irregular bleeding and discharge per vaginum for three years. She had history of post-coital bleeding and inter-menstrual bleeding; and significant weight loss over the last two years. There was no history of genitourinary malignancy or tuberculosis in the past or in the family. The patient was a non-smoker, non-alcoholic and did not have any other significant medical or surgical illness in the past.\nGeneral physical examination was essentially normal with no palpable lymph nodes. Systemic examination did not reveal any abnormality. On per speculum examination, cervix was replaced by an irregular friable growth, which was bleeding on touch . On bimanual examination, same growth was felt. Uterus was anteverted, normal in size and bilateral fornices were free. Per rectal examination did not reveal any induration or nodularity of parametria and rectal mucosa was smooth and freely mobile. Colposcopic examination showed increased vascularity without any acetowhite or iodine negative areas. PAP smear showed epitheloid like cell clusters without any dysplasia. Biopsy taken from the cervical growth revealed granulomatous inflammation with caseous necrosis. Smear from cervix was found positive for acid-fast bacilli. Endometrial biopsy was normal with no AFB . A chest radiograph was normal. Sputum and urine samples were negative for AFB and failed to culture mycobacterium. CECT abdomen showed bulky cervix with evidence of soft tissue streaking in parametrium. HIV 1 and 2 was negative. Patient was started on antitubercular treatment (four drugs: isoniazid, ethambutol, rifampicin and pyrazinamide) and discharged. At six months, the cervix had an almost normal appearance and there was complete relief from symptoms.", + "fulltext_subclaims": [ + "A case of tuberculosis of the cervix presenting as cervical carcinoma is being reported for its rarity.", + "The patient was a 26-year-old P2L2 Indian lady.", + "She had pain abdomen, irregular bleeding, and discharge per vaginum for three years.", + "She had a history of post-coital bleeding and inter-menstrual bleeding.", + "She had significant weight loss over the last two years.", + "There was no history of genitourinary malignancy or tuberculosis in the past or in the family.", + "The patient was a non-smoker, non-alcoholic, and did not have any other significant medical or surgical illness in the past.", + "On per speculum examination, the cervix was replaced by an irregular friable growth that was bleeding on touch.", + "PAP smear showed epitheloid like cell clusters without any dysplasia.", + "Biopsy taken from the cervical growth revealed granulomatous inflammation with caseous necrosis.", + "Smear from cervix was found positive for acid-fast bacilli.", + "Endometrial biopsy was normal with no AFB.", + "Sputum and urine samples were negative for AFB and failed to culture mycobacterium.", + "CECT abdomen showed a bulky cervix with evidence of soft tissue streaking in parametrium.", + "HIV 1 and 2 were negative.", + "The patient was started on antitubercular treatment with four drugs: isoniazid, ethambutol, rifampicin, and pyrazinamide.", + "At six months, the cervix had an almost normal appearance and there was complete relief from symptoms." + ], + "summary": "On per speculum examination, cervix was replaced by an irregular friable growth, which was bleeding on touch. A clinical diagnosis of carcinoma cervix was made but the cervical biopsy revealed granulomatous inflammation with presence of acid-fast bacilli on cervical smear consistent with tuberculosis. The patient responded to six months of anti-tubercular therapy.", + "summary_subclaims": [ + "On per speculum examination, cervix was replaced by an irregular friable growth.", + "The growth was bleeding on touch.", + "A clinical diagnosis of carcinoma cervix was made.", + "The cervical biopsy revealed granulomatous inflammation.", + "Acid-fast bacilli were present on cervical smear.", + "The findings were consistent with tuberculosis.", + "The patient responded to six months of anti-tubercular therapy." + ] + }, + { + "id": "multiclinsum_test_200_en.txt", + "fulltext": "A 17-year-old female was admitted to our hospital in December 2019 because of increased urine foam and fatigue for 3 weeks.\nLaboratory examinations showed protein (3+) and occult blood (2+) in urine. The blood urea nitrogen was 5.39 mmol/l, the serum creatinine was 69 μmol/l, and the lymphocyte ratio was 62.01%. Kidney color Doppler ultrasound showed increased volume in both kidneys as well as enhanced parenchymal echo. Then kidney biopsy was performed, indicating lymphoblastic lymphoma or leukemia with kidney involvement . Immunohistochemistry showed TdT(+), CD99(+), CD3(−), CD20(part+), CD73(−), PAX5(+), and LCA(part+). Fluorescence in situ hybridization (FISH) of the kidney biopsy sample indicated ZNF384 rearrangement . Then, bone marrow aspiration and biopsy were performed, revealing the disappearance of fat vacuoles and the appearance of immature lymphoid cells. However, conventional G-banding cytogenetic analysis showed a normal bone marrow karyotype . A suspected diagnosis of ALL was made. There was extreme lymphocyte proliferation and the proportion of lymphoblasts was 50.8% . Flow cytometry (FCM) of bone marrow revealed CD34(+), CD117(−), CD33(+), CD64(−), CD13(+), CD14(−), CD274(−), TSLPR(−), CD11b(−), IgM(+), CD71(−), CD56(+), CD2(−), CD7(−), CD5(−), CD10(+), CD3(−), CD4(−), CD8(−), CD38(+), CD81(+), HLA-DR(+), CD19(+), CD22(+), CD20(+), cMPO(−), cCD3(−), cCD79a(+), TDT(+), CD58(+), CD61(−), CD235a(−), and CD11c(−), and these findings are compatible with BCP-ALL . Next-generation sequencing (NGS) showed STAG2 gene mutations in the bone marrow, and reverse transcription-polymerase chain reaction (RT–PCR) showed that common fusion genes for BCP-ALL, including TCF3-PBX1, TCF3-HLF, ETV6-RUNX1 and BCR-ABL, were negative. Other less common fusion genes for Ph-like ALL were also negative.\nHer medical history was unremarkable. On physical examination, the patient had an anemic appearance without ecchymosis. The initial laboratory evaluation revealed lymphocytosis (2.37 × 109/l) and moderate anemia (Hb78 g/l, vitamin B12 164 pg/ml, folic acid 3.00 ng/ml and serum ferritin 426.7 ug/l). She was diagnosed with BCP-ALL with involvement of both kidneys.\nAfter a cycle of the VCDLP regimen, the bone marrow was obviously hyperplastic and active, and immature lymphocytes were occasionally observed. FCM showed the ratio of lymphoblasts was 42% with CD34(+), CD10(−), CD19(+), CD38(+), HLA-DR(+), CD64(−), CD13(+), CD20(−), and CD33(+). Since the patient did not achieve remission, a cycle of FLAG salvage treatment was administered, and then the patient was assessed as complete remission (CR). No lymphoblasts were seen in the bone marrow. FCM showed that the ratio of lymphoblasts was 0.8% with CD34(+), CD10(−), CD19(+), CD38(+), HLA-DR(+), CD13(+) and STAG2 gene mutations. The volume of both kidneys returned to normal according to color Doppler ultrasound. After the patient achieved CR, an intrathecal drug injection was performed for consolidation therapy. Eight months after the continued complete remission (CCR), the disease relapsed. A bone marrow smear revealed 55.2% lymphoblasts, and FCM showed ALL with partial expression of CD33. FISH showed ZNF384 rearrangement (39%) according to its probe and positivity for IgH rearrangement (37%). The leukemia fusion genes and mutation panels were both negative. However, there was no remission in the bone marrow after she was treated with chidamide and a dose-adjusted FLAG plus VP chemotherapeutic regimen, as well as a highly sensitive treatment, HAD. The percentage of lymphoblasts was 14.4% and ZNF384 rearrangement was positive (17.6%) according to FISH. Currently, the patient has been admitted to the hospital and is receiving chemotherapy regularly. The details of the treatment process are summarized in Additional file .", + "fulltext_subclaims": [ + "A 17-year-old female was admitted to our hospital in December 2019 because of increased urine foam and fatigue for 3 weeks.", + "Laboratory examinations showed protein (3+) and occult blood (2+) in urine.", + "The blood urea nitrogen was 5.39 mmol/l.", + "The serum creatinine was 69 μmol/l.", + "The lymphocyte ratio was 62.01%.", + "Kidney color Doppler ultrasound showed increased volume in both kidneys.", + "Kidney color Doppler ultrasound showed enhanced parenchymal echo.", + "Kidney biopsy was performed.", + "Kidney biopsy indicated lymphoblastic lymphoma or leukemia with kidney involvement.", + "Immunohistochemistry showed TdT(+).", + "Immunohistochemistry showed CD99(+).", + "Immunohistochemistry showed CD3(−).", + "Immunohistochemistry showed CD20(part+).", + "Immunohistochemistry showed CD73(−).", + "Immunohistochemistry showed PAX5(+).", + "Immunohistochemistry showed LCA(part+).", + "Fluorescence in situ hybridization (FISH) of the kidney biopsy sample indicated ZNF384 rearrangement.", + "Bone marrow aspiration and biopsy were performed.", + "Bone marrow aspiration and biopsy revealed the disappearance of fat vacuoles.", + "Bone marrow aspiration and biopsy revealed the appearance of immature lymphoid cells.", + "Conventional G-banding cytogenetic analysis showed a normal bone marrow karyotype.", + "A suspected diagnosis of ALL was made.", + "There was extreme lymphocyte proliferation.", + "The proportion of lymphoblasts was 50.8%.", + "Flow cytometry (FCM) of bone marrow revealed CD34(+).", + "Flow cytometry (FCM) of bone marrow revealed CD117(−).", + "Flow cytometry (FCM) of bone marrow revealed CD33(+).", + "Flow cytometry (FCM) of bone marrow revealed CD64(−).", + "Flow cytometry (FCM) of bone marrow revealed CD13(+).", + "Flow cytometry (FCM) of bone marrow revealed CD14(−).", + "Flow cytometry (FCM) of bone marrow revealed CD274(−).", + "Flow cytometry (FCM) of bone marrow revealed TSLPR(−).", + "Flow cytometry (FCM) of bone marrow revealed CD11b(−).", + "Flow cytometry (FCM) of bone marrow revealed IgM(+).", + "Flow cytometry (FCM) of bone marrow revealed CD71(−).", + "Flow cytometry (FCM) of bone marrow revealed CD56(+).", + "Flow cytometry (FCM) of bone marrow revealed CD2(−).", + "Flow cytometry (FCM) of bone marrow revealed CD7(−).", + "Flow cytometry (FCM) of bone marrow revealed CD5(−).", + "Flow cytometry (FCM) of bone marrow revealed CD10(+).", + "Flow cytometry (FCM) of bone marrow revealed CD3(−).", + "Flow cytometry (FCM) of bone marrow revealed CD4(−).", + "Flow cytometry (FCM) of bone marrow revealed CD8(−).", + "Flow cytometry (FCM) of bone marrow revealed CD38(+).", + "Flow cytometry (FCM) of bone marrow revealed CD81(+).", + "Flow cytometry (FCM) of bone marrow revealed HLA-DR(+).", + "Flow cytometry (FCM) of bone marrow revealed CD19(+).", + "Flow cytometry (FCM) of bone marrow revealed CD22(+).", + "Flow cytometry (FCM) of bone marrow revealed CD20(+).", + "Flow cytometry (FCM) of bone marrow revealed cMPO(−).", + "Flow cytometry (FCM) of bone marrow revealed cCD3(−).", + "Flow cytometry (FCM) of bone marrow revealed cCD79a(+).", + "Flow cytometry (FCM) of bone marrow revealed TDT(+).", + "Flow cytometry (FCM) of bone marrow revealed CD58(+).", + "Flow cytometry (FCM) of bone marrow revealed CD61(−).", + "Flow cytometry (FCM) of bone marrow revealed CD235a(−).", + "Flow cytometry (FCM) of bone marrow revealed CD11c(−).", + "These findings are compatible with BCP-ALL.", + "Next-generation sequencing (NGS) showed STAG2 gene mutations in the bone marrow.", + "Reverse transcription-polymerase chain reaction (RT–PCR) showed that common fusion genes for BCP-ALL, including TCF3-PBX1, TCF3-HLF, ETV6-RUNX1 and BCR-ABL, were negative.", + "Other less common fusion genes for Ph-like ALL were also negative.", + "The patient was diagnosed with BCP-ALL with involvement of both kidneys.", + "After a cycle of the VCDLP regimen, the bone marrow was obviously hyperplastic and active.", + "After a cycle of the VCDLP regimen, immature lymphocytes were occasionally observed.", + "FCM showed the ratio of lymphoblasts was 42%.", + "Since the patient did not achieve remission, a cycle of FLAG salvage treatment was administered.", + "The patient was assessed as complete remission (CR).", + "No lymphoblasts were seen in the bone marrow.", + "FCM showed that the ratio of lymphoblasts was 0.8%.", + "The volume of both kidneys returned to normal according to color Doppler ultrasound.", + "An intrathecal drug injection was performed for consolidation therapy.", + "Eight months after the continued complete remission (CCR), the disease relapsed.", + "A bone marrow smear revealed 55.2% lymphoblasts.", + "FCM showed ALL with partial expression of CD33.", + "FISH showed ZNF384 rearrangement (39%) according to its probe.", + "FISH showed positivity for IgH rearrangement (37%).", + "The leukemia fusion genes and mutation panels were both negative.", + "There was no remission in the bone marrow after she was treated with chidamide and a dose-adjusted FLAG plus VP chemotherapeutic regimen.", + "There was no remission in the bone marrow after she was treated with a highly sensitive treatment, HAD.", + "The percentage of lymphoblasts was 14.4%.", + "ZNF384 rearrangement was positive (17.6%) according to FISH.", + "The patient has been admitted to the hospital and is receiving chemotherapy regularly." + ], + "summary": "We described a 17-year-old adolescent who was diagnosed with ALL and had renal involvement as the first manifestation, which was very rare in the existing studies. FISH analysis indicated a rearrangement of ZNF384 according to its probe. The patient had a typical characteristic immunophenotype of ZNF384 rearrangement, with CD10 negativity and CD13 and CD33 positivity. She had an unfavorable prognosis because she responded poorly to chemotherapy and developed a relapse shortly after reaching CR.", + "summary_subclaims": [ + "We described a 17-year-old adolescent who was diagnosed with ALL.", + "The patient had renal involvement as the first manifestation.", + "Renal involvement as the first manifestation was very rare in the existing studies.", + "FISH analysis indicated a rearrangement of ZNF384 according to its probe.", + "The patient had a typical characteristic immunophenotype of ZNF384 rearrangement.", + "The patient had CD10 negativity.", + "The patient had CD13 positivity.", + "The patient had CD33 positivity.", + "She had an unfavorable prognosis.", + "She responded poorly to chemotherapy.", + "She developed a relapse shortly after reaching CR." + ] + }, + { + "id": "multiclinsum_test_3304_en.txt", + "fulltext": "An 18-year-old woman sustained a neck contusion following blunt trauma to the submandibular region from her bicycle handlebar grip end after a light contact with a motor vehicle. Upon initial examination, the patient's level of consciousness and vital signs were within normal ranges, and she did not report any previous medical history of concern. The patient did not express any concerns regarding the condition of the neck or throat. A secondary survey revealed a 25-mm contusion in the submandibular region with a 3 × 5 mm laceration at its center. The wound was free of contamination, exhibited no active bleeding, and did not present with surrounding hematoma formation. Furthermore, it was determined that there was no tracheal injury due to the absence of abnormal breath sounds at the neck and the absence of any airway deformity or deviation. Computed tomography (CT) revealed the presence of interstitial air extending through the soft tissue gap between the sternocleidomastoid muscle and the larynx, extending to the retropharyngeal space. While the wound was cleansed with saline solution, the patient reported the presence of water in her oral cavity. Therefore, we established a connection between the pharynx and the exterior laceration site. Subsequently, a water drinking test was conducted to ascertain the presence of a fistula from the pharyngeal side to the neck wound. However, no fluid was observed to leak from the wound, and the fistula was thus determined to be unidirectional. A film-shaped drain was placed within the wound, and the wound was sutured in a roughly approximated manner. The patient was admitted to the hospital for a follow-up examination. Fluids and oral antimicrobials were administered 3 h after admission, and the patient was permitted to commence oral feeding after 12 h. The patient was discharged on the third day without any issues with her general condition or neck. Subsequent to her discharge from our institution, the patient did not contact us to express any concerns regarding unusual occurrences. The outpatient examination conducted on the sixth day following the injury revealed no abnormal physical findings, and the drain was subsequently removed.", + "fulltext_subclaims": [ + "The patient is an 18-year-old woman.", + "She sustained a neck contusion following blunt trauma to the submandibular region.", + "The trauma occurred from her bicycle handlebar grip end after a light contact with a motor vehicle.", + "Upon initial examination, the patient's level of consciousness was within normal ranges.", + "The patient did not report any previous medical history of concern.", + "A secondary survey revealed a 25-mm contusion in the submandibular region.", + "The contusion had a 3 × 5 mm laceration at its center.", + "The wound was free of contamination.", + "The wound exhibited no active bleeding.", + "There was no surrounding hematoma formation.", + "There was no tracheal injury.", + "Computed tomography revealed interstitial air extending through the soft tissue gap between the sternocleidomastoid muscle and the larynx.", + "The interstitial air extended to the retropharyngeal space.", + "The patient reported the presence of water in her oral cavity.", + "A connection was established between the pharynx and the exterior laceration site.", + "A water drinking test was conducted.", + "No fluid was observed to leak from the wound.", + "The fistula was determined to be unidirectional.", + "A film-shaped drain was placed within the wound.", + "The wound was sutured in a roughly approximated manner.", + "The patient was admitted to the hospital for a follow-up examination.", + "Fluids and oral antimicrobials were administered 3 h after admission.", + "The patient was permitted to commence oral feeding after 12 h.", + "The patient was discharged on the third day.", + "The patient did not contact us to express any concerns regarding unusual occurrences.", + "The outpatient examination conducted on the sixth day following the injury revealed no abnormal physical findings.", + "The drain was subsequently removed." + ], + "summary": "An 18-year-old woman sustained a contusion of the neck due to blunt trauma to the left submandibular region from her bicycle handlebar grip following a collision with a motor vehicle. The patient exhibited a minor contusion of the neck, devoid of active bleeding or hematoma. Furthermore, she did not express any concerns regarding the condition of her neck or throat. A medical examination revealed the absence of abnormal breath sounds in the neck and the absence of any deformity or deviation of the airway. Despite the absence of a foreign body, computed tomography demonstrated the presence of free air extending through the interstitial space between the sternocleidomastoid muscle and larynx, reaching the posterior pharyngeal wall. While the wound was being cleansed with saline solution, the patient reported a sensation of water entering the mouth, which led to the confirmation of a perforation injury to the pharynx. No evidence of leakage was observed during the drinking tests, and the fistula was determined to be unidirectional. The patient was admitted to the hospital for follow-up and discharged on the third day without any additional complications. The outpatient examination conducted on the sixth day following the injury revealed no abnormalities in the physical findings.", + "summary_subclaims": [ + "The patient sustained a contusion of the neck due to blunt trauma to the left submandibular region.", + "The contusion was caused by the bicycle handlebar grip.", + "The patient exhibited a minor contusion of the neck.", + "There was no active bleeding or hematoma.", + "The patient did not express any concerns regarding the condition of her neck or throat.", + "A medical examination revealed the absence of abnormal breath sounds in the neck.", + "There was no deformity or deviation of the airway.", + "Computed tomography demonstrated the presence of free air extending through the interstitial space between the sternocleidomastoid muscle and larynx.", + "The free air reached the posterior pharyngeal wall.", + "During wound cleansing with saline solution, the patient reported a sensation of water entering the mouth.", + "This sensation led to the confirmation of a perforation injury to the pharynx.", + "No evidence of leakage was observed during the drinking tests.", + "The fistula was determined to be unidirectional.", + "The patient was admitted to the hospital for follow-up.", + "The patient was discharged on the third day without any additional complications.", + "The outpatient examination conducted on the sixth day following the injury revealed no abnormalities in the physical findings." + ] + }, + { + "id": "multiclinsum_test_2303_en.txt", + "fulltext": "A 22-year-old white Caucasian man came to our office complaining of blurred vision in his left eye (LE) with night blindness and difficulty in driving. A flu-like illness was reported 2 weeks before the ocular symptoms began. His best-corrected visual acuity (BCVA) was 20/20 in his right eye (RE) and 20/20 in his LE. A fundus examination showed the healthy condition of his RE, while his LE showed only a scattered mottling of the fundus pigment on the temporal side of the optic nerve. We performed B-scan optical coherence tomography (OCT) around the optic nerve head that showed hyperreflectivity in the outer retina with interruption of the ellipsoid layers in the juxtapapillary region . An en face scan showed diffuse hyperreflective spots in the RPE slab . After performing autofluorescence (FAF), FA, indocyanine green angiography (ICG), and OCTA, MEWDS was diagnosed . FAF showed diffuse hyperautofluorescent areas around the optic disc that extended into the macula region . The en face scan showed small hyperreflective dots at the posterior pole. The FA revealed juxtapapillary hyperfluorescent dots of leakage similar to the ICG early and late phase . Furthermore, the late frames of ICG showed diffuse dots of hypocyanescence at the posterior pole. OCTA showed anomalous neovascularization as an arcuate flow vascular net on the disc temporal side. The vascular net was formed by thin tangled capillaries . The neovascular tangled net area was outlined in the assessment . Although it is known that MEWDS is often self-limiting, to reduce the possible inflammatory reaction, we preferred to administer prednisolone orally with an initial prescription of 50 mg/day for 7 days, followed by 25 mg/day for 7 days, 12.5 mg/day for 7 days, and 5 mg/day for the last 7 days. After 1 month of therapy, significant regression of juxtapapillary neovascularization was observed. Small capillaries regressed almost completely, leaving only wide and straight main vessels . Our patient’s symptoms resolved. Figure shows the evolution over a 4-year observation period. A steady situation was observed after 4 years with an absence of symptoms, and BCVA was 20/20.", + "fulltext_subclaims": [ + "A 22-year-old white Caucasian man came to our office complaining of blurred vision in his left eye (LE) with night blindness and difficulty in driving.", + "A flu-like illness was reported 2 weeks before the ocular symptoms began.", + "His best-corrected visual acuity (BCVA) was 20/20 in his right eye (RE) and 20/20 in his LE.", + "A fundus examination showed the healthy condition of his RE.", + "His LE showed only a scattered mottling of the fundus pigment on the temporal side of the optic nerve.", + "B-scan optical coherence tomography (OCT) around the optic nerve head showed hyperreflectivity in the outer retina with interruption of the ellipsoid layers in the juxtapapillary region.", + "An en face scan showed diffuse hyperreflective spots in the RPE slab.", + "After performing autofluorescence (FAF), FA, indocyanine green angiography (ICG), and OCTA, MEWDS was diagnosed.", + "FAF showed diffuse hyperautofluorescent areas around the optic disc that extended into the macula region.", + "The en face scan showed small hyperreflective dots at the posterior pole.", + "The FA revealed juxtapapillary hyperfluorescent dots of leakage similar to the ICG early and late phase.", + "The late frames of ICG showed diffuse dots of hypocyanescence at the posterior pole.", + "OCTA showed anomalous neovascularization as an arcuate flow vascular net on the disc temporal side.", + "The vascular net was formed by thin tangled capillaries.", + "The neovascular tangled net area was outlined in the assessment.", + "We preferred to administer prednisolone orally with an initial prescription of 50 mg/day for 7 days, followed by 25 mg/day for 7 days, 12.5 mg/day for 7 days, and 5 mg/day for the last 7 days.", + "After 1 month of therapy, significant regression of juxtapapillary neovascularization was observed.", + "Small capillaries regressed almost completely, leaving only wide and straight main vessels.", + "Our patient’s symptoms resolved.", + "A steady situation was observed after 4 years with an absence of symptoms, and BCVA was 20/20." + ], + "summary": "Here, we describe a case of a 22-year-old white Caucasian man with blurred vision in his left eye who exhibited juxtapapillary choroidal neovascularization on optical coherence tomography angiography. Although multiple evanescent white dot syndrome is often self-limiting, to reduce the possibility of an inflammatory reaction, we preferred to administer prednisolone orally. After 3 months, significant regression of juxtapapillary neovascularization was observed by B-scan and optical coherence tomography angiography. Symptoms resolved in 3 months. A steady situation was observed at 4 years of follow-up.", + "summary_subclaims": [ + "The patient was a 22-year-old white Caucasian man.", + "The patient had blurred vision in his left eye.", + "The patient exhibited juxtapapillary choroidal neovascularization on optical coherence tomography angiography.", + "Multiple evanescent white dot syndrome is often self-limiting.", + "Prednisolone was administered orally.", + "Significant regression of juxtapapillary neovascularization was observed by B-scan and optical coherence tomography angiography after 3 months.", + "Symptoms resolved in 3 months.", + "A steady situation was observed at 4 years of follow-up." + ] + }, + { + "id": "multiclinsum_test_2347_en.txt", + "fulltext": "The patient was a 38-year-old single man from Kerman city who was admitted in Shahid Beheshti Hospital of Kerman four years ago because of aggression and behavioral change for the first time. According to the patient, he has been using oral Ritalin for the past 6 months and in the recent months, he has diluted tablets in water and injected intravenously and after injection, the shape and meaning of objects have changed for him. He had sometimes injected even up to 4 Ritalin tablets. According to the patient, he feels that he has parasitic infection and he sees cockroaches with blue color crewel on his body and because of that he has burned different parts of his body by cigarettes to destroy them. Also, he sees these bugs on the floor and around objects and because of that he fired house items many times and even fired his bed, TV and personal computer (PC). Even once, his entire house was burned in fire. Sometimes he washed objects with water to destroy bugs. He would stand under the shower for hours to send away these bugs. People around him have always seen him playing with water or fire. Along with these symptoms, he was suspicious to others and believed that they have prepared amulet for him and followed him sometimes. He complained of sleeplessness and restlessness. In physical examination, multiple skin abscesses and acute cellulitis caused by injections were visible on different areas of his body and there was bilateral pitting edema on his legs. He had also tachycardia and there was no problem in the brain CT scan and heart echocardiography.\nIn psychological condition examination, he was restless and to some extent irritable. He also had flight of ideas and noted vision and touch fantasies as well as delirium of harm and damage and being under control. Attention was reduced but immediate, near and far memories were natural. Also, knowledge of time, place and person was normal. Impairment in judgment and vision was evident. The patient was hospitalized for the diagnosis of psychotic disorder due to Ritalin injection and after preventing Ritalin consumption and recovery from infection symptoms, fornication signs were resolved. In later interviews with the patient, schizophrenic symptoms such as deliriums of pessimism and being under control were detected and the patient was treated for schizophrenia diagnosis. After discharge, in spite of regular medication, he was hospitalized for two times and both times it was after Ritalin tablet injections and he was discharged after disease symptoms were controlled and there was no obstacle for medication. By preventing Ritalin consumption after discharge, he has not experienced psychotic symptoms yet and his background disease is under control with anti-psychotic drugs.", + "fulltext_subclaims": [ + "The patient was a 38-year-old single man from Kerman city.", + "He was admitted in Shahid Beheshti Hospital of Kerman four years ago.", + "He was admitted because of aggression and behavioral change for the first time.", + "According to the patient, he has been using oral Ritalin for the past 6 months.", + "In the recent months, he has diluted tablets in water and injected intravenously.", + "After injection, the shape and meaning of objects have changed for him.", + "He has sometimes injected even up to 4 Ritalin tablets.", + "He feels that he has parasitic infection.", + "He sees cockroaches with blue color crewel on his body.", + "He has burned different parts of his body by cigarettes to destroy them.", + "He sees these bugs on the floor and around objects.", + "He fired house items many times and even fired his bed, TV and personal computer.", + "His entire house was burned in fire once.", + "He washed objects with water to destroy bugs.", + "He would stand under the shower for hours to send away these bugs.", + "People around him have always seen him playing with water or fire.", + "He was suspicious to others and believed that they have prepared amulet for him.", + "He believed that others followed him sometimes.", + "He complained of sleeplessness and restlessness.", + "In physical examination, multiple skin abscesses and acute cellulitis caused by injections were visible on different areas of his body.", + "There was bilateral pitting edema on his legs.", + "He had tachycardia.", + "There was no problem in the brain CT scan.", + "There was no problem in heart echocardiography.", + "In psychological condition examination, he was restless and to some extent irritable.", + "He had flight of ideas.", + "He noted vision and touch fantasies.", + "He had delirium of harm and damage.", + "He had delirium of being under control.", + "Attention was reduced.", + "Immediate, near and far memories were natural.", + "Knowledge of time, place and person was normal.", + "Impairment in judgment and vision was evident.", + "The patient was hospitalized for the diagnosis of psychotic disorder due to Ritalin injection.", + "After preventing Ritalin consumption and recovery from infection symptoms, fornication signs were resolved.", + "In later interviews with the patient, schizophrenic symptoms such as deliriums of pessimism and being under control were detected.", + "The patient was treated for schizophrenia diagnosis.", + "After discharge, in spite of regular medication, he was hospitalized for two times.", + "Both times it was after Ritalin tablet injections.", + "He was discharged after disease symptoms were controlled and there was no obstacle for medication.", + "By preventing Ritalin consumption after discharge, he has not experienced psychotic symptoms yet.", + "His background disease is under control with anti-psychotic drugs." + ], + "summary": "In this paper, a young man is presented with injection of methylphenidate tablets with acute cellulitis due to this injection and the related symptoms. In the first hospitalization and after recovery from psychotic disorder due to tablet injections, he was under treatment with anti-psychotics because of other symptoms related to schizophrenia. Although the patient was regularly under schizophrenic medication after discharge, he was hospitalized twice more due to psychotic symptoms that appeared after injecting methylphenidate.", + "summary_subclaims": [ + "A young man is presented with injection of methylphenidate tablets.", + "The patient had acute cellulitis due to this injection.", + "The patient was hospitalized after recovery from psychotic disorder due to tablet injections.", + "The patient was under treatment with anti-psychotics because of other symptoms related to schizophrenia.", + "The patient was regularly under schizophrenic medication after discharge.", + "The patient was hospitalized twice more due to psychotic symptoms.", + "The psychotic symptoms appeared after injecting methylphenidate." + ] + }, + { + "id": "multiclinsum_test_1356_en.txt", + "fulltext": "A 47-year-old man (body weight 62.1 kg and height 166.8 cm) was reported in our hospital with a past medical history of tongue cancer that was operable. The preoperative spirometry test, electrocardiography, and transthoracic echocardiogram were normal. He is a non-smoker with no history of cerebrovascular disease. In his thirties, he had undergone resection of the mandibular area with plate reconstruction for treatment of tongue cancer; however, the site became infected and the plate was removed 8 months before presentation. The patient returned for reoperation involving a free abdominal muscle flap with vascular anastomosis and partial mandibular resection with tracheostomy. After surgery, the patient was in the ICU for deep sedation and ventilator management for 48 h, until the vascular anastomosis stabilized. Initially, the iASV ventilator mode was selected to change only the percentage minute volume (%MV) automatically. On the postoperative day 3, the patient’s oxygenation worsened, and purulent sputum increased; fiberoptic suctioning of sputum was performed once along with sputum culturing. Although no significant organism was detected with sputum Gram staining, Klebsiella pneumoniae and Pseudomonas otitidis were detected in the sputum culture test. We therefore arrived at a diagnosis of VAP and changed the patient’s antibiotic from ampicillin/sulbactam 1.5 g per 6 h to meropenem 0.5 g per 8 h. At the time of entering the ICU, his PaO2/FiO2 ratio was 462, which indicated a good oxygenation capacity; this decreased to 171.5 at the time of VAP diagnosis. At the same time, the other patient entered the ICU with a severe respiratory emergency. We continued the iASV mode as we judged that the respiratory condition could be improved. PEEP and FiO2 were selected as additional automatic settings in iASV, %MV was automatically set, and the delta P (ΔP) approximating the driving pressure did not exceed 10 cm H2O. .\nArterial blood gas (PaO2, PaCO2, and pH) was measured every 6 h to confirm that his respiratory condition was within the expected range.\nOnce the patient’s oxygenation capacity started improving, the INTELLiVENT®-ASV started to show a decline in FiO2, first until it reached 0.3, and then reduced PEEP from 14 to 5 cm H2O based on the lung protective ventilation strategy. Two days after changing the antibiotics to treat VAP, his WBC, CRP, and the sputum secretion from the lungs decreased, indicating resolution of VAP. Therefore, mechanical ventilation was successfully withdrawn. During this time, the ΔP obtained by subtracting PEEP from the inspiratory plateau pressure was kept below 10 cm H2O .\nWe used dexmedetomidine (0.2γ to 0.5γ) and propofol (1 mg/kg/h to 3 mg/kg/h) for sedation during his admission in ICU. We continued the same sedation dosage after VAP diagnosis, and after stopping ventilator usage, the propofol administration was also stopped. Dexmedetomidine was continued after extubation at night for the purpose of sleeping.\nTwo days after stopping ventilator usage, the patient’s respiratory condition was stable and he was transferred to the general ward.", + "fulltext_subclaims": [ + "The patient was a 47-year-old man.", + "The patient had a past medical history of tongue cancer that was operable.", + "The preoperative spirometry test was normal.", + "The preoperative electrocardiography was normal.", + "The preoperative transthoracic echocardiogram was normal.", + "The patient is a non-smoker.", + "The patient had no history of cerebrovascular disease.", + "The patient had undergone resection of the mandibular area with plate reconstruction for treatment of tongue cancer.", + "The plate was removed 8 months before presentation.", + "The patient returned for reoperation involving a free abdominal muscle flap with vascular anastomosis.", + "The patient underwent partial mandibular resection with tracheostomy.", + "The patient was in the ICU for deep sedation and ventilator management for 48 h.", + "The iASV ventilator mode was selected to change only the percentage minute volume (%MV) automatically.", + "On postoperative day 3, the patient’s oxygenation worsened.", + "Purulent sputum increased on postoperative day 3.", + "Fiberoptic suctioning of sputum was performed once.", + "Sputum culturing was performed.", + "Klebsiella pneumoniae was detected in the sputum culture test.", + "Pseudomonas otitidis was detected in the sputum culture test.", + "The diagnosis of VAP was made.", + "The patient’s antibiotic was changed from ampicillin/sulbactam 1.5 g per 6 h to meropenem 0.5 g per 8 h.", + "At the time of entering the ICU, the patient’s PaO2/FiO2 ratio was 462.", + "At the time of VAP diagnosis, the patient’s PaO2/FiO2 ratio was 171.5.", + "The iASV mode was continued.", + "PEEP and FiO2 were selected as additional automatic settings in iASV.", + "The delta P (ΔP) approximating the driving pressure did not exceed 10 cm H2O.", + "Arterial blood gas was measured every 6 h.", + "The INTELLiVENT®-ASV reduced FiO2 until it reached 0.3.", + "The INTELLiVENT®-ASV reduced PEEP from 14 to 5 cm H2O.", + "Two days after changing the antibiotics to treat VAP, the patient’s WBC decreased.", + "Two days after changing the antibiotics to treat VAP, the patient’s CRP decreased.", + "Two days after changing the antibiotics to treat VAP, the patient’s sputum secretion from the lungs decreased.", + "Mechanical ventilation was successfully withdrawn.", + "The ΔP obtained by subtracting PEEP from the inspiratory plateau pressure was kept below 10 cm H2O.", + "Dexmedetomidine (0.2γ to 0.5γ) was used for sedation during ICU admission.", + "Propofol (1 mg/kg/h to 3 mg/kg/h) was used for sedation during ICU admission.", + "The same sedation dosage was continued after VAP diagnosis.", + "Propofol administration was stopped after stopping ventilator usage.", + "Dexmedetomidine was continued after extubation at night for the purpose of sleeping.", + "Two days after stopping ventilator usage, the patient’s respiratory condition was stable.", + "The patient was transferred to the general ward." + ], + "summary": "A 47-year-old man underwent reconstruction surgery with free musculocutaneous flap for tongue resection. After surgery, the patient entered the ICU, and the iASV, which automatically changed only the percent minute volume (%MV) in respiration mode, was selected. On the second day, ventilator-associated pneumonia (VAP) was diagnosed, and the antibiotic treatment was changed. Using the settings of the iASV, automated FiO2 and positive end-expiratory pressure (PEEP) control were added to the ventilator mode. The patient's oxygenation was improved.", + "summary_subclaims": [ + "The patient is a 47-year-old man.", + "The patient underwent reconstruction surgery with free musculocutaneous flap for tongue resection.", + "The iASV, which automatically changed only the percent minute volume (%MV) in respiration mode, was selected.", + "On the second day, ventilator-associated pneumonia (VAP) was diagnosed.", + "The antibiotic treatment was changed.", + "Automated FiO2 and positive end-expiratory pressure (PEEP) control were added to the ventilator mode.", + "The patient's oxygenation was improved." + ] + }, + { + "id": "multiclinsum_test_1213_en.txt", + "fulltext": "A 25-year-old male with no pertinent past medical history presented to the ED by ambulance with obvious right wrist deformity following a high-speed motor vehicle collision as a restrained driver. The patient had braced his outstretched hand against the steering wheel during vehicular impact, resulting in traumatic injury to the wrist. His vital signs on arrival were within normal limits, but he was in significant distress, rating his pain as a 10/10. Physical examination revealed a grossly deformed right wrist with dorsal swelling and severe tenderness to palpation, but no evidence of neurovascular compromise. Radiographs of his right wrist revealed a transverse fracture of the distal radius with dorsal angulation of the distal fragment (Colles fracture), as well as an ulnar styloid fracture.\nDespite receiving opioid and nonsteroidal anti-inflammatory analgesia, the patient still reported intractable, severe pain with intolerance of radial manipulation. To avoid procedural sedation, an ultrasound-guided CCBPB was performed to augment patient analgesia and facilitate reduction (–, ).\nInformed consent for CCBPB performance was obtained, and the patient was placed on a cardiac monitor with intravenous access established. The patient was positioned supine with the right arm abducted 90 degrees to stretch the pectoralis muscles and bring the costoclavicular brachial plexus more superficial toward the skin surface. The patient was prepped and draped in the standard manner, and sterility was maintained for the duration of the procedure. A high-frequency linear ultrasound probe was oriented transversely just inferior to the midpoint of the right clavicle in the infraclavicular fossa. The probe beam was angled slightly cephalad to visualize the costoclavicular space posterior to the clavicle. The costoclavicular brachial plexus cords were identified just lateral to the axillary artery and between the subclavius and serratus anterior (upper slips) muscles. An in-plane, lateral-to-medial approach was used to guide a 22-gauge, 50-millimeter echogenic block needle between the lateral and posterior cords. Twenty milliliters of 0.5% ropivacaine were injected perineurally around the brachial plexus cords. The procedure was performed without complications.\nFifteen minutes post-block performance, the patient had dense sensorimotor blockade of the right upper extremity and reported his pain at 0/10. Despite aggressive manipulation, the patient reported no pain, and successful reduction of the distal radius fracture was achieved. A sugar-tong forearm splint was applied, and the patient was discharged from the ED with outpatient orthopedic surgery follow-up. On telephone inquiry the next day, the patient reported no numbness, tingling, or residual sensorimotor deficit.", + "fulltext_subclaims": [ + "The patient is a 25-year-old male.", + "The patient had no pertinent past medical history.", + "The patient presented to the ED by ambulance.", + "The patient had an obvious right wrist deformity.", + "The injury occurred following a high-speed motor vehicle collision.", + "The patient was a restrained driver.", + "The patient braced his outstretched hand against the steering wheel during vehicular impact.", + "The patient had traumatic injury to the wrist.", + "The patient's vital signs on arrival were within normal limits.", + "The patient was in significant distress.", + "The patient rated his pain as a 10/10.", + "Physical examination revealed a grossly deformed right wrist.", + "There was dorsal swelling and severe tenderness to palpation.", + "There was no evidence of neurovascular compromise.", + "Radiographs revealed a transverse fracture of the distal radius.", + "Radiographs showed dorsal angulation of the distal fragment.", + "The fracture was identified as a Colles fracture.", + "There was an ulnar styloid fracture.", + "The patient received opioid and nonsteroidal anti-inflammatory analgesia.", + "The patient still reported intractable, severe pain.", + "The patient had intolerance of radial manipulation.", + "An ultrasound-guided CCBPB was performed.", + "The procedure was performed to augment patient analgesia.", + "The procedure was performed to facilitate reduction.", + "Informed consent for CCBPB performance was obtained.", + "The patient was placed on a cardiac monitor.", + "Intravenous access was established.", + "The patient was positioned supine.", + "The right arm was abducted 90 degrees.", + "The patient was prepped and draped in the standard manner.", + "Sterility was maintained for the duration of the procedure.", + "A high-frequency linear ultrasound probe was oriented transversely.", + "The probe was placed just inferior to the midpoint of the right clavicle.", + "The probe was in the infraclavicular fossa.", + "The probe beam was angled slightly cephalad.", + "The costoclavicular space was visualized posterior to the clavicle.", + "The costoclavicular brachial plexus cords were identified.", + "The cords were identified just lateral to the axillary artery.", + "The cords were identified between the subclavius and serratus anterior (upper slips) muscles.", + "An in-plane, lateral-to-medial approach was used.", + "A 22-gauge, 50-millimeter echogenic block needle was used.", + "Twenty milliliters of 0.5% ropivacaine were injected perineurally.", + "The injection was around the brachial plexus cords.", + "The procedure was performed without complications.", + "Fifteen minutes post-block performance, the patient had dense sensorimotor blockade.", + "The patient reported his pain at 0/10.", + "Successful reduction of the distal radius fracture was achieved.", + "A sugar-tong forearm splint was applied.", + "The patient was discharged from the ED.", + "The patient was scheduled for outpatient orthopedic surgery follow-up.", + "On telephone inquiry the next day, the patient reported no numbness.", + "The patient reported no tingling.", + "The patient reported no residual sensorimotor deficit." + ], + "summary": "A 25-year-old male presented to the ED with a traumatic Colles fracture sustained during a high-speed motor vehicle collision. Despite multimodal analgesia, the patient reported intractable severe pain with intolerance of radial manipulation. An ultrasound-guided CCBPB was performed to augment pain control and avoid procedural sedation, resulting in dense, surgical anesthesia of the upper extremity, and painless fracture reduction.", + "summary_subclaims": [ + "The patient is a 25-year-old male.", + "The patient presented to the ED with a traumatic Colles fracture.", + "The fracture was sustained during a high-speed motor vehicle collision.", + "The patient reported intractable severe pain.", + "The patient had intolerance of radial manipulation.", + "An ultrasound-guided CCBPB was performed.", + "The procedure was performed to augment pain control.", + "The procedure was performed to avoid procedural sedation.", + "The procedure resulted in dense, surgical anesthesia of the upper extremity.", + "The procedure resulted in painless fracture reduction." + ] + }, + { + "id": "multiclinsum_test_1483_en.txt", + "fulltext": "A 25-year-old Sri Lankan woman presented with several episodes of central abdominal pain, abdominal fullness, and non-projectile vomiting for 1-week duration. The vomitus was non-bilious, with undigested food particles and was noted particularly 1 to 2 hours after meals. Episodes of vomiting were accompanied with colicky central abdominal pain but these symptoms were only mild and between attacks she was completely asymptomatic. As she had had at least five similar episodes over the last 3 years, she sought medical advice. Most of those episodes were self-limiting, but she had a couple of hospital admissions during which she was managed conservatively. During one episode, she had noticed pruritus and darkening of urine as well, which again resolved spontaneously. She had undergone an upper GI endoscopy 1 year earlier which did not provide a positive finding. She had a past history of rectal polypectomy, at the age of 16 years, when she was investigated for painless per rectal bleeding, the histology of which was consistent with a tubular adenoma. Follow-up colonoscopies had not detected any further polyps.\nOn examination, she had a body mass index of 20.3 kg/m2. She had a few scratch marks on her trunk and upper limbs confirming pruritus. She was not icteric or febrile. An abdominal examination was unremarkable and her gall bladder was not palpable. Succussion splash was not elicited. There was no mucocutaneous pigmentation.\nThere was biochemical evidence of biliary obstruction with alkaline phosphatase (ALP) of 896 IU/L, a total bilirubin of 2.6 mg/dl and direct bilirubin of 2.2 mg/dL. An ultrasound scan of her abdomen detected intrahepatic and extrahepatic duct dilatation with a dilated common bile duct (CBD) of 11.5 mm without evidence of gallstones or CBD stones. She was found positive for fecal occult blood and was subjected to upper GI endoscopy and colonoscopy both of which were negative. Plain radiographies of her chest and abdomen were unremarkable. She was further investigated with a computed tomography (CT) enterogram and a magnetic resonance cholangiopancreatogram (MRCP). The CT enterogram revealed a large soft tissue mass causing duodenal intussusception into her proximal jejunum. Her CBD was found to be stretched to the left of the midline resulting in its dilatation of up to 12 mm at the lower end. MRCP also confirmed the absence of gall stones and other filling defects in her CBD . Based on these findings she underwent a small bowel enteroscopy which demonstrated a large duodenal polyp, originating from the second part of her duodenum and intussuscepting into the proximal jejunum beyond the duodenojejunal junction. The major duodenal papilla appeared stretched and elongated along the long axis of her duodenum. The rest of the enteroscopy study was normal. A biopsy was not taken because of the presence of intussusception.\nEven though it was possible to negotiate the scope beyond the polyp it was decided to go ahead with open surgery after two multidisciplinary team meetings because of the large size of the polyp, its critical location, and the presence of the intussusception. An intraoperative upper GI endoscopy was performed to localize the polyp because the polyp was not readily palpable through her duodenal wall. An oblique duodenotomy was done and a large polyp with a broad and long stalk was found. The origin of the stalk was at the second part of her duodenum, 1 cm below the ampulla. A polypectomy was done and the intussusception was reduced and the duodenum was closed transversely with 5/0 polydioxanone sutures . She had an uncomplicated recovery and was discharged on sixth postoperative day.\nOn macroscopic examination the specimen was a polyp of 50 × 45 × 30 mm in size with a broad, 20 mm long stalk . On microscopic examination it was composed of a branching villous structure of small intestinal mucosa containing a core of smooth muscle. The overlapping mucosa was histologically normal. Thus, microscopically this was a hamartomatous polyp consistent with a Peutz–Jeghers polyp .\nOur patient became completely asymptomatic following surgery. She is followed up in general surgical clinic and is scheduled for routine upper GI endoscopy surveillance every 3 years.", + "fulltext_subclaims": [ + "The patient is a 25-year-old Sri Lankan woman.", + "She had several episodes of central abdominal pain, abdominal fullness, and non-projectile vomiting for 1 week.", + "The vomitus was non-bilious, with undigested food particles.", + "Vomiting occurred 1 to 2 hours after meals.", + "Episodes of vomiting were accompanied by colicky central abdominal pain.", + "Between attacks, she was completely asymptomatic.", + "She had at least five similar episodes over the last 3 years.", + "Most of those episodes were self-limiting.", + "She had a couple of hospital admissions during which she was managed conservatively.", + "During one episode, she had noticed pruritus and darkening of urine.", + "She had undergone an upper GI endoscopy 1 year earlier which did not provide a positive finding.", + "She had a past history of rectal polypectomy at the age of 16 years.", + "The histology of the rectal polyp was consistent with a tubular adenoma.", + "Follow-up colonoscopies had not detected any further polyps.", + "On examination, she had a body mass index of 20.3 kg/m2.", + "She had a few scratch marks on her trunk and upper limbs confirming pruritus.", + "An abdominal examination was unremarkable.", + "There was biochemical evidence of biliary obstruction with alkaline phosphatase of 896 IU/L.", + "An ultrasound scan detected intrahepatic and extrahepatic duct dilatation.", + "The common bile duct was dilated to 11.5 mm without evidence of gallstones or CBD stones.", + "She was found positive for fecal occult blood.", + "Upper GI endoscopy and colonoscopy were both negative.", + "A CT enterogram revealed a large soft tissue mass causing duodenal intussusception into the proximal jejunum.", + "The CBD was stretched to the left of the midline and dilated to 12 mm at the lower end.", + "MRCP confirmed the absence of gall stones and other filling defects in the CBD.", + "A small bowel enteroscopy demonstrated a large duodenal polyp originating from the second part of the duodenum.", + "The polyp intussuscepted into the proximal jejunum beyond the duodenojejunal junction.", + "A biopsy was not taken because of the presence of intussusception.", + "An intraoperative upper GI endoscopy was performed to localize the polyp.", + "An oblique duodenotomy was done and a large polyp with a broad, 20 mm long stalk was found.", + "The origin of the stalk was at the second part of the duodenum, 1 cm below the ampulla.", + "A polypectomy was done and the intussusception was reduced.", + "The duodenum was closed transversely with 5/0 polydioxanone sutures.", + "She had an uncomplicated recovery and was discharged on the sixth postoperative day.", + "On macroscopic examination, the specimen was a polyp of 50 × 45 × 30 mm in size with a broad, 20 mm long stalk.", + "On microscopic examination, it was composed of a branching villous structure of small intestinal mucosa containing a core of smooth muscle.", + "The overlapping mucosa was histologically normal.", + "Microscopically, this was a hamartomatous polyp consistent with a Peutz–Jeghers polyp.", + "Our patient became completely asymptomatic following surgery.", + "She is followed up in the general surgical clinic.", + "She is scheduled for routine upper GI endoscopy surveillance every 3 years." + ], + "summary": "We report a case of a 25-year-old Sri Lankan woman presenting with features of recurrent upper small intestinal obstruction and biliary obstruction. She had clinical as well as biochemical evidence of intermittent biliary obstruction. Evidence of duodenal intussusception was found in a computed tomography enterogram and a duodenal polyp was noted as the lead point. Marked elongation and distortion of her lower common bile duct with intrahepatic duct dilatation was also noted and the ampulla was found to be on the left side of the midline pulled toward the intussusceptum. Open polypectomy and reduction of intussusception were done and she became fully asymptomatic following surgery. Histology of the resected specimen was reported as a typical \"Peutz-Jeghers polyp\". As there was not enough evidence to diagnose Peutz-Jeghers syndrome this was considered to be a sporadic Peutz-Jeghers polyp.", + "summary_subclaims": [ + "The patient was a 25-year-old Sri Lankan woman.", + "She presented with features of recurrent upper small intestinal obstruction.", + "She had features of biliary obstruction.", + "She had clinical evidence of intermittent biliary obstruction.", + "She had biochemical evidence of intermittent biliary obstruction.", + "A computed tomography enterogram showed evidence of duodenal intussusception.", + "A duodenal polyp was noted as the lead point.", + "Marked elongation and distortion of the lower common bile duct was noted.", + "Intrahepatic duct dilatation was noted.", + "The ampulla was found to be on the left side of the midline pulled toward the intussusceptum.", + "Open polypectomy was performed.", + "Reduction of intussusception was performed.", + "She became fully asymptomatic following surgery.", + "Histology of the resected specimen was reported as a typical 'Peutz-Jeghers polyp'.", + "There was not enough evidence to diagnose Peutz-Jeghers syndrome.", + "This was considered to be a sporadic Peutz-Jeghers polyp." + ] + }, + { + "id": "multiclinsum_test_207_en.txt", + "fulltext": "A 61-year-old Japanese woman underwent resection of a malignant peripheral nerve sheath tumor of the hand when she was aged 43 years and was followed up by radiological examination. Chest radiography revealed a mass lesion in the left upper lung 18 years later. She was a current smoker but had no history of asbestos exposure, and presented no specific clinical symptoms. As a result of a detailed examination, she was diagnosed with clinical stage I lung adenocarcinoma. Simultaneously, contrast-enhanced computed tomography (CT) detected a 20-mm enhancing nodule with slow growth on the right diaphragm . 18-Fluoro-2-deoxyglucose positron emission tomography revealed that the maximum standard uptake value of the nodule was 3.5 . Ultrasonography (US) revealed a low-echoic lesion, and early enhancement was observed on Sonazoid-enhanced US . These results indicated that the lesion was a hypervascular tumor of borderline malignancy, such as solitary fibrous tumor (SFT). After a left upper lobectomy for lung adenocarcinoma, the patient was referred to our department for surgical resection of the peritoneal tumor. Laboratory data at the time of presentation were as follows: white blood cell count, 7240 cells/μL; hemoglobin level, 14.2 g/dL; platelet count, 10.4 × 104 cells/μL; aspartate transaminase, 22 IU/L; alanine aminotransferase, 24 IU/L; total bilirubin, 0.57 mg/dL; albumin, 4.1 g/dL; creatinine, 0.58 mg/dL. Serum tumor markers, such as proteins induced by vitamin K absence or antagonist II and alpha-fetoprotein, were within the normal range (25 μg/mL and 2.1 ng/mL, respectively). Laparoscopic tumor resection was performed. Intraoperative findings are shown in Fig. . A thin pedunculated tumor was found to originate from the peritoneal surface of the right diaphragm. The tumor was compressing liver segment 8 but without apparent invasion. Well-developed capillary vessels were observed around the tumor. The pedicle of the tumor was clipped at its origin and divided, and a tumorectomy was completed. Gross examination showed a 28 × 20 x 11 mm3 brown–red tumor with a smooth cut surface . Histopathological examination revealed papillary architecture with focal small aggregates of mesothelial cells . Glandular lumen formation, indicative of an adenomatoid pattern, was partially observed. Immunohistochemical analysis showed that the tumor cells were positive for cytokeratin 5/6 (CK 5/6) and calretinin, and negative for carcinoembryonic antigen (CEA), thyroid transcription factor-1 (TTF-1), cluster of differentiation 34 (CD34), and signal transducer and activator of transcription 6 (STAT6) . In addition, hot-spot mutations in TNF receptor associated factor 7 (TRAF7) were not detected by Sanger sequencing, and the tumor cells displayed negative immunostaining for L1 cell adhesion molecule. Fluorescence in situ hybridization (FISH) showed no homozygous deletion of 9p21 or hemizygous deletion of NF2 (data not shown). Based on these results, the patient was diagnosed with localized adenomatoid mesothelioma. The postoperative course was uneventful, and the patient was discharged on the fourth postoperative day. She remains alive and is being monitored in an outpatient setting. No recurrence was noted 6 months after surgery.", + "fulltext_subclaims": [ + "The patient is a 61-year-old Japanese woman.", + "She underwent resection of a malignant peripheral nerve sheath tumor of the hand when she was 43 years old.", + "Chest radiography revealed a mass lesion in the left upper lung 18 years after the tumor resection.", + "She was a current smoker.", + "She had no history of asbestos exposure.", + "She was diagnosed with clinical stage I lung adenocarcinoma.", + "Contrast-enhanced CT detected a 20-mm enhancing nodule with slow growth on the right diaphragm.", + "The maximum standard uptake value of the nodule was 3.5.", + "Ultrasonography revealed a low-echoic lesion.", + "Early enhancement was observed on Sonazoid-enhanced US.", + "The lesion was considered a hypervascular tumor of borderline malignancy, such as solitary fibrous tumor.", + "Laparoscopic tumor resection was performed.", + "A thin pedunculated tumor was found to originate from the peritoneal surface of the right diaphragm.", + "The tumor was compressing liver segment 8 but without apparent invasion.", + "The pedicle of the tumor was clipped at its origin and divided.", + "A tumorectomy was completed.", + "Gross examination showed a 28 × 20 × 11 mm3 brown–red tumor with a smooth cut surface.", + "Histopathological examination revealed papillary architecture with focal small aggregates of mesothelial cells.", + "Glandular lumen formation, indicative of an adenomatoid pattern, was partially observed.", + "The tumor cells were positive for cytokeratin 5/6 (CK 5/6) and calretinin.", + "The tumor cells were negative for carcinoembryonic antigen (CEA), thyroid transcription factor-1 (TTF-1), cluster of differentiation 34 (CD34), and signal transducer and activator of transcription 6 (STAT6).", + "Hot-spot mutations in TNF receptor associated factor 7 (TRAF7) were not detected by Sanger sequencing.", + "The tumor cells displayed negative immunostaining for L1 cell adhesion molecule.", + "Fluorescence in situ hybridization showed no homozygous deletion of 9p21 or hemizygous deletion of NF2.", + "The patient was diagnosed with localized adenomatoid mesothelioma.", + "The postoperative course was uneventful.", + "The patient was discharged on the fourth postoperative day.", + "No recurrence was noted 6 months after surgery." + ], + "summary": "The patient was a 61-year-old Japanese woman who had undergone resection of a malignant peripheral nerve sheath tumor of the hand 18 years prior. She was diagnosed with clinical stage I lung adenocarcinoma on follow-up chest radiography. Simultaneously, a 20-mm enhancing nodule with slow growth on the right diaphragm was detected on contrast-enhanced computed tomography. She presented no specific clinical symptoms. At this point, the lesion was suspected to be a hypervascular tumor of borderline malignancy, such as a solitary fibrous tumor. After a left upper lobectomy for lung adenocarcinoma, she was referred to our department, and laparoscopic tumor resection was performed. Adenomatoid tumors were also considered based on the histopathological and immunohistochemical analyses, but we made the final diagnosis of adenomatoid mesothelioma using the results of the genetic profile. The patient remains alive, with no recurrence noted 6 months after surgery.", + "summary_subclaims": [ + "The patient was a 61-year-old Japanese woman.", + "She had undergone resection of a malignant peripheral nerve sheath tumor of the hand 18 years prior.", + "She was diagnosed with clinical stage I lung adenocarcinoma on follow-up chest radiography.", + "A 20-mm enhancing nodule with slow growth on the right diaphragm was detected on contrast-enhanced computed tomography.", + "The lesion was suspected to be a hypervascular tumor of borderline malignancy, such as a solitary fibrous tumor.", + "After a left upper lobectomy for lung adenocarcinoma, she was referred to our department.", + "Laparoscopic tumor resection was performed.", + "Adenomatoid tumors were also considered based on the histopathological and immunohistochemical analyses.", + "The final diagnosis was adenomatoid mesothelioma using the results of the genetic profile.", + "The patient remains alive, with no recurrence noted 6 months after surgery." + ] + }, + { + "id": "multiclinsum_test_2540_en.txt", + "fulltext": "A 23-year-old woman with no relevant past medical or surgical history was referred from a local hospital after complaining of right upper quadrant pain for several weeks. On physical examination, right upper quadrant tenderness was the only abnormal finding during the first visit. Initial laboratory findings were also unremarkable, except for a high level of carbohydrate antigen 19-9 (CA19-9; 20,300 U/ml). Abdominal computed tomography (CT) and magnetic resonance imaging (MRI) revealed focal dilation of the right intrahepatic bile duct and a low contract effect tumor measuring 42 mm in hepatic segments 1 and 8; ICC was suspected . The tumor was attached to the inferior vena cava (IVC) and had invaded the right portal vein (PV) leading to cavernous transformation instead of canonical PV. Positron emission tomography (PET) showed fluorodeoxyglucose (FDG) uptake in the primary liver tumor and para-aortic lymph nodes . We consider the cases those in which surgical resection could not be achieved even by aggressive surgical procedures, including combined vascular resection as unresectable ICCs. On the basis of these findings, the patient was diagnosed with initially unresectable ICC with para-aortic lymph node metastasis and subsequently treated with a combined chemotherapy regimen of gemcitabine (GEM 1000 mg/m2) and cisplatin (CDDP 25 mg/m2). This combination was intravenously administered on days 1 and 8 and was repeated every 3 weeks under a downsizing regimen.\nAfter eight courses of combination chemotherapy over 5 months, CT, MRI, and PET imaging demonstrated an effective response to chemotherapy. The size of the primary tumor had decreased to 18 mm (55% reduction), and the tumor was no longer attached to the IVC . FDG uptake in the para-aortic lymph nodes almost disappeared , and the level of CA19-9 decreased to 738 U/ml . The effect of downsizing chemotherapy was partial response (PR) in RECIST criteria. The TNM staging of pre- and post-chemotherapy were T3N1M1 stage IVb and T1N0M0 stage I in UICC criteria, respectively. Nevertheless, the PV cavernous transformation did not improve. We thus concluded that this PV cavernous transformation had originated from a congenital anomaly . After discussion with the patient and her family, we decided to perform radical surgical resection to achieve the cure of disease. Right hemihepatectomy and dissection of lymph nodes, including the para-aortic lymph nodes, were performed. During right PV resection, the PV cavernous transformation was preserved to maintain collateral flow through the PV as much as possible . The margins of the right bile duct showed no evidence of malignancy during intraoperative frozen section analysis.\nMicroscopic pathological examination showed that R0 (no residual tumor) resection had been successful and that more than 50% of the tumor cells had been replaced with fibrosis (Evans’ criteria IIb) . No viable tumor cells were visible in the para-aortic lymph nodes that showed FDG uptake in the initial PET scan. However, there was slight extracapsular invasion in the para-aortic nerve . According to the pathological findings (well differentiated tubular adenocarcinoma, pT3, pN0, pM1 (OTH, para-aortic nerve)), UICC stage of this patient was defined as stage IVb. The patient suffered from bile duct stricture as a postoperative complication. After re-suture of the stump of the bile duct with enough patency in reoperation, the patient made a satisfactory recovery and was discharged on postoperative day 11. The patient is alive 31 months after the initial treatment (24 months after operation) with a local tumor recurrence.\nIn surgical resection for ICC, R0 resection is one of the most favorable prognostic factors [, ]. The prognosis of R1 and R2 (microscopic and macroscopic residual tumor) resection is comparable to the prognosis of patients who do not undergo surgical resection and those who receive only palliative treatment . Furthermore, the number of lymph node metastases is another important prognostic factor in ICC. Patients with more than three lymph nodes metastases have more unfavorable outcomes than patients with one or two lymph node metastases (3-year survival: 0 vs. 50%, respectively) .\nMany patients are diagnosed initially with unresectable tumors due to locally advanced or metastatic disease, silent clinical symptoms, involvement of blood vessels, extension into both hepatic lobes, or rapid disease progression . The optimal treatment for patients with locally advanced unresectable or metastatic disease is yet to be determined. Recently, systemic chemotherapy has contributed to improvements in overall survival. In the UK, a phase III randomized controlled trial demonstrated that the median survival time (MST) of overall survival (OS) with GEM plus CDDP combination therapy was significantly improved compared to that with gemcitabine alone (11.7 vs. 8.3 months, respectively, p < 0.001) . For unresectable BTC, GEM plus CDDP combination therapy is recommended as a standard therapy.\nA previous report looked at the effectiveness of downsizing chemotherapy (distinguished from neoadjuvant chemotherapy) and subsequent so-called “conversion surgery” for initially unresectable BTC . We also recently reported that in 10 of 39 (25.6%) locally advanced unresectable BTC patients, the size of the tumor was reduced by downsizing chemotherapy, and conversion surgery was successfully performed as a result. Additionally, this downsizing chemotherapy and conversion surgery strategy led to longer survival than that with chemotherapy alone (MST: 17.9 months for chemotherapy plus surgical resection vs. 12.4 months for chemotherapy alone) . Although there is a certain bias in patient selection, this could represent a promising treatment for initially unresectable locally advanced BTC.\nThe efficacy of neoadjuvant chemotherapy against potentially resectable BTC is uncertain. A previous report indicated that neoadjuvant therapy can improve survival by controlling regional extension . Contrary to this, another report suggested that neoadjuvant chemotherapy decreased the survival rate compared to that on immediate resection . Prospective studies are needed to establish neoadjuvant chemotherapy as a treatment for potentially resectable BTC.\nPV cavernous transformation is the angiographic appearance of numerous collateral vessels around the PV owing to various reasons. These are classified as idiopathic causes (e.g., congenital malformation, or following hepatobiliary surgery) or secondary causes (e.g., liver cirrhosis, thrombosis, tumor) . In this case, there were no hepatofugal collateral pathways caused by splenomegaly, a gastric or esophageal varix, or any hepatopetal collateral pathways. Furthermore, intraoperative findings suggested that the cavernous transformation was due to a congenital etiology, as the obstruction site was distant from the tumor and was soft under palpation. Unfortunately there is no previous CT or portography, however, it is speculated that the etiology of congenital PV cavernous transformation may result from portal vein malformation, or portal thrombosis for omphalitis or pylephlebitis.\nUntil October 2016, we experienced 15 cases of surgical resection for initially unresectable BTCs including this case. The periods of downsizing chemotherapy to surgical resection were varied; 22.7 ± 11.1 weeks (mean ± standard deviation). Among all 15 patients, N0 (no lymph node metastasis) was pathologically diagnosed for 9 patients and N1 (positive for lymph node metastasis) for 6 patients, and R0 resection was performed for 12 patients and R1 resection for 3 patients, respectively. According to Kaplan-Meier method, the MST of OS was calculated and log-lank test was used to test for significant differences between N0 and N1 group, and between R0 and R1 group. The MST of OS in N0 group (34.3 months) was significantly longer compared with that in N1 group (12.4 months) (p = 0.031). The MST of OS in R0 group was also significantly longer than that in R1 group (30.9 months for R0 group vs. 4.1 months for R1 group, p = 0.012). Although the number of cases is limited, these results implicated that N0 and R0 resection are important favorable prognostic factors for unresectable BTC patients who have undergone surgery after downsizing chemotherapy.", + "fulltext_subclaims": [ + "The patient was a 23-year-old woman with no relevant past medical or surgical history.", + "The patient complained of right upper quadrant pain for several weeks.", + "Right upper quadrant tenderness was the only abnormal finding during the first visit.", + "Initial laboratory findings were unremarkable, except for a high level of carbohydrate antigen 19-9 (CA19-9; 20,300 U/ml).", + "Abdominal computed tomography (CT) and magnetic resonance imaging (MRI) revealed focal dilation of the right intrahepatic bile duct.", + "Abdominal CT and MRI showed a low contract effect tumor measuring 42 mm in hepatic segments 1 and 8.", + "ICC was suspected.", + "The tumor was attached to the inferior vena cava (IVC).", + "The tumor had invaded the right portal vein (PV) leading to cavernous transformation instead of canonical PV.", + "Positron emission tomography (PET) showed fluorodeoxyglucose (FDG) uptake in the primary liver tumor.", + "PET showed FDG uptake in para-aortic lymph nodes.", + "We consider the cases those in which surgical resection could not be achieved even by aggressive surgical procedures, including combined vascular resection as unresectable ICCs.", + "The patient was diagnosed with initially unresectable ICC with para-aortic lymph node metastasis.", + "The patient was treated with a combined chemotherapy regimen of gemcitabine (GEM 1000 mg/m2) and cisplatin (CDDP 25 mg/m2).", + "The combination chemotherapy was intravenously administered on days 1 and 8.", + "The chemotherapy was repeated every 3 weeks under a downsizing regimen.", + "After eight courses of combination chemotherapy over 5 months, CT, MRI, and PET imaging demonstrated an effective response to chemotherapy.", + "The size of the primary tumor had decreased to 18 mm (55% reduction).", + "The tumor was no longer attached to the IVC.", + "FDG uptake in the para-aortic lymph nodes almost disappeared.", + "The level of CA19-9 decreased to 738 U/ml.", + "The effect of downsizing chemotherapy was partial response (PR) in RECIST criteria.", + "The TNM staging of pre-chemotherapy was T3N1M1 stage IVb in UICC criteria.", + "The TNM staging of post-chemotherapy was T1N0M0 stage I in UICC criteria.", + "The PV cavernous transformation did not improve.", + "We concluded that this PV cavernous transformation had originated from a congenital anomaly.", + "Right hemihepatectomy and dissection of lymph nodes, including the para-aortic lymph nodes, were performed.", + "During right PV resection, the PV cavernous transformation was preserved to maintain collateral flow through the PV as much as possible.", + "The margins of the right bile duct showed no evidence of malignancy during intraoperative frozen section analysis.", + "Microscopic pathological examination showed that R0 (no residual tumor) resection had been successful.", + "More than 50% of the tumor cells had been replaced with fibrosis (Evans’ criteria IIb).", + "No viable tumor cells were visible in the para-aortic lymph nodes that showed FDG uptake in the initial PET scan.", + "There was slight extracapsular invasion in the para-aortic nerve.", + "According to the pathological findings, the UICC stage of this patient was defined as stage IVb.", + "The patient suffered from bile duct stricture as a postoperative complication.", + "After re-suture of the stump of the bile duct with enough patency in reoperation, the patient made a satisfactory recovery.", + "The patient was discharged on postoperative day 11.", + "The patient is alive 31 months after the initial treatment.", + "The patient is alive 24 months after operation.", + "The patient has a local tumor recurrence.", + "In surgical resection for ICC, R0 resection is one of the most favorable prognostic factors.", + "The prognosis of R1 and R2 resection is comparable to the prognosis of patients who do not undergo surgical resection.", + "The prognosis of R1 and R2 resection is comparable to the prognosis of patients who receive only palliative treatment.", + "The number of lymph node metastases is another important prognostic factor in ICC.", + "Patients with more than three lymph node metastases have more unfavorable outcomes than patients with one or two lymph node metastases.", + "Many patients are diagnosed initially with unresectable tumors due to locally advanced or metastatic disease.", + "Many patients are diagnosed initially with unresectable tumors due to silent clinical symptoms.", + "Many patients are diagnosed initially with unresectable tumors due to involvement of blood vessels.", + "Many patients are diagnosed initially with unresectable tumors due to extension into both hepatic lobes.", + "Many patients are diagnosed initially with unresectable tumors due to rapid disease progression.", + "The optimal treatment for patients with locally advanced unresectable or metastatic disease is yet to be determined.", + "Systemic chemotherapy has contributed to improvements in overall survival.", + "In the UK, a phase III randomized controlled trial demonstrated that the median survival time (MST) of overall survival (OS) with GEM plus CDDP combination therapy was significantly improved compared to that with gemcitabine alone.", + "For unresectable BTC, GEM plus CDDP combination therapy is recommended as a standard therapy.", + "A previous report looked at the effectiveness of downsizing chemotherapy and subsequent conversion surgery for initially unresectable BTC.", + "In 10 of 39 (25.6%) locally advanced unresectable BTC patients, the size of the tumor was reduced by downsizing chemotherapy.", + "Conversion surgery was successfully performed as a result.", + "This downsizing chemotherapy and conversion surgery strategy led to longer survival than that with chemotherapy alone.", + "The MST for chemotherapy plus surgical resection was 17.9 months.", + "The MST for chemotherapy alone was 12.4 months.", + "The efficacy of neoadjuvant chemotherapy against potentially resectable BTC is uncertain.", + "A previous report indicated that neoadjuvant therapy can improve survival by controlling regional extension.", + "Another report suggested that neoadjuvant chemotherapy decreased the survival rate compared to that on immediate resection.", + "PV cavernous transformation is the angiographic appearance of numerous collateral vessels around the PV owing to various reasons.", + "These are classified as idiopathic causes (e.g., congenital malformation, or following hepatobiliary surgery).", + "These are classified as secondary causes (e.g., liver cirrhosis, thrombosis, tumor).", + "In this case, there were no hepatofugal collateral pathways caused by splenomegaly.", + "In this case, there were no hepatofugal collateral pathways caused by a gastric or esophageal varix.", + "In this case, there were no hepatopetal collateral pathways.", + "Intraoperative findings suggested that the cavernous transformation was due to a congenital etiology.", + "The obstruction site was distant from the tumor.", + "The obstruction site was soft under palpation.", + "Until October 2016, we experienced 15 cases of surgical resection for initially unresectable BTCs including this case.", + "The periods of downsizing chemotherapy to surgical resection were varied; 22.7 ± 11.1 weeks.", + "Among all 15 patients, N0 (no lymph node metastasis) was pathologically diagnosed for 9 patients.", + "Among all 15 patients, N1 (positive for lymph node metastasis) was pathologically diagnosed for 6 patients.", + "Among all 15 patients, R0 resection was performed for 12 patients.", + "Among all 15 patients, R1 resection was performed for 3 patients.", + "The MST of OS in N0 group (34.3 months) was significantly longer compared with that in N1 group (12.4 months).", + "The MST of OS in R0 group was also significantly longer than that in R1 group (30.9 months for R0 group vs. 4.1 months for R1 group)." + ], + "summary": "We report a case of liver resection in a 23-year-old woman who was diagnosed with initially unresectable ICC attached to the inferior vena cava, with portal vein (PV) cavernous transformation. Positron emission tomography (PET) showed fluorodeoxyglucose (FDG) uptake in the para-aortic lymph nodes. Upon using downsizing chemotherapy (the combination of gemcitabine", + "summary_subclaims": [ + "The patient is a 23-year-old woman.", + "The patient was diagnosed with initially unresectable ICC attached to the inferior vena cava.", + "The patient had portal vein cavernous transformation.", + "Positron emission tomography showed fluorodeoxyglucose uptake in the para-aortic lymph nodes.", + "Downsizing chemotherapy was used." + ] + }, + { + "id": "multiclinsum_test_3361_en.txt", + "fulltext": "Patient history\nAn 11-year-old female patient diagnosed with high-grade osteosarcoma of the left distal femur underwent wide resection and subsequent prosthetic reconstruction with an endoprosthesis. Six months after the index surgery, immediately after completing the last cycle of adjuvant chemotherapy, the patient was admitted to the hospital with septic shock due to an acute deep infection. Extensive pus formation led to skin tearing on the anteromedial aspect of the knee exposing the implant.\n\nFirst stage - explantation of the infected endoprosthesis\nSurgical revision was indicated for infection control. The original implant was removed, and thorough debridement of soft tissues and intramedullary canals was performed, including high-pressure lavage irrigation. A reinforced temporary cement spacer with antibiotics was used to fill the defect after explanting the prosthesis. Calcium phosphate beads with Vancomycin (STIMULAN®) were placed inside the medullary canals as well as into the soft tissues. A vacuum-assisted device was used to cover the surgical site. Microbiological and bacterial PCR testing turned positive for polymicrobial flora including Staphylococcus Epidermidis, Neisseria Mucosa, Cutibacterium Acnes and Bacillus sp. Genetic testing turned negative for all tested genotypes of antibiotic resistance. Laboratory tests showed standard antibiotic sensitivity.\n\nInterim period\nEmpiric antibiotic therapy with Ciprofloxacin and Metronidazole was started. These were switched to Linezolid and Cefixime once cultures were finalized. Clinical improvement with wound healing and normalization of inflammatory markers was achieved. Unfortunately, despite the recommended activity restriction, the patient developed a Salter-Harris type V-like fracture of the proximal tibia due to independent transition to full weight-bearing. This resulted in the formation of a bony bridge across the lateral half of the physis eliminating the growth potential of proximal tibia.\n\nThe treated lower extremity had now lost the distal femur and the proximal tibia physes, resulting in a 5 cm leg length discrepancy at the time of the planned second stage. The length of the cement spacer was 10 cm, which is too short for an expandable prosthesis as the shortest distal femur implant is 18 cm in length.\n\nThe expected length discrepancy at the end of growth was calculated at 10 cm which is unmanageable without the use of a lengthening implant. However, we wanted to avoid resecting additional bone and using a massive implant in the setting of a previous deep infection. A decision was then made to use the bioexpandable MUTARS® BioXpand prosthesis (Implantcast, Germany). The prosthesis is 10 cm long and connected to the FITBONE® extendable motorized nail (Wittenstein, Germany), allowing non-invasive lengthening through callus distraction. The total lengthening potential of this implant is 8 cm.\n\nSecond stage - implantation of the bioexpandable endoprosthesis\nThe cement spacer was removed and a reconstruction with the BioXpand prosthesis was performed. Since the tibia growth plate was nonfunctional we used a definitive cemented proximal tibial MUTARS component, which is fully compatible with the BioXpand system. A femoral osteotomy site was marked with a Kirschner wire according to the manufacturer’s manual. The osteotomy was performed through a separate anterior thigh incision. The FITBONE® nail was then inserted into the femoral canal and connected to the BioXpand femoral component. The nail was proximally fixed with one bicortical screw, and the distal femoral fragment was fixed to the prosthesis using screws and plates. A receiver for transcutaneous energy transmission was placed subcutaneously on the lateral side of the knee. The implant was lengthened intraoperatively 1 cm. A medial gastrocnemius muscle flap was advanced over the femoral component. All intraoperative cultures were negative.\n\nFive days after the surgery, the nail elongation at 1 mm per day started. The distraction consisted of external transmission of electromagnetic pulses to the subcutaneous receiver. Unfortunately, a bony callus was observed at the 3-month follow-up at the osteotomy site. Following a discussion with the family, this was attributed to poor compliance of the family with the recommended protocol. The lengthening intervals were inconsistent, and they avoided using an stethoscope for auditory control.\n\nA re-osteotomy was performed from a lateral incision to protect the medial gastrocnemius flap. The functionality of the lengthening mechanism was verified intraoperatively and the nail elongated by 1 cm. Postoperatively all subsequent elongations were carried out by the medical team without complications.\n\nConversion to definitive endoprosthesis\nOnce the maximum lengthening of 8 cm was reached, an exchange of the bioexpandable prosthesis for the definitive modular MUTARS® Distal Femur MK implant (Implantcast, Germany) was performed. An extended lateral approach including the previous approach used for the re-osteotomy was utilized. The newly formed bone was noted to be firm. Additionally, we enhanced the regenerated bone with iliac crest cancellous graft and bone from the reamers. The final uncemented stem was inserted with good primary stability and secured proximally with two bicortical screws. The final adult-size femoral component was connected to the previously implanted tibial part. Primary closure of the wound was achieved. All intraoperative cultures were negative.\n\nOutcomes\nAt the 12-month follow-up after implantation of the definitive endoprosthesis the patient was doing well with no evidence of infection or tumor recurrence. Despite the initial arthrofibrosis resulting from the infection and multiple surgical procedures, the patient progressively regained knee range of motion (0-100°) with full active extension allowing her to independently climb stairs. The affected left leg was 1.5 cm longer in the immediate postoperative period, however, this discrepancy decreased over time with a subsequent discrepancy of less than 1 cm at the last follow-up. Nevertheless, the proximal tibia growth arrest led to an unequal knee joint level of approximately 3 cm. At the last follow-up the patient was painless, full weight-bearing and had resumed all daily routine activities including recreational sports. Final Musculoskeletal Tumor Society (MSTS) and Toronto Extremity Salvage Scores (TESS) were 27/30 and 87%, respectively.", + "fulltext_subclaims": [ + "The patient is an 11-year-old female.", + "The patient was diagnosed with high-grade osteosarcoma of the left distal femur.", + "The patient underwent wide resection and prosthetic reconstruction with an endoprosthesis.", + "Six months after the index surgery, the patient was admitted with septic shock due to an acute deep infection.", + "Extensive pus formation led to skin tearing on the anteromedial aspect of the knee.", + "The surgical revision included removal of the original implant.", + "Thorough debridement of soft tissues and intramedullary canals was performed.", + "A reinforced temporary cement spacer with antibiotics was used to fill the defect.", + "Calcium phosphate beads with Vancomycin were placed inside the medullary canals.", + "A vacuum-assisted device was used to cover the surgical site.", + "Microbiological and bacterial PCR testing turned positive for polymicrobial flora.", + "Genetic testing turned negative for all tested genotypes of antibiotic resistance.", + "Empiric antibiotic therapy with Ciprofloxacin and Metronidazole was started.", + "The patient developed a Salter-Harris type V-like fracture of the proximal tibia.", + "The fracture resulted in a bony bridge across the lateral half of the physis.", + "The treated lower extremity had a 5 cm leg length discrepancy.", + "The length of the cement spacer was 10 cm.", + "The shortest distal femur implant is 18 cm in length.", + "The expected length discrepancy at the end of growth was calculated at 10 cm.", + "The bioexpandable MUTARS® BioXpand prosthesis was used.", + "The prosthesis is 10 cm long.", + "The prosthesis is connected to the FITBONE® extendable motorized nail.", + "The total lengthening potential of this implant is 8 cm.", + "The cement spacer was removed and a reconstruction with the BioXpand prosthesis was performed.", + "A femoral osteotomy site was marked with a Kirschner wire.", + "The FITBONE® nail was inserted into the femoral canal.", + "The implant was lengthened intraoperatively 1 cm.", + "A medial gastrocnemius muscle flap was advanced over the femoral component.", + "All intraoperative cultures were negative.", + "Five days after the surgery, the nail elongation at 1 mm per day started.", + "A bony callus was observed at the 3-month follow-up.", + "A re-osteotomy was performed from a lateral incision.", + "The functionality of the lengthening mechanism was verified intraoperatively.", + "The nail elongated by 1 cm.", + "Postoperatively all subsequent elongations were carried out by the medical team.", + "Once the maximum lengthening of 8 cm was reached, an exchange of the bioexpandable prosthesis for the definitive modular MUTARS® Distal Femur MK implant was performed.", + "The newly formed bone was noted to be firm.", + "The final uncemented stem was inserted with good primary stability.", + "The final adult-size femoral component was connected to the previously implanted tibial part.", + "Primary closure of the wound was achieved.", + "All intraoperative cultures were negative.", + "At the 12-month follow-up, the patient was doing well with no evidence of infection or tumor recurrence.", + "The patient progressively regained knee range of motion (0-100°).", + "The affected left leg was 1.5 cm longer in the immediate postoperative period.", + "The discrepancy decreased over time to less than 1 cm at the last follow-up.", + "The proximal tibia growth arrest led to an unequal knee joint level of approximately 3 cm.", + "The patient was painless, full weight-bearing, and had resumed all daily routine activities.", + "Final Musculoskeletal Tumor Society (MSTS) and Toronto Extremity Salvage Scores (TESS) were 27/30 and 87%, respectively." + ], + "summary": "In this report, we present our unique experience with the bio-expandable MUTARS® BioXpand prosthesis, utilized during the second stage of a revision surgery in an adolescent female patient. Initially, the patient underwent reconstruction using a conventional endoprosthesis following the resection of a high-grade distal femur osteosarcoma; however, she developed a deep infection six months later. During a two-stage revision procedure, the infection was successfully eradicated at the cost of loss of growth potential at also the site of proximal tibia. The initial 5 cm limb-length discrepancy was restored through the application of bioexpandable endoprosthesis, which allowed for an 8 cm gain in bone stock. At the last follow-up appointment, the patient was fully weight-bearing and demonstrated excellent clinical outcomes, with no evidence of infection or tumor recurrence.", + "summary_subclaims": [ + "The patient was an adolescent female.", + "The patient had a high-grade distal femur osteosarcoma.", + "The patient underwent reconstruction using a conventional endoprosthesis.", + "The patient developed a deep infection six months after the initial surgery.", + "A two-stage revision procedure was performed.", + "The infection was successfully eradicated.", + "There was a loss of growth potential at the site of proximal tibia.", + "The initial 5 cm limb-length discrepancy was restored.", + "The bioexpandable endoprosthesis allowed for an 8 cm gain in bone stock.", + "At the last follow-up, the patient was fully weight-bearing.", + "There was no evidence of infection at the last follow-up.", + "There was no evidence of tumor recurrence at the last follow-up." + ] + }, + { + "id": "multiclinsum_test_3245_en.txt", + "fulltext": "The patient, a 3-year-old female, visited the dentistry and pediatric clinics in the Uji-Tokushukai Medical Center, Uji, Japan. She had no fever, right jaw pain, mild trismus, and preauricular facial swelling around the right mandible, but had neither acne nor pustulosis. She was the only child in her family, and her family history was unremarkable. She had healthy dentition and no history of trauma or recurrent aphthous ulcer. Computed tomography (CT) revealed a hyperostotic right mandible, with osteolytic and sclerotic changes associated with periosteal reactions, which led us first to suspect bacterial osteomyelitis (BOM), although she did not have high C-reactive protein (CRP) values with normal white blood cell counts, and her blood culture was negative. Serum lactate dehydrogenase (LDH) and uric acid were within the normal ranges, while alkaline phosphatase was slightly elevated. Vitamin C levels were not examined.\n\nPhysically, there was no apparent abscess or fistula at the jaw lesion. Though she received oral antibiotics (AMPC) for 1 month, her symptoms did not improve. From CT images, Langerhans’ cell histiocytosis was thought to be improbable, rather, CNO was highly likely. Consultation with otolaryngologists led to some debate about whether a biopsy of the affected mandible was required to reach a correct diagnosis, as reported by several authors; however, we chose no invasive measures. During the following 5 months, no clinical features of BOM manifested, and the follow-up of blood tests remained normal. At 6 months after the initial visit, MRI (STIR image) revealed a low-density hyperostotic right mandible. In addition, inflammation had spread to the right masseter muscle, and to the right interior and exterior wing pterygoid muscles, which was suggestive of CNO rather than BOM.\n\nUnder a probable diagnosis of CNO, the patient received flurbiprofen (Froben; 3 mg/kg/day), which is a nonsteroidal anti-inflammatory drug (NSAID). During the 6 months of treatment with flurbiprofen, she was doing well; the facial swelling was ameliorated, with only occasional mild pain in the involved jaw. However, to obtain a better outcome, we then switched treatment after 12 months; the patient received a combined treatment with oral alendronate jelly (2/5 adult dose; 14 mg; 0.7 mg/kg/day), which is normally used for adults at 35 mg/day, plus flurbiprofen. This alendronate treatment was administered once per week. After 1 month of treatment with this regimen, her symptoms subsided markedly, with normalized serum CRP levels and no acceleration of the erythrocyte sedimentation rate. At the age of 4.5 years (18 months from the initial visit), the patient was almost symptom-free. Thereafter, both drugs were tapered.", + "fulltext_subclaims": [ + "The patient is a 3-year-old female.", + "She had no fever.", + "She had right jaw pain.", + "She had mild trismus.", + "She had preauricular facial swelling around the right mandible.", + "She had neither acne nor pustulosis.", + "Her family history was unremarkable.", + "She had healthy dentition.", + "She had no history of trauma.", + "She had no history of recurrent aphthous ulcer.", + "Computed tomography (CT) revealed a hyperostotic right mandible.", + "CT showed osteolytic and sclerotic changes associated with periosteal reactions.", + "The initial suspicion was bacterial osteomyelitis (BOM).", + "She did not have high C-reactive protein (CRP) values.", + "Her white blood cell counts were normal.", + "Her blood culture was negative.", + "Serum lactate dehydrogenase (LDH) was within the normal range.", + "Serum uric acid was within the normal range.", + "Alkaline phosphatase was slightly elevated.", + "Vitamin C levels were not examined.", + "There was no apparent abscess at the jaw lesion.", + "There was no fistula at the jaw lesion.", + "She received oral antibiotics (AMPC) for 1 month.", + "Her symptoms did not improve with oral antibiotics.", + "Langerhans’ cell histiocytosis was thought to be improbable.", + "CNO was considered highly likely.", + "Consultation with otolaryngologists led to some debate about whether a biopsy was required.", + "No invasive measures were chosen.", + "No clinical features of BOM manifested during the following 5 months.", + "Follow-up blood tests remained normal.", + "MRI (STIR image) at 6 months revealed a low-density hyperostotic right mandible.", + "Inflammation had spread to the right masseter muscle.", + "Inflammation had spread to the right interior and exterior wing pterygoid muscles.", + "The findings were suggestive of CNO rather than BOM.", + "The patient received flurbiprofen (3 mg/kg/day).", + "Flurbiprofen is a nonsteroidal anti-inflammatory drug (NSAID).", + "During 6 months of treatment with flurbiprofen, she was doing well.", + "Facial swelling was ameliorated.", + "She had occasional mild pain in the involved jaw.", + "Treatment was switched after 12 months.", + "The patient received combined treatment with oral alendronate jelly (0.7 mg/kg/day) and flurbiprofen.", + "Alendronate treatment was administered once per week.", + "After 1 month of this regimen, symptoms subsided markedly.", + "Serum CRP levels normalized.", + "The erythrocyte sedimentation rate did not accelerate.", + "At 18 months from the initial visit, the patient was almost symptom-free.", + "Both drugs were tapered." + ], + "summary": "A 3-year-old female developed CNO at the jaw alone. She presented with no fever, right jaw pain, mild trismus, and a preauricular facial swelling around the right mandible. Computed tomography (CT) revealed a hyperostotic right mandible, with osteolytic and sclerotic changes associated with periosteal reaction. At first, we suspected BOM and antibiotics were administered. Subsequently, CNO was diagnosed, and the patient received flurbiprofen (a nonsteroidal anti-inflammatory drug (NSAIDs)). Lack of a sufficient response led to successful treatment with a combination of oral alendronate and flurbiprofen.", + "summary_subclaims": [ + "The patient is a 3-year-old female.", + "The patient developed CNO at the jaw alone.", + "The patient had no fever.", + "The patient had right jaw pain.", + "The patient had mild trismus.", + "The patient had a preauricular facial swelling around the right mandible.", + "Computed tomography (CT) revealed a hyperostotic right mandible.", + "Computed tomography (CT) showed osteolytic and sclerotic changes.", + "Computed tomography (CT) showed a periosteal reaction.", + "At first, we suspected BOM.", + "Antibiotics were administered.", + "CNO was diagnosed.", + "The patient received flurbiprofen.", + "Flurbiprofen is a nonsteroidal anti-inflammatory drug (NSAIDs).", + "Lack of a sufficient response occurred.", + "The patient was treated with a combination of oral alendronate and flurbiprofen.", + "The treatment with a combination of oral alendronate and flurbiprofen was successful." + ] + }, + { + "id": "multiclinsum_test_519_en.txt", + "fulltext": "A 67-year-old male patient consulted the emergency department for intermittent back pain and aggravation of exertional dyspnea since 4 months. Physical examination revealed an arterial pressure of 106/82 mmHg, heart rates of 94 beats per minute, and a bilateral lower limb edema. He weighted 79 kg and his height was 181 cm. A rumbling 3/6 heart murmur was heard at the 4th left intercostal space. The biological exams showed a five-fold elevation of high sensitive Troponin-I and a 700-fold elevation of NT-pro brain natriuretic peptide, a moderate renal insufficiency with creatinine clearance rates of 55ml/min.m², and signs of tissue hypoperfusion with lactate level of 2.1mmol/L. The electrocardiogram showed a sinus rhythm and an ST-elevation in the leads V2-V3. The transthoracic echocardiography showed a dilated left ventricle (left ventricular end diastolic diameter of 68 mm) and severely depressed ejection fraction of 29% with a large antero-apical aneurysm which was confirmed by Computerized Tomography Angiography ; a ventricular septal defect measured 8 mm was also visualized . Cardiac index was calculated to be 1.4 L/min/m². Mitral regurgitation was mild (grade I, Fig. A), and right ventricular dysfunction was severe with tricuspid annular plane systolic excursion (TAPSE) of 7 mm. Systolic pulmonary artery pressure was estimated to be 63mmHg. Cardiac magnetic resonance imaging (MRI) confirmed the ventricular septal defect with an estimated ratio pulmonary/systemic flow of 3.6. The extent of transmural infarction in the left ventricle was assessed to be 55%. Coronary angiography uncovered a sub-acute occlusion from the middle of the left anterior descending artery, a chronic occlusion of the ostium of the 3rd obtuse marginal artery as well as a significant stenosis of the right coronary artery. The EuroSCORE II was 30.8%.\nAfter panel discussion and medical preparation including Levosimendan infusion, a semi-urgent operation was scheduled which consisted of VSR closure, surgical ventricular restoration and right coronary artery bypass grafting. After harvesting of the great saphenous vein, full sternotmy and dividing the dense inter-pericardial adhesions, the heart was put onto cardiopulmonary bypass (CPB) with cannulation of the ascending aorta, and superior and inferior vena cava. The distal ascending aorta was then cross clamped, the right coronary artery bypass grafting was performed using great saphenous vein; left ventriculotomy was thereafter made through apical aneurysm, the demarcation between healthy myocardium and scarred tissue was obvious and there was no involvement of the mitral subvalvular apparatus; a muscular VSD sized 8 mm*10mm was then identified and repaired using bovine pericardial patch; finally, ventricular restoration was accomplished according to the Dor procedure. The first weaning cardiopulmonary bypass was uneventful; however, intraoperative transesophageal echocardiography (TOE) uncovered a severe type IIIb mitral regurgitation (MR, Fig. E) which did not exist preoperatively. A decision of re-clamping was soon made to perform mitral valve plasty using a downsized ring (Edwards Physio II, 28 mm). The subsequent TOE of control showed a trial residual MR with a mean transvalvular pressure gradient of 3mmHg. The second CPB was weaned with multiple inotropic supports but without mechanical circulatory assist. The total aortic cross clamping time and CPB time were 190 and 270 min, respectively.\nThe postoperative course was complicated with, in particular, an hypoxemia necessitating a delayed extubation (Day 1) and high-flow oxygen therapy, an acute renal failure requiring continuous renal replacement therapy during 4 days, a sepsis complicating a bacteremia treated with antibiotics over 2 weeks, and a bilateral pleural effusion managed with pleurocentesis twice. Nevertheless, the patient did not present with severe low cardiac output syndrome and the catecholamines were progressively weaned on Day 11. After 30-day stay in intensive care unit and 6 days in the ward, the patient was finally discharged for rehabilitative training. At discharge, transthoracic echocardiography of control showed left ventricular dimension of normal range with an ejection fraction of 40% and cardiac index of 2.4 L/min.m², a good result of mitral plasty with a mean transvalvular pressure gradient of 2mmHg. The TAPSE was assessed to be 12 mm and systolic pulmonary pressure 23 mmHg. During eighteen months following this major operation, he was doing well, the computerized tomography angiography in follow up showed an almost-normal left ventricular morphology , and transthoracic echocardiography of control showed no signs of MR recurrence and a preserved left ventricular ejection of 50%.", + "fulltext_subclaims": [ + "The patient is a 67-year-old male.", + "The patient had intermittent back pain.", + "The patient had aggravation of exertional dyspnea since 4 months.", + "Physical examination revealed an arterial pressure of 106/82 mmHg.", + "Physical examination revealed heart rates of 94 beats per minute.", + "A bilateral lower limb edema was noted.", + "The patient weighed 79 kg.", + "The patient's height was 181 cm.", + "A rumbling 3/6 heart murmur was heard at the 4th left intercostal space.", + "High sensitive Troponin-I was five-fold elevated.", + "NT-pro brain natriuretic peptide was 700-fold elevated.", + "Creatinine clearance rates were 55 ml/min.m².", + "Lactate level was 2.1 mmol/L.", + "The electrocardiogram showed a sinus rhythm.", + "The electrocardiogram showed ST-elevation in the leads V2-V3.", + "Transthoracic echocardiography showed a dilated left ventricle with a left ventricular end diastolic diameter of 68 mm.", + "Transthoracic echocardiography showed a severely depressed ejection fraction of 29%.", + "Computerized Tomography Angiography confirmed a large antero-apical aneurysm.", + "A ventricular septal defect measured 8 mm.", + "Cardiac index was calculated to be 1.4 L/min/m².", + "Mitral regurgitation was mild (grade I).", + "Tricuspid annular plane systolic excursion (TAPSE) was 7 mm.", + "Systolic pulmonary artery pressure was estimated to be 63 mmHg.", + "Cardiac magnetic resonance imaging confirmed the ventricular septal defect.", + "The estimated ratio pulmonary/systemic flow was 3.6.", + "The extent of transmural infarction in the left ventricle was 55%.", + "Coronary angiography uncovered a sub-acute occlusion from the middle of the left anterior descending artery.", + "Coronary angiography uncovered a chronic occlusion of the ostium of the 3rd obtuse marginal artery.", + "Coronary angiography uncovered a significant stenosis of the right coronary artery.", + "The EuroSCORE II was 30.8%.", + "A semi-urgent operation was scheduled.", + "The operation consisted of VSR closure.", + "The operation consisted of surgical ventricular restoration.", + "The operation consisted of right coronary artery bypass grafting.", + "A great saphenous vein was harvested.", + "A full sternotomy was performed.", + "The heart was put onto cardiopulmonary bypass with cannulation of the ascending aorta, and superior and inferior vena cava.", + "The distal ascending aorta was cross clamped.", + "Right coronary artery bypass grafting was performed using great saphenous vein.", + "A left ventriculotomy was made through apical aneurysm.", + "A muscular VSD sized 8 mm*10 mm was identified.", + "The VSD was repaired using bovine pericardial patch.", + "Ventricular restoration was accomplished according to the Dor procedure.", + "The first weaning from cardiopulmonary bypass was uneventful.", + "Intraoperative transesophageal echocardiography uncovered a severe type IIIb mitral regurgitation.", + "A decision was made to perform mitral valve plasty using a downsized ring (Edwards Physio II, 28 mm).", + "The subsequent TOE showed a trial residual MR with a mean transvalvular pressure gradient of 3 mmHg.", + "The second CPB was weaned with multiple inotropic supports.", + "The total aortic cross clamping time was 190 minutes.", + "The total CPB time was 270 minutes.", + "The postoperative course was complicated with hypoxemia necessitating delayed extubation on Day 1.", + "The postoperative course was complicated with high-flow oxygen therapy.", + "The postoperative course was complicated with acute renal failure requiring continuous renal replacement therapy during 4 days.", + "The postoperative course was complicated with sepsis complicating a bacteremia treated with antibiotics over 2 weeks.", + "The postoperative course was complicated with bilateral pleural effusion managed with pleurocentesis twice.", + "The patient did not present with severe low cardiac output syndrome.", + "Catecholamines were progressively weaned on Day 11.", + "The patient was discharged after 30-day stay in intensive care unit and 6 days in the ward.", + "Transthoracic echocardiography at discharge showed left ventricular dimension of normal range.", + "Transthoracic echocardiography at discharge showed an ejection fraction of 40%.", + "Transthoracic echocardiography at discharge showed a cardiac index of 2.4 L/min/m².", + "Transthoracic echocardiography at discharge showed a good result of mitral plasty with a mean transvalvular pressure gradient of 2 mmHg.", + "TAPSE was assessed to be 12 mm at discharge.", + "Systolic pulmonary pressure was 23 mmHg at discharge.", + "During eighteen months following the operation, the patient was doing well.", + "Computerized tomography angiography in follow up showed an almost-normal left ventricular morphology.", + "Transthoracic echocardiography in follow up showed no signs of MR recurrence.", + "Transthoracic echocardiography in follow up showed a preserved left ventricular ejection of 50%." + ], + "summary": "Semi-emergent surgical ventricular restoration combined with ventricular septal rupture closure and coronary artery bypassing was performed in a 67-year-old male patient. Severe mitral regurgitation was detected after the weaning of cardiopulmonary bypass. Two key questions arose in the management of this condition: did the regurgitation exist previously and was dissimulated by significant left-to-right shunt, or it occurred secondarily to the Dor procedure? Which was the better management strategy, chordal-sparing mitral valve replacement or mitral plasty? We believed that severe mitral regurgitation was under-estimated pre-operatively and we performed an downsizing annuloplasty to treat mitral regurgitation. The outcomes were promising and the patient did well in follow-up.", + "summary_subclaims": [ + "Semi-emergent surgical ventricular restoration combined with ventricular septal rupture closure and coronary artery bypassing was performed in a 67-year-old male patient.", + "Severe mitral regurgitation was detected after the weaning of cardiopulmonary bypass.", + "Two key questions arose in the management of this condition: did the regurgitation exist previously and was dissimulated by significant left-to-right shunt, or it occurred secondarily to the Dor procedure?", + "Which was the better management strategy, chordal-sparing mitral valve replacement or mitral plasty?", + "We believed that severe mitral regurgitation was under-estimated pre-operatively.", + "We performed a downsizing annuloplasty to treat mitral regurgitation.", + "The outcomes were promising.", + "The patient did well in follow-up." + ] + }, + { + "id": "multiclinsum_test_346_en.txt", + "fulltext": "A 67-year-old male patient was admitted to the hospital with new onset fever, chest pain and dyspnea for 7 days and previous diagnose of right lung squamous cell carcinoma. His previous medical history was notable for right lung squamous cell carcinoma stage IV (T3N3M1) complicated with mediastinal lymph nodes and liver metastasis 1 year before. Cardiac and pulmonary function was normal at that time. Four cycles of chemotherapy with paclitaxel-cisplatin regimen was initiated but afterwards stopped due to 2019 coronavirus outbreak. Ten months thereafter, he was admitted to the hospital because of right massive pleural effusion. Twice bacterial culture of pleural effusion displayed Prevotella nigrescens, indicating right lung squamous cell carcinoma complicated with empyema. With subsequent treatment of meropenem as the anti-bacterial agent, his symptoms were relieved and his temperature was normal. As a result, chemotherapy was discontinued and replaced with PD-L1 immune checkpoint inhibitor, durvalumab monotherapy for four cycles (500 mg intravenous drip). And he presented with the symptom of fever, chest pain and dyspnea 7 days after last cycle of durvalumab. Moreover, the previous medical, family, and psychosocial history as well as genetic information showed nothing special.\nPhysical and laboratory examination was done for the patients upon this admission. The highest temperature was 39.4°C. His blood pressure was 121/69 mmHg. Chest computed tomography (CT) examination indicated right bronchial obstruction, obstructive pneumonia and right pleural effusion . Echocardiography revealed ventricle size within normal range (left ventricle end diastolic dimension 46 mm), increased atrium size (left atrium dimension LA 36 mm) and markedly decrease cardiac ejection fraction (left ventricular ejection fraction 41%), tracing 2 mm pericardial effusion . The electrocardiogram showed sinus tachycardia, low voltage of limb leads, T wave inversion in anterior waves and V1–V3 QS type . Markers of myocardial injury were elevated: Natriuretic peptide BNP 18 942 ng/L; Troponin T 0.066 ng/L; Troponin I 200.83 ng/L; Creatine kinase (CK) and Creatine kinase isoenzyme (CKMB) normal. Moreover, inflammatory indicators were significantly elevated. Erythrocyte sedimentation rate (ESR) was markedly increased with the level of 101 mm/h, and C-reactive protein (CRP) 268.2 mg/L. Interleukin-6 was 44.93 pg/mL.\nJudging by the decreased cardiac function and elevated myocardial injury markers at this admission, the patient was diagnosed of acute immune-associated myocarditis and right lung squamous cell carcinoma complicated with empyema. Treatments included methylprednisolone to suppress inflammation (40 mg, once per day, iv), meropenem to control infection (1.0 g, q8h, iv.drip) and symptomatic and supportive treatments. Seven days after admission, the patient's symptoms were relieved. Myocardial injury and inflammation markers were significantly decreased: Natriuretic peptide BNP was down to 2,298 ng/L; Troponin T, Troponin I, CK and CKMB normal; ESR 41 mm/h; CRP 29.8 mg/L; and Interleukin-6 normal. The electrocardiogram showed normal sinus rate and V2–V5 T wave inversion . Echocardiography revealed ventricle size within normal range (left ventricle end diastolic dimension 48 mm), increased atrium size (left atrium dimension LA 30 mm) and markedly recovered cardiac ejection fraction (left ventricular ejection fraction 66%). The patient was discharged with prescription of continuing oral methylprednisolone (20 mg, once per day, po) and anti-bacterial therapy of faroenem to control infection (150 mg, q8h, po). No further heart failure exacerbations have occurred to date.", + "fulltext_subclaims": [ + "A 67-year-old male patient was admitted to the hospital with new onset fever, chest pain and dyspnea for 7 days.", + "The patient had a previous diagnosis of right lung squamous cell carcinoma.", + "The patient's previous medical history was notable for right lung squamous cell carcinoma stage IV (T3N3M1) complicated with mediastinal lymph nodes and liver metastasis 1 year before.", + "Cardiac and pulmonary function was normal at that time.", + "Four cycles of chemotherapy with paclitaxel-cisplatin regimen was initiated.", + "Chemotherapy was afterwards stopped due to 2019 coronavirus outbreak.", + "Ten months after stopping chemotherapy, he was admitted to the hospital because of right massive pleural effusion.", + "Twice bacterial culture of pleural effusion displayed Prevotella nigrescens.", + "The diagnosis was right lung squamous cell carcinoma complicated with empyema.", + "With subsequent treatment of meropenem as the anti-bacterial agent, his symptoms were relieved and his temperature was normal.", + "Chemotherapy was discontinued and replaced with PD-L1 immune checkpoint inhibitor, durvalumab monotherapy for four cycles (500 mg intravenous drip).", + "He presented with the symptom of fever, chest pain and dyspnea 7 days after last cycle of durvalumab.", + "The patient's highest temperature was 39.4°C.", + "Chest computed tomography (CT) examination indicated right bronchial obstruction, obstructive pneumonia and right pleural effusion.", + "Echocardiography revealed ventricle size within normal range (left ventricle end diastolic dimension 46 mm).", + "Echocardiography revealed increased atrium size (left atrium dimension LA 36 mm).", + "Echocardiography revealed markedly decreased cardiac ejection fraction (left ventricular ejection fraction 41%).", + "Echocardiography revealed 2 mm pericardial effusion.", + "The electrocardiogram showed sinus tachycardia, low voltage of limb leads, T wave inversion in anterior waves and V1–V3 QS type.", + "Natriuretic peptide BNP was 18 942 ng/L.", + "Troponin T was 0.066 ng/L.", + "Troponin I was 200.83 ng/L.", + "Creatine kinase (CK) and Creatine kinase isoenzyme (CKMB) were normal.", + "Erythrocyte sedimentation rate (ESR) was 101 mm/h.", + "C-reactive protein (CRP) was 268.2 mg/L.", + "Interleukin-6 was 44.93 pg/mL.", + "The patient was diagnosed of acute immune-associated myocarditis.", + "The patient was diagnosed of right lung squamous cell carcinoma complicated with empyema.", + "Treatments included methylprednisolone to suppress inflammation (40 mg, once per day, iv).", + "Treatments included meropenem to control infection (1.0 g, q8h, iv.drip).", + "Seven days after admission, the patient's symptoms were relieved.", + "Natriuretic peptide BNP was down to 2,298 ng/L.", + "Troponin T, Troponin I, CK and CKMB were normal.", + "ESR was 41 mm/h.", + "CRP was 29.8 mg/L.", + "Interleukin-6 was normal.", + "The electrocardiogram showed normal sinus rate and V2–V5 T wave inversion.", + "Echocardiography revealed ventricle size within normal range (left ventricle end diastolic dimension 48 mm).", + "Echocardiography revealed increased atrium size (left atrium dimension LA 30 mm).", + "Echocardiography revealed markedly recovered cardiac ejection fraction (left ventricular ejection fraction 66%).", + "The patient was discharged with prescription of continuing oral methylprednisolone (20 mg, once per day, po).", + "The patient was discharged with anti-bacterial therapy of faroenem to control infection (150 mg, q8h, po).", + "No further heart failure exacerbations have occurred to date." + ], + "summary": "Here we present a rare case of a 67-year-old male with lung squamous cell carcinoma complicated with empyema who experienced myocarditis after only PD-L1 inhibitor durvalumab monotherapy. He presented with markedly decrease left ventricular ejection fraction, elevated Natriuretic peptide BNP, Troponin T, Troponin I, ESR, CRP and interleukin-6. The electrocardiogram showed sinus tachycardia, low voltage of limb leads, T wave inversion in anterior waves and V1-V3 QS type. Myocardial injury occurred in a short period and quickly returned to normal after glucocorticoids therapy.", + "summary_subclaims": [ + "The patient is a 67-year-old male.", + "The patient had lung squamous cell carcinoma.", + "The patient had empyema.", + "The patient experienced myocarditis after PD-L1 inhibitor durvalumab monotherapy.", + "The patient had a markedly decreased left ventricular ejection fraction.", + "The patient had elevated Natriuretic peptide BNP.", + "The patient had elevated Troponin T.", + "The patient had elevated Troponin I.", + "The patient had elevated ESR.", + "The patient had elevated CRP.", + "The patient had elevated interleukin-6.", + "The electrocardiogram showed sinus tachycardia.", + "The electrocardiogram showed low voltage of limb leads.", + "The electrocardiogram showed T wave inversion in anterior waves.", + "The electrocardiogram showed V1-V3 QS type.", + "Myocardial injury occurred in a short period.", + "Myocardial injury quickly returned to normal after glucocorticoids therapy." + ] + }, + { + "id": "multiclinsum_test_3156_en.txt", + "fulltext": "A 32-year-old Japanese man with no medical history visited a local doctor because his blood pressure (BP) was alarmingly high (215/150 mmHg) at the time of a health check-up, and he was aware of a loss of appetite and headache lasting more than 2 months. Given the diagnosis of severe hypertension, the patient was administered doxazosin, an α-adrenergic antagonist, and he was referred to our hospital for further examination and treatment. He was a current smoker of up to 10 cigarettes per day.\n\nAt the referral visit, the patient’s BP was still severely high at 170/102 mmHg, and his pulse rate was 74 beats per minute. Physical examination revealed no edema or signs of meningeal irritation. Laboratory data indicated polycythemia (RBC 703 × 104/µL, hemoglobin [Hb] 20.2 g/dL) and renal failure with proteinuria and hematuria (creatinine [Cr] 3.70 mg/dL, urine protein-to-Cr ratio 0.28 g/gCr, RBC 10–19/high-power field) (Table 1). His serum cortisol, plasma renin activity, plasma aldosterone concentration, and catecholamine levels were within normal ranges, and no autoantibodies associated with glomerulonephritis were detected (Table 1). Abdominal ultrasonography showed bilaterally enlarged kidneys (right: 14.2 cm × 8.4 cm, left: 14.0 cm× 8.5 cm) and no hydronephrosis. Although severe hypertension caused by polycythemia and renal failure was suspected, the precise cause of the polycythemia, renal failure, and renal enlargement was unclear.\n\nTo reduce BP, 40 mg/ day of nifedipine controlled-release (CR), a long-acting calcium channel blocker, and 20 mg/day of olmesartan, an angiotensin receptor blocker, were added. The patient’s BP improved significantly to 135/95 mmHg on day 8 (7 days after the referral visit), and a renal biopsy was performed to determine the cause of renal failure and enlargement. Light microscopy revealed virtually normal structures in seven obtained glomeruli, but diffuse and extensive interstitial infiltration with medium- to large-sized atypical lymphoid cells. Immunohistochemistry showed the cells to be positive for cytoplasmic CD3, terminal deoxynucleotidyl transferase, and Ki-67, but negative for CD20. Immunofluorescence staining and electron microscopy revealed no evidence of immune deposits. Bone marrow biopsy revealed > 25% blasts, and myeloperoxidase staining was negative. Based on these findings, the patient was diagnosed with T-ALL and bilaterally enlarged kidneys caused by renal infiltration of leukemic cells. Computed tomography (CT) showed moderate right pleural effusion; anterior mediastinum mass; slightly enlarged lymph nodes in the neck, mediastinal, right hilar, right axillary, and abdominal para-aortic areas; and enlarged kidneys. Consistent with these findings, [18F]-fluorodeoxyglucose (18FDG)-positron emission tomography (PET)/CT demonstrated an increase in metabolic uptake in these organs, with the largest increase observed in the kidneys. Serum EPO levels were high at 38.7 mIU/mL (normal range: 4.2–23.7 mIU/mL) despite high Hb levels; thus, he was diagnosed with secondary polycythemia. No adrenal or liver tumors or hypoxic lung disease were detected, and oxygen saturation was 95% in room air; therefore, we considered that secondary polycythemia may have been caused by the bilaterally enlarged, infiltrated kidneys.\n\nOn day 20, the patient was treated with prednisolone to reduce the tumor mass. After 1 week, remission induction chemotherapy (vincristine, daunorubicin, dexamethasone, l-asparaginase, methotrexate, cytarabine, prednisolone) was administered according to the Japan Adult Leukemia Study Group (JALSG) ALL202-O protocol. On day 21, hemodialysis was initiated due to severe tumor lysis syndrome. After 1 month of chemotherapy, the patient’s renal function improved, and he was taken off hemodialysis. His kidneys were smaller on day 24 (right: 11.9 cm × 7.2 cm, left: 13.0 cm× 7.5 cm) and their size had normalized on day 60 (right: 9.4 cm × 5.5 cm, left: 10.8 cm× 5.0 cm). His Hb levels normalized on day 23 but gradually decreased from day 45 to day 62, at which time the Hb level was 7.3 g/dL. EPO level was low at 12.0 mIU/mL on day 59; therefore, 30 µg of darbepoetin alfa was started for the treatment of renal anemia. Consistent with the improvements of the bilaterally enlarged kidneys and polycythemia, his BP improved, and doxazosin and olmesartan were discontinued on day 22. His systolic BP improved to 110–120 mmHg at a dose of only 20 mg/day of nifedipine CR. Future plans for the patient include a hematopoietic stem cell transplantation after hyper-CVAD therapy (cyclophosphamide, vincristine, doxorubicin, dexamethasone) and MA therapy (methotrexate, cytarabine).", + "fulltext_subclaims": [ + "The patient is a 32-year-old Japanese man.", + "The patient had no medical history.", + "The patient's blood pressure was 215/150 mmHg at the time of a health check-up.", + "The patient was aware of a loss of appetite and headache lasting more than 2 months.", + "The patient was diagnosed with severe hypertension.", + "The patient was administered doxazosin, an α-adrenergic antagonist.", + "The patient was referred to the hospital for further examination and treatment.", + "The patient was a current smoker of up to 10 cigarettes per day.", + "At the referral visit, the patient’s blood pressure was 170/102 mmHg.", + "Physical examination revealed no edema.", + "Laboratory data indicated polycythemia.", + "Laboratory data indicated renal failure with proteinuria and hematuria.", + "Abdominal ultrasonography showed bilaterally enlarged kidneys.", + "Severe hypertension caused by polycythemia and renal failure was suspected.", + "The precise cause of the polycythemia, renal failure, and renal enlargement was unclear.", + "40 mg/day of nifedipine controlled-release and 20 mg/day of olmesartan were added.", + "The patient’s blood pressure improved significantly to 135/95 mmHg on day 8.", + "A renal biopsy was performed.", + "Light microscopy revealed diffuse and extensive interstitial infiltration with medium- to large-sized atypical lymphoid cells.", + "Immunohistochemistry showed the cells to be positive for cytoplasmic CD3, terminal deoxynucleotidyl transferase, and Ki-67.", + "Immunohistochemistry showed the cells to be negative for CD20.", + "Bone marrow biopsy revealed >25% blasts.", + "Myeloperoxidase staining was negative.", + "The patient was diagnosed with T-ALL.", + "The patient was diagnosed with bilaterally enlarged kidneys caused by renal infiltration of leukemic cells.", + "Computed tomography showed moderate right pleural effusion.", + "Computed tomography showed an anterior mediastinum mass.", + "Computed tomography showed enlarged lymph nodes in the neck, mediastinal, right hilar, right axillary, and abdominal para-aortic areas.", + "Computed tomography showed enlarged kidneys.", + "18FDG-PET/CT demonstrated an increase in metabolic uptake in the kidneys.", + "Serum EPO levels were high at 38.7 mIU/mL.", + "The patient was diagnosed with secondary polycythemia.", + "No adrenal or liver tumors or hypoxic lung disease were detected.", + "Oxygen saturation was 95% in room air.", + "The patient was treated with prednisolone to reduce the tumor mass.", + "Remission induction chemotherapy was administered according to the JALSG ALL202-O protocol.", + "Hemodialysis was initiated on day 21 due to severe tumor lysis syndrome.", + "After 1 month of chemotherapy, the patient’s renal function improved.", + "The patient was taken off hemodialysis.", + "The patient’s kidneys were smaller on day 24.", + "The patient’s kidneys had normalized on day 60.", + "The patient’s Hb levels normalized on day 23.", + "The patient’s Hb level was 7.3 g/dL on day 62.", + "EPO level was low at 12.0 mIU/mL on day 59.", + "30 µg of darbepoetin alfa was started for the treatment of renal anemia.", + "The patient’s systolic BP improved to 110–120 mmHg at a dose of only 20 mg/day of nifedipine CR.", + "Doxazosin and olmesartan were discontinued on day 22.", + "Future plans for the patient include a hematopoietic stem cell transplantation after hyper-CVAD therapy and MA therapy." + ], + "summary": "A 32-year-old Japanese man presented with marked hypertension (215/150 mmHg) with renal insufficiency (creatinine 3.7 mg/dL), proteinuria, hematuria, bilateral nephromegaly, polycythemia (hemoglobin 20.2 g/dL), and increased serum EPO (38.7 mIU/mL, range 4.2-23.7 mIU/mL). Based on renal and bone marrow biopsy findings, he was diagnosed with T-ALL and bilaterally enlarged kidneys caused by renal infiltration of leukemic cells. There was no evidence of endocrine hypertension or fluid retention. Remission induction chemotherapy led to a decrease in kidney size, hemoglobin levels, and serum EPO levels, and allowed dose reductions of most hypertensive drugs, suggesting that hypertension was secondary to polycythemia. The patient's renal function gradually improved and hemodialysis was discontinued after 1 month of chemotherapy.", + "summary_subclaims": [ + "The patient is a 32-year-old Japanese man.", + "The patient had marked hypertension with blood pressure of 215/150 mmHg.", + "The patient had renal insufficiency with a creatinine level of 3.7 mg/dL.", + "The patient had proteinuria.", + "The patient had hematuria.", + "The patient had bilateral nephromegaly.", + "The patient had polycythemia with a hemoglobin level of 20.2 g/dL.", + "The patient had increased serum EPO levels of 38.7 mIU/mL.", + "Based on renal and bone marrow biopsy findings, the patient was diagnosed with T-ALL.", + "The patient was diagnosed with bilaterally enlarged kidneys caused by renal infiltration of leukemic cells.", + "There was no evidence of endocrine hypertension.", + "There was no evidence of fluid retention.", + "Remission induction chemotherapy led to a decrease in kidney size.", + "Remission induction chemotherapy led to a decrease in hemoglobin levels.", + "Remission induction chemotherapy led to a decrease in serum EPO levels.", + "Remission induction chemotherapy allowed dose reductions of most hypertensive drugs.", + "The patient's hypertension was suggested to be secondary to polycythemia.", + "The patient's renal function gradually improved.", + "Hemodialysis was discontinued after 1 month of chemotherapy." + ] + }, + { + "id": "multiclinsum_test_234_en.txt", + "fulltext": "A 53-year-old female patient presented to the First Affiliated Hospital of Beilun Branch of Zhejiang University China on September 2015 complaining of pain on the right side of her abdomen associated with abdominal distension and multiple episodes of vomiting for 1-week duration. She denied changes in bowel habits, blood in stools, and past abdominal operations. Her family history was insignificant for neurofibromatosis type 1. On abdominal examination, she exhibited abdominal guarding, but no palpable mass was found. Abdominal CECT demonstrated intussusception in the ascending colon with a smooth enhancing 3.5 cm mass suspicious for neoplasm . Colonoscopy was deferred due to significant exacerbation of pain and worsening peritonitis. The patient subsequently underwent emergent exploratory laparotomy. Due to difficulty reducing the ileocolic , right hemicolectomy with ileocolic anastamosis was performed . Exploration of the abdomen revealed no carcinomatosis. The intraoperative frozen section displayed spindle cell tumor of the small bowel. Although there seemed to be no apparent lymphadenopathy in the mesentery, we resected the mesentery to include the potential lymph node metastases. The resected specimen revealed a 4.0 × 3.5 × 2.3 cm submucosal mass of the distal ileum . Macroscopic examination demonstrated a gray-white appearance of the tumor cross section, without hemorrhage and necrosis. Histologically, the tumor was composed of bundles and palisading arrangement of malignant spindle cells that extended into the muscularis mucosa . The tumor had dense cellularity with significant mitotic activity of approximately 10 mitoses per 10 high-power fields. The surgical margins were negative for the tumor. On immunohistochemical staining, the tumor was positive for S-100 and CD34, but negative for CD117, DOG-1, SMA, AE1/AE3, HMB45, and PNL-2. The Ki67 labeling index was approximately 15–20% . On the basis of these pathological findings, the tumor was identified as a low-grade malignant peripheral nerve sheath tumor (MPNST).\nThe patient declined to undergo further genetic analysis and chemotherapy. She had a good postoperative course and was discharged 2 weeks after surgery. She presented with diarrhea, fever, and moderate anemia at 3 and 7 months post-operation. Abdominal CECT demonstrated no sign of tumor recurrence and metastatic disease. She underwent symptomatic treatment and was discharged home. In June 2016, she died due to complications of her disease.\nAccording to the WHO, MPNSTs are defined as any tumor originating from a peripheral nerve or exhibiting nerve sheath differentiation. MPNST is the sixth most common type of soft tissue sarcoma [, ]. Approximately 50% of all MPNST cases arise sporadically, whereas the other cases are observed in patients with neurofibromatosis type 1 (NF1) [, ], who carry an estimated 8 to 13% lifetime risk of developing MPNST . An estimated 3 to 10% of all MPNST patients have a clinical history of prior radiation exposure after a latent period of more than 15 years . MPNST is typically characterized in adults with most tumors occurring in patients between 20 and 50 years of age with a median age of 35 .\nMost MPNSTs are located along major nerve trunks, commonly arising on the body trunk, extremities, head, neck, and paravertebral regions . MPNSTs arising from nerves of the small intestinal wall are extremely rare, with only fewer than 10 cases reported worldwide [–].\nThere seems to be no characteristic clinical symptoms of MPNST of the intestine. Most patients experience fatigue, weight loss, emesis, abdominal pain, and intestinal bleed . Our patient presented with intestinal obstruction due to intussusception. The diagnosis is often delayed because these symptoms are usually non-specific and vague, thereby increasing the difficulty of a preoperative diagnosis of MPNST of the small intestine.\nThe quantitative FDG-PET imaging is used to distinguish between benign PNST and MPNST based on a tumor’s metabolic activity [, ]. Due to the disability to effectively confirm malignant transformation of lesions, CT and MRI are limited to define the anatomic tumor size and local invasiveness of PNST [, ]. The quantitative FDG-PET imaging combined with CT or MRI may be the best way to distinguish MPNST from benign PNST. However, radiographic imaging of MPNST has not supplanted histopathologic examination as the gold standard for the diagnosis of MPNST . In our case, the CECT of the abdomen revealed an intussusception in the ascending colon with a smooth enhancing 3.5 cm mass suspicious for neoplasm, but could not confirm its definite lesion.\nIt is important to recognize that there is still a lack of widely accepted diagnostic criteria for MPNST . These tumors have well-described morphological heterogeneity, and staining reveals highly cellular spindle cell tumor in fascicles . S-100 protein has been the classic and most widely used antigen for documenting nerve sheath differentiation. CD34 is expressed in some MPNSTs and is likely a reflection of perineurial differentiation. Many studies suggest that elevated Ki67 expression is associated with decreased survival in MPNST [, ]. The reactivity of S-100 protein and high levels of p53 and Ki67 can be useful in making the final diagnosis . In our case, the diffuse expression of S-100 protein and the level of Ki67 were in favor of MPNST.\nForty to 65% of MPNST patients experience local recurrence, and 30 to 60% develop metastases within 12 months of initial surgery . Factors that predict recurrence include anatomic site, tumor size (≥10 cm), and adequacy of margins. Factors that predict metastases include tumor size (≥10 cm) or tumors that are American Joint Committee on Cancer stage III . Over two thirds of metastases develop in the lung, whereas the other sites include the liver, brain, bone, and adrenal gland . To date, there is little knowledge on MPNST of the small bowel, which is thought to have a far worse prognosis than other soft tissue sarcomas.\nBecause of its rarity, the optimal treatment of the small bowel MPNST is not well established . Current recommendations and treatment may be based only on what is known of this tumor in other locations of the body. Complete surgical resection with wide negative margins is the current standard of care for localized MPNST and is a strong predictor of survival . Adjuvant radiation therapy can been used to locally control MPNST . However, small bowel MPNST may not benefit from the radiotherapy due to the location in the abdominal cavity . Although chemotherapy has been carried out on gastrointestinal MPNST after surgical treatment, there are no further trials evaluating the role of chemotherapy in unresectable and metastatic tumors . Recent advances in therapy have focused on targeting the molecular pathways in MPNST, but the outcomes of recently clinical trials demonstrate that further studies are needed [, ]. The multidisciplinary approach should be adopted to cope with these tumors.\nAccording to the clinical and pathological characteristics, this patient was diagnosed the MPNST of the small bowel. Unfortunately, further genetic analysis was not obtained, due to patient preference as this could have been helpful for creating further treatment plans. Here, we report a rare case of MPNST of the distal ileum, which, to the best of our knowledge, was also the first Chinese case of this disease. Although MPNST arising from the small bowel is extremely rare, a surgeon should also be aware of the possibility of MPNST when dealing with intestinal obstruction or intussusception. Since patients with MPNST have very poor prognosis, it is necessary to perform a quick frozen section in the operation for a clear diagnosis. We suggest an extended radical operation in case of the fast frozen section displaying spindle cell tumors of the small bowel.", + "fulltext_subclaims": [ + "The patient was a 53-year-old female.", + "She presented to the First Affiliated Hospital of Beilun Branch of Zhejiang University China on September 2015.", + "She complained of pain on the right side of her abdomen.", + "She had abdominal distension and multiple episodes of vomiting for 1-week duration.", + "She denied changes in bowel habits.", + "She denied blood in stools.", + "She denied past abdominal operations.", + "Her family history was insignificant for neurofibromatosis type 1.", + "On abdominal examination, she exhibited abdominal guarding.", + "No palpable mass was found on abdominal examination.", + "Abdominal CECT demonstrated intussusception in the ascending colon.", + "The CECT showed a smooth enhancing 3.5 cm mass suspicious for neoplasm.", + "Colonoscopy was deferred due to significant exacerbation of pain.", + "Colonoscopy was deferred due to worsening peritonitis.", + "The patient underwent emergent exploratory laparotomy.", + "Right hemicolectomy with ileocolic anastamosis was performed.", + "Exploration of the abdomen revealed no carcinomatosis.", + "The intraoperative frozen section displayed spindle cell tumor of the small bowel.", + "The resected specimen revealed a 4.0 × 3.5 × 2.3 cm submucosal mass of the distal ileum.", + "Macroscopic examination demonstrated a gray-white appearance of the tumor cross section.", + "The tumor had no hemorrhage.", + "The tumor had no necrosis.", + "Histologically, the tumor was composed of bundles and palisading arrangement of malignant spindle cells.", + "The tumor extended into the muscularis mucosa.", + "The tumor had dense cellularity.", + "The tumor had significant mitotic activity of approximately 10 mitoses per 10 high-power fields.", + "The surgical margins were negative for the tumor.", + "On immunohistochemical staining, the tumor was positive for S-100.", + "On immunohistochemical staining, the tumor was positive for CD34.", + "On immunohistochemical staining, the tumor was negative for CD117.", + "On immunohistochemical staining, the tumor was negative for DOG-1.", + "On immunohistochemical staining, the tumor was negative for SMA.", + "On immunohistochemical staining, the tumor was negative for AE1/AE3.", + "On immunohistochemical staining, the tumor was negative for HMB45.", + "On immunohistochemical staining, the tumor was negative for PNL-2.", + "The Ki67 labeling index was approximately 15–20%.", + "The tumor was identified as a low-grade malignant peripheral nerve sheath tumor (MPNST).", + "The patient declined to undergo further genetic analysis.", + "The patient declined to undergo chemotherapy.", + "She had a good postoperative course.", + "She was discharged 2 weeks after surgery.", + "She presented with diarrhea at 3 months post-operation.", + "She presented with fever at 3 months post-operation.", + "She presented with moderate anemia at 3 months post-operation.", + "She presented with diarrhea at 7 months post-operation.", + "She presented with fever at 7 months post-operation.", + "She presented with moderate anemia at 7 months post-operation.", + "Abdominal CECT demonstrated no sign of tumor recurrence.", + "Abdominal CECT demonstrated no sign of metastatic disease.", + "She underwent symptomatic treatment.", + "She was discharged home.", + "In June 2016, she died due to complications of her disease.", + "MPNSTs are defined as any tumor originating from a peripheral nerve or exhibiting nerve sheath differentiation.", + "MPNST is the sixth most common type of soft tissue sarcoma.", + "Approximately 50% of all MPNST cases arise sporadically.", + "The other cases are observed in patients with neurofibromatosis type 1.", + "Patients with neurofibromatosis type 1 have an estimated 8 to 13% lifetime risk of developing MPNST.", + "An estimated 3 to 10% of all MPNST patients have a clinical history of prior radiation exposure.", + "MPNST typically occurs in adults.", + "Most MPNST tumors occur in patients between 20 and 50 years of age.", + "MPNSTs are typically located along major nerve trunks.", + "MPNSTs commonly arise on the body trunk.", + "MPNSTs commonly arise on the extremities.", + "MPNSTs commonly arise on the head.", + "MPNSTs commonly arise on the neck.", + "MPNSTs commonly arise on the paravertebral regions.", + "MPNSTs arising from nerves of the small intestinal wall are extremely rare.", + "There are fewer than 10 reported cases worldwide of MPNSTs arising from the small intestinal wall.", + "There seems to be no characteristic clinical symptoms of MPNST of the intestine.", + "Most patients experience fatigue.", + "Most patients experience weight loss.", + "Most patients experience emesis.", + "Most patients experience abdominal pain.", + "Most patients experience intestinal bleed.", + "The diagnosis is often delayed.", + "The symptoms are usually non-specific.", + "The symptoms are usually vague.", + "The difficulty of a preoperative diagnosis of MPNST of the small intestine is increased.", + "Quantitative FDG-PET imaging is used to distinguish between benign PNST and MPNST.", + "CT and MRI are limited to define the anatomic tumor size and local invasiveness of PNST.", + "Quantitative FDG-PET imaging combined with CT or MRI may be the best way to distinguish MPNST from benign PNST.", + "Radiographic imaging of MPNST has not supplanted histopathologic examination as the gold standard for the diagnosis of MPNST.", + "The CECT of the abdomen revealed an intussusception in the ascending colon with a smooth enhancing 3.5 cm mass suspicious for neoplasm.", + "The CECT could not confirm its definite lesion.", + "There is still a lack of widely accepted diagnostic criteria for MPNST.", + "MPNSTs have well-described morphological heterogeneity.", + "Staining reveals highly cellular spindle cell tumor in fascicles.", + "S-100 protein has been the classic and most widely used antigen for documenting nerve sheath differentiation.", + "CD34 is expressed in some MPNSTs.", + "Elevated Ki67 expression is associated with decreased survival in MPNST.", + "The reactivity of S-100 protein and high levels of p53 and Ki67 can be useful in making the final diagnosis.", + "In our case, the diffuse expression of S-100 protein and the level of Ki67 were in favor of MPNST.", + "Forty to 65% of MPNST patients experience local recurrence.", + "Thirty to 60% of MPNST patients develop metastases within 12 months of initial surgery.", + "Factors that predict recurrence include anatomic site.", + "Factors that predict recurrence include tumor size (≥10 cm).", + "Factors that predict recurrence include adequacy of margins.", + "Factors that predict metastases include tumor size (≥10 cm).", + "Factors that predict metastases include tumors that are American Joint Committee on Cancer stage III.", + "Over two thirds of metastases develop in the lung.", + "Other metastatic sites include the liver.", + "Other metastatic sites include the brain.", + "Other metastatic sites include the bone.", + "Other metastatic sites include the adrenal gland.", + "There is little knowledge on MPNST of the small bowel.", + "MPNST of the small bowel is thought to have a far worse prognosis than other soft tissue sarcomas.", + "The optimal treatment of the small bowel MPNST is not well established.", + "Complete surgical resection with wide negative margins is the current standard of care for localized MPNST.", + "Complete surgical resection with wide negative margins is a strong predictor of survival.", + "Adjuvant radiation therapy can be used to locally control MPNST.", + "Small bowel MPNST may not benefit from radiotherapy due to the location in the abdominal cavity.", + "Chemotherapy has been carried out on gastrointestinal MPNST after surgical treatment.", + "There are no further trials evaluating the role of chemotherapy in unresectable and metastatic tumors.", + "Recent advances in therapy have focused on targeting the molecular pathways in MPNST.", + "The outcomes of recent clinical trials demonstrate that further studies are needed.", + "A multidisciplinary approach should be adopted to cope with these tumors.", + "This patient was diagnosed with MPNST of the small bowel.", + "Further genetic analysis was not obtained due to patient preference.", + "This case was the first Chinese case of MPNST of the small bowel.", + "A surgeon should be aware of the possibility of MPNST when dealing with intestinal obstruction.", + "A surgeon should be aware of the possibility of MPNST when dealing with intussusception.", + "It is necessary to perform a quick frozen section in the operation for a clear diagnosis.", + "An extended radical operation is suggested in case of the fast frozen section displaying spindle cell tumors of the small bowel." + ], + "summary": "Here, we report the first Chinese case of a malignant peripheral nerve sheath tumor of the distal ileum presenting as intussusception. A 53-year-old female patient without pathological antecedent for neurofibromatosis was admitted with pain in the right lower abdomen and multiple episodes of vomiting for 1 week. Preoperative diagnosis was intussusception with a contrast-enhanced computed tomography scan (CECT) of the abdomen showing characteristic target sign. Due to difficulty reducing the ileum-colon intussusception, right hemicolectomy with ileocolostomy was performed. Histopathology was suggestive of low-grade MPNST. The patient received postoperative care and was followed up for 9 months. There is no sign of tumor recurrence and metastatic disease.", + "summary_subclaims": [ + "This is the first reported Chinese case of a malignant peripheral nerve sheath tumor of the distal ileum presenting as intussusception.", + "The patient was a 53-year-old female.", + "The patient had no pathological antecedent for neurofibromatosis.", + "The patient was admitted with pain in the right lower abdomen and multiple episodes of vomiting for 1 week.", + "A contrast-enhanced computed tomography scan of the abdomen showed a target sign.", + "The preoperative diagnosis was intussusception.", + "The ileum-colon intussusception was difficult to reduce.", + "Right hemicolectomy with ileocolostomy was performed.", + "Histopathology was suggestive of low-grade MPNST.", + "The patient received postoperative care.", + "The patient was followed up for 9 months.", + "There is no sign of tumor recurrence.", + "There is no sign of metastatic disease." + ] + }, + { + "id": "multiclinsum_test_184_en.txt", + "fulltext": "A 43-year-old male patient presented to the emergency department with a 20-day history of fever, predominantly at nights and headaches. His previous medical history is unremarkable; he only referred to a 20-year history of smoking and denied use of intravenous or recreational drugs, any prior sexually transmitted diseases, or blood transfusions. At presentation, the patient had a blood pressure of 109/75 mmHg, heart rate 87 bpm, respiration rate 24 breaths/minute, temperature 38.5°C, and oxygen saturation of 70% at atmospheric pressure. Physical examination revealed pale skin and mucosa; tongue and soft palate had lesions consistent with oral candidiasis and congestive pharynx. Pulmonary fields revealed decreased sounds without crackles or wheezing and painful hepatomegaly and extremities with hyperchromic nodular lesions on both ankles, suggestive of Kaposi sarcoma. Due to these findings, initial blood tests included HIV serology that came out positive; CBC: Hb 11.1 g/dL, hematocrit 33.8%, WBC 7,100/mm3, lymphocytes 3%, and neutrophils 95%; IgE 788.2 UI/ml; VSG 77 mm/hr; TGO 91 UI/L; TGP 66 UI/L; and DHL 2250 UI/L. Chest X-ray revealed disseminated infiltrates in both lungs. Medical management was initiated with omeprazole, metamizole, and oxygen with nasal prongs 3 L/min. On day 2 of hospitalization, the bronchoscopy fluid examination resulted positive for C. albicans and negative for other pathogenic bacteria and fungi. However, we decided to start dexamethasone 6 mg IV, trimethoprim/sulfamethoxazole 160/800 mg, nebulization with ipratropium, and budesonide due to high suspicion of P. jirovecii infection. On day 3 of hospitalization, HIV infection was confirmed with a viral load of 531,000 copies/ml and CD4+ T-cell count of 11 cells/mm3. Other studies were performed including a PPD (negative test 0 mm) and anticytomegalovirus serology (IgG positive). On day 4 of hospitalization, the infectious disease division started ART with ritonavir/lopinavir, tenofovir, and emtricitabine. During the subsequent days, the patient showed clinical improvement. However, on day 13, his clinical condition declined with progressive dyspnea, severe dysphagia, and abdominal pain. Auscultation showed basal rales in both lungs; a new chest X-ray demonstrated no changes compared with the previous one. New blood tests included CBC: Hb 14.5 g/dl, hematocrit 44%, VCM 90 fL, platelets 284,000 × 103, WBC 18,400/mm3, neutrophils 89%, and lymphocytes 5%. Serum electrolytes, glucose, BUN, and creatinine had no alterations. He developed dysphagia and episodes of oxygen desaturation partially corrected with nasal prongs. On day 19 of hospitalization, due to continuous episodes of low oxygen saturation, a chest CT-scan was ordered , showing generalized lung involvement and mediastinal adenopathy (Video 1 in Supplementary Material ).\nSupplementary Video 1 showed digitalized CT-scan of the thorax in coronal sectioning.\nLater that day, an endoscopy showed chronic reflux esophagitis (Grade D of the Los Angeles Classification System), with ulceration . On day 23 of hospitalization, dyspnea worsened; oxygen supply was administered with continuous positive airway pressure (CPAP). A pulmonary biopsy was performed on day 24, which reported CMV pneumonia ; the patient was transferred to the intensive care unit (ICU) due to persistent hypoxemia and was started on methylprednisolone 500 mg IV (maintained for 2 days) and ganciclovir 500 mg IV, and ART was changed to efavirenz, emtricitabine, and tenofovir, to decrease pill intake (1 pill/day). Intravenous sedation was initiated and oxygen supply was maintained with CPAP. The patient had 2 episodes of heart failure that required management with furosemide and nitroglycerin. He developed fever and respiratory distress with episodes of delirium treated with antipsychotics; we suspected the development of IRIS due to a paradoxical worsening of his condition despite being treated with ART and ganciclovir. Therefore, we started methylprednisolone and thalidomide 100 mg/day for immunosuppression and immunomodulation, respectively. After 17 days in the ICU, the oxygen requirements began to drop and the mental status improved. He remained hemodynamically stable with clinical and radiological improvemt. A new viral load reported 12,800 copies/ml. A new CBC reported hemoglobin 8 g/dL, hematocrit 26.4%, MCV 29 pg., platelets 366,000, WBC 7,400 mm3, neutrophils 86%, and lymphocytes 6%. Patient was discharged from the hospital after 45 days of treatment .", + "fulltext_subclaims": [ + "The patient is a 43-year-old male.", + "He had a 20-day history of fever, predominantly at nights and headaches.", + "He had a 20-year history of smoking.", + "He denied use of intravenous or recreational drugs.", + "He denied prior sexually transmitted diseases.", + "He denied blood transfusions.", + "At presentation, his oxygen saturation was 70% at atmospheric pressure.", + "Physical examination revealed pale skin and mucosa.", + "Tongue and soft palate had lesions consistent with oral candidiasis.", + "Pulmonary fields revealed decreased sounds without crackles or wheezing.", + "He had painful hepatomegaly.", + "He had hyperchromic nodular lesions on both ankles, suggestive of Kaposi sarcoma.", + "HIV serology was positive.", + "CBC showed Hb 11.1 g/dL.", + "CBC showed hematocrit 33.8%.", + "CBC showed WBC 7,100/mm3.", + "CBC showed lymphocytes 3%.", + "CBC showed neutrophils 95%.", + "IgE was 788.2 UI/ml.", + "VSG was 77 mm/hr.", + "TGO was 91 UI/L.", + "TGP was 66 UI/L.", + "DHL was 2250 UI/L.", + "Chest X-ray revealed disseminated infiltrates in both lungs.", + "Medical management was initiated with omeprazole.", + "Medical management was initiated with metamizole.", + "Medical management was initiated with oxygen with nasal prongs 3 L/min.", + "On day 2 of hospitalization, bronchoscopy fluid examination was positive for C. albicans.", + "On day 2 of hospitalization, bronchoscopy fluid examination was negative for other pathogenic bacteria and fungi.", + "Dexamethasone 6 mg IV was started.", + "Trimethoprim/sulfamethoxazole 160/800 mg was started.", + "Nebulization with ipratropium was started.", + "Nebulization with budesonide was started.", + "On day 3 of hospitalization, HIV infection was confirmed.", + "On day 3 of hospitalization, viral load was 531,000 copies/ml.", + "On day 3 of hospitalization, CD4+ T-cell count was 11 cells/mm3.", + "PPD was negative (0 mm).", + "Anticytomegalovirus serology was IgG positive.", + "On day 4 of hospitalization, ART was started with ritonavir/lopinavir.", + "On day 4 of hospitalization, ART was started with tenofovir.", + "On day 4 of hospitalization, ART was started with emtricitabine.", + "During the subsequent days, the patient showed clinical improvement.", + "On day 13 of hospitalization, the patient's clinical condition declined with progressive dyspnea.", + "On day 13 of hospitalization, the patient had severe dysphagia.", + "On day 13 of hospitalization, the patient had abdominal pain.", + "On day 13 of hospitalization, auscultation showed basal rales in both lungs.", + "On day 13 of hospitalization, a new chest X-ray showed no changes compared with the previous one.", + "On day 13 of hospitalization, CBC showed Hb 14.5 g/dl.", + "On day 13 of hospitalization, CBC showed hematocrit 44%.", + "On day 13 of hospitalization, CBC showed platelets 284,000 × 103.", + "On day 13 of hospitalization, CBC showed WBC 18,400/mm3.", + "On day 13 of hospitalization, CBC showed neutrophils 89%.", + "On day 13 of hospitalization, CBC showed lymphocytes 5%.", + "On day 13 of hospitalization, serum electrolytes had no alterations.", + "On day 13 of hospitalization, glucose had no alterations.", + "On day 13 of hospitalization, BUN had no alterations.", + "On day 13 of hospitalization, creatinine had no alterations.", + "On day 13 of hospitalization, the patient developed dysphagia.", + "On day 13 of hospitalization, the patient had episodes of oxygen desaturation partially corrected with nasal prongs.", + "On day 19 of hospitalization, a chest CT-scan was ordered.", + "Supplementary Video 1 showed digitalized CT-scan of the thorax in coronal sectioning.", + "On day 19 of hospitalization, endoscopy showed chronic reflux esophagitis (Grade D of the Los Angeles Classification System).", + "On day 19 of hospitalization, endoscopy showed ulceration.", + "On day 23 of hospitalization, dyspnea worsened.", + "On day 23 of hospitalization, oxygen supply was administered with continuous positive airway pressure (CPAP).", + "On day 24 of hospitalization, a pulmonary biopsy was performed.", + "On day 24 of hospitalization, the pulmonary biopsy reported CMV pneumonia.", + "The patient was transferred to the intensive care unit (ICU) due to persistent hypoxemia.", + "Methylprednisolone 500 mg IV was started.", + "Methylprednisolone was maintained for 2 days.", + "Ganciclovir 500 mg IV was started.", + "ART was changed to efavirenz.", + "ART was changed to emtricitabine.", + "ART was changed to tenofovir.", + "ART was changed to decrease pill intake (1 pill/day).", + "Intravenous sedation was initiated.", + "Oxygen supply was maintained with CPAP.", + "The patient had 2 episodes of heart failure.", + "Heart failure was managed with furosemide.", + "Heart failure was managed with nitroglycerin.", + "The patient developed fever.", + "The patient developed respiratory distress.", + "The patient had episodes of delirium treated with antipsychotics.", + "IRIS was suspected due to a paradoxical worsening of his condition.", + "Methylprednisolone was started.", + "Thalidomide 100 mg/day was started.", + "After 17 days in the ICU, oxygen requirements began to drop.", + "After 17 days in the ICU, mental status improved.", + "The patient remained hemodynamically stable.", + "The patient had clinical and radiological improvement.", + "A new viral load reported 12,800 copies/ml.", + "A new CBC reported hemoglobin 8 g/dL.", + "A new CBC reported hematocrit 26.4%.", + "A new CBC reported platelets 366,000.", + "A new CBC reported WBC 7,400 mm3.", + "A new CBC reported neutrophils 86%.", + "A new CBC reported lymphocytes 6%.", + "The patient was discharged from the hospital after 45 days of treatment." + ], + "summary": "Here, we describe the case of a 43-year-old HIV-infected male who developed an unusual case of IRIS after cytomegalovirus (CMV) pneumonia. Clinically there was a progressive and paradoxical worsening of respiratory distress, despite being treated for CMV after initiation with antiretroviral therapy. Chest X-ray revealed disseminated infiltrates in both lungs; chest CT-scan showed generalized lung involvement and mediastinal adenopathy. Pulmonary biopsy confirmed CMV pneumonia with the observation of typical viral inclusions on pneumocytes.", + "summary_subclaims": [ + "The patient is a 43-year-old HIV-infected male.", + "The patient developed an unusual case of IRIS after cytomegalovirus (CMV) pneumonia.", + "There was a progressive and paradoxical worsening of respiratory distress.", + "The patient was treated for CMV after initiation with antiretroviral therapy.", + "Chest X-ray revealed disseminated infiltrates in both lungs.", + "Chest CT-scan showed generalized lung involvement and mediastinal adenopathy.", + "Pulmonary biopsy confirmed CMV pneumonia.", + "Typical viral inclusions were observed on pneumocytes." + ] + }, + { + "id": "multiclinsum_test_2965_en.txt", + "fulltext": "In January 2021, a 20-year-old male presented with swelling over the right hand for 5 years, insidious in onset, progressive in nature, located over the medial border on the palmar side ( and ). The swelling was associated with dull aching minimal pain, aggravated with excessive activities and relived on rest. However, the swelling was not associated with night pain, fever, and restriction in daily routine activities.\nOn clinical examination, the swelling was of size 4 cm × 3 cm × 2 cm ( and ), bony hard, irregular surface, adherent to the underlying bone with no coronal or sagittal plane movement possible. It was palpable on the ulnar aspect of the hand. There was no local rise of temperature, and the patient has no regional lymphadenopathy, scars, sinuses, dilated veins, and skin changes on and around the swelling. There are no similar swellings elsewhere in the body.\nRadiographs (X-ray) showed a pedunculated bony lesion arising from the distal metaphyseal region of the fifth metacarpal .\nIn magnetic resonance imaging, there was evidence of 2 × 2.5 × 3 cm (AP × TR × SI) sized bony overgrowth seen arising from distal metaphyseal region of 5th metacarpal bone showing continuity with a medullary cavity in growing away from epiphysis . This lesion is seen displacing the 5th flexor digitorum profundus tendon laterally and causing compression over flexor digiti minimi and abductor digiti minimi muscles. In addition, there was evidence of the formation of bursa with inflammatory collection within the bursa. A provisional diagnosis of osteochondroma was made based on clinical and radiological findings.\nOsteochondroma excised under general anesthesia and tourniquet control, the bony swelling was approached through the posteromedial incision . Tumor of size approximately 3 × 2 cm was excised from the root of the pedicle . The excised specimen was then sent for histopathological examination.\nThe histopathological report (HPR) showed a cartilaginous cap with underlying bony tissue with bony trabeculae. The cartilaginous tissue is lined by perichondrium and is composed of clusters of chondrocytes. At foci, the chondrocytes are organized into cords and show endochondral ossification, which is continuous with bony tissue. HPR did not show any mitotic activity or necrosis in the sections studied .\nPost-operative period was uneventful, check x-ray of the hand was taken on day 1 with satisfactory findings , regular dressing was done and sutures were removed on post-operative day 12. The patient had minimal pain at the operative site with a complete and painless range of motion at the wrist and metacarpophalangeal joint. At 1 year of follow up patient was evaluated radiologically and clinically with satisfactory outcome.", + "fulltext_subclaims": [ + "A 20-year-old male presented with swelling over the right hand for 5 years.", + "The swelling was insidious in onset.", + "The swelling was progressive in nature.", + "The swelling was located over the medial border on the palmar side.", + "The swelling was associated with dull aching minimal pain.", + "The pain was aggravated with excessive activities.", + "The pain was relieved on rest.", + "The swelling was not associated with night pain.", + "The swelling was not associated with fever.", + "The swelling was not associated with restriction in daily routine activities.", + "On clinical examination, the swelling was of size 4 cm × 3 cm × 2 cm.", + "The swelling was bony hard.", + "The swelling had an irregular surface.", + "The swelling was adherent to the underlying bone.", + "There was no coronal or sagittal plane movement possible.", + "The swelling was palpable on the ulnar aspect of the hand.", + "There was no local rise of temperature.", + "The patient has no regional lymphadenopathy.", + "There were no scars, sinuses, dilated veins, or skin changes on and around the swelling.", + "There are no similar swellings elsewhere in the body.", + "Radiographs showed a pedunculated bony lesion arising from the distal metaphyseal region of the fifth metacarpal.", + "Magnetic resonance imaging showed evidence of 2 × 2.5 × 3 cm sized bony overgrowth arising from the distal metaphyseal region of the 5th metacarpal bone.", + "The lesion showed continuity with a medullary cavity in growing away from epiphysis.", + "The lesion displaced the 5th flexor digitorum profundus tendon laterally.", + "The lesion caused compression over flexor digiti minimi and abductor digiti minimi muscles.", + "There was evidence of the formation of bursa with inflammatory collection within the bursa.", + "A provisional diagnosis of osteochondroma was made based on clinical and radiological findings.", + "Osteochondroma was excised under general anesthesia and tourniquet control.", + "The bony swelling was approached through the posteromedial incision.", + "A tumor of size approximately 3 × 2 cm was excised from the root of the pedicle.", + "The excised specimen was sent for histopathological examination.", + "The histopathological report showed a cartilaginous cap with underlying bony tissue with bony trabeculae.", + "The cartilaginous tissue was lined by perichondrium and composed of clusters of chondrocytes.", + "At foci, the chondrocytes were organized into cords and showed endochondral ossification, which was continuous with bony tissue.", + "The histopathological report did not show any mitotic activity or necrosis in the sections studied.", + "Post-operative period was uneventful.", + "A check x-ray of the hand was taken on day 1 with satisfactory findings.", + "Regular dressing was done.", + "Sutures were removed on post-operative day 12.", + "The patient had minimal pain at the operative site.", + "The patient had a complete and painless range of motion at the wrist and metacarpophalangeal joint.", + "At 1 year of follow up, the patient was evaluated radiologically and clinically with satisfactory outcome." + ], + "summary": "A case report of a 20-year- old male presenting with swelling for 5 years, which is gradually increasing in size over the hand and reached 4 cm ×x 3 cm ×x 2 cm; following clinical and radiological examination, the patient was diagnosed with osteochondroma of a fifth metacarpal head of the right hand. We did magnetic resonance imaging scan for confirmation and reported it as osteochondroma which was treated surgically with excision of swelling in total, and specimen sent for histopathology and osteochondroma was confirmed.", + "summary_subclaims": [ + "A 20-year-old male presented with swelling for 5 years.", + "The swelling is gradually increasing in size over the hand.", + "The swelling measured 4 cm × 3 cm × 2 cm.", + "The patient was diagnosed with osteochondroma of a fifth metacarpal head of the right hand.", + "A magnetic resonance imaging scan was performed for confirmation.", + "The MRI reported it as osteochondroma.", + "The patient was treated surgically with excision of the swelling in total.", + "The specimen was sent for histopathology.", + "Osteochondroma was confirmed." + ] + }, + { + "id": "multiclinsum_test_2417_en.txt", + "fulltext": "A 77-year-old Korean woman, gravida 5, para 5, was admitted through the emergency room because of lower abdominal pain, poor oral intake, and a recent increase in abdominal size for 4 days. The symptoms had gradually increased in severity. She had no history of acute pain or previous operation. Abdominal examination revealed tenderness and rebound tenderness of the lower abdomen with a palpable mass in the left lower quadrant. Ultrasound examination showed an enlarged left ovarian cyst measuring 14.3 × 14 × 8.6 cm with diffuse internal echoes, including a 6.1 × 6.0 cm hypoechogenic component without significant vascularity. The right ovary was not seen and the uterus was normal and atrophied. Contrast-enhanced computed tomography (CT) revealed an approximately 12-cm well-circumscribed mass (of fat and soft tissue density) in the pelvic cavity and a 9-cm well-circumscribed mass (of fat and soft tissue density) with calcification in the right subhepatic space . The suggested preoperative diagnosis was benign teratoma of the left ovary and right subhepatic space. With regard to preoperative examination, the laboratory tests, biochemical tests, complete blood counts, blood coagulation profile, and urinalysis were all normal. The C-reactive protein (CRP) level was elevated at 6.87 (normal range 0–0.3 mg/dL), CA-125 was elevated at 50.76 (normal range 0–35 U/mL), and CA 19-9 was normal at 22.06 (normal range 0–37 U/mL). We decided to proceed with laparoscopy. Laparoendoscopic single-site surgery (LESS) was performed through a 20-mm intraumbilical incision using a Glove port (NELIS, Bucheon, South Korea). During laparoscopy, torsion of the left adnexa due to an approximately 12 × 10 cm left ovarian cyst was visualized, with an atrophied normal uterus. The left adnexa was rotated 1440° clockwise with multifocal purple discoloration and severe adhesion to the sigmoid colon . The right ovary and tube could not be identified in the proper anatomical location . A second cystic mass of about 10 × 7 cm was noted in the right subhepatic space. It was surrounded by thin filmy adhesions to the omentum, bowel, and appendix . Left adnexectomy, intra-abdominal mass excision, and appendectomy were performed by LESS. The abdominal mass was carefully dissected from the surrounding omentum and bowel using a monopolar hook dissector and harmonic scalpel (Ethicon, Somerville, NJ, USA). There was no pedicle that needed to be clamped and no identifiable blood supply. The mass was removed intact. The entire specimen was removed through the umbilical incision without leakage of content using an EndoBag (LapBag, Sejong Medical, Paju City, South Korea). The patient recovered uneventfully and was discharged 4 days after surgery. The histopathological examination confirmed MCTs in the left ovary and right subhepatic space. The abdominal mass included ovarian tissue. These findings could also be interpreted as an autoamputation of the adnexa due to torsion of a previous ovarian cyst arising from the right ovary.", + "fulltext_subclaims": [ + "The patient is a 77-year-old Korean woman.", + "She was admitted through the emergency room.", + "She had lower abdominal pain for 4 days.", + "She had poor oral intake.", + "She had a recent increase in abdominal size.", + "The symptoms had gradually increased in severity.", + "She had no history of acute pain.", + "She had no history of previous operation.", + "Abdominal examination revealed tenderness.", + "Abdominal examination revealed rebound tenderness of the lower abdomen.", + "A palpable mass was noted in the left lower quadrant.", + "Ultrasound showed an enlarged left ovarian cyst measuring 14.3 × 14 × 8.6 cm.", + "The cyst had diffuse internal echoes.", + "A 6.1 × 6.0 cm hypoechogenic component was noted.", + "The hypoechogenic component had no significant vascularity.", + "The right ovary was not seen.", + "The uterus was normal and atrophied.", + "Contrast-enhanced CT revealed an approximately 12-cm well-circumscribed mass in the pelvic cavity.", + "The pelvic mass was of fat and soft tissue density.", + "A 9-cm well-circumscribed mass was noted in the right subhepatic space.", + "The subhepatic mass was of fat and soft tissue density.", + "The subhepatic mass had calcification.", + "The preoperative diagnosis was benign teratoma of the left ovary.", + "The preoperative diagnosis was benign teratoma of the right subhepatic space.", + "The C-reactive protein level was 6.87 mg/dL.", + "The CA-125 level was 50.76 U/mL.", + "The CA 19-9 level was 22.06 U/mL.", + "Laparoendoscopic single-site surgery was performed.", + "The surgery was performed through a 20-mm intraumbilical incision.", + "A Glove port was used.", + "During laparoscopy, torsion of the left adnexa was visualized.", + "The left adnexa was rotated 1440° clockwise.", + "Multifocal purple discoloration was noted.", + "Severe adhesion to the sigmoid colon was noted.", + "The right ovary and tube could not be identified.", + "A second cystic mass of about 10 × 7 cm was noted in the right subhepatic space.", + "The subhepatic mass was surrounded by thin filmy adhesions.", + "Left adnexectomy was performed.", + "Intra-abdominal mass excision was performed.", + "Appendectomy was performed.", + "The abdominal mass was dissected from the surrounding omentum and bowel.", + "The mass was removed intact.", + "The entire specimen was removed through the umbilical incision.", + "The patient was discharged 4 days after surgery.", + "Histopathological examination confirmed MCTs in the left ovary.", + "Histopathological examination confirmed MCTs in the right subhepatic space.", + "The abdominal mass included ovarian tissue.", + "The findings could be interpreted as an autoamputation of the adnexa due to torsion." + ], + "summary": "A parasitic ovarian teratoma that underwent torsion, autoamputation, and reimplantation was found incidentally during laparoendoscopic single-site surgery (LESS). The amputated tumor was located in the omentum of the right upper abdomen of a patient with concomitant torsion of a left ovarian teratoma. The right ovary and tube were absent even though she had no surgical history. This finding could be interpreted as an autoamputation of the adnexa due to torsion of a previous ovarian cyst arising from the right ovary. We removed all masses by LESS.", + "summary_subclaims": [ + "A parasitic ovarian teratoma that underwent torsion, autoamputation, and reimplantation was found incidentally during laparoendoscopic single-site surgery.", + "The amputated tumor was located in the omentum of the right upper abdomen.", + "The patient had concomitant torsion of a left ovarian teratoma.", + "The right ovary and tube were absent.", + "She had no surgical history.", + "This finding could be interpreted as an autoamputation of the adnexa due to torsion of a previous ovarian cyst arising from the right ovary.", + "We removed all masses by LESS." + ] + }, + { + "id": "multiclinsum_test_71_en.txt", + "fulltext": "A 48-year-old man with end-stage kidney failure, on maintenance dialysis since 2011, was referred in February 2020 with a 6-month history of general malaise and progressive evolvement of painless icterus and necrotizing skin ulcers.\nThe patient’s medical history included diabetes mellitus (DM) type I with end-stage kidney failure, ischemic cardiomyopathy (obstructive lesions of left anterior descending coronary artery resolved by stent placement in 2018), and signs of predominantly diastolic heart failure (ultrasound of the heart prior to the occurrence of the symptoms referred to herein showed a 49% ejection fraction, mild mitral and aortic regurgitation, and moderate pulmonary hypertension with 47 mmHg). His official therapy consisted of lacidipine, furosemide, acetylsalicylic acid, calcium carbonate, bisoprolol, sevelamer, and pantoprazole, and was substantially unchanged in the last year.\nIn December 2018, the patient underwent stem cell transplantation in Ukraine. The stem cell clinic NBS/ICH/Kiev/London promised––as cited from the brochure, with many grammatical errors»…it is expected strengthening of the regenerative abilities of the body, improving of all functions of organs and tissues and repairing of pathologically damaged tissues, rejuvenate body…« The patient explained he mostly hoped for restitution of his kidney function. Although the patient could not provide an exact operative report, he explained that the product was supposed to be stem cells of embryonal origin and was injected in a single infusion in his peripheral vein. The stem cell clinic claimed in their informative material that examination (including determination of normal heart, lungs, kidney and liver function, as well as ruling out infection) would be performed. However, the patient could not recall any preadmission testing.\nAt the current referral, jaundice (bilirubin 142/116 μmol/l, increased alkaline phosphatase, slightly elevated alanine aminotransferase) and necrotizing skin changes predominated in the clinical picture . He described his skin wounds as aching and itching. The first skin lesions appeared 6 months after stem cell treatment, starting as bullae, which then burst, and a scab formed underneath. The wounds spread all over the body, the most severely affected being the skin on the arms and legs. A deep-punch skin biopsy disclosed segmental medial basophilic calcification with focal atrophy of smooth muscle in media, intimal fibroplasia of small- and/or medium-sized arteries and arterioles in subcutaneous adipose tissue consistent with calciphylaxis. Additional staining with von Kossa highlighted subtle calcium deposits also in the interstitium of the dermis and elastic fibers. Inflammation was relatively scant as well as extravasation of erythrocytes. There were no changes suggestive for graft versus host disease .\nHowever, the pathohistological diagnosis of calciphylaxis was not consistently supported by clinical findings, as there was no severe deterioration of phosphate/calcium metabolism on admission, parathyroid hormone was within limits, and, according to the angiologist's clinical assessment and ultrasound Doppler measurements of perfusion pressure in the lower extremity arteries, macrovascular peripheral arterial disease was not likely.\nThe first laboratory signs of icterus were present in September 2019. Investigations of icterus included transabdominal and endoscopic ultrasound, which showed hepatosplenomegaly without signs of extrahepatic cholestasis. The most likely infectious, metabolic and autoimmune causes, as well as biliary obstruction (see Additional file 1: Table S1) were ruled out. Since the patient also experienced severe deterioration of heart function in the same time frame (heart ultrasound revealed a severe reduction of the left ventricular ejection fraction to 30%, segmental contraction disorders, right-sided heart failure, and moderate mitral regurgitation), the differential diagnosis included liver congestion due to heart failure of unknown etiology (acute coronary syndrome was ruled out). This was not, however, supported by the liver histology , which revealed subacute hepatitis with portal inflammation of mixed type (mainly neutrophilic and eosinophilic granulocytes) without convincing signs of chronic liver congestion. We concluded that the hepatic impairment was probably the result of combined liver defect: chronic congestive hepatopathy (dilated sinusoids and ultrasound dilated hepatic veins) and toxic injury of idiosyncratic type, which manifested as cholestatic hepatitis, revealed by liver biopsy. A reasonable trigger for this reaction was, however, unclear and difficult to identify.\nIn accordance with assumed calciphylaxis, treatment with sodium thiosulfate, intensified dialysis, and hyperbaric oxygen were initiated. The inflammatory parameters decreased, and the patient was cardiopulmonary compensated, with better but not normal laboratory results (bilirubin 45/45 μmol/l) and with slight improvement in skin condition. He insisted on dismission and continued with regular dialysis thrice weekly at our outpatient service. Four days after dismission he was found dead in his apartment. An autopsy was not performed.", + "fulltext_subclaims": [ + "The patient is a 48-year-old man with end-stage kidney failure.", + "He has been on maintenance dialysis since 2011.", + "He was referred in February 2020.", + "He had a 6-month history of general malaise.", + "He had a 6-month history of progressive evolvement of painless icterus.", + "He had a 6-month history of necrotizing skin ulcers.", + "His medical history included diabetes mellitus type I with end-stage kidney failure.", + "His medical history included ischemic cardiomyopathy.", + "He had obstructive lesions of the left anterior descending coronary artery resolved by stent placement in 2018.", + "Ultrasound of the heart prior to the symptoms showed a 49% ejection fraction.", + "Ultrasound showed mild mitral and aortic regurgitation.", + "Ultrasound showed moderate pulmonary hypertension with 47 mmHg.", + "His official therapy included lacidipine.", + "His official therapy included furosemide.", + "His official therapy included acetylsalicylic acid.", + "His official therapy included calcium carbonate.", + "His official therapy included bisoprolol.", + "His official therapy included sevelamer.", + "His official therapy included pantoprazole.", + "His therapy had been substantially unchanged in the last year.", + "In December 2018, the patient underwent stem cell transplantation in Ukraine.", + "The stem cell clinic promised strengthening of the regenerative abilities of the body.", + "The stem cell clinic promised improving of all functions of organs and tissues.", + "The stem cell clinic promised repairing of pathologically damaged tissues.", + "The stem cell clinic promised rejuvenation of the body.", + "The patient hoped for restitution of his kidney function.", + "The product was supposed to be stem cells of embryonal origin.", + "The product was injected in a single infusion in his peripheral vein.", + "The stem cell clinic claimed examination including determination of normal heart, lungs, kidney and liver function.", + "The stem cell clinic claimed ruling out infection.", + "The patient could not recall any preadmission testing.", + "At referral, jaundice was present.", + "Bilirubin was 142/116 μmol/l.", + "Alkaline phosphatase was increased.", + "Alanine aminotransferase was slightly elevated.", + "Necrotizing skin changes predominated in the clinical picture.", + "The first skin lesions appeared 6 months after stem cell treatment.", + "The first skin lesions started as bullae.", + "The bullae then burst, and a scab formed underneath.", + "The wounds spread all over the body.", + "The most severely affected skin was on the arms and legs.", + "A deep-punch skin biopsy disclosed segmental medial basophilic calcification.", + "A deep-punch skin biopsy showed focal atrophy of smooth muscle in media.", + "A deep-punch skin biopsy showed intimal fibroplasia of small- and/or medium-sized arteries and arterioles in subcutaneous adipose tissue.", + "The findings were consistent with calciphylaxis.", + "Additional staining with von Kossa highlighted subtle calcium deposits also in the interstitium of the dermis.", + "Additional staining with von Kossa highlighted subtle calcium deposits also in elastic fibers.", + "Inflammation was relatively scant.", + "Extravasation of erythrocytes was relatively scant.", + "There were no changes suggestive for graft versus host disease.", + "The pathohistological diagnosis of calciphylaxis was not consistently supported by clinical findings.", + "There was no severe deterioration of phosphate/calcium metabolism on admission.", + "Parathyroid hormone was within limits.", + "Macrovascular peripheral arterial disease was not likely.", + "The first laboratory signs of icterus were present in September 2019.", + "Transabdominal and endoscopic ultrasound showed hepatosplenomegaly.", + "Transabdominal and endoscopic ultrasound showed no signs of extrahepatic cholestasis.", + "The most likely infectious, metabolic and autoimmune causes were ruled out.", + "Biliary obstruction was ruled out.", + "The patient also experienced severe deterioration of heart function in the same time frame.", + "Heart ultrasound revealed a severe reduction of the left ventricular ejection fraction to 30%.", + "Heart ultrasound revealed segmental contraction disorders.", + "Heart ultrasound revealed right-sided heart failure.", + "Heart ultrasound revealed moderate mitral regurgitation.", + "The differential diagnosis included liver congestion due to heart failure of unknown etiology.", + "Acute coronary syndrome was ruled out.", + "The liver histology did not show chronic liver congestion.", + "The liver histology revealed subacute hepatitis with portal inflammation of mixed type.", + "The portal inflammation was mainly neutrophilic and eosinophilic granulocytes.", + "The hepatic impairment was probably the result of combined liver defect.", + "The combined liver defect included chronic congestive hepatopathy.", + "The combined liver defect included toxic injury of idiosyncratic type.", + "The toxic injury manifested as cholestatic hepatitis.", + "A reasonable trigger for the reaction was unclear.", + "A reasonable trigger for the reaction was difficult to identify.", + "In accordance with assumed calciphylaxis, treatment with sodium thiosulfate was initiated.", + "In accordance with assumed calciphylaxis, intensified dialysis was initiated.", + "In accordance with assumed calciphylaxis, hyperbaric oxygen was initiated.", + "The inflammatory parameters decreased.", + "The patient was cardiopulmonary compensated.", + "The patient had better but not normal laboratory results.", + "Bilirubin was 45/45 μmol/l.", + "There was a slight improvement in skin condition.", + "He insisted on dismission.", + "He continued with regular dialysis thrice weekly at the outpatient service.", + "Four days after dismission he was found dead in his apartment.", + "An autopsy was not performed." + ], + "summary": "Here we present a case report of a 48-year-old patient with serious side effects, including disseminated skin ulcers, hepatitis, and cardiomyopathy, with eventual fatal outcome following unproven stem cell treatment.", + "summary_subclaims": [ + "The patient was 48 years old.", + "The patient had disseminated skin ulcers.", + "The patient had hepatitis.", + "The patient had cardiomyopathy.", + "The patient had a fatal outcome.", + "The patient received unproven stem cell treatment." + ] + }, + { + "id": "multiclinsum_test_1045_en.txt", + "fulltext": "A 25-year-old male, a worker in a garment factory, presented with complaints of band like feeling in the upper abdomen, not associated with any abdominal or back pain for 3 months duration. Simultaneously he had urinary hesitancy, a feeling of incomplete voiding of urine along with sense of inadequate evacuation of stool. Fifteen days later he developed descending paresthesia from the upper abdomen up to the both feet followed by weakness of trunk muscles, weakness and tightness of both lower limbs over a period of 2 months, which initially started in left lower limb and subsequently involved the right lower limb. There was no loss of perianal sensation. On examination, his higher mental functions and cranial nerves were normal. His upper limb power was 5 on both sides with normal tone and deep tendon reflexes. His lower limb power was 3 with hypertonia, exaggerated reflexes and ill-sustained clonus on the both side. He had sensory impairment below T5 corresponding to vertebral level D3. General physical examination and other system examinations were normal. A provisional diagnosis of thoracic myelopathy was made and patient was investigated. His complete blood count, renal profile, liver function tests, human immunodeficiency virus (HIV) and hepatitis B surface antigen were negative. His chest X-ray was normal. Erythrocyte sedimentation rate was moderately high and Mantoux was nonreactive. Magnetic resonance imaging (MRI) of whole cord revealed an iso- to hypointense lesion at D3 level on T1-weighted imaging (T1WI). The lesion was iso- to subtle hyperintense with central flow void onT2-weighted imaging (T2WI) , with cord edema rostral to the mass. Contrast-enhanced MRI showed a brilliantly enhancing lesion with hypointense centre at D3 with sharp margins . The oval-shaped lesion measured 16 × 10 mm. The diagnosis was intramedullary spinal cord tumor by MRI. Because of worsening of the patient's neurological examination, surgical removal of the lesion was undertaken. At D3-4, laminectomy was performed, posterior longidutinal myelotomy was executed, and a well-circumscribed pinkish fleshy mass was found to be located 2 mm anterior to posterior aspect of the cord. The lesion was dissected along a readily definable plane and was removed totally by use of the operating microscope. The histopathology showed multiple granulomas comprising of lymphocytes plasma cells, neutrophils, and large number of epitheloid cells in clusters with demonstration of acid fast bacilli (AFB) typical of Mycobacterium tuberculosis. Postoperatively the patient was given antituberculus treatment (ATT), started with isoniazid (INH) 300 mg/day, rifampicin (RF) 450 mg/day, pyrazinamide 1500 mg/day, and ethambutol 800 mg/day daily for 2 months, followed by INH and RF for 10 months. Pyridoxine at 40 mg/day was given for all 10 months. Postoperatively, the patient's neurological examination gradually improved and he could sit erect on the bed and able to walk over a period of 3 weeks without support. The follow-up time is 1 ½ year.", + "fulltext_subclaims": [ + "The patient is a 25-year-old male.", + "The patient is a worker in a garment factory.", + "The patient had a band-like feeling in the upper abdomen.", + "The band-like feeling was not associated with abdominal or back pain.", + "The band-like feeling lasted for 3 months.", + "The patient had urinary hesitancy.", + "The patient had a feeling of incomplete voiding of urine.", + "The patient had a sense of inadequate evacuation of stool.", + "Fifteen days later, the patient developed descending paresthesia from the upper abdomen up to both feet.", + "The patient had weakness of trunk muscles.", + "The patient had weakness and tightness of both lower limbs.", + "The weakness and tightness developed over a period of 2 months.", + "The weakness and tightness initially started in the left lower limb.", + "The weakness and tightness subsequently involved the right lower limb.", + "There was no loss of perianal sensation.", + "Higher mental functions were normal.", + "Cranial nerves were normal.", + "Upper limb power was 5 on both sides.", + "Upper limb tone was normal.", + "Upper limb deep tendon reflexes were normal.", + "Lower limb power was 3.", + "Lower limb tone was hypertonic.", + "Lower limb reflexes were exaggerated.", + "Clonus was ill-sustained on both sides.", + "Sensory impairment was below T5.", + "The sensory impairment corresponded to vertebral level D3.", + "General physical examination was normal.", + "Other system examinations were normal.", + "A provisional diagnosis of thoracic myelopathy was made.", + "Complete blood count was negative.", + "Renal profile was negative.", + "Liver function tests were negative.", + "HIV was negative.", + "Hepatitis B surface antigen was negative.", + "Chest X-ray was normal.", + "Erythrocyte sedimentation rate was moderately high.", + "Mantoux was nonreactive.", + "MRI of the whole cord revealed an iso- to hypointense lesion at D3 level on T1WI.", + "The lesion was iso- to subtle hyperintense with central flow void on T2WI.", + "There was cord edema rostral to the mass.", + "Contrast-enhanced MRI showed a brilliantly enhancing lesion with hypointense centre at D3.", + "The lesion had sharp margins.", + "The lesion measured 16 × 10 mm.", + "The diagnosis was intramedullary spinal cord tumor by MRI.", + "Surgical removal of the lesion was undertaken.", + "Laminectomy was performed at D3-4.", + "Posterior longitudinal myelotomy was executed.", + "A well-circumscribed pinkish fleshy mass was found.", + "The mass was located 2 mm anterior to the posterior aspect of the cord.", + "The lesion was dissected along a readily definable plane.", + "The lesion was removed totally by use of the operating microscope.", + "Histopathology showed multiple granulomas comprising lymphocytes, plasma cells, neutrophils, and large number of epitheloid cells.", + "Acid fast bacilli typical of Mycobacterium tuberculosis were demonstrated.", + "Postoperatively, the patient was given antituberculous treatment.", + "The treatment included isoniazid 300 mg/day, rifampicin 450 mg/day, pyrazinamide 1500 mg/day, and ethambutol 800 mg/day daily for 2 months.", + "The treatment was followed by isoniazid and rifampicin for 10 months.", + "Pyridoxine at 40 mg/day was given for all 10 months.", + "The patient's neurological examination gradually improved postoperatively.", + "The patient could sit erect on the bed.", + "The patient could walk without support after 3 weeks.", + "The follow-up time was 1 ½ year." + ], + "summary": "The patient was a 25-year-old male who presented with a history of progressive paraparesis. Initial diagnosis was made as an intramedullary tumor by magnetic resonance imaging (MRI). The treatment of the patient involved is complete surgical excision of intramedullary lesion followed by appropriate antituberculous therapy. Postoperatively, his neurological symptoms were dramatically improved. With combination of both surgical and medical treatments, excellent clinical outcome was obtained.", + "summary_subclaims": [ + "The patient was a 25-year-old male.", + "The patient presented with a history of progressive paraparesis.", + "Initial diagnosis was made as an intramedullary tumor by magnetic resonance imaging.", + "The treatment of the patient involved is complete surgical excision of intramedullary lesion.", + "The treatment of the patient involved followed by appropriate antituberculous therapy.", + "Postoperatively, his neurological symptoms were dramatically improved.", + "With combination of both surgical and medical treatments, excellent clinical outcome was obtained." + ] + }, + { + "id": "multiclinsum_test_1132_en.txt", + "fulltext": "A 24-year-old southeast Asian woman was admitted with a history of a white spot on the right cornea and increasing discomfort. On examination, her vision was 6/36 on the right and 6/9 on the left. She had a corneal ulcer measuring 5.5 × 2 mm on her right cornea. A small localized area of scarring was present lateral to where the defect was present . There was a +1 cell reaction in her right anterior chamber. She had a history of bilateral anterior uveitis. Corneal sensation was normal in both eyes. There were early bilateral posterior subcapsular cataracts.\nIn view of the findings, corneal scrapes were taken for microscopy, culture, and sensitivity. Virology assays inclusive of herpes simplex virus and varicella-zoster virus polymerase chain reaction were performed. Our patient had normal C-reactive protein, rheumatoid factor, anti-nuclear antibody, extractable nuclear antigen, syphilis, and hepatitis B and C serology. She was started on topical g. cephalothin 5% and g. gentamicin 0.9% hourly for 48 hours. She made a mild initial improvement and was changed to topical g. chloramphenicol 1% four times each day and g. prednisolone 0.5% four times each day once her microbiology and virology results were negative. A bandage contact lens was inserted to facilitate healing .\nIn the third week of admission, she complained of a headache and was found to be mildly tachycardic. She was apyrexial with no reported malaise. A urinary dipstick analysis was performed, and her urinary glucose level was 21 mmol/L. Blood glucose was urgently requested and was found to be 23 mmol/L. A blood gas analysis showed a pH of 7.38, a partial pressure of carbon dioxide (pCO2) of 44.7 mmHg, and a partial pressure of oxygen (pO2) of 89.5 mmHg.\nShe was transferred to the care of the medical team and a diagnosis of type 1 diabetes was made. She was started on treatment with insulin. Her corneal ulcer persisted and punctal plugs were inserted to increase the tear film and facilitate healing. Autologous serum drops were started every two hours during waking hours. There was a rapid reduction of the epithelial defect as her blood glucose levels normalized .\nFour days after insulin treatment was started, her ulcer had healed and she was discharged from the hospital and follow-up was conducted at her local diabetes clinic. At a one-month review in the eye clinic, her ulcer remained healed, leaving a localized area of subepithelial scarring .", + "fulltext_subclaims": [ + "The patient is a 24-year-old southeast Asian woman.", + "She was admitted with a history of a white spot on the right cornea.", + "She had increasing discomfort.", + "On examination, her vision was 6/36 on the right.", + "On examination, her vision was 6/9 on the left.", + "She had a corneal ulcer measuring 5.5 × 2 mm on her right cornea.", + "A small localized area of scarring was present lateral to where the defect was present.", + "There was a +1 cell reaction in her right anterior chamber.", + "She had a history of bilateral anterior uveitis.", + "Corneal sensation was normal in both eyes.", + "There were early bilateral posterior subcapsular cataracts.", + "Corneal scrapes were taken for microscopy, culture, and sensitivity.", + "Virology assays inclusive of herpes simplex virus and varicella-zoster virus polymerase chain reaction were performed.", + "She had normal C-reactive protein.", + "She had normal rheumatoid factor.", + "She had normal anti-nuclear antibody.", + "She had normal extractable nuclear antigen.", + "She had normal syphilis serology.", + "She had normal hepatitis B and C serology.", + "She was started on topical g. cephalothin 5% hourly for 48 hours.", + "She was started on topical g. gentamicin 0.9% hourly for 48 hours.", + "She made a mild initial improvement.", + "She was changed to topical g. chloramphenicol 1% four times each day.", + "She was changed to topical g. prednisolone 0.5% four times each day.", + "A bandage contact lens was inserted.", + "In the third week of admission, she complained of a headache.", + "She was found to be mildly tachycardic.", + "She was apyrexial.", + "A urinary dipstick analysis was performed.", + "Her urinary glucose level was 21 mmol/L.", + "Blood glucose was urgently requested and was found to be 23 mmol/L.", + "A blood gas analysis showed a pH of 7.38.", + "A blood gas analysis showed a pCO2 of 44.7 mmHg.", + "A blood gas analysis showed a pO2 of 89.5 mmHg.", + "She was transferred to the care of the medical team.", + "A diagnosis of type 1 diabetes was made.", + "She was started on treatment with insulin.", + "Her corneal ulcer persisted.", + "Punctal plugs were inserted.", + "Autologous serum drops were started every two hours during waking hours.", + "There was a rapid reduction of the epithelial defect.", + "Four days after insulin treatment was started, her ulcer had healed.", + "She was discharged from the hospital.", + "Follow-up was conducted at her local diabetes clinic.", + "At a one-month review in the eye clinic, her ulcer remained healed.", + "A localized area of subepithelial scarring was left." + ], + "summary": "We report the unusual case of a 24-year-old southeast Asian woman who presented with a sterile corneal ulcer to our hospital and later was found to be diabetic after a prolonged hospital stay. Despite all efforts, the corneal ulcer had failed to heal until treatment for previously undiagnosed diabetes was started. The sterile corneal ulcer began to heal once blood sugar levels began to normalize.", + "summary_subclaims": [ + "The patient was a 24-year-old southeast Asian woman.", + "The patient presented with a sterile corneal ulcer.", + "The patient was found to be diabetic after a prolonged hospital stay.", + "The corneal ulcer had failed to heal until treatment for previously undiagnosed diabetes was started.", + "The sterile corneal ulcer began to heal once blood sugar levels began to normalize." + ] + }, + { + "id": "multiclinsum_test_1612_en.txt", + "fulltext": "A 40-year-old female presenting with mild hepatic dysfunction was referred to our hospital. She did not smoke but had a drinking habit. At age 28 years, she had presented with elevated platelet counts (> 100 × 104/μL); ET had been diagnosed based on bone marrow biopsy results. She was prescribed aspirin (100 mg/day) and anagrelide (2.5 mg/day). She had also been prescribed ebastine for itching a while ago.\nOn admission to our hospital, laboratory examination revealed slightly elevated alanine aminotransferase (ALT) levels (82 IU/L), although the patient’s ALT level had improved from that recorded previously. Her platelet count was slightly elevated (62.4 × 104/μL). Prothrombin time and activated partial thromboplastin time were normal. Abdominal ultrasonography revealed a cecal tumor. Colonoscopy revealed advanced cecal cancer . Computed tomography (CT) indicated cecal wall thickening .\nThe patient recovered from liver dysfunction without treatment. She stopped taking oral aspirin 1 week prior to surgery but continued anagrelide until the day before surgery. To prevent thrombosis, she wore elastic stockings; furthermore, intermittent pneumatic compression was performed during surgery. Laparoscopic-assisted ileocecal resection was performed. We used a soft coagulation system to achieve complete hemostasis. The operative duration was 202 min; blood loss was 34 mL.\nFrom the first postoperative day, the patient started walking, drinking water, and resumed oral anagrelide intake. She resumed oral aspirin intake on the fifth postoperative day. Her perioperative platelet count was controlled to approximately 40–60 × 104/μL . Prothrombin time and activated partial thromboplastin time also did not show abnormal values during the perioperative period. The postoperative course was uneventful and she was discharged on the seventh postoperative day.\nThe tumor pathological stage was T3N1M0 (Stage IIIB). The patient received intravenous oxaliplatin plus oral capecitabine (CapeOX) as postoperative adjuvant chemotherapy (oxaliplatin 130 mg/m2, capecitabine 1000 mg/m2). However, after one course, she again experienced liver dysfunction (aspartate aminotransferase [AST] level, 388 IU/L; ALT level, 531 IU/L); because of anagrelide, her platelet count decreased to 17.8 × 104/μL. Therefore, we asked her to discontinue anagrelide and aspirin that day onwards; 5 days later, her platelet count recovered to 50 × 104/μL. Subsequently, she resumed taking anagrelide and aspirin; however, she refused to resume any adjuvant chemotherapy after this incident. Her liver function normalized gradually in 4 months. There were no clinical signs of thrombosis, and there was no appearance of a new thrombus on contrast-enhanced CT 6 months after the operation. One-year post operation, she is well without tumor recurrence or new metastasis.", + "fulltext_subclaims": [ + "The patient was a 40-year-old female.", + "She had mild hepatic dysfunction.", + "She did not smoke.", + "She had a drinking habit.", + "At age 28, she had elevated platelet counts (> 100 × 104/μL).", + "ET had been diagnosed based on bone marrow biopsy results.", + "She was prescribed aspirin (100 mg/day) and anagrelide (2.5 mg/day).", + "She had been prescribed ebastine for itching.", + "On admission, her ALT level was 82 IU/L.", + "Her ALT level had improved from that recorded previously.", + "Her platelet count was 62.4 × 104/μL.", + "Prothrombin time and activated partial thromboplastin time were normal.", + "Abdominal ultrasonography revealed a cecal tumor.", + "Colonoscopy revealed advanced cecal cancer.", + "CT indicated cecal wall thickening.", + "The patient recovered from liver dysfunction without treatment.", + "She stopped taking oral aspirin 1 week prior to surgery.", + "She continued anagrelide until the day before surgery.", + "To prevent thrombosis, she wore elastic stockings.", + "Intermittent pneumatic compression was performed during surgery.", + "Laparoscopic-assisted ileocecal resection was performed.", + "The operative duration was 202 min.", + "Blood loss was 34 mL.", + "From the first postoperative day, she started walking.", + "From the first postoperative day, she started drinking water.", + "From the first postoperative day, she resumed oral anagrelide intake.", + "She resumed oral aspirin intake on the fifth postoperative day.", + "Her perioperative platelet count was controlled to approximately 40–60 × 104/μL.", + "Prothrombin time and activated partial thromboplastin time did not show abnormal values during the perioperative period.", + "The postoperative course was uneventful.", + "She was discharged on the seventh postoperative day.", + "The tumor pathological stage was T3N1M0 (Stage IIIB).", + "She received intravenous oxaliplatin plus oral capecitabine as postoperative adjuvant chemotherapy.", + "After one course, she again experienced liver dysfunction (AST 388 IU/L; ALT 531 IU/L).", + "Her platelet count decreased to 17.8 × 104/μL.", + "She was asked to discontinue anagrelide and aspirin that day onwards.", + "Five days later, her platelet count recovered to 50 × 104/μL.", + "She resumed taking anagrelide and aspirin.", + "She refused to resume any adjuvant chemotherapy after this incident.", + "Her liver function normalized gradually in 4 months.", + "There were no clinical signs of thrombosis.", + "There was no appearance of a new thrombus on contrast-enhanced CT 6 months after the operation.", + "One-year post operation, she is well without tumor recurrence or new metastasis." + ], + "summary": "A 40-year-old woman was admitted to our hospital after presenting with liver dysfunction. She had been previously diagnosed with ET; aspirin and anagrelide had been prescribed. Subsequent examination at our hospital revealed cecal cancer. Distant metastasis was absent; laparoscopic ileocecal resection was performed. Anagrelide was discontinued only on the surgery day. She was discharged on the seventh postoperative day without thrombosis or hemorrhage. However, when capecitabine and oxaliplatin were administered as adjuvant chemotherapy with continued anagrelide administration, she experienced hepatic dysfunction and thrombocytopenia; thus, anagrelide was discontinued. Five days later, her platelet count recovered. Subsequently, anagrelide and aspirin administration was resumed, without any adjuvant chemotherapy. Her liver function normalized gradually in 4 months. One-year post operation, she is well without tumor recurrence or new metastasis.", + "summary_subclaims": [ + "A 40-year-old woman was admitted to our hospital after presenting with liver dysfunction.", + "She had been previously diagnosed with ET.", + "Aspirin and anagrelide had been prescribed.", + "Subsequent examination at our hospital revealed cecal cancer.", + "Distant metastasis was absent.", + "Laparoscopic ileocecal resection was performed.", + "Anagrelide was discontinued only on the surgery day.", + "She was discharged on the seventh postoperative day without thrombosis or hemorrhage.", + "When capecitabine and oxaliplatin were administered as adjuvant chemotherapy with continued anagrelide administration, she experienced hepatic dysfunction and thrombocytopenia.", + "Anagrelide was discontinued.", + "Five days later, her platelet count recovered.", + "Subsequently, anagrelide and aspirin administration was resumed, without any adjuvant chemotherapy.", + "Her liver function normalized gradually in 4 months.", + "One-year post operation, she is well without tumor recurrence or new metastasis." + ] + }, + { + "id": "multiclinsum_test_1818_en.txt", + "fulltext": "A 59-year-old man with no related medical history presented to the emergency room with chest pain and syncope. On admission, he showed signs of hypovolemic shock with paleness, sweating, low blood pressure (BP) of 62/36 mmHg, poor peripheral perfusion, and acutely deteriorating anemia (blood level of 12.3 d/dL on first check and 9.5 d/dL on the second) check; he was alert at this time.\nElectrocardiography and chest radiography showed no significant findings. After fluid resuscitation, contrast-enhanced computed tomography (CT) showed that the middle and distal third of the splenic artery were fully replaced by an aneurysm (10 cm in maximum diameter), with active contrast extravasation into the aneurysm. It was packed into the posterior wall of the stomach. The stomach showed significant expansion with mud fluid . Subsequently, we suspected a splenic artery pseudoaneurysm that had ruptured into the stomach. A nasogastric tube was inserted to aid in the prevention of vomiting and aspiration because we suspected UGI bleeding. Bright red blood (300 mL) was drawn using the tube. At that time, he lost consciousness showing a rapid drop in BP of 54/37 mmHg, HR70 again. In total, 4 units of red blood cells (RBCs) and 2 units of fresh frozen plasma (FFP) were administered, and while preparing to move the patient to the operating room, the systolic BP stabilized to > 100 mmHg. Laparotomy was performed immediately. The aneurysm was located in the distal part of the splenic artery, adhering to the body of the pancreas. Its wall densely adhered to the posterior wall of the stomach covered with necrotic slough around that was the ruptured root of the splenic aneurysm to the stomach . The pancreas was mobilized along with the splenic artery from the retroperitoneum, and a tape was passed around the body of the pancreas to enable bleeding control and the ligation of the splenic artery. After dissecting the body–tail of the pancreas, we performed a distal splenopancreatectomy including the aneurysm and partial gastric resection . The total durations required for the surgery and general anesthesia were 212 min and 292 min, respectively. The intraoperative fluid balance was + 440 mL with an estimated blood loss of 1950 mL, including gastric clots and the urine output of 340 mL. Intraoperatively, 6 units of RBCs and 2 units of FFP were transfused.\nThe postoperative vitals of the patient stabilized immediately and his general condition improved quickly. He was discharged from the hospital on the 42nd postoperative day, after waiting for decrease in the pancreatic fistula output and the removal of the drainage tube. The pathology of the resected specimen showed a splenic artery aneurysmal sac eroding into the gastric mucosa. The surrounding gastric mucosa did not show any malignant evidence, but exhibited the destruction of the elastic fibers of the vessel wall, suggesting pseudoaneurysm of the splenic artery.", + "fulltext_subclaims": [ + "The patient was a 59-year-old man.", + "He had no related medical history.", + "He presented to the emergency room with chest pain and syncope.", + "On admission, he showed signs of hypovolemic shock.", + "His blood pressure was 62/36 mmHg.", + "He had poor peripheral perfusion.", + "His first blood level was 12.3 d/dL.", + "His second blood level was 9.5 d/dL.", + "Electrocardiography showed no significant findings.", + "Chest radiography showed no significant findings.", + "Contrast-enhanced CT showed the middle and distal third of the splenic artery were fully replaced by an aneurysm.", + "The aneurysm was 10 cm in maximum diameter.", + "There was active contrast extravasation into the aneurysm.", + "The aneurysm was packed into the posterior wall of the stomach.", + "The stomach showed significant expansion with mud fluid.", + "A nasogastric tube was inserted.", + "Bright red blood (300 mL) was drawn using the tube.", + "The patient lost consciousness.", + "His systolic blood pressure stabilized to > 100 mmHg.", + "Laparotomy was performed.", + "The aneurysm was located in the distal part of the splenic artery.", + "The aneurysm adhered to the body of the pancreas.", + "The aneurysm's wall densely adhered to the posterior wall of the stomach.", + "The ruptured root of the splenic aneurysm was to the stomach.", + "A distal splenopancreatectomy including the aneurysm was performed.", + "A partial gastric resection was performed.", + "The total duration of the surgery was 212 minutes.", + "The total duration of general anesthesia was 292 minutes.", + "The intraoperative fluid balance was + 440 mL.", + "The estimated blood loss was 1950 mL.", + "Intraoperatively, 6 units of RBCs were transfused.", + "Intraoperatively, 2 units of FFP were transfused.", + "The postoperative vitals of the patient stabilized immediately.", + "The patient was discharged on the 42nd postoperative day.", + "The pathology showed a splenic artery aneurysmal sac eroding into the gastric mucosa.", + "The surrounding gastric mucosa did not show any malignant evidence.", + "The destruction of the elastic fibers of the vessel wall was noted.", + "The destruction suggested pseudoaneurysm of the splenic artery." + ], + "summary": "A 59-year-old man presented to the emergency department with chest pain and syncope. Contrast-enhanced computed tomography showed splenic artery aneurysm with active contrast extravasation. He developed upper gastrointestinal (UGI) bleeding and hypovolemic shock. We diagnosed a splenic artery aneurysm ruptured in to the stomach, performed emergency distal splenopancreatectomy including the aneurysm and partial gastric resection, and could prevent patient death.", + "summary_subclaims": [ + "A 59-year-old man presented to the emergency department with chest pain and syncope.", + "Contrast-enhanced computed tomography showed splenic artery aneurysm with active contrast extravasation.", + "He developed upper gastrointestinal (UGI) bleeding and hypovolemic shock.", + "We diagnosed a splenic artery aneurysm ruptured into the stomach.", + "We performed emergency distal splenopancreatectomy including the aneurysm and partial gastric resection.", + "We could prevent patient death." + ] + }, + { + "id": "multiclinsum_test_1041_en.txt", + "fulltext": "A 54-year-old woman was referred to our center due to right ventricular enlargement which was incidentally detected on pre-operative echocardiography for ankle surgery at a local clinic. The patient was asymptomatic and in normal sinus rhythm. A transthoracic echocardiography (TTE) showed a large secundum ASD with a diameter of 17 mm. A transesophageal echocardiography (TEE) was performed and showed 20 × 23 mm secundum ASD with left to right shunt and right ventricle (RV), right atrium (RA) enlargement . The patient had a D-shaped small left ventricle (LV) with a left ventricular ejection fraction of 59%. Mitral valve leaflets were normal with no MR detected . Moderate tricuspid regurgitation (Grade II) due to dilated tricuspid valve annulus (46 mm) and mild pulmonary hypertension were observed. The rims to both sides of the superior vena cava and inferior vena cava were short, thus surgical repair of ASD under mini-thoracotomy was planned.\nIn the operating room, standard vital signs (pulse oximetry, end-tidal carbon dioxide, electrocardiogram, and non-invasive blood pressure) were monitored. The left radial artery was catheterized for continuous arterial blood pressure monitoring. After 3 min of 100% pre-oxygenation, general anesthesia was induced with midazolam (3 mg) followed by continuous infusion of propofol with remifentanil, and bolus administration of rocuronium (50 mg). The patient was intubated with a 35 Fr left-sided double-lumen tube for one-lung ventilation. A central venous catheter was inserted via the right subclavian vein because the right internal jugular vein was reserved for superior vena cava cannulation for cardiopulmonary bypass (CPB). A TEE probe was inserted to permit close observation.\nRight anterolateral mini-thoracotomy was done via 4th Intercostal space. Following full anticoagulation with heparin given at a dose of 300 IU/kg, CPB was instituted using femoral artery, femoral vein and right internal jugular vein cannulation. Next, the aortic Detachable Glauber clamp (Cardiomedical GmbH, Germany) was deployed for aortic cross-clamp, and 2000 mL of Custodiol® HTK (Koehler Chemie, Bensheim, Germany) solution was infused through aortic root cannula for myocardial protection. Moderate Hypothermia of 31.5 °C was permitted as measured by nasopharyngeal and rectal probes. Subsequently, right atrium was opened and ASD was closed with a trimmed bovine pericardial patch. Tricuspid ring annuloplasty and right atrium reduction plasty were also conducted. After completion of the operation, right atrium was closed and CPB was weaned.\nIntra-operative TEE showed that ASD was closed with no remnant inter-atrial shunt. There was no tricuspid regurgitation and left ventricular ejection fraction was 55%. Newly developed Grade II MR with end-diastolic rightward deviated inter-ventricular septum was detected which was not found in pre-operative echocardiography . We notified the surgeon of the newly developed MR. Because no abnormal findings, such as mitral valve prolapse, perforation, or chordae rupture, were observed in the mitral valve leaflets, it was determined that the surgery should proceed. No further adverse surgical events occurred throughout the remainder of the surgical procedure. The surgery lasted for 345 min with the CPB time of 190 min and aortic cross-clamp time of 140 min. The estimated blood loss of 800 ml. After surgery, the patient was transferred to the Intensive Care Unit. Bilateral lung haziness due to acute MR was observed in the immediate post-operative chest x-ray. Otherwise, the vital signs were stable without complaint of any symptoms. The patient was extubated after 3 h on arrival of the intensive care unit and transferred to general ward on postoperative day (POD) 1.\nTransesophageal echocardiography on POD 3 confirmed that the ASD patch was intact without shunt flow or remnant tricuspid regurgitation. Both left and right ventricular function was well preserved with left ventricular ejection fraction of 69%. However, LV diastolic dysfunction (E/E’ = 26) and aggravated pulmonary hypertension which was not observed in the preoperative TEE was found. The MR was shown to have deteriorated to severe level without evidence of vegetation or chordae rupture . Because the patient was asymptomatic, conservative treatment using diuretics and close monitoring was determined to be the best course of action. Daily follow-up chest x-ray showed gradual improvement in pulmonary edema. On POD 6, the patient was discharged and attend follow-up outpatient appointments. On POD 10, TTE was evaluated. MR disappeared to trivial level and the LV chamber size and deviated septum became normalized .", + "fulltext_subclaims": [ + "A 54-year-old woman was referred to our center due to right ventricular enlargement which was incidentally detected on pre-operative echocardiography for ankle surgery at a local clinic.", + "The patient was asymptomatic and in normal sinus rhythm.", + "A transthoracic echocardiography (TTE) showed a large secundum ASD with a diameter of 17 mm.", + "A transesophageal echocardiography (TEE) was performed and showed 20 × 23 mm secundum ASD with left to right shunt and right ventricle (RV), right atrium (RA) enlargement.", + "The patient had a D-shaped small left ventricle (LV) with a left ventricular ejection fraction of 59%.", + "Mitral valve leaflets were normal with no MR detected.", + "Moderate tricuspid regurgitation (Grade II) due to dilated tricuspid valve annulus (46 mm) and mild pulmonary hypertension were observed.", + "The rims to both sides of the superior vena cava and inferior vena cava were short.", + "Surgical repair of ASD under mini-thoracotomy was planned.", + "Standard vital signs (pulse oximetry, end-tidal carbon dioxide, electrocardiogram, and non-invasive blood pressure) were monitored.", + "The left radial artery was catheterized for continuous arterial blood pressure monitoring.", + "After 3 min of 100% pre-oxygenation, general anesthesia was induced with midazolam (3 mg) followed by continuous infusion of propofol with remifentanil, and bolus administration of rocuronium (50 mg).", + "The patient was intubated with a 35 Fr left-sided double-lumen tube for one-lung ventilation.", + "A central venous catheter was inserted via the right subclavian vein because the right internal jugular vein was reserved for superior vena cava cannulation for cardiopulmonary bypass (CPB).", + "A TEE probe was inserted to permit close observation.", + "Right anterolateral mini-thoracotomy was done via 4th Intercostal space.", + "Following full anticoagulation with heparin given at a dose of 300 IU/kg, CPB was instituted using femoral artery, femoral vein and right internal jugular vein cannulation.", + "The aortic Detachable Glauber clamp (Cardiomedical GmbH, Germany) was deployed for aortic cross-clamp.", + "2000 mL of Custodiol® HTK (Koehler Chemie, Bensheim, Germany) solution was infused through aortic root cannula for myocardial protection.", + "Moderate Hypothermia of 31.5 °C was permitted as measured by nasopharyngeal and rectal probes.", + "Right atrium was opened and ASD was closed with a trimmed bovine pericardial patch.", + "Tricuspid ring annuloplasty and right atrium reduction plasty were also conducted.", + "Intra-operative TEE showed that ASD was closed with no remnant inter-atrial shunt.", + "There was no tricuspid regurgitation and left ventricular ejection fraction was 55%.", + "Newly developed Grade II MR with end-diastolic rightward deviated inter-ventricular septum was detected which was not found in pre-operative echocardiography.", + "We notified the surgeon of the newly developed MR.", + "Because no abnormal findings, such as mitral valve prolapse, perforation, or chordae rupture, were observed in the mitral valve leaflets, it was determined that the surgery should proceed.", + "No further adverse surgical events occurred throughout the remainder of the surgical procedure.", + "The surgery lasted for 345 min with the CPB time of 190 min and aortic cross-clamp time of 140 min.", + "The estimated blood loss of 800 ml.", + "After surgery, the patient was transferred to the Intensive Care Unit.", + "Bilateral lung haziness due to acute MR was observed in the immediate post-operative chest x-ray.", + "Otherwise, the vital signs were stable without complaint of any symptoms.", + "The patient was extubated after 3 h on arrival of the intensive care unit and transferred to general ward on postoperative day (POD) 1.", + "Transesophageal echocardiography on POD 3 confirmed that the ASD patch was intact without shunt flow or remnant tricuspid regurgitation.", + "Both left and right ventricular function was well preserved with left ventricular ejection fraction of 69%.", + "However, LV diastolic dysfunction (E/E’ = 26) and aggravated pulmonary hypertension which was not observed in the preoperative TEE was found.", + "The MR was shown to have deteriorated to severe level without evidence of vegetation or chordae rupture.", + "Because the patient was asymptomatic, conservative treatment using diuretics and close monitoring was determined to be the best course of action.", + "Daily follow-up chest x-ray showed gradual improvement in pulmonary edema.", + "On POD 6, the patient was discharged and attend follow-up outpatient appointments.", + "On POD 10, TTE was evaluated.", + "MR disappeared to trivial level and the LV chamber size and deviated septum became normalized." + ], + "summary": "A 54-year-old woman was referred to our center due to large secundum ASD with a diameter of 17 mm which was incidentally detected on pre-operative echocardiography at a local clinic. Surgical repair of ASD under mini-thoracotomy was performed. After completion of the operation, intra-operative transesophageal echocardiography showed newly developed Grade II MR which subsequently deteriorated to severe level on postoperative day 3. Because the patient was asymptomatic, we decided to observe closely and treat conservatively with diuretics. Thereafter, echocardiography was evaluated on postoperative day 10 and MR disappeared to trivial level.", + "summary_subclaims": [ + "The patient is a 54-year-old woman.", + "She was referred due to large secundum ASD with a diameter of 17 mm.", + "The ASD was incidentally detected on pre-operative echocardiography at a local clinic.", + "Surgical repair of ASD under mini-thoracotomy was performed.", + "Intra-operative transesophageal echocardiography showed newly developed Grade II MR.", + "The MR deteriorated to severe level on postoperative day 3.", + "The patient was asymptomatic.", + "We decided to observe closely and treat conservatively with diuretics.", + "Echocardiography was evaluated on postoperative day 10.", + "MR disappeared to trivial level." + ] + }, + { + "id": "multiclinsum_test_2184_en.txt", + "fulltext": "A 5.8-year-old boy was admitted to our hospital with a 6-month of facial hair and phallic growth, deepen voice and accelerate growth velocity. The Tanner stage was II for genital development and II-III for pubic hair. Both side testicular volumes were 4 mLby Prader. Family history of PP was denied. The serum sex hormone profile indicated prepubertal levels of gonadotropins with basal LH < 0.1IU/L (prepubertal range < 0.1–0.3 IU/L) and basal FSH < below 0.1 IU/L (prepubertal range < 0.1-3), and pubertal testosterone level (4.48 ng/ml, prepubertal: <0.2-1ng/mL). His height reached 129 cm (+ 2.4 standard deviation scores,) with a high serum insulin like growth factor-1 level (+ 3.5 standard deviation scores) in National-specific charts . Other anterior pituitary hormonal profiles were normal. HCG was detectable both in serum and in cerebrospinal fluid (CSF), 7.12 and 15.66 IU/L separately. Bone age (BA) was advanced to 8 years old. Contrast-enhanced brain magnetic resonance imaging (MRI) revealed a homogeneously enhanced pineal mass . The elevated serum hCG level and pineal mass on imaging suggested the clinicial diagnosis of intracranial germ cell tumor (iGCT) and then two courses of ICE chemotherapy (ifosfamide, carboplatin and etoposide) were performed. Repeated MRI did not reflect a significant shrinkage of the pineal lesion although hCG (< 0.1 IU/L, range 0-2.6 IU/L) has been normalized. Meanwhile, basal serum gonadotropin levels (LH 2.96 and FSH 1.86 IU/L, separately) unexpectedly increased . Considering the possibility of mixed germ cell tumor due to elevated hCG level and poor response to chemotherapy [, ], the patient underwent a neurosurgical operation and the histological result revealed a mature teratoma. Subsequently, he continued to receive two additional courses of ICE chemotherapy and the radiotherapy targeting the whole brain (24 Gy) plus the pineal region boosting (12 Gy). During this period, his gonadotropin and testosterone levels were within the normal pubertal range, although with a transient change . After operation and chemoradiotherapy, MRI indicated the morphological disorders of the pineal gland without an enhanced lesion . The patient’s puberty progressed with the Tanner stage III for genital development and stage III for pubic hair. Meanwhile, the patient’s height reached 134 cm (+ 2.7SD) with a bone age of 12 years. To postpone epiphyseal closure and save growth potential, GnRH analogue therapy was started to suppress gonadal activation. This boy decided to return to the local hospital to continue GnRH analogs therapy. Through telephone survey after 2 months of GnRH analogue therapy, the patient’s gonadotropin levels normalized (LH 0.29 and the FSH 0.13 IU/L) and premature presentations gradually regressed. After 18 months of regular GnRH analogue therapy, the patient’s LH and FSH remained undetectable while his precocious puberty regressed. The growth velocity is approximately 5 cm per year.", + "fulltext_subclaims": [ + "A 5.8-year-old boy was admitted with 6-month history of facial hair and phallic growth.", + "The Tanner stage was II for genital development.", + "The Tanner stage was II-III for pubic hair.", + "Both side testicular volumes were 4 mL by Prader.", + "Family history of PP was denied.", + "Serum basal LH was < 0.1 IU/L.", + "Serum basal FSH was < 0.1 IU/L.", + "Serum testosterone level was 4.48 ng/ml.", + "His height was 129 cm (+ 2.4 standard deviation scores).", + "Serum insulin like growth factor-1 level was + 3.5 standard deviation scores.", + "HCG was detectable in serum at 7.12 IU/L.", + "HCG was detectable in cerebrospinal fluid at 15.66 IU/L.", + "Bone age was advanced to 8 years old.", + "Contrast-enhanced brain MRI revealed a homogeneously enhanced pineal mass.", + "The elevated serum hCG level and pineal mass suggested the clinical diagnosis of intracranial germ cell tumor.", + "Two courses of ICE chemotherapy were performed.", + "Repeated MRI did not reflect significant shrinkage of the pineal lesion.", + "Serum hCG normalized to < 0.1 IU/L.", + "Basal serum gonadotropin levels unexpectedly increased.", + "The patient underwent a neurosurgical operation.", + "The histological result revealed a mature teratoma.", + "The patient received two additional courses of ICE chemotherapy.", + "Radiotherapy targeting the whole brain (24 Gy) plus the pineal region boosting (12 Gy) was performed.", + "GnRH analogue therapy was started to suppress gonadal activation.", + "After 18 months of regular GnRH analogue therapy, the patient’s LH and FSH remained undetectable.", + "Premature puberty regressed after 18 months of GnRH analogue therapy.", + "The growth velocity is approximately 5 cm per year." + ], + "summary": "A 5.8-year-old male presented facial hair and phallic growth, deepened voice, and accelerated growth velocity for 6 months. The elevated human chorionic gonadotropin level with undetectable gonadotropin levels indicated peripheral precocious puberty. Brain imaging revealed a pineal mass and further pathology indicated the diagnosis of teratoma. During chemoradiotherapy with operation, the elevated human chorionic gonadotropin level reduced to normal range, while the levels of gonadotropins and testosterone increased. Subsequently, progressing precocious puberty was arrested with gonadotrophin-releasing hormone analog therapy. Previous cases of transition from peripheral precocious puberty to central precocious puberty were reviewed. The transitions were caused by the suddenly reduced feedback inhibition of sex steroid hormones on gonadotropin releasing hormone and gonadotropins.", + "summary_subclaims": [ + "The patient is a 5.8-year-old male.", + "The patient had facial hair.", + "The patient had phallic growth.", + "The patient had a deepened voice.", + "The patient had accelerated growth velocity.", + "The symptoms had been present for 6 months.", + "The human chorionic gonadotropin level was elevated.", + "The gonadotropin levels were undetectable.", + "The elevated human chorionic gonadotropin level with undetectable gonadotropin levels indicated peripheral precocious puberty.", + "Brain imaging revealed a pineal mass.", + "The diagnosis was teratoma.", + "During chemoradiotherapy with operation, the elevated human chorionic gonadotropin level reduced to normal range.", + "During chemoradiotherapy with operation, the levels of gonadotropins and testosterone increased.", + "Progressing precocious puberty was arrested with gonadotrophin-releasing hormone analog therapy.", + "Previous cases of transition from peripheral precocious puberty to central precocious puberty were reviewed.", + "The transitions were caused by the suddenly reduced feedback inhibition of sex steroid hormones on gonadotropin releasing hormone and gonadotropins." + ] + }, + { + "id": "multiclinsum_test_499_en.txt", + "fulltext": "A 12-year-old boy with KD and major acquired coronary abnormalities was admitted to our hospital for follow-up at the request of his former physician in Ukraine. Initial diagnosis of KD was in 2019. He was initially treated with immunoglobulins and acetylsalicylic acid (ASA). Despite the treatment, follow-up cardiology assessments revealed giant CAAs, whereupon antiplatelet therapy and oral anticoagulation with warfarin were started. Computed tomography performed in November 2021 (images are not available), and cardiac catheterization in February 2022 showed chronic occlusion of the right coronary artery (RCA) with bridging collateral vessels ( and ). In 2022, the patient and his family fled Ukraine to Germany because of the war. At our initial encounter, the patient was asymptomatic and clinical examination was unremarkable except for mild right ventricular conduction delay . Cardiopulmonary exercise testing showed reduced functional capacity but no ECG changes suspicious for myocardial ischaemia. Blood test showed an International Normalized Ratio (INR) value of 2.8, which lays within an effective therapeutic range (2.0–3.0). Additional cardiovascular magnetic resonance (CMR) imaging was performed and confirmed RCA and left anterior descending artery (LAD) aneurysms with a maximum transverse diameter of 11 × 12 mm (RCA) and of 11 × 15 mm (LAD). In addition, there was also evidence of chronic occlusion of the RCA with bridging collateral vessels and mural thrombi in LAD (; also see ). Late-gadolinium enhancement imaging did not show any evidence for myocardial infarction suggesting a chronic aetiology of coronary artery disease and not an acute thrombotic event ( and ). No obvious perfusion defect was detected during stress perfusion imaging. Physical stress echocardiography did not show significant wall motion abnormalities. Further history revealed that he is on antiplatelet medication since spring 2021 and that oral anticoagulation was started in October 2021. Thus, we suspect that inadequate antithrombotic medication contributed to CA thromboses. The patient’s findings were discussed in a multidisciplinary team meeting. As there was no clear evidence for myocardial ischaemia, a decision against CABG and for continuing warfarin and ASA was made.\nFollow-up assessments are performed in accordance with the American Heart Association consensus statement (3). Currently, the patient is seen in the paediatric cardiology clinic every 3–6 months with investigations for inducible myocardial ischaemia every 6–12 months. Follow-up CMR was performed 5 months after the first study including stress perfusion and did not differ compared to the first scan. Clinically, the patient is well and free of cardiac symptoms.", + "fulltext_subclaims": [ + "The patient is a 12-year-old boy with KD and major acquired coronary abnormalities.", + "The patient was admitted to our hospital for follow-up at the request of his former physician in Ukraine.", + "The initial diagnosis of KD was in 2019.", + "He was initially treated with immunoglobulins and acetylsalicylic acid (ASA).", + "Follow-up cardiology assessments revealed giant CAAs.", + "Antiplatelet therapy and oral anticoagulation with warfarin were started.", + "Computed tomography was performed in November 2021.", + "Cardiac catheterization in February 2022 showed chronic occlusion of the right coronary artery (RCA) with bridging collateral vessels.", + "The patient and his family fled Ukraine to Germany because of the war.", + "At our initial encounter, the patient was asymptomatic.", + "Clinical examination was unremarkable except for mild right ventricular conduction delay.", + "Cardiopulmonary exercise testing showed reduced functional capacity.", + "Blood test showed an International Normalized Ratio (INR) value of 2.8.", + "The INR value of 2.8 lays within an effective therapeutic range (2.0–3.0).", + "Cardiovascular magnetic resonance (CMR) imaging was performed.", + "CMR confirmed RCA and left anterior descending artery (LAD) aneurysms with a maximum transverse diameter of 11 × 12 mm (RCA) and of 11 × 15 mm (LAD).", + "There was evidence of chronic occlusion of the RCA with bridging collateral vessels.", + "There was evidence of mural thrombi in LAD.", + "Late-gadolinium enhancement imaging did not show any evidence for myocardial infarction.", + "No obvious perfusion defect was detected during stress perfusion imaging.", + "Physical stress echocardiography did not show significant wall motion abnormalities.", + "The patient is on antiplatelet medication since spring 2021.", + "Oral anticoagulation was started in October 2021.", + "We suspect that inadequate antithrombotic medication contributed to CA thromboses.", + "The patient’s findings were discussed in a multidisciplinary team meeting.", + "There was no clear evidence for myocardial ischaemia.", + "A decision against CABG and for continuing warfarin and ASA was made.", + "Follow-up assessments are performed in accordance with the American Heart Association consensus statement.", + "The patient is seen in the paediatric cardiology clinic every 3–6 months.", + "Investigations for inducible myocardial ischaemia are performed every 6–12 months.", + "Follow-up CMR was performed 5 months after the first study including stress perfusion.", + "Follow-up CMR did not differ compared to the first scan.", + "The patient is clinically well and free of cardiac symptoms." + ], + "summary": "This case report presents a 12-year-old patient with KD who developed CAAs in two coronary arteries despite initial administration of intravenous immunoglobulins and acetylsalicylic acid, followed by extensive thrombosis of both coronary arteries, although antithrombotic therapy was started after the diagnosis of CAAs.", + "summary_subclaims": [ + "This case report presents a 12-year-old patient with KD.", + "The patient developed CAAs in two coronary arteries.", + "The patient received initial administration of intravenous immunoglobulins.", + "The patient received initial administration of acetylsalicylic acid.", + "The patient had extensive thrombosis of both coronary arteries.", + "Antithrombotic therapy was started after the diagnosis of CAAs." + ] + }, + { + "id": "multiclinsum_test_1885_en.txt", + "fulltext": "A 19-year-old Hispanic female with a past medical history of acne, asthma, and extensive psychosocial distress but no psychiatric diagnoses, presented to the ED with complaints of an episode of lightheadedness, generalized weakness, diaphoresis, diarrhea, and vomiting. Previously, she presented to the hospital with similar complaints two other times; however, she was not seen by our team until the third visit. On this first visit she stated that she used the blood glucose monitor of her girlfriend/roommate, who is a type 1 diabetic, and that her blood sugar reading was 53 mg/dL and later rose to 80 mg/dL after she ate two sandwiches and some chocolate. Upon arriving to the ED, the patient’s symptoms had improved. Vital signs obtained at the time of triage were: blood pressure (BP) 98/65 mmHg, heart rate 81 beats per minute (bpm), respiratory rate 18 breaths per min, oxygen saturation (SpO2) of 100% on room air, and an oral temperature of 37 °C (98.6 °F). The patient reported no pertinent past surgical history. She stated that she was allergic to pineapples and that she does not take any medications. In addition, she did not report any tobacco or alcohol use. Initial examination revealed a well-developed, asymptomatic, obese young female in no acute distress. Her blood glucose according to the glucose monitor was 60 mg/dL, which was confirmed with lab draw. Physical exam and labs were unremarkable, and the patient was discharged after being given intravenous (IV) 0.9% sodium chloride (NaCl) for volume restoration, ondansetron for her nausea and vomiting, further directions on diet for hypoglycemia (i.e. adding protein to each meal and eating small frequent meals), and instructions on follow-up with her primary care provider (PCP) for recommendation on further testing for the cause of her hypoglycemic episode and GI symptoms.\nThe next day, the patient arrived via emergency medical services (EMS) to the ED after she was found unresponsive. She stated that she was not feeling too well due to a virus and became very lightheaded and passed out. Her blood sugar was 46 mg/dL at home prior to administration of half an ampule of dextrose (D50W). Her family mentioned the patient has a history of her blood sugar dropping rather frequently and that they are unsure what to do for this problem. Vital signs obtained at the time of triage were: BP 122/75 mmHg, heart rate 100 bpm, respiratory rate 18 breaths per minute, SpO2 of 100% on room air, and an oral temperature of 36.7 °C (98 °F). Physical exam and other labs were unremarkable, and the patient was discharged after being given instructions once again on following-up with a PCP.\nThree weeks after her initial presentation, she was rushed to the ED via EMS after being found unresponsive at work with a blood glucose level of 23 mg/dL. She was given 1 ampule of IV D50W by EMS at the scene and her blood sugar rose to 172 mg/dL. Upon arrival to the ED, her blood sugar had dropped back down to 61 mg/dL; and she was noted to again have symptoms of dizziness and decreased alertness with her hypoglycemia. Vital signs obtained at the time of triage were: BP 135/78 mmHg, heart rate 108 bpm, respiratory rate 18 breaths per minute, SpO2 of 100% on room air, and an oral temperature of 36.4 °C (97.6 °F). She was given one half of an ampule of D50W IV because of her symptoms of dizziness and evidence of decreased alertness with a decreased blood glucose level, which was suspected to still be dropping. She responded to this treatment with improvement of dizziness and alertness but later had a second hypoglycemic episode in the ED. At this time she was treated with a full ampule of D50W IV and was started on dextrose 5% with 0.45% NaCl (D5 half-normal). Despite a brief improvement a few minutes after starting D5 half-normal, she had a third episode of hypoglycemia in the ED and was treated with another ampule of D50W IV and her IV changed to dextrose 10% in water (D10W) at 100 cm3 (cc’s) an hour. Despite this change, her blood glucose further dropped to 105 mg/dL from 140 mg/dL, so her D10W was increased to 150 cc’s an hour. Detailed glucose readings throughout this time are reported in Table . Her girlfriend/roommate was asked to leave the patient to rest, in order to help determine whether the patient, her roommate, or both might be involved in giving insulin to cause the abrupt hypoglycemic episodes. The patient was weak, confused, profusely sweating with chills, short of breath, nauseated, had heart palpitations, and an altered mental status during all of her hypoglycemic episodes. Of note, once alert, the patient told the charge nurse that her PCP had found a mass in her pancreas that was responsible for her hypoglycemic episodes. Due to the critical nature of her recurrent hypoglycemic episodes in the ED, the patient was admitted to the ICU, where she became more responsive. An electrocardiogram demonstrated normal sinus rhythm, normal axis and intervals, and no acute changes in ST-segment or T wave morphology. The laboratory findings from all three ED visits are reported in Table .\nStandard drug screen was done to rule out any symptoms from toxicity; however the results were negative. To determine if factitious use of insulin was the cause for the patient’s presentation, further tests were performed: hemoglobin A1C of 5.1%, C-peptide level of 9.9 ng/mL, free insulin level of 370 mIU/L and a total insulin level of 377 mIU/L.\nTo rule out any neurological causes, a computed tomography (CT) scan of the head without IV contrast was performed and revealed no evidence of intracranial findings or suspicious intracranial mass. To rule out any pancreatic masses, CT of the abdomen was obtained and showed a 1.8 cm collapsing cyst in the right ovary and trace fluid in the pelvis, which is likely physiological . Otherwise, no acute intra-abdominal or intra-pelvic process was seen.\nThe patient was interviewed at length by the ED hospital team in the ICU the following day, and the diagnosis of factitious disorder was suggested. The encounter revealed that the patient is an undocumented immigrant from Honduras, who has been in the US since she was 14 years old. She used to reside with foster parents. However, she recently graduated from being a minor and is currently living at a halfway house with four other women. She works full-time at a thrift store. She is unaware of her family history. She states that she was heavily involved with illicit drug use in the past but does not smoke or drink alcohol anymore. When confronted with evidence about no mass found on imaging, the patient did not deny injecting insulin. She had significant knowledge about insulin administration as well as the amount of units her girlfriend/roommate currently injects for her type 1 diabetes management. She mentioned that she frequently checks her blood sugar at home, where her readings range from 30s – 100 s mg/dL. The patient reported missing several meals throughout the day due to time restraints and work. Her caregiver called the hospital to let the hospital staff know that the patient had been taking her girlfriend/roommate’s insulin resulting in her previous ED visits. She has also asked for insulin needles and may have taken insulin to gain attention.", + "fulltext_subclaims": [ + "The patient is a 19-year-old Hispanic female.", + "She has a past medical history of acne.", + "She has a past medical history of asthma.", + "She has extensive psychosocial distress.", + "She has no psychiatric diagnoses.", + "She presented to the ED with complaints of an episode of lightheadedness.", + "She presented to the ED with complaints of generalized weakness.", + "She presented to the ED with complaints of diaphoresis.", + "She presented to the ED with complaints of diarrhea.", + "She presented to the ED with complaints of vomiting.", + "She had previously presented to the hospital with similar complaints two other times.", + "She was not seen by our team until the third visit.", + "On the first visit, she stated that she used the blood glucose monitor of her girlfriend/roommate.", + "Her blood sugar reading was 53 mg/dL.", + "Her blood sugar reading later rose to 80 mg/dL after she ate two sandwiches and some chocolate.", + "Upon arriving to the ED, her symptoms had improved.", + "Her vital signs at triage were blood pressure 98/65 mmHg.", + "Her vital signs at triage were heart rate 81 bpm.", + "Her vital signs at triage were respiratory rate 18 breaths per minute.", + "Her vital signs at triage were oxygen saturation 100% on room air.", + "Her vital signs at triage were an oral temperature of 37 °C (98.6 °F).", + "She reported no pertinent past surgical history.", + "She stated that she was allergic to pineapples.", + "She stated that she does not take any medications.", + "She did not report any tobacco use.", + "She did not report any alcohol use.", + "Initial examination revealed a well-developed, asymptomatic, obese young female.", + "Her blood glucose according to the glucose monitor was 60 mg/dL.", + "Her blood glucose was confirmed with lab draw.", + "Physical exam and labs were unremarkable.", + "The patient was discharged after being given intravenous 0.9% sodium chloride.", + "The patient was discharged after being given ondansetron.", + "The patient was given further directions on diet for hypoglycemia.", + "The patient was instructed to follow-up with her primary care provider.", + "The next day, the patient arrived via emergency medical services to the ED after being found unresponsive.", + "She stated that she was not feeling too well due to a virus.", + "Her blood sugar was 46 mg/dL at home prior to administration of half an ampule of dextrose.", + "Her family mentioned the patient has a history of her blood sugar dropping rather frequently.", + "Three weeks after her initial presentation, she was rushed to the ED via EMS after being found unresponsive at work.", + "Her blood glucose level at the scene was 23 mg/dL.", + "She was given 1 ampule of IV D50W by EMS at the scene.", + "Her blood sugar rose to 172 mg/dL.", + "Upon arrival to the ED, her blood sugar had dropped back down to 61 mg/dL.", + "She was noted to again have symptoms of dizziness and decreased alertness with her hypoglycemia.", + "She was given one half of an ampule of D50W IV.", + "She responded to this treatment with improvement of dizziness and alertness.", + "She had a second hypoglycemic episode in the ED.", + "She was treated with a full ampule of D50W IV.", + "She was started on dextrose 5% with 0.45% NaCl.", + "She had a third episode of hypoglycemia in the ED.", + "She was treated with another ampule of D50W IV.", + "Her IV was changed to dextrose 10% in water at 100 cm3 an hour.", + "Her blood glucose further dropped to 105 mg/dL from 140 mg/dL.", + "Her D10W was increased to 150 cc’s an hour.", + "The patient was weak, confused, profusely sweating with chills, short of breath, nauseated, had heart palpitations, and an altered mental status during all of her hypoglycemic episodes.", + "Once alert, the patient told the charge nurse that her PCP had found a mass in her pancreas.", + "The patient was admitted to the ICU.", + "An electrocardiogram demonstrated normal sinus rhythm.", + "A standard drug screen was done to rule out any symptoms from toxicity.", + "The drug screen results were negative.", + "Further tests were performed to determine if factitious use of insulin was the cause.", + "A hemoglobin A1C of 5.1% was obtained.", + "A C-peptide level of 9.9 ng/mL was obtained.", + "A free insulin level of 370 mIU/L was obtained.", + "A total insulin level of 377 mIU/L was obtained.", + "A CT scan of the head without IV contrast was performed.", + "The CT scan revealed no evidence of intracranial findings.", + "A CT of the abdomen was obtained.", + "The CT showed a 1.8 cm collapsing cyst in the right ovary.", + "The CT showed trace fluid in the pelvis, which is likely physiological.", + "The patient was interviewed at length by the ED hospital team.", + "The diagnosis of factitious disorder was suggested.", + "The patient is an undocumented immigrant from Honduras.", + "She has been in the US since she was 14 years old.", + "She used to reside with foster parents.", + "She recently graduated from being a minor.", + "She is currently living at a halfway house with four other women.", + "She works full-time at a thrift store.", + "She is unaware of her family history.", + "She stated that she was heavily involved with illicit drug use in the past.", + "She does not smoke or drink alcohol anymore.", + "When confronted with evidence about no mass found on imaging, the patient did not deny injecting insulin.", + "She had significant knowledge about insulin administration.", + "She mentioned that she frequently checks her blood sugar at home.", + "Her blood sugar readings at home range from 30s – 100s mg/dL.", + "She reported missing several meals throughout the day due to time restraints and work.", + "Her caregiver called the hospital to let the hospital staff know that the patient had been taking her girlfriend/roommate’s insulin.", + "She has also asked for insulin needles and may have taken insulin to gain attention." + ], + "summary": "We report a case of factitious hypoglycemia in a 19-year-old foster care adolescent female who presented to the Emergency Department with recurrent hypoglycemic episodes, to the degree that the patient required large amounts of dextrose and further management by intensive care unit hospitalization. Further inquiry revealed that the patient intentionally injected herself with large doses of insulin for the purposes of seeking hospital admission.", + "summary_subclaims": [ + "The patient is a 19-year-old foster care adolescent female.", + "The patient presented to the Emergency Department with recurrent hypoglycemic episodes.", + "The patient required large amounts of dextrose.", + "The patient required further management by intensive care unit hospitalization.", + "Further inquiry revealed that the patient intentionally injected herself with large doses of insulin.", + "The patient injected herself with large doses of insulin for the purposes of seeking hospital admission." + ] + }, + { + "id": "multiclinsum_test_1713_en.txt", + "fulltext": "A 40 year-old Nigerian housewife was seen at the oncology clinic of the University College Hospital (UCH) Ibadan, Nigeria in June 2002 with a 1 year 8 months history of painful left breast lump which had been previously excised in another hospital but recurred 8 months before presentation at UCH. There was no information about histological diagnosis of the excised breast lesion from the first hospital. There were no systemic symptoms. She was Para 7+1 and had no family history of breast or ovarian cancer. Physical examination revealed globular enlargement of the left breast measuring 20 cm × 18 cm. The mass occupied the whole breast, was warm, multinodular and fixed to the pectoralis fascia. The ipsilateral axillary lymph nodes were enlarged, but examination of the other systems was normal. A clinical diagnosis of locally advanced cancer of the left breast was made.\nPlain radiograph of the chest and abdominal ultrasound scan were normal. A core-needle biopsy of the mass was done and histology showed a malignant neoplasm comprising islands of chondroblastic and osteoblastic stromal cells, with no normal breast tissue seen. A diagnosis of osteogenic sarcoma was made. The patient had a left modified radical mastectomy and latissimus dorsi musculocutaneous flap to cover an anterior chest wall defect. The mastectomy specimen weighed 350 g. Cut sections revealed areas of cystic degeneration and necrosis, with focal areas that were firm with a cartilaginous consistency. Conventional representative sections were obtained from each of the four breast quadrants, areola region, resection margins and axillary lymph nodes. Microscopic examination of the sections showed a malignant breast neoplasm displaying fibrosarcomatous, chondrosarcomatous as well as osteosarcomatous differentiation. There was metastasis to one of the lymph nodes. She was scheduled for radiotherapy to the chest wall but she defaulted. Contact tracing revealed that she died about 6 months after mastectomy.", + "fulltext_subclaims": [ + "The patient was a 40 year-old Nigerian housewife.", + "She was seen at the oncology clinic of the University College Hospital (UCH) Ibadan, Nigeria in June 2002.", + "She had a 1 year 8 months history of painful left breast lump.", + "The breast lump had been previously excised in another hospital.", + "The breast lump recurred 8 months before presentation at UCH.", + "There was no information about histological diagnosis of the excised breast lesion from the first hospital.", + "There were no systemic symptoms.", + "She was Para 7+1.", + "She had no family history of breast or ovarian cancer.", + "Physical examination revealed globular enlargement of the left breast measuring 20 cm × 18 cm.", + "The mass occupied the whole breast.", + "The mass was warm, multinodular and fixed to the pectoralis fascia.", + "The ipsilateral axillary lymph nodes were enlarged.", + "A clinical diagnosis of locally advanced cancer of the left breast was made.", + "Plain radiograph of the chest and abdominal ultrasound scan were normal.", + "A core-needle biopsy of the mass was done.", + "Histology showed a malignant neoplasm comprising islands of chondroblastic and osteoblastic stromal cells.", + "No normal breast tissue was seen.", + "A diagnosis of osteogenic sarcoma was made.", + "The patient had a left modified radical mastectomy.", + "A latissimus dorsi musculocutaneous flap was used to cover an anterior chest wall defect.", + "The mastectomy specimen weighed 350 g.", + "Cut sections revealed areas of cystic degeneration and necrosis.", + "There were focal areas that were firm with a cartilaginous consistency.", + "Conventional representative sections were obtained from each of the four breast quadrants, areola region, resection margins and axillary lymph nodes.", + "Microscopic examination showed a malignant breast neoplasm displaying fibrosarcomatous, chondrosarcomatous as well as osteosarcomatous differentiation.", + "There was metastasis to one of the lymph nodes.", + "She was scheduled for radiotherapy to the chest wall.", + "She defaulted.", + "Contact tracing revealed that she died about 6 months after mastectomy." + ], + "summary": "A 40 year-old Nigerian woman was clinically diagnosed to have carcinoma of the left breast. The histology report of core-needle biopsy of the mass showed a malignant neoplasm comprising islands of chondroblastic and osteoblastic stromal cells. This report changed the diagnosis from carcinoma to osteogenic sarcoma of the breast. She had a left modified radical mastectomy, however there was significant post surgery skin deficit. A latissimus dorsi musculocutaneous flap was used to cover the anterior chest wall defect. Sections from the mastectomy specimen confirmed the diagnosis of osteogenic sarcoma. She died six months after mastectomy.", + "summary_subclaims": [ + "The patient is a 40 year-old Nigerian woman.", + "The patient was clinically diagnosed to have carcinoma of the left breast.", + "The histology report of core-needle biopsy of the mass showed a malignant neoplasm comprising islands of chondroblastic and osteoblastic stromal cells.", + "This report changed the diagnosis from carcinoma to osteogenic sarcoma of the breast.", + "The patient had a left modified radical mastectomy.", + "There was significant post surgery skin deficit.", + "A latissimus dorsi musculocutaneous flap was used to cover the anterior chest wall defect.", + "Sections from the mastectomy specimen confirmed the diagnosis of osteogenic sarcoma.", + "The patient died six months after mastectomy." + ] + }, + { + "id": "multiclinsum_test_1112_en.txt", + "fulltext": "A 54-year-old woman presented at our hospital had left knee pain and gradually uncomfortable for 5 years. Symptoms rapidly worsened with limited activity in the last 5 months. The patient suffered from idiopathic thrombocytopenic purpura which needed low-dosage oral prednisone (5 mg for three times per day) 6 years ago. Recently, she was frequently suffering from pain on the lateral side of the knee during long time walk and stair performance.\nPhysical examination: There was focal tenderness over the lateral femoral condyle of the left knee. The physical examination elicited severely knee pain of the lateral side on extremes of range of motion, as well as during valgus stress test on the knee, but range of motion was not significantly limited. The EuroQol five-dimension (EQ-5D) quality of life score was 0.587, Knee Society score (KSS) was 64 and WOMAC score was 38.\nPreoperative radiographs: Magnetic Resonance Imaging (MRI) revealed avascular necrosis of the lateral femoral condyle and bilateral femoral head necrosis . According to the Ficat-Arlet classification (modified version) [, ], this knee osteonecrosis was classified as stage IV.\nThe diagnosis was secondary osteonecrosis of the lateral condyle and Idiopathic thrombocytopenic purpura. Due to the presence of a large lesion limited to lateral femoral condyle, no evidence of joint space narrowing in the medial tibia-femoral compartment, and intact cruciate and collateral ligaments, the therapeutic treatment was fixed bearing lateral unicompartmental knee arthroplasty (LINK German). General anesthesia combined with midthigh saphenous nerve block was used for the operation. The knee was exposed via a lateral parapatellar approach to achieving a good view. Osteonecrosis of the distal aspect of the femur produces a large segment of dead bone (approximately 8.17 cm2) on the weight-bearing portion of the lateral femoral condyle . A large amount of necrotic bone, which mainly located on the posterior portion of femoral condyle, was completely removed down to the bleeding bed of bone by a spatula. Then we drilled several holes on the necrotic bone bed and filled the large bone defect with cement, which facilitated a solid initial fixation for cemented prosthesis. The rest of procedures was performed according to the lateral UKA operation manual. After the surgery, we enjoined her to avoid excessive knee flexion and intense activity in the early stage after surgery.\nFollow-up: The patient was evaluated clinically and radiographically at 6 weeks, 3 months, 6 months and 1 year postoperatively and on an annual basis thereafter unless a problem arose. She could walk without ambulation aid shortly after the operation on the surgery day by virtue of rapid anesthetic resuscitation from general anesthesia combined with midthigh saphenous nerve block. Postoperative radiographic imaging showed optimal size and precise position of the prosthesis. On the 2nd day after surgery, she felt significant pain relief and VAS pain score improved from 7 to 2. Her left knee range of motion (ROM) was at 0° to 90° . The patient could unlimitedly walk for hours, go up and down stairs freely and achieved satisfactory knee joint function with ROM of 0° to 120° at 6 weeks after the operation. Improving joint function provided a physical, mental and emotional boost to the patient. She could return to work and sport at two months postoperatively. The EQ-5D score was 1, the KSS and WOMAC score were 91, 20 respectively at the latest follow-up. The total follow-up period was 1 year and there was no pain, loosening, fracture, or wear of the prosthesis.", + "fulltext_subclaims": [ + "The patient was a 54-year-old woman.", + "She had left knee pain and gradually uncomfortable for 5 years.", + "Symptoms rapidly worsened with limited activity in the last 5 months.", + "The patient had idiopathic thrombocytopenic purpura.", + "She was taking low-dosage oral prednisone (5 mg three times per day) 6 years ago.", + "She was frequently suffering from pain on the lateral side of the knee during long time walk and stair performance.", + "Physical examination showed focal tenderness over the lateral femoral condyle of the left knee.", + "The physical examination elicited severely knee pain of the lateral side on extremes of range of motion.", + "The EuroQol five-dimension (EQ-5D) quality of life score was 0.587.", + "The Knee Society score (KSS) was 64.", + "The WOMAC score was 38.", + "Magnetic Resonance Imaging (MRI) revealed avascular necrosis of the lateral femoral condyle.", + "MRI also revealed bilateral femoral head necrosis.", + "According to the Ficat-Arlet classification (modified version), this knee osteonecrosis was classified as stage IV.", + "The diagnosis was secondary osteonecrosis of the lateral condyle.", + "The diagnosis also included Idiopathic thrombocytopenic purpura.", + "The therapeutic treatment was fixed bearing lateral unicompartmental knee arthroplasty (LINK German).", + "General anesthesia combined with midthigh saphenous nerve block was used for the operation.", + "The knee was exposed via a lateral parapatellar approach.", + "Osteonecrosis of the distal aspect of the femur produced a large segment of dead bone (approximately 8.17 cm2) on the weight-bearing portion of the lateral femoral condyle.", + "A large amount of necrotic bone, mainly located on the posterior portion of femoral condyle, was completely removed down to the bleeding bed of bone by a spatula.", + "Several holes were drilled on the necrotic bone bed.", + "The large bone defect was filled with cement.", + "The rest of procedures was performed according to the lateral UKA operation manual.", + "After the surgery, she was advised to avoid excessive knee flexion and intense activity in the early stage after surgery.", + "The patient was evaluated clinically and radiographically at 6 weeks, 3 months, 6 months and 1 year postoperatively.", + "She could walk without ambulation aid shortly after the operation on the surgery day.", + "Postoperative radiographic imaging showed optimal size and precise position of the prosthesis.", + "On the 2nd day after surgery, she felt significant pain relief.", + "The VAS pain score improved from 7 to 2.", + "Her left knee range of motion (ROM) was at 0° to 90°.", + "The patient could walk for hours, go up and down stairs freely, and achieved satisfactory knee joint function with ROM of 0° to 120° at 6 weeks after the operation.", + "The EQ-5D score was 1 at the latest follow-up.", + "The KSS score was 91 at the latest follow-up.", + "The WOMAC score was 20 at the latest follow-up.", + "The total follow-up period was 1 year.", + "There was no pain, loosening, fracture, or wear of the prosthesis." + ], + "summary": "A 54-year-old woman with idiopathic thrombocytopenic purpura, who received low-dosage corticosteroids, complained of knee pain for 5 years and difficulty walking in the last 5 months. Fixed-bearing lateral UKA was performed under general anesthesia combined with midthigh saphenous nerve block. The patient could walk without ambulation aid shortly after the operation and achieved satisfactory knee joint function at the 6-week follow-up. The knee society score (KSS) increased from 68 to 91. The follow-up period was up to 1 year. There was no pain, loosening, or fracture of the prosthesis at the latest follow-up.", + "summary_subclaims": [ + "The patient is a 54-year-old woman.", + "The patient has idiopathic thrombocytopenic purpura.", + "The patient received low-dosage corticosteroids.", + "The patient complained of knee pain for 5 years.", + "The patient had difficulty walking in the last 5 months.", + "Fixed-bearing lateral UKA was performed.", + "The operation was performed under general anesthesia.", + "The operation was combined with midthigh saphenous nerve block.", + "The patient could walk without ambulation aid shortly after the operation.", + "The patient achieved satisfactory knee joint function at the 6-week follow-up.", + "The knee society score (KSS) increased from 68 to 91.", + "The follow-up period was up to 1 year.", + "There was no pain at the latest follow-up.", + "There was no loosening of the prosthesis at the latest follow-up.", + "There was no fracture of the prosthesis at the latest follow-up." + ] + }, + { + "id": "multiclinsum_test_2424_en.txt", + "fulltext": "A 57-year-old previously healthy gentleman presented to our service complaining of a new onset shortness of breath for 2 months. He initially sought medical attention outside King Hussein Cancer Center (KHCC) where he was found to have a huge mediastinal mass on a chest x-ray from which a biopsy revealed a thymoma . At KHCC, a chest computed tomography (CT) scan showed a lobulated anterior mediastinal soft tissue mass measuring 11.3 × 7.7 cm at the level of the aortic arch. It appeared to be inseparable from the anterior wall of the superior vena cava (SVC), compressing it mildly but keeping it patent. In addition, it had a wide area of contact with the ascending aorta and upper pericardium. Multiple small nodular soft tissue masses were seen in the anterior epicardial space, mostly representing small lymph nodes. Otherwise no other mediastinal lymphadenopathy was reported .\nA multidisciplinary team explained to the patient and his family the treatment options, which included neoadjuvant chemotherapy and re-assessment of tumor size for potential resectability afterwards. The patient received two cycles of Cisplatin/Doxorubicin/Cyclophosphamide (CAP). Follow up imaging showed a slight regression in size of the previously noted anterior mediastinal mass which now measured 10.2 × 7.2 cm. The patient received a third cycle of neoadjuvant chemotherapy however, the tumor size remained unchanged.\nThe patient was then scheduled for a total thymectomy through a mid-sternotomy. Intraoperatively, there was a huge hard thymic mass invading the inner surface of the anterior pericardium and the right phrenic nerve, being very close to the left phrenic nerve. It was also attached to the superior vena cava, innominate vein (InV), ascending aorta (AsA) and part of the right middle and right upper lung lobes.\nTotal thymectomy with anterior pericardial resection was done; the tumor was dissected from the SVC, the InV and the AsA without complications, the right phrenic nerve was resected en bloc with the tumor and part of the pericardium while the left phrenic nerve was dissected from the mass and preserved. The operation was smooth and uneventful. Postoperatively the chest tube collected 2 l of blood and the patient became hypotensive despite receiving two units of packed red blood cells (PRBCs) and intravenous normal saline. The decision was then made to take the patient back to the operation room and an emergency surgical site exploration via reopening of the midline sternotomy was done within 3 h of the first procedure.\nThe bleeding source was identified from the left internal mammary vessel and was controlled by clipping, cautery and SURGICEL (Ethicon US). During the intraoperative thirty-minute monitoring for blood pressure improvement, the patient developed ventricular tachycardia, and the defibrillator could not be readily started for technical reasons, so the heart became severely distended and developed asystole. Cardiopulmonary resuscitation (CPR) was initiated manually by cardiac massage with intra-cardiac adrenaline injection. Right ventricular rupture occurred with a 3-cm hole that was followed immediately by an attempt of Proline stich repair that failed, so manual massage continued with a hand closure of the defect until the sinus rhythm reverted. Eventually, repair of the defect was successfully achieved with pericardial patch. Meanwhile, the blood loss was compensated by continuous blood infusion. Within 5 h, the patient received a total of thirteen units of PRBCs, eleven units of fresh frozen plasma (FFP) and one unit of single donor platelet. Blood pressure and vital signs improved afterward and the heart returned to a synchronized rhythm.\nThe patient was transferred to the intensive care unit (ICU) on mechanical ventilation for observation. An echocardiogram was done the next day; the left ventricular ejection fraction (EF) was 60% with no evidence of thrombi. On the second post-operative day, the patient developed atrial fibrillation (A.Fib) which was controlled with antiarrhythmic medication (Amiodarone). The patient’s overall status and multi-organ functions returned back to normal during his prolonged ICU stay. However, he remained dependent on ventilator support in spite of multiple trials of weaning. This necessitated a fluoroscopy scan that revealed no appreciable movement in both hemi-diaphragms , suggesting bilateral phrenic nerve palsy and a decision for elective tracheostomy was made on the 8th post-operative day.\nThe patient remained completely dependent on the portable mechanical ventilator for a total of 2 months and was discharged from the ICU to the surgical floor 66 days post-operatively with aggressive chest rehabilitation and physiotherapy. He was gradually weaned off ventilation and was discharged on the 85th post-operative day. His tracheostomy tube incision site was closed 5 months after the initial procedure. Two years from the incident, the patient remains in complete remission and is back to his normal daily life with minimal shortness of breath, controlled by an inhaler.", + "fulltext_subclaims": [ + "The patient is a 57-year-old previously healthy gentleman.", + "He presented with new onset shortness of breath for 2 months.", + "He was found to have a huge mediastinal mass on a chest x-ray.", + "A biopsy revealed a thymoma.", + "A chest CT scan showed a lobulated anterior mediastinal soft tissue mass measuring 11.3 × 7.7 cm.", + "The mass appeared to be inseparable from the anterior wall of the superior vena cava.", + "The mass mildly compressed the superior vena cava but kept it patent.", + "The mass had a wide area of contact with the ascending aorta and upper pericardium.", + "Multiple small nodular soft tissue masses were seen in the anterior epicardial space.", + "The small nodular masses were mostly small lymph nodes.", + "No other mediastinal lymphadenopathy was reported.", + "The treatment options included neoadjuvant chemotherapy.", + "The patient received two cycles of Cisplatin/Doxorubicin/Cyclophosphamide (CAP).", + "Follow-up imaging showed a slight regression in the size of the anterior mediastinal mass.", + "The mass now measured 10.2 × 7.2 cm.", + "The patient received a third cycle of neoadjuvant chemotherapy.", + "The tumor size remained unchanged.", + "The patient was scheduled for a total thymectomy through a mid-sternotomy.", + "Intraoperatively, there was a huge hard thymic mass invading the inner surface of the anterior pericardium.", + "The mass was invading the right phrenic nerve.", + "The mass was very close to the left phrenic nerve.", + "The mass was attached to the superior vena cava.", + "The mass was attached to the innominate vein.", + "The mass was attached to the ascending aorta.", + "The mass was attached to part of the right middle and right upper lung lobes.", + "Total thymectomy with anterior pericardial resection was done.", + "The tumor was dissected from the SVC, the InV, and the AsA without complications.", + "The right phrenic nerve was resected en bloc with the tumor and part of the pericardium.", + "The left phrenic nerve was dissected from the mass and preserved.", + "The operation was smooth and uneventful.", + "Postoperatively, the chest tube collected 2 l of blood.", + "The patient became hypotensive despite receiving two units of packed red blood cells and intravenous normal saline.", + "The decision was made to take the patient back to the operation room.", + "An emergency surgical site exploration via reopening of the midline sternotomy was done within 3 h of the first procedure.", + "The bleeding source was identified from the left internal mammary vessel.", + "The bleeding was controlled by clipping, cautery, and SURGICEL.", + "During intraoperative thirty-minute monitoring, the patient developed ventricular tachycardia.", + "The defibrillator could not be readily started for technical reasons.", + "The heart became severely distended and developed asystole.", + "CPR was initiated manually by cardiac massage with intra-cardiac adrenaline injection.", + "Right ventricular rupture occurred with a 3-cm hole.", + "An attempt of Proline stitch repair failed.", + "Manual massage continued with hand closure of the defect until the sinus rhythm reverted.", + "Eventually, repair of the defect was successfully achieved with pericardial patch.", + "The patient received a total of thirteen units of PRBCs, eleven units of FFP, and one unit of single donor platelet within 5 h.", + "Blood pressure and vital signs improved afterward.", + "The heart returned to a synchronized rhythm.", + "The patient was transferred to the ICU on mechanical ventilation.", + "An echocardiogram showed a left ventricular ejection fraction of 60%.", + "There was no evidence of thrombi.", + "On the second post-operative day, the patient developed atrial fibrillation.", + "Atrial fibrillation was controlled with Amiodarone.", + "The patient remained dependent on ventilator support despite multiple trials of weaning.", + "A fluoroscopy scan revealed no appreciable movement in both hemi-diaphragms.", + "Bilateral phrenic nerve palsy was suggested.", + "A decision for elective tracheostomy was made on the 8th post-operative day.", + "The patient remained completely dependent on the portable mechanical ventilator for 2 months.", + "He was discharged from the ICU to the surgical floor 66 days post-operatively.", + "He was gradually weaned off ventilation.", + "He was discharged on the 85th post-operative day.", + "His tracheostomy tube incision site was closed 5 months after the initial procedure.", + "Two years from the incident, the patient remains in complete remission.", + "He is back to his normal daily life with minimal shortness of breath.", + "His shortness of breath is controlled by an inhaler." + ], + "summary": "A 57-year-old previously healthy gentleman presented complaining of a new onset shortness of breath for 2 months. A large mediastinal mass was found on chest imaging and biopsy revealed a thymoma. Patient received a neoadjuvant Cisplatin/Doxorubicin/Cyclophosphamide (CAP) regimen chemotherapy then sternotomy and thymectomy en bloc with anterior pericardium. Post-thymectomy, the patient continued to be hypotensive in recovery despite aggressive fluid resuscitation. He was sent back to theatre, aggressive fluid resuscitation continued, surgical site exploration was done by reopening the sternum, and the bleeding source was identified and controlled, but intraoperative asystole developed. During internal cardiac massage, the right ventricle ruptured with a 3 cm defect which was successfully repaired using a pericardial patch without a bypass machine due to unavailability at our cancer center. The patient remained dependent on mechanical ventilation through tracheostomy for a total of 2 months due to bilateral phrenic nerve paralysis, was discharged from ICU to the surgical floor 66 days after the operation and weaned off ventilator support after 85 days, adequate respiratory and physical rehabilitation followed. Patient is doing very well now with excellent performance, and free of tumor recurrence 30 months after surgery.", + "summary_subclaims": [ + "The patient is a 57-year-old previously healthy gentleman.", + "The patient had new onset shortness of breath for 2 months.", + "A large mediastinal mass was found on chest imaging.", + "Biopsy revealed a thymoma.", + "The patient received a neoadjuvant Cisplatin/Doxorubicin/Cyclophosphamide (CAP) regimen chemotherapy.", + "The patient had a sternotomy and thymectomy en bloc with anterior pericardium.", + "Post-thymectomy, the patient continued to be hypotensive in recovery despite aggressive fluid resuscitation.", + "The patient was sent back to theatre.", + "Surgical site exploration was done by reopening the sternum.", + "The bleeding source was identified and controlled.", + "Intraoperative asystole developed.", + "During internal cardiac massage, the right ventricle ruptured with a 3 cm defect.", + "The defect was successfully repaired using a pericardial patch.", + "The repair was done without a bypass machine due to unavailability at the cancer center.", + "The patient remained dependent on mechanical ventilation through tracheostomy for a total of 2 months.", + "The patient was discharged from ICU to the surgical floor 66 days after the operation.", + "The patient was weaned off ventilator support after 85 days.", + "Adequate respiratory and physical rehabilitation followed.", + "The patient is doing very well now with excellent performance.", + "The patient is free of tumor recurrence 30 months after surgery." + ] + }, + { + "id": "multiclinsum_test_3030_en.txt", + "fulltext": "This 30-year-old male patient presented with a frontal head swelling of one year duration that started after he sustained a stick injury on the frontal head one year ago, and he has an associated frontal headache for one year. There was no history of rhinosinusitis, no history of sinus surgery, and no history of radiation exposure. There was a 4 × 5 cm frontal, firm, palpable, non-tender lesion extending from the nasion to the frontal head. The neurologic examination was unremarkable; there was no sign or symptom of meningitis or a brain abscess. On a brain CT scan, there was frontal bone erosion at multiple sites with partial frontal sinus opacity, an externally growing mass, and an old frontal sinus fracture noted. An MRI was not done due to social reasons. Nasal endoscopy and ophthalmologic examination were unremarkable. We prepared him and took him to the OR after informed written consent was obtained. We put him in a supine position, intubated him, and placed him in a supine position with slight neck extension, a bicoronal skin incision, and a bifrontal craniotomy. The intraoperative finding was a soft tissue mass eroding the frontal bone and involving the frontal head galea and enlarged frontal sinuses filled with mucocele. Then, we did soft tissue mass resection from the frontal galea, mucocele exenteration, frontal sinus posterior wall or inner wall rongeoured and flattened, all frontal sinus mucosa excised, and the ostium identified and packed with muscle bilaterally. Then a pericranial pedicled flap was applied on the frontal lobe dura down to the frontal skull base. Skin closed in two layers with a drain left in the subgaleal space, the patient was stable, extubated, transferred to PACU, and then discharged on the third postoperative day with an improved headache and frontal swelling. After a month at an outpatient follow-up clinic, we found him completely improved from his headache and swelling.", + "fulltext_subclaims": [ + "The patient is a 30-year-old male.", + "He presented with a frontal head swelling of one year duration.", + "The swelling started after he sustained a stick injury on the frontal head one year ago.", + "He has an associated frontal headache for one year.", + "There was no history of rhinosinusitis.", + "There was no history of sinus surgery.", + "There was no history of radiation exposure.", + "There was a 4 × 5 cm frontal, firm, palpable, non-tender lesion extending from the nasion to the frontal head.", + "The neurologic examination was unremarkable.", + "There was no sign or symptom of meningitis.", + "There was no sign or symptom of a brain abscess.", + "On a brain CT scan, there was frontal bone erosion at multiple sites.", + "On a brain CT scan, there was partial frontal sinus opacity.", + "On a brain CT scan, there was an externally growing mass.", + "On a brain CT scan, an old frontal sinus fracture was noted.", + "An MRI was not done due to social reasons.", + "Nasal endoscopy was unremarkable.", + "Ophthalmologic examination was unremarkable.", + "Informed written consent was obtained.", + "The patient was placed in a supine position with slight neck extension.", + "A bicoronal skin incision was made.", + "A bifrontal craniotomy was performed.", + "The intraoperative finding was a soft tissue mass eroding the frontal bone.", + "The intraoperative finding was involvement of the frontal head galea.", + "The intraoperative finding was enlarged frontal sinuses filled with mucocele.", + "Soft tissue mass resection from the frontal galea was performed.", + "Mucocele exenteration was performed.", + "The frontal sinus posterior wall or inner wall was rongeoured and flattened.", + "All frontal sinus mucosa was excised.", + "The ostium was identified and packed with muscle bilaterally.", + "A pericranial pedicled flap was applied on the frontal lobe dura down to the frontal skull base.", + "Skin was closed in two layers.", + "A drain was left in the subgaleal space.", + "The patient was stable and extubated.", + "The patient was discharged on the third postoperative day.", + "The patient had an improved headache and frontal swelling.", + "At a one-month outpatient follow-up, the patient was completely improved from his headache and swelling." + ], + "summary": "This 30-year-old male patient presented with a frontal head swelling of one year duration that started after he sustained a stick injury on the frontal head one year ago, and he has an associated frontal headache for one year. There was a 4x5cm frontal, firm, palpable, non-tender lesion extending from the nasion to the frontal head. On the brain CT scan, there was frontal bone erosion at multiple sites with partial frontal sinus opacity, an externally growing mass, and an old frontal sinus fracture noted. Bifrontal craniotomy and bilateral frontal sinus cranialization were done, and the patient was discharged on the third day and seen a month later with complete improvement from headache and swelling.", + "summary_subclaims": [ + "The patient is a 30-year-old male.", + "The patient had a frontal head swelling of one year duration.", + "The swelling started after a stick injury on the frontal head one year ago.", + "The patient has had an associated frontal headache for one year.", + "There was a 4x5cm frontal, firm, palpable, non-tender lesion.", + "The lesion extended from the nasion to the frontal head.", + "On the brain CT scan, there was frontal bone erosion at multiple sites.", + "There was partial frontal sinus opacity on the CT scan.", + "An externally growing mass was noted on the CT scan.", + "An old frontal sinus fracture was noted on the CT scan.", + "Bifrontal craniotomy and bilateral frontal sinus cranialization were performed.", + "The patient was discharged on the third day.", + "The patient was seen a month later.", + "There was complete improvement from headache and swelling." + ] + }, + { + "id": "multiclinsum_test_2696_en.txt", + "fulltext": "A 7-year-old neutered male, mixed-breed cat presented with subcutaneous oedema and\nerythema of the right axilla extending to the abdomen, and swelling of the right\nforelimb .\nClinical examinations revealed mild fever (39.7°C) and a subcutaneous soft mass (3.0\n× 2.0 cm) on the back. A complete blood count revealed anaemia (packed cell volume\n[PCV] 26%) and thrombocytopenia (96,000 platelets/μl) . A blood smear examination\nrevealed a small number of large atypical round cells. The cells had\nsmall-to-moderate amounts of basophilic cytoplasm and large nuclei with finely\ndiffused chromatin and several nucleoli. The cells rarely contained fine azurophilic\ngranules in the cytoplasm . Examinations for feline immunodeficiency\nvirus antibodies and feline leukaemia virus antigens were not performed. Thoracic\nand abdominal radiography and abdominal ultrasonography showed no significant\nfindings. Cytological analysis with fine-needle aspiration from the subcutaneous\nlesion of the right axilla and the dorsal subcutaneous mass revealed the presence of\nlarge atypical round cells. The cells had small-to-moderate amounts of basophilic\ncytoplasm and irregular nuclear membranes, and were occasionally binucleated . The nucleus had one\nor several distinct nuclei with finely diffused chromatin. Azurophilic granules were\nnot observed in the cytoplasm. The cells were thought to be lymphoid cells and the\npresumed diagnosis was lymphoma. A PCR-based clonality analysis for TCR-gamma (TCRγ)\nand immunoglobulin heavy chain (IgH) genes with DNA extracted from the subcutaneous\nlesions revealed no clonal rearrangement of both genes. All PCR products were\nassessed by heteroduplex analysis as previously described.\nThe cat was treated with prednisolone at a dose of 1.0–1.5 mg/kg/day and\nL-asparaginase at a dose of 400 U/kg, four times in total at various intervals. The\ntreatment led to a transient improvement of oedema and regression of the dorsal\nmass. However, the cat died after 78 days of initial treatment owing to loss of\nappetite, severe anaemia (PCV 8.9%) and liver dysfunction. A complete necropsy was\nperformed on the day. At necropsy, the cat presented with severe jaundice and an\noedematous subcutaneous mass in the right chest. Moderate hepatomegaly,\nsplenomegaly, lymphadenopathy of the mediastinal (1.2 × 0.8 cm) and left axilla (0.8\n× 0.8 cm), and haemorrhage in multiple organs were also observed .\nThe subcutaneous tumour tissue, visceral organs and brain were fixed in 10%\nneutral-buffered formalin, embedded in paraffin, sectioned at 4 μm thickness, and\nstained with haematoxylin and eosin. Immunohistochemistry was performed using\nprimary antibodies listed in . The following normal tissues without lesions were used as\npositive controls: normal thymus, spleen, lymph node, bone marrow, liver, intestine\nand brain. A horseradish peroxidase (HRP)-labelled polymer system (EnVision+ System;\nDako) was used as a secondary antibody. Labelled complexes were visualised with the\n3,3′-diaminobenzidine chromogen, and the sections were counterstained with\nhaematoxylin. Double immunofluorescence was performed on normal thymus, spleen and\nliver tissues of cats to detect CD56+ and CD3− cells. Alexa\n488-conjugated donkey anti-mouse IgG (1:200; Invitrogen) and Alexa 594-conjugated\ndonkey anti-rabbit IgG (1:200; Invitrogen) were used as secondary antibodies and\ncounterstained with 4′,6-diamidino-2-phenylindole (Vector Laboratories). Western\nblotting analysis was performed to confirm the reactivity with an appropriate\nmolecular weight antigen of anti-CD56 and anti-CD57 antibodies using feline and\ncanine brain tissues. The membranes were incubated with each antibody (1:1000) at 4°C overnight,\nand then incubated with HRP-conjugated sheep anti-mouse IgG (1:5000) (Bethyl\nLaboratories, Montgomery, TX) at room temperature for 1 h.\nHistologically, extensive necrosis, oedema and focal infiltration of large atypical\nround cells were observed in the subcutaneous mass . The tumour cells had scarce\ncytoplasm, an irregular nuclear membrane, coarse nuclear chromatin and a distinct\nnucleolus. The cells were occasionally binucleated, and anisocytosis and\nanisokaryosis were moderate. The nucleus of the tumour cell was approximately three\ntimes the diameter of a red blood cell. The tumour cells were also observed in the\nliver, spleen, bone marrow and lymph nodes of the mediastinal and left axilla. In\nthe liver, the tumour cells were diffusely infiltrated . Multifocal haemorrhage and bile\nplugs in the capillary bile duct were also observed. In the spleen, neoplastic cells\nwere diffusely infiltrated and replaced the red pulp, with multifocal haemorrhage.\nThe bone marrow was hypoplastic and the tumour cells were diffusely infiltrated,\ncomprising approximately 10% of nucleated cells . The tumour cells diffusely\ninfiltrated the sinus with haemorrhage in the mediastinal and left axilla lymph\nnodes. The number of mitotic figures was two per field (× 400 magnification).\nImmunohistochemically, in normal cat tissues, CD3 labelling was detected in the cell\nmembrane and cytoplasm of lymphocytes . CD56+ lymphoid cells were\ndetected in the thymus , spleen and liver. CD57+ lymphoid cells were detected in\nthe thymus ,\nintestinal mucosa, spleen and lymph node. In the brain, neuropil was positive for\nCD56 and CD57 . CD34+ lymphoid cells were\ndetected in the thymus , spleen and lymph node. CD10+\nlymphoid cells were detected in the thymus, spleen, lymph node and bone marrow. Monocytes, macrophages and\ninterstitial dendritic cells were positive for CD204 . Myeloid cells in bone marrow , neutrophils, monocytes and macrophages\nwere positive for myeloperoxidase. In the present cat, the cell membrane of tumour\ncells was strongly positive for CD56 but negative for a\nT-cell-associated marker (CD3) , B-cell-associated markers (CD20, CD79a, Pax5 and BLA36),\nmacrophage/histiocyte markers (Iba-1 and CD204), a major histocompatibility complex\nclass II antigen presenting cell marker (HLA-DR), mast cell-associated marker\n(CD117), a myeloid cell-associated marker (myeloperoxidase), haematopoietic\nprogenitor-associated marker (CD34), lymphocyte precursor cell-associated markers\n(CD10), mature NK cell marker (CD57) and cytotoxic cell markers (granzyme B and\nperforin).\nIn double immunofluorescence, CD56+ CD3− lymphoid cells were\ndetected in the thymus , spleen and liver. By Western blotting\nanalysis, in both brain samples of cat and dog, anti-CD56 antibody labelled bands of\n100–120 kDa, 140 kDa and 180 kDa, and anti-CD57 antibody labelled a band of 110 kDa,\nconsistent with the molecular weights of CD56 and CD57 .", + "fulltext_subclaims": [ + "The cat was a 7-year-old neutered male, mixed-breed.", + "The cat had subcutaneous oedema and erythema of the right axilla extending to the abdomen.", + "The cat had swelling of the right forelimb.", + "Clinical examinations revealed a subcutaneous soft mass (3.0 × 2.0 cm) on the back.", + "A complete blood count revealed anaemia (packed cell volume [PCV] 26%).", + "A complete blood count revealed thrombocytopenia (96,000 platelets/μl).", + "A blood smear examination revealed a small number of large atypical round cells.", + "The cells had small-to-moderate amounts of basophilic cytoplasm.", + "The cells had large nuclei with finely diffused chromatin and several nucleoli.", + "The cells rarely contained fine azurophilic granules in the cytoplasm.", + "Examinations for feline immunodeficiency virus antibodies and feline leukaemia virus antigens were not performed.", + "Thoracic and abdominal radiography showed no significant findings.", + "Abdominal ultrasonography showed no significant findings.", + "Cytological analysis with fine-needle aspiration from the subcutaneous lesion of the right axilla revealed the presence of large atypical round cells.", + "Cytological analysis with fine-needle aspiration from the dorsal subcutaneous mass revealed the presence of large atypical round cells.", + "The cells had small-to-moderate amounts of basophilic cytoplasm.", + "The cells had irregular nuclear membranes.", + "The cells were occasionally binucleated.", + "The nucleus had one or several distinct nuclei with finely diffused chromatin.", + "Azurophilic granules were not observed in the cytoplasm.", + "The cells were thought to be lymphoid cells.", + "The presumed diagnosis was lymphoma.", + "A PCR-based clonality analysis for TCR-gamma (TCRγ) and immunoglobulin heavy chain (IgH) genes revealed no clonal rearrangement of both genes.", + "The cat was treated with prednisolone at a dose of 1.0–1.5 mg/kg/day.", + "The cat was treated with L-asparaginase at a dose of 400 U/kg, four times in total at various intervals.", + "The treatment led to a transient improvement of oedema.", + "The treatment led to regression of the dorsal mass.", + "The cat died after 78 days of initial treatment.", + "The cat died owing to loss of appetite.", + "The cat died owing to severe anaemia (PCV 8.9%).", + "The cat died owing to liver dysfunction.", + "A complete necropsy was performed on the day of death.", + "At necropsy, the cat presented with severe jaundice.", + "At necropsy, an oedematous subcutaneous mass in the right chest was observed.", + "Moderate hepatomegaly was observed.", + "Moderate splenomegaly was observed.", + "Lymphadenopathy of the mediastinal (1.2 × 0.8 cm) and left axilla (0.8 × 0.8 cm) was observed.", + "Haemorrhage in multiple organs was observed.", + "The subcutaneous tumour tissue, visceral organs and brain were fixed in 10% neutral-buffered formalin.", + "The subcutaneous tumour tissue, visceral organs and brain were embedded in paraffin.", + "The subcutaneous tumour tissue, visceral organs and brain were sectioned at 4 μm thickness.", + "The subcutaneous tumour tissue, visceral organs and brain were stained with haematoxylin and eosin.", + "Immunohistochemistry was performed using primary antibodies listed.", + "A horseradish peroxidase (HRP)-labelled polymer system (EnVision+ System; Dako) was used as a secondary antibody.", + "Labelled complexes were visualised with the 3,3′-diaminobenzidine chromogen.", + "The sections were counterstained with haematoxylin.", + "Double immunofluorescence was performed on normal thymus, spleen and liver tissues of cats.", + "Alexa 488-conjugated donkey anti-mouse IgG (1:200; Invitrogen) was used as a secondary antibody.", + "Alexa 594-conjugated donkey anti-rabbit IgG (1:200; Invitrogen) was used as a secondary antibody.", + "The sections were counterstained with 4′,6-diamidino-2-phenylindole.", + "Western blotting analysis was performed to confirm the reactivity with an appropriate molecular weight antigen of anti-CD56 and anti-CD57 antibodies.", + "The membranes were incubated with each antibody (1:1000) at 4°C overnight.", + "The membranes were incubated with HRP-conjugated sheep anti-mouse IgG (1:5000) at room temperature for 1 h.", + "Histologically, extensive necrosis, oedema and focal infiltration of large atypical round cells were observed in the subcutaneous mass.", + "The tumour cells had scarce cytoplasm.", + "The tumour cells had an irregular nuclear membrane.", + "The tumour cells had coarse nuclear chromatin.", + "The tumour cells had a distinct nucleolus.", + "The tumour cells were occasionally binucleated.", + "Anisocytosis and anisokaryosis were moderate.", + "The nucleus of the tumour cell was approximately three times the diameter of a red blood cell.", + "The tumour cells were observed in the liver.", + "The tumour cells were observed in the spleen.", + "The tumour cells were observed in the bone marrow.", + "The tumour cells were observed in the lymph nodes of the mediastinal and left axilla.", + "In the liver, the tumour cells were diffusely infiltrated.", + "Multifocal haemorrhage and bile plugs in the capillary bile duct were observed in the liver.", + "In the spleen, neoplastic cells were diffusely infiltrated and replaced the red pulp.", + "Multifocal haemorrhage was observed in the spleen.", + "The bone marrow was hypoplastic.", + "The tumour cells were diffusely infiltrated in the bone marrow, comprising approximately 10% of nucleated cells.", + "The tumour cells diffusely infiltrated the sinus with haemorrhage in the mediastinal and left axilla lymph nodes.", + "The number of mitotic figures was two per field (× 400 magnification).", + "In normal cat tissues, CD3 labelling was detected in the cell membrane and cytoplasm of lymphocytes.", + "CD56+ lymphoid cells were detected in the thymus.", + "CD56+ lymphoid cells were detected in the spleen.", + "CD56+ lymphoid cells were detected in the liver.", + "CD57+ lymphoid cells were detected in the thymus.", + "CD57+ lymphoid cells were detected in the intestinal mucosa.", + "CD57+ lymphoid cells were detected in the spleen.", + "CD57+ lymphoid cells were detected in the lymph node.", + "In the brain, neuropil was positive for CD56.", + "In the brain, neuropil was positive for CD57.", + "CD34+ lymphoid cells were detected in the thymus.", + "CD34+ lymphoid cells were detected in the spleen.", + "CD34+ lymphoid cells were detected in the lymph node.", + "CD10+ lymphoid cells were detected in the thymus.", + "CD10+ lymphoid cells were detected in the spleen.", + "CD10+ lymphoid cells were detected in the lymph node.", + "CD10+ lymphoid cells were detected in the bone marrow.", + "Monocytes, macrophages and interstitial dendritic cells were positive for CD204.", + "Myeloid cells in bone marrow, neutrophils, monocytes and macrophages were positive for myeloperoxidase.", + "In the present cat, the cell membrane of tumour cells was strongly positive for CD56.", + "In the present cat, the tumour cells were negative for a T-cell-associated marker (CD3).", + "In the present cat, the tumour cells were negative for B-cell-associated markers (CD20, CD79a, Pax5 and BLA36).", + "In the present cat, the tumour cells were negative for macrophage/histiocyte markers (Iba-1 and CD204).", + "In the present cat, the tumour cells were negative for a major histocompatibility complex class II antigen presenting cell marker (HLA-DR).", + "In the present cat, the tumour cells were negative for mast cell-associated marker (CD117).", + "In the present cat, the tumour cells were negative for a myeloid cell-associated marker (myeloperoxidase).", + "In the present cat, the tumour cells were negative for haematopoietic progenitor-associated marker (CD34).", + "In the present cat, the tumour cells were negative for lymphocyte precursor cell-associated markers (CD10).", + "In the present cat, the tumour cells were negative for mature NK cell marker (CD57).", + "In the present cat, the tumour cells were negative for cytotoxic cell markers (granzyme B and perforin).", + "In double immunofluorescence, CD56+ CD3− lymphoid cells were detected in the thymus.", + "In double immunofluorescence, CD56+ CD3− lymphoid cells were detected in the spleen.", + "In double immunofluorescence, CD56+ CD3− lymphoid cells were detected in the liver.", + "By Western blotting analysis, in both brain samples of cat and dog, anti-CD56 antibody labelled bands of 100–120 kDa, 140 kDa and 180 kDa.", + "By Western blotting analysis, in both brain samples of cat and dog, anti-CD57 antibody labelled a band of 110 kDa." + ], + "summary": "A 7-year-old mixed-breed cat presented with subcutaneous oedema and erythema extending from the right axilla to the abdomen. Fine-needle aspiration of the subcutaneous lesion revealed large, atypical, round cells. A clonality analysis for the T-cell receptor-gamma and immunoglobulin heavy chain genes showed no clonal rearrangement. The presumed diagnosis was lymphoma and the cat was treated with prednisolone and L-asparaginase but died 78 days after initial treatment. At necropsy, an oedematous subcutaneous mass in the right axilla, hepatomegaly, splenomegaly and lymphadenopathy of the mediastinum and left axilla were observed. Histopathological examination revealed diffuse infiltration of large atypical round cells in the subcutaneous mass, liver, spleen, lymph nodes and bone marrow. Immunohistochemically, the tumour cells were strongly positive for CD56, and negative for CD3, CD20, CD79a, CD57, granzyme B and perforin. Based on these findings, the cat was diagnosed with blastic natural killer (NK) cell lymphoma/leukaemia.", + "summary_subclaims": [ + "The cat was a 7-year-old mixed-breed.", + "The cat presented with subcutaneous oedema and erythema extending from the right axilla to the abdomen.", + "Fine-needle aspiration of the subcutaneous lesion revealed large, atypical, round cells.", + "A clonality analysis for the T-cell receptor-gamma and immunoglobulin heavy chain genes showed no clonal rearrangement.", + "The presumed diagnosis was lymphoma.", + "The cat was treated with prednisolone and L-asparaginase.", + "The cat died 78 days after initial treatment.", + "At necropsy, an oedematous subcutaneous mass in the right axilla was observed.", + "Hepatomegaly was observed at necropsy.", + "Splenomegaly was observed at necropsy.", + "Lymphadenopathy of the mediastinum and left axilla was observed at necropsy.", + "Histopathological examination revealed diffuse infiltration of large atypical round cells in the subcutaneous mass.", + "Histopathological examination revealed diffuse infiltration of large atypical round cells in the liver.", + "Histopathological examination revealed diffuse infiltration of large atypical round cells in the spleen.", + "Histopathological examination revealed diffuse infiltration of large atypical round cells in the lymph nodes.", + "Histopathological examination revealed diffuse infiltration of large atypical round cells in the bone marrow.", + "The tumour cells were strongly positive for CD56.", + "The tumour cells were negative for CD3.", + "The tumour cells were negative for CD20.", + "The tumour cells were negative for CD79a.", + "The tumour cells were negative for CD57.", + "The tumour cells were negative for granzyme B.", + "The tumour cells were negative for perforin.", + "Based on these findings, the cat was diagnosed with blastic natural killer (NK) cell lymphoma/leukaemia." + ] + }, + { + "id": "multiclinsum_test_2659_en.txt", + "fulltext": "A 19-year-old Asian man presented at our hospital’s emergency department with reduced consciousness and seizures. He had a Glasgow Coma Score of 11 to 12, and was agitated and confused during the first 2 days. He experienced two to three general tonic–clonic seizures of approximately 15 to 30 seconds’ duration each within hours of each other, and he was awake between seizures. His seizures started with stiffness in his whole body and his eyes were rolled back during seizures. His Glasgow Coma Score was reduced to 8 on the third day and he was intubated and sent to our intensive care unit (ICU). He had a continuous high fever, ranging from 39 °C to 40 °C, headache, confusion, and vomitus. His fever began to decline to 38.0 °C several hours before hospital admission. He and his family had no history of epilepsy, weakness and paralysis of limbs, drug abuse, tobacco smoking, or alcoholism.\nA physical examination showed nuchal rigidity and tetraparesis with accentuated tendon reflexes. Cranial nerves and ophthalmoscopy examinations were normal. An immediate electroencephalography (EEG) showed periodic epileptogenic waves at his right temporal area and general bitemporal cortical dysfunction. These findings suggested an acute structural lesion at his right temporal area or an epileptic state, and a possible viral cause.\nEvaluation of hematology showed dynamic changes of leukocytes and C-reactive protein (CRP) level during his illness. His white blood cell count and CRP reached peak level at day 70 when ventilator-associated pneumonia and pleural effusion occurred . Coagulation parameters and a liver function test showed normal values. A cerebral spinal fluid examination showed a white blood cell count of 16/mm3, polymorphonucleocytes (PMN) of 13/mm3, mononuclear (MN) cells of 87/mm3, glucose level of 42/dL, and an increased protein level of 216 mg/dL, which suggested a nonspecific viral infection. Gram, India ink, and Ziehl–Neelsen stains were negative. Computed tomography (CT) scans were performed twice, on 2 September 2014 (day 6) and 22 September 2014 (day 26). The first CT scan result was normal but the second showed a smeared bright area in ependymal cells at the lower area of the third ventricle . Serology tests were performed against herpes simplex virus and varicella zoster virus. These tests showed negative results for immunoglobulin (Ig) M and IgG. The possibility of human immunodeficiency virus was eliminated by a CD4 count of 750 cells/mm3. Different results were found in the serology test for CMV. First, a serology test showed negative results for IgM and IgG anti-CMV. A second serology test showed a borderline positive result for IgG anti-CMV with a titer of 0.9 U/mL. The last two serology tests showed positive results for IgG anti-CMV with titers of 5.0 U/mL and 3.8 U/mL. The four-fold increase in IgG anti-CMV from 0.9 U/mL to 5.0 U/mL within 8 days is an important finding . Serial images of his thorax and clinical pulmonary infection score assessment accompanied by blood and sputum cultures were regularly performed, and confirmed a diagnosis of pneumonia in our patient. Based on his medical history, physical examinations, laboratory results, and supporting examinations, the diagnosis of CMV meningoencephalitis was made.\nHis clinical condition deteriorated even though therapy with cefixime, acyclovir, dexamethasone, and phenytoin was administered intravenously. His cranial reflexes started to become reduced after 1 week in our ICU. On day 19, spontaneous respiration disappeared, cranial reflexes became negative, and BSD was suspected because he had no response to all brain stem tests, including an apnea test . A vasopressor was used to maintain his hemodynamic stability. His family insisted life support should be continued indefinitely. This condition lasted for almost 2 weeks with no improvement and brain stem tests were regularly performed with negative results.\nOn day 30, he provided a vague response to painful stimuli at his supraorbital nerve. On day 35, he opened his eyes. Respiration started to appear on day 37, followed by gradual movement of his fingers. His consciousness improved from day 37, and he became fully conscious on day 50. Ganciclovir replaced acyclovir based on a four-fold increase of IgG anti-CMV serology in a test result on day 27. Other therapies on days 19 to 30 included antibiotics based on culture, corticosteroids, antibiotics, antipyretics, and antifungal agents. He also had pleural effusion and a water-sealed device was installed on day 75. A higher positive end-expiratory pressure (PEEP) on the ventilator was applied to maintain oxygenation and prevent alveoli collapse. After day 80, his respiration improved. On day 85, he was weaned from the ventilator and was able to breathe without it. He started to move his arms but his legs were still paralyzed. On day 90, he was moved from our ICU to in-patient care where he stayed for 10 days until he went home.", + "fulltext_subclaims": [ + "The patient was a 19-year-old Asian man.", + "He presented with reduced consciousness and seizures.", + "His Glasgow Coma Score was 11 to 12.", + "He was agitated and confused during the first 2 days.", + "He experienced two to three general tonic–clonic seizures of approximately 15 to 30 seconds’ duration each within hours of each other.", + "He was awake between seizures.", + "His seizures started with stiffness in his whole body.", + "His eyes were rolled back during seizures.", + "His Glasgow Coma Score was reduced to 8 on the third day.", + "He was intubated and sent to the ICU.", + "He had a continuous high fever, ranging from 39 °C to 40 °C.", + "He had headache, confusion, and vomitus.", + "His fever began to decline to 38.0 °C several hours before hospital admission.", + "He and his family had no history of epilepsy.", + "He and his family had no history of drug abuse.", + "He and his family had no history of tobacco smoking.", + "He and his family had no history of alcoholism.", + "A physical examination showed nuchal rigidity.", + "A physical examination showed tetraparesis with accentuated tendon reflexes.", + "Cranial nerves and ophthalmoscopy examinations were normal.", + "An immediate EEG showed periodic epileptogenic waves at his right temporal area.", + "An immediate EEG showed general bitemporal cortical dysfunction.", + "These findings suggested an acute structural lesion at his right temporal area.", + "These findings suggested an epileptic state.", + "These findings suggested a possible viral cause.", + "His white blood cell count and CRP reached peak level at day 70.", + "His white blood cell count and CRP reached peak level when ventilator-associated pneumonia and pleural effusion occurred.", + "Coagulation parameters and a liver function test showed normal values.", + "A cerebral spinal fluid examination showed a white blood cell count of 16/mm3.", + "A cerebral spinal fluid examination showed polymorphonucleocytes of 13/mm3.", + "A cerebral spinal fluid examination showed mononuclear cells of 87/mm3.", + "A cerebral spinal fluid examination showed glucose level of 42/dL.", + "A cerebral spinal fluid examination showed an increased protein level of 216 mg/dL.", + "Gram, India ink, and Ziehl–Neelsen stains were negative.", + "CT scans were performed twice, on 2 September 2014 (day 6) and 22 September 2014 (day 26).", + "The first CT scan result was normal.", + "The second CT scan showed a smeared bright area in ependymal cells at the lower area of the third ventricle.", + "Serology tests were performed against herpes simplex virus and varicella zoster virus.", + "These tests showed negative results for immunoglobulin M and IgG.", + "The possibility of human immunodeficiency virus was eliminated by a CD4 count of 750 cells/mm3.", + "A first serology test showed negative results for IgM and IgG anti-CMV.", + "A second serology test showed a borderline positive result for IgG anti-CMV with a titer of 0.9 U/mL.", + "The last two serology tests showed positive results for IgG anti-CMV with titers of 5.0 U/mL and 3.8 U/mL.", + "The four-fold increase in IgG anti-CMV from 0.9 U/mL to 5.0 U/mL within 8 days is an important finding.", + "Serial images of his thorax and clinical pulmonary infection score assessment accompanied by blood and sputum cultures were regularly performed.", + "These confirmed a diagnosis of pneumonia in our patient.", + "The diagnosis of CMV meningoencephalitis was made.", + "His clinical condition deteriorated even though therapy with cefixime, acyclovir, dexamethasone, and phenytoin was administered intravenously.", + "His cranial reflexes started to become reduced after 1 week in the ICU.", + "On day 19, spontaneous respiration disappeared.", + "On day 19, cranial reflexes became negative.", + "BSD was suspected because he had no response to all brain stem tests, including an apnea test.", + "A vasopressor was used to maintain his hemodynamic stability.", + "His family insisted life support should be continued indefinitely.", + "This condition lasted for almost 2 weeks with no improvement.", + "Brain stem tests were regularly performed with negative results.", + "On day 30, he provided a vague response to painful stimuli at his supraorbital nerve.", + "On day 35, he opened his eyes.", + "Respiration started to appear on day 37.", + "Gradual movement of his fingers followed.", + "His consciousness improved from day 37.", + "He became fully conscious on day 50.", + "Ganciclovir replaced acyclovir based on a four-fold increase of IgG anti-CMV serology in a test result on day 27.", + "Other therapies on days 19 to 30 included antibiotics based on culture.", + "Other therapies on days 19 to 30 included corticosteroids.", + "Other therapies on days 19 to 30 included antibiotics.", + "Other therapies on days 19 to 30 included antipyretics.", + "Other therapies on days 19 to 30 included antifungal agents.", + "He also had pleural effusion.", + "A water-sealed device was installed on day 75.", + "A higher positive end-expiratory pressure on the ventilator was applied to maintain oxygenation and prevent alveoli collapse.", + "After day 80, his respiration improved.", + "On day 85, he was weaned from the ventilator and was able to breathe without it.", + "He started to move his arms.", + "His legs were still paralyzed.", + "On day 90, he was moved from the ICU to in-patient care.", + "He stayed in in-patient care for 10 days.", + "He went home after 10 days in in-patient care." + ], + "summary": "A 19-year-old Asian man presented at our hospital's emergency department with reduced consciousness and seizures following high fever, headache, confusion, and vomitus within a week before arrival. He was intubated and sent to our intensive care unit. He had nuchal rigidity and tetraparesis with accentuated tendon reflexes. Electroencephalography findings suggested an acute structural lesion at his right temporal area or an epileptic state. A cerebral spinal fluid examination suggested viral infection. A computed tomography scan was normal at the early stage of disease. Immunoglobulin M, immunoglobulin G anti-herpes simplex virus, and immunoglobulin M anti-cytomegalovirus were negative. However, immunoglobulin G anti-cytomegalovirus was positive, which supported a diagnosis of cytomegalovirus meningoencephalitis. His clinical condition deteriorated, spontaneous respiration disappeared, cranial reflexes became negative, and brain stem death was suspected. Therapy included antivirals, corticosteroids, antibiotics, anticonvulsant, antipyretics, antifungal agents, and a vasopressor to maintain hemodynamic stability. After 1 month, he showed a vague response to painful stimuli at his supraorbital nerve and respiration started to appear the following week. After pneumonia and pleural effusion were resolved, he was weaned from the ventilator and moved from the intensive care unit on day 90.", + "summary_subclaims": [ + "The patient was a 19-year-old Asian man.", + "He presented with reduced consciousness and seizures.", + "He had high fever, headache, confusion, and vomitus within a week before arrival.", + "He was intubated and sent to the intensive care unit.", + "He had nuchal rigidity and tetraparesis.", + "Electroencephalography findings suggested an acute structural lesion at his right temporal area or an epileptic state.", + "Cerebral spinal fluid examination suggested viral infection.", + "Computed tomography scan was normal at the early stage of disease.", + "Immunoglobulin M, immunoglobulin G anti-herpes simplex virus, and immunoglobulin M anti-cytomegalovirus were negative.", + "Immunoglobulin G anti-cytomegalovirus was positive.", + "The diagnosis was cytomegalovirus meningoencephalitis.", + "His clinical condition deteriorated.", + "Spontaneous respiration disappeared.", + "Cranial reflexes became negative.", + "Brain stem death was suspected.", + "Therapy included antivirals, corticosteroids, antibiotics, anticonvulsant, antipyretics, antifungal agents, and a vasopressor.", + "After 1 month, he showed a vague response to painful stimuli at his supraorbital nerve.", + "Respiration started to appear the following week.", + "After pneumonia and pleural effusion were resolved, he was weaned from the ventilator.", + "He was moved from the intensive care unit on day 90." + ] + }, + { + "id": "multiclinsum_test_1208_en.txt", + "fulltext": "A 62-year-old male patient, known to have primary hypertension and type 2 diabetes mellitus, presented with a brutal onset of loss of consciousness, muscle pain in the upper limbs accompanied by increased movement impairment. In the emergency department a rapid antigen test for SARS-CoV-2 was performed which was found to be positive. The patient had not been vaccinated against SARS-CoV-2. Clinical assessment showed no significant changes: BMI = 32.41 kg/m2; BP = 140/85 mmHg; HR = 95 bpm with normal rhythmic heart beats; SpO2 = 97% (room air); no fever; no pulmonary rales. Initial lab values showed increased inflammation (CRP = 59.5 mg/L), increased values of cardiac enzymes (hsTnI = 8248 ng/L) and possible sepsis (procalcitonin = 68.03 ng/L). The ECG showed no acute ischemic changes. A CT angiography of the pulmonary arteries was performed with the following result: cardiomegaly with contrast refluxed into the hepatic veins, pulmonary arteries with dimensions at the upper limits for normal values, homogeneously opacified, without acute pulmonary lesions. Considering these data, the patient underwent a standard cardiac ultrasound examination revealing concentric hypertrophy of the left ventricle, severe hypokinesia of the interventricular septum, of the anterior and antero-lateral wall, and hypokinesia of the inferior and posterior wall with an estimated ejection fraction of the left ventricle to be approximately 34% ; global strain was −7.7% ; systolic pressure in the pulmonary artery was 50 mmHg. Approximately 2 h after admission, the dynamics of myocardial necrosis was entertained, enzymes registered an increasing trend (hsTnI = 9755 ng/mL; CK = 51432 U/L; CK-MB = 189 U/L). As a result of the accumulated data, an acute coronary syndrome without ST segment elevation was suspected. The patient underwent coronary angiography using the right radial artery approach, in which the coronary arteries revealed no significant angiographic lesions. and show the dynamics of hsTnI, CK and CK-MB.\nConsidering possible sepsis of unknown origin, antibiotics were initiated with ceftriaxone. A sputum culture was positive for Klebsiella pneumoniae spp pneumoniae, and ceftriaxone was continued according to the antibiogram. Blood cultures taken consecutively were negative. During day 3, a thorax CT scan was performed, which showed fine areas of ground glass arranged peripherally and classified as minimal lung damage and small bilateral areas of pleurisy with a maximum thickness of 10 mm in the right costo-phrenic recess. Methylprednisolone was given, with progressive decreasing of the dose over time. Standard medication for heart failure with a reduced ejection fraction was given . The serum level of interleukin-6 was 2.32 pg/mL, which was considered to be normal . The evolution was favorable: cardiac enzymes, inflammatory markers and procalcitonin continued to decrease and eventually were normalized. Kidney function was preserved. The muscle pain in the upper limbs subsided, with full recovery of functionality. Patient tested negative for SARS-CoV-2 infection on day 14 (RT-PCR).\nCorroborating the clinical, paraclinical and biological context, the panel of IgG antibodies specific for myositis was observed, with a positive result for anti-PL-7 antibodies. We consider that the episode of myocarditis and extensive myositis was clinically triggered by the SARS-CoV-2 infection, possibly linked to his autoimmune status, which was unknown to the patient.", + "fulltext_subclaims": [ + "The patient is a 62-year-old male.", + "The patient has primary hypertension.", + "The patient has type 2 diabetes mellitus.", + "The patient presented with a brutal onset of loss of consciousness.", + "The patient had muscle pain in the upper limbs.", + "The patient had increased movement impairment.", + "A rapid antigen test for SARS-CoV-2 was performed.", + "The rapid antigen test for SARS-CoV-2 was positive.", + "The patient had not been vaccinated against SARS-CoV-2.", + "The ECG showed no acute ischemic changes.", + "The CT angiography of the pulmonary arteries showed cardiomegaly with contrast refluxed into the hepatic veins.", + "The CT angiography showed pulmonary arteries with dimensions at the upper limits for normal values.", + "The CT angiography showed no acute pulmonary lesions.", + "The cardiac ultrasound showed concentric hypertrophy of the left ventricle.", + "The cardiac ultrasound showed severe hypokinesia of the interventricular septum.", + "The cardiac ultrasound showed hypokinesia of the inferior and posterior wall.", + "The estimated ejection fraction of the left ventricle was approximately 34%.", + "The systolic pressure in the pulmonary artery was 50 mmHg.", + "hsTnI increased from 8248 ng/L to 9755 ng/mL within 2 hours.", + "CK increased to 51432 U/L.", + "CK-MB increased to 189 U/L.", + "An acute coronary syndrome without ST segment elevation was suspected.", + "Coronary angiography revealed no significant angiographic lesions.", + "A sputum culture was positive for Klebsiella pneumoniae spp pneumoniae.", + "Ceftriaxone was continued according to the antibiogram.", + "Blood cultures were negative.", + "A thorax CT scan showed fine areas of ground glass arranged peripherally.", + "The thorax CT scan showed small bilateral areas of pleurisy.", + "Methylprednisolone was given with progressive decreasing of the dose over time.", + "Standard medication for heart failure with a reduced ejection fraction was given.", + "The serum level of interleukin-6 was 2.32 pg/mL.", + "The serum level of interleukin-6 was considered to be normal.", + "The evolution was favorable.", + "The muscle pain in the upper limbs subsided.", + "The patient tested negative for SARS-CoV-2 infection on day 14.", + "The panel of IgG antibodies specific for myositis showed a positive result for anti-PL-7 antibodies.", + "The episode of myocarditis and extensive myositis was considered to be clinically triggered by the SARS-CoV-2 infection." + ], + "summary": "We present a case of COVID-19 infection in a non-vaccinated male patient, who presented to our clinic with no symptoms of respiratory involvement but with severe muscle aches. Cardiac markers and procalcitonin levels were high, and concentric hypertrophy of the left ventricle, severe hypokinesia of the interventricular septum and of the antero-lateral wall, hypokinesia of the inferior and posterior wall and an ejection fraction of the left ventricle being around 34% was noted. Coronary angiography showed no lesions. Corticosteroids and antibiotics were instituted which showed improvement. A possible link to an autoimmune process was suspected, due to the presence of anti-PL-7 antibody, suggesting an antisynthetase syndrome.", + "summary_subclaims": [ + "The patient was non-vaccinated.", + "The patient had no symptoms of respiratory involvement.", + "The patient had severe muscle aches.", + "Cardiac markers were high.", + "Procalcitonin levels were high.", + "Concentric hypertrophy of the left ventricle was noted.", + "Severe hypokinesia of the interventricular septum and of the antero-lateral wall was noted.", + "Hypokinesia of the inferior and posterior wall was noted.", + "The ejection fraction of the left ventricle was around 34%.", + "Coronary angiography showed no lesions.", + "Corticosteroids were instituted.", + "Antibiotics were instituted.", + "Improvement was noted.", + "A possible link to an autoimmune process was suspected.", + "Anti-PL-7 antibody was present.", + "An antisynthetase syndrome was suggested." + ] + }, + { + "id": "multiclinsum_test_636_en.txt", + "fulltext": "A 37-year-old female complained of dizziness. She had started experiencing dizziness 3 years ago, following the infertility treatment that she had received. She experienced dizziness following an injection of human menopausal gonadotropin administered by a gynecologist and a visit psychologist. In addition to her dizziness, she also suffered from insomnia, tinnitus, and anxiety. Therefore, she was referred to a psychologist. However, the treatment of tranquilizers such as benzodiazepines and antidepressants such as serotonin selective re-uptake inhibitors (SSRIs) failed to cure the dizziness and only slightly improved her insomnia. She was therefore referred to our department for further examination and treatment. She expressed her dizziness as an event wherein she experienced frequent paroxysmal earthquakes occurring within seconds. The frequency of such episodes had recently increased to once every 5 minutes. She felt stable while doing her household tasks and she had never fallen. Audio-vestibular examination, including pure tone audiometry, posturography, and head MRI, revealed no abnormal findings. Her blood examination findings were normal; there was no spontaneous or evoked nystagmus. However, the peripheral part of her hand and foot often became pale due to poor peripheral circulation, an observation similar to Raynaud's phenomenon. She also experienced chronic headache and insomnia, whereby she woke up every 2 hours during the night. The results of the psychological examination were as follows: Self-rating Depression Scale (SDS), 47; Japanese version of the Cornell Medical Index (CMI), III; Manifest Anxiety Scale (MAS), 27; and Maudsley Obsessional-Compulsive Inventory (MOCI ), 9. MAS indicated a high level of anxiety. We deduced that her dizziness was due to psychosomatic reasons together with poor peripheral circulation. We prescribed setiptiline maleate and an additional herbal medicine, which is known to improve peripheral circulation. Within 2 weeks her symptoms slightly improved and the level of dizziness reduced to less than one third. However she didn't want to keep taking these drugs, since she want to have a baby. No abnormality was reported in any physical examination, including posturography. We diagnosed the patient's condition as phobic postural vertigo. Although she often experienced palpitations, cardiological examination reported no abnormal findings. These results indicate the existence of autonomic dysfunction due to psychological stress, including anxiety. We decided to focus on treating the patient's anxiety and the supposed autonomic dysfunction. After 1 month following the patient's first visit, AT was introduced by a clinical psychologist so as to ease her mental stress. The psychotherapy consisted of one 45-minute session every 3 weeks. The first session began with a brief introduction to the general background information about the cognitive approach, after which the patient was instructed how to perform AT. Thereafter, the patient performed AT in a relaxed sitting position on a chair for 10 minutes 3 times a day. No self-monitoring was advised. The patient was instructed to carry out slow and deep abdominal breathing at the beginning of AT and regular breathing during AT. She diligently and regularly continued this AT routine 3 times a day at her home, according to a written timetable. She learned all 6 standard formulas of AT in 6 psychotherapy sessions. Astonishingly, after the introduction of AT, her mood stabilized and her dizziness, insomnia, and headache disappeared in a few weeks. The dose of clotiazepam was reduced to 5 mg once a day. No additional treatment was administered. At 6- and 9-month follow-ups, the patient was free from dizziness, insomnia, and headache.", + "fulltext_subclaims": [ + "The patient is a 37-year-old female.", + "She complained of dizziness.", + "She had started experiencing dizziness 3 years ago.", + "The dizziness began following the infertility treatment she had received.", + "She experienced dizziness following an injection of human menopausal gonadotropin.", + "The injection was administered by a gynecologist and a visit psychologist.", + "She also suffered from insomnia.", + "She also suffered from tinnitus.", + "She also suffered from anxiety.", + "She was referred to a psychologist.", + "Treatment with tranquilizers such as benzodiazepines failed to cure the dizziness.", + "Treatment with antidepressants such as serotonin selective re-uptake inhibitors (SSRIs) failed to cure the dizziness.", + "The treatment only slightly improved her insomnia.", + "She was referred to the department for further examination and treatment.", + "She described her dizziness as frequent paroxysmal earthquakes occurring within seconds.", + "The frequency of the episodes had recently increased to once every 5 minutes.", + "She felt stable while doing household tasks.", + "She had never fallen.", + "Audio-vestibular examination, including pure tone audiometry, posturography, and head MRI, revealed no abnormal findings.", + "Her blood examination findings were normal.", + "There was no spontaneous or evoked nystagmus.", + "The peripheral part of her hand and foot often became pale due to poor peripheral circulation.", + "This observation was similar to Raynaud's phenomenon.", + "She experienced chronic headache.", + "She experienced chronic insomnia.", + "She woke up every 2 hours during the night.", + "The results of the psychological examination were as follows: Self-rating Depression Scale (SDS), 47; Japanese version of the Cornell Medical Index (CMI), III; Manifest Anxiety Scale (MAS), 27; and Maudsley Obsessional-Compulsive Inventory (MOCI), 9.", + "MAS indicated a high level of anxiety.", + "The dizziness was deduced to be due to psychosomatic reasons together with poor peripheral circulation.", + "Setiptiline maleate was prescribed.", + "An additional herbal medicine was prescribed.", + "The herbal medicine is known to improve peripheral circulation.", + "Within 2 weeks, her symptoms slightly improved.", + "The level of dizziness reduced to less than one third.", + "She did not want to keep taking these drugs.", + "She wants to have a baby.", + "No abnormality was reported in any physical examination, including posturography.", + "The patient's condition was diagnosed as phobic postural vertigo.", + "She often experienced palpitations.", + "Cardiological examination reported no abnormal findings.", + "These results indicate the existence of autonomic dysfunction due to psychological stress, including anxiety.", + "The decision was made to focus on treating the patient's anxiety and the supposed autonomic dysfunction.", + "After 1 month following the patient's first visit, AT was introduced by a clinical psychologist.", + "The psychotherapy consisted of one 45-minute session every 3 weeks.", + "The first session began with a brief introduction to the general background information about the cognitive approach.", + "The patient was instructed how to perform AT.", + "The patient performed AT in a relaxed sitting position on a chair for 10 minutes 3 times a day.", + "No self-monitoring was advised.", + "The patient was instructed to carry out slow and deep abdominal breathing at the beginning of AT.", + "The patient was instructed to perform regular breathing during AT.", + "She diligently and regularly continued this AT routine 3 times a day at her home, according to a written timetable.", + "She learned all 6 standard formulas of AT in 6 psychotherapy sessions.", + "After the introduction of AT, her mood stabilized.", + "Her dizziness, insomnia, and headache disappeared in a few weeks.", + "The dose of clotiazepam was reduced to 5 mg once a day.", + "No additional treatment was administered.", + "At 6- and 9-month follow-ups, the patient was free from dizziness, insomnia, and headache." + ], + "summary": "We present a case of a patient who suffered from phobic postural vertigo. A 37-year-old female complained of dizziness. She had started experiencing dizziness almost 3 years She was intractable to many sort of conventional therapy. In the end, her symptom disappeared after introduction of autogenic training.", + "summary_subclaims": [ + "The patient suffered from phobic postural vertigo.", + "The patient was a 37-year-old female.", + "The patient complained of dizziness.", + "She had started experiencing dizziness almost 3 years.", + "She was intractable to many sort of conventional therapy.", + "Her symptom disappeared after introduction of autogenic training." + ] + }, + { + "id": "multiclinsum_test_2895_en.txt", + "fulltext": "A 49-year-old female with a body mass index of 17 kg/m2 presented for pathological fracture of right femoral bone head with metastatic adenocarcinoma and was scheduled to undergo bone tumor resection and artificial bone replacement. She was diagnosed with Osler-Weber-Rendu syndrome at the age of 30 and accompanied with multiple pulmonary arteriovenous malformations (AVMs) and pheochromocytoma. She had a history of brain abscess, takotsubo cardiomyopathy and preoperative coil embolization of the AVMs. She did not have any history of recurrent epistaxis or gastrointestinal bleeding.\nA preoperative physical examination did not reveal any special finding on her body surface. Blood pressure was 105/64 mmHg, with doxazosin at a dose of 3 mg per day, and heart rate was 97 bpm. Peripheral oxygen saturation (SpO2) was 86% in room air, possibly due to the remaining pulmonary AVMs, but the Hugh-Jones classification was class I. Blood tests were remarkable only for hemoglobin level of 11.2 g/dL. Urinary adrenaline, noradrenaline and dopamine levels were 14.2 mcg/day, 965.8 mcg/day and 807.3 mcg/day, respectively. An electrocardiogram (ECG) showed negative T-waves on V3-5 and a transthoracic echocardiogram showed a peripheral left ventricle hypertrophy with an ejection fraction of 67%. Preoperative image examination revealed bilateral pulmonary AVMs , but no AVM in the brain or in the spinal cord, and a pancreas tail tumor, which was considered to be the origin of the metastatic bone tumor.\nPreoperative estimation of the operation duration was 5 h, and estimated intraoperative blood loss was 500 mL. She was in anxiety and wished to have sedation during the procedure.\nCombined spinal and epidural anesthesia was planned in order to reduce the risk of rupture of the pulmonary AVMs due to inadequate pain control and positive pressure mechanical ventilation. We planned to add sedation by general anesthesia with a supraglottic airway device (SGA) to maintain spontaneous ventilation because of the estimated long duration of surgery, her mental status and large amount of blood loss.\nAfter entering the operating room, a peripheral venous line was secured, and a pericapsular nerve group block was performed using 20 mL of 1% lidocaine in order to relieve the pain of transferring between beds in the operating room and of positioning for spinal and epidural anesthesia . Then the patient was positioned laterally on the left side, an epidural catheter was inserted at the L2-3 lumbar intervertebral space, and spinal anesthesia was performed at the L3-4 lumbar intervertebral space using 3.3 mL of 0.5% isobaric bupivacaine. After changing to the supine position and confirming Th10 or lower levels of the block, SGA device (Air-Q®, Cookgas LLC, USA) was inserted with 50 mg propofol and 75 mcg fentanyl, and spontaneous breathing was maintained with concentrations of 1.0–1.5% sevoflurane. Under sedation, a central venous line and an arterial line were secured, and processed regional cerebral oxygen saturation (rSO2) was monitored in addition to standard monitoring including 5-lead ECG, pulse oximetry and capnography. Although no major blood pressure changes were observed during induction of anesthesia, her systolic blood pressure fluctuated in the range of 70 to 220 mmHg during the operation, necessitating frequent boluses of phentolamine and nicardipine. Her SpO2 and rSO2 were stable in the range of 89–92% and 55–60%, respectively, under a fraction of inspired oxygen of 0.3. Neither positive end-expiratory pressure nor pressure support was applied, and respiratory rate of spontaneous breathing was 20–30 per minute with expired carbon dioxide concentration of 30–38 mmHg during the procedure. There was no difficulty or trouble in managing her airway with an SGA device in the lateral position. No epidural local anesthetic agent was required, and the total amounts of fentanyl used during the procedure was 300 mcg. The surgery was competed in 170 min and the total amount of hemorrhage was 630 mL. A total of 1953 mL of Ringer’s solution and 4 units of red blood cells were administered during the procedure with 630 mL of urine output. After confirming emergence from anesthesia without a new neurological abnormality, the SGA device was removed in the operating room.\nAfter the operation, she was transferred to the intensive care unit (ICU) as planned. Her pain was well controlled with patient-controlled epidural analgesia. Her postoperative course was uneventful, and she was discharged from the ICU on postoperative day 1.", + "fulltext_subclaims": [ + "The patient is a 49-year-old female.", + "The patient has a body mass index of 17 kg/m2.", + "The patient presented for a pathological fracture of the right femoral bone head.", + "The patient has metastatic adenocarcinoma.", + "The patient was scheduled to undergo bone tumor resection and artificial bone replacement.", + "The patient was diagnosed with Osler-Weber-Rendu syndrome at the age of 30.", + "The patient has multiple pulmonary arteriovenous malformations.", + "The patient has pheochromocytoma.", + "The patient had a history of brain abscess.", + "The patient had a history of takotsubo cardiomyopathy.", + "The patient had preoperative coil embolization of the AVMs.", + "The patient did not have a history of recurrent epistaxis.", + "The patient did not have a history of gastrointestinal bleeding.", + "A preoperative physical examination did not reveal any special finding on her body surface.", + "Blood pressure was 105/64 mmHg.", + "The patient was taking doxazosin at a dose of 3 mg per day.", + "Heart rate was 97 bpm.", + "Peripheral oxygen saturation (SpO2) was 86% in room air.", + "The Hugh-Jones classification was class I.", + "Blood tests were remarkable only for hemoglobin level of 11.2 g/dL.", + "Urinary adrenaline level was 14.2 mcg/day.", + "Urinary noradrenaline level was 965.8 mcg/day.", + "Urinary dopamine level was 807.3 mcg/day.", + "An electrocardiogram (ECG) showed negative T-waves on V3-5.", + "A transthoracic echocardiogram showed peripheral left ventricle hypertrophy.", + "The ejection fraction was 67%.", + "Preoperative image examination revealed bilateral pulmonary AVMs.", + "Preoperative image examination revealed no AVM in the brain.", + "Preoperative image examination revealed no AVM in the spinal cord.", + "Preoperative image examination revealed a pancreas tail tumor.", + "The pancreas tail tumor was considered to be the origin of the metastatic bone tumor.", + "Preoperative estimation of the operation duration was 5 h.", + "Estimated intraoperative blood loss was 500 mL.", + "The patient was in anxiety.", + "The patient wished to have sedation during the procedure.", + "Combined spinal and epidural anesthesia was planned.", + "A supraglottic airway device (SGA) was planned to maintain spontaneous ventilation.", + "A pericapsular nerve group block was performed using 20 mL of 1% lidocaine.", + "An epidural catheter was inserted at the L2-3 lumbar intervertebral space.", + "Spinal anesthesia was performed at the L3-4 lumbar intervertebral space using 3.3 mL of 0.5% isobaric bupivacaine.", + "The SGA device used was Air-Q®.", + "The patient received 50 mg propofol.", + "The patient received 75 mcg fentanyl.", + "Spontaneous breathing was maintained with concentrations of 1.0–1.5% sevoflurane.", + "Processed regional cerebral oxygen saturation (rSO2) was monitored.", + "Systolic blood pressure fluctuated in the range of 70 to 220 mmHg during the operation.", + "Phentolamine and nicardipine were used during the operation.", + "SpO2 was stable in the range of 89–92%.", + "rSO2 was stable in the range of 55–60%.", + "No positive end-expiratory pressure was applied.", + "No pressure support was applied.", + "Respiratory rate of spontaneous breathing was 20–30 per minute.", + "Expired carbon dioxide concentration was 30–38 mmHg.", + "There was no difficulty in managing the airway with an SGA device in the lateral position.", + "No epidural local anesthetic agent was required.", + "The total amount of fentanyl used during the procedure was 300 mcg.", + "The surgery was completed in 170 min.", + "The total amount of hemorrhage was 630 mL.", + "A total of 1953 mL of Ringer’s solution was administered.", + "Four units of red blood cells were administered.", + "The urine output was 630 mL.", + "The SGA device was removed in the operating room.", + "The patient was transferred to the ICU as planned.", + "The patient was discharged from the ICU on postoperative day 1." + ], + "summary": "The case was a 49-year-old female with Osler-Weber-Rendu syndrome, multiple pulmonary arteriovenous malformations and pheochromocytoma who presented for femoral bone head fracture with metastatic adenocarcinoma. The patient was scheduled to undergo bone tumor resection and artificial bone replacement, being positioned laterally with a planned operation duration of 5 h. Anesthesia was managed with spinal and epidural anesthesia, combined with sedation by sevoflurane using a supraglottic airway (SGA) device under spontaneous breathing. Her intraoperative and postoperative courses were uneventful.", + "summary_subclaims": [ + "The patient was a 49-year-old female.", + "The patient had Osler-Weber-Rendu syndrome.", + "The patient had multiple pulmonary arteriovenous malformations.", + "The patient had pheochromocytoma.", + "The patient presented for femoral bone head fracture.", + "The patient had metastatic adenocarcinoma.", + "The patient was scheduled to undergo bone tumor resection.", + "The patient was scheduled to undergo artificial bone replacement.", + "The planned operation duration was 5 h.", + "Anesthesia was managed with spinal and epidural anesthesia.", + "Anesthesia was combined with sedation by sevoflurane.", + "A supraglottic airway (SGA) device was used under spontaneous breathing.", + "The intraoperative course was uneventful.", + "The postoperative course was uneventful." + ] + }, + { + "id": "multiclinsum_test_1567_en.txt", + "fulltext": "A 29-year-old smoking White man, without any personal or family history, was hospitalized in our department for the management of a small bowel obstruction (SBO). There was no fever or night sweats. The general condition was preserved. He had a history of a 2 months non-bloody diarrhea (5 stools/day). At presentation, physical examination revealed marked abdominal distension, diffuse tympanism with tenderness without rebound tenderness. There was no fever and vital signs were stable. Neurological and cutaneous examinations were normal. Examination of the anal margin and the rectal examination were normal.\nAbdominal CT scan revealed segmental, multifocal thickened small intestinal walls (8 mm) and dilated loops in the small bowel (up to 41 mm). The thickening was circumferential with a target appearance due to submucosal oedema.\nWhite blood cell and eosinophilic polynuclei count was elevated (700/mm3). Hemoglobin value was 12.8 g/dl and platelet count was within normal ranges. The C-reactive protein value was elevated (96 µmol/l). Liver and kidney function tests were normal. The SBO had improved with conservative management.\nParasitological examination of stool and stool culture were negative. Quantiferon, ASCA, PANCA and anti-transglutaminase antibodies were negative. LDH levels were normal.\nThe MR enterography showed a discontinuous multifocal inflammatory thickening of the ileum . Ileo-colonoscopy showed normal ileum and segmental petechial colitis. Pathology was normal for ileal biopsies and showed a catarrhal0 colitis with high eosinophilic infiltration without epithelial architectural changes for colonic biopsies . The gastroscopy showed a congestive and petechial gastropathy. Pathology was normal for esophageal and duodenal biopsies and showed chronic gastritis without HP for gastric biopsies.\nThe patient did not have antibiotics, since the Parasitological examination of stool and stool culture were negative. He was diagnosed with primary eosinophilic enterocolitis. He received corticosteroid therapy. We observed the resolution of the subocclusives syndromes, the diarrhea and the biological inflammatory syndrome, the normalization of the PNE level. Control MR enterography was normal three months after corticosteroid therapy. Since the patient was asymptomatic, we did not do a second look endoscopy.\nAfter a year, the patient was asymptomatic and the biological tests were normal.", + "fulltext_subclaims": [ + "The patient is a 29-year-old smoking White man.", + "The patient had no personal or family history.", + "The patient was hospitalized for the management of a small bowel obstruction.", + "The patient had a history of a 2 months non-bloody diarrhea.", + "Physical examination revealed marked abdominal distension.", + "Abdominal CT scan showed segmental, multifocal thickened small intestinal walls.", + "The thickening was circumferential with a target appearance due to submucosal oedema.", + "White blood cell and eosinophilic polynuclei count was elevated.", + "The C-reactive protein value was elevated.", + "Parasitological examination of stool and stool culture were negative.", + "Quantiferon, ASCA, PANCA, and anti-transglutaminase antibodies were negative.", + "MR enterography showed a discontinuous multifocal inflammatory thickening of the ileum.", + "Ileo-colonoscopy showed segmental petechial colitis.", + "Pathology showed a catarrhal colitis with high eosinophilic infiltration for colonic biopsies.", + "The gastroscopy showed a congestive and petechial gastropathy.", + "Pathology showed chronic gastritis without HP for gastric biopsies.", + "The patient did not have antibiotics.", + "The patient was diagnosed with primary eosinophilic enterocolitis.", + "The patient received corticosteroid therapy.", + "Control MR enterography was normal three months after corticosteroid therapy.", + "The patient was asymptomatic after a year." + ], + "summary": "We report a case of a 29-year-old White man, who presented with an acute bowel obstruction. He had a history of a 2 months non-bloody diarrhea. An abdominal computed tomography (CT) and a MR enterography showed a multifocal extensive ileitis. White blood cell and eosinophilic polynuclei count was elevated (700/mm3). Ileo-colonoscopy showed normal ileum and segmental petechial colitis. Pathology showed a high eosinophilic infiltration in the colon. The patient was treated with steroids, with a clinical, biological and radiological recovery.", + "summary_subclaims": [ + "The patient was a 29-year-old White man.", + "He presented with an acute bowel obstruction.", + "He had a history of a 2 months non-bloody diarrhea.", + "An abdominal computed tomography (CT) and a MR enterography showed a multifocal extensive ileitis.", + "White blood cell and eosinophilic polynuclei count was elevated (700/mm3).", + "Ileo-colonoscopy showed normal ileum.", + "Ileo-colonoscopy showed segmental petechial colitis.", + "Pathology showed a high eosinophilic infiltration in the colon.", + "The patient was treated with steroids.", + "The patient had a clinical, biological and radiological recovery." + ] + }, + { + "id": "multiclinsum_test_1858_en.txt", + "fulltext": "In 2019, a 20-year-old woman was referred to the Division of Dentistry, Department of Periodontics and Endodontics, Okayama University Hospital in Japan by a general practice dentist. The referral aimed to seek specialized periodontal treatment due to significant periodontal tissue destruction caused by ligneous periodontitis associated with plasminogen deficiency. Herein, we present the sequence of events leading to the diagnosis of plasminogen deficiency during the patient’s childhood and her subsequent presentation to our department in 2019.\nThe patient initially received a diagnosis of ligneous gingivitis linked to plasminogen deficiency at the Department of Oral and Maxillofacial Surgery, Okayama University Hospital, in 2008, when she was just nine years old. At that time, her blood plasminogen activity was as low as 10%, and pseudomembranous white lesions were evident on the gingiva and eye . Dental radiographs taken in 2012, when she was 12 years old, unveiled signs of vertical bone resorption in the lower first molar, indicative of ligneous periodontitis accompanied by alveolar bone destruction . Despite receiving regular supportive periodontal therapy (SPT) at her referring dental office for eight years, she was referred back to Okayama University Hospital in 2019 due to the remarkable extent of alveolar bone destruction for her age.\nUpon re-referral in 2019, her plasminogen activity was less than 25%, confirming the diagnosis of plasminogen deficiency. However, other markers, such as prothrombin time-international normalized ratio (PT-INR) and D-dimer, were within normal ranges, indicating no predisposition to bleeding. In terms of oral health, despite maintaining good oral hygiene (O’Leary plaque control record (PCR): 11.6%), the patient exhibited marginal gingival redness in the molar region, gingival hyperplasia on the buccal gingiva of the maxillary anterior teeth and mandibular molars, and deep periodontal pockets primarily in the molar area (4 mm < probing pocket depth (PPD): 33.4%; periodontal inflamed surface area (PISA): 1,025 mm2). Dental radiographic examination revealed horizontal bone resorption of approximately one-third of the root and vertical bone resorption in all molars . Histological examination of the gingival hyperplastic area demonstrated fibrin deposition and epithelial degeneration with neutrophilic infiltration . Based on the above intraoral and radiographic findings, blood test results, and histological tissue examination, she was again diagnosed with ligneous periodontitis (Stage III, Grade C).\nWe analyzed genomic sequences using targeted next-generation sequencing (NGS) with the hybrid capture method to explore potential germline variants underlying plasminogen deficiency. The analysis focused on a several-gene panel, including F12 and PLG, associated with plasminogen deficiency. Rare variants in F12 and PLG were identified through comparison with population database such as the Genome Aggregation Database (gnomAD). Specifically, the F12 variant A343P had been registered with conflicting interpretations of pathogenicity in the ClinVar database, with an allele frequency of 3.00 × 10–3. PLG c.581A > T (p.Asp194Val) was registered as benign in the ClinVar database (Variation ID: 780,122), with an allele frequency of 7.68 × 10–4. PLG c.1468C > T (p.Arg490*) was not reported in the ClinVar database, and its allele frequency in the gnomAD database was 1.19 × 10–5 . The PLG gene exhibited a c.581A > T missense mutation in this patient and a c.1468C > T stop-gain mutation . These mutations resulted in the truncation of the PLG protein and the loss of its plasminogen activator cleavage site . The patient had no family history of plasminogen deficiency or Behçet’s disease .\nInitial periodontal treatment for the patient involved non-surgical scaling and root planning (SRP) to eliminate the subgingival source of infection. Additionally, the patient used a mouthpiece to alleviate occlusal forces. Subsequent SPT was provided at short intervals from 2021 to stabilize the periodontal condition, although gingival hyperplasia and swelling showed minimal improvement. Periodontal surgery was not considered due to the potential for increased fibrin deposition with gingival incision. The patient’s oral condition at SPT was as follows: PCR 22.3%, BOP 49.4%, 4 mm < PPD 23.8%, PISA 981.4 mm2 .\nDespite maintaining stability systemically and orally, the patient presented to the Department of General Medicine, Okayama University Hospital, in 2022 with complaints of fever (body temperature (BT) 40.0 °C), diarrhea, and general malaise. Blood tests revealed a significantly elevated white blood cell (WBC) count (21.09 × 103 cells/µL) and C-reactive protein (CRP) level (20.24 mg/dL), leading to urgent hospital admission for further evaluation and treatment. Initial suspicion was directed towards infectious diseases, prompting the initiation of antibiotic therapy (tazobactam/piperacillin hydrate, 4.5 g × 3 times/day). However, the patient rapidly developed additional systemic symptoms, including hematochezia, vulvar ulcers, and an erythema nodosum-like rash on the extremities. In the oral cavity, marginal gingival hyperplasia, erosions, and multiple aphthous stomatitis were observed. Additionally, the tongue was coated with a thick biofilm . Subsequently, she was diagnosed with intestinal Behçet’s disease based on the primary symptoms of erythema nodosum-like skin rash on the extremities, recurrent aphthous ulcers on the oral mucosa, and atypical genital ulcer. Secondary symptoms, including vasculitis and gastrointestinal involvement, were confirmed through histological examination of the erythematous nodular area. Seven days after hospitalization, the presence of HLA-B51 antigens was detected, further supporting this diagnosis.\nPrompt administration of oral prednisolone (PSL) at 1 mg/kg/day was initiated upon the diagnosis of Behçet’s disease. Oral hygiene was maintained during hospitalization, and mucosal treatment was provided using glycerin mouthwashes. On the 15th day after hospitalization, with reduced systemic inflammation due to PSL treatment (CRP 0.18 mg/dL, WBC 9,330 cells/µL, BT 36.9 °C), aphthous ulceration, gingival hyperplasia, and erosion areas showed improvement, and the biofilm on the tongue disappeared. However, redness in the pharyngeal region persisted. Consequently, the PSL dosage was gradually reduced to 30 mg/day. On the 45th day of hospitalization, the patient’s overall condition had significantly improved, leading to her discharge from the hospital (CRP 0.02 mg/dL, WBC 13,101 cells/µL, BT 36.6 °C). Around the same time, aphthous ulceration in the oral cavity had resolved. Gingival hyperplasia had decreased to a level similar to when she transferred to SPT, though gingival recession seemed to have progressed (PCR 51.8%, BOP 10.7%, 4 mm < PPD 16.7%, PISA 226.4 mm2). Conversely, dental radiographs revealed progressive horizontal alveolar bone resorption (bone resorption of approximately two-thirds of the root of the tooth) compared to the previous assessment .\nFollowing her discharge, the patient initiated the treatment with the anti-tumor necrosis factor (TNF)-α antibody drug adalimumab at 40 mg every two weeks. This treatment aimed to decrease reliance on steroids and provide symptom relief through the anti-inflammatory effects of the medication. The patient experienced intermittent flares and remissions of systemic inflammation after hospital discharge, although to a lesser extent than during the initial hospitalization period.", + "fulltext_subclaims": [ + "In 2019, a 20-year-old woman was referred to the Division of Dentistry, Department of Periodontics and Endodontics, Okayama University Hospital in Japan.", + "The referral aimed to seek specialized periodontal treatment due to significant periodontal tissue destruction caused by ligneous periodontitis associated with plasminogen deficiency.", + "The patient initially received a diagnosis of ligneous gingivitis linked to plasminogen deficiency at the Department of Oral and Maxillofacial Surgery, Okayama University Hospital, in 2008.", + "At that time, her blood plasminogen activity was as low as 10%.", + "Dental radiographs taken in 2012 unveiled signs of vertical bone resorption in the lower first molar.", + "Despite receiving regular supportive periodontal therapy at her referring dental office for eight years, she was referred back to Okayama University Hospital in 2019 due to the remarkable extent of alveolar bone destruction for her age.", + "Upon re-referral in 2019, her plasminogen activity was less than 25%, confirming the diagnosis of plasminogen deficiency.", + "Other markers, such as prothrombin time-international normalized ratio (PT-INR) and D-dimer, were within normal ranges.", + "In terms of oral health, the patient exhibited marginal gingival redness in the molar region.", + "Dental radiographic examination revealed horizontal bone resorption of approximately one-third of the root and vertical bone resorption in all molars.", + "Histological examination of the gingival hyperplastic area demonstrated fibrin deposition and epithelial degeneration with neutrophilic infiltration.", + "Based on the above intraoral and radiographic findings, blood test results, and histological tissue examination, she was again diagnosed with ligneous perioditis (Stage III, Grade C).", + "We analyzed genomic sequences using targeted next-generation sequencing (NGS) with the hybrid capture method.", + "The analysis focused on a several-gene panel, including F12 and PLG, associated with plasminogen deficiency.", + "Rare variants in F12 and PLG were identified through comparison with population databases such as the Genome Aggregation Database (gnomAD).", + "The F12 variant A343P had been registered with conflicting interpretations of pathogenicity in the ClinVar database.", + "The PLG c.581A > T (p.Asp194Val) was registered as benign in the ClinVar database.", + "The PLG c.1468C > T (p.Arg490*) was not reported in the ClinVar database.", + "The PLG gene exhibited a c.581A > T missense mutation in this patient and a c.1468C > T stop-gain mutation.", + "These mutations resulted in the truncation of the PLG protein and the loss of its plasminogen activator cleavage site.", + "The patient had no family history of plasminogen deficiency or Behçet’s disease.", + "Initial periodontal treatment involved non-surgical scaling and root planning (SRP) to eliminate the subgingival source of infection.", + "The patient used a mouthpiece to alleviate occlusal forces.", + "Subsequent SPT was provided at short intervals from 2021 to stabilize the periodontal condition.", + "Periodontal surgery was not considered due to the potential for increased fibrin deposition with gingival incision.", + "The patient’s oral condition at SPT had PCR 22.3%, BOP 49.4%, 4 mm < PPD 23.8%, PISA 981.4 mm2.", + "Despite maintaining stability systemically and orally, the patient presented to the Department of General Medicine, Okayama University Hospital, in 2022 with complaints of fever, diarrhea, and general malaise.", + "Blood tests revealed a significantly elevated white blood cell (WBC) count and C-reactive protein (CRP) level.", + "Initial suspicion was directed towards infectious diseases, prompting the initiation of antibiotic therapy.", + "The patient rapidly developed additional systemic symptoms, including hematochezia, vulvar ulcers, and an erythema nodosum-like rash on the extremities.", + "In the oral cavity, marginal gingival hyperplasia, erosions, and multiple aphthous stomatitis were observed.", + "The tongue was coated with a thick biofilm.", + "She was diagnosed with intestinal Behçet’s disease based on the primary symptoms of erythema nodosum-like skin rash on the extremities, recurrent aphthous ulcers on the oral mucosa, and atypical genital ulcer.", + "Secondary symptoms, including vasculitis and gastrointestinal involvement, were confirmed through histological examination of the erythematous nodular area.", + "The presence of HLA-B51 antigens was detected, further supporting this diagnosis.", + "Prompt administration of oral prednisolone (PSL) at 1 mg/kg/day was initiated upon the diagnosis of Behçet’s disease.", + "Oral hygiene was maintained during hospitalization, and mucosal treatment was provided using glycerin mouthwashes.", + "On the 15th day after hospitalization, with reduced systemic inflammation due to PSL treatment, aphthous ulceration, gingival hyperplasia, and erosion areas showed improvement.", + "The PSL dosage was gradually reduced to 30 mg/day.", + "On the 45th day of hospitalization, the patient’s overall condition had significantly improved, leading to her discharge from the hospital.", + "Around the same time, aphthous ulceration in the oral cavity had resolved.", + "Gingival hyperplasia had decreased to a level similar to when she transferred to SPT.", + "Dental radiographs revealed progressive horizontal alveolar bone resorption compared to the previous assessment.", + "Following her discharge, the patient initiated treatment with the anti-tumor necrosis factor (TNF)-α antibody drug adalimumab at 40 mg every two weeks.", + "The patient experienced intermittent flares and remissions of systemic inflammation after hospital discharge." + ], + "summary": "This case report depicts a patient diagnosed with ligneous gingivitis during childhood, originating from plasminogen deficiency and progressing to periodontitis. Genetic testing revealed a suspected association with the PLG c.1468C > T (p.Arg490*) stop-gain mutation. The patient's periodontal condition remained stable with brief intervals of supportive periodontal therapy. However, the emergence of Behçet's disease induced acute systemic inflammation, necessitating hospitalization and treatment with steroids. During hospitalization, the dental approach focused on maintaining oral hygiene and alleviating contact-related pain. The patient's overall health improved with inpatient care and the periodontal tissues deteriorated.", + "summary_subclaims": [ + "The patient was diagnosed with ligneous gingivitis during childhood.", + "The patient's ligneous gingivitis originated from plasminogen deficiency.", + "The patient's condition progressed to periodontitis.", + "Genetic testing revealed a suspected association with the PLG c.1468C > T (p.Arg490*) stop-gain mutation.", + "The patient's periodontal condition remained stable with brief intervals of supportive periodontal therapy.", + "The emergence of Behçet's disease induced acute systemic inflammation.", + "Hospitalization was necessary due to Behçet's disease.", + "Treatment with steroids was administered.", + "The dental approach during hospitalization focused on maintaining oral hygiene.", + "The dental approach during hospitalization included alleviating contact-related pain.", + "The patient's overall health improved with inpatient care.", + "The periodontal tissues deteriorated." + ] + }, + { + "id": "multiclinsum_test_371_en.txt", + "fulltext": "A 59-year-old female patient with asymptomatic severe AR was referred to our institution for surgical treatment. She was being followed up at an outpatient clinic for QAV and moderate AR for 7 years. AVR was indicated for the progressively worsening AR and left ventricular function.\nOn admission, the patient’s blood pressure was 122/62 mmHg, and heart rate was 102 bpm with an irregular rhythm. Chest radiography showed a cardiothoracic ratio of 56%. Electrocardiography (ECG) revealed a heart rate of 100 bpm with atrial fibrillation. Transthoracic echocardiography revealed a QAV with a severe central AR jet due to incomplete coaptation. The left ventricular ejection fraction was 50%, without local asynergy. The left ventricular end-systolic and end-diastolic diameters were 46 mm and 62 mm, respectively, and the diameter of the aortic valve annulus was 23 mm. Coronary angiography revealed no significant coronary artery stenosis or anomalies. ECG-gated enhanced computed tomography was not performed, and no coronary ostium anomalies were detected preoperatively.\nThe patient underwent median sternotomy. The aortic valve had four cusps of almost equal size (Hurwitz and Roberts type A , Fig. ). Macroscopically, partial calcification and thickening of the cusps were observed. The left coronary ostium was located in the middle of the left aortic sinus. Although the course of the right coronary artery was normal, the right coronary artery ostium was located slightly below the sinotubular junction and in close proximity to the commissure between the right coronary cusp and one of the two non-coronary cusps . After excision of all cusps, the annular stitches were placed in a non-everting mattress fashion with pledgets on the ventricular side, and three stitches near the right coronary ostium were transitioned to the subannular ventricular myocardium to maintain the distance from the ostium . We decided to use a biologic prosthesis, according to the patients’ desire. A 25-mm prosthetic sizer was able to pass through the annulus but mild resistance was noted. We selected a 23-mm Inspiris Resillia biologic prosthesis (Edwards Lifesciences, Irvine, California, United States of America), because an oversized prosthetic valve could potentially compress the right coronary ostium. In addition to AVR, pulmonary vein isolation using AtriCure (AtriCure, Mason, OH, USA) and left atrial appendage closure using AtriClip (AtriCure) was performed for atrial fibrillation.\nThe patient tolerated the procedure adequately, and postoperative echocardiography revealed normal prosthetic valve function without paravalvular leakage. Except for recurrent atrial fibrillation, the postoperative course was uneventful. The patient was discharged on postoperative day 17.", + "fulltext_subclaims": [ + "The patient was a 59-year-old female.", + "The patient had asymptomatic severe AR.", + "The patient was referred to our institution for surgical treatment.", + "The patient was being followed up at an outpatient clinic for QAV and moderate AR for 7 years.", + "AVR was indicated for the progressively worsening AR and left ventricular function.", + "On admission, the patient’s blood pressure was 122/62 mmHg.", + "On admission, the patient’s heart rate was 102 bpm with an irregular rhythm.", + "Chest radiography showed a cardiothoracic ratio of 56%.", + "ECG revealed a heart rate of 100 bpm with atrial fibrillation.", + "Transthoracic echocardiography revealed a QAV with a severe central AR jet due to incomplete coaptation.", + "The left ventricular ejection fraction was 50%.", + "The left ventricular end-systolic diameter was 46 mm.", + "The left ventricular end-diastolic diameter was 62 mm.", + "The diameter of the aortic valve annulus was 23 mm.", + "Coronary angiography revealed no significant coronary artery stenosis or anomalies.", + "ECG-gated enhanced computed tomography was not performed.", + "No coronary ostium anomalies were detected preoperatively.", + "The patient underwent median sternotomy.", + "The aortic valve had four cusps of almost equal size.", + "The left coronary ostium was located in the middle of the left aortic sinus.", + "The right coronary artery ostium was located slightly below the sinotubular junction.", + "The right coronary artery ostium was in close proximity to the commissure between the right coronary cusp and one of the two non-coronary cusps.", + "A 25-mm prosthetic sizer was able to pass through the annulus.", + "Mild resistance was noted when passing the 25-mm prosthetic sizer.", + "A 23-mm Inspiris Resillia biologic prosthesis was selected.", + "An oversized prosthetic valve could potentially compress the right coronary ostium.", + "Pulmonary vein isolation using AtriCure was performed.", + "Left atrial appendage closure using AtriClip was performed.", + "Postoperative echocardiography revealed normal prosthetic valve function.", + "Postoperative echocardiography revealed no paravalvular leakage.", + "The patient was discharged on postoperative day 17." + ], + "summary": "Herein, we report a case of a 59-year-old woman who underwent aortic valve replacement for a quadricuspid aortic valve with severe aortic regurgitation. Intraoperatively, the aortic valve had four cusps of almost equal size and the right coronary artery arose adjacent to the commissure between the right coronary cusp and one of the two non-coronary cusps. The annular stitches were placed in a non-everting mattress fashion with pledgets on the ventricular side, and stitches near the right coronary ostium were transitioned to the subannular ventricular myocardium to maintain the distance from the ostium. A one-step smaller-sized prosthesis was selected to avoid an oversized prosthetic valve potentially compressing the right coronary ostium.", + "summary_subclaims": [ + "The patient was a 59-year-old woman.", + "She underwent aortic valve replacement.", + "The indication was a quadricuspid aortic valve with severe aortic regurgitation.", + "Intraoperatively, the aortic valve had four cusps of almost equal size.", + "The right coronary artery arose adjacent to the commissure between the right coronary cusp and one of the two non-coronary cusps.", + "The annular stitches were placed in a non-everting mattress fashion with pledgets on the ventricular side.", + "Stitches near the right coronary ostium were transitioned to the subannular ventricular myocardium.", + "A one-step smaller-sized prosthesis was selected.", + "The smaller prosthesis was selected to avoid an oversized prosthetic valve potentially compressing the right coronary ostium." + ] + }, + { + "id": "multiclinsum_test_3263_en.txt", + "fulltext": "A 66-year-old Japanese man was consulted to our hospital due to the progression of dyspnea and edema in both legs, which had occurred during the previous week. He presented with a low-grade fever (37.4°C by armpit), productive cough and hypoxemia with 94% of percutaneous oxygen saturation in ambient air. He was an ex-smoker (10 cigarettes per day, for 6 years from 20 to 25 years of age), but had no particular past medical history or medications.\n\nThe results of the initial laboratory tests showed hypoproteinemia, proteinuria, and moderate renal insufficiency. On electrocardiography, low voltage and a long QT interval were detected. A chest x-ray showed dilation of a cardiac shadow and bilateral pleural effusion. Echocardiography revealed left ventricular hypertrophy (mean wall thickness, 15 mm) and granular high echoic spots at the septum. His plasma brain natriuretic peptide level was increased (448.7 pg/mL; normal range, < 18.4 pg/mL). These typical observations are compatible with amyloid cardiomyopathy.\n\nPercutaneous kidney and endoscopic gastric mucosal biopsy demonstrated Periodic acid-Schiff (PAS)-positive hyalinization in most of the glomeruli and surrounding vessel walls in the kidney and submucosal stroma. These lesions were congophilic, which is considered a signature of systemic amyloidosis. Immunofluorescent (IF) staining revealed strong deposition of IgA and lambda (λ) chain in mesangial regions, but little IgG and IgM deposition, and no kappa (κ) light chain deposition. The amyloid deposits were composed of randomly oriented fibrils with a mean diameter of 10 nm on electron microscopy. Bone marrow aspiration biopsy showed little atypical plasma cell infiltration (<1%) and no evidence of myeloma.\n\nThe patient was referred to hematology for further treatment and moved to another hospital for the administration of chemotherapy using melphalan and dexamethasone. After 15-month follow-up from the initial diagnosis, the patient was still alive.", + "fulltext_subclaims": [ + "A 66-year-old Japanese man was consulted to our hospital due to the progression of dyspnea and edema in both legs.", + "He had a low-grade fever of 37.4°C by armpit.", + "He had a productive cough.", + "He had hypoxemia with 94% percutaneous oxygen saturation in ambient air.", + "He was an ex-smoker (10 cigarettes per day, for 6 years from 20 to 25 years of age).", + "He had no particular past medical history or medications.", + "The initial laboratory tests showed hypoproteinemia.", + "The initial laboratory tests showed proteinuria.", + "The initial laboratory tests showed moderate renal insufficiency.", + "Electrocardiography detected low voltage.", + "Electrocardiography detected a long QT interval.", + "A chest x-ray showed dilation of a cardiac shadow.", + "A chest x-ray showed bilateral pleural effusion.", + "Echocardiography revealed left ventricular hypertrophy with a mean wall thickness of 15 mm.", + "Echocardiography revealed granular high echoic spots at the septum.", + "His plasma brain natriuretic peptide level was 448.7 pg/mL.", + "These typical observations are compatible with amyloid cardiomyopathy.", + "Percutaneous kidney and endoscopic gastric mucosal biopsy demonstrated PAS-positive hyalinization in most of the glomeruli.", + "Percutaneous kidney and endoscopic gastric mucosal biopsy demonstrated PAS-positive hyalinization in surrounding vessel walls in the kidney.", + "Percutaneous kidney and endoscopic gastric mucosal biopsy demonstrated PAS-positive hyalinization in the submucosal stroma.", + "These lesions were congophilic.", + "Immunofluorescent staining revealed strong deposition of IgA in mesangial regions.", + "Immunofluorescent staining revealed strong deposition of lambda (λ) chain in mesangial regions.", + "Immunofluorescent staining revealed little IgG deposition.", + "Immunofluorescent staining revealed little IgM deposition.", + "Immunofluorescent staining revealed no kappa (κ) light chain deposition.", + "The amyloid deposits were composed of randomly oriented fibrils with a mean diameter of 10 nm on electron microscopy.", + "Bone marrow aspiration biopsy showed little atypical plasma cell infiltration (<1%).", + "Bone marrow aspiration biopsy showed no evidence of myeloma.", + "The patient was referred to hematology for further treatment.", + "The patient was moved to another hospital for the administration of chemotherapy using melphalan and dexamethasone.", + "After 15-month follow-up from the initial diagnosis, the patient was still alive." + ], + "summary": "Patient concerns:\nA 66-year-old Japanese man was admitted to our hospital presenting with nephrotic syndrome and congestive heart failure.\n\nDiagnosis:\nKidney and endoscopic gastric mucosal biopsy demonstrated congophilic hyalinization in most of the glomeruli and surrounding vessel walls, which were highly positive for immunoglobulin A and lambda. Finally, the patient was diagnosed as an atypical multiple myeloma with systemic heavy and light chain amyloidosis.\n\nInterventions:\nThe patient was referred to hematology for further treatment and was moved to another hospital for the administration of chemotherapy using melphalan and dexamethasone.", + "summary_subclaims": [ + "The patient is a 66-year-old Japanese man.", + "The patient was admitted to the hospital.", + "The patient presented with nephrotic syndrome.", + "The patient presented with congestive heart failure.", + "Kidney and endoscopic gastric mucosal biopsy demonstrated congophilic hyalinization in most of the glomeruli and surrounding vessel walls.", + "The congophilic hyalinization was highly positive for immunoglobulin A.", + "The congophilic hyalinization was highly positive for lambda.", + "The patient was diagnosed as an atypical multiple myeloma.", + "The patient was diagnosed with systemic heavy and light chain amyloidosis.", + "The patient was referred to hematology for further treatment.", + "The patient was moved to another hospital for the administration of chemotherapy.", + "Chemotherapy using melphalan and dexamethasone was planned." + ] + }, + { + "id": "multiclinsum_test_1128_en.txt", + "fulltext": "A 77-year-old female with a history of chronic kidney disease and type II diabetes mellitus underwent workup for ongoing sinusitis, fatigue, malaise, and 20-pound weight loss. Patient quit smoking 30 years ago and denies any drug or alcohol use. She reports no significant family history including history of malignancy. MRI of the brain performed at an outside hospital to evaluate the extent of sinusitis revealed a posterior fossa lesion with surrounding edema causing compression on the fourth ventricle. The patient was transferred to our institution for neurosurgical evaluation. On presentation the patient was found to have mild cerebellar signs but an otherwise non-focal exam. Patient was surprised to learn of the cerebellar findings considering her lack of significant symptoms. MRI of the brain, including 3DT1, and T2 Flair showed an irregular enhancing lesion along the inferior & posterior surface of the right cerebellar hemisphere suggestive of an infiltrative malignancy . Based on these imaging findings, top differentials at the time included a metastatic disease process, an atypical meningioma, or a glioma. Upon retrospective review of this case and imaging findings, an additional differential was hypertrophic pachymeningitis. Contrast CT of the chest, abdomen, and pelvis was then performed and found to be negative for a primary malignancy. H1-MR-spectroscoy was not considered prior to resection. After discussion with the patient and her family, she elected to undergo open biopsy with or without further resection of the lesion. One week after her initial referral, she was taken to the operative theater and underwent a suboccipital craniotomy.\nAn intraoperative frozen section biopsy was taken. Sections showed round or “whorled” structures, suggestive of meningioma. Additional tissue for permanent sections was requested. Permanent sections showed more of the well-circumscribed structures. Without frozen section artifact, the structures could be definitively characterized as necrotizing granulomas, involving both dura and cerebellum. The granulomas comprise central eosinophilic necrosis with surrounding epithelioid histiocytes and lymphocytes . No vasculitis was seen. Acid fast and Gomori methenamine silver (GMS) special stains were performed; they revealed no acid fast or fungal organisms.\nGiven the frozen histology, imaging findings, and cerebellar symptoms further resection was completed to the point of gross total resection. cANCA and pANCA studies were sent and were found to be negative. The patient was discharged home on post-operative day 5 with a three-day steroid taper and referral to outpatient physical therapy. She returned for an office follow-up after 6 weeks and was informed that despite extensive work-up to explore the etiology of her granulomatous inflammation, no etiology was found. She had a follow-up MRI at this time which showed a non-enhancing fluid collection extending beyond the titanium mesh cranioplasty, differential to include seroma and pseudomeningocele. A follow up in 2 weeks was planned to monitor this fluid collection. At this appointment, it was found that the fluid collection under the incision was significantly decreased in size and continuing to resolve. Patient stated she was overall doing well. The current plan is to follow up in 1 year with an MRI. Patient stated she was happy with her recovery progress and plan of care moving forward.", + "fulltext_subclaims": [ + "The patient is a 77-year-old female.", + "The patient has a history of chronic kidney disease.", + "The patient has a history of type II diabetes mellitus.", + "The patient underwent workup for ongoing sinusitis.", + "The patient reports 20-pound weight loss.", + "MRI of the brain performed at an outside hospital revealed a posterior fossa lesion with surrounding edema.", + "The posterior fossa lesion was causing compression on the fourth ventricle.", + "The patient was transferred to our institution for neurosurgical evaluation.", + "On presentation, the patient was found to have mild cerebellar signs.", + "MRI of the brain showed an irregular enhancing lesion along the inferior & posterior surface of the right cerebellar hemisphere.", + "The lesion was suggestive of an infiltrative malignancy.", + "Top differentials included a metastatic disease process, an atypical meningioma, or a glioma.", + "An additional differential was hypertrophic pachymeningitis.", + "Contrast CT of the chest, abdomen, and pelvis was negative for a primary malignancy.", + "H1-MR-spectroscoy was not considered prior to resection.", + "The patient elected to undergo open biopsy with or without further resection.", + "The patient underwent a suboccipital craniotomy.", + "An intraoperative frozen section biopsy was taken.", + "Frozen sections showed round or 'whorled' structures, suggestive of meningioma.", + "Permanent sections showed more of the well-circumscribed structures.", + "The structures were definitively characterized as necrotizing granulomas.", + "The granulomas comprised central eosinophilic necrosis with surrounding epithelioid histiocytes and lymphocytes.", + "Acid fast and GMS special stains revealed no acid fast or fungal organisms.", + "cANCA and pANCA studies were sent.", + "cANCA and pANCA studies were found to be negative.", + "The patient was discharged home on post-operative day 5.", + "The patient was given a three-day steroid taper.", + "The patient was referred to outpatient physical therapy.", + "The patient returned for an office follow-up after 6 weeks.", + "A follow-up MRI showed a non-enhancing fluid collection extending beyond the titanium mesh cranioplasty.", + "The fluid collection differential included seroma and pseudomeningocele.", + "At the 6-week follow-up, the fluid collection under the incision was significantly decreased in size.", + "The current plan is to follow up in 1 year with an MRI.", + "The patient stated she was happy with her recovery progress." + ], + "summary": "This report presents the case of a 77-year-old female with sinusitis and fatigue who underwent an MRI revealing a posterior fossa lesion compressing the fourth ventricle. Subsequent contrast CT of the chest, abdomen, and pelvis was negative for primary malignancy. Histopathologic examination of the lesion following biopsy showed it to be a necrotizing granuloma in an antineutrophil cytoplasmic antibody (ANCA) negative patient. The most likely diagnosis was determined to be spontaneous necrotizing granuloma, a rare entity with only one previous report noted.", + "summary_subclaims": [ + "The patient is a 77-year-old female.", + "The patient had sinusitis.", + "The patient had fatigue.", + "The MRI revealed a posterior fossa lesion.", + "The posterior fossa lesion was compressing the fourth ventricle.", + "A contrast CT of the chest, abdomen, and pelvis was negative for primary malignancy.", + "A biopsy of the lesion was performed.", + "Histopathologic examination showed the lesion to be a necrotizing granuloma.", + "The patient was ANCA negative.", + "The most likely diagnosis was determined to be spontaneous necrotizing granuloma.", + "Spontaneous necrotizing granuloma is a rare entity.", + "Only one previous report of spontaneous necrotizing granuloma was noted." + ] + }, + { + "id": "multiclinsum_test_2635_en.txt", + "fulltext": "A 33-year-old nulligravid woman with newly diagnosed AA (WHO grade III, IDH1 negative) presented to our office for fertility preservation. The patient had undergone a craniotomy with complete resection of her right parietal lobe tumor one month prior, and was scheduled to start chemotherapy and radiation in the next month. Her neuro-oncologist recommended that she undergo fertility preservation prior to chemo-radiation. The fertility preservation did not delay the anticipated start of her chemo-radiation treatment.\nThe patient had no significant medical or gynecological history. On physical exam, the patient was a healthy-appearing woman. She had left lower extremity weakness and instability. Transvaginal ultrasound demonstrated a normal-appearing uterus and ovaries bilaterally. A dominant follicle was noted on her right ovary; therefore, it was decided to administer HCG 10,000 IU at the time of her presentation to trigger ovulation, thus enabling the initiation of gonadotropins two weeks later. The patient had a high antral follicle count (6 on right, 7 on left).\nThe patient received low dose gonadotropins: 1 ampule of Human Menopausal Gonadotropin (Menopur®, Ferring Pharmaceuticals, Parsippany, NJ, USA), 75–187.5 IU of FSH (Gonal F®, EMD Serono, Rockland, MA, USA) for 10 days and cetrorelix acetate (Ganirelex®, GnRH antagonist, EMD Serono, Rockland, MA, USA) for the last 6 days. Final oocyte maturation was triggered with Lupron Luprolide Acetate (Lupron®, GnRH agonist, SANDOZ Pharmaceuticals, Princeton, NJ, USA) 40u. Twelve oocytes were retrieved transvaginally under ultrasound guidance. Eight embryos developed and were vitrified in liquid nitrogen (6 on day 3 and 2 on day 5 post-retrieval).\nThe patient returned to our Center one year later after she was cleared by her neuro-oncologist following the completion of chemotherapy and radiation. The patient had 6 weeks of radiation therapy with Temozolomide (Temodar®, Merck&Co, Inc., Whitehouse Station, NJ, USA) followed by 6 months of maintenance dose. Her last dose of chemotherapy was one month prior to returning to the office. The patient had maintained regular cycles post chemotherapy. The patient underwent a frozen-thaw natural cycle embryo transfer of a single day-3 embryo with vaginal progesterone (Crinone®, Actavis, Parsippany, NJ, USA) luteal phase support. The patient remained on Keppra® 500 TID (levetiracetam, UCB Pharmacueticals, Brussels, Belgium) and Lactulose throughout the pregnancy. A viable singleton pregnancy was seen on ultrasound 1 month later. The patient delivered a healthy female baby weighing 7lbs 5 oz. at term.\nThe patient returned two years later desirous of another pregnancy. Her neurological status had been stable, was tumor free and was cleared by her oncologist to conceive again. This time the patient was treated with Estrace® (estradiol, Warner Chilcott, Rockaway, NJ, USA) 6 mg a day and underwent a frozen-thaw cycle with a single day-5 blastocyst transferred. The patient conceived with a viable singleton pregnancy and delivered a healthy male at term weighing 6lbs.\nThroughout the patient’s treatment regimen for fertility preservation and frozen embryo transfers, no adverse or unanticipated events were encountered.", + "fulltext_subclaims": [ + "The patient is a 33-year-old nulligravid woman.", + "The patient had newly diagnosed AA (WHO grade III, IDH1 negative).", + "The patient had undergone a craniotomy with complete resection of her right parietal lobe tumor one month prior.", + "The patient was scheduled to start chemotherapy and radiation in the next month.", + "The patient’s neuro-oncologist recommended fertility preservation prior to chemo-radiation.", + "The fertility preservation did not delay the anticipated start of her chemo-radiation treatment.", + "The patient had no significant medical or gynecological history.", + "On physical exam, the patient was a healthy-appearing woman.", + "Transvaginal ultrasound demonstrated a normal-appearing uterus and ovaries bilaterally.", + "A dominant follicle was noted on the patient’s right ovary.", + "It was decided to administer HCG 10,000 IU at the time of her presentation to trigger ovulation.", + "The patient had a high antral follicle count (6 on right, 7 on left).", + "The patient received low dose gonadotropins: 1 ampule of Human Menopausal Gonadotropin (Menopur®), 75–187.5 IU of FSH (Gonal F®) for 10 days.", + "The patient received cetrorelix acetate (Ganirelex®) for the last 6 days.", + "Final oocyte maturation was triggered with Lupron Luprolide Acetate (Lupron®) 40u.", + "Twelve oocytes were retrieved transvaginally under ultrasound guidance.", + "Eight embryos developed and were vitrified in liquid nitrogen.", + "The patient returned to the Center one year later after being cleared by her neuro-oncologist.", + "The patient had 6 weeks of radiation therapy with Temozolomide (Temodar®).", + "The patient had 6 months of maintenance dose chemotherapy.", + "The patient’s last dose of chemotherapy was one month prior to returning to the office.", + "The patient had maintained regular cycles post chemotherapy.", + "The patient underwent a frozen-thaw natural cycle embryo transfer of a single day-3 embryo.", + "The patient used vaginal progesterone (Crinone®) for luteal phase support.", + "A viable singleton pregnancy was seen on ultrasound 1 month later.", + "The patient delivered a healthy female baby weighing 7lbs 5 oz. at term.", + "The patient returned two years later desirous of another pregnancy.", + "The patient was tumor free and cleared by her oncologist to conceive again.", + "This time the patient was treated with Estrace® 6 mg a day.", + "The patient underwent a frozen-thaw cycle with a single day-5 blastocyst transferred.", + "The patient conceived with a viable singleton pregnancy.", + "The patient delivered a healthy male at term weighing 6lbs.", + "Throughout the patient’s treatment regimen for fertility preservation and frozen embryo transfers, no adverse or unanticipated events were encountered." + ], + "summary": "33-year-old nulligravid woman with newly diagnosed anaplastic astrocytoma (AA; WHO grade III, IDH1-negative) sought fertility preservation. Prior to chemotherapy and radiation for AA, the patient underwent in vitro fertilization (IVF) for fertility preservation, resulting in 8 vitrified embryos. Following chemo-radiation, the patient underwent two rounds of frozen embryo transfers (FET), each resulting in a successful singleton pregnancy.", + "summary_subclaims": [ + "The patient is a 33-year-old nulligravid woman.", + "The patient has newly diagnosed anaplastic astrocytoma.", + "The anaplastic astrocytoma is WHO grade III.", + "The anaplastic astrocytoma is IDH1-negative.", + "The patient sought fertility preservation.", + "The patient underwent in vitro fertilization for fertility preservation.", + "The in vitro fertilization resulted in 8 vitrified embryos.", + "The patient underwent two rounds of frozen embryo transfers.", + "Each frozen embryo transfer resulted in a successful singleton pregnancy." + ] + }, + { + "id": "multiclinsum_test_2151_en.txt", + "fulltext": "A 56-year-old female patient was initially admitted to a secondary care centre. Her medical history included arterial hypertension, type 2 diabetes mellitus and breast cancer undergone full remission following treatment more than 15 years ago. The patient had just returned from a pilgrimage when she noticed a subacute sensorimotor deficit in her left hand. Initially physicians suspected a stroke, but the brain magnetic resonance imaging (MRI) showed no signs of acute or subacute ischemia or inflammation. She was admitted for further diagnostic evaluation. The next day she complained of blurred vision with no reported loss of visual acuity at that time. Over the next 3 days there was a marked clinical deterioration: The patient developed a vesiculopapular rash with secondary clustered crustation on her neck, ear and décolletage and became increasingly agitated and confused. Cerebrospinal fluid (CSF) examination revealed a mild pleocytosis of 10 [0–4] /μl. Empirical antiviral treatment with aciclovir was started on suspicion of herpes zoster encephalitis. However, subsequent polymerase chain reaction testing of the CSF was negative for varicella-zoster, herpes simplex and other neurotropic viruses. A follow-up cerebral MRI revealed a right parahippocampal T2 lesion that was not evident on the initial MRI . In addition, there were T2 hyperintense lesions in both optic nerves, which were consistent with optic neuritis . At this point the patient was referred to our tertiary care facility.\nHere the patient was diagnosed with blindness in the right eye, severe reduction of visual acuity in the left eye (<0.1) and a marked ataxic tetraparesis. The rash, misdiagnosed as herpes zoster, turned out to be self-induced excoriation caused by the patient’s own fingers in an attempt to relieve a perceived severe burning and itching over the skin, which we attributed to a central pain syndrome, probably the cause of the agitation.\nMRI of the spinal cord revealed spinal cord T2 hyperintense lesion locations and extension compatible with transverse myelitis (,). A follow-up spinal tap was negative for oligoclonal bands. Chest/lung computed tomography scan revealed no evidence of pulmonary sarcoidosis. Initial testing for anti-AQP4 and anti-MOG antibodies was performed 12 days after clinical onset and prior to immunotherapy. Sera were analysed by cell-based indirect immunofluorescence at EUROIMMUN (Lübeck, Germany); staining at serum dilutions ≥1:10 was considered positive. Assays were negative at that time and at follow-up . In contrast to AQP4-Ab-positive NMOSD, the diagnostic criteria for seronegative NMOSD are far more complex and require the presence of ≥2 core criteria, at least one of which must be ON, LETM or area postrema syndrome. Additional MR criteria must also be met. In our case, the patient had two core clinical features (bilateral ON and LETM) with brain MRI showing extensive (>1/2 optic nerve length) T2 hyperintense lesions of both optic nerves, a white matter lesion not suggestive of MS and acute myelitis involving more than 3 contiguous segments. In addition, differential diagnoses were ruled out as far as possible by repeated serological and CSF analysis. Thus, we diagnosed seronegative NMOSD according to the 2015 revised criteria of the International Panel for NMO Diagnosis . We started treatment with high-dose intravenous methylprednisolone at 1 g per day for 5 consecutive days. Due to lack of improvement, 7 sessions of plasma exchange were performed every other day with concomitant oral prednisolone therapy (60 mg/d) and prolonged tapering. The concomitant medications at that time were pantoprazole, L-thyroxine, liraglutide, basal insulin, naloxegol, pregabalin and mirtazapine.\nGiven the recently approved therapies for AQP4-positive NMOSD and the fulminant onset of the disease, we decided to start INE as an off-label use. Administration of 300 mg on days 1 and 15 was well tolerated with no immediate or subacute adverse events. Prior to discharge to a rehabilitation clinic, the patient could recognise the basic shapes of most everyday objects with her left eye and was able to stand with much assistance.\nAt a follow-up visit 3 months later, the patient reported being able to walk up to 500 m with a walker. The right eye remained blind, colour vision had returned to the left eye, but she was still unable to read a newspaper. A brain MRI showed a new inflammatory T2 lesion in the left frontal white matter, possibly representing paraclinical disease activity before the immunotherapy could take full effect. Prednisolone was reduced from 20 mg to 5 mg/d. When we administered the second cycle of INE at the six-month follow-up, there were no new cerebral lesions and the inflammatory cervical myelopathy decreased in volume . Walking was unrestricted; unfortunately, the visual impairment remained unchanged. Clinical stability was maintained after 12 months of treatment. A synopsis of the clinical course is shown in .", + "fulltext_subclaims": [ + "The patient was initially admitted to a secondary care centre.", + "Her medical history included arterial hypertension.", + "Her medical history included type 2 diabetes mellitus.", + "She had breast cancer that was in full remission following treatment more than 15 years ago.", + "She had just returned from a pilgrimage.", + "She noticed a subacute sensorimotor deficit in her left hand.", + "Physicians initially suspected a stroke.", + "The brain MRI showed no signs of acute or subacute ischemia.", + "The brain MRI showed no signs of inflammation.", + "She was admitted for further diagnostic evaluation.", + "The next day she complained of blurred vision.", + "There was no reported loss of visual acuity at that time.", + "Over the next 3 days there was a marked clinical deterioration.", + "The patient developed a vesiculopapular rash with secondary clustered crustation on her neck, ear and décolletage.", + "The patient became increasingly agitated and confused.", + "CSF examination revealed a mild pleocytosis of 10 [0–4] /μl.", + "Empirical antiviral treatment with aciclovir was started on suspicion of herpes zoster encephalitis.", + "Subsequent PCR testing of the CSF was negative for varicella-zoster.", + "Subsequent PCR testing of the CSF was negative for herpes simplex.", + "Subsequent PCR testing of the CSF was negative for other neurotropic viruses.", + "A follow-up cerebral MRI revealed a right parahippocampal T2 lesion that was not evident on the initial MRI.", + "There were T2 hyperintense lesions in both optic nerves, which were consistent with optic neuritis.", + "The patient was referred to a tertiary care facility.", + "The patient was diagnosed with blindness in the right eye.", + "The patient had a severe reduction of visual acuity in the left eye (<0.1).", + "The patient had a marked ataxic tetraparesis.", + "The rash was misdiagnosed as herpes zoster.", + "The rash turned out to be self-induced excoriation caused by the patient’s own fingers.", + "The patient had a perceived severe burning and itching over the skin.", + "The rash was attributed to a central pain syndrome.", + "MRI of the spinal cord revealed spinal cord T2 hyperintense lesion locations and extension compatible with transverse myelitis.", + "A follow-up spinal tap was negative for oligoclonal bands.", + "Chest/lung CT scan revealed no evidence of pulmonary sarcoidosis.", + "Initial testing for anti-AQP4 and anti-MOG antibodies was performed 12 days after clinical onset.", + "Initial testing for anti-AQP4 and anti-MOG antibodies was performed prior to immunotherapy.", + "Sera were analysed by cell-based indirect immunofluorescence at EUROIMMUN.", + "Staining at serum dilutions ≥1:10 was considered positive.", + "Assays were negative at that time.", + "Assays were negative at follow-up.", + "The diagnostic criteria for seronegative NMOSD require the presence of ≥2 core criteria.", + "At least one of the core criteria must be ON, LETM or area postrema syndrome.", + "Additional MR criteria must also be met.", + "The patient had two core clinical features (bilateral ON and LETM).", + "Brain MRI showed extensive (>1/2 optic nerve length) T2 hyperintense lesions of both optic nerves.", + "The brain MRI showed a white matter lesion not suggestive of MS.", + "The patient had acute myelitis involving more than 3 contiguous segments.", + "Differential diagnoses were ruled out as far as possible by repeated serological and CSF analysis.", + "The patient was diagnosed with seronegative NMOSD according to the 2015 revised criteria.", + "Treatment with high-dose intravenous methylprednisolone at 1 g per day for 5 consecutive days was started.", + "Due to lack of improvement, 7 sessions of plasma exchange were performed every other day.", + "Plasma exchange was performed with concomitant oral prednisolone therapy (60 mg/d).", + "Plasma exchange was performed with prolonged tapering.", + "The concomitant medications included pantoprazole.", + "The concomitant medications included L-thyroxine.", + "The concomitant medications included liraglutide.", + "The concomitant medications included basal insulin.", + "The concomitant medications included naloxegol.", + "The concomitant medications included pregabalin.", + "The concomitant medications included mirtazapine.", + "INE was started as an off-label use.", + "INE was administered at 300 mg on days 1 and 15.", + "INE was well tolerated with no immediate or subacute adverse events.", + "Prior to discharge, the patient could recognize the basic shapes of most everyday objects with her left eye.", + "Prior to discharge, the patient was able to stand with much assistance.", + "At a follow-up visit 3 months later, the patient reported being able to walk up to 500 m with a walker.", + "The right eye remained blind.", + "Color vision had returned to the left eye.", + "She was still unable to read a newspaper.", + "A brain MRI showed a new inflammatory T2 lesion in the left frontal white matter.", + "Prednisolone was reduced from 20 mg to 5 mg/d.", + "When the second cycle of INE was administered at the six-month follow-up, there were no new cerebral lesions.", + "The inflammatory cervical myelopathy decreased in volume.", + "Walking was unrestricted.", + "The visual impairment remained unchanged.", + "Clinical stability was maintained after 12 months of treatment." + ], + "summary": "We report a 56-year-old woman with bilateral optic neuritis and longitudinally extensive myelitis as the index events of a seronegative NMOSD, who was successfully treated with inebilizumab.", + "summary_subclaims": [ + "The patient is a 56-year-old woman.", + "The patient had bilateral optic neuritis.", + "The patient had longitudinally extensive myelitis.", + "The index events were bilateral optic neuritis and longitudinally extensive myelitis.", + "The diagnosis was seronegative NMOSD.", + "The patient was successfully treated with inebilizumab." + ] + }, + { + "id": "multiclinsum_test_835_en.txt", + "fulltext": "A 36-year-old pregnant woman (gravida 3, para 1) presented at our gynecological oncology department with vaginal bleeding after thinprep cytologic test (TCT) at 13 gestational weeks. She reported no abdominal/pelvic pain and no medical and surgical histories. Gynecologic pelvic examination revealed a cervical lesion 5 cm in diameter without involvement of vagina and parametrium. An ultrasound scan revealed an enlarged uterus for a pregnancy at the 13th week. Gadolinium-free pelvic magnetic resonance imaging (MRI) confirmed that no regional lymph node engagement was documented. Squamous cell carcinoma of invasive non-keratinizing type was confirmed by cervical biopsy. Human papilloma virus (HPV) DNA testing was positive for HPV 18. The case was diagnosed as stage IB3 according to the latest 2018 International Federation of Gynecology and Obstetrics classification.\nThe patient strongly desired to maintain the pregnancy and refused to perform surgery. All the potential risks and complications of therapy were presented and the informed consent was signed. After thorough discussion in a multidisciplinary team (MDT) meeting, we decided for NACT with carboplatin (area under the curve of concentration × time [AUC]= 5 on day 1 every 21 days) and paclitaxel (175 mg/mq every 21 days), followed by caesarean section and radical hysterectomy with monitoring the evolution of the mass and pregnancy. The patient received 5 cycles of chemotherapy from 20 gestational weeks to 32 gestational weeks. The only toxic effects were slight nausea and vomiting. Concerning the advanced maternal age (36-year-old), prenatal screening for the common fetal autosomal aneuploidies was suggested. But malignancy among pregnant women could result in discordance between noninvasive prenatal testing (NIPT) results and the fetal karyotype . Therefore, an amniocentesis was performed and revealed no chromosome anomalies at 24 gestational weeks. Fetal and maternal Doppler readings demonstrated no intrauterine growth restriction through pregnancy. After careful MDT discussion and a review of literature , fetal lung maturity was achieved for babies at 35 weeks and 3-week-interval between the last cycle of chemotherapy (32 weeks) and delivery was recommended . Thus, a caesarean section at 35 weeks’ gestation was performed 3 weeks after the last cycle of chemotherapy to allow both maternal and fetal bone marrow to recover, followed by radical hysterectomy and pelvic lymphadenectomy. The caesarean section was performed under locoregional anesthesia, with conversion to general anesthesia for the hysterectomy and lymphadenectomy . The infant was a female, with an Apgar score at 1 and 5 min of 9 and 10, weighing 2060 g (21th percentile according to WHO growth curves). After placental expulsion, radical hysterectomy plus pelvic lymphadenectomy were performed. As no lymph node engagement was indicated by MRI and assessment during the surgery, para-aortic lymph nodes dissection was not considered. The patient and infant were discharged on the twelfth postoperative day in good general condition. The identifiable lesion was 3.5 cm in diameter during the surgery . Histologic report revealed a poorly differentiated cervical adenocarcinoma, locally adenosquamous carcinoma with 75% stromal invasion, invasion of the posterior vaginal wall, no lymphovascular space invasion, clear vaginal resection margins and negative pelvic lymph nodes. Postoperative radiotherapy was proposed. Extensive pathological examination of placenta and umbilical cord showed no metastasis of maternal malignancy. Neonate physical examination, blood count, biochemical analysis and auditory brain stem evoked potential test turned out to show no sign of abnormality. At last follow-up (4 months post-surgery) both the mother and infant are in good general condition.", + "fulltext_subclaims": [ + "The patient is a 36-year-old pregnant woman.", + "She is gravida 3, para 1.", + "She presented with vaginal bleeding after thinprep cytologic test at 13 gestational weeks.", + "She reported no abdominal/pelvic pain.", + "She had no medical and surgical histories.", + "Gynecologic pelvic examination revealed a cervical lesion 5 cm in diameter.", + "There was no involvement of vagina and parametrium.", + "An ultrasound scan revealed an enlarged uterus for a pregnancy at the 13th week.", + "Gadolinium-free pelvic MRI confirmed no regional lymph node engagement.", + "Squamous cell carcinoma of invasive non-keratinizing type was confirmed by cervical biopsy.", + "HPV DNA testing was positive for HPV 18.", + "The case was diagnosed as stage IB3 according to the 2018 International Federation of Gynecology and Obstetrics classification.", + "The patient strongly desired to maintain the pregnancy.", + "The patient refused to perform surgery.", + "All potential risks and complications of therapy were presented.", + "Informed consent was signed.", + "A decision was made for NACT with carboplatin (AUC=5 on day 1 every 21 days) and paclitaxel (175 mg/mq every 21 days).", + "The plan included caesarean section and radical hysterectomy.", + "The patient received 5 cycles of chemotherapy from 20 to 32 gestational weeks.", + "The only toxic effects were slight nausea and vomiting.", + "Prenatal screening for fetal autosomal aneuploidies was suggested.", + "An amniocentesis was performed at 24 gestational weeks.", + "Amniocentesis revealed no chromosome anomalies.", + "Fetal and maternal Doppler readings showed no intrauterine growth restriction.", + "Fetal lung maturity was achieved at 35 weeks.", + "A 3-week interval between the last cycle of chemotherapy and delivery was recommended.", + "A caesarean section at 35 weeks was performed 3 weeks after the last cycle of chemotherapy.", + "The caesarean section was performed under locoregional anesthesia.", + "The infant was a female.", + "The Apgar score at 1 and 5 minutes was 9 and 10.", + "The infant weighed 2060 g.", + "Radical hysterectomy plus pelvic lymphadenectomy were performed after placental expulsion.", + "Para-aortic lymph nodes dissection was not considered.", + "The patient and infant were discharged on the twelfth postoperative day.", + "The identifiable lesion was 3.5 cm in diameter during surgery.", + "Histologic report revealed a poorly differentiated cervical adenocarcinoma.", + "The tumor was locally adenosquamous carcinoma with 75% stromal invasion.", + "There was invasion of the posterior vaginal wall.", + "There was no lymphovascular space invasion.", + "Vaginal resection margins were clear.", + "Pelvic lymph nodes were negative.", + "Postoperative radiotherapy was proposed.", + "Extensive pathological examination of placenta and umbilical cord showed no metastasis.", + "Neonate physical examination showed no sign of abnormality.", + "Neonate blood count showed no sign of abnormality.", + "Neonate biochemical analysis showed no sign of abnormality.", + "Neonate auditory brain stem evoked potential test showed no sign of abnormality.", + "At last follow-up (4 months post-surgery), both the mother and infant were in good general condition." + ], + "summary": "A 36-year-old pregnant woman was diagnosed with a 5-cm-diameter stage IB3 squamous cell carcinoma of the uterine cervix at 13 gestational weeks. The patient received 5 courses of systemic chemotherapy with carboplatin and paclitaxel every 3 weeks, followed by caesarean section and radical hysterectomy. Both the mother and infant are in good general condition.", + "summary_subclaims": [ + "The patient is a 36-year-old pregnant woman.", + "She was diagnosed with a 5-cm-diameter stage IB3 squamous cell carcinoma of the uterine cervix.", + "The diagnosis occurred at 13 gestational weeks.", + "The patient received 5 courses of systemic chemotherapy.", + "The chemotherapy regimen included carboplatin and paclitaxel.", + "The chemotherapy was administered every 3 weeks.", + "The patient underwent caesarean section.", + "The patient underwent radical hysterectomy.", + "Both the mother and infant are in good general condition." + ] + }, + { + "id": "multiclinsum_test_781_en.txt", + "fulltext": "A 58-year-old male presented with diarrhea. His medical history included type 2 diabetes, hypertension, and a lumbar hernia. He had a history of smoking and occasional alcohol consumption. Physical examination results were unremarkable. Initial laboratory tests revealed a serum hemoglobin level of 12.7 g/dL, a serum carcinoembryonic antigen level of 1.5 ng/dL (reference range: 0–2.5 ng/mL), and a carbohydrate antigen 19–9 level of 13.0 ng/dL (reference range: 0–37 U/mL). Lower gastrointestinal endoscopy revealed a half-circumferential rectal tumor. A biopsy confirmed a well-differentiated adenocarcinoma. Contrast-enhanced computed tomography (CT) revealed focal wall thickening of the rectum (T3) with several enlarged perienteric lymph nodes (N2) and extramural vascular invasion, without evidence of metastasis (M0). The patient received two courses of neoadjuvant chemotherapy of mFOLFOX6 regimen, followed by laparoscopic Hartmann's operation. Arterial flow at the edge of the sigmoid colostomy was preserved during surgery. The perienteric peritoneal metastasis was completely resected. Postoperative histopathological findings revealed a residual adenocarcinoma with a TNM score of ypT3N2aM1c. The patient was discharged from the hospital on postoperative day 13.\nOn postoperative day 28, the patient reported an abnormal orifice in the stoma and painful defecation. Physical examination revealed a colostomy fistula at the 6 o'clock position of the stoma orifice . No intra-abdominal abscess or inflammation was observed , and adjuvant chemotherapy with mFOLFOX6 was administered. However, the colostomy fistula gradually enlarged and painful defecation persisted. Consequently, laparoscopic colostomy reconstruction was performed.\nDuring surgery, no necrosis or abscesses were observed in the abdominal cavity. The edge of the stoma was resected, and colostomy reconstruction was performed without complications. Macroscopic examination of the resected intestinal tract revealed thickening of the surrounding intestinal wall, without the evidence of a diverticulum . Histopathological analysis of the resected colon with the fistula showed a fibrosis replacement where originally muscularis propria exists, with adjacent ganglion cells . The patient did not experience any adverse events or gastrointestinal symptoms following surgery.", + "fulltext_subclaims": [ + "The patient is a 58-year-old male.", + "The patient presented with diarrhea.", + "The patient's medical history included type 2 diabetes.", + "The patient's medical history included hypertension.", + "The patient had a history of smoking.", + "The patient had occasional alcohol consumption.", + "Physical examination results were unremarkable.", + "Initial laboratory tests revealed a serum hemoglobin level of 12.7 g/dL.", + "Initial laboratory tests revealed a serum carcinoembryonic antigen level of 1.5 ng/dL.", + "Initial laboratory tests revealed a carbohydrate antigen 19–9 level of 13.0 ng/dL.", + "Lower gastrointestinal endoscopy revealed a half-circumferential rectal tumor.", + "A biopsy confirmed a well-differentiated adenocarcinoma.", + "Contrast-enhanced computed tomography (CT) revealed focal wall thickening of the rectum (T3).", + "Contrast-enhanced CT revealed several enlarged perienteric lymph nodes (N2).", + "Contrast-enhanced CT revealed extramural vascular invasion.", + "Contrast-enhanced CT showed no evidence of metastasis (M0).", + "The patient received two courses of neoadjuvant chemotherapy of mFOLFOX6 regimen.", + "The patient underwent laparoscopic Hartmann's operation.", + "Arterial flow at the edge of the sigmoid colostomy was preserved during surgery.", + "The perienteric peritoneal metastasis was completely resected.", + "Postoperative histopathological findings revealed a residual adenocarcinoma with a TNM score of ypT3N2aM1c.", + "The patient was discharged from the hospital on postoperative day 13.", + "On postoperative day 28, the patient reported an abnormal orifice in the stoma.", + "On postoperative day 28, the patient reported painful defecation.", + "Physical examination revealed a colostomy fistula at the 6 o'clock position of the stoma orifice.", + "No intra-abdominal abscess or inflammation was observed.", + "Adjuvant chemotherapy with mFOLFOX6 was administered.", + "The colostomy fistula gradually enlarged.", + "Painful defecation persisted.", + "Laparoscopic colostomy reconstruction was performed.", + "During surgery, no necrosis or abscesses were observed in the abdominal cavity.", + "The edge of the stoma was resected.", + "Colostomy reconstruction was performed without complications.", + "Macroscopic examination of the resected intestinal tract revealed thickening of the surrounding intestinal wall.", + "Macroscopic examination showed no evidence of a diverticulum.", + "Histopathological analysis of the resected colon with the fistula showed fibrosis replacement where originally muscularis propria exists.", + "Histopathological analysis showed adjacent ganglion cells.", + "The patient did not experience any adverse events or gastrointestinal symptoms following surgery." + ], + "summary": "A 58-year-old male with a history of type 2 diabetes, hypertension, and lumbar hernia presented with diarrhea. Lower gastrointestinal endoscopy revealed a tumor in the rectum, for which he was diagnosed with a well-differentiated adenocarcinoma. The patient underwent a laparoscopic Hartmann operation. After the operation, an entero-entero-fistula was identified at the sigmoid colostomy site. Subsequently, laparoscopic reconstruction of the colostomy was performed, and the patient had a favorable postoperative course without complications. Histopathological examination confirmed the localized absence of the muscularis propria in the resected colon, with fibrosis and nearby ganglion cells.", + "summary_subclaims": [ + "The patient is a 58-year-old male.", + "The patient has a history of type 2 diabetes.", + "The patient has a history of hypertension.", + "The patient has a history of lumbar hernia.", + "The patient presented with diarrhea.", + "Lower gastrointestinal endoscopy revealed a tumor in the rectum.", + "The patient was diagnosed with a well-differentiated adenocarcinoma.", + "The patient underwent a laparoscopic Hartmann operation.", + "An entero-entero-fistula was identified at the sigmoid colostomy site after the operation.", + "Laparoscopic reconstruction of the colostomy was performed.", + "The patient had a favorable postoperative course without complications.", + "Histopathological examination confirmed the localized absence of the muscularis propria in the resected colon.", + "Fibrosis was noted in the resected colon.", + "Nearby ganglion cells were identified in the resected colon." + ] + }, + { + "id": "multiclinsum_test_1160_en.txt", + "fulltext": "A 61-year-old female, known to suffer from chronic hepatitis C (Child Pugh A), presented in Jan 2001 to another hospital complaining of abdominal pain. CT-Scan of the abdomen showed a solitary 5 × 5 cm mass in segment VII of the liver. Fine needle aspiration cytology (FNAC) showed features consistent with HCC. AFP level at the time was normal 2.23 ng/ml (normal < 5.6 ng/ml). She traveled abroad (outside Kuwait), underwent resection of the tumor and returned back to Kuwait. A brief report stated that the tumor was resected from segment VII with about 1.5 cm safety margin with an uneventful postoperative course. Histopathology of the original tumor proved to be a well differentiated HCC with clear margins and no vascular invasion.\nUpon return to Kuwait, she was under the care of the hepatologist who treating her chronic hepatitis with Pegelated Interferon and Ribaverin for 6 months. Unfortunately she remained HCV positive.\nIn Oct. 2004, three years following her original surgery, she was referred to the Liver Unit, Mubarak Al-Kabeer Hospital with an abdominal wall mass of one-year duration. On physical examination an obvious 7 × 5 cm smooth oval mass was seen in the right upper quadrant at the lateral border of her previous right subcostal scar. Clinically the mass seemed to be within the abdominal wall and the skin over it was free. CT scan of the abdomen showed a round well defined enhancing soft tissue density mass measuring 11 × 5 × 5 cm within the anterior abdominal wall with no intra-abdominal extension or skin infiltration . The liver was free except from signs of previous surgery in segment VII. Tumor markers were: AFP 6.23 ng/ml (normal < 5.6 ng/ml), CEA 1.5 ng/ml (normal < 6.9 ng/ml) and CA19-9 15.9 (normal < 43 ng/dl). FNAC from this mass, was consistent with metastatic HCC . En-bloc resection of the mass (including the mass, overlying skin, abdominal wall muscles and peritoneum) was performed under general anesthesia with primary closure. Histopathology of the removed specimen confirmed implantation of HCC in the abdominal muscles with free surgical margin and no peritoneal penetration . The patient had an uneventful recovery and was discharged home on the 7th postoperative day.\nTo date, 20 months since resection of the metastatic mass, she remains well with normal AFP and liver functions and no evidence of recurrence in the liver or abdominal wall.", + "fulltext_subclaims": [ + "The patient is a 61-year-old female.", + "She has chronic hepatitis C (Child Pugh A).", + "She presented in Jan 2001 to another hospital complaining of abdominal pain.", + "CT-Scan of the abdomen showed a solitary 5 × 5 cm mass in segment VII of the liver.", + "Fine needle aspiration cytology showed features consistent with HCC.", + "AFP level at the time was 2.23 ng/ml.", + "The normal AFP level is < 5.6 ng/ml.", + "She traveled abroad and underwent resection of the tumor.", + "The tumor was resected from segment VII with about 1.5 cm safety margin.", + "The postoperative course was uneventful.", + "Histopathology of the original tumor proved to be a well differentiated HCC.", + "The original tumor had clear margins.", + "The original tumor showed no vascular invasion.", + "She was treated with Pegelated Interferon and Ribaverin for 6 months.", + "She remained HCV positive.", + "In Oct. 2004, she was referred to the Liver Unit, Mubarak Al-Kabeer Hospital with an abdominal wall mass of one-year duration.", + "On physical examination, an obvious 7 × 5 cm smooth oval mass was seen in the right upper quadrant.", + "The mass was at the lateral border of her previous right subcostal scar.", + "CT scan showed a round well defined enhancing soft tissue density mass measuring 11 × 5 × 5 cm within the anterior abdominal wall.", + "The mass had no intra-abdominal extension.", + "The mass had no skin infiltration.", + "The liver was free except from signs of previous surgery in segment VII.", + "AFP was 6.23 ng/ml.", + "FNAC from this mass was consistent with metastatic HCC.", + "En-bloc resection of the mass was performed.", + "The resection included the mass, overlying skin, abdominal wall muscles, and peritoneum.", + "Histopathology confirmed implantation of HCC in the abdominal muscles.", + "The surgical margin was free.", + "There was no peritoneal penetration.", + "The patient had an uneventful recovery.", + "She was discharged home on the 7th postoperative day.", + "To date, 20 months since resection of the metastatic mass, she remains well.", + "She has normal AFP.", + "She has normal liver functions.", + "There is no evidence of recurrence in the liver.", + "There is no evidence of recurrence in the abdominal wall." + ], + "summary": "We report a female patient who presented with a right upper abdominal wall mass 3 years following a fine needle aspiration cytology (FNAC) and resection of a solitary hepatocellular carcinoma (HCC) from the liver. The mass proved to be a metastatic HCC; it was locally resected with safety margins. To date (20 months later) she remains well with no recurrence.", + "summary_subclaims": [ + "The patient is female.", + "The patient had a right upper abdominal wall mass.", + "The mass was 3 years after a fine needle aspiration cytology and resection of a solitary hepatocellular carcinoma.", + "The mass was a metastatic hepatocellular carcinoma.", + "The mass was locally resected with safety margins.", + "To date (20 months later) she remains well.", + "To date (20 months later) she has no recurrence." + ] + }, + { + "id": "multiclinsum_test_1635_en.txt", + "fulltext": "Two cases of STS of the lower limb characterized by DVT and pulmonary embolism (PE) as the initial presentation were observed in our Orthopedic department: a 47-year-old man diagnosed with an idiopathic DVT of the right distal femoral vein and the popliteal vein and a 44-years-old woman with a massive PE . The patient with DVT was treated with therapeutic doses of subcutaneous enoxaparin for 6 months. After 2 months of enoxaparin, the case with PE was referred to our outpatient clinic for worsening of leg swelling and dyspnea. Neither of the patients had a past or family history of VTE. Physical and radiographic examination did not reveal any mass in either case, but only the signs of DVT or PE. Due to the persistence of symptoms and the inefficacy of anticoagulant therapy, patients underwent magnetic resonance imaging (MRI) of the lower limbs and excisional biopsy of the visualized mass.\nIn the first case , MRI showed a large mass in the anterior muscle compartment of the right thigh, with inhomogeneous appearance after gadolinium administration. The lesion was associated with multiple lymphadenopathy in the inguinal and external iliac region, and thrombosis of the right common femoral vein involving the ipsilateral common iliac vein and the inferior vena cava until the confluence of the renal veins. An excisional biopsy of the mass was performed. The lesion was found to be adherent to the femoral vein. The dissection of the vein showed a thrombus that obliterated the lumen of the common iliac vein. The histological examination revealed a high-grade leiomyosarcoma. The patient subsequently underwent chemotherapy and radiotherapy. A computerized tomography (CT) scan performed 6 months after surgery showed multiple pulmonary metastases. The patients is currently receiving chemotherapy in the Oncology division of our hospital.\nIn the second case, MRI showed a large mass located in the middle third of the right thigh, with low signal intensity in T1- and T2-weighted sequences and enhancement after gadolinium administration . The lesion was in close proximity to the superficial femoral artery that appeared deformed and was adherent to the superficial femoral vein that appeared compressed and showed signs of thrombosis. After arterial embolization, an excisional biopsy was performed, followed by intraoperative brachytherapy. The histological examination of the bioptic specimen revealed a high-grade leiomyosarcoma. At one year of follow-up the patient was asymptomatic and showed no evidence of recurrence of malignancy at MRI.", + "fulltext_subclaims": [ + "Two cases of STS of the lower limb characterized by DVT and pulmonary embolism (PE) as the initial presentation were observed in our Orthopedic department.", + "A 47-year-old man was diagnosed with an idiopathic DVT of the right distal femoral vein and the popliteal vein.", + "A 44-year-old woman had a massive PE.", + "The patient with DVT was treated with therapeutic doses of subcutaneous enoxaparin for 6 months.", + "After 2 months of enoxaparin, the case with PE was referred to our outpatient clinic for worsening of leg swelling and dyspnea.", + "Neither of the patients had a past or family history of VTE.", + "Physical and radiographic examination did not reveal any mass in either case.", + "Due to the persistence of symptoms and the inefficacy of anticoagulant therapy, patients underwent magnetic resonance imaging (MRI) of the lower limbs and excisional biopsy of the visualized mass.", + "In the first case, MRI showed a large mass in the anterior muscle compartment of the right thigh, with inhomogeneous appearance after gadolinium administration.", + "The lesion was associated with multiple lymphadenopathy in the inguinal and external iliac region.", + "Thrombosis of the right common femoral vein involved the ipsilateral common iliac vein and the inferior vena cava until the confluence of the renal veins.", + "An excisional biopsy of the mass was performed.", + "The lesion was found to be adherent to the femoral vein.", + "The dissection of the vein showed a thrombus that obliterated the lumen of the common iliac vein.", + "The histological examination revealed a high-grade leiomyosarcoma.", + "The patient subsequently underwent chemotherapy and radiotherapy.", + "A computerized tomography (CT) scan performed 6 months after surgery showed multiple pulmonary metastases.", + "The patient is currently receiving chemotherapy in the Oncology division of our hospital.", + "In the second case, MRI showed a large mass located in the middle third of the right thigh, with low signal intensity in T1- and T2-weighted sequences and enhancement after gadolinium administration.", + "The lesion was in close proximity to the superficial femoral artery that appeared deformed.", + "The superficial femoral vein appeared compressed and showed signs of thrombosis.", + "After arterial embolization, an excisional biopsy was performed, followed by intraoperative brachytherapy.", + "The histological examination of the bioptic specimen revealed a high-grade leiomyosarcoma.", + "At one year of follow-up the patient was asymptomatic and showed no evidence of recurrence of malignancy at MRI." + ], + "summary": "We describe two cases of STS who presented with DVT and PE. Physical and radiographic examination only showed the presence of DVT. Both patients were treated for DVT or PE for several months. Due to the persistence of symptoms and the inefficacy of anticoagulant therapy, magnetic resonance imaging (MRI) was performed, which revealed the presence of a lower limb mass in both cases. The definite diagnosis was reached via excisional biopsy and histological examination.In one case, MRI showed a large tumor in the anterior muscle compartment of the right thigh, with thrombosis of the right common femoral vein and involvement of the ipsilateral common iliac vein and inferior vena cava until the confluence of the renal veins. In the other case, MRI showed a large tumor in the middle third of the right thigh. The lesion was in close proximity to the superficial femoral vein that appeared compressed and showed signs of thrombosis. In both cases, histological examination revealed a high-grade leiomyosarcoma.", + "summary_subclaims": [ + "We describe two cases of STS who presented with DVT and PE.", + "Physical and radiographic examination only showed the presence of DVT.", + "Both patients were treated for DVT or PE for several months.", + "Due to the persistence of symptoms and the inefficacy of anticoagulant therapy, magnetic resonance imaging (MRI) was performed.", + "MRI revealed the presence of a lower limb mass in both cases.", + "The definite diagnosis was reached via excisional biopsy and histological examination.", + "In one case, MRI showed a large tumor in the anterior muscle compartment of the right thigh.", + "In one case, MRI showed thrombosis of the right common femoral vein.", + "In one case, MRI showed involvement of the ipsilateral common iliac vein and inferior vena cava until the confluence of the renal veins.", + "In the other case, MRI showed a large tumor in the middle third of the right thigh.", + "In the other case, MRI showed the lesion was in close proximity to the superficial femoral vein.", + "In the other case, MRI showed the superficial femoral vein appeared compressed and showed signs of thrombosis.", + "In both cases, histological examination revealed a high-grade leiomyosarcoma." + ] + }, + { + "id": "multiclinsum_test_825_en.txt", + "fulltext": "The patient was a 16-month-old girl. No prenatal abnormalities were noted. She visited a nearby doctor on a remote island for fever and was treated with antibiotic therapy as an outpatient. She gradually developed clouding of consciousness and dyspnea. She was transferred to our hospital on the 13th day after the onset of symptoms due to a huge dilated common bile duct that was detected on imaging at the previous hospital.\nContrast-enhanced computed tomography showed dilation of the common bile duct (maximum diameter: 5 cm) , suggesting CBD. However, her laboratory data on admission showed severe liver disfunction (AST, 79 IU/L; ALT, 43 IU/L; γ-GTP, 491 mg/dl; D-bil, 0.3 mg/dl; Alb 2.5 mg/dl; CHE, 90 IU/L; NH3, 123 μg/dl) . The Child-Pugh classification was equivalent to Grade A–B when combined with the fact that she had consciousness disturbance, a history of vitamin K treatment, and her laboratory findings at the time of admission. We initially performed laparoscopic exploration and bile drainage via the gallbladder, noting severe hepatic fibrosis resembling end-stage liver cirrhosis . A 5-mm 30° laparoscope was inserted through an umbilical incision along with a 5 mm trocar with a multichannel port device (E.Z Access/LAP-PROTECTOR minimini; Hakko Co., Ltd., Tokyo, Japan). Since the view of the lower liver space could not be obtained, a 3-mm port was additionally inserted through the EZ Access to secure the view. The liver had many hoop-like notches on both lobes, which is a finding of liver sclerosis. A 3-mm port was additionally inserted into the right upper abdomen and the gallbladder was pulled out from the port wound. A double purse suture was applied with 4–0 PDS outside the body and an incision was made, and then an 8-Fr balloon catheter was inserted, and the tip was placed in the common bile duct. After placing a drainage tube in the gallbladder, cholangiography was performed. We confirmed continuity between dilation of the intrahepatic bile ducts and the common bile duct, and it consistent with findings of biliary dilatation. There was no gallbladder atrophy, which is seen in I cyst-type biliary atresia . Cholangiography revealed Todani type IVa CBD with pancreaticobiliary maljunction. Then, the patient received liver-supporting therapy and nutritional support for 7 weeks before definitive surgery.\nFollowing the improvement of the hepatic synthetic capacity (Alb, 4.0 mg/dl; AST, 82 IU/L; ALT, 78 IU/L; γ-GTP, 157 mg/dl; D-bil, 0.2 mg/dl; CHE, 232 IU/L; NH3, 75 μg/dl) , we performed extrahepatic bile duct excision and hepaticojejunostomy laparoscopically . Laparoscopic choledochal cyst excision was performed using five ports. Under general anesthesia, the patient was placed in the broad base position, and the operator stand to the right side of the patient. A 10-mm 30° laparoscope was inserted through an umbilical incision along with a trocar with a multichannel port device (E.Z Access/LAP-PROTECTOR minimini; Hakko Co., Ltd., Tokyo, Japan). Pneumoperitoneum was established with 8-mm Hg CO2 insufflation. Three additional trocars and a 2.4-mm needle-type grasper (Teleflex, Morrisville, NC, USA) were inserted into the right upper abdomen (operator's left hand, 3.5 mm) and at the right side of the umbilicus (operator's right hand, 5 mm), the left lateral abdomen (assistant's left hand, 3.5 mm), and the left upper abdomen (assistant's right hand, 2.4 mm). The dilated CBD was dissected and then taping was performed. After imaging the lower bile duct and confirming that the bile duct on the side of the pancreas was sufficiently detached, the lower bile duct was clipped and transected. Subsequently, after dissection and transection of the cystic duct, the hepatic duct just above the dilated common hepatic duct was transected. The jejunum was then extracted from the umbilical wound, and Roux-en Y jejunojejunostomy was performed. The mucosa and serosa of the opened hole was approximated using 6–0 absorbable sutures to secure hepaticojejunostomy. The jejunum was pulled up through the retro-colic route. Both the posterior and anterior walls were approximated using interrupted intracorporeal knot-tying with 5–0 absorbable sutures. Laparoscopic surgery was successfully performed along with liver biopsy. Histopathologically, the liver specimen showed chronic hepatitis and fibrosis (F3A2) based on the new Inuyama classification . F4 is defined as liver cirrhosis, but it presents clinical findings as disturbed consciousness with hyperammonemia and intraoperative findings as advanced liver fibrosis, and we clinically diagnosed to be almost equivalent to liver cirrhosis in the compensation stage. Biliary scintigraphy showed good bile excretion on postoperative day 15 . The postoperative course was uneventful and the patient was discharged on the 23rd day after surgery.\nAt 6 months after laparoscopic extrahepatic bile duct resection and hepaticojejunostomy, she was readmitted and underwent needle liver biopsy to confirm the morphological improvement after surgery. After discharge from the hospital, her hepatic function normalized, and her cholinesterase level, which was low before surgery, showed a tendency toward improvement; however, her NH3 level remained above the normal range . A histopathological examination showed mild improvement of chronic hepatitis and fibrosis (F2-3A1) . The patient was regularly followed at the outpatient clinic.", + "fulltext_subclaims": [ + "The patient was a 16-month-old girl.", + "No prenatal abnormalities were noted.", + "She visited a nearby doctor on a remote island for fever.", + "She was treated with antibiotic therapy as an outpatient.", + "She gradually developed clouding of consciousness and dyspnea.", + "She was transferred to our hospital on the 13th day after the onset of symptoms.", + "A huge dilated common bile duct was detected on imaging at the previous hospital.", + "Contrast-enhanced computed tomography showed dilation of the common bile duct (maximum diameter: 5 cm).", + "The dilation of the common bile duct suggested CBD.", + "Her laboratory data on admission showed severe liver dysfunction.", + "The Child-Pugh classification was equivalent to Grade A–B.", + "We initially performed laparoscopic exploration and bile drainage via the gallbladder.", + "The liver had many hoop-like notches on both lobes.", + "The hoop-like notches are a finding of liver sclerosis.", + "A 3-mm port was additionally inserted into the right upper abdomen.", + "The gallbladder was pulled out from the port wound.", + "A double purse suture was applied with 4–0 PDS outside the body.", + "An 8-Fr balloon catheter was inserted, and the tip was placed in the common bile duct.", + "Cholangiography was performed.", + "We confirmed continuity between dilation of the intrahepatic bile ducts and the common bile duct.", + "The findings were consistent with biliary dilatation.", + "There was no gallbladder atrophy.", + "Cholangiography revealed Todani type IVa CBD with pancreaticobiliary maljunction.", + "The patient received liver-supporting therapy and nutritional support for 7 weeks before definitive surgery.", + "Following the improvement of the hepatic synthetic capacity, we performed extrahepatic bile duct excision and hepaticojejunostomy laparoscopically.", + "Laparoscopic choledochal cyst excision was performed using five ports.", + "A 10-mm 30° laparoscope was inserted through an umbilical incision.", + "Pneumoperitoneum was established with 8-mm Hg CO2 insufflation.", + "The dilated CBD was dissected and then taping was performed.", + "The lower bile duct was clipped and transected.", + "The hepatic duct just above the dilated common hepatic duct was transected.", + "Roux-en Y jejunojejunostomy was performed.", + "The mucosa and serosa of the opened hole were approximated using 6–0 absorbable sutures.", + "The jejunum was pulled up through the retro-colic route.", + "Both the posterior and anterior walls were approximated using interrupted intracorporeal knot-tying with 5–0 absorbable sutures.", + "Laparoscopic surgery was successfully performed along with liver biopsy.", + "Histopathologically, the liver specimen showed chronic hepatitis and fibrosis (F3A2) based on the new Inuyama classification.", + "F4 is defined as liver cirrhosis.", + "We clinically diagnosed the patient to be almost equivalent to liver cirrhosis in the compensation stage.", + "Biliary scintigraphy showed good bile excretion on postoperative day 15.", + "The postoperative course was uneventful.", + "The patient was discharged on the 23rd day after surgery.", + "At 6 months after laparoscopic extrahepatic bile duct resection and hepaticojejunostomy, she was readmitted.", + "She underwent needle liver biopsy to confirm the morphological improvement after surgery.", + "Her hepatic function normalized after surgery.", + "Her cholinesterase level showed a tendency toward improvement.", + "Her NH3 level remained above the normal range.", + "A histopathological examination showed mild improvement of chronic hepatitis and fibrosis (F2-3A1).", + "The patient was regularly followed at the outpatient clinic." + ], + "summary": "A 16-month-old girl underwent conservative therapy for liver dysfunction and cholangitis on a remote island of our prefecture. She was transferred to our hospital after the detection of a huge dilated common bile duct on imaging at the previous hospital. Contrast-enhanced computed tomography showed a dilated common bile duct (maximum diameter: 5 cm), thus suggesting CBD. However, her laboratory data on admission showed a poor nutritional status and severe liver dysfunction (Alb, 2.5 mg/dl; AST, 79 IU/L; ALT, 43 IU/L; γ-GTP, 491 mg/dl; D-bil, 0.3 mg/dl; CHE, 90 IU/L; NH3, 123 μg/dl). We initially performed laparoscopic exploration and bile drainage via the gallbladder, noting severe hepatic fibrosis resembling end-stage liver cirrhosis. After placing a drainage tube in the gallbladder, cholangiography was performed. Cholangiography showed Todani type IVa CBD with pancreaticobiliary maljunction. Contrast agent flowing into the duodenum could not be confirmed. The patient received liver-supporting therapy and nutritional support for 7 weeks before definitive surgery. Following the improvement of the hepatic synthetic capacity (Alb, 4.0 mg/dl; AST, 82 IU/L; ALT, 78 IU/L; γ-GTP, 157 mg/dl; D-bil, 0.2 mg/dl; CHE, 232 IU/L; NH3, 75 μg/dl), we performed extrahepatic bile duct excision and hepaticojejunostomy laparoscopically. Laparoscopic surgery was successfully performed along with liver biopsy. Histopathologically, the liver specimen showed chronic hepatitis and fibrosis (F3A2). Biliary scintigraphy showed good bile excretion at postoperative day 15. The postoperative course uneventful, and the patient was discharged on the 23rd day after surgery. A needle liver biopsy six months later showed mild improvement of chronic hepatitis and fibrosis (F2-3A1). The patient was regularly followed at the outpatient clinic.", + "summary_subclaims": [ + "A 16-month-old girl underwent conservative therapy for liver dysfunction and cholangitis on a remote island of our prefecture.", + "She was transferred to our hospital after the detection of a huge dilated common bile duct on imaging at the previous hospital.", + "Contrast-enhanced computed tomography showed a dilated common bile duct (maximum diameter: 5 cm), thus suggesting CBD.", + "Her laboratory data on admission showed a poor nutritional status and severe liver dysfunction.", + "We initially performed laparoscopic exploration and bile drainage via the gallbladder.", + "Cholangiography showed Todani type IVa CBD with pancreaticobiliary maljunction.", + "Contrast agent flowing into the duodenum could not be confirmed.", + "The patient received liver-supporting therapy and nutritional support for 7 weeks before definitive surgery.", + "Following the improvement of the hepatic synthetic capacity, we performed extrahepatic bile duct excision and hepaticojejunostomy laparoscopically.", + "Laparoscopic surgery was successfully performed along with liver biopsy.", + "Histopathologically, the liver specimen showed chronic hepatitis and fibrosis (F3A2).", + "Biliary scintigraphy showed good bile excretion at postoperative day 15.", + "The postoperative course was uneventful, and the patient was discharged on the 23rd day after surgery.", + "A needle liver biopsy six months later showed mild improvement of chronic hepatitis and fibrosis (F2-3A1).", + "The patient was regularly followed at the outpatient clinic." + ] + }, + { + "id": "multiclinsum_test_2576_en.txt", + "fulltext": "A 24-year-old Caucasian man with fever and upper quadrant abdominal pain over the previous 20 days was admitted to our hospital. Before admission, ciprofloxacin and metronidazole, followed by cefixime had been prescribed. Six years prior, the patient had been diagnosed with PSC, UC, suspected retroperitoneal fibrosis, bile sludge and splenomegaly. For this, he was prescribed ursodiol 300mg BID and mesalamine 4g per day. At that time, investigations included exploratory laparotomy and a biopsy of the perihepatic, retroperitoneal tissue which excluded malignancy. Over this six-year period, the patient presented with recurrent episodes of cholangitis, the serum level of aminotransferases remained substantially normal while there was a progressive worsening of cholestatic test results and a progressive liver enlargement along with fibrosis. Specifically, gamma glutamyl transpeptidase (GGT) and alkaline phosphatase (ALP) increased from 141UI/L to 344UI/L and 847UI/L to 2534UI/L, respectively. Hepatic tissue stiffness, measured by FibroScan®, progressed from 12.6 to 17.3kPa. The patient was never treated with immunosuppressive therapy or corticosteroids. One month before admission, an upper endoscopy was performed which excluded esophageal varices. One week before admission, a magnetic resonance of his abdomen and bile ducts revealed further enlargement of the liver, spleen and the tissue surrounding his hepatic hilum , posterior to the pancreas head. The latter caused a compression of his second duodenal tract and a wrapping of the splenic and hepatic arteries. Beading and narrowing of the intra-hepatic and common bile ducts resulted in more extension and a narrowing of the pancreatic duct was also reported.\nAt admission, our patient had a fever of 38.8°C and physical examination revealed tenderness of his epigastrium and right upper hypochondrium. Results from blood tests are reported in Table . Microbiological blood and urine investigations were negative for bacteria. A chest radiograph was normal while an abdominal sonography revealed an enlarged liver, thickened choledocus, dilatation of the intra-hepatic biliary tree, splenomegaly and lymphadenopathy of the hepatic hilus. A colonoscopy showed erythema of the colonic mucosa from the rectum to the cecum, with areas of increased erythema and telangiectasia in the ascending colon. Random biopsy showed focal atrophy of the colonic mucosa with edema and chronic inflammatory infiltrates, but specific investigations for CMV were not carried out. Imipenem 500mg IV four times daily was administered. Three days later, due to our patient’s persisting fever and abdominal pain, imipenem was substituted with tigecycline 50mg IV BID. Further blood and urine cultures for bacteria were negative. Both the erythrocyte sedimentation rate (ESR) and C-reactive protein level (C-RP) remained high, whereas the white blood cell (WBC) and neutrophil counts decreased and the procalcitonin level was 0.38ng/ml. The fever persisted while the upper abdominal pain subsided slightly. Investigations for HIV, Toxoplasma gondii, CMV, measles, parotitis and hepatitis C virus (HCV) all were negative, while results for varicella zoster virus, human herpes virus, Epstein Barr, rubella, and parvo virus B19 indicated previous infection. CD4?+?T lymphocytes were 1055mm3 (20.3%) and CD3?+?T lymphocytes were 3193mm3 (67%). Mycobacterium tuberculosis interferon gamma release assay (QuantiFERON®–TB Gold, Cellestis Limited, Carnegie, Victoria, Australia) showed negative results. Twelve days after admission, teicoplanin 400mg die, gentamicin 80mg TID, metronidazole 500mg TID were prescribed, while tigecycline was stopped. Two days later, deoxyribonucleic acid (DNA) Cytomegalovirus (Q-CMV Real Time, Nanogen Advanced Diagnostics, Torino, Italy) was detected in the blood with ≤253 copies/mL. Three days later, this value increased to 6189 copies/mL, while 1431 copies/mL were evidenced from a urine sample, the CMV pp65-antigen (Indirect Immunofluorescence, anti-CMV pp-UL83, Argene, France) was also positive, and CMV serology indicated acute CMV infection . Our patient’s fever rose to 39.2°C and his abdominal pain extended to the right lower abdominal quadrant with radiation to the right groin and right testicle. Ultrasound suggested acute appendicitis and he underwent surgery . Histology showed inflammatory infiltrates, including lymphocytes and neutrophils, while histochemistry was positive for CMV early antigens (Monoclonal Mouse Anti-Cytomegalovirus Clone CCH2?+?DDG9, Ventana Medical System, Roche, USA) . Real time reaction and shell vial culture of the appendix tissue also were positive. Microbiological investigations for bacteria and fungi showed Peptococcus spp. and Candida albicans. Teicoplanin, gentamicin and metronidazole were administered for a total of 12 days along with intravenous ganciclovir 5mg/kg twice for 15 days. After discharge, oral valganciclovir 900mg BID was prescribed for 10 days. After this, the CMV nucleic acid in the blood and urine was negative while ESR and cholestatic liver test results remained abnormally high .", + "fulltext_subclaims": [ + "The patient is a 24-year-old Caucasian man.", + "He had fever and upper quadrant abdominal pain over the previous 20 days.", + "Before admission, ciprofloxacin and metronidazole, followed by cefixime had been prescribed.", + "Six years prior, the patient had been diagnosed with PSC.", + "Six years prior, the patient had been diagnosed with UC.", + "Six years prior, the patient had been diagnosed with suspected retroperitoneal fibrosis.", + "Six years prior, the patient had been diagnosed with bile sludge.", + "Six years prior, the patient had been diagnosed with splenomegaly.", + "At that time, ursodiol 300mg BID was prescribed.", + "At that time, mesalamine 4g per day was prescribed.", + "At that time, exploratory laparotomy and a biopsy of the perihepatic, retroperitoneal tissue were performed.", + "The biopsy excluded malignancy.", + "Over this six-year period, the patient presented with recurrent episodes of cholangitis.", + "The serum level of aminotransferases remained substantially normal.", + "There was a progressive worsening of cholestatic test results.", + "There was a progressive liver enlargement along with fibrosis.", + "Gamma glutamyl transpeptidase (GGT) increased from 141UI/L to 344UI/L.", + "Alkaline phosphatase (ALP) increased from 847UI/L to 2534UI/L.", + "Hepatic tissue stiffness, measured by FibroScan®, progressed from 12.6 to 17.3kPa.", + "The patient was never treated with immunosuppressive therapy.", + "The patient was never treated with corticosteroids.", + "One month before admission, an upper endoscopy was performed.", + "The upper endoscopy excluded esophageal varices.", + "One week before admission, a magnetic resonance of his abdomen and bile ducts was performed.", + "The magnetic resonance revealed further enlargement of the liver.", + "The magnetic resonance revealed further enlargement of the spleen.", + "The magnetic resonance revealed further enlargement of the tissue surrounding his hepatic hilum.", + "The tissue surrounding his hepatic hilum caused a compression of his second duodenal tract.", + "The tissue surrounding his hepatic hilum caused a wrapping of the splenic and hepatic arteries.", + "Beading and narrowing of the intra-hepatic and common bile ducts were reported.", + "A narrowing of the pancreatic duct was also reported.", + "At admission, the patient had a fever of 38.8°C.", + "Physical examination revealed tenderness of his epigastrium.", + "Physical examination revealed tenderness of his right upper hypochondrium.", + "Microbiological blood and urine investigations were negative for bacteria.", + "A chest radiograph was normal.", + "An abdominal sonography revealed an enlarged liver.", + "An abdominal sonography revealed thickened choledocus.", + "An abdominal sonography revealed dilatation of the intra-hepatic biliary tree.", + "An abdominal sonography revealed splenomegaly.", + "An abdominal sonography revealed lymphadenopathy of the hepatic hilus.", + "A colonoscopy showed erythema of the colonic mucosa from the rectum to the cecum.", + "Random biopsy showed focal atrophy of the colonic mucosa with edema.", + "Random biopsy showed chronic inflammatory infiltrates.", + "Specific investigations for CMV were not carried out.", + "Imipenem 500mg IV four times daily was administered.", + "Three days later, imipenem was substituted with tigecycline 50mg IV BID.", + "Further blood and urine cultures for bacteria were negative.", + "The erythrocyte sedimentation rate (ESR) remained high.", + "The C-reactive protein level (C-RP) remained high.", + "The white blood cell (WBC) count decreased.", + "The neutrophil count decreased.", + "The procalcitonin level was 0.38ng/ml.", + "The fever persisted.", + "The upper abdominal pain subsided slightly.", + "Investigations for HIV were negative.", + "Investigations for Toxoplasma gondii were negative.", + "Investigations for CMV were negative.", + "Investigations for measles were negative.", + "Investigations for parotitis were negative.", + "Investigations for hepatitis C virus (HCV) were negative.", + "Results for varicella zoster virus indicated previous infection.", + "Results for human herpes virus indicated previous infection.", + "Results for Epstein Barr indicated previous infection.", + "Results for rubella indicated previous infection.", + "Results for parvo virus B19 indicated previous infection.", + "CD4?+?T lymphocytes were 1055mm3 (20.3%).", + "CD3?+?T lymphocytes were 3193mm3 (67%).", + "Mycobacterium tuberculosis interferon gamma release assay showed negative results.", + "Twelve days after admission, teicoplanin 400mg die was prescribed.", + "Twelve days after admission, gentamicin 80mg TID was prescribed.", + "Twelve days after admission, metronidazole 500mg TID was prescribed.", + "Tigecycline was stopped.", + "Two days later, DNA Cytomegalovirus was detected in the blood with ≤253 copies/mL.", + "Three days later, this value increased to 6189 copies/mL.", + "Three days later, 1431 copies/mL were evidenced from a urine sample.", + "CMV pp65-antigen was also positive.", + "CMV serology indicated acute CMV infection.", + "The patient’s fever rose to 39.2°C.", + "The patient’s abdominal pain extended to the right lower abdominal quadrant.", + "The patient’s abdominal pain radiated to the right groin.", + "The patient’s abdominal pain radiated to the right testicle.", + "Ultrasound suggested acute appendicitis.", + "He underwent surgery.", + "Histology showed inflammatory infiltrates, including lymphocytes and neutrophils.", + "Histochemistry was positive for CMV early antigens.", + "Real time reaction of the appendix tissue was positive.", + "Shell vial culture of the appendix tissue was positive.", + "Microbiological investigations for bacteria showed Peptococcus spp.", + "Microbiological investigations for fungi showed Candida albicans.", + "Teicoplanin, gentamicin and metronidazole were administered for a total of 12 days.", + "Intravenous ganciclovir 5mg/kg twice was administered for 15 days.", + "After discharge, oral valganciclovir 900mg BID was prescribed for 10 days.", + "After this, the CMV nucleic acid in the blood and urine was negative.", + "After this, ESR remained abnormally high.", + "After this, cholestatic liver test results remained abnormally high." + ], + "summary": "The authors report on a case of acute primary Cytomegalovirus infection complicated with acute appendicitis due to Cytomegalovirus in an apparently immunocompetent 24-year-old Caucasian man also suffering from primary sclerosing cholangitis and ulcerative colitis. Diagnosis was based on clinical manifestations, serology results, as well as microbiological and histological findings. Treatment consisted of surgery and anti-Cytomegalovirus therapy.", + "summary_subclaims": [ + "The authors report on a case of acute primary Cytomegalovirus infection complicated with acute appendicitis due to Cytomegalovirus in an apparently immunocompetent 24-year-old Caucasian man.", + "The patient also suffered from primary sclerosing cholangitis and ulcerative colitis.", + "Diagnosis was based on clinical manifestations.", + "Diagnosis was based on serology results.", + "Diagnosis was based on microbiological findings.", + "Diagnosis was based on histological findings.", + "Treatment consisted of surgery.", + "Treatment consisted of anti-Cytomegalovirus therapy." + ] + }, + { + "id": "multiclinsum_test_2155_en.txt", + "fulltext": "A 63-year-old man presented with hematuria and urinary obstruction symptoms. He came to the hospital four times each with presence of gross hematuria. Moreover, the patient suffered from frequency and nocturia at least for six months. Physical examination revealed enlargement of prostate, but there was no palpable nodule on the digital rectal examination. PSA was normal and there was also no evidence of hepatomegaly or splenomegaly.\nThe first transurethral resection of the prostate (TURP) and biopsy was done for him, but pathologic results showed the evidence of BPH. After 28 days, the patient was admitted again due to gross hematuria. Rectal examination was normal. Pelvic CT-scan revealed a big clot in bladder without any lymphadenopathy. There was a significant heterogeneity in prostate. In second TURP, clot evacuation and biopsy were performed on more than 15 different areas of prostate. During the next 2 weeks, the patient underwent 3 other trans-urethral coagulation and clot evacuations due to hematuria.\nHowever, laboratory tests such as prothrombin time (PT) , partial thromboplastin time (PTT), clotting time (CT), bleeding time (BT) and platelet count were normal. After 15 days hematuria was stopped and was not repeated. Sections from prostate show foci of hemorrhage, and ).\nThe first transfusion was 2 units of PC during the second surgery. The second transfusion was 2 units of PC and 2 FFP, two days later. The consecutive third and fourth transfusions were done two days later during which the patient received 3 units of FFP, and 3 units of whole blood.\nImmunohistochemistry studies demonstrate CD20-positive in 90% of lymphoid cells and in the lymphoepithelial lesions , CD5-positive in background lymphocytes, CD43-positive in 90% of lymphoid cells, CD3-positive in background lymphocytes, CK and PSA markers are negative in neoplastic cells. Further evaluation and examination such as bone marrow biopsy, abdominal and pelvic CT-scan did not show other involvement.\nIn the last fallow up, around eight months after discharging, the patient was alive and asymptomatic. Moreover, there is no evidence of other organ involvement.", + "fulltext_subclaims": [ + "The patient is a 63-year-old man.", + "He presented with hematuria and urinary obstruction symptoms.", + "He came to the hospital four times each with presence of gross hematuria.", + "The patient suffered from frequency and nocturia at least for six months.", + "Physical examination revealed enlargement of prostate.", + "There was no palpable nodule on the digital rectal examination.", + "PSA was normal.", + "There was no evidence of hepatomegaly.", + "There was no evidence of splenomegaly.", + "The first transurethral resection of the prostate (TURP) and biopsy was done.", + "Pathologic results showed the evidence of BPH.", + "After 28 days, the patient was admitted again due to gross hematuria.", + "Rectal examination was normal.", + "Pelvic CT-scan revealed a big clot in bladder without any lymphadenopathy.", + "There was significant heterogeneity in prostate.", + "In second TURP, clot evacuation and biopsy were performed on more than 15 different areas of prostate.", + "During the next 2 weeks, the patient underwent 3 other trans-urethral coagulation and clot evacuations due to hematuria.", + "Prothrombin time (PT) was normal.", + "Partial thromboplastin time (PTT) was normal.", + "Clotting time (CT) was normal.", + "Bleeding time (BT) was normal.", + "Platelet count was normal.", + "After 15 days hematuria was stopped.", + "Hematuria was not repeated.", + "Sections from prostate show foci of hemorrhage.", + "The first transfusion was 2 units of PC during the second surgery.", + "The second transfusion was 2 units of PC and 2 FFP, two days later.", + "The consecutive third and fourth transfusions were done two days later.", + "During the third and fourth transfusions, the patient received 3 units of FFP.", + "During the third and fourth transfusions, the patient received 3 units of whole blood.", + "Immunohistochemistry studies demonstrate CD20-positive in 90% of lymphoid cells.", + "Immunohistochemistry studies demonstrate CD20-positive in the lymphoepithelial lesions.", + "CD5-positive in background lymphocytes.", + "CD43-positive in 90% of lymphoid cells.", + "CD3-positive in background lymphocytes.", + "CK markers are negative in neoplastic cells.", + "PSA markers are negative in neoplastic cells.", + "Bone marrow biopsy did not show other involvement.", + "Abdominal and pelvic CT-scan did not show other involvement.", + "In the last follow up, around eight months after discharging, the patient was alive.", + "In the last follow up, around eight months after discharging, the patient was asymptomatic.", + "There is no evidence of other organ involvement." + ], + "summary": "We report here another case of primary prostatic MALT lymphoma which is presented by hematuria and diagnosed primarily as BPH. Immunohistochemistry studies demonstrate the diagnosis and MALT lymphoma. Six months after starting the treatment the patient was alive and well.", + "summary_subclaims": [ + "We report here another case of primary prostatic MALT lymphoma.", + "The case is presented by hematuria.", + "The diagnosis was primarily considered as BPH.", + "Immunohistochemistry studies demonstrate the diagnosis.", + "Immunohistochemistry studies demonstrate MALT lymphoma.", + "Six months after starting the treatment the patient was alive and well." + ] + }, + { + "id": "multiclinsum_test_495_en.txt", + "fulltext": "A 48-year-old woman presented with crushing chest pain at rest with an elevated troponin I of 2.72 μg/L (normal <0.04 μg/L) and a normal electrocardiogram (ECG). Her background history includes 30 pack years of cigarette smoking, obesity, gastric banding, fibromyalgia, and depression/anxiety. On examination, her heart rate was 70 b.p.m., her blood pressure was 127/82 mmHg, and her oxygen saturation was 98%. Cardiac and pulmonary auscultations were normal. She was given loading doses of aspirin and ticagrelor. She had a coronary angiogram which showed first diagonal artery (D1) and right marginal branch (RM) occlusion with an angiographic appearance that is consistent with SCAD. It did not resolve with intracoronary nitrate. We performed a computed tomography aortogram to look for fibromuscular dysplasia in the carotid, renal, and iliac arteries and they were absent. She was medically managed on aspirin 100 mg and clopidogrel 75 mg daily, and metoprolol 25 mg twice daily.\nShe represented 2 months later with similar symptoms with a troponin elevation of 2500 ng/L (normal <18 ng/L) and a normal ECG. She had another coronary angiogram which showed healing SCAD in the D1 and RM, but a new SCAD in the first obtuse marginal artery (OM1) . She was managed conservatively on the same medications.\nShe represented 4 months later complaining of angina every 2 days with a normal troponin and ECG. This time her coronary angiogram showed healed SCAD in OM1 and RM, but the recurrence of SCAD in D1. Given that she had recurrent events despite medical therapy, we decided to proceed with PCI. After cautious wiring and confirmation of guidewire placement in the true lumen with selective coronary contrast injection, we deployed a 2.25 × 15 mm Resolute Onyx (Medtronic, CA, USA) in D1, with excellent final result . She remained on the same medications. She presented with an atypical chest pain 10 months later and her coronary angiogram showed complete healing of all coronary arteries and a patent stent in D1. She has remained symptom free.", + "fulltext_subclaims": [ + "The patient is a 48-year-old woman.", + "She presented with crushing chest pain at rest.", + "Her troponin I was 2.72 μg/L.", + "The normal troponin I level is <0.04 μg/L.", + "Her electrocardiogram was normal.", + "She has a background history of 30 pack years of cigarette smoking.", + "She has a history of obesity.", + "She had gastric banding.", + "She has fibromyalgia.", + "She has depression and anxiety.", + "Her heart rate was 70 b.p.m.", + "Her blood pressure was 127/82 mmHg.", + "Her oxygen saturation was 98%.", + "Cardiac and pulmonary auscultations were normal.", + "She was given loading doses of aspirin and ticagrelor.", + "The coronary angiogram showed first diagonal artery (D1) and right marginal branch (RM) occlusion.", + "The angiographic appearance was consistent with SCAD.", + "The occlusion did not resolve with intracoronary nitrate.", + "A computed tomography aortogram was performed.", + "The computed tomography aortogram looked for fibromuscular dysplasia in the carotid, renal, and iliac arteries.", + "Fibromuscular dysplasia was absent.", + "She was medically managed on aspirin 100 mg and clopidogrel 75 mg daily.", + "She was medically managed on metoprolol 25 mg twice daily.", + "She represented 2 months later with similar symptoms.", + "Her troponin elevation was 2500 ng/L.", + "The normal troponin level is <18 ng/L.", + "Her ECG was normal.", + "The coronary angiogram showed healing SCAD in the D1 and RM.", + "There was a new SCAD in the first obtuse marginal artery (OM1).", + "She was managed conservatively on the same medications.", + "She represented 4 months later complaining of angina every 2 days.", + "Her troponin was normal.", + "Her ECG was normal.", + "The coronary angiogram showed healed SCAD in OM1 and RM.", + "There was recurrence of SCAD in D1.", + "We decided to proceed with PCI.", + "After cautious wiring and confirmation of guidewire placement in the true lumen with selective coronary contrast injection, we deployed a 2.25 × 15 mm Resolute Onyx stent in D1.", + "The final result was excellent.", + "She remained on the same medications.", + "She presented with atypical chest pain 10 months later.", + "The coronary angiogram showed complete healing of all coronary arteries.", + "The coronary angiogram showed a patent stent in D1.", + "She has remained symptom free." + ], + "summary": "A 48-year-old woman presented with non-ST-elevation myocardial infarction (NSTEMI) on a background of cigarette smoking. Her coronary angiogram showed the first diagonal artery (D1) and right marginal branch (RM) occlusion with angiographic appearance that is consistent with SCAD. She was medically managed. She represented 2 months later with another NSTEMI, and her coronary angiogram showed healing SCAD in the D1 and RM, but a new SCAD in the first obtuse marginal artery (OM1). She was managed medically. She represented 4 months later complaining of angina every 2 days. This time her coronary angiogram showed healed SCAD in OM1 and RM, but the recurrence of SCAD in D1. Given that she had recurrent events despite medical therapy, we decided to proceed with percutaneous coronary intervention (PCI) to D1. She presented with an atypical chest pain 10 months later and her coronary angiogram showed complete healing of all coronary arteries and a patent stent in D1. She has remained symptom free.", + "summary_subclaims": [ + "The patient is a 48-year-old woman.", + "She presented with non-ST-elevation myocardial infarction (NSTEMI).", + "She has a background of cigarette smoking.", + "Her coronary angiogram showed the first diagonal artery (D1) occlusion.", + "Her coronary angiogram showed the right marginal branch (RM) occlusion.", + "The angiographic appearance was consistent with SCAD.", + "She was medically managed.", + "She represented 2 months later with another NSTEMI.", + "Her coronary angiogram showed healing SCAD in the D1.", + "Her coronary angiogram showed healing SCAD in the RM.", + "Her coronary angiogram showed a new SCAD in the first obtuse marginal artery (OM1).", + "She was managed medically.", + "She represented 4 months later complaining of angina every 2 days.", + "Her coronary angiogram showed healed SCAD in OM1.", + "Her coronary angiogram showed healed SCAD in RM.", + "Her coronary angiogram showed the recurrence of SCAD in D1.", + "We decided to proceed with percutaneous coronary intervention (PCI) to D1.", + "She presented with atypical chest pain 10 months later.", + "Her coronary angiogram showed complete healing of all coronary arteries.", + "Her coronary angiogram showed a patent stent in D1.", + "She has remained symptom free." + ] + }, + { + "id": "multiclinsum_test_3147_en.txt", + "fulltext": "The patient in this fatal case was a 2-year-old girl who was born full-term and had developed normally. She had no medical history of asthma or pneumonia and no familial history of immunodeficiency. She had no brothers or sisters.\n\nThe patient was admitted to the hospital due to 3 days of fever and 15 min of respiratory and cardiac arrest. The symptoms started on 10 November (3 days before admission), with a fever (up to 39.8 °C) but no chills, rash or convulsions. Ibuprofen was given orally. The body temperature decreased for 4 to 5 h but then climbed to 40.3 °C. Shortness of breath accompanied the fever, and the body temperature did not decrease obviously after the oral administration of ibuprofen. Wheezing caused by the retention of phlegm in the throat and a single paroxysmal cough occurred. The patient occasionally coughed up a small amount of yellow phlegm and had a slightly runny nose. She had no asthma, breathing difficulty or hemoptysis; she had lethargy and a poor appetite but no vomiting or diarrhea. On 11 November (2 days before admission), the patient still had a high fever, and her body temperature fluctuated around approximately 40 °C. The patient’s body temperature did not obviously decrease after she was given oral ibuprofen and acetaminophen alternately. Acute infection was considered from then on. The patient received an intravenous infusion of 0.14 g Zithromax and 120 mg rographolide as well as aerosol inhalation of 2 mg budesonide, but her fever persisted, and her body temperature rose to a peak of 40 °C. On 12 November (1 day before admission), the patient still had a persistent fever and wheezing due to the retention of phlegm in her throat. She had shortness of breath, a light cough, and a drooping spirit, accompanied by a rash on the torso and limbs. Her appetite was slightly improved, and she had no vomiting or convulsions. On 13 November, the patient had sudden respiratory and cardiac arrest 3 h before admission. She was immediately and continuously treated with cardiopulmonary resuscitation by physicians and the intravenous injection of adrenaline (4 times). She was treated with trachea cannula and mechanical ventilation, and her heart beat recovered approximately 15 min later, but the patient remained in a deep comatose state with no spontaneous breathing. Then, the patient was transferred to our hospital and immediately underwent electrocardiogram (ECG) monitoring. Bloody fluid was visible in the indwelling gastrointestinal decompression tube, and the blood-gas analysis showed metabolic acidosis. The patient was treated with sodium bicarbonate to correct the acidosis. She was diagnosed with an acute CNS infection and brain hernia. After cardiopulmonary resuscitation, she was admitted to the pediatric intensive care unit (PICU). The head CT scan showed extensive brain swelling, decreased brain parenchymal density, narrowed cerebral ventricles and cisterns. These findings prompted a diagnosis of extensive brain edema and hernia. The chest posteroanterior radiograph showed fuzzy, coarse bilateral lung markings, visible small patchy shadows in the right inferior lung and a clear pulmonary hilus. These findings were diagnosed as pneumonia. Routine blood examination results suggested the presence of a bacterial infection; thus, the patient was treated with vancomycin and meropenem to control an infection. After that, immunoglobulin (1 g/kg) was administered for immune support. The patient was still in a deep coma state, and light reflexes of both pupils were absent. The patient’s spontaneous breathing was weak and irregular, and she had no response to painful stimulation. Compared with earlier, her rash was reduced, and the pulmonary lesions shown on the chest posteroanterior radiograph were slightly absorbed. Immunoglobulin (1 g/kg) was continuously administered to neutralize pathogens. On 15 November (3 days after admission), transcranial Doppler ultrasound assessment showed that the patient’s anterior and posterior cerebral circulation corresponded to the diagnostic criteria for brain death. On 17 November (5 days after admission), various organ functions failed, and the patient could not tolerate a spontaneous breathing test. Her guardian chose to quit treatment, and the patient died.\n\nLaboratory diagnosis\nViral antigen detection based on both an immunofluorescence assay and the Luminex xTAG respiratory viral panel assay was positive for RSV in the patient’s nasopharyngeal aspirates (which were collected on 14 Nov, the 5th day of disease onset and the 2nd day of admission) and negative for adenovirus, influenza A and B viruses, parainfluenza virus 1–4, human metapneumovirus, enteroviruses and rhinoviruses, human coronavirus HKU1, 229E, NL63 and OC43, and human bocavirus. Because the patient’s guardian refused to consent to lumbar puncture, cerebrospinal fluid (CSF) was not available for the detection of CNS infection.\n\nThe blood biochemistry results are summarized. The amounts of red blood cells (RBCs), hemoglobin, and platelets continuously decreased after the onset of symptoms. Extremely high levels of C-reactive protein from the third day (36–104 mg/L) suggested viral or bacterial infection; however, bacterial cultures of blood specimens yielded negative results.\n\n\nThe percentage of T lymphocytes was 46.6%, of which helper T cells and suppressor T cells accounted for 29.6 and 13.2%, respectively. The ratio of CD4/CD8 was 2.2. The proportions of B lymphocytes and NK cells were 45.6 and 3%, respectively. All these immunological indexes indicated dysfunction of the patient’s immune system.\n\nMetagenomic and viral molecular analysis\nOral swab, nasopharyngeal aspirate, and serum specimens collected on 14 Nov (the 5th day of disease onset and the 2nd day of admission) were subjected to multiplex metagenomic analyses using an NGS platform. The nucleic acid library was constructed as previously described. The amplified nucleic acid libraries were then analyzed using an Illumina HiSeq 4000 sequencer for a single read of 126 bp. The raw sequence reads were filtered using previously described criteria to obtain valid sequences.\n\nWhen bacteriophages, plant-origin sequences resulting from food debris in the oral cavity, and contamination from the reagents used in the sample processing step (murine leukemia virus (MLV), for example) were excluded, only human RSV (based on the NCBI taxonomy database) was identified, with at least one specific sequence from the oral swab (2137 reads) and the nasopharyngeal aspirate (146 reads). No virus-related sequences were detected in the serum specimen. Meanwhile, large numbers of sequence reads related to bacteria, including Streptococcus mitis, Streptococcus parasanguinis, Streptococcus pneumoniae, Streptococcus salivarius, Streptococcus infantis, Streptococcus suis, Neisseria meningitidis, Neisseria gonorrhoeae, Haemophilus sputorum, Haemophilus parainfluenzae, Enterococcus cecorum, and other conditioned pathogenic bacteria were also detected in the oral swab, nasopharyngeal aspirate, or/and serum specimens. However, although the metagenomic analysis showed sequence reads assigned to Kingdom Bacteria, the bacterial culture of the blood specimens yielded negative results.\n\n\n\nBased on the random distribution of reads of the RSV virus genome, the complete length of the genome was obtained using NGS methods and gap amplification. This RSV strain was subtyped as RSVB; it was found to cluster in the BA genotype and had the signature 60-bp duplication in the G gene. The newly identified virus was named RSVB/BCH-Y/2016, and the full genome sequence was deposited in GenBank under accession number KY924878. The phylogenetic analysis was conducted with representative sequences from nearly all RSVB subgroups (BA1–10, GB1–4, SAB1–4, URU1–2) from GenBank; RSVB/BCH-Y/2016 belonged to BA9 subgroup. The nucleotide homology comparisons revealed that the G gene of this strain was most closely related (share 98.82% homology) to strain RSVB/GZ/13–730, which was isolated from a child in Guangzhou, China, in 2013. For the six most important antigenic sites (Ø, I, II, IV, V, VI) in the fusion protein for drug or vaccine (such as palivizumab) targeting, no mutation was found in RSVB/BCH-Y/2016.", + "fulltext_subclaims": [ + "The patient was a 2-year-old girl.", + "She was born full-term.", + "She had developed normally.", + "She had no medical history of asthma.", + "She had no medical history of pneumonia.", + "She had no familial history of immunodeficiency.", + "She had no brothers or sisters.", + "She was admitted to the hospital due to 3 days of fever.", + "She had 15 min of respiratory and cardiac arrest.", + "The symptoms started on 10 November.", + "She had a fever up to 39.8 °C.", + "She had no chills.", + "She had no rash.", + "She had no convulsions.", + "Ibuprofen was given orally.", + "The body temperature decreased for 4 to 5 h.", + "The body temperature climbed to 40.3 °C.", + "Shortness of breath accompanied the fever.", + "The body temperature did not decrease obviously after oral administration of ibuprofen.", + "Wheezing caused by the retention of phlegm in the throat occurred.", + "A single paroxysmal cough occurred.", + "She occasionally coughed up a small amount of yellow phlegm.", + "She had a slightly runny nose.", + "She had no asthma.", + "She had no breathing difficulty.", + "She had no hemoptysis.", + "She had lethargy.", + "She had a poor appetite.", + "She had no vomiting.", + "She had no diarrhea.", + "On 11 November, the patient still had a high fever.", + "Her body temperature fluctuated around approximately 40 °C.", + "The patient’s body temperature did not obviously decrease after oral ibuprofen and acetaminophen alternately.", + "Acute infection was considered from then on.", + "The patient received an intravenous infusion of 0.14 g Zithromax.", + "The patient received an intravenous infusion of 120 mg rographolide.", + "The patient received aerosol inhalation of 2 mg budesonide.", + "Her fever persisted.", + "Her body temperature rose to a peak of 40 °C.", + "On 12 November, the patient still had a persistent fever.", + "She had wheezing due to the retention of phlegm in her throat.", + "She had shortness of breath.", + "She had a light cough.", + "She had a drooping spirit.", + "She had a rash on the torso and limbs.", + "Her appetite was slightly improved.", + "She had no vomiting.", + "She had no convulsions.", + "On 13 November, the patient had sudden respiratory and cardiac arrest 3 h before admission.", + "She was immediately and continuously treated with cardiopulmonary resuscitation by physicians.", + "She received intravenous injection of adrenaline (4 times).", + "She was treated with trachea cannula and mechanical ventilation.", + "Her heart beat recovered approximately 15 min later.", + "The patient remained in a deep comatose state with no spontaneous breathing.", + "The patient was transferred to our hospital.", + "She immediately underwent electrocardiogram (ECG) monitoring.", + "Bloody fluid was visible in the indwelling gastrointestinal decompression tube.", + "The blood-gas analysis showed metabolic acidosis.", + "The patient was treated with sodium bicarbonate to correct the acidosis.", + "She was diagnosed with an acute CNS infection.", + "She was diagnosed with brain hernia.", + "After cardiopulmonary resuscitation, she was admitted to the pediatric intensive care unit (PICU).", + "The head CT scan showed extensive brain swelling.", + "The head CT scan showed decreased brain parenchymal density.", + "The head CT scan showed narrowed cerebral ventricles and cisterns.", + "These findings prompted a diagnosis of extensive brain edema and hernia.", + "The chest posteroanterior radiograph showed fuzzy, coarse bilateral lung markings.", + "The chest posteroanterior radiograph showed visible small patchy shadows in the right inferior lung.", + "The chest posteroanterior radiograph showed a clear pulmonary hilus.", + "These findings were diagnosed as pneumonia.", + "Routine blood examination results suggested the presence of a bacterial infection.", + "The patient was treated with vancomycin to control an infection.", + "The patient was treated with meropenem to control an infection.", + "After that, immunoglobulin (1 g/kg) was administered for immune support.", + "The patient was still in a deep coma state.", + "Light reflexes of both pupils were absent.", + "The patient’s spontaneous breathing was weak and irregular.", + "She had no response to painful stimulation.", + "Compared with earlier, her rash was reduced.", + "The pulmonary lesions shown on the chest posteroanterior radiograph were slightly absorbed.", + "Immunoglobulin (1 g/kg) was continuously administered to neutralize pathogens.", + "On 15 November, transcranial Doppler ultrasound assessment showed that the patient’s anterior and posterior cerebral circulation corresponded to the diagnostic criteria for brain death.", + "On 17 November, various organ functions failed.", + "The patient could not tolerate a spontaneous breathing test.", + "Her guardian chose to quit treatment.", + "The patient died.", + "Viral antigen detection based on both an immunofluorescence assay and the Luminex xTAG respiratory viral panel assay was positive for RSV in the patient’s nasopharyngeal aspirates.", + "The nasopharyngeal aspirates were collected on 14 Nov.", + "The viral antigen detection was negative for adenovirus.", + "The viral antigen detection was negative for influenza A and B viruses.", + "The viral antigen detection was negative for parainfluenza virus 1–4.", + "The viral antigen detection was negative for human metapneumovirus.", + "The viral antigen detection was negative for enteroviruses and rhinoviruses.", + "The viral antigen detection was negative for human coronavirus HKU1, 229E, NL63 and OC43.", + "The viral antigen detection was negative for human bocavirus.", + "The patient’s guardian refused to consent to lumbar puncture.", + "Cerebrospinal fluid (CSF) was not available for the detection of CNS infection.", + "The amounts of red blood cells (RBCs) continuously decreased after the onset of symptoms.", + "The amounts of hemoglobin continuously decreased after the onset of symptoms.", + "The amounts of platelets continuously decreased after the onset of symptoms.", + "Extremely high levels of C-reactive protein from the third day suggested viral or bacterial infection.", + "Bacterial cultures of blood specimens yielded negative results.", + "The percentage of T lymphocytes was 46.6%.", + "Helper T cells accounted for 29.6%.", + "Suppressor T cells accounted for 13.2%.", + "The ratio of CD4/CD8 was 2.2.", + "The proportions of B lymphocytes were 45.6%.", + "The proportions of NK cells were 3%.", + "All these immunological indexes indicated dysfunction of the patient’s immune system.", + "Oral swab, nasopharyngeal aspirate, and serum specimens were collected on 14 Nov.", + "The specimens were subjected to multiplex metagenomic analyses using an NGS platform.", + "The nucleic acid library was constructed as previously described.", + "The amplified nucleic acid libraries were analyzed using an Illumina HiSeq 4000 sequencer.", + "The raw sequence reads were filtered using previously described criteria to obtain valid sequences.", + "When bacteriophages, plant-origin sequences, and contamination from reagents were excluded, only human RSV was identified.", + "At least one specific sequence from the oral swab was identified.", + "At least one specific sequence from the nasopharyngeal aspirate was identified.", + "No virus-related sequences were detected in the serum specimen.", + "Large numbers of sequence reads related to bacteria were detected in the oral swab, nasopharyngeal aspirate, or/and serum specimens.", + "Bacterial culture of the blood specimens yielded negative results.", + "The complete length of the RSV genome was obtained using NGS methods and gap amplification.", + "This RSV strain was subtyped as RSVB.", + "It was found to cluster in the BA genotype.", + "It had the signature 60-bp duplication in the G gene.", + "The newly identified virus was named RSVB/BCH-Y/2016.", + "The full genome sequence was deposited in GenBank under accession number KY924878.", + "The phylogenetic analysis was conducted with representative sequences from nearly all RSVB subgroups.", + "RSVB/BCH-Y/2016 belonged to BA9 subgroup.", + "The G gene of this strain was most closely related to strain RSVB/GZ/13–730.", + "The G gene shared 98.82% homology with strain RSVB/GZ/13–730.", + "Strain RSVB/GZ/13–730 was isolated from a child in Guangzhou, China, in 2013.", + "For the six most important antigenic sites in the fusion protein, no mutation was found in RSVB/BCH-Y/2016." + ], + "summary": "In this report, we present the case of an RSV-associated death of a child who was born at full-term and developed normally up to the age of 2 years old. Cardiopulmonary arrest occurred within 3 days after the onset of symptoms, which included cough and high fever. Complete brain edema was prominent, and encephalopathy was developing. Viral antigen detection and microbiome analyses of oral swab and nasopharyngeal aspirate specimens verified an RSV infection, while bacterial culture of blood specimens yielded negative results. The RSV strain detected in this patient was subtyped as RSVB9, and no mutation was found in the six antigenic sites for targeted drugs or vaccines.", + "summary_subclaims": [ + "The child was born at full-term.", + "The child developed normally up to the age of 2 years old.", + "Cardiopulmonary arrest occurred within 3 days after the onset of symptoms.", + "The symptoms included cough and high fever.", + "Complete brain edema was prominent.", + "Encephalopathy was developing.", + "Viral antigen detection verified an RSV infection.", + "Microbiome analyses of oral swab and nasopharyngeal aspirate specimens verified an RSV infection.", + "Bacterial culture of blood specimens yielded negative results.", + "The RSV strain detected in this patient was subtyped as RSVB9.", + "No mutation was found in the six antigenic sites for targeted drugs or vaccines." + ] + }, + { + "id": "multiclinsum_test_1669_en.txt", + "fulltext": "A 29-year-old woman with stage I grade 1 endometrioid endometrial carcinoma presented with lung metastasis.\nIn 2015, the patient experienced abnormal vaginal bleeding. Her BMI was 20.3 kg/m2. G2P1+1. Ultrasound examination revealed a 3+cm mass in the uterine cavity. In February 2015, she underwent curettage and was diagnosed with FIGO grade 1 endometrioid carcinoma. Magnetic resonance imaging suggested the possibility of cervical invasion. Thoracic computed tomography (CT) was negative. She subsequently underwent comprehensive cancer staging including laparoscopic radical hysterectomy, bilateral salpingo-oophorectomy, pelvic and para-aortic lymphadenectomy, with pelvic washing. Postoperative pathological examinations showed the followings: FIGO grade 1 endometrioid adenocarcinoma infiltrating the superficial muscle layer, and no lymphovascular space invasion. The ovaries and fallopian tubes showed no malignancy. Left and right pelvic and para-aortic lymph nodes showed no evidence of malignancy in 26 examined nodes. Peritoneal cytology was negative. A diagnosis of FIGO (2018) stage I endometrioid adenocarcinoma was made. Immunohistochemical (IHC) staining showed that the tumor tissue had a high expression of estrogen receptors (ERs) and progesterone receptors (PRs) and normal DNA mismatch repair (MMR) protein expression . IHC staining for p53 showed a wild-type pattern . Notably, clustered nuclear staining of β-catenin was detected . A postoperative CT scan of the chest, abdomen and pelvis was negative. According to the NCCN Guidelines at that time, the patient did not receive adjuvant therapy. The patient was followed up regularly in another hospital. In June 2019, she returned to our hospital with an irregular cough without apparent cause. A pulmonary CT scan showed multiple high-density pulmonary nodules in the anterior basal region of the right lower lobe and right middle lobe of the lung, indicating metastatic tumors . She then underwent thoracoscopic resection of the affected lobes. IHC confirmed an FIGO grade 1 endometrioid adenocarcinoma infiltrating the lung tissue. The patient was then treated with six cycles of combined chemotherapy of paclitaxel and carboplatin. Combined with the computed tomography scan result and the cancer antigen 125, complete remission following treatment was confirmed. The patient was followed up regularly for 18 months after completing chemotherapy, and no tumor recurrence occurred during this period.\nThe patient denied a history of systematic diseases and a history of smoking.\nThe patient denied a personal and family history of related diseases.\nThere was no physical examination.\nRoutine blood test, liver and kidney function, and tumor markers like cancer antigen 125 (CA125), cancer antigen 199 (CA199), carcinoembryonic antigen(CEA), alpha-fetoprotein (AFP) were normal.\nA pulmonary CT scan showed multiple high-density pulmonary nodules in the anterior basal region of the right lower lobe and right middle lobe of the lung, indicating metastatic tumors .\nTo gain further insight into the driver gene mutation mediating metastasis, targeted next-generation sequencing (NGS) of 688 cancer-related genes was performed on both primary tumor and lung metastasis specimens (Supplementary Table ). DNA was extracted from the paraffin-embedded specimens and blood samples from the patient to evaluate somatic and germline mutations, respectively. The variant frequency for each sample was calculated as the percent variant reads from total reads. The data showed that there was no germline mutation in this patient. Somatic mutations of 44 genes were detected in primary tumor samples. Mutations of PTEN (p.P248Lfs*8), CTNNB1 (p.D32A), BCOR (p.N1425S) and CBL (p.S439N) were detected in the lung metastasis, which were shared by primary tumors . Exonic sequence data across all genes showed no MMR deficiency signature, ultramutated phenotype in POLE or TP53 mutation for both primary and metastatic tumors . According to genomic classification, the patient belonged to the CN-low group.\nIHC of the postoperative sample after primary surgery revealed the following: ER + + + , PR + + + , β-catenin + + + , PTEN + + , P53-, and Ki67 25% . The expressions of four MMR proteins (MSH2, MLH1, MSH6 and PMS2) were retained in primary and metastatic tumor tissues, suggestive of microsatellite stable carcinoma, which was consistent with the NGS results . IHC of pulmonary metastatic lesion was as follws: Napsin-A (-), TTF-1 (-), PAX-8 ( +), Ck7 (-), ER (+ +), and PR (+ + +).We evaluated β-catenin by IHC in primary and metastatic tumors, and found clustered nuclear location of β-catenin in both the primary tumor and lung metastatic tumor , indicating high β-catenin activity.\nScreening of gene mutations in endometrioid carcinoma was performed using the TCGA. The results showed that there are 130 mutations of CTNNB1 in 399 cases of endometrioid adenocarcinoma, including 2 cases with mutation of D32A.", + "fulltext_subclaims": [ + "The patient is a 29-year-old woman with stage I grade 1 endometrioid endometrial carcinoma.", + "The patient presented with lung metastasis.", + "In 2015, the patient experienced abnormal vaginal bleeding.", + "Her BMI was 20.3 kg/m2.", + "Ultrasound examination revealed a 3+cm mass in the uterine cavity.", + "In February 2015, she underwent curettage and was diagnosed with FIGO grade 1 endometrioid carcinoma.", + "Magnetic resonance imaging suggested the possibility of cervical invasion.", + "Thoracic computed tomography (CT) was negative.", + "She underwent comprehensive cancer staging including laparoscopic radical hysterectomy, bilateral salpingo-oophorectomy, pelvic and para-aortic lymphadenectomy, with pelvic washing.", + "Postoperative pathological examinations showed FIGO grade 1 endometrioid adenocarcinoma infiltrating the superficial muscle layer.", + "The ovaries and fallopian tubes showed no malignancy.", + "Left and right pelvic and para-aortic lymph nodes showed no evidence of malignancy in 26 examined nodes.", + "Peritoneal cytology was negative.", + "A diagnosis of FIGO (2018) stage I endometrioid adenocarcinoma was made.", + "Immunohistochemical (IHC) staining showed that the tumor tissue had a high expression of estrogen receptors (ERs) and progesterone receptors (PRs).", + "IHC staining showed normal DNA mismatch repair (MMR) protein expression.", + "IHC staining for p53 showed a wild-type pattern.", + "Clustered nuclear staining of β-catenin was detected.", + "A postoperative CT scan of the chest, abdomen and pelvis was negative.", + "According to the NCCN Guidelines at that time, the patient did not receive adjuvant therapy.", + "In June 2019, she returned to our hospital with an irregular cough without apparent cause.", + "A pulmonary CT scan showed multiple high-density pulmonary nodules in the anterior basal region of the right lower lobe and right middle lobe of the lung, indicating metastatic tumors.", + "She then underwent thoracoscopic resection of the affected lobes.", + "IHC confirmed an FIGO grade 1 endometrioid adenocarcinoma infiltrating the lung tissue.", + "The patient was then treated with six cycles of combined chemotherapy of paclitaxel and carboplatin.", + "Combined with the computed tomography scan result and the cancer antigen 125, complete remission following treatment was confirmed.", + "The patient was followed up regularly for 18 months after completing chemotherapy, and no tumor recurrence occurred during this period.", + "The patient denied a history of systematic diseases and a history of smoking.", + "The patient denied a personal and family history of related diseases.", + "There was no physical examination.", + "Routine blood test, liver and kidney function, and tumor markers like cancer antigen 125 (CA125), cancer antigen 199 (CA199), carcinoembryonic antigen (CEA), alpha-fetoprotein (AFP) were normal.", + "A pulmonary CT scan showed multiple high-density pulmonary nodules in the anterior basal region of the right lower lobe and right middle lobe of the lung, indicating metastatic tumors.", + "Targeted next-generation sequencing (NGS) of 688 cancer-related genes was performed on both primary tumor and lung metastasis specimens.", + "DNA was extracted from the paraffin-embedded specimens and blood samples from the patient to evaluate somatic and germline mutations, respectively.", + "The variant frequency for each sample was calculated as the percent variant reads from total reads.", + "The data showed that there was no germline mutation in this patient.", + "Somatic mutations of 44 genes were detected in primary tumor samples.", + "Mutations of PTEN (p.P248Lfs*8), CTNNB1 (p.D32A), BCOR (p.N1425S) and CBL (p.S439N) were detected in the lung metastasis, which were shared by primary tumors.", + "Exonic sequence data across all genes showed no MMR deficiency signature, ultramutated phenotype in POLE or TP53 mutation for both primary and metastatic tumors.", + "According to genomic classification, the patient belonged to the CN-low group.", + "IHC of the postoperative sample after primary surgery revealed the following: ER + + + , PR + + + , β-catenin + + + , PTEN + + , P53-, and Ki67 25%.", + "The expressions of four MMR proteins (MSH2, MLH1, MSH6 and PMS2) were retained in primary and metastatic tumor tissues.", + "IHC of pulmonary metastatic lesion was as follows: Napsin-A (-), TTF-1 (-), PAX-8 ( +), Ck7 (-), ER (+ +), and PR (+ + +).", + "We evaluated β-catenin by IHC in primary and metastatic tumors, and found clustered nuclear location of β-catenin in both the primary tumor and lung metastatic tumor.", + "Screening of gene mutations in endometrioid carcinoma was performed using the TCGA.", + "The results showed that there are 130 mutations of CTNNB1 in 399 cases of endometrioid adenocarcinoma, including 2 cases with mutation of D32A." + ], + "summary": "A 29-year-old woman presented with abnormal vaginal bleeding and was diagnosed with FIGO grade 1 endometrioid endometrial carcinoma by curettage. Comprehensive cancer staging including pelvic and para-aortic lymphadenectomy was then performed. Postoperative pathological findings suggested an FIGO grade 1 endometrioid endometrial carcinoma infiltrating the superficial muscle layer. The patient did not receive adjuvant therapy. After 4 years of follow-up, the patient returned to our institution with lung metastasis. She underwent thoracoscopic resection of the affected lobes, followed by six cycles of combined chemotherapy of paclitaxel and carboplatin. Next-generation sequencing showed that the primary and lung metastatic tumors shared 4 mutations: PTEN (p.P248Lfs*8), CTNNB1 (p.D32A), BCOR (p.N1425S) and CBL (p.S439N). Immunohistochemistry revealed nuclear location of β-catenin in the primary and lung metastatic tumor samples, indicating abnormal activation of β-catenin.", + "summary_subclaims": [ + "A 29-year-old woman presented with abnormal vaginal bleeding.", + "She was diagnosed with FIGO grade 1 endometrioid endometrial carcinoma by curettage.", + "Comprehensive cancer staging including pelvic and para-aortic lymphadenectomy was performed.", + "Postoperative pathological findings suggested FIGO grade 1 endometrioid endometrial carcinoma.", + "The tumor infiltrated the superficial muscle layer.", + "The patient did not receive adjuvant therapy.", + "After 4 years of follow-up, the patient returned with lung metastasis.", + "She underwent thoracoscopic resection of the affected lobes.", + "She received six cycles of combined chemotherapy of paclitaxel and carboplatin.", + "Next-generation sequencing showed that the primary and lung metastatic tumors shared 4 mutations.", + "The mutations included PTEN (p.P248Lfs*8), CTNNB1 (p.D32A), BCOR (p.N1425S), and CBL (p.S439N).", + "Immunohistochemistry revealed nuclear location of β-catenin in the primary and lung metastatic tumor samples.", + "The nuclear location of β-catenin indicated abnormal activation of β-catenin." + ] + }, + { + "id": "multiclinsum_test_672_en.txt", + "fulltext": "A 62-year-old previously healthy postmenopausal Hispanic woman without prior cardiac history presented to our emergency department with recurrent retrosternal chest pain. Our patient denied any illicit drug use, smoking or excessive alcohol consumption. She also denied any family history of heart disease. Of note, our patient reported that she had attained menopause around the age of 50 years; between the ages of 20 and 30 years, she had three full-term pregnancies resulting in the birth of her three children.\nAn initial electrocardiogram was remarkable for ST elevations in the precordial leads , with a troponin I level of 0.02ng/ml. Her symptoms improved after receiving aspirin, clopidogrel, nitroglycerine, heparin, beta blockade and a statin. Repeat electrocardiograms after admission were remarkable for complete resolution of the ST segment elevation and our patient reported no further episodes of chest pain. Cardiac catheterization was performed which showed non-obstructive single vessel coronary artery disease with dissection in the mid portion of her left anterior descending artery, with significant luminal compromise . Intracoronary nitroglycerine was not given and no other tests were done to induce vasospasm. Because our patient was symptom free and demonstrated complete resolution of ST segment elevation, and there was no evidence of compromise in coronary flow, a decision was made to defer any revascularization and continue with medical management, including the addition of nifedipine. A full panel of tests, including erythrocyte sedimentation rate, C- reactive protein level, complement level, anti-nuclear antibody test, rheumatoid factor level, perinuclear anti-neutrophil cytoplasmic antibody and centrally accentuated anti-neutrophil cytoplasmic antibody tests, were found to be normal. Our patient continued to remain asymptomatic at two- and six-week follow-ups.", + "fulltext_subclaims": [ + "The patient is a 62-year-old postmenopausal Hispanic woman.", + "The patient had three full-term pregnancies between the ages of 20 and 30 years.", + "The patient attained menopause around the age of 50 years.", + "The patient presented with recurrent retrosternal chest pain.", + "The patient denied any illicit drug use.", + "The patient denied any family history of heart disease.", + "An initial electrocardiogram was remarkable for ST elevations in the precordial leads.", + "The troponin I level was 0.02ng/ml.", + "The patient received aspirin, clopidogrel, nitroglycerine, heparin, beta blockade, and a statin.", + "Repeat electrocardiograms after admission showed complete resolution of the ST segment elevation.", + "Cardiac catheterization showed non-obstructive single vessel coronary artery disease with dissection in the mid portion of the left anterior descending artery.", + "There was significant luminal compromise.", + "Intracoronary nitroglycerine was not given.", + "No other tests were done to induce vasospasm.", + "A decision was made to defer any revascularization.", + "Medical management included the addition of nifedipine.", + "A full panel of tests, including erythrocyte sedimentation rate, C-reactive protein level, complement level, anti-nuclear antibody test, rheumatoid factor level, perinuclear anti-neutrophil cytoplasmic antibody, and centrally accentuated anti-neutrophil cytoplasmic antibody tests, were found to be normal.", + "The patient remained asymptomatic at two- and six-week follow-ups." + ], + "summary": "A 62-year-old previously healthy postmenopausal Hispanic woman presented with chest pain and was found to have an ST elevation myocardial infarction. Cardiac catheterization revealed a dissection in her left anterior descending artery. Revascularization was deferred; our patient received appropriate medical management and remained asymptomatic. A full panel of tests was done to exclude underlying connective tissue disorders and vasculitis. On subsequent follow-up, our patient continued to do well and all work-up was reported as negative.", + "summary_subclaims": [ + "The patient is a 62-year-old postmenopausal Hispanic woman.", + "The patient had chest pain.", + "The patient had an ST elevation myocardial infarction.", + "Cardiac catheterization revealed a dissection in her left anterior descending artery.", + "Revascularization was deferred.", + "The patient received appropriate medical management.", + "The patient remained asymptomatic.", + "A full panel of tests was done to exclude underlying connective tissue disorders and vasculitis.", + "On subsequent follow-up, the patient continued to do well.", + "All work-up was reported as negative." + ] + }, + { + "id": "multiclinsum_test_3150_en.txt", + "fulltext": "We report the case of a 64-year-old woman with regular cardiological follow-up for severe aortic valve regurgitation. She complained of fatigue and dyspnea with moderate exertion, dizziness and sporadic palpitations, with recent clinical (New York Heart Association functional class II-III) and echocardiographic deterioration. She had a previous history of hypertension, dyslipidemia, overweight, asthma and Sjögren syndrome, and was on diuretics, but with no previous hospitalizations for heart failure.\nShe was in sinus rhythm (∼80 bpm) with a diastolic murmur at the apex. The chest X-ray was normal with preserved cardiothoracic index. The preoperative echocardiogram revealed slightly enlarged left chambers (left atrium 46 mm; left ventricular systolic/diastolic diameters 41/59 mm; interventricular septal systolic/diastolic dimensions 11/15 mm, respectively) and preserved contractility (ejection fraction 63%). The aortic valve had four leaflets with preserved opening (no transvalvular gradient was present) but poor coaptation causing severe aortic regurgitation (vena contracta 8 mm). The ascending aorta measured 36 mm.\n\nCardiac catheterization revealed a slightly dilated ascending aorta (42 mm) and an incompetent aortic valve causing severe aortic regurgitation. No coronary or carotid disease was found.\nThe patient was operated electively. In the operating room, a concentrically hypertrophied left ventricle, dilated ascending aorta and fibrosed quadricuspid aortic valve (QAV) with leaflet retraction and a central orifice were observed. The supernumerary leaflet was the smallest and the others were of equal size. The left coronary ostium was tunneled under the commissure, which warranted special care in order to avoid damage during excision of the valve or obstruction by the prosthesis. Cardioplegia was delivered antegradely, directly in the coronary ostia. We also routinely use topical ice slush or cold saline solution as an adjuvant to myocardial protection. A 21-mm St. Jude mechanical prosthesis was implanted and the surgery ended uneventfully. The predischarge echocardiogram showed preserved ejection fraction (50%) and the mechanical aortic valve with normal opening and no paravalvular leak. Transvalvular gradients (maximum/mean) were 22/12 mmHg. No other valve lesions or significant pericardial effusion were found. The patient was discharged on the fifth postoperative day.", + "fulltext_subclaims": [ + "The patient was a 64-year-old woman.", + "She had regular cardiological follow-up for severe aortic valve regurgitation.", + "She complained of fatigue.", + "She complained of dyspnea with moderate exertion.", + "She complained of dizziness.", + "She complained of sporadic palpitations.", + "She had recent clinical deterioration.", + "She had recent echocardiographic deterioration.", + "She had a previous history of hypertension.", + "She had a previous history of dyslipidemia.", + "She had a previous history of asthma.", + "She had a previous history of Sjögren syndrome.", + "She was on diuretics.", + "She had no previous hospitalizations for heart failure.", + "She was in sinus rhythm with a heart rate of approximately 80 bpm.", + "The chest X-ray was normal.", + "The preoperative echocardiogram revealed slightly enlarged left chambers.", + "The aortic valve had four leaflets.", + "The aortic valve had severe aortic regurgitation.", + "The ascending aorta measured 36 mm.", + "Cardiac catheterization revealed a slightly dilated ascending aorta.", + "No coronary disease was found.", + "The patient was operated electively.", + "A 21-mm St. Jude mechanical prosthesis was implanted.", + "The predischarge echocardiogram showed preserved ejection fraction.", + "The mechanical aortic valve had normal opening.", + "Transvalvular gradients were 22/12 mmHg.", + "The patient was discharged on the fifth postoperative day." + ], + "summary": "We describe the case of a 64-year-old woman with regular cardiological follow-up for severe aortic valve regurgitation who had suffered recent clinical and echocardiographic deterioration. Conventional open surgery was indicated. During the procedure, a QAV with leaflet retraction and central orifice was observed. The aortic valve was successfully replaced.", + "summary_subclaims": [ + "The patient was a 64-year-old woman.", + "The patient had regular cardiological follow-up.", + "The patient had severe aortic valve regurgitation.", + "The patient had suffered recent clinical and echocardiographic deterioration.", + "Conventional open surgery was indicated.", + "During the procedure, a QAV with leaflet retraction and central orifice was observed.", + "The aortic valve was successfully replaced." + ] + }, + { + "id": "multiclinsum_test_2130_en.txt", + "fulltext": "A 63-year-old male presented complaints of weakness in bilateral lower limbs left more than right, paraesthesia in bilateral lower limbs and difficulty in walking from past 5 months. On examination, patient was found to have increased tone in bilateral lower limbs and power of 4/5(MRC grading) in bilateral lower limbs. Patient also had reduced touch and pain sensation below eighth thoracic dermatome level. Bladder function and sphincter control were preserved.\nMRI demonstrated a T1 hypointense and T2 hyperintense and contrasts enhancing intradural extramedullary lesion at eighth thoracic level. Contrast MRI of the brain revealed a 4.2 × 3.6 × 3.5 cm lesion in the trigonal area of the left lateral ventricle. The lesion was T1 hypointense and heterogeneously contrasts enhancing .\nPatient, due to his symptoms of the spinal lesion underwent excision of the spinal lesion. D7 and D8 laminectomy was performed. Tumor was dorsal placed and total excision along with attached dura was performed. Dural defect was closed and wound closed with a drain in situ. Patient’s spasticity and gait improved in the postoperative period. Patient complained of headache in the postoperative period and hence MRI brain was performed. The cranial lesion was planned for a second stage surgery since patient did not exhibit any symptom for the same.\nOn follow-up patient presented to us with two episodes of seizures, 2 months after the spinal surgery and patient was admitted for excision of the cranial component. The left parietal craniotomy was performed and trigone was approached through the keens point. Excision was performed and patient had an uneventful postoperative course.\nMicroscopic examination of the spinal tumor showed a meningothelial neoplasm having transitional morphology. The cells were moderately pleomorphic and were arranged in fascicles, whorls, and lobules with few psammoma bodies. The tumor had mitotic activity reaching upto 4/10hpf and a Ki-67 labeling index of 12–15%. Due to the increased mitotic count, this tumor was classified as atypical meningioma, the WHO Grade II .\nResected tissue from the trigone showed a meningothelial neoplasm exhibiting transitional morphology with few psammoma bodies, lymphocytic, and foamy macrophage infiltration. The cells were arranged in fascicles and whorls and had moderate nuclear pleomorphism, mitotic activity of 1–2/10hpf and Ki-67 labeling index of 4–5%. There was no evidence of brain parenchymal invasion. These features were of a transitional meningioma, the WHO Grade I.", + "fulltext_subclaims": [ + "The patient is a 63-year-old male.", + "The patient had weakness in bilateral lower limbs, left more than right.", + "The patient had paraesthesia in bilateral lower limbs.", + "The patient had difficulty in walking for past 5 months.", + "On examination, the patient had increased tone in bilateral lower limbs.", + "The patient had power of 4/5 in bilateral lower limbs.", + "The patient had reduced touch and pain sensation below the eighth thoracic dermatome level.", + "Bladder function and sphincter control were preserved.", + "MRI showed a T1 hypointense and T2 hyperintense, contrast-enhancing intradural extramedullary lesion at the eighth thoracic level.", + "Contrast MRI of the brain showed a 4.2 × 3.6 × 3.5 cm lesion in the trigonal area of the left lateral ventricle.", + "The cranial lesion was T1 hypointense and heterogeneously contrast-enhancing.", + "The patient underwent excision of the spinal lesion.", + "D7 and D8 laminectomy was performed.", + "The tumor was dorsal placed.", + "Total excision along with attached dura was performed.", + "The dural defect was closed.", + "The wound was closed with a drain in situ.", + "The patient’s spasticity and gait improved in the postoperative period.", + "The patient complained of headache in the postoperative period.", + "MRI brain was performed due to the headache.", + "The cranial lesion was planned for a second stage surgery.", + "The patient did not exhibit any symptoms for the cranial lesion.", + "On follow-up, the patient had two episodes of seizures 2 months after spinal surgery.", + "The patient was admitted for excision of the cranial component.", + "A left parietal craniotomy was performed.", + "The trigone was approached through the Keen’s point.", + "Excision was performed.", + "The patient had an uneventful postoperative course.", + "Microscopic examination of the spinal tumor showed a meningothelial neoplasm with transitional morphology.", + "The cells were moderately pleomorphic and arranged in fascicles, whorls, and lobules.", + "The tumor had few psammoma bodies.", + "The tumor had mitotic activity up to 4/10hpf.", + "The Ki-67 labeling index was 12–15%.", + "The tumor was classified as atypical meningioma, WHO Grade II.", + "The resected tissue from the trigone showed a meningothelial neoplasm with transitional morphology.", + "The tumor had few psammoma bodies, lymphocytic, and foamy macrophage infiltration.", + "The cells were arranged in fascicles and whorls.", + "The tumor had moderate nuclear pleomorphism.", + "The mitotic activity was 1–2/10hpf.", + "The Ki-67 labeling index was 4–5%.", + "There was no evidence of brain parenchymal invasion.", + "These features were of a transitional meningioma, WHO Grade I." + ], + "summary": "We report a case of a 63-year-old male with the left trigonal and spinal meningioma. Both the meningiomas were resected in different settings. The histological examination of tumors revealed to be of varied histology, that is, meningothelial and atypical meningioma, respectively.", + "summary_subclaims": [ + "The patient is a 63-year-old male.", + "The patient had a left trigonal meningioma.", + "The patient had a spinal meningioma.", + "Both meningiomas were resected in different settings.", + "The histological examination revealed varied histology.", + "One tumor was meningothelial.", + "The other tumor was atypical meningioma." + ] + }, + { + "id": "multiclinsum_test_1269_en.txt", + "fulltext": "A 16-year-old girl was diagnosed with TOF, secundum, and sinus venosus atrial septal defect (ASD) at birth. Additionally, she had Turner syndrome [46, X, del(X)(p11.2)] and a horseshoe kidney. She underwent total correction of TOF and ASD closure at the age of 14-months, including patch closure of the subarterial ventricular septal defect, direct closure of the ASD, resection of the infundibular muscle, and transannular patch extending to the main pulmonary artery. However, the diagnosis of PAPVR was missed. She was doing well at her annual outpatient clinic follow-up. At the age of 16, she developed dyspnea on exercise. Echocardiography demonstrated severe pulmonary regurgitation, mild tricuspid regurgitation, and D-shaped left ventricle (LV) with paradoxical septal motion along with RIV and sinus venous ASD. Computed tomography also confirmed RIV and PAPVR . The right upper pulmonary vein (RUPV) drained into the SVC and the right middle pulmonary vein (RMPV) showed dual drainage into the SVC and LA. Surgical repair of PAPVR, sinus venous ASD, and pulmonary regurgitation was planned.\nRedo-median sternotomy and bicaval venous cannulation were performed. SVC cannulation was performed with a 20 Fr angle catheter at the utmost distal SVC above the anomalous PV and RIV. Under mild hypothermia cardiopulmonary bypass and after pharmacological cardiac arrest, the lateral wall of the SVC was incised from just above the junction of the anomalous RUPV to just below the junction of anomalous RMPV . Systemic and pulmonary venous blood pathways were separated by bovine pericardial patch. Consequently, dual pulmonary venous blood flow was created; RUPV and RMPV drained directly or through the intra-atrial tunnel and sinus venous ASD into the LA . Pulmonary valve replacement was performed with a 25 mm Trifecta aortic bioprosthesis valve (St. Jude Medical, Inc., USA). The duration of bypass and aortic cross-clamp was 125 and 96 min, respectively. After an uneventful postoperative course, patient was discharged on postoperative day 6. Postoperative echocardiography demonstrated improvement of D-shaped LV and laminar flow through the SVC and PVs. Postoperative computed tomography showed a well-reconstructed SVC and pulmonary venous pathway without stenosis .", + "fulltext_subclaims": [ + "The patient was diagnosed with TOF, secundum, and sinus venosus atrial septal defect at birth.", + "The patient had Turner syndrome [46, X, del(X)(p11.2)].", + "The patient had a horseshoe kidney.", + "She underwent total correction of TOF and ASD closure at the age of 14 months.", + "The diagnosis of PAPVR was missed.", + "At the age of 16, she developed dyspnea on exercise.", + "Echocardiography demonstrated severe pulmonary regurgitation.", + "Echocardiography demonstrated mild tricuspid regurgitation.", + "Echocardiography showed a D-shaped left ventricle with paradoxical septal motion.", + "Computed tomography confirmed RIV.", + "Computed tomography confirmed PAPVR.", + "The right upper pulmonary vein drained into the SVC.", + "The right middle pulmonary vein showed dual drainage into the SVC and LA.", + "Surgical repair of PAPVR, sinus venous ASD, and pulmonary regurgitation was planned.", + "Redo-median sternotomy and bicaval venous cannulation were performed.", + "SVC cannulation was performed with a 20 Fr angle catheter at the utmost distal SVC above the anomalous PV and RIV.", + "The lateral wall of the SVC was incised from just above the junction of the anomalous RUPV to just below the junction of anomalous RMPV.", + "Systemic and pulmonary venous blood pathways were separated by bovine pericardial patch.", + "Pulmonary valve replacement was performed with a 25 mm Trifecta aortic bioprosthesis valve.", + "The duration of bypass was 125 minutes.", + "The duration of aortic cross-clamp was 96 minutes.", + "The patient was discharged on postoperative day 6.", + "Postoperative echocardiography demonstrated improvement of D-shaped LV.", + "Postoperative computed tomography showed a well-reconstructed SVC and pulmonary venous pathway without stenosis." + ], + "summary": "A 16-year-old girl was diagnosed with tetralogy of Fallot, secundum, and sinus venosus atrial septal defect (ASD) at birth. She underwent total correction of tetralogy of Fallot and ASD closure at the age of 14-months. However, the diagnosis of PAPVR was missed. At the age of 16, she developed dyspnea on exercise. Echocardiography demonstrated severe pulmonary regurgitation, mild tricuspid regurgitation, and D-shaped left ventricle with paradoxical septal motion along with RIV and sinus venous ASD. Computed tomography confirmed RIV and PAPVR. Systemic and pulmonary venous blood pathways were separated by bovine pericardial patch, and pulmonary valve replacement was performed. Postoperative echocardiography demonstrated improvement of D-shaped left ventricle and laminar flow through the SVC and pulmonary veins. Postoperative computed tomography showed a well-reconstructed SVC and pulmonary venous pathway without stenosis. After an uneventful postoperative course, patient was discharged.", + "summary_subclaims": [ + "The patient is a 16-year-old girl.", + "She was diagnosed with tetralogy of Fallot, secundum, and sinus venosus atrial septal defect at birth.", + "She underwent total correction of tetralogy of Fallot and ASD closure at the age of 14-months.", + "The diagnosis of PAPVR was missed.", + "At the age of 16, she developed dyspnea on exercise.", + "Echocardiography demonstrated severe pulmonary regurgitation.", + "Echocardiography demonstrated mild tricuspid regurgitation.", + "Echocardiography demonstrated D-shaped left ventricle with paradoxical septal motion.", + "Echocardiography demonstrated RIV and sinus venous ASD.", + "Computed tomography confirmed RIV and PAPVR.", + "Systemic and pulmonary venous blood pathways were separated by bovine pericardial patch.", + "Pulmonary valve replacement was performed.", + "Postoperative echocardiography demonstrated improvement of D-shaped left ventricle.", + "Postoperative echocardiography demonstrated laminar flow through the SVC and pulmonary veins.", + "Postoperative computed tomography showed a well-reconstructed SVC and pulmonary venous pathway without stenosis.", + "The patient was discharged after an uneventful postoperative course." + ] + }, + { + "id": "multiclinsum_test_2981_en.txt", + "fulltext": "A 73-year-old right-handed Taiwanese man was admitted to our hospital after suffering syncope. On the day of admission, he had been well until 7:00 in the morning, when he was playing tennis. Specifically, he suddenly lost consciousness and fell to the ground. The patient promptly regained consciousness, but his verbal output was limited to saying the word “hao” (meaning “yes” in English). His friends took him to our emergency department at 8:39 am.\nOn arrival, the patient was E2VaM4. On examination, he was alert. He had impairments in speech fluency, comprehension and repetition. His only verbal output was the sound “hao” or “hum”. Gait, extraocular motion, motor, and sensory functions were all normal. He showed no eye ptosis nor facial palsy. Blood parameters, including homocysteine levels, lipid profile, diabetes, oncology and endocrine measures, were unremarkable. Brain CT with contrast revealed no apparent intracranial haemorrhage or mass. However, CT perfusion indicated poor perfusion over the left middle cerebral territory .\nTracing back his medical history, the patient was normostenic (body mass index was 18). He had hypertension for more than twenty years. He also suffered from hyperlipidaemia and coronary artery disease, and 7 months previously, he had received one drug-eluting stent. His daily medications included amlodipine 5 mg, aspirin 100 mg and rosuvastatin 5 mg. He played tennis twice a day and never smoked or drank alcohol. His highest education was senior high school and was fluent in Chinese, Taiwanese and Japanese. He used to work at an international trading company but had been retired for two years.\nUnder the impression of acute cerebral infarction with global aphasia, he then received a recombinant tissue plasminogen activator (rtPA) injection at 9:26 am and was switched to our intensive care unit for further management. Brain non-contrast magnetic resonance imaging (MRI; Fig. ) was conducted on day 5, disclosing an acute infarction in the territory of the left middle cerebral artery (MCA), just in the perisylvian gyri, the classic areas of Wernicke and Broca. After 12 days of inpatient treatment, the patient was later discharged under stable conditions with global aphasia status and no focal neurologic signs. He was able to resume playing tennis on a daily basis soon after discharge.\nThe patient then received speech rehabilitation, including verbal production, auditory comprehension training, augmentative communication training, phonetic placement and high-level cognitive function training at our hospital and another hospital. His language expression gradually recovered. The CCAT was then performed 14 months after the initial stroke. His average CCAT score was 5.6, indicating moderate to severe aphasia . Detailed analyses of his spoken language characteristics showed subnormal performances for both sentence intonation and sentence length , indicating he had fluent aphasia.\nWe subsequently checked is cerebral blood flow using regional brain single photon emission computed tomography (SPECT; Fig. ). No radioactivity was found in the left frontal and left parietotemporal regions, and instead, a relatively high level of radioactivity uptake was noted over the right thalamus, frontal and occipital lobes.", + "fulltext_subclaims": [ + "The patient was a 73-year-old right-handed Taiwanese man.", + "He was admitted after suffering syncope.", + "On the day of admission, he had been well until 7:00 in the morning.", + "He was playing tennis when he suddenly lost consciousness and fell to the ground.", + "He promptly regained consciousness.", + "His verbal output was limited to saying the word “hao”.", + "He was taken to the emergency department at 8:39 am.", + "On arrival, he was E2VaM4.", + "He was alert.", + "He had impairments in speech fluency, comprehension and repetition.", + "His only verbal output was the sound “hao” or “hum”.", + "Gait, extraocular motion, motor, and sensory functions were all normal.", + "He showed no eye ptosis nor facial palsy.", + "Blood parameters, including homocysteine levels, lipid profile, diabetes, oncology and endocrine measures, were unremarkable.", + "Brain CT with contrast revealed no apparent intracranial haemorrhage or mass.", + "CT perfusion indicated poor perfusion over the left middle cerebral territory.", + "He had hypertension for more than twenty years.", + "He had hyperlipidaemia and coronary artery disease.", + "He had received one drug-eluting stent 7 months previously.", + "He played tennis twice a day.", + "He never smoked or drank alcohol.", + "He had a body mass index of 18.", + "He was under the impression of acute cerebral infarction with global aphasia.", + "He received a recombinant tissue plasminogen activator (rtPA) injection at 9:26 am.", + "Brain non-contrast MRI on day 5 disclosed an acute infarction in the territory of the left middle cerebral artery.", + "The infarction was in the perisylvian gyri, the classic areas of Wernicke and Broca.", + "He was discharged after 12 days of inpatient treatment.", + "He was discharged with global aphasia status and no focal neurologic signs.", + "He was able to resume playing tennis on a daily basis soon after discharge.", + "He received speech rehabilitation, including verbal production, auditory comprehension training, augmentative communication training, phonetic placement and high-level cognitive function training.", + "The CCAT was performed 14 months after the initial stroke.", + "His average CCAT score was 5.6.", + "His average CCAT score indicated moderate to severe aphasia.", + "Detailed analyses showed subnormal performances for both sentence intonation and sentence length.", + "He had fluent aphasia.", + "Cerebral blood flow was checked using regional brain SPECT.", + "No radioactivity was found in the left frontal and left parietotemporal regions.", + "A relatively high level of radioactivity uptake was noted over the right thalamus, frontal and occipital lobes." + ], + "summary": "A 73-year-old man was admitted to our emergency department immediately after an episode of syncope. On arrival, we noted his global aphasia but without any focal neurologic signs. Computed tomography (CT) perfusion scans showed a large hypodense region over his left perisylvian area. Under the impression of acute ischaemic stroke, he received recombinant tissue plasminogen activator (rtPA) injection and was treated as an inpatient. The patient was later discharged with GAWH status and received regular speech rehabilitation. After 14 months of rehabilitation, the patient gradually recovered his language expression ability. The degree of aphasia was evaluated with the Concise Chinese Aphasia Test (CCAT), and we obtained brain single photon emission computed tomography (SPECT) scans to assess cerebral blood flow.", + "summary_subclaims": [ + "A 73-year-old man was admitted to our emergency department immediately after an episode of syncope.", + "On arrival, we noted his global aphasia.", + "Computed tomography perfusion scans showed a large hypodense region over his left perisylvian area.", + "He received recombinant tissue plasminogen activator injection.", + "The patient was later discharged with GAWH status.", + "The patient received regular speech rehabilitation.", + "After 14 months of rehabilitation, the patient gradually recovered his language expression ability.", + "The degree of aphasia was evaluated with the Concise Chinese Aphasia Test.", + "We obtained brain single photon emission computed tomography scans to assess cerebral blood flow." + ] + }, + { + "id": "multiclinsum_test_2753_en.txt", + "fulltext": "Written patient consent was obtained and our institutional ethical committee approved publication of this case report.\nA 55-year-old female (157 cm tall and weighing 58 kg) was admitted to our hospital for annuloaortic ectasia (AAE) and moderate aortic valve regurgitation (AR). The preoperative transthoracic echocardiography (TTE) examination confirmed AAE and moderate AR and detected abnormal blood flow just superior to the pulmonary valve. A coronary angiography demonstrated two fistulas from the right coronary cusp and left coronary artery with contrast draining to the pulmonary artery. Thus, the patient was diagnosed with AAE, AR, and coronary artery to pulmonary artery fistula and scheduled for repairing the dilated aortic root while preserving the native aortic valve and closure of the fistula.\nAnesthesia was induced with midazolam, 10 mg; fentanyl, 0.2 mg; and vecuronium, 8 mg and maintained with propofol, remifentanil, and vecuronium. After induction of anesthesia, a pulmonary artery catheter was placed through the right internal jugular vein and we performed blood sampling from the pulmonary artery, the right atrium, and the radial artery. We detected the oxygen step-up in the pulmonary artery and calculated that pulmonary flow/systemic flow (Qp/Qs) and left-to-right shunt ratio was 1.9 and 46%, respectively (oxygen saturation in the radial artery, the right atrium, and the pulmonary artery is 99.6, 73.3, and 85.5, respectively). Furthermore, we confirmed shunt flow of the coronary artery to pulmonary artery fistula draining to just superior to the pulmonary valve by TEE. Since the calculated values of Qp/Qs and left-to-right shunt ratio were unexpectedly high, we explored the presence of another shunt which had not been detected by preoperative TTE or plain computed tomography. Then, we found abnormal blood flow contrast draining from the descending aorta to the pulmonary trunk with upper esophageal aortic arch short-axis view . We suspected the presence of PDA and reported it to surgeons, and then, closure of PDA was added to the schedule.\nAfter establishment of cardiopulmonary bypass (CPB), the fistula from the right coronary cusp was found easily on the heart and it drained to the pulmonary artery. We tried to snare the fistula and confirmed no ECG changes, and then, we ligated this fistula. Then, the aorta was cross-clamped and the heart was arrested. The surgical findings after incision of the pulmonary main truncus included two orifices at just superior to the pulmonary valve and at the roof of the pulmonary trunk. The former orifice was drained from the fistula from the right and left coronary artery. After cardiac arrest, significant blood flow was noted through the latter orifice, so we considered that the latter orifice was drained from PDA. These orifices were closed, and then, repairing the dilated aortic root while preserving the native aortic valve was performed. Weaning from CPB was uneventful. We confirmed no residual shunt by TEE and calculated Qp/Qs as 1.0.", + "fulltext_subclaims": [ + "Written patient consent was obtained.", + "Our institutional ethical committee approved publication of this case report.", + "A 55-year-old female was admitted to our hospital for annuloaortic ectasia and moderate aortic valve regurgitation.", + "The preoperative transthoracic echocardiography examination confirmed annuloaortic ectasia and moderate aortic valve regurgitation.", + "The preoperative transthoracic echocardiography detected abnormal blood flow just superior to the pulmonary valve.", + "A coronary angiography demonstrated two fistulas from the right coronary cusp and left coronary artery with contrast draining to the pulmonary artery.", + "The patient was diagnosed with annuloaortic ectasia, aortic valve regurgitation, and coronary artery to pulmonary artery fistula.", + "The patient was scheduled for repairing the dilated aortic root while preserving the native aortic valve and closure of the fistula.", + "Anesthesia was induced with midazolam, 10 mg; fentanyl, 0.2 mg; and vecuronium, 8 mg.", + "Anesthesia was maintained with propofol, remifentanil, and vecuronium.", + "A pulmonary artery catheter was placed through the right internal jugular vein.", + "Blood sampling was performed from the pulmonary artery, the right atrium, and the radial artery.", + "The oxygen step-up in the pulmonary artery was detected.", + "The calculated pulmonary flow/systemic flow (Qp/Qs) was 1.9.", + "The calculated left-to-right shunt ratio was 46%.", + "Oxygen saturation in the radial artery was 99.6%.", + "Oxygen saturation in the right atrium was 73.3%.", + "Oxygen saturation in the pulmonary artery was 85.5%.", + "Shunt flow of the coronary artery to pulmonary artery fistula draining to just superior to the pulmonary valve was confirmed by TEE.", + "The calculated values of Qp/Qs and left-to-right shunt ratio were unexpectedly high.", + "The presence of another shunt was explored.", + "Abnormal blood flow contrast draining from the descending aorta to the pulmonary trunk was found with upper esophageal aortic arch short-axis view.", + "PDA was suspected.", + "Closure of PDA was added to the schedule.", + "After establishment of cardiopulmonary bypass, the fistula from the right coronary cusp was found easily on the heart and it drained to the pulmonary artery.", + "The fistula from the right coronary cusp was snared and no ECG changes were confirmed.", + "The fistula from the right coronary cusp was ligated.", + "The aorta was cross-clamped and the heart was arrested.", + "Two orifices were found at just superior to the pulmonary valve and at the roof of the pulmonary trunk.", + "The former orifice was drained from the fistula from the right and left coronary artery.", + "Significant blood flow was noted through the latter orifice after cardiac arrest.", + "The latter orifice was considered to be drained from PDA.", + "These orifices were closed.", + "Repairing the dilated aortic root while preserving the native aortic valve was performed.", + "Weaning from cardiopulmonary bypass was uneventful.", + "No residual shunt was confirmed by TEE.", + "Qp/Qs was calculated as 1.0 after the procedure." + ], + "summary": "We report anesthetic management of a 55-year-old female with annuloaortic ectasia, aortic valve regurgitation, and coronary artery to pulmonary artery fistula undergoing radical repair. We calculated the left-to-right shunt ratio after placement of a pulmonary artery catheter and found that the ratio was unexpectedly high. Thus, we explored the presence of another shunt by intraoperative transesophageal echocardiography and found patent ductus arteriosus undiagnosed before operation.", + "summary_subclaims": [ + "The patient was a 55-year-old female.", + "The patient had annuloaortic ectasia.", + "The patient had aortic valve regurgitation.", + "The patient had a coronary artery to pulmonary artery fistula.", + "The patient underwent radical repair.", + "A pulmonary artery catheter was placed.", + "The left-to-right shunt ratio was calculated.", + "The left-to-right shunt ratio was unexpectedly high.", + "Intraoperative transesophageal echocardiography was performed.", + "Patent ductus arteriosus was found.", + "The patent ductus arteriosus was undiagnosed before the operation." + ] + }, + { + "id": "multiclinsum_test_3212_en.txt", + "fulltext": "The case of a 59-year-old non-smoker who consulted for a month-long cough and mucous expectoration is described. On physical examination, he was in good general condition and a dull sound was heard in the lower right lung field with decreased wheezy murmurs in that area. A chest X-ray showed a round opacity (3-4 cm) in the lower right lung field. A chest CT scan showed a heterogeneous mass of 65 mm x 56 mm with lobar margins in the lower right lung field with heterogeneous enhancement with intravenous contrast that compromised the bronchus of the same lobe. A video bronchoscopy was performed, where a white, irregular, endobronchial formation was observed in the lower right lung field that occluded the same, after the exit of the apical segment. Remains of white membranes similar to those frequently observed in patients with complicated hydatid cyst were aspirated. Also, the adherence of these formations to the bronchus wall was observed, for which several biopsies were taken. The cytology of the endobronchial wash and brush was positive for neoplastic cells, and remains of hydatid membranes were also observed. The histopathology showed a high-grade sarcoma, without the immunohistochemical type of the same being able to be typified; in the biopsies, fragments of hydatid membranes were also visualized, with which the final diagnosis of pulmonary sarcoma associated with hydatid disease was reached. In the abdominal tomography, no images compatible with hepatic hydatid disease were found. The ELISA serological test was positive for Echinococcus. The patient underwent surgery, where the impossibility of resection of the tumor was observed in surgery. He was subsequently referred to oncology, where it was decided to perform radiotherapy and chemotherapy, but he died before initiating the same due to a cardiovascular complication.\n", + "fulltext_subclaims": [ + "The patient was a 59-year-old non-smoker.", + "The patient had a month-long cough and mucous expectoration.", + "On physical examination, a dull sound was heard in the lower right lung field.", + "A chest X-ray showed a round opacity (3-4 cm) in the lower right lung field.", + "A chest CT scan showed a heterogeneous mass of 65 mm x 56 mm with lobar margins in the lower right lung field.", + "The mass showed heterogeneous enhancement with intravenous contrast.", + "The mass compromised the bronchus of the same lobe.", + "A video bronchoscopy was performed.", + "A white, irregular, endobronchial formation was observed in the lower right lung field.", + "The formation occluded the bronchus after the exit of the apical segment.", + "Remains of white membranes similar to those observed in patients with complicated hydatid cyst were aspirated.", + "The adherence of these formations to the bronchus wall was observed.", + "Several biopsies were taken.", + "The cytology of the endobronchial wash and brush was positive for neoplastic cells.", + "Remains of hydatid membranes were observed in the cytology.", + "The histopathology showed a high-grade sarcoma.", + "The immunohistochemical type of the sarcoma could not be typified.", + "Fragments of hydatid membranes were visualized in the biopsies.", + "The final diagnosis was pulmonary sarcoma associated with hydatid disease.", + "In the abdominal tomography, no images compatible with hepatic hydatid disease were found.", + "The ELISA serological test was positive for Echinococcus.", + "The patient underwent surgery.", + "The impossibility of resection of the tumor was observed in surgery.", + "The patient was referred to oncology.", + "It was decided to perform radiotherapy and chemotherapy.", + "The patient died before initiating radiotherapy and chemotherapy.", + "The patient died due to a cardiovascular complication." + ], + "summary": "A patient presented with a cough and an imaging study showed a mass in the lower lobe of the right lung. A bronchoscopy showed a white, irregular, endobronchial formation, from which white membranes were aspirated. Biopsies were taken from the aspirate and sent for analysis. A cytological and histopathological study showed pulmonary hydatid disease coexisting with a sarcoma.\n", + "summary_subclaims": [ + "A patient presented with a cough.", + "An imaging study showed a mass in the lower lobe of the right lung.", + "A bronchoscopy showed a white, irregular, endobronchial formation.", + "White membranes were aspirated.", + "Biopsies were taken from the aspirate and sent for analysis.", + "A cytological and histopathological study showed pulmonary hydatid disease coexisting with a sarcoma." + ] + }, + { + "id": "multiclinsum_test_3048_en.txt", + "fulltext": "Patient information\n\nA 36-year-old female presented with dyspnea and chest constriction that had persisted for 20 days without any preceding predisposing factors. Progressive exacerbation of dyspnea and chest constriction was accompanied by nocturnal bouts of dyspnea and limb weakness lasting for 20 days. The patient denied experiencing fever or palpitations. The patient had no history of hypertension or cardiac ailments. No relevant treatment was undertaken before admission, and there was no record of prior surgeries or medications. The patient lacked pertinent personal or familial medical history. The patient exhibited acutely distressed countenance, lip cyanosis, marked lower extremity edema, blood pressure of 122/68 mm Hg, respiratory rate of 34 breaths/minutes, scattered moist rales in the bilateral lower lung fields, tachycardia at 188 beats/min, irregular rhythm, and discernible gallop rhythm upon cardiac auscultation.\n\nOutpatient laboratory examinations: erythrocyte 5.12*1012/L (normal range 3.8–5.112/L). Liver function: total bilirubin 43.6 µmol/L (normal range 3.4–20.5 µmol/L), direct bilirubin 20.5 µmol/L (normal range 0.5–8.6 µmol/L), indirect bilirubin 23.1 µmol/L (normal range 1.7–17 µmol/L). N-terminal pro-b-type natriuretic peptide (NT-proBNP) was 4021 pg/mL (normal range 0–450 pg/mL). Cardiac enzyme and troponin levels were within normal ranges, ruling out acute myocarditis and acute myocardial infarction. Outpatient electrocardiography revealed a rapid atrial fibrillation rhythm with type A preexcitation syndrome. Outpatient echocardiography. The left ventricular end-systolic volume was 113 mL, end-diastolic volume was 176 mL, the right ventricular anterior–posterior diameter was 31 mm, left atrial index was (LAVI) 19.9 mL/m2, left ventricular ejection fraction (LVEF) was 36%. M: Diffuse hypokinesia of ventricular wall motion and mitral regurgitation over an area of 12 cm2. This suggests an enlargement of the entire heart. Severe mitral valve regurgitation and impairment of left ventricular systolic function impairment outpatient chest CT showed calcified spots in the upper lobe of the right lung and an enlarged heart. Thyroid ultrasound revealed thyroid parenchyma with uneven echogenicity and increased blood flow.\n\n\nInitial diagnosis and treatment\n\nThe patient experienced an abrupt escalation in dyspnea severity during an outpatient consultation and was initially diagnosed with dilated cardiomyopathy (DCM), atrial fibrillation with preexcitation syndrome, and acute heart failure, as ascertained through an electrocardiogram, cardiac ultrasound, and an anomalous NT-proBNP finding.\n\nImmediate resuscitation measures were initiated in the emergency department. Multifunctional monitoring indicated that the patient’s blood pressure fluctuated at approximately 134/60 mm Hg, respiratory rate was 38 breaths/minute, oxygen saturation was maintained at 93%, and heart rate was 190 beats/minute. Numerous dry and wet rales were auscultated in both lung fields, and a furosemide injection 40 mg IV was administered immediately to improve the pulmonary edema. Oxygen support was provided because the patient had rapid atrial fibrillation with preexcitation syndrome, and digitalis glycoside drugs were not administered to prevent possible ventricular fibrillation. After the administration of esmolol hydrochloride, the patient’s heart rate did not decrease significantly, and the patient rapidly developed acute heart failure decompensation. The patient presented in a forced sitting position with severe dyspnea, oxygen level of 88%, respiratory rate of 40 breaths/minute, heart rate of 156 beats/minute, and blood pressure of 126/69 mm Hg. Following confirmation of the absence of a history of bronchial asthma, 5 mg morphine was intramuscularly administered and 5 mg dexamethasone sodium phosphate was intravenously administered. Administered intravenous dihydroxypropyltheophylline 0.5 g of solution was administered intravenously to the patient to relieve airway spasms, and subsequently, recombinant human brain natriuretic peptide was injected to ameliorate heart failure. Following a loading dose of 1.5 µg/kg administered over 5 minutes, continuous infusion at a rate of 0.01 µg/kg/minute was initiated. After 30 minutes of resuscitation therapy, the patient’s heart rate remained above 140 beats/minute and rapid atrial fibrillation with preexcitation syndrome persisted. Consequently, amiodarone hydrochloride injection was initiated. Initially, 150 mg was administered intravenously for 10 minutes, followed by a subsequent infusion of 360 mg at a rate of 1 mg/minute. Following approximately 2-hours of resuscitation therapy, the patient acute heart failure was successfully corrected. Monitoring revealed an oxygen saturation of 96%, respiratory rate of 25 breaths/minute, heart rate of 126 beats/minute, and blood pressure of 132/74 mm Hg. The patient electrocardiographic rhythm persisted with atrial fibrillation; however, there were no signs of preexcitation syndrome. An improvement in dyspnea was noted, and low-molecular-weight heparin was administered to prevent thrombus formation. Calcium injections (5000 IU) were administered subcutaneously twice daily. Concurrently, alterations in the coagulation function were observed. Subsequently, propranolol hydrochloride was administered orally at a dose of 20 mg 3 times daily, accompanied by a minimal dosage of furosemide tablets (20 mg) and daily oral intake of spironolactone (20 mg). The patient received 20 mg methimazole tablets orally twice daily. Following a 2-week course of treatment, the patient exhibited robust recovery, marked by substantial amelioration of symptoms associated with heart failure, notably dyspnea. The patient was discharged with a prescription for oral medication.\n\n\nFinal diagnosis\n\nLaboratory examinations on the second day: thyroid-stimulating hormone < 0.005 µIU/mL (normal range 0.27–4.2 µIU/mL), serum free T3 30.02 pmol/L (normal range 3.1–6.8 pmol/L), serum free T4 96.22 pmol/L (normal range 12–22 pmol/L), and antithyroid peroxidase antibody 270.90 IU/mL (normal range 0–34 IU/mL), NT-proBNP 3381 pg/mL (normal range 0–450 pg/mL). Coronary angiography did not reveal any stenosis of the coronary lumen, ruling out coronary artery disease. Upon evaluating the patient’s symptoms, conducting a thorough physical examination, considering the lack of previous medical history, and analyzing laboratory and imaging results such as thyroid function, the conclusive diagnosis is reached through a process of elimination encompassing the following conditions: thyrotoxic cardiomyopathy, acute heart failure, and atrial fibrillation with preexcitation syndrome.\n\n\nOutcome and follow-up\n\nDuring the 1-month post-discharge follow-up period, the patient had no symptoms of heart failure or dyspnea. Physical examination revealed an absence of overt positive signs. Electrocardiography indicated the restoration of normal sinus rhythm with effective heart rate control. A review of the thyroid function revealed a return to normal levels. The NT-proBNP was 321 pg/mL (reference range 0–450 pg/mL); and notable alterations in the patient indices were evident compared with the initial admission. Evaluation of the echocardiograms revealed significant changes compared with the initial visit. The left ventricular end-systolic volume was 78 mL, end-diastolic volume was 141 mL, the right ventricular anterior–posterior diameter was 27 mm, and the left atrial index (LAVI) was 14.2 mL/m2, LVEF was 45%. The mitral regurgitation area had contracted to 1.7 cm2. Subsequent thyroid ultrasound revealed heterogeneous parenchymal echogenicity in the thyroid gland, and the blood flow signal had decreased compared to the prior examination.", + "fulltext_subclaims": [ + "The patient is a 36-year-old female.", + "The patient had dyspnea and chest constriction that had persisted for 20 days.", + "The dyspnea and chest constriction were accompanied by nocturnal dyspnea and limb weakness.", + "The patient denied experiencing fever or palpitations.", + "The patient had no history of hypertension or cardiac ailments.", + "No relevant treatment was undertaken before admission.", + "The patient exhibited acutely distressed countenance.", + "The patient had lip cyanosis.", + "The patient had marked lower extremity edema.", + "The patient’s blood pressure was 122/68 mm Hg.", + "The patient’s respiratory rate was 34 breaths/minute.", + "Scattered moist rales were heard in the bilateral lower lung fields.", + "The patient’s heart rate was 188 beats/min.", + "The patient’s rhythm was irregular.", + "A discernible gallop rhythm was heard upon cardiac auscultation.", + "Outpatient laboratory examinations showed erythrocyte 5.12*1012/L.", + "Outpatient laboratory examinations showed total bilirubin 43.6 µmol/L.", + "Outpatient laboratory examinations showed direct bilirubin 20.5 µmol/L.", + "Outpatient laboratory examinations showed indirect bilirubin 23.1 µmol/L.", + "Outpatient laboratory examinations showed NT-proBNP 4021 pg/mL.", + "Cardiac enzyme and troponin levels were within normal ranges.", + "Outpatient electrocardiography revealed rapid atrial fibrillation with type A preexcitation syndrome.", + "Outpatient echocardiography showed left ventricular end-systolic volume of 113 mL.", + "Outpatient echocardiography showed left ventricular end-diastolic volume of 176 mL.", + "Outpatient echocardiography showed right ventricular anterior–posterior diameter of 31 mm.", + "Outpatient echocardiography showed left atrial index of 19.9 mL/m2.", + "Outpatient echocardiography showed left ventricular ejection fraction of 36%.", + "Outpatient echocardiography showed diffuse hypokinesia of ventricular wall motion.", + "Outpatient echocardiography showed mitral regurgitation over an area of 12 cm2.", + "Outpatient echocardiography suggested an enlargement of the entire heart.", + "Outpatient chest CT showed calcified spots in the upper lobe of the right lung.", + "Outpatient chest CT showed an enlarged heart.", + "Thyroid ultrasound revealed thyroid parenchyma with uneven echogenicity.", + "Thyroid ultrasound revealed increased blood flow.", + "The patient was initially diagnosed with dilated cardiomyopathy.", + "The patient was diagnosed with atrial fibrillation with preexcitation syndrome.", + "The patient was diagnosed with acute heart failure.", + "The patient’s blood pressure fluctuated at approximately 134/60 mm Hg.", + "The patient’s respiratory rate was 38 breaths/minute.", + "The patient’s oxygen saturation was maintained at 93%.", + "The patient’s heart rate was 190 beats/minute.", + "Numerous dry and wet rales were auscultated in both lung fields.", + "A furosemide injection 40 mg IV was administered.", + "Oxygen support was provided.", + "Digitalis glycoside drugs were not administered.", + "Esmolol hydrochloride was administered.", + "The patient’s heart rate did not decrease significantly.", + "The patient rapidly developed acute heart failure decompensation.", + "The patient presented in a forced sitting position.", + "The patient’s oxygen level was 88%.", + "The patient’s respiratory rate was 40 breaths/minute.", + "The patient’s heart rate was 156 beats/minute.", + "The patient’s blood pressure was 126/69 mm Hg.", + "5 mg morphine was intramuscularly administered.", + "5 mg dexamethasone sodium phosphate was intravenously administered.", + "Intravenous dihydroxypropyltheophylline 0.5 g was administered.", + "Recombinant human brain natriuretic peptide was injected.", + "A loading dose of 1.5 µg/kg was administered over 5 minutes.", + "A continuous infusion at a rate of 0.01 µg/kg/minute was initiated.", + "After 30 minutes of resuscitation therapy, the patient’s heart rate remained above 140 beats/minute.", + "Rapid atrial fibrillation with preexcitation syndrome persisted.", + "Amiodarone hydrochloride injection was initiated.", + "150 mg was administered intravenously for 10 minutes.", + "360 mg was administered at a rate of 1 mg/minute.", + "Following approximately 2-hours of resuscitation therapy, the patient’s acute heart failure was successfully corrected.", + "The patient’s oxygen saturation was 96%.", + "The patient’s respiratory rate was 25 breaths/minute.", + "The patient’s heart rate was 126 beats/minute.", + "The patient’s blood pressure was 132/74 mm Hg.", + "The patient’s electrocardiographic rhythm persisted with atrial fibrillation.", + "There were no signs of preexcitation syndrome.", + "An improvement in dyspnea was noted.", + "Low-molecular-weight heparin was administered.", + "Calcium injections (5000 IU) were administered subcutaneously twice daily.", + "Alterations in the coagulation function were observed.", + "Propranolol hydrochloride was administered orally at a dose of 20 mg 3 times daily.", + "Furosemide tablets 20 mg were administered daily.", + "Spironolactone 20 mg was administered daily.", + "Methimazole tablets 20 mg were administered orally twice daily.", + "Following a 2-week course of treatment, the patient exhibited robust recovery.", + "The patient was discharged with a prescription for oral medication.", + "Laboratory examinations on the second day showed thyroid-stimulating hormone < 0.005 µIU/mL.", + "Laboratory examinations on the second day showed serum free T3 30.02 pmol/L.", + "Laboratory examinations on the second day showed serum free T4 96.22 pmol/L.", + "Laboratory examinations on the second day showed antithyroid peroxidase antibody 270.90 IU/mL.", + "Laboratory examinations on the second day showed NT-proBNP 3381 pg/mL.", + "Coronary angiography did not reveal any stenosis of the coronary lumen.", + "The conclusive diagnosis is thyrotoxic cardiomyopathy.", + "The conclusive diagnosis is acute heart failure.", + "The conclusive diagnosis is atrial fibrillation with preexcitation syndrome.", + "During the 1-month post-discharge follow-up period, the patient had no symptoms of heart failure.", + "During the 1-month post-discharge follow-up period, the patient had no symptoms of dyspnea.", + "Physical examination revealed an absence of overt positive signs.", + "Electrocardiography indicated the restoration of normal sinus rhythm.", + "A review of the thyroid function revealed a return to normal levels.", + "NT-proBNP was 321 pg/mL.", + "Echocardiograms revealed significant changes compared with the initial visit.", + "The left ventricular end-systolic volume was 78 mL.", + "The left ventricular end-diastolic volume was 141 mL.", + "The right ventricular anterior–posterior diameter was 27 mm.", + "The left atrial index was 14.2 mL/m2.", + "The left ventricular ejection fraction was 45%.", + "The mitral regurgitation area had contracted to 1.7 cm2.", + "Subsequent thyroid ultrasound revealed heterogeneous parenchymal echogenicity in the thyroid gland.", + "The blood flow signal had decreased compared to the prior examination." + ], + "summary": "Patient concerns:\nThis patient presented with dyspnea and chest constriction, without any antecedent predisposing factors. Subsequently, the patient abruptly manifested symptoms indicative of acute heart failure during outpatient consultation. Electrocardiography revealed rapid atrial fibrillation with type A preexcitation syndrome, whereas cardiac ultrasonography demonstrated global cardiac enlargement with a diminished ejection fraction (EF).\n\nDiagnoses:\nAfter a comprehensive evaluation, the patient was diagnosed with thyrotoxic cardiomyopathy, acute heart failure, and atrial fibrillation with preexcitation syndrome.\n\nInterventions:\nImmediate interventions comprised diuretic administration, oxygen therapy, and antiarrhythmic agents, addressing acute heart failure concomitant with preexcitation syndrome. Following a fortnight of comprehensive therapeutic measures, the patient was discharged with a prescription for oral medications, notably methimazole.\n\nOutcomes:\nFollowing the intervention, the patient showed significant improvement with the resolution of heart failure symptoms and dyspnea, restoration of sinus rhythm, improved left ventricular ejection fraction (LVEF improved from 36% to 45%), and normalization of thyroid function. These outcomes underscore the efficacy of the intervention strategy and offer a hopeful prognosis for similar cases.", + "summary_subclaims": [ + "The patient presented with dyspnea and chest constriction.", + "The patient had no antecedent predisposing factors.", + "The patient abruptly manifested symptoms indicative of acute heart failure during outpatient consultation.", + "Electrocardiography revealed rapid atrial fibrillation with type A preexcitation syndrome.", + "Cardiac ultrasonography demonstrated global cardiac enlargement with a diminished ejection fraction.", + "The patient was diagnosed with thyrotoxic cardiomyopathy.", + "The patient was diagnosed with acute heart failure.", + "The patient was diagnosed with atrial fibrillation with preexcitation syndrome.", + "Immediate interventions comprised diuretic administration.", + "Immediate interventions comprised oxygen therapy.", + "Immediate interventions comprised antiarrhythmic agents.", + "Following a fortnight of comprehensive therapeutic measures, the patient was discharged.", + "The patient was prescribed oral methimazole.", + "Following the intervention, the patient showed significant improvement.", + "Heart failure symptoms resolved following the intervention.", + "Dyspnea resolved following the intervention.", + "Sinus rhythm was restored following the intervention.", + "Left ventricular ejection fraction improved from 36% to 45%.", + "Thyroid function normalized following the intervention." + ] + }, + { + "id": "multiclinsum_test_1864_en.txt", + "fulltext": "The index patient was a 16-year-old girl in the second year of junior middle school in Zhejiang Province, China, who has experienced persistent cough and expectoration for 37 days since 1 March 2014. She tested positive for smear pulmonary TB and extrapulmonary TB (TB of the cervical lymph nodes) on 8 April 2014 (see Table ). She was subsequently suspended from school and treated with chemotherapy comprising isoniazid (H), rifampicin (R), ethambutol (E), and pyrazinamide (Z) since 9 April 2014, with the dosages of these medications dependent on patient’s weight (see Table ). During the treatment period (9 April 2014–8 November 2015), the index patient visited the local TB-designated hospital for further consultation every month and was followed up once a month by the local community health service center. However, the Mycobacterium tuberculosis isolate was resistant to H/R/E/S based on the results of the drug susceptibility test (DST) on 1 May 2014.\nOn 19 May 2014, the index patient was treated with regimens of moxifloxacin, propylthioisonicotinamide, amikacin, pyrazinamide, and pasiniazide (see Table ). On 17 July 2014, as she experienced heel pain, the chemotherapy program was adjusted to regimens of propylthioisonicotinamide, amikacin, pyrazinamide, and pasiniazide. On 1 January 2015, the chemotherapy program was adjusted to regimens of propylthioisonicotinamide, pyrazinamide, and pasiniazide.\nOn 14 November 2016, she was subsequently cured according to the results of the laboratory smear and X-ray examination. During the treatment period, the sputum smear test results were negative in June, September, and October 2014.\nBased on the interview conducted on the index patient, her classmates and teachers were her primary close contacts. Local health authorities conducted a contact investigation in April 2014. All potential contacts were screened by performing the tuberculin skin test (TST), and close contacts with positive TST results and with induration larger than 5 mm were diagnosed with MDR-TB . The index patient’s two family members all had negative TST and X-ray examination results. There was no history of TB in her family. All 54 (49 classmates and five teachers) individuals with close contact with the index patient in the same class were screened during 12–15 April 2014, and five of these contacts had positive TST results. However, these five individuals refused to receive preventive anti-TB treatment. The five TST-positive contacts in our investigation had been consistently followed up, and based on the follow-up result, TB infection was no longer observed in the next two years in these five patients.\nIn April 2016, two student patients (P1 and P2) tested positive for smear pulmonary TB in different high schools. P1 has persistently experienced the symptoms of cough and expectoration since 15 January 2016 and has left school because of winter vacation since 21 January 2016. P1 tested positive for smear pulmonary TB on 2 April 2016 and experienced hemoptysis, with multiple cavities in the lung parenchyma. His M. tuberculosis isolate was resistant to H/R/E/S based on the results of his DST on 22 June 2016. P2 has persistently experienced the symptoms of cough and expectoration since 12 March 2016, and she tested positive for smear pulmonary TB on 5 April 2016. She also experienced hemoptysis during that time. The M. tuberculosis isolate was resistant to H/R/E/S based on the results of her DST on 19 June 2016. They were suspended from school since 3 April 2016 and 6 April 2016, respectively, and were initially treated with chemotherapy comprising isoniazid (H), rifampicin (R), ethambutol (E), and pyrazinamide (Z), with the dosages of medications dependent on the patient’s weight. Subsequently, the chemotherapy program was adjusted to regimens of moxifloxacin, propylthioisonicotinamide, amikacin, pyrazinamide, and pasiniazide according to their DST results. All 56 (50 classmates and six teachers) individuals who were in close contact with P1 were screened through X-ray examination and TST during 6–8 April 2016. Moreover, all 58 individuals (52 classmates and six teachers) who were in close contact with P2 were screened during 7–11 April 2016. No other cases of TB or infection were observed.\nOn 2 February 2017, one student (P3) from another high school tested positive for smear pulmonary TB. P3 had persistently experienced symptoms of cough and expectoration since 1 December 2016. The M. tuberculosis isolate was resistant to H/R/E/S based on the results of her DST on 20 May 2017. She was also suspended from school since 22 February 2017 and was initially treated with chemotherapy comprising isoniazid (H), rifampicin (R), ethambutol (E), and pyrazinamide (Z), with the medication dosages dependent on the patient’s weight. Subsequently, the chemotherapy program was adjusted to regimens of moxifloxacin, propylthioisonicotinamide, amikacin, pyrazinamide, and pasiniazide according to the patient’s DST results. All 51 (46 classmates and five teachers) individuals with close contact with the patient were screened through X-ray examination and TST during 22–24 February 2017, and 14 of these 51 patients had positive TST results.\nThrough a retrospective epidemiological investigation by local health authorities, there were no histories of TB in the patients’ families, although three student (P1, P2, and P3) patients clinically diagnosed with MDR-TB were from three different high schools in Lanxi City. However, they attended the same junior middle school and the same class as the index patient. Furthermore, they sat together in the classroom. The index patient sat in the middle of them, P1 was in the front of her, and P2, P3 were on her right and left side. Moreover, two of these patients (P2 and P3) lived with the index patient in the same dormitory , and their exposure time to the index patient was approximately 37 days. Although they all had negative TST and negative X-ray examination results at that time, the drug resistance patterns of the four patients diagnosed with pulmonary TB were identical (resistant to H/R/E/S). Their average discovery delay was 55 days.\nAfter further retrospective epidemiological investigation, we learned that the index patient had evident risk factors for MDR-TB transmission. Epidemiological links were categorized into neighborhood environments. The neighbors (N1, N2, and N3) living around the index patient were all diagnosed with TB in 2011, 2012, and 2013, respectively . N4, who was the wife of N2, was diagnosed with TB in July 2015. Four neighbors of the index patient experienced treatment failure due to irregular treatment, and three of them did not undergo further DST investigation. All neighbors were initially treated with regimens of isoniazid (H), rifampicin (R), ethambutol (E), and pyrazinamide (Z). Only N2 was diagnosed with MDR-TB and treated with regimens of moxifloxacin, propylthioisonicotinamide, ethambutol, pyrazinamide, and pasiniazide according to the patient’s DST results (resistant to H/R/E/S). However, he still experienced treatment failure due to the adverse effects of the medications and the heavy economic cost of treatment.\nIsolated strains from four patients (index patient, P1, P2, P3) were sent to Zhejiang Provincial Center for Disease Prevention and Control for repeat drug sensitivity tests and gene typing tests . Variable-number tandem repeats of mycobacterial interspersed repetitive unit loci were used to genotype the strains. When 15 site combinations were used, the TB strains of four patients were clustered. The results showed that four patients had homologous transmission (see Fig. ).", + "fulltext_subclaims": [ + "The index patient was a 16-year-old girl in the second year of junior middle school in Zhejiang Province, China.", + "She experienced persistent cough and expectoration for 37 days since 1 March 2014.", + "She tested positive for smear pulmonary TB and extrapulmonary TB (TB of the cervical lymph nodes) on 8 April 2014.", + "She was treated with chemotherapy comprising isoniazid (H), rifampicin (R), ethambutol (E), and pyrazinamide (Z) since 9 April 2014.", + "The dosages of these medications were dependent on the patient’s weight.", + "The Mycobacterium tuberculosis isolate was resistant to H/R/E/S based on the results of the drug susceptibility test on 1 May 2014.", + "On 19 May 2014, the index patient was treated with regimens of moxifloxacin, propylthioisonicotinamide, amikacin, pyrazinamide, and pasiniazide.", + "On 17 July 2014, the chemotherapy program was adjusted to regimens of propylthioisonicotinamide, amikacin, pyrazinamide, and pasiniazide.", + "On 1 January 2015, the chemotherapy program was adjusted to regimens of propylthioisonicotinamide, pyrazinamide, and pasiniazide.", + "On 14 November 2016, she was subsequently cured according to the results of the laboratory smear and X-ray examination.", + "During the treatment period, the sputum smear test results were negative in June, September, and October 2014.", + "Her classmates and teachers were her primary close contacts.", + "Local health authorities conducted a contact investigation in April 2014.", + "All potential contacts were screened by performing the tuberculin skin test (TST).", + "Close contacts with positive TST results and with induration larger than 5 mm were diagnosed with MDR-TB.", + "The index patient’s two family members all had negative TST and X-ray examination results.", + "There was no history of TB in her family.", + "All 54 individuals with close contact with the index patient in the same class were screened during 12–15 April 2014.", + "Five of these contacts had positive TST results.", + "These five individuals refused to receive preventive anti-TB treatment.", + "The five TST-positive contacts were consistently followed up.", + "TB infection was no longer observed in the next two years in these five patients.", + "In April 2016, two student patients (P1 and P2) tested positive for smear pulmonary TB in different high schools.", + "P1 has persistently experienced the symptoms of cough and expectoration since 15 January 2016.", + "P1 tested positive for smear pulmonary TB on 2 April 2016.", + "P1 experienced hemoptysis, with multiple cavities in the lung parenchyma.", + "The M. tuberculosis isolate was resistant to H/R/E/S based on the results of his DST on 22 June 2016.", + "P1 was suspended from school since 3 April 2016.", + "P1 was initially treated with chemotherapy comprising isoniazid (H), rifampicin (R), ethambutol (E), and pyrazinamide (Z).", + "The chemotherapy program was adjusted to regimens of moxifloxacin, propylthioisonicotinamide, amikacin, pyrazinamide, and pasiniazide according to his DST results.", + "P2 has persistently experienced the symptoms of cough and expectoration since 12 March 2016.", + "P2 tested positive for smear pulmonary TB on 5 April 2016.", + "P2 also experienced hemoptysis during that time.", + "The M. tuberculosis isolate was resistant to H/R/E/S based on the results of her DST on 19 June 2016.", + "P2 was suspended from school since 6 April 2016.", + "P2 was initially treated with chemotherapy comprising isoniazid (H), rifampicin (R), ethambutol (E), and pyrazinamide (Z).", + "The chemotherapy program was adjusted to regimens of moxifloxacin, propylthioisonicotinamide, amikacin, pyrazinamide, and pasiniazide according to her DST results.", + "All 56 individuals who were in close contact with P1 were screened through X-ray examination and TST during 6–8 April 2016.", + "All 58 individuals who were in close contact with P2 were screened during 7–11 April 2016.", + "No other cases of TB or infection were observed.", + "On 2 February 2017, one student (P3) from another high school tested positive for smear pulmonary TB.", + "P3 had persistently experienced symptoms of cough and expectoration since 1 December 2016.", + "The M. tuberculosis isolate was resistant to H/R/E/S based on the results of her DST on 20 May 2017.", + "P3 was suspended from school since 22 February 2017.", + "P3 was initially treated with chemotherapy comprising isoniazid (H), rifampicin (R), ethambutol (E), and pyrazinamide (Z).", + "The chemotherapy program was adjusted to regimens of moxifloxacin, propylthioisonicotinamide, amikacin, pyrazinamide, and pasiniazide according to the patient’s DST results.", + "All 51 individuals with close contact with the patient were screened through X-ray examination and TST during 22–24 February 2017.", + "Fourteen of these 51 patients had positive TST results.", + "Through a retrospective epidemiological investigation, there were no histories of TB in the patients’ families.", + "Three student patients (P1, P2, and P3) clinically diagnosed with MDR-TB were from three different high schools in Lanxi City.", + "They attended the same junior middle school and the same class as the index patient.", + "They sat together in the classroom.", + "The index patient sat in the middle of them, P1 was in the front of her, and P2, P3 were on her right and left side.", + "Two of these patients (P2 and P3) lived with the index patient in the same dormitory.", + "Their exposure time to the index patient was approximately 37 days.", + "Although they all had negative TST and negative X-ray examination results at that time, the drug resistance patterns of the four patients diagnosed with pulmonary TB were identical (resistant to H/R/E/S).", + "Their average discovery delay was 55 days.", + "The index patient had evident risk factors for MDR-TB transmission.", + "Epidemiological links were categorized into neighborhood environments.", + "The neighbors (N1, N2, and N3) living around the index patient were all diagnosed with TB in 2011, 2012, and 2013, respectively.", + "N4, who was the wife of N2, was diagnosed with TB in July 2015.", + "Four neighbors of the index patient experienced treatment failure due to irregular treatment.", + "Three of them did not undergo further DST investigation.", + "All neighbors were initially treated with regimens of isoniazid (H), rifampicin (R), ethambutol (E), and pyrazinamide (Z).", + "Only N2 was diagnosed with MDR-TB and treated with regimens of moxifloxacin, propylthioisonicotinamide, ethambutol, pyrazinamide, and pasiniazide according to the patient’s DST results (resistant to H/R/E/S).", + "He still experienced treatment failure due to the adverse effects of the medications and the heavy economic cost of treatment.", + "Isolated strains from four patients (index patient, P1, P2, P3) were sent to Zhejiang Provincial Center for Disease Prevention and Control for repeat drug sensitivity tests and gene typing tests.", + "Variable-number tandem repeats of mycobacterial interspersed repetitive unit loci were used to genotype the strains.", + "When 15 site combinations were used, the TB strains of four patients were clustered.", + "The results showed that four patients had homologous transmission." + ], + "summary": "The index patient was a 16-year-old girl in the second year of junior middle school in Zhejiang Province, China, who had been experiencing persistent cough and expectoration for 37 days since 1 March 2014. She tested positive for smear pulmonary and extrapulmonary TB on 8 April 2014 and was subsequently diagnosed with MDR-TB on 1 May 2014. However, the patient was resistant to isoniazid, rifampicin, ethambutol, and streptomycin. Thus, she was suspended from school for anti-TB treatment. All 54 students who were in close contact with the index patient in the same class were screened, and 5 tested positive on the tuberculin skin test. Their exposure time to the index patient was approximately 37 days. Three classmates were subsequently diagnosed with MDR-TB, with similar resistance profiles nearly two years later. Their average discovery delay was 55 days. These three classmates were also suspended from school for anti-TB treatment. During the treatment period, four students visited the local TB-designated hospital for further consultation every month and were followed up once a month by the local community health service center until they were completely cured.", + "summary_subclaims": [ + "The index patient was a 16-year-old girl in the second year of junior middle school in Zhejiang Province, China.", + "She had been experiencing persistent cough and expectoration for 37 days since 1 March 2014.", + "She tested positive for smear pulmonary and extrapulmonary TB on 8 April 2014.", + "She was diagnosed with MDR-TB on 1 May 2014.", + "The patient was resistant to isoniazid, rifampicin, ethambutol, and streptomycin.", + "She was suspended from school for anti-TB treatment.", + "All 54 students who were in close contact with the index patient in the same class were screened.", + "Five students tested positive on the tuberculin skin test.", + "Their exposure time to the index patient was approximately 37 days.", + "Three classmates were subsequently diagnosed with MDR-TB.", + "The three classmates had similar resistance profiles nearly two years later.", + "The average discovery delay was 55 days.", + "The three classmates were also suspended from school for anti-TB treatment.", + "During the treatment period, four students visited the local TB-designated hospital for further consultation every month.", + "They were followed up once a month by the local community health service center until they were completely cured." + ] + }, + { + "id": "multiclinsum_test_644_en.txt", + "fulltext": "A 35 year old primiparous woman underwent an emergency caesarean section due to failure to progress in the second stage of labour. After a successful operative delivery, mother and child were discharged three days later, having had an uneventful recovery.\nEighteen days post caesarean section, the mother presented to hospital with continuous vaginal discharge necessitating pad changes every hour. The discharge was clear, consistent with urine. She underwent a computed tomography intravenous urogram (CT-IVU) which suggested a diagnosis of a uretero-uterine fistula .\nTwo days later, an examination under anaesthesia, and a cystoscopy and ureteroscopy, were performed. A small amount of blood was found on vaginal examination and cystoscopy revealed normal bladder and ureteric orifices. A guidewire inserted in the right ureter under imaging would only advance approximately 6 cm up the ureter. Retrograde ureterography was performed and showed the passage of dye from the right ureter to the uterus . The procedure was abandoned and a nephrostomy was inserted post-operatively to help divert urine away from the fistula.\nAfter a two months interval, the mother returned to clinic for follow-up and reported that she had not experienced any further vaginal leakage of urine. In order to assess the condition of the ureter and fistula, a nephrostogram was performed which showed complete blockage of the ureter . Following the nephrostogram, vaginal discharge of urine recurred indicating persistence of the fistula.\nSix weeks later she underwent re-implantation of the right ureter and JJ-stent insertion. A suprapubic and urethral catheter were inserted and the nephrostomy clamped. The urethral catheter was removed five days post-operatively and a cystogram performed 10 days post-operatively showed no evidence of an anastomotic leak. The nephrostomy tube was removed under radiological guidance, and was inadvertently accompanied by the JJ-stent. One week later, an IVU revealed both right and left ureters to be draining well with no evidence of obstruction or fistula . The patient went on to make a full recovery.", + "fulltext_subclaims": [ + "A 35 year old primiparous woman underwent an emergency caesarean section due to failure to progress in the second stage of labour.", + "Mother and child were discharged three days after the caesarean section.", + "Eighteen days post caesarean section, the mother presented to hospital with continuous vaginal discharge necessitating pad changes every hour.", + "The discharge was clear, consistent with urine.", + "A CT-IVU suggested a diagnosis of a uretero-uterine fistula.", + "An examination under anaesthesia, and a cystoscopy and ureteroscopy, were performed.", + "A guidewire inserted in the right ureter under imaging would only advance approximately 6 cm up the ureter.", + "Retrograde ureterography showed the passage of dye from the right ureter to the uterus.", + "A nephrostomy was inserted post-operatively.", + "After a two months interval, the mother returned to clinic and reported no further vaginal leakage of urine.", + "A nephrostogram showed complete blockage of the ureter.", + "Vaginal discharge of urine recurred following the nephrostogram.", + "She underwent re-implantation of the right ureter and JJ-stent insertion.", + "A suprapubic and urethral catheter were inserted.", + "The urethral catheter was removed five days post-operatively.", + "A cystogram performed 10 days post-operatively showed no evidence of an anastomotic leak.", + "The nephrostomy tube was removed under radiological guidance.", + "The nephrostomy tube was inadvertently accompanied by the JJ-stent.", + "An IVU revealed both right and left ureters to be draining well with no evidence of obstruction or fistula.", + "The patient went on to make a full recovery." + ], + "summary": "We present the case of a 35 year old woman who presented with continuous vaginal discharge three weeks after undergoing caesarean section.", + "summary_subclaims": [ + "The patient is a 35 year old woman.", + "The patient presented with continuous vaginal discharge.", + "The discharge occurred three weeks after undergoing caesarean section." + ] + }, + { + "id": "multiclinsum_test_2313_en.txt", + "fulltext": "A 30-year-old Persian woman presented weakness, stress, low blood pressure, and low-grade fever. On the tenth day after the onset of the symptoms, she complained of chest pain, cough, and tachycardia.\nA chest computerized tomography (CT) scan revealed the presence of unilateral ground-glass opacities . Following gastrointestinal complications, including diarrhea, vomiting, and 78% oxygen saturation, the patient was hospitalized and moved to the intensive care unit for invasive ventilation. She was treated with hydroxychloroquine, antiviral therapy (remdesivir), and tocilizumab. After partial recovery, the patient was discharged home. However, 30 days after the onset of symptoms, the patient manifested neurological complications . She developed acute weakness in the lower limb, numbness and tingling, loss of touch and vibration sensation in the feet and, a few days later, in the upper limb and the hands. She also developed gait disorder and loss of balance. Subsequently, muscle stretch reflex examination revealed absent deep tendon reflexes in the upper and lower limbs. The patient also showed acute onset of unilateral eyelid ptosis (right), blurred vision (right), areflexia, dysphagia, vomiting, urinary incontinence (UI), and unilateral numbness of the chin and lower lip [numb chin syndrome (NCS)]. Electroneurography revealed severe sensory-motor axonal polyneuropathy with relative sparing of conduction velocities. The nerve conduction studies showed reduced or absent compound muscle action potentials (CMAP) and sensory nerve action potentials in the lower and upper limbs. Brain and spinal cord magnetic resonance imaging (MRI) did not reveal any abnormal and pathological findings. SARS-Cov-2 RNA was not tested in cerebrospinal fluid (CSF).\nThe patient received intravenous immunoglobulin (IG) (0.4 g/kg/day for 5 days). The patient was highly responsive to treatment with the rapid clinical response on swallowing, strength, and eyelid ptosis. Also, the patient performed physical therapy successfully at her rehabilitation facility.", + "fulltext_subclaims": [ + "The patient was a 30-year-old Persian woman.", + "She presented with weakness, stress, low blood pressure, and low-grade fever.", + "On the tenth day after the onset of the symptoms, she complained of chest pain, cough, and tachycardia.", + "A chest CT scan revealed the presence of unilateral ground-glass opacities.", + "Following gastrointestinal complications, including diarrhea, vomiting, and 78% oxygen saturation, the patient was hospitalized.", + "She was moved to the intensive care unit for invasive ventilation.", + "She was treated with hydroxychloroquine, antiviral therapy (remdesivir), and tocilizumab.", + "After partial recovery, the patient was discharged home.", + "30 days after the onset of symptoms, the patient manifested neurological complications.", + "She developed acute weakness in the lower limb.", + "She developed numbness and tingling.", + "She developed loss of touch and vibration sensation in the feet.", + "A few days later, she developed loss of touch and vibration sensation in the upper limb and the hands.", + "She developed gait disorder and loss of balance.", + "Muscle stretch reflex examination revealed absent deep tendon reflexes in the upper and lower limbs.", + "She developed acute onset of unilateral eyelid ptosis (right).", + "She developed blurred vision (right).", + "She developed areflexia.", + "She developed dysphagia.", + "She developed vomiting.", + "She developed urinary incontinence.", + "She developed unilateral numbness of the chin and lower lip.", + "Electroneurography revealed severe sensory-motor axonal polyneuropathy with relative sparing of conduction velocities.", + "The nerve conduction studies showed reduced or absent compound muscle action potentials in the lower and upper limbs.", + "The nerve conduction studies showed reduced or absent sensory nerve action potentials in the lower and upper limbs.", + "Brain and spinal cord MRI did not reveal any abnormal and pathological findings.", + "SARS-Cov-2 RNA was not tested in cerebrospinal fluid.", + "The patient received intravenous immunoglobulin (0.4 g/kg/day for 5 days).", + "The patient was highly responsive to treatment with the rapid clinical response on swallowing.", + "The patient was highly responsive to treatment with the rapid clinical response on strength.", + "The patient was highly responsive to treatment with the rapid clinical response on eyelid ptosis.", + "The patient performed physical therapy successfully at her rehabilitation facility." + ], + "summary": "We observed a 30-year-old Persian woman developing acute motor sensory axonal neuropathy, a variant of Guillain-Barré syndrome that overlaps Miller Fisher syndrome, 30 days after confirmed coronavirus disease-2019 infection. Our case highlight the rare occurrence of Guillain-Barré syndrome overlapping with Miller Fisher during the coronavirus disease-2019 pandemic. These neurologic manifestations may occur because of an aberrant immune response to coronavirus disease-2019.", + "summary_subclaims": [ + "We observed a 30-year-old Persian woman.", + "She developed acute motor sensory axonal neuropathy.", + "Acute motor sensory axonal neuropathy is a variant of Guillain-Barré syndrome.", + "The acute motor sensory axonal neuropathy overlapped Miller Fisher syndrome.", + "The acute motor sensory axonal neuropathy occurred 30 days after confirmed coronavirus disease-2019 infection.", + "Our case highlights the rare occurrence of Guillain-Barré syndrome overlapping with Miller Fisher during the coronavirus disease-2019 pandemic.", + "These neurologic manifestations may occur because of an aberrant immune response to coronavirus disease-2019." + ] + }, + { + "id": "multiclinsum_test_588_en.txt", + "fulltext": "A 47-year-old female patient presented with a palpable lesion protruding from the left areola. This lesion was first noted 10 years earlier and had not shown changes. However, recently it noticeably increased in size.\nShe underwent breast augmentation surgery with silicone implants eight years ago.\nPhysical examination revealed a soft, fluctuating, mobile, and non-tender mass measuring approximately 4 cm in size. Part of the overlying skin was slightly greenish in appearance with mild protrusion. However, there was no ulcer or other skin changes.\nSonography showed a well circumscribed oval cystic lesion with internal hyperechoic debris and fluid-fluid level. There was no internal blood flow on color doppler study. The mass broadly contacted with dermis, compressing the breast parenchyma . Breast magnetic resonance imaging (MRI) was performed to check breast implants, on which the lesion could also be evaluated. MRI showed a well circumscribed oval mass of left subareolar area measuring 3.9 cm. The lesion attached to the cutaneous layer of the areola and compressed the breast parenchyma. Thin fatty layer was noted between the mass and the breast parenchyma, suggesting separated mass from the breast. The lesion showed T1 hyper-intensity compared to muscle and high T2 signal intensity. On post-contrast fat saturation T1-weighted image, the mass showed a well-circumscribed thin and even enhancing wall. There was a small enhancing mural component in the inner wall of the mass . It was not detected on ultrasound because internal debris filling the mass masked the mural component. In differentiation of the lesion, we overlooked the enhancing solid portion and considered the lesion as benign such as epidermal inclusion cyst.\nThe tumor was resected due to its persistent and growing tendency. The mass was well demarcated with dense fibrous tissue. It was located between the breast parenchyma and the areola. The mass showed deep khaki color. It was filled with brownish and tan necrotic mucoid fluid. Microscopically, the lesion was predominantly cystic, measuring 3.5 cm × 2.5 cm × 2.4 cm with solid portion of 1 cm × 0.3 cm carcinoma and benign tissue of less than 0.1 cm. The carcinoma was composed of epithelial cells with clear or eosinophilic cytoplasm, prominent nucleoli, and frequent mitosis. Suspicious microinvasion to the fibrous cystic wall was noted . Resection margin was less than 1 mm and free of pathology. There was no lymphovascular invasion. Cytokeratin expression of the tumor showed positive for CK7 but negative for CK20. It was moderately positive for Ki-67, reflecting cell proliferation. Regarding other results in immunohistochemistry, it was positive for P63, C-erbB-2, and P53, but negative for estrogen and progesterone receptor.", + "fulltext_subclaims": [ + "The patient is a 47-year-old female.", + "She presented with a palpable lesion protruding from the left areola.", + "The lesion was first noted 10 years earlier.", + "The lesion had not shown changes until recently.", + "The lesion recently increased in size.", + "She underwent breast augmentation surgery with silicone implants eight years ago.", + "Physical examination revealed a soft, fluctuating, mobile, and non-tender mass measuring approximately 4 cm.", + "Part of the overlying skin was slightly greenish in appearance with mild protrusion.", + "There was no ulcer or other skin changes.", + "Sonography showed a well circumscribed oval cystic lesion with internal hyperechoic debris and fluid-fluid level.", + "There was no internal blood flow on color doppler study.", + "The mass broadly contacted with dermis, compressing the breast parenchyma.", + "Breast MRI showed a well circumscribed oval mass of left subareolar area measuring 3.9 cm.", + "The lesion attached to the cutaneous layer of the areola and compressed the breast parenchyma.", + "Thin fatty layer was noted between the mass and the breast parenchyma, suggesting separated mass from the breast.", + "The lesion showed T1 hyper-intensity compared to muscle and high T2 signal intensity.", + "On post-contrast fat saturation T1-weighted image, the mass showed a well-circumscribed thin and even enhancing wall.", + "There was a small enhancing mural component in the inner wall of the mass.", + "The enhancing mural component was not detected on ultrasound because internal debris filled the mass.", + "The lesion was considered benign such as epidermal inclusion cyst.", + "The tumor was resected due to its persistent and growing tendency.", + "The mass was well demarcated with dense fibrous tissue.", + "The mass was located between the breast parenchyma and the areola.", + "The mass showed deep khaki color.", + "The mass was filled with brownish and tan necrotic mucoid fluid.", + "Microscopically, the lesion was predominantly cystic, measuring 3.5 cm × 2.5 cm × 2.4 cm.", + "The solid portion of the tumor was 1 cm × 0.3 cm carcinoma.", + "The benign tissue was less than 0.1 cm.", + "The carcinoma was composed of epithelial cells with clear or eosinophilic cytoplasm, prominent nucleoli, and frequent mitosis.", + "Suspicious microinvasion to the fibrous cystic wall was noted.", + "Resection margin was less than 1 mm and free of pathology.", + "There was no lymphovascular invasion.", + "Cytokeratin expression of the tumor was positive for CK7 and negative for CK20.", + "The tumor was moderately positive for Ki-67.", + "The tumor was positive for P63, C-erbB-2, and P53.", + "The tumor was negative for estrogen and progesterone receptor." + ], + "summary": "A 47-year-old woman visited our hospital with a non-tender palpable lesion in her left breast. The lesion had not shown changes for 10 years. However, it recently increased in size. Sonography showed a well circumscribed cystic lesion with internal debris and fluid-fluid level. Magnetic resonance imaging showed a well circumscribed oval mass with T1 hyper-intensity compared to muscle and T2 high signal intensity. There was a small enhancing mural component in the inner wall of the mass. The tumor was resected. Its pathologic result was a malignant transformation of benign sweat gland tumor such as hidradenoma. The lesion was treated with excision and radiation therapy. At 1-year follow up, there was no local recurrence or metastasis in the patient.", + "summary_subclaims": [ + "The patient is a 47-year-old woman.", + "She had a non-tender palpable lesion in her left breast.", + "The lesion had not shown changes for 10 years.", + "The lesion recently increased in size.", + "Sonography showed a well circumscribed cystic lesion with internal debris and fluid-fluid level.", + "Magnetic resonance imaging showed a well circumscribed oval mass with T1 hyper-intensity compared to muscle.", + "The mass had T2 high signal intensity.", + "There was a small enhancing mural component in the inner wall of the mass.", + "The tumor was resected.", + "The pathologic result was a malignant transformation of benign sweat gland tumor such as hidradenoma.", + "The lesion was treated with excision and radiation therapy.", + "At 1-year follow up, there was no local recurrence.", + "At 1-year follow up, there was no metastasis." + ] + }, + { + "id": "multiclinsum_test_733_en.txt", + "fulltext": "A 46-year-old male presented with a mass in the left parotid region of 6-month duration. The patient's history was only remarkable for a facial swelling, night sweats and a 38.5 C° fever. There were no other symptoms such as pain, facial paralysis, cough associated with this swelling. His past medical history was nonrevealing. There was no family history of tuberculosis. On physical examination, a 2 × 3-cm mobile, non-tender, mass with a smooth surface was palpated on left parotid tail. The physical examination was otherwise unremarkable. Routine laboratory tests, and a chest radiograph were normal. Ultrasound examination showed a well-defined, hypoechoic solid mass in the superficial lobe of the left parotid gland accompanied with the lymph node in same region. CT examination showed a well defined 30 mm in diameter tumor mass in the left superficial lobe of the parotid gland . A superficial parotidectomy operation was performed under general anesthesia. The lymph nodes were also excised. The final pathological diagnosis of the parotidectomy specimen was reported as a Warthin tumor and epitheloid granulomas with caseification necrosis . An intradermal test with purified protein derivative (PPD) was performed and it was 30 mm in enduration. Antituberculosis treatment with isoniazid, rifampicin, pyrazinamid and ethambutol was started for a 6-month duration. Two weeks after the antituberculosis treatment fever declined to normal values and night sweats decreased.", + "fulltext_subclaims": [ + "A 46-year-old male presented with a mass in the left parotid region of 6-month duration.", + "The patient's history was only remarkable for a facial swelling, night sweats and a 38.5 C° fever.", + "There were no other symptoms such as pain, facial paralysis, cough associated with this swelling.", + "On physical examination, a 2 × 3-cm mobile, non-tender, mass with a smooth surface was palpated on left parotid tail.", + "Routine laboratory tests, and a chest radiograph were normal.", + "Ultrasound examination showed a well-defined, hypoechoic solid mass in the superficial lobe of the left parotid gland accompanied with the lymph node in same region.", + "CT examination showed a well defined 30 mm in diameter tumor mass in the left superficial lobe of the parotid gland.", + "A superficial parotidectomy operation was performed under general anesthesia.", + "The lymph nodes were also excised.", + "The final pathological diagnosis of the parotidectomy specimen was reported as a Warthin tumor and epitheloid granulomas with caseification necrosis.", + "An intradermal test with purified protein derivative (PPD) was performed and it was 30 mm in enduration.", + "Antituberculosis treatment with isoniazid, rifampicin, pyrazinamid and ethambutol was started for a 6-month duration.", + "Two weeks after the antituberculosis treatment fever declined to normal values and night sweats decreased." + ], + "summary": "A 46-year-old male presented with a mass in the left parotid region of 6-month duration. The patient's history was only remarkable for a facial swelling, night sweats and a 38.5 C° fever. A 2 × 3-cm mobile, non-tender, mass with a smooth surface was palpated on left parotid tail. CT examination showed a well-defined 30 mm in diameter tumor mass in the left superficial lobe of the parotid gland. A superficial parotidectomy was performed. The final pathological diagnosis of the parotidectomy specimen was reported as a Warthin tumor and epitheloid granulomas with caseification necrosis. Purified protein derivative (PPD) was 30 mm in enduration. Two weeks after the antituberculosis treatment fever declined to normal values and night sweats decreased.", + "summary_subclaims": [ + "The patient is a 46-year-old male.", + "The patient had a mass in the left parotid region for 6 months.", + "The patient's history was only remarkable for a facial swelling.", + "The patient had night sweats.", + "The patient had a 38.5 C° fever.", + "A 2 × 3-cm mobile, non-tender, mass with a smooth surface was palpated on the left parotid tail.", + "CT examination showed a well-defined 30 mm in diameter tumor mass in the left superficial lobe of the parotid gland.", + "A superficial parotidectomy was performed.", + "The final pathological diagnosis of the parotidectomy specimen was reported as a Warthin tumor.", + "The final pathological diagnosis of the parotidectomy specimen was reported as epitheloid granulomas with caseification necrosis.", + "Purified protein derivative (PPD) was 30 mm in enduration.", + "Two weeks after the antituberculosis treatment, fever declined to normal values.", + "Two weeks after the antituberculosis treatment, night sweats decreased." + ] + }, + { + "id": "multiclinsum_test_2159_en.txt", + "fulltext": "A 61-year-old male presented to orthopedic OPD with complaint of pus discharge from a sinus on his left shoulder tip since 2 years and pain in left shoulder region since 2 months.\nInitially, patient was treated outside as a case of soft tissue abscess over shoulder tip for which incision and drainage were done, and antibiotics were given. Later, he developed a discharging sinus. Pus was whitish in color, sticky in nature, and non-foul smelling. He consulted several local practitioners who gave him antibiotics. But there was no change in the amount and color of pus from the sinus.\nLater, patient developed pain in left shoulder just after getting up from bed. Pain was continuous and not relieved by painkillers. There is no history of trauma and swelling in the neck.\nLocal examination revealed a single sinus at left shoulder tip. No signs of inflammation were present . The margins of the opening of the sinus were inverted, and no granulation tissue was observed at its mouth. Tenderness at lateral end clavicle was present. On pressing, the sinus minimal thick purulent discharge was seen. Sinus was thick walled and fixed to underlying bone. On probing, hard bony structure was felt in the depth of the wound. No cervical or axillary lymphadenopathy was present.\nLaboratory tests showed hemoglobin - 14.4 g/dl, total leucocyte count of - 10500/cumm, neutrophils - 62%, lymphocytes - 30% with erythrocyte sedimentation rate - 35 mm/h. On X-ray, lung fields were clear. Culture revealed coagulase-negative staphylococcus and Acinetobacter calcoacetcus baumanni complex sensitive to a combination of amoxycillin clavulanic acid and amikacin. Anteroposterior radiographs of left shoulder with clavicle revealed pathological fracture of the lateral end of clavicle and sequestrum with periosteal reaction at lateral end clavicle. Acomioclavicular joint appeared to be normal .\nA clinicoradiological diagnosis of chronic pyogenic osteomyeltis of clavicle with discharging sinus was made. Patient was put on injectable antibiotics. Sequestrectomy with sinus tract excision was done . Histopathology showed chronic necrotizing granulomatous inflammation, suggestive of the tubercular osteomyelitis . Patient was started on a multidrug antitubercular therapy. The wound healed with the primary intention.\nThere is terminal restriction of all range of movements at shoulder after 1 year of follow-up. .", + "fulltext_subclaims": [ + "The patient is a 61-year-old male.", + "The patient presented with pus discharge from a sinus on his left shoulder tip since 2 years.", + "The patient had pain in the left shoulder region since 2 months.", + "Initially, the patient was treated outside as a case of soft tissue abscess over the shoulder tip.", + "Incision and drainage were done.", + "Antibiotics were given.", + "Later, the patient developed a discharging sinus.", + "The pus was whitish in color.", + "The pus was sticky in nature.", + "The pus was non-foul smelling.", + "The patient consulted several local practitioners.", + "The local practitioners gave him antibiotics.", + "There was no change in the amount and color of pus from the sinus.", + "The patient developed pain in the left shoulder just after getting up from bed.", + "The pain was continuous.", + "The pain was not relieved by painkillers.", + "There is no history of trauma.", + "There is no history of swelling in the neck.", + "Local examination revealed a single sinus at the left shoulder tip.", + "No signs of inflammation were present.", + "The margins of the opening of the sinus were inverted.", + "No granulation tissue was observed at the mouth of the sinus.", + "Tenderness at the lateral end of the clavicle was present.", + "On pressing, the sinus had minimal thick purulent discharge.", + "The sinus was thick walled.", + "The sinus was fixed to the underlying bone.", + "On probing, a hard bony structure was felt in the depth of the wound.", + "No cervical or axillary lymphadenopathy was present.", + "Hemoglobin was 14.4 g/dl.", + "Total leucocyte count was 10500/cumm.", + "Neutrophils were 62%.", + "Lymphocytes were 30%.", + "Erythrocyte sedimentation rate was 35 mm/h.", + "X-ray showed clear lung fields.", + "Culture revealed coagulase-negative staphylococcus.", + "Culture also revealed Acinetobacter calcoaceticus baumanni complex.", + "The organisms were sensitive to a combination of amoxycillin clavulanic acid and amikacin.", + "Anteroposterior radiographs of the left shoulder with clavicle revealed a pathological fracture of the lateral end of the clavicle.", + "A sequestrum was noted with periosteal reaction at the lateral end of the clavicle.", + "The acromioclavicular joint appeared to be normal.", + "A clinicoradiological diagnosis of chronic pyogenic osteomyelitis of the clavicle with discharging sinus was made.", + "The patient was put on injectable antibiotics.", + "Sequestrectomy with sinus tract excision was done.", + "Histopathology showed chronic necrotizing granulomatous inflammation.", + "The histopathology was suggestive of tubercular osteomyelitis.", + "The patient was started on multidrug antitubercular therapy.", + "The wound healed with primary intention.", + "There is terminal restriction of all range of movements at the shoulder after 1 year of follow-up." + ], + "summary": "We describe this case in a 61-year-old male who presented with a discharging sinus since 2 years at his left shoulder tip with purulent discharge. Clinicoradiologically, patient was diagnosed as a case of pyogenic osteomyelitis of the lateral end of the clavicle. However, biopsy proved it to be a tubercular osteomyelitis.", + "summary_subclaims": [ + "The patient is a 61-year-old male.", + "The patient had a discharging sinus since 2 years at his left shoulder tip.", + "The discharging sinus had purulent discharge.", + "The patient was diagnosed as a case of pyogenic osteomyelitis of the lateral end of the clavicle.", + "Biopsy proved it to be a tubercular osteomyelitis." + ] + }, + { + "id": "multiclinsum_test_2453_en.txt", + "fulltext": "A 44 year old afro-Trinidadian female presented with a two week history of abdominal distension, weight loss, decreased appetite and low grade fever. She had a normal white cell count, a haemoglobin of 9.02 g/dL and a CA125 level of 909 U/ml. Ultrasound scan showed moderate ascites with a septated cystic left adnexal mass . CT scan showed smooth peritoneal thickening . There was no lymphadenopathy or peritoneal or hepatic deposits. Chest CT showed no lung parenchyma lesions. An ascitic tap was negative for malignant cells and a mantoux test was negative. Primary ovarian malignancy was suspected and the patient was referred to the gyne-oncology clinic. One week later her symptoms improved and the CA125 level fell to 303 U/ml. Due to this unexpected result, alternate diagnoses were considered. The patient declined to have a diagnostic laparotomy at this time as her symptoms had resolved. She agreed however to be monitored in the clinic but was counselled on the need for definitive diagnosis due to the possibility of ovarian carcinoma.\nA few months later she developed dyspnoea due to a large right pleural effusion. A chest tube was inserted and the pleural fluid was negative for malignant cells and acid-fast bacilli (AFB). Repeat CT showed multiple subcentimeter nodules as well as a ‘tree in bud’ appearance throughout the lung parenchyma . The ascitic volume decreased but became denser. Bowel loops appeared matted with mesenteric stranding . In view of the radiological findings tuberculosis was strongly suspected in spite of the negative skin and bacteriologic tests.\nThe patient then agreed to diagnostic laparotomy (laparoscopy services were not available).\nAt laparotomy the peritoneal cavity was difficult to enter with thick adhesions and miliary seedlings . Frozen section facilities were not available however biopsies were taken for tissue diagnosis, leaving the uterus and ovaries intact. Histology revealed caseating granulomas with epithelioid and Langhan’s type giant cells. The Ziehl–Neelsen stain for AFB was negative. PCR testing was unavailable however the patient’s symptoms resolved and the CA125 levels normalized after 2 months of antituberculosis therapy. She is to continue her treatment for a total of 6 months.", + "fulltext_subclaims": [ + "The patient is a 44 year old afro-Trinidadian female.", + "She had a two week history of abdominal distension.", + "She had a two week history of weight loss.", + "She had a two week history of decreased appetite.", + "She had a two week history of low grade fever.", + "Her white cell count was normal.", + "Her haemoglobin was 9.02 g/dL.", + "Her CA125 level was 909 U/ml.", + "Ultrasound scan showed moderate ascites.", + "Ultrasound scan showed a septated cystic left adnexal mass.", + "CT scan showed smooth peritoneal thickening.", + "There was no lymphadenopathy.", + "There were no peritoneal deposits.", + "There were no hepatic deposits.", + "Chest CT showed no lung parenchyma lesions.", + "An ascitic tap was negative for malignant cells.", + "A mantoux test was negative.", + "Primary ovarian malignancy was suspected.", + "The patient was referred to the gyne-oncology clinic.", + "One week later her symptoms improved.", + "One week later her CA125 level fell to 303 U/ml.", + "The patient declined to have a diagnostic laparotomy.", + "She agreed to be monitored in the clinic.", + "She was counselled on the need for definitive diagnosis.", + "A few months later she developed dyspnoea due to a large right pleural effusion.", + "A chest tube was inserted.", + "Pleural fluid was negative for malignant cells.", + "Pleural fluid was negative for acid-fast bacilli.", + "Repeat CT showed multiple subcentimeter nodules.", + "Repeat CT showed a ‘tree in bud’ appearance throughout the lung parenchyma.", + "The ascitic volume decreased.", + "The ascitic fluid became denser.", + "Bowel loops appeared matted.", + "Bowel loops showed mesenteric stranding.", + "Tuberculosis was strongly suspected.", + "The patient then agreed to diagnostic laparotomy.", + "Laparoscopy services were not available.", + "At laparotomy the peritoneal cavity was difficult to enter.", + "There were thick adhesions.", + "There were miliary seedlings.", + "Frozen section facilities were not available.", + "Biopsies were taken for tissue diagnosis.", + "The uterus and ovaries were left intact.", + "Histology revealed caseating granulomas.", + "Histology showed epithelioid cells.", + "Histology showed Langhan’s type giant cells.", + "Ziehl–Neelsen stain for AFB was negative.", + "PCR testing was unavailable.", + "The patient’s symptoms resolved after 2 months of antituberculosis therapy.", + "CA125 levels normalized after 2 months of antituberculosis therapy.", + "She is to continue her treatment for a total of 6 months." + ], + "summary": "A 44 year old female presented with abdominal distension, weight loss and low grade fever. Her CA125 level was 909 U/ml. Imaging studies revealed an adnexal lesion and ascites. The lungs appeared normal and a Mantoux test was negative. Ovarian malignancy was highly suspected. Cytology of ascites was negative for malignant cells. The patient subsequently developed a large pleural effusion which was drained and negative for malignant cells and acid fast bacilli. Repeat imaging revealed a 'tree in bud' appearance of the lung parenchyma and dense ascites. Histology from diagnostic laparotomy revealed caseating granulomas with epithelioid cells and Langhan's type giant cells. The patient responded well to antituberculosis therapy with normalization of CA125 levels, confirming the diagnosis of peritoneal tuberculosis.", + "summary_subclaims": [ + "The patient is a 44 year old female.", + "She presented with abdominal distension.", + "She had weight loss.", + "She had low grade fever.", + "Her CA125 level was 909 U/ml.", + "Imaging studies revealed an adnexal lesion.", + "Imaging studies revealed ascites.", + "The lungs appeared normal.", + "A Mantoux test was negative.", + "Ovarian malignancy was highly suspected.", + "Cytology of ascites was negative for malignant cells.", + "The patient subsequently developed a large pleural effusion.", + "The pleural effusion was drained.", + "The pleural effusion was negative for malignant cells.", + "The pleural effusion was negative for acid fast bacilli.", + "Repeat imaging revealed a 'tree in bud' appearance of the lung parenchyma.", + "Repeat imaging revealed dense ascites.", + "Histology from diagnostic laparotomy revealed caseating granulomas.", + "Histology showed epithelioid cells.", + "Histology showed Langhan's type giant cells.", + "The patient responded well to antituberculosis therapy.", + "CA125 levels normalized.", + "The diagnosis was confirmed as peritoneal tuberculosis." + ] + }, + { + "id": "multiclinsum_test_378_en.txt", + "fulltext": "A 72-year-old woman suffered from repeated fever, nausea and vomiting for 3 years following pancreatoduodenectomy, which had been aggravated for 2 d prior to her presentation at the hospital.\nThe patient presented with a complaint of repeated fever, sometimes accompanied by nausea and vomiting following pancreatoduodenectomy for 3 years. No associated abdominal pain, diarrhea, or melena was observed. Similar symptoms appeared repeatedly, once every 1-2 mo, with fever symptoms that gradually resolved 3-5 d after antibiotic treatment. Two days later, she became febrile again. The use of oral moxifloxacin tablets could not control the infection, and her body temperature reached 39.8 °C.\nThe patient underwent pancreatoduodenectomy with child reconstruction for adenocarcinoma of duodenal papilla 3 years prior. Histological analysis revealed a moderately differentiated adenocarcinoma at stage T2N0M0, Ia. The patient recovered well and was followed-up regularly. No evidence of local recurrence or distant metastasis was noted within 3 years after surgery. Multiple cysts of the liver were detected over more than 40 years but were asymptomatic. She also had hypertension, which was controlled with medication for more than 20 years.\nThe patient’s temperature was 39.8 ��C, heart rate was 92 bpm, and blood pressure was 145/92 mmHg. Physical examination revealed yellowish skin and icteric sclera. The abdomen was soft with no abdominal pain or rebound pain.\nLaboratory findings revealed a white cell count of 8900/µL (reference value, 4000 to 10000/µL), neutrophil ratio of 90%, serum C-reactive protein concentration of 126 mg/dL (reference value, < 8 mg/dL), serum gamma glutamic transpeptidase concentration (GGT) of 158 IU/L (reference value, 8 to 50 IU/L), serum alkaline phosphatase concentration (ALP) of 576 IU/L (reference value, 40 to 150 IU/L), serum total bilirubin (TBIL) level of 95 µmol/L (reference value, 3 to 22 µmol/L), serum direct bilirubin (DBIL) level of 76.5 µmol/L (reference value, 0 to 7 µmol/L), serum aspartate aminotransferase concentration (AST) of 55 IU/L (reference value, 15 to 40 IU/L), and serum alanine aminotransferase concentration (ALT) of 115 IU/L (reference value, 7 to 40 IU/L). In the past 3 years, blood culture was positive for Klebsiella pneumoniae and Escherichia coli 7 times and 4 times, respectively.\nPreoperative computed tomography (CT) showed several asymptomatic hepatic cysts . Abdominal CT performed 2 mo postoperatively did not reveal signs of hepatic cyst infection, such as an enhanced thickened wall, edema of the perilesional hepatic parenchyma or a significant increase in cyst diameter . Abdominal CT performed 5 mo postoperatively and Magnetic Resonance Imaging (MRI) performed 9 mo postoperatively both showed that the cyst on the lateral side of the right liver had significantly decreased in size, and the wall of the cyst was slightly thickened. The interior cyst appeared slightly enlarged, but it had a thin smooth wall and homogenous contents, and no edema was observed in the surrounding liver tissue. Three years postoperatively, a CT plain scan showed that the cyst on the lateral side of the right liver had disappeared and that the cyst on the inner side of the right lobe had obviously increased in size. Mild dilatation of the intrahepatic bile duct was also noted .\nEnhanced CT revealed that the cyst on the inner side of the right lobe had obviously increased in size, had a thick wall and was surrounded by edema, with less pleural and peritoneal effusion . The cyst showed obvious infection. The blood culture was positive for Klebsiella pneumoniae at this time.", + "fulltext_subclaims": [ + "The patient is a 72-year-old woman.", + "She suffered from repeated fever, nausea and vomiting for 3 years following pancreatoduodenectomy.", + "The symptoms had been aggravated for 2 d prior to her presentation at the hospital.", + "The patient underwent pancreatoduodenectomy with child reconstruction for adenocarcinoma of duodenal papilla 3 years prior.", + "Histological analysis revealed a moderately differentiated adenocarcinoma at stage T2N0M0, Ia.", + "No evidence of local recurrence or distant metastasis was noted within 3 years after surgery.", + "Multiple cysts of the liver were detected over more than 40 years.", + "The cysts were asymptomatic.", + "The patient had hypertension controlled with medication for more than 20 years.", + "The patient’s temperature was 39.8 °C.", + "The white cell count was 8900/µL.", + "The neutrophil ratio was 90%.", + "The serum C-reactive protein concentration was 126 mg/dL.", + "The serum gamma glutamic transpeptidase concentration was 158 IU/L.", + "The serum alkaline phosphatase concentration was 576 IU/L.", + "The serum total bilirubin level was 95 µmol/L.", + "The serum direct bilirubin level was 76.5 µmol/L.", + "The serum aspartate aminotransferase concentration was 55 IU/L.", + "The serum alanine aminotransferase concentration was 115 IU/L.", + "Blood culture was positive for Klebsiella pneumoniae and Escherichia coli 7 times and 4 times, respectively, in the past 3 years.", + "Preoperative computed tomography showed several asymptomatic hepatic cysts.", + "Abdominal CT performed 2 mo postoperatively did not reveal signs of hepatic cyst infection.", + "Abdominal CT performed 5 mo postoperatively showed that the cyst on the lateral side of the right liver had significantly decreased in size.", + "The wall of the cyst on the lateral side of the right liver was slightly thickened.", + "The interior cyst had a thin smooth wall and homogenous contents.", + "No edema was observed in the surrounding liver tissue.", + "Three years postoperatively, a CT plain scan showed that the cyst on the lateral side of the right liver had disappeared.", + "The cyst on the inner side of the right lobe had obviously increased in size.", + "Mild dilatation of the intrahepatic bile duct was noted.", + "Enhanced CT revealed that the cyst on the inner side of the right lobe had obviously increased in size.", + "The cyst had a thick wall and was surrounded by edema.", + "The blood culture was positive for Klebsiella pneumoniae at this time." + ], + "summary": "A 72-year-old woman diagnosed with adenocarcinoma of duodenal papilla underwent pancreatoduodenectomy with Child reconstruction. She then suffered repeated occurrences of bacteremia and hepatic cyst infection for 3 years. Blood cultures were positive for Klebsiella pneumoniae and Escherichia coli a total of 7 times and 4 times, respectively. During the early stage, we suspected that postoperative reflux cholangitis was the cause of fever and bacteremia. Multiple cysts were observed, so it was difficult to determine which cyst was infected. Through repeat examination, we found the focus of infection, and we treated the patient with antimicrobials and performed percutaneous cyst drainage. The patient did not experience another cyst infection for more than 4 years.", + "summary_subclaims": [ + "The patient is a 72-year-old woman.", + "She was diagnosed with adenocarcinoma of the duodenal papilla.", + "She underwent pancreatoduodenectomy with Child reconstruction.", + "She suffered repeated occurrences of bacteremia and hepatic cyst infection for 3 years.", + "Blood cultures were positive for Klebsiella pneumoniae a total of 7 times.", + "Blood cultures were positive for Escherichia coli a total of 4 times.", + "During the early stage, we suspected that postoperative reflux cholangitis was the cause of fever and bacteremia.", + "Multiple cysts were observed.", + "It was difficult to determine which cyst was infected.", + "Through repeat examination, we found the focus of infection.", + "We treated the patient with antimicrobials.", + "We performed percutaneous cyst drainage.", + "The patient did not experience another cyst infection for more than 4 years." + ] + }, + { + "id": "multiclinsum_test_2956_en.txt", + "fulltext": "A 50-year-old post-menopausal woman was diagnosed with a stage IIB (T2N1M0) right breast cancer and subsequently years later developed an unusual recurrence that was diagnosed following rupture of one of her breast prostheses. Following initial diagnosis, she underwent a right modified radical mastectomy and review of surgical pathology revealed a grade 4 (of 4) invasive lobular carcinoma, nuclear grade 2 (of 3), forming a 2.2 × 2 × 1.8 cm mass. No definite vascular invasion was noted apart from the central tumor mass, although lobular carcinoma in-situ with extension into adjacent ducts was seen. Lactiferous ducts beneath the nipple showed pagetoid spread of carcinoma cells. One of 14 right axillary lymph nodes was positive for metastatic involvement with focal extranodal extension of disease. Tumor cells were ER/PR positive. Following surgery, she received six months of chemotherapy with cyclophosphamide, methotrexate and 5-fluorouracil (CMF). A subsequent prophylactic left simple mastectomy with bilateral breast reconstruction was performed 4 months following completion of chemotherapy. Approximately 4 months after surgery, tamoxifen therapy was started and administered for 5 years. Of note, this patient underwent a total abdominal hysterectomy and bilateral salpingo-oophorectomy a year after breast reconstructive surgery.\nThe patient had regular follow up without evidence of disease recurrence. Approximately 12 years after her breast reconstructive surgery, she developed a deflated right breast implant. She was scheduled for bilateral implant exchange surgery. During preoperative evaluation, she was found to have evidence of mitral valve regurgitation due to a flail mitral valve posterior leaflet, and subsequently underwent mitral valve repair. The cardiothoracic surgeon informed the patient that her sternum was found to be “somewhat mushy” during her sternotomy.\nAbout 5 months after open heart surgery, the patient had developed a neck lump and back pain. Imaging studies with CT revealed postoperative mastectomies with implants. However, the right breast implant was ruptured with extensive soft tissue mass and nodularity involving the anterior chest wall, predominantly anterior to both sides of the sternum but slightly more marked on the right with subcutaneous nodularity throughout the right mastectomy site . This was noted to be inseparable from the adjacent pectoralis muscles along with right subpectoral adenopathy and right neck base adenopathy consistent with tumor recurrence. The anterior chest wall mass extended posteriorly through the chest wall into the hemithorax and was also associated with internal mammary adenopathy. Partial lytic lesions were seen in the mid sternum. In addition, there was bulky anterior mediastinal adenopathy and tumor extending inferiorly along the anterior pericardium and anterior to the right atrium and right ventricle as well as to the root of the aorta . Nodularity was noted in the right upper lung pleura and left lung base pleura. There were bulky soft tissue masses in both costophrenic angles. Tumor nodularity was noted anterior to the liver representing peritoneal implants. Skin thickening was noted over both anterior chest walls but greater on the right. Bony metastases were noted in the T5 and L1 vertebral bodies, the right temporal bone of the skull, and the right anterior iliac bone.\nThe patient underwent a T10 vertebroplasty and then subsequent palliative radiotherapy to T8 through L1 vertebral bodies. During palliative radiotherapy, she developed right hip pain and was found to have a destructive metastasis in the right femoral head and neck requiring surgery with a right hip replacement followed by palliative radiotherapy to bilateral hips and the right femur. She went on to receive palliative chemotherapy but ultimately expired from disease progression approximately 11 months following diagnosis of metastatic disease.", + "fulltext_subclaims": [ + "The patient was a 50-year-old post-menopausal woman.", + "She was diagnosed with stage IIB right breast cancer.", + "She underwent a right modified radical mastectomy.", + "Surgical pathology revealed a grade 4 invasive lobular carcinoma.", + "The tumor formed a 2.2 × 2 × 1.8 cm mass.", + "Lobular carcinoma in-situ with extension into adjacent ducts was seen.", + "Lactiferous ducts beneath the nipple showed pagetoid spread of carcinoma cells.", + "One of 14 right axillary lymph nodes was positive for metastatic involvement.", + "Tumor cells were ER/PR positive.", + "She received six months of chemotherapy with cyclophosphamide, methotrexate, and 5-fluorouracil.", + "A prophylactic left simple mastectomy with bilateral breast reconstruction was performed.", + "Tamoxifen therapy was started approximately 4 months after surgery.", + "She underwent a total abdominal hysterectomy and bilateral salpingo-oophorectomy.", + "She had regular follow-up without evidence of disease recurrence.", + "Approximately 12 years after breast reconstructive surgery, she developed a deflated right breast implant.", + "She was scheduled for bilateral implant exchange surgery.", + "During preoperative evaluation, she was found to have mitral valve regurgitation.", + "She underwent mitral valve repair.", + "The cardiothoracic surgeon noted the sternum was 'somewhat mushy' during sternotomy.", + "About 5 months after open heart surgery, she developed a neck lump and back pain.", + "CT imaging revealed a ruptured right breast implant with extensive soft tissue mass.", + "The mass involved the anterior chest wall, predominantly on the right.", + "The mass was inseparable from the adjacent pectoralis muscles.", + "Right subpectoral and right neck base adenopathy were noted.", + "The anterior chest wall mass extended into the hemithorax.", + "Internal mammary adenopathy was noted.", + "Tumor extended inferiorly along the anterior pericardium.", + "Tumor extended anterior to the right atrium and right ventricle.", + "Tumor extended to the root of the aorta.", + "Nodularity was noted in the right upper lung pleura.", + "Nodularity was noted in the left lung base pleura.", + "Bulky soft tissue masses were present in both costophrenic angles.", + "Tumor nodularity was noted anterior to the liver.", + "Skin thickening was noted over both anterior chest walls.", + "Bony metastases were noted in the T5 and L1 vertebral bodies.", + "Bony metastases were noted in the right temporal bone of the skull.", + "Bony metastases were noted in the right anterior iliac bone.", + "She underwent a T10 vertebroplasty.", + "She received palliative radiotherapy to T8 through L1 vertebral bodies.", + "She developed a destructive metastasis in the right femoral head and neck.", + "She underwent surgery with a right hip replacement.", + "She received palliative radiotherapy to bilateral hips and the right femur.", + "She received palliative chemotherapy.", + "She expired from disease progression approximately 11 months following diagnosis of metastatic disease." + ], + "summary": "We describe the case of a 50-year-old woman with stage IIB (T2N1M0) ER/PR positive right breast ILC who underwent a right modified radical mastectomy, postoperative chemotherapy, a prophylactic left simple mastectomy with bilateral breast reconstruction and tamoxifen. Approximately 12 years later, she presented with a deflated breast implant and recurrent breast cancer with metastatic spread. She received palliative radiotherapy then palliative chemotherapy. Unfortunately, she succumbed to the cancer less than a year after being diagnosed with metastatic disease.", + "summary_subclaims": [ + "The patient was a 50-year-old woman.", + "She had stage IIB (T2N1M0) ER/PR positive right breast ILC.", + "She underwent a right modified radical mastectomy.", + "She received postoperative chemotherapy.", + "She had a prophylactic left simple mastectomy.", + "She had bilateral breast reconstruction.", + "She was treated with tamoxifen.", + "Approximately 12 years later, she presented with a deflated breast implant.", + "She had recurrent breast cancer with metastatic spread.", + "She received palliative radiotherapy.", + "She received palliative chemotherapy.", + "She succumbed to the cancer less than a year after being diagnosed with metastatic disease." + ] + }, + { + "id": "multiclinsum_test_935_en.txt", + "fulltext": "A 40-year-old premenopausal nulligravida woman presented with vaginal bleeding in January 2020. The patient was otherwise well, had no prior surgery, and was not taking hormone medication. Her medical history was significant for morbid obesity, with a body mass index (BMI) of 36.4 kg/m2.\nA gynecologic examination revealed a multiple polypoid mass on the posterior vaginal fornix. . Punch biopsy revealed endometriosis. The cervix appeared normal. A cervical smear showed reactive cellular changes but was negative for human papilloma virus. Magnetic Resonance Imaging of the pelvis showed two masses abutting respectively on the anterior uterine wall, and in the rectovaginal septum. , diffuse thickening of endometrium without gross mass, and a 4.4 cm mass in the left ovary. A sigmoidoscopy detected an invasive polypoid lesion protruding into the rectum and biopsy revealed endometriosis . She decided to undergo a surgery to remove lesions and confirm the pathologic diagnosis.\nFirstly, the vaginal protruding mass was excised completely. Secondly, the globular mass were adequately removed via laparoscopy. Thirdly, dilatation and curettage of endometrial tissue was performed. Laparoscopic findings showed 5 × 4 × 4 and 4 × 3 × 3 cm globular mass on the anterior uterine wall and a 3 × 3 × 2 cm globular mass on the rectovaginal septum; all of which were filled with chocolate-colored fluid and cheezy like materials. Histopathologically, the vaginal polypoid mass was diagnosed as endometriosis-associated complex hyperplasia and endometrioid cancer, International Federation of Gynecologic Oncology grade I/III. Meanwhile, globular lesions on anterior uterine wall and rectovaginal mass was diagnosed as endometriosis-associated complex hyperplasia. Furthermore, a synchronous endometrioid endometrial cancer, FIGO grade II/III was reported.\nAfter being confirmed as a case of synchronous vaginal and endometrial cancer, a staging surgery for endometrial cancer and en bloc extirpation of the remnant rectovaginal mass were performed. The patient underwent a total laparoscopic excision of the rectovaginal mass, radical hysterectomy and low anterior resection of the rectum. The remnant rectovaginal mass was diagnosed as only endometriosis, which invaded extensively to the rectal mucosa. Perineural invasion in the specimen of the vagina was absent. The lack of perineural invasion did not request a subsequent lymph nodal dissection . The resection margin of parametria, vaginal vault, and rectum were invaded by endometriosis but, free of cancer. Finally, the patient was diagnosed as endometriosis-associated endometrioid vaginal cancer and synchronous endometrioid endometrial cancer (stage 1A1) . One month post operation, she was treated with dienogest and was clinically free of disease (no evidence of disease recurrence in the imaging study) for 8 months since undergoing last surgery.", + "fulltext_subclaims": [ + "The patient was a 40-year-old premenopausal nulligravida woman.", + "She presented with vaginal bleeding in January 2020.", + "Her medical history was significant for morbid obesity with a BMI of 36.4 kg/m2.", + "A gynecologic examination revealed a multiple polypoid mass on the posterior vaginal fornix.", + "Punch biopsy revealed endometriosis.", + "Magnetic Resonance Imaging of the pelvis showed two masses abutting respectively on the anterior uterine wall and in the rectovaginal septum.", + "A 4.4 cm mass was noted in the left ovary.", + "A sigmoidoscopy detected an invasive polypoid lesion protruding into the rectum.", + "Biopsy of the rectal lesion revealed endometriosis.", + "The vaginal protruding mass was excised completely.", + "The globular mass was adequately removed via laparoscopy.", + "Dilatation and curettage of endometrial tissue was performed.", + "Laparoscopic findings showed 5 × 4 × 4 and 4 × 3 × 3 cm globular masses on the anterior uterine wall.", + "A 3 × 3 × 2 cm globular mass was found on the rectovaginal septum.", + "All masses were filled with chocolate-colored fluid and cheezy like materials.", + "The vaginal polypoid mass was diagnosed as endometriosis-associated complex hyperplasia and endometrioid cancer, International Federation of Gynecologic Oncology grade I/III.", + "The globular lesions on the anterior uterine wall and rectovaginal mass were diagnosed as endometriosis-associated complex hyperplasia.", + "A synchronous endometrioid endometrial cancer, FIGO grade II/III was reported.", + "A staging surgery for endometrial cancer and en bloc extirpation of the remnant rectovaginal mass were performed.", + "The patient underwent a total laparoscopic excision of the rectovaginal mass, radical hysterectomy, and low anterior resection of the rectum.", + "The remnant rectovaginal mass was diagnosed as only endometriosis, which invaded extensively to the rectal mucosa.", + "Perineural invasion in the specimen of the vagina was absent.", + "The lack of perineural invasion did not request a subsequent lymph nodal dissection.", + "The resection margin of parametria, vaginal vault, and rectum were invaded by endometriosis but free of cancer.", + "The patient was diagnosed as endometriosis-associated endometrioid vaginal cancer and synchronous endometrioid endometrial cancer (stage 1A1).", + "One month post operation, she was treated with dienogest.", + "She was clinically free of disease for 8 months since undergoing last surgery." + ], + "summary": "Herein, we report the case of a 40-year-old premenopausal nulligravida woman who presented with vaginal bleeding and who was finally diagnosed with a vaginal cancer originating from endometriosis and with a synchronous endometrial cancer. A gynecologic examination revealed a multiple polypoid mass on the posterior vaginal fornix. Magnetic Resonance Imaging of the pelvis showed two masses abutting respectively on the anterior uterine wall, and in the rectovaginal septum. The patient underwent a total laparoscopic excision of the rectovaginal mass, radical hysterectomy and low anterior resection of the rectum. The lesions were diagnosed as endometriosis, endometriosis-associated complex hyperplasia and endometrioid cancer. Furthermore, a synchronous endometrioid endometrial cancer was reported.", + "summary_subclaims": [ + "The patient was a 40-year-old premenopausal nulligravida woman.", + "The patient presented with vaginal bleeding.", + "The patient was finally diagnosed with a vaginal cancer originating from endometriosis.", + "The patient had a synchronous endometrial cancer.", + "A gynecologic examination revealed a multiple polypoid mass on the posterior vaginal fornix.", + "Magnetic Resonance Imaging of the pelvis showed two masses abutting respectively on the anterior uterine wall and in the rectovaginal septum.", + "The patient underwent a total laparoscopic excision of the rectovaginal mass.", + "The patient underwent a radical hysterectomy.", + "The patient underwent a low anterior resection of the rectum.", + "The lesions were diagnosed as endometriosis.", + "The lesions were diagnosed as endometriosis-associated complex hyperplasia.", + "The lesions were diagnosed as endometrioid cancer.", + "A synchronous endometrioid endometrial cancer was reported." + ] + }, + { + "id": "multiclinsum_test_957_en.txt", + "fulltext": "A 50-year-old Mediterranean woman presented with 1-year history of involuntary movement of the toes of her right foot. Our patient was not known to have diabetes or hypertension. Initially, the patient started to have an odd but painless feeling in her foot; she described the feeling as something moving inside her foot. This had gradually progressed to visible movement of the toes of her right foot; she did not describe any aggravating or relieving factors to the movement. However, the severity of movement varied during the day. There was no history of lower limb trauma or psychological problems. There was no history of neuroleptics use or symptoms of thyroid disease [, ]. Our patient reported that she had a history of low back pain 15 years ago. She had been told that surgery was required for her lower back pain but she did not recall the reason for the surgery; unfortunately, her previous MRI scan was not available.\nOn clinical examination, our patient appeared healthy with no signs of anxiety or psychological problems. She had a normal gait with normal tandem gait and a negative Romberg’s sign. The movement did not affect her gait and she could walk on her toes and her heels . Her upper and lower limb power and reflexes were normal. There was normal coordination of the upper and lower limbs with no evidence of cerebellar signs, nystagmus or ophthalmoplegia. Her peripheral pulses were intact but there was mild swelling of her feet and legs due to mild varicose veins.\nThe movement was a continuous semirhythmic movement involving the right first, second, third and fourth toes. It was a constant, flexion/relaxation movement with a variable frequency between 0.5 and 1 Hz. There was no associated visible movement of her ankle or calf muscles. The patient was able to temporarily suppress the movement by powerful extension of her toes and dorsiflexion of her ankle.\nLaboratory investigations did not show any remarkable abnormalities. Her vitamin B12 level was normal and she was already on vitamin D3 treatment. A nerve conduction study of her right lower limb showed no evidence of demyelination or axonal loss. There was no neurophysiological evidence of peroneal nerve compression at the fibular head or tarsal tunnel syndrome. F wave examination and electromyography (EMG) did not show any evidence of denervation.\nA lumbar MRI scan demonstrated a mild disc protrusion between L4 and L5. There was a much smaller disc protrusion between L5 and S1. Both discs did not show spinal cord or nerve root compression on axial view. A Tarlov cyst was seen at the sacral area .", + "fulltext_subclaims": [ + "The patient is a 50-year-old Mediterranean woman.", + "She presented with a 1-year history of involuntary movement of the toes of her right foot.", + "The patient was not known to have diabetes.", + "The patient was not known to have hypertension.", + "Initially, she had an odd but painless feeling in her foot.", + "She described the feeling as something moving inside her foot.", + "This had gradually progressed to visible movement of the toes of her right foot.", + "The severity of movement varied during the day.", + "There was no history of lower limb trauma.", + "There was no history of psychological problems.", + "There was no history of neuroleptics use.", + "There were no symptoms of thyroid disease.", + "She reported a history of low back pain 15 years ago.", + "She had been told that surgery was required for her lower back pain.", + "Her previous MRI scan was not available.", + "On clinical examination, the patient appeared healthy.", + "There were no signs of anxiety or psychological problems.", + "She had a normal gait.", + "She had a normal tandem gait.", + "Romberg’s sign was negative.", + "The movement did not affect her gait.", + "She could walk on her toes and her heels.", + "Upper and lower limb power and reflexes were normal.", + "There was normal coordination of the upper and lower limbs.", + "There was no evidence of cerebellar signs.", + "There was no nystagmus.", + "There was no ophthalmoplegia.", + "Peripheral pulses were intact.", + "There was mild swelling of her feet and legs due to mild varicose veins.", + "The movement was a continuous semirhythmic movement involving the right first, second, third, and fourth toes.", + "It was a constant, flexion/relaxation movement.", + "The frequency varied between 0.5 and 1 Hz.", + "There was no associated visible movement of her ankle or calf muscles.", + "The patient could temporarily suppress the movement by powerful extension of her toes and dorsiflexion of her ankle.", + "Laboratory investigations did not show any remarkable abnormalities.", + "Her vitamin B12 level was normal.", + "She was already on vitamin D3 treatment.", + "A nerve conduction study of her right lower limb showed no evidence of demyelination or axonal loss.", + "There was no neurophysiological evidence of peroneal nerve compression at the fibular head.", + "There was no neurophysiological evidence of tarsal tunnel syndrome.", + "F wave examination and electromyography did not show any evidence of denervation.", + "A lumbar MRI scan demonstrated a mild disc protrusion between L4 and L5.", + "There was a much smaller disc protrusion between L5 and S1.", + "Both discs did not show spinal cord or nerve root compression on axial view.", + "A Tarlov cyst was seen at the sacral area." + ], + "summary": "A 50-year-old Mediterranean woman presented with a 1-year history of involuntary sustained movement of her right toes. Her physical examination and laboratory findings did not show any remarkable abnormality. Her lumbosacral magnetic resonance imaging scan showed a sacral Tarlov cyst. Our patient was given gabapentin, 100 mg per day as a starting dose, and showed modest improvement. Our patient preferred not to continue with the treatment as her symptoms were not disabling and she was only concerned about the cosmetic appearance.", + "summary_subclaims": [ + "The patient is a 50-year-old Mediterranean woman.", + "She had a 1-year history of involuntary sustained movement of her right toes.", + "Her physical examination did not show any remarkable abnormality.", + "Her lumbosacral magnetic resonance imaging scan showed a sacral Tarlov cyst.", + "Our patient was given gabapentin, 100 mg per day as a starting dose.", + "Our patient showed modest improvement.", + "Our patient preferred not to continue with the treatment.", + "Her symptoms were not disabling.", + "She was only concerned about the cosmetic appearance." + ] + }, + { + "id": "multiclinsum_test_3231_en.txt", + "fulltext": "Female, 77 years old, ECOG Performance Status Scale-1 (restricted in physically strenuous activity but ambulatory and able to carry out work of a light or sedentary nature), with a history of basalioma, arterial hypertension, total hip prosthesis, colonic diverticulitis, referred to the Hematology consultation in September 2018 for mild neutropenia, with no other cytopenias. She reported anorexia, with no infectious or hemorrhagic clinical signs. Two months later, she presented pancytopenia: Leuc 2.3 x 109/L (N = 4.0 - 10.0 x 109/L), Neut 0.97 x 109/L (N = 2 - 7 x 109/L), Hb 9.3 g/dL (N = 12.0 - 16.0 g/dL), Plaq 121 x 109/L (N = 150 – 400 x 109/L); and blastemia of 6% (N < 0%). The bone marrow study revealed multi-lineage dysplasia ≥ 50%, with the presence of erythroid dysplasia, with the presence of karyorexis (nucleus fragmentation), internuclear bridges, and myeloid dysplasia with abnormal segmentation and maturational asynchrony; and 33% of blasts; karyotype 46,XX,i(7)(p10). The NPM1 and FLT3-ITD mutational study was negative. The diagnosis of AML-ARM was established with an intermediate prognosis (ELN 20179).\n", + "fulltext_subclaims": [ + "The patient is a 77-year-old woman.", + "The patient has an ECOG Performance Status Scale-1.", + "The patient has a history of basalioma.", + "The patient has a history of arterial hypertension.", + "The patient has a total hip prosthesis.", + "The patient has colonic diverticulitis.", + "The patient was referred to Hematology consultation in September 2018.", + "The patient had mild neutropenia.", + "The patient had no other cytopenias.", + "The patient reported anorexia.", + "The patient had no infectious clinical signs.", + "The patient had no hemorrhagic clinical signs.", + "Two months later, the patient presented pancytopenia.", + "Leuc was 2.3 x 109/L.", + "Neut was 0.97 x 109/L.", + "Hb was 9.3 g/dL.", + "Plaq was 121 x 109/L.", + "Blastemia was 6%.", + "The bone marrow study revealed multi-lineage dysplasia ≥ 50%.", + "The bone marrow study showed the presence of erythroid dysplasia.", + "The bone marrow study showed the presence of karyorexis.", + "The bone marrow study showed the presence of internuclear bridges.", + "The bone marrow study showed myeloid dysplasia with abnormal segmentation.", + "The bone marrow study showed maturational asynchrony.", + "The bone marrow study showed 33% of blasts.", + "The karyotype was 46,XX,i(7)(p10).", + "The NPM1 mutational study was negative.", + "The FLT3-ITD mutational study was negative.", + "The diagnosis of AML-ARM was established.", + "The prognosis was intermediate according to ELN 2017." + ], + "summary": "We describe the case of a 77-year-old female patient with a diagnosis of high-risk AML-ARM, ineligible for intensive chemotherapy, with frequent transfusion needs.\n", + "summary_subclaims": [ + "The patient is a 77-year-old female.", + "The patient has a diagnosis of high-risk AML-ARM.", + "The patient is ineligible for intensive chemotherapy.", + "The patient has frequent transfusion needs." + ] + }, + { + "id": "multiclinsum_test_1444_en.txt", + "fulltext": "A 47-year-old male who complained of upper abdominal pain and vomiting was referred to our hospital. He was a heavy drinker and had a past history of hospitalization for alcoholic chronic pancreatitis. Laboratory data revealed elevated levels of amylase (245 IU/L), CRP (14.99 mg/dl), and white blood cell count (14900/μL). Plain abdominal computed tomography (CT) showed a cystic lesion of 7 cm in size in the lumen near the second part of the duodenum. The cystic lesion showed high density inside. The pancreas was slightly enlarged, and the main pancreatic duct was dilated. Calcifications were seen in the uncus of the pancreas . Gastrointestinal endoscopy revealed that the lumen of the duodenum was deformed by a submucosal tumor-like mass and the endoscope could not pass through it . However, active bleeding was not seen in the lumen of the duodenum. A submucosal tumor or hematoma of the duodenum or a pancreatic pseudocyst associated with chronic pancreatitis was suspected. On the fourth day of hospitalization, his hemoglobin level had decreased from 14.0 to 11.1 g/dl. Contrast-enhanced CT demonstrated a high-density spot on the wall of the cystic lesion . A pancreatic pseudocyst complicated with intracystic hemorrhage was preliminary considered. Angiography was immediately performed, and a pseudoaneurysm was identified in the branch of the anterior superior pancreaticoduodenal artery (ASPDA) . The pseudoaneurysm was successfully treated with transcatheter arterial embolization (TAE). Anemia did not progress after that. Upper gastrointestinal series demonstrated a filling defect in the duodenum, while the inside of the cystic lesion was not contrasted . Magnetic resonance cholangiopancreatography (MRCP) was performed but did not show a communication between the cyst and the pancreatic and biliary ducts. Follow-up CT on the 27th day after TAE showed that the cyst had decreased in size to 2 cm and obstruction of the duodenum was gradually improved . Surgical treatment was considered for the pancreatic pseudocyst with intracystic hemorrhage. However, he refused an operation and was discharged on the 34th day after TAE.\nTwo years later, abdominal pain and vomiting recurred. The cyst was enlarged again, and CT showed that it contained high-density fluid. Recurrence of a pancreatic pseudocyst with intracystic hemorrhage was suspected because of anemia progression. TAE was performed in the branches of the ASPDA and posterior superior pancreaticoduodenal artery (PSPDA). After TAE, the size of the cyst decreased and symptoms were relieved. However, the same symptoms recurred 2 months later. We obtained informed consent for surgical treatment, and we performed subtotal stomach-preserving pancreatoduodenectomy (SSPPD). Intraoperatively, severe inflammatory adhesion was noted around the pancreas head and the border between the pancreas and the cystic lesion was unclear. Macroscopically, a cystic mass of 5 cm in size was adjacent to the second part of the duodenum on the pancreas side and was close to the ampulla . A pinhole-sized communication was identified between the cyst and the duodenum lumen. Microscopically, the cyst was filled with mucus and the wall of the cyst was composed of gastric mucosa and shared a common proper muscle layer with the duodenum. Chronic ulcers and erosions were seen in the cyst . Ectopic gastric mucosa was observed in non-ulcerative region . Based on these findings, a diagnosis of duodenal duplication cyst was made. The patient’s postoperative course was uneventful, and he was discharged on the 30th day after the operation.", + "fulltext_subclaims": [ + "The patient was a 47-year-old male.", + "He complained of upper abdominal pain and vomiting.", + "He was a heavy drinker.", + "He had a past history of hospitalization for alcoholic chronic pancreatitis.", + "Laboratory data revealed elevated levels of amylase (245 IU/L).", + "Laboratory data revealed elevated levels of CRP (14.99 mg/dl).", + "Laboratory data revealed elevated levels of white blood cell count (14900/μL).", + "Plain abdominal computed tomography showed a cystic lesion of 7 cm in size in the lumen near the second part of the duodenum.", + "The cystic lesion showed high density inside.", + "The pancreas was slightly enlarged.", + "The main pancreatic duct was dilated.", + "Calcifications were seen in the uncus of the pancreas.", + "Gastrointestinal endoscopy revealed that the lumen of the duodenum was deformed by a submucosal tumor-like mass.", + "The endoscope could not pass through the deformed duodenum.", + "Active bleeding was not seen in the lumen of the duodenum.", + "A submucosal tumor or hematoma of the duodenum or a pancreatic pseudocyst associated with chronic pancreatitis was suspected.", + "On the fourth day of hospitalization, his hemoglobin level had decreased from 14.0 to 11.1 g/dl.", + "Contrast-enhanced CT demonstrated a high-density spot on the wall of the cystic lesion.", + "A pancreatic pseudocyst complicated with intracystic hemorrhage was preliminary considered.", + "Angiography was immediately performed.", + "A pseudoaneurysm was identified in the branch of the anterior superior pancreaticoduodenal artery.", + "The pseudoaneurysm was successfully treated with transcatheter arterial embolization.", + "Anemia did not progress after that.", + "Upper gastrointestinal series demonstrated a filling defect in the duodenum.", + "The inside of the cystic lesion was not contrasted.", + "Magnetic resonance cholangiopancreatography was performed.", + "MRCP did not show a communication between the cyst and the pancreatic and biliary ducts.", + "Follow-up CT on the 27th day after TAE showed that the cyst had decreased in size to 2 cm.", + "Obstruction of the duodenum was gradually improved.", + "Surgical treatment was considered for the pancreatic pseudocyst with intracystic hemorrhage.", + "He refused an operation.", + "He was discharged on the 34th day after TAE.", + "Two years later, abdominal pain and vomiting recurred.", + "The cyst was enlarged again.", + "CT showed that it contained high-density fluid.", + "Recurrence of a pancreatic pseudocyst with intracystic hemorrhage was suspected because of anemia progression.", + "TAE was performed in the branches of the ASPDA and posterior superior pancreaticoduodenal artery.", + "After TAE, the size of the cyst decreased.", + "Symptoms were relieved.", + "The same symptoms recurred 2 months later.", + "We obtained informed consent for surgical treatment.", + "We performed subtotal stomach-preserving pancreatoduodenectomy.", + "Intraoperatively, severe inflammatory adhesion was noted around the pancreas head.", + "The border between the pancreas and the cystic lesion was unclear.", + "Macroscopically, a cystic mass of 5 cm in size was adjacent to the second part of the duodenum on the pancreas side.", + "The cystic mass was close to the ampulla.", + "A pinhole-sized communication was identified between the cyst and the duodenum lumen.", + "Microscopically, the cyst was filled with mucus.", + "The wall of the cyst was composed of gastric mucosa.", + "The wall of the cyst shared a common proper muscle layer with the duodenum.", + "Chronic ulcers and erosions were seen in the cyst.", + "Ectopic gastric mucosa was observed in non-ulcerative region.", + "Based on these findings, a diagnosis of duodenal duplication cyst was made.", + "The patient’s postoperative course was uneventful.", + "He was discharged on the 30th day after the operation." + ], + "summary": "A 47-year-old male who complained of upper abdominal pain and vomiting was referred to our hospital. He was a heavy drinker and had a past history of hospitalization for alcoholic chronic pancreatitis. Plain abdominal computed tomography (CT) showed a cystic lesion of 7 cm in size in the lumen near the second part of the duodenum. The cystic lesion showed high density inside. Gastrointestinal endoscopy revealed that the lumen of the duodenum was deformed by a submucosal tumor-like mass and the endoscope could not pass through it, but active bleeding was not seen in the lumen of the duodenum. On the fourth day of hospitalization, anemia progressed and contrast-enhanced CT demonstrated a high-density spot on the wall of the cystic lesion. A pancreatic pseudocyst complicated with intracystic hemorrhage was preliminarily considered. Angiography was immediately performed, and a pseudoaneurysm was identified in the branch of the anterior superior pancreaticoduodenal artery (ASPDA). Transcatheter arterial embolization (TAE) was performed. Anemia did not progress after that, and follow-up CT showed reduction in the size of the cystic lesion. Afterward, the same symptoms recurred twice and surgical treatment was performed for the pancreatic pseudocyst with repeated intracystic hemorrhage. Macroscopically, a cystic mass of 5 cm in size was adjacent to the second part of the duodenum on the pancreas side. A pinhole-sized communication was identified between the cyst and the duodenum lumen. Microscopically, the cyst wall was composed of gastric mucosa and shared a common proper muscle layer with the duodenum. Chronic ulcers and erosions were seen in the cyst. Based on these findings, a diagnosis of duodenal duplication cyst was made.", + "summary_subclaims": [ + "The patient was a 47-year-old male.", + "He complained of upper abdominal pain and vomiting.", + "He was referred to the hospital.", + "He was a heavy drinker.", + "He had a past history of hospitalization for alcoholic chronic pancreatitis.", + "Plain abdominal CT showed a cystic lesion of 7 cm in size in the lumen near the second part of the duodenum.", + "The cystic lesion showed high density inside.", + "Gastrointestinal endoscopy revealed that the lumen of the duodenum was deformed by a submucosal tumor-like mass.", + "The endoscope could not pass through the mass.", + "Active bleeding was not seen in the lumen of the duodenum.", + "On the fourth day of hospitalization, anemia progressed.", + "Contrast-enhanced CT demonstrated a high-density spot on the wall of the cystic lesion.", + "A pancreatic pseudocyst complicated with intracystic hemorrhage was preliminarily considered.", + "Angiography was immediately performed.", + "A pseudoaneurysm was identified in the branch of the anterior superior pancreaticoduodenal artery.", + "Transcatheter arterial embolization was performed.", + "Anemia did not progress after that.", + "Follow-up CT showed reduction in the size of the cystic lesion.", + "The same symptoms recurred twice.", + "Surgical treatment was performed for the pancreatic pseudocyst with repeated intracystic hemorrhage.", + "Macroscopically, a cystic mass of 5 cm in size was adjacent to the second part of the duodenum on the pancreas side.", + "A pinhole-sized communication was identified between the cyst and the duodenum lumen.", + "Microscopically, the cyst wall was composed of gastric mucosa.", + "The cyst wall shared a common proper muscle layer with the duodenum.", + "Chronic ulcers and erosions were seen in the cyst.", + "Based on these findings, a diagnosis of duodenal duplication cyst was made." + ] + }, + { + "id": "multiclinsum_test_1422_en.txt", + "fulltext": "A 50-year-old man was referred to our institution with several years of right heart failure symptoms, AF, and liver disease of unknown aetiology. He was a fisherman and had contact with contaminated water in the past. He had lower limb oedema, significant ascites, jugular vein distention, and 3/6 pansystolic murmur heard loudest at the left lower sternal edge suggestive of tricuspid regurgitation. The patient came from the northeastern region of Brazil, where there is high prevalence of schistosomiasis. Considering the local epidemiology and the presence of hepatosplenomegaly, schistosomiasis was suspected. Due to the symptoms of right heart failure mentioned, cardiac investigations were performed as a primary cause of the liver disease.\nThe electrocardiogram showed AF rhythm and there was cardiomegaly noted on chest radiograph, with gross enlargement of the right atrial shadow. Blood tests showed thrombocytopenia of 75 000/mm3 [normal values (NV): 150 000–400 000], normal renal function and liver enzymes, and brain natriuretic peptide of 198 pg/mL (NV ≤ 35). The TTE showed a left ventricle of normal dimensions with a preserved left ventricular ejection fraction (LVEF) (, ). However, the RV cavity was small secondary to a large homogeneous hypoechoic mass with evidence of severe tricuspid insufficiency, secondary to dilatation of the annulus, and severe tethering of the valve leaflets. Besides, the TTE exhibited an intracavitary thrombus adhered to the roof of the right atrium (RA; ; , ). The cardiac magnetic resonance (CMR) imaging showed severe RA dilation. This examination confirmed that RV had small cavity with reduced indexed end-diastolic and end-systolic volumes (38 and 13 mL/m2, respectively), normal systolic function (EF 65%), and moderate pericardial effusion . The late gadolinium enhancement sequence showed diffuse and heterogeneous subendocardial fibrosis in the RV apex . The patient was diagnosed with EMF and schistosomiasis by positive IgG ELISA and treated with praziquantel, but declined endocardiectomy. His heart failure symptoms improved on diuretics (furosemide 120 mg/day, spironolactone 50 mg/day, and hydrochlorothiazide 50 mg/day). In addition, the patient was commenced on warfarin with adequate international normalized ratio control for the presence of AF and thrombus.", + "fulltext_subclaims": [ + "The patient was a 50-year-old man.", + "He had several years of right heart failure symptoms.", + "He had atrial fibrillation.", + "He had liver disease of unknown aetiology.", + "He had lower limb oedema.", + "He had significant ascites.", + "He had jugular vein distention.", + "He had a 3/6 pansystolic murmur heard loudest at the left lower sternal edge.", + "The murmur was suggestive of tricuspid regurgitation.", + "The patient came from the northeastern region of Brazil.", + "There is high prevalence of schistosomiasis in the northeastern region of Brazil.", + "Schistosomiasis was suspected.", + "The electrocardiogram showed AF rhythm.", + "Cardiomegaly was noted on chest radiograph.", + "There was gross enlargement of the right atrial shadow.", + "Blood tests showed thrombocytopenia of 75 000/mm3.", + "The TTE showed a left ventricle of normal dimensions.", + "The TTE showed a preserved left ventricular ejection fraction.", + "The RV cavity was small secondary to a large homogeneous hypoechoic mass.", + "There was evidence of severe tricuspid insufficiency.", + "The TTE exhibited an intracavitary thrombus adhered to the roof of the right atrium.", + "The CMR imaging showed severe RA dilation.", + "The CMR confirmed that the RV had small cavity.", + "The CMR showed reduced indexed end-diastolic and end-systolic volumes.", + "The CMR showed normal systolic function.", + "The CMR showed moderate pericardial effusion.", + "The late gadolinium enhancement sequence showed diffuse and heterogeneous subendocardial fibrosis in the RV apex.", + "The patient was diagnosed with EMF.", + "The patient was diagnosed with schistosomiasis by positive IgG ELISA.", + "The patient was treated with praziquantel.", + "The patient declined endocardiectomy.", + "The patient was commenced on warfarin." + ], + "summary": "We describe a case of a 50-year-old man from the northeastern region of Brazil, where there is high prevalence of schistosomiasis. He presented to our centre with symptoms of right heart failure. The echocardiogram showed normal left ventricular ejection fraction. Right ventricular had normal systolic function but in the apical region was filled with a homogeneous and hypoechoic image causing obliteration and restriction of the apex. The late gadolinium enhancement with cardiac magnetic resonance showed diffuse and heterogeneous subendocardial fibrosis in the right ventricle apex consistent with EMF, but declined endocardiectomy.", + "summary_subclaims": [ + "The patient is a 50-year-old man.", + "The patient is from the northeastern region of Brazil.", + "The echocardiogram showed normal left ventricular ejection fraction.", + "The right ventricular had normal systolic function.", + "The apical region was filled with a homogeneous and hypoechoic image.", + "The late gadolinium enhancement with cardiac magnetic resonance showed diffuse and heterogeneous subendocardial fibrosis in the right ventricle apex.", + "The findings were consistent with EMF.", + "Endocardiectomy was declined." + ] + }, + { + "id": "multiclinsum_test_3061_en.txt", + "fulltext": "50-year-old female patient with a history of dermatomyositis and antisynthetase syndrome associated with secondary diffuse pulmonary disease (EPD), on treatment with mycophenolate and corticosteroids. She progressed with weight loss of 18 kg, night sweats and progressive increase in volume of the upper left eyelid. Orbital CT scan was performed which showed an increase in volume of the lacrimal gland.\n\nHe was admitted to our center electively for biopsy, with a presumptive diagnosis of MALT lymphoma of the lacrimal gland. Twenty-four hours after the procedure he presented clinical signs of acute abdomen. A TAC showed multiple nodular lesions in the liver, spleen, adrenal glands and subcutaneous tissue, as well as thickening of the colonic walls. An emergency exploratory laparotomy was performed, where peritonitis of 4 quadrants was evident, as well as perforated transverse colon tumour and 3 implants in the omentum. A hemicolectomy and terminal ileostomy were performed and the surgical piece was sent to pathological anatomy.\n\nOther infectious or rheumatologic etiologies that could explain the picture in the context of immunosuppression were discarded. In addition, a myelogram was performed, in which a sample was obtained for myeloculture and universal PCR of bacteria and fungi, which were negative. The immunophenotype of the bone marrow sample showed 9% of polyclonal lymphocytes. A CT scan of the brain, neck, thorax, abdomen and pelvis was performed to extend the study of the nodules found in surgery, which did not show new lesions to those already described. The presumptive diagnosis was unknown primary neoplasm.\n\nFinally, the biopsy result of the lacrimal gland tumor showed extensive necrosis and lymphoid infiltration, mixed with CD68-positive histiocytoid cells and some plasma cells. Occasionally, a multinucleated cell was recognized. The lymphocytes were predominantly small, although larger around the vessels. Medium to large lymphocytes were present with angiocentricity, causing infiltration and necrosis of blood vessels. These cells were CD20 positive and EBER positive, with the majority of lymphocytes being small T-cell lymphocytes. The biopsy of the colon tumor showed the same histology.\n\nGiven the clinical picture and results described in the biopsies, the diagnosis of atypical presentation of lymphomatoid granulomatosis (GL) was concluded in the first instance. The case was presented to the haemato-oncological committee, and given the patient's nutritional and functional status, and high risk of intestinal perforation with chemotherapy, it was decided to initiate the R-COP protocol as a prephase to be able to progress to the R-CHOEP scheme after stabilisation. The patient completed 6 cycles of R-CHOEP, without complications, and has been in complete remission for 1 year.\n\nIn 2022 in light of new classifications and definitions of lymphoid neoplasms, it was concluded that both clinically and histologically, the case is more like a GL-type, polymorphic B-LPD.\n", + "fulltext_subclaims": [ + "The patient is a 50-year-old female.", + "She has a history of dermatomyositis.", + "She has a history of antisynthetase syndrome.", + "She has secondary diffuse pulmonary disease.", + "She is on treatment with mycophenolate.", + "She is on treatment with corticosteroids.", + "She had a weight loss of 18 kg.", + "She had night sweats.", + "She had progressive increase in volume of the upper left eyelid.", + "An orbital CT scan showed an increase in volume of the lacrimal gland.", + "The presumptive diagnosis was MALT lymphoma of the lacrimal gland.", + "Twenty-four hours after the procedure, she presented clinical signs of acute abdomen.", + "A TAC showed multiple nodular lesions in the liver.", + "A TAC showed multiple nodular lesions in the spleen.", + "A TAC showed multiple nodular lesions in the adrenal glands.", + "A TAC showed multiple nodular lesions in the subcutaneous tissue.", + "A TAC showed thickening of the colonic walls.", + "An emergency exploratory laparotomy was performed.", + "Peritonitis of 4 quadrants was evident.", + "A perforated transverse colon tumour was found.", + "Three implants in the omentum were found.", + "A hemicolectomy and terminal ileostomy were performed.", + "The surgical piece was sent to pathological anatomy.", + "Other infectious or rheumatologic etiologies were discarded.", + "A myelogram was performed.", + "A sample was obtained for myeloculture.", + "Universal PCR of bacteria and fungi were negative.", + "The immunophenotype of the bone marrow sample showed 9% of polyclonal lymphocytes.", + "A CT scan of the brain, neck, thorax, abdomen, and pelvis was performed.", + "The CT scan did not show new lesions.", + "The presumptive diagnosis was unknown primary neoplasm.", + "The biopsy result of the lacrimal gland tumor showed extensive necrosis.", + "The biopsy result showed lymphoid infiltration.", + "The lymphoid infiltration was mixed with CD68-positive histiocytoid cells.", + "The lymphoid infiltration was mixed with some plasma cells.", + "Occasionally, a multinucleated cell was recognized.", + "The lymphocytes were predominantly small.", + "Some larger lymphocytes were around the vessels.", + "Medium to large lymphocytes were present.", + "The lymphocytes showed angiocentricity.", + "The lymphocytes caused infiltration and necrosis of blood vessels.", + "The lymphocytes were CD20 positive.", + "The lymphocytes were EBER positive.", + "The majority of lymphocytes were small T-cell lymphocytes.", + "The biopsy of the colon tumor showed the same histology.", + "The diagnosis of atypical presentation of lymphomatoid granulomatosis was concluded.", + "The case was presented to the haemato-oncological committee.", + "The patient's nutritional and functional status was considered.", + "The patient had a high risk of intestinal perforation with chemotherapy.", + "It was decided to initiate the R-COP protocol as a prephase.", + "The goal was to progress to the R-CHOEP scheme after stabilisation.", + "The patient completed 6 cycles of R-CHOEP.", + "The patient had no complications.", + "The patient has been in complete remission for 1 year.", + "In 2022, new classifications and definitions of lymphoid neoplasms were considered.", + "It was concluded that the case is more like a GL-type, polymorphic B-LPD." + ], + "summary": "A 50-year-old female patient with a history of dermatomyositis and antisynthetase syndrome on immunosuppressive therapy presented with a left upper eyelid lacrimal gland mass associated with weight loss and night sweats. She was admitted for elective biopsy. The day after the postoperative period, she developed an acute abdomen. A computed axial tomography scan showed multiple hypodensities in the liver, spleen, kidneys and adrenal glands, associated with a perforated tumour in the transverse colon and free fluid in the peritoneal cavity. In this scenario, an infectious, neoplastic or rheumatological etiology was considered as a differential diagnosis, especially in the context of our patient. Finally, extensive necrosis with angiocentric lymphoid infiltration and angiodestructive necrosis was observed in both the lacrimal gland and colon biopsies, associated with EBER-positive EBV. After a thorough review of the clinical, histological and new classifications of mature B lymphoid neoplasms, a diagnosis of a polymorphic B lymphoproliferative disorder, a lymphomatoid granulomatosis, an infrequent entity rarely associated with iatrogenic immunosuppression, was made.\n", + "summary_subclaims": [ + "The patient is a 50-year-old female.", + "The patient has a history of dermatomyositis.", + "The patient has a history of antisynthetase syndrome.", + "The patient is on immunosuppressive therapy.", + "The patient presented with a left upper eyelid lacrimal gland mass.", + "The patient had weight loss.", + "The patient had night sweats.", + "The patient was admitted for elective biopsy.", + "The day after the postoperative period, she developed an acute abdomen.", + "A computed axial tomography scan showed multiple hypodensities in the liver.", + "A computed axial tomography scan showed multiple hypodensities in the spleen.", + "A computed axial tomography scan showed multiple hypodensities in the kidneys.", + "A computed axial tomography scan showed multiple hypodensities in the adrenal glands.", + "A computed axial tomography scan showed a perforated tumour in the transverse colon.", + "A computed axial tomography scan showed free fluid in the peritoneal cavity.", + "An infectious, neoplastic or rheumatological etiology was considered as a differential diagnosis.", + "Extensive necrosis with angiocentric lymphoid infiltration was observed in the lacrimal gland biopsy.", + "Extensive necrosis with angiodestructive necrosis was observed in the colon biopsy.", + "EBER-positive EBV was associated with the findings.", + "A diagnosis of polymorphic B lymphoproliferative disorder was made.", + "A diagnosis of lymphomatoid granulomatosis was made.", + "Lymphomatoid granulomatosis is an infrequent entity.", + "Lymphomatoid granulomatosis is rarely associated with iatrogenic immunosuppression." + ] + }, + { + "id": "multiclinsum_test_1020_en.txt", + "fulltext": "A 45-year-old man presented to our center with gradually developing weakness of the right limbs for 3 months. He underwent brain magnetic resonance imaging (MRI) at another hospital 3 months prior to admission, which showed an acute ischemic stroke of the left parietal lobe. Twenty days before admission, MRI showed cerebral and subarachnoid hemorrhages, although he had no new symptoms or exacerbation at that time. Ten days before admission, he presented with a sudden headache in the occipital region, difficulty in finding words, and unsteady walking. The patient did not complain of abdominal or bone pain.\nAt admission, his vital signs and general examination were normal. Mucocutaneous alterations were not observed. Neurologic examination revealed expressive aphasia and right-sided extremity weakness graded 4/5 on the Medical Research Council scale (total range, 0 [no movement is observed] to 5 [muscle contracts normally against full resistance]).\nHis medical history was unremarkable, with no history of vascular risk factors, including diabetes, hypertension, hyperlipidemia, cardiomyopathy, and atrial fibrillation. He also denied smoking, alcohol consumption, or illicit drug use. The patient’s father died of cerebral hemorrhage.\nA computed tomography scan of the brain showed an area of infarction with hemorrhage in the left subcortical and corona radiata regions , and the European Cooperative Acute Stroke Study classification was that of parenchymal hematomas 2 (PH2). MRI revealed meningeal and peripheral enhancement but no significant enhancement in the hemorrhage area. High-resolution MRI revealed a thrombosis on the surface of the atherosclerotic plaque. Digital subtraction angiography (DSA; Fig. ) revealed an insect bite-like change in the C1 branch of the left internal carotid artery, which caused up to 50% stenosis. Cerebrovascular malformations and other carotid or intracranial arterial stenoses were excluded.\nAll blood test results were unremarkable, except for a continued elevation in the platelet (501 × 109/L-601 × 109/L) and white blood cell counts , with normal coagulation function. Therefore, bone marrow biopsy and genetic testing were performed after consultation with a hematologist. Bone marrow biopsy revealed proliferative bone marrow changes, with numerous megakaryocytes and proliferative but mature granulocytes. Further genetic testing revealed a positive JAK2-V617F mutation.\nMyeloproliferative disease is a possible cause of complex cerebrovascular lesions. Therefore, the diagnosis of ET was confirmed according to the diagnostic criteria of the World Health Organization (WHO) 2016. After discussing with the hematologist, we decided to administer aspirin and hydroxyurea. After treatment, the patient remained stroke free (mRS score = 1/6, total range 0 [symptom-free] to 6 [dead]), and platelet levels were normal throughout the 1-year follow-up period.", + "fulltext_subclaims": [ + "The patient is a 45-year-old man.", + "He presented with gradually developing weakness of the right limbs for 3 months.", + "He underwent brain MRI at another hospital 3 months prior to admission.", + "The MRI showed an acute ischemic stroke of the left parietal lobe.", + "Twenty days before admission, MRI showed cerebral and subarachnoid hemorrhages.", + "He had no new symptoms or exacerbation 20 days before admission.", + "Ten days before admission, he presented with a sudden headache in the occipital region.", + "Ten days before admission, he had difficulty in finding words.", + "Ten days before admission, he had unsteady walking.", + "The patient did not complain of abdominal or bone pain.", + "At admission, his vital signs and general examination were normal.", + "Mucocutaneous alterations were not observed.", + "Neurologic examination revealed expressive aphasia.", + "Right-sided extremity weakness was graded 4/5 on the Medical Research Council scale.", + "The patient had no history of vascular risk factors.", + "He denied smoking, alcohol consumption, or illicit drug use.", + "The patient’s father died of cerebral hemorrhage.", + "Computed tomography scan showed an area of infarction with hemorrhage in the left subcortical and corona radiata regions.", + "The European Cooperative Acute Stroke Study classification was that of parenchymal hematomas 2 (PH2).", + "MRI revealed meningeal and peripheral enhancement.", + "High-resolution MRI revealed a thrombosis on the surface of the atherosclerotic plaque.", + "Digital subtraction angiography revealed an insect bite-like change in the C1 branch of the left internal carotid artery.", + "The insect bite-like change caused up to 50% stenosis.", + "Cerebrovascular malformations were excluded.", + "Other carotid or intracranial arterial stenoses were excluded.", + "Platelet counts were elevated (501 × 109/L-601 × 109/L).", + "White blood cell counts were elevated.", + "Coagulation function was normal.", + "Bone marrow biopsy revealed proliferative bone marrow changes.", + "Bone marrow biopsy showed numerous megakaryocytes.", + "Bone marrow biopsy showed proliferative but mature granulocytes.", + "Genetic testing revealed a positive JAK2-V617F mutation.", + "Myeloproliferative disease is a possible cause of complex cerebrovascular lesions.", + "The diagnosis of ET was confirmed according to the WHO 2016 diagnostic criteria.", + "Aspirin and hydroxyurea were administered.", + "The patient remained stroke free during the 1-year follow-up period.", + "Platelet levels were normal throughout the 1-year follow-up period." + ], + "summary": "A 45-year-old Chinese male presented to our center with gradually developing weakness of the right limbs for 3 months. A computed tomography scan of the brain showed an area of infarction with hemorrhage in the left subcortical and corona radiata regions. High-resolution magnetic resonance imaging revealed a thrombosis on the surface of the atherosclerotic plaque. Digital subtraction angiography revealed an insect bite-like change in the C1 branch of the left internal carotid artery, which caused up to 50% stenosis. Blood tests showed continued elevation of the platelet and white blood cell counts. After consultation with a hematologist, a bone marrow biopsy was performed, which revealed proliferative bone marrow changes with numerous megakaryocytes and proliferative but mature granulocytes. Further genetic testing revealed a positive JAK2-V617F mutation. Therefore, the diagnosis of ET was confirmed according to the World Health Organization (WHO) 2016 diagnostic criteria. Finally, we decided to administer aspirin and hydroxyurea. The patient remained stroke free and the platelet levels were normal throughout the 1-year follow-up period.", + "summary_subclaims": [ + "A 45-year-old Chinese male presented to our center with gradually developing weakness of the right limbs for 3 months.", + "A computed tomography scan of the brain showed an area of infarction with hemorrhage in the left subcortical and corona radiata regions.", + "High-resolution magnetic resonance imaging revealed a thrombosis on the surface of the atherosclerotic plaque.", + "Digital subtraction angiography revealed an insect bite-like change in the C1 branch of the left internal carotid artery, which caused up to 50% stenosis.", + "Blood tests showed continued elevation of the platelet and white blood cell counts.", + "A bone marrow biopsy was performed, which revealed proliferative bone marrow changes with numerous megakaryocytes and proliferative but mature granulocytes.", + "Further genetic testing revealed a positive JAK2-V617F mutation.", + "The diagnosis of ET was confirmed according to the World Health Organization (WHO) 2016 diagnostic criteria.", + "We decided to administer aspirin and hydroxyurea.", + "The patient remained stroke free and the platelet levels were normal throughout the 1-year follow-up period." + ] + }, + { + "id": "multiclinsum_test_1195_en.txt", + "fulltext": "A 68-year-old Iranian man was investigated for about 12 months with a history of recurrent hematemesis and chronic anemia without any diagnosis. Due to multiple normal endoscopy and colonoscopy results, he was referred to us in the surgery department for further evaluation and care. Before the occurrence of bleeding, the patient was asymptomatic and without any significant complaints. Due to the intermittent nature of the bleeding, the patient had a normal fecal digital rectal examination without any signs of blood at the time of admission. According to the patient’s records during the bleeding periods, anemia and a significant decrease in hemoglobin (Hb, 8.7 g/dL) were found. He had no past medical history of any other diseases and mentioned a normal family and psychosocial history.", + "fulltext_subclaims": [ + "The patient is a 68-year-old Iranian man.", + "The patient had a history of recurrent hematemesis.", + "The patient had chronic anemia.", + "The patient had no diagnosis for 12 months.", + "Multiple normal endoscopy and colonoscopy results were reported.", + "The patient was referred to the surgery department.", + "Before bleeding, the patient was asymptomatic.", + "The patient had a normal fecal digital rectal examination at the time of admission.", + "Anemia was found during the bleeding periods.", + "A significant decrease in hemoglobin (Hb, 8.7 g/dL) was found.", + "The patient had no past medical history of any other diseases." + ], + "summary": "In this article, we discuss the case of a 68-year-old caucasian man with a history of recurrent hematemesis and chronic anemia with evidence of extravasation of contrast in the lumen of the bowel loop on computed tomography angiography. The patient was taken to the operating room, and a laparotomy procedure was performed.", + "summary_subclaims": [ + "The patient is a 68-year-old caucasian man.", + "The patient has a history of recurrent hematemesis.", + "The patient has chronic anemia.", + "There was evidence of extravasation of contrast in the lumen of the bowel loop on computed tomography angiography.", + "The patient was taken to the operating room.", + "A laparotomy procedure was performed." + ] + }, + { + "id": "multiclinsum_test_3224_en.txt", + "fulltext": "A 69-year-old elderly woman presented to the Bazhong Traditional Chinese Medicine Hospital with symptoms of abdominal pain and vomiting. She was diagnosed with intestinal obstruction and underwent laparoscopic exploration, removal of foreign body in the ileum, lysis of adhesions, and resection and anastomosis of the affected intestinal segment. After surgery, the patient was instructed to abstain from oral intake, thus she was treated with a 250mL infusion of C14-24 fat emulsion containing 75g (manufactured by Sichuan Kelun Pharmaceutical Co., Ltd.) once a day via intravenous drip. The postoperative review revealed a triglyceride (TG) level of 19.71 mmol/L. On the third day after surgery, the patient experienced worsening abdominal pain and black stools, prompting them to seek medical attention at our hospital (Bazhong Central Hospital). Upon admission, a comprehensive physical examination was performed on the patient. Specifically, auscultation of the lungs revealed decreased breath sounds and the presence of crackles, indicating the presence of pulmonary inflammation. Abdominal examination revealed abdominal distension, generalized tenderness, and muscle guarding. Further, an abdominal CT scan was performed on the patient, revealing acute pancreatitis with pancreatic swelling and slightly decreased enhancement of the local density. The specific performance might be peripancreatic fluid collection, thickening of the peritoneum and omentum, homogeneous decrease in splenic density, and homogeneous increase in gallbladder density. Moreover, Extensive fluid accumulation was observed surrounding the abdominal aorta, splenic artery, and anterior renal fascia, with blurred fat planes in the abdominal cavity. The chest CT scan indicated inflammation in the bilateral lower lobes of the lungs, minimal pleural effusion, and atelectasis in the lower lobes of both lungs. Further analysis of the complete blood count revealed a white blood cell count (WBC) of 33.68×10^9/L, with 89.1% neutrophils (Neu), hemoglobin (Hb) level of 146g/L, platelet count (PLT) of 242×10^9/L, procalcitonin (PCT) level of 1.17 ng/mL, and C-reactive protein (CRP) level of 12.03mg/L. The fecal occult blood test was positive, suggesting gastrointestinal bleeding likely induced by postoperative and prolonged fasting. It is worth noting that due to the severe hypertriglyceridemia, it was not possible to evaluate the liver and kidney function, as well as the lipid profile. Overall, blood purification, plasma exchange, oral lipid-lowering medications, CT-guided precise puncture drainage and catheter placement in the necrotic area of the pancreas, along with antimicrobial therapy, fluid resuscitation, and supportive care, are all considered beneficial in aiding the patient’s recovery. On the first day of admission, the patient underwent plasma exchange, perfusion, antimicrobial therapy, antispasmodics, acid suppression, enzyme inhibition, and measures to stabilize electrolytes and provide nutritional support as symptomatic treatment. On the second day of admission, despite undergoing plasma exchange, the patient’s lipid levels remained elevated, and an electrocardiogram revealed atrial fibrillation (Table 1). To address this, amiodarone was added to the existing treatment plan for rhythm control therapy. Nevertheless, on the third day of admission, the patient exhibited poor mental status and drowsiness. Despite undergoing another round of plasma exchange, both lipid levels and inflammatory markers remained elevated. At this point, the patient developed multi-organ dysfunction involving the cardiovascular, respiratory, and coagulation systems, necessitating endotracheal intubation. Blood perfusion with HA380 and HA330 was initiated to support hemodynamic stability. Following perfusion therapy, a subsequent examination revealed a significant decrease in lipid levels compared to previous measurements. Therefore, plasma exchange was discontinued and the patient was switched to oral lipid-lowering medications for continued treatment. By the fourth day of admission, coagulation function indicators had essentially returned to normal. On the fifth day of admission, there was a significant decrease in the patient’s lipid levels compared to previous measurements. However, due to the patient’s rapid respiratory rate, diminished breath sounds in both lungs, and chest CT findings suggestive of atelectasis, blood purification was implemented as an adjunct to the existing treatment plan to alleviate fluid overload. On the eighth day of admission, the patient’s lipid levels showed significant improvement compared to previous measurements. Whereas, the patient developed recurrent fever, and after ruling out pulmonary infection, we considered acute necrotizing pancreatitis as the cause of fever. Hence, on the sixteenth day of admission, we performed CT-guided precise puncture drainage and catheter placement at the site of pancreatic necrosis, during which purulent fluid with a dark red color was obtained. Meanwhile, we continued with antimicrobial therapy and other treatments. On the twenty-fourth day of admission, approximately 5mL of purulent fluid was still draining from the catheter, but the color was lighter compared to previous drainage. A follow-up abdominal ultrasound showed normal pancreatic size and shape, clear contours, and uniform echo in the parenchyma, with no dilation of the main pancreatic duct. The results of the follow-up abdominal CT scan are consistent with the ultrasound findings. Further review of the chest CT reveals improved pneumonia bilaterally, with minimal pleural effusion in both lungs. Considering the significant improvement in the patient’s condition, the patient was discharged on the twenty-fourth day of admission. Moreover, we have conducted long-term follow-up of the patient. The prognosis is favorable, with repeated measurements indicating normal lipid levels.", + "fulltext_subclaims": [ + "A 69-year-old elderly woman presented to the Bazhong Traditional Chinese Medicine Hospital with symptoms of abdominal pain and vomiting.", + "She was diagnosed with intestinal obstruction.", + "She underwent laparoscopic exploration, removal of foreign body in the ileum, lysis of adhesions, and resection and anastomosis of the affected intestinal segment.", + "After surgery, the patient was instructed to abstain from oral intake.", + "She was treated with a 250mL infusion of C14-24 fat emulsion containing 75g (manufactured by Sichuan Kelun Pharmaceutical Co., Ltd.) once a day via intravenous drip.", + "The postoperative review revealed a triglyceride (TG) level of 19.71 mmol/L.", + "On the third day after surgery, the patient experienced worsening abdominal pain and black stools.", + "They sought medical attention at Bazhong Central Hospital.", + "Upon admission, a comprehensive physical examination was performed on the patient.", + "Auscultation of the lungs revealed decreased breath sounds and the presence of crackles, indicating the presence of pulmonary inflammation.", + "Abdominal examination revealed abdominal distension, generalized tenderness, and muscle guarding.", + "An abdominal CT scan revealed acute pancreatitis with pancreatic swelling and slightly decreased enhancement of the local density.", + "The specific performance might be peripancreatic fluid collection.", + "The specific performance might be thickening of the peritoneum and omentum.", + "The specific performance might be homogeneous decrease in splenic density.", + "The specific performance might be homogeneous increase in gallbladder density.", + "Extensive fluid accumulation was observed surrounding the abdominal aorta, splenic artery, and anterior renal fascia.", + "Blurred fat planes in the abdominal cavity were observed.", + "The chest CT scan indicated inflammation in the bilateral lower lobes of the lungs.", + "The chest CT scan indicated minimal pleural effusion.", + "The chest CT scan indicated atelectasis in the lower lobes of both lungs.", + "The complete blood count revealed a white blood cell count (WBC) of 33.68×10^9/L.", + "The complete blood count revealed 89.1% neutrophils (Neu).", + "The complete blood count revealed hemoglobin (Hb) level of 146g/L.", + "The complete blood count revealed platelet count (PLT) of 242×10^9/L.", + "The complete blood count revealed procalcitonin (PCT) level of 1.17 ng/mL.", + "The complete blood count revealed C-reactive protein (CRP) level of 12.03mg/L.", + "The fecal occult blood test was positive.", + "The fecal occult blood test suggested gastrointestinal bleeding likely induced by postoperative and prolonged fasting.", + "Due to the severe hypertriglyceridemia, it was not possible to evaluate the liver and kidney function.", + "Due to the severe hypertriglyceridemia, it was not possible to evaluate the lipid profile.", + "Blood purification, plasma exchange, oral lipid-lowering medications, CT-guided precise puncture drainage and catheter placement in the necrotic area of the pancreas, along with antimicrobial therapy, fluid resuscitation, and supportive care, are all considered beneficial in aiding the patient’s recovery.", + "On the first day of admission, the patient underwent plasma exchange.", + "On the first day of admission, the patient underwent perfusion.", + "On the first day of admission, the patient underwent antimicrobial therapy.", + "On the first day of admission, the patient underwent antispasmodics.", + "On the first day of admission, the patient underwent acid suppression.", + "On the first day of admission, the patient underwent enzyme inhibition.", + "On the first day of admission, measures to stabilize electrolytes and provide nutritional support were implemented.", + "On the second day of admission, despite undergoing plasma exchange, the patient’s lipid levels remained elevated.", + "On the second day of admission, an electrocardiogram revealed atrial fibrillation.", + "To address this, amiodarone was added to the existing treatment plan for rhythm control therapy.", + "On the third day of admission, the patient exhibited poor mental status and drowsiness.", + "Despite undergoing another round of plasma exchange, both lipid levels and inflammatory markers remained elevated.", + "At this point, the patient developed multi-organ dysfunction involving the cardiovascular, respiratory, and coagulation systems.", + "Endotracheal intubation was necessitated.", + "Blood perfusion with HA380 and HA330 was initiated to support hemodynamic stability.", + "Following perfusion therapy, a subsequent examination revealed a significant decrease in lipid levels compared to previous measurements.", + "Plasma exchange was discontinued.", + "The patient was switched to oral lipid-lowering medications for continued treatment.", + "By the fourth day of admission, coagulation function indicators had essentially returned to normal.", + "On the fifth day of admission, there was a significant decrease in the patient’s lipid levels compared to previous measurements.", + "Due to the patient’s rapid respiratory rate, diminished breath sounds in both lungs, and chest CT findings suggestive of atelectasis, blood purification was implemented as an adjunct to the existing treatment plan to alleviate fluid overload.", + "On the eighth day of admission, the patient’s lipid levels showed significant improvement compared to previous measurements.", + "The patient developed recurrent fever.", + "After ruling out pulmonary infection, we considered acute necrotizing pancreatitis as the cause of fever.", + "On the sixteenth day of admission, we performed CT-guided precise puncture drainage and catheter placement at the site of pancreatic necrosis.", + "During the procedure, purulent fluid with a dark red color was obtained.", + "We continued with antimicrobial therapy and other treatments.", + "On the twenty-fourth day of admission, approximately 5mL of purulent fluid was still draining from the catheter, but the color was lighter compared to previous drainage.", + "A follow-up abdominal ultrasound showed normal pancreatic size and shape.", + "A follow-up abdominal ultrasound showed clear contours.", + "A follow-up abdominal ultrasound showed uniform echo in the parenchyma.", + "A follow-up abdominal ultrasound showed no dilation of the main pancreatic duct.", + "The results of the follow-up abdominal CT scan are consistent with the ultrasound findings.", + "Further review of the chest CT reveals improved pneumonia bilaterally.", + "Further review of the chest CT reveals minimal pleural effusion in both lungs.", + "Considering the significant improvement in the patient’s condition, the patient was discharged on the twenty-fourth day of admission.", + "We have conducted long-term follow-up of the patient.", + "The prognosis is favorable.", + "Repeated measurements indicate normal lipid levels." + ], + "summary": "We present a case report of a female patient who developed fat overload syndrome following prolonged and excessive infusion of lipid emulsion after colon resection surgery. In the setting of compromised immune function and malnutrition, the patient's pulmonary infection and respiratory distress symptoms have further exacerbated. Hence, in addition to severe pancreatitis, the patient has also contracted severe pneumonia. Upon admission, tracheal intubation, plasma exchange and blood perfusion were performed. Subsequently, comprehensive treatment was provided, including anti-infection, antispasmodic, acid suppression, enzyme inhibition, as well as targeted supportive measures to stabilize electrolytes and nutritional status. After treatment, there was a progressive reduction in blood lipid levels. After assessing the relevant risks, it was deemed necessary to perform an emergency computed tomography (CT)-guided percutaneous drainage tube placement procedure targeting the necrotic area of the pancreas while the patient was still intubated. Finally, the patient was discharged from the hospital.", + "summary_subclaims": [ + "The patient is female.", + "The patient developed fat overload syndrome.", + "The fat overload syndrome occurred following prolonged and excessive infusion of lipid emulsion.", + "The lipid emulsion infusion occurred after colon resection surgery.", + "The patient had compromised immune function.", + "The patient had malnutrition.", + "The patient's pulmonary infection and respiratory distress symptoms have further exacerbated.", + "The patient has severe pancreatitis.", + "The patient has severe pneumonia.", + "Upon admission, tracheal intubation was performed.", + "Upon admission, plasma exchange was performed.", + "Upon admission, blood perfusion was performed.", + "Comprehensive treatment included anti-infection.", + "Comprehensive treatment included antispasmodic.", + "Comprehensive treatment included acid suppression.", + "Comprehensive treatment included enzyme inhibition.", + "Comprehensive treatment included targeted supportive measures to stabilize electrolytes.", + "Comprehensive treatment included targeted supportive measures to stabilize nutritional status.", + "There was a progressive reduction in blood lipid levels after treatment.", + "It was deemed necessary to perform an emergency CT-guided percutaneous drainage tube placement procedure.", + "The CT-guided procedure targeted the necrotic area of the pancreas.", + "The procedure was performed while the patient was still intubated.", + "The patient was discharged from the hospital." + ] + }, + { + "id": "multiclinsum_test_2008_en.txt", + "fulltext": "A 32-year-old woman, gravida 2 and para1, withregular menstruation, detected a small lump of 2 × 1.5 cm in her left breast upon self-examination in July 2010. The breast ultrasound confirmed the presence of a 1.8 × 1.2 cm lump of low echo-levels in August 2010. In January 2011, the position emission tomography-computer tomography (PET-CT) of the whole body revealed that there were metabolism-elevating occupying lesions in the left breast, left kidney, and two lungs. Computed tomography (CT) confirmed the occupying lesions in the lung and left kidney . The core needle biopsy in the left breast was performed, but no cancer cells were detected. The levels of human chorionic gonadotropin (HCG) was 22,931 U/L (normal values: 0–5 U/L). In February 2011, the breast excisional biopsy was performed and a diagnosis of breast infiltrating ductal carcinoma was made. In the chemotherapy regimen, one cycle was 21 days. Two cycles of docetaxel (75 mg/m2, once per cycle) combined with epirubicin (75 mg/m2, once per cycle) reduced the lesions in the lungs and kidney and the HCG level (5,773 U/L at the end of the first cycle but 9,026 U/L at the end of the second cycle), while new lesions appeared in the lungs. The chemotherapy regimen was then changed to two cycles of docetaxel (75 mg/m2, once per cycle) and cisplatin (75 mg/m2, once per cycle), and the lesions in the lungs remained stable; the HCG level continued to decrease to 1,490 U/L at the end of the regimen. During this regimen, resection of the left kidney was performed due to rupture and bleeding. The left kidney excisional biopsy was also performed and a diagnosis of high-level infiltrating renal carcinoma (breast cancer metastatic to the kidney) was made. The chemotherapy regimen was changed to one cycle of docetaxel (75 mg/m2, once per cycle) and lobaplatin (35 mg/m2, once per cycle), and the HCG level continued to decrease to 57.86 U/L at the end of the regimen. Due to the severe marrow depression of docetaxel and lobaplatin, the chemotherapy regimen was changed to three cycles of docetaxel (75 mg/m2, once per cycle) and capecitabine (2 g/m2) (one cycle means once-daily administration for 2 weeks followed by 1 week of rest). At the end of the regimen, the HCG level continued to decrease to 17.64 U/L and the lesions in the lungs remained stable. A single capecitabine was then used instead of docetaxel and capecitabine. After two cycles of capecitabine (2 g/m2, one cycle means once-daily administration for 2 weeks followed by 1 week of rest), the HCG level continued to decrease to 0.12 U/L as didthe lesions in the lungs. The excised breast cancer and breast cancer metastatic to the kidney were retrospectively analyzed using HCG immunohistochemistry (IHC) staining. The IHC results demonstrated that all the cancer cells strongly expressed HCG, and the final pathological diagnosis was corrected to BCCF and BCCF metastatic to the kidney . After a further 9 cycles of capecitabine (2 g/m2, one cycle means once-daily administration for 2 weeks followed by 1 week of rest), the HCG level returned to normal values and the lesions in the lungs disappeared . At this time, the patient was still alive (the survival was 37 months), and was undergoing her 26th cycle of capecitabine (2 g/m2, one cycle means once-daily administration for 2 weeks followed by 1 week of rest) with no additional treatment.\nGrossly, the left breast of the patient was normal and BCCF did not protrude through the skin surface. The BCCF was 3.2 × 3.2 × 1.8 cm in size, and was a solid, well-circumscribed, and dark red mass, with extensive necrosis and hemorrhage in the lesion. The BCCF metastatic to the kidney was 5 × 3.5 × 2 cm in size, and was a solid, well-circumscribed, and chromatic mass, with extensive necrosis and hemorrhage in the lesion.Histologically, the BCCF showed well-demarcated borders with extensive hemorrhage, and no infiltrating ductal carcinoma and ductal carcinoma in situ could be found . At high magnification, a sheet-like arrangement of oval-shaped epithelial cells with prominent nucleoli was seen. Multinucleated giant cells with oval nuclei, prominent multiple nucleoli, and irregular chromatin clumping resembling syncytiotrophoblastic cells could also be seen . The BCCF metastatic to the kidney showed a very similar pattern in histology . The cancer (presented as a thin border of intact choriocarcinoma) was well-circumscribed and cystic, surrounded by normal renal tissue, with extensive hemorrhage around it . In the background of hemorrhage, giant cells with prominent pleomorphic nuclei, and abundant acidophilic and vacuolated cytoplasm resembling cytotrophoblastic cells could be seen . In all, the BCCF and BCCF metastatic to the kidney were made up of proliferation of large sized cells with high nucleus/cytoplasm ratio and increased nuclear chromatin. Multinucleated or mononucleated giant cells resembling syncytiotrophoblastic and cytotrophoblastic cells could be seen. This finding was similar to choriocarcinoma originating from genital tract. No subtypes of breast infiltrating ductal carcinoma or ductal carcinoma were identified in the cancer. No lymphovascular invasion was identified.\nIHC staining was performed on paraffin-embedded tissue sections, using a standard avidin-biotin-peroxidase complex method. The IHC staining demonstrated that all the cancer cells strongly expressed HCG in the BCCF and BCCF metastatic to the kidney . In BCCF, other IHC markers were described as follows: HER-1 (++); HER-2 (-); p53(-); Cyclin D1 (-); ER (-); Ki-67 (+ >75%); PR (-); Top-IIα (+50% to 75%); p120 (++); CK5 (-); CK7 (+); CK20 (-); CK (+); EMA (+); and GCDFP-15 (+). In BCCF metastatic to the kidney, other IHC markers were described as follows: HER-2 (-); ER (-); Ki-67 (+ >75%); PR (-); CK (+); CK7 (+); CK20 (-); EMA (+); p63 (-); Vimentin (-), and PLAP (-).\nAccording to the IHC study findings, the diagnosis of BCCF and BCCF metastatic to the kidney was confirmed.", + "fulltext_subclaims": [ + "The patient is a 32-year-old woman, gravida 2 and para1.", + "The patient detected a small lump of 2 × 1.5 cm in her left breast upon self-examination in July 2010.", + "The breast ultrasound confirmed the presence of a 1.8 × 1.2 cm lump of low echo-levels in August 2010.", + "The PET-CT of the whole body in January 2011 revealed metabolism-elevating occupying lesions in the left breast, left kidney, and two lungs.", + "Computed tomography confirmed the occupying lesions in the lung and left kidney.", + "The core needle biopsy in the left breast was performed, but no cancer cells were detected.", + "The levels of human chorionic gonadotropin (HCG) were 22,931 U/L.", + "In February 2011, the breast excisional biopsy was performed and a diagnosis of breast infiltrating ductal carcinoma was made.", + "Two cycles of docetaxel combined with epirubicin reduced the lesions in the lungs and kidney and the HCG level.", + "New lesions appeared in the lungs after two cycles of docetaxel combined with epirubicin.", + "The chemotherapy regimen was changed to two cycles of docetaxel and cisplatin.", + "The lesions in the lungs remained stable after two cycles of docetaxel and cisplatin.", + "The HCG level continued to decrease to 1,490 U/L at the end of the docetaxel and cisplatin regimen.", + "The left kidney was resected due to rupture and bleeding.", + "The left kidney excisional biopsy was performed and a diagnosis of high-level infiltrating renal carcinoma (breast cancer metastatic to the kidney) was made.", + "The chemotherapy regimen was changed to one cycle of docetaxel and lobaplatin.", + "The HCG level continued to decrease to 57.86 U/L at the end of the docetaxel and lobaplatin regimen.", + "The chemotherapy regimen was changed to three cycles of docetaxel and capecitabine.", + "At the end of the docetaxel and capecitabine regimen, the HCG level continued to decrease to 17.64 U/L.", + "The lesions in the lungs remained stable at the end of the docetaxel and capecitabine regimen.", + "A single capecitabine was then used instead of docetaxel and capecitabine.", + "After two cycles of capecitabine, the HCG level continued to decrease to 0.12 U/L.", + "The lesions in the lungs continued to decrease after two cycles of capecitabine.", + "The excised breast cancer and breast cancer metastatic to the kidney were retrospectively analyzed using HCG immunohistochemistry (IHC) staining.", + "The IHC results demonstrated that all the cancer cells strongly expressed HCG.", + "The final pathological diagnosis was corrected to BCCF and BCCF metastatic to the kidney.", + "After a further 9 cycles of capecitabine, the HCG level returned to normal values.", + "The lesions in the lungs disappeared after a further 9 cycles of capecitabine.", + "At this time, the patient was still alive (the survival was 37 months).", + "The patient was undergoing her 26th cycle of capecitabine.", + "The BCCF was 3.2 × 3.2 × 1.8 cm in size.", + "The BCCF was a solid, well-circumscribed, and dark red mass.", + "The BCCF showed well-demarcated borders with extensive hemorrhage.", + "No infiltrating ductal carcinoma and ductal carcinoma in situ could be found in the BCCF.", + "At high magnification, a sheet-like arrangement of oval-shaped epithelial cells with prominent nucleoli was seen.", + "Multinucleated giant cells with oval nuclei, prominent multiple nucleoli, and irregular chromatin clumping resembling syncytiotrophoblastic cells could also be seen.", + "The BCCF metastatic to the kidney showed a very similar pattern in histology.", + "The cancer was well-circumscribed and cystic, surrounded by normal renal tissue.", + "In the background of hemorrhage, giant cells with prominent pleomorphic nuclei, and abundant acidophilic and vacuolated cytoplasm resembling cytotrophoblastic cells could be seen.", + "In all, the BCCF and BCCF metastatic to the kidney were made up of proliferation of large sized cells with high nucleus/cytoplasm ratio and increased nuclear chromatin.", + "Multinucleated or mononucleated giant cells resembling syncytiotrophoblastic and cytotrophoblastic cells could be seen.", + "This finding was similar to choriocarcinoma originating from the genital tract.", + "No subtypes of breast infiltrating ductal carcinoma or ductal carcinoma were identified in the cancer.", + "No lymphovascular invasion was identified.", + "The IHC staining demonstrated that all the cancer cells strongly expressed HCG in the BCCF and BCCF metastatic to the kidney.", + "In BCCF, HER-1 was (++); HER-2 was (-); p53 was (-); Cyclin D1 was (-); ER was (-); Ki-67 was (+ >75%); PR was (-); Top-IIα was (+50% to 75%); p120 was (++); CK5 was (-); CK7 was (+); CK20 was (-); CK was (+); EMA was (+); and GCDFP-15 was (+).", + "In BCCF metastatic to the kidney, HER-2 was (-); ER was (-); Ki-67 was (+ >75%); PR was (-); CK was (+); CK7 was (+); CK20 was (-); EMA was (+); p63 was (-); Vimentin was (-), and PLAP was (-).", + "According to the IHC study findings, the diagnosis of BCCF and BCCF metastatic to the kidney was confirmed." + ], + "summary": "A 32-year-old female patient presented with a small lump in her left breast 3 years prior. The mass was clinically suspected to be breast infiltrating ductal carcinoma based on breast excisional biopsy and magnetic resonance imaging findings. Due to rupture and bleeding of the left kidney, the left kidney excisional biopsy was performed. After a retrospective analysis of the initial excised breast cancer and breast cancer metastatic to the kidney, the cancer cells were positive for HCG by immunohistochemistry, and multinucleated or mononucleated giant cells resembled syncytiotrophoblastic and cytotrophoblastic cells which could be seen in a background of poor differentiated breast carcinoma and extensive necrosis and hemorrhage in the lesion. Thus, a final diagnosis of BCCF and BCCF metastatic to the kidney was made. After combination of surgical resection (the affected left breast and left kidney wereremoved) and consecutive chemotherapy consisting of docetaxel, epirubicin, cisplatin, lobaplatin, and capecitabine, the patient achieved favorable therapeutic efficacy (the HCG level returned to normal values, the metastatic lesions in the lungs disappeared, and the survival was 37 months). Capecitabine was very efficient and highly recommended due to its superior efficacy in reducing the HCG level and eliminating the metastatic lesions in the lungs.", + "summary_subclaims": [ + "A 32-year-old female patient presented with a small lump in her left breast 3 years prior.", + "The mass was clinically suspected to be breast infiltrating ductal carcinoma based on breast excisional biopsy and magnetic resonance imaging findings.", + "Due to rupture and bleeding of the left kidney, the left kidney excisional biopsy was performed.", + "After a retrospective analysis of the initial excised breast cancer and breast cancer metastatic to the kidney, the cancer cells were positive for HCG by immunohistochemistry.", + "Multinucleated or mononucleated giant cells resembled syncytiotrophoblastic and cytotrophoblastic cells.", + "The giant cells could be seen in a background of poor differentiated breast carcinoma.", + "The lesion showed extensive necrosis and hemorrhage.", + "A final diagnosis of BCCF and BCCF metastatic to the kidney was made.", + "Surgical resection of the affected left breast and left kidney was performed.", + "Consecutive chemotherapy consisting of docetaxel, epirubicin, cisplatin, lobaplatin, and capecitabine was administered.", + "The patient achieved favorable therapeutic efficacy.", + "The HCG level returned to normal values.", + "The metastatic lesions in the lungs disappeared.", + "The survival was 37 months.", + "Capecitabine was very efficient and highly recommended due to its superior efficacy in reducing the HCG level and eliminating the metastatic lesions in the lungs." + ] + }, + { + "id": "multiclinsum_test_782_en.txt", + "fulltext": "A 34-year-old man received proton-beam radiation therapy in 2003 for a 17.0 × 14.0 × 10.5 mm melanoma involving the left choroid and ciliary body. He was treated with proton-beam therapy to a dose of 70 Cobalt Gray Equivalent, in five fractions, over 10 days. In 2017, the patient was in a motor vehicle accident, which resulted in rupture of his left globe. He underwent enucleation of the left globe and was found to have recurrent melanoma. The patient healed well from surgery and a left eye prosthesis was fitted. However, over the next 9 months the patient reported that the prosthesis became progressively displaced and increasingly painful to wear. A diagnostic CT revealed a heterogeneous lobular soft tissue mass in the anterior and inferior left orbit measuring 27.0 × 26.0 × 19.0 mm. He underwent salvage left orbital exenteration in March 2018. Surgical pathology confirmed multiple recurrent melanoma with a positive inferior-medial surgical margin. Restaging imaging revealed no evidence of metastatic disease and he was referred for consideration of re-irradiation.\nWritten informed consent was obtained from the patient for publication of this case report and accompanying images.\nAn applicator for HDR brachytherapy was designed in the AutoCAD Inventor Suite (Autodesk, San Rafael, CA) based on the latest diagnostic CT. DICOM structures were converted into stereolithography files using 3DSlicer . The primary contours of interest were the patient’s surface and the PTV. The patient surface was used to generate an applicator with a flush fit against the left orbital cavity and a protruding horizontal surface 10.0 mm anteriorly from the supraorbital ridge. Support wings with a thickness of 5.0 mm were designed to extend superiorly and inferiorly by 15.0 mm and laterally by 60.0 mm. The wings were designed to be flush against the patient’s skin in order to provide a stable and reproducible fit.\nThe involved left orbital surfaces, including the residual mucosa and soft tissue abutting the mass found on pre-operative imaging and the sites with positive margins, were contoured as the clinical target volume (CTV; Volume ~ 4.0 cm3) and radially expanded by 2.0 mm to generate a PTV. The PTV was used to devise channels that allowed for access and sufficient coverage of the target with the Ir-192 HDR source. The channels were constructed to fit an endobronchial HDR source guide tube with an outer diameter of 2.0 mm (Varian Medical Systems, Palo Alto, CA). While considering the size of the orbital cavity and the distance of the PTV to the cavity surface, it was found that sufficient target access would be provided when all channels were tilted 15° toward the patient’s right and 10° superiorly. For the most superior channel, patient anatomy did not allow for the 10° tilt. Under these constraints, the applicator was designed with 16 channels of varying length, ranging from 46.0 mm to 63.0 mm. The channels were organized in two rectilinear groups to minimize applicator size. The distance between the centers of the channels in each group was 9.0 mm. The tip of the channels, corresponding to the location of the first possible dwell position, was chosen to be at 5.0 mm from the surface of the orbital cavity. Figure shows the applicator geometry overlaid on patient anatomy. The material for printing the applicator, an acrylic photopolymer (Polymerized TangoPlus and Agilus30 Family, Stratasys Ltd., Eden Prairie, MN), was selected based on similarity with the biomechanical properties of human skin , specifically using tensile strength and shore hardness. Note that these materials are not approved per the International Standard ISO-10993-1 as a biocompatible material. The applicator was covered in a sterile wrap to prevent any contact with patient skin. Given the flexibility of this material, a solid sheath with a thickness of 2.0 mm was designed as an outer support-wall for each channel to prevent bending or accidental puncturing of the surface of the applicator. The assembly was created using a J750 PolyJet 3D printer (Stratasys Ltd., Eden Prairie, MN) which allows for simultaneous printing of materials with varying physical properties. The primary applicator was designed as 80/20% mixing of polymers in the Agilus30/TangoPlus family; the sheath was 80/20% mixing of TangoPlus/Agilus30. Print time was approximately 20 h, while cost was approximately 400$. Figure presents the design of the applicator and a model of the channel sheath. Photographs of the final 3D printed applicator are provided in the appendix Figure A. Prior to use in the patient, the applicator was imaged with a helical CT scanner (120kVp, 1.0 mm3 isotropic voxels). The mean Hounsfield unit (HU) values were measured in a large region-of-interest in the applicator and found to be (mean ± std.dev.) 85 ± 11 HU, comparable to tissue-equivalent media. While previous research has highlighted the limitations of HU values in modeling the radiation interactions of 3D printed materials , the work of Baltz et al. has shown Agilus to be a reasonable tissue equivalent material based on CT and percent depth dose measurements .\nAt the time of treatment simulation, the patient was immobilized supine with a custom thermoplastic mask and head holder. Serial axial CT images were obtained for treatment planning after placing the patient-specific applicator, covered in a plastic and sterile latex wrap, inside the left orbital cavity and securing it using self-adherent wrap. Figure A in the appendix shows the applicator inside the orbit at time of CT simulation. Treatment planning and dose calculation were performed in the Brachytherapy Planning module of Eclipse (Varian Medical Systems, Palo Alto, CA) based on the AAPM TG-43 formalism, using Ir-192 at a nominal source strength of 10 Ci. The planned prescription was 3400 cGy, to be delivered in 10 fractions, twice daily, over five consecutive days . Figure shows the dose-volume histogram for the PTV, orbit bones, right eye, right lens, and brain.\nAn end-to-end dosimetric test was designed to determine feasibility for clinical use. Two calibrated pairs of optically stimulated luminesce dosimeters (OSLDs) were firmly placed on the surface of the applicator at two locations representing dose to PTV and another high-resolution CT was acquired. The clinical HDR plan was transferred to the CT containing the OSLDs in order to calculate the mean dose to the dosimeters. Figure A shows the registration between the CT of the applicator and the patient HDR plan. The applicator was then immersed in a water-filled container to mimic scattering conditions, and the clinical HDR plan was delivered. In the two sampled positions on the surface of the applicator, the mean difference in measured and calculated dose was 12% and 18%. For this setup, the standard error of the mean is equal to 50% of the standard deviation. This dose difference is in the range of published uncertainties for in vivo dosimetry in HDR brachytherapy [, ]. Finally, all ten fractions of the clinical HDR plan were consecutively delivered, amounting to a dose of at least 300 Gy to the surface of the applicator, and the applicator was monitored for structural damage. No damage was found over the course of 2 weeks.\nA second CT simulation scan was obtained without the brachytherapy applicator for the purpose of generating an alternative stereotactic body radiotherapy (SBRT) plan. The orbital air density was assigned to water (i.e., 0 HU) in the treatment planning system to simulate a fluid filled cavity. A 4-arc volumetric modulated arc therapy plan with 6MV photons, utilizing superiorly oriented non-coplanar beams to avoid entry or exit into the contralateral eye, was created in Eclipse version 13.6 (Varian Medical Systems, Palo Alto, CA). The prescription dose was 2500 cGy, in 5 daily fractions.\nAlthough most of the previously irradiated soft tissue was resected, the patient was consented for osteoradionecrosis and non-healing wounds. He was treated with SBRT instead of brachytherapy because the 3D printed material was not approved for biocompatibility and because filling the orbital cavity with sterile saline provided a reproducible bolus with fewer air gaps. While the surface of the applicator was generally flush with the orbit, we observe a maximum airgap of approximately 8.0 mm, comparable to previously published values . This is illustrated in Figure A in the appendix which shows two slices from the CT of the patient fitted with the applicator. To confirm consistency with treatment planning, daily cone-beam CT was performed after filling the orbit with sterile saline.", + "fulltext_subclaims": [ + "The patient was a 34-year-old man.", + "He received proton-beam radiation therapy in 2003.", + "The melanoma measured 17.0 × 14.0 × 10.5 mm.", + "The melanoma involved the left choroid and ciliary body.", + "He was treated with proton-beam therapy to a dose of 70 Cobalt Gray Equivalent.", + "The treatment was delivered in five fractions.", + "The treatment was delivered over 10 days.", + "In 2017, the patient was in a motor vehicle accident.", + "The motor vehicle accident resulted in rupture of his left globe.", + "He underwent enucleation of the left globe.", + "He was found to have recurrent melanoma.", + "He healed well from surgery.", + "A left eye prosthesis was fitted.", + "Over the next 9 months, the prosthesis became progressively displaced.", + "Over the next 9 months, the prosthesis became increasingly painful to wear.", + "A diagnostic CT revealed a heterogeneous lobular soft tissue mass.", + "The mass was in the anterior and inferior left orbit.", + "The mass measured 27.0 × 26.0 × 19.0 mm.", + "He underwent salvage left orbital exenteration in March 2018.", + "Surgical pathology confirmed multiple recurrent melanoma.", + "The surgical margin was positive inferior-medially.", + "Restaging imaging revealed no evidence of metastatic disease.", + "He was referred for consideration of re-irradiation.", + "Written informed consent was obtained from the patient.", + "An applicator for HDR brachytherapy was designed in the AutoCAD Inventor Suite.", + "DICOM structures were converted into stereolithography files using 3DSlicer.", + "The primary contours of interest were the patient’s surface and the PTV.", + "The patient surface was used to generate an applicator with a flush fit against the left orbital cavity.", + "The applicator had a protruding horizontal surface 10.0 mm anteriorly from the supraorbital ridge.", + "Support wings with a thickness of 5.0 mm were designed.", + "The wings extended superiorly and inferiorly by 15.0 mm.", + "The wings extended laterally by 60.0 mm.", + "The wings were designed to be flush against the patient’s skin.", + "The involved left orbital surfaces were contoured as the clinical target volume (CTV).", + "The CTV volume was approximately 4.0 cm3.", + "The CTV was radially expanded by 2.0 mm to generate a PTV.", + "The PTV was used to devise channels for the Ir-192 HDR source.", + "The channels were constructed to fit an endobronchial HDR source guide tube.", + "The guide tube had an outer diameter of 2.0 mm.", + "The channels were tilted 15° toward the patient’s right.", + "The channels were tilted 10° superiorly.", + "The most superior channel could not be tilted 10° due to patient anatomy.", + "The applicator was designed with 16 channels of varying length.", + "The channel lengths ranged from 46.0 mm to 63.0 mm.", + "The channels were organized in two rectilinear groups.", + "The distance between the centers of the channels in each group was 9.0 mm.", + "The tip of the channels was 5.0 mm from the surface of the orbital cavity.", + "The material for printing the applicator was an acrylic photopolymer.", + "The material was selected based on similarity with the biomechanical properties of human skin.", + "The material was not approved per the International Standard ISO-10993-1 as a biocompatible material.", + "The applicator was covered in a sterile wrap.", + "A solid sheath with a thickness of 2.0 mm was designed for each channel.", + "The sheath was designed to prevent bending or accidental puncturing.", + "The assembly was created using a J750 PolyJet 3D printer.", + "The primary applicator was 80/20% mixing of polymers in the Agilus30/TangoPlus family.", + "The sheath was 80/20% mixing of TangoPlus/Agilus30.", + "Print time was approximately 20 hours.", + "The cost was approximately 400 dollars.", + "The applicator was imaged with a helical CT scanner.", + "The CT scanner used 120kVp and 1.0 mm3 isotropic voxels.", + "The mean Hounsfield unit (HU) values were 85 ± 11 HU.", + "The HU values were comparable to tissue-equivalent media.", + "The patient was immobilized supine with a custom thermoplastic mask.", + "The patient was immobilized with a head holder.", + "Serial axial CT images were obtained for treatment planning.", + "The patient-specific applicator was placed inside the left orbital cavity.", + "The applicator was covered in a plastic and sterile latex wrap.", + "The applicator was secured using self-adherent wrap.", + "Treatment planning was performed in the Brachytherapy Planning module of Eclipse.", + "The planning used the AAPM TG-43 formalism.", + "The source strength was 10 Ci.", + "The planned prescription was 3400 cGy.", + "The dose was to be delivered in 10 fractions.", + "The dose was to be delivered twice daily over five consecutive days.", + "An end-to-end dosimetric test was designed.", + "Two calibrated pairs of optically stimulated luminesce dosimeters were placed on the applicator.", + "The applicator was immersed in a water-filled container.", + "The clinical HDR plan was delivered.", + "The mean difference in measured and calculated dose was 12% and 18%.", + "The dose difference was in the range of published uncertainties.", + "All ten fractions of the clinical HDR plan were consecutively delivered.", + "The applicator was monitored for structural damage.", + "No damage was found over the course of 2 weeks.", + "A second CT simulation scan was obtained without the brachytherapy applicator.", + "The orbital air density was assigned to water (0 HU).", + "A 4-arc volumetric modulated arc therapy plan was created.", + "The plan used 6MV photons.", + "The prescription dose was 2500 cGy.", + "The dose was delivered in 5 daily fractions.", + "The patient was treated with SBRT instead of brachytherapy.", + "The 3D printed material was not approved for biocompatibility.", + "Filling the orbital cavity with sterile saline provided a reproducible bolus.", + "The maximum airgap was approximately 8.0 mm.", + "Daily cone-beam CT was performed after filling the orbit with sterile saline." + ], + "summary": "A 34-year-old man with recurrent melanoma of the orbit was referred for consideration of re-irradiation. An applicator for HDR brachytherapy was designed based on the computed tomography (CT) of patient anatomy. The body contour was used to generate an applicator with a flush fit against the patient's skin while the planning target volume (PTV) was used to devise channels that allow for access and coverage of the tumor bed. An end-to-end dosimetric test was devised to determine feasibility for clinical use. The applicator was designed to conform to the volume and contours inside the orbital cavity. Support wings placed flush with the patient skin provided stability and reproducibility, while 16 source channels of varying length were needed for sufficient access to the target. A solid sheath, printed as an outer support-wall for each channel, prevented bending or accidental puncturing of the surface of the applicator.", + "summary_subclaims": [ + "The patient is a 34-year-old man.", + "The patient has recurrent melanoma of the orbit.", + "The patient was referred for consideration of re-irradiation.", + "An applicator for HDR brachytherapy was designed based on the computed tomography of patient anatomy.", + "The body contour was used to generate an applicator with a flush fit against the patient's skin.", + "The planning target volume was used to devise channels that allow for access and coverage of the tumor bed.", + "An end-to-end dosimetric test was devised to determine feasibility for clinical use.", + "The applicator was designed to conform to the volume and contours inside the orbital cavity.", + "Support wings placed flush with the patient skin provided stability and reproducibility.", + "Sixteen source channels of varying length were needed for sufficient access to the target.", + "A solid sheath, printed as an outer support-wall for each channel, prevented bending or accidental puncturing of the surface of the applicator." + ] + }, + { + "id": "multiclinsum_test_549_en.txt", + "fulltext": "A 60 year old Caucasian gentleman with rheumatoid arthritis on infliximab therapy for one year presented with acute onset palpitations. Which started within three hours after receiving the eight weekly infliximab infusion for his rheumatoid arthritis. There was no past medical history of diabtes mellitus, ischemic heart disease, hypertension or heart failure. He has never smoked cigarettes and there was no history of alcohol or illicit drug use. He had no known drug or food allergies. His medical therapy on admission included azathioprine, prednisolone, diclofenac, omeprazole, Dihydrocodeine, paracetamol, salbutamol inhaler and eight weekly Infliximab infusions.\nOn examination he was tachycardic at 168 beats per minute. Blood pressure was 110/90 and respiratory rate of 16 per minute; oxygen saturation was 99% on room air. Systemic examination was unremarkable. The electrocardiogram showed a supraventricular tachycardia (SVT), which reverted rapidly to sinus rhythm with intravenous adenosine therapy (9 milligrams). His complete blood count, cardiac enzymes, troponinI, serum electrolytes, renal functions and liver enzymes all were normal. Chest X-ray did not show any evidence of cardiomegaly or pulmonary congestion and 2-D echocardiogram revealed normal left ventricular systolic and diastolic functions.", + "fulltext_subclaims": [ + "The patient is a 60 year old Caucasian gentleman.", + "The patient has rheumatoid arthritis.", + "The patient was on infliximab therapy for one year.", + "The patient presented with acute onset palpitations.", + "The palpitations started within three hours after receiving the eight weekly infliximab infusion.", + "The patient had no past medical history of diabetes mellitus.", + "The patient had no past medical history of ischemic heart disease.", + "The patient had no past medical history of hypertension.", + "The patient had no past medical history of heart failure.", + "The patient had no history of cigarette smoking.", + "The patient had no history of alcohol use.", + "The patient had no history of illicit drug use.", + "The patient had no known drug or food allergies.", + "The patient's medical therapy on admission included azathioprine.", + "The patient's medical therapy on admission included prednisolone.", + "The patient's medical therapy on admission included diclofenac.", + "The patient's medical therapy on admission included omeprazole.", + "The patient's medical therapy on admission included dihydrocodeine.", + "The patient's medical therapy on admission included paracetamol.", + "The patient's medical therapy on admission included salbutamol inhaler.", + "The patient's medical therapy on admission included eight weekly infliximab infusions.", + "On examination, the patient was tachycardic at 168 beats per minute.", + "The electrocardiogram showed a supraventricular tachycardia.", + "The supraventricular tachycardia reverted rapidly to sinus rhythm with intravenous adenosine therapy.", + "The intravenous adenosine therapy was 9 milligrams.", + "The complete blood count was normal.", + "The cardiac enzymes were normal.", + "The troponin I was normal.", + "The serum electrolytes were normal.", + "The renal functions were normal.", + "The liver enzymes were normal.", + "The chest X-ray did not show any evidence of cardiomegaly.", + "The chest X-ray did not show any evidence of pulmonary congestion.", + "The 2-D echocardiogram revealed normal left ventricular systolic function.", + "The 2-D echocardiogram revealed normal left ventricular diastolic function." + ], + "summary": "We report the case of a supraventricular tachycardia that occurred within three hours of Infliximab infusion in a patient with rheumatoid arthritis.", + "summary_subclaims": [ + "A supraventricular tachycardia occurred within three hours of Infliximab infusion.", + "The patient had rheumatoid arthritis." + ] + }, + { + "id": "multiclinsum_test_2454_en.txt", + "fulltext": "A 12-year-old female has presented to the clinic with the history of early-onset scoliosis and progressive deformity for 6 months. She underwent deformity correction surgery with spinal loop rectangle and sublaminar wires 4 years ago. On examination, patient was decompensating in coronal and sagittal plane. Neurological examination was within normal limits. Standing anteroposterior and lateral radiograph revealed failed implant with progression of deformity. Cobb’s angle was 64° at presentation. The patient underwent implant removal and revision deformity correction surgery with pedicle screw-rod system simultaneously. The patient-specific 3D-printed pedicle screw templates were used for safe pedicle screw placement. These templates are manufactured by 3D printing technology using CAD files but in a sequential manner . In the first step, images were acquired using multidetector computed tomography(CT) scan and a 3D image of patient’s vertebral column was created. Computer software was used to convert digital imaging and communications in medicine (DICOM) images to 3D model of spine. This software was Mimics Innovation Suite®, Materialise, Belgium (Mimics Medical and 3-Matic Medical 11). DICOM data of the patient’s CT scan were imported into Mimics Medical 19. On initial examination of 3D model, it was asserted necessary to separate the vertebral column from the residual implant. This was done initially by segmenting the bone and implant using different respective threshold values. Next, further segmentation was done manually to eliminate the artifacts caused by stainless steel spinal rectangle loop and sublaminar wires. The implant and vertebral column were then imported into 3-Matic Medical 11 software and were used as base data to manufacture pediclelocating guides for each vertebra, using various CAD tools available in the software. Biomedical engineer and surgeon together differentiated metal artifacts and bone defects so as to make templates with maximum bone contact surface possible. The final 3D-printed model of spine and the design of templates are illustrated. These templates were manufactured using polyurethane material. Hence, they could be sterilized and used intraoperatively for creating the tract for appropriate placement of pedicle screws as bony landmarks for putting pedicle screws by free-hand technique were obscured. Placement of pedicle screws was assessed postoperatively on CT scan. illustrates the pre-operative and post-operative radiographs of a patient.", + "fulltext_subclaims": [ + "The patient is a 12-year-old female.", + "She has a history of early-onset scoliosis.", + "She has had progressive deformity for 6 months.", + "She underwent deformity correction surgery with spinal loop rectangle and sublaminar wires 4 years ago.", + "On examination, the patient was decompensating in coronal and sagittal plane.", + "Neurological examination was within normal limits.", + "Standing anteroposterior and lateral radiograph revealed failed implant with progression of deformity.", + "Cobb’s angle was 64° at presentation.", + "The patient underwent implant removal and revision deformity correction surgery with pedicle screw-rod system simultaneously.", + "Patient-specific 3D-printed pedicle screw templates were used for safe pedicle screw placement.", + "These templates are manufactured by 3D printing technology using CAD files but in a sequential manner.", + "Images were acquired using multidetector computed tomography (CT) scan.", + "A 3D image of the patient’s vertebral column was created.", + "Computer software was used to convert digital imaging and communications in medicine (DICOM) images to 3D model of spine.", + "This software was Mimics Innovation Suite®, Materialise, Belgium (Mimics Medical and 3-Matic Medical 11).", + "DICOM data of the patient’s CT scan were imported into Mimics Medical 19.", + "On initial examination of 3D model, it was asserted necessary to separate the vertebral column from the residual implant.", + "This was done initially by segmenting the bone and implant using different respective threshold values.", + "Next, further segmentation was done manually to eliminate the artifacts caused by stainless steel spinal rectangle loop and sublaminar wires.", + "The implant and vertebral column were then imported into 3-Matic Medical 11 software.", + "These were used as base data to manufacture pediclelocating guides for each vertebra.", + "Biomedical engineer and surgeon together differentiated metal artifacts and bone defects.", + "The final 3D-printed model of spine and the design of templates are illustrated.", + "These templates were manufactured using polyurethane material.", + "Hence, they could be sterilized and used intraoperatively for creating the tract for appropriate placement of pedicle screws.", + "Placement of pedicle screws was assessed postoperatively on CT scan." + ], + "summary": "A 12-year-old female presented to the clinic with a history of early-onset scoliosis, for which she underwent deformity correction surgery with spinal rectangle loop and sublaminar wires 4 years ago. At presentation, she had decompensated with increase in deformity and failed implant. She underwent revision deformity correction surgery with pedicle screws. 3D-printed patient-specific pedicle screw templates were useful in this patient for appropriate pedicle screw placement, as patient had obscured native anatomy due to fusion mass and in situ sublaminar wires.", + "summary_subclaims": [ + "The patient is a 12-year-old female.", + "The patient had early-onset scoliosis.", + "The patient underwent deformity correction surgery with spinal rectangle loop and sublaminar wires 4 years ago.", + "At presentation, the patient had decompensated with increase in deformity.", + "At presentation, the patient had a failed implant.", + "The patient underwent revision deformity correction surgery with pedicle screws.", + "3D-printed patient-specific pedicle screw templates were useful in this patient.", + "The patient had obscured native anatomy due to fusion mass.", + "The patient had obscured native anatomy due to in situ sublaminar wires." + ] + }, + { + "id": "multiclinsum_test_1408_en.txt", + "fulltext": "A 50-year-old female presented to the emergency department at the onset of acute severe chest and upper back pain. Her medical history consisted of controlled stage II hypertension, treated with losartan. No other comorbidities were present. Laboratory testing showed normal kidney functions. Blood pressure was 170/90 mmHg at presentation.\nSubsequent diagnostic contrast-enhanced computed tomography (CT) revealed a type B aortic dissection (TBAD) that extended from the left subclavian artery (LSA) to the right common iliac artery (RCIA) . Only the right renal artery (RRA) originated from the false lumen. The maximum compression was at T5 level, where the true lumen was compressed to less than 10% of the total diameter .\nDespite primary medical treatment with intravenous metoprolol and sodium nitroprusside and oral beta blockers controlling the blood pressure, the patient’s symptoms did not improve. Because of her persistent back pain over 4 days, invasive treatment was deemed necessary. Moreover, due to the involvement of the visceral aorta into the dissection, it was deemed necessary to treat the dissected aorta extensively. As the site was located in the Brazilian state of Tocatins, more than 2000 kilometers away from the closest vascular center, the decision was made to treat the patient locally.\nThe procedure was performed on day 4 after symptoms onset, under local anesthetic and sedation. Unilateral ultrasound-guided right femoral access was obtained by a preclose technique with two Proglide devices (Abbot Vascular, Santa Clara, California). Proper guidewire introduction and advancement in the true lumen was ensured by angiographic guidance. Through a 20 Fr sheath, two overlapping multilayer stents were implanted. To ensure a sufficient healthy landing zone and obtain adequate proximal seal, decision was made to deliver the proximal stent over the aortic arch. The open mesh structure of the multilayer stent made this possible, ensuring preserved perfusion of the supra-aortic branches.\nNo rapid pacing nor adjunctive procedure were necessary for the deployment of the stents. Angiogram at the end of the procedure showed approximation of the entry tear and total exclusion of the false lumen in front of the entry tear, with patent side branches, particularly the supra-aortic arteries, mesenteric arteries and both renal arteries. Total procedure time was 68 minutes. Less than 100 milliliters of contrast agent were administered.\nThe patient was completely asymptomatic after the procedure. She remained in the ICU (Intensive Care Unit) for 12 hours postoperatively. There were no signs of stroke or spinal cord ischemia. Postoperative kidney function tests remained normal. The next day she was discharged from the hospital in good health. Dual antiplatelet therapy (DAPT), i.e., clopidogrel and acetylsalicylic acid, were started as per our site standard practice after endovascular procedures.\nAt follow-up examinations after 6 and 12 months, the patient remained asymptomatic. Review of the CT scans confirmed that the stent had reopened the true lumen to the original aorta diameter, with stable true and false lumen diameters and volumes between 6 and 12 months. The 12-month follow-up CT scan revealed that the false lumen at the proximal end of dissection completely disappeared . Also, the maximum diameter of the false lumen significantly decreased whereas the true lumen diameter increased . All supra-aortic and visceral branches were patent .", + "fulltext_subclaims": [ + "A 50-year-old female presented to the emergency department at the onset of acute severe chest and upper back pain.", + "Her medical history consisted of controlled stage II hypertension, treated with losartan.", + "No other comorbidities were present.", + "Laboratory testing showed normal kidney functions.", + "Blood pressure was 170/90 mmHg at presentation.", + "Subsequent diagnostic contrast-enhanced computed tomography (CT) revealed a type B aortic dissection (TBAD) that extended from the left subclavian artery (LSA) to the right common iliac artery (RCIA).", + "Only the right renal artery (RRA) originated from the false lumen.", + "The maximum compression was at T5 level, where the true lumen was compressed to less than 10% of the total diameter.", + "Despite primary medical treatment with intravenous metoprolol and sodium nitroprusside and oral beta blockers controlling the blood pressure, the patient’s symptoms did not improve.", + "Because of her persistent back pain over 4 days, invasive treatment was deemed necessary.", + "Due to the involvement of the visceral aorta into the dissection, it was deemed necessary to treat the dissected aorta extensively.", + "The site was located in the Brazilian state of Tocatins, more than 2000 kilometers away from the closest vascular center.", + "The decision was made to treat the patient locally.", + "The procedure was performed on day 4 after symptoms onset, under local anesthetic and sedation.", + "Unilateral ultrasound-guided right femoral access was obtained by a preclose technique with two Proglide devices (Abbot Vascular, Santa Clara, California).", + "Proper guidewire introduction and advancement in the true lumen was ensured by angiographic guidance.", + "Through a 20 Fr sheath, two overlapping multilayer stents were implanted.", + "To ensure a sufficient healthy landing zone and obtain adequate proximal seal, decision was made to deliver the proximal stent over the aortic arch.", + "The open mesh structure of the multilayer stent made this possible, ensuring preserved perfusion of the supra-aortic branches.", + "No rapid pacing nor adjunctive procedure were necessary for the deployment of the stents.", + "Angiogram at the end of the procedure showed approximation of the entry tear and total exclusion of the false lumen in front of the entry tear, with patent side branches, particularly the supra-aortic arteries, mesenteric arteries and both renal arteries.", + "Total procedure time was 68 minutes.", + "Less than 100 milliliters of contrast agent were administered.", + "The patient was completely asymptomatic after the procedure.", + "She remained in the ICU for 12 hours postoperatively.", + "There were no signs of stroke or spinal cord ischemia.", + "Postoperative kidney function tests remained normal.", + "The next day she was discharged from the hospital in good health.", + "Dual antiplatelet therapy (DAPT), i.e., clopidogrel and acetylsalicylic acid, were started as per our site standard practice after endovascular procedures.", + "At follow-up examinations after 6 and 12 months, the patient remained asymptomatic.", + "Review of the CT scans confirmed that the stent had reopened the true lumen to the original aorta diameter, with stable true and false lumen diameters and volumes between 6 and 12 months.", + "The 12-month follow-up CT scan revealed that the false lumen at the proximal end of dissection completely disappeared.", + "The maximum diameter of the false lumen significantly decreased whereas the true lumen diameter increased.", + "All supra-aortic and visceral branches were patent." + ], + "summary": "A 50-year-old female patient presented to the emergency department with an acute type B aortic dissection. Conservative medical treatment did control blood pressure but did not alleviate her dissection symptoms. She was treated endovascularly with multilayer stents extensively covering the whole dissected area. HThe aortic arch side branches, visceral arteries and renal arteries remained patent after treatment. The recovery was uneventful, and she was discharged the day after the intervention. At 6- and 12-month follow-up, the patient remained asymptomatic, the true lumen volume increased and all side branches remained patent.", + "summary_subclaims": [ + "The patient is a 50-year-old female.", + "She presented to the emergency department with an acute type B aortic dissection.", + "Conservative medical treatment did control blood pressure.", + "Conservative medical treatment did not alleviate her dissection symptoms.", + "She was treated endovascularly with multilayer stents.", + "The multilayer stents extensively covered the whole dissected area.", + "The aortic arch side branches remained patent after treatment.", + "The visceral arteries remained patent after treatment.", + "The renal arteries remained patent after treatment.", + "The recovery was uneventful.", + "She was discharged the day after the intervention.", + "At 6- and 12-month follow-up, the patient remained asymptomatic.", + "The true lumen volume increased.", + "All side branches remained patent." + ] + }, + { + "id": "multiclinsum_test_1656_en.txt", + "fulltext": "A 34-year-old Caucasian male presented to the emergency department complaining of a 4-day history of unbearable leg pain with diffuse arthralgia, fluctuating low-grade fever with profuse sweating, vomiting and diarrhea without abdominal pain, odynophagia, dry cough, headaches, and fatigue. He denied any contact with animals or travel abroad, had not consumed unpasteurized food, and had his last unprotected sexual intercourse 4 months earlier.\nHe was taking no medications and was known for alcohol abuse (mainly beer and spirit, approximately 185 alcohol units/week), drug abuse (cocaine, ecstasy, cannabis, methylphenidate, clonazepam, lorazepam), and smoking tobacco. On physical examination, he was afebrile and hypotensive (blood pressure 94/50 mmHg) with a normal heart rate (77 beats/minute). Oral examination revealed dry mucosa and erythematous tonsils without exudate, cardiopulmonary examination was normal, abdominal palpation was unremarkable, and no cutaneous rash was noted. Testing of the lower limbs revealed preserved strength and sensitivity as well as symmetric deep tendon reflexes.\nLaboratory findings showed normocytic, normochromic, hypoproliferative anemia (hemoglobin 99 g/l, normal range 140–180 g/l) with thrombocytopenia (24 G/l, normal range 150–350 G/l), left shift without leukocytosis, elevated C-reactive protein (213 mg/l, normal range < 10 mg/l), elevated transaminases (three times the upper limit of normal) with cholestasis and elevated conjugated bilirubin (29 µmol/l on admission, 190 µmol/l on hospital day 8, normal range 0.5–9.5 µmol/l). There was a stage 3 acute kidney injury according to the Kidney Disease Improving Global Outcomes (KDIGO) criteria with a serum creatinine of 112 µmol/l on admission and 247 µmol/l on hospital day 3 (patient’s baseline value 70 µmol/l), a serum urea of 11.4 mmol/l on admission (12 mmol/l on hospital day 3), and preserved urine output. Urinalysis revealed proteinuria (spot urine: protein 1.4 g/l, creatinine 11.5 mmol/l, urine protein–creatinine ratio 1.076 g/g), albuminuria (2+ on semiquantitative analysis), presence of 97 M/l leukocytes, 25 M/l erythrocytes, and renal tubular cells (1+ on semiquantitative analysis). Sodium excretion was high (fractional excretion of sodium on spot urine 3.56%). Due to the context of sepsis, hypovolemic status of the patient, and urinalysis findings, acute tubular necrosis was the suspected mechanism of acute kidney injury.\nAnalysis of serum electrolytes showed mild hyperphosphatemia (1.53 mmol/l, normal range 0.80–1.45 mmol/l), hyponatremia (131 mmol/l, normal range 136–144 mmol/l), mild hypouricemia (246 µmol/l, normal range 286–518 µmol/l), low serum chloride (94 mmol/l, normal range 98–106 mmol/l), hypokalemia (2.8 mmol/l, normal range 3.6–4.6 mmol/l), and an anion gap of 10 mmol/l. The transtubular potassium gradient was elevated (16.4). Albumin level was 29 g/l (normal range 35–48 g/l), and creatinine kinase level was 312 U/l on admission, rising to 404 U/l the next day and normalizing on hospital day 4. Blood gas analysis showed a pH of 7.49 (normal range 7.35–7.45) with elevated bicarbonates (29.3 mmol/l, normal range 22–26 mmol/l) and normal pCO2 (5.25 kPa, normal range 4.7–6.4 kPa). Urine pH was 6 (normal range 5–6.5). Presence of glycosuria (7 mmol/l, normal range 0.1–0.9 mmol/l), with concomitant euglycemia (6.6 mmol/l, normal range 4.1–11 mmol/l) and a hemoglobin A1c of 5.1% was highly suspicious of proximal tubular dysfunction.\nUpon admission, Streptococcus A rapid test was negative, chest radiograph was normal, and an abdominal ultrasound showed hepatomegaly, a heterogeneous parenchyma with hyperechogenicity around periportal spaces and lymph nodes, liver parenchymal arterialization, and a layer of perihepatic fluid, all consistent with hepatitis. The bile ducts were not dilated. Kidneys were of normal size and morphology, without any urinary tract dilatation. On the second day after admission, the patient developed drowsiness and confusion with high fever (exceeding 40 °C). Normal cerebral magnetic resonance imaging and lumbar puncture excluded central nervous system infection. Clinical features were suggestive of bacterial sepsis [sequential organ failure assessment [SOFA] score of 10], justifying empiric broad spectrum antibiotic therapy with intravenous ceftriaxone and oral clarithromycin.\nDetailed history revealed that the patient swam in a river in the Geneva lake area 1 week before hospital admission, raising the diagnostic suspicion of leptospirosis in this clinical setting. Serum polymerase chain reaction (PCR) for Leptospira interrogans was positive, and specific serologies revealed elevated IgM levels (> 100 U/ml, normal range < 15 U/ml). Although IgG levels were below the positive threshold, the values increased from < 2 U/ml initially to 6 U/ml 1 week later (normal range < 10 U/ml). Unfortunately, no ulterior dosage was performed. Antibiotic therapy was changed to intravenous amoxicillin–clavulanate and doxycycline for 7 days with clinical improvement. Serology for hantavirus was performed, revealing an indeterminate result due to nonspecific reactions. Considering the positive results for Leptospira interrogans, additional tests for hantavirus were not performed.\nAlong with clinical improvement, kidney function recovered with creatinine normalizing to 87 μmol/l on the sixth hospital day, and all electrolyte abnormalities resolved. Liver tests also normalized as confirmed by a routine blood sample 1 year after discharge. In addition, glycosuria significantly decreased from 7 to 0.5 mmol/l on the 12th day of hospital stay.", + "fulltext_subclaims": [ + "The patient is a 34-year-old Caucasian male.", + "He presented with a 4-day history of unbearable leg pain.", + "He had diffuse arthralgia.", + "He had fluctuating low-grade fever with profuse sweating.", + "He had vomiting and diarrhea without abdominal pain.", + "He denied contact with animals.", + "He had not consumed unpasteurized food.", + "He had his last unprotected sexual intercourse 4 months earlier.", + "He was taking no medications.", + "He had alcohol abuse with approximately 185 alcohol units/week.", + "He had drug abuse including cocaine, ecstasy, cannabis, methylphenidate, clonazepam, and lorazepam.", + "He was afebrile on presentation.", + "He was hypotensive with blood pressure 94/50 mmHg.", + "Oral examination revealed dry mucosa.", + "Oral examination revealed erythematous tonsils without exudate.", + "Laboratory findings showed normocytic, normochromic, hypoproliferative anemia with hemoglobin 99 g/l.", + "There was thrombocytopenia with platelet count 24 G/l.", + "C-reactive protein was elevated to 213 mg/l.", + "Transaminases were elevated three times the upper limit of normal.", + "Conjugated bilirubin was 29 µmol/l on admission.", + "There was stage 3 acute kidney injury according to KDIGO criteria.", + "Serum creatinine was 112 µmol/l on admission.", + "Serum creatinine increased to 247 µmol/l on hospital day 3.", + "Urinalysis showed proteinuria with a urine protein–creatinine ratio of 1.076 g/g.", + "Urinalysis showed albuminuria (2+ on semiquantitative analysis).", + "Urinalysis showed 97 M/l leukocytes.", + "Urinalysis showed 25 M/l erythrocytes.", + "Urinalysis showed renal tubular cells (1+ on semiquantitative analysis).", + "Fractional excretion of sodium was 3.56%.", + "Acute tubular necrosis was the suspected mechanism of acute kidney injury.", + "Serum sodium was 131 mmol/l.", + "Serum potassium was 2.8 mmol/l.", + "Albumin level was 29 g/l.", + "Creatinine kinase level was 312 U/l on admission.", + "Blood gas analysis showed a pH of 7.49.", + "Urine pH was 6.", + "Glycosuria was 7 mmol/l.", + "Hemoglobin A1c was 5.1%.", + "Chest radiograph was normal.", + "Abdominal ultrasound showed hepatomegaly.", + "Abdominal ultrasound showed a heterogeneous parenchyma with hyperechogenicity around periportal spaces.", + "Abdominal ultrasound showed lymph nodes.", + "Abdominal ultrasound showed liver parenchymal arterialization.", + "Abdominal ultrasound showed a layer of perihepatic fluid.", + "The patient developed drowsiness and confusion on the second day after admission.", + "The patient had high fever exceeding 40 °C.", + "Cerebral magnetic resonance imaging was normal.", + "Lumbar puncture excluded central nervous system infection.", + "The SOFA score was 10.", + "Empiric broad spectrum antibiotic therapy with ceftriaxone and clarithromycin was started.", + "The patient swam in a river in the Geneva lake area 1 week before hospital admission.", + "Serum PCR for Leptospira interrogans was positive.", + "Serum IgM levels were > 100 U/ml.", + "IgG levels increased from < 2 U/ml to 6 U/ml 1 week later.", + "Antibiotic therapy was changed to amoxicillin–clavulanate and doxycycline.", + "Serology for hantavirus was indeterminate.", + "Kidney function recovered with creatinine normalizing to 87 μmol/l on the sixth hospital day.", + "Liver tests normalized as confirmed by a routine blood sample 1 year after discharge.", + "Glycosuria decreased from 7 to 0.5 mmol/l on the 12th day of hospital stay." + ], + "summary": "A 34-year-old Caucasian male known for alcohol and drug abuse presented to our emergency department suffering from severe pain in the lower limbs, jaundice, and fever with flu-like symptoms. Physical examination was not contributory. Blood tests showed cytopenia, elevated inflammatory markers, acute kidney injury, and altered liver function tests with predominant cholestasis. Urinalysis showed proteinuria and significant glycosuria without concomitant hyperglycemia. Leptospirosis was suspected and confirmed by both positive serum polymerase chain reaction and elevated immunoglobulin M for Leptospira interrogans. The patient was treated with intravenous amoxicillin-clavulanate and doxycycline for 7 days. After antibiotic treatment, symptoms disappeared, and kidney dysfunction completely resolved.", + "summary_subclaims": [ + "The patient is a 34-year-old Caucasian male.", + "The patient has a history of alcohol and drug abuse.", + "The patient presented with severe pain in the lower limbs.", + "The patient had jaundice.", + "The patient had fever with flu-like symptoms.", + "Physical examination was not contributory.", + "Blood tests showed cytopenia.", + "Blood tests showed elevated inflammatory markers.", + "Blood tests showed acute kidney injury.", + "Blood tests showed altered liver function tests with predominant cholestasis.", + "Urinalysis showed proteinuria.", + "Urinalysis showed significant glycosuria.", + "Urinalysis showed no concomitant hyperglycemia.", + "Leptospirosis was suspected.", + "Leptospirosis was confirmed by positive serum polymerase chain reaction.", + "Leptospirosis was confirmed by elevated immunoglobulin M for Leptospira interrogans.", + "The patient was treated with intravenous amoxicillin-clavulanate.", + "The patient was treated with doxycycline for 7 days.", + "After antibiotic treatment, symptoms disappeared.", + "After antibiotic treatment, kidney dysfunction completely resolved." + ] + }, + { + "id": "multiclinsum_test_1774_en.txt", + "fulltext": "A 54-year-old man with a body mass index of 43.7 kg/m2 (weight, 124.8 kg; height, 169.0 cm) had a medical history of high blood pressure, bronchial asthma, sleep apnea syndrome, and surgery for a right bronchial gangliocytic paraganglioma. He had previously undergone esophagogastroduodenoscopy (EGD) at another hospital for screening examination, without any symptoms and abdominal findings. EGD revealed a tumor in the duodenal bulb; therefore, he was admitted to our hospital for close examination.\nEGD revealed two smooth elevated lesions with a diameter of 10 mm in the anterior wall of the duodenal bulb . A biopsy of the tumors in the anterior wall indicated the presence of neuroendocrine cells. The tumors were diagnosed as duodenal neuroendocrine tumors (NET). Abdominal plain computed tomography (CT) revealed no lesions, apparent enlarged lymph nodes, or distant metastasis. Endoscopic ultrasonography showed that the lesions were hypoechoic masses primarily comprising the third layer having an unclear border with the fourth layer. Because this finding suggested that the tumors had invaded the muscle layer, we decided that surgical resection was necessary. Therefore, laparoscopic distal gastrectomy with lymph node dissection and Roux en-Y reconstruction was performed. The extent of lymph node dissection was D1+ with No.12a lymph node because the tumors were located in the duodenum bulb. Intraoperative findings revealed that the tumors were not exposed to the serosal surface. The surgery was performed in the same way as usual for gastric cancer. The duodenum was transected using linear stapling device, and the stump was reinforced with serosal muscle suturing. A curative resection was performed without intraoperative complications. On the basis of pathological findings and immunostaining, the diagnosis was NET, which was classified as NET G1 according to World Health Organization (WHO) classification 2010 .\nFrom the physical findings and laboratory test results, the postoperative course up to postoperative day (POD) 3 was uneventful. The drain amylase level at POD1 was as low as 157 U/L; he started eating on POD3. He had a fever on POD5; hence, the meal was stopped, and a course of antibiotics was started. However, the fever was not improved, so CT was performed on POD8. Abdominal plain CT showed fluid collection in the anterior cavity of the pancreatic head . Consequently, CT-guided drainage of the collected fluid was performed. The contrast radiography through the drainage tube showed that there was no fistula between the fluid and gastrointestinal tract and no obvious anastomotic leakage. The amylase level of the drainage fluid was high at 4667 U/L, which suggested that the peripancreatic fluid collection was caused by pancreatic fistula and poor drainage. The drainage was continued, and the fluid cavity tended to shrink.\nOn POD28, he passed a large amount of blood stool. His vital signs were stable. Abdominal contrast-enhanced CT showed a small amount of fluid collection on the anterior side of the pancreatic head but no apparent extravasation findings. Although the CT imaging showed no evidence of abdominal bleeding or pseudoaneurysm, bleeding from a pseudoaneurysm was suspected because of the clinical findings; therefore, an emergency angiography was performed. We performed angiography of the celiac artery, splenic artery, and gastroduodenal artery as well as their branches that perfused the pancreas and the inferior pancreaticoduodenal artery branching from the superior mesenteric artery; however, no apparent pseudoaneurysm or extravasation was found. Therefore, no action other than observation was performed .\nEGD showed no bleeding from the gastrojejunal anastomosis site, jejunojejunostomy, and duodenal blind end. Colonoscopy also revealed no bleeding foci. We could not detect the source of bleeding, and there was no blood stool subsequently. The meal was restarted on POD34. Abdominal contrast-enhanced CT on POD36 showed no hemorrhage or pseudoaneurysm, and the abscess had disappeared. Therefore, on the same day, we removed the drainage tube. He was discharged on POD50.\nA plain CT 6 months after the surgery showed no abnormal findings and no pseudoaneurysm. Approximately 1 year after the initial surgery (POD350), he passed a bloody stool and was admitted to a local hospital after experiencing hemorrhagic shock. Laboratory tests revealed severe anemia with a hemoglobin level of 4.5 g/dL; therefore, blood transfusion was performed. Because colorectal bleeding was suspected, a colonoscopy was also performed; however, the bleeding source was not detected. A few days later, he again experienced a bloody stool and subsequently underwent EGD. An ulcer with pulsating exposed blood vessels near the duodenal blind end was observed. He was diagnosed as having a hemorrhage from a delayed pseudoaneurysm associated with surgery and was transferred to our hospital.\nAlthough his vital signs were stable, laboratory tests showed a hemoglobin level of 7.1 g/dL. Abdominal contrast-enhanced CT revealed a pseudoaneurysm arising from the proximal gastroduodenal artery (GDA), extending into the duodenal wall . Emergency angiography was performed, which revealed a pseudoaneurysm that had developed from the proximal GDA, as demonstrated in the CT findings . Transcatheter arterial embolization (TAE) was successfully performed with the isolation and packing technique. First, the proper hepatic artery distal to the pseudoaneurysm was embolized by using coils. Second, the pseudoaneurysm and posterior superior pancreaticoduodenal artery branching from the pseudoaneurysm were embolized with N-butyl-2-cyanoacrylate. Finally, the common hepatic artery proximal to the pseudoaneurysm was also embolized by using coils . Laboratory tests performed 1 day after TAE showed no evidence of liver failure. No clinical signs of rebleeding were observed during the course, and he was discharged on the seventh day after TAE. Subsequently, abdominal contrast-enhanced CT was performed twice approximately 3 and 9 months after TAE, and there were no findings, such as pseudoaneurysm recurrence, and no symptoms suggesting rebleeding.", + "fulltext_subclaims": [ + "The patient was a 54-year-old man with a body mass index of 43.7 kg/m2.", + "He had a medical history of high blood pressure, bronchial asthma, sleep apnea syndrome, and surgery for a right bronchial gangliocytic paraganglioma.", + "He had previously undergone esophagogastroduodenoscopy at another hospital for screening examination.", + "EGD revealed a tumor in the duodenal bulb.", + "He was admitted to our hospital for close examination.", + "EGD revealed two smooth elevated lesions with a diameter of 10 mm in the anterior wall of the duodenal bulb.", + "A biopsy of the tumors in the anterior wall indicated the presence of neuroendocrine cells.", + "The tumors were diagnosed as duodenal neuroendocrine tumors (NET).", + "Abdominal plain computed tomography revealed no lesions, apparent enlarged lymph nodes, or distant metastasis.", + "Endoscopic ultrasonography showed that the lesions were hypoechoic masses primarily comprising the third layer.", + "The lesions had an unclear border with the fourth layer.", + "The tumors were suspected to have invaded the muscle layer.", + "Laparoscopic distal gastrectomy with lymph node dissection and Roux en-Y reconstruction was performed.", + "The extent of lymph node dissection was D1+ with No.12a lymph node.", + "Intraoperative findings revealed that the tumors were not exposed to the serosal surface.", + "The surgery was performed in the same way as usual for gastric cancer.", + "The duodenum was transected using a linear stapling device.", + "The stump was reinforced with serosal muscle suturing.", + "A curative resection was performed without intraoperative complications.", + "The diagnosis was NET, classified as NET G1 according to WHO classification 2010.", + "The postoperative course up to postoperative day 3 was uneventful.", + "The drain amylase level at postoperative day 1 was 157 U/L.", + "He started eating on postoperative day 3.", + "He had a fever on postoperative day 5.", + "A course of antibiotics was started.", + "Abdominal plain CT was performed on postoperative day 8.", + "Abdominal plain CT showed fluid collection in the anterior cavity of the pancreatic head.", + "CT-guided drainage of the collected fluid was performed.", + "Contrast radiography through the drainage tube showed no fistula between the fluid and gastrointestinal tract.", + "The amylase level of the drainage fluid was 4667 U/L.", + "The peripancreatic fluid collection was suggested to be caused by pancreatic fistula and poor drainage.", + "He passed a large amount of blood stool on postoperative day 28.", + "Abdominal contrast-enhanced CT showed a small amount of fluid collection on the anterior side of the pancreatic head.", + "No apparent extravasation findings were observed.", + "Bleeding from a pseudoaneurysm was suspected.", + "Emergency angiography was performed.", + "Angiography of the celiac artery, splenic artery, and gastroduodenal artery was performed.", + "No apparent pseudoaneurysm or extravasation was found.", + "No action other than observation was performed.", + "EGD showed no bleeding from the gastrojejunal anastomosis site, jejunojejunostomy, and duodenal blind end.", + "Colonoscopy also revealed no bleeding foci.", + "The meal was restarted on postoperative day 34.", + "Abdominal contrast-enhanced CT on postoperative day 36 showed no hemorrhage or pseudoaneurysm.", + "The abscess had disappeared.", + "The drainage tube was removed on postoperative day 36.", + "He was discharged on postoperative day 50.", + "A plain CT 6 months after the surgery showed no abnormal findings and no pseudoaneurysm.", + "Approximately 1 year after the initial surgery, he passed a bloody stool and was admitted to a local hospital.", + "He experienced hemorrhagic shock.", + "Laboratory tests revealed severe anemia with a hemoglobin level of 4.5 g/dL.", + "Blood transfusion was performed.", + "Colorectal bleeding was suspected.", + "A colonoscopy was performed.", + "The bleeding source was not detected.", + "He again experienced a bloody stool.", + "EGD revealed an ulcer with pulsating exposed blood vessels near the duodenal blind end.", + "He was diagnosed as having a hemorrhage from a delayed pseudoaneurysm associated with surgery.", + "He was transferred to our hospital.", + "Laboratory tests showed a hemoglobin level of 7.1 g/dL.", + "Abdominal contrast-enhanced CT revealed a pseudoaneurysm arising from the proximal gastroduodenal artery.", + "Emergency angiography was performed.", + "A pseudoaneurysm that had developed from the proximal GDA was demonstrated.", + "Transcatheter arterial embolization was successfully performed.", + "The proper hepatic artery distal to the pseudoaneurysm was embolized using coils.", + "The pseudoaneurysm and posterior superior pancreaticoduodenal artery were embolized with N-butyl-2-cyanoacrylate.", + "The common hepatic artery proximal to the pseudoaneurysm was embolized using coils.", + "Laboratory tests performed 1 day after TAE showed no evidence of liver failure.", + "No clinical signs of rebleeding were observed.", + "He was discharged on the seventh day after TAE.", + "Abdominal contrast-enhanced CT was performed twice approximately 3 and 9 months after TAE.", + "There were no findings, such as pseudoaneurysm recurrence.", + "No symptoms suggesting rebleeding were observed." + ], + "summary": "A 54-year-old man underwent laparoscopic distal gastrectomy, D2 lymph node dissection, and Roux en-Y reconstruction for duodenal neuroendocrine tumors. Drainage was performed for a postoperative pancreatic fistula and abdominal abscess. On the 28th postoperative day, he passed a large amount of bloody stool; therefore, emergency esophagogastroduodenoscopy (EGD) and angiography were performed. However, neither examination demonstrated any bleeding foci or pseudoaneurysm. He was conservatively observed and discharged on the 50th postoperative day. Approximately 1 year after the surgery, he passed a bloody stool and experienced hemorrhagic shock. An EGD revealed exposed blood vessels at the duodenal blind end. His condition was diagnosed as a pseudoaneurysm arising from gastroduodenal artery, which ruptured into the duodenum, based on abdominal contrast-enhanced computed tomography findings. Emergency angiography was performed, and the pseudoaneurysm and artery were successfully embolized.", + "summary_subclaims": [ + "The patient underwent laparoscopic distal gastrectomy.", + "The patient underwent D2 lymph node dissection.", + "The patient underwent Roux en-Y reconstruction.", + "The surgery was performed for duodenal neuroendocrine tumors.", + "Drainage was performed for a postoperative pancreatic fistula.", + "Drainage was performed for an abdominal abscess.", + "On the 28th postoperative day, the patient passed a large amount of bloody stool.", + "Emergency esophagogastroduodenoscopy was performed.", + "Emergency angiography was performed.", + "Neither esophagogastroduodenoscopy nor angiography demonstrated any bleeding foci.", + "Neither esophagogastroduodenoscopy nor angiography demonstrated any pseudoaneurysm.", + "The patient was conservatively observed.", + "The patient was discharged on the 50th postoperative day.", + "Approximately 1 year after the surgery, the patient passed a bloody stool.", + "The patient experienced hemorrhagic shock.", + "An esophagogastroduodenoscopy revealed exposed blood vessels at the duodenal blind end.", + "The condition was diagnosed as a pseudoaneurysm arising from the gastroduodenal artery.", + "The pseudoaneurysm ruptured into the duodenum.", + "The diagnosis was based on abdominal contrast-enhanced computed tomography findings.", + "Emergency angiography was performed.", + "The pseudoaneurysm and artery were successfully embolized." + ] + }, + { + "id": "multiclinsum_test_1787_en.txt", + "fulltext": "A 26-year-old female with no past medical history was referred to acute care by her primary care provider with fever and haematuria. She described 2 months of fevers up to 40°C, malaise and night sweats. Her primary care provider diagnosed a urinary tract infection due to a positive urine dipstick for blood and she received two courses of antibiotics that failed to improve symptoms. At presentation, she reported a dental scaling procedure 1 month after the onset of fevers. Blood cultures were obtained, and she was discharged to the community. Within 48 h, these grew S. gordonii, and she was recalled by the clinical infection unit.\nOn examination, her respiratory rate was 16 breaths/min, SpO2 99%, blood pressure 116/74 mmHg, pulse 85 b.p.m., and temperature of 36.7°C. She had an early diastolic murmur loudest in expiration at the left lower sternal edge. There were no peripheral stigmata of infective endocarditis or signs of dental infection and no features of cardiac failure.\nAn electrocardiogram showed sinus rhythm, normal PR interval, and T wave inversion in leads V2–V4. A chest radiograph showed clear lung fields. Blood tests showed normocytic anaemia with Hb 112 g/L, mean corpuscular volume of 88 fL, normal white cell count of 9.6 × 109g/L, and an elevated C-reactive protein of 81 mg/L. Urine culture showed no growth. Two subsequent sets of blood cultures grew S. gordonii, sensitive to penicillin with a minimum inhibitory concentration of 0.012 µg/mL .\nA transthoracic echocardiogram showed a BAV, moderate aortic regurgitation, and possible aortic root abscess. The left ventricle was mildly dilated (left ventricular internal diameter in diastole 5.3 cm) with concentric remodelling, and the ejection fraction was 57%. A transoesophageal echocardiogram revealed aortic valve vegetations and an anechoic lesion at the aortic root not in communication with the atria. This was interpreted as an aortic root abscess . There was severe aortic regurgitation with a valvular jet directed towards the anterior mitral valve leaflet in early diastole, followed by a mid-late diastolic septally directed jet originating through the abscess cavity (see , ). This confirmed a diagnosis of native aortic valve infective endocarditis secondary to S. gordonii.\nTwo days later, the patient reported headaches and visual disturbance without focal neurology. A magnetic resonance imaging brain revealed dural enhancement overlying the left occipital lobe with associated signal change reported as a small empyema .\nOn 14 February 2022, she was commenced on 2 g amoxicillin IV 6 hourly. Subsequent blood cultures were negative by 17 February.\nThe cardiothoracic surgeons offered her mechanical or bioprosthetic valve replacement. She opted for mechanical valve replacement to reduce the likelihood of requiring redo surgery. Surgery was performed 5 days after admission. Intra-operatively, vegetations were present on the BAV, and a sub-valvular cavity was closed with a pericardial patch. This native aortic valve showed no growth after prolonged incubation. She received a 19 mm On-X mechanical aortic valve and post-operatively commenced warfarin therapy.\nAfter 2 weeks of inpatient antibiotics, she was discharged under the outpatient parenteral antibiotic therapy service on once-daily ceftriaxone for 4 weeks.\nShe was followed up by clinical infection and cardiothoracic surgery services. A further MRI brain on 28 April 2022 showed resolution of the cerebral empyema, and she remains well with no further neurological symptoms.", + "fulltext_subclaims": [ + "The patient is a 26-year-old female.", + "She had no past medical history.", + "She was referred to acute care by her primary care provider.", + "She had fever and haematuria.", + "She described 2 months of fevers up to 40°C.", + "She had malaise and night sweats.", + "Her primary care provider diagnosed a urinary tract infection.", + "She received two courses of antibiotics.", + "The antibiotics failed to improve symptoms.", + "Blood cultures were obtained.", + "She was discharged to the community.", + "Within 48 h, blood cultures grew S. gordonii.", + "She was recalled by the clinical infection unit.", + "On examination, she had an early diastolic murmur loudest in expiration at the left lower sternal edge.", + "There were no peripheral stigmata of infective endocarditis.", + "There were no signs of dental infection.", + "An electrocardiogram showed T wave inversion in leads V2–V4.", + "A chest radiograph showed clear lung fields.", + "Blood tests showed normocytic anaemia with Hb 112 g/L.", + "Urine culture showed no growth.", + "Two subsequent sets of blood cultures grew S. gordonii.", + "S. gordonii was sensitive to penicillin with a minimum inhibitory concentration of 0.012 µg/mL.", + "A transthoracic echocardiogram showed a BAV.", + "A transoesophageal echocardiogram revealed aortic valve vegetations.", + "The diagnosis was native aortic valve infective endocarditis secondary to S. gordonii.", + "The patient reported headaches and visual disturbance without focal neurology.", + "A magnetic resonance imaging brain revealed dural enhancement overlying the left occipital lobe.", + "She was commenced on 2 g amoxicillin IV 6 hourly.", + "Subsequent blood cultures were negative by 17 February.", + "The cardiothoracic surgeons offered mechanical or bioprosthetic valve replacement.", + "She opted for mechanical valve replacement.", + "Surgery was performed 5 days after admission.", + "Intra-operatively, vegetations were present on the BAV.", + "She received a 19 mm On-X mechanical aortic valve.", + "She was discharged on once-daily ceftriaxone for 4 weeks.", + "A further MRI brain on 28 April 2022 showed resolution of the cerebral empyema.", + "She remains well with no further neurological symptoms." + ], + "summary": "We present a case of a previously healthy 26-year-old woman who presented with a 2-month history of fevers. Blood cultures on admission were positive for S. gordonii. Echocardiography demonstrated a congenital bicuspid aortic valve with vegetations and abscess, supporting a diagnosis of infective endocarditis. A magnetic resonance imaging (MRI) brain revealed a small cerebral empyema. She was treated with intravenous antibiotics and underwent an aortic valve replacement.", + "summary_subclaims": [ + "The patient was a 26-year-old woman.", + "She had a 2-month history of fevers.", + "Blood cultures on admission were positive for S. gordonii.", + "Echocardiography demonstrated a congenital bicuspid aortic valve.", + "Echocardiography showed vegetations.", + "Echocardiography showed abscess.", + "The diagnosis was infective endocarditis.", + "MRI brain revealed a small cerebral empyema.", + "She was treated with intravenous antibiotics.", + "She underwent an aortic valve replacement." + ] + }, + { + "id": "multiclinsum_test_3351_en.txt", + "fulltext": "19-year-old pregnant woman from the city of Jauja in Junín, with a history of previous pregnancy without complications and irregular attendance at her prenatal check-ups. No previous history of threatened abortion in her current pregnancy. With a family history of a mother with a diagnosis of pulmonary hydatid disease that was treated. She presented abdominal pain of the stabbing type for four months, with a sensation of a mass in the left hypochondrium that was occasionally associated with dyspnoea during inspiration and expiration.\n\nShe was admitted to hospital for exacerbation of symptoms with vital signs: blood pressure of 120/70 mmHg, heart rate of 60 per min, respiratory rate of 16 per min, temperature of 36.5 °C. Physical examination showed a pregnant abdomen, uterine height of 27 cm, fetal heartbeat of 140 per min, estimated weight by ultrasound of 2532 g (8th percentile) with a gestational age of 37 weeks and 2 days, with a diagnosis of intrauterine growth restriction. Presence of a palpable tumour in the upper left half of the abdomen of approximately 10 cm × 10 cm with a hard, mobile and non-painful consistency to the touch.\n\nLaboratory study reported leukocytes: 17,400/uL, segmented: 15,400/uL, hemoglobin: 14 g/dL, platelets: 12,200/uL, C-reactive protein: 26.47 mg/dL, serum creatinine: 0.57 mg/dL, ALT: 14.79 U/L, AST: 5.19 U/L, total bilirubin: 0.27 mg/dL. Serologic study for HIV, syphilis and hepatitis B was performed and was non-reactive.\n\nThe transabdominal ultrasound evaluation showed a large cystic image dependent on the spleen measuring 190 mm × 154 mm × 164 mm, with an approximate volume of 2500 cm3, with thin walls with a mass effect on adjacent structures, very reduced splenic parenchyma, without calcifications.\n\nThe cesarean section allowed a product of 37 weeks according to Capurro, Apgar 9/9, with weight of 2225 g, head circumference of 32 cm, abdominal circumference of 27 cm, height of 43 cm. Then an exploratory laparotomy was performed where a surgical piece with characteristics of abdominal tumour depending on the spleen was obtained. The measures were 28 cm × 17.5 cm × 12 cm, with transverse section transparent serous liquid content, and with multiple cystic formations inside. In the histopathology of the spleen by staining with haematoxylin and eosin, numerous inflammatory cells and hydatid membranes with viable head were found.\n\nThe patient recovered satisfactorily. A computed tomography of the thorax, abdomen and pelvis was performed, which did not find any hepatic, pulmonary or other organ involvement. She received prophylaxis with albendazole 400 mg orally every 12 h for 6 weeks, pneumococcal vaccination and seasonal influenza vaccination. She was discharged without observing a recurrence of hydatid foci during follow-up. The newborn gained adequate weight and height, did not receive specific treatment and received his vaccination according to his months of life.\n", + "fulltext_subclaims": [ + "The patient is a 19-year-old pregnant woman from the city of Jauja in Junín.", + "She has a history of previous pregnancy without complications.", + "She has irregular attendance at her prenatal check-ups.", + "There is no previous history of threatened abortion in her current pregnancy.", + "Her mother has a diagnosis of pulmonary hydatid disease that was treated.", + "She presented abdominal pain of the stabbing type for four months.", + "She had a sensation of a mass in the left hypochondrium.", + "The sensation of a mass was occasionally associated with dyspnoea during inspiration and expiration.", + "On admission, her blood pressure was 120/70 mmHg.", + "On admission, her heart rate was 60 per min.", + "On admission, her respiratory rate was 16 per min.", + "On admission, her temperature was 36.5 °C.", + "Physical examination showed a pregnant abdomen.", + "Uterine height was 27 cm.", + "Fetal heartbeat was 140 per min.", + "Estimated fetal weight by ultrasound was 2532 g.", + "Estimated fetal weight was at the 8th percentile.", + "Gestational age was 37 weeks and 2 days.", + "The diagnosis was intrauterine growth restriction.", + "A palpable tumour was found in the upper left half of the abdomen.", + "The tumour measured approximately 10 cm × 10 cm.", + "The tumour had a hard, mobile, and non-painful consistency.", + "Laboratory study reported leukocytes of 17,400/uL.", + "Laboratory study reported segmented leukocytes of 15,400/uL.", + "Laboratory study reported platelets of 12,200/uL.", + "Laboratory study reported C-reactive protein of 26.47 mg/dL.", + "Serologic study for HIV, syphilis, and hepatitis B was performed.", + "The serologic study was non-reactive.", + "The transabdominal ultrasound showed a large cystic image dependent on the spleen.", + "The cystic image measured 190 mm × 154 mm × 164 mm.", + "The cystic image had an approximate volume of 2500 cm3.", + "The cystic image had thin walls with a mass effect on adjacent structures.", + "The cesarean section delivered a product of 37 weeks.", + "The newborn had an Apgar score of 9/9.", + "The newborn weighed 2225 g.", + "An exploratory laparotomy was performed.", + "A surgical piece with characteristics of an abdominal tumour depending on the spleen was obtained.", + "The surgical piece measured 28 cm × 17.5 cm × 12 cm.", + "The surgical piece had transparent serous liquid content.", + "The surgical piece had multiple cystic formations inside.", + "Histopathology of the spleen showed numerous inflammatory cells.", + "Histopathology showed hydatid membranes with viable head.", + "Computed tomography of the thorax, abdomen, and pelvis did not find any hepatic, pulmonary, or other organ involvement.", + "She received prophylaxis with albendazole 400 mg orally every 12 h for 6 weeks.", + "She received pneumococcal vaccination.", + "She received seasonal influenza vaccination.", + "She was discharged without observing a recurrence of hydatid foci during follow-up.", + "The newborn gained adequate weight and height.", + "The newborn did not receive specific treatment.", + "The newborn received vaccination according to his months of life." + ], + "summary": "We present the case of a young pregnant woman with abdominal pain and a feeling of a mass in the left hypochondrium. The ultrasound study revealed a multi-tabic cystic image in the left half of the abdomen with a viable foetus. A caesarean section was performed, followed by an exploratory laparotomy and a giant tumour of the spleen was found, which, according to the anatomopathological study, corresponds to a multi-cystic splenic hydatid disease. Also, intrauterine growth restriction occurred as a foetal complication. The patient had a favourable evolution without recurrence of hydatid foci, while the newborn showed an adequate growth pattern.\n", + "summary_subclaims": [ + "The patient was a young pregnant woman.", + "She had abdominal pain.", + "She had a feeling of a mass in the left hypochondrium.", + "The ultrasound study revealed a multi-tabic cystic image in the left half of the abdomen.", + "The ultrasound study showed a viable foetus.", + "A caesarean section was performed.", + "An exploratory laparotomy was performed.", + "A giant tumour of the spleen was found.", + "The anatomopathological study showed the tumour corresponds to a multi-cystic splenic hydatid disease.", + "Intrauterine growth restriction occurred as a foetal complication.", + "The patient had a favourable evolution.", + "There was no recurrence of hydatid foci.", + "The newborn showed an adequate growth pattern." + ] + }, + { + "id": "multiclinsum_test_3295_en.txt", + "fulltext": "A two-year-old female child was brought to the University Eye Hospital (UEH, Kabul, Afghanistan). According to her parents’ history, in the last three weeks the patient has progressive pain, tearing and tonic blepharospasm such that she cannot open her eyes. The child weighed 10 kg and measured 60 cm in height. The patient attended the provincial hospital and due to the absence of an ophthalmologist, she was then referred to the University Eye Hospital in Kabul.\n\nThe patient’s parents were living in a remote district under insurgents’ control, where no medical facilities are present and no vaccination campaigns are allowed; it is worthwhile that during vaccination campaigns in Afghanistan, supplemental vitamin A is also given to children under the age of five years. The socio-economic situation of the parents was not good, as the child’s father was disabled with no stable payment, meanwhile family planning was not observed. At presentation the patient was cachectic and irritable, the hairs were thin and pale, and trichomegaly was found.\n\nAs slit-lamp examination was impossible, she was admitted for Exam Under Anesthesia (EUA) the next day. The EUA revealed diffusely chemotic and keratinized conjunctiva in both eyes (OU) with xerosis but no Bitot’s spots. Both corneas demonstrated total melt from limbus to limbus, with a collapsed anterior chamber. The right eye had a purulent iris that was affixed to the lens by extensive posterior synechiae.\n\nA diagnosis of X3-B keratomalacia with severe protein-energy malnutrition was made. Treatment was initiated in the form of 200.000 units of vitamin-A acetate administered by mouth in divided doses for 2 days and repeated 2 weeks later.\n\nBecause of poor visual potential and risk of sympathetic ophthalmia, the patient’s right eye was eviscerated and the patient’s left eye was treated with temporary tarsorrhaphy. The patient was then referred to a specialized eye institution for possible corneal graft.", + "fulltext_subclaims": [ + "The patient is a two-year-old female child.", + "She was brought to the University Eye Hospital in Kabul.", + "According to her parents, she has had progressive pain, tearing, and tonic blepharospasm for the last three weeks.", + "The child weighed 10 kg and measured 60 cm in height.", + "She was referred to the University Eye Hospital from a provincial hospital due to the absence of an ophthalmologist.", + "The patient’s parents were living in a remote district under insurgents’ control.", + "No medical facilities are present in the district where the parents were living.", + "During vaccination campaigns in Afghanistan, supplemental vitamin A is given to children under the age of five years.", + "The patient was cachectic and irritable at presentation.", + "Trichomegaly was found.", + "Slit-lamp examination was impossible.", + "The patient was admitted for Exam Under Anesthesia the next day.", + "The EUA revealed diffusely chemotic and keratinized conjunctiva in both eyes.", + "Both corneas demonstrated total melt from limbus to limbus.", + "The right eye had a purulent iris affixed to the lens by extensive posterior synechiae.", + "A diagnosis of X3-B keratomalacia with severe protein-energy malnutrition was made.", + "Treatment was initiated with 200,000 units of vitamin-A acetate administered by mouth in divided doses for 2 days.", + "The treatment was repeated 2 weeks later.", + "The patient’s right eye was eviscerated due to poor visual potential and risk of sympathetic ophthalmia.", + "The patient’s left eye was treated with temporary tarsorrhaphy.", + "The patient was referred to a specialized eye institution for possible corneal graft." + ], + "summary": "A two-year-old female with severe malnutrition presented with 3 weeks of watering and tonic blepharospasm affecting the right and left eyes. She exhibited trichomegaly, severe weight loss, abnormal hairs with complete corneal melt in the right and left eyes and inflamed iris tissue in the right eye. She was treated with high dose vitamin A, but the right eye required evisceration and tarsorrhaphy was done in the left eye.", + "summary_subclaims": [ + "The patient is a two-year-old female.", + "The patient has severe malnutrition.", + "The patient had 3 weeks of watering.", + "The patient had tonic blepharospasm affecting the right and left eyes.", + "The patient exhibited trichomegaly.", + "The patient had severe weight loss.", + "The patient had abnormal hairs.", + "The patient had complete corneal melt in the right and left eyes.", + "The patient had inflamed iris tissue in the right eye.", + "The patient was treated with high dose vitamin A.", + "The right eye required evisceration.", + "Tarsorrhaphy was done in the left eye." + ] + }, + { + "id": "multiclinsum_test_3025_en.txt", + "fulltext": "A 43-year-old female presented at our Emergency Department complaining of an acute generalized abdominal pain. Eight days ago, the patient was hit by a motorbike, resulting in a closed left tibial plateau fracture. The patient underwent bone fusion surgery and was discharged after four days without any complications. The patient could urinate independently after the injury, and routine urine analysis showed no obvious abnormalities. Two days ago, the patient experienced hypogastric discomfort accompanied by urinary retention. One hour before admission, the patient felt severe bladder retention and then heard a “poof” sound from her abdomen, which relieved the bladder retention but caused generalized abdominal pain. At admission, the patient reported a sudden, constant, dull pain in the lower abdomen, along with a gradually distending abdomen. Physical examination revealed a pulse of 110 beats per minute, blood pressure of 80/60 mmHg, oxygen saturation of 92 %, and a respiratory rate of 22 breaths per minute. Laboratory tests showed elevated white blood cells (17.55 K/uL) with 91.6 % neutrophils, elevated creatinine (331 umol/L), and high potassium (6 mmol/L). Urinalysis results indicated significant hematuria (+++). No abnormal findings were found on the abdominal X-ray. A point-of-care ultrasound (POCUS) revealed large amounts of abdominal fluid. Subsequently, abdominal paracentesis showed a yellow-like urine fluid, increasing creatinine levels (1383 umol/L) and urea (44.4 mmol/L).\n\nThe patient was diagnosed with generalized peritonitis due to a late bladder rupture and underwent exploratory laparoscopic surgery. During the surgery, approximately 2.4 L of clear yellow fluid was suctioned from the abdomen, and a hole about 2x3cm in size with rough edges was found at the top of the bladder. The surgical team decided to biopsy the edge of the perforation and suture it with two-layer Vloc 3.0 sutures, placing an abdominal drain at Douglas. Post-surgery, the patient received intravenous antibiotics, fluids, and painkillers. On the first postoperative day, kidney function and potassium levels returned to normal, and abdominal fluid culture results showed no bacteria. Postoperative pathology results indicated acute cystitis. A follow-up ultrasound on the fourth postoperative day revealed no abdominal fluid. The drainage tube was removed on day five, and the patient was discharged on day nine in stable condition with average laboratory results. A two-week follow-up showed an asymptomatic patient without signs of recurrence or complications.", + "fulltext_subclaims": [ + "The patient is a 43-year-old female.", + "The patient presented at the Emergency Department with acute generalized abdominal pain.", + "Eight days prior, the patient was hit by a motorbike.", + "The patient sustained a closed left tibial plateau fracture.", + "The patient underwent bone fusion surgery.", + "The patient was discharged after four days without complications.", + "The patient could urinate independently after the injury.", + "Routine urine analysis showed no obvious abnormalities.", + "Two days prior to admission, the patient experienced hypogastric discomfort and urinary retention.", + "One hour before admission, the patient felt severe bladder retention.", + "The patient heard a 'poof' sound from her abdomen.", + "The 'poof' sound relieved the bladder retention.", + "The 'poof' sound caused generalized abdominal pain.", + "At admission, the patient reported a sudden, constant, dull pain in the lower abdomen.", + "The abdomen was gradually distending.", + "Physical examination revealed a pulse of 110 beats per minute.", + "Physical examination revealed a blood pressure of 80/60 mmHg.", + "Physical examination revealed oxygen saturation of 92%.", + "Physical examination revealed a respiratory rate of 22 breaths per minute.", + "Laboratory tests showed elevated white blood cells (17.55 K/uL).", + "Laboratory tests showed 91.6% neutrophils.", + "Laboratory tests showed elevated creatinine (331 umol/L).", + "Laboratory tests showed high potassium (6 mmol/L).", + "Urinalysis results indicated significant hematuria (+++).", + "No abnormal findings were found on the abdominal X-ray.", + "A point-of-care ultrasound (POCUS) revealed large amounts of abdominal fluid.", + "Abdominal paracentesis showed a yellow-like urine fluid.", + "Abdominal paracentesis showed increased creatinine levels (1383 umol/L).", + "Abdominal paracentesis showed increased urea (44.4 mmol/L).", + "The patient was diagnosed with generalized peritonitis due to a late bladder rupture.", + "The patient underwent exploratory laparoscopic surgery.", + "During surgery, approximately 2.4 L of clear yellow fluid was suctioned from the abdomen.", + "A hole about 2x3 cm in size with rough edges was found at the top of the bladder.", + "The surgical team decided to biopsy the edge of the perforation.", + "The surgical team sutured the perforation with two-layer Vloc 3.0 sutures.", + "An abdominal drain was placed at Douglas.", + "Post-surgery, the patient received intravenous antibiotics.", + "Post-surgery, the patient received intravenous fluids.", + "Post-surgery, the patient received painkillers.", + "On the first postoperative day, kidney function and potassium levels returned to normal.", + "Abdominal fluid culture results showed no bacteria.", + "Postoperative pathology results indicated acute cystitis.", + "A follow-up ultrasound on the fourth postoperative day revealed no abdominal fluid.", + "The drainage tube was removed on day five.", + "The patient was discharged on day nine.", + "The patient was in stable condition at discharge.", + "A two-week follow-up showed an asymptomatic patient.", + "A two-week follow-up showed no signs of recurrence.", + "A two-week follow-up showed no complications." + ], + "summary": "We report the case of a 43-year-old female who presented with an 8-day history of blunt trauma and a 2-day abdominal discomfort. After using point-of-care ultrasound for abdominal paracentesis to confirm the diagnosis, the patient was transferred to the operating room to suture the ruptured bladder. After nine days, she was discharged free of symptoms.", + "summary_subclaims": [ + "The patient is a 43-year-old female.", + "The patient had an 8-day history of blunt trauma.", + "The patient had a 2-day history of abdominal discomfort.", + "Point-of-care ultrasound was used for abdominal paracentesis.", + "The patient was transferred to the operating room.", + "The ruptured bladder was sutured.", + "The patient was discharged after nine days.", + "The patient was free of symptoms at discharge." + ] + }, + { + "id": "multiclinsum_test_1153_en.txt", + "fulltext": "A 65-year-old man with severe, symptomatic AS was referred to our heart team. The preoperative echocardiography showed a severely degenerated bicuspid AS with a mean gradient of 41 mmHg (LVEF 47%). With an estimated mortality of 10.12% (Euroscore II) based on various severe co-morbidities, the heart-team recommended an interventional aortic valve approach. Because of furthermore severely calcified and stenotic iliac arteries, an approach via left subclavian artery was chosen using a self-expandable valve (Evolut pro+; Medtronic, Minneapolis, Minnesotta, USA).\nThe procedure was performed in a hybrid operating room under general anesthesia. A transesophageal echocardiography (TEE) probe was inserted for periprocedural valve assessment. Via an incision in the infraclavicular fossa the left subclavian artery (8 mm in diameter) was exposed and an 8 mm Dacron tube was grafted for vascular access. The delivery sheath was introduced into the Dacron tube without passing the artery. By advancing the TAVI prosthesis under fluoroscopy within the subclavian artery an impediment at the level of the vertebral artery was sensed. The prosthesis was retracted and the location radiographically inspected. There was no severe kinking or harm to the vessel detected. Hence, the valve was reinserted and under slight resistance positioned in the annulus. After uneventful deployment of the prosthesis, function was assessed with TEE. It showed a 6 cm floating cylindrical structure in the course of the TAVI-prosthesis (Additional file ). Suspecting some intravascular damage, a control angiogram was performed, displaying a filling defect of the subclavian artery . We suspected an intimal tear caused by the valve insertion with subsequent dislocation and fixation in the struts of the TAVI-prosthesis. Since this highly mobile structure was considered to be potentially embolic, we proceeded to surgical extraction via sternotomy. Under CPB a median sternotomy was performed and routine cannulation for cardiopulmonary bypass was initiated. After aortic cross-clamping and cardioplegic arrest, aortotomy was performed. The intraoperative inspection revealed an intimal cylinder of the left subclavian artery nailed by the valve stent into the annulus, subsequently being completely removed leaving the correctly implanted TAVI in situ. Postoperatively, valve function (no regurgitation and a mean gradient of 2 mmHg) and blood circulation of the left arm were uncompromised.\nYet, on postoperative day 4 absence of pulsation of the left-sided radial artery occurred. The CTA scan showed a dissection flap in the proximal left subclavian artery and distal contrast loss . Catheter-based vascular intervention with Fogarty balloon-removal of the dissected intimal flap was performed. Postoperative control revealed return of peripheral pulse on the radial artery . Further postoperative course was uneventful. The patient presented no new cardiac, vascular or neurologic sequelae at discharge.", + "fulltext_subclaims": [ + "The patient is a 65-year-old man.", + "The patient had severe, symptomatic aortic stenosis.", + "The preoperative echocardiography showed a severely degenerated bicuspid aortic stenosis.", + "The mean gradient was 41 mmHg.", + "The left ventricular ejection fraction was 47%.", + "The estimated mortality was 10.12% (Euroscore II).", + "The heart-team recommended an interventional aortic valve approach.", + "The left subclavian artery was chosen as the access site.", + "A self-expandable valve (Evolut pro+; Medtronic) was used.", + "The procedure was performed in a hybrid operating room.", + "General anesthesia was used.", + "A transesophageal echocardiography probe was inserted.", + "An 8 mm Dacron tube was grafted for vascular access.", + "The delivery sheath was introduced into the Dacron tube without passing the artery.", + "An impediment at the level of the vertebral artery was sensed.", + "The prosthesis was retracted.", + "No severe kinking or harm to the vessel was detected.", + "The valve was reinserted.", + "TEE showed a 6 cm floating cylindrical structure in the course of the TAVI-prosthesis.", + "A control angiogram was performed.", + "A filling defect of the subclavian artery was displayed.", + "An intimal tear was suspected.", + "Surgical extraction via sternotomy was performed.", + "Cardiopulmonary bypass was initiated.", + "An intraoperative inspection revealed an intimal cylinder of the left subclavian artery nailed by the valve stent into the annulus.", + "The intimal cylinder was completely removed.", + "The TAVI was left in situ.", + "Postoperatively, there was no regurgitation.", + "The mean gradient was 2 mmHg.", + "Blood circulation of the left arm was uncompromised.", + "On postoperative day 4, absence of pulsation of the left-sided radial artery occurred.", + "A CTA scan showed a dissection flap in the proximal left subclavian artery.", + "Distal contrast loss was noted.", + "Catheter-based vascular intervention with Fogarty balloon-removal of the dissected intimal flap was performed.", + "Postoperative control revealed return of peripheral pulse on the radial artery.", + "The patient had no new cardiac, vascular, or neurologic sequelae at discharge." + ], + "summary": "A 65-year-old man with severe aortic valve stenosis (AS) was referred for transcatheter aortic valve implantation (TAVI) via left subclavian artery. After uneventful deployment of the TAVI prosthesis, consequent valve assessment with transeosophageal echocardiography and angiography showed a highly mobile and tubular structure shifting within the valve. We went for a surgical extraction via sternotomy on cardiopulmonary bypass (CPB). A 6 cm longish intimal cylinder was hassle-free extracted. 4 days postoperatively the left sided radial pulse was missing. In a subsequent computed tomography angiography (CTA) scan a proximal dissection as well as an intimal flap, causing a subtotal stenosis of the left subclavian artery, was detected. Consecutively the intimal cylinder was removed using a Fogarty-balloon. Pre-discharge control revealed recurrence of peripheral radial pulse and an unimpeded function of the TAVI prosthesis. The patient presented no sequela at discharge.", + "summary_subclaims": [ + "The patient was a 65-year-old man.", + "The patient had severe aortic valve stenosis.", + "The patient was referred for transcatheter aortic valve implantation via left subclavian artery.", + "After deployment of the TAVI prosthesis, valve assessment showed a highly mobile and tubular structure shifting within the valve.", + "A surgical extraction via sternotomy on cardiopulmonary bypass was performed.", + "A 6 cm longish intimal cylinder was extracted.", + "4 days postoperatively the left sided radial pulse was missing.", + "A computed tomography angiography scan detected a proximal dissection and an intimal flap causing a subtotal stenosis of the left subclavian artery.", + "The intimal cylinder was removed using a Fogarty-balloon.", + "Pre-discharge control revealed recurrence of peripheral radial pulse.", + "Pre-discharge control revealed an unimpeded function of the TAVI prosthesis.", + "The patient presented no sequela at discharge." + ] + }, + { + "id": "multiclinsum_test_1857_en.txt", + "fulltext": "A 71-year-old man with highly symptomatic severe aortic-valve stenosis (AS) and in acute heart failure with pulmonary oedema and dyspnoea was urgently admitted to our Heart Center. Transthoracic echocardiography showed high-gradient stenosis (Vmax 4.4 m/s, ΔPmean 49 mmHg, aortic valve area 0.6 cm2) and reduced left-ventricular function (32%; see , ). Pulmonary hypertension was not documented. He had exertional angina, Canadian Cardiovascular Society Class II, and one syncope. His medical history included hypertension, paroxysmal atrial fibrillation, diabetes mellitus Type 2, chronic obstructive pulmonary disease GOLD III, and multiple prior percutaneous endovascular treatments with stents due to severe peripheral artery disease. At admission, his medical regimen included single antiplatelet therapy, atorvastatin, a beta-blocker, mineralocorticoid receptor antagonist, and bronchodilators. Upon examination, his blood pressure was 170/90 mmHg. Baseline electrocardiography showed sinus tachycardia, left-ventricular hypertrophy with strain pattern, and AV-block first degree.\nHe had bilateral crackles at the lung bases and clinical findings of severe symptomatic AS. N-terminal pro-brain natriuretic peptide (NT-proBNP) level at admission was 11 200 pg/mL (normal <125 pg/mL). After initial management with intravenous diuretics and recompensation on our ICU, the patient underwent coronary angiography which revealed no significant coronary artery disease. Invasive assessment of AS showed a peak-to-peak and mean aortic gradient of 133 and 44 mmHg, respectively. Left-ventricular end diastolic pressure was 35 mmHg. Given his comorbidities and surgical risk, he was deemed a candidate for TAVI by our heart valve team. The pre-procedural multi-detector computed tomography revealed unfavourable vessels for transfemoral access from both groins due to multiple prior stenting procedures and due to a severe calcified aortic valve with an aortic annulus perimeter of 76.8 mm and annulus area of 502.3 mm2 . Further calcification of the annulus was excluded. We evaluated the left axillary artery (9 mm) as an alternative access site and found it to be feasible for TAVI (TAx-TAVI; ).", + "fulltext_subclaims": [ + "The patient is a 71-year-old man.", + "He has highly symptomatic severe aortic-valve stenosis.", + "He was urgently admitted to the Heart Center.", + "Transthoracic echocardiography showed high-gradient stenosis.", + "The aortic valve area was 0.6 cm2.", + "The left-ventricular function was 32%.", + "Pulmonary hypertension was not documented.", + "He had one syncope.", + "His medical history included chronic obstructive pulmonary disease GOLD III.", + "At admission, his medical regimen included a beta-blocker.", + "Baseline electrocardiography showed sinus tachycardia.", + "NT-proBNP level at admission was 11 200 pg/mL.", + "Coronary angiography revealed no significant coronary artery disease.", + "Invasive assessment showed a mean aortic gradient of 44 mmHg.", + "He was deemed a candidate for TAVI by the heart valve team.", + "The pre-procedural CT showed unfavourable vessels for transfemoral access.", + "The left axillary artery was evaluated as an alternative access site.", + "The left axillary artery was found to be feasible for TAVI." + ], + "summary": "We describe here a simplified non-transfemoral TAx-TAVI approach in a 71-year-old patient with pulmonary oedema due to severe symptomatic aortic stenosis with a prohibitively high surgical risk (Society of Thoracic Surgeons Mortality 11.9%) and extensive peripheral artery disease that rendered the femoral arteries unsuitable for access. Importantly, this strategy also allows for successful management of bleeding events, particularly those associated with vascular closure device failure, by the use of a new covered stent device. The patient was discharged on Day 6 after admission in stable conditions. In short-term follow-up (30 days), he is asymptomatic with normal left-ventricular function.", + "summary_subclaims": [ + "The patient was a 71-year-old individual.", + "The patient had pulmonary oedema due to severe symptomatic aortic stenosis.", + "The patient had a prohibitively high surgical risk with a Society of Thoracic Surgeons Mortality of 11.9%.", + "The patient had extensive peripheral artery disease.", + "The femoral arteries were unsuitable for access.", + "A simplified non-transfemoral TAx-TAVI approach was used.", + "This strategy allows for successful management of bleeding events.", + "The management of bleeding events was particularly associated with vascular closure device failure.", + "The management used a new covered stent device.", + "The patient was discharged on Day 6 after admission in stable conditions.", + "In short-term follow-up (30 days), the patient was asymptomatic.", + "In short-term follow-up (30 days), the patient had normal left-ventricular function." + ] + }, + { + "id": "multiclinsum_test_1107_en.txt", + "fulltext": "My patient was a 19-year-old man diagnosed in early childhood with ADHD and ASD. He was referred by his local doctor for ongoing treatment as an adult. He had experienced long-term difficulties in establishing and maintaining lasting relationships and reading social cues. His conversations were awkward and restricted to a narrow range of subjects and he was frequently impulsive and insensitive during these interactions. These impairments had contributed to his increasing social isolation and conflict within the family environment. He had a low threshold of irritation and intolerance of noise, light and crowds. There was also a long history of outbursts of anger, physical intimidation and frequent destruction to property at home. He was also disorganized, forgetful and had difficulty completing tasks. He has always been overactive, restless and impulsive. There was no history of pervasive mood disturbance.\nThere were early concerns about a potential developmental delay and he was referred for a pediatric assessment at age two years. He received speech therapy prior to school and also repeated his pre-school year. Although he was of average intellect, his significant and specific learning, behavioral and communication difficulties warranted a placement in a special education unit to manage his needs. He experienced difficulties in both reading and writing and he performed below all national standards of literacy and numeracy. Reading remained effortful and unrewarding, with difficulties focusing on and reading along a line of text. At the age of seven he had an occupational therapy assessment, which reported difficulties with coordination, fine motor control, planning and sequencing. In the classroom he was reported to be distracted and restless, presented with extreme outbursts of anger and frequently ran away. He had poor interpersonal skills, established few friendships, had odd idiosyncratic language and repetitive hand flapping, and had a history of being bullied.\nHe commenced stimulant medication during early childhood and had trials of immediate-release dexamphetamine and methylphenidate with improvement in classroom behavior. He had little interest or motivation in taking his medication, resulting in generally poor adherence. Without stimulant medication his behavior quickly deteriorated.\nSince leaving school he had obtained a number of part-time unskilled jobs for eight to ten hours per week. He was, however, unable to maintain them because of behavioral and communication difficulties. He did not smoke cigarettes or consume alcohol or illicit substances. There was no significant family psychiatric history.\nOn presentation, he was taking methylphenidate extended-release 72mg daily via an osmotic-controlled release oral delivery system and melatonin 4mg every night. He had been prescribed this medication for the previous two years.\nDuring my clinical assessment, he was constantly restless, appeared disinterested and was easily distracted. He made little eye contact either when listening or speaking and his non-verbal interaction was limited. His answers to questions were minimal and his speech lacked normal prosody. His blood pressure and pulse were within the normal range although he was significantly overweight with a body mass index of 34kg/m2 (weight 102kg, height 1.72m).\nFollowing completion of his assessment an additional dose of methylphenidate was recommended in the late afternoon to try and reduce his frequent aggression at this time. However, he stated that this suggestion was of no interest to him and he did not care that others might be upset by his behavior.\nDuring the three months following his initial assessment there was no alteration to his pharmacotherapy and no improvement in his behavior. As a consequence of his persistent social difficulties the option of a trial of low-dose phenytoin was discussed. It was explained to my patient and his mother that improvements in social functioning had been observed by myself and been reported by other patients who also had taken low-dose phenytoin; although, these effects had not been demonstrated outside the clinic nor was this an approved indication for the medication. My patient and his mother signed a disclosure and informed consent document and a trial of medication was organized for the following consultation.\nTwo weeks later a sublingual test dose of approximately 2mg phenytoin was administered. Prior to this dose my patient’s interaction reflected his usual behavior, with little interest and social engagement. He was reluctant to participate in conversation and his verbal responses were minimal and lacked elaboration; there was only minimal facial expression, which appeared to be unconnected to the content of his speech. Within 10 minutes of taking the sublingual phenytoin he reported a reduction in the effort required to contribute to conversation and was able to sustain eye contact both when listening and speaking. He was surprised about the effortless nature of his eye gaze and also commented that he had never done this before, and that previously he had always found it easier to avoid eye contact when speaking. He was now experiencing the reverse, finding it harder to break away from the mutual eye gaze. He stated he felt more relaxed and was less distracted by other environmental visual and sensory stimuli. His non-verbal interaction, demonstrated by the raising of his eyebrows, smiling and nodding of his head, appeared to be more spontaneous and natural. During this assessment he read aloud two standardized examples of a text, pre- and post-administration of the phenytoin. He reported a reduction in the effort required and improved comprehension and accuracy. He stated that he was no longer as distracted by the other lines of text on the page, which previously had resulted in becoming overwhelmed and lost on the page. His speech was also more fluid with more appropriate intonation. He denied any adverse effects of the test dose. The following day he started taking compounded 2mg phenytoin capsules in the morning in conjunction with his methylphenidate.\nAfter two weeks both he and his mother stated that his communication with the family had improved and there had been no aggressive outbursts. During the consultation he was noticeably more engaged and appeared to enjoy the interaction. His ability to maintain eye contact and his non-verbal communication - facial expression, head movements and posture -were more synchronized and spontaneous.\nOver the next four weeks he became inconsistent in taking the phenytoin, and then ceased altogether. His behavior reverted to the previous pattern of poor social interaction; he became oppositional with outbursts of anger and physical violence.\nNine months later he resumed taking the phenytoin, this time as a single 4mg capsule in the morning. After his first dose there was an improvement of his social behavior similar to his previous response, although there was an apparent deterioration in the late afternoon. The dose was increased from 4mg to 5mg and a larger capsule formulated to try and prolong the release of the phenytoin. This appeared to achieve a more consistent improvement in behavior throughout the day, evident both at home and at work. Increases in the dose above 5mg were not associated with any additional benefit. He remained on the 5mg dose of phenytoin for over 18 months and reported that his work performance had consistently improved sufficient to increase his working hours and his level of responsibility. The violence and destruction at home abated. His confidence improved and for the first time he has established and sustained peer-appropriate friendships.\nHis behavioral ratings prior to treatment with phenytoin and after seven months on the 5mg phenytoin are presented in Figure . The manner in which my patient endorsed the items on the AQ highlighted a reduction of symptoms, with the most robust improvements in his enjoyment of social occasions, ability to cope with chit chat, and his preference to be with people rather than be alone. His total AQ score dropped from 41 pre- to 27 post-treatment with phenytoin; a score of 32 or more is considered to indicate clinically significant levels of autistic traits . Before treatment with phenytoin, his DASS ratings recorded both depression and anxiety as severe and stress as very severe. Post-treatment, there was robust change in all domains, with an absence of depressive symptoms and with both anxiety and stress being recorded as moderate.", + "fulltext_subclaims": [ + "The patient was a 19-year-old man diagnosed in early childhood with ADHD and ASD.", + "He was referred by his local doctor for ongoing treatment as an adult.", + "He had experienced long-term difficulties in establishing and maintaining lasting relationships.", + "His conversations were awkward and restricted to a narrow range of subjects.", + "He was frequently impulsive and insensitive during these interactions.", + "These impairments had contributed to his increasing social isolation.", + "He had a low threshold of irritation and intolerance of noise, light and crowds.", + "There was also a long history of outbursts of anger, physical intimidation and frequent destruction to property at home.", + "He was also disorganized, forgetful and had difficulty completing tasks.", + "He has always been overactive, restless and impulsive.", + "There was no history of pervasive mood disturbance.", + "There were early concerns about a potential developmental delay.", + "He was referred for a pediatric assessment at age two years.", + "He received speech therapy prior to school.", + "He repeated his pre-school year.", + "He was of average intellect.", + "His significant and specific learning, behavioral and communication difficulties warranted a placement in a special education unit.", + "He experienced difficulties in both reading and writing.", + "He performed below all national standards of literacy and numeracy.", + "Reading remained effortful and unrewarding.", + "At the age of seven he had an occupational therapy assessment.", + "The occupational therapy assessment reported difficulties with coordination, fine motor control, planning and sequencing.", + "In the classroom he was reported to be distracted and restless.", + "He presented with extreme outbursts of anger and frequently ran away.", + "He had poor interpersonal skills.", + "He established few friendships.", + "He had odd idiosyncratic language.", + "He had repetitive hand flapping.", + "He had a history of being bullied.", + "He commenced stimulant medication during early childhood.", + "He had trials of immediate-release dexamphetamine and methylphenidate with improvement in classroom behavior.", + "He had little interest or motivation in taking his medication.", + "He generally had poor adherence.", + "Without stimulant medication his behavior quickly deteriorated.", + "Since leaving school he had obtained a number of part-time unskilled jobs for eight to ten hours per week.", + "He was unable to maintain them because of behavioral and communication difficulties.", + "He did not smoke cigarettes or consume alcohol or illicit substances.", + "There was no significant family psychiatric history.", + "On presentation, he was taking methylphenidate extended-release 72mg daily via an osmotic-controlled release oral delivery system.", + "He had been prescribed this medication for the previous two years.", + "During my clinical assessment, he was constantly restless.", + "He made little eye contact either when listening or speaking.", + "His answers to questions were minimal.", + "His speech lacked normal prosody.", + "His blood pressure and pulse were within the normal range.", + "He was significantly overweight with a body mass index of 34kg/m2.", + "Following completion of his assessment an additional dose of methylphenidate was recommended in the late afternoon.", + "He stated that this suggestion was of no interest to him.", + "He did not care that others might be upset by his behavior.", + "During the three months following his initial assessment there was no alteration to his pharmacotherapy.", + "There was no improvement in his behavior.", + "The option of a trial of low-dose phenytoin was discussed.", + "It was explained to my patient and his mother that improvements in social functioning had been observed by myself.", + "It was explained that improvements in social functioning had been reported by other patients who also had taken low-dose phenytoin.", + "These effects had not been demonstrated outside the clinic.", + "This was not an approved indication for the medication.", + "My patient and his mother signed a disclosure and informed consent document.", + "A trial of medication was organized for the following consultation.", + "Two weeks later a sublingual test dose of approximately 2mg phenytoin was administered.", + "Prior to this dose my patient’s interaction reflected his usual behavior.", + "He was reluctant to participate in conversation.", + "His verbal responses were minimal and lacked elaboration.", + "There was only minimal facial expression, which appeared to be unconnected to the content of his speech.", + "Within 10 minutes of taking the sublingual phenytoin he reported a reduction in the effort required to contribute to conversation.", + "He was able to sustain eye contact both when listening and speaking.", + "He was surprised about the effortless nature of his eye gaze.", + "He commented that he had never done this before.", + "He found it harder to break away from the mutual eye gaze.", + "He stated he felt more relaxed.", + "He was less distracted by other environmental visual and sensory stimuli.", + "His non-verbal interaction appeared to be more spontaneous and natural.", + "During this assessment he read aloud two standardized examples of a text, pre- and post-administration of the phenytoin.", + "He reported a reduction in the effort required and improved comprehension and accuracy.", + "He stated that he was no longer as distracted by the other lines of text on the page.", + "His speech was also more fluid with more appropriate intonation.", + "He denied any adverse effects of the test dose.", + "The following day he started taking compounded 2mg phenytoin capsules in the morning in conjunction with his methylphenidate.", + "After two weeks both he and his mother stated that his communication with the family had improved.", + "There had been no aggressive outbursts.", + "During the consultation he was noticeably more engaged.", + "He appeared to enjoy the interaction.", + "His ability to maintain eye contact and his non-verbal communication were more synchronized and spontaneous.", + "Over the next four weeks he became inconsistent in taking the phenytoin, and then ceased altogether.", + "His behavior reverted to the previous pattern of poor social interaction.", + "He became oppositional with outbursts of anger and physical violence.", + "Nine months later he resumed taking the phenytoin, this time as a single 4mg capsule in the morning.", + "After his first dose there was an improvement of his social behavior similar to his previous response.", + "There was an apparent deterioration in the late afternoon.", + "The dose was increased from 4mg to 5mg.", + "A larger capsule was formulated to try and prolong the release of the phenytoin.", + "This appeared to achieve a more consistent improvement in behavior throughout the day.", + "This improvement was evident both at home and at work.", + "Increases in the dose above 5mg were not associated with any additional benefit.", + "He remained on the 5mg dose of phenytoin for over 18 months.", + "He reported that his work performance had consistently improved sufficient to increase his working hours and his level of responsibility.", + "The violence and destruction at home abated.", + "His confidence improved.", + "For the first time he has established and sustained peer-appropriate friendships.", + "His behavioral ratings prior to treatment with phenytoin and after seven months on the 5mg phenytoin are presented in Figure .", + "The manner in which my patient endorsed the items on the AQ highlighted a reduction of symptoms.", + "The most robust improvements were in his enjoyment of social occasions, ability to cope with chit chat, and his preference to be with people rather than be alone.", + "His total AQ score dropped from 41 pre- to 27 post-treatment with phenytoin.", + "A score of 32 or more is considered to indicate clinically significant levels of autistic traits.", + "Before treatment with phenytoin, his DASS ratings recorded both depression and anxiety as severe and stress as very severe.", + "Post-treatment, there was robust change in all domains.", + "There was an absence of depressive symptoms.", + "Both anxiety and stress were recorded as moderate." + ], + "summary": "I present the case of a 19-year-old Caucasian man with autism spectrum disorder treated with stimulant medication since early childhood. He experienced long-standing difficulties in establishing and maintaining relationships and reading social cues, and was socially isolated. Within 10 minutes of a single sublingual low dose of phenytoin there was an immediate observable improvement in his eye contact and integration of both verbal and non-verbal communication. This enhanced social functioning associated with his adherence to the low-dose phenytoin therapy was maintained for over 18 months of follow-up. These clinical observations were supported by ratings using the Autism-Spectrum Quotient and the Depression, Anxiety and Stress Scales, recorded pre-treatment and after seven months on 5mg phenytoin.", + "summary_subclaims": [ + "The patient is a 19-year-old Caucasian man.", + "The patient has autism spectrum disorder.", + "The patient was treated with stimulant medication since early childhood.", + "The patient experienced long-standing difficulties in establishing and maintaining relationships.", + "The patient had difficulties reading social cues.", + "The patient was socially isolated.", + "Within 10 minutes of a single sublingual low dose of phenytoin, there was an immediate observable improvement in his eye contact.", + "There was an immediate observable improvement in integration of both verbal and non-verbal communication.", + "The enhanced social functioning was maintained for over 18 months of follow-up.", + "The clinical observations were supported by ratings using the Autism-Spectrum Quotient.", + "The clinical observations were supported by ratings using the Depression, Anxiety and Stress Scales.", + "The ratings were recorded pre-treatment and after seven months on 5mg phenytoin." + ] + }, + { + "id": "multiclinsum_test_381_en.txt", + "fulltext": "A 32-year-old Japanese woman with recurrent hyperthyroidism was introduced to the out-patient department of Kohnan Hospital. She had a family history of Graves’ disease. She began to feel thirst, frequent palpitations, and body weight loss from around June 2006, and hyperthyroidism was detected. Her serum free triiodothyronine (T3) was more than 20pg/mL, free thyroxine (T4) was 7.7ng/dL, TSH was less than the detectable level and anti-TSH receptor antibody (TRAb) was 77.5% (normal range, less than 10%). The 24-hour uptake of iodine-123 to the thyroid gland was 38.47% in the right lobe and 44.16% in the left lobe (total 82.63%). A head magnetic resonance imaging (MRI) with contrast medium revealed thickening of the bilateral ocular muscles, but no evident tumor in the sella turcica . The diagnosis was established as Graves’ disease, and propylthiouracil (PTU) was administered. TRAb had fallen to the normal range, and a euthyroid state was achieved in June 2008. However, occasional elevation of free T3 was detected, so PTU administration was continued. Re-elevation of TSH was seen in December 2010 . A head MRI revealed abnormal findings in the sella turcica, and she was introduced to the neurosurgical department of Kohnan Hospital in May 2011.\nOn admission her blood pressure was 152/112mmHg. Electrocardiography recorded her heart rate as 70 beats/minute but she complained of frequent palpitations. Her consciousness was clear, and no abnormal neurological signs were detected. Endocrinological examinations in the morning with oral intake of 100mg of PTU revealed free T3 of 2.77pg/mL, free T4 of 1.09ng/dL and TSH of 2.433μIU/mL. Because of her frequent palpitations the thyroid-releasing hormone (TRH) loading test without discontinuing PTU was performed, which revealed no abnormal response. All other pituitary hormones were within the normal ranges, and head MR imaging with contrast medium showed an area of less enhancement in the left lateral wing of the sella turcica with a diameter of 5mm , and transsphenoidal surgery was planned under a diagnosis of TSH-secreting pituitary adenoma.\nThe milky-white soft tumor was enclosed within a thin cellulose-like membrane. Total removal was achieved in addition to medical fixation of the cleavage with pure ethanol. Postoperative histological examination showed diffuse cell arrangement with mild variation in size but without atypism or mitosis of the nucleus . Immunohistochemical examination disclosed plurihormonal expression of pituitary hormones including TSH-β, and the diagnosis was established as TSH-secreting plurihormonal adenoma .\nAdministration of PTU was discontinued from the day of surgery. Diastolic blood pressure did not exceed 100mmHg for six days after the operation. Pituitary and thyroid hormones were re-evaluated at 11 days after the operation, showing free T3 was 3.31pg/mL, free T4 was 1.00ng/dL and TSH was 1.567μIU/mL. Additional TRH loading test found no abnormal responses, and she was discharged at 12 days after the operation. Her blood pressure was 133/86mmHg, and palpitations had disappeared without medication.", + "fulltext_subclaims": [ + "The patient is a 32-year-old Japanese woman.", + "She has a family history of Graves’ disease.", + "She had recurrent hyperthyroidism.", + "She began to feel thirst, frequent palpitations, and body weight loss from around June 2006.", + "Hyperthyroidism was detected.", + "Her serum free triiodothyronine (T3) was more than 20pg/mL.", + "Her serum free thyroxine (T4) was 7.7ng/dL.", + "Her TSH was less than the detectable level.", + "Her anti-TSH receptor antibody (TRAb) was 77.5%.", + "The normal range for TRAb is less than 10%.", + "The 24-hour uptake of iodine-123 to the thyroid gland was 38.47% in the right lobe.", + "The 24-hour uptake of iodine-123 to the thyroid gland was 44.16% in the left lobe.", + "The total 24-hour uptake of iodine-123 to the thyroid gland was 82.63%.", + "A head MRI with contrast medium revealed thickening of the bilateral ocular muscles.", + "The head MRI showed no evident tumor in the sella turcica.", + "The diagnosis was established as Graves’ disease.", + "Propylthiouracil (PTU) was administered.", + "TRAb had fallen to the normal range by June 2008.", + "A euthyroid state was achieved in June 2008.", + "Occasional elevation of free T3 was detected.", + "PTU administration was continued.", + "Re-elevation of TSH was seen in December 2010.", + "A head MRI revealed abnormal findings in the sella turcica.", + "She was introduced to the neurosurgical department of Kohnan Hospital in May 2011.", + "On admission, her blood pressure was 152/112mmHg.", + "Electrocardiography recorded her heart rate as 70 beats/minute.", + "She complained of frequent palpitations.", + "Her consciousness was clear.", + "No abnormal neurological signs were detected.", + "Endocrinological examinations were performed in the morning with oral intake of 100mg of PTU.", + "Her free T3 was 2.77pg/mL.", + "Her free T4 was 1.09ng/dL.", + "Her TSH was 2.433μIU/mL.", + "A TRH loading test without discontinuing PTU was performed.", + "The TRH loading test revealed no abnormal response.", + "All other pituitary hormones were within the normal ranges.", + "Head MR imaging with contrast medium showed an area of less enhancement in the left lateral wing of the sella turcica.", + "The area of less enhancement had a diameter of 5mm.", + "Transsphenoidal surgery was planned under a diagnosis of TSH-secreting pituitary adenoma.", + "The milky-white soft tumor was enclosed within a thin cellulose-like membrane.", + "Total removal was achieved.", + "Medical fixation of the cleavage with pure ethanol was performed.", + "Postoperative histological examination showed diffuse cell arrangement with mild variation in size.", + "Postoperative histological examination showed no atypism or mitosis of the nucleus.", + "Immunohistochemical examination disclosed plurihormonal expression of pituitary hormones including TSH-β.", + "The diagnosis was established as TSH-secreting plurihormonal adenoma.", + "Administration of PTU was discontinued from the day of surgery.", + "Diastolic blood pressure did not exceed 100mmHg for six days after the operation.", + "Pituitary and thyroid hormones were re-evaluated at 11 days after the operation.", + "Free T3 was 3.31pg/mL at 11 days after the operation.", + "Free T4 was 1.00ng/dL at 11 days after the operation.", + "TSH was 1.567μIU/mL at 11 days after the operation.", + "An additional TRH loading test found no abnormal responses.", + "She was discharged at 12 days after the operation.", + "Her blood pressure was 133/86mmHg at discharge.", + "Palpitations had disappeared without medication." + ], + "summary": "A 32-year-old Japanese woman had recurrent hyperthyroidism. She had a history of Graves' hyperthyroidism, which had been successfully treated with propylthiouracil. A head magnetic resonance imaging showed a less enhanced area in the left lateral wing of her sella turcica. Transsphenoidal surgery was performed, and the diagnosis was established as thyroid-stimulating hormone-secreting plurihormonal adenoma. A rapid reduction in thyroid hormone levels was achieved, and her blood pressure was normalized after the operation.", + "summary_subclaims": [ + "The patient is a 32-year-old Japanese woman.", + "She had recurrent hyperthyroidism.", + "She had a history of Graves' hyperthyroidism.", + "Graves' hyperthyroidism had been successfully treated with propylthiouracil.", + "A head magnetic resonance imaging showed a less enhanced area in the left lateral wing of her sella turcica.", + "Transsphenoidal surgery was performed.", + "The diagnosis was established as thyroid-stimulating hormone-secreting plurihormonal adenoma.", + "A rapid reduction in thyroid hormone levels was achieved.", + "Her blood pressure was normalized after the operation." + ] + }, + { + "id": "multiclinsum_test_1741_en.txt", + "fulltext": "A 72-year-old male was transferred to our institution presenting temporary dysarthria and consciousness disorder. Diffusion-weighted image (DWI) revealed several small infarctions and magnetic resonance angiography showed a decrease of flow signal of the right intracranial arteries , which was due to partial disappearance of the high cervical portion of the left internal carotid artery (ICA) . Furthermore, a three-dimensional computed tomography angiogram (3D-CTA) revealed an elongated styloid process stenosing the nearby ICA . The arterial spin labeling study revealed a remarkable decrease in cerebral blood flow (CBF) , with mural hematoma around the stenotic ICA on thin slice T1-weighted images. Angiogram examination again revealed severe stenosis of the left ICA [ and ] at around the elongated styloid process. The final diagnosis was a case of carotid artery dissection due to the elongated styloid process (Eagle’s syndrome).\nAs the patient’s neurological symptoms recovered during the initial assessment, medical treatment was chosen, and the patient was treated conservatively by aspirin (100 mg/body/day). Oral administration of clopidogrel (loading 150 mg/day, maintenance 75 mg/day) and intravenous infusion of argatroban were added later on, as the patient suffered from repeatedly appearing transient neurological deficits with no change in DWI. Systolic blood pressure was also maintained above 160 mmHg to counteract the cerebral hemodynamic stress. CAS was performed 15 days after admission. The procedure was performed under general anesthesia, and an eight French temporally occlusion balloon catheter (OPTIMO, Tokai Medical Products, Japan) was delivered proximal to the stenotic lesion. A micro-guidewire was passed through the lesion right after balloon inflation. The blood from the distal ICA was flowed out through to the femoral vein. After percutaneous transluminal angioplasty (PTA) for stenosis, A 6 to 8 mm tapered Carotid WALLSTENT (Boston Scientific, Boston, USA) was placed at the stenotic lesion after PTA . MRA 3d-tof improved the signal intensity compared to before CAS . Post stenting angiogram showed no distal embolization at the intracranial arteries and postoperative iodoamphetamine single-photon emission computed tomography (IMP-SPECT) showed recovered left CBF . The blood pressure target was decreased to under 120 mmHg just after stent placement to prevent cerebral hyperperfusion syndrome, and the patient showed neither hyperperfusion nor ischemic symptoms. The patient was discharged to a rehabilitation hospital at a modified Rankin Scale of 2.", + "fulltext_subclaims": [ + "The patient was a 72-year-old male.", + "The patient was transferred to the institution.", + "The patient presented with temporary dysarthria.", + "The patient presented with consciousness disorder.", + "Diffusion-weighted image (DWI) revealed several small infarctions.", + "Magnetic resonance angiography showed a decrease of flow signal of the right intracranial arteries.", + "The decrease of flow signal of the right intracranial arteries was due to partial disappearance of the high cervical portion of the left internal carotid artery (ICA).", + "A three-dimensional computed tomography angiogram (3D-CTA) revealed an elongated styloid process stenosing the nearby ICA.", + "The arterial spin labeling study revealed a remarkable decrease in cerebral blood flow (CBF).", + "Mural hematoma around the stenotic ICA was seen on thin slice T1-weighted images.", + "Angiogram examination revealed severe stenosis of the left ICA at around the elongated styloid process.", + "The final diagnosis was carotid artery dissection due to the elongated styloid process.", + "Medical treatment was chosen.", + "The patient was treated conservatively by aspirin (100 mg/body/day).", + "Oral administration of clopidogrel (loading 150 mg/day, maintenance 75 mg/day) was added.", + "Intravenous infusion of argatroban was added.", + "Systolic blood pressure was maintained above 160 mmHg.", + "CAS was performed 15 days after admission.", + "The procedure was performed under general anesthesia.", + "An eight French temporally occlusion balloon catheter (OPTIMO) was delivered proximal to the stenotic lesion.", + "A micro-guidewire was passed through the lesion right after balloon inflation.", + "Blood from the distal ICA was flowed out through to the femoral vein.", + "Per cutaneous transluminal angioplasty (PTA) was performed for stenosis.", + "A 6 to 8 mm tapered Carotid WALLSTENT was placed at the stenotic lesion after PTA.", + "MRA 3d-tof improved the signal intensity compared to before CAS.", + "Post stenting angiogram showed no distal embolization at the intracranial arteries.", + "Postoperative iodoamphetamine single-photon emission computed tomography (IMP-SPECT) showed recovered left CBF.", + "The blood pressure target was decreased to under 120 mmHg just after stent placement.", + "The patient showed neither hyperperfusion nor ischemic symptoms.", + "The patient was discharged to a rehabilitation hospital.", + "The patient had a modified Rankin Scale of 2." + ], + "summary": "A 72-year-old male with temporary dysarthria and consciousness disorder was diagnosed to suffer from multiple cerebral infarctions due to Eagle's syndrome. A cerebral blood flow (CBF) study revealed decreased blood flow and a CAS was performed 15 days after admission to preserve antegrade blood flow, resulting in full recovery of the affected CBF.", + "summary_subclaims": [ + "The patient is a 72-year-old male.", + "The patient had temporary dysarthria.", + "The patient had a consciousness disorder.", + "The patient was diagnosed to suffer from multiple cerebral infarctions due to Eagle's syndrome.", + "A cerebral blood flow study revealed decreased blood flow.", + "A CAS was performed 15 days after admission.", + "The CAS was performed to preserve antegrade blood flow.", + "The affected cerebral blood flow fully recovered." + ] + }, + { + "id": "multiclinsum_test_3004_en.txt", + "fulltext": "A 68-year-old woman presented to our hospital complaining of dyspnea at rest for approximately 2 months and was classified as New York Heart Association functional class III. She had previously been treated for breast and colon cancers and had not suffered from cardiovascular disease. Her height, weight, and body mass index were 150.0 cm, 91.0 kg, and 40.4 kg/m2, respectively. A grade IV/VI pan-systolic murmur was heard at the apex on cardiac auscultation. Her pulse rate was 105 beats/min and she was diagnosed with an irregularly rapid heartbeat (tachycardia). Her blood pressure was 124/76 mmHg. A chest radiograph revealed severe cardiomegaly with a cardiothoracic ratio of 80%, while an electrocardiogram showed persistent atrial fibrillation with a low-voltage F-wave. Computed tomography demonstrated the retention of pleural fluid or abdominal dropsy and hepatosplenomegaly. No significant coronary stenosis was observed by coronary angiography. Transthoracic echocardiography revealed severe mitral regurgitation with annular enlargement and severe tricuspid regurgitation. The cause of mitral regurgitation was severe tethering due to extreme annular enlargement, and the prolapse of the anterior leaflet. The left ventricular ejection fraction was 49%, the left ventricular diastolic diameter was 63 mm, and the left atrial diameter was 71 mm. Laboratory evaluations did not show any abnormalities, apart from an N-terminal-proB-type natriuretic peptide level of 7439 pg/ml. Because of the medication-refractory heart failure, we decided to perform surgery after a written informed consent was obtained.\n\nA median sternotomy was performed and standard cardio-pulmonary bypass was initiated with ascending aortic and bicaval cannulation. A left atrial vent was introduced from the right upper pulmonary vein. Myocardial protection was achieved in an antegrade and retrograde fashion. The retrograde cardioplegia cannula was inserted smoothly under direct vision. After aortic cross-clamping, the left atrium was opened through a longitudinal left atriotomy, revealing the tethering mechanism secondary to the prolapse of the anterior leaflet of the mitral valve. The clear zone of the anterior leaflet was excised and the rough zone with its attached chord were divided equally. Each divided structure was transferred to the anterolateral and the posteromedial commissures separately. The posterior leaflet, including the subvalvular apparatus, was wholly preserved. The mitral valve was replaced with a 29-mm St. Jude mechanical valve (St. Jude Medical Inc., St. Paul, MN) in an intra-annular position using everting mattress sutures. Subsequently, tricuspid annuloplasty was performed with a 32-mm Carpentier-Edwards PhysioTricuspid ring (Edwards LifeSciences, Irvine, CA) for annular enlargement. Weaning from the cardio-pulmonary bypass was successful. After closing the thorax, to our surprise, an atrial mass of 3 cm × 2 cm was detected by TEE, which showed an oval hypoechoic appearance extending from the posterior annulus of the mitral valve to the posterior wall of the left atrium. Although it occupied one-third of the left atrium, there was no significant obstruction of the pulmonary venous return and left ventricular filling. The prosthetic valve movement was unobstructed and there were no paravalvular leaks or pericardial effusion. No communication between the mass and the atrial true lumen was detected using color Doppler echocardiogram. We diagnosed the mass as LAD. Because hemodynamic conditions were stable after a consulting with the anesthesiologist, the patient was deemed unsuitable for surgery. She was transferred to the intensive care unit and remained under close observation. On postoperative day 2, TEE showed that the atrial mass had vanished and the broken piece of the endocardium merely remained fluttering in the atrium. On postoperative day 6, the appearance of the left atrium had normalized completely, leaving no traces of LAD. The patient had an uneventful postoperative course, except for prolonged respiratory failure. She was discharged from the hospital on postoperative day 47 and is currently being followed up once a month.", + "fulltext_subclaims": [ + "The patient was a 68-year-old woman.", + "She had dyspnea at rest for approximately 2 months.", + "She was classified as New York Heart Association functional class III.", + "She had previously been treated for breast and colon cancers.", + "She had not suffered from cardiovascular disease.", + "Her body mass index was 40.4 kg/m2.", + "A grade IV/VI pan-systolic murmur was heard at the apex on cardiac auscultation.", + "Her pulse rate was 105 beats/min.", + "She was diagnosed with an irregularly rapid heartbeat.", + "A chest radiograph revealed severe cardiomegaly with a cardiothoracic ratio of 80%.", + "An electrocardiogram showed persistent atrial fibrillation with a low-voltage F-wave.", + "Computed tomography demonstrated the retention of pleural fluid or abdominal dropsy.", + "Computed tomography showed hepatosplenomegaly.", + "No significant coronary stenosis was observed by coronary angiography.", + "Transthoracic echocardiography revealed severe mitral regurgitation with annular enlargement.", + "Transthoracic echocardiography revealed severe tricuspid regurgitation.", + "The cause of mitral regurgitation was severe tethering due to extreme annular enlargement.", + "The cause of mitral regurgitation was the prolapse of the anterior leaflet.", + "The left ventricular ejection fraction was 49%.", + "The left atrial diameter was 71 mm.", + "The N-terminal-proB-type natriuretic peptide level was 7439 pg/ml.", + "Because of the medication-refractory heart failure, surgery was decided upon.", + "A median sternotomy was performed.", + "Standard cardio-pulmonary bypass was initiated with ascending aortic and bicaval cannulation.", + "A left atrial vent was introduced from the right upper pulmonary vein.", + "Myocardial protection was achieved in an antegrade and retrograde fashion.", + "The retrograde cardioplegia cannula was inserted smoothly under direct vision.", + "After aortic cross-clamping, the left atrium was opened through a longitudinal left atriotomy.", + "The tethering mechanism was secondary to the prolapse of the anterior leaflet of the mitral valve.", + "The clear zone of the anterior leaflet was excised.", + "The rough zone with its attached chord were divided equally.", + "Each divided structure was transferred to the anterolateral and the posteromedial commissures separately.", + "The posterior leaflet, including the subvalvular apparatus, was wholly preserved.", + "The mitral valve was replaced with a 29-mm St. Jude mechanical valve in an intra-annular position.", + "Tricuspid annuloplasty was performed with a 32-mm Carpentier-Edwards PhysioTricuspid ring.", + "Weaning from the cardio-pulmonary bypass was successful.", + "After closing the thorax, an atrial mass of 3 cm × 2 cm was detected by TEE.", + "The atrial mass showed an oval hypoechoic appearance extending from the posterior annulus of the mitral valve to the posterior wall of the left atrium.", + "The atrial mass occupied one-third of the left atrium.", + "There was no significant obstruction of the pulmonary venous return and left ventricular filling.", + "The prosthetic valve movement was unobstructed.", + "There were no paravalvular leaks or pericardial effusion.", + "No communication between the mass and the atrial true lumen was detected using color Doppler echocardiogram.", + "The mass was diagnosed as LAD.", + "The patient was deemed unsuitable for surgery.", + "She was transferred to the intensive care unit.", + "On postoperative day 2, TEE showed that the atrial mass had vanished.", + "On postoperative day 6, the appearance of the left atrium had normalized completely.", + "The patient had an uneventful postoperative course, except for prolonged respiratory failure.", + "She was discharged from the hospital on postoperative day 47." + ], + "summary": "Herein, we have reported left atrial dissection after mitral valve replacement in a 68-year-old obese woman. After closing the thorax, transesophageal echocardiography (TEE) revealed an atrial mass of 3 cm × 2 cm, visualized as an oval hypoechoic appearance extending from the posterior annulus of the mitral valve to the posterior wall of the left atrium. Because hemodynamic conditions were stable, surgery was ruled out and conservative treatment with close observation was selected. On postoperative day 2, TEE revealed that the atrial mass had vanished and the broken piece of the endocardium merely remained fluttering in the atrium. On postoperative day 6, the appearance of the left atrium was normalized completely, leaving no traces of left atrial dissection. The patient recovered uneventfully. Serial TEE was a very effective imaging modality during the non-surgical treatment of left atrial dissection.", + "summary_subclaims": [ + "The patient was a 68-year-old obese woman.", + "Left atrial dissection occurred after mitral valve replacement.", + "Transesophageal echocardiography revealed an atrial mass of 3 cm × 2 cm.", + "The atrial mass was visualized as an oval hypoechoic appearance.", + "The mass extended from the posterior annulus of the mitral valve to the posterior wall of the left atrium.", + "Hemodynamic conditions were stable.", + "Surgery was ruled out.", + "Conservative treatment with close observation was selected.", + "On postoperative day 2, TEE revealed that the atrial mass had vanished.", + "On postoperative day 2, the broken piece of the endocardium remained fluttering in the atrium.", + "On postoperative day 6, the appearance of the left atrium was normalized completely.", + "On postoperative day 6, no traces of left atrial dissection were present.", + "The patient recovered uneventfully.", + "Serial TEE was a very effective imaging modality during the non-surgical treatment of left atrial dissection." + ] + }, + { + "id": "multiclinsum_test_1266_en.txt", + "fulltext": "A 58-year-old Japanese man was presented to our out-patient unit complaining of posterior cervical pain. The pain firstly appeared 3 months before the first contact to us without any particular triggers such as trauma. He was relieved from the pain when lying flat; however, he kept working as a plumber and the pain got worse over the time period. A brain computed tomography (CT) was performed 1.5 months after the onset in another clinic and it revealed bilateral subdural effusion , still, no treatment was given at this point. Later on, when he was presented to our hospital, numbness and weakness of extremities also appeared in addition to the progressive posterior cervical pain as well as headache. He had a medical history of hemorrhoid and no particular familial history.\nThe patient admitted to our department soon after the initial contact. A hand-held dynamometer revealed his weakened grip strength of both of his hands by 30–40 kg. He was also presented with bilateral muscle weakness in his lower extremities which was 4 of 5 in the Manual Muscle Test (MMT) score , as well as sensory disturbances in his forearms, hands and the posterior surface of thighs on both sides. His Japanese Orthopedic Association (JOA) score was 13.5.\nA fat suppression T2-weighted MRI without gadolinium enhancement of the cervical spine illustrated a fluid collection in the soft tissue spaces of the retrospinal region at C1-C2 level . Additionally, it demonstrated spinal canal stenosis at C3/4 level. Subsequently, a cisternoscintigram and a CT myelogram were performed with intradural injection of 111In-DTPA (Nihon Mediphysics, Tokyo, Japan) and Omnipaque 240® (Daiichi-Sankyo, Tokyo, Japan), an iodine contrast agent, through a lumber puncture. The 111In-DTPA cisternoscintigram clearly revealed CSF leakage into the retrospinal region at C1-C2 level, as well as blockage of the 111In-DTPA at lower level of the cervical spinal canal . Furthermore, the CT myelogram also suggested blockage at lower level of the cervical spinal canal; though it did not demonstrated the sign of CSF at C1-C2 level or any other sites .\n72 h of conservative therapy, including bed rest, intravenous fluid hydration, muscle relaxants and non-steroidal anti-inflammatory drugs, was ineffective at improving his symptoms, and the re-examination of brain CT showed progression of the bilateral subdural effusions to bilateral subdural hematomas .\nAfter reviewing of his imaging data and confirmation that no other cause presented in development of subdural hematoma along with careful discussions, we gave a diagnosis of intracranial hypotension due to the CSF leakage from C1-C2 level, which might be caused by spinal canal stenosis at C3/4 level. We, therefore, performed burr-hole drainage of the subdural hematoma, blood-patch therapy at C1/2 level and laminoplasty at C3–4, at the same time. In the laminoplasty, CSF flew out from the epidural space subsequently to the opening of lamina, and after sufficient decompression, the CSF flow was reduced in the operation field, without detection and restoration of dural tear (Video). In the blood-patch therapy, an epidural catheter was inserted from the surgical field at C3–4 level to C1-C2 level under x-ray fluoroscopy observation. Approximately 5 ml of autologous blood sampled from patient’s peripheral vein was injected to the epidural site at C1-C2 level and the blood-patch therapy was achieved.\nPostoperative response was significantly favorable. His symptoms completely improved and the imaging features that suggested CSF leak and intracranial hypotension disappeared . He discharged on postoperative day 10 with satisfaction, and no signs of recurrence were observed for 5 months postoperatively up to this point. The patient returned to his daily life as well as his occupation.", + "fulltext_subclaims": [ + "A 58-year-old Japanese man was presented to our out-patient unit complaining of posterior cervical pain.", + "The pain firstly appeared 3 months before the first contact to us without any particular triggers such as trauma.", + "He was relieved from the pain when lying flat.", + "He kept working as a plumber and the pain got worse over the time period.", + "A brain computed tomography (CT) was performed 1.5 months after the onset in another clinic.", + "The brain CT revealed bilateral subdural effusion.", + "No treatment was given at this point.", + "Later on, when he was presented to our hospital, numbness and weakness of extremities also appeared.", + "He had a medical history of hemorrhoid.", + "He had no particular familial history.", + "A hand-held dynamometer revealed his weakened grip strength of both of his hands by 30–40 kg.", + "He was presented with bilateral muscle weakness in his lower extremities which was 4 of 5 in the Manual Muscle Test (MMT) score.", + "His Japanese Orthopedic Association (JOA) score was 13.5.", + "A fat suppression T2-weighted MRI without gadolinium enhancement of the cervical spine illustrated a fluid collection in the soft tissue spaces of the retrospinal region at C1-C2 level.", + "The MRI demonstrated spinal canal stenosis at C3/4 level.", + "A cisternoscintigram and a CT myelogram were performed with intradural injection of 111In-DTPA.", + "The 111In-DTPA cisternoscintigram clearly revealed CSF leakage into the retrospinal region at C1-C2 level.", + "The CT myelogram also suggested blockage at lower level of the cervical spinal canal.", + "72 h of conservative therapy, including bed rest, intravenous fluid hydration, muscle relaxants and non-steroidal anti-inflammatory drugs, was ineffective at improving his symptoms.", + "The re-examination of brain CT showed progression of the bilateral subdural effusions to bilateral subdural hematomas.", + "We gave a diagnosis of intracranial hypotension due to the CSF leakage from C1-C2 level.", + "We performed burr-hole drainage of the subdural hematoma.", + "We performed blood-patch therapy at C1/2 level.", + "We performed laminoplasty at C3–4.", + "In the laminoplasty, CSF flew out from the epidural space subsequently to the opening of lamina.", + "After sufficient decompression, the CSF flow was reduced in the operation field, without detection and restoration of dural tear.", + "In the blood-patch therapy, an epidural catheter was inserted from the surgical field at C3–4 level to C1-C2 level under x-ray fluoroscopy observation.", + "Approximately 5 ml of autologous blood sampled from patient’s peripheral vein was injected to the epidural site at C1-C2 level.", + "The blood-patch therapy was achieved.", + "Postoperative response was significantly favorable.", + "His symptoms completely improved.", + "The imaging features that suggested CSF leak and intracranial hypotension disappeared.", + "He discharged on postoperative day 10 with satisfaction.", + "No signs of recurrence were observed for 5 months postoperatively up to this point.", + "The patient returned to his daily life as well as his occupation." + ], + "summary": "A 58-year-old man was presented to our institute with complaints of posterior cervical pain persisting for 3 months, along with numbness and muscle weakness of extremities. A fat suppression T2-weighted image of MRI illustrated fluid collection in the retrospinal region at C1-C2 level, and an 111In-DTPA cisternoscintigram clearly revealed the presence of CSF leakage into the same region. The MRI also showed stenosis in spinal canal at C3/4 level, and a computed tomography (CT) myelogram suggested a blockage at the same level. We gave a diagnosis as intracranial hypotension due to the CSF leakage, which might be caused by the spinal canal stenosis at C3/4 level. Despite 72 h of conservative therapy, a brain CT showed the development of bilateral subdural hematomas. We, therefore, performed burr-hole drainage of the subdural hematoma, blood-patch therapy at C1/2 level, and laminoplasty at C3-4 at the same time. Improvement of symptoms and imaging features which suggested the CSF leak and subdural hematoma were obtained post-operatively.", + "summary_subclaims": [ + "The patient was a 58-year-old man.", + "The patient had posterior cervical pain persisting for 3 months.", + "The patient had numbness and muscle weakness of extremities.", + "A fat suppression T2-weighted image of MRI illustrated fluid collection in the retrospinal region at C1-C2 level.", + "An 111In-DTPA cisternoscintigram revealed the presence of CSF leakage into the same region.", + "The MRI showed stenosis in spinal canal at C3/4 level.", + "A CT myelogram suggested a blockage at the C3/4 level.", + "The diagnosis was intracranial hypotension due to the CSF leakage.", + "The CSF leakage might be caused by the spinal canal stenosis at C3/4 level.", + "Despite 72 h of conservative therapy, a brain CT showed the development of bilateral subdural hematomas.", + "Burr-hole drainage of the subdural hematoma was performed.", + "Blood-patch therapy at C1/2 level was performed.", + "Laminoplasty at C3-4 was performed.", + "Improvement of symptoms was obtained post-operatively.", + "Imaging features suggesting the CSF leak and subdural hematoma were obtained post-operatively." + ] + }, + { + "id": "multiclinsum_test_3000_en.txt", + "fulltext": "A 77-year-old Japanese man presented with a follicular thyroid tumor, and the blood thyroglobulin level was 1800 ng/ml. He had no medical history or medications, but his mother and brother had history of colorectal carcinoma and prostate carcinoma. He had smoked three cigarettes for 3 years, and he did not consume alcohol regularly. He received right thyroid lobectomy, and the pathological examination showed no malignant findings such as vascular invasion or capsular invasion. The thyroglobulin level decreased to 14 ng/ml postoperatively. Follow-up at our hospital was discontinued.\nNine years after the operation, he presented to our hospital again with numbness of the right leg and difficulty of walk. On examination, weakness of the right lower limbs was observed but no mass was palpable on the lower back and lower limbs. CT showed a tumor 90 mm in size from the lumbar spine to the sacrum, causing spinal cord compression . Blood tests showed that the thyroglobulin level was increased to 11,600 ng/ml. Ultrasonography of thyroid showed a 14 mm iso-echoic mass in the residual left lobe suggesting follicular tumor. We diagnosed him with thyroid cancer with bone metastases. External beam radiotherapy (39 Gy/13 Fr) was performed on the bone metastases, followed by total thyroidectomy and radioactive iodine therapy (RAI; 131-I 100 mCi).\nThe pathology of the residual thyroid gland was follicular tumor. Although we examined the whole thyroid, including the previous specimen of right lobe, we could not find any malignant features such as vascular invasion or capsular invasion. However, we diagnosed follicular thyroid carcinoma owing to the presence of bone metastasis. Scintigraphy of RAI therapy showed high accumulation on the right pelvis and the thyroid bed . The numbness in the right thigh and weakness of the lower limbs improved after the start of treatment, and the thyroglobulin level decreased to 3940 ng/ml. However, 4 months after RAI therapy, the symptoms of numbness and weakness in the lower extremities recurred. The tumor size of pelvic bone metastasis was re-increased, and the thyroglobulin level increased to 5270 ng/ml. The patient was diagnosed with RAI-resistant thyroid follicular cancer, and lenvatinib was introduced.\nLenvatinib was introduced at dose of 24 mg per oral once daily, and he was started on calcium blocker and angiotensin II receptor blocker because of hypertension. Two weeks later, he developed National Cancer Institute (NCI) Common Terminology Criteria for Adverse Event (CTCAE) grade 3 paronychia of the right foot, which was improved by partial nail avulsion, intravenous administration of ceftriaxone, and discontinuation of lenvatinib for 3 weeks. Lenvatinib was reduced to 14 mg and resumed. Although no significant adverse events occurred after dose reduction, emphysema was found in the intestinal wall of the ascending colon on a scheduled CT image taken 14 weeks after the introduction of lenvatinib to determine the therapeutic effect .\nThe patient visited our hospital 9 days after the CT examination as planned. He had no abdominal or digestive symptoms. On examination, temperature was 36.8 °C, blood pressure 115/75 mmHg, and pulse 63 beats per minute. Physical examination of neck and abdomen was normal, and neurological abnormalities of the legs were not observed. Laboratory testing revealed a white cell count of 4400/μL (reference range 3900–9800/μL), hemoglobin level of 11.4 g/dL (reference range 13.5–17.6 g/dL), and platelet count of 279,000/μL (reference range 131,000–362,000/μL). Blood levels of electrolytes and C-reactive protein were normal, as were results of tests for renal function and liver function. Urinalysis was normal, including urine protein. Re-examination of CT was performed, and it showed the air in the intestinal wall was reduced. Because there were no findings suggestive of intestinal ischemia or perforation, he was diagnosed with pneumatosis intestinalis and lenvatinib was discontinued. He was not hospitalized and did not need any medications.\nThe numbness of the right leg worsened after withdrawal of lenvatinib, so the patient was required to restart lenvatinib at a dose of 10 mg after a week of withdrawal. Three weeks later, we tried increasing the dose of lenvatinib to 14 mg. However, we needed to reduce back to 10 mg because of anorexia . Two months after the diagnosis of pneumatosis intestinalis, CT showed that the emphysema of the intestinal tract had completely disappeared. Three years and 5 months passed since the introduction of lenvatinib; we continued lenvatinib treatment, and the therapeutic effect remains partial response. There was no recurrence of PI.", + "fulltext_subclaims": [ + "A 77-year-old Japanese man presented with a follicular thyroid tumor.", + "The blood thyroglobulin level was 1800 ng/ml.", + "He had no medical history or medications.", + "His mother and brother had history of colorectal carcinoma and prostate carcinoma.", + "He had smoked three cigarettes for 3 years.", + "He did not consume alcohol regularly.", + "He received right thyroid lobectomy.", + "The pathological examination showed no malignant findings such as vascular invasion or capsular invasion.", + "The thyroglobulin level decreased to 14 ng/ml postoperatively.", + "Follow-up at our hospital was discontinued.", + "Nine years after the operation, he presented to our hospital again with numbness of the right leg and difficulty of walk.", + "On examination, weakness of the right lower limbs was observed.", + "No mass was palpable on the lower back and lower limbs.", + "CT showed a tumor 90 mm in size from the lumbar spine to the sacrum, causing spinal cord compression.", + "Blood tests showed that the thyroglobulin level was increased to 11,600 ng/ml.", + "Ultrasonography of thyroid showed a 14 mm iso-echoic mass in the residual left lobe suggesting follicular tumor.", + "We diagnosed him with thyroid cancer with bone metastases.", + "External beam radiotherapy (39 Gy/13 Fr) was performed on the bone metastases.", + "Total thyroidectomy and radioactive iodine therapy (RAI; 131-I 100 mCi) were performed.", + "The pathology of the residual thyroid gland was follicular tumor.", + "We could not find any malignant features such as vascular invasion or capsular invasion.", + "We diagnosed follicular thyroid carcinoma owing to the presence of bone metastasis.", + "Scintigraphy of RAI therapy showed high accumulation on the right pelvis and the thyroid bed.", + "The numbness in the right thigh and weakness of the lower limbs improved after the start of treatment.", + "The thyroglobulin level decreased to 3940 ng/ml.", + "Four months after RAI therapy, the symptoms of numbness and weakness in the lower extremities recurred.", + "The tumor size of pelvic bone metastasis was re-increased.", + "The thyroglobulin level increased to 5270 ng/ml.", + "The patient was diagnosed with RAI-resistant thyroid follicular cancer.", + "Lenvatinib was introduced at dose of 24 mg per oral once daily.", + "He was started on calcium blocker and angiotensin II receptor blocker because of hypertension.", + "Two weeks later, he developed NCI CTCAE grade 3 paronychia of the right foot.", + "The paronychia was improved by partial nail avulsion, intravenous administration of ceftriaxone, and discontinuation of lenvatinib for 3 weeks.", + "Lenvatinib was reduced to 14 mg and resumed.", + "No significant adverse events occurred after dose reduction.", + "Emphysema was found in the intestinal wall of the ascending colon on a scheduled CT image taken 14 weeks after the introduction of lenvatinib.", + "The patient visited our hospital 9 days after the CT examination as planned.", + "He had no abdominal or digestive symptoms.", + "Temperature was 36.8 °C.", + "Blood pressure was 115/75 mmHg.", + "Pulse was 63 beats per minute.", + "Physical examination of neck and abdomen was normal.", + "Neurological abnormalities of the legs were not observed.", + "Laboratory testing revealed a white cell count of 4400/μL.", + "Hemoglobin level was 11.4 g/dL.", + "Platelet count was 279,000/μL.", + "Blood levels of electrolytes and C-reactive protein were normal.", + "Results of tests for renal function and liver function were normal.", + "Urinalysis was normal, including urine protein.", + "Re-examination of CT was performed, and it showed the air in the intestinal wall was reduced.", + "There were no findings suggestive of intestinal ischemia or perforation.", + "He was diagnosed with pneumatosis intestinalis.", + "Lenvatinib was discontinued.", + "He was not hospitalized and did not need any medications.", + "The numbness of the right leg worsened after withdrawal of lenvatinib.", + "The patient was required to restart lenvatinib at a dose of 10 mg after a week of withdrawal.", + "Three weeks later, we tried increasing the dose of lenvatinib to 14 mg.", + "We needed to reduce back to 10 mg because of anorexia.", + "Two months after the diagnosis of pneumatosis intestinalis, CT showed that the emphysema of the intestinal tract had completely disappeared.", + "Three years and 5 months passed since the introduction of lenvatinib.", + "We continued lenvatinib treatment.", + "The therapeutic effect remains partial response.", + "There was no recurrence of PI." + ], + "summary": "A 77-year-old Japanese man presented to our hospital with a chief complaint of numbness in the right leg and weakness of the lower limbs 9 years after right thyroid lobectomy. Computed tomography showed a tumor 90 mm in size from the lumbar spine to the sacrum, causing spinal cord compression. Blood tests showed that the patient's thyroglobulin level was increased to 11,600 ng/ml. We diagnosed him with thyroid cancer with bone metastases. External beam radiotherapy (39 Gy/13 Fr) was performed on the bone metastases, followed by total thyroidectomy and radioactive iodine therapy. Four months after radioactive iodine therapy, lenvatinib was introduced because the symptoms of numbness and weakness recurred. Lenvatinib was introduced at dose of 24 mg, and then it was reduced to 14 mg owing to Common Terminology Criteria for Adverse Event grade 3 paronychia of the right foot. Although no further significant adverse events occurred, a scheduled computed tomography image showed pneumatosis intestinalis of the ascending colon 14 weeks after the introduction of lenvatinib. No abdominal or digestive symptoms were observed; therefore, we selected conservative treatment. We discontinued lenvatinib for a week, but we were required to restart lenvatinib as the numbness in the right leg worsened after withdrawal. Since the introduction of lenvatinib, 3 years and 5 months passed; we continued lenvatinib treatment, and the therapeutic effect remains partial response. There has been no recurrence of pneumatosis intestinalis.", + "summary_subclaims": [ + "The patient is a 77-year-old Japanese man.", + "The patient had numbness in the right leg and weakness of the lower limbs.", + "The symptoms occurred 9 years after right thyroid lobectomy.", + "Computed tomography showed a tumor 90 mm in size from the lumbar spine to the sacrum.", + "The tumor caused spinal cord compression.", + "The patient's thyroglobulin level was increased to 11,600 ng/ml.", + "The patient was diagnosed with thyroid cancer with bone metastases.", + "External beam radiotherapy (39 Gy/13 Fr) was performed on the bone metastases.", + "Total thyroidectomy was performed.", + "Radioactive iodine therapy was performed.", + "Lenvatinib was introduced four months after radioactive iodine therapy.", + "Lenvatinib was introduced at a dose of 24 mg.", + "Lenvatinib was reduced to 14 mg owing to grade 3 paronychia of the right foot.", + "A scheduled computed tomography image showed pneumatosis intestinalis of the ascending colon 14 weeks after the introduction of lenvatinib.", + "No abdominal or digestive symptoms were observed.", + "Lenvatinib was discontinued for a week.", + "Lenvatinib was restarted as the numbness in the right leg worsened after withdrawal.", + "The therapeutic effect remains partial response.", + "There has been no recurrence of pneumatosis intestinalis." + ] + }, + { + "id": "multiclinsum_test_524_en.txt", + "fulltext": "A 29-year-old man presented to his local emergency department due to an increasingly severe headache for the past 2 weeks, and new-onset neurological symptoms. A CT scan of the head revealed three right-sided supratentorial lesions . He received betamethasone and was emergently transferred to the neurosurgical unit at Linköping University Hospital. The following morning a head magnetic resonance imaging was performed and confirmed intracerebral abscesses. He was started on metronidazole and cefotaxime for empiric antibiotic coverage, and the lesions were drained. Blood, urine, and abscess material were collected for culture. Aggregatibacter Aphrophilus and Eikenella Corrodens, two bacteria commonly found in the normal bacterial flora of the oral cavity were isolated from the abscess cultures.\nThe patient’s past medical history was insignificant. He had not used recreational drugs and did not abuse alcohol. He was a non-smoker but used nicotine pouches. He was of normal weight (body mass index 23.1 kg/m2) and physically fit. He worked as a serviceman for the army and was in active service. On cardiac review, he had never experienced chest pain, palpitations, decreased effort tolerance, cyanosis, or syncopal episodes. There was no recent travelling history. Family history revealed premature coronary heart disease but no sudden death or CHD. His mother had not used medications during pregnancy.\nThe patient remained afebrile, with normal pulse variability, blood pressure, and oxygen saturation on room air during the entire hospital stay. He displayed no signs of skin, ENT, dental, lung, or GI infection. The patient confirmed a visit to his dentist for scaling 1 week before the onset of the headache. Cardiac auscultation revealed regular rhythm without gallops or rubs. There was a Grade II/VI pan systolic murmur along the left sternal border increasing with inspiration. No significant jugular distension, hepatomegaly, or hepatojugular reflux was evident. Electrocardiogram (ECG) was normal .\nAs routine screening, transthoracic echocardiography (TTE) was conducted. The investigation revealed a dilated CS and atypical appearance of the tricuspid valve with moderate insufficiency. To rule out endocarditis or shunt, transoesophageal echocardiography (TOE) was scheduled along with an agitated saline study.\nThe TOE ruled out valvular vegetation, and no shunt was evident utilizing colour Doppler. Agitated saline was injected via the central venous catheter located in the right internal jugular vein; contrast appeared in LA first with a short delay before evident in the RA. To obtain a wider field of observation, the investigation was converted from TOE to TTE (Video 1). The finding raised suspicion of an extracardiac R–L shunt with a simultaneous intracardiac shunt. The same result occurred when utilizing the right cubital vein for injection. However, when agitated saline was injected via a venous line on the dorsum of the right foot, the contrast was only observed in the RA (Video 2). To further evaluate the shunt, cardiac magnetic resonance (CMR) and magnetic resonance angiography were scheduled.\nCardiac magnetic resonance confirmed normal cardiac size and function. The tricuspid valve was found to have an atypical appearance presenting elongated leaflets; however, it did not display tethering of the septal leaflet or displacement associated with Ebstein’s anomaly, or any other diagnostic pathology. Increased trabeculation of the right ventricle was observed but was non-diagnostic for non-compaction cardiomyopathy.\nMagnetic resonance angiography confirmed the presence of a bilateral superior vena caval system without a bridging vein. The PLSVC connected to the CS which drained in the RA. The RSVC presented an anomalous trajectory directly to the LA . An intracardiac connection between the RSVC and the RA could not be identified utilizing this modality and no CS defect was evident (, ) An R–L shunt involving the venous drainage of the right upper extremity and right-sided neck veins was confirmed.\nAs the extracardiac shunt in isolation could not explain the findings of the agitated saline study, the patient was scheduled to return for an ECG-gated cardiac CT (CCT) with angiography after a prolonged course of I.V. antibiotic therapy at his local hospital.\nUpon return, the CCT uncovered a 5-mm vessel branching off of the RSVC to form a connection with the RA revealing the extracardiac sinus venosus defect .", + "fulltext_subclaims": [ + "A 29-year-old man presented to his local emergency department due to an increasingly severe headache for the past 2 weeks.", + "He had new-onset neurological symptoms.", + "A CT scan of the head revealed three right-sided supratentorial lesions.", + "He received betamethasone.", + "He was emergently transferred to the neurosurgical unit at Linköping University Hospital.", + "A head magnetic resonance imaging was performed the following morning.", + "The MRI confirmed intracerebral abscesses.", + "He was started on metronidazole and cefotaxime for empiric antibiotic coverage.", + "The lesions were drained.", + "Blood, urine, and abscess material were collected for culture.", + "Aggregatibacter Aphrophilus and Eikenella Corrodens were isolated from the abscess cultures.", + "The patient’s past medical history was insignificant.", + "He had not used recreational drugs.", + "He did not abuse alcohol.", + "He was a non-smoker but used nicotine pouches.", + "He was of normal weight (body mass index 23.1 kg/m2).", + "He was physically fit.", + "He worked as a serviceman for the army and was in active service.", + "On cardiac review, he had never experienced chest pain.", + "There was no recent travelling history.", + "Family history revealed premature coronary heart disease.", + "The patient remained afebrile during the entire hospital stay.", + "He displayed no signs of skin, ENT, dental, lung, or GI infection.", + "The patient confirmed a visit to his dentist for scaling 1 week before the onset of the headache.", + "Cardiac auscultation revealed a Grade II/VI pan systolic murmur along the left sternal border increasing with inspiration.", + "Electrocardiogram (ECG) was normal.", + "Transthoracic echocardiography (TTE) was conducted.", + "The TTE revealed a dilated CS and atypical appearance of the tricuspid valve with moderate insufficiency.", + "Transoesophageal echocardiography (TOE) was scheduled.", + "Agitated saline was injected via the central venous catheter located in the right internal jugular vein.", + "Contrast appeared in LA first with a short delay before evident in the RA.", + "The investigation was converted from TOE to TTE.", + "The finding raised suspicion of an extracardiac R–L shunt with a simultaneous intracardiac shunt.", + "The same result occurred when utilizing the right cubital vein for injection.", + "When agitated saline was injected via a venous line on the dorsum of the right foot, the contrast was only observed in the RA.", + "Cardiac magnetic resonance confirmed normal cardiac size and function.", + "The tricuspid valve was found to have an atypical appearance presenting elongated leaflets.", + "Magnetic resonance angiography confirmed the presence of a bilateral superior vena caval system without a bridging vein.", + "The PLSVC connected to the CS which drained in the RA.", + "The RSVC presented an anomalous trajectory directly to the LA.", + "An R–L shunt involving the venous drainage of the right upper extremity and right-sided neck veins was confirmed.", + "The patient was scheduled to return for an ECG-gated cardiac CT (CCT) with angiography after a prolonged course of I.V. antibiotic therapy.", + "The CCT uncovered a 5-mm vessel branching off of the RSVC to form a connection with the RA revealing the extracardiac sinus venosus defect." + ], + "summary": "A 29-year-old male presented to the neurosurgical unit due to intracranial abscesses requiring intervention following a visit to his dentist. The abscess cultures isolated bacteria commonly found in the normal oral flora. Transthoracic echocardiography revealed an enlarged coronary sinus consistent with PLSVC. An agitated saline study was performed and raised suspicion of simultaneous extra- and intracardiac shunting. Magnetic resonance angiography confirmed the presence of a PLSVC and revealed an RSVC connected to the LA; however, no intracardiac shunt was evident. Electrocardiogram-gated computed tomography was therefore conducted and discovered the rudimentary remains of the physiologic RSVC forming a connection to the right atrium, explaining the bilateral contrast loading seen on the agitated saline study and diagnosing an extracardiac sinus venosus defect (SVD). The patient recovered and has been referred for surgery.", + "summary_subclaims": [ + "A 29-year-old male presented to the neurosurgical unit due to intracranial abscesses requiring intervention.", + "The abscess cultures isolated bacteria commonly found in the normal oral flora.", + "Transthoracic echocardiography revealed an enlarged coronary sinus consistent with PLSVC.", + "An agitated saline study was performed and raised suspicion of simultaneous extra- and intracardiac shunting.", + "Magnetic resonance angiography confirmed the presence of a PLSVC.", + "Magnetic resonance angiography revealed an RSVC connected to the LA.", + "No intracardiac shunt was evident.", + "Electrocardiogram-gated computed tomography was therefore conducted.", + "The rudimentary remains of the physiologic RSVC forming a connection to the right atrium were discovered.", + "The bilateral contrast loading seen on the agitated saline study was explained.", + "An extracardiac sinus venosus defect (SVD) was diagnosed.", + "The patient recovered.", + "The patient has been referred for surgery." + ] + }, + { + "id": "multiclinsum_test_2894_en.txt", + "fulltext": "A 65-year-old, right-handed Caucasian woman was transferred from a local hospital to our neurological intensive care unit (NICU) after a witnessed generalized tonic-clonic seizure. She had hypertension, diabetes mellitus, dyslipidemia, chronic obstructive pulmonary disorder, a history of heavy cigarette smoking and a long-standing but well-controlled bipolar disorder. Three weeks before the seizure, biopsy of a right hilar mass via mediastinoscopy confirmed the diagnosis of SCLC. Treatment for the cancer had not been initiated. Shortly after the biopsy, her family found her to be intermittently confused. Over the following two days, she developed fever, dizziness, vomiting, poor appetite and progressive shortness of breath. Confusion worsened to the point that she could no longer recognize her family and became non-interactive. She remained lethargic and confused despite treatment with ceftriaxone and azithromycin for right lower lobe pneumonia. Investigations and results at the local hospital included: (1) CSF analysis showed 28 white blood cells with 99% lymphocytes, glucose 122 g/L, protein 36 g/L, no organisms on Gram stain and no growth from bacterial culture; (2) MRI of the brain showed T2 and FLAIR hyperintensities in both mesial temporal regions without contrast enhancement, diffusion or susceptibility changes; (3) EEG demonstrated background slowing with focal sharp and slow discharges in the right mid-temporal and right posterior temporal region. Empiric treatment with intravenous acyclovir was initiated while HSV polymerase chain reaction (PCR) study from CSF was sent for analysis. On her seventh day at the local hospital, she was observed having a generalized tonic-clonic seizure for which she received intravenous fosphenytoin. She was intubated and transferred to our NICU.\nOn examination, she was unresponsive to verbal or noxious stimuli. Her pupils were restricted from previous cataract procedures. There was no gaze preference. Corneal, vestibular-ocular and gag reflexes were intact. Her tone was normal. She made no purposeful withdrawal on the left side. A Babinski maneuver elicited a plantar response from both feet.\nShe had a second, brief, witnessed generalized tonic-clonic seizure with left gaze deviation and left head turning. An EEG demonstrated electrographic seizures consisting of bilateral independent periodic lateralized epileptiform discharges (bi-PLEDs) in both temporal lobes with right-sided predominance . Intravenous lorazepam was given and phenytoin was reloaded. Levetiracetam and topiramate were subsequently added in increasing doses (up to maximum dosages) to treat persistent electrographic seizures. Repeat CSF analysis again demonstrated mild pleocytosis with lymphocytic predominance (23 white blood cells with 94% lymphocytes) but was otherwise normal. CSF cytology did not show any malignant cells. Empiric treatment with acyclovir for HSV encephalitis continued until a second negative CSF HSV PCR returned. Epstein-Barr virus (EBV), cytomegalovirus (CMV), varicella zoster virus (VZV) and human herpesvirus 6 (HHV-6) were all negative. Repeat MRI of the brain showed T2-FLAIR hyperintensities in both mesial temporal lobes without restricted diffusion or post-gadolinium enhancement . Chest X-ray showed post-obstructive pneumonia in the right lower lobe with collapse of the right middle and upper lobes due to compressive atelectasis from the lung cancer . Computed tomography (CT) scan of the chest demonstrated mediastinal and hilar lymphadenopathy and pleural effusion in addition to a loculated right lower lobe . Her lung cancer was not amenable to resection. She continued to receive broad-spectrum antibiotics for pneumonia, and chemotherapy for SCLC with carboplatin and etoposide was commenced.\nSerum contained markedly elevated anti-N-type voltage-gated calcium channel (VGCC) antibody titer of 0.42 nmol/L (normal value < 0.03) and mildly elevated anti-P/Q-type VGCC antibody titer of 0.04 nmol/L (normal value < 0.02). No other paraneoplastic antibody (including binding, ganglionic and striational acetycholine [Ach] receptor antibodies, Purjinke cell antibodies type 1 [PCA-1 or anti-Yo], PCA-2, PCA-Tr [anti-Tr, immune response marker for Hodgkin's lymphoma], anti-neuronal nuclear antibodies type 1 [ANNA-1 or aniti-Hu], ANNA-2 [anti-Ri], ANNA-3, anti-Ma1, anti-Ta, collapsin response-mediator protein-5 [CRMP-5 or CV2], amphiphysin, anti-glial/neuronal nuclear antibody, Type 1 AGNA-1) was detected. Voltage-gated potassium channel (VGKC), N-methyl-D-aspartate receptor (NMDAR) and glutamic acid decarboxylase (GAD) antibodies were not sent. Our patient received IVIG (0.4 mg/kg daily for five days) and 1 g of Solu-medrol (methylprednisolone) daily for three days, followed by tapering doses of prednisone over four weeks. Long-term monitoring (LTM) EEG showed gradual resolution of epileptiform activities only after initiation of immune therapy, despite being on multiple anti-epileptic drugs.\nTwo months after the onset of her neurological illness, she was following commands and had become conversant but she still displayed cognitive impairment and still suffered episodes of delirium. Our patient had multiple subsequent hospitalizations for aspiration pneumonia and seizures that were refractory to anti-epileptic drug adjustments and only responsive to IVIG and steroids on a monthly basis. MRI six months later showed resolution of T2-FLAIR hyperintensities . However, she continued to have severe short-term memory deficits. She died eight months after the initial presentation due to progressive lung cancer.", + "fulltext_subclaims": [ + "The patient was a 65-year-old, right-handed Caucasian woman.", + "She was transferred to the neurological intensive care unit after a witnessed generalized tonic-clonic seizure.", + "She had a history of hypertension, diabetes mellitus, dyslipidemia, chronic obstructive pulmonary disorder, heavy cigarette smoking, and well-controlled bipolar disorder.", + "Three weeks before the seizure, biopsy of a right hilar mass confirmed the diagnosis of small cell lung cancer.", + "Treatment for the cancer had not been initiated.", + "Her family found her intermittently confused shortly after the biopsy.", + "Over the following two days, she developed fever, dizziness, vomiting, poor appetite, and progressive shortness of breath.", + "Confusion worsened to the point that she could no longer recognize her family and became non-interactive.", + "She remained lethargic and confused despite treatment with ceftriaxone and azithromycin for right lower lobe pneumonia.", + "CSF analysis showed 28 white blood cells with 99% lymphocytes, glucose 122 g/L, protein 36 g/L, no organisms on Gram stain, and no growth from bacterial culture.", + "MRI of the brain showed T2 and FLAIR hyperintensities in both mesial temporal regions without contrast enhancement, diffusion, or susceptibility changes.", + "EEG demonstrated background slowing with focal sharp and slow discharges in the right mid-temporal and right posterior temporal region.", + "Empiric treatment with intravenous acyclovir was initiated while HSV PCR study from CSF was sent for analysis.", + "On her seventh day at the local hospital, she was observed having a generalized tonic-clonic seizure for which she received intravenous fosphenytoin.", + "She was intubated and transferred to the neurological intensive care unit.", + "On examination, she was unresponsive to verbal or noxious stimuli.", + "Her pupils were restricted from previous cataract procedures.", + "There was no gaze preference.", + "Corneal, vestibular-ocular, and gag reflexes were intact.", + "Her tone was normal.", + "She made no purposeful withdrawal on the left side.", + "A Babinski maneuver elicited a plantar response from both feet.", + "She had a second, brief, witnessed generalized tonic-clonic seizure with left gaze deviation and left head turning.", + "An EEG demonstrated electrographic seizures consisting of bilateral independent periodic lateralized epileptiform discharges in both temporal lobes with right-sided predominance.", + "Intravenous lorazepam was given and phenytoin was reloaded.", + "Levetiracetam and topiramate were subsequently added in increasing doses to treat persistent electrographic seizures.", + "Repeat CSF analysis again demonstrated mild pleocytosis with lymphocytic predominance (23 white blood cells with 94% lymphocytes) but was otherwise normal.", + "CSF cytology did not show any malignant cells.", + "Empiric treatment with acyclovir for HSV encephalitis continued until a second negative CSF HSV PCR returned.", + "Epstein-Barr virus, cytomegalovirus, varicella zoster virus, and human herpesvirus 6 were all negative.", + "Repeat MRI of the brain showed T2-FLAIR hyperintensities in both mesial temporal lobes without restricted diffusion or post-gadolinium enhancement.", + "Chest X-ray showed post-obstructive pneumonia in the right lower lobe with collapse of the right middle and upper lobes due to compressive atelectasis from the lung cancer.", + "Computed tomography scan of the chest demonstrated mediastinal and hilar lymphadenopathy and pleural effusion in addition to a loculated right lower lobe.", + "Her lung cancer was not amenable to resection.", + "She continued to receive broad-spectrum antibiotics for pneumonia.", + "Chemotherapy for SCLC with carboplatin and etoposide was commenced.", + "Serum contained markedly elevated anti-N-type voltage-gated calcium channel antibody titer of 0.42 nmol/L.", + "Serum contained mildly elevated anti-P/Q-type voltage-gated calcium channel antibody titer of 0.04 nmol/L.", + "No other paraneoplastic antibody was detected.", + "Voltage-gated potassium channel, N-methyl-D-aspartate receptor, and glutamic acid decarboxylase antibodies were not sent.", + "The patient received IVIG (0.4 mg/kg daily for five days) and 1 g of methylprednisolone daily for three days.", + "Long-term monitoring EEG showed gradual resolution of epileptiform activities only after initiation of immune therapy.", + "Two months after the onset of her neurological illness, she was following commands and had become conversant.", + "She still displayed cognitive impairment and episodes of delirium.", + "She had multiple subsequent hospitalizations for aspiration pneumonia and seizures.", + "MRI six months later showed resolution of T2-FLAIR hyperintensities.", + "She continued to have severe short-term memory deficits.", + "She died eight months after the initial presentation due to progressive lung cancer." + ], + "summary": "A 65-year-old Caucasian woman presented with generalized tonic-clonic seizures and increasing confusion shortly after a lung biopsy that led to the diagnosis of small-cell lung cancer. She had a complicated hospital course, and had recurrent respiratory distress due to aspiration pneumonia, and fluctuating mental status and seizures that were refractory to anti-epileptic drug treatment. Routine laboratory testing, magnetic resonance imaging of the brain, electroencephalogram, lumbar puncture, serum and cerebrospinal fluid tests for paraneoplastic antibodies, and chest computed tomography were performed on our patient. The diagnosis was paraneoplastic limbic encephalitis in the setting of small-cell lung cancer with positive N-type voltage-gated calcium channel antibody titer. Anti-epileptic drugs for seizures, chemotherapy for small-cell lung cancer, and intravenous immunoglobulin and steroids for paraneoplastic limbic encephalitis led to a resolution of her seizures and improved her mental status.", + "summary_subclaims": [ + "The patient is a 65-year-old Caucasian woman.", + "She presented with generalized tonic-clonic seizures.", + "She had increasing confusion.", + "She had a lung biopsy that led to the diagnosis of small-cell lung cancer.", + "She had recurrent respiratory distress due to aspiration pneumonia.", + "She had fluctuating mental status.", + "She had seizures that were refractory to anti-epileptic drug treatment.", + "Routine laboratory testing was performed.", + "Magnetic resonance imaging of the brain was performed.", + "An electroencephalogram was performed.", + "A lumbar puncture was performed.", + "Serum and cerebrospinal fluid tests for paraneoplastic antibodies were performed.", + "Chest computed tomography was performed.", + "The diagnosis was paraneoplastic limbic encephalitis.", + "The diagnosis was in the setting of small-cell lung cancer.", + "The patient had positive N-type voltage-gated calcium channel antibody titer.", + "Anti-epileptic drugs for seizures were used.", + "Chemotherapy for small-cell lung cancer was used.", + "Intravenous immunoglobulin and steroids for paraneoplastic limbic encephalitis were used.", + "Her seizures resolved.", + "Her mental status improved." + ] + }, + { + "id": "multiclinsum_test_2493_en.txt", + "fulltext": "A 43-year-old Malay female was referred by an ophthalmologist to the low vision clinic for low vision rehabilitation assessment. She was diagnosed with tractional retinal detachment secondary to diabetic retinopathy. She reported that she was diagnosed with diabetes mellitus 5 years ago. Currently, the patient is on follow-up and receiving treatment for diabetes mellitus from a government hospital. Her treatment includes metformin 500 mg twice daily, glicazide 60 mg daily and insulin 18 unit/day (nocte). Her glycosylated hemoglobin (HbAIc) assay at her last visit was 7 mmol/L. Apart from the diabetes mellitus, she is also on treatment for hypertension with hydrochlorothiazide 12.5 mg daily and for cholesterol with atorvastatin 20 mg daily. However, there was no evidence of any end organ damage i.e. diabetic nephropathy or diabetic neuropathy. There was no family history of diabetes mellitus or retinal detachment. Her main complaints at presentation at the low vision clinic was 1) blurred vision at both distance and near but she had never used nor was ever prescribed with any contact lens or glasses, 2) difficulty in recognizing faces and 3) difficulty with orientation and mobility. She had exhausted all her efforts to get treatment/rehabilitation for her visual problem and was frequently told that “nothing more can be done” to alleviate her condition. She agreed to be referred to the low vision clinic by the private ophthalmologist as a last attempt to improve her vision and quality of life through low vision rehabilitation.\nUpon examination, her distance vision for right eye (RE) and left eye (LE) was 6/48. Her near vision was N28 at 20 cm bilaterally. Subjective refraction, improved her distance vision to RE 6/48 using -1.75Ds, and LE 6/38 with a +3.50 Ds. For near, addition of +2.50 Ds enabled her to read N24 for RE and N16 for LE both at a reading distance of 20 cm. Visual field assessment testing at near using an Amsler’s chart revealed no abnormality. Contrast sensitivity function was not measured. Examination of her fundi using binocular indirect ophthalmoscopy and fundus photography showed diabetic retinopathy changes and tractional retinal detachment . She was informed of her eye condition with respect to the pathological process and its effect on her functional vision. The DASS score showed that she was in a state of severe stress (score = 34); she was severely anxious (score = 16), and she was depressed (score = 38). The LVQoL questionnaire assessment score was 43, which indicated that her quality of life was at the moderate stage.\nLow vision assessment was conducted for near and distance vision. Using a +6.00 Ds spectacle magnifier she was able to improve her near vision to N10 at a reading distance of 20 cm. For her LE distance vision, a 3× monocular telescope was able to improve her vision to 6/12. She was also introduced to eccentric viewing techniques to identify/recognize faces. To assist her with orientation and mobility, a pair of distance spectacles with prescription of RE-1.75 Ds, LE +3.50 Ds and a 3x monocular telescope was prescribed. She was also referred to an orientation & mobility clinic at a training center organized by a blind person’s association. She agreed to a referral to the Social Welfare Department for registration purposes and eligibility assessment for benefits. To help her cope with her mental health status, she was referred to a clinical psychology clinic. She was also referred to an occupational therapy clinic to cope with her daily living activities. She was advised to return for a review at the low vision clinic in 3 months to monitor her functional vision for distance and near work and to repeat her DASS and LVQoL evaluations. Her mental health state will be monitored using DASS and her quality of life scores will be measured using the LVQoL questionnaire at the follow up.\nAfter 3 months, the patient returned for a follow-up low vision. A routine low vision assessment was conducted and the DASS and LVQoL questionnaire was readministered. It was found that the patient’s visual acuity for both eyes remains the same i.e. 6/48. Subjective refraction and visual field status were similarly unchanged. The DASS and LVQoL questionnaire on the other hand showed significant improvement. The DASS score indicated that the stress level had come down from extremely severe (score = 34) to normal (score = 14) and the depression level also registered a decrease from extremely severe to moderate (score = 18) level. The anxiety score remained at 16 while the LVQoL score markedly improved from 43 to 98. A further three months review was given to the patient at the low vision clinic. At the same time, the patient was advised to continue with her sessions at the psychology clinic, occupational therapy clinic and the orientation & mobility clinic at the association for the blind.", + "fulltext_subclaims": [ + "The patient is a 43-year-old Malay female.", + "She was referred to the low vision clinic by an ophthalmologist.", + "She was diagnosed with tractional retinal detachment secondary to diabetic retinopathy.", + "She was diagnosed with diabetes mellitus 5 years ago.", + "She is currently on treatment for diabetes mellitus at a government hospital.", + "Her treatment includes metformin 500 mg twice daily.", + "Her treatment includes glicazide 60 mg daily.", + "Her treatment includes insulin 18 unit/day (nocte).", + "Her glycosylated hemoglobin (HbAIc) was 7 mmol/L at her last visit.", + "She is on treatment for hypertension with hydrochlorothiazide 12.5 mg daily.", + "She is on treatment for cholesterol with atorvastatin 20 mg daily.", + "There was no evidence of diabetic nephropathy.", + "There was no evidence of diabetic neuropathy.", + "There was no family history of diabetes mellitus.", + "There was no family history of retinal detachment.", + "Her main complaint at presentation was blurred vision at both distance and near.", + "She had never used nor was ever prescribed contact lens or glasses.", + "She reported difficulty in recognizing faces.", + "She reported difficulty with orientation and mobility.", + "She had been told that 'nothing more can be done' to alleviate her condition.", + "She agreed to be referred to the low vision clinic as a last attempt.", + "Her distance vision for right eye was 6/48.", + "Her distance vision for left eye was 6/48.", + "Subjective refraction improved her distance vision to 6/48 using -1.75Ds in the right eye.", + "Subjective refraction improved her distance vision to 6/38 with a +3.50 Ds in the left eye.", + "Addition of +2.50 Ds enabled her to read N24 for the right eye.", + "Addition of +2.50 Ds enabled her to read N16 for the left eye.", + "Visual field assessment testing at near using an Amsler’s chart revealed no abnormality.", + "Examination of her fundi showed diabetic retinopathy changes.", + "Examination of her fundi showed tractional retinal detachment.", + "The DASS score showed she was in a state of severe stress (score = 34).", + "The DASS score showed she was severely anxious (score = 16).", + "The DASS score showed she was depressed (score = 38).", + "The LVQoL questionnaire assessment score was 43.", + "Using a +6.00 Ds spectacle magnifier, she improved her near vision to N10 at 20 cm.", + "A 3× monocular telescope improved her left eye distance vision to 6/12.", + "She was introduced to eccentric viewing techniques.", + "A pair of distance spectacles with prescription RE-1.75 Ds, LE +3.50 Ds was prescribed.", + "A 3x monocular telescope was prescribed.", + "She was referred to an orientation & mobility clinic.", + "She agreed to a referral to the Social Welfare Department.", + "She was referred to a clinical psychology clinic.", + "She was referred to an occupational therapy clinic.", + "She was advised to return for a review in 3 months.", + "After 3 months, the patient returned for a follow-up.", + "Her visual acuity for both eyes remained the same at 6/48.", + "Subjective refraction and visual field status were unchanged.", + "The DASS score for stress decreased from 34 to 14.", + "The DASS score for depression decreased from 38 to 18.", + "The LVQoL score improved from 43 to 98.", + "A further three months review was given.", + "She was advised to continue with sessions at the psychology clinic.", + "She was advised to continue with sessions at the occupational therapy clinic.", + "She was advised to continue with sessions at the orientation & mobility clinic." + ], + "summary": "We describe the case of a 43-year-old Asian female who has mild vision impairment due to tractional retinal detachment secondary to diabetic retinopathy and how mental health screening and quality of life screening during low vision rehabilitation can improve in the management of this patient.", + "summary_subclaims": [ + "The patient is a 43-year-old Asian female.", + "The patient has mild vision impairment.", + "The patient has tractional retinal detachment.", + "The tractional retinal detachment is secondary to diabetic retinopathy.", + "Mental health screening was performed during low vision rehabilitation.", + "Quality of life screening was performed during low vision rehabilitation.", + "Mental health screening and quality of life screening can improve the management of this patient." + ] + }, + { + "id": "multiclinsum_test_2318_en.txt", + "fulltext": "A 58-year-old woman was referred to our center for further investigation of a cystic lesion in the pancreas. She has a history of repeated resection for brain tumor diagnosed as meningioma in another hospital. The first brain surgery was performed at 31 years of age, and she underwent surgical excision of the recurrent tumor 16 and 26 years after the initial resection. During admission in a community hospital for the treatment of a femoral bone fracture, computed tomography (CT) incidentally detected a 5.5-cm cystic tumor in the pancreas tail.\nThe laboratory data on admission in our hospital indicated a slightly elevated level of serum lipase (56 IU/L; normal range, 13–55 IU/L) and gamma-glutamyl transpeptidase (47 IU/L; normal range, 9–32 IU/L). In contrast, the tumor marker levels of carcinoembryonic antigen, carbohydrate antigen 19-9, and DUPAN-2 were within the normal range.\nEndoscopic ultrasonography (EUS) revealed a circumscribed well-encapsulated cystic mass in the pancreas tail with protruding vascularity-rich components inside. A hypervascular area that appeared like collateral vessels was also observed on the surface of the tumor . Dynamic contrast-enhanced CT showed a heterogeneously enhancing mass beside the splenic hilum with a large non-enhancing portion inside. From the arterial to portal phase, strong enhancement was observed both in the rim and the edge of the protruding solid components with the hypoattenuating area inside the solid lesions. During the portal to delay phase, all of these were gradually isoattenuated compared to the surrounding pancreatic parenchyma except for the non-enhancing portion . Magnetic resonance imaging (MRI) confirmed low signal intensity in the solid components on T1-weighted imaging and slightly higher signal intensity on T2-weighted imaging compared with the pancreas parenchyma. Additionally, the large non-enhancing portion on CT appeared as a bright signal on T2-weighted imaging, indicating cystic or necrotic change .\nBased on these findings, we considered pancreatic neuroendocrine neoplasm, solid pseudopapillary neoplasm, and hemangioma in the differential diagnosis. Although its morphological structure is untypical, mucinous cystic neoplasm was also considered given the patient’s sex and tumor location. Invasive carcinoma of the pancreas was excluded from the differential diagnosis. EUS-guided fine-needle aspiration biopsy (EUS-FNA) was not performed considering the risk of cystic puncture and bleeding. We performed distal pancreatectomy with regional lymph node dissection for this disease. The pancreatic parenchyma was resected above the left edge of the superior mesenteric artery. The postoperative course was uneventful, and the patient was discharged on the 15th postoperative day.\nThe resected specimen revealed a well-demarcated hemispheric cystic mass projecting from the pancreas tail and measuring 5.6 × 5.4 cm in diameter. The solid components occupied most of the lesion . The pancreatic stump was free of tumor with a margin of approximately 3 cm including the width of the stapler closure. Histopathological examination confirmed that oval and spindle-shaped cells proliferated bluntly with a richly vascular stroma, and they were configured to be a hemangiopericytoma-like structure . Immunohistochemically, the specimen stained positively for CD34, a mesenchymal marker , but negatively for cytokeratin AE1/3, an epithelium marker (data not shown). Furthermore, CD99, Bcl-2, and STAT6 were diffusely positive , whereas beta-catenin, chromogranin, and synaptophysin were all negative (data not shown). Therefore, we diagnosed this tumor as SFT of the pancreas. Further, the tumor showed an increased mitotic rate (ten mitoses per ten high-power fields), indicating its malignant potential.\nConsidering the similarity of meningioma, which was the patient’s past disease, to intracranial SFT, we conducted a histopathological review of her brain tumor. We found that it had the same characteristics as the pancreatic tumor and thus determined that the SFT of the pancreas was derived from the central nervous system tumor.\nShe underwent no adjuvant therapy, and no recurrence has been observed in the abdominal cavity. However, she developed meningeal dissemination 4 years after the pancreatectomy and is currently undergoing treatment.", + "fulltext_subclaims": [ + "A 58-year-old woman was referred to our center for further investigation of a cystic lesion in the pancreas.", + "She has a history of repeated resection for brain tumor diagnosed as meningioma in another hospital.", + "The first brain surgery was performed at 31 years of age.", + "She underwent surgical excision of the recurrent tumor 16 and 26 years after the initial resection.", + "Computed tomography (CT) incidentally detected a 5.5-cm cystic tumor in the pancreas tail.", + "The laboratory data on admission in our hospital indicated a slightly elevated level of serum lipase (56 IU/L; normal range, 13–55 IU/L).", + "The tumor marker levels of carcinoembryonic antigen, carbohydrate antigen 19-9, and DUPAN-2 were within the normal range.", + "Endoscopic ultrasonography (EUS) revealed a circumscribed well-encapsulated cystic mass in the pancreas tail with protruding vascularity-rich components inside.", + "Dynamic contrast-enhanced CT showed a heterogeneously enhancing mass beside the splenic hilum with a large non-enhancing portion inside.", + "Magnetic resonance imaging (MRI) confirmed low signal intensity in the solid components on T1-weighted imaging.", + "The large non-enhancing portion on CT appeared as a bright signal on T2-weighted imaging.", + "We considered pancreatic neuroendocrine neoplasm, solid pseudopapillary neoplasm, and hemangioma in the differential diagnosis.", + "Invasive carcinoma of the pancreas was excluded from the differential diagnosis.", + "EUS-guided fine-needle aspiration biopsy (EUS-FNA) was not performed considering the risk of cystic puncture and bleeding.", + "We performed distal pancreatectomy with regional lymph node dissection for this disease.", + "The resected specimen revealed a well-demarcated hemispheric cystic mass projecting from the pancreas tail and measuring 5.6 × 5.4 cm in diameter.", + "The solid components occupied most of the lesion.", + "Histopathological examination confirmed that oval and spindle-shaped cells proliferated bluntly with a richly vascular stroma.", + "The specimen stained positively for CD34, a mesenchymal marker.", + "The specimen stained negatively for cytokeratin AE1/3, an epithelium marker.", + "CD99, Bcl-2, and STAT6 were diffusely positive.", + "Beta-catenin, chromogranin, and synaptophysin were all negative.", + "We diagnosed this tumor as SFT of the pancreas.", + "The tumor showed an increased mitotic rate (ten mitoses per ten high-power fields), indicating its malignant potential.", + "We conducted a histopathological review of her brain tumor.", + "We found that it had the same characteristics as the pancreatic tumor.", + "We determined that the SFT of the pancreas was derived from the central nervous system tumor.", + "She underwent no adjuvant therapy.", + "No recurrence has been observed in the abdominal cavity.", + "She developed meningeal dissemination 4 years after the pancreatectomy.", + "She is currently undergoing treatment." + ], + "summary": "A 58-year-old woman with a past medical history of brain tumor visited the hospital for further investigation of a cystic tumor in the pancreas tail. Abdominal imaging showed a heterogeneously enhancing mass that was initially suspected as a neuroendocrine neoplasm, solid pseudopapillary neoplasm, or mucinous cystic neoplasm of the pancreas. Distal pancreatectomy was performed without any intraoperative and postoperative complications. Pathological findings confirmed a diagnosis of malignant SFT of the pancreas with hyperproliferative potential. A histopathological review of her brain tumor revealed that the pancreatic tumor was derived from her brain lesion. The patient developed recurrent brain disease 4 years after the pancreatectomy, but no recurrence has been observed in the abdominal cavity.", + "summary_subclaims": [ + "The patient is a 58-year-old woman.", + "She has a past medical history of brain tumor.", + "She visited the hospital for further investigation of a cystic tumor in the pancreas tail.", + "Abdominal imaging showed a heterogeneously enhancing mass.", + "The mass was initially suspected as a neuroendocrine neoplasm.", + "The mass was initially suspected as a solid pseudopapillary neoplasm.", + "The mass was initially suspected as a mucinous cystic neoplasm of the pancreas.", + "Distal pancreatectomy was performed.", + "There were no intraoperative complications.", + "There were no postoperative complications.", + "Pathological findings confirmed a diagnosis of malignant SFT of the pancreas.", + "The pancreatic tumor was diagnosed with hyperproliferative potential.", + "A histopathological review of her brain tumor revealed that the pancreatic tumor was derived from her brain lesion.", + "The patient developed recurrent brain disease 4 years after the pancreatectomy.", + "No recurrence has been observed in the abdominal cavity." + ] + }, + { + "id": "multiclinsum_test_2553_en.txt", + "fulltext": "A 50 year old male from a VL endemic village of Bihar presented to the OPD of this institute in August 2007. He had fever with weakness and pallor of about 3 months duration. The fever was associated with chills. He also complained of frequent loose motions in the last 6 months and had lost about 7 kg of weight. He had dry cough of one month duration associated with small amount of haemoptysis and oral ulceration more marked on the tongue. He also complained of frequent micturition and pain in the metatarsophalangeal joints of the big toes bilaterally alongwith some amount of generalized joint pain.\nHe was a truck driver by profession and was a frequent visitor to the red light areas of metropolitan cities namely Mumbai and Kolkata. On close questioning he revealed having frequent sex with multiple commercial sex workers. He use to take alcohol, toddy and smoked 2–3 cigarettes per day. He had two small children aged 8 years & 6 years (both girls). At the time of presentation he had bradykinesia with mask facies and characteristic pill rolling tremor more marked on the right side. The arms swing was also absent on the right side while walking and his gait was festinant. There were no features of forgetfulness or dementia, history of falls or any associated autonomic disturbances. He however had micrographia with monotonous speech.\nOn clinical examination he had a mouth temperature of 102°F (39°C) with a pulse rate of 120/min. His respiration rate was 20/min and his blood pressure was 110/70 mmHg in the left upper limb in supine posture. Chest and cardio vascular system examination were normal except for sinus tachycardia. His liver and spleen were palpable 2 cm and 4 cm below the respective coastal margins in the mid axillary lines. On central nervous system examination the mask facies, bradykinesia, pill rolling tremor, cogwheel rigidity and festinant gait were elicited. Bradykinesia and rigidity were asymmetric. The palmo-mental and glabellar tap reflexes were positive bilaterally. The planters were bilaterally flexor. All the above symptoms were more marked on the right side.\nThe patient was subjected to various hematological and biochemical investigations along with splenic aspiration, chest x-ray postero-anterior view, ultra sonography of abdomen and computerized tomography (CT scan) of the brain. He had a hemoglobin level of 6 gm/dl along with a total count of 4000 cells/mm3. Liver and renal function tests were normal. His fasting blood sugar was 120 mg/dl and post prandial level was 160 mg/dl. His serum uric acid was 7.2 mg/dl. Western Blot for HIV1 was positive. His CD4 count was 180/μl and CD8 count was 643/μl. Splenic aspirate for Leishman Donovan bodies was 3+ according to WHO criteria. Ultra sound showed hepatosplenomegaly with features of fatty liver. CT scan of the brain and ECG were normal. ELISA and PCR for tuberculosis were negative. MRI and spinal fluid examination were also done and found normal.\nBased of the above findings a diagnosis of HIV1, VL and Parkinsonism was made. Other associations were diabetes mellitus and hyperuricaemia. He was put on diabetic diet and started on Miltefosine 50 mg capsules twice daily for 28 days after meals along with iron and folic acid supplements. He was also administered Allopurinol in the dose of 100 mg tablets twice daily. He was started on highly active antiretroviral therapy with two nucleoside reverse transcriptase inhibitors namely Zidovudine (200 mg) plus Lamivudine (150 mg) and one non nucleoside reverse transcriptase inhibitor namely Nevirapine 200 mg twice daily after food. Parkinson's disease was treated with Entecapone (100 mg), levodopa (100 mg) and Carbidopa (25 mg) combination twice daily with Triphenhexidyl (2 mg) twice daily along with Selegiline hydrochloride 5 mg twice daily. Other D2 receptor agonists like ropinirole or pramipexole were not added.\nAfter one month of treatment his spleen had regressed, there was no fever and no LD bodies were seen in the bone-marrow aspirate. He was continued on antiretroviral therapy (ART) and Anti-Parkinsonian therapy (entekapone, levodopa, carbidopa, triphenhexidyl and selegeline) along with allopurinol. His CD4 increased to 300/ml. He was able to walk with considerably less tremor. He, however, relapsed for visceral leishmaniasis after 3 months of therapy and was treated with Amphotericin B in the dose of 1 mg/kg body weight for 15 days in 5% dextrose intravenous infusion on alternate days. He was told to report after one month but was ultimately lost to follow up. About 6 months later, it was gathered from his relatives that he had died. VL, itself, is a disease of poorest of the poor as it mainly affects the low socio-economic group and the combination of HIV and Parkinsonism makes it more difficult for the people of poor countries likes India for proper treatment compliance and regular follow-up visits. It is hoped that possibly due to this reason the patient could not turn up and eventually he might have contracted some other AIDS related complications and lost his life. We really feel pity for his poor family.", + "fulltext_subclaims": [ + "The patient was a 50 year old male from a VL endemic village of Bihar.", + "He presented to the OPD in August 2007.", + "He had fever with weakness and pallor of about 3 months duration.", + "The fever was associated with chills.", + "He had frequent loose motions in the last 6 months.", + "He had lost about 7 kg of weight.", + "He had dry cough of one month duration associated with small amount of haemoptysis.", + "He had oral ulceration more marked on the tongue.", + "He had frequent micturition.", + "He had pain in the metatarsophalangeal joints of the big toes bilaterally.", + "He had generalized joint pain.", + "He was a truck driver by profession.", + "He was a frequent visitor to the red light areas of Mumbai and Kolkata.", + "He had frequent sex with multiple commercial sex workers.", + "He used to take alcohol, toddy and smoked 2–3 cigarettes per day.", + "He had two small children aged 8 years & 6 years.", + "At the time of presentation he had bradykinesia with mask facies.", + "He had a characteristic pill rolling tremor more marked on the right side.", + "The arms swing was absent on the right side while walking.", + "His gait was festinant.", + "There were no features of forgetfulness or dementia.", + "There was no history of falls or any associated autonomic disturbances.", + "He had micrographia with monotonous speech.", + "On clinical examination he had a mouth temperature of 102°F (39°C).", + "His pulse rate was 120/min.", + "His respiration rate was 20/min.", + "His blood pressure was 110/70 mmHg in the left upper limb in supine posture.", + "His liver and spleen were palpable 2 cm and 4 cm below the respective coastal margins.", + "On central nervous system examination the mask facies, bradykinesia, pill rolling tremor, cogwheel rigidity and festinant gait were elicited.", + "The palmo-mental and glabellar tap reflexes were positive bilaterally.", + "The planters were bilaterally flexor.", + "All the above symptoms were more marked on the right side.", + "The patient was subjected to various hematological and biochemical investigations.", + "He had a hemoglobin level of 6 gm/dl.", + "His total count was 4000 cells/mm3.", + "His fasting blood sugar was 120 mg/dl.", + "His post prandial blood sugar level was 160 mg/dl.", + "His serum uric acid was 7.2 mg/dl.", + "Western Blot for HIV1 was positive.", + "His CD4 count was 180/μl.", + "His CD8 count was 643/μl.", + "Splenic aspirate for Leishman Donovan bodies was 3+ according to WHO criteria.", + "Ultra sound showed hepatosplenomegaly with features of fatty liver.", + "CT scan of the brain and ECG were normal.", + "ELISA and PCR for tuberculosis were negative.", + "MRI and spinal fluid examination were also done and found normal.", + "A diagnosis of HIV1, VL and Parkinsonism was made.", + "Other associations were diabetes mellitus and hyperuricaemia.", + "He was put on diabetic diet.", + "He was started on Miltefosine 50 mg capsules twice daily for 28 days after meals.", + "He was administered Allopurinol in the dose of 100 mg tablets twice daily.", + "He was started on highly active antiretroviral therapy with Zidovudine (200 mg) plus Lamivudine (150 mg).", + "He was started on Nevirapine 200 mg twice daily after food.", + "Parkinson's disease was treated with Entecapone (100 mg), levodopa (100 mg) and Carbidopa (25 mg) combination twice daily.", + "He was given Triphenhexidyl (2 mg) twice daily.", + "He was given Selegiline hydrochloride 5 mg twice daily.", + "Other D2 receptor agonists like ropinirole or pramipexole were not added.", + "After one month of treatment his spleen had regressed.", + "There was no fever.", + "No LD bodies were seen in the bone-marrow aspirate.", + "He was continued on antiretroviral therapy (ART) and Anti-Parkinsonian therapy.", + "His CD4 increased to 300/ml.", + "He was able to walk with considerably less tremor.", + "He relapsed for visceral leishmaniasis after 3 months of therapy.", + "He was treated with Amphotericin B in the dose of 1 mg/kg body weight for 15 days.", + "He was told to report after one month but was ultimately lost to follow up.", + "About 6 months later, it was gathered from his relatives that he had died.", + "VL is a disease of poorest of the poor as it mainly affects the low socio-economic group.", + "The combination of HIV and Parkinsonism makes it more difficult for the people of poor countries like India for proper treatment compliance and regular follow-up visits.", + "It is hoped that possibly due to this reason the patient could not turn up.", + "He might have contracted some other AIDS related complications and lost his life." + ], + "summary": "We hereby report an unusual case presentation of Visceral leishmaniasis/HIV co-infection with additional features of Parkinsonism and hyperuriciemia in an Indian male patient aged about 50 years.", + "summary_subclaims": [ + "The patient is an Indian male.", + "The patient is about 50 years old.", + "The case involves Visceral leishmaniasis/HIV co-infection.", + "The case presentation includes features of Parkinsonism.", + "The case presentation includes hyperuricemia." + ] + }, + { + "id": "multiclinsum_test_1307_en.txt", + "fulltext": "A 37-year-old female, 159 cm tall, weighing 53 kg, presented with progressive exertional dyspnea for 6 months. A diagnosis of autoimmune PAP was confirmed based on her history, high-resolution computerized tomography (HRCT), and bronchoalveolar lavage (BAL) findings. WLL of the left lung, in which pulmonary infiltrates were denser than in the right lung on HRCT, was performed under general anesthesia due to exacerbation of dyspnea during follow-up. The first lavages were performed with 10,000 ml of normal saline, with an almost equal volume of returning effluent. Although her postoperative course was smooth for 4 months, she again developed exertional dyspnea and new and denser pulmonary infiltrates. Thus, a second WLL was planned 8 months after the first WLL.\nArterial blood gas (ABG) values before the second WLL, with the patient breathing room air, are as shown in Table . Pulmonary function tests revealed a restrictive pattern: vital capacity (VC)=1.44 (44.1%), forced expiratory volume in 1 s (FEV1) =1.07 (39.8%), and carbon monoxide diffusion capacity (DLCO)=4.80 (20.8%). A 6-min walk test showed desaturation with exercise from 91 to 73%, resulting in the test being aborted after 3 min. Since the radiological involvement was greater on the left side, a repeated left lung lavage was planned with stand-by extracorporeal membrane oxygenation (ECMO) to prevent fatal hypoxemia.\nAfter entering the operating room, electrocardiography, pulse oximeter (SpO2), and non-invasive blood pressure monitors were attached. After pre-oxygenation with 5 L/min of 100% O2 for 5 min, general anesthesia was induced and maintained with propofol, remifentanil, and rocuronium, and a 37 Fr left-sided double-lumen tube (DLT) was inserted. Correct positioning of the DLT was confirmed using bronchoscopy. Radial artery cannulation was performed for ABG analysis, which revealed a PaO2 of 467.4 mmHg following 5 min of bilateral mechanical ventilation with an FiO2 of 1.0. End-tidal PaCO2, arterial blood pressure, and bladder temperature were also monitored intraoperatively. In addition to usual monitors, a FloTracTM monitoring system (Edwards Lifesciences, California, USA) and transesophageal echocardiography (TEE) were prepared. After induction of anesthesia, baseline ABG revealed within the normal limits . The patient was placed in the supine position with the right lung side slightly tilted downward.\nThe bronchial lumen of the DLT in the left main bronchus was connected to the saline delivery system. During one lung ventilation (OLV) of the right lung, after letting the patient’s left lung degas for 15 min and recruitment maneuver, ABG showed a PaO2 of 194.9 mmHg under an FiO2 of 1.0. Confirming adequate oxygenation during OLV, we started lavage. The ventilator settings were kept unchanged during OLV [PCV Peak 15 cmH2O, PEEP 6 cmH2O, I: E 1:1.5, RR 14/min]. Lavage was performed by repeatedly filling the left lung with irrigating solution while performing OLV of the right lung with an FiO2 of 1.0.\nIn every lavage procedure, 600 to 1000 ml of normal saline flowed into the left lung at a rate of 100 ml/min from a height of 30 cm above the patient, followed by passive drainage under gravity. The procedure was repeated 15 times using the instillation of warm saline and removal of the effluent. A total of 14 l of fluid was instilled into the left lung. WLL was performed satisfactorily, with the amount of effluent removed being almost equal to the instilled volume. The effluent contained very large amounts of amorphous sediment which gradually cleared. After 2.5 h of lavage, that is, nearly at the end of WLL, ABG values are as shown in Table . The pH, base excess, glucose, Na+, K+, and Cl− values suggested a strong ion difference (SID=20.36) . Dilutional hyperchloremic metabolic acidosis was diagnosed, likely due to excessive alveolar absorption of normal saline during WLL. The intraoperative infusion was 1260 ml including 700 ml of acetate Ringer’s, 50ml of Carbonate Ringer’s, and 510 ml of normal saline. Intraoperative urine volume was 90ml.\nThe patient remained hemodynamically stable during WLL, and there were no significant findings suggesting massive absorption of the lavage fluid by FloTrac Sensor, TEE, or no pulmonary edema on the chest X-ray.\nDue to concern of continued postoperative fluid shifts, we decided to keep the patient intubated, and the DLT was replaced with a single lumen endotracheal tube. The patient was transferred to the ICU overnight for mechanical ventilation with a positive end-expiratory pressure of 10 cm H2O. Additionally, furosemide was given to remove excess fluid. ABG values returned to their normal limits 10 h after WLL was completed . She was extubated 15 h following the completion of WLL. She had no further metabolic acidosis and was subsequently discharged 4 days post-procedure.", + "fulltext_subclaims": [ + "The patient is a 37-year-old female.", + "She is 159 cm tall and weighs 53 kg.", + "She had progressive exertional dyspnea for 6 months.", + "A diagnosis of autoimmune PAP was confirmed.", + "The diagnosis was based on her history, HRCT, and BAL findings.", + "WLL of the left lung was performed under general anesthesia.", + "The first lavages were performed with 10,000 ml of normal saline.", + "An almost equal volume of returning effluent was observed.", + "Her postoperative course was smooth for 4 months.", + "She again developed exertional dyspnea.", + "New and denser pulmonary infiltrates were observed.", + "A second WLL was planned 8 months after the first WLL.", + "Pulmonary function tests revealed a restrictive pattern.", + "Vital capacity was 1.44 (44.1% predicted).", + "Forced expiratory volume in 1 s was 1.07 (39.8% predicted).", + "Carbon monoxide diffusion capacity was 4.80 (20.8% predicted).", + "A 6-min walk test showed desaturation from 91 to 73%.", + "The test was aborted after 3 min.", + "A repeated left lung lavage was planned.", + "Stand-by extracorporeal membrane oxygenation was prepared.", + "Electrocardiography, pulse oximeter, and non-invasive blood pressure monitors were attached.", + "Pre-oxygenation with 5 L/min of 100% O2 was performed for 5 min.", + "General anesthesia was induced with propofol, remifentanil, and rocuronium.", + "A 37 Fr left-sided double-lumen tube was inserted.", + "Correct positioning of the DLT was confirmed using bronchoscopy.", + "Radial artery cannulation was performed.", + "Baseline ABG revealed values within the normal limits.", + "The patient was placed in the supine position with the right lung side slightly tilted downward.", + "The bronchial lumen of the DLT was connected to the saline delivery system.", + "During one lung ventilation, ABG showed a PaO2 of 194.9 mmHg under an FiO2 of 1.0.", + "Lavage was performed by repeatedly filling the left lung with normal saline.", + "The ventilator settings were kept unchanged during OLV.", + "A total of 14 l of fluid was instilled into the left lung.", + "The amount of effluent removed was almost equal to the instilled volume.", + "The effluent contained very large amounts of amorphous sediment.", + "ABG values suggested a strong ion difference (SID=20.36).", + "Dilutional hyperchloremic metabolic acidosis was diagnosed.", + "The intraoperative infusion was 1260 ml.", + "Intraoperative urine volume was 90 ml.", + "The patient remained hemodynamically stable during WLL.", + "The DLT was replaced with a single lumen endotracheal tube.", + "The patient was transferred to the ICU overnight.", + "Mechanical ventilation with a positive end-expiratory pressure of 10 cm H2O was provided.", + "Furosemide was given to remove excess fluid.", + "ABG values returned to their normal limits 10 h after WLL.", + "She was extubated 15 h following the completion of WLL.", + "She had no further metabolic acidosis.", + "She was discharged 4 days post-procedure." + ], + "summary": "Under general anesthesia, a left-sided double-lumen tube was inserted with its bronchial lumen connected to the saline delivery system. Preoperatively, arterial blood gases were within normal limits. During 14 l of fluid was instilled into the lung for 2.5 hours, a decrease in pH, K+, and base excess, alongside an increase in Na+ and Cl-, indicated a strong ion difference; the diagnosis was dilutional hyperchloremic metabolic acidosis. Although she remained hemodynamically stable and had no indicators of massive absorption, she stayed in the ICU for mechanical ventilation for one night out of concern of pulmonary edema.", + "summary_subclaims": [ + "A left-sided double-lumen tube was inserted with its bronchial lumen connected to the saline delivery system.", + "Arterial blood gases were within normal limits preoperatively.", + "During 14 l of fluid was instilled into the lung for 2.5 hours, a decrease in pH, K+, and base excess, alongside an increase in Na+ and Cl-, indicated a strong ion difference.", + "The diagnosis was dilutional hyperchloremic metabolic acidosis.", + "She remained hemodynamically stable.", + "She had no indicators of massive absorption.", + "She stayed in the ICU for mechanical ventilation for one night out of concern of pulmonary edema." + ] + }, + { + "id": "multiclinsum_test_2462_en.txt", + "fulltext": "A 23-year-old American female patient with 2-week history of blistering and drainage from suture sites from recent cosmetic surgery (abdominoplasty, liposuction of abdominal flanks and back, with immediate fat transfer to the gluteal region in the Dominican Republic on 5 March 2020), presented to the emergency department (ED) with severe abdominal pain between low pelvic sutures and umbilicus, preventing her from being able to stand up straight, pruritis and boils on her back from the area of liposuction preventing her from being able to stand up straight. The patient denied fever and chills. Her blood pressure and pulse were 122/78 mmHg and 101 beats per minute, respectively. General appearance showed an overweight female with three linear open wounds along with incision sites: two on the right and one on the left with residual scars, with clear yellow drainage, erythematous and tender area, and areas of burn and dried scabs on back. The patient had no significant past medical history.\nAbdominal examination showed a morbidly obese patient with a non-distended, soft, tender abdomen to palpation around the wound, multiple open draining sinuses along the transverse incisional scar, and the base of openings with healthy granulation tissue. There was no erythema, with no warmth to touch. Respiratory, cardiac, musculoskeletal, and neurological examinations were normal. The patient reported that she was being kept in a “recovery clinic” in the Dominican Republic after the cosmetic operation, and because she complained of severe discomfort from her back drain, the doctor removed the posterior drain. She eventually left the clinic and the Dominican Republic against medical advice and flew back to the USA (11 March 2020).\nAfter arriving from the Dominican Republic, she treated her back pain with a heating pad, causing a partial-thickness burn. She was then treated at Nassau University Medical Center (NUMC) Burn Clinic for her partial-thickness burns. The patient reported that she had multiple draining sinuses along her transverse abdominal incision, as well as her umbilicus. She had been packing the sinuses by herself at home with gauze, wounds continued to drain, and she completed a course of cefalexin and doxycycline after admission to urgent care. The patient was also seen at Good Samaritan Hospital, which recommended trimethoprim–sulfametoxazole, which the patient did not take. She was treated with oxycodone–acetaminophen 10 mg, acetaminophen 1 g, and clindamycin 900 mg at the emergency department.\nComputed tomography (CT) of abdomen and pelvis was performed and showed a minor fat-containing umbilical hernia, status post-Roux-en-Y gastric bypass, no evidence of afferent limb dilation, no evidence of obstruction, unremarkable appendix and terminal ileum, and reactive bilateral inguinal lymphadenopathy, with the largest node measuring up to approximately 1.5 cm on the left. The CT also showed infiltration of the lower abdominal soft tissues containing an 11.9 × 1.4 × 4.4 cm3 fluid collection compatible with abscess. Several foci of air were noted within the right side of this fluid collection, tracking to a soft tissue defect in the right pyramid line lower abdomen. There was a thickening of the skin and subcutaneous fat-containing globules in the gluteal soft tissues. The urinary bladder was collapsed. The uterus and adnexa were not enlarged.\nA management plan was put in place for the patient after the CT, which included intravenous hydration, clindamycin 600 mg, pain control with oxycodone, follow-up blood cultures, interventional radiology (IR) for image-guided drainage, plastic surgery, and wound consult, and skincare referral. IR procedure was done. A fluid culture was sent to the laboratory, and the sample was also to be tested for acid-fast bacillus (AFB). Blood culture was done and showed no growth after 5 days, the abdominal fluid culture showed no growth after 48 hours, and abdominal fluid AFB showed no growth after 24 hours. After 8 days, the culture showed acid-fast bacilli in the liquid culture medium, and the DNA probe result was negative for M. tuberculosis.\nThe management plan at this stage included no clinical indication for the patient to receive antibiotics at this time; the patient was to be discharged with pain medication, proper irrigation and debridement, daily packing, sterile dressing change, and a plastic surgery appointment was scheduled within the following 2 weeks. Laboratory investigations were ordered and noted as white blood cell (WBC) count: 4.28 × 109/L.\nUnder real-time ultrasound guidance by IR procedure, access to the fluid collection was obtained with a 19G single-wall needle. Approximately 7 cm3 of cloudy fluid was aspirated and sent for appropriate analysis. After 25 days, the bacterial culture showed M. abscessus complex on 21 June. The patient was prescribed doxycycline for 10 days and azithromycin 500 mg. On 29 June, the left side of the wound almost completely healed, with few open draining tracts on the right side and some minor erythema. The patient was advised to continue on the recommended antibiotics, continue local wound care, and come to the ED for worsening pain, erythema, and drainage from wounds.", + "fulltext_subclaims": [ + "The patient is a 23-year-old American female.", + "The patient had cosmetic surgery in the Dominican Republic on 5 March 2020.", + "The surgery included abdominoplasty, liposuction of abdominal flanks and back, and immediate fat transfer to the gluteal region.", + "The patient presented to the emergency department with severe abdominal pain between low pelvic sutures and umbilicus.", + "The patient had pruritis and boils on her back from the area of liposuction.", + "The patient denied fever and chills.", + "The patient's blood pressure was 122/78 mmHg.", + "The patient's pulse was 101 beats per minute.", + "General appearance showed an overweight female with three linear open wounds along incision sites.", + "The wounds had clear yellow drainage, erythematous and tender area, and areas of burn and dried scabs on back.", + "The patient had no significant past medical history.", + "Abdominal examination showed a morbidly obese patient with a non-distended, soft, tender abdomen to palpation around the wound.", + "There were multiple open draining sinuses along the transverse incisional scar.", + "The base of openings had healthy granulation tissue.", + "There was no erythema, with no warmth to touch.", + "The patient was kept in a 'recovery clinic' in the Dominican Republic after the cosmetic operation.", + "The patient left the clinic and the Dominican Republic against medical advice and flew back to the USA on 11 March 2020.", + "After arriving from the Dominican Republic, she treated her back pain with a heating pad, causing a partial-thickness burn.", + "She was treated at Nassau University Medical Center Burn Clinic for her partial-thickness burns.", + "The patient reported multiple draining sinuses along her transverse abdominal incision and umbilicus.", + "She had been packing the sinuses by herself at home with gauze.", + "The wounds continued to drain.", + "She completed a course of cefalexin and doxycycline after admission to urgent care.", + "She was seen at Good Samaritan Hospital, which recommended trimethoprim–sulfametoxazole, which the patient did not take.", + "She was treated with oxycodone–acetaminophen 10 mg, acetaminophen 1 g, and clindamycin 900 mg at the emergency department.", + "Computed tomography (CT) of abdomen and pelvis showed a minor fat-containing umbilical hernia.", + "The CT showed no evidence of afferent limb dilation.", + "The CT showed no evidence of obstruction.", + "The CT showed unremarkable appendix and terminal ileum.", + "The CT showed reactive bilateral inguinal lymphadenopathy, with the largest node measuring up to approximately 1.5 cm on the left.", + "The CT showed infiltration of the lower abdominal soft tissues containing an 11.9 × 1.4 × 4.4 cm3 fluid collection compatible with abscess.", + "Several foci of air were noted within the right side of this fluid collection, tracking to a soft tissue defect in the right pyramid line lower abdomen.", + "There was thickening of the skin and subcutaneous fat-containing globules in the gluteal soft tissues.", + "The urinary bladder was collapsed.", + "The uterus and adnexa were not enlarged.", + "A management plan included intravenous hydration, clindamycin 600 mg, pain control with oxycodone, follow-up blood cultures, interventional radiology for image-guided drainage, plastic surgery, wound consult, and skincare referral.", + "An interventional radiology procedure was done.", + "A fluid culture was sent to the laboratory.", + "The sample was also to be tested for acid-fast bacillus (AFB).", + "Blood culture showed no growth after 5 days.", + "Abdominal fluid culture showed no growth after 48 hours.", + "Abdominal fluid AFB showed no growth after 24 hours.", + "After 8 days, the culture showed acid-fast bacilli in the liquid culture medium.", + "The DNA probe result was negative for M. tuberculosis.", + "The management plan at this stage included no clinical indication for the patient to receive antibiotics at this time.", + "The patient was to be discharged with pain medication, proper irrigation and debridement, daily packing, sterile dressing change, and a plastic surgery appointment was scheduled within the following 2 weeks.", + "Laboratory investigations were ordered and noted as white blood cell (WBC) count: 4.28 × 109/L.", + "Under real-time ultrasound guidance by IR procedure, access to the fluid collection was obtained with a 19G single-wall needle.", + "Approximately 7 cm3 of cloudy fluid was aspirated and sent for appropriate analysis.", + "After 25 days, the bacterial culture showed M. abscessus complex on 21 June.", + "The patient was prescribed doxycycline for 10 days and azithromycin 500 mg.", + "On 29 June, the left side of the wound almost completely healed, with few open draining tracts on the right side and some minor erythema.", + "The patient was advised to continue on the recommended antibiotics, continue local wound care, and come to the ED for worsening pain, erythema, and drainage from wounds." + ], + "summary": "We present the case of a 23-year-old American female patient who presented to the emergency room with significant abdominal pain between low pelvic sutures and the umbilicus. She reported abdominal pain, pruritus, and boils on her back preventing her from standing upright. The symptoms occurred in the liposuction area after cosmetic surgery in the Dominican Republic. The clinical, radiological, and cultural findings helped diagnose Mycobacterium abscessus infection. We conducted a mini literature review on the published reports of Mycobacterium abscessus.", + "summary_subclaims": [ + "The patient is a 23-year-old American female.", + "The patient presented to the emergency room with significant abdominal pain between low pelvic sutures and the umbilicus.", + "The patient reported abdominal pain.", + "The patient reported pruritus.", + "The patient reported boils on her back.", + "The symptoms occurred in the liposuction area.", + "The symptoms occurred after cosmetic surgery in the Dominican Republic.", + "The clinical, radiological, and cultural findings helped diagnose Mycobacterium abscessus infection.", + "A mini literature review on the published reports of Mycobacterium abscessus was conducted." + ] + }, + { + "id": "multiclinsum_test_1351_en.txt", + "fulltext": "Written informed consent was obtained from the patient.\nA 28-year old pregnant woman (gravida 0, para 0) was recommended for C-sec at a local gynecology hospital due to cephalopelvic disproportion. She had been in contact with a SARS-CoV-2 infected patient, and she began self-isolation on February 14, 2020. She developed fever (> 38℃), mild sore throat, and cough, after which she visited a public health center and was tested positive for SARS-CoV-2 on February 25 (36+2 weeks gestation). She self-isolated herself at home after diagnosis and observed her prognosis. She had mild symptoms and received conservative treatment without medication. The symptoms improved and she only had a mild cough with no fever and sputum on February 29. She wanted to delay delivery until she recovered from the infection. However, an emergency C-sec was decided on March 6 (37+6 weeks) due to obstructed labor with incomplete rotation of the fetal head. The patient was transferred to our center, which is a designated hospital for pregnant patients infected with SARS-Cov-2. Her blood type was ‘O-Rh (+)’ and pre-natal workup did not show any specific findings. On arrival, she was immediately transferred to the radiology center for chest radiographs and computer tomography (CT) scans. We then transferred her to a pre-treatment room in the delivery center equipped with negative-pressure ventilation, exclusive elevators, and pre-operative laboratory test kits, including electrocardiograph (ECG), X-ray machine, blood tests, and urine test. Hemoglobin was 10.9 g/dl, erythrocyte sedimentation rate was slightly elevated (42 mm/h), C-reactive protein was normal (0.15 mg/dl), and other pre-operative laboratory test and ECG results seemed normal. The chest radiographs revealed left lower/middle lobe consolidation and increased vascular marking . We also observed multifocal peribronchial ground glass appearance and consolidation in the left lower lobe from chest CT scans . The SARS-CoV-2 reverse transcription-polymerase chain reaction (RT-PCR) result of sputum and nasopharyngeal swab was obtained pre-operatively. Baseline fetal heart rate was 129 beats/min.\nThe C-sec was performed in an operating room at the delivery center, which is located on a different floor from the main operating room ( and ). Hence, the traffic line of the patient did not overlap with that of the other surgical patients. In this case, spinal anesthesia was selected as the anesthetic method, because even if we started with spinal anesthesia, there could still be chances of switching to general anesthesia in case of inadequate anesthesia or sudden changes in the patient’s clinical condition. We were already equipped with a ventilator protected by three mechanical high-efficiency particulate air filters, video laryngoscope, fiber-optic laryngoscope blades and handles, endotracheal tubes (6.5 mm, 7.0 mm, and stylet), medication drugs such as propofol, lidocaine, rocuronium, sugammadex, atropine, and closed suction catheter before the patient entered the operating room.\nAll medical staff members wore enhanced personal protective equipment (PPE), including N95 mask, surgical cap, double gown, double gloves, shoe covers, and a powered air-purifying respirator ( and ) in the fitting room . In the operating room, we measured the initial blood pressure (115/69 mmHg), heart rate (82 beats/min), and peripheral capillary oxygen saturation (99%) under a facial N95 mask without any O2 supply , and the ECG result showed normal sinus rhythm.\nThe patient was 166 cm in height and 62 kg in weight. She was placed in the left lateral decubitus position. Spinal anesthesia was performed with a 25-gauge Pencan spinal needle at the L3/4 interspace, and 9 mg of 0.5% marcaine and 20 μg of fentanyl were injected intrathecally. She was placed in the supine position with a left lateral tilt after 10 min, and anesthesia was assessed bilaterally with cold alcohol cotton and the T4 level blockage was checked.\nAfter spinal injection, the patient experienced nausea and had low blood pressure (71/40 mmHg). The nausea improved with elevation in blood pressure (103/60 mmHg), and the vital signs stabilized after five injections of 100 μg phenylephrine and fast dropping 400 cc of Hartmann solution and 250 cc of colloid (Volulyte®, Fresenius Kabi, Bad Homburg, Germany). The C-sec was performed uneventfully. The baby was born 6 min after incision, and then 100 mg carbetocin was administered intravenously shortly after the birth. Oxytocin 20 IU/1000 ml Hartmann dextrose was also infused continuously to produce uterine contraction and minimize the blood loss.\nTotal anesthesia time was 50 min and operation time was 40 min . An estimated blood loss of 400 cc was noted, and 780 cc of crystalloid and 250 cc of colloid were administered during surgery. For pain control, a patient-controlled analgesia pump (ANAPA AC0605®, Ehwa Biomedics, Korea) with butorphanol (10 mg), ketorolac tromethamine (180 mg), ramosetron (0.6 mg), and normal saline (26 ml) was used.\nDuring the recovery state, the patient stayed in the operating room. Her vital signs remained stable and the patient had no complaints. Recovery blockage on T8 was confirmed and she was transferred to a single room in the SARS-CoV-2 ward (another SARS-CoV-2 suspected mother stayed separately there) through an exclusive elevator with a nurse wearing PPE.\nBoth SARS-CoV-2 RT-PCR tests conducted on March 6 and March 8 were confirmed negative. Therefore, the patient was transferred from the SARS-CoV-2 ward to the general ward on March 10 and discharged on March 11 without any complications.\nThe baby girl weighing 3130 gm was born on March 6, 2020 at 11:22 with Apgar scores at 1 and 5 min of 9 and 10, respectively. She was transferred immediately to a private newborn’s room in the neonatal intensive care unit (NICU) in order to avoid being exposed to SARS-CoV-2. The NICU consists of two separate spaces: one for suspected or confirmed SARS-CoV-2 babies and the other for healthy babies. All four newborn babies delivered from mothers with suspected SARS-CoV-2 tested negative and were transferred to the latter in the NICU.\nThe SARS-CoV-2 RT-PCR results using placenta, amniotic fluid, and cord blood were negative. Furthermore, the nasopharyngeal swab of the baby was negative on two consecutive SARS-CoV-2 RT-PCR tests. The medical staff had to wear level ‘D’ PPE until their SARS-CoV-2 PCR testing was reported negative.\nThe neonate was in a healthy state getting oral feeding and was discharged with her mother.", + "fulltext_subclaims": [ + "Written informed consent was obtained from the patient.", + "A 28-year old pregnant woman (gravida 0, para 0) was recommended for C-sec at a local gynecology hospital due to cephalopelvic disproportion.", + "She had been in contact with a SARS-CoV-2 infected patient.", + "She began self-isolation on February 14, 2020.", + "She developed fever (> 38℃), mild sore throat, and cough.", + "She visited a public health center and was tested positive for SARS-CoV-2 on February 25 (36+2 weeks gestation).", + "She self-isolated herself at home after diagnosis.", + "She had mild symptoms and received conservative treatment without medication.", + "The symptoms improved and she only had a mild cough with no fever and sputum on February 29.", + "She wanted to delay delivery until she recovered from the infection.", + "An emergency C-sec was decided on March 6 (37+6 weeks) due to obstructed labor with incomplete rotation of the fetal head.", + "The patient was transferred to our center, which is a designated hospital for pregnant patients infected with SARS-Cov-2.", + "Her blood type was ‘O-Rh (+)’.", + "Pre-natal workup did not show any specific findings.", + "On arrival, she was immediately transferred to the radiology center for chest radiographs and computer tomography (CT) scans.", + "We then transferred her to a pre-treatment room in the delivery center equipped with negative-pressure ventilation, exclusive elevators, and pre-operative laboratory test kits.", + "Hemoglobin was 10.9 g/dl.", + "Erythrocyte sedimentation rate was slightly elevated (42 mm/h).", + "C-reactive protein was normal (0.15 mg/dl).", + "Other pre-operative laboratory test and ECG results seemed normal.", + "The chest radiographs revealed left lower/middle lobe consolidation and increased vascular marking.", + "We also observed multifocal peribronchial ground glass appearance and consolidation in the left lower lobe from chest CT scans.", + "The SARS-CoV-2 reverse transcription-polymerase chain reaction (RT-PCR) result of sputum and nasopharyngeal swab was obtained pre-operatively.", + "Baseline fetal heart rate was 129 beats/min.", + "The C-sec was performed in an operating room at the delivery center, which is located on a different floor from the main operating room.", + "The traffic line of the patient did not overlap with that of the other surgical patients.", + "Spinal anesthesia was selected as the anesthetic method.", + "We were already equipped with a ventilator protected by three mechanical high-efficiency particulate air filters.", + "All medical staff members wore enhanced personal protective equipment (PPE), including N95 mask, surgical cap, double gown, double gloves, shoe covers, and a powered air-purifying respirator.", + "In the operating room, we measured the initial blood pressure (115/69 mmHg), heart rate (82 beats/min), and peripheral capillary oxygen saturation (99%) under a facial N95 mask without any O2 supply.", + "The ECG result showed normal sinus rhythm.", + "The patient was 166 cm in height and 62 kg in weight.", + "Spinal anesthesia was performed with a 25-gauge Pencan spinal needle at the L3/4 interspace.", + "9 mg of 0.5% marcaine and 20 μg of fentanyl were injected intrathecally.", + "After spinal injection, the patient experienced nausea and had low blood pressure (71/40 mmHg).", + "The nausea improved with elevation in blood pressure (103/60 mmHg), and the vital signs stabilized after five injections of 100 μg phenylephrine and fast dropping 400 cc of Hartmann solution and 250 cc of colloid.", + "The C-sec was performed uneventfully.", + "The baby was born 6 min after incision.", + "100 mg carbetocin was administered intravenously shortly after the birth.", + "Oxytocin 20 IU/1000 ml Hartmann dextrose was also infused continuously.", + "Total anesthesia time was 50 min.", + "Operation time was 40 min.", + "An estimated blood loss of 400 cc was noted.", + "780 cc of crystalloid and 250 cc of colloid were administered during surgery.", + "A patient-controlled analgesia pump with butorphanol (10 mg), ketorolac tromethamine (180 mg), ramosetron (0.6 mg), and normal saline (26 ml) was used.", + "During the recovery state, the patient stayed in the operating room.", + "Her vital signs remained stable and the patient had no complaints.", + "Recovery blockage on T8 was confirmed.", + "She was transferred to a single room in the SARS-CoV-2 ward through an exclusive elevator with a nurse wearing PPE.", + "Both SARS-CoV-2 RT-PCR tests conducted on March 6 and March 8 were confirmed negative.", + "The patient was transferred from the SARS-CoV-2 ward to the general ward on March 10.", + "The patient was discharged on March 11 without any complications.", + "The baby girl weighing 3130 gm was born on March 6, 2020 at 11:22.", + "She was transferred immediately to a private newborn’s room in the neonatal intensive care unit (NICU).", + "The NICU consists of two separate spaces: one for suspected or confirmed SARS-CoV-2 babies and the other for healthy babies.", + "All four newborn babies delivered from mothers with suspected SARS-CoV-2 tested negative and were transferred to the latter in the NICU.", + "The SARS-CoV-2 RT-PCR results using placenta, amniotic fluid, and cord blood were negative.", + "The nasopharyngeal swab of the baby was negative on two consecutive SARS-CoV-2 RT-PCR tests.", + "The medical staff had to wear level ���D’ PPE until their SARS-CoV-2 PCR testing was reported negative.", + "The neonate was in a healthy state getting oral feeding.", + "The neonate was discharged with her mother." + ], + "summary": "We report the first case of a SARS-CoV-2 positive woman delivering a baby through cesarean section at 37+6 weeks of pregnancy in the Republic of Korea.", + "summary_subclaims": [ + "We report the first case of a SARS-CoV-2 positive woman delivering a baby through cesarean section at 37+6 weeks of pregnancy in the Republic of Korea." + ] + }, + { + "id": "multiclinsum_test_2428_en.txt", + "fulltext": "A 42-year-old man presented with a 13-year history of intractable tonic seizures that were indicative of right parietal lobe brain tumor. Plain computed tomography (CT) of the head revealed a tumor 40 mm in diameter and consisting of calcification and cyst formation located in the right parietal region. Magnetic resonance imaging (MRI) revealed an area of marked signal hypointensity around the solid component on T2 and T2 *-weighted imaging. These findings were thought to represent the calcification seen on CT, or perhaps hemosiderin deposition due to old hemorrhage. The tumor was located adjacent to the lateral ventricle, and the posterior part of the lateral ventricle was slightly enlarged toward the tumor. Normal choroid plexus of the right lateral ventricle was located in the normal position, and continuity of the normal choroid plexus to the tumor was not confirmed . Cerebral angiography did not show any tumor staining or vascular abnormalities. The provisional diagnosis was cerebral cavernous angioma with hemorrhagic episode.\nA right parietal craniotomy was performed using a navigation system and motor-evoked potentials. A yellowish, granulomatous, moderately hard, slightly lobulated avascular tumor was located in the right parietal lobe, with scant hemosiderin deposition identified within the lesion. The margin of the tumor was covered with predominant gliosis. At the deepest part of the tumor, the tumor was firmly adhered to the subependymal layer of the lateral ventricle. During dissection of the adhered area, the ventricular ependyma was penetrated and the body of the lateral ventricle was visualized through the cavity of the removed tumor. The normal-appearing choroid plexus was placed within the posterior part of the lateral ventricle and continuity of the normal choroid plexus and the tumor was not confirmed. The lateral wall on the lateral ventricle showed a normal appearance and continuous coverage with ependymal . The tumor thus originated completely in the cerebrum parenchyma and was firmly adhered to the wall of the lateral ventricle.\nPathological examination of the tumor revealed a papillary structure with a single layer of well-differentiated columnar epithelium in the lesion. Part of this lesion growth had infiltrated the cerebral parenchyma. In addition, activated macrophages were prominent around the cerebral parenchyma and were considered to represent a reactive lesion related to an old hemorrhage. Immunohistochemical examination was accomplished with the antibodies detailed in . Vimentin was strongly immunoreactive. Neural Cell Adhesion Molecule (N-CAM, CD56), Epithelial Membrane Antigen (EM) and Cytokeratin 7 (CK7) exhibited focal immunoreactivity. Cytokeratin 20 (CK20) and prealbumin were not immunoreactive. Glial Fibrillary Acidic Protein (GFAP) was strongly immunoreactive. Podoplanin exhibited focal immunoreactivity in a few reactive cells . Mindbomb Homolog 1 (MIB1) labeling index (MIB1-LI) was 0.4%. Based on these findings, histological diagnosis was CPP with hemorrhagic episode.\nThe patient showed no postoperative neurological deficits, and cranial MRI confirmed complete removal of the tumor. Postoperatively, seizures were well controlled using antiepileptic drugs.", + "fulltext_subclaims": [ + "The patient was a 42-year-old man.", + "He had a 13-year history of intractable tonic seizures.", + "The seizures were indicative of a right parietal lobe brain tumor.", + "Plain CT of the head revealed a tumor 40 mm in diameter.", + "The tumor consisted of calcification and cyst formation.", + "The tumor was located in the right parietal region.", + "MRI showed marked signal hypointensity around the solid component on T2 and T2 *-weighted imaging.", + "These findings were thought to represent calcification seen on CT, or perhaps hemosiderin deposition due to old hemorrhage.", + "The tumor was located adjacent to the lateral ventricle.", + "The posterior part of the lateral ventricle was slightly enlarged toward the tumor.", + "Normal choroid plexus of the right lateral ventricle was located in the normal position.", + "Continuity of the normal choroid plexus to the tumor was not confirmed.", + "Cerebral angiography did not show any tumor staining or vascular abnormalities.", + "The provisional diagnosis was cerebral cavernous angioma with hemorrhagic episode.", + "A right parietal craniotomy was performed using a navigation system and motor-evoked potentials.", + "The tumor was yellowish, granulomatous, moderately hard, slightly lobulated, and avascular.", + "The tumor was located in the right parietal lobe.", + "Scant hemosiderin deposition was identified within the lesion.", + "The margin of the tumor was covered with predominant gliosis.", + "The tumor was firmly adhered to the subependymal layer of the lateral ventricle.", + "During dissection, the ventricular ependyma was penetrated.", + "The body of the lateral ventricle was visualized through the cavity of the removed tumor.", + "The normal-appearing choroid plexus was placed within the posterior part of the lateral ventricle.", + "Continuity of the normal choroid plexus and the tumor was not confirmed.", + "The lateral wall on the lateral ventricle showed a normal appearance and continuous coverage with ependymal.", + "The tumor originated completely in the cerebral parenchyma.", + "The tumor was firmly adhered to the wall of the lateral ventricle.", + "Pathological examination revealed a papillary structure with a single layer of well-differentiated columnar epithelium.", + "Part of the lesion growth had infiltrated the cerebral parenchyma.", + "Activated macrophages were prominent around the cerebral parenchyma.", + "The activated macrophages were considered to represent a reactive lesion related to an old hemorrhage.", + "Vimentin was strongly immunoreactive.", + "N-CAM (CD56) exhibited focal immunoreactivity.", + "Epithelial Membrane Antigen (EMA) exhibited focal immunoreactivity.", + "Cytokeratin 7 (CK7) exhibited focal immunoreactivity.", + "Cytokeratin 20 (CK20) was not immunoreactive.", + "Prealbumin was not immunoreactive.", + "Glial Fibrillary Acidic Protein (GFAP) was strongly immunoreactive.", + "Podoplanin exhibited focal immunoreactivity in a few reactive cells.", + "MIB1 labeling index (MIB1-LI) was 0.4%.", + "The histological diagnosis was choroid plexus papilloma with hemorrhagic episode.", + "The patient showed no postoperative neurological deficits.", + "Cranial MRI confirmed complete removal of the tumor.", + "Postoperatively, seizures were well controlled using antiepileptic drugs." + ], + "summary": "Preoperative imaging and operative findings showed that the tumor originated entirely within the cerebrum parenchyma, with no connections between the tumor and the ventricular system. Histopathological examination of the tumor revealed a papillary structure with a single layer of well-differentiated columnar epithelium in the lesion. Furthermore, part of this lesion had infiltrated the cerebral parenchyma. Therefore, the tumor was diagnosed as CPP, and the diagnosis was confirmed by immunohistological examination.", + "summary_subclaims": [ + "Preoperative imaging and operative findings showed that the tumor originated entirely within the cerebrum parenchyma.", + "There were no connections between the tumor and the ventricular system.", + "Histopathological examination of the tumor revealed a papillary structure with a single layer of well-differentiated columnar epithelium in the lesion.", + "Part of this lesion had infiltrated the cerebral parenchyma.", + "The tumor was diagnosed as CPP.", + "The diagnosis was confirmed by immunohistological examination." + ] + }, + { + "id": "multiclinsum_test_2256_en.txt", + "fulltext": "An 85-year-old male, who had been able to walk with a wheeled walker and had no definitive cognitive problem, was admitted to our hospital because of mild disturbance of consciousness and right hemiparesis. He had no history of head trauma but had been taking oral antiplatelet agent for previous ischemic heart disease. Computed tomography (CT) revealed left CSDH with moderate rightward midline shift [, left]. Emergency irrigation and drainage through a left frontal burr hole was performed under local anesthesia. Thick outer membrane was observed during the operation. After removal of the hematoma with irrigation [, right], a drainage tube was placed posteriorly. His symptoms disappeared immediately and he was discharged after 12 days. He visited our hospital again because of headache and mild right hemiparesis 8 days after the discharge. CT revealed recurrence of the CSDH [, left]. Second irrigation and drainage was performed similar to the first operation. His symptoms improved, however, he was transferred to a rehabilitation hospital because of general muscle weakness 37 days after the surgery. The oral antiplatelet medication was stopped after the second surgery. Fifteen days after the transfer, he was admitted to our hospital again because of right hemiparesis. CT showed recurrent CSDH [, right], and hence we considered applying middle meningeal artery (MMA) embolization to him. However, because his previous imaging studies revealed severe arteriosclerosis, we abandoned the procedure. Instead, we performed third irrigation and drainage through the same burr hole. The hematoma cavity was irrigated with artificial cerebrospinal fluid (CSF). The right hemiparesis disappeared after the surgery. The patient was admitted to observe any recurrence of CSDH as well as for rehabilitation. Twenty-seven days after the third surgery, he suffered gait disturbance, and CT revealed recurrent CSDH [ left]. Fourth irrigation and drainage through another burr hole on the left parietal convexity was performed. The drain was placed anteriorly to reduce postoperative air collection [, right]. Unfortunately, the CSDH recurred with mild right hemiparesis after 9 days [, left].\nFifth surgery was supplemented by a simple noninvasive treatment, fibrin glue injection into the hematoma cavity through the drainage tube. Fifth irrigation and drainage through the former parietal burr hole was performed, the hematoma was removed and the cavity thoroughly irrigated, and then a drainage tube was placed anteriorly toward the frontal tip, minimizing the hematoma cavity. On the following day, CT confirmed the collapsed hematoma cavity with minimum air collection [, right]. After obtaining informed consent, fibrin glue was injected through the drainage tube. The patient was placed in the left lateral position so that the affected side was lower. First, 12 ml of the residual hematoma was carefully evacuated through the drainage tube. Then, 5 ml of solution A of fibrin glue (Beriplast® P Combi-Set, Aventis Behring GmbH) was injected through the drainage tube and flushed with a few ml of saline, and subsequently 5 ml of solution B was injected. Finally, the drainage tube was slowly pulled away during flushing with a few ml of saline . No harmful event occurred during and after the procedure. CSDH did not recur after the procedure and the patient was discharged. No further recurrence was confirmed in 6 months after the treatment , and the patient has been free from symptoms for over 2 years.", + "fulltext_subclaims": [ + "The patient was an 85-year-old male.", + "He had been able to walk with a wheeled walker.", + "He had no definitive cognitive problem.", + "He was admitted because of mild disturbance of consciousness and right hemiparesis.", + "He had no history of head trauma.", + "He had been taking oral antiplatelet agent for previous ischemic heart disease.", + "Computed tomography revealed left CSDH with moderate rightward midline shift.", + "Emergency irrigation and drainage through a left frontal burr hole was performed under local anesthesia.", + "Thick outer membrane was observed during the operation.", + "After removal of the hematoma with irrigation, a drainage tube was placed posteriorly.", + "His symptoms disappeared immediately.", + "He was discharged after 12 days.", + "He visited the hospital again because of headache and mild right hemiparesis 8 days after discharge.", + "CT revealed recurrence of the CSDH.", + "Second irrigation and drainage was performed similar to the first operation.", + "His symptoms improved.", + "He was transferred to a rehabilitation hospital because of general muscle weakness 37 days after the surgery.", + "The oral antiplatelet medication was stopped after the second surgery.", + "Fifteen days after the transfer, he was admitted again because of right hemiparesis.", + "CT showed recurrent CSDH.", + "We considered applying middle meningeal artery embolization.", + "We abandoned the procedure because his previous imaging studies revealed severe arteriosclerosis.", + "We performed third irrigation and drainage through the same burr hole.", + "The hematoma cavity was irrigated with artificial cerebrospinal fluid.", + "The right hemiparesis disappeared after the surgery.", + "The patient was admitted to observe any recurrence of CSDH as well as for rehabilitation.", + "Twenty-seven days after the third surgery, he suffered gait disturbance.", + "CT revealed recurrent CSDH.", + "Fourth irrigation and drainage through another burr hole on the left parietal convexity was performed.", + "The drain was placed anteriorly to reduce postoperative air collection.", + "The CSDH recurred with mild right hemiparesis after 9 days.", + "Fifth surgery was supplemented by a simple noninvasive treatment, fibrin glue injection into the hematoma cavity through the drainage tube.", + "Fifth irrigation and drainage through the former parietal burr hole was performed.", + "The hematoma was removed and the cavity thoroughly irrigated.", + "A drainage tube was placed anteriorly toward the frontal tip, minimizing the hematoma cavity.", + "On the following day, CT confirmed the collapsed hematoma cavity with minimum air collection.", + "After obtaining informed consent, fibrin glue was injected through the drainage tube.", + "The patient was placed in the left lateral position so that the affected side was lower.", + "First, 12 ml of the residual hematoma was carefully evacuated through the drainage tube.", + "Then, 5 ml of solution A of fibrin glue (Beriplast® P Combi-Set, Aventis Behring GmbH) was injected through the drainage tube and flushed with a few ml of saline.", + "Subsequently, 5 ml of solution B was injected.", + "Finally, the drainage tube was slowly pulled away during flushing with a few ml of saline.", + "No harmful event occurred during and after the procedure.", + "CSDH did not recur after the procedure.", + "The patient was discharged.", + "No further recurrence was confirmed in 6 months after the treatment.", + "The patient has been free from symptoms for over 2 years." + ], + "summary": "An 85-year-old male presented with left CSDH, which recurred five times. The hematoma was irrigated and drained through a left frontal burr hole during the first to third surgery and through a left parietal burr hole during the fourth and fifth surgery. The hematoma had no septation and was well-evacuated during each surgery. Antiplatelet therapy for preventing ischemic heart disease was stopped after the second surgery, the hematoma cavity was irrigated with artificial cerebrospinal fluid at the third surgery, and the direction of the drainage tube was changed to reduce the postoperative subdural air collection at the fourth surgery. However, none of these interventions was effective. He was successfully treated by fibrin glue injection into the hematoma cavity after the fifth surgery.", + "summary_subclaims": [ + "The patient is an 85-year-old male.", + "The patient had a left chronic subdural hematoma.", + "The hematoma recurred five times.", + "The hematoma was irrigated and drained through a left frontal burr hole during the first to third surgery.", + "The hematoma was drained through a left parietal burr hole during the fourth and fifth surgery.", + "The hematoma had no septation.", + "The hematoma was well-evacuated during each surgery.", + "Antiplatelet therapy was stopped after the second surgery.", + "The hematoma cavity was irrigated with artificial cerebrospinal fluid at the third surgery.", + "The direction of the drainage tube was changed at the fourth surgery.", + "The interventions were not effective.", + "The patient was successfully treated by fibrin glue injection into the hematoma cavity after the fifth surgery." + ] + }, + { + "id": "multiclinsum_test_255_en.txt", + "fulltext": "The patient presented with intermittent abdominal pain and bloating for six months and sudden shortness of breath and confusion during diagnostic colonoscopy.\nA 58-year-old man presented with intermittent abdominal pain, bloating and reduced defecation in the past six months. To determine the severity of intestinal lesions and rule out intestinal tumors, the patient underwent a routine diagnostic colonoscopy using air insufflation under nontracheal intubation intravenous general anesthesia (propofol). Upon withdrawal of the colonoscope, the patient suddenly experienced shortness of breath and confusion and gradually developed cyanosis.\nThe patient underwent a colonoscopy 12 years prior, and colonic ulcers were observed. Because the patient had oral and perianal ulcers and the colonic ulcers were considered to be a manifestation of intestinal BD, the patient was diagnosed with intestinal BD by a rheumatologist. He had suffered severe pain in the right lower abdomen 11 years prior. Acute appendicitis was initially suspected, but spontaneous ileocecal perforation was confirmed during an emergency exploratory laparotomy, and surgical repair of the ileocecal perforation was performed. He still suffered from the recurrence of oral and perianal ulcers but did not experience unbearable abdominal symptoms after taking prednisone and leflunomide irregularly.\nThe patient had a 30-year history of smoking (1 pack per day).\nThe physical examination upon admission showed tenderness in the right lower abdomen. When cyanosis occurred, the oxygen saturation dropped to 68%, and the heart rate was 130 beats/min. Assisted mask ventilation was initiated with 100% oxygen, but the patient’s saturation did not improve. An abdominal examination revealed a distended abdomen on palpation and drum sounds on percussion. On auscultation, breath sounds were absent on the right side and diminished on the left side of the chest.\nThe patient had an antinuclear antibody titer of 1:320 (granular type, cytoplasmic type) and a positive fecal occult blood test upon admission. The laboratory results were not available during rescue.\nThe computed tomography (CT) scan of the abdomen and pelvis before colonoscopy revealed bowel wall thickening in the terminal ileum, ileocecal area and appendix, ileocecal stenosis and incomplete bowel obstruction.\nColonoscopy revealed deformation, mucosal hyperplasia and multiple deep ulcers in the ileocecal region . The possibility of perforation could not be ruled out. The colonoscope could not enter the small intestine due to stenosis and deformation of the ileocecal valve. Pseudopolyps in the ascending colon and ring ulcers in the transverse colon and descending colon were also shown on colonoscopy. Biopsies were taken from the ileocecal region, ascending colon and transverse colon. Pathology revealed chronic active mucosal inflammation in the ileocecal region and chronic mucosal inflammation in the ascending and transverse colon.\nThe CT scan of the chest, abdomen and pelvis after chest drain tube insertion showed bilateral pneumothorax, pneumomediastinum, pneumoperitoneum, pneumoretroperitoneum and subcutaneous emphysema of the neck, chest, abdomen, back and scrotum .", + "fulltext_subclaims": [ + "The patient presented with intermittent abdominal pain, bloating and reduced defecation in the past six months.", + "The patient underwent a routine diagnostic colonoscopy using air insufflation under nontracheal intubation intravenous general anesthesia (propofol).", + "Upon withdrawal of the colonoscope, the patient suddenly experienced shortness of breath and confusion and gradually developed cyanosis.", + "The patient had colonic ulcers observed during a colonoscopy 12 years prior.", + "The patient was diagnosed with intestinal BD by a rheumatologist.", + "The patient had suffered severe pain in the right lower abdomen 11 years prior.", + "Acute appendicitis was initially suspected, but spontaneous ileocecal perforation was confirmed during an emergency exploratory laparotomy.", + "Surgical repair of the ileocecal perforation was performed.", + "The patient had a 30-year history of smoking (1 pack per day).", + "The physical examination upon admission showed tenderness in the right lower abdomen.", + "When cyanosis occurred, the oxygen saturation dropped to 68%.", + "The heart rate was 130 beats/min.", + "Assisted mask ventilation was initiated with 100% oxygen, but the patient’s saturation did not improve.", + "An abdominal examination revealed a distended abdomen on palpation and drum sounds on percussion.", + "On auscultation, breath sounds were absent on the right side and diminished on the left side of the chest.", + "The patient had an antinuclear antibody titer of 1:320 (granular type, cytoplasmic type).", + "The patient had a positive fecal occult blood test upon admission.", + "The computed tomography (CT) scan of the abdomen and pelvis before colonoscopy revealed bowel wall thickening in the terminal ileum, ileocecal area and appendix.", + "The CT scan showed ileocecal stenosis and incomplete bowel obstruction.", + "Colonoscopy revealed deformation, mucosal hyperplasia and multiple deep ulcers in the ileocecal region.", + "The possibility of perforation could not be ruled out.", + "The colonoscope could not enter the small intestine due to stenosis and deformation of the ileocecal valve.", + "Pseudopolyps in the ascending colon and ring ulcers in the transverse colon and descending colon were shown on colonoscopy.", + "Biopsies were taken from the ileocecal region, ascending colon and transverse colon.", + "Pathology revealed chronic active mucosal inflammation in the ileocecal region.", + "The CT scan of the chest, abdomen and pelvis after chest drain tube insertion showed bilateral pneumothorax.", + "The CT scan showed pneumomediastinum, pneumoperitoneum, pneumoretroperitoneum and subcutaneous emphysema of the neck, chest, abdomen, back and scrotum." + ], + "summary": "Herein, we describe a patient with intestinal BD who presented with decreased oxygen saturation and shortness of breath during a diagnostic colonoscopy. Bilateral pneumothorax, pneumomediastinum, pneumoperitoneum, pneumoretroperitoneum and subcutaneous emphysema of the neck, chest, abdomen, back and scrotum were confirmed by computed tomography scan. The sudden change in condition was considered to be associated with iatrogenic bowel perforation. After receiving closed thoracic drainage and conservative therapy, the patient was discharged in stable condition.", + "summary_subclaims": [ + "The patient had intestinal Behçet's disease.", + "The patient presented with decreased oxygen saturation.", + "The patient had shortness of breath during a diagnostic colonoscopy.", + "Computed tomography scan confirmed bilateral pneumothorax.", + "Computed tomography scan confirmed pneumomediastinum.", + "Computed tomography scan confirmed pneumoperitoneum.", + "Computed tomography scan confirmed pneumoretroperitoneum.", + "Computed tomography scan confirmed subcutaneous emphysema of the neck.", + "Computed tomography scan confirmed subcutaneous emphysema of the chest.", + "Computed tomography scan confirmed subcutaneous emphysema of the abdomen.", + "Computed tomography scan confirmed subcutaneous emphysema of the back.", + "Computed tomography scan confirmed subcutaneous emphysema of the scrotum.", + "The sudden change in condition was considered to be associated with iatrogenic bowel perforation.", + "The patient received closed thoracic drainage.", + "The patient received conservative therapy.", + "The patient was discharged in stable condition." + ] + }, + { + "id": "multiclinsum_test_2506_en.txt", + "fulltext": "A 37-year-old man, right-handed driver, presented to the emergency department for a closed trauma of his left upper extremity after landing on the wrist with an out-stretched elbow following a fall. Initial physical examination revealed swelling and transverse widening of the left elbow. The forearm and the wrist were deformed. No open wounds were found. The radial head and the olecranon were palpable laterally and medially. The patient’s hand was well perfused without neurologic abnormalities. Plain radiographs showed a divergent left elbow dislocation associated with ipsilateral ulnar diaphysis fracture, a tearing of epitrochlea , and a fracture of the radial styloid process . The elbow joint was reduced under general anesthesia. Because of the radiohumeral instability, the reduction was stabilized with two Kirschner wires through the distal part of the humerus into the radius . A reinsertion of the medial collateral ligament was performed and the epitrochlea was fixed with two Kirschner wires .\nThe ulnar diaphysis fracture was reduced and fixed by a screwed plate with Kirschner wire-fixation of the radial styloid process . Postoperatively, the elbow was placed in 90° of flexion and immobilized with a posterior splint for 3 weeks, and then the radiohumeral Kirschner wires were removed. An articulated elbow orthosis was placed; supervised forearm rotation and gentle passive elbow flexion and extension were initiated after the 3rd week. Full extension of the elbow was not aggressively executed until 6-week postoperatively. At that time, the orthosis immobilization was discontinued and the Kirschner wires of the radial styloid process were removed. The patient continued to work on range of motion with a 3 times per week physical therapy. At 4-month postoperatively, all fractures were united ( and ) and the patient continued to show improvement in range of motion with an elbow flexion-extension arc of 30° to 140°. At 3 years of follow-up, the patient was asymptomatic, with 10° of limitation in elbow extension and a full flexion of 145° , he also recovered 80° of pronation and 30° of supination , the patient was satisfied with the clinical outcome.", + "fulltext_subclaims": [ + "The patient is a 37-year-old man.", + "The patient is right-handed.", + "The patient is a driver.", + "The patient presented to the emergency department for a closed trauma of his left upper extremity.", + "The trauma occurred after landing on the wrist with an out-stretched elbow following a fall.", + "Initial physical examination revealed swelling and transverse widening of the left elbow.", + "The forearm and the wrist were deformed.", + "No open wounds were found.", + "The radial head and the olecranon were palpable laterally and medially.", + "The patient’s hand was well perfused.", + "There were no neurologic abnormalities.", + "Plain radiographs showed a divergent left elbow dislocation.", + "Plain radiographs showed an ipsilateral ulnar diaphysis fracture.", + "Plain radiographs showed a tearing of epitrochlea.", + "Plain radiographs showed a fracture of the radial styloid process.", + "The elbow joint was reduced under general anesthesia.", + "The reduction was stabilized with two Kirschner wires through the distal part of the humerus into the radius.", + "A reinsertion of the medial collateral ligament was performed.", + "The epitrochlea was fixed with two Kirschner wires.", + "The ulnar diaphysis fracture was reduced and fixed by a screwed plate.", + "The radial styloid process was fixed with Kirschner wire.", + "Postoperatively, the elbow was placed in 90° of flexion.", + "The elbow was immobilized with a posterior splint for 3 weeks.", + "The radiohumeral Kirschner wires were removed after 3 weeks.", + "An articulated elbow orthosis was placed.", + "Supervised forearm rotation and gentle passive elbow flexion and extension were initiated after the 3rd week.", + "Full extension of the elbow was not aggressively executed until 6 weeks postoperatively.", + "At 6 weeks postoperatively, orthosis immobilization was discontinued.", + "The Kirschner wires of the radial styloid process were removed at 6 weeks postoperatively.", + "The patient continued to work on range of motion with a 3 times per week physical therapy.", + "At 4 months postoperatively, all fractures were united.", + "At 4 months postoperatively, the patient continued to show improvement in range of motion.", + "At 4 months postoperatively, the elbow flexion-extension arc was 30° to 140°.", + "At 3 years of follow-up, the patient was asymptomatic.", + "At 3 years of follow-up, the patient had 10° of limitation in elbow extension.", + "At 3 years of follow-up, the patient had full flexion of 145°.", + "At 3 years of follow-up, the patient recovered 80° of pronation.", + "At 3 years of follow-up, the patient recovered 30° of supination.", + "At 3 years of follow-up, the patient was satisfied with the clinical outcome." + ], + "summary": "We report the case of a 37-year-old male patient who had a traumatic divergent dislocation of the left elbow, associated with ipsilateral fractures of the ulnar diaphysis and the radial styloid process. The elbow joint was reduced under general anesthesia with internal fixation of the ulnar diaphysis fracture and a pinning of the radial styloid fracture. At 3 years of follow-up, the fractures were consolidated and the elbow was stable with a satisfying mobility.", + "summary_subclaims": [ + "The patient was a 37-year-old male.", + "The patient had a traumatic divergent dislocation of the left elbow.", + "The dislocation was associated with ipsilateral fractures of the ulnar diaphysis and the radial styloid process.", + "The elbow joint was reduced under general anesthesia.", + "The ulnar diaphysis fracture was internally fixed.", + "The radial styloid fracture was pinned.", + "At 3 years of follow-up, the fractures were consolidated.", + "At 3 years of follow-up, the elbow was stable.", + "At 3 years of follow-up, the elbow had satisfying mobility." + ] + }, + { + "id": "multiclinsum_test_637_en.txt", + "fulltext": "A 44-year-old Indonesian female patient presented to the Emergency Department of Sanglah General Hospital (Bali, Indonesia) with the chief complaint of blackish stool that had occurred 2 hours prior to admission and was accompanied by coffee ground vomitus and epigastric pain. Two weeks prior to admission, the patient had been admitted to the district hospital with complaint of blackish stool and received a blood transfusion. The blackish stool recurred 1 week later.\nThe patient denied a history of abdominal trauma but reported a history of elective LC due to cholelithiasis 3 years prior to admission and was hospitalized for 5 days. History of abdominal pain or gastrointestinal bleeding afterwards was denied. History of alcoholism, hepatitis, or chronic liver diseases was denied.\nThe patient’s vitals were within normal range; blood pressure was 110/70 mmHg, heart rate was 84 beats per minute, respiratory rate was 16 breaths per minute, and axillary temperature was 36.6°C. Pallor of the conjunctiva indicated anemia, and scleral icterus suggested slight jaundice. The patient expressed pain on palpation at the epigastric and right hypochondriac region.\nBlood analysis revealed low hemoglobin 9.88 g/dL (normal range: 12–15.5 g/dL) but normal platelet and white blood cell count. Liver function markers were abnormal, with aspartate transaminase of 354.9 U/L (11–33 U/L), alanine transaminase of 321.3 U/L (11–50 U/L), total bilirubin of 3.52 mg/dL (0.3–1.3 mg/dL), direct bilirubin of 2.95 mg/dL (0.0–0.3 mg/dL), alkaline phosphatase of 233 U/L (53–128 U/L), and gamma-glutamyl transferase of 301 U/L (70–140 U/L). Amylase, lipase, prothrombin, and partial thromboplastin times were normal.\nResults from abdominal ultrasonography were unremarkable; there were no signs of biliary obstruction or intraabdominal free fluid. Nonvariceal UGIB caused by peptic ulcer was suspected, and appropriate conservative treatment with lansoprazole bolus 60 mg intravenously followed by continuous drip 6 mg/hour intravenously was initiated, with esophagogastroduodenoscopy (EGD) ordered for further evaluation.\nThe EGD revealed blood covering the gastric tissues up to the second part of the duodenum. After cleansing, the source of bleeding remained inapparent. However, a blood clot was found at the ampulla of Vater . The diagnosis of hemobilia was made, and computed tomography (CT) scan was planned\nWhile waiting for the abdominal CT scan, the patient experienced massive hematemesis and hematochezia. Emergent angiography was performed to determine the source of bleeding and address the patient’s hemodynamic instability. The imaging showed contrast extravasation from a gastroduodenal artery pseudoaneurysm distal to the common bile duct, with flow to the duodenum . The patient was diagnosed with hemobilia due to ruptured gastroduodenal artery pseudoaneurysm.\nThe patient was treated with fluid resuscitation and packed red cell transfusion. Although transcatheter arterial embolization would have been the preferred procedure to stop the bleeding, it was unavailable in our center; therefore, laparotomy surgery was performed. The laparotomy confirmed the bleeding from gastroduodenal artery pseudoaneurysm, and ligation and excision of the pseudoaneurysm were performed . After surgery, the patient’s vital signs were stable, and no recurrent bleeding episode occurred. Unfortunately, the patient developed ventilator-associated pneumonia and passed away.", + "fulltext_subclaims": [ + "The patient was a 44-year-old Indonesian female.", + "She presented with blackish stool that had occurred 2 hours prior to admission.", + "The blackish stool was accompanied by coffee ground vomitus.", + "The patient had a history of elective laparoscopic cholecystectomy due to cholelithiasis 3 years prior to admission.", + "The patient denied a history of alcoholism.", + "The patient's blood pressure was 110/70 mmHg.", + "The patient's hemoglobin was 9.88 g/dL.", + "The patient's aspartate transaminase was 354.9 U/L.", + "The patient's alanine transaminase was 321.3 U/L.", + "The patient's total bilirubin was 3.52 mg/dL.", + "The patient's direct bilirubin was 2.95 mg/dL.", + "The patient's alkaline phosphatase was 233 U/L.", + "The patient's gamma-glutamyl transferase was 301 U/L.", + "Abdominal ultrasonography showed no signs of biliary obstruction.", + "Nonvariceal upper gastrointestinal bleeding caused by peptic ulcer was suspected.", + "Lansoprazole bolus 60 mg intravenously was administered.", + "Lansoprazole continuous drip 6 mg/hour intravenously was initiated.", + "Esophagogastroduodenoscopy was ordered.", + "The EGD revealed blood covering the gastric tissues up to the second part of the duodenum.", + "A blood clot was found at the ampulla of Vater.", + "The diagnosis of hemobilia was made.", + "A computed tomography scan was planned.", + "The patient experienced massive hematemesis and hematochezia.", + "Emergent angiography was performed.", + "Contrast extravasation from a gastroduodenal artery pseudoaneurysm distal to the common bile duct was found.", + "The patient was diagnosed with hemobilia due to ruptured gastroduodenal artery pseudoaneurysm.", + "Transcatheter arterial embolization was unavailable in the center.", + "Laparotomy surgery was performed.", + "The laparotomy confirmed bleeding from the gastroduodenal artery pseudoaneurysm.", + "Ligation and excision of the pseudoaneurysm were performed.", + "The patient developed ventilator-associated pneumonia.", + "The patient passed away." + ], + "summary": "A 44-year-old Indonesian female presented to the emergency department with complaint of hematemesis and melena accompanied by abdominal pain and icterus. History of an abdominal trauma was denied. However, she reported having undergone a laparoscopic cholecystectomy 3 years prior to presentation. On physical examination, we found anemic conjunctiva and icteric sclera. Nonvariceal bleeding was suspected, but esophagogastroduodenoscopy showed a blood clot at the ampulla of Vater. Angiography showed contrast extravasation from a gastroduodenal artery pseudoaneurysm. The patient underwent pseudoaneurysm ligation and excision surgery to stop the bleeding. After surgery, the patient's vital signs were stable, and there was no sign of rebleeding.", + "summary_subclaims": [ + "The patient is a 44-year-old Indonesian female.", + "She presented with hematemesis and melena.", + "She had abdominal pain and icterus.", + "History of an abdominal trauma was denied.", + "She reported having undergone a laparoscopic cholecystectomy 3 years prior to presentation.", + "On physical examination, anemic conjunctiva was found.", + "Icteric sclera was found on physical examination.", + "Nonvariceal bleeding was suspected.", + "Esophagogastroduodenoscopy showed a blood clot at the ampulla of Vater.", + "Angiography showed contrast extravasation from a gastroduodenal artery pseudoaneurysm.", + "The patient underwent pseudoaneurysm ligation and excision surgery.", + "After surgery, the patient's vital signs were stable.", + "There was no sign of rebleeding after surgery." + ] + }, + { + "id": "multiclinsum_test_509_en.txt", + "fulltext": "The patient is a 67-year-old male with a history of hypertension, hyperlipidemia, chronic hepatitis B, and chronic obstructive pulmonary disease secondary to remote smoking. After presenting to an outside hospital with conjunctivitis, elevated intraocular pressure, and hyperthyroidism, he was referred to our clinic and diagnosed with TED. His clinical activity score was 4 in the right eye and 5 in the left eye, with exophthalmometry of 19 OD and 21 OS (a). He was also diagnosed with anterior uveitis secondary to herpes simplex virus and noted to be hepatitis B positive.\nHe initially received treatment for his uveitis and hepatitis B since his proptosis was not severe at this initial appointment. However, due to his persistent uveitis and gradually worsening proptosis, he developed a perforated corneal ulcer in the left eye requiring an urgent penetrating keratoplasty and, when deemed safe, an orbital decompression. The patient later developed a corneal ulcer in the right eye and was scheduled for an orbital decompression. However, with the onset of the COVID-19 pandemic, all non-elective cases were canceled, delaying his surgery. While waiting for surgery, he received multiple temporary tarsorrhaphy procedures and initiated teprotumumab. His BMI was low, approximately 16 kg/m2 at baseline. He was not suspected to be diabetic at that time, and because original guidelines did not recommend any labaratory tests except for pregnancy prior to teprotumumab initiation, none were performed. An HbA1c, measured 6 months prior during his initial admission at the outside hospital, was later found to be 6.3%.\nThe patient received his first dose of teprotumumab partially alleviating his symptoms. Three weeks later, he received his scheduled 3-wall decompression in the right eye. One day after his surgery, a comprehensive metabolic panel reported a non-fasting blood sugar of 263 mg/dL. This was thought to be due to perioperative conditions, including perioperative steroids. He did not receive any follow-up treatment for his blood sugar elevation. A few days after his surgery, he received his second infusion and 3 weeks later, his third infusion.\nSoon after his third dose of teprotumumab, the patient experienced vomiting and low appetite for 1 week. In the ED, he was found to have a blood urea nitrogen of 70, creatinine of 2.4, and blood glucose level of 1,059 with no ketonuria. His HbA1c at the time of presentation was 11.7%. He was admitted to the hospital with a diagnosis of hyperosmolar hyperglycemic nonketotic syndrome and transferred to the ICU on an insulin drip at 4 units/h. Upon discharge, he was diagnosed with type 2 diabetes mellitus, started on glimepiride, insulin glargine 15 units, and set up with regular endocrine follow-up. His teprotumumab was discontinued.\nAt his first follow-up appointment after hospitalization, glimepiride and insulin glargine were discontinued and insulin aspart mixed 70/30 with meals was started (20 units in the morning and 15 units in the afternoon) to improve blood glucose levels, which were in the 250s. Given his known autoimmune thyroid disease, workup was done to assess for autoimmune-mediated diabetes. The insulin autoantibody and anti-glutamic acid decarboxylase 65 antibody were negative, with detectable C-peptide of 3.1 ng/mL, suggesting medication-induced versus type 2 diabetes mellitus. Nine months after hospitalization, his insulin regimen was decreased to 15 units in the morning and 10 units in the afternoon with an A1c of 6.0%. He self-discontinued insulin approximately a year after hospitalization. An A1c performed on no insulin medication was 5.5%. At his latest follow-up, approximately two and a half years after his hospitalization, the patient had an A1c of 6.1% on no diabetes medication. The patient received a bilateral upper eyelid retraction repair and lower eyelid ectropion repair for his residual exposure keratopathy approximately 6 months after his hospitalization (b).", + "fulltext_subclaims": [ + "The patient is a 67-year-old male.", + "He has a history of hypertension.", + "He has a history of hyperlipidemia.", + "He has a history of chronic hepatitis B.", + "He has a history of chronic obstructive pulmonary disease.", + "He had conjunctivitis.", + "He had elevated intraocular pressure.", + "He was diagnosed with TED.", + "His clinical activity score was 4 in the right eye.", + "His clinical activity score was 5 in the left eye.", + "He was diagnosed with anterior uveitis secondary to herpes simplex virus.", + "He was noted to be hepatitis B positive.", + "He developed a perforated corneal ulcer in the left eye.", + "He required an urgent penetrating keratoplasty.", + "He received multiple temporary tarsorrhaphy procedures.", + "He was initiated on teprotumumab.", + "His BMI was approximately 16 kg/m2 at baseline.", + "He was not suspected to be diabetic at that time.", + "Original guidelines did not recommend any laboratory tests except for pregnancy prior to teprotumumab initiation.", + "He received his first dose of teprotumumab.", + "He received a 3-wall decompression in the right eye.", + "A comprehensive metabolic panel reported a non-fasting blood sugar of 263 mg/dL.", + "This was thought to be due to perioperative conditions, including perioperative steroids.", + "He did not receive any follow-up treatment for his blood sugar elevation.", + "He received his second infusion.", + "He received his third infusion.", + "He experienced vomiting and low appetite for 1 week.", + "In the ED, he had a blood urea nitrogen of 70.", + "In the ED, he had a creatinine of 2.4.", + "In the ED, he had a blood glucose level of 1,059.", + "He had no ketonuria.", + "His HbA1c at the time of presentation was 11.7%.", + "He was admitted to the hospital with a diagnosis of hyperosmolar hyperglycemic nonketotic syndrome.", + "He was transferred to the ICU on an insulin drip at 4 units/h.", + "Upon discharge, he was diagnosed with type 2 diabetes mellitus.", + "He was started on glimepiride.", + "He was started on insulin glargine 15 units.", + "He was set up with regular endocrine follow-up.", + "His teprotumumab was discontinued.", + "Glimepiride and insulin glargine were discontinued.", + "Insulin aspart mixed 70/30 with meals was started.", + "He received 20 units in the morning and 15 units in the afternoon.", + "The insulin autoantibody was negative.", + "The anti-glutamic acid decarboxylase 65 antibody was negative.", + "C-peptide was 3.1 ng/mL.", + "Nine months after hospitalization, his insulin regimen was decreased.", + "He had an A1c of 6.0%.", + "He self-discontinued insulin approximately a year after hospitalization.", + "An A1c performed on no insulin medication was 5.5%.", + "At his latest follow-up, approximately two and a half years after his hospitalization, the patient had an A1c of 6.1%.", + "He received a bilateral upper eyelid retraction repair.", + "He received a lower eyelid ectropion repair." + ], + "summary": "This patient's HbA1c was in the pre-diabetic range (6.3%) 6 months prior to initiating teprotumumab. After three doses, the patient was hospitalized with hyperosmolar hyperglycemic nonketotic syndrome and an HbA1c of 11.7%. He was diagnosed with type 2 diabetes mellitus and treated with insulin aspart mixed 70/30. He remained on this regimen for 14 months with an A1c of 6.0%. He then self-discontinued the insulin, with an A1c 4 months later measuring 5.5%. The patient's latest HbA1c approximately two and a half years after hospitalization was 6.1% on no medications.", + "summary_subclaims": [ + "The patient's HbA1c was 6.3% 6 months prior to initiating teprotumumab.", + "After three doses of teprotumumab, the patient was hospitalized with hyperosmolar hyperglycemic nonketotic syndrome.", + "At the time of hospitalization, the patient's HbA1c was 11.7%.", + "The patient was diagnosed with type 2 diabetes mellitus.", + "The patient was treated with insulin aspart mixed 70/30.", + "The patient remained on insulin aspart mixed 70/30 for 14 months.", + "After 14 months on insulin, the patient's A1c was 6.0%.", + "The patient self-discontinued insulin.", + "Four months after self-discontinuing insulin, the patient's A1c was 5.5%.", + "Approximately two and a half years after hospitalization, the patient's latest HbA1c was 6.1%.", + "At the time of the latest HbA1c measurement, the patient was on no medications." + ] + }, + { + "id": "multiclinsum_test_1769_en.txt", + "fulltext": "Our patient was a little girl one month old who came at our service from neonatology. This girl was the third child of healthy Albanian parents, without history of consanguinity. During the pregnancy the mother had presented oligohygramnios. The baby had a birth weight 2500g. She was born at term but she was small for gestational age. APGARE score was 8/10. She was discharged at day three but she was admitted in neonatology at age of 20 days because of jaundice, weight loss, feeding problems, failure to thrive and contractures of lower limbs . At age of one month she was transferred at our service of gastrohepatology because of cholestasis. In this moment the girl weight was 2350 g. We decided to feed her by nasogastric tube. The first results of blood analyses had shown cholestasis ( direct bilirubine=5,2 U/L; total bilirubine =8,9U/L; ALT=85U/l;AST=66U/L; GGT=30U/L). Abdominal echography has shown important ascites . We had performed a blood transfusion because of severe anemia. In consultation with our neurologist and geneticist the contractures of lower limbs are interpreted as talipes calcaneovalgus . The recent urinary analyses had shown glucosuria ,urinary ph was basic, aminoaciduria. We found also hyperchloremia and low bicarbonate. This combination of arthrogryposis , cholestasis and renal dysfunction make us to think about ARC syndrome. At the same time we have excluded the most part of pathologies that presents cholestasis like cystic fibrosis,TORCH, a1 antitripsine deficiency, endocrinopathy, Allagille syndrome,some metabolic disorders. Cranial computed tomography was unremarkable. We didn’t perform a liver biopsy because of an abnormal prothrombine time. Approximately one month later the girl presented a severe ichtyosis and recurrent febrile episodes despite antibiotic therapy. We have expected that this child will present diarrhea but she presented a severe form of constipation. We treated her with several enema but constipation has persisted .Other part of treatment were ursofalk, vitamine A,D,E,K , sodium bicarbonate and antibiotics. Unfortunately she died at age of three months of septicemia. Permission for autopsy was refused. Three weeks later we had a response of molecular biology that was sent abroad which confirms VPS33B mutation", + "fulltext_subclaims": [ + "The patient was a one-month-old girl.", + "The patient was transferred from neonatology to the gastrohepatology service.", + "The patient was the third child of healthy Albanian parents.", + "There was no history of consanguinity.", + "During pregnancy, the mother had presented oligohydramnios.", + "The baby had a birth weight of 2500g.", + "The baby was born at term.", + "The baby was small for gestational age.", + "The APGAR score was 8/10.", + "The baby was discharged at day three.", + "The baby was admitted to neonatology at age of 20 days.", + "The baby was admitted due to jaundice.", + "The baby was admitted due to weight loss.", + "The baby was admitted due to feeding problems.", + "The baby was admitted due to failure to thrive.", + "The baby was admitted due to contractures of lower limbs.", + "At age of one month, the patient was transferred to the gastrohepatology service.", + "The patient was transferred due to cholestasis.", + "The patient's weight at one month was 2350g.", + "The patient was fed by nasogastric tube.", + "Blood analyses showed cholestasis.", + "Direct bilirubin was 5.2 U/L.", + "Total bilirubin was 8.9 U/L.", + "ALT was 85 U/L.", + "AST was 66 U/L.", + "GGT was 30 U/L.", + "Abdominal echography showed important ascites.", + "A blood transfusion was performed due to severe anemia.", + "The contractures of lower limbs were interpreted as talipes calcaneovalgus.", + "Urinary analyses showed glucosuria.", + "Urinary pH was basic.", + "Aminoaciduria was present.", + "Hyperchloremia was found.", + "Low bicarbonate was found.", + "The combination of arthrogryposis, cholestasis, and renal dysfunction made the team think about ARC syndrome.", + "Cystic fibrosis was excluded.", + "TORCH was excluded.", + "Alpha-1 antitrypsin deficiency was excluded.", + "Endocrinopathy was excluded.", + "Alagille syndrome was excluded.", + "Some metabolic disorders were excluded.", + "Cranial computed tomography was unremarkable.", + "A liver biopsy was not performed due to abnormal prothrombin time.", + "One month later, the patient presented severe ichthyosis.", + "One month later, the patient had recurrent febrile episodes.", + "Antibiotic therapy was ineffective.", + "The patient was expected to present diarrhea.", + "The patient presented severe constipation.", + "The patient was treated with several enemas.", + "Constipation persisted.", + "The patient was treated with ursodeoxycholic acid.", + "The patient was treated with vitamins A, D, E, and K.", + "The patient was treated with sodium bicarbonate.", + "The patient was treated with antibiotics.", + "The patient died at age of three months.", + "The cause of death was septicemia.", + "Permission for autopsy was refused.", + "Three weeks later, a molecular biology response was received.", + "The molecular biology response was sent abroad.", + "The molecular biology response confirmed VPS33B mutation." + ], + "summary": "This girl presented after birth severe contractures of legs. She was admitted at 30 days of age with poor feeding, cholestatic jaundice with normal GGT and failure to thrive . Also we have noted a severe acidosis (pH=7.2) associated with aminoaciduria and glucosuria. At second month of age the girl presented a severe ichtyosis, recurrent fever and constipation. Apart from treatment the constipation has persisted. The baby died of sepsis at 12 weeks of age.", + "summary_subclaims": [ + "The girl presented after birth with severe contractures of legs.", + "She was admitted at 30 days of age.", + "She had poor feeding.", + "She had cholestatic jaundice.", + "GGT was normal.", + "She had failure to thrive.", + "A severe acidosis (pH=7.2) was noted.", + "Aminoaciduria was noted.", + "Glucosuria was noted.", + "At second month of age the girl presented a severe ichtyosis.", + "At second month of age the girl had recurrent fever.", + "At second month of age the girl had constipation.", + "The constipation has persisted.", + "The baby died of sepsis at 12 weeks of age." + ] + }, + { + "id": "multiclinsum_test_3125_en.txt", + "fulltext": "We report an 83-year-old Caucasian woman with a past medical history significant for squamous cell carcinoma and basal cell carcinoma of the face treated with surgical removal 11 years previously who presented to her primary care provider with left thumb pain for 1 week. She reports pain on the dorsal aspect of the distal left phalanx, including her nail plate, with mild associated swelling. She denies specific trauma or injury. Examination showed a focal area of erythema under the nail plate without other discoloration. Radiographs were obtained in the clinic with no occult fracture or bony erosion findings. She was prescribed an antibiotic and ibuprofen and asked to follow-up if there was no improvement. After several weeks, she presented again with worsening thumb pain. Examination showed similar but progressive findings. A felon was suspected, and she was prescribed oral antibiotics and instructed to complete warm water soaks. Nail plate removal was offered which the patient declined.\n\nSeveral days after this encounter, she presented to her annual dermatology appointment where the provider noted onychodystrophy of the left thumbnail with firmness to the distal thumb and interruption of the ulnar nail plate. She was offered a referral to orthopedic hand surgery versus a trial of intralesional triamcinolone injection. She chose injection into the left thumb ulnar paronychium. The patient was instructed to follow-up in a few weeks for reassessment and possible biopsy if the lesion did not improve. Reassessment several weeks later yielded no improvement of symptoms. At that time, the left thumb was noted to have significant erythema, tenderness, and swelling of the pad with dystrophic changes to the ulnar nail fold and distal onycholysis. This prompted an orthopedic hand surgery referral for concern of developing subungual tumor. That same day, radiographs showed new osseous erosion of the thumb distal phalanx. A magnetic resonance imaging (MRI) scan of the thumb showed a destructive mass involving the left thumb distal phalangeal tuft extending to the mid phalanx to the nail bed.\n\nWithin a week, the patient was evaluated in the orthopedic hand surgery clinic. Computed tomography-guided biopsy was performed for differentiation between osteomyelitis versus an oncologic process. Biopsy revealed an invasive, well-differentiated squamous cell carcinoma involving the nail plate with underlying bony infiltration. Orthopedic hand surgery recommended surgical excision with disarticulating amputation through the interphalangeal joint of the thumb. Oncology was consulted prior to surgery and no sentinel lymph node or adjuvant therapy was indicated.\n\nAmputation through the interphalangeal joint of the left thumb was performed without event. Gross examination of the specimen showed tumor involvement of the nail bed. Further examination of the amputated distal phalanx revealed tumor involvement of the bone. Pathologic report of the specimen showed a 1.7 × 1.7 cm invasive squamous cell carcinoma with free tissue margins. Oncology determined no indication for adjuvant therapies with long-term follow-up per National Comprehensive Cancer Network guidelines with low threshold for imaging if new symptoms arise. At her 4-month postoperative visit, she has recovered well, is pain-free, and is clinically free of disease recurrence.", + "fulltext_subclaims": [ + "The patient is an 83-year-old Caucasian woman.", + "She has a past medical history significant for squamous cell carcinoma and basal cell carcinoma of the face.", + "The skin cancers were treated with surgical removal 11 years previously.", + "She presented to her primary care provider with left thumb pain for 1 week.", + "She reports pain on the dorsal aspect of the distal left phalanx.", + "She reports pain including her nail plate.", + "She reports mild associated swelling.", + "She denies specific trauma or injury.", + "Examination showed a focal area of erythema under the nail plate.", + "Radiographs were obtained in the clinic.", + "Radiographs showed no occult fracture.", + "Radiographs showed no bony erosion.", + "She was prescribed an antibiotic.", + "She was prescribed ibuprofen.", + "She was asked to follow-up if there was no improvement.", + "After several weeks, she presented again with worsening thumb pain.", + "Examination showed similar but progressive findings.", + "A felon was suspected.", + "She was prescribed oral antibiotics.", + "She was instructed to complete warm water soaks.", + "Nail plate removal was offered.", + "The patient declined nail plate removal.", + "Several days after this encounter, she presented to her annual dermatology appointment.", + "The provider noted onychodystrophy of the left thumbnail.", + "The provider noted firmness to the distal thumb.", + "The provider noted interruption of the ulnar nail plate.", + "She was offered a referral to orthopedic hand surgery.", + "She was offered a trial of intralesional triamcinolone injection.", + "She chose injection into the left thumb ulnar paronychium.", + "She was instructed to follow-up in a few weeks for reassessment.", + "She was instructed that a biopsy might be needed if the lesion did not improve.", + "Reassessment several weeks later yielded no improvement of symptoms.", + "The left thumb was noted to have significant erythema.", + "The left thumb was noted to have tenderness.", + "The left thumb was noted to have swelling of the pad.", + "The left thumb was noted to have dystrophic changes to the ulnar nail fold.", + "The left thumb was noted to have distal onycholysis.", + "This prompted an orthopedic hand surgery referral.", + "There was concern of developing subungual tumor.", + "Radiographs showed new osseous erosion of the thumb distal phalanx.", + "An MRI scan of the thumb showed a destructive mass involving the left thumb distal phalangeal tuft.", + "The MRI scan showed extension to the mid phalanx.", + "The MRI scan showed extension to the nail bed.", + "The patient was evaluated in the orthopedic hand surgery clinic within a week.", + "Computed tomography-guided biopsy was performed.", + "Biopsy was performed for differentiation between osteomyelitis versus an oncologic process.", + "Biopsy revealed an invasive, well-differentiated squamous cell carcinoma.", + "The squamous cell carcinoma involved the nail plate.", + "The squamous cell carcinoma showed underlying bony infiltration.", + "Orthopedic hand surgery recommended surgical excision.", + "Orthopedic hand surgery recommended disarticulating amputation through the interphalangeal joint of the thumb.", + "Oncology was consulted prior to surgery.", + "No sentinel lymph node was indicated.", + "No adjuvant therapy was indicated.", + "Amputation through the interphalangeal joint of the left thumb was performed.", + "Gross examination of the specimen showed tumor involvement of the nail bed.", + "Further examination of the amputated distal phalanx revealed tumor involvement of the bone.", + "The pathologic report showed a 1.7 × 1.7 cm invasive squamous cell carcinoma.", + "The pathologic report showed free tissue margins.", + "Oncology determined no indication for adjuvant therapies.", + "Long-term follow-up was recommended per National Comprehensive Cancer Network guidelines.", + "A low threshold for imaging was recommended if new symptoms arise.", + "At her 4-month postoperative visit, she has recovered well.", + "At her 4-month postoperative visit, she is pain-free.", + "At her 4-month postoperative visit, she is clinically free of disease recurrence." + ], + "summary": "We report an 83-year-old woman who presented to her primary care provider with pain and swelling of her left thumb distal phalanx for 1 week. Initial imaging was benign. The patient underwent treatment for presumed soft tissue infection with 2 separate oral antibiotic courses. An intralesional corticosteroid injection did not provide relief and repeat radiographs showed a destructive lesion to the tuft of the distal phalanx. Advanced imaging showed bony destruction and biopsy revealed invasive squamous cell carcinoma involving the nail plate with bony invasion. Amputation through the interphalangeal joint of the left thumb was conducted with disease-free margins. The patient currently is following with oncology for clinical surveillance.", + "summary_subclaims": [ + "The patient is an 83-year-old woman.", + "She presented with pain and swelling of her left thumb distal phalanx for 1 week.", + "Initial imaging was benign.", + "The patient underwent treatment for presumed soft tissue infection with 2 separate oral antibiotic courses.", + "An intralesional corticosteroid injection did not provide relief.", + "Repeat radiographs showed a destructive lesion to the tuft of the distal phalanx.", + "Advanced imaging showed bony destruction.", + "Biopsy revealed invasive squamous cell carcinoma involving the nail plate with bony invasion.", + "Amputation through the interphalangeal joint of the left thumb was conducted.", + "The amputation had disease-free margins.", + "The patient is following with oncology for clinical surveillance." + ] + }, + { + "id": "multiclinsum_test_2725_en.txt", + "fulltext": "A 50-year-old female patient, known case of hypertension (HTN) and taking normatin as a medication, was in her usual state of health until 6 months prior to admission when she started to complain from headache, tinnitus and vertigo. She sought medical advice and was treated as otitis media (according to the patient).\nBefore ten days from her admission to our hospital, she had episodes of imbalance while she was walking and recurrent vomiting.\nOnce again, she sought medical help and, after a brain CT and a brain MRI were done, the doctors found a left cerebellar tumor . In the upcoming days, she was referred to our hospital in April 2019 for further evaluation and surgical management.\nThe patient came to our hospital by her own (using public transportation) because there were no facilities for the tumor management in other places and there was no need to being transported by ambulance.\nWe did a physical examination focused on a neurological examination due to her symptoms and diagnosis. The patient was conscious, oriented and alert, with a Glasgow coma scale (GCS) of 15/15.\nThe cranial nerves were intact, and she was positive for cerebellar signs. She also was positive for the Romberg sign, had an ataxic gait and could not perform the tandem gait.\nThe patient then underwent surgery in which a midline suboccipital craniectomy with microscopic gross total resection (GTR) of the left cerebellar tumor and a cranioplasty under neuromonitoring was performed successfully.\nThe surgery was smooth and without intraoperative complications with an estimated blood loss of 500 cc.\nAfter the surgery, the patient was transferred to the ICU in good conditions with stable vital signs, conscious, oriented, alert and a GCS of 15/15. The cranial nerves were intact, she was able to move all limbs freely and the wound was dry and clean. Afterwards, she was discharged in good conditions, with stable vital signs and no complications or sequela.\nAccording to the histology department, the specimen that they received in formalin consisted of a multiple pieces and fragments of a grayish tissue measuring in aggregate 7.5 × 5 cm grossly. Further microscopic investigations of the histologic sections showed a biphasic tumor with a mixture of neurocytes and lipidized cells in which the neurocytes were arranged in density cellular sheets of monotonous cells with scanty and often clear cytoplasm, rounded to oval nuclei and salt-and-pepper chromatin. Lipidized cells were clustered and resembling mature adipocytes.\nRare mitotic figures were noted and were investigated. The tumor cells were positive for synaptophysin and neuron specific enolase (ESN) immunostains, focal for glial fibrillary acidic protein (GFAP) and negative for epithelial membrane antigen (EMA).\nWith all these histological findings, it was concluded that the sample was consistent with a cerebellar liponeurocytoma, WHO grade 2.\nAfter a month from the operation, the patient came to the out-patient clinic for follow-up in which we could see that she was in good conditions, with no complains and the cerebellar signs were gone. Since there was no residual tumor left after the surgery and there were no symptoms showing us cerebellar involvement, there was no need for our patient to take radiotherapy once she was discharged.\nSince the patient did not come to us again, we suspect that she is not complaining from any other symptom in the neurosurgical field.", + "fulltext_subclaims": [ + "The patient is a 50-year-old female.", + "The patient has a known case of hypertension.", + "The patient was taking normatin as a medication.", + "The patient was in her usual state of health until 6 months prior to admission.", + "The patient started to complain from headache, tinnitus, and vertigo.", + "The patient was treated as otitis media according to the patient.", + "The patient had episodes of imbalance while walking.", + "The patient had recurrent vomiting.", + "A brain CT and a brain MRI were done.", + "The doctors found a left cerebellar tumor.", + "The patient was referred to our hospital in April 2019.", + "The patient came to our hospital by her own using public transportation.", + "The patient underwent a physical examination focused on a neurological examination.", + "The patient was conscious, oriented, and alert.", + "The patient had a Glasgow coma scale (GCS) of 15/15.", + "The cranial nerves were intact.", + "The patient was positive for cerebellar signs.", + "The patient was positive for the Romberg sign.", + "The patient had an ataxic gait.", + "The patient could not perform the tandem gait.", + "The patient underwent surgery.", + "The surgery was a midline suboccipital craniectomy with microscopic gross total resection (GTR) of the left cerebellar tumor.", + "A cranioplasty was performed.", + "The surgery was performed under neuromonitoring.", + "The surgery was successful.", + "The surgery was smooth and without intraoperative complications.", + "The estimated blood loss was 500 cc.", + "After the surgery, the patient was transferred to the ICU.", + "The patient was in good conditions with stable vital signs.", + "The patient was conscious, oriented, alert, and had a GCS of 15/15.", + "The cranial nerves were intact.", + "The patient was able to move all limbs freely.", + "The wound was dry and clean.", + "The patient was discharged in good conditions.", + "The patient had stable vital signs.", + "There were no complications or sequela.", + "The specimen received in formalin consisted of multiple pieces and fragments of a grayish tissue.", + "The aggregate size of the tissue was 7.5 × 5 cm.", + "The histologic sections showed a biphasic tumor with a mixture of neurocytes and lipidized cells.", + "The neurocytes were arranged in density cellular sheets of monotonous cells.", + "The neurocytes had scanty and often clear cytoplasm.", + "The neurocytes had rounded to oval nuclei.", + "The neurocytes had salt-and-pepper chromatin.", + "The lipidized cells were clustered and resembled mature adipocytes.", + "Rare mitotic figures were noted.", + "The tumor cells were positive for synaptophysin.", + "The tumor cells were positive for neuron specific enolase (ESN) immunostains.", + "The tumor cells were focal for glial fibrillary acidic protein (GFAP).", + "The tumor cells were negative for epithelial membrane antigen (EMA).", + "The sample was consistent with a cerebellar liponeurocytoma.", + "The tumor was WHO grade 2.", + "After a month from the operation, the patient came to the out-patient clinic.", + "The patient was in good conditions.", + "The patient had no complaints.", + "The cerebellar signs were gone.", + "There was no residual tumor left after the surgery.", + "There were no symptoms showing cerebellar involvement.", + "There was no need for the patient to take radiotherapy.", + "The patient did not come to us again.", + "We suspect that the patient is not complaining from any other symptom in the neurosurgical field." + ], + "summary": "Herein, we describe a 50-year-old female patient who presented to the hospital complaining of headache, tinnitus, and vertigo with positive cerebellar signs. MRI revealed a left cerebellar tumor. After tumor resection, histological examination and immunohistochemistry were done and the diagnosis of cerebellar liponeurocytoma was confirmed.", + "summary_subclaims": [ + "The patient is a 50-year-old female.", + "The patient presented with headache.", + "The patient presented with tinnitus.", + "The patient presented with vertigo.", + "The patient had positive cerebellar signs.", + "MRI revealed a left cerebellar tumor.", + "After tumor resection, histological examination was done.", + "Immunohistochemistry was performed.", + "The diagnosis of cerebellar liponeurocytoma was confirmed." + ] + }, + { + "id": "multiclinsum_test_1241_en.txt", + "fulltext": "A healthy 13 month-old boy was receiving oral propranolol hydrochloride for a large IH. There was no history of hypoglycemia or other medications. The initial dose of propranolol hydrochloride was 0,5 mg/kg/day and over several weeks was titrated to 1mg/kg/d. He received the treatment for about 9 months and had a significant reduction in the size of IH. The night prior to hospitalization, the child looked tired, drowsy and had a very poor oral intake. Due to his sleepiness, he didn’t receive the evening dose of propranolol. With the child's poor feeding, it was important to skip the propranolol dose and hold it temporarily. Since his mother had no clear information about the importance of taking propranolol with food, as well as when to stop temporarily the propranolol, she gave him the missed dose during the night, without food (about six hours before hospital admission). In the morning the child was unresponsive, unarousable, with a grey pallor. The clinical situation was critical: in a deep coma, with a severe hypothermia (34°C), cold sweats, slow heart beats (60-65 beats/minute) and a low blood pressure (85/46 mmHg). After immediate suspicion, we confirmed a severe hypoglycemia (26 mg/dl). After confirming the hypoglycemia, we asked about the presence of any medication at home, in order to exclude the possibility of a drug poisoning. The mother didn’t inform us at the first moment that the child was taking propranolol for IH. No advices were given to the parents about adverse effects of propranolol and how recognizing signs of its serious adverse effects (including hypotension, bradycardia, wheezing, and hypoglycemia). The child was given initially 30 ml of 10% dextrose solution intravenously, which resulted in stabilization of his glucose level. We continued the treatment with 7.5% dextrose for a few hours after. Clinical condition was completely normalized.", + "fulltext_subclaims": [ + "The child was receiving oral propranolol hydrochloride for a large IH.", + "There was no history of hypoglycemia or other medications.", + "The initial dose of propranolol hydrochloride was 0,5 mg/kg/day.", + "The dose was titrated to 1mg/kg/d over several weeks.", + "The treatment lasted about 9 months.", + "The child had a significant reduction in the size of IH.", + "The night prior to hospitalization, the child looked tired and drowsy.", + "The child had a very poor oral intake.", + "Due to his sleepiness, he didn’t receive the evening dose of propranolol.", + "The mother gave him the missed dose during the night, without food.", + "In the morning, the child was unresponsive and unarousable.", + "The child had a grey pallor.", + "The child had a severe hypothermia (34°C).", + "The child had slow heart beats (60-65 beats/minute).", + "The child had a low blood pressure (85/46 mmHg).", + "Severe hypoglycemia (26 mg/dl) was confirmed.", + "The mother didn’t inform us at the first moment that the child was taking propranolol for IH.", + "No advices were given to the parents about adverse effects of propranolol.", + "The child was given 30 ml of 10% dextrose solution intravenously.", + "The glucose level stabilized after the dextrose infusion.", + "The clinical condition was completely normalized." + ], + "summary": "We report a case presented in deep hypoglycemic coma during his treatment with propranolol for IH. Through our case report and the review of the literature, we aimed to underline the importance of recognizing adverse effects during propranolol therapy. Although propranolol has a long history of safe and effective use in infants and children, pediatricians should be aware that life-threatening adverse effects can happen during propranolol therapy for IH.", + "summary_subclaims": [ + "The patient was presented in deep hypoglycemic coma during his treatment with propranolol for IH.", + "We aimed to underline the importance of recognizing adverse effects during propranolol therapy.", + "Propranolol has a long history of safe and effective use in infants and children.", + "Pediatricians should be aware that life-threatening adverse effects can happen during propranolol therapy for IH." + ] + }, + { + "id": "multiclinsum_test_3184_en.txt", + "fulltext": "Past Medical History\nThe patient had a longstanding history of occasional exertional chest pain dating back to youth, intensifying over the years with physical activity. Otherwise, the patient was healthy, not taking any medicines.\nDifferential Diagnosis\nDifferential considerations included the following: 1) myocardial ischemia due to coronary artery disease; 2) coronary artery anomaly; and 3) microvascular angina.\n\nInvestigations\n\n1. Coronary angiography: demonstrated a thin, tortuous left main artery with minimal calcification. The left coronary artery showed tortuosity and diminished branching as it formed the left anterior descending artery.\n\n2. Coronary physiology and intravascular ultrasound (IVUS): physiological measurements indicated flow limitation (diastolic flow ratio: 0.88, fractional flow reserve: 0.76). IVUS revealed a half-moon sign, a marker of myocardial bridging (MB).\n\n3. CT angiography: confirmed a deeply tunneled course of the left main coronary artery (LMCA) within the myocardium.\n\nManagement (Medical/Interventions)\nThe patient was started on a pharmacologic regimen including acetylsalicylic acid 75 mg daily, metoprolol 50 mg twice daily, amlodipine 10 mg daily, and rosuvastatin 40 mg daily. Nitrates were avoided due to potential adverse effects in MB.\n\nOutcome and Follow-Up\nOver 6 months, the patient experienced complete symptom resolution, improved exercise tolerance, and reported reduced chest pain.", + "fulltext_subclaims": [ + "The patient had a longstanding history of occasional exertional chest pain dating back to youth.", + "The patient's chest pain intensified over the years with physical activity.", + "The patient was healthy and not taking any medicines.", + "Differential considerations included myocardial ischemia due to coronary artery disease.", + "Differential considerations included coronary artery anomaly.", + "Differential considerations included microvascular angina.", + "Coronary angiography demonstrated a thin, tortuous left main artery with minimal calcification.", + "The left coronary artery showed tortuosity and diminished branching as it formed the left anterior descending artery.", + "Physiological measurements indicated flow limitation (diastolic flow ratio: 0.88, fractional flow reserve: 0.76).", + "IVUS revealed a half-moon sign, a marker of myocardial bridging.", + "CT angiography confirmed a deeply tunneled course of the left main coronary artery within the myocardium.", + "The patient was started on acetylsalicylic acid 75 mg daily.", + "The patient was started on metoprolol 50 mg twice daily.", + "The patient was started on amlodipine 10 mg daily.", + "The patient was started on rosuvastatin 40 mg daily.", + "Nitrates were avoided due to potential adverse effects in MB.", + "Over 6 months, the patient experienced complete symptom resolution.", + "Over 6 months, the patient had improved exercise tolerance.", + "Over 6 months, the patient reported reduced chest pain." + ], + "summary": "A 58-year-old man presented with stable angina and worsening exertional chest pain. Diagnostic work-up, including coronary angiography, intravascular ultrasound, and computed tomography angiography, confirmed LMCA MB with significant flow obstruction. A tailored pharmacologic regimen involving beta-blockers and calcium antagonists led to complete symptom resolution over 6 months.", + "summary_subclaims": [ + "The patient is a 58-year-old man.", + "The patient had stable angina.", + "The patient had worsening exertional chest pain.", + "Diagnostic work-up included coronary angiography.", + "Diagnostic work-up included intravascular ultrasound.", + "Diagnostic work-up included computed tomography angiography.", + "LMCA MB was confirmed.", + "There was significant flow obstruction.", + "A tailored pharmacologic regimen involved beta-blockers.", + "A tailored pharmacologic regimen involved calcium antagonists.", + "Symptoms resolved completely over 6 months." + ] + }, + { + "id": "multiclinsum_test_3293_en.txt", + "fulltext": "The patient is a 51-year-old white man with a medical history significant for severe coronary artery disease resulting in cardiogenic shock (at one point requiring a short-term left ventricular assist device), heart failure with reduced ejection fraction estimated at 20%–25%, hypertension and schizophrenia who presented with his brother to the emergency department with 5-day history of fatigue, ataxia, altered mental status and abnormal behaviour.\n\nHis brother states that he has been getting steadily worse, with multiple near falls and unsteadiness in 2 days leading up to admission. He has never had any symptoms like this before, and has poor insight into his symptoms. His behaviour and mental status have also been inappropriate, as the brother states he has been unable to complete activities of daily living such as bathing or feeding himself. His affect has also been more flat than normal, with the patient’s brother reporting significantly longer time to respond to questions than his baseline. He also reported one episode of hyper elation and agitation that resolved after several hours. He has been alert and oriented to only person and place, but not time (normally he is fully oriented). The patient denies any shortness of breath, chest pain, nausea, headache, vomiting, diarrhoea or decreased oral intake. He and his brother deny any trauma. The patient denies any hallucinations, delusions, depressed mood or worsening negative symptoms of schizophrenia. His medication regimen is notable for spironolactone 25 mg daily, torsemide 200 mg two times per day and metolazone 2.5 mg daily for diuresis. This large dose of diuretics was due to a recent hospitalisation for congestive heart failure exacerbation with volume overload. It was during this hospitalisation that torsemide was increased, and spironolactone was added with metolazone. His other home medications included atorvastatin 80 mg daily, clopidogrel 75 mg daily, hydroxyzine 25 mg as needed for itching, mirtazapine 30 mg daily, olanzapine 10 mg daily, trazodone 50 mg as needed for sleep, metoclopramide 5 mg as needed for nausea and pantoprazole 40 mg two times per day for heartburn. While the patient does have a history of poor medication adherence and health literacy, his brother states that he has been taking his medications as prescribed leading up to the onset of these symptoms.\n\nThe patient had a blood pressure of 91/73 mm Hg on admission, with his normal baseline systolic blood pressure being around 100 mm Hg. His pulse, temperature, oxygen saturations and respiratory rate were within normal limits. On physical examination, he was generally in no acute distress. He was alert and oriented, with no focal neurologic deficit, and a flat affect. He had very dry mucous membranes, decreased skin turgor and no oedema. His cardiac examination was notable for an irregular rhythm, no appreciated jugular venous distention with equal peripheral pulses. His pulmonary examination was overall clear to auscultation. Abdomen was non-distended, with normal bowel sounds.\n\nBasic metabolic panel on admission was notable for a serum sodium of 108 mmol/L, potassium of 1.5 mmol/L, chloride of 65 mmol/L, blood urea nitrogen (BUN) of 82 mg/dL and a creatinine of 2.32 mg/dL (baseline 1.2 mg/dL). His serum osmolality was 242 mOsm/Kg H2O. His urine sodium was 20 mmol/L, urine potassium 25.6 mmol/L, urine chloride 20 mmol/L and urine osmolality 204 mOsm/kg H2O. His brain natriuretic peptide (BNP) was 2113 pg/mL, which is around his baseline. His glucose on admission was 119 mg/dL. His most recent lipid panel from 8 months prior had a total cholesterol of 263 mg/dL, high-density lipoprotein (HDL) of 37 mg/dL, low-density lipoprotein (LDL) of 183 mg/dL and triglycerides of 217 mg/dL.\n\nNotable imaging includes a non-contrast CT head that was unrevealing for acute abnormalities, and his ECG was found to have no changes from the previous studies. In the setting of the patient’s presenting symptoms and severe hyponatremia, he was admitted to the internal medicine teaching service.\n\n\nOutcome and follow-up\n\nGiven his significant electrolyte abnormalities, prerenal azotemia, extensive and recently advanced home diuretic regimen and hypovolemic physical examination, the patient was assessed to be in severe hypotonic hyponatremia due to hypovolemia from over-diuresis as the cause of his presenting symptoms. In concordance with cardiology consultation, he was treated with gradual sodium correction with isotonic fluids. Normal saline was introduced at 100 mL/hour, with sodium checks in every 4 hours to avoid correction greater than 8–10 mmol/L in 24 hours. His home diuretics were held while correcting sodium. We also held his other home medications, including his schizophrenia medication olanzapine due to the risk of syndrome of inappropriate antidiuretic hormone (SIADH), which may worsen his hyponatremia. In addition, with the patient’s hypokalemia requiring aggressive repletion, we were concerned with continuing his olanzapine and its inherent risk of QT-interval prolongation. His electrolytes improved on this therapy, with a peak in sodium to 119 mmol/L on the morning of hospital day 4. However, by that afternoon, his sodium actually decreased to 116 mmol/L. At this point, his potassium and chloride had corrected, and his creatinine returned close to baseline. His presenting symptoms of ataxia, altered mental status and fatigue had slightly improved. He was able to walk around the room with supervision and had no falls. He was awake throughout the day and did not report fatigue. However, given that he was a poor historian with a very flat affect secondary to his schizophrenia history, it was difficult to ascertain his insight into his symptoms. It was also difficult to tell if his negative symptoms had worsened while holding olanzapine, but his brother confirmed that he was around his baseline in this regard. While he was oriented to person, place and time, his lack of insight and inability to describe his concerns remained a challenge throughout the hospitalisation.\n\nFollowing his initial presentation and volume repletion, his physical examination, symptoms, labs and imaging supported an euvolemic aetiology of his hyponatremia. He remained clear on pulmonary auscultation and did not have any abdominal distention, jugular venous distention or lower extremity oedema. He also did not report any cough, orthopnea, or paroxysmal nocturnal dyspnoea. His BNP had decreased to 1837 pg/mL. A chest radiograph showed right basilar atelectasis with possible infiltrate, but was mostly stable compared with baseline. In conjunction with an euvolemic hyponatremia, an evaluation for SIADH was started. This was not only supported by his current examination status, but he was also being treated with olanzapine prior to admission, which has a risk for SIADH. His intravenous fluids were stopped and he was placed on a 1000 mL/day fluid restriction. However, his hyponatremia failed to significantly improve with a value of 117 mmol/L on the morning of hospital day 5, and 118 mmol/L on the morning of day 6. His urine electrolytes included a urine sodium of less than 20 mmol/L, urine potassium 26.9 mmol/L, urine chloride 23 mmol/L and urine osmolality 315 mOsm/kg H2O. His low urine sodium suggested that SIADH was not the aetiology of his hyponatremia. He remained clinically euvolemic on physical examination on hospital day 6, including normal pulmonary examination to auscultation, no jugular venous distention, no oedema, normal capillary refill and no abdominal distention. He also did not report cough, orthopnea or paroxysmal nocturnal dyspnoea, and continued to state that he had been resting comfortably every night.\n\nIn the setting of likely mismanagement of this patient’s hyponatremia, the primary inpatient teaching service used point-of-care ultrasound on the morning of hospital day 6 to better assess the patient’s volume status. The patient was found to have a moderate-sized right pleural effusion and diffuse pulmonary parenchymal B-lines suggesting pulmonary oedema. His inferior vena cava appeared plethoric and its diameter measured 2.5 cm with no respiratory variation. His estimated Caval Index was 1, given this lack of respiratory change, which is significantly higher than the estimated 0.35 in euvolemic patients.2 In all, the ultrasound findings supported hypervolemia. As a result, a diuretic regimen was started with oral torsemide 60 mg two times per day and his volume response and sodium were monitored closely. His sodium improved to 126 mmol/L on hospital day 7, and then he was successfully discharged home with a sodium of 132 mmol/L on hospital day 8. He was stable at time of discharge, with discharge summary stating to monitor volume status closely in upcoming appointments. He was also counselled on medication adherence, frequent weight monitoring and fluid restriction. Home health services were called prior to his discharge to discuss assisting his mother and brother with his care.\n\nWhile the internal medicine teaching service and the cardiology service recommended discharge to skilled nursing facility to help manage his medications and chronic debility, he wanted to be discharged home to his mother and brother. He followed up with his cardiologist 2 weeks after discharge, and was scheduled with his primary care physician but never arrived at that appointment. At the time of his cardiology follow-up, his diuretic regimen was torsemide 100 mg two times per day (down from 200 mg two times per day), spironolactone 25 mg daily (same as prior to hospitalisation) and metolazone 2.5 mg daily (same as prior to hospitalisation). In setting of his heart failure with reduced ejection fraction, he was started on 25 mg daily of metoprolol succinate. He had also resumed his home medications that were held during the hospitalisation, most notably olanzapine 10 mg daily and mirtazapine 30 mg daily for his schizophrenia. He had no complaints of fatigue, altered mental status, ataxia or abnormal behaviour. His sodium at this visit was 130 mmol/L, somewhat stable since discharge. Medication non-adherence remained an issue at follow-up, with patient having little understanding of his medical history or current medications. Home healthcare services assisted with medication adherence.", + "fulltext_subclaims": [ + "The patient is a 51-year-old white man.", + "He has a medical history significant for severe coronary artery disease.", + "He had cardiogenic shock requiring a short-term left ventricular assist device.", + "He has heart failure with reduced ejection fraction estimated at 20%–25%.", + "He has hypertension.", + "He has schizophrenia.", + "He presented with a 5-day history of fatigue.", + "He had ataxia.", + "He had altered mental status.", + "He had abnormal behaviour.", + "His brother reported multiple near falls in 2 days.", + "He has never had symptoms like this before.", + "He has poor insight into his symptoms.", + "He was unable to complete activities of daily living such as bathing or feeding himself.", + "His affect was more flat than normal.", + "He had significantly longer time to respond to questions than his baseline.", + "He had one episode of hyper elation and agitation that resolved after several hours.", + "He was alert and oriented to only person and place, but not time.", + "He denied shortness of breath.", + "He denied chest pain.", + "He denied nausea.", + "He denied headache.", + "He denied vomiting.", + "He denied diarrhoea.", + "He denied decreased oral intake.", + "He and his brother denied any trauma.", + "He denied hallucinations.", + "He denied delusions.", + "He denied a depressed mood.", + "He denied worsening negative symptoms of schizophrenia.", + "His medication regimen included spironolactone 25 mg daily.", + "He took torsemide 200 mg two times per day.", + "He took metolazone 2.5 mg daily.", + "The large dose of diuretics was due to a recent hospitalisation for congestive heart failure exacerbation with volume overload.", + "Torsemide was increased during this hospitalisation.", + "Spironolactone was added during this hospitalisation.", + "His other home medications included atorvastatin 80 mg daily.", + "He took clopidogrel 75 mg daily.", + "He took mirtazapine 30 mg daily.", + "He took olanzapine 10 mg daily.", + "He took trazodone 50 mg as needed for sleep.", + "He took metoclopramide 5 mg as needed for nausea.", + "He took pantoprazole 40 mg two times per day.", + "He had a history of poor medication adherence.", + "His brother stated he had been taking his medications as prescribed leading up to the onset of these symptoms.", + "On admission, his blood pressure was 91/73 mm Hg.", + "His baseline systolic blood pressure was around 100 mm Hg.", + "His serum sodium on admission was 108 mmol/L.", + "His serum potassium on admission was 1.5 mmol/L.", + "His BUN on admission was 82 mg/dL.", + "His creatinine on admission was 2.32 mg/dL.", + "His serum osmolality was 242 mOsm/Kg H2O.", + "His urine sodium was 20 mmol/L.", + "His urine potassium was 25.6 mmol/L.", + "His urine osmolality was 204 mOsm/kg H2O.", + "His BNP was 2113 pg/mL.", + "His glucose on admission was 119 mg/dL.", + "He was admitted to the internal medicine teaching service.", + "He was assessed to be in severe hypotonic hyponatremia due to hypovolemia from over-diuresis.", + "He was treated with gradual sodium correction with isotonic fluids.", + "Normal saline was introduced at 100 mL/hour.", + "Sodium checks were done every 4 hours.", + "His home diuretics were held while correcting sodium.", + "His olanzapine was held due to the risk of SIADH.", + "His electrolytes improved on this therapy.", + "His sodium peaked at 119 mmol/L on the morning of hospital day 4.", + "By the afternoon of hospital day 4, his sodium decreased to 116 mmol/L.", + "His potassium and chloride had corrected.", + "His creatinine returned close to baseline.", + "His presenting symptoms of ataxia, altered mental status and fatigue had slightly improved.", + "He was able to walk around the room with supervision.", + "He had no falls.", + "He was awake throughout the day and did not report fatigue.", + "It was difficult to ascertain his insight into his symptoms.", + "He was oriented to person, place and time.", + "He remained clear on pulmonary auscultation.", + "He did not have any abdominal distention.", + "He did not have jugular venous distention.", + "He did not have lower extremity oedema.", + "He did not report cough, orthopnea, or paroxysmal nocturnal dyspnoea.", + "His BNP had decreased to 1837 pg/mL.", + "A chest radiograph showed right basilar atelectasis with possible infiltrate.", + "He was placed on a 1000 mL/day fluid restriction.", + "His hyponatremia failed to significantly improve.", + "His urine sodium was less than 20 mmol/L.", + "His urine osmolality was 315 mOsm/kg H2O.", + "His low urine sodium suggested that SIADH was not the aetiology of his hyponatremia.", + "He remained clinically euvolemic on physical examination.", + "Point-of-care ultrasound showed a moderate-sized right pleural effusion.", + "The ultrasound showed diffuse pulmonary parenchymal B-lines suggesting pulmonary oedema.", + "His inferior vena cava appeared plethoric.", + "His estimated Caval Index was 1.", + "A diuretic regimen was started with oral torsemide 60 mg two times per day.", + "His sodium improved to 126 mmol/L on hospital day 7.", + "He was discharged home with a sodium of 132 mmol/L on hospital day 8.", + "He was stable at time of discharge.", + "He was counselled on medication adherence.", + "He was counselled on frequent weight monitoring.", + "He was counselled on fluid restriction.", + "Home health services were called prior to discharge.", + "He wanted to be discharged home to his mother and brother.", + "He followed up with his cardiologist 2 weeks after discharge.", + "His diuretic regimen was torsemide 100 mg two times per day.", + "He resumed his home medications that were held during hospitalisation.", + "He had no complaints of fatigue, altered mental status, ataxia or abnormal behaviour.", + "His sodium at this visit was 130 mmol/L.", + "Medication non-adherence remained an issue at follow-up.", + "Home healthcare services assisted with medication adherence." + ], + "summary": "A 51-year-old man was hospitalised for severe hyponatremia. Initial history and physical examination suggested hypovolemia, and he was treated with normal saline at 100 mL/hour. After several days, his hyponatremia failed to improve, and then worsened without resolution of presenting ataxia and fatigue. He had no new complaints including no cough or orthopnea. He had no jugular venous distention or oedema, and his lungs were clear to auscultation. Point-of-care ultrasound was used, revealing a distended inferior vena cava, pulmonary oedema and pleural effusion, suggesting hypervolemia. Based on ultrasound findings, we treated with 60 mg oral torsemide two times per day. Hyponatremia resolved without complication within 48 hours.", + "summary_subclaims": [ + "The patient was hospitalised for severe hyponatremia.", + "Initial history and physical examination suggested hypovolemia.", + "He was treated with normal saline at 100 mL/hour.", + "After several days, his hyponatremia failed to improve.", + "His hyponatremia then worsened without resolution of presenting ataxia and fatigue.", + "He had no new complaints including no cough or orthopnea.", + "He had no jugular venous distention or oedema.", + "His lungs were clear to auscultation.", + "Point-of-care ultrasound was used.", + "Point-of-care ultrasound revealed a distended inferior vena cava.", + "Point-of-care ultrasound revealed pulmonary oedema.", + "Point-of-care ultrasound revealed pleural effusion.", + "The ultrasound findings suggested hypervolemia.", + "We treated with 60 mg oral torsemide two times per day.", + "Hyponatremia resolved without complication within 48 hours." + ] + }, + { + "id": "multiclinsum_test_836_en.txt", + "fulltext": "A 46-year-old Asian man without any significant past medical history presented to an out-patient clinic complaining of fever, epigastric pain, and back pain. He was diagnosed as having gastric ulcer by upper gastrointestinal endoscopy and prescribed a proton pomp inhibitor; however, his fever of approximately 38 °C and his back pain remained. Two weeks later, his back pain had worsened, and the laboratory data of the out-patient clinic showed an elevated C-reactive protein level (17.2 mg/dL); thus, he came to our hospital for further evaluation. His medication included only orally administered azelnidipine for hypertension. There was no significant family medical history. He denied smoking tobacco, alcohol consumption, and exposure to toxins. He worked at a ceremonial hall without any ill contacts. He had a fever of 37.9 °C, heart rate of 90 beats per minute (bpm), respiratory rate of 20 breaths/minute, blood pressure of 126/78 mmHg, and oxygen saturation of 97% on room air. A physical examination including a neurological examination showed a well man without any specific abnormal findings. Blood tests at the first encounter revealed a white blood cell count of 10,300/μL with 70% neutrophils, 14% lymphocytes, and 16% monocytes, and the platelet count was 275,000/μL. His lactate dehydrogenase level was 299 IU/L (normal range, 119–229 IU/L), his alkaline phosphatase level was 983 U/L (normal range, 103–335 U/L), and his gamma-glutamyl transpeptidase level was 256 IU/L (normal range, 0–73 IU/L). His C-reactive protein level was 23.47 mg/dL (normal range, 0–0.29 mg/dL). Other results are shown in Table . A contrasted computed tomography (CT) scan showed edema around his gallbladder without gallstones or bile duct dilation, along with left adrenal enlargement without contrast, suggesting necrosis and slight pleural effusion . His right adrenal gland was contrasted normally. Contrasted magnetic resonance imaging (MRI) of his adrenal glands was also performed, and the results showed necrosis of his left adrenal gland with a slight possibility of infarction and no specific evidence of hemorrhage. He was hospitalized for further investigation into the cause of the unilateral adrenal necrosis.\nLupus anticoagulant and don't break the value complex antibody were measured, and both were negative, which suggested a low possibility of antiphospholipid syndrome. He did not meet the criteria for diagnosis of systemic lupus erythematosus. We considered the possibility of adrenal insufficiency or pheochromocytoma and measured several types of adrenal hormones, such as serum cortisol, adrenocorticotropic hormone, plasma renin activity, plasma aldosterone activity, and urinary metanephrine and normetanephrine, but none of them explained our patient’s condition. The culture results from blood drawn at the first encounter were all negative. We performed CT-guided needle biopsy of his left adrenal gland, which revealed necrosis and the formation of fibrotic granulomatous tissue . There was no epithelioid granuloma, malignant lymphoma cells, or hemosiderin deposition, suggesting a low possibility of the involvement of a hemorrhagic etiology. The bacterial culture of this biopsy tissue was also negative. After the biopsy was finished, he was discharged. However, 1 week later, severe thrombocytopenia (5000/μL) appeared, and he was rehospitalized. His creatinine level had increased to 1.03 mg/dL from the initial value of 0.85 mg/dL. Bone marrow aspiration first resulted in a dry tap, but subsequent results showed increased megakaryocytes and hypercellular marrow with fibrosis classified as MF-1 according to the European consensus on bone marrow fibrosis staging . A contrasted CT scan showed new left axillary lymphadenopathy with a size of 15 mm, right pleural effusion, and increased ascites . Because our patient’s condition was worsening, we needed to start immediate treatment for any possible underlying causes, including bacterial infection and autoimmune disease, before obtaining the exact diagnosis. The laboratory data from the second hospitalization are shown in Table . The clinical course of this case is shown in Fig. . The initial treatment included ampicillin/sulbactam and a methylprednisolone pulse followed by orally administered prednisolone and intravenous immunoglobulin therapy (400 mg/kg for 5 days), considering the underlying causes mentioned above, such as severe bacterial infection or autoimmune diseases including antiphospholipid syndrome and immune thrombocytopenia; however, all of these treatments seemed to be ineffective. We also used recombinant thrombomodulin (380 U/kg) for 7 days to cope with the possibility of a thrombotic event or disseminated intravascular coagulation. Because the blood and adrenal gland biopsy culture results were both negative, we stopped the antibiotic treatment. On hospital day 9, we performed a left axillary lymph node needle biopsy, which showed no evidence of malignant lymphoma. With the edema, severe thrombocytopenia, fever above 37.5 °C, reticulin myelofibrosis (MF), mild lymphadenopathy, and progressive renal insufficiency and with other diseases excluded, we diagnosed this patient as having TAFRO syndrome according to the diagnostic criteria . The administration of intravenously administered tocilizumab (8 mg/kg) was begun on the same day with tapering prednisolone dose; his C-reactive protein and alkaline phosphatase levels gradually improved, along with his renal function and fever . For the anasarca, furosemide and potassium canrenoate were used and were highly effective.\nBecause the thrombocytopenia remained, we added eltrombopag, a thrombopoietin receptor agonist, on hospital day 14, followed by tocilizumab administered on hospital day 16. Then, his platelet count began to increase. Under the strong immunosuppressive treatment, he contracted methicillin-resistant Staphylococcus epidermidis bacteremia on hospital day 20 and cytomegalovirus viremia on hospital day 31, which were successfully treated with vancomycin and ganciclovir, respectively. Tocilizumab was administered a third time on hospital day 47, and our patient was discharged on hospital day 48. After discharge, he remained afebrile and with an alkaline phosphate level within normal limits, and tocilizumab administration was no longer necessary. Eltrombopag administration was stopped because his platelet count increased and remained stable within normal limits. Nine months after the first treatment, this patient continues to do well. He is only being treated with low-dose prednisolone at approximately 5 mg per day and is still tapering carefully because of the presence of unilateral adrenal necrosis, considering the possibility of adrenal insufficiency.", + "fulltext_subclaims": [ + "The patient was a 46-year-old Asian man.", + "He had no significant past medical history.", + "He presented with fever, epigastric pain, and back pain.", + "He was diagnosed with gastric ulcer by upper gastrointestinal endoscopy.", + "He was prescribed a proton pomp inhibitor.", + "His fever of approximately 38 °C and back pain remained.", + "Two weeks later, his back pain had worsened.", + "The out-patient clinic laboratory data showed an elevated C-reactive protein level (17.2 mg/dL).", + "He came to our hospital for further evaluation.", + "His medication included orally administered azelnidipine for hypertension.", + "He denied smoking tobacco, alcohol consumption, and exposure to toxins.", + "He worked at a ceremonial hall without any ill contacts.", + "He had a fever of 37.9 °C.", + "His blood pressure was 126/78 mmHg.", + "A physical examination showed a well man without any specific abnormal findings.", + "Blood tests revealed a white blood cell count of 10,300/μL.", + "The platelet count was 275,000/μL.", + "His lactate dehydrogenase level was 299 IU/L.", + "His C-reactive protein level was 23.47 mg/dL.", + "A contrasted CT scan showed edema around his gallbladder.", + "The CT scan showed left adrenal enlargement without contrast.", + "The CT scan suggested necrosis and slight pleural effusion.", + "Contrasted MRI of his adrenal glands showed necrosis of his left adrenal gland.", + "The MRI showed a slight possibility of infarction.", + "The MRI showed no specific evidence of hemorrhage.", + "He was hospitalized for further investigation into the cause of the unilateral adrenal necrosis.", + "Lupus anticoagulant was measured and was negative.", + "The don't break the value complex antibody was measured and was negative.", + "Both were negative, which suggested a low possibility of antiphospholipid syndrome.", + "He did not meet the criteria for diagnosis of systemic lupus erythematosus.", + "We considered the possibility of adrenal insufficiency or pheochromocytoma.", + "We measured several types of adrenal hormones.", + "None of them explained our patient’s condition.", + "The culture results from blood drawn at the first encounter were all negative.", + "We performed CT-guided needle biopsy of his left adrenal gland.", + "The biopsy revealed necrosis and the formation of fibrotic granulomatous tissue.", + "There was no epithelioid granuloma, malignant lymphoma cells, or hemosiderin deposition.", + "The bacterial culture of this biopsy tissue was also negative.", + "After the biopsy was finished, he was discharged.", + "One week later, severe thrombocytopenia (5000/μL) appeared.", + "His creatinine level had increased to 1.03 mg/dL.", + "Bone marrow aspiration first resulted in a dry tap.", + "Subsequent results showed increased megakaryocytes and hypercellular marrow with fibrosis classified as MF-1.", + "A contrasted CT scan showed new left axillary lymphadenopathy with a size of 15 mm.", + "We needed to start immediate treatment for any possible underlying causes.", + "The initial treatment included ampicillin/sulbactam.", + "The initial treatment included a methylprednisolone pulse.", + "The initial treatment included orally administered prednisolone.", + "The initial treatment included intravenous immunoglobulin therapy.", + "All of these treatments seemed to be ineffective.", + "We used recombinant thrombomodulin for 7 days.", + "We stopped the antibiotic treatment.", + "On hospital day 9, we performed a left axillary lymph node needle biopsy.", + "The biopsy showed no evidence of malignant lymphoma.", + "With the edema, severe thrombocytopenia, fever above 37.5 °C, reticulin myelofibrosis (MF), mild lymphadenopathy, and progressive renal insufficiency, we diagnosed this patient as having TAFRO syndrome.", + "The administration of intravenously administered tocilizumab was begun.", + "His C-reactive protein and alkaline phosphatase levels gradually improved.", + "His renal function and fever improved.", + "Because the thrombocytopenia remained, we added eltrombopag.", + "Tocilizumab was administered a third time on hospital day 47.", + "Our patient was discharged on hospital day 48.", + "After discharge, he remained afebrile.", + "His alkaline phosphate level was within normal limits.", + "Tocilizumab administration was no longer necessary.", + "Eltrombopag administration was stopped.", + "Nine months after the first treatment, this patient continues to do well.", + "He is only being treated with low-dose prednisolone at approximately 5 mg per day.", + "He is still tapering carefully because of the presence of unilateral adrenal necrosis.", + "He is still tapering carefully considering the possibility of adrenal insufficiency." + ], + "summary": "This report describes the case of a 46-year-old Asian man who presented with fever, epigastric pain, and back pain for 1 month. A computed tomographic scan revealed ascites, mild lymphadenopathy, and left adrenal necrosis without hemorrhage. A blood test showed thrombocytopenia, anemia, and elevated C-reactive protein, alkaline phosphatase, and creatinine levels. Based on the edema, severe thrombocytopenia, fever, reticulin myelofibrosis shown by bone marrow biopsy, mild lymphadenopathy, and progressive renal insufficiency, we diagnosed this patient as having TAFRO syndrome. He was successfully treated by immediate administration of glucocorticoids and tocilizumab.", + "summary_subclaims": [ + "The patient is a 46-year-old Asian man.", + "The patient had fever, epigastric pain, and back pain for 1 month.", + "A computed tomographic scan revealed ascites.", + "A computed tomographic scan revealed mild lymphadenopathy.", + "A computed tomographic scan revealed left adrenal necrosis without hemorrhage.", + "A blood test showed thrombocytopenia.", + "A blood test showed anemia.", + "A blood test showed elevated C-reactive protein levels.", + "A blood test showed elevated alkaline phosphatase levels.", + "A blood test showed elevated creatinine levels.", + "The diagnosis was based on edema.", + "The diagnosis was based on severe thrombocytopenia.", + "The diagnosis was based on fever.", + "The diagnosis was based on reticulin myelofibrosis shown by bone marrow biopsy.", + "The diagnosis was based on mild lymphadenopathy.", + "The diagnosis was based on progressive renal insufficiency.", + "The patient was diagnosed as having TAFRO syndrome.", + "The patient was successfully treated by immediate administration of glucocorticoids and tocilizumab." + ] + }, + { + "id": "multiclinsum_test_3075_en.txt", + "fulltext": "The 15-year-old boy’s parents are both healthy. His main manifestations are epilepsy, autism, and dystonia, which progressively worsens. His family has no similar illnesses, half a month past the due date, cesarean section, weighed 9 pounds at birth, weak sucking ability, no history of asphyxia.\n\nThe boy reached the peak of his morbidity before the age of 15. He was diagnosed with epilepsy at birth. The main manifestation is has involuntary upper limb jerks and hand clumsiness, treatment with phenobarbital, sodium valproate, and levetiracetam. He learned to walk at the age of 2 and less verbal, but can say duplicate word, diagnosed with autism, rehabilitation was given with poor results. Involuntary jerks of both upper limbs disappears at about 9 years of age, discontinuation of “phenobarbital, sodium valproate, and levetiracetam.” At the age of 12, who appeared myoclonic jerks of the limbs, involuntary lifting of both upper limbs and stick out one’s lips, weakness of both lower limbs, the right lower limb is obvious, with abnormal posture of hands, feet and left shoulder, manifested by involuntary lifting of the hands, flexion of the fingers and toes of both hands, symptoms progressively worsen until they become unsteady and prone to falls. Completely unable to walk at age 14. Symptoms worsened again at about 14.5 years of age, accompanied by involuntary tilt back of the neck, have difficulty chewing, aggravated by external stimuli and/or stress, symptoms are worse at night, difficulty sleeping, occasional fecal incontinence. He was treated with oral baclofen tablets 3 times a day, but the results were not satisfactory, so he came to our hospital.\n\nPhysical examination of the nervous system shows, loss of speech, bilateral pupils are equal in size and circumference about 3 mm in diameter, sensitive to light reflection, limb flexion, involuntary limb movement, hypertonia of both hands and feet, inside left shoulder, the bilateral pathological signs were not elicited, and the physical examination of the residual nervous system did not cooperate.\n\nReturn of test results, blood routine: hemoglobin 115 g/L. Six items of blood coagulation: fibrinogen 1.39 g/L, thrombin time 21.5 s; thyroid function 3 items: thyrotropin 10.7 uIU/mL, the rest is normal; liver function: total protein 57.8 g/L, albumin 38 g/L; blood lipids: low density lipoprotein cholesterol 1.83 mmol/L; electrolytes: potassium 3.69 mmol/L, sodium 146 mmo1/L; no obvious abnormality was found in Hs-CRP, SAA, vitamin B12, folic acid, blood homocysteine, vitamin B1, and blood ammonia. Brain magnetic resonance imaging (MRI) showed mild brain atrophy-like changes. Two-hour video electroencephalogram (EEG) showed that during the awakening period of abnormal adolescents, the background fast wave activity increased, and the family members identified the event without seizure pattern. Genetic testing showed that NM_024496.4 (IRF2BPL): c.379C > T (p.Q127*) may be pathogenic, and the frequency of this variant in the gnomAD database is 0. This variant is nonsense and is predicted to result in the possible premature appearance of the termination codon, with multiple losses of function reported downstream of this locus, the patient’s father, mother, and sister did not carry the variant, considering the clinical relevance of this variant in the context of the patient’s clinical presentation, as a result he has been diagnosed with NEDAMSS, autism. Sodium valproate oral solution 15 mL twice/day, levetiracetam tablets 0.125 g twice/day, clonazepam tablets 0.5 mg twice/day, baclofen tablets 15 mg in the morning, 10 mg in the afternoon and 10 mg at night were given. The patient did not have any further seizures and the dystonia improved over the previous period.", + "fulltext_subclaims": [ + "The 15-year-old boy’s parents are both healthy.", + "His main manifestations are epilepsy, autism, and dystonia.", + "The dystonia progressively worsens.", + "His family has no similar illnesses.", + "The boy was born half a month past the due date.", + "The boy was delivered by cesarean section.", + "The boy weighed 9 pounds at birth.", + "The boy had weak sucking ability.", + "The boy has no history of asphyxia.", + "The boy reached the peak of his morbidity before the age of 15.", + "The boy was diagnosed with epilepsy at birth.", + "The main manifestation is involuntary upper limb jerks and hand clumsiness.", + "The boy was treated with phenobarbital, sodium valproate, and levetiracetam.", + "The boy learned to walk at the age of 2.", + "The boy is less verbal but can say duplicate words.", + "The boy was diagnosed with autism.", + "Rehabilitation was given with poor results.", + "Involuntary jerks of both upper limbs disappeared at about 9 years of age.", + "Phenobarbital, sodium valproate, and levetiracetam were discontinued.", + "At the age of 12, the boy appeared with myoclonic jerks of the limbs.", + "The boy had involuntary lifting of both upper limbs and stick out one’s lips.", + "The boy had weakness of both lower limbs, the right lower limb is obvious.", + "The boy had an abnormal posture of hands, feet, and left shoulder.", + "The boy had involuntary lifting of the hands, flexion of the fingers and toes of both hands.", + "The symptoms progressively worsened until the boy became unsteady and prone to falls.", + "The boy was completely unable to walk at age 14.", + "Symptoms worsened again at about 14.5 years of age.", + "The boy had involuntary tilt back of the neck.", + "The boy had difficulty chewing.", + "The symptoms were aggravated by external stimuli and/or stress.", + "The symptoms were worse at night.", + "The boy had difficulty sleeping.", + "The boy had occasional fecal incontinence.", + "The boy was treated with oral baclofen tablets 3 times a day.", + "The results of baclofen treatment were not satisfactory.", + "The boy came to the hospital.", + "Physical examination showed loss of speech.", + "Bilateral pupils were equal in size and circumference about 3 mm in diameter.", + "Bilateral pupils were sensitive to light reflection.", + "Limb flexion and involuntary limb movement were observed.", + "Hypertonia of both hands and feet was observed.", + "Inside left shoulder was observed.", + "Bilateral pathological signs were not elicited.", + "The physical examination of the residual nervous system did not cooperate.", + "Blood routine showed hemoglobin 115 g/L.", + "Blood coagulation showed fibrinogen 1.39 g/L.", + "Blood coagulation showed thrombin time 21.5 s.", + "Thyroid function showed thyrotropin 10.7 uIU/mL.", + "The rest of the thyroid function was normal.", + "Liver function showed total protein 57.8 g/L.", + "Liver function showed albumin 38 g/L.", + "Blood lipids showed low density lipoprotein cholesterol 1.83 mmol/L.", + "Electrolytes showed potassium 3.69 mmol/L.", + "Electrolytes showed sodium 146 mmo1/L.", + "No obvious abnormality was found in Hs-CRP, SAA, vitamin B12, folic acid, blood homocysteine, vitamin B1, and blood ammonia.", + "Brain MRI showed mild brain atrophy-like changes.", + "Two-hour video EEG showed increased background fast wave activity during the awakening period of abnormal adolescents.", + "The family members identified the event without seizure pattern.", + "Genetic testing showed NM_024496.4 (IRF2BPL): c.379C > T (p.Q127*) may be pathogenic.", + "The frequency of this variant in the gnomAD database is 0.", + "The variant is nonsense and is predicted to result in the possible premature appearance of the termination codon.", + "Multiple losses of function were reported downstream of this locus.", + "The patient’s father, mother, and sister did not carry the variant.", + "The variant is considered clinically relevant in the context of the patient’s clinical presentation.", + "The patient has been diagnosed with NEDAMSS.", + "The patient has been diagnosed with autism.", + "Sodium valproate oral solution 15 mL twice/day was given.", + "Levetiracetam tablets 0.125 g twice/day were given.", + "Clonazepam tablets 0.5 mg twice/day were given.", + "Baclofen tablets 15 mg in the morning, 10 mg in the afternoon, and 10 mg at night were given.", + "The patient did not have any further seizures.", + "The dystonia improved over the previous period." + ], + "summary": "Patient concerns: In this report, we discuss the case of a 15-year-old male patient. The patient started with epilepsy and dystonia and was treated with antiepileptic seizure medication, then he was admitted to our hospital for recurrent seizures of epilepsy and dystonia, and the diagnosis of NEDAMSS was confirmed by whole exome genetic testing.\n\nDiagnoses: Exome-wide genetic testing confirmed the diagnosis of NEADMSS due to IRF2BPL.\n\nInterventions: Exome-wide genetic testing reveals mutations in the IFR2BPL gene.\n\nOutcomes: Symptoms improved from before after antiepileptic seizure medication combined with drugs to improve dystonia.", + "summary_subclaims": [ + "The patient is a 15-year-old male.", + "The patient started with epilepsy and dystonia.", + "The patient was treated with antiepileptic seizure medication.", + "The patient was admitted to the hospital for recurrent seizures of epilepsy and dystonia.", + "The diagnosis of NEDAMSS was confirmed by whole exome genetic testing.", + "Exome-wide genetic testing confirmed the diagnosis of NEADMSS due to IRF2BPL.", + "Exome-wide genetic testing reveals mutations in the IFR2BPL gene.", + "Symptoms improved from before after antiepileptic seizure medication combined with drugs to improve dystonia." + ] + }, + { + "id": "multiclinsum_test_1577_en.txt", + "fulltext": "A 33-year-old male presented to our institute with pain in the left elbow on extending the elbow. He had limited extension of 10–15 degrees. Patient had developed painful elbow on throwing the cricket ball from the periphery of the ground. This pain started to increase on repeated throws. He had conservative treatment for the same. Over the span of 18 months, he developed loss of terminal extension.\nOn clinical examination, he had tenderness in the posterior aspect of elbow along with crepitus and extension lag of 15 degrees and painful passive and active terminal extension. He did not have any instability of the medial and lateral ulnar collateral ligament.\nRoentgenogram showed no radiological abnormality. Magnetic resonance imaging MRI revealed posterior fat pad hypertrophy withimpingement between olecranon and olecranon fossa whichwas the primary cause of pain and extension lag. After getting informed consent patient was posted for arthroscopic excision of posterior fat pad. Patient positioned in right lateral position and left elbow scrubbed, painted, and draped under aseptic precautions. Standard anterolateral portal was made and the anterior joint was visualized. Later on standard posterior and posterolateral portals were made revealing posterior fat pad hypertrophy locked and preventing complete olecranon extension.\nThe fat pad was shaved off using 3.5 mm shaver and no impingement of soft-tissue was evident. An incidental finding of small foramen was found in the olecranon fossa. It was found that the rent in the olecranon fossa got the fat pad locked into it, causing impingement on elbow extension.\nPortals were closed and postoperatively dressings were changed and active complete elbow mobilization was started on post-operative day 1and 2,respectively. Patient was advised against heavy usage of elbow such as lifting heavy objects for 3 weeks. Patient was on regular follow-up and was symptom free. He got back to contact sports in 1 month duration. His last visit was 1year following surgery; he was comfortable with full range of movements.", + "fulltext_subclaims": [ + "The patient is a 33-year-old male.", + "He presented with pain in the left elbow on extending the elbow.", + "He had limited extension of 10–15 degrees.", + "The pain started to increase on repeated throws.", + "He had conservative treatment.", + "Over the span of 18 months, he developed loss of terminal extension.", + "On clinical examination, he had tenderness in the posterior aspect of the elbow.", + "He had crepitus.", + "He had extension lag of 15 degrees.", + "He had painful passive and active terminal extension.", + "He did not have any instability of the medial and lateral ulnar collateral ligament.", + "Roentgenogram showed no radiological abnormality.", + "MRI revealed posterior fat pad hypertrophy.", + "MRI showed impingement between the olecranon and olecranon fossa.", + "The impingement was the primary cause of pain and extension lag.", + "The patient was posted for arthroscopic excision of the posterior fat pad.", + "The patient was positioned in the right lateral position.", + "Standard anterolateral portal was made.", + "The anterior joint was visualized.", + "Standard posterior and posterolateral portals were made.", + "Posterior fat pad hypertrophy was found locked and preventing complete olecranon extension.", + "The fat pad was shaved off using a 3.5 mm shaver.", + "No impingement of soft-tissue was evident after excision.", + "An incidental finding of a small foramen was found in the olecranon fossa.", + "The rent in the olecranon fossa got the fat pad locked into it.", + "The locked fat pad caused impingement on elbow extension.", + "Postoperatively, dressings were changed.", + "Active complete elbow mobilization was started on post-operative day 1 and 2, respectively.", + "The patient was advised against heavy usage of the elbow for 3 weeks.", + "The patient was on regular follow-up.", + "The patient was symptom free.", + "He got back to contact sports in 1 month.", + "His last visit was 1 year following surgery.", + "He was comfortable with full range of movements." + ], + "summary": "A male patient aged 33 years presented to us in the outpatient department with18 months history of impingement. Magnetic resonance confirmed soft-tissue as cause for impingement. Elbow arthroscopy revealed a rent in the olecranon fossa showing the fat pad locked into it. Debridement with arthroscopic shaver made the patient symptom free.", + "summary_subclaims": [ + "A male patient aged 33 years presented to us in the outpatient department.", + "The patient had an 18-month history of impingement.", + "Magnetic resonance confirmed soft-tissue as cause for impingement.", + "Elbow arthroscopy revealed a rent in the olecranon fossa.", + "The rent showed the fat pad locked into it.", + "Debridement with arthroscopic shaver made the patient symptom free." + ] + }, + { + "id": "multiclinsum_test_1342_en.txt", + "fulltext": "A 25-year-old woman, gravida 1 para 0 with satisfactory antenatal progress was admitted for an elective cesarean delivery by maternal request at 39+ 1 weeks of gestation. She denied any medical history of chronic disease. As requested by the patient, combined spinal-epidural anesthesia was administered for cesarean delivery. Fifteen milligrams of 0.5% ropivacainehydro chloride injection (AstraZeneca AB, Sweden) was injected into the subarachnoid space and 5 mL of 2% lidocaine (Shanxi Shiyao Yinhu, China) was injected into the epidural space. Cefathiamidine (1.0 g, Shandong Luoxin, China) was administered intravenously as a prophylactic antibiotic. During the surgery, the patient started shivering, but the vital signs remained stable. The operation was completed successfully, and she was monitored in an anesthetic resuscitation room.\nIn the anesthetic resuscitation room, she continued to shiver and complained of general numbness and breathlessness. She was febrile with a temperature of 40.7 °C. Her blood pressure dropped to its lowest point of 78/44 mmHg, she had tachycardia with a maximum heart rate of 177 bpm, and she had intermittent vaginal bleeding. However, her oxygen saturation remained at 98%. Hence, septic shock was suspected, but we were unable to rule out anaphylactic shock. Resuscitation was initiated with massive fluid replacement, intravenous dexamethasone (Sinopharm, China), and a uterotonic agent, namely, 250 μg of intramuscular carboprost tromethamine (Pharmacia and Upjohn company, America). Concurrently, a Bakri Postpartum Balloon (Cook, America) was placed. Despite these treatments, her blood pressure remained unstable (< 90/60 mmHg). The blood investigations revealed metabolic acidosis (a pH of 7.252 [7.35–7.45], a serum lactic acid concentration of 6.52 mmol/L [0.36–1.25]), a raised procalcitonin of 94.5 ng/mL [0.0–0.5], an increased white blood cell count of 15 × 109/L [4–10 × 109], increased neutrophilia of 96.1% [50–70%], decreased platelets of 83 × 109/L [100–450 × 109], a hemoglobin concentration of 105 g/L [110–155], a hematocrit of 30.7% [35–45%], coagulopathy with a prolonged activated partial thromboplastin time (APTT) of 91.3 s [22.3–32.5] with low fibrinogen (FIB) < 0.25 G/L[2-4], and hypokalemia of 3.26 mmol/L [3.5–5.5]. The sequential organ failure assessment (SOFA) score was above 2 (oxygenation index ≤400 mmHg, platelet count≤150,000/uL and mean arterial pressure < 70 mmHg). A central venous catheter and a femoral artery catheter were inserted, red blood cell concentrates and fresh frozen plasma were transfused, low-dose noradrenalin (Grandpharma, China) was administered, and the antibiotic was changed to 2.0 g of ceftriaxone sulbactam sodium (Pfizer, America) at 12-h intervals. Five hours after surgery, all vital signs except her body temperature stabilized. Eighteen hours after surgery, her temperature decreased to 37.8 °C, with a raised white blood cell count of 23.13 × 109/L, neutrophilia of 91.7%, procalcitonin above 100 ng/mL, a decreased platelet count of 64 × 109/L, hemoglobin of 71 g/L and hematocrit of 19.8%. The antibiotic dose was altered to 500 mg of intravenous imipenem/cilastatin sodium (Merck Sharp &Dohme, America) at 6-h intervals. Five days after surgery, the results of the blood culture and microbe identification confirmed R. mannitolilytica. At that time, the patient’s body temperature had fluctuated to approximately 37.4 °C, and the hemogram decreased significantly (white blood cell count, 10.43 × 109/L; neutrophilia, 76.9%; procalcitonin, 11.6 ng/mL). Treatment with imipenem/cilastatin sodium was continued because the drug sensitivity test of the bacteria could not be carried out in our laboratory. Eight days after surgery, the patient’s body temperature returned to normal. Blood analysis showed a white blood cell count of 12.09 × 109/L, neutrophilia of 76.6% and procalcitonin of 2.26 ng/mL. The antibiotic was changed to 2.0 g of intravenous cefoperazone sulbactam sodium at 6-h intervals for 6 days. All the blood results had returned to normal, the repeated blood culture was negative on day 14 postoperatively and she was discharged well on day 15. No abnormality was found during follow-up at half a year after discharge.", + "fulltext_subclaims": [ + "The patient was a 25-year-old woman, gravida 1 para 0.", + "She was admitted for an elective cesarean delivery by maternal request at 39+ 1 weeks of gestation.", + "She denied any medical history of chronic disease.", + "Combined spinal-epidural anesthesia was administered for cesarean delivery.", + "Fifteen milligrams of 0.5% ropivacaine hydrochloride injection was injected into the subarachnoid space.", + "Five mL of 2% lidocaine was injected into the epidural space.", + "Cefathiamidine (1.0 g) was administered intravenously as a prophylactic antibiotic.", + "During the surgery, the patient started shivering.", + "The vital signs remained stable.", + "The operation was completed successfully.", + "She was monitored in an anesthetic resuscitation room.", + "In the anesthetic resuscitation room, she continued to shiver.", + "She complained of general numbness and breathlessness.", + "She was febrile with a temperature of 40.7 °C.", + "Her blood pressure dropped to its lowest point of 78/44 mmHg.", + "She had tachycardia with a maximum heart rate of 177 bpm.", + "She had intermittent vaginal bleeding.", + "Her oxygen saturation remained at 98%.", + "Septic shock was suspected.", + "We were unable to rule out anaphylactic shock.", + "Resuscitation was initiated with massive fluid replacement.", + "Intravenous dexamethasone was administered.", + "Twenty-five micrograms of intramuscular carboprost tromethamine was administered.", + "A Bakri Postpartum Balloon was placed.", + "Despite these treatments, her blood pressure remained unstable (< 90/60 mmHg).", + "The blood investigations revealed metabolic acidosis with a pH of 7.252.", + "The serum lactic acid concentration was 6.52 mmol/L.", + "The procalcitonin was 94.5 ng/mL.", + "The white blood cell count was 15 × 109/L.", + "Neutrophilia was 96.1%.", + "The platelet count was 83 × 109/L.", + "The hemoglobin concentration was 105 g/L.", + "The hematocrit was 30.7%.", + "The APTT was 91.3 s.", + "The fibrinogen was < 0.25 G/L.", + "The potassium was 3.26 mmol/L.", + "The SOFA score was above 2.", + "A central venous catheter and a femoral artery catheter were inserted.", + "Red blood cell concentrates and fresh frozen plasma were transfused.", + "Low-dose noradrenalin was administered.", + "The antibiotic was changed to 2.0 g of ceftriaxone sulbactam sodium at 12-h intervals.", + "Five hours after surgery, all vital signs except her body temperature stabilized.", + "Eighteen hours after surgery, her temperature decreased to 37.8 °C.", + "The white blood cell count was 23.13 × 109/L.", + "Neutrophilia was 91.7%.", + "The procalcitonin was above 100 ng/mL.", + "The platelet count was 64 × 109/L.", + "The hemoglobin was 71 g/L.", + "The antibiotic dose was altered to 500 mg of intravenous imipenem/cilastatin sodium at 6-h intervals.", + "Five days after surgery, the results of the blood culture and microbe identification confirmed R. mannitolilytica.", + "The patient’s body temperature had fluctuated to approximately 37.4 °C.", + "The white blood cell count was 10.43 × 109/L.", + "Neutrophilia was 76.9%.", + "The procalcitonin was 11.6 ng/mL.", + "Treatment with imipenem/cilastatin sodium was continued.", + "The drug sensitivity test of the bacteria could not be carried out in our laboratory.", + "Eight days after surgery, the patient’s body temperature returned to normal.", + "The white blood cell count was 12.09 × 109/L.", + "Neutrophilia was 76.6%.", + "The procalcitonin was 2.26 ng/mL.", + "The antibiotic was changed to 2.0 g of intravenous cefoperazone sulbactam sodium at 6-h intervals for 6 days.", + "All the blood results had returned to normal.", + "The repeated blood culture was negative on day 14 postoperatively.", + "She was discharged well on day 15.", + "No abnormality was found during follow-up at half a year after discharge." + ], + "summary": "A 25-year-old woman, gravida 1 para 0, was scheduled for an elective cesarean delivery at 39+ 1 weeks of gestation. Sudden high fever and decreased blood pressure occurred a short time after the operation. Ralstonia mannitolilytica was identified in her blood culture 5 days after the operation. Based on the presence of sepsis and septic shock, massive fluid replacement, blood transfusion, vasoactive agents, imipenem/cilastatin and cefoperazone sulbactam sodium were applied. She was discharged after intensive care without complications.", + "summary_subclaims": [ + "The patient was a 25-year-old woman, gravida 1 para 0.", + "She was scheduled for an elective cesarean delivery at 39+ 1 weeks of gestation.", + "Sudden high fever and decreased blood pressure occurred a short time after the operation.", + "Ralstonia mannitolilytica was identified in her blood culture 5 days after the operation.", + "Based on the presence of sepsis and septic shock, massive fluid replacement, blood transfusion, vasoactive agents, imipenem/cilastatin and cefoperazone sulbactam sodium were applied.", + "She was discharged after intensive care without complications." + ] + }, + { + "id": "multiclinsum_test_492_en.txt", + "fulltext": "We describe a case of a 36-year-old multiparous (G3P2) woman who presented with an acute episode of pelvic pain. She was referred to a general gynaecological clinic after ultrasound findings revealed a 4.1 cm complex left ovarian cyst suggestive of an endometrioma.\nShe also reported a 2-year history of a bulge that protruded from her vagina and was associated with discomfort and dyspareunia and occasionally required digital reduction especially with tampon use. She had been diagnosed with a vaginal prolapse by a gynaecology clinic at another institution.\nHer past medical history consisted of migraines with aura, exercise induced asthma, and a family history of breast cancer (half-sister). She had never had a PAP smear.\nOn bimanual examination, a well-delineated solid mass was found on the anterior vaginal wall in the midline, measuring 5 cm by 5 cm. There was no evidence of pelvic organ prolapse with good support of the uterus, posterior wall, and anterior wall above the mass. The cervix was visualised anteriorly and there was no evidence of cervical excitation. A routine PAP smear was performed with difficulty secondary to the vaginal mass.\nWith respect to investigations, Ca 125 was 29 U/mL giving a low relative malignancy index. A repeat ultrasound scan demonstrated a 2.9 cm left ovarian cyst, suggestive of an endometrioma and a solid mass inferior to the uterus and anterior to the vagina, displacing the bladder .\nOn Magnetic Resonance Imaging, a 45 mm × 50 mm solid mass in the vesicovaginal septum with a well-defined margin was demonstrated . The mass was displacing the bladder anteriorly and displacing the urethra towards the left of the midline. T2 imaging showed a predominantly hypointense, heterogenous signal with areas of hyperintensity. There was mild enhancement after gadolinium injection. Close to the external urethral orifice, the interface between the mass and the urethra was ill defined. Evidence of a left ovarian endometrioma and endometriosis deposits were seen elsewhere in the pelvis.\nThese MRI findings suggested that the mass was either endometriosis with surrounding reactive fibrous and smooth muscle proliferation, neoplasm, or an infection relating to a urethral diverticulum. After a multidisciplinary meeting with a urogynaecologist, the patient underwent an examination under anaesthesia, diagnostic laparoscopy, cystoscopy, excision of endometriosis, and excision of the vaginal mass.\nThe vaginal mass was removed with laparoscopic assessment via a midline incision on the anterior vaginal wall with lateral dissection around the cystic structure . A cystoscopy and urethroscopy suggested no involvement and the cyst was enucleated. Multiple haemostatic sutures were needed with surgical snow to achieve haemostasis and the defect was closed. A repeat cystoscopy and urethroscopy showed no injury.\nHistopathological macroscopic assessment of the mass showed pale tan tissue surrounded by a thin capsule and on sectioning a homogeneous whorled tan tissue . Microscopically the low power photomicrographs showed a well-circumscribed border. It comprised collagenised areas of epithelioid to spindled cells with small to thin walled arborizing vessels. Aggregation of cells around vessels was noted and there were no atypical mitoses, necrosis, or atypia .\nThe immunohistochemistry showed positive desmin, SMA, CD34, and vimentin. The cells displayed high intensity nuclear positivity for progesterone and oestrogen receptors. These findings were consistent with a diagnosis of angiomyofibroblastoma.", + "fulltext_subclaims": [ + "The patient is a 36-year-old multiparous woman.", + "She presented with an acute episode of pelvic pain.", + "She was referred to a general gynaecological clinic.", + "Ultrasound findings revealed a 4.1 cm complex left ovarian cyst.", + "The cyst was suggestive of an endometrioma.", + "She reported a 2-year history of a bulge that protruded from her vagina.", + "The bulge was associated with discomfort and dyspareunia.", + "The bulge occasionally required digital reduction especially with tampon use.", + "She had been diagnosed with a vaginal prolapse by a gynaecology clinic at another institution.", + "Her past medical history included migraines with aura.", + "She had exercise-induced asthma.", + "She had a family history of breast cancer (half-sister).", + "She had never had a PAP smear.", + "On bimanual examination, a well-delineated solid mass was found on the anterior vaginal wall in the midline.", + "The mass measured 5 cm by 5 cm.", + "There was no evidence of pelvic organ prolapse.", + "The cervix was visualised anteriorly.", + "A routine PAP smear was performed with difficulty secondary to the vaginal mass.", + "Ca 125 was 29 U/mL.", + "A repeat ultrasound scan demonstrated a 2.9 cm left ovarian cyst.", + "The cyst was suggestive of an endometrioma.", + "A solid mass inferior to the uterus and anterior to the vagina was seen on the repeat ultrasound.", + "The mass displaced the bladder.", + "Magnetic Resonance Imaging showed a 45 mm × 50 mm solid mass in the vesicovaginal septum.", + "The mass had a well-defined margin.", + "The mass displaced the bladder anteriorly.", + "The mass displaced the urethra towards the left of the midline.", + "T2 imaging showed a predominantly hypointense, heterogeneous signal with areas of hyperintensity.", + "There was mild enhancement after gadolinium injection.", + "The interface between the mass and the urethra was ill defined.", + "Evidence of a left ovarian endometrioma was seen.", + "Endometriosis deposits were seen elsewhere in the pelvis.", + "MRI findings suggested the mass was either endometriosis with surrounding reactive fibrous and smooth muscle proliferation, neoplasm, or an infection relating to a urethral diverticulum.", + "The patient underwent an examination under anaesthesia.", + "The patient underwent diagnostic laparoscopy.", + "The patient underwent cystoscopy.", + "The patient underwent excision of endometriosis.", + "The patient underwent excision of the vaginal mass.", + "The vaginal mass was removed with laparoscopic assessment via a midline incision on the anterior vaginal wall.", + "Lateral dissection around the cystic structure was performed.", + "A cystoscopy and urethroscopy suggested no involvement.", + "The cyst was enucleated.", + "Multiple haemostatic sutures were needed with surgical snow to achieve haemostasis.", + "The defect was closed.", + "A repeat cystoscopy and urethroscopy showed no injury.", + "Histopathological macroscopic assessment showed pale tan tissue surrounded by a thin capsule.", + "On sectioning, the tissue was homogeneous and whorled.", + "Low power photomicrographs showed a well-circumscribed border.", + "The tissue comprised collagenised areas of epithelioid to spindled cells.", + "The cells had small to thin walled arborizing vessels.", + "Aggregation of cells around vessels was noted.", + "There were no atypical mitoses, necrosis, or atypia.", + "Immunohistochemistry showed positive desmin, SMA, CD34, and vimentin.", + "The cells displayed high intensity nuclear positivity for progesterone and oestrogen receptors.", + "These findings were consistent with a diagnosis of angiomyofibroblastoma." + ], + "summary": "We report a case of a multiparous, 36-year-old woman with an anterior vaginal mass which was inappropriately treated as a vaginal prolapse prior to definitive surgical management. This is only the second reported case of an AMFB presenting as a prolapsing mass.", + "summary_subclaims": [ + "The patient was a multiparous, 36-year-old woman.", + "The patient had an anterior vaginal mass.", + "The mass was inappropriately treated as a vaginal prolapse prior to definitive surgical management.", + "This is only the second reported case of an AMFB presenting as a prolapsing mass." + ] + }, + { + "id": "multiclinsum_test_3357_en.txt", + "fulltext": "A 62-year-old female was referred to our hospital as a case of upper airway obstruction secondary to possible advanced thyroid cancer + Grade 5 dysphagia after five days of stay. She presented with anterior neck swelling of 12 years’ duration, which increased in size rapidly over five days with associated fever, shortness of breath, a hoarse voice, difficulty swallowing both solids and a fluid diet, and vomiting of ingested matter. She had long-standing intolerance of heat and irritability, and was easily fatigued, and had experienced unquantified weight loss despite having a good appetite along with anterior neck swelling. Otherwise, she had no history of cough, orthopnea, body swelling, previous neck surgery or trauma, treatment for tuberculosis, or chronic medical illnesses like diabetes, asthma, hypertension, cardiac or renal disease. For the above complaint, she was treated at the referring hospital with oxygen supplementation, ceftriaxone, and dexamethasone for a week but did not show improvement.\n\nUpon presentation, the patient was acutely sick looking, in severe respiratory distress and had a stridor with oxygen saturation (SPO2) of 77% on a 15-liter per minute face mask. She had a respiratory rate of 40–44 breaths per minute, pulse rate of 118 beats per minute, blood pressure of 145/90 mm Hg, and temperature of 37.8 0C. Examination of the neck revealed a large mass more on the right side of the anterior neck, which was shiny without ulceration or discharge. The mass was non-tender and warm to the touch, with a firm-to-hard consistency. It measured 15×13 centimeters, extending from the sternum to the submental area, but had no retrosternal extension on either palpation or percussion. Upon oropharyngeal assessment, the patient had a Mallampati score of III.9 Otherwise, there were no oropharyngeal lesions or cervical lymphadenopathy, and no pertinent findings on other systems.\n\nLaryngoscopic glottis visualization showed complete obstruction of the glottis, class 4 according to the Cormack–Lehane scale, but no visible mucosal infiltration, thickening, or bleeding.9 With the above history and following physical examination, mixed type 1 and 2 respiratory failure, secondary to upper airway obstruction, anterior neck mass compression, and hospital-acquired pneumonia was considered. With this, a difficult airway was anticipated and prepared for double setup airway management but there was no place for a surgical airway. Adequate preparation was made to increase the success rate of endotracheal intubation with a bronchoscope. A rigid bronchoscope with a size of 7 mm was used to visualize the airway and possible intubation; however, we could not advance the scope beyond the glottis area due to the compression effect of the mass causing resistance. No visible infiltrative mass was noted to the level of the airway evaluated. The patient was then intubated with a 6 mm endotracheal tube secured at a depth of 18 cm and put on a mechanical ventilator: AC/VCV mode, FiO2 of 100%, positive end-expiratory pressure of 5 cm of H2O, SPO2 ranging from 96–98%, tidal volume of 360 mL, and rate of 14.\n\n\nOnce the patient was stabilized, she was investigated with a complete blood count showing leucocytosis of 25.47×103, with left-shift and moderate anemia. Her thyroid function test result was within the normal range. Fluid analysis from the aspirate of swelling was chocolate-colored thick pus with a cell count of 108,000/mm3, a neutrophil of 85%, and a low glucose level. Gram stain from aspirate revealed gram-positive cocci in pairs; however, culture and sensitivity tests were not done due to their unavailability in our setup. Cytology results from the aspirate demonstrated intense suppurative inflammation along with necrotic material, which raised suspicion of malignancy. Neck ultrasound showed a homogenously hypoechoic avascular midline ovoid mass more on the right, with posterior acoustic enhancement measuring 13×10.7 cm, and a significant mass effect on the cervical esophagus and trachea. Head and neck computed tomography (CT) performed two days prior to her presentation revealed a well-defined lesion, with water attenuation at the right neck region extending from the clavicle inferiorly to the hyoid bone level, cranially measuring 11×10.5x10.8 cm (craniocaudal, transverse, anterior–posterior). The lesion had enhancing soft tissue foci, likely thyroid tissue. The lesion displaced right-side vascular structures postero-laterally and midline structures (larynx, trachea, and esophagus) on the left lateral side, suggesting a large cystic mass originating from thyroid tissue.\n\nSubsequently, after stabilization and initial investigation, incision and drainage (I & D) of the thyroid abscess was done, draining a total of 900 mL thin pus with the initial aspirate. Antibiotics were initiated and wound care was done on a daily basis. The patient was extubated after four days of intubation with improvement. Subsequently, the patient had persistent discharge from the wound and neck swelling increased. A right-side thyroid lobectomy with cystic mass excision was then performed, and a 6×6 cm smooth cystic mass on the right thyroid lobe on an elective base was found interoperatively. The patient was discharged in a better condition after 10 days of stay in the hospital. The biopsy result turned out to be follicular nodular disease.", + "fulltext_subclaims": [ + "The patient was a 62-year-old female.", + "She was referred to the hospital as a case of upper airway obstruction secondary to possible advanced thyroid cancer.", + "She had Grade 5 dysphagia.", + "She had anterior neck swelling of 12 years’ duration.", + "The neck swelling increased in size rapidly over five days.", + "She had associated fever.", + "She had shortness of breath.", + "She had a hoarse voice.", + "She had difficulty swallowing both solids and a fluid diet.", + "She had vomiting of ingested matter.", + "She had long-standing intolerance of heat.", + "She had irritability.", + "She had easy fatigability.", + "She had unquantified weight loss.", + "She had anterior neck swelling.", + "She had no history of cough.", + "She had no history of orthopnea.", + "She had no history of body swelling.", + "She had no history of previous neck surgery.", + "She had no history of trauma.", + "She had no history of treatment for tuberculosis.", + "She had no history of chronic medical illnesses like diabetes.", + "She had no history of asthma.", + "She had no history of hypertension.", + "She had no history of cardiac disease.", + "She had no history of renal disease.", + "She was treated at the referring hospital with oxygen supplementation.", + "She was treated at the referring hospital with ceftriaxone.", + "She was treated at the referring hospital with dexamethasone.", + "She did not show improvement after a week of treatment.", + "Upon presentation, she was acutely sick looking.", + "She was in severe respiratory distress.", + "She had a stridor.", + "Her oxygen saturation was 77% on a 15-liter per minute face mask.", + "Her respiratory rate was 40–44 breaths per minute.", + "Her pulse rate was 118 beats per minute.", + "Her blood pressure was 145/90 mm Hg.", + "Her temperature was 37.8 0C.", + "Examination of the neck revealed a large mass more on the right side of the anterior neck.", + "The mass was shiny without ulceration or discharge.", + "The mass was non-tender and warm to the touch.", + "The mass had a firm-to-hard consistency.", + "The mass measured 15×13 centimeters.", + "The mass extended from the sternum to the submental area.", + "The mass had no retrosternal extension on either palpation or percussion.", + "The patient had a Mallampati score of III.", + "Laryngoscopic glottis visualization showed complete obstruction of the glottis.", + "The obstruction was class 4 according to the Cormack–Lehane scale.", + "There was no visible mucosal infiltration.", + "There was no visible mucosal thickening.", + "There was no visible bleeding.", + "Mixed type 1 and 2 respiratory failure was considered.", + "The respiratory failure was secondary to upper airway obstruction.", + "The respiratory failure was secondary to anterior neck mass compression.", + "The respiratory failure was secondary to hospital-acquired pneumonia.", + "A difficult airway was anticipated.", + "Preparation was made for double setup airway management.", + "There was no place for a surgical airway.", + "A rigid bronchoscope with a size of 7 mm was used.", + "The scope could not be advanced beyond the glottis area.", + "The mass caused resistance.", + "No visible infiltrative mass was noted to the level of the airway evaluated.", + "The patient was intubated with a 6 mm endotracheal tube.", + "The tube was secured at a depth of 18 cm.", + "The patient was put on a mechanical ventilator.", + "The ventilator was in AC/VCV mode.", + "The FiO2 was 100%.", + "The positive end-expiratory pressure was 5 cm of H2O.", + "The SPO2 ranged from 96–98%.", + "The tidal volume was 360 mL.", + "The rate was 14.", + "A complete blood count showed leucocytosis of 25.47×103.", + "There was a left-shift.", + "There was moderate anemia.", + "Thyroid function test results were within the normal range.", + "Fluid analysis from the aspirate showed chocolate-colored thick pus.", + "The aspirate had a cell count of 108,000/mm3.", + "The aspirate had a neutrophil of 85%.", + "The aspirate had a low glucose level.", + "Gram stain from the aspirate revealed gram-positive cocci in pairs.", + "Cytology results showed intense suppurative inflammation.", + "Cytology results showed necrotic material.", + "Cytology results raised suspicion of malignancy.", + "Neck ultrasound showed a homogenously hypoechoic avascular midline ovoid mass more on the right.", + "The mass measured 13×10.7 cm.", + "The mass had a significant mass effect on the cervical esophagus.", + "The mass had a significant mass effect on the trachea.", + "Head and neck CT performed two days prior showed a well-defined lesion.", + "The lesion had water attenuation at the right neck region.", + "The lesion extended from the clavicle inferiorly to the hyoid bone level.", + "The lesion measured 11×10.5x10.8 cm.", + "The lesion had enhancing soft tissue foci.", + "The lesion likely represented thyroid tissue.", + "The lesion displaced right-side vascular structures postero-laterally.", + "The lesion displaced midline structures on the left lateral side.", + "The lesion suggested a large cystic mass originating from thyroid tissue.", + "Incision and drainage of the thyroid abscess was done.", + "A total of 900 mL thin pus was drained.", + "Antibiotics were initiated.", + "Wound care was done on a daily basis.", + "The patient was extubated after four days of intubation.", + "The patient had persistent discharge from the wound.", + "The patient had increased neck swelling.", + "A right-side thyroid lobectomy with cystic mass excision was performed.", + "A 6×6 cm smooth cystic mass on the right thyroid lobe was found.", + "The procedure was performed on an elective basis.", + "The patient was discharged after 10 days of stay in the hospital.", + "The biopsy result turned out to be follicular nodular disease." + ], + "summary": "A 62-year-old female patient presenting with worsening of painful anterior neck swelling with associated fever, shortness of breath, and difficulty swallowing. The patient was found to have a thyroid abscess causing upper airway obstruction, against a background of follicular nodular disease found on clinical examination, cytology and fluid analysis from aspirate, biopsy, ultrasonography, and computed tomography. The patient was managed with endotracheal intubation and was subsequently discharged after recovery with antibiotic therapy, incision and drainage, and thyroid lobectomy.", + "summary_subclaims": [ + "The patient is a 62-year-old female.", + "The patient had worsening of painful anterior neck swelling.", + "The patient had associated fever.", + "The patient had shortness of breath.", + "The patient had difficulty swallowing.", + "The patient was found to have a thyroid abscess.", + "The thyroid abscess caused upper airway obstruction.", + "The patient had follicular nodular disease.", + "The diagnosis was based on clinical examination.", + "The diagnosis was based on cytology.", + "The diagnosis was based on fluid analysis from aspirate.", + "The diagnosis was based on biopsy.", + "The diagnosis was based on ultrasonography.", + "The diagnosis was based on computed tomography.", + "The patient was managed with endotracheal intubation.", + "The patient was discharged after recovery.", + "The patient received antibiotic therapy.", + "The patient underwent incision and drainage.", + "The patient underwent thyroid lobectomy." + ] + }, + { + "id": "multiclinsum_test_2279_en.txt", + "fulltext": "A 24-year-old primigravida presented to our hospital at 29 weeks of gestation. She had undergone bilateral ureteral reimplantation by the Politano-Leadbetter technique at the age of 3 years for vesicoureteral reflux and her postoperative course had been uneventful. However, she had mild back pain at presentation, and abdominal ultrasound revealed severe bilateral hydronephrosis. Blood pressure was 120/80 mmHg and serum creatinine was increased to 3.57 mg/dl. We diagnosed acute postrenal failure and hospitalized her immediately. A double-pigtail ureteral stent (4.7 French) was placed into each ureter by our senior urologist under ultrasound guidance without using fluoroscopy.\nBecause daily urine output exceeded 6 L after ureteral stenting, a urethral catheter was inserted and saline was infused intravenously to prevent dehydration. Serum creatinine rapidly decreased to 1.1 mg/dl and hydronephrosis improved, so the urethral catheter was removed 7 days after ureteral stenting . Subsequently, the patient developed high fever and severe back pain. Laboratory data and urine culture revealed evidence of pyelonephritis, with a white blood cell count of 13.1 × 103/μL and C-reactive protein of 11.34 mg/dl. Streptococcus agalactiae was isolated from a urine specimen. Another urethral catheter was inserted and ceftriaxone sodium (2 g/day) was administered intravenously for 6 days, after which her symptoms resolved. The urethral catheter was removed again when urine output decreased. Because there was no longer any clinical or laboratory evidence of infection, she was discharged at 33 weeks of gestation. Signs or symptoms of preterm labor, such as shortening of the cervix or frequent uterine contractions, did not occur during hospitalization.\nThe patient was re-admitted at 39 weeks with gestational hypertension. Her systolic blood pressure was persistently higher than 140 mmHg, although no proteinuria was detected. After induction, she delivered a boy weighing 3140 g. The Apgar score was 9 at 1 min and 10 at 5 min.\nShe complained of back pain and fever on the day after delivery, and it was found that both ureteral stents had migrated into the urethra. Her symptoms subsided after stents were placed into the bilateral ureters again under spinal anesthesia. The patient was discharged two weeks after delivery. An urologist removed both stents at 6 months after delivery, but distal obstruction of the right ureter was noted and a stent was inserted on the right again. She is scheduled to undergo repeat bilateral ureteral reimplantation.", + "fulltext_subclaims": [ + "The patient was a 24-year-old primigravida.", + "She presented at 29 weeks of gestation.", + "She had undergone bilateral ureteral reimplantation by the Politano-Leadbetter technique at the age of 3 years.", + "Her postoperative course had been uneventful.", + "She had mild back pain at presentation.", + "Abdominal ultrasound revealed severe bilateral hydronephrosis.", + "Blood pressure was 120/80 mmHg.", + "Serum creatinine was increased to 3.57 mg/dl.", + "We diagnosed acute postrenal failure.", + "A double-pigtail ureteral stent (4.7 French) was placed into each ureter.", + "The stents were placed by a senior urologist.", + "The stents were placed under ultrasound guidance.", + "Fluoroscopy was not used.", + "Daily urine output exceeded 6 L after ureteral stenting.", + "A urethral catheter was inserted.", + "Saline was infused intravenously.", + "Serum creatinine rapidly decreased to 1.1 mg/dl.", + "Hydronephrosis improved.", + "The urethral catheter was removed 7 days after ureteral stenting.", + "The patient developed high fever.", + "The patient developed severe back pain.", + "Laboratory data and urine culture revealed evidence of pyelonephritis.", + "White blood cell count was 13.1 × 103/μL.", + "C-reactive protein was 11.34 mg/dl.", + "Streptococcus agalactiae was isolated from a urine specimen.", + "Another urethral catheter was inserted.", + "Ceftriaxone sodium (2 g/day) was administered intravenously.", + "Ceftriaxone was administered for 6 days.", + "Her symptoms resolved.", + "The urethral catheter was removed again when urine output decreased.", + "There was no longer any clinical or laboratory evidence of infection.", + "She was discharged at 33 weeks of gestation.", + "Signs or symptoms of preterm labor did not occur during hospitalization.", + "The patient was re-admitted at 39 weeks with gestational hypertension.", + "Her systolic blood pressure was persistently higher than 140 mmHg.", + "No proteinuria was detected.", + "She delivered a boy weighing 3140 g.", + "The Apgar score was 9 at 1 min.", + "The Apgar score was 10 at 5 min.", + "She complained of back pain and fever on the day after delivery.", + "Both ureteral stents had migrated into the urethra.", + "Her symptoms subsided after stents were placed into the bilateral ureters again.", + "The stents were placed again under spinal anesthesia.", + "The patient was discharged two weeks after delivery.", + "An urologist removed both stents at 6 months after delivery.", + "Distal obstruction of the right ureter was noted.", + "A stent was inserted on the right again.", + "She is scheduled to undergo repeat bilateral ureteral reimplantation." + ], + "summary": "A primigravida with severe hydronephrosis was referred to us at 29 weeks of gestation. Bilateral Politano-Leadbetter ureteral reimplantation had been performed at the age of 3 years. She was hospitalized immediately, and bilateral ureteral stents were successfully inserted. Post-obstructive diuresis occurred after the stents were placed. Urinary tract infection developed after removal of the urethral catheter 1 week later, but responded to antibiotic therapy and catheter replacement. Labor was induced at 39 weeks of gestation, with vaginal delivery of a healthy male infant. Both stents were found to have spontaneously migrated into the urethra after delivery. Repeat stenting under spinal anesthesia was required to improve postpartum symptoms of back pain and fever. Right distal ureteral obstruction persisted at 6 months after delivery and repeat ureteral reimplantation is planned.", + "summary_subclaims": [ + "The patient is a primigravida.", + "The patient had severe hydronephrosis.", + "She was referred at 29 weeks of gestation.", + "Bilateral Politano-Leadbetter ureteral reimplantation had been performed at the age of 3 years.", + "She was hospitalized immediately.", + "Bilateral ureteral stents were successfully inserted.", + "Post-obstructive diuresis occurred after the stents were placed.", + "Urinary tract infection developed after removal of the urethral catheter 1 week later.", + "The urinary tract infection responded to antibiotic therapy.", + "The urinary tract infection responded to catheter replacement.", + "Labor was induced at 39 weeks of gestation.", + "Vaginal delivery of a healthy male infant occurred.", + "Both stents were found to have spontaneously migrated into the urethra after delivery.", + "Repeat stenting under spinal anesthesia was required.", + "Right distal ureteral obstruction persisted at 6 months after delivery.", + "Repeat ureteral reimplantation is planned." + ] + }, + { + "id": "multiclinsum_test_728_en.txt", + "fulltext": "The patient was a 53 years old woman with a history of hypertension and diabetes mellitus type II who was referred to a heart center for inserting an implantable cardioverter defibrillator (ICD) after a few attacks of sudden ventricular tachycardia and loss of consciousness that had not responded to medical therapy. The ICD was successfully inserted.\nAfter six months, the patient returned to the heart center complaining of an awkward and unpleasant sensation from the moments the ICD sensed the tachyarrhythmia and shocked her. Following is the patient's drug history: Mexiletine, diabezide, aspirin, amlodipine, metohexital, metformin, atorvastatin, valsartan, and empagliflozin. Stellate ganglion block was done twice in the center, aiming to modulate the pulse rate and ICD shock number. Aspirin was discontinued four days before each block.\nThe first session of SGB was done six months after the insertion of the ICD. The block was performed unilaterally under fluoroscopy guidance with 40 mg triamcinolone and 6cc ropivacaine 0.25%, first on the right side and the next day on the left side in two successive days with the same method and the same drugs. Generation of horner's syndrome and unilateral block side change in the temperature of the upper limb was determined as block success (, -).\nAfter these successful blocks, the patient was symptom-free for about two months. Symptom-free means there was no activity or shocking ICD due to tachyarrythmias. After this time, another event of ICD's shock happened. The patient was admitted, and another session of unilateral SGB was done with the same method and drugs. At this time, such as the previous time, the symptom-free period was also about two months.\nFinally, it was decided to perform radiofrequency SGB to increase the duration of the effect. Before initiating the procedure, we consulted with a cardiologist. He visited the patient a few days earlier and came to the operating room at the beginning of the procedure initiation. Monitoring vital signs, including heart rate, blood pressure, and electrocardiogram (six leads) was performed in the operation room, and the cardiologist deactivated the ICD with a magnet before initiating the block. Furthermore, the cardiologist stayed in the operating room all over the time of block until the end and then reactivated the ICD again.\nPatient preparation with neck extension and slight head rotation to the opposite side was done in the supine position. The skin was sterilized with betadine and alcohol. By linear ultrasound transducer, 5 - 12 MHz (Sonosite, EDGE2, USA), the anterior tubercle of the transverse process of C6 and, after moving caudally, the C7 transverse was confirmed. Then under the guidance of sonography with a short axial view, the internal jugular vein, the longus colli muscle, and the carotid artery were identified . For better screening of the vessels through the needle course, color Doppler mode was used. After skin infiltration, with a real-time ultrasound guide, an RF sharp needle 22-gauge with a 5 cm length and 5 mm active tip (Cosman, USA) from the lateral side of the probe was introduced in-plane (from the left direction for doing unilateral RF neurolysis). As we first performed PRF, which had no significant pain and irritation, we did not inject any local anesthetic before doing PRF. The needle tip was placed on the longus Colli muscle and under the prevertebral fascia. Aspiration for cerebrospinal fluid, air, or blood was negative, and 1 mL of saline was injected. A neuro-term RF electrode with a 50 mm length was inserted and connected to the generator. The RF needle was positioned perpendicular to the ganglion for performing PRF, and for thermal RF, the needle was placed alongside the SG. In the next step, sensory stimulation was performed with 50 Hz, 0.1 - 0.5 V, with no neural numbness to the upper limbs or other areas. We checked the proximity to recurrent laryngeal nerves, phrenic or the segmental nerve, which are crucial.\nFor motor stimulation, at 2 Hz, 0.4 - 1.0 V exercise test, no corresponding segmental muscle tremors, and the jumping sensation was observed. Motor stimulation was performed by asking the patient to say \"ee\" to check for preservation of the motor function and exclude needle malposition. After the negative sensory and motor test, high voltage (60 V) PRF at 42°C for 360 s, 20 ms pulse width, and 2 Hz frequency started. Then before starting RF at 80ºC, we injected 1cc lidocaine 2% to prevent irritation and pain that may result from neurolysis at high temperatures. At 80ºC for 60 seconds, thermal left unilateral RF neurolysis was performed and repeated four times after needle-tip rotation and directed to the most medial site and most ventral aspect of the C6 and C7 transverse process under US guidance, with repeated sensory and motor stimulation before RF lesioning. Thirty minutes after the procedure's termination, a follow-up ultrasound screening was done to exclude any hematoma formation.\nFrom pre- to post-block, there was an increase in the forehead and hands temperature, as recorded by a skin thermometer, which was used as a surrogate for a successful block.\nAfter doing RF neurolysis in multiple time intervals, we visited the patient 1, 3, 6, 12, and 14 months later, and observed no signs of ventricular tachycardia. The patient did not complain about the unpleasant sensation of ICD activity and shock. At this time, she did not have the problem up to 14 months after the procedure and showed no sign of recurrence of the cardiac tachyarrhythmia.", + "fulltext_subclaims": [ + "The patient was a 53 years old woman.", + "The patient had a history of hypertension.", + "The patient had a history of diabetes mellitus type II.", + "The patient was referred for inserting an implantable cardioverter defibrillator (ICD).", + "The ICD was successfully inserted.", + "After six months, the patient returned complaining of an awkward and unpleasant sensation.", + "The patient's drug history included Mexiletine, diabezide, aspirin, amlodipine, metohexital, metformin, atorvastatin, valsartan, and empagliflozin.", + "Stellate ganglion block was done twice in the center.", + "Aspirin was discontinued four days before each block.", + "The first session of SGB was done six months after the insertion of the ICD.", + "The block was performed unilaterally under fluoroscopy guidance.", + "The block was performed with 40 mg triamcinolone and 6cc ropivacaine 0.25%.", + "The block was done first on the right side and the next day on the left side.", + "Generation of horner's syndrome and unilateral block side change in the temperature of the upper limb was determined as block success.", + "After these successful blocks, the patient was symptom-free for about two months.", + "Symptom-free means there was no activity or shocking ICD due to tachyarrythmias.", + "After two months, another event of ICD's shock happened.", + "Another session of unilateral SGB was done with the same method and drugs.", + "The symptom-free period after the second block was also about two months.", + "It was decided to perform radiofrequency SGB to increase the duration of the effect.", + "A cardiologist was consulted before initiating the procedure.", + "The cardiologist visited the patient a few days earlier and came to the operating room at the beginning of the procedure.", + "Monitoring vital signs, including heart rate, blood pressure, and electrocardiogram (six leads), was performed in the operation room.", + "The cardiologist deactivated the ICD with a magnet before initiating the block.", + "The cardiologist stayed in the operating room all over the time of block until the end.", + "The cardiologist reactivated the ICD again.", + "Patient preparation with neck extension and slight head rotation to the opposite side was done in the supine position.", + "The skin was sterilized with betadine and alcohol.", + "A linear ultrasound transducer, 5 - 12 MHz (Sonosite, EDGE2, USA), was used.", + "The anterior tubercle of the transverse process of C6 and the C7 transverse were confirmed.", + "Under sonography guidance, the internal jugular vein, the longus colli muscle, and the carotid artery were identified.", + "Color Doppler mode was used for better screening of the vessels through the needle course.", + "After skin infiltration, an RF sharp needle 22-gauge with a 5 cm length and 5 mm active tip (Cosman, USA) was introduced in-plane.", + "The needle tip was placed on the longus Colli muscle and under the prevertebral fascia.", + "Aspiration for cerebrospinal fluid, air, or blood was negative.", + "1 mL of saline was injected.", + "A neuro-term RF electrode with a 50 mm length was inserted and connected to the generator.", + "The RF needle was positioned perpendicular to the ganglion for performing PRF.", + "For thermal RF, the needle was placed alongside the SG.", + "Sensory stimulation was performed with 50 Hz, 0.1 - 0.5 V, with no neural numbness to the upper limbs or other areas.", + "Motor stimulation was performed at 2 Hz, 0.4 - 1.0 V exercise test, with no corresponding segmental muscle tremors.", + "Motor stimulation was performed by asking the patient to say 'ee' to check for preservation of the motor function.", + "High voltage (60 V) PRF at 42°C for 360 s, 20 ms pulse width, and 2 Hz frequency started.", + "Before starting RF at 80ºC, 1cc lidocaine 2% was injected.", + "Thermal left unilateral RF neurolysis was performed at 80ºC for 60 seconds.", + "Thermal RF neurolysis was repeated four times after needle-tip rotation.", + "The needle was directed to the most medial site and most ventral aspect of the C6 and C7 transverse process under US guidance.", + "Sensory and motor stimulation were repeated before RF lesioning.", + "Thirty minutes after the procedure's termination, a follow-up ultrasound screening was done.", + "No hematoma formation was excluded by follow-up ultrasound.", + "From pre- to post-block, there was an increase in the forehead and hands temperature.", + "The increase in temperature was used as a surrogate for a successful block.", + "After doing RF neurolysis in multiple time intervals, the patient was visited 1, 3, 6, 12, and 14 months later.", + "No signs of ventricular tachycardia were observed.", + "The patient did not complain about the unpleasant sensation of ICD activity and shock.", + "The patient did not have the problem up to 14 months after the procedure.", + "The patient showed no sign of recurrence of the cardiac tachyarrhythmia." + ], + "summary": "The patient was a 53 years old woman with a history of implantable cardioverter defibrillator (ICD) insertion due to ventricular tachycardia. The patient complained of an awkward and unpleasant sensation when the ICD sensed the tachyarrhythmia and shocked her. Regarding the positive response to the previous SG block, with the goal of a longer duration of this effect, stellate ganglion radiofrequency was performed.", + "summary_subclaims": [ + "The patient was a 53 years old woman.", + "The patient had a history of implantable cardioverter defibrillator (ICD) insertion due to ventricular tachycardia.", + "The patient complained of an awkward and unpleasant sensation when the ICD sensed the tachyarrhythmia and shocked her.", + "The patient had a positive response to the previous SG block.", + "The goal was a longer duration of this effect.", + "Stellate ganglion radiofrequency was performed." + ] + }, + { + "id": "multiclinsum_test_2541_en.txt", + "fulltext": "A 70-year-old female patient was scheduled for abdominal aortic aneurysm resection and reconstruction. She had undergone general anesthesia for surgery of purulent cervical spondylitis about 6 years ago without any adverse event. The height of the patient was 142 cm, and the weight was 54 kg.\nA catheter was inserted into the thoracic vertebrae 9–10 epidural interspace to enable analgesia prior to sedation using propofol. Anesthesia was induced with continuously injected remifentanil at a rate of 0.15–0.3 mg/kg/h, and propofol was started intravenously at a target plasma concentration of 3 μg/ml using a target-controlled infusion (TCI) pump, followed by 40 mg of rocuronium bromide for endotracheal intubation. Anesthesia was maintained with 70% nitrous oxide, 30% oxygen, and propofol continuously injected at a target plasma concentration of 1–2 μg/ml.\nThe abdominal aortic aneurysm, which measured 4.9 cm in diameter, was observed from the infrarenal artery to the level of bifurcation of the inferior mesenteric artery (IMA), while the renal artery and iliac artery were not clamped. The peripheral anastomosis to the aorta was possible above the IMA. The operation time was extended significantly beyond the scheduled time in order to control bleeding due to a lumbar vein injury, and the anesthesia lasted 5 h 38 min. Total blood loss was 3424 ml, 1159 ml in the blood loss was returned by the autologous blood collection device, and 6 units of red cell concentrates mannitol-adenine-phosphate were used. However, abdominal aortic aneurysm resection and reconstruction were performed routinely, and the patient’s hemodynamic condition was stable throughout the anesthesia course. We confirmed adequate arousal after the surgery, and the endotracheal tube was removed in the operating room, after which the patient was transferred to the recovery room.\nOn the second post-operative day, oliguria was prolonged, and her respiratory frequency exceeded 45 times with respiratory distress appearing due to pulmonary edema. Therefore, we decided that re-intubation and a ventilator were necessary, and propofol was used for sedation. Prior to endotracheal intubation, 30 mg of propofol was injected, and sedation was maintained with propofol at a rate of 50 mg/h using an infusion pump instead of a TCI pump.\nFrom the following day, a fever of 39.7 °C and a decrease in blood pressure appeared. Blood tests showed that platelets had dropped to 26,000/μl, and creatinine phosphokinase (CPK) had risen to 57220 U/l. A blood gas analysis during propofol infusion showed pH 7.40, PCO2 23.4 mmHg, HCO3 14.2 mmol/L, base excess − 9.0 mmol/L, anion gap 22.0 mmol/L, and lactate 1.5 mmol/L. No significant elevation of lactate or acidosis was observed. Metabolic acidosis may have been compensated by mechanical ventilation .\nWe suspected intestinal ischemia and severe infection, and immediately started treatment for disseminated intravascular coagulation, stopping using epidural anesthesia. Colonoscopy revealed mild ulcers but no intestinal necrosis, myocardial infarction was denied from echocardiographic findings, and skeletal muscle necrosis was negative according to clinical findings. Thereafter, a fever of 41.1 °C and high CPK persisted, and her hemodynamics were disrupted, so we finally stopped propofol infusion to maintain her blood pressure. Continuous hemodiafiltration (CHDF) was started for the oliguria due to deterioration of the renal function.\nFrom the day after the propofol infusion was stopped, the fever decreased to 36.8 °C, CPK started to decease, and the hemodynamics improved dramatically . Two weeks later, her respiratory condition improved, and the ventilator was able to be removed. The urine volume and renal function had been stable, and hemodialysis was able to be discontinued. However, the patient suffered from prolonged consciousness disorder. Neither computed tomography (CT) nor magnetic resonance imaging (MRI) of the brain revealed any particular lesions causing prolong consciousness disorder other than a small area of cerebral infarction in the subacute phase. Concerning the continuation of consciousness disorder, an electroencephalogram was conducted, which suggested the possibility of seizures; however, the details were unclear. After two more weeks, the level of consciousness gradually improved, and speech and spontaneous movement became apparent.\nAfter normalization of CPK and improvement of the general condition, re-examinations were performed, including CT and MRI; however, no disease other than PRIS causing an increase in CPK or a disruption of hemodynamics was suspected. Immediately after the injection of propofol was stopped, her condition improved, which eventually prompted our diagnosis.\nTen months after the operation, the patient’s communication level had improved, but hemiplegia remained due to cerebral infarction and muscle weakness due to disuse, so she was transferred to a rehabilitation hospital for functional recovery.", + "fulltext_subclaims": [ + "The patient was a 70-year-old female.", + "The patient was scheduled for abdominal aortic aneurysm resection and reconstruction.", + "She had undergone general anesthesia for surgery of purulent cervical spondylitis about 6 years ago without any adverse event.", + "The height of the patient was 142 cm.", + "The weight of the patient was 54 kg.", + "A catheter was inserted into the thoracic vertebrae 9–10 epidural interspace.", + "Anesthesia was induced with continuously injected remifentanil at a rate of 0.15–0.3 mg/kg/h.", + "Propofol was started intravenously at a target plasma concentration of 3 μg/ml using a target-controlled infusion (TCI) pump.", + "40 mg of rocuronium bromide was used for endotracheal intubation.", + "Anesthesia was maintained with 70% nitrous oxide, 30% oxygen, and propofol continuously injected at a target plasma concentration of 1–2 μg/ml.", + "The abdominal aortic aneurysm measured 4.9 cm in diameter.", + "The aneurysm was observed from the infrarenal artery to the level of bifurcation of the inferior mesenteric artery.", + "The renal artery and iliac artery were not clamped.", + "The peripheral anastomosis to the aorta was possible above the IMA.", + "The operation time was extended significantly beyond the scheduled time.", + "The anesthesia lasted 5 h 38 min.", + "Total blood loss was 3424 ml.", + "1159 ml of blood loss was returned by the autologous blood collection device.", + "6 units of red cell concentrates mannitol-adenine-phosphate were used.", + "The patient’s hemodynamic condition was stable throughout the anesthesia course.", + "Adequate arousal was confirmed after the surgery.", + "The endotracheal tube was removed in the operating room.", + "The patient was transferred to the recovery room.", + "On the second post-operative day, oliguria was prolonged.", + "Her respiratory frequency exceeded 45 times with respiratory distress due to pulmonary edema.", + "Re-intubation and a ventilator were necessary.", + "30 mg of propofol was injected prior to endotracheal intubation.", + "Sedation was maintained with propofol at a rate of 50 mg/h using an infusion pump.", + "A fever of 39.7 °C and a decrease in blood pressure appeared.", + "Platelets had dropped to 26,000/μl.", + "Creatinine phosphokinase (CPK) had risen to 57220 U/l.", + "A blood gas analysis during propofol infusion showed pH 7.40, PCO2 23.4 mmHg, HCO3 14.2 mmol/L, base excess −9.0 mmol/L, anion gap 22.0 mmol/L, and lactate 1.5 mmol/L.", + "No significant elevation of lactate or acidosis was observed.", + "Metabolic acidosis may have been compensated by mechanical ventilation.", + "We suspected intestinal ischemia and severe infection.", + "Treatment for disseminated intravascular coagulation was started.", + "Epidural anesthesia was stopped.", + "Colonoscopy revealed mild ulcers but no intestinal necrosis.", + "Myocardial infarction was denied from echocardiographic findings.", + "Skeletal muscle necrosis was negative according to clinical findings.", + "A fever of 41.1 °C and high CPK persisted.", + "Her hemodynamics were disrupted.", + "Propofol infusion was finally stopped to maintain her blood pressure.", + "Continuous hemodiafiltration (CHDF) was started for the oliguria due to deterioration of the renal function.", + "From the day after the propofol infusion was stopped, the fever decreased to 36.8 °C.", + "CPK started to decrease.", + "The hemodynamics improved dramatically.", + "Two weeks later, the ventilator was able to be removed.", + "The urine volume and renal function had been stable.", + "Hemodialysis was able to be discontinued.", + "The patient suffered from prolonged consciousness disorder.", + "Neither CT nor MRI of the brain revealed any particular lesions causing prolonged consciousness disorder other than a small area of cerebral infarction in the subacute phase.", + "An electroencephalogram suggested the possibility of seizures.", + "After two more weeks, the level of consciousness gradually improved.", + "Speech and spontaneous movement became apparent.", + "After normalization of CPK and improvement of the general condition, re-examinations were performed, including CT and MRI.", + "No disease other than PRIS causing an increase in CPK or a disruption of hemodynamics was suspected.", + "Immediately after the injection of propofol was stopped, her condition improved.", + "Ten months after the operation, the patient’s communication level had improved.", + "Hemiplegia remained due to cerebral infarction.", + "Muscle weakness due to disuse remained.", + "The patient was transferred to a rehabilitation hospital for functional recovery." + ], + "summary": "The patient was scheduled for abdominal aortic aneurysm resection and reconstruction. Propofol used during sedation for ventilation after the surgery-induced rhabdomyolysis, heart failure, and renal failure. Discontinuation of propofol administration led to a dramatic improvement in the fatal symptoms, resulting in a diagnosis of PRIS.", + "summary_subclaims": [ + "The patient was scheduled for abdominal aortic aneurysm resection and reconstruction.", + "Propofol used during sedation for ventilation after the surgery.", + "The surgery-induced rhabdomyolysis, heart failure, and renal failure.", + "Discontinuation of propofol administration led to a dramatic improvement in the fatal symptoms.", + "The diagnosis was PRIS." + ] + }, + { + "id": "multiclinsum_test_689_en.txt", + "fulltext": "A 46-year-old man of Macedonian ethnicity presented with a pruritic perianal lesion measuring up to 2cm without pain or bleeding. Our patient was diabetic and had a family history of diabetes and hypertension. Five months after his initial presentation, a colonoscopy and a biopsy were performed at Clinical Hospital Sistina - Adzibadem. The next month, our patient was admitted to our University Clinic of Digestive Surgery, where a physical examination revealed a perianal eczematous lesion measuring 6 × 4cm and enlarged inguinal lymph nodes. A second biopsy with a left lymphadenectomy was performed.\nThe tissue specimens were formalin-fixed and paraffin-embedded at our Institute of Pathology. We used a routine hematoxylin-eosin stain and performed additional histochemical and immunohistochemical analysis, including staining with Alcian blue and for cytokeratin (CK)7, CK20, epithelial membrane antigen, carcinoembryonic antigen, melan-A, androgen receptor and human epidermal growth factor receptor 2 (Her2/neu).\nMicroscopic analysis of the biopsy specimens showed large Paget cells with abundant pale cytoplasm, and large nuclei infiltrating the basal part and the whole thickness of the squamous epithelium and adnexal epithelium. Occasional cells had a signet-ring appearance. His inguinal lymph node revealed reactive lymphadenopathy. A diagnosis of EMPD was made.\nThe perianal surgical skin excision measured 5.5 × 6.5 × 0.7cm and showed diffuse ulcerated eczematous plaques . Histopathology revealed identical Paget cells as viewed in the biopsy specimen, infiltrating the epidermis and adnexal epithelium with ulceration. In the basal epidermal layers there were some duct-like structures with small central lumina . There was intense mononuclear infiltrate in the dermal connective tissue. An immunohistochemical analysis on both biopsy and excision specimens revealed positive Paget cell expression for CK7, epithelial membrane antigen, carcinoembryonic antigen, androgen receptor and Her2/neu , and negative expression for CK20 and melan-A. Intracytoplasmic sialomucin stained positive for Alcian blue . A diagnosis of primary in situ PPD was made.\nAfter two biopsy findings of EMPD, a wide surgical excision was performed . The patient was discharged in good condition and advised to attend a follow-up examination. After six months, a check-up revealed his skin area to be disease free.", + "fulltext_subclaims": [ + "The patient is a 46-year-old man of Macedonian ethnicity.", + "He presented with a pruritic perianal lesion measuring up to 2cm.", + "The lesion had no pain or bleeding.", + "The patient was diabetic.", + "He had a family history of diabetes.", + "He had a family history of hypertension.", + "Five months after his initial presentation, a colonoscopy and a biopsy were performed at Clinical Hospital Sistina - Adzibadem.", + "The next month, the patient was admitted to the University Clinic of Digestive Surgery.", + "A physical examination revealed a perianal eczematous lesion measuring 6 × 4cm.", + "Enlarged inguinal lymph nodes were noted.", + "A second biopsy with a left lymphadenectomy was performed.", + "The tissue specimens were formalin-fixed and paraffin-embedded at the Institute of Pathology.", + "A routine hematoxylin-eosin stain was used.", + "Additional histochemical and immunohistochemical analysis was performed.", + "Staining with Alcian blue was performed.", + "Staining for cytokeratin (CK)7 was performed.", + "Staining for CK20 was performed.", + "Staining for epithelial membrane antigen was performed.", + "Staining for carcinoembryonic antigen was performed.", + "Staining for melan-A was performed.", + "Staining for androgen receptor was performed.", + "Staining for human epidermal growth factor receptor 2 (Her2/neu) was performed.", + "Microscopic analysis showed large Paget cells with abundant pale cytoplasm.", + "The Paget cells had large nuclei infiltrating the basal part and the whole thickness of the squamous epithelium.", + "The Paget cells infiltrated the adnexal epithelium.", + "Occasional cells had a signet-ring appearance.", + "The inguinal lymph node revealed reactive lymphadenopathy.", + "A diagnosis of EMPD was made.", + "The perianal surgical skin excision measured 5.5 × 6.5 × 0.7cm.", + "The excision showed diffuse ulcerated eczematous plaques.", + "Histopathology revealed identical Paget cells as viewed in the biopsy specimen.", + "The Paget cells infiltrated the epidermis and adnexal epithelium with ulceration.", + "In the basal epidermal layers there were some duct-like structures with small central lumina.", + "There was intense mononuclear infiltrate in the dermal connective tissue.", + "Immunohistochemical analysis on both biopsy and excision specimens revealed positive Paget cell expression for CK7.", + "Immunohistochemical analysis revealed positive expression for epithelial membrane antigen.", + "Immunohistochemical analysis revealed positive expression for carcinoembryonic antigen.", + "Immunohistochemical analysis revealed positive expression for androgen receptor.", + "Immunohistochemical analysis revealed positive expression for Her2/neu.", + "Immunohistochemical analysis revealed negative expression for CK20.", + "Immunohistochemical analysis revealed negative expression for melan-A.", + "Intracytoplasmic sialomucin stained positive for Alcian blue.", + "A diagnosis of primary in situ PPD was made.", + "After two biopsy findings of EMPD, a wide surgical excision was performed.", + "The patient was discharged in good condition.", + "The patient was advised to attend a follow-up examination.", + "After six months, a check-up revealed his skin area to be disease free." + ], + "summary": "Our patient was a 46-year-old man of Macedonian ethnicity who presented with a pruritic perianal lesion measuring up to 6cm without pain or bleeding. Two biopsies and a perianal wide surgical excision were performed. The tissue specimens were formalin-fixed and the paraffin-embedded samples analyzed according to standard histochemical and immunohistochemical procedures.Surgical perianal skin excision revealed diffuse eczematoid, whitish plaques. Pathohistology showed Paget cells infiltrating his epidermis and adnexal epithelium, with ulceration. Immunohistochemical analysis revealed positive Paget cell expression for cytokeratin 7, epithelial membrane antigen, carcinoembryonic antigen, androgen receptor and human epidermal growth factor receptor 2, and negative expression for cytokeratin 20 and melan-A.", + "summary_subclaims": [ + "The patient was a 46-year-old man of Macedonian ethnicity.", + "The patient presented with a pruritic perianal lesion measuring up to 6cm.", + "The lesion had no pain or bleeding.", + "Two biopsies and a perianal wide surgical excision were performed.", + "The tissue specimens were formalin-fixed.", + "The paraffin-embedded samples were analyzed according to standard histochemical and immunohistochemical procedures.", + "Surgical perianal skin excision revealed diffuse eczematoid, whitish plaques.", + "Pathohistology showed Paget cells infiltrating his epidermis and adnexal epithelium.", + "Immunohistochemical analysis revealed positive Paget cell expression for cytokeratin 7.", + "Immunohistochemical analysis revealed positive Paget cell expression for epithelial membrane antigen.", + "Immunohistochemical analysis revealed positive Paget cell expression for carcinoembryonic antigen.", + "Immunohistochemical analysis revealed positive Paget cell expression for androgen receptor.", + "Immunohistochemical analysis revealed positive Paget cell expression for human epidermal growth factor receptor 2.", + "Immunohistochemical analysis revealed negative Paget cell expression for cytokeratin 20.", + "Immunohistochemical analysis revealed negative Paget cell expression for melan-A." + ] + }, + { + "id": "multiclinsum_test_2879_en.txt", + "fulltext": "A 54-year-old female presented with a progressively enlarging mass in her right distal leg anterior aspect for 2 years, associated with occasional pain over the past 6 months. Physical examination revealed a palpable, non-tender, subcutaneous mass measuring approximately 2 cm in diameter, located in the medial aspect of the distal leg. Ultrasonography demonstrated a well-defined hypoechoic lesion with vascularity. Considering the suspicious nature of the mass, surgical excision was performed under regional anesthesia . Histopathological analysis revealed a well-circumscribed encapsulated neoplasm composed of myoepithelial cells proliferating with perivascular attenuation around slit such as vascular spaces, consistent with a diagnosis of angioleiomyoma . The patient recovered completely and was followed up at 6 monthly intervals for 2 years without any recurrence.", + "fulltext_subclaims": [ + "The patient is a 54-year-old female.", + "She had a progressively enlarging mass in her right distal leg anterior aspect for 2 years.", + "The mass was associated with occasional pain over the past 6 months.", + "Physical examination revealed a palpable, non-tender, subcutaneous mass measuring approximately 2 cm in diameter.", + "The mass was located in the medial aspect of the distal leg.", + "Ultrasonography demonstrated a well-defined hypoechoic lesion with vascularity.", + "Surgical excision was performed under regional anesthesia.", + "Histopathological analysis revealed a well-circumscribed encapsulated neoplasm composed of myoepithelial cells proliferating with perivascular attenuation around slit such as vascular spaces.", + "The diagnosis was angioleiomyoma.", + "The patient recovered completely.", + "She was followed up at 6 monthly intervals for 2 years.", + "There was no recurrence." + ], + "summary": "We present a case of angioleiomyoma in a 54-year-old female who presented with a palpable mass in her distal leg. The tumor was surgically excised, and histopathological examination confirmed the diagnosis of angioleiomyoma. In this article, we discuss the clinical presentation, diagnostic evaluation, and management of angioleiomyoma, with a focus on distal leg tumors. Furthermore, we provide a comprehensive review of the existing literature on angioleiomyomas, emphasizing findings and treatment outcomes reported in previous studies.", + "summary_subclaims": [ + "The patient was a 54-year-old female.", + "The patient had a palpable mass in her distal leg.", + "The tumor was surgically excised.", + "Histopathological examination confirmed the diagnosis of angioleiomyoma.", + "The article discusses the clinical presentation of angioleiomyoma.", + "The article discusses the diagnostic evaluation of angioleiomyoma.", + "The article discusses the management of angioleiomyoma.", + "The article focuses on distal leg tumors.", + "The article provides a comprehensive review of the existing literature on angioleiomyomas.", + "The article emphasizes findings reported in previous studies.", + "The article emphasizes treatment outcomes reported in previous studies." + ] + }, + { + "id": "multiclinsum_test_2497_en.txt", + "fulltext": "A 59-year-old Korean male with complaints of sudden metamorphopsia and reduced visual acuity for three days in the left eye was referred to our clinic. His past ophthalmological and other medical history was unremarkable except for hypertension.\nOn examination, the best-corrected distance visual acuity (BCVA) was 20/20 in the right eye and 20/200 in the left eye. On slit-lamp examination, the cornea and conjunctiva were unremarkable, and there was no evidence of active inflammation in the anterior chamber or neovascularization in the iris. Fundus photography and fluorescein angiography showed BRVO in the left eye . Optical coherence tomography showed ME in the left eye . We performed intravitreal dexamethasone implantation and scatter laser photocoagulation in the left eye. The intravitreal dexamethasone implant injection was performed inferotemporally, 3.5 mm from the limbus. The implant was properly positioned in the vitreous chamber after the injection. One month after the intravitreal dexamethasone implantation, a decrease in the ME and an improvement of the BCVA to 20/40 was observed on left eye examination. Three months after the intravitreal dexamethasone implantation, recurrence of the ME and deterioration of the BCVA to 20/200 was observed on left eye examination. Therefore, we performed the second intravitreal dexamethasone implantation in the left eye in the same manner. One month after the second intravitreal dexamethasone implantation, the ME improved and the BCVA was 20/60 in the left eye. The ME recurred and the BCVA was 20/200 about four months after the second intravitreal injection. Therefore, we performed the third intravitreal dexamethasone implantation in the left eye in the same manner. Every intravitreal injections and the consequent follow-up examinations were performed by an experienced, single vitreoretinal specialist. On every follow-up examinations performed a day after the three dexamethasone implantations, the implant was positioned properly in the vitreous chamber, away from the crystalline lens. On slit-lamp examination performed one week after the third injection, grade 1 posterior subcapsular opacity was observed and the IOP was 42 mmHg by Goldmann applanation tonometer; however, there was improvement in the ME and the BCVA was 20/100. He was treated with oral acetazolamide, topical dorzolamide/timolol, and topical bimatoprost in the left eye. His IOP decreased to 18 mmHg in the left eye. He was discharged and prescribed topical dorzolamide/timolol and topical bimatoprost in the left eye and oral acetazolamide 10 mg/kg three times a day. Three weeks after the treatment, on slit-lamp examination, we observed that the posterior subcapsular cataract had progressed to mature stage ; anterior chamber was shallower than that observed in the previous examination. The IOP was 18 mmHg and the BCVA was reduced to hand motion in the left eye. Phacoemulsification and the consequent posterior chamber intraocular lens implantation was performed to treat the mature cataract, and intravitreal ranibizumab was performed in order to decrease the remnant ME in the left eye. The procedure was uneventful. His BCVA in the left eye was 20/60 one week after the procedure.", + "fulltext_subclaims": [ + "A 59-year-old Korean male with complaints of sudden metamorphopsia and reduced visual acuity for three days in the left eye was referred to our clinic.", + "His past ophthalmological and other medical history was unremarkable except for hypertension.", + "On examination, the best-corrected distance visual acuity (BCVA) was 20/20 in the right eye and 20/200 in the left eye.", + "On slit-lamp examination, the cornea and conjunctiva were unremarkable.", + "There was no evidence of active inflammation in the anterior chamber.", + "There was no evidence of neovascularization in the iris.", + "Fundus photography and fluorescein angiography showed BRVO in the left eye.", + "Optical coherence tomography showed ME in the left eye.", + "We performed intravitreal dexamethasone implantation and scatter laser photocoagulation in the left eye.", + "The intravitreal dexamethasone implant injection was performed inferotemporally, 3.5 mm from the limbus.", + "The implant was properly positioned in the vitreous chamber after the injection.", + "One month after the intravitreal dexamethasone implantation, a decrease in the ME and an improvement of the BCVA to 20/40 was observed on left eye examination.", + "Three months after the intravitreal dexamethasone implantation, recurrence of the ME and deterioration of the BCVA to 20/200 was observed on left eye examination.", + "We performed the second intravitreal dexamethasone implantation in the left eye in the same manner.", + "One month after the second intravitreal dexamethasone implantation, the ME improved and the BCVA was 20/60 in the left eye.", + "The ME recurred and the BCVA was 20/200 about four months after the second intravitreal injection.", + "We performed the third intravitreal dexamethasone implantation in the left eye in the same manner.", + "Every intravitreal injections and the consequent follow-up examinations were performed by an experienced, single vitreoretinal specialist.", + "On every follow-up examinations performed a day after the three dexamethasone implantations, the implant was positioned properly in the vitreous chamber, away from the crystalline lens.", + "On slit-lamp examination performed one week after the third injection, grade 1 posterior subcapsular opacity was observed and the IOP was 42 mmHg by Goldmann applanation tonometer.", + "There was improvement in the ME and the BCVA was 20/100.", + "He was treated with oral acetazolamide, topical dorzolamide/timolol, and topical bimatoprost in the left eye.", + "His IOP decreased to 18 mmHg in the left eye.", + "He was discharged and prescribed topical dorzolamide/timolol and topical bimatoprost in the left eye and oral acetazolamide 10 mg/kg three times a day.", + "Three weeks after the treatment, on slit-lamp examination, we observed that the posterior subcapsular cataract had progressed to mature stage.", + "The anterior chamber was shallower than that observed in the previous examination.", + "The IOP was 18 mmHg and the BCVA was reduced to hand motion in the left eye.", + "Phacoemulsification and the consequent posterior chamber intraocular lens implantation was performed to treat the mature cataract.", + "Intravitreal ranibizumab was performed in order to decrease the remnant ME in the left eye.", + "The procedure was uneventful.", + "His BCVA in the left eye was 20/60 one week after the procedure." + ], + "summary": "A 59-year-old Korean male with complaints of sudden metamorphopsia and reduced visual acuity for three days in the left eye was referred to our clinic. Ophthalmological investigations included fundus photography, fluorescein angiography, and optical coherence tomography. In the left eye, branch retinal vein occlusion with macular edema was observed. We performed intravitreal dexamethasone implantation in the left eye three times within a period of one year. One week after the third intravitreal dexamethasone implantation, grade 1 posterior subcapsular opacity and raised intraocular pressure were observed in the left eye. Three weeks later, mature cataract was observed in the left eye. We performed cataract surgery along with intravitreal ranibizumab injection in the left eye. The procedure was uneventful, and the visual acuity improved postoperatively.", + "summary_subclaims": [ + "The patient is a 59-year-old Korean male.", + "The patient had complaints of sudden metamorphopsia and reduced visual acuity for three days in the left eye.", + "The patient was referred to the clinic.", + "Ophthalmological investigations included fundus photography.", + "Ophthalmological investigations included fluorescein angiography.", + "Ophthalmological investigations included optical coherence tomography.", + "Branch retinal vein occlusion with macular edema was observed in the left eye.", + "Intravitreal dexamethasone implantation was performed in the left eye three times within a period of one year.", + "One week after the third intravitreal dexamethasone implantation, grade 1 posterior subcapsular opacity was observed in the left eye.", + "One week after the third intravitreal dexamethasone implantation, raised intraocular pressure was observed in the left eye.", + "Three weeks after the third intravitreal dexamethasone implantation, mature cataract was observed in the left eye.", + "Cataract surgery was performed in the left eye.", + "Intravitreal ranibizumab injection was performed in the left eye.", + "The procedure was uneventful.", + "The visual acuity improved postoperatively." + ] + }, + { + "id": "multiclinsum_test_2734_en.txt", + "fulltext": "A 25-month-old boy was referred to our outpatient clinic without complaints due to a gestational ultrasound that showed kidney cysts. The patient was already under antibiotic prophylaxis and physical examination and vital signs within normal limits. The parents reported no family history of kidney disease and/or other heredofamilial disorders. Renal ultrasound performed at 2 days of life showed bilateral hydronephrosis, mainly on the right kidney. At 5 months of age, a DTPA and a DMSA were performed. The DTPA showed strong retention of the marker in the pyelocalyceal system bilaterally, with little response to diuretic stimulus (. A1, A2), while the DMSA indicated preserved kidney function and symmetrical radiotracer distribution in kidneys with relative kidney function of 46% in the left kidney and 54% in the right kidney (. A3).\nBased on the first appointment at our clinic, the antibiotic prophylaxis was maintained and a new kidney ultrasound was requested, which showed dilation in the entire length of both ureters (10 mm on the right side and 8 mm on the left), with an abrupt stenosis in the distal region of both ureters at the bladder entrance with a caliber of only 2 mm. In addition, moderate bilateral hydronephrosis and slight thinning of the renal cortex parenchyma were also observed (. C2-C5). These findings indicated the diagnosis of bilateral megaureter secondary to stenosis caused by VUJO and vesicoureteral reflux (VUR). At 2 years and 10 months of age, DTPA and DMSA were requested. The DTPA showed obstructive pyelocalyceal and urethral stasis in both kidneys, with a scintigraphic pattern compatible with bilateral hydronephrosis secondary to stasis at the level of the VUJ with preservation of kidney function (. B1, B2). Despite the observed dilation, the parenchyma and renal cortex were preserved and the pattern of DTPA showed a slow emptying degree, while the DMSA showed that relative kidney function remained stable at 46:54 (. B3).\nTaking into account the clinical and imaging findings, non-surgical management was adopted, with clinical follow-up and serial imaging evaluation. During the first year, the patient visited the ambulatory semiannually and in the following 2 years, annually. At 7 years and 7 months, antibiotic prophylaxis was discontinued, with no history of urinary tract infections, and follow-up visits were maintained every 2 years. Kidney ultrasonography at 10 years of age showed significant improvement of all parameters with ureteral transverse diameter exhibiting a slight to moderate increase (0.9 cm) and preserved VUJ, indicating a satisfactory evolution and expected bilateral kidney development with the non-surgical approach. For the entire follow-up time, the patient stayed normotensive, with normal serum urea and creatinine levels, and without proteinuria, indicating favorable clinical evolution.", + "fulltext_subclaims": [ + "A 25-month-old boy was referred to the outpatient clinic without complaints.", + "The referral was due to a gestational ultrasound that showed kidney cysts.", + "The patient was already under antibiotic prophylaxis.", + "Physical examination and vital signs were within normal limits.", + "The parents reported no family history of kidney disease and/or other heredofamilial disorders.", + "Renal ultrasound performed at 2 days of life showed bilateral hydronephrosis, mainly on the right kidney.", + "At 5 months of age, a DTPA and a DMSA were performed.", + "The DTPA showed strong retention of the marker in the pyelocalyceal system bilaterally, with little response to diuretic stimulus.", + "The DMSA indicated preserved kidney function and symmetrical radiotracer distribution in kidneys.", + "The relative kidney function was 46% in the left kidney and 54% in the right kidney.", + "Based on the first appointment at the clinic, the antibiotic prophylaxis was maintained.", + "A new kidney ultrasound was requested.", + "The ultrasound showed dilation in the entire length of both ureters (10 mm on the right side and 8 mm on the left).", + "There was an abrupt stenosis in the distal region of both ureters at the bladder entrance with a caliber of only 2 mm.", + "Moderate bilateral hydronephrosis and slight thinning of the renal cortex parenchyma were observed.", + "These findings indicated the diagnosis of bilateral megaureter secondary to stenosis caused by VUJO and vesicoureteral reflux.", + "At 2 years and 10 months of age, DTPA and DMSA were requested.", + "The DTPA showed obstructive pyelocalyceal and urethral stasis in both kidneys.", + "The scintigraphic pattern was compatible with bilateral hydronephrosis secondary to stasis at the level of the VUJ.", + "The pattern showed preservation of kidney function.", + "Despite the observed dilation, the parenchyma and renal cortex were preserved.", + "The DTPA showed a slow emptying degree.", + "The DMSA showed that relative kidney function remained stable at 46:54.", + "Non-surgical management was adopted.", + "Clinical follow-up and serial imaging evaluation were planned.", + "During the first year, the patient visited the ambulatory semiannually.", + "In the following 2 years, visits were annual.", + "At 7 years and 7 months, antibiotic prophylaxis was discontinued.", + "There was no history of urinary tract infections.", + "Follow-up visits were maintained every 2 years.", + "Kidney ultrasonography at 10 years of age showed significant improvement of all parameters.", + "The ureteral transverse diameter exhibited a slight to moderate increase (0.9 cm).", + "The VUJ was preserved.", + "The evolution indicated a satisfactory outcome.", + "The expected bilateral kidney development was achieved with the non-surgical approach.", + "For the entire follow-up time, the patient stayed normotensive.", + "Serum urea and creatinine levels were normal.", + "There was no proteinuria.", + "The clinical evolution was favorable." + ], + "summary": "A 25-month-old boy was referred without complaints for consultation due to prenatal ultrasound showing kidneys with cysts. He was under antibiotic prophylaxis. No family history of kidney disease and/or inherited disorders was reported. Renal ultrasound (RUS) at 2 days of life showed bilateral hydronephrosis, thus ruling out the possibility of kidney cystic disease. Dynamic renal scintigraphy (DTPA) showed marked retention of the marker in the pyelocaliceal system bilaterally, with little response to diuretic drug. He was maintained under antibiotic prophylaxis, when a new RUS showed bilateral ureteral dilatation, abrupt stenosis in the ureterovesical transition region (0.2 cm caliber), moderate bilateral hydronephrosis, and slight renal cortical thickness, confirming the diagnosis of VUJO. At 2 years and 10 months of age, DTPA showed hydronephrosis and ureteral stasis in both kidneys secondary to stenosis at the vesicoureteral junction (VUJ) level, with preservation of kidney function and slow degree of emptying. We opted for a non-surgical approach. RUS at 10 years of age showed significant improvement of all parameters, with ureteral transverse diameter of 9 mm, preserved VUJ, and age-appropriate bilateral kidney development.", + "summary_subclaims": [ + "A 25-month-old boy was referred without complaints for consultation due to prenatal ultrasound showing kidneys with cysts.", + "He was under antibiotic prophylaxis.", + "No family history of kidney disease and/or inherited disorders was reported.", + "Renal ultrasound at 2 days of life showed bilateral hydronephrosis.", + "Renal ultrasound at 2 days of life ruled out the possibility of kidney cystic disease.", + "Dynamic renal scintigraphy (DTPA) showed marked retention of the marker in the pyelocaliceal system bilaterally.", + "Dynamic renal scintigraphy showed little response to diuretic drug.", + "A new renal ultrasound showed bilateral ureteral dilatation.", + "A new renal ultrasound showed abrupt stenosis in the ureterovesical transition region (0.2 cm caliber).", + "A new renal ultrasound showed moderate bilateral hydronephrosis.", + "A new renal ultrasound showed slight renal cortical thickness.", + "The diagnosis of VUJO was confirmed.", + "At 2 years and 10 months of age, DTPA showed hydronephrosis and ureteral stasis in both kidneys secondary to stenosis at the vesicoureteral junction (VUJ) level.", + "At 2 years and 10 months of age, kidney function was preserved.", + "At 2 years and 10 months of age, there was a slow degree of emptying.", + "A non-surgical approach was opted for.", + "Renal ultrasound at 10 years of age showed significant improvement of all parameters.", + "Renal ultrasound at 10 years of age showed ureteral transverse diameter of 9 mm.", + "Renal ultrasound at 10 years of age showed preserved VUJ.", + "Renal ultrasound at 10 years of age showed age-appropriate bilateral kidney development." + ] + }, + { + "id": "multiclinsum_test_2310_en.txt", + "fulltext": "A 50-year-old Chinese woman accidentally injured her left thumb at 5 pm, while cutting a fish for dinner. She washed the wound with cold, running water for 1 minute and applied a bandage. However, on the night of the incident, her left thumb became red and swollen, which gradually spread to the left dorsal hand and extended to the forearm within 12 hours after the injury, warranting a visit to the emergency department of local hospital the next morning. The doctor recommended hospitalization for surgery. She refused and came to our hospital for treatment a day after the injury.\nDuring admission, there was significant swelling on the dorsum of the left hand and left forearm, high tension, and severe infection. She had a history of dilated cardiomyopathy, chronic heart failure, atrial fibrillation, and type 2 diabetes. Physical examination on admission showed a temperature of 36.8 °C, pulse rate of 80 beats per minute, respiratory rate of 20 breaths per minute, and blood pressure of 87/54 mmHg. A linear wound was also observed at approximately 0.5 cm in length at the left thumb interphalangeal joint on the radial side. The skin and soft tissues of the left hand and the left forearm were red and swollen, especially the left dorsal hand extending to the left dorsal forearm. A purple ecchymosis was noted on the skin of the left dorsal hand, accompanied by scattered tiny tension blisters, high skin tension, significant tenderness, slightly above normal skin temperature, and a weak pulse in the ulnar and radial arteries . Emergency laboratory and clinical examinations performed revealed white blood cell count (WBC) of 21.41 × 109/L, N of 92.0%, platelet count (PCT) of 6.72 ng/mL, GLU of 16.4 mmol/L, HbA1c of 8.0%, and BNP > 5002 pg/mL. A standard 12-lead electrocardiogram (ECG) showed atrial fibrillation, while a plain computerized tomography (CT) scan of the left forearm and left hand revealed moderate to severe swollen skin and soft tissue.\nInitial diagnosis was skin and soft tissue infection in the left upper limb, dilated cardiomyopathy, congestive heart failure (CHF) (grade III cardiac function), atrial fibrillation, postoperative state of cardiac pacemaker implantation, and type 2 diabetes mellitus (DM). Combining the patient’s history of injury, the possibility of infection by aquatic-related bacteria such as Vibrio, Aeromonas, Mycobacterium marinum was considered .\nEmergency open decompression was performed on the left upper limb. A longitudinal incision was made to the deep fascial layer, along the most significantly swollen site, to achieve complete tension reduction and drainage . Intraoperatively, a large amount of clear yellow discharge was found in the deep fascia of the dorsal area of the left wrist and hand. We sent the discharge for bacterial culture. The wound was thoroughly flushed with a large amount of hydrogen peroxide, normal saline, and iodophor and then packed and bandaged with iodoform gauze. Postoperatively, we administered antibiotics such as cefoperazone–sulbactam sodium 3 g intravenously twice a day, combined with moxifloxacin 0.4 g once a day. During postoperative change of dressing, we found that the wound infection continued to spread, partly to the second phalanxes, accompanied by skin blackening and tissue necrosis . On the second day after admission, surgical debridement was performed on the left upper limb. Further open decompression and drainage was conducted. During the operation, the viability of fat and tendon tissues was found to be poor and the subcutaneous venous network was scattered and embolized ; therefore, another discharge sample was sent for bacterial culture. The wound was flushed with a large amount of hydrogen peroxide, normal saline, and iodine and then packed and bandaged with iodoform gauze. On the fourth day after admission, the results of bacterial culture were reported as A. veronii and A. ichthiosmia. The drug sensitivity test results showed that the two bacteria were sensitive to cephalosporins, aminoglycosides, and quinolones but resistant to penicillin and carbapenems. Based on the drug sensitivity test results of the bacterial culture, we administered cefoperazone–sulbactam sodium 3 g intravenously twice daily (BID), combined with levofloxacin 0.5 g four times daily (QD). Subsequently, multiple operations to control the wound infection, and further skin grafting to close the wound, were performed. Finally, the patient recovered and was discharged 1 month after the injury. After 3 months of rehabilitation, the left hand recovered well in appearance and function . The patient was very satisfied with our treatment and expressed great gratitude.", + "fulltext_subclaims": [ + "The patient is a 50-year-old Chinese woman.", + "She injured her left thumb at 5 pm while cutting a fish.", + "She washed the wound with cold, running water for 1 minute.", + "She applied a bandage.", + "On the night of the incident, her left thumb became red and swollen.", + "The redness and swelling spread to the left dorsal hand and extended to the forearm within 12 hours.", + "She visited the emergency department of a local hospital the next morning.", + "The doctor recommended hospitalization for surgery.", + "She refused hospitalization and came to the hospital a day after the injury.", + "There was significant swelling on the dorsum of the left hand and left forearm.", + "The skin and soft tissues of the left hand and forearm were red and swollen.", + "A purple ecchymosis was noted on the skin of the left dorsal hand.", + "Scattered tiny tension blisters were observed.", + "The skin had high tension.", + "There was significant tenderness.", + "The skin temperature was slightly above normal.", + "The ulnar and radial arteries had a weak pulse.", + "The white blood cell count (WBC) was 21.41 × 109/L.", + "The neutrophil percentage (N) was 92.0%.", + "The platelet count (PCT) was 6.72 ng/mL.", + "The glucose (GLU) was 16.4 mmol/L.", + "The HbA1c was 8.0%.", + "The BNP was > 5002 pg/mL.", + "The electrocardiogram showed atrial fibrillation.", + "A plain CT scan showed moderate to severe swollen skin and soft tissue.", + "The initial diagnosis included skin and soft tissue infection in the left upper limb.", + "The initial diagnosis included dilated cardiomyopathy.", + "The initial diagnosis included congestive heart failure (CHF) grade III.", + "The initial diagnosis included atrial fibrillation.", + "The initial diagnosis included type 2 diabetes mellitus.", + "Emergency open decompression was performed on the left upper limb.", + "A longitudinal incision was made to the deep fascial layer.", + "A large amount of clear yellow discharge was found in the deep fascia.", + "The discharge was sent for bacterial culture.", + "The wound was flushed with hydrogen peroxide, normal saline, and iodophor.", + "The wound was packed and bandaged with iodoform gauze.", + "Cefoperazone–sulbactam sodium 3 g was administered intravenously twice a day.", + "Moxifloxacin 0.4 g was administered once a day.", + "The wound infection continued to spread to the second phalanxes.", + "Skin blackening and tissue necrosis were observed.", + "Surgical debridement was performed on the left upper limb.", + "The subcutaneous venous network was scattered and embolized.", + "Another discharge sample was sent for bacterial culture.", + "The wound was flushed with hydrogen peroxide, normal saline, and iodine.", + "The wound was packed and bandaged with iodoform gauze.", + "Bacterial culture results were reported as A. veronii and A. ichthiosmia.", + "The bacteria were sensitive to cephalosporins, aminoglycosides, and quinolones.", + "The bacteria were resistant to penicillin and carbapenems.", + "Cefoperazone–sulbactam sodium 3 g was administered intravenously twice daily.", + "Levofloxacin 0.5 g was administered four times daily.", + "Multiple operations were performed to control the wound infection.", + "Further skin grafting was performed to close the wound.", + "The patient was discharged 1 month after the injury.", + "After 3 months of rehabilitation, the left hand recovered well in appearance and function.", + "The patient expressed great gratitude." + ], + "summary": "We report a case of severe skin and soft tissue infection of the left upper limb caused by Aeromonas veronii. A 50-year-old Chinese woman, who had a history of cardiac disease and type 2 diabetes mellitus, accidentally injured her left thumb while cutting a fish. Early antibiotic therapy and surgical debridement was performed before the result of bacterial culture came back. Whole-genome sequencing was further performed to confirm the pathogen and reveal the drug resistance and virulence genes. The wound was gradually repaired after 1 month of treatment, and the left hand recovered well in appearance and function after 3 months of rehabilitation.", + "summary_subclaims": [ + "The case involved a severe skin and soft tissue infection of the left upper limb caused by Aeromonas veronii.", + "The patient was a 50-year-old Chinese woman.", + "She had a history of cardiac disease.", + "She had a history of type 2 diabetes mellitus.", + "She accidentally injured her left thumb while cutting a fish.", + "Early antibiotic therapy and surgical debridement was performed before the result of bacterial culture came back.", + "Whole-genome sequencing was further performed to confirm the pathogen.", + "Whole-genome sequencing was performed to reveal the drug resistance and virulence genes.", + "The wound was gradually repaired after 1 month of treatment.", + "The left hand recovered well in appearance and function after 3 months of rehabilitation." + ] + }, + { + "id": "multiclinsum_test_883_en.txt", + "fulltext": "A 20-year-old male patient was admitted to our hospital on July 9, 2021, for evaluation of recurring abdominal pain, diarrhea, and black stools, which had been persisting for 6 years.\nThe patient received treatment at a local hospital 6 years back for seven days of unexplained abdominal pain. On examination, the peritoneal stimulation sign was positive. Abdominal X-ray at the time revealed a gas shadow located below the diaphragm. On diagnostic abdominal puncture, 5 mL of purulent fluid was withdrawn, thereby raising the suspicion of perforation in the digestive tract. Laparotomy performed for exploration revealed diffuse peritonitis, acute gangrenous appendicitis with perforation, adhesive intestinal obstruction, and pelvic abscess. Appendectomy, intestinal adhesiolysis, and pelvic abscess removal surgery were performed during the procedure (July 2, 2015). Following surgery, the patient’s condition improved and he was discharged. However, one year after discharge, the patient stared experiencing recurrent abdominal pain and dark red loose stools, with positive test results for fecal occult blood and mild to moderate anemia. Colonoscopy had been performed several times before and showed the presence of intestinal ulcers and bleeding at other hospitals. In light of the colonoscopy findings, a clinical diagnosis of IBD was made. Oral treatment with mesalazine was administered at a local hospital, at a dose of 2 tablets four times a day for a total of 6 weeks. However, there was no improvement in the symptoms of rectal bleeding. Subsequently, oral treatment with azathioprine was added, at a dose of 50 mg once a day for a total of 2 months. Even with this treatment, the symptoms of rectal bleeding did not improve. The Mayo score was 8 points both before and after medication (with an increase of 2-3 times per day compared to the normal bowel movements, mixed blood in the stool within less than half of the time, ulcer formation detected by endoscopy, and moderate condition). Considering its ineffectiveness, mesalazine and azathioprine treatment was discontinued.\nOn July 9, 2021, the patient presented with persistence and worsening of the abovementioned symptoms. The frequency of episodes of abdominal pain and black stool had increased, with approximately 30 mL of dark red loose stools about 3-4 times a day, without mucus, or pus. In addition, he reported dizziness, but did not report any nausea, vomiting, abdominal distension, or constipation. The patient did not experience any loss of consciousness. Moreover, the patient did not show any signs of fever, chills, or night sweats. Subsequently, the patient sought medical attention and was hospitalized for further evaluation, diagnosis, and treatment.\nThe patient's medical history was the same as before, with no other surgical or traumatic history. He also denied having any history of long-term use of NSAIDs or glucocorticoids. Due to gastrointestinal bleeding, the patient received red blood cell infusion twice, without any negative reactions during the process. There was no evidence of infectious diseases, such as typhoid fever and tuberculosis, or any sexually transmitted diseases.\nThe individual reported a history of alcohol consumption for three years, although the amount consumed was unknown. He denied having any history of smoking or exposure to toxins; he also denied any family history of genetic diseases.\nOn examination, the patient had stable vital signs, a clear mind, an anemic face, and pallor of the palpebral conjunctiva, lips, and nail beds. Superficial lymph nodes were not palpable, and cardiopulmonary examination revealed no apparent positive signs; only an old longitudinal surgical scar measuring approximately 20 cm in length was noted on the abdomen. Tenderness was noted beneath the xiphoid process, but there was no rebound pain or muscle tension. No shifting dullness was detected, and bowel sounds were heard at a rate of 6 per minute. No edema was observed in either lower limb.\nRoutine blood tests revealed moderate anemia and a decrease in the average red blood cell volume . Other tests conducted after admission showed no abnormalities in coagulation function and blood biochemistry. No abnormal findings were obtained in laboratory tests for antineutrophil cytoplasmic antibody, antinuclear antibodies, immunoglobulin, lymphocyte immunochip, C-reactive protein (CRP), blood sedimentation rate, and detection of common viruses such as human immunodeficiency virus, hepatitis B virus, and cytomegalovirus. Analysis of the stool sample collected revealed the presence of occult blood. Fecal bacterial culture and fecal fungal culture did not show positive findings. Additionally, the 13C-urea breath test yielded a negative result. Whole-exome sequencing performed for the detection of genetic diseases led to the identification of autosomal ACVRL1 and PLA2G4A gene mutations (July 21, 2021; Figure ).\nOn gastroscopy performed on July 12, 2021, the esophagus appeared to have normal morphology and color, with no evident abnormalities . The distance from the cardia to the incisor was approximately 40 cm, and the dentate line was clearly visible. No abnormalities were visible in the mucosa and structure of the gastric fundus and gastric body. The gastric fundus showed a moderate amount of mucus and yellow turbidity, with a smoothly curved gastric angle. In addition, congestion and edema of the gastric antrum mucosa were noted, with no signs of ulcers or masses. The pylorus appeared to be circular and functioning properly, with smooth opening and closure. Similarly, no abnormalities were detected in the duodenal bulb and mucosa of the descending duodenum. The above findings led to the conclusion of chronic non-atrophic gastritis with bile reflux.\nColonoscopy performed on July 16, 2021 revealed that the surgical repair site between the ascending colon and the ileum was visible 55 cm from the anus (usually 60-70 cm away from the anus); the ileocecal valve and cecum were indistinguishable . There were scattered nodular protrusions, lamellar vesicle, and shallow ulcers at the site of surgical repair, as well as in the ileum. Additionally, local mucosal protrusions, ulcers, and nodular protrusions were observed near the hepatic flexure of the transverse colon. The morphology of the remaining part of the descending colon and sigmoid colon appeared normal, with regular folds, a smooth mucosal surface, and rich and clear vascular network; no abnormal secretions, erosion, ulcers, or masses were detected in these segments of the colon. Similarly, the rectal mucosa exhibited no obvious abnormalities, But a fistula in the perianal area was suspected. The colonoscopy findings raised a suspicion of CD.\nPathological examination of the appendix removed on July 2, 2015, showed acute gangrenous appendicitis, peritonitis, appendix perforation, and fecal stone incarceration within the cavity.\nHistopathologic examination of a sample of intestinal mucosa obtained on July 19, 2021 revealed superficial mucosa ulceration in the ileum with abundant inflammatory exudates, formation of granulomas, infiltration of lymphocytes and plasma cells, and no caseous necrosis . Additionally, the superficial mucosa of the colon showed signs of acute and chronic inflammation.\nMultiple routine investigations during hospitalization revealed a decrease in the levels of red blood cells, hemoglobin, and average red blood cell volume; slightly higher fibrinogen levels; and a positive fecal occult blood. Given the patient’s history of appendiceal perforation, special care was taken to remain vigilant for signs of gastrointestinal ulcers, and a careful gastroenteroscopy and pathological examination was performed, which validated the atypical intestinal lesions of CD or UC. Additionally, the patient did not exhibit symptoms such as low fever or night sweats, and did not have abnormalities in chest CT and erythrocyte sedimentation rate. Moreover, enteroscopy did not show any transverse ulcers, and pathological findings did not suggest caseous necrosis. Absence of the typical symptoms and the investigative findings together rule out the possibility of tuberculosis infection. The 13C-urea breath test result was negative, which ruled out Helicobacter pylori infection. Since the patient did not have any history of taking NSAIDs or corticosteroids, drug-induced ulcers were also ruled out. Moreover, no abnormalities were detected in tests for urine cytomegalovirus deoxyribonucleic acid, fecal bacterial culture, fecal fungal culture, and common virological tests; therefore, viral, bacterial, and fungal infections were ruled out. Upon retrospective analysis of the clinical manifestations, enteroscopic and pathological findings, the diagnosis was established as IBD without typical features of CD or UC. The patient did not have extraintestinal manifestations, and tests for CRP, antineutrophil cytoplasmic antibody, antinuclear antibodies, immunoglobulin levels, lymphocyte immunochip showed no abnormalities. Furthermore, despite undergoing mesalazine and immune-modulating therapy with azathioprine, there was no improvement in the patient's symptoms. Thus, the early age of onset; recurrence of symptoms; atypical features of CD and UC; and lack of response to aminosalicylic acid, immunotherapy, and related symptomatic treatment raised suspicion of the potential etiopathogenetic role of genetic factors in this case.\nSubsequently, whole-exome sequencing for genetic diseases was performed, which revealed mutations in the ACVRL1 and PLA2G4A genes. Mutations of both these genes are known to cause a decrease in the ability of the intestinal mucosa to resist injury and sustain repair. Kangfuxin liquid is known to have an effect of accelerating the repair of pathological tissue, shedding of necrotic tissue, and healing of ulcers and wounds. Accordingly, we modified the treatment plan and administered oral Kangfuxin liquid of 10 mL three times daily to promote the repair of the intestinal repair. The patient was discharged once his symptoms improved on initiating this treatment, and treatment was continued for 4 wk after discharge. If the patient occasionally experiences symptoms such as abdominal pain, diarrhea, and black stool, oral administration of Kangfuxin liquid can alleviate the symptoms.", + "fulltext_subclaims": [ + "A 20-year-old male patient was admitted to our hospital on July 9, 2021, for evaluation of recurring abdominal pain, diarrhea, and black stools, which had been persisting for 6 years.", + "The patient received treatment at a local hospital 6 years back for seven days of unexplained abdominal pain.", + "On examination, the peritoneal stimulation sign was positive.", + "Abdominal X-ray at the time revealed a gas shadow located below the diaphragm.", + "On diagnostic abdominal puncture, 5 mL of purulent fluid was withdrawn, thereby raising the suspicion of perforation in the digestive tract.", + "Laparotomy performed for exploration revealed diffuse peritonitis, acute gangrenous appendicitis with perforation, adhesive intestinal obstruction, and pelvic abscess.", + "Appendectomy, intestinal adhesiolysis, and pelvic abscess removal surgery were performed during the procedure (July 2, 2015).", + "Following surgery, the patient’s condition improved and he was discharged.", + "One year after discharge, the patient started experiencing recurrent abdominal pain and dark red loose stools, with positive test results for fecal occult blood and mild to moderate anemia.", + "Colonoscopy had been performed several times before and showed the presence of intestinal ulcers and bleeding at other hospitals.", + "In light of the colonoscopy findings, a clinical diagnosis of IBD was made.", + "Oral treatment with mesalazine was administered at a local hospital, at a dose of 2 tablets four times a day for a total of 6 weeks.", + "However, there was no improvement in the symptoms of rectal bleeding.", + "Subsequently, oral treatment with azathioprine was added, at a dose of 50 mg once a day for a total of 2 months.", + "Even with this treatment, the symptoms of rectal bleeding did not improve.", + "The Mayo score was 8 points both before and after medication.", + "Considering its ineffectiveness, mesalazine and azathioprine treatment was discontinued.", + "On July 9, 2021, the patient presented with persistence and worsening of the abovementioned symptoms.", + "The frequency of episodes of abdominal pain and black stool had increased, with approximately 30 mL of dark red loose stools about 3-4 times a day, without mucus, or pus.", + "The patient reported dizziness, but did not report any nausea, vomiting, abdominal distension, or constipation.", + "The patient did not experience any loss of consciousness.", + "The patient did not show any signs of fever, chills, or night sweats.", + "Subsequently, the patient sought medical attention and was hospitalized for further evaluation, diagnosis, and treatment.", + "The patient's medical history was the same as before, with no other surgical or traumatic history.", + "He also denied having any history of long-term use of NSAIDs or glucocorticoids.", + "Due to gastrointestinal bleeding, the patient received red blood cell infusion twice, without any negative reactions during the process.", + "There was no evidence of infectious diseases, such as typhoid fever and tuberculosis, or any sexually transmitted diseases.", + "The individual reported a history of alcohol consumption for three years, although the amount consumed was unknown.", + "He denied having any history of smoking or exposure to toxins; he also denied any family history of genetic diseases.", + "On examination, the patient had stable vital signs, a clear mind, an anemic face, and pallor of the palpebral conjunctiva, lips, and nail beds.", + "Superficial lymph nodes were not palpable, and cardiopulmonary examination revealed no apparent positive signs.", + "Only an old longitudinal surgical scar measuring approximately 20 cm in length was noted on the abdomen.", + "Tenderness was noted beneath the xiphoid process, but there was no rebound pain or muscle tension.", + "No shifting dullness was detected, and bowel sounds were heard at a rate of 6 per minute.", + "No edema was observed in either lower limb.", + "Routine blood tests revealed moderate anemia and a decrease in the average red blood cell volume.", + "Other tests conducted after admission showed no abnormalities in coagulation function and blood biochemistry.", + "No abnormal findings were obtained in laboratory tests for antineutrophil cytoplasmic antibody, antinuclear antibodies, immunoglobulin, lymphocyte immunochip, C-reactive protein (CRP), blood sedimentation rate, and detection of common viruses such as human immunodeficiency virus, hepatitis B virus, and cytomegalovirus.", + "Analysis of the stool sample collected revealed the presence of occult blood.", + "Fecal bacterial culture and fecal fungal culture did not show positive findings.", + "Additionally, the 13C-urea breath test yielded a negative result.", + "Whole-exome sequencing performed for the detection of genetic diseases led to the identification of autosomal ACVRL1 and PLA2G4A gene mutations (July 21, 2021).", + "On gastroscopy performed on July 12, 2021, the esophagus appeared to have normal morphology and color, with no evident abnormalities.", + "The distance from the cardia to the incisor was approximately 40 cm, and the dentate line was clearly visible.", + "No abnormalities were visible in the mucosa and structure of the gastric fundus and gastric body.", + "The gastric fundus showed a moderate amount of mucus and yellow turbidity, with a smoothly curved gastric angle.", + "In addition, congestion and edema of the gastric antrum mucosa were noted, with no signs of ulcers or masses.", + "The pylorus appeared to be circular and functioning properly, with smooth opening and closure.", + "Similarly, no abnormalities were detected in the duodenal bulb and mucosa of the descending duodenum.", + "The above findings led to the conclusion of chronic non-atrophic gastritis with bile reflux.", + "Colonoscopy performed on July 16, 2021 revealed that the surgical repair site between the ascending colon and the ileum was visible 55 cm from the anus.", + "There were scattered nodular protrusions, lamellar vesicle, and shallow ulcers at the site of surgical repair, as well as in the ileum.", + "Additionally, local mucosal protrusions, ulcers, and nodular protrusions were observed near the hepatic flexure of the transverse colon.", + "The morphology of the remaining part of the descending colon and sigmoid colon appeared normal, with regular folds, a smooth mucosal surface, and rich and clear vascular network.", + "No abnormal secretions, erosion, ulcers, or masses were detected in these segments of the colon.", + "Similarly, the rectal mucosa exhibited no obvious abnormalities, but a fistula in the perianal area was suspected.", + "The colonoscopy findings raised a suspicion of CD.", + "Pathological examination of the appendix removed on July 2, 2015, showed acute gangrenous appendicitis, peritonitis, appendix perforation, and fecal stone incarceration within the cavity.", + "Histopathologic examination of a sample of intestinal mucosa obtained on July 19, 2021 revealed superficial mucosa ulceration in the ileum with abundant inflammatory exudates, formation of granulomas, infiltration of lymphocytes and plasma cells, and no caseous necrosis.", + "Additionally, the superficial mucosa of the colon showed signs of acute and chronic inflammation.", + "Multiple routine investigations during hospitalization revealed a decrease in the levels of red blood cells, hemoglobin, and average red blood cell volume.", + "Slightly higher fibrinogen levels were noted.", + "A positive fecal occult blood was detected.", + "Given the patient’s history of appendiceal perforation, special care was taken to remain vigilant for signs of gastrointestinal ulcers.", + "A careful gastroenteroscopy and pathological examination was performed, which validated the atypical intestinal lesions of CD or UC.", + "Additionally, the patient did not exhibit symptoms such as low fever or night sweats, and did not have abnormalities in chest CT and erythrocyte sedimentation rate.", + "Moreover, enteroscopy did not show any transverse ulcers, and pathological findings did not suggest caseous necrosis.", + "Absence of the typical symptoms and the investigative findings together rule out the possibility of tuberculosis infection.", + "The 13C-urea breath test result was negative, which ruled out Helicobacter pylori infection.", + "Since the patient did not have any history of taking NSAIDs or corticosteroids, drug-induced ulcers were also ruled out.", + "Moreover, no abnormalities were detected in tests for urine cytomegalovirus deoxyribonucleic acid, fecal bacterial culture, fecal fungal culture, and common virological tests; therefore, viral, bacterial, and fungal infections were ruled out.", + "Upon retrospective analysis of the clinical manifestations, enteroscopic and pathological findings, the diagnosis was established as IBD without typical features of CD or UC.", + "The patient did not have extraintestinal manifestations, and tests for CRP, antineutrophil cytoplasmic antibody, antinuclear antibodies, immunoglobulin levels, lymphocyte immunochip showed no abnormalities.", + "Furthermore, despite undergoing mesalazine and immune-modulating therapy with azathioprine, there was no improvement in the patient's symptoms.", + "Thus, the early age of onset; recurrence of symptoms; atypical features of CD and UC; and lack of response to aminosalicylic acid, immunotherapy, and related symptomatic treatment raised suspicion of the potential etiopathogenetic role of genetic factors in this case.", + "Subsequently, whole-exome sequencing for genetic diseases was performed, which revealed mutations in the ACVRL1 and PLA2G4A genes.", + "Mutations of both these genes are known to cause a decrease in the ability of the intestinal mucosa to resist injury and sustain repair.", + "Kangfuxin liquid is known to have an effect of accelerating the repair of pathological tissue, shedding of necrotic tissue, and healing of ulcers and wounds.", + "Accordingly, we modified the treatment plan and administered oral Kangfuxin liquid of 10 mL three times daily to promote the repair of the intestinal repair.", + "The patient was discharged once his symptoms improved on initiating this treatment, and treatment was continued for 4 wk after discharge.", + "If the patient occasionally experiences symptoms such as abdominal pain, diarrhea, and black stool, oral administration of Kangfuxin liquid can alleviate the symptoms." + ], + "summary": "A 20-year-old man was admitted to our center with a 6-year history of recurrent abdominal pain, diarrhea, and dark stools. At the onset 6 years ago, the patient had received treatment at a local hospital for abdominal pain persisting for 7 d, under the diagnosis of diffuse peritonitis, acute gangrenous appendicitis with perforation, adhesive intestinal obstruction, and pelvic abscess. The surgical treatment included exploratory laparotomy, appendectomy, intestinal adhesiolysis, and pelvic abscess removal. The patient's condition improved and he was discharged. However, the recurrent episodes of abdominal pain and passage of black stools started again one year after discharge. On the basis of these features and results of subsequent colonoscopy, the clinical diagnosis was established as inflammatory bowel disease (IBD). Accordingly, aminosalicylic acid, immunotherapy, and related symptomatic treatment were administered, but the symptoms of the patient did not improve significantly. Further investigations revealed mutations in the ACVRL1 and PLA2G4A genes. ACVRL1 and PLA2G4A are involved in angiogenesis and coagulation, respectively. This suggests that the chronic intestinal ulcers and bleeding in this case may be linked to mutations in the ACVRL1 and PLA2G4A genes. Oral Kangfuxin liquid was administered to promote healing of the intestinal mucosa and effectively manage clinical symptoms.", + "summary_subclaims": [ + "The patient is a 20-year-old man.", + "The patient had a 6-year history of recurrent abdominal pain, diarrhea, and dark stools.", + "At the onset 6 years ago, the patient had received treatment at a local hospital for abdominal pain persisting for 7 d.", + "The diagnosis at the local hospital was diffuse peritonitis, acute gangrenous appendicitis with perforation, adhesive intestinal obstruction, and pelvic abscess.", + "The surgical treatment included exploratory laparotomy, appendectomy, intestinal adhesiolysis, and pelvic abscess removal.", + "The patient's condition improved and he was discharged.", + "The recurrent episodes of abdominal pain and passage of black stools started again one year after discharge.", + "The clinical diagnosis was established as inflammatory bowel disease (IBD).", + "Aminosalicylic acid, immunotherapy, and related symptomatic treatment were administered.", + "The symptoms of the patient did not improve significantly.", + "Further investigations revealed mutations in the ACVRL1 and PLA2G4A genes.", + "ACVRL1 and PLA2G4A are involved in angiogenesis and coagulation, respectively.", + "This suggests that the chronic intestinal ulcers and bleeding in this case may be linked to mutations in the ACVRL1 and PLA2G4A genes.", + "Oral Kangfuxin liquid was administered to promote healing of the intestinal mucosa and effectively manage clinical symptoms." + ] + }, + { + "id": "multiclinsum_test_2969_en.txt", + "fulltext": "A 26-year-old female, gravida-3 para-1, at 30 1/7 weeks of gestation presented to the Emergency Department with symptoms of lower back and sacroiliac joint pain, along with abdominal distension. Her medical history revealed that she had been admitted to a county hospital during the second month of her pregnancy due to hyperemesis gravidarum. After one week of supportive therapy, her symptoms mostly subsided. During the fourth month of her pregnancy, fetal movement was observed, and she had regular antenatal care with normal NT (Nuchal Translucency), low-risk Down’s screening, and normal OGTT (Oral Glucose Tolerance Test) results. Four-dimensional ultrasonography suggested an intrauterine pregnancy with a single alive fetus in the breech position and strong light spots in the left ventricle of the fetal heart. Approximately four weeks before admission to our hospital, she experienced progressively worsening low back pain, for which a local doctor recommended observation and rest considering her enlarged pregnancy abdomen.\nThe patient presented with abdominal distension, lower limb dyskinesia, and severe ache, which appeared one day before admission. A pelvic examination conducted in the county hospital revealed the presence of a large fungating gray mass that encompassed the entire cervix, with cervical contact bleeding testing positive. The patient exhibited symptoms such as a pale face, poor spirit and appetite, normal sleep, dry stool occurring once every three days, normal urination, and a weight loss of 10 kg compared to before her pregnancy, since the onset of the disease.\nThe patient received multiple blood transfusions due to severe anemia. Ultrasound examination revealed the presence of a diffuse echo-change approximately 13.6 cm by 11.5 cm in size in the liver, which appeared to be a solid-cystic mass that could potentially be a metastatic tumor. To confirm the diagnosis, cervical cancer screening and biopsy were conducted . Immunohistochemical analysis was performed and the results revealed positive expression of AE1/AE3, CK8/18, CAM5.2, P16, PAX-8, Syn, CD56, and CgA. Additionally, the tumor showed high proliferation index with over 90% of cells staining positively for Ki-67.\nThe magnetic resonance imaging (MRI) results indicated the presence of a significant cervical mass measuring 5.3 × 6.6 × 7.2 cm. In addition, abnormal signals were detected in multiple other locations, including the right scapula, clavicle, multiple ribs, thoracic vertebrae, lung, lumbar vertebrae, right femoral lesser trochanter, bilateral iliac crest, right ischium, acetabulum, and surrounding soft tissue. Multiple cystic solid masses were also detected in the liver, with the largest mass measuring approximately 13.5 × 13.7 × 14.8 cm, which may suggest metastasis .\nA multidisciplinary team consisting of specialists in gynecology, oncology, maternal-fetal medicine, neonatology, interventional medicine, palliative care, and pain management was convened to discuss the case. It was unanimously agreed that a biopsy was warranted, which subsequently revealed poorly differentiated cervical carcinoma exhibiting high-grade neuroendocrine features that were consistent with a diagnosis of large cell neuroendocrine carcinoma. The collective diagnostic results confirmed that the patient was suffering from a rare form of cervical cancer, specifically cervical neuroendocrine carcinoma (CNECC) with HPV18(+) and stage IVB. Considering the gestational age of the fetus and the patient’s deteriorating pain and desire to terminate the pregnancy, she declined neo-adjuvant chemotherapy (NACT) and elected to undergo cesarean section delivery at 31 4/7 weeks gestation after receiving fetal lung maturation therapy. The placenta was unremarkable and no tumors were found . The neonate had Apgar scores of 10 and 10 at 1 and 5 min, respectively, weighed 1700 g, and was subsequently transferred to the neonatal intensive care unit under the care of a neonatologist.\nFollowing surgery, the patient was treated with three cycles of carboplatin and etoposide chemotherapy, followed by an additional five cycles of paclitaxel, nedaplatin, and bevacizumab chemotherapy, with each course administered at 3-week intervals. Unfortunately, she succumbed to multiple tumor metastases six months post-treatment, leading to cardiopulmonary failure, infection, and cachexia. Despite this tragic outcome, the infant was discharged in a healthy condition.", + "fulltext_subclaims": [ + "The patient is a 26-year-old female, gravida-3 para-1, at 30 1/7 weeks of gestation.", + "She presented to the Emergency Department with symptoms of lower back and sacroiliac joint pain, along with abdominal distension.", + "Her medical history included admission to a county hospital during the second month of pregnancy due to hyperemesis gravidarum.", + "After one week of supportive therapy, her symptoms mostly subsided.", + "During the fourth month of pregnancy, fetal movement was observed.", + "She had regular antenatal care with normal NT, low-risk Down’s screening, and normal OGTT results.", + "Four-dimensional ultrasonography suggested an intrauterine pregnancy with a single alive fetus in the breech position.", + "The fetus showed strong light spots in the left ventricle of the fetal heart.", + "Approximately four weeks before admission to our hospital, she experienced progressively worsening low back pain.", + "A local doctor recommended observation and rest.", + "She experienced abdominal distension, lower limb dyskinesia, and severe ache one day before admission.", + "A pelvic examination in the county hospital revealed a large fungating gray mass encompassing the entire cervix.", + "Cervical contact bleeding tested positive.", + "The patient exhibited a pale face, poor spirit and appetite, and a weight loss of 10 kg since the onset of the disease.", + "She received multiple blood transfusions due to severe anemia.", + "Ultrasound revealed a diffuse echo-change approximately 13.6 cm by 11.5 cm in the liver, which appeared to be a solid-cystic mass.", + "Cervical cancer screening and biopsy were conducted.", + "Immunohistochemical analysis showed positive expression of AE1/AE3, CK8/18, CAM5.2, P16, PAX-8, Syn, CD56, and CgA.", + "The tumor showed a high proliferation index with over 90% of cells staining positively for Ki-67.", + "MRI showed a cervical mass measuring 5.3 × 6.6 × 7.2 cm.", + "Abnormal signals were detected in multiple locations, including the right scapula, clavicle, multiple ribs, thoracic vertebrae, lung, lumbar vertebrae, right femoral lesser trochanter, bilateral iliac crest, right ischium, acetabulum, and surrounding soft tissue.", + "Multiple cystic solid masses were detected in the liver, with the largest measuring approximately 13.5 × 13.7 × 14.8 cm.", + "A multidisciplinary team was convened to discuss the case.", + "The biopsy revealed poorly differentiated cervical carcinoma with high-grade neuroendocrine features.", + "The diagnosis was large cell neuroendocrine carcinoma.", + "The patient was diagnosed with cervical neuroendocrine carcinoma (CNECC) with HPV18(+) and stage IVB.", + "She declined neo-adjuvant chemotherapy and elected to undergo cesarean section delivery at 31 4/7 weeks gestation.", + "The neonate had Apgar scores of 10 and 10 at 1 and 5 min, respectively.", + "The neonate weighed 1700 g and was transferred to the neonatal intensive care unit.", + "The placenta was unremarkable and no tumors were found.", + "Following surgery, the patient received three cycles of carboplatin and etoposide chemotherapy.", + "She received an additional five cycles of paclitaxel, nedaplatin, and bevacizumab chemotherapy.", + "Each chemotherapy course was administered at 3-week intervals.", + "She succumbed to multiple tumor metastases six months post-treatment.", + "The cause of death was cardiopulmonary failure, infection, and cachexia.", + "The infant was discharged in a healthy condition." + ], + "summary": "A 26-year-old female at 30 1/7 weeks of gestation presented with lower back and sacroiliac joint pain, abdominal distension, and lower limb dyskinesia. A pelvic examination revealed a large fungating gray mass that encompassed the entire cervix, with cervical contact bleeding testing positive. Imaging studies showed a significant cervical mass, diffuse liver changes, and metastasis to multiple sites. Biopsy results revealed poorly differentiated cervical carcinoma exhibiting high-grade neuroendocrine features, consistent with a diagnosis of large cell neuroendocrine carcinoma. The patient was diagnosed with stage IVB CNECC with HPV18 (+), and due to the gestational age of the fetus and her deteriorating condition, she underwent cesarean section delivery after receiving fetal lung maturation therapy. Following surgery, eight cycles of neoadjuvant chemotherapy were applied. Unfortunately, she succumbed to multiple tumor metastases six months post-treatment. Despite this tragic outcome, the infant was discharged in a healthy condition.", + "summary_subclaims": [ + "The patient was a 26-year-old female at 30 1/7 weeks of gestation.", + "She presented with lower back and sacroiliac joint pain.", + "She had abdominal distension.", + "She had lower limb dyskinesia.", + "A pelvic examination revealed a large fungating gray mass that encompassed the entire cervix.", + "Cervical contact bleeding tested positive.", + "Imaging studies showed a significant cervical mass.", + "Imaging studies showed diffuse liver changes.", + "Imaging studies showed metastasis to multiple sites.", + "Biopsy results revealed poorly differentiated cervical carcinoma.", + "The biopsy showed high-grade neuroendocrine features.", + "The diagnosis was large cell neuroendocrine carcinoma.", + "The patient was diagnosed with stage IVB CNECC with HPV18 (+).", + "She underwent cesarean section delivery.", + "The cesarean section was after receiving fetal lung maturation therapy.", + "Eight cycles of neoadjuvant chemotherapy were applied.", + "She succumbed to multiple tumor metastases six months post-treatment.", + "The infant was discharged in a healthy condition." + ] + }, + { + "id": "multiclinsum_test_106_en.txt", + "fulltext": "A 46-year-old man presented with chest pain and acute paraplegia with acute type A aortic dissection,3 h prior admission. He had no known relevant medical history. Transthoracic echocardiography revealed normal left ventricular function and mild aortic regurgitation. Motor and sensory grades of both lower extremities were zero and pulses of both femoral arteries were absent. Figure shows preoperative aorta computed tomographic angiography (CTA).\nWe decided to perform surgery as soon as possible. Figure shows the cardiopulmonary bypass (CPB) circuit. Partial CPB was established (blood flow 1000 cc/min) after insertion of two 14-Fr DLP® arterial cannulas (Medtronic Inc., Minneapolis,MN) via both common femoral arteries for antegrade distal perfusion of both lower extremities as well as 24-Fr venous cannula (Edwards Lifescience LLC, Irvine, CA) via the right common femoral vein. The left axillary artery was used for arterial cannulation using the side graft technique with a 10-mm Dacron graft (Atrium Medical Corporation,Hudson, NH) because of dissection of the innominate artery. Total arch replacement was performed by establishing routine CPB with systemic circulatory arrest (rectal temperature 26 °C) and bilateral antegrade selective cerebral perfusion. During systemic circulatory arrest, perfusion of both lower extremities was maintained.\nMaintaining partial CPB for right lower extremity perfusion (blood flow 500 cc/min), left- sided axillo-femoral bypass with an 8 mm Dacron graft (Atrium) was performed. The times for total CPB, aortic cross clamp and systemic circulatory arrest were 320 min, 175 min and 40 min, respectively. In turn, terminating the CPB, femoro-femoral bypass with an 8 mm Dacron graft (Atrium) was performed. At the time of discharge, motor and sensory grades of both lower extremities were 2 and 3, respectively. Figure shows the follow- up aorticCTA.", + "fulltext_subclaims": [ + "A 46-year-old man presented with chest pain and acute paraplegia.", + "The patient had acute type A aortic dissection.", + "The dissection occurred 3 h prior to admission.", + "The patient had no known relevant medical history.", + "Transthoracic echocardiography revealed normal left ventricular function.", + "Transthoracic echocardiography revealed mild aortic regurgitation.", + "Motor grades of both lower extremities were zero.", + "Sensory grades of both lower extremities were zero.", + "Pulses of both femoral arteries were absent.", + "We decided to perform surgery as soon as possible.", + "Partial CPB was established after insertion of two 14-Fr DLP® arterial cannulas via both common femoral arteries.", + "The blood flow during partial CPB was 1000 cc/min.", + "A 24-Fr venous cannula was inserted via the right common femoral vein.", + "The left axillary artery was used for arterial cannulation using the side graft technique.", + "A 10-mm Dacron graft was used for the side graft technique.", + "Total arch replacement was performed.", + "Systemic circulatory arrest was established with a rectal temperature of 26 °C.", + "Bilateral antegrade selective cerebral perfusion was used.", + "Perfusion of both lower extremities was maintained during systemic circulatory arrest.", + "Maintaining partial CPB for right lower extremity perfusion (blood flow 500 cc/min), left-sided axillo-femoral bypass with an 8 mm Dacron graft was performed.", + "The time for total CPB was 320 min.", + "The time for aortic cross clamp was 175 min.", + "The time for systemic circulatory arrest was 40 min.", + "Terminating the CPB, femoro-femoral bypass with an 8 mm Dacron graft was performed.", + "At the time of discharge, motor grades of both lower extremities were 2.", + "At the time of discharge, sensory grades of both lower extremities were 3." + ], + "summary": "A 46-year-old man presented to another institution with acute type A aortic dissection with abdominal aorta occlusion. Motor and sensory grade of both lower extremities were zero. Immediate antegrade distal perfusion of both lower extremities was achieved, and total arch replacement with left axillo-bifemoral bypass was performed. At the time of discharge, motor and sensory grades of both lower extremities were 2 and 3, respectively.", + "summary_subclaims": [ + "The patient is a 46-year-old man.", + "He presented to another institution with acute type A aortic dissection with abdominal aorta occlusion.", + "Motor and sensory grade of both lower extremities were zero.", + "Immediate antegrade distal perfusion of both lower extremities was achieved.", + "Total arch replacement with left axillo-bifemoral bypass was performed.", + "At the time of discharge, motor and sensory grades of both lower extremities were 2 and 3, respectively." + ] + }, + { + "id": "multiclinsum_test_687_en.txt", + "fulltext": "A 66-year-old hospitalized male who complained of dizziness.\nThe patient developed dizziness, nausea, and vomiting 4 d prior. The vomit was non-brown-colored stomach contents, accompanied by confusion, headache, and hearing loss in both ears. One day prior, his dizziness aggravated, and he presented to the hospital.\nThe man was healthy, with no specific diseases.\nBody temperature 38.5 °C, heart rate 66 bpm, and blood pressure 210/110 mmHg. The patient reported blurred consciousness, binaural hearing loss, signs of meningeal irritation displayed by neck rigidity, positive Kernig’s and Lesage’s signs, normal muscular strength and limb muscle tension, and negative pathologic signs.\nOn admission, the patient’s examination results were completely normal, including leukocyte count, hypersensitive C-reactive protein, procalcitonin, electrolytes, liver and kidney function tests and coagulation function tests. On the second day of hospitalization, cerebrospinal fluid examination showed 62.9 × 103 white blood cells (WBCs)/μL, with a protein level of 8036 mg/L, glucose level of 3.8 mmol/L and chloride ion concentration of 139 mmol/L. The cerebrospinal fluid pressure was 270 mm H2O; in routine examination of the cerebrospinal fluid, the appearance was light yellow and slightly muddy; the Pandy test was positive, with 2.4 × 108/L karyocytes, 51% neutrophils, and 69% lymphocytes. Biochemical examination of cerebrospinal fluid revealed a total protein content > 1.07 g/L (normal, approximately 0.15-0.40 g/L), dextrose level of 1.87 mmol/L (normal, approximately 2.5-4.4 mmol/L), chloride level of 114.60 mmol/L (normal, approximately 120-132 mmol/L), body temperature of 38.5 °C, heart rate of 66 bpm, and blood pressure of 210/110 mmHg. The patient reported blurred consciousness and binaural hearing loss. He had signs of meningeal irritation in the form of neck stiffness and positive Kernig’s and Lesage’s signs.\nAfter 5 d, cerebrospinal fluid was extracted by lumbar puncture and subjected to mNGS. The result revealed S. suis (with 1884 detected sequences), and the relative abundance was 93.27%. No pathogens were found by routine methods such as cerebrospinal fluid culture or blood culture.\nWe then performed lumbar puncture every week to extract cerebrospinal fluid and examined inflammatory indices, with cerebrospinal fluid culture and blood culture performed.\nAfter 37 d, the patient’s condition worsened. We repeated mNGS of cerebrospinal fluid, and the results revealed S. suis (the number of detected sequences was 130) and Nocardia asiatica (the number of detected sequences was 31598). The results of the seven cerebrospinal fluid examinations are shown in Table , and the etiological examination of the cerebrospinal fluid is shown in Table .", + "fulltext_subclaims": [ + "The patient was a 66-year-old hospitalized male.", + "The patient complained of dizziness.", + "The patient developed dizziness, nausea, and vomiting 4 d prior.", + "The vomit was non-brown-colored stomach contents.", + "The patient had confusion.", + "The patient had headache.", + "The patient had hearing loss in both ears.", + "One day prior, his dizziness aggravated.", + "The patient presented to the hospital.", + "The patient was healthy, with no specific diseases.", + "Body temperature was 38.5 °C.", + "Heart rate was 66 bpm.", + "Blood pressure was 210/110 mmHg.", + "The patient reported blurred consciousness.", + "The patient had binaural hearing loss.", + "The patient had signs of meningeal irritation displayed by neck rigidity.", + "Kernig’s sign was positive.", + "Lesage’s sign was positive.", + "Muscular strength was normal.", + "Limb muscle tension was normal.", + "Pathologic signs were negative.", + "On admission, the patient’s examination results were completely normal.", + "On the second day of hospitalization, cerebrospinal fluid examination showed 62.9 × 103 white blood cells (WBCs)/μL.", + "Cerebrospinal fluid protein level was 8036 mg/L.", + "Cerebrospinal fluid glucose level was 3.8 mmol/L.", + "Cerebrospinal fluid chloride ion concentration was 139 mmol/L.", + "Cerebrospinal fluid pressure was 270 mm H2O.", + "The cerebrospinal fluid appearance was light yellow and slightly muddy.", + "The Pandy test was positive.", + "Cerebrospinal fluid karyocytes were 2.4 × 108/L.", + "Cerebrospinal fluid neutrophils were 51%.", + "Cerebrospinal fluid lymphocytes were 69%.", + "Cerebrospinal fluid total protein content was > 1.07 g/L.", + "Cerebrospinal fluid dextrose level was 1.87 mmol/L.", + "Cerebrospinal fluid chloride level was 114.60 mmol/L.", + "After 5 d, cerebrospinal fluid was extracted by lumbar puncture and subjected to mNGS.", + "The mNGS result revealed S. suis (with 1884 detected sequences).", + "The relative abundance of S. suis was 93.27%.", + "No pathogens were found by routine methods such as cerebrospinal fluid culture or blood culture.", + "Lumbar puncture was performed every week to extract cerebrospinal fluid.", + "Inflammatory indices were examined.", + "Cerebrospinal fluid culture and blood culture were performed.", + "After 37 d, the patient’s condition worsened.", + "mNGS of cerebrospinal fluid was repeated.", + "The results revealed S. suis (the number of detected sequences was 130).", + "The results revealed Nocardia asiatica (the number of detected sequences was 31598)." + ], + "summary": "A 66-year-old male presented at Liaocheng People's Hospital (Liaocheng, Shandong Province, China) reporting dizziness with nausea and vomiting. Metagenomic next-generation sequencing (mNGS) was performed on cerebrospinal fluid for examination, and the patient was diagnosed with suppurative meningitis caused by S. suis infection. He received anti-infection treatment with penicillin sodium and ceftriaxone. The patient's condition initially improved but then deteriorated. Further mNGS of cerebrospinal fluid revealed both S. suis and Nocardia. Imaging examination revealed a brain abscess. Furthermore, a mixed infection of S. suis and Nocardia was detected in the patient's central nervous system. The patient was treated with antibiotics and sulfamethoxazole. He was discharged after his condition improved.", + "summary_subclaims": [ + "The patient is a 66-year-old male.", + "The patient presented at Liaocheng People's Hospital.", + "The patient reported dizziness with nausea and vomiting.", + "Metagenomic next-generation sequencing was performed on cerebrospinal fluid.", + "The patient was diagnosed with suppurative meningitis caused by S. suis infection.", + "The patient received anti-infection treatment with penicillin sodium and ceftriaxone.", + "The patient's condition initially improved but then deteriorated.", + "Further mNGS of cerebrospinal fluid revealed both S. suis and Nocardia.", + "Imaging examination revealed a brain abscess.", + "A mixed infection of S. suis and Nocardia was detected in the patient's central nervous system.", + "The patient was treated with antibiotics and sulfamethoxazole.", + "The patient was discharged after his condition improved." + ] + }, + { + "id": "multiclinsum_test_1343_en.txt", + "fulltext": "Here, we report the case of a 63-year-old Japanese man with no medical or psychiatric history, except for type-2 diabetes mellitus and essential hypertension. He had no previous history of psychotropic drug use, including antidepressants and antipsychotics. Additionally, he had no developmental abnormalities or neurodevelopmental disorders. He held a steady job from college graduation until retirement age, and his wife described his premorbid personality as dependable, sociable, and patient. He had no family history of psychiatric disorders, migraine, or epilepsy.\nOne year before his first admission to an inpatient psychiatric unit, he started experiencing mild depressive moods and fatigue that did not disrupt his day-to-day functioning. Two months before the first hospital admission, he began complaining about typical AIWS symptoms, including micropsia, altered perception of his body image, and a disturbed sense of the passage of distance and time. All sorts of objects in his environment, such as buildings and cars, looked extremely small to him. He gave up driving because cars looked so small that he lost his sense of speed and distance in relation to the cars around him. Nearby objects also looked very small, with the single exception of pill strips that he had difficulty opening. Moreover, even though he knew it was not possible, he felt as if he could ‘step over’ long distances in a flash, such as the 50 km from his suburban town to the center of Tokyo. Additionally, he felt that days passed extremely quickly, as if in a single moment. He also sometimes felt his body was slightly enlarged or shrunken compared with normal. These AIWS symptoms persisted all day long during the depressive episodes.\nIn addition to the typical AIWS symptoms described above, he also complained of disturbances in high-order cognition. For instance, he said, “I cannot sense how important the news is. For example, when I see news about a serial murder on television, I can understand intellectually how sad it is, but I cannot realize it emotionally”. Similarly, he said, “I cannot appreciate the value of money. Even if there were a ¥10,000 bill in front of me, I wouldn’t care about it because I can’t realize how much value it would have”. Although his bowel movements and urination were normal, he complained of a decreased urge to defecate and urinate.\nThe depressed mood, loss of interest and pleasure, psychomotor retardation, fatigue, and reduced concentration gradually worsened. He was referred to a neurologist. Organic causes were ruled out as follows: his blood-sugar level and blood pressure were well controlled with insulin injections and oral medications; he was a non-drinker, had no history of head trauma, and took no medications associated with adverse reactions that could mimic depression, such as beta-blockers and cimetidine. Neurological examinations and laboratory tests including endocrine evaluations and an HIV test, electroencephalography, and brain magnetic resonance imaging (MRI) detected no abnormalities. He was then referred to a psychiatrist. After confirming that he was not experiencing a manic episode, was not using illicit drugs, and had not experienced any recent stressful life events, he was diagnosed as having a severe depressive episode with AIWS. His condition worsened to the degree that he could not continue working despite taking paroxetine, and he was hospitalized for the first time.\nAt this first admission, he was bed-ridden all day because of severe depressive symptoms. Administration of amitriptyline (75 mg/day) and perphenazine (6 mg/day) induced gradual improvement of depressive and AIWS symptoms. He was discharged on day 47 after he had remitted almost completely from the depressive episode, with the exception of easily becoming fatigued and waking at night. At that time, he was also completely remitted from AIWS. His day-to-day functioning returned to normal, and his work and life continued as they had before the episode began.\nThree years after discharge, he relapsed into another major depressive episode, again simultaneously presenting with AIWS. The symptoms worsened despite the use of amitriptyline (50 mg/day) and aripiprazole (6 mg/day) in the outpatient clinic. The Visual Perception Test for Agnosia detected nothing abnormal. His thoughts became stunted and he became very inactive, lying in bed all day. He continuously refused inpatient treatment because he delusionally believed he was too poor. Upon the strong recommendation from his family, 8 months after this recurrence, he was admitted to the hospital with recurrent severe depressive symptoms and AIWS at the age of 67 years.\nAt this second admission, he was alert and oriented, but had prolonged speech latency and spoke in a slow and quiet manner without making eye contact. His face was unshaven and he did not smile. Dementia was ruled out as a plausible cause of his symptoms for the following reasons: 1) his Mini-Mental State Examination (MMSE) score was 28/30 during this depressive episode, 2) he made a complete recovery from the observed reduction in concentration and processing speed after treatment of the first episode, 3) he exhibited no other signs of recognizable cognitive decline such as impaired executive function, learning, memory, language, or social recognition, and 4) he did not exhibit any typical symptoms of common dementia subtypes, such as amnesia, fluctuating cognition, visual hallucinations, extrapyramidal symptoms, or behavioral symptoms. Evidence of depressive symptoms and AIWS was comparable between the first and second episodes. He scored 30/63 on the Beck Depression Inventory-II (BDI-II), indicating severe depression. An ophthalmologist confirmed no eye/visual abnormalities with the exception of bilateral cataracts. Pre-therapy FDG-PET was performed as described below. After 2 weeks of maprotiline (75 mg/day) had no effect, twice-weekly ECT, duloxetine (60 mg/day) and mirtazapine (45 mg/day) were administered. He remitted completely from AIWS and almost completely from the depressive episode after 12 ECT sessions, except for a mild reduction in concentration. He scored 12/63 on the BDI-II, which also indicated significant recovery from depression. He was discharged after 75 days, just after post-therapeutic FDG-PET was performed.\nWe obtained the pre- and post-treatment FDG-PET images of the brain during the second admission. The patient was kept at rest in supine posture with a blinder in a quiet and dim room from 10 min before each PET examination until the end of the scan. Scans were recorded with a PET scanner (Advance NXi; GE Medical Systems, Milwaukee, WI, USA) 45 min after the injection of 296 MBq FDG.\nUpon visual inspection, the pre-treatment FDG-PET images depicted moderate hypometabolism in the frontal cortex and relative hypermetabolism in the occipital and parietal cortices . These abnormalities improved slightly after treatment .\nStatistical analysis was performed in the following steps: (1) morphological co-registration between pre-and post-treatment FDG-PET; (2) normalization of voxel values to the global mean voxel counts using proportional scaling; (3) subtraction of pre-treatment from post-treatment images to obtain pre-post difference images; (4) mean and standard deviations of voxel values were calculated for the difference images; and (5) identification of area with statistically significant difference, using a cutoff value of z > 2 and extent threshold k > 200. These methods are part of the standard process for subtracting ictal single photon emission computed tomography (SPECT) coregistered to MRI (SISCOM), which is generally used for comparing ictal and interictal SPECT images in epileptic patients . The statistical analysis showed that metabolism decreased after treatment in the posterior half of the cerebral cortex, including the posterior part of the bilateral temporal cortex, the occipital cortex, the inferior part of parietal cortex, precuneus, and posterior cingulate cortex . No area showed statistically significant increases in metabolism after treatment.", + "fulltext_subclaims": [ + "The patient was a 63-year-old Japanese man.", + "He had no medical or psychiatric history except for type-2 diabetes mellitus and essential hypertension.", + "He had no previous history of psychotropic drug use.", + "He had no developmental abnormalities or neurodevelopmental disorders.", + "He held a steady job from college graduation until retirement age.", + "His wife described his premorbid personality as dependable, sociable, and patient.", + "He had no family history of psychiatric disorders, migraine, or epilepsy.", + "One year before his first admission, he started experiencing mild depressive moods and fatigue.", + "Two months before the first hospital admission, he began complaining about typical AIWS symptoms.", + "He gave up driving because cars looked so small that he lost his sense of speed and distance.", + "He felt as if he could 'step over' long distances in a flash.", + "He felt that days passed extremely quickly.", + "He sometimes felt his body was slightly enlarged or shrunken.", + "These AIWS symptoms persisted all day long during the depressive episodes.", + "He also complained of disturbances in high-order cognition.", + "He said, 'I cannot sense how important the news is.'", + "He said, 'I cannot appreciate the value of money.'", + "He complained of a decreased urge to defecate and urinate.", + "The depressed mood, loss of interest and pleasure, psychomotor retardation, fatigue, and reduced concentration gradually worsened.", + "He was referred to a neurologist.", + "Organic causes were ruled out.", + "Neurological examinations and laboratory tests detected no abnormalities.", + "He was then referred to a psychiatrist.", + "He was diagnosed as having a severe depressive episode with AIWS.", + "He was hospitalized for the first time.", + "At this first admission, he was bed-ridden all day because of severe depressive symptoms.", + "Administration of amitriptyline (75 mg/day) and perphenazine (6 mg/day) induced gradual improvement.", + "He was discharged on day 47 after he had remitted almost completely from the depressive episode.", + "He was also completely remitted from AIWS.", + "Three years after discharge, he relapsed into another major depressive episode, again simultaneously presenting with AIWS.", + "The symptoms worsened despite the use of amitriptyline (50 mg/day) and aripiprazole (6 mg/day).", + "He continuously refused inpatient treatment because he delusionally believed he was too poor.", + "He was admitted to the hospital with recurrent severe depressive symptoms and AIWS at the age of 67 years.", + "At this second admission, he was alert and oriented.", + "He had prolonged speech latency and spoke in a slow and quiet manner without making eye contact.", + "Dementia was ruled out as a plausible cause of his symptoms.", + "He scored 30/63 on the Beck Depression Inventory-II (BDI-II), indicating severe depression.", + "An ophthalmologist confirmed no eye/visual abnormalities with the exception of bilateral cataracts.", + "Pre-therapy FDG-PET was performed.", + "After 2 weeks of maprotiline (75 mg/day) had no effect, twice-weekly ECT, duloxetine (60 mg/day), and mirtazapine (45 mg/day) were administered.", + "He remitted completely from AIWS and almost completely from the depressive episode after 12 ECT sessions.", + "He was discharged after 75 days, just after post-therapeutic FDG-PET was performed.", + "We obtained the pre- and post-treatment FDG-PET images of the brain during the second admission.", + "The patient was kept at rest in supine posture with a blinder in a quiet and dim room.", + "Scans were recorded with a PET scanner (Advance NXi; GE Medical Systems, Milwaukee, WI, USA).", + "Scans were recorded 45 min after the injection of 296 MBq FDG.", + "The pre-treatment FDG-PET images depicted moderate hypometabolism in the frontal cortex.", + "The pre-treatment FDG-PET images depicted relative hypermetabolism in the occipital and parietal cortices.", + "These abnormalities improved slightly after treatment.", + "Statistical analysis showed that metabolism decreased after treatment in the posterior half of the cerebral cortex.", + "No area showed statistically significant increases in metabolism after treatment." + ], + "summary": "We describe a 63-year-old Japanese male who developed two distinct episodes of major depression concurrent with AIWS. In addition to typical AIWS perceptual symptoms, he complained of losing the ability to intuitively grasp the seriousness of news and the value of money, which implies disturbance of high-order cognition related to estimating magnitude and worth. Both depression and AIWS remitted after treatment in each episode. Pre-treatment FDG-PET images showed significant hypometabolism in the frontal cortex and hypermetabolism in the occipital and parietal cortex. Post-treatment images showed improvement of these abnormalities.", + "summary_subclaims": [ + "The patient is a 63-year-old Japanese male.", + "The patient developed two distinct episodes of major depression.", + "The episodes of major depression were concurrent with AIWS.", + "The patient complained of losing the ability to intuitively grasp the seriousness of news.", + "The patient complained of losing the ability to intuitively grasp the value of money.", + "This implies disturbance of high-order cognition related to estimating magnitude and worth.", + "Both depression and AIWS remitted after treatment in each episode.", + "Pre-treatment FDG-PET images showed significant hypometabolism in the frontal cortex.", + "Pre-treatment FDG-PET images showed hypermetabolism in the occipital and parietal cortex.", + "Post-treatment images showed improvement of these abnormalities." + ] + }, + { + "id": "multiclinsum_test_2529_en.txt", + "fulltext": "A 13-year-old and 6-month-old girl was brought to our attention because she was hospitalized twice in our hospital . The first complaint was “fever and vomiting for 2 days with abnormal mental behavior for 1 day”. The fever peaked at 39.2℃. 1 day earlier, she suddenly babbled, had disorientation of persons and places, was markedly irritable, and alternated with delirium indifference. Cerebrospinal fluid routine, biochemical, pressure, virus, and culture were negative. Cranial MRI suggested multiple punctate abnormal signal shadows in the white matter of the frontoparietal brain on both sides, considering the possibility of intracranial infectious lesions, diagnosed as “viral encephalitis”. After 10 days of treatment with acyclovir antiviral, dexamethasone anti-inflammatory, supplemented with mannitol dehydration to lower cranial pressure, the above symptoms soon disappeared. However, a review of liver function showed that alanine aminotransferase (ALT436U/L; reference range 5 ~ 40U/L) and aspartate aminotransferase (AST96.7 U/L; reference range 5 ~ 40 U/L) indicators were elevated, suggesting liver function impairment, and liver ultrasound indicated liver enlargement, so acyclovir was discontinued and liver-protective treatment was given, while hepatitis virus was perfected and blood ammonia was sent. However, because the blood ammonia needed to be sent for out-of-hospital testing at that time, which was a cumbersome process, and because the parents believed that the child’s liver function and condition had improved significantly, they temporarily refused. After 1 week of hepatoprotective treatment, liver function and head MRI were normal, so the child was discharged on oral hepatoprotective medication. More than two years later, the child was readmitted with “vomiting for 1 week and headache with poor mental response for 3 days”, after having been treated for 1 week at an external hospital for a proposed diagnosis of “viral encephalitis” with poor results, and was then referred to our hospital. History taken: The patient was G2P1, with no abnormalities recorded during birth. Her parents were healthy and non-consanguineous Chinese, but her mother had an unexplained miscarriage at 28 weeks of gestation in G1. The patient showed appropriate growth and normal psychomotor milestones, but with academic failure. Physical examination: drowsiness, poor mental status, normal development, non-specific cardiopulmonary and abdominal examination, negative neurological examination. The blood ammonia concentration was 287umom/L and hyperammonemia was considered at the moment. The EEG suggested a slow background, but the cerebrospinal fluid examination was not abnormal. In combination with an abdominal CT suggesting a slightly hypodense liver and brain MRI findings: abnormal nodal signal in the white matter of the brain , genetic metabolic disease was considered. Further refinement of the blood genetic metabolic screening showed elevated blood alanine (757.06umol/L; reference range 148.8 ~ 739.74µmol/L) and decreased blood citrulline (4.26umol/L; reference range 5.45 ~ 36.77umol/L). Urine organic acid gas mass spectrometry showed normal whey acids and urea, suggesting impaired urea cycling. Immediately after admission, the child was given a low protein diet, arginine to promote ammonia excretion (100 ~ 200 mg/(kg-d)), coenzyme Q10 (10 ~ 20 mg/(kg-d)) and levocarnitine (30 ~ 200 mg/(kg-d)) to regulate metabolism, lactulose to improve ammonia metabolism, vitamin B complex to promote nerve repair, and intravenous fluids to The child was given intravenous fluids to promote urinary ammonia excretion. After 1 week of treatment, the child’s headache and vomiting resolved significantly and she was discharged with instructions to follow a strict low-protein diet and to recheck her blood ammonia regularly. During hospitalization to clarify the type of urea cycle disorder, further refinement of whole exome sequencing after seeking parental consent identified compound heterozygous mutations in CPS1 (NM_001875), a missense mutation (c.1145 C > T, p. Pro382Leu) and an unreported de novo non-frame shift mutation (c.4080_c.4091delAGGCATCCTGAT, p.Lys1360_I le1364delinsLys), respectively.\nCPS1 is localized on chromosome 2q34 and contains 43 exons spanning over 120 kb and encoding 1500 amino acids . We performed mutation screening using high-throughput sequencing technology, and all detected CPS1 mutations were lineage verified by Sanger sequencing, aligned with the human genome (GRCh37 / hg19) reference sequence provided by the UCSC database, and compared with the currently known human CPS1 sequence (National Center for Biotechnology Information, transcript number NM_001875). The database of mutant loci and single nucleotide polymorphisms (dbSNP) , the Human Gene Mutation Database (HGMD) and the Millennium Genome Database for comparative annotation. Finally, two compound heterozygous mutations were found in CPS1 of this child, the missense mutation c.1145 C > T (p.Pro382Leu) (NM_001875) and the non-frame shift mutation c.4080_c.4091delAGGCATCCTGAT (p.Lys1360_Ile1364delinsLys) (NM_001875), where c.1145 C > T is a reported pathogenic mutation in CPS1D , while the non-shifted mutation c.4080_c.4091delAGGCATCCTGAT is found in OMIM, UCSC, HGMD, dbSNP, 1000 Genome, ExAC and gnomAD publications and public databases are new and not reported. The missense mutation c.1145 C > T results in an amino acid change from the non-polar amino acid proline (P) to the non-polar amino acid leucine (L), and the non-shift mutation c.4080_c.4091delAGGCATCCTGAT would result in an amino acid deletion at positions 1361–1364 (isoleucine-leucine-isoleucine-glycine), resulting in a protein length change. The pathogenicity of these two mutant loci was further analyzed using various prediction tools (SIFT, Polyphen2_HDIV, PROVEAN, MutationTaster, M-CAP, REVEL, GERP, phyloP20way, phastCons20way), Fig. A shows the pathogenicity using Mutation Taster for the pathogenicity prediction. Two variants were classified as “possibly pathogenic” according to the variant classification criteria of the American College of Medical Genetics and Genomics (ACMG 2015), and these variants were verified by Sanger sequencing in a family with a mother carrying the c. 4080_c.4091delAGGCATCCTGAT heterozygous mutation and a father with the c.1145 C > T heterozygous mutation , but without clinical manifestations, were consistent with an autosomal recessive disease pathogenesis pattern. Protein structure maps were generated using Swiss-pdb Viewer 4.10.The CPS1 protein structure of the missense mutation c.1145 C > T is shown in Fig. , and the CPS1 protein structure of the non-frame shift mutation c.4080_c.4091delAGGCATCCTGAT is shown in Fig. , with a theoretical 25% risk of disease in either fetus at the time of parental birth.\nAlthough the child complied with a low protein diet for a short time after discharge and had regular blood ammonia checks, due to poor compliance, he was rushed to our PICU more than 8 months after his second discharge due to vomiting and coma after a large high-protein diet (hot pot), and in combination with the cause of this onset and the underlying disease of CPS1D, the emergency blood ammonia was 301 µmol/L (reference range 11.2 ~ 48.2umol/L). As the child was in a critical condition and in a coma, he was immediately given haemodialysis 7 times (1 time/day), fluid infusion, arginine and sodium benzoate to promote ammonia excretion, levocarnitine to promote metabolism, lactulose to reduce ammonia build-up in the intestine and B vitamins, as well as a ban on oral feeding and low amino acid intravenous nutrition. The child’s consciousness turned clear on the 7th day of treatment, the blood ammonia completely decreased to normal on the 43rd day, and he was discharged from the hospital on the 46th day. No hospital admissions for hyperammonemia at follow-up to date.", + "fulltext_subclaims": [ + "The patient is a 13-year-old and 6-month-old girl.", + "She was hospitalized twice in the hospital.", + "The first complaint was 'fever and vomiting for 2 days with abnormal mental behavior for 1 day'.", + "The fever peaked at 39.2℃.", + "One day earlier, she suddenly babbled.", + "She had disorientation of persons and places.", + "She was markedly irritable.", + "She alternated with delirium indifference.", + "Cerebrospinal fluid routine, biochemical, pressure, virus, and culture were negative.", + "Cranial MRI suggested multiple punctate abnormal signal shadows in the white matter of the frontoparietal brain on both sides.", + "The MRI findings considered the possibility of intracranial infectious lesions.", + "The diagnosis was 'viral encephalitis'.", + "She received 10 days of treatment with acyclovir antiviral, dexamethasone anti-inflammatory, and mannitol dehydration to lower cranial pressure.", + "The above symptoms soon disappeared.", + "Liver function showed elevated alanine aminotransferase (ALT436U/L; reference range 5 ~ 40U/L).", + "Liver function showed elevated aspartate aminotransferase (AST96.7 U/L; reference range 5 ~ 40 U/L).", + "Liver ultrasound indicated liver enlargement.", + "Acyclovir was discontinued.", + "Hepatitis virus testing was perfected.", + "Blood ammonia was sent for testing.", + "The parents temporarily refused blood ammonia testing due to the cumbersome process.", + "After 1 week of hepatoprotective treatment, liver function and head MRI were normal.", + "The child was discharged on oral hepatoprotective medication.", + "More than two years later, the child was readmitted with 'vomiting for 1 week and headache with poor mental response for 3 days'.", + "She had been treated for 1 week at an external hospital for a proposed diagnosis of 'viral encephalitis' with poor results.", + "The patient was G2P1.", + "There were no abnormalities recorded during birth.", + "Her parents were healthy and non-consanguineous Chinese.", + "Her mother had an unexplained miscarriage at 28 weeks of gestation in G1.", + "The patient showed appropriate growth and normal psychomotor milestones.", + "The patient had academic failure.", + "Physical examination showed drowsiness.", + "Physical examination showed poor mental status.", + "Blood ammonia concentration was 287umol/L.", + "Hyperammonemia was considered.", + "EEG suggested a slow background.", + "Cerebrospinal fluid examination was not abnormal.", + "Abdominal CT suggested a slightly hypodense liver.", + "Brain MRI findings suggested abnormal nodal signal in the white matter of the brain.", + "Genetic metabolic disease was considered.", + "Blood genetic metabolic screening showed elevated blood alanine (757.06umol/L; reference range 148.8 ~ 739.74µmol/L).", + "Blood genetic metabolic screening showed decreased blood citrulline (4.26umol/L; reference range 5.45 ~ 36.77umol/L).", + "Urine organic acid gas mass spectrometry showed normal whey acids.", + "Urine organic acid gas mass spectrometry showed normal urea.", + "Impaired urea cycling was suggested.", + "The child was given a low protein diet.", + "The child was given arginine to promote ammonia excretion.", + "The child was given coenzyme Q10 to regulate metabolism.", + "The child was given levocarnitine to regulate metabolism.", + "The child was given lactulose to improve ammonia metabolism.", + "The child was given vitamin B complex to promote nerve repair.", + "The child was given intravenous fluids to promote urinary ammonia excretion.", + "After 1 week of treatment, the child’s headache and vomiting resolved significantly.", + "The child was discharged with instructions to follow a strict low-protein diet.", + "The child was instructed to recheck blood ammonia regularly.", + "Whole exome sequencing identified compound heterozygous mutations in CPS1.", + "The mutations were a missense mutation (c.1145 C > T, p. Pro382Leu) and an unreported de novo non-frame shift mutation (c.4080_c.4091delAGGCATCCTGAT, p.Lys1360_Ile1364delinsLys).", + "CPS1 is localized on chromosome 2q34.", + "CPS1 contains 43 exons.", + "CPS1 spans over 120 kb.", + "CPS1 encodes 1500 amino acids.", + "Mutation screening was performed using high-throughput sequencing technology.", + "Detected CPS1 mutations were lineage verified by Sanger sequencing.", + "The mutations were aligned with the human genome (GRCh37 / hg19) reference sequence.", + "The mutations were compared with the currently known human CPS1 sequence (National Center for Biotechnology Information, transcript number NM_001875).", + "The mutations were compared with the database of mutant loci and single nucleotide polymorphisms (dbSNP).", + "The mutations were compared with the Human Gene Mutation Database (HGMD).", + "The mutations were compared with the Millennium Genome Database.", + "Two compound heterozygous mutations were found in CPS1 of this child.", + "The missense mutation c.1145 C > T is a reported pathogenic mutation in CPS1D.", + "The non-shifted mutation c.4080_c.4091delAGGCATCCTGAT is found in OMIM, UCSC, HGMD, dbSNP, 1000 Genome, ExAC and gnomAD publications and public databases.", + "The non-shifted mutation c.4080_c.4091delAGGCATCCTGAT is new and not reported.", + "The missense mutation c.1145 C > T results in an amino acid change from proline (P) to leucine (L).", + "The non-shift mutation c.4080_c.4091delAGGCATCCTGAT results in an amino acid deletion at positions 1361–1364.", + "The pathogenicity of these two mutant loci was analyzed using various prediction tools.", + "Two variants were classified as 'possibly pathogenic' according to the variant classification criteria of the American College of Medical Genetics and Genomics (ACMG 2015).", + "The variants were verified by Sanger sequencing in a family.", + "The mother carried the c.4080_c.4091delAGGCATCCTGAT heterozygous mutation.", + "The father carried the c.1145 C > T heterozygous mutation.", + "The parents did not have clinical manifestations.", + "The findings were consistent with an autosomal recessive disease pathogenesis pattern.", + "Protein structure maps were generated using Swiss-pdb Viewer 4.10.", + "The CPS1 protein structure of the missense mutation c.1145 C > T is shown in Fig.", + "The CPS1 protein structure of the non-frame shift mutation c.4080_c.4091delAGGCATCCTGAT is shown in Fig.", + "The theoretical risk of disease in either fetus at the time of parental birth was 25%.", + "The child complied with a low protein diet for a short time after discharge.", + "The child had regular blood ammonia checks.", + "The child was rushed to the PICU more than 8 months after the second discharge.", + "The child had vomiting and coma after a large high-protein diet (hot pot).", + "Emergency blood ammonia was 301 µmol/L.", + "The child was in a critical condition and in a coma.", + "The child was given haemodialysis 7 times.", + "The child was given fluid infusion.", + "The child was given arginine and sodium benzoate to promote ammonia excretion.", + "The child was given levocarnitine to promote metabolism.", + "The child was given lactulose to reduce ammonia build-up in the intestine.", + "The child was given B vitamins.", + "Oral feeding was banned.", + "The child received low amino acid intravenous nutrition.", + "The child’s consciousness turned clear on the 7th day of treatment.", + "Blood ammonia completely decreased to normal on the 43rd day.", + "The child was discharged from the hospital on the 46th day.", + "There have been no hospital admissions for hyperammonemia at follow-up to date." + ], + "summary": "We present a rare case of adolescent-onset CPS1D that had been misdiagnosed due to atypical clinical features, and further investigations revealed severe hyperammonemia (287µmol/L; reference range 11.2 ~ 48.2umol/L). MRI of the brain showed diffuse white matter lesions. Blood genetic metabolic screening showed elevated blood alanine (757.06umol/L; reference range 148.8 ~ 739.74umol/L) and decreased blood citrulline (4.26umol/L; reference range 5.45 ~ 36.77umol/L). Urine metabolic screening showed normal whey acids and uracil. Whole-exome sequencing revealed compound heterozygous mutations in the CPS1, a missense mutation (c.1145 C > T) and an unreported de novo non-frame shift mutation (c.4080_c.4091delAGGCATCCTGAT), respectively, which provided a clinical diagnosis.", + "summary_subclaims": [ + "The patient had adolescent-onset CPS1D.", + "The patient had been misdiagnosed due to atypical clinical features.", + "Severe hyperammonemia was found with a level of 287µmol/L.", + "The reference range for ammonia is 11.2 ~ 48.2µmol/L.", + "MRI of the brain showed diffuse white matter lesions.", + "Blood alanine was elevated at 757.06µmol/L.", + "The reference range for blood alanine is 148.8 ~ 739.74µmol/L.", + "Blood citrulline was decreased at 4.26µmol/L.", + "The reference range for blood citrulline is 5.45 ~ 36.77µmol/L.", + "Urine metabolic screening showed normal whey acids.", + "Urine metabolic screening showed normal uracil.", + "Whole-exome sequencing revealed compound heterozygous mutations in the CPS1.", + "A missense mutation (c.1145 C > T) was identified.", + "An unreported de novo non-frame shift mutation (c.4080_c.4091delAGGCATCCTGAT) was identified.", + "The mutations provided a clinical diagnosis." + ] + }, + { + "id": "multiclinsum_test_2_en.txt", + "fulltext": "A 71-year-old man presented to his family physician with upper right leg pain. His symptoms progressed with deterioration in his balance and decreased strength and coordination in his upper limbs. Functionally, the patient remarked being clumsy at home, dropping objects on a regular basis, unable to do buttons and/or zippers, and excluded several activities of daily living due to these limitations. The patient had no previous spinal trauma and an unremarkable family history. His previous surgical history included a bilateral hip replacement, tonsillectomy, and carpal tunnel release. A referral was then made to neurosurgery for further management.\nNeurological examination revealed an unsteady gait with the inability to heel-to-toe walk and a positive Romberg’s sign. He was unable to sit comfortably and exhibited a reduced range of motion of the neck in all planes. Examination of his upper limbs revealed deficits that were particular to his right side. This included atrophy in the first web space, decreased grip strength (4−/5), poor finger function and reduced sensation. Left arm and hand involvement was present but to a lesser degree. Lower limb involvement included decreased sensation in both feet and in the right L3 dermatome. Reflexes were brisk.\nDue to the neurological findings, computed tomography (CT), and nerve conduction study (NCS) were obtained. NCS revealed no abnormal findings while the CT scan showed a mass (28x15x39mm) that compressed the cervical spinal cord at C2.\nMagnetic resonance imaging (MRI) was obtained revealing a congenitally narrow cervical spinal canal and significant compression of the spinal cord at C1 and C2 . Some canal stenosis, in the thoracic and lumbar regions, was present. This was secondary to degenerative changes and ligamentous hypertrophy.\nA diagnosis of cervical myelopathy secondary to a C2 mass was made. Informed consent for surgery was obtained. Surgical management consisted of decompression of the cervical spinal cord with a posterior cervical fusion of C1-C3. Tissue biopsies were obtained and sent to pathology for investigation.\nCT imaging was performed in the early postoperative period which demonstrated no bony or hardware complications. MRI imaging was done 6 months postoperatively which illustrated the decompression of the cervical spinal cord. Follow-up clinical examination at that stage found increased grip strength, mobility, and balance with an overall improvement as compared to pre-operative symptomology. He was referred to physiotherapy to aid with rehabilitation.\nFurther radiological investigations were obtained to verify that the mass was not secondary to systemic amyloidosis. Results were negative, leading to the confirmation of primary solitary amyloidosis treated with uncomplicated cervical spine surgery.\nFurthermore, the patient has been referred to Cardiology and completed a MIBI scan with no evidence of cardiac infiltration. Additional cardiac studies and genetic assessment are planned but have not yet been completed at the time of this report; however, it is suspected the ATTR subtype is non-genetic in nature. The patient is receiving further work-up regarding his lumbar spinal stenosis as it requires treatment.", + "fulltext_subclaims": [ + "The patient is a 71-year-old man.", + "He presented with upper right leg pain.", + "He had deterioration in balance.", + "He had decreased strength and coordination in his upper limbs.", + "He was clumsy at home and dropped objects regularly.", + "He was unable to do buttons and/or zippers.", + "He excluded several activities of daily living due to these limitations.", + "He had no previous spinal trauma.", + "He had an unremarkable family history.", + "His previous surgical history included a bilateral hip replacement.", + "His previous surgical history included a tonsillectomy.", + "His previous surgical history included a carpal tunnel release.", + "A referral was made to neurosurgery for further management.", + "Neurological examination revealed an unsteady gait.", + "He was unable to heel-to-toe walk.", + "Romberg’s sign was positive.", + "He was unable to sit comfortably.", + "He exhibited reduced range of motion of the neck in all planes.", + "Upper limb deficits were particular to his right side.", + "There was atrophy in the first web space.", + "Grip strength was 4−/5.", + "There was poor finger function.", + "There was reduced sensation.", + "Left arm and hand involvement was present but to a lesser degree.", + "Lower limb involvement included decreased sensation in both feet.", + "Decreased sensation was present in the right L3 dermatome.", + "Reflexes were brisk.", + "Computed tomography (CT) and nerve conduction study (NCS) were obtained.", + "NCS revealed no abnormal findings.", + "CT scan showed a mass (28x15x39mm) that compressed the cervical spinal cord at C2.", + "MRI revealed a congenitally narrow cervical spinal canal.", + "MRI showed significant compression of the spinal cord at C1 and C2.", + "Some canal stenosis was present in the thoracic and lumbar regions.", + "The canal stenosis was secondary to degenerative changes and ligamentous hypertrophy.", + "A diagnosis of cervical myelopathy secondary to a C2 mass was made.", + "Informed consent for surgery was obtained.", + "Surgical management consisted of decompression of the cervical spinal cord.", + "Surgical management included a posterior cervical fusion of C1-C3.", + "Tissue biopsies were obtained and sent to pathology.", + "CT imaging in the early postoperative period demonstrated no bony or hardware complications.", + "MRI imaging 6 months postoperatively illustrated decompression of the cervical spinal cord.", + "Follow-up clinical examination found increased grip strength.", + "Follow-up clinical examination found increased mobility.", + "Follow-up clinical examination found increased balance.", + "There was overall improvement compared to pre-operative symptomology.", + "The patient was referred to physiotherapy.", + "Further radiological investigations were obtained to verify that the mass was not secondary to systemic amyloidosis.", + "Results were negative.", + "This led to the confirmation of primary solitary amyloidosis.", + "Primary solitary amyloidosis was treated with uncomplicated cervical spine surgery.", + "The patient was referred to Cardiology.", + "A MIBI scan showed no evidence of cardiac infiltration.", + "Additional cardiac studies and genetic assessment are planned.", + "It is suspected the ATTR subtype is non-genetic in nature.", + "The patient is receiving further work-up regarding his lumbar spinal stenosis.", + "Lumbar spinal stenosis requires treatment." + ], + "summary": "We report a case of a 71-year-old male who presented with worsening strength and coordination of his upper extremities, right upper-leg pain, unsteady gait, and a reduced range of motion of his neck in all planes. Magnetic resonance imaging revealed a solitary mass compressing the spinal cord at C1-C2. Treatment consisted of cervical decompression and stabilization. Pathological examination confirmed solitary amyloid deposition of ATTR. Postoperative neurological assessment revealed improved balance, gait, hand function, and grip strength. Investigational imaging was ordered 8 months postoperatively revealing no evidence of systemic involvement, confirming the diagnosis of cervical ATTR amyloidoma. A discussion is provided surrounding the published literature of ATTR amyloidoma with description of the typical presentation, management, and outcomes of this rare pathology.", + "summary_subclaims": [ + "The patient was a 71-year-old male.", + "He presented with worsening strength and coordination of his upper extremities.", + "He had right upper-leg pain.", + "He had an unsteady gait.", + "He had a reduced range of motion of his neck in all planes.", + "Magnetic resonance imaging revealed a solitary mass compressing the spinal cord at C1-C2.", + "Treatment consisted of cervical decompression and stabilization.", + "Pathological examination confirmed solitary amyloid deposition of ATTR.", + "Postoperative neurological assessment revealed improved balance.", + "Postoperative neurological assessment revealed improved gait.", + "Postoperative neurological assessment revealed improved hand function.", + "Postoperative neurological assessment revealed improved grip strength.", + "Investigational imaging was ordered 8 months postoperatively.", + "The imaging revealed no evidence of systemic involvement.", + "The imaging confirmed the diagnosis of cervical ATTR amyloidoma.", + "A discussion is provided surrounding the published literature of ATTR amyloidoma.", + "The discussion includes a description of the typical presentation.", + "The discussion includes a description of the management.", + "The discussion includes a description of the outcomes of this rare pathology." + ] + }, + { + "id": "multiclinsum_test_2368_en.txt", + "fulltext": "An 18-year-old male presented to a local hospital with sudden chest pain accompanied by headache, palpitations, and shortness of breath for 18 h. He was in good health, had no previous underlying diseases, and no history of cardiopulmonary disease.\nInitially, the patient presented with sudden chest pain, described as persistent, non-radiating, dull pain, followed by palpitations and headache, accompanied by shortness of breath and cough with a small amount of phlegm, which could not be relieved by rest. He consulted at the local hospital for treatment and was admitted to the intensive care unit (ICU). After admission, he developed anuria and mixed acidosis, which were difficult to correct. His vital signs were as follows: heart rate of 138 beats/min, respiratory rate of 32 breaths/min, blood pressure of 105/38 mmHg (after continuous infusion of high-dose norepinephrine and dobutamine), central venous pressure (CVP) of 9 mmHg, and oxygen saturation of 100% (oxygen absorption flow rate at 4 L/min). Bedside color echocardiography showed an aneurysm of the right coronary sinus of the aorta, which ruptured into the right atrium. The width of the base was 24 mm, the height was 15 mm, and the rupture point was 7 mm. A continuous shunt was observed on color Doppler flow imaging (CDFI) . Left ventricular ejection fraction was 63%. Spectral Doppler showed that the aortic valve jet velocity was normal. CDFI showed that there was no abnormal blood flow across the atrial septum. Minimal aortic valve regurgitation, mild tricuspid regurgitation with a regurgitant area of approximately 3.8 cm2 and a maximum velocity of 2.8 m/s, and a pulmonary artery systolic pressure (PASP) of 35 mmHg were observed. The patient was diagnosed with a ruptured sinus of Valsalva aneurysm into the right atrium.\nThe local hospital contacted our hospital for consultation. After discussion, the plan was to transfer the patient immediately to our hospital for emergency ruptured sinus of Valsalva aneurysm repair. Considering that the patient's condition was critical and the hemodynamics were still unstable after administration of a large amount of vasoactive drugs, bedside VA-ECMO was performed immediately using 15-French arterial, 8-French arterial backflow, and 21-French venous cannulae via an open right femoral cutdown, achieving flows of 3 L/min. At this time, the patient's vital signs were as follows: heart rate of 130 beats/min, respiratory rate of 22 breaths/min, blood pressure of 109/47 mmHg, and CVP of 29 mmHg. The ECMO flow and dobutamine dose were adjusted to reduce shunting . After establishment of ECMO, the patient was transferred by ambulance to our hospital for emergency surgery. Transesophageal echocardiography demonstrated a right sinus of Valsalva aneurysm rupture into the right atrium (, ).\nThe patient underwent emergency surgical repair. A median sternotomy was performed, and after systemic heparinization, cardiopulmonary bypass was established with bicaval cannulation. A cardioplegia cannula was inserted into the aortic root, and a left ventricular vent was inserted into the right superior pulmonary vein. The patient was then placed under moderate hypothermia. After an aortic cross-clamping, antegrade and retrograde cross perfusion of histidine-tryptophan-ketoglutarate (HTK) cardioplegia solution were performed. The right atrium was incised, and the aortic valve was exposed through an oblique incision at the aortic root. Exploration showed that the aortic sinus was grossly dilated and penetrated into the right atrium, with a rupture size of approximately 1.2 × 1 cm . The rupture was repaired with a pericardial patch sutured intermittently using 4-0 polypropylene. No leak was detected after the repair. The aortic root and the right atrial incision were then closed using 5-0 polypropylene sutures. Cardiac circulation was then resumed, cardiopulmonary bypass was discontinued when the blood pressure stabilized. Ventilator parameters were as follows: tidal volume of 500 ml, respiratory rate of 14 breaths/min, positive end-expiratory pressure of 5 cm H2O, inspired oxygen concentration of 60%. The following vital signs were observed: blood pressure of 125/65 mmHg, heart rate of 80 beats/min, pulse oxygen saturation of 100%. Blood gas analysis showed the following results: pH of 7.45, PCO2 of 39 mmHg, PO2 of 270 mmHg, glucose of 8 mmol/L, lactic acid of 1.10 mmol/L, HCO3 of 27.1 mmol/L, and hemoglobin (Hgb) of 94 g/L. Urine output was 3 ml/kg body weight/h. The patient's hemodynamic status stabilized, ECMO was discontinued. Then protamine was administered. The patient was hooked to ECMO for 8 h. He returned to the surgical ICU after surgery and to the general ward after 7 days. He was successfully discharged after 40 days . After 2 years of follow-up, the patient's heart structure and function were normal. He had good exercise tolerance and no evidence of heart failure.", + "fulltext_subclaims": [ + "The patient was an 18-year-old male.", + "He presented with sudden chest pain accompanied by headache, palpitations, and shortness of breath for 18 h.", + "He had no previous underlying diseases.", + "He had no history of cardiopulmonary disease.", + "The chest pain was described as persistent, non-radiating, dull pain.", + "The chest pain was followed by palpitations and headache.", + "The chest pain was accompanied by shortness of breath and cough with a small amount of phlegm.", + "The symptoms could not be relieved by rest.", + "He was admitted to the intensive care unit (ICU).", + "After admission, he developed anuria.", + "After admission, he developed mixed acidosis.", + "The mixed acidosis was difficult to correct.", + "His heart rate was 138 beats/min.", + "His respiratory rate was 32 breaths/min.", + "His blood pressure was 105/38 mmHg after continuous infusion of high-dose norepinephrine and dobutamine.", + "His central venous pressure (CVP) was 9 mmHg.", + "His oxygen saturation was 100% with an oxygen absorption flow rate of 4 L/min.", + "Bedside color echocardiography showed an aneurysm of the right coronary sinus of the aorta.", + "The aneurysm ruptured into the right atrium.", + "The width of the base of the aneurysm was 24 mm.", + "The height of the aneurysm was 15 mm.", + "The rupture point was 7 mm.", + "A continuous shunt was observed on color Doppler flow imaging (CDFI).", + "Left ventricular ejection fraction was 63%.", + "Spectral Doppler showed that the aortic valve jet velocity was normal.", + "CDFI showed that there was no abnormal blood flow across the atrial septum.", + "Minimal aortic valve regurgitation was observed.", + "Mild tricuspid regurgitation with a regurgitant area of approximately 3.8 cm2 was observed.", + "The maximum velocity of the tricuspid regurgitation was 2.8 m/s.", + "The pulmonary artery systolic pressure (PASP) was 35 mmHg.", + "The patient was diagnosed with a ruptured sinus of Valsalva aneurysm into the right atrium.", + "The local hospital contacted our hospital for consultation.", + "The plan was to transfer the patient immediately to our hospital for emergency ruptured sinus of Valsalva aneurysm repair.", + "The patient's condition was critical.", + "The patient's hemodynamics were still unstable after administration of a large amount of vasoactive drugs.", + "Bedside VA-ECMO was performed immediately.", + "VA-ECMO was performed using 15-French arterial, 8-French arterial backflow, and 21-French venous cannulae via an open right femoral cutdown.", + "VA-ECMO achieved flows of 3 L/min.", + "The patient's heart rate at the time of VA-ECMO was 130 beats/min.", + "The patient's blood pressure at the time of VA-ECMO was 109/47 mmHg.", + "The patient's CVP at the time of VA-ECMO was 29 mmHg.", + "The ECMO flow and dobutamine dose were adjusted to reduce shunting.", + "After establishment of ECMO, the patient was transferred by ambulance to our hospital for emergency surgery.", + "Transesophageal echocardiography demonstrated a right sinus of Valsalva aneurysm rupture into the right atrium.", + "The patient underwent emergency surgical repair.", + "A median sternotomy was performed.", + "After systemic heparinization, cardiopulmonary bypass was established with bicaval cannulation.", + "A cardioplegia cannula was inserted into the aortic root.", + "A left ventricular vent was inserted into the right superior pulmonary vein.", + "The patient was placed under moderate hypothermia.", + "Antegrade and retrograde cross perfusion of histidine-tryptophan-ketoglutarate (HTK) cardioplegia solution were performed after an aortic cross-clamping.", + "The right atrium was incised.", + "The aortic valve was exposed through an oblique incision at the aortic root.", + "The aortic sinus was grossly dilated and penetrated into the right atrium.", + "The rupture size was approximately 1.2 × 1 cm.", + "The rupture was repaired with a pericardial patch sutured intermittently using 4-0 polypropylene.", + "No leak was detected after the repair.", + "The aortic root and the right atrial incision were closed using 5-0 polypropylene sutures.", + "Cardiac circulation was then resumed.", + "Cardiopulmonary bypass was discontinued when the blood pressure stabilized.", + "Ventilator tidal volume was 500 ml.", + "Ventilator respiratory rate was 14 breaths/min.", + "Ventilator positive end-expiratory pressure was 5 cm H2O.", + "Ventilator inspired oxygen concentration was 60%.", + "Blood pressure after surgery was 125/65 mmHg.", + "Heart rate after surgery was 80 beats/min.", + "Pulse oxygen saturation after surgery was 100%.", + "Blood gas pH after surgery was 7.45.", + "Blood gas PCO2 after surgery was 39 mmHg.", + "Blood gas PO2 after surgery was 270 mmHg.", + "Blood glucose after surgery was 8 mmol/L.", + "Blood lactic acid after surgery was 1.10 mmol/L.", + "Blood HCO3 after surgery was 27.1 mmol/L.", + "Blood hemoglobin (Hgb) after surgery was 94 g/L.", + "Urine output after surgery was 3 ml/kg body weight/h.", + "The patient's hemodynamic status stabilized.", + "ECMO was discontinued.", + "Protamine was administered.", + "The patient was hooked to ECMO for 8 h.", + "The patient returned to the surgical ICU after surgery.", + "The patient returned to the general ward after 7 days.", + "The patient was successfully discharged after 40 days.", + "After 2 years of follow-up, the patient's heart structure and function were normal.", + "The patient had good exercise tolerance.", + "There was no evidence of heart failure." + ], + "summary": "We describe the case of an 18-year-old male who began having acute episodes of chest pain, shortness of breath, palpitations, and dizziness 18 h before presenting to the emergency department. An echocardiogram revealed an acute ruptured sinus of Valsalva aneurysm and a shunt to the right atrium. The patient presented with severe shock. VA-ECMO was administered to ensure safe transport to the cardiac center. The outcome of emergency surgical repair was good. The patient was on ECMO for 8 h. He returned to the general ward after 7 days and was successfully discharged after 40 days. He had good exercise tolerance 2 years after surgery and no evidence of heart failure.", + "summary_subclaims": [ + "The patient was an 18-year-old male.", + "The patient began having acute episodes of chest pain, shortness of breath, palpitations, and dizziness 18 h before presenting to the emergency department.", + "An echocardiogram revealed an acute ruptured sinus of Valsalva aneurysm.", + "An echocardiogram revealed a shunt to the right atrium.", + "The patient presented with severe shock.", + "VA-ECMO was administered to ensure safe transport to the cardiac center.", + "The outcome of emergency surgical repair was good.", + "The patient was on ECMO for 8 h.", + "The patient returned to the general ward after 7 days.", + "The patient was successfully discharged after 40 days.", + "The patient had good exercise tolerance 2 years after surgery.", + "There was no evidence of heart failure." + ] + }, + { + "id": "multiclinsum_test_2340_en.txt", + "fulltext": "A 40-year-old man presented with painful inflammation of the right toenail for 3 years. He had undergone several nail extractions and long-term antibiotic treatment. However, the pincer nail continued to recur after several surgeries. The patient had no relevant family history of genetic disorders and the absence of skin diseases such as nail moss on the right foot. Physical examination revealed a pincer-like deformity of the right great toenail with peri-nail redness and swelling without pus exudation. The rest of the toes did not show pincer deformity. Measurement using a method proposed by Yabe in 2013 to assess the severity of the PN revealed a curvature index of 64.5%. It belonged to type 1 according to the Baran classification . At the same time, the patient was evaluated with a VAS score of 6.\nThe patient underwent the procedure under combined spinal and epidural anesthesia with tourniquet control. First, the ingrown nail plate was turned up and removed with mosquito forceps. When removing the nail, we need to protect the nail root, which has the nail matrix. Proliferation, keratinization, and forward migration of the nail cells determine the growth of the toenail. We then trimmed the edges of the nail bed and separated the nail bed from the lateral nail fold by cutting through the border of both sides of the embedded segment. We suggest the incision be at least 3-mm-long from the nail root. Too long an incision will affect the nutrient supply to the nail bed, while too short an incision will not adequately correct the ingrown nail. Subsequently, the nail bed was dissected from the phalanx with a scalpel at the edge of the incised nail bed along the nail grooves bilaterally. We made the separation to preserve the nail midline at least 5 mm wide to minimize the disruption of blood circulation to the nail bed. Be careful to maintain the integrity of the nail bed. We turned over the nail bed to expose the sub-bed tissue. After that, the DLAD from Lando, Shenzhen was soaked in saline for 5 min, and the surface silicone layer was removed. The remaining multinull matrix complex composed of depsipeptide-activated collagen and chondroitin sulfate was filled with the subnail bed tissue. There needs to be sufficient filling below the nail bed in both inset nail grooves to bring the nail bed closer to the physiological curvature. It is also vital to ensure that the proper width of the nail groove is retained to allow for nail plate growth. Finally, the nail bed was re-covered back onto the toe bone and checked again to see whether the nail bed was level. The shape of the nail bed determines the shape of the new toenail, and if the nail bed is still ingrown, the pincer nail may recur. Next, the nail bed was resutured with its original corresponding lateral nail crease using 4-0 absorbable sutures to form a new nail groove (avoiding dislodgement of the filled multivessel matrix complex). Finally, we covered the surface with oiled gauze and bandaged the surgical incision. The whole operation process is shown in . After the procedure was completed, antibiotics and anti-inflammatory pain management were given to the patient. The schematic diagram of this procedure is shown in .\nThe dressing was replaced every 1–2 days postoperatively, and the patient was told to wear loose shoes postoperatively. The follow-up 1 month after surgery showed complete healing of the surgical wound and well growth of the nail with the DLAD . About 3 mm of nail plate growth could be observed at this time. Then, at the 3-month postoperative follow-up, about 15 mm of nail plate growth was seen. The growth rate of the bilateral area of the nail was lower than that of the middle part of the nail, and the nail plate was abnormally thickened . Probably because of the damage to the nail grooves on both sides of the affected toe after repeated nail extractions. Nine months after the operation, we saw that the nail plate growth improved obviously, the curvature index reached 87.5%, and the VAS score reduced to 1 . So far, the nail plate is fully grown and looks good; the patient has not felt pain and is back to work, feeling satisfied with this operation .", + "fulltext_subclaims": [ + "The patient is a 40-year-old man.", + "He had painful inflammation of the right toenail for 3 years.", + "He had undergone several nail extractions.", + "He had long-term antibiotic treatment.", + "The pincer nail continued to recur after several surgeries.", + "The patient had no relevant family history of genetic disorders.", + "There was absence of skin diseases such as nail moss on the right foot.", + "Physical examination revealed a pincer-like deformity of the right great toenail.", + "Peri-nail redness and swelling were present.", + "There was no pus exudation.", + "The rest of the toes did not show pincer deformity.", + "The curvature index was 64.5% using the method proposed by Yabe in 2013.", + "It belonged to type 1 according to the Baran classification.", + "The patient was evaluated with a VAS score of 6.", + "The procedure was performed under combined spinal and epidural anesthesia.", + "A tourniquet was used for control.", + "The ingrown nail plate was turned up and removed with mosquito forceps.", + "The nail root, which has the nail matrix, needed to be protected.", + "Proliferation, keratinization, and forward migration of the nail cells determine the growth of the toenail.", + "The incision was suggested to be at least 3-mm-long from the nail root.", + "Too long an incision will affect the nutrient supply to the nail bed.", + "Too short an incision will not adequately correct the ingrown nail.", + "The nail bed was dissected from the phalanx with a scalpel at the edge of the incised nail bed along the nail grooves bilaterally.", + "The separation was made to preserve the nail midline at least 5 mm wide.", + "The DLAD from Lando, Shenzhen was soaked in saline for 5 min.", + "The surface silicone layer was removed.", + "The remaining multinull matrix complex composed of depsipeptide-activated collagen and chondroitin sulfate was filled with the subnail bed tissue.", + "There needs to be sufficient filling below the nail bed in both inset nail grooves.", + "It is vital to ensure that the proper width of the nail groove is retained.", + "The nail bed was re-covered back onto the toe bone.", + "The shape of the nail bed determines the shape of the new toenail.", + "If the nail bed is still ingrown, the pincer nail may recur.", + "The nail bed was resutured with its original corresponding lateral nail crease using 4-0 absorbable sutures.", + "The dressing was replaced every 1–2 days postoperatively.", + "The patient was told to wear loose shoes postoperatively.", + "At 1 month postoperative follow-up, the surgical wound was completely healed.", + "The nail was growing well at 1 month postoperatively.", + "About 3 mm of nail plate growth could be observed at 1 month.", + "At 3 months postoperative follow-up, about 15 mm of nail plate growth was seen.", + "The growth rate of the bilateral area of the nail was lower than that of the middle part.", + "The nail plate was abnormally thickened.", + "This was probably because of the damage to the nail grooves after repeated nail extractions.", + "Nine months after the operation, the nail plate growth improved obviously.", + "The curvature index reached 87.5% at 9 months.", + "The VAS score reduced to 1 at 9 months.", + "The nail plate is fully grown and looks good.", + "The patient has not felt pain.", + "The patient is back to work.", + "The patient feels satisfied with this operation." + ], + "summary": "A 40-year-old man suffering from PN was treated with DLAD. After 1 year of follow-up, the patient's great toenail plate of the right foot was completely grown out. His pain was relieved, and the curvature of the toenail was corrected.", + "summary_subclaims": [ + "A 40-year-old man suffering from PN was treated with DLAD.", + "After 1 year of follow-up, the patient's great toenail plate of the right foot was completely grown out.", + "His pain was relieved.", + "The curvature of the toenail was corrected." + ] + }, + { + "id": "multiclinsum_test_2970_en.txt", + "fulltext": "A twenty-year-old Sri Lankan female presented following self-ingestion of 20 ml of amitraz (12.5 W/V) following a family dispute leading to the compulsive act. She was 66 kg in weight and 144 cm in height, resulting in 37.8 mg/ kg of amitraz poisoning. She recalled being alert for about 20 min following ingestion and was found unconscious by her parents. Four hours following ingestion, on admission to the hospital, her Glasgow coma scale (GCS) was 10/15. Pupils were equal and 3 mm in size. Deep tendon reflexes were normal. She had bradycardia with a heart rate of 55 beats per minute, hypotension with a blood pressure of 80/60 mmHg and a respiratory rate of 18 cycles per minute. Gastric lavage was performed along with intravenous fluid boluses. Intravenous dopamine 5 μg/kg/min was given for four hours to maintain blood pressure. Her bradycardia persisted for 36 h and she was drowsy for 48 h. She had nausea but not vomiting and did not open her bowels for 3 days. However the bowel sounds were normal. She did not develop respiratory depression, convulsions or hypothermia and the urine output was normal.\nECG revealed sinus bradycardia with a normal QT duration and the blood sugar was normal throughout. Full blood count, liver function tests, Urine full report, serum creatinine and electrolytes were normal . Arterial blood gases revealed mild respiratory alkalosis with a pH of 7.47, pCO2 of 30 mmHg and a HCO3− of 21.6 mmol/L. There was no hypoxia. She recovered fully within 48 h and was discharged on day 3.", + "fulltext_subclaims": [ + "The patient was a twenty-year-old Sri Lankan female.", + "She self-ingested 20 ml of amitraz (12.5 W/V).", + "The ingestion occurred following a family dispute.", + "She weighed 66 kg and was 144 cm tall.", + "The amitraz poisoning was 37.8 mg/kg.", + "She was found unconscious by her parents.", + "On admission, her Glasgow coma scale was 10/15.", + "Her pupils were equal and 3 mm in size.", + "She had bradycardia with a heart rate of 55 beats per minute.", + "She had hypotension with a blood pressure of 80/60 mmHg.", + "Gastric lavage was performed.", + "Intravenous dopamine 5 μg/kg/min was given for four hours.", + "Her bradycardia persisted for 36 hours.", + "She was drowsy for 48 hours.", + "She had nausea but not vomiting.", + "She did not open her bowels for 3 days.", + "She did not develop respiratory depression.", + "She did not develop convulsions.", + "She did not develop hypothermia.", + "The urine output was normal.", + "ECG revealed sinus bradycardia with a normal QT duration.", + "Arterial blood gases revealed mild respiratory alkalosis.", + "There was no hypoxia.", + "She recovered fully within 48 hours.", + "She was discharged on day 3." + ], + "summary": "A twenty-year-old Sri Lankan female presented following self-ingestion of 20 ml of amitraz resulting in 37.8 mg/ kg of amitraz poisoning. She lost consciousness after 20 min of ingestion, developed bradycardia and hypotension, which needed intravenous fluid resuscitation and dobutamine. Gastric lavage was performed. Her bradycardia persisted for 36 h and she was drowsy for 48 h. She did not develop respiratory depression, convulsions or hypothermia and the urine output was normal. Arterial blood gas revealed mild respiratory alkalosis. She recovered fully within 48 h and was discharged on day 3.", + "summary_subclaims": [ + "The patient was a twenty-year-old Sri Lankan female.", + "She self-ingested 20 ml of amitraz.", + "The ingestion resulted in 37.8 mg/kg of amitraz poisoning.", + "She lost consciousness after 20 min of ingestion.", + "She developed bradycardia.", + "She developed hypotension.", + "She received intravenous fluid resuscitation.", + "She received dobutamine.", + "Gastric lavage was performed.", + "Her bradycardia persisted for 36 h.", + "She was drowsy for 48 h.", + "She did not develop respiratory depression.", + "She did not develop convulsions.", + "She did not develop hypothermia.", + "Her urine output was normal.", + "Arterial blood gas revealed mild respiratory alkalosis.", + "She recovered fully within 48 h.", + "She was discharged on day 3." + ] + }, + { + "id": "multiclinsum_test_712_en.txt", + "fulltext": "A 60-year-old Chinese male has developed slow response, abnormal behavior and sleep disorder for 1 month. At first, after admitted to the hospital in his hometown and given only sodium supplement and support treatment, his symptoms disappeared but quickly reoccurred. After that, his symptoms became more and more serious and he gradually developed seizures and irritability. He demonstrated confusion, memory loss, insomnia and abnormal behavior when transferred to our hospital in April 2020.\nHe had no particular previous medical history except for typhia 40 years ago and recovered with no sequel. Neurological exam revealed poor mental state, slow response and damaged memory, attention, calculation and orientation. Cranial nerves, cerebellar function, motor system, sensory system, deep tendon reflexes and pathological reflexes remained normal.\nSerum sodium was 119 mmol/L (reference range: 135 ~ 153 mmol/mL) and chlorine was 81 mmol/L (reference range: 90 ~ 110 mmol/L) at first admission. Serum procalcitonin was 0.048 ng/mL (reference range: < 0.046 ng/mL), C reaction protein was 8.05 mg/L (reference range: < 5 mg/L). Cerebrospinal fluid (CSF) electrophoresis IgG index was 0.71 (reference range: 0.3 ~ 0.7). Intracranial pressure was 150mmH2O. CSF routine biochemistry for protein content and glucose were normal and infectious test for virus, including herpes simplex virus, tuberculosis, fungal and Cryptococcus were negative. CSF cytology and cytometry were negative for malignant cells. Serum AE antibody spectrum demonstrated positive anti-LGI1 IgG and anti-GABABR1 IgG using cell-based assays, while other AE-related auto-antibody, such as anti-NMDAR, anti-AMPAR1, anti-AMPAR2, anti-CASPR2 were negative . Mini mental state examination score was 15. Electroencephalogram (EEG) indicated moderate diffusion abnormality . Brain enhanced MRI scan was normal. Tests for screening malignancy, including tumor markers and an ultrasound of the liver, gallbladder, spleen, pancreas, kidney, testicle were normal. Chest enhanced CT scan revealed mild inflammation in left lower lobe.\nFor treatment of AE with coexistent anti-LGI1 and anti-GABABR1, he received 1 g and 0.5 g intravenous methylprednisolone separately, 3 days for each dosage, and then remained on an oral steroid taper for half year. After intravenous and oral sodium supplement, blood sodium and chlorine gradually increased to normal . His symptoms improved greatly and EEG recovered to normal.", + "fulltext_subclaims": [ + "The patient is a 60-year-old Chinese male.", + "He developed slow response, abnormal behavior, and sleep disorder for 1 month.", + "At first, after admitted to the hospital in his hometown and given only sodium supplement and support treatment, his symptoms disappeared but quickly reoccurred.", + "After that, his symptoms became more and more serious and he gradually developed seizures and irritability.", + "He demonstrated confusion, memory loss, insomnia, and abnormal behavior when transferred to our hospital in April 2020.", + "He had no particular previous medical history except for typhia 40 years ago.", + "Neurological exam revealed poor mental state, slow response, and damaged memory, attention, calculation, and orientation.", + "Cranial nerves, cerebellar function, motor system, sensory system, deep tendon reflexes, and pathological reflexes remained normal.", + "Serum sodium was 119 mmol/L.", + "Serum chlorine was 81 mmol/L.", + "Serum procalcitonin was 0.048 ng/mL.", + "C reaction protein was 8.05 mg/L.", + "CSF electrophoresis IgG index was 0.71.", + "Intracranial pressure was 150 mmH2O.", + "CSF routine biochemistry for protein content and glucose were normal.", + "Infectious tests for virus, including herpes simplex virus, tuberculosis, fungal, and Cryptococcus were negative.", + "CSF cytology and cytometry were negative for malignant cells.", + "Serum AE antibody spectrum demonstrated positive anti-LGI1 IgG and anti-GABABR1 IgG using cell-based assays.", + "Other AE-related auto-antibodies, such as anti-NMDAR, anti-AMPAR1, anti-AMPAR2, and anti-CASPR2 were negative.", + "Mini mental state examination score was 15.", + "EEG indicated moderate diffusion abnormality.", + "Brain enhanced MRI scan was normal.", + "Tests for screening malignancy, including tumor markers and an ultrasound of the liver, gallbladder, spleen, pancreas, kidney, and testicle were normal.", + "Chest enhanced CT scan revealed mild inflammation in the left lower lobe.", + "He received 1 g and 0.5 g intravenous methylprednisolone separately, 3 days for each dosage.", + "He remained on an oral steroid taper for half a year.", + "After intravenous and oral sodium supplement, blood sodium and chlorine gradually increased to normal.", + "His symptoms improved greatly.", + "EEG recovered to normal." + ], + "summary": "We herein present the case of a 60-year-old man with slow response, behavioral changes, psychosis and sleep disorders. Laboratory test included serum hyponatremia, positive serum LGI1 and GABABR1 antibodies using transfected cell-based assays. Electroencephalogram exhibited moderate diffusion abnormality. The patient responded well to steroid impulse treatment and sodium supplement therapy, and did not recur during the follow-up.", + "summary_subclaims": [ + "The patient is a 60-year-old man.", + "The patient had slow response.", + "The patient had behavioral changes.", + "The patient had psychosis.", + "The patient had sleep disorders.", + "Laboratory tests included serum hyponatremia.", + "Serum LGI1 antibodies were positive.", + "Serum GABABR1 antibodies were positive.", + "Transfected cell-based assays were used.", + "Electroencephalogram exhibited moderate diffusion abnormality.", + "The patient responded well to steroid impulse treatment.", + "The patient received sodium supplement therapy.", + "The patient did not recur during the follow-up." + ] + }, + { + "id": "multiclinsum_test_821_en.txt", + "fulltext": "The patient is a 22-month-old Caucasian boy, born at 36 weeks by spontaneous vaginal delivery with normal prenatal care. He had no family history of glaucoma or anterior segment dysgenesis. At birth, he was noted to have bilateral cloudy corneas with no epiphora nor photophobia. He was started on presumptive treatment of topical dorzolamide 2% and hypertonic sodium chloride ophthalmic solution 5% prior to his presentation at the Bascom Palmer Eye Institute. A bedside eye exam revealed a “corneal opacity centrally sparing the periphery” and he was diagnosed with possible congenital glaucoma associated with Peters anomaly. Extraocular findings included short extremities and brachydactyly, cleft palate, characteristic facial features, developmental delay, and pulmonary stenosis .\nAn exam under anesthesia (EUA) was performed the same day. Intraocular pressures (IOP) were 32 mmHg and 27 mmHg in the right eye (OD) and left eye (OS), respectively (Tono-Pen XL, Reichert Inc. Depew, NY). Bright red reflexes were noted prior to dilation in both eyes (OU). Other ocular abnormalities included iridocorneal adhesion superiorly OS and posterior capsular cataract OU. Given the absence of limbal enlargement, normal axial lengths, and an intact red reflex prior to dilation, glaucoma surgery was deferred. Phenylephrine 2.5% OU was added for optical dilation and visual rehabilitation, and topical dorzolamide 2% was continued.\nFour months later, a second EUA was performed, IOPs were 30 mmHg OD and 35 mmHg OS by Tono-pen. The corneal opacities were noted to have enlarged centrally, though the clear peripheral cornea still maintained intact red reflexes. The irides were noted to have formed whispy attachments to the corneas in both eyes. The view of the lens and posterior structures at this point were suboptimal. A diagnosis of Peters anomaly type 1 was made. Genetic testing subsequently identified a homozygous pathogenic variant in B3GLCT (c. 660 + 1 G > A splice donor; Invitae, Pediatric Genetics Specialty Practice, 60 W Gore St, Orlando, FL 32806, Oct 2017). His axial length measurements and B scan ultrasound estimate of cupping were both stable compared to baseline. Patient was monitored on the same medications without surgical intervention. Genetic screening were offered to patient’s parents but were declined.\nIn the subsequent serial EUA, more adhesions between the iris and cornea OS were noted despite the generally improved corneal opacities OU. Posterior segment improved as the media opacity cleared. Fluorescein angiography (FA) was performed (RetCam3, Ophthalmic Imaging System, Natus Medical), and spectral-domain optical coherence tomography (SD-OCT) images were obtain (Spectralis flex module, Heidelberg Engineering). The optic discs were noted to have morning glory-like appearances suggestive of colobomatous changes, with a cup to disc ratio of approximately 0.7 OU. Diffuse chorioretinal atrophies were noted [Fig. a-b]. The right eye had a well-defined white-yellowish, comet shaped lesion along the superotemporal arcade [Fig. a]. A similar lesion that was well-circumscribed, oval-shaped and atrophic was seen in the central macula of the left eye [Fig. b]. FA demonstrated early hyperfluorescence of the lesion with no leakage in the right eye, and early hyperfluorescence secondary to a window defect corresponding to the macular lesion in the left eye. Late frames of the FA showed hyperfluorescence of the atrophic lesions [Fig. c-d]. There were neither leakage from the optic disc, nor vascular abnormalities in the peripheral retina. Intraoperative SD-OCT of the macula showed severe diffuse thinning of the retina and choroid in the atrophic lesions. Additionally, in the left eye oval shaped atrophic lesion, a complete loss of retinal structure was noted [Fig. ]. Written informed consent to publish the acquired images were obtained from the patient’s guardians.", + "fulltext_subclaims": [ + "The patient is a 22-month-old Caucasian boy.", + "He was born at 36 weeks by spontaneous vaginal delivery.", + "He had normal prenatal care.", + "There was no family history of glaucoma.", + "There was no family history of anterior segment dysgenesis.", + "At birth, he had bilateral cloudy corneas.", + "At birth, he had no epiphora.", + "At birth, he had no photophobia.", + "He was started on topical dorzolamide 2% prior to his presentation at the Bascom Palmer Eye Institute.", + "He was started on hypertonic sodium chloride ophthalmic solution 5% prior to his presentation at the Bascom Palmer Eye Institute.", + "A bedside eye exam revealed a 'corneal opacity centrally sparing the periphery'.", + "He was diagnosed with possible congenital glaucoma associated with Peters anomaly.", + "Extraocular findings included short extremities.", + "Extraocular findings included brachydactyly.", + "Extraocular findings included cleft palate.", + "Extraocular findings included characteristic facial features.", + "Extraocular findings included developmental delay.", + "Extraocular findings included pulmonary stenosis.", + "An exam under anesthesia was performed the same day.", + "Intraocular pressures were 32 mmHg in the right eye.", + "Intraocular pressures were 27 mmHg in the left eye.", + "Bright red reflexes were noted prior to dilation in both eyes.", + "Other ocular abnormalities included iridocorneal adhesion superiorly in the left eye.", + "Other ocular abnormalities included posterior capsular cataract in both eyes.", + "Glaucoma surgery was deferred.", + "Phenylephrine 2.5% was added for optical dilation.", + "Topical dorzolamide 2% was continued.", + "Four months later, a second exam under anesthesia was performed.", + "Intraocular pressures were 30 mmHg in the right eye.", + "Intraocular pressures were 35 mmHg in the left eye.", + "The corneal opacities were noted to have enlarged centrally.", + "The clear peripheral cornea still maintained intact red reflexes.", + "The irides were noted to have formed wispy attachments to the corneas in both eyes.", + "The view of the lens and posterior structures was suboptimal.", + "A diagnosis of Peters anomaly type 1 was made.", + "Genetic testing identified a homozygous pathogenic variant in B3GLCT.", + "The variant was c. 660 + 1 G > A splice donor.", + "The axial length measurements were stable compared to baseline.", + "The B scan ultrasound estimate of cupping was stable compared to baseline.", + "The patient was monitored on the same medications without surgical intervention.", + "Genetic screening was offered to the patient’s parents.", + "Genetic screening was declined.", + "In subsequent exams, more adhesions between the iris and cornea in the left eye were noted.", + "The corneal opacities generally improved in both eyes.", + "The posterior segment improved as the media opacity cleared.", + "Fluorescein angiography was performed.", + "Spectral-domain optical coherence tomography images were obtained.", + "The optic discs had morning glory-like appearances.", + "The optic discs were suggestive of colobomatous changes.", + "The cup to disc ratio was approximately 0.7 in both eyes.", + "Diffuse chorioretinal atrophies were noted.", + "The right eye had a well-defined white-yellowish, comet shaped lesion along the superotemporal arcade.", + "A similar lesion was seen in the central macula of the left eye.", + "The lesion in the left eye was well-circumscribed, oval-shaped, and atrophic.", + "Fluorescein angiography demonstrated early hyperfluorescence of the lesion in the right eye.", + "Fluorescein angiography showed no leakage in the right eye.", + "Fluorescein angiography showed early hyperfluorescence secondary to a window defect in the left eye.", + "Late frames of the fluorescein angiography showed hyperfluorescence of the atrophic lesions.", + "There was no leakage from the optic disc.", + "There were no vascular abnormalities in the peripheral retina.", + "Intraoperative spectral-domain optical coherence tomography showed severe diffuse thinning of the retina and choroid in the atrophic lesions.", + "In the left eye, a complete loss of retinal structure was noted.", + "Written informed consent to publish the acquired images was obtained from the patient’s guardians." + ], + "summary": "In this presentation, we report a case of PPS with homozygous pathogenic variant in B3GLCT who presented with classic anterior segment findings, systemic abnormalities, as well as atypical bilateral chorioretinal atrophy. The chorioretinal findings were characterized with spectral-domain optical coherence tomography.", + "summary_subclaims": [ + "This presentation reports a case of PPS with homozygous pathogenic variant in B3GLCT.", + "The patient presented with classic anterior segment findings.", + "The patient had systemic abnormalities.", + "The patient had atypical bilateral chorioretinal atrophy.", + "The chorioretinal findings were characterized with spectral-domain optical coherence tomography." + ] + }, + { + "id": "multiclinsum_test_1686_en.txt", + "fulltext": "A healthy, nonimmunocompromised 43-year-old female with bilateral lower extremity radiculopathy had a fluoroscopically guided percutaneous ozone treatment for degenerative lumbar disc disease . Three months later, she presented with severe back pain (VAS 9/10), bilateral lower extremity radiculopathy (leg VAS-7/10), and a partial right-sided foot drop. The C-reactive protein (CRP 27 mg/dl) and erythrocyte sedimentation rate (ESR 58 mm/h) rates were both elevated, the leukocyte count was at 7.03 thous/ul with 2100 lymphocytes; and she was also anemic (hemoglobin 11.7g/dl).\nThe repeat MR of the lumbar spine demonstrated L4–L5 spondylodiscitis with paradiscal erosion consistent with a tubercular type of infection [ and ]. The patient underwent a L4–L5 transforaminal lumbar interbody fusion , with soft-tissue debridement; the purulent/ infected epidural tissues were sent for bacterial, fungal, and tubercular cultures. The rapid AFB cultures showed MA.\nThe patient was discharged on intravenous cefoperazone- sulbactam 1.5 g twice daily. She, however, returned after 6 weeks with a fluid collection in the wound, and the CRP and ESR studies remained elevated. The wound was debrided and then she was discharged on intravenous amikacin 500 mg (intravenously) twice daily for 6 weeks, supplemented with oral clarithromycin 500 mg twice daily. Subsequently, she was continued on oral clarithromycin for another 6 weeks following resolution of the primary infection.", + "fulltext_subclaims": [ + "The patient is a 43-year-old female.", + "She had bilateral lower extremity radiculopathy.", + "She had a fluoroscopically guided percutaneous ozone treatment for degenerative lumbar disc disease.", + "Three months later, she presented with severe back pain (VAS 9/10).", + "She had bilateral lower extremity radiculopathy (leg VAS-7/10).", + "She had a partial right-sided foot drop.", + "The C-reactive protein (CRP) was 27 mg/dl.", + "The erythrocyte sedimentation rate (ESR) was 58 mm/h.", + "The leukocyte count was 7.03 thous/ul.", + "The lymphocyte count was 2100.", + "The hemoglobin was 11.7 g/dl.", + "The repeat MR of the lumbar spine demonstrated L4–L5 spondylodiscitis.", + "The MR showed paradiscal erosion consistent with a tubercular type of infection.", + "The patient underwent a L4–L5 transforaminal lumbar interbody fusion.", + "Soft-tissue debridement was performed.", + "The purulent/infected epidural tissues were sent for bacterial, fungal, and tubercular cultures.", + "The rapid AFB cultures showed MA.", + "The patient was discharged on intravenous cefoperazone-sulbactam 1.5 g twice daily.", + "She returned after 6 weeks with a fluid collection in the wound.", + "The CRP and ESR studies remained elevated.", + "The wound was debrided.", + "She was discharged on intravenous amikacin 500 mg twice daily for 6 weeks.", + "She was supplemented with oral clarithromycin 500 mg twice daily.", + "She was continued on oral clarithromycin for another 6 weeks following resolution of the primary infection." + ], + "summary": "A healthy, nonimmunocompromised 43-year-old female presented with bilateral lower extremity radiculopathy. She underwent a fluoroscopically guided percutaneous ozone treatment for degenerated disc disease at the L4-L5 level. She was symptom free for 3 months duration. She then presented with severe low back pain, bilateral lower extremity radiculopathy, and spondylodiscitis at the L4-L5 level. This was treated with a L4-L5 transforaminal lumbar interbody fusion. MA was cultured from the epidural purulent material collected during the surgery. The patient was discharged on oral clarithromycin 500 mg twice daily and intravenous amikacin 500 mg twice daily for 6 weeks. The plan was to then continue oral clarithromycin for another 6 weeks till resolution of primary infection.", + "summary_subclaims": [ + "The patient is a 43-year-old female.", + "The patient is nonimmunocompromised.", + "The patient had bilateral lower extremity radiculopathy.", + "The patient underwent a fluoroscopically guided percutaneous ozone treatment.", + "The treatment was for degenerated disc disease at the L4-L5 level.", + "The patient was symptom free for 3 months.", + "The patient then presented with severe low back pain.", + "The patient had bilateral lower extremity radiculopathy.", + "The patient had spondylodiscitis at the L4-L5 level.", + "The patient was treated with a L4-L5 transforaminal lumbar interbody fusion.", + "Mycobacterium avium was cultured from the epidural purulent material.", + "The patient was discharged on oral clarithromycin 500 mg twice daily.", + "The patient was discharged on intravenous amikacin 500 mg twice daily.", + "The duration of treatment was 6 weeks.", + "The plan was to continue oral clarithromycin for another 6 weeks.", + "The plan was to continue treatment till resolution of primary infection." + ] + }, + { + "id": "multiclinsum_test_11_en.txt", + "fulltext": "A 40-year-old white American woman presented to primary care with a chief concern of nontraumatic umbilical bleeding that began 2 days prior; she woke up and noticed her shirt soaked in blood from her umbilicus. Upon applying pressure with a rag, she was able to stop the bleeding. The patient continued to experience intermittent umbilical bleeding associated with nonradiating periumbilical pain that was exacerbated by movement and associated with nausea and emesis. She had been seen for non-painful umbilical bleeding 5 years prior when she had been occasionally cleaning her umbilicus in the shower with a cotton swab and peroxide; this would sometimes leave small spots of blood on the cotton swab. At that time, no imaging was performed; she was prescribed bacitracin and told to apply Vaseline for what was presumed to be superficial irritation. She had no interim symptoms and discontinued cleaning her umbilicus with a cotton swab.\nPast medical history included hypertension, gastroesophageal reflux disease, class III obesity with BMI 45, major depression, and generalized anxiety. Patient is a G1P1001. Surgical history was notable only for elective caesarean section 12 years prior without complications. The patient was divorced and worked in retail. She did not smoke, use illicit drugs, or drink alcohol. Family history included diabetes, Crohn’s disease, diverticulitis, and breast, lung, and prostate cancer. The patient was taking multiple long-term prescription medications, including losartan 50 mg tablet by mouth daily, propranolol 60 mg tablet by mouth twice daily, escitalopram 20 mg tablet by mouth daily, bupropion 450 mg tablet by mouth daily, gabapentin 300 mg capsule by mouth three times daily, norethindrone-ethinyl estradiol 1 mg–35 µg tablet by mouth daily, trazodone 100 mg tablet by mouth daily, and diclofenac 1% gel topically four times daily as needed.\nOn the day of presentation, the patient’s blood pressure was 125/81 mmHg with a pulse of 65 beats per minute. She was afebrile. Inspection revealed a non-distended abdomen and completely normal skin without erythema, fissuring, or visible discharge, though there was some dried blood. There was mild periumbilical tenderness with deep palpation. Deep palpation around the umbilicus produced a thin, watery, serosanguinous fluid directly from the umbilicus. The remainder of the physical examination including cardiac, pulmonary, and neurologic examinations, which were normal.\nThe patient was referred for CT of the abdomen/pelvis the same day, which revealed a small fat-containing umbilical hernia with a likely small area of fat necrosis just superior to the umbilical hernia . Laboratory workup was notable for a mildly elevated high-sensitivity CRP at 13.8. The remainder of labs, including complete blood count (CBC) with differential, electrolytes, renal function, and liver function were within normal limits. No coagulation parameters were checked. Four weeks later, the patient underwent outpatient open umbilical hernia repair without mesh and umbilectomy with open wound packing. Dissection was performed down to the level of the fascia, and a 4.2-by-3.5-by-2.6 cm specimen consisting of the hernia sac and urachal remnants was excised and sent for pathologic interpretation. No cultures were sent since there was low suspicion for infection. She had complete resolution of symptoms and bleeding on follow-up 30 days postoperation. She did not receive any antibiotics or other prescription medications for this condition. Surgical pathology interpretation revealed ulcerated skin with abscess, umbilical remnant, granulation tissue, and foreign body suture material. At 1-month and 2-month wound check visits, the patient denied any pain, nausea, or vomiting. At next follow-up 6 months postoperation, the patient continued to do well without recurrence of her symptoms. A timeline of the patient’s history and care is presented in Fig. .", + "fulltext_subclaims": [ + "A 40-year-old white American woman presented to primary care with a chief concern of nontraumatic umbilical bleeding that began 2 days prior.", + "She woke up and noticed her shirt soaked in blood from her umbilicus.", + "Upon applying pressure with a rag, she was able to stop the bleeding.", + "The patient continued to experience intermittent umbilical bleeding.", + "The bleeding was associated with nonradiating periumbilical pain.", + "The pain was exacerbated by movement.", + "The pain was associated with nausea and emesis.", + "She had been seen for non-painful umbilical bleeding 5 years prior.", + "At that time, no imaging was performed.", + "She was prescribed bacitracin and told to apply Vaseline.", + "The patient had no interim symptoms.", + "She discontinued cleaning her umbilicus with a cotton swab.", + "Past medical history included hypertension.", + "Past medical history included gastroesophageal reflux disease.", + "Past medical history included class III obesity with BMI 45.", + "Past medical history included major depression.", + "Past medical history included generalized anxiety.", + "The patient was a G1P1001.", + "Surgical history was notable only for elective caesarean section 12 years prior without complications.", + "The patient did not smoke, use illicit drugs, or drink alcohol.", + "Family history included diabetes.", + "Family history included Crohn’s disease.", + "Family history included diverticulitis.", + "Family history included breast, lung, and prostate cancer.", + "The patient was taking losartan 50 mg tablet by mouth daily.", + "The patient was taking propranolol 60 mg tablet by mouth twice daily.", + "The patient was taking escitalopram 20 mg tablet by mouth daily.", + "The patient was taking bupropion 450 mg tablet by mouth daily.", + "The patient was taking gabapentin 300 mg capsule by mouth three times daily.", + "The patient was taking norethindrone-ethinyl estradiol 1 mg–35 µg tablet by mouth daily.", + "The patient was taking trazodone 100 mg tablet by mouth daily.", + "The patient was taking diclofenac 1% gel topically four times daily as needed.", + "On the day of presentation, the patient’s blood pressure was 125/81 mmHg.", + "On the day of presentation, the patient’s pulse was 65 beats per minute.", + "The patient was afebrile.", + "Inspection revealed a non-distended abdomen.", + "There was some dried blood.", + "There was mild periumbilical tenderness with deep palpation.", + "Deep palpation around the umbilicus produced a thin, watery, serosanguinous fluid directly from the umbilicus.", + "The remainder of the physical examination, including cardiac, pulmonary, and neurologic examinations, was normal.", + "The patient was referred for CT of the abdomen/pelvis the same day.", + "The CT revealed a small fat-containing umbilical hernia.", + "The CT revealed a likely small area of fat necrosis just superior to the umbilical hernia.", + "Laboratory workup was notable for a mildly elevated high-sensitivity CRP at 13.8.", + "The remainder of labs, including complete blood count (CBC) with differential, electrolytes, renal function, and liver function were within normal limits.", + "No coagulation parameters were checked.", + "Four weeks later, the patient underwent outpatient open umbilical hernia repair without mesh and umbilectomy with open wound packing.", + "Dissection was performed down to the level of the fascia.", + "A 4.2-by-3.5-by-2.6 cm specimen consisting of the hernia sac and urachal remnants was excised.", + "The specimen was sent for pathologic interpretation.", + "No cultures were sent since there was low suspicion for infection.", + "She had complete resolution of symptoms and bleeding on follow-up 30 days postoperation.", + "She did not receive any antibiotics or other prescription medications for this condition.", + "Surgical pathology interpretation revealed ulcerated skin with abscess.", + "Surgical pathology interpretation revealed umbilical remnant.", + "Surgical pathology interpretation revealed granulation tissue.", + "Surgical pathology interpretation revealed foreign body suture material.", + "At 1-month and 2-month wound check visits, the patient denied any pain, nausea, or vomiting.", + "At next follow-up 6 months postoperation, the patient continued to do well without recurrence of her symptoms." + ], + "summary": "A 40-year-old white American woman came to the clinic with a 2-day history of spontaneous umbilical bleeding. She reported periumbilical pain associated with nausea and emesis. There were no visible skin abnormalities, but deep palpation of the abdomen produced a thin, watery, serosanguineous fluid from the umbilicus. She experienced a similar episode of umbilical bleeding 5 years prior without clear cause. Laboratory workup was notable for mildly elevated C-reactive protein . Computed tomography imaging revealed a fat-containing umbilical hernia with fat necrosis, necessitating complete surgical resection of the umbilicus.", + "summary_subclaims": [ + "The patient is a 40-year-old white American woman.", + "She had a 2-day history of spontaneous umbilical bleeding.", + "She reported periumbilical pain associated with nausea and emesis.", + "There were no visible skin abnormalities.", + "Deep palpation of the abdomen produced a thin, watery, serosanguineous fluid from the umbilicus.", + "She experienced a similar episode of umbilical bleeding 5 years prior.", + "Laboratory workup was notable for mildly elevated C-reactive protein.", + "Computed tomography imaging revealed a fat-containing umbilical hernia with fat necrosis.", + "The umbilical hernia necessitated complete surgical resection of the umbilicus." + ] + }, + { + "id": "multiclinsum_test_2914_en.txt", + "fulltext": "A 71-year-old male with past medical history significant for diabetes mellitus,\ncoronary artery disease, chronic hypotension, hyperglycemia, chronic obstructive\npulmonary disease, nicotine use, obstructive sleep apnea, and peripheral artery\ndisease presented to the ED with right buttock and scrotal swelling for three days,\nassociated with generalized weakness, shortness of breath, and urinary retention\nwith dysuria. One day prior to presentation, the patient noticed non-traumatic\nbruising to his scrotum. He additionally reported increasing buttock pain that was\nnot controlled by home oxycodone/acetaminophen 5/325 milligram (mg) tablets.\nUpon arrival, his vital signs were notable for an oral temperature of 38.2°\nCelsius, blood pressure of 119/54 millimeters of mercury (mm Hg), and heart rate of\n93 beats per minute. He was also tachypneic with a respiratory rate of 25 breaths\nper minute; oxygen saturation was 97% on room air. The physical examination\nwas notable for an ill-appearing gentleman. He was awake and alert. Heart sounds\nwere unremarkable aside from tachycardia, and lungs were clear to auscultation.\nAbdominal examination was soft, protuberant, and nontender. A focused genitourinary\nexamination revealed an edematous, erythematous and exquisitely tender scrotum. Of\nnote, there was a coin-sized, ecchymotic-appearing lesion on the scrotum with\nerythema and induration extending from the scrotum and perineum to the right\nbuttock. No crepitus or fluctuance was palpated on examination.\nLaboratory results were remarkable for leukocytosis to 15,000 thousand per\nmillimeters cubed (K/mm3) (reference range: 4–10 K/mm3), lactic\nacidosis of 3.4 millimoles per liter (mmol/L) (0.4–2.0 mmol/L), marked acute\nkidney injury with creatinine of 5 mg per deciliter (mg/dL) (0.55–1.3mg/dL),\nand venous blood gas pH of 7.22 (7.310–7.410) secondary to the lactic\nacidosis and severe sepsis. The patient was mildly hyponatremic at 133 mmol/L\n(136–145 mmol/L) and hyperkalemic at 5.3 mmol/L (3.5–5.1 mmol/L),\nwith the remainder of electrolytes within reference range. Intravenous antibiotics\nwere initiated and emergent consultations with surgery and urology promptly\nobtained. Despite initial fluid resuscitation with administration of 30 milliliters\nper kilogram (ml/kg) of normal saline, the patient decompensated into septic shock.\nHis blood pressure decreased to 88/41 mm Hg during the ED course; thus, he was not\nstable for transport or advanced imaging. By this time, the ecchymotic-appearing\nlesion and edema had expanded across his scrotum and perineum.\nWe used POCUS for the rapid assessment of the patient’s presumed clinical\ndiagnosis of Fournier’s gangrene, a specific type of necrotizing fasciitis\ninvolving the perineum. Transverse and sagittal views of the perineum and scrotum\nwere obtained using a high-frequency linear probe and revealed diffuse hyperechoic\nfoci with posterior “dirty” shadowing, representative of\nsubcutaneous air, and small fluid collections tracking along the fascial planes\n.\nAfter confirming the diagnosis using POCUS imaging, the patient was taken directly\nfrom the ED to the operating room for immediate surgical debridement within three\nhours of his arrival at the hospital. An area of tissue measuring 25 centimeters\n(cm) × 30 cm that included both fascia and muscle was debrided from the\nscrotum, perineum, and right buttock. Dark, necrotic tissue and foul-smelling fluid\nwere noted during surgery, consistent with Fournier’s gangrene. The patient\nwas admitted to the intensive care unit until being transferred to a tertiary care\ncenter where he ultimately died of complications related to his illness.", + "fulltext_subclaims": [ + "The patient is a 71-year-old male.", + "The patient has a past medical history significant for diabetes mellitus.", + "The patient has a past medical history significant for coronary artery disease.", + "The patient has a past medical history significant for chronic hypotension.", + "The patient has a past medical history significant for chronic obstructive pulmonary disease.", + "The patient has a past medical history significant for obstructive sleep apnea.", + "The patient has a past medical history significant for peripheral artery disease.", + "The patient presented to the ED with right buttock and scrotal swelling for three days.", + "The patient reported generalized weakness.", + "The patient reported shortness of breath.", + "The patient reported urinary retention with dysuria.", + "The patient noticed non-traumatic bruising to his scrotum one day prior to presentation.", + "The patient reported increasing buttock pain not controlled by home oxycodone/acetaminophen 5/325 mg tablets.", + "Upon arrival, the patient's oral temperature was 38.2°C.", + "The patient's blood pressure was 119/54 mm Hg.", + "The patient's heart rate was 93 beats per minute.", + "The patient's respiratory rate was 25 breaths per minute.", + "The patient's oxygen saturation was 97% on room air.", + "The physical examination was notable for an ill-appearing gentleman.", + "The patient was awake and alert.", + "Heart sounds were unremarkable aside from tachycardia.", + "Lungs were clear to auscultation.", + "The abdominal examination was soft, protuberant, and nontender.", + "A focused genitourinary examination revealed an edematous, erythematous, and exquisitely tender scrotum.", + "There was a coin-sized, ecchymotic-appearing lesion on the scrotum.", + "Erythema and induration extended from the scrotum and perineum to the right buttock.", + "No crepitus or fluctuance was palpated on examination.", + "Laboratory results were remarkable for leukocytosis to 15,000 K/mm3.", + "The patient had lactic acidosis of 3.4 mmol/L.", + "The patient had marked acute kidney injury with creatinine of 5 mg/dL.", + "The patient had a venous blood gas pH of 7.22.", + "The patient was mildly hyponatremic at 133 mmol/L.", + "The patient was hyperkalemic at 5.3 mmol/L.", + "Intravenous antibiotics were initiated.", + "Emergent consultations with surgery and urology were obtained.", + "The patient decompensated into septic shock.", + "The patient's blood pressure decreased to 88/41 mm Hg during the ED course.", + "The patient was not stable for transport or advanced imaging.", + "The ecchymotic-appearing lesion and edema had expanded across his scrotum and perineum.", + "POCUS was used for the rapid assessment of the patient’s presumed clinical diagnosis of Fournier’s gangrene.", + "Transverse and sagittal views of the perineum and scrotum were obtained using a high-frequency linear probe.", + "The POCUS imaging revealed diffuse hyperechoic foci with posterior 'dirty' shadowing, representative of subcutaneous air.", + "The POCUS imaging revealed small fluid collections tracking along the fascial planes.", + "The patient was taken directly from the ED to the operating room for immediate surgical debridement.", + "An area of tissue measuring 25 cm × 30 cm was debrided from the scrotum, perineum, and right buttock.", + "Dark, necrotic tissue and foul-smelling fluid were noted during surgery, consistent with Fournier’s gangrene.", + "The patient was admitted to the intensive care unit.", + "The patient was transferred to a tertiary care center.", + "The patient ultimately died of complications related to his illness." + ], + "summary": "We present a case in which POCUS was used to rapidly confirm diagnosis in an unstable, severely septic patient presenting to the emergency department with Fournier's gangrene.", + "summary_subclaims": [ + "POCUS was used to rapidly confirm diagnosis.", + "The patient was unstable.", + "The patient had severe sepsis.", + "The patient presented to the emergency department.", + "The patient had Fournier's gangrene." + ] + }, + { + "id": "multiclinsum_test_1852_en.txt", + "fulltext": "A 42-year-old female presented with 3-month history of mild chest tightness. Her medical history was unremarkable. Physical examination found that her left arm muscles were thicker than the contralateral ones . Breath sounds on auscultation were diminished at the upper left lung. Plain X-ray of the chest revealed a mass in the superior mediastinum . Computed tomography (CT) of the chest showed a mass, measuring 10 cm × 5.5 cm in size with fat densities in the middle superior mediastinum . On the post contrast images the tumor was slightly heterogeneously enhanced and the adjacent blood vessel was surrounded by the lesion with obscure boundary . Laboratory tests were negative.\nThis large infiltrating mass was considered a tumor of liposarcoma. Taking into account the provisions of China’s health insurance and the practice of local surgeons, a biopsy during operation should be done to determine the pathological type. The patient was scheduled for a thoracotomy. During the operation, a large mass, invaded the left subclavian artery and brachiocephalic vein, was found in the anterior mediastinum. Since it was very difficult to dissect the mass completely from the mediastinal structures, especially the left subclavian artery, an incomplete resection was performed. Macroscopically, it was revealed a hard mass of 10 cm × 6 cm × 6 cm in size with a gray-yellowish in color and a sense of oily . Pathologic evaluation demonstrated mature adipose tissue with many hyperplastic blood vessels, being consistent with the typical findings of angiolipoma . The patient recovered very well and was discharged 7 days after the surgery. Considering the incomplete resection, we recommened that the patient undergo a strategic radiation therapy after 1 month of the surgery. After 7 months of follow-up the patient was clinically well and asymptomatic.", + "fulltext_subclaims": [ + "The patient was a 42-year-old female.", + "She had a 3-month history of mild chest tightness.", + "Her medical history was unremarkable.", + "Physical examination found that her left arm muscles were thicker than the contralateral ones.", + "Breath sounds on auscultation were diminished at the upper left lung.", + "Plain X-ray of the chest revealed a mass in the superior mediastinum.", + "Computed tomography (CT) of the chest showed a mass measuring 10 cm × 5.5 cm with fat densities in the middle superior mediastinum.", + "On post contrast images, the tumor was slightly heterogeneously enhanced.", + "The adjacent blood vessel was surrounded by the lesion with obscure boundary.", + "Laboratory tests were negative.", + "The large infiltrating mass was considered a tumor of liposarcoma.", + "A biopsy during operation should be done to determine the pathological type.", + "The patient was scheduled for a thoracotomy.", + "During the operation, a large mass invading the left subclavian artery and brachiocephalic vein was found in the anterior mediastinum.", + "It was very difficult to dissect the mass completely from the mediastinal structures.", + "An incomplete resection was performed.", + "Macroscopically, it was revealed a hard mass of 10 cm × 6 cm × 6 cm in size with a gray-yellowish in color and a sense of oily.", + "Pathologic evaluation demonstrated mature adipose tissue with many hyperplastic blood vessels.", + "The findings were consistent with the typical findings of angiolipoma.", + "The patient recovered very well and was discharged 7 days after the surgery.", + "Considering the incomplete resection, we recommended that the patient undergo strategic radiation therapy after 1 month of the surgery.", + "After 7 months of follow-up, the patient was clinically well and asymptomatic." + ], + "summary": "A 42-year-old woman was presented with 3-month history of mild chest tightness. Imaging of the chest showed a large mass with fat densities in the middle superior mediastinum. A presumptive diagnosis was a tumor of liposarcoma. The patient was scheduled for a thoracotomy. After the excision, the symptoms were relieved and histological study revealed that the tumor was an angiolipoma. The patient recovered very well and was discharged 7 days after the surgery. After 7 months of follow-up the patient was clinically well and asymptomatic.", + "summary_subclaims": [ + "The patient was a 42-year-old woman.", + "The patient had a 3-month history of mild chest tightness.", + "Imaging of the chest showed a large mass with fat densities in the middle superior mediastinum.", + "A presumptive diagnosis was a tumor of liposarcoma.", + "The patient was scheduled for a thoracotomy.", + "After the excision, the symptoms were relieved.", + "Histological study revealed that the tumor was an angiolipoma.", + "The patient was discharged 7 days after the surgery.", + "After 7 months of follow-up the patient was clinically well and asymptomatic." + ] + }, + { + "id": "multiclinsum_test_620_en.txt", + "fulltext": "A 59-year-old hypertensive white female was diagnosed with CLL in 2009. Informed consent was obtained from the patient for being included in the study.\nChemotherapy with fludarabine was initiated 3 months earlier and corticotherapy with methylprednisolone 2 months earlier for hemolytic anemia secondary to fludarabine treatment. The patient presented with a 24 h history of confusion, agitation, and mild right-lower extremity weakness.\nPhysical examination was notable for grade 1 obesity and subfebrility (99.32 ºF; 37.4 ºC).\nNeurological examination revealed a grade 4 right-lower extremity weakness with reflex asymmetry and right-sided Babinski sign. No signs of meningeal irritation were detectable.\nLaboratory findings included: white blood cell (WBC) count of 3.5 × 103/μL; hemoglobin 7.1 g/dL; hematocrit 21.5%; platelets 109 × 103/μL; aspartate aminotransferase 59 U/L; alanine transaminase 79 U/L. Serum glucose, urea nitrogen, creatinine, bilirubin, sodium, and potassium were normal.\nCerebral computed tomography (CT) scan revealed a hypodense lesion in the left frontal lobe suggestive of an ischemic stroke .\nDuring the second day after admission, the patient developed fever (101.12 ºF; 38.4 ºC) and neurological examination revealed signs of meningeal irritation (positive Kernig’s sign).\nCerebral magnetic resonance imaging (MRI) revealed a hyperintense lesion in the left frontal lobe with extension toward the basal ganglia (T2 and Fluid-Attenuated Inversion Recovery [FLAIR] sequences) , and small nodular enhancing lesions after gadolinium infusion in the affected territory .\nLumbar puncture was performed on the second day and the CSF analysis revealed the following abnormalities: red blood cells (RBCs) 24 cells/mm3; WBCs 829 cells/mm3 (76% lymphocytes, 22% neutrophils, 2% monocytes); protein level 111.2 mg/dL; glucose level 10.2 mg/dL (serum glucose 86 mg/dL). CSF and blood samples were sent to laboratory for culture. Empiric anti-infection treatment was started with intravenous (i. v.) ceftriaxone, ciprofloxacine, aciclovir, and fluconasole. The neurological status of the patient was unchanged 2 days after the initiation of anti-infection therapy and the patient presented septic fever. CSF examination was negative for fungal infections, Mycobacterium tuberculosis, and JC virus. Both blood cultures and CSF cultures were positive for L. monocytogenes. The microbial identification was performed with Vitek 2 automated analyzer system (bioMérieux, Marcy l’Etoile, France). The culture was not verified by molecular methods. The serotype of L. monocytogenes was not determined. There was no history of consumption of high-risk foods for L. monocytogenes infection (such as soft-cheeses made with unpasteurized milk, frankfurters, sliced deli meats, etc.) in the past 10–14 days. The infection was not associated with any known food outbreaks.\nThe diagnosis of Listeria meningoencephalitis was established and antibiotic therapy with ampicillin was started (12 g/day). Forty-eight hours after the initiation of antibiotic treatment with ampicillin, the patient was afebrile with significantly improved neurological status. CSF analysis after 1 week of treatment revealed: RBCs 0 cells/mm3; WBCs 80 cells/mm3; protein level 73 mg/dL; glucose level 49 mg/dL (serum glucose 90 mg/dL). One month later, the neurological examination of the patient was normal.", + "fulltext_subclaims": [ + "The patient was a 59-year-old hypertensive white female.", + "The patient was diagnosed with CLL in 2009.", + "Informed consent was obtained from the patient for being included in the study.", + "Chemotherapy with fludarabine was initiated 3 months earlier.", + "Corticotherapy with methylprednisolone was initiated 2 months earlier.", + "The corticotherapy was for hemolytic anemia secondary to fludarabine treatment.", + "The patient presented with a 24 h history of confusion, agitation, and mild right-lower extremity weakness.", + "Physical examination was notable for grade 1 obesity.", + "Physical examination was notable for subfebrility (99.32 ºF; 37.4 ºC).", + "Neurological examination revealed grade 4 right-lower extremity weakness.", + "Neurological examination revealed reflex asymmetry.", + "Neurological examination revealed a right-sided Babinski sign.", + "No signs of meningeal irritation were detectable.", + "The white blood cell count was 3.5 × 103/μL.", + "The hemoglobin was 7.1 g/dL.", + "The hematocrit was 21.5%.", + "The platelet count was 109 × 103/μL.", + "The aspartate aminotransferase was 59 U/L.", + "The alanine transaminase was 79 U/L.", + "Serum glucose, urea nitrogen, creatinine, bilirubin, sodium, and potassium were normal.", + "Cerebral CT scan revealed a hypodense lesion in the left frontal lobe.", + "The CT scan findings were suggestive of an ischemic stroke.", + "During the second day after admission, the patient developed fever (101.12 ºF; 38.4 ºC).", + "Neurological examination on the second day revealed signs of meningeal irritation.", + "Cerebral MRI revealed a hyperintense lesion in the left frontal lobe.", + "The MRI showed extension toward the basal ganglia on T2 and FLAIR sequences.", + "Small nodular enhancing lesions were seen after gadolinium infusion in the affected territory.", + "Lumbar puncture was performed on the second day.", + "CSF analysis revealed 24 RBCs/mm3.", + "CSF analysis revealed 829 WBCs/mm3.", + "CSF WBCs were 76% lymphocytes, 22% neutrophils, and 2% monocytes.", + "CSF protein level was 111.2 mg/dL.", + "CSF glucose level was 10.2 mg/dL.", + "Serum glucose was 86 mg/dL.", + "CSF and blood samples were sent to laboratory for culture.", + "Empiric anti-infection treatment was started with intravenous ceftriaxone.", + "Empiric anti-infection treatment was started with intravenous ciprofloxacine.", + "Empiric anti-infection treatment was started with intravenous aciclovir.", + "Empiric anti-infection treatment was started with intravenous fluconasole.", + "The neurological status of the patient was unchanged 2 days after the initiation of anti-infection therapy.", + "The patient presented septic fever.", + "CSF examination was negative for fungal infections.", + "CSF examination was negative for Mycobacterium tuberculosis.", + "CSF examination was negative for JC virus.", + "Both blood cultures and CSF cultures were positive for L. monocytogenes.", + "The microbial identification was performed with Vitek 2 automated analyzer system.", + "The culture was not verified by molecular methods.", + "The serotype of L. monocytogenes was not determined.", + "There was no history of consumption of high-risk foods for L. monocytogenes infection in the past 10–14 days.", + "The infection was not associated with any known food outbreaks.", + "The diagnosis of Listeria meningoencephalitis was established.", + "Antibiotic therapy with ampicillin was started.", + "Forty-eight hours after the initiation of antibiotic treatment with ampicillin, the patient was afebrile.", + "Forty-eight hours after the initiation of antibiotic treatment with ampicillin, the patient had significantly improved neurological status.", + "CSF analysis after 1 week of treatment revealed 0 RBCs/mm3.", + "CSF analysis after 1 week of treatment revealed 80 WBCs/mm3.", + "CSF protein level after 1 week of treatment was 73 mg/dL.", + "CSF glucose level after 1 week of treatment was 49 mg/dL.", + "Serum glucose after 1 week of treatment was 90 mg/dL.", + "One month later, the neurological examination of the patient was normal." + ], + "summary": "The authors report the case of a 59-year-old woman who was admitted for confusion, agitation, and right-lower extremity weakness. The patient was treated for 3 months with fludarabine and 2 months with corticosteroids for chronic lymphocytic leukemia and hemolytic anemia, respectively. At the time of admission, the neurological examination revealed grade 4 right-lower extremity weakness with reflex asymmetry and right-sided Babinski sign; no signs of meningeal irritation were detectable. Physical examination was notable for grade 1 obesity and subfebrility. The cerebral computed tomography scan demonstrated a hypodense lesion in the left frontal lobe. Cerebral magnetic resonance imaging revealed a hyperintense lesion in the left frontal lobe with extension toward the basal ganglia (T2 and Fluid-Attenuated Inversion Recovery", + "summary_subclaims": [ + "The authors report the case of a 59-year-old woman.", + "The patient was admitted for confusion.", + "The patient was admitted for agitation.", + "The patient was admitted for right-lower extremity weakness.", + "The patient was treated for 3 months with fludarabine.", + "The patient was treated for 2 months with corticosteroids.", + "The cerebral computed tomography scan demonstrated a hypodense lesion in the left frontal lobe.", + "Cerebral magnetic resonance imaging revealed a hyperintense lesion in the left frontal lobe with extension toward the basal ganglia." + ] + }, + { + "id": "multiclinsum_test_2272_en.txt", + "fulltext": "A 69-year-old Tunisian female with no family history of auto-immune disease. She had a history of hypertension and was explored 4 years prior to admission for transient arthralgias and arthritis. At age 69, she experienced photosensitivity, malar rash and diffuse discoid lesions in her trunk and face for which she visited our hospital. She also reported weight loss of approximately 3 kg in the last three months. She had no history of drug abuse or significant alcohol consumption prior her admission. The physical examination showed synovitis of the wrists. Her general state of health was regular, eupneic. Cardiovascular and respiratory examinations were within the normal range. The patient had no previous laboratory tests. On admission, her initial laboratory tests were as follows: erythrocyte sedimentation rate at 45 mm/1st hour associated with hyper-γ-globulinemia 20 gr/l. Her leukogram showed lymphopenia 850/mm3, and platelets were normal. Creatinin and urinalysis are normal. The autoimmune profile confirmed a strong positivity of Antinuclear antibodies (ANA) with titre 1:400 and anti-double-stranded DNA (anti-dsDNA) at 115 UI/ml with normal serum complements. The patient was non-reactive for the following antibodies: anti-La; anti-cardiolipin; lupus anticoagulant; anti-SM; anti-RNP; anti-SCL-70; and anticentromere, rheumatoid factor and autoantibodies against citrullinated protein. Serology for VDRL was negative, hepatobiliary enzyme and lactate dehydrogenase levels were within normal range. Therefore, presence of 6 of 11 American College of Rheumatology criteria (photosensitivity + malar erythema + positive ANA and anti-dsDNA tests + hematologic abnormalities including lymphopenia + arthritis) allowed the diagnosis of SLE. The patient was treated with Chloroquine (200 mg/day). The patient showed improvement of her general state of health, and weight gain. No aggravation of SLE was observed. However one year later, she developed liver dysfunction. The patient was referred to gastroenterology unit. On physical exam, skin rash involving her face was observed. Abdominal examination revealed neither hepatosplenomegaly nor pruritus. Laboratory investigations revealed a normal complete blood count and urinalysis. His erythrocyte sedimentation rate was at 60 mm/1st hour while C-reactive protein was within normal range. Concentrations of both serum cholesterol and triglyceride are normal. Blood creatinine clearance 80 mL/min and there was no proteinuria. Aspartate aminotransferase 92 IU/L (normal range: 8–38); alanine aminotransferase 87 IU/L (normal range: 4–44 IU/L) (2 times above the normal limit), total bilirubin 0.9 mg/dl; alkaline phosphatase 107 IU/L, gammaglutamyl transpeptidase 42 IU/L and lactate dehydrogenase 230 IU/L are at normal range. Antimitochondrial antibodies (AMA) were positive (1:164), with positive anti-E2 fraction. The antinuclear antibody was positif as well as anti-dsDNA. Negative results were seen for anti-smooth muscle antibody and anti-centromere antibody. Serologic makers for hepatitis B and hepatitis C viruses were negative. Abdominal echo showed no fatty change of the liver and no abnormality of the bile ducts. Biochemical liver tests and AMA results are compatible to PBC. However, liver biopsy is required to give information on the stage of PBC. Microscopic examination reveals a focal florid duct lesion characterized by a portal lymphocytic infiltrate and epitheloid cells that are centred on interlobular ducts with evidence of destruction . These lesions are associated with a lymphocytic cholangitis and a portal inflammation containing conspicuous plasma cells and numerous lymphocytes . No granuloma was found in lobule. These findings led to a diagnosis of stage I PBC according to Scheuer’s classification. Based on the hematology and liver-tissue results, as well, she was diagnosed with asymptomatic PBC. Treatment with ursodeoxycholic acid (600 mg daily) was started. The transaminase levels normalized with one month. The patient has not complained liver dysfunction. She was followed up regularly with stable health.", + "fulltext_subclaims": [ + "The patient is a 69-year-old Tunisian female.", + "She has no family history of auto-immune disease.", + "She had a history of hypertension.", + "She was explored 4 years prior to admission for transient arthralgias and arthritis.", + "She experienced photosensitivity, malar rash, and diffuse discoid lesions in her trunk and face.", + "She reported weight loss of approximately 3 kg in the last three months.", + "The physical examination showed synovitis of the wrists.", + "The autoimmune profile confirmed a strong positivity of Antinuclear antibodies (ANA) with titre 1:400.", + "The autoimmune profile showed anti-double-stranded DNA (anti-dsDNA) at 115 UI/ml.", + "The autoimmune profile showed normal serum complements.", + "The patient was non-reactive for anti-La antibodies.", + "The patient was non-reactive for anti-cardiolipin antibodies.", + "The patient was non-reactive for lupus anticoagulant.", + "The patient was non-reactive for anti-SM antibodies.", + "The patient was non-reactive for anti-RNP antibodies.", + "The patient was non-reactive for anti-SCL-70 antibodies.", + "The patient was non-reactive for anticentromere antibodies.", + "The patient was non-reactive for rheumatoid factor.", + "The patient was non-reactive for autoantibodies against citrullinated protein.", + "The presence of 6 of 11 American College of Rheumatology criteria allowed the diagnosis of SLE.", + "The patient was treated with Chloroquine (200 mg/day).", + "The patient showed improvement of her general state of health.", + "The patient showed weight gain.", + "One year later, she developed liver dysfunction.", + "Antimitochondrial antibodies (AMA) were positive (1:164).", + "Antimitochondrial antibodies were positive with positive anti-E2 fraction.", + "The antinuclear antibody was positive.", + "The anti-dsDNA was positive.", + "Serologic markers for hepatitis B and hepatitis C viruses were negative.", + "Abdominal echo showed no fatty change of the liver.", + "Abdominal echo showed no abnormality of the bile ducts.", + "Microscopic examination reveals a focal florid duct lesion characterized by a portal lymphocytic infiltrate and epitheloid cells that are centred on interlobular ducts with evidence of destruction.", + "These lesions are associated with a lymphocytic cholangitis and a portal inflammation containing conspicuous plasma cells and numerous lymphocytes.", + "No granuloma was found in lobule.", + "These findings led to a diagnosis of stage I PBC according to Scheuer’s classification.", + "Based on the hematology and liver-tissue results, she was diagnosed with asymptomatic PBC.", + "Treatment with ursodeoxycholic acid (600 mg daily) was started.", + "The transaminase levels normalized with one month.", + "The patient has not complained liver dysfunction.", + "She was followed up regularly with stable health." + ], + "summary": "A 70-years-old woman, who had been diagnosed with SLE at 69 years, was admitted for further examination of liver dysfunction. PBC was confirmed based on elevated serum levels of transaminase, high levels of antimitochondrial antibodies and following a liver biopsy. The oral administration of ursodeoxycholic acid stabilized the liver dysfunction.", + "summary_subclaims": [ + "The patient is a 70-years-old woman.", + "The patient was diagnosed with SLE at 69 years.", + "The patient was admitted for further examination of liver dysfunction.", + "PBC was confirmed based on elevated serum levels of transaminase.", + "PBC was confirmed based on high levels of antimitochondrial antibodies.", + "PBC was confirmed following a liver biopsy.", + "The oral administration of ursodeoxycholic acid stabilized the liver dysfunction." + ] + }, + { + "id": "multiclinsum_test_2342_en.txt", + "fulltext": "A 32-year-old, unrestrained male driver was involved in head-on motor vehicle accident at high speed. He was initially evaluated at the pre-hospital setting and was reported to be hemodynamically stable. On arrival, his score on the Glasgow Coma Scale was 15, blood pressure 110/75 mm Hg, pulse rate 100/min, and respiratory rate 17/min. The patent had a deep scalp laceration, signs of recent nasal bleeding and facial bruising suggestive of a high-energy head injury while he was also complaining of a mild mid-epigastrium pain.\nOn exam, the patient was alert and oriented. The chest wall was not tender to palpation. Auscultation of the chest wall did not reveal any pathology. The abdomen was non-distended, soft with mild tenderness however to palpation of the upper abdomen (mid-epigastrium). Motor and sensory function of all extremities was intact. The urine was grossly clear. Initial radiographic studies included a supine chest film that besides a widened mediastinum was generally inconclusive. Ultrasonography in the trauma unit did not show any abnormal fluid collection. The initial hematocrit value was 39.5% and blood gas pH was 7.37 with a base deficit of 3.8. Meanwhile the patient started complaining of nausea and several blood-spotted vomiting episodes were noted. An investigation in the direction of a traumatic brain injury was conducted with a standard protocol head Computed Tomography (CT) scan. No evidences of midline shift were observed. The presence of a possible intracranial hematoma or a cranial bone fracture was ruled out. Notable oedema of the facial soft tissues, without however underlining fractures, was an additional finding. Approximately, six hours after the initial imaging evaluation, the persistence of patient’s symptoms i.e. vomiting as well as the migration of pain into the lower thorax dictated an additional workup. A second chest x-ray was obtained. (Figures . An elevated left hemi-diaphragm with the stomach in the left chest was observed. Abdominal CT scan confirmed the presence of a left-sided diaphragmatic tear with herniation of abdominal context within the left hemi-thorax. (Figures .\nThe patient underwent emergency laparotomy via a midline incision where a near total herniation of the stomach into the left hemithorax was observed. No resection was necessary as there were no ischemic changes or signs of perforation of the involved organ. The stomach was then successfully reduced into the abdomen revealing the hernia opening about 5 cm in length. (Figures . A primary repair with interrupted non-absorbable sutures was carried out without the use of a prosthetic mesh. (Figures . The relatively small size of the hernia opening was the main argument for this approach. A chest tube was not necessary as pleura was not violated and a pneumothorax was not present. Operating time was 45 minutes. The patient had an uneventful postoperative period and was discharged on the fifth postoperative day.", + "fulltext_subclaims": [ + "The patient was a 32-year-old, unrestrained male driver.", + "He was involved in a head-on motor vehicle accident at high speed.", + "He was initially evaluated at the pre-hospital setting.", + "He was reported to be hemodynamically stable.", + "On arrival, his Glasgow Coma Scale score was 15.", + "On arrival, his blood pressure was 110/75 mm Hg.", + "On arrival, his pulse rate was 100/min.", + "On arrival, his respiratory rate was 17/min.", + "The patient had a deep scalp laceration.", + "The patient had signs of recent nasal bleeding.", + "The patient had facial bruising.", + "The patient was alert and oriented.", + "The chest wall was not tender to palpation.", + "Auscultation of the chest wall did not reveal any pathology.", + "The abdomen was non-distended.", + "The abdomen was soft.", + "There was mild tenderness to palpation of the upper abdomen (mid-epigastrium).", + "Motor and sensory function of all extremities was intact.", + "The urine was grossly clear.", + "The initial radiographic studies included a supine chest film.", + "The supine chest film showed a widened mediastinum.", + "The supine chest film was generally inconclusive.", + "Ultrasonography in the trauma unit did not show any abnormal fluid collection.", + "The initial hematocrit value was 39.5%.", + "The blood gas pH was 7.37.", + "The blood gas base deficit was 3.8.", + "The patient started complaining of nausea.", + "The patient had several blood-spotted vomiting episodes.", + "An investigation in the direction of a traumatic brain injury was conducted.", + "A standard protocol head CT scan was performed.", + "No evidences of midline shift were observed.", + "The presence of a possible intracranial hematoma was ruled out.", + "The presence of a cranial bone fracture was ruled out.", + "Notable oedema of the facial soft tissues was an additional finding.", + "The presence of underlining fractures was ruled out.", + "Approximately six hours after the initial imaging evaluation, the persistence of patient’s symptoms dictated an additional workup.", + "A second chest x-ray was obtained.", + "An elevated left hemi-diaphragm with the stomach in the left chest was observed.", + "An abdominal CT scan confirmed the presence of a left-sided diaphragmatic tear.", + "The abdominal CT scan showed herniation of abdominal content within the left hemi-thorax.", + "The patient underwent emergency laparotomy via a midline incision.", + "A near total herniation of the stomach into the left hemithorax was observed.", + "No resection was necessary.", + "There were no ischemic changes of the involved organ.", + "There were no signs of perforation of the involved organ.", + "The stomach was successfully reduced into the abdomen.", + "The hernia opening was about 5 cm in length.", + "A primary repair with interrupted non-absorbable sutures was carried out.", + "A prosthetic mesh was not used.", + "A chest tube was not necessary.", + "The operating time was 45 minutes.", + "The patient had an uneventful postoperative period.", + "The patient was discharged on the fifth postoperative day." + ], + "summary": "We present a challenging case of a young male with combined abdominal and head trauma. Repeated episodes of vomiting dominated on clinical presentation that in the presence of a deep scalp laceration and facial bruising shifted differential diagnosis towards a traumatic brain injury. However, a computed tomography scan of the brain ruled out any intracranial pathology. Finally, a more meticulous investigation with additional imaging studies confirmed the presence of diaphragmatic rupture that justified the clinical symptoms.", + "summary_subclaims": [ + "The patient was a young male.", + "The patient had combined abdominal and head trauma.", + "Repeated episodes of vomiting dominated on clinical presentation.", + "A deep scalp laceration was present.", + "Facial bruising was present.", + "The differential diagnosis shifted towards a traumatic brain injury.", + "A computed tomography scan of the brain ruled out any intracranial pathology.", + "Additional imaging studies confirmed the presence of diaphragmatic rupture.", + "The diaphragmatic rupture justified the clinical symptoms." + ] + }, + { + "id": "multiclinsum_test_1421_en.txt", + "fulltext": "In 2015, a then 52-year-old man was referred to our radiation oncology department for evaluation of hemostatic treatment. He presented with chest pain, dyspnea, fatigue, loss of appetite, weight loss, recurrent respiratory infections, and episodes of significant hemoptysis. Medical history included pulmonary TB in 1995 , which was adequately treated with antitubercular medications for 6 months, resulting in a residual cavity in the left lower lobe. Hemoptysis first occurred a couple of years after initial TB treatment and symptoms had become aggravated since then. In 2007, the patient presented with a new episode of hemoptysis. His medical history and a CT scan of the chest lead to the differential diagnosis of pulmonary aspergillosis. The patient was hemodynamically stable and a hemoglobin of 155 g/L (reference value 135–168 g/L) was measured. Since bronchoscopy confirmed endobronchial bleeding from the segments where the lesion was located, partial resection of the left inferior lobe was performed in the same year. Aspergilloma was confirmed by histopathological examination of the resected lung tissue. A post-interventional CT scan of the chest, however, showed persistence of the aspergilloma. In addition, persistence was suggested microbiologically by positive Aspergillus cultures from bronchoalveolar lavage fluid and sputum at different timepoints. In the following years, three attempts at endovascular embolization of pulmonary arteries, the first in 2008, were performed due to recurring hemoptysis, without achieving lasting hemostasis. Therefore, long-term antifungal therapy with itraconazole was initiated in 2009 and continued for 2.5 years. In addition to the aspergillosis, the patient was diagnosed with a pulmonary actinomycosis in 2015, a rare opportunistic bacterial infection of the lung. Actinomyces were also isolated from a bronchoscopic biopsy in the left lower lobe. Although Aspergillus cultures and Aspergillus precipitin could not reaffirm aspergilloma persistence at that time, these results did not definitely rule out a concomitant fungal and bacterial infection. The patient’s pulmonary function was further reduced after suffering multiple pulmonary emboli. The last complete pulmonary function testing prior to radiotherapy was performed in 2013. It revealed a vital capacity (VC) of 2.15 L (44% of reference value), forced expiratory volume in one second (FEV1) of 1.55 L (41%), and a diffusing capacity of the lungs for carbon monoxide (DLCO) of 7.4 mmol/min/kPa (71%), so that the patient was considered unfit for further surgical interventions. During the first consultation in our clinic, the patient reported recurrent episodes of hemoptysis causing blood loss of more than 100 ml per day. A CT of the chest showed a persistent, spiculated, partly cavernous lesion in the left lower lobe with a diameter of approximately 5 cm . Treatment planning also included an 18F‑FDG-PET/CT scan to localize the fungal manifestation and identified the metabolically active inflamed vascular lining of the cavity as the most likely cause of bleeding . SBRT with a total dose of 16 Gy was applied in two fractions of 8 Gy on consecutive days with a robotic arm-mounted linear accelerator equipped with an iris collimator (CyberKnife®, Accuray Inc., Sunnyvale, CA, USA; Fig. b). Dose was prescribed to the 80% isodose line and the ray-tracing algorithm was used for dose calculation. After acquisition of a 4D-planning CT to account for respiratory motion, the planning target volume (PTV) was generated from an internal target volume (ITV), adding a 2-mm margin. Despite an irregularly shaped PTV, the chosen irradiation technique allowed us to achieve a conformal dose distribution of the target volume and tolerable doses for relevant organs at risk (OAR) as shown in the dose–volume histogram (DVH; Fig. c). The treatment was well tolerated, and no side effects were reported by the patient. During the 6 years of follow-up at our department, the patient has reported a significant decrease in hemoptysis frequency and volume, and no new long-term medication or invasive treatments have been necessary since then. When he presented at the hospital’s emergency unit with dyspnea and small-volume hemoptysis in 2016, there were no signs of an active or older bleeding evident in CT or bronchoscopy. Hemoglobin level remained stable at around 140 g/L over the years and fell below 120 g/L only once during an episode of community-acquired pneumonia in 2016 not accompanied by hemoptysis. Regular CT scans of the chest confirmed a stable size of the pulmonary lesion after an initial pseudoprogression, which is often observed after SBRT for large target volumes .", + "fulltext_subclaims": [ + "In 2015, a then 52-year-old man was referred to our radiation oncology department for evaluation of hemostatic treatment.", + "He presented with chest pain, dyspnea, fatigue, loss of appetite, weight loss, recurrent respiratory infections, and episodes of significant hemoptysis.", + "Medical history included pulmonary TB in 1995, which was adequately treated with antitubercular medications for 6 months, resulting in a residual cavity in the left lower lobe.", + "Hemoptysis first occurred a couple of years after initial TB treatment and symptoms had become aggravated since then.", + "In 2007, the patient presented with a new episode of hemoptysis.", + "Medical history and a CT scan of the chest lead to the differential diagnosis of pulmonary aspergillosis.", + "The patient was hemodynamically stable and a hemoglobin of 155 g/L was measured.", + "Bronchoscopy confirmed endobronchial bleeding from the segments where the lesion was located.", + "Partial resection of the left inferior lobe was performed in 2007.", + "Aspergilloma was confirmed by histopathological examination of the resected lung tissue.", + "A post-interventional CT scan of the chest showed persistence of the aspergilloma.", + "Persistence was suggested microbiologically by positive Aspergillus cultures from bronchoalveolar lavage fluid and sputum at different timepoints.", + "In the following years, three attempts at endovascular embolization of pulmonary arteries, the first in 2008, were performed due to recurring hemoptysis, without achieving lasting hemostasis.", + "Long-term antifungal therapy with itraconazole was initiated in 2009 and continued for 2.5 years.", + "In 2015, the patient was diagnosed with a pulmonary actinomycosis, a rare opportunistic bacterial infection of the lung.", + "Actinomyces were also isolated from a bronchoscopic biopsy in the left lower lobe.", + "Aspergillus cultures and Aspergillus precipitin could not reaffirm aspergilloma persistence at that time.", + "These results did not definitely rule out a concomitant fungal and bacterial infection.", + "The patient’s pulmonary function was further reduced after suffering multiple pulmonary emboli.", + "The last complete pulmonary function testing prior to radiotherapy was performed in 2013.", + "It revealed a vital capacity (VC) of 2.15 L (44% of reference value), forced expiratory volume in one second (FEV1) of 1.55 L (41%), and a diffusing capacity of the lungs for carbon monoxide (DLCO) of 7.4 mmol/min/kPa (71%).", + "The patient was considered unfit for further surgical interventions.", + "During the first consultation in our clinic, the patient reported recurrent episodes of hemoptysis causing blood loss of more than 100 ml per day.", + "A CT of the chest showed a persistent, spiculated, partly cavernous lesion in the left lower lobe with a diameter of approximately 5 cm.", + "Treatment planning also included an 18F‑FDG-PET/CT scan to localize the fungal manifestation and identified the metabolically active inflamed vascular lining of the cavity as the most likely cause of bleeding.", + "SBRT with a total dose of 16 Gy was applied in two fractions of 8 Gy on consecutive days with a robotic arm-mounted linear accelerator equipped with an iris collimator.", + "Dose was prescribed to the 80% isodose line and the ray-tracing algorithm was used for dose calculation.", + "After acquisition of a 4D-planning CT to account for respiratory motion, the planning target volume (PTV) was generated from an internal target volume (ITV), adding a 2-mm margin.", + "Despite an irregularly shaped PTV, the chosen irradiation technique allowed us to achieve a conformal dose distribution of the target volume and tolerable doses for relevant organs at risk.", + "The treatment was well tolerated, and no side effects were reported by the patient.", + "During the 6 years of follow-up at our department, the patient has reported a significant decrease in hemoptysis frequency and volume.", + "No new long-term medication or invasive treatments have been necessary since then.", + "When he presented at the hospital’s emergency unit with dyspnea and small-volume hemoptysis in 2016, there were no signs of an active or older bleeding evident in CT or bronchoscopy.", + "Hemoglobin level remained stable at around 140 g/L over the years and fell below 120 g/L only once during an episode of community-acquired pneumonia in 2016 not accompanied by hemoptysis.", + "Regular CT scans of the chest confirmed a stable size of the pulmonary lesion after an initial pseudoprogression, which is often observed after SBRT for large target volumes." + ], + "summary": "A 52-year-old man presented with recurring and treatment-refractory hemoptysis caused by chronic cavitary aspergillosis localized in the left lower lobe. We applied SBRT on two consecutive days with a total dose of 16 Gy. Hemoptysis frequency decreased to a clinically insignificant level.", + "summary_subclaims": [ + "A 52-year-old man presented with recurring and treatment-refractory hemoptysis.", + "The hemoptysis was caused by chronic cavitary aspergillosis localized in the left lower lobe.", + "We applied SBRT on two consecutive days.", + "The total dose of SBRT was 16 Gy.", + "Hemoptysis frequency decreased to a clinically insignificant level." + ] + }, + { + "id": "multiclinsum_test_248_en.txt", + "fulltext": "The case is a 26 years old lady who had referred to a gynecologist because of infertility 2 years ago. She has married 8 years ago and after 2 years, she decided to have child. During the first two years of marriage they used natural method for contraception and she had not used any OCP or IUD. Her menarche was at the age of 14 and from then on she has a regular and normal monthly menstruation.\nShe had a negative past medical history with no sign or symptoms of neurologic diseases such as anxiety or depression. She had also no history of any clinical disease, pelvic or abdominal surgery, and extensive weight loss and drug or alcohol abuse.\nIn her family history the only positive clues were; the presence of hypothyroidism, diabetes and vitiligo in her mother and aunts. In physical exams: BMI=23, secondary sexual signs were normal and there was no sign or symptom of hirsutism, acne or any other systemic disease. Evaluation of her husband revealed normal male factor and spermogram. Laboratory findings included: serum FSH, serum LH, serum prolactin, TSH, testosterone, progesterone and estradiol which all of them were at the normal range.\nPost coital test (PCT) and histrosalpangography were normal. Diagnostic laparoscopy showed no signs of tubal adhesion or endometriosis. After seven months and performing primary and secondary evaluation, she was diagnosed as a case of unexplained infertility and IVF was suggested for her.\nAbout 9 months ago, the patient had a medical consultation because of diarrhea and 3 kg of weight loss. She reports a history of 12 months intermittent, non bloody and osmotic diarrhea which consists of normal bowel habits intervals. There was no history of fatty stool or consumption of laxatives.\nLab findings:\nHB: 11.8 (NL: 12-16) MCV: 76 (NL: 80-95)\nMCH: 27 (NL: 36-48) Serum Fe: 110 (NL: 80-180)\nTIBC: 320 (NL: 250-460) Serum Ferritin: 54 ngr/ml (12-300) CRP: +ESR: 18 S/E: negative\nOB: negative. AST: 29 IU (NL: 5-40)\nALT: 31 IU (NL: 8-40)\nConsidering iron deficiency anemia, intestinal signs and the history of 4 years infertility, we became suspicious to celiac disease and checked serological factors (total IgA and tTG).\nThe positive results of these tests (Total IgA>40 and tTG>30) followed by upper GI endoscopy and biopsy of the second portion of duodenum. The obtained tissues were observed by two expert pathologists and they reported severe malabsorption with flattening of villi, hyperplasia of crypts and total atrophy of mucosa which was presenting stage III of modified marsh classification ( and ). Based on patient's history and serologic and pathologic findings diagnosis of CD was confirmed and she received a complete gluten free diet. After 3 months all her clinical features including; diarrhea, flatulence and anemia were eradicated and pregnancy occurred.", + "fulltext_subclaims": [ + "The patient is a 26 years old lady.", + "She had referred to a gynecologist because of infertility 2 years ago.", + "She has married 8 years ago.", + "After 2 years of marriage, she decided to have a child.", + "During the first two years of marriage, they used natural method for contraception.", + "She had not used any OCP or IUD.", + "Her menarche was at the age of 14.", + "She has a regular and normal monthly menstruation.", + "She had a negative past medical history.", + "She had no sign or symptoms of neurologic diseases such as anxiety or depression.", + "She had no history of any clinical disease.", + "She had no history of pelvic or abdominal surgery.", + "She had no history of extensive weight loss.", + "She had no history of drug or alcohol abuse.", + "In her family history, the only positive clues were the presence of hypothyroidism, diabetes and vitiligo in her mother and aunts.", + "In physical exams, BMI=23.", + "Secondary sexual signs were normal.", + "There was no sign or symptom of hirsutism, acne or any other systemic disease.", + "Evaluation of her husband revealed normal male factor and spermogram.", + "Laboratory findings included serum FSH, serum LH, serum prolactin, TSH, testosterone, progesterone and estradiol which all of them were at the normal range.", + "Post coital test (PCT) and histrosalpangography were normal.", + "Diagnostic laparoscopy showed no signs of tubal adhesion or endometriosis.", + "After seven months and performing primary and secondary evaluation, she was diagnosed as a case of unexplained infertility.", + "IVF was suggested for her.", + "About 9 months ago, the patient had a medical consultation because of diarrhea and 3 kg of weight loss.", + "She reports a history of 12 months intermittent, non bloody and osmotic diarrhea.", + "There was no history of fatty stool or consumption of laxatives.", + "HB was 11.8 (NL: 12-16).", + "MCV was 76 (NL: 80-95).", + "MCH was 27 (NL: 36-48).", + "Serum Fe was 110 (NL: 80-180).", + "TIBC was 320 (NL: 250-460).", + "Serum Ferritin was 54 ngr/ml (12-300).", + "CRP was positive.", + "ESR was 18.", + "S/E was negative.", + "OB was negative.", + "AST was 29 IU (NL: 5-40).", + "ALT was 31 IU (NL: 8-40).", + "Considering iron deficiency anemia, intestinal signs and the history of 4 years infertility, we became suspicious to celiac disease.", + "We checked serological factors (total IgA and tTG).", + "The positive results of these tests (Total IgA>40 and tTG>30) followed by upper GI endoscopy and biopsy of the second portion of duodenum.", + "The obtained tissues were observed by two expert pathologists.", + "They reported severe malabsorption with flattening of villi, hyperplasia of crypts and total atrophy of mucosa.", + "This was presenting stage III of modified marsh classification.", + "Based on patient's history and serologic and pathologic findings, diagnosis of CD was confirmed.", + "She received a complete gluten free diet.", + "After 3 months, all her clinical features including diarrhea, flatulence and anemia were eradicated.", + "Pregnancy occurred." + ], + "summary": "The case is a 26 years old lady who had referred to a gynecologist because of infertility for 2 years and later it revealed that she has celiac sprue.", + "summary_subclaims": [ + "The patient is a 26 years old lady.", + "She had referred to a gynecologist because of infertility for 2 years.", + "It later revealed that she has celiac sprue." + ] + }, + { + "id": "multiclinsum_test_1306_en.txt", + "fulltext": "A 19-year old Caucasian male presented to the University Hospital of Muenster emergency department after being unresponsive for 5 h. After consuming liquid methadone intravenously the night before, the patient awoke and immediately complained of partial bilateral hearing loss, walking impairment and numbness of both inner thighs.\nAccording to third-party history obtained from two accompanying friends (the patient was amnestic regarding the night before) the patient had consumed 3 × 2.5 mL of liquid methadone (produced for substitution therapy) intravenously. They reported observing unconsciousness, urinary incontinence, and a twist of his eyes. The patient and accompanying friends admitted to occasionally orally using illegally obtained methadone and cannabis but credibly denied consuming these substances or other opiods and illegal drugs in the days before. This was the first event of intravenous methadone abuse. The medical history of the patient was otherwise unremarkable.\nIn the neurological examination the patient presented fluctuating consciousness, severe psychomotor and cognitive slowing (slowed speech, increased response latency, concentration deficits), mild paraparesis of the lower limbs, clonus when testing the left patellar reflex and symmetrical bilateral hypoesthesia of the inner thigh. Medical examination showed a heart rate of 76 beats per minute, blood pressure 121/73 mmHg, peripheral oxygen saturation of 97% and temperature of 36.8 °C. An electrocardiogram (ECG) showed only unspecific change of the ST-segment in V2 and V3. FAST-ultrasound did not reveal any abnormalities.\nBlood tests revealed a slightly elevated c-reactive protein (5.2 mg/dl; reference < .5 mg/dl), an elevated GOP (400 U /l; reference: < 30 U/l), GPT (118 U/l; reference < 40 U /l) and an increased creatin-kinase (7104 U/l; reference: < 174 U/l) and lactatdehydrogenase (563 U/l; reference 117–217 U/l). Sodium and potassium levels were within normal range. Intoxication screening of the urine was positive for methadone (2.55 mg/l) and cannabinoids (THC-COOH: 29 μg/l) but was negative for other drugs including non-methadone opioids and barbiturates, benzodiazepines, tricyclic antidepressive drugs, methamphetamines, cocaine, phencyclidine and paracetamol. An initial magnetic resonance imaging (MRI) showed multifocal, bilateral edema of the basal ganglia , of both cerebellar hemispheres as well as the capsula interna with diffusion restriction and apparent diffusion coefficient (ADC) signal reductions and fluid attenuated inversion recovery (FLAIR) imaging revealed hyperintense alterations in those areas. In addition, DWI and FLAIR imaging presented mild, confluent white matter abnormalities above the lateral ventricle (Supplementary figure A, B). A time-of-flight (TOF)-angiography was normal. An initial spinal tap and subsequent cerebrospinal fluid analysis revealed a disturbance of the blood-brain barrier but normal total protein (542 mg/l) and normal lymphocyte counts (4/μL) and no intrathecal antibody synthesis. An electroencephalogram (EEG) revealed intermittent deceleration without epileptic discharges.\nAfter admission, the patient was continuously awake and responsive and did not require intensive care treatment. Initially, walking was impaired without a need for a walking aid.\nA transesophageal echocardiography revealed no cardiac abnormalities and especially no endocarditis. Repeated blood cultures were negative. Ear-nose-throat consultation revealed an injury of the inner ear with a diminished ability to hear below 55 dB. We performed treatment with prednisolone for 3 days (days 7–9) at 1 mg per kilogram body weight, which did not cause any immediate conceivable improvement of hearing but the hearing ability improved continuously. The unsteady gait improved to an almost normal level between days 9–11 of inpatient treatment. In contrast, cognitive deficits remained unchanged with increased response latency, slowed speech and concentration deficits. Additionally, the hypoesthesia of the inner thigh remained unchanged.\nAn additional MRI after 11 days revealed the known FLAIR-hyperintense lesions of basal ganglia, capsula interna and subtle abnormalities above the lateral ventricles (Supplementary figure C, D) as well as the cerebellar hemispheres , which were now ADC increased. Interestingly, new lesions were found in the crura cerebri bilaterally . Another spinal tap revealed an increase of lymphocytes (11/μl), but otherwise no pathological findings with a normal blood-brain barrier. Flow cytometry analysis of cerebrospinal fluid (CSF) cells revealed a shift in monocyte subtypes with a significant increase of the non-classical CD14 + CD16+ monocyte-fraction and decrease of the CD56bright natural killer cell-fraction in the lymphocyte subset in the CSF . Reference values had been previously collected from 29 patients (female: 58%, mean age: 24.1y + − 5.0 standard deviation (SD)) with psychsosomatic disorder (exclusion of inflammatory CNS disorder; CSF: less than 5 cells/μl, normal protein, no intrathecal antibody synthesis).\nWith improved walking and hearing but considerable neurocognitive impairment we discharged the patient after 13 days to subsequent rehabilitation.\nA neuropsychological assessment on day 18 revealed mild-to-moderate overall cognitive impairments when compared with normative data stratified for age and education . Particularly tests assessing cognitive processing speed (e.g., TAP, SDMT, TMT, Time to copy a complex figure) showed consistent alterations from the norm. Learning efficiency of both verbal (RAVLT) and visual material (BVMT-R) was also impaired whereas recall from memory was only reduced for verbal but preserved for complex visual material. Interestingly, the patient showed preserved performance in tests for complex attention and higher executive functions such as planning abilities (D-KEFS Tower Test).", + "fulltext_subclaims": [ + "The patient was a 19-year old Caucasian male.", + "He presented to the University Hospital of Muenster emergency department after being unresponsive for 5 h.", + "He had consumed liquid methadone intravenously the night before.", + "He awoke and immediately complained of partial bilateral hearing loss.", + "He complained of walking impairment.", + "He complained of numbness of both inner thighs.", + "Third-party history was obtained from two accompanying friends.", + "The patient was amnestic regarding the night before.", + "The patient had consumed 3 × 2.5 mL of liquid methadone intravenously.", + "The liquid methadone was produced for substitution therapy.", + "The accompanying friends reported observing unconsciousness.", + "The accompanying friends reported observing urinary incontinence.", + "The accompanying friends reported observing a twist of his eyes.", + "The patient and accompanying friends admitted to occasionally orally using illegally obtained methadone.", + "The patient and accompanying friends admitted to occasionally orally using cannabis.", + "They credibly denied consuming these substances or other opioids and illegal drugs in the days before.", + "This was the first event of intravenous methadone abuse.", + "The medical history of the patient was otherwise unremarkable.", + "In the neurological examination, the patient presented fluctuating consciousness.", + "The patient had severe psychomotor and cognitive slowing.", + "The patient had mild paraparesis of the lower limbs.", + "The patient had clonus when testing the left patellar reflex.", + "The patient had symmetrical bilateral hypoesthesia of the inner thigh.", + "Medical examination showed a heart rate of 76 beats per minute.", + "Medical examination showed blood pressure of 121/73 mmHg.", + "Medical examination showed peripheral oxygen saturation of 97%.", + "Medical examination showed temperature of 36.8 °C.", + "An electrocardiogram showed only unspecific change of the ST-segment in V2 and V3.", + "FAST-ultrasound did not reveal any abnormalities.", + "Blood tests revealed a slightly elevated c-reactive protein (5.2 mg/dl).", + "Blood tests revealed an elevated GOP (400 U /l).", + "Blood tests revealed an elevated GPT (118 U/l).", + "Blood tests revealed an increased creatin-kinase (7104 U/l).", + "Blood tests revealed an increased lactatdehydrogenase (563 U/l).", + "Intoxication screening of the urine was positive for methadone (2.55 mg/l).", + "Intoxication screening of the urine was positive for cannabinoids (THC-COOH: 29 μg/l).", + "Intoxication screening of the urine was negative for other drugs including non-methadone opioids and barbiturates.", + "Intoxication screening of the urine was negative for benzodiazepines.", + "Intoxication screening of the urine was negative for tricyclic antidepressive drugs.", + "Intoxication screening of the urine was negative for methamphetamines.", + "Intoxication screening of the urine was negative for cocaine.", + "Intoxication screening of the urine was negative for phencyclidine.", + "Intoxication screening of the urine was negative for paracetamol.", + "An initial MRI showed multifocal, bilateral edema of the basal ganglia.", + "An initial MRI showed bilateral edema of both cerebellar hemispheres.", + "An initial MRI showed edema of the capsula interna.", + "An initial MRI showed diffusion restriction.", + "An initial MRI showed apparent diffusion coefficient (ADC) signal reductions.", + "FLAIR imaging revealed hyperintense alterations in those areas.", + "DWI and FLAIR imaging presented mild, confluent white matter abnormalities above the lateral ventricle.", + "A time-of-flight (TOF)-angiography was normal.", + "An initial spinal tap and subsequent cerebrospinal fluid analysis revealed a disturbance of the blood-brain barrier.", + "An initial spinal tap revealed normal total protein (542 mg/l).", + "An initial spinal tap revealed normal lymphocyte counts (4/μL).", + "An initial spinal tap revealed no intrathecal antibody synthesis.", + "An electroencephalogram revealed intermittent deceleration.", + "An electroencephalogram revealed no epileptic discharges.", + "After admission, the patient was continuously awake and responsive.", + "After admission, the patient did not require intensive care treatment.", + "Initially, walking was impaired without a need for a walking aid.", + "A transesophageal echocardiography revealed no cardiac abnormalities.", + "A transesophageal echocardiography revealed no endocarditis.", + "Repeated blood cultures were negative.", + "Ear-nose-throat consultation revealed an injury of the inner ear.", + "Ear-nose-throat consultation revealed a diminished ability to hear below 55 dB.", + "Treatment with prednisolone for 3 days (days 7–9) at 1 mg per kilogram body weight was performed.", + "Prednisolone treatment did not cause any immediate conceivable improvement of hearing.", + "Hearing ability improved continuously.", + "The unsteady gait improved to an almost normal level between days 9–11 of inpatient treatment.", + "Cognitive deficits remained unchanged with increased response latency.", + "Cognitive deficits remained unchanged with slowed speech.", + "Cognitive deficits remained unchanged with concentration deficits.", + "The hypoesthesia of the inner thigh remained unchanged.", + "An additional MRI after 11 days revealed the known FLAIR-hyperintense lesions of basal ganglia.", + "An additional MRI after 11 days revealed the known FLAIR-hyperintense lesions of capsula interna.", + "An additional MRI after 11 days revealed subtle abnormalities above the lateral ventricles.", + "An additional MRI after 11 days revealed ADC increased in cerebellar hemispheres.", + "New lesions were found in the crura cerebri bilaterally.", + "Another spinal tap revealed an increase of lymphocytes (11/μl).", + "Flow cytometry analysis of cerebrospinal fluid (CSF) cells revealed a shift in monocyte subtypes.", + "Flow cytometry analysis revealed a significant increase of the non-classical CD14 + CD16+ monocyte-fraction.", + "Flow cytometry analysis revealed a decrease of the CD56bright natural killer cell-fraction in the lymphocyte subset.", + "Reference values had been previously collected from 29 patients with psychosomatic disorder.", + "The patient was discharged after 13 days to subsequent rehabilitation.", + "A neuropsychological assessment on day 18 revealed mild-to-moderate overall cognitive impairments.", + "Tests assessing cognitive processing speed showed consistent alterations from the norm.", + "Learning efficiency of both verbal material was impaired.", + "Learning efficiency of visual material was impaired.", + "Recall from memory was only reduced for verbal but preserved for complex visual material.", + "The patient showed preserved performance in tests for complex attention.", + "The patient showed preserved performance in tests for higher executive functions such as planning abilities." + ], + "summary": "Here, we report a patient who developed acute bilateral hearing loss, ataxia and paraparesis subsequently to intravenous methadone-abuse. While the patient gradually recovered from these deficits, widespread magnetic resonance imaging changes progressed and delayed-onset encephalopathy with signs of cortical dysfunction persisted. This was associated with changes in the composition of monocyte and natural killer cell subsets in the cerebrospinal fluid.", + "summary_subclaims": [ + "The patient developed acute bilateral hearing loss.", + "The patient had ataxia.", + "The patient had paraparesis.", + "The patient's deficits gradually recovered.", + "Widespread magnetic resonance imaging changes progressed.", + "Delayed-onset encephalopathy with signs of cortical dysfunction persisted.", + "Changes in the composition of monocyte and natural killer cell subsets in the cerebrospinal fluid were associated with the encephalopathy." + ] + }, + { + "id": "multiclinsum_test_2406_en.txt", + "fulltext": "A 53-year-old Caucasian man presented with a five-day history of malaise, productive cough, fever and rigors. He had been treated by his primary care doctor for two days with oral clarithromycin without improvement. He had undergone dental root canal surgery two months previously; the dental filling fell out the day before admission and our patient may have accidentally swallowed it. He never injected drugs intravenously or received blood transfusion. He never smoked, rarely drank alcohol and took no other medication. On examination, he had a fever of 39°C, blood pressure of 132/68 mmHg, sinus tachycardia of 110 beats per minute. Auscultation of the chest revealed some crackles at the right lung base. His heart sounds were normal, and abdominal examination was normal.\nThe haemoglobin level was 13.0 g/dL (mean corpuscular volume of 85fl); the platelet count was 84 × 109/L; the white cell count 10.0 × 109/L, with a neutrophilia of 9.0 × 109/L. The serum albumin was reduced at 29 g/L, bilirubin 2 micromoles/L, alkaline phosphatase 466 U/L (normal range 25 to 140) and alanine aminotransferase 239 U/L (normal range 10 to 40). The C-reactive protein (CRP) was raised at 178 mg/L. Serum urea, creatinine, electrolytes, glucose and coagulation were within normal reference ranges. Urine analysis showed nitrites, 1+ protein, 1+ bilirubin, and trace blood. The ECG showed sinus tachycardia. Chest radiography showed a prominent right hilum. Blood cultures taken on our patient after admission showed no growth.\nCommunity-acquired pneumonia was suspected for which our patient was treated with intravenous amoxicillin-clavulanic acid 1.2 g every 8 hours and oral clarithromycin 500 mg every 12 hours. A liver ultrasound performed because of the abnormal liver function tests revealed two well-defined areas of mixed echogenicity in the right lobe of the liver measuring 49mm and 40mm in diameter. Metastatic tumor was suspected.\nThe fever of our patient continued, and on the third day, he developed a severe headache with persistent vomiting. Fundoscopy was normal. Computer tomography (CT) scanning of the head with contrast was normal. Lumbar puncture was performed which showed no white cells or red cells and no organisms identified on Gram stain or upon culture of the cerebrospinal fluid (CSF). A CT scan of the chest revealed minor basal atelectasis. A CT scan of the abdomen and pelvis revealed a single enhancing low attenuation 4.5 cm mass in the right lobe of the liver which showed some contrast enhancement [figure ]. The other solid organs and appendix were normal, and a metal artefact was seen in the colon [figure ].\nBecause he was not improving, he underwent percutaneous aspiration of the liver lesion under ultrasound guidance after six days. This drained 30 ml of pus from our patient. Gram stain showed no organisms and culture was negative. He continued to have upper abdominal pain and high fever. A repeat abdominal CT scan showed persistence of the liver abscess, and a mildly dilated appendix (approx. 12 mm diameter). Plain abdominal radiography confirmed a dense radio-opaque object consistent with amalgam dental filling in the right lower quadrant. A percutaneous pigtail drain was inserted and a further 20 ml of pus was aspirated. He was treated with intravenous ertapenem 1 g once daily and intravenous metronidazole 500 mg three times a day.\nBoth samples of pus that were aspirated from the liver abscess were culture negative. The causative organism was identified as Aggregatibacter paraphrophilus by polymerase chain reaction (PCR) amplification of the bacterial 16S ribosomal DNA followed by nucleotide sequencing, using published primers . Serological tests for influenza A and B, parainfluenza, adenovirus, respiratory syncytial virus, Chlamydia, and Mycoplasma were negative. All urine, stool, cerebrospinal fluid and methicillin resistant Staphylococcus aureus multisite cultures were negative. A trans-thoracic echocardiogram (TTE) prior to discharge did not show evidence of endocarditis. Repeat CT scan of the abdomen after 14 days showed improvement in the liver abscess and some bilateral basal consolidation. The fever of our patient was resolved. After completing 19 days of intravenous ertapenem, it was shifted to oral amoxicillin 500 mg every eight hours for two weeks. During discharge after 29 days, his liver function tests had returned to normal, but he was anaemic with a haemoglobin of 10.7 g/dL, an erythrocyte sedimentation rate (ESR) of 94 mm/hr and CRP of 17 mg/L.\nThree weeks after discharge and two weeks after having completed the course of oral amoxicillin, our patient re-presented to our hospital. Since discharge, he had been bumping into objects on his left side and for one day he had headache, rigors and a sore throat - he was re-admitted on that day 51. On examination, he was febrile with no signs of infective endocarditis. Ophthalmological examination revealed a left homonymous hemianopia with normal fundi. Repeat blood tests showed a haemoglobin of 11.4 g/dl (MCV 86.0fl) and a CRP of 62 mg/L; his renal and liver function tests were normal. A CT scan of the head with contrast performed on day 52 revealed multiple brain abscesses: a ring-enhancing lesion in the left occipital lobe and a non-enhancing low attenuation lesion in the right occipital lobe, with no mass effect. A CT scan of the abdomen showed a small resolving area of low attenuation in the liver; the appendix was normal. He was treated with intavenous meropenem 2 g every eight hours and transferred to a tertiary hospital. Magnetic resonance imaging (MRI) of the head confirmed multiple brain abscesses; there were multiple foci of contrast enhancement near the grey-white junction of both cerebral hemispheres, a more confluent area of signal change and enhancement was seen in the right occipital lobe, and a small enhancing lesion was seen in the right cerebellar hemisphere [figure ].\nOn day 53, a mini-craniotomy and biopsy was performed on a left occipital ring-enhancing lesion. On microscopy, pus cells were seen but no organisms were observed on gram staining, and enriched aerobic, anaerobic and fungal cultures were negative. Results of the 16S rDNA PCR of the brain abscess biopsy again detected the sequence of Aggregatibacter paraphrophilus. Histopathology showed appearances typical of a brain abscess. A trans-oesophageal echo performed on day 55 showed no evidence of endocarditis but there was evidence of a patent foramen ovale (PFO) and an atrial septal aneurysm. A bubble echo was performed on day 60; during provocation by Valsalva maneuver, there was a large right-to-left shunt through the patent foramen ovale. Ultrasound scanning of the liver showed no remaining collection. Maxillo-facial assessment including dental panoramic tomography revealed no ongoing dental infection. His immunoglobulins were normal, anti-nuclear antibody and anti-neutrophil cytoplasmic antibody negative, and serological tests for human immunodeficiency virus, syphilis and toxoplasma were negative. He continued treatment with intravenous meropenem 2 g every eight hours and oral metronidazole 400 mg every eight hours added on day 54, and remained afebrile. He was discharged on day 65 since first presentation (white cell count 7.3 × 109/L and CRP 5 mg/L) with intravenous ceftriaxone 2 g every 12 hours to complete four weeks of out-patient antibiotics via a peripherally inserted central line.\nFollow-up CT scan of the head on day 71 showed surgical changes deep to the left occipital craniotomy; resolving right frontal and left occipital lobe abscesses; and a large hypodense area in the right occipital lobe in keeping with an established occipital infarct. Follow-up cranial MRI on day 81 revealed improvement in the size of the multiple small enhancing subcortical white matter lesions (likely microabscesses); with persistence of the right occipital infarct.\nOn outpatient follow-up, intravenous antibiotics were extended to complete a six week course in total; our patient was then switched to oral amoxicillin-clavulanic acid 625 mg every eight hours for a duration of two weeks. Unfortunately, his left homonymous hemianopia persisted.\nCardiology follow-up concluded that it was prudent to close the PFO as there was a possibility of further paradoxical emboli and this is planned. Our patient was put on anti-coagulant and anticonvulsant therapy and a cranial MRI on day 137 has shown further improvement of the cerebral abscesses.", + "fulltext_subclaims": [ + "A 53-year-old Caucasian man presented with a five-day history of malaise, productive cough, fever and rigors.", + "He had been treated by his primary care doctor for two days with oral clarithromycin without improvement.", + "He had undergone dental root canal surgery two months previously.", + "The dental filling fell out the day before admission and our patient may have accidentally swallowed it.", + "He never injected drugs intravenously or received blood transfusion.", + "He never smoked, rarely drank alcohol and took no other medication.", + "On examination, he had a fever of 39°C.", + "The white cell count was 10.0 × 109/L, with a neutrophilia of 9.0 × 109/L.", + "The serum albumin was reduced at 29 g/L.", + "The C-reactive protein (CRP) was raised at 178 mg/L.", + "Urine analysis showed nitrites, 1+ protein, 1+ bilirubin, and trace blood.", + "The ECG showed sinus tachycardia.", + "Chest radiography showed a prominent right hilum.", + "Community-acquired pneumonia was suspected.", + "A liver ultrasound revealed two well-defined areas of mixed echogenicity in the right lobe of the liver measuring 49mm and 40mm in diameter.", + "Metastatic tumor was suspected.", + "The fever of our patient continued, and on the third day, he developed a severe headache with persistent vomiting.", + "Lumbar puncture showed no white cells or red cells and no organisms identified on Gram stain or upon culture of the cerebrospinal fluid.", + "A CT scan of the abdomen and pelvis revealed a single enhancing low attenuation 4.5 cm mass in the right lobe of the liver.", + "A metal artefact was seen in the colon.", + "He underwent percutaneous aspiration of the liver lesion under ultrasound guidance after six days.", + "This drained 30 ml of pus from our patient.", + "Gram stain showed no organisms and culture was negative.", + "A repeat abdominal CT scan showed persistence of the liver abscess, and a mildly dilated appendix (approx. 12 mm diameter).", + "Plain abdominal radiography confirmed a dense radio-opaque object consistent with amalgam dental filling in the right lower quadrant.", + "A percutaneous pigtail drain was inserted and a further 20 ml of pus was aspirated.", + "He was treated with intravenous ertapenem 1 g once daily and intravenous metronidazole 500 mg three times a day.", + "Both samples of pus that were aspirated from the liver abscess were culture negative.", + "The causative organism was identified as Aggregatibacter paraphrophilus by polymerase chain reaction (PCR) amplification of the bacterial 16S ribosomal DNA followed by nucleotide sequencing.", + "A trans-thoracic echocardiogram (TTE) prior to discharge did not show evidence of endocarditis.", + "Repeat CT scan of the abdomen after 14 days showed improvement in the liver abscess.", + "The fever of our patient was resolved.", + "After completing 19 days of intravenous ertapenem, it was shifted to oral amoxicillin 500 mg every eight hours for two weeks.", + "During discharge after 29 days, his liver function tests had returned to normal.", + "Three weeks after discharge and two weeks after having completed the course of oral amoxicillin, our patient re-presented to our hospital.", + "Since discharge, he had been bumping into objects on his left side and for one day he had headache, rigors and a sore throat.", + "On examination, he was febrile with no signs of infective endocarditis.", + "Ophthalmological examination revealed a left homonymous hemianopia with normal fundi.", + "A CT scan of the head with contrast performed on day 52 revealed multiple brain abscesses.", + "A CT scan of the abdomen showed a small resolving area of low attenuation in the liver; the appendix was normal.", + "He was treated with intravenous meropenem 2 g every eight hours and transferred to a tertiary hospital.", + "Magnetic resonance imaging (MRI) of the head confirmed multiple brain abscesses.", + "A mini-craniotomy and biopsy was performed on a left occipital ring-enhancing lesion.", + "On microscopy, pus cells were seen but no organisms were observed on gram staining, and enriched aerobic, anaerobic and fungal cultures were negative.", + "Results of the 16S rDNA PCR of the brain abscess biopsy again detected the sequence of Aggregatibacter paraphrophilus.", + "A trans-oesophageal echo performed on day 55 showed no evidence of endocarditis but there was evidence of a patent foramen ovale (PFO) and an atrial septal aneurysm.", + "A bubble echo was performed on day 60; during provocation by Valsalva maneuver, there was a large right-to-left shunt through the patent foramen ovale.", + "He continued treatment with intravenous meropenem 2 g every eight hours and oral metronidazole 400 mg every eight hours added on day 54.", + "He was discharged on day 65 since first presentation with intravenous ceftriaxone 2 g every 12 hours to complete four weeks of out-patient antibiotics via a peripherally inserted central line.", + "Follow-up CT scan of the head on day 71 showed surgical changes deep to the left occipital craniotomy; resolving right frontal and left occipital lobe abscesses; and a large hypodense area in the right occipital lobe in keeping with an established occipital infarct.", + "Follow-up cranial MRI on day 81 revealed improvement in the size of the multiple small enhancing subcortical white matter lesions.", + "On outpatient follow-up, intravenous antibiotics were extended to complete a six week course in total.", + "Our patient was then switched to oral amoxicillin-clavulanic acid 625 mg every eight hours for a duration of two weeks.", + "His left homonymous hemianopia persisted.", + "Cardiology follow-up concluded that it was prudent to close the PFO as there was a possibility of further paradoxical emboli.", + "Our patient was put on anti-coagulant and anticonvulsant therapy.", + "A cranial MRI on day 137 has shown further improvement of the cerebral abscesses." + ], + "summary": "We report a case of a 53-year-old Caucasian man with a liver abscess and subsequent brain abscesses caused by Aggregatibacter paraphrophilus. The probable source of the infection was the oral flora of our patient following ingestion of a dental filling. The presence of a large patent foramen ovale was a predisposing factor for multifocal abscesses.", + "summary_subclaims": [ + "The patient was a 53-year-old Caucasian man.", + "The patient had a liver abscess.", + "The patient had subsequent brain abscesses.", + "Aggregatibacter paraphrophilus was the causative organism.", + "The probable source of the infection was the oral flora of the patient.", + "The infection followed ingestion of a dental filling.", + "The presence of a large patent foramen ovale was a predisposing factor.", + "The patent foramen ovale was associated with multifocal abscesses." + ] + }, + { + "id": "multiclinsum_test_1138_en.txt", + "fulltext": "A 3-months-old female was referred to our department because of suspicion of child physical abuse. She was born at term, a product of uneventful gestation. At birth her weight was 3310 gm, length of 51 cm and her occipito-frontal circumference was 33.5 cm. No irritability, feeding or pulmonary abnormalities, and fever were recorded. The mother was 29-year-old-gravida 2, married to a 33-year-old-unrelated man. She had no history of spontaneous abortions, stillbirths, prematurity and or polyhydramnios. No maternal use of medications or antenatal illnesses was reported. Physical examination of the baby showed normal facial features, no blue sclerae, normal nose but swelling of the mandible was noted. There were swellings of some of the long bones (right leg, and radius). Neither feeding abnormalities nor fever was present. Her chest was noted to be symmetrical and of normal appearance. Hands and feet were normal. There were no associated signs of abnormal skin stigmata such as fragility/extensibility and or ligamentous hyperlaxity was noted. Hearing, vision and neurological examinations were all normal. Laboratory studies including metabolic tests, which aimed to tests calcium, phosphorus, and vitamin D metabolism were normal. No specific genetic test has been done for this baby.\nAnteroposterior radiograph of the skull showed massive sclerosis of the skull bone associated with significant cortical hyperostosis and enlargement of the mandible secondary to cortical new bone formation . Lateral skull radiograph showed sclerosis of the skull base (arrow) and hyperostosis of the calvaria . Coronal MRI imaging showed significant calvarial/facial and mandibular hyperostosis . Anteroposterior radiograph of the radius showed cortical new bone formation associated with subperiosteal thickening. Note marked bloating along the diaphysis with sparing of the epi-metaphyseal components associated with expansion of the bone marrow cavity and a persistent-like deformity . Anteroposterior radiograph of the tibia showed a thick and broad ballooning occupies the diaphyses (proximally and distally) there is gaining in the diameter comes from subperiosteal new bone apposition by intramembraneous bone formation .", + "fulltext_subclaims": [ + "The patient is a 3-months-old female.", + "The patient was referred because of suspicion of child physical abuse.", + "She was born at term.", + "The mother was 29-year-old-gravida 2.", + "The mother was married to a 33-year-old-unrelated man.", + "No maternal use of medications or antenatal illnesses was reported.", + "Physical examination showed swelling of the mandible.", + "There were swellings of some of the long bones (right leg, and radius).", + "No feeding abnormalities were present.", + "Laboratory studies including metabolic tests were normal.", + "No specific genetic test has been done for this baby.", + "Anteroposterior radiograph of the skull showed massive sclerosis of the skull bone associated with significant cortical hyperostosis.", + "Lateral skull radiograph showed sclerosis of the skull base.", + "Coronal MRI imaging showed significant calvarial/facial and mandibular hyperostosis.", + "Anteroposterior radiograph of the radius showed cortical new bone formation associated with subperiosteal thickening.", + "Anteroposterior radiograph of the tibia showed a thick and broad ballooning occupies the diaphyses." + ], + "summary": "We report on a clinical case of a 3-months-old baby girl of non-consanguineous parents. Multiple long bone swellings were the motive of referral to our department for clinical evaluation. Radiographic documentation was consistent with infantile cortical hyperostosis (Caffey disease). Interestingly, skull base sclerosis associated with excessive thickening was the most unusual malformation. We report a baby with mixed endochondral and intramembraneous ossification defects.", + "summary_subclaims": [ + "The patient is a 3-months-old baby girl.", + "The parents are non-consanguineous.", + "Multiple long bone swellings were the motive of referral.", + "Radiographic documentation was consistent with infantile cortical hyperostosis.", + "Skull base sclerosis associated with excessive thickening was the most unusual malformation.", + "The baby had mixed endochondral and intramembraneous ossification defects." + ] + }, + { + "id": "multiclinsum_test_1291_en.txt", + "fulltext": "A 54-year-old Caucasian Greek man presented to the Accident and Emergency department of our hospital with a 20-day history of abdominal pain, vomiting and loss of appetite. He mentioned an eight kg weight loss over the last 20 days, as he had been drinking almost exclusively water due to his symptoms. He had not presented to any hospital facility earlier because he lived in a remote area in the mountains. On admission, he had the septic image of paleness, tachypnea, tachycardia (110 beats/minute) and a fever of 38.5°C, as well as a rigid abdomen. Abdominal and plain chest X-rays demonstrated free gas under both the hemidiaphragms. After initial resuscitation (placement of intravenous lines and nasogastric tube followed by adequate administration of fluids), our patient underwent an emergency exploratory laparotomy. Our patient's worsening clinical image and his deteriorating clinical signs (tachypnea and tachycardia), along with the presence of his acute abdomen led us to conclude that an emergency laparotomy constituted the treatment of choice. In the face of the emergency situation a computed tomography (CT) scan was not performed. Laparotomy revealed peritonitis due to a perforated ulcer on the anterior wall of the duodenum, which was sutured, while the suture line was reinforced with an omental patch . After a thorough lavage of the peritoneal cavity, further exploration of the intra-abdominal organs revealed a second posterior pre-pyloric ulcer on the lesser curvature of the stomach, perforated into the lesser sac . A wedge resection with staplers was carried out , while no further acid reduction procedures were undertaken due to sepsis. A Nissen fundoplication was performed as an anti-reflux measure. Our patient recovered uneventfully and was discharged home on the 13th post-operative day; at this time we administered an appropriate eradication therapy. More specifically, we followed the protocol of triple therapy: a proton pump inhibitor, amoxicillin and clarithromycin were administered. After discharge our patient was referred to gastrointestinal specialists. Our colleagues planned a surveillance endoscopy according to their protocol.", + "fulltext_subclaims": [ + "The patient is a 54-year-old Caucasian Greek man.", + "He presented with a 20-day history of abdominal pain, vomiting, and loss of appetite.", + "He had an eight kg weight loss over the last 20 days.", + "He had not presented to any hospital facility earlier.", + "On admission, he had a fever of 38.5°C.", + "Abdominal and plain chest X-rays demonstrated free gas under both hemidiaphragms.", + "The patient underwent an emergency exploratory laparotomy.", + "Laparotomy revealed peritonitis due to a perforated ulcer on the anterior wall of the duodenum.", + "The ulcer was sutured, and the suture line was reinforced with an omental patch.", + "A second posterior pre-pyloric ulcer on the lesser curvature of the stomach was found, perforated into the lesser sac.", + "A wedge resection with staplers was carried out.", + "A Nissen fundoplication was performed as an anti-reflux measure.", + "The patient was discharged home on the 13th post-operative day.", + "Triple therapy (proton pump inhibitor, amoxicillin, and clarithromycin) was administered.", + "The patient was referred to gastrointestinal specialists after discharge." + ], + "summary": "We present a rare case of a 54-year-old Caucasian man who underwent an emergency laparotomy for peritonitis caused by perforation of two peptic ulcers. The first was located on the anterior wall of the duodenum and the second was posterior, pre-pyloric, close to the lesser curvature.", + "summary_subclaims": [ + "The patient is a 54-year-old Caucasian man.", + "The patient underwent an emergency laparotomy.", + "The laparotomy was performed for peritonitis.", + "The peritonitis was caused by perforation of two peptic ulcers.", + "The first ulcer was located on the anterior wall of the duodenum.", + "The second ulcer was posterior, pre-pyloric, close to the lesser curvature." + ] + }, + { + "id": "multiclinsum_test_2259_en.txt", + "fulltext": "A 57-year-old Chinese man presented to the urology clinic with unable to self-urinate for two weeks.\nAfter two weeks of having the catheter in place and consistently taking tamsulosin, the patient remained unable to self-urinate.\nA 57-year-old male initially visited an outpatient clinic specialising in urological surgery due to urinary urgency and frequency. In October 2022, the patient was diagnosed with benign prostatic hyperplasia (BPH). Despite treatment with tamsulosin, an α-blocker, his symptoms rapidly worsened within two months. Subsequently, he was admitted to the emergency department for acute urinary retention and received an indwelling catheter. After two weeks of having the catheter in place and consistently taking tamsulosin, the patient remained unable to self-urinate. He revisited the urological surgery outpatient clinic in December 2022 and was admitted for BPH. Over the previous two months, the patient experienced no other symptoms, such as fever or weight loss.\nThe patient denied any family history of malignant tumours.\nThe patient's physical examination revealed no apparent abnormalities. Digital rectal examination indicated a Grade II prostate, characterised by a firm texture, smooth surface, lack of tenderness and an absent central groove.\nBlood routine examination and liver and kidney function test results were within normal limits. The serum total prostate-specific antigen measured 4.30 ng/mL (normal < 4 ng/mL), and the free prostate-specific antigen was 0.42 ng/mL. Routine urine analysis presented no significant abnormalities.\nUltrasound examination of the urinary system demonstrated normal left and right kidneys. Computerised tomography (CT) estimated the prostate size to be approximately 57 mm × 36 mm × 34 mm, with a volume of around 36 mL. The bladder's residual urine volume was approximately 552 mL, as illustrated in Figure . The preoperative international prostate symptom score was 27, and the quality of life (QOL) score was 5. Urodynamic examination indicated a maximum urine flow rate of 6.4 mL/s and an average urine flow rate of 5.2 mL/s.\nBased on the aforementioned examinations and tests, the patient was preliminarily diagnosed with prostatic hyperplasia. Upon conducting a physical examination, laboratory tests and imaging, a HoLEP procedure was performed on the patient in December 2022.\nThe surgeon observed that the patient's prostate tissue was notably swollen, with the left lobe of the prostate exhibiting significant oedema and protruding into the bladder. Additionally, extensive trabeculation was present within the bladder. The prostate tissue's texture was delicate, making it prone to bleeding upon contact. Once the bleeding from the prostate wound was controlled, the excised tissue was collected and submitted for examination. The patient experienced symptom regression following surgery.", + "fulltext_subclaims": [ + "A 57-year-old Chinese man presented to the urology clinic with unable to self-urinate for two weeks.", + "After two weeks of having the catheter in place and consistently taking tamsulosin, the patient remained unable to self-urinate.", + "The patient was diagnosed with benign prostatic hyperplasia (BPH) in October 2022.", + "The patient was admitted to the emergency department for acute urinary retention and received an indwelling catheter.", + "The patient revisited the urological surgery outpatient clinic in December 2022 and was admitted for BPH.", + "The patient experienced no other symptoms, such as fever or weight loss.", + "The patient denied any family history of malignant tumours.", + "Digital rectal examination indicated a Grade II prostate, characterised by a firm texture, smooth surface, lack of tenderness and an absent central groove.", + "The serum total prostate-specific antigen measured 4.30 ng/mL.", + "The free prostate-specific antigen was 0.42 ng/mL.", + "Computerised tomography estimated the prostate size to be approximately 57 mm × 36 mm × 34 mm.", + "The bladder's residual urine volume was approximately 552 mL.", + "The preoperative international prostate symptom score was 27.", + "The quality of life (QOL) score was 5.", + "Urodynamic examination indicated a maximum urine flow rate of 6.4 mL/s.", + "The surgeon observed that the patient's prostate tissue was notably swollen.", + "The left lobe of the prostate exhibited significant oedema and protruded into the bladder.", + "Extensive trabeculation was present within the bladder.", + "The prostate tissue's texture was delicate, making it prone to bleeding upon contact.", + "The patient experienced symptom regression following surgery." + ], + "summary": "This report presents a case of a 57-year-old male with primary prostate Burkitt's lymphoma, initially misdiagnosed as prostatic hyperplasia. This case's operative process, intraoperative findings and postoperative management are discussed in detail.", + "summary_subclaims": [ + "The patient is a 57-year-old male.", + "The patient has primary prostate Burkitt's lymphoma.", + "The patient was initially misdiagnosed as having prostatic hyperplasia.", + "This case's operative process is discussed.", + "Intraoperative findings are discussed.", + "Postoperative management is discussed." + ] + }, + { + "id": "multiclinsum_test_945_en.txt", + "fulltext": "A 54-year-old male with a remote history of Hodgkin lymphoma treated with chemotherapy and mediastinal radiation was admitted to the hospital to undergo elective surgical mitral valve (MV) replacement and tricuspid valve (TV) repair. He previously had radiation-induced aortic valve stenosis requiring surgical aortic valve replacement with bioprosthetic aortic root in 2013. He was again referred to cardiothoracic surgery in 2019 for shortness of breath, fatigue, and severe pulmonary arterial (PA) hypertension (mean PA pressure 75 mmHg on right heart catheterization) resulting from radiation-induced calcific mitral stenosis, mitral regurgitation (MR) and tricuspid regurgitation (TR). Intraoperatively, there was enormous calcification extending from the interannular fibrosa to the A1, A2, P1, and P3 regions of the mitral valve requiring extensive debridement (Video 1, Figure ). A bioprosthetic MV and TV annuloplasty ring were then successfully inserted with initial improvement in PA pressures by approximately 30% by invasive monitoring. Limited intraoperative TOE post-cardiopulmonary bypass showed preserved ventricular function, trace TR, and trace paravalvular MR in the A1 region where calcification had been heaviest, and debridement caused disruption of the anterior mitral annular structure.\nHe was admitted to the intensive care unit for post-operative care and weaned off ventilator and vasopressor support. He was found to have post-surgical complete heart block requiring placement of a permanent pacemaker on post-operative Day 11.\nOne week later, he developed shortness of breath, orthopnoea, and weight gain. Physical exam was notable for jugular venous distention, bibasilar pulmonary crackles, and peripheral pitting oedema. Despite escalating diuretics, the volume overload progressed with a net weight gain of 16 kg. He developed acute kidney injury, transaminitis, and hypotension requiring inotropic and vasopressor support. Laboratory investigation also revealed worsening haemolytic anaemia (haemoglobin nadir 8.1 g/dL, total bilirubin 43.8 mg/dL, lactate dehydrogenase 2993 U/L, haptoglobin <30 mg/dL, and schistocytes on peripheral smear). Additional testing ruled out adrenal insufficiency (Ante meridiem (AM) cortisol 18.8 µg/dL), hyperthyroidism (thyroid stimulating hormone (TSH) 3.59 mIU/L, free thyroxine 1.25 ng/dL), or arteriovenous fistula at the recent left heart catheterization femoral access site.\nRepeat transthoracic echocardiogram (TTE) identified increased transmitral gradient (mean 14 mmHg, peak 33 mmHg) with normal pressure half-time (81 ms), elevated peak velocity (2.8 m/s), elevated velocity Time integral (VTI) ratio (2.92), and decreased indexed effective orifice area (0.4 cm2/m2) suggestive of significant occult MR vs. patient-prosthesis mismatch; it also revealed moderate TR and an estimated right ventricular systolic pressure of 80.3 mmHg . Due to concern for paravalvular leak causing severe haemolytic anaemia and high-output heart failure, a TOE was performed. Images confirmed a moderate-to-severe medial paravalvular mitral leak and a smaller posterolateral leak without evidence of valvular MR. There was a pacemaker lead crossing through the septal portion of the tricuspid annuloplasty ring with dehiscence and associated moderate TR. Most notably, the TOE unexpectedly identified a large septal defect between the LV and the RA , making the diagnosis of acquired iatrogenic Gerbode defect.\nThe Gerbode defect was adjacent to the medial aspect of the MV prosthesis and posterior to the TV apparatus. Because of the significant risk posed by surgical intervention, the decision was made to pursue transcatheter device closure.\nThe patient subsequently underwent right heart catheterization, which demonstrated mean RA pressure 30 mmHg, right ventricular (RV) pressure 80/8 mmHg with end-diastolic pressure of 28 mmHg, PA pressure 80/30 (52) mmHg, and mean pulmonary capillary wedge pressure 36 mmHg. Intraoperative TOE confirmed a Gerbode defect (6.5 mm × 7.8 mm). The defect was closed via right internal jugular approach using a 12-10mm AMPLATZER Duct Occluder (Abbott, Lake Bluff, IL, USA) with immediate drop in mean RA pressure to 21 mmHg, increase in systolic blood pressure by 30 mmHg, and trace residual shunt (Video 3). Because of the hemodynamic significance of the Gerbode defect, as well as the proximity of the defect to the mitral valve prosthesis, the paravalvular mitral leak was not primarily addressed. Incidentally, there was mild improvement of the paravalvular mitral leak following Gerbode closure due to some overlap of the retention disc with this area (Video 3).\nFollowing defect closure, there was rapid recovery of renal function, resolution of haemolysis and increased response to diuresis . On repeat TTE 1 week later, the device remained in appropriate position with insignificant residual shunt. Despite the fact that a mild paravalvular mitral leak persisted with a prosthetic mitral valve mean gradient of 9.5 mmHg, the patient clinically improved, and the decision was made to defer any further attempts at repair. He was discharged after a prolonged hospital course asymptomatic on daily diuretics, including bumetanide, spironolactone, and metolazone. The patient completed his subsequent follow-up visits at an outside facility closer to his home, but 8 months later, he remained well with no hospitalizations following his discharge.", + "fulltext_subclaims": [ + "The patient is a 54-year-old male.", + "He has a remote history of Hodgkin lymphoma.", + "He was treated with chemotherapy and mediastinal radiation.", + "He underwent elective surgical mitral valve replacement and tricuspid valve repair.", + "He had radiation-induced aortic valve stenosis.", + "He had surgical aortic valve replacement with bioprosthetic aortic root in 2013.", + "He was referred to cardiothoracic surgery in 2019.", + "He had shortness of breath, fatigue, and severe pulmonary arterial hypertension.", + "Right heart catheterization showed mean PA pressure 75 mmHg.", + "The pulmonary arterial hypertension resulted from radiation-induced calcific mitral stenosis.", + "The pulmonary arterial hypertension resulted from mitral regurgitation.", + "The pulmonary arterial hypertension resulted from tricuspid regurgitation.", + "Intraoperatively, there was enormous calcification extending from the interannular fibrosa to the A1, A2, P1, and P3 regions of the mitral valve.", + "A bioprosthetic MV and TV annuloplasty ring were inserted.", + "Initial improvement in PA pressures by approximately 30% was noted.", + "Limited intraoperative TOE post-cardiopulmonary bypass showed preserved ventricular function.", + "Limited intraoperative TOE post-cardiopulmonary bypass showed trace TR.", + "Limited intraoperative TOE post-cardiopulmonary bypass showed trace paravalvular MR in the A1 region.", + "The anterior mitral annular structure was disrupted due to calcification and debridement.", + "He was admitted to the intensive care unit.", + "He was weaned off ventilator and vasopressor support.", + "He developed post-surgical complete heart block.", + "A permanent pacemaker was placed on post-operative Day 11.", + "One week later, he developed shortness of breath, orthopnoea, and weight gain.", + "Physical exam showed jugular venous distention.", + "Physical exam showed bibasilar pulmonary crackles.", + "Physical exam showed peripheral pitting oedema.", + "Despite escalating diuretics, volume overload progressed.", + "He had a net weight gain of 16 kg.", + "He developed acute kidney injury.", + "He developed transaminitis.", + "He developed hypotension requiring inotropic and vasopressor support.", + "Laboratory investigation revealed worsening haemolytic anaemia.", + "Haemoglobin was 8.1 g/dL.", + "Total bilirubin was 43.8 mg/dL.", + "Lactate dehydrogenase was 2993 U/L.", + "Haptoglobin was <30 mg/dL.", + "Schistocytes were noted on peripheral smear.", + "Adrenal insufficiency was ruled out.", + "Hyperthyroidism was ruled out.", + "An arteriovenous fistula at the recent left heart catheterization femoral access site was ruled out.", + "Repeat TTE identified increased transmitral gradient.", + "Repeat TTE showed mean transmitral gradient 14 mmHg.", + "Repeat TTE showed peak transmitral gradient 33 mmHg.", + "Repeat TTE showed normal pressure half-time 81 ms.", + "Repeat TTE showed elevated peak velocity 2.8 m/s.", + "Repeat TTE showed elevated velocity time integral ratio 2.92.", + "Repeat TTE showed decreased indexed effective orifice area 0.4 cm2/m2.", + "Repeat TTE suggested significant occult MR vs. patient-prosthesis mismatch.", + "Repeat TTE revealed moderate TR.", + "Repeat TTE estimated right ventricular systolic pressure 80.3 mmHg.", + "A TOE was performed due to concern for paravalvular leak.", + "TOE confirmed a moderate-to-severe medial paravalvular mitral leak.", + "TOE showed a smaller posterolateral leak.", + "TOE showed no evidence of valvular MR.", + "A pacemaker lead crossed through the septal portion of the tricuspid annuloplasty ring.", + "There was dehiscence and associated moderate TR.", + "TOE identified a large septal defect between the LV and the RA.", + "The diagnosis was acquired iatrogenic Gerbode defect.", + "The Gerbode defect was adjacent to the medial aspect of the MV prosthesis.", + "The Gerbode defect was posterior to the TV apparatus.", + "The decision was made to pursue transcatheter device closure.", + "Right heart catheterization showed mean RA pressure 30 mmHg.", + "Right heart catheterization showed RV pressure 80/8 mmHg.", + "Right heart catheterization showed end-diastolic pressure 28 mmHg.", + "Right heart catheterization showed PA pressure 80/30 (52) mmHg.", + "Right heart catheterization showed mean pulmonary capillary wedge pressure 36 mmHg.", + "Intraoperative TOE confirmed a Gerbode defect 6.5 mm × 7.8 mm.", + "The defect was closed via right internal jugular approach.", + "A 12-10mm AMPLATZER Duct Occluder was used.", + "There was immediate drop in mean RA pressure to 21 mmHg.", + "There was increase in systolic blood pressure by 30 mmHg.", + "There was trace residual shunt.", + "The paravalvular mitral leak was not primarily addressed.", + "There was mild improvement of the paravalvular mitral leak following Gerbode closure.", + "There was some overlap of the retention disc with the paravalvular leak area.", + "Following defect closure, there was rapid recovery of renal function.", + "Haemolysis resolved.", + "There was increased response to diuresis.", + "On repeat TTE 1 week later, the device remained in appropriate position.", + "There was insignificant residual shunt.", + "A mild paravalvular mitral leak persisted.", + "The prosthetic mitral valve mean gradient was 9.5 mmHg.", + "The patient clinically improved.", + "The decision was made to defer any further attempts at repair.", + "He was discharged asymptomatic on daily diuretics.", + "He was on bumetanide, spironolactone, and metolazone.", + "He completed follow-up visits at an outside facility.", + "He remained well 8 months later.", + "He had no hospitalizations following discharge." + ], + "summary": "We report a patient with severe mitral stenosis as a result of remote mediastinal radiation who underwent extensive decalcification during surgical mitral valve replacement and tricuspid valve repair. Following the procedure, he developed progressive heart failure refractory to medical management. Extensive workup ultimately led to the diagnosis of iatrogenic acquired Gerbode defect. Close collaboration between adult cardiology, cardiothoracic surgery, and the congenital cardiology services led to an optimal treatment plan involving percutaneous closure of the defect.", + "summary_subclaims": [ + "The patient had severe mitral stenosis as a result of remote mediastinal radiation.", + "The patient underwent surgical mitral valve replacement.", + "The patient underwent tricuspid valve repair.", + "The patient developed progressive heart failure following the procedure.", + "The heart failure was refractory to medical management.", + "An extensive workup led to the diagnosis of iatrogenic acquired Gerbode defect.", + "Close collaboration between adult cardiology, cardiothoracic surgery, and congenital cardiology services occurred.", + "The treatment plan involved percutaneous closure of the defect." + ] + }, + { + "id": "multiclinsum_test_1724_en.txt", + "fulltext": "On April 1, 2020, a 47-year-old man, suffering from psoriasis, visited our clinic. The patient had inflammation on the fingers, the backs of the hands, both wrists, and both ears. Erythema was widely spread on both hands, all fingers, and both wrists. Erythema was also found on the inside of the auricle and on the lower part of the earlobe . Also, he complained of itchiness.\nHe had been diagnosed with psoriasis in 1995. Subsequently, over the next 25 years, he had received herbal treatment, dermatological laser treatment, and drug treatment.\nThe patient has been no specific disease excepted psoriasis.\nThe patient had no diseases personal and family histories.\nWhen the patient visited the hospital, the lesion area was spread over several parts of the body.\nThe severity of psoriasis was evaluated using the PASI and DLQI at the time of the patient’s visit. The PASI and DLQI scores were 9.9 and 27, respectively.", + "fulltext_subclaims": [ + "On April 1, 2020, a 47-year-old man, suffering from psoriasis, visited our clinic.", + "The patient had inflammation on the fingers, the backs of the hands, both wrists, and both ears.", + "Erythema was widely spread on both hands, all fingers, and both wrists.", + "Erythema was also found on the inside of the auricle and on the lower part of the earlobe.", + "He complained of itchiness.", + "He had been diagnosed with psoriasis in 1995.", + "Over the next 25 years, he had received herbal treatment, dermatological laser treatment, and drug treatment.", + "The patient has been no specific disease excepted psoriasis.", + "The patient had no diseases personal and family histories.", + "When the patient visited the hospital, the lesion area was spread over several parts of the body.", + "The severity of psoriasis was evaluated using the PASI and DLQI at the time of the patient’s visit.", + "The PASI and DLQI scores were 9.9 and 27, respectively." + ], + "summary": "The patient was a 47-year-old male, diagnosed with psoriasis in 1995. He had received various treatments for 25 years, but the psoriatic condition was not significantly improved. He was given three rounds of minimally manipulated umbilical cord-derived MSCs over 2 wk. The erythema gradually disappeared. Three months after the 1st round, all erythema completely disappeared, and the psoriasis did not recur.", + "summary_subclaims": [ + "The patient was a 47-year-old male.", + "He was diagnosed with psoriasis in 1995.", + "He had received various treatments for 25 years.", + "The psoriatic condition was not significantly improved.", + "He was given three rounds of minimally manipulated umbilical cord-derived MSCs over 2 wk.", + "The erythema gradually disappeared.", + "Three months after the 1st round, all erythema completely disappeared.", + "The psoriasis did not recur." + ] + }, + { + "id": "multiclinsum_test_2657_en.txt", + "fulltext": "An 83-year-old white man presented to our emergency department with shortness of breath. His past medical history was significant for chronic obstructive pulmonary disease, atrial fibrillation, congestive heart failure, anemia of chronic disease, sick sinus syndrome, pulmonary hypertension, and chronic kidney disease. His medications included probenecid, finasteride, albuterol-ipratropium bromide by inhalation, furosemide, carvedilol, omeprazole, tamsulosin, mirtazapine, ferrous sulfate, metolazone, losartan, budesonide, and prednisone. He was also on apixaban 2.5 mg twice daily for anticoagulation due to non-valvular atrial fibrillation. He did not have a history of bleeding or clotting disorders, although he had presented to our emergency department with complaints of hemoptysis at least once previously due to his cardiopulmonary disease.\nAcute-on-chronic congestive heart failure and exacerbation of chronic obstructive pulmonary disease were diagnosed. Five days into his hospital stay he awoke with diffuse abdominal pain. He and his wife both denied history of recent abdominal or chest trauma, including falls. After the onset of his abdominal pain, while sitting up in bed, he had a witnessed syncopal event and became unresponsive. A medical emergency response team was called to his bedside and laboratory tests were immediately performed. He recovered and was stabilized, but soon after he developed abdominal distention, tympanic bowel sounds, and altered mental status. He decompensated rapidly with a drop in blood pressure from baseline values of 100/50 mm Hg to 54/32 mm Hg. An immediate abdominal computed tomography (CT) scan was completed at that time with the differential diagnosis being considered including bleeding gastric or duodenal ulcer, ischemic bowel, myocardial infarction, or septic shock. His CT showed a splenic hematoma with associated enlargement of his spleen measuring 13.6×11.5×15.5 cm and blood in his abdominal cavity . On hematologic tests, his serum hemoglobin was reduced from his baseline value of 9.3 g/dL on admission to 5.3 g/dL (normal range 13.5 to 18 g/dL). His activated partial thromboplastin time (aPTT) was within normal range; however, his prothrombin time (PT) was elevated at 16.1 seconds (normal range, 9.5 to 12.7 seconds) consistent with his use of apixaban.\nRapid transfusion of two units of packed red blood cells, followed by three units of fresh frozen plasma was initiated. Despite attempts at resuscitation, he remained hypotensive and in shock. Due to multiple comorbidities which could potentially complicate surgical intervention, he was urgently transferred to interventional radiology for an emergency splenic artery embolization. An angiogram completed during the procedure showed a splenic artery that was patent and tortuous, with medial displacement of his spleen by a hematoma consistent with what was seen on CT imaging. He was successfully stabilized by embolization of the bleeding source; he was subsequently transferred to our intensive care unit.\nThe following morning, subsequent to the embolization of the bleeding source, his hemoglobin had decreased from 8.6 g/dL to 6.6 g/dL, which raised a concern that he had recurrent bleeding; a laparotomy was performed with a splenectomy and evacuation of a large intra-abdominal hematoma. During the procedure, 3600 mL of blood and clots were evacuated from his abdominal cavity.\nFollowing the surgery, he underwent prolonged mechanical ventilation due to respiratory failure and temporary hemodialysis for acute-on-chronic kidney injury. He was eventually discharged to a short-term rehabilitation facility for physical therapy after an extensive hospitalization.", + "fulltext_subclaims": [ + "An 83-year-old white man presented to the emergency department with shortness of breath.", + "His past medical history was significant for chronic obstructive pulmonary disease.", + "His past medical history was significant for atrial fibrillation.", + "His past medical history was significant for congestive heart failure.", + "His past medical history was significant for anemia of chronic disease.", + "His past medical history was significant for sick sinus syndrome.", + "His past medical history was significant for pulmonary hypertension.", + "His past medical history was significant for chronic kidney disease.", + "He was on apixaban 2.5 mg twice daily for anticoagulation due to non-valvular atrial fibrillation.", + "He did not have a history of bleeding or clotting disorders.", + "He had previously presented to the emergency department with hemoptysis due to cardiopulmonary disease.", + "Acute-on-chronic congestive heart failure was diagnosed.", + "Exacerbation of chronic obstructive pulmonary disease was diagnosed.", + "Five days into his hospital stay, he awoke with diffuse abdominal pain.", + "He and his wife denied history of recent abdominal or chest trauma, including falls.", + "After the onset of abdominal pain, he had a witnessed syncopal event and became unresponsive.", + "A medical emergency response team was called to his bedside.", + "He developed abdominal distention, tympanic bowel sounds, and altered mental status.", + "He decompensated rapidly with a drop in blood pressure from baseline values of 100/50 mm Hg to 54/32 mm Hg.", + "An immediate abdominal CT scan was completed.", + "The CT showed a splenic hematoma with associated enlargement of the spleen measuring 13.6×11.5×15.5 cm.", + "The CT showed blood in the abdominal cavity.", + "His serum hemoglobin was reduced from 9.3 g/dL on admission to 5.3 g/dL.", + "His prothrombin time (PT) was elevated at 16.1 seconds.", + "Rapid transfusion of two units of packed red blood cells was initiated.", + "Rapid transfusion of three units of fresh frozen plasma was initiated.", + "He was urgently transferred to interventional radiology for an emergency splenic artery embolization.", + "An angiogram showed a splenic artery that was patent and tortuous.", + "He was successfully stabilized by embolization of the bleeding source.", + "The following morning, his hemoglobin had decreased from 8.6 g/dL to 6.6 g/dL.", + "A laparotomy was performed with a splenectomy and evacuation of a large intra-abdominal hematoma.", + "During the procedure, 3600 mL of blood and clots were evacuated from the abdominal cavity.", + "He underwent prolonged mechanical ventilation due to respiratory failure.", + "He underwent temporary hemodialysis for acute-on-chronic kidney injury.", + "He was discharged to a short-term rehabilitation facility for physical therapy." + ], + "summary": "We describe the clinical case of an 83-year-old white man who complained of sudden severe abdominal pain 5 days into a hospital stay for acute-on-chronic congestive heart failure and exacerbation of chronic obstructive pulmonary disease. Neither he nor his wife reported any significant trauma for the past 6 months prior to his admission. His medical history included chronic atrial fibrillation treated with medications including apixaban 2.5 mg twice daily. An urgent abdominal computed tomography scan demonstrated a large splenic hematoma and evidence of intraperitoneal bleeding from which he rapidly declined, developing hypovolemic shock. An emergency splenic arteriogram displayed a patent splenic artery and an embolization was successful in stabilizing him. Due to evidence of recurrent bleeding, an exploratory laparotomy and splenectomy was subsequently performed the following day.", + "summary_subclaims": [ + "The patient was an 83-year-old white man.", + "He complained of sudden severe abdominal pain 5 days into a hospital stay.", + "He was hospitalized for acute-on-chronic congestive heart failure.", + "He had an exacerbation of chronic obstructive pulmonary disease.", + "Neither he nor his wife reported any significant trauma for the past 6 months prior to admission.", + "His medical history included chronic atrial fibrillation.", + "He was treated with apixaban 2.5 mg twice daily.", + "An urgent abdominal computed tomography scan demonstrated a large splenic hematoma.", + "The computed tomography scan showed evidence of intraperitoneal bleeding.", + "He rapidly declined and developed hypovolemic shock.", + "An emergency splenic arteriogram displayed a patent splenic artery.", + "An embolization was successful in stabilizing him.", + "An exploratory laparotomy and splenectomy was performed the following day." + ] + }, + { + "id": "multiclinsum_test_3127_en.txt", + "fulltext": "4-year-old male patient with a full vaccination schedule for his age, eutrophic and with no previous pathological antecedents, was admitted with a clinical picture of 4 days of evolution consisting of rapidly progressive edema and ptosis of the left upper eyelid, associated in the last 2 days with the appearance of a painful mass in the upper bulbar conjunctiva, without any other associated symptomatology. On admission, left ptosis of 3 mm was observed with occupation of the superior orbito-palpebral sulcus, presence of a mass of 10 mm in diameter depending on the superior bulbar conjunctiva, elevated and salmon-coloured, extending to the superior fundus of the sac, associated with multiple bilateral cervical and inguinal adenopathies. In the directed ophthalmological evaluation, visual acuity, ocular movements and pupillary reflexes were preserved, and the biomicroscopy and fundoscopy were without alterations.\n\nIn conjunction with paediatric lymphoproliferative disease, extension studies were performed and a computed tomography (CT) of orbits was found to show thickening of the upper left eyelid with peripheral enhancement, diameter of 12 mm and thickness of 0.9 mm; a CT of the face showed multiple cervical adenopathies between 4-8 mm with a tendency to form conglomerates in the cervical ganglion stations Va, Vb and IV; a CT of the thorax showed a single nodule of 2.8 mm in the lateral segment of the middle lobe; a CT of the abdomen showed a liver size at the upper limit of normal (112 mm) and splenomegaly, splenic index 177 mm (mean 124 mm).\n\nLaboratory tests showed a relative lymphocytosis of 50% with a normal leukocyte count for the age (14,100) and atypical lymphocytes of 17% without anaemia or thrombocytopenia. Renal function and electrolytes within normal limits. Lactic dehydrogenase (LDH) elevated 453 U/L [150-300 U/L). Peripheral blood smear showed increased white blood cells and some atypical lymphocytes. Bone marrow aspirate showed a granulocytic predominance with mainly CD8 positive T lymphocytes and increased gamma delta T lymphocytes, without significant increase in CD34 precursors. In conjunctival flow cytometry immunoproliferative study, a lymphoid CD8 positive phenotype was predominant. Indirect negative human immunodeficiency virus (HIV) study.\n\nIn view of the findings and results, the paediatric haemato-oncologist suggested a possible viral process (Epstein Barr or cytomegalovirus), an immune disorder or, less likely, a lymphoproliferative neoplasia. An excisional biopsy of the conjunctival lesion was performed, which showed a diffuse pattern of large cells with Reed-Stemberg-like popcorn-like morphology, reactive to CD45, CD20, MUM1, BCL-2, CD30, PAX-5, weak nuclear, Oct-2 positive, BOB-1 negative. Associated with this was a large population of T lymphocytes with a usual morphology that expressed CD2, CD3, CD5, CD7, CD43 and Granzyme, with a predominance of CD8 positive cytotoxic T lymphocytes and a lower number of CD4 positive helper T lymphocytes. In addition, a lower number of B lymphocytes reactive to CD79a, reactive histiocytes reactive to CD68 and lysozyme and a positive reaction to EBV RNA in immunoblastic B cells were observed. The final report was that the morphological and immunophenotypical findings were consistent with a chronic EBV infection. Antibodies were detected for Epstein Barr IgM positive 15.13 IU/ml (positive greater than 11 IU/ml) and IgG 10.85 IU/ml (indeterminate 9 - 10 IU/ml), cytomegalovirus infection was ruled out.\n\nIn the evaluation by paediatric infectology, symptomatic management and follow-up were recommended. In the controls, complete resolution of conjunctival lesion with adequate healing after excisional biopsy, complete resolution of ptosis and a decrease in serological antibodies for Epstein Barr IgM 4.54 IU/ml and elevation of IgG 12.66 IU/ml, studies of cellular immunity with CD3, CD4 and CD8 lymphocytes in the normal range for age were observed. After 15 months of follow-up, he remains asymptomatic.\n", + "fulltext_subclaims": [ + "The patient is a 4-year-old male.", + "The patient has a full vaccination schedule for his age.", + "The patient is eutrophic.", + "The patient has no previous pathological antecedents.", + "The clinical picture has been evolving for 4 days.", + "The clinical picture consists of rapidly progressive edema and ptosis of the left upper eyelid.", + "A painful mass in the upper bulbar conjunctiva appeared in the last 2 days.", + "There are no other associated symptomatology.", + "On admission, left ptosis of 3 mm was observed.", + "There is occupation of the superior orbito-palpebral sulcus.", + "A mass of 10 mm in diameter depends on the superior bulbar conjunctiva.", + "The mass is elevated and salmon-coloured.", + "The mass extends to the superior fundus of the sac.", + "Multiple bilateral cervical and inguinal adenopathies are present.", + "Visual acuity, ocular movements, and pupillary reflexes are preserved.", + "Biomicroscopy and fundoscopy are without alterations.", + "A CT of the orbits showed thickening of the upper left eyelid with peripheral enhancement.", + "The eyelid thickening has a diameter of 12 mm and thickness of 0.9 mm.", + "A CT of the face showed multiple cervical adenopathies between 4-8 mm.", + "The adenopathies tend to form conglomerates in the cervical ganglion stations Va, Vb, and IV.", + "A CT of the thorax showed a single nodule of 2.8 mm in the lateral segment of the middle lobe.", + "A CT of the abdomen showed a liver size at the upper limit of normal (112 mm).", + "Splenomegaly is present with a splenic index of 177 mm.", + "Laboratory tests showed a relative lymphocytosis of 50%.", + "The leukocyte count is 14,100, which is normal for the age.", + "Atypical lymphocytes are 17%.", + "There is no anaemia or thrombocytopenia.", + "Renal function and electrolytes are within normal limits.", + "Lactic dehydrogenase (LDH) is elevated at 453 U/L.", + "The peripheral blood smear showed increased white blood cells.", + "Some atypical lymphocytes are present.", + "The bone marrow aspirate showed granulocytic predominance.", + "The bone marrow aspirate showed mainly CD8 positive T lymphocytes.", + "The bone marrow aspirate showed increased gamma delta T lymphocytes.", + "There is no significant increase in CD34 precursors.", + "The conjunctival flow cytometry immunoproliferative study showed a lymphoid CD8 positive phenotype.", + "The indirect HIV study is negative.", + "The excisional biopsy of the conjunctival lesion showed a diffuse pattern of large cells with Reed-Stemberg-like popcorn-like morphology.", + "The cells are reactive to CD45, CD20, MUM1, BCL-2, CD30, PAX-5, weak nuclear, Oct-2 positive, BOB-1 negative.", + "A large population of T lymphocytes with usual morphology expresses CD2, CD3, CD5, CD7, CD43, and Granzyme.", + "There is a predominance of CD8 positive cytotoxic T lymphocytes.", + "There is a lower number of CD4 positive helper T lymphocytes.", + "A lower number of B lymphocytes reactive to CD79a are observed.", + "Reactive histiocytes reactive to CD68 and lysozyme are observed.", + "EBV RNA is positive in immunoblastic B cells.", + "The final report states that the morphological and immunophenotypical findings are consistent with chronic EBV infection.", + "Epstein Barr IgM is positive at 15.13 IU/ml.", + "Epstein Barr IgG is 10.85 IU/ml.", + "Cytomegalovirus infection is ruled out.", + "Symptomatic management and follow-up were recommended.", + "The conjunctival lesion showed complete resolution after excisional biopsy.", + "Ptosis showed complete resolution.", + "Serological antibodies for Epstein Barr IgM decreased to 4.54 IU/ml.", + "Serological antibodies for Epstein Barr IgG increased to 12.66 IU/ml.", + "Cellular immunity studies showed CD3, CD4, and CD8 lymphocytes in the normal range for age.", + "After 15 months of follow-up, the patient remains asymptomatic." + ], + "summary": "4-year-old boy with a 4-day history of edema and ptosis of the left upper eyelid associated with a large, fast-growing, elevated, painful, salmon-colored superior bulbar conjunctival mass with superior orbital extension associated with bilateral cervical and inguinal lymphadenopathies. Lymphoproliferative process was initially suspected, with a blood count showing lymphocytosis and atypical lymphocytes, elevated lactate dehydrogenase (LDH), a peripheral blood smear with increased white cells and some atypical lymphocytes, a bone marrow aspirate with a predominance of granulocytes and mostly CD8-positive T lymphocytes, and an increase in gamma-delta T lymphocytes. A computed tomography (CT) scan of the orbits showed a thickening of the left upper eyelid with peripheral enhancement, a CT scan of the abdomen showed a splenomegaly. A biopsy confirmed a EBV infection with positive IgM antibodies and an indeterminate IgG. Symptomatic treatment was indicated and the patient's condition was satisfactory with a complete resolution of the conjunctival lesion and lymphadenopathies.\n", + "summary_subclaims": [ + "The patient is a 4-year-old boy.", + "The patient has a 4-day history of edema and ptosis of the left upper eyelid.", + "The patient has a large, fast-growing, elevated, painful, salmon-colored superior bulbar conjunctival mass.", + "The conjunctival mass has superior orbital extension.", + "The patient has bilateral cervical and inguinal lymphadenopathies.", + "A blood count showed lymphocytosis and atypical lymphocytes.", + "Lactate dehydrogenase (LDH) was elevated.", + "A peripheral blood smear showed increased white cells and some atypical lymphocytes.", + "A bone marrow aspirate showed a predominance of granulocytes and mostly CD8-positive T lymphocytes.", + "There was an increase in gamma-delta T lymphocytes.", + "A CT scan of the orbits showed thickening of the left upper eyelid with peripheral enhancement.", + "A CT scan of the abdomen showed splenomegaly.", + "A biopsy confirmed an EBV infection.", + "IgM antibodies were positive.", + "IgG antibodies were indeterminate.", + "Symptomatic treatment was indicated.", + "The patient's condition was satisfactory.", + "There was a complete resolution of the conjunctival lesion.", + "There was a complete resolution of the lymphadenopathies." + ] + }, + { + "id": "multiclinsum_test_269_en.txt", + "fulltext": "A 53-year-old female was admitted to our institute with a sudden severe headache, accompanied by nausea and vomiting with a slight left hemiparesis. There was no history of traumatic events, infectious or inflammatory diseases, hypertension, or other cardiovascular disorders. The results of the routine hematologic tests showed indices within normal limits. The computed tomography (CT) scan of the head showed subarachnoid hemorrhage (SAH) in the left sylvian fissure and intracerebral hemorrhage (ICH), measured 22 mm × 26 mm, in the left posterior parietal area . The CT angiography (CTA) reconstructed with 3D imaging software showed a small saccular aneurysm in the M4 segment in proximity of the angular area . No digital subtraction angiography (DSA) was performed. Due to a sudden decreased level of consciousness, the emergency surgery was necessary. A left parieto-temporal craniotomy was performed. Through the use of neuronavigation it was possible to locate the ICH and the aneurysm. Under microscopic vision, a small corticotomy was made and the ICH was gently evacuated. A small saccular aneurysm was found. Before clipping, the indocyanine green videoangiography (ICGV) was used to identify the perforating arteries close to the aneurysm sac, and to detect the neck. The aneurysm neck was clipped with a mini-clip and the aneurysm sac was coagulated with a bipolar forceps. After clipping, the ICGV showed the patency of all efferent and afferent arteries to the aneurysm and confirmed the aneurysm exclusion. The postoperative CTA showed neither residual aneurysm nor occlusion of the parent vessel . The motor deficit was progressively recovered and the patient was discharged on the 20th postoperative day without complications. At 3-month follow-up examination, the patient was asymptomatic and feeling well.", + "fulltext_subclaims": [ + "The patient was a 53-year-old female.", + "She was admitted with a sudden severe headache.", + "She had nausea and vomiting.", + "She had slight left hemiparesis.", + "There was no history of traumatic events.", + "There was no history of infectious or inflammatory diseases.", + "There was no history of hypertension.", + "There was no history of other cardiovascular disorders.", + "The routine hematologic tests showed indices within normal limits.", + "The CT scan showed subarachnoid hemorrhage in the left sylvian fissure.", + "The CT scan showed intracerebral hemorrhage in the left posterior parietal area.", + "The intracerebral hemorrhage measured 22 mm × 26 mm.", + "The CTA showed a small saccular aneurysm in the M4 segment.", + "The aneurysm was in proximity of the angular area.", + "No digital subtraction angiography was performed.", + "Emergency surgery was necessary due to a sudden decreased level of consciousness.", + "A left parieto-temporal craniotomy was performed.", + "Neuronavigation was used to locate the ICH and the aneurysm.", + "A small corticotomy was made.", + "The ICH was gently evacuated.", + "A small saccular aneurysm was found.", + "Indocyanine green videoangiography was used before clipping.", + "The aneurysm neck was clipped with a mini-clip.", + "The aneurysm sac was coagulated with a bipolar forceps.", + "The postoperative CTA showed no residual aneurysm.", + "The postoperative CTA showed no occlusion of the parent vessel.", + "The motor deficit was progressively recovered.", + "The patient was discharged on the 20th postoperative day.", + "The patient was discharged without complications.", + "At 3-month follow-up, the patient was asymptomatic.", + "At 3-month follow-up, the patient was feeling well." + ], + "summary": "A 53-year-old female was admitted with a sudden severe headache, nausea, vomiting, and a slight left hemiparesis. The computed tomography (CT) scan showed subarachnoid hemorrhage (SAH) in the left sylvian fissure and intracerebral hemorrhage (ICH) in the left posterior parietal area. The CT angiography (CTA) reconstructed with 3D imaging showed a small saccular aneurysm in the M4 segment in proximity of the angular area. A left parieto-temporal craniotomy was performed, the aneurysm was clipped and the ICH evacuated. The motor deficit was progressively recovered. At 3-month follow-up examination, the patient was asymptomatic and feeling well.", + "summary_subclaims": [ + "The patient was a 53-year-old female.", + "The patient was admitted with a sudden severe headache.", + "The patient had nausea.", + "The patient had vomiting.", + "The patient had a slight left hemiparesis.", + "The CT scan showed subarachnoid hemorrhage in the left sylvian fissure.", + "The CT scan showed intracerebral hemorrhage in the left posterior parietal area.", + "The CT angiography showed a small saccular aneurysm in the M4 segment.", + "The aneurysm was in proximity of the angular area.", + "A left parieto-temporal craniotomy was performed.", + "The aneurysm was clipped.", + "The intracerebral hemorrhage was evacuated.", + "The motor deficit was progressively recovered.", + "At 3-month follow-up, the patient was asymptomatic.", + "At 3-month follow-up, the patient was feeling well." + ] + }, + { + "id": "multiclinsum_test_1298_en.txt", + "fulltext": "A 38-year-old woman in her 19th wk of pregnancy (G2P1) was referred to our clinic for a sudden persistent pain on the left side of the waist on July 28, 2017.\nThe patient’s physical examination revealed tenderness over the left kidney area. Her blood pressure was 120/85 mmHg, heart rate was 86 beats/min, and body temperature was 36.8 °C. The patient had no significant medical history. She had not undergone any related abdominal examination previously.\nThe patient had no significant medical history. She had not undergone any related abdominal examination previously.\nThe patient was hospitalized and given conservative treatment, but her left-side waist pain continued to be intense. Because the size of the tumor was so large, and the fetal heart rate was unstable, the patient decided to undergo left nephrectomy after the induction of labor.\nLaboratory tests indicated that the patient’s hemoglobin level was 80 g/L, and the hematocrit was 0.242 L/L. On the 2nd d, hemoglobin was 95 g/L, and the hematocrit was 0.286 L/L.\nUltrasound examination of the urinary system (LOGIQ E9, GE) revealed a giant nonhomogenous lump in the left kidney area, which had caused the left kidney to move to the midabdomen. The size of the lump was approximately 159 mm × 100 mm, and the border was faintly visible. The lump showed a “striped sign” in which the outer part was hypoechoic with a strong stripe echo , and the inner part near the left kidney was hyperechoic . A stripe-shaped echoless zone was seen around the lump (arrow). Color Doppler flow image showed some spot-like blood flow signals around the lump . A hyperechoic nodule was seen in the right kidney with a size of 30 mm × 25 mm. There was a fetus echo in the uterus. Preoperative CT showed a large, mixed-density mass in the left kidney . The density of the area adjacent to the kidney was low, and the area far from the kidney showed high density.", + "fulltext_subclaims": [ + "The patient is a 38-year-old woman in her 19th wk of pregnancy (G2P1).", + "She was referred to the clinic for a sudden persistent pain on the left side of the waist on July 28, 2017.", + "The patient’s physical examination revealed tenderness over the left kidney area.", + "Her blood pressure was 120/85 mmHg.", + "Her heart rate was 86 beats/min.", + "Her body temperature was 36.8 °C.", + "The patient had no significant medical history.", + "She had not undergone any related abdominal examination previously.", + "The patient was hospitalized and given conservative treatment.", + "Her left-side waist pain continued to be intense.", + "Because the size of the tumor was so large, and the fetal heart rate was unstable, the patient decided to undergo left nephrectomy after the induction of labor.", + "Laboratory tests indicated that the patient’s hemoglobin level was 80 g/L.", + "The hematocrit was 0.242 L/L.", + "On the 2nd d, hemoglobin was 95 g/L.", + "The hematocrit was 0.286 L/L.", + "Ultrasound examination of the urinary system revealed a giant nonhomogenous lump in the left kidney area.", + "The lump had caused the left kidney to move to the midabdomen.", + "The size of the lump was approximately 159 mm × 100 mm.", + "The border of the lump was faintly visible.", + "The lump showed a “striped sign” in which the outer part was hypoechoic with a strong stripe echo.", + "The inner part near the left kidney was hyperechoic.", + "A stripe-shaped echoless zone was seen around the lump.", + "Color Doppler flow image showed some spot-like blood flow signals around the lump.", + "A hyperechoic nodule was seen in the right kidney with a size of 30 mm × 25 mm.", + "There was a fetus echo in the uterus.", + "Preoperative CT showed a large, mixed-density mass in the left kidney.", + "The density of the area adjacent to the kidney was low.", + "The area far from the kidney showed high density." + ], + "summary": "A 38-year-old woman in her 19th wk of pregnancy (G2P1) was referred to our clinic for a sudden, persistent pain on the left side of the waist. She had not undergone any previous related abdominal examination. Ultrasound of the urinary system revealed a giant nonhomogenous lump in the left kidney area. The diagnosis was considered spontaneous rupture and hemorrhage of the left RAML in pregnancy via ultrasound. Her left-side waist pain continued to be intense. Subsequently, she underwent computed tomography, which led to the same diagnosis. Based on many factors, the patient underwent left nephrectomy after the induction of labor. The pathological result was the rupture and hemorrhage of a vascular leiomyoma lipoma.", + "summary_subclaims": [ + "The patient is a 38-year-old woman in her 19th wk of pregnancy.", + "She was referred to the clinic for a sudden, persistent pain on the left side of the waist.", + "She had not undergone any previous related abdominal examination.", + "Ultrasound of the urinary system revealed a giant nonhomogenous lump in the left kidney area.", + "The diagnosis was considered spontaneous rupture and hemorrhage of the left RAML in pregnancy via ultrasound.", + "Her left-side waist pain continued to be intense.", + "She underwent computed tomography, which led to the same diagnosis.", + "The patient underwent left nephrectomy after the induction of labor.", + "The pathological result was the rupture and hemorrhage of a vascular leiomyoma lipoma." + ] + }, + { + "id": "multiclinsum_test_1576_en.txt", + "fulltext": "A 25-years-old male of Afghani origin with a history of recurrent acute pancreatitis was referred to the intensive care unit of the Jena University Hospital in November 2019.\nAbdominal pain debuted two years ago when the patient was 23 years old. The family history revealed that the patient’s brother and sister similarly suffer from abdominal pain and have been hospitalized several times. His niece died at the age of three due to acute pancreatitis. The patient’s whole family resides in Afghanistan, so neither clinical nor genetic investigation of relatives was possible in our clinic.\nOn physical examination, the patient’s BMI was 23.4 kg/m2, blood pressure, and heart rate were 146/83 mm Hg and 95/min, respectively. He showed no xanthomas but did have lipemia retinalis on retinal examination. Examination of the abdomen revealed pain in the upper left area and an enlarged spleen. No other abnormalities were observed.\nTG levels were at 29 mmol/L, and low-density lipoprotein (LDL) and high-density lipoprotein cholesterol (HDL) cholesterol were within reference ranges. According to the previous records, TGs were as high as 82 mmol/L in the past. Inflammation markers (C-reactive protein and white blood cells) were remarkably elevated. There were no clinical symptoms or laboratory indicators of secondary (pancreoprivic) diabetes mellitus (HbA1c 5.1%, blood glucose 5.8 mmol/L). Other laboratory parameters are shown in Table .\nAbdominal computer tomography demonstrated edematous pancreatitis, most prominently within the corpus pancreaticus with surrounding fat tissue fibrosis and splenomegaly. There were no signs of choledocholithiasis.\nA panel screening for HTG-related genes (Additional file ) was performed. The sequencing was performed using the next-generation sequencing on Illumina-Sequencer (NextSeq500/NovaSeq6000) with a > 98% coverage of regions of interest. The analysis revealed homozygosity for a frameshift mutation of APOA5 (c427delC, p.Arg143Alafs*57) with a minor allele frequency of 0.006%. This mutation causes an alteration in the translational reading frame and results in a premature stop of protein synthesis due to the introduction of a stop codon at position 57. The patient was also a homozygous carrier of haplotype APOA5*2.\nAcute pancreatitis was treated with aggressive fluid resuscitation and therapeutic plasma exchange (Spectra Optia, Terumo BCT, Inc. Lakewood USA). The patient was then put on a low-fat diet and a combination of ezetimibe (10 mg daily) and fenofibrate (160 mg micronized daily). Shortly after the discharge, another episode of acute pancreatitis occurred. The patient was prescribed omega-3 fatty acids; however, the inability to obtain reimbursement for omega-3 fatty acids in Germany hindered their usage. The patient was regularly followed up at our outpatient clinic. A satisfactory range of TG, between 9.2 and 11.2 mmol/L , was maintained through a combination of stringent dietary measures and consistent intake of fibrates. After two years, another episode of pancreatitis occurred, with TG elevation up to 18.8 mmol/L. The patient was started on weekly injections of volanesorsen. On this regimen, TG levels were stably under 4 mmol/L . The platelet count decreased from 201,000 to 114,000/µL. Therefore, according to recommendations, we switched to biweekly administrations. As a result, the platelet count stabilized (at ~ 150,000/µL). The patient had no episodes of bleeding. Volanesorsen therapy was continued with regular assessment of platelet count.", + "fulltext_subclaims": [ + "A 25-years-old male of Afghani origin with a history of recurrent acute pancreatitis was referred to the intensive care unit of the Jena University Hospital in November 2019.", + "Abdominal pain debuted two years ago when the patient was 23 years old.", + "The patient’s brother and sister similarly suffer from abdominal pain and have been hospitalized several times.", + "The patient’s whole family resides in Afghanistan.", + "The patient showed no xanthomas.", + "The patient had lipemia retinalis on retinal examination.", + "Examination of the abdomen revealed pain in the upper left area.", + "Examination of the abdomen revealed an enlarged spleen.", + "TG levels were at 29 mmol/L.", + "Inflammation markers (C-reactive protein and white blood cells) were remarkably elevated.", + "There were no clinical symptoms or laboratory indicators of secondary (pancreoprivic) diabetes mellitus.", + "Abdominal computer tomography demonstrated edematous pancreatitis, most prominently within the corpus pancreaticus.", + "There were no signs of choledocholithiasis.", + "The analysis revealed homozygosity for a frameshift mutation of APOA5 (c427delC, p.Arg143Alafs*57).", + "The patient was also a homozygous carrier of haplotype APOA5*2.", + "The patient was put on a low-fat diet.", + "The patient was prescribed a combination of ezetimibe (10 mg daily) and fenofibrate (160 mg micronized daily).", + "Shortly after the discharge, another episode of acute pancreatitis occurred.", + "The patient was prescribed omega-3 fatty acids.", + "The inability to obtain reimbursement for omega-3 fatty acids in Germany hindered their usage.", + "A satisfactory range of TG, between 9.2 and 11.2 mmol/L, was maintained through a combination of stringent dietary measures and consistent intake of fibrates.", + "After two years, another episode of pancreatitis occurred, with TG elevation up to 18.8 mmol/L.", + "The patient was started on weekly injections of volanesorsen.", + "On this regimen, TG levels were stably under 4 mmol/L.", + "The platelet count decreased from 201,000 to 114,000/µL.", + "We switched to biweekly administrations.", + "The platelet count stabilized (at ~ 150,000/µL).", + "The patient had no episodes of bleeding.", + "Volanesorsen therapy was continued with regular assessment of platelet count." + ], + "summary": "We report a case of a 25-years old Afghani male presenting with acute pancreatitis due to severe hypertriglyceridemia up to 29.8 mmol/L caused by homozygosity in APOA5 (c.427delC, p.Arg143Alafs*57). A low-fat diet enriched with medium-chain TG (MCT) oil and fibrate therapy did not prevent recurrent relapses, and volanesorsen was initiated. Volanesorsen resulted in almost normalized triglyceride levels. No further relapses of acute pancreatitis occurred. Patient reported an improve life quality due to alleviated chronic abdominal pain and headaches.", + "summary_subclaims": [ + "The patient is a 25-years old Afghani male.", + "The patient presented with acute pancreatitis.", + "The acute pancreatitis was due to severe hypertriglyceridemia up to 29.8 mmol/L.", + "The hypertriglyceridemia was caused by homozygosity in APOA5 (c.427delC, p.Arg143Alafs*57).", + "A low-fat diet enriched with medium-chain TG (MCT) oil and fibrate therapy did not prevent recurrent relapses.", + "Volanesorsen was initiated.", + "Volanesorsen resulted in almost normalized triglyceride levels.", + "No further relapses of acute pancreatitis occurred.", + "The patient reported an improve life quality due to alleviated chronic abdominal pain and headaches." + ] + }, + { + "id": "multiclinsum_test_2720_en.txt", + "fulltext": "A 40-year-old Sri Lankan female presented with exertional breathlessness (NYHA II) and weight loss for 4 weeks duration. There was no cough, hemoptysis, evening pyrexia or night sweats and no history of limb claudication. Her past history was negative for connective tissue disorders, vasculitis or tuberculosis. The family history was unremarkable. General examination did not reveal any abnormal physical signs. She had collapsing pulse and blood pressure of 110/40 mmHg in both arms. Early diastolic murmur was heard in both left and right sternal edge. The lung bases were clear and rest of the systemic examination was normal.\nChest x-ray showed smooth dilatation of the ascending aorta and walls of it are not parallel to each other. Transthoracic and transeseophageal echocardiogram showed ascending aortic aneurysm (maximum diameter of 54 mm) with severe aortic regurgitation. Cardiac chamber dimensions were within normal limits and left ventricular ejection fraction was normal. Computed tomographic (CT) aortography confirmed the dilatation of aortic root and ascending aorta without dissection or leaking. Acute phase reactants were slightly elevated (erythrocyte sedimentation rate 50 mm 1st hour, C-reactive protein 18 mg/dL). Venereal Disease Research Laboratory test (VDRL) was non-reactive. Antinuclear antibody was negative.\nCardiology team proceeded their further evaluation with pre-operative coronary angiogram which showed normal epicardial coronary arteries. Aortic valve and root replacement was recommended by the cardiologist. Cardiothoracic surgical team carried out the aortic valve replacement (AVR) with 19 mm bileaflet St Jude Medical mechanical valve and aortic root replacement with 30 mm Albo graft. Surgeon noted evidence of aortitis with external inflammatory adhesions during the surgery. Post-operative period was uneventful. Warfarin therapy was started while closely monitoring the INR and it was kept between 2 and 3. Histological examination of aortic wall revealed granulomatous aortitis with caseous necrosis even though it did not show acid fast bacilli (AFB) on Ziehl–Neelsen staining (ZNS).\nThe final diagnosis of ascending aortic aneurysm with severe aortic regurgitation due to tuberculous aortitis was made on the basis of clinical, imaging and histological findings. She was treated with category one antituberculous therapy (ATT) consisting of 3 fixed dose combination tablets per day each containing rifampicin 150 mg, isoniazid 75 mg, pyrazinamide 400 mg and ethambutol 275 mg (RHZE). Frequent dose adjustment of warfarin was required during ATT. Continuation phase of ATT was extended for up to 10 months with rifampicin and isoniazid as in the case of disseminated tuberculosis. She made a good clinical recovery with improvement of her symptoms and follow up image showed functioning aortic prosthesis while maintaining INR in therapeutic range.", + "fulltext_subclaims": [ + "The patient is a 40-year-old Sri Lankan female.", + "She had exertional breathlessness for 4 weeks.", + "She had weight loss for 4 weeks.", + "There was no cough.", + "There was no hemoptysis.", + "There was no evening pyrexia.", + "There was no night sweats.", + "There was no history of limb claudication.", + "The past history was negative for connective tissue disorders.", + "The past history was negative for vasculitis.", + "The past history was negative for tuberculosis.", + "The family history was unremarkable.", + "General examination did not reveal any abnormal physical signs.", + "She had a collapsing pulse.", + "Blood pressure was 110/40 mmHg in both arms.", + "An early diastolic murmur was heard in both left and right sternal edge.", + "Chest x-ray showed smooth dilatation of the ascending aorta.", + "Transthoracic and transesophageal echocardiogram showed ascending aortic aneurysm with a maximum diameter of 54 mm.", + "Transthoracic and transesophageal echocardiogram showed severe aortic regurgitation.", + "Cardiac chamber dimensions were within normal limits.", + "Left ventricular ejection fraction was normal.", + "Computed tomographic aortography confirmed dilatation of aortic root and ascending aorta.", + "Computed tomographic aortography showed no dissection.", + "Computed tomographic aortography showed no leaking.", + "Erythrocyte sedimentation rate was 50 mm 1st hour.", + "C-reactive protein was 18 mg/dL.", + "Venereal Disease Research Laboratory test was non-reactive.", + "Antinuclear antibody was negative.", + "A pre-operative coronary angiogram showed normal epicardial coronary arteries.", + "Aortic valve and root replacement was recommended.", + "Aortic valve replacement was performed with a 19 mm bileaflet St Jude Medical mechanical valve.", + "Aortic root replacement was performed with a 30 mm Albo graft.", + "Evidence of aortitis with external inflammatory adhesions was noted during surgery.", + "Post-operative period was uneventful.", + "Warfarin therapy was started.", + "INR was kept between 2 and 3.", + "Histological examination of the aortic wall revealed granulomatous aortitis with caseous necrosis.", + "Acid fast bacilli were not seen on Ziehl–Neelsen staining.", + "The final diagnosis was ascending aortic aneurysm with severe aortic regurgitation due to tuberculous aortitis.", + "She was treated with category one antituberculous therapy.", + "Category one antituberculous therapy included 3 fixed dose combination tablets per day.", + "Each fixed dose combination tablet contained rifampicin 150 mg, isoniazid 75 mg, pyrazinamide 400 mg, and ethambutol 275 mg.", + "Frequent dose adjustment of warfarin was required during antituberculous therapy.", + "The continuation phase of antituberculous therapy was extended for up to 10 months.", + "The continuation phase included rifampicin and isoniazid.", + "She made a good clinical recovery.", + "Follow-up imaging showed a functioning aortic prosthesis.", + "INR was maintained in the therapeutic range." + ], + "summary": "A 40-year-old Sri Lankan female who presented with exertional breathlessness (NYHA II) and weight loss for 4 weeks duration was found to have collapsing pulse and early diastolic murmur at left sternal edge. Transthoracic and transesophageal echocardiogram showed ascending aortic aneurysm with severe aortic regurgitation. Computed tomographic aortography confirmed the diagnosis of aneurysmal dilatation of the ascending aorta. She underwent successful aortic valve replacement and aortic root replacement. The final diagnosis of tuberculous aortitis was made on the basis of macroscopic appearance of inflammation and microscopic confirmation of caseating granuloma. She made a good clinical recovery with category 1 antituberculous chemotherapy.", + "summary_subclaims": [ + "The patient is a 40-year-old Sri Lankan female.", + "She had exertional breathlessness for 4 weeks.", + "She had a NYHA class II functional status.", + "She had weight loss for 4 weeks.", + "She had a collapsing pulse.", + "She had an early diastolic murmur at the left sternal edge.", + "Transthoracic and transesophageal echocardiogram showed ascending aortic aneurysm.", + "Transthoracic and transesophageal echocardiogram showed severe aortic regurgitation.", + "Computed tomographic aortography confirmed aneurysmal dilatation of the ascending aorta.", + "She underwent aortic valve replacement.", + "She underwent aortic root replacement.", + "The final diagnosis was tuberculous aortitis.", + "The diagnosis was based on macroscopic appearance of inflammation.", + "The diagnosis was based on microscopic confirmation of caseating granuloma.", + "She received category 1 antituberculous chemotherapy.", + "She made a good clinical recovery." + ] + }, + { + "id": "multiclinsum_test_2521_en.txt", + "fulltext": "The patient was a 67-year-old man experiencing abdominal distension since September 2006. In October 2006, the abdominal fullness became progressive, and he had hard general fatigue. There was no history of vomiting, fever, or gastrointestinal bleeding. Renal failure occurred due to diabetes mellitus (DM). On admission in November 2006, a physical examination revealed a 25 × 30 cm hard mass that was palpable in the middle and lower left abdomen minimal intrinsic mobility and massive ascites.\nAn upper gastrointestinal barium study and gastric endoscopic examination indicated no anomalies. Tumor findings of Doppler ultrasonography showed a hypoechoic lesion with a hypervascular area . An abdominal computed tomography (CT) scan showed a huge heterogeneous mass sized 20 × 25 cm extending from the greater curvature of the middle body of the stomach . Abdominal magnetic resonance imaging (MRI) was performed, and almost the entire abdominal cavity was visualized in the coronal view. The irregular wall of the lesion exhibited a low intensity signal on the T1-weihted image and a high-intensity signal on the T2-weighted image .\nRoutine biochemical investigation revealed hypoalbuminemia, renal dysfunction, and hyperglycemia. Since the admitted patient was diagnosed with DIC (platelet count: 2000 mm3, FDP: 135.4 μg/ml, PT: 1.20, SIRS score: over 3 heads) surgery could not be performed. The patient received a platelet transfusion of 20 units each day 6 times, and the DIC was treated with nafamostat mesilate and fresh-frozen plasma. Due to this treatment, the platelet count recovered to 7.0 × 104; tumor resection was performed at 16 days after admission. Laparotomy revealed a huge extraluminal tumor arising from the greater curvature of the stomach that measured 25 × 30 cm and had not ruptured into the peritoneal cavity or infiltrated other organs . An attaching pedicle approximately 3 cm in breadth was observed in the greater curvature of middle body of the stomach. Partial gastric resection was performed .\nThe resected mass measured 25 × 25 × 20 cm. In cross section, the tumor appeared hard and homogenous with a small polycystic area . Histopathology of the resected specimen showed large spindle cell GIST with >5/50 HPF (high-power field) mitotic activity . No evidence of infiltration was observed in the resected margins of the stomach wall. Immunohistochemical staining was strongly positive for CD34 and CD117 , and negative for α-SMA, S-100 and Desmin.\nThe postoperative course was uneventful, and the coagulopathy improved rapidly. The patient was carefully followed up regularly. Imatinib mesylate (Gleevec™/Novartis Pharma AG, Basel, Switzerland) was administered orally 300 mg per day because the patient displayed renal dysfunction (serum creatinine: 3.98, blood urea nitrogen (BUN): 41.5)", + "fulltext_subclaims": [ + "The patient was a 67-year-old man.", + "He experienced abdominal distension since September 2006.", + "In October 2006, the abdominal fullness became progressive.", + "He had hard general fatigue.", + "There was no history of vomiting.", + "There was no history of fever.", + "There was no history of gastrointestinal bleeding.", + "Renal failure occurred due to diabetes mellitus.", + "On admission in November 2006, a physical examination revealed a 25 × 30 cm hard mass that was palpable in the middle and lower left abdomen.", + "The mass had minimal intrinsic mobility.", + "Massive ascites was present.", + "An upper gastrointestinal barium study indicated no anomalies.", + "A gastric endoscopic examination indicated no anomalies.", + "Tumor findings of Doppler ultrasonography showed a hypoechoic lesion with a hypervascular area.", + "An abdominal CT scan showed a huge heterogeneous mass sized 20 × 25 cm extending from the greater curvature of the middle body of the stomach.", + "Abdominal MRI was performed.", + "The coronal view visualized almost the entire abdominal cavity.", + "The irregular wall of the lesion exhibited a low intensity signal on the T1-weighted image.", + "The irregular wall of the lesion exhibited a high-intensity signal on the T2-weighted image.", + "Routine biochemical investigation revealed hypoalbuminemia.", + "Routine biochemical investigation revealed renal dysfunction.", + "Routine biochemical investigation revealed hyperglycemia.", + "The patient was diagnosed with DIC.", + "The platelet count was 2000 mm3.", + "The FDP was 135.4 μg/ml.", + "The PT was 1.20.", + "The SIRS score was over 3.", + "Surgery could not be performed.", + "The patient received a platelet transfusion of 20 units each day 6 times.", + "DIC was treated with nafamostat mesilate.", + "DIC was treated with fresh-frozen plasma.", + "The platelet count recovered to 7.0 × 104.", + "Tumor resection was performed at 16 days after admission.", + "Laparotomy revealed a huge extraluminal tumor arising from the greater curvature of the stomach.", + "The tumor measured 25 × 30 cm.", + "The tumor had not ruptured into the peritoneal cavity.", + "The tumor had not infiltrated other organs.", + "An attaching pedicle approximately 3 cm in breadth was observed in the greater curvature of the middle body of the stomach.", + "Partial gastric resection was performed.", + "The resected mass measured 25 × 25 × 20 cm.", + "In cross section, the tumor appeared hard and homogenous with a small polycystic area.", + "Histopathology showed large spindle cell GIST.", + "Mitotic activity was >5/50 HPF.", + "No evidence of infiltration was observed in the resected margins of the stomach wall.", + "Immunohistochemical staining was strongly positive for CD34.", + "Immunohistochemical staining was strongly positive for CD117.", + "Immunohistochemical staining was negative for α-SMA.", + "Immunohistochemical staining was negative for S-100.", + "Immunohistochemical staining was negative for Desmin.", + "The postoperative course was uneventful.", + "The coagulopathy improved rapidly.", + "The patient was followed up regularly.", + "Imatinib mesylate was administered orally 300 mg per day.", + "The patient displayed renal dysfunction.", + "The serum creatinine was 3.98.", + "The blood urea nitrogen was 41.5." + ], + "summary": "The patient was a 67-year-old man experiencing abdominal distension since September 2006. A physical examination revealed a 25 x 30 cm hard mass that was palpable in the middle and lower left abdomen minimal intrinsic mobility and massive ascites. Since the admitted patient was diagnosed with DIC, surgery could not be performed. The patient received a platelet transfusion and the DIC was treated. Due to this treatment, the platelet count recovered to 7.0 x 10(4); tumor resection was performed at 16 days after admission. Laparotomy revealed a huge extraluminal tumor arising from the greater curvature of the stomach that measured 25 x 30 cm and had not ruptured into the peritoneal cavity or infiltrated other organs. Partial gastric resection was performed. The resected mass measured 25 x 25 x 20 cm. In cross section, the tumor appeared hard and homogenous with a small polycystic area. Histopathology of the resected specimen showed large spindle cell GIST with >5/50 HPF (high-power field) mitotic activity. The postoperative course was uneventful, and the coagulopathy improved rapidly.", + "summary_subclaims": [ + "The patient was a 67-year-old man.", + "The patient experienced abdominal distension since September 2006.", + "A physical examination revealed a 25 x 30 cm hard mass palpable in the middle and lower left abdomen.", + "The mass had minimal intrinsic mobility.", + "Massive ascites was present.", + "The patient was diagnosed with DIC.", + "Surgery could not be performed due to the DIC.", + "The patient received a platelet transfusion.", + "The DIC was treated.", + "The platelet count recovered to 7.0 x 10(4).", + "Tumor resection was performed 16 days after admission.", + "Laparotomy revealed a huge extraluminal tumor arising from the greater curvature of the stomach.", + "The tumor measured 25 x 30 cm.", + "The tumor had not ruptured into the peritoneal cavity.", + "The tumor had not infiltrated other organs.", + "Partial gastric resection was performed.", + "The resected mass measured 25 x 25 x 20 cm.", + "In cross section, the tumor appeared hard and homogenous.", + "The tumor had a small polycystic area.", + "Histopathology showed large spindle cell GIST.", + "The mitotic activity was >5/50 HPF.", + "The postoperative course was uneventful.", + "The coagulopathy improved rapidly." + ] + }, + { + "id": "multiclinsum_test_2571_en.txt", + "fulltext": "A 55-year-old male, with no past medical history, was referred to our department for lower urinary tract symptoms. The patient has neither pain nor hematuria. Physical examination and blood tests were normal. Cytobacteriological examination of the urine was sterile. A routine renal ultrasound (US) showed a 36 mm cortical mass on the low pole of the left kidney with no dilation or deformation of the renal pelvis calyces. The ureters were normal. Subsequent computed tomography (CT) revealed an exophytic lesion in the lower pole of the left kidney, measuring 36 × 23 × 39 mm, well demarked, with peripheral enhancement, and a central fluid collection . No intratumoral calcification was identified. No invasion of perinephric fat tissues or adjacent structures, such as renal vein or inferior vena cava (IVC) was noted. No metastasis or lymphadenopathy was evident. On magnetic resonance imaging (MRI), the mass was iso intense to the kidney in T1 weighted image and hyper intense with restricted diffusion in T2 weighted image. T2 weighted image also demonstrated a hyper intense peripheral signal associated to an exocentric, heterogenous and irregular hypointense signal in the center of the tumor .\nThe diagnosis of renal cell cancer was very likely, the patient underwent an open surgery. It was an 80% exophytic tumor lying on the lower pole of the left kidney, a clampless partial nephrectomy was performed. The postoperative course was uneventful and the patient was discharged on the fourth postoperative day.\nLaboratory examination showed a well circumscribed, white, firm tumor confined to the lower pole which measuring 4 × 4 × 3 cm. There was no macroscopic capsular involvement.\nMicroscopic examination showed a well mesenchymal neoplasm surrounded by fibrous tissue occasionally separated by strip-like bands of collagen. The proliferation was composed of long spindle cell with acidophilic cytoplasm and vesicular nuclei, round to oval, organized in a patternless architecture with a combination of alternating hypocellular and hypercellular areas separated from each other by thick bands of hyalinized collagen. It also showed a thin-walled, hemangiopericytoma-like vessels . Mitotic activity and atypia have not been observed. Immunohistochemical staining was positive for CD34 and Bcl-2 and HMB45 stain was negative . Based on the histological and immunohistochemical features, the diagnosis of SFT of the kidney was established.\nNine months after discharge the patient had a Chest-abdomen-pelvis CT follow up with no evidence of tumor recurrence or metastasis.", + "fulltext_subclaims": [ + "The patient is a 55-year-old male.", + "The patient has no past medical history.", + "The patient was referred for lower urinary tract symptoms.", + "The patient has neither pain nor hematuria.", + "Physical examination was normal.", + "Blood tests were normal.", + "Cytobacteriological examination of the urine was sterile.", + "A routine renal ultrasound showed a 36 mm cortical mass on the low pole of the left kidney.", + "The renal pelvis calyces showed no dilation or deformation.", + "The ureters were normal.", + "Computed tomography revealed an exophytic lesion in the lower pole of the left kidney.", + "The lesion measured 36 × 23 × 39 mm.", + "The lesion was well demarked.", + "The lesion showed peripheral enhancement.", + "The lesion had a central fluid collection.", + "No intratumoral calcification was identified.", + "No invasion of perinephric fat tissues was noted.", + "No invasion of the renal vein or inferior vena cava was noted.", + "No metastasis was evident.", + "No lymphadenopathy was evident.", + "On MRI, the mass was iso intense to the kidney in T1 weighted image.", + "On MRI, the mass was hyper intense with restricted diffusion in T2 weighted image.", + "T2 weighted image showed a hyper intense peripheral signal.", + "T2 weighted image showed an exocentric, heterogeneous and irregular hypointense signal in the center of the tumor.", + "The diagnosis of renal cell cancer was very likely.", + "The patient underwent an open surgery.", + "It was an 80% exophytic tumor lying on the lower pole of the left kidney.", + "A clampless partial nephrectomy was performed.", + "The postoperative course was uneventful.", + "The patient was discharged on the fourth postoperative day.", + "Laboratory examination showed a well circumscribed, white, firm tumor confined to the lower pole.", + "The tumor measured 4 × 4 × 3 cm.", + "There was no macroscopic capsular involvement.", + "Microscopic examination showed a well mesenchymal neoplasm surrounded by fibrous tissue.", + "The proliferation was composed of long spindle cells with acidophilic cytoplasm and vesicular nuclei.", + "The nuclei were round to oval.", + "The cells were organized in a patternless architecture.", + "The tumor showed alternating hypocellular and hypercellular areas.", + "The areas were separated by thick bands of hyalinized collagen.", + "The tumor showed thin-walled, hemangiopericytoma-like vessels.", + "Mitotic activity was not observed.", + "Atypia was not observed.", + "Immunohistochemical staining was positive for CD34.", + "Immunohistochemical staining was positive for Bcl-2.", + "HMB45 stain was negative.", + "The diagnosis of SFT of the kidney was established.", + "Nine months after discharge, the patient had a Chest-abdomen-pelvis CT follow up.", + "There was no evidence of tumor recurrence.", + "There was no evidence of metastasis." + ], + "summary": "A 55-year-old men with lower urinary tract symptoms, had a routine renal ultrasound which showed a cortical mass of the left kidney measuring 36 × 23 × 39 mm, with peripheral enhancement, and a central fluid collection on CT. On MRI, it was iso-intense to the kidney in T1 and hyper-intense with restricted diffusion in T2 images. The diagnosis of renal cell cancer was likely and an open partial nephrectomy was performed. Microscopic examination showed a mesenchymal neoplasm with long spindle cell and Immunohistochemical staining positive for CD34 and Bcl-2 confirming the diagnosis of SFT. There was no evidence of tumor recurrence or metastasis nine months after discharge.", + "summary_subclaims": [ + "The patient is a 55-year-old man.", + "The patient had lower urinary tract symptoms.", + "A routine renal ultrasound showed a cortical mass of the left kidney measuring 36 × 23 × 39 mm.", + "The mass had peripheral enhancement.", + "The mass had a central fluid collection on CT.", + "On MRI, the mass was iso-intense to the kidney in T1.", + "On MRI, the mass was hyper-intense with restricted diffusion in T2 images.", + "The diagnosis of renal cell cancer was likely.", + "An open partial nephrectomy was performed.", + "Microscopic examination showed a mesenchymal neoplasm with long spindle cells.", + "Immunohistochemical staining was positive for CD34.", + "Immunohistochemical staining was positive for Bcl-2.", + "The diagnosis was confirmed as SFT.", + "There was no evidence of tumor recurrence nine months after discharge.", + "There was no evidence of metastasis nine months after discharge." + ] + }, + { + "id": "multiclinsum_test_1855_en.txt", + "fulltext": "A 54-year-old Caucasian female proceeded to our institution with epigastric pain, nausea and vomiting along with pain located around the lumbar area lasting for one week. No previous surgical history or commorbidities existed. Clinical examination did not reveal any palpable abdominal masses or abdominal tenderness and the patient’s vital signs were within the normal spectrum. Blood test detected hypercalcemia (serum calcium: 10.2 mg/dL) and parathyroid hormone level of 111.8 pg/mL. All the findings in conjunction with the clinical presentation lead to the assumption that the patient had primary hyperparathyroidism (PHPT).\nThen, an ultrasound was performed but it was negative for any thyroid or parathyroid abnormalities. Subsequently, the thoracic and abdominal CT revealed a soft tissue in the anterior mediastinum 7 × 1 cm. Additional Tc-99m-MIBI scintigraphy followed, which detected an ectopic adenoma located in the lower anterior mediastinum, on the left of the median line . Following these, a mid-sternal thoracotomy was finally scheduled.\nDuring the operation, after the thoracotomy, surgeons attempted to detect deep into the mediastinum the parathyroid adenoma according to the preoparative localization. Indeed, the mediastinal mass was detected on the left of the median line, at the anterior mediastinum, in front of the anterior surface of the pericardium and close to the left pericardiophrenic vessels and the left phrenic nerve . The adenoma was covered by a thin fibrous capsule. When surgeons removed the capsule, a dark red mass of 7 × 2.8 × 1 cm was finally revealed . The detailful preoperative localization of the present mediastinal adenoma which was in close relation with various anatomical structures of the thorax, reduced effectively the difficulty of the mass excision and the potentiality of accidental surgical injuries which may lead to thoracic bleeding and subsequent obstructive symptoms.\nThen, the operation continued in the usual fashion and a drainage was placed into the left side of the thoracic cavity. The patient was discharged the 5th postoperative day with instructions, when the drainage was finally removed.\nHistology of the mass confirmed the diagnosis of ectopic parathyroid adenoma that was composed predominantly of oxyphil cells arranged in an acinar pattern. Serum calcium level was 2.60 mmol/L and iPTH 17.6 pg/mL 12 h after the operation. Serum calcium and iPTH remained normal after 6 months’ follow-up.", + "fulltext_subclaims": [ + "The patient is a 54-year-old Caucasian female.", + "The patient had epigastric pain, nausea, vomiting, and lumbar pain lasting for one week.", + "The patient had no previous surgical history.", + "The patient had no comorbidities.", + "Clinical examination did not reveal any palpable abdominal masses.", + "Clinical examination did not reveal abdominal tenderness.", + "The patient’s vital signs were within the normal spectrum.", + "Blood tests detected hypercalcemia with a serum calcium level of 10.2 mg/dL.", + "The parathyroid hormone level was 111.8 pg/mL.", + "The findings in conjunction with the clinical presentation led to the assumption of primary hyperparathyroidism.", + "An ultrasound was performed.", + "The ultrasound was negative for any thyroid or parathyroid abnormalities.", + "A thoracic and abdominal CT revealed a 7 × 1 cm soft tissue in the anterior mediastinum.", + "Tc-99m-MIBI scintigraphy detected an ectopic adenoma located in the lower anterior mediastinum, on the left of the median line.", + "A mid-sternal thoracotomy was scheduled.", + "During the operation, the mediastinal mass was detected on the left of the median line, at the anterior mediastinum.", + "The mass was located in front of the anterior surface of the pericardium.", + "The mass was close to the left pericardiophrenic vessels.", + "The mass was close to the left phrenic nerve.", + "The adenoma was covered by a thin fibrous capsule.", + "When the capsule was removed, a dark red mass of 7 × 2.8 × 1 cm was revealed.", + "The detailful preoperative localization reduced the difficulty of the mass excision.", + "The detailful preoperative localization reduced the potentiality of accidental surgical injuries.", + "The operation continued in the usual fashion.", + "A drainage was placed into the left side of the thoracic cavity.", + "The patient was discharged on the 5th postoperative day.", + "The drainage was removed before discharge.", + "Histology of the mass confirmed the diagnosis of ectopic parathyroid adenoma.", + "The mass was composed predominantly of oxyphil cells arranged in an acinar pattern.", + "Serum calcium level was 2.60 mmol/L 12 hours after the operation.", + "Intact parathyroid hormone level was 17.6 pg/mL 12 hours after the operation.", + "Serum calcium and iPTH remained normal after 6 months’ follow-up." + ], + "summary": "A 54-year-old Caucasian female proceeded to our institution with signs and symptoms of PHPT. Imaging studies performed identified a large mass localized in the lower anterior mediastinum, on the left of the median line. A mid-sternal thoracotomy was performed and the aberrant adenoma was finally detected anterior to the pericardium and the left pericardiophrenic vessels and the left phrenic nerve. The operation was uneventful. A meticulous review of the literature was conducted as well.", + "summary_subclaims": [ + "The patient is a 54-year-old Caucasian female.", + "The patient had signs and symptoms of PHPT.", + "Imaging studies identified a large mass in the lower anterior mediastinum.", + "The mass was localized on the left of the median line.", + "A mid-sternal thoracotomy was performed.", + "The aberrant adenoma was detected anterior to the pericardium.", + "The operation was uneventful.", + "A meticulous review of the literature was conducted." + ] + }, + { + "id": "multiclinsum_test_1654_en.txt", + "fulltext": "A 62-year-old Indian male, a chronic smoker, presented with three episodes of rest angina for the last 1 month. He was detected with hypertension and was taking telmisartan hydrochloride, 40 mg once a day for the last 5 years. There was no history of any other comorbidity. At presentation, his blood pressure was 130/82 mmHg, and his pulse rate was 90 beats per minute. His cardiovascular examination was unremarkable. The electrocardiograph showed T-wave inversion in leads LII, LIII, and aVF . Echocardiography revealed a structurally normal heart with a left ventricular ejection fraction of 55%. Cardiac troponin-I level was normal.\nAt the age of 52, he was diagnosed with chronic stable angina when a coronary angiogram revealed a diffuse lesion in the right coronary artery (RCA), causing critical stenosis . PCI to RCA was done with implantation of three second-generation DES (zotarolimus-eluting Endeavor Spirit stent, Medtronic Vascular, CA, USA) with an adequate overlap of stent edges. Post dilatation with a 3.0 × 15 mm non-compliant (NC) balloon in the distal RCA and a 3.5 × 15 mm NC balloon in mid-proximal RCA achieved good angiographic results . Intracoronary imaging was not done at that time. He received dual antiplatelet therapy (DAPT), including aspirin and clopidogrel, for 1-year post-PCI, after which only aspirin was continued. He has also received metoprolol and atorvastatin since then. He did well for the last 9 years following PCI.\nDuring the current presentation, he was diagnosed with non-ST-elevation acute coronary syndrome and was given 180 mg ticagrelor along with 75 mg aspirin. A coronary angiogram revealed diffuse in-stent restenosis (ISR) extending from proximal to the mid-stented segment of RCA with a focal haziness causing 90% stenosis . This hazy lesion corresponds to the overlap segment of proximal-mid RCA stents ( and ). An intracoronary OCT imaging of RCA was performed (ILUMIEN TM Optis systems, MA, USA) to elucidate the mechanism of stent failure. Longitudinal OCT image (, middle panel) revealed well-apposed struts throughout the length of the stented segment, diffuse intimal hyperplasia, and neo-atherosclerosis, causing a variable degree of luminal stenosis. Furthermore, the OCT appearance of neo-atherosclerosis was variable. While predominantly fibrotic hyperplasia was noticed in the distal and proximal stent, neo-atheroma in the middle stent showed a predominantly lipid-rich plaque with minimal fibrous element, especially at the site of proximal stent overlap. This segment also revealed a thin overlying fibrous cap, plaque rupture, and a white thrombus causing significant luminal area reduction (, upper and lower panels, Videos 1 and 2). Further analysis of the OCT images revealed a vessel diameter of 3.2 mm in the distal reference segment of RCA. This correlates well with the measured mean stent diameter of 3.18 mm in distal RCA, 3.51 mm at the distal stent overlap, and 3.55 mm at the proximal stent overlap segments of RCA, thereby ruling out under-expansion as a mechanism of stent malfunction in the index patient .\nWe pre-dilated the ISR lesion with a 2.5 × 15 mm semi-compliant balloon followed by a 3.0 × 15 mm NC balloon and a 3.5 × 15 mm NC balloon at high pressure. Our initial plan was to treat the lesion with a drug-eluting balloon as ISR was intrastent. However, OCT imaging after balloon angioplasty revealed a dissection flap at the upper edge of the proximal stent, extending from the neoatheroma. A review of OCT images revealed a predominantly fibrotic plaque at this site . So, the diseased segment was treated with a 3.5 × 38 mm third-generation Sirolimus-Eluting Polymer Free Coronary Stent (Coroflex ISAR-Neo Stent, B. Braun, Melsungen, Germany) followed by high pressure (18 atm) post-dilatation with a 3.5 × 12 mm NC balloon. Repeat OCT imaging showed a well expanded and well-apposed stent with minimal stent area (6.54 mm2) , except at the proximal part where it was malapposed (, Video 3). This segment was further post-dilated with a 4.5 mm NC Balloon at 14 atm as guided by OCT. The final angiogram showed thrombolysis in myocardial infarction III flow . No further OCT imaging was done in view of contrast load. He was discharged on metoprolol, telmisartan, atorvastatin, and DAPT, including 75 mg of aspirin once a day and 90 mg of ticagrelor twice a day. Being a candidate with high thrombotic risk, he was prescribed an extended duration of DAPT as per current guidelines. He is doing well on follow-up at 6 months after discharge.", + "fulltext_subclaims": [ + "The patient is a 62-year-old Indian male.", + "He is a chronic smoker.", + "He had three episodes of rest angina for the last 1 month.", + "He was taking telmisartan hydrochloride, 40 mg once a day for the last 5 years.", + "There was no history of any other comorbidity.", + "His blood pressure at presentation was 130/82 mmHg.", + "His pulse rate at presentation was 90 beats per minute.", + "The electrocardiograph showed T-wave inversion in leads LII, LIII, and aVF.", + "Echocardiography revealed a left ventricular ejection fraction of 55%.", + "Cardiac troponin-I level was normal.", + "At age 52, he was diagnosed with chronic stable angina.", + "A coronary angiogram at age 52 revealed a diffuse lesion in the right coronary artery (RCA), causing critical stenosis.", + "PCI to RCA was done with implantation of three second-generation DES (zotarolimus-eluting Endeavor Spirit stent).", + "Post dilatation with a 3.0 × 15 mm non-compliant balloon in the distal RCA and a 3.5 × 15 mm NC balloon in mid-proximal RCA achieved good angiographic results.", + "He received dual antiplatelet therapy (DAPT), including aspirin and clopidogrel, for 1-year post-PCI.", + "He has received metoprolol and atorvastatin since the PCI.", + "He did well for the last 9 years following PCI.", + "During the current presentation, he was diagnosed with non-ST-elevation acute coronary syndrome.", + "He was given 180 mg ticagrelor along with 75 mg aspirin.", + "A coronary angiogram revealed diffuse in-stent restenosis (ISR) extending from proximal to the mid-stented segment of RCA with a focal haziness causing 90% stenosis.", + "An intracoronary OCT imaging of RCA was performed (ILUMIEN TM Optis systems).", + "The OCT appearance of neo-atherosclerosis was variable.", + "The segment also revealed a thin overlying fibrous cap, plaque rupture, and a white thrombus causing significant luminal area reduction.", + "The vessel diameter of 3.2 mm in the distal reference segment of RCA correlates well with the measured mean stent diameter of 3.18 mm in distal RCA.", + "This ruled out under-expansion as a mechanism of stent malfunction in the index patient.", + "We pre-dilated the ISR lesion with a 2.5 × 15 mm semi-compliant balloon followed by a 3.0 × 15 mm NC balloon and a 3.5 × 15 mm NC balloon at high pressure.", + "OCT imaging after balloon angioplasty revealed a dissection flap at the upper edge of the proximal stent, extending from the neoatheroma.", + "The diseased segment was treated with a 3.5 × 38 mm third-generation Sirolimus-Eluting Polymer Free Coronary Stent.", + "Repeat OCT imaging showed a well expanded and well-apposed stent with minimal stent area (6.54 mm2), except at the proximal part where it was malapposed.", + "The final angiogram showed thrombolysis in myocardial infarction III flow.", + "He was discharged on metoprolol, telmisartan, atorvastatin, and DAPT, including 75 mg of aspirin once a day and 90 mg of ticagrelor twice a day.", + "He was prescribed an extended duration of DAPT as per current guidelines.", + "He is doing well on follow-up at 6 months after discharge." + ], + "summary": "A 62-year-old man presented with the acute coronary syndrome. He has a history of percutaneous coronary intervention (PCI) to the right coronary artery using the three second-generation DES more than 9 years ago. Coronary angiogram revealed in-stent restenosis (ISR) with doubtful angiographic thrombus. Optical coherence tomography (OCT) confirmed the diagnosis of stent thrombosis (STh) localized to the stent overlap zone with underlying ISR. Patient underwent OCT-guided PCI with DES implantation and was discharged on dual antiplatelet therapy including ticagrelor. He is doing well on follow-up at 6 months.", + "summary_subclaims": [ + "The patient is a 62-year-old man.", + "He presented with the acute coronary syndrome.", + "He has a history of percutaneous coronary intervention (PCI) to the right coronary artery using the three second-generation DES more than 9 years ago.", + "Coronary angiogram revealed in-stent restenosis (ISR) with doubtful angiographic thrombus.", + "Optical coherence tomography (OCT) confirmed the diagnosis of stent thrombosis (STh) localized to the stent overlap zone with underlying ISR.", + "The patient underwent OCT-guided PCI with DES implantation.", + "He was discharged on dual antiplatelet therapy including ticagrelor.", + "He is doing well on follow-up at 6 months." + ] + }, + { + "id": "multiclinsum_test_1336_en.txt", + "fulltext": "The patient was a 67-year-old man, who had been admitted to the hospital due to melena and a hematocrit level of 20.1 %. Nasogastric intubation revealed a fresh blood clot in the stomach. Urinalysis, chest and abdominal films, and liver function tests were within normal limits, and serum creatinine was 1.2 mg/dl. Five units of packed blood cells were transfused promptly.\nAbdominal CT scan showed a well-defined, heterogeneous mass (3 × 4 m) which was located in the lower part of the stomach body . Gastric endoscopy showed the ulcerated tumor with bleeding along the lesser curvature of the proximal stomach and a submucosal nodule that measured about 3 cm in diameter in the lower part of the stomach body . No other metastatic lesions in other organs were found on abdominal ultrasonography or the CT scan. High-grade gastrointestinal bleeding persisted, necessitating the additional transfusion of ten units of packed red blood cells. Subsequently, the patient underwent a total gastrectomy. During the operation, there was no other evidence of metastatic disease in the intra-abdominal cavity. Macroscopic examination of the total gastrectomy specimen showed Borrman type-2 tumor measuring 5 × 6 cm and submucosal nodule measuring 3 × 4 cm in the stomach . On histopathological examination, the Borrman type-2 tumor gastric tumor showed transmural infiltration by a poorly differentiated diffuse adenocarcinoma . There was no vascular invasion and no lymph node metastasis. Further histopathological examination of the submucosal nodule revealed GIST of the low-risk category , which was composed of cytologically bland spindle cells and showed a low mitotic index (< 5/50HPF).\nThe immunohistochemistry indicated strong staining for CD34 and C-kit, while expressions of SMA and S-100 were negative . These findings confirmed the simultaneous development of gastric cancer and GIST. The patient was subsequently discharged without any complications.", + "fulltext_subclaims": [ + "The patient was a 67-year-old man.", + "The patient was admitted to the hospital due to melena.", + "The patient's hematocrit level was 20.1%.", + "Nasogastric intubation revealed a fresh blood clot in the stomach.", + "Urinalysis was within normal limits.", + "Chest and abdominal films were within normal limits.", + "Liver function tests were within normal limits.", + "Serum creatinine was 1.2 mg/dl.", + "Five units of packed blood cells were transfused promptly.", + "Abdominal CT scan showed a well-defined, heterogeneous mass (3 × 4 cm) located in the lower part of the stomach body.", + "Gastric endoscopy showed an ulcerated tumor with bleeding along the lesser curvature of the proximal stomach.", + "Gastric endoscopy showed a submucosal nodule that measured about 3 cm in diameter in the lower part of the stomach body.", + "No other metastatic lesions in other organs were found on abdominal ultrasonography.", + "No other metastatic lesions in other organs were found on the CT scan.", + "High-grade gastrointestinal bleeding persisted.", + "The patient received an additional transfusion of ten units of packed red blood cells.", + "The patient underwent a total gastrectomy.", + "During the operation, there was no other evidence of metastatic disease in the intra-abdominal cavity.", + "Macroscopic examination of the total gastrectomy specimen showed a Borrman type-2 tumor measuring 5 × 6 cm.", + "Macroscopic examination showed a submucosal nodule measuring 3 × 4 cm in the stomach.", + "The Borrman type-2 tumor showed transmural infiltration by a poorly differentiated diffuse adenocarcinoma.", + "There was no vascular invasion.", + "There was no lymph node metastasis.", + "Further histopathological examination of the submucosal nodule revealed GIST of the low-risk category.", + "The GIST was composed of cytologically bland spindle cells.", + "The GIST showed a low mitotic index (< 5/50HPF).", + "The immunohistochemistry indicated strong staining for CD34.", + "The immunohistochemistry indicated strong staining for C-kit.", + "The immunohistochemistry showed negative expression of SMA.", + "The immunohistochemistry showed negative expression of S-100.", + "These findings confirmed the simultaneous development of gastric cancer and GIST.", + "The patient was discharged without any complications." + ], + "summary": "We report a case of the coexistence of adenocarcinoma and gastrointestinal stromal tumor (GIST). Gastric endoscopy showed the ulcerated tumor with bleeding along the lesser curvature of the proximal stomach and a submucosal nodule that measured about 3 cm in diameter in the lower part of the stomach body. Their pathological examination showed gastric cancer (poorly differentiated diffuse adenocarcinoma) and GIST (low-risk category). Further, immunohistochemical staining for C-kit and CD34 was positive, while that for SMA and S-100 was negative.", + "summary_subclaims": [ + "We report a case of the coexistence of adenocarcinoma and gastrointestinal stromal tumor.", + "Gastric endoscopy showed the ulcerated tumor with bleeding along the lesser curvature of the proximal stomach.", + "Gastric endoscopy showed a submucosal nodule that measured about 3 cm in diameter in the lower part of the stomach body.", + "Their pathological examination showed gastric cancer (poorly differentiated diffuse adenocarcinoma).", + "Their pathological examination showed GIST (low-risk category).", + "Immunohistochemical staining for C-kit was positive.", + "Immunohistochemical staining for CD34 was positive.", + "Immunohistochemical staining for SMA was negative.", + "Immunohistochemical staining for S-100 was negative." + ] + }, + { + "id": "multiclinsum_test_2193_en.txt", + "fulltext": "A 32-year-old Mongoloid female with headache, progressive disturbance of consciousness, and right limb weakness was transferred to our hospital. On arrival, she was in a mild coma with dilated pupils. Glasgow Coma Scale (GCS) score was 9 (4 + 4 + 1). No movement but muscle retraction was observed in the right limb and the Babinski sign is positive. The National Institute of Health Stroke Scale (NIHSS) score was 17. The patient was a fruit seller without previous chronic diseases, and denied smoking and drinking history, toxic and drug exposure, and family history. Noncontrast brain computed tomography (CT) and CT venography scan in another hospital showed CVST in straight sinus and sagittal sinus . Subcutaneous injection of weight-based low-molecular-weight heparin was immediately administered, yet symptoms deteriorated within 2 days.\nAfter admission, cerebrovascular intervention was performed immediately, and the images indicated nonvisualization of right transverse, sigmoid sinus, and straight sinus, and large thrombus was identified among the junction of the superior sagittal sinus, the left transverse sinus, and the sigmoid sinus, with severe stenosis of the corresponding vein lumens . Urokinase was injected into right transverse sinus and upper sagittal sinus via microcatheter. After the operation, the microcatheter and the sheath were kept for alternate use of urokinase and alteplase in the next 2 days. Unfortunately, the patient’s symptoms did not improve significantly. We performed a second cerebral angiography and found nonvisualization of the straight sinus and the right transverse, while the large thrombus almost disappeared. Using balloon dilation and thrombus aspiration, we found that the visualization of right transverse sinus and sigmoid sinus was improved, while that of the straight sinus was not . After intervention, full-dose anticoagulation therapy was administrated, despite large bruises on both upper limbs and slight hemorrhage in the thalamus. The patient’s consciousness state was gradually improved within 2 days. Her later laboratory examination showed that serum thyroid-stimulating hormone was low with high free triiodothyronine (T3), free thyroxine (T4), and antibodies, but she was never diagnosed or treated. The department of endocrinology was consulted, she was diagnosed with hyperthyroidism (Graves’ disease), and corresponding drug treatment was carried out. She was discharged with her NIHSS score decreased to 2, diagnosed with hyperthyroidism and refractory CVST. Three months later, she complained of occasional numbness in right limb with NIHSS score of 0. Magnetic resonance venography (MRV) showed that sagittal sinus, transverse sinus, and sigmoid sinus visualized well, although the straight sinus was less clear.", + "fulltext_subclaims": [ + "The patient was a 32-year-old Mongoloid female.", + "She had headache, progressive disturbance of consciousness, and right limb weakness.", + "On arrival, she was in a mild coma with dilated pupils.", + "Glasgow Coma Scale (GCS) score was 9 (4 + 4 + 1).", + "No movement but muscle retraction was observed in the right limb.", + "The Babinski sign is positive.", + "The NIHSS score was 17.", + "Noncontrast brain CT and CT venography scan showed CVST in straight sinus and sagittal sinus.", + "Subcutaneous injection of weight-based low-molecular-weight heparin was immediately administered.", + "Symptoms deteriorated within 2 days.", + "Cerebrovascular intervention was performed immediately.", + "The images indicated nonvisualization of right transverse, sigmoid sinus, and straight sinus.", + "A large thrombus was identified among the junction of the superior sagittal sinus, the left transverse sinus, and the sigmoid sinus.", + "Urokinase was injected into right transverse sinus and upper sagittal sinus via microcatheter.", + "The microcatheter and the sheath were kept for alternate use of urokinase and alteplase in the next 2 days.", + "The patient’s symptoms did not improve significantly.", + "The second cerebral angiography found nonvisualization of the straight sinus and the right transverse.", + "The large thrombus almost disappeared.", + "Balloon dilation and thrombus aspiration were performed.", + "The visualization of right transverse sinus and sigmoid sinus was improved.", + "The visualization of the straight sinus was not improved.", + "Full-dose anticoagulation therapy was administrated.", + "The patient’s consciousness state was gradually improved within 2 days.", + "Serum thyroid-stimulating hormone was low.", + "Free triiodothyronine (T3) was high.", + "Free thyroxine (T4) was high.", + "Antibodies were high.", + "She was never diagnosed or treated.", + "The department of endocrinology was consulted.", + "She was diagnosed with hyperthyroidism (Graves’ disease).", + "Corresponding drug treatment was carried out.", + "She was discharged with her NIHSS score decreased to 2.", + "She was diagnosed with hyperthyroidism and refractory CVST.", + "Three months later, she complained of occasional numbness in right limb.", + "Magnetic resonance venography showed that sagittal sinus, transverse sinus, and sigmoid sinus visualized well.", + "The straight sinus was less clear." + ], + "summary": "In this case report, we present a 32-year-old Mongoloid woman admitted with progressive headache, impaired consciousness, and right limb weakness, diagnosed with cerebral venous sinus thrombosis caused by hyperthyroidism. A cerebrovascular intervention with local thrombolytic infusion was performed at the site of thrombosis, followed by dilatation with balloon and thrombus aspiration in venous sinus, with partial recanalization observed and anticoagulation given as a next step. After cerebrovascular intervention, the patient's condition improved rapidly and she was discharged with her National Institute of Health Stroke Scale score being decreased from 17 to 2.", + "summary_subclaims": [ + "The patient was a 32-year-old Mongoloid woman.", + "She was admitted with progressive headache.", + "She had impaired consciousness.", + "She had right limb weakness.", + "She was diagnosed with cerebral venous sinus thrombosis.", + "The cerebral venous sinus thrombosis was caused by hyperthyroidism.", + "A cerebrovascular intervention with local thrombolytic infusion was performed.", + "The intervention was performed at the site of thrombosis.", + "Dilatation with balloon and thrombus aspiration in venous sinus was performed.", + "Partial recanalization was observed.", + "Anticoagulation was given as a next step.", + "After cerebrovascular intervention, the patient's condition improved rapidly.", + "She was discharged.", + "Her National Institute of Health Stroke Scale score was decreased from 17 to 2." + ] + }, + { + "id": "multiclinsum_test_573_en.txt", + "fulltext": "A 73-year-old man was diagnosed with colon cancer and underwent right hemicolectomy at our hospital. The final diagnosis of colon cancer revealed adenocarcinoma, type 2, 70 × 40 mm, tub2 > tub1, T4a (SE), int, INFb, Ly1a, V1b, Pn0, N1a (1/30), p-stage IIIB (according to the ninth edition of TNM classification). Computed tomography (CT) before surgery for colon cancer revealed a solid nodule measuring 16 mm in diameter in the laterobasal segment (S9) of the right lung . Three months after the surgery for colon cancer, the size of the pulmonary nodule increased (diameter, 18 mm; Fig. b). The levels of tumor markers, including carcinoembryonic antigen (1.7 ng/mL), carbohydrate antigen 19-9 (5.2 U/mL), cytokeratin 19 fragment (2.2 ng/mL), and pro-gastrin-releasing peptide (66.9 pg/mL), were all within normal levels. The pulmonary tumor was highly suspected to be a metastasis from the colon cancer because of the tumor growth. No other metastases were observed on contrast-enhanced CT. We considered preoperative bronchoscopy. However, the patient preferred surgery for diagnostic and therapeutic purposes. Preoperative three-dimensional CT (3D-CT) angiography revealed that A7a branched from the right main PA, whereas A7b branched from the A8+9+10 as usual . The A7a and A7b were located on the ventral and dorsal sides of the basal vein, respectively.\nRight basal segmentectomy was performed via video-assisted thoracic surgery. The interlobar fissure between the middle and lower lobes was incomplete. Then, we dissected around the inferior pulmonary vein (IPV) to identify the border of the middle and lower lobes. Subsequently, during dissection of the cranial side of V6, we found the A7a that was close to V6 . The A7a branching from the right main PA was observed behind the V4+5 and middle lobe bronchus during surgery . The basal PA except for A7a was divided using a stapler, and A7a was ligated and divided . Then, the basal bronchus was divided using the stapler. After the vein of the basal segment (V7–10) was divided, the intersegmental plane was dissected using the stapler along the inflation and deflation lines. Intraoperative frozen section diagnosis revealed that the tumor was compatible with a metastasis from the colon cancer. The total operation time was 144 min, and the total blood loss volume was 30 mL.\nThe postoperative course was uneventful. The tumor had reached a maximum diameter of 20 mm, and the final pathologic diagnosis was combined small cell carcinoma and adenocarcinoma as opposed to the frozen section diagnosis. The pathological staging of the tumor was p-T1cN0M0, p-stage IA3. Although we proposed completion right lower lobectomy with systemic mediastinal lymph node dissection, the patient did not agree. The patient received adjuvant chemotherapy (XELOX) for colon cancer after a discussion with the cancer board in our institution. There was no recurrence of lung and colon cancer at a 1-year follow-up.", + "fulltext_subclaims": [ + "The patient was a 73-year-old man.", + "The patient was diagnosed with colon cancer.", + "The patient underwent right hemicolectomy at our hospital.", + "The final diagnosis of colon cancer revealed adenocarcinoma, type 2, 70 × 40 mm, tub2 > tub1, T4a (SE), int, INFb, Ly1a, V1b, Pn0, N1a (1/30), p-stage IIIB.", + "Computed tomography before surgery for colon cancer revealed a solid nodule measuring 16 mm in diameter in the laterobasal segment (S9) of the right lung.", + "Three months after the surgery for colon cancer, the size of the pulmonary nodule increased to 18 mm.", + "The levels of carcinoembryonic antigen were 1.7 ng/mL.", + "The levels of carbohydrate antigen 19-9 were 5.2 U/mL.", + "The levels of cytokeratin 19 fragment were 2.2 ng/mL.", + "The levels of pro-gastrin-releasing peptide were 66.9 pg/mL.", + "The pulmonary tumor was highly suspected to be a metastasis from the colon cancer because of the tumor growth.", + "No other metastases were observed on contrast-enhanced CT.", + "The patient preferred surgery for diagnostic and therapeutic purposes.", + "Preoperative three-dimensional CT angiography revealed that A7a branched from the right main PA.", + "Preoperative three-dimensional CT angiography revealed that A7b branched from the A8+9+10 as usual.", + "Right basal segmentectomy was performed via video-assisted thoracic surgery.", + "The interlobar fissure between the middle and lower lobes was incomplete.", + "The A7a branching from the right main PA was observed behind the V4+5 and middle lobe bronchus during surgery.", + "The A7a was ligated and divided.", + "The basal bronchus was divided using the stapler.", + "Intraoperative frozen section diagnosis revealed that the tumor was compatible with a metastasis from the colon cancer.", + "The total operation time was 144 min.", + "The total blood loss volume was 30 mL.", + "The postoperative course was uneventful.", + "The tumor had reached a maximum diameter of 20 mm.", + "The final pathologic diagnosis was combined small cell carcinoma and adenocarcinoma.", + "The pathological staging of the tumor was p-T1cN0M0, p-stage IA3.", + "The patient did not agree to completion right lower lobectomy with systemic mediastinal lymph node dissection.", + "The patient received adjuvant chemotherapy (XELOX) for colon cancer.", + "There was no recurrence of lung and colon cancer at a 1-year follow-up." + ], + "summary": "A 73-year-old man was referred to our department for a right lower lobe nodule measuring 18 mm in diameter on computed tomography (CT). Three-dimensional (3D) CT revealed mediastinal A7a branching from the right main PA. As the patient had undergone colectomy for advanced ascending colon cancer, the nodule was suspected to be a metastasis from the colon primary, and thus, basal segmentectomy of the right lung was performed. Intraoperatively, the A7a was observed behind the V4+5 and middle lobe bronchus. The pathological diagnosis was combined small cell carcinoma with an adenocarcinoma component (p-T1cN0M0, stage IA3). The patient subsequently received adjuvant chemotherapy for colon cancer. At 1-year postoperative follow-up, there was no evidence of disease.", + "summary_subclaims": [ + "The patient was a 73-year-old man.", + "The patient was referred for a right lower lobe nodule measuring 18 mm in diameter on CT.", + "Three-dimensional CT revealed mediastinal A7a branching from the right main PA.", + "The patient had undergone colectomy for advanced ascending colon cancer.", + "The nodule was suspected to be a metastasis from the colon primary.", + "Basal segmentectomy of the right lung was performed.", + "Intraoperatively, the A7a was observed behind the V4+5 and middle lobe bronchus.", + "The pathological diagnosis was combined small cell carcinoma with an adenocarcinoma component.", + "The stage was p-T1cN0M0, stage IA3.", + "The patient received adjuvant chemotherapy for colon cancer.", + "At 1-year postoperative follow-up, there was no evidence of disease." + ] + }, + { + "id": "multiclinsum_test_1552_en.txt", + "fulltext": "A 35 year old woman WITH no significant past medical history. The history of her illness goes back 2 years marked by the appearance of a left parotid tumefaction. The initial histological study by biopsy revealed a mixed salivary gland tumor of 28 mm without signs of malignancy. The patient had a large resection of this mass with negative surgical margins. 6 months later, she presented with a nodule next to the surgical scar at the subangulomandibular level of 6 cm fixed firm painful on palpation without inflammatory signs associated with left peripheral facial paralysis. Examination of lymph node areas was normal. A parotid MRI revealed an expansive process measuring 42 mm, poorly limited, moderately infiltrating the masseter and pterygoid muscles with heterogeneous spontaneous signal with dynamic enhancement according to a type C curve and a very low ADC (–).\nThe extension assessment made by a thoraco-abdomino-pelvic scanner and a bone scintigraphy requested in the face of bone pain, was without abnormality. The patient underwent excision of the mass with extemporaneous examination suggesting an infiltrating carcinoma from which the surgical procedure was completed by a wide left parotidectomy with ipsilateral triangular dissection and preservation of the left facial nerve. The definitive pathological examination showed an undifferentiated malignant tumor proliferation whose immunohistochimical profile suggested a primary peripheral neuroectodermal tumor or PNET. Tumor cells were CK (+) and CD99(+), on the other hand synaptophysin, EMA, NSE, chromogranin, and vimentin were negatives. The study by Fluorescence in situ hybridization (FISH) confirmed the presence of a specific EWING/PNET type translocation in 60% of the tumor cells. The diagnosis of extra-skeletal Ewing’s sarcoma was retained. VDC/IE type chemotherapy (vincristine, doxorubicin, cyclophosphamide alternating with ifosfamide, and etoposide) was indicated followed by external radiotherapy on the operating bed delivered at a dose of 54 Gy in standard spreading and fractionation (1.8 Gy/session and 5 sessions/week). The CTV and PTV margins were 1.5 cm and 5 mm respectively . Treatment planning was performed on the Varian AAA 13.7 Eclipse TPS via a Linac-type linear accelerator. The tolerance of the treatment was good with maximum toxicity of grade 2 mucositis and grade 1 dermatitis which progressed well under symptomatic treatment. A clinical and radiological follow-up by cervical MRI was done every 3 months. The 10-month follow-up showed no locoregional and distant recurrence.", + "fulltext_subclaims": [ + "The patient is a 35 year old woman.", + "The patient has no significant past medical history.", + "The history of her illness goes back 2 years.", + "A left parotid tumefaction appeared.", + "The initial histological study by biopsy revealed a mixed salivary gland tumor of 28 mm.", + "The tumor showed no signs of malignancy.", + "The patient had a large resection of this mass.", + "The surgical margins were negative.", + "6 months later, she presented with a nodule next to the surgical scar.", + "The nodule was at the subangulomandibular level.", + "The nodule measured 6 cm.", + "The nodule was fixed, firm, and painful on palpation.", + "The nodule was without inflammatory signs.", + "The patient had left peripheral facial paralysis.", + "Examination of lymph node areas was normal.", + "A parotid MRI revealed an expansive process measuring 42 mm.", + "The process was poorly limited.", + "The process was moderately infiltrating the masseter and pterygoid muscles.", + "The MRI showed heterogeneous spontaneous signal.", + "The MRI showed dynamic enhancement according to a type C curve.", + "The ADC was very low.", + "The extension assessment was made by a thoraco-abdomino-pelvic scanner.", + "Bone scintigraphy was requested in the face of bone pain.", + "The extension assessment was without abnormality.", + "The patient underwent excision of the mass.", + "The extemporaneous examination suggested an infiltrating carcinoma.", + "The surgical procedure was completed by a wide left parotidectomy.", + "The surgical procedure included ipsilateral triangular dissection.", + "The left facial nerve was preserved.", + "The definitive pathological examination showed an undifferentiated malignant tumor proliferation.", + "The immunohistochimical profile suggested a primary peripheral neuroectodermal tumor or PNET.", + "Tumor cells were CK (+).", + "Tumor cells were CD99(+).", + "Synaptophysin was negative.", + "EMA was negative.", + "NSE was negative.", + "Chromogranin was negative.", + "Vimentin was negative.", + "FISH confirmed the presence of a specific EWING/PNET type translocation in 60% of the tumor cells.", + "The diagnosis of extra-skeletal Ewing’s sarcoma was retained.", + "VDC/IE type chemotherapy was indicated.", + "The chemotherapy included vincristine, doxorubicin, cyclophosphamide alternating with ifosfamide, and etoposide.", + "External radiotherapy was delivered at a dose of 54 Gy.", + "The radiotherapy was in standard spreading and fractionation.", + "The radiotherapy was 1.8 Gy/session and 5 sessions/week.", + "The CTV margins were 1.5 cm.", + "The PTV margins were 5 mm.", + "Treatment planning was performed on the Varian AAA 13.7 Eclipse TPS.", + "The treatment was delivered via a Linac-type linear accelerator.", + "The tolerance of the treatment was good.", + "The maximum toxicity was grade 2 mucositis.", + "The maximum toxicity was grade 1 dermatitis.", + "The toxicity progressed well under symptomatic treatment.", + "A clinical and radiological follow-up by cervical MRI was done every 3 months.", + "The 10-month follow-up showed no locoregional recurrence.", + "The 10-month follow-up showed no distant recurrence." + ], + "summary": "We report a rare case of EES of the parotid gland in a 35-year-old female. She presented with left parotid tumefaction. Physical examination revealed solid and fixed mass associated with facial paralysis. Magnetic resonance imaging illustrated a left intra-parotid process occupying the entire gland measuring 42 mm infiltrating the masseter and pterygoid muscles. The patient had a total left parotidectomy with ipsilateral triangular lymph node dissection. The definitive pathological examination and the immunohistochemical staining confirmed a primary peripheral neuroectodermal tumor or PNET with the presence of a specific EWING/PNET-type translocation in 60% of the tumor cells. She had an adjuvant chemotherapy (four cycles of vincristine, doxorubicin, cyclophosphamide alternating with ifosfamide and etoposide) followed by external radiotherapy.", + "summary_subclaims": [ + "We report a rare case of EES of the parotid gland in a 35-year-old female.", + "She presented with left parotid tumefaction.", + "Physical examination revealed solid and fixed mass associated with facial paralysis.", + "Magnetic resonance imaging illustrated a left intra-parotid process occupying the entire gland measuring 42 mm.", + "The process infiltrated the masseter and pterygoid muscles.", + "The patient had a total left parotidectomy with ipsilateral triangular lymph node dissection.", + "The definitive pathological examination confirmed a primary peripheral neuroectodermal tumor or PNET.", + "Immunohistochemical staining confirmed the presence of a specific EWING/PNET-type translocation in 60% of the tumor cells.", + "She had an adjuvant chemotherapy with four cycles of vincristine, doxorubicin, cyclophosphamide alternating with ifosfamide and etoposide.", + "She had external radiotherapy." + ] + }, + { + "id": "multiclinsum_test_1276_en.txt", + "fulltext": "A 22-year-old female Caucasian patient was diagnosed with UC 3 mo ago, complaining of bloody diarrhea, abdominal pain and weight loss, and discontinued mesalamine due to the gastric intolerance. The patient underwent a colonoscopy 2 wk before the admission to the hospital, which revealed lesions consistent with UC of moderate endoscopic activity (Mayo endoscopic score 2).\nShe was admitted to the emergency department in due to frequent liquid and bloody stool and intense abdominal pain for 2 mo, with worsening of the symptoms during the last week, in poor condition with nausea, vomiting, and weight loss (10 kg) and without the improvement from the previous use of antibiotics.\nAt hospital admission (day 1 of hospital admission), the patient presented in poor condition, dehydrated, tachycardic (110 beat/min), blood pressure 100/60 mmHg, temperature > 37.8 °C, with distended and diffusely painful abdomen, and rebound tenderness.\nLaboratory tests showed inflammatory process (C-reactive protein 20.3 mg/dL) and anemia (hematocrit 25.8%, hemoglobin 8.1 g/dL) at admission .\nAbdominal X-ray revealed colonic dilation of 7 cm, consistent with megacolon .\nClostridium difficile (C. difficile) A and B toxin was positive, and the treatment with oral vancomycin 250 mg qid was initiated. However, the patient presented with worsening of diarrhea and rectal bleeding (> 10 episodes/d), increased abdominal distension, and fever. A flexible sigmoidoscopy was performed (day 4 of hospital admission) and inserted up to 25 cm with no insufflation, showing ulcers covered by fibrin, mucosal friability, edema, and intense enanthem with spontaneous bleeding in sigmoid and rectum, consistent with UC of severe activity (Mayo endoscopic score 3) . Histopathological evaluation showed chronic colitis in intense activity with structural abnormalities of the mucosa, presence of crypt micro-abscesses and plasmacytosis, consistent with severe inflammatory activity without the evidence of C. difficile or cytomegalovirus infection.", + "fulltext_subclaims": [ + "The patient is a 22-year-old female Caucasian.", + "The patient was diagnosed with UC 3 mo ago.", + "The patient discontinued mesalamine due to gastric intolerance.", + "A colonoscopy 2 wk before admission showed lesions consistent with UC of moderate endoscopic activity.", + "The patient was admitted due to frequent liquid and bloody stool and intense abdominal pain for 2 mo.", + "The patient had weight loss of 10 kg.", + "The patient was dehydrated at hospital admission.", + "The patient had a heart rate of 110 beat/min at admission.", + "The patient had a blood pressure of 100/60 mmHg at admission.", + "The patient had a temperature > 37.8 °C at admission.", + "The patient had a distended and diffusely painful abdomen at admission.", + "C-reactive protein was 20.3 mg/dL at admission.", + "Hematocrit was 25.8% at admission.", + "Abdominal X-ray showed colonic dilation of 7 cm.", + "Clostridium difficile A and B toxin was positive.", + "The patient was treated with oral vancomycin 250 mg qid.", + "A flexible sigmoidoscopy was performed on day 4 of hospital admission.", + "The sigmoidoscopy showed ulcers covered by fibrin.", + "The sigmoidoscopy showed mucosal friability.", + "The sigmoidoscopy showed edema.", + "The sigmoidoscopy showed intense enanthem with spontaneous bleeding.", + "The endoscopic findings were consistent with UC of severe activity.", + "Histopathological evaluation showed chronic colitis in intense activity.", + "Histopathological evaluation showed crypt micro-abscesses.", + "Histopathological evaluation showed plasmacytosis.", + "There was no evidence of C. difficile infection on histopathological evaluation.", + "There was no evidence of cytomegalovirus infection on histopathological evaluation." + ], + "summary": "A 22-year-old female patient diagnosed with ulcerative colitis, presented with diarrhea, rectal bleeding, abdominal pain, vomiting, and distended abdomen. During investigation, a positive toxin for Clostridium difficile and colonic dilatation of 7 cm consistent with megacolon were observed. She was treated with oral vancomycin for pseudomembranous colitis and intravenous hydrocortisone for severe colitis, which led to the resolution of megacolon. Due to the persistent severe colitis symptoms, infliximab 5 mg/kg was prescribed, monitored by drug trough level (8.8 μg/mL) and fecal calprotectin of 921 μg/g (< 30 μg/g). Based on the low infliximab trough level after one week from the first infliximab dose, the patient received a second infusion at week 1, consistent with the accelerated regimen (infusions at weeks 0, 1, 2 and 6). We achieved a positive clinical and endoscopic response after 6 mo of therapy, without the need for a colectomy.", + "summary_subclaims": [ + "The patient is a 22-year-old female.", + "The patient was diagnosed with ulcerative colitis.", + "The patient presented with diarrhea.", + "The patient presented with rectal bleeding.", + "The patient presented with abdominal pain.", + "The patient presented with vomiting.", + "The patient had a distended abdomen.", + "A positive toxin for Clostridium difficile was observed.", + "Colonic dilatation of 7 cm consistent with megacolon was observed.", + "The patient was treated with oral vancomycin for pseudomembranous colitis.", + "The patient was treated with intravenous hydrocortisone for severe colitis.", + "The treatment led to the resolution of megacolon.", + "Infliximab 5 mg/kg was prescribed.", + "The drug trough level was 8.8 μg/mL.", + "The fecal calprotectin was 921 μg/g.", + "The fecal calprotectin reference range is < 30 μg/g.", + "A second infusion was given at week 1.", + "The accelerated regimen included infusions at weeks 0, 1, 2, and 6.", + "A positive clinical response was achieved after 6 mo of therapy.", + "A positive endoscopic response was achieved after 6 mo of therapy.", + "The patient did not require a colectomy." + ] + }, + { + "id": "multiclinsum_test_949_en.txt", + "fulltext": "A 63-year-old woman was admitted to our hospital in December 2017 with a mass in the urethral orifice. She had noticed the mass 2 yr prior without any diagnosis and treatment, and it had slowly increased in size in the past few months. She had no other symptoms. Physical examination found a fleshy, hemorrhaged, uneven polypoidal mass 3 cm × 4 cm in diameter located at the bottom right of the urethral orifice. Radiographic examination of the chest, abdomen, and pelvis was unremarkable. Urine analysis showed that urinary occult blood test was positive and 65.34 red blood cells were observed per high-power field. There was no significant past medical history except for hypertension, and other laboratory tests were normal. Cystourethroscopy demonstrated a villous mass with exophytic growth in the distal urethra and smooth mucosa of the bladder. Biopsy of the urethral lesion showed villous adenoma with well-differentiated adenocarcinoma. Complete gastrointestinal evaluation failed to find any similar lesions. The whole urethra and part of the bladder were excised and the specimen was sent to the Department of Pathology for pathological and immunohistochemical examination. No further treatment was offered. After follow-up at 11 mo, the patient had no recurrence. Publication of this case report was approved by the Ethics Committee of Affiliated Hospital of Qingdao University.\nThe excised lesion was a soft grayish mass measuring 1.5 cm in diameter and appeared papillary and fleshy with hemorrhage and negative surgical margins. The appearance was identical to villous adenoma of the colon. Several blunt finger-like processes lined by pseudostratified columnar cells with frequent goblet cells were observed under a light microscope . The nuclei were stratified atypical and hyperchromatic. Abundant mucin was seen both intracellularly and extracellularly . Carcinomatous areas consisted of dysplastic glands and some of the glands presented with high-grade intraepithelial neoplasia . In focal areas, the glandular component was characterized by increased disorganization of structure. More importantly, the carcinoma invaded the muscularis layer. The gross and microscopic examination was suggestive of urethral villous adenoma with focal well-differentiated adenocarcinoma.\nFormalin-fixed, paraffin-embedded tissue was cut into 5-µm sections for im-munohistochemical evaluation. Immunohistochemical examination was positive for carcinoembryonic antigen (CEA), cytokeratin (CK) 7, CK20, epithelial membrane antigen (EMA), and p53 protein, and the positive ratio of Ki-67 was 60% in the adenocarcinoma . All immunohistochemical staining was carried out by the avidin–biotin–complex method, as previously described[,].\nWe carried out a review of the literature on urethral villous adenoma. PubMed and Embase were searched using the following keywords: urethra OR urethral AND villous adenoma. We only included articles in English. A total of 11 cases with urethral villous adenoma were reported from 1981 to 2003 .", + "fulltext_subclaims": [ + "A 63-year-old woman was admitted to our hospital in December 2017 with a mass in the urethral orifice.", + "She had noticed the mass 2 yr prior without any diagnosis and treatment.", + "The mass had slowly increased in size in the past few months.", + "She had no other symptoms.", + "Physical examination found a fleshy, hemorrhaged, uneven polypoidal mass 3 cm × 4 cm in diameter located at the bottom right of the urethral orifice.", + "Radiographic examination of the chest, abdomen, and pelvis was unremarkable.", + "Urine analysis showed that urinary occult blood test was positive.", + "65.34 red blood cells were observed per high-power field.", + "There was no significant past medical history except for hypertension.", + "Cystourethroscopy demonstrated a villous mass with exophytic growth in the distal urethra.", + "Biopsy of the urethral lesion showed villous adenoma with well-differentiated adenocarcinoma.", + "Complete gastrointestinal evaluation failed to find any similar lesions.", + "The whole urethra and part of the bladder were excised.", + "The specimen was sent to the Department of Pathology for pathological and immunohistochemical examination.", + "No further treatment was offered.", + "After follow-up at 11 mo, the patient had no recurrence.", + "Publication of this case report was approved by the Ethics Committee of Affiliated Hospital of Qingdao University.", + "The excised lesion was a soft grayish mass measuring 1.5 cm in diameter.", + "The appearance was identical to villous adenoma of the colon.", + "Several blunt finger-like processes lined by pseudostratified columnar cells with frequent goblet cells were observed under a light microscope.", + "The nuclei were stratified atypical and hyperchromatic.", + "Abundant mucin was seen both intracellularly and extracellularly.", + "Carcinomatous areas consisted of dysplastic glands.", + "Some of the glands presented with high-grade intraepithelial neoplasia.", + "In focal areas, the glandular component was characterized by increased disorganization of structure.", + "The carcinoma invaded the muscularis layer.", + "The gross and microscopic examination was suggestive of urethral villous adenoma with focal well-differentiated adenocarcinoma.", + "Formalin-fixed, paraffin-embedded tissue was cut into 5-µm sections for immunohistochemical evaluation.", + "Immunohistochemical examination was positive for carcinoembryonic antigen (CEA).", + "Immunohistochemical examination was positive for cytokeratin (CK) 7.", + "Immunohistochemical examination was positive for CK20.", + "Immunohistochemical examination was positive for epithelial membrane antigen (EMA).", + "Immunohistochemical examination was positive for p53 protein.", + "The positive ratio of Ki-67 was 60% in the adenocarcinoma.", + "All immunohistochemical staining was carried out by the avidin–biotin–complex method.", + "We carried out a review of the literature on urethral villous adenoma.", + "PubMed and Embase were searched using the following keywords: urethra OR urethral AND villous adenoma.", + "We only included articles in English.", + "A total of 11 cases with urethral villous adenoma were reported from 1981 to 2003." + ], + "summary": "A 63-year-old woman was admitted to our hospital with a mass in the urethral orifice. Gross and microscopic pathological examination was suggestive of urethral villous adenoma with focal well-differentiated adenocarcinoma. The whole urethra and part of the bladder were excised. No further treatment was offered. Carcinoembryonic antigen, cytokeratin 7, cytokeratin 20, epithelial membrane antigen, and p53 protein were positive, and the ratio of Ki-67 was 60%. After follow-up at 11 mo, the patient was cured and had no recurrence.", + "summary_subclaims": [ + "The patient was a 63-year-old woman.", + "The patient was admitted to our hospital with a mass in the urethral orifice.", + "Gross and microscopic pathological examination was suggestive of urethral villous adenoma with focal well-differentiated adenocarcinoma.", + "The whole urethra and part of the bladder were excised.", + "No further treatment was offered.", + "Carcinoembryonic antigen was positive.", + "Cytokeratin 7 was positive.", + "Cytokeratin 20 was positive.", + "Epithelial membrane antigen was positive.", + "p53 protein was positive.", + "The ratio of Ki-67 was 60%.", + "After follow-up at 11 mo, the patient was cured and had no recurrence." + ] + }, + { + "id": "multiclinsum_test_443_en.txt", + "fulltext": "A 53-year-old married man (weight: 85 kg, height: 187 cm, body mass index: 24 kg/m2) presented with a history of nasal obstruction for two years. Otorhinolaryngologists planned a septoplasty operation under general anesthesia for him. He had not had any prior operation under general anesthesia, so he did not have any history of difficult intubation, and he did not have any chronic systemic disease. The patient was evaluated for obstructive sleep apnea syndrome (OSAS) with a comprehensive questionnaire on his sleeping habits and medical history; no complaints or predictors pertaining to OSAS were identified.\nThe patient’s preoperative airway assessment was normal, Mallampati class was II, thyromental distance was 7 cm, inter-incisor gap was 5 cm, and head extension was >35°. His physical examination was characterized by lack of secondary sexual characteristics and presence of fine facial wrinkles. Although, as previously indicated, the patient was married, he had had no children. He had consulted urologists, and primary infertility and erectile dysfunction had been diagnosed. His hormone profile was: testosterone 0.3 ng/mL (reference range 1.75–7.81), free testosterone 0.91 (reference range 4.5–42.0), prolactin 1.31 ng/mL (reference range 2.64–26.72), luteinizing hormone (LH) 0.33 mIU/mL (reference range 1.24–103.03). His thyroid hormone levels were normal. No other pathological finding was obtained as the result of magnetic resonance imaging of the pituitary gland. Thus, the patients was diagnosed with primary hypogonadotropic hypogonadism.\nHe was admitted to the operating theater, and following the induction of anesthesia with a dose of 5 mg/kg intravenous thiopental, bag-mask ventilation was barely sustained. Fentanyl (1–2 μgr/kg) and, as a muscle relaxant, rocuronium (0.6 mg/kg) were administered. While the patient’s head was in the sniffing position, direct laryngoscopy and intubation of the trachea were attempted three times with different sizes of Macintosh and Miller blades by an assistant professor of anesthesiology with 5 years’ experience. However, unfortunately, the intubation failed. The lungs were then ventilated with 100% oxygen via a face mask in order to avoid desaturation. Glottic visualization was assessed with Cook’s modification of the Cormack–Lehane classification; a grade of 3A (with direct laryngoscopy, only the epiglottis can be visualized; the epiglottis can be lifted using an introducer or bougie) was assigned. The patient was subsequently successfully intubated with a gum-elastic bougie.\nAfter the operation, the patient was extubated successfully without any complication and then examined by otorhinolaryngologists via fexible laryngoscopy. The epiglottis was found to be in a slightly lower than normal position .", + "fulltext_subclaims": [ + "The patient is a 53-year-old married man.", + "The patient's weight is 85 kg.", + "The patient's height is 187 cm.", + "The patient's body mass index is 24 kg/m2.", + "The patient had nasal obstruction for two years.", + "Otorhinolaryngologists planned a septoplasty operation under general anesthesia.", + "The patient had not had any prior operation under general anesthesia.", + "The patient did not have any history of difficult intubation.", + "The patient did not have any chronic systemic disease.", + "The patient was evaluated for obstructive sleep apnea syndrome with a comprehensive questionnaire.", + "No complaints or predictors pertaining to OSAS were identified.", + "The patient’s preoperative airway assessment was normal.", + "The patient’s Mallampati class was II.", + "The patient’s thyromental distance was 7 cm.", + "The patient’s inter-incisor gap was 5 cm.", + "The patient’s head extension was >35°.", + "The patient’s physical examination showed lack of secondary sexual characteristics.", + "The patient had fine facial wrinkles.", + "The patient had no children.", + "The patient had consulted urologists.", + "Primary infertility and erectile dysfunction had been diagnosed.", + "The patient’s testosterone level was 0.3 ng/mL.", + "The reference range for testosterone is 1.75–7.81 ng/mL.", + "The patient’s free testosterone level was 0.91.", + "The reference range for free testosterone is 4.5–42.0.", + "The patient’s prolactin level was 1.31 ng/mL.", + "The reference range for prolactin is 2.64–26.72 ng/mL.", + "The patient’s luteinizing hormone level was 0.33 mIU/mL.", + "The reference range for luteinizing hormone is 1.24–103.03 mIU/mL.", + "The patient’s thyroid hormone levels were normal.", + "No other pathological finding was obtained as the result of magnetic resonance imaging of the pituitary gland.", + "The patient was diagnosed with primary hypogonadotropic hypogonadism.", + "Following the induction of anesthesia with 5 mg/kg intravenous thiopental, bag-mask ventilation was barely sustained.", + "Fentanyl 1–2 μgr/kg was administered.", + "Rocuronium 0.6 mg/kg was administered.", + "Direct laryngoscopy and intubation of the trachea were attempted three times.", + "The intubation failed.", + "The lungs were ventilated with 100% oxygen via a face mask.", + "Glottic visualization was assessed with Cook’s modification of the Cormack–Lehane classification.", + "A grade of 3A was assigned.", + "The patient was successfully intubated with a gum-elastic bougie.", + "The patient was extubated successfully without any complication.", + "The patient was examined by otorhinolaryngologists via flexible laryngoscopy.", + "The epiglottis was found to be in a slightly lower than normal position." + ], + "summary": "A 53-year-old male patient with hypogonadotropic hypogonadism presented as an unexpected difficult intubation after the induction of anesthesia. No pathological finding or predictor of difficult intubation was present. In addition, bag-mask ventilation was poor and inadequate. The patient was finally successfully intubated with a gum-elastic bougie.", + "summary_subclaims": [ + "The patient is a 53-year-old male.", + "The patient has hypogonadotropic hypogonadism.", + "The patient presented as an unexpected difficult intubation after the induction of anesthesia.", + "No pathological finding or predictor of difficult intubation was present.", + "Bag-mask ventilation was poor and inadequate.", + "The patient was finally successfully intubated with a gum-elastic bougie." + ] + }, + { + "id": "multiclinsum_test_908_en.txt", + "fulltext": "A 44-year-old Filipino lady presented with a 11-d history of right hypochondrium and epigastric pain which worsened after meals.\nA 44-year-old Filipino lady presented with a 11-d history of right hypochondrium and epigastric pain which worsened after meals. There was no history of fever, night sweats, cough with hemoptysis, tea-coloured urine, pale stools or unintentional weight loss.\nShe had no significant past history.\nOn examination, there was no scleral icterus and Murphy’s sign was positive. There was no cervical lymphadenopathy. Physical examination was otherwise unremarkable.\nSerum biochemistry revealed neutrophil-predominant leukocytosis with normal liver and renal function tests. Her blood cultures did not reveal microbial growth.\nChest x-ray was normal and computerized tomography scan of the abdomen and pelvis (CTAP) showed heterogeneous density of the gallbladder wall with marked gallbladder wall edema and a gallstone . The gallbladder wall thickness was 15 mm; the size of the extrahepatic common bile duct was 8.5 mm and the intrahepatic bile ducts were not dilated. CTAP also showed mesenteric and retroperitoneal lymphadenopathy which was deemed non-specific by size criteria.", + "fulltext_subclaims": [ + "A 44-year-old Filipino lady presented with a 11-d history of right hypochondrium and epigastric pain which worsened after meals.", + "There was no history of fever, night sweats, cough with hemoptysis, tea-coloured urine, pale stools or unintentional weight loss.", + "She had no significant past history.", + "On examination, there was no scleral icterus.", + "Murphy’s sign was positive.", + "There was no cervical lymphadenopathy.", + "Physical examination was otherwise unremarkable.", + "Serum biochemistry revealed neutrophil-predominant leukocytosis.", + "Liver and renal function tests were normal.", + "Blood cultures did not reveal microbial growth.", + "Chest x-ray was normal.", + "Computerized tomography scan of the abdomen and pelvis showed heterogeneous density of the gallbladder wall.", + "Computerized tomography scan of the abdomen and pelvis showed marked gallbladder wall edema.", + "Computerized tomography scan of the abdomen and pelvis showed a gallstone.", + "The gallbladder wall thickness was 15 mm.", + "The size of the extrahepatic common bile duct was 8.5 mm.", + "The intrahepatic bile ducts were not dilated.", + "Computerized tomography scan of the abdomen and pelvis showed mesenteric and retroperitoneal lymphadenopathy.", + "The mesenteric and retroperitoneal lymphadenopathy was deemed non-specific by size criteria." + ], + "summary": "We present a case of gallbladder tuberculosis presenting as acute cholecystitis. A 44-year-old Filipino lady presented with a 11-d history of right hypochondrium and epigastric pain which worsened after meals with no significant past medical history. She underwent laparoscopic cholecystectomy on the presumptive diagnosis of acute cholecystitis and diagnosed as gallbladder tuberculosis after histopathological examination. The patient did not have features of pulmonary or systemic tuberculosis nor was she immunocompromised. She recovered uneventfully. She was subsequently discharged and followed-up at a hospital in her home country due to financial and social reasons.", + "summary_subclaims": [ + "We present a case of gallbladder tuberculosis presenting as acute cholecystitis.", + "A 44-year-old Filipino lady presented with a 11-d history of right hypochondrium and epigastric pain.", + "The pain worsened after meals.", + "She had no significant past medical history.", + "She underwent laparoscopic cholecystectomy on the presumptive diagnosis of acute cholecystitis.", + "She was diagnosed as gallbladder tuberculosis after histopathological examination.", + "The patient did not have features of pulmonary or systemic tuberculosis.", + "She was not immunocompromised.", + "She recovered uneventfully.", + "She was subsequently discharged.", + "She was followed-up at a hospital in her home country.", + "The follow-up was due to financial and social reasons." + ] + }, + { + "id": "multiclinsum_test_1614_en.txt", + "fulltext": "A 40-year-old man with a history of MLS in the right thigh was treated with wide excision at our hospital . At the time of diagnosis, he had no distant metastasis. Histological findings of the resected specimen revealed a round cell component of 10% and a negative margin . Adjuvant chemotherapy with four cycles of doxorubicin (70 mg/m2, every 3 weeks) was administered.\nTwo years after the surgery for the primary tumor, follow-up chest computed tomography (CT) showed a low-density area in the left ventricle. The patient was then asymptomatic. Contrast-enhanced CT showed a mass, measuring 4 cm × 2 cm in the left ventricle . Transthoracic echocardiography also identified the mass in the left ventricle, which was suggestive of a neoplasm . Clinical images revealed no evidence of local recurrence or distant metastasis other than the cardiac mass at that time. Given the risk of valve obstruction, he was immediately admitted to our hospital for cardiovascular surgery. On magnetic resonance imaging (MRI), the left ventricular tumor showed a lower-signal intensity than that of skeletal muscle on T1-weighted images, higher-signal intensity on T2-weighted images, and slight enhancement with a contrast agent . Considering the clinical course, the mass was regarded as a metastasis of MLS. He underwent surgical excision of the lesion in the left ventricle. Intraoperatively, we found a reddish-white tumor arising from the papillary muscle without invasion of the interventricular septum. Histopathological examination of the specimen showed a mixture of oval non-lipogenic cells and small signet ring lipoblasts in a prominent myxoid stroma, which was consistent with the findings of the primary tumor in the thigh. However, the proportion of round cell component in the ventricular specimen was increased compared with that in the specimen of the primary tumor . A negative margin was histologically confirmed in the ventricular specimen.\nSix months later, he complained of back pain and developed metastatic disease in the sixth thoracic vertebra. Conventional radiotherapy was administered to the spine lesion, which was delivered as 50 Gy in 25 fractions.\nFifteen months after the cardiac metastasectomy, he presented slight dyspnea on effort. Contrast-enhanced CT showed a tumor in the right atrium involving the atrium septum . Our cardiovascular surgeons decided that the lesion was not amenable to complete excision with an adequate margin. The patient was treated with surgical excision of the tumor with R2 margin (macroscopically evident margin positivity) . The histological findings of the specimen indicated MLS with hypercellular lesions with a round cell component of about 30%, which represented progression compared to that of the left ventricular specimen at the first cardiac metastasectomy . Radiotherapy of 50 Gy in 25 fractions was performed for the residual disease of the right atrium and atrial septum postoperatively. His ejection fraction evaluated with echocardiography after the second cardiac metastasectomy remained 40%, and he could perform his daily activities without difficulty. There was no recurrence in the heart after the second cardiac metastasectomy, although multiple metastases occurred in the abdominal cavity, lungs, and muscles. Despite palliative chemotherapy with trabectedin and eribulin, he finally died of the disease 2 years after the second cardiac metastasectomy.", + "fulltext_subclaims": [ + "The patient was a 40-year-old man.", + "He had a history of MLS in the right thigh.", + "He was treated with wide excision at our hospital.", + "At the time of diagnosis, he had no distant metastasis.", + "Histological findings of the resected specimen revealed a round cell component of 10%.", + "The margin was negative.", + "Adjuvant chemotherapy with four cycles of doxorubicin (70 mg/m2, every 3 weeks) was administered.", + "Two years after the surgery for the primary tumor, follow-up chest CT showed a low-density area in the left ventricle.", + "The patient was asymptomatic.", + "Contrast-enhanced CT showed a mass measuring 4 cm × 2 cm in the left ventricle.", + "Transthoracic echocardiography identified the mass in the left ventricle.", + "The mass was suggestive of a neoplasm.", + "Clinical images revealed no evidence of local recurrence or distant metastasis other than the cardiac mass at that time.", + "He was immediately admitted to our hospital for cardiovascular surgery.", + "On MRI, the left ventricular tumor showed a lower-signal intensity than that of skeletal muscle on T1-weighted images.", + "The tumor showed higher-signal intensity on T2-weighted images.", + "The tumor showed slight enhancement with a contrast agent.", + "The mass was regarded as a metastasis of MLS.", + "He underwent surgical excision of the lesion in the left ventricle.", + "Intraoperatively, a reddish-white tumor arising from the papillary muscle was found.", + "There was no invasion of the interventricular septum.", + "Histopathological examination showed a mixture of oval non-lipogenic cells and small signet ring lipoblasts in a prominent myxoid stroma.", + "The findings were consistent with the findings of the primary tumor in the thigh.", + "The proportion of round cell component in the ventricular specimen was increased compared with that in the specimen of the primary tumor.", + "A negative margin was histologically confirmed in the ventricular specimen.", + "Six months later, he complained of back pain.", + "He developed metastatic disease in the sixth thoracic vertebra.", + "Conventional radiotherapy was administered to the spine lesion.", + "The radiotherapy was delivered as 50 Gy in 25 fractions.", + "Fifteen months after the cardiac metastasectomy, he presented slight dyspnea on effort.", + "Contrast-enhanced CT showed a tumor in the right atrium involving the atrium septum.", + "The lesion was not amenable to complete excision with an adequate margin.", + "The patient was treated with surgical excision of the tumor with R2 margin.", + "The histological findings indicated MLS with hypercellular lesions with a round cell component of about 30%.", + "The round cell component represented progression compared to that of the left ventricular specimen at the first cardiac metastasectomy.", + "Radiotherapy of 50 Gy in 25 fractions was performed for the residual disease of the right atrium and atrial septum postoperatively.", + "His ejection fraction evaluated with echocardiography after the second cardiac metastasectomy remained 40%.", + "He could perform his daily activities without difficulty.", + "There was no recurrence in the heart after the second cardiac metastasectomy.", + "Multiple metastases occurred in the abdominal cavity, lungs, and muscles.", + "Despite palliative chemotherapy with trabectedin and eribulin, he finally died of the disease.", + "He died 2 years after the second cardiac metastasectomy." + ], + "summary": "A 40-year-old man was diagnosed with myxoid liposarcoma of the right thigh and treated with wide resection. Two years after the surgery, a low-density area in the left ventricle was found on follow-up chest computed tomography, and was suspected of being metastatic disease. He underwent surgical treatment, and the lesion was pathologically confirmed as metastasis of myxoid liposarcoma. Fifteen months later, he complained of slight dyspnea and developed metastatic disease in the right atrium. He was treated with surgical excision, followed by radiotherapy. Although there was no recurrence in the heart since the second cardiac metastasectomy, multiple metastases occurred in the abdominal cavity, lungs, and muscles. He finally died of the disease 2 years after the second cardiac metastasectomy.", + "summary_subclaims": [ + "A 40-year-old man was diagnosed with myxoid liposarcoma of the right thigh.", + "He was treated with wide resection.", + "Two years after the surgery, a low-density area in the left ventricle was found on follow-up chest computed tomography.", + "The low-density area was suspected of being metastatic disease.", + "He underwent surgical treatment.", + "The lesion was pathologically confirmed as metastasis of myxoid liposarcoma.", + "Fifteen months later, he complained of slight dyspnea.", + "He developed metastatic disease in the right atrium.", + "He was treated with surgical excision.", + "He received radiotherapy.", + "There was no recurrence in the heart since the second cardiac metastasectomy.", + "Multiple metastases occurred in the abdominal cavity.", + "Multiple metastases occurred in the lungs.", + "Multiple metastases occurred in the muscles.", + "He finally died of the disease 2 years after the second cardiac metastasectomy." + ] + }, + { + "id": "multiclinsum_test_491_en.txt", + "fulltext": "After having developed fever and fatigue, a 72-year-old male patient (body mass index 29.2) was diagnosed with COVID-19 and put in quarantine at home. Clinical worsening resulted in delirium. After 6 days, emergency medical services found the patient severely hypoxic (SpO2 65%) despite his not complaining about dyspnoea. Oxygen was administered and the patient was transported to a designated COVID-19 pulmonary intensive care unit (ICU).\nHistory revealed a non-insulin-dependent diabetes mellitus type 2 (recent Hba1c 6.4%), aortic dissection type B (stable over time in various CTs), persistent AF, a smoking history (cessation 20 years ago), and chronic obstructive sleep apnoea syndrome (no therapy). Chronic medication consisted of apixaban (5 mg twice daily), gabapentin (150 mg twice daily), bisoprolol (5 mg twice daily), and metformin (500 mg twice daily), and did not include angiotensin-converting enzyme inhibitors or angiotensin receptor blockers.\nUpon arrival, the patient was normotensive with an irregular heart rhythm, appearing exhausted and perspiring, but not subjectively dyspnoeic. Auscultation revealed bilateral medium to coarse crackle sounds. He was intubated due to severe hypoxaemia [Horovitz index 111, positive end-expiratory pressure (PEEP) 18 cmH2O, pressure control max. 32 cmH2O, FiO2 80%]. Sufficient oxygenation and normocapnia (pO2 89 mmHg, pCO2 45 mmHg) were achieved. Tachycardic AF up to 180 b.p.m. was successfully electrically cardioverted. However, bedside echocardiography showed globally reduced left ventricular systolic function (LVSF) and ejection fraction (EF, 30%), necessitating noradrenaline and dobutamine support (initial dosages 0.32 μg/kg/min and 6.67 μg/kg/min, respectively). Pulse contour cardiac output monitoring was established (initial values: cardiac index 1.6 L/min/m2, cardiac function index 2.2 L/min, global end-diastolic volume index 791 mL/m2, pulse pressure variation 14%, extra-vasal lung water index 35.3 mL/kg, pulmonary–vascular permeability index 7.2) to guide further treatment, including careful volume resuscitation, argipressin (1.8 IU/h), hydrocortisone (8 mg/h), and continuous landiolol (initial dose 8 μg/kg/min) for control of reoccurring tachycardic AF.\nA chest X-ray showed bilateral consolidations compatible with ARDS . Laboratory results showed AKI. Continuous renal replacement therapy (CRRT) was established and upgraded with an immunoadsorbant filter (Cytosorb®) for 48 h to counteract a suspected cytokine storm mirrored by rising interleukin-6 (IL-6) levels. The initial pro-brain natriuretic peptide (BNP) was 1612 ng/L, ultimately reaching 10-fold levels. High sensitivity troponin T (hs-TnT) values were undulant during the entire stay, with maximum levels of 200 ng/L. For the development of laboratory values over time, see . Due to organizational reasons and potential cardiac side effects, it was chosen not to administer experimental therapeutics such as hydroxychloroquine, tocilizumab, or antiviral agents.\nMore frequent tachycardic AF episodes did not respond to electrical cardioversion, escalation of landiolol (up to 40 μg/kg/min without effect of further escalation), or addition of amiodarone (300 mg in 30 min and 38 mg/h over 24 h thereafter). Also, digitoxin (0.25 mg daily) and ivabradine (5 mg twice daily)—initially showing promising results—ultimately proved ineffective. Progressing heart failure seemed to be mainly dependent on tachycardic AF. Levosimendan (10 μg/kg/min for 10 min and 0.2 μg/kg/min for 24 h thereafter) led to a transient positive effect that only lasted ∼24 h. In echocardiographic controls, pericardial effusion (circumference, 2–3 cm, ) developed in 48 h, leading to pericardial tamponade that was successfully drained (a SARS-CoV-2 test from the fluid was negative). After pericardiocentesis, haemodynamics improved only transiently, and LVSF/EF deteriorated rapidly. At this stage, an ultima ratio treatment option would have been veno-arterial extracorporeal membrane oxygenation (VA-ECMO). However, existing literature surrounding the role of VA-ECMO in the treatment of COVID-19-associated cardiogenic shock is scarce. Due to the multiple comorbidities, resource availability, and the perceived risk–benefit ratio, a decision against ECMO was made. In a multidisciplinary way, a do not resuscitate order was agreed on. Nine days after ICU admission, the patient died from multiorgan failure. gives an overview of the entire case.", + "fulltext_subclaims": [ + "The patient was a 72-year-old male.", + "The patient had a body mass index of 29.2.", + "The patient was diagnosed with COVID-19.", + "The patient was put in quarantine at home.", + "The patient developed delirium.", + "Emergency medical services found the patient severely hypoxic (SpO2 65%).", + "The patient was transported to a designated COVID-19 pulmonary ICU.", + "The patient had non-insulin-dependent diabetes mellitus type 2.", + "The patient had a recent Hba1c of 6.4%.", + "The patient had a history of aortic dissection type B.", + "The patient had persistent atrial fibrillation.", + "The patient had a smoking history with cessation 20 years ago.", + "The patient had chronic obstructive sleep apnoea syndrome.", + "The patient was not on angiotensin-converting enzyme inhibitors or angiotensin receptor blockers.", + "The patient was intubated due to severe hypoxaemia.", + "The patient had a Horovitz index of 111.", + "The patient had a positive end-expiratory pressure of 18 cmH2O.", + "The patient had a pressure control maximum of 32 cmH2O.", + "The patient had an FiO2 of 80%.", + "The patient had sufficient oxygenation and normocapnia.", + "The patient had a pO2 of 89 mmHg.", + "The patient had a pCO2 of 45 mmHg.", + "The patient had tachycardic atrial fibrillation up to 180 b.p.m.", + "The patient was successfully electrically cardioverted.", + "Bedside echocardiography showed globally reduced left ventricular systolic function.", + "The patient's ejection fraction was 30%.", + "The patient required noradrenaline and dobutamine support.", + "The initial noradrenaline dosage was 0.32 μg/kg/min.", + "The initial dobutamine dosage was 6.67 μg/kg/min.", + "Pulse contour cardiac output monitoring was established.", + "The initial cardiac index was 1.6 L/min/m2.", + "The initial cardiac function index was 2.2 L/min.", + "The initial global end-diastolic volume index was 791 mL/m2.", + "The initial pulse pressure variation was 14%.", + "The initial extra-vascular lung water index was 35.3 mL/kg.", + "The initial pulmonary–vascular permeability index was 7.2.", + "The patient received argipressin at 1.8 IU/h.", + "The patient received hydrocortisone at 8 mg/h.", + "The patient received continuous landiolol at an initial dose of 8 μg/kg/min.", + "A chest X-ray showed bilateral consolidations compatible with ARDS.", + "The patient had acute kidney injury.", + "The patient received continuous renal replacement therapy.", + "The patient received an immunoadsorbant filter (Cytosorb®) for 48 h.", + "The patient had rising interleukin-6 levels.", + "The patient's pro-brain natriuretic peptide was 1612 ng/L.", + "The patient's pro-brain natriuretic peptide ultimately reached 10-fold levels.", + "The patient had undulant high sensitivity troponin T values.", + "The patient's maximum high sensitivity troponin T was 200 ng/L.", + "The patient did not receive hydroxychloroquine.", + "The patient did not receive tocilizumab.", + "The patient did not receive antiviral agents.", + "The patient had more frequent tachycardic AF episodes.", + "The patient did not respond to electrical cardioversion.", + "The patient did not respond to escalation of landiolol.", + "The patient did not respond to addition of amiodarone.", + "The patient did not respond to digitoxin.", + "The patient did not respond to ivabradine.", + "The patient received levosimendan at 10 μg/kg/min for 10 min.", + "The patient received levosimendan at 0.2 μg/kg/min for 24 h.", + "The patient had a transient positive effect from levosimendan.", + "The patient developed pericardial effusion.", + "The patient had a pericardial effusion circumference of 2–3 cm.", + "The patient had pericardial tamponade.", + "The patient's pericardial tamponade was successfully drained.", + "The patient's SARS-CoV-2 test from the fluid was negative.", + "The patient's haemodynamics improved only transiently after pericardiocentesis.", + "The patient's left ventricular systolic function and ejection fraction deteriorated rapidly.", + "The patient did not receive veno-arterial extracorporeal membrane oxygenation.", + "The patient had a do not resuscitate order.", + "The patient died nine days after ICU admission.", + "The patient died from multiorgan failure." + ], + "summary": "A 72-year-old male SARS-CoV2-positive patient was admitted to the intensive care unit due to delirium and acute respiratory failure. Atrial fibrillation known from history was exacerbated, and made complex rate and rhythm control necessary. Progressive heart failure with haemodynamic deterioration and acute kidney injury with the need for continuous renal replacement therapy were further aggravated by pericardial tamponade.", + "summary_subclaims": [ + "The patient is a 72-year-old male.", + "The patient is SARS-CoV2-positive.", + "The patient was admitted to the intensive care unit.", + "The patient had delirium.", + "The patient had acute respiratory failure.", + "The patient had atrial fibrillation known from history.", + "The atrial fibrillation was exacerbated.", + "The patient required complex rate and rhythm control.", + "The patient had progressive heart failure.", + "The patient had haemodynamic deterioration.", + "The patient had acute kidney injury.", + "The patient required continuous renal replacement therapy.", + "The patient had pericardial tamponade." + ] + }, + { + "id": "multiclinsum_test_3018_en.txt", + "fulltext": "We report the case of a 66-year-old female patient with no prior medical history, she was operated for a transverse colon tumor she had an extended right hemicolectomy. Histopathological examination of the specimen revealed a well differentiated adenocarcinoma of the colon classified pT4aN1b.No distant metastases were detected by the pre-operative CT scan of chest and abdomen. The patient received an adjuvant chemotherapy (XELOX 6 cycles) and was regularly monitored in our outpatient department.\nDuring follow up, the patient was asymptomatic with a soft abdomen on clinical examination, laboratory test especially liver enzymes and tumor markers ACE and CA19-9 were in normal range. However, the CT scan after two years of the surgery revealed intrahepatic biliary duct dilation particularly in segments VI and II of the liver, with subtle low dense lesions in these bile ducts. The CT scan revealed also multiple millimetric nodules of the spleen. Hepatic MRI showed two endoluminal biliary nodules in segments VII and I, measuring 30 mm and 10 mm respectively with upstream biliary duct dilation, suggestive of secondary lesions with multiple metastatic splenic nodules.\n\nThe patient underwent a percutaneous biopsy of the hepatic lesions, histopathological and immuhistochemical findings confirmed the presence of adenocarcinoma cells of primary colonic origin.\n\nThe standard hematoxylin eosin-stained slides showed tubulo-papillary carcinomatous expansion budding in intra-lumen bordered by a biliary epithelium, the neoplastic cells were all positive for CDX2 and negative for CD20 supporting the diagnosis of intrabiliary colonic metastasis. After multidisciplinary discussion it was decided to put the patient under chemotherapy (FOLFIRINOX).", + "fulltext_subclaims": [ + "The patient is a 66-year-old female.", + "The patient had no prior medical history.", + "The patient was operated for a transverse colon tumor.", + "The patient had an extended right hemicolectomy.", + "Histopathological examination of the specimen revealed a well differentiated adenocarcinoma of the colon.", + "The tumor was classified pT4aN1b.", + "No distant metastases were detected by the pre-operative CT scan of chest and abdomen.", + "The patient received an adjuvant chemotherapy (XELOX 6 cycles).", + "The patient was regularly monitored in the outpatient department.", + "During follow up, the patient was asymptomatic.", + "Clinical examination showed a soft abdomen.", + "Liver enzymes were in normal range.", + "Tumor markers CEA and CA19-9 were in normal range.", + "The CT scan after two years of the surgery revealed intrahepatic biliary duct dilation particularly in segments VI and II of the liver.", + "The CT scan revealed multiple millimetric nodules of the spleen.", + "Hepatic MRI showed two endoluminal biliary nodules in segments VII and I.", + "The nodules measured 30 mm and 10 mm respectively.", + "There was upstream biliary duct dilation.", + "The findings were suggestive of secondary lesions with multiple metastatic splenic nodules.", + "The patient underwent a percutaneous biopsy of the hepatic lesions.", + "Histopathological and immunohistochemical findings confirmed the presence of adenocarcinoma cells of primary colonic origin.", + "The standard hematoxylin eosin-stained slides showed tubulo-papillary carcinomatous expansion budding in intra-lumen bordered by a biliary epithelium.", + "The neoplastic cells were all positive for CDX2.", + "The neoplastic cells were negative for CD20.", + "The diagnosis was intrabiliary colonic metastasis.", + "After multidisciplinary discussion it was decided to put the patient under chemotherapy (FOLFIRINOX)." + ], + "summary": "We report a 66-year-old female who underwent an extended right hemicolectomy for a well-differentiated adenocarcinoma of the transverse colon pT4aN1bM0. Two years after surgery, follow-up imaging revealed intrahepatic biliary dilation and subtle intraductal lesions, along with suspicious splenic nodules. Hepatic MRI confirmed the presence of endoluminal biliary nodules with upstream dilation. Percutaneous biopsy and immunohistochemical analysis showed tumor cells positive for CDX2 and negative for CD20, supported the diagnosis of intrabiliary colonic metastasis.", + "summary_subclaims": [ + "The patient is a 66-year-old female.", + "The patient underwent an extended right hemicolectomy.", + "The tumor was a well-differentiated adenocarcinoma of the transverse colon.", + "The tumor was staged as pT4aN1bM0.", + "Two years after surgery, follow-up imaging revealed intrahepatic biliary dilation.", + "Follow-up imaging showed subtle intraductal lesions.", + "Follow-up imaging showed suspicious splenic nodules.", + "Hepatic MRI confirmed the presence of endoluminal biliary nodules.", + "Hepatic MRI showed upstream dilation.", + "Percutaneous biopsy showed tumor cells positive for CDX2.", + "Percutaneous biopsy showed tumor cells negative for CD20.", + "The biopsy and immunohistochemical analysis supported the diagnosis of intrabiliary colonic metastasis." + ] + }, + { + "id": "multiclinsum_test_231_en.txt", + "fulltext": "A 12-year-old Syrian boy was admitted to our hospital due to epistaxis, anorexia, weight loss, and night sweats. Medical and family history were unremarkable. The physical examination revealed preauricular, postauricular and submandibular lymphadenopathy with the largest node measuring approximately (3 × 5) cm . Furthermore, a hard palate mass was found deviating the uvula to the right causing dysphagia and dyspnea. Laboratory tests showed WBC count 35380/μL, Hgb 10,1 g/dl, platelets 641 × 103/μL and ESR 124 mm/hr.\nAbdominal ultrasound showed mild spleen enlargement without focal lesions. Chest radiography was normal without mediastinal widening.\nA CT scan revealed multiple enlarged lymph nodes on the right side of the neck .\nExcisional biopsy of the enlarged cervical lymph node (3 × 4)cm was performed and further pathological assessment showed complete effacement of lymph node architecture with proliferation medium to large-sized anaplastic and Reed-Sternberg-like cells in the interfollicular zones and subcapsular sinuses admixed with histiocytes, small lymphocytes and few eosinophils. In addition, the neoplastic cells showed cohesive growth pattern with abundant cytoplasm, wreath-like or multiple nuclei, multiple nucleoli, and occasional mitotic figures .\nIn addition, a bone marrow sample showed reactive inflammation with hypercellular bone marrow. No evidence of involvement by neoplastic cells was found. Consequently, the patient was diagnosed with Classical Hodgkin Lymphoma (CHL) based on routine staining with the recommendation to proceed with immunohistochemistry staining to confirm the diagnosis. However, immunohistochemistry was not available in our institution at the time.\nThe patient received chemotherapy based on ABVD protocol. However, the patient reentered our hospital 5 months later with no evidence of significant improvement, therefore, the diagnosis was doubted. Consequent immunohistochemistry staining showed strong CD30 positivity for large Reed-Stenberg-like cells and CD3 positivity whereas ALK, CD15 and CD20 were negative . Based on these findings, the patient was diagnosed with ALK-negative ALCL. The patient received 5 cycles of chemotherapy comprising of (vinblastine 10 mg/m2, methotrexate 500 mg/m2, ifosfamide 1g/m2, etoposide 100 mg/m2and cytarabine 1g/m2). Unfortunately, the patient passed away after 6 months.", + "fulltext_subclaims": [ + "The patient was a 12-year-old Syrian boy.", + "The patient was admitted due to epistaxis.", + "The patient was admitted due to anorexia.", + "The patient was admitted due to weight loss.", + "The patient was admitted due to night sweats.", + "Medical and family history were unremarkable.", + "The physical examination revealed preauricular lymphadenopathy.", + "The physical examination revealed postauricular lymphadenopathy.", + "The physical examination revealed submandibular lymphadenopathy.", + "The largest lymph node measured approximately 3 × 5 cm.", + "A hard palate mass was found.", + "The hard palate mass deviated the uvula to the right.", + "The hard palate mass caused dysphagia.", + "The hard palate mass caused dyspnea.", + "Laboratory tests showed WBC count 35380/μL.", + "Laboratory tests showed Hgb 10.1 g/dl.", + "Laboratory tests showed platelets 641 × 103/μL.", + "Laboratory tests showed ESR 124 mm/hr.", + "Abdominal ultrasound showed mild spleen enlargement.", + "Chest radiography was normal.", + "A CT scan revealed multiple enlarged lymph nodes on the right side of the neck.", + "Excisional biopsy of the enlarged cervical lymph node (3 × 4) cm was performed.", + "The pathological assessment showed complete effacement of lymph node architecture.", + "The neoplastic cells showed cohesive growth pattern.", + "The neoplastic cells had abundant cytoplasm.", + "The neoplastic cells had wreath-like or multiple nuclei.", + "The neoplastic cells had multiple nucleoli.", + "The neoplastic cells showed occasional mitotic figures.", + "The patient was diagnosed with Classical Hodgkin Lymphoma.", + "The patient received chemotherapy based on ABVD protocol.", + "The patient reentered the hospital 5 months later.", + "The patient showed no evidence of significant improvement.", + "The diagnosis was doubted.", + "Immunohistochemistry staining showed strong CD30 positivity for large Reed-Sternberg-like cells.", + "Immunohistochemistry staining showed CD3 positivity.", + "ALK was negative.", + "CD15 was negative.", + "CD20 was negative.", + "The patient was diagnosed with ALK-negative ALCL.", + "The patient received 5 cycles of chemotherapy comprising vinblastine 10 mg/m2, methotrexate 500 mg/m2, ifosfamide 1g/m2, etoposide 100 mg/m2 and cytarabine 1g/m2.", + "The patient passed away after 6 months." + ], + "summary": "A 12-year-old Syrian boy was admitted to our hospital due to epistaxis, anorexia, weight loss and night sweats. The physical examination revealed preauricular, postauricular and submandibular lymphadenopathy. Pathological examination of the biopsy suggested Classical Hodgkin Lymphoma. Later on, Immunohistochemistry staining confirmed the diagnosis of ALK-negative Anaplastic Large Cell Lymphoma.", + "summary_subclaims": [ + "A 12-year-old Syrian boy was admitted to our hospital due to epistaxis, anorexia, weight loss and night sweats.", + "The physical examination revealed preauricular, postauricular and submandibular lymphadenopathy.", + "Pathological examination of the biopsy suggested Classical Hodgkin Lymphoma.", + "Immunohistochemistry staining confirmed the diagnosis of ALK-negative Anaplastic Large Cell Lymphoma." + ] + }, + { + "id": "multiclinsum_test_3087_en.txt", + "fulltext": "A 6-year-old boy presented with erythematous scaly lesions on the scalp and back. The clinical diagnosis of psoriasis was established and he started treatment with topical corticosteroid (methylprednisolone ointment). A partial clinical improvement of the lesions was noted, but residual plaques persisted. About one month later, purplish lesions appeared in the infrapopliteal region, in the gluteal area and in the upper limbs. He did not have fever, arthralgia and no gastrointestinal or genitourinary symptoms. A skin biopsy was performed in the affected area, which revealed a small vessel vasculitis affecting the papillary dermis. He continued the treatment with topical corticosteroid in the newly affected areas with good clinical response. A few days later, a urine analysis was performed that showed microscopic haematuria and nephrotic range proteinuria (urine creatinine protein (UCR) ratio of 4998 mg/g). These urinalysis abnormalities persisted for the following two months, although he always maintained normal blood pressure, without oedema or macroscopic urine abnormalities, and with normal serum albumin, creatinine and lipid profile. A complete investigation showed no abnormal findings, including measurement of circulating complement proteins (C3 and C4), immunoglobulins (IgA), ANA, anti-dsDNA and ENA antibodies, and serologic testing for hepatitis B, HIV, and Epstein-Barr virus (EBV). Ultrasound of the kidneys and bladder was normal. Almost three months after the first altered urine analysis, new macroscopic haematuria was observed, concomitant with abdominal pain and vomiting. Nefrotic range proteinuria (10 mg/m2/h) persisted. Histopathology of renal biopsy revealed mesangial proliferation and growing fibrocellular in 6/16 glomeruli with fibrinoid necrosis, and direct immunofluorescence showed predominantly mesangial IgA granulomatous deposits. These aspects were consistent with IgA nephropathy, class III of Haas. Three pulses of methylprednisolone of 30 mg/kg/day were administered, with decreasing macroscopic haematuria. The patient maintained oral prednisolone (60 mg/m2/day) for 4 weeks. During this treatment period, psoriatic lesions improved clinically, but nephrotic range proteinuria persisted. For this reason, cyclophosphamide (2 mg/kg/day) was initiated, concomitant with gradual withdrawal of prednisolone. Nine weeks later, the proteinuria decreased to a non-nephrotic range (RPCU < 2000 mg/g), but persisted above 1000 mg/g and, therefore, enalapril was introduced. He completed 12 weeks of cyclophosphamide. The proteinuria continued to decrease and became negative one month later. Renal function remained normal. The psoriatic lesions worsened with the gradual adjustment of prednisolone dose, despite cyclophosphamide. The use of topical corticosteroid (mometasone) and calcitriol ointment was initiated, but clinical improvement was insignificant. The patient then initiated phototherapy with a significant clinical improvement.\n", + "fulltext_subclaims": [ + "The patient is a 6-year-old boy.", + "He presented with erythematous scaly lesions on the scalp and back.", + "The clinical diagnosis of psoriasis was established.", + "He started treatment with topical corticosteroid (methylprednisolone ointment).", + "A partial clinical improvement of the lesions was noted.", + "Residual plaques persisted.", + "About one month later, purplish lesions appeared in the infrapopliteal region, in the gluteal area and in the upper limbs.", + "He did not have fever.", + "He did not have arthralgia.", + "He did not have gastrointestinal or genitourinary symptoms.", + "A skin biopsy was performed in the affected area.", + "The skin biopsy revealed a small vessel vasculitis affecting the papillary dermis.", + "He continued the treatment with topical corticosteroid in the newly affected areas.", + "He had good clinical response.", + "A urine analysis showed microscopic haematuria.", + "The urine analysis showed nephrotic range proteinuria (urine creatinine protein (UCR) ratio of 4998 mg/g).", + "These urinalysis abnormalities persisted for the following two months.", + "He always maintained normal blood pressure.", + "He did not have oedema.", + "He did not have macroscopic urine abnormalities.", + "He had normal serum albumin.", + "He had normal serum creatinine.", + "He had a normal lipid profile.", + "A complete investigation showed no abnormal findings.", + "Measurement of circulating complement proteins (C3 and C4) was normal.", + "Measurement of immunoglobulins (IgA) was normal.", + "ANA testing was negative.", + "Anti-dsDNA testing was negative.", + "ENA antibodies testing was negative.", + "Serologic testing for hepatitis B was negative.", + "Serologic testing for HIV was negative.", + "Serologic testing for Epstein-Barr virus (EBV) was negative.", + "Ultrasound of the kidneys and bladder was normal.", + "Almost three months after the first altered urine analysis, new macroscopic haematuria was observed.", + "Nephrotic range proteinuria (10 mg/m2/h) persisted.", + "Histopathology of renal biopsy revealed mesangial proliferation.", + "Histopathology showed growing fibrocellular in 6/16 glomeruli with fibrinoid necrosis.", + "Direct immunofluorescence showed predominantly mesangial IgA granulomatous deposits.", + "These aspects were consistent with IgA nephropathy, class III of Haas.", + "Three pulses of methylprednisolone of 30 mg/kg/day were administered.", + "Macroscopic haematuria decreased.", + "The patient maintained oral prednisolone (60 mg/m2/day) for 4 weeks.", + "During this treatment period, psoriatic lesions improved clinically.", + "Nephrotic range proteinuria persisted.", + "Cyclophosphamide (2 mg/kg/day) was initiated.", + "Prednisolone was gradually withdrawn.", + "Nine weeks later, the proteinuria decreased to a non-nephrotic range (RPCU < 2000 mg/g).", + "The proteinuria continued to decrease and became negative one month later.", + "Renal function remained normal.", + "The psoriatic lesions worsened with the gradual adjustment of prednisolone dose.", + "The use of topical corticosteroid (mometasone) and calcitriol ointment was initiated.", + "Clinical improvement was insignificant.", + "The patient then initiated phototherapy.", + "The patient had significant clinical improvement with phototherapy." + ], + "summary": "A 6-year-old boy with newly onset psoriasis developed PHS with renal involvement, clinically manifested by nephrotic proteinuria and haematuria. A renal biopsy revealed glomerular fibrocellular crescents and mesangial deposits of IgA consistent with IgA nephropathy. Treatment with systemic corticosteroids led to control of haematuria, but as the nephrotic proteinuria persisted, cyclophosphamide was added, leading to a gradual decrease of proteinuria.\n", + "summary_subclaims": [ + "The patient is a 6-year-old boy.", + "The patient had newly onset psoriasis.", + "The patient developed PHS with renal involvement.", + "Nephrotic proteinuria was clinically manifested.", + "Haematuria was clinically manifested.", + "A renal biopsy revealed glomerular fibrocellular crescents.", + "A renal biopsy revealed mesangial deposits of IgA.", + "The findings were consistent with IgA nephropathy.", + "Treatment with systemic corticosteroids led to control of haematuria.", + "Nephrotic proteinuria persisted.", + "Cyclophosphamide was added.", + "Cyclophosphamide led to a gradual decrease of proteinuria." + ] + }, + { + "id": "multiclinsum_test_3161_en.txt", + "fulltext": "In July 2022, a male preterm infant with a gestational age of 31 weeks was admitted to the neonatal intensive care unit due to prematurity. The mother, G1P0, had no medical illness and did not receive dexamethasone. The neonate was delivered through spontaneous vaginal delivery and was born weighing 1.46 kg with Apgar scores of 7 at 1 min and 8 at 5 min. Moreover, physical examination and chest radiography revealed signs of respiratory distress syndrome. Subsequently, the infant was intubated immediately after delivery and connected to mechanical ventilation. Chest radiography confirmed grade II respiratory distress syndrome and two doses of bovine surfactant were administered. Furthermore, the infant developed hypotension, requiring inotropes. Empirical antibiotics, ampicillin, and gentamicin were started according to the Neofax dosage, pending blood culture. Oral caffeine citrate and prophylactic fluconazole were administered at 3 mg/kg/dose. Thereafter, total parenteral nutrition (TPN) was initiated, and an umbilical venous catheter was inserted.\n\nOn post-natal Day 2, the patient developed respiratory acidosis and pulmonary hemorrhage, requiring high-frequency ventilation. His complete blood count (CBC) revealed white blood cell count (WBC) of 8.3 × 103 per mm3, hemoglobin level of 8.5 gm/dl, platelet count of 6,000/mm³, prothrombin time of 18 s, partial thromboplastin time of 36 s, and an international normalized ratio of 1.8. Blood culture results were negative. The patient received supportive management of epinephrine via the endotracheal tube and was administered vitamin K, fresh frozen plasma, and PRBCS.\n\nOn Day 3, the echocardiogram (ECHO) showed a 2·5 mm patent ductus arterious (PDA) and pulmonary hypertension. The patient was initiated on paracetamol and sildenafil, and following improvement, antibiotics were discontinued. On Day 6, the patient was switched to conventional mechanical ventilation; the CBC was normal.\n\nOn Day 11, the patient experienced severe respiratory distress and desaturation, requiring increased ventilation. Moreover, he had low blood pressure, hypothermia, abdominal distension, leukocytosis (WBC of 17,030/mm3, including 21% band forms), thrombocytopenia (platelet count of 96,000/ mm3), and elevated C-reactive protein of 105 mg/L). Cerebrospinal fluid (CSF) analysis revealed pleocytosis with a total CSF WBC of 34,000/mm3; the culture was negative. Therefore, the patient was upgraded to vancomycin and amikacin antibiotics at a dose according to the Neofax. Blood culture yielded Staphylococcus epidermidis from the central line, leading to the discontinuation of Amikacin and the continued use of vancomycin. On Day 12, umbilical venous catheterization was performed.\n\nOn Day 13, the patient experienced clinical deterioration, including increased abdominal girth, severe metabolic acidosis, thrombocytopenia, and anemia. Supportive management was provided through PRBCS and platelet transfusions. Blood culture yielded Klebsiella oxytoca, for which meropenem was initiated, and prophylactic fluconazole and vancomycin were continued. Two sets of blood culture bottles were utilized.\n\nOn Day 14, we incubated a Pediatric Plus™/F blood bottle for five days and a Mycosis IC/F blood bottle specific for the isolation of fungus for 14 days, following our laboratory’s protocol. The Pediatric Plus blood culture bottle showed positive results after 72 h, whereas the Mycosis bottle showed positive results on the sixth day of incubation. Moreover, we performed Gram staining of the positive blood culture bottles, and the stained films showed round-to-oval, yeast-like fungi; we sub-cultured the colonies on Sabouraud Dextrose agar at 37 °C and isolated growth after 48 h. Colonies were initially creamy in color but gradually darkened as they aged, and the isolated growth was identified by the VITEK®2 YST ID card (bioMérieux, Inc. St. Louis, Mo. France) as C. albidus. Identification was confirmed using matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI-TOF mass spectrometry) (Vitek MS, BioMerieux®, Marcy l’Étoile, France).\n\nIn our hospital, we do not utilize the Ligase Chain Reaction (LCR) method for the identification of Candida albidus, primarily because it is not available in our general hospital setting. LCR is a highly specialized molecular diagnostic technique often found in research centers or advanced diagnostic laboratories.\n\nInstead, we rely on alternative diagnostic systems. For the identification of Candida albidus, we commonly use the Vitek system, which provides accurate identification of fungal species based on biochemical characteristics. To confirm the results obtained from the Vitek system, we employed MALDI-TOF mass spectrometry, a cutting-edge technology that identifies microorganisms based on protein profiles. This approach is both efficient and suitable for routine diagnostic purposes in our general hospital setting, even though more advanced molecular techniques, such as LCR, are reserved for research institutions.\n\nOn Day 16, the Infectious Diseases team was consulted, and CFS sampling was recommended, continuing vancomycin and meropenem for two weeks from the first blood culture. ECHO, eye examination, abdominal ultrasound, and administration of liposomal amphotericin B (5 mg/kg/day, once daily) were initiated. The CSF culture returned negative, ECHO showed no vegetation, the PDA was not closed, and the platelet count improved to 128,000/mm3. Finally, abdominal ultrasonography revealed no focal lesions.\n\nAt 33 days of age, the patient was switched to conventional mechanical ventilation. A brain MRI revealed bilateral frontal and right periventricular white matter hemorrhages and a minimal subdural hemorrhage. The neurosurgeon advised the patient against any intervention. The patient received liposomal amphotericin B for six weeks and was discharged 57 days after completing the antifungal course. Follow-up appointments for one year revealed no complications, and good milestones were achieved.", + "fulltext_subclaims": [ + "In July 2022, a male preterm infant with a gestational age of 31 weeks was admitted to the neonatal intensive care unit due to prematurity.", + "The mother, G1P0, had no medical illness and did not receive dexamethasone.", + "The neonate was delivered through spontaneous vaginal delivery.", + "The neonate was born weighing 1.46 kg.", + "The neonate had Apgar scores of 7 at 1 min and 8 at 5 min.", + "Physical examination and chest radiography revealed signs of respiratory distress syndrome.", + "The infant was intubated immediately after delivery.", + "The infant was connected to mechanical ventilation.", + "Chest radiography confirmed grade II respiratory distress syndrome.", + "Two doses of bovine surfactant were administered.", + "The infant developed hypotension, requiring inotropes.", + "Empirical antibiotics, ampicillin, and gentamicin were started according to the Neofax dosage, pending blood culture.", + "Oral caffeine citrate and prophylactic fluconazole were administered at 3 mg/kg/dose.", + "Total parenteral nutrition (TPN) was initiated.", + "An umbilical venous catheter was inserted.", + "On post-natal Day 2, the patient developed respiratory acidosis.", + "On post-natal Day 2, the patient developed pulmonary hemorrhage.", + "On post-natal Day 2, the patient required high-frequency ventilation.", + "On post-natal Day 2, the complete blood count (CBC) revealed white blood cell count (WBC) of 8.3 × 103 per mm3.", + "On post-natal Day 2, the complete blood count (CBC) revealed hemoglobin level of 8.5 gm/dl.", + "On post-natal Day 2, the complete blood count (CBC) revealed platelet count of 6,000/mm³.", + "On post-natal Day 2, the prothrombin time was 18 s.", + "On post-natal Day 2, the partial thromboplastin time was 36 s.", + "On post-natal Day 2, the international normalized ratio was 1.8.", + "Blood culture results were negative.", + "The patient received supportive management of epinephrine via the endotracheal tube.", + "The patient was administered vitamin K.", + "The patient was administered fresh frozen plasma.", + "The patient was administered PRBCS.", + "On Day 3, the echocardiogram (ECHO) showed a 2·5 mm patent ductus arterious (PDA).", + "On Day 3, the echocardiogram (ECHO) showed pulmonary hypertension.", + "On Day 3, the patient was initiated on paracetamol.", + "On Day 3, the patient was initiated on sildenafil.", + "On Day 3, following improvement, antibiotics were discontinued.", + "On Day 6, the patient was switched to conventional mechanical ventilation.", + "On Day 6, the CBC was normal.", + "On Day 11, the patient experienced severe respiratory distress.", + "On Day 11, the patient experienced desaturation.", + "On Day 11, the patient had low blood pressure.", + "On Day 11, the patient had hypothermia.", + "On Day 11, the patient had abdominal distension.", + "On Day 11, the patient had leukocytosis (WBC of 17,030/mm3, including 21% band forms).", + "On Day 11, the patient had thrombocytopenia (platelet count of 96,000/ mm3).", + "On Day 11, the patient had elevated C-reactive protein of 105 mg/L.", + "Cerebrospinal fluid (CSF) analysis revealed pleocytosis with a total CSF WBC of 34,000/mm3.", + "Cerebrospinal fluid (CSF) culture was negative.", + "The patient was upgraded to vancomycin and amikacin antibiotics at a dose according to the Neofax.", + "Blood culture yielded Staphylococcus epidermidis from the central line.", + "Amikacin was discontinued.", + "Vancomycin was continued.", + "On Day 12, umbilical venous catheterization was performed.", + "On Day 13, the patient experienced clinical deterioration.", + "On Day 13, the patient had increased abdominal girth.", + "On Day 13, the patient had severe metabolic acidosis.", + "On Day 13, the patient had thrombocytopenia.", + "On Day 13, the patient had anemia.", + "Supportive management was provided through PRBCS and platelet transfusions.", + "Blood culture yielded Klebsiella oxytoca.", + "Meropenem was initiated.", + "Prophylactic fluconazole and vancomycin were continued.", + "Two sets of blood culture bottles were utilized.", + "On Day 14, a Pediatric Plus™/F blood bottle was incubated for five days.", + "On Day 14, a Mycosis IC/F blood bottle specific for the isolation of fungus was incubated for 14 days.", + "The Pediatric Plus blood culture bottle showed positive results after 72 h.", + "The Mycosis bottle showed positive results on the sixth day of incubation.", + "Gram staining of the positive blood culture bottles showed round-to-oval, yeast-like fungi.", + "The colonies were sub-cultured on Sabouraud Dextrose agar at 37 °C.", + "Growth was isolated after 48 h.", + "The isolated growth was identified by the VITEK®2 YST ID card as C. albidus.", + "Identification was confirmed using matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI-TOF mass spectrometry).", + "In our hospital, we do not utilize the Ligase Chain Reaction (LCR) method for the identification of Candida albidus.", + "The Ligase Chain Reaction (LCR) method is not available in our general hospital setting.", + "We commonly use the Vitek system for the identification of Candida albidus.", + "We employed MALDI-TOF mass spectrometry to confirm the results obtained from the Vitek system.", + "On Day 16, the Infectious Diseases team was consulted.", + "CFS sampling was recommended.", + "Vancomycin and meropenem were continued for two weeks from the first blood culture.", + "ECHO, eye examination, abdominal ultrasound, and administration of liposomal amphotericin B were initiated.", + "The CSF culture returned negative.", + "ECHO showed no vegetation.", + "The PDA was not closed.", + "The platelet count improved to 128,000/mm3.", + "Abdominal ultrasonography revealed no focal lesions.", + "At 33 days of age, the patient was switched to conventional mechanical ventilation.", + "A brain MRI revealed bilateral frontal and right periventricular white matter hemorrhages.", + "A brain MRI revealed a minimal subdural hemorrhage.", + "The neurosurgeon advised the patient against any intervention.", + "The patient received liposomal amphotericin B for six weeks.", + "The patient was discharged 57 days after completing the antifungal course.", + "Follow-up appointments for one year revealed no complications.", + "Good milestones were achieved." + ], + "summary": "We report the first case of C. albidus fungemia and meningitis in a very low-birth-weight, preterm infant of 31 weeks. Notably, the patient was admitted for lifesaving treatment from the Alleith Hospital due to prematurity. The patient received surfactant due to ARDS, TPN, and fluconazole prophylaxis. On day 11, features of sepsis were observed and the blood culture grew C. albidus, which was sensitive to liposomal agents. CSF evaluation suggested meningitis. The patient improved following a six-week treatment regimen with liposomal formulations of amphotericin B at a dosage of 5 mg/kg body weight once daily, notably administered without 5-fluorocytosine, and experienced no sequelae.", + "summary_subclaims": [ + "This is the first reported case of C. albidus fungemia and meningitis in a very low-birth-weight, preterm infant of 31 weeks.", + "The patient was admitted from the Alleith Hospital for lifesaving treatment due to prematurity.", + "The patient received surfactant due to ARDS.", + "The patient received TPN.", + "The patient received fluconazole prophylaxis.", + "On day 11, features of sepsis were observed.", + "The blood culture grew C. albidus.", + "C. albidus was sensitive to liposomal agents.", + "CSF evaluation suggested meningitis.", + "The patient received a six-week treatment regimen with liposomal formulations of amphotericin B at a dosage of 5 mg/kg body weight once daily.", + "The treatment regimen did not include 5-fluorocytosine.", + "The patient experienced no sequelae." + ] + }, + { + "id": "multiclinsum_test_1971_en.txt", + "fulltext": "A 50-year-old man with a history of an atrial septal defect and hypertension presented to our hospital for further examination of a previously diagnosed gallbladder polyp. He had no right quadrant pain, fever, jaundice, weight loss, or carcinoid syndrome-related symptoms such as diarrhea, flushing, edema, or wheezing. The patient hoped to avoid cholecystectomy. Abdominal ultrasonography revealed an 8.3-mm elevated polyp in the region around the gallbladder neck . During the next 3 years, the polyp gradually increased in size to 9.9 mm . Furthermore, contrast-enhanced computed tomography showed enhancement of the polyp . Magnetic resonance cholangiopancreatography (MRCP) showed no abnormality in the bile duct or pancreatic duct, while the polyp showed iso-intensity on T1-weighted images and low intensity on T2-weighted images .\nThe patient had smoked 20 cigarettes per day for 20 years. He also had a history of drinking alcohol (one bottle of beer per day). Physical examination showed no abnormalities. Blood tests also showed no abnormalities, including elevations of tumor markers such as carcinoembryonic antigen (1.5 ng/ml) and carbohydrate antigen 19–9 (9.3 U/ml). Taken together, these results suggested that the polyp included a malignant component. Therefore, we performed laparoscopic cholecystectomy. The whole gallbladder was successfully removed. Macroscopic examination of the resected specimen revealed a tumor of approximately 10 mm in diameter in the gallbladder neck region . Histologically, hematoxylin and eosin staining showed an alveolar pattern consisting of monomorphous round cells with centrally located nuclei . The extent of tumor infiltration was within the lamina propria of the mucosal membrane, and the tumor resection margin was negative. Immunohistochemical staining revealed positivity for chromogranin A, synaptophysin, and CD56 . Immunohistochemical staining of Ki-67 showed that the proliferative index in the tumor was < 3% and that the mitotic count ranged from 0 to 2 per 10 high-power fields . Taken together, these results led to a diagnosis of a grade 1 well-differentiated NET. Immunohistochemical staining was negative for DAXX and slightly positive for ATRX . The patient’s postoperative course was uneventful, and he developed no signs of recurrence either clinically or radiologically for 8 years.", + "fulltext_subclaims": [ + "The patient is a 50-year-old man.", + "He has a history of an atrial septal defect.", + "He has a history of hypertension.", + "He had a previously diagnosed gallbladder polyp.", + "He had no right quadrant pain.", + "He had no fever.", + "He had no jaundice.", + "He had no weight loss.", + "He had no carcinoid syndrome-related symptoms.", + "Abdominal ultrasonography revealed an 8.3-mm elevated polyp in the region around the gallbladder neck.", + "During the next 3 years, the polyp gradually increased in size to 9.9 mm.", + "Contrast-enhanced computed tomography showed enhancement of the polyp.", + "Magnetic resonance cholangiopancreatography showed no abnormality in the bile duct.", + "Magnetic resonance cholangiopancreatography showed no abnormality in the pancreatic duct.", + "The polyp showed iso-intensity on T1-weighted images.", + "The polyp showed low intensity on T2-weighted images.", + "The patient had smoked 20 cigarettes per day for 20 years.", + "He had a history of drinking one bottle of beer per day.", + "Physical examination showed no abnormalities.", + "Blood tests showed no abnormalities.", + "Carcinoembryonic antigen was 1.5 ng/ml.", + "Carbohydrate antigen 19–9 was 9.3 U/ml.", + "These results suggested that the polyp included a malignant component.", + "We performed laparoscopic cholecystectomy.", + "The whole gallbladder was successfully removed.", + "Macroscopic examination revealed a tumor of approximately 10 mm in diameter in the gallbladder neck region.", + "Hematoxylin and eosin staining showed an alveolar pattern consisting of monomorphous round cells with centrally located nuclei.", + "The extent of tumor infiltration was within the lamina propria of the mucosal membrane.", + "The tumor resection margin was negative.", + "Immunohistochemical staining revealed positivity for chromogranin A.", + "Immunohistochemical staining revealed positivity for synaptophysin.", + "Immunohistochemical staining revealed positivity for CD56.", + "The proliferative index in the tumor was < 3%.", + "The mitotic count ranged from 0 to 2 per 10 high-power fields.", + "These results led to a diagnosis of a grade 1 well-differentiated NET.", + "Immunohistochemical staining was negative for DAXX.", + "Immunohistochemical staining was slightly positive for ATRX.", + "The patient’s postoperative course was uneventful.", + "He developed no signs of recurrence either clinically or radiologically for 8 years." + ], + "summary": "A 50-year-old man presented to our hospital for further examination of a gallbladder polyp. He had no right quadrant pain, fever, jaundice, weight loss, or carcinoid syndrome-related symptoms. The patient hoped to avoid cholecystectomy. During the 3-year observation period, the polyp gradually increased in size from 8.3 to 9.9 mm. He decided to undergo surgery, and whole cholecystectomy was successfully performed. Immunohistochemical staining revealed positivity for chromogranin A, synaptophysin, and CD56. The Ki-67 index was < 3%. Taken together, these results led to a diagnosis of a grade 1 GB-NET. We also performed immunohistochemical staining of DAXX and ATRX, which revealed that DAXX protein expression was negative. The patient's postoperative course was uneventful, and he developed no recurrence for 8 years after surgery.", + "summary_subclaims": [ + "The patient was a 50-year-old man.", + "He had no right quadrant pain.", + "He had no fever.", + "He had no jaundice.", + "He had no weight loss.", + "He had no carcinoid syndrome-related symptoms.", + "The patient hoped to avoid cholecystectomy.", + "During the 3-year observation period, the gallbladder polyp gradually increased in size from 8.3 to 9.9 mm.", + "He decided to undergo surgery.", + "Whole cholecystectomy was successfully performed.", + "Immunohistochemical staining revealed positivity for chromogranin A.", + "Immunohistochemical staining revealed positivity for synaptophysin.", + "Immunohistochemical staining revealed positivity for CD56.", + "The Ki-67 index was < 3%.", + "These results led to a diagnosis of a grade 1 gallbladder neuroendocrine tumor.", + "Immunohistochemical staining of DAXX and ATRX was performed.", + "DAXX protein expression was negative.", + "The patient's postoperative course was uneventful.", + "He developed no recurrence for 8 years after surgery." + ] + }, + { + "id": "multiclinsum_test_1163_en.txt", + "fulltext": "Our patient was a 68 year old African American female who developed diffuse abdominal pain, associated with nausea and bilious vomiting, 24 hours prior to her emergency room visit. The pain was localized to the epigastric region and had a progressive course. Her last bowel movement was reported as four days prior and she denied any recent weight loss, wheezing, flushing, palpitation or change in bowel habits.\nThe patient's past medical and surgical history included hypertension, hyperlipidemia, total abdominal hysterectomy and bilateral salpingoophorectomy secondary to fibroids.\nThe patient also reported a history of progressive loss of vision ten years earlier that was investigated by brain MRI after an extensive ophthalmological evaluation. The MRI showed a pituitary tumor and the patient benefited from a transphenoidal pituitary tumor resection. The pathological examination revealed a chromophobic pituitary adenoma.\nThe patient had a strong family history of cancer. Her father died from colon cancer, a brother died from esophageal cancer, an uncle died from brain tumor, one aunt had been diagnosed with breast cancer and one aunt with gastric cancer.\nUpon physical exam, the patient had a tense, distended abdomen, with a well healed paramedian incision and no bowel sounds. There was non localized diffuse tenderness with positive rebound and voluntary guarding. Rectal examination revealed no masses and an empty vault. Laboratory values revealed no leukocytosis, however the lactic acid level was elevated. A computed tomography scan of the abdomen revealed a small bowel obstruction. Subsequently, the patient was decompressed with a nasogastric tube and fluid resuscitation, and brought to the operating room for an exploratory laparotomy. Intraoperatively, there was significant small bowel congestion with no necrosis. One adhesive band was found and lysed at the mid jejunum where it was fixed to the pelvic wall. The bowel was thoroughly inspected to look for any other points of obstruction or abnormalities. A serosal lesion was found on the surface of the jejunum ten centimeters from the adhesion . Also a suspicious hard draining mesenteric lymph node was seen. The serosal lesion, and the suspicious lymph node were both resected , and sent for pathologic determination.\nPostoperatively, the patient did well, however, the pathological evaluation of both the serosal lesion and the mesenteric lymph node revealed carcinoid tumor.\nThree days later, the patient was brought back to the operating room for exploratory laparotomy and small bowel resection. During the surgery, there was no intestinal lesion noted, and about 15 cm of small bowel on each side from the previous serosal lesion was resected with its corresponded mesentery . One enlarged and firm mesenteric lymph node, included in the specimen was marked with a stitch.\nThe pathological examination of the specimen revealed a carcinoid tumor approximately 0.4 cm in greatest dimension, penetrating subserosa five centimeters from the previously resected serosal lesion . A metastatic carcinoid tumor was seen in three out of 17 lymph nodes including the one marked with the stitch. The surgical resection margins were negative.\nDuring the postoperative inpatient period, a 24 hour urine 5-Hydroxyindole Acetic Acid (5-HIAA) was within normal value and no focal area of increase uptake was noted on an octreotide scan.\nThere was no postoperative morbidity, and the patient was followed as an outpatient at two and six month interval. During these follow up visits, the patient reported feeling better and denied any weight loss, wheezing, flushing, palpitations or diarrhea.\nA postoperative CT scan of the chest abdomen and pelvis six months after the surgery, revealed no evidence of recurrent disease, and no intra abdominal masses. A repeat octreotide scan at six months after the surgery did not show any area of increase uptake. Chromogranin A level was followed, and was decreasing from 142 ng/ml at two months post resection, to 64 ng/ml at six months post resection.", + "fulltext_subclaims": [ + "The patient was a 68 year old African American female.", + "She developed diffuse abdominal pain, associated with nausea and bilious vomiting, 24 hours prior to her emergency room visit.", + "The pain was localized to the epigastric region.", + "The pain had a progressive course.", + "Her last bowel movement was reported as four days prior.", + "She denied any recent weight loss.", + "She denied wheezing.", + "She denied flushing.", + "She denied palpitations.", + "She denied change in bowel habits.", + "The patient's past medical history included hypertension.", + "The patient's past medical history included hyperlipidemia.", + "The patient had a total abdominal hysterectomy.", + "The patient had a bilateral salpingoophorectomy secondary to fibroids.", + "The patient had a history of progressive loss of vision ten years earlier.", + "The patient had a brain MRI after an extensive ophthalmological evaluation.", + "The MRI showed a pituitary tumor.", + "The patient had a transphenoidal pituitary tumor resection.", + "The pathological examination revealed a chromophobic pituitary adenoma.", + "The patient had a strong family history of cancer.", + "Her father died from colon cancer.", + "A brother died from esophageal cancer.", + "An uncle died from brain tumor.", + "One aunt had been diagnosed with breast cancer.", + "One aunt had been diagnosed with gastric cancer.", + "Upon physical exam, the patient had a tense, distended abdomen.", + "There was non localized diffuse tenderness.", + "There was positive rebound.", + "There was voluntary guarding.", + "Rectal examination revealed no masses.", + "Rectal examination revealed an empty vault.", + "Laboratory values revealed no leukocytosis.", + "The lactic acid level was elevated.", + "A computed tomography scan of the abdomen revealed a small bowel obstruction.", + "The patient was decompressed with a nasogastric tube.", + "The patient was brought to the operating room for an exploratory laparotomy.", + "Intraoperatively, there was significant small bowel congestion with no necrosis.", + "One adhesive band was found and lysed at the mid jejunum.", + "A serosal lesion was found on the surface of the jejunum ten centimeters from the adhesion.", + "A suspicious hard draining mesenteric lymph node was seen.", + "The serosal lesion and the suspicious lymph node were both resected.", + "The pathological evaluation of both the serosal lesion and the mesenteric lymph node revealed carcinoid tumor.", + "Three days later, the patient was brought back to the operating room for exploratory laparotomy and small bowel resection.", + "During the surgery, there was no intestinal lesion noted.", + "About 15 cm of small bowel on each side from the previous serosal lesion was resected.", + "One enlarged and firm mesenteric lymph node, included in the specimen, was marked with a stitch.", + "The pathological examination of the specimen revealed a carcinoid tumor approximately 0.4 cm in greatest dimension.", + "The carcinoid tumor penetrated subserosa five centimeters from the previously resected serosal lesion.", + "A metastatic carcinoid tumor was seen in three out of 17 lymph nodes.", + "The surgical resection margins were negative.", + "A 24 hour urine 5-Hydroxyindole Acetic Acid (5-HIAA) was within normal value.", + "No focal area of increase uptake was noted on an octreotide scan.", + "There was no postoperative morbidity.", + "The patient was followed as an outpatient at two and six month intervals.", + "During these follow up visits, the patient reported feeling better.", + "A postoperative CT scan of the chest, abdomen, and pelvis six months after the surgery revealed no evidence of recurrent disease.", + "A postoperative CT scan six months after the surgery revealed no intra abdominal masses.", + "A repeat octreotide scan at six months after the surgery did not show any area of increase uptake.", + "Chromogranin A level was decreasing from 142 ng/ml at two months post resection to 64 ng/ml at six months post resection." + ], + "summary": "A sixty eight year old female presented with intestinal obstruction four years after transphenoidal pituitary resection for pituitary adenoma. During surgical exploration and lysis of adhesions, we accidentally discovered an intestinal carcinoid tumour. Resection of the involved small bowel segment and the draining lymph nodes was undertaken. Postoperative follow up showed no biochemical or radiological evidence of residual tumor.Neuroendocrine tumors (NETs) may occur as part of familial endocrine cancer syndromes including MEN-1. It is recommended that clinicians search thoroughly for MEN-1 in patients presented with NETs, however, there is no current consensus for screening patients suspected to have MEN-1 to rule out NET.", + "summary_subclaims": [ + "A sixty eight year old female presented with intestinal obstruction four years after transphenoidal pituitary resection for pituitary adenoma.", + "During surgical exploration and lysis of adhesions, we accidentally discovered an intestinal carcinoid tumour.", + "Resection of the involved small bowel segment and the draining lymph nodes was undertaken.", + "Postoperative follow up showed no biochemical or radiological evidence of residual tumor.", + "Neuroendocrine tumors (NETs) may occur as part of familial endocrine cancer syndromes including MEN-1.", + "It is recommended that clinicians search thoroughly for MEN-1 in patients presented with NETs.", + "There is no current consensus for screening patients suspected to have MEN-1 to rule out NET." + ] + }, + { + "id": "multiclinsum_test_375_en.txt", + "fulltext": "A 74-year-old male, history of a left A2 aneurysm, presented after a motor vehicle accident at low speeds. At the scene, the patient exhibited confusion. He sustained abrasions above his left eye, around his nose, and above his lip. Upon further investigation, patient had also had a syncopal episode on the prior day, where he fell and hit his head as well. Besides the confusion, he exhibited no focal neurological deficits. A computed tomography (CT) head demonstrated a 4 cm × 6 cm hyperdensity and edema with mass effect on left frontal area . The concerns included possible traumatic brain contusion, aneurysmal hemorrhage (given history of left A2 aneurysm), or hemorrhage from an underlying tumor given profound edema. The patient was started on fosphenytoin. A CT angiography of the head demonstrated a pericallosal cerebral aneurysm . A magnetic resonance imaging of the brain demonstrated a bifrontal, enhancing brain lesion with surrounding edema, concerning for a high-grade glioma . Subsequently, he was started on intravenous decadron.\nThe patient was discussed at the brain tumor board, where the plan was to address the aneurysm followed by resection of the mass versus close monitoring with subsequent imaging. The high risk of rehemorrhage, given the possibility of an aneurysmal hemorrhage, motivated prompt treatment of the aneurysm. The patient was taken to the angiography suite. An anterosuperiorly projecting azygous A2 aneurysm, measuring 4.5 mm × 5.5 mm with a neck width at 3.5 mm and a small daughter sac, was completely obliterated with primary coiling . Visualization of the external carotid arteries and internal carotid arteries bilaterally did not show any tumor blush. The following day, he underwent a left craniotomy along a forehead skin crease for mass excision. Final pathology revealed glioblastoma. The patient recovered well from both procedures, with a baseline neurological exam. The patient subsequently underwent hypofractionated radiation and temodar. The Medical College of Wisconsin does not require Institutional Review Board approval or patient consent for this case study.", + "fulltext_subclaims": [ + "The patient is a 74-year-old male.", + "The patient has a history of a left A2 aneurysm.", + "The patient presented after a motor vehicle accident at low speeds.", + "At the scene, the patient exhibited confusion.", + "The patient sustained abrasions above his left eye.", + "The patient sustained abrasions around his nose.", + "The patient sustained abrasions above his lip.", + "The patient had a syncopal episode on the prior day.", + "During the syncopal episode, the patient fell and hit his head.", + "The patient exhibited no focal neurological deficits.", + "A CT head demonstrated a 4 cm × 6 cm hyperdensity and edema with mass effect on the left frontal area.", + "The CT head findings raised concerns for traumatic brain contusion.", + "The CT head findings raised concerns for aneurysmal hemorrhage.", + "The CT head findings raised concerns for hemorrhage from an underlying tumor.", + "The patient was started on fosphenytoin.", + "A CT angiography of the head demonstrated a pericallosal cerebral aneurysm.", + "A magnetic resonance imaging of the brain demonstrated a bifrontal, enhancing brain lesion with surrounding edema.", + "The MRI findings were concerning for a high-grade glioma.", + "The patient was started on intravenous decadron.", + "The patient was discussed at the brain tumor board.", + "The plan was to address the aneurysm followed by resection of the mass versus close monitoring.", + "The high risk of rehemorrhage motivated prompt treatment of the aneurysm.", + "The patient was taken to the angiography suite.", + "An anterosuperiorly projecting azygous A2 aneurysm was completely obliterated with primary coiling.", + "The aneurysm measured 4.5 mm × 5.5 mm with a neck width at 3.5 mm and a small daughter sac.", + "Visualization of the external carotid arteries and internal carotid arteries bilaterally did not show any tumor blush.", + "The patient underwent a left craniotomy along a forehead skin crease for mass excision.", + "Final pathology revealed glioblastoma.", + "The patient recovered well from both procedures.", + "The patient had a baseline neurological exam.", + "The patient subsequently underwent hypofractionated radiation.", + "The patient subsequently underwent temodar.", + "The Medical College of Wisconsin does not require Institutional Review Board approval for this case study.", + "The Medical College of Wisconsin does not require patient consent for this case study." + ], + "summary": "A 74-year-old male, history of a left A2 aneurysm, presented after a motor vehicle accident at low speeds. Imaging was concerning for a possible traumatic brain contusion, an aneurysmal hemorrhage given history of left A2 aneurysm, or a hemorrhage from an underlying tumor given profound edema. The patient was discussed at the brain tumor board, where the plan was to address the aneurysm followed by resection of the mass versus close monitoring with subsequent imaging. The high risk of rehemorrhage, given the real possibility of an aneurysmal hemorrhage, motivated prompt treatment of the aneurysm. The patient was taken to the angiography suite; an anterosuperiorly projecting azygous A2 aneurysm, measuring 4.5 mm × 5.5 mm with a neck width at 3.5 mm and a small daughter sac, was completely obliterated with primary coiling. The following day, he underwent a left craniotomy along a forehead skin crease for mass excision. Final pathology revealed glioblastoma. The patient recovered well from both procedures, with a baseline neurological exam. The patient subsequently underwent hypofractionated radiation and temodar.", + "summary_subclaims": [ + "The patient is a 74-year-old male.", + "The patient has a history of a left A2 aneurysm.", + "The patient presented after a motor vehicle accident at low speeds.", + "Imaging was concerning for a possible traumatic brain contusion.", + "Imaging was concerning for an aneurysmal hemorrhage given history of left A2 aneurysm.", + "Imaging was concerning for a hemorrhage from an underlying tumor given profound edema.", + "The patient was discussed at the brain tumor board.", + "The plan was to address the aneurysm followed by resection of the mass versus close monitoring with subsequent imaging.", + "The high risk of rehemorrhage, given the real possibility of an aneurysmal hemorrhage, motivated prompt treatment of the aneurysm.", + "The patient was taken to the angiography suite.", + "An anterosuperiorly projecting azygous A2 aneurysm was found.", + "The aneurysm measured 4.5 mm × 5.5 mm.", + "The aneurysm had a neck width at 3.5 mm.", + "The aneurysm had a small daughter sac.", + "The aneurysm was completely obliterated with primary coiling.", + "The following day, the patient underwent a left craniotomy along a forehead skin crease for mass excision.", + "Final pathology revealed glioblastoma.", + "The patient recovered well from both procedures.", + "The patient had a baseline neurological exam.", + "The patient subsequently underwent hypofractionated radiation.", + "The patient subsequently underwent temodar." + ] + }, + { + "id": "multiclinsum_test_2041_en.txt", + "fulltext": "A 41-year-old man (height, 178 cm; weight, 58 kg) with no medical history was admitted to the emergency unit on foot complaining of severe right inguinal pain. A right inguinal bulge was noted, and there was no lower limb edema. CT showed bilateral common iliac aneurysms , and the internal iliac artery had a maximum diameter of 8 cm . An AVF was not detected on CT, and chest radiography did not show heart or lung disorders. Emergent laparotomy was planned for the aneurysm rupture.\nPreoperatively, his arterial pressure was stable with a systolic pressure of approximately 100 mmHg; however, there was a characteristic hemodynamic change , with pressure shifting between 95/48 mmHg and 85/25 mmHg for one or two heartbeats out of five beats, with normal sinus rhythm.\nAnesthetic induction was successful. The detection of high central venous pressure (CVP) coincidently with reduction of arterial pressure indicated the presence of an AVF. During the surgery, his systemic hemodynamic condition worsened . The CVP was initially 9 mmHg; however, it increased to 20 mmHg. His arterial pressure shifted frequently, and it reached a plateau of 60/50 mmHg. Urgent laparotomy and impetuous aortic clamping resulted in quick hemodynamic recovery, and the CVP reduced to approximately 6 mmHg. The right common iliac artery aneurysm showed a communication with the right common iliac vein. Therefore, he underwent aortobifemoral graft replacement, and no complications were noted. Postoperatively, he was not diagnosed with any connective tissue disorders, such as Ehlers-Danlos syndrome and Marfan’s syndrome.\nWe presented a case of acute aneurysmal rapture into the iliac vein. Sometimes, a definite diagnosis of an AVF associated with a SIA is difficult preoperatively because there might not be enough symptoms and time for diagnosis . An AVF associated with an AAA has the following triad of symptoms: congestive heart failure, continuous abdominal bruit, and a pulsating abdominal mass ; however, these symptoms are noted in only 20–50 % of reported cases . An AVF associated with a SIA might show lower limb edema as an additional feature; however, many cases do not have hemodynamic symptoms [–]. Definite diagnosis of an AVF offers advantages for surgical and anesthetic management.\nArterial pressure shifts rarely occur in a clinical situation. In the present case, these shifts indicated that an AVF was present and that the shunt was about to having a high flow. These hemodynamic changes could be explained by pooling of the transient increased shunt flow to a high-capacitance venous circuit and a decreased in preload, which can produce low arterial pressure at the next heartbeat. Simultaneously, an increase in venous return raised the blood pressure following a downward shift in the blood pressure. We hypothesized that the mechanical compression of a huge aneurysm should occlude the AVF and the fistula would appear by changing of lower limb posture, high blood pressure, or pulse of the aneurysm itself. The shift disappeared during the operative preparation, indicating that shunt dilation due to anesthetic agents and muscle relaxants decreased peripheral resistance, including aneurysmal compression at the vein.\nCT has been recommended to determine the subtypes, sizes, and complications of aneurysms [, –]. CT can contribute to the detection of an asymptomatic AVF associated with a SIA [–]. Although our case had hemodynamic catastrophe, the CT findings in our case were much fewer than the findings presented in previous reports. We were unsure of the presence of an AVF preoperatively because the dilated vena cava, which was not enhanced in the arterial phase, appeared to be apart from the aneurysm and the iliac veins were indistinguishable from the hematomas on CT. An asymptomatic aortocaval fistula due to abdominal aneurysmal compression and an ilio-iliac AVF associated with a huge common iliac aneurysm have been reported. Therefore, a huge iliac aneurysm could push the iliac vein aside and occlude the shunt easily. Postoperatively, we detected the enhanced left paravertebral vein and the left ascending lumbar vein on arterial-phase CT, and these were the only indications of the presence of an AVF on CT. The enhancement was noted at only the left paravertebral vein, although the laceration of the AVF was located at the right common iliac vein. The huge aneurysm obstructed the left common iliac vein and resulted in arterial inflow to the contralateral side. This supported the hypothesis that the aneurysm decreased shunt flow by compressing the adjacent vein.", + "fulltext_subclaims": [ + "The patient was a 41-year-old man with no medical history.", + "He was admitted to the emergency unit on foot.", + "He complained of severe right inguinal pain.", + "A right inguinal bulge was noted.", + "There was no lower limb edema.", + "CT showed bilateral common iliac aneurysms.", + "The internal iliac artery had a maximum diameter of 8 cm.", + "An AVF was not detected on CT.", + "Chest radiography did not show heart or lung disorders.", + "Emergent laparotomy was planned for the aneurysm rupture.", + "Preoperatively, his arterial pressure was stable with a systolic pressure of approximately 100 mmHg.", + "There was a characteristic hemodynamic change with pressure shifting between 95/48 mmHg and 85/25 mmHg for one or two heartbeats out of five beats.", + "The detection of high central venous pressure coincidently with reduction of arterial pressure indicated the presence of an AVF.", + "During the surgery, his systemic hemodynamic condition worsened.", + "The CVP increased to 20 mmHg.", + "His arterial pressure reached a plateau of 60/50 mmHg.", + "Urgent laparotomy and impetuous aortic clamping resulted in quick hemodynamic recovery.", + "The right common iliac artery aneurysm showed a communication with the right common iliac vein.", + "He underwent aortobifemoral graft replacement.", + "No complications were noted.", + "Postoperatively, he was not diagnosed with any connective tissue disorders.", + "An AVF associated with an AAA has the following triad of symptoms: congestive heart failure, continuous abdominal bruit, and a pulsating abdominal mass.", + "These symptoms are noted in only 20–50 % of reported cases.", + "An AVF associated with a SIA might show lower limb edema as an additional feature.", + "Many cases do not have hemodynamic symptoms.", + "Arterial pressure shifts rarely occur in a clinical situation.", + "In the present case, these shifts indicated that an AVF was present and that the shunt was about to having a high flow.", + "The shift disappeared during the operative preparation.", + "CT has been recommended to determine the subtypes, sizes, and complications of aneurysms.", + "CT can contribute to the detection of an asymptomatic AVF associated with a SIA.", + "The CT findings in our case were much fewer than the findings presented in previous reports.", + "We were unsure of the presence of an AVF preoperatively.", + "Postoperatively, we detected the enhanced left paravertebral vein and the left ascending lumbar vein on arterial-phase CT.", + "These were the only indications of the presence of an AVF on CT.", + "The enhancement was noted at only the left paravertebral vein.", + "The laceration of the AVF was located at the right common iliac vein.", + "The huge aneurysm obstructed the left common iliac vein and resulted in arterial inflow to the contralateral side." + ], + "summary": "A 41-year-old man with a huge SIA underwent aortobifemoral graft replacement. Preoperatively, his blood pressure showed characteristic shifts for one or two heartbeats out of five beats, indicating that an AVF was present and that the shunt was about to having a high flow. During surgery, an AVF associated with the SIA was found to be concealed owing to compression from the huge iliac artery aneurysm, and the shunt showed a high flow, resulting in shock during the surgery. No complications were noted after aortobifemoral graft replacement. Postoperatively, we noted an enhanced paravertebral vein on computed tomography (CT), which indicated the presence of an AVF.", + "summary_subclaims": [ + "The patient is a 41-year-old man.", + "The patient had a huge SIA.", + "The patient underwent aortobifemoral graft replacement.", + "Preoperatively, his blood pressure showed characteristic shifts for one or two heartbeats out of five beats.", + "The characteristic shifts indicated that an AVF was present.", + "The characteristic shifts indicated that the shunt was about to having a high flow.", + "During surgery, an AVF associated with the SIA was found.", + "The AVF was concealed owing to compression from the huge iliac artery aneurysm.", + "The shunt showed a high flow.", + "The high flow resulted in shock during the surgery.", + "No complications were noted after aortobifemoral graft replacement.", + "Postoperatively, an enhanced paravertebral vein was noted on CT.", + "The enhanced paravertebral vein indicated the presence of an AVF." + ] + }, + { + "id": "multiclinsum_test_559_en.txt", + "fulltext": "A 70-year-old male patient was admitted to hospital because of lumbago accompanied by left lower extremity pain, numbness and weakness for 2 years, which aggravated for 2 months. Ten years ago, he underwent PLIF for lumbar spinal stenosis, and recovered well after the operation. Physical examination revealed tenderness and percussion pain in the L3–4 spine area, and limited lumbar extension. Decreased skin sensation in the medial calf and medial malleolus of the left lower extremity. The muscle strength of the left lower extremity was grade III, the muscle strength of the right lower limb was grade IV, and the muscle tone was normal. The straight leg raising test of the left lower extremity was positive (30 degrees), and the straight leg raising test of the right lower extremity was negative. Physiological reflexes of the lower limbs were elicited normally, but pathological reflexes were not elicited. Based on the Japanese Orthopaedic Association (JOA) scoring system, the neurological function score of the patient was 10 points. Back pain Visual Analogue Scale (VAS) score is 7 points, leg pain VAS score is 8 points. Preoperative lumbar spine Oswestry Disability Index (ODI) score was 60%.\nMagnetic resonance imaging (MRI) revealed disc herniation at the L3/4 level, along with hypertrophy of the ligamentum flavum, inward hyperplasia of the articular process, and spinal canal stenosis . A diagnosis of ASD after lumbar fusion was made. The treatment plan for ASD after lumbar fusion involved bilateral microdecompression through a unilateral percutaneous microchannel approach.", + "fulltext_subclaims": [ + "The patient is a 70-year-old male.", + "The patient was admitted to hospital because of lumbago accompanied by left lower extremity pain, numbness and weakness for 2 years, which aggravated for 2 months.", + "Ten years ago, he underwent PLIF for lumbar spinal stenosis.", + "Physical examination revealed tenderness and percussion pain in the L3–4 spine area.", + "The straight leg raising test of the left lower extremity was positive (30 degrees).", + "The straight leg raising test of the right lower extremity was negative.", + "Based on the Japanese Orthopaedic Association (JOA) scoring system, the neurological function score of the patient was 10 points.", + "Back pain Visual Analogue Scale (VAS) score is 7 points.", + "Leg pain VAS score is 8 points.", + "Preoperative lumbar spine Oswestry Disability Index (ODI) score was 60%.", + "Magnetic resonance imaging (MRI) revealed disc herniation at the L3/4 level.", + "A diagnosis of ASD after lumbar fusion was made.", + "The treatment plan for ASD after lumbar fusion involved bilateral microdecompression through a unilateral percutaneous microchannel approach." + ], + "summary": "A 70-year-old male patient was admitted to hospital because of lumbago accompanied by left lower extremity pain, numbness and weakness for 2 years, which aggravated for 2 months. Ten years ago, he underwent PLIF for lumbar spinal stenosis, and recovered well after the operation. According to imaging data and physical examination, the diagnosis was adjacent segmental degeneration after lumbar fusion. Bilateral microdecompression was performed through a unilateral approach under a microchannel. Good clinical outcomes was observed through 1-year postoperative follow-up.", + "summary_subclaims": [ + "The patient is a 70-year-old male.", + "The patient was admitted to hospital because of lumbago accompanied by left lower extremity pain, numbness and weakness.", + "The symptoms had been present for 2 years.", + "The symptoms had aggravated for 2 months.", + "Ten years ago, he underwent PLIF for lumbar spinal stenosis.", + "He recovered well after the operation.", + "The diagnosis was adjacent segmental degeneration after lumbar fusion.", + "Bilateral microdecompression was performed through a unilateral approach under a microchannel.", + "Good clinical outcomes was observed through 1-year postoperative follow-up." + ] + }, + { + "id": "multiclinsum_test_581_en.txt", + "fulltext": "A 57-year-old male patient visited the Department of Oral Medicine, Kyungpook National University Dental Hospital with the chief complaint of painful ulcer on the tip of the tongue. The ulcer had developed 3–4 weeks ago without any apparent initiating event such as trauma. He described a pricking sensation and an increased soreness at the tongue tip area upon touching. The patient’s medical history revealed a diagnosis of TB over 40 years ago. He reported that complete recovery was gained at that time.\nIntraoral examination revealed a round ulcer measuring approximately 0.7 cm in diameter on the tip of the tongue. The ulcer was characterized by a granulomatous center and a whitish, well-defined border with slight elevation . The base of lesion was firm in consistency on digital palpation. Extraorally, there was no evidence of lymph node involvement. A panoramic radiograph showed no evidence of bone involvement. The laboratory examinations showed that complete blood count (CBC) was within normal limits. Serologic tests for human immunodeficiency virus and hepatitis C also revealed negative findings. Based on the clinical examination, differential diagnosis included major aphthous ulcer, traumatic ulcer, granulomatous diseases, and infections.\nTopical mouthwash with a mixture of amoxicillin 1.0 g and prednisolone 30 mg in 500 mL distilled water was used for 7 weeks with careful instruction to avoid possible stimuli, and triamcinolone acetonide 5 mg was also injected into lesion twice for 2 months. Despite subtle improvement after these conservative managements, the ulcer had not completely disappeared. Biopsy was eventually performed to rule out malignancy.\nAn incisional biopsy of the ulcer was carried out under local anesthesia (2% lidocaine with epinephrine 1:100,000). Histological examination revealed the presence of numerous epithelioid cells and multiple Langhans giant cells and Ziehl–Neelsen staining demonstrated acid-fast bacilli (AFB) . Based on histological findings, the oral ulcer was finally diagnosed as lingual TB.\nThe patient was immediately referred to a pneumologist for further examination and management. AFB stains of lesion were positive for M. tuberculosis. AFB cultures were positive for M. tuberculosis complex. Polymerase chain reaction (PCR) was conducted on his sputum, and analysis confirmed the presence of M. tuberculosis.. Additional blood biochemistry revealed the increased values of erythrocyte sedimentation rate (ESR) (103 mm/h) and c-reactive protein (CRP) (2.54 mg/dL). An IFN-γ release assay (IGRA) using the QuantiFERON-TB Gold in-tube method was positive. Chest computed tomography (CT) showed destructive findings with consolidation and fibrothorax in right lung and formation of cavitary lesion with clustered centrilobular micronodules in left lung apex .\nAfter about 2 months of drug therapy, the oral ulcer of patient almost disappeared , and after another 2 months, AFB culture showed no growth of M. tuberculosis in 4 weeks. The patient was followed up for 9 months without any complications .", + "fulltext_subclaims": [ + "The patient is a 57-year-old male.", + "The patient visited the Department of Oral Medicine, Kyungpook National University Dental Hospital.", + "The chief complaint was a painful ulcer on the tip of the tongue.", + "The ulcer had developed 3–4 weeks ago.", + "The ulcer developed without any apparent initiating event such as trauma.", + "The patient described a pricking sensation and increased soreness at the tongue tip area upon touching.", + "The patient had a medical history of TB over 40 years ago.", + "The patient reported that complete recovery was gained at that time.", + "Intraoral examination revealed a round ulcer measuring approximately 0.7 cm in diameter on the tip of the tongue.", + "The ulcer was characterized by a granulomatous center.", + "The ulcer had a whitish, well-defined border with slight elevation.", + "The base of the lesion was firm in consistency on digital palpation.", + "Extraorally, there was no evidence of lymph node involvement.", + "A panoramic radiograph showed no evidence of bone involvement.", + "The complete blood count (CBC) was within normal limits.", + "Serologic tests for human immunodeficiency virus and hepatitis C revealed negative findings.", + "Differential diagnosis included major aphthous ulcer.", + "Differential diagnosis included traumatic ulcer.", + "Differential diagnosis included granulomatous diseases.", + "Differential diagnosis included infections.", + "Topical mouthwash with a mixture of amoxicillin 1.0 g and prednisolone 30 mg in 500 mL distilled water was used for 7 weeks.", + "Triamcinolone acetonide 5 mg was injected into the lesion twice for 2 months.", + "Despite subtle improvement after these conservative managements, the ulcer had not completely disappeared.", + "An incisional biopsy of the ulcer was carried out under local anesthesia (2% lidocaine with epinephrine 1:100,000).", + "Histological examination revealed the presence of numerous epithelioid cells.", + "Histological examination revealed multiple Langhans giant cells.", + "Ziehl–Neelsen staining demonstrated acid-fast bacilli (AFB).", + "The oral ulcer was finally diagnosed as lingual TB.", + "The patient was immediately referred to a pneumologist for further examination and management.", + "AFB stains of the lesion were positive for M. tuberculosis.", + "AFB cultures were positive for M. tuberculosis complex.", + "PCR was conducted on his sputum.", + "PCR analysis confirmed the presence of M. tuberculosis.", + "Erythrocyte sedimentation rate (ESR) was 103 mm/h.", + "c-reactive protein (CRP) was 2.54 mg/dL.", + "An IFN-γ release assay (IGRA) using the QuantiFERON-TB Gold in-tube method was positive.", + "Chest computed tomography (CT) showed destructive findings with consolidation and fibrothorax in the right lung.", + "Chest CT showed formation of a cavitary lesion with clustered centrilobular micronodules in the left lung apex.", + "After about 2 months of drug therapy, the oral ulcer of the patient almost disappeared.", + "After another 2 months, AFB culture showed no growth of M. tuberculosis in 4 weeks.", + "The patient was followed up for 9 months without any complications." + ], + "summary": "A 57-year-old male patient presented with chief complaint of painful ulcer on tip of his tongue. He reported that the ulcer developed without any remarkable event such as mechanical trauma, vesicle formation or systemic illness. His past medical history revealed the TB over 40 years ago, which had reportedly healed after pharmacological treatments. As the ulceration persisted after topical steroid application and careful education about avoiding possible mechanical stimuli, biopsy was performed and histological finding showed typical findings of oral tuberculosis including intense granulomatous inflammatory features with small red rods of mycobacterial organisms as well as epithelioid cells and Langhans giant cells. After suitable antituberculosis treatments, oral tuberculosis ulcer was almost completely healed. We present a case of oral TB affecting tip of the tongue in a patient with a history of pulmonary TB and emphasize the understanding of intraoral manifestations for early diagnosis and prompt treatment of TB.", + "summary_subclaims": [ + "The patient is a 57-year-old male.", + "The patient's chief complaint was a painful ulcer on the tip of his tongue.", + "The ulcer developed without any remarkable event such as mechanical trauma.", + "The ulcer developed without vesicle formation.", + "The ulcer developed without systemic illness.", + "The patient's past medical history revealed TB over 40 years ago.", + "The TB reportedly healed after pharmacological treatments.", + "The ulceration persisted after topical steroid application.", + "Biopsy was performed.", + "Histological findings showed typical findings of oral tuberculosis.", + "Histological findings included intense granulomatous inflammatory features.", + "Histological findings showed small red rods of mycobacterial organisms.", + "Histological findings showed epithelioid cells.", + "Histological findings showed Langhans giant cells.", + "After suitable antituberculosis treatments, the oral tuberculosis ulcer was almost completely healed.", + "We present a case of oral TB affecting the tip of the tongue.", + "The patient had a history of pulmonary TB.", + "The case emphasizes the understanding of intraoral manifestations for early diagnosis and prompt treatment of TB." + ] + }, + { + "id": "multiclinsum_test_1533_en.txt", + "fulltext": "A 5-year-old Asian boy presented with decreased visual acuity in his right eye . He was born with CL/P at 40 weeks of gestation. However, he had no family history of CL/P. His mother received a measles, mumps, and rubella vaccine during the first trimester of pregnancy. No relevant history of smoking, alcohol consumption, folate deficiency, exposure to ionizing radiation, or any severe infection during pregnancy was found. Prenatal fetal ultrasonography showed unilateral CL/P on the right side without brain lesions. Postnatal renal ultrasonography of the child revealed mild hydronephrosis in the right kidney without dysfunction. Follow-up examination at 4 years of age confirmed that both the kidneys were normal. He underwent several cardiological and endocrinological investigations for the evaluation of congenital rubella syndrome, which revealed no abnormal findings. Neurological examination revealed no midline defect of the vertebral bodies. At 9 months of age, he underwent successful surgical repair of his unilateral CL on the right side . He experienced two episodes of febrile seizures at the age of 2 years with no sequelae. Electroencephalography after the seizures revealed no remarkable findings. Although genetic analysis was recommended, his parents refused to undergo chromosomal evaluation. Magnetic resonance imaging showed no other midline defects or neurological anomalies. He did not have any intellectual or psychomotor developmental delays.\nAt initial presentation, his best-corrected visual acuity (BCVA) was 20/60 in the right eye and 20/25 in the left eye. Slit lamp examination revealed iris coloboma in the inferonasal quadrant of the right eye . Fundus examination showed optic nerve and chorioretinal colobomas in the inferonasal quadrant of the right eye . Spectral domain optical coherence tomography showed preserved foveal anatomy without retinoschisis or neurosensory detachment in the right eye . No evidence of microphthalmia, scleromalacia, congenital cataract, or ocular motility disorder was found. The left eye had no remarkable findings. He was prescribed glasses based on his cycloplegic refractive errors (Right eye: − 2.00 Dsph − 2.00 Dcyl × Axis 180°; Left eye: + 1.50 Dsph − 1.00 Dcyl × Axis 180°). We recommended daily occlusion therapy in the left eye for 4 h. After 3 months, BCVA in the right eye improved to 20/30. In addition, the patient was referred to the otolaryngology department for otological and audiological assessments, which revealed no relevant abnormalities.", + "fulltext_subclaims": [ + "A 5-year-old Asian boy presented with decreased visual acuity in his right eye.", + "He was born with CL/P at 40 weeks of gestation.", + "He had no family history of CL/P.", + "His mother received a measles, mumps, and rubella vaccine during the first trimester of pregnancy.", + "Prenatal fetal ultrasonography showed unilateral CL/P on the right side without brain lesions.", + "Postnatal renal ultrasonography of the child revealed mild hydronephrosis in the right kidney without dysfunction.", + "Follow-up examination at 4 years of age confirmed that both the kidneys were normal.", + "He underwent several cardiological and endocrinological investigations for the evaluation of congenital rubella syndrome, which revealed no abnormal findings.", + "Neurological examination revealed no midline defect of the vertebral bodies.", + "At 9 months of age, he underwent successful surgical repair of his unilateral CL on the right side.", + "He experienced two episodes of febrile seizures at the age of 2 years with no sequelae.", + "Electroencephalography after the seizures revealed no remarkable findings.", + "Although genetic analysis was recommended, his parents refused to undergo chromosomal evaluation.", + "Magnetic resonance imaging showed no other midline defects or neurological anomalies.", + "He did not have any intellectual or psychomotor developmental delays.", + "At initial presentation, his best-corrected visual acuity (BCVA) was 20/60 in the right eye and 20/25 in the left eye.", + "Slit lamp examination revealed iris coloboma in the inferonasal quadrant of the right eye.", + "Fundus examination showed optic nerve and chorioretinal colobomas in the inferonasal quadrant of the right eye.", + "Spectral domain optical coherence tomography showed preserved foveal anatomy without retinoschisis or neurosensory detachment in the right eye.", + "No evidence of microphthalmia, scleromalacia, congenital cataract, or ocular motility disorder was found.", + "The left eye had no remarkable findings.", + "He was prescribed glasses based on his cycloplegic refractive errors (Right eye: − 2.00 Dsph − 2.00 Dcyl × Axis 180°; Left eye: + 1.50 Dsph − 1.00 Dcyl × Axis 180°).", + "We recommended daily occlusion therapy in the left eye for 4 h.", + "After 3 months, BCVA in the right eye improved to 20/30.", + "The patient was referred to the otolaryngology department for otological and audiological assessments, which revealed no relevant abnormalities." + ], + "summary": "A 5-year-old Asian boy presented with decreased visual acuity in his right eye. Physical examination revealed no abnormal findings except CL/P, which was surgically corrected at the age of 9 months. Best-corrected visual acuity was 20/60 in the right eye and 20/25 in the left eye. Anterior segment examination revealed iris coloboma in the inferior quadrant of his right eye as well as a large inferonasal optic disc and chorioretinal coloboma in the same eye. He was prescribed glasses based on his cycloplegic refractive errors and part-time occlusion of the left eye was recommended. After 3 months, best-corrected visual acuity improved to 20/30 in the right eye.", + "summary_subclaims": [ + "The patient is a 5-year-old Asian boy.", + "He presented with decreased visual acuity in his right eye.", + "Physical examination revealed no abnormal findings except CL/P.", + "CL/P was surgically corrected at the age of 9 months.", + "Best-corrected visual acuity was 20/60 in the right eye.", + "Best-corrected visual acuity was 20/25 in the left eye.", + "Anterior segment examination revealed iris coloboma in the inferior quadrant of his right eye.", + "A large inferonasal optic disc and chorioretinal coloboma were found in the right eye.", + "He was prescribed glasses based on his cycloplegic refractive errors.", + "Part-time occlusion of the left eye was recommended.", + "After 3 months, best-corrected visual acuity improved to 20/30 in the right eye." + ] + }, + { + "id": "multiclinsum_test_417_en.txt", + "fulltext": "A 42 year old female with cutaneous lupus for 16 years was evaluated for new onset hypertension and ankle oedema of 2 months duration. She was found to have a nephrotic range proteinuria (3.7 g per day) with microscopic haematuria and underwent renal biopsy for suspected lupus nephritis. She did not have coagulopathy, local skin sepsis or uncontrolled hypertension at the time of the biopsy. The procedure was performed under ultrasound guidance, adhering to aseptic precautions by an experienced specialty trainee in nephrology. Two cores were obtained with two passes using a Histo Automated Spring-loaded renal biopsy gun with a 16G needle. No complications were observed during the immediate post-procedure period. Patient did not develop undue pain, haematuria or overt bleeding from the biopsy site. She was discharged from hospital the next day.\nShe was on prednisolone 60 mg daily and had steroid induced diabetes mellitus. Her glycemic control was poor (HbA1c 9.0%, fasting plasma glucose 188 mg/dL) while being on treatment with metformin 750 mg thrice daily and gliclazide 40 mg twice daily.\nEight weeks later she was re-admitted with pain in the left flank, intermittent fever and malaise for 1 week. She did not have urinary symptoms, haematuria, nausea or vomiting.\nHer past medical, surgical, gynaecological and family history was otherwise unremarkable. She was a housewife, leading an active lifestyle, well supported by family members and was well compliant with treatment.\nOn admission, she was ill, febrile (37.5 °C), had tachycardia (112 beats per minute) with normal blood pressure (120/70 mmHg), respiratory rate (18 per minute) and oxygen saturation (99% on ambient air). She was pale and had bilateral symmetrical pitting ankle oedema, malar rash, and erythematous desquamating rash over sun exposed areas. Abdominal examination revealed an exquisitely tender subcutaneous induration in the left flank without overlying erythema, warmth or rash. Cardiovascular, respiratory and neurological examinations were unremarkable.\nInvestigations revealed a neutrophil leukocytosis (total white cell count 22 300 / mm3, neutrophils 88% with left shift and toxic granules), elevated C-reactive protein (120 mg/L, reference < 6 mg/L) and erythrocyte sedimentation rate (88 mm 1st hour). She also had normochromic normocytic anaemia (haemoglobin 8.9 g/dL), normal renal functions (Creatinine 57 micmol/L) and normal liver biochemistry except for hypoalbuminaemia (26 g/L). Renal biopsy was reported as having insufficient tissue as it contained only tubules, without any glomeruli.\nUrinalysis showed proteinuria and microscopic haematuria without pyuria. Urine and blood cultures grew no organisms. Ultrasound scan of the abdomen showed a subcutaneous hypoechoeic area over the left flank suggestive of a fluid collection. A contrast enhanced CT scan of the abdomen was done which showed a retroperitoneal collection of pus that extended in to the subcutaneous tissues through the muscles of the posterior abdominal wall . No communication was reported between the abscess and the renal tissue.\nShe underwent incision and drainage of the abscess, which drained 400 mL of blood stained pus. Collection was found to be extending from the retroperitoneal region to the subcutaneous tissue plane, two regions communicating through a channel that penetrated the posterior abdominal wall musculature. The abscess had no communication with renal tissues or the collecting system. Pus culture isolated an extended spectrum beta lactamase producing Escherichia coli. She was treated with intravenous meropenem 1 g 8 hourly along with regular debridement of the surgical site.\nHer symptoms gradually resolved with treatment and inflammatory markers returned to normal. Follow up imaging with ultrasonography did not reveal any residual collection. Two weeks later, she was discharged from in patient care with a plan for repeat biopsy from the right kidney.", + "fulltext_subclaims": [ + "The patient is a 42 year old female.", + "She has cutaneous lupus for 16 years.", + "She had new onset hypertension and ankle oedema of 2 months duration.", + "She had nephrotic range proteinuria (3.7 g per day).", + "She had microscopic haematuria.", + "She underwent renal biopsy for suspected lupus nephritis.", + "She did not have coagulopathy at the time of the biopsy.", + "She did not have local skin sepsis at the time of the biopsy.", + "She did not have uncontrolled hypertension at the time of the biopsy.", + "The procedure was performed under ultrasound guidance.", + "Aseptic precautions were adhered to during the procedure.", + "The biopsy was performed by an experienced specialty trainee in nephrology.", + "Two cores were obtained with two passes.", + "A Histo Automated Spring-loaded renal biopsy gun with a 16G needle was used.", + "No complications were observed during the immediate post-procedure period.", + "The patient did not develop undue pain.", + "The patient did not develop haematuria.", + "The patient did not develop overt bleeding from the biopsy site.", + "She was discharged from hospital the next day.", + "She was on prednisolone 60 mg daily.", + "She had steroid induced diabetes mellitus.", + "Her HbA1c was 9.0%.", + "Her fasting plasma glucose was 188 mg/dL.", + "She was being treated with metformin 750 mg thrice daily.", + "She was being treated with gliclazide 40 mg twice daily.", + "Eight weeks later she was re-admitted with pain in the left flank.", + "She had intermittent fever and malaise for 1 week.", + "She did not have urinary symptoms.", + "She did not have haematuria.", + "She did not have nausea or vomiting.", + "Her past medical, surgical, gynaecological and family history was otherwise unremarkable.", + "She was a housewife.", + "She led an active lifestyle.", + "She was well supported by family members.", + "She was well compliant with treatment.", + "On admission, she was ill.", + "She was febrile (37.5 °C).", + "She had tachycardia (112 beats per minute).", + "She had normal blood pressure (120/70 mmHg).", + "She had normal respiratory rate (18 per minute).", + "She had normal oxygen saturation (99% on ambient air).", + "She was pale.", + "She had bilateral symmetrical pitting ankle oedema.", + "She had a malar rash.", + "She had an erythematous desquamating rash over sun exposed areas.", + "Abdominal examination revealed an exquisitely tender subcutaneous induration in the left flank.", + "There was no overlying erythema, warmth or rash.", + "Cardiovascular, respiratory and neurological examinations were unremarkable.", + "Investigations revealed a neutrophil leukocytosis (total white cell count 22 300 / mm3).", + "Neutrophils were 88% with left shift and toxic granules.", + "C-reactive protein was 120 mg/L.", + "Erythrocyte sedimentation rate was 88 mm 1st hour.", + "She had normochromic normocytic anaemia (haemoglobin 8.9 g/dL).", + "She had normal renal functions (Creatinine 57 micmol/L).", + "She had normal liver biochemistry.", + "She had hypoalbuminaemia (26 g/L).", + "Renal biopsy was reported as having insufficient tissue.", + "The renal biopsy contained only tubules, without any glomeruli.", + "Urinalysis showed proteinuria.", + "Urinalysis showed microscopic haematuria.", + "Urinalysis showed no pyuria.", + "Urine and blood cultures grew no organisms.", + "Ultrasound scan showed a subcutaneous hypoechoeic area over the left flank.", + "A contrast enhanced CT scan showed a retroperitoneal collection of pus.", + "The abscess extended into the subcutaneous tissues through the muscles of the posterior abdominal wall.", + "No communication was reported between the abscess and the renal tissue.", + "She underwent incision and drainage of the abscess.", + "The abscess drained 400 mL of blood stained pus.", + "The collection extended from the retroperitoneal region to the subcutaneous tissue plane.", + "The abscess had no communication with renal tissues or the collecting system.", + "Pus culture isolated an extended spectrum beta lactamase producing Escherichia coli.", + "She was treated with intravenous meropenem 1 g 8 hourly.", + "She had regular debridement of the surgical site.", + "Her symptoms gradually resolved with treatment.", + "Inflammatory markers returned to normal.", + "Follow up imaging with ultrasonography did not reveal any residual collection.", + "She was discharged from in patient care two weeks later.", + "She had a plan for repeat biopsy from the right kidney." + ], + "summary": "A 42-year-old female with long standing cutaneous lupus underwent renal biopsy for evaluation of nephrotic range proteinuria. She was on high dose prednisolone complicated with steroid induced hyperglycaemia. Eight weeks after the biopsy she presented with left flank pain, malaise and fever. There was a tender subcutaneous induration over the biopsy site. Contrast CT abdomen showed a retroperitoneal abscess with subcutaneous extension along the path of the biopsy needle. This was successfully treated with surgical drainage and broad-spectrum antibiotics.", + "summary_subclaims": [ + "The patient is a 42-year-old female.", + "She has long standing cutaneous lupus.", + "She underwent renal biopsy for evaluation of nephrotic range proteinuria.", + "She was on high dose prednisolone.", + "She had steroid induced hyperglycaemia.", + "Eight weeks after the biopsy she presented with left flank pain.", + "She had malaise.", + "She had fever.", + "There was a tender subcutaneous induration over the biopsy site.", + "Contrast CT abdomen showed a retroperitoneal abscess.", + "The abscess had subcutaneous extension along the path of the biopsy needle.", + "The abscess was successfully treated with surgical drainage.", + "The abscess was successfully treated with broad-spectrum antibiotics." + ] + }, + { + "id": "multiclinsum_test_1575_en.txt", + "fulltext": "An 81-year-old Lithuanian woman was tested for faecal occult blood during preventive colorectal cancer screening. Test results were positive and she underwent a colonoscopy. The colonoscopy revealed a tumour in her caecum. Abdominal and thoracic computed tomography (CT) scanning revealed no metastasis. She then underwent elective surgery. During the operation, a 6×5cm tumour was found in her caecum. Her MD was found 40cm from the hepatoduodenal ligament . A right hemicolectomy was performed to excise the MD from her jejunal loop. After the operation, she underwent chemotherapy. There were no complications related to the surgery. Histological results showed a poorly differentiated G3 adenocarcinoma of the caecum. In her small intestine a muscular layer of excised MD and mesenteric adipose tissue was found, which was pancreatic tissue morphologically. Microscopic analysis revealed pancreatic tissue without islets of Langerhans in the small intestine and mesenteric adipose tissue. Moreover, in the HP tissue, dilatation of the pancreatic ducts was observed.", + "fulltext_subclaims": [ + "An 81-year-old Lithuanian woman was tested for faecal occult blood during preventive colorectal cancer screening.", + "Test results were positive.", + "She underwent a colonoscopy.", + "The colonoscopy revealed a tumour in her caecum.", + "Abdominal and thoracic computed tomography (CT) scanning revealed no metastasis.", + "She then underwent elective surgery.", + "During the operation, a 6×5cm tumour was found in her caecum.", + "Her MD was found 40cm from the hepatoduodenal ligament.", + "A right hemicolectomy was performed to excise the MD from her jejunal loop.", + "After the operation, she underwent chemotherapy.", + "There were no complications related to the surgery.", + "Histological results showed a poorly differentiated G3 adenocarcinoma of the caecum.", + "In her small intestine a muscular layer of excised MD and mesenteric adipose tissue was found, which was pancreatic tissue morphologically.", + "Microscopic analysis revealed pancreatic tissue without islets of Langerhans in the small intestine and mesenteric adipose tissue.", + "In the HP tissue, dilatation of the pancreatic ducts was observed." + ], + "summary": "An 81-year-old Lithuanian woman was diagnosed with caecal cancer and had undergone elective surgery. A right hemicolectomy was performed and a Meckel's diverticulum was observed and excised. Histological results showed a poorly differentiated G3 adenocarcinoma of her large intestine and heterotopic pancreas tissue in the Meckel's diverticulum and mesenteric adipose tissue.", + "summary_subclaims": [ + "The patient is an 81-year-old Lithuanian woman.", + "She was diagnosed with caecal cancer.", + "She had undergone elective surgery.", + "A right hemicolectomy was performed.", + "A Meckel's diverticulum was observed and excised.", + "Histological results showed a poorly differentiated G3 adenocarcinoma of her large intestine.", + "Heterotopic pancreas tissue was found in the Meckel's diverticulum.", + "Heterotopic pancreas tissue was found in the mesenteric adipose tissue." + ] + }, + { + "id": "multiclinsum_test_1800_en.txt", + "fulltext": "JLLP, a 49-year-old man, industrial worker, resident in Manaus, Amazonas, Brazil, was admitted to the emergency at Hospital Adventista de Manaus (HAM). The patient showed skin rash, pruritus, arthralgia, headache, myalgia, bilateral conjunctivitis, fever (38.5 °C) and hypertensive crisis with blood pressure (BP) of 240/120 mmHg, but heart rate and cardiac auscultation were normal. The patient had no travel history and described the appearance of symptoms 3 days before seeking medical attention. Besides, the patient reported the absence of hypertensive episodes or any other cardiac disorder in the past.\nImmediately, the treatment for the hypertensive crisis was initiated with sodium nitroprusside (250 ml glycated serum 5% + Nipride – 1 ampoule = 2 ml) administered 5 ml/h by continuous infusion. In the following two, three and 4 hours it was administered 7 ml, 10 ml and 15 ml of sodium nitroprusside, respectively, but the blood pressure was still elevated. No abnormalities in electrocardiogram (ECG) and chest radiography (CR) were observed.\nThe patient was still refractory to blood pressure control (BP 238/120 mmHg) 4 hours after starting treatment, and showed elevated blood glucose levels (250 mg/dL), therefore, he was transferred to the Intensive Care Unit (ICU). Suddenly, the patient suffered a cardiac arrhythmia (atrial fibrillation - AF) which was chemically reversed with an attack dose of two ampoules (6 ml) of intravenous amiodarone hydrochloride (50 mg/ml). For the maintenance dose, six ampoules of amiodarone (8 ml/h) were administered in 5% glycated serum (250 ml) by continuous infusion for 12 h.\nDue to the symptoms presented at the time of attendance, and the ongoing Zika outbreak in course, the patient and his wife, an asymptomatic contact, were inserted into the protocol for ZIKV surveillance. Both had samples of blood, urine, and saliva collected for arboviral testing by the reverse transcription real-time polymerase chain reaction (RT-qPCR).\nOn the sixth day of hospitalization, the patient underwent magnetic resonance imaging (MRI); echocardiographic doppler (DE) and coronary angiography (CA). Only the MRI was altered with bilateral supratentorial microangiopathic gliosis. A second ECG was performed on the eighth day of hospitalization, which presented no alterations and the patient was discharged. Serological tests for other infectious diseases were negative and the RT-qPCR results showed positivity for ZIKV in the saliva sample. Although still asymptomatic, his wife also tested positive for ZIKV in the serum sample.", + "fulltext_subclaims": [ + "JLLP is a 49-year-old man.", + "JLLP is an industrial worker.", + "JLLP is a resident in Manaus, Amazonas, Brazil.", + "JLLP was admitted to the emergency at Hospital Adventista de Manaus.", + "The patient showed skin rash.", + "The patient showed pruritus.", + "The patient showed arthralgia.", + "The patient showed headache.", + "The patient showed myalgia.", + "The patient showed bilateral conjunctivitis.", + "The patient had fever of 38.5 °C.", + "The patient had a blood pressure of 240/120 mmHg.", + "The patient had no travel history.", + "The patient described the appearance of symptoms 3 days before seeking medical attention.", + "The patient reported the absence of hypertensive episodes in the past.", + "The patient reported the absence of any other cardiac disorder in the past.", + "The treatment for the hypertensive crisis was initiated with sodium nitroprusside.", + "Sodium nitroprusside was administered 5 ml/h by continuous infusion.", + "In the following two hours, 7 ml of sodium nitroprusside was administered.", + "In the following three hours, 10 ml of sodium nitroprusside was administered.", + "In the following four hours, 15 ml of sodium nitroprusside was administered.", + "No abnormalities in electrocardiogram were observed.", + "No abnormalities in chest radiography were observed.", + "The patient was still refractory to blood pressure control 4 hours after starting treatment.", + "The patient's blood pressure was 238/120 mmHg 4 hours after starting treatment.", + "The patient had blood glucose levels of 250 mg/dL.", + "The patient was transferred to the Intensive Care Unit.", + "The patient suffered a cardiac arrhythmia.", + "The arrhythmia was atrial fibrillation.", + "The arrhythmia was chemically reversed with an attack dose of two ampoules of intravenous amiodarone hydrochloride.", + "The maintenance dose of amiodarone was six ampoules administered in 5% glycated serum by continuous infusion for 12 h.", + "The patient and his wife were inserted into the protocol for ZIKV surveillance.", + "Both the patient and his wife had samples of blood, urine, and saliva collected for arboviral testing.", + "The arboviral testing was performed by reverse transcription real-time polymerase chain reaction.", + "On the sixth day of hospitalization, the patient underwent magnetic resonance imaging.", + "On the sixth day of hospitalization, the patient underwent echocardiographic doppler.", + "On the sixth day of hospitalization, the patient underwent coronary angiography.", + "The MRI showed bilateral supratentorial microangiopathic gliosis.", + "A second ECG was performed on the eighth day of hospitalization.", + "The second ECG presented no alterations.", + "The patient was discharged.", + "Serological tests for other infectious diseases were negative.", + "The RT-qPCR results showed positivity for ZIKV in the saliva sample.", + "The wife tested positive for ZIKV in the serum sample." + ], + "summary": "We report a case of atrial fibrillation disclosed during an acute Zika virus infection in a 49-year-old man. Different biological samples were analyzed for the molecular diagnosis of Zika by real-time PCR, however only the saliva specimen was positive. The patient's wife tested positive in the serum sample, although she was an asymptomatic carrier. Moreover, a complete overview of patient's biomarkers, including cytokines, chemokines, and growth-factors levels, was analyzed and compared to gender and age matching non-infected controls, as well as other Zika infected patients, considering the 95%CI of the mean values. Elevated levels of CXCL8, CCL11, CCL2, CXCL10, IL-1β, IL-6, TNF-α, IFN-γ, IL-17, IL-1Ra, IL-4, IL-9, FGF-basic, PDGF, G-CSF, and GM-CSF were observed in the Atrial fibrillation patient, in contrast to uninfected controls. Furthermore, increased levels of CCL5, IL-1β, TNF-α, IFN-γ, IL-9, G-CSF, and GM-CSF were observed only in the atrial fibrillation patient, when compared to other Zika patients.", + "summary_subclaims": [ + "A 49-year-old man had atrial fibrillation disclosed during an acute Zika virus infection.", + "Different biological samples were analyzed for the molecular diagnosis of Zika by real-time PCR.", + "Only the saliva specimen was positive for Zika virus.", + "The patient's wife tested positive in the serum sample.", + "The patient's wife was an asymptomatic carrier.", + "A complete overview of the patient's biomarkers, including cytokines, chemokines, and growth-factors levels, was analyzed.", + "Biomarkers were compared to gender and age matching non-infected controls.", + "Biomarkers were compared to other Zika infected patients.", + "The comparison considered the 95%CI of the mean values.", + "Elevated levels of CXCL8, CCL11, CCL2, CXCL10, IL-1β, IL-6, TNF-α, IFN-γ, IL-17, IL-1Ra, IL-4, IL-9, FGF-basic, PDGF, G-CSF, and GM-CSF were observed in the atrial fibrillation patient, in contrast to uninfected controls.", + "Increased levels of CCL5, IL-1β, TNF-α, IFN-γ, IL-9, G-CSF, and GM-CSF were observed only in the atrial fibrillation patient, when compared to other Zika patients." + ] + }, + { + "id": "multiclinsum_test_3310_en.txt", + "fulltext": "A 16-year-old Ukrainian boy was admitted to the Department of Children’s Infectious Diseases in Warsaw, Poland, due to jaundice lasting for four days with malaise, diarrhoea, and vomiting. The boy has lived in Poland for 1.5 years; he was working (training) in the profession of a hairdresser. The medical interview revealed that he had a tattoo made at home by his mother’s partner six months earlier and a finger was also cut by hairdressing scissors six weeks before the admission. The patient confirmed that he had two secured heterosexual encounters during the last six months. In Ukraine, he had been vaccinated against tuberculosis, diphtheria, tetanus, pertussis, poliomyelitis, measles, mumps, and rubella; he has not been vaccinated against hepatitis B. He negated any dietary errors and had never had blood transfusion nor surgery. He was once hospitalized due to acute gastroenteritis (in Ukraine). The physical examination revealed jaundice, hepatomegaly (2 cm below the rib arch), and a tattoo on the right forearm. Laboratory tests showed a significantly elevated level of aminotransferases (alanine aminotransferase (ALT) 2439 IU/L and aspartate aminotransferase (AST) 1418 IU/L). Serological testing was positive for HBsAg and anti-Hbc IgM antibodies, and negative for hepatitis A and hepatitis C viruses. The HBV viral load was 5.82 copies/mL and HBV genotype A was confirmed. Acute hepatitis B was diagnosed and the patient was treated conservatively. There were no signs of hepatic failure. During observation, hepatic parameters were firstly elevated, but after 14 days they improved and the patient was discharged home with the recommendation to appear for the follow-up examinations after six months (in order to exclude or confirm chronic hepatitis B). The patient did not appear for the visit. After 15 months, he wrote a message on Facebook to his practitioner asking if he had to report on a follow-up, as he felt good. A visit in the clinic was arranged for him. Hepatic parameters were normal, testing towards the hepatitis B antigen was negative, and the chronic HBV infection was excluded. The extended interview revealed a urinary tract infection a year before and unprotected sexual encounters of both homo and heterosexual relations. During physical examination, a small ulcer around his anus was found. Thus, additional tests for HIV, syphilis, gonorrhoea, and chlamydia trachomatis were ordered and they were all negative except for syphilis. Due to risky sexual behaviour, the patient was offered pre-exposure prophylaxis. The patient applied for further treatment of syphilis to the Clinic of Dermatology and Venereology in Warsaw.\n\n", + "fulltext_subclaims": [ + "A 16-year-old Ukrainian boy was admitted to the Department of Children’s Infectious Diseases in Warsaw, Poland.", + "The boy had jaundice lasting for four days.", + "The boy had malaise.", + "The boy had diarrhoea.", + "The boy had vomiting.", + "The boy had lived in Poland for 1.5 years.", + "The boy was working (training) in the profession of a hairdresser.", + "The boy had a tattoo made at home by his mother’s partner six months earlier.", + "The boy had a finger cut by hairdressing scissors six weeks before the admission.", + "The patient confirmed that he had two secured heterosexual encounters during the last six months.", + "In Ukraine, he had been vaccinated against tuberculosis, diphtheria, tetanus, pertussis, poliomyelitis, measles, mumps, and rubella.", + "He has not been vaccinated against hepatitis B.", + "He negated any dietary errors.", + "He had never had blood transfusion nor surgery.", + "He was once hospitalized due to acute gastroenteritis in Ukraine.", + "The physical examination revealed jaundice.", + "The physical examination revealed hepatomegaly (2 cm below the rib arch).", + "The physical examination revealed a tattoo on the right forearm.", + "Laboratory tests showed a significantly elevated level of aminotransferases.", + "Alanine aminotransferase (ALT) was 2439 IU/L.", + "Aspartate aminotransferase (AST) was 1418 IU/L.", + "Serological testing was positive for HBsAg.", + "Serological testing was positive for anti-Hbc IgM antibodies.", + "Serological testing was negative for hepatitis A and hepatitis C viruses.", + "The HBV viral load was 5.82 copies/mL.", + "HBV genotype A was confirmed.", + "Acute hepatitis B was diagnosed.", + "The patient was treated conservatively.", + "There were no signs of hepatic failure.", + "During observation, hepatic parameters were firstly elevated.", + "After 14 days, hepatic parameters improved.", + "The patient was discharged home with the recommendation to appear for follow-up examinations after six months.", + "The patient did not appear for the visit.", + "After 15 months, he wrote a message on Facebook to his practitioner asking if he had to report on a follow-up.", + "A visit in the clinic was arranged for him.", + "Hepatic parameters were normal.", + "Testing towards the hepatitis B antigen was negative.", + "Chronic HBV infection was excluded.", + "The extended interview revealed a urinary tract infection a year before.", + "The extended interview revealed unprotected sexual encounters of both homo and heterosexual relations.", + "During physical examination, a small ulcer around his anus was found.", + "Additional tests for HIV, syphilis, gonorrhoea, and chlamydia trachomatis were ordered.", + "All tests were negative except for syphilis.", + "Due to risky sexual behaviour, the patient was offered pre-exposure prophylaxis.", + "The patient applied for further treatment of syphilis to the Clinic of Dermatology and Venereology in Warsaw." + ], + "summary": "In this case report, we present a 16-year-old Ukrainian boy with acute hepatitis B. He had not been previously vaccinated against hepatitis B. Possible sources of infection included: a tattoo made at home, a finger cut made with hairdresser scissors during work, and unprotected sexual encounters. The clinical course of the disease was typical with jaundice and elevated aminotransferases levels without liver failure. During the follow-up visit 16 months after the onset of the disease, chronic hepatitis b was excluded but an ulcer around his anus was found. Additional tests for sexually transmitted diseases were ordered and they were positive for syphilis. The extended interview revealed that the patient had several unprotected bisexual encounters, which may have indicated a potential source of infections including the hepatitis B virus (HBV).", + "summary_subclaims": [ + "The patient is a 16-year-old Ukrainian boy.", + "The patient had acute hepatitis B.", + "The patient had not been previously vaccinated against hepatitis B.", + "Possible sources of infection included a tattoo made at home.", + "Possible sources of infection included a finger cut made with hairdresser scissors during work.", + "Possible sources of infection included unprotected sexual encounters.", + "The clinical course of the disease was typical with jaundice.", + "The clinical course of the disease was typical with elevated aminotransferases levels.", + "There was no liver failure.", + "During the follow-up visit 16 months after the onset of the disease, chronic hepatitis B was excluded.", + "An ulcer around his anus was found.", + "Additional tests for sexually transmitted diseases were ordered.", + "The tests were positive for syphilis.", + "The extended interview revealed that the patient had several unprotected bisexual encounters.", + "The patient's unprotected bisexual encounters may have indicated a potential source of infections including the hepatitis B virus." + ] + }, + { + "id": "multiclinsum_test_1799_en.txt", + "fulltext": "A 23-year-old-woman was referred to our hospital for severe pain and decreased visual acuity started one day ago in the right eye. Two days prior to this, the patient had foldable iris-fixated pIOL (Artiflex; Ophtec BV, Groningen, the Netherlands) implanted in both eyes at an outside clinic. On postoperative day one, she had undergone anterior chamber (AC) irrigation to remove residual viscoelastics which caused intraocular pressure (IOP) spike in the right eye.On examination, uncorrected distant visual acuity (UDVA) was hand motion with IOP of 21 mmHg for the right eye. Biomicroscopy of the eye revealed severe conjunctival injection, corneal edema, corneal infiltration at superior main incision, membrane formation around the pIOL, and a deep AC with a 1.5 mm hypopyon, which were thought to represent infectious endophthalmitis (Figure A). Posterior segment evaluations such as vitreous cell grading and fundus examination were impossible because of severe corneal edema and AC inflammation. B-scan ultrasonography showed no definite vitreous involvement, and the left eye was normal.\nImmediate management involved AC irrigation, obtaining aqueous humor for culture and stain, and intravitreal vancomycin (1.0 mg/0.1 cc) and amikacin (0.4 mg/0.1 cc) injection. Gram and KOH stain smear revealed no bacteria or fungus. The patient was also treated with systemic (flomoxef 1.0 g every 12 hours) and topical (fortified vancomycin (50 mg/mL) and amikacin (20 mg/mL) hourly) antibiotics, prednisolone 1.0% four times daily, and homatropine 2% twice daily eye drops for a week, then the frequency was reduced according to the clinical response, culture, and sensitivity results. After 5 days of incubation, cultures became positive for Streptococcus mitis/oralis. By day 2 of admission, the patient did not improve so that AC irrigation, intracameral vancomycin (1.0 mg/0.1 cc) and amikacin (0.4 mg/0.1 cc) injection, and subtenon triamcinolone injection (40 mg/1.0 cc) were performed.\nAfter the second round of intervention, the patient began to improve clinically. On day 5, UDVA improved to 20/100, and biomicroscopy revealed moderate AC reaction without hypopyon and decreased inflammatory membrane behind the pIOL (Figures B, C). At 2 weeks, UDVA was 20/40 and IOP was 11 mmHg (Figure D). Endothelial cell density was measured at 3143cells/mm2. At 1 month, UDVA improved to 20/32, and biomicroscopy showed minimal AC reaction and corneal edema.", + "fulltext_subclaims": [ + "A 23-year-old woman was referred to the hospital for severe pain and decreased visual acuity in the right eye.", + "The patient had foldable iris-fixated pIOL (Artiflex; Ophtec BV, Groningen, the Netherlands) implanted in both eyes at an outside clinic.", + "On postoperative day one, she had undergone anterior chamber irrigation to remove residual viscoelastics.", + "Anterior chamber irrigation caused intraocular pressure spike in the right eye.", + "Uncorrected distant visual acuity was hand motion in the right eye.", + "Intraocular pressure was 21 mmHg in the right eye.", + "Biomicroscopy revealed severe conjunctival injection in the right eye.", + "Biomicroscopy revealed corneal edema in the right eye.", + "Biomicroscopy revealed corneal infiltration at the superior main incision in the right eye.", + "Biomicroscopy revealed membrane formation around the pIOL in the right eye.", + "Biomicroscopy revealed a deep anterior chamber with a 1.5 mm hypopyon in the right eye.", + "The findings were thought to represent infectious endophthalmitis.", + "Posterior segment evaluations were impossible due to severe corneal edema and anterior chamber inflammation.", + "B-scan ultrasonography showed no definite vitreous involvement.", + "The left eye was normal.", + "Immediate management involved anterior chamber irrigation.", + "Aqueous humor was obtained for culture and stain.", + "Intravitreal vancomycin (1.0 mg/0.1 cc) was injected.", + "Intravitreal amikacin (0.4 mg/0.1 cc) was injected.", + "Gram and KOH stain smear revealed no bacteria or fungus.", + "The patient was treated with systemic flomoxef 1.0 g every 12 hours.", + "The patient was treated with topical fortified vancomycin (50 mg/mL) hourly.", + "The patient was treated with topical amikacin (20 mg/mL) hourly.", + "The patient was treated with prednisolone 1.0% four times daily.", + "The patient was treated with homatropine 2% twice daily eye drops for a week.", + "After 5 days of incubation, cultures became positive for Streptococcus mitis/oralis.", + "By day 2 of admission, the patient did not improve.", + "A second round of anterior chamber irrigation was performed.", + "Intracameral vancomycin (1.0 mg/0.1 cc) was injected.", + "Intracameral amikacin (0.4 mg/0.1 cc) was injected.", + "Subtenon triamcinolone injection (40 mg/1.0 cc) was performed.", + "After the second round of intervention, the patient began to improve clinically.", + "On day 5, uncorrected distant visual acuity improved to 20/100.", + "Biomicroscopy revealed moderate anterior chamber reaction without hypopyon.", + "Biomicroscopy revealed decreased inflammatory membrane behind the pIOL.", + "At 2 weeks, uncorrected distant visual acuity was 20/40.", + "At 2 weeks, intraocular pressure was 11 mmHg.", + "Endothelial cell density was measured at 3143 cells/mm2.", + "At 1 month, uncorrected distant visual acuity improved to 20/32.", + "Biomicroscopy showed minimal anterior chamber reaction.", + "Biomicroscopy showed minimal corneal edema." + ], + "summary": "A 23-year-old-woman received pIOL implantation followed secondary intraocular intervention to lower intraocular pressure. The patient presented with severe pain and decreased visual acuity and was managed with intravitreal and intracameral antibiotic injection with topical applications of fortified antibiotics. Culture of aqueous humor was positive for S. mitis/oralis, which was sensitive to the empiric antibiotic regimen. Clinical features started to improve 5 days after treatment and the pIOL was left in place. The uncorrected distant visual acuity and endothelial cell count were 20/32 and 3143 cells/mm2 four weeks after treatment, respectively.", + "summary_subclaims": [ + "The patient received pIOL implantation.", + "The patient had secondary intraocular intervention to lower intraocular pressure.", + "The patient presented with severe pain.", + "The patient had decreased visual acuity.", + "The patient was managed with intravitreal and intracameral antibiotic injection.", + "The patient received topical applications of fortified antibiotics.", + "Culture of aqueous humor was positive for S. mitis/oralis.", + "The empiric antibiotic regimen was sensitive to S. mitis/oralis.", + "Clinical features started to improve 5 days after treatment.", + "The pIOL was left in place.", + "The uncorrected distant visual acuity was 20/32 four weeks after treatment.", + "The endothelial cell count was 3143 cells/mm2 four weeks after treatment." + ] + }, + { + "id": "multiclinsum_test_1073_en.txt", + "fulltext": "A 72-year-old man visited our hospital complaining of gross hematuria. There were no GI illnesses in his medical history. Cystoscopy revealed multiple bladder tumors. CT and MRI showed stage cT1N0M0 disease. The patient underwent transurethral resection of the bladder tumors. Complete resection of the bladder tumors was not achievable because of the extensive lesions. The pathological result was high-grade pT1 urothelial carcinoma. After pathological diagnosis, the patient was treated with two cycles of a gemcitabine and cisplatin regimen as neoadjuvant chemotherapy. The patient then underwent laparoscopic radical cystectomy with the creation of a U-shaped ileal neobladder and limited dissection of the lymph node. Pathological examination showed high-grade pT2 urothelial carcinoma with negative resection margins and pN0 (two lymph nodes). Recurrence evaluation after surgery was determined by FDG-PET-CT due to reduced renal function. Three months after surgery, FDG-PET-CT taken to evaluate the effect of initial postoperative treatment revealed a new appearance of abdominal lymph node metastasis . Due to reduced renal function, combination chemotherapy with gemcitabine and carboplatin was administrated. However, enlargement of lymph node metastases was identified on FDG-PET-CT after two cycles . The patient began treatment with pembrolizumab (200 mg/body administrated every 3 weeks) as second-line treatment. FDG-PET-CT after three cycles of pembrolizumab showed a marked response with the disappearance of FDG accumulation in all metastatic lesions .\nThe patient had no adverse effects, but after 10 months complained of anorexia and upper abdominal pain. EDG demonstrated diffusely erythematous and edematous gastric mucosa covered with a whitish, fibrin-like membrane . In addition, diffuse erosions were found in the gastric antrum .\nBiopsy specimens revealed inflammatory cell infiltration and apoptosis in the epithelium. High numbers of lymphocytes and plasma cells were observed infiltrating into the lamina propria . In addition, T cell infiltration and apoptotic bodies were observed in the gastric epithelium . Immunostaining identified these lymphocytes as CD3+ and CD8+ T-cells in the epithelium. No histological or immunohistochemical evidence of Helicobacter pylori or cytomegalovirus was apparent. However, the serum H. pylori antibody concentration was elevated (15 U/mL; normal <10 U/mL). The clinical and pathological findings were comparable with lymphocytic gastritis induced by pembrolizumab. The patient received eradication therapy combined with the administration of a PPI, amoxicillin, and clarithromycin for 1 week. Eradication therapy and cessation of pembrolizumab led to improvement of clinical symptoms and findings on EDG without steroid therapy in 4 months . The patient has since resumed and continued pembrolizumab administration while maintaining CR for 28 months to date.", + "fulltext_subclaims": [ + "The patient was a 72-year-old man.", + "The patient visited the hospital complaining of gross hematuria.", + "There were no GI illnesses in his medical history.", + "Cystoscopy revealed multiple bladder tumors.", + "CT and MRI showed stage cT1N0M0 disease.", + "The patient underwent transurethral resection of the bladder tumors.", + "Complete resection of the bladder tumors was not achievable because of the extensive lesions.", + "The pathological result was high-grade pT1 urothelial carcinoma.", + "After pathological diagnosis, the patient was treated with two cycles of a gemcitabine and cisplatin regimen as neoadjuvant chemotherapy.", + "The patient then underwent laparoscopic radical cystectomy with the creation of a U-shaped ileal neobladder and limited dissection of the lymph node.", + "Pathological examination showed high-grade pT2 urothelial carcinoma with negative resection margins and pN0 (two lymph nodes).", + "Recurrence evaluation after surgery was determined by FDG-PET-CT due to reduced renal function.", + "Three months after surgery, FDG-PET-CT taken to evaluate the effect of initial postoperative treatment revealed a new appearance of abdominal lymph node metastasis.", + "Due to reduced renal function, combination chemotherapy with gemcitabine and carboplatin was administered.", + "Enlargement of lymph node metastases was identified on FDG-PET-CT after two cycles.", + "The patient began treatment with pembrolizumab (200 mg/body administered every 3 weeks) as second-line treatment.", + "FDG-PET-CT after three cycles of pembrolizumab showed a marked response with the disappearance of FDG accumulation in all metastatic lesions.", + "The patient had no adverse effects.", + "After 10 months, the patient complained of anorexia and upper abdominal pain.", + "EDG demonstrated diffusely erythematous and edematous gastric mucosa covered with a whitish, fibrin-like membrane.", + "Diffuse erosions were found in the gastric antrum.", + "Biopsy specimens revealed inflammatory cell infiltration and apoptosis in the epithelium.", + "High numbers of lymphocytes and plasma cells were observed infiltrating into the lamina propria.", + "T cell infiltration and apoptotic bodies were observed in the gastric epithelium.", + "Immunostaining identified these lymphocytes as CD3+ and CD8+ T-cells in the epithelium.", + "No histological or immunohistochemical evidence of Helicobacter pylori or cytomegalovirus was apparent.", + "The serum H. pylori antibody concentration was elevated (15 U/mL; normal <10 U/mL).", + "The clinical and pathological findings were comparable with lymphocytic gastritis induced by pembrolizumab.", + "The patient received eradication therapy combined with the administration of a PPI, amoxicillin, and clarithromycin for 1 week.", + "Eradication therapy and cessation of pembrolizumab led to improvement of clinical symptoms and findings on EDG without steroid therapy in 4 months.", + "The patient has since resumed and continued pembrolizumab administration while maintaining CR for 28 months to date." + ], + "summary": "A 72-year-old man underwent laparoscopic radical cystectomy for muscle-invasive bladder cancer (pT2N0M0). Multiple lymph node metastases appeared in the paraaortic region. First-line chemotherapy comprising gemcitabine and carboplatin failed to stop disease progression. After the administration of pembrolizumab as second-line treatment, the patient showed symptomatic gastroesophageal reflux disease. Esophagogastroduodenoscopic biopsy of the gastric body showed severe lymphoplasmacytic and neutrophilic infiltration.", + "summary_subclaims": [ + "The patient is a 72-year-old man.", + "The patient underwent laparoscopic radical cystectomy.", + "The cystectomy was performed for muscle-invasive bladder cancer.", + "The tumor stage was pT2N0M0.", + "Multiple lymph node metastases appeared in the paraaortic region.", + "First-line chemotherapy comprising gemcitabine and carboplatin failed to stop disease progression.", + "Pembrolizumab was administered as second-line treatment.", + "The patient showed symptomatic gastroesophageal reflux disease.", + "Esophagogastroduodenoscopic biopsy of the gastric body showed severe lymphoplasmacytic and neutrophilic infiltration." + ] + }, + { + "id": "multiclinsum_test_1019_en.txt", + "fulltext": "A 57-year-old female presented with vision loss in the left eye during the restoration of consciousness after endoscopic DCR surgery for the left eye. In this case, the DCR surgery was performed under general anesthesia. Notably, 2 ml of 1% lidocaine with 1:100,000 epinephrine was injected into the axilla of the middle turbinate and the frontal process of the maxilla using a dental syringe. In this case, the neurosurgical patties soaked in 2 ml of 1:1000 epinephrine were inserted between the inferior turbinate and the nasal septum and in the middle meatus to achieve topical decongestion. In the process of making mucosal flap and incision, the patient had a higher bleeding tendency than was noted with other patients, and a suction diathermy was used meticulously for the incidence of hemostasis. For this reason, it did not lead to a major bleeding in this case.\nThe patient’s medical history was notable for thrombocytopenia and MHA. Upon review, the patient denied temporal headache, pain, or flashes. When tested, the patient’s best-corrected visual acuity (BCVA) was 20/20 in the right eye and light perception in the left eye. Her intraocular pressure (IOP) was 14 mmHg in the right eye and 16 mmHg in the left eye. Her visual field test result was normal for the right eye. However, the test could not be conducted for the left eye due to the incidence of poor vision. When tested with the swinging flashlight maneuver, a relative afferent pupillary defect was found in the left eye of the patient. Her extraocular movements were noted as being full and painless. However, mild periorbital bruising and swelling were detected in the left eye. Additionally, there was mild maxillary sinusitis noted as well. However, it was shown there was no underlying disease in the other sinuses. On the funduscopic examination, there were no obvious abnormal findings in the macula of either eye. The use of a fluorescent angiography did not reveal leakage or a filling defect at the disc. The baseline testing included blood tests to evaluate syphilis, systemic lupus erythematosus, and neuromyelitis optica. Her erythrocyte sedimentation rate and C-reactive protein results were noted as normal. Her pre-operative platelet count was 61 × 103/mm3. A chest x-ray was performed to evaluate sarcoidosis. She was transfused with six units of platelets preoperatively, which increased her platelet count to 123 × 103/mm3. No other cause of optic neuropathy was found in this evaluation.\nThe pattern visual evoked potential revealed delayed P100 latency . Her electroretinogram showed normal electrical activity in the retina. The magnetic resonance imaging (MRI) of the orbit revealed a focal hyperintensity within the intra-orbital segment of the left optic nerve on the T2-weighted image (T2-WI) and flair image. At evaluation, the MRI showed an enhancement on the T1 post-contrast imaging . It did not show any demyelinating disease in the brain. The patient was diagnosed with left optic neuropathy and treated with 1 g/day of intravenous methylprednisolone for 3 days, followed by 1 mg/kg/day of oral prednisone with subsequent dose tapering. It is noted that the patient’s BCVA improved to 20/30 after the treatment. Although her vision improved, she was left with a visual field defect in the left eye.", + "fulltext_subclaims": [ + "A 57-year-old female presented with vision loss in the left eye during the restoration of consciousness after endoscopic DCR surgery for the left eye.", + "The DCR surgery was performed under general anesthesia.", + "2 ml of 1% lidocaine with 1:100,000 epinephrine was injected into the axilla of the middle turbinate and the frontal process of the maxilla using a dental syringe.", + "Neurosurgical patties soaked in 2 ml of 1:1000 epinephrine were inserted between the inferior turbinate and the nasal septum and in the middle meatus.", + "The patient had a higher bleeding tendency than was noted with other patients.", + "A suction diathermy was used meticulously for the incidence of hemostasis.", + "It did not lead to a major bleeding in this case.", + "The patient’s medical history was notable for thrombocytopenia and MHA.", + "The patient denied temporal headache, pain, or flashes.", + "The patient’s best-corrected visual acuity (BCVA) was 20/20 in the right eye and light perception in the left eye.", + "Her intraocular pressure (IOP) was 14 mmHg in the right eye and 16 mmHg in the left eye.", + "The test could not be conducted for the left eye due to the incidence of poor vision.", + "A relative afferent pupillary defect was found in the left eye of the patient.", + "Mild periorbital bruising and swelling were detected in the left eye.", + "There was mild maxillary sinusitis noted.", + "There was no underlying disease in the other sinuses.", + "On the funduscopic examination, there were no obvious abnormal findings in the macula of either eye.", + "The use of a fluorescent angiography did not reveal leakage or a filling defect at the disc.", + "Baseline testing included blood tests to evaluate syphilis, systemic lupus erythematosus, and neuromyelitis optica.", + "Her erythrocyte sedimentation rate and C-reactive protein results were noted as normal.", + "Her pre-operative platelet count was 61 × 103/mm3.", + "A chest x-ray was performed to evaluate sarcoidosis.", + "She was transfused with six units of platelets preoperatively, which increased her platelet count to 123 × 103/mm3.", + "The pattern visual evoked potential revealed delayed P100 latency.", + "The electroretinogram showed normal electrical activity in the retina.", + "The MRI of the orbit revealed a focal hyperintensity within the intra-orbital segment of the left optic nerve on the T2-weighted image and flair image.", + "The MRI showed an enhancement on the T1 post-contrast imaging.", + "It did not show any demyelinating disease in the brain.", + "The patient was diagnosed with left optic neuropathy.", + "The patient was treated with 1 g/day of intravenous methylprednisolone for 3 days, followed by 1 mg/kg/day of oral prednisone with subsequent dose tapering.", + "The patient’s BCVA improved to 20/30 after the treatment.", + "Although her vision improved, she was left with a visual field defect in the left eye." + ], + "summary": "The patient was presented with sudden onset of vision loss for the left eye after DCR under general anesthesia. Her best corrected visual acuity was light perception in the left eye. Relative afferent pupillary defect was detected in her left eye. Magnetic resonance imaging of the orbit revealed an hyperintensity at the intra-orbital segment of the left optic nerve on T2-weighted image and Flair image. The patient was diagnosed with acute postoperative optic neuropathy and treated with methylprednisolone. Although her vision partially improved, she was left with a visual field defect in the left eye.", + "summary_subclaims": [ + "The patient was presented with sudden onset of vision loss for the left eye after DCR under general anesthesia.", + "Her best corrected visual acuity was light perception in the left eye.", + "Relative afferent pupillary defect was detected in her left eye.", + "Magnetic resonance imaging of the orbit revealed an hyperintensity at the intra-orbital segment of the left optic nerve on T2-weighted image.", + "Magnetic resonance imaging of the orbit revealed an hyperintensity at the intra-orbital segment of the left optic nerve on Flair image.", + "The patient was diagnosed with acute postoperative optic neuropathy.", + "The patient was treated with methylprednisolone.", + "Her vision partially improved.", + "She was left with a visual field defect in the left eye." + ] + }, + { + "id": "multiclinsum_test_373_en.txt", + "fulltext": "In 2018, a 68-year-old woman was referred to our hospital for surgery for a right inguinal hernia. Preoperative computed tomography (CT) revealed an asymptomatic mass 43 mm in size in the presacral space. Her medical history included Sjogren's syndrome, renal tubular acidosis, and Hashimoto's disease. Although the details were unknown, she had an allergy to intravascular contrast agents. None of her family had a clear history of cancer. Hematological examination showed no elevations in tumor markers or inflammation. No abnormality was observed on upper and lower gastrointestinal endoscopy. CT revealed a 43 mm-sized mass with clear calcification on the ventral side of S3 . Magnetic resonance imaging revealed a multilocular 43 mm-sized mass with well-defined lobules and septa at the same site, which was observed as slightly high signal intensity on T1 and T2 images, high signal intensity on diffusion-weighted images, and low signal intensity on the apparent diffusion coefficient map. Sacral invasion by the tumor was not observed on imaging . 18F-fluorodeoxyglucose positron emission tomography/CT showed strong accumulation with a maximum standardized uptake value of 10.3 in the tumor . Thus, we suspected a malignant tumor in the presacral space, such as a malignant schwannoma, metastatic malignant tumor, extragastrointestinal stromal tumor, solitary fibrous tumor, and malignant transformation of a teratoma or tailgut cyst.\nWe performed laparoscopic surgery to obtain a definitive diagnosis. After administering general anesthesia, the patient was placed in the lithotomy position and underwent laparoscopic surgery using 5 ports. As in rectal surgery, the retroperitoneum was dissected caudally from the promontrium using a medial approach, and the rectal mesentery was dissected. After mesenteric mobilization, a well-defined mass was observed in the presacral space . The rectum was completely divided from the tumor, and the rectum and uterus were suspended to obtain a good visual field. The tumor located dorsal side of pre-hypogastric nerve facia and did not show clear communication with the hypogastric nerve and pelvic nerve plexus. The main feeding vessels of the tumor were the branch of the median sacral vein and some branches of the superior rectal artery. The tumor was rolled using gauze to prevent capsular injury and then detached. The inflowing blood vessel was carefully sealed using laparoscopic coagulation shears. The dorsal detachment in contact with the front of the sacrum, where bleeding was expected, was performed last . The tumor was resected en bloc without exposure . Although a small amount of bleeding was observed in the anterior sacrum, hemostasis was achieved by compression and cauterization, using gauzes, an absorbable haemostats, a coagulation and spray mode of the electrocautery and an argon beam coagulator. The operation time was 296 min, and the blood loss volume was 314 mL. The postoperative course was uneventful, and the patient was discharged on the 7th postoperative day. The patient is currently undergoing outpatient follow-up for 1 year after the surgery, with no recurrence.\nThe macroscopic findings of the resected specimen were covered with a fibrous capsule and had a well-defined mass. The cut surface was a gray-white solid component, and a small cyst was found in the periphery . Histopathologically, the tumor was composed of relatively uniform cells with fine chromatin, with round to oval nuclei arranged in solid, trabecular, or rosette-like growth patterns. On immunostaining, the tumor cells tested diffusely positive for synaptophysin and cluster of differentiation-56, somatostatin receptor subtype 2a (SSTR2a) and pancreatic polypeptide, and focally positive for progesterone receptor. No positivity for Chromogranin A, p53, estrogen receptor, gastrin, serotonin, somatostatin, CDX2 and TTF1 was observed. The Ki-67 (MIB-1) labeling index was less than 2%. Thus, she was diagnosed with a NET (Grade 1). The cysts found in the periphery were lined with stratified squamous epithelium and contained flocculent eosinophilic material with focal calcification, which was considered to be necrotic tissue. Multiple small cysts were found within the solid component and lined with columnar epithelium . No components other than those derived from the ectoderm were found in the tumor. The presence of cysts lined by multiple epithelia was consistent with the characteristics of tailgut cysts, and it was considered that the NET originated from tailgut cysts and replaced almost all of them.", + "fulltext_subclaims": [ + "In 2018, a 68-year-old woman was referred to our hospital for surgery for a right inguinal hernia.", + "Preoperative computed tomography (CT) revealed an asymptomatic mass 43 mm in size in the presacral space.", + "Her medical history included Sjogren's syndrome, renal tubular acidosis, and Hashimoto's disease.", + "She had an allergy to intravascular contrast agents.", + "None of her family had a clear history of cancer.", + "Hematological examination showed no elevations in tumor markers or inflammation.", + "No abnormality was observed on upper and lower gastrointestinal endoscopy.", + "CT revealed a 43 mm-sized mass with clear calcification on the ventral side of S3.", + "Magnetic resonance imaging revealed a multilocular 43 mm-sized mass with well-defined lobules and septa at the same site.", + "The mass was observed as slightly high signal intensity on T1 and T2 images.", + "The mass was observed as high signal intensity on diffusion-weighted images.", + "The mass was observed as low signal intensity on the apparent diffusion coefficient map.", + "Sacral invasion by the tumor was not observed on imaging.", + "18F-fluorodeoxyglucose positron emission tomography/CT showed strong accumulation with a maximum standardized uptake value of 10.3 in the tumor.", + "We suspected a malignant tumor in the presacral space, such as a malignant schwannoma, metastatic malignant tumor, extragastrointestinal stromal tumor, solitary fibrous tumor, and malignant transformation of a teratoma or tailgut cyst.", + "We performed laparoscopic surgery to obtain a definitive diagnosis.", + "The patient was placed in the lithotomy position and underwent laparoscopic surgery using 5 ports.", + "A well-defined mass was observed in the presacral space.", + "The tumor was located dorsal side of pre-hypogastric nerve facia and did not show clear communication with the hypogastric nerve and pelvic nerve plexus.", + "The main feeding vessels of the tumor were the branch of the median sacral vein and some branches of the superior rectal artery.", + "The tumor was rolled using gauze to prevent capsular injury and then detached.", + "The inflowing blood vessel was carefully sealed using laparoscopic coagulation shears.", + "The dorsal detachment in contact with the front of the sacrum, where bleeding was expected, was performed last.", + "The tumor was resected en bloc without exposure.", + "The operation time was 296 min.", + "The blood loss volume was 314 mL.", + "The postoperative course was uneventful, and the patient was discharged on the 7th postoperative day.", + "The patient is currently undergoing outpatient follow-up for 1 year after the surgery.", + "The patient has no recurrence.", + "The macroscopic findings of the resected specimen were covered with a fibrous capsule and had a well-defined mass.", + "The cut surface was a gray-white solid component, and a small cyst was found in the periphery.", + "The tumor was composed of relatively uniform cells with fine chromatin, with round to oval nuclei arranged in solid, trabecular, or rosette-like growth patterns.", + "The tumor cells tested diffusely positive for synaptophysin and cluster of differentiation-56, somatostatin receptor subtype 2a (SSTR2a) and pancreatic polypeptide.", + "The tumor cells tested focally positive for progesterone receptor.", + "No positivity for Chromogranin A, p53, estrogen receptor, gastrin, serotonin, somatostatin, CDX2 and TTF1 was observed.", + "The Ki-67 (MIB-1) labeling index was less than 2%.", + "She was diagnosed with a NET (Grade 1).", + "The cysts found in the periphery were lined with stratified squamous epithelium and contained flocculent eosinophilic material with focal calcification, which was considered to be necrotic tissue.", + "Multiple small cysts were found within the solid component and lined with columnar epithelium.", + "No components other than those derived from the ectoderm were found in the tumor.", + "The presence of cysts lined by multiple epithelia was consistent with the characteristics of tailgut cysts.", + "It was considered that the NET originated from tailgut cysts and replaced almost all of them." + ], + "summary": "A 68-year-old woman was referred to our hospital for surgery of a right inguinal hernia, but preoperative computed tomography revealed an asymptomatic 43-mm mass in the presacral space. Magnetic resonance imaging showed a multilocular solid mass with clear boundaries and a slightly high signal intensity on T1- and T2-weighted images. Positron emission tomography showed 18F-fluorodeoxyglucose uptake. Thus, we suspected a malignant tumor and performed laparoscopic resection to obtain a definitive diagnosis. Macroscopically, the tumor was 43 mm in size with clear boundaries, and the cut surface was a gray-white solid component. Histopathological findings revealed that the tumor was composed of relatively uniform cells with fine chromatin, with round to oval nuclei arranged in solid, trabecular, or rosette-like growth patterns. Small cysts lined with stratified squamous epithelium and columnar epithelium were observed along with solid components of the tumor, which is a feature of tailgut cysts. Therefore, the final diagnosis was NET Grade 1 arising from tailgut cysts. No recurrence was observed within 1 year after surgery.", + "summary_subclaims": [ + "The patient was a 68-year-old woman.", + "She was referred to the hospital for surgery of a right inguinal hernia.", + "Preoperative computed tomography revealed an asymptomatic 43-mm mass in the presacral space.", + "Magnetic resonance imaging showed a multilocular solid mass with clear boundaries.", + "The mass had a slightly high signal intensity on T1- and T2-weighted images.", + "Positron emission tomography showed 18F-fluorodeoxyglucose uptake.", + "The tumor was suspected to be malignant.", + "Laparoscopic resection was performed to obtain a definitive diagnosis.", + "Macroscopically, the tumor was 43 mm in size with clear boundaries.", + "The cut surface was a gray-white solid component.", + "Histopathological findings revealed relatively uniform cells with fine chromatin.", + "The nuclei were round to oval and arranged in solid, trabecular, or rosette-like growth patterns.", + "Small cysts lined with stratified squamous epithelium and columnar epithelium were observed.", + "These cysts were found along with solid components of the tumor.", + "This finding is a feature of tailgut cysts.", + "The final diagnosis was NET Grade 1 arising from tailgut cysts.", + "No recurrence was observed within 1 year after surgery." + ] + }, + { + "id": "multiclinsum_test_3254_en.txt", + "fulltext": "A 31-year-old male presented to the emergency department (ED) with an acute onset of left-sided weakness including upper and lower extremities, which began approximately one hour prior, following a fall while seated. The patient reported a frontal headache and slurred speech, along with non-radiating, burning epigastric pain.\n\nThe patient had an unremarkable medical history, aside from recurrent episodes of left flank pain previously treated as renal colic at a urology clinic. For this, he had been prescribed a non-steroidal anti-inflammatory drug, his only medication. The patient also reported a smoking history of 18 pack-years but denied any alcohol or substance abuse.\n\nThe patient was conscious, alert, and oriented to time, place, and person, with hemodynamically stable and an oxygen saturation of 98% on room air. Neurologic examination showed non-fluent speech with intact comprehension and repetition. Sensation was preserved bilaterally; however, there was a marked reduction in power on the left side, with both upper and lower limbs scoring 1/5, and a muted Babinski sign on the left compared to the normal response on the right. Cranial nerve function was intact.\n\nInitial laboratory results in the ED revealed elevated cardiac enzymes and normocytic anemia, with a hemoglobin level of 7 g/dl, a high reticulocyte count, and a low platelet count. Coagulation studies showed an elevated activated partial thromboplastin time (aPTT) with normal prothrombin time (PT) and international normalized ratio (INR). Evidence of intrarenal injury was noted, with a blood urea nitrogen (BUN) to creatinine ratio of 17:1. Additional findings included indirect hyperbilirubinemia, elevated inflammatory markers (C-reactive protein and erythrocyte sedimentation rate), normal serum electrolytes, and normal haptoglobin. The patient’s baseline creatinine was 0.7 mg/dl. Urinalysis showed + 2 proteinuria and + 3 hematuria.\n\nDiagnostic investigations included an electrocardiogram (ECG) that showed sinus rhythm with prolonged PR interval and diffuse ST-segment elevation, suggestive of myopericarditis. The echocardiogram revealed a Left ventricular ejection fraction of 60% and bi-atrial dilation. Cardiac catheterization showed non-obstructive coronary artery disease, indicating microvascular thrombosis. A CT scan showed a large acute nonhemorrhagic infarction in the right fronto-parietal–temporal lobes, along with multiple lacunar infarctions, confirmed by magnetic resonance imaging (MRI). Magnetic resonance angiography (MRA) revealed total occlusion of the middle cerebral artery.\n\nThe patient was admitted to the intensive care unit (ICU), where additional laboratory investigations revealed schistocytes on blood smear, positive direct and indirect Coomb’s test, increased ferritin, and a negative rheumatoid factor. Complement component C3 was decreased, and LAC was positive (ratio: 1.74). aCL was positive (26 IU/ml), while IgA and IgM β2GP1 antibodies were negative. Anti-nuclear antibodies (titer: 1:86) and anti-dsDNA antibodies (95.4 IU/ml) were also positive.\n\nThe patient received three units of packed red blood cells; two units were administered after the patient remained anemic following the first unit. The patient’s condition dramatically improved after initiating treatment with Methylprednisolone, Hydroxychloroquine, Colchicine, and Rituximab.\n\nOver the following 10 days, the patient exhibited further improvement with significant progress observed in both physical exam and laboratory results. An ECG demonstrated regular sinus rhythm with no ST-segment elevation, but T wave inversion was noted in lead aVL. On the 12th day, the patient was discharged in stable condition with residual left-side weakness (1/5 in the upper limbs and 3/5 in the lower limbs) and normal strength on the right side. An ECG showed regular sinus rhythm with negative T waves in the anterior and inferior leads. An echocardiogram revealed normal findings, including a left atrial size of 20 mm (within the normal range of 20–40 mm).\n\nAt his last follow-up visit, 10 weeks after discharge, the patient remained stable and showed improvements in the strength of his left upper lower limb, which were 4/5 and 3/5, respectively. He continued to use crutches to assist with mobility while undergoing physiotherapy.\n\nThirteen weeks after discharge, the patient visited the rheumatology clinic, where the diagnosis of APS was confirmed through repeat laboratory tests. The results showed positive LAC (ratio: 1.85), as well as positive IgG aCL (46 IU/ml), IgM aCL (22 IU/ml), IgG aβ2GP1 (46 U/ml), IgA aβ2GP1 (39 U/ml), and IgM aβ2GP1 (35 U/ml) antibodies.", + "fulltext_subclaims": [ + "A 31-year-old male presented to the emergency department with an acute onset of left-sided weakness including upper and lower extremities.", + "The left-sided weakness began approximately one hour prior.", + "The patient reported a frontal headache.", + "The patient reported slurred speech.", + "The patient reported non-radiating, burning epigastric pain.", + "The patient had an unremarkable medical history aside from recurrent episodes of left flank pain previously treated as renal colic.", + "The patient had been prescribed a non-steroidal anti-inflammatory drug for the left flank pain.", + "The patient had a smoking history of 18 pack-years.", + "The patient was conscious, alert, and oriented to time, place, and person.", + "The patient was hemodynamically stable.", + "The patient's oxygen saturation was 98% on room air.", + "Neurologic examination showed non-fluent speech with intact comprehension and repetition.", + "There was a marked reduction in power on the left side, with both upper and lower limbs scoring 1/5.", + "The Babinski sign was muted on the left compared to the normal response on the right.", + "Cranial nerve function was intact.", + "Initial laboratory results in the ED revealed elevated cardiac enzymes.", + "Initial laboratory results in the ED revealed normocytic anemia.", + "The patient's hemoglobin level was 7 g/dl.", + "The patient had a high reticulocyte count.", + "The patient had a low platelet count.", + "Coagulation studies showed an elevated activated partial thromboplastin time.", + "Coagulation studies showed normal prothrombin time.", + "Coagulation studies showed normal international normalized ratio.", + "Evidence of intrarenal injury was noted, with a blood urea nitrogen to creatinine ratio of 17:1.", + "Additional findings included indirect hyperbilirubinemia.", + "Additional findings included elevated inflammatory markers.", + "The patient’s baseline creatinine was 0.7 mg/dl.", + "Urinalysis showed +2 proteinuria.", + "Urinalysis showed +3 hematuria.", + "The ECG showed sinus rhythm with prolonged PR interval.", + "The ECG showed diffuse ST-segment elevation.", + "The ECG findings were suggestive of myopericarditis.", + "The echocardiogram revealed a left ventricular ejection fraction of 60%.", + "The echocardiogram revealed bi-atrial dilation.", + "Cardiac catheterization showed non-obstructive coronary artery disease.", + "Cardiac catheterization findings indicated microvascular thrombosis.", + "A CT scan showed a large acute nonhemorrhagic infarction in the right fronto-parietal–temporal lobes.", + "Multiple lacunar infarctions were confirmed by magnetic resonance imaging.", + "Magnetic resonance angiography revealed total occlusion of the middle cerebral artery.", + "The patient was admitted to the intensive care unit.", + "Additional laboratory investigations revealed schistocytes on blood smear.", + "The direct Coomb’s test was positive.", + "The indirect Coomb’s test was positive.", + "The patient had increased ferritin.", + "The patient had a negative rheumatoid factor.", + "Complement component C3 was decreased.", + "LAC was positive with a ratio of 1.74.", + "aCL was positive with a value of 26 IU/ml.", + "IgA and IgM β2GP1 antibodies were negative.", + "Anti-nuclear antibodies were positive with a titer of 1:86.", + "Anti-dsDNA antibodies were positive with a value of 95.4 IU/ml.", + "The patient received three units of packed red blood cells.", + "Two units were administered after the patient remained anemic following the first unit.", + "The patient’s condition dramatically improved after initiating treatment with Methylprednisolone, Hydroxychloroquine, Colchicine, and Rituximab.", + "Over the following 10 days, the patient exhibited further improvement with significant progress observed in both physical exam and laboratory results.", + "An ECG demonstrated regular sinus rhythm with no ST-segment elevation.", + "T wave inversion was noted in lead aVL.", + "On the 12th day, the patient was discharged in stable condition.", + "The patient had residual left-side weakness (1/5 in the upper limbs and 3/5 in the lower limbs).", + "The patient had normal strength on the right side.", + "An ECG showed regular sinus rhythm with negative T waves in the anterior and inferior leads.", + "An echocardiogram revealed normal findings.", + "The left atrial size was 20 mm.", + "The normal range for left atrial size is 20–40 mm.", + "At his last follow-up visit, 10 weeks after discharge, the patient remained stable.", + "The patient showed improvements in the strength of his left upper limb to 4/5.", + "The patient showed improvements in the strength of his left lower limb to 3/5.", + "The patient continued to use crutches to assist with mobility.", + "The patient was undergoing physiotherapy.", + "Thirteen weeks after discharge, the patient visited the rheumatology clinic.", + "The diagnosis of APS was confirmed through repeat laboratory tests.", + "Repeat tests showed positive LAC with a ratio of 1.85.", + "Repeat tests showed positive IgG aCL with a value of 46 IU/ml.", + "Repeat tests showed positive IgM aCL with a value of 22 IU/ml.", + "Repeat tests showed positive IgG aβ2GP1 with a value of 46 U/ml.", + "Repeat tests showed positive IgA aβ2GP1 with a value of 39 U/ml.", + "Repeat tests showed positive IgM aβ2GP1 with a value of 35 U/ml." + ], + "summary": "A 31-year-old male patient with unremarkable medical history presented with a sudden onset of left-sided body weakness including upper and lower extremities, frontal headache, and slurred speech. Diagnostic workup revealed diffuse ST elevation with elevated cardiac enzymes, elevated inflammatory markers, prolonged activated partial thromboplastin time (aPTT), hemolytic anemia, and intrarenal kidney injury. Further investigations confirmed the diagnosis of probable CAPS secondary to SLE, based on the simultaneous involvement of the brain, heart, and kidneys, along with the presence of positive antiphospholipid antibodies (aPL). The patient showed significant improvement in neurological functioning after treatment with Methylprednisolone, Hydroxychloroquine, Colchicine, and Rituximab.", + "summary_subclaims": [ + "The patient is a 31-year-old male.", + "The patient had unremarkable medical history.", + "The patient presented with sudden onset of left-sided body weakness.", + "The patient had frontal headache.", + "The patient had slurred speech.", + "Diagnostic workup revealed diffuse ST elevation.", + "Diagnostic workup revealed elevated cardiac enzymes.", + "Diagnostic workup revealed elevated inflammatory markers.", + "Diagnostic workup revealed prolonged activated partial thromboplastin time (aPTT).", + "Diagnostic workup revealed hemolytic anemia.", + "Diagnostic workup revealed intrarenal kidney injury.", + "Further investigations confirmed the diagnosis of probable CAPS secondary to SLE.", + "The diagnosis was based on the simultaneous involvement of the brain, heart, and kidneys.", + "The diagnosis was based on the presence of positive antiphospholipid antibodies (aPL).", + "The patient showed significant improvement in neurological functioning.", + "The patient was treated with Methylprednisolone.", + "The patient was treated with Hydroxychloroquine.", + "The patient was treated with Colchicine.", + "The patient was treated with Rituximab." + ] + }, + { + "id": "multiclinsum_test_2402_en.txt", + "fulltext": "A 60-year-old Caucasian male from Austria presented with dyspnoea, intermitted claudication and fatigue. In the last 2 months he noticed an unvoluntary weight loss of 15 kg. Physical examination showed an indolent resistance on the right flank. Blood sample in a peripheral vein showed results within normal ranges (haemoglobin 13.1 g/dl, white blood cell count 6.7 G/l; polymorphonuclear cells 63.5%, lymphocytes 13.5%, monocytes 9.0%, eosinophils 13.0%, basophils 0.5%, platelet count 158 G/l; serum creatinine 1.16 mg/dl), whereas urinary analysis showed microhaematuria and proteinuria.\nAn ultrasound (US) examination (Acuson Sequoia, California, USA) of the abdomen and pelvis showed a large and hypoechoic retroperitoneal mass surrounding the right kidney with extension into the right renal hilum and no evidence of urinary obstruction. The contralateral kidney appeared to be normal.\nA 4-row helical CT examination (4 Volume Zoom, Siemens, Erlangen, Germany) of the whole body with a standard examination protocol showed a retroperitoneal mass (with 14.8 × 11.5 cm size) from the right kidney and infiltrating Gerota’s fascia (see ). Lymphadenopathy was detected in the lower part of mediastinum and in the retroperitoneal space with borderline size values. Beside infitrative destruction of the flanking right rip no further infiltration of other organs or metastasis was found. The volume of liver and spleen was within normal range.\nScintigraphically, a radioisotope Tc-99m bone scan showed no suspicious lesions.\nUS guided percutaneous biopsy of the retroperitoneal mass was performed under local anaesthesia. Immunohistochemical stains were positive for bcl-2, bcl-6, CD10, CD20 and negative for CD 5, CD23, Cyklin D1. The histological diagnosis was a grad 2 low proliferating follicular non-Hodgkin lymphoma (NHL). Chemotherapy was started according to the CHOP scheme. The tumor responded well to the chemotherapy and about 70% of regression was achieved after six courses of chemotherapy. Thereafter a nephrectomy with complete lymph node dissection and dissection of the retroperitoneal mass has been performed. Final diagnosis was a primary renal non-Hodgkin lymphoma (NHL).", + "fulltext_subclaims": [ + "The patient is a 60-year-old Caucasian male from Austria.", + "The patient reported dyspnoea, intermitted claudication, and fatigue.", + "The patient had an involuntary weight loss of 15 kg in the last 2 months.", + "Physical examination showed an indolent resistance on the right flank.", + "Blood sample results were within normal ranges.", + "Urinary analysis showed microhaematuria and proteinuria.", + "An ultrasound examination showed a large and hypoechoic retroperitoneal mass surrounding the right kidney.", + "The ultrasound showed extension of the mass into the right renal hilum.", + "The ultrasound showed no evidence of urinary obstruction.", + "The contralateral kidney appeared to be normal.", + "A 4-row helical CT examination showed a retroperitoneal mass with 14.8 × 11.5 cm size.", + "The CT showed infiltration of Gerota’s fascia.", + "Lymphadenopathy was detected in the lower part of the mediastinum.", + "Lymphadenopathy was detected in the retroperitoneal space.", + "The CT showed no further infiltration of other organs or metastasis.", + "The volume of liver and spleen was within normal range.", + "A radioisotope Tc-99m bone scan showed no suspicious lesions.", + "US guided percutaneous biopsy of the retroperitoneal mass was performed.", + "Immunohistochemical stains were positive for bcl-2, bcl-6, CD10, CD20.", + "Immunohistochemical stains were negative for CD 5, CD23, Cyklin D1.", + "The histological diagnosis was a grad 2 low proliferating follicular non-Hodgkin lymphoma.", + "Chemotherapy was started according to the CHOP scheme.", + "The tumor responded well to the chemotherapy.", + "About 70% of regression was achieved after six courses of chemotherapy.", + "A nephrectomy with complete lymph node dissection was performed.", + "Dissection of the retroperitoneal mass was performed.", + "The final diagnosis was a primary renal non-Hodgkin lymphoma." + ], + "summary": "We report a case in a 60-year-old man. Computed tomography revealed a large, homogeneous, retroperitoneal mass with 14.8 x 11.5 cm size arising from the right kidney. An ultrasound guided percutaneous biopsy was performed and the tumour was diagnosed histopathological as non-Hodgkin lymphoma. The patient was treated by systemic chemotherapy and thereafter a nephrectomy was performed.", + "summary_subclaims": [ + "The patient is a 60-year-old man.", + "Computed tomography revealed a large, homogeneous, retroperitoneal mass.", + "The mass measured 14.8 x 11.5 cm.", + "The mass arose from the right kidney.", + "An ultrasound guided percutaneous biopsy was performed.", + "The tumour was diagnosed histopathologically as non-Hodgkin lymphoma.", + "The patient was treated by systemic chemotherapy.", + "A nephrectomy was performed after chemotherapy." + ] + }, + { + "id": "multiclinsum_test_63_en.txt", + "fulltext": "An 18-month-old boy was referred to our center for the first time because of fever, lethargy, repeated seizures, and vomiting since two days ago. During hospitalization, he experienced three focal clonic seizures affecting the right side of his body with orofacial automatism. Seizures were ultimately controlled with phenytoin, phenobarbital, and levetiracetam, followed by clonazepam.\nThe infant had no nuchal rigidity on physical examinations with negative Kernig and Brudzinski’s signs. No sign of organomegaly was detected either. On neurological examinations, cranial nerves were intact. His muscle tone and deep tendon reflexes were slightly decreased, but the Babinski sign was seen in his right foot.\nHe was the first child of non-consanguineous parents born through Cesarean –section. He had no history of asphyxia at birth and no history of previous seizures or medication consumption. He had normal development before starting the disease.\nDue to fever, loss of consciousness, and seizures, Electroencephalography (EEG) and brain Magnetic Resonance Imaging (MRI) were requested. MRI revealed diffuse involvement of the left fronto-parieto-temporal regions and the left thalamus. EEG showed periodic lateralized epileptiform discharges (PLEDs) in the left hemisphere .\nA lumbar puncture was requested to rule out herpetic encephalitis, which indicated red blood cell=1000 / mm3 and white blood cell=100 /mm3 (60% neutrophils and 40% lymphocytes). Glucose and protein levels were in the normal range. Cerebrospinal fluid PCR for herpes simplex virus was also requested. According to imaging and CSF findings, the patient’s treatment started with ceftriaxone and acyclovir, with a presumptive diagnosis of herpetic encephalitis. After three days, HSV -PCR of CSF showed a positive result for HSV 1, and treatment was continued with acyclovir.\nDuring hospitalization, the patient regained consciousness, his fever recessed, and the seizures did not recur. After a twenty-one-day course of acyclovir, the patient was discharged while phenytoin, phenobarbital, and clonazepam were prescribed for him.\nOne week after being discharged, the patient returned with restlessness, speech difficulties, and choreic movement, especially in the upper extremities. For better evaluation, he was re-admitted, and brain imaging was performed. A brain MRI revealed abnormal high signals in his left fronto-parieto-temporal regions with encephalomalacic changes due to sequella of previous infection and recent right temporal involvement\nNo leukocytosis was reported in his initial tests. Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) were normal. Organic acids in blood and urine samples and serum ammonia and lactate levels were tested for metabolic disorders; all were in the normal range. CSF- PCR for herpes simplex was requested again to rule out relapsing herpetic encephalitis, and its result was negative. The history and extrapyramidal signs, including choreic movements, raised the possibility of autoimmune encephalitis. Therefore, serum and CSF were analyzed for autoimmune disorders. The Anti-N-Methyl-D-Aspartate receptor antibody test was positive in the autoimmune panel investigation in CSF, and the diagnosis of Anti-N-Methyl-D-Aspartate receptor autoimmune encephalitis was confirmed. The patient was treated with five-day methylprednisolone pulse therapy, followed by intravenous immunoglobulin (IVIG) for three days and aripiprazole. After three months, the patient’s speaking, behavior, and restlessness improved, and his choreic movement resolved.", + "fulltext_subclaims": [ + "An 18-month-old boy was referred for fever, lethargy, repeated seizures, and vomiting since two days ago.", + "During hospitalization, he experienced three focal clonic seizures affecting the right side of his body with orofacial automatism.", + "Seizures were ultimately controlled with phenytoin, phenobarbital, and levetiracetam, followed by clonazepam.", + "The infant had no nuchal rigidity on physical examinations with negative Kernig and Brudzinski’s signs.", + "On neurological examinations, cranial nerves were intact.", + "His muscle tone and deep tendon reflexes were slightly decreased, but the Babinski sign was seen in his right foot.", + "He was the first child of non-consanguineous parents born through Cesarean-section.", + "He had no history of asphyxia at birth and no history of previous seizures or medication consumption.", + "He had normal development before starting the disease.", + "Due to fever, loss of consciousness, and seizures, Electroencephalography (EEG) and brain Magnetic Resonance Imaging (MRI) were requested.", + "MRI revealed diffuse involvement of the left fronto-parieto-temporal regions and the left thalamus.", + "EEG showed periodic lateralized epileptiform discharges (PLEDs) in the left hemisphere.", + "A lumbar puncture was requested to rule out herpetic encephalitis.", + "Cerebrospinal fluid PCR for herpes simplex virus was also requested.", + "According to imaging and CSF findings, the patient’s treatment started with ceftriaxone and acyclovir, with a presumptive diagnosis of herpetic encephalitis.", + "After three days, HSV-PCR of CSF showed a positive result for HSV 1, and treatment was continued with acyclovir.", + "During hospitalization, the patient regained consciousness, his fever recessed, and the seizures did not recur.", + "After a twenty-one-day course of acyclovir, the patient was discharged while phenytoin, phenobarbital, and clonazepam were prescribed for him.", + "One week after being discharged, the patient returned with restlessness, speech difficulties, and choreic movement, especially in the upper extremities.", + "A brain MRI revealed abnormal high signals in his left fronto-parieto-temporal regions with encephalomalacic changes due to sequella of previous infection and recent right temporal involvement.", + "No leukocytosis was reported in his initial tests.", + "Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) were normal.", + "Organic acids in blood and urine samples and serum ammonia and lactate levels were tested for metabolic disorders; all were in the normal range.", + "CSF-PCR for herpes simplex was requested again to rule out relapsing herpetic encephalitis, and its result was negative.", + "The history and extrapyramidal signs, including choreic movements, raised the possibility of autoimmune encephalitis.", + "The Anti-N-Methyl-D-Aspartate receptor antibody test was positive in the autoimmune panel investigation in CSF.", + "The diagnosis of Anti-N-Methyl-D-Aspartate receptor autoimmune encephalitis was confirmed.", + "The patient was treated with five-day methylprednisolone pulse therapy, followed by intravenous immunoglobulin (IVIG) for three days and aripiprazole.", + "After three months, the patient’s speaking, behavior, and restlessness improved, and his choreic movement resolved." + ], + "summary": "The article pertains to the presentation of an 18-month-old infant with a primary diagnosis of herpetic encephalitis who was re-admitted to the hospital shortly after discharge with restlessness, speech disorder, and abnormal movements. The movements were predominantly choreiform and disappeared during sleep. Brain MRI revealed abnormal predominance in the left temporoparietal regions with encephalomalacic changes in some areas in favor of sequella of previous encephalitis in addition to recent right temporal involvement of sequella of previous encephalitis. The polymerase chain reaction test of cerebrospinal fluid for herpes simplex infection was negative. Therefore, the possibility of autoimmune encephalitis was raised. More laboratory examinations revealed that the Anti-N-Methyl-D-Aspartate receptor antibody level was significantly elevated in cerebrospinal fluid. Thus, the diagnosis of Anti-N-Methyl-D-Aspartate receptor encephalitis was established.", + "summary_subclaims": [ + "The patient is an 18-month-old infant.", + "The primary diagnosis was herpetic encephalitis.", + "The infant was re-admitted shortly after discharge.", + "The infant presented with restlessness.", + "The infant presented with speech disorder.", + "The infant presented with abnormal movements.", + "The movements were predominantly choreiform.", + "The movements disappeared during sleep.", + "Brain MRI showed abnormal predominance in the left temporoparietal regions.", + "Brain MRI showed encephalomalacic changes in some areas.", + "The findings were in favor of sequella of previous encephalitis.", + "There was recent right temporal involvement of sequella of previous encephalitis.", + "The polymerase chain reaction test of cerebrospinal fluid for herpes simplex infection was negative.", + "The possibility of autoimmune encephalitis was raised.", + "The Anti-N-Methyl-D-Aspartate receptor antibody level was significantly elevated in cerebrospinal fluid.", + "The diagnosis of Anti-N-Methyl-D-Aspartate receptor encephalitis was established." + ] + }, + { + "id": "multiclinsum_test_846_en.txt", + "fulltext": "A 9-month-old Caucasian female without any birth or past medical history was diagnosed with isolated enophthalmos of the right eye. The mother had noticed a backwards displacement of the right eye 3 months prior to presentation and consulted various specialists who stated a constitutional feature. General examination was normal with no deterioration of health status, neurological, abdominal or skeletal bone integrity. Ophthalmological examination revealed nothing but a mild right enophthalmos. There was no facial disfigurement such as flattening. Pupil size and reactivity to light, direct and consensual accommodation, fixation and following, binocular function, eye-hand coordination, reaction to patching, slit lamp and fundus examination were all normal. Before this isolated enophthalmos, blood and urine samples were collected and orbital computed tomography (CT) undertaken. Routine biology labs, in particular creatinin levels, were normal. An orbital CT scan confirmed the enophthalmos (Figure a) and showed irregularly shaped osteolysis with periosteal reaction of orbital walls, malar bones and zygomatic arches, predominantly on the right side (Figure b), arousing suspicion of a tumor. A thoracic- abdominal CT scan showed an 83 mm*43 mm*42 mm retroperitoneal heterogeneous mass located on the left adrenal gland (Figure ) embracing vascular elements and associated with intra-abdominal, left supraclavicular swollen lymph nodes and vertebral condensations, which was evocative of a stage-4 neuroblastoma. The patient was immediately referred to oncology for further investigation and treatment. The stage-4 neuroblastoma was confirmed and the patient treated with chemotherapy and surgical evacuation of residual masses. She achieved complete remission with no recurrence at 10-month follow-up.", + "fulltext_subclaims": [ + "The patient is a 9-month-old Caucasian female.", + "The patient had no birth or past medical history.", + "The patient was diagnosed with isolated enophthalmos of the right eye.", + "The mother had noticed a backwards displacement of the right eye 3 months prior to presentation.", + "Various specialists stated the enophthalmos was a constitutional feature.", + "General examination was normal.", + "Ophthalmological examination revealed mild right enophthalmos.", + "Pupil size and reactivity to light were normal.", + "Fixation and following were normal.", + "Binocular function was normal.", + "Blood and urine samples were collected before the isolated enophthalmos.", + "An orbital CT scan confirmed the enophthalmos.", + "The orbital CT scan showed irregularly shaped osteolysis with periosteal reaction of orbital walls, malar bones and zygomatic arches, predominantly on the right side.", + "A thoracic-abdominal CT scan showed an 83 mm*43 mm*42 mm retroperitoneal heterogeneous mass located on the left adrenal gland.", + "The mass was associated with intra-abdominal, left supraclavicular swollen lymph nodes and vertebral condensations.", + "The findings were evocative of a stage-4 neuroblastoma.", + "The patient was immediately referred to oncology for further investigation and treatment.", + "The stage-4 neuroblastoma was confirmed.", + "The patient was treated with chemotherapy and surgical evacuation of residual masses.", + "The patient achieved complete remission.", + "There was no recurrence at 10-month follow-up." + ], + "summary": "A 9-month-old girl was diagnosed with isolated right-sided enophthalmos. An orbital tumor was suspected and computed tomography undertaken showing osteolysis and periosteal reaction of orbital walls, malar bones and zygomatic arches. A Thoracic- abdominal CT scan confirmed a stage-4 neuroblastoma.", + "summary_subclaims": [ + "A 9-month-old girl was diagnosed with isolated right-sided enophthalmos.", + "An orbital tumor was suspected.", + "Computed tomography showed osteolysis and periosteal reaction of orbital walls.", + "Computed tomography showed osteolysis and periosteal reaction of malar bones.", + "Computed tomography showed osteolysis and periosteal reaction of zygomatic arches.", + "A Thoracic-abdominal CT scan confirmed a stage-4 neuroblastoma." + ] + }, + { + "id": "multiclinsum_test_413_en.txt", + "fulltext": "Patient 1 The proband , a 6.6-year-old girl, was admitted to our hospital because of short stature. As the first child of nonconsanguineous parents, she was born at 41 weeks of gestation via vaginal delivery, whose birth weight and length were 1800 g ( T) from their affected mother. Moreover, the proband accompanied by growth hormone deficiency without other associated variants.", + "summary_subclaims": [ + "The family described has LZTR1-related Noonan syndrome.", + "The proband, sister, mother, maternal aunt, grandmother, and female cousin showed typical or atypical features of Noonan syndrome.", + "Only 3 patients underwent whole-exome sequencing analysis.", + "The proband and her sister inherited the same heterozygous LZTR1 variant (c.1149 + 1G > T) from their affected mother.", + "The proband had growth hormone deficiency." + ] + }, + { + "id": "multiclinsum_test_129_en.txt", + "fulltext": "A 71-year-old female with a past medical history of undifferentiated connective tissue disease (UCTD) presented to an acute care hospital in December, 2020 after experiencing sudden onset of lower extremity weakness over 8-10 min, sensory loss from the lower trunk down, urinary retention, and worsening hypotension.\nThis individual had recently been exposed to COVID-19 through a household member and subsequently tested positive, with COVID cycle thresholds suggestive of recent infection. She demonstrated cough and fever before hospitalization, but did not require supplemental oxygen beyond the first few hospital days. She was issued 5 d of IV methylprednisolone and remdesivir, followed by an oral prednisone taper of 5 additional days. Neurological exam in acute care found incomplete sensory deficits T3-8 but complete absence of sensation from T9 and below.\nDuring inpatient rehabilitation, we did acquire some key historical information about her UCTD, which to date had never progressed to a defined connective tissue disorder such as mixed connective tissue disease (MCTD). This condition is characterized by the presence of certain antibodies, particularly presence of the U1 small nuclear ribonucleoprotein particles (snRNP). Notes received indicate a negative titer for U1snRNP in 2020 when she had acute COVID-19, similar to her level when last tested in 2016. No lab quantification of U1-anti RNP titer was listed among lab results, other than a note stating it was not present. She had no clinical features of MCTD other than presence of sclerodactyly and stated history of Raynaud’s, which was not active during rehabilitation. She had myalgias but no evidence of synovitis or myositis that would prompt us to request a muscle biopsy. At the time of her admission to rehabilitation, this individual’s discomfort and spasms, as well as pain were in the middle and upper trunk and mid-back. However, during past UCTD exacerbations, she had endured aching and often sharp pain specifically in the posterior cervical spine and shoulders and during more significant attacks, pain and swelling in her fingers. Except during practice with wheelchair transfers, she reported no shoulder, arm, or hand pain with physical or occupational therapies.\nThe possibility exists that some of the pain and spasms she was feeling was a different manifestation of her usual UCTD flare. In the past, such instances had always affected more proximal areas of the body, specifically neck, shoulders and hands. In her 2.5 years since discharge from her second inpatient rehabilitation stay, she has only experienced two significant UCTD exacerbations, both during an acute hospital admission for secondary complications of her NTSCI. The first occurred in the summer of 2022 when septic from a severe UTI. Her antibiotics for that condition included first intravenous cephalosporins and then ciprofloxacin. Both agents may have impaired absorption of hydroxychloroquine prescribed daily for chronic UCTD. In addition, several doses of this long-term medication were missed due to acute illness. During this hospitalization, she became weaker and had increased joint pain, neck pain, and hand swelling. However, the only serology that was abnormal among rheumatologic indices was an elevated ESR of 3 points beyond the upper limit of normal, which could have been outside the normal range simply due to the UTI. During this admission, the same labs as appeared in Table were performed and no findings revealed a change in her degree of UCTD.\nUpon arriving to rehabilitation, her exam demonstrated a C7 left, T3 right ASIA Impairment Scale A, with a zone of sensory preservation to T8 bilaterally and complete absence of sensory and motor function from T9-S5. Her first month of rehabilitation was marked by expected neurogenic bowel and bladder, moderate thoracic non-radiating back pain, and mild spasticity below T9. She also had a band-like tightness in the T4-5 dermatomes in the absence of imaging findings there. The pain continued to intensify during subsequent weeks in rehabilitation, progressively taking on more neuropathic features with relentless mid-back and chest tightness.\nShe was discharged home after 8 wk but continued to experience unrelenting truncal pain between the T3-T8 dermatomes, above and at the level of the infarct, estimated to be located at T8. Several additional acute care and rehabilitation admissions for pain and urinary tract infections ensued during the subsequent two months. Her exam in this time now showed T3 complete SCI with partial preservation to T8.\nTable gives additional studies undertaken in the diagnostic workup, including the presence of viruses other than SARS-CoV-2 (enterovirus, Varicella zoster, Herpes simplex, and West Nile), and markers of inflammatory, autoimmune, and neoplastic disorders. Specifically, there was no evidence of Neuromyelitis Optica, based on absent aquaporin-4, and no evidence of myelin oligodendrocyte glycoprotein antibody, which is characterized by immune mediated demyelination of the spinal cord and other regions of the central nervous system. Moreover, immunoglobulin G synthesis of the cerebral spinal fluid (CSF) index was also negative, suggesting other inflammatory processes were not present. No oligoclonal bands were detected in CSF, a finding commonly seen in multiple sclerosis (MS) and in neoplastic processes such as multiple myeloma. Myelin basic protein was elevated but is a nonspecific finding, present in autoimmune disorders such as MS and ischemic conditions. including stroke. Lumbar puncture on presentation had serum and cerebrospinal fluid studies that were entirely unremarkable.\nHer managing team at the acute care hospital did not have access to her outpatient records about her rheumatologic condition from her community physicians. They did perform a comprehensive serologic workup during her acute COVID admission, but the specimens were sent to an outside lab. Her results were not finalized prior to acute hospital discharge and thus were never added to her inpatient record, nor subsequently forwarded to the rehabilitation team.\nSeveral weeks into her first inpatient rehabilitation stay, partial rheumatologic history and the labs drawn while admitted for COVID-19 were eventually obtained from her outpatient physician’s office. This individual’s initial diagnosis of UCTD occurred in 1993, prior to acute COVID-19, and was classified as non-antinuclear antibody UCTD. Her condition was based on the presence of CREST syndrome, the pneumonic of which represents calcinosis, Raynaud’s syndrome, esophageal dysmotility, sclerodactyly, and telangiectasias. This information was from her first available outpatient record dating back to 2004, nearly 20 years preceding this publication. In 1993, her predominant features were Raynaud’s affecting fingers and sclerodactyly. She began on disease-modifying medication hydroxychloroquine and a plan was made to arrange for oral prednisone as needed for any exacerbations. Outpatient records from 2004-2020 indicate patient reported feeling well, with a “stable UCTD presentation”, without changes in lab indices, recorded hospitalizations, or flares. Documents did note an exacerbation of symptoms of neck and shoulder pain in 2016 that was managed as an outpatient with a combination of hydroxychloroquine and nifedipine, a calcium-channel blocker. At that time a core panel of rheumatologic markers was drawn, identical to the panel drawn in December 2020 given in Table . No specific rheumatologic markers were concerning, with the exception of an elevated erythrocyte sedimentation rate that resolved using the above medications. Between 2016-2020, she continued with annual visits to rheumatology without a documented flare or change in medications. Although normal values vary from one lab to another, the purpose of each test and the ratio of positive to negative values is similar between institutions. The labs were selected by the referring facility where the acute care team made the decisions in diagnostic workup.\nInitial workup included magnetic resonance imaging (MRI) of the cervical, thoracic, and lumbar spine, which showed acute cord ischemia T9 to the conus medullaris. Thoracic cord expansion and increased intramedullary signal extending many vertebral segments were compatible with a spinal cord infarct, particularly in light of the CSF findings and her acute onset of weakness. The above helped to differentiate an infarct from transverse myelitis. The brain MRI was negative for optic neuritis or lesions suggestive of MS, features needed to diagnose those conditions.\nFigure demonstrates a lengthy region of T2 hyperintensity from T9 to the conus, yet absent imaging findings above T9, despite observed sensory abnormalities for many segments rostral to T9. She was diagnosed with a T8 spinal cord thrombotic stroke. Her infarct occurred approximately 7 d after acute infection with COVID-19, consistent with the timing reported by Zhang et al in relation to COVID cytokine storm.", + "fulltext_subclaims": [ + "The patient is a 71-year-old female with a past medical history of undifferentiated connective tissue disease (UCTD).", + "She presented to an acute care hospital in December, 2020.", + "She experienced sudden onset of lower extremity weakness over 8-10 min.", + "She had sensory loss from the lower trunk down.", + "She had urinary retention.", + "She had worsening hypotension.", + "She had recently been exposed to COVID-19 through a household member.", + "She tested positive for COVID-19.", + "Her COVID cycle thresholds were suggestive of recent infection.", + "She demonstrated cough and fever before hospitalization.", + "She did not require supplemental oxygen beyond the first few hospital days.", + "She was issued 5 d of IV methylprednisolone and remdesivir.", + "She was issued an oral prednisone taper of 5 additional days.", + "Neurological exam in acute care found incomplete sensory deficits T3-8.", + "Neurological exam in acute care found complete absence of sensation from T9 and below.", + "Her UCTD had never progressed to a defined connective tissue disorder.", + "Her UCTD is characterized by the presence of certain antibodies, particularly presence of the U1 small nuclear ribonucleoprotein particles (snRNP).", + "Notes received indicate a negative titer for U1snRNP in 2020.", + "Notes received indicate a negative titer for U1snRNP in 2016.", + "No lab quantification of U1-anti RNP titer was listed among lab results.", + "A note stated that U1-anti RNP titer was not present.", + "She had no clinical features of MCTD other than presence of sclerodactyly and stated history of Raynaud’s.", + "Her Raynaud’s was not active during rehabilitation.", + "She had myalgias.", + "She had no evidence of synovitis.", + "She had no evidence of myositis.", + "She had discomfort and spasms in the middle and upper trunk and mid-back.", + "During past UCTD exacerbations, she had endured aching and often sharp pain specifically in the posterior cervical spine and shoulders.", + "During more significant attacks, she had pain and swelling in her fingers.", + "She reported no shoulder, arm, or hand pain with physical or occupational therapies.", + "The possibility exists that some of the pain and spasms she was feeling was a different manifestation of her usual UCTD flare.", + "In the past, such instances had always affected more proximal areas of the body, specifically neck, shoulders and hands.", + "In her 2.5 years since discharge from her second inpatient rehabilitation stay, she has only experienced two significant UCTD exacerbations.", + "Both UCTD exacerbations occurred during an acute hospital admission for secondary complications of her NTSCI.", + "The first UCTD exacerbation occurred in the summer of 2022 when septic from a severe UTI.", + "Her antibiotics for the 2022 UTI included first intravenous cephalosporins and then ciprofloxacin.", + "Both agents may have impaired absorption of hydroxychloroquine prescribed daily for chronic UCTD.", + "Several doses of hydroxychloroquine were missed due to acute illness.", + "During this hospitalization, she became weaker and had increased joint pain, neck pain, and hand swelling.", + "The only serology that was abnormal among rheumatologic indices was an elevated ESR of 3 points beyond the upper limit of normal.", + "The elevated ESR could have been outside the normal range simply due to the UTI.", + "During this admission, the same labs as appeared in Table were performed.", + "No findings revealed a change in her degree of UCTD.", + "Upon arriving to rehabilitation, her exam demonstrated a C7 left, T3 right ASIA Impairment Scale A.", + "Her exam demonstrated a zone of sensory preservation to T8 bilaterally.", + "Her exam demonstrated complete absence of sensory and motor function from T9-S5.", + "Her first month of rehabilitation was marked by expected neurogenic bowel and bladder.", + "Her first month of rehabilitation was marked by moderate thoracic non-radiating back pain.", + "Her first month of rehabilitation was marked by mild spasticity below T9.", + "She had a band-like tightness in the T4-5 dermatomes.", + "The pain continued to intensify during subsequent weeks in rehabilitation.", + "The pain progressively took on more neuropathic features with relentless mid-back and chest tightness.", + "She was discharged home after 8 wk.", + "She continued to experience unrelenting truncal pain between the T3-T8 dermatomes.", + "The infarct was estimated to be located at T8.", + "Several additional acute care and rehabilitation admissions for pain and urinary tract infections ensued during the subsequent two months.", + "Her exam in this time now showed T3 complete SCI with partial preservation to T8.", + "Table gives additional studies undertaken in the diagnostic workup.", + "There was no evidence of Neuromyelitis Optica, based on absent aquaporin-4.", + "There was no evidence of myelin oligodendrocyte glycoprotein antibody.", + "Immunoglobulin G synthesis of the cerebral spinal fluid (CSF) index was also negative.", + "No oligoclonal bands were detected in CSF.", + "Myelin basic protein was elevated.", + "Lumbar puncture on presentation had serum and cerebrospinal fluid studies that were entirely unremarkable.", + "Her managing team at the acute care hospital did not have access to her outpatient records about her rheumatologic condition.", + "They did perform a comprehensive serologic workup during her acute COVID admission.", + "The specimens were sent to an outside lab.", + "The results were not finalized prior to acute hospital discharge.", + "The results were never added to her inpatient record.", + "The results were never forwarded to the rehabilitation team.", + "Several weeks into her first inpatient rehabilitation stay, partial rheumatologic history and the labs drawn while admitted for COVID-19 were eventually obtained.", + "Her initial diagnosis of UCTD occurred in 1993.", + "Her UCTD was classified as non-antinuclear antibody UCTD.", + "Her UCTD was based on the presence of CREST syndrome.", + "CREST syndrome represents calcinosis, Raynaud’s syndrome, esophageal dysmotility, sclerodactyly, and telangiectasias.", + "This information was from her first available outpatient record dating back to 2004.", + "In 1993, her predominant features were Raynaud’s affecting fingers and sclerodactyly.", + "She began on disease-modifying medication hydroxychloroquine.", + "Outpatient records from 2004-2020 indicate patient reported feeling well.", + "Outpatient records from 2004-2020 indicate a “stable UCTD presentation”.", + "Outpatient records from 2004-2020 indicate no changes in lab indices.", + "Outpatient records from 2004-2020 indicate no recorded hospitalizations.", + "Outpatient records from 2004-2020 indicate no flares.", + "Documents did note an exacerbation of symptoms of neck and shoulder pain in 2016.", + "The 2016 exacerbation was managed as an outpatient with a combination of hydroxychloroquine and nifedipine.", + "At that time a core panel of rheumatologic markers was drawn.", + "The labs were selected by the referring facility where the acute care team made the decisions in diagnostic workup.", + "Initial workup included magnetic resonance imaging (MRI) of the cervical, thoracic, and lumbar spine.", + "MRI showed acute cord ischemia T9 to the conus medullaris.", + "Thoracic cord expansion and increased intramedullary signal extending many vertebral segments were compatible with a spinal cord infarct.", + "The above helped to differentiate an infarct from transverse myelitis.", + "The brain MRI was negative for optic neuritis.", + "The brain MRI was negative for lesions suggestive of MS.", + "She was diagnosed with a T8 spinal cord thrombotic stroke.", + "Her infarct occurred approximately 7 d after acute infection with COVID-19.", + "This timing is consistent with the timing reported by Zhang et al in relation to COVID cytokine storm." + ], + "summary": "We present the case of a 70-year-old female with sudden onset of trunk and lower extremity sensorimotor loss due to spinal cord infarction, attributed to acute infection with SARS-CoV-2. Diagnostic work up confirmed a T3 complete (ASIA impairment Scale A) paraplegia resulting from a thrombotic infarct. Her reported myalgias, neuropathic pain, spasticity, bladder spasms, and urinary tract infections exceeded the frequency and severity of many spinal cord injury (SCI) individuals of similar age and degree of neurologic impairment. In her first year after contracting COVID-19, she underwent 2 separate inpatient rehabilitation courses, but also required acute hospitalization 6 additional times for subsequent infections or uncontrolled pain. Yet other complications of complete non-traumatic SCI (NTSCI), including neurogenic bowel and temperature hypersensitivity, were mild, and pressure injuries were absent. She has now transitioned from the acute to chronic phase of spinal cord injury care, with subsequent development of post-acute sequelae of SARS-CoV-2 infection (PASC).", + "summary_subclaims": [ + "The patient is a 70-year-old female.", + "She had sudden onset of trunk and lower extremity sensorimotor loss.", + "The cause was attributed to acute infection with SARS-CoV-2.", + "Diagnostic work up confirmed a T3 complete (ASIA impairment Scale A) paraplegia.", + "The paraplegia resulted from a thrombotic infarct.", + "Her myalgias exceeded the frequency and severity of many spinal cord injury individuals of similar age and degree of neurologic impairment.", + "Her neuropathic pain exceeded the frequency and severity of many spinal cord injury individuals of similar age and degree of neurologic impairment.", + "Her spasticity exceeded the frequency and severity of many spinal cord injury individuals of similar age and degree of neurologic impairment.", + "Her bladder spasms exceeded the frequency and severity of many spinal cord injury individuals of similar age and degree of neurologic impairment.", + "Her urinary tract infections exceeded the frequency and severity of many spinal cord injury individuals of similar age and degree of neurologic impairment.", + "In her first year after contracting COVID-19, she underwent 2 separate inpatient rehabilitation courses.", + "In her first year after contracting COVID-19, she required acute hospitalization 6 additional times for subsequent infections or uncontrolled pain.", + "Neurogenic bowel was mild.", + "Temperature hypersensitivity was mild.", + "Pressure injuries were absent.", + "She has transitioned from the acute to chronic phase of spinal cord injury care.", + "She has developed post-acute sequelae of SARS-CoV-2 infection (PASC)." + ] + }, + { + "id": "multiclinsum_test_2319_en.txt", + "fulltext": "A 49-year-old single man (rural worker), born and raised in Laranjal Paulista-SP, was admitted to our Emergency Room at the Botucatu Medical School University hospital with 3 months history of bilateral occipital headache. Along with a history of active smoking and previous use of alcohol, the patient reported a personal history of mild occipitotemporal injury 3 months ago. On physical examination, left dysdiadochokinesia and three palpable cervical lymph nodes were noted on the left side; one of them with increased dimensions. The patient was submitted to computed tomography (CT) in a 16-row multidetector scanner, which revealed, after iodinated contrast infusion, a nodular hypodense lesion with ring enhancement and associated perilesional edema in the left cerebellar hemisphere . In light of these findings, hypothetic diagnoses of cerebellar abscess and neoplasy (primary or metastatic) were made. Radiological workup was initiated to investigate the eventual primary neoplastic site. Chest radiography showed reticular opacities, perihilar and poorly defined in the right hemithorax. The CT in a 16-row multidetector scanner and high-resolution chest protocol were done, showing pulmonary nodules in the right, some of them with excavated wall, sometimes thin and smooth, sometimes asymmetrical, and occasionally associated with perilesional ground-glass opacities. Magnetic resonance imaging (MRI) scans of the brain revealed similar finding found on CT of the anterior skull, in T1-weighted sequences , showed peripheral hyperintense rim surrounding a hypointense center and ring enhancement after intravenous infusion of paramagnetic contrast . The T2-weigthted sequences and fluid-attenuated inversion recovery (FLAIR) [Figure and ] showed perilesional edema in the left cerebellar hemisphere and peripheral hypointense in the center of the respective lesion. The diffusion-weighted (DWI) sequences and apparent diffusion coefficient (ADC), respectively, showed hyperintense and hypointense lesions with restricted diffusion of water molecules [Figure and ]. The proton spectroscopy curves for MR of cerebellar lesions showed an increase in lactate and lipids peaks and reduction of N-acetyl-aspartate (NAA) peak, without increase in choline peak . Fine needle aspiration of the lymph node was performed, and cytological analysis revealed a nonspecific reactive lymphadenopathy. Microsurgery biopsy of cerebellar lesion was performed, and the histological analysis concluded that it was paracoccidioidomycosis without neoplasia signals .", + "fulltext_subclaims": [ + "The patient is a 49-year-old single man from Laranjal Paulista-SP.", + "He was admitted with a 3-month history of bilateral occipital headache.", + "The patient reported a personal history of mild occipitotemporal injury 3 months ago.", + "On physical examination, left dysdiadochokinesia was noted.", + "Three palpable cervical lymph nodes were found on the left side.", + "One of the cervical lymph nodes had increased dimensions.", + "CT with iodinated contrast showed a nodular hypodense lesion with ring enhancement in the left cerebellar hemisphere.", + "The CT showed associated perilesional edema in the left cerebellar hemisphere.", + "Hypothetic diagnoses of cerebellar abscess and neoplasy were made.", + "Chest radiography showed reticular opacities, perihilar and poorly defined in the right hemithorax.", + "Chest CT showed pulmonary nodules in the right lung.", + "Some pulmonary nodules had excavated walls.", + "MRI scans showed similar findings to the CT in the anterior skull.", + "T1-weighted MRI showed a peripheral hyperintense rim surrounding a hypointense center.", + "T2-weighted and FLAIR MRI showed perilesional edema in the left cerebellar hemisphere.", + "DWI sequences showed hyperintense lesions with restricted diffusion.", + "ADC sequences showed hypointense lesions with restricted diffusion.", + "Proton spectroscopy showed increased lactate and lipids peaks.", + "Proton spectroscopy showed reduced N-acetyl-aspartate (NAA) peak.", + "Fine needle aspiration of the lymph node showed nonspecific reactive lymphadenopathy.", + "Microsurgery biopsy of the cerebellar lesion was performed.", + "Histological analysis concluded the lesion was paracoccidioidomycosis without neoplasia." + ], + "summary": "A 49-year-old single man, rural worker, born and raised in Laranjal Paulista-SP, was admitted to the hospital with 3 months history of bilateral occipital headache every day. Along with a history of active smoking and previous use of alcohol, the patient reported personal history of mild occipitotemporal injury 3 months ago. The patient was submitted to computed tomography in a 16-row multidetector scanner, which revealed a nodular hypodense lesion with a ring-enhancement and associated perilesional edema in the left cerebellar hemisphere. Radiological workup was initiated to investigate the eventual primary neoplastic site.", + "summary_subclaims": [ + "The patient is a 49-year-old single man.", + "He is a rural worker.", + "He was born and raised in Laranjal Paulista-SP.", + "He was admitted to the hospital with 3 months history of bilateral occipital headache every day.", + "He has a history of active smoking.", + "He had previous use of alcohol.", + "He reported a personal history of mild occipitotemporal injury 3 months ago.", + "He was submitted to computed tomography in a 16-row multidetector scanner.", + "The computed tomography revealed a nodular hypodense lesion with a ring-enhancement and associated perilesional edema in the left cerebellar hemisphere.", + "Radiological workup was initiated to investigate the eventual primary neoplastic site." + ] + }, + { + "id": "multiclinsum_test_2500_en.txt", + "fulltext": "A 9-month-old male infant weighing 8450 g presented to the primary care pediatrician with acute onset high fever, non-bilious vomiting, and continuous crying in a glum mood. He showed no bloody stool. On clinical examination, his abdomen was almost flat and it seemed that there is no apparent tenderness but he is crying constantly.\nBlood investigations revealed no remarkable inflammation, and the white cell count was 7700/mm3 and CRP was 0.35 mg/dl (< 0.14) with normal coagulation parameters. Liver function tests showed mild transaminase elevations with ALT 57 U/L (10–42), AST 71 U/L (13–30), and normal level of total bilirubin 0.7 mg/dl (0.4–1.5). Blood urea was 3.5 mg/dl (< 20), and creatinine 0.26 mg/dl (< 1.07). Serum CK level was in the normal range with 237 U/L (59–248).\nThe plain X ray-film showed no sign of bowel obstruction, but the ultrasound demonstrated micro-gas bubbles continuously floating in the intrahepatic portal vein, suggesting any deteriorating clinical problems (Additional file 1: Video S1). The infant was emergently transferred to our department. On admission, he appeared with no acute distress and showed no irritability. Contrast-enhanced CT, performed 1 h later from echography, revealed a whirlpool sign at the right upper abdomen but with neither intrahepatic portal venous gas nor signs of pneumatosis intestinalis . Contrast upper gastrointestinal series showed a corkscrew sign of the jejunum, and additional contrast enema showed a cecum at the mid-upper abdomen . The preoperative evaluation was concerned for intestinal malrotation with midgut volvulus.\nEmergent laparoscopic operation was performed. The patient was placed in reverse Trendelenberg position. At a first laparoscopic glance, the cecum was located just under the liver at mid-abdomen . The small bowel showed a 180° clockwise volvulus, but with neither congestion nor ischemic signs. Using atraumatic bowel forceps, the small bowel was examined from distal ileum end to proximal with continuous spreading of the anterior mesentery surface in a stepwise fashion, ensuring no residual volvulus or local twists. After the complete volvulus reduction, the Ladd’s band was divided and the duodenum was mobilized with dissection of adhesions using SonoSurg™ ultrasonic surgical device (Olympus, Tokyo, Japan). For the separation of the duodenum and ileocecal region, mesentery was widened with dissection of interlaced thin ligaments on the anterior surface of mesentery. The gastrocolic ligament connecting Ladd’s band was additionally dissected to mobilize the right colon furthermore to the left . Appendectomy was added outside the umbilical porthole.\nThe postoperative course was uneventful, and the patient was discharged at the sixth postoperative day.", + "fulltext_subclaims": [ + "A 9-month-old male infant weighing 8450 g presented to the primary care pediatrician with acute onset high fever.", + "The infant had non-bilious vomiting.", + "The infant showed continuous crying in a glum mood.", + "The infant showed no bloody stool.", + "On clinical examination, the abdomen was almost flat.", + "It seemed that there is no apparent tenderness.", + "The infant was crying constantly.", + "Blood investigations revealed no remarkable inflammation.", + "The white cell count was 7700/mm3.", + "CRP was 0.35 mg/dl (< 0.14).", + "Coagulation parameters were normal.", + "ALT was 57 U/L (10–42).", + "AST was 71 U/L (13–30).", + "Total bilirubin was 0.7 mg/dl (0.4–1.5).", + "Blood urea was 3.5 mg/dl (< 20).", + "Creatinine was 0.26 mg/dl (< 1.07).", + "Serum CK level was 237 U/L (59–248).", + "The plain X ray-film showed no sign of bowel obstruction.", + "The ultrasound demonstrated micro-gas bubbles continuously floating in the intrahepatic portal vein.", + "The ultrasound findings suggested any deteriorating clinical problems.", + "The infant was emergently transferred to the department.", + "On admission, the infant appeared with no acute distress.", + "The infant showed no irritability.", + "Contrast-enhanced CT revealed a whirlpool sign at the right upper abdomen.", + "Contrast-enhanced CT showed neither intrahepatic portal venous gas nor signs of pneumatosis intestinalis.", + "Contrast upper gastrointestinal series showed a corkscrew sign of the jejunum.", + "Additional contrast enema showed a cecum at the mid-upper abdomen.", + "The preoperative evaluation was concerned for intestinal malrotation with midgut volvulus.", + "Emergent laparoscopic operation was performed.", + "The patient was placed in reverse Trendelenberg position.", + "At a first laparoscopic glance, the cecum was located just under the liver at mid-abdomen.", + "The small bowel showed a 180° clockwise volvulus.", + "The small bowel showed neither congestion nor ischemic signs.", + "The small bowel was examined from distal ileum end to proximal.", + "The anterior mesentery surface was continuously spread in a stepwise fashion.", + "After the complete volvulus reduction, the Ladd’s band was divided.", + "The duodenum was mobilized with dissection of adhesions using SonoSurg™ ultrasonic surgical device.", + "The mesentery was widened with dissection of interlaced thin ligaments on the anterior surface of mesentery.", + "The gastrocolic ligament connecting Ladd’s band was additionally dissected.", + "Appendectomy was added outside the umbilical porthole.", + "The postoperative course was uneventful.", + "The patient was discharged at the sixth postoperative day." + ], + "summary": "We describe a 9-month-old boy with acute onset high fever and vomiting. The ultrasonography demonstrated micro-gas bubbles continuously floating in the intrahepatic portal vein. Contrast-enhanced CT, performed 1 h later from echography, revealed a whirlpool sign suggesting an intestinal malrotation with midgut volvulus, but with no signs of residual intrahepatic gas. Operative findings showed a mild volvulus with neither congestion nor ischemic change of the twisted bowel. Detorsion and Ladd's procedure were completed laparoscopically.", + "summary_subclaims": [ + "The patient is a 9-month-old boy.", + "The patient had acute onset high fever.", + "The patient had vomiting.", + "Ultrasonography demonstrated micro-gas bubbles continuously floating in the intrahepatic portal vein.", + "Contrast-enhanced CT was performed 1 h later from echography.", + "Contrast-enhanced CT revealed a whirlpool sign.", + "The whirlpool sign suggests an intestinal malrotation with midgut volvulus.", + "Contrast-enhanced CT showed no signs of residual intrahepatic gas.", + "Operative findings showed a mild volvulus.", + "Operative findings showed neither congestion nor ischemic change of the twisted bowel.", + "Detorsion and Ladd's procedure were completed laparoscopically." + ] + }, + { + "id": "multiclinsum_test_2278_en.txt", + "fulltext": "A 44-year-old man presented to the Department of Oncology in our hospital with a 2-month history of local pain of the left shoulder joint. He initially visited a local hospital, where magnetic resonance imaging (MRI) was performed . A 70 × 40 mm mass with an unclear boundary, a mixed hyperintense signal on T2-weighted imaging (T2WI), and a hyperintense signal on T1-weighted imaging (T1WI) of the proximal left humerus was observed. In addition, the adjacent bone was damaged, and a patchy bone marrow oedema signal was observed. This mass presented a state of expansion growth and cortical osteolysis. Based on these results, the patient was diagnosed with a malignant bone tumour by a local doctor. For further treatment, the patient was referred to a superior hospital.\nHis physical examination on admission revealed that the left shoulder joint and proximal superior arm were slightly swollen and tender, and the local skin temperature was normal. Shoulder lifting was limited. The patient’s body mass index was 21.4 kg/m2. His blood investigations revealed the following: calcaemia, 3.09 mmol/L (2.11–2.52 mmol/L); phosphoraemia, 0.55 mmol/L (0.85–1.51 mmol/L); and alkaline phosphatase level, 461 U/L (45–125 U/L). The other investigation results were normal. Standard anteroposterior and oblique radiographs of the left shoulder joint showed large osteolytic lesions involving the proximal humerus and humeral head without any joint involvement . Subsequent computed tomography (CT) of the left shoulder joint showed a soft tissue mass of approximately 34 × 70 mm in the medullary cavity . These imaging findings were suggestive of a bone malignancy. For further diagnosis, a colour ultrasound-guided puncture biopsy of the proximal left humerus was performed, and a brown spongy material consisting of several multinucleated giant cells without atypia was observed. This was suggestive of an aneurysmal bone cyst .\nAfter discussion about the choice of treatment, tumour resection with postoperative pathological examination of the lesions was recommended. Therefore, the patient underwent surgery. Intraoperatively, we noticed that the cortical bone of the proximal humerus was thin and brittle. In addition, several cystic cavities filled with brown viscous substances were observed in the medullary cavity, showing honeycomb changes. We excised all the lesions, and an autologous bone was implanted in the cavity. Subsequently, proper internal fixations were installed to stabilise the bone . A postoperative pathological examination was performed again, and the findings were suggestive of a malignant fibrous histiocytoma of the left humerus . Systemic radionuclide bone scanning was performed to further exclude other bone diseases as the pre- and postoperative diagnoses differed. It showed active metabolism of the superior part of the left humerus, sternum, and left femoral neck . CT revealed multiple osteolytic lesions in the sternum and left femoral neck .\nDue to the limited diagnostic level in our hospital, we sent the pathological sections and clinical data to the Department of Pathology of the First Affiliated Hospital of Sun Yat-sen University; the suggested diagnosis was brown tumour. They suggested we perform further parathyroid function tests. His blood PTH level was 577 pg/ml (15–65 pg/ml). Colour Doppler ultrasonography of the parathyroid gland showed that the left dorsal thyroid was hypoechogenic, 17 × 12 mm, with unclear boundaries and an irregular shape, which was considered as a parathyroid adenoma . Ultimately, the confirmed diagnosis was a brown tumour caused by PHPT.\nRegarding the treatment of PHPT, the patient was transferred to the Department of Otolaryngology for surgery. The left parathyroid adenoma was removed by axillary endoscopic resection. Intraoperatively, 20 × 10 mm solid yellow nodules with clear boundaries were observed at the left dorsal lobe of the thyroid gland . The parathyroid adenoma was completely removed after separation. A postoperative pathologic examination was conducted, which proved to be a parathyroid adenoma . The PTH levels dropped to 29 pg/ml (15–65 pg/ml) 4 days after surgery.\nOne year after the surgery , the left humerus lesions had healed completely, and the left shoulder joint had a good range of movement.", + "fulltext_subclaims": [ + "The patient was a 44-year-old man.", + "He presented with a 2-month history of local pain of the left shoulder joint.", + "Magnetic resonance imaging (MRI) was performed at a local hospital.", + "A 70 × 40 mm mass with an unclear boundary was observed.", + "The mass showed a mixed hyperintense signal on T2-weighted imaging.", + "The mass showed a hyperintense signal on T1-weighted imaging.", + "The mass was located in the proximal left humerus.", + "Adjacent bone was damaged.", + "A patchy bone marrow oedema signal was observed.", + "The mass presented a state of expansion growth.", + "Cortical osteolysis was observed.", + "The patient was diagnosed with a malignant bone tumour by a local doctor.", + "The patient was referred to a superior hospital.", + "On admission, the left shoulder joint and proximal superior arm were slightly swollen and tender.", + "The local skin temperature was normal.", + "Shoulder lifting was limited.", + "The patient’s body mass index was 21.4 kg/m2.", + "Serum calcium was 3.09 mmol/L.", + "Serum phosphorus was 0.55 mmol/L.", + "Alkaline phosphatase was 461 U/L.", + "Standard radiographs showed large osteolytic lesions involving the proximal humerus.", + "Radiographs showed no joint involvement.", + "Computed tomography showed a soft tissue mass of approximately 34 × 70 mm.", + "The mass was in the medullary cavity.", + "The imaging findings were suggestive of a bone malignancy.", + "A colour ultrasound-guided puncture biopsy was performed.", + "Brown spongy material consisting of multinucleated giant cells without atypia was observed.", + "The findings were suggestive of an aneurysmal bone cyst.", + "Tumour resection with postoperative pathological examination was recommended.", + "The patient underwent surgery.", + "Intraoperatively, the cortical bone of the proximal humerus was thin and brittle.", + "Several cystic cavities filled with brown viscous substances were observed.", + "The cavities showed honeycomb changes.", + "All the lesions were excised.", + "An autologous bone was implanted in the cavity.", + "Proper internal fixations were installed.", + "Postoperative pathological examination was performed.", + "The findings were suggestive of a malignant fibrous histiocytoma of the left humerus.", + "Systemic radionuclide bone scanning showed active metabolism of the superior part of the left humerus.", + "Bone scanning showed active metabolism of the sternum.", + "Bone scanning showed active metabolism of the left femoral neck.", + "CT revealed multiple osteolytic lesions in the sternum.", + "CT revealed multiple osteolytic lesions in the left femoral neck.", + "The pathological sections and clinical data were sent to the Department of Pathology of the First Affiliated Hospital of Sun Yat-sen University.", + "The suggested diagnosis was brown tumour.", + "Further parathyroid function tests were suggested.", + "Serum PTH was 577 pg/ml.", + "Colour Doppler ultrasonography showed a left dorsal thyroid hypoechogenic nodule, 17 × 12 mm.", + "The nodule had unclear boundaries and an irregular shape.", + "The nodule was considered a parathyroid adenoma.", + "The confirmed diagnosis was a brown tumour caused by PHPT.", + "The patient was transferred to the Department of Otolaryngology for surgery.", + "The left parathyroid adenoma was removed by axillary endoscopic resection.", + "Intraoperatively, 20 × 10 mm solid yellow nodules with clear boundaries were observed.", + "The nodules were at the left dorsal lobe of the thyroid gland.", + "The parathyroid adenoma was completely removed.", + "Postoperative pathologic examination proved to be a parathyroid adenoma.", + "PTH levels dropped to 29 pg/ml 4 days after surgery.", + "One year after surgery, the left humerus lesions had healed completely.", + "The left shoulder joint had a good range of movement." + ], + "summary": "We report the case of a 44-year-old man who presented to the Department of Oncology in our hospital with a 2-month history of local pain in his left shoulder joint. The initial diagnosis was an aneurysmal bone cyst by biopsy, for which the patient underwent tumour resection surgery. The diagnosis of a malignant tumour was made again following postoperative pathological examination. The pathological sections and all clinical data were sent to the Department of Pathology of the First Affiliated Hospital of Sun Yat-sen University; the diagnosis made there was brown tumour. His blood PTH level was 577 pg/ml (15-65 pg/ml). Colour Doppler ultrasonography of the parathyroid gland suggested a parathyroid adenoma. For further treatment, the left parathyroid adenoma was removed by axillary endoscopic resection. Postoperatively, a pathologic examination was performed, and the diagnosis of a parathyroid adenoma was confirmed. One year after the surgery, the left humerus was completely healed, and the left shoulder joint had a good range of movement.", + "summary_subclaims": [ + "The patient was a 44-year-old man.", + "He presented with a 2-month history of local pain in his left shoulder joint.", + "The initial diagnosis was an aneurysmal bone cyst by biopsy.", + "The patient underwent tumour resection surgery.", + "The diagnosis of a malignant tumour was made following postoperative pathological examination.", + "The pathological sections and all clinical data were sent to the Department of Pathology of the First Affiliated Hospital of Sun Yat-sen University.", + "The diagnosis made there was brown tumour.", + "His blood PTH level was 577 pg/ml.", + "The reference range for PTH was 15-65 pg/ml.", + "Colour Doppler ultrasonography of the parathyroid gland suggested a parathyroid adenoma.", + "The left parathyroid adenoma was removed by axillary endoscopic resection.", + "Postoperatively, a pathologic examination was performed.", + "The diagnosis of a parathyroid adenoma was confirmed.", + "One year after the surgery, the left humerus was completely healed.", + "One year after the surgery, the left shoulder joint had a good range of movement." + ] + }, + { + "id": "multiclinsum_test_2982_en.txt", + "fulltext": "A 9 year-old boy with severe OI and previous history of multiple fractures, small stature and associated skull deformities presented with loss of vision in his right eye of unknown duration. The patient exhibited a low degree of myopia (RE −1.50/−3.00 × 180; LE −1.00/−3.50 × 173) and the anterior sclera was abnormally thin. Posterior segment examination revealed a right macula-off retinal detachment associated with a giant retinal tear (GRT) and C3 proliferative vitreoretinopathy (PVR).\nGenetic analysis was performed by an NHS England molecular genetics service, when the child was 2 years old. At that time (2008) no potentially causative DNA change was found in COL1A1 or COL1A2, and so genetic analysis targeted regions of the CRTAP and P3H1 (previously named LEPRE1) genes, which had only recently been shown to cause recessive osteogenesis imperfecta . This revealed a homozygous change c.1914 + 1G > A (NM_001243246.1) splice site mutation in intron 13 of P3H1 gene with parents being first cousins and heterozygous for same mutation. The same change has also been reported by Pepin et al. in a case of osteogenesis imperfecta with compound heterozygous mutations of P3H1. Although they were unable to determine the effect of this particular c.1914 + 1G > A mutation on the mRNA, in the majority of the other cases of P3H1 mutations that they studied, mRNA instability was the outcome .\nExamination under anaesthetic (EUA) showed a right GRT from 6 to 10 o’clock associated with a macula-off detachment and inferior epiretinal and subretinal fibrosis . EUA of the fellow eye revealed a further 180-degree GRT from 1 to 7 o’clock associated with a macula-sparing retinal detachment. A right 360-degree peritomy for placement of bridle sutures revealed a sclera that was more grey than blue in hue but very thin (see Fig. ). Right RD repair was performed via single-port pars plana vitrectomy (PPV), tamponade with silicone oil and cryoretinopexy extended to 360 degrees. The single sclerostomy and conjunctiva were successfully closed with polyglactin absorbable sutures.\nSurgery for the left eye consisted of PPV and fluid/perfluorocarbon liquid (PFCL) exchange to unroll the posterior flap of the GRT, followed by direct PFCL-silicone oil exchange. Retinopexy was again applied to both the GRT and completed through 360 degrees.\nPersistent antero-posterior PVR meant further right eye surgery was required, involving a 360-degree buckle, a silicone oil top-up and further retinopexy to seal a leak in the lower horn of the GRT. Scleral fixation sutures were not possible for the buckling procedure, which was completed with two 5/0 vicryl sutures tethering the anterior edge of the buckle to the medial and lateral recti to prevent posterior buckle migration with end to end shortening and suturing of the 360-degree explant. Retinal stability was achieved in both eyes but a chronic inferior RD in context of extensive PVR remains under silicone oil in the right eye. Visual acuity with silicone oil in situ at time of writing is RE 6/36, LE 6/12.", + "fulltext_subclaims": [ + "The patient is a 9 year-old boy with severe OI and previous history of multiple fractures.", + "The patient has a history of small stature and associated skull deformities.", + "The patient presented with loss of vision in his right eye of unknown duration.", + "The patient exhibited a low degree of myopia (RE −1.50/−3.00 × 180; LE −1.00/−3.50 × 173).", + "The anterior sclera was abnormally thin.", + "Posterior segment examination revealed a right macula-off retinal detachment associated with a giant retinal tear (GRT).", + "The retinal detachment was associated with C3 proliferative vitreoretinopathy (PVR).", + "Genetic analysis was performed by an NHS England molecular genetics service when the child was 2 years old.", + "At that time (2008), no potentially causative DNA change was found in COL1A1 or COL1A2.", + "Genetic analysis targeted regions of the CRTAP and P3H1 (previously named LEPRE1) genes.", + "This revealed a homozygous change c.1914 + 1G > A (NM_001243246.1) splice site mutation in intron 13 of P3H1 gene.", + "The parents were first cousins and heterozygous for the same mutation.", + "The same change has also been reported by Pepin et al. in a case of osteogenesis imperfecta with compound heterozygous mutations of P3H1.", + "They were unable to determine the effect of this particular c.1914 + 1G > A mutation on the mRNA.", + "In the majority of the other cases of P3H1 mutations that they studied, mRNA instability was the outcome.", + "Examination under anaesthetic showed a right GRT from 6 to 10 o’clock associated with a macula-off detachment.", + "EUA of the fellow eye revealed a further 180-degree GRT from 1 to 7 o’clock associated with a macula-sparing retinal detachment.", + "Right RD repair was performed via single-port pars plana vitrectomy (PPV), tamponade with silicone oil and cryoretinopexy extended to 360 degrees.", + "The single sclerostomy and conjunctiva were successfully closed with polyglactin absorbable sutures.", + "Surgery for the left eye consisted of PPV and fluid/perfluorocarbon liquid (PFCL) exchange to unroll the posterior flap of the GRT.", + "Retinopexy was again applied to both the GRT and completed through 360 degrees.", + "Persistent antero-posterior PVR meant further right eye surgery was required.", + "Further right eye surgery involved a 360-degree buckle, a silicone oil top-up and further retinopexy to seal a leak in the lower horn of the GRT.", + "Scleral fixation sutures were not possible for the buckling procedure.", + "The buckling procedure was completed with two 5/0 vicryl sutures tethering the anterior edge of the buckle to the medial and lateral recti.", + "Retinal stability was achieved in both eyes.", + "A chronic inferior RD in context of extensive PVR remains under silicone oil in the right eye.", + "Visual acuity with silicone oil in situ at time of writing is RE 6/36, LE 6/12." + ], + "summary": "We report the first case of a child with a rare recessive type of OI, subtype VIII, resulting from a P3H1 (also known as LEPRE1) gene mutation presenting with bilateral giant retinal tears and the surgical challenges encountered in performing retinal detachment repair due to scleral thinning. The P3H1 gene encodes for prolyl 3-hydroxylase 1 which is involved in the post-translational modification of not only collagen type I but also types II and V which when mutated may result in pathological posterior vitreous detachment (PVD) and giant retinal tear detachments.", + "summary_subclaims": [ + "We report the first case of a child with a rare recessive type of OI, subtype VIII.", + "The case involved a P3H1 (also known as LEPRE1) gene mutation.", + "The child presented with bilateral giant retinal tears.", + "The surgical challenges encountered were in performing retinal detachment repair due to scleral thinning.", + "The P3H1 gene encodes for prolyl 3-hydroxylase 1.", + "Prolyl 3-hydroxylase 1 is involved in the post-translational modification of collagen type I.", + "Prolyl 3-hydroxylase 1 is also involved in the post-translational modification of types II and V collagen.", + "When mutated, the P3H1 gene may result in pathological posterior vitreous detachment.", + "When mutated, the P3H1 gene may result in giant retinal tear detachments." + ] + }, + { + "id": "multiclinsum_test_50_en.txt", + "fulltext": "A 32-year-old Caucasian woman presented to our facility at 39 weeks gestation for an emergency cesarean section due to prolapse of the umbilical cord and fetal distress. The course of her pregnancy had been uneventful and our patient was admitted after the onset of regular contractions. When the cervix was dilated at 5 cm, the amniotic membranes ruptured and the fetus quickly developed signs of fetal distress, including fetal bradycardia down to 100 beats/minute and variant decelerations. A vaginal examination revealed prolapse of the umbilical cord.\nOur patient was immediately brought to the operating room for an urgent cesarean section. A pre-operative anesthetic examination did not reveal any coexisting medical conditions, though she had a predictive difficult airway: Mallampati score III, thyromental distance measured 4 cm, no prominent incisors, limited neck extension and limited mouth opening (3 cm). Her blood pressure measured 110/70, heart rate 80 beats/minute, pulse oximetry (saturated O2 (SaO2)) was 99% on room air. Our patient was 180 cm tall and weighed 100 kg. She was denied food and water for nine hours for food and three hours for clear liquids. She refused an epidural catheter.\nConsidering the urgency of the surgery due to severe fetal distress it was decided to proceed immediately with general anesthesia via rapid sequence induction. Considering the risk of difficult intubation, the difficult intubation cart was brought and an attending anesthesiologist experienced in the difficult airway management of patients in childbirth was called in. An attempt to perform a conscious fiber-optic intubation was considered but not performed because of the urgency of the situation and 'pressure' from the obstetricians. Our patient was attached to standard monitors, including pulse oximetry, non-invasive blood pressure, electrocardiogram (ECG), end-tidal carbon dioxide (ETCO2) analyzer, and nerve stimulator.\nOur patient received aspiration prophylaxis with metoclopramide 10 mg intravenously prior to induction. After a short pre-oxygenation step (four deep breaths), anesthesia was induced with propofol 2 mg/kg and succinylcholine 1 mg/kg. Cricoid pressure was applied immediately after the injection of propofol. Direct laryngoscopy (DL) was then attempted using a Macintosh (number 3 blade). The first attempt at intubation was performed by an experienced resident, and was unsuccessful because of an inability to visualize the vocal cords (grade III view) and an inability to pass the ETT blindly. Mask ventilation with 100% oxygen was performed easily, and SaO2 remained 99%. The second and third attempts at DL were made unsuccessfully by the attending anesthesiologist. All attempts to improve visualization, including repositioning the head and the use of a laryngoscope with Miller's blade, were unsuccessful. Mask ventilation was applied between the attempts at intubation.\nAfter the third attempt, an LMA size 4 was successfully placed and positive pressure ventilation was applied with following parameters: tidal volume (TV) 500 mL, respiratory rate (RR) 12 breaths/minute, positive-end expiratory pressure (PEEP) 0, inspiratory/expiratory (I/E) ratio 1:2. Peak inspiratory pressure did not exceed 25 cm H2O and no leak was detected. Cricoid pressure was maintained during the entire procedure to prevent possible aspiration. Anesthesia was maintained with isoflurane 1.2% in pure oxygen. 100% oxygen was maintained to optimize the conditions if the airway was lost. The surgical incision was made immediately after the insertion of the LMA and the fetus was delivered 10 minutes later. Apgar scores were 7 and 10 at the first and 10th minute, respectively.\nOur patient remained hemodynamically stable during the surgery, though her SaO2 decreased gradually, reaching 90% by the end of the surgery. Her trachea was suctioned, revealing the accumulation of a significant amount of blood in both the pharynx and trachea. Her pulse oximetry (SpO2) did not improve after suctioning, and her peak inspiratory pressure increased by 30 cm H2O, suggesting aspiration of blood and possibly of gastric contents. The decision was made to intubate our patient in order to facilitate suctioning the tracheobronchial tree and providing ventilatory support for respiratory failure.\nConsidering that intubation under DL was unsuccessful and fiber-optic intubation with a flexible fiber-optic bronchoscope (FOB) would be extremely difficult due to the presence of upper airway bleeding and swelling from traumatic attempts at intubation, the decision was made to intubate using an AIC dressed over a FOB, via LMA in situ. The procedure was performed by the attending anesthesiologist with experience in difficult intubations with patients who are pregnant. An AIC (19 F/56 cm; Cook Inc., Bloomington, IN, USA) was placed on a FOB (Olympus model LF-2 with an external diameter of 4.0 mm). Continuous fresh gas flow of oxygen at 4 L/minute was maintained via the suction port of the FOB in order to maintain better oxygenation and improve visualization by blowing out the blood bubbles. After suctioning the LMA, the FOB was easily passed between the grids of the LMA, the epiglottis and vocal cords were visualized, and the FOB was passed between the vocal cords into the trachea and introduced almost until the tracheal bifurcation. The AIC was then slid down over the FOB, and the FOB was removed .\nWe attempted to 'railroad' a cuffed ETT with an internal diameter of 6.5 mm down to the trachea using the AIC as a guide. Because our patient was tall, a significant length of the AIC had to be inserted into our patient in order for the distal tip of the AIC to be positioned just before the carina. This left only a short length of the proximal portion of the AIC available for the ETT to be 'railroaded' over (the portion of the AIC that was outside our patient). However, this free portion of the AIC was shorter than the ETT. Therefore, the ETT could not be safely slid over the AIC while simultaneously holding the proximal end of the AIC to maintain its position and prevent its slipping from within the trachea. . Additionally, the catheter was very slippery because of our patient's secretions and blood. Our patient's SaO2 dropped to 80%. Attempts to introduce the ETT were postponed to allow for mask ventilation, and the ETT was removed while the position of the AIC was maintained.\nAfter two minutes of mask ventilation, when the SaO2 reached 90%, another attempt at introducing the ETT was made. With this attempt, however, a novel approach was used to create a longer guide as illustrated in Figure . After positioning of AIC via LMA with FOB . The AIC was replaced with an exchange catheter for a double-lumen ETT (14 F/100 cm, Cook Inc.). The exchange catheter was lubricated and inserted into the trachea via the inner port of AIC until mild resistance of the tracheobronchial tree was felt (60 cm deep) . The AIC was slowly removed over the exchange catheter, with careful attention made to keep the exchange catheter in place . Fortunately, this was easily accomplished because the exchange catheter was very long.\nAfter the Aintree catheter was removed, a cuffed ETT size 6.5 was easily introduced into the trachea over the exchange catheter until 21 cm deep, and the exchange catheter was removed . The cuff of the ETT was inflated and mechanical ventilation was resumed with the following parameters: TV 500 mL, RR 12 breaths/minute, PEEP 7.5 cm H2O, I/E ratio 1:2, fraction of inspired O2 (FiO2) 1.0. Our patient's peak inspiratory pressure measured 30 cm H2O (including PEEP). The position of the ETT was verified by both the appearance of ETCO2 waveform on the monitor and via bronchoscopy (the tip of the ETT was observed 3 to 4 cm above the carina). The bronchoscopy revealed traces of blood in the trachea, which was suctioned via the suction port of the bronchoscope. No food particles were detected in the trachea. Her SaO2 level gradually reached 99%. Analysis of arterial blood revealed moderate hypercapnia (partial pressure CO2 (pCO2) of 50 mmHg) and relative hypoxemia (partial pressure of O2 in blood (PaO2) of 110 mmHg).\nConsidering our patient's risk of developing aspiration pneumonitis and upper airway edema, sedation with a propofol drip at a dose of 3 mg/kg/hour was initiated and our patient was transferred to the intensive care unit. Fortunately, our patient remained hemodynamically stable and was well oxygenated and ventilated. Our patient did not receive any antibiotics or steroids. She was subsequently extubated 24 hours later, after performing a leak test to rule out pharyngeal or vocal cord edema. No additional complications were noted and our patient was discharged home without any sequelae 48 hours after she was extubated.", + "fulltext_subclaims": [ + "The patient was a 32-year-old Caucasian woman.", + "She was 39 weeks gestation.", + "She presented for an emergency cesarean section.", + "The indication for the cesarean section was prolapse of the umbilical cord.", + "The indication for the cesarean section was fetal distress.", + "The course of her pregnancy had been uneventful.", + "She was admitted after the onset of regular contractions.", + "When the cervix was dilated at 5 cm, the amniotic membranes ruptured.", + "The fetus developed signs of fetal distress.", + "Fetal bradycardia down to 100 beats/minute was observed.", + "Variant decelerations were observed.", + "A vaginal examination revealed prolapse of the umbilical cord.", + "The patient was immediately brought to the operating room for an urgent cesarean section.", + "A pre-operative anesthetic examination did not reveal any coexisting medical conditions.", + "She had a predictive difficult airway.", + "Her Mallampati score was III.", + "Her thyromental distance measured 4 cm.", + "She had limited neck extension.", + "She had limited mouth opening of 3 cm.", + "She was 180 cm tall.", + "She weighed 100 kg.", + "She was denied food and water for nine hours.", + "She was denied clear liquids for three hours.", + "She refused an epidural catheter.", + "It was decided to proceed immediately with general anesthesia via rapid sequence induction.", + "The difficult intubation cart was brought.", + "An attending anesthesiologist experienced in the difficult airway management of patients in childbirth was called in.", + "An attempt to perform a conscious fiber-optic intubation was considered.", + "A conscious fiber-optic intubation was not performed.", + "The patient was attached to standard monitors.", + "The patient received metoclopramide 10 mg intravenously prior to induction.", + "Anesthesia was induced with propofol 2 mg/kg.", + "Anesthesia was induced with succinylcholine 1 mg/kg.", + "Cricoid pressure was applied immediately after the injection of propofol.", + "Direct laryngoscopy was attempted using a Macintosh number 3 blade.", + "The first attempt at intubation was performed by an experienced resident.", + "The first attempt at intubation was unsuccessful.", + "The first attempt at intubation was unsuccessful because of an inability to visualize the vocal cords.", + "The first attempt at intubation was unsuccessful because of an inability to pass the ETT blindly.", + "Mask ventilation with 100% oxygen was performed easily.", + "SaO2 remained 99%.", + "The second and third attempts at direct laryngoscopy were made by the attending anesthesiologist.", + "All attempts to improve visualization were unsuccessful.", + "An LMA size 4 was successfully placed.", + "Positive pressure ventilation was applied with tidal volume 500 mL.", + "Positive pressure ventilation was applied with respiratory rate 12 breaths/minute.", + "Positive pressure ventilation was applied with PEEP 0.", + "Positive pressure ventilation was applied with I/E ratio 1:2.", + "Peak inspiratory pressure did not exceed 25 cm H2O.", + "No leak was detected.", + "Cricoid pressure was maintained during the entire procedure.", + "Anesthesia was maintained with isoflurane 1.2% in pure oxygen.", + "100% oxygen was maintained.", + "The surgical incision was made immediately after the insertion of the LMA.", + "The fetus was delivered 10 minutes later.", + "Apgar scores were 7 at the first minute.", + "Apgar scores were 10 at the 10th minute.", + "The patient remained hemodynamically stable during the surgery.", + "Her SaO2 decreased gradually.", + "Her SaO2 reached 90% by the end of the surgery.", + "Her trachea was suctioned.", + "A significant amount of blood was found in both the pharynx and trachea.", + "Her pulse oximetry did not improve after suctioning.", + "Her peak inspiratory pressure increased by 30 cm H2O.", + "The decision was made to intubate the patient.", + "Intubation was decided to facilitate suctioning the tracheobronchial tree.", + "Intubation was decided to provide ventilatory support for respiratory failure.", + "Intubation under direct laryngoscopy was unsuccessful.", + "Fiber-optic intubation with a flexible fiber-optic bronchoscope would be extremely difficult.", + "The decision was made to intubate using an Aintree Intubation Catheter (AIC) dressed over a fiber-optic bronchoscope (FOB).", + "The procedure was performed by the attending anesthesiologist.", + "An AIC was placed on a FOB.", + "Continuous fresh gas flow of oxygen at 4 L/minute was maintained.", + "The FOB was passed between the grids of the LMA.", + "The FOB was passed between the vocal cords into the trachea.", + "The AIC was slid down over the FOB.", + "The FOB was removed.", + "An attempt to railroad a cuffed ETT with an internal diameter of 6.5 mm was made.", + "The ETT could not be safely slid over the AIC.", + "The patient's SaO2 dropped to 80%.", + "Attempts to introduce the ETT were postponed.", + "Mask ventilation was performed.", + "The ETT was removed while the position of the AIC was maintained.", + "After two minutes of mask ventilation, SaO2 reached 90%.", + "Another attempt at introducing the ETT was made.", + "A novel approach was used to create a longer guide.", + "The AIC was replaced with an exchange catheter for a double-lumen ETT.", + "The exchange catheter was lubricated.", + "The exchange catheter was inserted into the trachea via the inner port of AIC.", + "The AIC was slowly removed over the exchange catheter.", + "A cuffed ETT size 6.5 was introduced into the trachea over the exchange catheter.", + "The ETT was introduced until 21 cm deep.", + "The exchange catheter was removed.", + "The cuff of the ETT was inflated.", + "Mechanical ventilation was resumed with tidal volume 500 mL.", + "Mechanical ventilation was resumed with respiratory rate 12 breaths/minute.", + "Mechanical ventilation was resumed with PEEP 7.5 cm H2O.", + "Mechanical ventilation was resumed with I/E ratio 1:2.", + "Mechanical ventilation was resumed with FiO2 1.0.", + "The position of the ETT was verified by the appearance of ETCO2 waveform.", + "The position of the ETT was verified via bronchoscopy.", + "The tip of the ETT was observed 3 to 4 cm above the carina.", + "Bronchoscopy revealed traces of blood in the trachea.", + "The blood was suctioned via the suction port of the bronchoscope.", + "No food particles were detected in the trachea.", + "The patient's SaO2 level gradually reached 99%.", + "Arterial blood analysis revealed moderate hypercapnia.", + "Arterial blood analysis revealed relative hypoxemia.", + "Sedation with a propofol drip at a dose of 3 mg/kg/hour was initiated.", + "The patient was transferred to the intensive care unit.", + "The patient remained hemodynamically stable.", + "The patient was well oxygenated and ventilated.", + "The patient did not receive any antibiotics.", + "The patient did not receive any steroids.", + "The patient was extubated 24 hours later.", + "A leak test was performed to rule out pharyngeal or vocal cord edema.", + "No additional complications were noted.", + "The patient was discharged home without any sequelae.", + "The patient was discharged 48 hours after she was extubated." + ], + "summary": "We present the case of a 32-year-old, 180 cm tall Caucasian woman with a predicted difficult airway who presented to our facility for an emergency cesarean section. After several failed intubation attempts via direct laryngoscopy, an airway was established with a laryngeal mask airway. After delivery of a healthy baby, our patient's condition necessitated tracheal intubation. A fiber-optic bronchoscope loaded with an Aintree intubating catheter (Cook® Medical Inc., Bloomington, IN, USA) was passed through the laryngeal mask airway into the trachea until just above the carina, but was too short to safely allow for the passage of an endotracheal tube.", + "summary_subclaims": [ + "The patient is a 32-year-old, 180 cm tall Caucasian woman.", + "The patient had a predicted difficult airway.", + "The patient presented for an emergency cesarean section.", + "Several failed intubation attempts occurred via direct laryngoscopy.", + "An airway was established with a laryngeal mask airway.", + "A healthy baby was delivered.", + "Tracheal intubation was necessitated after delivery.", + "A fiber-optic bronchoscope loaded with an Aintree intubating catheter was used.", + "The bronchoscope was passed through the laryngeal mask airway into the trachea.", + "The bronchoscope was positioned just above the carina.", + "The bronchoscope was too short to safely allow for the passage of an endotracheal tube." + ] + }, + { + "id": "multiclinsum_test_364_en.txt", + "fulltext": "A 53-year-old man presented with increasing dyspnea and a weight loss of 3 kg over a 4-month period. Past medical history was significant for emphysema, seizure disorder and hepatitis C. Medications included albuterol and dilantin. The patient was unemployed and had a 35-pack/year history of smoking. He also reported intravenous heroin abuse 30 years previously (undertaken for a period of 10 years).\nLaboratory results including complete blood count, renal function and liver function tests were all within normal limits. Human immunodeficiency virus (HIV) serology was negative. A chest X-ray showed an ill-defined density close to the right heart border, and a computed tomography (CT) scan confirmed a 4.5 × 2.2 cm opacity in the medial aspect of the right middle lobe, with emphysematous changes and spiculated opacities in both lung fields suspicious for malignant spread. A CT scan of the abdomen and pelvis was unremarkable.\nThe patient underwent autofluorescence bronchoscopy and the visualized portions of the upper and lower airways were widely patent with no abnormalities. Ultrasound of the mediastinum using ultrasonic bronchofibervideoscope located the echodensity inferior to the right hilum, and fine needle biopsy of this structure was obtained via endobronchial ultrasound-guided transbronchial needle aspiration. Biopsies were also obtained from four further echodense areas suggestive of malignant lesions involving both lungs.\nThe biopsy returned negative for malignancy, and histology from the multiple sites showed bronchial epithelial cells with a marked foreign body giant cell reaction and associated polarizable birefringent foreign bodies . A diagnosis of talc granulomatosis secondary to previous intravenous drug abuse was made. The patient was discharged home and his dyspnea and weight loss were attributed to worsening emphysema in the setting of continued heavy smoking, superimposed on talc granulomatosis, causing deteriorating lung infection.", + "fulltext_subclaims": [ + "The patient is a 53-year-old man.", + "He had increasing dyspnea.", + "He had a weight loss of 3 kg over a 4-month period.", + "His past medical history was significant for emphysema.", + "His past medical history was significant for a seizure disorder.", + "His past medical history was significant for hepatitis C.", + "He reported intravenous heroin abuse 30 years previously.", + "The intravenous heroin abuse had been undertaken for a period of 10 years.", + "A chest X-ray showed an ill-defined density close to the right heart border.", + "A CT scan confirmed a 4.5 × 2.2 cm opacity in the medial aspect of the right middle lobe.", + "The CT scan showed emphysematous changes.", + "The CT scan showed spiculated opacities in both lung fields suspicious for malignant spread.", + "A CT scan of the abdomen and pelvis was unremarkable.", + "The patient underwent autofluorescence bronchoscopy.", + "The visualized portions of the upper and lower airways were widely patent with no abnormalities.", + "Ultrasound of the mediastinum located the echodensity inferior to the right hilum.", + "Fine needle biopsy of the echodensity was obtained via endobronchial ultrasound-guided transbronchial needle aspiration.", + "Biopsies were obtained from four further echodense areas.", + "The biopsy returned negative for malignancy.", + "Histology showed bronchial epithelial cells.", + "Histology showed a marked foreign body giant cell reaction.", + "Histology showed associated polarizable birefringent foreign bodies.", + "A diagnosis of talc granulomatosis secondary to previous intravenous drug abuse was made.", + "The patient was discharged home." + ], + "summary": "A 53-year-old man reported a 4-month history of increasing dyspnea and weight loss. He had a long history of smoking and admission chest X-ray revealed a density in the right hemithorax. Computed tomography confirmed a probable mass with further speculated opacities in both lung fields suspicious for malignant spread. Biopsies obtained using endobronchial ultrasound-guided aspiration returned negative for malignancy and showed bronchial epithelial cells with foreign body giant cell reaction and polarizable birefringent talc crystals.", + "summary_subclaims": [ + "The patient is a 53-year-old man.", + "He reported a 4-month history of increasing dyspnea.", + "He reported a 4-month history of weight loss.", + "He had a long history of smoking.", + "Admission chest X-ray revealed a density in the right hemithorax.", + "Computed tomography confirmed a probable mass.", + "Computed tomography showed further speculated opacities in both lung fields suspicious for malignant spread.", + "Biopsies obtained using endobronchial ultrasound-guided aspiration returned negative for malignancy.", + "Biopsies showed bronchial epithelial cells.", + "Biopsies showed a foreign body giant cell reaction.", + "Biopsies showed polarizable birefringent talc crystals." + ] + }, + { + "id": "multiclinsum_test_1337_en.txt", + "fulltext": "A 24-year-old male was admitted to the acute medical assessment unit through emergency department with presenting complaint of left sided chest pain. Chest pain was gradual in onset, started overnight with 6/10 in intensity, sharp in character, increased by deep breathing and lying down, and improved by leaning forward. Chest pain was associated with nausea and single episode of non-bloody vomiting. Patient also reported fever, generalized tiredness, lethargy, and insomnia. Patient also had pounding of heart but thought that it was result of his anxiety. There was no history of sore throat, rigours, chills, cough, or sputum. Patient also denied history of shortness of breath, paroxysmal nocturnal dyspnoea, and orthopnoea or ankle oedema. There was no history of chest trauma or skin rash. There was no prior history of chest pains. Patient had history of insomnia, had significant unintentional weight loss of 6–8 kg over last 3 weeks despite good appetite, heat intolerance, shakiness of hands, and nervousness. He adamantly denied any visual disturbance or change in appearance of his eyes. His vitals on arrival were temperature 38˚C, blood pressure 130/80 mmHg, heart rate 125 b.p.m., and respiratory rate 18.\nOn clinical examination patient looked anxious and in agony, there were fine tremors on outstretched hands with sweaty palms. His pulse was fast, regular, and high in volume. There was no exophthalmos clinically. Neck examination shows diffuse enlargement of thyroid gland which was non-tender, there was no associated lymphadenopathy. No bruit was heard over thyroid gland. On cardiac examination, heart tones were normal and no rub was appreciated. Respiratory and rest of systemic examination was normal. His medical history was only significant for anxiety disorder. He was a non-smoker and teetotaller. He denied use of herbal medicines or recreational drugs. Family history was unremarkable for pericarditis or thyroidal problems.\nHis electrocardiogram (ECG) showed sinus tachycardia, diffuse ST-elevation in both chest and limb leads, PR depression in most of limb leads. In addition, there was PR elevation and reciprocal ST-depression in lead aVR. All of these features were suggestive of acute pericarditis. Chest X-ray was normal. Ultrasound thyroid with Doppler was done which showed enlarged thyroid with heterogeneous echotexture and increased vascularity also known as thyroid inferno suggestive of Graves’ disease. In addition, there was neither focal nodule nor abnormality in thyroid, nor cervical lymphadenopathy. His thyroid function test demonstrated thyroid stimulating hormone (TSH) <0.02 mU/L (normal range 0.27–4.20) and freeT4 was >100 pmol/L (normal range 11–26). Anti-thyroglobulin antibodies were also significantly elevated 58.2 U/L (normal range 0–0.99). His first troponin was normal 14 ng/L (normal range 0–14), and repeat one was 19 ng/L (only minimally elevated). His C-reactive protein (CRP) was <5 mg/L (normal range 0–9) and erythrocyte sedimentation rate (ESR) was 5 (normal range 1–13). Antinuclear antibodies profile was negative , and rest of his blood investigations was unremarkable. Echocardiogram was performed which showed preserved left ventricular systolic function without any regional wall motion abnormalities. There was a small global pericardial effusion noted (1 cm around right atrial free wall, 0.6 cm around lateral wall, and 0.3 cm posteriorly) which was not causing any haemodynamic compromise or tamponade. Right ventricular systolic function was preserved with no evidence of right heart strain.\nHis overall clinical picture, based on history and investigations, was consistent with a diagnosis of pericarditis associated with Graves’ disease. Given his clinical context, he was started on ibuprofen 400 mg thrice daily (TDS) to control pain and inflammation with Pericarditis along with Omeprazole 40 mg once daily (OD). Carbimazole 40 mg OD was commenced to control Graves’s systemic symptoms and Propranolol 40 mg TDS was prescribed to control anxiety, tremors, and tachycardia. Patient had remarkable improvement of his symptoms and was discharged a couple of days later with follow-up arranged in endocrine outpatients. He became clinically and biochemically euthyroid with subsequent thyroid functions after 12 weeks as: TSH 1.1 mU/L (normal range −0.27 to 4.20), free T4 20 pmol/L (normal range 11–26). Both his CRP and ESR on subsequent testing after 3 months remained normal. Both repeat ECG and echocardiography after 4 months revealed complete resolution of pericarditis.", + "fulltext_subclaims": [ + "The patient was a 24-year-old male.", + "The patient was admitted to the acute medical assessment unit through the emergency department.", + "The presenting complaint was left-sided chest pain.", + "The chest pain was gradual in onset and started overnight.", + "The chest pain was 6/10 in intensity.", + "The chest pain was sharp in character.", + "The chest pain increased with deep breathing.", + "The chest pain increased with lying down.", + "The chest pain improved with leaning forward.", + "The chest pain was associated with nausea.", + "The patient had a single episode of non-bloody vomiting.", + "The patient reported fever.", + "The patient reported generalized tiredness.", + "The patient reported insomnia.", + "The patient reported unintentional weight loss of 6–8 kg over the last 3 weeks.", + "The patient reported heat intolerance.", + "The patient reported shakiness of hands.", + "The patient reported nervousness.", + "The patient denied any visual disturbance.", + "The patient denied any change in appearance of his eyes.", + "On arrival, the temperature was 38°C.", + "On arrival, the heart rate was 125 b.p.m.", + "The ECG showed sinus tachycardia.", + "The ECG showed diffuse ST-elevation in both chest and limb leads.", + "The ECG showed PR depression in most limb leads.", + "The ECG showed PR elevation and reciprocal ST-depression in lead aVR.", + "These ECG features were suggestive of acute pericarditis.", + "The chest X-ray was normal.", + "The ultrasound thyroid showed enlarged thyroid with heterogeneous echotexture.", + "The ultrasound thyroid showed increased vascularity, known as thyroid inferno.", + "The ultrasound thyroid showed no focal nodule.", + "The ultrasound thyroid showed no abnormality in the thyroid.", + "The ultrasound thyroid showed no cervical lymphadenopathy.", + "The thyroid function test showed TSH <0.02 mU/L.", + "The thyroid function test showed free T4 >100 pmol/L.", + "The anti-thyroglobulin antibodies were 58.2 U/L.", + "The first troponin was 14 ng/L.", + "The repeat troponin was 19 ng/L.", + "The echocardiogram showed a small global pericardial effusion.", + "The echocardiogram showed no haemodynamic compromise.", + "The echocardiogram showed no tamponade.", + "The overall clinical picture was consistent with a diagnosis of pericarditis associated with Graves’ disease.", + "The patient was started on ibuprofen 400 mg thrice daily.", + "The patient was started on carbimazole 40 mg once daily.", + "The patient was started on propranolol 40 mg thrice daily.", + "The patient had remarkable improvement of his symptoms.", + "The patient was discharged a couple of days later.", + "The patient became clinically and biochemically euthyroid after 12 weeks.", + "The TSH after 12 weeks was 1.1 mU/L.", + "The free T4 after 12 weeks was 20 pmol/L.", + "Both repeat ECG and echocardiography after 4 months revealed complete resolution of pericarditis." + ], + "summary": "A 24-year-old male was admitted to hospital with presenting complaint of left-sided chest pain, gradual in onset, 6/10 in intensity, sharp in character, increased by deep breathing and improved by leaning forward. Patient also gave a history of insomnia, unintentional weight loss despite a good appetite, heat intolerance, and anxiety. On clinical examination, the patient had features of thyrotoxicosis, i.e., tachycardia, high volume pulse, and sweaty palms with fine tremors. There was no associated pericardial rub. Neck examination shows diffuse, non-tender goitre. Electrocardiogram findings were consistent with acute pericarditis. His thyroid function tests demonstrated hyperthyroidism and anti-thyroglobulin antibodies were also significantly elevated. Echocardiogram showed preserved left ventricular systolic function and a small global pericardial effusion without any signs of tamponade. He was diagnosed with Graves' disease revealing itself as pericarditis and was started on ibuprofen, beta-blockers, and carbimazole. Patient had marked clinical and biochemical improvement on 3 monthly follow-ups.", + "summary_subclaims": [ + "A 24-year-old male was admitted to hospital with presenting complaint of left-sided chest pain.", + "The chest pain was gradual in onset.", + "The chest pain was 6/10 in intensity.", + "The chest pain was sharp in character.", + "The chest pain increased by deep breathing.", + "The chest pain improved by leaning forward.", + "The patient gave a history of insomnia.", + "The patient had unintentional weight loss despite a good appetite.", + "The patient reported heat intolerance.", + "The patient had anxiety.", + "Clinical examination showed features of thyrotoxicosis.", + "There was no associated pericardial rub.", + "Neck examination showed diffuse, non-tender goitre.", + "Electrocardiogram findings were consistent with acute pericarditis.", + "Thyroid function tests demonstrated hyperthyroidism.", + "Anti-thyroglobulin antibodies were significantly elevated.", + "Echocardiogram showed a small global pericardial effusion.", + "Echocardiogram showed preserved left ventricular systolic function.", + "There were no signs of tamponade.", + "The patient was diagnosed with Graves' disease revealing itself as pericarditis.", + "The patient was started on ibuprofen.", + "The patient was started on beta-blockers.", + "The patient was started on carbimazole.", + "The patient had marked clinical and biochemical improvement on 3 monthly follow-ups." + ] + }, + { + "id": "multiclinsum_test_3283_en.txt", + "fulltext": "An 87-year-old woman with dyspnea on exertion and lower limb pitting edema was referred to our hospital because of suspected heart failure. She also noticed watery melena 3 months before and slight fever and bilateral lower limb pitting edema 2 weeks before admission. She had been diagnosed as having hypertension and had been taking calcium antagonist and angiotensin receptor blocker. She had no history of taking statin-based medicine.\n\nOn admission, her vitals were as follows: body temperature, 38.8 °C; heart rate, 70 beats/min; respiration rate, 25 breaths/min; and blood pressure, 186/91 mmHg. Her oxygen saturation was 97% at room air.\n\nPhysical examination revealed bilateral lower limb pitting edema and a Levine 2/6 systolic regurgitation murmur at the apex. She had no signs or symptoms that indicated dermatomyositis (i.e., muscle grasping pain, Gottron’s papule, and heliotrope rash). Neurological examinations revealed proximal limb motor weakness (manual muscle test score, 3–4/4), mainly in the neck flexor, deltoid, iliopsoas, gluteus maximus, and quadriceps muscle. We did not observe cranial nerve palsies, muscle pains, fasciculation, sensory disturbances, cerebellar ataxia, or abnormal deep tendon reflexes.\n\nLaboratory examinations revealed high serum levels of the muscle-related enzymes (CK, 4195 mg/dL and CK-Mb, 191.8 ng/mL) and brain natriuretic peptide (285.9 pg/mL). She also showed anemia (hemoglobin level, 10.2 g/dL), hyponatremia (Na, 126 mEq/L), and thyroidal dysfunction (thyroid-stimulating hormone, 8.3 μIU/mL; free T3, 1.5 pg/mL; and free T4, 1.0 ng/dL). Renal function, glycometabolism, and other myocardial markers were within the normal ranges.\n\nElectrocardiography revealed sinus rhythm with the narrow QRS complex. The p-wave morphology was biphasic. The findings met the criteria of left ventricular high voltage without ST-segment abnormalities. Transthoracic echocardiography revealed diastolic left ventricular dysfunction (E/e′ = 19.2) with well-preserved ejection fraction (73%), along with left ventricular wall hypertrophy (end-diastolic intraventricular septal thickness, 13 mm) and pericardial effusion.\n\nChest computed tomography (CT) revealed bilateral pleural fluid retention and pericardial effusion without lung congestion indicating right heart failure. An abdominopelvic CT scan showed wall thickening of the Ra region on the rectum and lateral lymphadenopathy, indicating advanced rectal cancer. Colonoscopy revealed a type I progressive rectal tumor located 5 cm proximal to the anal verge and a type I primary rectal tumor located 18 cm proximal to the anal verge. In addition, primary colon cancer was found in the ascending colon. Histological results confirmed triple adenocarcinomas of the rectum and ascending colon with no evidence of metastasis.\n\nFemoral magnetic resonance imaging (MRI) of the short T1 inversion recovery (STIR) sequence revealed high-intensity lesions in the left vastus lateralis muscle. A needle electromyographic study (nEMG) showed fibrillation potential, positive sharp wave, and poly-phasic motor unit potential on the right vastus lateralis muscle but not on the right tibialis anterior muscle.\n\nA muscle biopsy from her left vastus lateralis muscle revealed muscle fibers of various sizes accompanied by necrotic and regenerating fibers along with immunopositivity for major histocompatibility complex class I, whereas only slight to mild inflammatory cell infiltration was noted around the muscle fibers. Furthermore, membrane attack complex (MAC) equivocally deposited on some muscular surfaces. The patient’s serum was positive for anti-SRP antibodies, but negative for anti-HMGCR antibodies and other myositis-specific antibodies. On the basis of the pathological findings and additional serum examinations, she was diagnosed as having anti-SRP antibody-positive NM.\n\nThe muscle weakness progressed rapidly after admission. The patient underwent laparoscopic lower anterior/ileocecal resection of the rectal/colon cancer and received high-dose methylprednisolone (1000 mg/day × 3 days intravenously) as initial treatment. Prednisolone (50 mg/day [1 mg/kg] orally) was administered after the initial treatment. Although her serum CK level decreased with the prednisolone therapy, her muscle weakness did not improve. After initiating IVIg therapy (400 mg/[kg·day]), her muscle weakness recovered remarkably. She was discharged 94 days after admission. Her prednisolone dose was gradually tapered to 8 mg/day without relapse 12 months after discharge.\n\nFor heart failure, administration of diuretics was initiated immediately after admission. During the in-hospital treatment, paroxysmal supraventricular tachycardia, atrial fibrillation, and non-sustained ventricular tachycardia were observed. Parallel with the improvement in muscle strength, her arrhythmia, diastolic left ventricular dysfunction, and pericardial effusion also improved.\n\nThe contrast-enhanced cardiac MRI performed 5 months after discharge revealed a spotty late gadolinium enhancement in the middle inferior wall of the left ventricle. T2-weighted imaging did not show any high-intensity area, suggesting a post-myocarditis change.", + "fulltext_subclaims": [ + "An 87-year-old woman with dyspnea on exertion and lower limb pitting edema was referred to our hospital because of suspected heart failure.", + "She noticed watery melena 3 months before.", + "She had slight fever and bilateral lower limb pitting edema 2 weeks before admission.", + "She had been diagnosed as having hypertension and had been taking calcium antagonist and angiotensin receptor blocker.", + "She had no history of taking statin-based medicine.", + "On admission, her body temperature was 38.8 °C.", + "Her oxygen saturation was 97% at room air.", + "Physical examination revealed bilateral lower limb pitting edema.", + "She had no signs or symptoms that indicated dermatomyositis.", + "Neurological examinations revealed proximal limb motor weakness.", + "Laboratory examinations revealed high serum levels of the muscle-related enzymes (CK, 4195 mg/dL and CK-Mb, 191.8 ng/mL).", + "She showed anemia (hemoglobin level, 10.2 g/dL).", + "She showed hyponatremia (Na, 126 mEq/L).", + "She showed thyroidal dysfunction (thyroid-stimulating hormone, 8.3 μIU/mL; free T3, 1.5 pg/mL; and free T4, 1.0 ng/dL).", + "Electrocardiography revealed sinus rhythm with the narrow QRS complex.", + "The findings met the criteria of left ventricular high voltage without ST-segment abnormalities.", + "Transthoracic echocardiography revealed diastolic left ventricular dysfunction (E/e′ = 19.2) with well-preserved ejection fraction (73%).", + "Chest computed tomography (CT) revealed bilateral pleural fluid retention and pericardial effusion.", + "An abdominopelvic CT scan showed wall thickening of the Ra region on the rectum and lateral lymphadenopathy.", + "Colonoscopy revealed a type I progressive rectal tumor located 5 cm proximal to the anal verge.", + "A muscle biopsy from her left vastus lateralis muscle revealed muscle fibers of various sizes accompanied by necrotic and regenerating fibers.", + "The patient’s serum was positive for anti-SRP antibodies.", + "The patient’s serum was negative for anti-HMGCR antibodies.", + "She was diagnosed as having anti-SRP antibody-positive NM.", + "The patient underwent laparoscopic lower anterior/ileocecal resection of the rectal/colon cancer.", + "She received high-dose methylprednisolone (1000 mg/day × 3 days intravenously) as initial treatment.", + "Prednisolone (50 mg/day [1 mg/kg] orally) was administered after the initial treatment.", + "After initiating IVIg therapy (400 mg/[kg·day]), her muscle weakness recovered remarkably.", + "She was discharged 94 days after admission.", + "Her prednisolone dose was gradually tapered to 8 mg/day without relapse 12 months after discharge.", + "For heart failure, administration of diuretics was initiated immediately after admission.", + "During the in-hospital treatment, paroxysmal supraventricular tachycardia, atrial fibrillation, and non-sustained ventricular tachycardia were observed.", + "The contrast-enhanced cardiac MRI performed 5 months after discharge revealed a spotty late gadolinium enhancement in the middle inferior wall of the left ventricle." + ], + "summary": "An 87-year-old woman with dyspnea on exertion and leg edema was referred to our hospital because of suspected heart failure and elevated serum creatine kinase level. Upon hospitalization, she developed muscle weakness predominantly in the proximal muscles. Muscle biopsy and immunological blood test led to the diagnosis of anti-SRP-antibody-positive myopathy. A colon carcinoma was also found and surgically removed. The muscle weakness remained despite the tumor resection and treatment with methylprednisolone. Cardiac screening revealed arrhythmia and diastolic dysfunction with pericardial effusion, which recovered with intravenous immunoglobulin (IVIg) treatment.", + "summary_subclaims": [ + "The patient is an 87-year-old woman.", + "She had dyspnea on exertion.", + "She had leg edema.", + "She was referred to the hospital because of suspected heart failure.", + "She had an elevated serum creatine kinase level.", + "She developed muscle weakness predominantly in the proximal muscles.", + "Muscle biopsy and immunological blood test led to the diagnosis of anti-SRP-antibody-positive myopathy.", + "A colon carcinoma was found.", + "The colon carcinoma was surgically removed.", + "The muscle weakness remained despite the tumor resection.", + "The muscle weakness remained despite treatment with methylprednisolone.", + "Cardiac screening revealed arrhythmia.", + "Cardiac screening revealed diastolic dysfunction.", + "Cardiac screening revealed pericardial effusion.", + "The arrhythmia and diastolic dysfunction with pericardial effusion recovered with intravenous immunoglobulin treatment." + ] + }, + { + "id": "multiclinsum_test_2724_en.txt", + "fulltext": "The case is of a 3.7-kg, 1-month-old male patient who presented at day 24 of life with severe aortic stenosis (AS) and coarctation of the aorta (CoA). He was born at term following an uncomplicated pregnancy. On day 5 of life, he was noted to be jaundiced and have a murmur. His jaundice resolved, and he was discharged home with cardiac follow-up. He then had progressive increase in his work of breathing and was not gaining weight. He had an echocardiogram on day 24 of life which showed a thickened and dysplastic bicuspid aortic valve with doming of the valve leaflets. The flow across the valve was measured on continuous wave doppler at 4 m/s. He was also found to have a discrete juxta ductal coarctation of the aorta with continuous doppler flow of 2.5 m/s with diastolic tail. His ventricular function remained preserved. He was started on intravenous prostaglandin and urgent surgery was scheduled.\nDue to the complexity of the case and the need for both aortic valve and aortic arch intervention, it was felt the best course of action would be a hybrid approach with surgical end-to-end anastomosis of the aortic arch via a thoracotomy followed by surgical carotid cut down for AoVP. This plan was made to avoid the need for a sternotomy on bypass to alleviate the aortic valve stenosis. The patient was taken to the hybrid catheter laboratory theater, where he was placed in the left lateral position, prepped and draped. He underwent the surgical end-to-end anastomosis via the thoracotomy via the third intercostal space, as planned. The arch, patent ductus arteriosus (PDA) and descending aorta were then dissected out. Clamps were applied to the arch and descending aorta. The coarctation segment was resected and PDA ligated. After this, an end to side anastomosis was performed between the aortic arch and the descending aorta. The pleura and chest were closed in layers.\nAt this point the patient was assessed and felt to be stable to proceed with the planned aortic balloon. The patient was turned from the lateral position to his back and the surgeon performed a carotid cutdown on the right common carotid artery. A 5/0 purse string suture was applied to the vessel, and through that a 4-Fr sheath was inserted in the right common carotid artery. Using a 4-Fr pigtail catheter, ascending aortic pressure was measured at 61/42 mmHg. An aortic angiogram was then performed and the aortic valve annulus measured 7.5 mm. The pigtail catheter was then replaced with a 4-Fr Judkins Right Coronary Catheter (JR). Using a Terumo 0.035″ guide wire the JR catheter was placed into the left ventricle (LV). The pressure in the LV was recorded at 110/13 mmHg, giving a peak to peak gradient of 49 mmHg. A 0.014 ChoICE PT extra support coronary wire (Boston Scientific) was then placed in the LV and the JR catheter removed. Next a NuMED Tyshak II 6 mm × 2 cm percutaneous transluminal valvuloplasty balloon catheter was chosen and delivered over the ChoICE wire to the aortic valve. The balloon was inflated to burst pressure of 4 atmospheres (atm) with waist seen within the balloon and dewaisting occurred. The balloon catheter was removed and the JR catheter re-introduced. The pressure was measured at 100/10 mmHg. Repeat angiogram at the aortic root at this stage did not demonstrate any significant aortic incompetence. The JR catheter and the Terumo wire were again used to recross the valve, and a 7 mm × 2 cm NuMED Tyshak II percutaneous transluminal valvuloplasty balloon catheter was chosen and delivered over the coronary guidewire in position. The balloon was inflated to 4 atm, a waist was again seen and dewaisting occurred. The balloon catheter was removed, and the JR catheter placed back into the LV. Pressure within the LV was now 90/10 mmHg with pullback peak to peak gradient between the LV and ascending aorta measuring 30 mmHg. The catheter and sheath were removed, the vessel was repaired by tightening the pursestring suture and the skin closed in layers.\nAn echocardiogram performed post procedure showed qualitatively normal ventricular function with no pericardial effusion. The arch was unobstructed with doppler flow velocity of 1.6 m/s. The aortic valve was bicuspid and obviously dysplastic. There was mild flow acceleration across the valve using continuous wave doppler of 3 m/s with mean doppler gradient of 15 mmHg. There was no obvious aortic incompetency seen.\nThe patient was transferred from the hybrid catheter laboratory to the pediatric intensive care unit (PICU). He remained cardiovascularly stable during his PICU admission. He was extubated but had to be reintubated within a few hours due to upper airway issues which prolonged his PICU stay. He was successfully extubated on day 3 post procedure and was transferred to the cardiac ward. His admission on the ward was uncomplicated and he was discharged on day 6 post intervention.\nAt 4 months of age, he was reviewed in the outpatient clinic. He was clinically asymptomatic with steady growth. His echocardiogram demonstrated qualitatively normal ventricular function, the aortic valve stenosis was mild to moderate with flow of 3.7 m/s on continuous wave doppler with mean gradient of 30 mmHg. There was evidence of mild aortic incompetence, his aortic arch remained unobstructed with flow velocity of 1.4 m/s. His most recent follow-up was at 8 months of age. He remained asymptomatic and well with his weight increasing to 9 kg. His echocardiogram again demonstrated qualitatively normal ventricular function, bicuspid aortic valve with flow of 3.2 m/s across the valve. There was mild aortic incompetence and the aortic arch remained unobstructed. There were no issues with his carotid artery access and there were no ongoing neurological issues.", + "fulltext_subclaims": [ + "The patient is a 3.7-kg, 1-month-old male.", + "He presented at day 24 of life with severe aortic stenosis and coarctation of the aorta.", + "He was born at term following an uncomplicated pregnancy.", + "On day 5 of life, he was noted to be jaundiced and have a murmur.", + "His jaundice resolved, and he was discharged home with cardiac follow-up.", + "He had progressive increase in his work of breathing.", + "He was not gaining weight.", + "An echocardiogram on day 24 of life showed a thickened and dysplastic bicuspid aortic valve with doming of the valve leaflets.", + "The flow across the valve was measured on continuous wave doppler at 4 m/s.", + "He was found to have a discrete juxta ductal coarctation of the aorta with continuous doppler flow of 2.5 m/s with diastolic tail.", + "His ventricular function remained preserved.", + "He was started on intravenous prostaglandin.", + "Urgent surgery was scheduled.", + "The best course of action was felt to be a hybrid approach with surgical end-to-end anastomosis of the aortic arch via a thoracotomy followed by surgical carotid cut down for AoVP.", + "The patient was taken to the hybrid catheter laboratory theater.", + "He underwent the surgical end-to-end anastomosis via the thoracotomy via the third intercostal space.", + "The arch, patent ductus arteriosus, and descending aorta were dissected out.", + "Clamps were applied to the arch and descending aorta.", + "The coarctation segment was resected.", + "The patent ductus arteriosus was ligated.", + "An end to side anastomosis was performed between the aortic arch and the descending aorta.", + "The pleura and chest were closed in layers.", + "The patient was assessed and felt to be stable to proceed with the planned aortic balloon.", + "A 5/0 purse string suture was applied to the right common carotid artery.", + "A 4-Fr sheath was inserted in the right common carotid artery.", + "Ascending aortic pressure was measured at 61/42 mmHg.", + "The aortic valve annulus measured 7.5 mm.", + "The pressure in the left ventricle was recorded at 110/13 mmHg.", + "A peak to peak gradient of 49 mmHg was calculated.", + "A 0.014 ChoICE PT extra support coronary wire was placed in the left ventricle.", + "A NuMED Tyshak II 6 mm × 2 cm percutaneous transluminal valvuloplasty balloon catheter was delivered over the ChoICE wire to the aortic valve.", + "The balloon was inflated to burst pressure of 4 atmospheres.", + "A waist was seen within the balloon and dewaisting occurred.", + "The balloon catheter was removed.", + "The pressure was measured at 100/10 mmHg.", + "Repeat angiogram at the aortic root did not demonstrate any significant aortic incompetence.", + "A 7 mm × 2 cm NuMED Tyshak II percutaneous transluminal valvuloplasty balloon catheter was delivered over the coronary guidewire in position.", + "The balloon was inflated to 4 atm.", + "A waist was again seen and dewaisting occurred.", + "The balloon catheter was removed.", + "The pressure within the left ventricle was now 90/10 mmHg.", + "The pullback peak to peak gradient between the left ventricle and ascending aorta measured 30 mmHg.", + "The catheter and sheath were removed.", + "The vessel was repaired by tightening the pursestring suture.", + "The skin was closed in layers.", + "An echocardiogram performed post procedure showed qualitatively normal ventricular function with no pericardial effusion.", + "The arch was unobstructed with doppler flow velocity of 1.6 m/s.", + "The aortic valve was bicuspid and obviously dysplastic.", + "There was mild flow acceleration across the valve using continuous wave doppler of 3 m/s.", + "There was a mean doppler gradient of 15 mmHg.", + "There was no obvious aortic incompetency seen.", + "The patient was transferred from the hybrid catheter laboratory to the pediatric intensive care unit.", + "He remained cardiovascularly stable during his PICU admission.", + "He was extubated but had to be reintubated within a few hours due to upper airway issues.", + "He was successfully extubated on day 3 post procedure.", + "He was transferred to the cardiac ward.", + "His admission on the ward was uncomplicated.", + "He was discharged on day 6 post intervention.", + "At 4 months of age, he was reviewed in the outpatient clinic.", + "He was clinically asymptomatic with steady growth.", + "His echocardiogram demonstrated qualitatively normal ventricular function.", + "The aortic valve stenosis was mild to moderate with flow of 3.7 m/s on continuous wave doppler.", + "There was evidence of mild aortic incompetence.", + "The aortic arch remained unobstructed with flow velocity of 1.4 m/s.", + "His most recent follow-up was at 8 months of age.", + "He remained asymptomatic and well with his weight increasing to 9 kg.", + "His echocardiogram again demonstrated qualitatively normal ventricular function.", + "The bicuspid aortic valve had flow of 3.2 m/s across the valve.", + "There was mild aortic incompetence.", + "The aortic arch remained unobstructed.", + "There were no issues with his carotid artery access.", + "There were no ongoing neurological issues." + ], + "summary": "a 1-month-old baby presented with severe AS and CoA. The decision was made to perform a hybrid surgical procedure. The patient underwent a lateral thoracotomy for repair of the CoA and carotid cutdown for aortic balloon valvuloplasty (AoVP).", + "summary_subclaims": [ + "The patient is a 1-month-old baby.", + "The baby presented with severe AS.", + "The baby presented with CoA.", + "The decision was made to perform a hybrid surgical procedure.", + "The patient underwent a lateral thoracotomy for repair of the CoA.", + "The patient underwent carotid cutdown for aortic balloon valvuloplasty." + ] + }, + { + "id": "multiclinsum_test_1484_en.txt", + "fulltext": "An 11.7-year-old boy was admitted to our hospital due to headache, vomiting and altered mental status.\nTwo days before admission, the patient complained of a headache without obvious inducement, accompanied by vomiting 25 times. The headache did not improve with cold medication. He became unconscious 12 h before admission, and relevant tests were completed at a referring hospital. His blood ammonia was > 500 µmol/L. He was referred to our hospital for further treatment.\nThe patient was the product of a first pregnancy and first birth (G1P1) mother, and delivered by cesarean section at term with a birth weight of 3.0 kg. His perinatal condition was unremarkable, with no history of asphyxia. He was generally healthy and developed normally for a child of the same age. Prior to this episode, the family was not aware that the patient had OTCD.\nThe patient had no significant family history. No patients in the family had OTCD or symptoms associated with the disease.\nOn physical examination, he was in a moderate comatose state [Glasgow coma score (GSC) 6] and was unresponsive to sound. His eyes could not be closed, the pupils were equally large and round, about 3 mm in diameter, and light reflex was delayed. There were no significant abnormalities on cardiopulmonary or abdominal examinations. Muscle strength in the limbs could not be tested, muscle tone was normal, and all pathological signs were negative.\nLaboratory tests showed a significantly elevated blood ammonia level . Liver function and coagulation times were abnormal. Blood tandem mass spectrometry showed moderately elevated glutamine. Citrulline and arginine were in the normal range. Urine organic acid gas phase mass spectrometry showed that uracil and orotic acid levels were elevated. Blood ammonia levels during the first week of admission are shown in Figure . During the remainder rest of his hospital stay, levels were in the normal range.\nWhole exome gene testing revealed the OTC gene exon2 hemizygote variant c.119G > A (p.R40H), inherited from his mother. The missense mutation was located in the well-studied exon functional domain without benign variation [Pathogenic moderate (PM) 1]. The frequencies of all normal population databases (dsSNP, 1000 genomes) were less than 0.0005 (PM2). This is a variant with different amino acid changes at the same locus reported in the literature as pathogenic variants (PM5). Pathogenic missense mutations of this gene are common, and benign missense mutations are rare [Pathogenic supporting (PP) 2]. The literature reported that variant to caused impaired gene function as show by in vitro functional assays [Pathogenic strong (PS) 3]. In summary, according to American College of Medical Genetics (ACMG)guidelines, this variant is likely pathogenic (PM1 + PM2 + PM5 + PP2 + PS3).\nBrain magnetic resonance imaging (MRI) revealed that large patches of symmetrical high signal shadows on T2 weighted imaging (T2WI) and fluid attenuated inversion recovery in the cerebral hemispheres, and diffusion WI (DWI) revealed a significant high signal, more pronounced in the bilateral dorsal thalamus, caudate nucleus, lenticular nucleus, insula, cingulate gyrus and frontal lobe into the cortex at the falx.", + "fulltext_subclaims": [ + "An 11.7-year-old boy was admitted to our hospital due to headache, vomiting and altered mental status.", + "Two days before admission, the patient complained of a headache without obvious inducement.", + "The headache was accompanied by vomiting 25 times.", + "The headache did not improve with cold medication.", + "He became unconscious 12 h before admission.", + "His blood ammonia was > 500 µmol/L.", + "He was referred to our hospital for further treatment.", + "The patient was the product of a first pregnancy and first birth (G1P1) mother.", + "He was delivered by cesarean section at term.", + "His birth weight was 3.0 kg.", + "His perinatal condition was unremarkable.", + "He had no history of asphyxia.", + "He was generally healthy and developed normally for a child of the same age.", + "Prior to this episode, the family was not aware that the patient had OTCD.", + "The patient had no significant family history.", + "No patients in the family had OTCD.", + "On physical examination, he was in a moderate comatose state [Glasgow coma score (GSC) 6].", + "His eyes could not be closed.", + "The pupils were equally large and round, about 3 mm in diameter.", + "Light reflex was delayed.", + "There were no significant abnormalities on cardiopulmonary or abdominal examinations.", + "Muscle tone was normal.", + "All pathological signs were negative.", + "Laboratory tests showed a significantly elevated blood ammonia level.", + "Liver function and coagulation times were abnormal.", + "Blood tandem mass spectrometry showed moderately elevated glutamine.", + "Citrulline and arginine were in the normal range.", + "Urine organic acid gas phase mass spectrometry showed that uracil and orotic acid levels were elevated.", + "Whole exome gene testing revealed the OTC gene exon2 hemizygote variant c.119G > A (p.R40H).", + "The variant was inherited from his mother.", + "The missense mutation was located in the well-studied exon functional domain without benign variation [Pathogenic moderate (PM) 1].", + "The frequencies of all normal population databases (dsSNP, 1000 genomes) were less than 0.0005 (PM2).", + "This is a variant with different amino acid changes at the same locus reported in the literature as pathogenic variants (PM5).", + "Pathogenic missense mutations of this gene are common, and benign missense mutations are rare [Pathogenic supporting (PP) 2].", + "The literature reported that the variant caused impaired gene function as shown by in vitro functional assays [Pathogenic strong (PS) 3].", + "According to American College of Medical Genetics (ACMG) guidelines, this variant is likely pathogenic (PM1 + PM2 + PM5 + PP2 + PS3).", + "Brain magnetic resonance imaging (MRI) revealed large patches of symmetrical high signal shadows on T2 weighted imaging (T2WI) and fluid attenuated inversion recovery in the cerebral hemispheres.", + "Diffusion WI (DWI) revealed a significant high signal, more pronounced in the bilateral dorsal thalamus, caudate nucleus, lenticular nucleus, insula, cingulate gyrus and frontal lobe into the cortex at the falx." + ], + "summary": "An 11.7-year-old boy presented with headache, vomiting, and altered consciousness. The patient was diagnosed with late-onset OTCD. After nitrogen scavenging treatment and a protein-free diet, ammonia levels were reduced to normal on the third day of admission. Nevertheless, the patient remained in a moderate coma. After discussion, LT was performed. Following LT, the patient's blood ammonia and biochemical indicators stabilized in the normal range, he regained consciousness, and his nervous system function significantly recovered. Two months after LT, blood amino acids and urine organic acids were normal, and brain magnetic resonance imaging showed a decrease in subcortical lesions.", + "summary_subclaims": [ + "An 11.7-year-old boy presented with headache, vomiting, and altered consciousness.", + "The patient was diagnosed with late-onset OTCD.", + "After nitrogen scavenging treatment and a protein-free diet, ammonia levels were reduced to normal on the third day of admission.", + "The patient remained in a moderate coma.", + "LT was performed after discussion.", + "Following LT, the patient's blood ammonia and biochemical indicators stabilized in the normal range.", + "The patient regained consciousness.", + "The patient's nervous system function significantly recovered.", + "Two months after LT, blood amino acids were normal.", + "Urine organic acids were normal two months after LT.", + "Brain magnetic resonance imaging showed a decrease in subcortical lesions." + ] + }, + { + "id": "multiclinsum_test_803_en.txt", + "fulltext": "A 48-year-old man was referred to our emergency room with a 10-day history of progressive dyspnea, non-productive cough and fever. He had previously visited his primary physician, who prescribed a 7-day treatment with an antibiotic. The patient had a 34-pack-year history of cigarette smoking, did not take any regular medications and had not recently visited any tropical country. Physical examination revealed hyperthermia (38.0°C), with blood pressure and pulse within normal ranges. He was slightly polypneic (28 cycles per minute) but had no other sign of respiratory difficulty. Respiratory sounds were diminished on both pulmonary bases and no adventitial sounds were heard. No rash or lymphadenopathy was noted and the remainder of his physical examination was normal. Room air arterial blood gas (ABG) was unremarkable and laboratory findings showed slight normocytic normochromic anemia (hemoglobin (Hb) 12.3 g/dL, hematocrit (Hct) 36.1%), leukocytosis (20,920/mm3), relative neutrophilia (75.5%), thrombocytosis (499,000/mm3) and elevated C-reactive protein (155.9 mg/L). Ionogram and renal function were normal. Chest X-ray revealed a mild reduction in lung volume and a mild and diffuse coarse reticular pattern on both lungs. The patient was diagnosed with community-acquired pneumonia, and, following admission to the Medicine ward, was started on empiric antibiotic therapy with levofloxacin.\nDuring the first days after admission, persistent fever and high levels of inflammatory markers were noted. Given the patient's condition, an investigative diagnostic procedure was initiated. Blood cultures, HIV and hepatitis testing were negative. Coagulation, hepatic function and urine sediment were unremarkable. Bronchofibroscopy and bronchoalveolar lavage were negative for malignant cells, and virologic, bacterial, and mycological examinations and polymerase chain reaction were negative for mycobacterial DNA. Transthoracic echocardiography showed no evidence of any valvular vegetation, and a blood smear was not compatible with any myelodysplastic syndrome. Thoracoabdominal-pelvic computed tomography (CT) scan revealed several lymph nodes in all mediastinal compartments but no hilar adenomegalies. Multiple cysts and nodules, with mid to upper zone predominance, and interstitial thickening were observed in the lungs . The dimensions of the liver were enlarged, with several irregular hypoattenuating lesions and infracentimetric lymph nodes in the hepatic hilum . As a result, an ultrasound-guided liver biopsy was performed. Histologic and immunohistochemical examination (i.e. positivity for S-100 protein and CD1a antigens) established a diagnosis of LCH.\nA course of steroids (prednisolone, 1.0 mg/kg/day) was initiated, and the patient was encouraged to discontinue smoking immediately, which clearly improved the clinical course of the disease. Six months later, he remains asymptomatic, with low levels of inflammatory markers, although his lung and liver radiological patterns remain unchanged.", + "fulltext_subclaims": [ + "A 48-year-old man was referred to the emergency room with a 10-day history of progressive dyspnea.", + "He had a 10-day history of non-productive cough.", + "He had a 10-day history of fever.", + "He had previously visited his primary physician.", + "The primary physician prescribed a 7-day treatment with an antibiotic.", + "The patient had a 34-pack-year history of cigarette smoking.", + "He had not recently visited any tropical country.", + "Physical examination revealed hyperthermia (38.0°C).", + "He was slightly polypneic (28 cycles per minute).", + "Respiratory sounds were diminished on both pulmonary bases.", + "No adventitial sounds were heard.", + "Room air arterial blood gas was unremarkable.", + "Laboratory findings showed slight normocytic normochromic anemia (hemoglobin 12.3 g/dL, hematocrit 36.1%).", + "Laboratory findings showed leukocytosis (20,920/mm3).", + "Laboratory findings showed relative neutrophilia (75.5%).", + "Laboratory findings showed thrombocytosis (499,000/mm3).", + "C-reactive protein was elevated (155.9 mg/L).", + "Chest X-ray revealed a mild reduction in lung volume.", + "Chest X-ray showed a mild and diffuse coarse reticular pattern on both lungs.", + "The patient was diagnosed with community-acquired pneumonia.", + "He was started on empiric antibiotic therapy with levofloxacin.", + "Persistent fever was noted during the first days after admission.", + "High levels of inflammatory markers were noted during the first days after admission.", + "An investigative diagnostic procedure was initiated.", + "Blood cultures were negative.", + "HIV testing was negative.", + "Hepatitis testing was negative.", + "Coagulation was unremarkable.", + "Hepatic function was unremarkable.", + "Bronchofibroscopy and bronchoalveolar lavage were negative for malignant cells.", + "Virologic, bacterial, and mycological examinations were negative.", + "Polymerase chain reaction was negative for mycobacterial DNA.", + "Transthoracic echocardiography showed no evidence of any valvular vegetation.", + "A blood smear was not compatible with any myelodysplastic syndrome.", + "Thoracoabdominal-pelvic CT scan revealed several lymph nodes in all mediastinal compartments.", + "Multiple cysts and nodules with mid to upper zone predominance were observed in the lungs.", + "Interstitial thickening was observed in the lungs.", + "The liver was enlarged with several irregular hypoattenuating lesions.", + "Infracentimetric lymph nodes were observed in the hepatic hilum.", + "An ultrasound-guided liver biopsy was performed.", + "Histologic and immunohistochemical examination showed positivity for S-100 protein.", + "Histologic and immunohistochemical examination showed positivity for CD1a antigens.", + "A diagnosis of LCH was established.", + "A course of steroids (prednisolone, 1.0 mg/kg/day) was initiated.", + "The patient was encouraged to discontinue smoking immediately.", + "The patient's clinical course improved after discontinuing smoking.", + "Six months later, he remains asymptomatic.", + "Six months later, inflammatory markers are at low levels.", + "Six months later, his lung and liver radiological patterns remain unchanged." + ], + "summary": "The authors report a case of Langerhans' cell histiocytosis in a 48-year-old man with multisystemic disease presentation, including liver involvement.", + "summary_subclaims": [ + "The authors report a case of Langerhans' cell histiocytosis.", + "The patient is a 48-year-old man.", + "The patient had multisystemic disease presentation.", + "The patient had liver involvement." + ] + }, + { + "id": "multiclinsum_test_1031_en.txt", + "fulltext": "XS, a 51-year-old gentleman, came to our attention complaining of several weeks of worsening angina now occurring upon minimal exertion. Hypertension was his only cardiovascular risk factor actively treated with an angiotensin converting enzyme (ACE) inhibitor. No other relevant past medical history was noted. Physical examination was unremarkable highlighting clear heart sounds with no added murmurs and normal lung sounds. His blood pressure was 140/85 mmHg whilst his electrocardiogram (ECG), upon presentation, showed normal sinus rhythm (98 b.p.m.) with widespread ST segment depression consistent with diffuse subendocardial ischaemia and a first troponin sample was below the limit of significance. Given the presentation with progressively worsening angina (unstable angina) and the ECG which suggested a large area of myocardium at jeopardy the patient was loaded with aspirin 300 mg and ticagrelor 180 mg and, following a new anginal episode at rest, a decision was made to undergo urgent invasive coronary angiography. The investigation highlighted a left dominant circulation with a severe mid-left anterior descending narrowing with reduced distal coronaryflow [thrombolysis in myocardial infarction (TIMI) 1] and a severe, large, first obtuse marginal (OM1) stenosis which were both treated with drug-eluting stents implantation with excellent angiographic result, no complications and resolution of ECG anomalies . A statin (atorvastatin 40 mg) was started as part of standard ACS therapy on top of dual antiplatelet therapy (DAPT) and ramipril, of interest no beta-blocker or other rate limiting drugs were commenced. The first 24 h a free of complications, no arrhythmic episode was registered by telemetry monitoring, a routine echocardiogram was unremarkable showing normal ejection fraction in the absence of regional wall motion abnormalities or major valvular dysfunctions, and the patient received two standard doses of ticagrelor (8 a.m. and 6 p.m.). On the second night of hospital stay, whilst lying in bed, the patient complained of the sudden feeling of lightheadness and profound sweating and called out for medical assistance. Upon medical review the patient denied any other symptoms, in particular any pain or angina, no ischaemic changes were noted on the ECG whilst telemetry monitoring review highlighted a 16 s long asystolic pause . The episode was self-limited with return of sinus rhythm thereafter. Electrolytes were checked and found to be within normal limits. Hence, new medications were investigated looking for a possible explanation to the unexpected asystole given also the patient had no history of syncope. Ticagrelor, due to its brady-arrhythmic effect was suspected to be involved and was therefore halted shifting the patient to prasugrel following the administration of a 60 mg loading dose. A temporary pacing line (TPL) was inserted fearing possible further episodes. However, no new brady-arrhythmic episodes were noted on telemetry monitoring and the unused TPL was removed 24 h later. After 2 further days of monitoring, the patient was discharged home on Day 5 post-PCI in excellent general conditions.", + "fulltext_subclaims": [ + "XS is a 51-year-old gentleman.", + "He complained of several weeks of worsening angina now occurring upon minimal exertion.", + "Hypertension was his only cardiovascular risk factor actively treated with an angiotensin converting enzyme (ACE) inhibitor.", + "Physical examination was unremarkable.", + "His blood pressure was 140/85 mmHg.", + "The ECG showed widespread ST segment depression consistent with diffuse subendocardial ischaemia.", + "The first troponin sample was below the limit of significance.", + "The patient was loaded with aspirin 300 mg and ticagrelor 180 mg.", + "A decision was made to undergo urgent invasive coronary angiography.", + "The investigation highlighted a severe mid-left anterior descending narrowing with reduced distal coronary flow (TIMI 1).", + "A severe, large, first obtuse marginal (OM1) stenosis was noted.", + "Both lesions were treated with drug-eluting stent implantation.", + "A statin (atorvastatin 40 mg) was started.", + "No beta-blocker or other rate limiting drugs were commenced.", + "The first 24 h were free of complications.", + "A routine echocardiogram was unremarkable.", + "The patient received two standard doses of ticagrelor (8 a.m. and 6 p.m.).", + "On the second night of hospital stay, the patient complained of sudden lightheadness and profound sweating.", + "Telemetry monitoring highlighted a 16 s long asystolic pause.", + "Electrolytes were within normal limits.", + "Ticagrelor was suspected to be involved in the asystole.", + "Ticagrelor was halted and the patient was shifted to prasugrel.", + "A temporary pacing line (TPL) was inserted.", + "No new brady-arrhythmic episodes were noted.", + "The unused TPL was removed 24 h later.", + "The patient was discharged home on Day 5 post-PCI." + ], + "summary": "A 51-year-old gentleman underwent PCI to left anterior descending and obtuse marginal for unstable angina receiving a loading dose of ticagrelor (180 mg). During hospital stay, whilst on telemetry monitoring, a 16 s long, symptomatic, asystolic ventricular standstill was recorded prompting ticagrelor interruption and a switch to prasugrel.", + "summary_subclaims": [ + "The patient is a 51-year-old gentleman.", + "The patient underwent PCI to the left anterior descending and obtuse marginal arteries.", + "The PCI was performed for unstable angina.", + "The patient received a loading dose of ticagrelor (180 mg).", + "During the hospital stay, telemetry monitoring was used.", + "A 16 s long, symptomatic, asystolic ventricular standstill was recorded.", + "The ventricular standstill prompted interruption of ticagrelor.", + "The patient was switched to prasugrel." + ] + }, + { + "id": "multiclinsum_test_1330_en.txt", + "fulltext": "A 9-year-old female patient arrived at the emergency room because of a 36-h history of intermittent right lower abdominal pain, anorexia, vomit, and quantified high-grade fever. She had no pathological personal or family history of interest. On examination, the right iliac fossa was tender to palpation and no frank peritoneal signs were observed. Initial laboratory evaluation showed leukocytosis, neutrophilia, and an elevated C-reactive protein. Ultrasonography of the abdomen was inconclusive. A heterogeneous lesion of 40 × 37 mm within the colon, no appendix and some swollen mesenteric nodes of at least 10 mm were reported. A complementary abdominal CT scan revealed findings suggestive of ileocolic intussusception with an invagination area of approximately 6.6 × 4.9 cm. After surgical consult, the patient underwent an exploratory laparoscopy that required laparotomy conversion. A well-defined, 5 cm mass at ileo cecal valve and multiple hard pericecal lymph nodes were observed. Preserved permeability between the ileum and colon, complete integrity of the cecum wall and lack of vermiform appendix were also reported. The possibility of an auto-digested appendix and a cecal tumor were discussed. At this time, surgeons decided to resect retrocecal and pericecal lymph nodes and send these samples to pathology before any further intervention. The patient was admitted to the inpatient floor where antibiotic therapy based on ampicillin sulbactam, and metronidazole was initiated. The oncologist department was consulted and complementary laboratory exams including liver and renal function tests, uric acid, electrolytes, lactic dehydrogenase, and quantiferon-TB tests were ordered. Only lactic dehydrogenase was altered. A chest x-ray ruled out mediastinal masses. No alarming findings were reported. However, the patient presented gastric distension, abdominal pain and fever by the second hospitalization day. The content inside the suprapubic JP drain changed from a serohematic aspect to a dense cloudy fluid. A culture and cytochemical analysis of peritoneal fluid was performed without significant results. CBC showed mild leukocytosis and neutrophilia. Reactive C-protein remained elevated. Two blood cultures and an urinalysis were negative. Due to the uncertainty of the etiology of her clinical picture, infectology decided to change antibiotic therapy to piperacillin/tazobactam and amikacin. An abdominal x-ray showed air fluid levels in the small bowel and a colonic distention projected at mesogastrium. Gastroenterology suggested initiating bowel rest and placing a central line for parenteral nutrition.\nAfter five more days, elevated inflammatory markers, abdominal distension and pain, and the unusual JP drain aspect persisted. A new ultrasound confirmed that the mass and surrounding area had the same aspect as days before. The histopathological description of paracecal-retrocecal lymph nodes and the sample of mesenteric omentum obtained during the first intervention failed to detect neoplastic cells. Macroscopically, three encapsulated lymph nodes from 0.8 to 2 cm were received. Their physiological architecture was preserved; secondary lymphoid follicles with hyperplastic germinal centers containing macrophages with cellular debris were reported. The interfollicular population was polymorphic and contained frequent large cells with prominent immunoblast-like nucleoli. Other areas showed sinusoidal histiocytosis with eosinophils and neutrophils. There was fibrosis with a predominantly neutrophilic mixed inflammatory infiltrate that spread to neighboring adipose tissue in the periphery of the nodes. The immunohistochemical study confirmed the presence of follicular dendritic cells and B lymphocytes in the germinal centers (CD23 + + +/+ + + and CD20 + + +/+ + + respectively), T lymphocytes in the mantle zone (CD3 + + +/+ ++), macrophages in germinal centers and sinusoidal area (CD68 +/+ ++). Frequent CD30 + + +/+ + + immunoblasts and actin + + +/+ + + myofibroblasts within areas of fibrosis were also observed. EBV study using EBER in situ hybridization was negative. Ziehl Neelsen and PAS did not show any pathogen. The 22 × 0.6 cm omentum sample showed fibrous thickening of the septa and the presence of a mainly lymphocytic infiltrate. Fibrino-leukocytic material was also seen in the serosa. Pathologists concluded the possibility of an unspecified acute versus chronic epiploitis, lymphadenitis and serositis. Nevertheless, due to her unfavorable clinical evolution and the elevated inflammatory markers, a second surgical intervention was decided. The patient underwent an omentectomy and resection of approximately 40 cm of terminal ileum, cecum and ascending colon. Pericolonic lymph nodes were resected as well. A sample of a collection observed near the cecum was taken for culture and cytochemical studies before aspiration and drainage. After surgery, the patient remained hemodynamically stable, without abdominal pain or distention. A nasogastric tube was placed and parenteral nutrition continued. The peritoneal fluid analysis was negative. Improvement in inflammatory markers lead to amikacin discontinuation. And by the fifth postoperative day, JP drain, and nasogastric tube were removed. Later, a regular diet was successfully initiated, and the patient was finally discharged.\nThe histopathological final report described an 8 cm ileal segment, and a 14 cm ascending colon including the cecum with a diameter that ranged from 1 to 3 cm. The external surface was covered by a pinkish-gray serosa with fibrinopurulent material over the ileocecal area. A completely subserous dilated appendix was identified within the cecum wall. It contained a white-yellowish purulent material at the tip . A well-defined nodular lesion of approximately 1.5 cm was also identified . The mucosa of the cecum was pink while ileal mucosa had a granular appearance. Nine nodules, which measured between 0.3 and 3 cm, were isolated from the surrounding area. The 12 × 4.5 cm omentum sample had no palpable nodes. A second omentum sample showed multiple whitish irregular fragments of bland tissue that measured between 0.8 and 1.5 cm. Microscopically, the histological findings of the fourteen isolated lymph nodes were compatible with follicular hyperplasia. The subserosal cecal appendix showed transmural necrosis and perforation causing leakage of purulent material and an acute inflammatory reaction of the surrounding adipose tissue which extended up to the cecal and ileal serosa. All layers of the appendix were independent and unrelated to the cecum wall . The distal portion of the appendix showed the proliferation of cellular nests that were composed of round uniform nuclei with a “salt and pepper” appearance . No mitotic activity was evidenced. It seemed to infiltrate the muscular layer of the appendix and reach a diameter of 1.5 cm. No lymphovascular or perineural invasion was observed. Disease free margins were reported. Ileum dissection showed Peyer’s patches hyperplasia with wide germinal centers. Tumoral cells’ immunochemical studies showed a Ki67 proliferative index of 2%, a positive (+ + +/+ + +) cytoplasmic granular pan-cytokeratin, a positive (+ + +/+ + +) cytoplasmic chromogranin and a negative synaptophysin reaction . Pathologists concluded the presence of an incidental well differentiated neuroendocrine tumor grade I pT1 pN0 at the tip of the appendix in the middle of a clinical picture caused by an acute necrotizing appendicitis of a complete subserosal appendix. Due to the stage, no further intervention was required. She fully recovered in subsequent controls. Nevertheless, correct management of short bowel syndrome will become a key feature for the preservation of her future quality of life.", + "fulltext_subclaims": [ + "The patient is a 9-year-old female.", + "She had a 36-h history of intermittent right lower abdominal pain.", + "She had anorexia.", + "She had vomit.", + "She had quantified high-grade fever.", + "She had no pathological personal or family history of interest.", + "On examination, the right iliac fossa was tender to palpation.", + "No frank peritoneal signs were observed.", + "Initial laboratory evaluation showed leukocytosis.", + "Initial laboratory evaluation showed neutrophilia.", + "Initial laboratory evaluation showed an elevated C-reactive protein.", + "Ultrasonography of the abdomen was inconclusive.", + "A heterogeneous lesion of 40 × 37 mm within the colon was reported.", + "No appendix was reported.", + "Some swollen mesenteric nodes of at least 10 mm were reported.", + "A complementary abdominal CT scan revealed findings suggestive of ileocolic intussusception.", + "The invagination area was approximately 6.6 × 4.9 cm.", + "The patient underwent an exploratory laparoscopy.", + "The laparoscopy required laparotomy conversion.", + "A well-defined, 5 cm mass at ileo cecal valve was observed.", + "Multiple hard pericecal lymph nodes were observed.", + "Preserved permeability between the ileum and colon was reported.", + "Complete integrity of the cecum wall was reported.", + "Lack of vermiform appendix was reported.", + "The possibility of an auto-digested appendix was discussed.", + "The possibility of a cecal tumor was discussed.", + "Surgeons decided to resect retrocecal and pericecal lymph nodes.", + "The samples were sent to pathology.", + "The patient was admitted to the inpatient floor.", + "Antibiotic therapy based on ampicillin sulbactam was initiated.", + "Antibiotic therapy based on metronidazole was initiated.", + "The oncologist department was consulted.", + "Complementary laboratory exams including liver and renal function tests were ordered.", + "Complementary laboratory exams including uric acid were ordered.", + "Complementary laboratory exams including electrolytes were ordered.", + "Complementary laboratory exams including lactic dehydrogenase were ordered.", + "Complementary laboratory exams including quantiferon-TB tests were ordered.", + "Only lactic dehydrogenase was altered.", + "A chest x-ray ruled out mediastinal masses.", + "No alarming findings were reported.", + "The patient presented gastric distension.", + "The patient presented abdominal pain.", + "The patient presented fever by the second hospitalization day.", + "The content inside the suprapubic JP drain changed from a serohematic aspect to a dense cloudy fluid.", + "A culture and cytochemical analysis of peritoneal fluid was performed.", + "CBC showed mild leukocytosis.", + "CBC showed mild neutrophilia.", + "Reactive C-protein remained elevated.", + "Two blood cultures were negative.", + "An urinalysis was negative.", + "Infectology decided to change antibiotic therapy to piperacillin/tazobactam.", + "Infectology decided to change antibiotic therapy to amikacin.", + "An abdominal x-ray showed air fluid levels in the small bowel.", + "An abdominal x-ray showed colonic distention projected at mesogastrium.", + "Gastroenterology suggested initiating bowel rest.", + "Gastroenterology suggested placing a central line for parenteral nutrition.", + "After five more days, elevated inflammatory markers persisted.", + "Abdominal distension and pain persisted.", + "The unusual JP drain aspect persisted.", + "A new ultrasound confirmed that the mass and surrounding area had the same aspect as days before.", + "The histopathological description of paracecal-retrocecal lymph nodes failed to detect neoplastic cells.", + "The sample of mesenteric omentum obtained during the first intervention failed to detect neoplastic cells.", + "Three encapsulated lymph nodes from 0.8 to 2 cm were received.", + "The physiological architecture of the lymph nodes was preserved.", + "Secondary lymphoid follicles with hyperplastic germinal centers containing macrophages with cellular debris were reported.", + "The interfollicular population was polymorphic and contained frequent large cells with prominent immunoblast-like nucleoli.", + "Other areas showed sinusoidal histiocytosis with eosinophils and neutrophils.", + "There was fibrosis with a predominantly neutrophilic mixed inflammatory infiltrate that spread to neighboring adipose tissue in the periphery of the nodes.", + "The immunohistochemical study confirmed the presence of follicular dendritic cells and B lymphocytes in the germinal centers.", + "The immunohistochemical study confirmed the presence of T lymphocytes in the mantle zone.", + "The immunohistochemical study confirmed the presence of macrophages in germinal centers and sinusoidal area.", + "Frequent CD30 + + +/+ + + immunoblasts were observed.", + "Actin + + +/+ + + myofibroblasts within areas of fibrosis were observed.", + "EBV study using EBER in situ hybridization was negative.", + "Ziehl Neelsen and PAS did not show any pathogen.", + "The 22 × 0.6 cm omentum sample showed fibrous thickening of the septa.", + "The omentum sample showed the presence of a mainly lymphocytic infiltrate.", + "Fibrino-leukocytic material was also seen in the serosa.", + "Pathologists concluded the possibility of an unspecified acute versus chronic epiploitis.", + "Pathologists concluded the possibility of lymphadenitis.", + "Pathologists concluded the possibility of serositis.", + "A second surgical intervention was decided.", + "The patient underwent an omentectomy.", + "The patient underwent resection of approximately 40 cm of terminal ileum.", + "The patient underwent resection of the cecum.", + "The patient underwent resection of the ascending colon.", + "Pericolonic lymph nodes were resected.", + "A sample of a collection observed near the cecum was taken for culture.", + "A sample of a collection observed near the cecum was taken for cytochemical studies.", + "After surgery, the patient remained hemodynamically stable.", + "The patient had no abdominal pain.", + "The patient had no distention.", + "A nasogastric tube was placed.", + "Parenteral nutrition continued.", + "The peritoneal fluid analysis was negative.", + "Improvement in inflammatory markers led to amikacin discontinuation.", + "By the fifth postoperative day, the JP drain was removed.", + "By the fifth postoperative day, the nasogastric tube was removed.", + "A regular diet was successfully initiated.", + "The patient was finally discharged.", + "The histopathological final report described an 8 cm ileal segment.", + "The histopathological final report described a 14 cm ascending colon including the cecum.", + "The cecum had a diameter that ranged from 1 to 3 cm.", + "The external surface was covered by a pinkish-gray serosa with fibrinopurulent material over the ileocecal area.", + "A completely subserous dilated appendix was identified within the cecum wall.", + "The appendix contained a white-yellowish purulent material at the tip.", + "A well-defined nodular lesion of approximately 1.5 cm was identified.", + "The mucosa of the cecum was pink.", + "The ileal mucosa had a granular appearance.", + "Nine nodules, which measured between 0.3 and 3 cm, were isolated from the surrounding area.", + "The 12 × 4.5 cm omentum sample had no palpable nodes.", + "A second omentum sample showed multiple whitish irregular fragments of bland tissue that measured between 0.8 and 1.5 cm.", + "The histological findings of the fourteen isolated lymph nodes were compatible with follicular hyperplasia.", + "The subserosal cecal appendix showed transmural necrosis.", + "The appendix showed perforation causing leakage of purulent material.", + "An acute inflammatory reaction of the surrounding adipose tissue extended up to the cecal and ileal serosa.", + "All layers of the appendix were independent and unrelated to the cecum wall.", + "The distal portion of the appendix showed the proliferation of cellular nests composed of round uniform nuclei with a “salt and pepper” appearance.", + "No mitotic activity was evidenced.", + "It seemed to infiltrate the muscular layer of the appendix.", + "It reached a diameter of 1.5 cm.", + "No lymphovascular invasion was observed.", + "No perineural invasion was observed.", + "Disease free margins were reported.", + "Ileum dissection showed Peyer’s patches hyperplasia with wide germinal centers.", + "Tumoral cells’ immunochemical studies showed a Ki67 proliferative index of 2%.", + "Tumoral cells’ immunochemical studies showed a positive (+ + +/+ + +) cytoplasmic granular pan-cytokeratin.", + "Tumoral cells’ immunochemical studies showed a positive (+ + +/+ + +) cytoplasmic chromogranin.", + "Tumoral cells’ immunochemical studies showed a negative synaptophysin reaction.", + "Pathologists concluded the presence of an incidental well differentiated neuroendocrine tumor grade I pT1 pN0 at the tip of the appendix.", + "The tumor was in the middle of a clinical picture caused by an acute necrotizing appendicitis.", + "The tumor was of a complete subserosal appendix.", + "Due to the stage, no further intervention was required.", + "She fully recovered in subsequent controls.", + "Correct management of short bowel syndrome will become a key feature for the preservation of her future quality of life." + ], + "summary": "We present a 9-year-old female patient that came with a clinical picture compatible with acute appendicitis. However, a cecal mass was identified instead of an inflamed appendix during surgery. Therapeutic decisions were extremely challenging due to clinical deterioration and an uncertain etiology. Only the histopathology report revealed the presence of a complete subserosal appendix which was responsible for the entire symptomatology. Here, we review all case reports regarding intramural, intracecal or subserosal appendixes. A discussion of the general approach to this specific case and the importance of consensual diagnostic criteria for these specimens are also presented. At last, an incidental finding is exposed and final treatment options are discussed given the overall presentation.", + "summary_subclaims": [ + "The patient was a 9-year-old female.", + "The clinical picture was compatible with acute appendicitis.", + "A cecal mass was identified during surgery.", + "An inflamed appendix was not found during surgery.", + "Therapeutic decisions were extremely challenging.", + "Clinical deterioration was observed.", + "The etiology was uncertain.", + "The histopathology report revealed the presence of a complete subserosal appendix.", + "The subserosal appendix was responsible for the entire symptomatology.", + "Case reports regarding intramural, intracecal, or subserosal appendixes were reviewed.", + "A discussion of the general approach to this specific case was presented.", + "The importance of consensual diagnostic criteria for these specimens was discussed.", + "An incidental finding was exposed.", + "Final treatment options were discussed." + ] + }, + { + "id": "multiclinsum_test_3381_en.txt", + "fulltext": "A previously healthy 18-year-old girl student unintentionally ingested a large dose (60 mg) of metoclopramide (6 tablets of 10 mg), exceeding the typical therapeutic dosage, for the management of nausea and vomiting. Approximately 6 h after the ingestion of the medication, she experienced dizziness, blurred vision, neck dystonia, and upward deviation of the eyes. Seeing these symptoms and worrying about their child’s physical condition, the parents brought her to the medical center. Following an initial examination during which stable vital signs were observed, the patient was diagnosed with extrapyramidal syndrome and administered 5 mg of biperiden ampoules intramuscularly. However, due to a lack of improvement in the patient’s symptoms, she was subsequently referred to the emergency room of a medical center in northern Iran for additional assessment and treatment.\n\nUpon arrival at the emergency room, the patient exhibited a constellation of symptoms, including neck dystonia, upward eye deviation, abdominal and leg muscle spasms. These clinical signs prompted the initiation of treatment with an intravenous infusion of 5 mg midazolam ampoules over a 6-hour period, as well as intravenous administration of 5 mg biperiden ampoules. Based on these initial management measures, the patient was subsequently admitted to the poisoning ward for ongoing monitoring and care.\n\nAfter a period of 6 h, the patient’s symptoms improved completely, with vital signs remaining stable and all laboratory tests and electrocardiography yielding unremarkable results. To continue treatment and prevent symptom recurrence, 2 mg biperiden oral tablets were prescribed every 12 h. The patient was discharged from the hospital in a good general condition, with instructions to take 2 mg biperiden tablets twice daily for 3 days. One week after discharge, the patient’s follow-up visit revealed that her vital signs and general symptoms remained stable, with no new complaints or adverse events reported. Written informed consent was obtained from the patient for publication of this case report. This study was conducted according to the Declaration of Helsinki Principles. Also, CARE guidelines and methodology were followed in this study.", + "fulltext_subclaims": [ + "The patient was an 18-year-old girl.", + "She unintentionally ingested 60 mg of metoclopramide.", + "The ingestion occurred for the management of nausea and vomiting.", + "Approximately 6 h after ingestion, she experienced dizziness.", + "Approximately 6 h after ingestion, she experienced blurred vision.", + "Approximately 6 h after ingestion, she experienced neck dystonia.", + "Approximately 6 h after ingestion, she experienced upward deviation of the eyes.", + "The parents brought her to the medical center.", + "The patient was diagnosed with extrapyramidal syndrome.", + "The patient was administered 5 mg of biperiden ampoules intramuscularly.", + "There was a lack of improvement in the patient’s symptoms.", + "She was referred to the emergency room of a medical center in northern Iran.", + "Upon arrival at the emergency room, the patient exhibited neck dystonia.", + "Upon arrival at the emergency room, the patient exhibited upward eye deviation.", + "Upon arrival at the emergency room, the patient exhibited abdominal and leg muscle spasms.", + "Treatment included an intravenous infusion of 5 mg midazolam ampoules over 6 h.", + "Treatment included intravenous administration of 5 mg biperiden ampoules.", + "The patient was admitted to the poisoning ward.", + "After 6 h, the patient’s symptoms improved completely.", + "All laboratory tests and electrocardiography yielded unremarkable results.", + "2 mg biperiden oral tablets were prescribed every 12 h.", + "The patient was discharged in a good general condition.", + "Instructions were given to take 2 mg biperiden tablets twice daily for 3 days.", + "One week after discharge, the patient’s follow-up visit revealed stable vital signs.", + "One week after discharge, the patient had no new complaints or adverse events.", + "Written informed consent was obtained from the patient.", + "This study was conducted according to the Declaration of Helsinki Principles.", + "CARE guidelines and methodology were followed in this study." + ], + "summary": "An 18-year-old girl student unintentionally consumed a large dose (60 mg) of metoclopramide, exceeding the recommended therapeutic dose, for the management of nausea and vomiting. Approximately six hours after the ingestion of the medication, she developed neck dystonia and upward deviation of the eyes. Seeing these symptoms and worrying about their child's physical condition, the parents took her to the local medical center in northern Iran. With the diagnosis of the extrapyramidal syndrome and intramuscular administration of biperiden 5 mg ampoule twice at 12-h intervals, unfortunately, the symptoms did not improve and finally he was referred to our hospital.", + "summary_subclaims": [ + "The patient is an 18-year-old girl student.", + "She unintentionally consumed a large dose (60 mg) of metoclopramide.", + "The dose exceeded the recommended therapeutic dose.", + "The ingestion was for the management of nausea and vomiting.", + "Approximately six hours after the ingestion, she developed neck dystonia.", + "She developed upward deviation of the eyes.", + "The parents took her to the local medical center in northern Iran.", + "The diagnosis was extrapyramidal syndrome.", + "Biperiden 5 mg ampoule was administered intramuscularly twice at 12-h intervals.", + "The symptoms did not improve.", + "The patient was referred to our hospital." + ] + }, + { + "id": "multiclinsum_test_753_en.txt", + "fulltext": "A 32-year-old male driver by profession presented to the cardiology department complaining of chest discomfort and a history of pain radiating to his back and left shoulder, which had gotten worse following four days of weight training. There are no comorbidities. History of similar complaints in the past with the first episode at the age of 10 years and similar such complaints are noted on lifting heavy weights, climbing uphill and on exertion. There is no history of concomitant surgical operations or substance abuse. There is no family history of ischaemic heart disease. Clinical assessment is normal. Routine blood tests and cardiac markers are normal. On presentations, vitals were heart rate of 164 beats per minute (tachycardia), blood pressure of 130/84 mmHg, and respiratory rate of 24 cycles per minute (tachypnoea), with normal blood glucose sugar level and showing normal ECG findings.\nThe patient was directed to the radiology department for additional assessment. The chest X-ray indicated a normal apex and left heart border but a lucent region, as well as lung tissue between the left hemidiaphragm and heart base . The patient was referred for echocardiography, which revealed substantial cardiac mobility with a high degree of levorotation, normal left ventricle size, normal systolic function, and a 60% ejection fraction. The next day, the patient was suggested to undergo a cardiac MRI, which revealed significant levorotation of the heart and lung tissue interposition anteriorly between the main pulmonary artery and aorta. An analogous interposition of lung tissue occurs between the left ventricle and the diaphragm. The left atrial appendage protrudes outward along the lateral face of the aortic arch. A 6-mm defect in the middle atrial septum is seen, most likely of the secundum type with left-to-right blood shunting. Hence, a suspicion of pericardial agenesis was made.\nThe left inferior pulmonary vein seems to have a restricted calibre as a result of compression between the descending aorta and left atrium, most likely caused by significant levorotation . On the left, the superior and inferior pulmonary veins measure 7 mm superior to the inferior and 4 mm inferior to the superior. On the right side, they were 18 mm and 12 mm.\nInvestigations on the mobility of the walls of the left and right ventricles show excessive cardiac mobility is defined by a 1.5-to-2 mm displacement of the heart apex. The normal pulmonary artery diameter is 25 mm. The rest of the heart looks normal. Pleural or pericardial effusion is absent with normal ventricular walls .\nA chest HRCT was performed, revealing the absence of the pericardium on the left side. Lung tissue may be recognised between the aorta and the primary pulmonary artery . Lung tissue was observed between the left hemidiaphragm and the heart's base, as well as an abnormally expanded left atrial appendage. The following day, with the same concerns, a repeat chest X-ray revealed a leftward migration of the heart apex (wandering cardiac apex) . The patient was treated conservatively with regular follow-up in the outpatient clinic and is advised not to lift heavy weights.", + "fulltext_subclaims": [ + "The patient is a 32-year-old male driver.", + "He presented with chest discomfort and a history of pain radiating to his back and left shoulder.", + "The pain had worsened following four days of weight training.", + "There are no comorbidities.", + "He has a history of similar complaints in the past, with the first episode at the age of 10 years.", + "He experiences similar complaints on lifting heavy weights, climbing uphill, and on exertion.", + "There is no history of concomitant surgical operations or substance abuse.", + "There is no family history of ischaemic heart disease.", + "Clinical assessment is normal.", + "Routine blood tests and cardiac markers are normal.", + "On presentation, the heart rate was 164 beats per minute.", + "The blood pressure was 130/84 mmHg.", + "The respiratory rate was 24 cycles per minute.", + "The blood glucose sugar level was normal.", + "The ECG findings were normal.", + "The chest X-ray indicated a normal apex and left heart border.", + "The chest X-ray showed a lucent region and lung tissue between the left hemidiaphragm and heart base.", + "Echocardiography revealed substantial cardiac mobility with a high degree of levorotation.", + "The left ventricle size was normal.", + "Systolic function was normal.", + "The ejection fraction was 60%.", + "A cardiac MRI revealed significant levorotation of the heart.", + "Lung tissue interposition occurred anteriorly between the main pulmonary artery and aorta.", + "An analogous interposition of lung tissue occurred between the left ventricle and the diaphragm.", + "The left atrial appendage protrudes outward along the lateral face of the aortic arch.", + "A 6-mm defect in the middle atrial septum was seen, most likely of the secundum type with left-to-right blood shunting.", + "A suspicion of pericardial agenesis was made.", + "The left inferior pulmonary vein had a restricted calibre due to compression between the descending aorta and left atrium.", + "On the left, the superior and inferior pulmonary veins measured 7 mm superior to the inferior and 4 mm inferior to the superior.", + "On the right side, the superior and inferior pulmonary veins measured 18 mm and 12 mm.", + "Excessive cardiac mobility was defined by a 1.5-to-2 mm displacement of the heart apex.", + "The normal pulmonary artery diameter is 25 mm.", + "Pleural or pericardial effusion was absent.", + "The ventricular walls were normal.", + "A chest HRCT revealed the absence of the pericardium on the left side.", + "Lung tissue may be recognised between the aorta and the primary pulmonary artery.", + "Lung tissue was observed between the left hemidiaphragm and the heart's base.", + "An abnormally expanded left atrial appendage was observed.", + "A repeat chest X-ray the following day revealed a leftward migration of the heart apex (wandering cardiac apex).", + "The patient was treated conservatively with regular follow-up in the outpatient clinic.", + "The patient was advised not to lift heavy weights." + ], + "summary": "A 32-year-old male who presented with chest discomfort and radiating pain to his back and left shoulder mimicking myocardial infarction with normal ECG and enzyme markers. A chest radiograph (taken 24 h apart) demonstrates the left lateral position of the heart and the bulging contour of the left heart border, a lucent area between the aorta and pulmonary artery. Subsequently, cardiac MRI reveals left pericardial agenesis.", + "summary_subclaims": [ + "The patient is a 32-year-old male.", + "The patient presented with chest discomfort.", + "The pain radiated to the back and left shoulder.", + "The pain mimicked myocardial infarction.", + "The ECG was normal.", + "The enzyme markers were normal.", + "A chest radiograph was taken 24 h apart.", + "The chest radiograph demonstrated the left lateral position of the heart.", + "The chest radiograph showed a bulging contour of the left heart border.", + "The chest radiograph showed a lucent area between the aorta and pulmonary artery.", + "Cardiac MRI reveals left pericardial agenesis." + ] + }, + { + "id": "multiclinsum_test_359_en.txt", + "fulltext": "A 39-year-old female presented painful ulceration on the oral mucosa for the past two months and visited the Hospital of Stomatology, Sun Yat-sen University in November 2021. She had received treatment for this condition with a systemic administration of corticosteroids for more than one month in other hospital without efficacy. She denied any history of other systemic medications, dental restorations, radiotherapy, smoking and tobacco use. She had no family history of relevant conditions and malignancies. Physical examination revealed extensive ulcerated lesions on the tongue dorsum, bilateral tongue and buccal mucosa as well as the lower lip, and Nikolsky’s sign was negative . A biopsy from the left tongue showed dyskeratosis of spinous cells, liquefaction and degeneration of basal cells, indistinct basement membrane, and a large number of lymphocytic infiltrates in all epidermal layers instead of band-like infiltrates, which are consistent with pathological changes of OLL . Oral thalidomide and topical tacrolimus mouthwashes were scheduled to control the OLL, while the oral lesions remained unhealed. We recommended the patient for further systemic examination.\nIn January 2022, the patient found a goiter in the right neck, accompanied with extensive unhealed ulcerated lesions on the oral mucosa. The patient visited Xiangya Hospital, Central South University for further examination. Contrast-enhanced computed tomography (CECT) confirmed the thyroid mass and revealed a mediastinal mass unexpectedly . Laboratory examination showed procalcitonin (PCT), C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), interleukin-1β (IL-1β) and cancer antigen 125 (CA125) were obviously elevated (PCT: 0.104 ng/mL, normal: < 0.06 ng/mL; CRP: 14.70 mg/L, normal: 0–8.00 mg/L; ESR: 46.00 mm/h, normal: 0–26.00 mm/h; IL-1β: 7.11 pg/mL, normal: < 5 pg/mL; CA125: 76.6 U/mL, normal: 0–35 U/mL). The neck and mediastinal masses were surgically removed and the histopathologic examination showed PTC in the right lobe of the thyroid and CD (unicentric, hyaline vascular type) in the anterior mediastinal mass . Further immunohistochemical staining confirmed the diagnosis of CD . After thyroid cancer surgery, oral levothyroxine was scheduled for the inhibition and replacement therapy, and topical tacrolimus mouthwashes were applied to subdue pain and inflammation for oral lesions.\nIn March 2022, two months after complete excision of the neoplasms, the patient revisited to the Hospital of Stomatology, Sun Yat-sen University. The mucosal involvement showed significant alleviation, but there remained unhealed ulceration on the bilateral tongue . Based on the manifestations and findings across the timeline, a definitive diagnosis of OLL associated with CD and PTC was made. We subsequently gave the patient intralesional injection of corticosteroids and systematic thalidomide, and applied triamcinolone acetonide ointment and tacrolimus mouthwashes topically. After one month, the tongue mucosal lesions gradually healed . Positron emission tomography/computed tomography confirmed that there was no recurrence/metastasis of CD and PTC. The management of the patient was summarized in Fig. .\nWe followed the guidelines of the Helsinki Declaration in this investigation. The procedure has been explained to the patient, who signed an informed consent allowing treatment procedures and publication of her data.", + "fulltext_subclaims": [ + "The patient is a 39-year-old female.", + "She had painful ulceration on the oral mucosa for the past two months.", + "She visited the Hospital of Stomatology, Sun Yat-sen University in November 2021.", + "She had received treatment with systemic corticosteroids for more than one month in another hospital.", + "The treatment with corticosteroids was without efficacy.", + "She denied any history of other systemic medications.", + "She denied any history of dental restorations.", + "She denied any history of radiotherapy.", + "She denied any history of smoking.", + "She had no family history of relevant conditions.", + "Physical examination revealed extensive ulcerated lesions on the tongue dorsum.", + "Nikolsky’s sign was negative.", + "A biopsy from the left tongue showed dyskeratosis of spinous cells.", + "The biopsy showed liquefaction and degeneration of basal cells.", + "The biopsy showed indistinct basement membrane.", + "The biopsy showed a large number of lymphocytic infiltrates in all epidermal layers.", + "The biopsy findings were consistent with pathological changes of OLL.", + "Oral thalidomide and topical tacrolimus mouthwashes were scheduled.", + "The oral lesions remained unhealed.", + "The patient was recommended for further systemic examination.", + "In January 2022, the patient found a goiter in the right neck.", + "The patient had extensive unhealed ulcerated lesions on the oral mucosa.", + "Contrast-enhanced computed tomography confirmed the thyroid mass.", + "The CECT revealed a mediastinal mass.", + "Laboratory examination showed elevated procalcitonin (PCT).", + "Laboratory examination showed elevated C-reactive protein (CRP).", + "Laboratory examination showed elevated erythrocyte sedimentation rate (ESR).", + "Laboratory examination showed elevated interleukin-1β (IL-1β).", + "Laboratory examination showed elevated cancer antigen 125 (CA125).", + "The neck and mediastinal masses were surgically removed.", + "Histopathologic examination showed papillary thyroid carcinoma (PTC) in the right lobe of the thyroid.", + "Histopathologic examination showed Castleman disease (CD) in the anterior mediastinal mass.", + "Further immunohistochemical staining confirmed the diagnosis of CD.", + "After thyroid cancer surgery, oral levothyroxine was scheduled.", + "Topical tacrolimus mouthwashes were applied.", + "In March 2022, the patient revisited the Hospital of Stomatology, Sun Yat-sen University.", + "The mucosal involvement showed significant alleviation.", + "There remained unhealed ulceration on the bilateral tongue.", + "A definitive diagnosis of OLL associated with CD and PTC was made.", + "The patient received intralesional injection of corticosteroids.", + "Systematic thalidomide was given.", + "Triamcinolone acetonide ointment was applied topically.", + "Tacrolimus mouthwashes were applied topically.", + "After one month, the tongue mucosal lesions gradually healed.", + "Positron emission tomography/computed tomography confirmed no recurrence/metastasis of CD and PTC.", + "The management of the patient was summarized in Fig.", + "The procedure has been explained to the patient.", + "The patient signed an informed consent allowing treatment procedures and publication of her data." + ], + "summary": "We report a rare case of a 39-year-old female with extensive ulcerated lesions on the oral mucosa, diagnosed as OLL by histopathology. Routine oral treatment was scheduled to control the OLL, while the oral lesions remained unhealed. Computed tomography examination was performed after the oral treatment and revealed thyroid and mediastinal masses, which were then surgically removed and pathologically diagnosed as PTC and CD, respectively. Two months after complete excision of the neoplasms, the oral lesions showed obvious alleviation. With subsequent treatment for oral lesions, the patient's OLL healed.", + "summary_subclaims": [ + "The patient was a 39-year-old female.", + "The patient had extensive ulcerated lesions on the oral mucosa.", + "The lesions were diagnosed as OLL by histopathology.", + "Routine oral treatment was scheduled to control the OLL.", + "The oral lesions remained unhealed.", + "Computed tomography examination was performed after the oral treatment.", + "The CT revealed thyroid and mediastinal masses.", + "The masses were surgically removed.", + "The masses were pathologically diagnosed as PTC and CD, respectively.", + "Two months after complete excision of the neoplasms, the oral lesions showed obvious alleviation.", + "With subsequent treatment for oral lesions, the patient's OLL healed." + ] + }, + { + "id": "multiclinsum_test_2269_en.txt", + "fulltext": "We report the case of an 8-year-old male child who presented to the neurology department with complaints of headache and vomiting for 3 months. Physical examination did not reveal any focal neurological deficits. The patient was referred to neurosurgery and underwent brain magnetic resonance imaging (MRI) . The imaging findings revealed a well-defined supratentorial cyst measuring approximately 4 × 5.5 × 6 cm located in the left occipital region. The cyst was isointense to CSF in all sequences, with faint isointensity in the fluid-attenuated inversion recovery (FLAIR) sequence, and was surrounded by a thin hypointense rim in T2* and T2WI. Minimal edema was noted anterior to the cyst, and there was no evidence of abnormal enhancement after contrast injection. However, the 3D thin slices showed meningeal enhancement around the upper margin of the lesion, suggesting that the cyst was located between meningeal layers. The posterior wall of the cyst appeared irregular and was associated with prominent enhancement at adjacent meninges, with irregular erosions of the adjacent occipital bone. The cyst was causing pressure effects on the straight and superior venous sinuses and the splenium of the corpus callosum and left lateral ventricle, and was deviating the midline to the right by approximately 8 mm. Radiological investigations of the chest and abdomen did not reveal any abnormalities.\nThe patient underwent a craniotomy . While retracting the bone, a thin layer of periosteal layer of the dura covering a cyst was noticed. The dura was gently retracted, and the cyst was visualized. No rupture was noted, and the cyst was successfully removed, leaving the inner layer of the dura intact. This gentle maneuver during the craniotomy is essential to avoid any eventual rupture of any superficial cyst that could be located anywhere under the bone flap. Postoperatively patients had a completely normal neurological examination, he was referred to internal medicine for medical treatment by albendazole. The follow-up lasted for 3 months without any complications .", + "fulltext_subclaims": [ + "The patient was an 8-year-old male child.", + "The patient presented with headache and vomiting for 3 months.", + "Physical examination did not reveal any focal neurological deficits.", + "The patient underwent brain magnetic resonance imaging.", + "The MRI revealed a well-defined supratentorial cyst measuring approximately 4 × 5.5 × 6 cm.", + "The cyst was located in the left occipital region.", + "The cyst was isointense to CSF in all sequences.", + "The cyst was surrounded by a thin hypointense rim in T2* and T2WI.", + "Minimal edema was noted anterior to the cyst.", + "There was no evidence of abnormal enhancement after contrast injection.", + "The 3D thin slices showed meningeal enhancement around the upper margin of the lesion.", + "The posterior wall of the cyst was irregular.", + "The cyst was causing pressure effects on the straight and superior venous sinuses.", + "The cyst was deviating the midline to the right by approximately 8 mm.", + "Radiological investigations of the chest and abdomen did not reveal any abnormalities.", + "The patient underwent a craniotomy.", + "A thin layer of periosteal layer of the dura covering a cyst was noticed.", + "The cyst was successfully removed, leaving the inner layer of the dura intact.", + "Postoperatively, the patient had a completely normal neurological examination.", + "The patient was referred to internal medicine for medical treatment by albendazole.", + "The follow-up lasted for 3 months without any complications." + ], + "summary": "This study presents the case of an 8-year-old boy presented with a 3-month history of headache and vomiting without any neurological deficit. Full radiological investigations were performed, the brain MRI showed a large cerebral hydatid cyst located within the dura layers between the periosteal and the endosteal layers. Surgery was performed without cyst rupture, confirming the intracerebral intradural location.", + "summary_subclaims": [ + "This study presents the case of an 8-year-old boy.", + "The boy had a 3-month history of headache and vomiting.", + "The boy had no neurological deficit.", + "Full radiological investigations were performed.", + "The brain MRI showed a large cerebral hydatid cyst.", + "The cyst was located within the dura layers between the periosteal and the endosteal layers.", + "Surgery was performed without cyst rupture.", + "Surgery confirmed the intracerebral intradural location." + ] + }, + { + "id": "multiclinsum_test_1704_en.txt", + "fulltext": "A 70-year-old Japanese man with melena that began five days before admission was admitted to our hospital. He complained of abdominal discomfort and epigastralgia. Five years before, he had undergone a right upper lobectomy for lung cancer (T1b N0 M0 Stage IA). Physical examination revealed no abnormal findings associated with the abdomen except a surgical scar on the right side of his chest. Evaluation of laboratory data on admission revealed that his hemoglobin level was 7.0 g/dL and hematocrit value was 23.1%. Upper gastrointestinal endoscopy revealed a distinctly protruding lesion (diameter: 5 cm) at the lesser curvature of the middle third of the gastric body . The surface of the tumor bled easily on contact with the endoscope. Microscopic examination of hematoxylin and eosin (H&E)-stained biopsy specimens of the lesion revealed sheets of spindle cells. Immunohistochemical studies showed that the tumor cells were positive for S-100 and negative for c-kit, CD34, and smooth muscle actin. The MIB-1 index was 48.5%. Based on these findings, the tumor was diagnosed as a gastric malignant schwannoma. Abdominal computed tomography (CT) revealed a thickened posterior wall of the gastric body . There was no evidence of lymph node swelling surrounding the stomach or metastatic liver tumors.\nHe underwent a distal gastrectomy with regional lymph node dissection. Macroscopically, the elevated lesion was approximately 6 × 5 cm in diameter and located at the lesser curvature of the gastric body . The covering mucosa was ulcerated. The tumor was located mainly in the proper muscle layer. There was no lymph node involvement and the surgical margin was negative for tumor cells. Microscopic examination of the resected and H&E-stained specimens showed a spindle cell neoplasm arranged in a palisade manner that was consistent with a schwannoma . Mitosis was scattered with 10 mitoses per 50 high-power fields. Immunohistochemistry revealed that the tumor cells were positive for S-100 protein and negative for c-kit and smooth muscle actin . These histopathological and immunohistochemical findings are consistent with a gastric malignant schwannoma.\nHis postoperative course was uneventful and he was discharged from our hospital on day 12 after surgery. However, abdominal CT performed three months after surgery revealed multiple liver metastases and ascites .. He died five months after surgery without undergoing any additional treatment.", + "fulltext_subclaims": [ + "A 70-year-old Japanese man with melena that began five days before admission was admitted to our hospital.", + "He complained of abdominal discomfort and epigastralgia.", + "Five years before, he had undergone a right upper lobectomy for lung cancer (T1b N0 M0 Stage IA).", + "Physical examination revealed no abnormal findings associated with the abdomen except a surgical scar on the right side of his chest.", + "Evaluation of laboratory data on admission revealed that his hemoglobin level was 7.0 g/dL.", + "Evaluation of laboratory data on admission revealed that his hematocrit value was 23.1%.", + "Upper gastrointestinal endoscopy revealed a distinctly protruding lesion (diameter: 5 cm) at the lesser curvature of the middle third of the gastric body.", + "The surface of the tumor bled easily on contact with the endoscope.", + "Microscopic examination of hematoxylin and eosin (H&E)-stained biopsy specimens of the lesion revealed sheets of spindle cells.", + "Immunohistochemical studies showed that the tumor cells were positive for S-100.", + "Immunohistochemical studies showed that the tumor cells were negative for c-kit.", + "Immunohistochemical studies showed that the tumor cells were negative for CD34.", + "Immunohistochemical studies showed that the tumor cells were negative for smooth muscle actin.", + "The MIB-1 index was 48.5%.", + "Based on these findings, the tumor was diagnosed as a gastric malignant schwannoma.", + "Abdominal computed tomography (CT) revealed a thickened posterior wall of the gastric body.", + "There was no evidence of lymph node swelling surrounding the stomach.", + "There was no evidence of metastatic liver tumors.", + "He underwent a distal gastrectomy with regional lymph node dissection.", + "Macroscopically, the elevated lesion was approximately 6 × 5 cm in diameter.", + "The lesion was located at the lesser curvature of the gastric body.", + "The covering mucosa was ulcerated.", + "The tumor was located mainly in the proper muscle layer.", + "There was no lymph node involvement.", + "The surgical margin was negative for tumor cells.", + "Microscopic examination of the resected and H&E-stained specimens showed a spindle cell neoplasm arranged in a palisade manner.", + "The histopathological findings were consistent with a schwannoma.", + "Mitosis was scattered with 10 mitoses per 50 high-power fields.", + "Immunohistochemistry revealed that the tumor cells were positive for S-100 protein.", + "Immunohistochemistry revealed that the tumor cells were negative for c-kit.", + "Immunohistochemistry revealed that the tumor cells were negative for smooth muscle actin.", + "These histopathological and immunohistochemical findings are consistent with a gastric malignant schwannoma.", + "His postoperative course was uneventful.", + "He was discharged from our hospital on day 12 after surgery.", + "Abdominal CT performed three months after surgery revealed multiple liver metastases.", + "Abdominal CT performed three months after surgery revealed ascites.", + "He died five months after surgery without undergoing any additional treatment." + ], + "summary": "A 70-year-old Japanese man presented with gastrointestinal bleeding to our hospital. Gastrointestinal endoscopy revealed a protruding lesion in the gastric body. Hematoxylin and eosin staining of biopsy specimens from this lesion revealed sheets of spindle cells. Immunohistochemistry revealed that these cells were positive for S-100 protein and negative for c-Kit and smooth muscle actin. Because mitosis was diffusely visible, this tumor was diagnosed as a gastric malignant schwannoma. Distal gastrectomy with lymph node dissection was performed and the patient's postoperative course was uneventful. However, five months after the surgery, he died from multiple liver metastases.", + "summary_subclaims": [ + "A 70-year-old Japanese man presented with gastrointestinal bleeding to our hospital.", + "Gastrointestinal endoscopy revealed a protruding lesion in the gastric body.", + "Hematoxylin and eosin staining of biopsy specimens from this lesion revealed sheets of spindle cells.", + "Immunohistochemistry revealed that these cells were positive for S-100 protein.", + "Immunohistochemistry revealed that these cells were negative for c-Kit.", + "Immunohistochemistry revealed that these cells were negative for smooth muscle actin.", + "Because mitosis was diffusely visible, this tumor was diagnosed as a gastric malignant schwannoma.", + "Distal gastrectomy with lymph node dissection was performed.", + "The patient's postoperative course was uneventful.", + "Five months after the surgery, he died from multiple liver metastases." + ] + }, + { + "id": "multiclinsum_test_2551_en.txt", + "fulltext": "A 12-year-old Asian female patient was referred from the pediatric hematology-oncology service, department of pediatrics, for the evaluation and management of swollen gingiva and chin . The patient had a history of patent ductus arteriosus (PDA) closure at age 6. She underwent four cycles of induction chemotherapy for acute myeloid leukemia (AML), which had been diagnosed a year previously. She was admitted for the management of neutropenic fever over 39 °C. She was on antibiotics (linezolid, meropenem, sulfamethoxazole, metronidazole, teicoplanin, cefpiramide, amikacin), antifungals (fluconazole, nystatin, amphotericin B, voriconazole, caspofungin), and an antiviral (acyclovir) for her febrile condition, under the impression of neutropenic fever and vancomycin-resistance enterococci (VRE) sepsis. The results of complete blood count with differential were as follows: white blood cell (WBC) counts 40/μL, platelet counts 8000/μL, absolute neutrophil count 0/μL.\nAs the patient was already on every possible antibiotic, antifungal, and antiviral, close observation and oral hygiene maintenance was the only possible management. Surgical intervention was contraindicated due to her systemic condition, especially considering her hematologic status. Six days after the initial presentation, the patient developed cardiac arrest under the background of uncontrolled fever. Return of spontaneous circulation was achieved after resuscitation, and her general condition improved as days went by. The oral and facial lesion progressed to full-thickness gangrene and underlying alveolar bone separated from the surrounding mandible . Teeth on the segment spontaneously fell out . The necrotic alveolar bone segment also spontaneously fell out.\nAfter the patient had become afebrile and able to return to regular activities, not only the disfigurement but the incompetency of the lips and resultant drooling posed severe obstacles in her daily life since oral intake was disabled. Considering the pancytopenic condition of the patient, surgical repair was done as simply as possible, by local flap, to achieve continuity of the orbicularis oris muscle and competency of the lip, thus enabling oral intake afterwards .", + "fulltext_subclaims": [ + "The patient was referred for the evaluation and management of swollen gingiva and chin.", + "The patient had a history of patent ductus arteriosus (PDA) closure at age 6.", + "She underwent four cycles of induction chemotherapy for acute myeloid leukemia (AML).", + "She was admitted for the management of neutropenic fever over 39 °C.", + "She was on antibiotics including linezolid, meropenem, sulfamethoxazole, metronidazole, teicoplanin, cefpiramide, and amikacin.", + "She was on antifungals including fluconazole, nystatin, amphotericin B, voriconazole, and caspofungin.", + "She was on an antiviral, acyclovir.", + "The impression was neutropenic fever and vancomycin-resistant enterococci (VRE) sepsis.", + "The white blood cell (WBC) count was 40/μL.", + "The platelet count was 8000/μL.", + "The absolute neutrophil count was 0/μL.", + "Surgical intervention was contraindicated due to her systemic condition.", + "Six days after the initial presentation, the patient developed cardiac arrest.", + "Return of spontaneous circulation was achieved after resuscitation.", + "The oral and facial lesion progressed to full-thickness gangrene.", + "The underlying alveolar bone separated from the surrounding mandible.", + "Teeth on the segment spontaneously fell out.", + "The necrotic alveolar bone segment also spontaneously fell out.", + "The patient became afebrile and able to return to regular activities.", + "The disfigurement and lip incompetency posed severe obstacles in daily life.", + "Surgical repair was done as simply as possible by local flap.", + "The surgical repair aimed to achieve continuity of the orbicularis oris muscle and competency of the lip." + ], + "summary": "The gingivitis that occurred in a 12-year-old Asian female patient with acute myeloid leukemia was getting increasingly worse. Although the proper treatment was done, the patient's condition did not improve, and eventually, a large full-thickness defect was left in the maxillofacial part.", + "summary_subclaims": [ + "The gingivitis that occurred in a 12-year-old Asian female patient with acute myeloid leukemia was getting increasingly worse.", + "The patient's condition did not improve.", + "A large full-thickness defect was left in the maxillofacial part." + ] + }, + { + "id": "multiclinsum_test_313_en.txt", + "fulltext": "A 66-year-old man presented with 1-month history of bloody stool and anal pain. His history included hypertension, hyperlipidemia, hyperuricemia, traffic trauma, and postoperative right inguinal hernia. He had no history of smoking. The histopathologic evaluation of the biopsy specimen obtained with colonoscopy led to the diagnosis of moderately differentiated tubular adenocarcinoma of the anal canal. The diagnosis was Stage IVa with lymph node and liver metastases (T3, N3 [#263L], M1a [H1]) based on evaluation with computed tomography and magnetic resonance imaging . RAS and BRAF gene status were wild type. MSI test was performed postrecurrence and was negative.\nAfter six cycles of systemic chemotherapy with 5-fluorouracil, leucovorin, oxaliplatin, and irinotecan (FOLFOXIRI) plus bevacizumab, clinical CR and clinical near-CR were detected in the liver metastatic lesion and the primary tumor, respectively, and surgery was planned . Robot-assisted laparoscopic perineal rectal amputation and left-sided lymph node dissection were performed with no postoperative complications. Pathological diagnosis was ypT0, N0, M0 ypStage0. Postoperative adjuvant chemotherapy was not administered, and the patient was evaluated every 3 months in the outpatient clinic.\nComputed tomography performed during 1-year postoperative follow-up revealed thickening of the left bladder wall , requiring cystoscopy, which revealed no significant findings. Repeat cystoscopy was performed 6 months later because of the worsening of the left bladder wall thickening detected by computed tomography . The deformity in the left bladder wall, which was biopsied by transurethral resection, was diagnosed as metastasis of anal cancer. The histopathologic examination of the resected tissue revealed that the tumor cells had invaded the lymphatic vessels of the bladder. The tumor cells did not invade venous vessels, and histology of this tumor was similar to rectal cancer, which is a moderately differentiated tubular adenocarcinoma . After two cycles of systemic chemotherapy with FOLFOXIRI plus bevacizumab, partial resection of the small intestine was performed because of the difficulty in resolving obstruction of the small intestine with conservative therapy . The evaluation of the resected small intestine revealed lymphogenous invasion of the muscularis mucosa and subserosa of all sections, although tumor formation in intestinal mucosa were not observed .\nAfter excluding oxaliplatin, which had to be discontinued due to allergic reaction, the chemotherapy regimen was continued for approximately 10 months. However, ten months after the first surgery for small bowel obstruction, skin nodules extending from the lower abdomen to the thighs were observed ; the nodules gradually worsened over few months. The histopathologic evaluation of the biopsy specimens of the nodules collected at the time of the second surgery for bowel obstruction led to the diagnosis of skin metastasis of anal cancer . Following the administration of panitumumab after surgery, the skin nodules appeared to get smaller . However, four months after the diagnosis of skin metastasis, the patient developed lymphangitis carcinomatosa, discontinued chemotherapy, and died three months later.", + "fulltext_subclaims": [ + "The patient is a 66-year-old man.", + "He presented with a 1-month history of bloody stool.", + "He had anal pain.", + "His history included hypertension.", + "His history included hyperlipidemia.", + "His history included hyperuricemia.", + "He had a history of traffic trauma.", + "He had a history of postoperative right inguinal hernia.", + "He had no history of smoking.", + "The histopathologic evaluation of the biopsy specimen obtained with colonoscopy led to the diagnosis of moderately differentiated tubular adenocarcinoma of the anal canal.", + "The diagnosis was Stage IVa with lymph node and liver metastases.", + "The staging was based on evaluation with computed tomography and magnetic resonance imaging.", + "The tumor was T3.", + "The tumor was N3 [#263L].", + "The tumor was M1a [H1].", + "RAS and BRAF gene status were wild type.", + "MSI test was performed postrecurrence.", + "MSI test was negative.", + "After six cycles of systemic chemotherapy with FOLFOXIRI plus bevacizumab, clinical CR was detected in the liver metastatic lesion.", + "After six cycles of systemic chemotherapy with FOLFOXIRI plus bevacizumab, clinical near-CR was detected in the primary tumor.", + "Robot-assisted laparoscopic perineal rectal amputation was performed.", + "Left-sided lymph node dissection was performed.", + "There were no postoperative complications.", + "Pathological diagnosis was ypT0.", + "Pathological diagnosis was N0.", + "Pathological diagnosis was M0.", + "Pathological diagnosis was ypStage0.", + "Postoperative adjuvant chemotherapy was not administered.", + "The patient was evaluated every 3 months in the outpatient clinic.", + "Computed tomography performed during 1-year postoperative follow-up revealed thickening of the left bladder wall.", + "Cystoscopy revealed no significant findings.", + "Repeat cystoscopy was performed 6 months later because of the worsening of the left bladder wall thickening detected by computed tomography.", + "The deformity in the left bladder wall was diagnosed as metastasis of anal cancer.", + "The histopathologic examination of the resected tissue revealed that the tumor cells had invaded the lymphatic vessels of the bladder.", + "The tumor cells did not invade venous vessels.", + "The histology of this tumor was similar to rectal cancer.", + "The histology was moderately differentiated tubular adenocarcinoma.", + "After two cycles of systemic chemotherapy with FOLFOXIRI plus bevacizumab, partial resection of the small intestine was performed.", + "The evaluation of the resected small intestine revealed lymphogenous invasion of the muscularis mucosa.", + "The evaluation of the resected small intestine revealed lymphogenous invasion of the subserosa.", + "Tumor formation in intestinal mucosa was not observed.", + "Oxaliplatin had to be discontinued due to allergic reaction.", + "The chemotherapy regimen was continued for approximately 10 months.", + "Ten months after the first surgery for small bowel obstruction, skin nodules extending from the lower abdomen to the thighs were observed.", + "The histopathologic evaluation of the biopsy specimens of the nodules collected at the time of the second surgery for bowel obstruction led to the diagnosis of skin metastasis of anal cancer.", + "Following the administration of panitumumab after surgery, the skin nodules appeared to get smaller.", + "Four months after the diagnosis of skin metastasis, the patient developed lymphangitis carcinomatosa.", + "Chemotherapy was discontinued.", + "The patient died three months after discontinuation of chemotherapy." + ], + "summary": "A 66-year-old man presented with 1-month history of bloody stool and anal pain and diagnosed with clinical Stage IVa anal cancer with lymph node and liver metastases (cT3, N3", + "summary_subclaims": [ + "The patient is a 66-year-old man.", + "The patient had a 1-month history of bloody stool.", + "The patient had anal pain.", + "The patient was diagnosed with clinical Stage IVa anal cancer.", + "The cancer had lymph node metastases.", + "The cancer had liver metastases.", + "The tumor stage was cT3.", + "The lymph node stage was N3." + ] + }, + { + "id": "multiclinsum_test_2742_en.txt", + "fulltext": "We report a case of a 65-year-old male with a medical history of hepatitis C (Genotype 1b, F0-1) infection treated with Exviera plus Viekirax (DAA) with a sustained virological response (SVR) and porphyria cutanea tarda also successfully treated.\nThe patient was admitted to the hospital with a 72 h history of abdominal pain in the right upper quadrant, exacerbated by food intake and partially relieved by vomiting; other remarkable symptoms such as acholia, choluria and a body temperature of 38 °C were documented. On inspection, the patient presented skin and conjunctival jaundice, and abdominal examination revealed diffuse pain upon palpation predominantly in the right upper quadrant with positive Murphy’s sign.\nBlood analysis data on admission were: leukocytes 6.72×103 mm−3 (neutrophils 83.4%), platelets 184×103 mm−3, total bilirubin 6.17 mg dl−1, gamma-glutamyl transferase (GGT) 289 U l–1, glutamic oxaloacetic transaminase (GOT)/aspartate transaminase (AST) 148 U l–1 and glutamate pyruvate transaminase (GPT)/alanine transaminase (ALT) 439 U l–1. An ultrasound scan of the patient’s abdomen indicated an acute lithiasic cholecystitis and an intra- and extrahepatic dilatation of bile duct, without the identification of an obstructive cause.\nGiven the patient’s symptoms and the results of complementary tests, the patient was empirically treated with piperacillin/tazobactam and was admitted to the hospital. During hospitalization, an endoscopic retrograde cholangiopancreatography (ERCP) showed a stenosis at about 20 cm from the distal common bile duct, and a biliary endoprosthesis was inserted. An abdominal computed tomography scanner revealed a lithiasic gallbladder without lesions suspicious of malignancy. The patient was discharged for detailed medical studies but required hospitalization 3 weeks later in the context of acute cholecystitis suspicion. Percutaneous cholecystectomy was performed and piperacillin/tazobactam treatment was initiated (4 g every 8 h for 14 days). Three biliary samples were obtained for microbiological studies. Seven days later, the patient was submitted to a pancreatoduodenectomy and the prosthesis previously implanted was also sent for microbiological procedures.\nCultures were performed following conventional procedures in the media and environment recommended. Identification and susceptibility tests were performed using matrix-assisted laser desorption/ionization-time of flight (MALDI-TOF) MS (Bruker Daltonics) and MicrosCan Walkay panels (Beckman Coulter), respectively. MICs were interpreted according to EUCAST 2020 criteria , and carbapenemase production was detected by immunochromatography (RESIST-4 OKNV carbapenemase; Coris BioConcept).\nThe three bile samples yielded the culture of OXA-48 carbapenemase-producing and in two of them was also isolated. OXA-48 carbapanemase-producing and were obtained from the culture of the biliary prosthesis, as well as ( gives a summary of microbiological results of the different samples). After microbiology results, antibiotic treatment was changed to amikacin (300 mg every 8 h) and meropenem (1 g every 8 h), for 6 days. Results of the antibiogram showed carbapenem resistance that revealed the presence of a carbapenemase. Carbapenemase production was confirmed by immunochromatography (RESIST-4 OKNV carbapenemase; Coris BioConcept) being positive for OXA-48 carbapenemase. The strain was sent to the National Center for Clinical Microbiology (Carlos III Research Institute, Madrid) that confirmed OXA-48 production by sequencing. Antimicrobial treatment was changed to ceftazidime/avibactam (2 g every 8 h for 10 days) and tygecicline (50 mg every 12 h for 5 days) due to an increase in procalcitonin and C-reactive protein (CRP); both parameters decreased after administration of the new treatment. Eighteen days after the pancreatoduodenectomy, the patient was discharged and attended at outpatient consultation area.", + "fulltext_subclaims": [ + "The patient was a 65-year-old male.", + "The patient had a medical history of hepatitis C (Genotype 1b, F0-1) infection.", + "The patient was treated with Exviera plus Viekirax (DAA).", + "The patient achieved a sustained virological response (SVR).", + "The patient had porphyria cutanea tarda.", + "The patient was admitted to the hospital with a 72 h history of abdominal pain in the right upper quadrant.", + "The patient’s abdominal pain was exacerbated by food intake.", + "The patient’s abdominal pain was partially relieved by vomiting.", + "The patient had a body temperature of 38 °C.", + "The patient presented skin and conjunctival jaundice.", + "The patient had a positive Murphy’s sign.", + "Blood analysis showed total bilirubin of 6.17 mg dl−1.", + "Blood analysis showed gamma-glutamyl transferase (GGT) of 289 U l–1.", + "Blood analysis showed glutamate pyruvate transaminase (GPT)/alanine transaminase (ALT) of 439 U l–1.", + "An ultrasound scan indicated an acute lithiasic cholecystitis.", + "An ultrasound scan showed intra- and extrahepatic dilatation of bile duct.", + "An ultrasound scan did not identify an obstructive cause.", + "The patient was empirically treated with piperacillin/tazobactam.", + "An endoscopic retrograde cholangiopancreatography (ERCP) showed a stenosis at about 20 cm from the distal common bile duct.", + "A biliary endoprosthesis was inserted.", + "An abdominal computed tomography scanner revealed a lithiasic gallbladder.", + "The patient was discharged for detailed medical studies.", + "The patient required hospitalization 3 weeks later in the context of acute cholecystitis suspicion.", + "Percutaneous cholecystectomy was performed.", + "Piperacillin/tazobactam treatment was initiated (4 g every 8 h for 14 days).", + "Three biliary samples were obtained for microbiological studies.", + "The patient was submitted to a pancreatoduodenectomy.", + "The prosthesis previously implanted was sent for microbiological procedures.", + "Cultures were performed following conventional procedures.", + "Identification and susceptibility tests were performed using matrix-assisted laser desorption/ionization-time of flight (MALDI-TOF) MS.", + "MICs were interpreted according to EUCAST 2020 criteria.", + "Carbapenemase production was detected by immunochromatography (RESIST-4 OKNV carbapenemase; Coris BioConcept).", + "The three bile samples yielded the culture of OXA-48 carbapenemase-producing.", + "OXA-48 carbapenemase-producing was obtained from the culture of the biliary prosthesis.", + "Antibiotic treatment was changed to amikacin (300 mg every 8 h) and meropenem (1 g every 8 h), for 6 days.", + "Results of the antibiogram showed carbapenem resistance.", + "Carbapenemase production was confirmed by immunochromatography (RESIST-4 OKNV carbapenemase; Coris BioConcept).", + "The strain was sent to the National Center for Clinical Microbiology (Carlos III Research Institute, Madrid).", + "OXA-48 production was confirmed by sequencing.", + "Antimicrobial treatment was changed to ceftazidime/avibactam (2 g every 8 h for 10 days) and tygecicline (50 mg every 12 h for 5 days).", + "The patient was discharged 18 days after the pancreatoduodenectomy." + ], + "summary": "We present the case of a 65-year-old male diagnosed with acute lithiasic cholecystitis. Culture of the biliary prosthesis yielded a OXA-48-producing H. alvei that was identified by MALDI-TOF (matrix-assisted laser desorption/ionization-time of flight) MS. Carbapenemase production was detected by immunochromatography and confirmed by sequencing.", + "summary_subclaims": [ + "The patient is a 65-year-old male.", + "The patient was diagnosed with acute lithiasic cholecystitis.", + "Culture of the biliary prosthesis yielded an OXA-48-producing H. alvei.", + "The organism was identified by MALDI-TOF MS.", + "Carbapenemase production was detected by immunochromatography.", + "Carbapenemase production was confirmed by sequencing." + ] + }, + { + "id": "multiclinsum_test_1582_en.txt", + "fulltext": "A 67 year-old female patient presented with left chest wall sinus one year ago. Local redness, pain and persistent purulent discharge occurred around the sinus orifice. Reviewing the medical history, the patient had undergone left mastectomy 20 years ago due to the diagnosis of left breast cancer, followed by regular radiotherapy and chemotherapy for several times. At the same time, she suffered from coronary heart disease, hypertension and other cardiovascular diseases. She underwent coronary stent implantation in 2017, 2019 and 2020 respectively. Currently, she regularly takes anticoagulant drugs (Aspirin Enteric-coated Tablets 100 mg QD) and antihypertensive drugs (Nifedipine Sustained Release Tablets 30 mg QD). Due to repeated non-healing of chest wall wound and formation of chest wall defect, ulcer and fistula caused by debridement, the patient was admitted to our hospital for further treatment. Chest CT scan showed partial defect of left chest wall with sinus formation, high-density shadow of left clavicle and some ribs. According to the patient's symptoms and imaging examination, we diagnosed chest wall sinus with infection and chronic osteomyelitis.\nAfter admission, the patient continued to be given local cleaning and dressing changes on the wound surface. The purulent secretions at the sinus orifice were subjected to microbial culture and drug susceptibility tests. The results of the three secretion cultures were all suggestive of Pseudomonas aeruginosa. Her BMI was 18.4 kg/m2 and albumin was 24.5 g/L. We chose sensitive antibiotics for systemic anti-infective treatment. At the same time, nutritional support and correction of hypoalbuminemia were given. Enhanced chest CT and three-dimensional reconstruction were performed. Before chest CT examination, 50% meglumine solution was injected into sinus orifice through a thin drainage tube to fully understand the shape, scope and adjacent conditions of sinus. Due to the long course of disease and lack of confidence in treatment, the patients were given necessary psychological counseling and appropriate anti anxiety drug treatment.\nThe operation was divided into two stages, both under general anesthesia. Before first-stage operation, we injected methylene blue solution from sinus orifice to make sinus wall fully stained to guide the scope of surgical curettage, which could not only ensure the complete removal of the diseased sinus wall tissue, but also avoided too much damage to the normal tissue and even the important organs behind the sternum. Taking the sinus orifice of chest wall as a center, a fusiform incision with a length of about 8 cm was made along the 1 cm around sinus orifice. The direction and length of the incision were determined according to the sinus shape (the sinus starts at the level of the left first rib and ends at the level of the left fourth rib, without communication with the thoracic cavity) shown on preoperative chest CT and the position of the myocutaneous flap to be filled. After incision of the skin, the sternum and infected area were fully exposed, sinus wall tissue was fully scraped with a curette, and then necrotic bone was completely removed with a rongeur (It starts from the junction of the left first rib and the manubrium cartilage. Part of the first rib, part of the lower edge of the left clavicle, and the adjacent medial end of the sternum are removed in sequence from near to far, from top to bottom, until the bone stump is fresh). When the chest wall wound tissue was fresh and there was no dye attached, we first rinse it with 1000 ml normal saline, then rinse it with diluted iodophor water (100 ml iodophor water and 400 ml normal saline) and 100 ml 3% hydrogen peroxide for one time, and then rinse it with 1000 ml normal saline again. Due to the huge wound defect after debridement, in order to ensure the cleanliness of the wound, improve local blood supply and prepare for the second-stage operation, vacuum sealing drainage (VSD) were performed after the operation . We adjusted the pressure scale of the VSD device to 0.04 Mpa, and the device was removed after 7 days.\nWhen the patient's general condition was good after first-stage operation, after the vacuum sealing drainage device was removed, the daily incision dressing change, anti-infection, nutritional support and other treatments were continued. When the granulation of sinus wound was fresh, the secretion was significantly reduced, the re-culturing of the wound secretion was negative, and the infection was preliminarily controlled, we were ready for the second-stage operation. Continue to appropriately expanded the wound along the original incision, thoroughly debrideed the necrotic tissue until the wound was fresh, and measured the size of the chest wall defect was about 15 × 8 cm. After hemostasis, rinsed the wound with a large amount of iodophor, hydrogen peroxide, and normal saline alternately. The patient's body position was changed to 90° lateral lying position. According to the preoperative planned flap incision, the pedicled latissimus dorsi myocutaneous flap was selected as the living tissue to fill the defect wound. The computed tomography angiography (CTA) examination of the subclavian artery showed that there were internal thoracic artery and thoracodorsal artery on the affected side without malformation. During the operation, first of all, an incision was made along the outer edge of latissimus dorsi muscle, starting from the proximal axillary apex, and the proximal and distal ends of latissimus dorsi muscle were dissociated and fully exposed in turn to protect the thoracodorsal artery and vein. Finally, a latissimus dorsi myocutaneous flap with thoracodorsal neurovascular bundle of sufficient length was formed. The size of the latissimus dorsi myocutaneous flap was about 30 × 8 cm, while the skin island of about 16cmx8cm was reserved. During harvesting of the myocutaneous flap, the blood supply should be preserved as much as possible, while avoiding excessive distortion of the pedicle of the myocutaneous flap. We first made a subcutaneous tunnel between the acquisition site of the myocutaneous flap and the sternal wound, transferred the myocutaneous flap to the chest wall defect wound, then sutured and fixed it with the soft tissue around the wound, closely combined the myocutaneous flap with the bottom of the chest wall wound to eliminate the dead space, and finally placed a drainage tube . The patient was treated with anti infection (Cefoperazone Sodium and Sulbactam Sodium + Levofloxacin and Sodium Chloride Injection), anti spasm (Raceanisodamine Hydrochloride Injection) and anticoagulation (Enoxaparin Sodium Injection) after operation. The color and temperature of the myocutaneous flap was closely observed and tested. The transplanted myocutaneous flap was kept warm, and the incision was avoided from compression to protect the smooth blood flow. The patient pulled out the chest tubes on the 4th postoperative day and was discharged from the hospital on the 7th day. At present, the patient was followed up for 6 months after the operation, the incision healed well and no malignant tumor tissue was found in the routine pathology after the two operations. Repeat chest CT showed that the chest wall sinus disappeared completely, and the pedicled myocutaneous flap fully survived.", + "fulltext_subclaims": [ + "The patient is a 67 year-old female.", + "The patient presented with left chest wall sinus one year ago.", + "Local redness, pain and persistent purulent discharge occurred around the sinus orifice.", + "The patient had undergone left mastectomy 20 years ago due to the diagnosis of left breast cancer.", + "The patient had regular radiotherapy and chemotherapy for several times.", + "The patient has coronary heart disease.", + "The patient has hypertension.", + "The patient underwent coronary stent implantation in 2017, 2019 and 2020.", + "The patient regularly takes Aspirin Enteric-coated Tablets 100 mg QD.", + "The patient regularly takes Nifedipine Sustained Release Tablets 30 mg QD.", + "The patient had repeated non-healing of chest wall wound.", + "The patient had formation of chest wall defect, ulcer and fistula caused by debridement.", + "Chest CT scan showed partial defect of left chest wall with sinus formation.", + "Chest CT scan showed high-density shadow of left clavicle and some ribs.", + "The diagnosis was chest wall sinus with infection and chronic osteomyelitis.", + "Local cleaning and dressing changes on the wound surface were given.", + "Purulent secretions at the sinus orifice were subjected to microbial culture and drug susceptibility tests.", + "The results of the three secretion cultures were all suggestive of Pseudomonas aeruginosa.", + "The patient's BMI was 18.4 kg/m2.", + "The patient's albumin was 24.5 g/L.", + "The patient was given systemic anti-infective treatment with sensitive antibiotics.", + "The patient was given nutritional support and correction of hypoalbuminemia.", + "Enhanced chest CT and three-dimensional reconstruction were performed.", + "Before chest CT examination, 50% meglumine solution was injected into sinus orifice through a thin drainage tube.", + "The operation was divided into two stages, both under general anesthesia.", + "Before first-stage operation, methylene blue solution was injected from sinus orifice to make sinus wall fully stained.", + "A fusiform incision with a length of about 8 cm was made along the 1 cm around sinus orifice.", + "The sinus starts at the level of the left first rib and ends at the level of the left fourth rib.", + "The sinus does not communicate with the thoracic cavity.", + "The sternum and infected area were fully exposed.", + "Sinus wall tissue was fully scraped with a curette.", + "Necrotic bone was completely removed with a rongeur.", + "The wound was rinsed with 1000 ml normal saline, then with diluted iodophor water, then with 3% hydrogen peroxide, and then with 1000 ml normal saline again.", + "Vacuum sealing drainage (VSD) was performed after the operation.", + "The pressure scale of the VSD device was adjusted to 0.04 Mpa.", + "The VSD device was removed after 7 days.", + "When the granulation of sinus wound was fresh, the secretion was significantly reduced, the re-culturing of the wound secretion was negative, and the infection was preliminarily controlled, the second-stage operation was prepared.", + "The wound was expanded along the original incision.", + "The size of the chest wall defect was about 15 × 8 cm.", + "The wound was rinsed with a large amount of iodophor, hydrogen peroxide, and normal saline alternately.", + "The patient's body position was changed to 90° lateral lying position.", + "A pedicled latissimus dorsi myocutaneous flap was selected as the living tissue to fill the defect wound.", + "Computed tomography angiography (CTA) showed that there were internal thoracic artery and thoracodorsal artery on the affected side without malformation.", + "An incision was made along the outer edge of latissimus dorsi muscle, starting from the proximal axillary apex.", + "The proximal and distal ends of latissimus dorsi muscle were dissociated and fully exposed in turn to protect the thoracodorsal artery and vein.", + "A latissimus dorsi myocutaneous flap with thoracodorsal neurovascular bundle of sufficient length was formed.", + "The size of the latissimus dorsi myocutaneous flap was about 30 × 8 cm.", + "A skin island of about 16cmx8cm was reserved.", + "A subcutaneous tunnel was made between the acquisition site of the myocutaneous flap and the sternal wound.", + "The myocutaneous flap was transferred to the chest wall defect wound.", + "The myocutaneous flap was sutured and fixed with the soft tissue around the wound.", + "The myocutaneous flap was closely combined with the bottom of the chest wall wound to eliminate the dead space.", + "A drainage tube was placed.", + "The patient was treated with anti infection (Cefoperazone Sodium and Sulbactam Sodium + Levofloxacin and Sodium Chloride Injection).", + "The patient was treated with anti spasm (Raceanisodamine Hydrochloride Injection).", + "The patient was treated with anticoagulation (Enoxaparin Sodium Injection).", + "The color and temperature of the myocutaneous flap was closely observed and tested.", + "The transplanted myocutaneous flap was kept warm.", + "The incision was avoided from compression to protect the smooth blood flow.", + "The patient pulled out the chest tubes on the 4th postoperative day.", + "The patient was discharged from the hospital on the 7th day.", + "The patient was followed up for 6 months after the operation.", + "The incision healed well.", + "No malignant tumor tissue was found in the routine pathology after the two operations.", + "Repeat chest CT showed that the chest wall sinus disappeared completely.", + "The pedicled myocutaneous flap fully survived." + ], + "summary": "Herein, we report a case of a 67 year-old woman who had undergone breast cancer surgery and a history of multiple cycles of radiotherapy and chemotherapy. One year ago, she had a fistula in the left chest wall with yellow purulent fluid. After admission to our hospital, chest computed tomography (CT) showed the formation of the left chest wall sinus, accompanied by high-density images of the left clavicle, part of the ribs and part of the sternu. According to the patient's symptoms, signs and imaging examination, we preliminarily diagnosed the patient as chest wall sinus with infection and chronic osteomyelitis. Therefore, in the first-stage operation, the patient underwent left chest wall sinus resection, left partial rib resection, left partial clavicular resection and left partial sternal resection, After surgery, the wound surface was changed with gauze dressing with sensitive antibiotic solution every day until the wound surface was clean and new granulation was formed. In the second-stage operation, the wound surface was appropriately expanded, and the pedicled latissimus dorsi myocutaneous flap was transferred to the chest wall defect. Finally, the skin paddle was sutured without tension to the normal skin around the chest, and two drainage tubes were placed. Anti-infection, anti-spasm, anti-coagulation and other treatments were given after operation, and the survival of myocutaneous flap, wound healing and sinus disappearance were observed.", + "summary_subclaims": [ + "The patient was a 67 year-old woman.", + "She had undergone breast cancer surgery.", + "She had a history of multiple cycles of radiotherapy and chemotherapy.", + "One year ago, she had a fistula in the left chest wall with yellow purulent fluid.", + "Chest computed tomography showed the formation of the left chest wall sinus.", + "Chest computed tomography showed high-density images of the left clavicle.", + "Chest computed tomography showed high-density images of part of the ribs.", + "Chest computed tomography showed high-density images of part of the sternum.", + "The preliminary diagnosis was chest wall sinus with infection.", + "The preliminary diagnosis included chronic osteomyelitis.", + "The first-stage operation included left chest wall sinus resection.", + "The first-stage operation included left partial rib resection.", + "The first-stage operation included left partial clavicular resection.", + "The first-stage operation included left partial sternal resection.", + "The wound surface was changed with gauze dressing with sensitive antibiotic solution every day.", + "The wound surface was clean and new granulation was formed.", + "The second-stage operation included appropriate expansion of the wound surface.", + "The second-stage operation included transfer of the pedicled latissimus dorsi myocutaneous flap.", + "The skin paddle was sutured without tension to the normal skin around the chest.", + "Two drainage tubes were placed.", + "Anti-infection treatment was given after operation.", + "Anti-spasm treatment was given after operation.", + "Anti-coagulation treatment was given after operation.", + "The survival of myocutaneous flap was observed.", + "Wound healing was observed.", + "Sinus disappearance was observed." + ] + }, + { + "id": "multiclinsum_test_3129_en.txt", + "fulltext": "A 44-year-old man who presented with shortness of breath on effort was admitted to our hospital. He had no history of hypertension, diabetes mellitus, or cardiovascular diseases. His blood pressure was 106/78 mmHg, pulse rate was 108 bpm, and blood oxygen saturation was 97% on room air. A Levine 3/6 holosystolic murmur and the third heart sound at the apex and bilateral rales were audible. Jugular venous distention and moderate pitting edema of the bilateral pretibials were noted.\n\nChest radiography revealed cardiac enlargement (cardiothoracic ratio 66%), pulmonary congestion, and mild pleural effusion. An electrocardiogram (ECG) showed sinus rhythm and complete left bundle branch block (QRS width: 132 ms). Regarding laboratory data, serum aspartate transaminase, serum creatinine, and serum uric acid were mildly elevated. The brain natriuretic peptide level was 885 pg/mL, and the troponin T level was 0.057 ng/mL (Table). Transthoracic echocardiography demonstrated LV dilatation [LV end-diastolic diameter (LVDd): 70 mm], global hypokinesis with an ejection fraction of 25%, prominent and deep intertrabecular recesses, increased noncompacted (NC) endomyocardial layer depth compared to the compacted (C) epicardial layer (NC 28.5 mm, C 8.3 mm, NC/C ratio >2.0), and apical aneurysm with spontaneous echo contrast and 2 thrombi (10×13 mm in the inferior wall, 15×8 mm in the anterior wall).\n\nThe NC region was localized at the mid-inferior and posterolateral LV and adjacent to the apical aneurysm. These thrombi were relatively highly echogenic and immobile and were detected in the apical aneurysm, not the NC region. Cardiac magnetic resonance imaging (cMRI) showed late gadolinium enhancement (LGE) in the endocardium in the apical anterolateral wall, an increased NC/C ratio (>2.3), and 2 thrombi in the apical aneurysm. Coronary angiography revealed no significant obstructive stenosis, but a left ventriculogram showed an aneurysm in the apex. A pathological analysis demonstrated no evidence of secondary cardiomyopathy, such as myocarditis, sarcoidosis, amyloidosis or hemochromatosis. Based on these findings, he was diagnosed with LVNC complicated with apical aneurysm.\n\nTo determine the link between gene mutations and LV aneurysm in this case, we performed a genetic test to diagnose the LVNC. However, we detected no genetic mutations associated with LVNC or other cardiomyopathies. This patient did not have a family history of LVNC or a history of other congenital, acquired, significant valvular heart disease or neuro-muscular disease. This patient was therefore thought to be an isolated case of LVNC with LV dysfunction.\n\nCarvedilol, enalapril, furosemide, and warfarin were started to manage HF and prevent stroke or systemic thromboembolism. Although the multiple apical thrombi disappeared without clinical signs of embolism after four weeks of anticoagulation, computed tomography (CT) revealed right cerebellar infarction. Eight months after medical therapy, despite the improvement in the LV dimension (LVDd: 63 mm) and systolic function (LVEF: 34%), the thicknesses of the NC and C layers were not markedly changed (NC: 28.8 mm, C: 8.2 mm).", + "fulltext_subclaims": [ + "The patient is a 44-year-old man.", + "He presented with shortness of breath on effort.", + "He had no history of hypertension.", + "He had no history of diabetes mellitus.", + "He had no history of cardiovascular diseases.", + "His blood pressure was 106/78 mmHg.", + "His pulse rate was 108 bpm.", + "His blood oxygen saturation was 97% on room air.", + "A Levine 3/6 holosystolic murmur was audible.", + "The third heart sound was audible at the apex.", + "Bilateral rales were audible.", + "Jugular venous distention was noted.", + "Moderate pitting edema of the bilateral pretibials was noted.", + "Chest radiography revealed cardiac enlargement.", + "Chest radiography showed a cardiothoracic ratio of 66%.", + "Chest radiography showed pulmonary congestion.", + "Chest radiography showed mild pleural effusion.", + "An electrocardiogram showed sinus rhythm.", + "An electrocardiogram showed complete left bundle branch block.", + "The QRS width was 132 ms.", + "Serum aspartate transaminase was mildly elevated.", + "Serum creatinine was mildly elevated.", + "Serum uric acid was mildly elevated.", + "The brain natriuretic peptide level was 885 pg/mL.", + "The troponin T level was 0.057 ng/mL.", + "Transthoracic echocardiography demonstrated LV dilatation.", + "LV end-diastolic diameter was 70 mm.", + "Global hypokinesis was present.", + "The ejection fraction was 25%.", + "Prominent and deep intertrabecular recesses were present.", + "The NC endomyocardial layer depth was 28.5 mm.", + "The C epicardial layer depth was 8.3 mm.", + "The NC/C ratio was greater than 2.0.", + "An apical aneurysm with spontaneous echo contrast was present.", + "Two thrombi were detected.", + "The NC region was localized at the mid-inferior and posterolateral LV.", + "The NC region was adjacent to the apical aneurysm.", + "The thrombi were detected in the apical aneurysm, not the NC region.", + "Cardiac magnetic resonance imaging showed late gadolinium enhancement in the endocardium in the apical anterolateral wall.", + "The NC/C ratio was greater than 2.3.", + "Two thrombi were present in the apical aneurysm.", + "Coronary angiography revealed no significant obstructive stenosis.", + "A left ventriculogram showed an aneurysm in the apex.", + "Pathological analysis demonstrated no evidence of secondary cardiomyopathy.", + "Based on these findings, he was diagnosed with LVNC complicated with apical aneurysm.", + "A genetic test was performed to diagnose LVNC.", + "No genetic mutations associated with LVNC were detected.", + "The patient did not have a family history of LVNC.", + "The patient was therefore thought to be an isolated case of LVNC with LV dysfunction.", + "Carvedilol was started.", + "Enalapril was started.", + "Furosemide was started.", + "Warfarin was started.", + "Multiple apical thrombi disappeared without clinical signs of embolism after four weeks of anticoagulation.", + "Computed tomography revealed right cerebellar infarction.", + "Eight months after medical therapy, the LV dimension improved.", + "LV end-diastolic diameter was 63 mm.", + "Systolic function improved.", + "The ejection fraction was 34%.", + "The thicknesses of the NC and C layers were not markedly changed." + ], + "summary": "A 44-year-old man was admitted to our hospital due to heart failure. Transthoracic echocardiography demonstrated global hypokinesis with an ejection fraction of 25%, prominent trabeculation and deep intertrabecular recesses, and apical aneurysm with multiple thrombi (10×13 mm in the inferior wall, 15×8 mm in the anterior wall). Cardiac magnetic resonance imaging showed an increased ratio of noncompacted (NC) to compacted (C) myocardium (NC/C ratio >2.3) and apical aneurysm. Coronary angiography revealed no significant stenosis. He was therefore diagnosed with left ventricular noncompaction complicated by apical aneurysm. Four weeks after starting anticoagulation, the multiple apical thrombi disappeared without clinical signs of embolism.", + "summary_subclaims": [ + "The patient is a 44-year-old man.", + "He was admitted to our hospital due to heart failure.", + "Transthoracic echocardiography demonstrated global hypokinesis.", + "Transthoracic echocardiography showed an ejection fraction of 25%.", + "Transthoracic echocardiography showed prominent trabeculation and deep intertrabecular recesses.", + "Transthoracic echocardiography showed apical aneurysm with multiple thrombi.", + "The thrombi measured 10×13 mm in the inferior wall.", + "The thrombi measured 15×8 mm in the anterior wall.", + "Cardiac magnetic resonance imaging showed an increased ratio of noncompacted to compacted myocardium.", + "The NC/C ratio was greater than 2.3.", + "Cardiac magnetic resonance imaging showed apical aneurysm.", + "Coronary angiography revealed no significant stenosis.", + "He was diagnosed with left ventricular noncompaction complicated by apical aneurysm.", + "Four weeks after starting anticoagulation, the multiple apical thrombi disappeared.", + "There were no clinical signs of embolism." + ] + }, + { + "id": "multiclinsum_test_1427_en.txt", + "fulltext": "She was 3 years old at the time of her first visit and presented on 16 September 2020 due to language delay. She is 5 years old now.\nSince age 6 mo, she had had obvious slow growth in height and weight. Language development was delayed. Her response to name calling was normal but there was no communication with people. Her eyes could not be met and there was no social smile. There was no autonomous language, However, the child had rich gesture language and body language, she could understand instructions, had a short temper, and when she wants to achieve something, she starts crying or shouting. She was thin, with a weight of 9 kg and height of 83 cm.\nThere was no obvious abnormality at birth, weight 3 kg, height 50 cm. She raised her head at 3 mo, crawled at 7 mo, and walked at 15 mo. She had a history of febrile convulsions twice, each lasting about 2 min, which resolved spontaneously, and a 1-year history of ulcerative colitis.\nBoth parents were healthy.\nBody temperature was 36.2 °C, heart rate 96 beats/min, breathing 24 beats/min, blood pressure 100/60 mmHg, height 83.0 cm and weight 9 kg. There was no special sick face, and cardiopulmonary and abdominal examinations showed no obvious abnormalities. Bilateral muscle strength and muscle tone were symmetrical and slightly decreased. Physiological reflexes were present but pathological reflexes were not elicited.\nRoutine blood and urine examinations, myocardial enzymes, lactic acid, liver function, renal function, electrolytes, blood glucose, thyroid function, and hematuria showed no obvious abnormalities. The peak growth hormone challenge test was 5.77 ng/mL.\nVideo electroencephalography showed no abnormalities. Magnetic resonance imaging (MRI) of the brain showed mild atrophy.", + "fulltext_subclaims": [ + "She was 3 years old at the time of her first visit.", + "She presented on 16 September 2020 due to language delay.", + "She is 5 years old now.", + "Since age 6 mo, she had had obvious slow growth in height and weight.", + "Language development was delayed.", + "Her response to name calling was normal.", + "There was no communication with people.", + "Her eyes could not be met.", + "There was no social smile.", + "There was no autonomous language.", + "The child had rich gesture language and body language.", + "She could understand instructions.", + "When she wants to achieve something, she starts crying or shouting.", + "She was thin, with a weight of 9 kg and height of 83 cm.", + "There was no obvious abnormality at birth.", + "Weight at birth was 3 kg.", + "Height at birth was 50 cm.", + "She raised her head at 3 mo.", + "She crawled at 7 mo.", + "She walked at 15 mo.", + "She had a history of febrile convulsions twice.", + "Each febrile convulsion lasted about 2 min.", + "Each febrile convulsion resolved spontaneously.", + "She had a 1-year history of ulcerative colitis.", + "Both parents were healthy.", + "Body temperature was 36.2 °C.", + "Heart rate was 96 beats/min.", + "Respiratory rate was 24 beats/min.", + "Blood pressure was 100/60 mmHg.", + "Height was 83.0 cm.", + "Weight was 9 kg.", + "There was no special sick face.", + "Cardiopulmonary and abdominal examinations showed no obvious abnormalities.", + "Bilateral muscle strength and muscle tone were symmetrical and slightly decreased.", + "Physiological reflexes were present.", + "Pathological reflexes were not elicited.", + "Routine blood and urine examinations showed no obvious abnormalities.", + "Myocardial enzymes showed no obvious abnormalities.", + "Lactic acid showed no obvious abnormalities.", + "Liver function showed no obvious abnormalities.", + "Renal function showed no obvious abnormalities.", + "Electrolytes showed no obvious abnormalities.", + "Blood glucose showed no obvious abnormalities.", + "Thyroid function showed no obvious abnormalities.", + "Hematuria showed no obvious abnormalities.", + "The peak growth hormone challenge test was 5.77 ng/mL.", + "Video electroencephalography showed no abnormalities.", + "Magnetic resonance imaging (MRI) of the brain showed mild atrophy." + ], + "summary": "The 5-year-old girl presented with postpartum height and weight growth retardation, language retardation, brain atrophy, convulsions, and growth hormone deficiency. DNA samples were obtained from peripheral blood from the child and her parents for whole-exome sequencing and test of genome-wide copy number variation. Heterozygous mutations in the IFIH1 gene were found. Physical examination at admission found that language development was delayed, the reaction to name calling was average, there was no communication with people, but there was eye contact, no social smile, and no autonomous language. However, the child had rich gesture language and body language, could understand instructions, had bad temper. When she wants to achieve something, she starts crying or shouting. Cardiopulmonary examination showed no obvious abnormality, and abdominal examination was normal. Bilateral muscle strength and muscle tone were symmetrical and slightly decreased. Physiological reflexes exist, but pathological reflexes were not elicited.", + "summary_subclaims": [ + "The 5-year-old girl presented with postpartum height and weight growth retardation.", + "The 5-year-old girl presented with language retardation.", + "The 5-year-old girl had brain atrophy.", + "The 5-year-old girl had convulsions.", + "The 5-year-old girl had growth hormone deficiency.", + "DNA samples were obtained from peripheral blood from the child and her parents.", + "Whole-exome sequencing was performed.", + "A test of genome-wide copy number variation was performed.", + "Heterozygous mutations in the IFIH1 gene were found.", + "Physical examination at admission found that language development was delayed.", + "The reaction to name calling was average.", + "There was no communication with people.", + "There was eye contact.", + "There was no social smile.", + "There was no autonomous language.", + "The child had rich gesture language and body language.", + "The child could understand instructions.", + "The child had bad temper.", + "When she wants to achieve something, she starts crying or shouting.", + "Cardiopulmonary examination showed no obvious abnormality.", + "Abdominal examination was normal.", + "Bilateral muscle strength and muscle tone were symmetrical and slightly decreased.", + "Physiological reflexes exist.", + "Pathological reflexes were not elicited." + ] + }, + { + "id": "multiclinsum_test_3377_en.txt", + "fulltext": "A 4-year-old Japanese girl with B-cell acute lymphoblastic leukemia (ALL) presented to the emergency room with febrile convulsion. The age of disease onset was 3 years and the patient received maintenance chemotherapy in our outpatient clinic. The patient had a high fever (40.1 C°), tachypnea (respiratory rate 38/min), and tachycardia (pulse rate 180/min). She was diagnosed with febrile neutropenia and systemic inflammatory response syndrome (SIRS) based on her neutrophil count, which was 322/μL, as well as remarkably elevated inflammatory responses (CRP: 2.2 mg/dl; procalicitonin: 67.8 ng/mL). Chest X-ray revealed mild perihilar infiltration with normal cardiothoracic ratio (51.6%), and chest computed tomographic scanning showed bilateral consolidation and pleural effusion. Within two hours after admission, the patient’s respiratory condition continued to deteriorate despite oxygen supplementation while lactate levels increased to 62.6 mg/dL. The patient was transferred to the intensive care unit for mechanical ventilation; however, her systolic blood pressure decreased gradually from 116 to 40 mmHg despite hydration and blood transfusion for volume expansion. Therefore, catecholamine administration, intravenous immunoglobulin, and continuous venovenous hemofiltration were initiated. As we suspected myocardial dysfunction, cardiac ultrasound was performed and showed depressed left ventricular function with an ejection fraction of 27%, as well as a left ventricular Tei index of 0.62 indicating global systolic and diastolic ventricular function, mitral regurgitation, and tricuspid regurgitation. An electrocardiogram showed ST-T wave change in V4-6. Furthermore, a marked increase in myocardial markers was noted, including Troponin-I 0.541 ng/mL (normal 0-0.04 ng/mL), myoglobin 91.2 ng/mL (normal 12.8-66.1 ng/mL), and CK-MB 10.6 ng/mL (0.9-5.9 ng/mL).\n\nTwo days after admission to the hospital, her systolic blood pressure improved to 120 mmHg and inotropic support was gradually reduced and stopped by day 9. In addition to the administration of milrinone for 11 days, continuous hemofiltration was carried out for 6 days to treat the heart failure. Subsequently, left ventricular function gradually improved, and myocardial markers returned to normal levels 17 days after admission to the hospital. Finally, she was discharged from the intensive care unit on day 13.\n\nThree separate blood cultures were negative. Additionally, the patient tested negative for influenza virus, human-metapneumovirus, adenovirus, and Group A streptococcus using rapid antigen tests; however, RSV antigens were detected in a nasal swab at the time of hospital admission. Moreover, seroconversion of RSV antibody titers (< 4 and 16) was confirmed using a neutralizing antibody test (SRL Inc., Tokyo, Japan). In order to elucidate the pathophysiology of RSV infection, serially collected tracheal tube aspirates and serum samples were examined using real-time RT-PCR. Real-time RT-PCR analysis detected high amounts of RSV type B RNA in the tracheal aspirates on day 2 (1.6 × 109 copies/ml) and day 5 (1.4 × 108 copies/ml) after the onset of the disease. Interestingly, viral RNA was also detected in the serum sample obtained on day 1 of the illness (3.2 × 104 copies/ml), but it had decreased to undetectable levels in serum samples collected on days 5 and 8.\n\nIn order to examine the pathophysiology of this severe cardiac complication caused by RSV infection, various cytokines and chemokines were measured in serially collected serum samples using the Cytometric Bead Array system. Serum samples were serially collected before the onset of the RSV infection and on days 1, 5, 7, and 14 after illness onset. IL-6, IL-10, IL-8, IFN-γ, MCP-1, and IP-10 were markedly elevated at the time of disease onset. The levels of these biomarkers returned to normal by 14 days after illness onset.", + "fulltext_subclaims": [ + "The patient is a 4-year-old Japanese girl.", + "She has B-cell acute lymphoblastic leukemia.", + "She presented with febrile convulsion.", + "The age of disease onset was 3 years.", + "She received maintenance chemotherapy in the outpatient clinic.", + "She had a high fever of 40.1 C°.", + "She had tachypnea with a respiratory rate of 38/min.", + "She had tachycardia with a pulse rate of 180/min.", + "She was diagnosed with febrile neutropenia.", + "She was diagnosed with systemic inflammatory response syndrome.", + "Her neutrophil count was 322/μL.", + "Her CRP was 2.2 mg/dl.", + "Her procalicitonin was 67.8 ng/mL.", + "Chest X-ray showed mild perihilar infiltration.", + "Chest CT showed bilateral consolidation.", + "Chest CT showed pleural effusion.", + "Her lactate levels increased to 62.6 mg/dL.", + "She was transferred to the intensive care unit.", + "Her systolic blood pressure decreased to 40 mmHg.", + "Catecholamine administration was initiated.", + "Intravenous immunoglobulin was initiated.", + "Continuous venovenous hemofiltration was initiated.", + "Cardiac ultrasound showed an ejection fraction of 27%.", + "The Tei index was 0.62.", + "An electrocardiogram showed ST-T wave change in V4-6.", + "Troponin-I was 0.541 ng/mL.", + "Myoglobin was 91.2 ng/mL.", + "CK-MB was 10.6 ng/mL.", + "Three blood cultures were negative.", + "RSV antigens were detected in a nasal swab.", + "RSV type B RNA was detected in tracheal aspirates on day 2.", + "RSV type B RNA was detected in tracheal aspirates on day 5.", + "Viral RNA was detected in the serum sample on day 1.", + "Viral RNA was undetectable in serum samples on days 5 and 8.", + "IL-6 was markedly elevated at the time of disease onset.", + "IL-10 was markedly elevated at the time of disease onset.", + "IL-8 was markedly elevated at the time of disease onset.", + "IFN-γ was markedly elevated at the time of disease onset.", + "MCP-1 was markedly elevated at the time of disease onset.", + "IP-10 was markedly elevated at the time of disease onset.", + "The levels of these biomarkers returned to normal by 14 days after illness onset." + ], + "summary": "A 4-year-old girl with acute lymphoblastic leukemia who received maintenance chemotherapy in an outpatient clinic developed systemic inflammatory response syndrome. RSV infection was confirmed by a positive rapid antigen test and serological assay. Subsequently, she was diagnosed with severe myocarditis caused by RSV infection, which was diagnosed by abnormal findings of cardiac echography and ECG and elevated biomarkers for myocardial damage. Then, she was treated in the intensive care unit for 13 days. High amounts of RSV type B RNA was detected in tracheal aspirates and serum sample.", + "summary_subclaims": [ + "The patient is a 4-year-old girl.", + "The patient has acute lymphoblastic leukemia.", + "The patient received maintenance chemotherapy in an outpatient clinic.", + "The patient developed systemic inflammatory response syndrome.", + "RSV infection was confirmed by a positive rapid antigen test.", + "RSV infection was confirmed by a serological assay.", + "The patient was diagnosed with severe myocarditis.", + "The severe myocarditis was caused by RSV infection.", + "The diagnosis of severe myocarditis was based on abnormal findings of cardiac echography.", + "The diagnosis of severe myocarditis was based on abnormal findings of ECG.", + "The diagnosis of severe myocarditis was based on elevated biomarkers for myocardial damage.", + "The patient was treated in the intensive care unit.", + "The patient was treated in the intensive care unit for 13 days.", + "High amounts of RSV type B RNA were detected in tracheal aspirates.", + "High amounts of RSV type B RNA were detected in a serum sample." + ] + }, + { + "id": "multiclinsum_test_3247_en.txt", + "fulltext": "A 32-year-old 38 week-pregnant Caucasian female was admitted to the emergency department with right upper abdominal pain since 2 weeks prior, which suddenly worsened 2 h before admission. She had been diagnosed with Gestational Hypertension and treated with Methyldopa. Initial examination during admission revealed elevated blood pressure of 180/110 mmHg and proteinuria with urinary dipstick test (3+). Laboratory investigation revealed mild thrombocytopenia (125.000/uL), increased alanine-aminotransferase (ALT) level of 10.54 μkat/L (=632 U/L) and aspartate-aminotransferase (AST) level of 13.20 μkat/L (=792 U/L), increased lactate dehydrogenase (LDH) levels of 28.10 μkat/L (=1686 U/L), hypoalbuminemia (25.0 g/L), and high serum folate (>20.0 ng/mL). An ultrasound scan of the fetus revealed normal development, with weight estimation at the 5 SD growth curve. Cardiotocography (CTG) examination resulted in pathologic CTG. Diagnosis of preeclampsia with HELLP syndrome was made based on clinical and biochemical features.\n\nDue to the deteriorating condition of the patient and fetal distress, an emergency Caesarean section was performed. A female newborn was delivered with respiratory distress, weighing 2,466 g at 5 SD, APGAR Score of 0/2/5, positive Rhesus, umbilical artery pH value of 7.06 and BE −9.1. The patient was then admitted to intensive care. Within 4 h postpartum, a hypertensive crisis, rapidly progressive severe anemia with thrombocytopenia, as well as liver and renal impairment was recorded. Hemoglobin level went down to 5.7 g/dL, platelet count dropped to 57 × 109/L, haptoglobin level dropped to <7.4 mg/dL, serum creatinine went up to 259 μmol/L, urine excretion deteriorated to around 7 mL/h. With the presence of thrombocytopenia, anemia with fragmentation of red blood cell (RBC) in blood film and evidence of hemolysis, TMA was considered. A disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13 (ADAMTS13) levels were sent for examination and daily plasma exchange therapy was initiated.\n\nThe patient’s blood pressure was managed and maintained with intravenous antihypertensive agents and she was given prophylactic anticonvulsant therapy with Magnesium. Due to ongoing hemolytic anemia, she was given multiple transfusion of blood products: four (4) units of red blood cell for four (4) days, three (3) units of fibrinogen and three (3) units of human prothrombin complex. The patient also underwent plasmapheresis with 42 units of fresh frozen plasma (FFP) for three (3) days. Rhophylac (Anti-D IgG 1500 IE) was also given due to Rhesus incompatibility with her baby.\n\nRenal sonography revealed patent renal vasculature with no blockage. Initial chest X-ray revealed basal pleural effusion which then progressed significantly over the next four days. Thoracocentesis was performed due to progressive dyspnea, yielding 500 mL of serous fluid. Transthoracic echocardiography results revealed normal functions of the left and right ventricle with no valve abnormalities.\n\nFurther diagnostics were made for differential diagnostic purposes. Complement tests revealed alternative pathway dysregulation with low plasma level of C3 at 47.1 mg/dL (90–180 mg/dL) and normal level of C4 at 12.5 mg/dL (10–40 mg/dL). Genotyping with Sanger sequencing of CFH and CFI genes showed no abnormality. Autoimmune diagnostic tests revealed negative Antinuclear Antibodies (ANA), c-ANCA, p-ANCA Serum. ADAMTS13 activity was within normal range (53%), which excluded TTP. Stool sample showed a negative test for E. coli and the patient had no previous history of diarrhea, excluding STEC-HUS. HELLP syndrome was doubted due to lack of significant postoperative liver function improvement.\n\nBased on our suspicion of p-AHUS, the patient then received prophylactic antibiotic therapy and vaccinated against meningococcus before a therapy of Eculizumab 900 mg was initiated. The patient’s clinical condition improved significantly after the first dose of Eculizumab, with stabilizing blood pressure and the resolution of dyspnea and hemolysis, as well as a gradual restoration of hematologic parameters, renal, and liver function. After being treated for 14 days in the Intensive Care Unit (ICU), the patient‘s condition stabilized and she was transferred to the nephrology department for further management.", + "fulltext_subclaims": [ + "The patient was a 32-year-old 38 week-pregnant Caucasian female.", + "She was admitted with right upper abdominal pain that had worsened 2 h before admission.", + "She had been diagnosed with Gestational Hypertension and treated with Methyldopa.", + "Initial examination revealed blood pressure of 180/110 mmHg.", + "Urinary dipstick test showed 3+ proteinuria.", + "Laboratory investigation revealed mild thrombocytopenia (125.000/uL).", + "ALT level was 10.54 μkat/L (=632 U/L).", + "AST level was 13.20 μkat/L (=792 U/L).", + "LDH levels were 28.10 μkat/L (=1686 U/L).", + "Serum albumin was 25.0 g/L.", + "Serum folate was >20.0 ng/mL.", + "An ultrasound scan showed normal fetal development.", + "Fetal weight estimation was at the 5 SD growth curve.", + "Cardiotocography (CTG) examination resulted in pathologic CTG.", + "Diagnosis of preeclampsia with HELLP syndrome was made.", + "An emergency Caesarean section was performed.", + "A female newborn was delivered with respiratory distress.", + "The newborn weighed 2,466 g at 5 SD.", + "The newborn had an APGAR Score of 0/2/5.", + "The newborn had a positive Rhesus factor.", + "The newborn had an umbilical artery pH value of 7.06.", + "The newborn had a base excess (BE) of −9.1.", + "The patient was admitted to intensive care.", + "Within 4 h postpartum, a hypertensive crisis was recorded.", + "Hemoglobin level dropped to 5.7 g/dL.", + "Platelet count dropped to 57 × 109/L.", + "Haptoglobin level dropped to <7.4 mg/dL.", + "Serum creatinine increased to 259 μmol/L.", + "Urine excretion was around 7 mL/h.", + "Thrombotic microangiopathy (TMA) was considered.", + "ADAMTS13 levels were sent for examination.", + "Daily plasma exchange therapy was initiated.", + "The patient was given prophylactic anticonvulsant therapy with Magnesium.", + "The patient received four (4) units of red blood cell over four (4) days.", + "The patient received three (3) units of fibrinogen.", + "The patient received three (3) units of human prothrombin complex.", + "The patient underwent plasmapheresis with 42 units of fresh frozen plasma (FFP) for three (3) days.", + "Rhophylac (Anti-D IgG 1500 IE) was given due to Rhesus incompatibility with her baby.", + "Renal sonography revealed patent renal vasculature with no blockage.", + "Initial chest X-ray revealed basal pleural effusion.", + "Thoracocentesis was performed due to progressive dyspnea, yielding 500 mL of serous fluid.", + "Transthoracic echocardiography showed normal functions of the left and right ventricle.", + "Complement tests revealed alternative pathway dysregulation.", + "C3 plasma level was 47.1 mg/dL.", + "C4 plasma level was 12.5 mg/dL.", + "Genotyping with Sanger sequencing of CFH and CFI genes showed no abnormality.", + "Autoimmune diagnostic tests revealed negative ANA.", + "Autoimmune diagnostic tests revealed negative c-ANCA.", + "Autoimmune diagnostic tests revealed negative p-ANCA.", + "ADAMTS13 activity was within normal range (53%).", + "Stool sample showed a negative test for E. coli.", + "HELLP syndrome was doubted due to lack of significant postoperative liver function improvement.", + "The patient received prophylactic antibiotic therapy.", + "The patient was vaccinated against meningococcus.", + "Eculizumab 900 mg was initiated.", + "The patient’s clinical condition improved significantly after the first dose of Eculizumab.", + "The patient was treated for 14 days in the ICU.", + "The patient was transferred to the nephrology department for further management." + ], + "summary": "A 32-year-old, 38 week pregnant Caucasian woman was admitted to Eberswalde Hospital with upper right abdominal pain. After a laboratory examination, a diagnosis of HELLP syndrome was established and a Caesarean Section was performed. The follow-up examination revealed deterioration of clinical signs with the patient experiencing dyspnea, oliguria, and oedema, as well as aggravation of laboratory values, ranging from severe thrombocytopenia, hemolytic anemia, liver injury, and acute kidney injury. After excluding other possible causes of TMA, a diagnosis of p-aHUS was established and a treatment with Eculizumab was administered. Clinical and laboratory signs of hemolysis and kidney functions were found to improve gradually after two administrations of Eculizumab. The patient was discharged after 20 days of hospitalization with significantly improved condition and hematological values.", + "summary_subclaims": [ + "A 32-year-old, 38 week pregnant Caucasian woman was admitted to Eberswalde Hospital with upper right abdominal pain.", + "After a laboratory examination, a diagnosis of HELLP syndrome was established.", + "A Caesarean Section was performed.", + "The follow-up examination revealed deterioration of clinical signs.", + "The patient experienced dyspnea.", + "The patient experienced oliguria.", + "The patient experienced oedema.", + "Laboratory values showed aggravation.", + "Severe thrombocytopenia was present.", + "Hemolytic anemia was present.", + "Liver injury was present.", + "Acute kidney injury was present.", + "After excluding other possible causes of TMA, a diagnosis of p-aHUS was established.", + "A treatment with Eculizumab was administered.", + "Clinical and laboratory signs of hemolysis and kidney functions were found to improve gradually after two administrations of Eculizumab.", + "The patient was discharged after 20 days of hospitalization.", + "The patient had a significantly improved condition at discharge.", + "Hematological values were significantly improved at discharge." + ] + }, + { + "id": "multiclinsum_test_2516_en.txt", + "fulltext": "We genetically analyzed an Iranian family with a consanguineous marriage with a 21-year-old boy with HHL. The family pedigree is depicted in . The blood specimens were obtained from all family members. All available medical history was collected. The otolaryngologist evaluated all family members.\nIt was determined that the subject had sensorineural HL (SNHL) based on pure tone audiometry (PTA). There were no clinical manifestations in favor of the syndromic phenotype. DNA extraction was conducted using the salting out method. We solely performed whole-exome sequencing (WES) for the proband. DNA sequencing was carried out by SureSelect Human All Exon Kit V6 (Agilent Technologies Inc., USA) and Illumina HiSeq 4000 machine (San Diego, USA) in accordance with the manufacturer's instructions. Genetic sequence analysis detected a novel, homozygous substitution at c.9908A>C (NM_016239.4) in exon 61 of the MYO15A gene. Bioinformatic tools, including SIFT, PolyPhen-2, and MutationTaster, predicted that this mutation is probably pathogenic .\nThe detected mutation in the proband was verified using Sanger direct sequencing (ABI 3130 Genetic Analyzer, California, USA). The sequences of used primers were as follows (forward primer: AAGCTGTGTCCCAGAAC AGG and the reverse primer ACAGGGCCT GAATCATGA AC). shows that the patient and his parents had the MYO15A mutation in the homozygous and heterozygous states, respectively. This missense mutation substitutes Lysine with Threonine (AAG>ACG) at the 3303-position of the MYO15A protein . These observations suggest that NM_016239.4 (MYO15A): c.9908A>C; p. Lys3303Thr mutation could be the cause of the progress of NSHL. The detected mutation information is shown in based on the Human Gene Mutation Database .", + "fulltext_subclaims": [ + "We genetically analyzed an Iranian family with a consanguineous marriage with a 21-year-old boy with HHL.", + "The blood specimens were obtained from all family members.", + "All available medical history was collected.", + "The otolaryngologist evaluated all family members.", + "It was determined that the subject had sensorineural HL (SNHL) based on pure tone audiometry (PTA).", + "There were no clinical manifestations in favor of the syndromic phenotype.", + "DNA extraction was conducted using the salting out method.", + "We solely performed whole-exome sequencing (WES) for the proband.", + "DNA sequencing was carried out by SureSelect Human All Exon Kit V6 (Agilent Technologies Inc., USA) and Illumina HiSeq 4000 machine (San Diego, USA) in accordance with the manufacturer's instructions.", + "Genetic sequence analysis detected a novel, homozygous substitution at c.9908A>C (NM_016239.4) in exon 61 of the MYO15A gene.", + "Bioinformatic tools, including SIFT, PolyPhen-2, and MutationTaster, predicted that this mutation is probably pathogenic.", + "The detected mutation in the proband was verified using Sanger direct sequencing (ABI 3130 Genetic Analyzer, California, USA).", + "The sequences of used primers were as follows (forward primer: AAGCTGTGTCCCAGAAC AGG and the reverse primer ACAGGGCCT GAATCATGA AC).", + "The patient and his parents had the MYO15A mutation in the homozygous and heterozygous states, respectively.", + "This missense mutation substitutes Lysine with Threonine (AAG>ACG) at the 3303-position of the MYO15A protein.", + "These observations suggest that NM_016239.4 (MYO15A): c.9908A>C; p. Lys3303Thr mutation could be the cause of the progress of NSHL.", + "The detected mutation information is shown in based on the Human Gene Mutation Database." + ], + "summary": "Here, we present a nonsyndromic HL (NSHL) case report. The patient is a 21-year-old man with progressive HL. The whole-exome sequencing (WES) demonstrated a novel homozygous missense mutation, c.9908A>C; p.Lys3303Thr, in the proband's exon 61 of the MYO15A gene. Further analysis has revealed that the detected mutation is present in a heterozygous state in the parents.", + "summary_subclaims": [ + "This is a nonsyndromic hearing loss (NSHL) case report.", + "The patient is a 21-year-old man.", + "The patient has progressive hearing loss.", + "Whole-exome sequencing demonstrated a novel homozygous missense mutation, c.9908A>C; p.Lys3303Thr, in the proband's exon 61 of the MYO15A gene.", + "The detected mutation is present in a heterozygous state in the parents." + ] + }, + { + "id": "multiclinsum_test_3341_en.txt", + "fulltext": "A woman in her 60s presented to the emergency department on April 27, 2021 with a sudden onset left hemiplegia and a severe, sudden onset, holocranial, oppressive headache in the last two hours. She had no history of vascular risk factors or heart or renal disease. She confirmed no heparin treatment in the previous 100 days. The first dose of the ChAdOx1-S vaccine was administered 16 days earlier.\n\nThe physical examination revealed a blood pressure of 120/80 mmHg. Initially, the patient was alert, but with moderate dysarthria, left hemiplegia and forced rightward deviation of the eye, with a score of 16 on the National Institute of Health Stroke Scale (NIHSS).\n\nUrgent cranial computed tomographic (CT) scan showed a hemorrhage in the right frontal lobe with no evidence of intracranial hypertension and computed tomographic angiography revealed no underlying vascular abnormality to the hematoma. There was no evidence of cerebral venous thrombosis visible on computed tomographic venography. Blood work showed moderate thrombocytopenia of 51,000/uL (reference: 140,000-400,000/uL), with normal hemoglobin and leukocytes. Coagulation laboratory results showed elevated levels of D-dimer of 2,317 ng/mL (reference: 0-250 ng/mL). Biochemical analysis showed a slight elevation of alanine transaminase (114 U/L; reference: 5-31 U/L) and aspartate transaminase (56 U/L; reference: 10-31 U/L). The ion, renal profile and cardiac markers were within normal ranges. Urine drug screen was negative. The patient had normal previous hematologic and coagulation parameters in tests performed in our center during the last five years. She had not received heparin or other drugs prior to admission.\n\nThe patient's level of consciousness deteriorated over the next two hours, with no ocular or verbal responses and flexion of the right limbs to painful stimuli, with a Glasgow Coma Scale score of 6. She was subsequently evaluated by neurosurgeons and intensive care doctors. The neurosurgeons decided to drain the haematoma. No vascular abnormalities were observed during surgery. A platelet transfusion was required for the procedure. She was subsequently admitted to the intensive care unit, where the post-operative CT scan showed signs of rebleeding as well as uncal and subfalcular herniation. Blood pressure values remained below 120/80 mmHg at all times. CT angiography and venography were repeated post-operatively with no evidence of vascular abnormalities or cerebral venous thrombosis.\n\nA progression of thrombocytopenia and a D-dimer increase was observed in the control blood tests showing a severe thrombocytopenia (19,000/uL; references: 140,000-400,000/uL) and higher levels of D-dimer (3,840 ng/mL; references: 0-250 ng/mL). In contrast, no data of disseminated intravascular coagulation was found. Antibodies against platelet factor 4 (PF4) were detected with the ELISA technique, suggesting a possible TTP, which was confirmed with a platelet activation induced by heparin. Therefore, it was treated with intravenous immunoglobulins from day 2 to 5 (Flebogamma© 5%, 1 g of weight adjusted to day) and methylprednisolone from day 6 to 11 (1 g of weight adjusted to day), without clinical response with either treatment. No prophylactic anticoagulation was administered.\n\nWhile in the ICU, the patient developed an irreversible intracranial hypertension syndrome with uncal and subfalcular herniation with a poor prognosis. A decision was made to limit the therapeutic effort and immunoglobulin and corticosteroid treatment was discontinued. Palliative sedation was initiated and the patient finally died on day 21 after the event.\n", + "fulltext_subclaims": [ + "A woman in her 60s presented to the emergency department on April 27, 2021.", + "She had a sudden onset left hemiplegia.", + "She had a severe, sudden onset, holocranial, oppressive headache in the last two hours.", + "She had no history of vascular risk factors.", + "She had no history of heart or renal disease.", + "She confirmed no heparin treatment in the previous 100 days.", + "The first dose of the ChAdOx1-S vaccine was administered 16 days earlier.", + "The physical examination revealed a blood pressure of 120/80 mmHg.", + "The patient was initially alert.", + "She had moderate dysarthria.", + "She had left hemiplegia.", + "She had forced rightward deviation of the eye.", + "She had a score of 16 on the National Institute of Health Stroke Scale.", + "Urgent cranial computed tomographic scan showed a hemorrhage in the right frontal lobe.", + "There was no evidence of intracranial hypertension.", + "Computed tomographic angiography revealed no underlying vascular abnormality to the hematoma.", + "There was no evidence of cerebral venous thrombosis visible on computed tomographic venography.", + "Blood work showed moderate thrombocytopenia of 51,000/uL.", + "The reference range for thrombocytopenia is 140,000-400,000/uL.", + "Coagulation laboratory results showed elevated levels of D-dimer of 2,317 ng/mL.", + "The reference range for D-dimer is 0-250 ng/mL.", + "Biochemical analysis showed a slight elevation of alanine transaminase (114 U/L).", + "The reference range for alanine transaminase is 5-31 U/L.", + "Biochemical analysis showed a slight elevation of aspartate transaminase (56 U/L).", + "The reference range for aspartate transaminase is 10-31 U/L.", + "The ion, renal profile and cardiac markers were within normal ranges.", + "Urine drug screen was negative.", + "The patient had normal previous hematologic and coagulation parameters in tests performed in our center during the last five years.", + "She had not received heparin or other drugs prior to admission.", + "The patient's level of consciousness deteriorated over the next two hours.", + "She had no ocular or verbal responses.", + "She had flexion of the right limbs to painful stimuli.", + "She had a Glasgow Coma Scale score of 6.", + "The neurosurgeons decided to drain the haematoma.", + "No vascular abnormalities were observed during surgery.", + "A platelet transfusion was required for the procedure.", + "The post-operative CT scan showed signs of rebleeding.", + "The post-operative CT scan showed uncal and subfalcular herniation.", + "Blood pressure values remained below 120/80 mmHg at all times.", + "CT angiography and venography were repeated post-operatively with no evidence of vascular abnormalities.", + "CT angiography and venography were repeated post-operatively with no evidence of cerebral venous thrombosis.", + "A progression of thrombocytopenia was observed in the control blood tests.", + "Control blood tests showed severe thrombocytopenia (19,000/uL).", + "Control blood tests showed higher levels of D-dimer (3,840 ng/mL).", + "No data of disseminated intravascular coagulation was found.", + "Antibodies against platelet factor 4 (PF4) were detected with the ELISA technique.", + "This suggested a possible TTP.", + "It was confirmed with a platelet activation induced by heparin.", + "It was treated with intravenous immunoglobulins from day 2 to 5.", + "The treatment was Flebogamma© 5%, 1 g of weight adjusted to day.", + "It was treated with methylprednisolone from day 6 to 11.", + "The treatment was 1 g of weight adjusted to day.", + "There was no clinical response with either treatment.", + "No prophylactic anticoagulation was administered.", + "The patient developed an irreversible intracranial hypertension syndrome.", + "The patient had uncal and subfalcular herniation.", + "A decision was made to limit the therapeutic effort.", + "Immunoglobulin and corticosteroid treatment was discontinued.", + "Palliative sedation was initiated.", + "The patient finally died on day 21 after the event." + ], + "summary": "We report a case of intracerebral hemorrhage following vaccination with ChAdOx1-S. A middle-aged female patient with no medical history of interest presented to the emergency department 16 days after the first dose of ChAdOx1-S with a sudden onset left-sided hemiplegia and severe occipital headaches. She had not received heparin in the previous 100 days. Blood work showed moderate thrombocytopenia and computed tomography showed a right frontal lobar hemorrhage without thrombosis on computed tomography venography. Antibodies to platelet factor 4 were confirmed in the blood. The patient developed a treatment-resistant intracranial hypertension syndrome and died three weeks later.\n", + "summary_subclaims": [ + "We report a case of intracerebral hemorrhage following vaccination with ChAdOx1-S.", + "A middle-aged female patient with no medical history of interest presented to the emergency department 16 days after the first dose of ChAdOx1-S.", + "She had not received heparin in the previous 100 days.", + "Blood work showed moderate thrombocytopenia.", + "Computed tomography showed a right frontal lobar hemorrhage.", + "Computed tomography venography showed no thrombosis.", + "Antibodies to platelet factor 4 were confirmed in the blood.", + "The patient developed a treatment-resistant intracranial hypertension syndrome.", + "The patient died three weeks later." + ] + }, + { + "id": "multiclinsum_test_1464_en.txt", + "fulltext": "A 74-year-old lady presented to our emergency department following 3 days’ history of watery diarrhoea and feeling generally unwell. She had been ‘off legs’ for 3 days and was not improving hence called the GP for a home visit. She was referred to the hospital as a case of severe sepsis for medical admission and pre-alerted into Resus by paramedics. She denied any cough, cold, or urinary symptoms. She had a past medical history of hypertension and CKD and was on Ramipril and Atorvastatin. She was at reasonably normal baseline health and 3 days back started with watery diarrhoea. There was no history of recent travel and no vomiting or per rectal bleed. On examination, she looked unwell, still responding to verbal commands, hypotensive at 80/50 mmHg, and tachycardic at 110 beats per minute with a temperature of 38.5 °C. She was hypoxic on air, with saturations of 90% on high flow oxygen. She had evidence of peripheral cyanosis and delayed capillary refill time. Her chest was clear and abdomen was soft, with no guarding or rigidity. Her Glasgow coma scale was 14 (E3V5M6). Her venous blood gas revealed metabolic acidosis with a lactate of 14.\nWith a working diagnosis of severe sepsis of unknown source, she was started on broad-spectrum intravenous antibiotics and fluids. As there was no improvement in her haemodynamic status, a referral to the intensive care team was made for inotropic support.\nWhile all of these were being done, she was noticed to have a tender bruise on her leg; however, she denied any trauma or fall. On examination, she had a large area of blackish discolouration and vesicle formation on the posteromedial aspect of the left thigh , which was tender on palpation. The area looked suspicious of necrotising fasciitis. Her antibiotics were changed as per the microbiology advice to Tazocin and Clindamycin. A urinary catheter was inserted to monitor her fluid balance. An urgent referral to the surgical and orthopaedic team was made for definitive management of surgical debridement. Her initial blood results showed a white cell count of 13.1 and neutrophilia at 11.7. She had a CRP of 439, CPK of 4187 and an AKI stage 3 with urea at 15.2, creatinine of 291 and e-GFR of 13. Serum electrolytes showed a sodium of 137, potassium of 3.4 and chloride of 101.\nShe underwent debridement of necrosed tissue within few hours of arrival into the emergency department. She subsequently stayed in the intensive care unit and had a further debridement and above-knee amputation of the affected limb . On the second surgery, she was found to have necrotic tissue extending up to the pelvis. A subsequent pus culture report confirmed group A Beta haemolytic streptococci as the causative organism. The blood culture showed no growth, and faeces culture was negative and showed no evidence of Salmonella, Shigella, Camplylobacter or Escherichia coli. MRSA was not isolated and there was no evidence of C-difficile in the stool.\nShe eventually died after about 48 h of hospital stay despite an early diagnosis and prompt surgical debridement.\nAlthough necrotising fasciitis is a rare condition, each one of us may still come across a case in our clinical practice. As a learning point from this case, we would like to highlight the importance of a thorough clinical examination of patients with sepsis with no obvious source. As in this patient, the presenting complaint was diarrhoea, which was actually a manifestation rather than a cause for sepsis and clearly had a hidden diagnosis, which could have been missed if the patient was not adequately exposed.", + "fulltext_subclaims": [ + "The patient was a 74-year-old lady.", + "She had 3 days of watery diarrhoea.", + "She was referred to the hospital as a case of severe sepsis.", + "She was pre-alerted into Resus by paramedics.", + "She denied any cough, cold, or urinary symptoms.", + "She had a past medical history of hypertension and CKD.", + "She was on Ramipril and Atorvastatin.", + "She had no history of recent travel.", + "On examination, she was hypotensive at 80/50 mmHg.", + "Her temperature was 38.5 °C.", + "Her venous blood gas showed a lactate of 14.", + "The working diagnosis was severe sepsis of unknown source.", + "She was started on broad-spectrum intravenous antibiotics.", + "She was noticed to have a tender bruise on her leg.", + "She denied any trauma or fall.", + "There was a large area of blackish discolouration and vesicle formation on the posteromedial aspect of the left thigh.", + "The area was suspicious of necrotising fasciitis.", + "Her antibiotics were changed to Tazocin and Clindamycin.", + "An urgent referral to the surgical and orthopaedic team was made.", + "Her initial blood results showed a white cell count of 13.1.", + "Her neutrophil count was 11.7.", + "Her CRP was 439.", + "Her CPK was 4187.", + "She had AKI stage 3 with a creatinine of 291.", + "She underwent debridement of necrosed tissue within a few hours of arrival.", + "She had a further debridement and above-knee amputation of the affected limb.", + "On the second surgery, necrotic tissue was found extending up to the pelvis.", + "A pus culture report confirmed group A Beta haemolytic streptococci as the causative organism.", + "Faeces culture showed no evidence of Salmonella, Shigella, Campylobacter, or Escherichia coli.", + "MRSA was not isolated.", + "There was no evidence of C-difficile in the stool.", + "She died after about 48 hours of hospital stay.", + "The presenting complaint of diarrhoea was a manifestation rather than a cause for sepsis." + ], + "summary": "We describe a 74-year-old lady who presented to our emergency department following 3 days' history of watery diarrhoea and feeling generally unwell. She had signs of severe sepsis and was started on broad-spectrum intravenous antibiotics and fluids for sepsis with unknown source. She was found to have an area of blackish discolouration on her thigh which was suspected as necrotising fasciitis (NF) and referred to the surgeons. She had no history of trauma or significant comorbidity. She underwent surgical exploration and debridement within few hours of arrival into the emergency department and subsequent further debridement with above-knee amputation of the affected limb. She eventually died after about 48 h of hospital stay despite an early diagnosis and prompt surgical debridement and a multidisciplinary approach.", + "summary_subclaims": [ + "The patient was a 74-year-old lady.", + "She presented to the emergency department following 3 days' history of watery diarrhoea.", + "She had signs of severe sepsis.", + "She was started on broad-spectrum intravenous antibiotics and fluids for sepsis with unknown source.", + "She was found to have an area of blackish discolouration on her thigh.", + "The blackish discolouration was suspected as necrotising fasciitis.", + "She had no history of trauma.", + "She underwent surgical exploration and debridement within few hours of arrival into the emergency department.", + "She underwent further debridement with above-knee amputation of the affected limb.", + "She eventually died after about 48 h of hospital stay." + ] + }, + { + "id": "multiclinsum_test_2364_en.txt", + "fulltext": "A previously healthy 1-month-old boy was admitted to our university hospital with 1 day of fever (39.0 ℃), rhinorrhea, cough, and erythematous papules covering his whole body . At the time of admission (day 1) he had no other symptoms suggestive of KD, such as extremity changes, conjunctivitis, oral changes, and cervical lymphadenopathy. Initial vital signs and laboratory results were as follows: blood pressure, 90/48 mmHg; heart rate, 142/min; respiratory rate (RR), 40/min; white blood cells (WBC), 10.2 × 103/μL with neutrophil predominance; C-reactive protein (CRP), 32 mg/L; serum sodium, 135 mmol/L; serum albumin, 36 g/L; and serum aspartate/alanine aminotransferase, 22/13 units/L. Urinalysis and cerebrospinal fluid examination revealed no abnormal findings. Rapid diagnostic tests for respiratory syncytial virus, metapneumovirus, and Mycoplasma pneumoniae were negative, and severe acute respiratory syndrome coronavirus 2 was not detected by RT-PCR. The patient was treated with 150 mg/kg/day of cefotaxime, 60 mg/kg/day of vancomycin, and 60 mg/kg/day of acyclovir.\nOn day 2 he exhibited frequent apnea (RR, 72/min), and blood gas analysis revealed hypercapnia (62.7 mmHg). Chest computerized tomography (CT) revealed bilateral consolidations . He was transferred to the ICU and underwent mechanical ventilation. IVIG (500 mg/kg/day) was administered for 3 days as adjunctive treatment for severe infection . He became afebrile on day 3, and acyclovir was discontinued due to negative PCR for herpes simplex virus. Moreover, administration of cefotaxime and vancomycin was discontinued due to negative blood and tracheal aspirate cultures on day 7. His condition gradually recovered without high fever or any clinical features suggesting KD, but elevated levels of CRP continued (63 mg/L on day 9). He was extubated on day 10 and discharged from the ICU on day 13. On day 14, however, fever recurred, and he also developed bilateral bulbar nonexudative conjunctival injection and desquamation of his fingers. KD was finally diagnosed by echocardiography, which detected CAA at the left main coronary trunk (2.3 mm, Z score = 3.2) and left circumflex coronary artery (1.8 mm, Z score = 2.8). Since KD in this case was refractory to the administration of IVIG, the patient was treated with aspirin and three courses of IVIG (2 g/kg/day on days 14, 19, and 35) plus 5 mg of cyclosporine from day 35 to 53. He was discharged on day 45 with small aneurysms present at the left main coronary trunk and the left circumflex coronary arteries. Left main coronary trunk was 2.4 mm (Z score = 2.2) and left circumflex coronary artery was 1.5 mm (Z score = 0.8) at 7 months after discharge.\nIn order to identify the causative agent of severe pneumonia that required mechanical ventilation, multiplex real-time PCR was carried out on tracheal aspirate and serum sample to detect the genomes of 163 viruses (47 DNA viruses and 116 RNA viruses), 68 bacterial species, and nine fungal species [, ]. Moreover, specific reverse-transcription PCR (RT-PCR) was performed to detect human parechovirus in serum and cerebrospinal fluid [, ]. DNA and RNA were extracted from the patient’s serum and tracheal aspirate using a Maxwell RSC Viral Total Nucleic Acid Purification Kit (Promega, Madison, WI). No infectious pathogens were detected in these samples collected at the time of hospitalization.\nIn addition, the patient’s serum cytokine profile demonstrated the following (normal values are shown in parentheses): interleukin (IL)-18, 175 pg/mL (< 500 pg/mL); IL-6, 410 pg/mL (< 5 pg/mL); neopterin, 36 nmol/L (< 5 nmol/L); soluble tumor necrosis factor receptor (sTNF-R)I, 3000 pg/mL (484–1407 pg/mL); and sTNF-RII, 14100 pg/mL (829–2262 pg/mL) by commercial ELISA (IL-18: MBL, Nagoya, Japan; IL-6, sTNF-RI, and sTNF-RII: R&D Systems, Minneapolis, MN, USA; neopterin: IBL, Hamburg, Germany) .", + "fulltext_subclaims": [ + "A previously healthy 1-month-old boy was admitted to our university hospital with 1 day of fever (39.0 ℃), rhinorrhea, cough, and erythematous papules covering his whole body.", + "At the time of admission (day 1) he had no other symptoms suggestive of KD, such as extremity changes, conjunctivitis, oral changes, and cervical lymphadenopathy.", + "Initial vital signs and laboratory results were as follows: blood pressure, 90/48 mmHg; heart rate, 142/min; respiratory rate (RR), 40/min; white blood cells (WBC), 10.2 × 103/μL with neutrophil predominance; C-reactive protein (CRP), 32 mg/L; serum sodium, 135 mmol/L; serum albumin, 36 g/L; and serum aspartate/alanine aminotransferase, 22/13 units/L.", + "Urinalysis and cerebrospinal fluid examination revealed no abnormal findings.", + "Rapid diagnostic tests for respiratory syncytial virus, metapneumovirus, and Mycoplasma pneumoniae were negative, and severe acute respiratory syndrome coronavirus 2 was not detected by RT-PCR.", + "The patient was treated with 150 mg/kg/day of cefotaxime, 60 mg/kg/day of vancomycin, and 60 mg/kg/day of acyclovir.", + "On day 2 he exhibited frequent apnea (RR, 72/min), and blood gas analysis revealed hypercapnia (62.7 mmHg).", + "Chest computerized tomography (CT) revealed bilateral consolidations.", + "He was transferred to the ICU and underwent mechanical ventilation.", + "IVIG (500 mg/kg/day) was administered for 3 days as adjunctive treatment for severe infection.", + "He became afebrile on day 3, and acyclovir was discontinued due to negative PCR for herpes simplex virus.", + "Administration of cefotaxime and vancomycin was discontinued due to negative blood and tracheal aspirate cultures on day 7.", + "His condition gradually recovered without high fever or any clinical features suggesting KD, but elevated levels of CRP continued (63 mg/L on day 9).", + "He was extubated on day 10 and discharged from the ICU on day 13.", + "On day 14, however, fever recurred, and he also developed bilateral bulbar nonexudative conjunctival injection and desquamation of his fingers.", + "KD was finally diagnosed by echocardiography, which detected CAA at the left main coronary trunk (2.3 mm, Z score = 3.2) and left circumflex coronary artery (1.8 mm, Z score = 2.8).", + "Since KD in this case was refractory to the administration of IVIG, the patient was treated with aspirin and three courses of IVIG (2 g/kg/day on days 14, 19, and 35) plus 5 mg of cyclosporine from day 35 to 53.", + "He was discharged on day 45 with small aneurysms present at the left main coronary trunk and the left circumflex coronary arteries.", + "Left main coronary trunk was 2.4 mm (Z score = 2.2) and left circumflex coronary artery was 1.5 mm (Z score = 0.8) at 7 months after discharge.", + "In order to identify the causative agent of severe pneumonia that required mechanical ventilation, multiplex real-time PCR was carried out on tracheal aspirate and serum sample to detect the genomes of 163 viruses (47 DNA viruses and 116 RNA viruses), 68 bacterial species, and nine fungal species.", + "Moreover, specific reverse-transcription PCR (RT-PCR) was performed to detect human parechovirus in serum and cerebrospinal fluid.", + "DNA and RNA were extracted from the patient’s serum and tracheal aspirate using a Maxwell RSC Viral Total Nucleic Acid Purification Kit (Promega, Madison, WI).", + "No infectious pathogens were detected in these samples collected at the time of hospitalization.", + "The patient’s serum cytokine profile demonstrated the following: interleukin (IL)-18, 175 pg/mL (< 500 pg/mL); IL-6, 410 pg/mL (< 5 pg/mL); neopterin, 36 nmol/L (< 5 nmol/L); soluble tumor necrosis factor receptor (sTNF-R)I, 3000 pg/mL (484–1407 pg/mL); and sTNF-RII, 14100 pg/mL (829–2262 pg/mL)." + ], + "summary": "Japanese one-month-old infant had only fever and rash on admission (day 1), and he was transferred to the intensive care unit for severe pneumonia on day 2. Although pneumonia improved following intensive care, he was diagnosed with KD on day 14 because of emerging typical clinical manifestations such as fever, bulbar nonexudative conjunctival injection, desquamation of the fingers, and coronary artery aneurysm. KD symptoms improved after three doses of intravenous immunoglobulin plus cyclosporine. However, small coronary aneurysms were present at the time of discharge. In a retrospective analysis, no pathogens were detected by multiplex real-time PCR in samples collected at admission, and the serum cytokine profile demonstrated prominent elevation of IL-6 as well as elevation of neopterin, sTNF-RI, and sTNF-RII, which suggested KD.", + "summary_subclaims": [ + "A one-month-old Japanese infant had only fever and rash on admission (day 1).", + "The infant was transferred to the intensive care unit for severe pneumonia on day 2.", + "Pneumonia improved following intensive care.", + "The infant was diagnosed with KD on day 14.", + "The KD diagnosis was based on emerging typical clinical manifestations such as fever, bulbar nonexudative conjunctival injection, desquamation of the fingers, and coronary artery aneurysm.", + "KD symptoms improved after three doses of intravenous immunoglobulin plus cyclosporine.", + "Small coronary aneurysms were present at the time of discharge.", + "No pathogens were detected by multiplex real-time PCR in samples collected at admission.", + "The serum cytokine profile demonstrated prominent elevation of IL-6.", + "The serum cytokine profile demonstrated elevation of neopterin, sTNF-RI, and sTNF-RII.", + "The serum cytokine profile suggested KD." + ] + }, + { + "id": "multiclinsum_test_2006_en.txt", + "fulltext": "A female patient, aged 23 years and 10 months, sought orthodontic treatment with the main complaint related to esthetic concerns, described as “crowded lower teeth”. She was seeking a second opinion and wished to avoid tooth extraction, as well as any form of surgery. Her general state of health was good, with no contributing medical history. Pre-treatment facial photographs showed a convex facial profile, with a protruded lower lip. In the front view, a small asymmetry was visible on the right side, which was a bit rounded compared to the left side.\nThe pre-treatment intraoral photographs showed a mild gingival recession in the mandibular left central incisor. The posterior teeth presented with a clinically significant palatal inclination and a constricted maxillary arch, with the right second premolar in crossbite. She presented an Angle’s Class II malocclusion, division 1, subdivision, crowding of 2 mm in the mandibular arch, and a 3-mm deep curve of Spee, 6.0 mm of overjet between teeth #11 and #41, and 2.0 mm between teeth #21 and #31, in addition to deep overbite. The width of the maxillary lateral incisors was proportionally smaller than that of the maxillary central incisors. The mandibular midline was deviated 1.5 mm to the right. Gingival recession was visible on the mandibular left central incisor.\nIn the panoramic radiograph, all permanent teeth were visible, including extensive restorations in the second molars and tapered incisor root tips .\nThe analysis of the pretreatment lateral cephalometric radiograph and tracings , ) revealed a Class II skeletal pattern (ANB = 7º) with a maxillary protrusion (SNA = 87º), protruded mandibular incisors (1.NB = 41º, 1-NB = 11mm and IMPA = 104º), and protruded maxillary incisors (1-NA = 7mm).\nThe patient had a constricted maxillary arch, with mandibular molars and premolars that were lingually inclined as a compensatory mechanism. The first objective, therefore, was to expand the maxillary arch transversely to create an adequate skeletal width, in order to correct the position of the teeth. Additional objectives were to achieve correct overbite and overjet, and to improve the dental and skeletal relationships in the three planes of space.\nOptions for treatment included the following: 1) Maxillary expansion with a Hyrax-type expander, which would require surgery (i.e., surgically-assisted rapid palatal expansion, SARPE); 2) Maxillary expansion with MARPE, in an attempt to avoid surgery; 3) Maxillary expansion with a Hyrax-type palatal expander fixed to the molars and premolars (a non-surgical procedure); 4) Align, level, and carry out dentoalveolar expansion with the orthodontic archwires and intermaxillary elastics; and 5) Perform light interproximal reduction and extraction of four first premolars.\nThe second option was chosen as the treatment plan for this patient. Treatment was initiated with the placement of a 11.0-mm maxillary skeletal expander (PecLab, Belo Horizonte/MG, Brazil) fixed with four miniscrews (1.8x5x4 mm anterior and 1.8x7x4 mm) and two immediate activations (2/4 of a turn), followed by activations of two turns per day for one week. Pain and some discomfort in the palate and nasal cavity areas, as well as headache, was reported by the patient on the fourth day. These issues were resolved by diminishing the expansion to an activation rate of 1 turn per day and prescribing an analgesic.\nBy the tenth day, the patient reported hearing clicks in the region of the palatal suture and, in the following days, reported the appearance of the midline diastema . There was a discrete opening of the anterior bite due to contact of the buccal cuspid of the left first maxillary molar, which moved in the direction of the overlapping mandibular molar. The activations were stopped after 25 turns and the appliance was stabilized. The radiographic image shows the opening of the midpalatal expansion .\nSubsequently, brackets were bonded to all teeth, except for the first molars. The following archwires were used: 0.016 x 0.016-in NiTi heat-activated, 0.016 x 0.022-in NiTi, 0.017 x 0.025-in NiTi heat-activated, 0.018 x 0.025-in SS, and 0.019 x 0.025-in SS finishing archwire.\nMiniscrews between the second premolars and first molars were applied to distalize the upper left molars and premolars.", + "fulltext_subclaims": [ + "The patient is a 23-year-old female.", + "The patient's main complaint was esthetic concerns, described as 'crowded lower teeth'.", + "The patient wished to avoid tooth extraction.", + "The patient wished to avoid any form of surgery.", + "Pre-treatment facial photographs showed a convex facial profile.", + "Pre-treatment facial photographs showed a protruded lower lip.", + "Pre-treatment intraoral photographs showed a mild gingival recession in the mandibular left central incisor.", + "The posterior teeth presented with a clinically significant palatal inclination.", + "The maxillary arch was constricted.", + "The right second premolar was in crossbite.", + "The patient presented an Angle’s Class II malocclusion, division 1, subdivision.", + "The patient had 2 mm of crowding in the mandibular arch.", + "The patient had a 3-mm deep curve of Spee.", + "The patient had 6.0 mm of overjet between teeth #11 and #41.", + "The patient had 2.0 mm of overjet between teeth #21 and #31.", + "The patient had deep overbite.", + "The maxillary lateral incisors were proportionally smaller than the maxillary central incisors.", + "The mandibular midline was deviated 1.5 mm to the right.", + "The panoramic radiograph showed all permanent teeth were visible.", + "The panoramic radiograph showed extensive restorations in the second molars.", + "The panoramic radiograph showed tapered incisor root tips.", + "The pretreatment lateral cephalometric radiograph revealed a Class II skeletal pattern (ANB = 7º).", + "The pretreatment lateral cephalometric radiograph showed a maxillary protrusion (SNA = 87º).", + "The pretreatment lateral cephalometric radiograph showed protruded mandibular incisors (1.NB = 41º, 1-NB = 11mm and IMPA = 104º).", + "The pretreatment lateral cephalometric radiograph showed protruded maxillary incisors (1-NA = 7mm).", + "The patient had a constricted maxillary arch.", + "The mandibular molars and premolars were lingually inclined as a compensatory mechanism.", + "The first objective was to expand the maxillary arch transversely.", + "The objective was to correct the position of the teeth.", + "The objective was to achieve correct overbite.", + "The objective was to achieve correct overjet.", + "The objective was to improve the dental and skeletal relationships in the three planes of space.", + "Treatment options included maxillary expansion with a Hyrax-type expander, which would require surgery.", + "Treatment options included maxillary expansion with MARPE, in an attempt to avoid surgery.", + "Treatment options included maxillary expansion with a Hyrax-type palatal expander fixed to the molars and premolars.", + "Treatment options included aligning, leveling, and dentoalveolar expansion with orthodontic archwires and intermaxillary elastics.", + "Treatment options included performing light interproximal reduction and extraction of four first premolars.", + "The second option was chosen as the treatment plan.", + "Treatment was initiated with the placement of a 11.0-mm maxillary skeletal expander.", + "The appliance was fixed with four miniscrews.", + "The appliance was fixed with two immediate activations.", + "The activations were two turns per day for one week.", + "On the fourth day, the patient reported pain and some discomfort in the palate and nasal cavity areas.", + "On the fourth day, the patient reported headache.", + "The issues were resolved by diminishing the expansion to an activation rate of 1 turn per day.", + "The issues were resolved by prescribing an analgesic.", + "By the tenth day, the patient reported hearing clicks in the region of the palatal suture.", + "In the following days, the patient reported the appearance of the midline diastema.", + "There was a discrete opening of the anterior bite due to contact of the buccal cuspid of the left first maxillary molar.", + "The activations were stopped after 25 turns.", + "The appliance was stabilized.", + "The radiographic image shows the opening of the midpalatal expansion.", + "Subsequently, brackets were bonded to all teeth, except for the first molars.", + "The following archwires were used: 0.016 x 0.016-in NiTi heat-activated, 0.016 x 0.022-in NiTi, 0.017 x 0.025-in NiTi heat-activated, 0.018 x 0.025-in SS, and 0.019 x 0.025-in SS finishing archwire.", + "Miniscrews between the second premolars and first molars were applied to distalize the upper left molars and premolars." + ], + "summary": "The patient's main complaint was mandibular anterior crowding. The treatment plan included expansion of the mandibular arch concurrent with maxillary expansion, using a MARPE appliance in combination with a full-fixed appliance to align and level the crowded mandibular teeth, along with miniscrews as anchorage for the maxillary teeth and for distalization of the molars and premolars. A successful non-extraction orthodontic treatment was accomplished after 28 months, and the occlusion and teeth alignment, as well as facial goals, were resolved in a clinically satisfactory manner.", + "summary_subclaims": [ + "The patient's main complaint was mandibular anterior crowding.", + "The treatment plan included expansion of the mandibular arch concurrent with maxillary expansion.", + "A MARPE appliance was used in combination with a full-fixed appliance.", + "Miniscrews were used as anchorage for the maxillary teeth.", + "Miniscrews were used for distalization of the molars and premolars.", + "A successful non-extraction orthodontic treatment was accomplished after 28 months.", + "The occlusion and teeth alignment were resolved in a clinically satisfactory manner.", + "The facial goals were resolved in a clinically satisfactory manner." + ] + }, + { + "id": "multiclinsum_test_856_en.txt", + "fulltext": "In 2017, a 10-month-old female infant was admitted to the Department of Gastroenterology, Children’s Hospital of Soochow University, because of a history of elevated liver transaminases for more than 3 months. She was born at 30 weeks of gestation, her birth weight was 2.35 kg, and she had a history of intrauterine growth retardation. She had shown global developmental delay since birth. She defecated once every 3–4 days and was crying and restless during defecation. Her parents were physically healthy and were unrelated. She had a brother who died of “convulsion” at the age of 10 months, and there was no family history of inherited diseases.\nPhysical examination was normal except for slightly high ankle tension. Her liver biochemical profile revealed elevated levels of alanine transaminase (147 U/L; normal range, 5–40 U/L) and aspartate transaminase (112 U/L; normal range, 8–40 U/L). Blood tests revealed mildly elevated levels of lactate (4 mmol/L; normal range, 0.5–2.5 mmol/L) and normal levels of IgG, IgA, IgM, and IgE immunoglobulins. Lymphocyte subset analysis was normal, as was blood coagulation function, thyroid function, blood tandem mass spectrometry, and levels of trace elements, ammonia, alpha foetal protein, and urine reducing substances. Pathogen testing was positive for cytomegalovirus IgM, and PCR for cytomegalovirus DNA in peripheral blood revealed the presence of 2.54 × 103 copies/ml; other pathogens such as Epstein-Barr virus and hepatitis A, B, C, and E were all negative. Ambulatory electroencephalography (EEG) monitoring suggested epilepsy in the form of subclinical seizures. Magnetic resonance imaging of the brain demonstrated increased extracerebral space . After the patient admission into hospital, she was treated with rehabilitation training and oral compound glycyrrhizin tablets (2.5 mg/kg per day) for 10 days. Liver transaminase levels were slightly reduced compared to the first presentation.", + "fulltext_subclaims": [ + "A 10-month-old female infant was admitted to the Department of Gastroenterology, Children’s Hospital of Soochow University in 2017.", + "She had a history of elevated liver transaminases for more than 3 months.", + "She was born at 30 weeks of gestation.", + "Her birth weight was 2.35 kg.", + "She had a history of intrauterine growth retardation.", + "She had shown global developmental delay since birth.", + "She defecated once every 3–4 days.", + "She was crying and restless during defecation.", + "Her parents were physically healthy and were unrelated.", + "She had a brother who died of 'convulsion' at the age of 10 months.", + "There was no family history of inherited diseases.", + "Physical examination was normal except for slightly high ankle tension.", + "Her alanine transaminase level was 147 U/L.", + "The normal range for alanine transaminase is 5–40 U/L.", + "Her aspartate transaminase level was 112 U/L.", + "The normal range for aspartate transaminase is 8–40 U/L.", + "Her lactate level was 4 mmol/L.", + "The normal range for lactate is 0.5–2.5 mmol/L.", + "Blood tests revealed normal levels of IgG, IgA, IgM, and IgE immunoglobulins.", + "Lymphocyte subset analysis was normal.", + "Blood coagulation function was normal.", + "Thyroid function was normal.", + "Blood tandem mass spectrometry was normal.", + "Levels of trace elements were normal.", + "Ammonia levels were normal.", + "Alpha foetal protein levels were normal.", + "Urine reducing substances were normal.", + "Pathogen testing was positive for cytomegalovirus IgM.", + "PCR for cytomegalovirus DNA in peripheral blood revealed the presence of 2.54 × 103 copies/ml.", + "Epstein-Barr virus was negative.", + "Hepatitis A, B, C, and E were all negative.", + "Ambulatory electroencephalography monitoring suggested epilepsy in the form of subclinical seizures.", + "Magnetic resonance imaging of the brain demonstrated increased extracerebral space.", + "She was treated with rehabilitation training.", + "She received oral compound glycyrrhizin tablets at 2.5 mg/kg per day for 10 days.", + "Liver transaminase levels were slightly reduced compared to the first presentation." + ], + "summary": "The proband was admitted to the Department of Gastroenterology, Children's Hospital of Soochow University, with elevated liver transaminases. She had a history of intrauterine growth retardation and exhibited elevated transaminases, global developmental delay, seizures and light constipation during early infancy. Whole-exome sequencing (WES) and Sanger sequencing revealed two compound heterozygous mutations in NGLY1 that had been inherited in an autosomal recessive manner from her parents. One was a termination mutation, c.1168C > T (p.R390*), and the other was a missense mutation, c.1156G > T (p.D386Y). NGLY1-CDDG is a rare disorder, with a few dozen cases. The two mutations of this proband has not been previously identified.", + "summary_subclaims": [ + "The proband was admitted to the Department of Gastroenterology, Children's Hospital of Soochow University, with elevated liver transaminases.", + "She had a history of intrauterine growth retardation.", + "She exhibited elevated transaminases during early infancy.", + "She exhibited global developmental delay during early infancy.", + "She exhibited seizures during early infancy.", + "She exhibited light constipation during early infancy.", + "Whole-exome sequencing (WES) and Sanger sequencing revealed two compound heterozygous mutations in NGLY1.", + "The mutations were inherited in an autosomal recessive manner from her parents.", + "One mutation was a termination mutation, c.1168C > T (p.R390*).", + "The other mutation was a missense mutation, c.1156G > T (p.D386Y).", + "NGLY1-CDDG is a rare disorder.", + "The two mutations of this proband have not been previously identified." + ] + }, + { + "id": "multiclinsum_test_1201_en.txt", + "fulltext": "Our patient, a 64-year-old woman who was a non-smoker with a background history of epilepsy, presented to our respiratory clinic in May 2008 with a six-month history of productive cough with whitish sputum associated with three episodes of hemoptysis. She had no constitutional symptoms. At a primary care clinic a diagnosis of tuberculosis (TB) was considered, but the results of a Mantoux test were negative and findings from the three sputum acid-fast bacilli samples and cultures for TB were also negative. Her symptoms were persistent despite a few courses with oral antibiotics such as oral amoxicillin, azithromycin and moxifloxacin. On examination, our patient was emaciated (body mass index of 19.3 kg/m2), hemodynamically stable, apyretic, eupneic and with peripheral oxygen saturation (SpO2) of 98% (FiO2 21%). She did not have clubbed fingers, palpable cervical lymph nodes or oral thrush.\nA bacillus Calmette-Guérin (BCG) scar was present. Her jugular venous pressure was not elevated, and her apex beat was not displaced. An examination of her respiratory system revealed reduced breath sounds at the bases. Based on our patient's history and the physical examination, the differential diagnoses were bronchogenic carcinoma, pulmonary tuberculosis and bronchiectasis.\nThe results of initial investigations showed a normocytic normochromic anemia (hemoglobin level of 10.3 g/dL) with normal white cell and platelet counts. Her inflammatory markers were raised: her CRP was 3.24 mmol/L and ESR was 66 mm/hour. Other blood investigations were normal. An initial chest radiograph showed bilateral pleural effusion with bibasal consolidation . A thoracocentesis procedure was not performed as the pleural effusion looked minimal. Subsequently, bronchoscopy was performed, showing an edematous and white coated bronchial tree mucosa; the right lower lobe mucosa had an infiltrate appearance. The mycological bronchoalveolar lavage culture tested positive for Aspergillus niger. The mycobacterial cultures tested negative. Unfortunately, a transbronchial biopsy was not performed in the same setting.\nFulfilling the proposed diagnostic criteria by Soubani et al. , a diagnosis of chronic necrotizing pulmonary aspergillosis was made based on the subacute presentation of six months' duration and microbiological culture that grew A. niger. Our patient was discharged with itraconazole 200 mg (syrup) to be taken once daily for an estimated duration of six months. The syrup form was chosen instead of the capsule form for better absorption. After two months of treatment, clinical and radiological improvements were noted on follow-up tests. The itraconazole syrup was continued, aiming for a minimum treatment duration of six months.", + "fulltext_subclaims": [ + "The patient is a 64-year-old woman.", + "She was a non-smoker.", + "She had a background history of epilepsy.", + "She presented to the respiratory clinic in May 2008.", + "She had a six-month history of productive cough with whitish sputum.", + "She had three episodes of hemoptysis.", + "She had no constitutional symptoms.", + "A diagnosis of tuberculosis was considered at a primary care clinic.", + "The results of a Mantoux test were negative.", + "The findings from three sputum acid-fast bacilli samples were negative.", + "The findings from cultures for tuberculosis were also negative.", + "Her symptoms were persistent despite a few courses with oral antibiotics.", + "She was emaciated with a body mass index of 19.3 kg/m2.", + "Her peripheral oxygen saturation was 98% on room air.", + "She did not have clubbed fingers.", + "She did not have palpable cervical lymph nodes.", + "She did not have oral thrush.", + "A bacillus Calmette-Guérin scar was present.", + "An examination of her respiratory system revealed reduced breath sounds at the bases.", + "The differential diagnoses were bronchogenic carcinoma, pulmonary tuberculosis and bronchiectasis.", + "The initial chest radiograph showed bilateral pleural effusion.", + "The initial chest radiograph showed bibasal consolidation.", + "A thoracocentesis procedure was not performed.", + "Bronchoscopy showed an edematous and white coated bronchial tree mucosa.", + "The right lower lobe mucosa had an infiltrate appearance.", + "The mycological bronchoalveolar lavage culture tested positive for Aspergillus niger.", + "The mycobacterial cultures tested negative.", + "A transbronchial biopsy was not performed in the same setting.", + "A diagnosis of chronic necrotizing pulmonary aspergillosis was made.", + "The diagnosis was based on the subacute presentation of six months' duration.", + "The diagnosis was based on microbiological culture that grew A. niger.", + "The patient was discharged with itraconazole 200 mg syrup.", + "The syrup was to be taken once daily.", + "The estimated duration of treatment was six months.", + "The syrup form was chosen instead of the capsule form.", + "After two months of treatment, clinical improvements were noted.", + "After two months of treatment, radiological improvements were noted." + ], + "summary": "Our patient was a 64-year-old Malay woman with a background history of epilepsy but no other comorbidities. She was a lifelong non-smoker. She presented to our facility with a six-month history of productive cough and three episodes of hemoptysis. An initial chest radiograph showed bilateral pleural effusion with bibasal consolidation. Bronchoscopy revealed a white-coated endobronchial tree and bronchoalveolar lavage culture grew Aspergillus niger. A diagnosis of chronic necrotizing pulmonary aspergillosis was made based on the clinical presentation and microbiological results. She responded well to treatment with oral itraconazole.", + "summary_subclaims": [ + "The patient was a 64-year-old Malay woman.", + "She had a background history of epilepsy.", + "She had no other comorbidities.", + "She was a lifelong non-smoker.", + "She presented with a six-month history of productive cough.", + "She had three episodes of hemoptysis.", + "An initial chest radiograph showed bilateral pleural effusion.", + "The chest radiograph showed bibasal consolidation.", + "Bronchoscopy revealed a white-coated endobronchial tree.", + "Bronchoalveolar lavage culture grew Aspergillus niger.", + "A diagnosis of chronic necrotizing pulmonary aspergillosis was made.", + "The diagnosis was based on the clinical presentation and microbiological results.", + "She responded well to treatment with oral itraconazole." + ] + }, + { + "id": "multiclinsum_test_111_en.txt", + "fulltext": "A 25 year old lady presented in a state of shock with massive haematuria. Patient gave a previous history of lower segment caesarean section 2 month ago following which she was doing well for one month. On 30th post-operative day of caesarean, she started passing blood and blood clots (long cylinder) in urine. There was no history of bleeding from per vaginum and other site. There was no history of dysuria or trauma and also no significant history of drugs or allergy found. She was evaluated outside and a CT was done which suggested a uterine/internal iliac artery pseudoaneurysm along with bladder clots. A cystoscopy was done outside 4 days before presentation which showed a defect of size 2.2 cm on dome of bladder. Intrabladder blood clot was evacuated. She was then referred to our center. On arrival she was haemodynamically unstable and her pulse rate, blood pressure, haemoglobin, blood urea, and serum creatinine were 154/min, 62/40 mm Hg, 4.8 g/dl, 10.8 mg/dl, and 0.44 mg/dl respectively. She was aggressively resuscitated with crystalloids and later 4 PRBC and 4 FFP was transfused. She was started on inotropic support and shifted to ICU for stabilisation. She responded to fluid resuscitation and her BP and pulse normalised. She developed blockage of the Foley catheter with clot retention in bladder. Foley catheter was removed and a tri-way Foley catheter with bladder irrigation was started. Later urine got cleared after irrigation. After 20 h when the patient stabilised, a CT angiography was done to localise the source of bleeding. CT angiogram was suggestive of left uterine pseudoaneurysm. She was taken to DSA after stabilisation which showed a pseudoaneurysm in the pelvis on the left side between the bladder and the lower uterus, possibly from the anterior uterine wall, with surrounding haematoma. There was clot and air within the urinary bladder; however no direct vesico-vaginal or vesico-uterine fistula was evident (A and B).The patient was urgently taken up for digital subtraction angiography and subsequent embolization. It revealed a hypertrophied and tortuous left uterine artery with a large pseudoaneurysm distally. Then after super selective microcatheterisation using 2.7 F microcatheter of left uterine artery, successful glue embolization was performed using 20% n-butyl cyanoacrylate and lipiodol mixture (C). Post procedure control angiogram showed complete devascularisation of pseudoaneurysm (D). This intervention was done by an additional professor with 12 years of experience in Level-1 trauma center. She was remaining haemodynamically stable throughout the procedure. In the post angio period she was kept in the ICU for 2 days where her condition remains stable. Haematuria persisted for 2 days and then it gradually cleared. She was later shifted to general wards from where she was discharged. She was doing well at 6 months of follow up.", + "fulltext_subclaims": [ + "The patient is a 25 year old lady.", + "She presented in a state of shock with massive haematuria.", + "She had a previous history of lower segment caesarean section 2 month ago.", + "On 30th post-operative day of caesarean, she started passing blood and blood clots (long cylinder) in urine.", + "There was no history of bleeding from per vaginum and other site.", + "There was no history of dysuria or trauma.", + "A CT done outside suggested a uterine/internal iliac artery pseudoaneurysm along with bladder clots.", + "A cystoscopy done outside 4 days before presentation showed a defect of size 2.2 cm on dome of bladder.", + "Intrabladder blood clot was evacuated during the cystoscopy.", + "On arrival, her pulse rate was 154/min.", + "On arrival, her blood pressure was 62/40 mm Hg.", + "On arrival, her haemoglobin was 4.8 g/dl.", + "She was aggressively resuscitated with crystalloids.", + "She received 4 PRBC and 4 FFP.", + "She was started on inotropic support.", + "She was shifted to ICU for stabilisation.", + "She responded to fluid resuscitation and her BP and pulse normalised.", + "She developed blockage of the Foley catheter with clot retention in bladder.", + "A tri-way Foley catheter with bladder irrigation was started.", + "Urine got cleared after irrigation.", + "A CT angiography was done after 20 h when the patient stabilised.", + "CT angiogram was suggestive of left uterine pseudoaneurysm.", + "A DSA showed a pseudoaneurysm in the pelvis on the left side between the bladder and the lower uterus.", + "There was no direct vesico-vaginal or vesico-uterine fistula evident.", + "The patient was urgently taken up for digital subtraction angiography and subsequent embolization.", + "It revealed a hypertrophied and tortuous left uterine artery with a large pseudoaneurysm distally.", + "Successful glue embolization was performed using 20% n-butyl cyanoacrylate and lipiodol mixture.", + "Post procedure control angiogram showed complete devascularisation of pseudoaneurysm.", + "This intervention was done by an additional professor with 12 years of experience in Level-1 trauma center.", + "She was kept in the ICU for 2 days.", + "Haematuria persisted for 2 days and then it gradually cleared.", + "She was discharged after being shifted to general wards.", + "She was doing well at 6 months of follow up." + ], + "summary": "A 25-year old female presented in a shock state with history of massive haematuria two months after delivering a baby. She was resuscitated with fluid, blood and blood products. A computed tomography angiogram was done which showed a large pseudoaneurysm of the left uterine artery so consequently angioembolization was done with n-butyl cyanoacrylate (NBCA) and lipoid mixture. Serial assessment of biochemical and clinical parameters depicted improvement in the clinical status of the patient. She was doing well at 6 months of follow up.", + "summary_subclaims": [ + "The patient is a 25-year old female.", + "She presented in a shock state.", + "She had a history of massive haematuria.", + "The haematuria occurred two months after delivering a baby.", + "She was resuscitated with fluid, blood and blood products.", + "A computed tomography angiogram was done.", + "The computed tomography angiogram showed a large pseudoaneurysm of the left uterine artery.", + "Angioembolization was done with n-butyl cyanoacrylate (NBCA) and lipoid mixture.", + "Serial assessment of biochemical and clinical parameters was performed.", + "Improvement in the clinical status of the patient was observed.", + "She was doing well at 6 months of follow up." + ] + }, + { + "id": "multiclinsum_test_2059_en.txt", + "fulltext": "A 71-year-old male presented with 3 years of low back and right lower extremity pain with accompanying numbness. Bertolotti’s syndrome was diagnosed on a preoperative CT scan. that showed a transitional vertebra at the lumbosacral spine junction (i.e., labeled as a partially lumbarized S1 with pseudoarthrosis on the right side [ and ].\nHe underwent a minimally invasive “wide” L5 transverse process resection for decompression of the right L5 nerve root (i.e., a bony ridge was found below the muscle extending from the transverse process of L5 to sacral ala). Using a drill and Kerrison rongeurs, the excess bone was removed from the transverse process superiorly to sacral ala inferiorly, and from the L5 pedicle medially all the way laterally. Postoperatively, the patient reported full resolution of his pain and radiculopathy.", + "fulltext_subclaims": [ + "A 71-year-old male presented with 3 years of low back and right lower extremity pain with accompanying numbness.", + "Bertolotti’s syndrome was diagnosed on a preoperative CT scan.", + "The CT scan showed a transitional vertebra at the lumbosacral spine junction.", + "The transitional vertebra was labeled as a partially lumbarized S1 with pseudoarthrosis on the right side.", + "The patient underwent a minimally invasive “wide” L5 transverse process resection.", + "The procedure was for decompression of the right L5 nerve root.", + "A bony ridge was found below the muscle extending from the transverse process of L5 to sacral ala.", + "The excess bone was removed from the transverse process superiorly to sacral ala inferiorly.", + "The excess bone was removed from the L5 pedicle medially all the way laterally.", + "Postoperatively, the patient reported full resolution of his pain and radiculopathy." + ], + "summary": "A 71-year-old male presented with low back pain of 3 years duration that radiated into the right lower extremity resulting in numbness in the L5 distribution. He then underwent a minimally invasive approach to resect the L5 \"wide\" transverse process following the CT diagnosis of Bertolotti's syndrome. Prior to surgery, patient reported pain that was exacerbated by ambulation that resolved post-operative.", + "summary_subclaims": [ + "The patient is a 71-year-old male.", + "The patient had low back pain of 3 years duration.", + "The pain radiated into the right lower extremity.", + "The patient had numbness in the L5 distribution.", + "The patient underwent a minimally invasive approach to resect the L5 'wide' transverse process.", + "The CT diagnosis was Bertolotti's syndrome.", + "Prior to surgery, the patient reported pain exacerbated by ambulation.", + "The pain resolved post-operative." + ] + }, + { + "id": "multiclinsum_test_1900_en.txt", + "fulltext": "A 69-year-old Japanese man underwent treatment for liver dysfunction 3 years after aortic valve replacement. Later, rapid elevation in his serum alkaline phosphatase (ALP) level was recorded and he was readmitted to determine the etiology. His body temperature was 36 °C, blood pressure 164/65 mmHg, and pulse rate was 66/minute. Laboratory data revealed mild anemia and liver-renal injury: white blood cells (WBC) 4600/uL, hemoglobin 9.7 g/dL, platelet 18.9 × 104/dL, C-reactive protein (CRP) 0.29 mg/dL, ALP 1138 U/L, aspartate aminotransferase (AST) 40 U/L, alanine aminotransferase (ALT) 37 U/L, and γ glutamyl transpeptidase (γ-GTP) 298 U/L. His blood urea nitrogen (BUN) was 22.4 mg/dL, creatinine 1.14 mg/dL, activated partial thromboplastin time (APTT) 45.6 seconds, and prothrombin time-international normalized ratio (PT-INR) 2.67. He also had a past history of duodenal ulcer perforation and was currently being treated with warfarin, angiotensin receptor blocker, and proton pump inhibitor. In addition, he was taking orally administered ursodeoxycholic acid for unknown liver function disorder. He had no alcohol consumption or tobacco smoking history and no relevant family history.\nA plain radiograph showed no significant findings, but computed tomography (CT) revealed an enhanced tumor within the hilar bile duct and dilatation of the left hepatic duct , which are typical findings for hilar cholangiocarcinoma. In addition, endoscopic retrograde cholangiopancreatography (ERCP) revealed tumor shadow in his bile duct, and the cytology confirmed malignant cells in the bile . As no lymph node and distant metastases were detected, we inserted endoscopic nasobiliary drainage (ENBD) to reduce jaundice as preparation for surgery. We performed extended left hepatectomy with resection of his bile duct; his postoperative course was good without severe complications. After 3 months postoperatively, he was readmitted for subacute cholangitis and obstructive jaundice. Immediately, percutaneous transhepatic cholangiography drainage (PTCD) was performed, followed by cholangiography that exhibited the intrabiliary tumor growth in the remnant liver.\nSimultaneously, histological examination of resected specimens revealed tumor growth in the hilar duct across the left hepatic duct . Microscopic findings at the same site revealed a dilated bile duct filled with well-differentiated tubular adenocarcinoma . On immunohistochemical examination, tumor cells were positive for cytokeratin (CK) 20 but negative for CK7 . Furthermore, CK18 as control and CDX2 were stained. Although these findings were not typical of intrahepatic cholangiocarcinoma, hepatic metastasis from another primary lesion was strongly suspected [, ]. Furthermore, CT revealed an enhanced tumor-like lesion at the descending colon, followed by diagnosis of type 2 cancer in total colonography. Then, left hemicolectomy was performed; the immunohistochemical-identified feature matched with an intrabiliary tumor. Meanwhile, the PTCD fluid turned bloody, which was considered to indicate bleeding from a residual bile duct tumor . Accordingly, we planned chemotherapy with orally administered capecitabine but our patient experienced a spike fever because of refractory cholangitis. Thus, we abandoned chemotherapy and initiated radiotherapy to stop the tumor bleeding around the hilar bile duct. After completing radiotherapy (total 50 Gy) for approximately 1 month, we observed an improvement in his liver function because of tumor shrinkage. Unfortunately, the effects were short-lived, intrabiliary growth and cholangitis rebooted after 1 month leading to his death due to septic liver failure . Autopsy revealed a remnant tumor in the bile duct , but no noticeable nodular metastasis was observed, except for a single small metastasis in the lower lobe of his left lung.", + "fulltext_subclaims": [ + "A 69-year-old Japanese man underwent treatment for liver dysfunction 3 years after aortic valve replacement.", + "Rapid elevation in his serum alkaline phosphatase (ALP) level was recorded.", + "He was readmitted to determine the etiology.", + "His body temperature was 36 °C.", + "His blood pressure was 164/65 mmHg.", + "His pulse rate was 66/minute.", + "Laboratory data revealed mild anemia.", + "Laboratory data revealed liver-renal injury.", + "White blood cells (WBC) were 4600/uL.", + "Hemoglobin was 9.7 g/dL.", + "Platelet count was 18.9 × 104/dL.", + "C-reactive protein (CRP) was 0.29 mg/dL.", + "Alkaline phosphatase (ALP) was 1138 U/L.", + "Aspartate aminotransferase (AST) was 40 U/L.", + "Alanine aminotransferase (ALT) was 37 U/L.", + "γ glutamyl transpeptidase (γ-GTP) was 298 U/L.", + "Blood urea nitrogen (BUN) was 22.4 mg/dL.", + "Creatinine was 1.14 mg/dL.", + "Activated partial thromboplastin time (APTT) was 45.6 seconds.", + "Prothrombin time-international normalized ratio (PT-INR) was 2.67.", + "He had a past history of duodenal ulcer perforation.", + "He was currently being treated with warfarin.", + "He was currently being treated with an angiotensin receptor blocker.", + "He was currently being treated with a proton pump inhibitor.", + "He was taking orally administered ursodeoxycholic acid for unknown liver function disorder.", + "He had no alcohol consumption history.", + "He had no tobacco smoking history.", + "He had no relevant family history.", + "A plain radiograph showed no significant findings.", + "Computed tomography (CT) revealed an enhanced tumor within the hilar bile duct.", + "Computed tomography (CT) revealed dilatation of the left hepatic duct.", + "These findings are typical for hilar cholangiocarcinoma.", + "Endoscopic retrograde cholangiopancreatography (ERCP) revealed tumor shadow in his bile duct.", + "Cytology confirmed malignant cells in the bile.", + "No lymph node metastases were detected.", + "No distant metastases were detected.", + "Endoscopic nasobiliary drainage (ENBD) was inserted to reduce jaundice.", + "Extended left hepatectomy with resection of his bile duct was performed.", + "His postoperative course was good without severe complications.", + "He was readmitted 3 months postoperatively for subacute cholangitis.", + "He was readmitted for obstructive jaundice.", + "Percutaneous transhepatic cholangiography drainage (PTCD) was performed.", + "Cholangiography exhibited intrabiliary tumor growth in the remnant liver.", + "Histological examination of resected specimens revealed tumor growth in the hilar duct across the left hepatic duct.", + "Microscopic findings at the same site revealed a dilated bile duct filled with well-differentiated tubular adenocarcinoma.", + "Tumor cells were positive for cytokeratin (CK) 20.", + "Tumor cells were negative for CK7.", + "CK18 as control and CDX2 were stained.", + "These findings were not typical of intrahepatic cholangiocarcinoma.", + "Hepatic metastasis from another primary lesion was strongly suspected.", + "CT revealed an enhanced tumor-like lesion at the descending colon.", + "Type 2 cancer was diagnosed in total colonography.", + "Left hemicolectomy was performed.", + "The immunohistochemical-identified feature matched with an intrabiliary tumor.", + "The PTCD fluid turned bloody.", + "This was considered to indicate bleeding from a residual bile duct tumor.", + "Chemotherapy with orally administered capecitabine was planned.", + "The patient experienced a spike fever because of refractory cholangitis.", + "Chemotherapy was abandoned.", + "Radiotherapy was initiated to stop the tumor bleeding around the hilar bile duct.", + "Radiotherapy totaled 50 Gy.", + "Radiotherapy was completed for approximately 1 month.", + "Improvement in liver function was observed because of tumor shrinkage.", + "The effects were short-lived.", + "Intrabiliary growth and cholangitis rebooted after 1 month.", + "The patient died due to septic liver failure.", + "Autopsy revealed a remnant tumor in the bile duct.", + "No noticeable nodular metastasis was observed, except for a single small metastasis in the lower lobe of his left lung." + ], + "summary": "A 69-year-old Japanese man underwent treatment for liver dysfunctions 3 years after aortic valve replacement. Computed tomography revealed an enhanced tumor within the hilar bile duct and dilatation of the left hepatic duct, typical of hilar cholangiocarcinoma. Endoscopic retrograde cholangiopancreatography revealed tumor shadow in his bile duct, and the cytology confirmed malignant cells in the bile. We performed extended left hepatectomy with bile duct resection; his postoperative course remained good without acute complications. After 3 months postoperatively, he was readmitted for subacute cholangitis and obstructive jaundice. Immediately, percutaneous transhepatic cholangiography drainage was performed, followed by cholangiography that exhibited intrabiliary tumor growth in the remnant liver. On immunohistochemical examination, tumor cells were positive for cytokeratin 20 and CDX2 but negative for cytokeratin 7. Then, computed tomography revealed an enhanced tumor-like lesion at the descending colon. After 3 months, left hemicolectomy was performed. Meanwhile, the percutaneous transhepatic cholangiography drainage fluid turned bloody, which was considered to be bleeding from a residual bile duct tumor. Accordingly, radiotherapy was initiated to prevent tumor bleeding around the hilar bile duct, but, unfortunately, the effects were short-lived, and cholangitis rebooted after 1 month leading to our patient's death due to septic liver failure. Autopsy revealed a remnant tumor in the bile duct, but no noticeable nodular metastasis was observed, except for a single small metastasis in the lower lobe of the left lung.", + "summary_subclaims": [ + "A 69-year-old Japanese man underwent treatment for liver dysfunctions 3 years after aortic valve replacement.", + "Computed tomography revealed an enhanced tumor within the hilar bile duct.", + "Computed tomography showed dilatation of the left hepatic duct.", + "Endoscopic retrograde cholangiopancreatography revealed tumor shadow in his bile duct.", + "Cytology confirmed malignant cells in the bile.", + "Extended left hepatectomy with bile duct resection was performed.", + "The postoperative course remained good without acute complications.", + "After 3 months postoperatively, he was readmitted for subacute cholangitis and obstructive jaundice.", + "Percutaneous transhepatic cholangiography drainage was performed.", + "Cholangiography exhibited intrabiliary tumor growth in the remnant liver.", + "Tumor cells were positive for cytokeratin 20.", + "Tumor cells were positive for CDX2.", + "Tumor cells were negative for cytokeratin 7.", + "Computed tomography revealed an enhanced tumor-like lesion at the descending colon.", + "Left hemicolectomy was performed after 3 months.", + "The percutaneous transhepatic cholangiography drainage fluid turned bloody.", + "Radiotherapy was initiated to prevent tumor bleeding around the hilar bile duct.", + "The effects of radiotherapy were short-lived.", + "Cholangitis rebooted after 1 month.", + "The patient's death was due to septic liver failure.", + "Autopsy revealed a remnant tumor in the bile duct.", + "No noticeable nodular metastasis was observed, except for a single small metastasis in the lower lobe of the left lung." + ] + }, + { + "id": "multiclinsum_test_531_en.txt", + "fulltext": "We present the case of a 25-year-old male who complained of difficulty adapting his right eye prothesis. He had a history of enucleation of the right eye due to a retinoblastoma in France when he was 4 years old. No orbital implant was placed at that time. Ophthalmological evaluation revealed a thickened bulbar conjunctiva with a central translucid round area, vascularized, and an associated inferior symblepharon . Orbital computed tomography (CT) was obtained and revealed a cyst-like structure on the right orbit, bilobated, with hyperdense walls and hypodense content. Magnetic resonance imaging (MRI) image was described as “raised anteroposterior diameter of a cystic-like structure with an ovoid morphology.” There was a structure with a T1 signal which was identical to an atrophied optic nerve, and there was no contrast uptake that indicated an expanding lesion . These exams were compared with previous orbital CT from 6 years before (after a trauma incident), in which the lesion was not apparent. Drainage of the cystic content and biopsy with partial resection were performed . Pathology exam revealed fragments of fibrous tissue with a cystic structure covered with conjunctival-like epithelium, with no evidence of dysplasia or malignancy . Diagnosis of a giant conjunctival cyst of the orbit was assumed. The CARE Checklist has been completed by the authors for this case report, attached as online supplementary material (for all online suppl. material, see ).", + "fulltext_subclaims": [ + "The patient is a 25-year-old male.", + "He complained of difficulty adapting his right eye prothesis.", + "He had a history of enucleation of the right eye due to a retinoblastoma in France when he was 4 years old.", + "No orbital implant was placed at the time of enucleation.", + "Ophthalmological evaluation revealed a thickened bulbar conjunctiva with a central translucid round area.", + "Orbital computed tomography (CT) revealed a cyst-like structure on the right orbit.", + "The cyst-like structure was bilobated.", + "The cyst-like structure had hyperdense walls.", + "The cyst-like structure had hypodense content.", + "Magnetic resonance imaging (MRI) showed a raised anteroposterior diameter of a cystic-like structure.", + "The cystic-like structure had an ovoid morphology.", + "There was a structure with a T1 signal identical to an atrophied optic nerve.", + "There was no contrast uptake indicating an expanding lesion.", + "Orbital CT from 6 years before showed no apparent lesion.", + "Drainage of the cystic content and biopsy with partial resection were performed.", + "Pathology exam revealed fragments of fibrous tissue with a cystic structure covered with conjunctival-like epithelium.", + "There was no evidence of dysplasia or malignancy.", + "Diagnosis of a giant conjunctival cyst of the orbit was assumed.", + "The CARE Checklist has been completed by the authors for this case report." + ], + "summary": "We report the case of a 25-year-old man with a history of enucleation for a retinoblastoma of the right eye who presented with difficulty in fitting his eye prothesis. On his past medical records, there was no reference to the placement of any orbital implant at the time of the surgery. Biomicroscopy of the right eye revealed a thickened bulbar conjunctiva, an inferior symblepharon, and a translucid central area with vascularization. Imaging was remarkable for a cystic cavity filling the whole right orbit. Biopsy revealed the diagnosis of a conjunctival cyst, and drainage was performed, alleviating the patient's symptoms.", + "summary_subclaims": [ + "The patient is a 25-year-old man.", + "The patient had a history of enucleation for a retinoblastoma of the right eye.", + "The patient presented with difficulty in fitting his eye prothesis.", + "There was no reference to the placement of any orbital implant at the time of the surgery.", + "Biomicroscopy of the right eye revealed a thickened bulbar conjunctiva.", + "Biomicroscopy of the right eye revealed an inferior symblepharon.", + "Biomicroscopy of the right eye revealed a translucid central area with vascularization.", + "Imaging was remarkable for a cystic cavity filling the whole right orbit.", + "Biopsy revealed the diagnosis of a conjunctival cyst.", + "Drainage was performed.", + "Drainage alleviated the patient's symptoms." + ] + }, + { + "id": "multiclinsum_test_566_en.txt", + "fulltext": "A 32-year-old woman referred regular menstrual cycles lasting 7 days with a normal flow and had no previous history of period pains. She was admitted to our hospital for abnormal vaginal bleeding for 2 months and lower abdominal pain for 4 days. The abnormal vaginal bleeding was described as persistent and the amount of blood loss was less than her normal menses. The lower abdominal pain was sudden and progressively worsening which she described as dull pain in nature, located over the lower abdomen, and resolved by changing to side lying position.\nPhysical examination revealed a well-healed cesarean section scar tenderness on palpation of the lower abdomen. Bimanual examination revealed that a cyst palpable in front of the uterus about 10 cm in diameter. It appeared to be attached to front of the uterus.\nLaboratory examination showed red blood cell count of 3.2*10∧12/L, hemoglobin of 77 g/L. The C-reactive protein level was 24.4 mg/L.\nPelvic ultrasound was performed which demonstrated normal adnexae and an enlarged uterus. It revealed a 10.3*10.2*9.3 cm cystic mass in the front of the uterus , and a 7.1*6.5*4.6 cm medium echo mass in the cystic mass with no apparent blood flow signal was detected by CDFI , and 2.6*2.5*2.5 cm masses could be seen outside the lower part of the anterior wall of the uterus . The two masses were closely adjacent to the cesarean section incision in the anterior wall of the uterus. The whole abdomen CT scan showed that cystic mass could be seen in the front of the uterus, with a range of about 11.1 * 9.7 cm. The boundary between the lesion and the anterior wall of the uterus was unclear .\nBased on the imaging studies and patient's history, suspicion of cystic adenomyosis was raised. We performed transabdominal surgery on the patient. The intraoperative exploration revealed a cystic mass with a size of about 10*10 cm arising from the cervical isthmus of the anterior wall of the uterus. We have detected a chocolate-like viscous liquid inside the cyst and noticed the adhesion of the anterior wall of the cyst to the anterior wall of the uterus and the bladder. The posterior wall of cyst adhered to the intestines, as shown in . There was an adenomyoma-like nodule about 3*3 cm deep in the cyst. It showed unremarkable adnexae.\nShe was nursed in the ward for a total of 5 days after the surgery and was discharged well without any post-operative complications. We asked the patient to continue treatment with GnRH after operation. Post-operative pathology confirmed cystic adenomyosis . The final diagnosis was cystic adenomyosis.\nTwo months after operation, we followed up the patient and no abnormality was found in ultrasonography . The patient remains asymptomatic.", + "fulltext_subclaims": [ + "The patient is a 32-year-old woman.", + "She had regular menstrual cycles lasting 7 days with a normal flow.", + "She had no previous history of period pains.", + "She was admitted for abnormal vaginal bleeding for 2 months.", + "The abnormal vaginal bleeding was described as persistent.", + "The amount of blood loss was less than her normal menses.", + "She had lower abdominal pain for 4 days.", + "The lower abdominal pain was sudden and progressively worsening.", + "The pain was described as dull in nature.", + "The pain was located over the lower abdomen.", + "The pain resolved by changing to side lying position.", + "Physical examination revealed a well-healed cesarean section scar.", + "There was tenderness on palpation of the lower abdomen.", + "Bimanual examination revealed a cyst palpable in front of the uterus about 10 cm in diameter.", + "The cyst appeared to be attached to the front of the uterus.", + "Laboratory examination showed a red blood cell count of 3.2*10∧12/L.", + "Hemoglobin was 77 g/L.", + "The C-reactive protein level was 24.4 mg/L.", + "Pelvic ultrasound demonstrated normal adnexae.", + "The uterus was enlarged.", + "A 10.3*10.2*9.3 cm cystic mass was seen in the front of the uterus.", + "A 7.1*6.5*4.6 cm medium echo mass was detected within the cystic mass.", + "The medium echo mass showed no apparent blood flow signal on CDFI.", + "Two 2.6*2.5*2.5 cm masses were seen outside the lower part of the anterior wall of the uterus.", + "The two masses were closely adjacent to the cesarean section incision in the anterior wall of the uterus.", + "The whole abdomen CT scan showed a cystic mass in the front of the uterus.", + "The cystic mass was about 11.1 * 9.7 cm in size.", + "The boundary between the lesion and the anterior wall of the uterus was unclear.", + "Based on the imaging studies and patient's history, suspicion of cystic adenomyosis was raised.", + "Transabdominal surgery was performed.", + "Intraoperative exploration revealed a cystic mass with a size of about 10*10 cm arising from the cervical isthmus of the anterior wall of the uterus.", + "A chocolate-like viscous liquid was detected inside the cyst.", + "The anterior wall of the cyst adhered to the anterior wall of the uterus and the bladder.", + "The posterior wall of the cyst adhered to the intestines.", + "An adenomyoma-like nodule about 3*3 cm was found deep in the cyst.", + "The adnexae showed no remarkable findings.", + "The patient was nursed in the ward for a total of 5 days after the surgery.", + "She was discharged well without any post-operative complications.", + "Post-operative pathology confirmed cystic adenomyosis.", + "The final diagnosis was cystic adenomyosis.", + "Two months after operation, no abnormality was found in ultrasonography.", + "The patient remains asymptomatic." + ], + "summary": "We treated a 32-year-old married patient with cystic adenomyosis that reported persistent abdominal pain and massive vaginal bleeding, so an emergency laparotomy was performed. The intraoperative findings and post-operative pathology proved that the diagnosis was correct. The prognosis of the patient is good, and there is no recurrence within 3 months after surgery.", + "summary_subclaims": [ + "The patient was a 32-year-old married woman.", + "The patient had cystic adenomyosis.", + "The patient reported persistent abdominal pain.", + "The patient had massive vaginal bleeding.", + "An emergency laparotomy was performed.", + "The intraoperative findings proved the diagnosis was correct.", + "The post-operative pathology proved the diagnosis was correct.", + "The prognosis of the patient is good.", + "There is no recurrence within 3 months after surgery." + ] + }, + { + "id": "multiclinsum_test_1458_en.txt", + "fulltext": "A 54-year-old woman applied to an out medical center with the complaints of weight loss, jaundice, and pain in the epigastric and right upper quadrant of the abdomen. Computer tomography (CT) scan revealed a mass with a size of 13 mm in the ampullary region consistent with periampullary tumor .\nThe patient underwent an endoscopic retrograde cholangiopancreatography (ERCP) procedure which revealed significant dilatation in the middle and distal segments of the common bile duct together with an abrupt ending in the distal segment of the common bile duct. A plastic stent was inserted to the common bile duct via ERCP, and multiple biopsies were taken from the periampullary region. The histopathological result was squamous cell carcinoma. The patient was referred to our hospital for further investigations.\nThe physical examination of the patient was unremarkable. Laboratory tests revealed elevated ALP (200 U/l; normal range, 30–120 U/l) and GGT (181 U/l; normal range, 0–38 U/l) levels. Billirubin level was within the normal limits. The serum level of the tumor markers of CEA and CA-125 were 2.41 and 14.23 ng/ml (normal range, 0–35 U/ml), respectively. CA-19-9 was 47.47 U/ml (normal range, 0–27 U/ml).\nMagnetic resonance imaging (MRI) and magnetic resonance cholangiopancreatography (MRCP) examinations demonstrated a T1 hypointense lesion with a size of 43 × 43 mm in the periampullary region occluding the distal segment of the common bile duct .\nBecause of the low incidence of squamous cell carcinoma in the periampullary region, primary malignancies of other organs were also explored. Positron emission tomography (PET CT) revealed FDG (fluorodeoxy-glucose) uptake only in the periampullary region of the pancreas .\nThe patient underwent an explorative laparotomy. Upon confirmation of neither lymphovascular invasion nor solid organ metastases, we decided to proceed with Whipple’s procedure. The postoperative course of the patient was uneventful. The patient was discharged, and adjuvant chemotherapy was recommended.\nThe histopathological examination demonstrated a moderately differentiated squamous cell carcinoma of periampullary tumor with a size of 3.7 × 3.1 × 2.1 cm, invading the duodenum and pancreas .\nMultiple serial sections of the tumor specimen failed to detect any adenomatous component. Although there were no signs of lymphovascular invasion, perineural invasion was present in the samples. Upon these findings, the tumor was staged as pT3N0M0.\nImmunohistochemical analysis showed that tumor cells were positive for p63 and high molecular-weight cytokeratin (HMWCK). To exclude other possible origins of primary squamous cell carcinoma, additional immunohistochemical staining analyses were performed. Tumor cells were negative for synaptophysin and chromogranin, ruling out neuroendocrine origin. Similarly, thyroid transcription factor-1 (TTF1) and CK19 were negative, excluding primary squamous cell cancer of the lung and cholangiocarcinoma. Photomicrographs of the resected specimen are shown in Figs. , , , and .\nDistal common bile duct, ampullary, and duodenal cancers are less common than pancreatic cancer . The most common histopathological type of tumor in the ampulla of Vater is adenocarcinoma. Other primary tumors that have been reported in the ampulla of Vater are squamous cell carcinoma, neuroendocrine carcinoma [, ], and signet cell carcinoma [, ]. There are only four case reports with primary squamous cell carcinoma [–] and one case report with co-existent primary squamous cell carcinoma and adenocarcinoma in the ampulla of Vater .\nBecause of the rarity of primary squamous cell carcinoma in the ampulla of Vater, other primary squamous cell malignancies must be excluded in all the patients. Buyukcelık et al. reported a case of squamous cell carcinoma of the larynx , and Sreenarasimhaiah and Hoang reported a case of esophageal squamous cell carcinoma metastasized to the ampulla of Vater . Therefore, in the present case, extensive imaging studies with CT, MRI, and PET CT were performed to rule out other possible origins.\nThere are also few case reports of neuroendocrine carcinoma of the ampulla of Vater with squamous cell components [, ]. Sugawara et al. reported a case of small cell neuroendocrine carcinoma of the ampulla of Vater with foci of squamous differentiation. In their case, immunohistochemical analyses including synaptophysin, chromogranin, neuron-specific enolase (NSE), and Leu-7 were performed to identify neuroendocrine cells, and squamous cell carcinoma components were weakly positive for NSE . In our case, after revealing squamous cell carcinoma by HMWCK and p63, additional staining analyses with synaptophysin and chromogranin were performed to exclude a neuroendocrine component.\nThe ampulla of Vater is normally devoid of squamous cells. Although the malignant transformation of ectopic squamous epithelium, the differentiation of the duodenal pluripotent stem cells , and squamous metaplasia secondary to chronic inflammation are all among the proposed mechanisms, the exact pathogenesis of primary squamous cell carcinoma in the ampulla of Vater is still unknown.\nTreatment options for periampullary tumors are surgical resection, operative or nonoperative palliation, and neoadjuvant or adjuvant therapies regardless of histopathology of tumor. Surgical resection which was also the choice of treatment in our case is the major treatment method for periampullary tumors. In another case of primary squamous cell carcinoma of the ampulla of Vater, the patient underwent curative resection without any further treatment and overall survival was 5 months after surgery was reported .\nWith limited experience of primary squamous cell carcinoma in the ampulla of Vater, long-term survival rates are not well known. On the other hand, pure squamous cell carcinomas of the biliary tract are associated with decreased survival rates compared to adenocarcinomas and adenosquamous carcinomas [, ]. Therefore, we suggest that primary squamous cell carcinomas of the ampulla of Vater should be considered as more aggressive than adenocarcinomas, and adjuvant chemotherapy should be recommended as another treatment option.\nDifferent adjuvant chemotherapy regimens have been investigated for metastatic and advanced ampullary adenocarcinomas in recent years. Shoji et al. reported a retrospective study comparing 5-fluorouracil-based regimens with gemcitabine-based regimens for median progression-free survival and median overall survival time in patients with advanced ampullary adenocarcinomas . Median overall survival time was found to be longer with gemcitabine-based regimens. A phase II study evaluated the efficacy of a combination regimen of capecitabine with oxaliplatin in advanced ampullary and small bowel adenocarcinomas . The response rate for this regimen was lower in the ampullary adenocarcinomas compared to small bowel adenocarcinomas. This difference was suggested to be related with the heterogenous epithelium of origin and the molecular heterogeneity for ampullary tumors. In many centers, the general approach to periampullary cancers has been to use gemcitabine-based regimens for pancreatic and biliary carcinomas and fluorouracil-based regimens for duodenal and ampullary carcinomas which is also the choice of treatment in our center.", + "fulltext_subclaims": [ + "A 54-year-old woman applied to an out medical center with the complaints of weight loss, jaundice, and pain in the epigastric and right upper quadrant of the abdomen.", + "Computer tomography (CT) scan revealed a mass with a size of 13 mm in the ampullary region consistent with periampullary tumor.", + "The patient underwent an endoscopic retrograde cholangiopancreatography (ERCP) procedure.", + "The ERCP procedure revealed significant dilatation in the middle and distal segments of the common bile duct.", + "The ERCP procedure revealed an abrupt ending in the distal segment of the common bile duct.", + "A plastic stent was inserted to the common bile duct via ERCP.", + "Multiple biopsies were taken from the periampullary region.", + "The histopathological result was squamous cell carcinoma.", + "The patient was referred to our hospital for further investigations.", + "The physical examination of the patient was unremarkable.", + "Laboratory tests revealed elevated ALP (200 U/l; normal range, 30–120 U/l) and GGT (181 U/l; normal range, 0–38 U/l) levels.", + "Billirubin level was within the normal limits.", + "The serum level of the tumor markers of CEA and CA-125 were 2.41 and 14.23 ng/ml (normal range, 0–35 U/ml), respectively.", + "CA-19-9 was 47.47 U/ml (normal range, 0–27 U/ml).", + "Magnetic resonance imaging (MRI) and magnetic resonance cholangiopancreatography (MRCP) examinations demonstrated a T1 hypointense lesion with a size of 43 × 43 mm in the periampullary region.", + "The lesion occluded the distal segment of the common bile duct.", + "Because of the low incidence of squamous cell carcinoma in the periampullary region, primary malignancies of other organs were also explored.", + "Positron emission tomography (PET CT) revealed FDG (fluorodeoxy-glucose) uptake only in the periampullary region of the pancreas.", + "The patient underwent an explorative laparotomy.", + "Upon confirmation of neither lymphovascular invasion nor solid organ metastases, we decided to proceed with Whipple’s procedure.", + "The postoperative course of the patient was uneventful.", + "The patient was discharged, and adjuvant chemotherapy was recommended.", + "The histopathological examination demonstrated a moderately differentiated squamous cell carcinoma of periampullary tumor with a size of 3.7 × 3.1 × 2.1 cm.", + "The tumor invaded the duodenum and pancreas.", + "Multiple serial sections of the tumor specimen failed to detect any adenomatous component.", + "Although there were no signs of lymphovascular invasion, perineural invasion was present in the samples.", + "The tumor was staged as pT3N0M0.", + "Immunohistochemical analysis showed that tumor cells were positive for p63 and high molecular-weight cytokeratin (HMWCK).", + "Tumor cells were negative for synaptophysin and chromogranin, ruling out neuroendocrine origin.", + "Tumor cells were negative for thyroid transcription factor-1 (TTF1) and CK19, excluding primary squamous cell cancer of the lung and cholangiocarcinoma.", + "Distal common bile duct, ampullary, and duodenal cancers are less common than pancreatic cancer.", + "The most common histopathological type of tumor in the ampulla of Vater is adenocarcinoma.", + "Other primary tumors that have been reported in the ampulla of Vater are squamous cell carcinoma, neuroendocrine carcinoma, and signet cell carcinoma.", + "There are only four case reports with primary squamous cell carcinoma and one case report with co-existent primary squamous cell carcinoma and adenocarcinoma in the ampulla of Vater.", + "Because of the rarity of primary squamous cell carcinoma in the ampulla of Vater, other primary squamous cell malignancies must be excluded in all the patients.", + "Buyukcelık et al. reported a case of squamous cell carcinoma of the larynx.", + "Sreenarasimhaiah and Hoang reported a case of esophageal squamous cell carcinoma metastasized to the ampulla of Vater.", + "In the present case, extensive imaging studies with CT, MRI, and PET CT were performed to rule out other possible origins.", + "There are also few case reports of neuroendocrine carcinoma of the ampulla of Vater with squamous cell components.", + "Sugawara et al. reported a case of small cell neuroendocrine carcinoma of the ampulla of Vater with foci of squamous differentiation.", + "In their case, immunohistochemical analyses including synaptophysin, chromogranin, neuron-specific enolase (NSE), and Leu-7 were performed to identify neuroendocrine cells.", + "Squamous cell carcinoma components were weakly positive for NSE.", + "In our case, after revealing squamous cell carcinoma by HMWCK and p63, additional staining analyses with synaptophysin and chromogranin were performed to exclude a neuroendocrine component.", + "The ampulla of Vater is normally devoid of squamous cells.", + "The exact pathogenesis of primary squamous cell carcinoma in the ampulla of Vater is still unknown.", + "Treatment options for periampullary tumors are surgical resection, operative or nonoperative palliation, and neoadjuvant or adjuvant therapies regardless of histopathology of tumor.", + "Surgical resection which was also the choice of treatment in our case is the major treatment method for periampullary tumors.", + "In another case of primary squamous cell carcinoma of the ampulla of Vater, the patient underwent curative resection without any further treatment and overall survival was 5 months after surgery was reported.", + "With limited experience of primary squamous cell carcinoma in the ampulla of Vater, long-term survival rates are not well known.", + "Pure squamous cell carcinomas of the biliary tract are associated with decreased survival rates compared to adenocarcinomas and adenosquamous carcinomas.", + "We suggest that primary squamous cell carcinomas of the ampulla of Vater should be considered as more aggressive than adenocarcinomas, and adjuvant chemotherapy should be recommended as another treatment option.", + "Different adjuvant chemotherapy regimens have been investigated for metastatic and advanced ampullary adenocarcinomas in recent years.", + "Shoji et al. reported a retrospective study comparing 5-fluorouracil-based regimens with gemcitabine-based regimens for median progression-free survival and median overall survival time in patients with advanced ampullary adenocarcinomas.", + "Median overall survival time was found to be longer with gemcitabine-based regimens.", + "A phase II study evaluated the efficacy of a combination regimen of capecitabine with oxaliplatin in advanced ampullary and small bowel adenocarcinomas.", + "The response rate for this regimen was lower in the ampullary adenocarcinomas compared to small bowel adenocarcinomas.", + "This difference was suggested to be related with the heterogenous epithelium of origin and the molecular heterogeneity for ampullary tumors.", + "In many centers, the general approach to periampullary cancers has been to use gemcitabine-based regimens for pancreatic and biliary carcinomas and fluorouracil-based regimens for duodenal and ampullary carcinomas.", + "This is also the choice of treatment in our center." + ], + "summary": "A 54-year-old woman presented with weight loss, jaundice, and pain in the epigastric and right upper quadrant of the abdomen. With extensive radiological imaging, the patient was diagnosed with periampullary tumor and Whipple's procedure was performed. The immunohistochemical analyses supported the diagnosis of primary squamous cell carcinoma. The postoperative course was uneventful. The patient was discharged, and adjuvant chemotherapy was recommended.", + "summary_subclaims": [ + "The patient is a 54-year-old woman.", + "The patient had weight loss.", + "The patient had jaundice.", + "The patient had pain in the epigastric and right upper quadrant of the abdomen.", + "The patient was diagnosed with periampullary tumor.", + "Whipple's procedure was performed.", + "Immunohistochemical analyses supported the diagnosis of primary squamous cell carcinoma.", + "The postoperative course was uneventful.", + "The patient was discharged.", + "Adjuvant chemotherapy was recommended." + ] + }, + { + "id": "multiclinsum_test_1091_en.txt", + "fulltext": "A 39-year-old female who had suffered from trichiasis for more than 30 years complained of a foreign-body sensation and epiphora. The corrected visual acuity of her left eye was 20/30. Slit-lamp examination revealed multiple milky-white soft masses on the corneal surface of her left eye . A slight opacity was suspected in the anterior stroma under the slit-lamp examination. In accordance with our previous classification guidelines, this mass was classified as having a gelatinous drop-like dystrophy-like appearance. These multiple masses were located at the cilia-attached region.\nOCT (Cirrus™ HD-OCT; Carl Zeiss, Jena, Germany; cube 4×4 mm, 512 A-scan, five-line raster 3 mm, A-scans) revealed that while there was a large mass under the thinned epithelial layer, there was no destruction on Bowman’s layer throughout the region , although a little high density stromal cells were observed in the anterior stromal layer.\nOn the other hand, the fellow cornea exhibited a linear subepithelial opacity that was not stained by fluorescein when observed under a slit-lamp examination . OCT revealed a high-density spot in Bowman’s layer , and this spot was coincident with the cilia-attached region and linear line observed under slit-lamp examination. There was normal thickness for the epithelial layer, and no change was observed in any other parts of the cornea in the fellow eye.\nTo resolve the foreign-body sensation in the patient, the corneal tissues were excised by lamellar keratoplasty. After these excised specimens were frozen in 30% sucrose, 3 μm sections were cut and then mounted on slides. After the slides were dried, samples were fixed with 10% formaldehyde and stained with Congo red and antilactoferrin antibody (2B8; Abcam, Cambridge, UK). All of the sections were incubated with 1% bovine serum albumin in phosphate-buffered saline at room temperature for 10 minutes each in order to block the nonspecific binding. Subsequently, the samples were then incubated with antilactoferrin antibody for 90 minutes at room temperature. The sections were washed three times in phosphate-buffered saline for 10 minutes, with the binding of the antibodies followed by reaction with biotinylated goat antirabbit immunoglobulin G and horseradish peroxidase-conjugated streptavidin (Histofine SAB-PO kit; Nichirei, Tokyo, Japan). The slides were dehydrated using an ethanol series (70%–95%) and xylene, after which they were covered with a coverslip using mounting medium. All slides were examined by both light and polarizing microscopy.\nHistological analysis showed that the eosinophilic material was positively stained, with Congo red showing apple-green birefringence under polarized light . The material was also positive when using the antilactoferrin antibody , with this area matching the Congo red-positive region. However, it should be noted that we found that Bowman’s layer was occasionally destroyed within the frozen section.\nTen months after the operation, the corrected visual acuity of the patient’s left eye was 20/20. Epilation of the cilia is performed regularly, and no recurrence of amyloid deposition has been found.", + "fulltext_subclaims": [ + "The patient is a 39-year-old female.", + "She had suffered from trichiasis for more than 30 years.", + "She complained of a foreign-body sensation.", + "She complained of epiphora.", + "The corrected visual acuity of her left eye was 20/30.", + "Slit-lamp examination revealed multiple milky-white soft masses on the corneal surface of her left eye.", + "A slight opacity was suspected in the anterior stroma under the slit-lamp examination.", + "This mass was classified as having a gelatinous drop-like dystrophy-like appearance.", + "These multiple masses were located at the cilia-attached region.", + "OCT revealed that there was a large mass under the thinned epithelial layer.", + "There was no destruction on Bowman’s layer throughout the region.", + "A little high density stromal cells were observed in the anterior stromal layer.", + "The fellow cornea exhibited a linear subepithelial opacity.", + "The opacity was not stained by fluorescein.", + "OCT revealed a high-density spot in Bowman’s layer.", + "This spot was coincident with the cilia-attached region.", + "The epithelial layer had normal thickness.", + "No change was observed in any other parts of the cornea in the fellow eye.", + "The corneal tissues were excised by lamellar keratoplasty.", + "The excised specimens were frozen in 30% sucrose.", + "3 μm sections were cut and then mounted on slides.", + "The slides were dried.", + "Samples were fixed with 10% formaldehyde.", + "The sections were incubated with 1% bovine serum albumin in phosphate-buffered saline at room temperature for 10 minutes each.", + "The samples were incubated with antilactoferrin antibody for 90 minutes at room temperature.", + "The sections were washed three times in phosphate-buffered saline for 10 minutes.", + "The binding of the antibodies was followed by reaction with biotinylated goat antirabbit immunoglobulin G and horseradish peroxidase-conjugated streptavidin.", + "The slides were dehydrated using an ethanol series (70%–95%) and xylene.", + "The slides were covered with a coverslip using mounting medium.", + "Histological analysis showed that the eosinophilic material was positively stained.", + "Congo red showed apple-green birefringence under polarized light.", + "The material was also positive when using the antilactoferrin antibody.", + "This area matched the Congo red-positive region.", + "Bowman’s layer was occasionally destroyed within the frozen section.", + "Ten months after the operation, the corrected visual acuity of the patient’s left eye was 20/20.", + "Epilation of the cilia is performed regularly.", + "No recurrence of amyloid deposition has been found." + ], + "summary": "A 39-year-old female had suffered from trichiasis in both of her eyes for more than 30 years. Slit-lamp examination showed a milky-white soft mass on her left cornea and a linear opacity on the fellow cornea at the cilia-attached region. OCT demonstrated the presence of a mass region within a thin epithelial layer and no destruction of Bowman's layer in her left cornea. In the fellow cornea, which exhibited a linear opacity, a high-density spot in Bowman's layer was observed at the cilia-attached region covered by the epithelial layer, with normal thickness. Histological examination of the excised cornea showed that the mass was positive with both Congo red and antilactoferrin antibody.", + "summary_subclaims": [ + "The patient is a 39-year-old female.", + "She had suffered from trichiasis in both of her eyes for more than 30 years.", + "Slit-lamp examination showed a milky-white soft mass on her left cornea.", + "Slit-lamp examination showed a linear opacity on the fellow cornea at the cilia-attached region.", + "OCT demonstrated the presence of a mass region within a thin epithelial layer in her left cornea.", + "OCT showed no destruction of Bowman's layer in her left cornea.", + "In the fellow cornea, a high-density spot in Bowman's layer was observed at the cilia-attached region.", + "The high-density spot in the fellow cornea was covered by the epithelial layer.", + "The thickness of the fellow cornea was normal.", + "Histological examination of the excised cornea showed that the mass was positive with Congo red.", + "Histological examination showed that the mass was positive with antilactoferrin antibody." + ] + }, + { + "id": "multiclinsum_test_2775_en.txt", + "fulltext": "Written informed consent was obtained from the parent of the patient who involved in this case.\nThe case was a 15-year-old boy, without any known prior illness. He was admitted to the hospital after feeling unwell and dropping to the ground while playing ball, and subsequently died. During the internal autopsy examination in our institution, a cystic structure, with dimensions of 13x6 cm, was observed in the left lobe of the liver. Hydatid cyst was not found in other organs of the body. In a macroscopic examination of the liver, a smooth-bordered cystic structure, with dimensions of 13x5x4.2 cm, was observed . On the sectional surface, a white membranous structure and haemorrhagic fluid were observed. The histomorphological examination of liver sections obtained from the cystic area revealed findings consistent with a hydatid cyst invading the external wall, the cuticular layer, and the germinal layer . In addition, the histomorphological examination of liver sections showed a fresh haemorrhage in areas near the cystic wall and scolices in the hepatic lumina , and the histomorphological examination of pulmonary sections showed scolices observed in pulmonary vessel lumina, thus a non-thrombosis hydatid embolism was diagnosed . No toxic agent was identified in a toxicological analysis. Based on the findings, the cause of death was recorded as a non-thrombotic hydatid embolism.", + "fulltext_subclaims": [ + "Written informed consent was obtained from the parent of the patient who involved in this case.", + "The case was a 15-year-old boy.", + "He was admitted to the hospital after feeling unwell and dropping to the ground while playing ball.", + "He subsequently died.", + "During the internal autopsy examination in our institution, a cystic structure, with dimensions of 13x6 cm, was observed in the left lobe of the liver.", + "Hydatid cyst was not found in other organs of the body.", + "In a macroscopic examination of the liver, a smooth-bordered cystic structure, with dimensions of 13x5x4.2 cm, was observed.", + "On the sectional surface, a white membranous structure and haemorrhagic fluid were observed.", + "The histomorphological examination of liver sections obtained from the cystic area revealed findings consistent with a hydatid cyst invading the external wall, the cuticular layer, and the germinal layer.", + "The histomorphological examination of liver sections showed a fresh haemorrhage in areas near the cystic wall and scolices in the hepatic lumina.", + "The histomorphological examination of pulmonary sections showed scolices observed in pulmonary vessel lumina, thus a non-thrombosis hydatid embolism was diagnosed.", + "No toxic agent was identified in a toxicological analysis.", + "Based on the findings, the cause of death was recorded as a non-thrombotic hydatid embolism." + ], + "summary": "We describe the fatal case of a 15-year-old boy without any known prior illness who was admitted to the hospital after feeling unwell and dropping to the ground while playing ball. During the autopsy, a lesional mass, with dimensions of 13x6 cm, was observed in the left lobe of the liver. The histomorphological examination of pulmonary sections showed scolices observed in pulmonary vessel lumina, thus a non-thrombosis hydatid embolism was diagnosed. Based on the findings, the cause of death was recorded as a non-thrombotic hydatid embolism.", + "summary_subclaims": [ + "The patient was a 15-year-old boy.", + "The patient had no known prior illness.", + "The patient was admitted to the hospital after feeling unwell and dropping to the ground while playing ball.", + "During the autopsy, a lesional mass with dimensions of 13x6 cm was observed in the left lobe of the liver.", + "The histomorphological examination of pulmonary sections showed scolices observed in pulmonary vessel lumina.", + "A non-thrombosis hydatid embolism was diagnosed.", + "The cause of death was recorded as a non-thrombotic hydatid embolism." + ] + }, + { + "id": "multiclinsum_test_1752_en.txt", + "fulltext": "A 9-week-old male infant presented multiple diffuse red skin lesions. These swellings gradually increased in number and size and were associated with subcutaneous harder blue lesions . Neurological examination revealed progressive macrocrania associated with irritability and vomiting. A total body angio-MR study showed multiple diffuse vascular lesions in the brain, spinal cord, bones, muscles, and viscera. Brain lesions were disseminated, involving both supra- and infratentorial regions, with intense and homogeneous contrast enhancement. The largest lesions were deep within the cerebral and cerebellar hemispheres, particularly the one located in the right lenticular nucleus, which showed acute hemorrhage with vasogenic edema, leading to compression of the mesencephalic aqueduct and resulting in triventricular hydrocephalus . An endoscopic ventriculocisternostomy (ETV) was performed on the same day. Surgical approach had included a transfontanellar access on the right, with navigation references to select the entry point and define the route for the 0° Gaab rigid endoscope. Fenestration was achieved between the mammillary bodies and the infundibulum of the pituitary gland using only a Fogarty balloon. During the procedure, we noted that the ventricular ependyma had a petechial appearance, but no significant hemorrhage occurred, and only minor bleeding was controlled with continuous irrigation. A post-operative MRI showed adequate flow signal through the stoma . A biopsy was performed during hospitalization to study some ulcerated and bleeding lesions, which revealed papillary endothelial hyperplasia with no pathognomonic features of a specific entity. Genetic mutations (EIF2AK4, ACVRL1, BMPR1B, BMPR2, CAV1, ENG, KCNK3, SMAD9, NOTCH3, and WES sequences) were investigated with no evidence found. Therapy was initiated with Prednisone (2 mg/kg/day) and Propranolol (1 mg/kg/day). However, due to further massive epistaxis requiring a blood transfusion and no improvement, the therapeutic scheme was modified to combine Prednisone and Vincristine. After 3 weeks of therapy with no improvement, Vincristine was replaced by Rapamycin (0.8 ml/day) with ethical committee consent. The therapy was effective, with no more bleeding observed, and the lesions gradually became smaller and clearer with some desquamative features. The patient was discharged, and therapy continued at home, with Rapamycin doses adjusted based on blood levels, while corticosteroids were gradually decreased. Follow-up over 5 years confirmed the absence of new lesions .", + "fulltext_subclaims": [ + "The patient was a 9-week-old male infant.", + "The infant had multiple diffuse red skin lesions.", + "The swellings gradually increased in number and size.", + "The swellings were associated with subcutaneous harder blue lesions.", + "Neurological examination revealed progressive macrocrania.", + "Neurological examination revealed irritability.", + "Neurological examination revealed vomiting.", + "A total body angio-MR study showed multiple diffuse vascular lesions in the brain.", + "A total body angio-MR study showed multiple diffuse vascular lesions in the spinal cord.", + "A total body angio-MR study showed multiple diffuse vascular lesions in the bones.", + "A total body angio-MR study showed multiple diffuse vascular lesions in the muscles.", + "A total body angio-MR study showed multiple diffuse vascular lesions in the viscera.", + "Brain lesions were disseminated, involving both supra- and infratentorial regions.", + "Brain lesions showed intense and homogeneous contrast enhancement.", + "The largest lesions were deep within the cerebral and cerebellar hemispheres.", + "The lesion located in the right lenticular nucleus showed acute hemorrhage.", + "The lesion located in the right lenticular nucleus showed vasogenic edema.", + "The lesion located in the right lenticular nucleus led to compression of the mesencephalic aqueduct.", + "The lesion located in the right lenticular nucleus resulted in triventricular hydrocephalus.", + "An endoscopic ventriculocisternostomy (ETV) was performed on the same day.", + "The surgical approach included a transfontanellar access on the right.", + "Navigation references were used to select the entry point.", + "Navigation references were used to define the route for the 0° Gaab rigid endoscope.", + "Fenestration was achieved between the mammillary bodies and the infundibulum of the pituitary gland.", + "Fenestration was achieved using only a Fogarty balloon.", + "The ventricular ependyma had a petechial appearance.", + "No significant hemorrhage occurred during the procedure.", + "Only minor bleeding was controlled with continuous irrigation.", + "A post-operative MRI showed adequate flow signal through the stoma.", + "A biopsy was performed during hospitalization.", + "The biopsy revealed papillary endothelial hyperplasia.", + "The biopsy revealed no pathognomonic features of a specific entity.", + "Genetic mutations were investigated.", + "No evidence of genetic mutations was found.", + "Therapy was initiated with Prednisone (2 mg/kg/day).", + "Therapy was initiated with Propranolol (1 mg/kg/day).", + "Due to further massive epistaxis requiring a blood transfusion, the therapeutic scheme was modified.", + "The therapeutic scheme was modified to combine Prednisone and Vincristine.", + "After 3 weeks of therapy with no improvement, Vincristine was replaced by Rapamycin (0.8 ml/day).", + "The therapy was effective, with no more bleeding observed.", + "The lesions gradually became smaller and clearer.", + "The lesions showed some desquamative features.", + "The patient was discharged.", + "Therapy continued at home.", + "Rapamycin doses were adjusted based on blood levels.", + "Corticosteroids were gradually decreased.", + "Follow-up over 5 years confirmed the absence of new lesions." + ], + "summary": "We present a case of DNH with intracranial hypertension and CNS hemorrhagic lesions on the mesencephalic aqueduct, resulting in triventricular hydrocephalus, treated with endoscopic ventriculocisternostomy (ETV) and medical therapy.", + "summary_subclaims": [ + "The case involves DNH.", + "The patient had intracranial hypertension.", + "The patient had CNS hemorrhagic lesions on the mesencephalic aqueduct.", + "The patient had triventricular hydrocephalus.", + "The patient was treated with endoscopic ventriculocisternostomy.", + "The patient received medical therapy." + ] + }, + { + "id": "multiclinsum_test_297_en.txt", + "fulltext": "A 21-year-old Sri Lankan male developed urticaria and difficulty in breathing one hour after ingestion of prawns, for which he was known to be allergic. He got admitted to the local hospital 2 h after the onset of symptoms. On admission to the local hospital he was dyspnoeic with a respiratory rate of 28/min and widespread rhonchi. His pulse rate was 94 beats per minute and the blood pressure was 100/70 mmHg. He was treated with intravenous hydrocortisone 200 mg, intravenous chlorpheniramine 10 mg and 0.5 ml of adrenaline (1:1000 solution) intramuscularly to the upper lateral side of the thigh (vastus lateralis). Ten minutes after the administration of adrenalin, he developed palpitations and tightening type central chest pain with autonomic symptoms. The pain lasted for about 30 min and resolved spontaneously. The first electrocardiogram (ECG), which was taken at the local hospital showed a sinus tachycardia and ST segment depressions in leads III, aVF and V1 to V5. He was not given any treatment for the chest pain in the local hospital and was transferred to our hospital about 2 h from the onset of the pain.\nOn admission to our hospital, he was not dyspnoeic and his pulse rate was 100 beats per minute and the blood pressure was 100/60 mmHg. His respiratory rate was 18/min and had a few rhonchi on auscultation. Rest of the examination was normal. The second ECG which was done in our hospital, 2 h after the 1st one, showed resolution of ST segment depressions but new T inversions in leads I and aVL . These T in versions persisted in subsequent ECGs . Troponin I done 6 h after the event was positive with a titer 2.15 ng/ml (<0.5). The test was repeated on the second day and it was still positive with a tire of 0.69 ng/ml. He was given sublingual glyceryl trinitrate 0.4 mg single dose after admission to our hospital. However antiplatelets and statins were not given and anticoagulation was not started as the most likely cause was assumed to be coronary vasospasm rather than plaque rupture.\nHe was previously healthy and did not have any risk factors for premature coronary vascular disease such as smoking. He has had a history urticaria to prawns but there was no previous history of anaphylaxis. He did not have asthma. There was no family history of diabetes, ischemic heart disease or premature deaths due to cardiovascular diseases. He worked as a computer operator trainee and was unmarried.\nFurther investigations which were done at our unit included transthoracic 2D echocardiogram which revealed an ejection fraction of 60% with no wall motion abnormalities. We did not proceed with a coronary angiogram as the patient was a young healthy adult and the cardiology team concluded that coronary artery vasospasm to be the likely cause for the myocardial ischaemia rather than atherosclerotic coronary artery disease. Subsequent stress ECG with treadmill was normal and CT coronary angiogram revealed normal coronary arteries . Complete blood count and renal functions were normal. Chest x ray was also normal. Fasting blood sugar was 98 mg/dl and the lipid profile was normal.\nPatient was asymptomatic during the hospital stay and was discharged after 2 days. At subsequent reviews he remained asymptomatic.", + "fulltext_subclaims": [ + "A 21-year-old Sri Lankan male developed urticaria and difficulty in breathing one hour after ingestion of prawns.", + "He was known to be allergic to prawns.", + "He was admitted to the local hospital 2 h after the onset of symptoms.", + "On admission to the local hospital, he was dyspnoeic with a respiratory rate of 28/min.", + "He had widespread rhonchi on admission to the local hospital.", + "He was treated with intravenous hydrocortisone 200 mg.", + "He was treated with intravenous chlorpheniramine 10 mg.", + "He received 0.5 ml of adrenaline (1:1000 solution) intramuscularly to the upper lateral side of the thigh.", + "Ten minutes after the administration of adrenaline, he developed palpitations and tightening type central chest pain.", + "The pain lasted for about 30 min and resolved spontaneously.", + "The first ECG showed a sinus tachycardia.", + "The first ECG showed ST segment depressions in leads III, aVF and V1 to V5.", + "He was not given any treatment for the chest pain in the local hospital.", + "He was transferred to our hospital about 2 h from the onset of the pain.", + "On admission to our hospital, he was not dyspnoeic.", + "The second ECG showed resolution of ST segment depressions.", + "The second ECG showed new T inversions in leads I and aVL.", + "These T inversions persisted in subsequent ECGs.", + "Troponin I done 6 h after the event was positive with a titer 2.15 ng/ml.", + "The test was repeated on the second day and it was still positive with a titer of 0.69 ng/ml.", + "He was given sublingual glyceryl trinitrate 0.4 mg single dose after admission to our hospital.", + "Antiplatelets and statins were not given.", + "Anticoagulation was not started.", + "The most likely cause was assumed to be coronary vasospasm rather than plaque rupture.", + "He was previously healthy.", + "He did not have any risk factors for premature coronary vascular disease.", + "He has had a history of urticaria to prawns.", + "There was no previous history of anaphylaxis.", + "There was no family history of diabetes, ischemic heart disease or premature deaths due to cardiovascular diseases.", + "A transthoracic 2D echocardiogram revealed an ejection fraction of 60%.", + "The echocardiogram showed no wall motion abnormalities.", + "We did not proceed with a coronary angiogram.", + "The cardiology team concluded that coronary artery vasospasm was the likely cause for the myocardial ischaemia.", + "Subsequent stress ECG with treadmill was normal.", + "CT coronary angiogram revealed normal coronary arteries.", + "Patient was asymptomatic during the hospital stay.", + "He was discharged after 2 days.", + "At subsequent reviews he remained asymptomatic." + ], + "summary": "A 21-year- old previously healthy male got admitted to the local hospital with an urticarial rash and difficulty in breathing, one hour after ingestion of prawns for which he was known to be allergic. He was treated with 0.5 ml of intramuscular adrenaline (1:1000) which was administered to the lateral side of the thigh, following which he developed palpitations and tightening type central chest pain. Electrocardiogram showed ST segment depressions in leads III, aVF and V1 to V5 and he was transferred to a tertiary care hospital. The second electrocardiogram, done 2 h later, showed resolution of ST segment depressions but new T inversions in leads I and aVL. Troponin I was elevated with a titer of 2.15 ng/ml. He was treated with sublingual GTN in the emergency treatment unit and the symptoms resolved. Transthoracic 2D echocardiogram and stress testing with treadmill was normal and CT coronary angiogram revealed normal coronary arteries.", + "summary_subclaims": [ + "The patient is a 21-year-old previously healthy male.", + "He was admitted to the local hospital with an urticarial rash and difficulty in breathing.", + "The symptoms occurred one hour after ingestion of prawns.", + "He was known to be allergic to prawns.", + "He was treated with 0.5 ml of intramuscular adrenaline (1:1000).", + "The adrenaline was administered to the lateral side of the thigh.", + "He developed palpitations after the adrenaline injection.", + "He experienced tightening type central chest pain.", + "Electrocardiogram showed ST segment depressions in leads III, aVF and V1 to V5.", + "He was transferred to a tertiary care hospital.", + "The second electrocardiogram, done 2 h later, showed resolution of ST segment depressions.", + "The second electrocardiogram showed new T inversions in leads I and aVL.", + "Troponin I was elevated with a titer of 2.15 ng/ml.", + "He was treated with sublingual GTN in the emergency treatment unit.", + "The symptoms resolved after sublingual GTN.", + "Transthoracic 2D echocardiogram was normal.", + "Stress testing with treadmill was normal.", + "CT coronary angiogram revealed normal coronary arteries." + ] + }, + { + "id": "multiclinsum_test_1991_en.txt", + "fulltext": "A 65-year-old Egyptian woman with a history of type 2 diabetes, hypertension, primary hypothyroidism, and class-III obesity presented acutely to the emergency room (ER) with an intractable headache and blurred vision. She had also recently experienced a worsening of her diabetes control despite being on a basal-bolus insulin regimen. She had no clear-cut cushingoid features apart from central obesity, and she had no family history of pituitary tumors or similar illness. She is a stay-at-home mother to four. Children are all a product of uneventful pregnancies and were delivered normally. She is married for 20 years to a physician. She never smoked or drank alcohol.\nComputed tomography (CT) brain imaging and subsequent magnetic resonance imaging (MRI) showed a sellar mass consisting of a pituitary macroadenoma that measured 2.9 × 1.5 cm invading the roof of the sphenoid sinuses and compressing the neurophysis and the optic chiasm . She has central obesity but did not appear cushingoid or acromegalic. Visual field examination revealed left homonymous hemianopia and right homonymous inferior quadrantanopia . Initial laboratory investigations revealed elevated corticotropin (ACTH) levels of 33.6 (1.03–10.7) pmol/L, mildly increased prolactin levels of 66.3 (5.18–26.53) ng/ml , normal IGF-1 levels of 17.29 (4.68–31.72) nmol/L, and normal GH levels of 0.72 (0.18–20.6) mIU/L. The remaining anterior pituitary hormone levels were as follows: FSH was 12.50 (4.5–21.5) IU/L, LH was 3.5 (9–19) pmol/L, TSH was 1.441 (2.6–5.7) mIU/L, and free T4 was 13.1 IU/L (9–23). Further investigations confirmed Cushing’s disease as follows: 24-hour urinary free cortisol was grossly elevated at 391 µg/24 hours (6–123), serum cortisol after the 1 mg dexamethasone suppression test was 783 nmol/l (normal < 50 nmol/l). Serum cortisol after the high-dose dexamethasone suppression test was 613 nmol/l (20% reduction from baseline). She underwent uneventful transsphenoidal surgery (TSS) for decompression of the optic chiasm, which was successful at normalizing her visual fields; however, residual tumor was still present on follow-up MRI after 3 months . Interestingly, histology of the resected tissue showed staining for ACTH , GH , and PRL , with a Ki-67 proliferation index of less than 2%. Postoperatively, she experienced symptom resolution with normalization of the visual fields . A follow-up evaluation 12 months postoperatively showed a normal response to the 1 mg dexamethasone suppression test; her cortisol levels were < 27.6 nmol/L, and 24-hour urinary free cortisol was also normal at 177 µg/24 hours (21–292). MRI pituitary performed 17 months postoperatively showed redemonstration of the residual enhancing lesion seen in the suprasellar region closely related to the pituitary stalk, which remained stable in size, measuring 12.5 × 11.5 mm. Her diabetes mellitus and hypertension also became controlled on fewer medications with ability to discontinue insulin therapy. She remained asymptomatic with no biochemical evidence of recurrence 17 months postoperatively, and there was no need for any treatment utilization.", + "fulltext_subclaims": [ + "The patient is a 65-year-old Egyptian woman.", + "She has a history of type 2 diabetes.", + "She has a history of hypertension.", + "She has a history of primary hypothyroidism.", + "She has class-III obesity.", + "She presented with an intractable headache.", + "She presented with blurred vision.", + "She had worsening diabetes control despite being on a basal-bolus insulin regimen.", + "She had no clear-cut cushingoid features.", + "She had central obesity.", + "She had no family history of pituitary tumors.", + "CT brain imaging showed a sellar mass.", + "MRI showed a pituitary macroadenoma measuring 2.9 × 1.5 cm.", + "The tumor invaded the roof of the sphenoid sinuses.", + "The tumor compressed the neurophysis.", + "The tumor compressed the optic chiasm.", + "Visual field examination revealed left homonymous hemianopia.", + "Visual field examination revealed right homonymous inferior quadrantanopia.", + "Initial laboratory investigations showed elevated ACTH levels of 33.6 pmol/L.", + "Initial laboratory investigations showed mildly increased prolactin levels of 66.3 ng/ml.", + "Initial laboratory investigations showed normal IGF-1 levels of 17.29 nmol/L.", + "Initial laboratory investigations showed normal GH levels of 0.72 mIU/L.", + "24-hour urinary free cortisol was 391 µg/24 hours.", + "Serum cortisol after the 1 mg dexamethasone suppression test was 783 nmol/l.", + "Serum cortisol after the high-dose dexamethasone suppression test was 613 nmol/l.", + "She underwent transsphenoidal surgery for decompression of the optic chiasm.", + "The surgery was successful at normalizing her visual fields.", + "Residual tumor was still present on follow-up MRI after 3 months.", + "Histology of the resected tissue showed staining for ACTH.", + "Histology of the resected tissue showed staining for GH.", + "Histology of the resected tissue showed staining for PRL.", + "The Ki-67 proliferation index was less than 2%.", + "Postoperatively, she experienced symptom resolution.", + "A follow-up evaluation 12 months postoperatively showed a normal response to the 1 mg dexamethasone suppression test.", + "Her cortisol levels were < 27.6 nmol/L 12 months postoperatively.", + "24-hour urinary free cortisol was 177 µg/24 hours 12 months postoperatively.", + "MRI pituitary performed 17 months postoperatively showed redemonstration of the residual enhancing lesion.", + "The residual lesion was in the suprasellar region.", + "The residual lesion was closely related to the pituitary stalk.", + "The residual lesion remained stable in size.", + "The residual lesion measured 12.5 × 11.5 mm.", + "Her diabetes mellitus became controlled on fewer medications.", + "She was able to discontinue insulin therapy.", + "She remained asymptomatic 17 months postoperatively.", + "There was no biochemical evidence of recurrence 17 months postoperatively.", + "There was no need for any treatment utilization." + ], + "summary": "Herein, we describe an unusual case of plurihormonal pituitary adenoma with triple-positive staining for adrenocorticotropic hormone, growth hormone, and prolactin. The patient is a 65-year-old Egyptian woman who presented with mass effect symptoms of the pituitary tumor, which primarily manifested as severe headache and visual field defects. She also presented with some cushingoid features, and further analysis confirmed Cushing's disease; slightly high prolactin and normal growth hormone levels were observed. She underwent transsphenoidal surgery and has been in remission thus far. Only a few cases have been reported in the literature, but none has exhibited silent acromegaly or mass effect symptoms as the initial presentation.", + "summary_subclaims": [ + "The case described is an unusual plurihormonal pituitary adenoma with triple-positive staining for adrenocorticotropic hormone, growth hormone, and prolactin.", + "The patient is a 65-year-old Egyptian woman.", + "The patient presented with mass effect symptoms of the pituitary tumor.", + "The mass effect symptoms primarily manifested as severe headache and visual field defects.", + "The patient presented with some cushingoid features.", + "Further analysis confirmed Cushing's disease.", + "Slightly high prolactin levels were observed.", + "Normal growth hormone levels were observed.", + "The patient underwent transsphenoidal surgery.", + "The patient has been in remission thus far.", + "Only a few cases of plurihormonal pituitary adenoma have been reported in the literature.", + "None of the previously reported cases exhibited silent acromegaly or mass effect symptoms as the initial presentation." + ] + }, + { + "id": "multiclinsum_test_3258_en.txt", + "fulltext": "In this case report, the patient gave informed consent to participate and to publish. A 59-year-old married female of Sundanese ethnicity who worked as a housewife. Upon admission to the high-care unit, a diagnosis of post-sympathectomy, namely Incessant Ventricular Tachycardia caused by Arrhythmogenic Cardiomyopathy dd IDCM (Ischemic Dilated Cardiomyopathy), and Chronic Heart Failure, NYHA FC II, was established. The patient had a history of palpitations for the last year and had been receiving tablet therapy at a local clinic, however the patient did not know the name of the medicine he was taking, according to him, he forgot and there were many kinds of medicine he was taking. Despite the intake of regular medication, the symptoms experienced remained persistent. In the two months preceding admission, the condition worsened, manifesting as increased palpitations, irregular heartbeats, shortness of breath, dizziness, and fainting. Consequently, the patient was referred to a specialized hospital and underwent sympathectomy with thoracic sympathetic nerve ablation (T1-T3) using Video Assisted Thoracoscopic Surgery (VATS).\n\nAccording to the patient, the symptoms experienced in the past two months were caused by emotional distress, characterized by sadness and anxiousness. This was because the eldest child of the patient, who was already married, went through a divorce and developed a mental disorder after the separation. The child’s erratic behavior, wandering around the neighbors’ houses and damaging properties, induced anxiousness, leading to increased palpitations. Examination showed a history of low blood pressure, but no history of hypertension or diabetes mellitus. Furthermore, in the family health history, there were no instances of heart disease or premature death due to heart attack.\n\nDuring the assessment on the first day after the surgery, there were complaints of shortness of breath, pain in the left chest where the operation was performed, and a general feeling of weakness. Observation showed a blood pressure of 98/61 mmHg, with 22 breath per minute respiratory rate (RR), 61 beats per minute heart rate (HR), 36.5°C temperature, 98% oxygen saturation (SPO2), and 106 mmHg mean arterial pressure (MAP). Furthermore, the pain level was rated as 2 on Numeric Rating Scale (NRS). The patient was conscious and alert, for neurological status using Glasgow Coma Scale (GCS) score of E = 4 M = 6 V = 5. The conjunctiva was not anemic, the sclera was not jaundiced, jugular venous pressure (JVP) was 5+2 cm, the shape and movement of the chest appeared symmetrical, heart sounds S1 and S2 were regular, with no S3 or S4 sounds, murmurs, rales, or wheezing. The abdomen was distended, with bowel sounds heard at 10 times per minute. Acral extremities were warm, capillary refill time (CRT) was less than 2 minutes, and there was no edema. The examination showed the presence of a wound on the chest with chest tube thoracostomy (CTT) measuring 5 cm × 2 cm. The fall risk assessment using the Morse scale showed a high-risk level.\n\nElectrocardiography (ECG) played a crucial role in the pre- and post-operative assessment. ECG showed a monomorphic Ventricular Tachycardia pattern before the procedure. After the operation, ECG showed sinus rhythm with a prolonged QTc (458ms). Chest X-ray before the operation showed cardiomegaly with no pulmonary congestion. Results before the procedure showed a dilated left ventricle (LV), eccentric left ventricular hypertrophy (LVH) with reduced LV systolic function (LVEF 33%), regional wall abnormalities, and regional right ventricular (RV) wall akinesia. LV diastolic dysfunction was classified as grade I, with normal anatomy and function of all valves. Furthermore, there was a low probability of ventricular hypertrophy (VH) and reduced RV systolic function with regional wall motion abnormalities, meeting the echo major criteria of PADUA score for arrhythmogenic cardiomyopathy. Angiography before the operation showed severely reduced LV systolic function (LVEF 27%). Laboratory results for ion calcium, magnesium, and troponin T before the surgery were within normal limits.\n\nThe patient received intravenous treatment with 0.9% NaCl fluid at a rate of 1500 cc per 24 hours, Paracetamol 1 × 1 gram, Omeprazole 2 × 1 gram, oral Cefixime antibiotics 2 × 200 mg, intravenous Vitamin K 3 × 10mg, intravenous Tranexamic Acid 3 × 500mg, and heart medication for arrhythmia, namely Bisoprolol tablet 1 × 2.5 mg (given when HR > 65 beats per minute), and Spironolactone tablet 1 × 25mg (given when mean arterial pressure is between 70 and 100 mmHg).\n\nIn terms of Nursing Diagnoses based on North American Nursing Diagnosis Association (NANDA), the priorities identified included 1). Decreased Cardiac Output related to changes in heart rhythm, 2). Impaired Gas Exchange related to an imbalance in ventilation-perfusion, and 3). Activity intolerance related to an imbalance between oxygen supply and demand.12\n\nThe selected nursing interventions based on NIC (Nursing Interventions Classification) and NOC (Nursing Outcomes Classification) for the first nursing problem, which was a decrease in cardiac output, emphasized cardiac care management and collaborative administration of medications, such as propranolol and spironolactone. This also comprised the evaluation of chest pain, monitoring fluid balance, changes in blood pressure, mean arterial pressure (MAP), and respiratory status, as well as assisting in reducing anxiety through deep breathing relaxation techniques. Vital sign management was also carried out including monitoring blood pressure, respiratory rate, heart rate, and temperature. The procedures also comprised recording blood pressure changes and monitoring heart sounds.\n\nFor the second nursing problem, which was the gas exchange issue, airway management was conducted. This included auscultating breath sounds, recording any additional sounds, and monitoring respiration, oxygen status, CTT hose as well as undulations, and fluid from CTT. The third nursing problem, namely patient activity intolerance, was managed through activity therapy. Continuous evaluation was carried out, and a follow-up was accomplished through a video call. The results showed that with planned nursing care, complications that often occurred after the surgery could be prevented. On the second day post-surgery, there was no complaint of shortness of breath and palpitations. This led to the removal of the chest tube and discharge. Mobilization and activities were performed gradually in this case. Upon discharge, the patient was able to stand and walk around the bed area, with enhanced adaptation to the pain. For the follow-up care evaluation with tele-nursing, a video call was conducted to provide guidance on maintaining activities according to the heart capacity. The patient was pleased to be contacted, had no shortness of breath complaints, and activities had started gradually.", + "fulltext_subclaims": [ + "The patient gave informed consent to participate and to publish.", + "The patient was a 59-year-old married female of Sundanese ethnicity.", + "The patient worked as a housewife.", + "Upon admission to the high-care unit, a diagnosis of post-sympathectomy was established.", + "The diagnosis included Incessant Ventricular Tachycardia caused by Arrhythmogenic Cardiomyopathy dd IDCM.", + "The diagnosis included Chronic Heart Failure, NYHA FC II.", + "The patient had a history of palpitations for the last year.", + "The patient had been receiving tablet therapy at a local clinic.", + "The patient did not know the name of the medicine he was taking.", + "The patient forgot the name of the medicine he was taking.", + "The patient said there were many kinds of medicine he was taking.", + "Despite the intake of regular medication, the symptoms experienced remained persistent.", + "In the two months preceding admission, the condition worsened.", + "The worsening condition manifested as increased palpitations.", + "The worsening condition manifested as irregular heartbeats.", + "The worsening condition manifested as shortness of breath.", + "The worsening condition manifested as dizziness.", + "The worsening condition manifested as fainting.", + "The patient was referred to a specialized hospital.", + "The patient underwent sympathectomy with thoracic sympathetic nerve ablation (T1-T3).", + "The sympathectomy was performed using Video Assisted Thoracoscopic Surgery (VATS).", + "The patient reported that the symptoms experienced in the past two months were caused by emotional distress.", + "The emotional distress was characterized by sadness and anxiousness.", + "The patient's eldest child went through a divorce.", + "The patient's eldest child developed a mental disorder after the separation.", + "The child’s erratic behavior included wandering around the neighbors’ houses.", + "The child’s erratic behavior included damaging properties.", + "The child’s behavior induced anxiousness in the patient.", + "The anxiousness led to increased palpitations.", + "Examination showed a history of low blood pressure.", + "There was no history of hypertension.", + "There was no history of diabetes mellitus.", + "There were no instances of heart disease in the family health history.", + "There were no instances of premature death due to heart attack in the family health history.", + "During the assessment on the first day after the surgery, there were complaints of shortness of breath.", + "During the assessment on the first day after the surgery, there was pain in the left chest where the operation was performed.", + "During the assessment on the first day after the surgery, there was a general feeling of weakness.", + "Observation showed a blood pressure of 98/61 mmHg.", + "Observation showed a respiratory rate of 22 breaths per minute.", + "Observation showed a heart rate of 61 beats per minute.", + "Observation showed a temperature of 36.5°C.", + "Observation showed oxygen saturation of 98%.", + "Observation showed mean arterial pressure of 106 mmHg.", + "The pain level was rated as 2 on Numeric Rating Scale (NRS).", + "The patient was conscious and alert.", + "The neurological status had a Glasgow Coma Scale (GCS) score of E = 4 M = 6 V = 5.", + "The conjunctiva was not anemic.", + "The sclera was not jaundiced.", + "Jugular venous pressure (JVP) was 5+2 cm.", + "The shape and movement of the chest appeared symmetrical.", + "Heart sounds S1 and S2 were regular.", + "There were no S3 or S4 sounds.", + "There were no murmurs.", + "There were no rales.", + "There were no wheezing.", + "The abdomen was distended.", + "Bowel sounds were heard at 10 times per minute.", + "Acral extremities were warm.", + "Capillary refill time (CRT) was less than 2 minutes.", + "There was no edema.", + "The examination showed the presence of a wound on the chest with chest tube thoracostomy (CTT) measuring 5 cm × 2 cm.", + "The fall risk assessment using the Morse scale showed a high-risk level.", + "Electrocardiography (ECG) played a crucial role in the pre- and post-operative assessment.", + "ECG showed a monomorphic Ventricular Tachycardia pattern before the procedure.", + "After the operation, ECG showed sinus rhythm with a prolonged QTc (458ms).", + "Chest X-ray before the operation showed cardiomegaly with no pulmonary congestion.", + "Results before the procedure showed a dilated left ventricle (LV).", + "Results before the procedure showed eccentric left ventricular hypertrophy (LVH) with reduced LV systolic function (LVEF 33%).", + "Results before the procedure showed regional wall abnormalities.", + "Results before the procedure showed regional right ventricular (RV) wall akinesia.", + "LV diastolic dysfunction was classified as grade I.", + "All valves had normal anatomy and function.", + "There was a low probability of ventricular hypertrophy (VH).", + "There was reduced RV systolic function with regional wall motion abnormalities.", + "The findings met the echo major criteria of PADUA score for arrhythmogenic cardiomyopathy.", + "Angiography before the operation showed severely reduced LV systolic function (LVEF 27%).", + "Laboratory results for ion calcium, magnesium, and troponin T before the surgery were within normal limits.", + "The patient received intravenous treatment with 0.9% NaCl fluid at a rate of 1500 cc per 24 hours.", + "The patient received Paracetamol 1 × 1 gram.", + "The patient received Omeprazole 2 × 1 gram.", + "The patient received oral Cefixime antibiotics 2 × 200 mg.", + "The patient received intravenous Vitamin K 3 × 10mg.", + "The patient received intravenous Tranexamic Acid 3 × 500mg.", + "The patient received Bisoprolol tablet 1 × 2.5 mg.", + "Bisoprolol was given when HR > 65 beats per minute.", + "The patient received Spironolactone tablet 1 × 25mg.", + "Spironolactone was given when mean arterial pressure is between 70 and 100 mmHg.", + "Nursing Diagnoses based on NANDA included Decreased Cardiac Output related to changes in heart rhythm.", + "Nursing Diagnoses based on NANDA included Impaired Gas Exchange related to an imbalance in ventilation-perfusion.", + "Nursing Diagnoses based on NANDA included Activity intolerance related to an imbalance between oxygen supply and demand.", + "The selected nursing interventions for the first nursing problem emphasized cardiac care management.", + "The selected nursing interventions included collaborative administration of medications, such as propranolol and spironolactone.", + "The selected nursing interventions included evaluation of chest pain.", + "The selected nursing interventions included monitoring fluid balance.", + "The selected nursing interventions included monitoring changes in blood pressure.", + "The selected nursing interventions included monitoring mean arterial pressure (MAP).", + "The selected nursing interventions included monitoring respiratory status.", + "The selected nursing interventions included assisting in reducing anxiety through deep breathing relaxation techniques.", + "Vital sign management included monitoring blood pressure.", + "Vital sign management included monitoring respiratory rate.", + "Vital sign management included monitoring heart rate.", + "Vital sign management included monitoring temperature.", + "The procedures included recording blood pressure changes.", + "The procedures included monitoring heart sounds.", + "For the second nursing problem, airway management was conducted.", + "Airway management included auscultating breath sounds.", + "Airway management included recording any additional sounds.", + "Airway management included monitoring respiration.", + "Airway management included monitoring oxygen status.", + "Airway management included monitoring CTT hose as well as undulations.", + "Airway management included monitoring fluid from CTT.", + "For the third nursing problem, activity therapy was conducted.", + "Continuous evaluation was carried out.", + "A follow-up was accomplished through a video call.", + "The results showed that with planned nursing care, complications that often occurred after the surgery could be prevented.", + "On the second day post-surgery, there was no complaint of shortness of breath.", + "On the second day post-surgery, there was no complaint of palpitations.", + "This led to the removal of the chest tube.", + "This led to discharge.", + "Mobilization and activities were performed gradually in this case.", + "Upon discharge, the patient was able to stand and walk around the bed area.", + "Upon discharge, the patient had enhanced adaptation to the pain.", + "For the follow-up care evaluation with tele-nursing, a video call was conducted.", + "The video call provided guidance on maintaining activities according to the heart capacity.", + "The patient was pleased to be contacted.", + "The patient had no shortness of breath complaints.", + "Activities had started gradually." + ], + "summary": "A 59-year-old female patient was admitted to the high-care unit with a diagnosis of post-sympathectomy, Incessant Ventricular Tachycardia due to Arrhythmogenic Cardiomyopathy. Nursing problems based on NANDA included decreased cardiac output, gas exchange impairment, and activity intolerance. Furthermore, the nursing interventions for the condition included self-care management and collaboration with an anesthesiologist and cardiologist. The interventions encompassed cardiac care, airway management, and activity therapy. Tele-nursing was also conducted through video calls to monitor the patient after hospital care.", + "summary_subclaims": [ + "The patient was a 59-year-old female.", + "The patient was admitted to the high-care unit.", + "The diagnosis was post-sympathectomy.", + "The diagnosis was Incessant Ventricular Tachycardia due to Arrhythmogenic Cardiomyopathy.", + "Nursing problems included decreased cardiac output.", + "Nursing problems included gas exchange impairment.", + "Nursing problems included activity intolerance.", + "Nursing interventions included self-care management.", + "Nursing interventions included collaboration with an anesthesiologist.", + "Nursing interventions included collaboration with a cardiologist.", + "Interventions encompassed cardiac care.", + "Interventions encompassed airway management.", + "Interventions encompassed activity therapy.", + "Tele-nursing was conducted through video calls.", + "Tele-nursing was used to monitor the patient after hospital care." + ] + }, + { + "id": "multiclinsum_test_1319_en.txt", + "fulltext": "A 28-year-old male was admitted to hospital with a one-month history of nausea, vomiting, the epigastric pain increased blood pressure and worsening of renal function with hypercalcemia. He was diagnosed in the outpatient setting as having gastroesophageal reflux disease with biliary regurgitation and, therefore, was given high doses of calcium containing antacids. A therapy with calcium antagonists was also initiated because of increased levels of blood pressure.\nUpon admission, he was well oriented, with slightly yellowish skin color, his blood pressure was 160/100 mmHg, his heart rate was 96/min. The rest of the physical examination was normal. He was a non-smoker and his past medical history was normal. The following initial analyzes have been performed:\nThe patient had severe hypercalcemia and anemia, renal insufficiency, metabolic alkalosis. Serum parathyroid hormone was almost undetectable. His lipids were normal, too and urine culture negative. All the available tumor markers were normal (CEA, AFP, CA 19-9, NSE, CYFRA 21-1, PSA, Ferritin). He was hepatitis B, C and HIV negative. Renal ultrasound was normal. Ultrasound of the parathyroid glands was normal. Computerized tomography of the abdomen showed normal findings. Bone biopsy showed osteoporosis and scattered zones with osteonecrosis. Renal biopsy showed tubulointerstitial lesions with calcium deposits in the interstitial tissue. Chest X-ray was also normal. Endoscopy of the upper gastrointestinal tract while hospitalized showed no pathologic changes. Beta-2 microglobulin, acid phosphatase, kappa and lambda light chains were normal. Coombs test and immunoelectrophoresis of proteins were negative. The calculated creatinine clearance at admission was 42 ml/min. The whole body Tc99m MDP bone scan was normal, as well as the parathyroid glands Tc99m MIBI scan. Cranial X-ray, as well as radiographs of hands and feet, was normal. He had mild metabolic alkalosis, and his ECG showed signs of hypercalcemia (shortened QT interval of 0.32 sec and abnormal ST morphology in V2, V3 and V4) .\nThe patient was hydrated with intravenous fluid, treated with bisphosphonates, corticosteroids and calcium antagonists for his elevated blood pressure. Antacids were stopped promptly after admission. He was also given vitamin B12 and folic acid upon the recommendation of a hematologist. The serum level of calcium decreased slowly to 2.6 mmol/l at the 43rd day after admission, and serum creatinine decreased to 154 μmol/l (calculated creatinine clearance 63.5 ml/min).\nAfter ruling out the differential diagnosis of multiple myelomas, other malignancies, primary hyperparathyroidism, hyperthyroidism or hypothyro-idism, it seemed plausible that the cause of hypercalcemia might be the ingestion of calcium containing antacids prescribed by his primary physician for his gastroesophageal reflux disease. He was discharged from hospital after 45 days of hospitalization.", + "fulltext_subclaims": [ + "The patient was a 28-year-old male.", + "He had a one-month history of nausea, vomiting, epigastric pain, increased blood pressure, worsening renal function, and hypercalcemia.", + "He was diagnosed in the outpatient setting as having gastroesophageal reflux disease with biliary regurgitation.", + "He was given high doses of calcium containing antacids.", + "A therapy with calcium antagonists was initiated because of increased levels of blood pressure.", + "Upon admission, his blood pressure was 160/100 mmHg.", + "The patient had severe hypercalcemia.", + "Serum parathyroid hormone was almost undetectable.", + "All the available tumor markers were normal.", + "He was hepatitis B, C and HIV negative.", + "Renal ultrasound was normal.", + "Ultrasound of the parathyroid glands was normal.", + "Computerized tomography of the abdomen showed normal findings.", + "Bone biopsy showed osteoporosis and scattered zones with osteonecrosis.", + "Renal biopsy showed tubulointerstitial lesions with calcium deposits in the interstitial tissue.", + "Chest X-ray was also normal.", + "Endoscopy of the upper gastrointestinal tract while hospitalized showed no pathologic changes.", + "Beta-2 microglobulin, acid phosphatase, kappa and lambda light chains were normal.", + "Coombs test and immunoelectrophoresis of proteins were negative.", + "The calculated creatinine clearance at admission was 42 ml/min.", + "The whole body Tc99m MDP bone scan was normal.", + "The parathyroid glands Tc99m MIBI scan was normal.", + "Cranial X-ray, as well as radiographs of hands and feet, was normal.", + "He had mild metabolic alkalosis.", + "His ECG showed signs of hypercalcemia (shortened QT interval of 0.32 sec and abnormal ST morphology in V2, V3 and V4).", + "The patient was hydrated with intravenous fluid.", + "He was treated with bisphosphonates.", + "He was treated with corticosteroids.", + "Antacids were stopped promptly after admission.", + "He was given vitamin B12 and folic acid.", + "The serum level of calcium decreased slowly to 2.6 mmol/l at the 43rd day after admission.", + "Serum creatinine decreased to 154 μmol/l.", + "The calculated creatinine clearance was 63.5 ml/min.", + "After ruling out the differential diagnosis of multiple myelomas, other malignancies, primary hyperparathyroidism, hyperthyroidism or hypothyroidism, it seemed plausible that the cause of hypercalcemia might be the ingestion of calcium containing antacids.", + "He was discharged from hospital after 45 days of hospitalization." + ], + "summary": "We present a 28-year old male admitted to hospital with a one-month history of nausea, vomiting, epigastric pain, increased blood pressure and worsening of renal function with hypercalcemia. His serum PTH level was almost undetectable; he had mild alkalosis, renal failure with eGFR of 42 ml/min, anemia, hypertension and abnormal ECG with shortened QT interval and ST elevation in V1-V4. He had a positive medical history for calcium-containing antacids intake and after ruling out primary hyperparathyroidism, malignancy, multiple myelomas, sarcoidosis, and thyroid dysfunction, it seemed plausible to diagnose him as having the milk-alkali syndrome.", + "summary_subclaims": [ + "The patient is a 28-year old male.", + "He was admitted to hospital.", + "He had a one-month history of nausea.", + "He had vomiting.", + "He had epigastric pain.", + "He had increased blood pressure.", + "He had worsening of renal function.", + "He had hypercalcemia.", + "His serum PTH level was almost undetectable.", + "He had mild alkalosis.", + "He had renal failure with eGFR of 42 ml/min.", + "He had anemia.", + "He had hypertension.", + "He had an abnormal ECG with shortened QT interval.", + "He had ST elevation in V1-V4.", + "He had a positive medical history for calcium-containing antacids intake.", + "Primary hyperparathyroidism was ruled out.", + "Malignancy was ruled out.", + "Multiple myelomas were ruled out.", + "Sarcoidosis was ruled out.", + "Thyroid dysfunction was ruled out.", + "It seemed plausible to diagnose him as having the milk-alkali syndrome." + ] + }, + { + "id": "multiclinsum_test_2849_en.txt", + "fulltext": "A 38-year-old woman received a tentative diagnosis of congenital cardiac disease in childhood. She is a farmer in Liaoning province (not high altitude) with no special lifestyles. She presented in our outpatient for further diagnosis. Physical examination revealed a loud murmur and cyanosis. Electrocardiogram demonstrated normal rhythm and right ventricular hypertrophy with right axis deviation. Echocardiographic study showed a severely dilated right ventricle, with a diameter of 39 mm; the left ventricle was relatively small, with a diameter of 33 mm. The arterial trunk was markedly enlarged (71–105 mm), with a type III APW measuring approximately 65 mm. A right pulmonary artery (RPA) originating from the posterior wall of the ascending aorta was also found, while the origin of the left pulmonary artery (LPA) was normal . The coronary arteries were normally positioned. Additionally, the patient had a type A IAA (distal to the left subclavian artery), an intact ventricular septum, and a large patent ductus arteriosus (PDA) with bidirectional shunts. The patient had severe pulmonary artery hypertension, approximately equal to the systemic blood pressure, and the left ventricular ejection fraction (LVEF) was nearly 53%. Computed tomography angiography with 3-dimensional reconstruction confirmed the large APW opening into the main and right pulmonary arteries, as well as type A IAA supplied by a large ductal artery . The patient refused to be hospitalized to further evaluate the possibility of surgery, and she was lost to follow-up. Although missing the opportunity to confirm above findings by surgery, a diagnose of Berry syndrome was made.", + "fulltext_subclaims": [ + "The patient is a 38-year-old woman.", + "She received a tentative diagnosis of congenital cardiac disease in childhood.", + "She is a farmer in Liaoning province.", + "She presented in our outpatient for further diagnosis.", + "Physical examination revealed a loud murmur.", + "Physical examination revealed cyanosis.", + "Electrocardiogram demonstrated right ventricular hypertrophy.", + "Electrocardiogram demonstrated right axis deviation.", + "Echocardiographic study showed a severely dilated right ventricle with a diameter of 39 mm.", + "The left ventricle was relatively small with a diameter of 33 mm.", + "The arterial trunk was markedly enlarged (71–105 mm).", + "A type III APW measuring approximately 65 mm was found.", + "A right pulmonary artery (RPA) originating from the posterior wall of the ascending aorta was found.", + "The origin of the left pulmonary artery (LPA) was normal.", + "The coronary arteries were normally positioned.", + "The patient had a type A IAA (distal to the left subclavian artery).", + "The ventricular septum was intact.", + "The patient had a large patent ductus arteriosus (PDA) with bidirectional shunts.", + "The patient had severe pulmonary artery hypertension, approximately equal to the systemic blood pressure.", + "The left ventricular ejection fraction (LVEF) was nearly 53%.", + "Computed tomography angiography with 3-dimensional reconstruction confirmed the large APW opening into the main and right pulmonary arteries.", + "Computed tomography angiography with 3-dimensional reconstruction confirmed type A IAA supplied by a large ductal artery.", + "The patient refused to be hospitalized to further evaluate the possibility of surgery.", + "The patient was lost to follow-up.", + "A diagnose of Berry syndrome was made." + ], + "summary": "A 38-year-old woman presented with a loud murmur and cyanosis. Transthoracic echocardiography demonstrated a severely dilated aorta and main pulmonary artery with a large intervening defect. Distal to the APW, the ascending aorta gave rise to the right pulmonary artery. Additionally, a type A IAA, an intact ventricular septum, and a large patent ductus arteriosus were revealed. Computed tomography angiography with 3-dimensional reconstruction confirmed above findings. This is the first report of a patient of this age with Berry syndrome who did not undergo surgery.", + "summary_subclaims": [ + "The patient is a 38-year-old woman.", + "She presented with a loud murmur.", + "She presented with cyanosis.", + "Transthoracic echocardiography demonstrated a severely dilated aorta.", + "Transthoracic echocardiography demonstrated a severely dilated main pulmonary artery.", + "Transthoracic echocardiography demonstrated a large intervening defect.", + "Distal to the APW, the ascending aorta gave rise to the right pulmonary artery.", + "A type A IAA was revealed.", + "An intact ventricular septum was revealed.", + "A large patent ductus arteriosus was revealed.", + "Computed tomography angiography with 3-dimensional reconstruction confirmed the above findings.", + "This is the first report of a patient of this age with Berry syndrome.", + "The patient did not undergo surgery." + ] + }, + { + "id": "multiclinsum_test_598_en.txt", + "fulltext": "The proband was an 18-year-old female who was hospitalized with abnormal behavior for 3 d beginning October 19, 2021.\nThree days before she visited the local psychiatric hospital, she suddenly refused to eat, accompanied by glazed eyes and with no definitive causes.\nShe was born by cesarean section at the 33rd week of her mother’s second pregnancy. Her weight was 3.8 kg [+1 standard deviation (SD)], and her height was 48 cm (-1 SD) at birth. Fontanel closure was delayed until she was 5 years old. During her childhood, she was always shorter than other children of the same age, but her body weight was overweight. She had occasional muscle tetany and limb numbness. Her studying ability in school was slightly poorer than that of her classmates. Menarche started at the age of 13 years, followed by irregular periods (cycle of 28-90 d).\nHer parents were not consanguineous and were in good health. The growth and development of her two sisters were normal, and there was no family history of hereditary diseases.\nThe patient’s blood pressure was 104/78 mmHg; her height was 132 cm (-5 SD), weight was 40 kg (-2 SD), waist circumference was 80 cm, and head circumference was 48 cm; and some peculiar clinical characteristics were observed, including cheek freckles, high anterior hairline, sparse scalp hair, prominent forehead, depressed nasal bridge, low-set ears, partially absent dentition, small mandible, slightly higher mandibular arch, increased quilt hair, stubby limbs, small hands and feet and short bilateral 4th toes . She had no cubitus valgus, no nail thickening or roughness and no scoliosis. Gynecological examination showed breast development at Tanner stage 4 and pubic hair at Tanner stage 4. Her Mini-Mental State Examination (MMSE) score was 28 points after her symptoms improved.\nThe patient had low calcium, low potassium, low magnesium, and high phosphorus levels. Her serum aspartate aminotransferase (AST) level was 94 U/L (reference range: 0 to 40), and her serum alanine transaminase (ALT) level was 70 U/L (reference range: 7 to 40). Serum potassium was 2.57 mmol/L (reference range: 3.5 to 5.3), chlorine was 96.4 mmol/L (reference range: 99.0 to 110.0), corrected calcium level was 1.06 mmol/L (reference range: 2.11 to 2.52), magnesium was 0.45 mmol/L (reference range: 0.75-1.02), and phosphorus was 1.86 mmol/L (reference range: 0.85 to 1.51). Details of laboratory findings are listed in Table . Therefore, she was referred to our hospital for further diagnosis and treatment.\nOphthalmological examination revealed hyperopia. Visual acuity was 0.15 in the left eye and 0.8 in the right eye. No evidence of cataract or papilledema was observed. Her hearing test results were normal. Cranial computed tomography showed sporadic symmetrical calcifications in the cerebellar hemisphere, frontotemporal parietal lobe, basal ganglia, and thalamus. Thyroid ultrasonography showed a cystic-solid mixed nodule measuring approximately 2.3 mm × 1.2 mm in the right lobe, with a Thyroid Imaging Reporting and Data System grade of 2. X-rays of the left knee, anteroposterior pelvis, left hand, and both feet showed a smaller right ilium compared to the contralateral side, shallow acetabular fossa on both sides, and no obvious abnormalities in the bone structure of the remaining pelvis or the structures of the sacroiliac and hip joints on either side . No abnormal density was observed in the pelvis. The phalanges of the left little finger were short, with thickening of the cortex of the tubular bone and narrowing of the medulla. The 4th and 5th metatarsal bones and the corresponding phalanges of both feet were short and small. Ultrasonography of the pelvic cavity showed an anteverted uterus measuring approximately 2.7 cm × 1.9 cm × 3.0 cm. Uniform endometrial echogenicity was observed with no obvious tumor-like structures. The endometrial thickness was approximately 0.4 cm. The bilateral ovaries were normal in size, with no obvious space-occupying lesions in the bilateral adnexal areas.", + "fulltext_subclaims": [ + "The proband was an 18-year-old female who was hospitalized with abnormal behavior for 3 d beginning October 19, 2021.", + "Three days before she visited the local psychiatric hospital, she suddenly refused to eat, accompanied by glazed eyes and with no definitive causes.", + "She was born by cesarean section at the 33rd week of her mother’s second pregnancy.", + "Her weight at birth was 3.8 kg [+1 standard deviation (SD)].", + "Her height at birth was 48 cm (-1 SD).", + "Fontanel closure was delayed until she was 5 years old.", + "During her childhood, she was always shorter than other children of the same age.", + "Her body weight was overweight.", + "She had occasional muscle tetany and limb numbness.", + "Her studying ability in school was slightly poorer than that of her classmates.", + "Menarche started at the age of 13 years.", + "Her periods were irregular with a cycle of 28-90 d.", + "Her parents were not consanguineous.", + "The growth and development of her two sisters were normal.", + "There was no family history of hereditary diseases.", + "Her height was 132 cm (-5 SD).", + "Her weight was 40 kg (-2 SD).", + "Her waist circumference was 80 cm.", + "Her head circumference was 48 cm.", + "She had cheek freckles.", + "She had a high anterior hairline.", + "She had sparse scalp hair.", + "She had a prominent forehead.", + "She had a depressed nasal bridge.", + "She had low-set ears.", + "She had partially absent dentition.", + "She had a small mandible.", + "She had a slightly higher mandibular arch.", + "She had increased quilt hair.", + "She had stubby limbs.", + "She had small hands and feet.", + "She had short bilateral 4th toes.", + "She had no cubitus valgus.", + "She had no nail thickening or roughness.", + "She had no scoliosis.", + "Gynecological examination showed breast development at Tanner stage 4.", + "Gynecological examination showed pubic hair at Tanner stage 4.", + "Her Mini-Mental State Examination (MMSE) score was 28 points after her symptoms improved.", + "She had low calcium levels.", + "She had low potassium levels.", + "She had low magnesium levels.", + "She had high phosphorus levels.", + "Her serum aspartate aminotransferase (AST) level was 94 U/L.", + "The reference range for AST was 0 to 40 U/L.", + "Her serum alanine transaminase (ALT) level was 70 U/L.", + "The reference range for ALT was 7 to 40 U/L.", + "Her serum potassium was 2.57 mmol/L.", + "The reference range for potassium was 3.5 to 5.3 mmol/L.", + "Her corrected calcium level was 1.06 mmol/L.", + "The reference range for calcium was 2.11 to 2.52 mmol/L.", + "Her magnesium level was 0.45 mmol/L.", + "The reference range for magnesium was 0.75 to 1.02 mmol/L.", + "Her phosphorus level was 1.86 mmol/L.", + "The reference range for phosphorus was 0.85 to 1.51 mmol/L.", + "Ophthalmological examination revealed hyperopia.", + "Visual acuity was 0.15 in the left eye.", + "Visual acuity was 0.8 in the right eye.", + "No evidence of cataract or papilledema was observed.", + "Her hearing test results were normal.", + "Cranial computed tomography showed sporadic symmetrical calcifications in the cerebellar hemisphere.", + "Cranial computed tomography showed sporadic symmetrical calcifications in the frontotemporal parietal lobe.", + "Cranial computed tomography showed sporadic symmetrical calcifications in the basal ganglia.", + "Cranial computed tomography showed sporadic symmetrical calcifications in the thalamus.", + "Thyroid ultrasonography showed a cystic-solid mixed nodule measuring approximately 2.3 mm × 1.2 mm in the right lobe.", + "The Thyroid Imaging Reporting and Data System grade was 2.", + "X-rays of the left knee showed a smaller right ilium compared to the contralateral side.", + "X-rays showed shallow acetabular fossa on both sides.", + "No obvious abnormalities in the bone structure of the remaining pelvis were observed.", + "No obvious abnormalities in the structures of the sacroiliac and hip joints on either side were observed.", + "The phalanges of the left little finger were short.", + "The cortex of the tubular bone of the left little finger was thickened.", + "The medulla of the left little finger was narrowed.", + "The 4th and 5th metatarsal bones and the corresponding phalanges of both feet were short and small.", + "Ultrasonography of the pelvic cavity showed an anteverted uterus measuring approximately 2.7 cm × 1.9 cm × 3.0 cm.", + "Uniform endometrial echogenicity was observed with no obvious tumor-like structures.", + "The endometrial thickness was approximately 0.4 cm.", + "The bilateral ovaries were normal in size.", + "No obvious space-occupying lesions in the bilateral adnexal areas were observed." + ], + "summary": "An 18-year-old female visited our clinic because of short stature and facial deformities, including typical phenotypes, such as low ear position, depression of the nasal bridge, small hands and feet, and loss of dentition. The lab results suggested normal parathyroid hormone but hypocalcemia. In addition, multiple electrolyte disturbances were found, including hypokalemia, hypocalcemia and hypomagnesemia. The physical signs showed a short fourth metatarsal bone of both feet. The X-ray images showed cortical thickening of long bones and narrowing of the medulla of the lumen. Cranial computed tomography indicated calcification in the bilateral basal ganglia. Finally, the genetic investigation showed a de novo heterogenous mutation of \"FAM111A\" (c. G1706A:p.R569H). Through a review of previously reported cases, the mutation was found to be the most common mutation site in Kenny-Caffey syndrome type 2 (KCS2) cases reported thus far (16/23, 69.6%). The mutation was slightly more prevalent in females than in males (11/16, 68.8%). Except for hypocalcemia, other clinical manifestations are heterogeneous.", + "summary_subclaims": [ + "The patient is an 18-year-old female.", + "The patient visited the clinic because of short stature and facial deformities.", + "The facial deformities included low ear position.", + "The facial deformities included depression of the nasal bridge.", + "The facial deformities included small hands and feet.", + "The facial deformities included loss of dentition.", + "The lab results suggested normal parathyroid hormone.", + "The lab results suggested hypocalcemia.", + "Multiple electrolyte disturbances were found.", + "The electrolyte disturbances included hypokalemia.", + "The electrolyte disturbances included hypocalcemia.", + "The electrolyte disturbances included hypomagnesemia.", + "The physical signs showed a short fourth metatarsal bone of both feet.", + "The X-ray images showed cortical thickening of long bones.", + "The X-ray images showed narrowing of the medulla of the lumen.", + "Cranial computed tomography indicated calcification in the bilateral basal ganglia.", + "The genetic investigation showed a de novo heterogenous mutation of 'FAM111A' (c. G1706A:p.R569H).", + "The mutation was found to be the most common mutation site in Kenny-Caffey syndrome type 2 (KCS2) cases reported thus far (16/23, 69.6%).", + "The mutation was slightly more prevalent in females than in males (11/16, 68.8%).", + "Except for hypocalcemia, other clinical manifestations are heterogeneous." + ] + }, + { + "id": "multiclinsum_test_430_en.txt", + "fulltext": "A previously healthy 12-year-old boy was admitted to the hospital with vision loss, headache and dizziness over 1 month, which was aggravated in the last 5 days. Magnetic resonance imaging (MRI) of the head revealed a large (19.8 mm*18.5 mm*23.5 mm) irregular mass located in the suprasellar region abutting the left aspect of the optic chiasm. It appeared isointense on T1-weighted imaging (T1WI) and homogenously hyperintense on T2-weighted imaging (T2WI). After gadolinium administration, a well-circumscribed enhancing lesion was observed . A small cerebellar lesion was also confirmed.\nThe mother of the patient underwent surgery for HGB in the CNS (spine, cerebellum) and had pheochromocytomas and pancreatic cysts. On the basis of the mother’s medical history, clinical manifestations and imaging examinations, she was diagnosed with VHL disease, although she refused genetic sequencing. Therefore, the patient was examined for VHL disease before surgery. Sequencing of exon 1 of the VHL gene revealed a c.257C>T mutation (amino acid p.P86L). Ophthalmological examination revealed that the boundary of the optic disc in the left eye was pale and that there were no abnormalities in the right eye. Abdominal computed tomography (CT) was also performed to identify associated lesions and pancreatic cysts . Based on these findings, the patient was definitely diagnosed with VHL syndrome.\nHe underwent surgery to remove the tumor from the suprasellar region at our neurosurgical department, and histology confirmed the diagnosis of HGB ( and ). The cerebellar lesion was not in the same surgical field as the suprasellar tumor and had no obvious mass effect, so they were not treated at the same time. Immunohistochemical analysis indicated that the Ki-67 index was approximately 2%. Furthermore, the neoplasm was positive for EGFR, NSE, CD34 and vimentin and negative for CK-pan, Pax-8, CD10, CD56, S-100, glial fibrillary acidic protein, inhibin, SSTR2, and epithelial membrane antigen .\nThe patient was transferred to the neurosurgery intensive care unit for postoperative monitoring and was ambulatory on postoperative day 1. Postoperative MRI demonstrated that the lesion in the suprasellar region was completely removed. He was discharged on postoperative day 7, and regular follow-up was performed. Unfortunately, the patient lost vision completely in the left eye after surgery.", + "fulltext_subclaims": [ + "The patient was a previously healthy 12-year-old boy.", + "He was admitted to the hospital with vision loss, headache and dizziness over 1 month.", + "The symptoms were aggravated in the last 5 days.", + "MRI of the head revealed a large (19.8 mm*18.5 mm*23.5 mm) irregular mass located in the suprasellar region.", + "The mass abutted the left aspect of the optic chiasm.", + "The mass appeared isointense on T1-weighted imaging.", + "The mass was homogenously hyperintense on T2-weighted imaging.", + "After gadolinium administration, a well-circumscribed enhancing lesion was observed.", + "A small cerebellar lesion was also confirmed.", + "The mother of the patient underwent surgery for HGB in the CNS (spine, cerebellum).", + "The mother had pheochromocytomas and pancreatic cysts.", + "The patient was examined for VHL disease before surgery.", + "Sequencing of exon 1 of the VHL gene revealed a c.257C>T mutation (amino acid p.P86L).", + "Ophthalmological examination revealed that the boundary of the optic disc in the left eye was pale.", + "There were no abnormalities in the right eye.", + "Abdominal CT was also performed to identify associated lesions and pancreatic cysts.", + "Based on these findings, the patient was definitely diagnosed with VHL syndrome.", + "He underwent surgery to remove the tumor from the suprasellar region.", + "Histology confirmed the diagnosis of HGB.", + "The cerebellar lesion was not in the same surgical field as the suprasellar tumor.", + "The cerebellar lesion had no obvious mass effect.", + "The cerebellar lesion was not treated at the same time.", + "Immunohistochemical analysis indicated that the Ki-67 index was approximately 2%.", + "The neoplasm was positive for EGFR, NSE, CD34 and vimentin.", + "The neoplasm was negative for CK-pan, Pax-8, CD10, CD56, S-100, glial fibrillary acidic protein, inhibin, SSTR2, and epithelial membrane antigen.", + "The patient was transferred to the neurosurgery intensive care unit for postoperative monitoring.", + "The patient was ambulatory on postoperative day 1.", + "Postoperative MRI demonstrated that the lesion in the suprasellar region was completely removed.", + "The patient was discharged on postoperative day 7.", + "The patient lost vision completely in the left eye after surgery." + ], + "summary": "A 12-year-old boy presented with vision loss, headache and dizziness at our hospital. Magnetic resonance imaging (MRI) revealed a large (19.8 mm*18.5 mm*23.5 mm) irregular mass located in the suprasellar region. The mass was successfully removed after craniotomy and microsurgical treatment. The pathological diagnosis was left optic nerve HGB. Genetic analyses showed p.Pro86Leu (c. 257C>T) heterozygous missense mutations in the VHL gene.", + "summary_subclaims": [ + "A 12-year-old boy presented with vision loss, headache and dizziness at our hospital.", + "Magnetic resonance imaging (MRI) revealed a large (19.8 mm*18.5 mm*23.5 mm) irregular mass located in the suprasellar region.", + "The mass was successfully removed after craniotomy and microsurgical treatment.", + "The pathological diagnosis was left optic nerve HGB.", + "Genetic analyses showed p.Pro86Leu (c. 257C>T) heterozygous missense mutations in the VHL gene." + ] + }, + { + "id": "multiclinsum_test_3342_en.txt", + "fulltext": "14-year-old female patient with CF of severe phenotype, heterozygous for the PheF508del mutation (Phe508del/1078delT, variants of classes II and I respectively), with pulmonary compromise and pancreatic insufficiency. She was diagnosed at 3 months of age, by the association of respiratory symptoms, persistent diarrhea and poor weight gain, by the electrolyte test in sweat, with a chloride of 88 meq/l (normal value < 30 meq/l). The pancreatic failure led to chronic malnutrition very early, so at 7 months of age a gastrostomy was installed that has been maintained until today.\n\nShe presented with numerous endobronchial infections requiring oral and intravenous antibiotic treatment, and was hospitalised 15 times for periods of 2 weeks to 85 days. Most of these infections were due to multi-resistant Staphylococcus aureus, which became chronic, and intermittent Pseudomonas aeruginosa, which was found twice.\n\nAt 12 years of age, a glucose tolerance test confirmed the diagnosis of CF-related diabetes mellitus as a complication of her pancreatic damage.\n\nHis respiratory treatment consisted of respiratory kinesiotherapy three times a day, preceded by nebulization of a-dornase once a day and 7% hypertonic NaCl solution twice a day. The nutritional and digestive treatment included pancreatic enzymes (Zenpep®) before each feeding, vitamins A, D, E, K, lansoprazole, hyper-caloric feeding by mouth and gastrostomy. The radiological bone density measured by densitometry was within the low normal range and diabetes was maintained with ultra-rapid insulin treatment.\n\nPulmonary damage was moderate to severe, manifested in pulmonary function with FEV1 at 66% of predicted, and thoracic axial tomography that showed diffuse, cylindrical and saccular bronchiectasis in all pulmonary segments, fibrosis and diffuse mucous impaction. The pulmonary impairment intensified, the patient presented persistent bronchorrhea and progressive fall of FEV1. Therefore, bronchoalveolar lavage (BAL) was performed at the level of the LSD, whose culture only showed Staphylococcus aureus multisensible, endobronchial infection by other bacterial agents was discarded, as well as non-tuberculous bacilli and fungi. Despite the management with antibiotics, kinesiological support, adequate nutrition, good control of diabetes, α-dornase and hypertonic serum, pulmonary function did not improve.\n\nThe patient’s parents opted to initiate treatment with CFTR modulators. Advised by our multidisciplinary team, the parents purchased tri-associated therapy with the ETI combination (Trikafta®) from the United States, which they initiated without discontinuing their background treatment. The drug was administered in two daily doses, one morning dose of 2 fixed-dose tablets of Elexacaftor 100 milligrams, Tezacaftor 50 milligrams, and Ivacaftor 75 milligrams, and another evening dose twelve hours later of 1 tablet of Ivacaftor 150 milligrams. The tablets were administered with a high-fat diet and pancreatic enzymes to maximize their efficacy.\n\nThe response to the ETI tritherapy was decided to be monitored by measuring the quality of life, pulmonary function and nutritional status. This was done in five clinical evaluations: the day of the start of the therapy, which we called day 0 or baseline, then 45, 90, 180 and 365 days from the start of the therapy. The evaluations were performed with informed consent from the parents and the agreement of the patient.\n\nThe Cystic Fibrosis Questionnaire Revised (CFQ-R 14+) was administered in Spanish in a self-administered, validated, paper version for adolescents over 14 years of age and adults.13 The survey was completed by the patient in all five assessments without problems and took approximately 15 minutes per assessment.\n\n\nPulmonary function was measured by spirometry using a Vyaire Vyntus v-176430 spirometer in accordance with international standards. In spirometry, forced vital capacity in liters and percent predicted (CVF L, CVF%), forced expiratory volume in one second in liters and percent predicted (VEF1 L, VEF1%), and flow between 25% and 75% of CVF in liters and percent predicted (FEF25-75 L, FEF 25%-75%) were measured using Quanjer's multi-ethnic predictive values. The patient was able to perform baseline spirometry without difficulty in all five assessments. The three pulmonary function parameters tested showed percent improvements from predicted values from the second visit. The evolution of CVF% was 74% (baseline), 95% (45 days), 95% (90 days), 94% (180 days) and 96% (365 days). The evolution of VEF1% was 69% (baseline), 89% (45 days), 96% (90 days), 95% (180 days) and 96% (365 days). The evolution of FEF 25%-75% was 53% (baseline), 76% (45 days), 90% (90 days), 80 (180 days) and 90% (365 days).\n\nThe patient was weighed and measured on a digital scale with a measuring rod, SECA model 769. The nutritional status was calculated by measuring the percentile of BMI (pBMI) in each evaluation, according to the WHO curves. From the initial evaluation to the completion of the 12-month follow-up, the patient gained 1.8 kg and increased her pBMI by 2.8.\n\nDuring the follow-up period, the patient did not have exacerbations, nor did she require hospitalization or unscheduled medical consultations. She continued with her usual therapy plus the ETI tritherapy for 12 months. Adherence to the treatment was adequate and no adverse effects related to the tritherapy were detected. For this, the liver function was monitored periodically and remained normal and abdominal ultrasound was performed to rule out liver involvement. During the follow-up period, no dermatological manifestations or symptoms suggestive of visual alterations were found, which was also corroborated with an ophthalmological evaluation before starting the tritherapy and once the follow-up was completed.\n", + "fulltext_subclaims": [ + "The patient is a 14-year-old female with cystic fibrosis of severe phenotype.", + "She is heterozygous for the Phe508del mutation (Phe508del/1078delT).", + "The Phe508del mutation is classified as variant class II.", + "The 1078delT mutation is classified as variant class I.", + "She has pulmonary compromise.", + "She has pancreatic insufficiency.", + "She was diagnosed at 3 months of age.", + "The diagnosis was based on the association of respiratory symptoms, persistent diarrhea, and poor weight gain.", + "The diagnosis was confirmed by the sweat electrolyte test, with a chloride level of 88 meq/l.", + "The normal chloride level is less than 30 meq/l.", + "Chronic malnutrition developed at 7 months of age.", + "A gastrostomy was installed at 7 months of age.", + "The gastrostomy has been maintained until today.", + "She has had numerous endobronchial infections.", + "She has been hospitalized 15 times.", + "Most of the infections were due to multi-resistant Staphylococcus aureus.", + "Intermittent Pseudomonas aeruginosa was found twice.", + "At 12 years of age, a glucose tolerance test confirmed the diagnosis of CF-related diabetes mellitus.", + "The diabetes was a complication of her pancreatic damage.", + "Her respiratory treatment included respiratory kinesiotherapy three times a day.", + "Her respiratory treatment included nebulization of a-dornase once a day.", + "Her respiratory treatment included 7% hypertonic NaCl solution twice a day.", + "Her nutritional and digestive treatment included pancreatic enzymes before each feeding.", + "Her nutritional and digestive treatment included vitamins A, D, E, and K.", + "Her nutritional and digestive treatment included lansoprazole.", + "Her nutritional and digestive treatment included hyper-caloric feeding by mouth and gastrostomy.", + "The radiological bone density measured by densitometry was within the low normal range.", + "Diabetes was managed with ultra-rapid insulin treatment.", + "Pulmonary damage was moderate to severe.", + "Pulmonary function testing showed FEV1 at 66% of predicted.", + "Thoracic axial tomography showed diffuse, cylindrical and saccular bronchiectasis in all pulmonary segments.", + "Thoracic axial tomography showed fibrosis.", + "Thoracic axial tomography showed diffuse mucous impaction.", + "The patient presented persistent bronchorrhea.", + "The patient had a progressive fall of FEV1.", + "Bronchoalveolar lavage was performed at the level of the LSD.", + "The bronchoalveolar lavage culture showed Staphylococcus aureus multisensible.", + "Endobronchial infection by other bacterial agents was discarded.", + "Non-tuberculous bacilli were discarded.", + "Fungi were discarded.", + "Pulmonary function did not improve despite management with antibiotics, kinesiological support, adequate nutrition, good control of diabetes, α-dornase, and hypertonic serum.", + "The patient’s parents opted to initiate treatment with CFTR modulators.", + "The parents purchased tri-associated therapy with the ETI combination (Trikafta®) from the United States.", + "The ETI combination was initiated without discontinuing background treatment.", + "The drug was administered in two daily doses.", + "The morning dose consisted of two fixed-dose tablets of Elexacaftor 100 milligrams, Tezacaftor 50 milligrams, and Ivacaftor 75 milligrams.", + "The evening dose consisted of one tablet of Ivacaftor 150 milligrams.", + "The tablets were administered with a high-fat diet.", + "The tablets were administered with pancreatic enzymes.", + "The response to the ETI tritherapy was monitored by measuring quality of life, pulmonary function, and nutritional status.", + "Monitoring was done in five clinical evaluations.", + "The evaluations were performed on day 0, 45 days, 90 days, 180 days, and 365 days from the start of the therapy.", + "The Cystic Fibrosis Questionnaire Revised (CFQ-R 14+) was administered in Spanish.", + "The CFQ-R 14+ was administered in a self-administered, validated, paper version.", + "The survey was completed by the patient in all five assessments.", + "Pulmonary function was measured by spirometry using a Vyaire Vyntus v-176430 spirometer.", + "The three pulmonary function parameters tested showed percent improvements from predicted values from the second visit.", + "The evolution of CVF% was 74% (baseline), 95% (45 days), 95% (90 days), 94% (180 days), and 96% (365 days).", + "The evolution of VEF1% was 69% (baseline), 89% (45 days), 96% (90 days), 95% (180 days), and 96% (365 days).", + "The evolution of FEF 25%-75% was 53% (baseline), 76% (45 days), 90% (90 days), 80% (180 days), and 90% (365 days).", + "The patient was weighed and measured on a digital scale with a measuring rod, SECA model 769.", + "Nutritional status was calculated by measuring the percentile of BMI (pBMI) according to WHO curves.", + "The patient gained 1.8 kg during the 12-month follow-up.", + "The patient increased her pBMI by 2.8 during the 12-month follow-up.", + "During the follow-up period, the patient did not have exacerbations.", + "During the follow-up period, the patient did not require hospitalization.", + "During the follow-up period, the patient did not require unscheduled medical consultations.", + "The patient continued with her usual therapy plus the ETI tritherapy for 12 months.", + "Adherence to the treatment was adequate.", + "No adverse effects related to the tritherapy were detected.", + "Liver function was monitored periodically and remained normal.", + "Abdominal ultrasound was performed to rule out liver involvement.", + "No dermatological manifestations were found during the follow-up period.", + "No symptoms suggestive of visual alterations were found during the follow-up period.", + "An ophthalmological evaluation was performed before starting the tritherapy.", + "An ophthalmological evaluation was performed once the follow-up was completed." + ], + "summary": "14-year-old female patient with cystic fibrosis of severe phenotype, heterozygous for the Phe508del mutation (Phe508del/1078delT), with moderate pulmonary involvement and pancreatic insufficiency (PI). The patient started ETI therapy after the disease entered the phase of clinical deterioration and pulmonary function. From the second visit (45 days) to the end of the follow-up (365 days), the patient experienced a significant improvement in the domains of quality of life measured by the CFQ-R 14+ questionnaire. In the study of pulmonary function, at 45 and 365 days, the FVC increased by 21% and 22%, the FEV1 by 20% and 27%, and the FEF 25-75 by 23% and 37%, respectively. The nutritional evaluation parameters in the first half of the follow-up showed an increase in BMI from 1.6 to 5.6 kg. No adverse effects were observed.\n", + "summary_subclaims": [ + "The patient is a 14-year-old female.", + "The patient has cystic fibrosis of severe phenotype.", + "The patient is heterozygous for the Phe508del mutation.", + "The patient's genotype is Phe508del/1078delT.", + "The patient has moderate pulmonary involvement.", + "The patient has pancreatic insufficiency.", + "The patient started ETI therapy after the disease entered the phase of clinical deterioration.", + "The patient started ETI therapy after the disease entered the phase of pulmonary function deterioration.", + "From the second visit to the end of the follow-up, the patient experienced a significant improvement in the domains of quality of life measured by the CFQ-R 14+ questionnaire.", + "At 45 days, the FVC increased by 21%.", + "At 365 days, the FVC increased by 22%.", + "At 45 days, the FEV1 increased by 20%.", + "At 365 days, the FEV1 increased by 27%.", + "At 45 days, the FEF 25-75 increased by 23%.", + "At 365 days, the FEF 25-75 increased by 37%.", + "In the first half of the follow-up, the BMI increased from 1.6 to 5.6 kg.", + "No adverse effects were observed." + ] + }, + { + "id": "multiclinsum_test_1578_en.txt", + "fulltext": "A 4-year-old Indian girl was referred to us with a diagnosis of hemorrhagic pericardial effusion that recurred despite aspiration twice in the past 6 months. The child had insidious onset of breathlessness for six months and had episodes of lower respiratory tract infection. Pericardial effusion was detected on chest X-ray and hemorrhagic fluid was aspirated. She was started on antitubercular drugs with steroids, but her condition did not improve significantly. Our patient had normal development in her early infancy stage and normal growth prior to this illness. There was no family history of heart disease, developmental defects, tuberculosis or connective tissue disease.\nOn examination, our patient was found to be in mild respiratory distress. She had a heart rate of 110/mt, BP of 90/60, respiratory rate of 30/mt, temperature of 37°C, and oxygen saturation of 96%. Her weight was 14 kg and her height was 110 cm. There were few basal crackles in her lungs and her heart sounds were distant. Chest X-ray showed marked cardiomegaly and streaky lung fields . Her hemoglobin count was 8.7 gm/dl, and her total leukocyte count (TLC) was 10600/mm3 with 65% neutrophils. An echocardiogram showed large pericardial effusion (2.0 cm circumferentially) with evidence of tamponade. There was no structural lesion in her lungs. A total of 300 ml of hemorrhagic pericardial fluid was aspirated with a pigtail catheter in the pericardium. The pericardial fluid showed numerous red blood cells (RBCs) but no malignant cells were found. The adenosine deaminase in the fluid was not elevated. The bacterial and fungal cultures were sterile. Results of her abdominal ultrasound examination were normal.\nThe fluid in our patient's lungs re-accumulated within weeks of drainage. The antitubercular treatment and steroids were stopped. Meanwhile, results of her thyroid function tests were normal. Her rheumatoid factor, anti-nuclear antibodies, and antineutrophilic cytoplasmic antibodies were negative. She tested negative for human immunodeficiency virus (HIV) via rapid screening test. High-resolution computed tomography (HRCT) scan showed peculiar diffuse polygonal lobular architect and soft tissue mediastinal mass. A needle biopsy of the mediastinal mass revealed only fat and connective tissues. Repeated pericardial fluid analyses for malignant cells were negative. Her platelet counts were 50 to 70,000/mm3 on multiple occasions. She also tested negative for disseminated intravascular coagulation (DIC). Her bone marrow was normal.\nThe diagnosis was unclear. A review of literature on similar HRCT picture prompted a skeletal survey which showed lytic lesions in her bones . Consequently, diffuse multisystem involvement, lytic bone lesions and HRCT findings led to the diagnosis of diffuse lymphangiomatosis. The triglyceride levels in our patient's pericardial fluid were high, but her pericardial fluid was always hemorrhagic. During the course of her illness, she required multiple pericardiocentesis due to the large reaccumulation of fluid, as well as respiratory distress. Multiple blood transfusions were also given to our patient.\nTreatment with interferon alpha was discussed but her parents did not consent to it. Thalidomide (50 mg/d), octreotide and epsilon-aminocaproic acid were tried empirically, but her response to this treatment was not sustained. Low-dose radiotherapy of 20 Gy over 10 days were also given to her pericardium. A pericardiectomy was done after exhausting all options. Lung biopsy taken at that time showed diffuse hemangiolymphangiomatosis . There were numerous anastomotic proliferating, and cystic spaces in the pulmonary interstitium were lined by endothelial cells. The cells lining the spaces were CD31+, which is a marker of endothelial cells, although it does not differentiate vascular from lymphatic capillaries. Many of her capillaries contained blood. The connective tissue stroma was predominantly lymphoid. Our patient's pericardium also showed similar findings. A diagnosis of diffuse lymphangiohemangiomatosis was thus made. Our patient had progressive respiratory failure and died after two months.", + "fulltext_subclaims": [ + "A 4-year-old Indian girl was referred with a diagnosis of hemorrhagic pericardial effusion.", + "The pericardial effusion had recurred despite aspiration twice in the past 6 months.", + "The child had insidious onset of breathlessness for six months.", + "Pericardial effusion was detected on chest X-ray.", + "Hemorrhagic fluid was aspirated.", + "She was started on antitubercular drugs with steroids.", + "Her condition did not improve significantly.", + "The patient had normal development in her early infancy stage.", + "There was no family history of heart disease.", + "On examination, the patient was in mild respiratory distress.", + "Her heart rate was 110/mt.", + "Her oxygen saturation was 96%.", + "Chest X-ray showed marked cardiomegaly.", + "An echocardiogram showed large pericardial effusion with evidence of tamponade.", + "A total of 300 ml of hemorrhagic pericardial fluid was aspirated with a pigtail catheter.", + "The pericardial fluid showed numerous red blood cells.", + "The adenosine deaminase in the fluid was not elevated.", + "The fluid re-accumulated within weeks of drainage.", + "The antitubercular treatment and steroids were stopped.", + "Her rheumatoid factor was negative.", + "She tested negative for human immunodeficiency virus (HIV).", + "High-resolution computed tomography showed peculiar diffuse polygonal lobular architecture.", + "A needle biopsy of the mediastinal mass revealed only fat and connective tissues.", + "Her platelet counts were 50 to 70,000/mm3 on multiple occasions.", + "A skeletal survey showed lytic lesions in her bones.", + "The diagnosis was diffuse lymphangiomatosis.", + "The pericardial fluid triglyceride levels were high.", + "She required multiple pericardiocentesis due to large reaccumulation of fluid.", + "Multiple blood transfusions were given to the patient.", + "Treatment with interferon alpha was discussed but her parents did not consent.", + "Thalidomide, octreotide, and epsilon-aminocaproic acid were tried empirically.", + "Low-dose radiotherapy of 20 Gy over 10 days was given to her pericardium.", + "A pericardiectomy was done after exhausting all options.", + "A lung biopsy showed diffuse hemangiolymphangiomatosis.", + "The cells lining the spaces were CD31+.", + "The connective tissue stroma was predominantly lymphoid.", + "A diagnosis of diffuse lymphangiohemangiomatosis was made.", + "The patient had progressive respiratory failure.", + "The patient died after two months." + ], + "summary": "We report the case of a 4-year-old Indian girl who presented with recurrent hemorrhagic pericardial effusion. Diffuse lymphangiomatosis was suspected when associated pulmonary involvement, soft tissue mediastinal mass, and lytic bone lesions were found. Pericardiectomy and lung biopsy confirmed the diagnosis of diffuse lymphangiohemangiomatosis. Partial clinical improvement occurred with thalidomide and low-dose radiotherapy, but our patient died from progressive respiratory failure.", + "summary_subclaims": [ + "The patient was a 4-year-old Indian girl.", + "The patient had recurrent hemorrhagic pericardial effusion.", + "Diffuse lymphangiomatosis was suspected.", + "Pulmonary involvement was found.", + "A soft tissue mediastinal mass was found.", + "Lytic bone lesions were found.", + "Pericardiectomy and lung biopsy confirmed the diagnosis of diffuse lymphangiohemangiomatosis.", + "Partial clinical improvement occurred with thalidomide and low-dose radiotherapy.", + "The patient died from progressive respiratory failure." + ] + }, + { + "id": "multiclinsum_test_1389_en.txt", + "fulltext": "A 15-year-old female presented with 3 d of seizures.\nThree days prior, the patient had two episodes of tonic clonic seizures, with a loss of consciousness followed by falling and tonic muscle spasms, a gray face, and jerky movements of the arms and legs, which gradually disappeared after 2-3 min.\nThe patient had no history of epilepsy or psychosis.\nBoth parents were healthy.\nThe patient’s body temperature was 36.5 °C, and her blood pressure was 116/80 mmHg. The findings of brain magnetic resonance imaging (MRI) and computed tomography (CT) were all initially normal. Electroencephalography (EEG) showed diffuse slow waves on basic activity. Our hypothesis was initially epilepsy, and we started treatment with levetiracetam (17 mg/kg/day), after which the seizures disappeared. Two weeks later, she started to experience behavioral problems and speech impairment, fearfulness, and auditory/visual hallucinations with an intermittent course during the day. On physical examination, the patient remained unresponsive to external stimuli. Then, she developed laryngospasms. When the laryngospasms occurred, there was an obvious tracheal pulling motion, accompanied by inspiratory stridor, and the patient’s oxygen saturation decreased from 97% to 70%. These episodes were initially self-limiting but later required aggressive pharmacological intervention, including intermittent intravenous diazepam injections at a dose of 10 mg and intravenous lobeline hydrochloride injections (3 mg/6 h). However, these drugs failed to suppress the laryngospasm episodes. Because the patient’s symptoms worsened, she underwent tracheal intubation and tracheotomy successively to help reduce airway irritation and reduce the administration of intravenous sedatives.\nAll listed blood investigation results were within normal ranges. For example, her white blood cell count was within the normal range at 7.2 × 109/L (normal range: 3.5-9.5 × 109/L), glucose was 5.8 mmol/L (normal range: 3.9-6.1 mmol/L), her triglyceride level was 0.90 mmol/L (normal range: 0.00-2.26 mmol/L), gamma glutamyl transpeptidase was 37 U/L (normal range: 10-60 U/L), thyrotropin was 1.36 mIU/L (normal range: 0.55-4.78 mIU/L), and creatine phosphokinase was 51 U/L (normal level: 0-171 U/L). Lumbar puncture examination of the cerebrospinal fluid (CSF) revealed a pressure of 200 mmH2O (normal range: 80-180 mmH2O). CSF analysis revealed the following: 12 nucleated cells/mL (normal level: 0-5 nucleated cells/mL); glucose 3.8 mmol/L (normal range: 2.5-4.5 mmol/L); protein 0.38 g/L (normal range: 0.15-0.45 g/L); and chloride 116.7 mmol/L (normal range: 116.0-130.0 mmol/L). NMDAR antibodies were detected in the CSF.\nThe findings of brain MRI and CT were all initially normal. However, upon re-examination 2 wk later, a cranial MRI revealed abnormally high signals in the left frontotemporal parietal occipital cortex and subcortical area on T2-weighted images and fluid-attenuated inversion recovery images . A 4-h video electroencephalogram showed nonspecific slow activity without epileptic discharge. Chest CT, pelvic and abdominal color ultrasound, and MRI did not reveal any tumors, including teratomas.", + "fulltext_subclaims": [ + "The patient was a 15-year-old female.", + "She presented with 3 d of seizures.", + "Three days prior, the patient had two episodes of tonic clonic seizures.", + "The seizures were associated with loss of consciousness.", + "The seizures were associated with falling.", + "The seizures were associated with tonic muscle spasms.", + "The seizures were associated with a gray face.", + "The seizures were associated with jerky movements of the arms and legs.", + "The seizures lasted 2-3 min.", + "The patient had no history of epilepsy.", + "The patient had no history of psychosis.", + "Both parents were healthy.", + "The patient’s body temperature was 36.5 °C.", + "The patient’s blood pressure was 116/80 mmHg.", + "The findings of brain MRI were initially normal.", + "The findings of brain CT were initially normal.", + "EEG showed diffuse slow waves on basic activity.", + "The initial hypothesis was epilepsy.", + "Levetiracetam (17 mg/kg/day) was started.", + "The seizures disappeared after starting levetiracetam.", + "Two weeks later, the patient started to experience behavioral problems.", + "Two weeks later, the patient started to experience speech impairment.", + "Two weeks later, the patient started to experience fearfulness.", + "Two weeks later, the patient started to experience auditory/visual hallucinations.", + "The hallucinations had an intermittent course during the day.", + "On physical examination, the patient remained unresponsive to external stimuli.", + "The patient developed laryngospasms.", + "The laryngospasms were accompanied by an obvious tracheal pulling motion.", + "The laryngospasms were accompanied by inspiratory stridor.", + "The patient’s oxygen saturation decreased from 97% to 70% during laryngospasms.", + "The laryngospasms were initially self-limiting.", + "The laryngospasms later required aggressive pharmacological intervention.", + "Intravenous diazepam injections at 10 mg were used.", + "Intravenous lobeline hydrochloride injections (3 mg/6 h) were used.", + "These drugs failed to suppress the laryngospasm episodes.", + "The patient underwent tracheal intubation.", + "The patient underwent tracheotomy.", + "Tracheotomy was performed to help reduce airway irritation.", + "Tracheotomy was performed to reduce the administration of intravenous sedatives.", + "All listed blood investigation results were within normal ranges.", + "The white blood cell count was 7.2 × 109/L.", + "The glucose level was 5.8 mmol/L.", + "The triglyceride level was 0.90 mmol/L.", + "Gamma glutamyl transpeptidase was 37 U/L.", + "Thyrotropin was 1.36 mIU/L.", + "Creatine phosphokinase was 51 U/L.", + "CSF pressure was 200 mmH2O.", + "CSF had 12 nucleated cells/mL.", + "CSF glucose was 3.8 mmol/L.", + "CSF protein was 0.38 g/L.", + "CSF chloride was 116.7 mmol/L.", + "NMDAR antibodies were detected in the CSF.", + "Brain MRI and CT were initially normal.", + "Upon re-examination 2 wk later, a cranial MRI revealed abnormally high signals in the left frontotemporal parietal occipital cortex and subcortical area on T2-weighted images.", + "Upon re-examination 2 wk later, a cranial MRI revealed abnormally high signals in the left frontotemporal parietal occipital cortex and subcortical area on fluid-attenuated inversion recovery images.", + "A 4-h video electroencephalogram showed nonspecific slow activity.", + "The 4-h video electroencephalogram showed no epileptic discharge.", + "Chest CT did not reveal any tumors.", + "Pelvic and abdominal color ultrasound did not reveal any tumors.", + "MRI did not reveal any tumors.", + "Teratomas were not detected." + ], + "summary": "The patient was a 15-year-old female with normal psychomotor development. She was initially admitted to our neurological intensive care unit with seizures. She received anti-epilepsy treatment, and the seizures disappeared. However, 2 wk later, she developed behavioral problems and speech impairment. Then, she developed severe laryngospasms, which were treated with intubation and a tracheotomy. Antibodies against the NMDAR were detected in the patient's cerebrospinal fluid. Therefore, she was diagnosed with anti-NMDAR encephalitis. In addition, she received intravenously administered immunoglobulins, and methylprednisolone was administered. The patient's symptoms gradually improved, and she was discharged from our hospital. Approximately 9 mo later, the patient could speak sentences, walk independently, and carry out activities of daily living independently. Through our case report, we highlighted laryngospasm as an uncommon presentation in patients with anti-NMDAR encephalitis.", + "summary_subclaims": [ + "The patient was a 15-year-old female.", + "The patient had normal psychomotor development.", + "The patient was admitted to the neurological intensive care unit with seizures.", + "The patient received anti-epilepsy treatment.", + "The seizures disappeared after treatment.", + "Two weeks later, the patient developed behavioral problems and speech impairment.", + "The patient developed severe laryngospasms.", + "The laryngospasms were treated with intubation and a tracheotomy.", + "Antibodies against the NMDAR were detected in the patient's cerebrospinal fluid.", + "The patient was diagnosed with anti-NMDAR encephalitis.", + "The patient received intravenously administered immunoglobulins.", + "The patient received methylprednisolone.", + "The patient's symptoms gradually improved.", + "The patient was discharged from the hospital.", + "Nine months later, the patient could speak sentences.", + "Nine months later, the patient could walk independently.", + "Nine months later, the patient could carry out activities of daily living independently.", + "Laryngospasm was highlighted as an uncommon presentation in patients with anti-NMDAR encephalitis." + ] + }, + { + "id": "multiclinsum_test_1940_en.txt", + "fulltext": "A 29-year-old female presented with a 22-month history of progressive dysphagia, neck pain, and cervical myelopathy. Although she had no motor deficit, she exhibited impaired pin appreciation on the left side from C2–C7, bilateral Hoffman’s signs, and diffuse upper and lower extremity hyperreflexia.\nThe computed tomography (CT) and full neuraxis enhanced MR studies showed a left-sided epidural enhanced mass from C2 to C7 compressing the spinal cord and displacing it to the right with a paravertebral extension [-].\nThree days after the presentation, a CT-guided biopsy was performed. However, due to the initiation of steroids (dexamethasone 4 mg every 6 h), the tumor had significantly decreased in size (e.g., repeat MRI showed that the lesion had profoundly regressed), and a biopsy was no longer feasible/ reliable [-].\nThe next MR performed 2 weeks after cessation of steroids revealed significant tumor recurrence [ and ]. The repeated CT-guided biopsy revealed a granuloma in a background of nonneoplastic skeletal muscular and fibrous tissues. This was followed by an open anterior C5–C6 biopsy of the large recurrent extradural lesion; the latter confirmed the diagnosis of neurosarcoidosis (i.e., nonnecrotizing granulomatous lymphadenitis) neurosarcoidosis [ and ]. She was later discharged on 60 mg prednisone/day and placed on an 8-week taper. Three months later, she exhibited substantial clinical improvement.", + "fulltext_subclaims": [ + "The patient is a 29-year-old female.", + "She had a 22-month history of progressive dysphagia.", + "She had a 22-month history of neck pain.", + "She had cervical myelopathy.", + "She had impaired pin appreciation on the left side from C2–C7.", + "She had bilateral Hoffman’s signs.", + "She had diffuse upper and lower extremity hyperreflexia.", + "CT and full neuraxis enhanced MR studies showed a left-sided epidural enhanced mass from C2 to C7.", + "The mass compressed the spinal cord.", + "The mass displaced the spinal cord to the right.", + "The mass had a paravertebral extension.", + "A CT-guided biopsy was performed three days after the presentation.", + "Dexamethasone 4 mg every 6 h was initiated.", + "Repeat MRI showed that the lesion had profoundly regressed.", + "A biopsy was no longer feasible.", + "A biopsy was no longer reliable.", + "The next MR performed 2 weeks after cessation of steroids revealed significant tumor recurrence.", + "The repeated CT-guided biopsy revealed a granuloma.", + "The granuloma was in a background of nonneoplastic skeletal muscular and fibrous tissues.", + "An open anterior C5–C6 biopsy of the large recurrent extradural lesion was performed.", + "The open biopsy confirmed the diagnosis of neurosarcoidosis.", + "The diagnosis was nonnecrotizing granulomatous lymphadenitis.", + "She was discharged on 60 mg prednisone/day.", + "She was placed on an 8-week taper.", + "Three months later, she exhibited substantial clinical improvement." + ], + "summary": "A 29-year-old patient presented with a 22-month history of progressive neck, upper limb pain, and myelopathy. The cervical MRI showed a large epidural mass infiltrating the paraspinal soft tissue. After an open biopsy, the diagnosis of neurosarcoidosis was established and was followed-up by appropriate medical management.", + "summary_subclaims": [ + "A 29-year-old patient presented with a 22-month history of progressive neck, upper limb pain, and myelopathy.", + "The cervical MRI showed a large epidural mass infiltrating the paraspinal soft tissue.", + "After an open biopsy, the diagnosis of neurosarcoidosis was established.", + "The diagnosis was followed-up by appropriate medical management." + ] + }, + { + "id": "multiclinsum_test_2821_en.txt", + "fulltext": "Our 54-year-old male Caucasian patient had had a severe car accident at the age of 38. He suffered multiple fractures of the central face. His right eye had to be enucleated and replaced by a prosthesis. The patient underwent multiple surgeries and stayed in the intensive care unit for more than two weeks, and then for several weeks in the hospital. He noticed a complete loss of his sense of smell, which was confirmed in subsequent litigation. The patient reported that he was not able to smell smoke or gas and he could not detect flavor in food and beverages. Consequently, the patient's quality-of-life significantly decreased.\nApproximately nine years after the accident, he reported his first olfactory impression. It was the smell of hay which was perceived during a walk. The ability to smell continually improved over three years, and has stayed constant since then. No specific therapies regarding smell function were given to the patient. Today, he has no problems with his sense of smell and has normal flavor perception during eating and drinking.\nComputed tomography showed patent olfactory clefts, both after the accident, when the patient was anosmic, and 10 years later, when he had regained his olfactory abilities. These images ruled out the presence of obstructions due to sinunasal disease as possible causes of smell dysfunction.\nAfter complete ear-nose-throat examination including nasal endoscopy, smell function was tested 16 years after the accident using the 'Sniffin' Sticks' test battery . This test has been extensively validated and comprises three subtests: a test of olfactory threshold, an odor discrimination task, and an odor identification test. The patient yielded 28.5 points, which represents a score within the lower normal range .\nIn order to confirm the absence of anosmia, evoked-response olfactometry was applied to the patient using an olfactometer (Burghart Instruments, Wedel, Germany). Following stimulation with selective olfactory stimuli (50% v/v phenylethanol), event-related potentials were clearly detectable .", + "fulltext_subclaims": [ + "The patient is a 54-year-old male Caucasian.", + "He had a severe car accident at the age of 38.", + "He suffered multiple fractures of the central face.", + "His right eye had to be enucleated and replaced by a prosthesis.", + "The patient underwent multiple surgeries.", + "He stayed in the intensive care unit for more than two weeks.", + "He stayed in the hospital for several weeks.", + "He noticed a complete loss of his sense of smell.", + "The loss of smell was confirmed in subsequent litigation.", + "He was not able to smell smoke or gas.", + "He could not detect flavor in food and beverages.", + "The patient's quality-of-life significantly decreased.", + "Approximately nine years after the accident, he reported his first olfactory impression.", + "The first olfactory impression was the smell of hay.", + "The ability to smell continually improved over three years.", + "The ability to smell has stayed constant since then.", + "No specific therapies regarding smell function were given to the patient.", + "Computed tomography showed patent olfactory clefts after the accident.", + "Computed tomography showed patent olfactory clefts 10 years after the accident.", + "The images ruled out the presence of obstructions due to sinusnasal disease.", + "Smell function was tested 16 years after the accident using the 'Sniffin' Sticks' test battery.", + "The 'Sniffin' Sticks' test battery comprises three subtests: a test of olfactory threshold, an odor discrimination task, and an odor identification test.", + "The patient yielded 28.5 points on the test.", + "The score represents a value within the lower normal range.", + "Evoked-response olfactometry was applied to the patient.", + "An olfactometer (Burghart Instruments, Wedel, Germany) was used.", + "Following stimulation with selective olfactory stimuli (50% v/v phenylethanol), event-related potentials were clearly detectable." + ], + "summary": "We report the case of a 54-year-old Caucasian man who suffered complete anosmia from a severe car accident. Smell function as well as flavor perception during eating and drinking were also completely lost. After nine years, the patient had his first olfactory impressions, with his sense of smell gradually improving over a period of three years. We confirmed recovery of olfactory function using psychophysical and electrophysiological techniques.", + "summary_subclaims": [ + "The patient was a 54-year-old Caucasian man.", + "The patient suffered complete anosmia from a severe car accident.", + "Smell function was completely lost.", + "Flavor perception during eating and drinking was also completely lost.", + "After nine years, the patient had his first olfactory impressions.", + "The patient's sense of smell gradually improved over a period of three years.", + "We confirmed recovery of olfactory function using psychophysical and electrophysiological techniques." + ] + }, + { + "id": "multiclinsum_test_3140_en.txt", + "fulltext": "Clinical examination showed a patient with stable cardiopulmonary status and a pulse of 86/min and blood pressure of 140/85 mm Hg. Body temperature was 36.7°C. Respiratory frequency was 16 per minute with an oxygen saturation of 96% without supplementary oxygen. Auscultation of the lung found dry rales in the basal compartments. Examination of the heart and abdomen was unremarkable.\n\nIn the initial arterial blood gas analysis, Po 2 was 88 mm Hg with a saturation of 97.2%; Pco 2 was 20.7 with pH 7535. Laboratory findings showed a procalcitonin of 0.12 ng/mL (<0.05 ng/mL) and a C-reactive protein level of 4.19 mg/dL (<0.5 mg/dL) with normal leukocytes and a blood sedimentaion rate of 56 mm/h (<46 mm/h). The differential blood count showed monocytosis, and lymphocytes were normal. There was a normocytic and normochromic anemia. Other values were lactate dehydrogenase, 271 U/L (135-255 U/L); D-dimer, 2.04 mg/L (<0.8 mg/L); hs-troponin T, 19 pg/mL (<14 pg/mL) without further increase after 3 hours; myoglobin, 122 µg/mL (28-72 µg/mL); elevated creatinine, 2.13 mg/dL (0.67-1.17 mg/dL); blood urea nitrogen, 77.6 mg/dL (16.6-48.5 mg/dL); and glomerular filtration rate calculated for cystatin C, 22 mL/min. Hemoglobin A1c was 6.5%.\n\nAn initial electrocardiographic study had no pathological findings. Computed tomography (CT) scan of the thorax showed distinct atypical opaque infiltration of the left lower lobe consistent with viral pneumonia. Swabs from throat and nose as well as sputum tested positive for SARS-CoV-2 on real-time polymerase chain reaction (PCR) on the day of admission.\n\nThe patient with heart transplant due to coronary artery disease with ischemic cardiomyopathy was diagnosed with SARS-CoV-2 infection with viral pneumonia.\n\n\nTREATMENT\n\nAfter establishing the diagnosis, we started a therapeutic trial with hydroxychloroquine with an initial dose of 400 mg twice daily for the first day followed by 200 mg twice daily. We refrained from therapy with lopinavir/ritonavir because of possible interactions due to the shared metabolization path via CYP3A4 with sirolimus. The patient preemptively received piperacillin/tazobactam and cotrimoxazole and ganciclovir because he had a history of CMV infections including colitis and pneumonia. In close cooperation with the transplant center (Ludwig-Maximilians-Universität), we modified immunosuppressive medication, replacing sirolimus with tacrolimus due to its potential lung toxicity.1 Once a steady serum level was reached, we withdrew mycophenolate.\n\nThe patient was monitored in an intensive care unit for 3 days and received 4 L oxygen supplementation via nasal cannula. Arterial oxygen saturation dropped as low as 89% with a Horovitz index of 169 mm Hg and an alveolar-arterial gradient of 162 mm Hg (age corrected <23 mm Hg) indicating a potential severe case with a moderate acute respiratory distress syndrome (ARDS) and a consecutive V/Q mismatch. As there were no signs of further relevant deterioration, the patient was transferred to our normal ward. CT was repeated 4 and 9 days after admission, showing fluctuation of the opaque infiltrations on the first and a general decline on the second scan. The patient additionally presented with diarrhea, but stool samples showed a negative culture and multiplex PCR for pathological bacteria or viruses.\n\nAfter 7 days, the patient started to show relevant improvement in the respiratory situation and required no further oxygen supplementation. There was no increase in procalcitonin or a left shift in granulocytes; thus, antibiotic treatment was discontinued. Respiratory symptoms declined after 9 days so we tested sputum as well as throat and nose swabs for SARS-CoV-2 on the following 2 days. PCR was negative in all specimens. A multiplex PCR in another sputum as well as serological results showed no clues for CMV reactivation or other viral or bacterial agents. The patient received hydroxychloroquine a total of 9 days. We were able to discharge the patient 12 days after admission.", + "fulltext_subclaims": [ + "Clinical examination showed a patient with stable cardiopulmonary status.", + "The patient's pulse was 86/min.", + "The patient's blood pressure was 140/85 mm Hg.", + "Body temperature was 36.7°C.", + "Respiratory frequency was 16 per minute.", + "Oxygen saturation was 96% without supplementary oxygen.", + "Auscultation of the lung found dry rales in the basal compartments.", + "Examination of the heart and abdomen was unremarkable.", + "In the initial arterial blood gas analysis, Po2 was 88 mm Hg.", + "In the initial arterial blood gas analysis, saturation was 97.2%.", + "In the initial arterial blood gas analysis, Pco2 was 20.7.", + "In the initial arterial blood gas analysis, pH was 7535.", + "Laboratory findings showed a procalcitonin of 0.12 ng/mL.", + "The procalcitonin reference range was <0.05 ng/mL.", + "C-reactive protein level was 4.19 mg/dL.", + "The C-reactive protein reference range was <0.5 mg/dL.", + "Blood sedimentation rate was 56 mm/h.", + "The blood sedimentation rate reference range was <46 mm/h.", + "The differential blood count showed monocytosis.", + "Lymphocytes were normal.", + "There was a normocytic and normochromic anemia.", + "Lactate dehydrogenase was 271 U/L.", + "The lactate dehydrogenase reference range was 135-255 U/L.", + "D-dimer was 2.04 mg/L.", + "The D-dimer reference range was <0.8 mg/L.", + "hs-troponin T was 19 pg/mL.", + "The hs-troponin T reference range was <14 pg/mL.", + "hs-troponin T did not increase further after 3 hours.", + "Myoglobin was 122 µg/mL.", + "The myoglobin reference range was 28-72 µg/mL.", + "Creatinine was 2.13 mg/dL.", + "The creatinine reference range was 0.67-1.17 mg/dL.", + "Blood urea nitrogen was 77.6 mg/dL.", + "The blood urea nitrogen reference range was 16.6-48.5 mg/dL.", + "Glomerular filtration rate calculated for cystatin C was 22 mL/min.", + "Hemoglobin A1c was 6.5%.", + "An initial electrocardiographic study had no pathological findings.", + "Computed tomography (CT) scan of the thorax showed distinct atypical opaque infiltration of the left lower lobe.", + "The CT scan findings were consistent with viral pneumonia.", + "Swabs from throat and nose as well as sputum tested positive for SARS-CoV-2 on real-time polymerase chain reaction (PCR) on the day of admission.", + "The patient had a heart transplant due to coronary artery disease.", + "The patient had ischemic cardiomyopathy.", + "The patient was diagnosed with SARS-CoV-2 infection.", + "The patient was diagnosed with viral pneumonia.", + "We started a therapeutic trial with hydroxychloroquine with an initial dose of 400 mg twice daily for the first day.", + "We refrained from therapy with lopinavir/ritonavir because of possible interactions due to the shared metabolization path via CYP3A4 with sirolimus.", + "The patient preemptively received piperacillin/tazobactam.", + "The patient preemptively received cotrimoxazole.", + "The patient preemptively received ganciclovir.", + "We modified immunosuppressive medication, replacing sirolimus with tacrolimus.", + "We withdrew mycophenolate once a steady serum level was reached.", + "The patient was monitored in an intensive care unit for 3 days.", + "The patient received 4 L oxygen supplementation via nasal cannula.", + "Arterial oxygen saturation dropped as low as 89%.", + "The Horovitz index was 169 mm Hg.", + "The alveolar-arterial gradient was 162 mm Hg.", + "The age-corrected alveolar-arterial gradient was <23 mm Hg.", + "The patient was transferred to our normal ward.", + "CT was repeated 4 and 9 days after admission.", + "The first repeat CT showed fluctuation of the opaque infiltrations.", + "The second repeat CT showed a general decline.", + "The patient presented with diarrhea.", + "Stool samples showed a negative culture.", + "Multiplex PCR in stool samples was negative for pathological bacteria or viruses.", + "After 7 days, the patient started to show relevant improvement in the respiratory situation.", + "The patient required no further oxygen supplementation.", + "There was no increase in procalcitonin.", + "There was no left shift in granulocytes.", + "Antibiotic treatment was discontinued.", + "Respiratory symptoms declined after 9 days.", + "We tested sputum as well as throat and nose swabs for SARS-CoV-2 on the following 2 days.", + "PCR was negative in all specimens.", + "A multiplex PCR in another sputum showed no clues for CMV reactivation or other viral or bacterial agents.", + "Serological results showed no clues for CMV reactivation or other viral or bacterial agents.", + "The patient received hydroxychloroquine a total of 9 days.", + "The patient was discharged 12 days after admission." + ], + "summary": "A 77-year-old male heart transplant recipient presented to our emergency department complaining about shortness of breath, pain on inspiration, and dry cough as well as body aches, fatigue, and decline in body weight for 3 days. Fever and angina pectoris were denied. He was unaware of a contact with a SARS-CoV-2–positive patient and had not been on trip to a high-risk area at that time.\n\nThe patient had undergone heart transplant surgery after ischemic cardiomyopathy in 2003. In 2019, he received percutaneous transluminal coronary angiography and drug-eluting stent of the left circumflex and ramus marginalis due to a tandem stenosis. Further past medical history included cytomegalovirus (CMV) colitis in 2005 and septicemia after CMV pneumonia, chronic kidney disease (G3b KDIGO classification), hypertension, and diabetes mellitus type 2 treated with oral medication.\n\nMedications included sirolimus 0.5 mg daily, mycophenolate 250 mg twice daily, acetylsalicylic acid 100 mg daily, clopidogrel 75 mg daily, bisoprolol 2.5 mg twice daily, telmisartan 80 mg daily, torasemide 5 mg daily, atorvastatin 40 mg daily, ezetimibe 10 mg daily, sitagliptin 25 mg twice daily, allopurinol 100 mg daily, pantoprazole 20 mg daily, and vitamin D 20 000 IE weekly.", + "summary_subclaims": [ + "The patient is a 77-year-old male heart transplant recipient.", + "He presented with shortness of breath.", + "He reported pain on inspiration.", + "He had a dry cough.", + "He experienced body aches.", + "He reported fatigue.", + "He noted a decline in body weight over 3 days.", + "Fever was denied.", + "Angina pectoris was denied.", + "He was unaware of contact with a SARS-CoV-2–positive patient.", + "He had not been on a trip to a high-risk area.", + "He underwent heart transplant surgery in 2003.", + "In 2019, he received percutaneous transluminal coronary angiography.", + "In 2019, he received a drug-eluting stent of the left circumflex and ramus marginalis.", + "He had a history of CMV colitis in 2005.", + "He had septicemia after CMV pneumonia.", + "He had chronic kidney disease classified as G3b KDIGO.", + "He had hypertension.", + "He had diabetes mellitus type 2 treated with oral medication.", + "He was taking sirolimus 0.5 mg daily.", + "He was taking mycophenolate 250 mg twice daily.", + "He was taking acetylsalicylic acid 100 mg daily.", + "He was taking clopidogrel 75 mg daily.", + "He was taking bisoprolol 2.5 mg twice daily.", + "He was taking telmisartan 80 mg daily.", + "He was taking torasemide 5 mg daily.", + "He was taking atorvastatin 40 mg daily.", + "He was taking ezetimibe 10 mg daily.", + "He was taking sitagliptin 25 mg twice daily.", + "He was taking allopurinol 100 mg daily.", + "He was taking pantoprazole 20 mg daily.", + "He was taking vitamin D 20 000 IE weekly." + ] + }, + { + "id": "multiclinsum_test_1660_en.txt", + "fulltext": "A 28-year-old female with no significant past medical history was apparently healthy until presenting to the emergency department with 1 week of worsening diffuse abdominal pain. Her intermittent pain had suddenly worsened over night which prompted her hospital visit. This sudden escalation in pain was also accompanied with multiple episodes of vomiting. She had been constipated with no bowel movement for the entire week prior to presenting to the hospital. The patient stated to have a well-balanced diet and live an active lifestyle for most of her life.\nUpon physical examination, the patient was in serious distress due to pain. Her vital signs were within normal limits. Her abdomen was very tender to palpations in all four quadrants. Rebound tenderness was also present. These signs and symptoms were of major concern, as they pointed towards the patient having developed peritonitis. A computed tomography (CT) of the abdomen and pelvis was conducted and was highly suggestive of a sigmoid colon volvulus. The CT showed a largely dilated colon with a pathognomonic “whirl” pattern present (see Fig. ).\nClinical suspicion for potential bowel necrosis was high given the patient’s peritoneal signs and sudden worsening of symptoms. Therefore, the patient underwent an emergent laparotomy. A sigmoidectomy of the distended portion of bowel was performed (see Fig. ). The remaining proximal and distal ends were inspected to be clean and a primary anastomotic continuity of the bowel was created. Intra-operatively, we noted an abnormally redundant sigmoid colonic mesentery.\nThe pathology report of the resected specimen revealed necrotic bowel with evidence of ischemic changes and focal ulcerations. Ischemic changes seen on microscopy included mucosal sloughing, mucosal hemorrhages, and fibrin deposition (see Fig. ). The patient recovered without complication with return to enteral nutrition and resumed bowel function. She was subsequently discharged on post operative day number five.", + "fulltext_subclaims": [ + "The patient is a 28-year-old female.", + "She has no significant past medical history.", + "She presented to the emergency department with 1 week of worsening diffuse abdominal pain.", + "Her intermittent pain had suddenly worsened overnight.", + "The sudden escalation in pain was accompanied with multiple episodes of vomiting.", + "She had been constipated with no bowel movement for the entire week prior to presenting.", + "The patient stated to have a well-balanced diet.", + "The patient was in serious distress due to pain.", + "Her vital signs were within normal limits.", + "Her abdomen was very tender to palpations in all four quadrants.", + "Rebound tenderness was also present.", + "The CT was highly suggestive of a sigmoid colon volvulus.", + "The CT showed a largely dilated colon with a pathognomonic 'whirl' pattern.", + "Clinical suspicion for potential bowel necrosis was high.", + "The patient underwent an emergent laparotomy.", + "A sigmoidectomy of the distended portion of bowel was performed.", + "The remaining proximal and distal ends were inspected to be clean.", + "A primary anastomotic continuity of the bowel was created.", + "Intra-operatively, an abnormally redundant sigmoid colonic mesentery was noted.", + "The pathology report revealed necrotic bowel with evidence of ischemic changes.", + "Ischemic changes included mucosal sloughing, mucosal hemorrhages, and fibrin deposition.", + "The patient recovered without complication.", + "She was discharged on post operative day number five." + ], + "summary": "A 28-year-old female presented with a one week history of constipation and abdominal pain. Her symptoms suddenly worsened and became associated with vomiting and severe pain. A focused history taking and physical examination showed peritoneal signs that led to timely diagnostic imaging to be implemented. Computed tomography (CT) of the abdomen was consistent with sigmoid volvulus. Our patient underwent emergent laparotomy with a sigmoidectomy and recovered with no post-operative complications.", + "summary_subclaims": [ + "The patient is a 28-year-old female.", + "She had a one week history of constipation and abdominal pain.", + "Her symptoms suddenly worsened.", + "The worsening symptoms were associated with vomiting and severe pain.", + "A focused history taking and physical examination showed peritoneal signs.", + "Timely diagnostic imaging was implemented.", + "Computed tomography (CT) of the abdomen was consistent with sigmoid volvulus.", + "The patient underwent emergent laparotomy.", + "A sigmoidectomy was performed.", + "The patient recovered with no post-operative complications." + ] + }, + { + "id": "multiclinsum_test_963_en.txt", + "fulltext": "A 45-year-old male patient gazed at the sun several times during a baseball game that took place on a sunny day at 7 weeks prior to his first visit to our clinic. Immediately after gazing at the sun, the subject reported having bilateral central scotoma and decreased vision. At the time of the incident, the patient was taking etizolam for a psychiatric condition (panic disorder). At the first visit, his decimal best corrected visual acuity was 0.8 (logMAR conversion: 0.10) (with -3.00 diopters, cylinder -1.00 diopters axis 5°) in the right eye and 0.7 (logMAR conversion: 0.15) (with -3.00 diopters, cylinder -1.00 diopters axis 180°) in the left eye. Slit lamp examinations showed no abnormalities in the anterior segments and media of both eyes. Fundus examinations showed a tiny, yellowish spot in the fovea bilaterally . FAF (Spectralis HRA; Heidelberg Engineering, Heidelberg, Germany) , fluorescein angiography, and indocyanine green angiography all indicated that there were no remarkable abnormalities in either of the eyes. OCT (Cirrus HD-OCT; Carl Zeiss Meditec AG, Dublin, CA, USA) images showed an elevated and blurred ellipsoid zone along with loss of the interdigitation zone at the foveal area bilaterally . There was also no vitreomacular adhesion or traction seen in either of the eyes . When the findings were taken together, the patient was diagnosed with solar retinopathy due to the characteristic symptoms and bilateral findings present after an episode of sun gazing. Treatment was started at the first visit, with the patient given a posterior sub-Tenon triamcinolone injection in his right eye followed by being placed on oral prednisolone therapy (30 mg per day) on the same day. The prednisolone therapy was decreased over a 12-week tapering period. There were no changes noted in the decimal best corrected visual acuity at 2, 4, and 6 weeks after starting the medication. However, at 9 weeks, there was improvement to 1.2 in the right eye and 1.0 in the left eye, with this good visual acuity sustained and observed at the examinations at 12 and 21 weeks. Fundus examinations performed at 12 weeks after the initial treatment showed the tiny, yellowish spots were diminished in both eyes. Sequential OCT images obtained during the follow-up examinations showed that the blurred ellipsoid zone that was visible in both eyes at 2 weeks after initiation of the therapy along with the elevated ellipsoid zone both improved to nearly normal at 4 weeks in the right eye and at 21 weeks in the left eye. However, loss of the interdigitation zone was observed after 12 weeks in the right eye and after 21 weeks in the left eye .", + "fulltext_subclaims": [ + "The patient is a 45-year-old male.", + "The patient gazed at the sun several times during a baseball game.", + "The baseball game took place on a sunny day.", + "The incident occurred 7 weeks prior to the first visit to the clinic.", + "The patient reported bilateral central scotoma immediately after gazing at the sun.", + "The patient reported decreased vision immediately after gazing at the sun.", + "At the time of the incident, the patient was taking etizolam.", + "Etizolam was being taken for a psychiatric condition.", + "The psychiatric condition was panic disorder.", + "At the first visit, the decimal best corrected visual acuity in the right eye was 0.8.", + "At the first visit, the decimal best corrected visual acuity in the left eye was 0.7.", + "The right eye had a correction of -3.00 diopters, cylinder -1.00 diopters axis 5°.", + "The left eye had a correction of -3.00 diopters, cylinder -1.00 diopters axis 180°.", + "Slit lamp examinations showed no abnormalities in the anterior segments of both eyes.", + "Fundus examinations showed a tiny, yellowish spot in the fovea bilaterally.", + "OCT images showed an elevated and blurred ellipsoid zone at the foveal area bilaterally.", + "OCT images showed loss of the interdigitation zone at the foveal area bilaterally.", + "There was no vitreomacular adhesion seen in either eye.", + "The patient was diagnosed with solar retinopathy.", + "The diagnosis was based on characteristic symptoms and bilateral findings.", + "The patient received a posterior sub-Tenon triamcinolone injection in the right eye at the first visit.", + "The patient was placed on oral prednisolone therapy (30 mg per day) at the first visit.", + "The prednisolone therapy was decreased over a 12-week tapering period.", + "There were no changes in decimal best corrected visual acuity at 2, 4, and 6 weeks after starting the medication.", + "At 9 weeks, the decimal best corrected visual acuity improved to 1.2 in the right eye.", + "At 9 weeks, the decimal best corrected visual acuity improved to 1.0 in the left eye.", + "The good visual acuity was sustained at 12 and 21 weeks.", + "Fundus examinations at 12 weeks showed the tiny, yellowish spots were diminished in both eyes.", + "Sequential OCT images showed the blurred ellipsoid zone improved to nearly normal at 4 weeks in the right eye.", + "Sequential OCT images showed the blurred ellipsoid zone improved to nearly normal at 21 weeks in the left eye.", + "Loss of the interdigitation zone was observed after 12 weeks in the right eye.", + "Loss of the interdigitation zone was observed after 21 weeks in the left eye." + ], + "summary": "A 45-year-old male gazed at the sun and noticed bilateral central scotoma and decreased vision after the episode. After 7 weeks from onset, ophthalmic examinations were firstly performed. Decimal best corrected visual acuity (BCVA) was decreased to 0.8 and 0.7 in the right and left eyes. Funduscopy showed a tiny, yellowish spot in the fovea bilaterally. Corresponding to the lesion, optical coherence tomography (OCT) images showed an elevated and blurred ellipsoid zone and loss of the interdigitation zone. A posterior sub-Tenon triamcinolone injection in the right eye and oral prednisolone therapy were performed as a medication. BCVA was improved to 1.2 and 1.0 in the right and left eyes at 9 weeks after medication. OCT images showed ellipsoid zone was gradually improved bilaterally, which became nearly normal at 4 weeks in the right eye and at 21 weeks in the left eye. The loss of the interdigitation zone remained at 12 weeks in the right eye and at 21 weeks at the left eye.", + "summary_subclaims": [ + "A 45-year-old male gazed at the sun and noticed bilateral central scotoma and decreased vision after the episode.", + "Ophthalmic examinations were firstly performed after 7 weeks from onset.", + "Decimal best corrected visual acuity (BCVA) was decreased to 0.8 and 0.7 in the right and left eyes.", + "Funduscopy showed a tiny, yellowish spot in the fovea bilaterally.", + "Optical coherence tomography (OCT) images showed an elevated and blurred ellipsoid zone and loss of the interdigitation zone.", + "A posterior sub-Tenon triamcinolone injection in the right eye and oral prednisolone therapy were performed as a medication.", + "BCVA was improved to 1.2 and 1.0 in the right and left eyes at 9 weeks after medication.", + "OCT images showed ellipsoid zone was gradually improved bilaterally.", + "The ellipsoid zone became nearly normal at 4 weeks in the right eye.", + "The ellipsoid zone became nearly normal at 21 weeks in the left eye.", + "The loss of the interdigitation zone remained at 12 weeks in the right eye.", + "The loss of the interdigitation zone remained at 21 weeks at the left eye." + ] + }, + { + "id": "multiclinsum_test_40_en.txt", + "fulltext": "A 34-year-old primiparous woman was referred to the obstetric anesthesia outpatient clinic at 26 weeks of pregnancy. The patient had histories of severe bruising in early childhood and difficulty in hemostasis after tooth extraction. She required blood transfusion during laparotomy for ovarian hemorrhage at the age of 15 years. Because of recurrent ovarian hemorrhage, her menstruation was controlled with estrogen and progesterone preparations. In addition, she had a family history of thrombocytopenia and intracranial hemorrhage. The patient’s platelet count hovered around 100,000/μL and was initially followed up as idiopathic thrombocytopenic purpura. At conization at age 25, 400 mL of platelet concentrate was transfused prophylactically, and the postoperative course continued without hemorrhagic complications.\nA thorough examination at the age of 29 demonstrated normal ristocetin-induced platelet aggregation, suppressed adenosine diphosphate (ADP) aggregation to 39% when ADP 3.00 μM was added (normal range 70–90%), and collagen aggregation to 20% when collagen 2.00 μg/ml added (normal range 70–90%), but normal CD41 (glycoprotein IIb/IIIa) antigen, leading to a diagnosis of autosomal dominant, but not previously classified, thrombasthenia. After confirming the negative platelet antigen, she underwent fertility treatment at the age of 30.\nTo avoid unnecessary blood transfusions and provide a basis for selecting the anesthesia method when a cesarean section was necessary, we performed TEGPM as well as usual blood tests at 26, 32, 36, 38, and 39 weeks of gestation, and at 1 day, 5 days, 2 weeks, and 1 month after delivery. The results of the tests are shown in Tables and . TEGPM results showed a normal to hypercoagulable state, and ADP aggregation was within the normal range until 38 weeks of gestation. The course of pregnancy was normal without obvious bleeding. The fetal growth remained within normal limits, and a vaginal delivery was planned.\nThe patient was admitted to the hospital with premature rupture of the membrane at 39 weeks of gestation. Two days after labor induction, an emergency cesarean section was performed with indications of labor arrest and nonreassuring fetal status. Because TEGPM results showed that ADP aggregation was within the normal range, blood coagulability had increased, and the patient did not manifest bleeding tendencies during pregnancy, we administered single-shot spinal anesthesia. The infant was admitted to the neonatal intensive care unit for transient tachypnea syndrome. The intraoperative blood loss was 480 g, and the postpartum blood loss was 210 g in the first 24 h after surgery. There were no postoperative complications and no prolongation of hospital stay. The baby was discharged from the neonatal intensive care unit on the fourth day after birth without bleeding tendency, and both mother and child were discharged on the sixth day. TEGPM revealed that ADP aggregation was not suppressed until delivery, although it continued to be suppressed after delivery and showed abnormal values 1 month later.", + "fulltext_subclaims": [ + "The patient was referred to the obstetric anesthesia outpatient clinic at 26 weeks of pregnancy.", + "The patient had a history of severe bruising in early childhood.", + "The patient had difficulty in hemostasis after tooth extraction.", + "The patient required blood transfusion during laparotomy for ovarian hemorrhage at the age of 15 years.", + "The patient's menstruation was controlled with estrogen and progesterone preparations.", + "The patient had a family history of thrombocytopenia.", + "The patient had a family history of intracranial hemorrhage.", + "The patient’s platelet count hovered around 100,000/μL.", + "The patient was initially followed up as idiopathic thrombocytopenic purpura.", + "At conization at age 25, 400 mL of platelet concentrate was transfused prophylactically.", + "The postoperative course after conization continued without hemorrhagic complications.", + "A thorough examination at the age of 29 demonstrated normal ristocetin-induced platelet aggregation.", + "ADP aggregation was suppressed to 39% when ADP 3.00 μM was added.", + "Collagen aggregation was 20% when collagen 2.00 μg/ml was added.", + "The diagnosis was autosomal dominant, but not previously classified, thrombasthenia.", + "TEGPM was performed at 26, 32, 36, 38, and 39 weeks of gestation.", + "TEGPM was performed at 1 day, 5 days, 2 weeks, and 1 month after delivery.", + "TEGPM results showed a normal to hypercoagulable state.", + "ADP aggregation was within the normal range until 38 weeks of gestation.", + "The course of pregnancy was normal without obvious bleeding.", + "The fetal growth remained within normal limits.", + "A vaginal delivery was planned.", + "The patient was admitted to the hospital with premature rupture of the membrane at 39 weeks of gestation.", + "An emergency cesarean section was performed with indications of labor arrest and nonreassuring fetal status.", + "TEGPM results showed that ADP aggregation was within the normal range.", + "Blood coagulability had increased.", + "The patient did not manifest bleeding tendencies during pregnancy.", + "Single-shot spinal anesthesia was administered.", + "The intraoperative blood loss was 480 g.", + "The postpartum blood loss was 210 g in the first 24 h after surgery.", + "There were no postoperative complications.", + "There was no prolongation of hospital stay.", + "The baby was discharged from the neonatal intensive care unit on the fourth day after birth.", + "Both mother and child were discharged on the sixth day.", + "ADP aggregation was not suppressed until delivery.", + "ADP aggregation continued to be suppressed after delivery.", + "ADP aggregation showed abnormal values 1 month after delivery." + ], + "summary": "A 34-year-old primipara was diagnosed with autosomal dominant thrombasthenia, which was not classified as any known type. A thorough examination revealed that adenosine diphosphate aggregation and collagen aggregation were suppressed. Platelet mapping of viscoelastic testing was used to observe the trajectory of platelet function during pregnancy, which was found to be normal to hypercoagulable until 38 weeks of gestation. On the basis of the results of testing and physiological status, we commenced spinal anesthesia and avoided prophylactic platelet transfusion.", + "summary_subclaims": [ + "The patient was diagnosed with autosomal dominant thrombasthenia.", + "The thrombasthenia was not classified as any known type.", + "Adenosine diphosphate aggregation was suppressed.", + "Collagen aggregation was suppressed.", + "Platelet mapping of viscoelastic testing was used to observe the trajectory of platelet function during pregnancy.", + "The trajectory of platelet function during pregnancy was found to be normal to hypercoagulable until 38 weeks of gestation.", + "We commenced spinal anesthesia.", + "We avoided prophylactic platelet transfusion." + ] + }, + { + "id": "multiclinsum_test_809_en.txt", + "fulltext": "A 39-year-old healthy male complained of pain in his left chest and back, the pain persisted for 11 days, with ring-shaped radiations to the precordial area, and numbness in both the lower extremities continued for 9 days. The skin sensation below the costal margin was weakened, and there was only a sense of banding. After a long walk, the patient could feel a sense of disharmony in both lower limbs. The most prevalent signs were patellar clonus, ankle clonus, and Babinski sign, which were significantly positive. MRI of thoracic vertebrae showed a strip-like structure equal to T1 signals in the spinal canal at the level of T1–T3 vertebrae, low and equal T2 signals, and high signals in the fat-suppression sequence. The contrast-enhanced T1 weighted phase showed a uniform enhancement, with clear borders and wide base attachments close to the dural membrane. The meningioma was located on the left posterolateral side of the spinal cord, and dumbbell-type growth was outward at the level of the T2–T3 intervertebral foramen . Computerized tomography (CT) with a value of 67HU showed a soft tissue mass in the spinal canal at the level of the T1–T3 vertebral body. A spot-like calcification density was observed, and the spinal cord was compressed and moved to the right. The enhanced scan showed moderately uneven enhancement. The CT-mediated biopsy of the T2–T3 intervertebral foramina lesion showed meningioma . Immunohistochemistry showed that Vim, E-cad, S-100, D2-40, PR, and EMA were (+), whereas, Ki67 (5%) and CK were (−). The left thoracic hemilaminectomy was performed under general anesthesia. The operation was extended to the maximum possibility to increase the exposure field and ensure the minimum displacement of the spinal cord during the operation. At the same time, the left intervertebral joint bone of T2/T3 was resected, and the resected bone was preserved; later, the bone graft was prepared by calcining and trimming. The tumor was gray-colored, appeared fish-like structure, rich in blood vessels, located on the left posterolateral side of the dura mater, and grew to the anterolateral side of the spinal cord but did not exceed the midline of the ventral side. The tumor penetrated deep in and grew outwards, located in the ventral side of the left nerve root of T1 and surrounded by the left nerve root of T2. With a nerve stripper exploration, the tumor could completely strip from the T1 root and dura mater and get separated from the T2 nerve root, which was unclear. To remove the tumor completely, the T2 nerve root was severed, the sleeve was burned, and a sufficient hemostatic was applied that was covered with a gelatin sponge to autologous with the bone grafted. Postoperative pathology showed meningioma, immunohistochemical EMA, PR, S-100 (+), Ki-67 (1%), and E-Cadherin (+). The patient’s sense of banding disappeared immediately after the surgery, and there was no uncoordinated walking even after attempting a long walk. Cerebrospinal fluid leakage occurred on the 3rd day postoperatively, but there were no symptoms of hypotensive cranial pressure such as headache, nausea, and vomiting. He was encouraged to walk daily, suggested to lie on his right side, and change his dressing daily. The cerebrospinal fluid leakage recovered on the 10th day of the postoperative procedure, and the patient was discharged on the 13th day of the postoperative procedure. The patient was advised to come for the follow-up on the 3rd, 6th, and 12th months postoperatively, and there were no further complaints observed. MRI showed no recurrence of the mass, no compression of the spinal cord, and no instability of the thoracic spine.", + "fulltext_subclaims": [ + "The patient is a 39-year-old healthy male.", + "The patient complained of pain in his left chest and back.", + "The pain persisted for 11 days.", + "The pain had ring-shaped radiations to the precordial area.", + "Numbness in both the lower extremities continued for 9 days.", + "The skin sensation below the costal margin was weakened.", + "There was a sense of banding.", + "After a long walk, the patient could feel a sense of disharmony in both lower limbs.", + "The most prevalent signs were patellar clonus, ankle clonus, and Babinski sign.", + "The signs were significantly positive.", + "MRI of thoracic vertebrae showed a strip-like structure equal to T1 signals in the spinal canal at the level of T1–T3 vertebrae.", + "The MRI showed low and equal T2 signals.", + "The MRI showed high signals in the fat-suppression sequence.", + "The contrast-enhanced T1 weighted phase showed a uniform enhancement.", + "The contrast-enhanced T1 weighted phase showed clear borders.", + "The contrast-enhanced T1 weighted phase showed wide base attachments close to the dural membrane.", + "The meningioma was located on the left posterolateral side of the spinal cord.", + "The meningioma showed dumbbell-type growth outward at the level of the T2–T3 intervertebral foramen.", + "CT showed a soft tissue mass in the spinal canal at the level of the T1–T3 vertebral body.", + "A spot-like calcification density was observed.", + "The spinal cord was compressed and moved to the right.", + "The enhanced scan showed moderately uneven enhancement.", + "CT-mediated biopsy of the T2–T3 intervertebral foramina lesion showed meningioma.", + "Immunohistochemistry showed that Vim, E-cad, S-100, D2-40, PR, and EMA were (+).", + "Immunohistochemistry showed that Ki67 (5%) and CK were (−).", + "The left thoracic hemilaminectomy was performed under general anesthesia.", + "The operation was extended to the maximum possibility to increase the exposure field.", + "The left intervertebral joint bone of T2/T3 was resected.", + "The resected bone was preserved.", + "The tumor was gray-colored.", + "The tumor appeared fish-like structure.", + "The tumor was rich in blood vessels.", + "The tumor was located on the left posterolateral side of the dura mater.", + "The tumor grew to the anterolateral side of the spinal cord.", + "The tumor did not exceed the midline of the ventral side.", + "The tumor penetrated deep in and grew outwards.", + "The tumor was located in the ventral side of the left nerve root of T1.", + "The tumor surrounded the left nerve root of T2.", + "With a nerve stripper exploration, the tumor could completely strip from the T1 root and dura mater.", + "The tumor could get separated from the T2 nerve root, which was unclear.", + "To remove the tumor completely, the T2 nerve root was severed.", + "The sleeve was burned.", + "A sufficient hemostatic was applied that was covered with a gelatin sponge to autologous with the bone grafted.", + "Postoperative pathology showed meningioma.", + "Postoperative immunohistochemical EMA, PR, S-100 (+).", + "Postoperative immunohistochemical Ki-67 (1%).", + "Postoperative immunohistochemical E-Cadherin (+).", + "The patient’s sense of banding disappeared immediately after the surgery.", + "There was no uncoordinated walking even after attempting a long walk.", + "Cerebrospinal fluid leakage occurred on the 3rd day postoperatively.", + "There were no symptoms of hypotensive cranial pressure such as headache, nausea, and vomiting.", + "The patient was encouraged to walk daily.", + "The patient was suggested to lie on his right side.", + "The patient was advised to change his dressing daily.", + "The cerebrospinal fluid leakage recovered on the 10th day of the postoperative procedure.", + "The patient was discharged on the 13th day of the postoperative procedure.", + "The patient was advised to come for the follow-up on the 3rd, 6th, and 12th months postoperatively.", + "MRI showed no recurrence of the mass.", + "MRI showed no compression of the spinal cord.", + "MRI showed no instability of the thoracic spine." + ], + "summary": "A 39-year-old male complained of chest and back pain with ring-shaped radiations to the precordial area and numbness in both the lower extremities. After a long walk, he felt disharmony in both his lower limbs. Magnetic resonance imaging showed a mass located on the left posterolateral side of the T1-T3 spinal cord and exhibited a dumbbell-type growth outward at the level of the T2-T3 intervertebral foramen. On the left side of the thoracic, a hemilaminectomy procedure was performed. The tumor was found in the ventral side of the left nerve root of T1 and was surrounded by the left nerve root of T2. To obliterate the tumor, the T2 nerve root was severed. The patient was advised to come for the follow-up on the 3rd, 6th, and 12th months postoperatively, and there were no complaints or signs of recurrence.", + "summary_subclaims": [ + "The patient is a 39-year-old male.", + "The patient complained of chest and back pain.", + "The pain had ring-shaped radiations to the precordial area.", + "The patient experienced numbness in both lower extremities.", + "The patient felt disharmony in both lower limbs after a long walk.", + "Magnetic resonance imaging showed a mass on the left posterolateral side of the T1-T3 spinal cord.", + "The mass exhibited a dumbbell-type growth outward at the T2-T3 intervertebral foramen.", + "A hemilaminectomy procedure was performed on the left side of the thoracic.", + "The tumor was found in the ventral side of the left nerve root of T1.", + "The tumor was surrounded by the left nerve root of T2.", + "The T2 nerve root was severed to obliterate the tumor.", + "The patient was advised to come for follow-up on the 3rd, 6th, and 12th months postoperatively.", + "There were no complaints or signs of recurrence." + ] + }, + { + "id": "multiclinsum_test_3364_en.txt", + "fulltext": "30-year-old male patient from the city of Intuto, located 172 km from the city of Iquitos, in the Peruvian Amazon. He has a history of untreated type 2 diabetes mellitus. He presents to the emergency department of the Regional Hospital of Loreto with convulsions, loss of consciousness and functional limitations, accompanied by chills, headache, feeling of heat and poor general condition. His vital signs at the clinical examination were as follows: BP: 90/60 mmHg; HR: 67/min; respiratory rate: 20/min; T°: 36.5 °C; oxygen saturation: 96%; weight: 60 kg; BMI: 19.6 m². He also presented pallor ++/+++, prostration, general malaise, coldness of extremities, sensory disorder, myalgia and arthralgia.\n\nThe illness lasted 14 days and began with convulsions of 1 to 2 minutes with a frequency of 5 to 6 times a day. Two days before admission, he presented loss of consciousness and limited motor function, so he was transferred to the nearest health center, where he was given a thick and extended gout examination, with observation of Plasmodium vivax trophozoites and initiation of treatment. However, the doctor decided to refer him to a health center of greater complexity, so the patient went to the emergency department of the Regional Hospital of Loreto where he was hospitalized.\n\nThe patient received intravenous artesunate 14.4 mg at admission, repeated at 12 and 24 h, all doses diluted with 5% dextrose in volume of 5 to 10 ml in a 5 min bolus. Artesunate was continued at 24 mg orally until day 5. Simultaneously with the initiation of intravenous artesunate, 600 mg of clindamycin diluted in 50 ml of 0.9% sodium chloride was infused over 20 to 30 min every 12 h for 5 days. Subsequently, a packed red blood cell transfusion was performed, after which primaquine was continued for 7 days.\n\nAfter receiving the treatment, the patient underwent a new examination for thick blood without observing the parasite. The laboratory examinations showed a depression of the three series of blood cells with a peripheral sheet extension, typical granulocytes ++, atypical lymphocytes +. In the erythrocytes series, microcytosis with anisocytosis and basophilic punctate was observed. The abdominal ultrasound showed splenomegaly and bilateral pleural effusion. A lumbar puncture was performed with analysis of cerebrospinal fluid. The patient showed clinical improvement with a neurological sequela of monoparesia of the motor nerves in the lower left.\n", + "fulltext_subclaims": [ + "The patient is a 30-year-old male.", + "He is from the city of Intuto.", + "Intuto is located 172 km from the city of Iquitos.", + "He has a history of untreated type 2 diabetes mellitus.", + "He presented to the emergency department of the Regional Hospital of Loreto.", + "He had convulsions.", + "He had loss of consciousness.", + "He had functional limitations.", + "He had chills.", + "He had headache.", + "He had a feeling of heat.", + "He had poor general condition.", + "His blood pressure was 90/60 mmHg.", + "His heart rate was 67/min.", + "His respiratory rate was 20/min.", + "His temperature was 36.5 °C.", + "His oxygen saturation was 96%.", + "His weight was 60 kg.", + "His BMI was 19.6 m².", + "He had pallor ++/+++.", + "He was prostrate.", + "He had general malaise.", + "He had coldness of extremities.", + "He had sensory disorder.", + "He had myalgia.", + "He had arthralgia.", + "The illness lasted 14 days.", + "The illness began with convulsions of 1 to 2 minutes.", + "The convulsions occurred 5 to 6 times a day.", + "Two days before admission, he had loss of consciousness.", + "Two days before admission, he had limited motor function.", + "He was transferred to the nearest health center.", + "At the health center, a thick and extended gout examination was performed.", + "Plasmodium vivax trophozoites were observed.", + "Treatment was initiated.", + "The doctor decided to refer him to a health center of greater complexity.", + "He went to the emergency department of the Regional Hospital of Loreto.", + "He was hospitalized.", + "He received intravenous artesunate 14.4 mg at admission.", + "Intravenous artesunate was repeated at 12 and 24 h.", + "Each dose was diluted with 5% dextrose in a volume of 5 to 10 ml.", + "Each dose was administered as a 5 min bolus.", + "Artesunate was continued at 24 mg orally until day 5.", + "600 mg of clindamycin was infused over 20 to 30 min every 12 h for 5 days.", + "Clindamycin was diluted in 50 ml of 0.9% sodium chloride.", + "A packed red blood cell transfusion was performed.", + "Primaquine was continued for 7 days.", + "A new thick blood examination was performed.", + "No parasite was observed in the thick blood examination.", + "The laboratory examinations showed depression of the three series of blood cells.", + "The peripheral sheet extension was typical granulocytes ++.", + "The peripheral sheet extension showed atypical lymphocytes +.", + "The erythrocyte series showed microcytosis.", + "The erythrocyte series showed anisocytosis.", + "The erythrocyte series showed basophilic punctate.", + "The abdominal ultrasound showed splenomegaly.", + "The abdominal ultrasound showed bilateral pleural effusion.", + "A lumbar puncture was performed.", + "Cerebrospinal fluid analysis was performed.", + "The patient showed clinical improvement.", + "The patient had a neurological sequela of monoparesia of the motor nerves in the lower left." + ], + "summary": "We present the case of an adult male patient with cerebral malaria by Plasmodium vivax, who starts with general discomfort and fever, then presents convulsions more than twice a day with loss of consciousness and motor functional limitation. He is given a thick drop where Plasmodium vivax trophozoites and depression of the three blood series are observed. He is given treatment with artesunate and clindamycin for five days, a blood transfusion and continues with primaquine for seven days. The patient shows clinical improvement with neurological sequelae in the left lower extremity.\n", + "summary_subclaims": [ + "The patient is an adult male.", + "The patient has cerebral malaria by Plasmodium vivax.", + "The patient starts with general discomfort and fever.", + "The patient presents convulsions more than twice a day.", + "The patient has loss of consciousness.", + "The patient has motor functional limitation.", + "A thick drop shows Plasmodium vivax trophozoites.", + "A thick drop shows depression of the three blood series.", + "The patient is given treatment with artesunate and clindamycin for five days.", + "The patient receives a blood transfusion.", + "The patient continues with primaquine for seven days.", + "The patient shows clinical improvement.", + "The patient has neurological sequelae in the left lower extremity." + ] + }, + { + "id": "multiclinsum_test_1011_en.txt", + "fulltext": "A 63-year-old man was hospitalized with COVID-19 in the emergency department. CT examination showed a 2-cm renal mass in the right kidney. He had no palpable lymphadenopathy, and blood tests showed low lymphocytes and hemoglobin and a normal LDH (white blood cell count 6.8 × 103/μL, 70.2% neutrophils, 11.5% lymphocytes, hemoglobin 12.0 g/dL, LDH 219 U/L). Anti-HTLV-1 antibodies in the serum were negative. Abdominal enhanced CT examination was performed that showed good enhancement of the noted mass in the corticomedullary phase and washout in the nephrographic phase . He was diagnosed as having cT1aN0M0 renal cell carcinoma, and RAPN using a retroperitoneal approach was carried out. The resected specimen was a tumor with a dark red cross-section and indistinct borders. HE staining of the tumor showed diffuse infiltration of intermediate-sized atypical lymphocytes. With further immunohistochemical staining, it was found that the lymphocytes were CD3(+) and CD20(−) , indicating that the neoplastic lymphoid cells were considered to be of T-cell origin. Immunostained lymphocytes were CD4(−), CD8(+), TIA-1(+), and EBER(−) . We diagnosed the patient as having PTCL-NOS. Postoperative FDG-PET did not show metastasis. From the above, the disease was considered to be in the IE stage of the Lugano classification. The patient has been followed for 20 months after RAPN without additional treatment and recurrence.", + "fulltext_subclaims": [ + "The patient was a 63-year-old man.", + "The patient was hospitalized with COVID-19 in the emergency department.", + "CT examination showed a 2-cm renal mass in the right kidney.", + "The patient had no palpable lymphadenopathy.", + "Blood tests showed low lymphocytes and hemoglobin.", + "The patient's LDH was normal.", + "Anti-HTLV-1 antibodies in the serum were negative.", + "Abdominal enhanced CT examination was performed.", + "The noted mass showed good enhancement in the corticomedullary phase.", + "The mass showed washout in the nephrographic phase.", + "The patient was diagnosed as having cT1aN0M0 renal cell carcinoma.", + "RAPN using a retroperitoneal approach was carried out.", + "The resected specimen was a tumor with a dark red cross-section.", + "The tumor had indistinct borders.", + "HE staining showed diffuse infiltration of intermediate-sized atypical lymphocytes.", + "The lymphocytes were CD3(+) and CD20(−).", + "The neoplastic lymphoid cells were considered to be of T-cell origin.", + "The lymphocytes were CD4(−), CD8(+), TIA-1(+), and EBER(−).", + "The patient was diagnosed as having PTCL-NOS.", + "Postoperative FDG-PET did not show metastasis.", + "The disease was considered to be in the IE stage of the Lugano classification.", + "The patient has been followed for 20 months after RAPN.", + "The patient has had no additional treatment.", + "The patient has had no recurrence." + ], + "summary": "A 63-year-old man was hospitalized with coronavirus infectious disease, emerged in 2019 in the emergency department. Computed tomography examination showed a 2-cm renal mass in the right kidney. Abdominal enhanced computed tomography examination revealed that the noted mass showed good enhancement in the corticomedullary phase and washout in the nephrogenic phase. No metastatic lesions were found. He was diagnosed as having cT1aN0M0 renal cell carcinoma, and robotic-assisted partial nephrectomy was carried out. The pathological diagnosis was peripheral T-cell lymphoma, not otherwise specified. He has been followed for 20 months after robotic-assisted partial nephrectomy without additional treatment and recurrence.", + "summary_subclaims": [ + "A 63-year-old man was hospitalized with coronavirus infectious disease, emerged in 2019 in the emergency department.", + "Computed tomography examination showed a 2-cm renal mass in the right kidney.", + "Abdominal enhanced computed tomography examination revealed that the noted mass showed good enhancement in the corticomedullary phase.", + "Abdominal enhanced computed tomography examination revealed that the noted mass showed washout in the nephrogenic phase.", + "No metastatic lesions were found.", + "He was diagnosed as having cT1aN0M0 renal cell carcinoma.", + "Robotic-assisted partial nephrectomy was carried out.", + "The pathological diagnosis was peripheral T-cell lymphoma, not otherwise specified.", + "He has been followed for 20 months after robotic-assisted partial nephrectomy without additional treatment.", + "He has been followed for 20 months after robotic-assisted partial nephrectomy without recurrence." + ] + }, + { + "id": "multiclinsum_test_841_en.txt", + "fulltext": "A 59-year-old Italian man presented with abdominal pain localized in the right upper quadrant, constipation and vomiting for longer than one week. The patient had inconstant symptoms including shortness of breath and dyspnea. His medical history included right-sided rib fractures in a motor vehicle crash seven years previously.\nOn physical examination, bowel sounds were present in the right hemithorax on auscultation. A chest X-ray showed elevation of the right hemidiaphragm elevation, with a portion of the colon and the small intestine transposed in the right hemithorax as a diaphragmatic rupture. A barium study showed small bowel and right colon herniation into the right hemithorax, passing behind the liver . Computed tomography (CT) scan confirmed the diaphragmatic herniation .\nThe patient underwent laparotomy, and herniation of the right colon and small intestine (40 mm in length) was seen. There were no ischemic changes or perforation, but the colon was slightly edematous. No resection of any part of the intestinal tract was necessary. The colon and the small intestine were reduced into the abdomen. As usual in traumatic lesions, there was absence of the hernial sack: the hernia opening was only 50 mm in length, . The hernia opening was repaired with interrupted non-absorbable sutures; placement of a polymeric prosthetic mesh was not required at the time of the intervention. A drain was placed in the right side of the thorax. The operating time was 45 minutes. The thoracic drain was removed on the third post-operative day and the patient was discharged on the fifth postoperative day.", + "fulltext_subclaims": [ + "The patient is a 59-year-old Italian man.", + "The patient had abdominal pain localized in the right upper quadrant.", + "The patient had constipation and vomiting for longer than one week.", + "The patient had inconstant symptoms including shortness of breath and dyspnea.", + "The patient had right-sided rib fractures in a motor vehicle crash seven years previously.", + "Bowel sounds were present in the right hemithorax on auscultation.", + "A chest X-ray showed elevation of the right hemidiaphragm.", + "A chest X-ray showed a portion of the colon and the small intestine transposed in the right hemithorax as a diaphragmatic rupture.", + "A barium study showed small bowel and right colon herniation into the right hemithorax.", + "A barium study showed the herniation passing behind the liver.", + "Computed tomography (CT) scan confirmed the diaphragmatic herniation.", + "The patient underwent laparotomy.", + "Herniation of the right colon and small intestine (40 mm in length) was seen.", + "There were no ischemic changes or perforation.", + "The colon was slightly edematous.", + "No resection of any part of the intestinal tract was necessary.", + "The colon and the small intestine were reduced into the abdomen.", + "There was absence of the hernial sack.", + "The hernia opening was only 50 mm in length.", + "The hernia opening was repaired with interrupted non-absorbable sutures.", + "Placement of a polymeric prosthetic mesh was not required at the time of the intervention.", + "A drain was placed in the right side of the thorax.", + "The operating time was 45 minutes.", + "The thoracic drain was removed on the third post-operative day.", + "The patient was discharged on the fifth postoperative day." + ], + "summary": "We report a case of a 59-year-old Italian man hospitalized for abdominal pain and vomiting. His medical history included a blunt trauma seven years previously. A chest X-ray showed right diaphragm elevation, and computed tomography revealed that the greater omentum, a portion of the colon and the small intestine had been transposed in the hemithorax through a diaphragm rupture. The patient underwent laparotomy, at which time the colon and small intestine were reduced back into the abdomen and the diaphragm was repaired.", + "summary_subclaims": [ + "The patient was a 59-year-old Italian man.", + "The patient was hospitalized for abdominal pain and vomiting.", + "His medical history included a blunt trauma seven years previously.", + "A chest X-ray showed right diaphragm elevation.", + "Computed tomography revealed that the greater omentum, a portion of the colon and the small intestine had been transposed in the hemithorax through a diaphragm rupture.", + "The patient underwent laparotomy.", + "At laparotomy, the colon and small intestine were reduced back into the abdomen.", + "The diaphragm was repaired." + ] + }, + { + "id": "multiclinsum_test_3340_en.txt", + "fulltext": "In this case report, prepared in adherence to the SCARE 2023 guidelines for surgical case reporting. A 35-year-old female presented to our urology clinic on [02-27-2023] with a 2-week history of left lumbar pain. Computed tomography urography (CTU) performed on [02-28-2023] identified Y-shaped double renal pelvis malformations in the left kidney. Preoperative renal function was normal (creatinine: 0.60 mg/dL). Urine analysis indicated elevated white blood cells and red blood cells in the urine, and no obvious abnormalities were found in the other test results. Urinary CTU suggested double renal pelvis malformations of the left kidney, the ureters fused at the lower edge of L3, multiple upper ureteral calculi on the left side with dilation of the upper renal pelvis. The upper calculus was slightly smaller, with a long diameter of about 25 mm and an average CT value of 850 hu. The lower calculus was larger and strip-shaped, with a long diameter of about 38 mm and an average CT value of 1101 hu.\n\nThe patient was placed in the right lateral position for surgical treatment. The surgical method selected was retroperitoneal laparoscopic ureterolithotomy. During the operation, it was observed that there was a double ureteral malformation in the upper left segment, in a Y shape, with severe adhesion to the surrounding tissues. After carefully separating the ureter, an incision was made at the calculus site of the upper ureter, and the incision was extended by about 3 cm. The calculus at the lower part was removed. The texture was slightly hard and was about 4 cm in length and elongated. The ureter was examined again up to the near renal hilum. No calculi were seen under laparoscopy. Considering that the calculus had moved upward to the upper left renal pelvis, a flexible ureteroscope was inserted from the first incision. With the assistance of laparoscopy, the flexible ureteroscope was placed along the ureteral incision into the renal pelvis. A calculus was seen in the left renal pelvis, about 3 cm in size. An attempt to insert a stone-catching basket to remove the calculus failed. Then, percutaneous nephrolithotomy under direct laparoscopy was changed, and a Fr18 channel was established. A ureteroscope was inserted, and the calculus could be seen. Then, a holmium laser was inserted to crush and remove the calculus. The angle of the ureteroscope was adjusted, and the junction of the left renal pelvis and ureter was found. An integrated double J stent was inserted. Under direct laparoscopy, it was seen that the double J stent passed through the ureteral incision. The operation time was approximately 3 h, and the intraoperative blood loss was about 50 mL. Postoperative review CT examination showed no obvious calculus shadow. The double J stent in the body was removed 1.5 months later. After half a year, the review of urinary CTU was normal.", + "fulltext_subclaims": [ + "The case report was prepared in adherence to the SCARE 2023 guidelines for surgical case reporting.", + "A 35-year-old female presented to the urology clinic on [02-27-2023] with a 2-week history of left lumbar pain.", + "Computed tomography urography (CTU) performed on [02-28-2023] identified Y-shaped double renal pelvis malformations in the left kidney.", + "Preoperative renal function was normal (creatinine: 0.60 mg/dL).", + "Urine analysis indicated elevated white blood cells and red blood cells in the urine.", + "No obvious abnormalities were found in the other test results.", + "Urinary CTU suggested double renal pelvis malformations of the left kidney.", + "The ureters fused at the lower edge of L3.", + "Multiple upper ureteral calculi on the left side were present.", + "The upper calculus had a long diameter of about 25 mm and an average CT value of 850 hu.", + "The lower calculus was larger and strip-shaped, with a long diameter of about 38 mm and an average CT value of 1101 hu.", + "The patient was placed in the right lateral position for surgical treatment.", + "The surgical method selected was retroperitoneal laparoscopic ureterolithotomy.", + "During the operation, a double ureteral malformation in the upper left segment, in a Y shape, was observed.", + "The ureter was severely adhered to the surrounding tissues.", + "An incision was made at the calculus site of the upper ureter and extended by about 3 cm.", + "The calculus at the lower part was removed.", + "The calculus was about 4 cm in length and elongated.", + "A flexible ureteroscope was inserted from the first incision.", + "The flexible ureteroscope was placed along the ureteral incision into the renal pelvis.", + "A calculus was seen in the left renal pelvis, about 3 cm in size.", + "An attempt to insert a stone-catching basket to remove the calculus failed.", + "Percutaneous nephrolithotomy under direct laparoscopy was changed.", + "A Fr18 channel was established.", + "A ureteroscope was inserted, and the calculus could be seen.", + "A holmium laser was inserted to crush and remove the calculus.", + "An integrated double J stent was inserted.", + "Under direct laparoscopy, the double J stent was seen to pass through the ureteral incision.", + "The operation time was approximately 3 h.", + "The intraoperative blood loss was about 50 mL.", + "Postoperative review CT examination showed no obvious calculus shadow.", + "The double J stent in the body was removed 1.5 months later.", + "After half a year, the review of urinary CTU was normal." + ], + "summary": "A 35-year-old female with flank pain and hydronephrosis was diagnosed with double renal pelvis malformations and impacted ureteral calculi. A staged approach was used: laparoscopy corrected ureteral malformations, followed by flexible ureteroscopy and percutaneous nephroscopic holmium laser lithotripsy. Complete calculus clearance was confirmed intraoperatively and postoperatively.", + "summary_subclaims": [ + "The patient is a 35-year-old female.", + "The patient had flank pain.", + "The patient had hydronephrosis.", + "The patient was diagnosed with double renal pelvis malformations.", + "The patient had impacted ureteral calculi.", + "A staged approach was used.", + "Laparoscopy corrected ureteral malformations.", + "Flexible ureteroscopy was performed.", + "Percutaneous nephroscopic holmium laser lithotripsy was performed.", + "Complete calculus clearance was confirmed intraoperatively.", + "Complete calculus clearance was confirmed postoperatively." + ] + }, + { + "id": "multiclinsum_test_2612_en.txt", + "fulltext": "In December 2022, a 26-year-old Iranian woman was referred to the otolaryngology clinic of our institution, complaining of a growing neck mass, hoarseness, dysphagia, and nocturnal sweating over four months. Her family history and past medical history were unremarkable.\nOn examination, a palpable mass (approximately 4 × 4 cm) was located at the left thyroid lobe. The mass was mobile, non-tender, and hard in consistency. The rest of the physical examination findings were unremarkable.\nThe laboratory tests revealed no abnormalities, and her thyroid function test results were all in the normal range.\nNeck ultrasonography showed the increased size of the thyroid gland (right lobe 50×19×17 mm and the left lobe 72×31×27 mm). Parenchymal echo of the isthmus and left thyroid lobe was decreased and heterogeneous, suggesting replacing the entire left lobe and the isthmus with a hypoechoic mass. Moreover, it revealed two hypoechoic nodules (sizes of 6 and 10 mm) with distinct boundaries in the right thyroid lobe. No calcification and lymphadenopathy were reported in the neck ultrasound.\nFine needle aspiration (FNA) cytology of the left lobe of the thyroid gland revealed colloid goiter without evidence of malignancy.\nThe patient underwent a total thyroidectomy. Intraoperatively, due to the firm consistency of the mass and suspicion of malignancy, the frozen section was performed. The frozen section analysis of the left lobe and isthmus was positive for malignancy. According to the lack of evidence regarding the lymph nodes’ involvement in ultrasound and benign FNA cytology results, only paratracheal lymph node dissection was performed for the patient, instead of complete neck dissection.\nThe postsurgical course was uneventful, and the patient was discharged on the third day following the operation.\nPostoperative histopathological examinations of the surgical specimens obtained from surgery were performed. Gross examination showed the replacement of most of the left thyroid lobe and isthmus with a white multinodular mass, as well as a part of the right lobe with different tumors, including a white multinodular mass and two distinct white nodules. On microscopic examination of the same tumors in the left and right lobe by H and E staining, tumor cells had ill-defined cell borders with vesicular nuclei and distinct nucleoli arranged in well-demarcated lobular growth with fibrous bands separating variably sized solid islands and some lymphocytes between tumoral cells with focal necrosis. The immunohistochemical analyses of this tumor were positive for CD5, P63, CD117, CK 5/6, CKAE1/AE3, and Ki-67 labeling index (15-20%, hot spot) but negative for thyroglobulin, calcitonin, TTF 1, and TdT. Hence, based on the immunohistochemical results, this tumor was definitely diagnosed as ITTC.\nThe gross examination of two other smaller tumors, which were near the first tumor in the right lobe, showed two white cream nodules with sizes of 0.2 and 0.7 cm attached to the thyroid capsule. Microscopic examination of both nodules showed small to medium-sized follicular structures with nuclear grooves, intranuclear inclusions, and ground glass appearance. These tumors were diagnosed as follicular variant of papillary thyroid carcinoma according to the immunohistochemical analyses: negative for CD5, P63, CK 5/6, while positive for TTF 1, thyroglobulin, and CKAE1/AE3.\nThe excised paratracheal lymph nodes were tumor-free based on histopathological studies.\nITTC invaded the cervical muscles and fibrofatty tissue with no lymphovascular or perineural invasion, but the PTC tumor was localized into the thyroid gland and did not spread outside the thyroid capsule.\nThe pathological and immunohistochemical analysis results of our case are shown in and , respectively.\nThe patient underwent postoperative radiotherapy with 60 Gy in 30 fractions over one month. She remained well during the one month of the follow-up period, with no tumor recurrence or metastasis on imaging studies.", + "fulltext_subclaims": [ + "A 26-year-old Iranian woman was referred to the otolaryngology clinic in December 2022.", + "She complained of a growing neck mass, hoarseness, dysphagia, and nocturnal sweating over four months.", + "Her family history and past medical history were unremarkable.", + "On examination, a palpable mass (approximately 4 × 4 cm) was located at the left thyroid lobe.", + "The mass was mobile, non-tender, and hard in consistency.", + "The rest of the physical examination findings were unremarkable.", + "The laboratory tests revealed no abnormalities.", + "Her thyroid function test results were all in the normal range.", + "Neck ultrasonography showed the increased size of the thyroid gland.", + "The right lobe was 50×19×17 mm and the left lobe was 72×31×27 mm.", + "Parenchymal echo of the isthmus and left thyroid lobe was decreased and heterogeneous.", + "The ultrasound suggested replacing the entire left lobe and the isthmus with a hypoechoic mass.", + "The ultrasound revealed two hypoechoic nodules (sizes of 6 and 10 mm) with distinct boundaries in the right thyroid lobe.", + "No calcification and lymphadenopathy were reported in the neck ultrasound.", + "Fine needle aspiration (FNA) cytology of the left lobe of the thyroid gland revealed colloid goiter without evidence of malignancy.", + "The patient underwent a total thyroidectomy.", + "Intraoperatively, due to the firm consistency of the mass and suspicion of malignancy, the frozen section was performed.", + "The frozen section analysis of the left lobe and isthmus was positive for malignancy.", + "According to the lack of evidence regarding the lymph nodes’ involvement in ultrasound and benign FNA cytology results, only paratracheal lymph node dissection was performed for the patient.", + "The postsurgical course was uneventful.", + "The patient was discharged on the third day following the operation.", + "Postoperative histopathological examinations of the surgical specimens obtained from surgery were performed.", + "Gross examination showed the replacement of most of the left thyroid lobe and isthmus with a white multinodular mass.", + "Gross examination showed a part of the right lobe with different tumors, including a white multinodular mass and two distinct white nodules.", + "On microscopic examination of the same tumors in the left and right lobe by H and E staining, tumor cells had ill-defined cell borders with vesicular nuclei and distinct nucleoli.", + "The tumor cells were arranged in well-demarcated lobular growth with fibrous bands separating variably sized solid islands.", + "Some lymphocytes were present between tumoral cells with focal necrosis.", + "The immunohistochemical analyses of this tumor were positive for CD5, P63, CD117, CK 5/6, CKAE1/AE3, and Ki-67 labeling index (15-20%, hot spot).", + "The immunohistochemical analyses were negative for thyroglobulin, calcitonin, TTF 1, and TdT.", + "Based on the immunohistochemical results, this tumor was definitely diagnosed as ITTC.", + "The gross examination of two other smaller tumors, which were near the first tumor in the right lobe, showed two white cream nodules with sizes of 0.2 and 0.7 cm attached to the thyroid capsule.", + "Microscopic examination of both nodules showed small to medium-sized follicular structures with nuclear grooves, intranuclear inclusions, and ground glass appearance.", + "These tumors were diagnosed as follicular variant of papillary thyroid carcinoma according to the immunohistochemical analyses.", + "The immunohistochemical analyses of these tumors were negative for CD5, P63, CK 5/6.", + "The immunohistochemical analyses were positive for TTF 1, thyroglobulin, and CKAE1/AE3.", + "The excised paratracheal lymph nodes were tumor-free based on histopathological studies.", + "ITTC invaded the cervical muscles and fibrofatty tissue.", + "There was no lymphovascular or perineural invasion.", + "The PTC tumor was localized into the thyroid gland and did not spread outside the thyroid capsule.", + "The patient underwent postoperative radiotherapy with 60 Gy in 30 fractions over one month.", + "She remained well during the one month of the follow-up period.", + "There was no tumor recurrence or metastasis on imaging studies." + ], + "summary": "A 26-year-old female presented with a growing neck mass, hoarseness, and dysphagia over four months. Ultrasonography revealed that the entire left lobe and the isthmus of the thyroid were replaced with a hypoechoic mass. Moreover, it revealed two hypoechoic nodules in the right thyroid. The patient underwent a total thyroidectomy and paratracheal lymph node dissection. Histopathological examinations revealed the coexistence of ITTC and PTC in the same thyroid. In immunohistochemical analyses, the ITTC was positive for CD5, P63, CD117, and CK 5/6 and negative for thyroglobulin, calcitonin, and TTF 1. At the same time, PTC was positive for TTF 1 and thyroglobulin and negative for CD5, P63, and CK 5/6. The patient received postoperative radiotherapy and remained well with no evidence of recurrence during one month follow-up.", + "summary_subclaims": [ + "The patient is a 26-year-old female.", + "The patient had a growing neck mass, hoarseness, and dysphagia over four months.", + "Ultrasonography revealed that the entire left lobe and the isthmus of the thyroid were replaced with a hypoechoic mass.", + "Ultrasonography revealed two hypoechoic nodules in the right thyroid.", + "The patient underwent a total thyroidectomy.", + "The patient underwent paratracheal lymph node dissection.", + "Histopathological examinations revealed the coexistence of ITTC and PTC in the same thyroid.", + "The ITTC was positive for CD5.", + "The ITTC was positive for P63.", + "The ITTC was positive for CD117.", + "The ITTC was positive for CK 5/6.", + "The ITTC was negative for thyroglobulin.", + "The ITTC was negative for calcitonin.", + "The ITTC was negative for TTF 1.", + "The PTC was positive for TTF 1.", + "The PTC was positive for thyroglobulin.", + "The PTC was negative for CD5.", + "The PTC was negative for P63.", + "The PTC was negative for CK 5/6.", + "The patient received postoperative radiotherapy.", + "The patient remained well with no evidence of recurrence during one month follow-up." + ] + }, + { + "id": "multiclinsum_test_655_en.txt", + "fulltext": "A 41-year-old Hispanic man with history of rheumatoid arthritis (RA) and type2 diabetes mellitus was referred to the emergency room (ER) of a large urban city hospital from the rheumatology clinic for newly developed bilateral lower extremity rashes and edema after 1 year of being lost to follow-up. He was diagnosed with RA 2 years prior to admission after presenting with polyarthritis and strongly positive serum immunologic markers (rheumatoid factor titer 1220 IU/ml [normal range, < 20 IU/ml], anti-cyclic citrullinated peptide titer 240.05 U/ml [normal range, < 20 U/ml; strongly positive, > 60 U/ml]). Methotrexate, low dose prednisone and sulfasalazine had resulted in better control of disease activity. Unfortunately, the patient was lost to follow-up. He had been off of disease-modifying antirheumatic drugs (DMARDs) for RA and was only taking ibuprofen 800 mg every 8 h as needed for about a month for joint pain.\nWhen the patient was seen in the ER (day 0), the physical exam showed pinpoint, non-tender, non-blanchable purpuric macules coalescing into large patches on the left leg, with smaller areas of involvement on the right leg. The skin lesions were in a dependent distribution involving more of the flexor surface than extensor surface. Joint exam revealed polyarticular arthritis with pain and swelling in the right 2nd and 3rd metacarpophalangeal (MCP) joints and left 3rd (MCP). Boutonniere deformities were observed in both hands (left more than right), as well as subcutaneous nodules under the elbow. Significant pitting edema was found in the lower extremities. The rest of the physical exam was unremarkable.\nHis urinalysis showed red blood cell of 21/high power field (hpf) and white blood cell 7/hpf. His creatinine was 0.9 mg/dl, with estimated GFR of 93 ml/min using MDRD equation. The diagnosis of nephrotic syndrome was established given large proteinuria (11 g/gm) on the spot urine sample, hypoalbuminemia (2.2 g/dL), and peripheral edema.\nFurther serology work-up showed low C3 of 86 (normal range 88–201), C4 of 24 (normal range 16–47), positive cryoglobulin qualitative with < 1% Cryocrit, as well as negative c-ANCA, p-ANCA, and ANA (including Anti-dsDNA, Anti-Smith, Anti-SSA and Anti-SSB). He had a polyclonal elevation in IgG (1790 mg/dl, normal range 694-1618 mg/dl) and IgA (661 mg/dl, normal range 68-378 mg/dl), with a normal IgM (181 mg/dl, normal range 77-220 mg/dl). There was absence of M-spike on serum protein electrophoresis. HIV, Hepatitis C and hepatitis B serologies were negative. Unfortunately, rheumatoid factor (RF) titer was not checked at that point of time. Prednisone was started at 10 mg daily empirically for treatment of nephrotic syndrome and active RA, and patient was referred to renal clinic for further diagnosis and monitoring of therapy.\nThree days after being discharged (Day 5) and prior to being seen in the renal clinic, the patient developed painful purplish discoloration of the distal right thumb, which prompted another ER visit (Day 12). On exam, the distal phalanx was cool to touch and exquisitely tender on palpation with signs of onycholysis. There was no sign of cutaneous necrosis or surrounding cellulitis. Doppler ultrasound showed good radial and ulnar pulses with good blood flow to the distal phalanx of the right thumb. He was discharged from the ER since no macrovascular signs were found, and he was given follow up with rheumatology. On Day 16, rheumatology noticed new lower lip purpuric lesions, which, in conjunction to the positive cryoglobulin qualitative test along with the thumb and lower leg lesions, prompted an increase in Prednisone dose to 80 mg daily for treatment of systemic cryoglobulinemic vasculitis. Unfortunately, his skin lesions were not biopsied.\nRenal biopsy was performed on day 28. A total of 23 glomeruli were obtained, of which 1 was sclerosed. Light microscopy showed diffuse capillary wall thickening with rare eosinophilic intracapillary thrombi . Silver stain showed spikes and holes in the glomerular basement membrane. Immunofluorescence (IF) staining showed diffuse, finely granular deposits of IgG , IgA, IgM, κ and γ light chains, C1q and C3. Anti-phospholipase A2 receptor (PLA2R) stain was negative. Electron microscopy (EM) showed widespread subepithelial and intramembranous electron-dense deposits, with diffuse foot process effacement . Subendothelial or mesangial tubuloreticular inclusions suggestive of lupus nephritis were not found. The final pathologic diagnosis was compatible with membranous nephropathy with features of cryoglobulinemic glomerulonephritis. There were no signs of diabetic nephropathy on light microscopy.\nGiven the multisystem involvement (purpuric, non-blanching lesions in multiple skin and mucosal surfaces), characteristic pathological features (intracapillary thrombi) on renal biopsy and positive cryoglobulin qualitative test, a decision was made to start treatment empirically as systemic cryoglobulinemic vasculitis with Rituximab, considering that this is the first line treatment for hepatitis C-related cryoglobulinemic disease and evidence is limited for treatment of renal involvement in non-infectious mixed cryoglobulinemia. Unfortunately, treatment was delayed due to indeterminate Quantiferon and PPD tests.\nOne and a half months after starting high dose steroids (day 62), his right thumb and lower lip lesions had resolved, and his urine protein/creatinine ratio had decreased to 3.4 g/g.\nPatient was started on Rituximab 1 g every 2 weeks and received 2 doses on day 67 and day 88, resulting in improvement of his proteinuria to 1.3 g/g (day 88). By this time, patient was on Prednisone 40 mg daily. Due to the persistently elevated blood sugar and Cushingoid features, a taper of the steroids occurred over the following 2 months.\nTwo months after he completed rituximab, the patient was admitted for presumed pneumonia (day 158) secondary to immunosuppression after presenting with 2-week history of dyspnea and cough. He underwent a CT scan of the chest with contrast, which showed hilar and mediastinal adenopathy without parenchymal consolidations. He underwent bronchoscopy with endobronchial ultrasound (EBUS), and the transbronchial lymph node biopsy of the mediastinal lymph node showed non-caseating granulomas. Acid fast stain and mycobacterium culture were negative. To rule out a lymphoproliferative disorder as a differential of non-caseating granulomas, PET scan, bone marrow biopsy and flow cytometry were performed, and they were negative for clonal lymphocytic proliferation. A clinical diagnosis of sarcoidosis was made, and his Prednisone dose was increased to 40 mg daily (patient was on a steroid taper and taking Prednisone 20 mg daily prior to this admission), resulting in rapid pulmonary symptoms improvement. No extrapulmonary signs of sarcoidosis developed in the course of his illness (e.g. erythema nodosum).\nSix months after his first course of Rituximab, his proteinuria had increased back to 7 g/gm (day 291), so a decision to repeat Rituximab course was made. Unfortunately, this was again delayed due to patient’s personal issues, and he started it 2 months later. This time he received weekly Rituximab 750 mg for a total of 4 doses. Patient again manifested a dramatic initial response to the treatment with reduction of proteinuria to 1.1 g/g (day 371), but with a slow increase in his urine protein to creatinine ratio over the following 3 months, to an average of 3.8 g/g, compatible with an overall partial response if compared with his initial proteinuria of 11 g/g on presentation . His Creatinine level has remained stable between 0.8 ~ 1.1 mg/dl during the period of one and half year follow-up. His skin lesions and articular manifestations have completely resolved since the initiation of high dose steroids on day 62. Repeat Cryoprecipitate levels has been persistently positive. A timeline of the disease course is summarized in Fig. .", + "fulltext_subclaims": [ + "The patient is a 41-year-old Hispanic man.", + "He has a history of rheumatoid arthritis.", + "He has a history of type 2 diabetes mellitus.", + "He was referred to the emergency room from the rheumatology clinic.", + "He had been lost to follow-up for about a month.", + "He was off of disease-modifying antirheumatic drugs for RA.", + "He was taking ibuprofen 800 mg every 8 hours as needed.", + "Physical exam showed pinpoint, non-tender, non-blanchable purpuric macules.", + "The skin lesions were in a dependent distribution.", + "The lesions involved more of the flexor surface than extensor surface.", + "Joint exam revealed polyarticular arthritis.", + "Boutonniere deformities were observed in both hands.", + "Subcutaneous nodules were found under the elbow.", + "Significant pitting edema was found in the lower extremities.", + "Urinalysis showed red blood cells of 21/high power field.", + "The diagnosis of nephrotic syndrome was established.", + "The spot urine sample showed large proteinuria of 11 g/gm.", + "Serum albumin was 2.2 g/dL.", + "Low C3 was 86.", + "Low C4 was 24.", + "Positive cryoglobulin qualitative test was found.", + "Prednisone was started at 10 mg daily.", + "The patient was referred to renal clinic.", + "Three days after discharge, the patient developed painful purplish discoloration of the distal right thumb.", + "He had new lower lip purpuric lesions.", + "Prednisone dose was increased to 80 mg daily.", + "Renal biopsy was performed on day 28.", + "Light microscopy showed diffuse capillary wall thickening.", + "Silver stain showed spikes and holes in the glomerular basement membrane.", + "Immunofluorescence staining showed diffuse, finely granular deposits of IgG, IgA, IgM, κ and γ light chains, C1q and C3.", + "Electron microscopy showed widespread subepithelial and intramembranous electron-dense deposits.", + "The final pathologic diagnosis was compatible with membranous nephropathy with features of cryoglobulinemic glomerulonephritis.", + "Treatment with Rituximab was started.", + "Treatment was delayed due to indeterminate Quantiferon and PPD tests.", + "One and a half months after starting high dose steroids, his right thumb and lower lip lesions had resolved.", + "His urine protein/creatinine ratio had decreased to 3.4 g/g.", + "He received two doses of Rituximab on day 67 and day 88.", + "His urine protein/creatinine ratio improved to 1.3 g/g.", + "He was started on a steroid taper.", + "He was admitted for presumed pneumonia.", + "CT scan showed hilar and mediastinal adenopathy.", + "Bronchoscopy with EBUS showed non-caseating granulomas.", + "A clinical diagnosis of sarcoidosis was made.", + "His Prednisone dose was increased to 40 mg daily.", + "Six months after his first course of Rituximab, his proteinuria had increased back to 7 g/gm.", + "A decision to repeat Rituximab course was made.", + "He received weekly Rituximab 750 mg for a total of 4 doses.", + "His proteinuria decreased to 1.1 g/g.", + "His Creatinine level remained stable between 0.8 ~ 1.1 mg/dl.", + "His skin lesions and articular manifestations have completely resolved.", + "Repeat Cryoprecipitate levels have been persistently positive." + ], + "summary": "A 41-year-old man with chronic active rheumatoid arthritis presented with nephrotic syndrome and was found to have membranous nephropathy with eosinophilic intracapillary thrombi on renal biopsy. Proteinuria persisted despite complete withdrawal from non-steroidal anti-inflammatory drugs (NSAIDs) and disease-modifying anti-rheumatic drugs (DMARDs). Throughout the disease course, he developed cryoglobulinemic vasculitis and pulmonary sarcoidosis, both of which achieved clinical resolution with glucocorticoids. However, only partial improvement was observed in proteinuria with treatment of steroids and Rituximab.", + "summary_subclaims": [ + "The patient is a 41-year-old man.", + "The patient has chronic active rheumatoid arthritis.", + "The patient presented with nephrotic syndrome.", + "The patient was found to have membranous nephropathy.", + "The patient had eosinophilic intracapillary thrombi on renal biopsy.", + "Proteinuria persisted despite complete withdrawal from non-steroidal anti-inflammatory drugs.", + "Proteinuria persisted despite complete withdrawal from disease-modifying anti-rheumatic drugs.", + "The patient developed cryoglobulinemic vasculitis.", + "The patient developed pulmonary sarcoidosis.", + "Cryoglobulinemic vasculitis achieved clinical resolution with glucocorticoids.", + "Pulmonary sarcoidosis achieved clinical resolution with glucocorticoids.", + "Only partial improvement was observed in proteinuria with treatment of steroids and Rituximab." + ] + }, + { + "id": "multiclinsum_test_1666_en.txt", + "fulltext": "A 40-year-old man was taken to the local hospital by his office supervisor by foot due to concerns over moving a foreign object impaling his chest (A). As soon as the emergency physician noted that an ice pick was penetrating the man’s left chest, we established an intravenous line while preventing the object from moving from its original position, and an ambulance took the patient to our emergency department.\nOn examination, the patient’s general condition was not critical (Glasgow Coma Scale score 15, respiratory rate 24 breaths/min, blood pressure 123/79 mmHg, heart rate 76 beats/min, oxygen saturation 100% on 2 L nasal cannula, and body temperature 37.2 °C). The patient would not reveal the actual cause of the injury. An interview with his family disclosed no history of depressive disorder, pharmacological treatment, substance use, or alcohol abuse, but the patient had a history of several pneumothorax injuries, one 10 years prior and two a year prior to this episode. In all episodes, he had been hospitalized for several days for chest drainage and discharged without any complications. Considering his condition, we strongly suspected a self-inflicted injury. However, our patient denied any suicidal ideation, depressive mood, or hopelessness. His family members described him as a quiet and gentle person who did not behave impulsively.\nCardiovascular auscultation was unremarkable without murmurs or gallops. Chest X ray demonstrated a clear lung field without pneumothorax or hemothorax (B). Emergency echocardiography disclosed a small amount of pericardial effusion without cardiac tamponade. Computed tomography (CT) of the chest showed linear metallic density in the pulmonary trunk and a small amount of pericardial fluid (A–D). Pneumothorax or bulla was not seen on chest CT. Based on the diagnosis of penetrating cardiac injury, we transferred the patient to the operating theater after cardiac surgery consultation.\nWe placed the patient in the supine position. After performing a full median sternotomy, the pericardium was opened. There was a small amount of pericardial effusion that seemed to be mixed with blood. The ice pick had been stuck in the main pulmonary artery (MPA) through the pericardium without any injury to the left lung or internal thoracic artery. Heparin was given and cardiopulmonary bypass (CPB) was commenced with ascending aortic and bicaval cannulation. The patient was cooled down to 32 ° Celsius. After aortic cross clamping, the cardioplegia was infused into the aortic root to obtain cardiac arrest. A longitudinal incision was made in the MPA, and we carefully removed the foreign body, which was lodged through the MPA from the anterior to posterior wall near the annulus of the pulmonary valve without injury to the left main coronary trunk. The holes made by the ice pick were closed using 5-0 polypropylene suture. The MPA was closed using 4-0 polypropylene over and over running suture. After rewarming and deairing, the aortic clamp was removed. The patient’s sinus rhythm came back spontaneously. CPB weaning was smooth, and protamine was given. The chest was closed in a normal fashion. Postoperative recovery was uneventful.\nA police investigation showed no criminal events associated with the injury. Although the patient denied stabbing himself with the ice pick, we strongly suspected the penetrating cardiac injury was self-inflicted and consulted the psychiatric department on day 7 to closely monitor the patient during hospitalization. During the psychiatric counseling sessions after the surgery, the patient continued to stubbornly deny a suicide attempt. At 16 days POD, the patient was discharged to home without psychiatric follow-up.", + "fulltext_subclaims": [ + "A 40-year-old man was taken to the local hospital by his office supervisor by foot due to concerns over moving a foreign object impaling his chest.", + "An ice pick was penetrating the man’s left chest.", + "An ambulance took the patient to the emergency department.", + "The patient’s Glasgow Coma Scale score was 15.", + "The patient’s oxygen saturation was 100% on 2 L nasal cannula.", + "The patient would not reveal the actual cause of the injury.", + "The patient had a history of several pneumothorax injuries.", + "In all episodes, he had been hospitalized for several days for chest drainage and discharged without any complications.", + "We strongly suspected a self-inflicted injury.", + "The patient denied any suicidal ideation, depressive mood, or hopelessness.", + "Chest X ray demonstrated a clear lung field without pneumothorax or hemothorax.", + "Emergency echocardiography disclosed a small amount of pericardial effusion without cardiac tamponade.", + "Computed tomography of the chest showed linear metallic density in the pulmonary trunk and a small amount of pericardial fluid.", + "Pneumothorax or bulla was not seen on chest CT.", + "Based on the diagnosis of penetrating cardiac injury, we transferred the patient to the operating theater after cardiac surgery consultation.", + "The ice pick had been stuck in the main pulmonary artery through the pericardium without any injury to the left lung or internal thoracic artery.", + "Heparin was given and cardiopulmonary bypass was commenced with ascending aortic and bicaval cannulation.", + "The patient was cooled down to 32 ° Celsius.", + "The cardioplegia was infused into the aortic root to obtain cardiac arrest.", + "A longitudinal incision was made in the MPA, and the foreign body was removed.", + "The holes made by the ice pick were closed using 5-0 polypropylene suture.", + "The MPA was closed using 4-0 polypropylene over and over running suture.", + "The patient’s sinus rhythm came back spontaneously.", + "CPB weaning was smooth, and protamine was given.", + "The chest was closed in a normal fashion.", + "Postoperative recovery was uneventful.", + "A police investigation showed no criminal events associated with the injury.", + "We strongly suspected the penetrating cardiac injury was self-inflicted.", + "The psychiatric department was consulted on day 7 to closely monitor the patient during hospitalization.", + "During the psychiatric counseling sessions after the surgery, the patient continued to stubbornly deny a suicide attempt.", + "At 16 days postoperative, the patient was discharged to home without psychiatric follow-up." + ], + "summary": "This paper illustrates a 40-year-old male with a penetrating pulmonary artery injury that was successfully treated with emergency surgery. The patient visited local hospital by foot complaining of moving object on his chest and was found that an ice pick was penetrating the man's left chest. An ambulance took the patient to our emergency department. Computed tomography of the chest showed linear metallic density in the pulmonary trunk and a small amount of pericardial fluid. Emergency surgery for removal of the object and repair of the pulmonary artery was performed. The ice pick had been stuck in the main pulmonary artery through the pericardium without any injury to the left lung or internal thoracic artery. Postoperative course was uneventful.", + "summary_subclaims": [ + "This paper illustrates a 40-year-old male with a penetrating pulmonary artery injury that was successfully treated with emergency surgery.", + "The patient visited local hospital by foot complaining of moving object on his chest.", + "An ice pick was penetrating the man's left chest.", + "An ambulance took the patient to our emergency department.", + "Computed tomography of the chest showed linear metallic density in the pulmonary trunk.", + "Computed tomography of the chest showed a small amount of pericardial fluid.", + "Emergency surgery for removal of the object and repair of the pulmonary artery was performed.", + "The ice pick had been stuck in the main pulmonary artery through the pericardium.", + "There was no injury to the left lung.", + "There was no injury to the internal thoracic artery.", + "Postoperative course was uneventful." + ] + }, + { + "id": "multiclinsum_test_2336_en.txt", + "fulltext": "A 63-year old female was admitted to the neurology department with a chief complaint of progressive forward and leftward flexion of the spine that was exacerbated during walking but lessened on recumbent position. Two years earlier, she had been diagnosed with a mild degree of lumbar spinal stenosis at L3–4 and L4–5 levels by an orthopedic specialist. Even though she still experienced intermittent radiating pain from the left hip down to her left leg, she was still able to do mountain climbing and carry out her usual activities of living. One month prior to her admission to the neurology department, she started to notice progressive forward and leftward flexion of the back and new-onset lower back pain. She went back to the orthopedic specialist for medical advice. Non-contrast-enhanced magnetic resonance imaging (MRI) of the lumbar spine revealed alterations of muscle signal intensity in the right paraspinal muscles at the L1–2 level on T2-weighted imaging (T2WI) , but no significant interval change of the known spinal canal stenosis. A facet joint injection of triamcinolone at right L4–5 level didn’t relieve her pain and it didn’t halt the progression of the spinal deformity. She was referred to the movement disorder clinic.\nUpon examination, the patient did not have weakness, dysarthria or decreased sensation despite her history of infarction twenty years earlier in the territory of right middle cerebral artery (MCA) involving the right pre-rolandic area, corona radiata, and postcentral gyrus . Muscle tone and deep tendon reflexes of the left extremities were unremarkable. Her sensation to proprioception was intact in all four extremities. She had action tremors of both hands, moderate bradykinesia and rigidity on her left side, and postural instability during turning. Her gait was not wide-based and she had no difficulty performing finger-to-nose and heel-to-shin. With definite evidence of parkinsonism, we gave her a trial of levodopa/carbidopa. Initially, levodopa equivalent daily dose (LEDD) of 150 mg per day was prescribed. Over a week, it was gradually increased to 600 mg per day. Even though the medication improved her gait by increasing step length without causing serious side effects, the forward flexion of the spine only became more apparent . Serum creatine kinase (CK) was not checked at the time.\nShe continued to experience severe back pain in the following months, besides which she developed erythematous pitting edema of and multiple bullae on both legs. She was subsequently admitted to the rheumatology. Her thyroid function was normal. CK was within normal limits. A repeat MRI scan of the spine, compared to the initial scan taken three months ago, showed diffuse enlargement and patchy enhancement of the paraspinal muscles on T1-weighted imaging (T1WI) from T4 through sacrum bilaterally . Electromyography (EMG) demonstrated a mild to moderate amount of ongoing denervation potentials in the thoracic and lumbosacral paraspinal muscles but no evidence of myopathic motor unit action potentials in either the paraspinal muscles or the lower extremity muscles – the left tibialis anterior, peroneus longus, and gastrocnemius. Atorvastatin, which she had been taking since five years ago, was discontinued as the possibility of drug-induced myopathy could not be ruled out. At discharge, she was on opioids for unremitting lower back pain.\nA year later she was re-admitted to the neurology department for evaluation of focal atrophy of the back muscles on the right. The pain had subsided considerably for a year now. MRI of the lumbar spine again confirmed the presence of non-specific myopathic changes of thoracolumbar paraspinal muscles. Patchy contrast enhancement along myotendinous or myofascial junction on T1WI and diffuse enlargement of thoracolumbar paraspinal muscles were still seen. But the extent of contrast enhancement and that of muscle enlargement were less compared to the MRI taken one year ago. She finally underwent an ultrasound-guided gun biopsy of the paraspinal muscles.\nThe biopsy specimen contained myofibers with moderate size variation. Degenerated, atrophic and regenerating fibers were abundant and mostly round in shape. Atrophic myofibers were not angular in shape. The increase in the number of internalized nuclei was seen in many myofibers. There was marked endomysial and perimysial fibrosis of the biopsied muscles but merely mild infiltration of inflammatory cells in endomysial and perivascular space . Overall, myopathic changes were evident, but the pathologist was unable to find clues with respect to the cause of fibrosis.\nTwo years after the onset of camptocormia, as her clinical course was not consistent with idiopathic PD with camptocormia being the presenting symptom, fluorine-18 labeled N-3-fluoropropyl-2β-carboxymethoxy-3β-(4-iodophenyl)-nortropane (FP-CIT) positron emission tomography (PET) was done to confirm degenerative parkinsonism in this patient. The PET imaging revealed severely decreased radiotracer uptake in both putamina, even after taking into account the old infarct in the right MCA territory . The bilateral caudate nuclei were not spared.\nSince she continued to experience back pain, follow-up spine MRI was done a year after the biopsy. Findings suggestive of active inflammation – contrast enhancement on T1WI and hyperintensity of the paraspinal muscles on T2WI – were still present albeit to a lesser extent. Newly identified hypointense signals on T1WI and T2WI were indicative of fibrotic changes. On account of persistent pain and MRI results indicative of the presence of ongoing inflammation, she was prescribed glucocorticoid, which she refused to take. Now merely two and a half years after the onset of camptocormia, she is in Hoehn and Yahr stage 4. The patient is still on levodopa currently at the LEDD of 420 mg per day. She hasn’t developed supranuclear gaze palsy, freezing of gait, blepharospasm, or gait ataxia. She has urinary dysfunction – urinary frequency starting a year before the onset of camptocormic symptom along with documented evidence of urinary retention (post-voiding residual volume > 200 ml). However, aside from urinary dysfunction, she has not developed other symptoms or signs of autonomic dysfunction (e.g., orthostatic hypotension and constipation).", + "fulltext_subclaims": [ + "The patient is a 63-year-old female.", + "She was admitted to the neurology department.", + "Her chief complaint was progressive forward and leftward flexion of the spine.", + "The flexion was exacerbated during walking.", + "The flexion lessened on recumbent position.", + "Two years earlier, she had been diagnosed with a mild degree of lumbar spinal stenosis at L3–4 and L4–5 levels.", + "She had intermittent radiating pain from the left hip down to her left leg.", + "She was still able to do mountain climbing.", + "One month prior to admission, she started to notice progressive forward and leftward flexion of the back.", + "She had new-onset lower back pain.", + "Non-contrast-enhanced MRI of the lumbar spine revealed alterations of muscle signal intensity in the right paraspinal muscles at the L1–2 level on T2-weighted imaging.", + "A facet joint injection of triamcinolone at right L4–5 level didn’t relieve her pain.", + "The injection didn’t halt the progression of the spinal deformity.", + "She was referred to the movement disorder clinic.", + "She had action tremors of both hands.", + "She had moderate bradykinesia and rigidity on her left side.", + "She had postural instability during turning.", + "She had definite evidence of parkinsonism.", + "A trial of levodopa/carbidopa was given.", + "The initial LEDD was 150 mg per day.", + "The LEDD was increased to 600 mg per day over a week.", + "The medication improved her gait by increasing step length.", + "The forward flexion of the spine only became more apparent.", + "Serum creatine kinase was not checked at the time.", + "She developed erythematous pitting edema of and multiple bullae on both legs.", + "She was admitted to the rheumatology department.", + "A repeat MRI scan showed diffuse enlargement and patchy enhancement of the paraspinal muscles from T4 through sacrum bilaterally.", + "EMG demonstrated ongoing denervation potentials in the thoracic and lumbosacral paraspinal muscles.", + "There was no evidence of myopathic motor unit action potentials in the paraspinal muscles.", + "Atorvastatin was discontinued as the possibility of drug-induced myopathy could not be ruled out.", + "She was on opioids for unremitting lower back pain at discharge.", + "She was re-admitted to the neurology department for evaluation of focal atrophy of the back muscles on the right.", + "MRI of the lumbar spine confirmed the presence of non-specific myopathic changes of thoracolumbar paraspinal muscles.", + "The extent of contrast enhancement and muscle enlargement was less compared to the MRI taken one year ago.", + "She underwent an ultrasound-guided gun biopsy of the paraspinal muscles.", + "The biopsy specimen contained myofibers with moderate size variation.", + "Degenerated, atrophic, and regenerating fibers were abundant.", + "There was marked endomysial and perimysial fibrosis.", + "The pathologist was unable to find clues with respect to the cause of fibrosis.", + "FP-CIT PET was done to confirm degenerative parkinsonism.", + "The PET imaging revealed severely decreased radiotracer uptake in both putamina.", + "The bilateral caudate nuclei were not spared.", + "Follow-up spine MRI showed findings suggestive of active inflammation.", + "Newly identified hypointense signals were indicative of fibrotic changes.", + "She was prescribed glucocorticoid, which she refused to take.", + "She is in Hoehn and Yahr stage 4.", + "She is still on levodopa at the LEDD of 420 mg per day.", + "She has urinary dysfunction.", + "She has urinary frequency starting a year before the onset of camptocormic symptom.", + "She has documented evidence of urinary retention (post-voiding residual volume > 200 ml)." + ], + "summary": "A patient presented with a relatively acute onset of camptocormia and new-onset back pain. Upon examination, she had asymmetric parkinsonism. Magnetic resonance imaging of the lumbar spine revealed alterations in muscle signal intensity in the right paraspinal muscles at the L1-2 level. In the presence of persistent back pain, repeat imaging done two months later showed diffuse enlargement and patchy enhancement of the paraspinal muscles on T1-weighted imaging from T4 through sacrum bilaterally. About fifteen months after the onset of camptocormia, she underwent ultrasound-guided gun biopsy of the paraspinal muscles for evaluation of focal atrophy of the back muscles on the right. The biopsy revealed unmistakable myopathic changes, marked endomysial and perimysial fibrosis of the muscles, and merely mild infiltration of inflammatory cells but no clues regarding the cause of myopathy. On account of persistent back pain and MRI results indicative of ongoing inflammation, she was prescribed glucocorticoid, which she refused to take. Now merely two and a half years after the onset of camptocormia, she is in Hoehn and Yahr stage 4.", + "summary_subclaims": [ + "The patient presented with a relatively acute onset of camptocormia.", + "The patient had new-onset back pain.", + "Upon examination, she had asymmetric parkinsonism.", + "Magnetic resonance imaging of the lumbar spine revealed alterations in muscle signal intensity in the right paraspinal muscles at the L1-2 level.", + "Repeat imaging done two months later showed diffuse enlargement and patchy enhancement of the paraspinal muscles on T1-weighted imaging from T4 through sacrum bilaterally.", + "About fifteen months after the onset of camptocormia, she underwent ultrasound-guided gun biopsy of the paraspinal muscles.", + "The biopsy revealed unmistakable myopathic changes.", + "The biopsy showed marked endomysial and perimysial fibrosis of the muscles.", + "The biopsy showed merely mild infiltration of inflammatory cells.", + "The biopsy revealed no clues regarding the cause of myopathy.", + "She was prescribed glucocorticoid.", + "She refused to take glucocorticoid.", + "Now merely two and a half years after the onset of camptocormia, she is in Hoehn and Yahr stage 4." + ] + }, + { + "id": "multiclinsum_test_2475_en.txt", + "fulltext": "A 69-year-old male presented to his primary-care physician in March 2019 due to progressive dysphagia during a period of approximately one year. He was previously healthy, except for urolithiasis and benign prostatic hyperplasia. A barium swallow study was performed and showed a stricture at the distal esophagus. Further investigation with an upper-gastrointestinal (GI) endoscopy revealed a tumor at the distal esophagus and biopsies confirmed poorly differentiated adenocarcinoma. The patient was referred to our unit, Department of Upper Abdominal Surgery, Karolinska University Hospital, Stockholm, Sweden, which is a tertiary referral center for upper-GI malignancies. Subsequent computed tomography (CT) and fluorodeoxyglucose - positron emission tomography (FDG-PET) were performed. The case was thereafter discussed at our upper-GI multidisciplinary team meeting. The disease was classified as a 6 cm Siewert type-II tumor at the GEJ, with a clinical stage of T3-4a, N1 (due to a 15 mm lymph node alongside the lesser curvature of the stomach), and Mx due to equivocal lesions with elevated FDG-uptake at the ampulla of Vater and at two segments of the small intestine . Further investigation with duodenoscopy did not confirm any lesion at the ampulla of Vater.\nThe patient underwent a diagnostic laparoscopy in April 2019, which revealed three suspicious lesions involving a 25 cm-long segment of the proximal jejunum , starting approximately at 25 cm distally to the ligament of Treitz. There was no obvious, macroscopic, serosal invasion of the primary tumor, no signs of peritoneal carcinomatosis or ascites, and the duodenum was found to be normal. Because of risk for leakage by taking jejunal biopsies as well as to avoid future risk for bowel obstruction, the affected segment of the jejunum was resected through a mini laparotomy. The pathologic examination showed three separate, radically resected, poorly differentiated adenocarcinomas (3 × 1 cm, 5,5 × 1,5 cm and 3 × 1 cm, respectively, ). Immunohistochemistry suggested that these tumors were most probably metastases of the primary GEJ tumor. The cytology from the abdominal washout taken during the laparoscopy was negative.\nAs the jejunal metastases were radically removed and there were no other indications of disseminated disease, neoadjuvant chemotherapy was decided with the intent for subsequent curative resection of the primary tumor. The patient received four cycles of Docetaxel, Oxaliplatin, Leucovorin and 5-flurouracil (FLOT). The patient tolerated the oncologic treatment well, except for some diarrhea (Grade 1 according to the common terminology for adverse events version 5). A new PET-CT after the completion of chemotherapy showed remarkable tumor response with only weak FDG-uptake in the primary tumor and the previously described regional lymph node. However, a new site of focal FDG-uptake appeared in another part of the small intestine at the left flank. Furthermore, there was also diffuse FDG-uptake in the left colon probably due to chemotherapy-induced colitis. The patient underwent another diagnostic laparoscopy, which did not show any suspicious findings. The anastomosis from the previous jejunum resection appeared as erythematous and fibrotic, corresponding to the suspicious lesion in the PET-CT.\nThe patient subsequently underwent a minimally invasive Ivor Lewis esophagectomy with two-field lymphadenectomy and gastric tube interposition in August 2019. There were no complications intraoperatively. shows the surgical specimen. An enhanced recovery program was implemented postoperatively and the patient was discharged on postoperative day 15. The postoperative course was uneventful, until the patient was re-admitted due to paralytic ileus on postoperative day 18, which was treated conservatively with gastrografin. The pathology examination showed complete tumor regression (ypT0N0 with 37 lymph nodes resected) and confirmed an R0 resection. The patient received adjuvant chemotherapy with additional four cycles of (FLOT). One year and four months after the esophagectomy there were no clinical or radiologic findings of tumor recurrence. At seventeen months post esophagectomy, he developed left-sided weakness and mild cognitive impairment. Magnetic resonance imaging revealed a 2,5 cm parietal tumor. There were no other signs of recurrence on CT-scan of the thorax and abdomen. The patient underwent surgical resection of the brain tumor in February 2021. Histopathology confirmed a radically resected metastasis of his previous GEJ cancer. He is now slowly recovering and he is awaiting complementary radiotherapy.", + "fulltext_subclaims": [ + "A 69-year-old male presented to his primary-care physician in March 2019 due to progressive dysphagia during a period of approximately one year.", + "He was previously healthy, except for urolithiasis and benign prostatic hyperplasia.", + "A barium swallow study was performed and showed a stricture at the distal esophagus.", + "Further investigation with an upper-gastrointestinal (GI) endoscopy revealed a tumor at the distal esophagus.", + "Biopsies confirmed poorly differentiated adenocarcinoma.", + "The patient was referred to the Department of Upper Abdominal Surgery, Karolinska University Hospital, Stockholm, Sweden.", + "Subsequent computed tomography (CT) and fluorodeoxyglucose - positron emission tomography (FDG-PET) were performed.", + "The case was discussed at an upper-GI multidisciplinary team meeting.", + "The disease was classified as a 6 cm Siewert type-II tumor at the GEJ.", + "The clinical stage was T3-4a, N1 due to a 15 mm lymph node alongside the lesser curvature of the stomach.", + "The M stage was Mx due to equivocal lesions with elevated FDG-uptake at the ampulla of Vater and at two segments of the small intestine.", + "Further investigation with duodenoscopy did not confirm any lesion at the ampulla of Vater.", + "The patient underwent a diagnostic laparoscopy in April 2019.", + "The laparoscopy revealed three suspicious lesions involving a 25 cm-long segment of the proximal jejunum.", + "There was no obvious, macroscopic, serosal invasion of the primary tumor.", + "There were no signs of peritoneal carcinomatosis or ascites.", + "The duodenum was found to be normal.", + "The affected segment of the jejunum was resected through a mini laparotomy.", + "The pathologic examination showed three separate, radically resected, poorly differentiated adenocarcinomas.", + "Immunohistochemistry suggested that these tumors were most probably metastases of the primary GEJ tumor.", + "The cytology from the abdominal washout taken during the laparoscopy was negative.", + "Neoadjuvant chemotherapy with Docetaxel, Oxaliplatin, Leucovorin and 5-flurouracil (FLOT) was decided.", + "The patient received four cycles of FLOT.", + "The patient tolerated the oncologic treatment well, except for some diarrhea (Grade 1).", + "A new PET-CT after the completion of chemotherapy showed remarkable tumor response.", + "There was only weak FDG-uptake in the primary tumor and the previously described regional lymph node.", + "A new site of focal FDG-uptake appeared in another part of the small intestine at the left flank.", + "There was also diffuse FDG-uptake in the left colon probably due to chemotherapy-induced colitis.", + "The patient underwent another diagnostic laparoscopy.", + "The anastomosis from the previous jejunum resection appeared as erythematous and fibrotic.", + "The patient underwent a minimally invasive Ivor Lewis esophagectomy with two-field lymphadenectomy and gastric tube interposition in August 2019.", + "There were no complications intraoperatively.", + "The patient was discharged on postoperative day 15.", + "The postoperative course was uneventful until the patient was re-admitted due to paralytic ileus on postoperative day 18.", + "The paralytic ileus was treated conservatively with gastrografin.", + "The pathology examination showed complete tumor regression (ypT0N0 with 37 lymph nodes resected).", + "The pathology examination confirmed an R0 resection.", + "The patient received adjuvant chemotherapy with additional four cycles of FLOT.", + "One year and four months after the esophagectomy there were no clinical or radiologic findings of tumor recurrence.", + "At seventeen months post esophagectomy, he developed left-sided weakness and mild cognitive impairment.", + "Magnetic resonance imaging revealed a 2,5 cm parietal tumor.", + "There were no other signs of recurrence on CT-scan of the thorax and abdomen.", + "The patient underwent surgical resection of the brain tumor in February 2021.", + "Histopathology confirmed a radically resected metastasis of his previous GEJ cancer.", + "He is now slowly recovering and he is awaiting complementary radiotherapy." + ], + "summary": "This is the case of a patient with poorly differentiated adenocarcinoma of the GEJ with synchronous metastases at the jejunum. The patient underwent extensive work-up including PET-CT. The metastases at the jejunum were completely resected during an initial staging laparoscopy and there was no evidence of further metastatic disease. The patient received chemotherapy and re-staging showed remarkable tumor response. Esophagectomy with curative intent was performed. Histopathology showed complete pathologic response after chemotherapy. Although our patient had a stage IV disease at presentation, he remained metastasis-free for a significant period of time, with no evidence of any distant recurrence during a follow-up of 16 months after esophagectomy.", + "summary_subclaims": [ + "The patient had poorly differentiated adenocarcinoma of the GEJ.", + "The patient had synchronous metastases at the jejunum.", + "The patient underwent a PET-CT as part of the work-up.", + "The metastases at the jejunum were completely resected during an initial staging laparoscopy.", + "There was no evidence of further metastatic disease.", + "The patient received chemotherapy.", + "Re-staging showed a remarkable tumor response.", + "Esophagectomy with curative intent was performed.", + "Histopathology showed complete pathologic response after chemotherapy.", + "The patient had stage IV disease at presentation.", + "The patient remained metastasis-free for a significant period of time.", + "There was no evidence of any distant recurrence during a follow-up of 16 months after esophagectomy." + ] + }, + { + "id": "multiclinsum_test_2951_en.txt", + "fulltext": "We report the case of a 43-year-old man who was admitted to our hospital with severe intake reduction due to early satiety.\nThe patient complained of severe abdominal pain, accompanied by nausea and vomiting, after heavy consumption of spirits with a high alcohol concentration 20 d prior. The local hospital diagnosed acute pancreatitis. After receiving medical treatment, such as medications to inhibit acid and inhibit pancreatic enzyme secretion, the patient was discharged with improvement. However, two weeks later, the patient experienced severe intake reduction due to early satiety and left upper abdominal pressure, and computed tomography (CT) showed multiple pseudocysts around the pancreas. The local hospital diagnosed PPC, and conservative treatment was ineffective.\nHe had no previous history of gallstones.\nThe patient had a history of drinking more than 20 years and drank approximately 500 mL/d of high-concentration liquor.\nThe left upper abdomen showed a large mass with clear boundaries and poor motion.\nThe patient’s leukocyte count was 9.72 × 109/L, his neutrophil ratio was 77.5%, and his C-reactive protein level was 73.49 mg/L. His pancreatic amylase level was slightly elevated (84 μ/L), while his blood amylase level was within normal limits.\nOn 13 February 2023, contrast-enhanced CT showed multiple cystic foci in the abdominal cavity and low-attenuated, homogeneous fluid collections, with a maximum diameter of 89 mm × 76 mm .\nEUS revealed multiple cystic masses with hyperechoic necrosis and arterial vessels, the maximum size of the cysts was 56 mm × 36 mm, and the necrotic collection was not completely wrapped .", + "fulltext_subclaims": [ + "The patient was a 43-year-old man.", + "The patient was admitted to the hospital with severe intake reduction due to early satiety.", + "The patient complained of severe abdominal pain, accompanied by nausea and vomiting, after heavy consumption of spirits with a high alcohol concentration 20 d prior.", + "The local hospital diagnosed acute pancreatitis.", + "The patient received medical treatment, such as medications to inhibit acid and inhibit pancreatic enzyme secretion.", + "The patient was discharged with improvement.", + "Two weeks later, the patient experienced severe intake reduction due to early satiety and left upper abdominal pressure.", + "Computed tomography (CT) showed multiple pseudocysts around the pancreas.", + "The local hospital diagnosed PPC.", + "Conservative treatment was ineffective.", + "The patient had no previous history of gallstones.", + "The patient had a history of drinking more than 20 years and drank approximately 500 mL/d of high-concentration liquor.", + "The left upper abdomen showed a large mass with clear boundaries and poor motion.", + "The patient’s leukocyte count was 9.72 × 109/L.", + "The patient’s neutrophil ratio was 77.5%.", + "The patient’s C-reactive protein level was 73.49 mg/L.", + "The patient’s pancreatic amylase level was slightly elevated (84 μ/L).", + "The patient’s blood amylase level was within normal limits.", + "On 13 February 2023, contrast-enhanced CT showed multiple cystic foci in the abdominal cavity.", + "Contrast-enhanced CT showed low-attenuated, homogeneous fluid collections.", + "The maximum diameter of the fluid collections was 89 mm × 76 mm.", + "EUS revealed multiple cystic masses with hyperechoic necrosis and arterial vessels.", + "The maximum size of the cysts was 56 mm × 36 mm.", + "The necrotic collection was not completely wrapped." + ], + "summary": "We report the case of a 43-year-old man who was admitted to the hospital with severe intake reduction due to early satiety 2 wk after treatment for acute pancreatitis; conservative treatment was ineffective, and a pancreatic pseudocyst was suspected on contrast-enhanced computed tomography (CT). Endoscopic ultrasonography (EUS) suggested hyperechoic necrotic tissue within the cyst cavity. The wall was not completely mature, and the culture of the puncture fluid was positive for A-haemolytic Streptococcus. Thus, the final diagnosis of ANC infection was made. The necrotic collection was not walled off and contained many solid components; therefore, the patient underwent EUS-guided aspiration and lavage. Two weeks after the collection was completely encapsulated, pancreatic duct stent drainage via endoscopic retrograde cholangiopancreatography (ERCP) was performed, and the patient was subsequently successfully discharged. On repeat CT, the pancreatic cysts had almost disappeared during the 6-month follow-up period after surgery.", + "summary_subclaims": [ + "The patient was a 43-year-old man.", + "He was admitted to the hospital with severe intake reduction due to early satiety.", + "The early satiety occurred 2 wk after treatment for acute pancreatitis.", + "Conservative treatment was ineffective.", + "A pancreatic pseudocyst was suspected on contrast-enhanced computed tomography.", + "Endoscopic ultrasonography suggested hyperechoic necrotic tissue within the cyst cavity.", + "The wall was not completely mature.", + "The culture of the puncture fluid was positive for A-haemolytic Streptococcus.", + "The final diagnosis was ANC infection.", + "The necrotic collection was not walled off.", + "The collection contained many solid components.", + "The patient underwent EUS-guided aspiration and lavage.", + "Two weeks after the collection was completely encapsulated, pancreatic duct stent drainage via ERCP was performed.", + "The patient was successfully discharged.", + "On repeat CT, the pancreatic cysts had almost disappeared during the 6-month follow-up period after surgery." + ] + }, + { + "id": "multiclinsum_test_1116_en.txt", + "fulltext": "A 91-year-old woman presented to our institution with ST-segment elevation myocardial infarction (STEMI). The right radial access was chosen for the performance of percutaneous coronary intervention (PCI). After the introduction of 6 F sheath, there was difficulty in the advancement of 0.035 J wire that was exchanged with a Terumo hydrophilic wire (0.035 × 180) which was advanced easily to the aortic root. Coronary angiography was done and revealed tortuous coronary arteries without significant lesions. Before sheath removal, radial arteriography was done and revealed perforation . Protamine sulfate (1 mg per 100 USP units of heparin) was administered intravenously to reverse the dose of heparin (70 U/kg), and APTT was monitored 15 min after the dose. This was followed by prolonged balloon inflation 2.5/3.0 . The perforation was not sealed so a 7-F-long vascular sheath was inserted to internally tamponade the vessel, and the patient was sent to the coronary care unit for monitoring of the forearm hematoma and the distal pulses . Over the next 3 days, serial radial angiographies were done which revealed the persistence of the perforation. After 4 days, angiography revealed multiple thrombi , and thrombus aspiration was done using Pronto V4 extraction catheter (Vascular Solutions, USA) and was followed by the implantation of a covered stent, which was dislodged, mostly secondary to under expansion, following another run of thrombus aspiration. The stent was successfully snared . Finally, the perforation was sealed spontaneously and there were no signs of intra-arterial thrombi .", + "fulltext_subclaims": [ + "A 91-year-old woman presented to our institution with ST-segment elevation myocardial infarction.", + "The right radial access was chosen for the performance of percutaneous coronary intervention.", + "After the introduction of 6 F sheath, there was difficulty in the advancement of 0.035 J wire.", + "The 0.035 J wire was exchanged with a Terumo hydrophilic wire (0.035 × 180).", + "The Terumo hydrophilic wire was advanced easily to the aortic root.", + "Coronary angiography was done.", + "Coronary angiography revealed tortuous coronary arteries without significant lesions.", + "Radial arteriography before sheath removal revealed perforation.", + "Protamine sulfate (1 mg per 100 USP units of heparin) was administered intravenously.", + "The dose of heparin was 70 U/kg.", + "APTT was monitored 15 min after the protamine dose.", + "Prolonged balloon inflation 2.5/3.0 was performed.", + "The perforation was not sealed.", + "A 7-F-long vascular sheath was inserted to internally tamponade the vessel.", + "The patient was sent to the coronary care unit for monitoring of the forearm hematoma and the distal pulses.", + "Over the next 3 days, serial radial angiographies were done.", + "Serial radial angiographies revealed the persistence of the perforation.", + "After 4 days, angiography revealed multiple thrombi.", + "Thrombus aspiration was done using Pronto V4 extraction catheter.", + "The implantation of a covered stent was performed.", + "The stent was dislodged, mostly secondary to under expansion.", + "The stent was successfully snared.", + "The perforation was sealed spontaneously.", + "There were no signs of intra-arterial thrombi." + ], + "summary": "A 91-year-old woman presented to our institution with ST-segment elevation myocardial infarction (STEMI). The right radial access was chosen for the performance of percutaneous coronary intervention. After the introduction of 6 F sheath, there was difficulty in the advancement of 0.035 J wire that was exchanged with a Terumo hydrophilic wire. After the procedure and before sheath removal, radial arteriography was done and revealed perforation. Protamine sulfate was administered and prolonged balloon inflation was attempted but failed to seal the perforation, so a 7-F-long vascular sheath was inserted to internally tamponade the vessel, and the patient was sent to the coronary care unit for monitoring. Over the next 3 days, serial radial angiographies were done revealing the persistence of the perforation, and on the fourth day, angiography revealed multiple thrombi. Thrombus aspiration was done using Pronto V4 extraction catheter (Vascular Solutions, USA) and was followed by the deployment of a covered stent. The stent was dislodged and successfully snared. Finally, the perforation was sealed spontaneously and there were no signs of intra-arterial thrombi.", + "summary_subclaims": [ + "A 91-year-old woman presented to our institution with ST-segment elevation myocardial infarction.", + "The right radial access was chosen for the performance of percutaneous coronary intervention.", + "After the introduction of 6 F sheath, there was difficulty in the advancement of 0.035 J wire.", + "The 0.035 J wire was exchanged with a Terumo hydrophilic wire.", + "After the procedure and before sheath removal, radial arteriography was done.", + "Radial arteriography revealed perforation.", + "Protamine sulfate was administered.", + "Prolonged balloon inflation was attempted.", + "Prolonged balloon inflation failed to seal the perforation.", + "A 7-F-long vascular sheath was inserted to internally tamponade the vessel.", + "The patient was sent to the coronary care unit for monitoring.", + "Over the next 3 days, serial radial angiographies were done.", + "Serial radial angiographies revealed the persistence of the perforation.", + "On the fourth day, angiography revealed multiple thrombi.", + "Thrombus aspiration was done using Pronto V4 extraction catheter.", + "Thrombus aspiration was followed by the deployment of a covered stent.", + "The stent was dislodged.", + "The dislodged stent was successfully snared.", + "The perforation was sealed spontaneously.", + "There were no signs of intra-arterial thrombi." + ] + }, + { + "id": "multiclinsum_test_3123_en.txt", + "fulltext": "A 65-year-old man on hemodialysis complained of malaise, lightheadedness, and confusion during one of his sessions. He did not report dyspnea, tachycardia, chest pain, or other symptoms. The patient had been previously diagnosed with hypertension, diabetes, morbid obesity, and cirrhosis secondary to non-alcoholic steatohepatitis. He was also on continuous use of allopurinol 100 mg/day, sertraline 50 mg/day, esomeprazole 40 mg/day, and sevelamer 2.4 g three times daily.\n\nThe patient had been on hemodialysis for two years for diabetic nephropathy, but frequently missed sessions. He had no residual diuresis in addition to a long history of high interdialytic weight gain and low adherence to the prescribed diet. The individual had a radiocephalic arteriovenous fistula in his right upper limb. To deal with his frequent absences, he was prescribed hemodialysis six times a week, with 2.5 hour sessions. The dialyser was a high-flux polysulfone membrane with a surface area of 2.2 m2, and his hemodialysis prescription consisted of Qb: 370mL/min. Qb: 370 mL/min and Qd: 800 mL/min. Dialysate prescription: Ca: 2.5 mEq/L; K: 1 mEq/L; Na: 138 mEq/L; bicarbonate: 36 mmol/L; unfractionated heparin: 5000 IU/session. If the patient had attended his sessions as prescribed, his calculated standard Kt/V would have been 2.45. However, since he came to the clinic for only three or four sessions per week, his actual Kt/V was 1.5-2.\n\nThe physical examination at admission showed the patient to be in poor general condition, pale and cyanotic. Pulmonary auscultation was normal. His respiratory rate was 16 bpm and his oxygen saturation was 88% in room air. Cardiac auscultation revealed hypophonic murmurs, no heart murmurs, a heart rate of 88 bpm, blood pressure of 50/30 mmHg with a prolonged capillary refill time and jugular venous stasis. His abdomen was normal and his legs showed no signs of oedema. He showed signs of confusion and slowness during the neurological examination. His electrocardiogram showed a sinus rhythm, low diffuse voltage of the QRS complex, and altered ventricular repolarization.\n\nThe patient was anuric and in shock. Resuscitation was performed with 1,000 ml of crystalloid fluid, but his blood pressure did not recover to normal levels. Cultures were collected and vancomycin and ceftazidime were prescribed until the etiology of the shock was clarified. He was referred to the intensive care unit (ICU), where noradrenaline 0.2 mcg/kg/min was initiated. His clinical and neurological condition improved despite the presence of paradoxical pulse.\n\nThe results of his examination were as follows: hemoglobin: 9.8 g/dL; hematocrit: 29.5%; leukocytes: 5,230/mm3; platelets: 98,000/mm3; C-reactive protein: 0.61 mg/dL; NUS: 66.82 mg/dL; creatinine: 7.94 mg/dL; Na: 134 mEq/L; K: 6.2 mEq/L; ionized calcium: 1.17 mmol/L; P: 7.8 mg/dL; ALT: 14 U/L; AST: 22 U/L; alkaline phosphatase: 81 U/L; total bilirubin: 0.51 mg/dL; albumin: 3.9 g/dL; INR: 1.3; and TAP: 1.29. The markers of myocardial ischemia and the subsequent blood cultures were negative.\n\nA transthoracic echocardiogram showed a mild enlargement of the left atrium. The ventricles had a systolic function with an ejection fraction of 67% despite abnormal septal motion. The patient had a thickened pericardium with no signs of effusion, along with areas of hyperechogenicity. His inferior vena cava (IVC) was dilated and showed no signs of inspiratory collapse. The association between the findings of tissue Doppler of the mitral annulus and the plethora of the IVC suggested constrictive pericarditis. A chest computed tomography showed a thickened pericardium with areas of coarse calcification. Cardiac catheterization showed equalization of diastolic pressures in all cardiac chambers and exhibited a square root signal, indicative of constrictive pericarditis. An echocardiogram performed ten months before admission showed no evidence of pericardial abnormalities.\n\nThe individual underwent a pericardiectomy based on a diagnosis of constrictive pericarditis and cardiogenic shock. The cultures of pericardial fluid were negative for fungal and bacterial infection, and the adenosine deaminase (ADA) level was 23 U/L (normal range: <40U/L). The culture of pericardial fluid and the polymerase chain reaction (PCR) tests were negative for Mycobacterium tuberculosis. The histological analysis of the surgical specimen showed marked fibrosis, areas of dystrophic calcification and mild foci of mononuclear inflammation, with no signs of granuloma or infection. The investigation for neoplasms and autoimmune diseases, as well as tuberculin testing were negative.\n\nAfter ruling out additional secondary causes, the combination of findings of constrictive pericarditis led to the diagnosis of dialysis-induced constrictive pericarditis (DICP). The patient was prescribed a more intensive haemodialysis protocol and was discharged nine days later. Since then, he has been attending haemodialysis sessions rigorously and has been complying with his prescribed diet and fluid intake recommendations.\n", + "fulltext_subclaims": [ + "The patient was a 65-year-old man on hemodialysis.", + "He complained of malaise, lightheadedness, and confusion during one of his hemodialysis sessions.", + "He did not report dyspnea, tachycardia, chest pain, or other symptoms.", + "The patient had been previously diagnosed with hypertension.", + "The patient had been previously diagnosed with diabetes.", + "The patient had been previously diagnosed with morbid obesity.", + "The patient had been previously diagnosed with cirrhosis secondary to non-alcoholic steatohepatitis.", + "He was on continuous use of allopurinol 100 mg/day.", + "He was on continuous use of sertraline 50 mg/day.", + "He was on continuous use of esomeprazole 40 mg/day.", + "He was on continuous use of sevelamer 2.4 g three times daily.", + "The patient had been on hemodialysis for two years for diabetic nephropathy.", + "He frequently missed hemodialysis sessions.", + "He had no residual diuresis.", + "He had a long history of high interdialytic weight gain.", + "He had a long history of low adherence to the prescribed diet.", + "He had a radiocephalic arteriovenous fistula in his right upper limb.", + "He was prescribed hemodialysis six times a week, with 2.5 hour sessions.", + "The dialyser was a high-flux polysulfone membrane with a surface area of 2.2 m2.", + "His hemodialysis prescription consisted of Qb: 370 mL/min.", + "His hemodialysis prescription consisted of Qd: 800 mL/min.", + "Dialysate prescription: Ca: 2.5 mEq/L.", + "Dialysate prescription: K: 1 mEq/L.", + "Dialysate prescription: Na: 138 mEq/L.", + "Dialysate prescription: bicarbonate: 36 mmol/L.", + "Dialysate prescription: unfractionated heparin: 5000 IU/session.", + "If the patient had attended his sessions as prescribed, his calculated standard Kt/V would have been 2.45.", + "Since he came to the clinic for only three or four sessions per week, his actual Kt/V was 1.5-2.", + "The physical examination at admission showed the patient to be in poor general condition, pale and cyanotic.", + "His oxygen saturation was 88% in room air.", + "His blood pressure was 50/30 mmHg.", + "He showed signs of confusion and slowness during the neurological examination.", + "His electrocardiogram showed a sinus rhythm.", + "His electrocardiogram showed low diffuse voltage of the QRS complex.", + "His electrocardiogram showed altered ventricular repolarization.", + "The patient was anuric and in shock.", + "Resuscitation was performed with 1,000 ml of crystalloid fluid.", + "His blood pressure did not recover to normal levels.", + "Cultures were collected.", + "Vancomycin and ceftazidime were prescribed until the etiology of the shock was clarified.", + "He was referred to the intensive care unit (ICU).", + "Noradrenaline 0.2 mcg/kg/min was initiated.", + "His clinical and neurological condition improved despite the presence of paradoxical pulse.", + "The markers of myocardial ischemia were negative.", + "The subsequent blood cultures were negative.", + "A transthoracic echocardiogram showed a mild enlargement of the left atrium.", + "The ventricles had a systolic function with an ejection fraction of 67%.", + "The patient had a thickened pericardium with no signs of effusion.", + "His inferior vena cava (IVC) was dilated and showed no signs of inspiratory collapse.", + "The association between the findings of tissue Doppler of the mitral annulus and the plethora of the IVC suggested constrictive pericarditis.", + "A chest computed tomography showed a thickened pericardium with areas of coarse calcification.", + "Cardiac catheterization showed equalization of diastolic pressures in all cardiac chambers.", + "Cardiac catheterization exhibited a square root signal, indicative of constrictive pericarditis.", + "An echocardiogram performed ten months before admission showed no evidence of pericardial abnormalities.", + "The individual underwent a pericardiectomy based on a diagnosis of constrictive pericarditis and cardiogenic shock.", + "The cultures of pericardial fluid were negative for fungal and bacterial infection.", + "The adenosine deaminase (ADA) level was 23 U/L.", + "The culture of pericardial fluid and the polymerase chain reaction (PCR) tests were negative for Mycobacterium tuberculosis.", + "The histological analysis of the surgical specimen showed marked fibrosis.", + "The histological analysis showed areas of dystrophic calcification.", + "The histological analysis showed mild foci of mononuclear inflammation.", + "The histological analysis showed no signs of granuloma or infection.", + "The investigation for neoplasms and autoimmune diseases, as well as tuberculin testing were negative.", + "After ruling out additional secondary causes, the combination of findings of constrictive pericarditis led to the diagnosis of dialysis-induced constrictive pericarditis (DICP).", + "The patient was prescribed a more intensive haemodialysis protocol.", + "The patient was discharged nine days later.", + "Since then, he has been attending haemodialysis sessions rigorously.", + "Since then, he has been complying with his prescribed diet and fluid intake recommendations." + ], + "summary": "A 65-year-old man with a history of hypertension, diabetes, obesity, and cirrhosis on hemodialysis for two years complained of symptoms during one of his sessions, described as malaise, lightheadedness, and confusion. He had a history of poor adherence to the prescribed diet and frequent absences from dialysis sessions. He was weak during the physical examination and had hypophonetic heart murmurs, blood pressure of 50/30 mmHg, and a prolonged capillary refill time. The patient was admitted to the intensive care unit and started treatment with antibiotics and vasoactive drugs. Laboratory investigation showed no signs of infection, while the electrocardiogram showed a low QRS complex voltage. His echocardiogram showed signs consistent with a thickened pericardium, without pericardial effusion. Cardiac catheterization showed equalization of diastolic pressures in all cardiac chambers, indicative of constrictive pericarditis. The patient underwent a pericardiectomy. The pathological examination showed signs of marked fibrosis and areas of dystrophic calcification without evidence of infection, consistent with dialysis-related constrictive pericarditis.\n", + "summary_subclaims": [ + "The patient is a 65-year-old man.", + "He has a history of hypertension.", + "He has a history of diabetes.", + "He has a history of obesity.", + "He has cirrhosis.", + "He is on hemodialysis.", + "He has been on hemodialysis for two years.", + "He complained of symptoms during one of his dialysis sessions.", + "The symptoms were described as malaise, lightheadedness, and confusion.", + "He had a history of poor adherence to the prescribed diet.", + "He had frequent absences from dialysis sessions.", + "He was weak during the physical examination.", + "He had hypophonetic heart murmurs.", + "His blood pressure was 50/30 mmHg.", + "He had a prolonged capillary refill time.", + "He was admitted to the intensive care unit.", + "He was started on treatment with antibiotics.", + "He was started on treatment with vasoactive drugs.", + "Laboratory investigation showed no signs of infection.", + "The electrocardiogram showed a low QRS complex voltage.", + "The echocardiogram showed signs consistent with a thickened pericardium.", + "The echocardiogram showed no pericardial effusion.", + "Cardiac catheterization showed equalization of diastolic pressures in all cardiac chambers.", + "The equalization of diastolic pressures was indicative of constrictive pericarditis.", + "The patient underwent a pericardiectomy.", + "The pathological examination showed signs of marked fibrosis.", + "The pathological examination showed areas of dystrophic calcification.", + "The pathological examination showed no evidence of infection.", + "The findings were consistent with dialysis-related constrictive pericarditis." + ] + }, + { + "id": "multiclinsum_test_2682_en.txt", + "fulltext": "A 64-year-old Caucasian man had severe regurgitation of the tricuspid aortic valve due to an aneurysm of the ascending aorta, which involved the sinus of Valsalva. Composite valve-graft conduit replacement of the aortic root was performed 4 years ago. The patient suffered a transient ischemic attack with a thrombotic occlusion of a branch of the left middle cerebral artery 18 months postoperatively, most likely due to subtherapeutic oral anticoagulation (international normalized ratio [INR] 1.8). Transesophageal echocardiography (TEE) did not show vegetations on the mechanical aortic valve and the concentration of C-reactive protein was 1 mg/L (normal value <5). Aspirin was then added to the vitamin K antagonist phenprocoumon, and the patient successfully self-monitored his INR values with a target range of 2.0–3.0. He did not use skin disinfectants, and he had no acne.\nA wasp sting to his upper lip was managed conservatively one month prior to hospitalization, and subdued sounds of his mechanical aortic valve were noticed by the patient. No dental procedures were performed in the six months prior to the sting. He became febrile up to 38 °C, had night sweats and felt ill. Upon admission, the patient was in good general condition. His body temperature was 37.3 °C; his blood pressure was 137/94 mmHg; and his pulse rate was 79 bpm. There was a 1/6 systolic murmur and a metallic hue to the second heart sound. There were no peripheral emboli in the skin. The spleen was not enlarged. Laboratory results showed an elevated concentration of C-reactive protein (73 mg/L, Fig. ) and a normal leukocyte count (7.3×109/L [normal values 4.0–9.8]). The kidney function (creatinine 90 μmol/L [62–110]) and the liver function tests (aspartate transaminase [AST] 29 U/L [<38]) were normal. The INR value was 2.4, consistent with therapeutic anticoagulation with phenprocoumon. The lactic dehydrogenase was slightly elevated (655 U/L [<248]). An infective endocarditis was suspected clinically, and TEE was performed. Vegetations on the mechanical bileaflet aortic valve were seen , but there was no perivalvular abscess formation. Ten blood cultures (BactecTM 9050, Becton Dickinson, Franklin Lakes, NJ) were inoculated with 10 ml blood samples, five cultured under aerobic and five under anaerobic conditions. All blood cultures were obtained before starting the antibiotic therapy. Initially, no bacterial growth was observed. Broad range polymerase chain reaction (PCR) using 16S rDNA primers failed to identify bacteria in blood samples. One anaerobic blood-culture showed growth of a Gram-positive rod after 6 days, which was sent to the reference laboratory for further testing. The identification of P. acnes was performed according to standard procedures with conventional tests. The Gram-positive rods were catalase positive, showed a positive CAMP reaction, reduced nitrate and produced indole, but were lipase and lecithinase negative. Utilizing gas-liquid chromatography, the production of propionic acid from the glucose broth was detected. In four of 5 anaerobic blood cultures bacteria grew within 12 days, and biochemical analysis again identified P. acnes; all aerobic blood cultures remained sterile. Furthermore, the antibody response to this bacterium was quantified . According to the modified Duke criteria, a definitive diagnosis of infective endocarditis was confirmed . The initial antibiotic treatment included vancomycin and gentamicin i.v. plus rifampicin p.o. After the identification of the P. acnes, vancomycin was stopped and ceftriaxone was started. The intravenous therapy was stopped after four weeks, and levofloxacine plus rifampicin were prescribed for an additional four weeks of oral antibiotic therapy. No bacteria grew in the blood cultures following the completion of the antibiotic therapy. A follow-up TEE showed no vegetations on the mechanical aortic valve, and the patient continues to be well. He consistently uses skin disinfectants prior to obtaining a blood specimen for his INR measurements.\nSera drawn at different time points were tested for antibodies against P. acnes by the Ouchterlony assay in the following 2½ years. For the antigen preparation of the P. acnes strain (ATCC 6916, Manassas, VA) colonies of 20 sheep blood agar plates were suspended in a tube with 10 ml of phosphate buffered saline (pH 7.2) and sonicated in a cup horn sonifier (60 W, Branson Sonic Power Co., Danbury, CT) 8 times for one minute. The tube was centrifuged at 2000xg for 10 min following overnight storage at 4 °C. Aliquots of the supernatant, each containing100 μL, were stored at −80 °C. The patient’s sera were tested against this antigen with the Ouchterlony test . The highest dilution of the serum that still precipitated the P. acnes antigen in the Ouchterlony test system (ID Plates Cleargel, IMMY, Norman, OK) represented the titer of this serum. The titers decreased during the following 2½ years indicating the clearing of the bacteria without relapse .", + "fulltext_subclaims": [ + "The patient is a 64-year-old Caucasian man.", + "The patient had severe regurgitation of the tricuspid aortic valve due to an aneurysm of the ascending aorta.", + "The aneurysm involved the sinus of Valsalva.", + "Composite valve-graft conduit replacement of the aortic root was performed 4 years ago.", + "The patient suffered a transient ischemic attack 18 months postoperatively.", + "The transient ischemic attack was due to thrombotic occlusion of a branch of the left middle cerebral artery.", + "The transient ischemic attack was most likely due to subtherapeutic oral anticoagulation.", + "The international normalized ratio (INR) was 1.8.", + "Transesophageal echocardiography did not show vegetations on the mechanical aortic valve.", + "The concentration of C-reactive protein was 1 mg/L.", + "Aspirin was added to the vitamin K antagonist phenprocoumon.", + "The patient self-monitored his INR values with a target range of 2.0–3.0.", + "The patient did not use skin disinfectants.", + "The patient had no acne.", + "A wasp sting to his upper lip was managed conservatively one month prior to hospitalization.", + "Subdued sounds of his mechanical aortic valve were noticed by the patient.", + "No dental procedures were performed in the six months prior to the sting.", + "The patient became febrile up to 38 °C.", + "The patient had night sweats.", + "The patient felt ill.", + "Upon admission, the patient was in good general condition.", + "The body temperature was 37.3 °C.", + "The blood pressure was 137/94 mmHg.", + "The pulse rate was 79 bpm.", + "There was a 1/6 systolic murmur.", + "There was a metallic hue to the second heart sound.", + "There were no peripheral emboli in the skin.", + "The spleen was not enlarged.", + "The concentration of C-reactive protein was 73 mg/L.", + "The leukocyte count was 7.3×109/L.", + "The kidney function was normal.", + "The liver function tests were normal.", + "The INR value was 2.4.", + "The INR value was consistent with therapeutic anticoagulation with phenprocoumon.", + "The lactic dehydrogenase was slightly elevated.", + "An infective endocarditis was suspected clinically.", + "Transesophageal echocardiography was performed.", + "Vegetations on the mechanical bileaflet aortic valve were seen.", + "There was no perivalvular abscess formation.", + "Ten blood cultures were inoculated with 10 ml blood samples.", + "Five blood cultures were cultured under aerobic conditions.", + "Five blood cultures were cultured under anaerobic conditions.", + "All blood cultures were obtained before starting the antibiotic therapy.", + "Initially, no bacterial growth was observed.", + "Broad range polymerase chain reaction using 16S rDNA primers failed to identify bacteria in blood samples.", + "One anaerobic blood culture showed growth of a Gram-positive rod after 6 days.", + "The identification of P. acnes was performed according to standard procedures.", + "The Gram-positive rods were catalase positive.", + "The Gram-positive rods showed a positive CAMP reaction.", + "The Gram-positive rods reduced nitrate.", + "The Gram-positive rods produced indole.", + "The Gram-positive rods were lipase negative.", + "The Gram-positive rods were lecithinase negative.", + "Utilizing gas-liquid chromatography, the production of propionic acid from the glucose broth was detected.", + "In four of 5 anaerobic blood cultures bacteria grew within 12 days.", + "Biochemical analysis again identified P. acnes.", + "All aerobic blood cultures remained sterile.", + "The antibody response to this bacterium was quantified.", + "A definitive diagnosis of infective endocarditis was confirmed according to the modified Duke criteria.", + "The initial antibiotic treatment included vancomycin and gentamicin i.v. plus rifampicin p.o.", + "After the identification of the P. acnes, vancomycin was stopped.", + "Ceftriaxone was started.", + "The intravenous therapy was stopped after four weeks.", + "Levofloxacin plus rifampicin were prescribed for an additional four weeks of oral antibiotic therapy.", + "No bacteria grew in the blood cultures following the completion of the antibiotic therapy.", + "A follow-up TEE showed no vegetations on the mechanical aortic valve.", + "The patient continues to be well.", + "The patient consistently uses skin disinfectants prior to obtaining a blood specimen for his INR measurements.", + "Sera drawn at different time points were tested for antibodies against P. acnes by the Ouchterlony assay.", + "The antigen preparation of the P. acnes strain was made from colonies of 20 sheep blood agar plates.", + "The colonies were suspended in 10 ml of phosphate buffered saline.", + "The tube was centrifuged at 2000xg for 10 min.", + "Aliquots of the supernatant were stored at −80 °C.", + "The patient’s sera were tested against this antigen with the Ouchterlony test.", + "The highest dilution of the serum that still precipitated the P. acnes antigen represented the titer of this serum.", + "The titers decreased during the following 2½ years.", + "The decreasing titers indicated the clearing of the bacteria without relapse." + ], + "summary": "We report on a 64-year-old Caucasian man who developed P. acnes endocarditis four years following a composite valve-graft conduit replacement of the aortic root. Bacterial growth in blood cultures was detected after an incubation period of 6 days. However, the antibody titer to P. acnes was 1:8 at the time of diagnosis and declined slowly thereafter over 2½ years. The patient's response to the antibiotic treatment was excellent, and no surgical re-intervention was necessary.", + "summary_subclaims": [ + "The patient was a 64-year-old Caucasian man.", + "The patient developed P. acnes endocarditis.", + "The endocarditis occurred four years following a composite valve-graft conduit replacement of the aortic root.", + "Bacterial growth in blood cultures was detected after an incubation period of 6 days.", + "The antibody titer to P. acnes was 1:8 at the time of diagnosis.", + "The antibody titer declined slowly over 2½ years.", + "The patient's response to the antibiotic treatment was excellent.", + "No surgical re-intervention was necessary." + ] + }, + { + "id": "multiclinsum_test_1793_en.txt", + "fulltext": "An 89 years old woman presented with an inability to swallow one day after band ligation of esophageal varices.\nThe patient experienced almost immediate regurgitation after any oral intake on the way home from endoscopy. Her initial esophagogastroduodenoscopy (EGD) was performed for surveillance of varices. She was found to have large, non-bleeding esophageal varices and type 1 gastroesophageal varices. Two bands were placed on the esophageal varices in the lower esophagus in an upward spiral motion for primary prophylaxis and varices were completely eradicated. She reported feeling well in recovery after the procedure and was discharged.\nShe has a past medical history of nonalcoholic steatohepatitis cirrhosis.\nUpon arrival to the hospital the day after endoscopy, her vital signs were stable. The patient appeared uncomfortable and was not able to tolerate her oral secretions. Her physical exam was otherwise unremarkable with pertinent negatives including ascites, hepatic encephalopathy, hepatosplenomegaly, lower extremity edema or crepitus.\nInitial blood work revealed a Model of End Organ Liver Disease score of 7. The rest of her blood work was unremarkable including a complete blood count, chemistry and liver function tests. She underwent a chest X-ray, which did not reveal any acute abnormalities.\nShe was treated symptomatically with sublingual nitroglycerin for esophageal spasm, which is a known complication after esophageal banding and was the presumed issue here. She failed to improve with intravenous fluids and conservative management for several days and, therefore, underwent an EGD for further evaluation. Images from endoscopy five days after initial band placement are shown in Figure . Endoscopy revealed the mucosa surrounding the banded varix was now necrosed and blocking the lumen of the esophagus.", + "fulltext_subclaims": [ + "An 89 years old woman presented with an inability to swallow one day after band ligation of esophageal varices.", + "The patient experienced almost immediate regurgitation after any oral intake on the way home from endoscopy.", + "Her initial esophagogastroduodenoscopy (EGD) was performed for surveillance of varices.", + "She was found to have large, non-bleeding esophageal varices and type 1 gastroesophageal varices.", + "Two bands were placed on the esophageal varices in the lower esophagus in an upward spiral motion for primary prophylaxis.", + "Varices were completely eradicated.", + "She reported feeling well in recovery after the procedure and was discharged.", + "She has a past medical history of nonalcoholic steatohepatitis cirrhosis.", + "Upon arrival to the hospital the day after endoscopy, her vital signs were stable.", + "The patient appeared uncomfortable and was not able to tolerate her oral secretions.", + "Her physical exam was otherwise unremarkable with pertinent negatives including ascites, hepatic encephalopathy, hepatosplenomegaly, lower extremity edema or crepitus.", + "Initial blood work revealed a Model of End Organ Liver Disease score of 7.", + "The rest of her blood work was unremarkable including a complete blood count, chemistry and liver function tests.", + "She underwent a chest X-ray, which did not reveal any acute abnormalities.", + "She was treated symptomatically with sublingual nitroglycerin for esophageal spasm.", + "Esophageal spasm is a known complication after esophageal banding.", + "She failed to improve with intravenous fluids and conservative management for several days.", + "She underwent an EGD for further evaluation.", + "Endoscopy revealed the mucosa surrounding the banded varix was now necrosed and blocking the lumen of the esophagus." + ], + "summary": "An 89 years old woman with a past medical history of nonalcoholic steatohepatitis cirrhosis presented to the hospital with an inability to swallow one day after screening esophagogastroduodenoscopy where band ligation of esophageal varices was performed for primary prophylaxis. The patient was not able to tolerate her oral secretions. Initial blood work revealed a Model of End Organ Liver Disease score of 7. She was treated with sublingual nitroglycerin for esophageal spasm, a known complication after esophageal banding. When she failed to improve, esophagogastroduodenoscopy was performed and revealed the mucosa surrounding the banded varix was necrosed and blocking the lumen of the esophagus. The band was purposefully dislodged, revealing distal ulceration and stricturing. Within 72 h after band removal, she was tolerating an oral diet. Endoscopy performed 2 wk later revealed an intrinsic stenosis, measuring 8 mm in diameter by 1 cm in length, which was dilated.", + "summary_subclaims": [ + "An 89 years old woman with a past medical history of nonalcoholic steatohepatitis cirrhosis presented to the hospital.", + "She presented with an inability to swallow one day after screening esophagogastroduodenoscopy.", + "Band ligation of esophageal varices was performed for primary prophylaxis.", + "The patient was not able to tolerate her oral secretions.", + "Initial blood work revealed a Model of End Organ Liver Disease score of 7.", + "She was treated with sublingual nitroglycerin for esophageal spasm.", + "Esophageal spasm is a known complication after esophageal banding.", + "Esophagogastroduodenoscopy revealed the mucosa surrounding the banded varix was necrosed and blocking the lumen of the esophagus.", + "The band was purposefully dislodged.", + "Distal ulceration and stricturing were revealed after band removal.", + "Within 72 h after band removal, she was tolerating an oral diet.", + "Endoscopy performed 2 wk later revealed an intrinsic stenosis.", + "The intrinsic stenosis measured 8 mm in diameter by 1 cm in length.", + "The stenosis was dilated." + ] + }, + { + "id": "multiclinsum_test_1140_en.txt", + "fulltext": "A 55-year-old man started to receive hemodialysis because of diabetic renal failure 2 years previously. He underwent renal transplantation 1.5 years previously, and had been receiving immunosuppressants since then. Eight months after transplantation, the serum creatinine level increased to 4.4 mg/dl. He had CMV enteritis with occult blood in the stool and an elevated CMV pp65 (C7-HRP) antigen level in blood mononuclear cells. Intravenous ganciclovir (150 mg/day) was administered for 11 days, followed by valganciclovir (450 mg/day). Because the enteritis was very severe, ganciclovir and valganciclovir were not reduced to maintenance doses, which are generally half of starting doses. Two days after starting valganciclovir, he had unsteady gait, but could walk unaided. On the next day, the patient needed assistance with walking. His consciousness was mildly disturbed (E3, V5, and M6 on the Glasgow Coma Scale). One day later, he became delirious intermittently. Two days later, he was found on the floor after falling, without major injuries. He was suspected to be irritated and exhausted because of severe enteritis. Nine days after starting valganciclovir, his level of consciousness worsened (E3, V3, and M5), and he could not receive oral drugs, including valganciclovir. Neurologists were consulted. Encephalitis was unlikely, since no meningeal signs or fever was noted; the cell count was normal (0.33 cells/μl) in the CSF, and the protein concentration marginally elevated (54 mg/dl). CMV, herpes simplex virus, varicella-zoster virus, and Epstein-Barr virus DNA was later found to be negative in the CSF. Ganciclovir-induced encephalopathy was suspected, and the drug was withdrawn. Because of the risk of further falls, hemodialysis using a VPS-15HA membrane, a vitamin E-coated polysulfone membrane (Asahi Kasei Kuraray Medical, Japan) was performed twice in 2 days. His consciousness improved considerably after the first session of dialysis (E3, V4, and M6) and was completely restored on the next morning after the second session (E4, V5, and M6). The trough levels of ganciclovir in the serum and CSF were retrospectively measured and are shown in table .", + "fulltext_subclaims": [ + "The patient is a 55-year-old man.", + "He started hemodialysis 2 years before the current admission.", + "The cause of hemodialysis was diabetic renal failure.", + "He underwent renal transplantation 1.5 years before the current admission.", + "He had been receiving immunosuppressants since the renal transplantation.", + "Eight months after transplantation, the serum creatinine level increased to 4.4 mg/dl.", + "He had CMV enteritis.", + "He had occult blood in the stool.", + "The CMV pp65 (C7-HRP) antigen level in blood mononuclear cells was elevated.", + "Intravenous ganciclovir (150 mg/day) was administered for 11 days.", + "Valganciclovir (450 mg/day) was administered after the ganciclovir.", + "Ganciclovir and valganciclovir were not reduced to maintenance doses.", + "Two days after starting valganciclovir, he had unsteady gait.", + "On the next day, the patient needed assistance with walking.", + "His consciousness was mildly disturbed (E3, V5, and M6 on the Glasgow Coma Scale).", + "One day later, he became delirious intermittently.", + "Two days later, he was found on the floor after falling.", + "He was suspected to be irritated and exhausted because of severe enteritis.", + "Nine days after starting valganciclovir, his level of consciousness worsened (E3, V3, and M5).", + "He could not receive oral drugs, including valganciclovir.", + "Neurologists were consulted.", + "Encephalitis was unlikely.", + "No meningeal signs were noted.", + "No fever was noted.", + "The cell count in the CSF was 0.33 cells/μl.", + "The protein concentration in the CSF was 54 mg/dl.", + "CMV DNA was found to be negative in the CSF.", + "Herpes simplex virus DNA was found to be negative in the CSF.", + "Varicella-zoster virus DNA was found to be negative in the CSF.", + "Epstein-Barr virus DNA was found to be negative in the CSF.", + "Ganciclovir-induced encephalopathy was suspected.", + "Ganciclovir was withdrawn.", + "Hemodialysis using a VPS-15HA membrane was performed twice in 2 days.", + "His consciousness improved considerably after the first session of dialysis.", + "His consciousness was completely restored on the next morning after the second session.", + "The trough levels of ganciclovir in the serum and CSF were retrospectively measured." + ], + "summary": "Here, we summarize clinical information of all patients with definite ganciclovir-induced encephalopathy including our own patient, who had severe symptoms, with the highest reported trough concentration of ganciclovir in the blood, and underwent therapeutic dialysis with complete recovery.", + "summary_subclaims": [ + "We summarize clinical information of all patients with definite ganciclovir-induced encephalopathy.", + "Our patient had severe symptoms.", + "Our patient had the highest reported trough concentration of ganciclovir in the blood.", + "Our patient underwent therapeutic dialysis.", + "Our patient had complete recovery." + ] + }, + { + "id": "multiclinsum_test_592_en.txt", + "fulltext": "A 65-year-old non-smoking and non-drinking woman had split-graft deceased-donor LT for end-stage primary biliary cirrhosis (PBC) . No pre-LT induction immunosuppressant was given. Her post-LT immunosuppressants included oral tacrolimus (1 mg twice daily) and mycophenolate mofetil (180 mg twice daily). She also had prednisolone (10 mg twice daily) immediately after LT and gradually tapered to 5 mg daily. Prophylactic medication included fluconazole (200 mg daily), trimethoprim-sulfamethoxazole (TMP-SMX) (480 mg daily) and acyclovir (400 mg tds) were also given for 3 months. She developed biliary anastomotic stricture and bile leakage, which improved with repeated endoscopic retrograde cholangiopancreatography with balloon dilatation without stenting. The last endoscopic retrograde cholangiopancreatography was performed at 22 months after LT. At 25 months after LT, she was admitted because of a 2-day history of fever, dyspnea and dry coughing. At admission, her blood pressure was 132/80 mmHg, pulse 106 beat per minute, and SpO2 88% at ambient air. SpO2 improved to 95% with supplemental oxygen (2 L/min) via nasal cannula, but rapidly deteriorated requiring 100% oxygen via re-breathing mask to maintain SpO2 ≥ 92%. Chest X-ray and other investigations were performed . Pneumocystis jirovecii, CMV and RSV were detected in bronchoalveolar lavage by respective accredited in-house polymerase chain reaction. Her condition improved with intravenous TMP-SMX (trimethoprim component at 15 mg/kg/d divided in every 8 h), a tapering dose of corticosteroid for PCP and intravenous ganciclovir (5 mg/kg every 12 h as induction, followed by 5 mg/kg every 24 h as maintenance) for CMV. Her immunosuppressants were reduced and tapered during the PCP treatment. On day-10 TMP-SMX, her chest X-ray showed subcutaneous emphysema bilaterally and right pneumothorax suspected of pneumomediastinum . Computed tomography of the thorax confirmed the presence of right pneumothorax, pneumomediastinum and subcutaneous emphysema . She was managed with 7-day chest drain in situ with a standard Argyle-type chest tube of Fr-32 until her right lung re-expanded, in addition to 21-day TMP-SMX. She was not put on mechanical ventilation. She survived and was discharged on day 31 after admission. Chest X-ray on discharge showed resolution of the pneumothorax .", + "fulltext_subclaims": [ + "The patient was a 65-year-old non-smoking and non-drinking woman.", + "She had split-graft deceased-donor liver transplantation for end-stage primary biliary cirrhosis.", + "No pre-LT induction immunosuppressant was given.", + "Post-LT immunosuppressants included oral tacrolimus (1 mg twice daily) and mycophenolate mofetil (180 mg twice daily).", + "She also had prednisolone (10 mg twice daily) immediately after LT.", + "Prednisolone was gradually tapered to 5 mg daily.", + "Prophylactic medication included fluconazole (200 mg daily), trimethoprim-sulfamethoxazole (480 mg daily), and acyclovir (400 mg tds) for 3 months.", + "She developed biliary anastomotic stricture and bile leakage.", + "The biliary anastomotic stricture and bile leakage improved with repeated endoscopic retrograde cholangiopancreatography with balloon dilatation without stenting.", + "The last endoscopic retrograde cholangiopancreatography was performed at 22 months after liver transplantation.", + "At 25 months after liver transplantation, she was admitted because of a 2-day history of fever, dyspnea, and dry coughing.", + "At admission, her blood pressure was 132/80 mmHg, pulse 106 beats per minute, and SpO2 88% at ambient air.", + "SpO2 improved to 95% with supplemental oxygen (2 L/min) via nasal cannula.", + "SpO2 rapidly deteriorated requiring 100% oxygen via re-breathing mask to maintain SpO2 ≥ 92%.", + "Pneumocystis jirovecii, CMV, and RSV were detected in bronchoalveolar lavage by respective accredited in-house polymerase chain reaction.", + "Her condition improved with intravenous TMP-SMX (trimethoprim component at 15 mg/kg/d divided every 8 h).", + "A tapering dose of corticosteroid was given for PCP.", + "Intravenous ganciclovir (5 mg/kg every 12 h as induction, followed by 5 mg/kg every 24 h as maintenance) was given for CMV.", + "Her immunosuppressants were reduced and tapered during the PCP treatment.", + "On day-10 TMP-SMX, her chest X-ray showed subcutaneous emphysema bilaterally and right pneumothorax suspected of pneumomediastinum.", + "Computed tomography of the thorax confirmed the presence of right pneumothorax, pneumomediastinum, and subcutaneous emphysema.", + "She was managed with 7-day chest drain in situ with a standard Argyle-type chest tube of Fr-32 until her right lung re-expanded.", + "She received 21-day TMP-SMX.", + "She was not put on mechanical ventilation.", + "She survived and was discharged on day 31 after admission.", + "Chest X-ray on discharge showed resolution of the pneumothorax." + ], + "summary": "A 65-year-old woman who had split-graft deceased-donor LT for primary biliary cirrhosis developed fever, dyspnea and dry coughing at 25 months after transplant. Her immunosuppressants included tacrolimus, mycophenolate mofetil, and prednisolone. PCP infection was confirmed by molecular detection of Pneumocystis jirovecii,in bronchoalveolar lavage. On day-10 trimethoprim-sulphamethoxazole, her chest X-ray showed subcutaneous emphysema bilaterally, right pneumothorax and pneumomediastinum. Computed tomography of the thorax confirmed the presence of right pneumothorax, pneumomediastinum and subcutaneous emphysema. She was managed with 7-day right-sided chest drain and a 21-day course of trimethoprim-sulphamethoxazole before discharge.", + "summary_subclaims": [ + "The patient was a 65-year-old woman.", + "The patient had split-graft deceased-donor liver transplantation for primary biliary cirrhosis.", + "The patient developed fever, dyspnea, and dry coughing at 25 months after transplant.", + "The patient's immunosuppressants included tacrolimus, mycophenolate mofetil, and prednisolone.", + "Pneumocystis jirovecii infection was confirmed by molecular detection in bronchoalveolar lavage.", + "On day-10 trimethoprim-sulphamethoxazole, the chest X-ray showed subcutaneous emphysema bilaterally.", + "On day-10 trimethoprim-sulphamethoxazole, the chest X-ray showed right pneumothorax.", + "On day-10 trimethoprim-sulphamethoxazole, the chest X-ray showed pneumomediastinum.", + "Computed tomography of the thorax confirmed the presence of right pneumothorax.", + "Computed tomography of the thorax confirmed the presence of pneumomediastinum.", + "Computed tomography of the thorax confirmed the presence of subcutaneous emphysema.", + "The patient was managed with 7-day right-sided chest drain.", + "The patient received a 21-day course of trimethoprim-sulphamethoxazole before discharge." + ] + }, + { + "id": "multiclinsum_test_2630_en.txt", + "fulltext": "A 72-year-old female was admitted to hospital suffering from fatigue, weight loss and rectal bleeding. Total colonoscopy demonstrated adenocarcinoma of the sigmoid colon at 25 cm from the anal verge. A chest x-ray was normal. No sites of distant metastasis were reported on abdominal computed tomography (CT) scan. The serum carcinoembryonic antigen level was normal. The patient underwent sigmoidectomy in May 2008. During the operation, the left ovary was fixed at the site of the sigmoid colon cancer and was removed en block. Thorough macroscopic examination of the liver and rest of the abdomen showed no sign of metastatic disease. Histopathological examination of the specimen revealed a moderately differentiated mucus-producing adenocarcinoma, 3 cm in diameter located 5 cm from the peripheral surgical margin . The tumor invaded into but not beyond the muscularis propria (T2). Ki 67 antigen and p53 tumor suppressor protein staining were positive and epidermal growth factor receptor (EGFR) negative. The left ovary was free of neoplasmatic tissue. Only four lymph nodes were counted, free of metastatic adenocarcinoma. The patient had an uneventful recovery. On rectum examination one year later a palpable extramucosal mass was noticed at the anterior rectum wall. An abdominal CT scan revealed a tumor 2 cm in size at the lower anterior mesorectum in close relation with the posterior vaginal wall and a second mass 2 cm in size at the anterior abdominal wall midline . Total colonoscopy showed no mucosal lesion. A chest x-ray was normal. Rectal endoscopic ultrasound (EUS) showed a tumor infiltrating the rectum muscularis propria from outside. Core needle biopsy demonstrated the presence of a mucus producing adenocarcinoma with the same histological futures with the primary tumor and therefore it was considered as metachronous metastasis. Serum carcinoembryonic antigen level was normal. Since no other site of recurrence was identified, an abdominoperineal resection was attempted . At laparotomy, the anterior abdominal wall mass was located at the site of previous incision and after complete resection, fast biopsy showed adenocarcinoma. Surgical examination of the abdominal cavity showed no sign of reccurence. At that time, sinus bradycardia and ST segment depression was noticed on electrocardiogram (ECG) monitoring. The termination of the operation was decided and a loop transverse colostomy was immediately perfomed. Postoperative cardiologic examination revealed an acute muocardium infract and the patient was treated respectively. Chemo-radiation of the mesorectum tumor and re-evaluation for surgical excision was decided and she was discharged on the eleventh post operative day.", + "fulltext_subclaims": [ + "A 72-year-old female was admitted to hospital suffering from fatigue, weight loss and rectal bleeding.", + "Total colonoscopy demonstrated adenocarcinoma of the sigmoid colon at 25 cm from the anal verge.", + "A chest x-ray was normal.", + "No sites of distant metastasis were reported on abdominal computed tomography (CT) scan.", + "The serum carcinoembryonic antigen level was normal.", + "The patient underwent sigmoidectomy in May 2008.", + "During the operation, the left ovary was fixed at the site of the sigmoid colon cancer and was removed en block.", + "Thorough macroscopic examination of the liver and rest of the abdomen showed no sign of metastatic disease.", + "Histopathological examination of the specimen revealed a moderately differentiated mucus-producing adenocarcinoma, 3 cm in diameter located 5 cm from the peripheral surgical margin.", + "The tumor invaded into but not beyond the muscularis propria (T2).", + "Ki 67 antigen and p53 tumor suppressor protein staining were positive and epidermal growth factor receptor (EGFR) negative.", + "The left ovary was free of neoplasmatic tissue.", + "Only four lymph nodes were counted, free of metastatic adenocarcinoma.", + "The patient had an uneventful recovery.", + "On rectum examination one year later a palpable extramucosal mass was noticed at the anterior rectum wall.", + "An abdominal CT scan revealed a tumor 2 cm in size at the lower anterior mesorectum in close relation with the posterior vaginal wall and a second mass 2 cm in size at the anterior abdominal wall midline.", + "Total colonoscopy showed no mucosal lesion.", + "A chest x-ray was normal.", + "Rectal endoscopic ultrasound (EUS) showed a tumor infiltrating the rectum muscularis propria from outside.", + "Core needle biopsy demonstrated the presence of a mucus producing adenocarcinoma with the same histological features with the primary tumor and therefore it was considered as metachronous metastasis.", + "Serum carcinoembryonic antigen level was normal.", + "Since no other site of recurrence was identified, an abdominoperineal resection was attempted.", + "At laparotomy, the anterior abdominal wall mass was located at the site of previous incision and after complete resection, fast biopsy showed adenocarcinoma.", + "Surgical examination of the abdominal cavity showed no sign of recurrence.", + "At that time, sinus bradycardia and ST segment depression was noticed on electrocardiogram (ECG) monitoring.", + "The termination of the operation was decided and a loop transverse colostomy was immediately performed.", + "Postoperative cardiologic examination revealed an acute myocardium infarct and the patient was treated respectively.", + "Chemo-radiation of the mesorectum tumor and re-evaluation for surgical excision was decided and she was discharged on the eleventh post operative day." + ], + "summary": "A 72-year-old female underwent sigmoidectomy for stage I (T2N0 M0) sigmoid colon cancer in May 2008. In June 2009, an abdominal computed tomography scan revealed a tumor 2 cm in size at the lower anterior mesorectum and a second mass 2 cm in size at the anterior abdominal wall midline. Total colonoscopy showed no mucosal lesion. The serum carcinoembryonic antigen level was normal. A biopsy of the mesorectum tumor showed similar histologic characteristics with the primary tumor. Since no other site of recurrence was identified, an abdominoperineal resection was attempted. During the operation and after the removal of the incision recurrence, sinus bradycardia and signs of myocardial ischemia were noticed. A loop transverse colostomy was immediately perfomed and the operation was terminated. Postoperative cardiologic examination revealed an acute myocardium infract. Chemo-radiation of the mesorectum tumor and re-evaluation for surgical excision was decided.", + "summary_subclaims": [ + "The patient is a 72-year-old female.", + "The patient underwent sigmoidectomy for stage I (T2N0 M0) sigmoid colon cancer in May 2008.", + "In June 2009, an abdominal computed tomography scan revealed a tumor 2 cm in size at the lower anterior mesorectum.", + "In June 2009, an abdominal computed tomography scan revealed a second mass 2 cm in size at the anterior abdominal wall midline.", + "Total colonoscopy showed no mucosal lesion.", + "The serum carcinoembryonic antigen level was normal.", + "A biopsy of the mesorectum tumor showed similar histologic characteristics with the primary tumor.", + "An abdominoperineal resection was attempted.", + "During the operation, sinus bradycardia and signs of myocardial ischemia were noticed.", + "A loop transverse colostomy was immediately performed.", + "The operation was terminated.", + "Postoperative cardiologic examination revealed an acute myocardium infarct.", + "Chemo-radiation of the mesorectum tumor was decided.", + "Re-evaluation for surgical excision was decided." + ] + }, + { + "id": "multiclinsum_test_3144_en.txt", + "fulltext": "A 32-year-old Iranian female presented to Rajaei Hospital Cardiac Center in Tehran, Iran with a chief complaint of progressive shortness of breath (dyspnea), which persisted even at rest. The patient was referred for an outpatient hematology consultation to assess for inherited coagulopathies and to further evaluate the etiology of the thromboembolic events. Initial clinical and paraclinical evaluations, including echocardiography and computed tomography (CT) angiography, were performed owing to the high clinical suspicion of pulmonary embolism; the diagnosis of pulmonary thromboembolism (PTE) was confirmed. Anticoagulation therapy with heparin was promptly initiated, and the patient was transitioned to oral rivaroxaban after stabilization. She was discharged in stable condition, with close follow-up recommendations.\n\nSubsequently, 2 weeks later, the patient returned with worsening dyspnea accompanied by systemic symptoms, including fever, chills, night sweats, and anorexia. Abdominal ultrasonography and contrast-enhanced abdominopelvic CT scan revealed a renal mass involving the inferior vena cava (IVC) with a tumor thrombus extending into the right atrium. Given these findings, the patient was referred to the emergency general surgery department at our referral hospital for further management and surgical evaluation.\n\nThe patient had no significant past medical or family history and denied smoking, alcohol use, or illicit drug use. On presentation, her vital signs included a body temperature of 37 °C, blood pressure of 100/60 mmHg, respiratory rate of 20 breaths per minute, and a pulse rate of 110 beats per minute. Physical examination revealed a painless, palpable abdominal mass located in the right flank region without tenderness, guarding, or percussion abnormalities. No signs of hepatosplenomegaly or lymphadenopathy were detected, and other systemic examinations were unremarkable.\n\nDiagnostic assessment and therapeutic interventions\nLaboratory assessments, including complete blood count (CBC), blood biochemistry, urinalysis (UA), and arterial blood gas (ABG) analysis, yielded normal results.\n\nThe initial spiral CT scan of the lungs, mediastinum, abdomen, and pelvis with and without contrast revealed an enlarged heterogeneously enhancing solid mass located at the mid to lower pole of the left kidney, measuring 70 mm × 75 mm × 105 mm with tumor thrombosis extending into the left renal vein and IVC superiorly over a craniocaudal length of ~23 cm, terminating below the right atrium. In addition, mild hypodense fluid was noted in the pelvic cavity. Pulmonary findings revealed filling defects in the right main pulmonary artery and its segmental branches, consistent with pulmonary thromboembolism and a 7 mm ground-glass nodule detected in the left lower lobe (LLL) superior segment. No signs of appendicitis, cholecystitis, pancreatitis, diverticulitis, hydronephrosis, urinary stones, gastrointestinal obstruction, or free air were observed, and major vascular structures remained open without gross pathology in other abdominal or pelvic regions.\n\nEchocardiography showed normal systolic function with an ejection fraction (EF) of 55%. There was mild to moderate tricuspid regurgitation (TR), mitral regurgitation (MR), and pulmonary insufficiency (PI), with a mean pulmonary artery pressure (PAP) of 27 mmHg and a peak instantaneous pressure gradient (PIPG) of 17 mmHg. A large, rope-like, hyperechoic mass with tissue texture was identified in the inferior vena cava (IVC), measuring 14 cm × 2.7 cm. The mass protruded from the IVC into the right atrium, highly suggestive of massive vein thrombosis.\n\nWith a possible diagnosis of renal tumor with extensive tumor thrombus into the inferior vena cava and right atrium, an open, left radical nephrectomy was performed by the urologist team, and then the cardiac surgery team performed IVC thrombectomy. During surgery, there was a huge intracardiac tumor (tumoral and fibrous in gross vision in the right atrium) that was resected, and then the IVC was evacuated from the tumor (extracardiac tumor) with cardiopulmonary bypass and abdominal exploration. The left kidney specimen, following radical nephrectomy, was preserved in formalin and submitted for pathological examination.\n\nMacroscopic examination of the left radical nephrectomy specimen revealed a 7 cm × 6.5 cm × 5 cm mass in the lower pole of the kidney with extension to the renal sinus. On microscopic examination, sheet-like diffuse infiltration of small and round neoplastic cells with monomorphic nuclei, fine speckled chromatin pattern, and inconspicuous nucleoli was seen. The arrangement of the tumor cells in occasional pseudorosette-like structures was also identified.\n\nResults of immunohistochemical staining (IHC) were as follows: positive staining for NKX2.2, CD99, synaptophysin (Syn), and chromogranin; negative staining for CK7, CK20, CK, LCA, PAX8, AMACR, P63, CКA1/A3, and TLE 1; and non-diagnostic staining for Ki67. Finally, the peripheral primitive neuroectodermal tumor (PNET/Ewing sarcoma) was diagnosed with 20% tumor necrosis.\n\nIn the fluorescence in situ hybridization (FISH) study, translocation was identified at (11;22), indicating the presence of an EWSR1 gene rearrangement. This finding confirmed the final diagnosis of primitive neuroectodermal tumor (PNET).\n\nDifferential diagnosis\nOn the basis of the clinical and paraclinical findings, the physicians considered a differential diagnosis that included a kidney tumor with thromboembolism in the superior vena cava (SVC), extending into the right atrium.\n\nOutcome and follow-up\nThe patient’s postoperative course was largely uneventful, aside from some minor incisional pain, which was well managed with analgesics. She was discharged 1 week after the operation in stable condition with appropriate follow-up care. She initiated systemic chemotherapy as part of her comprehensive treatment plan 2 months postoperatively. Given the prothrombotic risk associated with both malignancy and chemotherapy, she has remained on anticoagulant therapy since her initial admission. This regimen was carefully maintained throughout her chemotherapy to minimize the risk of thrombotic complications, ensuring optimal management of her condition.\n\nAdjuvant therapy\nFollowing surgery, the patient was initiated on interval-compressed therapy with alternating cycles of vincristine/doxorubicin/cyclophosphamide (VDC) and ifosfamide/etoposide (IE), which was administered every 14 days with hematopoietic growth factor support. Our radiation oncology team indicated that there was no need for radiotherapy. The treatment demonstrated a favorable response, and the final management plan included an autologous stem cell transplant to consolidate the response. However, after 12 weeks of therapy, some adjustments were necessary owing to significant toxicity and the onset of cytopenia. To mitigate these side effects, doxorubicin was replaced with dactinomycin, and the duration of each cycle was extended from 2 to 3 weeks to accommodate the patient’s tolerance and recovery better.\n\nSpiral CT scan\nAt the end of the eighth cycle of chemotherapy, 4 months later, we evaluated the patient using spiral CT. Multislice CT spiral imaging before and after oral and intravenous contrast revealed normal findings in the lungs, pleura, mediastinum, heart, chest wall, liver, pancreas, spleen, right kidney, adrenal glands, aorta, IVC, retroperitoneum, bowel loops, stomach, bladder, and pelvic organs. The left kidney was absent owing to prior nephrectomy, and no lymphadenopathy, ascites, or abnormalities in the bones were detected. A chemotherapy port was noted on the left upper chest wall. All findings were stable compared with the previous multislice CT spiral.", + "fulltext_subclaims": [ + "The patient was a 32-year-old Iranian female.", + "She presented with progressive shortness of breath.", + "The dyspnea persisted even at rest.", + "The patient was referred for an outpatient hematology consultation.", + "The consultation aimed to assess for inherited coagulopathies.", + "The consultation aimed to further evaluate the etiology of the thromboembolic events.", + "Initial clinical and paraclinical evaluations were performed.", + "The evaluations included echocardiography.", + "The evaluations included computed tomography (CT) angiography.", + "The diagnosis of pulmonary thromboembolism (PTE) was confirmed.", + "Anticoagulation therapy with heparin was initiated.", + "The patient was transitioned to oral rivaroxaban after stabilization.", + "She was discharged in stable condition.", + "The patient returned 2 weeks later with worsening dyspnea.", + "She had fever, chills, night sweats, and anorexia.", + "Abdominal ultrasonography and contrast-enhanced abdominopelvic CT scan revealed a renal mass.", + "The renal mass involved the inferior vena cava (IVC).", + "The tumor thrombus extended into the right atrium.", + "The patient was referred to the emergency general surgery department.", + "The patient had no significant past medical or family history.", + "She denied smoking, alcohol use, or illicit drug use.", + "On presentation, her body temperature was 37 °C.", + "Her blood pressure was 100/60 mmHg.", + "Her respiratory rate was 20 breaths per minute.", + "Her pulse rate was 110 beats per minute.", + "Physical examination revealed a painless, palpable abdominal mass in the right flank region.", + "No signs of hepatosplenomegaly or lymphadenopathy were detected.", + "Other systemic examinations were unremarkable.", + "Laboratory assessments, including complete blood count (CBC), blood biochemistry, urinalysis (UA), and arterial blood gas (ABG) analysis, yielded normal results.", + "The initial spiral CT scan revealed an enlarged heterogeneously enhancing solid mass at the mid to lower pole of the left kidney.", + "The mass measured 70 mm × 75 mm × 105 mm.", + "The tumor thrombosis extended into the left renal vein and IVC.", + "The thrombus extended over a craniocaudal length of ~23 cm.", + "The thrombus terminated below the right atrium.", + "Mild hypodense fluid was noted in the pelvic cavity.", + "Pulmonary findings revealed filling defects in the right main pulmonary artery and its segmental branches.", + "The filling defects were consistent with pulmonary thromboembolism.", + "A 7 mm ground-glass nodule was detected in the left lower lobe (LLL) superior segment.", + "No signs of appendicitis, cholecystitis, pancreatitis, diverticulitis, hydronephrosis, urinary stones, gastrointestinal obstruction, or free air were observed.", + "Major vascular structures remained open without gross pathology.", + "Echocardiography showed normal systolic function with an ejection fraction (EF) of 55%.", + "There was mild to moderate tricuspid regurgitation (TR).", + "There was mild to moderate mitral regurgitation (MR).", + "There was mild to moderate pulmonary insufficiency (PI).", + "The mean pulmonary artery pressure (PAP) was 27 mmHg.", + "The peak instantaneous pressure gradient (PIPG) was 17 mmHg.", + "A large, rope-like, hyperechoic mass with tissue texture was identified in the inferior vena cava (IVC).", + "The mass measured 14 cm × 2.7 cm.", + "The mass protruded from the IVC into the right atrium.", + "The mass was highly suggestive of massive vein thrombosis.", + "An open, left radical nephrectomy was performed.", + "The cardiac surgery team performed IVC thrombectomy.", + "During surgery, a huge intracardiac tumor was resected.", + "The IVC was evacuated from the tumor with cardiopulmonary bypass.", + "The left kidney specimen was preserved in formalin.", + "The specimen was submitted for pathological examination.", + "Macroscopic examination revealed a 7 cm × 6.5 cm × 5 cm mass in the lower pole of the kidney.", + "The mass extended to the renal sinus.", + "Microscopic examination showed sheet-like diffuse infiltration of small and round neoplastic cells.", + "The tumor cells had monomorphic nuclei.", + "The tumor cells had a fine speckled chromatin pattern.", + "The tumor cells had inconspicuous nucleoli.", + "The tumor cells arranged in occasional pseudorosette-like structures.", + "Immunohistochemical staining was positive for NKX2.2.", + "Immunohistochemical staining was positive for CD99.", + "Immunohistochemical staining was positive for synaptophysin (Syn).", + "Immunohistochemical staining was positive for chromogranin.", + "Immunohistochemical staining was negative for CK7.", + "Immunohistochemical staining was negative for CK20.", + "Immunohistochemical staining was negative for CK.", + "Immunohistochemical staining was negative for LCA.", + "Immunohistochemical staining was negative for PAX8.", + "Immunohistochemical staining was negative for AMACR.", + "Immunohistochemical staining was negative for P63.", + "Immunohistochemical staining was negative for CКA1/A3.", + "Immunohistochemical staining was negative for TLE 1.", + "Immunohistochemical staining for Ki67 was non-diagnostic.", + "The final diagnosis was peripheral primitive neuroectodermal tumor (PNET/Ewing sarcoma).", + "The tumor had 20% tumor necrosis.", + "Fluorescence in situ hybridization (FISH) identified translocation at (11;22).", + "The translocation indicated the presence of an EWSR1 gene rearrangement.", + "The final diagnosis was confirmed as primitive neuroectodermal tumor (PNET).", + "The differential diagnosis included a kidney tumor with thromboembolism in the superior vena cava (SVC), extending into the right atrium.", + "The patient’s postoperative course was largely uneventful.", + "She had some minor incisional pain.", + "The pain was well managed with analgesics.", + "She was discharged 1 week after the operation.", + "She was discharged in stable condition.", + "She initiated systemic chemotherapy 2 months postoperatively.", + "She has remained on anticoagulant therapy since her initial admission.", + "The anticoagulant regimen was maintained throughout chemotherapy.", + "The regimen aimed to minimize the risk of thrombotic complications.", + "Following surgery, the patient was initiated on interval-compressed therapy.", + "The therapy included alternating cycles of vincristine/doxorubicin/cyclophosphamide (VDC) and ifosfamide/etoposide (IE).", + "The therapy was administered every 14 days.", + "Hematopoietic growth factor support was provided.", + "The radiation oncology team indicated that there was no need for radiotherapy.", + "The treatment demonstrated a favorable response.", + "The final management plan included an autologous stem cell transplant.", + "After 12 weeks of therapy, adjustments were necessary.", + "Adjustments were made owing to significant toxicity.", + "Adjustments were made owing to the onset of cytopenia.", + "Doxorubicin was replaced with dactinomycin.", + "The duration of each cycle was extended from 2 to 3 weeks.", + "The extension accommodated the patient’s tolerance.", + "The extension accommodated the patient’s recovery.", + "At the end of the eighth cycle of chemotherapy, 4 months later, the patient was evaluated using spiral CT.", + "Multislice CT spiral imaging before and after oral and intravenous contrast revealed normal findings.", + "The findings were in the lungs, pleura, mediastinum, heart, chest wall, liver, pancreas, spleen, right kidney, adrenal glands, aorta, IVC, retroperitoneum, bowel loops, stomach, bladder, and pelvic organs.", + "The left kidney was absent owing to prior nephrectomy.", + "No lymphadenopathy was detected.", + "No ascites was detected.", + "No abnormalities in the bones were detected.", + "A chemotherapy port was noted on the left upper chest wall.", + "All findings were stable compared with the previous multislice CT spiral." + ], + "summary": "A 32-year-old Iranian female patient presented with a chief complaint of progressive dyspnea, anorexia, and night sweating in the last 2 weeks before her admission. Computed tomography scan showed a tumoral lesion in the left kidney with thrombosis extending into the left renal vein and inferior vena cava up to the right atrium. The patient underwent open cardiac surgery and a radical nephrectomy. During surgery, the mass protruded from the inferior vena cava into the right atrium; it was ultimately diagnosed as renal-origin Ewing's sarcoma, and EWSR1 rearrangement was confirmed on pathology.", + "summary_subclaims": [ + "The patient is a 32-year-old Iranian female.", + "The patient had progressive dyspnea, anorexia, and night sweating for 2 weeks before admission.", + "Computed tomography scan showed a tumoral lesion in the left kidney.", + "The tumoral lesion had thrombosis extending into the left renal vein.", + "The thrombosis extended into the inferior vena cava up to the right atrium.", + "The patient underwent open cardiac surgery.", + "The patient underwent a radical nephrectomy.", + "During surgery, the mass protruded from the inferior vena cava into the right atrium.", + "The mass was ultimately diagnosed as renal-origin Ewing's sarcoma.", + "EWSR1 rearrangement was confirmed on pathology." + ] + }, + { + "id": "multiclinsum_test_2030_en.txt", + "fulltext": "A boy aged 5 years and 4 months, with a height of 101.2 cm and weight of 15.1 kg, was scheduled for circumcision under general anesthesia to treat true phimosis. He had a history of chronic granulomatosis and had undergone allogenic bone marrow transplantation when 4 years old. Over the course of treatment, he had general anesthesia five times using propofol and remifentanil and experienced no postoperative nausea. He also had no family history of PONV. The preoperative examination was otherwise unremarkable, aside from chronically slightly elevated AST (46 IU/L).\nThe patient was admitted to the operating room without premedication. Slow induction with sevoflurane and nitrous oxide was performed, and after intravenous access was established, intubation was performed using a supraglottic device. Anesthesia was maintained with oxygen, air, 0.9–1.1% of sevoflurane, and 0.4–0.5 mcg/kg/min of remifentanil during surgery. Sacral epidural anesthesia with 1ml/kg of 0.2% ropivacaine and 15mg/kg of intravenous acetaminophen was administered for postoperative analgesia. The operation time was 1 h and 2 min, and the anesthesia time was 1 h and 43 min.\nThe patient complained of nausea in the PACU and was administered 0.1mg/kg of ondansetron. After the nausea resolved, he was transferred to the general ward.\nThe patient was able to drink water at 1 h and 2 h after transfer to the ward, but intravenous infusion was continued because he did not feel well enough to eat dinner. He vomited after breakfast the following day and complained of continued nausea. Discharge to home was postponed, and 0.1mg/kg ondansetron was re-administered—23 h had elapsed since the first dose in the PACU. Thirty minutes after re-administration, he became drowsy and showed only a slight response to stimulation, scoring 5 on the Ramsay sedation scale. Since vital signs were stable with no respiratory depression or need for oxygen, follow-up was continued in the ward with a pulse oximeter.\nThree hours after re-administration, the patient recovered to a score of 3 on the Ramsay sedation scale. He could have water without nausea or vomiting. He was discharged later on the same day at the strong request of his guardian. Because the drowsiness improved spontaneously, no additional testing was performed. After discharge from the hospital, he was able to have meals as usual, and drowsiness was not observed.", + "fulltext_subclaims": [ + "The patient was a boy aged 5 years and 4 months.", + "The patient's height was 101.2 cm.", + "The patient's weight was 15.1 kg.", + "The patient was scheduled for circumcision under general anesthesia.", + "The indication for surgery was true phimosis.", + "The patient had a history of chronic granulomatosis.", + "The patient had undergone allogenic bone marrow transplantation when 4 years old.", + "The patient had general anesthesia five times using propofol and remifentanil.", + "The patient experienced no postoperative nausea after prior anesthetics.", + "The patient had no family history of postoperative nausea and vomiting.", + "The preoperative examination was otherwise unremarkable.", + "The patient had chronically slightly elevated AST (46 IU/L).", + "The patient was admitted to the operating room without premedication.", + "Slow induction with sevoflurane and nitrous oxide was performed.", + "Intubation was performed using a supraglottic device.", + "Anesthesia was maintained with oxygen, air, 0.9–1.1% of sevoflurane, and 0.4–0.5 mcg/kg/min of remifentanil.", + "Sacral epidural anesthesia with 1ml/kg of 0.2% ropivacaine was administered.", + "The operation time was 1 h and 2 min.", + "The anesthesia time was 1 h and 43 min.", + "The patient complained of nausea in the PACU.", + "The patient was administered 0.1mg/kg of ondansetron in the PACU.", + "The patient was transferred to the general ward after nausea resolved.", + "The patient was able to drink water at 1 h after transfer to the ward.", + "The patient was able to drink water at 2 h after transfer to the ward.", + "Intravenous infusion was continued because the patient did not feel well enough to eat dinner.", + "The patient vomited after breakfast the following day.", + "The patient complained of continued nausea after breakfast the following day.", + "Discharge to home was postponed.", + "0.1mg/kg ondansetron was re-administered.", + "23 h had elapsed since the first dose of ondansetron in the PACU.", + "Thirty minutes after re-administration, the patient became drowsy and showed only a slight response to stimulation.", + "The patient scored 5 on the Ramsay sedation scale.", + "Vital signs were stable with no respiratory depression.", + "No oxygen was needed.", + "Follow-up was continued in the ward with a pulse oximeter.", + "Three hours after re-administration, the patient recovered to a score of 3 on the Ramsay sedation scale.", + "The patient could have water without nausea or vomiting.", + "The patient was discharged later on the same day at the strong request of his guardian.", + "No additional testing was performed.", + "After discharge from the hospital, the patient was able to have meals as usual.", + "Drowsiness was not observed after discharge." + ], + "summary": "A 5-year-old boy underwent circumcision under general anesthesia and suffered from postoperative nausea and vomiting. He was administered 0.1mg/kg of ondansetron in the PACU and 23 h later on the day after surgery. After the second dose, he acutely exhibited drowsiness which resolved in 3 h. He was discharged to home later on the same day. He was not given any other drugs at the time, and the drowsiness was thought to be directly attributable to ondansetron, though the exact mechanism was unknown.", + "summary_subclaims": [ + "A 5-year-old boy underwent circumcision under general anesthesia.", + "He suffered from postoperative nausea and vomiting.", + "He was administered 0.1mg/kg of ondansetron in the PACU.", + "He was administered 0.1mg/kg of ondansetron 23 h later on the day after surgery.", + "After the second dose, he acutely exhibited drowsiness.", + "The drowsiness resolved in 3 h.", + "He was discharged to home later on the same day.", + "He was not given any other drugs at the time.", + "The drowsiness was thought to be directly attributable to ondansetron.", + "The exact mechanism was unknown." + ] + }, + { + "id": "multiclinsum_test_2946_en.txt", + "fulltext": "A 51-year-old perimenopausal white woman with no significant past medical history other than chronic back pain presented to her primary care physician in October 2013 with fainting spells, worsening back pain and severe fatigue of 1 month's duration. Her laboratory workup revealed a white blood count of 7,100/μl, hemoglobin of 8.9 g/dl and a platelet count of 60,000/μl, an unremarkable basic metabolic profile and normal liver function tests. Her ferritin (682 ng/ml) was elevated and both vitamin B12 (392 pg/ml) and folate (20 ng/ml) levels were within normal range. The patient developed another syncopal episode at home, and an emergency room workup confirmed mild anemia and thrombocytopenia with no clear evidence of active gastrointestinal bleeding. In December 2013, due to worsening symptoms, the patient presented to a different emergency room with gingival bleeding and petechiae on her lower extremities. She was found to have a hemoglobin level of 7.2 g/dl with a platelet count of 10,000/μl. The patient was admitted to the hospital, and a bone marrow biopsy was performed. Bone marrow aspiration could not be obtained, and the core biopsy revealed extensive involvement of metastatic carcinoma . Immunohistochemistry studies were highly suggestive of a breast primary (data not shown). A mammogram demonstrated a 2.4-cm mass at the 2 o'clock position in the right breast with suspicious axillary lymph nodes. The patient underwent a biopsy of both the primary breast lesion and of the axillary lymph nodes, which revealed invasive ductal carcinoma that was estrogen receptor-positive, progesterone receptor-positive and human epithelial growth factor receptor (HER2)-negative. Further staging workup demonstrated extensive osseous metastases, but no visceral metastases. She received a transfusion with 2 units of red blood cells and 1 apheresis unit of platelets, resulting in an improvement in hemoglobin from 7.2 to 10.1 g/dl and platelet count from 10,000 to 20,000/μl. She was discharged home and was started on endocrine therapy with both leuprolide and letrozole. Denosumab was also administered monthly for bone metastases. However, she did not respond either clinically or biochemically (rising CA 15-3) to the endocrine therapy and continued to experience frequent gum bleeds and petechial rashes throughout her body.\nIn March 2014, the patient transferred her care to our center. Restaging workup demonstrated extensive skeletal metastases without visceral involvement or splenomegaly (data not shown). A complete blood count showed a white blood count of 5,000/μl, hemoglobin of 9 g/dl and a platelet count of 10,000/μl. The patient received 1 unit of apheresis platelets urgently. Surprisingly, her platelet count did not increase at all, but decreased to 6,000/μl. The patient did not have headache, but she developed more extensive petechiae and hemorrhagic blisters in her mouth. Hence, she was admitted to the inpatient unit for further management. Both bone marrow biopsy from an outside facility and peripheral smear from our center were reviewed, and our pathologist concurred with the initial diagnosis. Peripheral blood examination of the peripheral blood smear in March 2014 revealed marked thrombocytopenia and anemia; some large platelets but no giant platelets were seen (photos are not available). There was no evidence of schistocytosis, which essentially ruled out intravascular or microangiopathic processes. It did reveal some teardrop cells, which was consistent with her bone marrow finding – a myelophthisis process. However, bone scan showed that a large fraction of long bones was spared by metastases. The disproportionate thrombocytopenia seems to suggest a dual pathological process: myelophthisis and peripheral consumption. The fact that her platelet count decreased upon platelet transfusion seems to suggest an immune-mediated peripheral destruction of platelets, which is, at least in part, responsible for her marked thrombocytopenia. All the other pertinent laboratory studies including folate, vitamin B12 level, thyroid function tests, antinuclear antibodies, Helicobacter pylori antibodies, hepatitis panel and HIV test were normal, and therefore a clinical diagnosis of ITP was established. In view of the substantial risk of fatal bleeding, the patient received IVIG (1 g/kg) daily for 2 days (3.4.2014 to 3.5.2014) and high-dose steroid methylprednisolone 500 mg i.v. daily for 3 days (3.4.2014 to 3.7.2014). As shown in figure , the patient's platelet count responded dramatically, increasing from 6,000 to 32,000/μl in 3 days. She was discharged home with oral prednisone 80 mg (1.5 mg/kg) daily. Her platelet count improved to 155,000/μl 1 week later and 171,000/μl 2 weeks after discharge. We started to taper down her prednisone and treat her metastatic breast cancer using chemotherapy with capecitabine (500 mg p.o. daily) since she did not respond to the first-line hormonal therapy. The patient's platelet count continued to improve and was stabilized at around 250,000/μl. Prednisone was tapered off over 3 months, and capecitabine was gradually increased to 1,500 mg p.o. daily. Interestingly, her hemoglobin had also improved during the course of the treatment, mirroring the response of platelet count. It cannot be explained by the therapeutic response from capecitabine which was started on 3.20.2014, while her hemoglobin improved dramatically from 8.1 to 10.3 g/dl in 3 days (3.4.2014 to 3.7.2014) and further improved to 12.2 g/dl on 3.14.2014. This seems to suggest a similar immune-mediated mechanism involved in the development of anemia. By the time of completion of this report, the patient continued to respond to the current therapy with discontinuation of steroids, and the restaging CT and bone scan in September 2014 demonstrated an excellent response to capecitabine.", + "fulltext_subclaims": [ + "The patient is a 51-year-old perimenopausal white woman.", + "The patient had no significant past medical history other than chronic back pain.", + "The patient presented to her primary care physician in October 2013.", + "The patient had fainting spells, worsening back pain, and severe fatigue of 1 month's duration.", + "The patient's laboratory workup revealed a white blood count of 7,100/μl.", + "The patient's laboratory workup revealed a hemoglobin of 8.9 g/dl.", + "The patient's laboratory workup revealed a platelet count of 60,000/μl.", + "The patient's basic metabolic profile was unremarkable.", + "The patient's liver function tests were normal.", + "The patient's ferritin was 682 ng/ml.", + "The patient's vitamin B12 was 392 pg/ml.", + "The patient's folate was 20 ng/ml.", + "The patient developed another syncopal episode at home.", + "An emergency room workup confirmed mild anemia.", + "An emergency room workup confirmed thrombocytopenia.", + "There was no clear evidence of active gastrointestinal bleeding.", + "In December 2013, the patient presented to a different emergency room with gingival bleeding and petechiae on her lower extremities.", + "The patient was found to have a hemoglobin level of 7.2 g/dl.", + "The patient was found to have a platelet count of 10,000/μl.", + "A bone marrow biopsy was performed.", + "Bone marrow aspiration could not be obtained.", + "The core biopsy revealed extensive involvement of metastatic carcinoma.", + "Immunohistochemistry studies were highly suggestive of a breast primary.", + "A mammogram demonstrated a 2.4-cm mass at the 2 o'clock position in the right breast.", + "The mammogram showed suspicious axillary lymph nodes.", + "The patient underwent a biopsy of both the primary breast lesion and of the axillary lymph nodes.", + "The biopsy revealed invasive ductal carcinoma.", + "The tumor was estrogen receptor-positive.", + "The tumor was progesterone receptor-positive.", + "The tumor was human epithelial growth factor receptor (HER2)-negative.", + "Further staging workup demonstrated extensive osseous metastases.", + "There were no visceral metastases.", + "The patient received a transfusion with 2 units of red blood cells.", + "The patient received a transfusion with 1 apheresis unit of platelets.", + "The transfusion resulted in an improvement in hemoglobin from 7.2 to 10.1 g/dl.", + "The transfusion resulted in an improvement in platelet count from 10,000 to 20,000/μl.", + "The patient was started on endocrine therapy with both leuprolide and letrozole.", + "Denosumab was administered monthly for bone metastases.", + "The patient did not respond either clinically or biochemically to the endocrine therapy.", + "The patient continued to experience frequent gum bleeds.", + "The patient continued to experience petechial rashes throughout her body.", + "In March 2014, the patient transferred her care to our center.", + "Restaging workup demonstrated extensive skeletal metastases.", + "There was no visceral involvement.", + "There was no splenomegaly.", + "A complete blood count showed a white blood count of 5,000/μl.", + "A complete blood count showed a hemoglobin of 9 g/dl.", + "A complete blood count showed a platelet count of 10,000/μl.", + "The patient received 1 unit of apheresis platelets urgently.", + "Her platelet count did not increase at all.", + "Her platelet count decreased to 6,000/μl.", + "The patient did not have headache.", + "The patient developed more extensive petechiae.", + "The patient developed hemorrhagic blisters in her mouth.", + "The patient was admitted to the inpatient unit for further management.", + "Bone marrow biopsy from an outside facility and peripheral smear from our center were reviewed.", + "Our pathologist concurred with the initial diagnosis.", + "Peripheral blood examination revealed marked thrombocytopenia.", + "Peripheral blood examination revealed anemia.", + "Some large platelets but no giant platelets were seen.", + "There was no evidence of schistocytosis.", + "There was no evidence of intravascular or microangiopathic processes.", + "There was some teardrop cells.", + "This was consistent with a myelophthisis process.", + "Bone scan showed that a large fraction of long bones was spared by metastases.", + "The disproportionate thrombocytopenia suggests a dual pathological process: myelophthisis and peripheral consumption.", + "The fact that her platelet count decreased upon platelet transfusion suggests an immune-mediated peripheral destruction of platelets.", + "All other pertinent laboratory studies were normal.", + "A clinical diagnosis of ITP was established.", + "The patient received IVIG (1 g/kg) daily for 2 days.", + "The patient received high-dose steroid methylprednisolone 500 mg i.v. daily for 3 days.", + "The patient's platelet count increased from 6,000 to 32,000/μl in 3 days.", + "The patient was discharged home with oral prednisone 80 mg daily.", + "Her platelet count improved to 155,000/μl 1 week later.", + "Her platelet count improved to 171,000/μl 2 weeks after discharge.", + "Prednisone was tapered off over 3 months.", + "The patient was treated with chemotherapy using capecitabine.", + "The patient's platelet count continued to improve.", + "The patient's platelet count was stabilized at around 250,000/μl.", + "Her hemoglobin improved from 8.1 to 10.3 g/dl in 3 days.", + "Her hemoglobin further improved to 12.2 g/dl on 3.14.2014.", + "This seems to suggest a similar immune-mediated mechanism involved in the development of anemia.", + "The patient continued to respond to the current therapy with discontinuation of steroids.", + "Restaging CT and bone scan in September 2014 demonstrated an excellent response to capecitabine." + ], + "summary": "We report a case of a 51-year-old female with no significant past medical history who presented with sudden onset of malaise, syncope, gingival bleed and epistaxis. She was found to have severe thrombocytopenia (platelet count 6,000/μl) and anemia (hemoglobin 7.2 g/dl). Her workup led to the diagnosis of metastatic ductal breast cancer with extensive bone metastasis. Bone marrow biopsy demonstrated myelophthisis which was initially thought to be consistent with her presentation of thrombocytopenia and anemia. Therefore, the patient was started on hormonal therapy for the treatment of her metastatic breast cancer. After 3 months of therapy, she did not improve and developed severe mucosal bleeding. Her clinical presentation was suspicious for ITP and immune-mediated anemia, and hence she was started on steroids and intravenous immunoglobulin. The patient had a dramatic response to therapy with normalization of her platelet count and hemoglobin within 2 weeks.", + "summary_subclaims": [ + "The patient was a 51-year-old female.", + "She had no significant past medical history.", + "She presented with sudden onset of malaise.", + "She presented with syncope.", + "She presented with gingival bleed.", + "She presented with epistaxis.", + "Her platelet count was 6,000/μl.", + "Her hemoglobin was 7.2 g/dl.", + "Her workup led to the diagnosis of metastatic ductal breast cancer.", + "Bone marrow biopsy demonstrated myelophthisis.", + "The patient was started on hormonal therapy for the treatment of her metastatic breast cancer.", + "After 3 months of therapy, she did not improve.", + "She developed severe mucosal bleeding.", + "Her clinical presentation was suspicious for ITP.", + "Her clinical presentation was suspicious for immune-mediated anemia.", + "She was started on steroids.", + "She was started on intravenous immunoglobulin.", + "The patient had a dramatic response to therapy.", + "Her platelet count normalized within 2 weeks.", + "Her hemoglobin normalized within 2 weeks." + ] + }, + { + "id": "multiclinsum_test_2046_en.txt", + "fulltext": "A 65 years old right-handed woman, came to neurosurgery for consultation due to progressive bilateral visual loss in her temporal fields. This had occurred over 10 months, and 2 weeks prior to her admission she reported sudden loss of consciousness, prompting her admission to the hospital. On examination, she was alert and oriented x 3, she had a normal cranial nerve examination except for decrease visual acuity (20/200 in her left eye, 20/80 in her right eye), bitemporal hemianopia and mild atrophy of the optic disk in the left eye. Gait, motor and sensory examination was normal.\nLaboratory studies showed a LH at 0.22 IU/L (reference value in Postmenopausal females 15.0–62.0 mIU/mL)and prolactin at 53 ng/mL (reference value in non-pregnant females 2–29 ng/mL)0.7. A contrast enhanced brain MRI was obtained and revealed a sellar lesion which was hypointense in T1 but hyperintense in T2 sequences with enhancement of the periphery. The lesion extended into the sphenoid sinus and parasellar space without encasement of the carotids and into the suprasellar cistern abutting the optic chiasm. The patient underwent endoscopic endonasal transsphenoidal surgery for resection of the sellar lesion . Intraoperatively, the lesion appeared reddish in color and it was of soft consistency. Moderately bleeding was encountered during resection and a sample was taken for pathology. At the end of the tumor removal, the scaffold was implanted to close the bone defect in the sphenoid sinus . Due to the fact that the graft could be molded into shape, it was easily set and allowed to cover the entire size of the defect. A standard fat graft was then placed in the sphenoid sinus covering the outer membrane of the chitosan graft. Finally, fibrin sealant was used, and a nasal packing was inserted in both nostrils.\nThe patient had an unremarkable postoperative period and after a few days the patient was discharged without evidence of CSF leak or complications. After one month the patient showed complete recovery of her visual acuity and visual fields. At follow up, the patient underwent a postoperative brain MRI illustrating gross total resection and good closure of the sellar floor. There were no signs of rejection or inflammation in the area where the chitosan scaffold was implanted.", + "fulltext_subclaims": [ + "The patient is a 65 years old right-handed woman.", + "She had progressive bilateral visual loss in her temporal fields.", + "The visual loss occurred over 10 months.", + "Two weeks prior to admission, she reported sudden loss of consciousness.", + "On examination, she was alert and oriented x 3.", + "She had decrease visual acuity (20/200 in her left eye, 20/80 in her right eye).", + "She had bitemporal hemianopia.", + "She had mild atrophy of the optic disk in the left eye.", + "Gait, motor and sensory examination was normal.", + "LH was 0.22 IU/L (reference value in Postmenopausal females 15.0–62.0 mIU/mL).", + "Prolactin was 53 ng/mL (reference value in non-pregnant females 2–29 ng/mL).", + "A contrast enhanced brain MRI revealed a sellar lesion.", + "The lesion was hypointense in T1 but hyperintense in T2 sequences.", + "The lesion extended into the sphenoid sinus and parasellar space.", + "The lesion extended into the suprasellar cistern abutting the optic chiasm.", + "The patient underwent endoscopic endonasal transsphenoidal surgery.", + "Intraoperatively, the lesion appeared reddish in color.", + "The lesion was of soft consistency.", + "Moderately bleeding was encountered during resection.", + "A sample was taken for pathology.", + "A scaffold was implanted to close the bone defect in the sphenoid sinus.", + "The scaffold was easily set and allowed to cover the entire size of the defect.", + "A standard fat graft was placed in the sphenoid sinus.", + "Fibrin sealant was used.", + "A nasal packing was inserted in both nostrils.", + "The patient had an unremarkable postoperative period.", + "The patient was discharged without evidence of CSF leak or complications.", + "After one month, the patient showed complete recovery of her visual acuity.", + "After one month, the patient showed complete recovery of her visual fields.", + "A postoperative brain MRI illustrated gross total resection.", + "The postoperative brain MRI showed good closure of the sellar floor.", + "There were no signs of rejection or inflammation in the area where the chitosan scaffold was implanted." + ], + "summary": "After a personalized design employing a tissue engineering strategy, we reconstructed the sellar floor in a 65-year-old woman who had undergone EETS for a pituitary adenoma with progressive bilateral visual loss. To repair the bony defect of the sellar floor, we used a novel bilaminar chitosan scaffold. The patient had an unremarkable postoperative course with no evidence of CSF leak. The polymer was well tolerated without toxicity, infection or complications. After 2 years of follow up the patient remains neurologically intact, and in good endocrinological status.", + "summary_subclaims": [ + "We reconstructed the sellar floor in a 65-year-old woman who had undergone EETS for a pituitary adenoma with progressive bilateral visual loss.", + "To repair the bony defect of the sellar floor, we used a novel bilaminar chitosan scaffold.", + "The patient had an unremarkable postoperative course with no evidence of CSF leak.", + "The polymer was well tolerated without toxicity.", + "The polymer was well tolerated without infection.", + "The polymer was well tolerated without complications.", + "After 2 years of follow up the patient remains neurologically intact.", + "After 2 years of follow up the patient is in good endocrinological status." + ] + }, + { + "id": "multiclinsum_test_196_en.txt", + "fulltext": "A 33-year-old man with a history of blindness in his right eye from a congenital cataract presented to the emergency department with blunt head trauma sustained during a motor vehicle collision. He complained of right eye pain and foreign body sensation. On examination, a round white object was visualized within the anterior chamber; his head was otherwise atraumatic. The patient stated that the white spot had been present prior to the accident but had now changed in size and appearance, noting that the spot had enlarged following his injury.\nFluorescein staining showed no abnormalities, and intraocular pressures were normal (18 millimeters mercury [mm Hg] right eye; 20 mm Hg left eye). Light perception was not present. Slit lamp examination demonstrated a round, white-speckled object in the dependent portion of the anterior chamber. Bedside ocular ultrasonography revealed a retinal detachment and an anterior dislocation of a cataract lens through the iris (–). Ophthalmology was consulted; anterior lens dislocations are considered an ocular emergency as they can result in acute angle-closure glaucoma and corneal edema; however, given the patient’s previous right-sided blindness they recommended next-day follow-up for operative repair.", + "fulltext_subclaims": [ + "The patient is a 33-year-old man.", + "He has a history of blindness in his right eye from a congenital cataract.", + "He presented to the emergency department with blunt head trauma.", + "The blunt head trauma was sustained during a motor vehicle collision.", + "He complained of right eye pain.", + "He complained of a foreign body sensation.", + "On examination, a round white object was visualized within the anterior chamber.", + "The patient stated that the white spot had been present prior to the accident.", + "The patient stated that the white spot had changed in size and appearance.", + "The patient noted that the spot had enlarged following his injury.", + "Fluorescein staining showed no abnormalities.", + "Intraocular pressure was 18 mm Hg in the right eye.", + "Intraocular pressure was 20 mm Hg in the left eye.", + "Light perception was not present.", + "Slit lamp examination demonstrated a round, white-speckled object in the dependent portion of the anterior chamber.", + "Bedside ocular ultrasonography revealed a retinal detachment.", + "Bedside ocular ultrasonography revealed an anterior dislocation of a cataract lens through the iris.", + "Ophthalmology was consulted.", + "Anterior lens dislocations are considered an ocular emergency.", + "Anterior lens dislocations can result in acute angle-closure glaucoma.", + "Anterior lens dislocations can result in corneal edema.", + "Given the patient’s previous right-sided blindness, ophthalmology recommended next-day follow-up for operative repair." + ], + "summary": "A 33-year-old male presented to the emergency department following a motor vehicle collision with complaints of right eye pain after hitting his head on the steering wheel. Point-of-care ultrasound (POCUS) revealed retinal detachment and an anterior lens dislocation.", + "summary_subclaims": [ + "The patient is a 33-year-old male.", + "The patient presented to the emergency department.", + "The presentation followed a motor vehicle collision.", + "The patient reported right eye pain.", + "The patient hit his head on the steering wheel.", + "Point-of-care ultrasound (POCUS) was performed.", + "POCUS revealed retinal detachment.", + "POCUS revealed an anterior lens dislocation." + ] + }, + { + "id": "multiclinsum_test_2835_en.txt", + "fulltext": "A 6-month-old female (body height 65 cm, body weight 6.6 kg) with tetralogy of Fallot, pulmonary artery atresia, and major aortopulmonary collateral artery (MAPCA) underwent palliative reconstruction of the right ventricular outflow tract and unifocalization of the MAPCA. Anesthesia was induced with sevoflurane, and the trachea was intubated with an uncuffed 3.0-mm tube. After induction, anesthesia was maintained with fentanyl, midazolam, and rocuronium. A total dose of 100 mcg/kg fentanyl and 1.5 mg/kg midazolam was administered during the operation. The operation was uneventful until separation from cardiopulmonary bypass, when her oxygen saturation could not be maintained due to the presumably high resistance of the pulmonary artery. Thus, she was transferred to the ICU with the sternum open, supported by venoarterial extracorporeal membrane oxygenation (ECMO). She was weaned off ECMO on the third day of admission (day 3) to the ICU. However, she required prolonged mechanical ventilation for the following reasons. First, venoarterial ECMO support was reinitiated on day 6 because an attempt of delayed sternal closure led to severe desaturation due to pulmonary hypertensive crisis. Second, percutaneous balloon dilatation of the left pulmonary artery stenosis performed on day 13 was complicated by severe bleeding from the trachea. Furthermore, on day 28, she experienced non-obstructive mesenteric ischemia and underwent exploratory laparotomy, resulting in marked abdominal distention and generalized edema.\nShe was finally weaned off ECMO support on day 36. The patient was sedated with dexmedetomidine, midazolam, fentanyl, and chlorpromazine hydrochloride during treatment in the ICU, but the drug doses were gradually decreased, resulting in minimum use of sedatives on day 52 (fentanyl 0.2 mcg/kg/h, midazolam 0.03 mg/kg/h, and dexmedetomidine 0.2 mcg/kg/h). On day 52, she met the extubation criteria with a rapid shallow breathing index of 6.5 and improved dynamic Crs at 0.65 mL/cmH2O/kg with no clinical signs of high airway resistance. Thus, her trachea was extubated on day 52. After extubation, ventilation and oxygenation were not problematic with high flow nasal cannula support for several hours with no clinical signs of upper airway stenosis. However, she became restless with sternal retraction several hours after extubation, suggesting increased respiratory effort. The arterial blood gas analysis showed elevated pCO2 (53 mmHg), and she was reintubated 20 h after extubation.\nAfter reintubation, Edi monitoring was initiated to assess diaphragm function. Measurements were carried out using a 12 Fr Neurally Adjusted Ventilatory Assist (NAVA) catheter attached to a SERVO-i ventilator (Maquet Critical Care, Solna, Sweden). The catheter position was adjusted with the Edi catheter position tool equipped in the NAVA software and confirmed by daily chest X-rays. Mechanical ventilation was managed by the Synchronized Intermittent Mandatory Ventilation (SIMV) mode with pressure support (PS) and positive end-expiratory pressure (PEEP) properly applied to ensure respiratory muscle unloading. Her typical Edi values during SIMV were in the range of 10–20 mcV. Daily SBTs from 15 min to 30 min (PS 5 cmH2O, PEEP 5 cmH2O) were performed from day 53. The maximal Edi and NVE values were recorded during the SBTs . In summary, the Edi during the SBTs was higher than 70 mcV just after the reintubation, indicating a strong inspiratory effort to deliver normal tidal volume; the Edi decreased gradually day by day while the tidal volume showed nearly constant values, leading to improvement of NVE. On day 58, her Edi values during the SBTs were 10–20 mcV, comparable to those during SIMV, and her trachea was extubated. After extubation, the patient received high-flow nasal cannula support and did not experience reintubation owing to respiratory collapse. She was discharged from the hospital without oxygen support on day 158.", + "fulltext_subclaims": [ + "The patient was a 6-month-old female with tetralogy of Fallot, pulmonary artery atresia, and major aortopulmonary collateral artery.", + "The patient underwent palliative reconstruction of the right ventricular outflow tract and unifocalization of the MAPCA.", + "Anesthesia was induced with sevoflurane.", + "The trachea was intubated with an uncuffed 3.0-mm tube.", + "A total dose of 100 mcg/kg fentanyl and 1.5 mg/kg midazolam was administered during the operation.", + "The operation was uneventful until separation from cardiopulmonary bypass.", + "Her oxygen saturation could not be maintained due to the presumably high resistance of the pulmonary artery.", + "She was transferred to the ICU with the sternum open, supported by venoarterial extracorporeal membrane oxygenation.", + "She was weaned off ECMO on the third day of admission to the ICU.", + "Venoarterial ECMO support was reinitiated on day 6 because an attempt of delayed sternal closure led to severe desaturation due to pulmonary hypertensive crisis.", + "Percutaneous balloon dilatation of the left pulmonary artery stenosis performed on day 13 was complicated by severe bleeding from the trachea.", + "On day 28, she experienced non-obstructive mesenteric ischemia and underwent exploratory laparotomy.", + "She was finally weaned off ECMO support on day 36.", + "The patient was sedated with dexmedetomidine, midazolam, fentanyl, and chlorpromazine hydrochloride during treatment in the ICU.", + "The drug doses were gradually decreased, resulting in minimum use of sedatives on day 52.", + "On day 52, she met the extubation criteria with a rapid shallow breathing index of 6.5.", + "Her trachea was extubated on day 52.", + "After extubation, ventilation and oxygenation were not problematic with high flow nasal cannula support for several hours.", + "She became restless with sternal retraction several hours after extubation, suggesting increased respiratory effort.", + "The arterial blood gas analysis showed elevated pCO2 (53 mmHg).", + "She was reintubated 20 h after extubation.", + "Edi monitoring was initiated to assess diaphragm function.", + "Measurements were carried out using a 12 Fr Neurally Adjusted Ventilatory Assist (NAVA) catheter attached to a SERVO-i ventilator.", + "The catheter position was adjusted with the Edi catheter position tool equipped in the NAVA software.", + "Mechanical ventilation was managed by the Synchronized Intermittent Mandatory Ventilation (SIMV) mode with pressure support and positive end-expiratory pressure.", + "Her typical Edi values during SIMV were in the range of 10–20 mcV.", + "Daily SBTs from 15 min to 30 min were performed from day 53.", + "The Edi during the SBTs was higher than 70 mcV just after the reintubation.", + "The Edi decreased gradually day by day while the tidal volume showed nearly constant values.", + "On day 58, her Edi values during the SBTs were 10–20 mcV, comparable to those during SIMV.", + "Her trachea was extubated on day 58.", + "After extubation, the patient received high-flow nasal cannula support.", + "She did not experience reintubation owing to respiratory collapse.", + "She was discharged from the hospital without oxygen support on day 158." + ], + "summary": "A 6-month-old female infant required prolonged mechanical ventilation after cardiac surgery. Fifty-two days after surgery, her trachea was extubated but required reintubation. Edi monitoring was initiated to assess diaphragm function. The Edi was > 70 mcV just after the reintubation, and her NVE was 1.0 mL/mcV, but gradually decreased. On day 59, her Edi values during the spontaneous breathing trials were 13 mcV with the improvement of NVE (2.5 mL/mcV) and her trachea was extubated without complications.", + "summary_subclaims": [ + "The patient was a 6-month-old female infant.", + "The patient required prolonged mechanical ventilation after cardiac surgery.", + "Fifty-two days after surgery, her trachea was extubated but required reintubation.", + "Edi monitoring was initiated to assess diaphragm function.", + "The Edi was > 70 mcV just after the reintubation.", + "Her NVE was 1.0 mL/mcV.", + "Her NVE gradually decreased.", + "On day 59, her Edi values during the spontaneous breathing trials were 13 mcV.", + "Her NVE improved to 2.5 mL/mcV.", + "Her trachea was extubated without complications." + ] + }, + { + "id": "multiclinsum_test_1513_en.txt", + "fulltext": "An 11-year-old boy consulted a family doctor for bloody diarrhea. The patient had no specific medical or family history. A colonoscopy from the rectum to the sigmoid colon led to the diagnosis of pediatric UC with a pediatric ulcerative colitis activity index (PUCAI) of 30. He was administered 5-aminosalicylic acid (5-ASA) suppositories (1 g/day) and was referred to our hospital for subsequent treatment. His symptoms promptly improved to a PUCAI of 5. His blood examination results were unremarkable but the fecal calprotectin (FC) level was elevated to 3,190 mg/kg. A complete colonoscopy was performed, which revealed inflammatory findings from the rectum to the transverse colon. Moreover, the cecum and ascending colon showed loss of vascular permeability and adherent purulent mucus . The patient was prescribed oral 5-ASA (3,000 mg/day). The FC level gradually decreased to 33.2 mg/kg by week 15 .\nAt 12 years old, he complained of epigastric pain on an empty stomach, which was relieved with dietary intake (week 19). He reported no UC symptoms, including diarrhea and bloody stools (PUCAI, 0); however, an elevated FC level was noted (week 20). Esophagogastroduodenoscopy (EGD) findings indicated an A1 ulcer on the lower wall of the duodenal bulb . A rapid urease test was positive, and he was diagnosed with a duodenal ulcer due to H. pylori infection. The H. pylori infection was treated using clarithromycin and amoxicillin for 7 days and a proton-pump inhibitor. The patient’s symptoms improved the day after treatment initiation. In week 33, an EGD was performed to evaluate the therapeutic effect. The duodenal ulcer had healed, and scarring was observed .\nThe FC level remained high despite improvement of duodenal ulcer symptoms and endoscopic findings of H. pylori eradication. The patient subsequently developed diarrhea (PUCAI, 10) in week 35 and a UC relapse was considered. Cytomegalovirus antibody, antigenemia, and tuberculosis (T-SPOT assay) tests were negative. Colonoscopy showed small aphthae and edematous mucosa throughout the colon in week 36 . Histopathological examination revealed UC lesions grades 3–5 based on the Matts classification. The patient was diagnosed with a UC relapse, and the 5-ASA dosage was increased to 4,000 mg/day (100 mg/kg/day).", + "fulltext_subclaims": [ + "An 11-year-old boy consulted a family doctor for bloody diarrhea.", + "The patient had no specific medical or family history.", + "A colonoscopy from the rectum to the sigmoid colon led to the diagnosis of pediatric UC.", + "The pediatric ulcerative colitis activity index (PUCAI) was 30.", + "He was administered 5-aminosalicylic acid (5-ASA) suppositories (1 g/day).", + "He was referred to our hospital for subsequent treatment.", + "His symptoms promptly improved to a PUCAI of 5.", + "His blood examination results were unremarkable.", + "The fecal calprotectin (FC) level was elevated to 3,190 mg/kg.", + "A complete colonoscopy was performed.", + "The colonoscopy revealed inflammatory findings from the rectum to the transverse colon.", + "The cecum and ascending colon showed loss of vascular permeability.", + "The cecum and ascending colon showed adherent purulent mucus.", + "The patient was prescribed oral 5-ASA (3,000 mg/day).", + "The FC level gradually decreased to 33.2 mg/kg by week 15.", + "At 12 years old, he complained of epigastric pain on an empty stomach.", + "The epigastric pain was relieved with dietary intake.", + "He reported no UC symptoms, including diarrhea and bloody stools.", + "The PUCAI was 0.", + "An elevated FC level was noted.", + "Esophagogastroduodenoscopy (EGD) findings indicated an A1 ulcer on the lower wall of the duodenal bulb.", + "A rapid urease test was positive.", + "He was diagnosed with a duodenal ulcer due to H. pylori infection.", + "The H. pylori infection was treated using clarithromycin and amoxicillin for 7 days.", + "The H. pylori infection was treated using a proton-pump inhibitor.", + "The patient’s symptoms improved the day after treatment initiation.", + "An EGD was performed to evaluate the therapeutic effect.", + "The duodenal ulcer had healed.", + "Scarring was observed.", + "The FC level remained high despite improvement of duodenal ulcer symptoms.", + "The FC level remained high despite endoscopic findings of H. pylori eradication.", + "The patient subsequently developed diarrhea.", + "The PUCAI was 10.", + "A UC relapse was considered.", + "Cytomegalovirus antibody tests were negative.", + "Antigenemia tests were negative.", + "Tuberculosis (T-SPOT assay) tests were negative.", + "Colonoscopy showed small aphthae and edematous mucosa throughout the colon.", + "Histopathological examination revealed UC lesions grades 3–5 based on the Matts classification.", + "The patient was diagnosed with a UC relapse.", + "The 5-ASA dosage was increased to 4,000 mg/day.", + "The 5-ASA dosage was 100 mg/kg/day." + ], + "summary": "An 11-year-old boy diagnosed with ulcerative colitis (UC) was in clinical remission, with treatment involving 5-aminosalicylic acid. Fecal calprotectin (FC) level had decreased to 33.2 mg/kg, indicating mucosal healing. At age 12, he experienced epigastric pain on an empty stomach, which was relieved with dietary intake. His FC level was elevated without UC symptoms, such as diarrhea and bloody stools. He was diagnosed with H. pylori duodenal ulcer. H. pylori eradication (clarithromycin and amoxicillin for 7 days and a proton-pump inhibitor) led to symptom improvement the day after treatment initiation. However, he developed diarrhea and his FC level remained high despite improvement in duodenal ulcer symptoms and endoscopic findings of H. pylori eradication. Colonoscopy results indicated UC relapse.", + "summary_subclaims": [ + "The patient is an 11-year-old boy.", + "The patient was diagnosed with ulcerative colitis.", + "The patient was in clinical remission.", + "The patient's treatment involved 5-aminosalicylic acid.", + "The patient's fecal calprotectin level had decreased to 33.2 mg/kg.", + "The patient's fecal calprotectin level decrease indicated mucosal healing.", + "At age 12, the patient experienced epigastric pain on an empty stomach.", + "The patient's epigastric pain was relieved with dietary intake.", + "The patient's fecal calprotectin level was elevated without UC symptoms.", + "The patient was diagnosed with H. pylori duodenal ulcer.", + "H. pylori eradication treatment included clarithromycin and amoxicillin for 7 days.", + "H. pylori eradication treatment included a proton-pump inhibitor.", + "Symptoms improved the day after treatment initiation.", + "The patient developed diarrhea.", + "The patient's fecal calprotectin level remained high.", + "The patient's duodenal ulcer symptoms improved.", + "Endoscopic findings indicated H. pylori eradication.", + "Colonoscopy results indicated UC relapse." + ] + }, + { + "id": "multiclinsum_test_2688_en.txt", + "fulltext": "A 22-year-old man presented to the emergency department at the general hospital no 58 (IMSS León Guanajuato México) after being stabbed once with an ice pick in the chest during a bar fight. On arrival, the patient was unstable with a blood pressure of 90/50 mmHg, no paradoxical pulse was noticed, heart rate was 110 beats/min, and respiratory rate was 28 breaths/min. The physical examination was notable for one penetrating stab wound, the object was not in situ, the entry site was a tiny hole in the fifth intercostal space to the left of the sternum, and there was a left pleural effusion syndrome and a holo-systolic murmur at the heart apex. The X-ray confirmed the haemothorax, and 3D transthoracic echocardiography showed an LV ejection fraction of 60%, a VSD located at the apex with a diameter measured around 6 × 8 mm, and no signs of tamponade or free wall of the right ventricle rupture (, , and ). A left chest tube was placed draining 700 mL of blood, and no transfusion was required. The patient was transferred to UMAE T1 Bajío Hospital (third-level centre) for treatment of the VSD. There was a discussion with the heart team and the patient. Because there was only one central defect with good rims and the patient rejected surgery, it was decided to perform percutaneous closure.\nThe procedure was performed under general anaesthesia and transthoracic echocardiography guidance. Right femoral arterial access and right internal jugular venous access were obtained. We considered no need to perform coronary angiography. Right and left heart haemodynamics demonstrated mild pulmonary hypertension and a QP:QS >1.5. A left ventricular angiogram shows an apical 10 mm VSD (, ). From the right femoral sheath, a 5F JR3.5 catheter was advanced into the left ventricle (LV). A 0.035″×260 cm glidewire was used to cross the VSD to the left pulmonary artery. A 20 mm Ensnare was used to snare and externalize the wire through the jugular sheath . We used the arteriovenous loop to introduce the 8 Fr TorqVue delivery sheath and placed it into the LV. The VSD was sealed by deploying an Amplatzer 14 mm muscular VSD occlude (St Jude Medical, St. Paul, MN) (, ).\nTransthoracic echocardiography performed on the third day after the procedure showed the excellent location of the device with a trace of flow through the mesh in colour Doppler imaging. The patient was discharged on the fifth postoperative day. After 6 months, the echo Doppler shows no residual shunt, normal pulmonary artery pressure, and normal biventricular function ( and , ). The patient remains asymptomatic.", + "fulltext_subclaims": [ + "The patient was a 22-year-old man.", + "The patient was stabbed once with an ice pick in the chest.", + "The stab wound occurred during a bar fight.", + "The patient was taken to the emergency department at the general hospital no 58 (IMSS León Guanajuato México).", + "On arrival, the patient was unstable.", + "The patient's blood pressure was 90/50 mmHg.", + "The patient had a heart rate of 110 beats/min.", + "The patient had a respiratory rate of 28 breaths/min.", + "The physical examination was notable for one penetrating stab wound.", + "The object was not in situ.", + "The entry site was a tiny hole in the fifth intercostal space to the left of the sternum.", + "There was a left pleural effusion syndrome.", + "There was a holo-systolic murmur at the heart apex.", + "The X-ray confirmed the haemothorax.", + "3D transthoracic echocardiography showed an LV ejection fraction of 60%.", + "3D transthoracic echocardiography showed a VSD located at the apex with a diameter measured around 6 × 8 mm.", + "3D transthoracic echocardiography showed no signs of tamponade.", + "3D transthoracic echocardiography showed no signs of free wall of the right ventricle rupture.", + "A left chest tube was placed.", + "The chest tube drained 700 mL of blood.", + "No transfusion was required.", + "The patient was transferred to UMAE T1 Bajío Hospital.", + "The patient was transferred for treatment of the VSD.", + "There was a discussion with the heart team and the patient.", + "There was only one central defect with good rims.", + "The patient rejected surgery.", + "It was decided to perform percutaneous closure.", + "The procedure was performed under general anaesthesia.", + "The procedure was performed under transthoracic echocardiography guidance.", + "Right femoral arterial access was obtained.", + "Right internal jugular venous access was obtained.", + "No coronary angiography was performed.", + "Right and left heart haemodynamics demonstrated mild pulmonary hypertension.", + "Right and left heart haemodynamics demonstrated a QP:QS >1.5.", + "A left ventricular angiogram shows an apical 10 mm VSD.", + "A 5F JR3.5 catheter was advanced into the left ventricle.", + "A 0.035\"×260 cm glidewire was used to cross the VSD to the left pulmonary artery.", + "A 20 mm Ensnare was used to snare and externalize the wire through the jugular sheath.", + "The arteriovenous loop was used to introduce the 8 Fr TorqVue delivery sheath.", + "The delivery sheath was placed into the LV.", + "The VSD was sealed by deploying an Amplatzer 14 mm muscular VSD occlude.", + "Transthoracic echocardiography performed on the third day after the procedure showed the excellent location of the device.", + "Transthoracic echocardiography performed on the third day after the procedure showed a trace of flow through the mesh in colour Doppler imaging.", + "The patient was discharged on the fifth postoperative day.", + "After 6 months, the echo Doppler shows no residual shunt.", + "After 6 months, the echo Doppler shows normal pulmonary artery pressure.", + "After 6 months, the echo Doppler shows normal biventricular function.", + "The patient remains asymptomatic." + ], + "summary": "We present a 22-year-old male with an ice pick-related VSD. It was successfully closed by primary percutaneous approach. After 6 months, the echo Doppler shows no residual shunt, normal pulmonary artery pressure, and normal biventricular function.", + "summary_subclaims": [ + "The patient is a 22-year-old male.", + "The patient had an ice pick-related VSD.", + "The VSD was successfully closed by primary percutaneous approach.", + "After 6 months, the echo Doppler shows no residual shunt.", + "After 6 months, the echo Doppler shows normal pulmonary artery pressure.", + "After 6 months, the echo Doppler shows normal biventricular function." + ] + }, + { + "id": "multiclinsum_test_1549_en.txt", + "fulltext": "On July 24, 2022, a 4-year-old pregnant Simmental beef cow (approximately 600 kg, 268 days gestation) stopped eating and had not drunk water for 8 days. The cow was not producing any feces despite being given 1 kg of sodium sulfate and 8 l of vegetable oil twice.\nPrimary symptoms\nThe affected cow had an increased abdominal circumference , was dehydrated (as evident by the recession of the eyes in the orbits and skin tent duration >2 seconds), and transabdominal palpation revealed a large accumulation of fluid in the rumen. The cow had a body temperature of 39.4°C, respiration rate of 42 breaths/minute, and heart rate of 74 beats/minute. The left 1–3 ribs had high-pitched “pinging” based on auscult ation and percussion. The right abomasum area was enlarged , which was hard and clearly defined on palpation. On rectal examination, the intestine was found to be empty, the intestinal wall was dry, and a small amount of black sticky feces was attached to the rectum . The fetus was confirmed to be alive by the rectal touch of the uterus.\nLaboratory examination\nBlood routine examination showed an elevated white blood cell count of 18.4 × 109/l (reference range: 4.9–12.0 × 109/l) and neutrophil count of 9.6 × 109/l (reference range: 1.8–6.3 × 109/l). There were also marked increases in the number of red blood cells (10.8 × 1012/l; reference range: 5.1–7.6 × 1012/l), hemoglobin content (154 g/l; reference range: 85–122 g/l), and hematocrit (0.75 l/l; reference range: 0.22–0.33 l/l).\nBiochemical results showed reduced potassium ions (3.2 mmol/l; reference range: 3.9–5.8 mmol/l), chloride ions (88 mmol/l; reference range: 95–110 mmol/l), and calcium ions (2.0 mmol/l; reference range: 2.43–3.10 mmol/l), with elevated creatinine (384.46 μmol/l; reference range: 88–175 μmol/l), urea nitrogen (28.2 mmol/l; reference range: 2.0–9.6 mmol/l), total bilirubin (19.23 μmol/l; reference range: 0.17–8.55 μmol/l), and γ-glutamyltransferase (29.7 U/l; reference range: 6.1–17.4 U/l).\nX-ray examination revealed a metallic foreign body in the reticulum . The rumen fluid pH was approximately 8.5. Based on the above results, the cow was diagnosed with TR and AI. Based on previous reports , the diagnosis of TR can be confirmed by foreign body tests and X-ray examination. However, the differential diagnoses include forestomach atony (FA), rumen obstruction (RO), omasal obstruction (OO), left displaced abomasum (LDA), abomasal torsion (AT), and intestinal obstruction (IO) .\nTreatment plan\nBoth TR and AI were treated surgically. To save the fetus, a cesarean section was performed on the cow before the two operations were carried out. Medication was administered 3 hours before surgery to correct the dehydration, electrolyte disturbances (hypokalemia, hypocalcemia, and hypochloremia), and acid-base disturbances (metabolic alkalosis). describes the specific treatment plan in the present case.\nAntibiotics and anti-inflammatory agents were administered in the following preoperative injections: (i) 500 ml Ringer’s solution, 5 mg vitamin C, and 50 ml of 10% potassium chloride; (ii) 100 ml of 10% glucose and 500 ml of 10% calcium gluconate; and (iii) 500 ml of 5% glucose and 5 g ampicillin, each as a one-time intravenous injection; and (iv) 0.3 g meloxicam as a one-time intramuscular injection.\nBefore surgery, the accumulated fluid in the rumen was extracted by inserting a gastric tube via the oral cavity, further relieving the abdominal pressure. After local-infiltration anesthesia with a 0.5% procaine solution, an incision was made in the middle of the paralumbar fossa in the lef t flank to open the abdominal cavity. Intraperitoneal exploration rev ealed that the wall of the reticulum had adhered to the diaphragm, although no inflammatory purulent exudate from the abdomen. The omasum was found to be approximately 0.5 times larger than normal and located in a more ventral position than normal. The volume of the abomasum was approximately 5–7 times normal and was very firm on palpation. The bowel was empty and the fetu s was active. The cesarean section was then performed. Part of the uterus was pulled out at the incision, the uterus was cut open, and the fetus was removed. The uterus was then sutured. Subsequently, the rumen was cut open and the wire attached to the wall of the reticulum was removed. The rumen was then sutured.\nThe abomasum was cut open to eva cuate its contents. Xylazine hydrochloride (60 mg) w as injected intramuscularly to sedate the cow while lying down on the left side. After administering local-infilt ration anesthesia using a 0.5% procaine solution around the right lower abdominal wall in the abomasum region, the surgical incision was sele cted at the location where the AI was the hardest and made contact with the body surface. The feed material was removed a nd the abomasum was sutured. It is worth noting that we apply a slightly different approach for suturing the rumen, abomasum, and uterus from the traditional method. In particular, continuous spiral sutures were made on the mucosa of the uterus, and on the mucosa and submucosa of the rumen and abomasum with thinner polyglycolic acid (PGA) sutures (USP: 2–0), followed by continuous spiral sutures throughout the layer with thicker PGA sutures (USP: 0). Finally, cushing sutures were made with the same thicker PGA suture.\nPostoperative treatment was provided for 5 days, including (i) 2 l Ringer’s solution, 5 g vitamin C, and 50 ml 10% potassium chloride; (ii) 1 l 10% glucose and 300 ml 10% calcium gluconate; (iii) 500 ml 10% concentrated sodium chloride; (iv) 500 ml 5% glucose and 5 g ampicillin; (v) 500 ml normal saline and 600 mg ranitidine, each as a single intravenous injection once per day; (vi) 20 mg neostigmine methylsulfate as a single subcutaneous injection twice a day; (vii) 20 ml compound vitamin B as a single intramuscular injection twice a day; and (viii) 100 IU of oxytocin as a single intramuscular injection once a day.\nOn the seco nd day after the surgery, the cow began to ruminate, had an appetite, was in good spirits, and passed a large amount of black mucous feces. The cow fed on 3 kg hay and 2 kg concentrate. On the third and fourth days after surgery, feed intake increased, with 7 kg hay and approximately 5 kg concentrate consumed. On the fifth day, the fetal coat was completely excreted, but the feed intake decreased, the number of ruminations was reduced, the rumen peristalsis was weakened, and only a small amount of feces was excreted. On the sixth day after surgery, the cow began to drink a substantial amount of water, the abdominal circumference increased, rumination stopped, only a small amount of hay was eaten, and no excrement was observed. With rumen effusion, the high-pitched “pinging” could be heard by auscultation of the left side of ribs 1–3 with percussion, and palpation of the genuine stomach area was slightly hard. Therefore, we suspected that the abomasum had become obstructed again.\nRoutine blood examination showed an elevated white blood cell count of 14.5 × 109 and neutrophil count of 7.2 × 109/l, whereas no obvious abnormalities were found in biochemical parameters. On the eighth and ninth days after the operation, Zeng Ye Cheng Qi Tang (a traditional Chinese medicine powder consisting of 300 g rhubarb, 600 g mirabilite, 60 g Magnolia officinalis, 80 g Fructus aurantii immaturus, 120 g Scrophularia ningpoensis, 120 g Ophiopogon japonicus, 120 g Rehmannia glutinosa, 150 g areca nut, 60 g Aucklandia, and 200 g Raphanus seed) was administered, which is often used to treat ruminal impaction and IO, along with 1 l of vegetable oil. The abomasum area was massaged at the same time as the administration of the formulation (1 hour each time, three times/day). Furthermore, a subcutaneous injection of 10 mg neostigmine was administered four times/day. The cow was fed hay only (2 kg a day) and concentrate feed was stopped. As of the 11th day, the ruminant returned to normal, feed intake gradually increased, the rumen and abomasum peristaltic sound was enhanced as detected by auscultation, and normal defecation was observed. The amount of hay fed daily was gradually increased (but not more than 10 kg). After continued observation for 5 days, all indices of the diseased cow returned to normal . After 120 days, the cow made a full recovery and became pregnant again. The calf born by cesarean section is in good health .\nThe animal study was reviewed and approved by the College of Animal Science and Technology, Chongqing Three Gorges Vocational College. Written informed consent was obtained from the owners for the participation of their animals in this study.", + "fulltext_subclaims": [ + "The cow was a 4-year-old pregnant Simmental beef cow.", + "The cow was approximately 600 kg.", + "The cow was 268 days gestation.", + "The cow had stopped eating and had not drunk water for 8 days.", + "The cow had not produced any feces despite being given 1 kg of sodium sulfate and 8 l of vegetable oil twice.", + "The cow had an increased abdominal circumference.", + "The cow was dehydrated.", + "The cow's skin tent duration was greater than 2 seconds.", + "Transabdominal palpation revealed a large accumulation of fluid in the rumen.", + "The cow had a body temperature of 39.4°C.", + "The cow had a respiration rate of 42 breaths/minute.", + "The cow had a heart rate of 74 beats/minute.", + "Auscultation and percussion of the left 1–3 ribs revealed high-pitched 'pinging'.", + "The right abomasum area was enlarged.", + "The right abomasum area was hard and clearly defined on palpation.", + "On rectal examination, the intestine was found to be empty.", + "The intestinal wall was dry.", + "A small amount of black sticky feces was attached to the rectum.", + "The fetus was confirmed to be alive by rectal touch of the uterus.", + "Blood routine examination showed an elevated white blood cell count of 18.4 × 109/l.", + "The reference range for white blood cell count is 4.9–12.0 × 109/l.", + "The neutrophil count was 9.6 × 109/l.", + "The reference range for neutrophil count is 1.8–6.3 × 109/l.", + "There were marked increases in the number of red blood cells.", + "The red blood cell count was 10.8 × 1012/l.", + "The reference range for red blood cells is 5.1–7.6 × 1012/l.", + "The hemoglobin content was 154 g/l.", + "The reference range for hemoglobin is 85–122 g/l.", + "The hematocrit was 0.75 l/l.", + "The reference range for hematocrit is 0.22–0.33 l/l.", + "Biochemical results showed reduced potassium ions.", + "The potassium ion level was 3.2 mmol/l.", + "The reference range for potassium ions is 3.9–5.8 mmol/l.", + "The chloride ion level was 88 mmol/l.", + "The reference range for chloride ions is 95–110 mmol/l.", + "The calcium ion level was 2.0 mmol/l.", + "The reference range for calcium ions is 2.43–3.10 mmol/l.", + "The creatinine level was 384.46 μmol/l.", + "The reference range for creatinine is 88–175 μmol/l.", + "The urea nitrogen level was 28.2 mmol/l.", + "The reference range for urea nitrogen is 2.0–9.6 mmol/l.", + "The total bilirubin level was 19.23 μmol/l.", + "The reference range for total bilirubin is 0.17–8.55 μmol/l.", + "The γ-glutamyltransferase level was 29.7 U/l.", + "The reference range for γ-glutamyltransferase is 6.1–17.4 U/l.", + "X-ray examination revealed a metallic foreign body in the reticulum.", + "The rumen fluid pH was approximately 8.5.", + "The cow was diagnosed with TR and AI.", + "The diagnosis of TR can be confirmed by foreign body tests and X-ray examination.", + "The differential diagnoses include forestomach atony (FA), rumen obstruction (RO), omasal obstruction (OO), left displaced abomasum (LDA), abomasal torsion (AT), and intestinal obstruction (IO).", + "Both TR and AI were treated surgically.", + "A cesarean section was performed on the cow before the two operations were carried out.", + "Medication was administered 3 hours before surgery to correct dehydration, electrolyte disturbances, and acid-base disturbances.", + "Antibiotics and anti-inflammatory agents were administered in preoperative injections.", + "The accumulated fluid in the rumen was extracted by inserting a gastric tube via the oral cavity.", + "An incision was made in the middle of the paralumbar fossa in the left flank to open the abdominal cavity.", + "Intraperitoneal exploration revealed that the wall of the reticulum had adhered to the diaphragm.", + "The omasum was found to be approximately 0.5 times larger than normal.", + "The volume of the abomasum was approximately 5–7 times normal.", + "The abomasum was very firm on palpation.", + "The bowel was empty.", + "The fetus was active.", + "The cesarean section was then performed.", + "Part of the uterus was pulled out at the incision.", + "The uterus was cut open and the fetus was removed.", + "The uterus was then sutured.", + "The rumen was cut open and the wire attached to the wall of the reticulum was removed.", + "The rumen was then sutured.", + "The abomasum was cut open to evacuate its contents.", + "Xylazine hydrochloride (60 mg) was injected intramuscularly to sedate the cow.", + "The surgical incision was selected at the location where the AI was the hardest and made contact with the body surface.", + "The feed material was removed and the abomasum was sutured.", + "Continuous spiral sutures were made on the mucosa of the uterus.", + "Continuous spiral sutures were made on the mucosa and submucosa of the rumen and abomasum with thinner PGA sutures.", + "Continuous spiral sutures were made throughout the layer with thicker PGA sutures.", + "Cushing sutures were made with the same thicker PGA suture.", + "Postoperative treatment was provided for 5 days.", + "On the second day after the surgery, the cow began to ruminate.", + "On the second day after the surgery, the cow had an appetite.", + "On the second day after the surgery, the cow passed a large amount of black mucous feces.", + "On the second day after the surgery, the cow fed on 3 kg hay and 2 kg concentrate.", + "On the third and fourth days after surgery, feed intake increased.", + "On the fifth day after surgery, the fetal coat was completely excreted.", + "On the fifth day after surgery, feed intake decreased.", + "On the fifth day after surgery, the number of ruminations was reduced.", + "On the fifth day after surgery, the rumen peristalsis was weakened.", + "On the sixth day after surgery, the cow began to drink a substantial amount of water.", + "On the sixth day after surgery, the abdominal circumference increased.", + "On the sixth day after surgery, rumination stopped.", + "On the sixth day after surgery, only a small amount of hay was eaten.", + "On the sixth day after surgery, no excrement was observed.", + "On the sixth day after surgery, high-pitched 'pinging' could be heard by auscultation of the left side of ribs 1–3 with percussion.", + "On the sixth day after surgery, palpation of the genuine stomach area was slightly hard.", + "We suspected that the abomasum had become obstructed again.", + "Routine blood examination showed an elevated white blood cell count of 14.5 × 109.", + "Routine blood examination showed an elevated neutrophil count of 7.2 × 109/l.", + "No obvious abnormalities were found in biochemical parameters.", + "Zeng Ye Cheng Qi Tang was administered on the eighth and ninth days after the operation.", + "Zeng Ye Cheng Qi Tang is a traditional Chinese medicine powder.", + "Zeng Ye Cheng Qi Tang consists of 300 g rhubarb, 600 g mirabilite, 60 g Magnolia officinalis, 80 g Fructus aurantii immaturus, 120 g Scrophularia ningpoensis, 120 g Ophiopogon japonicus, 120 g Rehmannia glutinosa, 150 g areca nut, 60 g Aucklandia, and 200 g Raphanus seed.", + "Zeng Ye Cheng Qi Tang is often used to treat ruminal impaction and IO.", + "1 l of vegetable oil was administered along with Zeng Ye Cheng Qi Tang.", + "The abomasum area was massaged at the same time as the administration of the formulation.", + "A subcutaneous injection of 10 mg neostigmine was administered four times/day.", + "The cow was fed hay only (2 kg a day) and concentrate feed was stopped.", + "As of the 11th day, the ruminant returned to normal.", + "As of the 11th day, feed intake gradually increased.", + "As of the 11th day, the rumen and abomasum peristaltic sound was enhanced as detected by auscultation.", + "As of the 11th day, normal defecation was observed.", + "The amount of hay fed daily was gradually increased (but not more than 10 kg).", + "After continued observation for 5 days, all indices of the diseased cow returned to normal.", + "After 120 days, the cow made a full recovery and became pregnant again.", + "The calf born by cesarean section is in good health.", + "The animal study was reviewed and approved by the College of Animal Science and Technology, Chongqing Three Gorges Vocational College.", + "Written informed consent was obtained from the owners for the participation of their animals in this study." + ], + "summary": "We here report a rare case of the diagnosis and treatment of TR associated with abomasal obstruction in a beef cow during late pregnancy. The affected cattle had an iron wire that was piercing the wall of the reticulum, but did not penetrate the wall; the abomasum was blocked and appeared solid; and the fetus survived well in utero (268 days gestation). To save the lives of the cow and fetus on the same day, a cesarean section was first performed, followed by rumenotomy, the foreign body (wire) was removed, and abomasotomy was finally performed. The fetus removed by cesarean section grew well, and the beef cow recovered and successfully became pregnant again.", + "summary_subclaims": [ + "This is a report of a rare case of TR associated with abomasal obstruction in a beef cow during late pregnancy.", + "The affected cattle had an iron wire that was piercing the wall of the reticulum.", + "The iron wire did not penetrate the wall.", + "The abomasum was blocked and appeared solid.", + "The fetus survived well in utero (268 days gestation).", + "A cesarean section was first performed.", + "Rumenotomy was performed.", + "The foreign body (wire) was removed.", + "Abomasotomy was finally performed.", + "The fetus removed by cesarean section grew well.", + "The beef cow recovered and successfully became pregnant again." + ] + }, + { + "id": "multiclinsum_test_1927_en.txt", + "fulltext": "A 28-year-old fit male soldier was brought by his family to Emergency Department (ED) with a history of severe headache, neck pain, nausea, and vomiting, which were associated with behavioral changes in the past 2 days. His symptoms started 2 months ago after lifting a heavy object when he developed neck pain associated with a severe headache that increased in severity over time. He has visited the ED twice before this time, and he was only investigated by a cervical spine X-ray with no brain images; then, he was discharged on analgesia and an outpatient department clinic appointment. As his symptoms did not improve with time, he went to an uncertified chiropractor for neck pain, asking for a neck therapy session, after which his symptoms increased in severity. As the headache became unbearable after the therapy session, he went to a hospital and did a brain computerized tomography (CT) which showed bilateral SDH [ and ]. There was no history of trauma, loss of consciousness, or seizure. He was not on any chronic medications, anticoagulants, or antiplatelets. The patient had a negative history of bleeding tendency, no constitutional symptoms, and an unremarkable systemic review. He was a nonsmoker with no history of alcohol or drug abuse. He had a negative family history of a brain aneurysm and bleeding disorders. On assessment, he was vitally stable, afebrile, conscious, alert, and oriented; however, he looked depressed and agitated. He had an abnormal involuntary repetitive extension movement involving his little fingers bilaterally that started 2 days ago. The rest of the neurological examination was unremarkable. All laboratory investigations were normal. CT angiography, magnetic resonance angiography, and whole spine magnetic resonance imaging did not reveal any identifiable cause that would explain the SDH [, and ]. The patient underwent bilateral mini craniotomies with bilateral subdural drains . A specimen of the SDH external membrane was sent for a histopathology examination, which revealed typical histological findings of the external membrane of the hematoma. The surgery went successfully with no complications or abnormal bleeding. His symptoms improved immediately after the surgery. During his hospital stay, further blood investigations (Blood smear,\nFactor VIII and XIII, and vWF cofactor and Antigen) were done and came within normal ranges. The psychiatry team was consulted, and he was diagnosed with major depressive disorder. Eventually, the patient was discharged home in stable condition and completely resolved symptoms on the 6th-day post-surgery. After 8 months, a follow-up brain CT scan was done, and it showed an interval resolution of the bilateral SDH with no signs of recurrence . The patient had no recurrence of the clinical symptoms and was discharged from the clinic.", + "fulltext_subclaims": [ + "The patient is a 28-year-old fit male soldier.", + "He was brought to the Emergency Department by his family.", + "He had a history of severe headache, neck pain, nausea, and vomiting.", + "The symptoms were associated with behavioral changes in the past 2 days.", + "The symptoms started 2 months ago after lifting a heavy object.", + "He developed neck pain associated with a severe headache.", + "The headache increased in severity over time.", + "He had visited the ED twice before.", + "He was investigated by a cervical spine X-ray with no brain images.", + "He was discharged on analgesia and an outpatient department clinic appointment.", + "His symptoms did not improve with time.", + "He went to an uncertified chiropractor for neck pain.", + "He asked for a neck therapy session.", + "His symptoms increased in severity after the therapy session.", + "He went to a hospital and did a brain CT.", + "The brain CT showed bilateral SDH.", + "There was no history of trauma.", + "There was no history of loss of consciousness.", + "There was no history of seizure.", + "He was not on any chronic medications.", + "He was not on anticoagulants.", + "He was not on antiplatelets.", + "He had a negative history of bleeding tendency.", + "He had no constitutional symptoms.", + "He had an unremarkable systemic review.", + "He was a nonsmoker.", + "He had no history of alcohol or drug abuse.", + "He had a negative family history of a brain aneurysm.", + "He had a negative family history of bleeding disorders.", + "On assessment, he was vitally stable.", + "He was afebrile.", + "He was conscious, alert, and oriented.", + "He looked depressed and agitated.", + "He had an abnormal involuntary repetitive extension movement involving his little fingers bilaterally.", + "The movement started 2 days ago.", + "The rest of the neurological examination was unremarkable.", + "All laboratory investigations were normal.", + "CT angiography did not reveal any identifiable cause that would explain the SDH.", + "Magnetic resonance angiography did not reveal any identifiable cause that would explain the SDH.", + "Whole spine magnetic resonance imaging did not reveal any identifiable cause that would explain the SDH.", + "The patient underwent bilateral mini craniotomies with bilateral subdural drains.", + "A specimen of the SDH external membrane was sent for histopathology examination.", + "The histopathology examination revealed typical histological findings of the external membrane of the hematoma.", + "The surgery went successfully with no complications or abnormal bleeding.", + "His symptoms improved immediately after the surgery.", + "Further blood investigations were done during his hospital stay.", + "The blood investigations included Blood smear, Factor VIII and XIII, and vWF cofactor and Antigen.", + "The blood investigations came within normal ranges.", + "The psychiatry team was consulted.", + "He was diagnosed with major depressive disorder.", + "The patient was discharged home in stable condition.", + "He had completely resolved symptoms on the 6th-day post-surgery.", + "After 8 months, a follow-up brain CT scan was done.", + "The follow-up brain CT showed an interval resolution of the bilateral SDH.", + "The follow-up brain CT showed no signs of recurrence.", + "The patient had no recurrence of the clinical symptoms.", + "The patient was discharged from the clinic." + ], + "summary": "A 28-year-old fit individual presented to the Emergency Department with a chronic history of severe headache and neck pain, associated with behavioral changes in the last 2 days. He reported that his symptoms started after lifting a heavy object 2 months ago; however, they became worse after a neck chiropractor therapy session. He is not on any chronic medications, and there was a negative history of trauma, seizure, hematological diseases, family history of neurological conditions, smoking, alcohol, or drug abuse with an unremarkable systemic review. A brain computerized tomography (CT) showed bilateral SDHs, for which he underwent bilateral mini craniotomies and drainage. The symptoms improved after surgery and the follow-up brain CT showed no recurrence.", + "summary_subclaims": [ + "The patient is a 28-year-old fit individual.", + "The patient presented to the Emergency Department with a chronic history of severe headache and neck pain.", + "The patient reported behavioral changes in the last 2 days.", + "The symptoms started after lifting a heavy object 2 months ago.", + "The symptoms became worse after a neck chiropractor therapy session.", + "The patient is not on any chronic medications.", + "There was a negative history of trauma.", + "There was a negative history of seizure.", + "There was a negative history of hematological diseases.", + "There was a negative family history of neurological conditions.", + "There was a negative history of smoking.", + "There was a negative history of alcohol or drug abuse.", + "The systemic review was unremarkable.", + "A brain computerized tomography showed bilateral subdural hematomas.", + "The patient underwent bilateral mini craniotomies and drainage.", + "The symptoms improved after surgery.", + "The follow-up brain CT showed no recurrence." + ] + }, + { + "id": "multiclinsum_test_1849_en.txt", + "fulltext": "A 56-year-old female patient was admitted to our hospital with a 2-year history of neck pain. No obvious abnormalities were detected on neurological or physical examination, and laboratory findings were all within normal limits. Computed tomography (CT) demonstrated low density in the seventh cervical vertebra, with high-density hardening visible around the edges. Magnetic resonance imaging (MRI) of the cervical spine indicated an expansile lytic lesion with isointensity on T1-weighted imaging and hyperintensity on T2-weighted imaging. These findings were explained to the patient as the possible causes of neck pain, and options for continued conservative observation or surgical treatment were provided. The patient refused to continue conservative observation treatment and requested surgery. The preoperative treatment team communicated sufficiently about the case, considered the existing clinical data of benign bone tumors, and recommended two surgical treatment options: (1) open biopsy with direct excision and internal fixation, which would involve extensive trauma and a long recovery time, or (2) open biopsy with bone cement injection, with later treatment options to be determined according to the pathological results after surgery and reoperation to remove the lesion, if necessary. The patient chose the scheme 2. C7 VP was performed after inducing general anesthesia. Imaging examinations were performed at 3 days, 6 months, and 1 year after surgery . The postoperative pathological results supported the diagnosis of FD , and the patient was ultimately diagnosed with MFD. At the 12-month follow-up visit, the patient reported no clinical symptoms, and no signs of tumor recurrence were detected.", + "fulltext_subclaims": [ + "The patient is a 56-year-old female.", + "The patient had a 2-year history of neck pain.", + "No obvious abnormalities were detected on neurological or physical examination.", + "Laboratory findings were all within normal limits.", + "Computed tomography demonstrated low density in the seventh cervical vertebra.", + "High-density hardening was visible around the edges on CT.", + "MRI of the cervical spine indicated an expansile lytic lesion.", + "The lesion was isointense on T1-weighted imaging.", + "The lesion was hyperintensive on T2-weighted imaging.", + "The findings were explained to the patient as the possible causes of neck pain.", + "Options for continued conservative observation or surgical treatment were provided.", + "The patient refused to continue conservative observation treatment.", + "The patient requested surgery.", + "The preoperative treatment team recommended two surgical treatment options.", + "Option 1 was open biopsy with direct excision and internal fixation.", + "Option 1 would involve extensive trauma and a long recovery time.", + "Option 2 was open biopsy with bone cement injection.", + "Later treatment options would be determined according to the pathological results after surgery.", + "The patient chose option 2.", + "C7 VP was performed after inducing general anesthesia.", + "Imaging examinations were performed at 3 days, 6 months, and 1 year after surgery.", + "The postoperative pathological results supported the diagnosis of FD.", + "The patient was ultimately diagnosed with MFD.", + "At the 12-month follow-up visit, the patient reported no clinical symptoms.", + "No signs of tumor recurrence were detected." + ], + "summary": "The patient was a 56-year-old woman with a 2-year history of neck pain. No obvious abnormalities were detected on neurological or physical examination, and laboratory findings were all within normal limits. An imaging examination suggested a C7 vertebral bone tumor. The patient refused to continue conservative observation treatment and requested surgery. Open VP of the C7 vertebral body was carried out, and her postoperative neck pain was completely relieved. The postoperative pathological results supported the diagnosis of fibrous dysplasia, and the patient was ultimately diagnosed with MFD. At the 12-month follow-up visit, the patient reported no clinical symptoms, and no signs of tumor recurrence were detected.", + "summary_subclaims": [ + "The patient was a 56-year-old woman with a 2-year history of neck pain.", + "No obvious abnormalities were detected on neurological or physical examination.", + "Laboratory findings were all within normal limits.", + "An imaging examination suggested a C7 vertebral bone tumor.", + "The patient refused to continue conservative observation treatment.", + "The patient requested surgery.", + "Open VP of the C7 vertebral body was carried out.", + "Her postoperative neck pain was completely relieved.", + "The postoperative pathological results supported the diagnosis of fibrous dysplasia.", + "The patient was ultimately diagnosed with MFD.", + "At the 12-month follow-up visit, the patient reported no clinical symptoms.", + "No signs of tumor recurrence were detected." + ] + }, + { + "id": "multiclinsum_test_2333_en.txt", + "fulltext": "A 65-year-old-man was admitted in the emergency department for seizures. His medical history included diabetes mellitus, arterial hypertension, and smoking. Four months before admission, a chest X-Ray performed because of a persistent cough revealed a lung mass. The lung biopsy yielded a squamous non-small-cell lung cancer with 80% expression of PD-L1. Extended evaluation including a brain CT , thoracic CT, abdominal MRI and whole-body PET-scan showed a unique hepatic metastasis. Following consultation with the institutional multidisciplinary team in charge of lung cancer, the patient was treated with intravenous pembrolizumab (anti-PD-1 antibody), started 3 months before admission, as a single-drug regimen, 200 mg every three weeks, with no tolerability or adherence issues.\nOn admission, the patient was afebrile, and clinical examination was normal. Routine biochemical and hematology tests were normal, with blood leukocytes count of 7.8 G/l, and serum C reactive protein at 1.1 mg/l. The electroencephalogram performed 12 h after seizures was normal. Brain CT scan found a focal hypodense lesion in the right frontal lobe, further characterized by brain MRI as an intracranial round-shaped lesion with a maximal diameter of 18 mm, low signal intensity on T1-weighted and intermediate signal intensity on T2-weighted images, associated with perilesional edema and wall enhancement on T1-weighted gadolinium-enhanced images , suggestive of brain abscess, while brain metastasis could not be ruled out. The patient was transferred to the neurosurgical department for a total removal of the lesion (excision with craniotomy), both for diagnostic and therapeutic purposes. Per-operative macroscopic findings were also suggestive of brain abscess, and empirical antimicrobial therapy was started after surgery with a combination of intravenous ceftriaxone and metronidazole. Microscopic examination revealed numerous filamentous-branching Gram-positive rods. Cultures yielded Nocardia farcinica, identified by MALDI-TOF mass spectrometry. Antibiotic treatment was modified to meropenem 1 g every 8 h associated with cotrimoxazole 1600 mg/400 mg every 8 h and folinic acid. Body-CT did not show any other localization of nocardiosis, while the mass tumor had decreased by 80% after the sixth cycle of pembrolizumab. Drug susceptibility testing found a meropenem MIC of 32 mg/L, while linezolid MIC was 4 mg/L, and cotrimoxazole MIC was 0.5 mg/L. Meropenem was replaced by linezolid 600 mg every 12 h, in combination with cotrimoxazole. Following the diagnosis, additional risk factors for cerebral nocardiosis were ruled out.\nAfter 2 months, the patient was asymptomatic, except for asthenia. Antibiotics were well tolerated. He did not receive additional dose of pembrolizumab. At 10 weeks of treatment, he developed thrombocytopenia due to linezolid. He died 3 months after the diagnosis of cerebral nocardiosis, because of a major upper-gastrointestinal bleeding probably related to a peptic ulcer disease and thrombocytopenia.", + "fulltext_subclaims": [ + "A 65-year-old man was admitted in the emergency department for seizures.", + "His medical history included diabetes mellitus.", + "His medical history included arterial hypertension.", + "His medical history included smoking.", + "Four months before admission, a chest X-Ray performed because of a persistent cough revealed a lung mass.", + "The lung biopsy yielded a squamous non-small-cell lung cancer.", + "The lung biopsy showed 80% expression of PD-L1.", + "Extended evaluation showed a unique hepatic metastasis.", + "Following consultation with the institutional multidisciplinary team in charge of lung cancer, the patient was treated with intravenous pembrolizumab.", + "Pembrolizumab was started 3 months before admission.", + "Pembrolizumab was given as a single-drug regimen.", + "Pembrolizumab was given at 200 mg every three weeks.", + "The patient had no tolerability issues with pembrolizumab.", + "The patient had no adherence issues with pembrolizumab.", + "On admission, the patient was afebrile.", + "Clinical examination was normal.", + "Routine biochemical and hematology tests were normal.", + "The electroencephalogram performed 12 h after seizures was normal.", + "Brain CT scan found a focal hypodense lesion in the right frontal lobe.", + "Brain MRI showed an intracranial round-shaped lesion with a maximal diameter of 18 mm.", + "The lesion had low signal intensity on T1-weighted images.", + "The lesion had intermediate signal intensity on T2-weighted images.", + "The lesion was associated with perilesional edema.", + "The lesion showed wall enhancement on T1-weighted gadolinium-enhanced images.", + "The lesion was suggestive of brain abscess.", + "Brain metastasis could not be ruled out.", + "The patient was transferred to the neurosurgical department for a total removal of the lesion.", + "The excision was performed with craniotomy.", + "Per-operative macroscopic findings were also suggestive of brain abscess.", + "Empirical antimicrobial therapy was started after surgery.", + "Antimicrobial therapy included intravenous ceftriaxone.", + "Antimicrobial therapy included metronidazole.", + "Microscopic examination revealed numerous filamentous-branching Gram-positive rods.", + "Cultures yielded Nocardia farcinica.", + "Nocardia farcinica was identified by MALDI-TOF mass spectrometry.", + "Antibiotic treatment was modified to meropenem 1 g every 8 h.", + "Antibiotic treatment was modified to cotrimoxazole 1600 mg/400 mg every 8 h.", + "Antibiotic treatment included folinic acid.", + "Body-CT did not show any other localization of nocardiosis.", + "The mass tumor had decreased by 80% after the sixth cycle of pembrolizumab.", + "Drug susceptibility testing found a meropenem MIC of 32 mg/L.", + "Drug susceptibility testing found a linezolid MIC of 4 mg/L.", + "Drug susceptibility testing found a cotrimoxazole MIC of 0.5 mg/L.", + "Meropenem was replaced by linezolid 600 mg every 12 h.", + "Linezolid was given in combination with cotrimoxazole.", + "Following the diagnosis, additional risk factors for cerebral nocardiosis were ruled out.", + "After 2 months, the patient was asymptomatic, except for asthenia.", + "Antibiotics were well tolerated.", + "The patient did not receive additional dose of pembrolizumab.", + "At 10 weeks of treatment, he developed thrombocytopenia due to linezolid.", + "He died 3 months after the diagnosis of cerebral nocardiosis.", + "His death was probably related to a major upper-gastrointestinal bleeding.", + "The upper-gastrointestinal bleeding was probably related to a peptic ulcer disease.", + "The upper-gastrointestinal bleeding was probably related to thrombocytopenia." + ], + "summary": "Here, we report the first clinical case of a cerebral nocardiosis revealed after seizure in a patient treated by pembrolizumab for a metastatic lung cancer, in the absence of any additional immunosuppressive therapy or risk factors for cerebral nocardiosis. The extended evaluation including a brain CT-scan did not reveal any lesion before pembrolizumab. Nevertheless, the 3-month delay between the start of Pembrolizumab and the diagnosis of cerebral nocardiosis suggests that the infection occurred prior to the CPI. Unfortunately, the patient died during treatment for cerebral nocardiosis, while the lung cancer tumor mass had decreased by 80% after the sixth cycle of pembrolizumab.", + "summary_subclaims": [ + "This is the first clinical case of a cerebral nocardiosis revealed after seizure in a patient treated by pembrolizumab for a metastatic lung cancer.", + "The patient was not receiving any additional immunosuppressive therapy.", + "The patient had no risk factors for cerebral nocardiosis.", + "A brain CT-scan did not reveal any lesion before pembrolizumab.", + "The 3-month delay between the start of pembrolizumab and the diagnosis of cerebral nocardiosis suggests that the infection occurred prior to the CPI.", + "The patient died during treatment for cerebral nocardiosis.", + "The lung cancer tumor mass had decreased by 80% after the sixth cycle of pembrolizumab." + ] + }, + { + "id": "multiclinsum_test_1431_en.txt", + "fulltext": "a) Clinical Presentation:\nA seven year old girl presented with pain in left distal third forearm for 8 months which was gradual in onset, non-progressive, mild in nature and non-activity related. Pain was associated with swelling which was initially small & gradually progressed over a period of eight months. There was no history of trauma/fever/weight loss or involvement of other bones. The general examination was unremarkable. Local examination of left forearm revealed a fusiform swelling in diaphyseal area measuring approximately 5cms by 2cms. Skin over swelling was normal, no engorged veins were present over the swelling. There was no local rise of temperature but local tenderness was present. Swelling was hard in consistency with well-defined margins, continuous with the radius. Forearm pronation and supination was painfully restricted; finger movements were normal and pain free. There was no associated distal neurovascular deficit.\nFig 1-Pre-operative X-ray\nFig 2-Pre-operative MRI\nb)Surgical Management:\nInitially, true cut biopsy was done in operation theater under strict asepsis under image guidance to confirm the diagnosis. Tissue histopathology revealed – sheets of polyhedral to oval cells with vesicular nuclei, some showing nuclear grooves and admixed with multinucleated giant cells. The sheets of cells being interrupted by islands of cartilage. No foci of calcification seen. Areas of hemorrhage are seen scattered throughout the tumor. Impression was benign cartilaginous tumor – Chondroblastoma/Chondromyxoid fibroma of radius.\nThe patient was scheduled for surgery after ten days. With a standard volar approach (Henry's approach) – tumor bearing portion of radius along with the healthy bone was excised measuring to a length of 5cm. Tumor mass was firm, brownish red in color. An autologous avascular ipsilateral fibular autograft was taken and secured proximally to the diaphysis with a dynamic compression plate and distally to the metaphysis with two crossed k wires. Wound was closed in layers after ensuring hemostasis.\nHistopathologically, the findings were consistent with trucut biopsy findings as mentioned before. Grossly, the tumor mass was seen to press on the cortical bone which showed thinning. However no extension into soft tissue was seen. The distal margin of excision was found to be free c)Post-operative period and follow up:\nImmediate postoperative period was uneventful. Patient was discharged on second postoperative day two after drain removal. . The patient was immobilized in below elbow cast for ten weeks. K wires were removed at the end of eight weeks. At twelfth week of follow up patient had developed stress fracture of the graft distal to the Dynamic compression plate. This was treated with a below elbow cast for a period of twelve weeks. The patient was immobilized with a below elbow splint for a period of three months. At two years of follow up there is full functional recovery and radiograph shows incorporation and hypertrophy of fibular graft (,)", + "fulltext_subclaims": [ + "A seven year old girl presented with pain in left distal third forearm for 8 months.", + "Pain was gradual in onset.", + "Pain was non-progressive.", + "Pain was mild in nature.", + "Pain was non-activity related.", + "Pain was associated with swelling.", + "Swelling was initially small.", + "Swelling gradually progressed over a period of eight months.", + "There was no history of trauma.", + "There was no history of fever.", + "There was no history of weight loss.", + "There was no involvement of other bones.", + "The general examination was unremarkable.", + "Local examination of left forearm revealed a fusiform swelling in diaphyseal area.", + "The swelling measured approximately 5cms by 2cms.", + "Skin over swelling was normal.", + "No engorged veins were present over the swelling.", + "There was no local rise of temperature.", + "Local tenderness was present.", + "Swelling was hard in consistency.", + "Swelling had well-defined margins.", + "Swelling was continuous with the radius.", + "Forearm pronation and supination was painfully restricted.", + "Finger movements were normal.", + "Finger movements were pain free.", + "There was no associated distal neurovascular deficit.", + "True cut biopsy was done in operation theater under strict asepsis under image guidance.", + "Tissue histopathology revealed sheets of polyhedral to oval cells with vesicular nuclei.", + "Some cells showed nuclear grooves.", + "Multinucleated giant cells were admixed.", + "Islands of cartilage were present.", + "No foci of calcification were seen.", + "Areas of hemorrhage were seen scattered throughout the tumor.", + "Impression was benign cartilaginous tumor – Chondroblastoma/Chondromyxoid fibroma of radius.", + "The patient was scheduled for surgery after ten days.", + "Tumor bearing portion of radius along with the healthy bone was excised.", + "Excised length was 5cm.", + "An autologous avascular ipsilateral fibular autograft was taken.", + "The graft was secured proximally to the diaphysis with a dynamic compression plate.", + "The graft was secured distally to the metaphysis with two crossed k wires.", + "Histopathologically, the findings were consistent with trucut biopsy findings.", + "Grossly, the tumor mass was seen to press on the cortical bone.", + "The cortical bone showed thinning.", + "No extension into soft tissue was seen.", + "The distal margin of excision was found to be free.", + "Immediate postoperative period was uneventful.", + "The patient was discharged on second postoperative day after drain removal.", + "The patient was immobilized in below elbow cast for ten weeks.", + "K wires were removed at the end of eight weeks.", + "At twelfth week of follow up, the patient had developed stress fracture of the graft distal to the Dynamic compression plate.", + "Stress fracture was treated with a below elbow cast for a period of twelve weeks.", + "The patient was immobilized with a below elbow splint for a period of three months.", + "At two years of follow up, there is full functional recovery.", + "Radiograph shows incorporation and hypertrophy of fibular graft." + ], + "summary": "The authors report a case of chondroblastoma involving the diaphyseal area of radius in a seven year old female child. She presented with pain and swelling around the left distal third forearm for eight months. Wide excision of tumor was performed and the defect was bridged with avascular fibular auto graft, secured to host bone with k-wires and dynamic compression plate to achieve osteosynthesis.", + "summary_subclaims": [ + "The authors report a case of chondroblastoma involving the diaphyseal area of radius in a seven year old female child.", + "She presented with pain and swelling around the left distal third forearm for eight months.", + "Wide excision of tumor was performed.", + "The defect was bridged with avascular fibular auto graft.", + "The graft was secured to host bone with k-wires and dynamic compression plate to achieve osteosynthesis." + ] + }, + { + "id": "multiclinsum_test_1137_en.txt", + "fulltext": "A 20-year-old young male presented to the emergency department following road traffic accident and on probing the patient, he had fallen with a flexed knee leading to axial impaction of tibial condyle over the posterior femoral condyle. Patient had an open lacerated transverse wound about 7 cm over the anterior aspect of the knee. The distal end of femur was protruding out along the avulsion of patellar tendon from the insertion site. Clinical examination was not possible because of open wound and intense pain. There was no distal neurovascular deficit and patient was hemodynamically stable.\nRadiological examination of the involved knee included the anterior-posterior and oblique views showing patella alta, suggesting the patellar tendon avulsion with fracture of anterior tibial spine and lateral-oblique view showing non-conjoint bicondylar Hoffa fracture. Initially, wound was debrided and an external fixator applied. The second procedure was taken after 2 days and both femoral condyles approached through the same open wound. The bicondylar Hoffa fracture was fixed with two 6.5 mm partially threaded cannulated cancellous screw. Screws were inserted from the non-articular portion of the femoral condyle on knee flexion. The anterior tibial spine fragment was fixed with 4.0 mm partially threaded cannulated cancellous screw and the patellar tendon avulsion was fixed to the tibia with ethibond trans-osseous suturing . The wound was primarily closed without the need of additional soft-tissue procedures. The patient was kept in external fixator for 6 weeks in view of healing of the patellar tendon and soft tissue. After 6 weeks, the external fixator was removed and patient was started on partial weight bearing and guarded knee flexion was started in fear of patellar tendon re-rupture. At the end of 3 months, full weight bearing was started and knee Rom was from 5° to 40°. At the end of 6 months, knee flexion further improved to 35° with the healing of the fracture .", + "fulltext_subclaims": [ + "A 20-year-old young male presented to the emergency department following road traffic accident.", + "On probing the patient, he had fallen with a flexed knee leading to axial impaction of tibial condyle over the posterior femoral condyle.", + "The patient had an open lacerated transverse wound about 7 cm over the anterior aspect of the knee.", + "The distal end of femur was protruding out along the avulsion of patellar tendon from the insertion site.", + "Clinical examination was not possible because of open wound and intense pain.", + "There was no distal neurovascular deficit.", + "The patient was hemodynamically stable.", + "Radiological examination of the involved knee included the anterior-posterior and oblique views.", + "The anterior-posterior and oblique views showed patella alta.", + "The anterior-posterior and oblique views suggested the patellar tendon avulsion.", + "The anterior-posterior and oblique views showed fracture of anterior tibial spine.", + "The lateral-oblique view showed non-conjoint bicondylar Hoffa fracture.", + "Initially, wound was debrided.", + "An external fixator was applied.", + "The second procedure was taken after 2 days.", + "Both femoral condyles were approached through the same open wound.", + "The bicondylar Hoffa fracture was fixed with two 6.5 mm partially threaded cannulated cancellous screws.", + "Screws were inserted from the non-articular portion of the femoral condyle on knee flexion.", + "The anterior tibial spine fragment was fixed with 4.0 mm partially threaded cannulated cancellous screw.", + "The patellar tendon avulsion was fixed to the tibia with ethibond trans-osseous suturing.", + "The wound was primarily closed.", + "There was no need of additional soft-tissue procedures.", + "The patient was kept in external fixator for 6 weeks.", + "The external fixator was removed after 6 weeks.", + "The patient was started on partial weight bearing after 6 weeks.", + "Guarded knee flexion was started in fear of patellar tendon re-rupture.", + "At the end of 3 months, full weight bearing was started.", + "At the end of 3 months, knee Rom was from 5° to 40°.", + "At the end of 6 months, knee flexion further improved to 35°.", + "At the end of 6 months, the fracture was healing." + ], + "summary": "We report a case of open Type 3b non-conjoint bicondylar Hoffa fracture accompanied with ipsilateral anterior tibial spine avulsion and disruption of the patellar tendon. Staged procedure was done, first procedure included wound debridement with external fixator. Second procedure involved definitive fixation of Hoffa fracture, anterior tibial spine, and patellar tendon avulsion. In our case, we have discussed the possible mechanism of injury, operative approaches, and early functional outcome.", + "summary_subclaims": [ + "The case involves an open Type 3b non-conjoint bicondylar Hoffa fracture.", + "The case is accompanied with ipsilateral anterior tibial spine avulsion.", + "The case involves disruption of the patellar tendon.", + "A staged procedure was done.", + "The first procedure included wound debridement with external fixator.", + "The second procedure involved definitive fixation of Hoffa fracture.", + "The second procedure involved definitive fixation of anterior tibial spine.", + "The second procedure involved definitive fixation of patellar tendon avulsion.", + "The case discusses the possible mechanism of injury.", + "The case discusses operative approaches.", + "The case discusses early functional outcome." + ] + }, + { + "id": "multiclinsum_test_1563_en.txt", + "fulltext": "A 15-year-old boy complained of pain in the right thumb MP joint after a hyperextension injury while playing 2 weeks before. He was diagnosed with a ligament injury by an orthopedic surgeon at the first visit and referred to our hospital because his symptoms did not improve. On physical examination, the 1st MP joint was slightly hyperextended, and passive and active flexions were not possible. Radiographs showed a hyperextended posture at the 1st MP joint at approximately 30°. There were no definite abnormal findings on the first anteroposterior and lateral radiographs . However, the clinical situation of the patient raised suspicion of a locked thumb MP joint, and we performed US. Distal displacement of the radial sesamoid was noted on US . Although limited, there were no conspicuous abnormalities in the volar plate or radial accessory collateral ligament on US. CT was also performed to ensure the diagnosis and evaluate the bony details. On CT, distal displacement of the radial sesamoid was visualized . In addition, a flat articular surface and prominent radial condyle of the metacarpal head were observed. We decided to attempt a closed manual reduction at the outpatient clinic under US guidance instead of a reduction under fluoroscopic guidance. After inducing local anesthesia with 1% lidocaine, closed manual reduction was attempted. After hyperextending the MP joint, continuous axial pressure was applied toward the metacarpal head, and subsequently, flexion of the MP joint was performed. The radial sesamoid was relocated with a snapping sound, and MP joint motion recovered. At that spot, we confirmed on US that the radial sesamoid returned to its place . A remo4vable thumb spica splint was applied for 2 weeks. Follow-up CT showed successful reduction of the radial sesamoid . During 3 months of follow-up, the patient did not have any recurrence.", + "fulltext_subclaims": [ + "The patient is a 15-year-old boy.", + "He complained of pain in the right thumb MP joint.", + "The pain occurred after a hyperextension injury.", + "The injury happened while playing.", + "The injury occurred 2 weeks before the visit.", + "He was diagnosed with a ligament injury by an orthopedic surgeon at the first visit.", + "He was referred to our hospital because his symptoms did not improve.", + "On physical examination, the 1st MP joint was slightly hyperextended.", + "Passive flexion of the 1st MP joint was not possible.", + "Active flexion of the 1st MP joint was not possible.", + "Radiographs showed a hyperextended posture at the 1st MP joint at approximately 30°.", + "There were no definite abnormal findings on the first anteroposterior radiographs.", + "There were no definite abnormal findings on the first lateral radiographs.", + "The clinical situation raised suspicion of a locked thumb MP joint.", + "We performed US.", + "Distal displacement of the radial sesamoid was noted on US.", + "There were no conspicuous abnormalities in the volar plate on US.", + "There were no conspicuous abnormalities in the radial accessory collateral ligament on US.", + "CT was performed to ensure the diagnosis.", + "CT was performed to evaluate the bony details.", + "On CT, distal displacement of the radial sesamoid was visualized.", + "A flat articular surface was observed on CT.", + "A prominent radial condyle of the metacarpal head was observed on CT.", + "We decided to attempt a closed manual reduction at the outpatient clinic.", + "The reduction was attempted under US guidance.", + "Local anesthesia with 1% lidocaine was induced.", + "Hyperextension of the MP joint was performed.", + "Continuous axial pressure was applied toward the metacarpal head.", + "Flexion of the MP joint was performed.", + "The radial sesamoid was relocated with a snapping sound.", + "MP joint motion recovered.", + "On US, the radial sesamoid returned to its place.", + "A removable thumb spica splint was applied for 2 weeks.", + "Follow-up CT showed successful reduction of the radial sesamoid.", + "During 3 months of follow-up, the patient did not have any recurrence." + ], + "summary": "A 15-year-old boy with a locked thumb metacarpophalangeal joint presented to our hospital. On physical examination, the 1st metacarpophalangeal joint was found to be hyperextended, and active and passive flexions were not possible. While radiographs were inconclusive, ultrasound revealed radial sesamoid entrapment at the 1st metacarpophalangeal joint causing locking. After closed manual reduction, metacarpophalangeal motions recovered. Success of the reduction was also confirmable by ultrasound.", + "summary_subclaims": [ + "A 15-year-old boy with a locked thumb metacarpophalangeal joint presented to our hospital.", + "On physical examination, the 1st metacarpophalangeal joint was found to be hyperextended.", + "Active and passive flexions were not possible.", + "Radiographs were inconclusive.", + "Ultrasound revealed radial sesamoid entrapment at the 1st metacarpophalangeal joint causing locking.", + "After closed manual reduction, metacarpophalangeal motions recovered.", + "Success of the reduction was also confirmable by ultrasound." + ] + }, + { + "id": "multiclinsum_test_621_en.txt", + "fulltext": "This is the case of a 18-year-old woman who visited the surgery due to discomfort caused by hypertrophy of the upper lip.\nNo findings were found on preoperative examination and electrocardiogram (ECG) .\nNo specific findings were found on the patient's history.\nThe patient had no family or genetic disease history.\nVital signs were assessed before anesthesia induction: Blood pressure, 111/79 mmHg; HR, 94 beats/min; and SpO2, 99%.\nOn perioperative laboratory examinations and the C-reactive protein (CRP) level were within normal range.\nShe was diagnosed with hemangioma by ultrasound . Intraoperative picture, tracing with black silk to expose the surgical site during the approach to the surgical site .\nAnesthesia was induced by injecting 2 mg/kg of IV propofol, ventilating with 5%–6 vol % of desflurane using a mask, and simultaneously administering remifentanil at the target site with a concentration of 2.0 ng/mL for balanced anesthesia using a target- controlled infusion pump (Orchestra®, Fresenius Vial, France). After the loss of consciousness was confirmed by a bispectral index (BIS) of less than 40, rocuronium 0.6 mg/kg IV was administered. After confirming that the muscle had appropriately relaxed, endotracheal intubation was performed. The blood pressure measured after intubation was 110/62 mmHg, and the heart rate was 59 beats/min. During the operation, the respiratory rate was controlled to maintain the end-tidal CO2 partial pressure of 32–38 mmHg, and mechanical ventilation was performed with oxygen 1 L/min and air 2 L/min. Desflurane was controlled to maintain BIS from 40 to 60. The operation proceeded normally for about 1 hour, but a constant 1:1 premature ventricular complex (PVC) was detected in the course of approaching the more profound part with more strong traction for exposure of the part , and blood pressure was decreased from 97/60 mmHg to 88/47 mmHg, respectively. The procedure was stopped after vital signs and ECG had changed. Arrhythmia disappeared shortly after traction was released, and vital signs were stabilized within a few seconds. When traction stimulation started for surgery again, bradycardia recurred with 35 PVCs.", + "fulltext_subclaims": [ + "The patient is an 18-year-old woman.", + "The patient visited the surgery due to discomfort caused by hypertrophy of the upper lip.", + "No findings were found on preoperative examination and electrocardiogram (ECG).", + "No specific findings were found on the patient's history.", + "The patient had no family or genetic disease history.", + "Vital signs were assessed before anesthesia induction: Blood pressure, 111/79 mmHg; HR, 94 beats/min; and SpO2, 99%.", + "On perioperative laboratory examinations and the C-reactive protein (CRP) level were within normal range.", + "She was diagnosed with hemangioma by ultrasound.", + "Intraoperative picture, tracing with black silk to expose the surgical site during the approach to the surgical site.", + "Anesthesia was induced by injecting 2 mg/kg of IV propofol.", + "Ventilating with 5%–6 vol % of desflurane using a mask.", + "Simultaneously administering remifentanil at the target site with a concentration of 2.0 ng/mL for balanced anesthesia using a target-controlled infusion pump (Orchestra®, Fresenius Vial, France).", + "After the loss of consciousness was confirmed by a bispectral index (BIS) of less than 40, rocuronium 0.6 mg/kg IV was administered.", + "After confirming that the muscle had appropriately relaxed, endotracheal intubation was performed.", + "The blood pressure measured after intubation was 110/62 mmHg, and the heart rate was 59 beats/min.", + "During the operation, the respiratory rate was controlled to maintain the end-tidal CO2 partial pressure of 32–38 mmHg.", + "Mechanical ventilation was performed with oxygen 1 L/min and air 2 L/min.", + "Desflurane was controlled to maintain BIS from 40 to 60.", + "The operation proceeded normally for about 1 hour.", + "A constant 1:1 premature ventricular complex (PVC) was detected in the course of approaching the more profound part with more strong traction for exposure of the part.", + "Blood pressure was decreased from 97/60 mmHg to 88/47 mmHg, respectively.", + "The procedure was stopped after vital signs and ECG had changed.", + "Arrhythmia disappeared shortly after traction was released.", + "Vital signs were stabilized within a few seconds.", + "When traction stimulation started for surgery again, bradycardia recurred with 35 PVCs." + ], + "summary": "This is the case of an 18-year-old woman diagnosed with hemangioma of the upper lip. During the operation, about 1 h after surgery started, a constant 1:1 premature ventricular complex was detected, and blood pressure was decreased when approaching the deeper part with more strong traction for exposure of the part. Although the management of arrhythmias, such as lidocaine and atropine, was injected, arrhythmia induced by surgical stimulation could not be eliminated completely. As the traction repeated, bradycardia was also repeated, despite injecting additional atropine. Therefore, the anesthesiologist and the surgeon decided to perform the operation only to the extent that the vascular tissue was selectively removed only at the site without the reflex.", + "summary_subclaims": [ + "The patient is an 18-year-old woman.", + "The patient was diagnosed with hemangioma of the upper lip.", + "During the operation, a constant 1:1 premature ventricular complex was detected.", + "Blood pressure was decreased when approaching the deeper part with more strong traction for exposure.", + "Lidocaine and atropine were injected for the management of arrhythmias.", + "Arrhythmia induced by surgical stimulation could not be eliminated completely.", + "Bradycardia was repeated as the traction was repeated.", + "Additional atropine was injected.", + "The anesthesiologist and the surgeon decided to perform the operation only to the extent that the vascular tissue was selectively removed only at the site without the reflex." + ] + }, + { + "id": "multiclinsum_test_3007_en.txt", + "fulltext": "A 25-year-old female with a history of substance abuse (smoking and daily cannabis use) and a 2017 arthroscopy of the right knee for pigmented villonodular synovitis presents to the emergency department. She presents for medical evaluation due to a severe acute pain syndrome localized to the right knee, which partially resolves with the use of non-steroidal anti-inflammatory drugs. On physical examination, the right knee is enlarged with evidence of free fluid in the joint and limited range of motion. As part of the evaluation, a magnetic resonance imaging of the knee is performed, which reveals extensive diffuse oedema in the subcutaneous cellular tissue, with involvement of the popliteal fossa muscle groups. Multiple multilobulated cystic images are observed with dimensions of approximately 34 mm, as well as hypointense nodules in the supra and infrapatellar bursae with dimensions of 29 mm. Edema is observed in the lateral portion of the outer femoral condyle that encompasses the anterior and posterior regions, as well as edema in the inner tibial plate, the medial region of the patella and signs of lateralization of the patella, suggestive of dislocation. With the suspicion of a recurrence of pigmented villonodular synovitis of the knee, the patient is scheduled for surgery, which consists of an open medial and lateral resection of the affected knee, preserving the neurovascular structures of the popliteal fossa. During surgery, severe synovial infiltration with hypertrophy and hyperpigmentation of a soft tumor that affects both the intraarticular and periarticular space, compromising approximately 190 degrees of the popliteal artery, is observed. Extensive synovectomy is performed and irrigation with 200 cm3 of solution is performed. Macroscopically, a membranous lesion of reddish brown appearance, with a medium consistency and dimensions of 10 × 8 cm is described and a sample is sent for histopathological analysis. The patient recovers in the postoperative period without complications. The histological analysis confirms the presence of villonodular synovial tissue-derived villous structures associated with a dense stromal tissue with inflammatory cells, giant cells and abundant histiocytes. This confirms the diagnosis of recurrent pigmented villonodular synovitis with extension to the soft tissue, without the presence of a sarcomatoid component. The patient is discharged with a pain management regimen, with no reported complications.\n", + "fulltext_subclaims": [ + "The patient is a 25-year-old female.", + "She has a history of substance abuse, including smoking and daily cannabis use.", + "She had an arthroscopy of the right knee in 2017 for pigmented villonodular synovitis.", + "She presents with a severe acute pain syndrome localized to the right knee.", + "The pain partially resolves with the use of non-steroidal anti-inflammatory drugs.", + "On physical examination, the right knee is enlarged with evidence of free fluid in the joint.", + "The right knee has limited range of motion.", + "A magnetic resonance imaging of the knee is performed.", + "The MRI reveals extensive diffuse oedema in the subcutaneous cellular tissue.", + "The oedema involves the popliteal fossa muscle groups.", + "Multiple multilobulated cystic images are observed with dimensions of approximately 34 mm.", + "Hypointense nodules in the supra and infrapatellar bursae with dimensions of 29 mm are observed.", + "Edema is observed in the lateral portion of the outer femoral condyle.", + "Edema is observed in the inner tibial plate.", + "There are signs of lateralization of the patella, suggestive of dislocation.", + "The patient is scheduled for surgery.", + "The surgery consists of an open medial and lateral resection of the affected knee.", + "The neurovascular structures of the popliteal fossa are preserved.", + "During surgery, severe synovial infiltration with hypertrophy and hyperpigmentation of a soft tumor is observed.", + "The tumor affects both the intraarticular and periarticular space.", + "The tumor compromises approximately 190 degrees of the popliteal artery.", + "Extensive synovectomy is performed.", + "Irrigation with 200 cm3 of solution is performed.", + "A membranous lesion of reddish brown appearance is described.", + "The lesion has dimensions of 10 × 8 cm.", + "A sample is sent for histopathological analysis.", + "The patient recovers in the postoperative period without complications.", + "The histological analysis confirms the presence of villonodular synovial tissue-derived villous structures.", + "The histological analysis shows dense stromal tissue with inflammatory cells, giant cells, and abundant histiocytes.", + "The diagnosis is confirmed as recurrent pigmented villonodular synovitis with extension to the soft tissue.", + "There is no presence of a sarcomatoid component.", + "The patient is discharged with a pain management regimen.", + "There are no reported complications." + ], + "summary": "A young woman presented with localized pain in the right knee due to a recurrence of SVNP. MRI revealed multiple multilobulated cystic lesions involving the entire joint including the ligaments. The patient underwent open surgical resection with a favorable clinical outcome. Histopathologic examination confirmed the absence of malignancy.\n", + "summary_subclaims": [ + "A young woman presented with localized pain in the right knee due to a recurrence of SVNP.", + "MRI revealed multiple multilobulated cystic lesions involving the entire joint including the ligaments.", + "The patient underwent open surgical resection.", + "The clinical outcome was favorable.", + "Histopathologic examination confirmed the absence of malignancy." + ] + }, + { + "id": "multiclinsum_test_204_en.txt", + "fulltext": "A 67-year-old man with no medical history consulted a nearby doctor for the main complaints of fever and lower abdominal pain. Laboratory analysis revealed hemoglobin, 13.1 g/dL; white blood cell count, 13.76 × 103/μL; platelets, 12.7 × 104/μL; and C-reactive protein, 1.41 mg/dL. He was diagnosed with acute appendicitis, and oral antibiotic treatment was initiated. On the following day, he was referred to our hospital for suspected DIC, as laboratory analysis revealed hemoglobin, 13.3 g/dL; white blood cell count, 3.55 × 103/μL; platelets, 7.4 × 104/μL; and C-reactive protein, 12.2 mg/dL. At the time of hospital consultation, physical examination revealed stable cardiorespiratory dynamics and a fever of 38.3 °C, no abdominal distension, and only slight spontaneous abdominal pain without tenderness and peritoneal irritation. Laboratory analysis revealed hemoglobin, 14.0 g/dL; white blood cell count, 9.41 × 103/μL; platelets, 6.9 × 104/μL; serum total protein, 5.2 g/dL; serum albumin, 3.3 g/dL; total bilirubin, 1.6 mg/dL; aspartate aminotransferase, 218 IU/L; alanine aminotransferase, 198 IU/L; lactic acid dehydrogenase, 315 IU/L; blood urea nitrogen, 20 mg/dL; creatinine, 0.96 mg/dL; C-reactive protein, 13.47 mg/dL; prothrombin activation, 54%; international normalized ratio of prothrombin time, 1.36; fibrinogen/fibrin degradation products, 116.4 μg/mL; and antithrombin III activity, 70%. The sequential organ failure assessment score was 2 points. The Japanese Association for Acute Medicine DIC diagnostic criteria score was 7 points (platelet counts; 3 points, prothrombin time; 1 point, and fibrin/fibrinogen degradation products; 3 points). Contrast-enhanced computed tomography (CT) demonstrated an enlarged appendix (10 mm in diameter) without fecalith, ascites, intraperitoneal free air, and abscess . There was no evidence of perforating appendicitis. Laboratory analysis revealed septic DIC. The patient was diagnosed with non-perforating acute appendicitis with septic DIC. The patient was distressed regarding whether he should be treated conservatively with an antibiotics-first strategy or undergo an appendectomy, because he had few symptoms, no perforation, and no abscess. Ultimately, laparoscopic appendectomy was performed due to anxiety about exacerbation of septic DIC. The resected specimen revealed a necrotized appendiceal mucous membrane. There was no evidence of appendiceal wall perforation . Histopathological examination showed non-perforating gangrenous appendicitis. He required DIC therapy (thrombomodulin administration, antithrombin administration, and nafamostat mesilate) for 2 days postoperatively. Preoperative blood culture detected Bacteroides thetaiotaomicron. He was discharged on postoperative day 9, and remained in good health 1 month after surgery.", + "fulltext_subclaims": [ + "The patient is a 67-year-old man.", + "The patient had no medical history.", + "The patient consulted a nearby doctor for fever and lower abdominal pain.", + "Laboratory analysis revealed hemoglobin, 13.1 g/dL.", + "Laboratory analysis revealed white blood cell count, 13.76 × 103/μL.", + "Laboratory analysis revealed platelets, 12.7 × 104/μL.", + "Laboratory analysis revealed C-reactive protein, 1.41 mg/dL.", + "The patient was diagnosed with acute appendicitis.", + "Oral antibiotic treatment was initiated.", + "On the following day, he was referred to our hospital for suspected DIC.", + "Laboratory analysis revealed hemoglobin, 13.3 g/dL.", + "Laboratory analysis revealed white blood cell count, 3.55 × 103/μL.", + "Laboratory analysis revealed platelets, 7.4 × 104/μL.", + "Laboratory analysis revealed C-reactive protein, 12.2 mg/dL.", + "Physical examination revealed stable cardiorespiratory dynamics.", + "Physical examination revealed a fever of 38.3 °C.", + "Physical examination revealed no abdominal distension.", + "Physical examination revealed only slight spontaneous abdominal pain.", + "Physical examination revealed no tenderness.", + "Physical examination revealed no peritoneal irritation.", + "Laboratory analysis revealed hemoglobin, 14.0 g/dL.", + "Laboratory analysis revealed white blood cell count, 9.41 × 103/μL.", + "Laboratory analysis revealed platelets, 6.9 × 104/μL.", + "Laboratory analysis revealed serum total protein, 5.2 g/dL.", + "Laboratory analysis revealed serum albumin, 3.3 g/dL.", + "Laboratory analysis revealed total bilirubin, 1.6 mg/dL.", + "Laboratory analysis revealed aspartate aminotransferase, 218 IU/L.", + "Laboratory analysis revealed alanine aminotransferase, 198 IU/L.", + "Laboratory analysis revealed lactic acid dehydrogenase, 315 IU/L.", + "Laboratory analysis revealed blood urea nitrogen, 20 mg/dL.", + "Laboratory analysis revealed creatinine, 0.96 mg/dL.", + "Laboratory analysis revealed C-reactive protein, 13.47 mg/dL.", + "Laboratory analysis revealed prothrombin activation, 54%.", + "Laboratory analysis revealed international normalized ratio of prothrombin time, 1.36.", + "Laboratory analysis revealed fibrinogen/fibrin degradation products, 116.4 μg/mL.", + "Laboratory analysis revealed antithrombin III activity, 70%.", + "The sequential organ failure assessment score was 2 points.", + "The Japanese Association for Acute Medicine DIC diagnostic criteria score was 7 points.", + "Contrast-enhanced computed tomography demonstrated an enlarged appendix (10 mm in diameter).", + "Contrast-enhanced computed tomography showed no fecalith.", + "Contrast-enhanced computed tomography showed no ascites.", + "Contrast-enhanced computed tomography showed no intraperitoneal free air.", + "Contrast-enhanced computed tomography showed no abscess.", + "There was no evidence of perforating appendicitis.", + "Laboratory analysis revealed septic DIC.", + "The patient was diagnosed with non-perforating acute appendicitis with septic DIC.", + "The patient was distressed regarding whether to be treated conservatively with an antibiotics-first strategy or undergo an appendectomy.", + "The patient had few symptoms.", + "The patient had no perforation.", + "The patient had no abscess.", + "Laparoscopic appendectomy was performed.", + "The resected specimen revealed a necrotized appendiceal mucous membrane.", + "There was no evidence of appendiceal wall perforation.", + "Histopathological examination showed non-perforating gangrenous appendicitis.", + "The patient required DIC therapy (thrombomodulin administration, antithrombin administration, and nafamostat mesilate) for 2 days postoperatively.", + "Preoperative blood culture detected Bacteroides thetaiotaomicron.", + "The patient was discharged on postoperative day 9.", + "The patient remained in good health 1 month after surgery." + ], + "summary": "A 67-year-old man was referred to our hospital one day after starting oral antibiotic treatment for acute appendicitis. Physical examination revealed only slight spontaneous abdominal pain without tenderness and peritoneal irritation. Contrast-enhanced computed tomography demonstrated an enlarged appendix (10 mm in diameter) without fecalith, ascites, intraperitoneal free air, and abscess. There was no evidence of perforating appendicitis. Laboratory analysis revealed septic DIC. The patient was diagnosed with non-perforating acute appendicitis with septic DIC. The patient was distressed regarding whether he should be treated conservatively with an antibiotics-first strategy or undergo an appendectomy. Ultimately, a laparoscopic appendectomy was performed. Histopathological examination showed non-perforating gangrenous appendicitis. He required DIC therapy for 2 days postoperatively. He was discharged on postoperative day 9, and remained in good health 1 month after surgery.", + "summary_subclaims": [ + "A 67-year-old man was referred to our hospital one day after starting oral antibiotic treatment for acute appendicitis.", + "Physical examination revealed only slight spontaneous abdominal pain without tenderness and peritoneal irritation.", + "Contrast-enhanced computed tomography demonstrated an enlarged appendix (10 mm in diameter) without fecalith.", + "There was no evidence of perforating appendicitis.", + "Laboratory analysis revealed septic DIC.", + "The patient was diagnosed with non-perforating acute appendicitis with septic DIC.", + "The patient was distressed regarding whether he should be treated conservatively with an antibiotics-first strategy or undergo an appendectomy.", + "A laparoscopic appendectomy was performed.", + "Histopathological examination showed non-perforating gangrenous appendicitis.", + "He required DIC therapy for 2 days postoperatively.", + "He was discharged on postoperative day 9.", + "He remained in good health 1 month after surgery." + ] + }, + { + "id": "multiclinsum_test_1917_en.txt", + "fulltext": "A 62-year-old woman complaining of dizziness was admitted to our college hospital. The patient had a past medical history of thyroid dysfunction. She was neurologically intact, and had no abnormalities in her blood tests. Magnetic resonance imaging (MRI) showed an extended intrasellar tumor, which measured 25-mm in its greatest diameter and did not attach to the optic chiasm. The lesion infiltrated the right cavernous sinus, and extended to the pharynx . Initially, the tumor was considered to be a nonfunctional pituitary adenoma.\nThe patient consented to TSS, and TSS was performed without incident . Seven days after TSS, the patient presented with associated hyponatremia . Approximately, 10 days after TSS, the patient complained of blurred near vision.\nIn the ophthalmological examination before TSS, her vision was almost completely intact without visual field loss. The corrected visual acuity of both eyes was 20/20, the spherical equivalent of the right eye was −2.125 diopters, and that of the left eye was −2.0 diopters before TSS. However, 11 days after TSS, the spherical equivalent of the right eye had changed to −0.75 diopters, and that of the left eye had changed to −1.125 diopters. Figure shows the time course of serum electrolyte and glucose levels, corneal radius, spherical equivalent, axial length, anterior chamber depth, and lens thickness of both eyes. Axial length, anterior chamber depth and lens thickness were calculated by A-mode ultrasonography. Lens power was calculated with Bennett’s formula at the onset of blurred vision (11 days after surgery) and follow up (264 days), but could not be calculated before onset (i.e. before surgery and upto 10 days after) because we did not calculate axial length, anterior chamber depth and lens thickness over this time frame. There were no changes in axial length during follow up; however, both spherical equivalent and lens thickness were decreased, while in contrast the anterior chamber depth was increased. In addition, the size of both the decrease in lens thickness and the increase in anterior chamber depth was the same. The lens power (right eye: 17.52 diopters, left eye: 18.30 diopters) at onset increased to 20.27 diopters (right eye) and 20.11 diopters (left eye) at follow up . Although her hyponatremia rapidly improved over a period of one week, the refractive change persisted for 6 weeks (43 days) after TSS and 4 weeks after onset. During her 7 months of follow-up, the level of serum glucose was not changed from a normal and the patient had no apparent recurrence. And also, the corrected visual acuity was not changed during the follow-up.", + "fulltext_subclaims": [ + "The patient was a 62-year-old woman.", + "The patient complained of dizziness.", + "The patient was admitted to our college hospital.", + "The patient had a past medical history of thyroid dysfunction.", + "The patient was neurologically intact.", + "The patient had no abnormalities in her blood tests.", + "Magnetic resonance imaging showed an extended intrasellar tumor.", + "The tumor measured 25-mm in its greatest diameter.", + "The tumor did not attach to the optic chiasm.", + "The lesion infiltrated the right cavernous sinus.", + "The lesion extended to the pharynx.", + "The tumor was initially considered to be a nonfunctional pituitary adenoma.", + "The patient consented to TSS.", + "TSS was performed without incident.", + "Seven days after TSS, the patient presented with associated hyponatremia.", + "Approximately 10 days after TSS, the patient complained of blurred near vision.", + "In the ophthalmological examination before TSS, her vision was almost completely intact without visual field loss.", + "The corrected visual acuity of both eyes was 20/20 before TSS.", + "The spherical equivalent of the right eye was −2.125 diopters before TSS.", + "The spherical equivalent of the left eye was −2.0 diopters before TSS.", + "11 days after TSS, the spherical equivalent of the right eye had changed to −0.75 diopters.", + "11 days after TSS, the spherical equivalent of the left eye had changed to −1.125 diopters.", + "Axial length, anterior chamber depth and lens thickness were calculated by A-mode ultrasonography.", + "Lens power was calculated with Bennett’s formula at the onset of blurred vision (11 days after surgery) and follow up (264 days).", + "Lens power could not be calculated before onset (i.e. before surgery and up to 10 days after) because we did not calculate axial length, anterior chamber depth and lens thickness over this time frame.", + "There were no changes in axial length during follow up.", + "Both spherical equivalent and lens thickness were decreased.", + "The anterior chamber depth was increased.", + "The size of both the decrease in lens thickness and the increase in anterior chamber depth was the same.", + "The lens power (right eye: 17.52 diopters, left eye: 18.30 diopters) at onset increased to 20.27 diopters (right eye) and 20.11 diopters (left eye) at follow up.", + "Her hyponatremia rapidly improved over a period of one week.", + "The refractive change persisted for 6 weeks (43 days) after TSS and 4 weeks after onset.", + "During her 7 months of follow-up, the level of serum glucose was not changed from a normal.", + "The patient had no apparent recurrence.", + "The corrected visual acuity was not changed during the follow-up." + ], + "summary": "A 62-year-old woman presented with blurred near vision 10 days after trans-sphenoidal surgery (TSS) for a pituitary tumor. Around the same time, she experienced intercurrent hyponatremia. The corrected visual acuity of both eyes was 20/20, the spherical equivalent of the right eye was -2.125 diopters, and of the left eye was -2.0 diopters before TSS. However, 11 days after TSS, the spherical equivalent of the right eye changed to -0.75 diopters, and that of left eye changed to -1.125 diopters without hyperglycemia. There were no changes in the corrected visual acuity during the follow-up.", + "summary_subclaims": [ + "A 62-year-old woman presented with blurred near vision 10 days after trans-sphenoidal surgery for a pituitary tumor.", + "She experienced intercurrent hyponatremia around the same time.", + "The corrected visual acuity of both eyes was 20/20 before trans-sphenoidal surgery.", + "The spherical equivalent of the right eye was -2.125 diopters before trans-sphenoidal surgery.", + "The spherical equivalent of the left eye was -2.0 diopters before trans-sphenoidal surgery.", + "Eleven days after trans-sphenoidal surgery, the spherical equivalent of the right eye changed to -0.75 diopters.", + "Eleven days after trans-sphenoidal surgery, the spherical equivalent of the left eye changed to -1.125 diopters.", + "There was no hyperglycemia.", + "There were no changes in the corrected visual acuity during the follow-up." + ] + }, + { + "id": "multiclinsum_test_2464_en.txt", + "fulltext": "An agitated 20-year-old boy without known past medical history, who had hallucinations referred to emergency toxicology department. He was reported to have abused 30 subcutaneous injections of somatropin, each containing 10 mg/1.5 mL all at once with the aim of enhancing performance for coming competition. He also had been using somatropin for the past 2 years for anabolic purposes. The initial vital signs were; BP = 145/96 mmHg, PR = 111/min, RR = 21/min, T = 37.10C and SPO2 with mask = 100%. He had been sedated in ED with midazolam. Laboratory tests revealed hypernatremia (157 mEq/L), hyperkalemia (5.3 mEq/L), high Lactate Dehydrogenases (LDH; 1448 U/L) and Creatine Phosphokinase (CPK; 2620 U/L) level which were all robustly signifying that a state of rhabdomyolysis had happened. Urine toxicology analysis was negative for all substances. The supine chest X-Ray had veiling opacities related to pleural effusion. In Electrocardiogram (ECG), left atrium (LA) abnormality was seen according to Romhilt-Estes criterion . The O2 saturation level dropped within hours and he had to be intubated. Brain CT scan demonstrated no pathologic changes. Consolidations in dependent sites of lungs were observed in his chest CT scan that were indicative of aspiration pneumonia . He experienced several episodes of hypertensive crisis during his admission and was then infused on trinitroglycerin drip. On the fourth day he had a temperature of 40 0C. The patient was evaluated for sepsis and samples of endotracheal tube were collected for culture which consisted of gram-positive staphylococcus aureus. Urine culture was also positive for klebsiella. Therefore, antibiotics including; ceftriaxone and clindamycin, were prescribed. As the consciousness level had not been improving up until then, and SPO2 levels had begun to decline, the decision was made to change the endotracheal tube and re-intubate him with suspicion of upper airway obstruction. In spite of no ischemic changes in electrocardiography, on the sixth day of admission; elevated troponin level (0.99 ng/ml) was detected. The case was consulted with cardiologists and considering his high d-dimer, they advised chest CT angiography with a high suspicion for pulmonary embolism, however, in view of his unstable condition CT angiography could not have been carried out. As a result, an alternative regimen of anticoagulant therapy with heparin was initiated. The next day he deteriorated with cardiopulmonary arrest, cardio pulmonary resuscitation was instituted but the cardiac rhythm remained unviable and he was declared dead after 40 min.", + "fulltext_subclaims": [ + "The patient was a 20-year-old agitated boy.", + "He had hallucinations.", + "He was referred to the emergency toxicology department.", + "He had no known past medical history.", + "He had abused 30 subcutaneous injections of somatropin, each containing 10 mg/1.5 mL, all at once.", + "He had been using somatropin for the past 2 years for anabolic purposes.", + "The initial blood pressure was 145/96 mmHg.", + "The initial pulse rate was 111/min.", + "The initial oxygen saturation with mask was 100%.", + "He was sedated in the ED with midazolam.", + "Laboratory tests revealed hypernatremia (157 mEq/L).", + "Laboratory tests revealed hyperkalemia (5.3 mEq/L).", + "Laboratory tests revealed high lactate dehydrogenase (1448 U/L).", + "Laboratory tests revealed high creatine phosphokinase (2620 U/L).", + "The high LDH and CPK levels were robustly signifying a state of rhabdomyolysis.", + "Urine toxicology analysis was negative for all substances.", + "The supine chest X-ray had veiling opacities related to pleural effusion.", + "The ECG showed left atrium abnormality according to Romhilt-Estes criterion.", + "The O2 saturation level dropped within hours.", + "He had to be intubated.", + "Brain CT scan demonstrated no pathologic changes.", + "Chest CT scan showed consolidations in dependent sites of the lungs.", + "The consolidations were indicative of aspiration pneumonia.", + "He experienced several episodes of hypertensive crisis during admission.", + "He was infused on trinitroglycerin drip.", + "On the fourth day, he had a temperature of 40°C.", + "The patient was evaluated for sepsis.", + "Endotracheal tube samples were collected for culture.", + "The endotracheal tube culture consisted of gram-positive staphylococcus aureus.", + "Urine culture was positive for klebsiella.", + "Antibiotics including ceftriaxone and clindamycin were prescribed.", + "The decision was made to change the endotracheal tube and re-intubate him.", + "The decision was made with suspicion of upper airway obstruction.", + "On the sixth day of admission, an elevated troponin level (0.99 ng/ml) was detected.", + "The case was consulted with cardiologists.", + "Chest CT angiography was advised with a high suspicion for pulmonary embolism.", + "Chest CT angiography could not be carried out due to the patient's unstable condition.", + "An alternative regimen of anticoagulant therapy with heparin was initiated.", + "The next day, he deteriorated with cardiopulmonary arrest.", + "Cardiopulmonary resuscitation was instituted.", + "The cardiac rhythm remained unviable.", + "He was declared dead after 40 minutes." + ], + "summary": "We present a first lethal case of HGH acute toxicity. A young-agitated-athlete with a history of somatropin for the past 2-year, who had hallucinations referred to the emergency department reporting to have abused of 300 mg subcutaneous injections of HGH. He was tachycardic with mild hypertension. Lab data revealed hypernatremia (157 mEq/L), hyperkalemia (5.3 mEq/L), high LDH (1448 U/L), and CPK (2620 U/L), in favor of rhabdomyolysis. Routine drug screening tests were negative for all substances. He was intubated due to low O2 saturation and progressive loss of consciousness. After several episodes of hyperthermia, hypertension, and possibly pulmonary embolism, he died subsequent to somatropin overdose.", + "summary_subclaims": [ + "This is a first lethal case of HGH acute toxicity.", + "The patient was a young-agitated-athlete with a history of somatropin for the past 2-year.", + "He had hallucinations.", + "He was referred to the emergency department.", + "He reported to have abused 300 mg subcutaneous injections of HGH.", + "He was tachycardic with mild hypertension.", + "Lab data revealed hypernatremia (157 mEq/L).", + "Lab data revealed hyperkalemia (5.3 mEq/L).", + "Lab data revealed high LDH (1448 U/L).", + "Lab data revealed high CPK (2620 U/L).", + "The lab findings were in favor of rhabdomyolysis.", + "Routine drug screening tests were negative for all substances.", + "He was intubated due to low O2 saturation.", + "He was intubated due to progressive loss of consciousness.", + "He had several episodes of hyperthermia.", + "He had several episodes of hypertension.", + "He possibly had pulmonary embolism.", + "He died subsequent to somatropin overdose." + ] + }, + { + "id": "multiclinsum_test_477_en.txt", + "fulltext": "A 21-year-old woman presented to the allergology clinic because of nausea, vomiting, abdominal pain, and itching of the skin each time after she ingested a chicken egg; symptoms had been present for 1 year. She also reported that two months before her visit there was an episode when 10 min after eating a raw chicken egg (in steak tartare) she started to experience severe abdominal pain, nausea, and severe itching of the skin all over her body; and she noticed hives with itchy wheals on her abdomen, chest, and lower limbs accompanied by facial redness as well as feeling of weakness and anxiety. The patient provoked vomiting and took an antihistamine drug in the form of a tablet, the name of which she could not remember. Within an hour, the symptoms resolved completely. Since then, the patient has eliminated chicken eggs from her diet. Her history revealed that she is a second-year psychology student, has an active lifestyle, practices yoga, does not use stimulants, and is interested in healthy nutrition. There is no history of allergic disease in the patient’s family. The patient had no history of chronic diseases and did not take any medications chronically. She had a history of diarrhea and spitting in infancy; at the age of 3 months she was diagnosed with cow's milk protein allergy, and thus was given milk replacer with a high degree of protein hydrolysis up to the age of 12 months. Currently, the patient fully tolerates dairy products. Due to her mother’s concerns, the diet was extended to other foods quite late, after the age of 12 months. In the 12th month of life, chicken egg yolk was introduced, which was well-tolerated; however, introduction of chicken egg white caused redness of the skin around the mouth accompanied by diarrhea. Until the age of 5, the patient did not consume any egg protein, and in the following years its consumption was heavily limited. Only at the age of 20, due to the patient’s belief about the high nutritional and health value of chicken eggs, she introduced this product into her diet in a large amount. It should be noted that initially the patient did not link her complaints with the consumption of eggs, and because of recurrent diarrhea and abdominal pain, she underwent full gastroenterological workup (including gastroscopy and colonoscopy), which ruled out gastrointestinal disorders.", + "fulltext_subclaims": [ + "A 21-year-old woman presented to the allergology clinic because of nausea, vomiting, abdominal pain, and itching of the skin each time after she ingested a chicken egg.", + "Symptoms had been present for 1 year.", + "Two months before her visit, there was an episode when 10 min after eating a raw chicken egg (in steak tartare) she started to experience severe abdominal pain, nausea, and severe itching of the skin all over her body.", + "She noticed hives with itchy wheals on her abdomen, chest, and lower limbs accompanied by facial redness as well as feeling of weakness and anxiety.", + "The patient provoked vomiting and took an antihistamine drug in the form of a tablet, the name of which she could not remember.", + "Within an hour, the symptoms resolved completely.", + "Since then, the patient has eliminated chicken eggs from her diet.", + "The patient had no history of chronic diseases and did not take any medications chronically.", + "At the age of 3 months she was diagnosed with cow's milk protein allergy.", + "She was given milk replacer with a high degree of protein hydrolysis up to the age of 12 months.", + "Currently, the patient fully tolerates dairy products.", + "In the 12th month of life, chicken egg yolk was introduced, which was well-tolerated.", + "Introduction of chicken egg white caused redness of the skin around the mouth accompanied by diarrhea.", + "Until the age of 5, the patient did not consume any egg protein.", + "Only at the age of 20, due to the patient’s belief about the high nutritional and health value of chicken eggs, she introduced this product into her diet in a large amount.", + "Initially the patient did not link her complaints with the consumption of eggs.", + "Because of recurrent diarrhea and abdominal pain, she underwent full gastroenterological workup (including gastroscopy and colonoscopy), which ruled out gastrointestinal disorders." + ], + "summary": "We present a case of a 21-year-old patient with egg allergy, who underwent a double-blind food provocation test with placebo (evaluating subjective complaints from the gastrointestinal tract) and a titrated nasal provocation test using dry chicken egg content. We assessed the response of the nasal mucosa in the provocation test using the visual analogue scale (VAS), acoustic and optical rhinometry, as well as measurements of nitric oxide concentration in the exhaled air. During the provocation test, we measured the changes in the transverse section of the nasal passages, which were accompanied by subjective complaints measured with the VAS scale, using objective techniques. In the nasal provocation test with a dose of 20 µg of chicken egg protein, we observed an increase in the reactivity of the nasal mucosa and a decrease in the level of nitric oxide in the exhaled air from the upper airways (920 ppb before the provocation test and up to 867 ppb during the early stage of the allergic reaction). During the provocation tests, we recorded typical symptoms associated with the early stage of the allergic reaction; including nasal obstruction (1.2 cm), leakage of watery discharge (0.8 cm) in the food test, and itchy nose (1.1 cm) in the food test vs. the nasal test: 4.6, 2.8, and 3.5 cm, respectively.", + "summary_subclaims": [ + "The patient is a 21-year-old with egg allergy.", + "The patient underwent a double-blind food provocation test with placebo.", + "The patient underwent a titrated nasal provocation test using dry chicken egg content.", + "The response of the nasal mucosa was assessed using the visual analogue scale.", + "The response of the nasal mucosa was assessed using acoustic and optical rhinometry.", + "The response of the nasal mucosa was assessed using measurements of nitric oxide concentration in exhaled air.", + "During the provocation test, changes in the transverse section of the nasal passages were measured.", + "Subjective complaints were measured with the VAS scale.", + "In the nasal provocation test with a dose of 20 µg of chicken egg protein, an increase in the reactivity of the nasal mucosa was observed.", + "In the nasal provocation test with a dose of 20 µg of chicken egg protein, a decrease in the level of nitric oxide in the exhaled air from the upper airways was observed.", + "The nitric oxide level in the exhaled air was 920 ppb before the provocation test.", + "The nitric oxide level in the exhaled air was 867 ppb during the early stage of the allergic reaction.", + "During the provocation tests, typical symptoms associated with the early stage of the allergic reaction were recorded.", + "Nasal obstruction was 1.2 cm in the food test.", + "Watery discharge was 0.8 cm in the food test.", + "Itchy nose was 1.1 cm in the food test.", + "Nasal obstruction was 4.6 cm in the nasal test.", + "Watery discharge was 2.8 cm in the nasal test.", + "Itchy nose was 3.5 cm in the nasal test." + ] + }, + { + "id": "multiclinsum_test_1806_en.txt", + "fulltext": "A 40-year-old female presented with chronic headache with infrequent exacerbations. She presents with worsening headache for three months with associated vertigo, nausea, and vomiting not responding to analgesics or vestibular sedatives. Her symptoms initially started twelve years ago as a diffused mild headache, which persisted through the day. Gradually, the headache worsened to a severe headache episodically associated with vertigo, nausea, and vomiting. These episodes lasted for two to three days and got resolved. She was treated with flunarizine for suspected basilar migraine but did not show any response. From the last year, she had monthly exacerbations of headache associated with distressing vertigo, unsteadiness of gait, and right-sided body numbness. In between these episodes, she had a significant dull diffuse headache not responding to simple analgesia. She did not complain of fever or night sweats but had constitutional symptoms lasting for several months. All of these symptoms severely affected her daily activities and functionality.\nDuring the last 17 years, she had repeated episodes of neurological deficits. Even before the headache appeared, she has presented with visual impairment of the right eye and right lateral rectus palsy and was treated as retrobulbar neuritis with good response to methylprednisolone. One year later, she developed left-sided visual impairment, which fully responded to methylprednisolone. MRI imaging at that time revealed normal results. Few months after this event, she got admitted with right hemisensory loss with hemiplegia, and a demyelination disease or hemiplegic migraine was suspected. Second MRI was performed at this admission, and no abnormalities were detected again. Eight years ago, she had developed a left lower motor type facial nerve palsy, which was attributed to Bell's palsy. Within the last year, she was diagnosed to have depression and anxiety for which she was treated for few months. Other than the first two instances, she was not treated with steroids thereafter. She did not complain of weight loss and did not have constitutional symptoms or chest symptoms during these periods.\nOn examination, she is an averagely built female with a BMI of 23 kg/m2. She is afebrile, pale, and did not have lymphadenopathy. Her GCS was 15/15, and she was conscious and rational with normal pupillary response, visual acuity, visual field examination, and fundoscopy. There was no neck rigidity, and she had residual left lower motor VII palsy. She had an ataxic broad-based gait with unsteadiness. Upper and lower limb examination is clinically normal. Her respiratory, cardiovascular, and abdomen examinations were unremarkable.\nInvestigations revealed a hemoglobin count of 9 g/dL with normal white cells and platelets. ESR was elevated to 86 mm/1st hour. Renal- and liver-related biochemical investigations were normal with an alkaline phosphatase within the normal range. Initial MRI scans of the brain done 10 years ago did not reveal any abnormalities such as demyelination, optic nerve enhancement of focal lesions in the cerebrum, or cerebellum. CSF examination revealed an elevated protein level of 55 mg/dl with normal glucose and cells with negative oligoclonal bands or TB-PCR. Vasculitis investigations including ANA, ANCA (ELISA and Immunofluorescence), and RF were negative. Syphilis serology and HIV testing were also negative. Chest radiograph, ultrasound abdomen, and CT scan of chest and abdomen did not reveal any mediastinal lymphadenopathy or focal lesions in visceral organ or evidence of any malignancy. Serum ACE levels (19 µ/l) and ionized calcium levels were normal. We performed a new MRI scan of the brain with contrast, which revealed a diffuse and patchy meningeal thickening and enhancement mainly in the right frontoparietal and left occipital regions with a minor enhancement of bilateral optic sheaths . Her NMO antibodies were normal, and the MRI did not show any areas of demyelination. Therefore, she underwent a dural biopsy from the thickened dura, which revealed large areas of caseous necrosis surrounded by epithelioid histiocytes and lymphoid cells with a few isolated giant cells in the adjacent vicinity . There were no features of vasculitis or sarcoidosis. TB-PCR of tissue and acid-fast bacilli were negative. Final conclusion was necrotizing granulomatous inflammation suggestive of dural tuberculosis. This diagnosis was presumed by the presence of necrotizing granulomatous necrosis with caseation with a strongly positive Mantoux test of 25 mm , and later was supported by a marked response to antituberculous medication.\nWe initiated her on antituberculous therapy (all four drugs for 3 months and 9 months of rifampicin and isoniazid) without streptomycin as she is already having vestibular symptoms. Steroids were added concurrently (1 mg/kg) and was continued for 6 weeks and was tailed off over a month. She experienced a marked improvement of her headache, and she could do her daily activities normally. After a year of anti-TB medication and follow-up, she did not complain of any worsening of symptoms.", + "fulltext_subclaims": [ + "The patient is a 40-year-old female.", + "She presented with chronic headache with infrequent exacerbations.", + "She had worsening headache for three months with associated vertigo, nausea, and vomiting.", + "Her symptoms did not respond to analgesics or vestibular sedatives.", + "Her symptoms initially started twelve years ago as a diffused mild headache.", + "The headache worsened to a severe headache episodically associated with vertigo, nausea, and vomiting.", + "These episodes lasted for two to three days and got resolved.", + "She was treated with flunarizine for suspected basilar migraine.", + "She did not show any response to flunarizine.", + "From the last year, she had monthly exacerbations of headache associated with distressing vertigo, unsteadiness of gait, and right-sided body numbness.", + "In between these episodes, she had a significant dull diffuse headache not responding to simple analgesia.", + "She did not complain of fever or night sweats.", + "She had constitutional symptoms lasting for several months.", + "All of these symptoms severely affected her daily activities and functionality.", + "During the last 17 years, she had repeated episodes of neurological deficits.", + "Even before the headache appeared, she had presented with visual impairment of the right eye and right lateral rectus palsy.", + "She was treated as retrobulbar neuritis with good response to methylprednisolone.", + "One year later, she developed left-sided visual impairment, which fully responded to methylprednisolone.", + "MRI imaging at that time revealed normal results.", + "Few months after this event, she got admitted with right hemisensory loss with hemiplegia.", + "A demyelination disease or hemiplegic migraine was suspected.", + "A second MRI was performed at this admission, and no abnormalities were detected again.", + "Eight years ago, she had developed a left lower motor type facial nerve palsy, which was attributed to Bell's palsy.", + "Within the last year, she was diagnosed to have depression and anxiety.", + "She was treated for depression and anxiety for few months.", + "Other than the first two instances, she was not treated with steroids thereafter.", + "She did not complain of weight loss and did not have constitutional symptoms or chest symptoms during these periods.", + "On examination, she is an averagely built female with a BMI of 23 kg/m2.", + "She is afebrile, pale, and did not have lymphadenopathy.", + "Her GCS was 15/15, and she was conscious and rational.", + "There was no neck rigidity.", + "She had residual left lower motor VII palsy.", + "She had an ataxic broad-based gait with unsteadiness.", + "Her upper and lower limb examination is clinically normal.", + "Her respiratory, cardiovascular, and abdomen examinations were unremarkable.", + "Investigations revealed a hemoglobin count of 9 g/dL.", + "ESR was elevated to 86 mm/1st hour.", + "Renal- and liver-related biochemical investigations were normal.", + "Initial MRI scans of the brain done 10 years ago did not reveal any abnormalities.", + "CSF examination revealed an elevated protein level of 55 mg/dl.", + "Vasculitis investigations including ANA, ANCA (ELISA and Immunofluorescence), and RF were negative.", + "Syphilis serology and HIV testing were also negative.", + "Chest radiograph, ultrasound abdomen, and CT scan of chest and abdomen did not reveal any mediastinal lymphadenopathy or focal lesions.", + "A new MRI scan of the brain with contrast revealed a diffuse and patchy meningeal thickening and enhancement mainly in the right frontoparietal and left occipital regions.", + "The MRI did not show any areas of demyelination.", + "A dural biopsy from the thickened dura revealed large areas of caseous necrosis surrounded by epithelioid histiocytes and lymphoid cells.", + "There were no features of vasculitis or sarcoidosis.", + "TB-PCR of tissue and acid-fast bacilli were negative.", + "The final conclusion was necrotizing granulomatous inflammation suggestive of dural tuberculosis.", + "This diagnosis was presumed by the presence of necrotizing granulomatous necrosis with caseation with a strongly positive Mantoux test of 25 mm.", + "The diagnosis was supported by a marked response to antituberculous medication.", + "Antituberculous therapy was initiated with all four drugs for 3 months and 9 months of rifampicin and isoniazid.", + "Steroids were added concurrently (1 mg/kg) and were continued for 6 weeks.", + "She experienced a marked improvement of her headache.", + "After a year of anti-TB medication and follow-up, she did not complain of any worsening of symptoms." + ], + "summary": "We report a 40-year-old female who presented with chronic headache over a decade associated with recurrent neurological abnormalities including optic neuritis, hemisensory loss, migraine, facial nerve palsy, and recurrent vertigo. Although there was an initial perceived response to steroids, the patient had a subsequent progressive course. On investigations, she was found to have a diffused dural thickening on contrast MRI with a strongly positive Mantoux test with caseating necrotizing granulomatous inflammation on dural histology. With initiation of antituberculous medication with steroids, the patient markedly improved, and the medication for tuberculosis was continued for a year with good response.", + "summary_subclaims": [ + "The patient is a 40-year-old female.", + "She had chronic headache over a decade.", + "She had recurrent neurological abnormalities.", + "The neurological abnormalities included optic neuritis.", + "The neurological abnormalities included hemisensory loss.", + "The neurological abnormalities included migraine.", + "The neurological abnormalities included facial nerve palsy.", + "The neurological abnormalities included recurrent vertigo.", + "There was an initial perceived response to steroids.", + "The patient had a subsequent progressive course.", + "She had diffused dural thickening on contrast MRI.", + "She had a strongly positive Mantoux test.", + "Dural histology showed caseating necrotizing granulomatous inflammation.", + "Antituberculous medication with steroids was initiated.", + "The patient markedly improved.", + "The medication for tuberculosis was continued for a year.", + "There was a good response." + ] + }, + { + "id": "multiclinsum_test_1001_en.txt", + "fulltext": "A 38-year-old woman developed numbness in the right limb and weakness and limited movement in the left limb following a fall from hitting her head on a door beam. She was unconscious on the spot. After treatment, her whole body was numb and limb activity was limited. Half an hour later, she felt numb and weak in the right limb and weak in the left limb. She had no previous hypertension, diabetes, or coronary heart disease. 13 years ago, she developed numbness in her right hand after pregnancy and was diagnosed with congenital fusion of cervical C2-5, which was not treated at that time . Her symptoms had improved and had not interfered with her normal life. There was no diplopia, slurred speech, hiccups, nausea and vomiting, dysphagia, urinary incontinence, and no corresponding symptoms such as facial sensory abnormalities. Physical examination revealed a short neck, limited cervical mobility, and low occipital hairline. Below the C3 level of spinal cord, bounded by the anterior median line, there were different sensory and motor abnormalities from left to right. The patient had decreased pinprick and temperature sensation on the right side and normal pinprick sensation on the left side. Her sense of spatial position was normal. There was increased muscle tone in the right upper and lower limbs and decreased muscle tone in the left upper and lower limbs. The muscle strength of the left upper and lower limbs was 0 out of 5 and the strength of the right upper and lower limbs was 4 out of 5. After conservative treatment, her muscle strength gradually recovered. 10 days later, some of the muscle strength showed changes, and the muscle strength of the key muscle groups was as follows: shrugging shoulder muscle strength (left 2, right4), elbow flexion muscle strength (left 2, right 4), elbow extension muscle strength (left 2, right 4), wrist flexion muscle strength (left 1, right 4). finger flexion muscle strength (left 1, right 4), finger extension muscle strength (left 1, right 3), hip flexion (left 2, right 4), knee extension (left 2, right 4), dorsalis pedis (left 3, right 4), plantarflexion (left 3, right 4), and hyperreflexia of the biceps and triceps tendons bilaterally. Abdominal wall reflexes were present, knee and Achilles tendon reflexes were hyperactive, patellar clonus was positive on the right, patellar clonus was positive on the left, ankle clonus was positive on the right and ankle clonus was positive on the left. The dorsalis pedis artery was palpable bilaterally. The bilateral Hoffman's sign was positive. Babinski's sign was positive and Kernig's sign was positive. The findings of Magnetic resonance imaging (MRI) in the neck revealed that small C2-5 vertebral body with partial fusion of the vertebral body; increased anterior atlantoaxial space, posterior superior displacement of the cardinal vertebrae, the narrowing of the spinal canal at the corresponding level and marked compression and thinning of the spinal cord (C1-2 joint instability, discontinuity of the odontoid process, congenital fusion of cervical C2-5). posterior protrusion of the C7-T1 intervertebral disc, with compression of the corresponding dural sac. No significant abnormal signs were seen in the cervical medulla. We considered that the woman sustained BBS because she had previously suffered from KFS, which according to ASIA(American Spinal Injury Association) Impairment Scale was a grade B: incomplete injury. After admission, the woman was given methylcobalamin for neurotropism and tizanidine to reduce muscle tone and received acupuncture and hyperbaric oxygen therapy. After conservative treatment, her spinal cord oedema decreased and the numbness on the right side gradually subsided, but the results were still unsatisfactory so the doctor recommended surgery. She then underwent posterior decompression of the spinal canal, and lateral mass fixation between atlas and axis with screw-plate system . After surgery, her numbness subsided and she continued to receive adenosine cobalamin for neurotropic treatment. She came to our hospital for a check 5 months later after the operation. The numbness of the right limb significantly decreased and the dysfunction of the limbs was slightly better than before. She could sit independently and stand with assistance, but she was still unable to take care of himself. She then underwent regular rehabilitation treatment in our hospital. 18 months later, the numbness of her limbs had disappeared and she was able to take care of herself with assistance, and her condition improved from grade B to grade D according to the ASIA classification.", + "fulltext_subclaims": [ + "The patient is a 38-year-old woman.", + "She developed numbness in the right limb and weakness and limited movement in the left limb following a fall from hitting her head on a door beam.", + "She was unconscious on the spot.", + "After treatment, her whole body was numb and limb activity was limited.", + "Half an hour later, she felt numb and weak in the right limb and weak in the left limb.", + "She had no previous hypertension, diabetes, or coronary heart disease.", + "13 years ago, she developed numbness in her right hand after pregnancy.", + "She was diagnosed with congenital fusion of cervical C2-5.", + "The congenital fusion of cervical C2-5 was not treated at that time.", + "Her symptoms had improved and had not interfered with her normal life.", + "There was no diplopia, slurred speech, hiccups, nausea and vomiting, dysphagia, urinary incontinence, or facial sensory abnormalities.", + "Physical examination revealed a short neck.", + "Physical examination revealed limited cervical mobility.", + "Physical examination revealed a low occipital hairline.", + "Below the C3 level of spinal cord, bounded by the anterior median line, there were different sensory and motor abnormalities from left to right.", + "The patient had decreased pinprick and temperature sensation on the right side.", + "The patient had normal pinprick sensation on the left side.", + "Her sense of spatial position was normal.", + "There was increased muscle tone in the right upper and lower limbs.", + "There was decreased muscle tone in the left upper and lower limbs.", + "The muscle strength of the left upper and lower limbs was 0 out of 5.", + "The strength of the right upper and lower limbs was 4 out of 5.", + "After conservative treatment, her muscle strength gradually recovered.", + "10 days later, some of the muscle strength showed changes.", + "The muscle strength of the shrugging shoulder muscle was left 2, right 4.", + "The muscle strength of the elbow flexion muscle was left 2, right 4.", + "The muscle strength of the elbow extension muscle was left 2, right 4.", + "The muscle strength of the wrist flexion muscle was left 1, right 4.", + "The muscle strength of the finger flexion muscle was left 1, right 4.", + "The muscle strength of the finger extension muscle was left 1, right 3.", + "The muscle strength of the hip flexion was left 2, right 4.", + "The muscle strength of the knee extension was left 2, right 4.", + "The muscle strength of the dorsalis pedis was left 3, right 4.", + "The muscle strength of the plantarflexion was left 3, right 4.", + "Hyperreflexia of the biceps and triceps tendons bilaterally was observed.", + "Abdominal wall reflexes were present.", + "Knee and Achilles tendon reflexes were hyperactive.", + "Patellar clonus was positive on the right.", + "Patellar clonus was positive on the left.", + "Ankle clonus was positive on the right.", + "Ankle clonus was positive on the left.", + "The dorsalis pedis artery was palpable bilaterally.", + "The bilateral Hoffman's sign was positive.", + "Babinski's sign was positive.", + "Kernig's sign was positive.", + "MRI in the neck revealed small C2-5 vertebral body with partial fusion of the vertebral body.", + "MRI showed increased anterior atlantoaxial space.", + "MRI showed posterior superior displacement of the cardinal vertebrae.", + "MRI showed narrowing of the spinal canal at the corresponding level.", + "MRI showed marked compression and thinning of the spinal cord.", + "MRI showed C1-2 joint instability.", + "MRI showed discontinuity of the odontoid process.", + "MRI showed congenital fusion of cervical C2-5.", + "MRI showed posterior protrusion of the C7-T1 intervertebral disc.", + "MRI showed compression of the corresponding dural sac.", + "No significant abnormal signs were seen in the cervical medulla.", + "The woman was considered to have sustained BBS.", + "She had previously suffered from KFS.", + "According to the ASIA Impairment Scale, the injury was grade B: incomplete injury.", + "After admission, the woman was given methylcobalamin for neurotropism.", + "After admission, the woman was given tizanidine to reduce muscle tone.", + "After admission, the woman received acupuncture.", + "After admission, the woman received hyperbaric oxygen therapy.", + "After conservative treatment, her spinal cord oedema decreased.", + "The numbness on the right side gradually subsided.", + "The results were still unsatisfactory.", + "The doctor recommended surgery.", + "She underwent posterior decompression of the spinal canal.", + "She underwent lateral mass fixation between atlas and axis with screw-plate system.", + "After surgery, her numbness subsided.", + "After surgery, she continued to receive adenosine cobalamin for neurotropic treatment.", + "She came to the hospital for a check 5 months later after the operation.", + "The numbness of the right limb significantly decreased.", + "The dysfunction of the limbs was slightly better than before.", + "She could sit independently.", + "She could stand with assistance.", + "She was still unable to take care of herself.", + "She then underwent regular rehabilitation treatment.", + "18 months later, the numbness of her limbs had disappeared.", + "She was able to take care of herself with assistance.", + "Her condition improved from grade B to grade D according to the ASIA classification." + ], + "summary": "We found a 38-year-old female patient with KFS in our clinical work. She was unconscious on the spot following a minor traumatic episode. After treatment, her whole body was numb and limb activity was limited. Half an hour later, she felt numb and weak in the right limb and weak in the left limb. She had no previous hypertension, diabetes, or coronary heart disease. After one-month treatment of medication, hyperbaric oxygen, rehabilitation, and acupuncture in our hospital, her muscle strength partially recovered, but the treatment effect was still not satisfactory. Then, she underwent surgical treatment and postoperative comprehensive treatment, and rehabilitation training. She was able to take care of herself with assistance, and her condition improved from grade B to grade D according to the ASIA (ASIA Impairment Scale) classification.", + "summary_subclaims": [ + "We found a 38-year-old female patient with KFS in our clinical work.", + "She was unconscious on the spot following a minor traumatic episode.", + "After treatment, her whole body was numb and limb activity was limited.", + "Half an hour later, she felt numb and weak in the right limb and weak in the left limb.", + "She had no previous hypertension, diabetes, or coronary heart disease.", + "After one-month treatment of medication, hyperbaric oxygen, rehabilitation, and acupuncture in our hospital, her muscle strength partially recovered.", + "The treatment effect was still not satisfactory.", + "She underwent surgical treatment and postoperative comprehensive treatment, and rehabilitation training.", + "She was able to take care of herself with assistance.", + "Her condition improved from grade B to grade D according to the ASIA (ASIA Impairment Scale) classification." + ] + }, + { + "id": "multiclinsum_test_3219_en.txt", + "fulltext": "History of Presentation\nA 67-year-old woman presented at our ambulatory clinic for a follow-up computed tomography (CT) scan of the thorax with contrast medium after pulmonary vein (PV) stenting to address PV stenosis after catheter ablation for atrial fibrillation (AF). During the visit, the patient reported dyspnea (NYHA functional class III), intermittent palpitations, nausea, and general weakness. The clinical examination revealed no notable abnormalities.\n\nPast Medical History\nThe patient’s medical history included persistent AF, first diagnosed 10 years before the current presentation, with a CHA₂DS₂-VASc score of 3 and an European Heart Rhythm Association score of 2b, under antiarrhythmic therapy with propafenone and oral anticoagulation with rivaroxaban. She had undergone 2 radiofrequency (RF)-based pulmonary vein isolation (PVI) procedures 8 and 7 years earlier. Due to AF recurrence, a new RF-based PVI was planned 3 years ago; however, PV stenosis was detected during angiography of the left PVs and a cryoballoon (CB)-based PVI was performed instead. A subsequent evaluation of the PV stenosis was recommended, but the patient failed to attend the appointment due to absence of symptoms.\n\nThe patient presented 9 months ago at our ambulatory clinic with recurrent AF, and a new RF-based ablation was performed 6 months ago. During electroanatomic mapping, a persistent bidirectional block of the PVs was documented. Due to induction of atrial tachycardia and typical atrial flutter, anterior and posterior line ablations, and a cavotricuspid isthmus ablation were performed, with successful termination of the arrhythmias. High-grade stenosis of the left PVs was confirmed angiographically, and PV stenting was successfully completed 5 months before the current presentation by a multidisciplinary team. The prestenotic diameter of the left superior pulmonary vein (LSPV) and left inferior pulmonary vein (LIPV) was 6.5 and 7.0 mm, respectively. The 2 left PVs were dilated, and a 20- × 7-mm stent and a 20- × 10-mm stent were implanted in the LSPV and LIPV, respectively (Video 3). One week before the current presentation, the patient was hospitalized at another institution due to recurrent atrial tachycardia. Electrical cardioversion was performed, and therapy with propafenone was initiated.\n\nThe medical history also included cardiac decompensation secondary to AF, with pulmonary edema, respiratory insufficiency, and intermittent noninvasive ventilation; chronic kidney disease; hypothyroidism managed with substitution therapy; arterial hypertension; hypercholesterolemia; and intolerance to flecainide.\n\nDifferential Diagnosis\nThe differential diagnosis considered AF or atrial tachycardia recurrence, worsening of left ventricular function, a new episode of pulmonary edema, propafenone intolerance, and progression of the PV stenosis leading to pulmonary hypertension.\n\nInvestigations\nThe electrocardiography at presentation showed a normofrequent sinus rhythm with no pathologic changes. Initial blood tests revealed previously known reduced renal function (glomerular filtration rate, 47 mL/min/1.73 m2) and hypothyroidism with inadequate substitution therapy.\nThe thoracic CT scan with contrast media showed the stent in the LSPV, with normal contrast and positioning and a slightly progressive, high-grade, short stenosis of the LIPV, with no visible stent at this level. Additional findings included dilatation of the truncus pulmonalis (diameter: 35 mm) and the right pulmonary artery (diameter: 28 mm). The scan concluded a dislocation of the stent from the LIPV, which could not be visualized in the thoracic scan, along with signs of pulmonary hypertension.\n\nA subsequent abdominal CT scan identified the displaced stent in the abdominal aorta, located just cranial to the aortoiliac bifurcation.\n\nManagement\nA multidisciplinary team consisting of electrophysiologists, radiologists, and interventional radiologists decided to implant an additional stent at the aortoiliac bifurcation to secure the displaced stent. Five days after presentation, an aortic digital subtraction angiography was performed, revealing the dislodged stent superior to the aortoiliac bifurcation and a moderate atherosclerotic stenosis of the right common iliac artery (CIA), by present peripheral artery disease. Due to the significant size mismatch between the diameter of the aorta, left CIA, and the displaced stent, overexpanding the stent in the abdominal aorta or repositioning the stent in the left CIA was deemed unfeasible. A double stenting procedure of the aortoiliac bifurcation using the kissing stents technique was performed. Two cobalt-chromium 9- × 58-mm stents (Dynetic, Biotronik) were implanted: the left one secured the displaced PV stent in place, whereas the right one treated the CIA stenosis. A Doppler ultrasound of the arteries of the lower limbs, performed on the first postprocedural day, showed no evidence of stenosis after stent implantation. The patient was discharged on rivaroxaban and clopidogrel therapy.\n\nOutcome and Follow-Up\nDue to recurrent AF despite propafenone therapy, a new RF-based AF ablation was performed 4 months after presentation, including reisolation of the anterior line and completion of the box lesion. During the procedure, atrioventricular nodal reentry tachycardia was induced by programmed stimulation, and a slow-pathway ablation was performed. During the slow-pathway ablation, a transient third-degree atrioventricular block occurred. Follow-up revealed a persistent second-degree 2:1 atrioventricular block, and a 2-chamber pacemaker was successfully implanted.\nSeven months after the presentation, the patient’s symptoms had significantly improved. A renewed ventilation-perfusion analysis, however, showed progressive worsening of the left lung perfusion. A new angiography of the LIPV, with subsequent stenting, was planned. A Doppler ultrasound examination of the main arteries in the lower limb did not reveal any pathologic findings.", + "fulltext_subclaims": [ + "The patient is a 67-year-old woman.", + "The patient presented for a follow-up CT scan of the thorax with contrast after pulmonary vein stenting.", + "The stenting was performed to address pulmonary vein stenosis after catheter ablation for atrial fibrillation.", + "The patient reported dyspnea (NYHA functional class III).", + "The patient reported intermittent palpitations.", + "The patient reported nausea.", + "The patient reported general weakness.", + "The clinical examination revealed no notable abnormalities.", + "The patient had a history of persistent atrial fibrillation.", + "The patient's CHA₂DS₂-VASc score was 3.", + "The patient's European Heart Rhythm Association score was 2b.", + "The patient was under antiarrhythmic therapy with propafenone.", + "The patient was on oral anticoagulation with rivaroxaban.", + "The patient had undergone two radiofrequency-based pulmonary vein isolation procedures.", + "The first RF-based PVI was 8 years before the current presentation.", + "The second RF-based PVI was 7 years before the current presentation.", + "A new RF-based PVI was planned 3 years before the current presentation.", + "PV stenosis was detected during angiography of the left PVs.", + "A cryoballoon-based PVI was performed instead of the planned RF-based PVI.", + "A subsequent evaluation of the PV stenosis was recommended.", + "The patient failed to attend the recommended evaluation due to absence of symptoms.", + "The patient presented 9 months before the current presentation with recurrent AF.", + "A new RF-based ablation was performed 6 months before the current presentation.", + "During electroanatomic mapping, a persistent bidirectional block of the PVs was documented.", + "Atrial tachycardia and typical atrial flutter were induced.", + "Anterior and posterior line ablations were performed.", + "A cavotricuspid isthmus ablation was performed.", + "High-grade stenosis of the left PVs was confirmed angiographically.", + "PV stenting was successfully completed 5 months before the current presentation.", + "The prestenotic diameter of the left superior pulmonary vein was 6.5 mm.", + "The prestenotic diameter of the left inferior pulmonary vein was 7.0 mm.", + "A 20- × 7-mm stent was implanted in the LSPV.", + "A 20- × 10-mm stent was implanted in the LIPV.", + "The patient was hospitalized one week before the current presentation due to recurrent atrial tachycardia.", + "Electrical cardioversion was performed.", + "Therapy with propafenone was initiated.", + "The medical history included cardiac decompensation secondary to AF.", + "The medical history included pulmonary edema.", + "The medical history included respiratory insufficiency.", + "The medical history included intermittent noninvasive ventilation.", + "The medical history included chronic kidney disease.", + "The medical history included hypothyroidism managed with substitution therapy.", + "The medical history included arterial hypertension.", + "The medical history included hypercholesterolemia.", + "The medical history included intolerance to flecainide.", + "The differential diagnosis considered AF or atrial tachycardia recurrence.", + "The differential diagnosis considered worsening of left ventricular function.", + "The differential diagnosis considered a new episode of pulmonary edema.", + "The differential diagnosis considered propafenone intolerance.", + "The differential diagnosis considered progression of PV stenosis leading to pulmonary hypertension.", + "The electrocardiography at presentation showed a normofrequent sinus rhythm.", + "The electrocardiography showed no pathologic changes.", + "Initial blood tests revealed reduced renal function.", + "The glomerular filtration rate was 47 mL/min/1.73 m2.", + "Initial blood tests revealed hypothyroidism with inadequate substitution therapy.", + "The thoracic CT scan showed the stent in the LSPV.", + "The thoracic CT scan showed normal contrast and positioning.", + "The thoracic CT scan showed a slightly progressive, high-grade, short stenosis of the LIPV.", + "The thoracic CT scan showed no visible stent in the LIPV.", + "The thoracic CT scan showed dilatation of the truncus pulmonalis.", + "The truncus pulmonalis diameter was 35 mm.", + "The thoracic CT scan showed dilatation of the right pulmonary artery.", + "The right pulmonary artery diameter was 28 mm.", + "The thoracic CT scan concluded a dislocation of the stent from the LIPV.", + "The thoracic CT scan showed signs of pulmonary hypertension.", + "The abdominal CT scan identified the displaced stent in the abdominal aorta.", + "The displaced stent was located just cranial to the aortoiliac bifurcation.", + "A multidisciplinary team decided to implant an additional stent at the aortoiliac bifurcation.", + "An aortic digital subtraction angiography was performed five days after presentation.", + "The angiography revealed the dislodged stent superior to the aortoiliac bifurcation.", + "The angiography revealed a moderate atherosclerotic stenosis of the right common iliac artery.", + "Due to the size mismatch, overexpanding the stent in the abdominal aorta was deemed unfeasible.", + "Due to the size mismatch, repositioning the stent in the left CIA was deemed unfeasible.", + "A double stenting procedure of the aortoiliac bifurcation using the kissing stents technique was performed.", + "Two cobalt-chromium 9- × 58-mm stents were implanted.", + "The left stent secured the displaced PV stent in place.", + "The right stent treated the CIA stenosis.", + "A Doppler ultrasound of the arteries of the lower limbs showed no evidence of stenosis.", + "The patient was discharged on rivaroxaban and clopidogrel therapy.", + "A new RF-based AF ablation was performed 4 months after presentation.", + "The ablation included reisolation of the anterior line.", + "The ablation included completion of the box lesion.", + "Atrial ventricular nodal reentry tachycardia was induced by programmed stimulation.", + "A slow-pathway ablation was performed.", + "A transient third-degree atrioventricular block occurred during the slow-pathway ablation.", + "Follow-up revealed a persistent second-degree 2:1 atrioventricular block.", + "A 2-chamber pacemaker was successfully implanted.", + "Seven months after presentation, the patient’s symptoms had significantly improved.", + "A renewed ventilation-perfusion analysis showed progressive worsening of the left lung perfusion.", + "A new angiography of the LIPV, with subsequent stenting, was planned.", + "A Doppler ultrasound examination of the main arteries in the lower limb did not reveal any pathologic findings." + ], + "summary": "A 67-year-old woman underwent a thoracic computed tomography scan after left PV stenting for stenosis after PVI. The scan revealed the stent missing in the left inferior PV and worsening high-grade stenosis. An abdominal computed tomography scan identified the displaced stent in the aorta, just above the aortoiliac bifurcation. Digital subtraction angiography also revealed moderate stenosis in the right common iliac artery. A double stenting procedure of the aortoiliac bifurcation using the kissing stents technique was performed, securing the PV stent and treating the common iliac artery stenosis. Follow-up on the displaced stent was favorable.", + "summary_subclaims": [ + "The patient is a 67-year-old woman.", + "She underwent a thoracic computed tomography scan.", + "The scan was performed after left PV stenting.", + "The stenting was for stenosis after PVI.", + "The thoracic computed tomography scan revealed the stent missing in the left inferior PV.", + "The scan showed worsening high-grade stenosis.", + "An abdominal computed tomography scan identified the displaced stent in the aorta.", + "The displaced stent was located just above the aortoiliac bifurcation.", + "Digital subtraction angiography revealed moderate stenosis in the right common iliac artery.", + "A double stenting procedure of the aortoiliac bifurcation was performed.", + "The procedure used the kissing stents technique.", + "The procedure secured the PV stent.", + "The procedure treated the common iliac artery stenosis.", + "Follow-up on the displaced stent was favorable." + ] + }, + { + "id": "multiclinsum_test_425_en.txt", + "fulltext": "A 70-year-old man was referred to our department for an asymptomatic thoracoabdominal aortic aneurysm. He had recently undergone percutaneous coronary procedure due to an ischemic cardiac event (myocardial infarction) and for this reason he was in treatment with a dual antiplatelet therapy (DAPT).\nThe patient, a former smoker with arterial hypertension under single medical therapy, had been previously treated for an infrarenal abdominal aortic aneurysm with open surgical repair approximately 15 years before. A computed tomography angiography (CTA) scan performed for other causes, revealed a type III TAAA with a maximum diameter of 55X65 mm . The patient was asymptomatic for abdominal pain, but complained of buttock and thigh claudication, even in the absence of defects in the pelvic perfusion. Symptoms were further evaluated with spinal magnetic resonance angiography (MRA) that showed a severe lumbar spinal stenosis (LSS) . The patient was deemed to be at high risk for open surgery due to concomitant chronic obstructive pulmonary disease and low ejection fraction 40%) and a staged endovascular aortic repair was then planned, consisting of TEVAR followed by a second step to be performed 4 weeks later with a fenestrated custom-made endovascular repair of the visceral and infrarenal aorta.\nConsidering that subclavian and hypogastric arteries were patent and the intended length of the tract of thoracic aorta to be covered was less than 20 cm, the procedure was estimated at intermediate risk of SCI for the previous infrarenal aortic repair. Additionally, considering the need for continuing with the DAPT for the recent cardiac procedure, in agreement with the anesthesiologist, it was decided not to place a preoperative CSF drainage.\nThe procedure was performed with the deployment of a thoracic endoprosthesis (Cook Medical Inc., Bloomington, ZTEG-2PT-40-30-165-PF), as planned. The intervention was performed under general anesthesia, with a duration of 110 min. At the end of procedure, the patient was transferred to Intensive care Unit for postoperative monitoring, without any sign of clinical complications (Hb > 10 g/dl, mean arterial pressure (MAP) > 90, oxygen saturation > 97%). After 24 h from the procedure, incomplete paraplegia with absence of deep tendon reflex was detected. Therefore, it was decided to immediately insert a spinal catheter for CSF drainage.\nCSF drainage was carried on for 7 days and the patient showed a partial recovery of the sensibility deficit (tactile dolorific hypoesthesia). The patient was transferred to the Spinal Unit, where a satisfactory recovery of the movements of the right leg was noted, whereas plegia of the left leg was still present. The patient was finally discharge in postoperative day 15th to a dedicated neurological rehabilitation center.\nThe second staged intervention was than delayed and, 1 week before the date of planned intervention, the patient came to the emergency department for hemoptysis and chest pain. An urgent CTA showed sudden increase of the thoracoabdominal aneurysm (78X63 mm) with contained sac rupture. The patient underwent urgent endovascular exclusion of the TAAA with the 4-branched custom made endoprosthesis: another thoracic stent-graft (Cook Medical Inc., Bloomington, ZTA-PT-36-32-161) was deployed to extend previous TEVAR. All the side branches were stented with Fluency (Bard Incorporated, Karlsruhe, Germany) and reinforced with a self-expandable stent (SMART, Cordis Endovascular, Warren, NJ). Distal abdominal stent grafting with both iliac artery extensions was performed landing distally inside the previous surgical graft.\nFinal digital subtraction angiography (DSA) showed complete exclusion of the TAAA and good patency of the visceral vessels. Postoperative course was uneventful. No changes in neurological status occurred. The patient was discharged in the 6th postoperative day. The CTA performed 12 months after the procedure demonstrated the continued exclusion of TAAA and the patency of visceral and renal vessels .", + "fulltext_subclaims": [ + "The patient was a 70-year-old man.", + "He was referred for an asymptomatic thoracoabdominal aortic aneurysm.", + "He had recently undergone a percutaneous coronary procedure.", + "The procedure was due to an ischemic cardiac event.", + "The ischemic cardiac event was a myocardial infarction.", + "He was in treatment with dual antiplatelet therapy.", + "The patient was a former smoker.", + "He had arterial hypertension under single medical therapy.", + "He had previously been treated for an infrarenal abdominal aortic aneurysm.", + "The previous treatment was open surgical repair.", + "The open surgical repair was approximately 15 years before.", + "A computed tomography angiography scan revealed a type III TAAA.", + "The maximum diameter of the TAAA was 55X65 mm.", + "The patient was asymptomatic for abdominal pain.", + "He complained of buttock and thigh claudication.", + "Spinal magnetic resonance angiography showed a severe lumbar spinal stenosis.", + "The patient was deemed to be at high risk for open surgery.", + "The high risk was due to concomitant chronic obstructive pulmonary disease.", + "The high risk was also due to a low ejection fraction of 40%.", + "A staged endovascular aortic repair was planned.", + "The staged repair consisted of TEVAR followed by a second step.", + "The second step was planned to be a fenestrated custom-made endovascular repair.", + "The second step was to repair the visceral and infrarenal aorta.", + "The subclavian and hypogastric arteries were patent.", + "The intended length of the tract of thoracic aorta to be covered was less than 20 cm.", + "The procedure was estimated at intermediate risk of SCI.", + "The intermediate risk was due to the previous infrarenal aortic repair.", + "It was decided not to place a preoperative CSF drainage.", + "The decision was due to the need for continuing dual antiplatelet therapy.", + "The procedure was performed with the deployment of a thoracic endoprosthesis.", + "The endoprosthesis was from Cook Medical Inc., Bloomington, ZTEG-2PT-40-30-165-PF.", + "The intervention was performed under general anesthesia.", + "The duration of the procedure was 110 minutes.", + "At the end of the procedure, the patient was transferred to the Intensive care Unit.", + "There were no signs of clinical complications.", + "After 24 hours, incomplete paraplegia with absence of deep tendon reflex was detected.", + "It was decided to immediately insert a spinal catheter for CSF drainage.", + "CSF drainage was carried on for 7 days.", + "The patient showed a partial recovery of the sensibility deficit.", + "The patient was transferred to the Spinal Unit.", + "A satisfactory recovery of the movements of the right leg was noted.", + "Plegia of the left leg was still present.", + "The patient was discharged on the 15th postoperative day.", + "The second staged intervention was delayed.", + "One week before the planned intervention, the patient came to the emergency department for hemoptysis and chest pain.", + "An urgent CTA showed a sudden increase of the thoracoabdominal aneurysm.", + "The aneurysm measured 78X63 mm.", + "The CTA showed contained sac rupture.", + "The patient underwent urgent endovascular exclusion of the TAAA.", + "A 4-branched custom made endoprosthesis was used.", + "Another thoracic stent-graft was deployed to extend the previous TEVAR.", + "All the side branches were stented with Fluency.", + "The side branches were reinforced with a self-expandable stent.", + "Distal abdominal stent grafting with both iliac artery extensions was performed.", + "The final digital subtraction angiography showed complete exclusion of the TAAA.", + "The final DSA showed good patency of the visceral vessels.", + "The postoperative course was uneventful.", + "No changes in neurological status occurred.", + "The patient was discharged on the 6th postoperative day.", + "A CTA performed 12 months after the procedure demonstrated continued exclusion of the TAAA.", + "The CTA showed patency of the visceral and renal vessels." + ], + "summary": "A 70-year-old man was admitted to our department with an asymptomatic type III TAAA in previous open repair for abdominal aortic aneurysm. The patient complained of buttock and thigh claudication in the absence of defects in the pelvic perfusion; a spinal magnetic resonance angiography (MRA) showed a severe narrowing of the lumbar canal.. After 24 h from first-step procedure (TEVAR) paraplegia was detected. A cerebrospinal fluid (CSF) drainage was then placed with incomplete recovery.", + "summary_subclaims": [ + "A 70-year-old man was admitted to our department with an asymptomatic type III TAAA in previous open repair for abdominal aortic aneurysm.", + "The patient complained of buttock and thigh claudication.", + "There were no defects in the pelvic perfusion.", + "A spinal magnetic resonance angiography showed a severe narrowing of the lumbar canal.", + "After 24 h from first-step procedure (TEVAR) paraplegia was detected.", + "A cerebrospinal fluid drainage was then placed.", + "There was incomplete recovery." + ] + }, + { + "id": "multiclinsum_test_571_en.txt", + "fulltext": "An 84-year-old Japanese man was bitten by a Mamushi on the right fifth finger and presented to our emergency department. He had a history of benign prostatic hyperplasia and an overactive bladder. He was taking mirabegron at a dosage of 50 mg/day and had an oxybutynin patch that delivered a dose of 73.5 mg/day. The patient was treated on surgical admission. On the second day of hospitalization, the bite reached Grade 4 (redness and swelling of the whole extremity) . Creatine kinase (CK) level was maximal at 1770 U/L on the fourth day of admission. Cephalantin (10 mg/day), acetate ringer (1000 mL/day), and maintenance fluid (sodium 35 mEq/L, potassium 20 mEq/L, and glucose 4.3% isotonic solution [1000 mL/day]) had been administered since the second day of admission. The total in–out balance had roughly passed zero.\nOn the eighth day of hospitalization, vomiting occurred. In the early hours of the ninth day of hospitalization, the patient experienced restlessness, and blood tests revealed hyponatremia. The patient was transferred to the department of internal medicine.\nAt the time of transfer to the department of internal medicine, the patient’s vital signs were as follows: consciousness level of 13 points (E3V4M6) on the Glasgow Coma Scale, blood pressure of 142/79 mmHg, pulse rate of 59 beats/min, respiratory rate of 24 breaths/min, SpO2 of 97% (room air), and body temperature of 37.2 °C in the axilla. Physical examination revealed no rigidity of the neck, no enlarged cervical lymph nodes, and clear respiratory sounds and no heart murmur on chest auscultation. The abdomen was flat and soft with no tenderness. No edema of the lower legs was observed, and tenderness, swelling, and heat were present from the right upper arm to the dorsum of the right hand. The findings in the right upper extremity remained unchanged from those on the previous day.\nTable shows the laboratory findings at the time of transfer to the department of internal medicine. Blood tests showed that the CK level was elevated again to 2267 U/L. The serum Na level was 114 mE/L, and serum osmolality was 237 mOsm/L. Urinalysis revealed a urine specific gravity of 1.020, urinary Na level of 195 mEq/L, and urine osmolality of 613 mOsm/L. Despite the hyponatremia, the urine was hypertonic.\nFigure shows the clinical course of the patient after admission. We determined that the CK re-elevation was due to hyponatremia. Severe symptomatic hyponatremia was corrected with administration of 3% sodium chloride solution. On the 10th day of admission, the serum Na level improved to 120 mEq/L, and the level of consciousness improved as the serum Na level improved. Since the blood cortisol level was low at 4.0 µg/dL (reference value 4.5–21.11 µg/dL), adrenal insufficiency was suspected, and administration of corticosteroids (dexamethasone 6.6 mg/day, then hydrocortisone 100 mg/day) was initiated on the 10th day of admission. On the 11th day of admission, the 3% sodium chloride solution was discontinued, and on the 15th day of admission, the corticosteroids were discontinued; however, the serum Na level did not decrease. An adrenocorticotrophin hormone (ACTH) loading test was performed on the 16th day of admission. Pituitary contrast-enhanced magnetic resonance imaging (MRI) and a corticotropin-releasing hormone / growth hormone-releasing factor / thyrotropin-releasing hormone / luteinizing hormone-releasing hormone (CRH/GRF/TRH/LHRH) stimulation test was performed on the 19th and 23rd day of admission, respectively. The results of the ACTH loading test and CRH/GRF/TRH/LHRH stimulation test are shown in Table . The peak blood cortisol levels after the ACTH loading and CRH/GRF/TRH/LHRH stimulation tests were below 18 µg/dL, and the peak ACTH level after the CRH/GRF/TRH/LHRH stimulation test was less than two-folds the basal value; thus, a diagnosis of pituitary adrenal insufficiency was made .\nContrast-enhanced MRI of the pituitary gland is shown in Fig. . The sella turcica was markedly enlarged and filled with cerebrospinal fluid.\nAfter discontinuation of corticosteroids, the hyponatremia did not recur, and the swelling in the right upper extremity improved. The patient was discharged on the 24th day of admission. He visited the outpatient clinic 9 and 16 days after discharge, and there was no hyponatremia relapse. The patient has not experienced hyponatremia in the three years since the Mamushi bite.", + "fulltext_subclaims": [ + "An 84-year-old Japanese man was bitten by a Mamushi on the right fifth finger.", + "He had a history of benign prostatic hyperplasia.", + "He was taking mirabegron at a dosage of 50 mg/day.", + "He had an oxybutynin patch that delivered a dose of 73.5 mg/day.", + "The patient was treated on surgical admission.", + "On the second day of hospitalization, the bite reached Grade 4 (redness and swelling of the whole extremity).", + "Creatine kinase (CK) level was maximal at 1770 U/L on the fourth day of admission.", + "Cephalantin (10 mg/day) had been administered since the second day of admission.", + "Acetate ringer (1000 mL/day) had been administered since the second day of admission.", + "Maintenance fluid (sodium 35 mEq/L, potassium 20 mEq/L, and glucose 4.3% isotonic solution [1000 mL/day]) had been administered since the second day of admission.", + "The total in–out balance had roughly passed zero.", + "On the eighth day of hospitalization, vomiting occurred.", + "In the early hours of the ninth day of hospitalization, the patient experienced restlessness.", + "Blood tests revealed hyponatremia.", + "The patient was transferred to the department of internal medicine.", + "At the time of transfer to the department of internal medicine, the patient’s vital signs were as follows: consciousness level of 13 points (E3V4M6) on the Glasgow Coma Scale, blood pressure of 142/79 mmHg, pulse rate of 59 beats/min, respiratory rate of 24 breaths/min, SpO2 of 97% (room air), and body temperature of 37.2 °C in the axilla.", + "Physical examination revealed no rigidity of the neck.", + "The abdomen was flat and soft with no tenderness.", + "No edema of the lower legs was observed.", + "Tenderness, swelling, and heat were present from the right upper arm to the dorsum of the right hand.", + "The findings in the right upper extremity remained unchanged from those on the previous day.", + "Blood tests showed that the CK level was elevated again to 2267 U/L.", + "The serum Na level was 114 mE/L.", + "Urinalysis revealed a urine specific gravity of 1.020.", + "Urinalysis revealed a urinary Na level of 195 mEq/L.", + "Urinalysis revealed a urine osmolality of 613 mOsm/L.", + "Despite the hyponatremia, the urine was hypertonic.", + "We determined that the CK re-elevation was due to hyponatremia.", + "Severe symptomatic hyponatremia was corrected with administration of 3% sodium chloride solution.", + "On the 10th day of admission, the serum Na level improved to 120 mEq/L.", + "The level of consciousness improved as the serum Na level improved.", + "The blood cortisol level was low at 4.0 µg/dL.", + "Adrenal insufficiency was suspected.", + "Administration of corticosteroids (dexamethasone 6.6 mg/day, then hydrocortisone 100 mg/day) was initiated on the 10th day of admission.", + "On the 11th day of admission, the 3% sodium chloride solution was discontinued.", + "On the 15th day of admission, the corticosteroids were discontinued.", + "The serum Na level did not decrease.", + "An adrenocorticotrophin hormone (ACTH) loading test was performed on the 16th day of admission.", + "A corticotropin-releasing hormone / growth hormone-releasing factor / thyrotropin-releasing hormone / luteinizing hormone-releasing hormone (CRH/GRF/TRH/LHRH) stimulation test was performed on the 23rd day of admission.", + "The peak blood cortisol levels after the ACTH loading and CRH/GRF/TRH/LHRH stimulation tests were below 18 µg/dL.", + "The peak ACTH level after the CRH/GRF/TRH/LHRH stimulation test was less than two-folds the basal value.", + "A diagnosis of pituitary adrenal insufficiency was made.", + "Contrast-enhanced MRI of the pituitary gland showed the sella turcica was markedly enlarged and filled with cerebrospinal fluid.", + "After discontinuation of corticosteroids, the hyponatremia did not recur.", + "The swelling in the right upper extremity improved.", + "The patient was discharged on the 24th day of admission.", + "He visited the outpatient clinic 9 and 16 days after discharge.", + "There was no hyponatremia relapse.", + "The patient has not experienced hyponatremia in the three years since the Mamushi bite." + ], + "summary": "An 84-year-old man was admitted to our hospital with a Mamushi bite on the right fifth finger. Serum sodium (Na) level remained in the normal range. On the ninth day of admission, he developed hyponatremia, with a serum Na level of 114 mEq/L and serum cortisol level of 4.0 μg/dL (reference value 4.5-21.1 μg/dL). His serum Na level was restored within the normal range after administration of corticosteroids with 3% NaCl solution. Both rapid adrenocorticotrophin and corticotropin-releasing hormone loading tests showed low cortisol response. Based on the results of the hormone loading tests, a diagnosis of pituitary adrenal insufficiency was made. Contrast-enhanced pituitary magnetic resonance imaging (MRI) showed primary empty sella. After discontinuation of corticosteroids, the hyponatremia did not recur, and the patient was discharged on the 24th day of hospitalization. After discharge, the patient visited an outpatient clinic, but hyponatremia recurrence was not observed.", + "summary_subclaims": [ + "An 84-year-old man was admitted to our hospital with a Mamushi bite on the right fifth finger.", + "Serum sodium (Na) level remained in the normal range.", + "On the ninth day of admission, he developed hyponatremia, with a serum Na level of 114 mEq/L.", + "His serum Na level was restored within the normal range after administration of corticosteroids with 3% NaCl solution.", + "Both rapid adrenocorticotrophin and corticotropin-releasing hormone loading tests showed low cortisol response.", + "Based on the results of the hormone loading tests, a diagnosis of pituitary adrenal insufficiency was made.", + "Contrast-enhanced pituitary magnetic resonance imaging (MRI) showed primary empty sella.", + "After discontinuation of corticosteroids, the hyponatremia did not recur.", + "The patient was discharged on the 24th day of hospitalization.", + "After discharge, the patient visited an outpatient clinic." + ] + }, + { + "id": "multiclinsum_test_1880_en.txt", + "fulltext": "A 61-year-old gentleman admitted 3 months ago because of multiple pulmonary nodules which had been found in health examination. HRCT showed that there were two nodules, including one solid pulmonary nodule (SPN) that was located at the right upper lobe and one GGO at the right lower lobe . Other preoperative examinations showed no contraindications. A right upper lobectomy and right lower lobe wedge resection by single-port video-assisted thoracic surgery (VATS) were performed, and about 3 h before the operation, a CT-guided hook wire localization of the GGO was performed in radiology department. According to the CT scan, the hook wire was inserted 3 cm deep into the pulmonary parenchyma and the hook-shaped tip was fixed 1.8 cm away from the GGO . There was no pneumothorax or hemothorax during this procedure.\nGeneral anesthesia was performed and then a 4 cm incision was made at the pivot of the fourth intercostal space and the anterior axillary line. While entering the thorax, the hookwire was found still attached to the right lower lobe and the tail outside the thorax was cut off to avoid bacterial contamination. As we planed before, the first step of the operation was wedge resection of the right lower lobe. After several attempts to search for the GGO by manual palpation, the hookwire was submerged in pulmonary parenchyma and could not be touched. A 1 cm incision at the pivot of the eighth intercostal space and the midaxillary line and a 3 cm incision at the pivot of the eighth intercostal space and the posterior axillary line were added but still helpless. Then the patient was sent to the radiologist department where a CT scan was performed and the hookwire was found in the artery of apical segment of right upper lobe, which was planned to be removed . When the patient was sent back to the theater, the operation continued from right lower lobe wedge resection, then right upper lobectomy. After successfully dissecting pulmonary vein and superior bronchus of the right upper lobe with endoscopic stapler (Ethicon), we ligatured and cut arteries of right upper lobe one by one manually but did not find the hookwire. Afterwards, a second CT scan was performed and the hookwire was found in the artery of apicoposterior segment of left upper lobe . Since this foreign body could not be reached through right thoracic cavity, the vascular surgery department was consulted after the incisions were closed. Following the suggestion of consultation, the patient was prepared to receive interventional therapy under digital substraction angiography (DSA).\nAs shown on the DSA images, the hook wire was still in the artery of apicoposterior segment of left upper lobe . A guide wire was inserted through right femoral vein to the target artery, subsequently, an endoloop was inserted to hitch the hookwire and extract it out . During the process of DSA, there was no bradycardia, tachycardia or arrhythmia.\nThe patient was eventually discharged 15 days after surgery. Low molecular weight heparin was injected in subcutaneous tissue two times a day from the second day after surgery to discharge day. The pathological results indicated that the SPN in right upper lobe was an invasive adenocarcinoma, while the GGO in right lower lobe was a minimally invasive adenocarcinoma, and there was no metastatic lymph node. The patient received follow-up CT scan 3 months after surgery, which showed no obvious abnormality.", + "fulltext_subclaims": [ + "The patient is a 61-year-old gentleman.", + "He was admitted 3 months ago because of multiple pulmonary nodules found in a health examination.", + "HRCT showed two pulmonary nodules.", + "One nodule was a solid pulmonary nodule located at the right upper lobe.", + "One nodule was a ground-glass opacity (GGO) at the right lower lobe.", + "Other preoperative examinations showed no contraindications.", + "A right upper lobectomy and right lower lobe wedge resection by single-port video-assisted thoracic surgery (VATS) were performed.", + "A CT-guided hook wire localization of the GGO was performed 3 h before the operation.", + "The hook wire was inserted 3 cm deep into the pulmonary parenchyma.", + "The hook-shaped tip was fixed 1.8 cm away from the GGO.", + "There was no pneumothorax or hemothorax during the hook wire localization procedure.", + "General anesthesia was performed.", + "A 4 cm incision was made at the pivot of the fourth intercostal space and the anterior axillary line.", + "The hook wire was found still attached to the right lower lobe.", + "The tail of the hook wire outside the thorax was cut off to avoid bacterial contamination.", + "The first step of the operation was wedge resection of the right lower lobe.", + "After several attempts to search for the GGO by manual palpation, the hook wire was submerged in pulmonary parenchyma and could not be touched.", + "A 1 cm incision at the pivot of the eighth intercostal space and the midaxillary line was added.", + "A 3 cm incision at the pivot of the eighth intercostal space and the posterior axillary line was added.", + "The patient was sent to the radiology department where a CT scan was performed.", + "The hook wire was found in the artery of the apical segment of the right upper lobe.", + "The operation continued with right upper lobectomy.", + "After successfully dissecting the pulmonary vein and superior bronchus of the right upper lobe, the arteries were ligated and cut manually.", + "A second CT scan was performed.", + "The hook wire was found in the artery of the apicoposterior segment of the left upper lobe.", + "The vascular surgery department was consulted after the incisions were closed.", + "The patient was prepared to receive interventional therapy under digital subtraction angiography (DSA).", + "DSA images showed the hook wire was still in the artery of the apicoposterior segment of the left upper lobe.", + "A guide wire was inserted through the right femoral vein to the target artery.", + "An endoloop was inserted to hitch the hook wire and extract it.", + "During the process of DSA, there was no bradycardia, tachycardia, or arrhythmia.", + "The patient was discharged 15 days after surgery.", + "Low molecular weight heparin was injected subcutaneously two times a day from the second day after surgery to discharge day.", + "The pathological results indicated that the SPN in the right upper lobe was an invasive adenocarcinoma.", + "The GGO in the right lower lobe was a minimally invasive adenocarcinoma.", + "There was no metastatic lymph node.", + "The patient received a follow-up CT scan 3 months after surgery.", + "The follow-up CT scan showed no obvious abnormality." + ], + "summary": "A 61-year-old male suffered from multiple pulmonary nodules received right upper lobectomy and right lower lobe wedge resection by video-assisted thoracic surgery (VATS) 3 months ago. Since it might be difficult to identify the ground-glass opacity located in the right lower lobe, a CT-guided hook wire was placed before surgery. During the operation, the hook wire unexpectedly slided into left upper lobe pulmonary artery. With the help of vascular surgery department, the hook wire was extracted by interventional therapy under digital substraction angiography (DSA). The patient was eventually recovered and discharged.", + "summary_subclaims": [ + "The patient is a 61-year-old male.", + "The patient suffered from multiple pulmonary nodules.", + "The patient received right upper lobectomy and right lower lobe wedge resection by video-assisted thoracic surgery 3 months ago.", + "A CT-guided hook wire was placed before surgery.", + "The hook wire unexpectedly slided into left upper lobe pulmonary artery.", + "The hook wire was extracted by interventional therapy under digital substraction angiography.", + "The patient was eventually recovered and discharged." + ] + }, + { + "id": "multiclinsum_test_2990_en.txt", + "fulltext": "A 66-year-old female patient with a history of dilated cardiomyopathy, first diagnosed 4 years ago, who had undergone surgical tricuspid valve repair with an incomplete three-dimensional-shaped rigid AR due to severe secondary TR 3 years ago presented with pronounced right heart decompensation including ascites, pitting pretibial oedema, bilateral pleural effusion, chronic kidney disease but without signs of liver dysfunction.\nThe transthoracic echocardiogram performed after 5 days of intensive diuretic therapy showed a severely impaired systolic left ventricular ejection fraction of 30% with dilation of all heart chambers and a resulting moderate secondary mitral regurgitation and severe TR. The basal diameter of the right heart was 50 mm and right heart function was severely impaired . A transoesophageal echocardiogram (TOE) confirmed severe TR as a consequence of severe leaflet tethering but showed no signs of dehiscence of the AR. Right heart catheterization revealed moderate post-capillary pulmonary hypertension filling pressures of the right heart were significantly elevated. Right ventricular stroke work index was 1.0 g/m2/beat and central venous pressure-to-pulmonary capillary wedge pressure-ratio 0.9.\nBased on the severity of right ventricular disease a right ventricular assist device (RVAD) was considered but this option was eventually discarded as it was declined by the patient at least as primary treatment option. Redo tricuspid surgery was—in line with the literature—felt to be associated with a too high perioperative risk because of renal insufficiency and poor clinical condition of the patient., Due to massive tethering with restrictive motion of the anterior leaflet and complete lack of coaptation particularly in the antero-septal area of the valve percutaneous edge-to-edge repair was also regarded as unfavourable. Our Heart Team finally decided to perform a percutaneous valve-in-ring-implantation with the option of RVAD implantation as a bail-out strategy in case of acute rHF following elimination of TR.\nThe procedure was performed in general anaesthesia under angiographic and TOE-guidance. A soft-tip Amplatz extra-stiff wire was placed from the femoral vein in the right pulmonary artery via a 7-Fr balloon-tipped pulmonary artery catheter. SP3 was inserted via a 16-Fr eSheath, with the company label facing towards the patient to allow for flexing of the catheter towards the tricuspid valve. Subsequently, the balloon was retracted under the valve, the valve was advanced to the tricuspid annular plane, the pusher was pulled back a couple of centimetres beyond the designated markers to allow flexible alignment of the valve and the position of the prosthesis was optimized aiming at a 15/85 right atrium to right ventricle position. The balloon was then inflated slowly, while carefully checking for correct positioning without pacing of the heart. The prosthesis could be implanted in an optimal position under an intentional overinflation of the balloon of 2 mL .\nEchocardiographic control, also after complete removal of the wire revealed a massive transvalvular regurgitation, which was found to be caused by complete immobility of the cusp adjacent to the ventricular septum resulting in a large coaptation gap , most likely caused by an asymmetric bulging of the valve stent in the area of the opening of AR . As there was only mild paravalvular leakage (PVL) , the decision was taken to implant a second SP3, which could be implanted uneventfully and lead to complete elimination of TR with only minimal septal PVL . Haemodynamics remained stable throughout the whole course of the procedure. The patient was extubated in the hybrid operating room and transferred to the general ward after one night in the intensive care unit. Her creatinine levels dropped from 1.8 mg/dL prior to the procedure to 1.3 g/dL on the first post-interventional day. After mobilization, the patient was discharged in good general condition to a follow-up treatment in a rehabilitation centre.\nAt follow-up after 2 months, the patient showed slightly improved right and left heart function and an improved general condition without signs for right heart and liver failure, ascites or oedemas .", + "fulltext_subclaims": [ + "The patient is a 66-year-old female.", + "She has a history of dilated cardiomyopathy.", + "The dilated cardiomyopathy was first diagnosed 4 years ago.", + "She had undergone surgical tricuspid valve repair.", + "The surgical tricuspid valve repair was performed with an incomplete three-dimensional-shaped rigid annuloplasty ring.", + "The surgical tricuspid valve repair was performed 3 years ago.", + "The surgical tricuspid valve repair was performed due to severe secondary tricuspid regurgitation.", + "She presented with pronounced right heart decompensation.", + "She had ascites.", + "She had pitting pretibial oedema.", + "She had bilateral pleural effusion.", + "She had chronic kidney disease.", + "There were no signs of liver dysfunction.", + "The transthoracic echocardiogram was performed after 5 days of intensive diuretic therapy.", + "The transthoracic echocardiogram showed a severely impaired systolic left ventricular ejection fraction of 30%.", + "The transthoracic echocardiogram showed dilation of all heart chambers.", + "The transthoracic echocardiogram showed moderate secondary mitral regurgitation.", + "The transthoracic echocardiogram showed severe tricuspid regurgitation.", + "The basal diameter of the right heart was 50 mm.", + "Right heart function was severely impaired.", + "A transoesophageal echocardiogram confirmed severe tricuspid regurgitation.", + "The transoesophageal echocardiogram showed severe leaflet tethering.", + "The transoesophageal echocardiogram showed no signs of dehiscence of the annuloplasty ring.", + "Right heart catheterization revealed moderate post-capillary pulmonary hypertension.", + "Right heart filling pressures were significantly elevated.", + "The right ventricular stroke work index was 1.0 g/m2/beat.", + "The central venous pressure-to-pulmonary capillary wedge pressure ratio was 0.9.", + "A right ventricular assist device was considered.", + "The right ventricular assist device was eventually discarded.", + "The right ventricular assist device was declined by the patient as a primary treatment option.", + "Redo tricuspid surgery was felt to be associated with a too high perioperative risk.", + "The high perioperative risk was due to renal insufficiency.", + "The high perioperative risk was due to poor clinical condition.", + "Percutaneous edge-to-edge repair was regarded as unfavourable.", + "The unfavourable percutaneous edge-to-edge repair was due to massive tethering.", + "The unfavourable percutaneous edge-to-edge repair was due to restrictive motion of the anterior leaflet.", + "The unfavourable percutaneous edge-to-edge repair was due to complete lack of coaptation in the antero-septal area.", + "The Heart Team decided to perform a percutaneous valve-in-ring-implantation.", + "The percutaneous valve-in-ring-implantation was performed in general anaesthesia.", + "The procedure was performed under angiographic guidance.", + "The procedure was performed under transoesophageal echocardiogram guidance.", + "A soft-tip Amplatz extra-stiff wire was placed from the femoral vein in the right pulmonary artery.", + "The wire was placed via a 7-Fr balloon-tipped pulmonary artery catheter.", + "An SP3 was inserted via a 16-Fr eSheath.", + "The company label of the SP3 was facing towards the patient.", + "The balloon was retracted under the valve.", + "The valve was advanced to the tricuspid annular plane.", + "The pusher was pulled back a couple of centimetres beyond the designated markers.", + "The position of the prosthesis was optimized aiming at a 15/85 right atrium to right ventricle position.", + "The balloon was inflated slowly.", + "The balloon was intentionally overinflated by 2 mL.", + "Echocardiographic control revealed a massive transvalvular regurgitation.", + "The transvalvular regurgitation was caused by complete immobility of the cusp adjacent to the ventricular septum.", + "The transvalvular regurgitation was caused by a large coaptation gap.", + "The coaptation gap was most likely caused by an asymmetric bulging of the valve stent.", + "The asymmetric bulging was in the area of the opening of the annuloplasty ring.", + "There was only mild paravalvular leakage.", + "A second SP3 was implanted.", + "The second SP3 was implanted uneventfully.", + "The second SP3 led to complete elimination of tricuspid regurgitation.", + "There was only minimal septal paravalvular leakage after the second implantation.", + "Haemodynamics remained stable throughout the procedure.", + "The patient was extubated in the hybrid operating room.", + "The patient was transferred to the general ward after one night in the intensive care unit.", + "Her creatinine levels dropped from 1.8 mg/dL prior to the procedure to 1.3 mg/dL on the first post-interventional day.", + "The patient was discharged in good general condition.", + "The patient was discharged to a follow-up treatment in a rehabilitation centre.", + "At follow-up after 2 months, the patient showed slightly improved right and left heart function.", + "At follow-up after 2 months, the patient showed an improved general condition.", + "There were no signs of right heart failure at follow-up.", + "There were no signs of liver failure at follow-up.", + "There were no signs of ascites at follow-up.", + "There were no signs of oedemas at follow-up." + ], + "summary": "We report on a 66-year-old patient with severe right heart failure (rHF) with recurrent TR after prior surgical valve repair with a 32-mm-Edwards-MC3 annuloplasty ring (AR). Surgical revision was discarded due to extreme high surgical risk. A right ventricular assist device was discussed but declined by the patient. Percutaneous edge-to-edge repair was not applicable due to massive tethering of the anterior leaflet and complete lack of coadaptation. According to the Heart team decision, percutaneous tricuspid valve-in-ring implantation was performed using a 29-mm Sapien-3 prosthesis (SP3) under moderate balloon overinflation. Despite satisfying positioning, the prosthesis showed massive intravalvular regurgitation due to immobility of the septally oriented cusp, which was most likely caused by eccentric bulging of the prosthesis in the opening region of the AR. Implantation of a second prosthesis leads to a perfectly functional result. Importantly, no major haemodynamic complications ensued.", + "summary_subclaims": [ + "The patient is a 66-year-old with severe right heart failure.", + "The patient had recurrent tricuspid regurgitation after prior surgical valve repair with a 32-mm-Edwards-MC3 annuloplasty ring.", + "Surgical revision was discarded due to extreme high surgical risk.", + "A right ventricular assist device was discussed but declined by the patient.", + "Percutaneous edge-to-edge repair was not applicable due to massive tethering of the anterior leaflet.", + "Percutaneous edge-to-edge repair was not applicable due to complete lack of coadaptation.", + "Percutaneous tricuspid valve-in-ring implantation was performed using a 29-mm Sapien-3 prosthesis.", + "The prosthesis was implanted under moderate balloon overinflation.", + "The prosthesis showed massive intravalvular regurgitation due to immobility of the septally oriented cusp.", + "The immobility was most likely caused by eccentric bulging of the prosthesis in the opening region of the annuloplasty ring.", + "Implantation of a second prosthesis leads to a perfectly functional result.", + "No major haemodynamic complications ensued." + ] + }, + { + "id": "multiclinsum_test_560_en.txt", + "fulltext": "A 83-year-old lady with a BMI of 32 presented to us with a history of fall at home. Radiographs showed left-sided intertrochanteric femur fracture (AO 31A2.1) with marked osteopenia (Singh’s index Grade 3) . She was operated with TFNA Depuy (Dimension 11 x 200 mm and helical blade of 80 mm). An acceptable reduction of the fracture and stable fixation was achieved intraoperatively . The position of the helical blade in the head was in the optimal position (center–center) assessed as per Cleveland index . Tip apex distance (TAD) was found to be 29 mm, assessed in magnification controlled anteroposterior view and lateral view as per the Baumgartner’s method . Neck-shaft angle measured after fixation was 132.1o and the normal side was 131.4o . The patient was mobilized partial weight-bearing with the help of walker from the next day of surgery.\nShe presented to us 6 weeks after the surgery with severe acute onset pain in the left hip, along with inability to bear weight. There was a history of fall at home. Radiographs showed implant failure (cut through of the helical blade) . Laboratory investigations ruled out infection. The patient was planned for implant removal and bipolar hemiarthroplasty.\nPosterior approach was used and the previous incision was incorporated. Intraoperative samples were sent for culture and histopathology. Cemented bipolar hemiarthroplasty with calcar reconstruction using a mesh was performed as the calcar was deficient . The patient was mobilized full weight-bearing from the same day of surgery with the help of walker. All intraoperative samples sent, which were negative. The patient was followed up at 2 weeks, 6 weeks, 3 months, 6 months, 1 year, and till her last follow-up of 14 months. At each follow-up visit, the patient was assessed clinically and radiologically. Clinically, the patient was asymptomatic at her last follow-up visit and was mobilizing full weight-bearing without any support. Radiologically, there was no sign of loosening or radiolucencies.", + "fulltext_subclaims": [ + "The patient is an 83-year-old lady with a BMI of 32.", + "She presented with a history of fall at home.", + "Radiographs showed a left-sided intertrochanteric femur fracture (AO 31A2.1).", + "There was marked osteopenia (Singh’s index Grade 3).", + "She was operated with TFNA Depuy (Dimension 11 x 200 mm and helical blade of 80 mm).", + "An acceptable reduction of the fracture and stable fixation was achieved intraoperatively.", + "The position of the helical blade in the head was in the optimal position (center–center) assessed as per Cleveland index.", + "Tip apex distance (TAD) was found to be 29 mm.", + "TAD was assessed in magnification controlled anteroposterior view and lateral view as per the Baumgartner’s method.", + "Neck-shaft angle measured after fixation was 132.1o.", + "The normal side neck-shaft angle was 131.4o.", + "The patient was mobilized partial weight-bearing with the help of walker from the next day of surgery.", + "She presented 6 weeks after the surgery with severe acute onset pain in the left hip.", + "She had inability to bear weight.", + "There was a history of fall at home.", + "Radiographs showed implant failure (cut through of the helical blade).", + "Laboratory investigations ruled out infection.", + "The patient was planned for implant removal and bipolar hemiarthroplasty.", + "Posterior approach was used and the previous incision was incorporated.", + "Intraoperative samples were sent for culture and histopathology.", + "Cemented bipolar hemiarthroplasty with calcar reconstruction using a mesh was performed.", + "The calcar was deficient.", + "The patient was mobilized full weight-bearing from the same day of surgery with the help of walker.", + "All intraoperative samples sent were negative.", + "The patient was followed up at 2 weeks, 6 weeks, 3 months, 6 months, 1 year, and till her last follow-up of 14 months.", + "At each follow-up visit, the patient was assessed clinically and radiologically.", + "Clinically, the patient was asymptomatic at her last follow-up visit.", + "The patient was mobilizing full weight-bearing without any support.", + "Radiologically, there was no sign of loosening or radiolucencies." + ], + "summary": "An 83-year-old female patient was treated with a TFNA nail for inter-trochanteric femur fracture (AO 31A2.1). An acceptable reduction and stable fixation were achieved. The position of the helical blade in the head was in the optimal position with a tip apex distance (TAD) of 29 mm. The patient presented to us 6 weeks later with implant failure with helical blade cut out after a history of fall. Cemented bipolar hemiarthroplasty with calcar reconstruction using a mesh was done. The patient was clinically asymptomatic and was walking full weight-bearing till her last follow-up at 14 months.", + "summary_subclaims": [ + "The patient was treated with a TFNA nail for inter-trochanteric femur fracture (AO 31A2.1).", + "An acceptable reduction and stable fixation were achieved.", + "The position of the helical blade in the head was in the optimal position.", + "The tip apex distance (TAD) was 29 mm.", + "The patient presented 6 weeks later with implant failure with helical blade cut out.", + "The patient had a history of fall.", + "Cemented bipolar hemiarthroplasty with calcar reconstruction using a mesh was done.", + "The patient was clinically asymptomatic at the last follow-up.", + "The patient was walking full weight-bearing at the last follow-up.", + "The last follow-up was at 14 months." + ] + }, + { + "id": "multiclinsum_test_739_en.txt", + "fulltext": "A 54-year-old woman presented with intermittent left-sided chest discomfort over 2 years. She described this symptom as a “pressure” sensation in the anterior chest which was brought on by physical strain such as heavy lifting. She also reported that this discomfort was more noticeable and severe during air travel over recent years, with discomfort peaking during the middle of the flight and easing with descent. The most recent flight-related.\nEpisode was particularly severe and this is what prompted her presentation. She had no dyspnoea or other symptoms of note.\nOn further discussion, she revealed that she had been followed-up in the respiratory outpatient clinic of a different hospital some 10 years previous for an incidentally noted large bulla in her left lung. Following 5 years of annual surveillance imaging, she was discharged as she had remained asymptomatic and the bulla had not increased in size.\nShe was a smoker in her youth, accumulating a 5-pack-year history and quitting before the age of 30. She had no medical history and no exposures of note. There was no family history of pneumothorax, lung or connective tissue disease.\nExamination revealed no hypoxia, digital clubbing or peripheral stigmata of respiratory disease. Auscultation revealed equal bilateral air entry with normal breath sounds.\nA chest X-ray was done which revealed a large bulla in the left upper zone. This was followed by a high-resolution CT of the thorax which demonstrated a large avascular, air-filled region occupying the upper half of the left hemithorax, consistent with a large bulla. A diagnosis of iGBE was made. There was compression of surrounding lung. There was no evidence of emphysematous lung disease (paraseptal or centrilobular) in the remainder of both lungs.\nPulmonary function tests showed normal spirometry and diffusion capacity. Lung volumes were not performed. A connective tissue disease blood panel and α1 anti-trypsin level were unremarkable.\nShe was referred for surgical assessment and a VATS Bullectomy was performed . This was a two-port procedure. The bulla was intentionally ruptured, creating space in the hemithorax. Adhesions within the surrounding structures were divided. The bulla was resected with a small rim of normal tissue. A 24 french drain was sited and the patient was then extubated. She tolerated this procedure well and without complication. At her recent 6-month follow-up, she was doing well and her previously described symptoms had completely resolved. Repeat spirometry is significantly improved and lung volumes are within normal limits .", + "fulltext_subclaims": [ + "The patient is a 54-year-old woman.", + "She had intermittent left-sided chest discomfort over 2 years.", + "She described the symptom as a 'pressure' sensation in the anterior chest.", + "The discomfort was brought on by physical strain such as heavy lifting.", + "The discomfort was more noticeable and severe during air travel over recent years.", + "The discomfort peaked during the middle of the flight.", + "The discomfort eased with descent.", + "The most recent flight-related episode was particularly severe.", + "This is what prompted her presentation.", + "She had no dyspnoea.", + "She had no other symptoms of note.", + "She had been followed-up in the respiratory outpatient clinic of a different hospital 10 years previous.", + "This was for an incidentally noted large bulla in her left lung.", + "She had 5 years of annual surveillance imaging.", + "She was discharged after 5 years of annual surveillance imaging.", + "She had remained asymptomatic during the 5 years of annual surveillance imaging.", + "The bulla had not increased in size during the 5 years of annual surveillance imaging.", + "She was a smoker in her youth.", + "She had a 5-pack-year history.", + "She quit smoking before the age of 30.", + "She had no medical history.", + "She had no exposures of note.", + "There was no family history of pneumothorax.", + "There was no family history of lung disease.", + "There was no family history of connective tissue disease.", + "Examination revealed no hypoxia.", + "Examination revealed no digital clubbing.", + "Examination revealed no peripheral stigmata of respiratory disease.", + "Auscultation revealed equal bilateral air entry.", + "A chest X-ray revealed a large bulla in the left upper zone.", + "A high-resolution CT of the thorax demonstrated a large avascular, air-filled region occupying the upper half of the left hemithorax.", + "The CT findings were consistent with a large bulla.", + "A diagnosis of iGBE was made.", + "There was compression of surrounding lung.", + "There was no evidence of emphysematous lung disease in the remainder of both lungs.", + "Pulmonary function tests showed normal spirometry.", + "Pulmonary function tests showed normal diffusion capacity.", + "Lung volumes were not performed.", + "A connective tissue disease blood panel was unremarkable.", + "An α1 anti-trypsin level was unremarkable.", + "She was referred for surgical assessment.", + "A VATS Bullectomy was performed.", + "The procedure was a two-port procedure.", + "The bulla was intentionally ruptured.", + "Adhesions within the surrounding structures were divided.", + "The bulla was resected with a small rim of normal tissue.", + "A 24 french drain was sited.", + "The patient was extubated.", + "She tolerated the procedure well.", + "She had no complication.", + "At her recent 6-month follow-up, she was doing well.", + "Her previously described symptoms had completely resolved.", + "Repeat spirometry is significantly improved.", + "Lung volumes are within normal limits." + ], + "summary": "A 54-year-old woman presented to the respiratory outpatient clinic with gradually worsening left sided chest discomfort, which was most marked during a recent flight. She had no significant dyspnoea or other symptoms. She had a remote 5-pack-year smoking history. Chest X-Ray revealed a large hyperlucent area in the left upper lobe. CT Thorax found this to be an isolated bulla occupying more than one-third of the hemithorax. The remaining lung parenchyma was normal. A diagnosis of Idiopathic Giant Bullous Emphysema was made. The patient was referred for VATS (Video-assisted thoracoscopic surgery) bullectomy which was carried out without complication. Her symptoms resolved completely following the operation.", + "summary_subclaims": [ + "A 54-year-old woman presented to the respiratory outpatient clinic.", + "She had gradually worsening left sided chest discomfort.", + "The chest discomfort was most marked during a recent flight.", + "She had no significant dyspnoea.", + "She had a remote 5-pack-year smoking history.", + "Chest X-Ray revealed a large hyperlucent area in the left upper lobe.", + "CT Thorax found this to be an isolated bulla occupying more than one-third of the hemithorax.", + "The remaining lung parenchyma was normal.", + "A diagnosis of Idiopathic Giant Bullous Emphysema was made.", + "The patient was referred for VATS bullectomy.", + "The VATS bullectomy was carried out without complication.", + "Her symptoms resolved completely following the operation." + ] + }, + { + "id": "multiclinsum_test_180_en.txt", + "fulltext": "A 55-year-old man with no significant past medical history presented to the ED for evaluation of right eye conjunctival injection, irritation, and painless visual field loss over the lower half of his vision in the ipsilateral eye. The patient stated that nine days prior a foreign body may have penetrated his right eye, for which he did not seek medical attention at that time. In the affected eye, he subsequently developed erythema, edema, purulent crusty drainage, itching, and a foreign body sensation. On day eight after the initial eye injury, the patient developed sudden-onset painless vision loss over the lower aspect of the right visual field. The following day, he presented to the ED with these symptoms. The patient denied blurry vision, floaters, or any past ophthalmological history.\nOn physical exam of the right eye, the patient had minimal conjunctival injection. Visual field deficits were appreciated over the lower temporal and lower nasal sides of the right eye. All remaining visual fields and visual acuity were intact. Fluorescein staining and Wood’s lamp exam did not reveal any foreign body, with negative Seidel sign. Point-of-care ocular ultrasonography showed retinal detachment of the right eye. The case was discussed with an ophthalmologist, who came to the ED, evaluated the patient, and arranged for next day follow-up and outpatient retinal repair.", + "fulltext_subclaims": [ + "The patient is a 55-year-old man.", + "The patient had no significant past medical history.", + "The patient presented to the ED for evaluation of right eye conjunctival injection.", + "The patient had painless visual field loss over the lower half of his vision in the right eye.", + "Nine days prior, a foreign body may have penetrated the patient's right eye.", + "The patient did not seek medical attention at the time of the foreign body injury.", + "The patient developed erythema in the affected eye.", + "The patient developed purulent crusty drainage in the affected eye.", + "The patient developed a foreign body sensation in the affected eye.", + "On day eight after the initial eye injury, the patient developed sudden-onset painless vision loss over the lower aspect of the right visual field.", + "The patient presented to the ED the following day after the vision loss.", + "The patient denied blurry vision.", + "The patient denied floaters.", + "The patient denied any past ophthalmological history.", + "On physical exam, the patient had minimal conjunctival injection in the right eye.", + "Visual field deficits were appreciated over the lower temporal and lower nasal sides of the right eye.", + "Fluorescein staining did not reveal any foreign body.", + "Wood’s lamp exam did not reveal any foreign body.", + "Point-of-care ocular ultrasonography showed retinal detachment of the right eye.", + "An ophthalmologist evaluated the patient.", + "The ophthalmologist arranged for next day follow-up.", + "The ophthalmologist arranged for outpatient retinal repair." + ], + "summary": "We describe a 55-year-old male presenting to the emergency department (ED) with unilateral, painless visual field deficit with ipsilateral conjunctivitis induced by a presumed foreign body. The patient described a foreign body sensation nine days prior to developing visual changes. In the ED, the patient was diagnosed with a retinal detachment using point-of-care ultrasonography, and emergent ophthalmologic consultation was obtained.", + "summary_subclaims": [ + "The patient is a 55-year-old male.", + "The patient presented to the emergency department with unilateral, painless visual field deficit.", + "The patient had ipsilateral conjunctivitis induced by a presumed foreign body.", + "The patient described a foreign body sensation nine days prior to developing visual changes.", + "The patient was diagnosed with a retinal detachment using point-of-care ultrasonography.", + "Emergent ophthalmologic consultation was obtained." + ] + }, + { + "id": "multiclinsum_test_967_en.txt", + "fulltext": "A 13-year-old female with previously diagnosed T1D, was admitted to the emergency department presenting incoercible vomiting since the previous day, oligo-anuria and deteriorating state of consciousness. The girl had been diagnosed with autoimmune T1D at the age of 9 years (no DKA at onset). Past medical history was unremarkable. Sensor-augmented pump therapy (SAP) was started, and her follow-up was characterized by suboptimal glucose control (latest HbA1c of 60 mmol/mol).\nOn admission, the child presented in hypovolemic shock with an altered state of consciousness (GCS 12) without evident focal neurological signs, pale skin and Kussmaul respiration. Her physical examination was unremarkable except for decreased and tachycardic distal pulses, cool extremities, prolonged capillary refill (> 2 sec). Venous blood gas analysis and lab tests showed severe DKA, hyperosmolar state, and acute kidney injury (AKI) with hyperkaliemia, confirmed at ECG analysis . Two boluses of normal saline were infused (10 mL/kg each) with improvement in vital parameters. No bicarbonates were administered. The patient was then transferred to the intensive care unit (ICU) and DKA correction was carried out according to the most recent guidelines with progressive resolution of the DKA, hyperosmolar state, AKI, and electrolyte imbalances. A brain CT excluded cerebral edema. On arrival the patient’s pump controller showed that the patch pump had expired. Of note, the patch pump is designed to shut-off automatically after 72h, after sounding alarms to alert the user to change the pump when approaching expiration. The child later admitted to not having changed the expiring patch pump while at her grandparents’ due to her not having any replacements and in fear of her mother’s anger. When DKA resolved, the patient was transferred to the pediatrics department and her SAP was reinstated. Since admission she referred modest abdominal pain that had persisted throughout DKA treatment. No other signs or symptoms were present apart from slightly loose stools which were collected for microbiological testing. An abdominal ultrasound only showed slight thickening of the ileal wall. On day 2 since DKA resolution, Clostridium difficile toxin tested positive and oral vancomycin treatment was started. On day 4, follow-up US only confirmed signs of enterocolitis. On day 5, abdominal symptoms and signs worsened alongside onset of fever and elevation of inflammatory indices (CRP 145 mg/L, normal range <6 mg/L). Thus, abdominal ultrasound was repeated, documenting an uneven multi-chambered area of 8x3 cm with a small aerial component . Treatment with metronidazole was started and the patient was transferred to the city’s center of reference for pediatric surgery. Abdominal magnetic resonance imaging revealed a large, fluid-filled pelvic abscess with air bubbles suspect for bowel perforation, with parietal contrast enhancement . Therefore, an urgent ileal resection (44 cm) was performed, and NOMI was diagnosed intraoperatively. Antibiotic treatment with piperacillin-tazobactam and gentamicin was administered for 7 days, and treatment with metronidazole and vancomycin was continued for 10 days. The patient was discharged after 3 weeks of transition from parenteral to enteral feeding. Pre-discharge abdominal ultrasound resulted normal without signs of inflammation or free abdominal fluid.", + "fulltext_subclaims": [ + "The patient is a 13-year-old female.", + "She had previously been diagnosed with type 1 diabetes.", + "She was admitted to the emergency department.", + "She had incoercible vomiting since the previous day.", + "She had oligo-anuria.", + "She had a deteriorating state of consciousness.", + "She had been diagnosed with autoimmune type 1 diabetes at the age of 9 years.", + "There was no DKA at the onset of her type 1 diabetes.", + "She was on sensor-augmented pump therapy.", + "Her latest HbA1c was 60 mmol/mol.", + "On admission, she presented in hypovolemic shock.", + "Her Glasgow Coma Scale score was 12.", + "Venous blood gas analysis showed severe DKA.", + "She had an acute kidney injury with hyperkalemia.", + "Two boluses of normal saline were infused.", + "No bicarbonates were administered.", + "The patient was transferred to the intensive care unit.", + "A brain CT excluded cerebral edema.", + "The patch pump had expired.", + "The patch pump is designed to shut-off automatically after 72 hours.", + "The child admitted to not having changed the expiring patch pump.", + "The patient was transferred to the pediatrics department after DKA resolution.", + "She had modest abdominal pain that persisted throughout DKA treatment.", + "An abdominal ultrasound showed slight thickening of the ileal wall.", + "Clostridium difficile toxin tested positive on day 2.", + "Oral vancomycin treatment was started.", + "On day 5, abdominal symptoms and signs worsened.", + "C-reactive protein was 145 mg/L.", + "An abdominal ultrasound documented an uneven multi-chambered area of 8x3 cm.", + "Abdominal magnetic resonance imaging revealed a large, fluid-filled pelvic abscess.", + "An urgent ileal resection was performed.", + "NOMI was diagnosed intraoperatively.", + "Antibiotic treatment with piperacillin-tazobactam and gentamicin was administered for 7 days.", + "The patient was discharged after 3 weeks of transition from parenteral to enteral feeding.", + "Pre-discharge abdominal ultrasound resulted normal." + ], + "summary": "A 13-year-old female with previously diagnosed T1D, was admitted at our emergency department with hypovolemic shock, DKA, hyperosmolar state and acute kidney injury (AKI). Mildly progressive abdominal pain persisted after DKA correction and after repeated ultrasound evaluations ultimately suspect for intestinal perforation, an intraoperative diagnosis of NOMI was made.", + "summary_subclaims": [ + "The patient is a 13-year-old female.", + "The patient has previously diagnosed type 1 diabetes.", + "The patient was admitted with hypovolemic shock.", + "The patient was admitted with diabetic ketoacidosis.", + "The patient was admitted with a hyperosmolar state.", + "The patient had acute kidney injury.", + "Mildly progressive abdominal pain persisted after diabetic ketoacidosis correction.", + "Repeated ultrasound evaluations were performed.", + "An intraoperative diagnosis of nonocclusive mesenteric ischemia was made." + ] + }, + { + "id": "multiclinsum_test_2078_en.txt", + "fulltext": "A 38-year-old male, not known to have any medical illnesses, presented to our ophthalmology clinic complaining of blurred vision in the left eye for five days. On past medical history, no history of taking any systemic medications or prior eye trauma or surgery were evident. On detailed ophthalmologic examination, best-corrected visual acuity (BCVA) in the right eye was 20/20 and in the left eye was 20/80, intraocular pressure was 15 mmHg in both eyes, normal color vision was evident in both eyes, there was no afferent pupillary defect (APD), the confrontation visual field was fully normal in both eyes, and there was full normal extra-ocular muscle function in both eyes. Anterior segment examination of both eyes revealed normal cornea, deep and quiet anterior chamber; the iris was round and regular, and the lens was clear. Dilated fundus examination of the right eye showed flat retina, normal macular reflex, healthy optic nerve head and the left eye showed blunt foveal reflex with neurosensory retinal detachment at the macula and subretinal fluid, leading to the impression of central serous chorioretinopathy (CSCR).\nUpon acquiring further history from the patient, he denied having features of type A personality or using steroids. However, he reported that blurred vision was preceded by using a special type of honey that he used to improve sexual function. On search back about that indigested honey, we found a recent announcement by the Saudi food and drug authority to stop using it because it was adulterated by tadalafil.\nOptical coherence tomography (OCT) of the left eye on presentation confirmed the diagnosis of CSCR . Four weeks after stopping taking the adulterated honey, BCVA in the left eye improved to 20/20 with a flat retina and no subretinal fluid. OCT was repeated, which confirmed the complete resolution of CSCR .", + "fulltext_subclaims": [ + "The patient is a 38-year-old male.", + "The patient is not known to have any medical illnesses.", + "The patient presented with blurred vision in the left eye for five days.", + "The patient had no history of taking any systemic medications.", + "The patient had no prior eye trauma or surgery.", + "Best-corrected visual acuity in the right eye was 20/20.", + "Best-corrected visual acuity in the left eye was 20/80.", + "Intraocular pressure was 15 mmHg in both eyes.", + "There was no afferent pupillary defect.", + "The confrontation visual field was fully normal in both eyes.", + "Anterior segment examination of both eyes revealed normal cornea.", + "The lens was clear.", + "Dilated fundus examination of the left eye showed blunt foveal reflex.", + "Dilated fundus examination of the left eye showed neurosensory retinal detachment at the macula.", + "Dilated fundus examination of the left eye showed subretinal fluid.", + "The impression was central serous chorioretinopathy.", + "The patient denied having features of type A personality.", + "The patient denied using steroids.", + "The patient reported using a special type of honey to improve sexual function.", + "The Saudi food and drug authority announced to stop using the honey because it was adulterated by tadalafil.", + "Optical coherence tomography of the left eye confirmed the diagnosis of CSCR.", + "Four weeks after stopping the honey, best-corrected visual acuity in the left eye improved to 20/20.", + "Four weeks after stopping the honey, the retina was flat with no subretinal fluid.", + "OCT repeated after four weeks confirmed complete resolution of CSCR." + ], + "summary": "A 38-year-old male, not known to have any medical illnesses, came to our ophthalmology clinic complaining of sudden onset of blurred central vision in the left eye for five days after taking an adulterated honey which was claimed to improve sexual performance. On taking a history, the patient denied taking any medications or past eye trauma or surgery. On detailed ophthalmologic examination, the best-corrected visual acuity (BCVA) was 20/20 in the right eye and 20/80 in the left eye. Dilated fundus examination of the right eye showed a flat retina, normal macular reflex, healthy optic nerve head and the left eye showed blunt foveal reflex with neurosensory retinal detachment at the macula and subretinal fluid. Optical coherence tomography (OCT) of the left eye showed marked macular thickening, leading to the impression of central serous chorioretinopathy (CSCR). Four weeks after stopping the adulterated honey, BCVA improved to 20/20 in the left eye, with complete resolution of subretinal fluids.", + "summary_subclaims": [ + "The patient is a 38-year-old male.", + "The patient is not known to have any medical illnesses.", + "The patient complained of sudden onset of blurred central vision in the left eye.", + "The symptoms began five days after taking an adulterated honey.", + "The honey was claimed to improve sexual performance.", + "The patient denied taking any medications.", + "The patient denied past eye trauma or surgery.", + "Best-corrected visual acuity was 20/20 in the right eye.", + "Best-corrected visual acuity was 20/80 in the left eye.", + "Dilated fundus examination showed blunt foveal reflex in the left eye.", + "Dilated fundus examination showed neurosensory retinal detachment at the macula in the left eye.", + "Optical coherence tomography showed marked macular thickening.", + "The impression was central serous chorioretinopathy.", + "Four weeks after stopping the adulterated honey, BCVA improved to 20/20 in the left eye.", + "Subretinal fluids completely resolved." + ] + }, + { + "id": "multiclinsum_test_3207_en.txt", + "fulltext": "Computed tomography (CT) was performed at a peripheral hospital in a 24-year-old female who had complained of persisting chest and back pain and been treated with analgesics for nearly 2 weeks after an event of acute thoracic pain. She was finally diagnosed with AAD that had led to compromise of the left coronary ostium. Echocardiography demonstrated a poor left ventricular (LV) ejection fraction that was in keeping with the finding of severely compromised coronary perfusion. She was transferred to our hospital for surgery, and a staged approach anticipating need for postoperative mechanical circulatory support was agreed upon.\n\nIntraoperative inspection of the dissected aorta and the LV myocardium yielded findings perfectly compatible with a process that had been ongoing since the patient had experienced the initial event of thoracic pain. After transection and direct true lumen cannulation of the ascending aorta, the left coronary ostium was found to have collapsed without, however, being irreversibly occluded. Therefore, antegrade cardioplegia was administered via the coronary ostia.\n\nSubsequently, supracoronary replacement of the ascending aorta was implemented in deep hypothermic circulatory arrest. When it was found that repair of the left coronary ostium had failed, the left internal thoracic artery was grafted to the patient’s extremely narrow left anterior descending artery. Grafting of the circumflex artery turned out to be unfeasible due to the extremely narrow caliber of the circumflex system. When weaning from cardiopulmonary bypass (CPB) turned out to be impossible, the patient was put on ECLS using a sidegraft (6 mm Dacron prosthesis) sewn to the aortic prosthesis for central cannulation (Nova Port Single Lumen Cannula, Novalung GmbH). The venous cannula (BioMedicus Multi-Stage Femoral Venous Cannula, Medtronic Inc.) was placed in the right femoral vein.\n\nThe ECLS system provided adequate circulatory support and the patient remained hemodynamically stable. Upon discontinuation of sedatives, her neurologic status was found normal. Considering that coronary malperfusion had been ongoing for some time preceding the surgical repair, and given the devastating LV damage seen intraoperatively and evidenced by CK and CK-MB levels of 8816 and 884 U/L and a troponin level of 488 899 pg/ml, respectively, sufficient recovery of the LV myocardium in the short run appeared unlikely. To prevent complications associated with prolonged ECLS, left ventricular assist device (LVAD) implantation as a bridge to recovery/transplantation was scheduled for the second day after the aortic procedure.\n\nAfter re-sternotomy, the arterial cannula was moved from the aorta to the femoral artery and the patient was switched back from ECLS to CPB. After implantation of the pump (HVAD, HeartWare Inc., Framingham, MA, USA), the aortic prosthesis was side-clamped, the sidegraft attached to the aorta was removed, and the LVAD outflow graft was joined to the aortic prosthesis. When chest closure turned out to be impossible due to massive edematous swelling of the heart, the patient was transferred back to the intensive care unit (ICU) with the sternotomy wound temporarily covered.\n\nAfter regredience of her massive cardiac edema and chest closure 2 days later, the patient took an unremarkable further course. She was transferred to the ward after 16 days in the ICU and discharged to a rehabilitation facility after a total hospital stay of 27 days.", + "fulltext_subclaims": [ + "Computed tomography (CT) was performed at a peripheral hospital.", + "The patient was a 24-year-old female.", + "She had complained of persisting chest and back pain.", + "She had been treated with analgesics for nearly 2 weeks after an event of acute thoracic pain.", + "She was finally diagnosed with AAD.", + "AAD had led to compromise of the left coronary ostium.", + "Echocardiography demonstrated a poor left ventricular (LV) ejection fraction.", + "The poor LV ejection fraction was in keeping with the finding of severely compromised coronary perfusion.", + "She was transferred to our hospital for surgery.", + "A staged approach anticipating need for postoperative mechanical circulatory support was agreed upon.", + "Intraoperative inspection of the dissected aorta and the LV myocardium yielded findings perfectly compatible with a process that had been ongoing since the patient had experienced the initial event of thoracic pain.", + "After transection and direct true lumen cannulation of the ascending aorta, the left coronary ostium was found to have collapsed.", + "The left coronary ostium was not irreversibly occluded.", + "Antegrade cardioplegia was administered via the coronary ostia.", + "Supracoronary replacement of the ascending aorta was implemented in deep hypothermic circulatory arrest.", + "When it was found that repair of the left coronary ostium had failed, the left internal thoracic artery was grafted to the patient’s extremely narrow left anterior descending artery.", + "Grafting of the circumflex artery turned out to be unfeasible due to the extremely narrow caliber of the circumflex system.", + "When weaning from cardiopulmonary bypass (CPB) turned out to be impossible, the patient was put on ECLS.", + "The ECLS system provided adequate circulatory support.", + "The patient remained hemodynamically stable.", + "Upon discontinuation of sedatives, her neurologic status was found normal.", + "Sufficient recovery of the LV myocardium in the short run appeared unlikely.", + "To prevent complications associated with prolonged ECLS, left ventricular assist device (LVAD) implantation as a bridge to recovery/transplantation was scheduled for the second day after the aortic procedure.", + "After re-sternotomy, the arterial cannula was moved from the aorta to the femoral artery.", + "The patient was switched back from ECLS to CPB.", + "After implantation of the pump (HVAD, HeartWare Inc.), the aortic prosthesis was side-clamped.", + "The sidegraft attached to the aorta was removed.", + "The LVAD outflow graft was joined to the aortic prosthesis.", + "When chest closure turned out to be impossible due to massive edematous swelling of the heart, the patient was transferred back to the ICU.", + "The sternotomy wound was temporarily covered.", + "After regredience of her massive cardiac edema and chest closure 2 days later, the patient took an unremarkable further course.", + "She was transferred to the ward after 16 days in the ICU.", + "She was discharged to a rehabilitation facility after a total hospital stay of 27 days." + ], + "summary": "A staged approach was applied in a 24-year-old female who suffered extensive infarction due to aortic dissection with left main stem involvement. After replacement of the ascending aorta and grafting of the left internal thoracic artery to the left anterior descending artery following a failed attempt at reconstruction of the left coronary ostium, she failed to wean from cardiopulmonary bypass (CPB) and underwent implantation of an extracorporeal life support (ECLS) system as a bridge to decision. Subsequent implantation of a left ventricular assist device (LVAD) as a bridge to recovery/transplantation was followed by an uneventful further course.", + "summary_subclaims": [ + "A staged approach was applied in a 24-year-old female.", + "She suffered extensive infarction due to aortic dissection with left main stem involvement.", + "Replacement of the ascending aorta and grafting of the left internal thoracic artery to the left anterior descending artery were performed.", + "There was a failed attempt at reconstruction of the left coronary ostium.", + "She failed to wean from cardiopulmonary bypass.", + "She underwent implantation of an extracorporeal life support system as a bridge to decision.", + "Subsequent implantation of a left ventricular assist device as a bridge to recovery/transplantation was performed.", + "The further course was uneventful." + ] + }, + { + "id": "multiclinsum_test_2827_en.txt", + "fulltext": "A 53-year-old caucasian G1P1 otherwise healthy female patient was known for a long history of diffuse right and left colonic diverticular disease, with repeated episodes of abdominal pain due to recurrent diverticulitis.\nShe presented to the emergency department at our institution with severe left-lower-quadrant abdominal pain, cramping and anorexia. Physical examination revealed a soft abdomen, with localized left lower quadrant sharp tenderness, guarding and moderate rebound on examination. Abdominal Computed Tomography (CT) scan showed bowel wall thickening and contrast-enhancement along a 45 mm portion of the medium-to-distal sigmoid colon. A marked increase in soft tissue density was also observed within the pericolonic fat, with evidence of a 23 mm paramedian fluid collection in the pre-sacral area. The patient was admitted to the surgical ward and antibiotic coverage was started together with analgesics. Symptoms resolved quickly, she was discharged home a week later with a diagnosis of self-limited diverticular microperforation, and an outpatient follow-up was scheduled for elective surgical planning.\nFour months later, she underwent a laparoscopic sigmoidectomy with a double-stapled colo-rectal transanal anastomosis. Surgery was successful, but on post-operative day 2, the patient developed signs of peritonitis, with pain, fever, and elevated markers of inflammation. After close clinical observation, and careful re-evaluation of the case, on post-operative day-6 a second exploratory laparoscopy was performed. The procedure ruled out an anastomotic leak, as well as no abnormalities were observed at any level within the abdominal cavity. Patient improved post-operatively and was discharged home a week later.\nNine days after hospital discharge, she presented to the outpatient clinic for a scheduled follow up. A control abdominal plain X-ray was obtained, confirming the stability of her condition. However, looking at the X-ray, the staff surgeon noted a filiform metallic object projected around the midline at the upper abdominal quadrant level (T11-T12). Considering patient’s history, a retained surgical item was strongly suspected, with the wire-like image being potentially consistent with the radiopaque marker of a surgical sponge. In order to clearly establish the nature of this foreign body, at first the surgical dressing was removed, but no superficial radio-opaque material was present. The patient’s medical record was then carefully reviewed. According to her chart, no epidural were ever placed at our institution. Preoperative available x-rays were also analyzed. Focusing on the area where the metallic image was expected, we surprisingly discovered it was visible in every exam including the interested region . At further questioning, the patient recalled an epidural catheter being placed twelve years before, at an outside hospital, during the last trimester of pregnancy. Apparently, at the time, the device was placed to provide analgesia for a painful-rib-syndrome . Particularly, she was experiencing excruciating pain in the upper abdomen-lower chest region, both anteriorly and posteriorly. As the patient’s pain was unresponsive to oral analgesics, the epidural catheter was placed (hence the low-thoracic location), and several cycles of analgesia were provided for about a month prior to labor through an elastomeric pump. The patient described the intervention as beneficial. Interestingly, she also recalled the catheter to be subcutaneously tunneled. After delivery, the pain immediately disappeared, thereby suggesting an association with pregnancy-related changes of the musculoskeletal structure. The epidural was removed in the immediate postpartum.\nAfter discussion of the case between the anesthesia and surgical teams, including neurosurgical consultation, and considering the will of the patient, the patient was scheduled for urgent surgical removal of the fragment.\nIn the operating room, inspecting the skin of the right paravertebral region, a small scar could be observed, with a fibrotic reaction attributable to a foreign body lying just underneath. A looped radio-opaque object with its tip at the T12 level was then seen on intraoperative fluoroscopy. Examining lateral projections, showing most of the catheter to be superficially located, the attending neurosurgeon excluded the need for laminectomy. Under sterile conditions and with the patient in the prone position, local anesthesia was administered and incision of the skin and fascia was performed at the level of the scar. The proximal end of the catheter fragment was isolated about 1 cm below the incision and then carefully removed by slow constant traction.\nA 15 cm fragment of a Flextip Plus 19G wire-reinforced epidural catheter (Arrow-Teleflex, Limerick, PA) was retrieved, with a large uncoiled portion close to its proximal end . The operator verified the black terminal marker indicating tip integrity was present. Surgery was performed without any complication. A fluoroscopic control showed the absence of any metallic residual foreign body, and direct visualization during dissection of the skin confirmed that no portion of the uncoiled portion was left behind.", + "fulltext_subclaims": [ + "The patient was a 53-year-old caucasian G1P1 otherwise healthy female.", + "She had a long history of diffuse right and left colonic diverticular disease.", + "She had repeated episodes of abdominal pain due to recurrent diverticulitis.", + "She presented with severe left-lower-quadrant abdominal pain.", + "Physical examination revealed localized left lower quadrant sharp tenderness.", + "Abdominal CT scan showed bowel wall thickening along a 45 mm portion of the medium-to-distal sigmoid colon.", + "A 23 mm paramedian fluid collection was observed in the pre-sacral area.", + "The patient was admitted to the surgical ward.", + "Antibiotic coverage was started.", + "She was discharged home a week later with a diagnosis of self-limited diverticular microperforation.", + "Four months later, she underwent a laparoscopic sigmoidectomy.", + "She had a double-stapled colo-rectal transanal anastomosis.", + "On post-operative day 2, she developed signs of peritonitis.", + "A second exploratory laparoscopy was performed on post-operative day-6.", + "The procedure ruled out an anastomotic leak.", + "No abnormalities were observed at any level within the abdominal cavity.", + "A control abdominal plain X-ray was obtained nine days after hospital discharge.", + "A filiform metallic object was noted around the midline at the upper abdominal quadrant level (T11-T12).", + "A retained surgical item was strongly suspected.", + "The wire-like image was potentially consistent with the radiopaque marker of a surgical sponge.", + "No epidural was ever placed at our institution.", + "Preoperative available x-rays showed the metallic image in every exam including the interested region.", + "The patient recalled an epidural catheter being placed twelve years before at an outside hospital.", + "The epidural catheter was placed during the last trimester of pregnancy.", + "The epidural catheter was placed to provide analgesia for a painful-rib-syndrome.", + "The epidural catheter was subcutaneously tunneled.", + "The epidural catheter was removed in the immediate postpartum.", + "The patient was scheduled for urgent surgical removal of the fragment.", + "A small scar was observed in the right paravertebral region.", + "A looped radio-opaque object with its tip at the T12 level was seen on intraoperative fluoroscopy.", + "The attending neurosurgeon excluded the need for laminectomy.", + "Local anesthesia was administered.", + "Incision of the skin and fascia was performed at the level of the scar.", + "A 15 cm fragment of a Flextip Plus 19G wire-reinforced epidural catheter was retrieved.", + "The black terminal marker indicating tip integrity was present.", + "A fluoroscopic control showed the absence of any metallic residual foreign body.", + "Direct visualization during dissection of the skin confirmed that no portion of the uncoiled portion was left behind." + ], + "summary": "A 53-year-old caucasian female with a history of diverticulitis requiring multiple hospitalizations underwent laparoscopic sigmoidectomy. The early postoperative period was complicated by peritonitis, demanding an urgent \"second-look\" exploratory laparoscopy. Nine days post-operatively, a filiform metallic object in the upper-quadrant was noted on x-ray. No epidural had been placed for either one of her recent surgeries. Given the patient's history, the object was initially thought to be a retained surgical sponge. Previous studies, however, showed that the same image was already present preoperatively. Upon further questioning, the patient reported an epidural being placed twelve years before, at the time of her pregnancy. No mention of breakage had been made to her at that time, nor a retained foreign body was ever reported afterwards, despite her many imaging exams. She also never experienced any symptoms. A 15 cm fragment of a wire-reinforced catheter was surgically retrieved under local anesthesia and fluoroscopic guidance.", + "summary_subclaims": [ + "The patient is a 53-year-old caucasian female.", + "The patient has a history of diverticulitis requiring multiple hospitalizations.", + "The patient underwent laparoscopic sigmoidectomy.", + "The early postoperative period was complicated by peritonitis.", + "An urgent 'second-look' exploratory laparoscopy was performed.", + "Nine days post-operatively, a filiform metallic object in the upper-quadrant was noted on x-ray.", + "No epidural had been placed for either one of her recent surgeries.", + "The object was initially thought to be a retained surgical sponge.", + "Previous studies showed that the same image was already present preoperatively.", + "The patient reported an epidural being placed twelve years before, at the time of her pregnancy.", + "No mention of breakage had been made to her at that time.", + "A 15 cm fragment of a wire-reinforced catheter was surgically retrieved under local anesthesia and fluoroscopic guidance." + ] + }, + { + "id": "multiclinsum_test_124_en.txt", + "fulltext": "For this proof-of-concept study the 4D cardiac-gated CT scan from a 55 year-old male patient suffering from VT was used. The CT data of this VT patient has been previously used for other purposes in a work published by Gianni et al. . The treatment target for this patient had a size of 45 cm3 and it was located on the left ventricular free wall. This clinical target volume (CTV) was determined by electrophysiological mapping and contoured prior to the treatment by a medical doctor from the Texas Heart Arrhythmia Institute in Austin, USA. The left anterior descending coronary artery, the circumflex coronary arteries and the non-involved left ventricle were OARs near the target.\nFirst, the 4D CT scan of the VT patient was loaded into the Raysearch® Raystation treatment planning system (version 10B, Raysearch Laboratories AB, Stockholm, Sweden). Subsequently, a virtual representation of the prototype version of the proprietary US probe system of EBAMed (Geneva, Switzerland) was manually inserted as volume of interest (VOI) in two locations representing the estimated position of the apical and parasternal US viewing windows. A separate study has already verified that these US viewing windows provide US images of sufficient quality for VT patients in supine position . The US probe was simulated as a cube of 2 × 2 × 2 cm. It is equipped with infra-red markers such that the probe can be localized by an optical camera (see ) and it is attached to a holder such that it can be fixed on the chest of the patient allowing for hands-free imaging during the treatment. To account for uncertainties in repositioning of the US probe during the treatment, including probe position uncertainties due to respiration and breath-hold differences, an isotropic safety margin of 10 mm has been added to the union of the US probe, holder, and optical marker.\nThe parasternal US probe position allowed entrance of the treatment beams from optimal directions with respect to dosimetry for this particular patient. After selection of this virtual US probe position, a pencil-beam scanned proton therapy treatment plan was generated with the treatment planning system using the CNAO (Pavia, Italy) synchrotron proton beam model adapted to the Hitachi PROBEAT gantry system with 360° range of beam angles . During planning, the solid angle was restricted to take into account the US probe, the probe holder and the localization marker. Two fields were applied both with a gantry angle of 25° and a couch rotation of 0° and 90° for beam 1 and 2, respectively. The treatment volume was planned with an internal target volume (ITV) approach in order to compensate for shape and position changes of the target due to the heartbeat. It was assumed that the motion of the heart due to respiration would be mitigated using a breath-hold technique or respiratory gating. The envisioned role of the US imaging during this treatment was real-time cardiac motion monitoring and sending an alert to the operator in case the measured motion was outside of predefined limits.\nFor the generation of the ITV, the heartbeat motion envelope was extracted from the 4D CT scan by deformable registration of each phase of the 4D CT scan to the planning CT scan. The resulting ITV is the union of the CTVs at all phases of the 4D CT. Finally, the planning target volume (PTV) was generated by adding a 5 mm margin to the ITV based on typical patient set-up errors which are expected when no image guidance tool like US imaging is used.\nDose constraints on dose-volume tolerances in agreement with prior investigators were set as planning objectives. All doses are reported in Cobalt Gray Equivalent Dose (CGyE). The plan required the ITV to be covered by the 25 CGyE isodose, which is a dose level used in prior clinical studies to achieve safe, efficacious radioablation. To achieve this, the plan was normalized so that PTV D92% = 25 CGyE. Also, in order to arrive at a satisfactory treatment plan (, ), robust optimization with 2 mm set-up error in all directions and 2% range uncertainty was used during planning.\nTo verify the clinical acceptability of the generated plan, evaluation of standard target dose-volume metrics D98, D95 D50 and D2 was performed. In addition, the dose to OARs and the target dose conformity and homogeneity were evaluated.", + "fulltext_subclaims": [ + "The 4D cardiac-gated CT scan was from a 55 year-old male patient suffering from VT.", + "The CT data of this VT patient has been previously used for other purposes in a work published by Gianni et al.", + "The treatment target for this patient had a size of 45 cm3.", + "The treatment target was located on the left ventricular free wall.", + "The clinical target volume (CTV) was determined by electrophysiological mapping.", + "The CTV was contoured prior to the treatment by a medical doctor from the Texas Heart Arrhythmia Institute in Austin, USA.", + "The left anterior descending coronary artery was an OAR near the target.", + "The circumflex coronary arteries were OARs near the target.", + "The non-involved left ventricle was an OAR near the target.", + "The 4D CT scan of the VT patient was loaded into the Raysearch® Raystation treatment planning system.", + "A virtual representation of the prototype version of the proprietary US probe system of EBAMed was manually inserted as volume of interest (VOI) in two locations.", + "The US probe was simulated as a cube of 2 × 2 × 2 cm.", + "The US probe is equipped with infra-red markers.", + "An isotropic safety margin of 10 mm has been added to the union of the US probe, holder, and optical marker.", + "A pencil-beam scanned proton therapy treatment plan was generated using the CNAO synchrotron proton beam model adapted to the Hitachi PROBEAT gantry system.", + "The treatment volume was planned with an internal target volume (ITV) approach.", + "The motion of the heart due to respiration was assumed to be mitigated using a breath-hold technique or respiratory gating.", + "The envisioned role of the US imaging during this treatment was real-time cardiac motion monitoring.", + "The ITV is the union of the CTVs at all phases of the 4D CT.", + "The planning target volume (PTV) was generated by adding a 5 mm margin to the ITV.", + "The plan required the ITV to be covered by the 25 CGyE isodose.", + "The plan was normalized so that PTV D92% = 25 CGyE.", + "Robust optimization with 2 mm set-up error in all directions and 2% range uncertainty was used during planning.", + "Evaluation of standard target dose-volume metrics D98, D95, D50 and D2 was performed.", + "The dose to OARs and the target dose conformity and homogeneity were evaluated." + ], + "summary": "A treatment plan study was performed based on a 4D cardiac-gated computed tomography scan of a 55 year-old male patient suffering from refractory ventricular tachycardia who underwent cardiac radioablation. A proton therapy treatment plan was generated for the actual treatment target in presence of an ultrasound probe on the chest of this patient. The clinical acceptability of the generated plan was confirmed by evaluating standard target dose-volume metrics, dose to organs-at-risk and target dose conformity and homogeneity.", + "summary_subclaims": [ + "A treatment plan study was performed based on a 4D cardiac-gated computed tomography scan.", + "The patient was a 55 year-old male.", + "The patient suffered from refractory ventricular tachycardia.", + "The patient underwent cardiac radioablation.", + "A proton therapy treatment plan was generated for the actual treatment target.", + "The proton therapy treatment plan was generated in presence of an ultrasound probe on the chest of this patient.", + "The clinical acceptability of the generated plan was confirmed.", + "Standard target dose-volume metrics were evaluated.", + "Dose to organs-at-risk was evaluated.", + "Target dose conformity and homogeneity were evaluated." + ] + }, + { + "id": "multiclinsum_test_254_en.txt", + "fulltext": "An 84-year-old woman was diagnosed with a simple liver cyst during a medical checkup. One year later, she was referred to our hospital for the evaluation of an enlarging distinct mural nodule in the liver cyst. No specific symptoms were present, and physical examinations did not reveal any abnormalities. The blood tests showed normal liver function and were negative for both hepatitis B surface antigen and hepatitis C virus antibody. However, the levels of carcinoembryonic antigen (5.0 ng/mL) and carbohydrate antigen (CA19-9; 43.5 U/mL) were slightly elevated. On contrast-enhanced computed tomography (CT), a well-defined, low-attenuation lesion without a septum was observed. The maximal diameter of the lesion had increased from 41 to 47 mm in one year . No dilation of the bile duct was observed. Enhanced ultrasonography showed an enhanced nodule with a distinct artery into the nodule . A 14 mm mural nodule with gradual enhancement was confirmed. MRI revealed a homogenous water intensity cystic lesion accompanied by a mural nodule, which exhibited peripheral low intensity and central high intensity on heavily T2-weighted image . Positron emission tomography/computed tomography (PET/CT) did not show increased fluorodeoxyglucose activity at the mural nodule . The cystic tumor was considered potentially malignant because the mural nodule was growing in size and had apparent blood flow inside, so we offered the patient two options: surgical resection or careful watching. Finally, she decided to have surgery, and partial liver resection with sufficient margins was performed. We never perform aspiration of intracystic fluid to avoid tumor cell spillage. Macroscopically, the cut surface of the resected specimen displayed a thin-walled liver cyst with a mural nodule and included denatured liquid content. Pathological examination revealed a cystic lesion with a thin whitish fibrous wall, and a black-colored 5-mm nodule was located in the cyst wall over the normal liver tissue. The cyst wall was lined by an inner layer of cytokeratin 19-positive columnar epithelium, and the black-colored nodule was composed of dilated vessels lined with CD31- and CD34-positive endothelial cells . The final diagnosis was cavernous hemangioma in a simple liver cyst. She was discharged on the 9th day after surgery without any complications and was doing well after three months.", + "fulltext_subclaims": [ + "An 84-year-old woman was diagnosed with a simple liver cyst during a medical checkup.", + "One year later, she was referred to our hospital for the evaluation of an enlarging distinct mural nodule in the liver cyst.", + "No specific symptoms were present.", + "Physical examinations did not reveal any abnormalities.", + "The blood tests showed normal liver function.", + "The blood tests were negative for hepatitis B surface antigen.", + "The blood tests were negative for hepatitis C virus antibody.", + "The levels of carcinoembryonic antigen were slightly elevated.", + "The levels of carbohydrate antigen (CA19-9) were slightly elevated.", + "On contrast-enhanced computed tomography (CT), a well-defined, low-attenuation lesion without a septum was observed.", + "The maximal diameter of the lesion had increased from 41 to 47 mm in one year.", + "No dilation of the bile duct was observed.", + "Enhanced ultrasonography showed an enhanced nodule with a distinct artery into the nodule.", + "A 14 mm mural nodule with gradual enhancement was confirmed.", + "MRI revealed a homogenous water intensity cystic lesion accompanied by a mural nodule.", + "The mural nodule exhibited peripheral low intensity and central high intensity on heavily T2-weighted image.", + "Positron emission tomography/computed tomography (PET/CT) did not show increased fluorodeoxyglucose activity at the mural nodule.", + "The cystic tumor was considered potentially malignant because the mural nodule was growing in size and had apparent blood flow inside.", + "We offered the patient two options: surgical resection or careful watching.", + "She decided to have surgery.", + "Partial liver resection with sufficient margins was performed.", + "We never perform aspiration of intracystic fluid to avoid tumor cell spillage.", + "Macroscopically, the cut surface of the resected specimen displayed a thin-walled liver cyst with a mural nodule.", + "The cyst wall was lined by an inner layer of cytokeratin 19-positive columnar epithelium.", + "The black-colored nodule was composed of dilated vessels lined with CD31- and CD34-positive endothelial cells.", + "The final diagnosis was cavernous hemangioma in a simple liver cyst.", + "She was discharged on the 9th day after surgery without any complications.", + "She was doing well after three months." + ], + "summary": "An 84-year-old woman with a history of simple liver cyst diagnosed one year prior was admitted for evaluation of a developed mural nodule in the cystic lesion. She had no specific symptoms and no abnormalities in blood tests except for carcinoembryonic antigen (5.0 ng/mL) and carbohydrate antigen (43.5 U/mL) levels. Contrast-enhanced computed tomography revealed a well-defined, low-attenuation lesion without a septum that had enlarged from 41 to 47 mm. No dilation of the bile duct was observed. A gradually enhancing mural nodule, 14 mm in diameter, was confirmed. MRI revealed a uniform water-intense cystic lesion with a mural nodule. This was followed by T2-enhanced imaging showing peripheral hypointensity and central hyperintensity. Enhanced ultrasonography revealed an enhanced nodule with a distinct artery within it. A needle biopsy of the wall nodule or aspiration of intracystic fluid was not performed to avoid tumor cell spillage. The possibility of a neoplastic cystic tumor could not be ruled out, so a partial hepatectomy was performed with adequate margins. Pathologically, the cystic lesion contained a black 5 mm nodule consisting of a thin, whitish fibrous wall and dilated vessels lined by CD31 and CD34 positive endothelial cells. The final diagnosis was a rare cavernous hemangioma within a simple liver cyst.", + "summary_subclaims": [ + "The patient is an 84-year-old woman.", + "She has a history of a simple liver cyst diagnosed one year prior.", + "She was admitted for evaluation of a developed mural nodule in the cystic lesion.", + "She had no specific symptoms.", + "There were no abnormalities in blood tests except for carcinoembryonic antigen (5.0 ng/mL) and carbohydrate antigen (43.5 U/mL) levels.", + "Contrast-enhanced computed tomography revealed a well-defined, low-attenuation lesion without a septum.", + "The lesion had enlarged from 41 to 47 mm.", + "No dilation of the bile duct was observed.", + "A gradually enhancing mural nodule, 14 mm in diameter, was confirmed.", + "MRI revealed a uniform water-intense cystic lesion with a mural nodule.", + "T2-enhanced imaging showed peripheral hypointensity and central hyperintensity.", + "Enhanced ultrasonography revealed an enhanced nodule with a distinct artery within it.", + "A needle biopsy of the wall nodule or aspiration of intracystic fluid was not performed.", + "The possibility of a neoplastic cystic tumor could not be ruled out.", + "A partial hepatectomy was performed with adequate margins.", + "The cystic lesion contained a black 5 mm nodule.", + "The nodule consisted of a thin, whitish fibrous wall and dilated vessels lined by CD31 and CD34 positive endothelial cells.", + "The final diagnosis was a rare cavernous hemangioma within a simple liver cyst." + ] + }, + { + "id": "multiclinsum_test_504_en.txt", + "fulltext": "A 18-year-old male presented to orthopedics clinic with complaint of lower back pain without any lower limb pain from past 6 months which was spontaneous in onset after trivial fall, increased with activity, and relieved by rest and analgesics, no diurnal and postural variation was observed. On examination, the patient was having muscular spasm of paravertebral muscle with reduced range of motion at lumbar spine noted. We did not observe any kind of neurological involvement in the patient. Chances of thecal sac compression are rare in these patients unless any concomitant disc disease. He had no visual deformity in spine, and no obvious swelling.\nWe evaluated the patient further with radiological imaging and blood investigations. On digital X-ray of lumbosacral spine which showed irregularity in superior end plate of L3 vertebrae with decreased lordosis in lumbar region. MRI of lumbosacral spine showed anterior wedging in L3 vertebral body, erosion of superior end plate of L3 vertebra, narrow disk space of L3–L4, and schomrl nodes in L3 vertebrae .\nBlood parameters CBC, ESR, and CRP were within normal limits which exclude any infective or inflammatory etiology. On basis of all above findings, it was suggestive of atypical Scheuermann disease (type IIa) which involves only one vertebra. This disease is divided into two types:\nTypical Scheuermann disease (type I): It involves three or more than three thoracic vertebrae which causes kyphotic deformity in dorsal spine. Adolescents have more chances of this type Atypical Scheuermann disease (type Iia): It involves one or two vertebrae of dorsolumbar or lumbar segment, disk space narrowing, and anterior schmorl nodes. It is seen less commonly Acute traumatic intraosseous disk herniation (type Iib): It consists history of acute vertical compression injury resulting in severe back pain and evidence of end plate fracture (anterior schmorl nodes).\nThe patient was explained about the disease and treated conservatively with anti-inflammatory medication and physical therapy. Indications for surgery include progression of deformity, cosmesis, severe pain and rarely, cardiopulmonary or neurological compromise.", + "fulltext_subclaims": [ + "The patient is an 18-year-old male.", + "The patient presented with lower back pain without any lower limb pain.", + "The pain had been present for 6 months.", + "The pain was spontaneous in onset after a trivial fall.", + "The pain increased with activity.", + "The pain was relieved by rest and analgesics.", + "No diurnal and postural variation was observed.", + "On examination, the patient had muscular spasm of the paravertebral muscle.", + "Reduced range of motion at the lumbar spine was noted.", + "No neurological involvement was observed.", + "Chances of thecal sac compression are rare in these patients unless there is concomitant disc disease.", + "There was no visual deformity in the spine.", + "There was no obvious swelling.", + "Digital X-ray of the lumbosacral spine showed irregularity in the superior end plate of the L3 vertebra.", + "MRI showed anterior wedging in the L3 vertebral body.", + "MRI showed erosion of the superior end plate of the L3 vertebra.", + "MRI showed narrow disk space of L3–L4.", + "MRI showed schmorl nodes in the L3 vertebra.", + "CBC, ESR, and CRP were within normal limits.", + "The findings were suggestive of atypical Scheuermann disease (type IIa).", + "Atypical Scheuermann disease involves one or two vertebrae of the dorsolumbar or lumbar segment.", + "Atypical Scheuermann disease is seen less commonly.", + "The patient was treated conservatively with anti-inflammatory medication and physical therapy.", + "Indications for surgery include progression of deformity.", + "Indications for surgery include cosmesis.", + "Indications for surgery include severe pain.", + "Indications for surgery include cardiopulmonary or neurological compromise." + ], + "summary": "An 18-year-old male presented in OPD with a complaint of chronic lower back pain without any lower limb pain and neurological deficit. Radiological imaging and blood parameters were in favor of atypical Scheuermann disease.", + "summary_subclaims": [ + "An 18-year-old male presented in OPD with a complaint of chronic lower back pain.", + "The patient had no lower limb pain.", + "The patient had no neurological deficit.", + "Radiological imaging and blood parameters were in favor of atypical Scheuermann disease." + ] + }, + { + "id": "multiclinsum_test_262_en.txt", + "fulltext": "A 46 year old Zambian woman was referred from another hospital with a 4 week history of fevers, night sweats, vomiting, diarrhoea, and renal impairment. She had been diagnosed HIV positive in 2005, and started on HAART one year later. She had previously been treated for Herpes simplex virus infection, Cytomegalovirus pneumonitis, and Pneumocystis jirovecii pneumonia (PCP). At referral her blood CD4 count was 480 × 106/L (range in HIV negative populations, 400-1500 × 106/L); and she had an undetectable plasma HIV load. On arrival at our centre, she was confused, and had obvious pitting oedema of both lower limbs, widespread lymphadenopathy, and hepato-splenomegaly. Investigations revealed anaemia, leucocytosis, thrombocytopaenia, and acute renal and liver dysfunction.\nA CT scan showed hepato-splenomegaly and gross lymphadenopathy involving the thorax, abdomen and pelvis . Inguinal lymph node excision biopsy confirmed the clinical suspicion of Multi-centric Castleman's disease (MCD) . Rituximab (375 mg/m2) together with hydrocortisone and rasburicase, was administered as specific treatment. She developed rapidly progressive metabolic acidosis, oliguria, and rising serum creatinine and was admitted to the ICU for haemofiltration. Antiretroviral therapy was continued on the ICU with ritonavir-boosted lopinavir and saquinavir. Abacavir and lamivudine, which the patient was already taking, were stopped because of their association with lactic acidosis and hepatic steatosis.\nFollowing admission to ICU she rapidly became hypotensive, hypoglycaemic, coagulopathic and more anaemic. A possible basis for this could have been the systemic manifestations of a \"cytokine storm\" associated with MCD; increased expression of IL-6 is typical of MCD. Vasopressor and inotropic support with noradrenaline and dobutamine was required to maintain an adequate mean arterial pressure (MAP). Because of rapidly escalating requirements for noradrenaline she received a continuous infusion of hydrocortisone (10 mg/h) as per local departmental protocol, to treat probable relative adrenal insufficiency. Empirical antibiotics and antifungal agents were given to treat sepsis as a potential cause for ensuing multi-organ dysfunction, and she required a continuous infusion of 20% dextrose for refractory hypoglycaemia. To treat her acute renal failure and profound metabolic acidosis (serum lactate of 18.5 mmol/L), haemofiltration was undertaken with large volume 5 litre cycles (~90 ml/kg/hour) of lactate-free replacement fluid. This strategy was adopted to target early shock reversal and removal of IL-6, increased expression of which is a hallmark feature of MCD.\nThe chest radiograph progressed over four days to bilateral diffuse patchy consolidation , associated with greatly increased oxygen requirements (FiO2 0.8), and consistent with a diagnosis of acute respiratory distress syndrome (ARDS). The patient became drowsy and hypercapnic. Her trachea was therefore intubated, and mechanical ventilation was commenced.\nShe developed epistaxis and bleeding from insertion sites of arterial, central venous, and haemofiltration catheters. She had a positive direct Coombs' test consistent with autoimmune haemolytic anaemia (AIHA), a recognised association of MCD. In addition she had elevated prothrombin (PT) and activated partial thromboplastin times (APTT), reduced platelets and reduced serum fibrinogen consistent with disseminated intravascular coagulation (DIC). She received methylprednisolone, folinic acid, and red cell concentrate to treat anaemia; plus cryoprecipitate, fresh frozen plasma, vitamin K, and platelets for DIC. In addition to this extensive physiological support, her Castleman's disease was treated with weekly infusions of the anti-CD20 monoclonal antibody, rituximab, for four weeks.\nFrom day 10 there was evidence of clinical improvement. She had a tracheostomy in the second week of her ICU stay, and she was slowly weaned from inotropic/vasopressor, ventilatory, and finally renal support. At day 21 of her ICU admission, she was discharged to the ward to complete her treatment with rituximab, and to continue rehabilitation from global muscle weakness, and reduce dependence on her tracheostomy. The patient was discharged home, in remission from her disease, after 149 days in hospital. When last seen in clinic she remained in remission and living independently 14 months from her treatment.", + "fulltext_subclaims": [ + "The patient was a 46 year old Zambian woman.", + "She had a 4 week history of fevers, night sweats, vomiting, diarrhoea, and renal impairment.", + "She had been diagnosed HIV positive in 2005.", + "She had previously been treated for Herpes simplex virus infection.", + "She had previously been treated for Cytomegalovirus pneumonitis.", + "She had previously been treated for Pneumocystis jirovecii pneumonia.", + "Her blood CD4 count was 480 × 106/L.", + "She had an undetectable plasma HIV load.", + "On arrival, she was confused.", + "She had pitting oedema of both lower limbs.", + "She had widespread lymphadenopathy.", + "She had hepato-splenomegaly.", + "Investigations revealed anaemia.", + "A CT scan showed hepato-splenomegaly.", + "A CT scan showed gross lymphadenopathy involving the thorax, abdomen and pelvis.", + "Inguinal lymph node excision biopsy confirmed Multi-centric Castleman's disease.", + "Rituximab (375 mg/m2) was administered as specific treatment.", + "She developed rapidly progressive metabolic acidosis.", + "She was admitted to the ICU for haemofiltration.", + "Antiretroviral therapy was continued on the ICU with ritonavir-boosted lopinavir and saquinavir.", + "Abacavir and lamivudine were stopped.", + "Following admission to ICU, she rapidly became hypotensive.", + "A possible basis for this could have been the systemic manifestations of a cytokine storm.", + "Vasopressor and inotropic support with noradrenaline and dobutamine was required.", + "She received a continuous infusion of hydrocortisone.", + "Empirical antibiotics and antifungal agents were given.", + "She required a continuous infusion of 20% dextrose.", + "Haemofiltration was undertaken with large volume 5 litre cycles.", + "The chest radiograph progressed to bilateral diffuse patchy consolidation.", + "The diagnosis was acute respiratory distress syndrome.", + "The patient became drowsy and hypercapnic.", + "The trachea was intubated.", + "Mechanical ventilation was commenced.", + "She developed epistaxis.", + "She had a positive direct Coombs' test.", + "She had elevated prothrombin times.", + "She had elevated activated partial thromboplastin times.", + "She had reduced platelets.", + "She had reduced serum fibrinogen.", + "She received methylprednisolone.", + "She received folinic acid.", + "She received red cell concentrate.", + "She received cryoprecipitate.", + "She received fresh frozen plasma.", + "She received vitamin K.", + "She received platelets.", + "She received weekly infusions of rituximab.", + "From day 10 there was evidence of clinical improvement.", + "She had a tracheostomy in the second week of her ICU stay.", + "She was weaned from inotropic/vasopressor support.", + "She was weaned from ventilatory support.", + "She was weaned from renal support.", + "At day 21 of her ICU admission, she was discharged to the ward.", + "She was discharged home after 149 days in hospital.", + "When last seen in clinic, she remained in remission.", + "She was living independently 14 months from her treatment." + ], + "summary": "We report the case of a 46 year old Zambian woman who presented with pyrexia, diarrhoea and vomiting, confusion, lymphadenopathy, and renal failure. She rapidly developed multiple organ failure following the initiation of treatment of MCD with rituximab. Following admission to intensive care (ICU), she received prompt multi-organ support. After 21 days on the ICU she returned to the haematology medical ward, and was discharged in remission from her disease after 149 days in hospital.", + "summary_subclaims": [ + "The patient is a 46 year old Zambian woman.", + "She presented with pyrexia.", + "She presented with diarrhoea.", + "She presented with vomiting.", + "She presented with confusion.", + "She presented with lymphadenopathy.", + "She presented with renal failure.", + "She rapidly developed multiple organ failure following the initiation of treatment of MCD with rituximab.", + "Following admission to intensive care (ICU), she received prompt multi-organ support.", + "After 21 days on the ICU she returned to the haematology medical ward.", + "She was discharged in remission from her disease after 149 days in hospital." + ] + }, + { + "id": "multiclinsum_test_3002_en.txt", + "fulltext": "A 63-year-old female with poorly controlled diabetes mellitus, hypertension and dyslipidemia on oral medication presented with 3 episodes of back-to-back GTC seizures, each lasting for approximately 5 minutes, in a background of mild on-and-off headache for several months but without any weight gain, visual impairment or features of pituitary hormonal abnormalities. The seizures were associated with loss of consciousness, frothing, eye deviation and tonic and clonic movements of all four limbs followed by postictal drowsiness lasting for 2 to 3 hours. She was admitted to the A&E department and thereafter transferred to the intensive care unit, where she was managed with Levetiracetam to which she responded.\n\nThe neurological examination was unremarkable except for a bitemporal quadrantanopia on the visual field assessment. Moreover, the rest of the physical exam did not elicit any features of pituitary hormonal excess or deficiency. The patient was further assessed by a consultant ophthalmologist, where bitemporal pallor and cupping in addition to bitemporal upper quadrantanopia were detected.\n\nMagnetic resonance imaging was subsequently used to detect a large pituitary tumour measuring 6.0 cm (craniocaudal) × 3.8 cm (transverse) × 4.0 cm (anteroposterior) with suprasellar extension through the third ventricle into both lateral ventricles, causing significant mass effects and impending hydrocephalus (Wilson-Hardy classification: IVC, Knosp classification: 0; Goel classification: IV). Blood investigations that were also carried out revealed normal serum electrolytes and endocrine panels.\n\nUpon stabilizing her and achieving significant glycemic and blood pressure control under the supervision of a consultant endocrinologist, she underwent neuro-navigation-guided endonasal transsphenoidal subtotal resection 2 weeks after her initial presentation. Histology revealed a null cell adenoma with a Ki-67 index of 3%. She was discharged one week after surgery, and at 3 months of follow-up, she was initiated on adjuvant radiotherapy but was well and seizure free (while on Levetiracetam) without any visual deficits. She is being closely followed up by the endocrinology team headed by a senior consultant endocrinologist and has not shown to have clinical or biochemical indicators of pituitary dysfunction. Close monitoring by MRI imaging will be performed at 3 months of completion of radiotherapy and at regular intervals thereafter to assess the growth of the residual tumour for a total cumulative period of 15 years (as per unit protocols).", + "fulltext_subclaims": [ + "The patient is a 63-year-old female.", + "She has poorly controlled diabetes mellitus.", + "She has hypertension.", + "She has dyslipidemia.", + "She was on oral medication.", + "She had 3 episodes of back-to-back generalized tonic-clonic seizures.", + "Each seizure lasted for approximately 5 minutes.", + "She had mild on-and-off headache for several months.", + "She did not have weight gain.", + "She did not have visual impairment.", + "She did not have features of pituitary hormonal abnormalities.", + "The seizures were associated with loss of consciousness.", + "The seizures were associated with frothing.", + "The seizures were associated with eye deviation.", + "The seizures were associated with tonic and clonic movements of all four limbs.", + "The seizures were followed by postictal drowsiness lasting for 2 to 3 hours.", + "She was admitted to the A&E department.", + "She was transferred to the intensive care unit.", + "She was managed with Levetiracetam.", + "She responded to Levetiracetam.", + "The neurological examination was unremarkable.", + "She had bitemporal quadrantanopia on visual field assessment.", + "The rest of the physical exam did not elicit features of pituitary hormonal excess.", + "The rest of the physical exam did not elicit features of pituitary hormonal deficiency.", + "She was assessed by a consultant ophthalmologist.", + "Bitemporal pallor and cupping were detected.", + "Bitemporal upper quadrantanopia was detected.", + "Magnetic resonance imaging detected a large pituitary tumour.", + "The tumour measured 6.0 cm (craniocaudal) × 3.8 cm (transverse) × 4.0 cm (anteroposterior).", + "The tumour had suprasellar extension through the third ventricle into both lateral ventricles.", + "The tumour caused significant mass effects.", + "The tumour caused impending hydrocephalus.", + "The Wilson-Hardy classification was IVC.", + "The Knosp classification was 0.", + "The Goel classification was IV.", + "Blood investigations revealed normal serum electrolytes.", + "Blood investigations revealed normal endocrine panels.", + "She underwent neuro-navigation-guided endonasal transsphenoidal subtotal resection.", + "The surgery was 2 weeks after her initial presentation.", + "Histology revealed a null cell adenoma.", + "The Ki-67 index was 3%.", + "She was discharged one week after surgery.", + "At 3 months of follow-up, she was initiated on adjuvant radiotherapy.", + "At 3 months of follow-up, she was well.", + "At 3 months of follow-up, she was seizure free.", + "At 3 months of follow-up, she was on Levetiracetam.", + "At 3 months of follow-up, she had no visual deficits.", + "She is being followed up by the endocrinology team.", + "The endocrinology team is headed by a senior consultant endocrinologist.", + "She has not shown clinical indicators of pituitary dysfunction.", + "She has not shown biochemical indicators of pituitary dysfunction.", + "Close monitoring by MRI imaging will be performed at 3 months of completion of radiotherapy.", + "Close monitoring by MRI imaging will be performed at regular intervals thereafter.", + "MRI imaging will be performed for a total cumulative period of 15 years." + ], + "summary": "A 63-year-old woman presented with back-to-back generalized tonic clonic seizures to the A&E and was treated with Levetiracetam. Following initial normal blood investigations, a visual field analysis revealed a bitemporal upper quadrantanopia and further evaluation using MRI found a giant pituitary lesion with suprasellar extension through the third ventricle into the lateral ventricles with significant mass effect. She underwent neuro-navigation guided endonasal transsphenoidal subtotal resection 2 weeks later. The histological diagnosis of null cell adenoma with a Ki67 of 3% was made. At 3 months of follow-up, she is symptom free and monitored with serial MRIs.", + "summary_subclaims": [ + "A 63-year-old woman presented with back-to-back generalized tonic clonic seizures to the A&E.", + "She was treated with Levetiracetam.", + "Initial blood investigations were normal.", + "Visual field analysis revealed a bitemporal upper quadrantanopia.", + "MRI found a giant pituitary lesion with suprasellar extension through the third ventricle into the lateral ventricles.", + "The lesion had significant mass effect.", + "She underwent neuro-navigation guided endonasal transsphenoidal subtotal resection 2 weeks later.", + "The histological diagnosis was null cell adenoma.", + "The Ki67 was 3%.", + "At 3 months of follow-up, she is symptom free.", + "She is monitored with serial MRIs." + ] + }, + { + "id": "multiclinsum_test_1803_en.txt", + "fulltext": "A 6 years-old male neutered pit bull terrier was presented for chronic infection and multiple draining tracts of the craniofacial region. The clients reported that the clinical signs including open wounds on the face, a foul odor from the mouth, and hyporexia that started approximately 3 years earlier. The dog was treated at various first opinion practices by means of sedated explorations of the extra- and intraoral lesions, where foreign plant material was retrieved on multiple occasions. A combination of primary closure and placement of Penrose drains was attempted, samples were collected for microbial culture tests, and analgesia and antimicrobial therapy based on culture results were prescribed. Over the course of 3 years, the following antimicrobials were prescribed: amoxicillin/clavulanate, ampicillin, amikacin, cefovecin, cephalexin, minocycline, and orbifloxacin. Due to the progressively worsening nature of the lesions, size, and invasion into deeper tissues after attempted repairs, the dog was referred.\nOn presentation, the dog appeared clinically stable. A large (20 × 20 mm) draining tract overlying the bridge of the nose between the eyes was observed (i.e., affecting the frontal, nasal, and maxillary bones). There were four additional cutaneous draining tracts noted approximately 4 × 4 mm ventral to the left eye, to the lateral side of the right eye, between the eyes, and on the medial aspect of the right eye . An intraoral examination revealed an oronasal fistula extending from the right maxillary canine tooth to the right maxillary fourth premolar tooth . The right maxillary buccal frenulum remained intact. There was mucopurulent discharge and crusting surrounding the multiple draining tracts. There was bilateral mandibular lymphadenopathy. Incidental physical examination findings included cataracts with nuclear sclerosis, iris atrophy, heterochromia iridum, and anisocoria. The hematologic assessment revealed leukocytosis (14,900/μL; reference interval 6,000–13,000/μL) characterized by mild neutrophilia (11,507/μL; reference interval 3,000–10,500/μL). The serum biochemical values were within reference ranges. The dog underwent general anesthesia for conventional computed tomography (CT) (HiSpeed FX/i or LightSpeed16, GE Healthcare, Waukesha, WI) of the skull with and without contrast (880 mg/kg, IV, iopamidol). Computed tomographic findings included multifocal to coalescing lucent osseous lesions predominantly affecting the cortical bone of the right rostral maxilla (,). There was a resultant large draining tract affecting the nasal, frontal, and maxillary bones that communicated with the cutaneous surface . Differential diagnosis included a neoplastic process (i.e., squamous cell carcinoma, osteosarcoma, and round cell tumor) or an infectious etiology (i.e., coccidiomycosis, aspergillosis, and bacterial infection); a component of osteomyelitis associated with the nasal fistulae was anticipated. There was a mildly contrast-enhancing soft tissue structure in the right frontal sinus (which could reflect a neoplastic mass or granuloma). The right mandibular and medial retropharyngeal lymph nodes were enlarged (it was unknown whether they were reactive or metastatic). Finally, severe right temporomandibular joint osteoarthritis was observed, which may be secondary to prior trauma or infection of the joint. The CT was followed by rhinoscopy and was performed using a combination of intra- and extraoral (trans-fistulous) approaches. The findings confirmed most of the previously described osseous and soft tissue lesions noted on CT. No gross lesions consistent with fungal plaques were found. Following rhinoscopy, samples of the lesions were surgically harvested utilizing rongeurs and iris scissors for histopathological evaluation, as well as microbial and fungal testing. A Stent bandage was placed and kept in place for 3 days. The dog was discharged with analgesia (carprofen 2.2 mg/kg, PO, q12h and gabapentin 10 mg/kg, PO, q12h) and a broad-spectrum antimicrobial amoxicillin/clavulanate (13.75 mg/kg, PO, q12h).\nThe biopsy sample submitted for histopathological evaluation consisted of exudate with crust and an osseous fragment associated with soft tissue . The bone tissue was a fragment of lamellar bone (mature bone) rimmed multifocally by woven bone (immature bone) . Multifocally resorption lacunae occupied by multinucleated osteoclasts were noted in the absence of osteoblasts, indicative of bone remodeling . Infection of the bone medullary cavities was not noted. The crust and exudate suspended large numbers of intact and degenerate neutrophils admixed with bacterial cocci colonies and birefringent foreign material resembling plant and pollen (–).\nSoft tissue associated with the bone fragment included loose fibrous connective tissue infiltrated by scattered lymphocytes and plasma cells and round clusters of lymphocytes (lymphofollicular hyperplasia). This fibrous connective tissue was lined by primarily pseudostratified columnar ciliated epithelium that was multifocally substituted by squamous epithelial lining, indicative of squamous metaplasia .\nThe microbial culture and susceptibility results revealed the presence of multi-drug resistant coagulase-negative Staphylococcus spp., and therefore, the antimicrobial treatment was changed to enrofloxacin (10 mg/kg, PO, q12h) for 4 weeks, as it was identified as the susceptible antimicrobial of choice.", + "fulltext_subclaims": [ + "A 6 years-old male neutered pit bull terrier was presented for chronic infection and multiple draining tracts of the craniofacial region.", + "The clients reported that the clinical signs including open wounds on the face, a foul odor from the mouth, and hyporexia that started approximately 3 years earlier.", + "The dog was treated at various first opinion practices by means of sedated explorations of the extra- and intraoral lesions.", + "Foreign plant material was retrieved on multiple occasions.", + "A combination of primary closure and placement of Penrose drains was attempted.", + "Samples were collected for microbial culture tests.", + "Analgesia and antimicrobial therapy based on culture results were prescribed.", + "Over the course of 3 years, the following antimicrobials were prescribed: amoxicillin/clavulanate, ampicillin, amikacin, cefovecin, cephalexin, minocycline, and orbifloxacin.", + "Due to the progressively worsening nature of the lesions, size, and invasion into deeper tissues after attempted repairs, the dog was referred.", + "On presentation, the dog appeared clinically stable.", + "A large (20 × 20 mm) draining tract overlying the bridge of the nose between the eyes was observed.", + "There were four additional cutaneous draining tracts noted approximately 4 × 4 mm ventral to the left eye, to the lateral side of the right eye, between the eyes, and on the medial aspect of the right eye.", + "An intraoral examination revealed an oronasal fistula extending from the right maxillary canine tooth to the right maxillary fourth premolar tooth.", + "The right maxillary buccal frenulum remained intact.", + "There was mucopurulent discharge and crusting surrounding the multiple draining tracts.", + "There was bilateral mandibular lymphadenopathy.", + "Incidental physical examination findings included cataracts with nuclear sclerosis, iris atrophy, heterochromia iridum, and anisocoria.", + "The hematologic assessment revealed leukocytosis (14,900/μL; reference interval 6,000–13,000/μL) characterized by mild neutrophilia (11,507/μL; reference interval 3,000–10,500/μL).", + "The serum biochemical values were within reference ranges.", + "The dog underwent general anesthesia for conventional computed tomography (CT) of the skull with and without contrast.", + "Computed tomographic findings included multifocal to coalescing lucent osseous lesions predominantly affecting the cortical bone of the right rostral maxilla.", + "There was a resultant large draining tract affecting the nasal, frontal, and maxillary bones that communicated with the cutaneous surface.", + "Differential diagnosis included a neoplastic process (i.e., squamous cell carcinoma, osteosarcoma, and round cell tumor) or an infectious etiology (i.e., coccidiomycosis, aspergillosis, and bacterial infection); a component of osteomyelitis associated with the nasal fistulae was anticipated.", + "There was a mildly contrast-enhancing soft tissue structure in the right frontal sinus.", + "The right mandibular and medial retropharyngeal lymph nodes were enlarged.", + "Severe right temporomandibular joint osteoarthritis was observed.", + "The CT was followed by rhinoscopy and was performed using a combination of intra- and extraoral (trans-fistulous) approaches.", + "The findings confirmed most of the previously described osseous and soft tissue lesions noted on CT.", + "No gross lesions consistent with fungal plaques were found.", + "Following rhinoscopy, samples of the lesions were surgically harvested utilizing rongeurs and iris scissors for histopathological evaluation, as well as microbial and fungal testing.", + "A Stent bandage was placed and kept in place for 3 days.", + "The dog was discharged with analgesia (carprofen 2.2 mg/kg, PO, q12h and gabapentin 10 mg/kg, PO, q12h) and a broad-spectrum antimicrobial amoxicillin/clavulanate (13.75 mg/kg, PO, q12h).", + "The biopsy sample submitted for histopathological evaluation consisted of exudate with crust and an osseous fragment associated with soft tissue.", + "The bone tissue was a fragment of lamellar bone (mature bone) rimmed multifocally by woven bone (immature bone).", + "Multifocally resorption lacunae occupied by multinucleated osteoclasts were noted in the absence of osteoblasts, indicative of bone remodeling.", + "Infection of the bone medullary cavities was not noted.", + "The crust and exudate suspended large numbers of intact and degenerate neutrophils admixed with bacterial cocci colonies and birefringent foreign material resembling plant and pollen.", + "Soft tissue associated with the bone fragment included loose fibrous connective tissue infiltrated by scattered lymphocytes and plasma cells and round clusters of lymphocytes (lymphofollicular hyperplasia).", + "This fibrous connective tissue was lined by primarily pseudostratified columnar ciliated epithelium that was multifocally substituted by squamous epithelial lining, indicative of squamous metaplasia.", + "The microbial culture and susceptibility results revealed the presence of multi-drug resistant coagulase-negative Staphylococcus spp.", + "The antimicrobial treatment was changed to enrofloxacin (10 mg/kg, PO, q12h) for 4 weeks, as it was identified as the susceptible antimicrobial of choice." + ], + "summary": "A 6 years-old, male neutered pit bull terrier dog underwent a staged procedure. First, a diagnostic work-up including hematologic and biochemical analysis, conventional computed tomography (CT) with contrast of the skull, and a rhinoscopic evaluation of the draining tracts was performed. Samples were obtained for histopathological, microbial, and fungal testing. Second, a 4 week course of antimicrobials based on culture and sensitivity results was administered. Third, an extraoral approach to soft tissue reconstruction was accomplished as a first stage in the repair process. Finally, an intraoral approach to repair the oronasal fistulous draining tracts was performed. A 6 months follow-up skull CT revealed various stages of repair and remodeling and adequate soft tissue healing.", + "summary_subclaims": [ + "A 6 years-old, male neutered pit bull terrier dog underwent a staged procedure.", + "A diagnostic work-up including hematologic and biochemical analysis was performed.", + "A conventional computed tomography (CT) with contrast of the skull was performed.", + "A rhinoscopic evaluation of the draining tracts was performed.", + "Samples were obtained for histopathological, microbial, and fungal testing.", + "A 4 week course of antimicrobials based on culture and sensitivity results was administered.", + "An extraoral approach to soft tissue reconstruction was accomplished as a first stage in the repair process.", + "An intraoral approach to repair the oronasal fistulous draining tracts was performed.", + "A 6 months follow-up skull CT revealed various stages of repair and remodeling.", + "A 6 months follow-up skull CT revealed adequate soft tissue healing." + ] + }, + { + "id": "multiclinsum_test_725_en.txt", + "fulltext": "A 44-year-old healthy Japanese female experienced pain in her left eye when she was relaxed and watching television. She massaged her eyes with strong pressure several times with her fingers. Subsequently, she noticed a sudden loss in the left central vision. The next day, she visited our hospital. When questioned, she could not remember having done anything that might induce Valsalva retinopathy.\nUpon examination, her left eye had a best-corrected visual acuity of 0.01, intraocular pressure (IOP) was 17 mm Hg, and the cornea and lens were clear. A left fundus examination showed a dense preretinal hemorrhage at the posterior pole . The preretinal hemorrhage appeared to be located under the internal limiting membrane (ILM) due to the reflection of the surface of the preretinal hemorrhage, and this was confirmed by optical coherence tomography . A mild vitreous hemorrhage was also observed. Fluorescein and indocyanine green angiography showed no retinal vascular abnormality, although the posterior pole was veiled by the preretinal hemorrhage . In her right eye, no abnormality was found. The blood examination including complete blood counts and clotting parameters were within normal limits.\nDuring her first visit to our hospital, we could not perform a neodymium-doped yttrium-aluminium-garnet laser membranotomy to perforate the ILM due to interference by the vitreous hemorrhage. Five days after the first visit, the vitreous hemorrhage had decreased and we successfully performed the neodymium-doped yttrium-aluminium-garnet laser membranotomy (power setting, 5.4 mJ) using Goldmann's three-mirror contact lens. The preretinal hemorrhage immediately moved to the vitreous cavity through the open hole in the ILM. Two days after the treatment, the best-corrected visual acuity improved to 1.0, but a small amount of the vitreous hemorrhage and residual preretinal hemorrhage were observed at the posterior pole . The optical coherence tomography image showed remaining ILM elevation . One month after the treatment, we performed another fluorescein and indocyanine green angiography, and it demonstrated no retinal vascular abnormalities in the macular area .", + "fulltext_subclaims": [ + "The patient is a 44-year-old healthy Japanese female.", + "She experienced pain in her left eye when she was relaxed and watching television.", + "She massaged her eyes with strong pressure several times with her fingers.", + "Subsequently, she noticed a sudden loss in the left central vision.", + "The next day, she visited our hospital.", + "When questioned, she could not remember having done anything that might induce Valsalva retinopathy.", + "Her left eye had a best-corrected visual acuity of 0.01.", + "The intraocular pressure (IOP) was 17 mm Hg.", + "The cornea and lens were clear.", + "A left fundus examination showed a dense preretinal hemorrhage at the posterior pole.", + "The preretinal hemorrhage appeared to be located under the internal limiting membrane (ILM).", + "This was confirmed by optical coherence tomography.", + "A mild vitreous hemorrhage was also observed.", + "Fluorescein and indocyanine green angiography showed no retinal vascular abnormality.", + "The posterior pole was veiled by the preretinal hemorrhage.", + "In her right eye, no abnormality was found.", + "The blood examination including complete blood counts and clotting parameters were within normal limits.", + "We could not perform a neodymium-doped yttrium-aluminium-garnet laser membranotomy due to interference by the vitreous hemorrhage.", + "Five days after the first visit, the vitreous hemorrhage had decreased.", + "We successfully performed the neodymium-doped yttrium-aluminium-garnet laser membranotomy.", + "The power setting was 5.4 mJ.", + "The preretinal hemorrhage immediately moved to the vitreous cavity through the open hole in the ILM.", + "Two days after the treatment, the best-corrected visual acuity improved to 1.0.", + "A small amount of the vitreous hemorrhage and residual preretinal hemorrhage were observed at the posterior pole.", + "The optical coherence tomography image showed remaining ILM elevation.", + "One month after the treatment, we performed another fluorescein and indocyanine green angiography.", + "It demonstrated no retinal vascular abnormalities in the macular area." + ], + "summary": "A healthy 44-year-old Japanese female had massaged her eye with strong pressure several times. Subsequently, she noticed a loss in the left central vision. A left-eye fundus examination showed a dense preretinal hemorrhage located under the internal limiting membrane at the posterior pole and a mild vitreous hemorrhage. We performed a neodymium-doped yttrium-aluminium-garnet laser membranotomy to perforate the internal limiting membrane. Her best-corrected visual acuity improved from 0.01 to 1.0. No retinal vascular abnormalities in the macular area were found.", + "summary_subclaims": [ + "The patient is a 44-year-old Japanese female.", + "She massaged her eye with strong pressure several times.", + "She noticed a loss in the left central vision.", + "A left-eye fundus examination showed a dense preretinal hemorrhage located under the internal limiting membrane at the posterior pole.", + "A left-eye fundus examination showed a mild vitreous hemorrhage.", + "We performed a neodymium-doped yttrium-aluminium-garnet laser membranotomy to perforate the internal limiting membrane.", + "Her best-corrected visual acuity improved from 0.01 to 1.0.", + "No retinal vascular abnormalities in the macular area were found." + ] + }, + { + "id": "multiclinsum_test_2722_en.txt", + "fulltext": "A 57-year-old Ashkenazi Jew woman, who aside from iron deficiency anemia was relatively well, with no family or personal history of malignancy, was admitted to our department of general surgery for treatment of her transverse colon tumor. Four months prior, she had begun experiencing periumbilical abdominal pain hematochezia, and she had a 10-kg weight loss. Upon physical examination, no masses were palpated, and there were no other pathologic findings. She underwent a colonoscopy, which revealed a large mass that involved nearly the whole circumference of the colon and seemed to be adjacent to the cecum. Biopsies were taken that failed to demonstrate any colonic pathology. She proceeded to undergo computed tomography (CT) of the chest and abdomen that demonstrated a huge mass that occupied the whole colonic lumen and caused a colocolic intussusception . Considerable mesenteric lymphadenopathy was seen with nodes up to 28 × 21 mm in diameter and was deemed to be evidence of positive tumoral lymph node involvement . No inguinal, pelvic, retroperitoneal, or other lymphadenopathy was seen. Considering the gross endoscopic and CT findings, she was scheduled for surgery. A laparoscopic right extended hemicolectomy was performed, which was uncomplicated, and during which considerable mesocolic lymphadenopathy was seen and widely resected accordingly.\nPathology of the surgical specimen showed findings consistent with small B cell lymphoproliferative disorders (LPDs) with plasmacytoid differentiation. At this point, though primary lymphoma of the colon was considered in the differential diagnosis, the disease was thought to be part of systemic dissemination of lymphoma. The patient was referred to the hematology clinic for further investigation. A bone marrow biopsy was performed, and the result was normal. The investigation was complemented by positron emission tomography-CT, which showed no other focus of lymphoma. Also, the result of a test for Epstein-Barr virus infection as a possible predisposing factor for lymphoma was negative. These results support the diagnosis of a primary colonic NHL small B-cell LPD with plasmacytoid differentiation, an exceedingly rare disease with only two such reports in the current literature [, ].", + "fulltext_subclaims": [ + "The patient is a 57-year-old Ashkenazi Jew woman.", + "She had iron deficiency anemia.", + "She had no family or personal history of malignancy.", + "She was admitted to the department of general surgery for treatment of her transverse colon tumor.", + "Four months prior, she had begun experiencing periumbilical abdominal pain.", + "She had hematochezia.", + "She had a 10-kg weight loss.", + "Upon physical examination, no masses were palpated.", + "There were no other pathologic findings.", + "She underwent a colonoscopy.", + "The colonoscopy revealed a large mass that involved nearly the whole circumference of the colon.", + "The mass seemed to be adjacent to the cecum.", + "Biopsies were taken.", + "The biopsies failed to demonstrate any colonic pathology.", + "She underwent computed tomography (CT) of the chest and abdomen.", + "The CT demonstrated a huge mass that occupied the whole colonic lumen.", + "The mass caused a colocolic intussusception.", + "Considerable mesenteric lymphadenopathy was seen.", + "The nodes were up to 28 × 21 mm in diameter.", + "The lymphadenopathy was deemed to be evidence of positive tumoral lymph node involvement.", + "No inguinal, pelvic, retroperitoneal, or other lymphadenopathy was seen.", + "She was scheduled for surgery.", + "A laparoscopic right extended hemicolectomy was performed.", + "The surgery was uncomplicated.", + "During surgery, considerable mesocolic lymphadenopathy was seen.", + "The mesocolic lymphadenopathy was widely resected accordingly.", + "Pathology of the surgical specimen showed findings consistent with small B cell lymphoproliferative disorders with plasmacytoid differentiation.", + "Primary lymphoma of the colon was considered in the differential diagnosis.", + "The disease was thought to be part of systemic dissemination of lymphoma.", + "The patient was referred to the hematology clinic for further investigation.", + "A bone marrow biopsy was performed.", + "The bone marrow biopsy result was normal.", + "Positron emission tomography-CT showed no other focus of lymphoma.", + "A test for Epstein-Barr virus infection was negative.", + "These results support the diagnosis of a primary colonic NHL small B-cell LPD with plasmacytoid differentiation.", + "The disease is an exceedingly rare disease.", + "There are only two such reports in the current literature." + ], + "summary": "We describe a case of a Ashkenazi Jew patient who presented in the typical way that carcinoma of the colon might present but turned out to have a very rare type of tumor in both its histology and its location.", + "summary_subclaims": [ + "We describe a case of an Ashkenazi Jew patient.", + "The patient presented in the typical way that carcinoma of the colon might present.", + "The patient turned out to have a very rare type of tumor.", + "The tumor was rare in its histology.", + "The tumor was rare in its location." + ] + }, + { + "id": "multiclinsum_test_888_en.txt", + "fulltext": "A 30-year-old woman with a body mass index (BMI) of 22.5 was hospitalized due to secondary amenorrhea and infertility. Having been married for 10 years with regular intercourse, she delivered a baby girl in 2009. After that, the patient could not become pregnant again in spite of not using contraception. She experienced amenorrhea for 6 years after giving birth, and had been treated with drugs and contraceptive rings without success. The patient could only adjust her menstrual cycle with medication. The results of basic endocrine examination showed that the serum level of follicle-stimulating hormone (FSH) was high. Examination in April, 2019 indicated that serum FSH was above normal, while the anti-Müllerian hormone (AMH) concentration remained normal. Ultrasound scanning indicated that the uterine volume was relatively small (4.0 × 3.9 × 3.3 cm), while both ovaries were normal in size and more than 10 antral follicles were observed in both ovaries . Blood tests and genetic analysis excluded lupus erythematosus, multiglandular insufficiency, diabetes, myasthenia gravis, and chromosomal abnormalities (Fragile X syndrome, Turner syndrome, and Swyer syndrome). The patient had a normal karyotype of 46, XX. Sanger sequencing did not identify associated candidate variants in the FSHR gene. Serological tests, combined with clinical diagnosis and the characteristics of the patient’s infertility suggested ROS.\nAccording to the 5th semen analysis standard of the world health organization, the husband’s sperm concentration and motility were in the normal range, and sperm acrosomal enzyme activity was normal. The study was conducted in accordance with the ethical guidelines of the institution and with the informed consent of the patient.\nAfter admission on March 4th, 2019, the patient underwent two cycles of ovarian hyperstimulation treatment . The first one (May 19, 2019) was initiated with 3.75 mg of GnRH analogue triptorelin acetate injection (Ferring, Switzerland), followed by gonadotropin (300 IU/d, 15d) on cycle day 30. During the ovarian hyperstimulation period, the follicle growth was followed by ultrasound scanning, and the serum hormone levels were determined at the same time. Unfortunately, after 15 days of stimulation, no follicles larger than 14 mm were seen, and this treatment cycle was cancelled.\nDue to the failure of the first cycle and a lack of FSHR associated variants in the genetic investigation, we tested the patient’s serum for antibodies directed against FSHR via dot blot analysis, which showed strong reactivity with FSHR . Consequently, we adjusted the procedure for the second cycle. During the whole period of downregulation and controlled ovarian hyperstimulation, the patient was orally administered dexamethasone at 0.75 mg daily. The second cycle was started on July 6, 2019, at which time the patient was first given a 3.75 mg injection of triptorelin acetate for downregulation on the second day of menstruation. Controlled ovarian hyperstimulation was initiated on day 30 with daily subcutaneous injections of 375 IU of gonadotropin (Gonal F® 225 IU/d plus HMG 150 IU/d) for 3 days, which was then increased to 525 IU (Gonal F® 225 IU/d, HMG 225 IU/d and Luveris 75 IU/d) for 7 days. During the stimulation period, the patient underwent regular ultrasound follicle tracking and hormone measurements (estradiol, luteinizing hormone, follicle-stimulating hormone and progesterone) to monitor follicular maturation. A subcutaneous injection of hCG 10,000 IU (Livzon Pharmaceuticals, China) was administered and oocyte retrieval was scheduled 36 h later, ultrasound guided transvaginal follicular aspiration was performed under negative pressure of 110 mmHg (14.7 kPa) using a single lumen aspiration needle (Cook; William Cook Australia Pty Ltd., Australia). A total of 8 Metaphase II (MII) oocytes were collected. After in vitro fertilization, 3 embryos were vitrified and cryopreserved, and the remaining embryos were discarded.\nAfter 2 months following the second ART cycle, a hormone replacement cycle for endometrial preparation was started on day 3 of menstrual cycle with estradiol valerate tablets (Bayer, Germany, 4 mg for 5 days and then 6 mg for the same period). The addition of oral estradiol (Bayer, Germany) at a dose of 8 mg daily for the next 3 days was successful in achieving an endometrial thickness of 9 mm. The serum E2 on day 16 was 346 pg/ml. Progesterone (0.05 ng/ml) and human chorionic gonadotropin (HCG, 10000 IU) were injected at night. Then, daily progesterone luteal support with vaginal tablets containing 40 mg of progesterone (Utrogestan, Besins, Paris, France) was started.\nOne embryo was thawed on day 20 (14 CII, grade II embryo with 14 cells) and transplanted. The serum value of β-hCG was 246.7 mIU/mL on the thirteenth day after the embryo transfer, and vaginal ultrasonography showed clinical pregnancy after 28 days. The pregnancy evolved without complications until the 35th week, at which point the patient exhibited oligohydramnios and gave birth to a baby girl by Caesarean section. The baby weighed 2200 g and was in good health.", + "fulltext_subclaims": [ + "The patient is a 30-year-old woman with a BMI of 22.5.", + "She had secondary amenorrhea and infertility.", + "She had been married for 10 years and delivered a baby girl in 2009.", + "After that, she could not become pregnant again in spite of not using contraception.", + "She experienced amenorrhea for 6 years after giving birth.", + "She had been treated with drugs and contraceptive rings without success.", + "The patient could only adjust her menstrual cycle with medication.", + "Basic endocrine examination showed that the serum level of follicle-stimulating hormone (FSH) was high.", + "Examination in April, 2019 indicated that serum FSH was above normal.", + "The anti-Müllerian hormone (AMH) concentration remained normal.", + "Ultrasound scanning indicated that the uterine volume was relatively small (4.0 × 3.9 × 3.3 cm).", + "Both ovaries were normal in size.", + "More than 10 antral follicles were observed in both ovaries.", + "Blood tests and genetic analysis excluded lupus erythematosus, multiglandular insufficiency, diabetes, myasthenia gravis, and chromosomal abnormalities.", + "The patient had a normal karyotype of 46, XX.", + "Sanger sequencing did not identify associated candidate variants in the FSHR gene.", + "Serological tests, combined with clinical diagnosis and the characteristics of the patient’s infertility suggested ROS.", + "The husband’s sperm concentration and motility were in the normal range.", + "Sperm acrosomal enzyme activity was normal.", + "The study was conducted in accordance with the ethical guidelines of the institution.", + "The study was conducted with the informed consent of the patient.", + "The patient underwent two cycles of ovarian hyperstimulation treatment.", + "The first cycle was initiated with 3.75 mg of GnRH analogue triptorelin acetate injection.", + "Gonadotropin was administered at 300 IU/d for 15 days.", + "After 15 days of stimulation, no follicles larger than 14 mm were seen.", + "This treatment cycle was cancelled.", + "Serum antibodies directed against FSHR were tested via dot blot analysis.", + "The dot blot analysis showed strong reactivity with FSHR.", + "The patient was orally administered dexamethasone at 0.75 mg daily.", + "The second cycle was started on July 6, 2019.", + "The patient was given a 3.75 mg injection of triptorelin acetate for downregulation on the second day of menstruation.", + "Controlled ovarian hyperstimulation was initiated on day 30 with daily subcutaneous injections of 375 IU of gonadotropin.", + "A subcutaneous injection of hCG 10,000 IU was administered.", + "Oocyte retrieval was scheduled 36 h after the hCG injection.", + "Ultrasound guided transvaginal follicular aspiration was performed under negative pressure of 110 mmHg.", + "A total of 8 Metaphase II (MII) oocytes were collected.", + "After in vitro fertilization, 3 embryos were vitrified and cryopreserved.", + "A hormone replacement cycle for endometrial preparation was started on day 3 of menstrual cycle.", + "Estradiol valerate tablets were administered at 4 mg for 5 days and then 6 mg for the same period.", + "The addition of oral estradiol at a dose of 8 mg daily for the next 3 days was successful in achieving an endometrial thickness of 9 mm.", + "The serum E2 on day 16 was 346 pg/ml.", + "Progesterone and human chorionic gonadotropin were injected at night.", + "Daily progesterone luteal support with vaginal tablets containing 40 mg of progesterone was started.", + "One embryo was thawed on day 20.", + "The embryo was a grade II embryo with 14 cells.", + "The serum value of β-hCG was 246.7 mIU/mL on the thirteenth day after the embryo transfer.", + "Vaginal ultrasonography showed clinical pregnancy after 28 days.", + "The pregnancy evolved without complications until the 35th week.", + "The patient exhibited oligohydramnios at the 35th week.", + "The patient gave birth to a baby girl by Caesarean section.", + "The baby weighed 2200 g.", + "The baby was in good health." + ], + "summary": "The 30-year-old woman presented with secondary amenorrhea and infertility. Her serum FSH levels were found to be higher than normal, but in discordance with a normal anti-Müllerian hormone (AMH) level and antral follicle count. Genetic investigation found no mutations potentially affecting FSHR. With reference of previous ROS studies, the patient's serum was analyzed for antibodies directed against FSHR and dot blot analysis showed strong reactivity with FSHR. Then, dexamethasone was proposed to the patient, and she successfully became pregnant, finally delivering a healthy girl by caesarean section.", + "summary_subclaims": [ + "The patient is a 30-year-old woman.", + "She presented with secondary amenorrhea.", + "She presented with infertility.", + "Her serum FSH levels were found to be higher than normal.", + "Her anti-Müllerian hormone (AMH) level was normal.", + "Her antral follicle count was normal.", + "Genetic investigation found no mutations potentially affecting FSHR.", + "The patient's serum was analyzed for antibodies directed against FSHR.", + "Dot blot analysis showed strong reactivity with FSHR.", + "Dexamethasone was proposed to the patient.", + "The patient successfully became pregnant.", + "The patient delivered a healthy girl by caesarean section." + ] + }, + { + "id": "multiclinsum_test_3064_en.txt", + "fulltext": "A 13-year-old patient with significant neurological impairment, weight loss of 14 kg, and severe and recurrent gastroesophageal reflux disease (GERD) who had undergone three prior surgeries to address GERD, including a laparoscopic Nissen fundoplication with a gastrostomy, a laparoscopic Collis-Nissen procedure, and a Nissen procedure performed openly. The patient underwent surgery to address a chronic esophageal stricture secondary to GERD that had failed to respond to dilation. The surgery involved a replacement of the esophagus with the right colon via a retrograde approach, closure of the prior gastrostomy, and creation of a new gastrostomy. Sutures and anastomoses were performed manually. On the ninth day postoperatively, the patient developed a surgical site infection in the laparotomy incision. Four days later, a skin fistula developed through the prior gastrostomy that drained gastric and purulent contents. A contrast-enhanced CT scan showed a gastric leak and confirmed the diagnosis of FGC. Initially, management was conservative with absolute diet, parenteral nutrition, broad spectrum antibiotics, and a skin ostomy bag placed over the skin defect. A skin fistula developed through the skin defect and drained gastric and purulent contents. A contrast-enhanced CT scan was performed three days later. A 5.9 mm gastroscope was inserted through the new gastrostomy and a guide wire was placed through the FGC and externalized through the skin defect. Two 4 Fr-24 cm and 3 Fr-12 cm CUDJs were placed over the guide wire from the skin, with the inner end of the guide wire in the gastric lumen and the outer end in the skin defect. A skin ostomy bag was placed over the skin defect. A gastrojejunal tube was placed through the new gastrostomy. A 0.64 mm-260 cm guide wire was placed through the FGC and externalized through the skin defect. Two CUDJs (4 Fr-24 cm and 3 Fr-12 cm) were placed over the guide wire from the skin, with the inner end of the guide wire in the gastric lumen and the outer end in the skin defect. A skin ostomy bag was placed over the skin defect. A gastrojejunal tube was placed through the new gastrostomy. A 0.64 mm-260 cm guide wire was placed through the FGC and externalized through the skin defect. Two CUDJs (4 Fr-24 cm and 3 Fr-12 cm) were placed over the guide wire from the skin, with the inner end of the guide wire in the gastric lumen and the outer end in the skin defect. The outer end of the catheters was not fully folded due to the small size and morphology of the space. A skin ostomy bag was placed over the skin defect. A gastrojejunal tube was placed through the new gastrostomy. A 0.64 mm-260 cm guide wire was placed through the FGC and externalized through the skin defect. Two CUDJs (4 Fr-24 cm and 3 Fr-12 cm) were placed over the guide wire from the skin, with the inner end of the guide wire in the gastric lumen and the outer end in the skin defect. The outer end of the catheters was not fully folded due to the small size and morphology of the space. A skin ostomy bag was placed over the skin defect. A gastrojejunal tube was placed through the new gastrostomy. A 0.64 mm-260 cm guide wire was placed through the FGC and externalized through the skin defect. Two CUDJs (4 Fr-24 cm and 3 Fr-12 cm) were placed over the guide wire from the skin, with the inner end of the guide wire in the gastric lumen and the outer end in the skin defect. The outer end of the catheters was not fully folded due to the small size and morphology of the space. A skin ostomy bag was placed over the skin defect. A gastrojejunal tube was placed through the new gastrostomy. A 0.64 mm-260 cm guide wire was placed through the FGC and externalized through the skin defect. Two CUDJs (4 Fr-24 cm and 3 Fr-12 cm) were placed over the guide wire from the skin, with the inner end of the guide wire in the gastric lumen and the outer end in the skin defect. The outer end of the catheters was not fully folded due to the small size and morphology of the space. A skin ostomy bag was placed over the skin defect. A gastrojejunal tube was placed through the new gastrostomy. A 0.64 mm-260 cm guide wire was placed through the FGC and externalized through the skin defect. Two CUDJs (4 Fr-24 cm and 3 Fr-12 cm) were placed over the guide wire from the skin, with the inner end of the guide wire in the gastric lumen and the outer end in the skin defect. The outer end of the catheters was not fully folded due to the small size and morphology of the space. A skin ostomy bag was placed over the skin defect. A gastrojejunal tube was placed through the new gastrostomy. A 0.64 mm-260 cm guide wire was placed through the FGC and externalized through the skin defect. Two CUDJs (4 Fr-24 cm and 3 Fr-12 cm) were placed over the guide wire from the skin, with the inner end of the guide wire in the gastric lumen and the outer end in the skin defect. The outer end of the catheters was not fully folded due to the small size and morphology of the space. A skin ostomy bag was placed over the skin defect. A gastrojejunal tube was placed through the new gastrostomy. A 0.64 mm-260 cm guide wire was placed through the FGC and externalized through the skin defect. Two CUDJs (4 Fr-24 cm and 3 Fr-12 cm) were placed over the guide wire from the skin, with the inner end of the guide wire in the gastric lumen and the outer end in the skin defect. The outer end of the catheters was not fully folded due to the small size and morphology of the space. A skin ostomy bag was placed over the skin defect. A gastrojejunal tube was placed through the new gastrostomy. A 0.64 mm-260 cm guide wire was placed through the FGC and externalized through the skin defect. Two CUDJs (4 Fr-24 cm and 3 Fr-12 cm) were placed over the guide wire from the skin, with the inner end of the guide wire in the gastric lumen and the outer end in the skin defect. The outer end of the catheters was not fully folded due to the small size and morphology of the space. A skin ostomy bag was placed over the skin defect. A gastrojejunal tube was placed through the new gastrostomy. A 0.64 mm-260 cm guide wire was placed through the FGC and externalized through the skin defect. Two CUDJs (4 Fr-24 cm and 3 Fr-12 cm) were placed over the guide wire from the skin, with the inner end of the guide wire in the gastric lumen and the outer end in the skin defect. The outer end of the catheters was not fully folded due to the small size and morphology of the space. A skin ostomy bag was placed over the skin defect. A gastrojejunal tube was placed through the new gastrostomy. A 0.64 mm-260 cm guide wire was placed through the FGC and externalized through the skin defect. Two CUDJs (4 Fr-24 cm and 3 Fr-12 cm) were placed over the guide wire from the skin, with the inner end of the guide wire in the gastric lumen and the outer end in the skin defect. The outer end of the catheters was not fully folded due to the small size and morphology of the space. A skin ostomy bag was placed over the skin defect. A gastrojejunal tube was placed through the new gastrostomy. A 0.64 mm-260 cm guide wire was placed through the FGC and externalized through the skin defect. Two CUDJs (4 Fr-24 cm and 3 Fr-12 cm) were placed over the guide wire from the skin, with the inner end of the guide wire in the gastric lumen and the outer end in the skin defect. The outer end of the catheters was not fully folded due to the small size and morphology of the space. A skin ostomy bag was placed over the skin defect. A gastrojejunal tube was placed through the new gastrostomy. A 0.64 mm-260 cm guide wire was placed through the FGC and externalized through the skin defect. Two CUDJs (4 Fr-24 cm and 3 Fr-12 cm) were placed over the guide wire from the skin, with the inner end of the guide wire in the gastric lumen and the outer end in the skin defect. The outer end of the catheters was not fully folded due to the small size and morphology of the space. A skin ostomy bag was placed over the skin defect. A gastrojejunal tube was placed through the new gastrostomy. A 0.64 mm-260 cm guide wire was placed through the FGC and externalized through the skin defect. Two CUDJs (4 Fr-24 cm and 3 Fr-12 cm) were placed over the guide wire from the skin, with the inner end of the guide wire in the gastric lumen and the outer end in the skin defect. The outer end of the catheters was not fully folded due to the small size and morphology of the space. A skin ostomy bag was placed over the skin defect. A gastrojejunal tube was placed through the new gastrostomy. A 0.64 mm-260 cm guide wire was placed through the FGC and externalized through the skin defect. Two CUDJs (4 Fr-24 cm and 3 Fr-12 cm) were placed over the guide wire from the skin, with the inner end of the guide wire in the gastric lumen and the outer end in the skin defect. The outer end of the catheters was not fully folded due to the small size and morphology of the space. A skin ostomy bag was placed over the skin defect. A gastrojejunal tube was placed through the new gastrostomy. A 0.64 mm-260 cm guide wire was placed through the FGC and externalized through the skin defect. Two CUDJs (4 Fr-24 cm and 3 Fr-12 cm) were placed over the guide wire from the skin, with the inner end of the guide wire in the gastric lumen and the outer end in the skin defect. The outer end of the catheters was not fully folded due to the small size and morphology of the space. A skin ostomy bag was placed over the skin defect. A gastrojejunal tube was placed through the new gastrostomy. A 0.64 mm-260 cm guide wire was placed through the FGC and externalized through the skin defect. Two CUDJs (4 Fr-24 cm and 3 Fr-12 cm) were placed over the guide wire from the skin, with the inner end of the guide wire in the gastric lumen and the outer end in the skin defect. The outer end of the catheters was not fully folded due to the small size and morphology of the space. A skin ostomy bag was placed over the skin defect. A gastrojejunal tube was placed through the new gastrostomy. A 0.64 mm-260 cm guide wire was placed through the FGC and externalized through the skin defect. Two CUDJs (4 Fr-24 cm and 3 Fr-12 cm) were placed over the guide wire from the skin, with the inner end of the guide wire in the gastric lumen and the outer end in the skin defect. The outer end of the catheters was not fully folded due to the small size and morphology of the space. A skin ostomy bag was placed over the skin defect. A gastrojejunal tube was placed through the new gastrostomy. A 0.64 mm-260 cm guide wire was placed through the FGC and externalized through the skin defect. Two CUDJs (4 Fr-24 cm and 3 Fr-12 cm) were placed over the guide wire from the skin, with the inner end of the guide wire in the gastric lumen and the outer end in the skin defect. The outer end of the catheters was not fully folded due to the small size and morphology of the space. A skin ostomy bag was placed over the skin defect. A gastrojejunal tube was placed through the new gastrostomy. A 0.64 mm-260 cm guide wire was placed through the FGC and externalized through the skin defect. Two CUDJs (4 Fr-24 cm and 3 Fr-12 cm) were placed over the guide wire from the skin, with the inner end of the guide wire in the gastric lumen and the outer end in the skin defect. The outer end of the catheters was not fully folded due to the small size and morphology of the space. A skin ostomy bag was placed over the skin defect. A gastrojejunal tube was placed through the new gastrostomy. A 0.64 mm-260 cm guide wire was placed through the FGC and externalized through the skin defect. Two CUDJs (4 Fr-24 cm and 3 Fr-12 cm) were placed over the guide wire from the skin, with the inner end of the guide wire in the gastric lumen and the outer end in the skin defect. The outer end of the catheters was not fully folded due to the small size and morphology of the space. A skin ostomy bag was placed over the skin defect. A gastrojejunal tube was placed through the new gastrostomy. A 0.64 mm-260 cm guide wire was placed through the FGC and externalized through the skin defect. Two CUDJs (4 Fr-24 cm and 3 Fr-12 cm) were placed over the guide wire from the skin, with the inner end of the guide wire in the gastric lumen and the outer end in the skin defect. The outer end of the catheters was not fully folded due to the small size and morphology of the space. A skin ostomy bag was placed over the skin defect. A gastrojejunal tube was placed through the new gastrostomy. A 0.64 mm-260 cm guide wire was placed through the FGC and externalized through the skin defect. Two CUDJs (4 Fr-24 cm and 3 Fr-12 cm) were placed over the guide wire from the skin, with the inner end of the guide wire in the gastric lumen and the outer end in the skin defect. The outer end of the catheters was not fully folded due to the small size and morphology of the space. A skin ostomy bag was placed over the skin defect. A gastrojejunal tube was placed through the new gastrostomy. A 0.64 mm-260 cm guide wire was placed through the FGC and externalized through the skin defect. Two CUDJs (4 Fr-24 cm and 3 Fr-12 cm) were placed over the guide wire from the skin, with the inner end of the guide wire in the gastric lumen and the outer end in the skin defect. The outer end of the catheters was not fully folded due to the small size and morphology of the space. A skin ostomy bag was placed over the skin defect. A gastrojejunal tube was placed through the new gastrostomy. A 0.64 mm-260 cm guide wire was placed through the FGC and externalized through the skin defect. Two CUDJs (4 Fr-24 cm and 3 Fr-12 cm) were placed over the guide wire from the skin, with the inner end of the guide wire in the gastric lumen and the outer end in the skin defect. The outer end of the catheters was not fully folded due to the small size and morphology of the space. A skin ostomy bag was placed over the skin defect. A gastrojejunal tube was placed through the new gastrostomy. A 0.64 mm-260 cm guide wire was placed through the FGC and externalized through the skin defect. Two CUDJs (4 Fr-24 cm and 3 Fr-12 cm) were placed over the guide wire from the skin, with the inner end of the guide wire in the gastric lumen and the outer end in the skin defect. The outer end of the catheters was not fully folded due to the small size and morphology of the space. A skin ostomy bag was placed over the skin defect. A gastrojejunal tube was placed through the new gastrostomy. A 0.64 mm-260 cm guide wire was placed through the FGC and externalized through the skin defect. Two CUDJs (4 Fr-24 cm and 3 Fr-12 cm) were placed over the guide wire from the skin, with the inner end of the guide wire in the gastric lumen and the outer end in the skin defect. The outer end of the catheters was not fully folded due to the small size and morphology of the space. A skin ostomy bag was placed over the skin defect. A gastrojejunal tube was placed through the new gastrostomy. A 0.64 mm-260 cm guide wire was placed through the FGC and externalized through the skin defect. Two CUDJs (4 Fr-24 cm and 3 Fr-12 cm) were placed over the guide wire from the skin, with the inner end of the guide wire in the gastric lumen and the outer end in the skin defect. The outer end of the catheters was not fully folded due to the small size and morphology of the space. A skin ostomy bag was placed over the skin defect. A gastrojejunal tube was placed through the new gastrostomy. A 0.64 mm-260 cm guide wire was placed through the FGC and externalized through the skin defect. Two CUDJs (4 Fr-24 cm and 3 Fr-12 cm) were placed over the guide wire from the skin, with the inner end of the guide wire in the gastric lumen and the outer end in the skin defect. The outer end of the catheters was not fully folded due to the small size and morphology of the space. A skin ostomy bag was placed over the skin defect. A gastrojejunal tube was placed through the new gastrostomy. A 0.64 mm-260 cm guide wire was placed through the FGC and externalized through the skin defect. Two CUDJs (4 Fr-24 cm and 3 Fr-12 cm) were placed over the guide wire from the skin, with the inner end of the guide wire in the gastric lumen and the outer end in the skin defect. The outer end of the catheters was not fully folded due to the small size and morphology of the space. A skin ostomy bag was placed over the skin defect. A gastrojejunal tube was placed through the new gastrostomy. A 0.64 mm-260 cm guide wire was placed through the FGC and externalized through the skin defect. Two CUDJs (4 Fr-24 cm and 3 Fr-12 cm) were placed over the guide wire from the skin, with the inner end of the guide wire in the gastric lumen and the outer end in the skin defect. The outer end of the catheters was not fully folded due to the small size and morphology of the space. A skin ostomy bag was placed over the skin defect. A gastrojejunal tube was placed through the new gastrostomy. A 0.64 mm-260 cm guide wire was placed through the FGC and externalized through the skin defect. Two CUDJs (4 Fr-24 cm and 3 Fr-12 cm) were placed over the guide wire from the skin, with the inner end of the guide wire in the gastric lumen and the outer end in the skin defect. The outer end of the catheters was not fully folded due to the small size and morphology of the space. A skin ostomy bag was placed over the skin defect. A gastrojejunal tube was placed through the new gastrostomy. A 0.64 mm-260 cm guide wire was placed through the FGC and externalized through the skin defect. Two CUDJs (4 Fr-24 cm and 3 Fr-12 cm) were placed over the guide wire from the skin, with the inner end of the guide wire in the gastric lumen and the outer end in the skin defect. The outer end of the catheters was not fully folded due to the small size and morphology of the space. A skin ostomy bag was placed over the skin defect. A gastrojejunal tube was placed through the new gastrostomy. A 0.64 mm-260 cm guide wire was placed through the FGC and externalized through the skin defect. Two CUDJs (4 Fr-24 cm and 3 Fr-12 cm) were placed over the guide wire from the skin, with the inner end of the guide wire in the gastric lumen and the outer end in the skin defect. The outer end of the catheters was not fully folded due to the small size and morphology of the space. A skin ostomy bag was placed over the skin defect. A gastrojejunal tube was placed through the new gastrostomy. A 0.64 mm-260 cm guide wire was placed through the FGC and externalized through the skin defect. Two CUDJs (4 Fr-24 cm and 3 Fr-12 cm) were placed over the guide wire from the skin, with the inner end of the guide wire in the gastric lumen and the outer end in the skin defect. The outer end of the catheters was not fully folded due to the small size and morphology of the space. A skin ostomy bag was placed over the skin defect. A gastrojejunal tube was placed through the new gastrostomy. A 0.64 mm-260 cm guide wire was placed through the FGC and externalized through the skin defect. Two CUDJs (4 Fr-24 cm and 3 Fr-12 cm) were placed over the guide wire from the skin, with the inner end of the guide wire in the gastric lumen and the outer end in the skin defect. The outer end of the catheters was not fully folded due to the small size and morphology of the space. A skin ostomy bag was placed over the skin defect. A gastrojejunal tube was placed through the new gastrostomy. A 0.64 mm-260 cm guide wire was placed through the FGC and externalized through the skin defect. Two CUDJs (4 Fr-24 cm and 3 Fr-12 cm) were placed over the guide wire from the skin, with the inner end of the guide wire in the gastric lumen and the outer end in the skin defect. The outer end of the catheters was not fully folded due to the small size and morphology of the space. A skin ostomy bag was placed over the skin defect. A gastrojejunal tube was placed through the new gastrostomy. A 0.64 mm-260 cm guide wire was placed through the FGC and externalized through the skin defect. Two CUDJs (4 Fr-24 cm and 3 Fr-12 cm) were placed over the guide wire from the skin, with the inner end of the guide wire in the gastric lumen and the outer end in the skin defect. The outer end of the catheters was not fully folded due to the small size and morphology of the space. A skin ostomy bag was placed over the skin defect. A gastrojejunal tube was placed through the new gastrostomy. A 0.64 mm-260 cm guide wire was placed through the FGC and externalized through the skin defect. Two CUDJs (4 Fr-24 cm and 3 Fr-12 cm) were placed over the guide wire from the skin, with the inner end of the guide wire in the gastric lumen and the outer end in the skin defect. The outer end of the catheters was not fully folded due to the small size and morphology of the space. A skin ostomy bag was placed over the skin defect. A gastrojejunal tube was placed through the new gastrostomy. A 0.64 mm-260 cm guide wire was placed through the FGC and externalized through the skin defect. Two CUDJs (4 Fr-24 cm and 3 Fr-12 cm) were placed over the guide wire from the skin, with the inner end of the guide wire in the gastric lumen and the outer end in the skin defect. The outer end of the catheters was not fully folded due to the small size and morphology of the space. A skin ostomy bag was placed over the skin defect. A gastrojejunal tube was placed through the new gastrostomy. A 0.64 mm-260 cm guide wire was placed through the FGC and externalized through the skin defect. Two CUDJs (4 Fr-24 cm and 3 Fr-12 cm) were placed over the guide wire from the skin, with the inner end of the guide wire in the gastric lumen and the outer end in the skin defect. The outer end of the catheters was not fully folded due to the small size and morphology of the space. A skin ostomy bag was placed over the skin defect. A gastrojejunal tube was placed through the new gastrostomy. A 0.64 mm-260 cm guide wire was placed through the FGC and externalized through the skin defect. Two CUDJs (4 Fr-24 cm and 3 Fr-12 cm) were placed over the guide wire from the skin, with the inner end of the guide wire in the gastric lumen and the outer end in the skin defect. The outer end of the catheters was not fully folded due to the small size and morphology of the space. A skin ostomy bag was placed over the skin defect. A gastrojejunal tube was placed through the new gastrostomy. A 0.64 mm-260 cm guide wire was placed through the FGC and externalized through the skin defect. Two CUDJs (4 Fr-24 cm and 3 Fr-12 cm) were placed over the guide wire from the skin, with the inner end of the guide wire in the gastric lumen and the outer end in the skin defect. The outer end of the catheters was not fully folded due to the small size and morphology of the space. A skin ostomy bag was placed over the skin defect. A gastrojejunal tube was placed through the new gastrostomy. A 0.64 mm-260 cm guide wire was placed through the FGC and externalized through the skin defect. Two CUDJs (4 Fr-24 cm and 3 Fr-12 cm) were placed over the guide wire from the skin, with the inner end of the guide wire in the gastric lumen and the outer end in the skin defect. The outer end of the catheters was not fully folded due to the small size and morphology of the space. A skin ostomy bag was placed over the skin defect. A gastrojejunal tube was placed through the new gastrostomy. A 0.64 mm-260 cm guide wire was placed through the FGC and externalized through the skin defect. Two CUDJs (4 Fr-24 cm and 3 Fr-12 cm) were placed over the guide wire from the skin, with the inner end of the guide wire in the gastric lumen and the outer end in the skin defect. The outer end of the catheters was not fully folded due to the small size and morphology of the space. A skin ostomy bag was placed over the skin defect. A gastrojejunal tube was placed through the new gastrostomy. A 0.64 mm-260 cm guide wire was placed through the FGC and externalized through the skin defect. Two CUDJs (4 Fr-24 cm and 3 Fr-12 cm) were placed over the guide wire from the skin, with the inner end of the guide wire in the gastric lumen and the outer end in the skin defect. The outer end of the catheters was not fully folded due to the small size and morphology of the space. A skin ostomy bag was placed over the skin defect. A gastrojejunal tube was placed through the new gastrostomy. A 0.64 mm-260 cm guide wire was placed through the FGC and externalized through the skin defect. Two CUDJs (4 Fr-24 cm and 3 Fr-12 cm) were placed over the guide wire from the skin, with the inner end of the guide wire in the gastric lumen and the outer end in the skin defect. The outer end of the catheters was not fully folded due to the small size and morphology of the space. A skin ostomy bag was placed over the skin defect. A gastrojejunal tube was placed through the new gastrostomy. A 0.64 mm-260 cm guide wire was placed through the FGC and externalized through the skin defect. Two CUDJs (4 Fr-24 cm and 3 Fr-12 cm) were placed over the guide wire from the skin, with the inner end of the guide wire in the gastric lumen and the outer end in the skin defect. The outer end of the catheters was not fully folded due to the small size and morphology of the space. A skin ostomy bag was placed over the skin defect. A gastrojejunal tube was placed through the new gastrostomy. A 0.64 mm-260 cm guide wire was placed through the FGC and externalized through the skin defect. Two CUDJs (4 Fr-24 cm and 3 Fr-12 cm) were placed over the guide wire from the skin, with the inner end of the guide wire in the gastric lumen and the outer end in the skin defect. The outer end of the catheters was not fully folded due to the small size and morphology of the space. A skin ostomy bag was placed over the skin defect. A gastrojejunal tube was placed through the new gastrostomy. A 0\n", + "fulltext_subclaims": [], + "summary": "A pediatric patient with weight deficit who developed FGC after surgery (esophagocoloplasty with right colon). FGC was treated endoscopically with double J ureteral catheters (CUDJ) with one end in the gastric lumen and the other end coming out through the skin orifice through the fistula. Laminar drainage was used to evacuate the intraabdominal cavity. The patient received feeding through a gastro-jejunal probe, with the diameter of the CUDJ being progressively reduced. At 92 days of the initial endoscopic therapy, the gastric orifice was closed. No serious complications or recurrences were recorded.\n", + "summary_subclaims": [ + "The patient had a weight deficit.", + "The patient developed FGC after surgery.", + "The surgery was esophagocoloplasty with right colon.", + "FGC was treated endoscopically with double J ureteral catheters.", + "The catheters were placed with one end in the gastric lumen.", + "The other end came out through the skin orifice through the fistula.", + "Laminar drainage was used to evacuate the intraabdominal cavity.", + "The patient received feeding through a gastro-jejunal probe.", + "The diameter of the CUDJ was progressively reduced.", + "At 92 days of the initial endoscopic therapy, the gastric orifice was closed.", + "No serious complications were recorded.", + "No recurrences were recorded." + ] + }, + { + "id": "multiclinsum_test_3195_en.txt", + "fulltext": "80-year-old woman with a history of significant hypertension for 6 years, diagnosed, treated with 50 mg losartan every 12 hours, which, according to the patient, was in adequate control.\n\nShe presented a 6-week history characterized by morning stiffness lasting 45 minutes, inflammatory-type pain in the shoulders, elbows, hands, knees, ankles, and feet, associated with fatigue. Within a week, she developed edema in the hands and feet, so she went for evaluation and began treatment with anti-inflammatory drugs, without improvement of the symptoms, which is why she was referred to the service. Physical examination revealed pain in the range of motion arcs in the neck, shoulders, elbows, and wrists. She had limited extension of the elbows, synovitis in the wrists, proximal metacarpofalangeal and interphalangeal joints, pain in the knees, ankles, metatarsophalangeal joints, and edema in the hands and feet with pitting.\n\nThe patient was examined and found to have glucose 94, Cr 0.6, uric acid 3.5, ALT 8, AST 14, IgG 1132, IgM 92, IgA 198, Hb 12, platelets 388, leukocytes 4.6.\n\nThe general urine examination was unremarkable: no increase in acute phase reactants, ESR 56, CRP 23, with negative rheumatoid factor, negative anti-citrullinated peptide antibodies, negative antinuclear antibodies by indirect immunofluorescence.\n\nAnteroposterior hand radiograph showed soft tissue edema and juxtaarticular osteopenia; there were no erosions.\n\nMastography and pelvic ultrasound were normal; tumour markers were in the normal range.\n\nRS3PE was diagnosed and was managed with 15 mg prednisone every 24 hours. The patient was reevaluated 6 weeks later and showed improvement in the symptoms. The patient reported that 72 hours after the start of treatment, she had a significant decrease in pain and the edema progressively subsided.\n\nThe control laboratory studies showed the following values: glucose 91, Cr 0.8, ALT 12, AST 16, Hb 12.8, platelets 223, leukocytes 5.4, ESR 10, CRP 1.\n\nThe steroid was gradually reduced and discontinued at 10 months. The patient is currently under surveillance, with no new inflammatory events and no suggestive data of neoplasia.\n", + "fulltext_subclaims": [ + "The patient is an 80-year-old woman.", + "She has a history of significant hypertension for 6 years.", + "She was treated with 50 mg losartan every 12 hours.", + "She reported that the hypertension was in adequate control.", + "She had a 6-week history of morning stiffness lasting 45 minutes.", + "She had inflammatory-type pain in the shoulders, elbows, hands, knees, ankles, and feet.", + "She had fatigue.", + "She developed edema in the hands and feet within a week.", + "She was evaluated and began treatment with anti-inflammatory drugs.", + "There was no improvement of the symptoms.", + "She was referred to the service.", + "Physical examination revealed pain in the range of motion arcs in the neck, shoulders, elbows, and wrists.", + "She had limited extension of the elbows.", + "She had synovitis in the wrists, proximal metacarpophalangeal and interphalangeal joints.", + "She had pain in the knees, ankles, metatarsophalangeal joints.", + "She had edema in the hands and feet with pitting.", + "The patient had glucose 94.", + "The patient had Cr 0.6.", + "The patient had uric acid 3.5.", + "The patient had ALT 8.", + "The patient had AST 14.", + "The patient had IgG 1132.", + "The patient had IgM 92.", + "The patient had IgA 198.", + "The patient had Hb 12.", + "The patient had platelets 388.", + "The patient had leukocytes 4.6.", + "The general urine examination was unremarkable.", + "There was no increase in acute phase reactants.", + "ESR was 56.", + "CRP was 23.", + "Rheumatoid factor was negative.", + "Anti-citrullinated peptide antibodies were negative.", + "Antinuclear antibodies by indirect immunofluorescence were negative.", + "Anteroposterior hand radiograph showed soft tissue edema.", + "Anteroposterior hand radiograph showed juxtaarticular osteopenia.", + "There were no erosions.", + "Mastography and pelvic ultrasound were normal.", + "Tumour markers were in the normal range.", + "RS3PE was diagnosed.", + "She was managed with 15 mg prednisone every 24 hours.", + "She was reevaluated 6 weeks later.", + "She showed improvement in the symptoms.", + "She reported a significant decrease in pain 72 hours after the start of treatment.", + "The edema progressively subsided.", + "Control laboratory studies showed glucose 91.", + "Control laboratory studies showed Cr 0.8.", + "Control laboratory studies showed ALT 12.", + "Control laboratory studies showed AST 16.", + "Control laboratory studies showed Hb 12.8.", + "Control laboratory studies showed platelets 223.", + "Control laboratory studies showed leukocytes 5.4.", + "Control laboratory studies showed ESR 10.", + "Control laboratory studies showed CRP 1.", + "The steroid was gradually reduced and discontinued at 10 months.", + "The patient is currently under surveillance.", + "There were no new inflammatory events.", + "There were no suggestive data of neoplasia." + ], + "summary": "80-year-old woman with a picture of acute onset with polyarthralgia, functional limitation associated with edema of hands and feet with fovea. After the approach and the associated neoplasms were ruled out, RS3PE was diagnosed. She was treated with prednisone and there was a good response, with remission of the manifestations at 6 weeks and subsequent suspension of the steroid.\n", + "summary_subclaims": [ + "The patient is an 80-year-old woman.", + "She had acute onset.", + "She had polyarthralgia.", + "She had functional limitation.", + "She had edema of hands and feet with fovea.", + "RS3PE was diagnosed.", + "The approach and associated neoplasms were ruled out.", + "She was treated with prednisone.", + "There was a good response.", + "The manifestations remitted at 6 weeks.", + "The steroid was suspended." + ] + }, + { + "id": "multiclinsum_test_832_en.txt", + "fulltext": "A previously healthy, 4 week old, Caucasian boy was brought to the emergency department by his mother because he had accidentally been given the mothers’ dose of citalopram. Instead of the vitamin D drops she intended to give him, she accidentally switched bottles of the citalopram and vitamin D. These bottles are similar, as shown in Fig. . The mother noticed the incorrect medication bottle around 30 min later and immediately presented the infant to the emergency department. She administered 10 drops of citalopram, corresponding to 20 mg. With a weight of 3355 g corresponding to a dose of around 6.0 mg/kg.\nUpon first physical examination we saw an extremely jittery, agitated infant with an evident opisthotonos, as shown in Fig. . Vital signs were stable, the patient had a respiratory rate of 50/min and an oxygen saturation of 100% in room air. At presentation the patient showed an isolated systolic hypertension. Blood pressure was 110/38 mmHg (reference value p95 for systolic pressure 105 mmHg), with a regular heart rate of 190 beats per minute . An electrocardiogram showed sinus tachycardia with normal intervals. A nasogastric tube was inserted to empty the stomach; activated charcoal and sodium sulfate were administered over a 2 h period to prevent any possible further absorption of the citalopram. Furthermore, an intravenous cannula was placed with maintenance fluid and secure intravenous access.\nThe patient was transferred to a neonatal intensive care unit (NICU) for intensive monitoring, concerning the possible risk of cardiac rhythm disturbances and convulsions. Laboratory testing was performed including a complete blood count, infection parameters and electrolyte concentration, all results were within normal limits. Because of the risk of convulsions and intracerebral hemorrhage, amplitude-integrated electroencephalography (aEEG) and cerebral ultrasound were performed, which showed no abnormalities.\nAfter 16 h the patient was transferred back to the medium care neonatal ward. In the following days he continued showing signs of extreme jitteriness and increased muscle tone. After 4 days these symptoms were found to be acceptable enough to discharge the patient. Before, during and after admission the patient was only fed formula feeding, breast milk was not used.\nDuring several weeks, at ambulant follow-up, the patient showed persistent signs of increased muscle tone for at least 1 month after discharge. Furthermore, he showed signs of agitation and gastro-oesophageal reflux. Treatment was started with esomeprazole to counteract the effect of the gastro-oesophageal reflux. After 7 months patients symptoms disappeared completely and the patient was discharged from further ambulant follow-up.\nTo assess pharmacokinetic parameters as well as to predict time to improvement of symptoms, citalopram and the active metabolite desmethylcitalopram concentrations were measured in the serum of the patient. Citalopram and desmethylcitalopram concentrations were analyzed using a validated UPLC-MS-MS method at the Onze Lieve Vrouwe Gasthuis hospital in Amsterdam, the Netherlands. Two hours after ingestion, the citalopram plasma concentration was 77 μg/l with no detectable desmethylcitalopram concentration. Fifty-four hours after ingestion, citalopram serum level decreased to 33 μg/l and desmethylcitalopram increased to a concentration of 43 μg/l.\nTo objectify the severity and clinical course, Finnegan scores were randomly measured during the course of admission (Additional file ) . Fig. shows the course of the known Finnegan scores, citalopram and desmethylcitalopram serum levels. Finnegan scores were as follows: 2 h after ingestion 11, 24 h after ingestion 8, 46 h after ingestion 6, 66 h after ingestion 3, more elaborate data is shown in Additional file . Unfortunately during the time of admittance at the NICU, Finnegan scores were not measured.", + "fulltext_subclaims": [ + "The patient was a 4 week old, previously healthy, Caucasian boy.", + "The mother accidentally gave the infant the mother's dose of citalopram instead of vitamin D drops.", + "The bottles of citalopram and vitamin D were similar.", + "The mother noticed the incorrect medication bottle around 30 min after administration.", + "The infant was presented to the emergency department immediately after the mother noticed the error.", + "The mother administered 10 drops of citalopram, corresponding to 20 mg.", + "The infant's weight was 3355 g.", + "The citalopram dose was around 6.0 mg/kg.", + "Upon first physical examination, the infant was extremely jittery and agitated.", + "The infant showed an evident opisthotonos.", + "Vital signs were stable.", + "The infant had a respiratory rate of 50/min.", + "The infant had an oxygen saturation of 100% in room air.", + "The patient showed an isolated systolic hypertension.", + "Blood pressure was 110/38 mmHg.", + "The reference value p95 for systolic pressure was 105 mmHg.", + "The heart rate was 190 beats per minute.", + "An electrocardiogram showed sinus tachycardia with normal intervals.", + "A nasogastric tube was inserted to empty the stomach.", + "Activated charcoal and sodium sulfate were administered over a 2 h period.", + "An intravenous cannula was placed with maintenance fluid and secure intravenous access.", + "The patient was transferred to a neonatal intensive care unit (NICU) for intensive monitoring.", + "Laboratory testing included a complete blood count, infection parameters, and electrolyte concentration.", + "All laboratory results were within normal limits.", + "Amplitude-integrated electroencephalography (aEEG) and cerebral ultrasound were performed.", + "aEEG and cerebral ultrasound showed no abnormalities.", + "After 16 h, the patient was transferred back to the medium care neonatal ward.", + "In the following days, the patient continued showing signs of extreme jitteriness and increased muscle tone.", + "After 4 days, these symptoms were found to be acceptable enough to discharge the patient.", + "Before, during, and after admission, the patient was only fed formula feeding.", + "At ambulant follow-up, the patient showed persistent signs of increased muscle tone for at least 1 month after discharge.", + "The patient showed signs of agitation and gastro-oesophageal reflux.", + "Treatment was started with esomeprazole to counteract the effect of the gastro-oesophageal reflux.", + "After 7 months, the patient's symptoms disappeared completely.", + "Citalopram and desmethylcitalopram concentrations were measured in the serum of the patient.", + "Citalopram and desmethylcitalopram concentrations were analyzed using a validated UPLC-MS-MS method.", + "Two hours after ingestion, the citalopram plasma concentration was 77 μg/l.", + "Two hours after ingestion, there was no detectable desmethylcitalopram concentration.", + "Fifty-four hours after ingestion, citalopram serum level decreased to 33 μg/l.", + "Fifty-four hours after ingestion, desmethylcitalopram increased to a concentration of 43 μg/l.", + "Finnegan scores were randomly measured during the course of admission.", + "Finnegan scores 2 h after ingestion was 11.", + "Finnegan scores 24 h after ingestion was 8.", + "Finnegan scores 46 h after ingestion was 6.", + "Finnegan scores 66 h after ingestion was 3.", + "During the time of admittance at the NICU, Finnegan scores were not measured." + ], + "summary": "This case report describes an unintentional citalopram intoxication in a 4 week old infant due to a vitamin D drops 'look alike' error. The infant showed extreme jitteriness and opisthotonus at presentation, as well as prolonged signs of gastro-oesophageal reflux. No cardiac rhythm disturbances or convulsions were seen. The clinical course combined with Finnegan scores was correlated to and supported by pharmacokinetic and pharmacokinetic data of citalopram in the patient.", + "summary_subclaims": [ + "This case report describes an unintentional citalopram intoxication in a 4 week old infant due to a vitamin D drops 'look alike' error.", + "The infant showed extreme jitteriness at presentation.", + "The infant showed opisthotonus at presentation.", + "The infant showed prolonged signs of gastro-oesophageal reflux.", + "No cardiac rhythm disturbances were seen.", + "No convulsions were seen.", + "The clinical course combined with Finnegan scores was correlated to and supported by pharmacokinetic and pharmacokinetic data of citalopram in the patient." + ] + }, + { + "id": "multiclinsum_test_1228_en.txt", + "fulltext": "Our patient is a 27-year old female that denied any past medical and surgical history. Her family and drug history were also unremarkable. The patient presented with a 7-month history of progressively enlarging mass on her left ring finger. The patient mentioned that the mass appeared suddenly with no history of trauma and that she was concerned about the potential malignant nature of the mass. The patient also mentioned that she underwent incision and drainage of that mass 2 months after its appearance with no improvement and provided no detailed surgical or pathological reports, which was the reason for her delayed presentation. Upon her assessment, the mass was located over the ulnar side of the proximal phalanx of left ring finger with extensive involvement of the 4th web space. The overlying skin coverage was ulcerative with no active signs of infection. Range of motion of the involved digit was limited, however neurovascular examination was normal. .\nRadiological evaluation of the involved hand showed a soft tissue swelling with no evidence of bone involvement . Further magnetic resonant (MRI) evaluation showed a mass on the volar aspect of the ring finger encasing about 50% of the flexor tendons of that digit with low signal intensity on T1 and high signal intensity on T2 evaluation with strong enhancement in post contrast evaluation. Assessment of neurovascular structures showed partial abutment of the radial sided bundle together with complete encirclement of the ulnar sided neurovascular bundle. The surrounding bone was free of any masses and associated mass effect.\nThe patient was taken to the OR for exploration and mass excision by the senior author. Possible risks associated with such intervention were explained. Intra-operatively, bruner type incision was designed together with island of skin involved in the mass. Exploration revealed extensive subcutaneous mass with fibro-fatty consistency with extensive fascia like extension to the surrounding soft tissue. The mass was encircling the ulnar neurovascular bundle with mass abutment over the radial bundle as seen in pre-op assessment. The mass was dissected freely from its attachment to those bundles preserving both radial and ulnar structures. The mass was then excised en-bloc having a dimension of 3.5 × 4x2.5 cm . Histological assessment showed a lesion with fasciitis like features, myofibroblastic proliferation and scattered foci of osteoid formation that was positive for Alpha-Smooth Muscle Actin (ASMA 1A4) immune staining and no evidence of malignancy . The resected margins were however, positive for residual lesion with difficulty in obtaining negative margins due to the extensive nature of the mass. Post-operatively, the patient had an un-eventual course. She was informed about the need for close follow-ups for both clinical and/or radiological signs of lesion recurrence, pending early surgical intervention (see ).", + "fulltext_subclaims": [ + "The patient is a 27-year old female.", + "The patient denied any past medical and surgical history.", + "The patient presented with a 7-month history of progressively enlarging mass on her left ring finger.", + "The mass appeared suddenly with no history of trauma.", + "The patient underwent incision and drainage of that mass 2 months after its appearance.", + "The incision and drainage provided no improvement.", + "The mass was located over the ulnar side of the proximal phalanx of left ring finger.", + "The overlying skin coverage was ulcerative.", + "Radiological evaluation showed a soft tissue swelling with no evidence of bone involvement.", + "MRI showed a mass on the volar aspect of the ring finger encasing about 50% of the flexor tendons.", + "The mass showed low signal intensity on T1 and high signal intensity on T2 evaluation.", + "The mass showed strong enhancement in post contrast evaluation.", + "The mass partially abutted the radial sided bundle.", + "The mass completely encircled the ulnar sided neurovascular bundle.", + "The patient was taken to the OR for exploration and mass excision.", + "Intra-operatively, a bruner type incision was designed.", + "The mass had fibro-fatty consistency.", + "The mass was encircling the ulnar neurovascular bundle.", + "The mass was dissected freely from its attachment to the radial and ulnar structures.", + "The mass was excised en-bloc with a dimension of 3.5 × 4x2.5 cm.", + "Histological assessment showed a lesion with fasciitis like features.", + "The lesion showed myofibroblastic proliferation.", + "The lesion showed scattered foci of osteoid formation.", + "The lesion was positive for Alpha-Smooth Muscle Actin (ASMA 1A4) immune staining.", + "There was no evidence of malignancy.", + "The resected margins were positive for residual lesion.", + "The patient had an un-eventual post-operative course.", + "The patient was informed about the need for close follow-ups for clinical and/or radiological signs of lesion recurrence." + ], + "summary": "A 27-year old female patient, presented with 7-months history of a progressively enlarging mass on her left hand. Upon assessment, the mass was located over the proximal phalanx of the left ring finger with extensive involvement of the 4th web space. Her neurovascular examination was normal. Radiological investigations showed partial involvement of the radial sided bundle together with complete involvement of the ulnar sided neurovascular bundle. The patient was bothered by the mass being painful with overlying skin ulceration. She was taken afterwards to the operating room where the mass was dissected freely from those bundles while preserving the radial and ulnar structures. The resected margins were however, positive for residual lesions due to the extensive nature of the mass. The patient was informed about the need for close follow-ups for both clinical and radiological signs of lesion recurrence pending early surgical intervention.", + "summary_subclaims": [ + "The patient is a 27-year old female.", + "She had a 7-months history of a progressively enlarging mass on her left hand.", + "The mass was located over the proximal phalanx of the left ring finger.", + "The mass involved the 4th web space.", + "Her neurovascular examination was normal.", + "Radiological investigations showed partial involvement of the radial sided bundle.", + "Radiological investigations showed complete involvement of the ulnar sided neurovascular bundle.", + "The mass was painful with overlying skin ulceration.", + "The mass was dissected freely from those bundles.", + "The radial and ulnar structures were preserved.", + "The resected margins were positive for residual lesions.", + "The patient was informed about the need for close follow-ups.", + "The patient was informed about the need for both clinical and radiological signs of lesion recurrence.", + "The patient was informed about the need for early surgical intervention." + ] + }, + { + "id": "multiclinsum_test_2582_en.txt", + "fulltext": "A 46-year-old female patient was previously diagnosed with breast cancer (right breast, cT2N1M0 Stage IIB, invasive ductal carcinoma, ER-positive, HER2-positive) at the age of 44. After initially completing preoperative chemotherapy (anthracycline and taxane plus anti-HER2 therapy), the patient underwent curative surgery. The final pathological diagnosis was pathological complete response (ypT0N0). Adjuvant treatment of 10-year TAM concomitantly with 1-year trastuzumab was planned. There was no previous or family history of cardiac disease, and no abnormal findings on cardiac function evaluated after surgery. The patient had a history of hepatitis C and was treated with antiviral agents (sofosbuvir and ribavirin) for 12 weeks resulting in a sustained virological response (SVR).\nTwo months after starting TAM and resuming trastuzumab, the patient visited her general physician with a complaint of fever and dyspnea. Blood tests showed a marked increase in hepatic enzymes, and the patient was rushed to our emergency room on suspicion of drug-induced liver injury. Upon arrival at the hospital, the patient was conscious, temperature was 36.6 °C, blood pressure was 110/70 mmHg, pulse was 80 bpm, respiratory rate was 20 breaths/min, and SpO2 was 99% (in-room air). Blood tests revealed elevated hepatic enzymes, decreased coagulability, thrombocytopenia and marked metabolic acidosis. Table A shows the blood test findings at the time of the emergency room visit. The patient was observed in the emergency room with bed rest and intravenous fluids, while the hospitalization process was underway based on the initial diagnosis of drug-induced fulminant hepatitis caused by TAM. During this time, tachycardia (140 beats/min) with ST-segment elevation appeared on the monitored electrocardiogram (ECG), and the ECG indicated anterior wall myocardial ischemia and third-degree atrioventricular block. Shortly thereafter, the patient went into cardiac arrest. Approximately 24 h had passed since the initial visit to her general physician. Resuscitation was started immediately, and because acute coronary syndrome was suspected, the patient was moved to the cardiac angiography room, where tracheal intubation, intra-aortic balloon pumping, and extracorporeal membrane oxygenation (V-A ECMO) were started.\nCoronary angiography (CAG) results were negative for ischemic heart disease. A diagnosis of fulminant myocarditis was made based on the pathophysiology and a myocardial biopsy was performed. Blood tests at the time showed CK 761 (U/μL), CK-MB 24 (U/μL), troponin T 1010 (ng/mL) and proBNP 7204 (pg/mL), with a significant increase in myocardial enzymes . Steroid pulse therapy (methylprednisolone 1000 mg × 5 days) and immunoglobulin therapy (1.0 g/day × 2 days) were started immediately after admission. Details of the main treatment after cardiac arrest are shown in Fig. . After the start of treatment, the symptoms of heart failure improved steadily and the patient was transferred to a general ward on the 14th day before being discharged on the 28th day.\nHistological findings of the myocardial biopsy taken at the time of CAG are shown in Fig. . Within the myocardial tissue, degeneration and necrosis of myocardial cells were observed with marked lymphocytic infiltration. There was no infiltration of eosinophils or multinucleated giant cells. The infiltrating lymphocytes were predominantly CD8-positive T cells, a finding consistent with the histology of lymphocytic myocarditis. Serum cytomegalovirus, coxsackie B virus and adenovirus antibodies were elevated eightfold, fourfold and fourfold (based on complement fixation test), respectively. Taken together, these findings were consistent with acute viral myocarditis. HCV–RNA was tested before steroid administration and RNA was not detected.\nAfter intensive care, despite the improvement in symptoms of heart failure, the patient’s heart rate remained at 20–30 bpm. Hence, a permanent pacemaker was inserted and the patient was discharged on the 28th day. After discharge from the hospital, an attempt was made to remove the pacemaker, but bradyarrhythmia remained, thus the pacemaker was retained and remains to date. Ten months have passed, since the TAM was recommenced, and the patient remains on a good course with no elevation of liver enzymes or any findings that suggest recurrence of breast cancer.", + "fulltext_subclaims": [ + "The patient was previously diagnosed with breast cancer (right breast, cT2N1M0 Stage IIB, invasive ductal carcinoma, ER-positive, HER2-positive) at the age of 44.", + "The patient completed preoperative chemotherapy (anthracycline and taxane plus anti-HER2 therapy).", + "The final pathological diagnosis was pathological complete response (ypT0N0).", + "Adjuvant treatment of 10-year TAM concomitantly with 1-year trastuzumab was planned.", + "There was no previous or family history of cardiac disease.", + "There were no abnormal findings on cardiac function evaluated after surgery.", + "The patient had a history of hepatitis C.", + "The patient was treated with antiviral agents (sofosbuvir and ribavirin) for 12 weeks.", + "The patient achieved a sustained virological response (SVR).", + "Two months after starting TAM and resuming trastuzumab, the patient visited her general physician with a complaint of fever and dyspnea.", + "Blood tests showed a marked increase in hepatic enzymes.", + "The patient was rushed to the emergency room on suspicion of drug-induced liver injury.", + "The patient was observed in the emergency room with bed rest and intravenous fluids.", + "The initial diagnosis was drug-induced fulminant hepatitis caused by TAM.", + "During observation, tachycardia (140 beats/min) with ST-segment elevation appeared on the monitored electrocardiogram.", + "The ECG indicated anterior wall myocardial ischemia and third-degree atrioventricular block.", + "The patient went into cardiac arrest.", + "Approximately 24 h had passed since the initial visit to her general physician.", + "Resuscitation was started immediately.", + "The patient was moved to the cardiac angiography room.", + "Tracheal intubation, intra-aortic balloon pumping, and extracorporeal membrane oxygenation (V-A ECMO) were started.", + "Coronary angiography (CAG) results were negative for ischemic heart disease.", + "A diagnosis of fulminant myocarditis was made based on the pathophysiology.", + "A myocardial biopsy was performed.", + "Blood tests showed CK 761 (U/μL), CK-MB 24 (U/μL), troponin T 1010 (ng/mL), and proBNP 7204 (pg/mL).", + "Steroid pulse therapy (methylprednisolone 1000 mg × 5 days) was started immediately after admission.", + "Immunoglobulin therapy (1.0 g/day × 2 days) was started immediately after admission.", + "The symptoms of heart failure improved steadily.", + "The patient was transferred to a general ward on the 14th day.", + "The patient was discharged on the 28th day.", + "Histological findings of the myocardial biopsy showed degeneration and necrosis of myocardial cells with marked lymphocytic infiltration.", + "There was no infiltration of eosinophils or multinucleated giant cells.", + "The infiltrating lymphocytes were predominantly CD8-positive T cells.", + "Serum cytomegalovirus, coxsackie B virus, and adenovirus antibodies were elevated.", + "HCV–RNA was tested before steroid administration.", + "HCV–RNA was not detected.", + "A permanent pacemaker was inserted.", + "The patient was discharged on the 28th day.", + "An attempt was made to remove the pacemaker after discharge.", + "Bradyarrhythmia remained, thus the pacemaker was retained.", + "Ten months have passed since TAM was recommenced.", + "The patient remains on a good course with no elevation of liver enzymes.", + "There are no findings that suggest recurrence of breast cancer." + ], + "summary": "After completing preoperative chemotherapy and undergoing curative surgery for right breast cancer, a 46-year-old female patient started adjuvant tamoxifen and resumed trastuzumab. Two months later, she complained fever and dyspnea. Blood tests showed a marked increase in hepatic enzymes, and the patient was rushed to our emergency room on suspicion of drug-induced liver injury. In the emergency room, the patient went into cardiac arrest shortly after tachycardia with ST-segment elevation appeared on the monitored electrocardiogram. Resuscitation was started immediately and tracheal intubation, intra-aortic balloon pumping, and extracorporeal membrane oxygenation were started. Coronary angiography results were negative for ischemic heart disease. A diagnosis of fulminant myocarditis was made and steroid pulse therapy and immunoglobulin therapy were started. After the start of treatment, the symptoms of heart failure improved steadily and the patient was discharged on the 28th day. Histological findings of the myocardial biopsy revealed degeneration and necrosis of myocardial cells with marked lymphocytic infiltration, consistent with the histology of lymphocytic myocarditis. Serum cytomegalovirus, coxsackie B virus and adenovirus antibodies were all elevated and these findings were consistent with acute viral myocarditis.", + "summary_subclaims": [ + "The patient is a 46-year-old female.", + "The patient had right breast cancer.", + "The patient completed preoperative chemotherapy.", + "The patient underwent curative surgery.", + "The patient started adjuvant tamoxifen.", + "The patient resumed trastuzumab.", + "Two months later, the patient complained of fever and dyspnea.", + "Blood tests showed a marked increase in hepatic enzymes.", + "The patient was rushed to the emergency room on suspicion of drug-induced liver injury.", + "In the emergency room, the patient went into cardiac arrest shortly after tachycardia with ST-segment elevation appeared on the monitored electrocardiogram.", + "Resuscitation was started immediately.", + "Tracheal intubation was started.", + "Intra-aortic balloon pumping was started.", + "Extracorporeal membrane oxygenation was started.", + "Coronary angiography results were negative for ischemic heart disease.", + "A diagnosis of fulminant myocarditis was made.", + "Steroid pulse therapy was started.", + "Immunoglobulin therapy was started.", + "After the start of treatment, the symptoms of heart failure improved steadily.", + "The patient was discharged on the 28th day.", + "Histological findings of the myocardial biopsy revealed degeneration and necrosis of myocardial cells with marked lymphocytic infiltration.", + "The histology was consistent with lymphocytic myocarditis.", + "Serum cytomegalovirus antibodies were elevated.", + "Serum coxsackie B virus antibodies were elevated.", + "Serum adenovirus antibodies were elevated.", + "These findings were consistent with acute viral myocarditis." + ] + }, + { + "id": "multiclinsum_test_1246_en.txt", + "fulltext": "A 46-year-old man with a history of hypertension, smoking, and alcohol use experienced a stroke on waking up with left limb weakness (4/5) and slurring speech on August 30, 2020. He was diagnosed to have a right internal carotid artery (ICA) territory infarct based on non-contrast computed tomography (NCCT) at local hospital. Despite antiplatelet therapy with aspirin 100 mg/d and clopidogrel 75 mg/d, over the next 3 days, left limb weakness progressively worsened (2/5), accompanied by somnolence (GCS 3 + 5 + 6). Therefore, he was transferred to our hospital on September 2, 2020. The Glasgow Coma Scale (GCS) score was 13/15. The head NCCT revealed new infarcts in the right internal watershed area and CT perfusion (CTP) showed a 100.3 mL mismatch of bilateral cerebral hemispheres, indicating that a considerable penumbral region was present in the supply area of each internal carotid artery (ICA) . Emergent EVT was performed under general anesthesia. The patient received IV heparin (50 U/Kg) before the surgical procedure. Preprocedural angiogram showed a double-lumen sign in the ascending segment of the right ICA with severe stenosis of the true lumen and linear stenosis in the ascending segment of the left ICA, suggesting dissections . The anterior communicating artery (ACom A) and the right posterior communicating artery (PCom A) were not open, and the left posterior cerebral artery (PCA) mildly compensated the left middle cerebral artery (MCA) through ipsilateral PCom A . Because we judged that the right ICA was the main vessel responsible for stroke, and worried about the risk of hyperperfusion-related bleeding in the simultaneous treatment of bilateral ICAs, we decided to treat right ICA first. An 8F Envoy guide catheter (Johnson & Johnson Co. Ltd., New Brunswick, NJ, USA) and 5F MPA catheter were introduced into the distal common carotid artery (CCA) by applying a coaxial technique. After traversing the true lumen with a Trevo Pro 18 microcatheter over a Synchro-2 microwire (Stryker Corp., Fremont, CA, USA), a Solitaire FR 6 × 30 mm stent-retriever (Medtronic Inc., Wexford, PA, USA) was temporarily deployed at the key flow-limiting site . An angiogram showed an image of a patent true lumen with a significantly reduced false lumen. After observation of 30 min, blood flow was maintained well, and ipsilateral anterior cerebral artery (ACA) compensated left ACA through ACom A. Thus, the Solitaire stent was detached . After recovery from anesthesia, the muscle strength of left limb was improved from grade 2/5 to grade 3/5, but the somnolence was not improved with a 13/15 GCS. Repeated CTP revealed that the perfusion of the right anterior circulation recovered, but a large area of hypoperfusion in the left anterior circulation was still seen . Due to concerns about clopidogrel resistance, the dual antiplatelet regimen was adjusted to aspirin 100 mg/d and ticagrelor 90 mg twice daily. On the 6th day after the procedure, the patient suffered from a generalized seizure and became stupor with a 9/15 GCS. Further, the muscle strength of right limb was decreased to grade 2/5. But no new lesions were found on the emergent head NCCT. Nevertheless, head CTP showed a new core infarction of 18.2 mL in the left frontal lobe with a penumbra of 100.4 mL in the left anterior circulation . Then, an emergent EVT was performed again. The angiogram revealed that the right ICA was patent with an inadequate compensation to the left anterior circulation via ACom A, and left ICA was occluded . A triaxial assembly including an 8F Mach1 guide catheter (Boston Scientific, Marlborough, MA, USA), AXS Catalyst 6 (Stryker Corp.), and a Trevo Pro 18 microcatheter over a Synchro-2 microwire were navigated through the left dissected segment . Subsequently, the Catalyst 6 and guide catheter were successively withdrawn to the beginning of the ICA under continuous negative pressure application, namely the simple catheter-passing (SCP) technique. Several dark red emboli were captured by Catalyst 6. A repeated angiogram showed that the left ICA was successfully recanalized and the structure of the dissection was fully revealed . After traversing the true lumen with the Pro 18 microcatheter over a Synchro-2 microwire, a Solitaire FR 6 × 30 mm stent-retriever was temporarily deployed at the key flow-limiting site . A subsequent angiogram showed that the antegrade blood flow was significantly improved and the dissecting aneurysm disappeared. After observation of 30 min, the Solitaire stent was detached. After recovery from anesthesia, the patient's consciousness became clear with a 15/15 GCS, the tracheal intubation was removed on the following day, and the muscle strength of four limbs was significantly improved to grade 4/5. A repeated head NCCT showed infarction in the left frontal lobe, but repeated head CTP showed that the cerebral perfusion of bilateral anterior circulations was recovered .\nAfter 3 months of dual antiplatelet therapy, another 3 months of aspirin single antiplatelet therapy was followed. The modified Rankins Scale score (mRS) was 1 at the 90-day follow-up. Follow-up neck CTA at three months showed no residual lesion in both ICAs. No relapse of cerebral ischemic events during the 15-month follow-up occurred. A recent neck CTA showed that both ICAs remained patent without relapse of dissection .", + "fulltext_subclaims": [ + "The patient was a 46-year-old man.", + "He had a history of hypertension.", + "He had a history of smoking.", + "He had a history of alcohol use.", + "He experienced a stroke on waking up with left limb weakness (4/5) and slurring speech on August 30, 2020.", + "He was diagnosed with a right internal carotid artery (ICA) territory infarct based on non-contrast computed tomography (NCCT) at local hospital.", + "He was on antiplatelet therapy with aspirin 100 mg/d and clopidogrel 75 mg/d.", + "Over the next 3 days, left limb weakness progressively worsened (2/5), accompanied by somnolence (GCS 3 + 5 + 6).", + "He was transferred to our hospital on September 2, 2020.", + "The Glasgow Coma Scale (GCS) score was 13/15.", + "The head NCCT revealed new infarcts in the right internal watershed area.", + "CT perfusion (CTP) showed a 100.3 mL mismatch of bilateral cerebral hemispheres.", + "Emergent EVT was performed under general anesthesia.", + "The patient received IV heparin (50 U/Kg) before the surgical procedure.", + "Preprocedural angiogram showed a double-lumen sign in the ascending segment of the right ICA.", + "The anterior communicating artery (ACom A) and the right posterior communicating artery (PCom A) were not open.", + "The left posterior cerebral artery (PCA) mildly compensated the left middle cerebral artery (MCA) through ipsilateral PCom A.", + "We decided to treat the right ICA first.", + "An 8F Envoy guide catheter and 5F MPA catheter were introduced into the distal common carotid artery (CCA) by applying a coaxial technique.", + "A Solitaire FR 6 × 30 mm stent-retriever was temporarily deployed at the key flow-limiting site.", + "An angiogram showed an image of a patent true lumen with a significantly reduced false lumen.", + "After observation of 30 min, blood flow was maintained well.", + "The ipsilateral anterior cerebral artery (ACA) compensated the left ACA through ACom A.", + "The Solitaire stent was detached.", + "After recovery from anesthesia, the muscle strength of the left limb was improved from grade 2/5 to grade 3/5.", + "The somnolence was not improved with a 13/15 GCS.", + "Repeted CTP revealed that the perfusion of the right anterior circulation recovered.", + "A large area of hypoperfusion in the left anterior circulation was still seen.", + "The dual antiplatelet regimen was adjusted to aspirin 100 mg/d and ticagrelor 90 mg twice daily.", + "On the 6th day after the procedure, the patient suffered from a generalized seizure.", + "The patient became stupor with a 9/15 GCS.", + "The muscle strength of the right limb was decreased to grade 2/5.", + "No new lesions were found on the emergent head NCCT.", + "Head CTP showed a new core infarction of 18.2 mL in the left frontal lobe.", + "An emergent EVT was performed again.", + "The angiogram revealed that the right ICA was patent with an inadequate compensation to the left anterior circulation via ACom A.", + "The left ICA was occluded.", + "A triaxial assembly including an 8F Mach1 guide catheter, AXS Catalyst 6, and a Trevo Pro 18 microcatheter were navigated through the left dissected segment.", + "The Catalyst 6 and guide catheter were successively withdrawn to the beginning of the ICA under continuous negative pressure application, namely the simple catheter-passing (SCP) technique.", + "Several dark red emboli were captured by Catalyst 6.", + "A repeated angiogram showed that the left ICA was successfully recanalized.", + "The structure of the dissection was fully revealed.", + "A Solitaire FR 6 × 30 mm stent-retriever was temporarily deployed at the key flow-limiting site.", + "A subsequent angiogram showed that the antegrade blood flow was significantly improved.", + "The dissecting aneurysm disappeared.", + "After observation of 30 min, the Solitaire stent was detached.", + "After recovery from anesthesia, the patient's consciousness became clear with a 15/15 GCS.", + "The tracheal intubation was removed on the following day.", + "The muscle strength of four limbs was significantly improved to grade 4/5.", + "A repeated head NCCT showed infarction in the left frontal lobe.", + "Repeted head CTP showed that the cerebral perfusion of bilateral anterior circulations was recovered.", + "After 3 months of dual antiplatelet therapy, another 3 months of aspirin single antiplatelet therapy was followed.", + "The modified Rankins Scale score (mRS) was 1 at the 90-day follow-up.", + "Follow-up neck CTA at three months showed no residual lesion in both ICAs.", + "No relapse of cerebral ischemic events during the 15-month follow-up occurred.", + "A recent neck CTA showed that both ICAs remained patent without relapse of dissection." + ], + "summary": "A bilateral spontaneous cICADs with hypoperfusion-related AIS after 72 h from the onset was presented herein. The patient responded well to primary Solitaire stent detachment at the critical flow-limiting site.", + "summary_subclaims": [ + "A bilateral spontaneous cICADs with hypoperfusion-related AIS after 72 h from the onset was presented.", + "The patient responded well to primary Solitaire stent detachment at the critical flow-limiting site." + ] + }, + { + "id": "multiclinsum_test_815_en.txt", + "fulltext": "A 69-year-old woman visited our hospital because of unexplained fatigue. Thoracic, abdominal, and pelvic CT showed several pulmonary lesions, with the largest having a maximum diameter of 2 cm. In addition, there were several rib masses, enlarged mediastinal lymph nodes, and a 9-cm mass resembling a malignancy in the left kidney. She underwent cytoreductive nephrectomy in July 2013. Histological examination revealed clear cell RCC.\nIn August 2013, first-line sunitinib was initiated. However, she still experienced fatigue, and the treatment was discontinued. Three tyrosine kinase inhibitors and two mTOR inhibitors were administered and discontinued because of adverse events, such as fatigue and anorexia, with a 3–6-month duration. In January 2016, palliative radiotherapy was administered for pain control; 30 Gy in 10 fractions was delivered to the ribs. In October 2016, treatment with nivolumab (3 mg/kg) was initiated. Three days after the initial administration, she presented with dyspnea, cough, and low-grade fever. There was no increase in KL-6 or SP-D. CT showed a right lung consolidation with ground glass opacities in a previously irradiated area . At that time, she was not receiving any drug, other than nivolumab, that could induce interstitial pneumonia. Accordingly, she was diagnosed with pneumonitis caused by nivolumab and radiotherapy. Oral prednisolone (1 mg/kg) was immediately initiated, and was discontinued after 4 months with gradual tapering. The patient's symptoms rapidly resolved, and follow-up chest CT 4 months after nivolumab cessation showed interval resolution of the consolidation in the right lung and persistent tumor shrinkage .", + "fulltext_subclaims": [ + "A 69-year-old woman visited our hospital because of unexplained fatigue.", + "Thoracic, abdominal, and pelvic CT showed several pulmonary lesions.", + "The largest pulmonary lesion had a maximum diameter of 2 cm.", + "There were several rib masses.", + "There were enlarged mediastinal lymph nodes.", + "There was a 9-cm mass resembling a malignancy in the left kidney.", + "She underwent cytoreductive nephrectomy in July 2013.", + "Histological examination revealed clear cell RCC.", + "In August 2013, first-line sunitinib was initiated.", + "She still experienced fatigue.", + "The treatment was discontinued.", + "Three tyrosine kinase inhibitors were administered.", + "Two mTOR inhibitors were administered.", + "The treatments were discontinued because of adverse events.", + "The adverse events included fatigue and anorexia.", + "The adverse events had a 3–6-month duration.", + "In January 2016, palliative radiotherapy was administered for pain control.", + "30 Gy in 10 fractions was delivered to the ribs.", + "In October 2016, treatment with nivolumab (3 mg/kg) was initiated.", + "Three days after the initial administration, she presented with dyspnea.", + "Three days after the initial administration, she presented with cough.", + "Three days after the initial administration, she presented with low-grade fever.", + "There was no increase in KL-6.", + "There was no increase in SP-D.", + "CT showed a right lung consolidation.", + "CT showed ground glass opacities in a previously irradiated area.", + "At that time, she was not receiving any drug, other than nivolumab, that could induce interstitial pneumonia.", + "She was diagnosed with pneumonitis caused by nivolumab and radiotherapy.", + "Oral prednisolone (1 mg/kg) was immediately initiated.", + "Oral prednisolone was discontinued after 4 months with gradual tapering.", + "The patient's symptoms rapidly resolved.", + "Follow-up chest CT 4 months after nivolumab cessation showed interval resolution of the consolidation in the right lung.", + "Follow-up chest CT 4 months after nivolumab cessation showed persistent tumor shrinkage." + ], + "summary": "The patient was a 69-year-old woman with renal cell carcinoma. She had received various drugs and palliative irradiation, which was followed by nivolumab treatment, for renal cell carcinoma. Three days after the initial nivolumab administration, she presented with respiratory symptoms. On the basis of chest computed tomography findings, she was diagnosed with nivolumab-induced radiation recall pneumonitis and treated with prednisolone (1 mg/kg). The condition resolved rapidly, and chest computed tomography 4 months after nivolumab cessation revealed interval resolution of the lung consolidation and persistent tumor shrinkage.", + "summary_subclaims": [ + "The patient was a 69-year-old woman with renal cell carcinoma.", + "She had received various drugs and palliative irradiation, which was followed by nivolumab treatment, for renal cell carcinoma.", + "Three days after the initial nivolumab administration, she presented with respiratory symptoms.", + "On the basis of chest computed tomography findings, she was diagnosed with nivolumab-induced radiation recall pneumonitis.", + "She was treated with prednisolone (1 mg/kg).", + "The condition resolved rapidly.", + "Chest computed tomography 4 months after nivolumab cessation revealed interval resolution of the lung consolidation.", + "Chest computed tomography 4 months after nivolumab cessation revealed persistent tumor shrinkage." + ] + }, + { + "id": "multiclinsum_test_1886_en.txt", + "fulltext": "A 63-year-old man was referred to our clinic for primary open glaucoma in both eyes, with an intraocular pressure of 25 mmHg in the right eye despite topic medications (Dorzolamide, Timolol, Travoprost). At the initial visit the anterior segment of the pseudophakic right eye was normal and the best corrected visual acuity was 20/200. The fundus examination showed peripapillary atrophy, glaucomatous neuroretinal rim loss (cup/disk ratio 0,7) and a full thickness macular hole in his right eye. The patient underwent an ab-interno gel stent implantation in the upper nasal quadrant (Xen45, Allergan) after a subconjunctival injection of mitomycin-C (0,1 ml 0,02%). After hydrating the incisions, 0.1 ml of 1% cefuroxime was injected in the anterior chamber and 4 mg/1 ml of dexamethasone phosphate subtenon (Decadron®, Farmaceutici Caber SpA, Italy). Post-surgery care included antibiotic prophylaxis and topical corticoids in decreasing dosage during 1 month. The IOP was 6 mmHg and 10 mmHg in post-operative day 1 and post-operative day 15, respectively. One month after the implantation, the patient underwent retinal surgery in his right eye. The macular hole was successfully closed with a 25-G pars plana vitrectomy (Constellation vitrectomy machine, Alcon Laboratories, Inc., Fort Worth, TX, USA), using the inverted ILM flap technique .\nThe surgery was uneventful and subconjunctival dexamethasone was used to minimize inflammation. Topical medication with combined antibiotic and steroid drops was prescribed for 1 week.\nSix days after vitreous surgery the IOP spiked to 25 mmHg, and the anterior segment examination (Takagi TD10 Eye Cam on a Takagi 700GL Slit lamp) showed a flattening of the conjunctival bleb and a translucent clot covering the internal ostium of the XEN. At the AS-OCT (AngioVue®, Optovue, Fremont, CA, USA) the conjunctival bleb appeared flat and non-functional, and the clot stood out as hyperreflective material which we presumed to be fibrin, occluding the internal end of the stent .\nLysis of the fibrin clot was attempted with YAG-laser (1,1 mJ of power), but the tube remained occluded and the IOP elevated. Therefore, an ab interno revision of the gel stent was performed.\nA surgical procedure was performed according to the following steps after obtaining written informed consent from the patient.After application of topical anesthesia with the usual sterile conditions in the operating room, one paracentesis site was created at 90° with respect to the tube (approx. at 10 o’clock) by using a 15° Knife (Stab 15° Safety Knife, Surgistar, California) Trypan blue (Vision Blue, DORC international, BV Zuidland, Netherlands) was injected into the anterior chamber to stain the clot and to verify the extension of tube occlusion. Viscoelastic was introduced in the anterior chamber and a careful fibrin clot removal was attempted with a 25-gauge inner limiting membrane (ILM) forceps (Revolution DSP 25+ Serrated Forceps, Alcon-Grieshaber, Fribourg, Switzerland); however, the clot was strongly adherent to the tube end, and it did not clear. A second paracentesis site was created at 90° with respect to the Xen tube position (approx.at 4 o’clock), and a 25 G straight vitreous scissors (Revolution DSP 25G Curved Scissors, Alcon-Grieshaber, Fribourg, Switzerland) was inserted to snip the proximal end of the Xen tube (a small segment of about 0,5 mm length), flush to the ILM forceps grabbing distally the tube. The flexible nature of the stent required a two-handed technique in order to both immobilize and truncate the end of the stent. The viscoelastic and the excised tube fragment were then removed, and the AC was irrigated with balanced salt solution (BSS) to induce subconjunctival bleb formation. The drainage efficiency was further verified by trypan blue injection into the AC. Finally, the corneal incisions were closed by hydrosuture.\nIn the postoperative day 1, the IOP was 8 mmHg; the anterior segment examination showed an open diffuse filtering bleb, a normal appearing new internal ostium, and a sustained blue staining of the stent . The AS-OCT confirmed a functional, layered, filtering bleb, and the normal appearance and patency of the stent. No side effects from the intervention were observed.\nTopical medication with combined antibiotic and steroid drops was prescribed for 2 weeks. One month after surgery the patient showed IOP =12 mmHg, a visual acuity of 20/40, a patent internal ostium, and an open diffuse filtering bleb.", + "fulltext_subclaims": [ + "The patient was a 63-year-old man.", + "He was referred for primary open glaucoma in both eyes.", + "The intraocular pressure in the right eye was 25 mmHg despite topical medications.", + "The anterior segment of the pseudophakic right eye was normal.", + "The best corrected visual acuity was 20/200.", + "The fundus examination showed peripapillary atrophy.", + "The fundus examination showed glaucomatous neuroretinal rim loss.", + "The cup/disk ratio was 0,7.", + "The fundus examination showed a full thickness macular hole in the right eye.", + "The patient underwent ab-interno gel stent implantation in the upper nasal quadrant.", + "The stent used was Xen45, Allergan.", + "A subconjunctival injection of mitomycin-C (0,1 ml 0,02%) was given.", + "After hydrating the incisions, 0.1 ml of 1% cefuroxime was injected in the anterior chamber.", + "4 mg/1 ml of dexamethasone phosphate subtenon was administered.", + "Post-surgery care included antibiotic prophylaxis.", + "Post-surgery care included topical corticoids in decreasing dosage during 1 month.", + "The IOP was 6 mmHg on post-operative day 1.", + "The IOP was 10 mmHg on post-operative day 15.", + "One month after the implantation, the patient underwent retinal surgery in his right eye.", + "The macular hole was successfully closed with a 25-G pars plana vitrectomy.", + "The vitrectomy machine used was Constellation, Alcon Laboratories, Inc., Fort Worth, TX, USA.", + "The inverted ILM flap technique was used.", + "The surgery was uneventful.", + "Subconjunctival dexamethasone was used to minimize inflammation.", + "Topical medication with combined antibiotic and steroid drops was prescribed for 1 week.", + "Six days after vitreous surgery the IOP spiked to 25 mmHg.", + "The anterior segment examination showed a flattening of the conjunctival bleb.", + "The anterior segment examination showed a translucent clot covering the internal ostium of the XEN.", + "The AS-OCT showed the conjunctival bleb appeared flat and non-functional.", + "The clot was presumed to be fibrin.", + "Lysis of the fibrin clot was attempted with YAG-laser.", + "The tube remained occluded.", + "An ab interno revision of the gel stent was performed.", + "A surgical procedure was performed after obtaining written informed consent.", + "Topical anesthesia was applied.", + "One paracentesis site was created at 90° with respect to the tube.", + "Trypan blue was injected into the anterior chamber.", + "Viscoelastic was introduced in the anterior chamber.", + "A 25-gauge ILM forceps was used to attempt fibrin clot removal.", + "The clot was strongly adherent to the tube end.", + "A second paracentesis site was created at 90° with respect to the Xen tube position.", + "A 25 G straight vitreous scissors was inserted to snip the proximal end of the Xen tube.", + "A small segment of about 0,5 mm length was snipped.", + "The flexible nature of the stent required a two-handed technique.", + "The viscoelastic and the excised tube fragment were removed.", + "The AC was irrigated with balanced salt solution.", + "The drainage efficiency was verified by trypan blue injection into the AC.", + "The corneal incisions were closed by hydrosuture.", + "In the postoperative day 1, the IOP was 8 mmHg.", + "The anterior segment examination showed an open diffuse filtering bleb.", + "The anterior segment examination showed a normal appearing new internal ostium.", + "The AS-OCT confirmed a functional, layered, filtering bleb.", + "The AS-OCT confirmed the normal appearance and patency of the stent.", + "No side effects from the intervention were observed.", + "Topical medication with combined antibiotic and steroid drops was prescribed for 2 weeks.", + "One month after surgery the patient showed IOP =12 mmHg.", + "One month after surgery the patient showed a visual acuity of 20/40.", + "One month after surgery the patient showed a patent internal ostium.", + "One month after surgery the patient showed an open diffuse filtering bleb." + ], + "summary": "A 63-year-old male patient affected by primary open angle glaucoma (IOP = 25 mmHg) and a full thickness macular hole in his right eye, underwent ab-interno Xen gel stent implantation and, 1 month later, a 25 G vitrectomy surgery. Despite a significant IOP reduction after stent implant, 6 days after vitrectomy, IOP increased (25 mmHg) and the conjunctival bleb flattened following occlusion of stent internal ostium by a clot of presumed fibrinous material. The Nd:YAG laser failed to remove the clot, so that we decided to snip a small bit of the proximal end of the Xen tube (about 0,5 mm length) with a 25 G vitreous scissors, using a bimanual technique. In the postoperative day 1 and month 1, the IOP was 8 mmHg and 12 mmHg, respectively. The Anterior Segment OCT confirmed a functional, layered, filtering bleb, and the normal appearance and patency of the XEN proximal segment. No side effects from the intervention were observed.", + "summary_subclaims": [ + "The patient is a 63-year-old male.", + "The patient has primary open angle glaucoma.", + "The patient's intraocular pressure was 25 mmHg.", + "The patient has a full thickness macular hole in his right eye.", + "The patient underwent ab-interno Xen gel stent implantation.", + "The patient underwent a 25G vitrectomy surgery.", + "The vitrectomy surgery was performed 1 month after the Xen gel stent implantation.", + "Six days after vitrectomy, the intraocular pressure increased to 25 mmHg.", + "The conjunctival bleb flattened following occlusion of the stent internal ostium by a clot of presumed fibrinous material.", + "The Nd:YAG laser failed to remove the clot.", + "A small bit of the proximal end of the Xen tube was snipped.", + "The snipped portion was about 0.5 mm in length.", + "A 25G vitreous scissors was used to snip the Xen tube.", + "A bimanual technique was used to snip the Xen tube.", + "On postoperative day 1, the intraocular pressure was 8 mmHg.", + "On postoperative month 1, the intraocular pressure was 12 mmHg.", + "Anterior Segment OCT confirmed a functional, layered, filtering bleb.", + "Anterior Segment OCT confirmed the normal appearance and patency of the XEN proximal segment.", + "No side effects from the intervention were observed." + ] + }, + { + "id": "multiclinsum_test_3241_en.txt", + "fulltext": "We present a case of a 10-year-old girl from a low socioeconomic background in a Hindu family from Sindh, Pakistan, who initially presented to our Pediatric Urology Clinic and was later transferred to Pediatric Nephrology Care. She presented with a 1-week history of severe right lumbar pain, gross hematuria, vomiting, and fever. The pain was severe enough to require pain relief medication, and she visited the emergency room 2–3 times before being admitted for hospitalization. She did not report any burning sensation during urination, dysuria, urinary retention, or incontinence. There were no other systemic manifestations, such as joint pain, prolonged fever, alopecia, mouth ulcers, or skin rash.\n\nShe was born by C-section to unrelated parents, and her early childhood was uneventful. She was fully immunized and developmentally normal. She is currently a student in the 8th grade. Her past medical and drug history was unremarkable, and there was no family history of kidney disease or other systemic disorders at the time of presentation. On examination, she appeared anxious and unwell, febrile (101°F), and hypertensive, with a systolic and diastolic blood pressure of 130/96 mmHg, which was above the 95th percentile for her age and height.\n\nHer anthropometric measurements were as follows: weight 36.4 kg (50th percentile), height 141 cm (above the 50th percentile), and body surface area (BSA) 1.2 m2 . She was mildly anemic and dehydrated, but not jaundiced. No rashes or lymphadenopathy were observed. Abdominal examination revealed tenderness in the right lumbar region, but there was no splenomegaly. Her respiratory and cardiovascular systems were normal, and locomotor and neurological examinations were unremarkable. Initially, a diagnosis of ureteric calculus and/or acute pyelonephritis was suspected.\n\nInitial laboratory results showed a hemoglobin (Hb) level of 12.4 g/dL, white blood cell count of 14.98 × 109/L, and platelet count of 75 × 109/L. Urinalysis revealed a reddish, hazy appearance with 150 mg/dL protein, 3 + blood, numerous red blood cells (RBCs) and white blood cells (15–20/hpf), while leukocyte esterase and nitrites were negative. The spot urine calcium-to-creatinine ratio was 0.06 (normal < 0.2), and the protein-to-creatinine ratio was 0.8 (normal < 0.2). Renal function was normal, with urea at 12 mg/dL, creatinine at 0.33 mg/dL, and electrolytes within normal limits. Liver function tests and coagulation profiles were normal as well. The serum lipase level was normal, but her serum albumin was slightly low (2.98 g/dL), and dengue serology was negative. Her C-reactive protein level was elevated at 48 mg/dL, lactate dehydrogenase (LDH) was 696 U/L, and D-dimer was significantly raised at 19.8 mg/L. Her blood and urine cultures were negative. Ultrasound (US) revealed a diffusely enlarged right kidney (11.5 cm × 6.7 cm) with patchy areas of increased echogenicity, while the left kidney appeared normal. A color Doppler study showed a hypoechoic thrombus in the right renal vein (RRV) that completely blocked blood flow and extended into the inferior vena cava (IVC). Renal computed tomography angiography confirmed these findings, showing an enlarged, edematous right kidney with a well-organized hypodense thrombus completely obstructing the RRV, extending into the IVC.\n\nHer work-up for hereditary thrombophilia (including protein-C, protein-S, antithrombin III, and factor V Leiden) was negative. Further serological testing confirmed a diagnosis of systemic lupus erythematosus (SLE), evidenced by low complement-3 (C3), positive antinuclear antibodies (ANA) with a titer of 1/5120, and positive anti-ds DNA antibodies. In addition, tests for antiphospholipid syndrome (APS) showed positive anticardiolipin antibodies (IgG and IgM), lupus anticoagulant, and prolonged confirmatory tests, which confirmed APS as secondary to SLE.\n\nThe patient was initially managed with intravenous paracetamol, hydration, and antibiotics. Her hypertension was controlled with oral captopril and amlodipine, and captopril was later switched to losartan. She was anticoagulated with low-molecular-weight (LMW) heparin (enoxaparin) and later switched to oral warfarin after 6 days. Her condition improved over 8–10 days, with her platelet count rising to 189 × 109/L. She was discharged after 12 days on warfarin, with strict observation for bleeding and regular monitoring of her prothrombin time and international normalized ratio (PT-INR), aiming to maintain a target INR of 2–3. She continued amlodipine and losartan for hypertension and proteinuria, along with hydroxychloroquine (200 mg) and acetylsalicylic acid (75 mg) for thrombosis prevention.\n\nWe closely monitored her for signs of pulmonary embolism owing to the risk of embolization from the IVC thrombus, but no such signs were observed. Immunosuppressive therapies, such as corticosteroids, were not considered as there were no systemic manifestations of SLE or lupus nephritis at that time.\n\nInitially, the patient was closely monitored in the outpatient department with regular checks on her blood pressure (BP), clinical symptoms (such as pain and gross hematuria), prothrombin time (PT) with international normalized ratio (INR), and complete blood count (CBC) to monitor thrombocytopenia; color Doppler ultrasound (US) for recanalization of the affected veins; serum creatinine (Cr) for kidney function; and a dimercaptosuccinic acid (DMSA) renal scan to assess right kidney function. Her echocardiogram did not reveal any valvular defects or vegetation. A repeat color Doppler US during follow-up showed persistence of the right renal vein (RRV) thrombus but resolution of the inferior vena cava (IVC) thrombus. The DMSA renal scan revealed a nonfunctioning right kidney, which was recommended for nephrectomy; however, the parents chose not to pursue this option.\n\nFour weeks after discharge, the patient contracted chickenpox but recovered smoothly without complications. We lost contact with the patient from November 2020 to September 2021 owing to the coronavirus disease 2019 (COVID-19) pandemic. During this period, she visited another healthcare center where her anticoagulant treatment, warfarin, was replaced with rivaroxaban (10 mg once daily) to avoid the need for frequent INR monitoring. During her subsequent follow-up visits, we monitored her growth (height and weight), hypertension (BP), kidney function (serum Cr), proteinuria (spot urine protein-to-creatinine ratio, suPCR), and hematuria (urinalysis) monthly for 3 months. She also underwent two ophthalmological reviews to check for hydroxychloroquine (HCQ)-associated retinopathy, which were both normal. We continued to monitor her clinically for lupus flare-ups, recurrence of thrombosis, and performed serial ultrasounds to assess the size of her right kidney.\n\nHer recent follow-up showed a weight of 56.9 kg, height of 160 cm, body mass index (BMI) of 22.7 kg/m2 (85th percentile), and a blood pressure of 120/70 mmHg (off amlodipine but continuing with losartan). Her kidney function was normal, with a serum creatinine of 0.6 mg/dL and an estimated glomerular filtration rate (eGFR) of > 170 ml/min/1.73 m2. However, she had slightly low hemoglobin (9.9 g/dL), a normal white blood cell (WBC) count (9.59 × 109/L), and a normal platelet count (418 × 109/L). Fortunately, she did not develop any further complications; however, she experienced menorrhagia, which resulted in anemia (Hb 9.9 g/dL). This was managed by consultation with a gynecologist, who adjusted her rivaroxaban dosage to 5 mg/day and prescribed 250 mg of tranexamic acid three times a day for 3–5 days during her menstrual period. We also tested her complement C3 (1.02 g/L) and anti-ds DNA levels (8.86 IU/mL), both of which were normal, indicating no active lupus.\n\nHer most recent ultrasound of the kidneys showed a small, shrunken, and echogenic right kidney (5.7 cm × 1.8 cm), with a compensatory enlargement of the left kidney (12.5 cm × 5 cm).\n\nWe plan to continue her anticoagulation, antiplatelet therapy, angiotensin receptor blockers (ARB), and hydroxychloroquine (HCQ) on a long-term basis, potentially for life. We also consulted a rheumatologist regarding the duration of anticoagulation therapy, but no decision has yet been made regarding discontinuation. Unfortunately, her mother developed systemic lupus erythematosus (SLE) 18 months later, and she is currently under the care of a rheumatologist.", + "fulltext_subclaims": [ + "The patient is a 10-year-old girl from a low socioeconomic background in a Hindu family from Sindh, Pakistan.", + "She presented with a 1-week history of severe right lumbar pain, gross hematuria, vomiting, and fever.", + "The pain was severe enough to require pain relief medication.", + "She visited the emergency room 2–3 times before being admitted for hospitalization.", + "She did not report any burning sensation during urination.", + "She did not report dysuria, urinary retention, or incontinence.", + "There were no other systemic manifestations, such as joint pain, prolonged fever, alopecia, mouth ulcers, or skin rash.", + "She was born by C-section to unrelated parents.", + "Her early childhood was uneventful.", + "She was fully immunized and developmentally normal.", + "She is currently a student in the 8th grade.", + "Her past medical and drug history was unremarkable.", + "There was no family history of kidney disease or other systemic disorders at the time of presentation.", + "On examination, she appeared anxious and unwell, febrile (101°F), and hypertensive, with a systolic and diastolic blood pressure of 130/96 mmHg.", + "Her anthropometric measurements were as follows: weight 36.4 kg (50th percentile), height 141 cm (above the 50th percentile), and body surface area (BSA) 1.2 m2.", + "She was mildly anemic and dehydrated, but not jaundiced.", + "Abdominal examination revealed tenderness in the right lumbar region.", + "Initial laboratory results showed a hemoglobin (Hb) level of 12.4 g/dL, white blood cell count of 14.98 × 109/L, and platelet count of 75 × 109/L.", + "Urinalysis revealed a reddish, hazy appearance with 150 mg/dL protein, 3 + blood, numerous red blood cells (RBCs) and white blood cells (15–20/hpf), while leukocyte esterase and nitrites were negative.", + "The spot urine calcium-to-creatinine ratio was 0.06 (normal < 0.2).", + "The protein-to-creatinine ratio was 0.8 (normal < 0.2).", + "Renal function was normal, with urea at 12 mg/dL, creatinine at 0.33 mg/dL, and electrolytes within normal limits.", + "Ultrasound (US) revealed a diffusely enlarged right kidney (11.5 cm × 6.7 cm) with patchy areas of increased echogenicity.", + "A color Doppler study showed a hypoechoic thrombus in the right renal vein (RRV) that completely blocked blood flow and extended into the inferior vena cava (IVC).", + "Her work-up for hereditary thrombophilia (including protein-C, protein-S, antithrombin III, and factor V Leiden) was negative.", + "Further serological testing confirmed a diagnosis of systemic lupus erythematosus (SLE), evidenced by low complement-3 (C3), positive antinuclear antibodies (ANA) with a titer of 1/5120, and positive anti-ds DNA antibodies.", + "Tests for antiphospholipid syndrome (APS) showed positive anticardiolipin antibodies (IgG and IgM), lupus anticoagulant, and prolonged confirmatory tests, which confirmed APS as secondary to SLE.", + "The patient was initially managed with intravenous paracetamol, hydration, and antibiotics.", + "Her hypertension was controlled with oral captopril and amlodipine, and captopril was later switched to losartan.", + "She was anticoagulated with low-molecular-weight (LMW) heparin (enoxaparin) and later switched to oral warfarin after 6 days.", + "Her condition improved over 8–10 days, with her platelet count rising to 189 × 109/L.", + "She was discharged after 12 days on warfarin, with strict observation for bleeding and regular monitoring of her prothrombin time and international normalized ratio (PT-INR), aiming to maintain a target INR of 2–3.", + "She continued amlodipine and losartan for hypertension and proteinuria, along with hydroxychloroquine (200 mg) and acetylsalicylic acid (75 mg) for thrombosis prevention.", + "A repeat color Doppler US during follow-up showed persistence of the right renal vein (RRV) thrombus but resolution of the inferior vena cava (IVC) thrombus.", + "The DMSA renal scan revealed a nonfunctioning right kidney, which was recommended for nephrectomy; however, the parents chose not to pursue this option.", + "Four weeks after discharge, the patient contracted chickenpox but recovered smoothly without complications.", + "During the period from November 2020 to September 2021, she visited another healthcare center where her anticoagulant treatment, warfarin, was replaced with rivaroxaban (10 mg once daily) to avoid the need for frequent INR monitoring.", + "Her recent follow-up showed a weight of 56.9 kg, height of 160 cm, body mass index (BMI) of 22.7 kg/m2 (85th percentile), and a blood pressure of 120/70 mmHg (off amlodipine but continuing with losartan).", + "Her kidney function was normal, with a serum creatinine of 0.6 mg/dL and an estimated glomerular filtration rate (eGFR) of > 170 ml/min/1.73 m2.", + "She had slightly low hemoglobin (9.9 g/dL), a normal white blood cell (WBC) count (9.59 × 109/L), and a normal platelet count (418 × 109/L).", + "She experienced menorrhagia, which resulted in anemia (Hb 9.9 g/dL).", + "This was managed by consultation with a gynecologist, who adjusted her rivaroxaban dosage to 5 mg/day and prescribed 250 mg of tranexamic acid three times a day for 3–5 days during her menstrual period.", + "Her most recent ultrasound of the kidneys showed a small, shrunken, and echogenic right kidney (5.7 cm × 1.8 cm), with a compensatory enlargement of the left kidney (12.5 cm × 5 cm).", + "We plan to continue her anticoagulation, antiplatelet therapy, angiotensin receptor blockers (ARB), and hydroxychloroquine (HCQ) on a long-term basis, potentially for life.", + "Her mother developed systemic lupus erythematosus (SLE) 18 months later, and she is currently under the care of a rheumatologist." + ], + "summary": "A 10 year-old girl from a Hindu family in Sindh, Pakistan, who had previously been healthy, presented in 2020 with a 1-week history of abdominal pain, gross hematuria, vomiting, and fever. On examination, she was anxious, febrile, hypertensive, and had an enlarged, tender right kidney. Other systemic examinations, including skin, locomotor, respiratory, cardiovascular, and nervous systems, were unremarkable. Initial investigations for ureteric colic and acute pyelonephritis were negative, but revealed thrombocytopenia on complete blood count, mild proteinuria, hematuria on urinalysis, and normal kidney and liver function tests, along with normal prothrombin and activated partial thromboplastin times. An abdominal ultrasound showed a diffusely enlarged, echogenic right kidney with a loss of corticomedullary distinction and cortical hypoechoic areas, while the left kidney appeared normal. Color Doppler ultrasound identified a large thrombus in the right renal vein, completely obstructing its lumen and showing no blood flow. The thrombus extended into the inferior vena cava. Computed tomography angiography confirmed an organized thrombus completely blocking the right renal vein and extending into the infrahepatic portion of the inferior vena cava. No prothrombotic risk factors were identified during clinical evaluation, and thrombophilia screening was negative. However, lupus serology and antiphospholipid antibodies were positive, confirming a diagnosis of secondary antiphospholipid syndrome.\n\nManagement and outcome: The patient was treated with enoxaparin anticoagulation, later transitioned to warfarin sodium, and her hypertension was managed with captopril and amlodipine. She showed gradual improvement over 10-12 days and was discharged on anticoagulants, antihypertensive medications, antiplatelet agents, and hydroxychloroquine. A follow-up Doppler ultrasound revealed persistent blockage of the right renal vein by the thrombus, with no thrombus in the inferior vena cava. A dimercaptosuccinic acid scan indicated a nonfunctioning right kidney. While nephrectomy was recommended, her parents declined the procedure. Anticoagulation therapy was switched to rivaroxaban to avoid frequent international normalized ratio monitoring. Her captopril was replaced after control of blood pressure with losartan. Over the next 4 years, her follow-up was uneventful. She demonstrated normal growth, stable blood pressure (off antihypertensive), and normal kidney function without proteinuria. There were no lupus flares or thrombotic recurrences. Her most recent urinalysis was normal, with a serum creatinine level of 0.6 mg/dL and an estimated glomerular filtration rate > 170 mL/min/1.73 m2.", + "summary_subclaims": [ + "The patient was a 10 year-old girl from a Hindu family in Sindh, Pakistan.", + "She had previously been healthy.", + "She presented in 2020 with a 1-week history of abdominal pain.", + "She had gross hematuria.", + "She had vomiting.", + "She had fever.", + "On examination, she was anxious.", + "On examination, she was febrile.", + "On examination, she was hypertensive.", + "She had an enlarged, tender right kidney.", + "Other systemic examinations were unremarkable.", + "Initial investigations for ureteric colic were negative.", + "Initial investigations for acute pyelonephritis were negative.", + "Thrombocytopenia was noted on complete blood count.", + "Mild proteinuria was noted on urinalysis.", + "Hematuria was noted on urinalysis.", + "Kidney function tests were normal.", + "Liver function tests were normal.", + "Prothrombin time was normal.", + "Activated partial thromboplastin time was normal.", + "An abdominal ultrasound showed a diffusely enlarged, echogenic right kidney.", + "The right kidney showed loss of corticomedullary distinction.", + "The right kidney showed cortical hypoechoic areas.", + "The left kidney appeared normal.", + "Color Doppler ultrasound identified a large thrombus in the right renal vein.", + "The thrombus completely obstructed the lumen of the right renal vein.", + "There was no blood flow in the right renal vein.", + "The thrombus extended into the inferior vena cava.", + "Computed tomography angiography confirmed an organized thrombus blocking the right renal vein.", + "The thrombus extended into the infrahepatic portion of the inferior vena cava.", + "No prothrombotic risk factors were identified.", + "Thrombophilia screening was negative.", + "Lupus serology was positive.", + "Antiphospholipid antibodies were positive.", + "The diagnosis was secondary antiphospholipid syndrome.", + "The patient was treated with enoxaparin anticoagulation.", + "The patient was later transitioned to warfarin sodium.", + "Hypertension was managed with captopril and amlodipine.", + "She showed gradual improvement over 10-12 days.", + "She was discharged on anticoagulants.", + "She was discharged on antihypertensive medications.", + "She was discharged on antiplatelet agents.", + "She was discharged on hydroxychloroquine.", + "A follow-up Doppler ultrasound revealed persistent blockage of the right renal vein by the thrombus.", + "There was no thrombus in the inferior vena cava.", + "A dimercaptosuccinic acid scan indicated a nonfunctioning right kidney.", + "Nephrectomy was recommended.", + "Her parents declined the procedure.", + "Anticoagulation therapy was switched to rivaroxaban.", + "Captopril was replaced after control of blood pressure with losartan.", + "Over the next 4 years, her follow-up was uneventful.", + "She demonstrated normal growth.", + "She had stable blood pressure (off antihypertensive).", + "She had normal kidney function without proteinuria.", + "There were no lupus flares.", + "There were no thrombotic recurrences.", + "Her most recent urinalysis was normal.", + "Her serum creatinine level was 0.6 mg/dL.", + "Her estimated glomerular filtration rate was > 170 mL/min/1.73 m2." + ] + }, + { + "id": "multiclinsum_test_3291_en.txt", + "fulltext": "Premature newborn from a second pregnancy, from non-consanguineous parents, 27-year-old mother with no significant morbid history, 3 prenatal checks, with diagnosis of omphalocele, but without subsequent follow-up. Personal, pathological and toxic allergic history is unknown, peripartum STORCH examinations negative.\n\nA newborn with undetermined sex was born at a gestational age (GA) estimated to be 33 weeks based on the Ballard test; with a weight of 2,300 g, a length of 43 cm, a head circumference of 32 cm, an anthropometric assessment of length/GA: -0.21 standard deviations (SD), weight/GA: +1.17 SD and head circumference/GA: + 1.11 SD; classified as adequate weight and length for the gestational age according to Intergrowth-21.\n\nThe initial physical examination highlighted a low anterior hairline, hypoplastic uvula, prominent lobes, broad nasal dorsum, anteverted nares, asymmetry with left hemifacial microsomia, absence of abdominal wall, giant omphalocele associated with vesicoureteral extrophy, epispadias, no palpable gonads, imperforate anus, a soft mass on the dorsum covered by skin at the lumbosacral level, bilateral club foot, hypoplastic nails, digitalized thumbs and halluxes.\n\nThe primary management was surgical correction of the omphalocele and ileostomy through an exploratory laparotomy. A defect of the anterior wall of the abdomen of a giant omphalocele of approximately 12 cm, centrally located, with an intact amnion containing the whole liver and some loops, associated with a vesical extrophia with exposed urethral orifices, a uterus didelphus (each hemi-uterus with its respective tube and ovary), a prolapse of approximately 15 cm of intestine through the cloaca, a small intestine ending in the cecum and the cecum in the cloaca, without evidence of the rest of the colon, and a diastasis of the pubis, were described at that time.\n\nIn the face of these malformations, an echocardiographic study was completed that reported a patent ductus arteriosus of 1 mm without haemodynamic repercussion, severe pulmonary hypertension of 65 mm hg. Radiological studies showed lower lumbar hemiverterbrae of the sacrum, butterfly vertebrae in the vertebral body of T9 and T12, hypoplastic iliac, without visualizing the coccyx.\n\nComputed tomography of the abdomen showed a left diaphragmatic hernia (Bochdalek), with hypertrophy of the left hepatic lobe displacing the liver anteriorly and inferiorly, causing an abnormal position of the intestinal loops posteriorly and caudally, as well as an ectopic gallbladder, a rejected bladder to the right with diffuse thickening of the walls, extrusion of the soft tissue of the pelvis with bone malformations and myelomeningocele. Magnetic resonance imaging of the brain showed myelocystocele.\n\nWith these findings, a high suspicion of OEIS complex with simultaneous presentation of Cantrell's pentalogia or 1p36 deletion was considered. In the genetic study, numerical and structural chromosome abnormalities were ruled out with a karyotype of 25 metaphase, G banding with a result of 46, XX.\n\nAs a management, the group of pediatric surgery and urology performed a colostomy, cloaca closure and midline vesical plaque, with adequate postoperative evolution, given respiratory stability during hospitalization, surgical correction of diaphragmatic hernia was deferred at that time and was planned to be performed later depending on clinical evolution.\n\nThe hospital stay was prolonged, however, she was discharged with indication of multidisciplinary outpatient control, but the patient died of intercurrent acute respiratory pathology shortly after.\n", + "fulltext_subclaims": [ + "The newborn was born at a gestational age estimated to be 33 weeks based on the Ballard test.", + "The newborn had a weight of 2,300 g.", + "The newborn had a length of 43 cm.", + "The newborn had a head circumference of 32 cm.", + "The anthropometric assessment showed length/GA: -0.21 standard deviations.", + "The anthropometric assessment showed weight/GA: +1.17 standard deviations.", + "The anthropometric assessment showed head circumference/GA: +1.11 standard deviations.", + "The newborn was classified as adequate weight and length for the gestational age according to Intergrowth-21.", + "The initial physical examination highlighted a low anterior hairline.", + "The initial physical examination highlighted hypoplastic uvula.", + "The initial physical examination highlighted prominent lobes.", + "The initial physical examination highlighted broad nasal dorsum.", + "The initial physical examination highlighted anteverted nares.", + "The initial physical examination highlighted asymmetry with left hemifacial microsomia.", + "The initial physical examination highlighted absence of abdominal wall.", + "The initial physical examination highlighted giant omphalocele associated with vesicoureteral extrophy.", + "The initial physical examination highlighted epispadias.", + "The initial physical examination highlighted no palpable gonads.", + "The initial physical examination highlighted imperforate anus.", + "The initial physical examination highlighted a soft mass on the dorsum covered by skin at the lumbosacral level.", + "The initial physical examination highlighted bilateral club foot.", + "The initial physical examination highlighted hypoplastic nails.", + "The initial physical examination highlighted digitalized thumbs and halluxes.", + "The primary management was surgical correction of the omphalocele and ileostomy through an exploratory laparotomy.", + "A defect of the anterior wall of the abdomen of a giant omphalocele of approximately 12 cm was described.", + "The omphalocele was centrally located.", + "The omphalocele had an intact amnion containing the whole liver and some loops.", + "The omphalocele was associated with a vesical extrophia with exposed urethral orifices.", + "A uterus didelphus (each hemi-uterus with its respective tube and ovary) was described.", + "A prolapse of approximately 15 cm of intestine through the cloaca was described.", + "The small intestine ended in the cecum and the cecum in the cloaca.", + "There was no evidence of the rest of the colon.", + "A diastasis of the pubis was described.", + "An echocardiographic study reported a patent ductus arteriosus of 1 mm without haemodynamic repercussion.", + "An echocardiographic study reported severe pulmonary hypertension of 65 mm hg.", + "Radiological studies showed lower lumbar hemiverterbrae of the sacrum.", + "Radiological studies showed butterfly vertebrae in the vertebral body of T9 and T12.", + "Radiological studies showed hypoplastic iliac.", + "Radiological studies showed no visualizing the coccyx.", + "Computed tomography of the abdomen showed a left diaphragmatic hernia (Bochdalek).", + "Computed tomography of the abdomen showed hypertrophy of the left hepatic lobe displacing the liver anteriorly and inferiorly.", + "Computed tomography of the abdomen showed an abnormal position of the intestinal loops posteriorly and caudally.", + "Computed tomography of the abdomen showed an ectopic gallbladder.", + "Computed tomography of the abdomen showed a rejected bladder to the right with diffuse thickening of the walls.", + "Computed tomography of the abdomen showed extrusion of the soft tissue of the pelvis with bone malformations.", + "Computed tomography of the abdomen showed myelomeningocele.", + "Magnetic resonance imaging of the brain showed myelocystocele.", + "A high suspicion of OEIS complex with simultaneous presentation of Cantrell's pentalogia or 1p36 deletion was considered.", + "Numerical and structural chromosome abnormalities were ruled out with a karyotype of 25 metaphase, G banding.", + "The karyotype result was 46, XX.", + "The group of pediatric surgery and urology performed a colostomy.", + "The group of pediatric surgery and urology performed cloaca closure.", + "The group of pediatric surgery and urology performed midline vesical plaque.", + "The postoperative evolution was adequate.", + "Surgical correction of diaphragmatic hernia was deferred at that time.", + "Surgical correction of diaphragmatic hernia was planned to be performed later depending on clinical evolution.", + "The hospital stay was prolonged.", + "The patient was discharged with indication of multidisciplinary outpatient control.", + "The patient died of intercurrent acute respiratory pathology shortly after." + ], + "summary": "Premature newborn with antenatal diagnosis of omphalocele. At birth, a giant omphalocele with an intact amnion containing the entire liver and loops, vesicoureteral atresia with an open bladder and exposed urethral orifices, a uterine didelphia, epispadias, no gonads were palpated, and soft tissue extrusion of the pelvis, left diaphragmatic hernia (Bochdalek), bone malformations, myelomeningocele and myelocystocele were detected by imaging. Based on these findings, a complex OEIS was proposed with the simultaneous presentation of Cantrell's pentalogia or deletion 1p36. Chromosome disorders were ruled out in the genetic study, but a more specific study could not be completed. A colostomy, cloaca closure and midline vesical plaque were performed with adequate postoperative evolution. Given respiratory stability, surgical correction of diaphragmatic hernia was deferred. She was discharged after a long hospital stay and died of acute respiratory intercurrent pathology.\n", + "summary_subclaims": [ + "The newborn had a giant omphalocele with an intact amnion containing the entire liver and loops.", + "Vesicoureteral atresia with an open bladder and exposed urethral orifices was present.", + "A uterine didelphia was detected.", + "Epispadias was present.", + "No gonads were palpated.", + "Soft tissue extrusion of the pelvis was detected.", + "A left diaphragmatic hernia (Bochdalek) was detected.", + "Bone malformations were detected.", + "Myelomeningocele and myelocystocele were detected.", + "A complex OEIS was proposed.", + "The simultaneous presentation of Cantrell's pentalogia or deletion 1p36 was proposed.", + "Chromosome disorders were ruled out in the genetic study.", + "A more specific study could not be completed.", + "A colostomy was performed.", + "Cloaca closure was performed.", + "A midline vesical plaque was performed.", + "The postoperative evolution was adequate.", + "Surgical correction of diaphragmatic hernia was deferred.", + "She was discharged after a long hospital stay.", + "She died of acute respiratory intercurrent pathology." + ] + }, + { + "id": "multiclinsum_test_851_en.txt", + "fulltext": "A 37-year-old man with a past medical history of AIDS-related lymphoma was admitted to Beijing Youan Hospital on 12 July 2016, for a relapse of diffuse large B cell lymphoma. The patient had been diagnosed with AIDS-related lymphoma 1 year earlier, and received eight courses of chemotherapy with rituximab, doxorubicin, vincristine, and etoposide (R-EPOCH). The patient recovered well and was discharged, with advice for regular follow-up. Three months ago, the results of a positron emission tomography-computed tomography scan suggested lymphoma recurrence, and the patient was transferred to our institution with an indwelling central venous catheter (CVC) catheter that had been inserted 3 months earlier for administration of chemotherapy. After 3 days of chemotherapy with etoposide, ifosfamide, and cisplatin, the results of clinical laboratory tests revealed myelosuppression, with white cell count of 0.11 × 109/L, hemoglobin of 4.0 g/dL, and platelet count of 8 × 109/L. His body temperature had been abnormal for 2 days, reaching 38.6 °C at the highest point, with procalcitonin of 0.96 μg/L, ESR of 56 mm/h, and CD4+ T-lymphocyte count of 52 × 106 cells/L. A physical examination revealed no specific signs of infections or skin manifestations. Two sets of blood cultures, one from a peripheral vein and the other through the CVC (each 10 ml in volume), were collected and sent to the laboratory for examination. The patient was started on empirical antimicrobial therapy with imipenem.\nThe blood culture drawn through the CVC was first flagged as positive by a BACTEC™ FX instrument (Becton, Dickinson and Company, USA) after 38 h of incubation in an aerobic bottle. After 61 h of culture in an aerobic bottle, the peripheral blood culture also became positive. Direct microscopic examination based on Gram staining revealed the presence of nonsporulating beaded Gram-positive bacilli. Subcultured blood specimens were plated on sheep blood agar and MacConkey agar. On the sheep blood agar incubated at 35 °C in an aerobic environment with 5% CO2, small white colonies became evident within 24 h. After 3 days of incubation, the colonies became mucoid, and the colonies turned yellow-orange. The bacteria were positive for catalase, negative for cytochrome oxidase activity, nonmotile, and unable to grow anaerobically.\nBacterial identification was performed by matrix-assisted laser desorption ionization–time of flight mass spectrometry (MALDI-TOF MS) according to the manufacturer’s instructions, and the obtained protein profiles were processed and analyzed by MALDI Biotyper 3.0 software (Bruker Daltonics, Germany). However, the MALDI-TOF MS failed to confidently identify the isolate to the species level. Nevertheless, the isolate was identified as a Gordonia species, with a top match score of 1.764 (for Gordonia rubripertincta; scores of ≥2.0 and <2.0 to ≥1.7 represent identification to the species level and genus level, respectively), suggesting it did not resemble any known Gordonia species in the database.\nThereafter, bacterial DNA extraction, PCR amplification, and DNA sequencing of the 16S rRNA with a universal primer pair were conducted to confirm the results. The obtained product sequence (1404 bp) was compared with published sequences in the GenBank database . The results showed that the isolate had 99% matches with the type strains of G. polyisoprenivorans (strains W8130 and VH2), Gordonia bronchialis (strain DSM 43247), and Gordonia terrae (strain EY-T12). Sequencing of the gyrB genes was then performed according to a previous report . The results showed that the gyrB gene of the isolate had 99.0% sequence identity with the gene sequence of the G. polyisoprenivorans strain, indicating that the isolate was G. polyisoprenivorans.\nThe isolate was sensitive to amikacin, ampicillin, amoxicillin-clavulanate, cefotaxime, imipenem, meropenem, ciprofloxacin, minocycline, linezolid, and vancomycin, with intermediate sensitivity to trimethoprim-sulfamethoxazole.\nAt 3 days after the start of imipenem therapy, there was a complete disappearance of fever and a remarkable improvement in the patient’s clinical status. From day 5 onward, the patient was switched to oral antibiotics. As there was no swelling or effusion around the CVC, the catheter was not removed. The patient was followed up for 3 months. There was no recurrence of the infection during the follow-up period. However, he died after 3 months apparently from progression of his hematological malignancies.", + "fulltext_subclaims": [ + "The patient was a 37-year-old man with a past medical history of AIDS-related lymphoma.", + "He was admitted to Beijing Youan Hospital on 12 July 2016 for a relapse of diffuse large B cell lymphoma.", + "He had been diagnosed with AIDS-related lymphoma 1 year earlier.", + "He received eight courses of chemotherapy with rituximab, doxorubicin, vincristine, and etoposide (R-EPOCH).", + "The patient recovered well and was discharged with advice for regular follow-up.", + "Three months ago, a positron emission tomography-computed tomography scan suggested lymphoma recurrence.", + "The patient had an indwelling central venous catheter (CVC) that had been inserted 3 months earlier.", + "After 3 days of chemotherapy with etoposide, ifosfamide, and cisplatin, clinical laboratory tests revealed myelosuppression.", + "His white cell count was 0.11 × 109/L.", + "His hemoglobin was 4.0 g/dL.", + "His platelet count was 8 × 109/L.", + "His body temperature had been abnormal for 2 days, reaching 38.6 °C at the highest point.", + "His procalcitonin was 0.96 μg/L.", + "His ESR was 56 mm/h.", + "His CD4+ T-lymphocyte count was 52 × 106 cells/L.", + "A physical examination revealed no specific signs of infections or skin manifestations.", + "Two sets of blood cultures were collected, one from a peripheral vein and the other through the CVC.", + "The blood culture drawn through the CVC was first flagged as positive by a BACTEC™ FX instrument after 38 h of incubation in an aerobic bottle.", + "The peripheral blood culture became positive after 61 h of culture in an aerobic bottle.", + "Direct microscopic examination based on Gram staining revealed the presence of nonsporulating beaded Gram-positive bacilli.", + "Subcultured blood specimens were plated on sheep blood agar and MacConkey agar.", + "On sheep blood agar incubated at 35 °C in an aerobic environment with 5% CO2, small white colonies became evident within 24 h.", + "After 3 days of incubation, the colonies became mucoid and turned yellow-orange.", + "The bacteria were positive for catalase.", + "The bacteria were negative for cytochrome oxidase activity.", + "The bacteria were nonmotile.", + "The bacteria were unable to grow anaerobically.", + "Bacterial identification was performed by matrix-assisted laser desorption ionization–time of flight mass spectrometry (MALDI-TOF MS).", + "The MALDI-TOF MS failed to confidently identify the isolate to the species level.", + "The isolate was identified as a Gordonia species with a top match score of 1.764 for Gordonia rubripertincta.", + "The isolate did not resemble any known Gordonia species in the database.", + "Bacterial DNA extraction, PCR amplification, and DNA sequencing of the 16S rRNA with a universal primer pair were conducted.", + "The obtained product sequence (1404 bp) had 99% matches with the type strains of G. polyisoprenivorans, Gordonia bronchialis, and Gordonia terrae.", + "Sequencing of the gyrB genes showed 99.0% sequence identity with the gene sequence of the G. polyisoprenivorans strain.", + "The isolate was sensitive to amikacin, ampicillin, amoxicillin-clavulanate, cefotaxime, imipenem, meropenem, ciprofloxacin, minocycline, linezolid, and vancomycin.", + "The isolate had intermediate sensitivity to trimethoprim-sulfamethoxazole.", + "At 3 days after the start of imipenem therapy, there was a complete disappearance of fever.", + "There was a remarkable improvement in the patient’s clinical status.", + "From day 5 onward, the patient was switched to oral antibiotics.", + "The catheter was not removed as there was no swelling or effusion around the CVC.", + "The patient was followed up for 3 months.", + "There was no recurrence of the infection during the follow-up period.", + "He died after 3 months apparently from progression of his hematological malignancies." + ], + "summary": "A 37-year-old man with a past medical history of AIDS-related lymphoma suffered bacteremia caused by a Gram-positive corynebacterium. The strain was identified as a Gordonia species by matrix-assisted laser desorption ionization-time of flight mass spectrometry and confirmed to G. polyisoprenivorans by 16S rRNA combined with gyrB gene sequencing analyses. The patient was treated with imipenem and had a good outcome.", + "summary_subclaims": [ + "The patient is a 37-year-old man.", + "The patient has a past medical history of AIDS-related lymphoma.", + "The patient suffered bacteremia caused by a Gram-positive corynebacterium.", + "The strain was identified as a Gordonia species by matrix-assisted laser desorption ionization-time of flight mass spectrometry.", + "The strain was confirmed to G. polyisoprenivorans by 16S rRNA combined with gyrB gene sequencing analyses.", + "The patient was treated with imipenem.", + "The patient had a good outcome." + ] + }, + { + "id": "multiclinsum_test_463_en.txt", + "fulltext": "On 7 March, 2018, a 73-year-old man, HIV-negative, was hospitalized to the local county hospital for 2-month chest pain, low-grade fever, asthenia, anorexia and weight loss. The patient had history of type II diabetes mellitus with regular administration of gliclazide, but efficacy was poor. Physical examination revealed body temperature 36.7 °C, pulse rate 96 beats/min, blood pressure 133/83 mmHg, respiratory rate 20/min, oxygen saturation 96% and mildly yellow skin and sclera. Respiratory system, cardiovascular system, neurological system and abdomen were normal. Laboratory examination showed anemia (hemoglobin 114 g/L), abnormal liver function (alanine aminotransferase 57 U/L, aspartate aminotransferase 48 U/L, γ-glutamyl transpeptidase 818 U/L, alkaline phosphatase 671 U/L, total bilirubin 44 μmol/L) and elevated cancer antigen 19-9 (CA19-9, 165 U/ml). The interferon-γ release assay test was negative. The skull computerized tomography (CT) showed lacunar infarction in bilateral basal ganglia. The thorax CT revealed multiple round or round-like nodules with variable sizes scattered throughout both lungs, suggestive of metastatic lung disease . Abdominal enhancement CT showed that a mass at the pancreatic head was obviously strengthened in the arterial phase, and the pancreatic duct and intrahepatic bile duct was slightly dilated . Taken together, all examination results were strongly suspected of lung metastasis, which was originated from the pancreatic head or intestinal origin. However, TB infection could not be excluded completely. The patient denied further biopsy, and chose to accept experimental anti-TB therapy with rifampin and isoniazid. After one month, chest CT showed that lung lesions were not absorbed. Laboratory test showed that CA19-9 sharply increased, up to 1167 U/ml. Sputum smear for acid-fast bacilli (AFB) was negative. The doctors in the local county hospital excluded TB infection and proposed gastrointestinal malignant tumors combined with lung metastasis. The patient family was in deep sorrow and prepared to give up.\nOn 7 May, 2018, his daughter persuaded the patient to the provincial hospital for further diagnosis. Laboratory examination revealed hyperbilirubinemia (total bilirubin 70 μmol/L), CA19-9 832 U/ml, cancer antigen 125 141 U/ml, neuron-specific enolase 22.98 ng/ml, angiotensin-converting enzyme 178 U/L and serum (1,3)-β-D-glucan 235 pg/ml. 18F-fluorodeoxyglucose positron-emission tomography (18F-FDG-PET) scan showed focal high uptake in the multiple organs, including lung, liver, pancreas, spleen, gallbladder neck , which suggested benign disease (especially TB). The patient accepted the endoscopic retrograde cholangiopancreatography to relieve hyperbilirubinemia, which was caused by bile duct obstruction. Biopsy from brushed biliary cell indicated no malignant tumor. A CT scan-guided transthoracic needle biopsy of the nodule at the left upper lobe was performed and the histopathology showed coagulative necrosis combining with granulomatous inflammation. AFB staining was positive and Periodic Acid-Schiff staining was negative . In the meanwhile, qPCR for MTB DNA showed 4900 copy/ml in the sputum. Thus, the diagnosis of TB infection was definite. The patient then accepted anti-TB regimen, including isoniazid (300 mg/once a day [QD]), rifampicin (450 mg/QD), ethambutol (750 mg/QD), pyrazinamide (1500 mg/QD), levofloxacin (600 mg/QD) for three months, followed by isoniazid (300 mg/QD) and rifampicin (450 mg/QD) for another nine months.\nOn 2 September, 2018, almost four months after hospitalization to our hospital, the thorax CT revealed that the lung lesions were absorbed significantly . After one year of treatment, continuous clinical and radiological improvement was observed, and the drugs were then withdrawn. The patient was asymptomatic at the follow-up of half year after withdrawal.", + "fulltext_subclaims": [ + "On 7 March, 2018, a 73-year-old man, HIV-negative, was hospitalized to the local county hospital.", + "The patient had 2-month chest pain, low-grade fever, asthenia, anorexia, and weight loss.", + "The patient had history of type II diabetes mellitus with regular administration of gliclazide.", + "Physical examination revealed body temperature 36.7 °C.", + "Physical examination revealed oxygen saturation 96%.", + "Physical examination revealed mildly yellow skin and sclera.", + "Laboratory examination showed anemia (hemoglobin 114 g/L).", + "Laboratory examination showed abnormal liver function (alanine aminotransferase 57 U/L, aspartate aminotransferase 48 U/L, γ-glutamyl transpeptidase 818 U/L, alkaline phosphatase 671 U/L, total bilirubin 44 μmol/L).", + "The interferon-γ release assay test was negative.", + "The thorax CT revealed multiple round or round-like nodules with variable sizes scattered throughout both lungs, suggestive of metastatic lung disease.", + "Abdominal enhancement CT showed that a mass at the pancreatic head was obviously strengthened in the arterial phase.", + "Taken together, all examination results were strongly suspected of lung metastasis, which was originated from the pancreatic head or intestinal origin.", + "TB infection could not be excluded completely.", + "The patient chose to accept experimental anti-TB therapy with rifampin and isoniazid.", + "After one month, chest CT showed that lung lesions were not absorbed.", + "Laboratory test showed that CA19-9 sharply increased, up to 1167 U/ml.", + "Sputum smear for acid-fast bacilli (AFB) was negative.", + "The doctors in the local county hospital excluded TB infection.", + "The doctors proposed gastrointestinal malignant tumors combined with lung metastasis.", + "On 7 May, 2018, his daughter persuaded the patient to the provincial hospital for further diagnosis.", + "18F-FDG-PET scan showed focal high uptake in multiple organs, including lung, liver, pancreas, spleen, gallbladder neck, which suggested benign disease (especially TB).", + "A CT scan-guided transthoracic needle biopsy of the nodule at the left upper lobe was performed.", + "The histopathology showed coagulative necrosis combining with granulomatous inflammation.", + "AFB staining was positive.", + "qPCR for MTB DNA showed 4900 copy/ml in the sputum.", + "The diagnosis of TB infection was definite.", + "The patient accepted anti-TB regimen, including isoniazid (300 mg/once a day), rifampicin (450 mg/once a day), ethambutol (750 mg/once a day), pyrazinamide (1500 mg/once a day), levofloxacin (600 mg/once a day) for three months.", + "On 2 September, 2018, the thorax CT revealed that the lung lesions were absorbed significantly.", + "After one year of treatment, continuous clinical and radiological improvement was observed.", + "The drugs were then withdrawn.", + "The patient was asymptomatic at the follow-up of half year after withdrawal." + ], + "summary": "A 73-year-old man, HIV-negative, was hospitalized to the local county hospital because of chest pain, low-grade fever, asthenia, anorexia and weight loss for the pasting two months. The CT findings of the two lungs showed multiple round or round-like nodules of different sizes, with clear boundaries and partial fusion. The level of serum CA19-9 was significantly higher than normal, and progressively increased. There were multiple enlarged lymph nodes in the neck, mediastinum, abdominal cavity and pelvic cavity. The symptoms were diagnosed as hematogenous spread of gastrointestinal tumor in the local county hospital. However, when transferred to our provincial hospital, through comprehensive dynamic analysis, this patient was diagnosed as atypical systemic HDTB, no cancer at all. Through routine anti-TB therapy for one year, the patient was recovered very well at the follow-up of half year after withdrawal.", + "summary_subclaims": [ + "The patient is a 73-year-old man.", + "The patient is HIV-negative.", + "The patient was hospitalized to the local county hospital.", + "The patient had chest pain.", + "The patient had low-grade fever.", + "The patient had asthenia.", + "The patient had anorexia.", + "The patient had weight loss.", + "The symptoms lasted for the past two months.", + "The CT findings of the two lungs showed multiple round or round-like nodules of different sizes.", + "The CT findings showed clear boundaries.", + "The CT findings showed partial fusion.", + "The level of serum CA19-9 was significantly higher than normal.", + "The level of serum CA19-9 progressively increased.", + "There were multiple enlarged lymph nodes in the neck.", + "There were multiple enlarged lymph nodes in the mediastinum.", + "There were multiple enlarged lymph nodes in the abdominal cavity.", + "There were multiple enlarged lymph nodes in the pelvic cavity.", + "The local county hospital diagnosed hematogenous spread of gastrointestinal tumor.", + "The provincial hospital diagnosed atypical systemic HDTB.", + "The provincial hospital found no cancer.", + "The patient received routine anti-TB therapy for one year.", + "The patient recovered very well at the follow-up of half year after withdrawal." + ] + }, + { + "id": "multiclinsum_test_2718_en.txt", + "fulltext": "A 15-year-old girl presented to the surgery unit with pain in the right hypochondrium and underwent appendicectomy for acute appendicitis with paralytic ileus. At laparotomy an enlarged mesentric lymph node was noted which was excised and sent for histopathological examination together with the appendicectomy specimen.\nGrossly, the excised mesenteric lymph node measured 2.5×1.5×1 cm. It was nodular on external examination. A cut section revealed multiple cysts varying in size from 0.5 to 0.8 cm in diameter containing shiny grey-white material. Microscopic examination showed numerous parasites with characteristic morphology scattered throughout the node . The parasites had an outer vesicular wall composed of three layers: an outer cuticular layer, a middle cellular layer and an inner reticular layer along with invaginated scolices which showed a rudimentary body with spiral canal. Some of these parasites were surrounded by host reaction in the form of palisaded histiocytes, fibrosis and calcification in places. The appendicectomy specimen measured 4×1 cm and showed changes of acute diffuse suppurative appendicitis.\nSubsequent to the histopathology report the patient underwent a further thorough physical examination that revealed no evidence of subcutaneous or muscular swelling. Further radiological and other investigations did not reveal cysticercus infestation anywhere else in the body. We were unable to confirm that the parasite was T. solium by serology, staining of the tissue by immunofluorescence assay or immunohistochemistry.", + "fulltext_subclaims": [ + "A 15-year-old girl presented to the surgery unit with pain in the right hypochondrium.", + "She underwent appendicectomy for acute appendicitis with paralytic ileus.", + "At laparotomy an enlarged mesenteric lymph node was noted.", + "The lymph node was excised and sent for histopathological examination.", + "The excised mesenteric lymph node measured 2.5×1.5×1 cm.", + "A cut section revealed multiple cysts varying in size from 0.5 to 0.8 cm in diameter containing shiny grey-white material.", + "Microscopic examination showed numerous parasites with characteristic morphology scattered throughout the node.", + "The parasites had an outer vesicular wall composed of three layers: an outer cuticular layer, a middle cellular layer and an inner reticular layer.", + "Some of these parasites were surrounded by host reaction in the form of palisaded histiocytes, fibrosis and calcification in places.", + "The appendicectomy specimen measured 4×1 cm.", + "The appendicectomy specimen showed changes of acute diffuse suppurative appendicitis.", + "Subsequent to the histopathology report the patient underwent a further thorough physical examination.", + "The physical examination revealed no evidence of subcutaneous or muscular swelling.", + "Further radiological and other investigations did not reveal cysticercus infestation anywhere else in the body.", + "We were unable to confirm that the parasite was T. solium by serology.", + "We were unable to confirm that the parasite was T. solium by staining of the tissue by immunofluorescence assay.", + "We were unable to confirm that the parasite was T. solium by immunohistochemistry." + ], + "summary": "Here we present the case of a 15-year-old girl who was incidentally detected as having mesenteric lymph node enlargement caused by multiple cysticerci. This is the second case report of lymph node enlargement due to cysticercus infestation.", + "summary_subclaims": [ + "A 15-year-old girl was incidentally detected as having mesenteric lymph node enlargement.", + "The mesenteric lymph node enlargement was caused by multiple cysticerci.", + "This is the second case report of lymph node enlargement due to cysticercus infestation." + ] + }, + { + "id": "multiclinsum_test_1628_en.txt", + "fulltext": "A 20-year-old nulliparous woman presented to our gynecologic department because of intermittent abdominal pain and a 3-month history of dysmenorrhea. She had a history of 2 right ovarian teratomas that were managed surgically. At the age of 16 years, she experienced lower abdominal pain for 2 weeks. A subsequent pelvic sonography showed a complex, right ovarian cyst, of approximately 5.36 × 4.3 cm in size; her carbohydrate antigen (CA) 125 level was 23.4 U/mL (normal, 0–25 U/mL, at our hospital). We performed a laparoscopically assisted ovarian cystectomy, and the subsequent pathologic analysis revealed a mature cystic teratoma. During the laparoscopy, the left ovary was visually examined, and morbid findings were not noted. One month after the surgery, her symptoms had improved and no residual tumor was observed on pelvic sonography. The patient was subsequently lost to follow-up. After 1 year, she presented to our out-patient department with a 2-month history of prolonged menstrual periods; a right ovarian complex mass, approximately 3.7 × 4.3 cm, with a solid component, was noted during a pelvic ultrasound examination (Figure ). Her CA125 level was 11.9 U/mL. She, again, underwent laparoscopically assisted ovarian cystectomy in our hospital, and the pathological report revealed another mature cystic teratoma. However, no abnormal findings were noted for the left ovary.\nShe received regular follow-up care every 6 months and had been well for the next 3 years. However, at the age of 20 years, she presented with intermittent abdominal pain as well as dysmenorrhea that had persisted for several months. A complex mass, that had an approximately 10% solid component, was detected on sonographic examination. In addition, her CA125 level was 103.1 U/mL. Based on the findings of serological tests, we suspected the presence of a malignancy. The patient underwent a contrast-enhanced abdominal and pelvic computed tomography (CT) scan, which revealed an 8.9 × 5.7-cm, complex, cystic tumor of the left adnexa, with compression and displacement of the urinary bladder. Moreover, a 5.1 × 3.9-cm, complex, cystic, partially solid tumor was noted on the right adnexa (Figure ).\nDue to the presence of bilateral adnexal lesions and the suspicion of malignancy, the patient underwent an exploratory laparotomy, bilateral ovarian cystectomy, and pelvic adhesiolysis. During the laparotomy, a capsulated, enlarged, 9 × 6 cm, left ovarian tumor was detected, with abundant sebaceous and hair-containing tissue. The right mass appeared to be a teratoma, 5 × 4 cm in size. Histopathological findings confirmed the presence of bilateral, mature cystic teratomas, composed of sebaceous and keratinous materials as well as hair shaft components. No evidence of malignancy was found. After discharge, the patient underwent follow-up at 1, 3, 9, and 15 months. She did not report abdominal pain or menstrual abnormalities, and a pelvic sonography did not demonstrate any signs of recurrence or residual tumor.", + "fulltext_subclaims": [ + "The patient is a 20-year-old nulliparous woman.", + "She presented with intermittent abdominal pain and a 3-month history of dysmenorrhea.", + "She had a history of 2 right ovarian teratomas that were managed surgically.", + "At age 16, she experienced lower abdominal pain for 2 weeks.", + "A pelvic sonography showed a complex, right ovarian cyst of approximately 5.36 × 4.3 cm.", + "Her CA125 level was 23.4 U/mL.", + "The normal CA125 range at the hospital is 0–25 U/mL.", + "A laparoscopically assisted ovarian cystectomy was performed.", + "The pathologic analysis revealed a mature cystic teratoma.", + "During the laparoscopy, the left ovary was visually examined, and morbid findings were not noted.", + "One month after the surgery, her symptoms had improved.", + "No residual tumor was observed on pelvic sonography.", + "The patient was lost to follow-up.", + "After 1 year, she presented with a 2-month history of prolonged menstrual periods.", + "A right ovarian complex mass, approximately 3.7 × 4.3 cm, with a solid component, was noted during a pelvic ultrasound.", + "Her CA125 level was 11.9 U/mL.", + "She underwent laparoscopically assisted ovarian cystectomy.", + "The pathological report revealed another mature cystic teratoma.", + "No abnormal findings were noted for the left ovary.", + "She received regular follow-up care every 6 months.", + "She had been well for the next 3 years.", + "At age 20, she presented with intermittent abdominal pain and dysmenorrhea that had persisted for several months.", + "A complex mass with an approximately 10% solid component was detected on sonographic examination.", + "Her CA125 level was 103.1 U/mL.", + "Based on the findings of serological tests, malignancy was suspected.", + "A contrast-enhanced abdominal and pelvic CT scan revealed an 8.9 × 5.7-cm complex cystic tumor of the left adnexa.", + "The tumor compressed and displaced the urinary bladder.", + "A 5.1 × 3.9-cm complex cystic, partially solid tumor was noted on the right adnexa.", + "Due to bilateral adnexal lesions and suspicion of malignancy, the patient underwent an exploratory laparotomy.", + "Bilateral ovarian cystectomy and pelvic adhesiolysis were performed.", + "A capsulated, enlarged, 9 × 6 cm left ovarian tumor was detected.", + "The tumor contained abundant sebaceous and hair-containing tissue.", + "The right mass appeared to be a teratoma, 5 × 4 cm in size.", + "Histopathological findings confirmed the presence of bilateral mature cystic teratomas.", + "The teratomas were composed of sebaceous and keratinous materials as well as hair shaft components.", + "No evidence of malignancy was found.", + "After discharge, the patient underwent follow-up at 1, 3, 9, and 15 months.", + "She did not report abdominal pain or menstrual abnormalities.", + "A pelvic sonography did not demonstrate any signs of recurrence or residual tumor." + ], + "summary": "A young woman with a recurrent, right ovarian teratoma had previously undergone surgical removal 2 times. After the second surgery, she underwent regular out-patient follow-up, and no residual tumor was observed. However, 3 years after the second surgery, she developed recurrent, bilateral ovarian teratomas, in conjunction with elevated carbohydrate antigen-125 levels.", + "summary_subclaims": [ + "A young woman had previously undergone surgical removal of a right ovarian teratoma 2 times.", + "After the second surgery, she underwent regular out-patient follow-up.", + "No residual tumor was observed during follow-up.", + "Three years after the second surgery, she developed recurrent, bilateral ovarian teratomas.", + "Elevated carbohydrate antigen-125 levels were observed." + ] + }, + { + "id": "multiclinsum_test_1381_en.txt", + "fulltext": "A 69-year-old lady presented to our hospital with a few days’ history of intermittent episodes of breathlessness, and reduced exercise tolerance to a few yards. On the morning of her admission, she described a brief episode of chest pain, which her family had thought was a panic attack.\nShe had a background history of alcoholic liver disease with cirrhosis (Child-Pugh score A), portal hypertensive gastropathy, hiatus hernia, healed duodenal ulcer, and chronic anxiety. She was a current smoker of over 30 pack years and had been abstinent from alcohol for 3 years.\nOn arrival, our patient was alert and oriented. Her observations showed a pulse rate of 127bpm, blood pressure (BP) of 166/78 mmHg, respiratory rate of 34, oxygen saturation of 86% on 5 L oxygen, and temperature of 36.3°C. Auscultation of her chest revealed bilateral wheeze, with normal heart sounds. She had cold peripheries with a prolonged capillary refill time and no peripheral oedema.\nHer first arterial blood gas (ABG) revealed acute decompensated type two respiratory failure (T2RF) . Given her background, she was treated initially as an infective exacerbation of likely underlying, undiagnosed COPD, and was started on antibiotics, nebulizers, and steroids.\nWithin a couple of hours, she became increasingly agitated and subsequently less responsive. A repeat ABG revealed worsening T2RF and non-invasive ventilation (NIV) in the form of bi-level positive airway pressure was commenced.\nChest X-ray revealed hyperinflation with upper lobe diversion , and her ECG showed ST elevation in the anterior leads . Blood tests revealed an elevated white cell count, troponin, brain natriuretic peptide, and D-dimer . She was reviewed by intensive care, and the working diagnosis was ST-elevation myocardial infarction with LV failure resulting in T2RF. ACS treatment with aspirin, clopidogrel, and fondaparinux was commenced, and urgent cardiology opinion was requested.\nUpon cardiology review, a bedside echocardiogram showed severe LV systolic dysfunction, with dyskinesis of the mid and apical septal and lateral walls, with preservation of basal function. The mid and apical segments of the RV free wall were dyskinetic with preservation of basal function. A possible diagnosis of BTC was proposed. However, based on the presence of Q waves across the chest leads on the ECG, and the fact that BTC is a diagnosis of exclusion, the differential diagnosis was that of a prior infarct with persistent ST elevation.\nA computed tomography pulmonary angiogram (CTPA) ruled out pulmonary embolism, and the patient was responding well to NIV, with a repeat ABG 3 hours after initiating NIV showing resolution of acidosis and hypercapnia, but persistent hypoxaemia .\nHer troponin increased to 2000 ng/L, and in view of the patient’s complex background and acute illness, she was managed in our intensive care department. She was deemed too unstable to undergo invasive coronary angiography.\nOn her second day in hospital, she became hypotensive with a BP of around 90/60 mmHg. Repeat ECG showed resolution of Q waves, and a new right bundle branch block with deep T-wave inversion. Her troponin had further risen to 3000 ng/L. Repeat bedside echocardiogram remained consistent with BTC . The systolic pulmonary pressure (SPAP) was elevated at 47–52 mmHg, estimated from the moderate tricuspid regurgitation. Metaraminol and subsequently dobutamine and noradrenaline were commenced for BP support. Our local tertiary centre advised switching these to a levosimendan infusion for 24 hours, and intra-aortic balloon pump support was felt unnecessary. Our patient haemodynamically stabilised with improved BP and urine output.\nOver Days 4 and 5, following the cessation of levosimendan, our patient still required low dose inotropic support.\nOn Day 6, our patient developed rate-controlled atrial fibrillation (AF) with ST elevation in V1-V4 with biphasic T waves, although, she remained free of chest pain . In spite of her new AF, repeat echocardiogram ( revealed complete recovery of the LV systolic function with no evidence of regional wall motion abnormality. Her right ventricle continued to show basal wall preservation of function and mid to apical RV dilatation and dyskinesis, and SPAP of 54 mmHg. Troponin level had further fallen to 329 ng/L. Supportive management continued.\nOver the next 48 hours, after clinical improvement, inotropic support was weaned. On Day 8, repeat echocardiography showed that in addition to the prior recovery of her LV function, her RV function had also fully recovered (, ). The previously documented SPAP remained >56 mmHg, which was interpreted as her baseline due to her COPD. Invasive coronary angiography confirmed no obstructive coronary artery disease , thus we could confirm that our patient had indeed suffered from BTC, as up until this point, we had been unable to rule out myocardial infarction. Her ECGs continued to show persistent anterior ST elevation with biphasic T-wave changes.\nOur patient continued to improve and was stepped down to the coronary care unit and was engaging well with inpatient rehabilitation. Unfortunately, on the morning of Day 15, she developed another episode of T2RF, possibly due to aspiration following a choking episode on breakfast. Focused echocardiography ruled out the recurrence of TC, and she responded swiftly to NIV, requiring less than 24 hours. She was transferred to the respiratory ward for ongoing management of her airway disease and discharged 2 weeks later.\nCo-incidentally, her thyroid function tests (TFT) on Day 6 showed raised T4 and undetectable thyroid-stimulating hormone level . After confirmation with repeated blood tests, the diagnosis of thyrotoxicosis was made. The endocrine review and subsequent thyroid-receptor antibody levels suggested autoimmune thyroiditis or Graves’ disease. At a later stage, carbimazole treatment was commenced and beta-blocker continued with regular endocrine follow-up. Our patient had a brief admission in September 2020 with mild shortness of breath. Repeat echocardiography showed normal biventricular systolic function, normal LV diastolic function and filling pressures and an SPAP of 40 mmHg.", + "fulltext_subclaims": [ + "The patient is a 69-year-old lady.", + "She presented with intermittent episodes of breathlessness.", + "She had a brief episode of chest pain on the morning of admission.", + "Her family thought the chest pain was a panic attack.", + "She had a background history of alcoholic liver disease with cirrhosis (Child-Pugh score A).", + "She had portal hypertensive gastropathy.", + "She had a healed duodenal ulcer.", + "She was a current smoker of over 30 pack years.", + "She had been abstinent from alcohol for 3 years.", + "On arrival, her pulse rate was 127bpm.", + "Her oxygen saturation was 86% on 5 L oxygen.", + "Auscultation of her chest revealed bilateral wheeze.", + "Her first arterial blood gas revealed acute decompensated type two respiratory failure.", + "She was treated initially as an infective exacerbation of likely underlying, undiagnosed COPD.", + "She was started on antibiotics, nebulizers, and steroids.", + "Within a couple of hours, she became increasingly agitated.", + "A repeat ABG revealed worsening T2RF.", + "Non-invasive ventilation in the form of bi-level positive airway pressure was commenced.", + "Chest X-ray revealed hyperinflation with upper lobe diversion.", + "Her ECG showed ST elevation in the anterior leads.", + "Blood tests revealed an elevated white cell count.", + "Blood tests revealed an elevated troponin.", + "Blood tests revealed an elevated D-dimer.", + "The working diagnosis was ST-elevation myocardial infarction with LV failure resulting in T2RF.", + "ACS treatment with aspirin, clopidogrel, and fondaparinux was commenced.", + "A bedside echocardiogram showed severe LV systolic dysfunction.", + "The mid and apical segments of the RV free wall were dyskinetic.", + "A possible diagnosis of BTC was proposed.", + "The differential diagnosis was that of a prior infarct with persistent ST elevation.", + "A computed tomography pulmonary angiogram ruled out pulmonary embolism.", + "A repeat ABG 3 hours after initiating NIV showed resolution of acidosis and hypercapnia.", + "Her troponin increased to 2000 ng/L.", + "She was managed in the intensive care department.", + "She was deemed too unstable to undergo invasive coronary angiography.", + "On her second day in hospital, she became hypotensive with a BP of around 90/60 mmHg.", + "Repeat ECG showed resolution of Q waves.", + "Repeat ECG showed a new right bundle branch block with deep T-wave inversion.", + "Her troponin had further risen to 3000 ng/L.", + "Repeat bedside echocardiogram remained consistent with BTC.", + "The systolic pulmonary pressure was estimated at 47–52 mmHg.", + "Metaraminol and subsequently dobutamine and noradrenaline were commenced for BP support.", + "The local tertiary centre advised switching to a levosimendan infusion for 24 hours.", + "Intra-aortic balloon pump support was felt unnecessary.", + "Our patient haemodynamically stabilised with improved BP and urine output.", + "Over Days 4 and 5, following the cessation of levosimendan, our patient still required low dose inotropic support.", + "On Day 6, our patient developed rate-controlled atrial fibrillation with ST elevation in V1-V4 with biphasic T waves.", + "She remained free of chest pain.", + "Repeat echocardiogram showed complete recovery of the LV systolic function.", + "Her right ventricle continued to show mid to apical RV dilatation and dyskinesis.", + "The systolic pulmonary pressure was 54 mmHg.", + "Troponin level had further fallen to 329 ng/L.", + "Inotropic support was weaned over the next 48 hours.", + "On Day 8, repeat echocardiography showed full recovery of her RV function.", + "Invasive coronary angiography confirmed no obstructive coronary artery disease.", + "We could confirm that our patient had indeed suffered from BTC.", + "Her ECGs continued to show persistent anterior ST elevation with biphasic T-wave changes.", + "She was stepped down to the coronary care unit.", + "She was engaging well with inpatient rehabilitation.", + "On the morning of Day 15, she developed another episode of T2RF, possibly due to aspiration following a choking episode on breakfast.", + "Focused echocardiography ruled out the recurrence of TC.", + "She responded swiftly to NIV, requiring less than 24 hours.", + "She was transferred to the respiratory ward for ongoing management of her airway disease.", + "She was discharged 2 weeks later.", + "Her thyroid function tests on Day 6 showed raised T4 and undetectable thyroid-stimulating hormone level.", + "After confirmation with repeated blood tests, the diagnosis of thyrotoxicosis was made.", + "The endocrine review and subsequent thyroid-receptor antibody levels suggested autoimmune thyroiditis or Graves’ disease.", + "Carbimazole treatment was commenced at a later stage.", + "Beta-blocker was continued with regular endocrine follow-up.", + "She had a brief admission in September 2020 with mild shortness of breath.", + "Repeat echocardiography showed normal biventricular systolic function.", + "Repeat echocardiography showed normal LV diastolic function and filling pressures.", + "The systolic pulmonary pressure was 40 mmHg." + ], + "summary": "We describe a 69-year-old woman who presented with dyspnoea and was subsequently diagnosed with BTC. We propose that this was triggered by an exacerbation of chronic obstructive pulmonary disease on a background of multiple predisposing factors including recent bereavement, previous excessive alcohol use, status as a current smoker, and anxiety. During her admission, she required non-invasive ventilation and inotropic support to manage her type two respiratory failure and acute heart failure. Serial echocardiograms during the admission allowed us to capture and present the sequential recovery of ventricular systolic function, with the left ventricular (LV) recovery preceding the right ventricle.", + "summary_subclaims": [ + "The patient was a 69-year-old woman.", + "She presented with dyspnoea.", + "She was subsequently diagnosed with BTC.", + "We propose that this was triggered by an exacerbation of chronic obstructive pulmonary disease.", + "Multiple predisposing factors included recent bereavement.", + "Multiple predisposing factors included previous excessive alcohol use.", + "Multiple predisposing factors included status as a current smoker.", + "Multiple predisposing factors included anxiety.", + "During her admission, she required non-invasive ventilation.", + "During her admission, she required inotropic support.", + "She had type two respiratory failure.", + "She had acute heart failure.", + "Serial echocardiograms during the admission captured the sequential recovery of ventricular systolic function.", + "The left ventricular recovery preceded the right ventricle." + ] + }, + { + "id": "multiclinsum_test_421_en.txt", + "fulltext": "A 60-year-old female patient was hospitalized for swelling and pain in the left lower extremity for 5 days. It was reported that, 5 days ago, the patient experienced swelling of thigh, which gradually spread to the lower leg, and increased local skin tension and temperature. The patient had no fever, shortness of breath, chest pain, cough, expectoration, hemoptysis, amaurosis, or syncope; no special relevant medical, family, psycho-social past histories, and no history of chronic lower limb symptoms, even during her previous pregnancy. Deep vein ultrasound of the lower extremity at local hospital reported thrombosis of left common femoral vein, superficial femoral vein, deep femoral vein, popliteal vein, anterior tibial vein, posterior tibial vein, and intermuscular vein for the first time. She had no history of surgery or catheterization. On physical examination, her heart rate was 88 bpm, and blood pressure was 130/74 mmHg. Examination of the left lower limb revealed swelling and edema with moderate tenderness and pain, while the right lower limb was normal. Blood tests revealed normal blood routine and normal liver and kidney functions. Computed tomography angiography (CTA) indicated compression of LCIV by RCIA, narrowed LCIV lumen, thrombi formed from the femoral vein to left external iliac vein, and collateral circulation formed between bilateral external iliac vein . She was diagnosed with DVT along with MTS.\nThe patient underwent IVC angiography, filter placement, left iliac vein plasty, and stent implantation under local anesthesia. The right femoral vein was punctured successfully with Seldinger technique and then placed into the catheter sheath. Contrast agent was passed smoothly through IVC without filling defect . The sheath of the filter was transported, and a Cordis Optease filter was placed in the IVC at second lumbar vertebrae , followed by puncturing of the left femoral vein. The catheter sheath was then inserted; angiography revealed severe stenosis of the left external iliac vein and the common iliac vein, and the pelvic collateral compensation was seen through contralateral reflux . A 14 mm - 60 mm balloon was inserted into the IVC through a narrow segment of left external iliac vein and common iliac vein . Then, an E-lunimexx 14 mm - 60 mm self-expanding stent was inserted . The stent was in good position, and the expansion remained satisfactory . The contrast medium was passed through smoothly, and the original stenosis was relieved. At the end of the operation, the sheath of the bilateral inguinal area was removed, and the wound was dressed with a bandage. The patient returned to the ward safely and tolerated well, and was discharged 5 days after the surgery. The patient was prescribed with oral rivaroxaban and aspirin. After 28 days of the surgery, she came back to the hospital for the removal of IVC filter. This procedure was successful. The DVTs were ablated after 4 months of anticoagulation therapy.", + "fulltext_subclaims": [ + "The patient was a 60-year-old female.", + "She was hospitalized for swelling and pain in the left lower extremity for 5 days.", + "The patient experienced swelling of the thigh 5 days ago.", + "The swelling gradually spread to the lower leg.", + "The patient had increased local skin tension and temperature.", + "The patient had no fever.", + "The patient had no shortness of breath.", + "The patient had no chest pain.", + "The patient had no cough.", + "The patient had no expectoration.", + "The patient had no hemoptysis.", + "The patient had no amaurosis.", + "The patient had no syncope.", + "The patient had no special relevant medical, family, psycho-social past histories.", + "The patient had no history of chronic lower limb symptoms.", + "Deep vein ultrasound of the lower extremity at the local hospital reported thrombosis of the left common femoral vein.", + "Deep vein ultrasound reported thrombosis of the left superficial femoral vein.", + "Deep vein ultrasound reported thrombosis of the left deep femoral vein.", + "Deep vein ultrasound reported thrombosis of the left popliteal vein.", + "Deep vein ultrasound reported thrombosis of the left anterior tibial vein.", + "Deep vein ultrasound reported thrombosis of the left posterior tibial vein.", + "Deep vein ultrasound reported thrombosis of the left intermuscular vein.", + "The patient had no history of surgery.", + "The patient had no history of catheterization.", + "On physical examination, the heart rate was 88 bpm.", + "On physical examination, the blood pressure was 130/74 mmHg.", + "Examination of the left lower limb revealed swelling and edema.", + "Examination of the left lower limb revealed moderate tenderness and pain.", + "The right lower limb was normal.", + "Blood tests revealed normal blood routine.", + "Blood tests revealed normal liver and kidney functions.", + "Computed tomography angiography indicated compression of the left common iliac vein by the right common iliac artery.", + "Computed tomography angiography showed narrowed left common iliac vein lumen.", + "Computed tomography angiography showed thrombi formed from the femoral vein to the left external iliac vein.", + "Computed tomography angiography showed collateral circulation formed between bilateral external iliac veins.", + "The patient was diagnosed with DVT.", + "The patient was diagnosed with May-Thurner syndrome.", + "The patient underwent IVC angiography.", + "The patient underwent filter placement.", + "The patient underwent left iliac vein plasty.", + "The patient underwent stent implantation under local anesthesia.", + "The right femoral vein was punctured successfully with the Seldinger technique.", + "A Cordis Optease filter was placed in the IVC at the second lumbar vertebrae.", + "Angiography revealed severe stenosis of the left external iliac vein.", + "Angiography revealed severe stenosis of the left common iliac vein.", + "A 14 mm - 60 mm balloon was inserted into the IVC through the narrow segment of the left external iliac vein and common iliac vein.", + "An E-lunimexx 14 mm - 60 mm self-expanding stent was inserted.", + "The stent was in good position.", + "The expansion of the stent remained satisfactory.", + "The contrast medium was passed through smoothly.", + "The original stenosis was relieved.", + "The patient returned to the ward safely.", + "The patient tolerated the procedure well.", + "The patient was discharged 5 days after the surgery.", + "The patient was prescribed oral rivaroxaban.", + "The patient was prescribed oral aspirin.", + "The patient came back to the hospital for IVC filter removal 28 days after the surgery.", + "The IVC filter removal was successful.", + "The DVTs were ablated after 4 months of anticoagulation therapy." + ], + "summary": "Here, we report the case of a 60-year-old female patient with a complaint of swelling in the left lower limb and pain for 5 days. Computed tomography angiography indicated MTS, and thrombus formation of left external iliac vein and femoral vein. The patient was diagnosed with deep venous thrombosis (DVT) and MTS. The patient underwent ascending venography from the lower extremity to inferior vena cava (IVC) and then to the pulmonary artery with IVC filter implantation, left iliac vein balloon plasty, and stent placement. The patient visited the hospital for the removal of IVC filter, 28 days after the operation. After the interventional therapy, the patient had no in-stent restenosis and had remission during the 2-year follow-up.", + "summary_subclaims": [ + "The patient is a 60-year-old female.", + "The patient had swelling in the left lower limb.", + "The patient had pain for 5 days.", + "Computed tomography angiography indicated MTS.", + "Computed tomography angiography showed thrombus formation of the left external iliac vein.", + "Computed tomography angiography showed thrombus formation of the left femoral vein.", + "The patient was diagnosed with deep venous thrombosis.", + "The patient underwent ascending venography from the lower extremity to inferior vena cava.", + "The patient underwent ascending venography from the inferior vena cava to the pulmonary artery.", + "The patient had IVC filter implantation.", + "The patient had left iliac vein balloon plasty.", + "The patient had stent placement.", + "The patient visited the hospital for the removal of IVC filter.", + "The IVC filter was removed 28 days after the operation.", + "After the interventional therapy, the patient had no in-stent restenosis.", + "The patient had remission during the 2-year follow-up." + ] + }, + { + "id": "multiclinsum_test_3012_en.txt", + "fulltext": "25-year-old nulliparous woman with no routine gynecological check-ups. She presented with a one-month history of a clinical picture characterized by acne-like lesions on the face, neck, chest, facial oedema and blurred vision. She initially went to another facility where hypertensive readings, hypokalaemia and an ultrasound scan showed multiple lesions in the liver consistent with neoproliferative disease. She subsequently developed delirium, incoherent speech and suicidal ideation, and was brought to our hospital by relatives. On admission, she was hypertensive (160/112 mmHg), disoriented, aggressive and delirious. She had acne-like lesions on the face and chest, marked hirsutism on the face, chest and back, a full moon face, dorsal hump, supraclavicular pads and generalised muscle weakness. Her laboratory test on admission showed hyperglycaemia, hypokalaemia, hyper-transaminasaemia and metabolic alkalosis. An ultrasound scan and a magnetic resonance scan of the brain showed no significant findings. With suspicion of encephalitis, a lumbar puncture was performed with the only relevant finding being hyperproteinaemia. She was admitted for study and treatment, and was interpreted as having a severe Cushing's syndrome with significant general impairment and rapid onset. Confirmatory biochemical tests were performed: Nugent test with cortisol 8 am > 60 ug/dL (positive > 1.8 ug/dL), inhibition test with dexamethasone 8 mg at 23 h: cortisol > 60 ug/dL, night salivary cortisol of 1610.2 ug/dL (VN < 7). ACTH dependence was found with frankly elevated values. The severity and rapidity of the onset of the clinical picture led to studies to detect a primary tumour responsible for ectopic ACTH secretion. An ultrasound scan was performed that showed bilateral, smaller than 3 mm, nodular opacities in the thorax, hyperplastic adrenal glands, lesions in the liver and vertebral bodies of the sacral region, L3 and dorsal, suggestive of secondary disease. When the patient was re-examined, she commented that she had presented postcoital bleeding weeks before the onset of the clinical picture. An ultrasound scan of the uterus was performed that showed an enlarged uterine cervix, after which a speculum was used to examine the cervix and a pathological characteristic was observed and a biopsy was taken. An ultrasound-guided biopsy of liver lesions was also performed. Other studies performed: fundus of eye that showed a serous central macular oedema in the left eye.\n\nDuring his admission, he developed severe hypokalaemia that persisted despite replacement. He received spironolactone and ketoconazole at increasing doses up to 1200 mg/day. Mifepristone was added, but had to be discontinued after 7 days due to severe hypokalaemia. Histopathological examination showed liver parenchyma and exocervical mucosa infiltrated by neoplastic proliferation composed of small cells with scant cytoplasm, fine and granular chromatin nuclei, with positivity for cytokeratin, chromogranin, synaptophysin, CD56, p16, with a proliferation index Ki 67 greater than 75%. With these findings, the diagnosis of neuroendocrine carcinoma of small cells was reached. He initiated chemotherapy with cisplatin and etoposide, developed a septic shock secondary to febrile neutropenia and died after 6 days.\n", + "fulltext_subclaims": [ + "The patient is a 25-year-old nulliparous woman.", + "She had no routine gynecological check-ups.", + "She presented with a one-month history of acne-like lesions on the face, neck, chest, facial oedema, and blurred vision.", + "She initially went to another facility.", + "Hypertensive readings were noted.", + "Hypokalaemia was noted.", + "An ultrasound scan showed multiple lesions in the liver consistent with neoproliferative disease.", + "She subsequently developed delirium, incoherent speech, and suicidal ideation.", + "She was brought to our hospital by relatives.", + "On admission, she was hypertensive (160/112 mmHg).", + "She was disoriented, aggressive, and delirious.", + "She had acne-like lesions on the face and chest.", + "She had marked hirsutism on the face, chest, and back.", + "She had a full moon face, dorsal hump, and supraclavicular pads.", + "She had generalised muscle weakness.", + "Her laboratory test on admission showed hyperglycaemia.", + "Her laboratory test on admission showed hypokalaemia.", + "Her laboratory test on admission showed hyper-transaminasaemia.", + "Her laboratory test on admission showed metabolic alkalosis.", + "An ultrasound scan and a magnetic resonance scan of the brain showed no significant findings.", + "A lumbar puncture was performed.", + "The only relevant finding in the lumbar puncture was hyperproteinaemia.", + "She was admitted for study and treatment.", + "She was interpreted as having a severe Cushing's syndrome with significant general impairment and rapid onset.", + "Confirmatory biochemical tests were performed.", + "The Nugent test with cortisol 8 am was > 60 ug/dL.", + "The inhibition test with dexamethasone 8 mg at 23 h showed cortisol > 60 ug/dL.", + "The night salivary cortisol was 1610.2 ug/dL.", + "ACTH dependence was found with frankly elevated values.", + "An ultrasound scan showed bilateral, smaller than 3 mm, nodular opacities in the thorax.", + "An ultrasound scan showed hyperplastic adrenal glands.", + "An ultrasound scan showed lesions in the liver and vertebral bodies of the sacral region, L3, and dorsal, suggestive of secondary disease.", + "The patient commented that she had presented postcoital bleeding weeks before the onset of the clinical picture.", + "An ultrasound scan of the uterus showed an enlarged uterine cervix.", + "A speculum was used to examine the cervix.", + "A pathological characteristic was observed.", + "A biopsy was taken.", + "An ultrasound-guided biopsy of liver lesions was performed.", + "A fundus of eye showed a serous central macular oedema in the left eye.", + "During his admission, he developed severe hypokalaemia that persisted despite replacement.", + "He received spironolactone.", + "He received ketoconazole at increasing doses up to 1200 mg/day.", + "Mifepristone was added.", + "Mifepristone had to be discontinued after 7 days due to severe hypokalaemia.", + "Histopathological examination showed liver parenchyma and exocervical mucosa infiltrated by neoplastic proliferation composed of small cells with scant cytoplasm, fine and granular chromatin nuclei.", + "The neoplastic proliferation was positive for cytokeratin, chromogranin, synaptophysin, CD56, and p16.", + "The proliferation index Ki 67 was greater than 75%.", + "The diagnosis of neuroendocrine carcinoma of small cells was reached.", + "He initiated chemotherapy with cisplatin and etoposide.", + "He developed septic shock secondary to febrile neutropenia.", + "He died after 6 days." + ], + "summary": "A 25-year-old female patient with no relevant history presented with a clinical picture of a one-month-old acneiform lesion on her face, neck and chest, facial oedema and blurred vision, which was accompanied by delirium, incoherent speech and suicidal ideation. Hypertensive, hypokalaemic, hyperglycaemic and metabolic alkalosis were also observed. The clinical picture was interpreted as a severe Cushing's syndrome with a significant impact on the general condition and a rapid onset. The syndrome and its dependence on ACTH were confirmed by biochemical tests. A computed tomography scan showed multiple lesions in the liver and spine suggestive of secondary involvement. After reporting a history of postcoital bleeding, speculoscopy was performed and a biopsy of the cervix and liver lesions was taken. In both cases, the pathological study was compatible with a neuroendocrine carcinoma of small cells, and chemotherapy with cisplatin and etoposide was initiated.\n", + "summary_subclaims": [ + "The patient is a 25-year-old female.", + "The patient had no relevant medical history.", + "The patient had a one-month-old acneiform lesion on her face, neck, and chest.", + "The patient had facial oedema.", + "The patient had blurred vision.", + "The patient had delirium.", + "The patient had incoherent speech.", + "The patient had suicidal ideation.", + "The patient was hypokalaemic.", + "The patient was hyperglycaemic.", + "The patient had metabolic alkalosis.", + "The clinical picture was interpreted as a severe Cushing's syndrome.", + "The syndrome had a rapid onset.", + "The syndrome was confirmed to be dependent on ACTH.", + "A computed tomography scan showed multiple lesions in the liver and spine.", + "The lesions were suggestive of secondary involvement.", + "The patient reported a history of postcoital bleeding.", + "Speculoscopy was performed.", + "A biopsy of the cervix was taken.", + "A biopsy of the liver lesions was taken.", + "The pathological study of the cervix was compatible with a neuroendocrine carcinoma of small cells.", + "The pathological study of the liver lesions was compatible with a neuroendocrine carcinoma of small cells.", + "Chemotherapy with cisplatin and etoposide was initiated." + ] + }, + { + "id": "multiclinsum_test_239_en.txt", + "fulltext": "A 49-year-old woman presented with acute chest pain. The past history was not remarkable apart from being treated with thyroxine 125 µg o.d. for hypothyroidism, pregabalin 150 mg b.i.d. for chronic neurogenic back pain, and atomoxetine 60 and 18 mg daily for ADHD. In association with sexual intercourse, she developed acute chest pain associated with mild dyspnoea and some dizziness. The chest pain disappeared after sublingual nitroglycerine on admission to the hospital. The patient developed transient hypotension and bradycardia after nitroglycerine, which stabilized after atropine injection. The electrocardiogram revealed no remarkable changes. Laboratory results showed modest elevation of troponin T (maximum 710 ng/L), C-reactive protein <5 mg/L, and normal cholesterol levels. Echocardiography 1 day after admission revealed a-/hypokinesia in the mid-apical regions with good contraction of the apical tip segment (apical tip-sparing) and the basal segments with marked reduction of left ventricular ejection fraction, 30–35% (, Video S1, echocardiography). Atomoxetine was discontinued and treatment with acetylsalicylic acid, beta blocker, and angiotensin-converting enzyme inhibitor was initiated. Invasive coronary angiography 1 day after admission showed normal coronary arteries (; , Video S2, left coronary artery). A new echocardiography 3 days after admission showed a-/hypokinesia in the middle segments of the left ventricle circumferentially, with good contractions in both the basal and apical segments resulting in a pattern consistent with mid-ventricular TS (, Video S3, contrast echocardiography). Left ventricular systolic function recovered completely within 1 month from admission as demonstrated by cardiac magnetic resonance imaging, which did not show late gadolinium enhancement (, Video S4, cardiac magnetic resonance imaging).", + "fulltext_subclaims": [ + "The patient is a 49-year-old woman.", + "She presented with acute chest pain.", + "The past history was not remarkable.", + "She was treated with thyroxine 125 µg o.d. for hypothyroidism.", + "She was treated with pregabalin 150 mg b.i.d. for chronic neurogenic back pain.", + "She was treated with atomoxetine 60 and 18 mg daily for ADHD.", + "The chest pain developed in association with sexual intercourse.", + "The chest pain was associated with mild dyspnoea.", + "The chest pain was associated with some dizziness.", + "The chest pain disappeared after sublingual nitroglycerine on admission to the hospital.", + "The patient developed transient hypotension after nitroglycerine.", + "The patient developed transient bradycardia after nitroglycerine.", + "The transient hypotension and bradycardia stabilized after atropine injection.", + "The electrocardiogram revealed no remarkable changes.", + "Laboratory results showed modest elevation of troponin T (maximum 710 ng/L).", + "C-reactive protein was <5 mg/L.", + "Cholesterol levels were normal.", + "Echocardiography 1 day after admission revealed a-/hypokinesia in the mid-apical regions.", + "Echocardiography showed good contraction of the apical tip segment.", + "Echocardiography showed good contraction of the basal segments.", + "Left ventricular ejection fraction was 30–35%.", + "Atomoxetine was discontinued.", + "Treatment with acetylsalicylic acid was initiated.", + "Treatment with a beta blocker was initiated.", + "Treatment with an angiotensin-converting enzyme inhibitor was initiated.", + "Invasive coronary angiography 1 day after admission showed normal coronary arteries.", + "A new echocardiography 3 days after admission showed a-/hypokinesia in the middle segments of the left ventricle circumferentially.", + "The new echocardiography showed good contractions in both the basal and apical segments.", + "The pattern was consistent with mid-ventricular takotsubo syndrome.", + "Left ventricular systolic function recovered completely within 1 month from admission.", + "Cardiac magnetic resonance imaging did not show late gadolinium enhancement." + ], + "summary": "We report on the case of a 49-year-old woman who was on atomoxetine treatment for attention deficit hyperactivity disorder, developed TS in association with sexual intercourse.", + "summary_subclaims": [ + "The patient was a 49-year-old woman.", + "The patient was on atomoxetine treatment for attention deficit hyperactivity disorder.", + "The patient developed TS in association with sexual intercourse." + ] + }, + { + "id": "multiclinsum_test_2471_en.txt", + "fulltext": "A 39-year-old male was referred to our hospital due to decreased vision and visual field defect in his right eye. Upon examination, this right-eye visual acuity was 0.03 and bullous rhegmatogenous retinal detachment was found in three quadrants, yet not in the upper part of the retina . For treatment, we performed the standard 4-port pars plana vitrectomy using the 25-gauge system. Following the core vitrectomy and artificial posterior vitreous detachment, we injected PFCL to flatten the detached retina. After endophotocoagulation was performed around the retinal break, we directly replaced the PFCL with SO. Due to misdirection of aqueous fluid into the subretinal space during the replacement, we attempted to remove the SO and exchange it with aqueous solution. However, a small amount of SO was found to be adhered to the posterior pole of the retinal surface, and it was impossible to remove the bubble of SO by active suction at the vitreous center . Although the shape of the SO bubble was easily deformed, the location of the sticky SO remained unchanged.\nThe PFCL layer between the SO and the underlying retina was easily aspirated and the SO was released from the retinal surface. Post release, the SO was relocated to the anterior chamber and safely removed through a corneal limbal incision. After complete removal of the SO, pneumatic retinal replacement and laser photocoagulation were performed, and sulfur hexafluoride gas was used as a temporary intraocular tamponade. At 7-months postoperative, the patient’s retina remained attached and his corrected visual acuity improved to 0.7.", + "fulltext_subclaims": [ + "The patient was a 39-year-old male.", + "The patient was referred due to decreased vision and visual field defect in his right eye.", + "Right-eye visual acuity was 0.03.", + "Bullous rhegmatogenous retinal detachment was found in three quadrants.", + "The retinal detachment was not in the upper part of the retina.", + "The standard 4-port pars plana vitrectomy was performed using the 25-gauge system.", + "PFCL was injected to flatten the detached retina.", + "Endophotocoagulation was performed around the retinal break.", + "SO was directly replaced with PFCL.", + "A small amount of SO was found to be adhered to the posterior pole of the retinal surface.", + "It was impossible to remove the bubble of SO by active suction at the vitreous center.", + "The shape of the SO bubble was easily deformed.", + "The location of the sticky SO remained unchanged.", + "The PFCL layer between the SO and the underlying retina was easily aspirated.", + "The SO was released from the retinal surface.", + "The SO was relocated to the anterior chamber.", + "The SO was safely removed through a corneal limbal incision.", + "Pneumatic retinal replacement and laser photocoagulation were performed.", + "Sulfur hexafluoride gas was used as a temporary intraocular tamponade.", + "At 7-months postoperative, the patient’s retina remained attached.", + "At 7-months postoperative, the patient’s corrected visual acuity improved to 0.7." + ], + "summary": "A 39-year-old male was referred to our hospital due to decreased vision and visual field defect in his right eye. Upon examination, he was diagnosed with rhegmatogenous retinal detachment in that eye. For treatment, he underwent vitrectomy with the use of PFCL and SO. The direct exchange of PFCL with SO resulted in residual subretinal fluid, so we subsequently attempted to remove the SO. However, a SO bubble adhering to the PFCL was visible on the posterior pole. After aspiration of the PFCL beneath the sticky SO, the SO was easily separated and removed from the retina.", + "summary_subclaims": [ + "The patient is a 39-year-old male.", + "He was referred to the hospital due to decreased vision and visual field defect in his right eye.", + "He was diagnosed with rhegmatogenous retinal detachment in his right eye.", + "He underwent vitrectomy with the use of PFCL and SO.", + "The direct exchange of PFCL with SO resulted in residual subretinal fluid.", + "A SO bubble adhering to the PFCL was visible on the posterior pole.", + "After aspiration of the PFCL beneath the sticky SO, the SO was easily separated and removed from the retina." + ] + }, + { + "id": "multiclinsum_test_2286_en.txt", + "fulltext": "A 28-year-old woman was admitted to Jordan University Hospital in Amman, Jordan, February 22, 2009, complaining of severe muscle spasm. The history of the present illness dated back to three months earlier when she started to complain of painful muscle spasms in her arms, hands and legs. This had been associated with mouth deviation, teeth clenching and involuntary eye twitches with left-sided predominance. The episodes were associated with loss of consciousness and on one occasion associated with tongue bite, but were never preceded with an aura. The attacks were only relieved by taking diazepam and were followed by dizziness and generalized weakness lasting for a few hours. Laboratory studies showed hypokalemia (K = 0.69 mmol/L), hypocalcemia (Ca = 1.47 mmol/L), hypomagnesemia (Mg = 0.58 mmol/L) and pure metabolic alkalosis. Five years ago, she had gone on many kinds of diets in order to lose weight, and decided that the suitable one for her comprised the eating of one small bag of chips and a large quantity of water daily, and she started to vomit several times a day after eating any kind of food. The only food she could tolerate was salt, lemon, citric acid, tomatoes and cucumbers. As a result she developed some sort of addiction to salty food; claiming to consume 3 to 4 tablespoons of table salt (NaCl), 4 tablespoons of citric acid, and 10 lemons a day. Over the past 18 months, she had had difficulty urinating without the use of diuretics (Lasix® Furosemide 40 mg 12 tablets per day) and had become physically dependent on it. On occasions she also experienced legs swelling associated with high blood pressure self managed by increasing her diuretic dose. Afterward, she suffered from severe constipation due to her lack of appetite and reduced food intake caused by depression, the patient relied mainly on salty chips and lemon only as her sole food and was not well-fed as normal healthy people; consequently, the gastrointestinal motility was negatively affected which led to constipation. The patient was unable to pass stool except by the help of a laxative (Dulcolax® bisacodyl 5 mg 12 tablets per day) which she had become dependent on.\nThe patient lives with her 3-year-old daughter and her sister in-law. She claimed to have poor sleeping habits and usually slept during the day. She sometimes spent 2 to 3 days without sleeping at all. She claimed to use amphetamine and have attempted suicide several times. The most recent was attempting to jump off the balcony, which was prevented by her mother. She has been a heavy smoker (3 packs/day for the past 15 years) and drunk one pint (one pint is equal to 473 mL) of beer every 3 days. The patient didn’t have any seizure.\nUpon hospitalization, and correction of serum K, Ca and Mg her symptoms were relieved. Known organic causes of salt craving such as Addison’s disease were excluded by appropriate investigations. A psychiatric consultation revealed a disturbed social history with masked depression. The patient was started and discharged on mirtazapine 30 mg 1×1, risperidone 1 mg 1×3 and citalopram 10 mg 1×2, CaCO3 tablets, K-gluconate syrup, Mg-sulfate sachets and vitamin D supplements for 6 months.", + "fulltext_subclaims": [ + "A 28-year-old woman was admitted to Jordan University Hospital in Amman, Jordan, February 22, 2009.", + "She complained of severe muscle spasm.", + "The history of the present illness dated back to three months earlier when she started to complain of painful muscle spasms in her arms, hands and legs.", + "The episodes were associated with loss of consciousness.", + "The attacks were only relieved by taking diazepam.", + "The attacks were followed by dizziness and generalized weakness lasting for a few hours.", + "Laboratory studies showed hypokalemia (K = 0.69 mmol/L).", + "Laboratory studies showed hypocalcemia (Ca = 1.47 mmol/L).", + "Laboratory studies showed hypomagnesemia (Mg = 0.58 mmol/L).", + "Laboratory studies showed pure metabolic alkalosis.", + "Five years ago, she had gone on many kinds of diets in order to lose weight.", + "She decided that the suitable one for her comprised the eating of one small bag of chips and a large quantity of water daily.", + "She started to vomit several times a day after eating any kind of food.", + "The only food she could tolerate was salt, lemon, citric acid, tomatoes and cucumbers.", + "She developed some sort of addiction to salty food.", + "She claimed to consume 3 to 4 tablespoons of table salt (NaCl), 4 tablespoons of citric acid, and 10 lemons a day.", + "Over the past 18 months, she had had difficulty urinating without the use of diuretics (Lasix® Furosemide 40 mg 12 tablets per day).", + "She had become physically dependent on diuretics.", + "She experienced legs swelling associated with high blood pressure self managed by increasing her diuretic dose.", + "She suffered from severe constipation due to her lack of appetite and reduced food intake caused by depression.", + "She relied mainly on salty chips and lemon only as her sole food.", + "She was unable to pass stool except by the help of a laxative (Dulcolax® bisacodyl 5 mg 12 tablets per day).", + "She had become dependent on laxatives.", + "She claimed to have poor sleeping habits and usually slept during the day.", + "She sometimes spent 2 to 3 days without sleeping at all.", + "She claimed to use amphetamine.", + "She has been a heavy smoker (3 packs/day for the past 15 years).", + "She drank one pint of beer every 3 days.", + "The patient didn’t have any seizure.", + "Upon hospitalization, and correction of serum K, Ca and Mg her symptoms were relieved.", + "Known organic causes of salt craving such as Addison’s disease were excluded by appropriate investigations.", + "A psychiatric consultation revealed a disturbed social history with masked depression.", + "The patient was started and discharged on mirtazapine 30 mg 1×1.", + "The patient was started and discharged on risperidone 1 mg 1×3.", + "The patient was started and discharged on citalopram 10 mg 1×2.", + "The patient was started and discharged on CaCO3 tablets.", + "The patient was started and discharged on K-gluconate syrup.", + "The patient was started and discharged on Mg-sulfate sachets.", + "The patient was started and discharged on vitamin D supplements for 6 months." + ], + "summary": "A 28-year-old woman presented with tetany due to hypocalcemia, hypokalemia and hypomagnesemia. She had a history of laxative and diuretic abuse, and salt craving. Psychiatric evaluation revealed a disturbed social history with masked depression that necessitated treatment.", + "summary_subclaims": [ + "The patient is a 28-year-old woman.", + "She presented with tetany.", + "She had hypocalcemia.", + "She had hypokalemia.", + "She had hypomagnesemia.", + "She had a history of laxative abuse.", + "She had a history of diuretic abuse.", + "She had salt craving.", + "Psychiatric evaluation revealed a disturbed social history.", + "Psychiatric evaluation revealed masked depression.", + "The masked depression necessitated treatment." + ] + }, + { + "id": "multiclinsum_test_2815_en.txt", + "fulltext": "A 27-year-old HIV-positive Chinese Manchu male complained of intermittent headache, nausea, and vomiting (non-projectile vomiting three times in total) for two weeks in January 2022. No fever, amaurosis, or unconsciousness were presented. He denied preceding travel or unusual animal exposures. He was diagnosed with HIV infection five years ago and nadir CD4+ T-cell count was 79 cells/μL. He initiated ART with tenofovir, lamivudine, and efavirenz, but treatment failure occurred one year later with plasma HIV RNA 2.19 × 105 copies/mL and CD4+ T-cell count 14 cells/μL. The local doctor shifted the ART regimen to tenofovir, lamivudine, lopinavir/ritonavir without a genotypic drug resistance test, and his plasma HIV viral load was well controlled thereafter. Neurological physical examination showed no abnormalities. The brain magnetic resonance imaging (MRI) presented bilateral multiple white matter T2-weighted hyperintensities especially in the FLAIR sequence , without T1-wighted enhancement or mass effect. Lumbar puncture showed high intracranial pressure, lymphocytic pleocytosis, and elevated CSF protein level . CSF HIV RNA was 774 copies/mL, while plasma HIV RNA was undetectable. The following blood tests all displayed negative results, including the T-cell enzyme-linked immuno-spot assay for tuberculosis, the syphilis rapid plasma reagin titer, Toxoplasma gondii IgG and IgM, cytomegalovirus (CMV) IgM, herpes simplex virus (HSV)1/2 IgM, Epstein-Barr virus (EBV)-IgM, galactomannan, 1,3-β-D-glucan, cryptococcus antigen, EBV-DNA, CMV-DNA. Besides, the CSF tests which detected acid-fast stain, India ink stain, cryptococcus antigen, culturing of bacteria and fungus, and CMV-DNA were also all negative. No other pathogens were confirmed by the next-generation sequencing in the CSF (using the MGISEQ-2000 platform in BGI PathoGenesis Pharmaceutical Technology, BGI-Shenzhen). The pathological phenotype of encephalitis was required, but the patient declined brain biopsy. CD8 encephalitis was suspected, and thus prednisone and glycerol fructose were prescribed empirically to reduce inflammation reactions in the brain.\nOne month later, the patient presented headache relief, and obvious improvement in MRI performance and laboratory tests in the CSF . Then, prednisone was tapered (60 mg daily followed by a reduction of 5 mg per week) and discontinued in May 2022. However, he complained of a headache relapse in June 2022. MRI showed the increased area of multifocal leukoencephalopathy . Moreover, increased HIV replication was observed in both CNS and plasma, and further HIV drug resistance tests of CSF and plasma (Sanger sequencing in Dongguan Medical Laboratory of Micro-scale and Presicion) presented identical results of major protease inhibitor (PI)-related mutations, nonnucleoside reverse transcriptase inhibitor (NNRTI)-related mutations, and nucleoside reverse transcriptase inhibitor (NRTI)-related mutations . The encephalitis owning to CSF drug-resistant HIV escape was considered. Thus, ART regimen was switched to zidovudine (sensitive), lamivudine (highly resistant), and dolutegravir (sensitive). As well, prednisone 60 mg daily was restarted. One month after that, HIV suppression was achieved in both CSF and plasma , and MRI displayed moderate shrink of diffused white matter area . Then, prednisone was tapered (the same as last time). A complete remission of brain MRI lesions was achieved in December 2022 . Meanwhile, prednisone had been withdrawn. The timeline for treatment adjustment and follow-up of this case was clearly outlined in Fig. .", + "fulltext_subclaims": [ + "The patient is a 27-year-old HIV-positive Chinese Manchu male.", + "He complained of intermittent headache, nausea, and vomiting for two weeks in January 2022.", + "He had non-projectile vomiting three times in total.", + "He denied preceding travel or unusual animal exposures.", + "He was diagnosed with HIV infection five years ago.", + "His nadir CD4+ T-cell count was 79 cells/μL.", + "He initiated ART with tenofovir, lamivudine, and efavirenz.", + "Treatment failure occurred one year later.", + "His plasma HIV RNA was 2.19 × 105 copies/mL.", + "His CD4+ T-cell count was 14 cells/μL.", + "The local doctor shifted the ART regimen to tenofovir, lamivudine, lopinavir/ritonavir.", + "No genotypic drug resistance test was performed.", + "His plasma HIV viral load was well controlled thereafter.", + "Neurological physical examination showed no abnormalities.", + "Brain MRI showed bilateral multiple white matter T2-weighted hyperintensities.", + "The hyperintensities were especially evident in the FLAIR sequence.", + "There was no T1-weighted enhancement.", + "There was no mass effect.", + "Lumbar puncture showed high intracranial pressure.", + "Lumbar puncture showed lymphocytic pleocytosis.", + "Lumbar puncture showed elevated CSF protein level.", + "CSF HIV RNA was 774 copies/mL.", + "Plasma HIV RNA was undetectable.", + "The T-cell enzyme-linked immuno-spot assay for tuberculosis was negative.", + "The syphilis rapid plasma reagin titer was negative.", + "Toxoplasma gondii IgG and IgM were negative.", + "CMV IgM was negative.", + "HSV1/2 IgM was negative.", + "EBV-IgM was negative.", + "Galactomannan was negative.", + "1,3-β-D-glucan was negative.", + "Cryptococcus antigen was negative.", + "EBV-DNA was negative.", + "CMV-DNA was negative.", + "CSF acid-fast stain was negative.", + "CSF India ink stain was negative.", + "CSF cryptococcus antigen was negative.", + "CSF culturing of bacteria and fungus was negative.", + "CSF CMV-DNA was negative.", + "No other pathogens were confirmed by next-generation sequencing in the CSF.", + "The patient declined brain biopsy.", + "CD8 encephalitis was suspected.", + "Prednisone and glycerol fructose were prescribed empirically.", + "One month later, the patient presented headache relief.", + "MRI performance showed obvious improvement.", + "CSF laboratory tests showed improvement.", + "Prednisone was tapered (60 mg daily followed by a reduction of 5 mg per week).", + "Prednisone was discontinued in May 2022.", + "He complained of a headache relapse in June 2022.", + "MRI showed increased area of multifocal leukoencephalopathy.", + "Increased HIV replication was observed in both CNS and plasma.", + "HIV drug resistance tests of CSF and plasma showed identical results.", + "The results included major protease inhibitor (PI)-related mutations.", + "The results included nonnucleoside reverse transcriptase inhibitor (NNRTI)-related mutations.", + "The results included nucleoside reverse transcriptase inhibitor (NRTI)-related mutations.", + "Encephalitis owing to CSF drug-resistant HIV escape was considered.", + "The ART regimen was switched to zidovudine, lamivudine, and dolutegravir.", + "Prednisone 60 mg daily was restarted.", + "One month later, HIV suppression was achieved in both CSF and plasma.", + "MRI displayed moderate shrink of diffused white matter area.", + "Prednisone was tapered (the same as last time).", + "A complete remission of brain MRI lesions was achieved in December 2022.", + "Prednisone had been withdrawn." + ], + "summary": "A 27-year-old man with HIV infection complained of recurrent headaches during the last year. His magnetic resonance imaging (MRI) presented diffused bilateral white matter lesions, and laboratory tests confirmed elevated CSF protein level, lymphocytic pleocytosis, and detectable CSF HIV RNA (774 copies/mL). Plasma HIV RNA was well suppressed with tenofovir, lamivudine, and lopinavir/ritonavir. Prednisone 60 mg once daily was initiated to reduce intracranial inflammation, followed by a good clinical response, with CSF HIV RNA still detectable (31.1 copies/mL). During the gradual tapering of prednisone, his headache relapsed, and booming viral loads were detected in both CSF (4580 copies/mL) and plasma (340 copies/mL) with consistent drug-resistant mutations. Thereupon, prednisone was resumed and the ART regimen was switched to zidovudine, lamivudine, and dolutegravir according to drug resistance tests. Persistent clinical recovery of symptoms, neuroimaging, and laboratory abnormalities were observed in the follow-up visits.", + "summary_subclaims": [ + "The patient is a 27-year-old man with HIV infection.", + "He complained of recurrent headaches during the last year.", + "His MRI presented diffused bilateral white matter lesions.", + "Laboratory tests confirmed elevated CSF protein level.", + "Laboratory tests confirmed lymphocytic pleocytosis.", + "CSF HIV RNA was detectable at 774 copies/mL.", + "Plasma HIV RNA was well suppressed with tenofovir, lamivudine, and lopinavir/ritonavir.", + "Prednisone 60 mg once daily was initiated to reduce intracranial inflammation.", + "There was a good clinical response to prednisone.", + "CSF HIV RNA was still detectable at 31.1 copies/mL after prednisone initiation.", + "During the gradual tapering of prednisone, his headache relapsed.", + "Booming viral loads were detected in both CSF and plasma.", + "CSF HIV RNA was 4580 copies/mL during the relapse.", + "Plasma HIV RNA was 340 copies/mL during the relapse.", + "Drug-resistant mutations were detected.", + "Prednisone was resumed.", + "The ART regimen was switched to zidovudine, lamivudine, and dolutegravir.", + "The switch was based on drug resistance tests.", + "Persistent clinical recovery of symptoms was observed in follow-up visits.", + "Persistent recovery of neuroimaging abnormalities was observed in follow-up visits.", + "Persistent recovery of laboratory abnormalities was observed in follow-up visits." + ] + }, + { + "id": "multiclinsum_test_211_en.txt", + "fulltext": "A 75-year-old man with acute cholecystitis was scheduled to undergo a laparoscopic cholecystectomy. He had a history of emphysema and spontaneous pneumothorax with no limitations in his daily activities. Preoperative respiratory function tests indicated mild obstructive disorder. Preoperative chest radiography indicated a giant bulla occupying the lower half of the right hemithorax . Computed tomography (CT) of the chest indicated that the giant bulla compressed the middle and lower lobes of the right lung, leading to atelectasis. Conversely, the upper lobe had good air content . To prevent rupture of the giant bulla and tension pneumothorax during laparoscopic cholecystectomy, we planned to manage the patient under general anesthesia with OLV. Anesthesia was induced with propofol 80 mg, fentanyl 100 mcg, rocuronium 60mg, and maintained with 4–5% desflurane and remifentanil 0.13–0.18 mcg/kg/min. After two to three times of manual ventilation via a facemask, the patient’s trachea was intubated with a 37-Fr left DLT. OLV was started immediately after intubation and continued throughout the surgery, with the right-sided lumen open to ambient air. The surgery was completed uneventfully in 125 min; peripheral oxygen saturation was 98–99% throughout the surgery. Chest radiography before extubation indicated a large lucency occupying the entire right hemithorax . Initially, we suspected a pneumothorax due to rupture of the giant bulla; however, chest tube insertion was withheld because his hemodynamics and respiratory status were stable. Instead, we continued the OLV and obtained a chest CT scan to determine whether any conditions other than pneumothorax were present. Chest CT indicated compression atelectasis of the entire right lung, including the upper lobe wrapped around the giant bulla. A small amount of pleural fluid did not form a liquid surface. Instead, it was compressed by a giant bulla to form a concave surface. These findings led us to diagnose hyperinflation of the giant bulla rather than a pneumothorax. Returning to the operating room, an attempt was made to relieve atelectasis using a recruitment maneuver with moderate pressure. However, follow-up radiography indicated that the right lung had not expanded. We decided to observe the hyperinflated giant bulla conservatively under spontaneous breathing and extubated the patient after emergence from general anesthesia. After extubation, the patient’s respiratory status was normal with no evident abnormalities. The hyperinflated giant bulla deflated and the right upper lobe gradually expanded under spontaneous breathing. The chest radiograph on postoperative day three was similar to the preoperative radiograph. The patient was discharged on postoperative day seven.", + "fulltext_subclaims": [ + "The patient was a 75-year-old man.", + "The patient had acute cholecystitis.", + "The patient was scheduled to undergo a laparoscopic cholecystectomy.", + "The patient had a history of emphysema.", + "The patient had a history of spontaneous pneumothorax.", + "The patient had no limitations in his daily activities.", + "Preoperative respiratory function tests indicated mild obstructive disorder.", + "Preoperative chest radiography indicated a giant bulla occupying the lower half of the right hemithorax.", + "Computed tomography of the chest indicated that the giant bulla compressed the middle and lower lobes of the right lung, leading to atelectasis.", + "The upper lobe had good air content.", + "The patient was managed under general anesthesia with one-lung ventilation.", + "Anesthesia was induced with propofol 80 mg, fentanyl 100 mcg, rocuronium 60 mg.", + "Anesthesia was maintained with 4–5% desflurane and remifentanil 0.13–0.18 mcg/kg/min.", + "The patient’s trachea was intubated with a 37-Fr left double-lumen tube.", + "One-lung ventilation was started immediately after intubation.", + "The right-sided lumen was open to ambient air.", + "The surgery was completed uneventfully in 125 min.", + "Peripheral oxygen saturation was 98–99% throughout the surgery.", + "Chest radiography before extubation indicated a large lucency occupying the entire right hemithorax.", + "Initially, pneumothorax due to rupture of the giant bulla was suspected.", + "Chest tube insertion was withheld.", + "Chest CT indicated compression atelectasis of the entire right lung, including the upper lobe wrapped around the giant bulla.", + "A small amount of pleural fluid did not form a liquid surface.", + "The pleural fluid was compressed by a giant bulla to form a concave surface.", + "These findings led to the diagnosis of hyperinflation of the giant bulla rather than pneumothorax.", + "An attempt was made to relieve atelectasis using a recruitment maneuver with moderate pressure.", + "Follow-up radiography indicated that the right lung had not expanded.", + "The decision was made to observe the hyperinflated giant bulla conservatively under spontaneous breathing.", + "The patient was extubated after emergence from general anesthesia.", + "After extubation, the patient’s respiratory status was normal with no evident abnormalities.", + "The hyperinflated giant bulla deflated and the right upper lobe gradually expanded under spontaneous breathing.", + "The chest radiograph on postoperative day three was similar to the preoperative radiograph.", + "The patient was discharged on postoperative day seven." + ], + "summary": "A 75-year-old man with a giant bulla occupying the lower half of the right hemithorax underwent laparoscopic cholecystectomy. We managed anesthesia with OLV to avoid positive pressure ventilation of the giant bulla. Surgery was completed uneventfully; however, postoperative chest radiography indicated a large lucency occupying the entire right hemithorax. Although we suspected a pneumothorax due to a ruptured bulla, chest computed tomography (CT) led to a diagnosis of giant bulla hyperinflation. The giant bulla deflated gradually to its preoperative size within three postoperative days.", + "summary_subclaims": [ + "The patient is a 75-year-old man.", + "The patient had a giant bulla occupying the lower half of the right hemithorax.", + "The patient underwent laparoscopic cholecystectomy.", + "Anesthesia was managed with OLV to avoid positive pressure ventilation of the giant bulla.", + "Surgery was completed uneventfully.", + "Postoperative chest radiography indicated a large lucency occupying the entire right hemithorax.", + "We suspected a pneumothorax due to a ruptured bulla.", + "Chest computed tomography (CT) led to a diagnosis of giant bulla hyperinflation.", + "The giant bulla deflated gradually to its preoperative size within three postoperative days." + ] + }, + { + "id": "multiclinsum_test_2770_en.txt", + "fulltext": "A 22-year-old female presented to the University Hospital of the West Indies, Jamaica for further investigation and management following transfer from a local Government hospital where she presented with a 5-day history of diarrhoea and fever. The diarrhoea commenced 5 days after starting clindamycin therapy for a recent tooth extraction due to a dental abscess. Despite discontinuation of clindamycin therapy and the introduction of chloramphenicol and metronidazole empiric therapy, the diarrhoea and fever continued.\nPhysical examination of the patient revealed a febrile female in severe cardiopulmonary distress with tachycardia, HR beats/150 min, and blood pressure 150/100 mm/Hg. Laboratory investigations showed haemoglobin of 10.4 gm/dl, white cell count of 2.1 × 109/litre, and platelet count of 182 × 109/litre. Diarrhoea persisted and progressed to toxic megacolon and bowel perforation. Blood cultures (brain heart infusion and thioglycollate broths) collected on admission grew K. pneumoniae from all four bottles after 24 hours incubation at 37°C. Diarrhoeal stool specimen sent the day after admission was positive for C. difficile toxin A/B (ELISA; Alexon Inc. 1190 Borregas Ave., Sunnyvale, CA. 94089–1302) and the corresponding organism isolated on selective culture medium, cycloserine, cefoxitin, fructose agar (CCFA).\nIn the interim period of empiric therapy, susceptibility testing on K. pneumoniae by the Kirby Bauer disc diffusion method showed susceptibilities to ceftriaxone, co-trimoxazole, ceporin, amikacin, gentamicin, ceftazidine, and augmentin, as well as resistance to chloramphenical, piperacillin and ampicillin. The patient continued therapy on intravenous metronidazole and with the introduction of ceftriaxone and gentamycin she became afebrile with subsequent blood cultures becoming sterile. Hypotension, pulmonary oedema, leucopenia, and thrombocytopenia persisted despite appropriate therapy and intensive care management. The patient died 10 days after hospital admission and an autopsy was performed. The most significant finding of the autopsy was multiple discrete plaques of yellowish exudate on the mucosal surface of the entire large bowel typical of pseudomembranous colitis (PMC), which was florid. Another noteworthy pathologic finding was that of markedly overweight lungs with features in keeping with adult respiratory distress syndrome.\nPolymerase chain reaction (PCR) was used to confirm the presence of C. difficile triphosphate isomerase (tpi), toxin genes tcdA and tcdB, the lack of binary toxin cdtB gene, and no deletion in tcdC gene\n. PCR ribotyping on the isolate revealed a ribotype of 087 and the pulsed-field gel electrophoresis (PFGE) macrorestriction pattern identified a fingerprint type 0515, not previously seen using this method, and when compared to a national collection of over 700 unique fingerprint types from more than 7,100 CDI isolates (Figure ). However, the fingerprint pattern was closely related to the North American Pulsotype (NAP) NAP12 strain with only a one band difference (Figure ). The minimal inhibitory concentrations (MIC) determined by Etest were as follows: susceptible to metronidazole 0.094 ug/ml; vancomycin 1 ug/ml; moxifloxacin 1 ug/ml; rifampicin < 0.002 ug/ml; tigecycline 0. 125 ug/ml; and resistant to clindamycin 256 ug/ml. K. pneumoniae was isolated from 2 sets of blood cultures following overnight incubation at 37°C.\nThe severe clinical outcomes seen in the present case were not unusual though more commonly seen in HA-CDI\n. In addition to these clinical presentations, associated hypotension and admission to the intensive care unit classified this patient as a severe complicated case of CDI\n. In a large study covering the period 1991–2005 in Olmsted County, Minnesota, it was interesting to note that only 4% of CA-CDI had progressed to severe complicated CDI\n. It was further noted that such cases are usually associated with a significantly older age group with a median age of 80 years\n. The manifested clinical involvements along with a significant age difference are important features to consider in CA-CDI and should serve to alert clinicians that there is always a potential risk of young adults progressing to severe complicated CDI. The source of K. pneumoniae sepsis in the patient was presumably the gastrointestinal tract, as there were no symptoms or signs to suggest other systems involvement. Notwithstanding treatment with metronidazole, the patient was unresponsive and progressed to toxic megacolon and bowel perforation. These were probably due to the failure to administer appropriate and adequate clinical and surgical interventions.\nOral metronidazole remained the preferred first line drug for treatment while vancomycin is reserved for severely ill patients and recurrence of C. difficile colitis\n. Interestingly, these interventions including the use of adjunctive intracolonic vancomycin therapy and total colectomy, as recommended options, were not followed in the management of the present case. It is important to note that PMC was confirmed by autopsy. The failure to apply the optimal required clinical and surgical interventions during the patient’s hospitalisation were probably due to the rapid progression of these clinical outcomes.\nWith the exception of toxins A and B produced by this isolate, there was no deletion observed in the negative regulator tcdC gene suggesting normal toxin expression. However, ATCC 43255, which also has a wild type tcdC, has shown increased toxin expression\n. Importantly, ATCC 43255 has the same ribotype (087) as the clinical isolate and only a single band difference in the DNA fingerprints was observed between the two isolates (Figure ). Based on the similarity of ribotypes and fingerprint patterns between the two isolates, one could speculate that the rapid progression to PMC in the patient may be due to increased toxin expression. Ribotype 087 is the predominant strain in Hungary but is uncommon internationally\n.\nThe patient had no history of hospitalisation 12 months prior to infection and no health care-associated risk factors to CDI were noted. On the contrary, this young adult female was actively pursuing a university education, which was disrupted by CA-CDI\n. The progression to toxic megacolon in the patient was not a predicted clinical outcome even after hospitalisation. The presence of a perforated colon was a clear indication for surgical intervention, especially if there were unresponsiveness to other treatments and if clinical improvement was not noted within 2 to 3 days of patient management\n.", + "fulltext_subclaims": [ + "The patient was a 22-year-old female.", + "She presented to the University Hospital of the West Indies, Jamaica.", + "She had a 5-day history of diarrhoea and fever.", + "The diarrhoea commenced 5 days after starting clindamycin therapy.", + "The clindamycin therapy was for a recent tooth extraction due to a dental abscess.", + "Chloramphenicol and metronidazole were introduced as empiric therapy.", + "The diarrhoea and fever continued despite discontinuation of clindamycin.", + "Physical examination revealed a febrile female in severe cardiopulmonary distress.", + "The heart rate was 150 beats per minute.", + "The blood pressure was 150/100 mm/Hg.", + "The haemoglobin was 10.4 gm/dl.", + "The white cell count was 2.1 × 109/litre.", + "The platelet count was 182 × 109/litre.", + "The diarrhoea progressed to toxic megacolon.", + "The diarrhoea progressed to bowel perforation.", + "Blood cultures collected on admission grew K. pneumoniae.", + "Diarrhoeal stool specimen sent the day after admission was positive for C. difficile toxin A/B.", + "The corresponding organism was isolated on cycloserine, cefoxitin, fructose agar.", + "Susceptibility testing showed susceptibility to ceftriaxone.", + "Susceptibility testing showed susceptibility to co-trimoxazole.", + "Susceptibility testing showed susceptibility to ceporin.", + "Susceptibility testing showed susceptibility to amikacin.", + "Susceptibility testing showed susceptibility to gentamicin.", + "Susceptibility testing showed susceptibility to ceftazidine.", + "Susceptibility testing showed susceptibility to augmentin.", + "Susceptibility testing showed resistance to chloramphenical.", + "Susceptibility testing showed resistance to piperacillin.", + "Susceptibility testing showed resistance to ampicillin.", + "The patient continued therapy on intravenous metronidazole.", + "The patient became afebrile with the introduction of ceftriaxone and gentamycin.", + "Subsequent blood cultures became sterile.", + "The patient died 10 days after hospital admission.", + "The autopsy showed multiple discrete plaques of yellowish exudate on the mucosal surface of the entire large bowel.", + "The plaques were typical of pseudomembranous colitis.", + "The pseudomembranous colitis was florid.", + "The lungs were markedly overweight with features in keeping with adult respiratory distress syndrome.", + "PCR confirmed the presence of C. difficile triphosphate isomerase (tpi).", + "PCR confirmed the presence of toxin genes tcdA and tcdB.", + "PCR showed the lack of binary toxin cdtB gene.", + "PCR showed no deletion in tcdC gene.", + "PCR ribotyping on the isolate revealed a ribotype of 087.", + "Pulsed-field gel electrophoresis macrorestriction pattern identified a fingerprint type 0515.", + "The fingerprint pattern was not previously seen using this method.", + "The fingerprint pattern was closely related to the North American Pulsotype NAP12 strain.", + "The minimal inhibitory concentration for metronidazole was 0.094 ug/ml.", + "The minimal inhibitory concentration for vancomycin was 1 ug/ml.", + "The minimal inhibitory concentration for moxifloxacin was 1 ug/ml.", + "The minimal inhibitory concentration for rifampicin was < 0.002 ug/ml.", + "The minimal inhibitory concentration for tigecycline was 0.125 ug/ml.", + "The minimal inhibitory concentration for clindamycin was 256 ug/ml.", + "K. pneumoniae was isolated from 2 sets of blood cultures.", + "The source of K. pneumoniae sepsis was presumably the gastrointestinal tract.", + "The patient was unresponsive to metronidazole.", + "The patient progressed to toxic megacolon.", + "The patient progressed to bowel perforation.", + "These were probably due to the failure to administer appropriate and adequate clinical and surgical interventions.", + "Oral metronidazole remained the preferred first line drug for treatment.", + "Vancomycin is reserved for severely ill patients and recurrence of C. difficile colitis.", + "Adjunctive intracolonic vancomycin therapy was not used in the management of the present case.", + "Total colectomy was not performed in the management of the present case.", + "PMC was confirmed by autopsy.", + "The failure to apply optimal clinical and surgical interventions was probably due to the rapid progression of clinical outcomes.", + "There was no deletion observed in the negative regulator tcdC gene.", + "ATCC 43255 also has a wild type tcdC.", + "ATCC 43255 has shown increased toxin expression.", + "ATCC 43255 has the same ribotype (087) as the clinical isolate.", + "A single band difference was observed between the two isolates in DNA fingerprints.", + "Ribotype 087 is the predominant strain in Hungary.", + "Ribotype 087 is uncommon internationally.", + "The patient had no history of hospitalisation 12 months prior to infection.", + "No health care-associated risk factors to CDI were noted.", + "The progression to toxic megacolon was not a predicted clinical outcome.", + "The presence of a perforated colon was a clear indication for surgical intervention.", + "Surgical intervention was especially indicated if there was unresponsiveness to other treatments.", + "Surgical intervention was especially indicated if clinical improvement was not noted within 2 to 3 days." + ], + "summary": "We report a case of a 22-year-old female university student who was admitted to the University Hospital of the West Indies, Jamaica with a presumptive diagnosis of pseudomembranous colitis PMC. She presented with a 5-day history of diarrhoea following clindamycin treatment for coverage of a tooth extraction due to a dental abscess. Her clinical condition deteriorated and progressed from diarrhoea to toxic megacolon, bowel perforation and Gram-negative sepsis. Clostridium difficile NAP12/ribotype 087 was isolated from her stool while blood cultures grew Klebsiella pneumoniae. Despite initial treatment intervention with empiric therapy of metronidazole and antibiotic clearance of Klebsiella pneumoniae from the blood, the patient died within 10 days of hospital admission.", + "summary_subclaims": [ + "The patient was a 22-year-old female university student.", + "She was admitted to the University Hospital of the West Indies, Jamaica.", + "The presumptive diagnosis was pseudomembranous colitis.", + "She had a 5-day history of diarrhoea following clindamycin treatment.", + "The clindamycin was used for coverage of a tooth extraction due to a dental abscess.", + "Her clinical condition deteriorated and progressed from diarrhoea to toxic megacolon.", + "She developed bowel perforation.", + "Gram-negative sepsis was diagnosed.", + "Clostridium difficile NAP12/ribotype 087 was isolated from her stool.", + "Blood cultures grew Klebsiella pneumoniae.", + "Initial treatment included empiric therapy with metronidazole.", + "Klebsiella pneumoniae was cleared from the blood.", + "The patient died within 10 days of hospital admission." + ] + }, + { + "id": "multiclinsum_test_288_en.txt", + "fulltext": "A 58-year-old man had experienced recurrent abdominal pain and melena for 3 years, but repeated gastroenteroscopy and CTA had failed to find bleeding lesions.\nOn June 30, 2020, the patient presented to our department with a history of recurrent abdominal pain and melena for 3 years. In June 2017, he developed recurrent localized and dark pain in the upper abdomen without obvious inducement. It was tolerable, lasted for about 1 h, occurred about 3 times a day and was accompanied by thin, textureless melena, dizziness, and fatigue. His symptoms occurred repeatedly. He had gone to major hospitals across the country many times, but there was no clear diagnosis, and conservative treatment was used for alleviation. Two months before admission, the above symptoms progressively worsened. Melena was passed 4-5 times a day, with a total volume of about 200 g, and the dizziness and fatigue were significantly worse than before. After symptomatic treatment of hemostasis in the local hospital, the symptoms were improved, but still existed.\nHe was diagnosed with syphilis in 2008. Multiple treatments were successful, but the disease recurred shortly afterward. Because of heart valve disease, he underwent a mitral valve replacement and tricuspid valvuloplasty at Fujian Provincial Hospital In 2010. In 2019, he was diagnosed with atrial fibrillation and chronic pancreatitis. Currently, he is taking Betaloc 23.75 mg qd orally.\nThe patient had a history of unprotected intercourse with multiple sexual partners, a smoking history for 40 years (20 cigarettes a day), and a drinking history for 30 years. There is no family history of infectious or heredity diseases.\nOn admission, his temperature was 36 ℃, pulse was 66 beats/min, respiration was 18 breaths/min, and blood pressure was 120/80 mmHg. He was conscious and could cooperate in the physical examination. The skin of the whole body was slightly pale. Systemic superficial lymph nodes were not enlarged or tender, the conjunctiva was pale, the lips were slightly pale, carotid artery pulsation was normal, jugular vein was normal, liver jugular vein return sign was negative, and lung physical examination was not remarkable. There was a postoperative scar of about 20 cm in length on the chest, which had healed well. The heart rate was 80 beats/min, the heart rhythm was absolutely uneven, the first heart sound varied in intensity, a systolic murmur was heard in the mitral valve auscultation area, no obvious pathological murmur was heard in the other auscultation area, the fricative consonant was unintentionally included, the abdomen was flat and soft without tenderness or rebound pain, and the abdomen was not lumped. The liver and spleen were not touched, Murphy’s sign was negative, and there was no mobile dullness. Intestinal sounds (4/min) were normal.\nThe initial hemoglobin of the patient was 78.0 g/L and fecal occult blood was present (++). The syphilis toluidine red unheated serum test (TRUST) was positive; the syphilis titer was 1:2 positive. The white blood cell count, platelets, coagulation function, antinuclear antibody, antinuclear antibody profile, fecal routine, urine routine, alpha fetoprotein, carcinoembryonic antigen, glycogen antigen 199, total iron binding capacity, serum iron, unsaturated iron binding capacity, ferritin, folic acid, vitamin B12, purified protein derivative (PPD tuberculin test, tuberculosis antibody, and tuberculosis T-cell test showed no obvious abnormalities.\nThe patient’s upper abdominal magnetic resonance cholangiopancreatography revealed splenomegaly, and dilatation of the intrahepatic and extrahepatic bile ducts and pancreatic ducts .\nAn electrocardiogram indicated atrial fibrillation . Colonoscopy found multiple small ridges in the terminal ileum, and the pathology showed chronic active inflammation and erosive mucosa. Additional gastroscopy showed atrophic gastritis, and pathology of the gastric antrum indicated inflammation, and the Helicobacter pylori test was negative. Ultrasound gastroscopy showed dilatation of pancreatic duct with pancreatic duct stones, which was considered as chronic pancreatitis . A capsule endoscopy was performed to further clarify the bleeding focus of the patient, and multiple intestinal erosions and ulcers were found . The bone marrow puncture smear of the iliac spine showed normal hematopoietic tissue hyperplasia, presence of three-line hematopoietic cells, expanded islands of erythroid cells, hyperplasia of erythroid cells, a reduced granulocytosis ratio, and a scattered distribution of megakaryocytes, which was considered as hyperplastic anemia .", + "fulltext_subclaims": [ + "The patient is a 58-year-old man.", + "He had experienced recurrent abdominal pain and melena for 3 years.", + "Repeated gastroenteroscopy and CTA had failed to find bleeding lesions.", + "On June 30, 2020, the patient presented to the department.", + "He had a history of recurrent abdominal pain and melena for 3 years.", + "In June 2017, he developed recurrent localized and dark pain in the upper abdomen.", + "The pain was tolerable, lasted for about 1 hour, occurred about 3 times a day, and was accompanied by thin, textureless melena, dizziness, and fatigue.", + "He had gone to major hospitals across the country many times, but there was no clear diagnosis.", + "He had received conservative treatment for alleviation.", + "Two months before admission, the symptoms progressively worsened.", + "Melena was passed 4-5 times a day, with a total volume of about 200 g.", + "Dizziness and fatigue were significantly worse than before.", + "After symptomatic treatment of hemostasis in the local hospital, the symptoms were improved, but still existed.", + "He was diagnosed with syphilis in 2008.", + "Multiple treatments were successful, but the disease recurred shortly afterward.", + "He underwent a mitral valve replacement and tricuspid valvuloplasty at Fujian Provincial Hospital in 2010.", + "In 2019, he was diagnosed with atrial fibrillation and chronic pancreatitis.", + "He is currently taking Betaloc 23.75 mg qd orally.", + "He had a history of unprotected intercourse with multiple sexual partners.", + "He had a 40-year smoking history (20 cigarettes a day).", + "He had a 30-year drinking history.", + "There is no family history of infectious or heredity diseases.", + "On admission, his temperature was 36 ℃, pulse was 66 beats/min, respiration was 18 breaths/min, and blood pressure was 120/80 mmHg.", + "The skin of the whole body was slightly pale.", + "Systemic superficial lymph nodes were not enlarged or tender.", + "The conjunctiva was pale.", + "The lips were slightly pale.", + "The initial hemoglobin of the patient was 78.0 g/L.", + "Fecal occult blood was present (++).", + "The syphilis toluidine red unheated serum test (TRUST) was positive.", + "The syphilis titer was 1:2 positive.", + "The white blood cell count, platelets, coagulation function, antinuclear antibody, antinuclear antibody profile, fecal routine, urine routine, alpha fetoprotein, carcinoembryonic antigen, glycogen antigen 199, total iron binding capacity, serum iron, unsaturated iron binding capacity, ferritin, folic acid, vitamin B12, purified protein derivative (PPD), tuberculin test, tuberculosis antibody, and tuberculosis T-cell test showed no obvious abnormalities.", + "The upper abdominal magnetic resonance cholangiopancreatography revealed splenomegaly.", + "The upper abdominal magnetic resonance cholangiopancreatography showed dilatation of the intrahepatic and extrahepatic bile ducts and pancreatic ducts.", + "An electrocardiogram indicated atrial fibrillation.", + "Colonoscopy found multiple small ridges in the terminal ileum.", + "The pathology showed chronic active inflammation and erosive mucosa.", + "Additional gastroscopy showed atrophic gastritis.", + "The pathology of the gastric antrum indicated inflammation.", + "The Helicobacter pylori test was negative.", + "Ultrasound gastroscopy showed dilatation of the pancreatic duct with pancreatic duct stones, which was considered as chronic pancreatitis.", + "A capsule endoscopy was performed to further clarify the bleeding focus of the patient.", + "Multiple intestinal erosions and ulcers were found.", + "The bone marrow puncture smear of the iliac spine showed normal hematopoietic tissue hyperplasia.", + "The bone marrow puncture smear showed presence of three-line hematopoietic cells.", + "The bone marrow puncture smear showed expanded islands of erythroid cells.", + "The bone marrow puncture smear showed hyperplasia of erythroid cells.", + "The bone marrow puncture smear showed a reduced granulocytosis ratio.", + "The bone marrow puncture smear showed a scattered distribution of megakaryocytes.", + "The bone marrow puncture smear was considered as hyperplastic anemia." + ], + "summary": "A 58-year-old man had experienced recurrent abdominal pain and melena for 3 years. Repeated gastroenteroscopy and computed tomography angiography examinations failed to find bleeding lesions. During the same admission, multiple intestinal ulcers were found by capsule endoscopy, and syphilis was also diagnosed. With a history of atrial fibrillation and chronic pancreatitis, he had undergone mitral valve replacement and tricuspid valvuloplasty for valvular heart disease. After anti-syphilis treatment, the melena and abdominal pain disappeared and his hemoglobin gradually increased. It is considered that gastrointestinal bleeding, chronic pancreatitis, atrial fibrillation, and heart valvular disease may have been caused by syphilis.", + "summary_subclaims": [ + "The patient is a 58-year-old man.", + "He had experienced recurrent abdominal pain and melena for 3 years.", + "Repeated gastroenteroscopy and computed tomography angiography examinations failed to find bleeding lesions.", + "Multiple intestinal ulcers were found by capsule endoscopy.", + "Syphilis was diagnosed.", + "He had a history of atrial fibrillation.", + "He had undergone mitral valve replacement.", + "He had undergone tricuspid valvuloplasty.", + "After anti-syphilis treatment, the melena and abdominal pain disappeared.", + "His hemoglobin gradually increased after anti-syphilis treatment.", + "It is considered that gastrointestinal bleeding, chronic pancreatitis, atrial fibrillation, and heart valvular disease may have been caused by syphilis." + ] + }, + { + "id": "multiclinsum_test_2290_en.txt", + "fulltext": "A male Chinese patient, aged 58 years, visited the cardiology clinic with recurring episodes of syncope for 20 days. He experienced episodes of transient loss of consciousness, each lasting approximately 30 seconds, accompanied by chest pain. The most recent episode of syncope occurred in the early morning and was characterized by dizziness and a temporary loss of consciousness. He had a history of hypertension.\nHe smoked one pack of cigarettes daily for about 20 years with frequent alcohol intake. During the examination of the patient’s cardiac system, auscultation indicated normal heart sounds and no murmurs. Magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA) of the brain, laboratory tests measuring cardiac enzymes, and electrocardiogram (ECG) were normal.\nA transthoracic echocardiogram provided confirmation of the left ventricle’s size and function being within normal parameters. Approximately 16 hours after admission, about at 5 a.m., during sleeping, the patient experienced a recurrence of sudden chest pain, diaphoresis, and subsequent syncope. Physical examination indicated a heart rate of 37 beats per minute (bpm), respiratory rate of 25 breaths per minute, and blood pressure of 62/38 mmHg. The ECG revealed dynamic ST-segment elevation of 0.1 mV in leads II, III, and augmented vector foot (aVF; Fig. ). Syndromes spontaneously improved within a few minutes, the ECG returned to baseline and blood pressure improved to normal later . Cardiac troponin I enzyme levels were negative. Coronary angiography (CAG) was not performed immediately due to the symptom relief. However, following the doctor’s advice, he had CAG examination 4 days later. Subsequent CAG confirmed diffuse coronary slow flow (thrombolysis in myocardial infarction flow grade 2), without any substantial flow-limiting lesions . The patient did not agree to undergo coronary vasospasm provocation testing due to possible adverse event risk, and refused further examination to further confirm the cause due to financial reasons. However, based on the patient’s symptoms, ECG findings, and coronary angiography, a diagnosis of CAS and presumptive CMD was established. The patient was prescribed diltiazem sustained-release capsules (30 mg, four times daily), nicorandil (5 mg, three times daily), and atorvastatin (20 mg/day).\nDuring the 3-month follow-up conducted on our outpatient basis, the patient successfully ceased smoking and effectively controlled his hypertension. Furthermore, he did not experience a recurrence of the previously reported chest discomfort, syncope, or any other symptoms.", + "fulltext_subclaims": [ + "The patient is a 58-year-old male Chinese man.", + "He had recurring episodes of syncope for 20 days.", + "Each episode of syncope lasted approximately 30 seconds.", + "The most recent episode occurred in the early morning.", + "The most recent episode was characterized by dizziness and a temporary loss of consciousness.", + "He had a history of hypertension.", + "He smoked one pack of cigarettes daily for about 20 years.", + "He had frequent alcohol intake.", + "Cardiac auscultation indicated normal heart sounds and no murmurs.", + "Magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA) of the brain were normal.", + "Laboratory tests measuring cardiac enzymes were normal.", + "The electrocardiogram (ECG) was normal.", + "A transthoracic echocardiogram showed the left ventricle’s size and function within normal parameters.", + "Approximately 16 hours after admission, the patient experienced a recurrence of sudden chest pain.", + "The recurrence was accompanied by diaphoresis and syncope.", + "Physical examination showed a heart rate of 37 bpm.", + "Physical examination showed blood pressure of 62/38 mmHg.", + "The ECG revealed dynamic ST-segment elevation of 0.1 mV in leads II, III, and aVF.", + "The ECG returned to baseline within a few minutes.", + "Cardiac troponin I enzyme levels were negative.", + "Coronary angiography (CAG) was not performed immediately due to symptom relief.", + "CAG was performed 4 days later.", + "CAG confirmed diffuse coronary slow flow (TIMI flow grade 2).", + "CAG found no substantial flow-limiting lesions.", + "The patient did not agree to undergo coronary vasospasm provocation testing.", + "The patient refused further examination due to financial reasons.", + "A diagnosis of CAS and presumptive CMD was established.", + "The patient was prescribed diltiazem sustained-release capsules (30 mg, four times daily).", + "The patient was prescribed nicorandil (5 mg, three times daily).", + "The patient was prescribed atorvastatin (20 mg/day).", + "During the 3-month follow-up, the patient successfully ceased smoking.", + "During the 3-month follow-up, the patient effectively controlled his hypertension.", + "The patient did not experience a recurrence of chest discomfort.", + "The patient did not experience a recurrence of syncope." + ], + "summary": "This case report describes the presentation of a 58-year-old Chinese male patient who experienced repeated episodes of syncope. The syncope was found to be caused by concomitant coronary artery spasm and presumptive coronary microvascular dysfunctionc suggested by \"slow flow\" on coronary angiography. The patient was prescribed diltiazem sustained-release capsules, nicorandil, and atorvastatin. During the three-month follow-up conducted on our outpatient basis, the patient did not experience a recurrence of syncope.", + "summary_subclaims": [ + "This case report describes the presentation of a 58-year-old Chinese male patient who experienced repeated episodes of syncope.", + "The syncope was found to be caused by concomitant coronary artery spasm and presumptive coronary microvascular dysfunction.", + "The syncope was suggested by 'slow flow' on coronary angiography.", + "The patient was prescribed diltiazem sustained-release capsules.", + "The patient was prescribed nicorandil.", + "The patient was prescribed atorvastatin.", + "During the three-month follow-up conducted on our outpatient basis, the patient did not experience a recurrence of syncope." + ] + }, + { + "id": "multiclinsum_test_135_en.txt", + "fulltext": "A 48-year-old Japanese woman had a sudden onset of severe headaches early in the morning during work and was transported to a local hospital. She was alert-oriented and had no neurologic deficits. She had a medical history of atopic dermatitis and metal allergy that had discouraged her from wearing any jewels.\nA head computed tomography (CT) scan demonstrated a subarachnoid hemorrhage (SAH) around the basal cistern with predominant SAH in the left sylvian cistern. A three-dimensional-CT angiography revealed a left internal carotid artery (ICA)-posterior communicating artery (Pcom) aneurysm. Although an emergent aneurysm clipping surgery was scheduled, the patient preferred a coil embolization rather than an open surgery so that she was referred to us for a coil embolization.\nOn the next day after the onset, a coil embolization was performed using a simple technique under the general anesthesia. The left ICA angiogram confirmed an irregular-shaped aneurysm measuring 7.7 mm in the maximum diameter at the left ICA-Pcom junction. Besides the ICAPcom aneurysm, aneurysms at the bilateral middle cerebral artery (MCA) bifurcations and at the top of the right ICA were also revealed. Given the distribution of SAH as well as the size and the shape of the aneurysm, the left ICA-Pcom aneurysm was believed to be the cause of the SAH.\nA guiding sheath (Flexor shuttle 7F × 90 cm ST 0.100”/2.54 mm) was advanced to the pre-petrous portion of the left ICA. A microcatheter (Excelsior SL-10 pre-shaped 90°) was placed in the aneurysm using a manual-shaped intermediate catheter (TACTICS 120 cm STR). Seven coils were used for the complete obliteration of the aneurysm (Raymond-Roy occlusion classification class I) and are listed in . The patient recovered well without any neurologic deficits. The head CT scan right after the embolization showed no abnormal findings, as shown in\nDespite no neurologic deficits after the surgery and no abnormal findings on a MRI 7 days after the coil embolization, an MRI study performed 24 days after the embolization demonstrated a round lesion beside the posterior horn of the left lateral ventricle, as shown in . The lesion showed homogeneously moderately high intensity on the T2-weighted image (T2WI) and the fluid-attenuated inversion recovery (FLAIR) sequence, mildly high intensity on the apparent diffusion coefficient (ADC) map but isointensity on diffusion-weighted imaging (DWI). An MRI taken 44 days after the surgery showed multiple patchy lesions at separate locations of the left frontal and parietal lobes. The lesions demonstrated high intensity on FLAIR as the previous one. An MRI obtained 70 days after the surgery still demonstrated an even larger high intense lesion on T2WI, FLAIR, and ADC map and an isointensity on DWI in the left frontal lobe, though the previous lesion had disappeared. An MRI taken 146 days after the surgery showed complete disappearance of the abnormal high intense lesions finally.\nMeanwhile, the ratio of eosinophils (EOS) among the leukocytes was 3.0% (0.0–7.0%) before the surgery, and it elevated up to 9.7% 16 days after the coil embolization and got back to 2.6% 147 days after the surgery, as shown in .\nDespite the MRI findings, the patient showed no neurologic deficits and complained of only mild headaches throughout the course. No specific treatments were performed, and the headaches gradually subsided and finally resolved completely.\nThe patient subsequently underwent a metal skin patch test that showed positive against only zinc though the patch test covered neither titanium, tungsten, nor molybdenum, as shown in .", + "fulltext_subclaims": [ + "The patient was a 48-year-old Japanese woman.", + "She had a sudden onset of severe headaches early in the morning during work.", + "She was transported to a local hospital.", + "She was alert-oriented and had no neurologic deficits.", + "She had a medical history of atopic dermatitis.", + "She had a medical history of metal allergy.", + "A head CT scan demonstrated a subarachnoid hemorrhage around the basal cistern.", + "A three-dimensional CT angiography revealed a left internal carotid artery-posterior communicating artery aneurysm.", + "An emergent aneurysm clipping surgery was scheduled.", + "The patient preferred a coil embolization rather than an open surgery.", + "A coil embolization was performed using a simple technique under general anesthesia.", + "The left ICA angiogram confirmed an irregular-shaped aneurysm measuring 7.7 mm in the maximum diameter at the left ICA-Pcom junction.", + "Aneurysms at the bilateral middle cerebral artery bifurcations were revealed.", + "An aneurysm at the top of the right internal carotid artery was revealed.", + "The left ICA-Pcom aneurysm was believed to be the cause of the subarachnoid hemorrhage.", + "A guiding sheath (Flexor shuttle 7F × 90 cm ST 0.100”/2.54 mm) was advanced to the pre-petrous portion of the left ICA.", + "A microcatheter (Excelsior SL-10 pre-shaped 90°) was placed in the aneurysm.", + "Seven coils were used for the complete obliteration of the aneurysm.", + "The patient recovered well without any neurologic deficits.", + "A head CT scan right after the embolization showed no abnormal findings.", + "An MRI study performed 24 days after the embolization demonstrated a round lesion beside the posterior horn of the left lateral ventricle.", + "The lesion showed homogeneously moderately high intensity on the T2-weighted image.", + "The lesion showed mildly high intensity on the apparent diffusion coefficient map.", + "The lesion showed isointensity on diffusion-weighted imaging.", + "An MRI taken 44 days after the surgery showed multiple patchy lesions at separate locations of the left frontal and parietal lobes.", + "The lesions demonstrated high intensity on FLAIR.", + "An MRI obtained 70 days after the surgery still demonstrated an even larger high intense lesion on T2WI, FLAIR, and ADC map.", + "The previous lesion had disappeared.", + "An MRI taken 146 days after the surgery showed complete disappearance of the abnormal high intense lesions.", + "The ratio of eosinophils among the leukocytes was 3.0% before the surgery.", + "The ratio of eosinophils elevated up to 9.7% 16 days after the coil embolization.", + "The ratio of eosinophils got back to 2.6% 147 days after the surgery.", + "The patient showed no neurologic deficits.", + "The patient complained of only mild headaches throughout the course.", + "The headaches gradually subsided and finally resolved completely.", + "The patient underwent a metal skin patch test.", + "The patch test showed positive against only zinc.", + "The patch test covered neither titanium, tungsten, nor molybdenum." + ], + "summary": "A 48-year-old woman had a sudden onset of severe headaches and was referred to us for coil embolization. She was alert-oriented and had no neurologic deficits. Her medical history was atopic dermatitis and metal allergy. A head computed tomography (CT) scan demonstrated subarachnoid hemorrhage, and three-dimensional-CT angiography revealed a left internal carotid artery-posterior communicating artery aneurysm. Coil embolization was performed on the next day and seven coils made by three different manufacturers were used for the embolization. Despite no neurologic deficits after the surgery and no abnormal findings in MRI 7 days after the coil embolization, an MRI 2 weeks after embolization demonstrated delayed multiple white matter high intense lesions on T2-weighted image and fluid-attenuated inversion recovery in the left hemisphere. Repeat MRI scans showed multiple high intense lesions at various locations and at different timings. The blood test revealed the elevation of the proportion of EOS up to 9.7%, strongly indicating some allergic response. The MRI scan obtained 3 months after the onset confirmed the complete disappearance of the lesions.", + "summary_subclaims": [ + "The patient was a 48-year-old woman.", + "She had a sudden onset of severe headaches.", + "She was referred for coil embolization.", + "She was alert and oriented.", + "She had no neurologic deficits.", + "Her medical history included atopic dermatitis.", + "Her medical history included metal allergy.", + "A head CT scan demonstrated subarachnoid hemorrhage.", + "Three-dimensional CT angiography revealed a left internal carotid artery-posterior communicating artery aneurysm.", + "Coil embolization was performed the next day.", + "Seven coils made by three different manufacturers were used for the embolization.", + "There were no neurologic deficits after the surgery.", + "An MRI 7 days after embolization showed no abnormal findings.", + "An MRI 2 weeks after embolization demonstrated delayed multiple white matter high intense lesions on T2-weighted image and fluid-attenuated inversion recovery in the left hemisphere.", + "Repeat MRI scans showed multiple high intense lesions at various locations and at different timings.", + "The blood test revealed the elevation of the proportion of EOS up to 9.7%.", + "The MRI scan obtained 3 months after the onset confirmed the complete disappearance of the lesions." + ] + }, + { + "id": "multiclinsum_test_3106_en.txt", + "fulltext": "The 62-year-old male patient underwent heart transplantation on November 2, 2019 for arrhythmogenic cardiomyopathy of the right ventricle. After transplantation, he remained hospitalized due to a series of complications including pneumonia and acute respiratory distress syndrome (ARDS). He required 56 days of mechanical ventilation and was in need of intermittent renal replacement therapy. Echocardiography revealed a left ventricular ejection fraction of 55% with no signs of transplant rejection. His immunosuppression regimen consisted of cyclosporine A (target range 135 ± 30 ng/mL), mycophenolate mofetil 500 mg b.i.d., and prednisone 10 mg q.d. No anti-lymphocyte globulins had been used as induction therapy. Blood count revealed anemia and leukopenia, the latter likely being caused by immunosuppressive medication, yet not improving significantly under dose reduction. He received cotrimoxazole and due to cytomegalovirus (CMV) high-risk constellation (D + R−), ganciclovir had been administered for 4 months after transplantation and was then switched to valganciclovir prophylaxis. Concurrent medication did not include angiotensin-converting enzyme inhibitors or angiotensin receptor blockers.\n\nOn March 13, 2020 (day 1), the patient developed fever (39.9°C), tachycardia (105 bpm), and a sore throat. Polymerase chain reaction (PCR) from throat swab revealed SARS-CoV-2 infection. Body temperature quickly normalized within the first 12 hours. Blood oxygen saturation levels remained stable in the range of 96%-100% without oxygen supplementation at a respiratory rate of 16 breaths per minute. Besides mild rhinorrhea and impaired exercise capacity, the patient showed no other symptoms, in particular no cough or dyspnea at rest. On day 7, a second increase in temperature up to 38.4°C was observed, which resolved spontaneously. This episode went along with a mild rise and peak of C-reactive protein (CRP), IL-6, and pro-B-type natriuretic peptide (proBNP) levels and lymphopenia. A computed tomography scan showed regressive postinflammatory alterations after bacterial pneumonia and ARDS, but no clear signs of COVID-19 pneumonia or bacterial superinfection. Procalcitonin levels remained low and blood cultures showed no bacterial or fungal growth. We decided to administer hydroxychloroquine (loading dose 400 mg b.i.d. followed by 200 mg b.i.d.) from day 7 to 14. Remarkably, while the patient was free of any marginal residual clinical symptom since day 20, SARS-CoV-2 PCR was positive on days 1, 5, 7, 11, 18, 21, 25, 28, 33, and still on day 35. Concurrent with the second onset of fever we observed an increased viral load after day 7 that slowly returned to the level of infection onset. Whereas the patient already was asymptomatic, virus culture on days 18 and 21 still confirmed active virus replication.\n\nAs proBNP levels increased and decreased simultaneously with the inflammation parameters, we considered a COVID-19-related myocardial infection, yet did not confirm it by myocardial biopsy. No signs of clinical deterioration, notably no signs of cardiorespiratory impairment, were observed. Weaning from hemodialysis was successful (day 1) and urine output and body weight remained stable. Cyclosporine A dose was adjusted several times over the course of infection to achieve a therapeutic range of 135 ± 30 ng/mL. Otherwise, medication including immunosuppression was continued unchanged except for an increase of prednisone dose to 50 mg for 3 days and 25 mg for another 3 days from day 14 on for treatment of acute gout in the left knee.", + "fulltext_subclaims": [ + "The 62-year-old male patient underwent heart transplantation on November 2, 2019.", + "The heart transplantation was for arrhythmogenic cardiomyopathy of the right ventricle.", + "After transplantation, he remained hospitalized due to complications including pneumonia and acute respiratory distress syndrome.", + "He required 56 days of mechanical ventilation.", + "He was in need of intermittent renal replacement therapy.", + "Echocardiography revealed a left ventricular ejection fraction of 55%.", + "Echocardiography showed no signs of transplant rejection.", + "His immunosuppression regimen consisted of cyclosporine A (target range 135 ± 30 ng/mL), mycophenolate mofetil 500 mg b.i.d., and prednisone 10 mg q.d.", + "No anti-lymphocyte globulins had been used as induction therapy.", + "Blood count revealed anemia.", + "Blood count revealed leukopenia.", + "The leukopenia was likely caused by immunosuppressive medication.", + "The leukopenia did not improve significantly under dose reduction.", + "He received cotrimoxazole.", + "He had a CMV high-risk constellation (D + R−).", + "Ganciclovir had been administered for 4 months after transplantation.", + "Ganciclovir was then switched to valganciclovir prophylaxis.", + "Concurrent medication did not include angiotensin-converting enzyme inhibitors.", + "Concurrent medication did not include angiotensin receptor blockers.", + "On March 13, 2020, the patient developed fever (39.9°C), tachycardia (105 bpm), and a sore throat.", + "PCR from throat swab revealed SARS-CoV-2 infection.", + "Body temperature quickly normalized within the first 12 hours.", + "Blood oxygen saturation levels remained stable in the range of 96%-100% without oxygen supplementation.", + "The patient showed no cough or dyspnea at rest.", + "On day 7, a second increase in temperature up to 38.4°C was observed.", + "This episode went along with a mild rise and peak of CRP, IL-6, and proBNP levels.", + "A computed tomography scan showed regressive postinflammatory alterations after bacterial pneumonia and ARDS.", + "The computed tomography scan showed no clear signs of COVID-19 pneumonia.", + "The computed tomography scan showed no clear signs of bacterial superinfection.", + "Procalcitonin levels remained low.", + "Blood cultures showed no bacterial or fungal growth.", + "Hydroxychloroquine was administered from day 7 to 14.", + "SARS-CoV-2 PCR was positive on days 1, 5, 7, 11, 18, 21, 25, 28, 33, and still on day 35.", + "Concurrent with the second onset of fever, an increased viral load was observed after day 7.", + "The viral load slowly returned to the level of infection onset.", + "Virus culture on days 18 and 21 confirmed active virus replication.", + "We considered a COVID-19-related myocardial infection.", + "We did not confirm the myocardial infection by myocardial biopsy.", + "No signs of clinical deterioration were observed.", + "Weaning from hemodialysis was successful on day 1.", + "Cyclosporine A dose was adjusted several times over the course of infection.", + "Prednisone dose was increased to 50 mg for 3 days from day 14 on.", + "Prednisone dose was increased to 25 mg for another 3 days from day 14 on.", + "The prednisone dose increase was for treatment of acute gout in the left knee." + ], + "summary": "Here, we present a 62-year-old male COVID-19 patient with recent heart transplantation who developed only mild symptoms, but had prolonged virus shedding, and summarize the available data on COVID-19 in cardiac allograft recipients. Initially the patient presented with a transient episode of fever and sore throat but no other symptoms, in particular no cough or dyspnea at rest. After diagnosis, immunosuppression was continued unchanged. On day 7, his temperature increased again with concurrent mild rise of C-reactive protein, IL-6, and pro-B-type natriuretic peptide levels. Hydroxychloroquine was started and continued for 7 days. While the patient no longer had clinical symptoms 20 days after initial presentation, virus culture of throat swabs on days 18 and 21 confirmed active virus replication and SARS-CoV-2 PCR remained positive on day 35 with copy numbers similar to the onset of infection. ", + "summary_subclaims": [ + "The patient was a 62-year-old male.", + "The patient had a recent heart transplantation.", + "The patient was a COVID-19 patient.", + "The patient developed only mild symptoms.", + "The patient had prolonged virus shedding.", + "The available data on COVID-19 in cardiac allograft recipients were summarized.", + "The patient initially presented with a transient episode of fever.", + "The patient initially presented with a sore throat.", + "The patient had no cough.", + "The patient had no dyspnea at rest.", + "After diagnosis, immunosuppression was continued unchanged.", + "On day 7, the patient's temperature increased again.", + "On day 7, there was a mild rise of C-reactive protein.", + "On day 7, there was a mild rise of IL-6.", + "On day 7, there was a mild rise of pro-B-type natriuretic peptide levels.", + "Hydroxychloroquine was started.", + "Hydroxychloroquine was continued for 7 days.", + "The patient no longer had clinical symptoms 20 days after initial presentation.", + "Virus culture of throat swabs on days 18 and 21 confirmed active virus replication.", + "SARS-CoV-2 PCR remained positive on day 35.", + "On day 35, SARS-CoV-2 copy numbers were similar to the onset of infection." + ] + }, + { + "id": "multiclinsum_test_1898_en.txt", + "fulltext": "A 60-year-old Caucasian man was transferred from a regional hospital to a tertiary referral centre for the emergency management of hypercalcaemic hyperparathyroid crisis. He initially presented with a two-week history of weakness and lethargy and a one-week history of vomiting, polyuria and polydipsia. He became acutely confused in the 24 hours prior to his admission to our hospital and registered 12 on the Glasgow Coma Scale. On examination he was normotensive with a regular pulse of 70 beats per minute. There was a left-sided mass in the anterior triangle of his neck measuring 3 × 3 cm. The mass was firm, regular, non-tender and mobile. See Figure and Table for results of the initial laboratory investigations.\nAn ultrasonography of his neck showed a 4 × 3 cm large cyst in the left lobe of his thyroid gland. His parathyroid glands were not visualised. A 99 mTc-sestamibi scintigraphy scan was performed, and no evidence of a parathyroid adenoma was found. An electrocardiogram revealed acute changes with ST depression in leads II, III, aVF and V2 to V6. An echocardiogram showed good left ventricular failure (LVF) with an ejection fraction of 63%.\nInitial management included aggressive fluid resuscitation, cardiac monitoring and the administration of intravenous bisphosphonates. A left thyroid lobectomy and left lower parathyroidectomy were performed. At the time of operation, a haemorrhagic cyst with a parathyroid gland within it was visualised. A biopsy was taken from the left upper parathyroid gland. Histology revealed a 4 cm parathyroid carcinoma within the cyst which was fully excised. The cyst had a macroscopic measurement of 6 × 6 × 5 cm. The wall of the cyst contained a well-circumscribed, unencapsulated soft tissue mass measuring 4 × 2.5 × 0.7 cm. It was light yellow-tan in colour and firm in consistency. There was a small amount of normal thyroid parenchyma within the specimen. The biopsy of the left upper parathyroid gland revealed normal parathyroid parenchyma without diagnostic abnormality.\nOur patient remained intubated and ventilated overnight in the intensive care unit. His metabolic laboratory profile resolved quickly following the surgery [Figure , Figure , Figure ]. A lower respiratory tract infection delayed his initial recovery. He was discharged home on oral calcium supplementation 24 days after surgery. He has been followed up for 6 months so far without any complications or disease recurrence.", + "fulltext_subclaims": [ + "The patient was a 60-year-old Caucasian man.", + "He was transferred to a tertiary referral centre for the emergency management of hypercalcaemic hyperparathyroid crisis.", + "He had a two-week history of weakness and lethargy.", + "He had a one-week history of vomiting, polyuria and polydipsia.", + "He became acutely confused in the 24 hours prior to his admission.", + "He registered 12 on the Glasgow Coma Scale.", + "On examination, he was normotensive.", + "There was a left-sided mass in the anterior triangle of his neck measuring 3 × 3 cm.", + "The mass was firm, regular, non-tender and mobile.", + "Ultrasonography of his neck showed a 4 × 3 cm large cyst in the left lobe of his thyroid gland.", + "His parathyroid glands were not visualised.", + "A 99 mTc-sestamibi scintigraphy scan was performed.", + "No evidence of a parathyroid adenoma was found.", + "An electrocardiogram revealed acute changes with ST depression in leads II, III, aVF and V2 to V6.", + "An echocardiogram showed good left ventricular function with an ejection fraction of 63%.", + "Initial management included aggressive fluid resuscitation.", + "Initial management included cardiac monitoring.", + "Initial management included the administration of intravenous bisphosphonates.", + "A left thyroid lobectomy and left lower parathyroidectomy were performed.", + "At the time of operation, a haemorrhagic cyst with a parathyroid gland within it was visualised.", + "A biopsy was taken from the left upper parathyroid gland.", + "Histology revealed a 4 cm parathyroid carcinoma within the cyst.", + "The cyst had a macroscopic measurement of 6 × 6 × 5 cm.", + "The wall of the cyst contained a well-circumscribed, unencapsulated soft tissue mass measuring 4 × 2.5 × 0.7 cm.", + "The mass was light yellow-tan in colour.", + "The mass was firm in consistency.", + "There was a small amount of normal thyroid parenchyma within the specimen.", + "The biopsy of the left upper parathyroid gland revealed normal parathyroid parenchyma.", + "The patient remained intubated and ventilated overnight in the intensive care unit.", + "His metabolic laboratory profile resolved quickly following the surgery.", + "A lower respiratory tract infection delayed his initial recovery.", + "He was discharged home on oral calcium supplementation.", + "He was discharged 24 days after surgery.", + "He has been followed up for 6 months so far.", + "There have been no complications.", + "There has been no disease recurrence." + ], + "summary": "We report the case of a 60-year-old Caucasian man with hypercalcaemic hyperparathyroid crisis associated with parathyroid carcinoma. He presented with a classic hypercalcaemic syndrome and his serum calcium and parathyroid hormone levels were at 4.65 mmol/L and 1743 ng/L, respectively. He initially presented with a two-week history of weakness and lethargy and a one-week history of vomiting, polyuria and polydipsia. An emergency left thyroid lobectomy and left lower parathyroidectomy were performed. There was a prompt decrease in his parathyroid hormone level immediately after surgery. Histology revealed that our patient had a 4-cm parathyroid carcinoma.", + "summary_subclaims": [ + "The patient was a 60-year-old Caucasian man.", + "The patient had a hypercalcaemic hyperparathyroid crisis associated with parathyroid carcinoma.", + "The patient's serum calcium level was 4.65 mmol/L.", + "The patient's parathyroid hormone level was 1743 ng/L.", + "The patient had a two-week history of weakness and lethargy.", + "The patient had a one-week history of vomiting, polyuria, and polydipsia.", + "An emergency left thyroid lobectomy and left lower parathyroidectomy were performed.", + "There was a prompt decrease in the patient's parathyroid hormone level immediately after surgery.", + "Histology revealed the patient had a 4-cm parathyroid carcinoma." + ] + }, + { + "id": "multiclinsum_test_730_en.txt", + "fulltext": "A 51-year-old man (height 174 cm, weight 78 kg) was diagnosed with a cardiac murmur in childhood. However, he did not have any further detailed cardiac examinations.\nHe had been suffering from chest pain since the age of 50. His chest pain was atypical with some non-specific characteristics. At this time, transthoracic echocardiography (TTE) was conducted, which showed a string-like abnormal structure in the LVOT. However, he did not follow up because he was asymptomatic. After a year, his chest pain recurred. TTE revealed the same structural abnormality again. Therefore, he underwent a detailed examination. Except for the cardiac murmur, he had no medical history and was not on any medications, and there was no family history of cardiac problems.\nA physical examination revealed a Levine type III to-and-fro heart murmur in the aortic area. His blood pressure was 123/79 mmHg, pulse rate was 64 beats per minute (bpm), and his lungs were clear on auscultation. A chest X-ray showed a normal cardiac silhouette and both lungs were clear and expanded, with no infiltrates or pleural effusions. An electrocardiogram (ECG) showed non-specific changes and a normal sinus rhythm.\nTransesophageal echocardiography (TEE) revealed an oval-like tissue with clean margins attached to the anterior leaflet of the mitral valve, causing an LVOT occlusion during systole . The maximum gradient pressure through the LVOT was measured at 26 mmHg with a mean gradient of 12 mmHg . The left ventricle wall motion was normal. The dimensions of the left ventricle during both systolic and diastolic phases were normal. No other cardiac anomalies were present. A diagnosis of AMVT was made based on the echocardiographic findings. Surgical treatment was recommended because of the presence of AMVT and the significant LVOT obstruction.\nSurgery was scheduled for resection of the AMVT. In the operating room, after placing an arterial catheter in the right radial artery to continually measure the patient’s blood pressure, we induced general anesthesia by intravenous administration of midazolam 10 mg, fentanyl 500 μg, and rocuronium 70 mg. A central venous catheter and pulmonary arterial catheter were inserted via the right internal jugular vein. Anesthesia was maintained with oxygen, sevoflurane, and propofol. Bolus intravenous fentanyl infusion was administered as needed. After starting extracorporeal cardiopulmonary bypass (CPB), the AMVT was resected via the aortic valves . After resecting the AMVT, we began removing the CPB. We ensured the LVOT was no longer obstructed, but severe mitral regurgitation (MR) was observed on TEE. Therefore, a mitral valvuloplasty was conducted under CPB. MR ceased after mitral valvuloplasty, and subsequently, we stopped using CPB with dobutamine at 4 μg/kg/min and commenced biventricular pacing (90 bpm). The mean arterial blood pressure was maintained at 60–70 mmHg, the central venous pressure (CVP) at 10–15 mmHg, and the pulmonary arterial pressure (PAP) at 20–30 mmHg.\nThe total surgical duration was 313 mins, CPB duration was 108 mins, and the anesthesia duration was 414 mins.\nThe patient received a total of 3500 mL of lactated Ringer’s solution, 300 mL of intraoperative blood salvage, and 2 units of fresh frozen plasma during the procedure. His estimated blood loss was 1320 mL. The patient was hemodynamically stable throughout the surgery, with no abnormal findings on the ECG . After the surgery, the patient was transported to the intensive care unit (ICU) without awakening or extubating.\nThe patient was extubated 6 h after being transported to the ICU. His hemodynamic state was stable with dobutamine at 0.6–1.3 μg/kg/min. There was no abnormity of the mitral valves including mitral regurgitation, and the maximum gradient pressure through the LVOT was measured at 4 mmHg with a mean gradient of 1 mmHg . Dobutamine was stopped on the second postoperative day. He responded well to treatment and was discharged 18 days after surgery.", + "fulltext_subclaims": [ + "The patient is a 51-year-old man.", + "The patient's height is 174 cm.", + "The patient's weight is 78 kg.", + "The patient was diagnosed with a cardiac murmur in childhood.", + "The patient did not have any further detailed cardiac examinations.", + "The patient had been suffering from chest pain since the age of 50.", + "The chest pain was atypical with some non-specific characteristics.", + "Transthoracic echocardiography (TTE) was conducted.", + "TTE showed a string-like abnormal structure in the LVOT.", + "The patient did not follow up because he was asymptomatic.", + "After a year, his chest pain recurred.", + "TTE revealed the same structural abnormality again.", + "A physical examination revealed a Levine type III to-and-fro heart murmur in the aortic area.", + "A chest X-ray showed a normal cardiac silhouette.", + "Transesophageal echocardiography (TEE) revealed an oval-like tissue with clean margins attached to the anterior leaflet of the mitral valve.", + "The oval-like tissue caused an LVOT occlusion during systole.", + "The maximum gradient pressure through the LVOT was measured at 26 mmHg.", + "The mean gradient was 12 mmHg.", + "The left ventricle wall motion was normal.", + "The dimensions of the left ventricle during both systolic and diastolic phases were normal.", + "No other cardiac anomalies were present.", + "A diagnosis of AMVT was made based on the echocardiographic findings.", + "Surgical treatment was recommended because of the presence of AMVT and the significant LVOT obstruction.", + "Surgery was scheduled for resection of the AMVT.", + "An arterial catheter was placed in the right radial artery.", + "General anesthesia was induced by intravenous administration of midazolam 10 mg, fentanyl 500 μg, and rocuronium 70 mg.", + "A central venous catheter and pulmonary arterial catheter were inserted via the right internal jugular vein.", + "Anesthesia was maintained with oxygen, sevoflurane, and propofol.", + "Bolus intravenous fentanyl infusion was administered as needed.", + "Extracorporeal cardiopulmonary bypass (CPB) was started.", + "The AMVT was resected via the aortic valves.", + "Severe mitral regurgitation (MR) was observed on TEE after resecting the AMVT.", + "A mitral valvuloplasty was conducted under CPB.", + "MR ceased after mitral valvuloplasty.", + "CPB was stopped with dobutamine at 4 μg/kg/min.", + "Biventricular pacing was commenced at 90 bpm.", + "The mean arterial blood pressure was maintained at 60–70 mmHg.", + "The central venous pressure (CVP) was maintained at 10–15 mmHg.", + "The pulmonary arterial pressure (PAP) was maintained at 20–30 mmHg.", + "The total surgical duration was 313 mins.", + "The CPB duration was 108 mins.", + "The anesthesia duration was 414 mins.", + "The patient received a total of 3500 mL of lactated Ringer’s solution.", + "The patient received 300 mL of intraoperative blood salvage.", + "The patient received 2 units of fresh frozen plasma.", + "The patient's estimated blood loss was 1320 mL.", + "The patient was hemodynamically stable throughout the surgery.", + "There were no abnormal findings on the ECG.", + "The patient was transported to the ICU without awakening or extubating.", + "The patient was extubated 6 h after being transported to the ICU.", + "The patient's hemodynamic state was stable with dobutamine at 0.6–1.3 μg/kg/min.", + "There was no abnormity of the mitral valves including mitral regurgitation.", + "The maximum gradient pressure through the LVOT was measured at 4 mmHg.", + "The mean gradient was 1 mmHg.", + "Dobutamine was stopped on the second postoperative day.", + "The patient responded well to treatment.", + "The patient was discharged 18 days after surgery." + ], + "summary": "A 51-year-old man was diagnosed with AMVT via transesophageal echocardiography, which resulted in an LVOT occlusion (mean gradient 12 mmHg) during systole. Resection of the AMVT was performed under general anesthesia. The patient was hemodynamically stable throughout the surgery and post-operation. There was no abnormity of the mitral valves, including mitral regurgitation.", + "summary_subclaims": [ + "The patient was a 51-year-old man.", + "The patient was diagnosed with AMVT via transesophageal echocardiography.", + "The AMVT resulted in an LVOT occlusion during systole.", + "The mean gradient was 12 mmHg.", + "Resection of the AMVT was performed under general anesthesia.", + "The patient was hemodynamically stable throughout the surgery.", + "The patient was hemodynamically stable post-operation.", + "There was no abnormity of the mitral valves.", + "There was no mitral regurgitation." + ] + }, + { + "id": "multiclinsum_test_557_en.txt", + "fulltext": "A 36 year old man presented to the emergency department with a 24 hour history of central abdominal pain, two episodes of vomiting and loose stool. He had a past history of Type II Diabetes Mellitus, hypertension, asthma and obstructive sleep apnoea. He weighed 130 kg with a Body Mass Index greater than 40.\nHis current medications were diltiazem, lisinopril, metformin, glicazide and orlistat. The orlistat had been commenced four days previously.\nHe was pyrexial and on examination was tender in the epigastrium. His initial white cell count was 20 × 109/L and a C reactive protein of more than 300 mg/l, an amylase of 136 iu/l, and a lactate dehydrogenase of 892 iu/l. a recent lipid profile was normal and his corrected calcium was 2.41 iu/l. The initial diagnosis was unclear and a CT scan of his abdomen was organised. This showed appearances of acute pancreatitis affecting the distal body and tail of the pancreas [figure ]. He was classified as having acute severe pancreatitis using the modified Glasgow Score 1984. Management was the standard of pancreatitis, mainly supportive. Antibiotics were not given. Common causes of pancreatitis were excluded. He was abstinent of alcohol, had a normal serum calcium, had no family history of pancreatitis or hyperlipidaemia, and had no history of trauma. His abdominal CT scan showed no evidence of gallstones. By exclusion the diagnosis of drug induced pancreatitis secondary to orlistat was made.\nHe was transferred to the intensive care and made good progress. The Medicines Control agency and Committee on Safety of Medicines were informed.", + "fulltext_subclaims": [ + "The patient is a 36 year old man.", + "He presented to the emergency department with a 24 hour history of central abdominal pain.", + "He had two episodes of vomiting.", + "He had loose stool.", + "He had a past history of Type II Diabetes Mellitus.", + "He had a past history of hypertension.", + "He had a past history of asthma.", + "He had a past history of obstructive sleep apnoea.", + "He weighed 130 kg.", + "His Body Mass Index was greater than 40.", + "His current medications were diltiazem, lisinopril, metformin, glicazide and orlistat.", + "The orlistat had been commenced four days previously.", + "He was pyrexial.", + "He was tender in the epigastrium.", + "His initial white cell count was 20 × 109/L.", + "His C reactive protein was more than 300 mg/l.", + "His amylase was 136 iu/l.", + "His lactate dehydrogenase was 892 iu/l.", + "His corrected calcium was 2.41 iu/l.", + "A CT scan of his abdomen was organised.", + "The CT scan showed appearances of acute pancreatitis affecting the distal body and tail of the pancreas.", + "He was classified as having acute severe pancreatitis using the modified Glasgow Score 1984.", + "Management was the standard of pancreatitis, mainly supportive.", + "Antibiotics were not given.", + "Common causes of pancreatitis were excluded.", + "He was abstinent of alcohol.", + "He had a normal serum calcium.", + "He had no family history of pancreatitis.", + "He had no family history of hyperlipidaemia.", + "He had no history of trauma.", + "His abdominal CT scan showed no evidence of gallstones.", + "By exclusion the diagnosis of drug induced pancreatitis secondary to orlistat was made.", + "He was transferred to the intensive care.", + "The Medicines Control agency and Committee on Safety of Medicines were informed." + ], + "summary": "A 36 year old man presented to hospital with acute severe pancreatitis four days after starting a course of Orlistat, a lipase inhibitor used in the treatment of obesity. A diagnosis of drug related pancreatitis was made by exclusion of other causes of pancreatitis; he was a teetotaller, had a normal serum calcium, had no family history of pancreatitis or hyperlipidaemia, no history of trauma and had no evidence of gallstones on Computerised Tomography scan (CT).", + "summary_subclaims": [ + "The patient is a 36 year old man.", + "He presented to hospital with acute severe pancreatitis.", + "The pancreatitis occurred four days after starting a course of Orlistat.", + "Orlistat is a lipase inhibitor used in the treatment of obesity.", + "A diagnosis of drug related pancreatitis was made.", + "The diagnosis was made by exclusion of other causes of pancreatitis.", + "He was a teetotaller.", + "He had a normal serum calcium.", + "He had no family history of pancreatitis.", + "He had no family history of hyperlipidaemia.", + "He had no history of trauma.", + "He had no evidence of gallstones on Computerised Tomography scan." + ] + }, + { + "id": "multiclinsum_test_3163_en.txt", + "fulltext": "We present a 40-year-old Gravida13 Para10 Abortion2 mother who presented with headache, epigastric pain, bilateral leg swelling, epistaxis, and decreased fetal movement for a two-day duration. Her previous pregnancies were uneventful with no prior history of hypertensive diseases in pregnancy or hyperthyroidism reported. Although she had eight home deliveries, there were no twin pregnancies or molar pregnancies. In addition, she had no family history of bleeding diathesis. On the current pregnancy, she had no bleeding, raised blood pressure or any danger signs on the antenatal follow-up she had at 9 weeks. She was referred from a local health center, where the diagnosis of co-existing molar pregnancy was overlooked, with the impression of twin pregnancy and pre-eclampsia.\n\nOn admission, her blood pressure was 186/100, her pulse rate was 136 and her respiratory rate was 20. On abdominal examination, she had 36 weeks sized gravid uterus with fetal heartbeat of 136 and grade 2 bilateral pitting edema. On the admission blood tests, hematocrit was 32.8% with O+ blood type. Serum β-HCG was found to be 215,400 IU/L, thyroid stimulating hormone was 0.05 IU/mL, urinalysis showed +1 proteinuria, other investigations (Renal function test, Liver function test, Complete blood count, and Chest X-ray) were all normal. With the impression of twin pregnancy complicated by pre-eclampsia with severity features and hyperthyroidism, the patient was managed for pre-eclampsia and a biophysical profile was done daily. Ultrasonography revealed two fetal sacs whereby twin A was a breech, alive twin with aggregate gestational age (AGA) of 28+6 weeks with the normal-appearing placenta. The other sac was filled with cystic spaces and snowstorm appearance, hinting towards a molar pregnancy.\n\nWe managed our patient expectantly for a week with daily biophysical profile, dexamethasone injections for fetal lung maturity, magnesium sulphate and anti-hypertensive for pre-eclampsia. After one week, a cesarean section was done for indication of twin pregnancy plus Twin A breech to affect the delivery of a 1.4 kg male neonate with Apgar score of 7 and 9 in the 1st and 5th minute, respectively. The grape-like vesicles, separate from the normal appearing placenta, were evacuated manually. There was intraoperative bleeding while removing the molar tissue. Initial evaluation of the neonate revealed no congenital abnormalities and he was admitted to the neonatal intensive care unit with a diagnosis of very low birth weight and discharged after attaining adequate weight. Although, the histopathology result showed a partial mole with variable-sized dilated chorionic villi with focal trophoblastic proliferation and multiple vascular proliferation seen, there were no malignant features. Post-operative hematocrit was 18.8% for which the patient was transfused with one unit of whole blood. The patient was discharged from our side on the 16th day after advice on subsequent follow-up. The level of β-HCG was determined to be normal on the 2nd follow-up at 7 weeks as illustrated in. On this visit, the mother had no new compliant with normal blood pressure and TSH levels. In addition, the infant’s interpretation of growth curves adjusted for gestational age showed adequate growth.", + "fulltext_subclaims": [ + "The patient is a 40-year-old Gravida13 Para10 Abortion2 mother.", + "She presented with headache, epigastric pain, bilateral leg swelling, epistaxis, and decreased fetal movement for two days.", + "Her previous pregnancies were uneventful with no prior history of hypertensive diseases in pregnancy.", + "She had no prior history of hyperthyroidism.", + "She had eight home deliveries.", + "There were no twin pregnancies or molar pregnancies in her previous pregnancies.", + "She had no family history of bleeding diathesis.", + "On the current pregnancy, she had no bleeding, raised blood pressure, or any danger signs on the antenatal follow-up at 9 weeks.", + "She was referred from a local health center.", + "The diagnosis of co-existing molar pregnancy was overlooked at the local health center.", + "The local health center had the impression of twin pregnancy and pre-eclampsia.", + "On admission, her blood pressure was 186/100.", + "Her pulse rate was 136.", + "Her respiratory rate was 20.", + "On abdominal examination, she had a 36 weeks sized gravid uterus.", + "The fetal heartbeat was 136.", + "There was grade 2 bilateral pitting edema.", + "Hematocrit was 32.8% with O+ blood type.", + "Serum β-HCG was 215,400 IU/L.", + "Thyroid stimulating hormone was 0.05 IU/mL.", + "Urinalysis showed +1 proteinuria.", + "Other investigations (Renal function test, Liver function test, Complete blood count, and Chest X-ray) were all normal.", + "The impression was twin pregnancy complicated by pre-eclampsia with severity features and hyperthyroidism.", + "The patient was managed for pre-eclampsia.", + "A biophysical profile was done daily.", + "Ultrasonography revealed two fetal sacs.", + "Twin A was a breech, alive twin with aggregate gestational age of 28+6 weeks.", + "The other sac had a snowstorm appearance, hinting towards a molar pregnancy.", + "The patient was managed expectantly for a week.", + "Daily biophysical profile was performed.", + "Dexamethasone injections were given for fetal lung maturity.", + "Magnesium sulphate and anti-hypertensive were used for pre-eclampsia.", + "A cesarean section was done after one week.", + "The indication for cesarean section was twin pregnancy plus Twin A breech.", + "A 1.4 kg male neonate was delivered.", + "The Apgar score was 7 in the 1st minute.", + "The Apgar score was 9 in the 5th minute.", + "Grape-like vesicles were evacuated manually.", + "The histopathology result showed a partial mole.", + "The histopathology showed variable-sized dilated chorionic villi.", + "Focal trophoblastic proliferation was seen.", + "Multiple vascular proliferation was seen.", + "There were no malignant features.", + "Post-operative hematocrit was 18.8%.", + "The patient was transfused with one unit of whole blood.", + "The patient was discharged on the 16th day.", + "The level of β-HCG was normal on the 2nd follow-up at 7 weeks.", + "The mother had no new complaints on the 2nd follow-up.", + "Blood pressure was normal on the 2nd follow-up.", + "TSH levels were normal on the 2nd follow-up.", + "The infant’s growth curves adjusted for gestational age showed adequate growth." + ], + "summary": "We report the case of a 40-year-old G13P10A2 mother who was referred to our hospital at 28 weeks as a case of twin pregnancy and pre-eclampsia. She had headache, epigastric pain, bilateral leg swelling, and decreased fetal movement for two days. Her physical examination was remarkable for raised blood pressure and uterus larger than gestational age. Ultrasound findings showed honeycomb-like echo suggestive of a molar pregnancy with a co-existing normal fetus. After she was admitted and managed for severe pre-eclampsia, a cesarean section was done to affect the delivery of a male neonate weighing 1400 grams. Histopathology confirmed the diagnosis of a partial mole with no malignant features. In follow-up, the serum β-HCG level normalized by the 7th week.", + "summary_subclaims": [ + "The patient was a 40-year-old G13P10A2 mother.", + "She was referred to the hospital at 28 weeks as a case of twin pregnancy and pre-eclampsia.", + "She had headache, epigastric pain, bilateral leg swelling, and decreased fetal movement for two days.", + "Her physical examination was remarkable for raised blood pressure and uterus larger than gestational age.", + "Ultrasound findings showed honeycomb-like echo suggestive of a molar pregnancy with a co-existing normal fetus.", + "A cesarean section was done to affect the delivery of a male neonate weighing 1400 grams.", + "Histopathology confirmed the diagnosis of a partial mole with no malignant features.", + "The serum β-HCG level normalized by the 7th week." + ] + }, + { + "id": "multiclinsum_test_658_en.txt", + "fulltext": "Timeline: The timeline of diagnosis and treatment after admission is shown in Table .\nAn 81-year-old Japanese woman had been diagnosed with a branch-duct disease IPMN lesion in the pancreas by abdominal computed tomography (CT) in 2015. In March 2017, an abdominal CT examination had showed no significant change in IPMN, but in November 2017, blood examinations found elevated CA19-9 (87 U/mL).\nIn March 2018, the patient was transferred to our hospital for further examination. CT and magnetic resonance imaging (MRI) found the known branch-duct disease IPMN lesion (12 mm) and confirmed localized pancreatitis in the tail of the pancreas and mild pancreatic duct dilatation (2.2 mm). In April 2018, endoscopic ultrasound (EUS) (UE260 Ultrasonic gastrovideoscope; Olympus, Tokyo, Japan) revealed a hypoechoic tumor (approximately 7 mm) and local atrophy in the tail of the pancreas. There were no changes in the lesions or other suspicious lesions on CT and MRI scans performed in May 2018.\nAfter admission, the patient’s temperature was 36.4 °C, heart rate was 72 beats per minute, respiratory rate was 16 breaths per minute, blood pressure was 112/60 mmHg, and oxygen saturation in room air was 98%. The physical examination did not reveal any abnormal findings.\nThe patient was admitted to our hospital for EUS-guided fine needle aspiration (EUS-FNA) for the pancreatic tail tumor. Gastroscopy revealed a suspicious 10 mm lesion in the greater curvature of the gastric antrum, which was confirmed as early gastric cancer (Tub1, 10 mm, M, UL-) by magnifying endoscopy with narrow band imaging and EUS, and as group V adenocarcinoma by pathological biopsy [negative for Helicobacter pylori (HP) antibody]. Thus, it met the indications of endoscopic submucosal dissection (ESD). Colonoscopy revealed no positive findings. Although pancreatic EUS confirmed a 7 mm pancreatic tail tumor, FNA could not be performed despite contrast-enhanced EUS because of its small size and poor reproducibility. Endoscopic retrograde cholangiopancreatography was performed, and the pancreatic juice was collected four times for cytological examination.\nThe patient was diagnosed with class III cellular atypia. CA19-9 levels continued to increase. Based on the American College of Gastroenterology clinical guidelines, we suggested surgical treatment, and her family supported the decision. The patient refused pancreatic surgery but agreed to gastric ESD. In February 2019, we attempted EUS-FNA again, as the lesion had enlarged (15 mm). We were able to successfully obtain a pathological diagnosis following puncture, from which the subsequent ex vivo examinations indicated adenocarcinoma class V.\nBlood test data on admission are shown in Table . The CA19-9 levels before and after treatment are shown in Figure .\nThe imaging comparison, pathology, and immunostaining of pancreatic cancer and IPMN are shown in Figure . The endoscopic images, pathological examination, and immunostaining of early gastric cancer are shown in Figure .", + "fulltext_subclaims": [ + "The patient was an 81-year-old Japanese woman.", + "In 2015, the patient had been diagnosed with a branch-duct disease IPMN lesion in the pancreas by abdominal computed tomography.", + "In March 2017, an abdominal CT examination showed no significant change in IPMN.", + "In November 2017, blood examinations found elevated CA19-9 (87 U/mL).", + "In March 2018, the patient was transferred to our hospital for further examination.", + "CT and magnetic resonance imaging found the known branch-duct disease IPMN lesion (12 mm).", + "CT and MRI confirmed localized pancreatitis in the tail of the pancreas.", + "CT and MRI confirmed mild pancreatic duct dilatation (2.2 mm).", + "In April 2018, endoscopic ultrasound revealed a hypoechoic tumor (approximately 7 mm) in the tail of the pancreas.", + "In April 2018, endoscopic ultrasound revealed local atrophy in the tail of the pancreas.", + "There were no changes in the lesions on CT and MRI scans performed in May 2018.", + "There were no other suspicious lesions on CT and MRI scans performed in May 2018.", + "The patient’s temperature was 36.4 °C after admission.", + "The patient’s heart rate was 72 beats per minute after admission.", + "The patient’s respiratory rate was 16 breaths per minute after admission.", + "The patient’s blood pressure was 112/60 mmHg after admission.", + "The patient’s oxygen saturation in room air was 98% after admission.", + "The physical examination did not reveal any abnormal findings.", + "The patient was admitted for EUS-guided fine needle aspiration for the pancreatic tail tumor.", + "Gastroscopy revealed a suspicious 10 mm lesion in the greater curvature of the gastric antrum.", + "The gastric lesion was confirmed as early gastric cancer (Tub1, 10 mm, M, UL-).", + "The gastric lesion was confirmed as group V adenocarcinoma by pathological biopsy.", + "The gastric lesion was negative for Helicobacter pylori antibody.", + "The gastric lesion met the indications of endoscopic submucosal dissection.", + "Colonoscopy revealed no positive findings.", + "Pancreatic EUS confirmed a 7 mm pancreatic tail tumor.", + "FNA could not be performed despite contrast-enhanced EUS because of its small size and poor reproducibility.", + "Endoscopic retrograde cholangiopancreatography was performed, and the pancreatic juice was collected four times for cytological examination.", + "The patient was diagnosed with class III cellular atypia.", + "CA19-9 levels continued to increase.", + "Based on the American College of Gastroenterology clinical guidelines, surgical treatment was suggested.", + "The patient refused pancreatic surgery.", + "The patient agreed to gastric ESD.", + "In February 2019, EUS-FNA was attempted again.", + "In February 2019, the lesion had enlarged to 15 mm.", + "A pathological diagnosis was successfully obtained following puncture.", + "Ex vivo examinations indicated adenocarcinoma class V." + ], + "summary": "An 81-year-old Japanese female diagnosed with IPMN developed elevated carbohydrate antigen (CA) 19-9 levels during follow-up. Because her CA19-9 levels continued to rise, endoscopic ultrasound (EUS) was performed and revealed a suspicious lesion at the pancreatic tail. However, lesions in the pancreas were not found by computed tomography, magnetic resonance imaging, or endoscopic retrograde cholangiopancreatography. To make an exact patho-logical diagnosis, EUS-guided fine needle aspiration was performed. To our supprise, early gastric cancer was found in preoperative gastroscopy. The gastric cancer was completely resected through endoscopic submucosal dissection before postoperative pathology identified early adenocarcinoma collided with DLBCL. Subsequent EUS-guided fine needle aspiration provided pathological support for the pancreatic cancer diagnosis, and then laparoscopic distal pancreatectomy and splenectomy were performed. CA19-9 levels returned to normal postoperatively.", + "summary_subclaims": [ + "An 81-year-old Japanese female diagnosed with IPMN developed elevated carbohydrate antigen (CA) 19-9 levels during follow-up.", + "Her CA19-9 levels continued to rise.", + "Endoscopic ultrasound (EUS) was performed and revealed a suspicious lesion at the pancreatic tail.", + "Lesions in the pancreas were not found by computed tomography.", + "Lesions in the pancreas were not found by magnetic resonance imaging.", + "Lesions in the pancreas were not found by endoscopic retrograde cholangiopancreatography.", + "EUS-guided fine needle aspiration was performed to make an exact pathological diagnosis.", + "Early gastric cancer was found in preoperative gastroscopy.", + "The gastric cancer was completely resected through endoscopic submucosal dissection.", + "Postoperative pathology identified early adenocarcinoma collided with DLBCL.", + "Subsequent EUS-guided fine needle aspiration provided pathological support for the pancreatic cancer diagnosis.", + "Laparoscopic distal pancreatectomy and splenectomy were performed.", + "CA19-9 levels returned to normal postoperatively." + ] + }, + { + "id": "multiclinsum_test_1813_en.txt", + "fulltext": "A 29-year-old Han woman presented with a chief complaint of a tumor under her right clavicle for 5 months, and right shoulder soreness and numbness of the exterior of her right upper arm for 10 days. At physical examination there was a red and warm mass over her right shoulder with mild pain and tenderness. The mass was tough, hardly moveable, and base-fixed. The strength of her right upper limb muscles was 4+. A chest X-ray showed a mass with a high density shadow at the superior posterior right clavicle . A right shoulder computed tomography scan showed a mixed density shadow in the serratus anterior, which correlated with clinical findings . A neck magnetic resonance imaging scan showed abnormal findings in the serratus anterior at the right-side of her chest wall, which also correlated clinically . An electromyogram showed a few positive sharp waves in muscles innervated by the brachial plexus upper trunk. Motor unit potential mixing interference patterns, compound muscle action potential, motor nerve conduction velocity, and sensory nerve conduction velocity were within the normal range. Her right brachial plexus upper trunk was slightly damaged. Based on the above examinations, the patient’s condition was diagnosed as a tumor beneath the right clavicle. She underwent surgery as a treatment. During the operation, the tumor boundary was found to be on the posterolateral side of the middle scalene; anteroinferior of the trapezius, levator scapulae, and postscalene; and behind the brachial plexus cervical nerves 5 and 6 (C5–6). The tumor invaded the serratus anterior. Anteromedial tumor adhered to the C5–6 nerve branches, posterolaterally adhered to the suprascapular nerve, and adhered to the rear edge of the brachial plexus sheath and omohyoid in the front. Under a microscope, the neurovascular and protective brachial plexus sheath, and the C5–6 nerve branches and the suprascapular nerve were carefully separated; tumor subordinates back below the upper edge of the scapula notch were detected; and the tumor of 7×4×3cm size was completely resected . Intraoperative suprascapular nerve stimulation and muscle contractions were normal; the brachial plexus upper trunk was able to be stimulated; contraction of deltoid, biceps, and flexor carpi were normal; and stimulation of the dorsal scapular nerve, scapular muscles, and rhomboid muscle revealed normal contraction. No intraoperative frozen section was obtained. A postoperative histopathological examination showed that lesions were consistent with myositis ossificans . The soreness of her right shoulder and right arm numbness disappeared completely postoperatively. After 1 year, she did not have any abnormalities.", + "fulltext_subclaims": [ + "The patient is a 29-year-old Han woman.", + "The patient had a tumor under her right clavicle for 5 months.", + "The patient had right shoulder soreness and numbness of the exterior of her right upper arm for 10 days.", + "At physical examination, there was a red and warm mass over her right shoulder.", + "The mass was tough, hardly moveable, and base-fixed.", + "The strength of her right upper limb muscles was 4+.", + "A chest X-ray showed a mass with a high density shadow at the superior posterior right clavicle.", + "A right shoulder computed tomography scan showed a mixed density shadow in the serratus anterior.", + "A neck magnetic resonance imaging scan showed abnormal findings in the serratus anterior at the right-side of her chest wall.", + "An electromyogram showed a few positive sharp waves in muscles innervated by the brachial plexus upper trunk.", + "Motor unit potential mixing interference patterns were within the normal range.", + "Compound muscle action potential was within the normal range.", + "Motor nerve conduction velocity was within the normal range.", + "Sensory nerve conduction velocity was within the normal range.", + "The patient’s right brachial plexus upper trunk was slightly damaged.", + "The patient’s condition was diagnosed as a tumor beneath the right clavicle.", + "The patient underwent surgery as a treatment.", + "During the operation, the tumor boundary was found to be on the posterolateral side of the middle scalene.", + "The tumor was anteroinferior of the trapezius, levator scapulae, and postscalene.", + "The tumor was behind the brachial plexus cervical nerves 5 and 6.", + "The tumor invaded the serratus anterior.", + "Anteromedial tumor adhered to the C5–6 nerve branches.", + "Posterolaterally, the tumor adhered to the suprascapular nerve.", + "The tumor adhered to the rear edge of the brachial plexus sheath and omohyoid in the front.", + "Under a microscope, the neurovascular and protective brachial plexus sheath, and the C5–6 nerve branches and the suprascapular nerve were carefully separated.", + "Tumor subordinates back below the upper edge of the scapula notch were detected.", + "The tumor of 7×4×3cm size was completely resected.", + "Intraoperative suprascapular nerve stimulation and muscle contractions were normal.", + "The brachial plexus upper trunk was able to be stimulated.", + "Contraction of deltoid, biceps, and flexor carpi were normal.", + "Stimulation of the dorsal scapular nerve, scapular muscles, and rhomboid muscle revealed normal contraction.", + "No intraoperative frozen section was obtained.", + "Postoperative histopathological examination showed that lesions were consistent with myositis ossificans.", + "The soreness of her right shoulder and right arm numbness disappeared completely postoperatively.", + "After 1 year, she did not have any abnormalities." + ], + "summary": "In this report we present a case of myositis ossificans within the serratus anterior which developed as a complication due to long-term nape massage. The patient was a 29-year-old Han woman. Because heterotopic ossificans constricted her brachial plexus the surface of her right upper arm was slightly numb; the symptom disappeared after surgery.", + "summary_subclaims": [ + "The case involves myositis ossificans within the serratus anterior.", + "The myositis ossificans developed as a complication due to long-term nape massage.", + "The patient was a 29-year-old Han woman.", + "Heterotopic ossificans constricted her brachial plexus.", + "The surface of her right upper arm was slightly numb.", + "The numbness symptom disappeared after surgery." + ] + }, + { + "id": "multiclinsum_test_1214_en.txt", + "fulltext": "An 8-year-old girl fell from a height of around 1.5 m and injured her left elbow. She was examined by a physician in her village and diagnosed as having an elbow sprain for which limb was immobilized in a plaster cast for 3 weeks. The child sustained another injury to the same elbow following fall on her outstretched hand 4 weeks after removal of the cast. Again the elbow was immobilized in a long arm cast for 3 weeks. After removal of the cast, the child complained of persistent pain and discomfort in the elbow. She was then referred to our hospital 3 months after the initial injury.\nExamination revealed a stiff elbow with a painless range of motion from 45° to 90°, with only terminal limitation of pronation and supination. The ununited fragment was palpable separately from the rest of the distal humerus and freely mobile. Valgus instability was also noted. There were no signs of ulnar nerve irritability or deficit. An anteroposterior and lateral radiographs revealed a displaced fragment of the medial condyle involving the trochlea .\nTo address the limitation of movement, articular incongruity and elbow instability, open reduction, and fixation of the fracture was planned. After obtaining consent from the parents, the patient was administered general anesthesia and positioned supine on the operating table with arm abducted on arm board. Limb was exsanguinated and surgery was commenced under tourniquet. Incision was made directly over the medial condyle fragment. The ulnar nerve was identified and protected with plastic tube. The medial condyle fragment was found displaced proximally and anteriorly. The fragment was rotated with its cancellous surface lying anteriorly. This surface was freshened with a curette. Fracture surface on the humeral side was identified and freshened. Medial articular edge of distal humerus was identified for accurate reduction. Without any undue soft tissue stripping, the fractured fragment was reduced to the best possible position with approximation of articular surfaces. Fixation with three smooth Kirschner (K) wires was done followed by suturing of surgical wound. Long arm cast was applied with elbow at 90° and forearm in mid-prone position. There were no post-operative complications.\nConsidering that the fracture was already 3 months old at the time of surgery, we anticipated that a longer duration of immobilization would be required; hence, the cast and K-wires were removed at 6 weeks under local anesthesia. Active and active-assisted elbow range of motion exercises were started after K-wire removal. Radiographs taken at 3-month follow-up show union of the fracture, with an irregular medial condyle. The patient regained an active flexion arc of 25° to 95°, with complete pronation and supination . Passively 20° to 100° arc of motion had been restored. At 6-month follow-up range from 10° to 120° had been restored and there was no coronal plane deformity.", + "fulltext_subclaims": [ + "The patient is an 8-year-old girl.", + "She fell from a height of around 1.5 m.", + "She injured her left elbow.", + "She was examined by a physician in her village.", + "She was diagnosed as having an elbow sprain.", + "The limb was immobilized in a plaster cast for 3 weeks.", + "She sustained another injury to the same elbow.", + "The injury occurred 4 weeks after removal of the cast.", + "The elbow was immobilized in a long arm cast for 3 weeks.", + "After removal of the cast, the child complained of persistent pain and discomfort in the elbow.", + "She was referred to our hospital 3 months after the initial injury.", + "Examination revealed a stiff elbow.", + "The range of motion was painless from 45° to 90°.", + "There was a terminal limitation of pronation and supination.", + "The ununited fragment was palpable separately from the rest of the distal humerus.", + "The fragment was freely mobile.", + "Valgus instability was noted.", + "There were no signs of ulnar nerve irritability or deficit.", + "Anteroposterior and lateral radiographs revealed a displaced fragment of the medial condyle.", + "The fragment involved the trochlea.", + "Open reduction and fixation of the fracture was planned.", + "Consent was obtained from the parents.", + "The patient was administered general anesthesia.", + "The patient was positioned supine on the operating table.", + "The arm was abducted on an arm board.", + "The limb was exsanguinated.", + "Surgery was commenced under tourniquet.", + "An incision was made directly over the medial condyle fragment.", + "The ulnar nerve was identified.", + "The ulnar nerve was protected with a plastic tube.", + "The medial condyle fragment was found displaced proximally and anteriorly.", + "The fragment was rotated with its cancellous surface lying anteriorly.", + "The surface was freshened with a curette.", + "The fracture surface on the humeral side was identified and freshened.", + "The medial articular edge of the distal humerus was identified.", + "The fractured fragment was reduced to the best possible position.", + "Articular surfaces were approximated.", + "Fixation with three smooth Kirschner wires was done.", + "The surgical wound was sutured.", + "A long arm cast was applied with the elbow at 90°.", + "The forearm was placed in mid-prone position.", + "There were no post-operative complications.", + "The fracture was 3 months old at the time of surgery.", + "A longer duration of immobilization was anticipated.", + "The cast and K-wires were removed at 6 weeks.", + "K-wire removal was done under local anesthesia.", + "Active and active-assisted elbow range of motion exercises were started after K-wire removal.", + "Radiographs at 3-month follow-up showed union of the fracture.", + "The medial condyle was irregular.", + "The patient regained an active flexion arc of 25° to 95°.", + "The patient had complete pronation and supination.", + "Passively, a 20° to 100° arc of motion had been restored.", + "At 6-month follow-up, a range from 10° to 120° had been restored.", + "There was no coronal plane deformity." + ], + "summary": "Here, we present a case of 3-month-old ununited fracture of the medial condyle in an 8-year-old child, treated by osteosynthesis that produced good result. The patient presented to us with valgus instability of elbow and restricted range of motion. Open reduction, freshening of margins, and fixation of the ununited fragment with K-wires were done. Postoperatively, the patient regained functional range of motion and had a stable elbow.", + "summary_subclaims": [ + "This is a case of 3-month-old ununited fracture of the medial condyle in an 8-year-old child.", + "The patient was treated by osteosynthesis.", + "The treatment produced good result.", + "The patient presented with valgus instability of elbow.", + "The patient had restricted range of motion.", + "Open reduction was performed.", + "Freshening of margins was performed.", + "Fixation of the ununited fragment with K-wires was performed.", + "Postoperatively, the patient regained functional range of motion.", + "Postoperatively, the patient had a stable elbow." + ] + }, + { + "id": "multiclinsum_test_1495_en.txt", + "fulltext": "A 67-year-old male patient presented with dyspnoea and reduced cardiopulmonary exercise capacity. In his past medical history there was an admission for recurrent exercise-induced palpitations in 1980. At that time, he participated in high-frequency/high-duration/intermediate intensity endurance training (Class B, ∼4200 MET minutes/week). Subsequent cardiologic workup was not able to define underlying structural or rhythmical disease. A recommendation against exercise was not given, but coincidentally the patient ceased from his regular workouts in the early 1980s, when starting an ambitious career. His activity was confined to moderate-intensity training. In 2012, he restarted regular activity (Class B, ∼1800 MET minutes/week) and increased his workout volume in February 2020 when he retired. In July 2020, symptoms worsened significantly.\nThe patient presented with regular heart rate (HR), blood pressure (BP), and body mass index. Physical examination was noticeable for a 3/6-systolic murmur with punctum maximum at fourth intercostal space right parasternal. Key laboratory findings are presented in . His electrocardiogram (ECG) showed sinus rhythm with epsilon waves in V1–4 and T-wave inversions in leads II, III, aVF, and V1–6 . Transthoracic echocardiography (TTE) showed enlarged and dyskinetic RV with aneurysmatic extension on RV free wall (RV end-diastolic diameter basal: 65 mm, tricuspid annular plane systolic excursion: 21 mm, RV outflow tract in parasternal long-axis view: 53 mm, RV outflow tract in parasternal short-axis view: 61 mm), as well as high-grade tricuspid regurgitation (TR) (grade III/III, effective regurgitant orifice area: 53 mm2, coaptation defect: 8–9 mm) and low-grade pulmonary regurgitation (grade I/III). Left ventricular (LV) size and function were preserved [LV ejection fraction (EF): 55%] and there were no relevant vitia of aortic and mitral valve (\nand\nVideo 1–3).\nWe suspected RV cardiomyopathy and investigated patient’s family history. Indeed, his sister had been diagnosed with ARVC as well as both of her teenage children, one of whom suffered from cardiac arrest while playing tennis at the age of 19 but was successfully resuscitated. His uncle, grandfather, and great-uncle sadly passed away from SCD at the age of 59, 60, and 19, respectively . In a synopsis of these initial findings, we initiated workup according to 2010 modified Task Force Criteria.\nSeven-day Holter ECG showed two non-sustained ventricular tachycardias (maximum length of 12 beats) and an ectopic beat burden of 22 000/24 h . Cardiac magnetic resonance imaging (MRI) correlated largely with echocardiographic findings: besides functional and morphological abnormalities, i.e. akinesia of the RV apical and medial anterior wall with signs of fatty degeneration, RV dilation and EF were further quantified (RV end-diastolic volume index: 227 mL/m2, RVEF18%) . Complementary genotyping revealed heterozygous nonsense substitution in PKP-2 gene (NM_004572.3: c.369G>A; p. Trp123Ter), which matched the ARVC phenotype in three databases for clinical variants (ClinVar, dbSNP, gnomAD) ., Conclusively, ARVC was established as definite diagnosis .\nMedical heart failure therapy including beta-blocker, angiotensin-converting enzyme-inhibitor, and aldosterone antagonist was introduced. Using the ARVC risk score, the risk for a fast ventricular tachycardia/ventricular flutter/sustained ventricular arrhythmia was calculated at 7.1% within 5 years and patient underwent prophylactic implantable cardioverter-defibrillator (ICD) implantation. The latter was complicated by poor impedance levels at preferred implantation site in apical RV myocardium. Adequate connectivity was finally achieved after implantation into high-septal myocardium.\nThe patient was advised against smoking, high-cholesterol diet, exercise training, and anaerobic activity. We offered psychological counselling and consultation of a local ARVC support group. Monthly follow-ups were set in our specialized ARVC centre and mutation-specific cascade family testing was recommended in our cardiogenetic centre.\nOn regular follow-up 4 months later, the patient reports clinical deterioration. Electrocardiogram findings appeared unchanged. The ICD device did not elicit ventricular tachycardias. Repeated echocardiography showed severe TR (effective regurgitant orifice area: 40 mm2, proximal isovelocity surface area: 7–8 mm), which now appeared to be additionally aggravated by interference of ICD lead with septal leaflet. Of note, echocardiography-controlled repositioning of the ICD lead did not seem to be promising considering the difficulties in ICD implantation and fragile nature of the RV myocardium. During exercise stress testing, systolic BP and HR increased appropriately. Furthermore, we performed stress echocardiography and supine incremental stepwise cycle exercise right heart catheterization to investigate resting and stress haemodynamics. The onset of dyspnoea at 75 W was correlated with diastolic LV compression and obstruction of LV filling by increasing RV pressure and RV failure . Left ventricular early systolic volume at 100 W was estimated to 50 mL.\nDiagnostic angiogram showed coronary sclerosis without obstructions . Resting pulmonary artery (PA) systolic/diastolic and mean pressures were measured at 25/16 and 23 mmHg, respectively. Exercise-induced PA pressures rose slightly to 32/23 and 26 mmHg. The transpulmonary gradient remained regular at rest and when subjected to stress at 12 and 14 mmHg, respectively. Pulmonary artery oxygen saturation was 49% at rest and 37% at performance limit, evidencing slightly increased peripheral oxygen extraction. Overall, there was no evidence for pulmonary hypertension. Extended pulmonary diagnostics using high resolution computed tomography of lungs and spirometry excluded any obstructive and restrictive lung pathologies. Abdominal ultrasound documented systolic flow reversal in dilated liver vessels and inferior vena cava . Gastrointestinal symptoms and dilated liver veins were interpreted as progressing signs of right heart congestion with beginning congestive gastritis and hepatopathy (AST 59 U/L, ALT 73 U/L, GGT 149 U/L, bilirubin 0.9 mg/dL).\nWe expanded medical treatment by adding standard coronary artery disease prophylactic agents, namely acetylsalicylic acid and rosuvastatin. Heart failure medication was modified by adding torasemide and antiarrhythmic medication was adjusted by discontinuation of bisoprolol in favour of sotalol . Despite conflicting evidence, sotalol is still a guideline-recommended prophylactic agent for patients with ARVC/D, which is based on data from the OPTIC study, showing a trend towards fewer ICD shocks in patients treated with sotalol compared to beta-blockers. On the next regular follow-up, the patient reported a significant improvement regarding symptom burden. Thus, therapy was continued in its present form with regular re-assessments in ongoing monthly follow-ups.", + "fulltext_subclaims": [ + "The patient is a 67-year-old male.", + "The patient presented with dyspnoea.", + "The patient had reduced cardiopulmonary exercise capacity.", + "In 1980, the patient had an admission for recurrent exercise-induced palpitations.", + "At that time, the patient participated in high-frequency/high-duration/intermediate intensity endurance training.", + "Subsequent cardiologic workup was not able to define underlying structural or rhythmical disease.", + "A recommendation against exercise was not given.", + "The patient ceased regular workouts in the early 1980s.", + "The patient's activity was confined to moderate-intensity training.", + "In 2012, the patient restarted regular activity.", + "In February 2020, the patient increased his workout volume.", + "In July 2020, symptoms worsened significantly.", + "The patient had a 3/6-systolic murmur with punctum maximum at fourth intercostal space right parasternal.", + "The ECG showed sinus rhythm with epsilon waves in V1–4.", + "The ECG showed T-wave inversions in leads II, III, aVF, and V1–6.", + "Transthoracic echocardiography showed enlarged and dyskinetic RV with aneurysmatic extension on RV free wall.", + "Transthoracic echocardiography showed high-grade tricuspid regurgitation.", + "Transthoracic echocardiography showed low-grade pulmonary regurgitation.", + "Left ventricular size and function were preserved.", + "The patient's sister had been diagnosed with ARVC.", + "One of the patient's nephews suffered from cardiac arrest while playing tennis at the age of 19.", + "The patient's uncle passed away from SCD at the age of 59.", + "The patient's grandfather passed away from SCD at the age of 60.", + "The patient's great-uncle passed away from SCD at the age of 19.", + "Seven-day Holter ECG showed two non-sustained ventricular tachycardias.", + "Cardiac MRI showed akinesia of the RV apical and medial anterior wall with signs of fatty degeneration.", + "Complementary genotyping revealed heterozygous nonsense substitution in PKP-2 gene.", + "ARVC was established as definite diagnosis.", + "Medical heart failure therapy including beta-blocker, angiotensin-converting enzyme-inhibitor, and aldosterone antagonist was introduced.", + "The risk for a fast ventricular tachycardia/ventricular flutter/sustained ventricular arrhythmia was calculated at 7.1% within 5 years.", + "The patient underwent prophylactic ICD implantation.", + "The ICD implantation was complicated by poor impedance levels at preferred implantation site.", + "Adequate connectivity was achieved after implantation into high-septal myocardium.", + "The patient was advised against smoking.", + "The patient was advised against high-cholesterol diet.", + "The patient was advised against exercise training.", + "The patient was advised against anaerobic activity.", + "The patient was offered psychological counselling.", + "The patient was offered consultation of a local ARVC support group.", + "Monthly follow-ups were set in a specialized ARVC centre.", + "Mutation-specific cascade family testing was recommended.", + "On regular follow-up 4 months later, the patient reports clinical deterioration.", + "The ICD device did not elicit ventricular tachycardias.", + "Repeated echocardiography showed severe TR.", + "Echocardiography-controlled repositioning of the ICD lead did not seem to be promising.", + "Exercise stress testing showed appropriate increase in systolic BP and HR.", + "Stress echocardiography was performed.", + "Supine incremental stepwise cycle exercise right heart catheterization was performed.", + "The onset of dyspnoea at 75 W was correlated with diastolic LV compression.", + "Diagnostic angiogram showed coronary sclerosis without obstructions.", + "Resting pulmonary artery systolic/diastolic and mean pressures were 25/16 and 23 mmHg, respectively.", + "Exercise-induced PA pressures rose slightly to 32/23 and 26 mmHg.", + "The transpulmonary gradient remained regular at rest and when subjected to stress.", + "Pulmonary artery oxygen saturation was 49% at rest.", + "Pulmonary artery oxygen saturation was 37% at performance limit.", + "Extended pulmonary diagnostics excluded obstructive and restrictive lung pathologies.", + "Abdominal ultrasound documented systolic flow reversal in dilated liver vessels.", + "Gastrointestinal symptoms and dilated liver veins were interpreted as progressing signs of right heart congestion.", + "Medical treatment was expanded by adding acetylsalicylic acid and rosuvastatin.", + "Heart failure medication was modified by adding torasemide.", + "Antiarrhythmic medication was adjusted by discontinuation of bisoprolol in favour of sotalol.", + "Sotalol is still a guideline-recommended prophylactic agent for patients with ARVC/D.", + "The patient reported a significant improvement regarding symptom burden.", + "Therapy was continued in its present form with regular re-assessments." + ], + "summary": "Here, a 67-year-old male patient who started extensive physical training upon retirement and presented with ventricular tachycardia and progressive heart failure as a first sign of his disease. Arrhythmogenic right ventricular cardiomyopathy diagnosis was established according to the 2010 modified Task Force Criteria and supported by HRS/EHRA consensus-based genotyping. After initial discharge on optimal medical therapy and prophylactic implantable cardioverter-defibrillator implantation according to his individual ARVC risk score, the patient reported rapid decline in physical capacity on a regular follow-up 4 months later. To better understand the aetiology of his clinical deterioration, we performed stress echocardiography, coronary angiogram, and exercise right heart catheterization, which conclusively suggest impaired left ventricular filling secondary to right ventricular failure as a main cause of global circulatory failure.", + "summary_subclaims": [ + "The patient is a 67-year-old male.", + "The patient started extensive physical training upon retirement.", + "The patient presented with ventricular tachycardia and progressive heart failure as a first sign of his disease.", + "Arrhythmogenic right ventricular cardiomyopathy diagnosis was established according to the 2010 modified Task Force Criteria.", + "The diagnosis was supported by HRS/EHRA consensus-based genotyping.", + "The patient was discharged on optimal medical therapy.", + "The patient received a prophylactic implantable cardioverter-defibrillator implantation according to his individual ARVC risk score.", + "The patient reported rapid decline in physical capacity 4 months later.", + "Stress echocardiography, coronary angiogram, and exercise right heart catheterization were performed.", + "The tests suggest impaired left ventricular filling secondary to right ventricular failure as a main cause of global circulatory failure." + ] + }, + { + "id": "multiclinsum_test_2104_en.txt", + "fulltext": "A 25-year-old female professional dancer presented to the sports medicine department due to increasing pain in the left iliac crest with radiation to the left leg. She initially noticed the pain after chiropractic treatment 6 months before (see timeline in Additional file ). Further medical history of the patient was unremarkable. After the clinical diagnosis of lumbar syndrome was established, the sports physician prescribed acupuncture and physiotherapy. Both did not ease the pain. Next, a swelling of the left hip region appeared. Ultrasound showed no signs of arthritis but raised suspicion of a soft tissue mass. The patient was then referred to the adult oncology department.\nMagnetic resonance imaging (MRI) of the pelvis revealed a large tumour of the left iliac bone with infiltration of periosteal muscles and soft tissue. Left-sided pubic bone, sacrum and sacroiliac joint were infiltrated . Skeletal scintigraphy revealed no further osseous lesions , computed tomography (CT) of chest and abdomen excluded metastases. A biopsy was performed, which resulted in diagnosis of OS, grade III of chondroblastic subtype. Despite recommendation for chemotherapy, the patient decided to perform a fasting cure and lost 6 kg weight.\nA further MRI was done a couple of weeks later due to increasing, intolerable pain, despite treatment with opioids, cox-2-inhibitors, non-steroidal anti-inflammatory drugs and coanalgesics. Tumour size remained stable. The patient then decided to start chemotherapy according to recommendations of EURAMOS-1/COSS protocol in the paediatric oncology department.\nUnder chemotherapy the pain subsided within 2 months and the tumour size decreased without relevant side effects except for nausea. Due to her profession as a dancer, the patient refused to undergo local therapy by surgery or radiation and discontinued chemotherapy after 4 months. We discussed the very poor prognosis of OS without local therapy in detail with the patient.\nMuch to our surprise, we found no signs of tumour relapse or metastases within the next year. Imaging studies displayed a stable residual tumour mass of the left iliac bone with further decline of contrast enhancement and soft tissue portions .\nUnfortunately, 16 months after the end of chemotherapy the patient first recognized a lump in her left breast. Clinical examination revealed enlarged lymph nodes (2 cm) of the left axilla. The patient refused mammography; ultrasound indicated possible breast cancer. A couple of weeks later, ultrasound-guided biopsy of the breast lump was performed resulting in the diagnosis of invasive ductal carcinoma (G2, B5b, ER/PR 0%, HER2/neu score 3, MIB-1 30%). Again, the patient declined biopsy of the lymph nodes. MRI of the chest revealed destructive carcinoma of the complete left mamma without signs of pulmonary metastases (TNM: cT2, cN1, cM0). Skeletal scintigraphy neither displayed activity of the pelvic OS nor of other bone lesions. Head MRI ruled out an initially suspected parietal metastasis with slightly increased tracer uptake . Ultrasound of the abdomen displayed a hypo-echogenic nodule of the liver.\nOnce again the patient refused any further treatment. Two months later, she was admitted to the gynaecologic department with severe headaches and intermittent visual field loss. The gynaecologists interpreted findings as migraine headaches due to spontaneous improvement of pain and unremarkable MRI of the head. A couple of days later, she presented to the emergency department with sudden deterioration of her general condition, dyspnoea and decreased oxygen saturation. A CT of chest and abdomen revealed diffuse pulmonary consolidations, pericardial effusion and several hypodense hepatic nodules consistent with disseminated end-stage breast cancer. Upon further deterioration, the patient and her family agreed to withhold invasive procedures and the patient soon died of respiratory failure.\nAfter establishing the diagnosis of breast cancer, we performed genetics for Li-Fraumeni syndrome and confirmed the diagnosis (common TP53 mutation: DNA binding domain, c.733G > A, p.Gly254Ser, heterozygous). Family history of the patient was unremarkable regarding classical Li-Fraumeni criteria, the patient’s father died from a pulmonary tumour at old age.\nTo elucidate the very uncommon course of the OS without signs of vital tumour, despite absence of local therapy and incomplete chemotherapy, we performed array-comparative genomic hybridization (aCGH) of the tumour material according to routine protocols . Table compares common CNA in OS with the individual CNA of our LFS patient.", + "fulltext_subclaims": [ + "The patient is a 25-year-old female professional dancer.", + "She presented to the sports medicine department due to increasing pain in the left iliac crest with radiation to the left leg.", + "She initially noticed the pain after chiropractic treatment 6 months before.", + "Further medical history of the patient was unremarkable.", + "The clinical diagnosis of lumbar syndrome was established.", + "The sports physician prescribed acupuncture and physiotherapy.", + "Both acupuncture and physiotherapy did not ease the pain.", + "A swelling of the left hip region appeared.", + "Ultrasound showed no signs of arthritis.", + "Ultrasound raised suspicion of a soft tissue mass.", + "The patient was referred to the adult oncology department.", + "MRI of the pelvis revealed a large tumour of the left iliac bone with infiltration of periosteal muscles and soft tissue.", + "Left-sided pubic bone, sacrum and sacroiliac joint were infiltrated.", + "Skeletal scintigraphy revealed no further osseous lesions.", + "CT of chest and abdomen excluded metastases.", + "A biopsy was performed, which resulted in diagnosis of OS, grade III of chondroblastic subtype.", + "The patient decided to perform a fasting cure and lost 6 kg weight.", + "A further MRI was done a couple of weeks later due to increasing, intolerable pain.", + "Tumour size remained stable.", + "The patient decided to start chemotherapy according to recommendations of EURAMOS-1/COSS protocol in the paediatric oncology department.", + "Under chemotherapy the pain subsided within 2 months.", + "The tumour size decreased without relevant side effects except for nausea.", + "The patient refused to undergo local therapy by surgery or radiation.", + "The patient discontinued chemotherapy after 4 months.", + "We discussed the very poor prognosis of OS without local therapy in detail with the patient.", + "We found no signs of tumour relapse or metastases within the next year.", + "Imaging studies displayed a stable residual tumour mass of the left iliac bone with further decline of contrast enhancement and soft tissue portions.", + "16 months after the end of chemotherapy the patient first recognized a lump in her left breast.", + "Clinical examination revealed enlarged lymph nodes (2 cm) of the left axilla.", + "The patient refused mammography.", + "Ultrasound indicated possible breast cancer.", + "Ultrasound-guided biopsy of the breast lump was performed.", + "The biopsy resulted in the diagnosis of invasive ductal carcinoma (G2, B5b, ER/PR 0%, HER2/neu score 3, MIB-1 30%).", + "The patient declined biopsy of the lymph nodes.", + "MRI of the chest revealed destructive carcinoma of the complete left mamma without signs of pulmonary metastases (TNM: cT2, cN1, cM0).", + "Skeletal scintigraphy neither displayed activity of the pelvic OS nor of other bone lesions.", + "Head MRI ruled out an initially suspected parietal metastasis with slightly increased tracer uptake.", + "Ultrasound of the abdomen displayed a hypo-echogenic nodule of the liver.", + "The patient refused any further treatment.", + "She was admitted to the gynaecologic department with severe headaches and intermittent visual field loss.", + "The gynaecologists interpreted findings as migraine headaches due to spontaneous improvement of pain and unremarkable MRI of the head.", + "She presented to the emergency department with sudden deterioration of her general condition, dyspnoea and decreased oxygen saturation.", + "CT of chest and abdomen revealed diffuse pulmonary consolidations, pericardial effusion and several hypodense hepatic nodules consistent with disseminated end-stage breast cancer.", + "The patient and her family agreed to withhold invasive procedures.", + "The patient soon died of respiratory failure.", + "Genetics for Li-Fraumeni syndrome were performed.", + "The diagnosis of Li-Fraumeni syndrome was confirmed (common TP53 mutation: DNA binding domain, c.733G > A, p.Gly254Ser, heterozygous).", + "Family history of the patient was unremarkable regarding classical Li-Fraumeni criteria.", + "The patient’s father died from a pulmonary tumour at old age.", + "Array-comparative genomic hybridization (aCGH) of the tumour material was performed according to routine protocols." + ], + "summary": "We report a 25-year-old female with pelvic osteosarcoma refusing continuation of therapy. She interrupted neo-adjuvant chemotherapy according to EURAMOS-1/COSS recommendations and declined local or further adjuvant therapy. Surprisingly, she remained in sustained remission for the osteosarcoma but eventually died from newly diagnosed breast cancer. After establishment of breast cancer, we detected TP53 germline mutation and investigated the osteosarcoma material with array-CGH.", + "summary_subclaims": [ + "The patient is a 25-year-old female.", + "The patient had pelvic osteosarcoma.", + "The patient refused continuation of therapy.", + "She interrupted neo-adjuvant chemotherapy according to EURAMOS-1/COSS recommendations.", + "She declined local or further adjuvant therapy.", + "She remained in sustained remission for the osteosarcoma.", + "She eventually died from newly diagnosed breast cancer.", + "After establishment of breast cancer, we detected TP53 germline mutation.", + "We investigated the osteosarcoma material with array-CGH." + ] + }, + { + "id": "multiclinsum_test_1983_en.txt", + "fulltext": "We present a case of a 13-year-old boy, admitted to hospital for planned neurosurgical procedure of clipping aneurysm of left middle cerebral artery (arteria cerebri media [ACM]). He was previously hospitalized for urgent embolization and reembolization of ruptured right ACM (5/2017 and 6/2017). During reembolization, he developed allergic reaction with severe rash after induction of anesthesia. For that reason, clinical allergological testing on different anesthetic drugs was done. After clinical testing, the patient was proved allergic to midazolam, propofol, fentanyl, sufentanil, sevofluran, thiopental, rocuronium, and vecuronium.\nBefore new planned aneurysmal clipping, he was prepared with metilprednisolon, antihistaminic, and ranitidine. Preoperative morning cortisol levels were slight higher (742 nmol/L) and adrenocorticotropic hormone (ACTH) was lower than range (<0.2 pmol/L).\nBecause of patient's allergy to different drugs used for induction and maintenance of general anesthesia, and due to high demands for hemodynamic stability for aneurysmal clipping, anesthesia was performed with continuous infusion of etomidate and remifentanil, with scalp block and without use of neuromuscular blocking agents. We had previous good experience with continuous etomidate infusion for total intravenous infusion (total intravenous anesthesia [TIVA]) in neurosurgical patients; so, we decided to use etomidate in this case also.\nOur protocol for anesthesia maintenance with etomidate infusion is dose of 100 mcg/kg/min for the first 5 min after anesthesia induction, followed by 60 mcg/kg/min for the next 25 min and then 10 mcg/kg/min until the end of the surgery. The protocol is based on recommendations from other research, and our clinical experience.\nEnhanced anesthetic monitoring was used, with invasive blood pressure and entropy of encephalogram (Datex-Ohmeda S/5 Entropy Module), and the doses of etomidate used in this case enable isoelectric EEG for the time of clipping the aneurysm or burst suppression ratio greater than 70%. The surgery lasted for 4 h. There were no complications, hemodynamic, or any other sequellae during surgical procedure, and afterward, he was placed in neurosurgical intensive care unit (ICU) analgosedated and mechanically ventilated. The patient was awake and extubated 1 h after admittance to ICU and Glasgow Coma Score (GCS) was 15.\nLevels of cortisol and ACTH were measured during next three consecutive days. Only one measured cortisol value, in the morning the day after the surgery, was below reference range, and the values were back to normal until that evening .\nThe explanation is more difficult due to the fact that the patient was prepared for the surgery with metilprednisolon because of his allergies which may diminish influence of perioperative stress on cortisol synthesis. ACTH returned to normal after the second day. He was dismissed from ICU on the second day with GCS 15.", + "fulltext_subclaims": [ + "The patient is a 13-year-old boy.", + "He was admitted for a planned neurosurgical procedure of clipping an aneurysm of the left middle cerebral artery.", + "He was previously hospitalized for urgent embolization and reembolization of a ruptured right middle cerebral artery aneurysm in May 2017 and June 2017.", + "During reembolization, he developed an allergic reaction with severe rash after induction of anesthesia.", + "Clinical allergological testing was done on different anesthetic drugs.", + "The patient was proved allergic to midazolam, propofol, fentanyl, sufentanil, sevoflurane, thiopental, rocuronium, and vecuronium.", + "Before the new planned aneurysmal clipping, he was prepared with methylprednisolone, an antihistaminic, and ranitidine.", + "Preoperative morning cortisol levels were slightly higher (742 nmol/L).", + "Preoperative morning adrenocorticotropic hormone (ACTH) was lower than the reference range (<0.2 pmol/L).", + "Anesthesia was performed with continuous infusion of etomidate and remifentanil, with scalp block and without use of neuromuscular blocking agents.", + "The patient's allergy to multiple drugs used for induction and maintenance of general anesthesia was a factor in the anesthesia plan.", + "The surgical procedure lasted 4 hours.", + "There were no complications, hemodynamic or other sequelae, during the surgical procedure.", + "The patient was extubated 1 hour after admission to the ICU.", + "The Glasgow Coma Score was 15 after extubation.", + "Cortisol levels were measured during the next three consecutive days.", + "Only one measured cortisol value, in the morning the day after surgery, was below the reference range.", + "ACTH returned to normal after the second day.", + "The patient was dismissed from the ICU on the second day with a Glasgow Coma Score of 15." + ], + "summary": "We describe a case of 13-year-old boy with aneurysm of left middle cerebral artery, planned for aneurysmal clipping, and previously treated for ruptured aneurysm of right middle cerebral artery. As he was tested and proved allergic to most of the anesthetic drugs, and stable hemodynamic conditions were of most importance during planned neurosurgery, general anesthesia was maintained with etomidate infusion. He was prepared with metilprednisolon, antihistaminic, and ranitidine before the surgery. Cortisol and adrenocorticotropic hormone levels were measured on three consecutive postoperative days. Only cortisol value, in the morning the day after the surgery, was below reference range, with the values back to normal until that evening. He was dismissed from the intensive care unit with Glasgow Coma Score 15.", + "summary_subclaims": [ + "The patient is a 13-year-old boy.", + "The patient has an aneurysm of the left middle cerebral artery.", + "The patient was planned for aneurysmal clipping.", + "The patient was previously treated for a ruptured aneurysm of the right middle cerebral artery.", + "The patient was tested and proved allergic to most of the anesthetic drugs.", + "Stable hemodynamic conditions were of most importance during the planned neurosurgery.", + "General anesthesia was maintained with etomidate infusion.", + "The patient was prepared with metilprednisolon before the surgery.", + "The patient was prepared with antihistaminic before the surgery.", + "The patient was prepared with ranitidine before the surgery.", + "Cortisol and adrenocorticotropic hormone levels were measured on three consecutive postoperative days.", + "Only the cortisol value, in the morning the day after the surgery, was below reference range.", + "The cortisol values were back to normal until that evening.", + "The patient was dismissed from the intensive care unit with Glasgow Coma Score 15." + ] + }, + { + "id": "multiclinsum_test_987_en.txt", + "fulltext": "A 42-year-old Caucasian man presented to our hospital with acute onset of fatigue, nausea, vomiting, early satiety, diarrhea, and weight loss 3 months after LCH had been diagnosed on the basis of biopsy of an asymptomatic lesion on the left arm. His physical examination was pertinent for tender hepatosplenomegaly and multiple eczematous papular lesions on the trunk and extremities. His complete blood count (CBC) results and lactate dehydrogenase (LDH) level were normal. Esophagogastroduodenoscopy (EGD) demonstrated herpes esophagitis and Helicobacter pylori gastritis. Biopsies of the duodenum and esophagus showed involvement by LCH with features suggestive of LCS . The BRAF V600E mutation was not detected. Imaging did not demonstrate any suspicious bone or central nervous system (CNS) involvement. His bone marrow biopsy (BMBx) showed no LCH or acute myeloid leukemia (AML). He was started on intravenous cytarabine 100 mg/m2 daily for 5 days every 4 weeks, which led to improvement but no resolution of his skin lesions or gastrointestinal (GI) symptoms. After four cycles, his therapy was adjusted to every 2 weeks in view of kinetic failure. This adjustment led to clinical improvement, but his LDH level continued to rise, leading to repeat BMBx performed after cycle 8, which showed no evidence of AML.\nThree weeks later, he presented with acute left hemianopia resulting from an ischemic cerebrovascular accident. Workup demonstrated circulating blasts, spontaneous tumor lysis syndrome, and disseminated intravascular coagulation (DIC). BMBx confirmed acute monoblastic leukemia with a complex karyotype. Next-generation sequencing (NGS) showed no additional mutations. The patient was started on induction 7 + 3 (daunorubicin/cytarabine), which led to transient resolution of skin lesions that quickly worsened by day 15. The lesions appeared as multiple erythematous papules and nodules throughout the back. Histological sections showed heavily epidermotropic and bandlike dermal infiltrates of leukemic cells in the dermis with pseudo-blisters formed by tumor necrosis . A subset of tumor cells showed features of Langerhans cells, including reniform nuclei and atypical large and hyperchromic nuclei . Immunophenotyping revealed that the tumor cells were positive for langerin, S100, and CD1a with intratumoral heterogeneity and a Ki67 showing a nearly 80% cell proliferation rate . The tumor cells were also positive for CD56, CD117, and CD123 in a subset of cells. The immunophenotype supported both myelomonoblastic and Langerhans cell differentiation. Marrow cytogenetics detected t(13:14) in all tumor cells and additional structural abnormalities involving chromosomes 1, 8, 9, 10, and Y. In this particular context, the cutaneous lesions were best classified as cutaneous involvement of leukemia. Cytogenetic profiling with NGS showed nonsynonymous mutation p.E69K affecting the PTPN11 gene (SHP2), homozygous loss of CDKN2A at 9p21, and a tumor mutational burden of 26%.\nHe was started on salvage therapy with CLAG-M (cladribine 5 g/m2, cytarabine 2 g/m2, granulocyte colony-stimulating factor (G-CSF), mitoxantrone 10 g/m2), and after the first dose of filgrastim (G-CSF), he developed acute diplopia with leptomeningeal involvement by AML as identified by brain magnetic resonance imaging and lumbar puncture . Intensive intrathecal therapy with methotrexate (MTX) was initiated twice per week for six cycles. The patient’s skin lesions and neurologic symptoms resolved with restaging consistent with complete remission. However, 1 week later, his skin lesions recurred, followed by recurrence of neurologic deficits that responded poorly to salvage therapy, including high-dose cytarabine, further intrathecal therapy, and CNS radiation. The patient died 1 year after diagnosis of LCH while undergoing treatment with MTX and cytarabine as a bridge to marrow transplant. Table summarizes the cardinal features associated with this case.", + "fulltext_subclaims": [ + "The patient was a 42-year-old Caucasian man.", + "He presented with acute onset of fatigue, nausea, vomiting, early satiety, diarrhea, and weight loss.", + "These symptoms occurred 3 months after LCH had been diagnosed.", + "The LCH diagnosis was based on biopsy of an asymptomatic lesion on the left arm.", + "Physical examination showed tender hepatosplenomegaly.", + "Multiple eczematous papular lesions were present on the trunk and extremities.", + "Complete blood count (CBC) results were normal.", + "Lactate dehydrogenase (LDH) level was normal.", + "Esophagogastroduodenoscopy (EGD) showed herpes esophagitis.", + "EGD also showed Helicobacter pylori gastritis.", + "Biopsies of the duodenum and esophagus showed involvement by LCH.", + "The biopsies showed features suggestive of LCS.", + "The BRAF V600E mutation was not detected.", + "Imaging did not demonstrate any suspicious bone involvement.", + "Imaging did not demonstrate any suspicious central nervous system (CNS) involvement.", + "Bone marrow biopsy (BMBx) showed no LCH.", + "BMBx showed no acute myeloid leukemia (AML).", + "He was started on intravenous cytarabine 100 mg/m2 daily for 5 days every 4 weeks.", + "This led to improvement but no resolution of his skin lesions.", + "This led to no resolution of his gastrointestinal (GI) symptoms.", + "After four cycles, his therapy was adjusted to every 2 weeks.", + "This adjustment was due to kinetic failure.", + "This adjustment led to clinical improvement.", + "His LDH level continued to rise.", + "Repeat BMBx was performed after cycle 8.", + "Repeat BMBx showed no evidence of AML.", + "Three weeks later, he presented with acute left hemianopia.", + "This resulted from an ischemic cerebrovascular accident.", + "Workup demonstrated circulating blasts.", + "Workup demonstrated spontaneous tumor lysis syndrome.", + "Workup demonstrated disseminated intravascular coagulation (DIC).", + "BMBx confirmed acute monoblastic leukemia.", + "BMBx showed a complex karyotype.", + "Next-generation sequencing (NGS) showed no additional mutations.", + "He was started on induction 7 + 3 (daunorubicin/cytarabine).", + "This led to transient resolution of skin lesions.", + "The skin lesions quickly worsened by day 15.", + "The lesions appeared as multiple erythematous papules and nodules throughout the back.", + "Histological sections showed heavily epidermotropic and bandlike dermal infiltrates of leukemic cells.", + "The infiltrates were in the dermis with pseudo-blisters formed by tumor necrosis.", + "A subset of tumor cells showed features of Langerhans cells.", + "These features included reniform nuclei and atypical large and hyperchromic nuclei.", + "Immunophenotyping revealed that the tumor cells were positive for langerin.", + "Immunophenotyping revealed that the tumor cells were positive for S100.", + "Immunophenotyping revealed that the tumor cells were positive for CD1a.", + "The tumor cells showed intratumoral heterogeneity.", + "Ki67 showed a nearly 80% cell proliferation rate.", + "The tumor cells were also positive for CD56.", + "The tumor cells were also positive for CD117 in a subset of cells.", + "The tumor cells were also positive for CD123 in a subset of cells.", + "The immunophenotype supported both myelomonoblastic and Langerhans cell differentiation.", + "Marrow cytogenetics detected t(13:14) in all tumor cells.", + "Marrow cytogenetics detected additional structural abnormalities involving chromosomes 1, 8, 9, 10, and Y.", + "The cutaneous lesions were best classified as cutaneous involvement of leukemia.", + "Cytogenetic profiling with NGS showed nonsynonymous mutation p.E69K affecting the PTPN11 gene (SHP2).", + "Cytogenetic profiling showed homozygous loss of CDKN2A at 9p21.", + "Cytogenetic profiling showed a tumor mutational burden of 26%.", + "He was started on salvage therapy with CLAG-M.", + "After the first dose of filgrastim (G-CSF), he developed acute diplopia.", + "Brain magnetic resonance imaging identified leptomeningeal involvement by AML.", + "Lumbar puncture identified leptomeningeal involvement by AML.", + "Intensive intrathecal therapy with methotrexate (MTX) was initiated twice per week for six cycles.", + "The patient’s skin lesions resolved with restaging consistent with complete remission.", + "The patient’s neurologic symptoms resolved with restaging consistent with complete remission.", + "One week later, his skin lesions recurred.", + "Neurologic deficits also recurred.", + "Salvage therapy included high-dose cytarabine.", + "Salvage therapy included further intrathecal therapy.", + "Salvage therapy included CNS radiation.", + "The patient died 1 year after diagnosis of LCH.", + "The patient was undergoing treatment with MTX and cytarabine as a bridge to marrow transplant.", + "The patient’s death occurred while undergoing treatment with MTX and cytarabine." + ], + "summary": "We describe the case of a 42-year-old Caucasian man with Langerhans cell histiocytosis diagnosed from a lesion on the left arm that presented with constitutional symptoms, early satiety, and weight loss. Esophagogastroduodenoscopy showed extensive esophageal and duodenal involvement by Langerhans cell histiocytosis with features of Langerhans cell sarcoma. He was initially treated for Langerhans cell histiocytosis with low doses of cytarabine until he eventually presented clear transformation to acute monoblastic leukemia with complex karyotype that could not be properly controlled, leading eventually to death.", + "summary_subclaims": [ + "The patient was a 42-year-old Caucasian man.", + "The patient had Langerhans cell histiocytosis.", + "The diagnosis was made from a lesion on the left arm.", + "The patient had constitutional symptoms.", + "The patient had early satiety.", + "The patient had weight loss.", + "Esophagogastroduodenoscopy showed extensive esophageal involvement by Langerhans cell histiocytosis.", + "Esophagogastroduodenoscopy showed extensive duodenal involvement by Langerhans cell histiocytosis.", + "The histiocytosis had features of Langerhans cell sarcoma.", + "The patient was initially treated for Langerhans cell histiocytosis with low doses of cytarabine.", + "The patient eventually presented clear transformation to acute monoblastic leukemia.", + "The leukemia had a complex karyotype.", + "The leukemia could not be properly controlled.", + "The patient eventually died." + ] + }, + { + "id": "multiclinsum_test_2603_en.txt", + "fulltext": "A 40-year-old man with history of intravenous drug use presented to the emergency department with altered mental status and dyspnoea. He was afebrile and haemodynamically stable. Auscultation of the chest revealed bibasilar lung crepitations and a 3/6 holosystolic murmur at the left upper sternal border and apex. Neurological exam revealed no focal deficits. The patient denied any relevant past medical and surgical history.\nLaboratory tests identified a neutrophilic leucocytosis (white blood cell count 13.6 K/μL, reference range 4.5–11 K/μL; absolute neutrophil count 11.7 K/μL, reference range 1.9–8 K/μL) and elevated C-reactive protein (75.2 mg/L, reference range 0–5 mg/L). 12-lead EKG showed normal sinus rhythm (SR) with no conduction disturbances . Transthoracic echocardiogram identified left ventricle (LV) dilation with an ejection fraction 54%, apical akinesis, aortic and mitral valve vegetations with severe regurgitation of both valves (, ). Brain CT showed an acute SAH , with acute obstructive hydrocephalus . Computed tomography angiography revealed a 4-mm irregular-shaped aneurysm arising from a RMCA branch .\nThe patient was intubated and an EVD was emergently placed. Digital subtraction angiography (DSA) documented a ruptured fusiform mycotic aneurysm in a distal parietal branch of the RMCA . Under fluoroscopic guidance, a Headway Duo micro-catheter was advanced over a 0.014’’ micro-guidewire into the RMCA. Embolization of the aneurysm was achieved with deployment of six coils, followed by n-butyl cyanoacrylate glue embolization . Final DSA showed excellent aneurysm obliteration (Raymond Roy Grade 1; ). Blood cultures were collected before empiric antibiotic therapy with Vancomycin 1 gr IV every 12 h and Ceftriaxone 2 g IV daily was started.\nOn Day 3, the patient became febrile (38.2°C) and EKG showed new STE in Leads II, III, aVF, V3–V4 . Troponin-I was 8 ng/mL (cut-off <0.03 ng/mL). Serial troponin levels showed a decreasing trend. A conservative approach without diagnostic coronary angiography was pursued, as the patient was at prohibitive risk for surgical or percutaneous revascularization if significant coronary artery disease was confirmed, given the attendant bleeding risk in the setting of recent SAH and EVD placement.\nOn Day 5, the patient developed bilateral upper limb paresis. Cerebral angiography demonstrated RMCA and anterior cerebral artery vasospasm, which was treated with Verapamil, Nimodipine, Milrinone, and monitored with transcranial Doppler.\nTransesophageal echocardiography (TEE; and , , ) identified a Sievers Type 0 bicuspid aortic valve with a large vegetation (1.8 × 1 cm) arising from the left cusp; there was associated left cusp perforation resulting in severe AR; perivalvular infection was also seen, with an aortic root abscess, and pseudo-aneurysm formation. The mitral valve also had a large vegetation (2.4 × 1.2 cm) with anterior mitral leaflet aneurysm and perforation, resulting in severe MR. There was no TEE evidence of left main (LM) coronary ostium obstruction. Blood cultures revealed growth of Streptococcus salivarius; Ceftriaxone and Vancomycin were continued according to microbiological sensitivities.\nOn Day 7, an EKG showed SR with new 1st degree atrio-ventricular block and stable V3–V5 STE. The clinical course was then complicated by development of hypotension, acute pulmonary oedema, pneumonia, and progressive left upper extremity weakness due to cerebral vasospasm, requiring intra-arterial Verapamil and stent angioplasty at the first segment of the RMCA. Electrocardiogram showed stable V3–V5 STE and accelerated junctional rhythm with retrograde P waves .\nOn Day 15, fluctuating conscious levels and neurological deficits prompted CT-angiography, which showed worsening basilar artery vasospasm and a new mycotic aneurysm in the distal M2 left middle cerebral artery branch (, ). The patient progressively deteriorated with rising intracranial pressure and drainage of blood from the EVD. There was also additional cardio-respiratory decompensation. Head CT showed a new left parieto-temporal intraparenchymal haematoma from a ruptured left distal mycotic aneurysm, with rightward midline shift and left lateral ventricle effacement (, ). Electrocardiogram showed worsening anterior STE with new bigeminy and multifascicular block without discernible P waves . Following multidisciplinary team meetings and Ethics committee reunion, the patient was managed conservatively and subsequently passed away on Day 24.", + "fulltext_subclaims": [ + "A 40-year-old man with history of intravenous drug use presented to the emergency department with altered mental status and dyspnoea.", + "He was afebrile and haemodynamically stable.", + "Auscultation of the chest revealed bibasilar lung crepitations.", + "Auscultation of the chest revealed a 3/6 holosystolic murmur at the left upper sternal border and apex.", + "Neurological exam revealed no focal deficits.", + "The patient denied any relevant past medical and surgical history.", + "Laboratory tests identified a neutrophilic leucocytosis (white blood cell count 13.6 K/μL, reference range 4.5–11 K/μL; absolute neutrophil count 11.7 K/μL, reference range 1.9–8 K/μL).", + "C-reactive protein was elevated at 75.2 mg/L, reference range 0–5 mg/L.", + "12-lead EKG showed normal sinus rhythm with no conduction disturbances.", + "Transthoracic echocardiogram identified left ventricle dilation with an ejection fraction 54%.", + "Transthoracic echocardiogram identified apical akinesis.", + "Brain CT showed an acute subarachnoid haemorrhage.", + "Brain CT showed acute obstructive hydrocephalus.", + "Computed tomography angiography revealed a 4-mm irregular-shaped aneurysm arising from a right middle cerebral artery branch.", + "The patient was intubated.", + "An external ventricular drain was emergently placed.", + "Digital subtraction angiography documented a ruptured fusiform mycotic aneurysm in a distal parietal branch of the right middle cerebral artery.", + "Embolization of the aneurysm was achieved with deployment of six coils.", + "Embolization of the aneurysm was achieved with n-butyl cyanoacrylate glue.", + "Final DSA showed excellent aneurysm obliteration (Raymond Roy Grade 1).", + "Blood cultures were collected before empiric antibiotic therapy.", + "Empiric antibiotic therapy included Vancomycin 1 gr IV every 12 h.", + "Empiric antibiotic therapy included Ceftriaxone 2 g IV daily.", + "On Day 3, the patient became febrile (38.2°C).", + "On Day 3, EKG showed new ST elevation in Leads II, III, aVF, V3–V4.", + "Troponin-I was 8 ng/mL (cut-off <0.03 ng/mL).", + "Serial troponin levels showed a decreasing trend.", + "A conservative approach without diagnostic coronary angiography was pursued.", + "On Day 5, the patient developed bilateral upper limb paresis.", + "Cerebral angiography demonstrated right middle cerebral artery and anterior cerebral artery vasospasm.", + "Vasospasm was treated with Verapamil, Nimodipine, Milrinone, and monitored with transcranial Doppler.", + "Transesophageal echocardiography identified a Sievers Type 0 bicuspid aortic valve.", + "Transesophageal echocardiography identified a large vegetation (1.8 × 1 cm) arising from the left cusp.", + "There was associated left cusp perforation resulting in severe aortic regurgitation.", + "Perivalvular infection was also seen, with an aortic root abscess.", + "Perivalvular infection was also seen, with pseudo-aneurysm formation.", + "The mitral valve had a large vegetation (2.4 × 1.2 cm).", + "There was anterior mitral leaflet aneurysm and perforation, resulting in severe mitral regurgitation.", + "There was no TEE evidence of left main coronary ostium obstruction.", + "Blood cultures revealed growth of Streptococcus salivarius.", + "Ceftriaxone and Vancomycin were continued according to microbiological sensitivities.", + "On Day 7, an EKG showed sinus rhythm with new 1st degree atrio-ventricular block.", + "On Day 7, an EKG showed stable V3–V5 ST elevation.", + "The clinical course was complicated by development of hypotension.", + "The clinical course was complicated by acute pulmonary oedema.", + "The clinical course was complicated by pneumonia.", + "The clinical course was complicated by progressive left upper extremity weakness due to cerebral vasospasm.", + "Progressive left upper extremity weakness was treated with intra-arterial Verapamil and stent angioplasty at the first segment of the right middle cerebral artery.", + "Electrocardiogram showed stable V3–V5 ST elevation and accelerated junctional rhythm with retrograde P waves.", + "On Day 15, fluctuating conscious levels and neurological deficits prompted CT-angiography.", + "CT-angiography showed worsening basilar artery vasospasm.", + "CT-angiography showed a new mycotic aneurysm in the distal M2 left middle cerebral artery branch.", + "The patient progressively deteriorated with rising intracranial pressure and drainage of blood from the external ventricular drain.", + "There was additional cardio-respiratory decompensation.", + "Head CT showed a new left parieto-temporal intraparenchymal haematoma from a ruptured left distal mycotic aneurysm.", + "Head CT showed rightward midline shift and left lateral ventricle effacement.", + "Electrocardiogram showed worsening anterior ST elevation with new bigeminy and multifascicular block without discernible P waves.", + "Following multidisciplinary team meetings and Ethics committee reunion, the patient was managed conservatively.", + "The patient subsequently passed away on Day 24." + ], + "summary": "We describe a case of Streptococcus salivarius bicuspid aortic and mitral valve endocarditis with concurrent spontaneous mycotic aneurysm rupture and acute subarachnoid haemorrhage (SAH). A 40-year-old man with history of intravenous drug abuse presented to our emergency department with altered mental status and dyspnoea. Echocardiography documented large vegetations on a bicuspid aortic valve and on the mitral valve, causing acute severe aortic and mitral regurgitation. Brain computed tomography imaging documented a ruptured fusiform aneurysm in a distal branch of the right middle cerebral artery causing acute SAH and acute obstructive hydrocephalus. An external ventricular drain was emergently placed and endovascular embolization of the aneurysm was achieved with deployment of six coils. Blood cultures grew S. salivarius and antibiotic therapy according to microbiological sensitivities was administered. Hospital stay was complicated by acute heart failure, ST-elevation myocardial infarction, conduction disturbances, cerebral vasospasm, recurrent mycotic aneurysm rupture, and death.", + "summary_subclaims": [ + "We describe a case of Streptococcus salivarius bicuspid aortic and mitral valve endocarditis with concurrent spontaneous mycotic aneurysm rupture and acute subarachnoid haemorrhage.", + "A 40-year-old man with history of intravenous drug abuse presented to our emergency department with altered mental status and dyspnoea.", + "Echocardiography documented large vegetations on a bicuspid aortic valve and on the mitral valve.", + "Brain computed tomography imaging documented a ruptured fusiform aneurysm in a distal branch of the right middle cerebral artery.", + "An external ventricular drain was emergently placed.", + "Endovascular embolization of the aneurysm was achieved with deployment of six coils.", + "Blood cultures grew S. salivarius.", + "Antibiotic therapy according to microbiological sensitivities was administered.", + "Hospital stay was complicated by acute heart failure.", + "Hospital stay was complicated by ST-elevation myocardial infarction.", + "Hospital stay was complicated by conduction disturbances.", + "Hospital stay was complicated by cerebral vasospasm.", + "Hospital stay was complicated by recurrent mycotic aneurysm rupture.", + "Hospital stay was complicated by death." + ] + }, + { + "id": "multiclinsum_test_1719_en.txt", + "fulltext": "A 20-year old Caucasian woman in septic shock with multiorgan dysfunction was transferred to our intensive care unit. Her medical history was remarkable for allergic asthma and Basedow’s disease. She had previously undergone a left-sided hemithyroidectomy and right-sided subtotal resection.\nAbout four weeks before admission to the transferring hospital, our patient had been treated with cefuroxime due to a retroareolar inflammation two years after a right-sided breast piercing. Because of the sustained fever and diarrhea, we substituted cefuroxime with metronidazole, suspecting an antibiotic-associated process. Metronidazole was then switched to vancomycin, with the assumption that our patient had pseudomembranous colitis. A colonoscopy showed inflammation and multiple small ulcerations of her entire colon, with the greatest extent in her ileum, cecum and sigma. However, neither pathogen germs nor Clostridium difficile toxin could be detected in stool samples and her blood and urine specimens were also sterile. A wound swab of her increasingly necrotic right breast showed Staphylococcus aureus, Actinomyces turicensis and Peptostreptococcus species. Consequently, the progressively damaged tissue was explored and extensively excised to exclude an abscess. Because of the considerable aggravation of her general condition, the antibiotic treatment was again diversified to a three-fold treatment with imipenem and cilastatin, moxifloxacin, and fluconazole. Owing to her hemodynamic and respiratory insufficiency, our patient was transferred to our intensive care unit.\nDuring admission to our ward, ventilation was conducted with 100% oxygen, and our patient needed high catecholamine doses. She was also anuric, with a creatinine level of 5.0mg/dL (reference range 0.7 to 1.2mg/dL) and elevated liver parameters, with total bilirubin 2.9mg/dL (reference range 0.2 to 1.0mg/dL), aspartate transaminase 2572U/L (reference range 10 to 50U/L) and alanine transaminase 608U/L (reference range 10 to 50U/L). She had leukocytosis, with a white blood cell count of 27.0G/L (reference range 4.3 to 10.0G/L). Her C-reactive protein level was >230mg/L (reference range <5mg/dL) and procalcitonin level was 9.3μg/L (reference range 0.1 to 0.5μg/L). An immediate colonoscopy showed multiple ulcerations of the colonic mucosa .\nBecause our patient was therapy-refractory and had persisting signs of septic shock and a risk of perforation, a subtotal colectomy was indicated. Just before the beginning of the abdominal surgery, her pulmonary gas exchange worsened. When examined by bronchoscopy, there was no evidence of an obstruction; however, the mucosa of her bronchi was highly inflamed and vulnerable. We observed bleeding originating from her upper airway. The ventilatory conditions were instantly ameliorated by a laparotomy - equivalent to the release of intra-abdominal compartment syndrome. Because of the incipient necrosis of her gall bladder, we performed a subtotal colectomy and a cholecystectomy. During the surgery, 20cm of her rectum were left and blindly closed according to Hartmann’s approach, with an ileostomy and a laparostomy.\nPostoperatively, we initiated a calculated therapy with meropenem and caspofungin as well as vancomycin to cover a possible translocation of C. difficile or its toxins. Furthermore, continuous veno-venous hemofiltration was started.\nPermanent stabilization of our patient’s organ functions could not be achieved. Hemodynamic, pulmonary and renal failure still persisted and her liver enzyme levels increased massively (aspartate transaminase 8848U/L, alanine transaminase 1039U/L, total bilirubin 9.4mg/dL), correlating with ischemic necrosis in liver segments six and seven detected by ultrasonic testing. Moreover, our patient showed recurrent ventricular and supraventricular tachycardia culminating in a short-term asystole. Echocardiography did not reveal any pathological changes. All blood, tracheal secretion and abdominal swab samples stayed free of pathological germs. A sudden rise in lactate necessitated a second-look operation, during which we found no evidence of mesenteric ischemia.\nHistologic examination of her colon showed multiple superficial areas of microulceration of the mucosa, lamina propria mucosae and, to a lesser extent, the lamina submucosa . Medium-sized arteries and arterioles of her entire colon, appendix and gallbladder showed acute vasculitic changes with fibrinoid necrosis of the walls and diffuse infiltration with neutrophil granulocytes, accompanied by a strong perivascular histiocyte-rich and partially granulomatous reaction . Many arterioles also had intraluminal platelet-rich thrombi , others were complete obliterated by inflammatory cells. The affected vessels were localized in the submucosal layer of her bowel and in her gall bladder. These findings strongly suggested an autoimmune multisystem disease like Wegener’s granulomatosis or microscopic polyangiitis. A diagnosis of Wegener’s granulomatosis was confirmed by the results of the serologic antibody tests: her c-ANCA titer was considerably elevated at 1:2560 specific for subclass proteinase 3 (PR3) (>200kU/L). After the histopathological diagnosis and the serological tests, immunosuppression with high doses of corticosteroids and plasmapheresis were started.\nContinuing a dosage of 100mg prednisolone daily and plasmapheresis twice a day for almost a week, we gradually achieved a durable stabilization of our patient’s circulation and lung function, a constant downsizing of the ischemic area in her right liver lobe and a cumulative resumption of urine production. After tapering catecholamines and eliminating about 10L of extravascular fluids, it was possible to close the laparostomy and extubate our patient. Her gas exchange was borderline and she required highly intensive airway treatment and intermittent application of continuously positive airway pressure.\nA couple of days later, she developed an acute abdomen and we measured a leap in leukocytes up to 75.0G/L. A computed tomography scan showed multiple hypodense areas in her liver appearing as partial necrosis and her spleen failed to show any contrast at all.\nA splenectomy was performed due to multiple septic infarctions, although several samples taken from biopsies of the hepatic lesions were sterile.\nPostoperatively, our patient could be extubated without difficulty, her leukocyte level fell and after a perioperative deterioration of kidney function, her creatinine and urea levels stayed within an acceptable range because of reparatory polyuria. She did not show any neurological deficits, slowly regained her strength and could be transferred to a standard ward only five days post-splenectomy.\nPlasmapheresis was continued three times a week and prednisolone was gradually reduced to 50mg per day. After completion of wound healing, cyclophosphamide treatment could be initiated.\nRetrospectively, we discovered some further, interesting aspects about our patient’s medical history: when she was diagnosed with Basedow’s disease two years before, our patient had positive titers for thyroid peroxidase antibodies (380U/mL; normal range <35U/mL), microsomal antibodies (1:6400; normal range <1:100) and thyroid-stimulating hormone receptor antibodies (29.5U/L; normal range <1U/L). Her parents reported that she had complained about painful knees after exercising and gingival problems for several weeks before exacerbation of the Wegener’s disease.", + "fulltext_subclaims": [ + "A 20-year old Caucasian woman was transferred to the intensive care unit with septic shock and multiorgan dysfunction.", + "Her medical history was remarkable for allergic asthma and Basedow’s disease.", + "She had previously undergone a left-sided hemithyroidectomy and right-sided subtotal resection.", + "About four weeks before admission to the transferring hospital, our patient had been treated with cefuroxime due to a retroareolar inflammation two years after a right-sided breast piercing.", + "Because of sustained fever and diarrhea, cefuroxime was substituted with metronidazole, suspecting an antibiotic-associated process.", + "Metronidazole was then switched to vancomycin, with the assumption that our patient had pseudomembranous colitis.", + "A colonoscopy showed inflammation and multiple small ulcerations of her entire colon, with the greatest extent in her ileum, cecum and sigma.", + "Neither pathogen germs nor Clostridium difficile toxin could be detected in stool samples.", + "Her blood and urine specimens were also sterile.", + "A wound swab of her increasingly necrotic right breast showed Staphylococcus aureus, Actinomyces turicensis and Peptostreptococcus species.", + "The progressively damaged tissue was explored and extensively excised to exclude an abscess.", + "Because of the considerable aggravation of her general condition, the antibiotic treatment was again diversified to a three-fold treatment with imipenem and cilastatin, moxifloxacin, and fluconazole.", + "Owing to her hemodynamic and respiratory insufficiency, our patient was transferred to our intensive care unit.", + "During admission to our ward, ventilation was conducted with 100% oxygen.", + "Our patient needed high catecholamine doses.", + "She was anuric, with a creatinine level of 5.0mg/dL.", + "Her total bilirubin was 2.9mg/dL.", + "Her aspartate transaminase was 2572U/L.", + "Her alanine transaminase was 608U/L.", + "She had leukocytosis, with a white blood cell count of 27.0G/L.", + "Her C-reactive protein level was >230mg/L.", + "Her procalcitonin level was 9.3μg/L.", + "An immediate colonoscopy showed multiple ulcerations of the colonic mucosa.", + "Because our patient was therapy-refractory and had persisting signs of septic shock and a risk of perforation, a subtotal colectomy was indicated.", + "Just before the beginning of the abdominal surgery, her pulmonary gas exchange worsened.", + "When examined by bronchoscopy, there was no evidence of an obstruction.", + "The mucosa of her bronchi was highly inflamed and vulnerable.", + "We observed bleeding originating from her upper airway.", + "The ventilatory conditions were instantly ameliorated by a laparotomy.", + "Because of the incipient necrosis of her gall bladder, we performed a subtotal colectomy and a cholecystectomy.", + "During the surgery, 20cm of her rectum were left and blindly closed according to Hartmann’s approach, with an ileostomy and a laparostomy.", + "Postoperatively, we initiated a calculated therapy with meropenem and caspofungin as well as vancomycin.", + "Furthermore, continuous veno-venous hemofiltration was started.", + "Permanent stabilization of our patient’s organ functions could not be achieved.", + "Hemodynamic, pulmonary and renal failure still persisted.", + "Her liver enzyme levels increased massively (aspartate transaminase 8848U/L, alanine transaminase 1039U/L, total bilirubin 9.4mg/dL).", + "Ultrasonic testing detected ischemic necrosis in liver segments six and seven.", + "Our patient showed recurrent ventricular and supraventricular tachycardia culminating in a short-term asystole.", + "Echocardiography did not reveal any pathological changes.", + "All blood, tracheal secretion and abdominal swab samples stayed free of pathological germs.", + "A sudden rise in lactate necessitated a second-look operation.", + "During the second-look operation, we found no evidence of mesenteric ischemia.", + "Histologic examination of her colon showed multiple superficial areas of microulceration of the mucosa, lamina propria mucosae and, to a lesser extent, the lamina submucosa.", + "Medium-sized arteries and arterioles of her entire colon, appendix and gallbladder showed acute vasculitic changes with fibrinoid necrosis of the walls and diffuse infiltration with neutrophil granulocytes.", + "Many arterioles also had intraluminal platelet-rich thrombi.", + "Others were complete obliterated by inflammatory cells.", + "The affected vessels were localized in the submucosal layer of her bowel and in her gall bladder.", + "These findings strongly suggested an autoimmune multisystem disease like Wegener’s granulomatosis or microscopic polyangiitis.", + "A diagnosis of Wegener’s granulomatosis was confirmed by the results of the serologic antibody tests.", + "Her c-ANCA titer was considerably elevated at 1:2560 specific for subclass proteinase 3 (PR3) (>200kU/L).", + "After the histopathological diagnosis and the serological tests, immunosuppression with high doses of corticosteroids and plasmapheresis were started.", + "Continuing a dosage of 100mg prednisolone daily and plasmapheresis twice a day for almost a week, we gradually achieved a durable stabilization of our patient’s circulation and lung function.", + "A computed tomography scan showed multiple hypodense areas in her liver appearing as partial necrosis.", + "Her spleen failed to show any contrast at all.", + "A splenectomy was performed due to multiple septic infarctions.", + "Several samples taken from biopsies of the hepatic lesions were sterile.", + "Postoperatively, our patient could be extubated without difficulty.", + "Her leukocyte level fell.", + "After a perioperative deterioration of kidney function, her creatinine and urea levels stayed within an acceptable range because of reparatory polyuria.", + "She did not show any neurological deficits.", + "She could be transferred to a standard ward only five days post-splenectomy.", + "Plasmapheresis was continued three times a week.", + "Prednisolone was gradually reduced to 50mg per day.", + "After completion of wound healing, cyclophosphamide treatment could be initiated.", + "Retrospectively, we discovered that when she was diagnosed with Basedow’s disease two years before, our patient had positive titers for thyroid peroxidase antibodies (380U/mL).", + "Her microsomal antibodies were 1:6400.", + "Her thyroid-stimulating hormone receptor antibodies were 29.5U/L.", + "Her parents reported that she had complained about painful knees after exercising and gingival problems for several weeks before exacerbation of the Wegener’s disease." + ], + "summary": "A 20-year old Caucasian woman presented with the principal feature of a pancolonic, superficial microulceration mimicking severe ulcerative colitis. Our patient was refractory to therapy and had persisting signs of septic shock as well as being at risk of perforation, so we performed a subtotal colectomy and a cholecystectomy due to the incipient necrosis of her gallbladder. Histologic analysis of her colon showed multiple superficial microulcera of the mucosa, lamina propria mucosae and, to a lesser extent, the lamina submucosa. The medium-sized arteries and arterioles of her entire colon, appendix and gallbladder showed acute vasculitic changes with fibrinoid necrosis of the walls and diffuse infiltration with neutrophil granulocytes, accompanied by a strong perivascular histiocyte-rich and partially granulomatous reaction. These findings strongly suggested an autoimmune multisystem disease like Wegener's granulomatosis or microscopic polyangiitis. A diagnosis of Wegener's granulomatosis was confirmed by the results of serologic antibody tests: her cytoplasmic antineutrophil cytoplasmic antibody titer was considerably elevated at 1:2560 specific for subclass proteinase 3 (>200kU/L). After the histopathological diagnosis and serological tests, immunosuppression with high doses of corticosteroids and plasmapheresis was started.", + "summary_subclaims": [ + "The patient was a 20-year old Caucasian woman.", + "The principal feature was a pancolonic, superficial microulceration mimicking severe ulcerative colitis.", + "The patient was refractory to therapy.", + "The patient had persisting signs of septic shock.", + "The patient was at risk of perforation.", + "A subtotal colectomy was performed.", + "A cholecystectomy was performed.", + "The gallbladder showed incipient necrosis.", + "Histologic analysis showed multiple superficial microulcera of the mucosa.", + "The microulcera involved the lamina propria mucosae.", + "The microulcera involved the lamina submucosa to a lesser extent.", + "The medium-sized arteries and arterioles of the entire colon showed acute vasculitic changes.", + "The medium-sized arteries and arterioles of the appendix showed acute vasculitic changes.", + "The medium-sized arteries and arterioles of the gallbladder showed acute vasculitic changes.", + "The vasculitic changes included fibrinoid necrosis of the walls.", + "The vasculitic changes were accompanied by diffuse infiltration with neutrophil granulocytes.", + "The vasculitic changes were accompanied by a strong perivascular histiocyte-rich reaction.", + "The vasculitic changes were accompanied by a partially granulomatous reaction.", + "These findings strongly suggested an autoimmune multisystem disease like Wegener's granulomatosis or microscopic polyangiitis.", + "The diagnosis of Wegener's granulomatosis was confirmed by serologic antibody tests.", + "The cytoplasmic antineutrophil cytoplasmic antibody titer was 1:2560.", + "The cytoplasmic antineutrophil cytoplasmic antibody was specific for subclass proteinase 3.", + "The cytoplasmic antineutrophil cytoplasmic antibody titer was >200kU/L.", + "After the histopathological diagnosis and serological tests, immunosuppression with high doses of corticosteroids was started.", + "After the histopathological diagnosis and serological tests, plasmapheresis was started." + ] + }, + { + "id": "multiclinsum_test_2617_en.txt", + "fulltext": "A 17-year-old girl suffered from a traumatic injury to her maxillary anterior teeth one month ago . The girl complained of severe pain to teeth 11 and 21 to touch and biting. Clinical examination showed that teeth 11 and 21 were slightly displaced labially . The teeth responded to electric and cold pulp sensibility tests (tooth #11: 77/80, tooth #21: 56/80). The teeth were moderately tender to percussion and palpation. Both teeth showed grade II mobility. Periodontal probing was in the 2–3 mm range. Radiographic examination showed that teeth 11 and 21 had fully developed and demonstrated multiple transverse fractures in the middle third of the root of tooth 11 and tooth 21 . The diagnosis was multiple transverse root fractures with treatment was required due to persistent pain experienced by the patient despite splinting of the teeth for 1 month. Treatment options included root canal treatment of the coronal fragment of the root, REPs for the coronal fragment, and extraction. The patient decided to have REPs and informed consent was obtained.\nAt the first visit, teeth 13, 12, 11, 21, 22 and 23 were splinted for 4 weeks after the first visit. Local anesthesia with 2% lidocaine containing 1:100,000 epinephrine was administered. The teeth were isolated with a rubber dam. Under a surgical microscope (Zumax, Zuzhou, China), the canals were accessed, and a moderate amount of bleeding immediately drained through the access cavity. The canals were gently irrigated with 1.5% sodium hypochlorite solution to a level of a1mm coronal to the fracture. The working length of each tooth was extended up to the most coronal fracture line determined radiographically with a #25 hand K-file. The canals of the coronal fragments were carefully, sequentially debrided to #40 K-files with constant irrigation with sodium hypochlorite to the most coronal fracture line preserving vital pulp tissue and with only minimal to no filing of the canal walls. The canals of the coronal fragments were dried with paper points and dressed with calcium hydroxide (ApexCal; Ivoclar Vivadent AG, Schaan, Liechtenstein). The access cavity was temporized with a sterile cotton pellet and glass ionomer cement (Fuji IX, GC, Tokyo, Japan).\nAt the second treatment visit two weeks later, both teeth were asymptomatic. Local infiltration anesthesia with 3% Mepivacaine (Septodont, Taican, Jiangsu, China) without vasoconstrictor was administered. The teeth were isolated with a rubber dam and the access cavity reopened. Calcium hydroxide was removed with copious amounts of sodium hypochlorite irrigation followed by saline solution irrigation. The coronal canal was dried and rinsed with 17% EDTA solution (Langlishangwu, Wuhan, China) for 1 min in each tooth and dried again. A #40 hand K-file measuring 21 mm was used to gently penetrate the apical fragment of the canal containing vital pulp to induce bleeding into the coronal canal spaces up to the cemento-enamel junction. After a blood clot was formed, CollaCote (Integra Life Sciences, Shanghai, China) was placed over the blood clot in the canal of each tooth. A 3 mm thickness of iRoot BP (Innovative Bioceramix, Inc, Shanghai, China) paste was then placed against the CollaCote followed by a moist cotton pellet. The teeth were restored with glass ionomer cement and composite resin (Fuji IX, GC, Tokyo, Japan). A final radiograph was taken to verify the location of the coronal seal . The patient was reviewed after 1, 3, 6, 12, 24, 36, and 48 months, respectively.", + "fulltext_subclaims": [ + "The patient is a 17-year-old girl.", + "The girl suffered from a traumatic injury to her maxillary anterior teeth one month ago.", + "The girl complained of severe pain to teeth 11 and 21 to touch and biting.", + "Clinical examination showed that teeth 11 and 21 were slightly displaced labially.", + "The teeth responded to electric and cold pulp sensibility tests (tooth #11: 77/80, tooth #21: 56/80).", + "The teeth were moderately tender to percussion and palpation.", + "Both teeth showed grade II mobility.", + "Periodontal probing was in the 2–3 mm range.", + "Radiographic examination showed that teeth 11 and 21 had fully developed.", + "Radiographic examination showed multiple transverse fractures in the middle third of the root of tooth 11 and tooth 21.", + "The diagnosis was multiple transverse root fractures.", + "Treatment was required due to persistent pain experienced by the patient despite splinting of the teeth for 1 month.", + "Treatment options included root canal treatment of the coronal fragment of the root.", + "Treatment options included REPs for the coronal fragment.", + "Treatment options included extraction.", + "The patient decided to have REPs.", + "Informed consent was obtained.", + "At the first visit, teeth 13, 12, 11, 21, 22, and 23 were splinted for 4 weeks after the first visit.", + "Local anesthesia with 2% lidocaine containing 1:100,000 epinephrine was administered.", + "The teeth were isolated with a rubber dam.", + "Under a surgical microscope (Zumax, Zuzhou, China), the canals were accessed.", + "A moderate amount of bleeding immediately drained through the access cavity.", + "The canals were gently irrigated with 1.5% sodium hypochlorite solution to a level of 1 mm coronal to the fracture.", + "The working length of each tooth was extended up to the most coronal fracture line determined radiographically with a #25 hand K-file.", + "The canals of the coronal fragments were carefully, sequentially debrided to #40 K-files with constant irrigation with sodium hypochlorite to the most coronal fracture line.", + "Vital pulp tissue was preserved.", + "Only minimal to no filing of the canal walls was performed.", + "The canals of the coronal fragments were dried with paper points.", + "The canals were dressed with calcium hydroxide (ApexCal; Ivoclar Vivadent AG, Schaan, Liechtenstein).", + "The access cavity was temporized with a sterile cotton pellet and glass ionomer cement (Fuji IX, GC, Tokyo, Japan).", + "At the second treatment visit two weeks later, both teeth were asymptomatic.", + "Local infiltration anesthesia with 3% Mepivacaine (Septodont, Taican, Jiangsu, China) without vasoconstrictor was administered.", + "The teeth were isolated with a rubber dam.", + "The access cavity was reopened.", + "Calcium hydroxide was removed with copious amounts of sodium hypochlorite irrigation followed by saline solution irrigation.", + "The coronal canal was dried and rinsed with 17% EDTA solution (Langlishangwu, Wuhan, China) for 1 min in each tooth.", + "A #40 hand K-file measuring 21 mm was used to gently penetrate the apical fragment of the canal containing vital pulp.", + "Bleeding into the coronal canal spaces up to the cemento-enamel junction was induced.", + "After a blood clot was formed, CollaCote (Integra Life Sciences, Shanghai, China) was placed over the blood clot in the canal of each tooth.", + "A 3 mm thickness of iRoot BP (Innovative Bioceramix, Inc, Shanghai, China) paste was placed against the CollaCote.", + "A moist cotton pellet was placed.", + "The teeth were restored with glass ionomer cement and composite resin (Fuji IX, GC, Tokyo, Japan).", + "A final radiograph was taken to verify the location of the coronal seal.", + "The patient was reviewed after 1, 3, 6, 12, 24, 36, and 48 months, respectively." + ], + "summary": "A 17-year-old girl had a history of traumatic injury to mature teeth 11 and tooth 21 resulting in multiple transverse root fractures. Clinical examination showed that both teeth responded to electric and thermal pulp sensibility tests with prolonged severe pain and were tender to percussion and palpation. Periapical radiographic examination showed both teeth were fully developed and had multiple transverse fractures in the mid-root. The pulp diagnosis was consistent with symptomatic irreversible pulpitis. REPs were initiated with only the coronal fragments treated to preserve pulp vitality in the apical fragment for potential pulp tissue regeneration. After REPs, clinical signs/symptoms subsided, and the two teeth were followed for 48 months when cone beam computed tomography (CBCT) imaging was also undertaken. At the last review, the case demonstrated root fractures healing with calcified tissue and pulp calcification in the apical fragments. Both teeth were stable and in function.", + "summary_subclaims": [ + "The patient was a 17-year-old girl.", + "The patient had a history of traumatic injury to mature teeth 11 and tooth 21.", + "The traumatic injury resulted in multiple transverse root fractures.", + "Clinical examination showed both teeth responded to electric and thermal pulp sensibility tests with prolonged severe pain.", + "Both teeth were tender to percussion and palpation.", + "Periapical radiographic examination showed both teeth were fully developed.", + "Periapical radiographic examination showed multiple transverse fractures in the mid-root.", + "The pulp diagnosis was consistent with symptomatic irreversible pulpitis.", + "REPs were initiated with only the coronal fragments treated.", + "The treatment aimed to preserve pulp vitality in the apical fragment for potential pulp tissue regeneration.", + "After REPs, clinical signs/symptoms subsided.", + "The two teeth were followed for 48 months.", + "Cone beam computed tomography (CBCT) imaging was undertaken at the last review.", + "The case demonstrated root fractures healing with calcified tissue.", + "Pulp calcification was noted in the apical fragments.", + "Both teeth were stable and in function." + ] + }, + { + "id": "multiclinsum_test_1766_en.txt", + "fulltext": "A 31-year old male patient admitted to the Tropical and Parasitic Disease Department of Poznań University of Medical Sciences, Poland, because of the presence of a tumor-like lesion within the liver. The patient had been living in a small village surrounded by forests in which a big foxes population has been detected.\nPrior to the admission the patient had suffered from influenza like syndromes, pain in the right subcostal region and suddenly joidance.\nHe was admitted to the local Surgery Department with suspicion of biliary tract pathology. CT scan gave the evidence of irregular mass with disseminated calcifications. He was diagnosed undifferentiated hepatitis with cholestasis.\nBecause of atypical radiology results suspicion of Echinococus infection was done. ELISA serology test was positive (2.9 Units; positive above 1.0). The patient was moved to the Tropical and Parasitic Clinic in Poznań for further investigations.\nOn admission day the physical examination was unremarkable. Blood tests showed elevated levels of bilirubine (2 mg%), alkaline phosphatase (172-248 U/l) gamma glutamylo trans peptidase- GGTP (135-262 U/l).\nUSG of the abdominal cavity revealed presence of a huge calcified lesion in the VII-th liver segment with the diameter of 12.3 × 2.8 cm and in the II-nd liver segment a solid hyperechogenic focus with calcifications inside as well as disseminated calcifications in the interhepatic biliary tracts neighborhood. MRI showed the liver enlargement, with irregular tissue. In the VII, VI and V segments polycyclic fluid lesion and disseminated inside the right lobe smaller fluid foci as well as biliary tract widening .\nAccording to the picturesque data suspicion of alvecococcosis was done.\nELISA test (Echinococcus IgG) was positive – 50 NTU (positive above 11NTU) and confirmed with positive Western-blot which revealed presence of specific for Echinococcus multilocularis IgG (7,16,18, 26–28 kDa). ELISA EM2-plus (anty-E.multilocularis) was also high positive (> 3.0ABS). The patient was finally diagnosed the liver alveococcosis with P2M0N0 stage.\nWhen the diagnosis was established the albendazol therapy (2x400mg/day) was initiated together with ursodeoksycholic acid (2x250mg/day) in order to lowered bilirubine level and protect from apoptosis healthy liver tissue . The patient was qualified to the surgery treatment and was moved to the General and Transplant Surgery Department, Poznan University of Medical Sciences. MELD score of the patient was 10 (creatinine 1.13 mg/dl; bilirubin 1,12 mg/dl, INR 1,15, not dialysed).\nThe right hepatectomy was performed. Access to the liver was achieved by bilateral subcostal incision and then mobilizing the liver from its ligamentous attachments, including the coronary ligament, and left and right triangular ligaments, then anatomic resection of the fifth, sixth, seventh and eighth liver segments was performed. Right portal vein, right hepatic artery and right hepatic duct was ligated and cutted. In addition, visible cysts were removed from the left lobe of the liver in nonanatomical resection and suspicious calcified lesions in hepatoduodenal ligament were also removed . Postoperative course complicated by lymphorrhea, conservative treatment was initiated, obtaining improvement. In ultrasound on the 8th postoperative day, spleen enlargement occurs (141x55mm).\nThe histopathology examination of the all 3 speciments revealed presence of chronic inflammatory changes with thick wall calcified granulomas and accelular homogeny infiltrates with necrosis cavities.\nAdditionally, the biological material after surgery was used for molecular genotyping of Echinococcus sp. For this reason, the DNA was extracted from the removed liver tissue with lesions, using the commercially available kit (NucleoSpin Tissue, Macherey Nagel, Dueren, Germany). Next, the isolated DNA was used as a template in the PCR with Echinococcus sp. 12S rRNA-specific primers (EM-H15 and EM-H17), according to Stieger et al. (2007) . Moreover, as a control of DNA quality and presence of PCR inhibitors, we used isolated genetic material to amplify human GAPDH, according to Xiang et al. (2012) . Finally, the PCR product was sequenced and the obtained sequences were aligned using BioEdit software.\nBased on the PCR reactions with Echinococcus-specific primers, we confirmed that the patient was infected with Echinococcus sp. . Further sequence analysis revealed the complete similarity with Echinococcus multilocularis 12S rRNA , suggesting that the clinical outcome and after surgery complications were not correlated with parasite genotype and potential more pathogenic Echinococcus multilocularis strain.\nAfter the operation albendazol treeatmet was continued. With no other major or minor complication patient with normal level of bilirubin, alanine transaminase and aspartate transaminase was discharge on 17th postoperative day.\nThe patient’s follow –up, performed 10 months after the operation gave the evidence of thrombocytopenia (80G/l), leucopenia (3.1G/l) and syderopenic anemia. MR of the abdomen cavity showed presence of numerous hypodensic partially calcified lesions within the remaining liver segments. Moreover critical portal vein constriction (the diameter 3-4 mm), collateral venous circulation in the liver hil were detected. The examination revealed also splenomegaly as a result of the portal hypertension . Performed endoscopy of upper gastrointestinal tract revealed presence of first degree varices oesophagi as well as gastritis and duodenitis.\nRecently, patient had control MRI (06.03.2020) and there are no active outbreaks of alveococosis in the liver parenchyma, compared to previous studies, the image is stable. Collateral vessels are visible in the liver cavity. The spleen is enlarged, by a maximum length of about 16 cm (before operation spleen length was 14 cm). Patient is clinically asymptomatic. But he still requires regular, every 6 months follow-up in the Tropical and Parasitic Clinic.", + "fulltext_subclaims": [ + "A 31-year old male patient was admitted to the Tropical and Parasitic Disease Department of Poznań University of Medical Sciences, Poland.", + "The patient had been living in a small village surrounded by forests.", + "A big foxes population has been detected in the village.", + "Prior to the admission, the patient had suffered from influenza like syndromes.", + "Prior to the admission, the patient had pain in the right subcostal region.", + "Prior to the admission, the patient had suddenly joidance.", + "He was admitted to the local Surgery Department with suspicion of biliary tract pathology.", + "CT scan gave the evidence of irregular mass with disseminated calcifications.", + "He was diagnosed undifferentiated hepatitis with cholestasis.", + "Because of atypical radiology results, suspicion of Echinococus infection was done.", + "ELISA serology test was positive (2.9 Units; positive above 1.0).", + "The patient was moved to the Tropical and Parasitic Clinic in Poznań for further investigations.", + "On admission day, the physical examination was unremarkable.", + "Blood tests showed elevated levels of bilirubine (2 mg%).", + "Blood tests showed elevated levels of alkaline phosphatase (172-248 U/l).", + "Blood tests showed elevated levels of gamma glutamylo trans peptidase (135-262 U/l).", + "USG of the abdominal cavity revealed presence of a huge calcified lesion in the VII-th liver segment with the diameter of 12.3 × 2.8 cm.", + "USG of the abdominal cavity revealed presence of a solid hyperechogenic focus with calcifications inside in the II-nd liver segment.", + "USG of the abdominal cavity revealed disseminated calcifications in the interhepatic biliary tracts neighborhood.", + "MRI showed the liver enlargement, with irregular tissue.", + "MRI showed polycyclic fluid lesion in the VII, VI and V segments.", + "MRI showed disseminated fluid foci inside the right lobe.", + "MRI showed biliary tract widening.", + "According to the picturesque data, suspicion of alvecococcosis was done.", + "ELISA test (Echinococcus IgG) was positive – 50 NTU (positive above 11NTU).", + "ELISA test was confirmed with positive Western-blot.", + "Western-blot revealed presence of specific for Echinococcus multilocularis IgG (7,16,18, 26–28 kDa).", + "ELISA EM2-plus (anty-E.multilocularis) was also high positive (> 3.0ABS).", + "The patient was finally diagnosed the liver alveococcosis with P2M0N0 stage.", + "When the diagnosis was established, the albendazol therapy (2x400mg/day) was initiated.", + "When the diagnosis was established, ursodeoksycholic acid (2x250mg/day) was initiated.", + "The patient was qualified to the surgery treatment.", + "The patient was moved to the General and Transplant Surgery Department, Poznan University of Medical Sciences.", + "The right hepatectomy was performed.", + "Access to the liver was achieved by bilateral subcostal incision.", + "Anatomic resection of the fifth, sixth, seventh and eighth liver segments was performed.", + "Right portal vein, right hepatic artery and right hepatic duct was ligated and cutted.", + "Visible cysts were removed from the left lobe of the liver in nonanatomical resection.", + "Suspicious calcified lesions in hepatoduodenal ligament were also removed.", + "Postoperative course complicated by lymphorrhea.", + "In ultrasound on the 8th postoperative day, spleen enlargement occurs (141x55mm).", + "The histopathology examination of the all 3 speciments revealed presence of chronic inflammatory changes.", + "The histopathology examination revealed presence of thick wall calcified granulomas.", + "The histopathology examination revealed presence of acellular homogeny infiltrates with necrosis cavities.", + "The biological material after surgery was used for molecular genotyping of Echinococcus sp.", + "DNA was extracted from the removed liver tissue with lesions, using the commercially available kit (NucleoSpin Tissue, Macherey Nagel, Dueren, Germany).", + "The isolated DNA was used as a template in the PCR with Echinococcus sp. 12S rRNA-specific primers (EM-H15 and EM-H17), according to Stieger et al. (2007).", + "The isolated genetic material was used to amplify human GAPDH, according to Xiang et al. (2012).", + "The PCR product was sequenced and the obtained sequences were aligned using BioEdit software.", + "Based on the PCR reactions with Echinococcus-specific primers, we confirmed that the patient was infected with Echinococcus sp.", + "Further sequence analysis revealed the complete similarity with Echinococcus multilocularis 12S rRNA.", + "The clinical outcome and after surgery complications were not correlated with parasite genotype.", + "The clinical outcome and after surgery complications were not correlated with potential more pathogenic Echinococcus multilocularis strain.", + "After the operation, albendazol therapy was continued.", + "With no other major or minor complication, the patient was discharged on 17th postoperative day.", + "The patient’s follow –up, performed 10 months after the operation, gave the evidence of thrombocytopenia (80G/l).", + "The patient’s follow –up, performed 10 months after the operation, gave the evidence of leucopenia (3.1G/l).", + "The patient’s follow –up, performed 10 months after the operation, gave the evidence of syderopenic anemia.", + "MR of the abdomen cavity showed presence of numerous hypodensic partially calcified lesions within the remaining liver segments.", + "MR of the abdomen cavity detected critical portal vein constriction (the diameter 3-4 mm).", + "MR of the abdomen cavity detected collateral venous circulation in the liver hil.", + "The examination revealed splenomegaly as a result of the portal hypertension.", + "Endoscopy of upper gastrointestinal tract revealed presence of first degree varices oesophagi.", + "Endoscopy of upper gastrointestinal tract revealed gastritis.", + "Endoscopy of upper gastrointestinal tract revealed duodenitis.", + "Recently, patient had control MRI (06.03.2020) and there are no active outbreaks of alveococosis in the liver parenchyma.", + "Compared to previous studies, the image is stable.", + "Collateral vessels are visible in the liver cavity.", + "The spleen is enlarged, by a maximum length of about 16 cm.", + "Before operation, the spleen length was 14 cm.", + "The patient is clinically asymptomatic.", + "The patient still requires regular, every 6 months follow-up in the Tropical and Parasitic Clinic." + ], + "summary": "We describe a young male patient, diagnosed, according to the radiological, immunological and histological examination results, infection of Echinococcus multilocularis, who was treated with not radical resection of pathologic mass together with persistent albendazole intake. The right hepatectomy was performed. In addition, visible cysts were removed from the left lobe of the liver in nonanatomical resection and suspicious calcified lesions in hepatoduodenal ligament were also removed. After the operation portal hypertension, with splenomegaly and symptoms of the liver cirrhosis occurred (thrombocytopenia, collateral venous circulation, first degree varices oesophagii). The portal hypertension probably could be a result of incomplete surgery due to extended parasitic infection and liver anathomical changes due to performed procedures, because the portal hypertension and it's further complications had not been observed before the operation.", + "summary_subclaims": [ + "The patient was diagnosed with infection of Echinococcus multilocularis.", + "The diagnosis was based on radiological, immunological, and histological examination results.", + "The patient was treated with not radical resection of the pathologic mass.", + "The patient received persistent albendazole intake.", + "A right hepatectomy was performed.", + "Visible cysts were removed from the left lobe of the liver in nonanatomical resection.", + "Suspicious calcified lesions in the hepatoduodenal ligament were removed.", + "Portal hypertension occurred after the operation.", + "Splenomegaly occurred after the operation.", + "Symptoms of liver cirrhosis occurred after the operation.", + "Thrombocytopenia was observed.", + "Collateral venous circulation was observed.", + "First degree varices oesophagii were observed.", + "The portal hypertension probably could be a result of incomplete surgery.", + "The portal hypertension probably could be due to extended parasitic infection.", + "The portal hypertension probably could be due to liver anatomical changes from the procedures.", + "Portal hypertension and its complications had not been observed before the operation." + ] + }, + { + "id": "multiclinsum_test_2903_en.txt", + "fulltext": "A 71-year-old Japanese man came to our hospital with a chief complaint of hematuria. Diagnosis of muscle invasive bladder cancer without distant metastases was confirmed after imaging tests and transurethral resection of bladder tumor (TURBT). He underwent radical cystectomy and pelvic lymph node dissection; an ileal conduit was also constructed. Microscopically, the tumor exhibited solid growth of spindle-shaped cells with atypia. Immunohistochemically, the cells were positive for CD56, a neural cell adhesion molecule expressed on the cell membrane of neurons, and synaptophysin, a synaptic vesicle glycoprotein that is present in neuroendocrine cells . In contrast, they were negative for CK20, which is a marker of urothelial carcinoma. The cells showed strong intranuclear positivity to ki-67 antibodies (> 70%) . Invasion beyond the bladder wall and metastasis of one of the thirteen regional lymph nodes that were excised were observed. Diagnosis of SCBC (pT3bN1M0) was confirmed. No component of urothelial carcinoma was found. Additionally, pathological re-examination of TURBT specimen exhibited similar features to the cystectomy specimen, which was pure SCBC. The patient received four cycles of adjuvant chemotherapy with gemcitabine (1000 mg/m2, administered intravenously) and cisplatin (70 mg/m2, administered intravenously); 6 months after cystectomy, he complained of right arm edema and hoarseness. Left tracheal deviation was observed on a chest radiograph ; Computed tomography (CT) scan revealed superior vena cava syndrome due to a 70 mm right-sided infraclavicular lymph node metastasis . Additionally, a 28 mm abdominal wall tumor and a 68 mm pelvic tumor were found. At that time, the serum neuron-specific enolase (NSE) level was 227 ng/ml. The 21-day cycle regimen (including carboplatin, etoposide, and atezolizumab) was administered intravenously, according to the clinical practice guidelines for extensive-disease SCLC . We administered carboplatin (area under the curve, 5 mg min/mL) on the first day, etoposide (100 mg/m2) from the first through the third day, and atezolizumab (1200 mg) on the first day. Considering the risk of nausea and loss of appetite, we intravenously administered palonosetron (0.75 mg) on the first day and dexamethasone (6.6 mg) from the first through the third day and orally administered aprepitant (125 mg) once daily on the first day, aprepitant (80 mg) once daily on the second and third day, and metoclopramide (5 mg) three times daily from the third through the seventh day. On the third day of the first cycle, right arm edema and hoarseness had improved. Additionally, tracheal deviation disappeared from the radiograph . While the patient experienced grade II neutropenia from days 8–10 of each cycle, it abated spontaneously without administration of the granulocyte colony-stimulating factor. He did not develop anemia or thrombocytopenia. Moreover, owing to the preventive therapy, he did not experience nausea or loss of appetite. After four cycles, all recurrent tumors completely disappeared from the CT scan. The serum NSE level decreased to 8.0 ng/ml. The patient continued to receive maintenance atezolizumab therapy (1200 mg, administered intravenously) every 21 days, without any evidence of recurrence over the 12 month follow up. Retrospectively, programmed death ligand 1 (PD-L1) staining was performed using a cystectomy specimen. The immune cells infiltrating the tumor were positive for PD-L1, whereas the tumor cells were negative for PD-L1 . The proportion of tumor-infiltrating immune cells expressing PD-L1 in the tumor area was more than 1% and less than 5%. Additionally, the proportion of tumor cells expressing PD-L1 in all tumor cells was less than 1%.", + "fulltext_subclaims": [ + "The patient is a 71-year-old Japanese man.", + "The patient had a chief complaint of hematuria.", + "Diagnosis of muscle invasive bladder cancer without distant metastases was confirmed.", + "The patient underwent radical cystectomy and pelvic lymph node dissection.", + "An ileal conduit was constructed.", + "The tumor exhibited solid growth of spindle-shaped cells with atypia.", + "The cells were positive for CD56.", + "The cells were positive for synaptophysin.", + "The cells were negative for CK20.", + "The cells showed strong intranuclear positivity to ki-67 antibodies (> 70%).", + "Invasion beyond the bladder wall was observed.", + "Metastasis of one of the thirteen regional lymph nodes that were excised was observed.", + "The diagnosis was SCBC (pT3bN1M0).", + "No component of urothelial carcinoma was found.", + "Pathological re-examination of TURBT specimen exhibited similar features to the cystectomy specimen.", + "The patient received four cycles of adjuvant chemotherapy with gemcitabine and cisplatin.", + "Six months after cystectomy, the patient complained of right arm edema and hoarseness.", + "Computed tomography scan revealed superior vena cava syndrome due to a 70 mm right-sided infraclavicular lymph node metastasis.", + "A 28 mm abdominal wall tumor was found.", + "A 68 mm pelvic tumor was found.", + "The serum neuron-specific enolase (NSE) level was 227 ng/ml.", + "The 21-day cycle regimen included carboplatin, etoposide, and atezolizumab.", + "Carboplatin (area under the curve, 5 mg min/mL) was administered on the first day.", + "Etoposide (100 mg/m2) was administered from the first through the third day.", + "Atezolizumab (1200 mg) was administered on the first day.", + "Palonosetron (0.75 mg) was administered on the first day.", + "Dexamethasone (6.6 mg) was administered from the first through the third day.", + "Aprepitant (125 mg) was administered orally once daily on the first day.", + "Aprepitant (80 mg) was administered orally once daily on the second and third day.", + "Metoclopramide (5 mg) was administered three times daily from the third through the seventh day.", + "On the third day of the first cycle, right arm edema and hoarseness had improved.", + "Tracheal deviation disappeared from the radiograph.", + "The patient experienced grade II neutropenia from days 8–10 of each cycle.", + "The neutropenia abated spontaneously without administration of granulocyte colony-stimulating factor.", + "The patient did not develop anemia or thrombocytopenia.", + "The patient did not experience nausea or loss of appetite.", + "After four cycles, all recurrent tumors completely disappeared from the CT scan.", + "The serum NSE level decreased to 8.0 ng/ml.", + "The patient continued to receive maintenance atezolizumab therapy every 21 days.", + "There was no evidence of recurrence over the 12 month follow up.", + "Programmed death ligand 1 (PD-L1) staining was performed using a cystectomy specimen.", + "The immune cells infiltrating the tumor were positive for PD-L1.", + "The tumor cells were negative for PD-L1.", + "The proportion of tumor-infiltrating immune cells expressing PD-L1 in the tumor area was more than 1% and less than 5%.", + "The proportion of tumor cells expressing PD-L1 in all tumor cells was less than 1%." + ], + "summary": "Herein, we report a case of a 71-year-old man with SCBC who underwent radical cystectomy and received adjuvant chemotherapy with gemcitabine and cisplatin. However, recurrent tumors were found 6 months postoperatively. The patient was then treated with carboplatin, etoposide, and atezolizumab and achieved complete response. He continues receiving maintenance therapy with atezolizumab monotherapy without any evidence of recurrence over the 12 months follow up.", + "summary_subclaims": [ + "The patient is a 71-year-old man with SCBC.", + "The patient underwent radical cystectomy.", + "The patient received adjuvant chemotherapy with gemcitabine and cisplatin.", + "Recurrent tumors were found 6 months postoperatively.", + "The patient was treated with carboplatin, etoposide, and atezolizumab.", + "The patient achieved complete response.", + "The patient continues receiving maintenance therapy with atezolizumab monotherapy.", + "There is no evidence of recurrence over the 12 months follow up." + ] + }, + { + "id": "multiclinsum_test_1781_en.txt", + "fulltext": "A 46-year-old Chinese man complained of four hands 7 d after SCI. The two supernumerary hands were painless but complicated with actual limb pain.\nThe patient suffered from tetraplegia caused by an accident on April 9, 2018. He underwent major surgery consisting of cervical posterior unilateral open-door expansive laminoplasty on 16 April 2018. Seven days after the accident, the patient felt the presence of an additional pair of hands that originated at the wrist joints and extended medially, with equal length to the paralyzed hands. He complained that he could feel but could not see the additional limbs. According to the patient’s description, the two supernumerary hands that were placed across his abdomen were not painful and persisted throughout the day . However, he felt a burning-like pain on both actual forearms, which measured 7 points (right side) and 5 points (left side) on the visual analogue scale. He experienced a more intense feeling of the existence and movement of the supernumerary hands, and stronger actual limb pain when he tried to control his limbs or someone touched his body.\nThe patient had no significant medical history, psychiatric history, and history of substance misuse, except for type 2 diabetes mellitus, which was diagnosed 5 years previously and treated with regular injections of insulin.\nAccording to the American Spinal Injury Association (ASIA) standards for neurological classification of SCI, the patient was classified as having an incomplete lesion (ASIA impairment scale B) with a neurologic level at C4. The ASIA evaluation for neurological function was performed 18 d after injury, and the motor score for the upper and lower limbs was 0, and the total score for light touch and pin prick, for both sides, was 31. Bulbocavernosus reflex was positive.\nComputed tomography scan of the cervical spine on the day of the accident did not show vertebral body fracture or SCI. Three days later, magnetic resonance imaging showed an abnormal signal at C3-6 cervical spinal cord on T2-weighted magnetic resonance imaging . No concomitant brain injury was observed on head computed tomography scans, and all cognitive evaluations suggested no abnormalities. Follow-up cervical spine X-ray was performed .", + "fulltext_subclaims": [ + "The patient is a 46-year-old Chinese man.", + "He complained of four hands 7 d after SCI.", + "The two supernumerary hands were painless.", + "The patient felt a burning-like pain on both actual forearms.", + "The patient's pain on the right forearm measured 7 points on the visual analogue scale.", + "The patient's pain on the left forearm measured 5 points on the visual analogue scale.", + "The patient felt the presence of an additional pair of hands that originated at the wrist joints.", + "The additional limbs extended medially.", + "The additional limbs were equal in length to the paralyzed hands.", + "The patient could feel but could not see the additional limbs.", + "The two supernumerary hands were placed across his abdomen.", + "The supernumerary hands persisted throughout the day.", + "The patient experienced a more intense feeling of the existence and movement of the supernumerary hands when he tried to control his limbs.", + "The patient experienced stronger actual limb pain when someone touched his body.", + "The patient had no significant medical history except for type 2 diabetes mellitus.", + "Type 2 diabetes mellitus was diagnosed 5 years previously.", + "The patient was treated with regular injections of insulin.", + "The patient was classified as having an incomplete lesion (ASIA impairment scale B).", + "The neurologic level was at C4.", + "The ASIA evaluation for neurological function was performed 18 d after injury.", + "The motor score for the upper and lower limbs was 0.", + "The total score for light touch and pin prick, for both sides, was 31.", + "Bulbocavernosus reflex was positive.", + "Computed tomography scan of the cervical spine on the day of the accident did not show vertebral body fracture or SCI.", + "Magnetic resonance imaging showed an abnormal signal at C3-6 cervical spinal cord on T2-weighted magnetic resonance imaging.", + "No concomitant brain injury was observed on head computed tomography scans.", + "All cognitive evaluations suggested no abnormalities.", + "Follow-up cervical spine X-ray was performed." + ], + "summary": "A 46-year-old man complained of four hands 7 d after SCI. He was diagnosed with SPL complicated with actual limb neuropathic pain. Following a period of treatment with neurotrophic agents and Chinese traditional and analgesic medications, SPL symptoms and actual limb pain did not improve. However, his symptoms gradually lessened after combined treatment with high-frequency repetitive transcranial magnetic stimulation (rTMS), a promising neuromodulation technique, over the M1 cortex and visual feedback. After 7 wk of this treatment, SPL disappeared completely and actual limb pain was significantly relieved.", + "summary_subclaims": [ + "A 46-year-old man complained of four hands 7 d after SCI.", + "He was diagnosed with SPL complicated with actual limb neuropathic pain.", + "Following a period of treatment with neurotrophic agents and Chinese traditional and analgesic medications, SPL symptoms and actual limb pain did not improve.", + "His symptoms gradually lessened after combined treatment with high-frequency repetitive transcranial magnetic stimulation (rTMS), a promising neuromodulation technique, over the M1 cortex and visual feedback.", + "After 7 wk of this treatment, SPL disappeared completely.", + "After 7 wk of this treatment, actual limb pain was significantly relieved." + ] + }, + { + "id": "multiclinsum_test_2249_en.txt", + "fulltext": "We present the case of a 16-year-old Caucasian man who attended the acute admissions unit of our hospital with a history of an acutely painful, red, and swollen right hemiscrotum for about five to six hours. No history of testicular trauma was elicited. He also complained of vague, generalized abdominal pain, somewhat worse in the periumbilical region and lower abdomen, and vomiting and watery diarrhea for about 24 hours.\nHe had a temperature of 38.5°C and pulse rate of 95 per minute. On examination, his right testicle was tender and somewhat elevated, and the right hemiscrotum, red and swollen. Abdominal examination evinced mild tenderness in his epigastrium and central abdomen, and less so in the right iliac fossa and suprapubic area. No convincing localizing abdominal signs were noted. Blood tests showed a white cell count of 15 × 109/L, neutrophilia, and C-reactive protein of about 300 mg/L.\nClinically, testicular torsion could not be excluded, and, on account of his young age and scrotal signs, a decision was made to explore the scrotum. At surgery, on opening the right tunica vaginalis, approximately 5 ml of pus was found, apparently coming down from the right groin. His right testicle appeared entirely normal. The scrotal abscess was drained, the area washed thoroughly with saline, and the scrotal wall closed in two layers with absorbable sutures. A Lanz incision was made to explore his right iliac fossa. It was found that he had a perforated retrocecal appendix, resulting in an abscess extending into the pelvis. The appendix was excised and the abdominopelvic abscess drained. Thorough saline lavage was performed, and the wound was closed without insertion of an abdominal drain. He was given three days of postoperative intravenous antibiotics.\nThe patient made an excellent recovery and was well at clinic follow-up four weeks later.", + "fulltext_subclaims": [ + "The patient was a 16-year-old Caucasian man.", + "He had an acutely painful, red, and swollen right hemiscrotum for about five to six hours.", + "No history of testicular trauma was elicited.", + "He had a temperature of 38.5°C.", + "His right testicle was tender and somewhat elevated.", + "Blood tests showed a white cell count of 15 × 109/L.", + "Clinically, testicular torsion could not be excluded.", + "A decision was made to explore the scrotum.", + "At surgery, approximately 5 ml of pus was found in the right tunica vaginalis.", + "The right testicle appeared entirely normal.", + "A Lanz incision was made to explore the right iliac fossa.", + "He was found to have a perforated retrocecal appendix.", + "The appendix was excised.", + "The abdominopelvic abscess was drained.", + "He was given three days of postoperative intravenous antibiotics.", + "The patient made an excellent recovery." + ], + "summary": "A 16-year-old Caucasian man presented as a surgical emergency with a five to six hour history of a painful, red, and swollen right hemiscrotum. He also complained of vague lower abdominal pain, vomiting, and watery diarrhea. He had a temperature of 38.5°C and a tender, red, and swollen right hemiscrotum. The right testicle appeared elevated. He was mildly tender in his central and upper abdomen and less so in the lower abdomen. No convincing localizing abdominal signs were noted. He had an increased white cell count (15 × 109/L) and C-reactive protein (CRP; 300 mg/L). Urgent right hemiscrotal exploration revealed about 5 ml of pus in the tunica vaginalis and a normal testicle. A right iliac fossa incision identified the cause: a perforated retrocecal appendix. Appendectomy was performed, and both the abdomen and scrotum washed copiously with saline before closure. The patient made an uneventful recovery.", + "summary_subclaims": [ + "A 16-year-old Caucasian man presented as a surgical emergency.", + "He had a five to six hour history of a painful, red, and swollen right hemiscrotum.", + "He also complained of vague lower abdominal pain.", + "He also complained of vomiting.", + "He also complained of watery diarrhea.", + "He had a temperature of 38.5°C.", + "The right testicle appeared elevated.", + "He was mildly tender in his central and upper abdomen.", + "He was less tender in the lower abdomen.", + "No convincing localizing abdominal signs were noted.", + "He had an increased white cell count (15 × 109/L).", + "He had an increased C-reactive protein (CRP; 300 mg/L).", + "Urgent right hemiscrotal exploration revealed about 5 ml of pus in the tunica vaginalis.", + "The testicle was normal.", + "A right iliac fossa incision identified the cause: a perforated retrocecal appendix.", + "Appendectomy was performed.", + "Both the abdomen and scrotum were washed copiously with saline before closure.", + "The patient made an uneventful recovery." + ] + }, + { + "id": "multiclinsum_test_579_en.txt", + "fulltext": "A 78-year-old woman presented to our department with borderline resectable pancreatic ductal adenocarcinoma involving the SMA nerve plexus . She underwent pancreaticoduodenectomy with en bloc resection of the superior mesenteric vein and the SMA nerve plexus after neoadjuvant chemotherapy . On postoperative day (POD) 3, the amylase content was less than three times the upper limit of the normal serum value. Therefore, the intraperitoneal drainage tube was removed. On POD 14, she developed sudden fever with chills. The white blood cell count was 3,100 μ/L with 89% neutrophils, and the serum C-reactive protein level was 3.43 mg/dL. Contrast-enhanced computed tomography (CECT) showed intrahepatic segmental portal vein thrombosis without macroscopic abscesses or distinct infectious signs, including pancreatic fistula or bile fistula . After blood specimens were obtained for culture, tazobactam/piperacillin was administered. Since the blood cultures were positive for Enterococcus faecium, tazobactam/piperacillin was switched to vancomycin. We started novel oral anticoagulants for portal vein thrombosis on the day of diagnosis. When antithrombin III activity decreased, we added it to the drug regimen. On POD 19, Enterobacter cloacae and Klebsiella pneumoniae were recovered from the blood cultures, and meropenem was additionally administered. On POD 27, the antimicrobial treatment regimen was switched to levofloxacin based on the microbiological results. On POD 29, intrahepatic portal thrombosis had decreased, and the patient was discharged on POD 37. On POD 54, the patient presented with melena and was hospitalized for gastrointestinal endoscopy. On POD 55, she experienced cardiopulmonary arrest caused by hemorrhagic shock due to melena. Cardiopulmonary resuscitation was successfully performed. CECT showed a ruptured SMA aneurysm and arterio-intestinal fistula . Blood was lost into the reconstructed jejunal limb in the main SMA. No major intraabdominal abscess due to pancreatic leakage or biliary fistula was observed. The white blood cell count was 5,400 μ/L with 86.1% neutrophils, and the serum C-reactive protein level was 2.98 mg/dL. Thus, she was diagnosed with a ruptured aneurysm of the SMA. Since the laparotomic approach seemed difficult after the PD operation with resection of the SMA nerve plexus, we selected a covered stent as the preferred treatment option. Repair using the covered stent was performed by the cardiology team. This treatment successfully stopped the intestinal bleeding, and the patient recovered from hemorrhagic shock . E. coli was isolated from arterial blood cultures during angiography. Finally, she was diagnosed with a ruptured infected aneurysm of the SMA. After a 6-week course of intravenous antibiotic therapy, she was switched to long-term oral amoxicillin and clavulanic acid and was discharged on POD 100. There was no recurrence of bleeding at the 4-month follow-up, and the stent was patent in all subsequent CECT scans. Unfortunately, the patient died 7 months after the initial operation due to disease progression with multiple liver metastases.", + "fulltext_subclaims": [ + "The patient was a 78-year-old woman.", + "She had borderline resectable pancreatic ductal adenocarcinoma involving the SMA nerve plexus.", + "She underwent pancreaticoduodenectomy with en bloc resection of the superior mesenteric vein and the SMA nerve plexus after neoadjuvant chemotherapy.", + "On postoperative day 3, the amylase content was less than three times the upper limit of the normal serum value.", + "The intraperitoneal drainage tube was removed.", + "On postoperative day 14, she developed sudden fever with chills.", + "The white blood cell count was 3,100 μ/L with 89% neutrophils.", + "The serum C-reactive protein level was 3.43 mg/dL.", + "Contrast-enhanced computed tomography showed intrahepatic segmental portal vein thrombosis.", + "There were no macroscopic abscesses.", + "There were no distinct infectious signs, including pancreatic fistula or bile fistula.", + "Blood specimens were obtained for culture.", + "Tazobactam/piperacillin was administered.", + "Blood cultures were positive for Enterococcus faecium.", + "Tazobactam/piperacillin was switched to vancomycin.", + "Novel oral anticoagulants were started for portal vein thrombosis on the day of diagnosis.", + "Antithrombin III activity decreased.", + "Antithrombin III was added to the drug regimen.", + "On postoperative day 19, Enterobacter cloacae and Klebsiella pneumoniae were recovered from the blood cultures.", + "Meropenem was additionally administered.", + "On postoperative day 27, the antimicrobial treatment regimen was switched to levofloxacin.", + "On postoperative day 29, intrahepatic portal thrombosis had decreased.", + "The patient was discharged on postoperative day 37.", + "On postoperative day 54, the patient presented with melena.", + "She was hospitalized for gastrointestinal endoscopy.", + "On postoperative day 55, she experienced cardiopulmonary arrest caused by hemorrhagic shock due to melena.", + "Cardiopulmonary resuscitation was successfully performed.", + "Contrast-enhanced computed tomography showed a ruptured SMA aneurysm and arterio-intestinal fistula.", + "Blood was lost into the reconstructed jejunal limb in the main SMA.", + "No major intraabdominal abscess due to pancreatic leakage or biliary fistula was observed.", + "The white blood cell count was 5,400 μ/L with 86.1% neutrophils.", + "The serum C-reactive protein level was 2.98 mg/dL.", + "She was diagnosed with a ruptured aneurysm of the SMA.", + "A covered stent was selected as the preferred treatment option.", + "Repair using the covered stent was performed by the cardiology team.", + "This treatment successfully stopped the intestinal bleeding.", + "The patient recovered from hemorrhagic shock.", + "E. coli was isolated from arterial blood cultures during angiography.", + "She was diagnosed with a ruptured infected aneurysm of the SMA.", + "After a 6-week course of intravenous antibiotic therapy, she was switched to long-term oral amoxicillin and clavulanic acid.", + "She was discharged on postoperative day 100.", + "There was no recurrence of bleeding at the 4-month follow-up.", + "The stent was patent in all subsequent CECT scans.", + "The patient died 7 months after the initial operation due to disease progression with multiple liver metastases." + ], + "summary": "A 78-year-old woman with borderline resectable pancreatic ductal adenocarcinoma involving the superior mesenteric arterial nerve plexus underwent pancreaticoduodenectomy with en bloc resection of the superior mesenteric vein and the superior mesenteric arterial nerve plexus after neoadjuvant chemotherapy. On postoperative day 14, she had bacteremia and sudden fever with chills. During the postoperative course, macroscopic abscesses or distinct infectious signs, including pancreatic fistula or bile fistula, were not present, but pylephlebitis was observed. After the antimicrobial treatment course, the patient was discharged. After 17 days, she was hospitalized for melena. Contrast-enhanced computed tomography showed a ruptured aneurysm of the superior mesenteric artery into the small intestine without a major intraabdominal abscess. E. coli was isolated from blood cultures. The patient was diagnosed with a ruptured infected aneurysm of the superior mesenteric artery. She was treated successfully with a covered stent by the cardiology team. There was no recurrence of bleeding at the 4-month follow-up, and the stent was patent in all subsequent computed tomography scans.", + "summary_subclaims": [ + "The patient was a 78-year-old woman.", + "She had borderline resectable pancreatic ductal adenocarcinoma involving the superior mesenteric arterial nerve plexus.", + "She underwent pancreaticoduodenectomy with en bloc resection of the superior mesenteric vein and the superior mesenteric arterial nerve plexus.", + "The surgery was performed after neoadjuvant chemotherapy.", + "On postoperative day 14, she had bacteremia and sudden fever with chills.", + "During the postoperative course, macroscopic abscesses were not present.", + "During the postoperative course, distinct infectious signs were not present.", + "During the postoperative course, pancreatic fistula was not present.", + "During the postoperative course, bile fistula was not present.", + "Pylephlebitis was observed.", + "After the antimicrobial treatment course, the patient was discharged.", + "After 17 days, she was hospitalized for melena.", + "Contrast-enhanced computed tomography showed a ruptured aneurysm of the superior mesenteric artery into the small intestine.", + "Contrast-enhanced computed tomography showed no major intraabdominal abscess.", + "E. coli was isolated from blood cultures.", + "The patient was diagnosed with a ruptured infected aneurysm of the superior mesenteric artery.", + "She was treated successfully with a covered stent by the cardiology team.", + "There was no recurrence of bleeding at the 4-month follow-up.", + "The stent was patent in all subsequent computed tomography scans." + ] + }, + { + "id": "multiclinsum_test_149_en.txt", + "fulltext": "We report the case of a 46-year-old female non-smoker without medical history of interest, who had been working in a cosmetics packaging company for 20 years. She had undergone daily exposure to several substances including a red azo dye known as Sudan red.\nOver the past 15 years, the patient had experienced dyspnea, dry cough, occasional wheezing, facial edema, rhinitis and conjunctivitis. These symptoms had worsened in the last 3 years; she had frequently required emergency-room assistance for acute episodes of bronchospasm and had been admitted to hospital on four times. The patient’s symptoms responded to inhaled long acting beta-2 agonist and inhaled corticosteroids, and were clearly work-related since they improved on weekends, during vacations, and after she finally left her job.\nPhysical examination and chest radiograph were normal. Blood tests showed eosinophilia (500 cells/mm3) and increased total serum IgE (846 KU/L). Lung function study revealed an obstructive ventilatory pattern with a forced vital capacity (FVC) of 3.14 L (91%), a forced expiratory volume in one second (FEV1) of 2.12 L (76%) and FEV1/FVC of 67%. Methacholine challenge test was positive, with a PC20 of 0.85 mg/mL and a fractional exhaled nitric oxide test (FENO) of 47.2 ppb.\nWith a suspected diagnosis of OA, the patient underwent a specific inhalation challenge (SIC) with the azoic dye, in accordance with the recommendations in the European Respiratory Society guidelines . The patient was exposed to a mixture of 2 g of “Sudan Red” and 100 g of lactose powder, tipped from one tray to another 30 cm away from her face for 10 min; she continued treatment with inhaled long acting beta-2 agonist and inhaled corticosteroids due to the persistence of bronchospasm. During the procedure, she suffered dyspnea and cough, and experienced a dual positive response with a fall in FEV1 of 22% in the first 20 min and another of 33% approximately 10 h after the exposure. No significant changes in FEV1 were observed in response to a control challenge of lactose powder alone conducted on a separate day .\nInduced sputum samples were obtained previously and in the 24 h following the procedure, with a rise in the percentage of eosinophils from 10 to 65%. Methacholine and FENO tests did not present significant variations from the results obtained prior to the SIC. The diagnosis of OA due to Sudan Red was established, and the patient was advised to avoid the causal agent.", + "fulltext_subclaims": [ + "The patient is a 46-year-old female non-smoker.", + "She had been working in a cosmetics packaging company for 20 years.", + "She had daily exposure to a red azo dye known as Sudan red.", + "Over the past 15 years, she had experienced dyspnea, dry cough, occasional wheezing, facial edema, rhinitis, and conjunctivitis.", + "She had been admitted to hospital on four occasions.", + "Her symptoms responded to inhaled long acting beta-2 agonist and inhaled corticosteroids.", + "Her symptoms were clearly work-related since they improved on weekends, during vacations, and after she left her job.", + "Physical examination and chest radiograph were normal.", + "Blood tests showed eosinophilia (500 cells/mm3).", + "Lung function study revealed an obstructive ventilatory pattern.", + "Methacholine challenge test was positive, with a PC20 of 0.85 mg/mL.", + "The patient underwent a specific inhalation challenge (SIC) with the azoic dye.", + "The SIC was conducted in accordance with the recommendations in the European Respiratory Society guidelines.", + "During the SIC, she suffered dyspnea and cough.", + "She experienced a dual positive response with a fall in FEV1 of 22% in the first 20 min and another of 33% approximately 10 h after the exposure.", + "No significant changes in FEV1 were observed in response to a control challenge of lactose powder alone.", + "Induced sputum samples showed a rise in the percentage of eosinophils from 10 to 65%.", + "The diagnosis of occupational asthma due to Sudan Red was established.", + "The patient was advised to avoid the causal agent." + ], + "summary": "We present the case of a 46-year-old female patient who had been working in a cosmetics packaging company for 20 years. The patient developed occupational asthma to a red azo dye known as Sudan red. The diagnosis was confirmed by specific bronchial provocation test. Induced sputum samples were obtained previously and in the 24 h following the procedure, with a rise in the percentage of eosinophils from 10 to 65%.", + "summary_subclaims": [ + "The patient is a 46-year-old female.", + "The patient had been working in a cosmetics packaging company for 20 years.", + "The patient developed occupational asthma to a red azo dye known as Sudan red.", + "The diagnosis was confirmed by specific bronchial provocation test.", + "Induced sputum samples were obtained previously and in the 24 h following the procedure.", + "There was a rise in the percentage of eosinophils from 10 to 65%." + ] + }, + { + "id": "multiclinsum_test_3172_en.txt", + "fulltext": "Medical History\nV.R. was a 2-year-old boy when he was referred to our Hospital Pediatric Emergency Room for a suspected allergic reaction. He was born at term via vaginal delivery, with birth weight adequate for gestational age. He had been exclusively breastfed for 6 months; thereafter, complementary feeding, including regular intake of fish, eggs, and cow’s milk, was introduced without clinical problems. His familial history was negative for allergies. At 12 months of age, he was diagnosed with atopic dermatitis and treated with skin moisturizers.\n\nClinical Presentation\nAt 2 years of age, due to the occurrence of generalized urticaria, angioedema, wheezing, sneezing, and two vomiting episodes, V.R. was referred to our Hospital Pediatric Emergency Room, after being assisted at home by the territorial Emergency Service Team (EST). On EST first clinical evaluation, he presented with fair general conditions; generalized urticaria, rhinitis, and lips and eyelid angioedema were still present, and his vital signs were as follows: 96% peripheral oxygen saturation rate on ambient air; blood pressure 95/55 mmHg (50° pc 101/63 mmHg); heart rate 150 beats per minute (bpm) (normal range 80–120 bpm), respiratory rate 32 breaths/min (normal range 25 ± 4 breaths/min), and a Glasgow Coma Scale score of 15. The symptoms had occurred 15 min after a meal of smoked salmon, anchovies, mayonnaise, butter, salmon roe, and lumpfish roe. V.R. had previously eaten smoked salmon and mayonnaise without any symptoms. No intake of other foods/juices, alcohol, or medications was reported. During the ambulance trip to the hospital, intramuscular adrenaline (0.01 mg/kg), methylprednisolone (1 mg/kg), and oral cetirizine (0.25 mg/kg) was administered by the EST. The child was admitted to our Pediatric Emergency Department in fair general condition with lips and eyelid angioedema; vital sign parameters were stable compared to the previous evaluation. The results of routine laboratory analysis on admission were within the normal range.\n\nClinical Course\nAfter 12 and 24 h, due to worsening eyelid angioedema with reappearance of urticaria, a further administration of intravenous chlorpheniramine (0.25 mg/kg) was necessary. Tryptase (a protease released from mast cells during an acute allergic reaction) serum level in the acute phase (peak) was 5.39 μg/L, whereas the baseline level, detected 24 h after the allergic reaction, was 2.34 μg/L. In the pediatric population, the peak total serum tryptase should be at least 120% of the baseline tryptase level plus 2 μg/L (≥1.2 × baseline tryptase + 2 μg/L) to diagnose acute mast cell activation in anaphylaxis [11]. Indeed, in our patient, the peak tryptase level met this criterion, exceeding the diagnostic cutoff level (4.81 μg/L = 120% + 2 µg/L of the baseline level). After 36 h of hospitalization, V.R. was discharged in fair clinical condition, though the result of the specific food IgE test was not yet available. An adrenaline auto injection kit (0.15 mg) was prescribed, after instructing the patient of its proper use.\n\n\nFollow Up and Specific Allergy Tests\nOne week later, the patient returned to our outpatient office for a routine visit and was in good clinical condition. Food-specific serum IgE (by Immuno-CAP, Thermo Fisher Scientific, Uppsala, Sweden), meantime assessed, tested as follows: egg white (0.67 kUA/L), milk (1.12 kUA/L), beta-lactoglobulin (0.13 kUA/L), caseine (0.18 kUA/L), alfa-lactalbumin (0.48 kUA/L), peanut (<0.35 kUA/L), cod (<0.35 kUA/L), wheat (<0.35 kUA/L), shrimp (<0.35 kUA/L), salmon (<0.35 kUA/L), parvalbumin (<0.35 kUA/L), LTP Pru p3 (<0.35 kUA/L), and Betv2 (<0.35 kUA/L). Level ≥ 0.35 kUA/L was considered positive. Unfortunately, we could not perform the serum food-specific IgE test for fish roe (salmon and lumpfish roe), because it was not yet available in Italy.\n\nBased on a food-specific serum IgE test, only an allergic sensitization to cow’s milk and egg proteins was evident; indeed, these foods had previously been eaten without any symptoms. Prick-by-prick tests for smoked salmon, anchovies, mayonnaise, salmon roe (red caviar), and lumpfish roe were also performed. All these foods had been eaten a few minutes before the occurrence of the allergic reaction. The prick by-prick test was positive for salmon roe (red caviar 11 mm × 10 mm) and lumpfish roe (4 mm × 4 mm), but negative for all the other foods tested. Positive (histamine) and negative (saline solution) controls were included.", + "fulltext_subclaims": [ + "V.R. was a 2-year-old boy when he was referred to our Hospital Pediatric Emergency Room for a suspected allergic reaction.", + "He was born at term via vaginal delivery.", + "He had been exclusively breastfed for 6 months.", + "Complementary feeding, including regular intake of fish, eggs, and cow’s milk, was introduced without clinical problems.", + "His familial history was negative for allergies.", + "At 12 months of age, he was diagnosed with atopic dermatitis.", + "He was treated with skin moisturizers.", + "At 2 years of age, he was referred to the Hospital Pediatric Emergency Room due to generalized urticaria, angioedema, wheezing, sneezing, and two vomiting episodes.", + "The symptoms had occurred 15 min after a meal of smoked salmon, anchovies, mayonnaise, butter, salmon roe, and lumpfish roe.", + "V.R. had previously eaten smoked salmon and mayonnaise without any symptoms.", + "During the ambulance trip to the hospital, intramuscular adrenaline (0.01 mg/kg), methylprednisolone (1 mg/kg), and oral cetirizine (0.25 mg/kg) was administered by the EST.", + "The child was admitted to our Pediatric Emergency Department in fair general condition.", + "The results of routine laboratory analysis on admission were within the normal range.", + "After 12 and 24 h, due to worsening eyelid angioedema with reappearance of urticaria, a further administration of intravenous chlorpheniramine (0.25 mg/kg) was necessary.", + "The peak total serum tryptase was 5.39 μg/L.", + "The baseline tryptase level, detected 24 h after the allergic reaction, was 2.34 μg/L.", + "In the pediatric population, the peak total serum tryptase should be at least 120% of the baseline tryptase level plus 2 μg/L to diagnose acute mast cell activation in anaphylaxis.", + "The peak tryptase level met this criterion, exceeding the diagnostic cutoff level.", + "After 36 h of hospitalization, V.R. was discharged in fair clinical condition.", + "An adrenaline auto injection kit (0.15 mg) was prescribed.", + "One week later, the patient returned to our outpatient office for a routine visit.", + "Food-specific serum IgE tested as follows: egg white (0.67 kUA/L), milk (1.12 kUA/L), beta-lactoglobulin (0.13 kUA/L), caseine (0.18 kUA/L), alfa-lactalbumin (0.48 kUA/L), peanut (<0.35 kUA/L), cod (<0.35 kUA/L), wheat (<0.35 kUA/L), shrimp (<0.35 kUA/L), salmon (<0.35 kUA/L), parvalbumin (<0.35 kUA/L), LTP Pru p3 (<0.35 kUA/L), and Betv2 (<0.35 kUA/L).", + "Level ≥ 0.35 kUA/L was considered positive.", + "We could not perform the serum food-specific IgE test for fish roe (salmon and lumpfish roe), because it was not yet available in Italy.", + "Based on a food-specific serum IgE test, only an allergic sensitization to cow’s milk and egg proteins was evident.", + "Prick-by-prick tests for smoked salmon, anchovies, mayonnaise, salmon roe (red caviar), and lumpfish roe were also performed.", + "The prick by-prick test was positive for salmon roe (red caviar 11 mm × 10 mm) and lumpfish roe (4 mm × 4 mm)." + ], + "summary": "For this report, we reported a case of anaphylaxis in a 2-year-old boy admitted to our Hospital Pediatric Emergency Room with a suspected allergic reaction. 15 min after the meal, he presented generalized urticaria, angioedema, wheezing, sneezing, and two vomiting episodes. The meal was smoked salmon, butter, mayonnaise, anchovies, and fish roe (salmon and lumpfish roe). Tryptase serum levels presented as elevated in the acute phase and normal after 24 h. Serum food-specific IgE tested negative for salmon and other fish, such as skin prick tests. Serum food-specific IgE showed that the patient was sensitized to cow's milk and eggs, but he doesn't have a food allergy. He had regularly consumed milk and eggs before and after the allergic reaction without clinical problems. A prick-by-prick test resulted positive for fish roe (salmon and lumpfish roe). Based on patient's history, allergy test results in vivo, and tryptase serum levels, the diagnosis of anaphylaxis induced by fish roe was confirmed.", + "summary_subclaims": [ + "The patient was a 2-year-old boy.", + "He was admitted to the Hospital Pediatric Emergency Room.", + "The allergic reaction occurred 15 min after the meal.", + "He presented generalized urticaria.", + "He presented angioedema.", + "He presented wheezing.", + "He presented sneezing.", + "He had two vomiting episodes.", + "The meal included smoked salmon.", + "The meal included butter.", + "The meal included mayonnaise.", + "The meal included anchovies.", + "The meal included fish roe (salmon and lumpfish roe).", + "Tryptase serum levels were elevated in the acute phase.", + "Tryptase serum levels were normal after 24 h.", + "Serum food-specific IgE tested negative for salmon.", + "Serum food-specific IgE tested negative for other fish.", + "Skin prick tests tested negative for salmon and other fish.", + "Serum food-specific IgE showed sensitization to cow's milk.", + "Serum food-specific IgE showed sensitization to eggs.", + "The patient does not have a food allergy.", + "The patient regularly consumed milk and eggs before the allergic reaction.", + "The patient regularly consumed milk and eggs after the allergic reaction.", + "The patient had no clinical problems after consuming milk and eggs.", + "A prick-by-prick test resulted positive for fish roe (salmon and lumpfish roe).", + "The diagnosis of anaphylaxis induced by fish roe was confirmed." + ] + }, + { + "id": "multiclinsum_test_1521_en.txt", + "fulltext": "A 56-year old woman presented with chronic back pain. No history of trauma and no other associated symptoms. Patient’s personal and family medical histories did not show positive signs and symptoms of any splenic pathology. Physical examination likewise did not show any palpable splenic mass or splenomegaly. Laboratory workup was within the normal limits. She underwent thoracolumbar MRI to investigate her chronic back pain which incidentally showed 5 cm splenic mass which appeared hyperintense on T1-weighted images .\nShe was admitted in our institution and was subsequently prepared for laparoscopic splenectomy. Preoperative cardiopulmonary screening did not reveal any significant comorbidities. She had previous immunization as per established protocols for elective splenectomy. On surgery under general anesthesia, she was positioned in right lateral semi-decubitus position. A 10 mm Hasson trocar was inserted through the left periumbilical area followed by CO2 insufflation. Three more trocars (10 mm, two 5 mm trocars) were inserted at the left subcostal area. Abdominal inspection was done. Splenic artery and vein were identified and doubly ligated and clipped. Afterwards, splenocolic, lienorenal and phrenicosplenic ligaments were dissected and proceeded with ligation of the short gastric vessels. The spleen was then extracted. Grossly, the spleen was enlarged to 6 × 4 × 10 cm (A and 2B) and weighed 380 g with well-defined 3.8 × 3.2 × 4.2 cm mass predominantly cysts measuring less than 5 mm in diameters and containing serous and mucinous fluid. No solid or complex areas were identified. The rest of the splenic parenchyma is normal. Perioperative course was uneventful and the chronic back pain resolved. Final histopathological result was splenic lymphangioma.", + "fulltext_subclaims": [ + "A 56-year old woman presented with chronic back pain.", + "No history of trauma and no other associated symptoms.", + "Patient’s personal and family medical histories did not show positive signs and symptoms of any splenic pathology.", + "Physical examination did not show any palpable splenic mass or splenomegaly.", + "Laboratory workup was within the normal limits.", + "She underwent thoracolumbar MRI to investigate her chronic back pain.", + "The thoracolumbar MRI incidentally showed 5 cm splenic mass.", + "The splenic mass appeared hyperintense on T1-weighted images.", + "She was admitted in our institution.", + "She was subsequently prepared for laparoscopic splenectomy.", + "Preoperative cardiopulmonary screening did not reveal any significant comorbidities.", + "She had previous immunization as per established protocols for elective splenectomy.", + "On surgery under general anesthesia, she was positioned in right lateral semi-decubitus position.", + "A 10 mm Hasson trocar was inserted through the left periumbilical area.", + "CO2 insufflation was performed.", + "Three more trocars (10 mm, two 5 mm trocars) were inserted at the left subcostal area.", + "Abdominal inspection was done.", + "Splenic artery and vein were identified and doubly ligated and clipped.", + "Splenocolic, lienorenal and phrenicosplenic ligaments were dissected.", + "Ligation of the short gastric vessels was performed.", + "The spleen was then extracted.", + "Grossly, the spleen was enlarged to 6 × 4 × 10 cm.", + "The spleen weighed 380 g.", + "The spleen had a well-defined 3.8 × 3.2 × 4.2 cm mass predominantly cysts.", + "The cysts measured less than 5 mm in diameters.", + "The cysts contained serous and mucinous fluid.", + "No solid or complex areas were identified.", + "The rest of the splenic parenchyma is normal.", + "Perioperative course was uneventful.", + "The chronic back pain resolved.", + "Final histopathological result was splenic lymphangioma." + ], + "summary": "We present of a case of splenic mass in a 56-year old female, which remained undetected until incidentally discovered on work-up for chronic back pain. Laparoscopic splenectomy was eventually performed with eventual resolution of the chronic back pain. Histopathologic examination revealed splenic lymphangioma.", + "summary_subclaims": [ + "The patient is a 56-year-old female.", + "The patient had a splenic mass.", + "The splenic mass remained undetected until incidentally discovered.", + "The splenic mass was discovered on work-up for chronic back pain.", + "Laparoscopic splenectomy was performed.", + "The chronic back pain resolved after laparoscopic splenectomy.", + "Histopathologic examination revealed splenic lymphangioma." + ] + }, + { + "id": "multiclinsum_test_2647_en.txt", + "fulltext": "A 44-year-old man with right vocal cord palsy and recurrent aspiration was admitted to the intensive care unit (ICU) for respiratory failure due to carbapenem-resistant Acinetobacter baumannii pneumonia. He was put on mechanical ventilator support and the ventilator (Servo-U, Maquet) was connected to a scavenging system (EVAC 180) as an additional infection control measure in face of the COVID-19 epidemic. On the fifth ICU day, the heat moisture exchange (HME) in the breathing circuit was changed to a heated humidifier (Fisher and Paykel MR850) due to copious amount of sputum. On the sixth ICU day, his condition continued to improve and he was on PS mode with PS of 10 cmH2O above a PEEP of 6 cmH2O. Twenty-eight hours after he was put on PS mode, he became dyssynchronous with the ventilator, and labored breathing was observed. Despite the patient's respiratory effort, the backup pressure control (PC) was activated with a backup mandatory breath rate of 15 breaths/minute (bpm). Despite low inspiratory flow being delivered at a rate of 15 bpm, neither triggered nor mandatory breath could be recorded . Paradoxical changes in airway pressures were observed with a decrease in pressure from 28 to 20 cmH2O during the inspiratory phase and an increase in pressure from 20 to 28 cmH2O during the expiratory phase. The ventilator wrongly regarded the expiratory pressure of 28 cmH2O as peak pressure and the inspiratory pressure of 20 cmH2O as PEEP. Ten to 20 seconds afterward, PS breaths were seen to be superimposed on a similar pattern of paradoxical pressure changes. Specifically, PS breaths of 10 cmH2O (with airway pressure up to 17 cmH2O) were triggered by flow when the airway pressure dropped below 8 cmH2O . End-tidal CO2 (ETCO2) varied between 75 and 90 mm Hg. It was also noted the reservoir bag of the scavenging system was hyperinflated and water condensate was seen in the tubing connecting the ventilator exhaust outlet and the scavenging system. The reservoir bag was removed for inspection and was found filled with water condensate. Patient-ventilator dyssynchrony was abolished immediately after the water condensate was drained . Such an event did not recur when the emptied reservoir bag was reinstalled into the scavenging system .\nThe patient was weaned and extubated on the 8th ICU day. On the 15th ICU day, he developed right pneumothorax for which did not require drainage. He underwent further rehabilitation and was discharged from ICU after 29 days.", + "fulltext_subclaims": [ + "The patient was a 44-year-old man.", + "The patient had right vocal cord palsy.", + "The patient had recurrent aspiration.", + "The patient was admitted to the ICU for respiratory failure due to carbapenem-resistant Acinetobacter baumannii pneumonia.", + "The patient was put on mechanical ventilator support.", + "The ventilator was connected to a scavenging system as an additional infection control measure in face of the COVID-19 epidemic.", + "On the fifth ICU day, the heat moisture exchange in the breathing circuit was changed to a heated humidifier due to copious amount of sputum.", + "On the sixth ICU day, the patient was on PS mode with PS of 10 cmH2O above a PEEP of 6 cmH2O.", + "Twenty-eight hours after being put on PS mode, the patient became dyssynchronous with the ventilator.", + "Despite the patient's respiratory effort, the backup pressure control was activated with a backup mandatory breath rate of 15 breaths/minute.", + "Neither triggered nor mandatory breath could be recorded.", + "Paradoxical changes in airway pressures were observed with a decrease in pressure from 28 to 20 cmH2O during the inspiratory phase and an increase in pressure from 20 to 28 cmH2O during the expiratory phase.", + "The ventilator wrongly regarded the expiratory pressure of 28 cmH2O as peak pressure and the inspiratory pressure of 20 cmH2O as PEEP.", + "Ten to 20 seconds afterward, PS breaths were seen to be superimposed on a similar pattern of paradoxical pressure changes.", + "PS breaths of 10 cmH2O (with airway pressure up to 17 cmH2O) were triggered by flow when the airway pressure dropped below 8 cmH2O.", + "End-tidal CO2 varied between 75 and 90 mm Hg.", + "The reservoir bag of the scavenging system was hyperinflated.", + "Water condensate was seen in the tubing connecting the ventilator exhaust outlet and the scavenging system.", + "The reservoir bag was removed for inspection and was found filled with water condensate.", + "Patient-ventilator dyssynchrony was abolished immediately after the water condensate was drained.", + "Such an event did not recur when the emptied reservoir bag was reinstalled into the scavenging system.", + "The patient was weaned and extubated on the 8th ICU day.", + "On the 15th ICU day, the patient developed right pneumothorax.", + "The patient did not require drainage for the right pneumothorax.", + "The patient underwent further rehabilitation.", + "The patient was discharged from ICU after 29 days." + ], + "summary": "We report a patient showing an unusual pattern of dyssynchronous breathing related to a blocked scavenging system caused by the failure of its rod valve to open. Collection of water condensate inside its reservoir bag leading to a weight drag and deformation of its shape was found to be the cause. Specifically, our patient manifested as failure to trigger with the development of high positive end-expiratory pressure (PEEP) and paradoxical pressure changes during pressure support ventilation.", + "summary_subclaims": [ + "We report a patient showing an unusual pattern of dyssynchronous breathing related to a blocked scavenging system caused by the failure of its rod valve to open.", + "Collection of water condensate inside its reservoir bag leading to a weight drag and deformation of its shape was found to be the cause.", + "Our patient manifested as failure to trigger with the development of high positive end-expiratory pressure (PEEP) and paradoxical pressure changes during pressure support ventilation." + ] + }, + { + "id": "multiclinsum_test_47_en.txt", + "fulltext": "A 78-year-old asymptomatic male patient underwent evaluation for prostate cancer. CT revealed a 56 × 77 mm mass at the posterior mediastinum ; subsequently, he was diagnosed with AVA. Apart from prostate cancer, his medical history was unremarkable. He did not have history of liver disfunction nor trauma.. In addition, the physical examination results and laboratory data were normal. When we had extensive discussion with the general thoracic surgeons, there was concern that there could be a strong adhesion to the surrounding tissues.The orifice of the azygos vein was larger than in previous cases reported as well. The chest surgeons suggested that it would be safer to perform the surgery under the cardiopulmonary bypass by cardiac surgeons considering the risk of major bleeding. We anticipated from the preoperative images that resection of the AVA would be difficult. Therefore, we planned to occlude the AVA inflow with coil embolization, and to surgically close the outflow from inside of the superior vena cava (SVC), thus excluding the aneurysm from the SVC. Any compression of the adjacent structures, thrombus formation, or pulmonary embolism were not evident. First, we performed the coil embolization of the caudal AVA inflow and the second, third, and fourth intercostal veins via the right internal jugular vein approach . Next, through a reversed L-shaped sternotomy (right fourth intercostal space) , a cardiopulmonary bypass was established by right femoral artery cannulation and venous drainage from the right atrium and both brachiocephalic veins. Intraoperative findings revealed no adhesion of the AVA to the lung and SVC ; therefore, we considered AVA resection. The orifice of the azygos vein was 20 × 50 mm on the posterior wall of the SVC . Subsequently, AVA was depressurized, allowing the aneurysm excision by a stapler. We excised the AVA with a stapler device (Powered ECHELON FLEX® 7; Ethicon, Tokyo, Japan) and closed the orifice. The cardiopulmonary bypass time was 64 min, operative time was 394 min, and bleeding volume was 105 ml. Histopathologic examination confirmed the preoperative diagnosis; it showed few inflammatory cell infiltration around vasa vasorum, intimal thickening and hypertrophy of the medial smooth muscle cell. The subsequent surgical and clinical courses were uneventful, and the patient was discharged in stable condition 8 days later. Postoperative CT showed no abnormalities, with the aneurysm having disappeared.", + "fulltext_subclaims": [ + "The patient is a 78-year-old asymptomatic male.", + "CT revealed a 56 × 77 mm mass at the posterior mediastinum.", + "The patient was diagnosed with AVA.", + "The patient's medical history was unremarkable apart from prostate cancer.", + "The patient did not have a history of liver dysfunction.", + "The patient did not have a history of trauma.", + "Physical examination results were normal.", + "Laboratory data were normal.", + "There was concern that there could be a strong adhesion to the surrounding tissues.", + "The orifice of the azygos vein was larger than in previous cases reported.", + "The chest surgeons suggested that it would be safer to perform the surgery under cardiopulmonary bypass by cardiac surgeons.", + "We anticipated that resection of the AVA would be difficult.", + "We planned to occlude the AVA inflow with coil embolization.", + "We planned to surgically close the outflow from inside of the superior vena cava.", + "Any compression of the adjacent structures was not evident.", + "Thrombus formation was not evident.", + "Pulmonary embolism was not evident.", + "We performed coil embolization of the caudal AVA inflow.", + "We performed coil embolization of the second, third, and fourth intercostal veins.", + "The coil embolization was via the right internal jugular vein approach.", + "A cardiopulmonary bypass was established through a reversed L-shaped sternotomy.", + "Intraoperative findings revealed no adhesion of the AVA to the lung.", + "Intraoperative findings revealed no adhesion of the AVA to the SVC.", + "The orifice of the azygos vein was 20 × 50 mm on the posterior wall of the SVC.", + "The AVA was depressurized.", + "The aneurysm excision was performed by a stapler.", + "The AVA was excised with a Powered ECHELON FLEX® 7 stapler.", + "The cardiopulmonary bypass time was 64 min.", + "The operative time was 394 min.", + "The bleeding volume was 105 ml.", + "Histopathologic examination confirmed the preoperative diagnosis.", + "The histopathologic findings showed few inflammatory cell infiltration around vasa vasorum.", + "The histopathologic findings showed intimal thickening.", + "The histopathologic findings showed hypertrophy of the medial smooth muscle cell.", + "The surgical course was uneventful.", + "The clinical course was uneventful.", + "The patient was discharged in stable condition 8 days after surgery.", + "Postoperative CT showed no abnormalities.", + "The aneurysm had disappeared on postoperative CT." + ], + "summary": "Herein, we report the case of a giant azygos vein aneurysm in a 78-year-old man that was treated with a reversed L-shaped incision. A 56 × 77 mm saccular azygos vein aneurysm was incidentally detected on computed tomography. Subsequently, surgical resection with interventional radiology and reversed L-shaped thoracotomy was performed. First, we performed coil embolization of the azygos vein aneurysm inflow. Next, a cardiopulmonary bypass was established through a reversed L-shaped sternotomy, and the aneurysm was excised.", + "summary_subclaims": [ + "The patient was a 78-year-old man.", + "A giant azygos vein aneurysm was treated with a reversed L-shaped incision.", + "A 56 × 77 mm saccular azygos vein aneurysm was incidentally detected on computed tomography.", + "Surgical resection with interventional radiology and reversed L-shaped thoracotomy was performed.", + "Coil embolization of the azygos vein aneurysm inflow was performed.", + "A cardiopulmonary bypass was established through a reversed L-shaped sternotomy.", + "The aneurysm was excised." + ] + }, + { + "id": "multiclinsum_test_3095_en.txt", + "fulltext": "A 50-year-old Semitic male presented with a 15-year history of progressively worsening right knee pain and associated swelling. The pain, initially mild, had intensified to the point where it was present at rest and worsened with weight-bearing activities. The patient reported increased swelling but denied knee locking, giving way, or nighttime pain. Ibuprofen provided partial relief of symptoms. He was otherwise healthy and physically active, with no notable medical or family history.\n\nOn examination, there was significant quadriceps wasting in the right lower limb, with visible swelling in the popliteal fossa and anterior knee. Palpation revealed a hard, immobile, well-defined mass in the anterior knee (measuring 4 × 8 cm) as well as a diffuse mass in the posterior aspect. There were no associated skin changes or tenderness, except for the medial joint line, which was slightly sensitive to the patient. The patient had a knee flexion of 100 degrees, with full extension. McMurray’s test was negative, indicating there was no ligamentous instability.\n\nMagnetic resonance imaging (MRI) revealed a knee effusion, synovial hypertrophy, and a loose calcific body exerting pressure on the popliteal fossa and patellar tendon, anterior to the femoral condyle, which was suggestive of synovial chondromatosis.\n\nGiven the significant involvement and size of the loose body within the knee joint, an open surgical approach was decided. A medial parapatellar approach was utilized following an anterior mid-line incision. Two large loose bodies approximately 4 × 4 cm and 3 × 5 cm were removed from beneath the suprapatellar pouch and patellar tendon. Histopathological analysis confirmed synovial chondromatosis with synovial papillary hyperplasia.\n\nAfter 6 weeks, a second procedure was performed for the posterior knee mass using a posterior knee approach, and a 5 × 4 cm mass was successfully removed. Postoperatively, the patient began physiotherapy immediately and achieved a knee range motion of 0–125 degrees at 6 months, and there was no recurrence identified at 1 year postoperatively.", + "fulltext_subclaims": [ + "A 50-year-old Semitic male presented with a 15-year history of progressively worsening right knee pain.", + "The pain was present at rest and worsened with weight-bearing activities.", + "The patient reported increased swelling.", + "The patient denied knee locking.", + "The patient denied giving way.", + "The patient denied nighttime pain.", + "Ibuprofen provided partial relief of symptoms.", + "The patient was otherwise healthy.", + "On examination, there was significant quadriceps wasting in the right lower limb.", + "There was visible swelling in the popliteal fossa and anterior knee.", + "Palpation revealed a hard, immobile, well-defined mass in the anterior knee measuring 4 × 8 cm.", + "There was a diffuse mass in the posterior aspect of the knee.", + "There were no associated skin changes.", + "The medial joint line was slightly sensitive to the patient.", + "The patient had knee flexion of 100 degrees.", + "McMurray’s test was negative.", + "Magnetic resonance imaging revealed a knee effusion.", + "MRI showed synovial hypertrophy.", + "MRI showed a loose calcific body exerting pressure on the popliteal fossa and patellar tendon.", + "The loose calcific body was anterior to the femoral condyle.", + "The MRI findings were suggestive of synovial chondromatosis.", + "An open surgical approach was decided.", + "A medial parapatellar approach was utilized.", + "Two large loose bodies were removed from beneath the suprapatellar pouch and patellar tendon.", + "Histopathological analysis confirmed synovial chondromatosis.", + "A second procedure was performed for the posterior knee mass.", + "A 5 × 4 cm mass was successfully removed.", + "Postoperatively, the patient began physiotherapy immediately.", + "The patient achieved a knee range motion of 0–125 degrees at 6 months.", + "There was no recurrence identified at 1 year postoperatively." + ], + "summary": "A 50-year-old Semitic male presented with a 15-year history of progressively worsening right knee pain and swelling. Physical examination revealed significant swelling, restricted range of motion, and a palpable mass in the anterior and posterior knee, prompting further imaging. Magnetic resonance imaging confirmed the presence of large loose bodies and extensive synovial hypertrophy, leading to the decision for surgical intervention. The patient underwent a staged open radical synovectomy, first targeting the anterior compartment followed by the posterior compartment. Two large loose bodies were removed, and histopathology confirmed synovial chondromatosis with synovial papillary hyperplasia. The patient responded well postoperatively, with improved range of motion following physiotherapy.", + "summary_subclaims": [ + "The patient is a 50-year-old Semitic male.", + "The patient had a 15-year history of progressively worsening right knee pain and swelling.", + "Physical examination revealed significant swelling.", + "Physical examination revealed restricted range of motion.", + "Physical examination revealed a palpable mass in the anterior and posterior knee.", + "Magnetic resonance imaging confirmed the presence of large loose bodies.", + "Magnetic resonance imaging confirmed extensive synovial hypertrophy.", + "The decision was made for surgical intervention.", + "The patient underwent a staged open radical synovectomy.", + "The first stage targeted the anterior compartment.", + "The second stage targeted the posterior compartment.", + "Two large loose bodies were removed.", + "Histopathology confirmed synovial chondromatosis.", + "Histopathology confirmed synovial papillary hyperplasia.", + "The patient responded well postoperatively.", + "The patient had improved range of motion following physiotherapy." + ] + }, + { + "id": "multiclinsum_test_2957_en.txt", + "fulltext": "A 34-year-old nulligravida with a remote history of follicular cyst treated by ovarian cystectomy presented with acute abdominal pain associated with emesis. She was hemodynamically stable, but her abdominal exam was remarkable for rebound tenderness. Complete blood count revealed hemoglobin of 5.4 mg/dL (hematocrit of 18.7%) and an undetectable platelet count. Computed tomography of the abdomen and pelvis revealed moderate-volume hemoperitoneum and contrast blush surrounding the left ovary , which was consistent with low volume active blood loss from the left ovary.\nFive weeks prior to presentation, the patient experienced prolonged gingival bleeding after a dental appointment. Two weeks following this, she began to experience spontaneous bruising, epistaxis with minimal trauma or sneezing, and cravings for ice chips. This was followed by uncharacteristically long and heavy menses, during which the patient soaked 1 pad every 1-2 hours. She began to feel fatigue and shortness of breath with minimal activity. The day prior to admission, she began to feel abdominal bloating and the following day she described waxing and waning, moderate to severe abdominal pain.\nShe was admitted to the intensive care unit out of concern for possible spontaneous intracranial hemorrhage (ICH). She was transfused two units of platelets and two units of packed red cells; her platelet count rose only to 13 × 109/L and several hours later fell to 11 × 109/L . After review of her peripheral blood smear, hematology began empiric treatment for immune thrombocytopenia with IV immunoglobulin and IV methylprednisolone. The patient's platelet counts began to spontaneously improve without additional transfusion, consistent with a consumptive thrombocytopenia; at discharge, platelets were 162 × 109/L. The patient's hemoglobin recovered appropriately after platelet count recovered, presumably because the spontaneous bleeding from the left ovary ceased.\nA battery of hematologic, infectious, and rheumatologic testing revealed an antinuclear antibody (ANA) titer of 1:640, a negative double-stranded DNA (dsDNA), positive anti-Smith antibodies, positive anti-SSA antibodies, and positive anti-RNP antibodies. The patient met criteria for systemic lupus erythematosus (SLE), and her thrombocytopenia was attributed to this. Interestingly, the patient's direct Coomb's test was positive, which is unusual for ITP. The patient had normal bilirubin and liver function tests, but it was thought that she had an early synchronous autoimmune hemolytic anemia (AIHA), which can be associated with thrombocytopenia and can develop in the early years of diagnosis . The patient's response to steroids and normalization of hemoglobin levels with normalization of platelet function illustrates that her AIHA was mild and responsive to steroids alone. The patient was discharged in stable condition on 1 mg/kg oral prednisone and plaquenil.\nOne week after discharge, the patient was without active bleeding and ecchymoses were fading. However, she was found to have a platelet count of 28 × 109/L, and was treated for steroid-refractory ITP with rituximab 375 mg/m2 weekly for four weeks. She was placed on oral imuran in hopes of better controlling the underlying SLE. The patient responded well to these interventions, with subsequent platelet recovery to normal levels. She was vaccinated for pneumococcus and meningococcus, and a discussion was held regarding H. influenzae vaccination in anticipation of possible splenectomy later in life.", + "fulltext_subclaims": [ + "The patient is a 34-year-old nulligravida.", + "She had a remote history of follicular cyst treated by ovarian cystectomy.", + "She presented with acute abdominal pain associated with emesis.", + "She was hemodynamically stable.", + "Her abdominal exam was remarkable for rebound tenderness.", + "Complete blood count revealed hemoglobin of 5.4 mg/dL.", + "Computed tomography of the abdomen and pelvis revealed moderate-volume hemoperitoneum.", + "Computed tomography showed contrast blush surrounding the left ovary.", + "The contrast blush was consistent with low volume active blood loss from the left ovary.", + "Five weeks prior to presentation, the patient experienced prolonged gingival bleeding after a dental appointment.", + "Two weeks following this, she began to experience spontaneous bruising.", + "She had epistaxis with minimal trauma or sneezing.", + "She had cravings for ice chips.", + "She had uncharacteristically long and heavy menses.", + "She soaked 1 pad every 1-2 hours during menses.", + "She felt fatigue and shortness of breath with minimal activity.", + "The day prior to admission, she began to feel abdominal bloating.", + "The following day she described waxing and waning, moderate to severe abdominal pain.", + "She was admitted to the intensive care unit.", + "She was transfused two units of platelets.", + "She was transfused two units of packed red cells.", + "Her platelet count rose only to 13 × 109/L.", + "Several hours later, her platelet count fell to 11 × 109/L.", + "Hematology began empiric treatment for immune thrombocytopenia.", + "Treatment included IV immunoglobulin.", + "Treatment included IV methylprednisolone.", + "The patient's platelet counts began to spontaneously improve.", + "This was consistent with a consumptive thrombocytopenia.", + "The patient's platelet counts improved without additional transfusion.", + "At discharge, platelets were 162 × 109/L.", + "The patient's hemoglobin recovered appropriately after platelet count recovered.", + "The spontaneous bleeding from the left ovary ceased.", + "A battery of hematologic, infectious, and rheumatologic testing revealed an antinuclear antibody (ANA) titer of 1:640.", + "The patient met criteria for systemic lupus erythematosus (SLE).", + "The patient's direct Coomb's test was positive.", + "The patient had normal bilirubin and liver function tests.", + "It was thought that she had an early synchronous autoimmune hemolytic anemia (AIHA).", + "The patient's response to steroids and normalization of hemoglobin levels with normalization of platelet function illustrates that her AIHA was mild.", + "The patient was discharged on 1 mg/kg oral prednisone.", + "The patient was discharged on plaquenil.", + "One week after discharge, the patient was without active bleeding.", + "She was found to have a platelet count of 28 × 109/L.", + "She was treated for steroid-refractory ITP with rituximab 375 mg/m2 weekly for four weeks.", + "She was placed on oral imuran.", + "She was vaccinated for pneumococcus.", + "She was vaccinated for meningococcus.", + "A discussion was held regarding H. influenzae vaccination in anticipation of possible splenectomy later in life." + ], + "summary": "A 34-year-old nulligravida presented with abdominal pain after a heavy period and rebound tenderness. Urine beta-hCG was negative, hemoglobin was 5.4, and platelet count was zero. CT revealed hemoperitoneum and contrast blush surrounding the left ovary. She was treated for newly diagnosed systemic lupus erythematosus and steroid-refractory ITP. Her platelet count and symptoms improved.", + "summary_subclaims": [ + "The patient is a 34-year-old nulligravida.", + "She presented with abdominal pain after a heavy period.", + "She had rebound tenderness.", + "Urine beta-hCG was negative.", + "Hemoglobin was 5.4.", + "Platelet count was zero.", + "CT revealed hemoperitoneum.", + "CT showed a contrast blush surrounding the left ovary.", + "She was treated for newly diagnosed systemic lupus erythematosus.", + "She was treated for steroid-refractory ITP.", + "Her platelet count improved." + ] + }, + { + "id": "multiclinsum_test_1450_en.txt", + "fulltext": "A 30-year-old Pakistani man presented to our general surgery outpatient department with a complaint of a slow growing painless scrotal swelling present for the past two years. His lesion was itchy and no discharge was present. On examination there was a soft copper-colored swelling involving the medial, lower and lateral sides of his scrotum. Clinical diagnosis of an infectious disorder such as molluscum contagiosum was made. He had no significant past medical history of sexually transmitted disease or surgical procedure in that particular area. He had a normal laboratory checkup including blood biochemistry, serum lactate dehydrogenase levels and serology for sexually transmitted diseases and filariasis. There was no peripheral eosinophilia. Detailed physical examination, serology and the absence of eosinophilia excluded the possibility of the common etiology, filariasis. Surgical resection was performed and the specimen was sent for histopathology. The tissue was skin covered, measured 2.5cm × 2.5cm and the skin had a soft nodular raised area measuring 1.5cm × 1.5cm . The histopathological examination revealed a very rare disorder of the scrotum with dilated thin walled lymphatic channels just beneath the skin . Re-resection of deeper tissue was advised, which was undertaken and he had post-operative antibiotics. He has been free of complaints during five post-operative months.", + "fulltext_subclaims": [ + "A 30-year-old Pakistani man presented with a slow growing painless scrotal swelling present for the past two years.", + "The lesion was itchy.", + "No discharge was present.", + "On examination there was a soft copper-colored swelling involving the medial, lower and lateral sides of his scrotum.", + "Clinical diagnosis of an infectious disorder such as molluscum contagiosum was made.", + "He had no significant past medical history of sexually transmitted disease.", + "He had no surgical procedure in that particular area.", + "He had a normal laboratory checkup including blood biochemistry.", + "Serum lactate dehydrogenase levels were normal.", + "Serology for sexually transmitted diseases was normal.", + "Serology for filariasis was normal.", + "There was no peripheral eosinophilia.", + "Detailed physical examination excluded the possibility of filariasis.", + "Surgical resection was performed.", + "The specimen was sent for histopathology.", + "The tissue was skin covered.", + "The tissue measured 2.5cm × 2.5cm.", + "The skin had a soft nodular raised area measuring 1.5cm × 1.5cm.", + "Histopathological examination revealed a very rare disorder of the scrotum.", + "The histopathological examination showed dilated thin walled lymphatic channels just beneath the skin.", + "Re-resection of deeper tissue was advised.", + "He had post-operative antibiotics.", + "He has been free of complaints during five post-operative months." + ], + "summary": "We report the case of a 30-year-old Pakistani man who presented with scrotal swelling which was clinically misinterpreted as an infectious disorder. Later on re-resection of deeper tissue was performed to prevent recurrence. He is still being followed-up on a regular basis.", + "summary_subclaims": [ + "The patient is a 30-year-old Pakistani man.", + "The patient presented with scrotal swelling.", + "The scrotal swelling was clinically misinterpreted as an infectious disorder.", + "Re-resection of deeper tissue was performed.", + "The re-resection was performed to prevent recurrence.", + "The patient is still being followed-up on a regular basis." + ] + }, + { + "id": "multiclinsum_test_406_en.txt", + "fulltext": "A 62-year-old Caucasian woman with cardiovascular risk factors of smoking and dyslipidaemia was evaluated in the ED of her local hospital due to sudden onset anterior chest tightness with no radiation, relief positioning nor intensification through breathing movements. The patient described throat pain, as well as fever and cough for the preceding 2 weeks. Constant CP started 2 h before the ECG was obtained, and it showed ST-segment elevation in the inferior and lateral leads . This clinical condition was interpreted as a ST-segment elevation myocardial infarction. Acetylsalicylic acid and clopidogrel loading doses were immediately administered and thrombolytic treatment with tenecteplase (7000 U) was initiated [time estimated to percutaneous coronary intervention (PCI) was more than 120 min]. The patient was transferred to a PCI centre. During the helicopter transportation, the patient experienced two episodes of diplopia, lasting a few minutes. At arrival, ECG was repeated showing no ST-segment deviation and the coronary angiogram did not identify any atherosclerotic lesions. The patient noted complete relief from CP, although during evaluation presented with tachypnoea, basal crackles upon pulmonary auscultation, a 3/6 systolic murmur in the cardiac area, blood pressure of 130/70 mmHg, heart rate of 90 b.p.m. and body temperature of 37.8°C. Bed rest, furosemide, and supplemental oxygen were initiated. The echocardiogram showed moderate to severe left ventricular systolic dysfunction, due to areas of akinesia in the apex, distal and mid segments of the walls, sparing most of the basal segments and a mobile friable mass inside the left atrium, attached to the septum with dimensions of approximately 55 mm × 42 mm . Images acquired 48 h after admission revealed a left ventricle ejection fraction slightly improved (, S1–S3).\nThe initial laboratory study showed leucocytosis (15.7 × 103cell/mm3) with neutrophilia and C-reactive protein (3.6 mg/dL), N-terminal prohormone of brain natriuretic peptide (1431 pg/mL), and troponin I (19.4 µg/L) slightly high. Other laboratory values were within normal range. On the second day, C-reactive protein increased to 14 mg/dL and the maximum troponin I levels were 20.2 µg/L.\nThe head computed tomography did not present bleeding or recent ischaemic lesions but could identify morphologic sequelae of focal ischaemic lesions in the cerebellum and left occipital lobe.\nIn order to clarify the characteristics of the mass and understand the cause of the cardiac dysfunction, the patient was transferred to a tertiary centre with CMR available and possibility of performing cardiac surgery.\nThe CMR showed a mobile left atrium mass (, S4 and S5), adherent to the interatrial septum, isointense with respect to myocardium on T1 weighted images (WI), hyperintense with respect to myocardium on T2 WI, with slight enhancement during first pass perfusion, and heterogeneous enhancement in the late gadolinium enhancement (LGE) images, suggesting a possible myxoma . Regarding the myocardium evaluation, the left ventricle was non-dilated with mild systolic dysfunction and multiple subepicardial LGE foci in the inferolateral and mid-distal segments of the anterolateral wall, consistent with the diagnosis of myocarditis .\nThe patient underwent surgery on the 6th day with total tumour excision and autologous pericardial patch repair of the atrial septal defect. The periprocedural transoesophageal echocardiogram showed the mobility of the mass in to the left ventricle during diastole (, S6–S8).\nDuring recovery, the patient presented with mild vertigo while walking and diplopia in extreme eye movements. After a neurologist assessment, a cerebral magnetic resonance imaging was requested where were identified multiple infracentimetric lesions throughout the cerebral parenchyma, infra and supratentorial, affecting the cerebellar peduncles and left caudate nucleus. These lesions were moderately hypointense on T1 WI and hyperintense on T2 WI, presenting enhancement after administration of gadolinium. These features were consistent with an embolization process caused by fragments of the myxoma. The histopathological results of the operative specimen confirmed the diagnosis of myxoma.\nThe patient started in a rehabilitation program and at the 2 months’ follow-up visit complete recovery from neurological deficits was noted with the echocardiogram revealing normal left ventricle ejection fraction.", + "fulltext_subclaims": [ + "The patient is a 62-year-old Caucasian woman.", + "The patient has cardiovascular risk factors of smoking and dyslipidaemia.", + "The patient was evaluated in the ED due to sudden onset anterior chest tightness.", + "The chest pain had no radiation, relief positioning, or intensification through breathing movements.", + "The patient described throat pain.", + "The patient had fever and cough for the preceding 2 weeks.", + "Constant chest pain started 2 hours before the ECG was obtained.", + "The ECG showed ST-segment elevation in the inferior and lateral leads.", + "The clinical condition was interpreted as a ST-segment elevation myocardial infarction.", + "Acetylsalicylic acid and clopidogrel loading doses were immediately administered.", + "Thrombolytic treatment with tenecteplase (7000 U) was initiated.", + "The estimated time to percutaneous coronary intervention was more than 120 minutes.", + "The patient was transferred to a PCI centre.", + "During helicopter transportation, the patient experienced two episodes of diplopia.", + "The episodes of diplopia lasted a few minutes.", + "At arrival, the ECG showed no ST-segment deviation.", + "The coronary angiogram did not identify any atherosclerotic lesions.", + "The patient noted complete relief from chest pain.", + "The patient presented with tachypnoea.", + "The patient had basal crackles upon pulmonary auscultation.", + "The patient had a 3/6 systolic murmur in the cardiac area.", + "The blood pressure was 130/70 mmHg.", + "The heart rate was 90 b.p.m.", + "The body temperature was 37.8°C.", + "Bed rest, furosemide, and supplemental oxygen were initiated.", + "The echocardiogram showed moderate to severe left ventricular systolic dysfunction.", + "The echocardiogram showed areas of akinesia in the apex, distal and mid segments of the walls.", + "The echocardiogram showed a mobile friable mass inside the left atrium.", + "The mass was attached to the septum with dimensions of approximately 55 mm × 42 mm.", + "Images acquired 48 hours after admission revealed a left ventricle ejection fraction slightly improved.", + "The initial laboratory study showed leucocytosis (15.7 × 103cell/mm3).", + "The initial laboratory study showed neutrophilia.", + "The initial laboratory study showed C-reactive protein (3.6 mg/dL).", + "The initial laboratory study showed N-terminal prohormone of brain natriuretic peptide (1431 pg/mL).", + "The initial laboratory study showed troponin I (19.4 µg/L) slightly high.", + "Other laboratory values were within normal range.", + "On the second day, C-reactive protein increased to 14 mg/dL.", + "The maximum troponin I levels were 20.2 µg/L.", + "The head computed tomography did not present bleeding or recent ischaemic lesions.", + "The head computed tomography identified morphologic sequelae of focal ischaemic lesions in the cerebellum.", + "The head computed tomography identified morphologic sequelae of focal ischaemic lesions in the left occipital lobe.", + "The patient was transferred to a tertiary centre with CMR available.", + "The CMR showed a mobile left atrium mass adherent to the interatrial septum.", + "The mass was isointense with respect to myocardium on T1 weighted images.", + "The mass was hyperintense with respect to myocardium on T2 weighted images.", + "The mass had slight enhancement during first pass perfusion.", + "The mass had heterogeneous enhancement in the late gadolinium enhancement images.", + "The CMR findings suggested a possible myxoma.", + "The CMR showed multiple subepicardial late gadolinium enhancement foci in the inferolateral and mid-distal segments of the anterolateral wall.", + "The CMR findings were consistent with the diagnosis of myocarditis.", + "The patient underwent surgery on the 6th day.", + "The surgery included total tumour excision.", + "The surgery included autologous pericardial patch repair of the atrial septal defect.", + "The periprocedural transoesophageal echocardiogram showed the mobility of the mass into the left ventricle during diastole.", + "During recovery, the patient presented with mild vertigo while walking.", + "During recovery, the patient presented with diplopia in extreme eye movements.", + "Cerebral magnetic resonance imaging identified multiple infracentimetric lesions throughout the cerebral parenchyma.", + "The lesions were moderately hypointense on T1 weighted images.", + "The lesions were hyperintense on T2 weighted images.", + "The lesions presented enhancement after administration of gadolinium.", + "The features were consistent with an embolization process caused by fragments of the myxoma.", + "The histopathological results of the operative specimen confirmed the diagnosis of myxoma.", + "The patient started in a rehabilitation program.", + "At the 2 months’ follow-up visit, complete recovery from neurological deficits was noted.", + "The echocardiogram at the 2 months’ follow-up visit revealed normal left ventricle ejection fraction." + ], + "summary": "A 62-year-old female presenting with sudden onset CP and infero-lateral ST-elevation in the electrocardiogram. The diagnosis of ST-elevation myocardial infarction was presumed and administered tenecteplase. The patient was immediately transported to a percutaneous coronary intervention centre. She complained of intermittent diplopia during transport and referred constitutional symptoms for the past 2 weeks. Coronary angiography showed normal arteries. The echocardiogram revealed moderate to severe left ventricular systolic dysfunction due to large areas of akinesia sparing most of the basal segments, and a mobile mass inside the left atrium attached to the septum. The cardiac magnetic resonance (CMR) suggested the diagnosis of myocarditis with concomitant left atrial myxoma. The patient underwent resection of the myxoma. Neurological evaluation was performed due to mild vertigo while walking and diplopia in extreme eye movements. The head magnetic resonance imaging identified multiple infracentimetric lesions throughout the cerebral parenchyma compatible with an embolization process caused by fragments of the tumour.", + "summary_subclaims": [ + "The patient is a 62-year-old female.", + "She had sudden onset chest pain.", + "The electrocardiogram showed infero-lateral ST-elevation.", + "The diagnosis of ST-elevation myocardial infarction was presumed.", + "Tenecteplase was administered.", + "The patient was transported to a percutaneous coronary intervention centre.", + "She complained of intermittent diplopia during transport.", + "She had constitutional symptoms for the past 2 weeks.", + "Coronary angiography showed normal arteries.", + "The echocardiogram revealed moderate to severe left ventricular systolic dysfunction.", + "The echocardiogram showed large areas of akinesia sparing most of the basal segments.", + "A mobile mass inside the left atrium attached to the septum was found.", + "The cardiac magnetic resonance suggested the diagnosis of myocarditis.", + "The CMR suggested the diagnosis of left atrial myxoma.", + "The patient underwent resection of the myxoma.", + "Neurological evaluation was performed due to mild vertigo while walking.", + "Neurological evaluation was performed due to diplopia in extreme eye movements.", + "Head magnetic resonance imaging identified multiple infracentimetric lesions throughout the cerebral parenchyma.", + "The head MRI findings were compatible with an embolization process.", + "The embolization process was caused by fragments of the tumour." + ] + }, + { + "id": "multiclinsum_test_303_en.txt", + "fulltext": "A 90-year-old female with atrial fibrillation treated with therapeutic apixaban and aortic stenosis status-post TAVR with a 29 mm self-expanding Medtronic core-valve placed 7 years prior presented to the clinic for the evaluation of acute onset chest pain and elevated blood pressure on home monitoring of 190/90 mmHg. The patient described the chest pain as substernal, severe, radiating posteriorly, and lasting for 45 min before resolving spontaneously.\nThe patient had a routine echocardiogram performed 2 months prior showing a properly functioning bioprosthetic aortic valve with normal haemodynamic performance . The Doppler measured peak transaortic gradient was 4 mmHg and the mean transaortic gradient was 2 mmHg.\nVital signs in the clinic (blood pressure of 110/41 mmHg, heart rate of 76 beats/min, oxygen saturation of 95% on room air) and physical examination were noted as unremarkable.\nThe patient was referred to the emergency department for assessment of the coronary anatomy and to rule out aortic dissection . During imaging, the patient developed acute respiratory failure with severe pruritis and urticaria and was admitted for inpatient management.\nEvaluation in the emergency department was notable for the absence of hives, stridor, or other associated signs or symptoms of anaphylaxis.\nLab evaluation in the emergency department demonstrated a troponin-I value of 0.22 ng/mL (reference <0.04 ng/mL), B-type natriuretic peptide (BNP) of 514 pg/mL (reference <100 pg/mL; patient baseline of 22–71 pg/mL), and a positive COVID-19 polymerase chain reaction rapid test.\nChest x-ray was notable for diffuse interstitial pulmonary oedema. Electrocardiogram demonstrated sinus tachycardia with the left bundle branch block unchanged from prior. Computed tomographic (CT) angiography of the chest demonstrated trace bilateral pleural effusions, enlarged pulmonary arteries, and ruled out acute aortic dissection and pulmonary embolism.\nThe patient was hospitalized for acute decompensated heart failure and treated with non-invasive positive pressure ventilation, nitroglycerine infusion, and intravenous furosemide 40 mg twice daily. The patient’s respiratory status improved by Day 1 of the hospital admission. The peak BNP was 1649 pg/mL.\nPoint-of-care ultrasound (POCUS) performed with a handheld device on hospital Day 2 was suggestive of a significant diastolic flow across the TAVR valve and directed further investigation for the diagnosis of prosthetic valve failure .\nTransthoracic echocardiogram (TTE) on hospital Day 3 revealed severe aortic regurgitation with an eccentric and anteriorly directed jet and holodiastolic flow reversal in the descending thoracic aorta . A peak measured transaortic gradient was 9 mmHg and the mean transaortic gradient was 5 mmHg. At the time of the patient’s hospitalization, the hospital system where the patient was admitted was experiencing staffing shortages and resource limitations related to an ongoing community COVID-19 surge. This served to delay access to the patient’s echocardiogram. The hospital policy at the time was to delay routine transoesophageal echocardiography (TEE) until patients were designated as COVID-19 recovered.\nDuring hospitalization, the patient was treated for COVID-19 with intravenous remdesivir 100 mg for 4 days and intravenous dexamethasone 6 mg for 7 days. Initially, the patient was managed for 2 days with continuous heparin infusion for presumptive treatment of acute coronary syndrome but was restarted on therapeutic apixaban 5 mg twice daily. The patient was discharged after 7 days and was transitioned from intravenous furosemide to oral torsemide 20 mg twice daily.\nThree days after hospital discharge, TEE confirmed proper positioning of the bioprosthetic stent-valve with leaflet thickening, abnormal cusp mobility, restriction of the non-coronary cusp prosthetic leaflet, and an eccentric regurgitant jet consistent with severe aortic regurgitation . The acute TAVR valve regurgitation was subsequently treated with a valve-in-valve TAVR 17 days post-discharge.\nThe patient was seen in the clinic 30 days after valve-in-valve TAVR. The patient denied chest pain and dyspnoea. A TTE demonstrated bioprosthetic stent-valve in the aortic position with normal leaflet mobility and without paravalvular aortic regurgitation.", + "fulltext_subclaims": [ + "The patient is a 90-year-old female.", + "The patient has atrial fibrillation.", + "The patient is treated with therapeutic apixaban.", + "The patient has aortic stenosis.", + "The patient had a TAVR with a 29 mm self-expanding Medtronic core-valve placed 7 years prior.", + "The patient presented to the clinic for the evaluation of acute onset chest pain.", + "The patient had elevated blood pressure on home monitoring of 190/90 mmHg.", + "The patient described the chest pain as substernal, severe, radiating posteriorly, and lasting for 45 min before resolving spontaneously.", + "A routine echocardiogram performed 2 months prior showed a properly functioning bioprosthetic aortic valve with normal haemodynamic performance.", + "The Doppler measured peak transaortic gradient was 4 mmHg.", + "The mean transaortic gradient was 2 mmHg.", + "Vital signs in the clinic were noted as unremarkable.", + "The patient was referred to the emergency department for assessment of the coronary anatomy and to rule out aortic dissection.", + "During imaging, the patient developed acute respiratory failure with severe pruritis and urticaria.", + "The patient was admitted for inpatient management.", + "Evaluation in the emergency department was notable for the absence of hives, stridor, or other associated signs or symptoms of anaphylaxis.", + "Lab evaluation demonstrated a troponin-I value of 0.22 ng/mL.", + "The troponin-I reference value is <0.04 ng/mL.", + "BNP was 514 pg/mL.", + "The BNP reference value is <100 pg/mL.", + "The patient’s baseline BNP was 22–71 pg/mL.", + "The patient had a positive COVID-19 polymerase chain reaction rapid test.", + "Chest x-ray was notable for diffuse interstitial pulmonary oedema.", + "Electrocardiogram demonstrated sinus tachycardia with the left bundle branch block unchanged from prior.", + "CT angiography of the chest ruled out acute aortic dissection.", + "CT angiography ruled out pulmonary embolism.", + "The patient was hospitalized for acute decompensated heart failure.", + "The patient was treated with non-invasive positive pressure ventilation.", + "The patient was treated with nitroglycerine infusion.", + "The patient was treated with intravenous furosemide 40 mg twice daily.", + "The patient’s respiratory status improved by Day 1 of the hospital admission.", + "The peak BNP was 1649 pg/mL.", + "POCUS performed on hospital Day 2 was suggestive of a significant diastolic flow across the TAVR valve.", + "POCUS directed further investigation for the diagnosis of prosthetic valve failure.", + "TTE on hospital Day 3 revealed severe aortic regurgitation with an eccentric and anteriorly directed jet.", + "TTE showed holodiastolic flow reversal in the descending thoracic aorta.", + "The peak measured transaortic gradient was 9 mmHg.", + "The mean transaortic gradient was 5 mmHg.", + "The hospital system was experiencing staffing shortages and resource limitations related to an ongoing community COVID-19 surge.", + "The hospital policy at the time was to delay routine TEE until patients were designated as COVID-19 recovered.", + "The patient was treated for 2 days with continuous heparin infusion for presumptive treatment of acute coronary syndrome.", + "The patient was restarted on therapeutic apixaban 5 mg twice daily.", + "The patient was discharged after 7 days.", + "The patient was transitioned from intravenous furosemide to oral torsemide 20 mg twice daily.", + "Three days after hospital discharge, TEE confirmed proper positioning of the bioprosthetic stent-valve.", + "TEE showed leaflet thickening.", + "TEE showed abnormal cusp mobility.", + "TEE showed restriction of the non-coronary cusp prosthetic leaflet.", + "TEE showed an eccentric regurgitant jet consistent with severe aortic regurgitation.", + "The acute TAVR valve regurgitation was treated with a valve-in-valve TAVR 17 days post-discharge.", + "The patient was seen in the clinic 30 days after valve-in-valve TAVR.", + "The patient denied chest pain.", + "The patient denied dyspnoea.", + "A TTE demonstrated bioprosthetic stent-valve in the aortic position.", + "The TTE showed normal leaflet mobility.", + "The TTE showed no paravalvular aortic regurgitation." + ], + "summary": "A 90-year-old female with atrial fibrillation on therapeutic apixaban and status-post TAVR presented with COVID-19 infection and was found to have severe bioprosthetic valvular regurgitation with features suggestive of valve thrombosis. She underwent valve-in-valve TAVR with resolution of valvular dysfunction.", + "summary_subclaims": [ + "The patient is a 90-year-old female.", + "She has atrial fibrillation.", + "She is on therapeutic apixaban.", + "She had a transcatheter aortic valve replacement (TAVR).", + "She presented with a COVID-19 infection.", + "She was found to have severe bioprosthetic valvular regurgitation.", + "Features were suggestive of valve thrombosis.", + "She underwent valve-in-valve TAVR.", + "Valvular dysfunction resolved." + ] + }, + { + "id": "multiclinsum_test_768_en.txt", + "fulltext": "A 75-year-old Chinese man who had been experiencing chest pain for 10 years presented at our institution. He was moderately active, doing odd jobs around the house, and accelerating angina over the past 2 years. The patient had been taking aspirin, nifedipine for high blood pressure and metformin for diabetes mellitus type 2 for almost 10 years. He smoked one pack of cigarettes per day for about 40 years before quitting the previous year. His past history was remarkable for chronic obstructive pulmonary disease.\nAt the time of admission, the physical examination showed heart rate (HR), 67 beats/min (bpm); blood pressure (BP), 156/89 mmHg; and blood glucose, 6.85 mmol/L. An electrocardiogram (ECG) showed a sinus rhythm with ST depression and T-wave inversion when chest pain occurred. A complete blood count and a basal metabolic profile were examined; the evaluation of kidney function, blood acid, base balance, and blood sugar levels showed that there were all within a normal range. The treadmill exercise test was positive, and showed ST depression on the ECG when chest pain or shortness of breath occurred. The patient’s response to clopidogrel therapy was determined by testing for CYP450 genetic polymorphism, which showed non-resistance to such therapy. Testing for CYP450 genetic polymorphism was to predict response to clopidogrel\n.\nThe patient was prepared for coronary angiography (and stent placement if necessary). Before the procedure, the patient’s spontaneous baroreflex sensitivity (BRS), heart rate variability (HRV), and blood pressure variability (BPV) were measured (Table ). Six hours before the patient underwent coronary angiography, he was given 300 mg aspirin and 300 mg clopidogrel. An initial dose of heparin (100U/kg) was intravenously given before the procedure; an additional dose of heparin at 500U would be given if the procedure lasted 1 hour. The activated clotting time was maintained at 325 s.\nThe coronary angiogram was done through the radial approach. The angiogramrevealed a proximal 90% diffuse stenosis with calcification in the middle segment of the left anterior descending artery (Figure A), and 95% stenosis with calcification in the left circumflex artery (Figure B). The right coronary artery was observed to have >80% diffuse stenosis with heavy calcification and occlusion in the middle segment (Figure C).\nTwo overlapping sirolimus-eluting stents (Cypher; Cordis, Miami, USA.), mounted on a balloon catheter, were inserted without a gap into the left anterior descending artery (stents were 36 mm in length and 3 mm in diameter) and the left circumflex artery (stents 14 mm in length and 3 mm in diameter), respectively (Figure A). The stents were advanced into the narrowed section of the arteries. When the stents were positioned, the balloon was inflated. To ensure full expansion of the stents, the stent balloon was gradually inflated to 14 atm in 10 to 40 seconds. Because of chronic total occlusion in the right coronary artery, we attempted to pass a wire through the lesion but failed. Considering that collateral circulation was already present, we abandoned the stent placement into the right coronary artery. After the stenting procedure, the thrombolysis in myocardial infarction (TIMI) grade was 3, and no cineangiographic characteristics of thrombus were present. The procedure was uneventful without a special condition for the patient.\nApproximately 20 minutes after the procedure (18:40), the patient developed nausea, vomiting, sweating and slow breathing associated with diaphoresis and pale complexion. His blood pressure was 87/52 mmHg and heart rate was 39 bpm. At that time, the patient was conscious and had no chest pain. No evidence of bleeding or hematoma was found. The ECG monitor showed no change in ST/T waves. The HRV and BRS were, however, found to be greatly elevated (Table ) compared with the levels measured before stenting, suggesting VBA. After administration of 1.5 L intravenous saline with dopamine and atropine, the BP and HR slightly improved.\nHowever, at 22:50, the patient complained of precordial chest pain and diaphoresis, and presented drowsy, cold and clammy extremities. His peripheral pulses were not palpable, and blood pressure was not recordable. The ECG monitors showed ST elevation in leads V1, V2, V3 and V4; reciprocal ST depression in leads I, aVL and aVF; and sinus bradycardia with first-degree heart block. The cardiac troponin I (cTnI) testing value was 0.06 ng/mL (normal value 0.04 ng/mL). A diagnosis of myocardial infarction associated with first-degree heart block and cardiogenic shock was made.\nImmediately a repeat coronary angiogram was done through the femoral approach, and the left anterior descending and circumflex arteries, into which the stents had been placed, were reexamined. The angiogram revealed thrombotic occlusion of the planted stents (Figure B) in both the left anterior descending and circumflex arteries, with TIMI flow grades of 1 and 0, respectively. The thrombus burden was graded as G3 in the circumflex artery and as G4 in the left anterior descending artery. No evidence of artery dissection was found.\nAn intra-aortic balloon pump (IABP) was immediately inserted. The TIMI flow grade showed no improvement after runs of aspiration in the two arteries; at that time the patient was still in cardiogenic shock. An intracoronary balloon was placed at the location where the thrombi adhered in the left anterior descending and circumflex arteries. While continuing counterpulsation of the IABP, the thrombi in the stents disappeared shortly afterward (Figure C). The patient was given tirofiban, aspirin, clopidogrel and heparin; the balloon counterpulsation was maintained until the patient’s heart rate normalized and blood pressure stabilized. The patient was discharged with a normal echocardiographic evaluation, and was asymptomatic at follow-up.", + "fulltext_subclaims": [ + "The patient was a 75-year-old Chinese man.", + "He had been experiencing chest pain for 10 years.", + "He was moderately active, doing odd jobs around the house.", + "He had accelerating angina over the past 2 years.", + "He had been taking aspirin, nifedipine, and metformin for almost 10 years.", + "He smoked one pack of cigarettes per day for about 40 years before quitting the previous year.", + "His past history was remarkable for chronic obstructive pulmonary disease.", + "At the time of admission, blood pressure was 156/89 mmHg.", + "An electrocardiogram showed ST depression and T-wave inversion when chest pain occurred.", + "The treadmill exercise test was positive and showed ST depression on the ECG when chest pain or shortness of breath occurred.", + "Testing for CYP450 genetic polymorphism showed non-resistance to clopidogrel therapy.", + "Testing for CYP450 genetic polymorphism was to predict response to clopidogrel.", + "The patient was prepared for coronary angiography.", + "Before the procedure, spontaneous baroreflex sensitivity, heart rate variability, and blood pressure variability were measured.", + "Six hours before the procedure, he was given 300 mg aspirin and 300 mg clopidogrel.", + "An initial dose of heparin (100U/kg) was intravenously given before the procedure.", + "The coronary angiogram was done through the radial approach.", + "The angiogram revealed a proximal 90% diffuse stenosis with calcification in the middle segment of the left anterior descending artery.", + "The right coronary artery had >80% diffuse stenosis with heavy calcification and occlusion in the middle segment.", + "Two overlapping sirolimus-eluting stents were inserted into the left anterior descending artery and the left circumflex artery.", + "The stents were advanced into the narrowed section of the arteries.", + "The stent balloon was gradually inflated to 14 atm in 10 to 40 seconds.", + "Because of chronic total occlusion in the right coronary artery, we attempted to pass a wire through the lesion but failed.", + "We abandoned the stent placement into the right coronary artery.", + "After the stenting procedure, the TIMI grade was 3.", + "Approximately 20 minutes after the procedure, the patient developed nausea, vomiting, sweating, and slow breathing.", + "His blood pressure was 87/52 mmHg and heart rate was 39 bpm.", + "The ECG monitor showed no change in ST/T waves.", + "The HRV and BRS were greatly elevated compared with the levels measured before stenting.", + "After administration of 1.5 L intravenous saline with dopamine and atropine, the BP and HR slightly improved.", + "At 22:50, the patient complained of precordial chest pain and diaphoresis.", + "The ECG showed ST elevation in leads V1, V2, V3, and V4.", + "The ECG showed reciprocal ST depression in leads I, aVL, and aVF.", + "The cardiac troponin I testing value was 0.06 ng/mL.", + "A diagnosis of myocardial infarction associated with first-degree heart block and cardiogenic shock was made.", + "A repeat coronary angiogram revealed thrombotic occlusion of the planted stents in both the left anterior descending and circumflex arteries.", + "The thrombus burden was graded as G3 in the circumflex artery and as G4 in the left anterior descending artery.", + "An intra-aortic balloon pump was immediately inserted.", + "The patient was given tirofiban, aspirin, clopidogrel, and heparin.", + "The patient was discharged with a normal echocardiographic evaluation." + ], + "summary": "In the present article, we report a case of a Chinese patient (a 75-year-old male) with coronary artery disease who presented with hemodynamic alterations as a complication of vagal baroreflex activation after implantation of overlapping stents, followed by stent thrombosis associated with myocardial infarction.", + "summary_subclaims": [ + "The patient is a 75-year-old male.", + "The patient is Chinese.", + "The patient has coronary artery disease.", + "The patient had overlapping stents implanted.", + "The patient experienced vagal baroreflex activation.", + "The patient had hemodynamic alterations.", + "The hemodynamic alterations were a complication of vagal baroreflex activation.", + "The patient had stent thrombosis.", + "The stent thrombosis was associated with myocardial infarction." + ] + }, + { + "id": "multiclinsum_test_929_en.txt", + "fulltext": "A 61-year-old male patient sought treatment for an infiltrating erythematous plaque on the nasal tip, which gradually enlarged with ulceration and haemorrhage over the prior 2 months. The patient developed a red papule on the nasal tip 2 months prior. The skin lesion gradually enlarged to the size of a broad bean. In the past 2 weeks, a plaque developed, with ulcerations and bleeding, and a black crust formed. The patient had a 40-year history of hepatitis B and had not received standardized antiviral therapy. Three years ago, a 2.0×1.5 cm space-occupying mass in the left lobe of the liver was found through a physical examination. Local surgical resection was performed. The patient was diagnosed with well-differentiated hepatocellular carcinoma and nodular cirrhosis based on postoperative histopathological and immunohistochemical examinations, and further treatment was not administered.\nThe patient’s systemic examination showed no obvious abnormalities. A dermatological examination showed that no obvious yellow staining in the skin and mucous membranes of the whole body. A red infiltrating nodule was seen on the nasal tip, without peduncles, with a hard and tough texture; the nodule was raised, ulcerated, and covered with a black crust . No similar lesions were found on the skin of any other area of the body. The alpha-fetoprotein level in peripheral blood was 260 μg/L (normal level ≤ 25 μg/L). Whole-body computed tomography (CT) showed irregular liver margins, an enlarged left hepatic lobe, a slightly low-density mass in the left hepatic lobe, an enlarged spleen, and a widened portal vein , findings that were consistent with liver cirrhosis and liver cancer. No space-occupying lesion was observed in other organs. Skin biopsy was performed after local anaesthesia. Histopathology showed epidermal necrosis with ulceration, a dense tumour cell mass in the dermis, with a sinus-like, nodular and cord-like distribution, and some atypical tumour cells . Immunohistochemistry of intradermal tumour cells revealed the following: HepPar-1(+), Arg-1(+), CK8(+), Villin(+), CK7(-), CK20(-), and Ki-67 positive (approximately 90%) . Based on the clinical manifestations, medical history, imaging results, and histopathology results, the patient was diagnosed with cutaneous metastases of hepatocellular carcinoma. The patient gave up systemic treatment and subsequently lost the visit.", + "fulltext_subclaims": [ + "The patient is a 61-year-old male.", + "The patient had an infiltrating erythematous plaque on the nasal tip.", + "The plaque gradually enlarged with ulceration and haemorrhage over the prior 2 months.", + "The patient developed a red papule on the nasal tip 2 months prior.", + "The skin lesion gradually enlarged to the size of a broad bean.", + "In the past 2 weeks, a plaque developed with ulcerations and bleeding.", + "A black crust formed on the nasal lesion.", + "The patient had a 40-year history of hepatitis B.", + "The patient had not received standardized antiviral therapy.", + "Three years ago, a 2.0×1.5 cm space-occupying mass in the left lobe of the liver was found through a physical examination.", + "Local surgical resection was performed.", + "The patient was diagnosed with well-differentiated hepatocellular carcinoma.", + "The patient was diagnosed with nodular cirrhosis.", + "The diagnosis was based on postoperative histopathological and immunohistochemical examinations.", + "The patient's systemic examination showed no obvious abnormalities.", + "A red infiltrating nodule was seen on the nasal tip.", + "The nodule was raised, ulcerated, and covered with a black crust.", + "No similar lesions were found on the skin of any other area of the body.", + "The alpha-fetoprotein level in peripheral blood was 260 μg/L.", + "Whole-body CT showed irregular liver margins.", + "Whole-body CT showed an enlarged left hepatic lobe.", + "Whole-body CT showed a slightly low-density mass in the left hepatic lobe.", + "Whole-body CT showed an enlarged spleen.", + "Whole-body CT showed a widened portal vein.", + "The CT findings were consistent with liver cirrhosis and liver cancer.", + "No space-occupying lesion was observed in other organs.", + "Skin biopsy was performed after local anaesthesia.", + "Histopathology showed epidermal necrosis with ulceration.", + "Histopathology showed a dense tumour cell mass in the dermis.", + "The tumour cells had a sinus-like, nodular and cord-like distribution.", + "Immunohistochemistry of intradermal tumour cells showed HepPar-1(+).", + "Immunohistochemistry of intradermal tumour cells showed Arg-1(+).", + "Immunohistochemistry of intradermal tumour cells showed CK8(+).", + "Immunohistochemistry of intradermal tumour cells showed Villin(+).", + "Immunohistochemistry of intradermal tumour cells showed CK7(-).", + "Immunohistochemistry of intradermal tumour cells showed CK20(-).", + "Immunohistochemistry of intradermal tumour cells showed Ki-67 positive (approximately 90%).", + "The patient was diagnosed with cutaneous metastases of hepatocellular carcinoma.", + "The patient gave up systemic treatment.", + "The patient subsequently lost the visit." + ], + "summary": "This report describes a male patient with HCC with cutaneous metastases to the nasal tip. The patient developed a raised nodule at the nasal tip 5 years after surgery for HCC, with surface ulceration and crusting and no obvious symptoms. Abdominal computed tomography (CT) showed an obvious mass in the liver. The skin lesions on the nasal tip were confirmed to be cutaneous metastasis of HCC by histopathological and immunohistochemical examinations.", + "summary_subclaims": [ + "The patient is male.", + "The patient has HCC.", + "The patient has cutaneous metastases to the nasal tip.", + "The patient developed a raised nodule at the nasal tip.", + "The nodule was 5 years after surgery for HCC.", + "The nodule had surface ulceration.", + "The nodule had crusting.", + "The nodule had no obvious symptoms.", + "Abdominal computed tomography showed an obvious mass in the liver.", + "The skin lesions on the nasal tip were confirmed to be cutaneous metastasis of HCC.", + "Histopathological and immunohistochemical examinations were performed." + ] + }, + { + "id": "multiclinsum_test_2676_en.txt", + "fulltext": "A 56-year-old woman presented with epigastric pain without heartburn, acid reflux, or abdominal distension and in a good overall condition. Her diet, faeces, and urine were normal, and she had no recent changes in body weight.\nThe patient experienced epigastric pain for the past 20 d.\nThe patient had a history of cervical spondylosis and had undergone bilateral pterygium surgery in the past. There was no history of drinking or smoking.\nNo special personal or family history.\nThe patient’s vital signs were stable and physical examination was unremarkable.\nPreoperative blood tests, such as routine blood examination, liver function, and serum tumour markers of the digestive system, showed no abnormalities.\nGastroscopy revealed a submucosal protuberance of the gastric antrum approximately 15 mm in diameter that had a smooth surface, scattered congestion, and an opening at the top . EUS revealed a submucosal protuberance of approximately 1.19 cm × 0.89 cm on the posterior wall of the gastric antrum. The protuberance was round, similar to mixed echogenic masses, predominately hypoechoic with unclear boundaries, and originating from the submucosa. We considered the possibility of a heterotopic pancreas. An abdominal CT scan showed no obvious abnormal thickening or enhancement shadow of the gastric antrum . Surgical contraindications were absent, and endoscopic submucosal dissection was performed with informed consent from the patient and her family. The lesion was located on the posterior wall of the gastric antrum. After marking and submucosal injection of methylene blue, glycerine fructose, adrenaline, and sodium hyaluronate, the lesion was cut with a dual knife (KD-650L; Olympus, Tokyo, Japan) and peeled off layer by layer. The recovered tissue was biopsied. While inspecting the wound, a strip of white foreign body was found under the wound that could not be pulled out using forceps .", + "fulltext_subclaims": [ + "The patient is a 56-year-old woman.", + "She presented with epigastric pain.", + "She had no heartburn.", + "She had no acid reflux.", + "She had no abdominal distension.", + "She was in a good overall condition.", + "Her diet was normal.", + "Her faeces were normal.", + "Her urine was normal.", + "She had no recent changes in body weight.", + "The patient experienced epigastric pain for the past 20 d.", + "The patient had a history of cervical spondylosis.", + "The patient had undergone bilateral pterygium surgery in the past.", + "There was no history of drinking.", + "There was no history of smoking.", + "There was no special personal or family history.", + "The patient’s vital signs were stable.", + "Physical examination was unremarkable.", + "Preoperative blood tests showed no abnormalities.", + "Gastroscopy revealed a submucosal protuberance of the gastric antrum approximately 15 mm in diameter.", + "The protuberance had a smooth surface.", + "The protuberance had scattered congestion.", + "The protuberance had an opening at the top.", + "EUS revealed a submucosal protuberance of approximately 1.19 cm × 0.89 cm on the posterior wall of the gastric antrum.", + "The protuberance was round.", + "The protuberance was similar to mixed echogenic masses.", + "The protuberance was predominately hypoechoic.", + "The protuberance had unclear boundaries.", + "The protuberance originated from the submucosa.", + "We considered the possibility of a heterotopic pancreas.", + "An abdominal CT scan showed no obvious abnormal thickening or enhancement shadow of the gastric antrum.", + "Surgical contraindications were absent.", + "Endoscopic submucosal dissection was performed.", + "Informed consent was obtained from the patient and her family.", + "The lesion was located on the posterior wall of the gastric antrum.", + "After marking and submucosal injection of methylene blue, glycerine fructose, adrenaline, and sodium hyaluronate, the lesion was cut with a dual knife.", + "The lesion was peeled off layer by layer.", + "The recovered tissue was biopsied.", + "A strip of white foreign body was found under the wound.", + "The foreign body could not be pulled out using forceps." + ], + "summary": "A 58-year-old woman presented with epigastric pain for the past 20 d and a submucosal protuberance. Abdominal computed tomography and endoscopic ultrasonography did not indicate the presence of a fish bone. We assumed the cause to be an ordinary submucosal eminence and performed an endoscopic submucosal dissection to confirm its essence. During the operation, a fish bone approximately 20 mm in length was found incidentally.", + "summary_subclaims": [ + "The patient is a 58-year-old woman.", + "She presented with epigastric pain for the past 20 d.", + "She had a submucosal protuberance.", + "Abdominal computed tomography did not indicate the presence of a fish bone.", + "Endoscopic ultrasonography did not indicate the presence of a fish bone.", + "We assumed the cause to be an ordinary submucosal eminence.", + "We performed an endoscopic submucosal dissection to confirm its essence.", + "During the operation, a fish bone approximately 20 mm in length was found incidentally." + ] + }, + { + "id": "multiclinsum_test_1679_en.txt", + "fulltext": "A 12-year-old Turkish girl, born at 38 weeks of gestational age to unrelated healthy parents, was well until 1 year of age, when she developed pustular cutaneous lesions that responded to corticosteroid and antibiotic treatment with healing and scar formation. Various treatments of these lesions had required four hospitalizations during the previous 11 years. No other family member had similar skin conditions. She was hospitalized at the age of 12 years for arthralgia of her knees, elbows, and ankles and arthritis of her left knee, with concomitant pustular cutaneous lesions. She developed septicemia and was admitted to the intensive care unit of a public hospital with respiratory insufficiency during her follow-up. After recovery, she was referred to our pediatric immunology department for further evaluation.\nA hyperpigmented scar lesion on the right side of the face; bilateral inguinal, paraumbilical hyperpigmented scar lesions; and paronychia of the thumbs were noted on admission . Additionally, the patient had contracture of the left knee limiting her motion, episcleritis, and failure to thrive [25kg (below third percentile), 132cm (below third percentile)]. The results of her laboratory studies revealed iron deficiency anemia, hypergammaglobulinemia, and elevated acute-phase reactants (red blood cell count 4.2 million/mm3, hemoglobin 9.1g/dl, hematocrit 27.8%, mean corpuscular volume 81fl, thrombocytes 254,000/mm3, immunoglobulin G (IgG) 1760mg/dl, IgM 186mg/dl, IgA 195mg/dl, C-reactive protein 6.5mg/dl, erythrocyte sedimentation rate 100mm/hr, and serum amyloid A 123mg/L). Total IgE level, eosinophil count, lymphocyte subset levels, and the oxidative burst activity of granulocytes were normal. Autoantibodies (anti-nuclear antibody, anti-neutrophilic cytoplasmic antibody, and rheumatic factor) were negative. She was evaluated for tuberculosis and was found to have two bacillus Calmette-Guérin scars, a 12mm tuberculin response, and a negative QuantiFERON® assay result (QIAGEN, Chadstone, Australia). Serologic investigations yielded negative results for cytomegalovirus, Epstein-Barr virus, hepatitis B and C viruses, syphilis, and HIV. Her blood and urine cultures were negative for bacteria. Splenomegaly was detected by abdominal ultrasonography. Skin biopsy of hyperpigmented lesions demonstrated neutrophil infiltration in epidermis and subepidermal pustular dermatosis. The results of chest radiography and skeletal surveys were normal.\nDIRA was clinically suspected on the basis of clinical similarities between our patient and other patients with DIRA described in the literature to date. The resequencing of the entire coding sequence of IL1RN and the flanking splice sites revealed a homozygous mutation (p.R26X) confirming DIRA. Treatment with canakinumab 150mg subcutaneously once every 6 weeks was initiated, and a full response was achieved. She did not experience any cutaneous lesions or arthritis during 12 months of treatment and follow-up. Her inflammatory markers regressed to normal values . She was able to walk independently, and gradual weight gain was observed. Treatment-related adverse events were not detected.", + "fulltext_subclaims": [ + "The patient is a 12-year-old Turkish girl.", + "She was born at 38 weeks of gestational age.", + "Her parents are unrelated and healthy.", + "She was well until 1 year of age.", + "At 1 year of age, she developed pustular cutaneous lesions.", + "The pustular cutaneous lesions responded to corticosteroid and antibiotic treatment.", + "The treatment resulted in healing and scar formation.", + "Various treatments of these lesions had required four hospitalizations during the previous 11 years.", + "No other family member had similar skin conditions.", + "She was hospitalized at the age of 12 years for arthralgia of her knees, elbows, and ankles.", + "She had arthritis of her left knee.", + "She had concomitant pustular cutaneous lesions.", + "She developed septicemia.", + "She was admitted to the intensive care unit of a public hospital.", + "She had respiratory insufficiency during her follow-up.", + "After recovery, she was referred to the pediatric immunology department for further evaluation.", + "A hyperpigmented scar lesion on the right side of the face was noted on admission.", + "Bilateral inguinal, paraumbilical hyperpigmented scar lesions were noted on admission.", + "Paronychia of the thumbs was noted on admission.", + "The patient had contracture of the left knee.", + "The contracture limited her motion.", + "She had episcleritis.", + "She had failure to thrive.", + "Her weight was 25kg, below the third percentile.", + "Her height was 132cm, below the third percentile.", + "Her laboratory studies revealed iron deficiency anemia.", + "Her laboratory studies revealed hypergammaglobulinemia.", + "Her laboratory studies revealed elevated acute-phase reactants.", + "Her red blood cell count was 4.2 million/mm3.", + "Her hemoglobin was 9.1g/dl.", + "Her hematocrit was 27.8%.", + "Her mean corpuscular volume was 81fl.", + "Her thrombocytes were 254,000/mm3.", + "Her immunoglobulin G (IgG) was 1760mg/dl.", + "Her IgM was 186mg/dl.", + "Her IgA was 195mg/dl.", + "Her C-reactive protein was 6.5mg/dl.", + "Her erythrocyte sedimentation rate was 100mm/hr.", + "Her serum amyloid A was 123mg/L.", + "Total IgE level, eosinophil count, lymphocyte subset levels, and the oxidative burst activity of granulocytes were normal.", + "Autoantibodies (anti-nuclear antibody, anti-neutrophilic cytoplasmic antibody, and rheumatic factor) were negative.", + "She was evaluated for tuberculosis.", + "She had two bacillus Calmette-Guérin scars.", + "She had a 12mm tuberculin response.", + "Her QuantiFERON® assay result was negative.", + "Serologic investigations yielded negative results for cytomegalovirus, Epstein-Barr virus, hepatitis B and C viruses, syphilis, and HIV.", + "Her blood and urine cultures were negative for bacteria.", + "Splenomegaly was detected by abdominal ultrasonography.", + "Skin biopsy of hyperpigmented lesions demonstrated neutrophil infiltration in epidermis.", + "Skin biopsy demonstrated subepidermal pustular dermatosis.", + "The results of chest radiography and skeletal surveys were normal.", + "DIRA was clinically suspected.", + "The resequencing of the entire coding sequence of IL1RN and the flanking splice sites revealed a homozygous mutation (p.R26X).", + "The mutation confirmed DIRA.", + "Treatment with canakinumab 150mg subcutaneously once every 6 weeks was initiated.", + "A full response was achieved.", + "She did not experience any cutaneous lesions during 12 months of treatment and follow-up.", + "She did not experience any arthritis during 12 months of treatment and follow-up.", + "Her inflammatory markers regressed to normal values.", + "She was able to walk independently.", + "Gradual weight gain was observed.", + "Treatment-related adverse events were not detected." + ], + "summary": "Our patient developed pustular cutaneous lesions at 1 year of age. At the age of 12 years, she was hospitalized for arthralgia of her knees, elbows, and ankles and arthritis of the left knee, with simultaneous pustular cutaneous lesions. She was admitted to the intensive care unit because of septicemia and respiratory insufficiency during follow-up. A skin biopsy of hyperpigmented lesions demonstrated neutrophil infiltration in the epidermis and subepidermal pustular dermatosis. Interleukin-1 receptor antagonist deficiency was suspected, and genetic analysis revealed a homozygous mutation (p.R26X) in IL1RN, which led to a diagnosis of interleukin-1 receptor antagonist deficiency. Treatment with canakinumab (recombinant human anti-human interleukin-1β monoclonal antibody) 150 mg subcutaneously once every 6 weeks was initiated. Our patient did not experience further cutaneous lesions or arthritis. Her post-treatment inflammatory markers were normal; she gained weight; and she was able to walk independently.", + "summary_subclaims": [ + "The patient developed pustular cutaneous lesions at 1 year of age.", + "At the age of 12 years, she was hospitalized for arthralgia of her knees, elbows, and ankles and arthritis of the left knee.", + "She was admitted to the intensive care unit because of septicemia and respiratory insufficiency during follow-up.", + "A skin biopsy of hyperpigmented lesions demonstrated neutrophil infiltration in the epidermis.", + "A skin biopsy of hyperpigmented lesions demonstrated subepidermal pustular dermatosis.", + "Interleukin-1 receptor antagonist deficiency was suspected.", + "Genetic analysis revealed a homozygous mutation (p.R26X) in IL1RN.", + "The diagnosis was interleukin-1 receptor antagonist deficiency.", + "Treatment with canakinumab 150 mg subcutaneously once every 6 weeks was initiated.", + "Our patient did not experience further cutaneous lesions or arthritis.", + "Her post-treatment inflammatory markers were normal.", + "She gained weight.", + "She was able to walk independently." + ] + }, + { + "id": "multiclinsum_test_1004_en.txt", + "fulltext": "A 55-year-old man was found unconscious on the street and transferred to the emergency center of our hospital. At admission, the patient’s vital signs were stable, but he was unresponsive, the Glasgow Coma Scale (GCS) score was 4 (eye opening, 1; verbal response, 1; and motor response, 2), both pupils were maximally dilated (diameter, 6.5 mm), and pupillary light reflexes on both sides and vestibulo- ocular reflex (VOR) were absent. There were no visible local head injuries. Head CT revealed massive acute subdural hematoma above the right cerebral convexity causing prominent brain shift with subfalcine and transtentorial herniation, the obliteration of basal cisterns, as well as diffuse subarachnoid hemorrhage [-]. Immediately upon diagnosis, burr hole above the hematoma was made under local anesthesia, dura was opened, and subdural drainage tube was inserted. The patient was transferred to the OR, where large size right-sided decompressive craniotomy with removal of the bone flap was done and subdural hematoma was evacuated. However, prominent swelling of the brain and its protrusion through the bone defect remained, thus it was decided to perform internal decompression with extensive resection of the lateral and medial part of the right temporal lobe. Thereafter, frontal and parietal lobes still remained swollen, thus for the avoidance of brain compression after surgery the bulk of the temporal muscle down to the zygomatic arch was removed from the skull in one piece along with the periosteum. Extensive lax duraplasty with DuraGen® (Integra LifeSciences, Princeton, NJ) was done, probe for ICP monitoring was inserted, and skin was closed. No subdural or subcutaneous drainage was left.\nImmediately after surgery, CT demonstrated significant reduction of the brain shift, “reappearance” of the ambient cistern, large area of infarction within the right parietal and occipital lobes caused by compression of the posterior cerebral artery at the time of herniation, and subcutaneous hematoma [-]. The patient underwent standard treatment in ICU, including normothermia therapy. On the 1st postoperative day, his best motor response was characterized as withdrawal to pain, diameter of the left (contralateral) pupil reduced from 6.5 to 3.5 mm, and VOR has recovered, whereas on the 3rd day, the left pupil started to react to light . Gradual recovery of the patient continued thereafter. On the 45th day after primary surgery, cranioplasty and ventriculoperitoneal shunting were done, and on the 70th day, he was transferred for further treatment to the neurorehabilitation facility. At that time, his GCS score was 4T4 (eye opening, 4; verbal response, tracheostomy; and motor response, 4) and CT demonstrated asymmetric hydrocephalus, extensive infarction of the right parietal and occipital lobes, and small epidural CSF collection in the right temporoparietal area [-]. At 3 months after discharge, the condition of the patient corresponded to the Glasgow Outcome Scale (GOS) score 3 (severe disability).", + "fulltext_subclaims": [ + "A 55-year-old man was found unconscious on the street.", + "The patient was transferred to the emergency center of our hospital.", + "At admission, the patient’s vital signs were stable.", + "The patient was unresponsive.", + "The Glasgow Coma Scale (GCS) score was 4.", + "Both pupils were maximally dilated (diameter, 6.5 mm).", + "Pupillary light reflexes on both sides and vestibulo-ocular reflex (VOR) were absent.", + "Head CT revealed massive acute subdural hematoma above the right cerebral convexity.", + "The subdural hematoma caused prominent brain shift with subfalcine and transtentorial herniation.", + "The subdural hematoma caused obliteration of basal cisterns.", + "The subdural hematoma caused diffuse subarachnoid hemorrhage.", + "Immediately upon diagnosis, burr hole above the hematoma was made under local anesthesia.", + "A subdural drainage tube was inserted.", + "The patient was transferred to the OR.", + "A large size right-sided decompressive craniotomy with removal of the bone flap was done.", + "Subdural hematoma was evacuated.", + "Prominent swelling of the brain and its protrusion through the bone defect remained.", + "It was decided to perform internal decompression with extensive resection of the lateral and medial part of the right temporal lobe.", + "Frontal and parietal lobes still remained swollen.", + "The bulk of the temporal muscle down to the zygomatic arch was removed from the skull in one piece along with the periosteum.", + "Extensive lax duraplasty with DuraGen® was done.", + "A probe for ICP monitoring was inserted.", + "No subdural or subcutaneous drainage was left.", + "Immediately after surgery, CT demonstrated significant reduction of the brain shift.", + "The ambient cistern 'reappeared' after surgery.", + "A large area of infarction within the right parietal and occipital lobes was caused by compression of the posterior cerebral artery at the time of herniation.", + "The patient underwent standard treatment in ICU, including normothermia therapy.", + "On the 1st postoperative day, the best motor response was characterized as withdrawal to pain.", + "On the 1st postoperative day, the diameter of the left (contralateral) pupil reduced from 6.5 to 3.5 mm.", + "On the 1st postoperative day, VOR has recovered.", + "On the 3rd postoperative day, the left pupil started to react to light.", + "On the 45th day after primary surgery, cranioplasty and ventriculoperitoneal shunting were done.", + "On the 70th day, the patient was transferred for further treatment to the neurorehabilitation facility.", + "At that time, the GCS score was 4T4.", + "At that time, CT demonstrated asymmetric hydrocephalus.", + "At that time, CT demonstrated extensive infarction of the right parietal and occipital lobes.", + "At that time, CT demonstrated small epidural CSF collection in the right temporoparietal area.", + "At 3 months after discharge, the condition of the patient corresponded to the Glasgow Outcome Scale (GOS) score 3." + ], + "summary": "A 55-year-old man was admitted with Glasgow Coma Scale (GCS) score 4, maximally dilated pupils, and absence of the pupillary light and vestibulo-ocular reflexes. Head CT revealed massive acute subdural hematoma, prominent brain shift with subfalcine and transtentorial herniation, and diffuse subarachnoid hemorrhage. Large size decompressive craniectomy and evacuation of subdural hematoma were done, however, prominent swelling of the brain and its protrusion through the bone defect remained. Therefore, extensive temporal lobectomy and removal of the bulk of temporal muscle were additionally attained followed by lax duraplasty. Gradual recovery of the patient was noted from the 1st postoperative day, and on the 70th day, his GCS score was 4T4. Three months later, his condition corresponded to the Glasgow Outcome Scale score 3 (severe disability).", + "summary_subclaims": [ + "The patient was a 55-year-old man.", + "The patient was admitted with Glasgow Coma Scale (GCS) score 4.", + "The patient had maximally dilated pupils.", + "The patient had absence of the pupillary light reflex.", + "The patient had absence of the vestibulo-ocular reflex.", + "Head CT revealed massive acute subdural hematoma.", + "Head CT showed prominent brain shift with subfalcine and transtentorial herniation.", + "Head CT showed diffuse subarachnoid hemorrhage.", + "Large size decompressive craniectomy and evacuation of subdural hematoma were done.", + "Prominent swelling of the brain and its protrusion through the bone defect remained.", + "Extensive temporal lobectomy and removal of the bulk of temporal muscle were additionally attained.", + "Lax duraplasty was performed.", + "Gradual recovery of the patient was noted from the 1st postoperative day.", + "On the 70th postoperative day, the patient's GCS score was 4T4.", + "Three months later, the patient's condition corresponded to the Glasgow Outcome Scale score 3." + ] + }, + { + "id": "multiclinsum_test_2590_en.txt", + "fulltext": "A previously healthy 51-year-old Hispanic female with a significant history of hypothyroidism presented with acute onset chest pain for 1 day. She described the chest pain to be pressure-like in nature, retrosternal, and radiating to her left arm and shoulder without associated shortness of breath. She reported to be sitting at rest when the pain occurred suddenly. She has been an active individual most of her life, but has had intermittent chest pain with exertion for the past 2 months. She has had to stop exercise for relief and has minimized her physical activity. The chest pain on presentation was reported to be similar in nature to the chest pain she had previously. According to the patient, she did not have any syncope, palpitations, racing of the heart, lightheadedness, anxiety, diarrhea, weight loss, or brittle hair. The reason she sought medical care this time was due to increased severity of pain.\nTwo months prior to presentation, she was diagnosed with hypothyroidism with a thyroid-stimulating hormone (TSH) level of ~500 U/mL and given levothyroxine 137 mcg daily. The dose was reduced a few days after labs indicated supranormal triiodothyronine (T3) and thyroxine (T4) levels, but low TSH after starting the medication. She had most recently been on levothyroxine 100 mcg daily, which she was compliant with. She also reported taking omeprazole 20 mg daily for gastroesophageal reflux disease. She did not use oral contraceptive pills. She has never had hypercholesterolemia and had a negative fasting lipid panel from ~1 year prior to presentation. She denied any other past medical or surgical history. She does not have allergies. She was a lifelong non-smoker, did not consume alcohol, and did not use illicit drugs.\nOn presentation, her vitals were normal. Her BMI was 27.3 kg/m2. The physical exam is only significant for a woman who appears in her stated age in mild distress due to chest pain. The electrocardiogram was consistent with normal sinus rhythm without any abnormalities. Troponins were elevated and trended upward from 0.080 to 0.120 to 0.222 ng/mL each 8 hours apart. TSH was nearly undetectable at <0.015 U/mL consistent with hyperthyroidism. T3 and T4 were not measured on presentation. Levothyroxine was stopped. Chest x-ray was unremarkable. Bedside 2D echocardiogram showed a normal left ventricle with EF of >60% without any regional wall motion abnormalities. The left atrium was mildly dilated, and right ventricular systolic pressure was 32 mm Hg. Non-ST elevation MI was diagnosed and patient was given atorvastatin 80 mg, heparin drip, clopidogrel 600 mg, and aspirin 324 mg. Sublingual nitroglycerin 0.4 mg was given, which improved the chest pain from a 10/10 on presentation to a 6/10. Coronary angiogram was done on the day of presentation, which showed an anomalous RCA arising from the left coronary cusp of the sinus of Valsalva, but no evidence of occlusion ( and ).\nA follow-up coronary computed tomography angiogram was done, which confirmed this finding and showed the anomalous RCA taking an inter-arterial course originating from the coronary ostium with a slit-like deformity and at least 50% luminal stenosis .\nTroponins trended downward and chest pain resolved. Due to known poor outcomes with this type of symptomatic coronary anomaly, the patient was referred to a cardiothoracic surgeon for definitive surgical correction. The patient was discharged home with levothyroxine 50 mcg daily, metoprolol 25 mg BID, and recommendation against aggressive physical activity.\nInformed consent was obtained from the patient for publication of this case report and any accompanying images.", + "fulltext_subclaims": [ + "The patient is a 51-year-old Hispanic female.", + "She has a history of hypothyroidism.", + "She presented with acute onset chest pain for 1 day.", + "The chest pain was pressure-like, retrosternal, and radiated to her left arm and shoulder.", + "She did not have shortness of breath.", + "She reported the chest pain occurred suddenly while sitting at rest.", + "She had intermittent chest pain with exertion for the past 2 months.", + "She had to stop exercise for relief.", + "She minimized her physical activity.", + "The chest pain on presentation was similar in nature to the chest pain she had previously.", + "She did not have syncope.", + "She did not have palpitations.", + "She did not have lightheadedness.", + "She did not have anxiety.", + "She did not have diarrhea.", + "She did not have weight loss.", + "She did not have brittle hair.", + "She sought medical care due to increased severity of pain.", + "Two months prior to presentation, she was diagnosed with hypothyroidism.", + "Her TSH was ~500 U/mL.", + "She was given levothyroxine 137 mcg daily.", + "The dose was reduced after labs indicated supranormal T3 and T4 levels.", + "She had most recently been on levothyroxine 100 mcg daily.", + "She was compliant with levothyroxine.", + "She took omeprazole 20 mg daily.", + "She did not use oral contraceptive pills.", + "She had a negative fasting lipid panel ~1 year prior.", + "She denied any other past medical or surgical history.", + "She did not have allergies.", + "She was a lifelong non-smoker.", + "She did not consume alcohol.", + "She did not use illicit drugs.", + "On presentation, her vitals were normal.", + "Her BMI was 27.3 kg/m2.", + "The physical exam was significant for a woman who appeared in her stated age in mild distress due to chest pain.", + "The electrocardiogram was consistent with normal sinus rhythm without any abnormalities.", + "Troponins were elevated and trended upward from 0.080 to 0.120 to 0.222 ng/mL each 8 hours apart.", + "TSH was nearly undetectable at <0.015 U/mL.", + "T3 and T4 were not measured on presentation.", + "Levothyroxine was stopped.", + "Chest x-ray was unremarkable.", + "Bedside 2D echocardiogram showed a normal left ventricle with EF of >60%.", + "There were no regional wall motion abnormalities.", + "The left atrium was mildly dilated.", + "Right ventricular systolic pressure was 32 mm Hg.", + "Non-ST elevation MI was diagnosed.", + "The patient was given atorvastatin 80 mg.", + "The patient was given a heparin drip.", + "The patient was given clopidogrel 600 mg.", + "The patient was given aspirin 324 mg.", + "Sublingual nitroglycerin 0.4 mg was given.", + "The chest pain improved from 10/10 to 6/10.", + "Coronary angiogram showed an anomalous RCA arising from the left coronary cusp of the sinus of Valsalva.", + "There was no evidence of occlusion.", + "A follow-up coronary computed tomography angiogram confirmed the anomalous RCA.", + "The anomalous RCA took an inter-arterial course.", + "The anomalous RCA originated from the coronary ostium.", + "There was a slit-like deformity.", + "There was at least 50% luminal stenosis.", + "Troponins trended downward.", + "Chest pain resolved.", + "The patient was referred to a cardiothoracic surgeon for definitive surgical correction.", + "The patient was discharged home with levothyroxine 50 mcg daily.", + "The patient was discharged home with metoprolol 25 mg BID.", + "The patient was advised against aggressive physical activity.", + "Informed consent was obtained from the patient for publication of this case report and any accompanying images." + ], + "summary": "A previously healthy 51-year-old female with history of hypothyroidism presented with acute onset chest pain for 1 day. Patient's electrocardiogram was normal, however, she had elevated troponins and given her typical chest pain, she was diagnosed with acute coronary syndrome (ACS). The patient had been on levothyroxine and was found to have a subnormal thyroid-stimulating hormone level suggesting hyperthyroidism. Echocardiogram was normal. Coronary angiogram showed an anomalous RCA arising from the left coronary cusp of the sinus of Valsalva and no evidence of atherosclerosis. A coronary computed tomography angiogram was done confirming this finding and showed a slit-like deformity of the coronary ostium with at least 50% luminal stenosis. The patient was referred to a cardiothoracic surgeon for potential coronary artery bypass graft.", + "summary_subclaims": [ + "The patient is a 51-year-old female.", + "The patient has a history of hypothyroidism.", + "The patient had acute onset chest pain for 1 day.", + "The patient's electrocardiogram was normal.", + "The patient had elevated troponins.", + "The patient was diagnosed with acute coronary syndrome.", + "The patient was on levothyroxine.", + "The patient had a subnormal thyroid-stimulating hormone level.", + "The subnormal thyroid-stimulating hormone level suggested hyperthyroidism.", + "The echocardiogram was normal.", + "The coronary angiogram showed an anomalous RCA arising from the left coronary cusp of the sinus of Valsalva.", + "The coronary angiogram showed no evidence of atherosclerosis.", + "A coronary computed tomography angiogram was done.", + "The coronary computed tomography angiogram confirmed the anomalous RCA.", + "The coronary computed tomography angiogram showed a slit-like deformity of the coronary ostium.", + "The coronary computed tomography angiogram showed at least 50% luminal stenosis.", + "The patient was referred to a cardiothoracic surgeon.", + "The patient was referred for potential coronary artery bypass graft." + ] + }, + { + "id": "multiclinsum_test_3171_en.txt", + "fulltext": "We present the case of an 81-year-old woman, with past medical history of hypertension and type 2 diabetes mellitus controlled with medication, who presented to the emergency department after falling from her own height onto her left hemibody and outstretched hand. She denied cranioencephalic trauma or loss of consciousness. At admission, she complained of intense pain in her left hand and reduction in the wrist's range of movement due to pain. At physical examination, she had a “fork back deformity”, swelling, and was tender to touch; the patient complained of a pain level of 9 out of 10 according to the VAS score with fracture manipulation. Plain radiographs showed a minimally displaced, dorsally angulated, extra-articular, shortened distal radius fracture with loss of radial tilt.\n\nThe patient referred severe pain with passive motion and near the fracture site, she was reluctant to allow for a block near the site and to receive surgery. Due to the intense pain referred by the patient, and the possibility of management with closed reduction, we opted for a supracondylar radial nerve block to ensure proper pain management. Therapeutic options were discussed with the patient and her daughter, and as a result of a shared decision-making process, she opted for closed reduction with supracondylar radial nerve block. After obtaining the patient's informed consent, the procedure was performed. With the patient supine and the arm flexed over the abdomen, the physician positioned themselves facing the lateral aspect of the affected arm. The ultrasound machine was placed front-facing the physician, allowing an unobstructed view of the screen. A high-frequency 6–13 MHz (MHz) Mindray linear transducer was used to locate the radial nerve on the lateral aspect of the humerus, approximately 2 cm above the lateral epicondyle. At this location, the nerve is followed distally, visualizing its bifurcation into deep and superficial branches. Subsequently, the probe was displaced proximally to ensure the correct anatomic location. The nerve (hyperechoic) travels through the intermuscular septum between the surrounding (more hypoechoic) brachial and brachioradial muscles.\n\nThe site was prepared with an aseptic technique and sterilized with a chlorhexidine solution. Sterile surgical lubricant was spread on the intended injection site. Later, a mixture of 10 ml of 1:1 0.25 % bupivacaine and 1 % lidocaine with epinephrine was injected with a 50-mm, 22-gauge Stimuplex® insulated echogenic needle around the radial nerve (proximal to its branch) under direct ultrasound guidance using an in-plane technique, identifying the needle in its full length. To prevent nerve injury due to high pressure at the injection site, low resistance during the procedure was assured. The patient manifested minimal discomfort during the injection process. Fifteen minutes after the injection, the patient reported no pain at rest, and the fracture was reduced. Axial traction maneuvers and ligamentotaxis, hyperextension, flexion, and ulnar deviation were performed with subsequent immobilization with a forearm sugar tong splint without complications. Shortly thereafter, the dorsally angulated distal fragment was reduced with minimal discomfort. After confirmatory radiographs showed adequate reduction, she was discharged with orthopedic follow-up. At the two-week follow-up, the sugar tong splint was replaced by a brachiopalmar closed cast, and at the monthly follow-up, the appropriate fracture reduction was again verified through radiographs. After that, the patient was lost to follow-up due to administrative concerns derived from her insurer, where we believe she was transferred elsewhere to continue here care.", + "fulltext_subclaims": [ + "The patient is an 81-year-old woman.", + "She has a past medical history of hypertension.", + "She has a past medical history of type 2 diabetes mellitus.", + "She presented to the emergency department after falling from her own height onto her left hemibody and outstretched hand.", + "She denied cranioencephalic trauma.", + "She denied loss of consciousness.", + "At admission, she complained of intense pain in her left hand.", + "She reported reduction in the wrist's range of movement due to pain.", + "At physical examination, she had a 'fork back deformity'.", + "She had swelling.", + "She was tender to touch.", + "She reported a pain level of 9 out of 10 according to the VAS score with fracture manipulation.", + "Plain radiographs showed a minimally displaced distal radius fracture.", + "The fracture was dorsally angulated.", + "The fracture was extra-articular.", + "The fracture was shortened.", + "There was loss of radial tilt.", + "The patient referred severe pain with passive motion.", + "The patient was reluctant to allow for a block near the fracture site.", + "The patient was reluctant to receive surgery.", + "We opted for a supracondylar radial nerve block.", + "Therapeutic options were discussed with the patient and her daughter.", + "A shared decision-making process was used.", + "The patient opted for closed reduction with a supracondylar radial nerve block.", + "Informed consent was obtained.", + "The procedure was performed.", + "The patient was supine with the arm flexed over the abdomen.", + "A high-frequency 6–13 MHz Mindray linear transducer was used.", + "The radial nerve was located on the lateral aspect of the humerus, approximately 2 cm above the lateral epicondyle.", + "A mixture of 10 ml of 1:1 0.25 % bupivacaine and 1 % lidocaine with epinephrine was injected.", + "The injection was performed with a 50-mm, 22-gauge Stimuplex® insulated echogenic needle.", + "The injection was performed under direct ultrasound guidance using an in-plane technique.", + "The patient reported no pain at rest 15 minutes after the injection.", + "The fracture was reduced.", + "Axial traction maneuvers were performed.", + "Ligamentotaxis was performed.", + "Hyperextension was performed.", + "Flexion was performed.", + "Ulnar deviation was performed.", + "The fracture was immobilized with a forearm sugar tong splint.", + "Confirmatory radiographs showed adequate reduction.", + "The patient was discharged with orthopedic follow-up.", + "At the two-week follow-up, the sugar tong splint was replaced by a brachiopalmar closed cast.", + "At the monthly follow-up, appropriate fracture reduction was verified through radiographs.", + "The patient was lost to follow-up due to administrative concerns derived from her insurer." + ], + "summary": "An 81-year-old woman who had a Colle's fracture (metaphyseal fracture with dorsal angulation) of the left distal radius arrived at the emergency room. Due to intense pain and need for proper pain management, an ultrasound-guided block of the radial nerve prior to its bifurcation into deep and superficial branches was carried out as an alternative to infiltration of the fracture site. The fracture could be reduced and immobilized with a closed cast as a result of the peripheral nerve block, which caused the patient the least amount of discomfort.", + "summary_subclaims": [ + "The patient is an 81-year-old woman.", + "She had a Colle's fracture of the left distal radius.", + "The fracture was a metaphyseal fracture with dorsal angulation.", + "She arrived at the emergency room.", + "An ultrasound-guided block of the radial nerve prior to its bifurcation into deep and superficial branches was carried out.", + "The block was carried out as an alternative to infiltration of the fracture site.", + "The fracture could be reduced and immobilized with a closed cast as a result of the peripheral nerve block.", + "The peripheral nerve block caused the patient the least amount of discomfort." + ] + }, + { + "id": "multiclinsum_test_1481_en.txt", + "fulltext": "A 68-year-old Caucasian woman presented with a rapidly progressive severe sensorimotor paraparesis a few days after having received the first mRNA COVID-19 vaccination (BNT162b2) in May 2021. The patient’s history showed the suspected diagnosis of a secondary progressive MS for over 40 years with unknown date of transition. After having suffered a severe relapse in the early 1980s the patient had lived with a residual mild paraparesis. The patient had never received a disease-modifying therapy (DMT). Relapses had been treated with intravenous corticosteroids. Regarding her vaccination history, the patient had regularly received the vaccines recommended by the German Standing Committee on Vaccination without any relevant side effects prior to the following events.\nIn April 2021, the patient first suffered a deterioration of the paraparesis shortly after having been vaccinated against tetanus and pneumococci. She was admitted to an external hospital. Spinal cord MRI showed signs of atrophy of the cervical and thoracic spinal cord without Gadolinium (GD)-enhancement. Cerebrospinal fluid (CSF) analysis did not show any abnormalities. Due to a suspected MS relapse the patient was treated with intravenous corticosteroids. Subsequently the symptoms receded and the patient reached prior level of disability.\nOn the 5th of May 2021 the patient received the first mRNA COVID-19 vaccination and 23 days later developed a severe exacerbation of the paraparesis with sensory level of T8 and inability to walk as well as loss of bladder and bowel control (EDSS 7.0). A new spinal cord MRI now showed T2-signal alteration ranging from C4 to T10 with GD-enhancement from C3 to C5 as sign of an acute LETM . CSF analysis displayed pleocytosis of 340 cells/μl (51% lymphocytes, 49% granulocytes) and disturbance of the blood-brain-barrier with elevated protein levels of 2590 mg/L. There was no evidence of oligoclonal bands. Also, there was no evidence of bacterial or viral infection. Cell-based assay showed positive AQP4-antibodies in serum and CSF. The patient fulfilled diagnostic criteria for AQP4-antibody positive NMOSD.\nInitial therapy with intravenous corticosteroids for five days was followed by seven cycles of plasmapheresis which led to a mild improvement of sensorimotor function (EDSS remaining at 7.0). Considering the highly active disease progression, DMT with eculizumab was initiated promptly. Since the patient showed deterioration of symptoms both times she was immunized, required meningococcal vaccination was not applied for safety reasons and prophylactic antibiotic therapy was initiated in the induction phase of eculizumab. The patient later decided not to receive the vaccination at all, hence therapy was changed to satralizumab. In the follow-up period of six months no new relapses have occurred. The patient also declined the second COVID-19 vaccination.", + "fulltext_subclaims": [ + "A 68-year-old Caucasian woman presented with a rapidly progressive severe sensorimotor paraparesis a few days after having received the first mRNA COVID-19 vaccination (BNT162b2) in May 2021.", + "The patient’s history showed the suspected diagnosis of a secondary progressive MS for over 40 years with unknown date of transition.", + "The patient had never received a disease-modifying therapy (DMT).", + "In April 2021, the patient first suffered a deterioration of the paraparesis shortly after having been vaccinated against tetanus and pneumococci.", + "Spinal cord MRI showed signs of atrophy of the cervical and thoracic spinal cord without Gadolinium (GD)-enhancement.", + "Cerebrospinal fluid (CSF) analysis did not show any abnormalities.", + "The patient was treated with intravenous corticosteroids.", + "On the 5th of May 2021 the patient received the first mRNA COVID-19 vaccination.", + "23 days later the patient developed a severe exacerbation of the paraparesis with sensory level of T8 and inability to walk as well as loss of bladder and bowel control (EDSS 7.0).", + "A new spinal cord MRI now showed T2-signal alteration ranging from C4 to T10 with GD-enhancement from C3 to C5 as sign of an acute LETM.", + "CSF analysis displayed pleocytosis of 340 cells/μl (51% lymphocytes, 49% granulocytes) and disturbance of the blood-brain-barrier with elevated protein levels of 2590 mg/L.", + "There was no evidence of oligoclonal bands.", + "There was no evidence of bacterial or viral infection.", + "Cell-based assay showed positive AQP4-antibodies in serum and CSF.", + "The patient fulfilled diagnostic criteria for AQP4-antibody positive NMOSD.", + "Initial therapy with intravenous corticosteroids for five days was followed by seven cycles of plasmapheresis.", + "The patient showed mild improvement of sensorimotor function (EDSS remaining at 7.0).", + "DMT with eculizumab was initiated promptly.", + "Required meningococcal vaccination was not applied for safety reasons.", + "Prophylactic antibiotic therapy was initiated in the induction phase of eculizumab.", + "The patient later decided not to receive the vaccination at all.", + "Therapy was changed to satralizumab.", + "In the follow-up period of six months no new relapses have occurred.", + "The patient also declined the second COVID-19 vaccination." + ], + "summary": "We present a case of a 68-year-old woman previously diagnosed with multiple sclerosis (MS) since the 1980s who suffered a rapidly progressive severe sensorimotor paraparesis with loss of bladder and bowel control due to an acute longitudinal extensive transverse myelitis (LETM) after immunization with the mRNA Pfizer-BioNTech COVID-19 vaccine. Detection of Aquaporin-4-antibodies (AQP4) in both serum and CSF led to diagnosis of AQP4-antibody positive neuromyelitis optica spectrum disorder (NMOSD). Treatment with intravenous corticosteroids and plasmapheresis led to a slight improvement of the patient's symptoms.", + "summary_subclaims": [ + "The patient is a 68-year-old woman.", + "She was previously diagnosed with multiple sclerosis since the 1980s.", + "She suffered a rapidly progressive severe sensorimotor paraparesis.", + "She had loss of bladder and bowel control.", + "The cause was an acute longitudinal extensive transverse myelitis.", + "The myelitis occurred after immunization with the mRNA Pfizer-BioNTech COVID-19 vaccine.", + "Aquaporin-4-antibodies were detected in both serum and CSF.", + "The diagnosis was AQP4-antibody positive neuromyelitis optica spectrum disorder.", + "Treatment included intravenous corticosteroids.", + "Treatment included plasmapheresis.", + "The patient's symptoms showed a slight improvement." + ] + }, + { + "id": "multiclinsum_test_1910_en.txt", + "fulltext": "In January 2011, a 45-year-old Italian bisexual man, known to be HIV-infected since 1998, presented to the Infectious Diseases Unit with partial vision loss in both eyes.\nSince 2000, HIV infection had been treated with combination antiretroviral therapy (cART) including zidovudine, lamivudine and lopinavir/ritonavir. Nadir absolute CD4+ T-cell count was 320/mm3.\nThe patient had been regularly attending different Day Hospital Services and was adhering well to cART. He had received two lines of cART, including ritonavir-boosted protease inhibitor regimens without experiencing virological failure.\nOn admission, his absolute CD4+ T-cell count was 385/mm3, HIV viremia was undetectable and his cART consisted of tenofovir emtricitabine and boosted atazanavir.\nThe patient's past treatment history revealed that he had received a single intramuscular injection of 2.4 million units of penicillin G benzathine for primary syphilis contracted in November 2000 after unprotected heterosexual exposure. At that time, he had a penile lesion with inguinal adenopathy, and he tested positive for syphilis as follows: serum Venereal Disease Research Laboratory (VDRL) test ++, Treponema pallidum haemoagglutination assay (TPHA) 1: 1280, positive FTA-Abs. Serological post-treatment follow-up showed that the VDRL test had reverted to non-reactivity within 12 months. His last known non-reactive VDRL test result was in June 2009.\nTwo weeks before admission to the Infectious Diseases Unit, the patient had noticed an ulcer on his left upper eyelid and four days before admission he had begun to experience reduced visual acuity, with associated photophobia and mild headache which had subsequently improved. His general practitioner suspected a chalazion and the patient was referred to our Ophthalmology Section because of visual impairment.\nA small, painless, resolving ulceration with barely elevated edges was present above the external canthus of the LE . No other abnormalities were seen in the remainder of his eyelids, eyelashes, cornea, bulbar conjunctiva, the other eye or on the rest of his face. His left preauricular and submandibular nodes were slightly enlarged, non-tender and firm.\nBest corrected Snellen visual acuity was 20/32 in both eyes. Fine pigmented keratic precipitates, aqueous cells, flare and posterior synechiae were seen in the anterior chamber. Examination of the posterior chamber revealed vitreitis, retinal vasculitis with perivascular sheathing and hemorrhages, edematous retinal areas and disc swelling. Intravenous fluorescein angiogram showed masked retinal areas, optic disc hyperfluorescence and leakage from retinal venules .\nStructured face-to-face interviews were conducted with the patient to obtain information about his behavioral risk factors and symptoms. He had a history of multiple sexual partners in the previous year and unprotected oral sex intercourse with a sperm contamination of his eyes. His sexual contacts were traced and two immunocompetent young men tested positive for syphilis.\nComplete blood count was unremarkable. Hematologic values were within normal range and Polymerase Chain Reaction (PCR) for Toxoplasma gondii, Herpes viruses, Mycobacterium tuberculosis (MT), non-tuberculous mycobacteria (NTM) and other pathogens which are epidemiologically relevant in our geographic area (i.e. Rickettsia conorii, Brucella spp) gave negative results. Negative results were obtained for CMV DNA (using Real Time for amplification of the IE region) and CMV pp65 antigen in 200000 leukocytes. EBV-DNA (amplifying the Bam Hi W region) and HSV DNA (amplifying viral polymerases) were also negative. Serum VDRL titer was 1 : 16, and TPHA titer was 1 : 1280.\nMacroscopic and humoral studies of cerebrospinal fluid (CSF) performed at the time of admission were negative. CSF VDRL and CSF PCR test results for the above-mentioned microorganisms were also negative.\nThe patient was treated with intravenous penicillin G (24 MU/day) for two weeks and received 1 intramuscular dose of penicillin G benzathine (2.4 MU) after completing the I.V. therapy [,].\nHe was treated topically with dexamethasone qid and atropine 1% bid, and was prescribed 60 mg of oral prednisone daily, tapered over 4 weeks.\nAt the two-week follow-up visit, papillitis had disappeared, and retinal vasculitis and uveitis had improved. Best corrected Snellen visual acuity remained unchanged. The topical therapy was tapered.\nAfter one month, aqueous cells and flare had further decreased but some retinal hemorrhages and perivascular sheathing were still observed.\nAt 2-months follow-up, signs of uveitis had disappeared, posterior synechiae were sporadic and fundus examination showed a normal disc and peripheral hyalinized vessels with attached retina .\nOne year after treatment, serological testing for syphilis was repeated, showing positive VDRL 1:2 and positive TPHA 1:80.\nAt present, the patient is regularly attending our Day Care Unit where we can monitor his adherence to therapy.\nHis last CD4+ T-cell count was 530cells/mm3 and viral load was undetectable.\nOcular examination showed that both eyes were quiet.", + "fulltext_subclaims": [ + "In January 2011, a 45-year-old Italian bisexual man, known to be HIV-infected since 1998, presented to the Infectious Diseases Unit with partial vision loss in both eyes.", + "Since 2000, HIV infection had been treated with combination antiretroviral therapy (cART) including zidovudine, lamivudine and lopinavir/ritonavir.", + "Nadir absolute CD4+ T-cell count was 320/mm3.", + "The patient had been regularly attending different Day Hospital Services and was adhering well to cART.", + "He had received two lines of cART, including ritonavir-boosted protease inhibitor regimens without experiencing virological failure.", + "On admission, his absolute CD4+ T-cell count was 385/mm3.", + "HIV viremia was undetectable.", + "His cART consisted of tenofovir emtricitabine and boosted atazanavir.", + "The patient's past treatment history revealed that he had received a single intramuscular injection of 2.4 million units of penicillin G benzathine for primary syphilis contracted in November 2000 after unprotected heterosexual exposure.", + "At that time, he had a penile lesion with inguinal adenopathy.", + "He tested positive for syphilis as follows: serum Venereal Disease Research Laboratory (VDRL) test ++, Treponema pallidum haemoagglutination assay (TPHA) 1: 1280, positive FTA-Abs.", + "Serological post-treatment follow-up showed that the VDRL test had reverted to non-reactivity within 12 months.", + "His last known non-reactive VDRL test result was in June 2009.", + "Two weeks before admission to the Infectious Diseases Unit, the patient had noticed an ulcer on his left upper eyelid.", + "Four days before admission he had begun to experience reduced visual acuity, with associated photophobia and mild headache which had subsequently improved.", + "His general practitioner suspected a chalazion.", + "The patient was referred to our Ophthalmology Section because of visual impairment.", + "A small, painless, resolving ulceration with barely elevated edges was present above the external canthus of the LE.", + "No other abnormalities were seen in the remainder of his eyelids, eyelashes, cornea, bulbar conjunctiva, the other eye or on the rest of his face.", + "His left preauricular and submandibular nodes were slightly enlarged, non-tender and firm.", + "Best corrected Snellen visual acuity was 20/32 in both eyes.", + "Fine pigmented keratic precipitates, aqueous cells, flare and posterior synechiae were seen in the anterior chamber.", + "Examination of the posterior chamber revealed vitreitis, retinal vasculitis with perivascular sheathing and hemorrhages, edematous retinal areas and disc swelling.", + "Intravenous fluorescein angiogram showed masked retinal areas, optic disc hyperfluorescence and leakage from retinal venules.", + "Structured face-to-face interviews were conducted with the patient to obtain information about his behavioral risk factors and symptoms.", + "He had a history of multiple sexual partners in the previous year and unprotected oral sex intercourse with a sperm contamination of his eyes.", + "His sexual contacts were traced and two immunocompetent young men tested positive for syphilis.", + "Complete blood count was unremarkable.", + "Hematologic values were within normal range.", + "Polymerase Chain Reaction (PCR) for Toxoplasma gondii, Herpes viruses, Mycobacterium tuberculosis (MT), non-tuberculous mycobacteria (NTM) and other pathogens which are epidemiologically relevant in our geographic area (i.e. Rickettsia conorii, Brucella spp) gave negative results.", + "Negative results were obtained for CMV DNA (using Real Time for amplification of the IE region) and CMV pp65 antigen in 200000 leukocytes.", + "EBV-DNA (amplifying the Bam Hi W region) and HSV DNA (amplifying viral polymerases) were also negative.", + "Serum VDRL titer was 1 : 16, and TPHA titer was 1 : 1280.", + "Macroscopic and humoral studies of cerebrospinal fluid (CSF) performed at the time of admission were negative.", + "CSF VDRL and CSF PCR test results for the above-mentioned microorganisms were also negative.", + "The patient was treated with intravenous penicillin G (24 MU/day) for two weeks.", + "He received 1 intramuscular dose of penicillin G benzathine (2.4 MU) after completing the I.V. therapy.", + "He was treated topically with dexamethasone qid and atropine 1% bid.", + "He was prescribed 60 mg of oral prednisone daily, tapered over 4 weeks.", + "At the two-week follow-up visit, papillitis had disappeared, and retinal vasculitis and uveitis had improved.", + "Best corrected Snellen visual acuity remained unchanged.", + "The topical therapy was tapered.", + "After one month, aqueous cells and flare had further decreased but some retinal hemorrhages and perivascular sheathing were still observed.", + "At 2-months follow-up, signs of uveitis had disappeared, posterior synechiae were sporadic and fundus examination showed a normal disc and peripheral hyalinized vessels with attached retina.", + "One year after treatment, serological testing for syphilis was repeated, showing positive VDRL 1:2 and positive TPHA 1:80.", + "At present, the patient is regularly attending our Day Care Unit where we can monitor his adherence to therapy.", + "His last CD4+ T-cell count was 530cells/mm3.", + "Viral load was undetectable.", + "Ocular examination showed that both eyes were quiet." + ], + "summary": "Herein the authors report an unusual primary syphilitic ocular lesion in a 45-year-old Italian HIV-infected bisexual man who presented with a unilateral eyelid lesion. Associated precocious signs and symptoms in the posterior segment of both eyes, bilateral chorioretinitis and uveitis, are described. Intravenous penicillin and steroid treatment produced a rapid improvement in clinical status and complete resolution.", + "summary_subclaims": [ + "The authors report an unusual primary syphilitic ocular lesion in a 45-year-old Italian HIV-infected bisexual man.", + "The patient presented with a unilateral eyelid lesion.", + "Associated precocious signs and symptoms in the posterior segment of both eyes are described.", + "Bilateral chorioretinitis is described.", + "Uveitis is described.", + "Intravenous penicillin and steroid treatment produced a rapid improvement in clinical status.", + "Intravenous penicillin and steroid treatment produced complete resolution." + ] + }, + { + "id": "multiclinsum_test_2913_en.txt", + "fulltext": "We report a case of a 29-year-old male patient with chief complaints were pain and instability on his left knee. He got injured when playing futsal with knee twisted externally. He suffered severe pain, swollen and difficult to walk. The magnetic resonance imaging (MRI) examination after the injury revealed ACL and PCL rupture of the left knee. He underwent arthroscopic surgical reconstruction for both ACL and PCL by previous surgeon. Two years after surgery, he felt instability, swollen knee without pain and no history of other trauma during the time after operation. On the physical examination we found posterior sagging and positive posterior drawer test as well as quadriceps active test. Anterior Lachman test for anterior cruciate ligament was negative.\nOn the MRI, we found failure of PCL graft with intact ACL. On the MRI and three dimensional CT scan, with more clear projection for bone structure, it was found that the tibial tunnel placement done in previous surgery was not placed on its anatomical position. The tunnel was placed too anterior to the PCL footprint .\nSubsquently we performed the PCL revision reconstruction surgery. We performed the arthroscopic-assisted reconstruction surgery using transseptal portal approach. We avoided to use only the jig to guide us when tunnelling the tibia instead, we used additional technique to see the posterior aspect of proximal tibia clearly. In this case, we choosed to make a transseptal portal that penetrated from posteromedial side of the knee inside-out to the posterolateral side of the knee . An incision was made on the posteromedial side of the knee with guidance of arthroscopic view and also transiluminatic arthroscopic light. Blunt obturator with sheath was inserted gently passed through intercondylar notch to posterolateral side of the knee and we made inside-out incision on it.\nDuring arthroscopy procedure, we found that the PCL was gone with small PCL remnant on femoral site. The ACL was still intact and adequately attached. We performed the reconstruction of PCL using peroneus longus tendon as the graft from the left ankle. When tunneling the tibia, we used jig guide for tibial tunnel placement, we also made a transseptal portal from medial to lateral in order to get better view of posterior aspect of the tibia ( and ). We used it as the graft because hamstring tendon was already used in previous surgery. showed post-operative X-ray of the left knee that tibial tunnel was revised to appropriate site of its footprint. The shadow of two endobuttons on the lmedial femoral condyle was seen because the endobutton of previous surgery was not removed.", + "fulltext_subclaims": [ + "The patient was a 29-year-old male.", + "The patient's chief complaints were pain and instability on his left knee.", + "He got injured when playing futsal with knee twisted externally.", + "He suffered severe pain, swollen and difficult to walk.", + "The MRI examination after the injury revealed ACL and PCL rupture of the left knee.", + "He underwent arthroscopic surgical reconstruction for both ACL and PCL by previous surgeon.", + "Two years after surgery, he felt instability, swollen knee without pain.", + "On the physical examination, posterior sagging was found.", + "The posterior drawer test was positive.", + "The quadriceps active test was positive.", + "The anterior Lachman test for anterior cruciate ligament was negative.", + "On the MRI, failure of PCL graft with intact ACL was found.", + "On the MRI and three dimensional CT scan, the tibial tunnel placement done in previous surgery was not placed on its anatomical position.", + "The tunnel was placed too anterior to the PCL footprint.", + "We performed the PCL revision reconstruction surgery.", + "We performed the arthroscopic-assisted reconstruction surgery using transseptal portal approach.", + "We avoided to use only the jig to guide us when tunnelling the tibia.", + "We used additional technique to see the posterior aspect of proximal tibia clearly.", + "We chose to make a transseptal portal that penetrated from posteromedial side of the knee inside-out to the posterolateral side of the knee.", + "An incision was made on the posteromedial side of the knee with guidance of arthroscopic view and also transiluminatic arthroscopic light.", + "Blunt obturator with sheath was inserted gently passed through intercondylar notch to posterolateral side of the knee.", + "We made inside-out incision on it.", + "During arthroscopy procedure, the PCL was gone with small PCL remnant on femoral site.", + "The ACL was still intact and adequately attached.", + "We performed the reconstruction of PCL using peroneus longus tendon as the graft from the left ankle.", + "When tunneling the tibia, we used jig guide for tibial tunnel placement.", + "We also made a transseptal portal from medial to lateral in order to get better view of posterior aspect of the tibia.", + "We used it as the graft because hamstring tendon was already used in previous surgery.", + "The post-operative X-ray of the left knee showed tibial tunnel was revised to appropriate site of its footprint.", + "The shadow of two endobuttons on the medial femoral condyle was seen because the endobutton of previous surgery was not removed." + ], + "summary": "We report a case of 29 year old male with total rupture of ACL and PCL that underwent reconstruction for both ligaments. We found the failure of the PCL graft 2 years after the surgery was related to the tibial tunnel placement which was placed not in proper anatomical site. We performed revision PCL surgery with transseptal portal technique to ensure the tibial tunnel is placed in appropriate position.", + "summary_subclaims": [ + "The patient is a 29 year old male.", + "The patient had total rupture of ACL and PCL.", + "The patient underwent reconstruction for both ACL and PCL.", + "The failure of the PCL graft occurred 2 years after the surgery.", + "The failure of the PCL graft was related to the tibial tunnel placement.", + "The tibial tunnel was placed not in proper anatomical site.", + "We performed revision PCL surgery.", + "We used transseptal portal technique.", + "The transseptal portal technique was used to ensure the tibial tunnel is placed in appropriate position." + ] + }, + { + "id": "multiclinsum_test_3242_en.txt", + "fulltext": "66-year-old male with a history of smoking, atrial fibrillation and hypertension, who was referred to the thoracic surgery department for a pulmonary nodule found on imaging studies performed during the staging of prostate cancer (Gleason 3 + 4 = 7). A 19.8 mm, bilobed, well-defined margin, pulmonary nodule was observed on a CT scan. A 18F-choline PET scan reported a heterogeneous formation in the prostate with a SUV 5.6 and a bilobed, well-defined margin, pulmonary nodule in the lingular segment of 19.5 mm with a SUV 5.4. The case was discussed in the Tumour Committee and, given the impossibility of ruling out a primary pulmonary neoplasm vs. pulmonary metastasis of prostate cancer, it was decided to perform a systematic pulmonary resection and lymph node sampling. Although the lung is a common site of metastasis of prostate cancer, it is rare for a small-sized neoplasm without other distant (bone) involvement to present a single pulmonary lesion. On the other hand, morphologically, it is not the typical image of a primary pulmonary neoplasm (spiky/irregular borders). The intraoperative study of the nodule was reported as “positive for neoplasm” and, given the difficulty of histological definition, it was decided to perform an anatomical pulmonary segmentation (lingulectomy) to avoid performing a sub-optimal oncological resection of a pulmonary primary and, eventually, preserve parenchyma, if it is a metastasis of prostate. The patient had a normal pulmonary function test and an Eastern Cooperative Oncology Group (ECOG) performance status of 0. The definitive pathological anatomical result was: perivascular epitheloid cell tumour (pulmonary PEComa or clear cell tumour) of 1.4 cm. The tumour did not present necrosis. Immunomarking techniques were performed on paraffin-embedded tissue sections, performed on a BenchMark-XT automatic equipment (Ventana-Roche) for the following determinations: HMB45: focal positive; CD117: negative; TTF1: negative; chromogranin: negative; AML: negative; PAX8: negative; NKX 3.1: negative; CK7: negative; CK 8/18: negative; CK: negative; CD34: positive; synaptophysin: negative; CD68: negative; CD31: negative; ERG: negative; Ki67: less than 1%; S100: negative.\n", + "fulltext_subclaims": [ + "The patient is a 66-year-old male.", + "The patient has a history of smoking.", + "The patient has a history of atrial fibrillation.", + "The patient has a history of hypertension.", + "The patient was referred to the thoracic surgery department.", + "The pulmonary nodule was found on imaging studies performed during the staging of prostate cancer.", + "The Gleason score of the prostate cancer is 3 + 4 = 7.", + "A 19.8 mm, bilobed, well-defined margin, pulmonary nodule was observed on a CT scan.", + "An 18F-choline PET scan reported a heterogeneous formation in the prostate with a SUV 5.6.", + "An 18F-choline PET scan reported a bilobed, well-defined margin, pulmonary nodule in the lingular segment of 19.5 mm with a SUV 5.4.", + "The case was discussed in the Tumour Committee.", + "It was decided to perform a systematic pulmonary resection and lymph node sampling.", + "The intraoperative study of the nodule was reported as 'positive for neoplasm'.", + "The definitive pathological anatomical result was: perivascular epitheloid cell tumour (pulmonary PEComa or clear cell tumour) of 1.4 cm.", + "The tumour did not present necrosis.", + "Immunomarking techniques were performed on paraffin-embedded tissue sections.", + "HMB45 was focal positive.", + "CD117 was negative.", + "TTF1 was negative.", + "Chromogranin was negative.", + "AML was negative.", + "PAX8 was negative.", + "NKX 3.1 was negative.", + "CK7 was negative.", + "CK 8/18 was negative.", + "CK was negative.", + "CD34 was positive.", + "Synaptophysin was negative.", + "CD68 was negative.", + "CD31 was negative.", + "ERG was negative.", + "Ki67 was less than 1%.", + "S100 was negative." + ], + "summary": "We present the case of a 66-year-old patient with a pulmonary nodule found during the oncological staging for prostate adenocarcinoma who underwent an anatomical pulmonary segmentectomy. The final pathological anatomy result was a perivascular epithelioid cell tumor (pulmonary PEComa or \"sugar\" clear cell tumor).\n", + "summary_subclaims": [ + "The patient was a 66-year-old man.", + "The patient had a pulmonary nodule found during the oncological staging for prostate adenocarcinoma.", + "The patient underwent an anatomical pulmonary segmentectomy.", + "The final pathological anatomy result was a perivascular epithelioid cell tumor.", + "The tumor was described as a pulmonary PEComa or 'sugar' clear cell tumor." + ] + }, + { + "id": "multiclinsum_test_147_en.txt", + "fulltext": "A 67 year-old male presented to his local hospital with six weeks of extreme lethargy. He complained of non-radiating chest and epigastric pain with associated breathlessness and anorexia. On further questioning he admitted to 25 kg weight loss over the previous six months. He reported a past history of empyema occurring decades previously.\nExamination revealed normal heart sounds, an irregular tachycardia with a pulse of 100 beats/min, raised jugular venous pulse, widespread peripheral edema, vesicular air entry to lungs, no abdominal signs, and no lymphadenopathy.\nVital signs revealed a pyrexia of 39 °C, relative hypotension of 110/67 mmHg, pulse oximetry 95 % on air, a tachypnea of 26 breaths/min and normal urine output.\nLaboratory investigations showed hemoglobin 57 g/L (125–160 g/L), MCV 71 fL (80–100 fL), white cell count 33.6 × 109/L (4-11 × 109/L), CRP 218 mg/L (<5 mg/L), sodium 127 mmol/L (135–145 mmol/L), potassium 5.9 mmol/L (3.5–5.5 mmol/L), creatinine 111 mmol/L (60–110 mmol/L), albumin 17 g/L (35–55 g/L), bilirubin 9 mg/L (0–17 mg/L), ALT 182 U/L (7–56 U/L), ALP 203 (44–107 U/L). Blood film demonstrated neutrophilia with left shift consistent with severe bacterial infection, and evidence of anemia including microcytosis, polychromasia, target cells and pencil red blood cells.\nInitial treatment included transfusion of 4 units of packed red blood cells, treatment of heart failure with diuresis and of sepsis with intravenous broad-spectrum antibiotics (tazobactam/piperacillin).\nSerial electrocardiograms showed sinus tachycardia with paroxysmal atrial fibrillation and widespread ST elevation of about 2 mm in leads II, III, aVF, V3-V6 , which later normalized. Serial troponin I ultra over a 24 h period after presentation were 695, 538, 491 ng/L (<20 ng/L) respectively. It was thought this represented cardiac stress secondary to persistent tachycardia and profound anemia. Thoracic radiogram showed a small left-sided pleural effusion .\nEchocardiography was obtained and showed mild left ventricular dilatation with severe dysfunction and an ejection fraction of 25 %. There was also a 0.9 cm apical, 1.4 cm anterior and 1.3 cm posterior simple pericardial effusion without hemodynamic compromise or tamponade. For this reason, pericardiocentesis was not performed.\nComputed tomogram of chest abdomen and pelvis demonstrated right lower lobe pulmonary artery embolus with infarction of lung parenchyma, pneumopericardium and pericardial effusion , fixed large hiatus hernia with a mass , enlarged 18 mm celiac node and unremarkable appearances elsewhere. Subsequent gastroscopy confirmed a large hiatus hernia with a bleeding ulcerated gastroesophageal junction tumor . Serosal breaching by this mass led to fistulation into the adjacent pericardium. Histological diagnosis was subsequently confirmed as poorly differentiated adenocarcinoma.\nAfter an initial improvement with antibacterial therapy and hemodynamic stabilization, drainage of his contaminated pericardial cavity was considered, but the patient rapidly deteriorated with uncontrolled sepsis and multi-organ failure. Management of a complex case such as this requires multidisciplinary team discussion. It was felt that aggressive management of a cachectic man with a poor cancer prognosis and a multiple serious clinical conditions arising from this was not in his best interest as he was unlikely to survive intervention or surgery. These discussions included the patient and his family, and led to a palliative management approach.", + "fulltext_subclaims": [ + "The patient is a 67 year-old male.", + "He had six weeks of extreme lethargy.", + "He complained of non-radiating chest and epigastric pain.", + "He had associated breathlessness.", + "He admitted to 25 kg weight loss over the previous six months.", + "He reported a past history of empyema occurring decades previously.", + "Examination revealed an irregular tachycardia with a pulse of 100 beats/min.", + "Vital signs revealed a pyrexia of 39 °C.", + "Vital signs revealed relative hypotension of 110/67 mmHg.", + "Laboratory investigations showed hemoglobin 57 g/L.", + "Blood film demonstrated neutrophilia with left shift consistent with severe bacterial infection.", + "Initial treatment included transfusion of 4 units of packed red blood cells.", + "Serial electrocardiograms showed sinus tachycardia with paroxysmal atrial fibrillation.", + "Serial electrocardiograms showed widespread ST elevation of about 2 mm in leads II, III, aVF, V3-V6.", + "Serial troponin I ultra over a 24 h period after presentation were 695, 538, 491 ng/L.", + "It was thought this represented cardiac stress secondary to persistent tachycardia and profound anemia.", + "Echocardiography showed mild left ventricular dilatation with severe dysfunction and an ejection fraction of 25 %.", + "Computed tomogram of chest abdomen and pelvis demonstrated right lower lobe pulmonary artery embolus with infarction of lung parenchyma.", + "Computed tomogram demonstrated pneumopericardium and pericardial effusion.", + "Computed tomogram demonstrated a fixed large hiatus hernia with a mass.", + "Computed tomogram demonstrated an enlarged 18 mm celiac node.", + "Subsequent gastroscopy confirmed a large hiatus hernia with a bleeding ulcerated gastroesophageal junction tumor.", + "Histological diagnosis was subsequently confirmed as poorly differentiated adenocarcinoma.", + "Management of a complex case such as this requires multidisciplinary team discussion.", + "It was felt that aggressive management of a cachectic man with a poor cancer prognosis and multiple serious clinical conditions arising from this was not in his best interest.", + "These discussions included the patient and his family.", + "A palliative management approach was chosen." + ], + "summary": "A 67 year-old man who presented with weight loss, chest pain and epigastric pain was found to have pericardial effusion and pneumopericardium on computed imaging. Endoscopy and histology confirmed a gastric adenocarcinoma within a hiatus hernia, which had fistulated to the pericardium. His condition was complicated by pulmonary emboli and lobar infarction, all contributing to rapid deterioration and death.", + "summary_subclaims": [ + "The patient was a 67 year-old man.", + "The patient presented with weight loss.", + "The patient presented with chest pain.", + "The patient presented with epigastric pain.", + "Computed imaging showed pericardial effusion.", + "Computed imaging showed pneumopericardium.", + "Endoscopy confirmed a gastric adenocarcinoma within a hiatus hernia.", + "Histology confirmed a gastric adenocarcinoma within a hiatus hernia.", + "The gastric adenocarcinoma had fistulated to the pericardium.", + "The patient had pulmonary emboli.", + "The patient had lobar infarction.", + "The patient's condition contributed to rapid deterioration.", + "The patient died." + ] + }, + { + "id": "multiclinsum_test_1055_en.txt", + "fulltext": "A 82-year old lady presented to the Department of General Surgery at the University of Heidelberg, Germany with recurrent attacks of hypoglycemia and a large abdominal mass. While diagnostic tests repeatedly documented glucose levels below 40 mg/dl (normal levels 80 – 120 mg/dl), a computed tomography (CT) scan of the abdomen revealed a large lesion of around 5 to 6 cm in relation to the pancreatic body and tail. There were also large masses of about 3–5 cm in the retroperitoneum and in the area of the celiac trunk and around the mesenteric artery. Furthermore, in the pancreatic body there was a hypervascularized area , that was suspicious for an insulinoma. Clinically this lady, who was not thriving, reported a weight loss of 12 kilograms over the previous 4 months. A somatostatin receptor scintigraphy showed an enhanced uptake in the region of the pancreatic body/tail as well as in the right axilla (a palpable mass was also noted there) and excluded the possibility of other involved areas.\nShe gave a past history of an operation done on the right eyebrow 2 years prior for a 0.8 × 0.8 cm lesion that was reported as a Merkel cell carcinoma. Histopathology showed rather uniform tumor cells in a trabecular growth pattern with monomorphous pale-stained nuclei and many mitoses . There was invasion of dermal lymphatics and blood vessels . Immunohistochemistry revealed strong positivity for cytokeratin 20 and neurofilament (not shown) in the characteristic dot-like pattern and a weak expression of chromogranin A . After excision, radiation therapy was also administered only at the site of the primary lesion, the draining lymphatic vessels and the first lymph node station. A year later, a large abdominal mass was noted of uncertain origin and an ultrasound guided biopsy showed an unspecified small cell cancer. In view of the large mass with additional suspicious areas being noted in the spleen, left adrenal gland and axilla, she had been subjected to palliative radiotherapy of 30 Gray over 2 months. However no definitive diagnosis of metastasis in these areas was established. With a working clinical diagnosis of symptomatic insulinoma not responding to medical measures, a decision for surgical resection of this large lesion was inevitable, the age of the patient and the previous history of palliative radiation just 6 months prior notwithstanding.\nSurgical exploration revealed a large mass of about 5 cm in the tail of the pancreas, in close proximity to the spleen and the splenic flexure of the transverse colon. However there was no evidence of any metastatic disease to the liver, peritoneum and the adnexae. After a careful and meticulous mobilization, a distal pancreatectomy, splenectomy, and adrenalectomy along with resection of the splenic flexure of the colon were performed.\nPathological examination revealed a tumor with manifestations in the pancreatic tail, the adrenal gland, the peripancreatic tissue, and the surrounding soft tissue. Grossly, the mass displayed a whitish and glassy cut surface, containing extended areas of haemorrhage and necrosis. Histologically, the tumor displayed endocrine architecture with mostly solid formations of rather monomorphic cells. The tumor was mitotically highly active (mitotic count >10 per high power field) and contained abundant areas of necrosis. Immunohistochemically, the tumor cells were strongly positive for the endocrine marker synaptophysin and for cytokeratin 20 while there was no expression of insulin. The proliferative activity (MIB-1) reached approximately 80% .\nFurthermore, gross examination of the resected specimen revealed a well demarcated, brownish tumor of the pancreatic body, measuring 1.2 cm in diameter. This tumor microscopically displayed endocrine architecture with trabecular arrangements of uniform tumor cells, showing no mitotic activity. Immunohistochemistry revealed strong positivity for synaptophysin as well as focal positivity for insulin. The proliferative activity (MIB-1) was approximately 1% . The diagnosis of a poorly differentiated endocrine carcinoma (Merkel cell carcinoma) along with that of benign pancreatic insulinoma was thus made.\nThe patient had a smooth postoperative recovery, the bouts of hypoglycaemia completely disappeared, and she was discharged home within 3 weeks of surgery. She is presently asymptomatic and remains on regular follow up.", + "fulltext_subclaims": [ + "The patient is an 82-year-old lady.", + "She presented with recurrent attacks of hypoglycemia.", + "Diagnostic tests repeatedly documented glucose levels below 40 mg/dl.", + "A CT scan of the abdomen revealed a large lesion of around 5 to 6 cm in relation to the pancreatic body and tail.", + "There were also large masses of about 3–5 cm in the retroperitoneum and in the area of the celiac trunk and around the mesenteric artery.", + "In the pancreatic body there was a hypervascularized area suspicious for an insulinoma.", + "The patient reported a weight loss of 12 kilograms over the previous 4 months.", + "A somatostatin receptor scintigraphy showed an enhanced uptake in the region of the pancreatic body/tail.", + "A somatostatin receptor scintigraphy showed an enhanced uptake in the right axilla.", + "A palpable mass was noted in the right axilla.", + "The scintigraphy excluded the possibility of other involved areas.", + "The patient had a past history of an operation on the right eyebrow 2 years prior.", + "The eyebrow lesion was reported as a Merkel cell carcinoma.", + "Histopathology showed rather uniform tumor cells in a trabecular growth pattern.", + "The tumor cells had monomorphous pale-stained nuclei.", + "There were many mitoses.", + "There was invasion of dermal lymphatics and blood vessels.", + "Immunohistochemistry revealed strong positivity for cytokeratin 20.", + "Immunohistochemistry revealed a dot-like pattern of cytokeratin 20.", + "There was a weak expression of chromogranin A.", + "After excision, radiation therapy was administered at the site of the primary lesion.", + "Radiation therapy was also administered at the draining lymphatic vessels.", + "Radiation therapy was also administered at the first lymph node station.", + "A year later, a large abdominal mass was noted of uncertain origin.", + "An ultrasound guided biopsy showed an unspecified small cell cancer.", + "Palliative radiotherapy of 30 Gray over 2 months was administered.", + "No definitive diagnosis of metastasis in the spleen, left adrenal gland, and axilla was established.", + "The working clinical diagnosis was symptomatic insulinoma not responding to medical measures.", + "A decision for surgical resection of the large lesion was made.", + "Surgical exploration revealed a large mass of about 5 cm in the tail of the pancreas.", + "The mass was in close proximity to the spleen and the splenic flexure of the transverse colon.", + "There was no evidence of any metastatic disease to the liver, peritoneum, and the adnexae.", + "A distal pancreatectomy, splenectomy, adrenalectomy, and resection of the splenic flexure of the colon were performed.", + "Pathological examination revealed a tumor in the pancreatic tail.", + "The tumor was also present in the adrenal gland.", + "The tumor was also present in the peripancreatic tissue.", + "The tumor was also present in the surrounding soft tissue.", + "Grossly, the mass displayed a whitish and glassy cut surface.", + "The mass contained extended areas of haemorrhage and necrosis.", + "Histologically, the tumor displayed endocrine architecture with mostly solid formations of rather monomorphic cells.", + "The tumor was mitotically highly active (mitotic count >10 per high power field).", + "The tumor contained abundant areas of necrosis.", + "Immunohistochemically, the tumor cells were strongly positive for synaptophysin.", + "Immunohistochemically, the tumor cells were strongly positive for cytokeratin 20.", + "There was no expression of insulin.", + "The proliferative activity (MIB-1) reached approximately 80%.", + "Gross examination of the resected specimen revealed a well demarcated, brownish tumor of the pancreatic body.", + "The tumor measured 1.2 cm in diameter.", + "Microscopically, the tumor displayed endocrine architecture with trabecular arrangements of uniform tumor cells.", + "There was no mitotic activity.", + "Immunohistochemistry revealed strong positivity for synaptophysin.", + "Immunohistochemistry revealed focal positivity for insulin.", + "The proliferative activity (MIB-1) was approximately 1%.", + "The diagnosis of a poorly differentiated endocrine carcinoma (Merkel cell carcinoma) was made.", + "The diagnosis of a benign pancreatic insulinoma was made.", + "The patient had a smooth postoperative recovery.", + "The bouts of hypoglycaemia completely disappeared.", + "She was discharged home within 3 weeks of surgery.", + "She is presently asymptomatic.", + "She remains on regular follow up." + ], + "summary": "We report an unusual occurrence of pancreatic metastases from a previously diagnosed Merkel cell carcinoma with the discovery of a concomitant insulinoma. An 82-year old lady suffered from recurrent attacks of hypoglycemia and presented with an abdominal mass, 2 years prior she had an excision done on her eyebrow that was reported as Merkel cell carcinoma. An extended distal pancreatectomy and splenectomy along with resection of the left flexure of the colon for her abdominal mass was carried out. Final histopathology of the mass was a poorly differentiated endocrine carcinoma in the pancreatic tail, in the peripancreatic tissue and in the surrounding soft tissue consistent with metastatic Merkel cell carcinoma in addition to an insulinoma of the pancreatic body.", + "summary_subclaims": [ + "We report an unusual occurrence of pancreatic metastases from a previously diagnosed Merkel cell carcinoma with the discovery of a concomitant insulinoma.", + "An 82-year old lady suffered from recurrent attacks of hypoglycemia.", + "She presented with an abdominal mass.", + "Two years prior she had an excision done on her eyebrow that was reported as Merkel cell carcinoma.", + "An extended distal pancreatectomy and splenectomy along with resection of the left flexure of the colon for her abdominal mass was carried out.", + "Final histopathology of the mass was a poorly differentiated endocrine carcinoma in the pancreatic tail.", + "Final histopathology showed the tumor in the peripancreatic tissue.", + "Final histopathology showed the tumor in the surrounding soft tissue.", + "The histopathology was consistent with metastatic Merkel cell carcinoma.", + "An insulinoma of the pancreatic body was also found." + ] + }, + { + "id": "multiclinsum_test_1247_en.txt", + "fulltext": "A 56-year-old male patient presented by a gradually progressive course of lower back pain, burning sensation of both lower limbs followed by urinary incontinence. The past history was irrelevant. X-ray of lumbosacral region revealed sacral osteolytic lesion with an associated soft-tissue mass. Non-contrast computed tomography of lumbosacral spine revealed a large 11 cm × 8 cm × 12 cm lobulated mass of the sacrum filling the sacral canal and having pre- and retro-sacral extension. The patient underwent maximal possible excision of sacral mass in December 2018 and the post-operative pathology revealed chordoma. Post-operative magnetic resonance imaging (MRI) showed a well-defined heterogeneously enhanced residual destructive bony lesion 8.5 cm × 6.5 cm × 7.5 cm affecting the sacrum (, ). The panel decided post-operative conventional radiotherapy dose of 60 Gy in 30 sessions. The follow-up MRI revealed about 30% response. There was clinical improvement following the surgery and radiotherapy.\nIn February 2020, the patient developed left inguinal swelling. Pelvic sonar showed enlarged left inguinal lymph node 3.5 cm × 2 cm × 3 cm with distorted hilum. Excisional biopsy was done and revealed metastatic chordoma (-). Metastatic work-up was free. The patient started Gleevec 400 mg daily. In June 2020, the patient developed an enlarged right inguinal lymph node 4 cm × 3.5 cm × 3 cm and the excision biopsy revealed metastatic chordoma as well. Metastatic work-up was free. Gleevec was stopped. A second-line target therapy was recommended but was not received by the patient. In September 2020, the patient developed headache, dysarthria, numbness at cheek, and lips. MRI brain revealed a well-defined abnormal signal intensity at the left side of clivus 3 cm × 4.5 cm × 4.8 cm suggesting chordoma . Transnasal biopsy revealed chordoma.\nIn October 2020 , the panel decided conventional radiotherapy of 60 Gy in 30 sittings. The follow-up MRI revealed regression of the clivus lesion and the patient improved clinically. At present, the patient is clinically stable while on follow-up.", + "fulltext_subclaims": [ + "A 56-year-old male patient presented with a gradually progressive course of lower back pain.", + "The patient had a burning sensation of both lower limbs.", + "The patient had urinary incontinence.", + "X-ray of the lumbosacral region revealed a sacral osteolytic lesion with an associated soft-tissue mass.", + "Non-contrast computed tomography of the lumbosacral spine revealed a large 11 cm × 8 cm × 12 cm lobulated mass of the sacrum.", + "The mass filled the sacral canal.", + "The mass had pre- and retro-sacral extension.", + "The patient underwent maximal possible excision of the sacral mass in December 2018.", + "Post-operative pathology revealed chordoma.", + "Post-operative MRI showed a well-defined heterogeneously enhanced residual destructive bony lesion 8.5 cm × 6.5 cm × 7.5 cm affecting the sacrum.", + "The panel decided on post-operative conventional radiotherapy of 60 Gy in 30 sessions.", + "The follow-up MRI showed about 30% response.", + "There was clinical improvement following the surgery and radiotherapy.", + "In February 2020, the patient developed a left inguinal swelling.", + "Pelvic sonar showed an enlarged left inguinal lymph node 3.5 cm × 2 cm × 3 cm with distorted hilum.", + "Excisional biopsy was done.", + "The excisional biopsy revealed metastatic chordoma.", + "Metastatic work-up was free.", + "The patient started Gleevec 400 mg daily.", + "In June 2020, the patient developed an enlarged right inguinal lymph node 4 cm × 3.5 cm × 3 cm.", + "The excision biopsy revealed metastatic chordoma.", + "Metastatic work-up was free.", + "Gleevec was stopped.", + "A second-line target therapy was recommended.", + "The patient did not receive the second-line target therapy.", + "In September 2020, the patient developed headache, dysarthria, numbness at cheek, and lips.", + "MRI brain revealed a well-defined abnormal signal intensity at the left side of clivus 3 cm × 4.5 cm × 4.8 cm suggesting chordoma.", + "Transnasal biopsy revealed chordoma.", + "In October 2020, the panel decided on conventional radiotherapy of 60 Gy in 30 sittings.", + "The follow-up MRI revealed regression of the clivus lesion.", + "The patient improved clinically.", + "At present, the patient is clinically stable while on follow-up." + ], + "summary": "A 56-year-old male patient of sacral chordoma was treated by surgery and radiotherapy. He developed later bilateral inguinal lymph node metastasis and metachronous clivus chordoma.", + "summary_subclaims": [ + "The patient is a 56-year-old male.", + "The patient had sacral chordoma.", + "The patient was treated by surgery.", + "The patient was treated by radiotherapy.", + "The patient developed bilateral inguinal lymph node metastasis.", + "The patient developed metachronous clivus chordoma." + ] + }, + { + "id": "multiclinsum_test_2012_en.txt", + "fulltext": "A 64-year-old Caucasian woman suffered from a first vertebral fracture in the second lumbar vertebra (L2) in 2004 following a fall from her bicycle. She did not obtain any treatment. Dual X-ray absorptiometry (DXA) revealed osteoporosis: lumbar T-score of − 3.2 standard deviation (SD). Our patient’s characteristics during follow up are summarized in Table . Her phosphorus and calcium levels were normal (plasma calcium concentration = 2.50 mmol/l; normal range 2.13 to 2.65 mmol/l), parathyroid hormone (PTH) concentration was normal (48 ng/l; normal range 15 to 65 ng/l), and vitamin D level was low (13.6 ng/ml; normal range 30 to 60 ng/l). She was included in the FREEDOM protocol, comparing denosumab (60 mg, subcutaneously, every 6 months, plus 1000 mg of calcium and 800 IU of vitamin D daily) with placebo for the treatment of postmenopausal osteoporosis in January 2005. The unblinding of the trial 3 years later showed that she had been randomized to the denosumab group. Several vertebral fractures occurred during this 3-year period: fifth thoracic vertebra (T5), eighth thoracic vertebra (T8), and an aggravation of the L2 fracture. She continued to participate in the extension protocol in open mode for 6 years, and then withdrew of her own volition, with a final injection of denosumab in July 2013; there were no new vertebral fractures during this entire period. DXA in September 2013 demonstrated increased bone mineral density (BMD) of 22.3% in her lumbar region (T-score, − 1.6 SD) and of 17.0% in her total left hip (T-score, − 1.1 SD). She was a former tobacco smoker and her medical history included osteoarthritis of the knee, a hiatus hernia, hypertension, amlodipine allergy, and colonic polyps. Calcaemia monitoring revealed a return to normal values until January 2012 (2.58 nmol/l; normal range 2.13 to 2.65 mmol/l). Check-ups while our patient was still on denosumab yielded values of 2.68 nmol/l in January 2013 and 2.73 in September 2013 .\nIn May 2014, our patient complained of acute intense spinal pain that resisted standard painkillers and required treatment with opiates. An evaluation was carried out in hospital in June 2014. Spinal X-rays revealed fractures of the fourth thoracic vertebra (T4; wedge, grade 2), T5 (biconcave, grade 3), T8 (wedge, grade 3), ninth thoracic vertebra (T9; crush, grade 3), tenth thoracic vertebra (T10; wedge, grade 1), 11th thoracic vertebra (T11; crush, grade 3), first lumbar vertebra (L1; biconcave, grade 1), L2 (wedge, grade 2), and third lumbar vertebra (L3; biconcave, grade 2) . Bone scintigraphy revealed hypersignals in all these vertebrae except L2 and T5, and in several ribs. Magnetic resonance imaging (MRI) identified vertebra T4 in hypersignal on a T2-weighted sequence and hyposignal on a T1-weighted sequence, with no signs of infiltration or suspected lysis . T9, T10, T11, L1, and L3 also showed hypersignal, and T5, T8, and L2 were older vertebral fractures with no bone marrow edema. Lumbar and dorsal pain remained severe throughout this period of exploration, justifying bed rest. Biological tests revealed hypercalcemia, with plasma concentrations of 2.83 mmol/l for calcium (normal range 2.13 to 2.65 mmol/l) and 1.06 mmol/l for phosphate (normal range 0.70 to 1.30 mmol/l), hypercalciuria (17.1 mmol/24 hours; normal range 1.5 to 6.2 mmol/24 hours), a 25(OH) vitamin D3 concentration of 15 ng/ml (normal range 30 to 60 ng/l), a PTH concentration of 41 pg/ml (normal range 15 to 65 ng/l), a C-reactive protein (CRP) concentration of 1.3 mg/l (normal values < 5 mg/l), normal protein electrophoresis with no Bence Jones proteinuria, and a plasma creatinine concentration of 44 μmol/l (normal range 45 to 84 μmol/l). Blood formula, and plasma concentrations of thyroid-stimulating hormone (TSH), parathyroid hormone-related peptide (PTHrp), cortisol and 1,25(OH)2D were normal. Carboxy-terminal collagen crosslink (CTX) levels were very high (2.09 μg/l; normal values < 0.43 μg/l), but were difficult to interpret in the context of vertebral fracture. DXA performed 1 year after the last injection of denosumab revealed BMD losses of 6.0% in our patient’s lumbar region and 2.9% in her total hip.\nThe association of fractures that are unusual for osteoporosis (T4), acute and persistent back pain, other rib fractures, and hypercalcemia were suggestive of a potential neoplasia, which led to systemic explorations, vertebral biopsy, and hyperparathyroidectomy and thyroidectomy (known goiter at the ultrasound exploration). A thoracic/abdominal/pelvic computed tomography (CT) scan showed only a heterogeneous multinodular goiter. Sesta-methoxy-isobutyl-isonitrile (MIBI) scintigraphy revealed a small area of fixation of the posterior lower right thyroid lobe and a lower lobe nodule displaying clear uptake. Fine-needle aspiration results were negative. A biopsy of the T4 was carried out under CT control and produced normal results. With hindsight, a gassy image of the upper facet of the T4 was suggestive of necrosis. A parathyroid neoplasia could have been evoked too. Surgery was performed at the end of July 2014 to remove the right upper parathyroid gland (13 × 10 × 2 mm; weight, 0.1 g), and histological analysis suggested nodular hyperplasia. Associated total thyroidectomy led to the detection of a dystrophic goiter with macrovesicular nodules and a 1 mm isthmic papillary microcarcinoma with no associated adenopathy.\nHer pain was initially acute but of the mechanical type with a generally favorable outcome. Her calcaemia normalized the day after surgery: 2.44 mmol/l, with a plasma PTH concentration of 51.5 ng/l (normal range 15 to 65 ng/l). A new bone densitometry evaluation was carried out in October 2016, at which time bone losses of 15.7% for the lumbar region (T-score, − 2.9 SD) and 15.5% for the total left hip (T-score, − 2.3 SD) were recorded . She continued to complain of disabling spinal pain. Her phosphorus and calcium evaluation results remained normal, as did her vitamin D levels, with the continuation of substitution treatment. Given the considerable decrease in BMD, she was placed on risedronate in September 2016, but this was badly tolerated. She was then placed on zoledronate (5 mg). Her calcaemia remained stable at 2.47 mmol/l (normal range 2.13 to 2.65 mmol/l). After two infusions (October 2016 and October 2017), a new DXA in August 2018 showed stabilization of the lumbar BMD (+ 0.5%) and a significant loss in the total hip BMD (− 8.5%). Her plasma calcium levels remained normal (2.60 mmol/l) and she did not have any new vertebral or peripheral fractures.", + "fulltext_subclaims": [ + "The patient was a 64-year-old Caucasian woman.", + "She suffered from a first vertebral fracture in the second lumbar vertebra (L2) in 2004 following a fall from her bicycle.", + "She did not obtain any treatment.", + "Dual X-ray absorptiometry (DXA) revealed osteoporosis: lumbar T-score of −3.2 standard deviation (SD).", + "Her phosphorus and calcium levels were normal.", + "Her plasma calcium concentration was 2.50 mmol/l.", + "The normal range for plasma calcium is 2.13 to 2.65 mmol/l.", + "Her parathyroid hormone (PTH) concentration was 48 ng/l.", + "The normal range for PTH is 15 to 65 ng/l.", + "Her vitamin D level was 13.6 ng/ml.", + "The normal range for vitamin D is 30 to 60 ng/l.", + "She was included in the FREEDOM protocol in January 2005.", + "The FREEDOM protocol compared denosumab with placebo for the treatment of postmenopausal osteoporosis.", + "The unblinding of the trial 3 years later showed that she had been randomized to the denosumab group.", + "Several vertebral fractures occurred during this 3-year period: fifth thoracic vertebra (T5), eighth thoracic vertebra (T8), and an aggravation of the L2 fracture.", + "She continued to participate in the extension protocol in open mode for 6 years.", + "She withdrew of her own volition, with a final injection of denosumab in July 2013.", + "There were no new vertebral fractures during this entire period.", + "DXA in September 2013 demonstrated increased bone mineral density (BMD) of 22.3% in her lumbar region.", + "The lumbar T-score in September 2013 was −1.6 SD.", + "DXA in September 2013 demonstrated increased BMD of 17.0% in her total left hip.", + "The total left hip T-score in September 2013 was −1.1 SD.", + "She was a former tobacco smoker.", + "Her medical history included osteoarthritis of the knee.", + "Her medical history included a hiatus hernia.", + "Her medical history included hypertension.", + "She had an allergy to amlodipine.", + "Her medical history included colonic polyps.", + "Calcaemia monitoring revealed a return to normal values until January 2012.", + "Her plasma calcium concentration in January 2012 was 2.58 nmol/l.", + "The normal range for plasma calcium is 2.13 to 2.65 mmol/l.", + "Check-ups while on denosumab yielded plasma calcium values of 2.68 nmol/l in January 2013.", + "Check-ups while on denosumab yielded plasma calcium values of 2.73 nmol/l in September 2013.", + "In May 2014, she complained of acute intense spinal pain that resisted standard painkillers.", + "The pain required treatment with opiates.", + "An evaluation was carried out in hospital in June 2014.", + "Spinal X-rays revealed fractures of the fourth thoracic vertebra (T4; wedge, grade 2).", + "Spinal X-rays revealed fractures of the fifth thoracic vertebra (T5; biconcave, grade 3).", + "Spinal X-rays revealed fractures of the eighth thoracic vertebra (T8; wedge, grade 3).", + "Spinal X-rays revealed fractures of the ninth thoracic vertebra (T9; crush, grade 3).", + "Spinal X-rays revealed fractures of the tenth thoracic vertebra (T10; wedge, grade 1).", + "Spinal X-rays revealed fractures of the 11th thoracic vertebra (T11; crush, grade 3).", + "Spinal X-rays revealed fractures of the first lumbar vertebra (L1; biconcave, grade 1).", + "Spinal X-rays revealed fractures of the third lumbar vertebra (L3; biconcave, grade 2).", + "Bone scintigraphy revealed hypersignals in all these vertebrae except L2 and T5.", + "Bone scintigraphy revealed hypersignals in several ribs.", + "Magnetic resonance imaging (MRI) identified vertebra T4 in hypersignal on a T2-weighted sequence.", + "MRI identified vertebra T4 in hyposignal on a T1-weighted sequence.", + "MRI showed no signs of infiltration or suspected lysis in vertebra T4.", + "T9, T10, T11, L1, and L3 also showed hypersignal on MRI.", + "T5, T8, and L2 were older vertebral fractures with no bone marrow edema.", + "Lumbar and dorsal pain remained severe throughout this period of exploration.", + "The pain justified bed rest.", + "Biological tests revealed hypercalcemia with plasma calcium concentrations of 2.83 mmol/l.", + "The normal range for plasma calcium is 2.13 to 2.65 mmol/l.", + "Biological tests revealed plasma phosphate concentrations of 1.06 mmol/l.", + "The normal range for plasma phosphate is 0.70 to 1.30 mmol/l.", + "Biological tests revealed hypercalciuria of 17.1 mmol/24 hours.", + "The normal range for hypercalciuria is 1.5 to 6.2 mmol/24 hours.", + "25(OH) vitamin D3 concentration was 15 ng/ml.", + "The normal range for 25(OH) vitamin D3 is 30 to 60 ng/l.", + "PTH concentration was 41 pg/ml.", + "The normal range for PTH is 15 to 65 ng/l.", + "C-reactive protein (CRP) concentration was 1.3 mg/l.", + "The normal values for CRP are < 5 mg/l.", + "Protein electrophoresis showed no Bence Jones proteinuria.", + "Plasma creatinine concentration was 44 μmol/l.", + "The normal range for plasma creatinine is 45 to 84 μmol/l.", + "Blood formula, plasma concentrations of TSH, PTHrp, cortisol, and 1,25(OH)2D were normal.", + "Carboxy-terminal collagen crosslink (CTX) levels were very high at 2.09 μg/l.", + "The normal values for CTX are < 0.43 μg/l.", + "DXA performed 1 year after the last injection of denosumab revealed BMD losses of 6.0% in the lumbar region.", + "DXA performed 1 year after the last injection of denosumab revealed BMD losses of 2.9% in the total hip.", + "The association of fractures that are unusual for osteoporosis (T4), acute and persistent back pain, other rib fractures, and hypercalcemia were suggestive of a potential neoplasia.", + "Systemic explorations, vertebral biopsy, and hyperparathyroidectomy and thyroidectomy were performed.", + "A thoracic/abdominal/pelvic computed tomography (CT) scan showed only a heterogeneous multinodular goiter.", + "Sesta-methoxy-isobutyl-isonitrile (MIBI) scintigraphy revealed a small area of fixation of the posterior lower right thyroid lobe.", + "A lower lobe nodule displayed clear uptake on MIBI scintigraphy.", + "Fine-needle aspiration results were negative.", + "A biopsy of the T4 was carried out under CT control and produced normal results.", + "A gassy image of the upper facet of the T4 was suggestive of necrosis.", + "A parathyroid neoplasia could have been evoked.", + "Surgery was performed at the end of July 2014 to remove the right upper parathyroid gland.", + "The removed parathyroid gland measured 13 × 10 × 2 mm.", + "The weight of the removed parathyroid gland was 0.1 g.", + "Histological analysis suggested nodular hyperplasia.", + "Associated total thyroidectomy led to the detection of a dystrophic goiter with macrovesicular nodules.", + "A 1 mm isthmic papillary microcarcinoma was detected.", + "There was no associated adenopathy.", + "Her pain was initially acute but of the mechanical type with a generally favorable outcome.", + "Her calcaemia normalized the day after surgery to 2.44 mmol/l.", + "Plasma PTH concentration after surgery was 51.5 ng/l.", + "The normal range for PTH is 15 to 65 ng/l.", + "A new bone densitometry evaluation was carried out in October 2016.", + "Bone losses of 15.7% for the lumbar region were recorded in October 2016.", + "The lumbar T-score in October 2016 was −2.9 SD.", + "Bone losses of 15.5% for the total left hip were recorded in October 2016.", + "The total left hip T-score in October 2016 was −2.3 SD.", + "She continued to complain of disabling spinal pain.", + "Her phosphorus and calcium evaluation results remained normal.", + "Her vitamin D levels remained normal.", + "She was placed on risedronate in September 2016.", + "Risedronate was badly tolerated.", + "She was then placed on zoledronate (5 mg).", + "Her calcaemia remained stable at 2.47 mmol/l.", + "The normal range for calcaemia is 2.13 to 2.65 mmol/l.", + "After two infusions (October 2016 and October 2017), a new DXA in August 2018 showed stabilization of the lumbar BMD (+0.5%).", + "A new DXA in August 2018 showed a significant loss in the total hip BMD (−8.5%).", + "Her plasma calcium levels remained normal at 2.60 mmol/l.", + "She did not have any new vertebral or peripheral fractures." + ], + "summary": "A 64-year-old osteoporotic Caucasian woman suffered from a fracture of her second lumbar vertebra in 2004. From January 2005, she was treated with denosumab for 9 years, with good densitometry results for her hip and lumbar areas, and no fractures over the last 6 years of treatment. Ten months after the treatment with denosumab was stopped, a cascade of vertebral fractures, including some in unusual locations (third thoracic vertebra), and multiple rib fractures in a context of hypercalcemia, suggested possible malignancy. A complete evaluation, including systemic, biological, and biopsy analyses, ruled out this hypothesis. The hypercalcemia was associated with normal plasma phosphate and vitamin D concentrations, and a high parathyroid hormone level, with an abnormal fixation of the lower lobe of the thyroid on sesta-methoxy-isobutyl-isonitrile scintigraphy. Histological analysis of the excised parathyroid tissue revealed hyperplasia. The associated thyroidectomy (goiter) led to the discovery of a thyroid papillary microcarcinoma.", + "summary_subclaims": [ + "The patient is a 64-year-old osteoporotic Caucasian woman.", + "She suffered from a fracture of her second lumbar vertebra in 2004.", + "From January 2005, she was treated with denosumab for 9 years.", + "She had good densitometry results for her hip and lumbar areas.", + "She had no fractures over the last 6 years of treatment.", + "Ten months after stopping denosumab, she had a cascade of vertebral fractures.", + "Some of the vertebral fractures were in unusual locations.", + "She had multiple rib fractures.", + "The fractures occurred in a context of hypercalcemia.", + "A complete evaluation ruled out malignancy.", + "The hypercalcemia was associated with normal plasma phosphate concentrations.", + "The hypercalcemia was associated with normal vitamin D concentrations.", + "The hypercalcemia was associated with a high parathyroid hormone level.", + "There was an abnormal fixation of the lower lobe of the thyroid on sesta-methoxy-isobutyl-isonitrile scintigraphy.", + "Histological analysis of the excised parathyroid tissue revealed hyperplasia.", + "The associated thyroidectomy led to the discovery of a thyroid papillary microcarcinoma." + ] + }, + { + "id": "multiclinsum_test_1959_en.txt", + "fulltext": "A 65-year-old female presented to the emergency room with uncontrolled abdominal pain, nausea, and vomiting. Medical history was significant for Type 2 diabetes mellitus, previous intestinal intussusceptions, and moderate abdominal pain. Initial abdominal CT scan indicated a small bowel obstruction with a transition point at the jejunal area . Related to this finding were mildly enlarged lymph nodes in the right pelvic region. Differential diagnosis included small bowel neoplasm, adhesions, or a reactive intestinal inflammatory process.\nShortly after presentation, the patient's clinical condition worsened, requiring emergency small bowel resection. Histological analysis of the resected bowel segments demonstrated small intestinal mucosa with intraepithelial and mucosal infiltrates of benign CD3 (+) T-cells, consistent with celiac sprue. Also found were medium-sized infiltrating lymphocytes with characteristic pleomorphic nuclei and prominent nucleoli. Immunohistochemical stains revealed tumor cells positive for CD-3, weakly positive for BCL-2, and negative for CD5, CD20, CD10 and cyclin-D1. Immunohistochemical analysis for Ki-67 showed a markedly increased proliferative index, with 90% of lymphocytes staining positive . Polymerase chain reaction analysis for T-cell receptor-gamma gene rearrangement was positive, demonstrating the presence of a clonal population of T-cells. The combined morphological and immunophenotypic features of this lesion were consistent with jejunal EATL. Further systemic investigations were all non-contributory. The patient was discharged and the recommended treatment for her primary condition was chemotherapy.\nThree weeks post-diagnosis, the patient received a positron emission tomography CT scan from her skull to mid-thigh, which indicated no hypermetabolic lesions suggestive of active malignancy in the skull base or neck. However, five weeks post-diagnosis, she developed new onset neurological symptoms consisting of changes in her mental status and left facio-brachial weakness. Brain MRI demonstrated a single ill-defined, irregular, right fronto-parietal enhancing lesion surrounded by vasogenic edema, with associated mass effect and midline shift . She underwent surgical resection of the intracranial lesion, and post-operative MRI demonstrated the resection of the right frontoparietal mass with small air fluid level and residual blood product seen at the tumor bed . Histopathologic evaluation of the lesion biopsy confirmed the diagnosis of metastatic EATL involving the brain .", + "fulltext_subclaims": [ + "A 65-year-old female presented to the emergency room with uncontrolled abdominal pain, nausea, and vomiting.", + "Medical history was significant for Type 2 diabetes mellitus.", + "Medical history was significant for previous intestinal intussusceptions.", + "Medical history was significant for moderate abdominal pain.", + "Initial abdominal CT scan indicated a small bowel obstruction with a transition point at the jejunal area.", + "Related to this finding were mildly enlarged lymph nodes in the right pelvic region.", + "Differential diagnosis included small bowel neoplasm.", + "Differential diagnosis included adhesions.", + "Differential diagnosis included a reactive intestinal inflammatory process.", + "The patient's clinical condition worsened shortly after presentation.", + "Emergency small bowel resection was performed.", + "Histological analysis of the resected bowel segments demonstrated small intestinal mucosa with intraepithelial and mucosal infiltrates of benign CD3 (+) T-cells.", + "Histological analysis demonstrated features consistent with celiac sprue.", + "Histological analysis found medium-sized infiltrating lymphocytes with characteristic pleomorphic nuclei and prominent nucleoli.", + "Immunohistochemical stains revealed tumor cells positive for CD-3.", + "Immunohistochemical stains revealed tumor cells weakly positive for BCL-2.", + "Immunohistochemical stains revealed tumor cells negative for CD5.", + "Immunohistochemical stains revealed tumor cells negative for CD20.", + "Immunohistochemical stains revealed tumor cells negative for CD10.", + "Immunohistochemical stains revealed tumor cells negative for cyclin-D1.", + "Immunohistochemical analysis for Ki-67 showed a markedly increased proliferative index, with 90% of lymphocytes staining positive.", + "Polymerase chain reaction analysis for T-cell receptor-gamma gene rearrangement was positive.", + "Polymerase chain reaction analysis demonstrated the presence of a clonal population of T-cells.", + "The combined morphological and immunophenotypic features of this lesion were consistent with jejunal EATL.", + "Further systemic investigations were all non-contributory.", + "The recommended treatment for her primary condition was chemotherapy.", + "Three weeks post-diagnosis, the patient received a positron emission tomography CT scan from her skull to mid-thigh.", + "The positron emission tomography CT scan indicated no hypermetabolic lesions suggestive of active malignancy in the skull base or neck.", + "Five weeks post-diagnosis, she developed new onset neurological symptoms consisting of changes in her mental status and left facio-brachial weakness.", + "Brain MRI demonstrated a single ill-defined, irregular, right fronto-parietal enhancing lesion surrounded by vasogenic edema.", + "Brain MRI showed associated mass effect and midline shift.", + "She underwent surgical resection of the intracranial lesion.", + "Post-operative MRI demonstrated the resection of the right frontoparietal mass with small air fluid level and residual blood product seen at the tumor bed.", + "Histopathologic evaluation of the lesion biopsy confirmed the diagnosis of metastatic EATL involving the brain." + ], + "summary": "A 65-year-old female presented to the emergency room with uncontrolled abdominal pain, nausea, and vomiting. Initial abdominal computed tomography (CT) scan indicated a small bowel obstruction with a transition point at the jejunal area. Differential diagnosis included small bowel neoplasm, adhesions, or a reactive intestinal inflammatory process. Shortly after presentation, the patient's clinical condition worsened, requiring emergency small bowel resection. Histological analysis of the resected bowel segments demonstrated medium-sized infiltrating lymphocytes with characteristic pleomorphic nuclei and prominent nucleoli. Immunohistochemical stains revealed tumor cells positive for CD-3. Immunohistochemical analysis for Ki-67 showed a markedly increased proliferative index, with 90% of lymphocytes staining positive. Polymerase chain reaction analysis for T-cell receptor-gamma gene rearrangement was positive, demonstrating the presence of a clonal population of T-cells. The combined morphological and immunophenotypic features of this lesion were consistent with jejunal EATL. Five weeks post-diagnosis, she developed new onset neurological symptoms consisting of changes in her mental status and left facio-brachial weakness. Brain magnetic resonance imaging (MRI) demonstrated a single ill-defined, irregular, right fronto-parietal enhancing lesion surrounded by vasogenic edema. Surgical resection and histopathologic evaluation of the biopsied lesion confirmed the diagnosis of metastatic EATL involving the brain.", + "summary_subclaims": [ + "A 65-year-old female presented to the emergency room with uncontrolled abdominal pain, nausea, and vomiting.", + "Initial abdominal computed tomography (CT) scan indicated a small bowel obstruction with a transition point at the jejunal area.", + "Differential diagnosis included small bowel neoplasm, adhesions, or a reactive intestinal inflammatory process.", + "The patient's clinical condition worsened shortly after presentation, requiring emergency small bowel resection.", + "Histological analysis of the resected bowel segments demonstrated medium-sized infiltrating lymphocytes with characteristic pleomorphic nuclei and prominent nucleoli.", + "Immunohistochemical stains revealed tumor cells positive for CD-3.", + "Immunohistochemical analysis for Ki-67 showed a markedly increased proliferative index, with 90% of lymphocytes staining positive.", + "Polymerase chain reaction analysis for T-cell receptor-gamma gene rearrangement was positive, demonstrating the presence of a clonal population of T-cells.", + "The combined morphological and immunophenotypic features of this lesion were consistent with jejunal EATL.", + "Five weeks post-diagnosis, she developed new onset neurological symptoms consisting of changes in her mental status and left facio-brachial weakness.", + "Brain magnetic resonance imaging (MRI) demonstrated a single ill-defined, irregular, right fronto-parietal enhancing lesion surrounded by vasogenic edema.", + "Surgical resection and histopathologic evaluation of the biopsied lesion confirmed the diagnosis of metastatic EATL involving the brain." + ] + }, + { + "id": "multiclinsum_test_1390_en.txt", + "fulltext": "A 28-year-old Caucasian male presented with fever and myalgia at our emergency department (= day 1). The patient reported having been on vacation on La Réunion until nine days prior, where a medium-level dengue epidemic had been declared by the WHO. His past medical history was uneventful; he was not on any medication. Physical examination revealed a body temperature of 39.7 °C but was otherwise unremarkable. Routine laboratory investigations were without pathological findings except for a C-reactive protein (CRP) of 2.5 mg/dl. Tests for Dengue virus and Chikungunya virus were ordered. The patient received metamizole and was discharged with a daily follow-up schedule which, however, he did not comply with. The microbiological laboratory tests returned negative. After three days, fever subsided and was followed by watery diarrhoea which lasted for three more days. On day 7, the patient had fully recovered.\nOn day 8, the patient noticed a weakness in his lower limbs which continuously worsened overnight. Thus, he presented in our neurological clinic the next morning. Physical examination revealed flaccid tetraparesis with a level of strength of 4/5 (MRC scale). Muscle reflexes of the upper limbs and patellar reflexes were decreased, Achilles reflexes were absent bilaterally. There were no sensory deficits; position sense and vibration sense were intact. Cerebrospinal fluid analysis was unremarkable. Electroneurography disclosed reduced amplitudes of compound muscle action potentials in tibial, peroneal and ulnar nerves. Half of the examined nerves displayed increased distal motor latency and total loss of F-waves, while sensory nerve action potentials were normal all over. Hence, pure motor axonal demyelinating polyneuropathy with acute onset, consistent with Guillain-Barré syndrome (GBS) was diagnosed. Furthermore, western blot for serum anti-ganglioside antibodies was highly positive for anti-GM2 IgM antibodies and borderline positive for anti-GM1 IgM antibodies, thus supporting the diagnosis of GBS. The occurrence of GBS raised the suspicion of a recent Campylobacter jejuni infection which was serologically confirmed (Mycoplasma pneumonia, another common trigger of GBS, and Zika virus infection were excluded).\nAs the clinical condition deteriorated rapidly with inability to walk occurring within the first 48 h, treatment with intravenous immunoglobulins was initiated (total dose 140 g over 5 days). Clinical nadir was reached after three days and the patient regained independent walking within the first week. He was transferred to a neurorehabilitation institution where he was treated for three weeks. Except for a temporary elevation of transaminases (ALT 661 U/l, AST 126 U/l) and a distortion of the left knee due to several falls, further recovery proceeded without complications.\nIn week 10, the patient presented at our clinic again. He complained of fever, loss of appetite, abdominal bloating, constipation and a dull pain in the right lower abdomen. He reported suffering from these symptoms periodically; they had first occurred three weeks ago and lasted for a couple of days, then completely disappeared and reoccurred six days ago. The onset as well as the disappearance of these symptoms was sudden. On enquiry, the patient could not think of any potential triggers preceding these episodes. Diarrhoea had not occurred.\nThe patient’s vital signs were all normal except for a body temperature of 38.8 °C. Compared to his first presentation, he had lost 11 kg (15% of his previous body weight). The abdominal examination was pertinent for tenderness on palpation in the right lower quadrant. Broad laboratory investigations were unremarkable apart from an elevated CRP of 8.5 mg/dl and a slightly elevated LDH. Abdominal ultrasound revealed a distinct mesenteric lymphadenopathy with > 10 pathological lymph nodes (max. 4 × 1.6 cm) . The largest mesenteric lymph nodes were found in the right lower quadrant and were painful when pressed with the ultrasound probe. Retroperitoneal, inguinal, supraclavicular, axillary and cervical lymph nodes as well as the appendix and colon appeared normal on ultrasound examination.\nA broad microbiological testing was initiated. While stool cultures remained negative, serology was positive for Y. pseudotuberculosis . Antibiotic treatment was initially started with azithromycin (500 mg p.o., QD, for 3 days) and switched to doxycycline (100 mg p.o., BID, for 10 days) after receiving the serology results.\nOn control ultrasound two weeks later (week 12), the lymphadenopathy was clearly regressive in all affected regions with the largest mesenteric lymphnode measuring 2 × 0.7 cm. In a telephone follow-up two months later, the patient reported no further episodes of fever or abdominal symptoms. Regarding GBS, he had not regained his full physical capacity but continued to improve constantly.", + "fulltext_subclaims": [ + "A 28-year-old Caucasian male presented with fever and myalgia at the emergency department.", + "The patient had been on vacation on La Réunion until nine days prior.", + "A medium-level dengue epidemic had been declared by the WHO on La Réunion.", + "The patient's past medical history was uneventful.", + "The patient was not on any medication.", + "Physical examination revealed a body temperature of 39.7 °C.", + "Routine laboratory investigations were without pathological findings except for a C-reactive protein (CRP) of 2.5 mg/dl.", + "Tests for Dengue virus and Chikungunya virus were ordered.", + "The patient received metamizole.", + "The patient was discharged with a daily follow-up schedule.", + "The patient did not comply with the follow-up schedule.", + "Microbiological laboratory tests returned negative.", + "After three days, fever subsided.", + "Watery diarrhoea lasted for three more days.", + "On day 7, the patient had fully recovered.", + "On day 8, the patient noticed weakness in his lower limbs.", + "The weakness in the lower limbs worsened overnight.", + "Physical examination revealed flaccid tetraparesis with a level of strength of 4/5 (MRC scale).", + "Muscle reflexes of the upper limbs and patellar reflexes were decreased.", + "Achilles reflexes were absent bilaterally.", + "Cerebrospinal fluid analysis was unremarkable.", + "Electroneurography disclosed reduced amplitudes of compound muscle action potentials in tibial, peroneal and ulnar nerves.", + "Half of the examined nerves displayed increased distal motor latency and total loss of F-waves.", + "Sensory nerve action potentials were normal all over.", + "Pure motor axonal demyelinating polyneuropathy with acute onset, consistent with Guillain-Barré syndrome (GBS), was diagnosed.", + "Western blot for serum anti-ganglioside antibodies was highly positive for anti-GM2 IgM antibodies.", + "Western blot for serum anti-ganglioside antibodies was borderline positive for anti-GM1 IgM antibodies.", + "The occurrence of GBS raised the suspicion of a recent Campylobacter jejuni infection.", + "Campylobacter jejuni infection was serologically confirmed.", + "Mycoplasma pneumonia was excluded.", + "Zika virus infection was excluded.", + "Treatment with intravenous immunoglobulins was initiated.", + "The total dose of intravenous immunoglobulins was 140 g over 5 days.", + "Clinical nadir was reached after three days.", + "The patient regained independent walking within the first week.", + "The patient was transferred to a neurorehabilitation institution.", + "The patient was treated at the neurorehabilitation institution for three weeks.", + "The patient had a temporary elevation of transaminases (ALT 661 U/l, AST 126 U/l).", + "The patient had a distortion of the left knee due to several falls.", + "In week 10, the patient presented at the clinic again.", + "The patient complained of fever, loss of appetite, abdominal bloating, constipation, and a dull pain in the right lower abdomen.", + "The patient reported that these symptoms had first occurred three weeks ago.", + "The symptoms lasted for a couple of days, then completely disappeared, and reoccurred six days ago.", + "The patient's body temperature was 38.8 °C.", + "The patient had lost 11 kg (15% of his previous body weight).", + "Abdominal examination was pertinent for tenderness on palpation in the right lower quadrant.", + "Abdominal ultrasound revealed a distinct mesenteric lymphadenopathy with > 10 pathological lymph nodes.", + "The largest mesenteric lymph nodes were found in the right lower quadrant.", + "The largest mesenteric lymph node measured 4 × 1.6 cm.", + "The largest mesenteric lymph nodes were painful when pressed with the ultrasound probe.", + "Serology was positive for Y. pseudotuberculosis.", + "Antibiotic treatment was initially started with azithromycin (500 mg p.o., QD, for 3 days).", + "Antibiotic treatment was switched to doxycycline (100 mg p.o., BID, for 10 days).", + "On control ultrasound two weeks later, the lymphadenopathy was clearly regressive.", + "The largest mesenteric lymph node measured 2 × 0.7 cm.", + "In a telephone follow-up two months later, the patient reported no further episodes of fever or abdominal symptoms.", + "Regarding GBS, the patient had not regained his full physical capacity.", + "The patient continued to improve constantly." + ], + "summary": "We report on a previously healthy patient who presented several times at our hospital with fever, Guillain-Barré syndrome, recurrent abdominal symptoms and distinct mesenteric lymphadenopathy, respectively. This complicated and diagnostically challenging course of disease was caused by a C. jejuni and Y. pseudotuberculosis coinfection. Antibiotic treatment with doxycycline was effective.", + "summary_subclaims": [ + "The patient was previously healthy.", + "The patient presented with fever.", + "The patient presented with Guillain-Barré syndrome.", + "The patient had recurrent abdominal symptoms.", + "The patient had distinct mesenteric lymphadenopathy.", + "The disease was caused by a C. jejuni and Y. pseudotuberculosis coinfection.", + "Antibiotic treatment with doxycycline was effective." + ] + }, + { + "id": "multiclinsum_test_186_en.txt", + "fulltext": "The patient was a 19-year-old Caucasian woman who presented to the clinic initially with nonspecific symptoms of fatigue, fever and abdominal pain. Past medical history was noncontributory; she was an otherwise healthy adult from the United States, and did not report ill contacts, intravenous drug use, or recent sexual contacts. She had a temperature of 102.3°F, WBC of 4,800, AST of 330 U/liter and ALT of 250 U/liter. She was thought at the time to have a viral prodrome and was treated symptomatically. The patient returned to the clinic 3 days later with resolution of her constitutional symptoms but with the development of inflammation and pain around her recent tongue piercing (1 to 2 weeks before this visit). The patient was treated for oral thrush, and cultures of the tongue were taken and grew normal oral flora and beta hemolytic streptococci group C. Several days later, the patient presented to the emergency room with worsening fever, abdominal pain, vomiting, diarrhea, myalgia, and arthralgia. At this time, she had an AST of 6000 U/liter and ALT of 4000 U/liter. The following day, her lab values increased to an AST of 9200 U/liter and an ALT of 4400 U/liter. Bilirubin and alkaline phosphatase were within normal limits. Other laboratory values were as follows: alcohol, non-detectable; CMV, infectious mononucleosis, leptospira, EBV, HBV, HCV, HEV, HIV all negative; urine drug screen negative; serum acetaminophen level of 3 μg/dl.\nCT scan showed a mottled liver and a 2 to 4 mm abscess of the anterior tongue. Shortly after admission to the ICU, she developed hypotension, coagulopathy with a PT of 83.2s and PTT of greater than 200s, hyperammonemia, and acute renal failure thought to be due to hepatorenal syndrome. The medical team was in the process of preparing her for transport to receive a liver transplant but the patient expired. Postmortem laboratory results revealed a tongue viral culture positive for HSV and a positive serum HSV PCR.\nAutopsy revealed a liver weighing 1620 g with diffuse geographic necrosis. Histological examination of the liver showed extensive hemorrhagic necrosis with HSV intranuclear inclusion , Cowdry type 1 and 2 , with immunoreactivity for HSV-1 . Other findings included bilateral pleural effusions (approximately 500 ml) and a pelvic wall hematoma (4.0 × 2.5 cm).", + "fulltext_subclaims": [ + "The patient was a 19-year-old Caucasian woman.", + "She presented to the clinic initially with nonspecific symptoms of fatigue, fever and abdominal pain.", + "Past medical history was noncontributory.", + "She was an otherwise healthy adult from the United States.", + "She did not report ill contacts, intravenous drug use, or recent sexual contacts.", + "She had a temperature of 102.3°F.", + "She had a WBC of 4,800.", + "She had an AST of 330 U/liter.", + "She had an ALT of 250 U/liter.", + "She was thought at the time to have a viral prodrome.", + "She was treated symptomatically.", + "The patient returned to the clinic 3 days later.", + "She had resolution of her constitutional symptoms.", + "She had the development of inflammation and pain around her recent tongue piercing.", + "The tongue piercing was 1 to 2 weeks before this visit.", + "The patient was treated for oral thrush.", + "Cultures of the tongue were taken.", + "Cultures grew normal oral flora.", + "Cultures grew beta hemolytic streptococci group C.", + "The patient presented to the emergency room with worsening fever, abdominal pain, vomiting, diarrhea, myalgia, and arthralgia.", + "At this time, she had an AST of 6000 U/liter.", + "At this time, she had an ALT of 4000 U/liter.", + "The following day, her lab values increased to an AST of 9200 U/liter.", + "The following day, her lab values increased to an ALT of 4400 U/liter.", + "Bilirubin and alkaline phosphatase were within normal limits.", + "Alcohol was non-detectable.", + "CMV was negative.", + "Infectious mononucleosis was negative.", + "Leptospira was negative.", + "EBV was negative.", + "HBV was negative.", + "HCV was negative.", + "HEV was negative.", + "HIV was negative.", + "Urine drug screen was negative.", + "Serum acetaminophen level was 3 μg/dl.", + "CT scan showed a mottled liver.", + "CT scan showed a 2 to 4 mm abscess of the anterior tongue.", + "She developed hypotension.", + "She developed coagulopathy with a PT of 83.2s.", + "She developed coagulopathy with a PTT of greater than 200s.", + "She developed hyperammonemia.", + "She developed acute renal failure.", + "Acute renal failure was thought to be due to hepatorenal syndrome.", + "The medical team was in the process of preparing her for transport to receive a liver transplant.", + "The patient expired.", + "Postmortem laboratory results revealed a tongue viral culture positive for HSV.", + "Postmortem laboratory results revealed a positive serum HSV PCR.", + "Autopsy revealed a liver weighing 1620 g.", + "Histological examination of the liver showed extensive hemorrhagic necrosis with HSV intranuclear inclusion.", + "Histological examination showed Cowdry type 1 and 2.", + "Histological examination showed immunoreactivity for HSV-1.", + "Other findings included bilateral pleural effusions (approximately 500 ml).", + "Other findings included a pelvic wall hematoma (4.0 × 2.5 cm)." + ], + "summary": "We present the case of an immunocompetent, previously healthy young woman who contracted herpes simplex virus, presumably through a recent tongue piercing, which progressed to fulminant hepatitis and death.", + "summary_subclaims": [ + "The patient was immunocompetent.", + "The patient was previously healthy.", + "The patient was a young woman.", + "The patient contracted herpes simplex virus.", + "The herpes simplex virus was presumably contracted through a recent tongue piercing.", + "The infection progressed to fulminant hepatitis.", + "The patient died." + ] + }, + { + "id": "multiclinsum_test_264_en.txt", + "fulltext": "A 69-year-old man referred to Pasteur Hospital in Bam, southeastern Iran, with clinical symptoms including itching and redness of his eye. On further examination by slit lamp, a white roundworm was seen in the nasal subconjunctival space in the right eye . Visual acuity was 7/10, IOP was normal and rest examination was unremarkable. The complete blood count (CBC) test was normal without any sign of eosinophilia. Under local anesthesia trough a conjunctival incision a white round worm was removed. After surgery, the patient was treated with antibiotics and corticosteroid and followed up for 1 month.\nMorphometric analysis revealed an immature nematode 180 mm in length. After the parasite was removed, the nematode was kept in 70% ethanol for further examination. For a definite diagnosis, it was sent to the Parasitology Department of Kerman University of Medical Sciences where the Dirofilaria parasite was identified based on morphological keys .\nMoreover, a piece of the worm’s body was separated, and DNA was extracted using a DNA minikit (Qiagen, Hilden, Germany). A 680-bp cox1 gene fragment was amplified using primers (Forward) 5′- CCTTTGAGTGTA-GAGGGTCAGC-3′ and (Reverse) 5′-ATTCCGCTCAAACCTCCAAT-3′ as previously described .\nAmplification was conducted under the following cycling conditions: 94 °C for 3 min, 40 cycles of 30 s at 94 °C, 35 s at 58 °C, and 1 min at 72 °C, followed by a final extension of 7 min at 72 °C. The quality of the PCR products was assessed by gel electrophoresis.\nNucleotide sequencing was performed by the Sanger method (Macrogen Inc., South Korea). Sequencing results were aligned using BioEdit (ver.7.0.9.0) and MEGA 6.0 software and sequence identity was evaluated using the . In addition, the cox1 gene fragment was submitted to the GenBank under the accession number MH920260 as D. immitis. Additionally, the phylogenetic analysis produced a sister clade as compared to D. immitis sequences recorded in the GenBank .", + "fulltext_subclaims": [ + "A 69-year-old man was referred to Pasteur Hospital in Bam, southeastern Iran.", + "The patient had clinical symptoms including itching and redness of his eye.", + "On slit lamp examination, a white roundworm was seen in the nasal subconjunctival space in the right eye.", + "Visual acuity was 7/10.", + "Intraocular pressure was normal.", + "The complete blood count test was normal without any sign of eosinophilia.", + "Under local anesthesia, a white roundworm was removed through a conjunctival incision.", + "After surgery, the patient was treated with antibiotics and corticosteroid.", + "The patient was followed up for 1 month.", + "Morphometric analysis revealed an immature nematode 180 mm in length.", + "The nematode was kept in 70% ethanol for further examination.", + "The parasite was sent to the Parasitology Department of Kerman University of Medical Sciences.", + "The Dirofilaria parasite was identified based on morphological keys.", + "A piece of the worm’s body was separated, and DNA was extracted using a DNA minikit (Qiagen, Hilden, Germany).", + "A 680-bp cox1 gene fragment was amplified using specific primers.", + "Amplification was conducted under specific cycling conditions.", + "The quality of the PCR products was assessed by gel electrophoresis.", + "Nucleotide sequencing was performed by the Sanger method.", + "Sequencing results were aligned using BioEdit and MEGA 6.0 software.", + "The cox1 gene fragment was submitted to GenBank under the accession number MH920260 as D. immitis.", + "The phylogenetic analysis produced a sister clade as compared to D. immitis sequences recorded in GenBank." + ], + "summary": "A nematode extracted from the right eye of a 69-year-old man referred with clinical symptoms including itching and redness was examined. After the morphometric analysis, Dirofilaria parasite was detected. Afterwards, a piece of worm body was cut and DNA was extracted and a 680-bp gene fragment amplification and nucleotide sequencing were performed. Phylogenetic analysis revealed a D. immitis roundworm as the causative agent of infection. The patient was treated with antibiotics and corticosteroid and followed up for 1 month.", + "summary_subclaims": [ + "A nematode was extracted from the right eye of a 69-year-old man.", + "The patient had clinical symptoms including itching and redness.", + "After morphometric analysis, Dirofilaria parasite was detected.", + "A piece of worm body was cut and DNA was extracted.", + "A 680-bp gene fragment amplification and nucleotide sequencing were performed.", + "Phylogenetic analysis revealed a D. immitis roundworm as the causative agent of infection.", + "The patient was treated with antibiotics and corticosteroid.", + "The patient was followed up for 1 month." + ] + }, + { + "id": "multiclinsum_test_552_en.txt", + "fulltext": "A 26-year-old male patient experienced a car accident and was diagnosed with an open fracture (Gustilo-Anderson type IIIB) of the right distal humerus with massive bone defects and severe intra-articular involvement, without neurovascular injuries or other associated injuries. Within 24 h after the injury, he was treated by surgical debridement, negative pressure vacuum sealing drainage, and immobilization by casting in a local hospital. Due to severe contamination and a poor soft tissue condition, the wound was surgically debrided again and closed 15 days later. Two months after the initial operation, the wound had finally healed, and the soft tissue was in good condition, without infection or effusion. The CRP (C-reactive protein) and ESR (erythrocyte sedimentation rate) levels returned to normal, and the patient was transferred to our department for additional treatment.\nThe patient’s height was 175 cm, and his weight was 130 kg. The preoperative anteroposterior (AP) and lateral X-rays (see Fig. ) and 3D-CT scans (see Fig. ) of the right elbow joint showed massive bone defects at the supracondylar level as well as a comminuted articular surface. According to the Association for Osteosynthesis/Association for the Study of Internal Fixation (AO/ASIF) criteria, the fracture was classified as a type 13-C3 fracture . The physical examination revealed pseudarthrosis at the fracture site, which made it much more difficult to reconstruct the distal humerus.\nAfter the induction of general anesthesia, the patient was placed in the supine position with elbow flexion and forearm crossing chest , and a longitudinal incision was made along the midline of the posterior aspect of the elbow and medially curved at the olecranon tip. The ulnar nerve was dissected carefully and protected by a rubber strip, and then, a V-shaped osteotomy was performed in the proximal olecranon. The proximal bone fragment and triceps muscle were flipped upward to expose the distal part of the humerus.\nThen, we removed all the fibrous scar tissue as well as the anterior and posterior capsules to release the elbow. The dead bones and redundant calli were debrided until fresh bone was evidently revealed, and then the bone callus was kept for grafting. The original articular cartilage was preserved to the greatest extent possible, but the trochlear groove was too severely comminuted to be reconstructed. Therefore, the fracture fragments and adhesive fibrous tissue were removed to facilitate reconstruction.\nThe trochlear and capitellar articular surfaces of the distal humerus were aligned with the olecranon and radial head articular surfaces, respectively. Then, we measured the width of the trochlear groove defect, harvested a cylindrical autograft of an appropriate size and shape from the iliac crest, and inserted the graft into the defect to reconstruct the distal humerus. The cortical bone surface of the graft was directed towards the articular cavity but was located 2 mm proximal to the cartilage. We stabilized the distal fragments using K-wires (Kirschner wires) for temporary reduction. Then, the intercondylar fracture was converted to a supracondylar fracture of the distal humerus.\nNext, the humeral shaft and both columns were reduced. First, the medullary canal was opened by a 3.5 mm diameter drill to promote fracture healing. The supracondylar bone defects were measured to be approximately 3 cm at the medial column and 5 cm at the lateral column. We performed shortening by 2 cm at the supracondylar level. Then, 2 pieces of autografts harvested from the iliac crest were trimmed according to the size and shape of the bony defects to reconstruct the medial and lateral columns, respectively. The cortical bone was directed outward, and the cancellous side was directed inward. The total bone loss was estimated by measuring the humeral length. Then, K-wires were inserted for temporary fixation.\nFinally, to optimize the stability of the bony structure, the distal humerus was stabilized using anatomical locking compression plates via a parallel configuration (Zimmer Biomet, USA). Several K-wires were left for the fixation of the tiny fragments.\nAfter internal fixation, the elbow joint exhibited almost full range of motion during passive flexion and extension (see Fig. ). The remaining iliac crest autografts and bone callus were cut into several strip-shaped bone chips and implanted around the supracondylar level.\nFinally, the olecranon osteotomy site was reduced and fixed by tension band wires. We performed subcutaneous transposition of the ulnar nerve using soft tissue sling to prevent direct contact and irritation from the hardware. The muscles and deep fascia were sutured carefully to cover the bone grafts and internal fixation site. The donor site was closed by direct suturing.\nAfter the surgery, standard AP and lateral radiographs of the elbow joint were taken to evaluate the quality of reconstruction (see Fig. ).\nThe drainage tube was removed 24 h after surgery. Active exercises of the hand and wrist, isometric contractions of the biceps and forearm muscles, and active elbow flexion and extension exercises were initiated on the second day after surgery.\nRoutine follow-ups were carried out. The fracture healed at 3 months postoperatively, and the radiographs showed the presence of a continuous callus passing through the fracture line. Six months after the index surgery, the patient had a painless elbow joint and almost full recovery (125° elbow flexion and 0° extension, 90° forearm supination and 65° pronation). The Mayo elbow performance score (MEPS) was 100 (excellent).\nThree years after the index surgery, the patient came to our department for hardware removal due to psychological factors. He was pain free at the affected elbow joint. The flexion-extension range of motion was 130–0°, and the supination-pronation range of rotation was 90–80°. The MEPS was 100 points. The patients was very satisfied.\nSecondary displacement or the loss of reduction, implant loosening or internal fixation breakage, and obvious articular degeneration were not observed. No other postoperative complications, such as infection, nonunion, delayed union, ulnar nerve symptoms, or donor site pain, occurred after the initial internal fixation procedure. After hardware removal, the overall bony structure of the affected elbow joint remained intact with only a partial deformity at the lateral column, which had no significant influence on the overall functional outcome (see Fig. ).", + "fulltext_subclaims": [ + "The patient was a 26-year-old male.", + "The patient experienced a car accident.", + "The patient was diagnosed with an open fracture (Gustilo-Anderson type IIIB) of the right distal humerus.", + "The fracture had massive bone defects.", + "The fracture had severe intra-articular involvement.", + "There were no neurovascular injuries.", + "There were no other associated injuries.", + "The patient was treated by surgical debridement within 24 h after the injury.", + "The patient was treated by negative pressure vacuum sealing drainage within 24 h after the injury.", + "The patient was immobilized by casting within 24 h after the injury.", + "The wound was surgically debrided again 15 days later.", + "The wound was closed 15 days later.", + "Two months after the initial operation, the wound had finally healed.", + "Two months after the initial operation, the soft tissue was in good condition.", + "There was no infection two months after the initial operation.", + "There was no effusion two months after the initial operation.", + "The CRP levels returned to normal.", + "The ESR levels returned to normal.", + "The patient was transferred to our department for additional treatment.", + "The patient’s height was 175 cm.", + "The patient’s weight was 130 kg.", + "Preoperative anteroposterior X-rays showed massive bone defects at the supracondylar level.", + "Preoperative lateral X-rays showed a comminuted articular surface.", + "3D-CT scans showed massive bone defects at the supracondylar level.", + "3D-CT scans showed a comminuted articular surface.", + "The fracture was classified as a type 13-C3 fracture according to the AO/ASIF criteria.", + "The physical examination revealed pseudarthrosis at the fracture site.", + "The pseudarthrosis made it much more difficult to reconstruct the distal humerus.", + "The patient was placed in the supine position with elbow flexion and forearm crossing chest.", + "A longitudinal incision was made along the midline of the posterior aspect of the elbow.", + "The incision was medially curved at the olecranon tip.", + "The ulnar nerve was dissected carefully.", + "The ulnar nerve was protected by a rubber strip.", + "A V-shaped osteotomy was performed in the proximal olecranon.", + "The proximal bone fragment and triceps muscle were flipped upward.", + "The distal part of the humerus was exposed.", + "All the fibrous scar tissue was removed.", + "The anterior and posterior capsules were removed.", + "The elbow was released.", + "The dead bones and redundant calli were debrided until fresh bone was evidently revealed.", + "The bone callus was kept for grafting.", + "The original articular cartilage was preserved to the greatest extent possible.", + "The trochlear groove was too severely comminuted to be reconstructed.", + "The fracture fragments and adhesive fibrous tissue were removed.", + "The trochlear and capitellar articular surfaces were aligned with the olecranon and radial head articular surfaces, respectively.", + "The width of the trochlear groove defect was measured.", + "A cylindrical autograft was harvested from the iliac crest.", + "The autograft was inserted into the defect to reconstruct the distal humerus.", + "The cortical bone surface of the graft was directed towards the articular cavity.", + "The graft was located 2 mm proximal to the cartilage.", + "The distal fragments were stabilized using K-wires for temporary reduction.", + "The intercondylar fracture was converted to a supracondylar fracture of the distal humerus.", + "The humeral shaft and both columns were reduced.", + "The medullary canal was opened by a 3.5 mm diameter drill.", + "The supracondylar bone defects were measured to be approximately 3 cm at the medial column.", + "The supracondylar bone defects were measured to be approximately 5 cm at the lateral column.", + "Shortening by 2 cm was performed at the supracondylar level.", + "Two pieces of autografts were trimmed to reconstruct the medial and lateral columns.", + "The cortical bone was directed outward.", + "The cancellous side was directed inward.", + "The total bone loss was estimated by measuring the humeral length.", + "K-wires were inserted for temporary fixation.", + "The distal humerus was stabilized using anatomical locking compression plates via a parallel configuration.", + "Several K-wires were left for the fixation of the tiny fragments.", + "The elbow joint exhibited almost full range of motion during passive flexion and extension.", + "The remaining iliac crest autografts and bone callus were cut into several strip-shaped bone chips.", + "The bone chips were implanted around the supracondylar level.", + "The olecranon osteotomy site was reduced and fixed by tension band wires.", + "Subcutaneous transposition of the ulnar nerve was performed using a soft tissue sling.", + "The muscles and deep fascia were sutured carefully.", + "The donor site was closed by direct suturing.", + "Standard AP and lateral radiographs of the elbow joint were taken after surgery.", + "The drainage tube was removed 24 h after surgery.", + "Active exercises of the hand and wrist were initiated on the second day after surgery.", + "Isometric contractions of the biceps and forearm muscles were initiated on the second day after surgery.", + "Active elbow flexion and extension exercises were initiated on the second day after surgery.", + "The fracture healed at 3 months postoperatively.", + "Radiographs showed the presence of a continuous callus passing through the fracture line.", + "Six months after the index surgery, the patient had a painless elbow joint.", + "Six months after the index surgery, the patient had almost full recovery.", + "Six months after the index surgery, the elbow flexion was 125°.", + "Six months after the index surgery, the elbow extension was 0°.", + "Six months after the index surgery, the forearm supination was 90°.", + "Six months after the index surgery, the forearm pronation was 65°.", + "The MEPS was 100 (excellent) six months after the index surgery.", + "Three years after the index surgery, the patient came for hardware removal due to psychological factors.", + "The patient was pain free at the affected elbow joint.", + "The flexion-extension range of motion was 130–0°.", + "The supination-pronation range of rotation was 90–80°.", + "The MEPS was 100 points.", + "The patient was very satisfied.", + "Secondary displacement or the loss of reduction was not observed.", + "Implant loosening or internal fixation breakage was not observed.", + "Obvious articular degeneration was not observed.", + "No infection occurred after the initial internal fixation procedure.", + "No nonunion occurred after the initial internal fixation procedure.", + "No delayed union occurred after the initial internal fixation procedure.", + "No ulnar nerve symptoms occurred after the initial internal fixation procedure.", + "No donor site pain occurred after the initial internal fixation procedure.", + "The overall bony structure of the affected elbow joint remained intact after hardware removal.", + "There was a partial deformity at the lateral column after hardware removal.", + "The partial deformity had no significant influence on the overall functional outcome." + ], + "summary": "A 26-year-old male patient experienced a major car accident and was diagnosed with an open fracture (Gustilo-Anderson type IIIB) of the right distal humerus with massive bone defects and severe intra-articular involvement, without neurovascular injuries or other associated injuries. Surgical debridement, negative pressure vacuum sealing drainage, and immobilization by braces were initially performed, and the wound was closed after 15 days. When the wound had finally healed and the soft tissue was in good condition without infection or effusion 45 days later, this young and active patient was diagnosed with a chronic type C3 distal humeral fracture associated with massive bone defects at the supracondylar level in both columns and severe comminution at the trochlear groove. We performed surgical debridement and arthrolysis around the fracture site, and then, we successfully reconstructed the triangular structure of the distal humerus using structural iliac crest autografts in both columns as well as in the defective trochlear groove. Finally, internal fixation via a parallel double-plate configuration was performed. Over a follow-up period of 3 years, the patient achieved almost full recovery of range of motion and an excellent functional score, without minor or major postoperative complications.", + "summary_subclaims": [ + "The patient was a 26-year-old male.", + "The patient experienced a major car accident.", + "The patient was diagnosed with an open fracture (Gustilo-Anderson type IIIB) of the right distal humerus.", + "The fracture had massive bone defects.", + "The fracture had severe intra-articular involvement.", + "There were no neurovascular injuries.", + "There were no other associated injuries.", + "Surgical debridement was initially performed.", + "Negative pressure vacuum sealing drainage was initially performed.", + "Immobilization by braces was initially performed.", + "The wound was closed after 15 days.", + "When the wound had finally healed, the patient was diagnosed with a chronic type C3 distal humeral fracture.", + "The patient had massive bone defects at the supracondylar level in both columns.", + "The patient had severe comminution at the trochlear groove.", + "Surgical debridement and arthrolysis around the fracture site were performed.", + "The triangular structure of the distal humerus was reconstructed using structural iliac crest autografts in both columns.", + "The triangular structure of the distal humerus was reconstructed using structural iliac crest autografts in the defective trochlear groove.", + "Internal fixation via a parallel double-plate configuration was performed.", + "The patient was followed up for 3 years.", + "The patient achieved almost full recovery of range of motion.", + "The patient had an excellent functional score.", + "There were no minor or major postoperative complications." + ] + }, + { + "id": "multiclinsum_test_948_en.txt", + "fulltext": "A 20-year-old woman with diagnosis of ASs was referred to our department for reduced vision in her left eye (LE) of 2 weeks onset; she was negative for pseudoxanthoma elasticum or any other systemic disease. The patient signed a comprehensive consent form according to Good Clinical Practice guidelines, before proceeding with all examinations and treatments. Her best-corrected visual acuity (BCVA) was 20/20 in the right eye (RE) and 20/100 in the LE, with no signs of inflammation in the anterior chamber and vitreous of either eye. Fundus biomicroscopy revealed ASs in both eyes (BE). RE had no evidence of inflammation at the fundus observation . Interestingly, only the LE had multiple discrete grey-white lesions (dots) scattered over the fundus, from the paramacular area up to the mid-periphery, and the macula had a granular appearance . Fluorescein angiography (FA) (HRA, Heidelberg Engineering, Heidelberg, Germany) indicated mild optic disk leakage with some hyperfluorescent changes scattered throughout the fundus (paramacular area and mid-periphery). No CNV was detected . Indocyanine green angiography (ICGA) (HRA, Heidelberg Engineering, Heidelberg, Germany) disclosed late hypofluorescent lesions scattered at the posterior pole and in the mid-periphery ; we interpreted these as signs of zonal outer retinal inflammation. Spectral-domain optical coherence tomography (SD-OCT) macular scans showed disruption in the photoreceptor layer . Automated static threshold perimetry indicated visual field defects mainly located paracentrally and temporally .\nOn the basis of all these findings a diagnosis of ASs and coincident MEWDS was made. The patient was prescribed oral prednisone (1 mg/kg) for 7 days then half the dosage for another 7 days.\nTwo weeks later, LE BCVA improved up to 20/25, with resolution of the MEWDS findings, except for the granular appearance at the macula; RE BCVA was 20/20 with no signs of inflammation at the fundus evaluation.\nTwo months later, the patient returned because of sudden vision loss in her LE (20/100). FA indicated CNV in the paramacular area in LE. FA and ICGA showed no signs of choriocapillaris inflammation in BE . We proposed to the patient an intravitreal injection of ranibizumab as an off-label treatment option. She signed informed consent and was given a single injection of ranibizumab (0.5 mg/0.05 mL) following the normal procedure. One month after the injection BCVA improved up to 20/40, the CNV showed regression , and there was no need for retreatment up to her latest follow-up visit 1 year after the injection, when BCVA had improved up to 20/25.\nASs are often complicated by the appearance of CNV [, ]. To date there are no reports of AS associated with acute ocular inflammation. MEWDS is a unilateral inflammatory disease, which usually resolves spontaneously, with full recovery . Here we describe a patient with ASs, who was diagnosed with coincident MEWDS. Two months after this diagnosis she developed CNV, which was effectively treated by intravitreal ranibizumab. In the current literature there are only six cases of CNV that developed after (from 4 weeks to 13 years) the diagnosis of MEWDS [–, ]. Only two were effectively treated by intravitreal anti-vascular endothelial growth factor (VEGF) [, ]. In all other cases the visual loss was permanent despite treatment [–].\nThe case described is unusual: the CNV occurred in a patient with ASs, 2 months after the diagnosis of MEWDS. Although both ASs and MEWDS may contribute to the onset of CNV, the patient’s young age, good prognosis after intravitreal ranibizumab and the presence of MEWDS involving the macular area may indicate an inflammatory etiology of the CNV.\nThough the pathophysiologic mechanism remains unclear, it has been suggested that alterations of Bruch’s membrane or the outer retinal barrier caused by choroidal inflammation may be associated with ischemic and/or inflammatory CNV . It has also been hypothesized that the inflammatory processes induce the release of chemokines that favor angiogenesis . This patient was in fact younger than the mean age at which CNV usually develops associated with ASs [, ]. Moreover, in this case a single intravitreal ranibizumab injection had a lasting effect (up to at least 1 year), as shown by FA and OCT, and by the maintenance of good BCVA.\nOur results are in agreement with Rouvas et al. who have described the good responses to intravitreal treatment with ranibizumab for inflammatory retinal diseases . This might be explained by the different nature of the CNV, in which inflammation may have played an important pathogenic role, compared to other CNVs secondary to ASs which tend to be associated with a worse visual prognosis, and need more injections .", + "fulltext_subclaims": [ + "The patient was a 20-year-old woman with a diagnosis of ASs.", + "She was referred for reduced vision in her left eye of 2 weeks onset.", + "She was negative for pseudoxanthoma elasticum.", + "She was negative for any other systemic disease.", + "She signed a comprehensive consent form before proceeding with all examinations and treatments.", + "Her best-corrected visual acuity was 20/20 in the right eye.", + "Her best-corrected visual acuity was 20/100 in the left eye.", + "There were no signs of inflammation in the anterior chamber of either eye.", + "There were no signs of inflammation in the vitreous of either eye.", + "Fundus biomicroscopy revealed ASs in both eyes.", + "The right eye had no evidence of inflammation at the fundus observation.", + "The left eye had multiple discrete grey-white lesions scattered over the fundus.", + "The macula had a granular appearance.", + "Fluorescein angiography indicated mild optic disk leakage.", + "Fluorescein angiography showed some hyperfluorescent changes scattered throughout the fundus.", + "No CNV was detected.", + "Indocyanine green angiography disclosed late hypofluorescent lesions scattered at the posterior pole and in the mid-periphery.", + "These hypofluorescent lesions were interpreted as signs of zonal outer retinal inflammation.", + "SD-OCT macular scans showed disruption in the photoreceptor layer.", + "Automated static threshold perimetry indicated visual field defects mainly located paracentrally and temporally.", + "A diagnosis of ASs and coincident MEWDS was made.", + "The patient was prescribed oral prednisone (1 mg/kg) for 7 days.", + "The dosage was then halved for another 7 days.", + "Two weeks later, left eye BCVA improved up to 20/25.", + "MEWDS findings resolved except for the granular appearance at the macula.", + "Right eye BCVA was 20/20 with no signs of inflammation at the fundus evaluation.", + "Two months later, the patient returned because of sudden vision loss in her left eye (20/100).", + "FA indicated CNV in the paramacular area in the left eye.", + "FA showed no signs of choriocapillaris inflammation in both eyes.", + "ICGA showed no signs of choriocapillaris inflammation in both eyes.", + "An intravitreal injection of ranibizumab was proposed as an off-label treatment option.", + "The patient signed informed consent and was given a single injection of ranibizumab (0.5 mg/0.05 mL).", + "One month after the injection, BCVA improved up to 20/40.", + "The CNV showed regression.", + "There was no need for retreatment up to the latest follow-up visit 1 year after the injection.", + "At the 1-year follow-up, BCVA had improved up to 20/25.", + "ASs are often complicated by the appearance of CNV.", + "There are no reports of AS associated with acute ocular inflammation.", + "MEWDS is a unilateral inflammatory disease.", + "MEWDS usually resolves spontaneously.", + "MEWDS usually results in full recovery.", + "The patient was diagnosed with coincident MEWDS.", + "Two months after the diagnosis of MEWDS, she developed CNV.", + "The CNV was effectively treated by intravitreal ranibizumab.", + "In the current literature, there are only six cases of CNV that developed after the diagnosis of MEWDS.", + "Only two of these cases were effectively treated by intravitreal anti-VEGF.", + "In all other cases, the visual loss was permanent despite treatment.", + "The case described is unusual.", + "The CNV occurred in a patient with ASs.", + "The CNV occurred 2 months after the diagnosis of MEWDS.", + "The patient’s young age, good prognosis after intravitreal ranibizumab, and the presence of MEWDS involving the macular area may indicate an inflammatory etiology of the CNV.", + "It has been suggested that alterations of Bruch’s membrane or the outer retinal barrier caused by choroidal inflammation may be associated with ischemic and/or inflammatory CNV.", + "It has also been hypothesized that inflammatory processes induce the release of chemokines that favor angiogenesis.", + "The patient was younger than the mean age at which CNV usually develops associated with ASs.", + "A single intravitreal ranibizumab injection had a lasting effect up to at least 1 year.", + "This was shown by FA and OCT.", + "This was shown by the maintenance of good BCVA.", + "Our results are in agreement with Rouvas et al. who described good responses to intravitreal treatment with ranibizumab for inflammatory retinal diseases.", + "This might be explained by the different nature of the CNV, in which inflammation may have played an important pathogenic role.", + "Other CNVs secondary to ASs tend to be associated with a worse visual prognosis.", + "Other CNVs secondary to ASs need more injections." + ], + "summary": "A 20-year-old woman presented with reduced vision (20/100) in her left eye (LE). Based on a complete ophthalmologic examination the patient was diagnosed with ASs and coincident MEWDS. Two weeks later best-corrected visual acuity (BCVA) improved up to 20/25 and the MEWDS findings almost disappeared. Two months later BCVA dropped again (20/100) due to the development of CNV which was treated by a single intravitreal injection of ranibizumab (0.5 mg/0.05 mL). One month after this BCVA improved up to 20/40, and there was regression of the CNV. There was no need for retreatment at the last follow-up visit, 1 year after the ranibizumab injection, when the patient showed further recovery of BCVA up to 20/25.", + "summary_subclaims": [ + "The patient is a 20-year-old woman.", + "She presented with reduced vision (20/100) in her left eye.", + "Based on a complete ophthalmologic examination, the patient was diagnosed with ASs.", + "Based on a complete ophthalmologic examination, the patient was diagnosed with coincident MEWDS.", + "Two weeks later, best-corrected visual acuity improved up to 20/25.", + "The MEWDS findings almost disappeared two weeks after presentation.", + "Two months after presentation, best-corrected visual acuity dropped again to 20/100.", + "The drop in best-corrected visual acuity was due to the development of CNV.", + "The patient was treated by a single intravitreal injection of ranibizumab (0.5 mg/0.05 mL).", + "One month after the ranibizumab injection, best-corrected visual acuity improved up to 20/40.", + "There was regression of the CNV one month after the ranibizumab injection.", + "There was no need for retreatment at the last follow-up visit.", + "The last follow-up visit occurred 1 year after the ranibizumab injection.", + "At the last follow-up visit, the patient showed further recovery of best-corrected visual acuity up to 20/25." + ] + }, + { + "id": "multiclinsum_test_1145_en.txt", + "fulltext": "A 77-year-old man fell from a height of approximately 3 m into the gutter and struck his pelvis. He was found immobile and was rushed to our hospital.\nMedical history: none.\nPhysical findings: Consciousness was clear, blood pressure was 100/70 mmHg, heart rate was 127/min, SpO2 was 97%, and no injury was noted on either the head or abdomen.\nAs shown in Table , blood work (day 1) showed Hb12.7 g/dl, but no increase in cell ectopic enzymes was observed.\nCT findings on day 1 revealed a right pelvic fracture and a haematoma in the pelvic extraperitoneal space . Neither free air nor ascites was observed in the abdominal cavity, and no damage was found to the intestinal tract. CT findings on day 2 showed the haematoma in the pelvic extraperitoneal space had increased in size from the previous day, and active bleeding was suspected. Blood work from day 2 demonstrated progression of Hb10.3 and anaemia, even after transfusion of 4 units of red blood cells . For vitals, blood pressure was 78/37 mmHg, and heart rate was 144 bpm, indicating shock, and active bleeding due to the pelvic fracture was suspected. Therefore, transcatheter arterial embolization (TAE) was adopted. Blood flow in the pelvis is supplied from both sides, and the presence of traffic branches may require TAE of the internal iliac arteries on both sides depending on the situation. Angiography identified the responsible vessel, which had embolized the bilateral internal iliac arteries, and confirmed haemostasis.\nCT findings on day 3 revealed thickening of the ascending colon wall, intramural emphysema, and a slight amount of air in the mesenteric vein. In addition, a small amount of ascites was observed near the ascending colon. There was no problem with the contrast effect of the small intestine, and the sigmoid colon was dilated, but there were no obvious necrotic findings. .\nBlood work on day 3 revealed elevated levels of cytopathic enzymes: AST 2363 IU/l, ALT 2233 IU/l, LDH 3181 IU/l, and CPK 4122 IU/l. Based these findings, we rendered a diagnosis of necrosis of the ascending colon and performed emergency surgery.\nIntraoperatively, necrosis was observed in the serosa of the ascending, transverse, and sigmoid colon. Subtotal resection was performed from the ileocecal region to the sigmoid colon. After confirming that there is no necrosis in the mucosa of cut end of small intestine, ileostomy was constructed. Although a slight ischaemic change such as edema and mild redness was observed in the serosa of the entire small intestine, we decided to preserve the entire intestine.\nExcised specimen findings showed scattered necrosis in the ascending, transverse, and sigmoid colon .\nPathological findings indicated necrosis throughout all layers of the intestinal wall in the ascending, transverse, and sigmoid colon.\nPostoperatively, the patient began drinking water 2 days after surgery. However, 6 days after surgery, CT revealed a dilated small intestine, which we diagnosed as paralytic ileus. Subsequently, the paralytic ileus did not improve, and melena was observed 10 days after surgery. CT performed 10 days after surgery revealed extensive small bowel dilation and niveau. In addition, wall thickening and a decrease in contrast effect were observed in partial small intestines .\nWe diagnosed haemorrhage due to necrosis of the residual small intestine. However, due to the postoperative total colectomy and deterioration of general condition, it was decided that intestinal resection was impossible, and treatment with blood transfusion and haemostatic agents was planned. At that time, the colour of stoma did not change greatly and there were no necrosis sites.\nThe patient's condition gradually worsened even after treatment, and over time, he developed liver and renal dysfunction and died 16 days after surgery.\nNOMI is a disorder that causes irreversible ischaemia in the intestine, resulting in intestinal necrosis, despite the absence of organic obstruction in the mesenteric artery trunk. This phenomenon was first reported by Heer and includes the following characteristics: (1) no obstruction in the mesenteric arteries or veins governed by intestinal necrosis, (2) segmental discontinuity of intestinal ischaemia and necrosis, and (3) pathological evidence of intestinal haemorrhage and necrosis. We define NOMI as satisfying these conditions. From 12 to 25% of acute intestinal ischaemia is thought to be due to NOMI in Europe and America [, ]. Various triggers increase hypoxia of the intestinal tract tissue, reduce cardiac output, and decrease circulating blood volume. As a result, the sympathetic nerves in the peripheral blood vessels of the mesenteric artery overreact, causing vasospasms and intestinal ischaemia. Since these spasms occur at random, the ischaemic area is sporadic. Fogaty suggests that severe congestive heart failure, digitalis intoxication, and blood concentration are important factors affecting this disorder and that dehydration is significantly related to vasopressin due to low cardiac output, haemorrhage, and shock. He asserts that vasopressin and angiotensin increase in the blood due to low cardiac output, haemorrhage, shock, etc., causing catecholamine-induced spasms of the mesenteric artery and resulting in NOMI. In addition, the general risk factors for NOMI are increased age, heart disease, arrhythmia, cerebrovascular disease, diabetes, burns, dialysis, dehydration, haemorrhage, and pancreatitis [–]. In any case, the basis of the pathology is considered a decrease in circulating blood volume. Pelvic fractures generally cause excessive bleeding in trauma, anywhere from 1000 to 4000 ml . In our patient, bleeding from a pelvic fracture caused a rapid decrease in circulating blood volume, and at one point, the patient was in shock. TAE was performed for active bleeding, and NOMI developed the next day, although haemostasis was attained. When a pelvic fracture with a large volume of blood loss occurs, the risk of NOMI onset should not be ignored.\nNOMI has no specific symptoms. Some of the many non-specific symptoms include abdominal pain, vomiting, abdominal distension, and melena, but these symptoms are often mild during onset. In particular, it is difficult to identify these symptoms in cases of sedation, analgesia, and consciousness disorder. In these cases, diagnosis is likely to be delayed. Similarly, in our case, it was difficult to diagnose intestinal ischaemia based on clinical symptoms, because analgesics are used for pelvic fractures, and systemic contusions are caused by trauma. Blood work showed an increase in deviant enzymes, but the diagnosis was made even more difficult after TAE was performed for active bleeding. In our case, follow-up CT was performed to identify active bleeding, but it is important to consider CT examination as necessary, keeping in mind that NOMI is caused by bleeding from trauma.\nWhen NOMI is considered as a diagnosis, one of the treatments is injection of a vasodilator into the responsible blood vessel using angiography , but this method is limited by equipment availability and the specific situation. In our case, a vasodilator could not be used due to instability of vital signs from bleeding. If intestinal necrosis is already suspected, as in our case, immediate surgical intervention is needed. At the time of surgery, it is important not only to remove the necrotic intestine but also to evaluate the viability of the remaining intestine. Intestinal ischaemia can be extensive postoperatively, and care must be taken in determining the extent of resection. When deciding the extent of resection, there is a method of observing changes in the colour tone of the mucous membrane using an intraoperative lower gastrointestinal endoscope and blood flow evaluation by fluorescein fluorescence [, ]. However, these methods may be difficult depending on equipment availability and the situation. In our case, we found clear discontinuous necrosis in the serosa of the caecum, transverse colon, and sigmoid colon. Therefore, we decided to remove the intestinal tract from the ascending colon to the sigmoid colon. Since only diffuse and mild oedema and redness in the small intestine were noted and no obvious necrosis was observed, we decided to preserve it and constructed an artificial anus in the terminal ileum. However, the small intestines became necrotic after a few days, eventually resulting in widespread intestinal necrosis. Of note, the prognosis cannot be judged only by the surgical findings. If long-term dilatation of the small intestine is observed after heavy bleeding, it is important to consider intestinal necrosis rather than assuming it as paralytic ileus. In that case, it is necessary to comprehensively judge clinical symptoms, vital signs, and imaging findings, but the diagnosis is very difficult. Importantly, pelvic fractures are typically accompanied by high blood loss, so even if active bleeding subsides and vital stability is obtained, NOMI may develop over time.", + "fulltext_subclaims": [ + "The patient was a 77-year-old man.", + "He fell from a height of approximately 3 m into the gutter and struck his pelvis.", + "He was found immobile and was rushed to the hospital.", + "Medical history was reported as none.", + "Physical findings showed consciousness was clear.", + "Blood pressure was 100/70 mmHg.", + "Heart rate was 127/min.", + "SpO2 was 97%.", + "No injury was noted on either the head or abdomen.", + "Blood work on day 1 showed Hb12.7 g/dl.", + "No increase in cell ectopic enzymes was observed.", + "CT findings on day 1 revealed a right pelvic fracture.", + "CT findings on day 1 revealed a haematoma in the pelvic extraperitoneal space.", + "No free air was observed in the abdominal cavity.", + "No ascites was observed in the abdominal cavity.", + "No damage was found to the intestinal tract.", + "CT findings on day 2 showed the haematoma in the pelvic extraperitoneal space had increased in size from the previous day.", + "Active bleeding was suspected.", + "Blood work from day 2 demonstrated progression of Hb10.3.", + "Blood work from day 2 demonstrated anaemia.", + "Transfusion of 4 units of red blood cells was performed.", + "Blood pressure was 78/37 mmHg.", + "Heart rate was 144 bpm.", + "Shock was indicated.", + "Active bleeding due to the pelvic fracture was suspected.", + "Transcatheter arterial embolization (TAE) was adopted.", + "Angiography identified the responsible vessel.", + "Angiography confirmed haemostasis.", + "CT findings on day 3 revealed thickening of the ascending colon wall.", + "CT findings on day 3 revealed intramural emphysema.", + "CT findings on day 3 revealed a slight amount of air in the mesenteric vein.", + "CT findings on day 3 revealed a small amount of ascites near the ascending colon.", + "Blood work on day 3 revealed elevated levels of cytopathic enzymes.", + "A diagnosis of necrosis of the ascending colon was rendered.", + "Emergency surgery was performed.", + "Intraoperatively, necrosis was observed in the serosa of the ascending, transverse, and sigmoid colon.", + "Subtotal resection was performed from the ileocecal region to the sigmoid colon.", + "Ileostomy was constructed.", + "Excised specimen findings showed scattered necrosis in the ascending, transverse, and sigmoid colon.", + "Pathological findings indicated necrosis throughout all layers of the intestinal wall in the ascending, transverse, and sigmoid colon.", + "The patient began drinking water 2 days after surgery.", + "CT performed 6 days after surgery revealed a dilated small intestine.", + "The diagnosis was paralytic ileus.", + "The paralytic ileus did not improve.", + "Melena was observed 10 days after surgery.", + "CT performed 10 days after surgery revealed extensive small bowel dilation.", + "CT performed 10 days after surgery revealed niveau.", + "Wall thickening was observed in partial small intestines.", + "A decrease in contrast effect was observed in partial small intestines.", + "The diagnosis was haemorrhage due to necrosis of the residual small intestine.", + "Intestinal resection was decided to be impossible.", + "Treatment with blood transfusion and haemostatic agents was planned.", + "The colour of stoma did not change greatly.", + "There were no necrosis sites.", + "The patient's condition gradually worsened.", + "Liver and renal dysfunction developed.", + "The patient died 16 days after surgery.", + "NOMI is a disorder that causes irreversible ischaemia in the intestine, resulting in intestinal necrosis.", + "NOMI is defined as satisfying the following conditions: (1) no obstruction in the mesenteric arteries or veins governed by intestinal necrosis, (2) segmental discontinuity of intestinal ischaemia and necrosis, and (3) pathological evidence of intestinal haemorrhage and necrosis.", + "Pelvic fractures generally cause excessive bleeding in trauma, anywhere from 1000 to 4000 ml.", + "Bleeding from a pelvic fracture caused a rapid decrease in circulating blood volume.", + "The patient was in shock.", + "TAE was performed for active bleeding.", + "NOMI developed the next day.", + "When a pelvic fracture with a large volume of blood loss occurs, the risk of NOMI onset should not be ignored.", + "NOMI has no specific symptoms.", + "Some non-specific symptoms include abdominal pain, vomiting, abdominal distension, and melena.", + "In our case, it was difficult to diagnose intestinal ischaemia based on clinical symptoms.", + "Blood work showed an increase in deviant enzymes.", + "The diagnosis was made more difficult after TAE was performed for active bleeding.", + "Follow-up CT was performed to identify active bleeding.", + "CT examination is important, keeping in mind that NOMI is caused by bleeding from trauma.", + "When NOMI is considered as a diagnosis, one of the treatments is injection of a vasodilator into the responsible blood vessel using angiography.", + "In our case, a vasodilator could not be used due to instability of vital signs from bleeding.", + "If intestinal necrosis is already suspected, immediate surgical intervention is needed.", + "At the time of surgery, it is important not only to remove the necrotic intestine but also to evaluate the viability of the remaining intestine.", + "In our case, we found clear discontinuous necrosis in the serosa of the caecum, transverse colon, and sigmoid colon.", + "We decided to remove the intestinal tract from the ascending colon to the sigmoid colon.", + "Only diffuse and mild oedema and redness in the small intestine were noted.", + "No obvious necrosis was observed.", + "We decided to preserve it and constructed an artificial anus in the terminal ileum.", + "The small intestines became necrotic after a few days.", + "Widespread intestinal necrosis eventually resulted.", + "The prognosis cannot be judged only by the surgical findings.", + "If long-term dilatation of the small intestine is observed after heavy bleeding, it is important to consider intestinal necrosis rather than assuming it as paralytic ileus.", + "Pelvic fractures are typically accompanied by high blood loss.", + "Even if active bleeding subsides and vital stability is obtained, NOMI may develop over time." + ], + "summary": "A 77-year-old man was transported to the hospital due to a fall injury. CT revealed a pelvic fracture and a haematoma in the pelvic extraperitoneal space. The next day, the patient developed shock, and CT revealed an increase in haematoma size. Both internal iliac arteries were embolized by transcatheter arterial embolization (TAE). The next day's CT revealed intestinal necrosis of the ascending colon, and emergency surgery was planned. During surgery, necrosis was identified in the serosa of the ascending, transverse, and sigmoid colon. We performed subtotal excision from the ascending colon to the sigmoid colon. On postoperative day 10, melena was observed, and CT revealed partial thickening of the small intestine and a decrease in the contrast effect. Considering the post-total colectomy and general condition, we proceeded with conservative treatment. Over time, the patient developed liver and renal dysfunction and died 16 days after surgery.", + "summary_subclaims": [ + "A 77-year-old man was transported to the hospital due to a fall injury.", + "CT revealed a pelvic fracture.", + "CT revealed a haematoma in the pelvic extraperitoneal space.", + "The next day, the patient developed shock.", + "CT revealed an increase in haematoma size.", + "Both internal iliac arteries were embolized by transcatheter arterial embolization (TAE).", + "The next day's CT revealed intestinal necrosis of the ascending colon.", + "Emergency surgery was planned.", + "During surgery, necrosis was identified in the serosa of the ascending, transverse, and sigmoid colon.", + "Subtotal excision from the ascending colon to the sigmoid colon was performed.", + "On postoperative day 10, melena was observed.", + "CT revealed partial thickening of the small intestine.", + "CT revealed a decrease in the contrast effect.", + "We proceeded with conservative treatment.", + "The patient developed liver and renal dysfunction.", + "The patient died 16 days after surgery." + ] + }, + { + "id": "multiclinsum_test_1933_en.txt", + "fulltext": "The patient was a 25-year-old male who had sustained sudden severe pain in the left lower back and radiated to the scapular area for 4 h, accompanied by breathing difficulties with shock. The CT scan confirmed a ruptured TAAA (Crawford type IV). Bilateral lens exchange surgery was operated 1 year ago. According to features like age, the past ocular damage, C-reactive protein level of 71.5 mg/L and calcitonin level of 0.414 ng/L, TAAA rupture caused by BD was highly suspected.\nEmergent arteriography demonstrated a huge ruptured TAAA with the maximal diameter of 102 mm. The proximal end of the aneurysm was parallel to the top of the celiac artery. The distal end was 20 mm below the opening of the right renal artery, while was proximal to the inferior mesenteric artery. The ruptured location of TAAA was near the opening of the right renal artery. The celiac artery, left renal artery and superior mesenteric artery were occluded, while the collateral circulation was from the inferior mesenteric artery . The maximal diameter of proximal aorta above the celiac artery was 21.2 mm, the diameter of distal aorta below the right renal artery was 15.2 mm and that of the proximal right renal artery was 6 mm measured by arteriography and CT.\nBecause of the different upper and lower diameters of the abdominal aorta in the lesion, we chose a bifurcated stent-graft (ENDURANT, Medtronic, USA, 23–16-145 mm). The main body of the abdominal aortic stent-graft was deployed on the back table in the operating room. Fenestration (6*6 mm) was then performed at 5 cm from the proximal top of the stent graft, and in the 9 o’clock direction with the radioactive “8” mark at the edge of the hole. The short bifurcated component of the stent-graft was occluded. The in-vitro fenestrated stent-graft was re-sent into the delivery system. The stent-graft was delivered from the right femoral artery to the aorta over the super-stiff guidewire, then deployed in the right position of the fenestration facing to the opening of the right renal artery. The arteriography demonstrated that the right renal artery was patent from the fenestration, but still with lots of endoleak. Then a covered stent (Viabahn, GORE, USA, 6*20 mm) was put into the right renal artery via the fenestration.\nA 5F vertebral catheter was preloaded into the aortic aneurysm sac for filling treatment from the left femoral artery before the aortic stent-graft was deployed. A Coda balloon (Cook Medical, Bloomington, Ind) was used to block proximal blood flow. Then, 30 ml fibrin sealant (Shanghai RAAS Blood Products Co, Ltd., Shanghai, China), including 15 ml fibrinogen (90 mg/ mL) and 15 ml thrombin (500 IU/mL) solutions, was injected into the sac of aneurysm. After the balloon was withdrawn, the arteriography was performed that the proximal end of the stent-graft was above the diaphragm and the distal end of the stent-graft was above the inferior mesenteric artery. The length of the proximal and distal landing zone was more than 4 cm. The right renal artery was patent without any endoleak, and the collateral circulation of the left renal artery and superior mesenteric artery was static from the patent inferior mesenteric artery. the patient was transferred to ICU after the surgery.\nAfter the endovascular treatment, the patient had no postoperative complications, such as renal insufficiency, ischemic intestinal symptoms and paraplegia. The hemodynamic function was kept stable. Tetracycline and dexamethasone were used for BD pulse therapy for 3 days. The patient kept taking prednisone for 1 year. The CTA follow-up 1 year after the surgery showed that the diameter of the aortic aneurysm was reduced even to the normal diameter of the artery and retroperitoneal hematoma was absorbed without any endoleak. The right renal artery and the collateral circulation from the inferior mesenteric artery were patent . The ESR and CRP values were within the normal range.", + "fulltext_subclaims": [ + "The patient was a 25-year-old male.", + "He had sustained sudden severe pain in the left lower back and radiated to the scapular area for 4 h.", + "The pain was accompanied by breathing difficulties with shock.", + "The CT scan confirmed a ruptured TAAA (Crawford type IV).", + "Bilateral lens exchange surgery was operated 1 year ago.", + "The C-reactive protein level was 71.5 mg/L.", + "The calcitonin level was 0.414 ng/L.", + "TAAA rupture caused by BD was highly suspected.", + "Emergent arteriography demonstrated a huge ruptured TAAA with the maximal diameter of 102 mm.", + "The proximal end of the aneurysm was parallel to the top of the celiac artery.", + "The distal end was 20 mm below the opening of the right renal artery.", + "The distal end was proximal to the inferior mesenteric artery.", + "The ruptured location of TAAA was near the opening of the right renal artery.", + "The celiac artery was occluded.", + "The left renal artery was occluded.", + "The superior mesenteric artery was occluded.", + "The collateral circulation was from the inferior mesenteric artery.", + "The maximal diameter of proximal aorta above the celiac artery was 21.2 mm.", + "The diameter of distal aorta below the right renal artery was 15.2 mm.", + "The maximal diameter of the proximal right renal artery was 6 mm.", + "A bifurcated stent-graft (ENDURANT, Medtronic, USA, 23–16-145 mm) was chosen.", + "The main body of the abdominal aortic stent-graft was deployed on the back table in the operating room.", + "Fenestration (6*6 mm) was performed at 5 cm from the proximal top of the stent graft.", + "The fenestration was in the 9 o’clock direction with the radioactive “8” mark at the edge of the hole.", + "The short bifurcated component of the stent-graft was occluded.", + "The in-vitro fenestrated stent-graft was re-sent into the delivery system.", + "The stent-graft was delivered from the right femoral artery to the aorta over the super-stiff guidewire.", + "The stent-graft was deployed in the right position of the fenestration facing to the opening of the right renal artery.", + "The arteriography demonstrated that the right renal artery was patent from the fenestration.", + "There was still lots of endoleak.", + "A covered stent (Viabahn, GORE, USA, 6*20 mm) was put into the right renal artery via the fenestration.", + "A 5F vertebral catheter was preloaded into the aortic aneurysm sac for filling treatment from the left femoral artery.", + "A Coda balloon (Cook Medical, Bloomington, Ind) was used to block proximal blood flow.", + "30 ml fibrin sealant was injected into the sac of aneurysm.", + "The fibrin sealant included 15 ml fibrinogen (90 mg/mL) and 15 ml thrombin (500 IU/mL) solutions.", + "The proximal end of the stent-graft was above the diaphragm.", + "The distal end of the stent-graft was above the inferior mesenteric artery.", + "The length of the proximal and distal landing zone was more than 4 cm.", + "The right renal artery was patent without any endoleak.", + "The collateral circulation of the left renal artery and superior mesenteric artery was static from the patent inferior mesenteric artery.", + "The patient was transferred to ICU after the surgery.", + "After the endovascular treatment, the patient had no postoperative complications.", + "The hemodynamic function was kept stable.", + "Tetracycline and dexamethasone were used for BD pulse therapy for 3 days.", + "The patient kept taking prednisone for 1 year.", + "The CTA follow-up 1 year after the surgery showed that the diameter of the aortic aneurysm was reduced even to the normal diameter of the artery.", + "Retroperitoneal hematoma was absorbed without any endoleak.", + "The right renal artery was patent.", + "The collateral circulation from the inferior mesenteric artery was patent.", + "The ESR and CRP values were within the normal range." + ], + "summary": "A 25-year-old man was diagnosed ruptured thoracoabdominal aortic aneurysm with Behcet's Disease according to his eye damage history, high level of ESR and C-reactive protein and the imaging result. We used in-vitro fenestration of the stent-graft combined with in-stent technique to occlude the ruptured aortic aneurysm and preserve the blood supply from the aorta for visceral arteries in emergency. Sac filling technique was used to treat the endoleak to quickly prevent bleeding. The patient kept post-operative immunotherapy for 1 year.", + "summary_subclaims": [ + "The patient was a 25-year-old man.", + "The patient was diagnosed with ruptured thoracoabdominal aortic aneurysm.", + "The patient had Behcet's Disease.", + "The diagnosis was based on the patient's eye damage history.", + "The diagnosis was based on high level of ESR.", + "The diagnosis was based on high level of C-reactive protein.", + "The diagnosis was based on the imaging result.", + "In-vitro fenestration of the stent-graft was used.", + "In-stent technique was used.", + "The techniques were used to occlude the ruptured aortic aneurysm.", + "The techniques were used to preserve the blood supply from the aorta for visceral arteries.", + "The procedure was performed in emergency.", + "Sac filling technique was used to treat the endoleak.", + "The patient kept post-operative immunotherapy for 1 year." + ] + }, + { + "id": "multiclinsum_test_3108_en.txt", + "fulltext": "41-year-old patient, in her third pregnancy, with a pregnancy of 23.6 weeks, who entered the consultation service of the Tolima Maternal and Infant Unit (UMIT) for a clinical case of six days of evolution, of abrupt onset and progressive deterioration, consisting of bilateral visual acuity decrease, predominantly on the right, accompanied by mild right temporal headache, without other neurological alterations. She had attended adequate prenatal controls without notification of previous symptoms, and fetal growth within expected parameters. The UMIT is a private institution of high complexity, which attends patients of the contributory regime of workers and the regime subsidized by the State in the General System of Social Security in Health (SGSSS), located in the central region of the country.\n\nOn physical examination, visual acuity of 20/400 in both eyes was observed, which did not improve with PH (pinhole), intraocular pressure was normal in both eyes (12 mm/Hg), confrontation perimetry with nasal field cut in the right eye (homonymous bitemporal hemianopsia), Marcus gun positive in the right eye, fundoscopy without papilla edema with pulses present, and normoreactive pupils. Initial suspicion of compressive optic neuropathy. A simple MRI of the sella turcica, brain and orbits was performed, with a relevant and consistent finding of a supraselar lesion that compressed and displaced the optic chiasm, with hemorrhage of the right optic tract. Craniofaryngioma was considered as the first diagnostic possibility. Due to the hemorrhage of the optic tract, cavernoma was ruled out as a possible differential diagnosis; an MRI with angiography was performed, in which no alterations in cranial arterial structures were observed.\n\nAs part of the evaluation for suspected craniopharyngioma, secondary endocrine disorders were ruled out, and a complete hormone profile was performed with normal results except for slightly elevated cortisol (23 [normal values-NV: 5.27-22.45]).\n\nA medical board of specialists in neurosurgery, perinatology and ophthalmology recommended that no contrast study be performed, given that at that point in the pregnancy, it would not change the expectant management. The pregnancy was ended at week 38, with outpatient follow-up and surgical intervention was defined for the postpartum period. During the pregnancy, there was no progressive deterioration of visual acuity or visual fields. The baby was delivered by cesarean section, without complications, on the recommendation of neurosurgery and perinatology due to the risk of increased intracranial pressure during valsalva maneuvers. A live male newborn was obtained (weight 3,115 g, height 50 cm).\n\nAt the end of her puerperium, the patient was evaluated by a neurosurgeon who decided to continue expectant management with ophthalmological follow-up, because the tumour lesion was in close contact with the optic chiasm. During the five-month follow-up, the lesion persisted with a decrease in bilateral visual acuity.", + "fulltext_subclaims": [ + "The patient is a 41-year-old woman in her third pregnancy.", + "The pregnancy is at 23.6 weeks.", + "She has had six days of bilateral visual acuity decrease, predominantly on the right.", + "She has mild right temporal headache.", + "She had adequate prenatal controls without previous symptoms.", + "Fetal growth was within expected parameters.", + "The UMIT is a private institution of high complexity.", + "The UMIT serves patients of the contributory regime of workers and the regime subsidized by the State.", + "On physical examination, visual acuity was 20/400 in both eyes.", + "Visual acuity did not improve with pinhole.", + "Intraocular pressure was normal in both eyes.", + "Confrontation perimetry showed a nasal field cut in the right eye.", + "Fundoscopy showed no papilla edema.", + "Initial suspicion was compressive optic neuropathy.", + "An MRI showed a suprasellar lesion compressing and displacing the optic chiasm.", + "The MRI showed hemorrhage of the right optic tract.", + "Craniofaryngioma was considered the first diagnostic possibility.", + "Cavernoma was ruled out due to the hemorrhage of the optic tract.", + "An MRI with angiography showed no alterations in cranial arterial structures.", + "A complete hormone profile was performed.", + "Cortisol was slightly elevated at 23.", + "A medical board recommended no contrast study during pregnancy.", + "The pregnancy was ended at week 38.", + "Surgical intervention was planned for the postpartum period.", + "The baby was delivered by cesarean section.", + "The baby was a live male newborn.", + "The baby weighed 3,115 g at birth.", + "The baby was 50 cm in height at birth.", + "During the puerperium, expectant management was continued.", + "The tumour lesion was in close contact with the optic chiasm.", + "During five months of follow-up, the lesion persisted.", + "Bilateral visual acuity decreased during the five-month follow-up." + ], + "summary": "41-year-old multiparous, 23.6 weeks pregnant, admitted to a private high-complexity hospital for a significant decrease in bilateral visual acuity and headaches. A diagnosis of craniopharyngioma was made and expectant management was decided. The patient had a cesarean delivery without complications.\n", + "summary_subclaims": [ + "The patient is a 41-year-old multiparous woman.", + "The patient is 23.6 weeks pregnant.", + "The patient was admitted to a private high-complexity hospital.", + "The patient had a significant decrease in bilateral visual acuity.", + "The patient had headaches.", + "A diagnosis of craniopharyngioma was made.", + "Expectant management was decided.", + "The patient had a cesarean delivery.", + "The cesarean delivery was without complications." + ] + }, + { + "id": "multiclinsum_test_2007_en.txt", + "fulltext": "The first donor was a 40-year-old man who suffered brain death due to intracranial hemorrhage after a traffic accident. His terminal serum creatinine level was 0.8 mg/dL and his Kidney Donor Profile Index score was 27%. The first recipient was a 45-year-old man with a 20-year history of hypertension and end-stage renal disease (ESRD) due to hypertensive nephropathy, who had received regular hemodialysis for 2 years. In June 2005, at another hospital, single renal transplantation was performed in the right iliac fossa, with a cold ischemia time of 5 h 10 min and a warm ischemia time of 1 h 48 min. After reperfusion, the recipient immediately passed urine. He was administered an immunosuppressive regimen comprising methylprednisolone, cyclosporine, everolimus, and mycophenolate mofetil, and he was discharged 10 days after the transplantation with a serum creatinine level of 1.4 mg/dL. At regular follow-up over the next 6 months, his serum creatinine levels remained within the normal range.\nOver the following 9 years, the recipient showed no episodes of rejection, and his serum creatinine levels and creatinine clearance rates were within the normal ranges . In 2010, he underwent coronary percutaneous angioplasty and stent placement for coronary artery disease, and thereafter he regularly took aspirin. However, in June 2014, he suffered a right cerebral aneurysm rupture that resulted in brain death. At that time, his serum creatinine level was 0.94 mg/dL and the creatinine clearance rate was 90 mL/min. Before his death, the patient (while completely conscious) and his family had expressed a wish for his organs to be donated; we therefore harvested the transplanted kidney for reuse.\nThe second recipient of the kidney was a 40-year-old man with ESRD caused by diabetic nephropathy, who had been undergoing hemodialysis for 5 years and had been added to the waiting list for renal transplantation at that time. His blood group was the same as that of the initial donor and the first recipient (A rhesus positive). There were four human leukocyte antigen mismatches with the original donor and two with the second donor . Crossmatching with the initial donor was not possible because of the long time that had elapsed since the initial transplantation, but crossmatching with the second donor was negative. A biopsy demonstrated the quality of the donated kidneys: the Remuzzi score was 1 and the Kidney Donor Profile Index score was 74%.\nKidney transplantation was performed in June 2014, with a cold ischemia time of 4 h 12 min and a warm ischemia time of 1 h 12 min. After transplantation, the recipient was administered an induction immunosuppressive regimen comprising basiliximab, high-dose methylprednisolone, and cyclosporine, subsequently shifted gradually to a maintenance immunosuppressive regimen comprising prednisolone, tacrolimus, everolimus, and mycophenolate mofetil. The second recipient was discharged 13 days after the transplantation, and his serum creatinine level was measured at follow-up every 3 months. As of June 2018, his renal function has remained stable, with a serum creatinine level of around 1.24 mg/dL . There have been no episodes of rejection, and the patient has remained in a good clinical condition.", + "fulltext_subclaims": [ + "The first donor was a 40-year-old man.", + "The first donor suffered brain death due to intracranial hemorrhage after a traffic accident.", + "The first donor's terminal serum creatinine level was 0.8 mg/dL.", + "The first donor's Kidney Donor Profile Index score was 27%.", + "The first recipient was a 45-year-old man.", + "The first recipient had a 20-year history of hypertension.", + "The first recipient had end-stage renal disease due to hypertensive nephropathy.", + "The first recipient had received regular hemodialysis for 2 years.", + "In June 2005, single renal transplantation was performed in the right iliac fossa.", + "The cold ischemia time was 5 h 10 min.", + "The warm ischemia time was 1 h 48 min.", + "After reperfusion, the recipient immediately passed urine.", + "The recipient was administered an immunosuppressive regimen comprising methylprednisolone, cyclosporine, everolimus, and mycophenolate mofetil.", + "The recipient was discharged 10 days after the transplantation.", + "The recipient's serum creatinine level at discharge was 1.4 mg/dL.", + "At regular follow-up over the next 6 months, the recipient's serum creatinine levels remained within the normal range.", + "Over the following 9 years, the recipient showed no episodes of rejection.", + "The recipient's serum creatinine levels and creatinine clearance rates were within the normal ranges.", + "In 2010, the recipient underwent coronary percutaneous angioplasty and stent placement for coronary artery disease.", + "The recipient regularly took aspirin after the 2010 procedure.", + "In June 2014, the recipient suffered a right cerebral aneurysm rupture that resulted in brain death.", + "At the time of brain death, the recipient's serum creatinine level was 0.94 mg/dL.", + "At the time of brain death, the recipient's creatinine clearance rate was 90 mL/min.", + "Before his death, the patient and his family had expressed a wish for his organs to be donated.", + "The transplanted kidney was harvested for reuse.", + "The second recipient was a 40-year-old man.", + "The second recipient had ESRD caused by diabetic nephropathy.", + "The second recipient had been undergoing hemodialysis for 5 years.", + "The second recipient had been added to the waiting list for renal transplantation.", + "The second recipient's blood group was A rhesus positive.", + "There were four human leukocyte antigen mismatches with the original donor.", + "There were two human leukocyte antigen mismatches with the second donor.", + "Crossmatching with the initial donor was not possible.", + "Crossmatching with the second donor was negative.", + "A biopsy demonstrated the quality of the donated kidneys.", + "The Remuzzi score was 1.", + "The Kidney Donor Profile Index score was 74%.", + "Kidney transplantation was performed in June 2014.", + "The cold ischemia time was 4 h 12 min.", + "The warm ischemia time was 1 h 12 min.", + "The second recipient was administered an induction immunosuppressive regimen comprising basiliximab, high-dose methylprednisolone, and cyclosporine.", + "The second recipient was shifted gradually to a maintenance immunosuppressive regimen comprising prednisolone, tacrolimus, everolimus, and mycophenolate mofetil.", + "The second recipient was discharged 13 days after the transplantation.", + "The second recipient's serum creatinine level was measured at follow-up every 3 months.", + "As of June 2018, the second recipient's renal function has remained stable.", + "As of June 2018, the second recipient's serum creatinine level was around 1.24 mg/dL.", + "There have been no episodes of rejection.", + "The second recipient has remained in a good clinical condition." + ], + "summary": "In 2005, a kidney was transplanted from a 40-year-old man, who suffered brain death due to an intracranial hemorrhage, into a 45-year-old man. Nine years later, the recipient suffered a ruptured cerebral aneurysm, resulting in brain death. The kidney was re-transplanted into a 40-year-old man with diabetic nephropathy who had received hemodialysis for 5 years. During 4 years of follow-up, the graft has functioned well.", + "summary_subclaims": [ + "In 2005, a kidney was transplanted from a 40-year-old man, who suffered brain death due to an intracranial hemorrhage, into a 45-year-old man.", + "Nine years later, the recipient suffered a ruptured cerebral aneurysm, resulting in brain death.", + "The kidney was re-transplanted into a 40-year-old man with diabetic nephropathy who had received hemodialysis for 5 years.", + "During 4 years of follow-up, the graft has functioned well." + ] + }, + { + "id": "multiclinsum_test_1042_en.txt", + "fulltext": "A 76-year-old male patient [body mass index (BMI), 21.5 kg/m2] was admitted to the General Surgery Department of our institution due to local abdominal distension in the left lower flank and intermittent abdominal pain for one year.\nBefore admission, the patient had undergone laparoscopic rectal resection one year ago in our institution. During the operation, five trocars were used in this patient, including a 10 mm trocar inserted at the umbilical site, two 5 mm trocars in the left flank, a 12 mm trocar and a 5 mm trocar in the right flank, respectively. Fascia layers were closed by an absorbable suture at the ≥ 10 mm trocar site. A 20 FR soft rubber tube was inserted in the left lower quadrant stoma port to drain excessive blood and exudates. The drainage tube was removed five days postoperatively following gastrointestinal function recovery, and the drainage liquid was ≤ 20 mL/d. The fascia layer at the drain site was not closed due to a tiny defect. The postoperative period was uneventful and the patient was discharged on the ninth day after the operation. The patient reported no discomfort postoperatively. However, one month later, there was abdominal bulging in the left lower flank in the standing position, which disappeared in the supine position. Little attention was paid to this initially; however, the patient felt a gradual progression of the abdominal bulge, accompanied by occasional dull abdominal pain over time.\nThe patient had a history of chronic bronchitis combined with intermittent cough without regular medical treatment. He also has a history of hypertension, coronary heart disease, and a laparoscopic cholecystectomy. The patient showed well controlled blood pressure without cardiovascular system symptoms. There were no restrictions on his daily activities.\nThe patient had no remarkable personal and family history.\nAccording to the physical examination after admission, the patient was found to have a local palpable mass (3 cm in length) in the left lower flank above the former drain-site and an abdominal wall defect (2 cm in length). Tenderness and rebound tenderness were not observed in the abdomen.\nRoutine serological examinations were performed without obvious abnormalities.\nA preoperative computed tomography scan confirmed the diagnosis and showed an abdominal wall hernia at the drainage site in the left lower quadrant, and the content consisted of the omentum majus . The detected abdominal wall fascial defect was 2 cm in diameter.", + "fulltext_subclaims": [ + "The patient is a 76-year-old male.", + "The patient's BMI is 21.5 kg/m2.", + "The patient was admitted to the General Surgery Department.", + "The patient had local abdominal distension in the left lower flank.", + "The patient had intermittent abdominal pain for one year.", + "The patient had undergone laparoscopic rectal resection one year ago.", + "Five trocars were used during the laparoscopic rectal resection.", + "A 10 mm trocar was inserted at the umbilical site.", + "Two 5 mm trocars were placed in the left flank.", + "A 12 mm trocar and a 5 mm trocar were placed in the right flank.", + "Fascia layers were closed by an absorbable suture at the ≥ 10 mm trocar site.", + "A 20 FR soft rubber tube was inserted in the left lower quadrant stoma port.", + "The drainage tube was removed five days postoperatively.", + "The drainage liquid was ≤ 20 mL/d.", + "The fascia layer at the drain site was not closed due to a tiny defect.", + "The patient was discharged on the ninth day after the operation.", + "The patient reported no discomfort postoperatively.", + "One month later, there was abdominal bulging in the left lower flank in the standing position.", + "The abdominal bulge disappeared in the supine position.", + "The patient felt a gradual progression of the abdominal bulge.", + "The patient had occasional dull abdominal pain over time.", + "The patient had a history of chronic bronchitis.", + "The patient had intermittent cough.", + "The patient had a history of hypertension.", + "The patient had a history of coronary heart disease.", + "The patient had a history of laparoscopic cholecystectomy.", + "The patient's blood pressure was well controlled.", + "There were no cardiovascular system symptoms.", + "There were no restrictions on the patient's daily activities.", + "The patient had no remarkable personal and family history.", + "A local palpable mass (3 cm in length) was found in the left lower flank above the former drain-site.", + "An abdominal wall defect (2 cm in length) was found.", + "Tenderness and rebound tenderness were not observed in the abdomen.", + "Routine serological examinations showed no obvious abnormalities.", + "A preoperative computed tomography scan confirmed the diagnosis.", + "The computed tomography scan showed an abdominal wall hernia at the drainage site in the left lower quadrant.", + "The hernia content consisted of the omentum majus.", + "The detected abdominal wall fascial defect was 2 cm in diameter." + ], + "summary": "A 76-year-old male patient was admitted to our institution with intermittent abdominal pain and a local abdominal mass which occurred one month after laparoscopic radical resection of rectal cancer one year ago. A computed tomography scan showed an abdominal wall hernia at the 5 mm former drain-site in the left lower quadrant, and that the content consisted of the large omentum. An elective herniorrhaphy was performed by closing the fascial defect and reinforcing the abdominal wall with a synthetic mesh simultaneously. The postoperative period was uneventful. The patient was discharged seven days after the operation without surgery-related complications at the 1-mo follow-up visit.", + "summary_subclaims": [ + "The patient was a 76-year-old male.", + "The patient was admitted with intermittent abdominal pain.", + "The patient had a local abdominal mass.", + "The abdominal mass occurred one month after laparoscopic radical resection of rectal cancer.", + "The rectal cancer resection had occurred one year before admission.", + "A computed tomography scan showed an abdominal wall hernia at the 5 mm former drain-site in the left lower quadrant.", + "The hernia content consisted of the large omentum.", + "An elective herniorrhaphy was performed.", + "The fascial defect was closed during the herniorrhaphy.", + "The abdominal wall was reinforced with a synthetic mesh.", + "The postoperative period was uneventful.", + "The patient was discharged seven days after the operation.", + "There were no surgery-related complications at the 1-mo follow-up visit." + ] + }, + { + "id": "multiclinsum_test_3191_en.txt", + "fulltext": "A 49-year-old female, was admitted to the hospital due to cardiopulmonary arrest. The patient has a medical history that includes untreated cervical cancer and sleep disorders. Three hours before admission, the patient’s family members noticed that the patient was lethargic, yawning, and found that the patient had taken about 20 tablets of amitriptyline 25mg, prompting an emergency call. During transport to Thu Duc City Hospital, the patient experienced one cardiac arrest and was successfully resuscitated, with the arrest and resuscitation lasting about 10 minutes. Upon admission to the Emergency Department at Thu Duc City Hospital, the patient was unconscious/on mechanical ventilation, with a blood pressure of 105/70 mmHg on a background of Noradrenaline at a dose of 0.5 µg/kg/min and Adrenaline at a dose of 0.3 µg/kg/min. The extremities were warm, the pulse was clear, and the heart rate was regular and fast at 115 beats per minute. After admission to the Emergency Department, the patient experienced a second cardiac arrest and was resuscitated with basic and advanced cardiopulmonary resuscitation, achieving return of spontaneous circulation after 15 minutes.\n\nThe pH level is 6.902 and bicarbonate (HCO3) is 18.4, which is very low compared to normal levels, indicating severe acidosis. Blood oxygen (pO2) is 52 and lactate is 10.39 mmol/L, indicating the patient is experiencing hypoxia. The results show that the patient is suffering from severe acidosis, respiratory failure, and tissue hypoxia.\n\nThe electrocardiogram (ECG) upon admission shows the patient with a slow heart rate of 46 cycles per minute and a widened QRS complex of 240 ms. Several short episodes of ventricular tachycardia were recorded on the monitoring device.\n\nThe patient was diagnosed with: Resuscitated cardiac arrest - Ventricular arrhythmias - QT prolongation - Seizures / Tricyclic antidepressant poisoning - Respiratory acidosis - Untreated cervical cancer - Sleep disorders.\n\nThe patient was treated with mechanical ventilation, noradrenaline 0.5µg/kg/minute, sedation, and 750mL of 4.2% sodium bicarbonate in the emergency room.\n\nOn the first day in the Cardiovascular Intensive Care Unit, we continued to maintain vasopressors, sedatives, and muscle relaxants, and administered isotonic sodium chloride solution and 4.2% sodium bicarbonate, adjusting the patient’s blood sodium and potassium levels. During the treatment monitoring process, the monitor showed ventricular tachycardia with a frequency of about 130 beats per minute, while the arterial blood gas results recorded a pH of 7.61, pO2 of 94, pCO2 of 40.4, and HCO3 of 40.6. Since the pH had reached the treatment threshold, the patient was administered an additional 1.5g of 15% magnesium sulfate intravenously over 15 minutes. The ECG results showed a narrowing QRS complex, but the monitor still recorded temporary episodes of ventricular tachycardia and frequent ventricular ectopic beats. The doctors decided to administer additional intravenous 2% lidocaine at a dose of 1.2mg/kg/h.\n\nOn the 2nd day after hospitalization, arterial blood gas results recorded a pH of 7.52; pO2 of 146; pCO2 of 31.8; HCO3 of 26; and a magnesium level of 4.69 mmol/L. Although the patient’s QTc was prolonged (510ms), due to the high blood magnesium level (4.69 mmol/L) after using 4.5g of 15% magnesium sulfate, and the monitor only recorded short episodes of ventricular tachycardia, we discontinued the magnesium sulfate and continued to maintain lidocaine intravenously. On the same day, the patient suddenly developed a high fever twice at 39°C, cough with yellow sputum, and was supplemented with antibiotics for pneumonia treatment. At this point, the 4.2% Sodium bicarbonate and sedation were discontinued.\n\nAt the end of the 3rd day of hospitalization, 2% lidocaine was discontinued for the patient. After discontinuing the use of 4.3% sodium bicarbonate and 2% lidocaine, the ECG showed a stable sinus rhythm of 95 cycles per minute, a narrowed QRS complex of 88 ms, and a QTc of 440 ms.\n\nThe patient was successfully weaned off mechanical ventilation and extubated after 48 hours of sedation discontinuation, able to understand and follow commands. The patient recovered well, with no fever after 1 day of antibiotic treatment, and antibiotics were discontinued after 10 days. After 12 days of treatment, the patient was able to walk independently. After 15 days of treatment, the patient was discharged from the hospital in good recovery.", + "fulltext_subclaims": [ + "The patient is a 49-year-old female.", + "The patient was admitted to the hospital due to cardiopulmonary arrest.", + "The patient has a medical history that includes untreated cervical cancer.", + "The patient has a medical history that includes sleep disorders.", + "Three hours before admission, the patient’s family members noticed that the patient was lethargic.", + "Three hours before admission, the patient’s family members noticed that the patient was yawning.", + "Three hours before admission, the patient had taken about 20 tablets of amitriptyline 25mg.", + "During transport to Thu Duc City Hospital, the patient experienced one cardiac arrest.", + "During transport to Thu Duc City Hospital, the patient was successfully resuscitated.", + "The arrest and resuscitation during transport lasted about 10 minutes.", + "Upon admission to the Emergency Department at Thu Duc City Hospital, the patient was unconscious.", + "Upon admission to the Emergency Department at Thu Duc City Hospital, the patient was on mechanical ventilation.", + "Upon admission to the Emergency Department at Thu Duc City Hospital, the patient’s blood pressure was 105/70 mmHg.", + "Upon admission to the Emergency Department at Thu Duc City Hospital, the patient was receiving Noradrenaline at a dose of 0.5 µg/kg/min.", + "Upon admission to the Emergency Department at Thu Duc City Hospital, the patient was receiving Adrenaline at a dose of 0.3 µg/kg/min.", + "After admission to the Emergency Department, the patient experienced a second cardiac arrest.", + "After admission to the Emergency Department, the patient was resuscitated with basic and advanced cardiopulmonary resuscitation.", + "After admission to the Emergency Department, the patient achieved return of spontaneous circulation after 15 minutes.", + "The pH level is 6.902.", + "The bicarbonate (HCO3) level is 18.4.", + "The blood oxygen (pO2) level is 52.", + "The lactate level is 10.39 mmol/L.", + "The ECG upon admission shows a slow heart rate of 46 cycles per minute.", + "The ECG upon admission shows a widened QRS complex of 240 ms.", + "Several short episodes of ventricular tachycardia were recorded on the monitoring device.", + "The patient was diagnosed with resuscitated cardiac arrest.", + "The patient was diagnosed with ventricular arrhythmias.", + "The patient was diagnosed with QT prolongation.", + "The patient was diagnosed with tricyclic antidepressant poisoning.", + "The patient was diagnosed with respiratory acidosis.", + "The patient was diagnosed with untreated cervical cancer.", + "The patient was diagnosed with sleep disorders.", + "The patient was treated with mechanical ventilation.", + "The patient was treated with noradrenaline 0.5µg/kg/minute.", + "The patient was treated with 750mL of 4.2% sodium bicarbonate in the emergency room.", + "On the first day in the Cardiovascular Intensive Care Unit, vasopressors were continued.", + "On the first day in the Cardiovascular Intensive Care Unit, sedatives were continued.", + "On the first day in the Cardiovascular Intensive Care Unit, muscle relaxants were continued.", + "On the first day in the Cardiovascular Intensive Care Unit, isotonic sodium chloride solution was administered.", + "On the first day in the Cardiovascular Intensive Care Unit, 4.2% sodium bicarbonate was administered.", + "On the first day in the Cardiovascular Intensive Care Unit, the patient’s blood sodium and potassium levels were adjusted.", + "During the treatment monitoring process, the monitor showed ventricular tachycardia with a frequency of about 130 beats per minute.", + "During the treatment monitoring process, the arterial blood gas results recorded a pH of 7.61.", + "During the treatment monitoring process, the arterial blood gas results recorded a pO2 of 94.", + "During the treatment monitoring process, the arterial blood gas results recorded a pCO2 of 40.4.", + "During the treatment monitoring process, the arterial blood gas results recorded an HCO3 of 40.6.", + "Since the pH had reached the treatment threshold, the patient was administered an additional 1.5g of 15% magnesium sulfate intravenously over 15 minutes.", + "The ECG results showed a narrowing QRS complex.", + "The ECG results showed temporary episodes of ventricular tachycardia.", + "The ECG results showed frequent ventricular ectopic beats.", + "The doctors decided to administer additional intravenous 2% lidocaine at a dose of 1.2mg/kg/h.", + "On the 2nd day after hospitalization, arterial blood gas results recorded a pH of 7.52.", + "On the 2nd day after hospitalization, arterial blood gas results recorded a pO2 of 146.", + "On the 2nd day after hospitalization, arterial blood gas results recorded a pCO2 of 31.8.", + "On the 2nd day after hospitalization, arterial blood gas results recorded an HCO3 of 26.", + "On the 2nd day after hospitalization, the magnesium level was 4.69 mmol/L.", + "On the 2nd day after hospitalization, the QTc was prolonged (510ms).", + "On the 2nd day after hospitalization, the patient’s blood magnesium level was 4.69 mmol/L after using 4.5g of 15% magnesium sulfate.", + "On the 2nd day after hospitalization, the monitor only recorded short episodes of ventricular tachycardia.", + "On the 2nd day after hospitalization, magnesium sulfate was discontinued.", + "On the 2nd day after hospitalization, lidocaine intravenously was continued.", + "On the 2nd day after hospitalization, the patient suddenly developed a high fever twice at 39°C.", + "On the 2nd day after hospitalization, the patient had cough with yellow sputum.", + "On the 2nd day after hospitalization, antibiotics were administered for pneumonia treatment.", + "At this point, 4.2% Sodium bicarbonate was discontinued.", + "At this point, sedation was discontinued.", + "At the end of the 3rd day of hospitalization, 2% lidocaine was discontinued.", + "After discontinuing the use of 4.3% sodium bicarbonate and 2% lidocaine, the ECG showed a stable sinus rhythm of 95 cycles per minute.", + "After discontinuing the use of 4.3% sodium bicarbonate and 2% lidocaine, the ECG showed a narrowed QRS complex of 88 ms.", + "After discontinuing the use of 4.3% sodium bicarbonate and 2% lidocaine, the ECG showed a QTc of 440 ms.", + "The patient was successfully weaned off mechanical ventilation.", + "The patient was extubated after 48 hours of sedation discontinuation.", + "The patient was able to understand and follow commands.", + "The patient recovered well.", + "The patient had no fever after 1 day of antibiotic treatment.", + "Antibiotics were discontinued after 10 days.", + "After 12 days of treatment, the patient was able to walk independently.", + "After 15 days of treatment, the patient was discharged from the hospital.", + "The patient was discharged from the hospital in good recovery." + ], + "summary": "A 49-year-old female patient was admitted to the hospital due to cardiac and respiratory arrest. The patient had a past medical history of untreated cervical cancer and sleep disorders. Prior to admission, the patient had taken about 20 tablets of amitriptyline 25mg and was in a drowsy state with gasping breaths. During transportation to the hospital, the patient experienced cardiac arrest once and was successfully resuscitated, with a total arrest and resuscitation time of approximately 10 minutes.", + "summary_subclaims": [ + "The patient was a 49-year-old female.", + "The patient was admitted to the hospital due to cardiac and respiratory arrest.", + "The patient had a past medical history of untreated cervical cancer.", + "The patient had a past medical history of sleep disorders.", + "Prior to admission, the patient had taken about 20 tablets of amitriptyline 25mg.", + "Prior to admission, the patient was in a drowsy state with gasping breaths.", + "During transportation to the hospital, the patient experienced cardiac arrest once.", + "The patient was successfully resuscitated during transportation.", + "The total arrest and resuscitation time was approximately 10 minutes." + ] + }, + { + "id": "multiclinsum_test_183_en.txt", + "fulltext": "A 60-year-old African American man was admitted to the hospital with worsening abdominal pain and declining functional status. He had become progressively weaker after receiving the first round of chemotherapy for advanced rectal adenocarcinoma with extensive metastasis to the liver, lungs and spine. On the day of admission, the hematologic analysis was significant for hemoglobin of 11.6 g/dL, platelets of 555/nL, and a white blood cell count of 7.4/nL. Blood work was significant for random glucose of 114 mg/dL, creatinine of 1.1 mg/dL, blood urea nitrogen of 20 mg/dL, potassium of 4.9 mmol/L, alanine aminotransferase of 215 U/L, aspartate aminotransferase of 180 U/L, alkaline phosphatase of 1,178 U/L, total bilirubin of 10.8 mg/dL, and serum sodium of 127 mmol/L. His serum sodium concentration 4 months earlier had been 137 mmol/L.\nMagnetic resonance cholangiopancreatography was performed to evaluate the possibility of palliative stenting for his progressive cholestasis and showed liver enlargement with numerous mildly T2 hyperintense/T1 hypointense metastatic lesions throughout the liver. There was intrahepatic biliary ductal dilation, which was not amenable to palliative stenting.\nHypovolemic hyponatremia was suspected because of the patient’s serum sodium of 127 mmol/L, his poor oral intake, and the presence of dry mucosal membranes on exam. Serum was sent to an outside laboratory to assess osmolality. Intravenous fluid boluses were given, and maintenance fluid was started. Despite adequate fluid resuscitation, on the third hospital day, the patient’s serum sodium level further decreased to 125 mmol/L; thus, syndrome of inappropriate secretion of antidiuretic hormone (SIADH) was suspected. Fluid intake was restricted to 1.2 L/day, and the patient’s serum sodium was 126 mEq/L on the following day. As a result of this improvement, therapy for SIADH was escalated with salt tablets. However, the serum sodium decreased to 121 mmol/L by the sixth day. At this time the result of serum osmolality became available revealing a normal level of 288 mOsm/kg, leading to a diagnosis of pseudohyponatremia.\nRepeated laboratory tests showed worsening alkaline phosphatase levels at 1,698 U/L and total bilirubin at 15.3 mg/dL; random urine sodium was 63 mmol/L. A serum lipid profile workup revealed a total serum cholesterol of 816 mg/dL with triglyceride levels of 382 mg/dL and high-density lipoprotein of 9 mg/dL; the low-density lipoprotein levels were unmeasurable because the total cholesterol was >500 mg/dL. Interestingly, the patient’s lipid profile 4 weeks earlier showed total cholesterol of only 213 mg/dL, triglycerides at 115 mg/dL, high-density lipoprotein at 36 mg/dL, and low-density lipoproteins at 153 mg/dL. No further treatment for hyponatremia was further offered as it was determined a laboratory artifact secondary to severe hypercholesterolemia.", + "fulltext_subclaims": [ + "The patient is a 60-year-old African American man.", + "He was admitted to the hospital with worsening abdominal pain and declining functional status.", + "He had received the first round of chemotherapy for advanced rectal adenocarcinoma.", + "The cancer had extensive metastasis to the liver, lungs, and spine.", + "On the day of admission, the hematologic analysis showed a hemoglobin of 11.6 g/dL.", + "On the day of admission, the hematologic analysis showed platelets of 555/nL.", + "On the day of admission, the hematologic analysis showed a white blood cell count of 7.4/nL.", + "Blood work showed a random glucose of 114 mg/dL.", + "Blood work showed a creatinine of 1.1 mg/dL.", + "Blood work showed a blood urea nitrogen of 20 mg/dL.", + "Blood work showed a potassium of 4.9 mmol/L.", + "Blood work showed an alanine aminotransferase of 215 U/L.", + "Blood work showed an aspartate aminotransferase of 180 U/L.", + "Blood work showed an alkaline phosphatase of 1,178 U/L.", + "Blood work showed a total bilirubin of 10.8 mg/dL.", + "Blood work showed a serum sodium of 127 mmol/L.", + "His serum sodium concentration 4 months earlier had been 137 mmol/L.", + "Magnetic resonance cholangiopancreatography was performed to evaluate the possibility of palliative stenting.", + "The MRI showed liver enlargement with numerous mildly T2 hyperintense/T1 hypointense metastatic lesions.", + "There was intrahepatic biliary ductal dilation.", + "The biliary ductal dilation was not amenable to palliative stenting.", + "Hypovolemic hyponatremia was suspected.", + "Serum was sent to an outside laboratory to assess osmolality.", + "Intravenous fluid boluses were given.", + "Maintenance fluid was started.", + "On the third hospital day, the patient’s serum sodium level further decreased to 125 mmol/L.", + "Syndrome of inappropriate secretion of antidiuretic hormone (SIADH) was suspected.", + "Fluid intake was restricted to 1.2 L/day.", + "The patient’s serum sodium was 126 mEq/L on the following day.", + "Therapy for SIADH was escalated with salt tablets.", + "The serum sodium decreased to 121 mmol/L by the sixth day.", + "The serum osmolality result became available revealing a normal level of 288 mOsm/kg.", + "The diagnosis was pseudohyponatremia.", + "Repeated laboratory tests showed worsening alkaline phosphatase levels at 1,698 U/L.", + "Repeated laboratory tests showed total bilirubin at 15.3 mg/dL.", + "Random urine sodium was 63 mmol/L.", + "A serum lipid profile showed a total serum cholesterol of 816 mg/dL.", + "A serum lipid profile showed triglyceride levels of 382 mg/dL.", + "A serum lipid profile showed high-density lipoprotein of 9 mg/dL.", + "Low-density lipoprotein levels were unmeasurable because the total cholesterol was >500 mg/dL.", + "The patient’s lipid profile 4 weeks earlier showed total cholesterol of 213 mg/dL.", + "The patient’s lipid profile 4 weeks earlier showed triglycerides at 115 mg/dL.", + "The patient’s lipid profile 4 weeks earlier showed high-density lipoprotein at 36 mg/dL.", + "The patient’s lipid profile 4 weeks earlier showed low-density lipoproteins at 153 mg/dL.", + "No further treatment for hyponatremia was offered.", + "It was determined that the hyponatremia was a laboratory artifact secondary to severe hypercholesterolemia." + ], + "summary": "We report a case of pseudohyponatremia in a 60-year-old man with rectal cancer with extensive metastasis to the liver. While assessing the patient for hyponatremia, extremely elevated serum cholesterol with normal serum osmolality was detected leading to the diagnosis of pseudohyponatremia. This is one of very few reports of pseudohyponatremia in patients with elevated cholesterol in cholestatic liver disease.", + "summary_subclaims": [ + "The patient was a 60-year-old man.", + "The patient had rectal cancer with extensive metastasis to the liver.", + "The patient was assessed for hyponatremia.", + "Extremely elevated serum cholesterol was detected.", + "Serum osmolality was normal.", + "The diagnosis was pseudohyponatremia.", + "This is one of very few reports of pseudohyponatremia in patients with elevated cholesterol in cholestatic liver disease." + ] + }, + { + "id": "multiclinsum_test_3193_en.txt", + "fulltext": "A 60-year-old Caucasian woman was referred to our department due to suspected cutaneous squamous cell carcinoma on the left thigh. She reported an 8-week history of a non-traumatic ulcer that initially resembled a bruise, but gradually developed into a painful, non-healing ulcer. The patient had a poor performance status and a past medical history of smoking, peripheral vascular disease (PVD), and rectal squamous cell carcinoma that had been treated with chemoradiotherapy 5 years earlier. There was no other known history of immunocompromise.\n\nOn examination, the patient was febrile (37.9°C) and tachycardic (109 bpm). A necrotic ulcer with a purple undermined border was present on the left inner thigh that was surrounded by warm and tender induration. No crepitus or discharge was present.\n\nBlood tests revealed raised inflammatory markers (white cell count [WCC] of 23.8 × 109/L and C-reactive protein of 282 mg/L). Autoimmune screen was unremarkable. Microscopy, culture, and sensitivity from a wound swab only identified contaminants. Ultrasonography was performed which excluded the presence of an underlying fluid collection. Given the lack of remarkable imaging and the slow advance of the condition, the possibility of necrotising fasciitis was excluded. The patient was therefore treated with co-amoxiclav and metronidazole for presumed pyoderma gangrenosum with superimposed cellulitis.\n\nThree days later, the patient was found to have spreading induration and increasing pain despite improving inflammatory markers (WBC of 10.9 × 109/L and C-reactive protein of 134 mg/L) and was admitted to hospital with presumed worsening cellulitis. She was escalated to intravenous antibiotics. A skin biopsy was performed that revealed ulceration to the subcutis, neovascularisation with proliferation of vascular channels and spindle cells. There was no evidence of neutrophilia, atypia or mitotic activity to suggest pyoderma gangrenosum or malignancy. Immunohistochemistry studies found positivity to the vascular marker CD31 and were negative to HHV-8. A diagnosis of RAE was thus made based on the clinical and histological findings, and the patient was urgently referred to the vascular team for consideration of surgical correction of PVD. Unfortunately, following their assessment, and due to her poor performance status, the patient was not found to be fit to undergo surgical treatment. Instead, antibiotics were continued with improving inflammatory markers and lessening pain. Wound dressings and topical timolol were also initiated. Unexpectedly, and despite ongoing antibiotic therapy, the patient’s condition deteriorated suddenly, leading to her demise within 3 weeks of her initial presentation to our department due to irretrievable PVD.", + "fulltext_subclaims": [ + "The patient was a 60-year-old Caucasian woman.", + "She was referred due to suspected cutaneous squamous cell carcinoma on the left thigh.", + "She reported an 8-week history of a non-traumatic ulcer.", + "The ulcer initially resembled a bruise.", + "The ulcer gradually developed into a painful, non-healing ulcer.", + "The patient had a past medical history of smoking.", + "The patient had a past medical history of peripheral vascular disease.", + "The patient had a past medical history of rectal squamous cell carcinoma treated with chemoradiotherapy 5 years earlier.", + "There was no known history of immunocompromise.", + "On examination, the patient was febrile (37.9°C).", + "On examination, the patient was tachycardic (109 bpm).", + "A necrotic ulcer with a purple undermined border was present on the left inner thigh.", + "The ulcer was surrounded by warm and tender induration.", + "No crepitus was present.", + "No discharge was present.", + "Blood tests revealed a white cell count of 23.8 × 109/L.", + "Blood tests revealed a C-reactive protein of 282 mg/L.", + "Microscopy, culture, and sensitivity from a wound swab only identified contaminants.", + "Ultrasonography excluded the presence of an underlying fluid collection.", + "The possibility of necrotising fasciitis was excluded.", + "The patient was treated with co-amoxiclav and metronidazole.", + "The treatment was for presumed pyoderma gangrenosum with superimposed cellulitis.", + "Three days later, the patient had spreading induration.", + "Three days later, the patient had increasing pain.", + "Inflammatory markers improved (WBC of 10.9 × 109/L and C-reactive protein of 134 mg/L).", + "The patient was admitted to hospital with presumed worsening cellulitis.", + "A skin biopsy revealed ulceration to the subcutis.", + "The biopsy showed neovascularisation with proliferation of vascular channels and spindle cells.", + "There was no evidence of neutrophilia.", + "There was no evidence of atypia.", + "There was no evidence of mitotic activity.", + "Immunohistochemistry studies found positivity to the vascular marker CD31.", + "Immunohistochemistry studies were negative to HHV-8.", + "A diagnosis of RAE was made.", + "The patient was urgently referred to the vascular team.", + "The patient was not found to be fit to undergo surgical treatment.", + "Antibiotics were continued.", + "Wound dressings were initiated.", + "Topical timolol was initiated.", + "The patient’s condition deteriorated suddenly.", + "The patient died within 3 weeks of her initial presentation.", + "The patient’s death was due to irretrievable PVD." + ], + "summary": "A 60-year-old female presented with an 8-week history of a painful, non-healing, and non-traumatic ulcer on the left thigh. Her past medical history included smoking, peripheral vascular disease (PVD) and previously treated rectal squamous cell carcinoma. The diagnosis of pyoderma gangrenosum with superimposed cellulitis was considered and treatment with oral antibiotics was initiated. Following failure to improve, a biopsy was undertaken leading to the diagnosis of RAE. The patient was referred for urgent consideration of surgical correction of PVD, but was deemed unsuitable for surgical treatment due to a poor performance status. The patient was treated with conservative measures, but her condition rapidly deteriorated and she passed away a few weeks later.", + "summary_subclaims": [ + "The patient is a 60-year-old female.", + "She had an 8-week history of a painful, non-healing, and non-traumatic ulcer on the left thigh.", + "Her past medical history included smoking.", + "Her past medical history included peripheral vascular disease.", + "She had previously treated rectal squamous cell carcinoma.", + "The diagnosis of pyoderma gangrenosum with superimposed cellulitis was considered.", + "Treatment with oral antibiotics was initiated.", + "Following failure to improve, a biopsy was undertaken.", + "The biopsy led to the diagnosis of RAE.", + "The patient was referred for urgent consideration of surgical correction of PVD.", + "She was deemed unsuitable for surgical treatment due to a poor performance status.", + "The patient was treated with conservative measures.", + "Her condition rapidly deteriorated.", + "She passed away a few weeks later." + ] + }, + { + "id": "multiclinsum_test_2446_en.txt", + "fulltext": "The patient was a 47-year-old male with non-contributory past medical history. He noticed weakness in the left lower extremity upon rising from bed in the morning, but the symptom gradually resolved. On the night of the same day, he suddenly developed headache and mild paralysis of the left lower extremity and presented to our hospital. On admission, the patient was alert and had mild paralysis of the left lower extremity. His blood pressure was 138/78 mm Hg. There were no abnormalities in the blood biochemistry tests taken upon arrival. The head CT and MRI showed cerebral infarctions in the right frontal lobe and subarachnoid hemorrhage in the frontal convexity and anterior interhemispheric fissure. In MRA, DAs were observed in the bilateral anterior cerebral arteries. In the 3D-CT angiography, dissecting intima was observed in the area with saccular enlargement . The patient was diagnosed with a combination of cerebral infarction and subarachnoid hemorrhage caused by the rupture of the DAs in the bilateral anterior cerebral arteries. In the left internal carotid angiography, saccular cerebral aneurysm was observed in the left A1–A2 junction . In addition, stenosis was seen in the left A2 segment and opaque vascular bulging was seen in its peripheral in the late arterial phase. Right internal carotid angiography showed cerebral aneurysm at the left A1–A2 junction . The right A2 segment was occluded and its peripheral vessels showed retrograde flow during the venous phase. The treatment plan included surgery to prevent recurrent hemorrhage and to reinforce the walls of the DAs in the anterior cerebral arteries. Surgery was performed on the fifteenth day after admission when the patient’s neurological symptoms stabilized. First, anterior interhemispheric approach in a supine position was used to confirm the presence of aneurysms in the bilateral areas from A2 to A3 segments. The arterial wall was dark purple, and the vascular diameters were irregular with bulging in one area. Wrapping was performed from A2 to A3 segments for the left anterior cerebral artery. The right peripheral vessels had weak walls and vascular anastomosis was difficult. Therefore, trapping was performed at the A2 segment. In the postoperative course, the patient had no apparent neurological deterioration. One month after the surgery his symptoms had resolved completely, and he could return to work.", + "fulltext_subclaims": [ + "The patient was a 47-year-old male.", + "He noticed weakness in the left lower extremity upon rising from bed in the morning.", + "The symptom gradually resolved.", + "On the night of the same day, he suddenly developed headache.", + "He had mild paralysis of the left lower extremity.", + "He presented to our hospital.", + "On admission, the patient was alert.", + "He had mild paralysis of the left lower extremity.", + "His blood pressure was 138/78 mm Hg.", + "There were no abnormalities in the blood biochemistry tests taken upon arrival.", + "The head CT and MRI showed cerebral infarctions in the right frontal lobe.", + "The head CT and MRI showed subarachnoid hemorrhage in the frontal convexity.", + "The head CT and MRI showed subarachnoid hemorrhage in the anterior interhemispheric fissure.", + "In MRA, DAs were observed in the bilateral anterior cerebral arteries.", + "In the 3D-CT angiography, dissecting intima was observed in the area with saccular enlargement.", + "The patient was diagnosed with a combination of cerebral infarction and subarachnoid hemorrhage.", + "The diagnosis was caused by the rupture of the DAs in the bilateral anterior cerebral arteries.", + "In the left internal carotid angiography, saccular cerebral aneurysm was observed in the left A1–A2 junction.", + "Stenosis was seen in the left A2 segment.", + "Opaque vascular bulging was seen in its peripheral in the late arterial phase.", + "Right internal carotid angiography showed cerebral aneurysm at the left A1–A2 junction.", + "The right A2 segment was occluded.", + "Its peripheral vessels showed retrograde flow during the venous phase.", + "The treatment plan included surgery to prevent recurrent hemorrhage.", + "The treatment plan included surgery to reinforce the walls of the DAs in the anterior cerebral arteries.", + "Surgery was performed on the fifteenth day after admission.", + "The patient’s neurological symptoms stabilized.", + "First, anterior interhemispheric approach in a supine position was used.", + "Aneurysms were confirmed in the bilateral areas from A2 to A3 segments.", + "The arterial wall was dark purple.", + "The vascular diameters were irregular with bulging in one area.", + "Wrapping was performed from A2 to A3 segments for the left anterior cerebral artery.", + "The right peripheral vessels had weak walls.", + "Vascular anastomosis was difficult.", + "Trapping was performed at the A2 segment.", + "In the postoperative course, the patient had no apparent neurological deterioration.", + "One month after the surgery, his symptoms had resolved completely.", + "He could return to work." + ], + "summary": "A 47-year-old male presented to our hospital with chief complaints of sudden headache and mild paralysis of the left lower extremity. Brain imaging at admission revealed cerebral infarction in the right frontal lobe and subarachnoid hemorrhage in the frontal convexy and anterior interhemispheric fissure. The left and right internal carotid angiography showed a bulging cerebral aneurysm at the left A1-A2 junction and stenosis and arterial dissections in the peripheral of the bilateral anterior cerebral artery. Wrapping was performed for the dissecting aneurysm of the left anterior cerebral artery. For the right anterior cerebral artery, trapping was performed at the A2 segment without vascular anastomosis. The patient's postoperative course was uneventful.", + "summary_subclaims": [ + "The patient is a 47-year-old male.", + "He presented with sudden headache.", + "He had mild paralysis of the left lower extremity.", + "Brain imaging at admission revealed cerebral infarction in the right frontal lobe.", + "Subarachnoid hemorrhage was found in the frontal convexy and anterior interhemispheric fissure.", + "Left and right internal carotid angiography showed a bulging cerebral aneurysm at the left A1-A2 junction.", + "Stenosis and arterial dissections were found in the peripheral of the bilateral anterior cerebral artery.", + "Wrapping was performed for the dissecting aneurysm of the left anterior cerebral artery.", + "Trapping was performed at the A2 segment of the right anterior cerebral artery.", + "Vascular anastomosis was not performed.", + "The patient's postoperative course was uneventful." + ] + }, + { + "id": "multiclinsum_test_941_en.txt", + "fulltext": "A 72-year-old Japanese male PD patient had experienced a slowly progressive gait disturbance and akinesia since 56 years of age. He was diagnosed with PD at 58 years. He had no history of any neurological disorders. His family history is unremarkable. During the next 15 years, he had been admitted to our hospital several times for drug control, and LD pharmacokinetics was checked twice when he was 68 years old. At the age of 71 years 10 months, although his parkinsonian features had not changed, he suddenly developed jaundice and he was diagnosed with cholangiocarcinoma. At this time, his Unified Parkinson's Disease Rating Scale (UPDRS) motor score (part III) was 28/108 , and his daily antiparkinsonian treatment was 500 mg/50 mg of LD/carbidopa, 0.5 mg of cabergoline, and 2.5 mg of selegiline.\nIn the next month (at the age of 71 years 11 months), pancreaticoduodenectomy was performed. In this operation, subtotal removal of the stomach (3 cm from the pylorus side), total removal of the duodenum, and subtotal removal of the jejunum (20 cm from the ligament of Treitz on the distal side) was performed . Reconstruction was made by end-to-end anastomosis of the pancreas to the bile duct to the jejunum . There were no surgical complications in his post-operative course, and he recovered without any surgical problems. After 5 days, he could take the same oral antiparkinsonian agents as before the operation (500 mg/50 mg of LD/carbidopa, 0.5 mg of cabergoline, and 2.5 mg of selegiline); however, his Parkinsonian features were gradually remarkable within 2 weeks after the operation. The patient did not receive any agents as chemotherapy. He was then transferred to our ward for parkinsonian drug treatment.\nAt this time, his height, body weight, and body mass index were 158.0 cm, 61.0 kg, and 24.4, respectively. His neurological examination revealed marked masked face, dysarthria, and dysphagia. Mild tremor at rest in the left upper extremity, severe rigidity in the bilateral upper and lower extremity, and poor finger taps on the dominant left side were also observed. Gait was unable without assistance. His parkinsonian features were obviously getting worse, and UPDRS motor score (part III) was 68/108. Thus, we checked whether this worsening of parkinsonian features was due to a change in LD absorption in the gastrointestinal tract by checking his LD pharmacokinetics.\nWritten informed consent was obtained from this patient, and the approval of the Institutional Review Board was obtained for the examination of LD pharmacokinetics. To assess LD pharmacokinetics, he took a tablet containing 100 mg of LD and 10 mg of carbidopa at 9:00 a.m. following an overnight fast and a medication-free period of at least 18 h. Blood specimens were collected through an intravenous catheter at 0, 15, 30, 60, 120, and 180 min after LD administration, and plasma LD concentrations were measured by high-performance liquid chromatography with electrochemical detection. The procedure of measurement of blood LD concentration has been described in our previous report . Peak drug concentration (Cmax), the time-to-peak drug concentration (Tmax), elimination halftime (T1/2), and area under the curve (AUC) were determined. Cmax and Tmax were observed values, T1/2 was determined by linear regression analysis, and AUC was estimated from the area under the time concentration line up to 3 h.\nIn his LD pharmacokinetics at the ages of 68 years 11 months (and 68 years 1 month), body weight was 64.2 (and 64.8) kg, AUC was 1,782.5 (and 1,825.0) mg·h/ml, Cmax was 1,500 (and 1,500) mg/ml, Tmax was 30 (and 30) min, and T1/2 was 48 (and 47) min. In the postoperative assessment (at the age of 72 years 4 months), AUC was 1,148.8 mg·h/ml, Cmax was 450 mg/ml, Tmax was 60 min, and T1/2 was >120 min .", + "fulltext_subclaims": [ + "The patient is a 72-year-old Japanese male.", + "He had experienced a slowly progressive gait disturbance and akinesia since 56 years of age.", + "He was diagnosed with PD at 58 years.", + "He had no history of any neurological disorders.", + "His family history is unremarkable.", + "He had been admitted to our hospital several times for drug control during the next 15 years.", + "LD pharmacokinetics was checked twice when he was 68 years old.", + "At the age of 71 years 10 months, he suddenly developed jaundice.", + "At this time, his UPDRS motor score (part III) was 28/108.", + "His daily antiparkinsonian treatment was 500 mg/50 mg of LD/carbidopa, 0.5 mg of cabergoline, and 2.5 mg of selegiline.", + "He was diagnosed with cholangiocarcinoma at this time.", + "Pancreaticoduodenectomy was performed at the age of 71 years 11 months.", + "In this operation, subtotal removal of the stomach, total removal of the duodenum, and subtotal removal of the jejunum was performed.", + "Reconstruction was made by end-to-end anastomosis of the pancreas to the bile duct to the jejunum.", + "There were no surgical complications in his post-operative course.", + "He could take the same oral antiparkinsonian agents as before the operation after 5 days.", + "His Parkinsonian features were gradually remarkable within 2 weeks after the operation.", + "The patient did not receive any agents as chemotherapy.", + "He was transferred to our ward for parkinsonian drug treatment.", + "His height was 158.0 cm.", + "His body weight was 61.0 kg.", + "His body mass index was 24.4.", + "His neurological examination revealed marked masked face, dysarthria, and dysphagia.", + "Mild tremor at rest in the left upper extremity was observed.", + "Severe rigidity in the bilateral upper and lower extremity was observed.", + "Poor finger taps on the dominant left side were observed.", + "Gait was unable without assistance.", + "His parkinsonian features were obviously getting worse.", + "His UPDRS motor score (part III) was 68/108.", + "We checked whether this worsening of parkinsonian features was due to a change in LD absorption in the gastrointestinal tract.", + "Written informed consent was obtained from this patient.", + "The approval of the Institutional Review Board was obtained for the examination of LD pharmacokinetics.", + "To assess LD pharmacokinetics, he took a tablet containing 100 mg of LD and 10 mg of carbidopa at 9:00 a.m.", + "Blood specimens were collected through an intravenous catheter at 0, 15, 30, 60, 120, and 180 min after LD administration.", + "Plasma LD concentrations were measured by high-performance liquid chromatography with electrochemical detection.", + "Peak drug concentration (Cmax), the time-to-peak drug concentration (Tmax), elimination halftime (T1/2), and area under the curve (AUC) were determined.", + "Cmax and Tmax were observed values.", + "T1/2 was determined by linear regression analysis.", + "AUC was estimated from the area under the time concentration line up to 3 h.", + "In his LD pharmacokinetics at the ages of 68 years 11 months and 68 years 1 month, body weight was 64.2 and 64.8 kg.", + "In his LD pharmacokinetics at the ages of 68 years 11 months and 68 years 1 month, AUC was 1,782.5 and 1,825.0 mg·h/ml.", + "In his LD pharmacokinetics at the ages of 68 years 11 months and 68 years 1 month, Cmax was 1,500 and 1,500 mg/ml.", + "In his LD pharmacokinetics at the ages of 68 years 11 months and 68 years 1 month, Tmax was 30 and 30 min.", + "In his LD pharmacokinetics at the ages of 68 years 11 months and 68 years 1 month, T1/2 was 48 and 47 min.", + "In the postoperative assessment (at the age of 72 years 4 months), AUC was 1,148.8 mg·h/ml.", + "In the postoperative assessment (at the age of 72 years 4 months), Cmax was 450 mg/ml.", + "In the postoperative assessment (at the age of 72 years 4 months), Tmax was 60 min.", + "In the postoperative assessment (at the age of 72 years 4 months), T1/2 was >120 min." + ], + "summary": "A 72-year-old Japanese male PD patient developed jaundice and was diagnosed with cholangiocarcinoma. Pancreaticoduodenectomy was performed and part of the stomach, total duodenum, and part of the jejunum were resected. The patient had been treated with LD, and his pharmacokinetics was checked twice at the age of 68 years. Because LD is absorbed in the duodenum and jejunum, we checked his pharmacokinetics again after the operation. The results before the operation were almost similar; however, in comparison, the area under the curve and peak drug concentration was reduced, and the time-to-peak drug concentration and elimination halftime were elongated after the operation.", + "summary_subclaims": [ + "The patient was a 72-year-old Japanese male.", + "The patient had Parkinson's disease.", + "The patient developed jaundice.", + "The patient was diagnosed with cholangiocarcinoma.", + "Pancreaticoduodenectomy was performed.", + "Part of the stomach was resected.", + "Total duodenum was resected.", + "Part of the jejunum was resected.", + "The patient had been treated with levodopa.", + "Pharmacokinetics was checked twice at the age of 68 years.", + "Levodopa is absorbed in the duodenum and jejunum.", + "Pharmacokinetics was checked again after the operation.", + "The results before the operation were almost similar.", + "The area under the curve was reduced after the operation.", + "The peak drug concentration was reduced after the operation.", + "The time-to-peak drug concentration was elongated after the operation.", + "The elimination halftime was elongated after the operation." + ] + }, + { + "id": "multiclinsum_test_1684_en.txt", + "fulltext": "A 35-year-old female was referred to our department in October 2021 because of thyroid dysfunction for 2 months. Her past and family histories were unremarkable. In the local hospital, thyroid function tests demonstrated high levels of free tri-iodothyronine (FT3) 10.18 pmol/L (3.1–6.89 pmol/L), free thyroxine (FT4) 25.8 pmol/L (11–22 pmol/L), and thyroid-stimulating hormone (TSH) 8.6 mU/L (0.27–4.2 mIU/L). Thyroid ultrasound revealed a solid, slightly hyperechoic nodule in the left lobe of the thyroid (9.6 × 7.8 × 10.1 mm). Based on this funding, the patient was diagnosed with Graves’ disease and given methimazole (MMI, 5 mg bid). After 20 days, her thyroid function test was rechecked: FT3 was 7.97 pmol/L, FT4 was 19.8 pmol/L, and TSH was 10.49 mU/L. A local hospital suspected the patient had TSHoma. Further inquiries did not find a family history of thyroid dysfunction.\nOn examination at our hospital, her body mass index (BMI) was 22.8 kg/m2, her blood pressure and heart rate were 116/79 mmHg and 105 bpm, respectively, and her body temperature was 37 °C. Physical examination showed a degree 2 enlarged thyroid gland with no oculopathy or symptoms of acromegaly (Supplementary Figure ).\nEndocrine function tests showed an elevated TSH level of 12.26 mU/L with high levels of FT3 8.99 pmol/L and FT4 19.78 pmol/L. Sex hormone-binding globulin (SHBG) was 93.3 nmol/L (34.3–147 nmol/L). Thyroglobulin antibody (TGAb) was 271.70 IU/mL (0–115 IU/mL), thyroid peroxidase antibody (TPOAb) was 455.91 IU/mL (0–5.61 IU/mL), and thyroid receptor antibody (TRAb) was negative . The α-subunit was not measured. After polyethylene glycol (PEG) precipitation, the TSH level was 9.1 to 3.48 mU/L, GH was 4.82 μg/L (0–8 μg/L), and IGF-1 insulin-like growth factor-1 (IGF-1) was 661.00 ng/mL (115–307 ng/mL, Table ). An oral glucose tolerance test (OGTT) showed that the GH level decreased from 4.82 to 2.65 μg/L (Supplementary Figure ). During a 24-h octreotide suppression test (0.1 mg subcutaneously every 4 hours during the first 12 h), TSH declined from 8.09 to 1.518 mIU/l, GH decreased from 4.31 to 0.24 mIU/l, and the suppression ratios of TSH and GH were 81.2 and 94.4%, respectively . Other endocrine hormone levels were within the normal range: adrenocorticotropic hormone (ACTH) was 35.86 ng/mL (7.2–63.3 ng/L), cortisol was 304.2 nmol/L (66–579.4 nmol/L), PRL was 19.03 ng/mL, luteinizing hormone (LH) was 50.83 mIU/mL (follicular phase 239–66 mIU/mL; mid-cycle 9.06–72.24 mIU/mL; luteal phase 0.90–9.33 mIU/mL; postmenopausal 10.39–64.57 mIU/mL), follicular stimulating hormone (FSH) was 15.15 mIU/mL (follicular phase 3.03–8.08 mIU/mL; mid-cycle 2.55–16.69 mIU/mL; luteal phase 1.38–5.47 mIU/mL; postmenopausal 26.72–133.41 mIU/ml), estradiol was 238.00 pg/mL (follicular phase 21–251 pg/mL; mid-cycle 38–649 pg/mL; luteal phase 21–312 pg/mL; postmenopausal < 10–144 pg/mL), Testo (testosterone) was 1.29 nmol/L (0.38–1.97 nmol/L), and dehydroepiandrosterone (DHEA) was 121.3 μg/dL (139.7–484.4 μg/dL). Renal and liver function was within the normal range. Due to a drug deficiency in our center, the T3 test and thyrotropin-releasing hormone (TRH) stimulation were not applicable. Mutations in the TSH receptor and thyroxine receptor-β (THR-β) genes were not found.\nHer initial brain magnetic resonance imaging (MRI) revealed a quasi-circular equal signal shadow in the sellar region and a pituitary macroadenoma (18 × 16 × 16 mm) adjacent to the siphon of the left internal carotid artery . The T2-weighted signal intensity was isointense. In addition, the Knosp and Hardy classifications of the pituitary tumor were grade 1 and 2, respectively. Additionally, the cavernous sinus invasion score (CSIS) was grade 1, the sphenoid sinus invasion score (SSIS) was grade 0, the suprasellar extension score (SSES) was grade 1, and the cumulative score was grade 2 . The visual field revealed a visual field defect in the left eye. In thyroid echography, enlarged thyroid and hyperechoic nodules in the left lobe of the thyroid (11 × 8.3 × 11 mm, TI-RADS class 3) were observed. An ultrasound-guided fine-needle biopsy of the thyroid nodules showed benign lesions.\nBased on these findings, this patient was finally diagnosed with TSH PitNET and acromegaly. After our multidisciplinary united team consultation, the patient was preoperatively treated with octreotide (OCT, 0.1 mg, s.c., tid). TSH, FT3, and FT4 levels decreased to the normal range in 5 days. Then, the pituitary mass was endoscopically removed via an endoscopic transsphenoidal resection. Surgical pathology confirmed a macroadenoma.\nHistologically, the tumor was composed of plurimorphic cells with a distinct cell border, abundant granulated cytoplasm, and round or oval nuclei. On light microscopy, histopathology revealed the plurihormonal adenoma with strong nuclear immunoreactivity with Pit-1 antibody . Immunohistochemistry revealed strong immunoreactivity for GH and diffuse positivity for TSH and PRL . The tumor had negative staining for ACTH, FSH, LH, and ER. In p53 staining, scattered p53-positive cells were observed . The Ki-67 index was < 1% . In GH and TSH immunohistochemical double staining, many GH cells and a minority of TSH cells were observed (Supplementary Figure B). Immunofluorescence double staining for GH and TSH positivity was found in different cell populations (Supplementary Figure A). In GH and PRL immunohistochemical and immunofluorescence double staining, GH was the most diffusely positive hormone, and PRL reactivity was scattered (Supplementary Figure C, D). Electron microscopy revealed that the tumor consisted of plurimorphous cells . Some adenoma cells (black arrow) were densely granulated. Secretory granules were spherical or ovoid and measured 300–450 nm. Many adenoma cells contained elongated or geometrically shaped secretory granules, suggesting crystallization within their substance, a phenomenon seen in densely granulated somatotropic adenomas. The thyrotropin cells (red arrow) had a predominantly spherical or ovoid nucleus, scattered lysosomes and mitochondria, prominent Golgi apparatus, and numerous secretory granules measuring 100 to 200 nm. The cell membrane was peripherally clustered with numerous small secretory granules that outlined the cell boundary.\nAfter surgery, TSH decreased slightly below the normal range (0.299 mIU/l), and FT3 and FT4 levels were normal at 2.75 pmol/L and 9.9 pmol/L, respectively. GH and IGF-1 levels were 0.16 μg/mL and 274 ng/mL 1 week after the surgery . Except for high TGAb and TPOAb levels, TSH, FT3, FT4, GH, and IGF-1 levels decreased to the normal range 1 month after surgery. The OGTT test successfully suppressed GH below 0.4 μg/mL (basal GH, 7.62 μg/mL; maximal suppression, 0.4 μg/mL, Supplementary Figure ). However, although no clinical symptoms of hyperthyroidism were observed in this patient, FT3 and FT4 levels increased, and TSH levels were slightly below the normal range 3 months after surgery . Considering previously consistently elevated TGAb, TPOAb, and TRAb levels and an enlarged thyroid nodule, the patient was suspected of having Hashimoto’s thyroiditis. Interestingly, her thyroid function normalized over 10 days without medical treatment . Four months after the surgery, her thyroid function showed increased TSH, TRAb, TPOAb, and TGAb levels and decreased FT4 levels. Hashimoto’s thyroiditis further destroyed the thyroid cells and led to hypothyroidism in this patient. Indeed, central hypothyroidism was also possible. Six months after the surgery, the patient was given levothyroxine sodium tablets (L-T4, 37.5 μg/day), and her FT4, TSH, and TRAb returned to the normal range . The MRI revealed no particular abnormalities after the surgery. The patient achieved basal clinical and biochemical remission during follow-up.", + "fulltext_subclaims": [ + "A 35-year-old female was referred to our department in October 2021 because of thyroid dysfunction for 2 months.", + "Her past and family histories were unremarkable.", + "In the local hospital, thyroid function tests demonstrated high levels of free tri-iodothyronine (FT3) 10.18 pmol/L (3.1–6.89 pmol/L).", + "In the local hospital, thyroid function tests demonstrated high levels of free thyroxine (FT4) 25.8 pmol/L (11–22 pmol/L).", + "In the local hospital, thyroid function tests demonstrated high levels of thyroid-stimulating hormone (TSH) 8.6 mU/L (0.27–4.2 mIU/L).", + "Thyroid ultrasound revealed a solid, slightly hyperechoic nodule in the left lobe of the thyroid (9.6 × 7.8 × 10.1 mm).", + "Based on this finding, the patient was diagnosed with Graves’ disease.", + "The patient was given methimazole (MMI, 5 mg bid).", + "After 20 days, her thyroid function test was rechecked: FT3 was 7.97 pmol/L.", + "After 20 days, her thyroid function test was rechecked: FT4 was 19.8 pmol/L.", + "After 20 days, her thyroid function test was rechecked: TSH was 10.49 mU/L.", + "A local hospital suspected the patient had TSHoma.", + "Further inquiries did not find a family history of thyroid dysfunction.", + "On examination at our hospital, her body mass index (BMI) was 22.8 kg/m2.", + "On examination at our hospital, her blood pressure was 116/79 mmHg.", + "On examination at our hospital, her heart rate was 105 bpm.", + "On examination at our hospital, her body temperature was 37 °C.", + "Physical examination showed a degree 2 enlarged thyroid gland.", + "Physical examination showed no oculopathy.", + "Physical examination showed no symptoms of acromegaly.", + "Endocrine function tests showed an elevated TSH level of 12.26 mU/L.", + "Endocrine function tests showed high levels of FT3 8.99 pmol/L.", + "Endocrine function tests showed high levels of FT4 19.78 pmol/L.", + "Sex hormone-binding globulin (SHBG) was 93.3 nmol/L (34.3–147 nmol/L).", + "Thyroglobulin antibody (TGAb) was 271.70 IU/mL (0–115 IU/mL).", + "Thyroid peroxidase antibody (TPOAb) was 455.91 IU/mL (0–5.61 IU/mL).", + "Thyroid receptor antibody (TRAb) was negative.", + "After polyethylene glycol (PEG) precipitation, the TSH level was 9.1 to 3.48 mU/L.", + "After polyethylene glycol (PEG) precipitation, GH was 4.82 μg/L (0–8 μg/L).", + "After polyethylene glycol (PEG) precipitation, IGF-1 was 661.00 ng/mL (115–307 ng/mL).", + "An oral glucose tolerance test (OGTT) showed that the GH level decreased from 4.82 to 2.65 μg/L.", + "During a 24-h octreotide suppression test, TSH declined from 8.09 to 1.518 mIU/l.", + "During a 24-h octreotide suppression test, GH decreased from 4.31 to 0.24 mIU/l.", + "The suppression ratios of TSH and GH were 81.2 and 94.4%, respectively.", + "Adrenocorticotropic hormone (ACTH) was 35.86 ng/mL (7.2–63.3 ng/L).", + "Cortisol was 304.2 nmol/L (66–579.4 nmol/L).", + "PRL was 19.03 ng/mL.", + "Luteinizing hormone (LH) was 50.83 mIU/mL.", + "Follicular stimulating hormone (FSH) was 15.15 mIU/mL.", + "Estradiol was 238.00 pg/mL.", + "Testosterone was 1.29 nmol/L (0.38–1.97 nmol/L).", + "Dehydroepiandrosterone (DHEA) was 121.3 μg/dL (139.7–484.4 μg/dL).", + "Renal and liver function was within the normal range.", + "Due to a drug deficiency in our center, the T3 test and thyrotropin-releasing hormone (TRH) stimulation were not applicable.", + "Mutations in the TSH receptor and thyroxine receptor-β (THR-β) genes were not found.", + "Her initial brain magnetic resonance imaging (MRI) revealed a quasi-circular equal signal shadow in the sellar region.", + "Her initial brain magnetic resonance imaging (MRI) revealed a pituitary macroadenoma (18 × 16 × 16 mm) adjacent to the siphon of the left internal carotid artery.", + "The T2-weighted signal intensity was isointense.", + "The Knosp and Hardy classifications of the pituitary tumor were grade 1 and 2, respectively.", + "The cavernous sinus invasion score (CSIS) was grade 1.", + "The sphenoid sinus invasion score (SSIS) was grade 0.", + "The suprasellar extension score (SSES) was grade 1.", + "The cumulative score was grade 2.", + "The visual field revealed a visual field defect in the left eye.", + "In thyroid echography, enlarged thyroid and hyperechoic nodules in the left lobe of the thyroid (11 × 8.3 × 11 mm, TI-RADS class 3) were observed.", + "An ultrasound-guided fine-needle biopsy of the thyroid nodules showed benign lesions.", + "Based on these findings, this patient was finally diagnosed with TSH PitNET and acromegaly.", + "After our multidisciplinary united team consultation, the patient was preoperatively treated with octreotide (OCT, 0.1 mg, s.c., tid).", + "TSH, FT3, and FT4 levels decreased to the normal range in 5 days.", + "The pituitary mass was endoscopically removed via an endoscopic transsphenoidal resection.", + "Surgical pathology confirmed a macroadenoma.", + "The tumor was composed of plurimorphic cells with a distinct cell border, abundant granulated cytoplasm, and round or oval nuclei.", + "Histopathology revealed the plurihormonal adenoma with strong nuclear immunoreactivity with Pit-1 antibody.", + "Immunohistochemistry revealed strong immunoreactivity for GH.", + "Immunohistochemistry revealed diffuse positivity for TSH.", + "Immunohistochemistry revealed diffuse positivity for PRL.", + "The tumor had negative staining for ACTH.", + "The tumor had negative staining for FSH.", + "The tumor had negative staining for LH.", + "The tumor had negative staining for ER.", + "In p53 staining, scattered p53-positive cells were observed.", + "The Ki-67 index was < 1%.", + "In GH and TSH immunohistochemical double staining, many GH cells and a minority of TSH cells were observed.", + "Immunofluorescence double staining for GH and TSH positivity was found in different cell populations.", + "In GH and PRL immunohistochemical and immunofluorescence double staining, GH was the most diffusely positive hormone.", + "In GH and PRL immunohistochemical and immunofluorescence double staining, PRL reactivity was scattered.", + "Electron microscopy revealed that the tumor consisted of plurimorphous cells.", + "Some adenoma cells were densely granulated.", + "Secretory granules were spherical or ovoid and measured 300–450 nm.", + "Many adenoma cells contained elongated or geometrically shaped secretory granules.", + "The thyrotropin cells had a predominantly spherical or ovoid nucleus.", + "The thyrotropin cells had scattered lysosomes and mitochondria.", + "The thyrotropin cells had a prominent Golgi apparatus.", + "The thyrotropin cells had numerous secretory granules measuring 100 to 200 nm.", + "The cell membrane was peripherally clustered with numerous small secretory granules that outlined the cell boundary.", + "After surgery, TSH decreased slightly below the normal range (0.299 mIU/l).", + "After surgery, FT3 levels were normal at 2.75 pmol/L.", + "After surgery, FT4 levels were normal at 9.9 pmol/L.", + "GH and IGF-1 levels were 0.16 μg/mL and 274 ng/mL 1 week after the surgery.", + "Except for high TGAb and TPOAb levels, TSH, FT3, FT4, GH, and IGF-1 levels decreased to the normal range 1 month after surgery.", + "The OGTT test successfully suppressed GH below 0.4 μg/mL.", + "Although no clinical symptoms of hyperthyroidism were observed in this patient, FT3 and FT4 levels increased, and TSH levels were slightly below the normal range 3 months after surgery.", + "Considering previously consistently elevated TGAb, TPOAb, and TRAb levels and an enlarged thyroid nodule, the patient was suspected of having Hashimoto’s thyroiditis.", + "Her thyroid function normalized over 10 days without medical treatment.", + "Four months after the surgery, her thyroid function showed increased TSH, TRAb, TPOAb, and TGAb levels and decreased FT4 levels.", + "Hashimoto’s thyroiditis further destroyed the thyroid cells and led to hypothyroidism in this patient.", + "Central hypothyroidism was also possible.", + "Six months after the surgery, the patient was given levothyroxine sodium tablets (L-T4, 37.5 μg/day).", + "Her FT4, TSH, and TRAb returned to the normal range.", + "The MRI revealed no particular abnormalities after the surgery.", + "The patient achieved basal clinical and biochemical remission during follow-up." + ], + "summary": "In this report, a 33-year-old female diagnosed with a TSH PitNET co-secreting GH presented no obvious clinical symptoms. The main characteristics were elevated thyroid-stimulating hormone (TSH), free tri-iodothyronine (FT3), and free thyroxine (FT4) levels accompanied by slightly elevated GH and insulin-like growth factor-1 (IGF-1) levels. Magnetic resonance imaging (MRI) detected a pituitary macroadenoma (18 × 16 × 16 mm) with cavernous sinus and suprasellar invasion. Immunohistochemistry revealed diffuse positivity for TSH, strong immunoreactivity for GH, and sporadic positivity for PRL. The electron microscope and double immunofluorescence staining confirmed a plurimorphous plurihormonal adenoma producing TSH, GH, and PRL. After preoperative somatostatin receptor ligand (SRL) treatment and transsphenoidal surgery, the patient achieved temporary clinical and biochemical remission. However, 3 months after surgery, the patient was suspected of having Hashimoto's thyroiditis due to higher thyroglobulin antibody (TGAb), thyroid peroxidase antibody (TPOAb), and thyroid receptor antibody (TRAb) and an enlarged thyroid nodule. During follow-up, thyroid function and TSH slowly transformed from transient hyperthyroidism to hypothyroidism. They were maintained in the normal range by L-T4.", + "summary_subclaims": [ + "The patient was a 33-year-old female.", + "The patient was diagnosed with a TSH PitNET co-secreting GH.", + "The patient presented no obvious clinical symptoms.", + "The main characteristics were elevated thyroid-stimulating hormone (TSH), free tri-iodothyronine (FT3), and free thyroxine (FT4) levels.", + "The main characteristics were accompanied by slightly elevated GH and insulin-like growth factor-1 (IGF-1) levels.", + "Magnetic resonance imaging (MRI) detected a pituitary macroadenoma (18 × 16 × 16 mm).", + "The pituitary macroadenoma had cavernous sinus invasion.", + "The pituitary macroadenoma had suprasellar invasion.", + "Immunohistochemistry revealed diffuse positivity for TSH.", + "Immunohistochemistry revealed strong immunoreactivity for GH.", + "Immunohistochemistry revealed sporadic positivity for PRL.", + "The electron microscope and double immunofluorescence staining confirmed a plurimorphous plurihormonal adenoma producing TSH, GH, and PRL.", + "The patient received preoperative somatostatin receptor ligand (SRL) treatment.", + "The patient underwent transsphenoidal surgery.", + "The patient achieved temporary clinical and biochemical remission.", + "Three months after surgery, the patient was suspected of having Hashimoto's thyroiditis.", + "Three months after surgery, thyroglobulin antibody (TGAb) was higher.", + "Three months after surgery, thyroid peroxidase antibody (TPOAb) was higher.", + "Three months after surgery, thyroid receptor antibody (TRAb) was higher.", + "Three months after surgery, an enlarged thyroid nodule was present.", + "During follow-up, thyroid function and TSH slowly transformed from transient hyperthyroidism to hypothyroidism.", + "During follow-up, thyroid function and TSH were maintained in the normal range by L-T4." + ] + }, + { + "id": "multiclinsum_test_1051_en.txt", + "fulltext": "A 25 year old Sinhalese Sri Lankan female presented with a 1 day history of bilateral lower limb weakness, and numbness with urinary incontinence. She had no back pain and no history of constitutional symptoms such as fever, loss of appetite, or recent subjective weight loss.\nOn examination she had atonic lower limbs, with absent muscle power, and absent bilateral lower limb reflexes below knee level, with sensory impairment up to T6 level. She had no spinal deformities or tenderness, and no papilloedema. Upper limb examination was unremarkable except for a hard non tender bony mass on the left scapular region. She had a blood pressure of 140/80 mmHg, pulse rate of 78 beats per minute and had no respiratory compromise.\nShe was investigated with a suspicion of metastatic disease and X-ray of the left shoulder showed a soft tissue and bony mass on the dorsal aspect of the left scapula with multiple lytic lesions suggestive of a primary bone neoplasm , but chest radiograph, ultrasound scan of the neck, and Computed tomography (CT) of abdomen were normal. Magnetic resonance imaging (MRI) of the spine showed an intradural extramedullary mass with an extra spinal component at C7-T2 level causing severe cord compression , hence intravenous dexamethasone regimen was started.\nUltrasound guided core needle biopsy from the left scapular mass showed malignant small round blue cell tumour suggestive of Ewing sarcoma. Blood investigations showed Heamoglobin of 9.2 g/dl, white blood cell count of 12 × 103/μl, Erythrocyte sedimentation rate (ESR)of 150 mm/h, C-reactive protein level of 96 mg/l, normal liver enzyme levels and liver functions tests, and serum alkaline phosphate level of 173 μ/l. Her blood picture showed increased rouleaux formation with anaemia of chronic disease.\nShe had no improvement of symptoms following treatment with dexamethasone. Before implementing on oncological management, 3 days after onset of symptoms, she developed sudden onset progressive ascending neurological impairment with upper limb and bulbar involvement, and unfortunately resulted with respiratory failure and death.", + "fulltext_subclaims": [ + "A 25 year old Sinhalese Sri Lankan female presented with a 1 day history of bilateral lower limb weakness.", + "She had numbness with urinary incontinence.", + "She had no back pain.", + "She had no history of constitutional symptoms such as fever.", + "She had no recent subjective weight loss.", + "On examination she had atonic lower limbs.", + "She had absent bilateral lower limb reflexes below knee level.", + "Sensory impairment was up to T6 level.", + "She had a hard non tender bony mass on the left scapular region.", + "X-ray of the left shoulder showed a soft tissue and bony mass on the dorsal aspect of the left scapula.", + "MRI of the spine showed an intradural extramedullary mass with an extra spinal component at C7-T2 level.", + "Intravenous dexamethasone regimen was started.", + "Ultrasound guided core needle biopsy from the left scapular mass showed malignant small round blue cell tumour.", + "Blood investigations showed Heamoglobin of 9.2 g/dl.", + "She had increased rouleaux formation with anaemia of chronic disease.", + "She had no improvement of symptoms following treatment with dexamethasone.", + "Before implementing oncological management, 3 days after onset of symptoms, she developed sudden onset progressive ascending neurological impairment.", + "She developed upper limb and bulbar involvement.", + "She developed respiratory failure.", + "She died." + ], + "summary": "We report a case of a 25 year old Sinhalese Sri Lankan female, presenting with a 1 day history of bilateral lower limb weakness and urinary incontinence. She had a sensory level with flaccid paralysis of lower limbs and a painless bony lump in the left dorsal scapula. Investigations showed scapular primary Ewing sarcoma giving rise to spinal intradural metastasis. For the best of our knowledge this is the first reported case of a scapular Ewing sarcoma with spinal intradural metastasis presenting with lower limb paralysis.", + "summary_subclaims": [ + "The patient is a 25 year old Sinhalese Sri Lankan female.", + "She presented with a 1 day history of bilateral lower limb weakness.", + "She had urinary incontinence.", + "She had a sensory level with flaccid paralysis of lower limbs.", + "She had a painless bony lump in the left dorsal scapula.", + "Investigations showed scapular primary Ewing sarcoma giving rise to spinal intradural metastasis.", + "For the best of our knowledge this is the first reported case of a scapular Ewing sarcoma with spinal intradural metastasis.", + "The case presented with lower limb paralysis." + ] + }, + { + "id": "multiclinsum_test_3371_en.txt", + "fulltext": "An 85-year-old menopausal woman was referred to our hospital for diagnostic evaluation of worsening dyspnea over 6 weeks. The patient had a history of chronic atrial fibrillation, hypertension, and chronic kidney disease (CKD) of uncertain etiology. She had a uterine fibroid diagnosed at 64 years of age. Pre-admission medication included amlodipine (10 mg/day), valsartan (40 mg/day), verapamil (120 mg/day), digoxin (0.125 mg/day), and rivaroxaban (10 mg/day).\n\nHer vital signs were as follows: blood pressure 146/97 mmHg, heart rate 90 beats/min and irregular, and respiratory rate 21 breaths/min. Physical examination revealed a third heart sound, diminished breath sounds from the right lower lungs, and notable bilateral leg edema, but no remarkable jugular vein distention (JVD) was observed. A hard mass was palpable in the lower abdomen. The electrocardiogram revealed atrial fibrillation. Chest radiography revealed cardiomegaly and right-sided PE. Laboratory testing revealed elevated levels of serum creatinine (1.36 mg/dL, reference, 0.65–1.07 mg/dL) and brain natriuretic peptide (BNP) (183 pg/mL, reference: < 18.4 pg/mL). Hepatic and thyroid function, C-reactive protein levels, and urinalysis were within normal ranges.\n\nEchocardiography demonstrated normal left ventricular (LV) cavity size and systolic function, with an ejection fraction of 54% and left atrial dilation (35 mL/m2). Doppler and tissue Doppler profiles for the assessment of LV diastolic function revealed a decreased septal e′ of 5.8 cm/sec and an elevated E/e′ of 17, indicating elevated LV filling pressure. In addition, continuous wave Doppler revealed a peak tricuspid regurgitation velocity of 2.6 m/s, consistent with a pressure gradient of 27 mmHg and an estimated right ventricular systolic pressure of approximately 35 mmHg. Echocardiographic evaluation of the right heart revealed almost normal systolic function; tissue Doppler of the free lateral wall (S′) = 9 cm/s (reference: ≥ 10 cm/s), tricuspid annular plane systolic excursion = 18 mm (reference: 16 ≥ mm), and fractional area change = 53% (reference: ≥ 35%), respectively.\n\nThus, a tentative diagnosis of heart failure with preserved ejection fraction (HFpEF) was made. The patient was administered oxygen at 3 L/min and treated with intravenous loop diuretics (furosemide 40 mg daily). On day 6, although diuretic treatment improved leg edema, PE remained unchanged.\n\nA subsequent diagnostic workup of unexplained PE was performed. The patient underwent thoracentesis with drainage of 1240 mL of serosanguineous PE. PE analysis revealed lymphocyte-predominant exudates fulfilling Light’s criteria. Additionally, the serum-to-effusion albumin gradient was 0.3 g/dL (reference: ≤ 1.2 g/dL), further confirming the true exudative effusion. The adenosine deaminase activity in PE was 9.3 U/L. PE cytology, as well as the bacterial and mycobacterial cultures, were unremarkable.\n\nChest computed tomography revealed an absence of lung tumors or inflammatory infiltration after the removal of PE. Abdominal/pelvic computed tomography scan revealed bilateral inhomogeneous ovarian masses. Magnetic resonance imaging further characterized the right substantial mass and detected a trivial ascites. Axial and sagittal T2-weighted images demonstrated the peripheral hypointense mass, which contained hyperintense and multilocular areas in the central portion, mimicking a malignant ovarian tumor with a central necrosis or a degenerated subserosal fibroid. Gadolinium-enhanced axial imaging showed inhomogeneous enhancement correspondently on the peripheral solid portion, suggesting malignancy. In addition, screening tests for tumor markers revealed elevated CA-125 levels (382 U/mL, reference: < 35 U/mL). Repeated serial thoracentesis was ineffective, and PE reaccumulated within a week. Thus, we highly suspected of ovarian cancer with pleural dissemination. Nevertheless, a repeated cytological examination of PE revealed no evidence of malignancy, which led us to consider the possibility of MS.\n\nOn day 26, the patient underwent bilateral salpingo-oophorectomy. The resected masses exhibited yellow-to-tan fleshy cut surfaces, with hemorrhage and extensive hyaline degeneration. Histopathological examination revealed a mitotically active cellular fibroma (MACF) of the ovary. Spontaneous resolution of the right-sided PE was noted post-operatively after 7 days of follow-up, confirming a definitive diagnosis of MS. A follow-up echocardiography revealed no significant changes. The post-operative course was uneventful, and the patient made a full recovery and was discharged with no changes to her pre-admission medication regimen on day 33. She remained clinically stable upon subsequent follow-up.", + "fulltext_subclaims": [ + "An 85-year-old menopausal woman was referred for diagnostic evaluation of worsening dyspnea over 6 weeks.", + "The patient had a history of chronic atrial fibrillation.", + "The patient had a history of hypertension.", + "The patient had a history of chronic kidney disease of uncertain etiology.", + "She had a uterine fibroid diagnosed at 64 years of age.", + "Pre-admission medication included amlodipine (10 mg/day).", + "Pre-admission medication included valsartan (40 mg/day).", + "Pre-admission medication included verapamil (120 mg/day).", + "Pre-admission medication included digoxin (0.125 mg/day).", + "Pre-admission medication included rivaroxaban (10 mg/day).", + "Blood pressure was 146/97 mmHg.", + "Heart rate was 90 beats/min and irregular.", + "Respiratory rate was 21 breaths/min.", + "Physical examination revealed a third heart sound.", + "Physical examination revealed diminished breath sounds from the right lower lungs.", + "Physical examination revealed notable bilateral leg edema.", + "No remarkable jugular vein distention was observed.", + "A hard mass was palpable in the lower abdomen.", + "The electrocardiogram revealed atrial fibrillation.", + "Chest radiography revealed cardiomegaly.", + "Chest radiography revealed right-sided pleural effusion.", + "Serum creatinine was 1.36 mg/dL.", + "Brain natriuretic peptide was 183 pg/mL.", + "Echocardiography demonstrated normal left ventricular cavity size.", + "Echocardiography demonstrated normal systolic function.", + "Echocardiography demonstrated an ejection fraction of 54%.", + "Echocardiography demonstrated left atrial dilation of 35 mL/m2.", + "Doppler and tissue Doppler profiles revealed a decreased septal e′ of 5.8 cm/sec.", + "Doppler and tissue Doppler profiles revealed an elevated E/e′ of 17.", + "Continuous wave Doppler revealed a peak tricuspid regurgitation velocity of 2.6 m/s.", + "The estimated right ventricular systolic pressure was approximately 35 mmHg.", + "Echocardiographic evaluation of the right heart revealed almost normal systolic function.", + "A tentative diagnosis of heart failure with preserved ejection fraction was made.", + "The patient was administered oxygen at 3 L/min.", + "The patient was treated with intravenous loop diuretics (furosemide 40 mg daily).", + "On day 6, diuretic treatment improved leg edema.", + "On day 6, pleural effusion remained unchanged.", + "Thoracentesis drained 1240 mL of serosanguineous pleural effusion.", + "Pleural effusion analysis revealed lymphocyte-predominant exudates fulfilling Light’s criteria.", + "The serum-to-effusion albumin gradient was 0.3 g/dL.", + "Adenosine deaminase activity in pleural effusion was 9.3 U/L.", + "Pleural effusion cytology was unremarkable.", + "Bacterial cultures of pleural effusion were unremarkable.", + "Mycobacterial cultures of pleural effusion were unremarkable.", + "Chest computed tomography revealed an absence of lung tumors.", + "Chest computed tomography revealed an absence of inflammatory infiltration.", + "Abdominal/pelvic computed tomography revealed bilateral inhomogeneous ovarian masses.", + "Magnetic resonance imaging detected a trivial ascites.", + "Axial and sagittal T2-weighted images demonstrated a peripheral hypointense mass.", + "Gadolinium-enhanced axial imaging showed inhomogeneous enhancement.", + "Screening tests revealed elevated CA-125 levels (382 U/mL).", + "Repeated serial thoracentesis was ineffective.", + "Pleural effusion reaccumulated within a week.", + "We highly suspected ovarian cancer with pleural dissemination.", + "A repeated cytological examination of pleural effusion revealed no evidence of malignancy.", + "The patient underwent bilateral salpingo-oophorectomy on day 26.", + "Histopathological examination revealed a mitotically active cellular fibroma of the ovary.", + "Spontaneous resolution of the right-sided pleural effusion was noted post-operatively.", + "Spontaneous resolution occurred after 7 days of follow-up.", + "A definitive diagnosis of Meigs syndrome was confirmed.", + "A follow-up echocardiography revealed no significant changes.", + "The patient was discharged on day 33.", + "The patient remained clinically stable upon subsequent follow-up." + ], + "summary": "We described a case of an 85-year-old postmenopausal female patient with atypical Meigs’ syndrome presenting with right-sided pleural effusion, notable leg edema, and trivial ascites, which was initially mistaken as heart failure with preserved ejection fraction. However, pleural effusion was totally ineffective against diuretic therapy. Subsequently, thoracentesis yielded serosanguineous exudative effusion. Moreover, refractory pleural effusions and abdominal/pelvic computed tomography and magnetic resonance imaging findings strongly suggested bilateral malignant ovarian tumors with pleural dissemination. Repetitive negative cytological results allowed the patient to undergo bilateral salpingo-oophorectomy. Finally, a definitive diagnosis of Meigs’ syndrome was made by confirming the presence of a benign mitotically active cellular fibroma of the ovary by pathology and that pleural effusion resolved following tumor resection.", + "summary_subclaims": [ + "The patient was an 85-year-old postmenopausal female.", + "The patient had atypical Meigs’ syndrome.", + "The patient presented with right-sided pleural effusion.", + "The patient had notable leg edema.", + "The patient had trivial ascites.", + "The initial diagnosis was heart failure with preserved ejection fraction.", + "Pleural effusion was totally ineffective against diuretic therapy.", + "Thoracentesis yielded serosanguineous exudative effusion.", + "Refractory pleural effusions and imaging findings suggested bilateral malignant ovarian tumors with pleural dissemination.", + "Repetitive negative cytological results allowed the patient to undergo bilateral salpingo-oophorectomy.", + "A definitive diagnosis of Meigs’ syndrome was made.", + "Pathology confirmed the presence of a benign mitotically active cellular fibroma of the ovary.", + "Pleural effusion resolved following tumor resection." + ] + }, + { + "id": "multiclinsum_test_1634_en.txt", + "fulltext": "A 67-year-old female with a 4-day history of a fever and cough was admitted to a local hospital for pneumonia. The diagnosis of COVID-19 was confirmed by a positive polymerase chain reaction (PCR) test result via a nasopharyngeal swab. Her respiratory condition gradually worsened after admission. Thus, she underwent intubation and was transferred to our hospital in need of intensive care 5 days after admission.\nHer height and weight were 164.9 cm and 46 kg, respectively. She had comorbidities of diabetes mellitus, diabetic nephropathy requiring dialysis, angina, post-resection gastric cancer and postoperative spinal canal stenosis. She was taking several regular medications including an antiplatelet agent. On arrival, a physical examination revealed a body temperature (BT) of 34 °C, blood pressure (BP) of 110/65 mmHg, heart rate (HR) of 102 beats/min, and Glasgow Coma Scale of E1VtM1 with deep sedation. The arterial blood gas analysis showed pH 7.309, partial pressure of carbon dioxide (PaCO2) 41.5 mmHg, partial pressure of oxygen (PaO2) 78.2 mmHg with pressure control mechanical ventilation set as follows: positive end-expiratory pressure (PEEP) of 8 cmH2O, peak inspiratory pressure (PiP) of 25 cmH2O, fraction of inspired O2 (FiO2) of 0.5. The laboratory results were as follows: white blood cell counts (WBC) of 13,900/μl, C-reactive protein (CRP) of 13.1 mg/dL, D-dimmer of 7.25 µg/mL, activated partial thromboplastin time (APTT) of 170 s, and international normalized ratio (INR) of 1.35. Computed tomography (CT) revealed bilateral ground-glass opacity with lower-lung predominance. There were no evident abnormal findings in the abdominal region or thromboembolism; however, the intestine, including the transverse colon was edematous, and the abdominal vessels showed strong sclerotic changes . Dexamethasone administration (6 mg/day), started at the previous hospital, was continued. Continuous renal replacement therapy was initiated for the chronic renal failure as well as appropriate body fluid management. On day 3 after admission, antibiotic therapy by cefepime was started for ventilator-associated pneumonia. The APTT decreased to 51.5 s, thus unfractionated heparin for prophylactic-dose anticoagulation was additionally administered to keep the APTT around 60 s.\nOn day 7 after admission, despite these treatments, her respiratory condition worsened as follows: pH 7.333, PaCO2 40.6 mmHg, PaO2 71.1 mmHg under the ventilator setting of PEEP of 10 cmH2O, PiP of 22 cmH2O, FiO2 of 0.8. Furthermore, hemodynamic deterioration also developed with a BP of 85/41 mmHg and HR of 108 beats/min under the noradrenaline administration (0.2 µg/kg/min). Laboratory tests revealed an increase in the inflammatory markers and derangements in the coagulative function as follows: WBC of 15,100 /µl, CRP of 32.14 mg/dL, D-dimmer of 26.51 µg/mL, APTT of 47.2 s, and PT-INR of 1.24. Therefore, follow-up CT was performed to re-evaluate the degree of lung injury and to detect other sources of infection. CT revealed massive ascites, free air, and wall defects of the transverse colon . Emergency laparotomy as the source control of pan-peritonitis due to intestinal perforation was performed with the extracorporeal membrane oxygenation (ECMO) team on standby, as her respiratory condition was close to the limit of being able to be supported by a ventilator only. All surgical procedures were undertaken in the negative-pressure room of the intensive-care unit (ICU), considering the risks related to patient transfer such as further deterioration of the patient’s condition and pathogen exposure to the medical staff.\nA midline skin incision was performed, and the abdomen was filled with contaminated ascites. Two perforation sites of 25 mm and 7 mm in diameter were identified at the right side of the transverse colon, and the tissue around the perforation sites changed necrotic . PCR for the ascites showed a positive result and the number of copies of the virus was 42,056 (the number of copies of the virus in the sputum: 501,420). Abdominal lavage and partial resection of 17 cm of the transverse colon were performed. Considering the hemodynamic instability of the patient, open abdominal management with ABTHERA™ (KCI, now part of 3 M Company, San Antonio, TX, USA) and a planned relaparotomy strategy was selected. The secondary surgery was performed 2 days after the first operation. The abdomen was uncontaminated, and no remnant ischemic lesion was observed. Thus, colostomy was done, and the abdominal incision was closed with several drainage tubes into the abdomen. A histopathological examination revealed necrosis of the intestinal mucosa around the perforation sites and microcirculatory thrombosis in the mesentery veins, which was suspected of having been induced by COVID-19-related coagulopathy .\nEnteral feeding was re-started on postoperative day 2. All drains were removed on postoperative day 7. Abdominal complications, such as surgical site infection, remnant abscess and stump leakage, were not noted; however, the COVID-19 pneumonia ultimately progressed, and she died due of respiratory failure 24 days after admission (17 days after the initial surgery).", + "fulltext_subclaims": [ + "The patient was a 67-year-old female.", + "She had a 4-day history of a fever and cough.", + "She was admitted to a local hospital for pneumonia.", + "The diagnosis of COVID-19 was confirmed by a positive polymerase chain reaction (PCR) test result via a nasopharyngeal swab.", + "Her respiratory condition gradually worsened after admission.", + "She underwent intubation.", + "She was transferred to our hospital in need of intensive care 5 days after admission.", + "Her height was 164.9 cm.", + "Her weight was 46 kg.", + "She had comorbidities of diabetes mellitus, diabetic nephropathy requiring dialysis, angina, post-resection gastric cancer, and postoperative spinal canal stenosis.", + "She was taking several regular medications including an antiplatelet agent.", + "On arrival, her body temperature was 34 °C.", + "On arrival, her blood pressure was 110/65 mmHg.", + "On arrival, her heart rate was 102 beats/min.", + "On arrival, her Glasgow Coma Scale was E1VtM1 with deep sedation.", + "The arterial blood gas analysis showed pH 7.309.", + "The arterial blood gas analysis showed PaCO2 41.5 mmHg.", + "The arterial blood gas analysis showed PaO2 78.2 mmHg.", + "The ventilator setting included positive end-expiratory pressure (PEEP) of 8 cmH2O.", + "The ventilator setting included peak inspiratory pressure (PiP) of 25 cmH2O.", + "The ventilator setting included fraction of inspired O2 (FiO2) of 0.5.", + "The white blood cell count was 13,900/μl.", + "The C-reactive protein was 13.1 mg/dL.", + "The D-dimer was 7.25 µg/mL.", + "The activated partial thromboplastin time (APTT) was 170 s.", + "The international normalized ratio (INR) was 1.35.", + "Computed tomography (CT) revealed bilateral ground-glass opacity with lower-lung predominance.", + "There were no evident abnormal findings in the abdominal region or thromboembolism.", + "The transverse colon was edematous.", + "The abdominal vessels showed strong sclerotic changes.", + "Dexamethasone administration (6 mg/day) was continued.", + "Continuous renal replacement therapy was initiated for chronic renal failure.", + "On day 3 after admission, antibiotic therapy by cefepime was started for ventilator-associated pneumonia.", + "The APTT decreased to 51.5 s.", + "Unfractionated heparin for prophylactic-dose anticoagulation was additionally administered to keep the APTT around 60 s.", + "On day 7 after admission, her respiratory condition worsened as follows: pH 7.333, PaCO2 40.6 mmHg, PaO2 71.1 mmHg under the ventilator setting of PEEP of 10 cmH2O, PiP of 22 cmH2O, FiO2 of 0.8.", + "On day 7 after admission, her blood pressure was 85/41 mmHg under noradrenaline administration (0.2 µg/kg/min).", + "On day 7 after admission, her heart rate was 108 beats/min.", + "On day 7 after admission, the white blood cell count was 15,100 /µl.", + "On day 7 after admission, the C-reactive protein was 32.14 mg/dL.", + "On day 7 after admission, the D-dimer was 26.51 µg/mL.", + "On day 7 after admission, the APTT was 47.2 s.", + "On day 7 after admission, the PT-INR was 1.24.", + "Follow-up CT was performed to re-evaluate the degree of lung injury and to detect other sources of infection.", + "CT revealed massive ascites.", + "CT revealed free air.", + "CT revealed wall defects of the transverse colon.", + "Emergency laparotomy was performed as the source control of pan-peritonitis due to intestinal perforation.", + "The extracorporeal membrane oxygenation (ECMO) team was on standby.", + "All surgical procedures were undertaken in the negative-pressure room of the ICU.", + "A midline skin incision was performed.", + "The abdomen was filled with contaminated ascites.", + "Two perforation sites of 25 mm and 7 mm in diameter were identified at the right side of the transverse colon.", + "The tissue around the perforation sites changed necrotic.", + "PCR for the ascites showed a positive result.", + "The number of copies of the virus in the ascites was 42,056.", + "The number of copies of the virus in the sputum was 501,420.", + "Abdominal lavage and partial resection of 17 cm of the transverse colon were performed.", + "Open abdominal management with ABTHERA™ and a planned relaparotomy strategy was selected.", + "The secondary surgery was performed 2 days after the first operation.", + "The abdomen was uncontaminated.", + "No remnant ischemic lesion was observed.", + "Colostomy was done.", + "The abdominal incision was closed with several drainage tubes into the abdomen.", + "A histopathological examination revealed necrosis of the intestinal mucosa around the perforation sites.", + "A histopathological examination revealed microcirculatory thrombosis in the mesentery veins.", + "The microcirculatory thrombosis was suspected of having been induced by COVID-19-related coagulopathy.", + "Enteral feeding was re-started on postoperative day 2.", + "All drains were removed on postoperative day 7.", + "Abdominal complications, such as surgical site infection, remnant abscess, and stump leakage, were not noted.", + "The patient died due to respiratory failure 24 days after admission.", + "The patient died 17 days after the initial surgery." + ], + "summary": "A 67-year-female was transferred to our hospital in need of intensive care for severe COVID-19 pneumonia. On day 7 after admission, despite the treatments, her respiratory and hemodynamic status deteriorated. Computed tomography revealed massive ascites and free air as well as wall defects of the transverse colon. An emergency laparotomy was undertaken in the intensive-care unit, and 17 cm of the transverse colon was resected. Histopathological findings revealed two perforation sites of 25 and 7 mm in diameter, necrosis of the intestinal mucosa around the perforation sites, and the microcirculatory thrombosis in the mesentery vessels which was suspected of having been induced by COVID-19-related coagulopathy.", + "summary_subclaims": [ + "The patient was a 67-year-old female.", + "The patient was transferred to the hospital in need of intensive care for severe COVID-19 pneumonia.", + "On day 7 after admission, her respiratory and hemodynamic status deteriorated.", + "Computed tomography revealed massive ascites.", + "Computed tomography revealed free air.", + "Computed tomography revealed wall defects of the transverse colon.", + "An emergency laparotomy was undertaken in the intensive-care unit.", + "17 cm of the transverse colon was resected.", + "Histopathological findings revealed two perforation sites of 25 and 7 mm in diameter.", + "Histopathological findings revealed necrosis of the intestinal mucosa around the perforation sites.", + "Histopathological findings revealed microcirculatory thrombosis in the mesentery vessels.", + "The microcirculatory thrombosis in the mesentery vessels was suspected of having been induced by COVID-19-related coagulopathy." + ] + }, + { + "id": "multiclinsum_test_446_en.txt", + "fulltext": "A 66-year-old Japanese man presented to a general hospital, where mucosal melanoma of his right maxillary gingiva was confirmed on biopsy. The mass was present in his right maxillary gingiva, and a black lesion was present across a wide extent of his palate . At presentation, magnetic resonance imaging (MRI) revealed a mass of 16×10 mm on his maxillary gingiva . 18F-fluorodeoxyglucose positron emission tomography revealed abnormal accumulation in the tumor . He was diagnosed with T4aN0M0, stage IVA mucosal melanoma of his right maxillary gingiva. Surgery with a safe margin was possible; however, C-ion RT was selected based on postoperative functional and aesthetic considerations and our patient’s preference . A total dose of 57.6 Gy (relative biological effectiveness; RBE) in 16 fractions was administered. Physical dose calculations were performed using the pencil beam algorithm. The clinical dose distribution was calculated according to the physical dose and the RBE. The dose of C-ion RT was expressed as “Gy (RBE)”: physical C-ion dose (Gy)×RBE. He was positioned in customized cradles (Moldcare, Alcare, Tokyo, Japan) and immobilized using a thermoplastic shell (Shellfitter, Kuraray, Osaka, Japan). A customized mouthpiece was used to fix the teeth of both his jaws and to maintain the position of his lower jaw. Computed tomography (CT) images with a 2-mm thickness were acquired for treatment planning, which used MRI as a reference. A margin of at least 5 mm was added to the gross tumor volume (GTV) to define the clinical target volume (CTV). CTV1 included the whole of each anatomical site (gum, palate, and maxillary sinus), while CTV2 was limited to the GTV and mucosal melanosis. Planning target volume (PTV) 1 and PTV2 had margins of 2 mm added around CTV1 and CTV2, respectively. PTV1 was irradiated initially with 32.4 Gy (RBE)/9 fractions, and thereafter; PTV2 was irradiated to a total dose of 57.6 Gy (RBE)/16 fractions. Organs at risk (OARs; the eye, optic nerve, optic chiasm, inner ear, brain stem, spinal cord, mandible, palate, and tongue) were outlined on the planning CT scan for treatment planning and dose-volume histogram analysis. Treatment planning was performed using a XiO-N system (Elekta AB, Stockholm, Sweden). The composite dose distribution is shown in Fig. .\nAcute radiation mucositis at his palate and acute radiation dermatitis were observed, both of which were classified as grade 2 based on the Common Terminology Criteria for Adverse Events (CTCAE), version 4.0 . His mucositis and dermatitis resolved 1 month after C-ion RT treatment. Three-course concomitant chemotherapy (Day 1, 120 mg/m2 dacarbazine, 70 mg/m2 nimustine, and 0.7 mg/m2 vincristine; Day 2 to 5, 120 mg/m2 dacarbazine) with a 4-week interval was administered, with the first course administered at C-ion RT initiation, the second course at C-ion RT completion, and the third course 4 weeks after the second course.\nOur patient did not experience any chronic adverse events, and a complete disease response was apparent 35 months after the C-ion RT without any signs of recurrence . There were no other adverse events such as dysgeusia, xerostomia, radio-osteonecrosis, or the loss of a tooth.", + "fulltext_subclaims": [ + "A 66-year-old Japanese man presented to a general hospital.", + "Mucosal melanoma of his right maxillary gingiva was confirmed on biopsy.", + "The mass was present in his right maxillary gingiva.", + "A black lesion was present across a wide extent of his palate.", + "Magnetic resonance imaging (MRI) revealed a mass of 16×10 mm on his maxillary gingiva.", + "18F-fluorodeoxyglucose positron emission tomography revealed abnormal accumulation in the tumor.", + "He was diagnosed with T4aN0M0, stage IVA mucosal melanoma of his right maxillary gingiva.", + "C-ion RT was selected based on postoperative functional and aesthetic considerations and our patient’s preference.", + "A total dose of 57.6 Gy (relative biological effectiveness; RBE) in 16 fractions was administered.", + "The dose of C-ion RT was expressed as “Gy (RBE)”: physical C-ion dose (Gy)×RBE.", + "He was positioned in customized cradles (Moldcare, Alcare, Tokyo, Japan).", + "A customized mouthpiece was used to fix the teeth of both his jaws and to maintain the position of his lower jaw.", + "Computed tomography (CT) images with a 2-mm thickness were acquired for treatment planning.", + "A margin of at least 5 mm was added to the gross tumor volume (GTV) to define the clinical target volume (CTV).", + "PTV1 was irradiated initially with 32.4 Gy (RBE)/9 fractions.", + "PTV2 was irradiated to a total dose of 57.6 Gy (RBE)/16 fractions.", + "Organs at risk (OARs; the eye, optic nerve, optic chiasm, inner ear, brain stem, spinal cord, mandible, palate, and tongue) were outlined on the planning CT scan.", + "Treatment planning was performed using a XiO-N system (Elekta AB, Stockholm, Sweden).", + "Acute radiation mucositis at his palate was observed.", + "Acute radiation dermatitis was observed.", + "Both acute radiation mucositis and dermatitis were classified as grade 2 based on the Common Terminology Criteria for Adverse Events (CTCAE), version 4.0.", + "His mucositis and dermatitis resolved 1 month after C-ion RT treatment.", + "Three-course concomitant chemotherapy was administered.", + "The first course of chemotherapy was administered at C-ion RT initiation.", + "The second course of chemotherapy was administered at C-ion RT completion.", + "The third course of chemotherapy was administered 4 weeks after the second course.", + "Our patient did not experience any chronic adverse events.", + "A complete disease response was apparent 35 months after the C-ion RT.", + "There were no signs of recurrence 35 months after the C-ion RT.", + "There were no other adverse events such as dysgeusia, xerostomia, radio-osteonecrosis, or the loss of a tooth." + ], + "summary": "Our patient was a 66-year-old Japanese man with oral mucosal melanoma of his right maxillary gingiva (T4aN0M0). He received carbon ion radiotherapy at 57.6 Gy (relative biological effectiveness) in 16 fractions for 4 weeks. Concomitant chemotherapy (dacarbazine + nimustine + vincristine) was administered at the same time as carbon ion radiotherapy initiation. Two courses of adjuvant chemotherapy were given after carbon ion radiotherapy. Although he experienced grade 2 acute oral mucositis, his symptoms improved within a few weeks of undergoing carbon ion radiotherapy. He was alive at the time of reporting, 35 months after treatment, without any recurrence. Late toxicity has not been observed.", + "summary_subclaims": [ + "The patient was a 66-year-old Japanese man.", + "He had oral mucosal melanoma of his right maxillary gingiva.", + "The tumor stage was T4aN0M0.", + "He received carbon ion radiotherapy at 57.6 Gy (relative biological effectiveness) in 16 fractions.", + "The carbon ion radiotherapy was given over 4 weeks.", + "Concomitant chemotherapy (dacarbazine + nimustine + vincristine) was administered at the same time as carbon ion radiotherapy initiation.", + "Two courses of adjuvant chemotherapy were given after carbon ion radiotherapy.", + "He experienced grade 2 acute oral mucositis.", + "His symptoms improved within a few weeks of undergoing carbon ion radiotherapy.", + "He was alive at the time of reporting.", + "He was 35 months post-treatment at the time of reporting.", + "There was no recurrence.", + "Late toxicity has not been observed." + ] + }, + { + "id": "multiclinsum_test_745_en.txt", + "fulltext": "Liver tumors were detected incidentally during a regular liver ultrasound examination in a 48-year-old male patient without symptoms or complaints.\nCirrhosis of the liver as well as two hepatic tumors (3 cm and 2.5 cm, both located in Couinaud’s hepatic segment 8) were discovered incidentally in March 2016 during a regular ultrasound examination.\nA 48-year-old male patient was on entecavir (baraclude) antiviral therapy for a number of years for hepatitis B viral infection.\nThere was no family history of liver disease.\nThe patient had no symptoms of jaundice, abdominal discomfort, or weight loss and had not received any treatment for the issue prior to admission. The abdomen was soft without any palpable masses or ascites. Sclera was not icteric.\nLaboratory results revealed serum alpha fetoprotein (AFP) elevated to 29.91 ng/mL (normal < 7.0 ng/mL). HCC was suspected without tissue evidence.\nMultiple hepatic nodules at the right hepatic lobe and left hepatic tip were recognized. The representative larger well-defined lesion, 2.5 cm in size, has obvious hypo-intensity on the fat-suppressed T1WI , hyperintensity on the fat-suppressed T2WI , significant diffusion restriction with hyperintensity on the diffusion-weighted imaging and dark signal on the ADC (apparent diffusion coefficient) map at the corresponding site , and early hyperenhancement & rapid washout .", + "fulltext_subclaims": [ + "Liver tumors were detected incidentally during a regular liver ultrasound examination in a 48-year-old male patient without symptoms or complaints.", + "Cirrhosis of the liver as well as two hepatic tumors (3 cm and 2.5 cm, both located in Couinaud’s hepatic segment 8) were discovered incidentally in March 2016 during a regular ultrasound examination.", + "A 48-year-old male patient was on entecavir (baraclude) antiviral therapy for a number of years for hepatitis B viral infection.", + "There was no family history of liver disease.", + "The patient had no symptoms of jaundice, abdominal discomfort, or weight loss and had not received any treatment for the issue prior to admission.", + "The abdomen was soft without any palpable masses or ascites.", + "Sclera was not icteric.", + "Laboratory results revealed serum alpha fetoprotein (AFP) elevated to 29.91 ng/mL (normal < 7.0 ng/mL).", + "HCC was suspected without tissue evidence.", + "Multiple hepatic nodules at the right hepatic lobe and left hepatic tip were recognized.", + "The representative larger well-defined lesion, 2.5 cm in size, has obvious hypo-intensity on the fat-suppressed T1WI.", + "The representative larger well-defined lesion, 2.5 cm in size, has hyperintensity on the fat-suppressed T2WI.", + "The representative larger well-defined lesion, 2.5 cm in size, has significant diffusion restriction with hyperintensity on the diffusion-weighted imaging and dark signal on the ADC (apparent diffusion coefficient) map at the corresponding site.", + "The representative larger well-defined lesion, 2.5 cm in size, has early hyperenhancement & rapid washout." + ], + "summary": "A 48-year-old man with typical findings of HCC underwent consecutive therapies, including radiofrequency ablation and embolization prior to resection. Diagnosis of the HCC-NEC collision tumor in the right liver and another HCC in the left liver was established following surgical resection. The patient displayed NEC metastasis following resection and succumbed to septicemia after 2 more rounds of chemotherapy. To our knowledge, this is the 25th reported case of mixed HCC-NEC tumor. The rarity of HCC-NEC collision tumors and the absence of diagnostic criteria make it difficult to differentiate this condition from simple liver tumors, especially in patients with chronic liver disease.", + "summary_subclaims": [ + "The patient was a 48-year-old man.", + "The patient had typical findings of HCC.", + "The patient underwent radiofrequency ablation prior to resection.", + "The patient underwent embolization prior to resection.", + "Diagnosis of the HCC-NEC collision tumor in the right liver was established following surgical resection.", + "Diagnosis of another HCC in the left liver was established following surgical resection.", + "The patient displayed NEC metastasis following resection.", + "The patient succumbed to septicemia after 2 more rounds of chemotherapy.", + "This is the 25th reported case of mixed HCC-NEC tumor.", + "The rarity of HCC-NEC collision tumors makes it difficult to differentiate this condition from simple liver tumors.", + "The absence of diagnostic criteria makes it difficult to differentiate this condition from simple liver tumors.", + "This difficulty is especially relevant in patients with chronic liver disease." + ] + }, + { + "id": "multiclinsum_test_1028_en.txt", + "fulltext": "A 54-year-old female patient developed chest tightness and shortness of breath following activity 2 years ago and occasionally coughed, with yellow, sticky sputum that was difficult to expel. The patient did not demonstrate any fever or receive systemic treatment prior to hospitalization. Despite subsequent recurrence of the same symptoms, the patient did not receive any systematic treatment. Half a month prior to admission, the symptoms recurred, with no obvious trigger. Right chest pain occurred upon performing light activity but could be gradually relieved with rest. Chest CT in the local hospital showed the lower lobe of the right lung was occupied, and the upper lobe of the left lung had nodular high-density opacity. After considering the upper and middle lobes and left pneumonia of the right lung, the patient received symptomatic anti-infective drugs. She reported that her symptoms did not significantly improve; thus, she was treated at the Second Hospital of Jilin University for further diagnosis and treatment. Physical examination showed coarse breath sounds in both lungs, weak breath sounds in the right lower lung, and a small number of crackles at the base of the right lung. Laboratory tests demonstrated the following results: white blood cell count, 2.5 × 109/L; neutrophil count, 1.61 × 109/L; hemoglobin level, 91 g/L; and β2-microglobulin count, 6.15 mg/L. Blood gas analysis without oxygen revealed the following results: pH, 7.45; PCO2, 37 mm Hg; PO2, 53 mm Hg; SaO2, 89%; immunoglobulin G levels, 19.8 g/L; immunoglobulin A levels, 52.5 g/L; complement C3 levels, 53.5 mg/dL; complement C4 levels, 14.3 mg/dL; SS A antibody (WB) status, positive (+++); 52 kDa protein antibody (WB) antibody status, positive (+++); and ribosomal P protein antibody (WB) status, weakly positive (+–). Antinuclear antibody (ANA) screening (IIF) revealed a ratio of 1:320 and an ANA fluorescence model nuclear particle type. Lip gland (lower lip) biopsy revealed multifocal lymphocytes around the mucus gland of the lip gland, with each foci being >50 lymphocytes. Ultrasound-guided right lung mass aspiration biopsy was performed, and the pathology revealed diffuse proliferation of plasmoid cells. The cells had a plasma cell phenotype and light chain restricted expression, which combined with immunohistochemical staining results to support non-Hodgkin’s B-cell lymphoma and plasma cell differentiation, leading us to suspect MALT lymphoma. Immunohistochemistry results were as follows: CD10 part (+), CD79a (+), Bcl-2 (+), CD3, CD5, CD20, CD56, Bcl-6, and cyclin D1 (–), Kappa (light chain restrictive expression), and Lambdn (light chain restrictive expression) .\nSubsequent positron-emission tomography CT showed that the soft tissue density mass in the lower lobe of the right lung was flaky and had a slight high-density shadow of approximately 90 × 75 × 120 mm in size. The maximum standardized uptake value was 13.2, and the multiple flaky and slight high-density opacities in both lungs were consistent with lymphoma accompanied by intrapulmonary invasion. Accordingly, the tumor stage was considered to be stage IVB according to the Ann Arbor classification of lymphoma. After a clear diagnosis was reached, the patient received 3 cycles of CHOP (cyclophosphamide, doxorubicin, vincristine, prednisolone) treatment starting October 2021. After combining the patient’s blood M protein, IGM-Kappa type persisted, globulin levels were >40 g/L, and a second pathology biopsy still showed obvious plasma cell differentiation. Accordingly, the R-CHOP regimen was administered for 4 cycles. Repeat examination after 6 cycles of chemotherapy showed that the SPD of intrapulmonary lesions was reduced by ≥50% . The patient was considered to have undergone partial remission based on the evaluation criteria of the treatment effect on Lugano lymphoma.\nEthical approval for this study was provided by the Ethics Committee of the Second Hospital of Jilin University, China, on May 18, 2023.", + "fulltext_subclaims": [ + "A 54-year-old female patient developed chest tightness and shortness of breath following activity 2 years ago.", + "The patient occasionally coughed with yellow, sticky sputum that was difficult to expel.", + "The patient did not demonstrate any fever prior to hospitalization.", + "The patient did not receive any systematic treatment prior to hospitalization.", + "Half a month prior to admission, the symptoms recurred with no obvious trigger.", + "Right chest pain occurred upon performing light activity.", + "Chest CT in the local hospital showed the lower lobe of the right lung was occupied.", + "The upper lobe of the left lung had nodular high-density opacity.", + "The patient received symptomatic anti-infective drugs.", + "She reported that her symptoms did not significantly improve.", + "Physical examination showed coarse breath sounds in both lungs.", + "Weak breath sounds were noted in the right lower lung.", + "A small number of crackles were heard at the base of the right lung.", + "White blood cell count was 2.5 × 109/L.", + "Neutrophil count was 1.61 × 109/L.", + "Hemoglobin level was 91 g/L.", + "β2-microglobulin count was 6.15 mg/L.", + "Blood gas analysis without oxygen showed pH 7.45.", + "PO2 was 53 mm Hg.", + "SaO2 was 89%.", + "Immunoglobulin G levels were 19.8 g/L.", + "Immunoglobulin A levels were 52.5 g/L.", + "Complement C3 levels were 53.5 mg/dL.", + "Complement C4 levels were 14.3 mg/dL.", + "SS A antibody (WB) status was positive (+++).", + "52 kDa protein antibody (WB) antibody status was positive (+++).", + "Ribosomal P protein antibody (WB) status was weakly positive (+–).", + "Antinuclear antibody (ANA) screening (IIF) revealed a ratio of 1:320.", + "ANA fluorescence model showed nuclear particle type.", + "Lip gland (lower lip) biopsy revealed multifocal lymphocytes around the mucus gland of the lip gland.", + "Ultrasound-guided right lung mass aspiration biopsy was performed.", + "The pathology revealed diffuse proliferation of plasmoid cells.", + "The cells had a plasma cell phenotype and light chain restricted expression.", + "Immunohistochemical staining results supported non-Hodgkin’s B-cell lymphoma and plasma cell differentiation.", + "The tumor stage was considered to be stage IVB according to the Ann Arbor classification of lymphoma.", + "The patient received 3 cycles of CHOP treatment starting October 2021.", + "The R-CHOP regimen was administered for 4 cycles.", + "Repeat examination after 6 cycles of chemotherapy showed that the SPD of intrapulmonary lesions was reduced by ≥50%.", + "The patient was considered to have undergone partial remission based on the evaluation criteria of the treatment effect on Lugano lymphoma.", + "Ethical approval for this study was provided by the Ethics Committee of the Second Hospital of Jilin University, China, on May 18, 2023." + ], + "summary": "The ultrasound-guided right lung mass biopsy showed mucosa-associated lymphoid tissue (MALT), and the patient was diagnosed with Sjögren's syndrome (SS). The patient's symptoms were partially relieved with chemotherapy.", + "summary_subclaims": [ + "The ultrasound-guided right lung mass biopsy showed mucosa-associated lymphoid tissue (MALT).", + "The patient was diagnosed with Sjögren's syndrome (SS).", + "The patient's symptoms were partially relieved with chemotherapy." + ] + }, + { + "id": "multiclinsum_test_302_en.txt", + "fulltext": "A 1-year-old female baby visited our department for the evaluation and treatment of an accessory opening above the left nostril which had been existed since her birth. The patient and her parents’ medical history was non-specific except that the patient had an accessory nostril. Also, the age of her mother was 32 years old and there was nothing wrong at parturition.\nPhysical examination showed a left accessory nostril that connected to the normal left nostril. The internal diameter of the accessory opening was measured about 0.2 cm . Normal ipsilateral nostril was a little smaller than the other side, but the size of the alar base was similar to the right nostril. There was no columellar deviation. The nasal cavity structure was normal. Also, there was no any other deformity on her body. The patient was diagnosed to have a supernumerary nostril.\nSurgery was operated under general anesthesia. First, we drew the abnormal structure around the left nostril by gentian violet solution . The incision was performed around the accessory nostril, and then, dissection of the tract was done by using Metzenbaum scissors . After opening the nostril, the soft tissue across the normal and false nostril was removed. De-epithelialized part of false and normal nostril was attached to each other . A wedge-shaped tissue of the alar side wall was removed. Layered suture of the alar rim was applied . Minimal surgical procedure was applied. To consider her growth, rhinoplasty will be left as an option for treatment.\nAfter 1-year follow up, the accessory nostril on the left side was totally obstructed but the irregular-shaped soft tissue was remained . The operated left nostril was larger than the contralateral side. To correct the nostril asymmetry, rhinoplasty was performed . The patient got cured without special problem. At 1-year postoperative examination, the result and cosmetic appearance was satisfied .\nThe nose develops from a frontonasal process in the early fourth week of gestation. The frontonasal process is formed from the forebrain by enlarging and pushing the ectoderm anteriorly and laterally. Nasal placode appears on both sides of the frontonasal process. The nasal placode is the surface ectoderm becoming thicker in two to three cell layers on frontonasal process. In the beginning of the fifth week, the center of the nasal placode sinks to form a nasal groove. As a result, a horseshoe-shaped lateral and medial nasal process appear. As the lateral nasal process and the medial nasal process develop, the nasal groove gets deeper and forms a nasal pit. In the end of the fifth week, the nasal pit gets deeper and becomes nasal sacs. The nasal sacs move into the middle, as maxillary process develops medially. And then, the nasal sacs forms nasal cavity and nostrils .\nAlthough the exact pathogenesis of supernumerary nostril has not been revealed, it might cause problem of division of lateral nasal process.\nIn 1906, Lindsay was first to report the bilateral supernumerary nostril . An accessory nostril was above the normal nostril and connected to the ipsilateral nasal cavity. In 1920, Tawse reported the case of unilateral supernumerary nostril above the right normal nostril . An accessory nostril was connected to the right nasal cavity. In 1962, Erich reported a patient who has two noses . He described that if the position of the accessory olfactory pit is too lateral, the fusion of the laminae is not interfered, which causes the supernumerary nostril. In 1987, Nakamura and Onizuka reported a patient who has divided right alar to medially and laterally . An accessory nostril was located medially. Nakamura and Onizuka hypothesized that supernumerary nostrils resulted from fissuring of the lateral nasal process accidentally. They proposed that the lateral nasal process is divided into two segments and each segment develops into each nostril on the one side of the nose. Also in 1987, Reddy and Rao reported a patient with triple nostrils . An accessory nostril is located below the left normal nostril and connecting into the nasal cavity posteriorly. They assumed that if an accessory olfactory pit appears either above or below the normal location of the placode, consequently, a supernumerary nostril will be formed. In 2009, Kashyap and Khan reported a case of supernumerary nostril on the left side with an accessory alar cartilage . An accessory cavity was smaller than the normal cavity and was not connected with the ipsilateral nasal cavity. Kashyap and Khan proposed that the presence of alar cartilage from the accessory nostril describes the embryological fissuring of the lateral nasal process. In most of the cases, the supernumerary nostril was located on the left side and above the normal nostril. It was either isolated or associated with other congenital anomalies such as cleft lip and palate, naso-ocular cleft, esophageal atresia, and patent ductus arteriosus . Franco et al. reported that 45 % of the patients were related to other congenital anomaly .\nIn the treatment of supernumerary nostril, it is important to remove the accessory nasal tract entirely and preserve the normal nostril. In most cases of supernumerary nostril, fistulectomy and reconstruction with local flaps was performed as a surgical technique. Surgery should be performed as early as possible, because in early age, it is easier to access the deep portion of the nasal cavity, avoid serious affect to nasal cartilage, and avoid deformity around the ala nasi due to fistula. In this case, the accessory opening was obstructed by using simple incision and primary closure without forming local flap. Although the patient had two surgeries to remove the accessory nostril, small and recognizable residual defect on nostril rim of affected side is observed. For the patient’s psychosocial growth, rhinoplasty will be performed after re-evaluating face.", + "fulltext_subclaims": [ + "A 1-year-old female baby visited our department for the evaluation and treatment of an accessory opening above the left nostril which had been existed since her birth.", + "The patient and her parents’ medical history was non-specific except that the patient had an accessory nostril.", + "The age of her mother was 32 years old.", + "Physical examination showed a left accessory nostril that connected to the normal left nostril.", + "The internal diameter of the accessory opening was measured about 0.2 cm.", + "The normal ipsilateral nostril was a little smaller than the other side.", + "The size of the alar base was similar to the right nostril.", + "There was no columellar deviation.", + "The nasal cavity structure was normal.", + "The patient was diagnosed to have a supernumerary nostril.", + "Surgery was operated under general anesthesia.", + "We drew the abnormal structure around the left nostril by gentian violet solution.", + "The incision was performed around the accessory nostril.", + "Dissection of the tract was done by using Metzenbaum scissors.", + "After opening the nostril, the soft tissue across the normal and false nostril was removed.", + "De-epithelialized part of false and normal nostril was attached to each other.", + "A wedge-shaped tissue of the alar side wall was removed.", + "Layered suture of the alar rim was applied.", + "Minimal surgical procedure was applied.", + "To consider her growth, rhinoplasty will be left as an option for treatment.", + "After 1-year follow up, the accessory nostril on the left side was totally obstructed.", + "The operated left nostril was larger than the contralateral side.", + "To correct the nostril asymmetry, rhinoplasty was performed.", + "The patient got cured without special problem.", + "At 1-year postoperative examination, the result and cosmetic appearance was satisfied.", + "The nose develops from a frontonasal process in the early fourth week of gestation.", + "The frontonasal process is formed from the forebrain by enlarging and pushing the ectoderm anteriorly and laterally.", + "Nasal placode appears on both sides of the frontonasal process.", + "The nasal placode is the surface ectoderm becoming thicker in two to three cell layers on frontonasal process.", + "In the beginning of the fifth week, the center of the nasal placode sinks to form a nasal groove.", + "A horseshoe-shaped lateral and medial nasal process appear.", + "As the lateral nasal process and the medial nasal process develop, the nasal groove gets deeper and forms a nasal pit.", + "In the end of the fifth week, the nasal pit gets deeper and becomes nasal sacs.", + "The nasal sacs move into the middle, as maxillary process develops medially.", + "And then, the nasal sacs forms nasal cavity and nostrils.", + "Although the exact pathogenesis of supernumerary nostril has not been revealed, it might cause problem of division of lateral nasal process.", + "In 1906, Lindsay was first to report the bilateral supernumerary nostril.", + "An accessory nostril was above the normal nostril and connected to the ipsilateral nasal cavity.", + "In 1920, Tawse reported the case of unilateral supernumerary nostril above the right normal nostril.", + "An accessory nostril was connected to the right nasal cavity.", + "In 1962, Erich reported a patient who has two noses.", + "He described that if the position of the accessory olfactory pit is too lateral, the fusion of the laminae is not interfered, which causes the supernumerary nostril.", + "In 1987, Nakamura and Onizuka reported a patient who has divided right alar to medially and laterally.", + "An accessory nostril was located medially.", + "Nakamura and Onizuka hypothesized that supernumerary nostrils resulted from fissuring of the lateral nasal process accidentally.", + "They proposed that the lateral nasal process is divided into two segments and each segment develops into each nostril on the one side of the nose.", + "Also in 1987, Reddy and Rao reported a patient with triple nostrils.", + "An accessory nostril is located below the left normal nostril and connecting into the nasal cavity posteriorly.", + "They assumed that if an accessory olfactory pit appears either above or below the normal location of the placode, consequently, a supernumerary nostril will be formed.", + "In 2009, Kashyap and Khan reported a case of supernumerary nostril on the left side with an accessory alar cartilage.", + "An accessory cavity was smaller than the normal cavity and was not connected with the ipsilateral nasal cavity.", + "Kashyap and Khan proposed that the presence of alar cartilage from the accessory nostril describes the embryological fissuring of the lateral nasal process.", + "In most of the cases, the supernumerary nostril was located on the left side and above the normal nostril.", + "It was either isolated or associated with other congenital anomalies such as cleft lip and palate, naso-ocular cleft, esophageal atresia, and patent ductus arteriosus.", + "Franco et al. reported that 45 % of the patients were related to other congenital anomaly.", + "In the treatment of supernumerary nostril, it is important to remove the accessory nasal tract entirely and preserve the normal nostril.", + "In most cases of supernumerary nostril, fistulectomy and reconstruction with local flaps was performed as a surgical technique.", + "Surgery should be performed as early as possible, because in early age, it is easier to access the deep portion of the nasal cavity, avoid serious affect to nasal cartilage, and avoid deformity around the ala nasi due to fistula.", + "In this case, the accessory opening was obstructed by using simple incision and primary closure without forming local flap.", + "Although the patient had two surgeries to remove the accessory nostril, small and recognizable residual defect on nostril rim of affected side is observed.", + "For the patient’s psychosocial growth, rhinoplasty will be performed after re-evaluating face." + ], + "summary": "A 1-year-old female baby was brought to our department group for the treatment of an accessory opening above the left nostril which had been presented since her birth. Medical history was non-specific and her birth was normal. The size of a supernumerary nostril was about 0.2 cm diameter and connected to the left nostril. The right one was normal. Minimal procedure was operated for the anomaly. After 1 year, rhinoplasty was performed for the nostril asymmetry.", + "summary_subclaims": [ + "A 1-year-old female baby was brought to our department group for the treatment of an accessory opening above the left nostril which had been presented since her birth.", + "Medical history was non-specific and her birth was normal.", + "The size of a supernumerary nostril was about 0.2 cm diameter and connected to the left nostril.", + "The right one was normal.", + "Minimal procedure was operated for the anomaly.", + "After 1 year, rhinoplasty was performed for the nostril asymmetry." + ] + }, + { + "id": "multiclinsum_test_390_en.txt", + "fulltext": "A 37-year-old female patient of caucasian origin was referred from a regional hospital with suspected acute leukemia. The referring physician reported on fever, cough, severe thrombocytopenia and irregular cells in the blood smear. Emergency unit crew arranged extensive laboratory investigations, ordered a CT scan, asked for bone marrow biopsy, and reserved a platelet concentrate. Examination of EDTA blood by an automated hematology analyzer (Coulter Counter LH750, Beckman-Coulter Inc., Nyon, Switzerland) showed an isolated thrombocytopenia (38 × 106/μl) as well as typical patterns of platelet and WBC histograms. The aggregated platelets lead to an serrated (“saw-teeth”) curve of the platelet histogram and the largest platelet aggregates are plotted as a peculiar peak on the left side of the WBC histogram . Furthermore, hematology analyzer reported on the following flags: “platelet clumps” and “giant platelets”. Visual inspection of the blood smear revealed activated lymphocytes and platelet aggregates . EDTA-dependent pseudothrombocytopenia (EDTA-PTCP) was confirmed by a normal platelet count when examining CPT-anticoagulated blood (173 × 106/μl). Due to normalisation of PLT, no blood smear of the citrated sample was performed. Review of previous laboratory tests with the family physician revealed normal PLT values. Thus, activated lymphocytes as well as EDTA-PTCP were interpreted as secondary to upper airway infection [,].", + "fulltext_subclaims": [ + "The patient is a 37-year-old female of caucasian origin.", + "The patient was referred from a regional hospital with suspected acute leukemia.", + "The referring physician reported on fever, cough, severe thrombocytopenia, and irregular cells in the blood smear.", + "Emergency unit crew ordered a CT scan.", + "Emergency unit crew asked for a bone marrow biopsy.", + "Examination of EDTA blood showed an isolated thrombocytopenia (38 × 106/μl).", + "The Coulter Counter LH750 reported typical patterns of platelet and WBC histograms.", + "Aggregated platelets led to a serrated curve on the platelet histogram.", + "The largest platelet aggregates were plotted as a peculiar peak on the left side of the WBC histogram.", + "The hematology analyzer reported the flag 'platelet clumps'.", + "The hematology analyzer reported the flag 'giant platelets'.", + "Visual inspection of the blood smear revealed activated lymphocytes.", + "Visual inspection of the blood smear revealed platelet aggregates.", + "EDTA-dependent pseudothrombocytopenia (EDTA-PTCP) was confirmed by a normal platelet count in CPT-anticoagulated blood (173 × 106/μl).", + "No blood smear of the citrated sample was performed.", + "Review of previous laboratory tests with the family physician revealed normal PLT values.", + "Activated lymphocytes and EDTA-PTCP were interpreted as secondary to upper airway infection." + ], + "summary": "A 37-year-old female patient of Caucasian origin was referred with suspected acute leukemia and the crew of the emergency unit arranged extensive investigations for work-up. However, examination of EDTA blood sample revealed atypical lymphocytes and an isolated thrombocytopenia together with typical patterns of WBC and PLT histograms: a serrated curve of the platelet histogram and a peculiar peak on the left side of the WBC histogram. EDTA-PTCP was confirmed by a normal platelet count when examining citrated blood.", + "summary_subclaims": [ + "The patient is a 37-year-old female of Caucasian origin.", + "The patient was referred with suspected acute leukemia.", + "The crew of the emergency unit arranged extensive investigations for work-up.", + "Examination of the EDTA blood sample revealed atypical lymphocytes.", + "Examination of the EDTA blood sample revealed isolated thrombocytopenia.", + "The WBC histogram showed a peculiar peak on the left side.", + "The platelet histogram showed a serrated curve.", + "EDTA-PTCP was confirmed by a normal platelet count when examining citrated blood." + ] + }, + { + "id": "multiclinsum_test_206_en.txt", + "fulltext": "A 12-year-old boy presented with a complaint of swelling above his left upper lid from a few months prior to admission. He did not experience pain, diplopia, irritation, and itching. Past medical and ophthalmic history were unremarkable. Visual acuity was 20/20 in both eyes. Slit lamp and fundus exams were normal. There was fullness above the medial part of left upper lid and globe was displaced laterally [Figure 1a]. Ocular motility was intact.\nMagnetic resonance imaging revealed a heterogeneous ill-defined mass in the superomedial part of the mid-orbit, involving the medial rectus and superior oblique muscles. The approximate size of the lesion was 1.51.21.2 cm. Magnetic resonance imaging showed an indistinct orbital lesion. The lesion had low signal in T1-weighted and high signal in T2-weighted imaging. It showed severe enhancement after gadolinium injection [Figure 2]. Considering the patient's age, and the clinical and imaging characteristics, malignant orbital neoplasms including rhabdomyosarcoma was on the top of the list of possible diagnoses. The high signal part of the lesion in T2-weighted acquisition was considered as a probable associated necrotic area. We assumed the worst-case scenario and decided to perform an orbitotomy and excision of the lesion. Under general anesthesia, an upper eyelid crease incision was made, and tissue dissection exposed the mass between the superior oblique and superior rectus muscles [Figure 3a]. A meticulous dissection was done with special attention to keep the integrity of globe, extraocular muscles, and the lesion [Figures 3b & 3c]. The mass had tight adhesion to the surrounding structures and was finally excised in toto. Upon bisection of the mass on the operating table, the lesion showed as a multilayered wall, consisting of fibrotic bands, and a gelatinous center with a threadlike structure inside the core. There was putrid fluid and a thread-like object in the center of the lesion [Figure 3d], which were sent for histologic, parasitology, and microbiology laboratory work-up.\nHistopathologic examination showed the mass to be composed of granulomatous inflammation and the thread-like object to be D. repens [Figure 4]. On the first follow-up visit, there was no palpable mass, nor any motility or visual disturbance. No other systemic involvement was found in the systemic evaluations. Considering the resolution of signs and symptoms and after consulting with infectious diseases specialists, systemic anti-parasite medications were not administered. At this time, when inquired about contact with probable infected animals, the boy disclosed that he was taking care of a stray dog. On the last follow-up about six months after the operation, the patient had no complaints, normal orbital exams, extra-ocular movements, and there was no recurrence of the disease [Figure 1b].", + "fulltext_subclaims": [ + "The patient was a 12-year-old boy.", + "He had swelling above his left upper lid for a few months prior to admission.", + "He did not experience pain.", + "He did not experience diplopia.", + "He did not experience irritation.", + "He did not experience itching.", + "Past medical history was unremarkable.", + "Past ophthalmic history was unremarkable.", + "Visual acuity was 20/20 in both eyes.", + "Slit lamp exam was normal.", + "Fundus exam was normal.", + "There was fullness above the medial part of the left upper lid.", + "The globe was displaced laterally.", + "Magnetic resonance imaging revealed a heterogeneous ill-defined mass in the superomedial part of the mid-orbit.", + "The lesion involved the medial rectus and superior oblique muscles.", + "The approximate size of the lesion was 1.51.21.2 cm.", + "The lesion had low signal in T1-weighted imaging.", + "The lesion had high signal in T2-weighted imaging.", + "The lesion showed severe enhancement after gadolinium injection.", + "Malignant orbital neoplasms including rhabdomyosarcoma was on the top of the list of possible diagnoses.", + "The high signal part of the lesion in T2-weighted acquisition was considered as a probable associated necrotic area.", + "An orbitotomy and excision of the lesion was performed.", + "An upper eyelid crease incision was made.", + "The mass was exposed between the superior oblique and superior rectus muscles.", + "The mass had tight adhesion to the surrounding structures.", + "The mass was excised in toto.", + "Upon bisection, the lesion showed a multilayered wall.", + "The lesion had a gelatinous center with a threadlike structure inside the core.", + "There was putrid fluid in the center of the lesion.", + "There was a thread-like object in the center of the lesion.", + "Histopathologic examination showed granulomatous inflammation.", + "The thread-like object was identified as D. repens.", + "On the first follow-up visit, there was no palpable mass.", + "There was no motility disturbance.", + "There was no visual disturbance.", + "No other systemic involvement was found.", + "Systemic anti-parasite medications were not administered.", + "The boy disclosed that he was taking care of a stray dog.", + "At the last follow-up, the patient had no complaints.", + "Orbital exams were normal.", + "Extra-ocular movements were normal.", + "There was no recurrence of the disease." + ], + "summary": "We describe a 12-year-old patient with a rapid growing orbital mass involving medial part of orbit and medial rectus muscle and imaging findings suggestive of rhabdomyosarcoma. Histopathologic examination showed the mass to be composed of granulomatous inflammation and the thread-like object to be Dirofilaria repens. The patient was well post-operation without morbidity. In this paper, we describe distinct clinical features and imaging findings of this interesting case.", + "summary_subclaims": [ + "We describe a 12-year-old patient with a rapid growing orbital mass involving medial part of orbit and medial rectus muscle.", + "Imaging findings were suggestive of rhabdomyosarcoma.", + "Histopathologic examination showed the mass to be composed of granulomatous inflammation.", + "The thread-like object was Dirofilaria repens.", + "The patient was well post-operation without morbidity.", + "In this paper, we describe distinct clinical features and imaging findings of this interesting case." + ] + }, + { + "id": "multiclinsum_test_1583_en.txt", + "fulltext": "An 83-year-old man was brought to our emergency room with 10-day history of fever, severe headache, and difficulty in moving. MRI revealed a brain abscess, which was treated by abscess drainage and systemic antibiotic treatment. Although the patient had no symptoms, a CT performed to determine the cause of the brain abscess revealed thickening of the wall of the esophagus , and the patient was referred to our department.\nBarium swallow revealed a tumor measuring 6 cm in length with an abnormal ulcer mound in the middle thoracic esophagus; endoscopy revealed a Type 2 tumor . Histopathological examination of biopsy specimens revealed the squamous cell carcinoma. Abdominal and chest CT revealed wall thickening in the middle thoracic esophagus without invasion of the adjacent mediastinal organs or mediastinal lymph node metastasis. In addition, CT revealed an azygos lobe in the right thoracic cavity . We planned the esophagectomy for the esophageal cancer after control of the brain abscess. Although intrathoracic adhesions were anticipated on account of a previous history of bacterial pyothorax 14 years ago, we decided to perform esophagectomy via a thoracoscopic approach without any preoperative treatment because of his advanced age. After consulting with the respiratory surgeons, we planned to resect the abnormal azygos vein during esophagectomy.\nThe patient was placed in the prone position. Due to the adhesions in the thoracic cavity as expected, insertion of the trocars required some ingenuity. We performed dissection of adhesions using a 10-mm flexible scope and obtained an adequate field of view. Trocars were inserted as needed while performing dissection of adhesion, and we finally inserted the four trocars into the right thoracic cavity: three 12-mm trocars into the fifth intercostal space on the posterior axillary line, seventh intercostal space at the midpoint between the inferior scapular angle line and the posterior axillary line, and ninth intercostal space on the level of the inferior scapular angle, and a 5-mm trocar into the sixth intercostal space on the mid-axillary line. Although we usually insert a trocar into the third intercostal space on the mid-axillary line, we could not insert it due to adhesion of upper lobe of the of right lung. Therefore, we performed all surgical procedures via the four trocars. Then, we continued the dissection of remaining adhesion in the thoracic cavity. The middle and lower mediastinum was manipulated first because of the strong adhesions around the esophagus in the middle and lower mediastinum and the tumor's extensive contact with the left main bronchus on preoperative CT . Fortunately, the adhesions were detached without any damage, and the esophagus could be dissected from surrounding organs. Adhesions around the upper esophagus were not severe and fortunately found the azygos lobe easier than expected, and the azygos vein was supported by the mesentery draining into the superior vena cava . It might interfere with forceps operation and the surgical field or pose a risk of injury during esophagectomy, after dividing the mesentery, we clipped and cut the vessel with a vessel-sealing system, and both ends were ligated using the endloop™ . After that, we performed McKeown esophagectomy with dissection for three field lymph nodes including around bilateral recurrent laryngeal nerve, as previously described . The operation time for the thoracic part was 325 min, and the blood loss during the thoracic part of the surgery amounted to 29 ml. The postoperative course was uneventful and physical functions that were impaired by the brain abscess recovered well. The patient was discharged on the 21st postoperative day. Histopathological examination of the resected specimen confirmed the diagnosis of esophageal squamous cell carcinoma, and the lesion was classified as pT3, pN0, M0, pStageIIB (UICC 8th).", + "fulltext_subclaims": [ + "An 83-year-old man was brought to the emergency room with a 10-day history of fever, severe headache, and difficulty in moving.", + "MRI revealed a brain abscess.", + "The brain abscess was treated by abscess drainage and systemic antibiotic treatment.", + "A CT performed to determine the cause of the brain abscess revealed thickening of the wall of the esophagus.", + "Barium swallow revealed a tumor measuring 6 cm in length with an abnormal ulcer mound in the middle thoracic esophagus.", + "Endoscopy revealed a Type 2 tumor.", + "Histopathological examination of biopsy specimens revealed squamous cell carcinoma.", + "Abdominal and chest CT revealed wall thickening in the middle thoracic esophagus without invasion of the adjacent mediastinal organs.", + "CT revealed an azygos lobe in the right thoracic cavity.", + "We planned the esophagectomy for the esophageal cancer after control of the brain abscess.", + "We decided to perform esophagectomy via a thoracoscopic approach.", + "We planned to resect the abnormal azygos vein during esophagectomy.", + "The patient was placed in the prone position.", + "Insertion of the trocars required some ingenuity due to adhesions in the thoracic cavity.", + "Trocars were inserted as needed while performing dissection of adhesion.", + "Four trocars were inserted into the right thoracic cavity.", + "The operation time for the thoracic part was 325 min.", + "The blood loss during the thoracic part of the surgery amounted to 29 ml.", + "The postoperative course was uneventful.", + "The patient was discharged on the 21st postoperative day.", + "Histopathological examination of the resected specimen confirmed the diagnosis of esophageal squamous cell carcinoma.", + "The lesion was classified as pT3, pN0, M0, pStageIIB (UICC 8th)." + ], + "summary": "An 83-years-old man was brought to our emergency room with fever, severe headache, and difficulty in moving. MRI revealed a brain abscess, which was treated by abscess drainage and systemic antibiotic treatment. Further examinations to determine the cause of the brain abscess revealed esophageal cancer. In addition, CT revealed an azygos lobe in the right thoracic cavity. Although intrathoracic adhesions were anticipated on account of a previous history of bacterial pyothorax, we decided to perform esophagectomy via a thoracoscopic approach. Despite the difficulty in dissecting the intrathoracic adhesions, we were able to obtain the surgical field thoracoscopically. Then, we found the azygos lobe, as diagnosed preoperatively, and the azygos vein was supported by the mesentery draining into the superior vena cava. After dividing the mesentery, we clipped and cut the vessel, and both ends were further ligated. After these procedures, we safely performed esophagectomy with 3-field lymph node dissection. The postoperative course was uneventful, and the patient was discharged on the 21st postoperative day.", + "summary_subclaims": [ + "An 83-years-old man was brought to our emergency room with fever.", + "An 83-years-old man was brought to our emergency room with severe headache.", + "An 83-years-old man was brought to our emergency room with difficulty in moving.", + "MRI revealed a brain abscess.", + "The brain abscess was treated by abscess drainage.", + "The brain abscess was treated by systemic antibiotic treatment.", + "Further examinations to determine the cause of the brain abscess revealed esophageal cancer.", + "CT revealed an azygos lobe in the right thoracic cavity.", + "The patient had a previous history of bacterial pyothorax.", + "We decided to perform esophagectomy via a thoracoscopic approach.", + "We were able to obtain the surgical field thoracoscopically.", + "We found the azygos lobe, as diagnosed preoperatively.", + "The azygos vein was supported by the mesentery draining into the superior vena cava.", + "After dividing the mesentery, we clipped and cut the vessel.", + "Both ends of the vessel were further ligated.", + "We safely performed esophagectomy with 3-field lymph node dissection.", + "The postoperative course was uneventful.", + "The patient was discharged on the 21st postoperative day." + ] + }, + { + "id": "multiclinsum_test_1617_en.txt", + "fulltext": "A 56-year-old female presenting with massive intestinal hemorrhage was admitted to hospital. The persistent and progressively worsening hemorrhage was complicated by disseminated intravascular coagulation.\nThe patient had a history of chronic constipation and multiple venous hemangiomas since childhood. The lesions increased in size and number with advancing age. She did not have hepatitis or liver cirrhosis.\nIn the prior 3 years, the patient was repeatedly admitted to hospital due to melena or fatigue and dizziness. No blood lesions were found under endoscopy or colonoscopy. After hemostatic treatment and multiple blood transfusions (14-64 units of red blood cell transfusions every year), the patient’s hemoglobin fluctuated between 39 g/L and 61 g/L.\nShe was again admitted to the emergency department with worsening symptoms, including 10 d of melena. The symptoms did not improve after treatment, and she was transferred urgently to our hospital.\nThere was no family history of venous hemangiomas or other relevant disorders.\nPhysical examination revealed anemia and multiple blue hemangiomas protruding from the skin surface . Skin ultrasound confirmed that the protrusions were hemangiomas .\nLaboratory examination showed white blood cell count of 1.78 × 1012/L (normal range: 3.80-5.10 × 1012/L), hemoglobin of 39 g/L (normal range: 115-150 g/L), platelets of 71 × 109/L (normal range: 125-350 × 109/L), and positivity for fecal occult blood. Additional testing revealed prothrombin time of 17.7 sec (normal range: 9.5-15.0 sec), activated partial thromboplastin time of 55.8 sec (normal range: 20.0-40.0 sec), prothrombin time-international normalized ratio of 1.65 (normal range: 0.80-1.50), fibrinogen of 0.349 g/L (normal range: 1.800-4.000 g/L), D-dimer of > 10000 ng/mL (normal range: 0-500 µg/mL), tissue plasminogen activator-inhibitor 1 complex of 14.10 ng/mL (normal range: 0.00-10.50 ng/mL), and plasmin-α2 cellulase inhibitor complex of 12.23 µg/mL (normal range: 0.00-0.80 µg/mL).\nImaging examination showed multiple hemangiomas throughout the body. Further examination showed hemorrhagic anemia with enhanced fibrinolytic type disseminated intravascular coagulation. No other bleeding causes were discovered after abdominal computed tomography examination or after digital subtraction angiography and mesenteric arteriography . No definitive bleeding lesions were found by endoscopy and colonoscopy.", + "fulltext_subclaims": [ + "The patient is a 56-year-old female.", + "The patient presented with massive intestinal hemorrhage.", + "The hemorrhage was persistent and progressively worsening.", + "The hemorrhage was complicated by disseminated intravascular coagulation.", + "The patient had a history of chronic constipation.", + "The patient had multiple venous hemangiomas since childhood.", + "The venous hemangiomas increased in size and number with advancing age.", + "The patient did not have hepatitis.", + "The patient did not have liver cirrhosis.", + "In the prior 3 years, the patient was repeatedly admitted to hospital due to melena or fatigue and dizziness.", + "No blood lesions were found under endoscopy or colonoscopy.", + "After hemostatic treatment and multiple blood transfusions, the patient’s hemoglobin fluctuated between 39 g/L and 61 g/L.", + "The patient was again admitted to the emergency department with worsening symptoms, including 10 d of melena.", + "The symptoms did not improve after treatment.", + "She was transferred urgently to our hospital.", + "There was no family history of venous hemangiomas.", + "There was no family history of other relevant disorders.", + "Physical examination revealed anemia.", + "Physical examination revealed multiple blue hemangiomas protruding from the skin surface.", + "Skin ultrasound confirmed that the protrusions were hemangiomas.", + "Laboratory examination showed white blood cell count of 1.78 × 1012/L.", + "The normal range for white blood cell count is 3.80-5.10 × 1012/L.", + "Laboratory examination showed hemoglobin of 39 g/L.", + "The normal range for hemoglobin is 115-150 g/L.", + "Laboratory examination showed platelets of 71 × 109/L.", + "The normal range for platelets is 125-350 × 109/L.", + "Laboratory examination showed positivity for fecal occult blood.", + "Additional testing revealed prothrombin time of 17.7 sec.", + "The normal range for prothrombin time is 9.5-15.0 sec.", + "Additional testing revealed activated partial thromboplastin time of 55.8 sec.", + "The normal range for activated partial thromboplastin time is 20.0-40.0 sec.", + "Additional testing revealed prothrombin time-international normalized ratio of 1.65.", + "The normal range for prothrombin time-international normalized ratio is 0.80-1.50.", + "Additional testing revealed fibrinogen of 0.349 g/L.", + "The normal range for fibrinogen is 1.800-4.000 g/L.", + "Additional testing revealed D-dimer of > 10000 ng/mL.", + "The normal range for D-dimer is 0-500 µg/mL.", + "Additional testing revealed tissue plasminogen activator-inhibitor 1 complex of 14.10 ng/mL.", + "The normal range for tissue plasminogen activator-inhibitor 1 complex is 0.00-10.50 ng/mL.", + "Additional testing revealed plasmin-α2 cellulase inhibitor complex of 12.23 µg/mL.", + "The normal range for plasmin-α2 cellulase inhibitor complex is 0.00-0.80 µg/mL.", + "Imaging examination showed multiple hemangiomas throughout the body.", + "Further examination showed hemorrhagic anemia with enhanced fibrinolytic type disseminated intravascular coagulation.", + "No other bleeding causes were discovered after abdominal computed tomography examination.", + "No other bleeding causes were discovered after digital subtraction angiography and mesenteric arteriography.", + "No definitive bleeding lesions were found by endoscopy and colonoscopy." + ], + "summary": "We report a case of blue rubber bleb nevus syndrome combined with disseminated intravascular coagulation and efficacy of treatment with argon plasma coagulation under enteroscopy and sirolimus. A 56-year-old female patient was admitted to the hospital with 3-year history of fatigue and dizziness that had aggravated over the past 10 d with melena. The patient had a history of repeated melena and multiple venous hemangiomas from childhood. After treatment with argon plasma coagulation combined with sirolimus for nearly 8 wk, the patient's serum hemoglobin increased to 100 g/L. At the 12-mo follow-up, the patient was well with stable hemoglobin (102 g/L) and no recurrent intestinal bleeding.", + "summary_subclaims": [ + "We report a case of blue rubber bleb nevus syndrome combined with disseminated intravascular coagulation and efficacy of treatment with argon plasma coagulation under enteroscopy and sirolimus.", + "A 56-year-old female patient was admitted to the hospital with 3-year history of fatigue and dizziness that had aggravated over the past 10 d with melena.", + "The patient had a history of repeated melena and multiple venous hemangiomas from childhood.", + "After treatment with argon plasma coagulation combined with sirolimus for nearly 8 wk, the patient's serum hemoglobin increased to 100 g/L.", + "At the 12-mo follow-up, the patient was well with stable hemoglobin (102 g/L) and no recurrent intestinal bleeding." + ] + }, + { + "id": "multiclinsum_test_67_en.txt", + "fulltext": "An 84-year-old male patient presented to our emergency department with bilateral hip joint pain and limited mobility due to high energy injury (a severe car accident). He suffered from trauma to the hips, chest, and lumbosacral region while riding an electric tricycle that collided with a truck. Physical examination in the emergency room indicated shortening and external rotation deformities in both lower limbs, tenderness in both hip joints (+), and vertical percussed pain of the lower limbs (+). Neurological and vascular examinations of the lower limbs were normal. Radiologic tests confirmed multiple injuries including bilateral intertrochanteric fractures, pelvic fracture, subarachnoid hemorrhage, multiple rib fractures and lung contusion. The bilateral intertrochanteric fractures were obviously displaced . Laboratory tests showed a hemoglobin level of 66 g/L, D-dimer of 5719 ug/L (normal 0-500), total bilirubin of 32.6 umol/L (normal 0–26), direct bilirubin of 12.5 umol/L (normal 0–8), and indirect bilirubin of 20.1 umol/L (normal 0–18). Despite no history of prior comorbidities, the patient was admitted to the emergency intensive care unit (ICU)due to his advanced age and poor general condition. The patient received blood transfusions and fluid resuscitation and other symptomatic supportive treatments in the ICU. The vital signs gradually stabilized, but he still complained of pain in his lower limbs (VAS 8). After 6 days, he was transferred to the orthopedic department. A multidisciplinary team (MDT) consultation was convened, involving experts from department of ICU, vascular surgery, cardiology, neurosurgery, hepatobiliary surgery, thoracic surgery, and anesthesiology. The decision was made to perform surgery after administering packed red blood cells and fresh frozen plasma to correct anemia and coagulation abnormalities. Intermuscular vein thromboses were discovered in both lower limbs. However, due to contraindications for anticoagulation therapy because of subarachnoid hemorrhage, an inferior vena cava filter was placed to prevent pulmonary embolism. Symptomatic treatment was provided for obstructive jaundice. The patient’s hemodynamics were stabilized preoperatively, with a hemoglobin level of 96 g/L and nearly normal bilirubin levels. Lactate levels decreased from 1.10 to 0.70mmol/L, and the pH value dropped from 7.454 to 7.382 .\nAfter 9 days of hospitalization and once the patient’s condition had stabilized, he was scheduled for surgery. The patient underwent a single spinal anesthesia session for bilateral femoral intertrochanteric fracture closed reduction and internal fixation with proximal femoral nail anti-rotation (PFNA). The surgery was smooth , lasting 2.5 h with a blood loss of 150 ml and no intraoperative transfusion. Postoperative vital signs remained stable, and the patient’s hemoglobin level was 91 g/L on the day of surgery.\nPostoperatively, the patient was under cardiac monitoring with normal blood pressure and heart rate. He experienced significant pain relief(VAS 8 to4)and was able to sit up at the bedside. On the third day after surgery, X-ray examination showed satisfactory placement of the internal implants . The patient began partial weight-bearing ambulation with the assistance of a walker. Due to the COVID-19 pandemic, the patient was discharged one month after the surgery.\nImmediately following the patient’s recovery from anesthesia, a conservative rehabilitation plan was initiated. The rehabilitation program commenced with isometric contractions of the quadriceps muscles and ankle pump exercises to promote circulation and muscle strength. On the 3rd day post-surgery, the patient was encouraged to stand and begin partial weight-bearing ambulation with the assistance of a walker. During the first two weeks post-operatively, the focus remained on bed-based and bedside muscle strengthening exercises, gradually progressing as the patient’s condition allowed. By the 4th week, at the time of discharge, the patient was able to move independently within the ward with the aid of a walker, including performing personal tasks such as using the restroom. Pre-discharge X-rays showed signs of fracture healing. The rehabilitation plan was progressively intensified, and by 3 months post-surgery, the patient had advanced to full weight-bearing indoor activities. At the six-month follow-up, bilateral femoral intertrochanteric fractures had healed , and the patient was able to walk and perform activities outdoors.", + "fulltext_subclaims": [ + "The patient is an 84-year-old male.", + "He presented with bilateral hip joint pain and limited mobility due to a high energy injury.", + "The injury was a severe car accident.", + "He suffered trauma to the hips, chest, and lumbosacral region.", + "Physical examination indicated shortening and external rotation deformities in both lower limbs.", + "Tenderness in both hip joints was positive.", + "Vertical percussed pain of the lower limbs was positive.", + "Neurological and vascular examinations of the lower limbs were normal.", + "Radiologic tests confirmed bilateral intertrochanteric fractures.", + "The bilateral intertrochanteric fractures were obviously displaced.", + "Laboratory tests showed a hemoglobin level of 66 g/L.", + "D-dimer was 5719 ug/L.", + "The patient was admitted to the emergency ICU due to his advanced age and poor general condition.", + "He received blood transfusions and fluid resuscitation.", + "After 6 days, he was transferred to the orthopedic department.", + "An MDT consultation was convened.", + "The decision was made to perform surgery after administering packed red blood cells and fresh frozen plasma.", + "Intermuscular vein thromboses were discovered in both lower limbs.", + "An inferior vena cava filter was placed to prevent pulmonary embolism.", + "The patient’s hemodynamics were stabilized preoperatively.", + "Lactate levels decreased from 1.10 to 0.70 mmol/L.", + "The pH value dropped from 7.454 to 7.382.", + "After 9 days of hospitalization, the patient was scheduled for surgery.", + "The patient underwent bilateral femoral intertrochanteric fracture closed reduction and internal fixation with PFNA.", + "The surgery lasted 2.5 hours.", + "Blood loss was 150 ml.", + "Postoperative vital signs remained stable.", + "The patient’s hemoglobin level was 91 g/L on the day of surgery.", + "On the third day after surgery, X-ray showed satisfactory placement of the internal implants.", + "The patient began partial weight-bearing ambulation with the assistance of a walker.", + "The patient was discharged one month after the surgery.", + "A conservative rehabilitation plan was initiated immediately following recovery from anesthesia.", + "The rehabilitation program commenced with isometric contractions of the quadriceps muscles.", + "On the 3rd day post-surgery, the patient was encouraged to stand and begin partial weight-bearing ambulation with a walker.", + "By the 4th week, the patient was able to move independently within the ward with the aid of a walker.", + "Pre-discharge X-rays showed signs of fracture healing.", + "By 3 months post-surgery, the patient had advanced to full weight-bearing indoor activities.", + "At the six-month follow-up, bilateral femoral intertrochanteric fractures had healed." + ], + "summary": "We report on an 84-year-old male who suffered severe trauma from a car accident, resulting in multiple injuries and shock state, with pain and limited mobility in both hip joints. After examination and imaging studies, the patient was diagnosed with multiple injuries and bilateral intertrochanteric fractures. Following emergency resuscitation, he was admitted to the orthopedic ward. A pre-surgical multidisciplinary team (MDT) consultation was convened to optimize surgical conditions. The patient underwent successful one-stage bilateral intramedullary nailing. The patient was assisted to stand with a walker on the third day after surgery. Six months post-surgery, the patient resumed outdoor activities.", + "summary_subclaims": [ + "The patient is an 84-year-old male.", + "The patient suffered severe trauma from a car accident.", + "The patient had pain and limited mobility in both hip joints.", + "The patient was diagnosed with multiple injuries.", + "The patient was diagnosed with bilateral intertrochanteric fractures.", + "The patient was admitted to the orthopedic ward.", + "A pre-surgical multidisciplinary team (MDT) consultation was convened.", + "The patient underwent one-stage bilateral intramedullary nailing.", + "The patient was assisted to stand with a walker on the third day after surgery.", + "Six months post-surgery, the patient resumed outdoor activities." + ] + }, + { + "id": "multiclinsum_test_2210_en.txt", + "fulltext": "A previously healthy 36-year-old Chinese man presented to the emergency department with a 1-month history of fever. He had consulted a nearby doctor before arriving at our hospital. Symptomatic treatment was given but did not work. Chest computed tomography (CT) showed diffused bilateral infiltration . Abdominal CT showed multiple focal lesions in the liver , without hepatosplenomegaly. Because of rapidly clinical deterioration with onset of acute respiratory failure, he was transferred to the medical intensive care unit.\nOn admission, his vital signs were: temperature, 37.2 °C; heart rate, 119 beats/min; blood pressure (BP), 90/48 mmHg; and respiration rate, 38 breaths/min with oxygen saturation of 88%. The patient appeared to be acutely ill. A pulmonary examination revealed rales in both lungs. His abdomen was soft, with no hepatomegaly and splenomegaly. Routine laboratory tests results were: white blood cell (WBC) count, 5.32 × 109 cells/L; hemoglobin, 94 g/L; platelet count, 70 × 109/L; aspartate aminotransferase (AST), 121 U/L; alanine aminotransferase (ALT), 47 U/L; total bilirubin (TB), 48.4 μmol/L; direct bilirubin (DB), 40.9 μmol/L; blood urea nitrogen (BUN), 11.35 mmol/L; creatinine, 106.0 μmol/L; lactic dehydrogenase (LDH) 508 U/L; serum ferritin, 17,208.98 ng/ml. Even with continuous high-flow oxygen inhalation, arterial blood gas analysis showed pH 7.45, PO2 57 mmHg, PCO2 35 mmHg and lactate 2.0 mmol/L. Coagulation tests demonstrated prothrombin time (PT) 16.9 s, prothrombin activity (PTA) 62%, and fibrinogen level 1.74 g/L. Autoimmune antibody blood tests were negative. Microbiological and serological work-up for HIV, hepatitis A, B, C and E viruses, EBV, cytomegalovirus, dengue virus, malaria, Leptospira, and scrub typhus was negative. Bacteriological assays as well as serology for respiratory viruses (adenovirus, and influenza A and B, parainfluenza and respiratory syncytial viruses), Mycoplasma pneumoniae, Chlamydia pneumoniae and Legionella were also negative. Repeated sputum smear samples were negative for acid-fast bacilli. The patient had no significant past medical history, specifically no prior TB infections, chronic illnesses, liver or kidney disease, transfusions, malignancy, or immune diseases. He was not taking any regular prescription and he had not travelled abroad.\nAfter admission, the patient was initially diagnosed with fever of unknown origin, pulmonary infection. According to chest and abdominal CT findings, pulmonary TB and hepatic abscess were highly suspected. Malignancy was excluded by positron emission tomography. Considering possible multisite infections due to hypervirulent Klebsiella pneumoniae, we started an antibiotic regimen with meropenem and amikacin. Non-invasive positive pressure ventilation was applied for respiratory support. However, the patient continued to present with recurrent high-grade fever. Peripheral blood TB ELISPOT assay was positive, which suggested TB. Anti-TB therapy with rifapentine (0.6 g once a week), isoniazid (0.3 g daily), ethambutol (0.75 g daily) and moxifloxacin (0.4 g daily) was administered.\nThe patient’s clinical course was notable for obvious dyspnea, intermittent fever, worsening pancytopenia, and hyperferritinemia during observation . On day 4, examination of bone marrow aspiration was undertaken, which revealed increased macrophage activity with hemophagocytosis . Additional blood tests showed low NK cell activity (11.9%, normal value: ≥15.1%) and high-soluble CD25 levels (> 44,000 pg/ml, normal value: < 2400 pg/ml). Accordingly, a diagnosis of HLH was made. However, the patient refused to undergo genetic testing. Following consultation with a hematologist, intravenous etoposide was started on day 7 (0.1 g twice a week for 2 weeks, 0.1 g once a week for the following 6 weeks). The patient responded well to the therapeutic strategy, with marked improvement of fever and cytopenia. On day 17, he was successfully withdrawn from the ventilator.\nOnce the patient was stable and free of symptoms of respiratory failure, he was transferred to the respiratory department on day 19. Anti-TB therapy with isoniazid, rifapentine, ethambutol and pyrazinamide was administered. After platelet recovery, ultrasound-guided percutaneous lung biopsy was performed on day 22. The pathological result was positive for acid-fast bacilli , which suggested differentiating between Mycobacterium tuberculosis (MTB) and non-tuberculosis mycobacteria (NTM). Re-examination of bone marrow aspiration showed no hemophagocytosis. After discharge in good condition on day 67, he was followed up for 3 months in our hospital and treated with a course of four standard anti-TB drugs. The patient has stayed systemically well. Six months later, the repeated chest CT findings in another tertiary hospital revealed fibrous proliferation, calcification and pleural thickening, which still indicated tuberculosis .", + "fulltext_subclaims": [ + "A previously healthy 36-year-old Chinese man presented to the emergency department with a 1-month history of fever.", + "He had consulted a nearby doctor before arriving at our hospital.", + "Symptomatic treatment was given but did not work.", + "Chest computed tomography (CT) showed diffused bilateral infiltration.", + "Abdominal CT showed multiple focal lesions in the liver.", + "Abdominal CT showed no hepatosplenomegaly.", + "Because of rapidly clinical deterioration with onset of acute respiratory failure, he was transferred to the medical intensive care unit.", + "On admission, his oxygen saturation was 88%.", + "The patient appeared to be acutely ill.", + "A pulmonary examination revealed rales in both lungs.", + "His abdomen was soft, with no hepatomegaly and splenomegaly.", + "Routine laboratory tests showed a platelet count of 70 × 109/L.", + "Routine laboratory tests showed total bilirubin of 48.4 μmol/L.", + "Routine laboratory tests showed direct bilirubin of 40.9 μmol/L.", + "Coagulation tests demonstrated prothrombin time of 16.9 s.", + "Coagulation tests demonstrated prothrombin activity of 62%.", + "Coagulation tests demonstrated fibrinogen level of 1.74 g/L.", + "Autoimmune antibody blood tests were negative.", + "Microbiological and serological work-up for HIV, hepatitis A, B, C and E viruses, EBV, cytomegalovirus, dengue virus, malaria, Leptospira, and scrub typhus was negative.", + "Bacteriological assays as well as serology for respiratory viruses, Mycoplasma pneumoniae, Chlamydia pneumoniae and Legionella were also negative.", + "Repeated sputum smear samples were negative for acid-fast bacilli.", + "The patient had no significant past medical history.", + "He was not taking any regular prescription.", + "He had not travelled abroad.", + "After admission, the patient was initially diagnosed with fever of unknown origin, pulmonary infection.", + "According to chest and abdominal CT findings, pulmonary TB and hepatic abscess were highly suspected.", + "Malignancy was excluded by positron emission tomography.", + "Considering possible multisite infections due to hypervirulent Klebsiella pneumoniae, we started an antibiotic regimen with meropenem and amikacin.", + "Non-invasive positive pressure ventilation was applied for respiratory support.", + "The patient continued to present with recurrent high-grade fever.", + "Peripheral blood TB ELISPOT assay was positive, which suggested TB.", + "Anti-TB therapy with rifapentine, isoniazid, ethambutol and moxifloxacin was administered.", + "The patient’s clinical course was notable for obvious dyspnea.", + "On day 4, examination of bone marrow aspiration was undertaken, which revealed increased macrophage activity with hemophagocytosis.", + "Additional blood tests showed low NK cell activity.", + "Additional blood tests showed high-soluble CD25 levels.", + "Accordingly, a diagnosis of HLH was made.", + "The patient refused to undergo genetic testing.", + "Following consultation with a hematologist, intravenous etoposide was started on day 7.", + "The patient responded well to the therapeutic strategy, with marked improvement of fever and cytopenia.", + "On day 17, he was successfully withdrawn from the ventilator.", + "Once the patient was stable and free of symptoms of respiratory failure, he was transferred to the respiratory department on day 19.", + "Anti-TB therapy with isoniazid, rifapentine, ethambutol and pyrazinamide was administered.", + "After platelet recovery, ultrasound-guided percutaneous lung biopsy was performed on day 22.", + "The pathological result was positive for acid-fast bacilli.", + "Re-examination of bone marrow aspiration showed no hemophagocytosis.", + "After discharge in good condition on day 67, he was followed up for 3 months in our hospital.", + "He was treated with a course of four standard anti-TB drugs.", + "The patient has stayed systemically well.", + "Six months later, the repeated chest CT findings in another tertiary hospital revealed fibrous proliferation, calcification and pleural thickening.", + "Six months later, the repeated chest CT findings still indicated tuberculosis." + ], + "summary": "A 36-year-old man presented with persistent fever, pancytopenia, and hyperferritinemia. A bone marrow smear demonstrated hemophagocytosis, and pathological examination of lung biopsy was positive for acid-fast bacilli, which established the diagnosis of Mycobacterium infection and HLH. Then the patient treated successfully with anti-TB therapy, along with 8 weeks of etoposide.", + "summary_subclaims": [ + "A 36-year-old man presented with persistent fever.", + "A 36-year-old man presented with pancytopenia.", + "A 36-year-old man presented with hyperferritinemia.", + "A bone marrow smear demonstrated hemophagocytosis.", + "Pathological examination of lung biopsy was positive for acid-fast bacilli.", + "The diagnosis of Mycobacterium infection and HLH was established.", + "The patient was treated successfully with anti-TB therapy.", + "The patient received 8 weeks of etoposide." + ] + }, + { + "id": "multiclinsum_test_1161_en.txt", + "fulltext": "A 47-year-old woman was admitted to our hospital because of an abnormal chest shadow found on a routine chest X-ray. SCD was diagnosed when she was 6 years of age. Chest computed tomography showed a well defined mass (48 × 31 mm) touching the pericardium and left lung . Laboratory examinations showed normal serum levels of alpha fetoprotein (2.4 ng/mL), human chorionic gonadotropin beta (< 0.2 ng/mL), and antiacetylcholine receptor antibody (< 0.2 nmol/L). The differential diagnosis included thymoma, thymic carcinoma, and germ cell tumor; and surgical resection was recommended. However, the patient was a high-risk surgical patient because of SCD. Physical examination revealed a patient who was 164 cm tall, weighing 56 kg. Her vital signs were normal. Neurological examination revealed limb, truncal, ocular, and ataxic dysarthria; hypotonia; areflexia; sensory disturbances; and muscle weakness. Her Eastern cooperative oncology group performance status was 4. Pulmonary function tests showed an obstructive pattern. Her vital capacity (1.57 L) was 56.3% of predicted value and her forced expiratory volume in 1 s /forced vital capacity was 70.5% of predicted value. Magnetic resonance imaging showed severe cerebellar atrophy and spinocerebellar degeneration .\nWe decided to follow the patient while evaluating her general condition. Three months after her initial diagnosis, her tumor had grown to 50 × 35 mm. We performed surgery with the patient under general anesthesia only (without epidural analgesia), after explaining the risk of respiratory failure in detail and obtaining consent from her and her family. She received 30 mg rocuronium bromide (0.5 mg/kg), target-controlled propofol intravenous infusion (4.0 μg/mL), and remifentanil intravenous infusion (0.2 μg/kg/min) as general anesthesia by single-lung ventilation via a double-lumen endotracheal tube. Resection of the mediastinal tumor was performed via VATS. Although the tumor was firmly adherent to the left phrenic nerve, the tumor was carefully resected to preserve the nerve.\nHistopathological examination of the tumor revealed small lymphocytes and atypical thymic cells of intermediate size that resembled epithelial cells . Immunohistochemical staining showed that the small lymphocytes were positive for CD99 expression and the medium-sized atypical cells were positive for cytokeratin AE1/AE3 and negative for c-kit and CD5 expression. The lesion was diagnosed as type B1 thymoma without capsular invasion (Masaoka stage I). The patient’s postoperative course was uneventful, and she was discharged from the hospital on postoperative day 9. At the time of this report, 36 months after resection, she was doing well.", + "fulltext_subclaims": [ + "The patient was a 47-year-old woman.", + "She was admitted to the hospital because of an abnormal chest shadow found on a routine chest X-ray.", + "SCD was diagnosed when she was 6 years of age.", + "Chest computed tomography showed a well defined mass (48 × 31 mm) touching the pericardium and left lung.", + "Serum alpha fetoprotein was 2.4 ng/mL.", + "Serum human chorionic gonadotropin beta was < 0.2 ng/mL.", + "Serum antiacetylcholine receptor antibody was < 0.2 nmol/L.", + "The differential diagnosis included thymoma, thymic carcinoma, and germ cell tumor.", + "Surgical resection was recommended.", + "The patient was a high-risk surgical patient because of SCD.", + "The patient was 164 cm tall and weighed 56 kg.", + "Her vital signs were normal.", + "Neurological examination revealed limb, truncal, ocular, and ataxic dysarthria.", + "Neurological examination revealed hypotonia.", + "Neurological examination revealed areflexia.", + "Neurological examination revealed sensory disturbances.", + "Neurological examination revealed muscle weakness.", + "Her Eastern cooperative oncology group performance status was 4.", + "Pulmonary function tests showed an obstructive pattern.", + "Her vital capacity was 1.57 L.", + "Her vital capacity was 56.3% of predicted value.", + "Her forced expiratory volume in 1 s /forced vital capacity was 70.5% of predicted value.", + "Magnetic resonance imaging showed severe cerebellar atrophy.", + "Magnetic resonance imaging showed spinocerebellar degeneration.", + "We decided to follow the patient while evaluating her general condition.", + "Three months after her initial diagnosis, her tumor had grown to 50 × 35 mm.", + "We performed surgery with the patient under general anesthesia only.", + "We performed surgery after explaining the risk of respiratory failure in detail.", + "We obtained consent from the patient and her family.", + "She received 30 mg rocuronium bromide.", + "She received target-controlled propofol intravenous infusion (4.0 μg/mL).", + "She received remifentanil intravenous infusion (0.2 μg/kg/min).", + "General anesthesia was provided by single-lung ventilation via a double-lumen endotracheal tube.", + "Resection of the mediastinal tumor was performed via VATS.", + "The tumor was firmly adherent to the left phrenic nerve.", + "The tumor was carefully resected to preserve the nerve.", + "Histopathological examination revealed small lymphocytes and atypical thymic cells of intermediate size.", + "The atypical thymic cells resembled epithelial cells.", + "The small lymphocytes were positive for CD99 expression.", + "The medium-sized atypical cells were positive for cytokeratin AE1/AE3.", + "The medium-sized atypical cells were negative for c-kit expression.", + "The medium-sized atypical cells were negative for CD5 expression.", + "The lesion was diagnosed as type B1 thymoma.", + "The lesion was diagnosed without capsular invasion.", + "The lesion was diagnosed as Masaoka stage I.", + "The patient’s postoperative course was uneventful.", + "She was discharged from the hospital on postoperative day 9.", + "At the time of this report, 36 months after resection, she was doing well." + ], + "summary": "A 47-year-old woman with spinocerebellar degeneration was admitted because of a well-defined mass measuring 48 × 31 mm in anterior mediastinum. She showed limb, truncal, ocular, and speech ataxia; hypotonia; areflexia; sensory disturbances; and muscle weakness. Her eastern cooperative oncology group performance status was 4. Surgical resection was performed via video-assisted thoracic surgery and under general anesthesia only without epidural analgesia. The mass was diagnosed as type B1 thymoma without capsular invasion (Masaoka stage I). The patients got a good postoperative course by cooperation with anesthesiologists and neurologists in perioperative managements. She has been well over 3 years of follow-up.", + "summary_subclaims": [ + "The patient is a 47-year-old woman with spinocerebellar degeneration.", + "She was admitted because of a well-defined mass measuring 48 × 31 mm in the anterior mediastinum.", + "She showed limb, truncal, ocular, and speech ataxia.", + "She showed hypotonia, areflexia, sensory disturbances, and muscle weakness.", + "Her eastern cooperative oncology group performance status was 4.", + "Surgical resection was performed via video-assisted thoracic surgery.", + "The surgery was performed under general anesthesia only without epidural analgesia.", + "The mass was diagnosed as type B1 thymoma without capsular invasion.", + "The mass was diagnosed as Masaoka stage I.", + "The patients got a good postoperative course by cooperation with anesthesiologists and neurologists in perioperative managements.", + "She has been well over 3 years of follow-up." + ] + }, + { + "id": "multiclinsum_test_2771_en.txt", + "fulltext": "A 74-year-old non-smoking woman was diagnosed with the right lung shadow following a chest computed tomography (CT) scan . She was admitted to the hospital because of coma after misusing hypnotics. Primary lung adenocarcinoma was diagnosed through radiological examinations and a lung biopsy in the right lower lobe. Immunohistochemically, it showed TTF-1 (+), Napsin A (+), CK5/6 (−), P40 (−), Ki-67 (<5%+), and AE1/AE3 (+). Surgery was not pursued due to concerns regarding age and tolerability. Enhanced CT scan revealed a 35 mm * 25 mm mass in the dorsal segment of the lower lobe in the right lung, accompanied by obstructive inflammation. Multiple slightly enlarged lymph nodes were observed in the mediastinum and hilum of the right lung (cT2N2Mx). At that time, the formalin-fixed paraffin-embedded (FFPE) tissue was examined using an NGS-based assay (Covance CLS China) and the METex14 splice region mutation was identified as c.3028G>T with the abundance of 18.81%. The woman began orally administering tepotinib (Merck-0.5g, once daily). After 1 month, a CT scan revealed that the mass on the right lung lesion had decreased in size to 14 mm * 13 mm. After nearly 5 months since the discontinuation of tepotinib, a chest CT revealed that the mass had reduced to 13 mm * 11 mm, marking the best response. However, the lesion in the right lung increased to 18 mm * 12 mm after 7.6 months of tepotinib treatment, indicating disease progression. Afterward, tepotinib treatment was discontinued.\nAdditionally, at this time, radiological examinations confirmed the diagnosis of NSCLC, with enlarged mediastinal, right hilar, and bilateral inguinal lymph nodes (cT2N3M1a, stage IVA). In addition, a fine-needle aspiration re-biopsy of the lung was performed for the NGS-based assay (OncoScreen® Focus panel, Burning Rock Dx), which revealed the same METex14 splice region mutations as previously identified, NM_000245.3(MET): c.3028G>T(p. Asp1010Tyr), without any newly identified resistant mutations. The patient was then enrolled in cohort 4 of a clinical trial (KUNPENG, NCT04258033) and initiated on vebreltinib (200 mg twice daily) as a second-line therapy. The patient had stable disease for 6.8 months.\nThe woman achieved her first PR after 6.8 months from vebreltinib treatment, and further reduction was observed in the size of the mass in the right lung (10.5 mm). The most recent chest CT shows an overall decrease (10.3 mm) in the size of the mass in the right lower lobe, and the treatment was ongoing for over 20 months. The DoR and PFS exceeded 13 months and 20 months, respectively. As of the latest visit, she maintained the response without any Grade 3 or above adverse events (AEs) and serious adverse events. No treatment-emergent adverse events led to permanent treatment discontinuation or dose reduction.\nThe woman developed Grade 2 bilateral lower-extremity edema, which was managed with spironolactone tablets. The patient had mild peripheral edema before starting vebreltinib treatment. A grade 2 AE of anemia was observed twice and recovered after intervention with traditional Chinese medicine. Grade 1 AEs of hyponatremia, amylase increase, and lipase increase were also observed once each, and they recovered without any intervention. A Grade 2 AE of ankle pain was still ongoing but was not considered related to the treatment.", + "fulltext_subclaims": [ + "A 74-year-old non-smoking woman was diagnosed with the right lung shadow following a chest computed tomography (CT) scan.", + "She was admitted to the hospital because of coma after misusing hypnotics.", + "Primary lung adenocarcinoma was diagnosed through radiological examinations and a lung biopsy in the right lower lobe.", + "Immunohistochemically, it showed TTF-1 (+), Napsin A (+), CK5/6 (−), P40 (−), Ki-67 (<5%+), and AE1/AE3 (+).", + "Surgery was not pursued due to concerns regarding age and tolerability.", + "Enhanced CT scan revealed a 35 mm * 25 mm mass in the dorsal segment of the lower lobe in the right lung.", + "Multiple slightly enlarged lymph nodes were observed in the mediastinum and hilum of the right lung (cT2N2Mx).", + "The formalin-fixed paraffin-embedded (FFPE) tissue was examined using an NGS-based assay (Covance CLS China).", + "The METex14 splice region mutation was identified as c.3028G>T with the abundance of 18.81%.", + "The woman began orally administering tepotinib (Merck-0.5g, once daily).", + "After 1 month, a CT scan revealed that the mass on the right lung lesion had decreased in size to 14 mm * 13 mm.", + "After nearly 5 months since the discontinuation of tepotinib, a chest CT revealed that the mass had reduced to 13 mm * 11 mm, marking the best response.", + "The lesion in the right lung increased to 18 mm * 12 mm after 7.6 months of tepotinib treatment, indicating disease progression.", + "Radiological examinations confirmed the diagnosis of NSCLC, with enlarged mediastinal, right hilar, and bilateral inguinal lymph nodes (cT2N3M1a, stage IVA).", + "A fine-needle aspiration re-biopsy of the lung was performed for the NGS-based assay (OncoScreen® Focus panel, Burning Rock Dx).", + "The same METex14 splice region mutations as previously identified, NM_000245.3(MET): c.3028G>T(p. Asp1010Tyr), were found without any newly identified resistant mutations.", + "The patient was enrolled in cohort 4 of a clinical trial (KUNPENG, NCT04258033) and initiated on vebreltinib (200 mg twice daily) as a second-line therapy.", + "The patient had stable disease for 6.8 months.", + "The woman achieved her first PR after 6.8 months from vebreltinib treatment.", + "The most recent chest CT shows an overall decrease (10.3 mm) in the size of the mass in the right lower lobe.", + "The treatment was ongoing for over 20 months.", + "The DoR and PFS exceeded 13 months and 20 months, respectively.", + "As of the latest visit, she maintained the response without any Grade 3 or above adverse events (AEs) and serious adverse events.", + "No treatment-emergent adverse events led to permanent treatment discontinuation or dose reduction.", + "The woman developed Grade 2 bilateral lower-extremity edema, which was managed with spironolactone tablets.", + "The patient had mild peripheral edema before starting vebreltinib treatment.", + "A grade 2 AE of anemia was observed twice and recovered after intervention with traditional Chinese medicine.", + "Grade 1 AEs of hyponatremia, amylase increase, and lipase increase were also observed once each, and they recovered without any intervention.", + "A Grade 2 AE of ankle pain was still ongoing but was not considered related to the treatment." + ], + "summary": "We report the first case of a 74-year-old woman with lung adenocarcinoma (cT1cNxM0) harboring METex14 splice region mutation, which was identified by a next-generation sequencing (NGS)-based assay. The patient was administered two treatments, including first-line tepotinib and second-line vebreltinib. The patient achieved progression-free survival (PFS) of 7.6 months, and then disease progression of tepotinib was observed. A re-biopsy was performed for NGS, which revealed the same mutations as before, with no new gene mutations detected. The woman received subsequent vebreltinib therapy and experienced durable clinical benefits. In the first 6.8 months, chest computed tomography demonstrated stable disease. Then, she achieved partial response (PR). The durable PR lasted for more than 13 months, and the PFS is currently over 20 months, exceeding the prior treatment.", + "summary_subclaims": [ + "The patient was a 74-year-old woman with lung adenocarcinoma (cT1cNxM0).", + "The tumor harbored a METex14 splice region mutation.", + "The mutation was identified by a next-generation sequencing (NGS)-based assay.", + "The patient received first-line tepotinib.", + "The patient received second-line vebreltinib.", + "The patient achieved progression-free survival (PFS) of 7.6 months.", + "Disease progression of tepotinib was observed.", + "A re-biopsy was performed for NGS.", + "The re-biopsy revealed the same mutations as before.", + "No new gene mutations were detected.", + "The woman received subsequent vebreltinib therapy.", + "Chest computed tomography demonstrated stable disease in the first 6.8 months.", + "She achieved partial response (PR).", + "The durable PR lasted for more than 13 months.", + "The PFS is currently over 20 months." + ] + }, + { + "id": "multiclinsum_test_2786_en.txt", + "fulltext": "A 27-year-old woman presented with progressively worsening chest tightness and shortness of breath on exertion.\nSix years ago, the patient began to experience chest distress and shortness of breath after activity, which was relieved after rest. The patient had occasional tussiculation but no paroxysmal dyspnea. She had low energy and lack of appetite, but her sleep quality was fair. The patient’s growth and development were within the normal range. Over time, the symptoms of chest tightness worsened, and were accompanied by dizziness and numbness of the extremities.\nThe patient had a history of incomplete abortion one year ago and had been treated with induced abortion.\nThe patient had never smoked and had no family history of heart or lung disease. She had congenital heart disease since childhood without standard treatment. The patient stated that she had a \"cold\" once a month. Symptoms such as shortness of breath and weakness appeared after walking up one flight of stairs and the symptoms were relieved after rest.\nOn admission, her blood pressure was 100/64 mmHg in both arms and her heart rate was approximately 74 bpm. Physical examination revealed that her heart rate was regular, and there was a 3/6 systolic murmur on the aortic second auscultation area. She had cyanotic lips and clubbing of her fingers.\nRoutine laboratory examinations were within normal limits.\nThe patient underwent multimodal imaging. A transthoracic echocardiogram revealed that the main pulmonary artery was dilated with a diameter of 54 mm. There was an abnormal passage between the descending aorta and pulmonary artery with an inner diameter of 9 mm. The entire heart was enlarged. The continuity of the ventricular septal outflow tract was interrupted, and the defect size was approximately 14 mm. Doppler ultrasound evaluation found bidirectional reflux of abnormal channels between the descending aorta and pulmonary artery, which was thought to be a patent ductus arteriosus (PDA) in the interrupted region . Chest radiography showed an enlarged heart shadow, a prominent pulmonary artery, and increased lung texture, which was consistent with pulmonary congestion . Computed tomography angiography (CTA) showed enlargement of the right heart and absence of the aortic arch. The descending aorta originated from the pulmonary trunk, and the junction was 13 mm wide. The diameter of the main pulmonary artery and the right pulmonary artery were thickened. The main pulmonary artery was 54 mm wide, and the right pulmonary artery was 27 mm wide. The ventricular septal wall defect measured 17 mm at the level of the right ventricular outflow tract. The aorta was shifted forward and to the right, straddling the two ventricles . Ven-triculography was performed via the left femoral arteries. Right ventriculography showed pulmonary artery dilatation with residual lung signs. Contrast medium was abnormally seen simultaneously in the left ventricle, ascending aorta, and descending aorta .", + "fulltext_subclaims": [ + "The patient is a 27-year-old woman.", + "She presented with progressively worsening chest tightness and shortness of breath on exertion.", + "Six years ago, the patient began to experience chest distress and shortness of breath after activity.", + "The symptoms were relieved after rest.", + "The patient had occasional tussiculation.", + "She had no paroxysmal dyspnea.", + "She had low energy and lack of appetite.", + "Her sleep quality was fair.", + "The patient’s growth and development were within the normal range.", + "Over time, the symptoms of chest tightness worsened.", + "The symptoms were accompanied by dizziness and numbness of the extremities.", + "The patient had a history of incomplete abortion one year ago.", + "She had been treated with induced abortion.", + "The patient had never smoked.", + "She had no family history of heart or lung disease.", + "She had congenital heart disease since childhood.", + "She had not received standard treatment for congenital heart disease.", + "The patient stated that she had a 'cold' once a month.", + "Symptoms such as shortness of breath and weakness appeared after walking up one flight of stairs.", + "The symptoms were relieved after rest.", + "On admission, her blood pressure was 100/64 mmHg in both arms.", + "Her heart rate was approximately 74 bpm.", + "Physical examination revealed a 3/6 systolic murmur on the aortic second auscultation area.", + "She had cyanotic lips.", + "She had clubbing of her fingers.", + "Routine laboratory examinations were within normal limits.", + "A transthoracic echocardiogram revealed that the main pulmonary artery was dilated with a diameter of 54 mm.", + "There was an abnormal passage between the descending aorta and pulmonary artery with an inner diameter of 9 mm.", + "The entire heart was enlarged.", + "The continuity of the ventricular septal outflow tract was interrupted.", + "The defect size was approximately 14 mm.", + "Doppler ultrasound evaluation found bidirectional reflux of abnormal channels between the descending aorta and pulmonary artery.", + "The abnormal channels were thought to be a patent ductus arteriosus (PDA) in the interrupted region.", + "Chest radiography showed an enlarged heart shadow.", + "Chest radiography showed a prominent pulmonary artery.", + "Chest radiography showed increased lung texture.", + "Chest radiography findings were consistent with pulmonary congestion.", + "Computed tomography angiography (CTA) showed enlargement of the right heart.", + "CTA showed absence of the aortic arch.", + "The descending aorta originated from the pulmonary trunk.", + "The junction was 13 mm wide.", + "The diameter of the main pulmonary artery and the right pulmonary artery were thickened.", + "The main pulmonary artery was 54 mm wide.", + "The right pulmonary artery was 27 mm wide.", + "The ventricular septal wall defect measured 17 mm at the level of the right ventricular outflow tract.", + "The aorta was shifted forward and to the right, straddling the two ventricles.", + "Ventriculography was performed via the left femoral arteries.", + "Right ventriculography showed pulmonary artery dilatation.", + "Right ventriculography showed residual lung signs.", + "Contrast medium was abnormally seen simultaneously in the left ventricle, ascending aorta, and descending aorta." + ], + "summary": "A 27-year-old woman presented with a 6-year history of progressively worsening shortness of breath and chest tightness on exertion. She had cyanotic lips and clubbing of the fingers. A transthoracic echocardiogram revealed an enlarged heart and dilation of the main pulmonary artery. There was an abnormal 9 mm passage between the descending aorta and pulmonary artery. The ventricular septal outflow tract had a 14 mm defect. Doppler ultrasound suggested a patent ductus arteriosus and computed tomographic angiography showed the absence of the aortic arch. The diagnoses were ventricular septal defect, patent ductus arteriosus, and definite interruption of the aortic arch. Although surgical correction was recommended, the patient declined due to the surgical risks and was treated with medications to reduce pulmonary artery pressure and treat heart failure. Her condition has been stable for 12 mo of follow-up.", + "summary_subclaims": [ + "The patient is a 27-year-old woman.", + "She had a 6-year history of progressively worsening shortness of breath and chest tightness on exertion.", + "She had cyanotic lips.", + "She had clubbing of the fingers.", + "A transthoracic echocardiogram revealed an enlarged heart.", + "A transthoracic echocardiogram revealed dilation of the main pulmonary artery.", + "There was an abnormal 9 mm passage between the descending aorta and pulmonary artery.", + "The ventricular septal outflow tract had a 14 mm defect.", + "Doppler ultrasound suggested a patent ductus arteriosus.", + "Computed tomographic angiography showed the absence of the aortic arch.", + "The diagnoses were ventricular septal defect, patent ductus arteriosus, and definite interruption of the aortic arch.", + "Surgical correction was recommended.", + "The patient declined surgery due to the surgical risks.", + "She was treated with medications to reduce pulmonary artery pressure and treat heart failure.", + "Her condition has been stable for 12 mo of follow-up." + ] + }, + { + "id": "multiclinsum_test_3183_en.txt", + "fulltext": "33-year-old woman with a history of essential hypertension who is attending a dermatology evaluation for her 15-day-old newborn son due to the recent appearance of non-scaling, erythematous, raised-border, round plaques that began in the retroauricular region 5 days after birth and then spread to the abdomen, posterior trunk and both newborn's inguinal folds. The newborn, born in winter, did not receive phototherapy at any time.\n\nThe mother, who had a normal pregnancy with no relevant perinatal history, had no personal or family history of connective tissue disorders.\n\nDue to the high suspicion of neonatal lupus, both the mother and the newborn were examined. The mother presented positive antinuclear antibodies with a titer of 1/1280, a spotted pattern, positive anti-double-stranded DNA antibodies with a titer of 1/20 and positive anti-RO and anti-LA antibodies with values greater than 200 U/ ml. She was evaluated in rheumatology and in a directed questioning she reported a history of fatigue, alopecia, xeroftalmia, acrocyanosis and recurrent non-painful ulcers at the level of the labial mucosa. Physical examination showed malar erythema and reticular livedo outlined on both upper extremities. The diagnosis of systemic lupus erythematosus with associated Sjogren's syndrome was raised, supported by a Schirmer's test consistent with severe dry eye due to hypolacrimia. Steroidal therapy was initiated with prednisone 20 mg daily for 30 days, then decreasing doses for 8 weeks until discontinuation associated with hydroxychloroquine at doses of 200 and 400 mg on alternate days, with good response and improvement of the general condition. The mother remains stable with her underlying disease and is under rheumatology control to date.\n\nIn the newborn examination, an initial electrocardiogram was within normal limits, then a Holter rhythm monitor showed normal atrio-ventricular and intra-ventricular conduction and an echocardiogram showed a patent foramen ovale. In the blood tests, moderate neutropenia (ANC = 620), altered liver tests with mild elevation of transaminases (GOT 95 IU/L and GPT 130 IU/L) and the presence of anti-Ro and anti-La antibodies were noted. Photoprotection was indicated and follow-up was performed with examinations at 2 and 5 months of life that showed recovery of neutropenia, normalization of liver tests and decrease of the anti-Ro and anti-La antibodies. In the dermatological controls, complete regression of the skin lesions was observed at 2 months of follow-up.\n", + "fulltext_subclaims": [ + "The patient is a 33-year-old woman with a history of essential hypertension.", + "The newborn is 15 days old.", + "The newborn has non-scaling, erythematous, raised-border, round plaques.", + "The plaques began in the retroauricular region 5 days after birth.", + "The plaques spread to the abdomen, posterior trunk, and both inguinal folds.", + "The newborn did not receive phototherapy at any time.", + "The mother had a normal pregnancy with no relevant perinatal history.", + "The mother had no personal or family history of connective tissue disorders.", + "The mother had positive antinuclear antibodies with a titer of 1/1280.", + "The mother had positive anti-double-stranded DNA antibodies with a titer of 1/20.", + "The mother had positive anti-RO and anti-LA antibodies with values greater than 200 U/ml.", + "The mother reported a history of fatigue, alopecia, xeroftalmia, acrocyanosis, and recurrent non-painful ulcers at the level of the labial mucosa.", + "The mother had malar erythema.", + "The mother had reticular livedo outlined on both upper extremities.", + "The mother was diagnosed with systemic lupus erythematosus with associated Sjogren's syndrome.", + "The mother's Schirmer's test was consistent with severe dry eye due to hypolacrimia.", + "The mother was treated with prednisone 20 mg daily for 30 days.", + "The mother was treated with hydroxychloroquine at doses of 200 and 400 mg on alternate days.", + "The mother had good response and improvement of the general condition.", + "The mother remains stable with her underlying disease.", + "The mother is under rheumatology control to date.", + "The newborn's initial electrocardiogram was within normal limits.", + "The newborn's Holter rhythm monitor showed normal atrio-ventricular and intra-ventricular conduction.", + "The newborn's echocardiogram showed a patent foramen ovale.", + "The newborn had moderate neutropenia with an ANC of 620.", + "The newborn had mild elevation of transaminases with GOT 95 IU/L and GPT 130 IU/L.", + "The newborn had the presence of anti-Ro and anti-La antibodies.", + "Photoprotection was indicated for the newborn.", + "The newborn had follow-up examinations at 2 and 5 months of life.", + "The newborn's neutropenia resolved.", + "The newborn's liver tests normalized.", + "The newborn's anti-Ro and anti-La antibodies decreased.", + "The newborn's skin lesions completely regressed at 2 months of follow-up." + ], + "summary": "33-year-old woman with a history of hypertension, consulted in dermatology for her 15-day-old male neonate, who presented with a recent appearance of rounded, erythematous, raised, non-descamative plaques, consistent with LEN. Myocardial conduction compromise was ruled out. The neonate's examinations highlighted moderate neutropenia, mild elevation of transaminases and positive anti-Ro and anti-La antibodies. In a directed question, the mother reported a personal history of symptoms consistent with connective tissue diseases, such as fatigue, alopecia and xeroftalmia. Antinuclear antibodies were requested from the mother, who presented a titre of 1/1280 with a spotted pattern, anti-Ro and anti-La antibodies and positive anti-double-stranded DNA antibodies, and a Schirmer's test consistent with dry eye, so systemic lupus erythematosus with associated Sjögren's syndrome was diagnosed. The infant was monitored for 5 months with remission of the cutaneous signs and normalisation of the laboratory examinations.\n", + "summary_subclaims": [ + "The neonate is a 15-day-old male.", + "The neonate presented with rounded, erythematous, raised, non-descamative plaques.", + "The lesions were consistent with LEN.", + "Myocardial conduction compromise was ruled out.", + "The neonate had moderate neutropenia.", + "The neonate had mild elevation of transaminases.", + "The neonate had positive anti-Ro and anti-La antibodies.", + "The mother reported fatigue.", + "The mother reported alopecia.", + "The mother reported xeroftalmia.", + "Antinuclear antibodies were requested from the mother.", + "The mother had an antinuclear antibody titre of 1/1280 with a spotted pattern.", + "The mother had positive anti-Ro and anti-La antibodies.", + "The mother had positive anti-double-stranded DNA antibodies.", + "The mother had a Schirmer's test consistent with dry eye.", + "Systemic lupus erythematosus with associated Sjögren's syndrome was diagnosed in the mother.", + "The infant was monitored for 5 months.", + "The infant's cutaneous signs went into remission.", + "The infant's laboratory examinations normalized." + ] + }, + { + "id": "multiclinsum_test_156_en.txt", + "fulltext": "A 25-year-old African American female presented to the Emergency Department (ED) complaining of diffuse abdominal pain, non-bloody diarrhea, nausea, and non-bloody emesis.\nThe patient’s symptoms started the day prior to arrival to the ED. She described the abdominal pain as sudden onset, sharp and stabbing in quality, 10 out of 10 in intensity, and located in the suprapubic region with radiation to the right and left flanks. She denied any rash (including malar erythema), aphthous ulcers, hematuria, pleuritic chest pain, shortness of breath, or fever. Of note, several months prior, the patient had developed left eyelid swelling non-specific arthralgias (without swelling) of her wrists, fingers, and ankles. Her workup, including autoimmune laboratory tests, was inconclusive at the time. No diagnosis was made. Her arthralgias resolved spontaneously after a few days. She denied any arthralgias at the time of examination. The rest of her review of systems was non-contributory.\nHer past medical history was significant for seasonal allergies. Her family history was significant for discoid lupus in her father, rheumatoid arthritis (RA) in one of her paternal cousins, and SLE in another paternal cousin.\nOn presentation, the patient’s vital signs were normal: 36.7 °C, heart rate of 92 bpm, blood pressure of 110/70 mmHg, respiratory rate of 18, and oxygen saturation of 100% on room air. Her abdominal exam revealed normal bowel sounds, mild abdominal distention but no lesions, scars, or hernias. There was significant lower abdominal tenderness without guarding or rigidity.\nInitial laboratory testing included a complete blood count (CBC) and comprehensive metabolic panel (CMP) . The patient had leukopenia with a WBC count of 3.25 k/uL, lymphopenia with an absolute lymphocyte count of 740, and anemia with a hemoglobin level of 11.7 g/dL. The CMP revealed a low albumin of 3.1 but was otherwise normal.\nA contrast computed tomography of the abdomen and pelvis done in the emergency room revealed marked circumferential wall thickening and edema of the proximal and mid small bowel loops predominantly involving the submucosa .\nAt this point, the main differential diagnoses were intestinal angioedema and mesenteric vein thrombosis given the radiographic findings. However, the mesenteric vessels were patent, and there was no evidence of thrombosis. Laboratory testing for hereditary angioedema showed a normal C1 Esterase inhibitor level, low C3 (48 mg/dL), and low C4 (4 mg/dL) . Autoimmune work-up revealed elevated ANA of 13.6, normal double stranded DNA antibody of 25 IU/mL (anti-dsDNA ab), high anti-Smith antibody (>8 AI), and high anti-ribonucleic protein of 6.9 AI (anti-RNP) antibody . A urinalysis to screen for concomitant lupus nephritis did not show hematuria or red blood cell casts, and a urine protein to creatinine ratio was negative (0.1).", + "fulltext_subclaims": [ + "The patient is a 25-year-old African American female.", + "She presented to the Emergency Department with diffuse abdominal pain.", + "She had non-bloody diarrhea.", + "She had nausea.", + "She had non-bloody emesis.", + "Her symptoms started the day prior to arrival.", + "The abdominal pain was sudden onset.", + "The pain was sharp and stabbing in quality.", + "The pain was 10 out of 10 in intensity.", + "The pain was located in the suprapubic region.", + "The pain radiated to the right and left flanks.", + "She denied any rash, including malar erythema.", + "She denied aphthous ulcers.", + "She denied hematuria.", + "She denied pleuritic chest pain.", + "She denied shortness of breath.", + "She denied fever.", + "Several months prior, she had developed left eyelid swelling.", + "She had non-specific arthralgias of her wrists, fingers, and ankles.", + "The arthralgias resolved spontaneously after a few days.", + "She denied any arthralgias at the time of examination.", + "Her past medical history was significant for seasonal allergies.", + "Her family history was significant for discoid lupus in her father.", + "Her family history was significant for rheumatoid arthritis in one paternal cousin.", + "Her family history was significant for SLE in another paternal cousin.", + "On presentation, her vital signs were normal.", + "Her abdominal exam revealed normal bowel sounds.", + "There was mild abdominal distention.", + "There was significant lower abdominal tenderness.", + "There was no guarding or rigidity.", + "Initial laboratory testing included a complete blood count and comprehensive metabolic panel.", + "The patient had leukopenia with a WBC count of 3.25 k/uL.", + "The patient had lymphopenia with an absolute lymphocyte count of 740.", + "The patient had anemia with a hemoglobin level of 11.7 g/dL.", + "The CMP revealed a low albumin of 3.1.", + "A contrast computed tomography of the abdomen and pelvis showed marked circumferential wall thickening and edema of the proximal and mid small bowel loops.", + "The main differential diagnoses were intestinal angioedema and mesenteric vein thrombosis.", + "The mesenteric vessels were patent.", + "There was no evidence of thrombosis.", + "Laboratory testing for hereditary angioedema showed a normal C1 Esterase inhibitor level.", + "The patient had low C3 (48 mg/dL).", + "The patient had low C4 (4 mg/dL).", + "Autoimmune work-up revealed elevated ANA of 13.6.", + "The double stranded DNA antibody was normal at 25 IU/mL.", + "The anti-Smith antibody was high (>8 AI).", + "The anti-RNP antibody was high at 6.9 AI.", + "A urinalysis did not show hematuria or red blood cell casts.", + "A urine protein to creatinine ratio was negative (0.1)." + ], + "summary": "A 25-year-old African American female presented to the Emergency Department complaining of diffuse abdominal pain, diarrhea, nausea, and vomiting for 2 days. Her past medical history was significant for seasonal allergies and family history was pertinent for discoid lupus in her father and SLE in a cousin. The patient's vital signs on presentation were normal. Her physical exam was remarkable for significant lower abdominal tenderness without guarding or rigidity. A computed tomography of the abdomen and pelvis revealed marked circumferential wall thickening and edema of the proximal and mid small bowel predominantly involving the submucosa. Our main differential diagnoses were intestinal angioedema and mesenteric vein thrombosis. However, mesenteric vessels were patent, and laboratory testing for hereditary angioedema showed a normal C1 Esterase Inhibitor level and low C3 and C4 levels. Infectious work-up was negative. Autoimmune tests showed elevated anti-nuclear antibodies (ANA) (13.6), anti-Smith antibody, and anti-ribonucleoprotein (anti-RNP) antibody. The patient was diagnosed with SLE enteritis. She was maintained on bowel rest, given intravenous hydration, and started on methylprednisolone 60 mg IV daily. She had significant improvement in her abdominal pain, diarrhea, and emesis after 2 days of treatment. Steroids were tapered and maintained on Hydroxychloroquine with no relapses one year after presentation.", + "summary_subclaims": [ + "The patient is a 25-year-old African American female.", + "She presented with diffuse abdominal pain, diarrhea, nausea, and vomiting for 2 days.", + "Her past medical history was significant for seasonal allergies.", + "Her family history was pertinent for discoid lupus in her father and SLE in a cousin.", + "The patient's vital signs on presentation were normal.", + "The physical exam was remarkable for significant lower abdominal tenderness without guarding or rigidity.", + "A computed tomography of the abdomen and pelvis revealed marked circumferential wall thickening and edema of the proximal and mid small bowel.", + "The main differential diagnoses were intestinal angioedema and mesenteric vein thrombosis.", + "Mesenteric vessels were patent.", + "Laboratory testing showed a normal C1 Esterase Inhibitor level.", + "Laboratory testing showed low C3 and C4 levels.", + "Infectious work-up was negative.", + "Autoimmune tests showed elevated anti-nuclear antibodies (ANA) (13.6).", + "Autoimmune tests showed anti-Smith antibody.", + "Autoimmune tests showed anti-ribonucleoprotein (anti-RNP) antibody.", + "The patient was diagnosed with SLE enteritis.", + "She was maintained on bowel rest.", + "She was given intravenous hydration.", + "She was started on methylprednisolone 60 mg IV daily.", + "She had significant improvement in her abdominal pain, diarrhea, and emesis after 2 days of treatment.", + "Steroids were tapered.", + "She was maintained on Hydroxychloroquine.", + "There were no relapses one year after presentation." + ] + }, + { + "id": "multiclinsum_test_2250_en.txt", + "fulltext": "A 67-year-old male presented for the repair of a chronic type A ascending aortic dissection, aortic valve replacement, and single vessel coronary artery bypass graft revision. The patient’s past medical history included a prior CABGx3 in 2008 at an outside hospital, coronary artery disease, rheumatic aortic stenosis, hypertension, diabetes, and dyslipidemia. Of note, one of the patient’s bypass grafts (saphenous vein graft to the first diagonal artery) was occluded as it arose from the false lumen of the ascending aortic dissection. On the pre-bypass TEE exam, the anesthesiologist noted a bifurcated CS with two small lumens (approximately 0.4 cm and 0.5 cm in luminal diameter) . The surgeon utilized this information to select a smaller diameter retrograde catheter to avoid damage or perforation of the vessel. With TEE guidance, the surgeon successfully cannulated one of the CS lumens . However, it was noted upon dosing of retrograde cardioplegia that all tributary vessels attached to the non-cannulated lumen remained devoid of cardioplegia, suggesting the bifurcation was noncommunicating between the two lumens. As a result of this blockage, the surgeon was forced to repeatedly administer anterograde cardioplegia via a handheld catheter through the coronary ostium throughout the case. The operative field was also flooded with topical ice saline slush to ensure cardiac protection. Ultimately, the operation was completed without incident despite the non-ideal conditions resulting from this anatomic variant.", + "fulltext_subclaims": [ + "The patient is a 67-year-old male.", + "The patient presented for the repair of a chronic type A ascending aortic dissection.", + "The patient had aortic valve replacement.", + "The patient had single vessel coronary artery bypass graft revision.", + "The patient’s past medical history included a prior CABGx3 in 2008 at an outside hospital.", + "The patient had coronary artery disease.", + "The patient had rheumatic aortic stenosis.", + "The patient had hypertension.", + "The patient had diabetes.", + "The patient had dyslipidemia.", + "One of the patient’s bypass grafts (saphenous vein graft to the first diagonal artery) was occluded as it arose from the false lumen of the ascending aortic dissection.", + "On the pre-bypass TEE exam, the anesthesiologist noted a bifurcated CS with two small lumens (approximately 0.4 cm and 0.5 cm in luminal diameter).", + "The surgeon utilized this information to select a smaller diameter retrograde catheter to avoid damage or perforation of the vessel.", + "With TEE guidance, the surgeon successfully cannulated one of the CS lumens.", + "It was noted upon dosing of retrograde cardioplegia that all tributary vessels attached to the non-cannulated lumen remained devoid of cardioplegia.", + "This suggested the bifurcation was noncommunicating between the two lumens.", + "As a result of this blockage, the surgeon was forced to repeatedly administer anterograde cardioplegia via a handheld catheter through the coronary ostium throughout the case.", + "The operative field was flooded with topical ice saline slush to ensure cardiac protection.", + "The operation was completed without incident despite the non-ideal conditions resulting from this anatomic variant." + ], + "summary": "A 67-year-old male presented for ascending aortic dissection repair, aortic valve replacement, and single vessel coronary artery bypass graft. On the pre-bypass TEE exam, the anesthesiologist noted a bifurcated CS with two small lumens. The surgeon utilized this information to select a smaller diameter retrograde catheter to avoid damage or perforation of the vessel. With TEE guidance, the surgeon successfully cannulated one of the CS lumens. However, it was noted upon dosing of retrograde cardioplegia that all tributary vessels attached to the non-cannulated lumen remained devoid of cardioplegia. The surgeon was forced to repeatedly administer anterograde cardioplegia via a handheld catheter through the coronary ostium throughout the case. The operative field was also flooded with topical ice saline slush to ensure cardiac protection. Ultimately, the operation was completed without incident despite the non-ideal conditions resulting from this anatomic variant.", + "summary_subclaims": [ + "The patient was a 67-year-old male.", + "The patient presented for ascending aortic dissection repair.", + "The patient presented for aortic valve replacement.", + "The patient presented for single vessel coronary artery bypass graft.", + "On the pre-bypass TEE exam, the anesthesiologist noted a bifurcated CS with two small lumens.", + "The surgeon selected a smaller diameter retrograde catheter to avoid damage or perforation of the vessel.", + "The surgeon cannulated one of the CS lumens with TEE guidance.", + "Upon dosing of retrograde cardioplegia, all tributary vessels attached to the non-cannulated lumen remained devoid of cardioplegia.", + "The surgeon repeatedly administered anterograde cardioplegia via a handheld catheter through the coronary ostium throughout the case.", + "The operative field was flooded with topical ice saline slush to ensure cardiac protection.", + "The operation was completed without incident." + ] + }, + { + "id": "multiclinsum_test_121_en.txt", + "fulltext": "A 38-year-old man presented with decreased vision in both eyes for 2 years. The patient had undergone ICL (ICL V4 Visian, STAAR Surgical Co., Monrovia, California, U.S.A.) implantation in both eyes 6 years prior. Postoperatively, the uncorrected distance visual acuity (UDVA) of both eyes was 20/32. The corrected distance visual acuity (CDVA) was similar to the UDVA.\nOn examination, ICLs were in situ with anterior subcapsular cataracts in both eyes . Both eyes underwent anterior segment optical coherence tomography (AS-OCT; CASIA SS-1000, Tomey Corp., Nagoya, Japan) imagining in the model of 3D. Then the ICL vault was manually measured from the back surface of the ICL to the front surface of crystalline lens, centered on the optic axis (shown as a white beam). The vault was shallow in the right eye and measured 72 μm through AS-OCT images. However, in the left eye, the ICL touched the anterior capsule, existing “0” vault . The endothelial cell density, calculated by the noncontact autofocus specular microscope (EM-3000, Tomey Corp., Nagoya, Japan), was 2587 cells/millimeter squared (mm2) in the right eye and 2531 cells/mm2 in the left eye.\nThe patient had planned explantation of the ICL with FLACS after obtaining written informed consent. Considering the unsatisfactory CDVA of the patient after ICL implantation, the surgeon suggested a monovision design for the patient with the implantation of monofocal IOLs rather than multifocal IOLs. And the LenSx laser system (LenSx Laser, Alcon Laboratories, Inc., Fort Worth, Texas, U.S.A.) was used for capsulotomy (5.1 mm diameter, 8 μJ energy) and chop nuclear pre-fragmentation (5.0 mm diameter, 6 chops, 8 μJ energy).\nThe surgery was performed first in the left “0” vault eye. Cavitation bubbles were trapped in the shallow space beneath the ICL around the capsulotomy area during the capsulotomy, developing from small bubbles into big ones . No additional cavitation bubbles appeared during nuclear pre-fragmentation.\nThen, a 2.0 mm primary superior corneal incision was made with a keratome at 135 degrees (°). The sodium hyaluronate 1.7% ophthalmic viscosurgical device (OVD, Amvisc Plus, Bausch & Lomb, Inc.) was injected into the anterior chamber. At first, we attempted to remove the ICL directly without rotating it but failed with the rupture of the ICL. Next, we carefully rotated the ICL. After its vertical angle faced the incision, the ICL was grasped with forceps and extracted through the corneal incision. After the removal of the ICL, the capsulotomy was found to be incomplete between the coordinates of nine o’clock and two o’clock. A second capsulorhexis according to the laser tracks was safely made . The nuclear pre-fragmentation was unsuccessful and could not be tracked.\nThe phacoemulsification was manipulated in a standard stop-and-chop manner with the Stellaris system (Bausch & Lomb Laboratories, Rochester, New York, U.S.A.), followed by the implantation of the hydrophobic IOL (Tecnis ZCB00, Abbott Medical Optics Inc., Santa Ana, CA) in the capsular bag.\nThe surgery was performed on the right eye one and a half months later. Learning from the experience of the left eye surgery, we made a 3.0 mm temporal corneal incision in the right eye, and the ICL was extracted smoothly without rotation. This time, the capsulotomy was complete. Lots of small cavitation bubbles appeared, dispersing to the central area, and no big bubbles formed . The nuclear pre-fragmentation, however, failed again. Other steps of the surgery were the same as in the previous surgery and proceeded uneventfully. Both IOLs were well centered in the capsular bag at the end of the surgery.\nHowever, it is worth noting that during the process of laser identification, the anterior ICL surface was accidently confused with the anterior capsule, not only in the shallow vaulted right eye, but also in the “0” vaulted left eye. Manual adjustment by the surgeon was needed to assign treatment zones to the anterior capsule surface in both eyes .\nThe patient was instructed to apply topical dexamethasone tobramycin for 2 weeks and pranoprofen for 1 month postoperatively. At the two-week follow-up for the right eye (two-month follow-up for the left eye), in both eyes, the UDVA was 20/32, and the near uncorrected visual acuity (UCVA) was 20/25.", + "fulltext_subclaims": [ + "The patient was a 38-year-old man.", + "The patient had decreased vision in both eyes for 2 years.", + "The patient had undergone ICL implantation in both eyes 6 years prior.", + "The ICLs were ICL V4 Visian from STAAR Surgical Co.", + "The postoperative uncorrected distance visual acuity (UDVA) of both eyes was 20/32.", + "The corrected distance visual acuity (CDVA) was similar to the UDVA.", + "ICLs were in situ with anterior subcapsular cataracts in both eyes.", + "Anterior segment optical coherence tomography (AS-OCT) imaging was performed in the 3D model.", + "The ICL vault was manually measured from the back surface of the ICL to the front surface of the crystalline lens.", + "The vault was shallow in the right eye and measured 72 μm.", + "In the left eye, the ICL touched the anterior capsule, existing '0' vault.", + "The endothelial cell density in the right eye was 2587 cells/mm2.", + "The endothelial cell density in the left eye was 2531 cells/mm2.", + "The patient had planned explantation of the ICL with FLACS.", + "The surgeon suggested a monovision design with monofocal IOLs.", + "The LenSx laser system was used for capsulotomy.", + "The capsulotomy was 5.1 mm diameter with 8 μJ energy.", + "The surgery was performed first in the left '0' vault eye.", + "Cavitation bubbles were trapped in the shallow space beneath the ICL during capsulotomy.", + "No additional cavitation bubbles appeared during nuclear pre-fragmentation.", + "A 2.0 mm primary superior corneal incision was made with a keratome at 135 degrees.", + "Sodium hyaluronate 1.7% ophthalmic viscosurgical device was injected into the anterior chamber.", + "The ICL was first attempted to be removed directly without rotating it.", + "The ICL ruptured during the direct removal attempt.", + "The ICL was rotated, and its vertical angle faced the incision.", + "The ICL was grasped with forceps and extracted through the corneal incision.", + "The capsulotomy was found to be incomplete between nine o’clock and two o’clock.", + "A second capsulorhexis according to the laser tracks was safely made.", + "The nuclear pre-fragmentation was unsuccessful and could not be tracked.", + "Phacoemulsification was performed in a standard stop-and-chop manner.", + "The Tecnis ZCB00 hydrophobic IOL was implanted in the capsular bag.", + "The surgery was performed on the right eye one and a half months later.", + "A 3.0 mm temporal corneal incision was made in the right eye.", + "The ICL was extracted smoothly without rotation in the right eye.", + "The capsulotomy was complete in the right eye.", + "Lots of small cavitation bubbles appeared and dispersed to the central area.", + "The nuclear pre-fragmentation failed again.", + "Other steps of the surgery were the same as in the previous surgery.", + "Both IOLs were well centered in the capsular bag.", + "During laser identification, the anterior ICL surface was accidently confused with the anterior capsule.", + "Manual adjustment by the surgeon was needed to assign treatment zones.", + "The patient was instructed to apply topical dexamethasone tobramycin for 2 weeks.", + "The patient was instructed to apply topical pranoprofen for 1 month.", + "At the two-week follow-up for the right eye, the UDVA was 20/32.", + "At the two-month follow-up for the left eye, the UDVA was 20/32.", + "At the two-week follow-up for the right eye, the near UCVA was 20/25.", + "At the two-month follow-up for the left eye, the near UCVA was 20/25." + ], + "summary": "A 38-year-old man with anterior subcapsular cataracts underwent the FLACS combined with ICLs extraction 6 years after ICLs implantation in both eyes. In his left eye, the ICL touched the anterior capsule, existing \"0\" vault. During the capsulotomy, cavitation bubbles were trapped in the shallow space beneath the ICL, developing from small bubbles into big ones, which resulted in the incomplete capsulotomy. Comparatively, in the right eye, the ICL vault was measured 72 μm, and the capsulotomy was complete and no big cavitation bubbles formed. In both eyes, capsulotomy zones were manually assigned to the anterior capsule surface in the process of laser identification. However, the nuclear pre-fragmentations were unsuccessful in both eyes. Other steps of surgeries were performed uneventfully. Depending on the design of monovision, the uncorrected distance visual acuity (UDVA) was 20/32, and the near uncorrected visual acuity (UCVA) was 20/25 in both eyes postoperatively.", + "summary_subclaims": [ + "The patient is a 38-year-old man with anterior subcapsular cataracts.", + "The patient underwent FLACS combined with ICLs extraction 6 years after ICLs implantation in both eyes.", + "In the left eye, the ICL touched the anterior capsule, existing '0' vault.", + "During the capsulotomy, cavitation bubbles were trapped in the shallow space beneath the ICL.", + "The cavitation bubbles developed from small bubbles into big ones.", + "The incomplete capsulotomy resulted from the cavitation bubbles.", + "In the right eye, the ICL vault was measured 72 μm.", + "The capsulotomy was complete in the right eye.", + "No big cavitation bubbles formed in the right eye.", + "In both eyes, capsulotomy zones were manually assigned to the anterior capsule surface in the process of laser identification.", + "The nuclear pre-fragmentations were unsuccessful in both eyes.", + "Other steps of surgeries were performed uneventfully.", + "Depending on the design of monovision, the uncorrected distance visual acuity (UDVA) was 20/32 in both eyes postoperatively.", + "Depending on the design of monovision, the near uncorrected visual acuity (UCVA) was 20/25 in both eyes postoperatively." + ] + }, + { + "id": "multiclinsum_test_860_en.txt", + "fulltext": "Diffuse cutaneous erythematous plaques and nodules .\nIn May 2018, a 74-year-old man showed diffuse cutaneous erythematous plaques and nodules with irregular borders on the chest; the effect of anti-allergy treatment was not prominent.\nThe patient’s history of past illness was not remarkable.\nThe patient’s father had a history of hypertension, and his mother had a history of breast cancer.\nAfter the first examination, the number of cutaneous lesions increased progressively and involved the entire body, with diameters ranging from 0.5 to 1 cm. The patient’s overall physical condition was good, without B symptoms.\nSkin lesions on the trunk and scrotum were biopsied. Histopathological examination showed diffuse monomorphic lymphocyte infiltration in the dermal and subcutaneous layers, but not in the epidermis . The lymphoid cells were mostly small to medium in size, with irregular nuclear contours .\nImmunohistochemistry showed the following phenotypic characteristics: CD21 and CD23 staining displayed a broken follicular dendritic cell network; staining for other markers was as follows: Cyclin D1+, SOX11+, CD5+, CD20+, CD43+, BCL2+, BCL-6 scattered+, CD10-, LEF1-, CD56-, CD30-, CD2-, TIA1-, CD4-, CD8-, and Ki-67+. Tumor cells showed a proliferation index of approximately 20%. In situ hybridization revealed the absence of EBER+ tumor cells. Fluorescence in situ hybridization (FISH) revealed CCND1/IGH gene rearrangement, a distinctive feature of the t(11;14)(q13;q32) chromosomal translocation . Altogether, these clinical phenotypes were consistent with the diagnosis of cutaneous MCL. The clinical data revealed no lymphadenopathy, bone marrow biopsy and peripheral blood examination were normal, and there was no spleen or liver involvement.\nPositron emission tomography did not reveal systemic involvement.", + "fulltext_subclaims": [ + "The patient was a 74-year-old man.", + "In May 2018, the patient showed diffuse cutaneous erythematous plaques and nodules with irregular borders on the chest.", + "The effect of anti-allergy treatment was not prominent.", + "The patient’s history of past illness was not remarkable.", + "The patient’s father had a history of hypertension.", + "The patient’s mother had a history of breast cancer.", + "After the first examination, the number of cutaneous lesions increased progressively and involved the entire body.", + "The cutaneous lesions had diameters ranging from 0.5 to 1 cm.", + "The patient’s overall physical condition was good.", + "Skin lesions on the trunk and scrotum were biopsied.", + "Histopathological examination showed diffuse monomorphic lymphocyte infiltration in the dermal and subcutaneous layers, but not in the epidermis.", + "The lymphoid cells were mostly small to medium in size.", + "The lymphoid cells had irregular nuclear contours.", + "Immunohistochemistry showed CD21 and CD23 staining displayed a broken follicular dendritic cell network.", + "Immunohistochemistry showed Cyclin D1+.", + "Immunohistochemistry showed SOX11+.", + "Immunohistochemistry showed CD5+.", + "Immunohistochemistry showed CD20+.", + "Immunohistochemistry showed CD43+.", + "Immunohistochemistry showed BCL2+.", + "Immunohistochemistry showed BCL-6 scattered+.", + "Immunohistochemistry showed CD10-.", + "Immunohistochemistry showed LEF1-.", + "Immunohistochemistry showed CD56-.", + "Immunohistochemistry showed CD30-.", + "Immunohistochemistry showed CD2-.", + "Immunohistochemistry showed TIA1-.", + "Immunohistochemistry showed CD4-.", + "Immunohistochemistry showed CD8-.", + "Immunohistochemistry showed Ki-67+.", + "Tumor cells showed a proliferation index of approximately 20%.", + "In situ hybridization revealed the absence of EBER+ tumor cells.", + "Fluorescence in situ hybridization (FISH) revealed CCND1/IGH gene rearrangement.", + "The CCND1/IGH gene rearrangement is a distinctive feature of the t(11;14)(q13;q32) chromosomal translocation.", + "The clinical phenotypes were consistent with the diagnosis of cutaneous MCL.", + "The clinical data revealed no lymphadenopathy.", + "Bone marrow biopsy and peripheral blood examination were normal.", + "There was no spleen or liver involvement.", + "Positron emission tomography did not reveal systemic involvement." + ], + "summary": "The patient presented diffuse cutaneous erythematous plaques and nodules throughout the body. Skin lesions were biopsied and histopathological examination showed diffuse monomorphic lymphocyte infiltration in the dermal and subcutaneous layers, sparing the epidermis. Immunohistochemical staining revealed CD20, cyclin-D1, CD5, and SOX-11 expression. Fluorescence in situ hybridization showed CCND1/IGH gene rearrangement. Correct diagnosis of primary cutaneous MCL requires ensuring that no other parts are involved; these cases require close follow-up to monitor their possible progression to systemic disease and for treating relapsed cutaneous disease. In this case, positron emission tomography scanning and clinical staging revealed no systemic involvement, and follow-up examination at 20 mo after diagnosis showed no evidence of systemic disease. The prognosis of primary cutaneous MCL is relatively good. Our patient received six cycles of chemotherapy, and the cutaneous manifestations presented almost complete remission.", + "summary_subclaims": [ + "The patient presented diffuse cutaneous erythematous plaques and nodules throughout the body.", + "Skin lesions were biopsied and histopathological examination showed diffuse monomorphic lymphocyte infiltration in the dermal and subcutaneous layers, sparing the epidermis.", + "Immunohistochemical staining revealed CD20, cyclin-D1, CD5, and SOX-11 expression.", + "Fluorescence in situ hybridization showed CCND1/IGH gene rearrangement.", + "Correct diagnosis of primary cutaneous MCL requires ensuring that no other parts are involved.", + "Positron emission tomography scanning and clinical staging revealed no systemic involvement.", + "Follow-up examination at 20 mo after diagnosis showed no evidence of systemic disease.", + "The prognosis of primary cutaneous MCL is relatively good.", + "Our patient received six cycles of chemotherapy.", + "The cutaneous manifestations presented almost complete remission." + ] + }, + { + "id": "multiclinsum_test_1189_en.txt", + "fulltext": "A 73-year old male with progressive impairment of gait, persisting neuropathic pain in his legs, dizziness due to postural changes, and unexplained weight loss of 20 kg (BMI 26.8 kg/m2) during the last 2–3 years presented to our outpatient clinic. Three years ago diagnosis of lumbar spinal stenosis was made and decompression surgery was performed to alleviate neuropathic pain. As symptoms progressed, 1 year before the first presentation a second surgical procedure was scheduled and it was only in the preoperative diagnostic workup that echocardiography revealed left ventricular hypertrophy suspected to represent cardiac amyloidosis (see Fig. ). Endomyocardial biopsy showed extensive amyloid deposition in Congo red stained tissue with a typcial apple green birefringence and fluorescence signal, which could be classified immunohistochemically as TTR derived amyloid (see Fig. ). Regarding the cardiac manifestation and the patient’s age and sex ATTRwt amyloidosis was suspected and treatment with tafamidis (61 mg daily) was initiated.\nAt the time of referral, the patient was not able to walk unaided for almost 1 year due to weakness of his legs and impairment of balance. Neuropathic pain and dizziness due to orthostatic dysregulation had progressed and the patient reported no obvious improvement after approximately 1 year of treatment with tafamidis. The patient’s family history revealed frequent deaths due to cardiac events in his first-degree relatives (see Fig. ). His father died at the age of 67 from a cardiac event not further specified, as well as two of the patient’s brothers. One of them reportedly suffered cardiomyopathy and polyneuropathy. The only living brother, aged 68, was considerably impaired by a cardiomyopathy and peripheral neuropathy of unknown etiology.\nThe clinical examination showed a severe impairment of gait due to sensory ataxia, bilateral distal paralyses of the lower extremities (ankle dorsiflexion MRC grade 2/5, plantar flexion MRC grade 2–3/5 on the right side, MRC grade 3–4/5 on the left side). A slight weakness of both hands (MRC grade 4/5) was evident, as well as moderate atrophy of distal limb muscles, distal symmetric hypesthesia, and lost tendon reflexes. Nerve conduction studies (NCS) confirmed a severe axonal sensorimotor neuropathy with bilaterally unobtainable sural and tibial nerve amplitudes. Corneal confocal microscopy (CCM) showed a highly reduced corneal nerve fiber density (7 fibers/mm2, reference: > 24 fibers/mm2) indicating prominent small fiber involvement. Extensive laboratory testing for potential causes of the neuropathy including HbA1c, vitamin B1, B6, B12, folic acid, TSH, ANA, ANCA, rheumatid factor, hepatitis serology, serum electrophoresis and immunofixation did not yield any relevant abnormalities. There was no history of alcohol abuse or any other exposure to neurotoxic agents. However, molecular genetic analysis (Sanger sequencing, bioinformatic analysis of collected data by means of Mutation Surveyor Version 3.10 and Alamut Visual Version 2.6.1) revealed a heterozygous sequence variant in exon 2 of the TTR gene (NM_000371.3 (TTR): c.194C > T, p.Ala65Val, s. Table and Fig. ), classified as likely pathogenic (class 4) according to the American College of Medical Genetics (ACMG) classification system, which had been reported in ClinVar twice (ClinVar Accession: VCV000448841.4, ClinVar Variation ID: 448841). In ClinVar, the variant is classified as a variant of uncertain significance (two submissions) and once with the condition amyloidogenic transthyretin amyloidosis, but there is no literature on individuals with TTR-related conditions with this genotype. ACMG criteria PM1 (variant located in a mutational hot spot), PM2 (variant absent from general population in databases gnomAD/ExAC), PM5 (novel missense change at an amino acid residue where a different missense change determined to be pathogenic has been seen before), and PP3 (multiple lines of computational evidence supported a deleterious effect on the gene product) were fulfilled . Presuming this genotype to be amyloidogenic, the patient’s brother underwent targeted genetic testing by Sanger sequencing that revealed the same heterozygous sequence variant.", + "fulltext_subclaims": [ + "The patient is a 73-year-old male.", + "The patient had progressive impairment of gait.", + "The patient had persisting neuropathic pain in his legs.", + "The patient had dizziness due to postural changes.", + "The patient had unexplained weight loss of 20 kg during the last 2–3 years.", + "The patient's BMI was 26.8 kg/m2.", + "Three years ago, a diagnosis of lumbar spinal stenosis was made.", + "Decompression surgery was performed to alleviate neuropathic pain.", + "One year before the first presentation, a second surgical procedure was scheduled.", + "Echocardiography revealed left ventricular hypertrophy suspected to represent cardiac amyloidosis.", + "Endomyocardial biopsy showed extensive amyloid deposition in Congo red stained tissue.", + "The amyloid showed typical apple green birefringence and fluorescence signal.", + "The amyloid was classified immunohistochemically as TTR derived amyloid.", + "ATTRwt amyloidosis was suspected.", + "Treatment with tafamidis (61 mg daily) was initiated.", + "The patient was not able to walk unaided for almost 1 year due to weakness of his legs and impairment of balance.", + "Neuropathic pain and dizziness due to orthostatic dysregulation had progressed.", + "The patient reported no obvious improvement after approximately 1 year of treatment with tafamidis.", + "The patient’s family history revealed frequent deaths due to cardiac events in his first-degree relatives.", + "The patient’s father died at the age of 67 from a cardiac event.", + "One of the patient’s brothers reportedly suffered cardiomyopathy and polyneuropathy.", + "The patient’s living brother, aged 68, was considerably impaired by a cardiomyopathy and peripheral neuropathy of unknown etiology.", + "The clinical examination showed a severe impairment of gait due to sensory ataxia.", + "Bilateral distal paralyses of the lower extremities were evident.", + "A slight weakness of both hands was evident.", + "Moderate atrophy of distal limb muscles was evident.", + "Distal symmetric hypesthesia was evident.", + "Lost tendon reflexes were evident.", + "Nerve conduction studies confirmed a severe axonal sensorimotor neuropathy.", + "Bilaterally unobtainable sural and tibial nerve amplitudes were found.", + "Corneal confocal microscopy showed a highly reduced corneal nerve fiber density (7 fibers/mm2).", + "Extensive laboratory testing did not yield any relevant abnormalities.", + "There was no history of alcohol abuse.", + "Molecular genetic analysis revealed a heterozygous sequence variant in exon 2 of the TTR gene.", + "The variant was classified as likely pathogenic (class 4) according to the American College of Medical Genetics.", + "The variant had been reported in ClinVar twice.", + "In ClinVar, the variant is classified as a variant of uncertain significance.", + "The variant is once reported with the condition amyloidogenic transthyretin amyloidosis.", + "There is no literature on individuals with TTR-related conditions with this genotype.", + "ACMG criteria PM1, PM2, PM5, and PP3 were fulfilled.", + "Presuming this genotype to be amyloidogenic, the patient’s brother underwent targeted genetic testing.", + "The patient’s brother revealed the same heterozygous sequence variant." + ], + "summary": "Here, we report on a 73-year old patient initially diagnosed with cardiac wild-type ATTR (ATTRwt) amyloidosis by endomyocardial biopsy. Molecular genetic analysis revealed a novel TTR sequence variant (p.Ala65Val) that is highly likely to be amyloidogenic in light of previously reported TTR mutations and the patient's clinical presentation and family history.", + "summary_subclaims": [ + "The patient was initially diagnosed with cardiac wild-type ATTR amyloidosis by endomyocardial biopsy.", + "Molecular genetic analysis revealed a novel TTR sequence variant (p.Ala65Val).", + "The variant is highly likely to be amyloidogenic.", + "The likelihood is based on previously reported TTR mutations.", + "The likelihood is based on the patient's clinical presentation.", + "The likelihood is based on the patient's family history." + ] + }, + { + "id": "multiclinsum_test_2266_en.txt", + "fulltext": "A 70-year-old female patient presented to the emergency department with rapidly progressive shortness of breath over a week. Her past medical history included significant weight loss, dysphagia, and anorexia 1 year prior to admission which was diagnosed as oesophageal carcinoma which was treated by oesophageal stenting 5 months prior to admission. On admission, the patient was in moderate distress with the following vital signs: blood pressure 130/80 mmHg, pulse: 130 b.p.m., temperature 37°C, and respiratory rate 25 b.p.m. Precordial examination revealed distant heart sounds. Chest examination revealed bilateral diminished air entry over both lung bases. Electrocardiogram demonstrated sinus tachycardia with premature atrial contractions (PACs), low voltage, and subtle electrical alternans .\nAs a first line imaging modality, we selected a transthoracic echocardiogram which demonstrated a metallic shadow behind the left atrium (oesophageal stent) . It also revealed a massive circumferential pericardial effusion (that was mainly posterior and lateral and measured 3 cm and 2.8 cm, respectively) as well as large left pleural effusion .The inferior vena cava (IVC) was dilated (2.6 cm) and it did not show adequate inspiratory collapse . Apart from significant respiratory variation in mitral and tricuspid inflow , the echocardiographic features of tamponade were absent. We decided to apply the triage chart proposed by the European Society of Cardiology Working Group on myocardial and pericardial diseases to calculate the pericardiocentesis score. Despite that the patient was normotensive, the pericardiocentesis score was 13.5 .\nSo urgent pericardiocentesis was performed with tapping of about 500 mL haemorrhagic fluid followed by immediate and marked improvement of symptoms and tachycardia (heart rate dropped to 100). Then, the patient was referred for pleuropericardial window.", + "fulltext_subclaims": [ + "The patient is a 70-year-old female.", + "She presented with rapidly progressive shortness of breath over a week.", + "Her past medical history included significant weight loss, dysphagia, and anorexia 1 year prior to admission.", + "The weight loss, dysphagia, and anorexia were diagnosed as oesophageal carcinoma.", + "The oesophageal carcinoma was treated by oesophageal stenting 5 months prior to admission.", + "On admission, she was in moderate distress.", + "Her blood pressure was 130/80 mmHg.", + "Her pulse was 130 b.p.m.", + "Her temperature was 37°C.", + "Her respiratory rate was 25 b.p.m.", + "Chest examination revealed bilateral diminished air entry over both lung bases.", + "Electrocardiogram demonstrated sinus tachycardia with premature atrial contractions.", + "The electrocardiogram showed low voltage.", + "The electrocardiogram showed subtle electrical alternans.", + "A transthoracic echocardiogram was selected as the first line imaging modality.", + "The echocardiogram demonstrated a metallic shadow behind the left atrium.", + "The echocardiogram revealed a massive circumferential pericardial effusion.", + "The pericardial effusion measured 3 cm posteriorly.", + "The pericardial effusion measured 2.8 cm laterally.", + "The echocardiogram revealed a large left pleural effusion.", + "The inferior vena cava was dilated to 2.6 cm.", + "The inferior vena cava did not show adequate inspiratory collapse.", + "Echocardiographic features of tamponade were absent apart from significant respiratory variation in mitral and tricuspid inflow.", + "The pericardiocentesis score was 13.5.", + "Urgent pericardiocentesis was performed.", + "About 500 mL of haemorrhagic fluid was tapped.", + "There was immediate and marked improvement of symptoms.", + "The heart rate dropped to 100.", + "The patient was referred for pleuropericardial window." + ], + "summary": "A 70-year-old female patient presented to the emergency department with rapid development of shortness of breath over a week. Her past medical history included oesophageal carcinoma 1 year before presentation. This was complicated by dysphagia for which the patient underwent oesophageal stenting 5 months before admission. On admission, the patient was in respiratory distress, tachycardia; however, she was normotensive. Echocardiography revealed massive circumferential pericardial effusion. Apart from significant respiratory variation in mitral and tricuspid inflow, the echocardiographic features of tamponade were absent. We discuss on how we applied European Society of Cardiology guidelines in order to calculate the pericardiocentesis score and make a firm management plan. Despite that the patient was normotensive, the pericardiocentesis score was 13.5, so urgent pericardiocentesis was done followed by immediate improvement.", + "summary_subclaims": [ + "A 70-year-old female patient presented to the emergency department with rapid development of shortness of breath over a week.", + "Her past medical history included oesophageal carcinoma 1 year before presentation.", + "The patient underwent oesophageal stenting 5 months before admission.", + "On admission, the patient was in respiratory distress.", + "Echocardiography revealed massive circumferential pericardial effusion.", + "The echocardiographic features of tamponade were absent.", + "The pericardiocentesis score was 13.5.", + "Urgent pericardiocentesis was done.", + "There was immediate improvement after pericardiocentesis." + ] + }, + { + "id": "multiclinsum_test_1891_en.txt", + "fulltext": "A 2-year-6-month-old girl was referred to our hospital due to complaints of fever, cough, and tachypnea 10 days prior to her presentation. Upon admission, physical examinations revealed a body temperature of 38.5 °C, and percutaneous oxygen saturation (SpO2) was 67% in room air. Chest auscultation revealed fine crackles in the posterior lung fields. Clubbing fingers, pigeon breast deformity, and chilblain-like rash on her face were observed . Her anterior fontanelle was not closed (0.3 cm×0.3 cm). Other cutaneous manifestations were not observed. The patient displayed a height of 87 cm (-1.08 SD) and a weight of 11.5 kg (-0.82 SD). The patient experienced recurrent respiratory tract infections since the age of 6 months (once a month), and fatigue after activities was noticed beginning at 2 years of age. Family history found that her 27-year-old father had chest tightness and shortness of breath after activity beginning at 22 years of age. The clubbed fingers presented in all limbs, and mild tissue loss showed up on his face . Chest high-resolution computed tomography (HRCT) showed interstitial pneumonia with pulmonary cyst , and pulmonary function tests indicated mixed ventilation dysfunction. Combined with positive levels of antinuclear antibodies (ANA) and signal recognition particles (SRP) autoantibody, he was initially diagnosed with connective tissue disease (CTD) associated with ILD. After receiving combined therapy with cyclophosphamide and hydroxychloroquine for half a year, the symptoms have been improved while continuing to take hydroxychloroquine. However, about three years ago, the drug was stopped for unknown reasons, and the symptoms of dyspnea reappeared and slowly progressed.\nLaboratory examinations of the female patient found an elevation in the levels of C-reactive protein (CRP, 54.19 mg/L, reference range: <8 mg/L), erythrocyte sedimentation rate (ESR, 89 mm/H, reference range: <20 mm/H), and white blood cell count (WBC, 16.3 × 103/mm3, reference range: 4 to 10 × 103/mm3). There was no elevation of hepatobiliary enzymes, and her renal and thyroid functions were normal. The autoimmune workup revealed elevated levels of IgG (25.3 g/L), IgA (3.26 g/L), and IgM (1.69 g/L) despite normal levels of C3 and C4 complement. Decreased CD4 + T lymphocyte counts and normal CD8 + T lymphocyte counts were identified. This patient was positive for auto-antibodies, including high-titer ANA (1:1000), anti-neutrophil cytoplasmic antibodies (ANCA), rheumatoid factor (RF), and anti-cyclic citrullinated peptide (CCP) antibodies. Cytokine testing showed an elevated interleukin (IL)-6 level (62.4 pg/ml, reference range: 1.7 to 16.6 pg/ml). Pathology tests were negative, and malignancy was ruled out. HRCT scanning of the chest exhibited diffuse ground-glass opacities . Brain magnetic resonance imaging showed widened cerebral sulci and enlarged extra-axial spaces. No abnormalities were found in the electrocardiogram or the echocardiogram. The results of abdominal ultrasound and vascular ultrasonography were normal.\nThe female (child) patient was initially diagnosed with ILD accompanied by severe pneumonia and received anti-infection treatment with intravenous immunoglobulin (IVIG) (2 g/kg). However, the patient’s symptoms did not respond to the treatment , and she experienced hypoxic respiratory failure on Day 12, which required endotracheal intubation and mechanical ventilation. Therapies with methylprednisolone (MP) pulse (30 mg/kg/d×5d) were started on Day 13 followed by intravenous MP in 4 mg/kg daily dosage combined with a second course of IVIG (1 g/kg/d×3d). After the treatment, symptoms of dyspnea improved, and the ventilator was withdrawn on Day 22. At the same time, whole-exome sequencing was also performed, and genetic analysis by Sanger sequencing confirmed a heterozygous mutation (c.463G > A p.V155M) in Exon 5 of STING1 (NM_198282), which had been described to cause SAVI. The mutation was inherited from her father . RNA sequencing on the proband and her father was conducted, which found that the expression of genes related to the interferon pathway was significantly upregulated compared to that of healthy controls . After the diagnosis of SAVI, baricitinib (2.5 mg/day gradually increased to 3 times a day within 2 weeks) was added with prophylactic trimethoprim/ sulfamethoxazole, and the dose of MP was reduced to 2 mg/kg/d on Day 32. Under appropriate treatment, the patient’s symptoms of fever, tachypnea, breathlessness, and cyanosis improved, while the repeated chest HRCT showed a better result . Low-flow oxygen support (SpO2 at 94–95% in room air) was required, and the patient was discharged on Day 48, following the treatment of MP (1 mg/kg/d) and baricitinib (reduced to 2 mg three times a day). The female (child) patient was followed for 14 months after discharge. She was infected with severe pneumonia in the fourth month. Although the respiratory symptoms improved after antibiotic therapy, combined treatment with pirfenidone (2.5 mg twice-daily dosage) was administered due to the progressed interstitial pneumonia observed in HRCT . In the sixth month, we reduced the MP dose to 2 mg/d (0.13 mg/kg/d), which has been maintained until now. During the follow-up, the lung HRCT scan was stable after treatment ; however, there was no obvious improvement. Laboratory indicators are still positive for ANA (1:1000), p-ANCA, RF, and CCP, while high IgG, IgA, and IgM immunoglobulin counts and low CD4 + T lymphocyte counts remain. Levels of inflammatory markers like CRP and IL-6 were normal, while levels of ESR (29 mm/H) and IFN-γ (20.1 pg/ml) were slightly elevated. Nevertheless, the evaluation of clinical features showed that the respiratory signs and symptoms have almost disappeared, except for slight dyspnea after strenuous exercise. The patient’s height increased from 87 cm (-1.08 SD) to 100 cm (-0.66 SD), weight increased from 11.5 kg (-0.82 SD) to 15.5 kg (-0.28 SD), and the fontanel closed. The little girl now lives a normal life.\nAfter diagnosis, the male (father) patient received oral steroids and tofacitinib combination therapy for over a year, but there was no significant improvement in pulmonary symptoms. Six months ago, tofacitinib was changed to baricitinib combined with oral steroids, and the patient felt an improvement in breathing difficulties. However, similarly, there was no improvement in pulmonary imaging findings.", + "fulltext_subclaims": [ + "The patient is a 2-year-6-month-old girl.", + "She was referred to the hospital due to fever, cough, and tachypnea 10 days prior to presentation.", + "Upon admission, her body temperature was 38.5 °C.", + "Her percutaneous oxygen saturation (SpO2) was 67% in room air.", + "Chest auscultation revealed fine crackles in the posterior lung fields.", + "Clubbing fingers, pigeon breast deformity, and chilblain-like rash on her face were observed.", + "Her anterior fontanelle was not closed (0.3 cm×0.3 cm).", + "Other cutaneous manifestations were not observed.", + "Her height was 87 cm (-1.08 SD).", + "Her weight was 11.5 kg (-0.82 SD).", + "She experienced recurrent respiratory tract infections since the age of 6 months.", + "Fatigue after activities was noticed beginning at 2 years of age.", + "Her father had chest tightness and shortness of breath after activity beginning at 22 years of age.", + "The father had clubbed fingers in all limbs.", + "The father had mild tissue loss on his face.", + "Chest HRCT showed interstitial pneumonia with pulmonary cyst.", + "Pulmonary function tests indicated mixed ventilation dysfunction.", + "The father was initially diagnosed with connective tissue disease (CTD) associated with ILD.", + "He received combined therapy with cyclophosphamide and hydroxychloroquine for half a year.", + "The father’s symptoms improved while continuing to take hydroxychloroquine.", + "About three years ago, the father stopped the drug for unknown reasons.", + "The father’s symptoms of dyspnea reappeared and slowly progressed.", + "The female patient had elevated C-reactive protein (CRP, 54.19 mg/L).", + "The female patient had elevated erythrocyte sedimentation rate (ESR, 89 mm/H).", + "The female patient had elevated white blood cell count (WBC, 16.3 × 103/mm3).", + "The female patient had elevated IgG (25.3 g/L).", + "The female patient had elevated IgA (3.26 g/L).", + "The female patient had elevated IgM (1.69 g/L).", + "The female patient had decreased CD4 + T lymphocyte counts.", + "The female patient was positive for high-titer ANA (1:1000).", + "The female patient was positive for anti-neutrophil cytoplasmic antibodies (ANCA).", + "The female patient was positive for rheumatoid factor (RF).", + "The female patient was positive for anti-cyclic citrullinated peptide (CCP) antibodies.", + "The female patient had elevated interleukin (IL)-6 level (62.4 pg/ml).", + "Pathology tests were negative.", + "Malignancy was ruled out.", + "Chest HRCT scanning showed diffuse ground-glass opacities.", + "Brain MRI showed widened cerebral sulci and enlarged extra-axial spaces.", + "The electrocardiogram and echocardiogram showed no abnormalities.", + "The female patient was initially diagnosed with ILD accompanied by severe pneumonia.", + "She received anti-infection treatment with intravenous immunoglobulin (IVIG) (2 g/kg).", + "The patient’s symptoms did not respond to the treatment.", + "She experienced hypoxic respiratory failure on Day 12.", + "Endotracheal intubation and mechanical ventilation were required.", + "Therapies with methylprednisolone (MP) pulse (30 mg/kg/d×5d) were started on Day 13.", + "Intravenous MP in 4 mg/kg daily dosage was given.", + "A second course of IVIG (1 g/kg/d×3d) was administered.", + "After the treatment, symptoms of dyspnea improved.", + "The ventilator was withdrawn on Day 22.", + "Whole-exome sequencing was performed.", + "Genetic analysis by Sanger sequencing confirmed a heterozygous mutation (c.463G > A p.V155M) in Exon 5 of STING1.", + "The mutation was inherited from her father.", + "RNA sequencing found that the expression of genes related to the interferon pathway was significantly upregulated.", + "The diagnosis of SAVI was made.", + "Baricitinib (2.5 mg/day) was added.", + "The dose of MP was reduced to 2 mg/kg/d on Day 32.", + "Under appropriate treatment, the patient’s symptoms of fever, tachypnea, breathlessness, and cyanosis improved.", + "Chest HRCT showed a better result.", + "Low-flow oxygen support (SpO2 at 94–95% in room air) was required.", + "The patient was discharged on Day 48.", + "She was followed for 14 months after discharge.", + "She was infected with severe pneumonia in the fourth month.", + "Respiratory symptoms improved after antibiotic therapy.", + "Combined treatment with pirfenidone (2.5 mg twice-daily dosage) was administered.", + "In the sixth month, the MP dose was reduced to 2 mg/d (0.13 mg/kg/d).", + "During follow-up, the lung HRCT scan was stable after treatment.", + "There was no obvious improvement.", + "ANA remained positive at 1:1000.", + "p-ANCA remained positive.", + "RF remained positive.", + "CCP remained positive.", + "High IgG, IgA, and IgM immunoglobulin counts remained.", + "Low CD4 + T lymphocyte counts remained.", + "CRP levels were normal.", + "IL-6 levels were normal.", + "ESR was slightly elevated at 29 mm/H.", + "IFN-γ was slightly elevated at 20.1 pg/ml.", + "Respiratory signs and symptoms have almost disappeared.", + "The patient’s height increased from 87 cm (-1.08 SD) to 100 cm (-0.66 SD).", + "The patient’s weight increased from 11.5 kg (-0.82 SD) to 15.5 kg (-0.28 SD).", + "The anterior fontanel closed.", + "The patient now lives a normal life.", + "The father received oral steroids and tofacitinib combination therapy for over a year.", + "There was no significant improvement in pulmonary symptoms.", + "Tofacitinib was changed to baricitinib combined with oral steroids six months ago.", + "The father felt an improvement in breathing difficulties.", + "There was no improvement in pulmonary imaging findings." + ], + "summary": "Herein, we report a kindred, heterozygous STING mutation (p.V155M) in which the 2-year-old proband suffered from severe interstitial lung disease (ILD) while her father was initially misdiagnosed with connective tissue disease associated with ILD at an adult age. Baricitinib was initiated after the diagnosis of SAVI in the proband combined with steroids, and during the 14-month follow-up, the respiratory symptoms were improved. However, as the improvement of laboratory indicators was limited, especially in autoimmune indices, and the lung CT images remained unaltered, it seems that JAK1/2 inhibition was unsatisfactory in completely controlling the inflammation of the disease in our study.", + "summary_subclaims": [ + "The proband is a 2-year-old with severe interstitial lung disease.", + "The proband has a heterozygous STING mutation (p.V155M).", + "The father was initially misdiagnosed with connective tissue disease associated with ILD.", + "Baricitinib was initiated after the diagnosis of SAVI in the proband.", + "Baricitinib was used in combination with steroids.", + "During the 14-month follow-up, respiratory symptoms were improved.", + "Improvement of laboratory indicators was limited.", + "Lung CT images remained unaltered.", + "JAK1/2 inhibition was unsatisfactory in completely controlling the inflammation of the disease." + ] + }, + { + "id": "multiclinsum_test_2752_en.txt", + "fulltext": "A 59-year-old male with no history of smoking exhibited a slightly increased carcinoembryonic antigen level (5.6 ng/mL) during a health check. Chest computed tomography (CT) revealed a tumor (maximum diameter: 13 mm) in the left lower pulmonary lobe . He was referred to our hospital with suspected left lower lobe lung cancer (cT1bN0M0 stage1A2). CT and three-dimensional CT (3D-CT), which was performed using the Fujifilm Synapse Vincent system (Fujifilm Corporation, Tokyo, Japan), revealed the following anatomical anomalies in the left lung: 1) a displaced B1 + 2 running behind the main pulmonary artery, 2) an anomalous V1 + 2 joining the left inferior pulmonary vein , and 3) hyperlobulation between S1 + 2 and S3 with a completely fused interlobar fissure between S1 + 2 and S6 . 3D-CT also indicated that the interlobar plane between S1 + 2 and S6 ran perpendicular to the cranio-caudal direction because the volume of S1 + 2 was relatively large . Bronchoscopy revealed that three bronchi branched from the left main bronchus .\nWe planned VATS for surgical diagnosis and treatment. Hyperlobulation between S1 + 2 and S3 and a fused fissure between S1 + 2 and S6 were observed . At first, we performed non-anatomical wedge resection of the lesion to achieve a rapid pathological diagnosis. The patient was diagnosed with adenocarcinoma, and left lower lobectomy and systematic nodal dissection were performed.\nThe major pitfalls that we had to pay attention to during this surgery were as follows: 1) to avoid injuring the displaced B1 + 2 running behind the main pulmonary artery and 2) to avoid cutting the anomalous V1 + 2.\nThe inferior pulmonary vein was identified on the posterior side of the hilum, and the anomalous V1 + 2 joined it . To prevent B1 + 2 from being mistaken for B6, we distinguished B1 + 2 from the distal section of B6 on the posterior side . The distal branch of A8 was identified using the interlobar fissure. After A8 was divided, we peeled away the pulmonary artery in the proximal direction to identify A6 and V1 + 2, which ran near A,6 and a branch of V1 + 2, which ran between S1 + 2 and S6 . This branch was used as a landmark when we divided the fissure between S1 + 2 and the inferior lobe. Forceps were passed from the anterior to posterior side between a branch of V1 + 2 and A,6 and the largely fused fissure between S1 + 2 and the inferior lobe was divided using a stapler. After dividing the fissure, A6 and A9 + 10 were identified and divided. The inferior bronchus branched from the left main bronchus at the level of the branches of B3 + B4 + 5 and the displaced B1 + 2, which was located at a more proximal site than normal; therefore, we needed to peel away the bronchus while holding down the pulmonary artery and identified the station 11 lymph nodes. Forceps were passed from the anterior to the posterior side along the station 11 lymph nodes, and the incomplete fissure between S5 and inferior lobe was divided using the stapler. After dividing the fissure, the inferior bronchus was divided, which completed the lobectomy ND2a-2 procedure.\nThe operation time was 185 min, and 30 mL intraoperative blood loss occurred. Pathologically, the tumor was diagnosed as an invasive mucinous adenocarcinoma with a maximal diameter of 15 mm, and the pathological stage was p-T1aN0M0 stage I A1. The patient’s postoperative course was uneventful, and he was discharged from hospital 6 days after the surgery.", + "fulltext_subclaims": [ + "The patient was a 59-year-old male.", + "The patient had no history of smoking.", + "The carcinoembryonic antigen level was 5.6 ng/mL.", + "Chest computed tomography revealed a tumor with a maximum diameter of 13 mm in the left lower pulmonary lobe.", + "The tumor was suspected to be left lower lobe lung cancer (cT1bN0M0 stage1A2).", + "Three-dimensional CT was performed using the Fujifilm Synapse Vincent system.", + "A displaced B1 + 2 was running behind the main pulmonary artery.", + "An anomalous V1 + 2 joined the left inferior pulmonary vein.", + "Hyperlobulation between S1 + 2 and S3 with a completely fused interlobar fissure between S1 + 2 and S6 was observed.", + "The interlobar plane between S1 + 2 and S6 ran perpendicular to the cranio-caudal direction.", + "Bronchoscopy revealed that three bronchi branched from the left main bronchus.", + "VATS was planned for surgical diagnosis and treatment.", + "Non-anatomical wedge resection of the lesion was performed.", + "The patient was diagnosed with adenocarcinoma.", + "Left lower lobectomy and systematic nodal dissection were performed.", + "The major pitfalls were to avoid injuring the displaced B1 + 2 and to avoid cutting the anomalous V1 + 2.", + "The inferior pulmonary vein was identified on the posterior side of the hilum.", + "The anomalous V1 + 2 joined the inferior pulmonary vein.", + "The distal branch of A8 was identified using the interlobar fissure.", + "A6 and V1 + 2 ran near A6 and a branch of V1 + 2 ran between S1 + 2 and S6.", + "The branch of V1 + 2 was used as a landmark when dividing the fissure between S1 + 2 and the inferior lobe.", + "Forceps were passed from the anterior to posterior side between a branch of V1 + 2 and A6.", + "The largely fused fissure between S1 + 2 and the inferior lobe was divided using a stapler.", + "A6 and A9 + 10 were identified and divided.", + "The inferior bronchus branched from the left main bronchus at the level of the branches of B3 + B4 + 5 and the displaced B1 + 2.", + "The displaced B1 + 2 was located at a more proximal site than normal.", + "The station 11 lymph nodes were identified.", + "Forceps were passed from the anterior to posterior side along the station 11 lymph nodes.", + "The incomplete fissure between S5 and inferior lobe was divided using the stapler.", + "The inferior bronchus was divided, which completed the lobectomy ND2a-2 procedure.", + "The operation time was 185 min.", + "Intraoperative blood loss was 30 mL.", + "The tumor was diagnosed as an invasive mucinous adenocarcinoma with a maximal diameter of 15 mm.", + "The pathological stage was p-T1aN0M0 stage I A1.", + "The patient was discharged from hospital 6 days after the surgery." + ], + "summary": "A 59-year-old male with suspected lung cancer in the left lower lobe was scheduled to undergo surgery. Chest computed tomography revealed a displaced B1 + 2 and hyperlobulation between S1 + 2 and S3, while the interlobar fissure between S1 + 2 and S6 was completely fused. Three-dimensional computed tomography (3D-CT) revealed an anomalous V1 + 2 joining the left inferior pulmonary vein and a branch of the V1 + 2 running between S1 + 2 and S6. We performed left lower lobectomy via video-assisted thoracic surgery, while taking care with the abovementioned anatomical structures. The strategy employed in this operation was to preserve V1 + 2 and confirm the locations of B1 + 2 and B6 when dividing the fissure.", + "summary_subclaims": [ + "The patient was a 59-year-old male.", + "The patient had suspected lung cancer in the left lower lobe.", + "The patient was scheduled to undergo surgery.", + "Chest computed tomography revealed a displaced B1 + 2.", + "Chest computed tomography showed hyperlobulation between S1 + 2 and S3.", + "The interlobar fissure between S1 + 2 and S6 was completely fused.", + "Three-dimensional computed tomography revealed an anomalous V1 + 2 joining the left inferior pulmonary vein.", + "A branch of the V1 + 2 ran between S1 + 2 and S6.", + "The operation was a left lower lobectomy via video-assisted thoracic surgery.", + "The strategy was to preserve V1 + 2.", + "The strategy included confirming the locations of B1 + 2 and B6 when dividing the fissure." + ] + }, + { + "id": "multiclinsum_test_1239_en.txt", + "fulltext": "A 48-years old Asian female was referred to our hospital with a recent history of weakness, myalgia and arthralgia. She also complained of anorexia with 3 kg weight loss. She had no past medical history and was free of any medication on admission. At presentation, blood pressure was 180/80 mmHg, heart rate was 91/min, temperature was normal. Heart and lung auscultation, as well as abdominal examination, were normal. She had no skin involvement nor lymphadenopathy or synovitis.\nBiology showed acute kidney injury with serum creatinine at 209 μmol/L. White blood cell count (4.8 G/L) and platelet count (269 G/L) were normal, but anemia with hemoglobin at 7.8 g/dL was present. C-reactive protein was slightly increased (14 mg/dL). Urinalysis revealed glomerular proteinuria (proteinuria to creatinine ratio (P/C) 3.6 g/g) and microscopic hematuria. Kidney ultrasound examination showed normal sized kidneys and excluded obstruction. Thus, we concluded to acute glomerular syndrome and performed immunological laboratory tests. Antinuclear antibodies (ANA) (1/2560), as well as anti-dsDNA (292 UI/mL), anti-SSA and anti-SSB antibodies were detected. Type 3 cryoglobulinemia and complement consumption (decreased C3, C4 and CH50) were also present. Search for lupus anticoagulant, IgG anti-cardiolipin and anti-beta-2GP1 antibodies was negative. Finally, pANCA were detected at 1/2000 titer using IIF. ELISA showed the concomitant presence of MPO, PR3 and lactoferrine ANCAs with a strong positivity for MPO and lactoferrine ANCAs and a low positivity for PR3 ANCAs. ANCA detection using multiplex technology also detected MPO ANCA at high level, and low PR3 ANCA level.\nLN was first considered leading us to perform a kidney biopsy. On optical examination, extra-capillary circumferential cellular or fibro-cellular crescents were observed in 10 of 16 glomeruli. Segmental endocapillary proliferation was absent to very modest, without any lesions of capillary necrosis . Immunofluorescence analysis showed strong and diffuse mesangial and parietal C1q staining with a granular deposition pattern, while IgG, IgA, IgM, and C3 deposits were quite limited, of mesangial topography and only segmental .\nFollowing biopsy, an immunosuppressive treatment was initiated with an association of steroids, hydoxychloroquine and pulse intravenous cyclophosphamide (CYC, 500 mg every two weeks) according to the Euro-Lupus protocol trial . Under this regimen, a progressive improvement of both her general condition and kidney function was observed. At month 3 from treatment initiation (after the 6th CYC injection), serum creatinine was 116 μmol/L and P/C ratio decreased to 0.50 g/g. Antinuclear antibodies decreased to 1/200, anti-dsDNA antibodies became undetectable, and complement returned within normal range. ANCAs were still detectable although at lower titer using IIF (1/200), with only MPO ANCAs remaining slightly positives at ELISA and multiplex assays.\nAt that time, we decided to perform a systematic kidney biopsy to analyze histological response to treatment. On optical examination, only fibrotic crescents were observed in 9/14 glomeruli, none of them being cellular of fibro-cellular. Global lesions of endocapillary proliferation were observed in most glomeruli, without lesions of capillary necrosis . Immunofluorescence analysis showed diffuse mesangial and parietal C1q staining at a lower intensity as compared to the diagnostic biopsy. IgG, IgA, IgM, and C3 deposits remained limited, in their pattern and intensity .\nAfter the biopsy results, we decided to continue CYC. However, after the 8th CYC injection, the patient developed toxidermia which we attributed to CYC. At that time, we decided to start mycophenolate mofetil (MMF) at 1.5 g/day.\nOne year after initial admission and under MMF for 12 months, she has no clinical manifestation of SLE and did not relapse nephritis. Renal function returned to near normal values (serum creatinine of 90 μmol/L, MDRD eGFR 60 mL/min/1.73m2). ANCA detection was negative on IIF evaluation and ELISA, with anti-MPO being still detectable at very low level using multiplex assay. ANA were stable at 1/200, complement was in normal range and search for cryoglobulin was negative.", + "fulltext_subclaims": [ + "The patient is a 48-years old Asian female.", + "She was referred to the hospital with a recent history of weakness, myalgia, and arthralgia.", + "She also complained of anorexia with 3 kg weight loss.", + "She had no past medical history.", + "She was free of any medication on admission.", + "At presentation, blood pressure was 180/80 mmHg.", + "Heart rate was 91/min.", + "Temperature was normal.", + "Heart and lung auscultation were normal.", + "Abdominal examination was normal.", + "She had no skin involvement.", + "She had no lymphadenopathy.", + "She had no synovitis.", + "Serum creatinine was 209 μmol/L.", + "White blood cell count was 4.8 G/L.", + "Platelet count was 269 G/L.", + "Hemoglobin was 7.8 g/dL.", + "C-reactive protein was 14 mg/dL.", + "Urinalysis revealed glomerular proteinuria with a proteinuria to creatinine ratio of 3.6 g/g.", + "Urinalysis showed microscopic hematuria.", + "Kidney ultrasound showed normal sized kidneys.", + "Kidney ultrasound excluded obstruction.", + "Antinuclear antibodies were 1/2560.", + "Anti-dsDNA antibodies were 292 UI/mL.", + "Anti-SSA and anti-SSB antibodies were detected.", + "Type 3 cryoglobulinemia was present.", + "Complement consumption was present with decreased C3, C4, and CH50.", + "Search for lupus anticoagulant, IgG anti-cardiolipin, and anti-beta-2GP1 antibodies was negative.", + "pANCA were detected at 1/2000 titer using IIF.", + "ELISA showed the concomitant presence of MPO, PR3, and lactoferrine ANCAs.", + "MPO and lactoferrine ANCAs were strongly positive.", + "PR3 ANCAs were low positive.", + "ANCA detection using multiplex technology showed high MPO ANCA levels.", + "ANCA detection using multiplex technology showed low PR3 ANCA levels.", + "A kidney biopsy was performed.", + "Extra-capillary circumferential cellular or fibro-cellular crescents were observed in 10 of 16 glomeruli.", + "Segmental endocapillary proliferation was absent to very modest.", + "Immunofluorescence analysis showed strong and diffuse mesangial and parietal C1q staining.", + "IgG, IgA, IgM, and C3 deposits were limited, of mesangial topography, and only segmental.", + "Immunosuppressive treatment was initiated with steroids, hydroxychloroquine, and pulse intravenous cyclophosphamide.", + "The treatment was based on the Euro-Lupus protocol trial.", + "At month 3 from treatment initiation, serum creatinine was 116 μmol/L.", + "The proteinuria to creatinine ratio decreased to 0.50 g/g.", + "Antinuclear antibodies decreased to 1/200.", + "Anti-dsDNA antibodies became undetectable.", + "Complement returned within normal range.", + "ANCAs were still detectable at lower titer using IIF (1/200).", + "MPO ANCAs remained slightly positive at ELISA and multiplex assays.", + "A systematic kidney biopsy was performed to analyze histological response to treatment.", + "Fibrotic crescents were observed in 9/14 glomeruli.", + "Global lesions of endocapillary proliferation were observed in most glomeruli.", + "Immunofluorescence analysis showed diffuse mesangial and parietal C1q staining at lower intensity.", + "IgG, IgA, IgM, and C3 deposits remained limited in pattern and intensity.", + "The decision was made to continue cyclophosphamide.", + "After the 8th cyclophosphamide injection, the patient developed toxidermia.", + "Toxidermia was attributed to cyclophosphamide.", + "Mycophenolate mofetil was started at 1.5 g/day.", + "One year after initial admission, the patient had no clinical manifestation of SLE.", + "She did not relapse nephritis.", + "Renal function returned to near normal values with serum creatinine of 90 μmol/L.", + "MDRD eGFR was 60 mL/min/1.73m2.", + "ANCA detection was negative on IIF evaluation.", + "Anti-MPO was detectable at very low level using multiplex assay.", + "ANA were stable at 1/200.", + "Complement was in normal range.", + "Search for cryoglobulin was negative." + ], + "summary": "We report the case of a 48-year-old female with rapidly progressive kidney failure, arthro-myalgia and weight loss. Auto-immune screening showed anti-dsDNA antibodies, complement consumption and triple ANCA positivity. A first kidney biopsy done at presentation highlighted class IV-G glomerulonephritis with elective extra-capillary involvement and mainly C1q glomerular deposition at immunofluorescence study. After three months of a regimen combining steroids and cyclophosphamide, a second biopsy was performed and showed class IV-G glomerulonephritis with mainly endocapillary proliferation.", + "summary_subclaims": [ + "The patient is a 48-year-old female.", + "The patient had rapidly progressive kidney failure.", + "The patient had arthromyalgia.", + "The patient had weight loss.", + "Auto-immune screening showed anti-dsDNA antibodies.", + "Auto-immune screening showed complement consumption.", + "Auto-immune screening showed triple ANCA positivity.", + "A first kidney biopsy was done at presentation.", + "The first kidney biopsy highlighted class IV-G glomerulonephritis.", + "The first kidney biopsy showed elective extra-capillary involvement.", + "The first kidney biopsy showed mainly C1q glomerular deposition at immunofluorescence study.", + "After three months of a regimen combining steroids and cyclophosphamide, a second biopsy was performed.", + "The second biopsy showed class IV-G glomerulonephritis.", + "The second biopsy showed mainly endocapillary proliferation." + ] + }, + { + "id": "multiclinsum_test_2994_en.txt", + "fulltext": "Our patient was a six-year-old girl who had presented at the age of eight months to\nour hospital with persistent symptoms of cough, dyspnea and hypoxaemia since she was\ntwo months old. She had an unremarkable neonatal history, which was the result of a\nfull-term pregnancy, and had a birth weight of 2.4 kg. Her symptoms led to an\ninitial diagnosis of viral bronchiolitis. However, her dyspnea persisted, and her\ncondition further deteriorated during successive viral infections. Her parent\ncomplained that she suffered from recurrent vomiting, choking and symptoms\nsuggestive of aspiration. The parents were first-degree consanguineous cousins, but\nthere was no family history suggestive of chronic respiratory diseases.\nOn clinical examination, she was in respiratory distress, was failing to thrive and\nhad a weight below the third percentile. Her height and head circumference were\nnormal. No dysmorphism was noted, and clubbing was not initially present. Her vital\nsigns showed tachypnea and hypoxaemia, and clear chest auscultation was observed. On\ncardiovascular examination, there was no murmur and no initial finding suggestive of\npulmonary hypertension.\nHer initial basic laboratory workup was normal apart from a nasopharyngeal polymerase\nchain reaction that was positive for rhinovirus. Chest X-rays showed diffuse\nbilateral ground glass opacity . An echocardiography was unremarkable. Her immunological work\nup was normal, and a bronchoscopy showed a normal airway structure. A workup for\ngastroesophageal reflux disease revealed moderate gastroesophageal reflux disease in\npH probe studies. She was managed accordingly, and because the patient did not\nrespond to optimal medical therapy, we proceeded with fundoplication and gastrostomy\ntube insertion.\nNevertheless, within the following year, she continued to exhibit dyspnea without\nexertion and hypoxaemia. Thus, a diagnosis of childhood interstitial lung disease\nwas suspected. A chest computed tomographic scan showed diffuse inhomogeneous\nbilateral ground glass opacity with scattered small, thin-walled cysts in the\nsuperior segments of both lower lobes and the lateral segments of the middle lobe\n.\nA wedge lung biopsy was obtained, which showed prominent large, irregular and cystic\nparenchymal distortion with marked thickening and fibrotic expansion of the\ninterstitial spaces . The alveolar spaces showed moderate epithelial hyperplasia with\nabundant foamy histiocytes, lymphocytic infiltrate and some areas with cholesterol\nclefts .\nHistiocytes also showed dense eosinophilic granules and occasionally globules of\nperiodic acid–Schiff stain-positive proteinosis material . The airways showed mild epithelial\nhyperplasia and focal mild subepithelial fibrosis. These histological features are\ntypical of genetic disorders of surfactant metabolism, and this morphological\npattern at this age is most commonly associated with mutation in SFTPC. This\ndiagnosis was confirmed by genetic testing, which showed a p.I73T pathogenic\nmutation located in coding exon 3 of the SFTPC gene, and no\nabnormalities were detected in the ABCA3 or NKX2.1\ngenes.\nCurrently, our patient is six years old. She was managed with six doses of monthly\npulse therapy with hydroxychloroquine and azithromycin, which led to subsequent\nimprovement in her respiratory status, as demonstrated by a decrease in her home\noxygen requirement from 2 l/min to 0.5 l/min. She is also managed with supportive\ncare, including nutritional, psychosocial and home care therapy. She was referred\nfor the evaluation of lung transplantation.", + "fulltext_subclaims": [ + "The patient was a six-year-old girl.", + "She had presented at the age of eight months.", + "She had persistent symptoms of cough, dyspnea and hypoxaemia since she was two months old.", + "She had an unremarkable neonatal history.", + "She was the result of a full-term pregnancy.", + "Her birth weight was 2.4 kg.", + "Her initial diagnosis was viral bronchiolitis.", + "Her dyspnea persisted.", + "Her condition further deteriorated during successive viral infections.", + "Her parent complained that she suffered from recurrent vomiting, choking and symptoms suggestive of aspiration.", + "The parents were first-degree consanguineous cousins.", + "There was no family history suggestive of chronic respiratory diseases.", + "On clinical examination, she was in respiratory distress.", + "She was failing to thrive.", + "Her weight was below the third percentile.", + "Her height and head circumference were normal.", + "No dysmorphism was noted.", + "Clubbing was not initially present.", + "Her vital signs showed tachypnea and hypoxaemia.", + "Clear chest auscultation was observed.", + "On cardiovascular examination, there was no murmur.", + "There was no initial finding suggestive of pulmonary hypertension.", + "Her initial basic laboratory workup was normal.", + "A nasopharyngeal polymerase chain reaction was positive for rhinovirus.", + "Chest X-rays showed diffuse bilateral ground glass opacity.", + "An echocardiography was unremarkable.", + "Her immunological workup was normal.", + "A bronchoscopy showed a normal airway structure.", + "A workup for gastroesophageal reflux disease revealed moderate gastroesophageal reflux disease in pH probe studies.", + "She was managed accordingly.", + "Because the patient did not respond to optimal medical therapy, we proceeded with fundoplication and gastrostomy tube insertion.", + "Within the following year, she continued to exhibit dyspnea without exertion and hypoxaemia.", + "A diagnosis of childhood interstitial lung disease was suspected.", + "A chest computed tomographic scan showed diffuse inhomogeneous bilateral ground glass opacity with scattered small, thin-walled cysts in the superior segments of both lower lobes and the lateral segments of the middle lobe.", + "A wedge lung biopsy was obtained.", + "The biopsy showed prominent large, irregular and cystic parenchymal distortion with marked thickening and fibrotic expansion of the interstitial spaces.", + "The alveolar spaces showed moderate epithelial hyperplasia with abundant foamy histiocytes, lymphocytic infiltrate and some areas with cholesterol clefts.", + "Histiocytes also showed dense eosinophilic granules and occasionally globules of periodic acid–Schiff stain-positive proteinosis material.", + "The airways showed mild epithelial hyperplasia and focal mild subepithelial fibrosis.", + "These histological features are typical of genetic disorders of surfactant metabolism.", + "This morphological pattern at this age is most commonly associated with mutation in SFTPC.", + "This diagnosis was confirmed by genetic testing.", + "Genetic testing showed a p.I73T pathogenic mutation located in coding exon 3 of the SFTPC gene.", + "No abnormalities were detected in the ABCA3 or NKX2.1 genes.", + "She was managed with six doses of monthly pulse therapy with hydroxychloroquine and azithromycin.", + "This led to subsequent improvement in her respiratory status.", + "A decrease in her home oxygen requirement from 2 l/min to 0.5 l/min was demonstrated.", + "She is also managed with supportive care, including nutritional, psychosocial and home care therapy.", + "She was referred for the evaluation of lung transplantation." + ], + "summary": "A six-year-old girl had presented at the age of eight months old with bronchiolitis followed by a persistent cough, dyspnea and hypoxaemia. She was found to have gastroesophageal reflux disease, but her symptoms did not resolve despite her therapy being optimised. Further tests, including a chest computed tomographic scan, lung biopsy and genetic testing, confirmed a diagnosis of surfactant protein C dysfunction.", + "summary_subclaims": [ + "A six-year-old girl had presented at the age of eight months old with bronchiolitis.", + "She had a persistent cough, dyspnea and hypoxaemia.", + "She was found to have gastroesophageal reflux disease.", + "Her symptoms did not resolve despite her therapy being optimised.", + "Further tests, including a chest computed tomographic scan, lung biopsy and genetic testing, confirmed a diagnosis of surfactant protein C dysfunction." + ] + }, + { + "id": "multiclinsum_test_1219_en.txt", + "fulltext": "A 25-year-old woman was referred to our outpatient clinic with complaints of chronic headache and irregular menses. Hormone profile showed only moderate increase in Prolactin (96 ng/ml). Sellar magnetic resonance imaging (MRI) showed a pituitary mass. The patient had total pituitary adenectomy using an endoscopic endonasal transsphenoidal approach. After tumor resection, diaphragmatic opening was seen with intra-operative evidence of CSF leak. Sellar floor reconstruction was performed by mucosal graft and Glubran®2 glue filling the surgical cavity. Early post-operative period was uneventful and clinical and histopathologic finding were consistent with a non-functional pituitary adenoma.\nAfter 2 months of surgery, the patient complained of headache, facial pain and greenish foul-smelling nasal discharge with solid particles. Patient was diagnosed with rhinosinusitis and treated with multiple courses of nasal decongestants and antibiotics for 4 months but without improvement. Brain MRI showed inflammation and thickening of the sphenoidal and para-sphenoidal mucosa .\nSurgery with endoscopic endonasal approach was decided. Intra-operatively, the sellar floor was seen intact with no CSF leak nor discharge. A solid glass-like patches (acrylic glue) was seen in the inferior and lateral areas of the sphenoid sinus and was surrounded with inflamed infected mucosa and abundant pussy discharge . Efforts were made to erupt and de-crust the solid mass until total resection was achieved. Early post-operative period was uneventful, and a course of antibiotics was continued until total regression of the discharge. Endoscopic follow-up was performed in the 1st, 2nd and 3rd post-operative months, and showed no signs of rhinosinusitis with well-healed nasal mucosa.", + "fulltext_subclaims": [ + "The patient was referred to the outpatient clinic with complaints of chronic headache and irregular menses.", + "Hormone profile showed only moderate increase in Prolactin (96 ng/ml).", + "Sellar magnetic resonance imaging (MRI) showed a pituitary mass.", + "The patient had total pituitary adenectomy using an endoscopic endonasal transsphenoidal approach.", + "After tumor resection, diaphragmatic opening was seen with intra-operative evidence of CSF leak.", + "Sellar floor reconstruction was performed by mucosal graft and Glubran®2 glue filling the surgical cavity.", + "Early post-operative period was uneventful.", + "Clinical and histopathologic findings were consistent with a non-functional pituitary adenoma.", + "After 2 months of surgery, the patient complained of headache, facial pain and greenish foul-smelling nasal discharge with solid particles.", + "Patient was diagnosed with rhinosinusitis.", + "The patient was treated with multiple courses of nasal decongestants and antibiotics for 4 months.", + "Brain MRI showed inflammation and thickening of the sphenoidal and para-sphenoidal mucosa.", + "Surgery with endoscopic endonasal approach was decided.", + "Intra-operatively, the sellar floor was seen intact with no CSF leak nor discharge.", + "A solid glass-like patches (acrylic glue) was seen in the inferior and lateral areas of the sphenoid sinus.", + "The solid glass-like patches were surrounded with inflamed infected mucosa and abundant pus discharge.", + "Efforts were made to erupt and de-crust the solid mass until total resection was achieved.", + "Early post-operative period was uneventful.", + "A course of antibiotics was continued until total regression of the discharge.", + "Endoscopic follow-up was performed in the 1st, 2nd and 3rd post-operative months.", + "Endoscopic follow-up showed no signs of rhinosinusitis with well-healed nasal mucosa." + ], + "summary": "A 25-year-old woman underwent endoscopic endonasal transsphenoidal surgery for pituitary adenoma. After tumor resection, sellar floor reconstruction was performed by mucosal graft and Glubran®2 glue. The early post-operative period was uneventful. However, 2 months after surgery, the patient complained of headache, facial pain and greenish foul-smelling nasal discharge with solid particles dripping from the nose. Medical treatment was unsuccessful. Brain MRI showed inflammation and thickening of the sphenoidal and para-sphenoidal mucosa. The patient underwent endoscopic endonasal surgery and a solid glass-like mass surrounded by inflamed infected mucosa was seen in the inferior and lateral aspects of the sphenoid sinus. Efforts were made to erupt and de-crust the solid mass until total resection was achieved. Early post-operative period was uneventful, and a course of antibiotics was continued until total disappearance of the discharge.", + "summary_subclaims": [ + "The patient is a 25-year-old woman.", + "She underwent endoscopic endonasal transsphenoidal surgery for pituitary adenoma.", + "Sellar floor reconstruction was performed by mucosal graft and Glubran®2 glue.", + "The early post-operative period was uneventful.", + "Two months after surgery, the patient complained of headache.", + "Two months after surgery, the patient complained of facial pain.", + "Two months after surgery, the patient had greenish foul-smelling nasal discharge with solid particles.", + "Medical treatment was unsuccessful.", + "Brain MRI showed inflammation and thickening of the sphenoidal and para-sphenoidal mucosa.", + "The patient underwent endoscopic endonasal surgery.", + "A solid glass-like mass surrounded by inflamed infected mucosa was seen in the inferior and lateral aspects of the sphenoid sinus.", + "Efforts were made to erupt and de-crust the solid mass until total resection was achieved.", + "The early post-operative period was uneventful.", + "A course of antibiotics was continued until total disappearance of the discharge." + ] + }, + { + "id": "multiclinsum_test_167_en.txt", + "fulltext": "A 53-year-old white man presented to our knee clinic with knee pain. The pain was located in the posteromedial aspect of his left knee and first presented whilst training for a marathon. The pain was a continuous dull ache, which would often wake him from sleep. He had no improvement from conservative management trialled by his general practitioner, which included rest, ice, elevation, orally administered non-steroidal anti-inflammatory drugs, and physiotherapy. There was no history of trauma, locking, or giving way of the knee. He was otherwise fit and well with no medical co-morbidities; he was very active and had not had any previous injuries or surgeries to his left knee.\nA physical examination revealed normal alignment of his knee and hindfoot, no effusion, and an area of point tenderness posteromedially, not over the hamstrings or the pes anserinus. There was full range of movement with a positive medial step off and good tracking of the patella with no gross patellofemoral crepitus. He also did not have any significant ligamentous instability and an examination of his ipsilateral hip joint was normal.\nPlain radiographs taken at the time of presentation did not reveal any significant abnormalities and magnetic resonance imaging (MRI) was organized, which demonstrated the presence of a cord-like structure that originated from the fabella and passed medially, dividing into two parts around the semimembranosus tendon . The superficial part appeared to blend in with the semimembranosus tendon sheath itself, whereas the deeper part was thought to blend in with the superficial fascia of the gracilis and semitendinosus. This was associated with the presence of diffuse thickening of the distal semimembranosus tendon suggesting impingement of the tendon .\nAs he continued to be symptomatic, and conservative measures had failed, he underwent a knee arthroscopy which demonstrated a grossly thickened semimembranosus with fluid collection around it. A band arising from the fabella, running transversely across the popliteal fossa and around the semimembranosus tendon was noted, confirming the diagnosis of semimembranosus impingement. This band, thought to be congenital in nature, was divided, and the semimembranosus fully released .\nPostoperatively, he recovered well and was allowed to fully weight bear with crutches. He was followed up at 6 weeks post-surgery, at which time his symptoms had resolved and he was back to training for a marathon.", + "fulltext_subclaims": [ + "A 53-year-old white man presented to our knee clinic with knee pain.", + "The pain was located in the posteromedial aspect of his left knee.", + "The pain was a continuous dull ache.", + "The pain would often wake him from sleep.", + "He had no improvement from conservative management trialled by his general practitioner.", + "Conservative management included rest, ice, elevation, orally administered non-steroidal anti-inflammatory drugs, and physiotherapy.", + "There was no history of trauma, locking, or giving way of the knee.", + "He was otherwise fit and well with no medical co-morbidities.", + "He had not had any previous injuries or surgeries to his left knee.", + "A physical examination revealed normal alignment of his knee and hindfoot.", + "There was no effusion.", + "There was an area of point tenderness posteromedially, not over the hamstrings or the pes anserinus.", + "There was full range of movement.", + "There was a positive medial step off.", + "There was good tracking of the patella with no gross patellofemoral crepitus.", + "There was no significant ligamentous instability.", + "An examination of his ipsilateral hip joint was normal.", + "Plain radiographs taken at the time of presentation did not reveal any significant abnormalities.", + "Magnetic resonance imaging (MRI) was organized.", + "MRI demonstrated the presence of a cord-like structure that originated from the fabella and passed medially, dividing into two parts around the semimembranosus tendon.", + "The superficial part appeared to blend in with the semimembranosus tendon sheath itself.", + "The deeper part was thought to blend in with the superficial fascia of the gracilis and semitendinosus.", + "This was associated with the presence of diffuse thickening of the distal semimembranosus tendon.", + "This was thought to suggest impingement of the tendon.", + "He underwent a knee arthroscopy.", + "Knee arthroscopy demonstrated a grossly thickened semimembranosus with fluid collection around it.", + "A band arising from the fabella, running transversely across the popliteal fossa and around the semimembranosus tendon was noted.", + "This band was thought to be congenital in nature.", + "This band was divided, and the semimembranosus fully released.", + "Postoperatively, he was allowed to fully weight bear with crutches.", + "He was followed up at 6 weeks post-surgery.", + "At 6 weeks post-surgery, his symptoms had resolved.", + "He was back to training for a marathon." + ], + "summary": "We present a case report of a 53-year-old white man who presented with atraumatic, posterior knee pain and was found to have a congenital, anomalous band originating from the fabella, causing semimembranosus impingement. This was diagnosed with magnetic resonance imaging; he underwent division of the anomalous band, which resulted in complete resolution of his symptoms.", + "summary_subclaims": [ + "The patient is a 53-year-old white man.", + "The patient presented with atraumatic, posterior knee pain.", + "The patient was found to have a congenital, anomalous band originating from the fabella.", + "The anomalous band was causing semimembranosus impingement.", + "The diagnosis was made with magnetic resonance imaging.", + "The patient underwent division of the anomalous band.", + "The patient experienced complete resolution of his symptoms." + ] + }, + { + "id": "multiclinsum_test_2558_en.txt", + "fulltext": "A 21-year-old Iranian man presented to the emergency ward of our hospital with 5 days of illness and a history of right upper quadrant abdominal pain, fatigue, fever, icterus, vomiting, and no appetite. He was examined physically, and abdominal tenderness was detected in all four quadrants, and scleral icterus. His blood pressure was normal at 110.70 mmHg and oxygen saturation rate was of 95% on ambient air. Axillary temperature was 38.8 °C. His medical history showed that was being treated with albendasol 800 mg daily for months because of two hydatid cysts in the liver. One of the cysts was located on the dome of liver segment III and the second was on segment VII just over the right kidney . On the CT scan of the liver, two cysts were observed in segment II and VII with septation, of which one was intact and the other one had ruptured. After 2 weeks on albendazole, fatigue, fever, icterus, and vomiting were present, which was the complication of albendazole since the values for all liver function tests had increased.\nLaboratory findings revealed increased white blood count (WBC; 17,000 K/uL, reference value 4–10.8 K/uL) and elevated liver enzymes (aspartate transaminase [AST] 120 U/L [reference value 11–72 U/L]; alanine transaminase [ALT] 83 IU/L [reference value < 40 IU/L]; alkaline phosphatase [ALP] 1250 IU/L; total bilirubin 9 mg/dL [reference value < 1.2 mg/dL]). The direct and indirect bilirubin measurements were 4 and 5 mg/dL, respectively, C-reactive protein concentration was 11 U/mL (reference value 0–0.5 mg/dL, amylase 320), and lipase was 180 IU/L. A prothrombin time of 42 s (reference value 9.6–14.2 s), activated partial thromboplastin time of 48 s (reference value, 20–38 s), and international normalized ratio of 5 (reference value 0.85–1.2) were also detected in the tests. The remaining laboratory test results were within normal limits. These test results show hepatitis due to albendazole toxicity.\nIn addition to considering these test findings and the patient’s ailments, we also used abdominal U/S to arrive at the diagnosis. Abdominal U/S revealed intrahepatic and extrahepatic bile duct dilation; the gallbladder was dilated but had normal wall thickening. Large intact hepatic cysts were observed in segment IV and another one were in segment II with detached laminated membranes, possibly indicative of a ruptured or complicated liver cyst. An intravenous contrast CT scan was performed for more evaluation and revealed unilocular hepatic cysts with segregated laminated membranes that corresponded to hepatic hydatid cysts on segment II and other unilocular intact hepatic cysts on segment IV . Further observations indicated intrahepatic and extrahepatic biliary duct dilation .\nThe reason for bile duct dilatation was investigated by MRCP, which showed the rupture of cysts of segment II into the intrahepatic ducts, common hepatic duct, and common biliary duct (CBD). In addition, laminated membranes of the hydatid cyst and daughter cysts were found in the CBD, causing the obstruction .\nThe patient underwent laparotomy due peritonitis resulting from the rupture of the liver hydatid cyst in the abdominal cavity with a right extensive subcostal incision. During exploration, 500 cc bile fluid was aspirated from the abdominal cavity and sent for analysis. The pancreas was inflamed, and its appearance showed pancreatitis. The liver was carefully inspected; one collapsed infected cystic lesion with a small perforation was present in segment II just over the right kidney.\nOur approach for surgical treatment began with the aspiration and evacuation of the cyst contents. To explore for any purulent or bile contents, cystostomy and irrigation were performed. Also, fibrotic tissue around the cyst was resected and the site of bile leakage ligated with a non-absorbable suture. Capitonnage, omentoplasty, and insertion of a Foley catheter inside the incision were performed to remove the residual cyst and prevent recurrence. The gall bladder was highly dilated and was full of a white mucous fluid with obstruction of the cystic duct; choledocotomy and drainage of the common bile duct were performed with saline irrigation. Moreover, daughter cysts were removed from the common bile duct and intrabiliary ducts. At the end of the surgery, a T-tube was inserted in the site of choledocotomy and a corrugated drain was fixed. During exploration, another intact cyst was found in segment VII; this cyst was aspirated and the laminated membrane removed; the cavity was then irrigated with betadine 10%. Pricystectomy was performed, and a Foley catheter 18 was put into the remnant cavity and fixed to the abdominal wall. Finally, the CBD (diameter 30 mm) was examined; it was full of laminated membrane, daughter cysts, and debrides of the hydrated cyst. After extraction of all materials from the CBD and subsequent irrigation, a T-tube was placed in the CBD and fixed into place. A Penrose drain was placed in the abdominal cavity, and then the abdomen was closed.\nThree days after surgery, the levels of bilirubin, amylase, lipase, AST, ALT, WBC, and ALP had decreased. The patient’s general condition (fever and appetite) was good, and he was discharged 10-day post-operation with good condition. Trans-T-tube cholangiography was performed 20 days after the operation with good results and was then removed", + "fulltext_subclaims": [ + "A 21-year-old Iranian man presented to the emergency ward with 5 days of illness.", + "He had a history of right upper quadrant abdominal pain.", + "He had fatigue.", + "He had fever.", + "He had icterus.", + "He had vomiting.", + "He had no appetite.", + "Abdominal tenderness was detected in all four quadrants.", + "Scleral icterus was observed.", + "His blood pressure was 110.70 mmHg.", + "His oxygen saturation was 95% on ambient air.", + "His axillary temperature was 38.8 °C.", + "He was being treated with albendazole 800 mg daily for months.", + "He had two hydatid cysts in the liver.", + "One cyst was located on the dome of liver segment III.", + "The second cyst was on segment VII just over the right kidney.", + "CT scan showed two cysts in segment II and VII with septation.", + "One cyst was intact.", + "The other cyst had ruptured.", + "After 2 weeks on albendazole, fatigue, fever, icterus, and vomiting were present.", + "The complications were due to albendazole.", + "Liver function tests had increased.", + "White blood count was 17,000 K/uL.", + "AST was 120 U/L.", + "ALT was 83 IU/L.", + "ALP was 1250 IU/L.", + "Total bilirubin was 9 mg/dL.", + "Direct bilirubin was 4 mg/dL.", + "Indirect bilirubin was 5 mg/dL.", + "C-reactive protein was 11 U/mL.", + "Amylase was 320.", + "Lipase was 180 IU/L.", + "Prothrombin time was 42 s.", + "Activated partial thromboplastin time was 48 s.", + "International normalized ratio was 5.", + "Abdominal U/S showed intrahepatic and extrahepatic bile duct dilation.", + "The gallbladder was dilated but had normal wall thickening.", + "Large intact hepatic cysts were observed in segment IV.", + "Another cyst was in segment II with detached laminated membranes.", + "Intravenous contrast CT showed unilocular hepatic cysts with segregated laminated membranes.", + "The cysts corresponded to hepatic hydatid cysts on segment II.", + "Other unilocular intact hepatic cysts were on segment IV.", + "MRCP showed rupture of cysts of segment II into the intrahepatic ducts, common hepatic duct, and common biliary duct.", + "Laminated membranes of the hydatid cyst and daughter cysts were found in the CBD, causing obstruction.", + "The patient underwent laparotomy due to peritonitis.", + "500 cc bile fluid was aspirated from the abdominal cavity.", + "The pancreas was inflamed, showing pancreatitis.", + "One collapsed infected cystic lesion with a small perforation was present in segment II.", + "Cyst contents were aspirated and evacuated.", + "Cystostomy and irrigation were performed.", + "Fibrotic tissue around the cyst was resected.", + "The site of bile leakage was ligated with a non-absorbable suture.", + "Capitonnage, omentoplasty, and insertion of a Foley catheter were performed.", + "Choledocotomy and drainage of the common bile duct were performed with saline irrigation.", + "Daughter cysts were removed from the common bile duct and intrabiliary ducts.", + "A T-tube was inserted in the site of choledocotomy.", + "A corrugated drain was fixed.", + "Another intact cyst was found in segment VII.", + "The cyst was aspirated, and the laminated membrane was removed.", + "The cavity was irrigated with betadine 10%.", + "Pricystectomy was performed.", + "A Foley catheter 18 was put into the remnant cavity.", + "The CBD was full of laminated membrane, daughter cysts, and debrides of the hydrated cyst.", + "A T-tube was placed in the CBD.", + "A Penrose drain was placed in the abdominal cavity.", + "Three days after surgery, bilirubin, amylase, lipase, AST, ALT, WBC, and ALP had decreased.", + "The patient’s general condition was good.", + "He was discharged 10 days post-operation.", + "Trans-T-tube cholangiography was performed 20 days after the operation with good results.", + "The T-tube was removed." + ], + "summary": "A 21-year-old Iranian man was admitted to the emergency ward with 5 days of serious sickness and a history of right upper quadrant abdominal pain, fatigue, fever, icterus, vomiting, and no appetite. In the physical examination, abdominal tenderness was detected in all four quadrants and in the scleral icterus. Abdominal ultrasound revealed intrahepatic and extrahepatic biliary duct dilation. Gallbladder wall thickening was normal but was very dilated, and large unilocular intact hepatic cysts were detected in segment IV and another one segment II which had detached laminated membranes and was a ruptured or complicated liver cyst.", + "summary_subclaims": [ + "The patient is a 21-year-old Iranian man.", + "He was admitted to the emergency ward.", + "He had 5 days of serious sickness.", + "He had a history of right upper quadrant abdominal pain.", + "He had fatigue.", + "He had fever.", + "He had icterus.", + "He had vomiting.", + "He had no appetite.", + "Abdominal tenderness was detected in all four quadrants.", + "Scleral icterus was detected.", + "Abdominal ultrasound revealed intrahepatic biliary duct dilation.", + "Abdominal ultrasound revealed extrahepatic biliary duct dilation.", + "Gallbladder wall thickening was normal.", + "The gallbladder was very dilated.", + "Large unilocular intact hepatic cysts were detected in segment IV.", + "Another large unilocular intact hepatic cyst was detected in segment II.", + "The segment II cyst had detached laminated membranes.", + "The segment II cyst was a ruptured or complicated liver cyst." + ] + }, + { + "id": "multiclinsum_test_1972_en.txt", + "fulltext": "We report the case of a 60-year-old woman of West African descent, with no history of asbestos exposure, who originally presented 24 years ago to another institution with acute abdominal pain. At that time, she underwent an exploratory laparotomy and was found to have nodules diffusely covering the peritoneum. A total abdominal hysterectomy and bilateral salpingo-oophorectomy were performed for suspected ovarian carcinoma, and biopsies were taken of the peritoneal nodules. The pathology from this original surgery was interpreted as low-grade papillary mesothelioma. She then received six adjuvant cycles of intravenous cyclophosphamide, doxorubicin and cisplatin. She underwent a second-look laparotomy six months later, and still had gross disease visible in the peritoneum. Post-operatively she received three additional cycles of intraperitoneal cisplatin and intravenous sodium thiosulfate. She subsequently received maintenance therapy with alternating courses of tamoxifen and megace alternating every two weeks.\nShe presented four years later with obstructive gastrointestinal symptoms and was again found on laparotomy to have diffuse peritoneal studding. Pathology from this surgery was interpreted again to be papillary mesothelioma. As a result, she began six cycles of carboplatin and cyclophosphamide chemotherapy for suspected progressive disease. Several months later, she presented with complaints of shortness of breath, orthopnea, and worsening lower extremity edema. A multi-gated acquisition scan (MUGA) revealed an ejection fraction of 14% and enlarged cardiac silhouette on chest X-ray, and she was clinically diagnosed as having anthracycline-induced cardiomyopathy. Medical therapy was initiated at that time for congestive heart failure.\nTwo years later, she was found on a computed topography (CT) scan to have an interval increase in loculated subhepatic fluid collection and a lobular soft tissue mass in the right subphrenic region. She then received three cycles of VP-16 and ifosfamide. She remained well until 2000, when she underwent an orthotopic heart transplant. Upon subsequent reimaging of her abdomen the next year, she was found to have continued slow progression of the tumor and was started on single-agent paclitaxel followed by cyclophosphamide for two months. She was then referred to our institution in late 2001 with stable disease on abdominal CT and a presumed diagnosis of malignant peritoneal mesothelioma refractory to therapy. Over the following year, she was maintained on combination capecitabine and gemcitabine therapy and had stable disease as assessed by CT scans. However, in early 2003 she was found to have declining renal function and was forced to stop chemotherapy.\nShe was observed closely until 2004 and had little change in her overall tumor burden, but had recurrent ascites requiring drainage by paracentesis on multiple occasions. Because of doubts about the true nature of her peritoneal tumor, a further biopsy of her tumor was performed in 2004, with the final interpretation demonstrating a low-grade papillary mesothelioma of the peritoneum (see Figure ). She has been observed closely since that time with periodic abdominal imaging showing a right side subphrenic mass, loculated subhepatic fluid collection, scattered soft tissue densities with calcification, and extensive anterior wall and peritoneal adhesive disease without obstruction (see Figure ). She continues to have chronic renal insufficiency and suffers from severe chronic abdominal pain and cramping, but has stable radiological evidence of disease.", + "fulltext_subclaims": [ + "The patient is a 60-year-old woman of West African descent.", + "She had no history of asbestos exposure.", + "She originally presented 24 years ago to another institution with acute abdominal pain.", + "She underwent an exploratory laparotomy.", + "She was found to have nodules diffusely covering the peritoneum.", + "A total abdominal hysterectomy and bilateral salpingo-oophorectomy were performed.", + "The surgery was performed for suspected ovarian carcinoma.", + "Biopsies were taken of the peritoneal nodules.", + "The pathology from this original surgery was interpreted as low-grade papillary mesothelioma.", + "She received six adjuvant cycles of intravenous cyclophosphamide, doxorubicin, and cisplatin.", + "She underwent a second-look laparotomy six months later.", + "She had gross disease visible in the peritoneum at the second-look laparotomy.", + "Post-operatively, she received three additional cycles of intraperitoneal cisplatin and intravenous sodium thiosulfate.", + "She received maintenance therapy with alternating courses of tamoxifen and megace every two weeks.", + "She presented four years later with obstructive gastrointestinal symptoms.", + "She was again found on laparotomy to have diffuse peritoneal studding.", + "Pathology from this surgery was interpreted again to be papillary mesothelioma.", + "She began six cycles of carboplatin and cyclophosphamide chemotherapy.", + "The chemotherapy was for suspected progressive disease.", + "She presented several months later with shortness of breath, orthopnea, and worsening lower extremity edema.", + "A MUGA scan revealed an ejection fraction of 14%.", + "A chest X-ray showed an enlarged cardiac silhouette.", + "She was clinically diagnosed as having anthracycline-induced cardiomyopathy.", + "Medical therapy was initiated for congestive heart failure.", + "She was found on a CT scan to have an interval increase in loculated subhepatic fluid collection.", + "She had a lobular soft tissue mass in the right subphrenic region.", + "She received three cycles of VP-16 and ifosfamide.", + "She underwent an orthotopic heart transplant in 2000.", + "Upon reimaging of her abdomen the next year, she was found to have continued slow progression of the tumor.", + "She was started on single-agent paclitaxel followed by cyclophosphamide for two months.", + "She was referred to our institution in late 2001 with stable disease on abdominal CT.", + "She had a presumed diagnosis of malignant peritoneal mesothelioma refractory to therapy.", + "She was maintained on combination capecitabine and gemcitabine therapy.", + "She had stable disease as assessed by CT scans.", + "In early 2003, she was found to have declining renal function.", + "She was forced to stop chemotherapy.", + "She was observed closely until 2004.", + "She had little change in her overall tumor burden.", + "She had recurrent ascites requiring drainage by paracentesis on multiple occasions.", + "A further biopsy of her tumor was performed in 2004.", + "The final interpretation demonstrated a low-grade papillary mesothelioma of the peritoneum.", + "She has been observed closely since that time.", + "Periodic abdominal imaging showed a right side subphrenic mass.", + "Periodic abdominal imaging showed loculated subhepatic fluid collection.", + "Periodic abdominal imaging showed scattered soft tissue densities with calcification.", + "Periodic abdominal imaging showed extensive anterior wall and peritoneal adhesive disease without obstruction.", + "She continues to have chronic renal insufficiency.", + "She suffers from severe chronic abdominal pain and cramping.", + "She has stable radiological evidence of disease." + ], + "summary": "We describe the long-term follow-up of a 60-year-old woman of West African descent who has survived 24 years with WDPMP after receiving extensive local and systemic adjuvant chemotherapy. Her clinical course has included three exploratory laparotomies with intraperitoneal and intravenous chemotherapy over two decades. Her course was complicated by anthracycline-induced cardiomyopathy, for which she underwent an orthotopic heart transplant. Our patient is alive with stable radiological evidence of peritoneal disease, and continues to suffer from chronic abdominal pain.", + "summary_subclaims": [ + "The patient is a 60-year-old woman of West African descent.", + "She has survived 24 years with WDPMP.", + "She received extensive local and systemic adjuvant chemotherapy.", + "Her clinical course included three exploratory laparotomies.", + "She received intraperitoneal and intravenous chemotherapy over two decades.", + "She developed anthracycline-induced cardiomyopathy.", + "She underwent an orthotopic heart transplant.", + "She is alive with stable radiological evidence of peritoneal disease.", + "She continues to suffer from chronic abdominal pain." + ] + }, + { + "id": "multiclinsum_test_1086_en.txt", + "fulltext": "A 68-year-old female underwent phacoemulsification + intraocular lens implantation + pars plana vitrectomy (PPV) + ILM peeling + 18% sulfur hexafluoride (SF6) tamponade in January 2016 due to an epiretinal membrane and a lamellar MH. Unfortunately, macular hole retinal detachment (MHRD) occurred one month after surgery. She received PPV + extended ILM peeling + silicone oil tamponade in February 2016 and underwent removal of silicone oil in October 2016. The retina had attached well, although the MH became refractory, and her best-corrected visual acuity (BCVA) was 20/500. She underwent two PPV + free ILM flap transplantation + 15% C3F8 treatments in April 2017 and July 2017, with unsatisfactory results. Due to her repeated surgeries, an autologous free ILM flap could not be harvested. We decided to perform a neurosensory retinal free flap transplantation for the repair of this refractory MH after discussion with the patient.\nA standard 25-g, 3-port PPV (Constellation; Alcon) was performed under general anesthesia. Endolaser photocoagulation was applied to outline the retinal free flap at the temporal retina. The neurosensory retinal free flap was approximately twice the diameter of the MH. The retina was cut with vertical scissors along the inner edge of the laser spots and was gently dissected with back-flush needle irrigation until a neurosensory retinal free flap with a 2-MH diameter area was harvested. The infusion was stopped temporarily to prevent turbulent flow. A drop of whole blood was placed within the MH, and the neurosensory retinal free flap was then placed on the blood. We performed fluid-gas exchange and flushed the vitreous cavity with 15% C3F8 at the end of the surgery . All of the techniques were performed under standard 25-g, 3-port PPV. We did not use a bimanual approach under chandelier illumination (see Additional file ). The patient was instructed to maintain a prone position for 14 days postoperatively and to avoid any unnecessary movement.\nThree weeks after surgery, optical coherence tomography (OCT) revealed closure of the MH. The flap was visible on OCT and had filled the MH without overlapping of the neurosensory retina. The 2-month postoperative OCT examination still showed the MH closure. The patient reported an improvement of visual acuity and a decrease in her scotoma area. The patient’s BCVA improved from 20/500 preoperatively to 20/50 at 2 months postoperatively.", + "fulltext_subclaims": [ + "The patient is a 68-year-old female.", + "She underwent phacoemulsification + intraocular lens implantation + pars plana vitrectomy + ILM peeling + 18% sulfur hexafluoride tamponade in January 2016.", + "The surgeries were performed due to an epiretinal membrane and a lamellar MH.", + "Macular hole retinal detachment occurred one month after surgery.", + "She received PPV + extended ILM peeling + silicone oil tamponade in February 2016.", + "She underwent removal of silicone oil in October 2016.", + "The retina had attached well.", + "The MH became refractory.", + "Her best-corrected visual acuity was 20/500.", + "She underwent two PPV + free ILM flap transplantation + 15% C3F8 treatments in April 2017 and July 2017.", + "The results of the two treatments were unsatisfactory.", + "An autologous free ILM flap could not be harvested due to her repeated surgeries.", + "A neurosensory retinal free flap transplantation was decided for the repair of the refractory MH.", + "The decision was made after discussion with the patient.", + "A standard 25-g, 3-port PPV was performed under general anesthesia.", + "Endolaser photocoagulation was applied to outline the retinal free flap at the temporal retina.", + "The neurosensory retinal free flap was approximately twice the diameter of the MH.", + "The retina was cut with vertical scissors along the inner edge of the laser spots.", + "The retina was gently dissected with back-flush needle irrigation.", + "A neurosensory retinal free flap with a 2-MH diameter area was harvested.", + "The infusion was stopped temporarily to prevent turbulent flow.", + "A drop of whole blood was placed within the MH.", + "The neurosensory retinal free flap was placed on the blood.", + "Fluid-gas exchange was performed.", + "The vitreous cavity was flushed with 15% C3F8 at the end of the surgery.", + "All techniques were performed under standard 25-g, 3-port PPV.", + "A bimanual approach under chandelier illumination was not used.", + "The patient was instructed to maintain a prone position for 14 days postoperatively.", + "The patient was instructed to avoid any unnecessary movement.", + "Three weeks after surgery, OCT revealed closure of the MH.", + "The flap was visible on OCT.", + "The flap had filled the MH without overlapping of the neurosensory retina.", + "The 2-month postoperative OCT examination showed MH closure.", + "The patient reported an improvement of visual acuity.", + "The patient reported a decrease in her scotoma area.", + "The patient’s BCVA improved from 20/500 preoperatively to 20/50 at 2 months postoperatively." + ], + "summary": "To treat a 68-year-old female patient with refractory MH after multiple surgeries, we harvested a neurosensory retinal free flap with a 2-MH diameter area. A drop of whole blood was placed within the MH as an adhesive to fix the neurosensory retinal free flap at the MH under gas tamponade. Two months after surgery, optical coherence tomography (OCT) revealed closure of the MH. The flap was visible on OCT and had filled the MH without overlapping the neurosensory retina. The patient's best-corrected visual acuity (BCVA) improved from 20/500 preoperatively to 20/50 at 2 months postoperatively.", + "summary_subclaims": [ + "The patient was a 68-year-old female.", + "The patient had refractory macular hole (MH) after multiple surgeries.", + "A neurosensory retinal free flap with a 2-MH diameter area was harvested.", + "A drop of whole blood was placed within the MH as an adhesive.", + "The neurosensory retinal free flap was fixed at the MH under gas tamponade.", + "Two months after surgery, optical coherence tomography revealed closure of the MH.", + "The flap was visible on optical coherence tomography.", + "The flap had filled the MH without overlapping the neurosensory retina.", + "The patient's best-corrected visual acuity improved from 20/500 preoperatively to 20/50 at 2 months postoperatively." + ] + }, + { + "id": "multiclinsum_test_585_en.txt", + "fulltext": "A 67-year-old male on anticoagulants for atrial fibrillation, suddenly complained of severe back pain, an L1-level paraparesis/sensory loss with urinary incontinence. On examinations, he had 3/5 motor function loss from L1 downward and a partial sensory level to pin appreciation.\nThe brain CT showed SAH clots in the posterior fossa. Cerebral angiography, however, showed no cranial vascular lesions. Notably, the lumbar MR demonstrated a T12-L1 lesion that was homogeneously enhanced with contrast consistent with a schwannoma . Furthermore, there was intratumoral hemorrhage with SAH/SDH spread resulting in cauda equina compression .\nThe patient underwent a T12-L2 laminectomy 3 weeks later using intraoperative sensory evoked potential (SEP) and motor evoked potential (MEP) . Once the dura was opened, there was subdural and subarachnoid blood underlying which a large tumor with intrinsic hemorrhage was identified. The rostral side of the tumor, was strongly adherent to the conus medullaris from which it had to be carefully dissected and removed. There were no SEP/MEP changes during surgery. Postoperatively, the paraparesis transiently worsened, but, over the next 6 months, the motor, sensory, and sphincteric function then gradually improved. At that point, the follow-up MRI revealed no recurrence of tumor.\nThe tumor was a typical schwannoma. It contained proliferating spindle cells arranged in short bundles or interlocking fascicles containing hypocellular and hypercellular area (Antoni A and B area, respectively). On immunohistochemistry, most of the tumor cells were positive for S-100 protein. Hyalinized and ectatic vessels were also found within the tumor close to the tumor capsule, with inflammatory cells clustered around them. Fresh hemorrhage associated with focal necrosis was also found within the tumor .", + "fulltext_subclaims": [ + "The patient is a 67-year-old male.", + "He is on anticoagulants for atrial fibrillation.", + "He suddenly complained of severe back pain.", + "He had an L1-level paraparesis/sensory loss with urinary incontinence.", + "On examination, he had 3/5 motor function loss from L1 downward.", + "There was a partial sensory level to pin appreciation.", + "The brain CT showed SAH clots in the posterior fossa.", + "Cerebral angiography showed no cranial vascular lesions.", + "The lumbar MR demonstrated a T12-L1 lesion that was homogeneously enhanced with contrast consistent with a schwannoma.", + "There was intratumoral hemorrhage with SAH/SDH spread resulting in cauda equina compression.", + "The patient underwent a T12-L2 laminectomy 3 weeks later.", + "Intraoperative sensory evoked potential (SEP) and motor evoked potential (MEP) were used.", + "Once the dura was opened, there was subdural and subarachnoid blood.", + "A large tumor with intrinsic hemorrhage was identified.", + "The rostral side of the tumor was strongly adherent to the conus medullaris.", + "The tumor had to be carefully dissected and removed.", + "There were no SEP/MEP changes during surgery.", + "Postoperatively, the paraparesis transiently worsened.", + "Over the next 6 months, motor, sensory, and sphincteric function gradually improved.", + "The follow-up MRI revealed no recurrence of tumor.", + "The tumor was a typical schwannoma.", + "It contained proliferating spindle cells arranged in short bundles or interlocking fascicles.", + "The tumor had hypocellular and hypercellular areas (Antoni A and B areas, respectively).", + "Most of the tumor cells were positive for S-100 protein.", + "Hyalinized and ectatic vessels were found within the tumor close to the tumor capsule.", + "Inflammatory cells were clustered around the vessels.", + "Fresh hemorrhage associated with focal necrosis was found within the tumor." + ], + "summary": "A 67-year-old male acutely presented with severe back pain and L1 paraparesis/sensory loss, with urinary incontinence. CT/MR studies showed a spinal SAH and SDH within a likely T12-L1 schwannoma. At surgery, the hemorrhage within the tumor was continuous through the lower pole of the tumor into the subarachnoid and subdural spaces; tumor was dissected away from the surrounding tissues and totally removed. The postoperative course was uneventful, and the preoperative neurological deficits gradually resolved. Histopathologically, the lesion was a schwannoma with intratumoral hemorrhage.", + "summary_subclaims": [ + "The patient is a 67-year-old male.", + "The patient acutely presented with severe back pain.", + "The patient had L1 paraparesis/sensory loss.", + "The patient had urinary incontinence.", + "CT/MR studies showed a spinal SAH.", + "CT/MR studies showed an SDH within a likely T12-L1 schwannoma.", + "At surgery, the hemorrhage within the tumor was continuous through the lower pole of the tumor into the subarachnoid and subdural spaces.", + "The tumor was dissected away from the surrounding tissues.", + "The tumor was totally removed.", + "The postoperative course was uneventful.", + "The preoperative neurological deficits gradually resolved.", + "Histopathologically, the lesion was a schwannoma.", + "Histopathologically, the lesion had intratumoral hemorrhage." + ] + }, + { + "id": "multiclinsum_test_1750_en.txt", + "fulltext": "A 20-year-old Japanese man presented with his father to our periodontic clinic at Osaka University Dental Hospital, Japan, because of his poor oral condition. His chief complaint was severely painful gums, which led to crying. He was unable to provide detailed information about when and how this problem had started. His father told us that our patient had thought there was a gingival problem since childhood, had complained of gingival pain for the previous six months, and had been unable to brush his teeth for the last two weeks. Our patient's height was 153 cm and his weight was 62 kg. His medical history included a three-month hospital stay caused by low birth weight and cyanosis just after birth. A clinical diagnosis of PWS had been made on the basis of symptoms such as hypotonia, genital hypoplasia, acromicria (short hands and feet) and genetic testing.\nAn intra-oral examination revealed poor oral hygiene with heavy generalized plaque throughout the permanent dentition. His gingival tissues showed marginal redness, swelling, and food impaction . An apparent anterior open bite, increasing overjet, an anterior crowded arch and malpositioning of the teeth were noted. In addition, circular caries and attrition of the mandibular first molars were present. Pocket depths ranged from 4 mm to 8 mm. Mobility grade 2 was present in the mandibular left second premolar. We tried to measure the pocket depth and clinical attachment level at his first visit. Unfortunately, however, our patient did not allow the pocket measurement because of pain. Thus, we could not perform the conventional pocket measurement and examined only the mesial and buccal/labial pockets. Periapical radiographs disclosed localized vertical bone resorption (mesiolateral of maxillary right first molar and mesiolateral of mandibular left first molar) . Of particular note, the mesiopalatal pocket depth of the maxillary right first molar was 8 mm.\nBased on pocket measurements and an X-ray examination, our patient was diagnosed with localized periodontitis. In addition, our patient exhibited several caries lesions from the mandibular right anterior teeth to the left molars. An orthopantomogram showed full permanent teeth with unerupted lower third molars. There was no family history of periodontitis.\nAdvice on periodontal treatment was provided in the presence of one of our patient's parents. This included oral hygiene instructions on how to control plaque using a manual toothbrush (Sam Friend Supersoft #300; Sun Dental, Osaka, Japan), 0.2% w/w chlorhexidine mouth rinse (ConCool F; Weltech, Osaka, Japan) and 1% v/w chlorhexidine gel (ConCool Gelcoat F; Weltech). Professional scaling was also performed to remove supragingival plaque. Our patient kept his treatment appointments with his father every three weeks, but his plaque control was poor. His father told us that our patient was motivated to brush his teeth and did so happily, but sometimes he fell asleep without brushing because of daytime somnolence; a common occurrence in PWS . He refused to allow his parents to help him brush his teeth. Furthermore, malpositioning of the teeth and difficulties with hand and wrist movements inhibited adequate plaque control. After three visits to the clinic our patient had become accustomed to the dental treatment, and subgingival scaling was performed using an ultrasonic scaler. However, active treatments such as root planing and periodontal surgery were not employed because of poor plaque control. Both tooth-brushing instruction (TBI) and subgingival scaling were performed every three weeks. Although some gingival inflammation remained, his gingival swelling and redness were reduced by six months after his first visit .", + "fulltext_subclaims": [ + "A 20-year-old Japanese man presented with his father to our periodontic clinic at Osaka University Dental Hospital, Japan.", + "His chief complaint was severely painful gums, which led to crying.", + "He was unable to provide detailed information about when and how this problem had started.", + "His father told us that our patient had thought there was a gingival problem since childhood.", + "His father told us that our patient had complained of gingival pain for the previous six months.", + "His father told us that our patient had been unable to brush his teeth for the last two weeks.", + "Our patient's height was 153 cm.", + "Our patient's weight was 62 kg.", + "His medical history included a three-month hospital stay caused by low birth weight and cyanosis just after birth.", + "A clinical diagnosis of PWS had been made on the basis of symptoms such as hypotonia, genital hypoplasia, acromicria (short hands and feet) and genetic testing.", + "An intra-oral examination revealed poor oral hygiene with heavy generalized plaque throughout the permanent dentition.", + "His gingival tissues showed marginal redness, swelling, and food impaction.", + "An apparent anterior open bite, increasing overjet, an anterior crowded arch and malpositioning of the teeth were noted.", + "Circular caries and attrition of the mandibular first molars were present.", + "Pocket depths ranged from 4 mm to 8 mm.", + "Mobility grade 2 was present in the mandibular left second premolar.", + "We tried to measure the pocket depth and clinical attachment level at his first visit.", + "Our patient did not allow the pocket measurement because of pain.", + "We could not perform the conventional pocket measurement and examined only the mesial and buccal/labial pockets.", + "Periapical radiographs disclosed localized vertical bone resorption (mesiolateral of maxillary right first molar and mesiolateral of mandibular left first molar).", + "The mesiopalatal pocket depth of the maxillary right first molar was 8 mm.", + "Based on pocket measurements and an X-ray examination, our patient was diagnosed with localized periodontitis.", + "Our patient exhibited several caries lesions from the mandibular right anterior teeth to the left molars.", + "An orthopantomogram showed full permanent teeth with unerupted lower third molars.", + "There was no family history of periodontitis.", + "Advice on periodontal treatment was provided in the presence of one of our patient's parents.", + "This included oral hygiene instructions on how to control plaque using a manual toothbrush (Sam Friend Supersoft #300; Sun Dental, Osaka, Japan).", + "This included oral hygiene instructions on how to control plaque using 0.2% w/w chlorhexidine mouth rinse (ConCool F; Weltech, Osaka, Japan).", + "This included oral hygiene instructions on how to control plaque using 1% v/w chlorhexidine gel (ConCool Gelcoat F; Weltech).", + "Professional scaling was also performed to remove supragingival plaque.", + "Our patient kept his treatment appointments with his father every three weeks.", + "His plaque control was poor.", + "His father told us that our patient was motivated to brush his teeth and did so happily.", + "His father told us that our patient sometimes fell asleep without brushing because of daytime somnolence.", + "Daytime somnolence is a common occurrence in PWS.", + "He refused to allow his parents to help him brush his teeth.", + "Malpositioning of the teeth and difficulties with hand and wrist movements inhibited adequate plaque control.", + "After three visits to the clinic our patient had become accustomed to the dental treatment.", + "Subgingival scaling was performed using an ultrasonic scaler.", + "Active treatments such as root planing and periodontal surgery were not employed because of poor plaque control.", + "Both tooth-brushing instruction (TBI) and subgingival scaling were performed every three weeks.", + "Although some gingival inflammation remained, his gingival swelling and redness were reduced by six months after his first visit." + ], + "summary": "We describe the clinical presentation and periodontal findings in a 20-year-old Japanese man with previously diagnosed Prader-Willi syndrome. Clinical and radiographic findings confirmed the diagnosis of periodontitis. The most striking oral findings were anterior open bite, and crowding and attrition of the lower first molars. Periodontal treatment consisted of tooth-brushing instruction and scaling. Home care involved recommended use of adjunctive chlorhexidine gel for tooth brushing twice a week and chlorhexidine mouthwash twice daily. Gingival swelling improved, but further treatment will be required and our patient's oral hygiene remains poor. The present treatment of tooth-brushing instruction and scaling every three weeks therefore only represents a temporary solution.", + "summary_subclaims": [ + "The patient is a 20-year-old Japanese man.", + "The patient has previously diagnosed Prader-Willi syndrome.", + "Clinical and radiographic findings confirmed the diagnosis of periodontitis.", + "The most striking oral findings were anterior open bite.", + "The most striking oral findings were crowding and attrition of the lower first molars.", + "Periodontal treatment consisted of tooth-brushing instruction and scaling.", + "Home care involved recommended use of adjunctive chlorhexidine gel for tooth brushing twice a week.", + "Home care involved recommended use of chlorhexidine mouthwash twice daily.", + "Gingival swelling improved.", + "Further treatment will be required.", + "The patient's oral hygiene remains poor.", + "The present treatment of tooth-brushing instruction and scaling every three weeks only represents a temporary solution." + ] + }, + { + "id": "multiclinsum_test_1780_en.txt", + "fulltext": "A 79 year old male with history of atrial fibrillation (previously on apixaban and switched to aspirin only), type II diabetes mellitus, asthma (well controlled on home inhalers), hypertension, and tested positive for coronavirus disease 2019 (COVID-19) on April 7th, 2021 and fully vaccinated with Moderna presented to the emergency department with progressive worsening of bilateral lower extremity edema and dyspnea over one month. Patient had a chronic two-pillow orthopnea, and at baseline performed all activities of daily living independently. In addition, this work has been reported in accordance with SCARE .\nAt presentation, the patient denied chest pain, fever, nausea, vomiting, diarrhea, dysuria, travel, trauma, drug use, and cough. Vital signs were all within normal limits on admission. Physical exam was notable for bibasilar crackles in the lungs, bilateral lower extremity 2+ pitting edema, and jugular venous distention up to 9 cm. Labs were notable for a pro B-type natriuretic peptide of 8458 pg/mL (reference range 1–450 pg/mL), a significant increase from 3301 pg/mL during a previous admission. In addition, the D-dimer was unremarkable. A chest radiograph obtained during admission showed bilateral ground glass opacities from prior COVID-19, pulmonary congestion, and interposition of the right hepatic flexure of the colon between subdiaphragmatic space and the right dome of the liver (Chilaiditi's sign) . The comparison was made from a prior chest radiograph that showed normal anatomy of the right subdiaphragmatic space . Electrocardiogram demonstrated atrial fibrillation with low voltage and no acute ischemic features. Echocardiogram showed an ejection fraction of 40%, reduced from 70% only a year ago, with normal right ventricular (RV) size, reduced RV contractility, and a dilated right atrium. In addition, the patient did not have any prior COVID-19 complications including intubation, development of pulmonary embolism or requiring supplemental oxygen. A negative D-dimer and CT chest without contrast showed no evidence of embolism, effectively ruling out acute pulmonary embolism.\nThe patient was subsequently admitted for congestive heart failure exacerbation, for which he was started on furosemide 40 mg IV twice a day with daily weight trend and strict intake and output documentation. Patient had an excellent response to diuretics with a net negative urine output of 6.8 L over 48 hours since admission. His home medications were resumed, including Losartan 25 mg daily, carvedilol 3.125 mg twice daily, atorvastatin 40 mg, aspirin 81mg, albuterol inhaler as needed every 6 hours and montelukast 10 mg daily. He was diuresed for 3 days, successfully achieving euvolemic status, resolution of bilateral leg edema, and improvement of jugular venous distention. Cardiology was consulted for a new reduction in ejection fraction to rule out acute coronary syndrome. Given an electrocardiogram showing no ischemic features and negative troponin on three separate assessments, it was concluded that the patient did not have acute coronary syndrome. Patient received coronary angiography and was found to have non-obstructive coronary artery disease. Patient continued to have persistent dyspnea with some mild pleuritic chest pain on the right subcostal region without any need for supplemental oxygen. The aforementioned medications were continued for a total of 5 days. Community or hospital acquired pneumonia was ruled out given normal cultures, absence of inflammatory response, no fevers, normal procalcitonin, and no imaging findings concerning pneumonia. Computed tomography scan of the chest without contrast was repeated to rule out other causes of dyspnea and pleurisy, and subsequently showed colonic interposition between the diaphragm and right lobe of the liver . Given the patient's dyspnea and pleurisy due to diaphragmatic irritation, as well as the imaging findings, surgery was consulted for potential Chilaiditi syndrome. Despite this, the patient refused to undergo any surgery and preferred to be discharged from the hospital. The patient was discharged with guidelines for long-term medical treatment for heart failure (Lasix 40mg by mouth twice daily, carvedilol 3.125 mg twice daily, Losartan 25mg daily), atrial fibrillation (carvedilol 3.125 twice daily, aspirin 81mg), hypertension (carvedilol 3.125 mg twice daily, Losartan 25mg daily) and asthma (albuterol inhaler as needed, montelukast 10mg daily).", + "fulltext_subclaims": [ + "The patient is a 79 year old male.", + "The patient has a history of atrial fibrillation.", + "The patient was previously on apixaban and was switched to aspirin only.", + "The patient has type II diabetes mellitus.", + "The patient has asthma, well controlled on home inhalers.", + "The patient has hypertension.", + "The patient tested positive for coronavirus disease 2019 (COVID-19) on April 7th, 2021.", + "The patient is fully vaccinated with Moderna.", + "The patient presented to the emergency department with progressive worsening of bilateral lower extremity edema and dyspnea over one month.", + "The patient had a chronic two-pillow orthopnea.", + "The patient performed all activities of daily living independently at baseline.", + "This work has been reported in accordance with SCARE.", + "At presentation, the patient denied chest pain.", + "At presentation, the patient denied fever.", + "At presentation, the patient denied nausea.", + "At presentation, the patient denied vomiting.", + "At presentation, the patient denied diarrhea.", + "At presentation, the patient denied dysuria.", + "At presentation, the patient denied travel.", + "At presentation, the patient denied trauma.", + "At presentation, the patient denied drug use.", + "At presentation, the patient denied cough.", + "Vital signs were all within normal limits on admission.", + "Physical exam was notable for bibasilar crackles in the lungs.", + "Physical exam was notable for bilateral lower extremity 2+ pitting edema.", + "Physical exam was notable for jugular venous distention up to 9 cm.", + "Labs were notable for a pro B-type natriuretic peptide of 8458 pg/mL.", + "The pro B-type natriuretic peptide reference range is 1–450 pg/mL.", + "The pro B-type natriuretic peptide was a significant increase from 3301 pg/mL during a previous admission.", + "The D-dimer was unremarkable.", + "A chest radiograph obtained during admission showed bilateral ground glass opacities from prior COVID-19.", + "A chest radiograph obtained during admission showed pulmonary congestion.", + "A chest radiograph obtained during admission showed interposition of the right hepatic flexure of the colon between subdiaphragmatic space and the right dome of the liver (Chilaiditi's sign).", + "The comparison was made from a prior chest radiograph that showed normal anatomy of the right subdiaphragmatic space.", + "Electrocardiogram demonstrated atrial fibrillation with low voltage.", + "Electrocardiogram showed no acute ischemic features.", + "Echocardiogram showed an ejection fraction of 40%.", + "The ejection fraction was reduced from 70% only a year ago.", + "Echocardiogram showed normal right ventricular (RV) size.", + "Echocardiogram showed reduced RV contractility.", + "Echocardiogram showed a dilated right atrium.", + "The patient did not have any prior COVID-19 complications.", + "The patient did not have intubation.", + "The patient did not have development of pulmonary embolism.", + "The patient did not require supplemental oxygen.", + "A negative D-dimer and CT chest without contrast showed no evidence of embolism.", + "Acute pulmonary embolism was effectively ruled out.", + "The patient was admitted for congestive heart failure exacerbation.", + "The patient was started on furosemide 40 mg IV twice a day.", + "The patient had a net negative urine output of 6.8 L over 48 hours since admission.", + "Home medications were resumed, including Losartan 25 mg daily.", + "Home medications were resumed, including carvedilol 3.125 mg twice daily.", + "Home medications were resumed, including atorvastatin 40 mg.", + "Home medications were resumed, including aspirin 81mg.", + "Home medications were resumed, including albuterol inhaler as needed every 6 hours.", + "Home medications were resumed, including montelukast 10 mg daily.", + "The patient was diuresed for 3 days.", + "The patient successfully achieved euvolemic status.", + "The patient had resolution of bilateral leg edema.", + "The patient had improvement of jugular venous distention.", + "Cardiology was consulted for a new reduction in ejection fraction to rule out acute coronary syndrome.", + "An electrocardiogram showed no ischemic features.", + "Troponin was negative on three separate assessments.", + "It was concluded that the patient did not have acute coronary syndrome.", + "The patient received coronary angiography.", + "Coronary angiography found non-obstructive coronary artery disease.", + "The patient continued to have persistent dyspnea.", + "The patient had some mild pleuritic chest pain on the right subcostal region.", + "The patient did not need supplemental oxygen.", + "The aforementioned medications were continued for a total of 5 days.", + "Community or hospital acquired pneumonia was ruled out.", + "Normal cultures were obtained.", + "There was an absence of inflammatory response.", + "There were no fevers.", + "Procalcitonin was normal.", + "There were no imaging findings concerning pneumonia.", + "A computed tomography scan of the chest without contrast was repeated.", + "The CT scan showed colonic interposition between the diaphragm and right lobe of the liver.", + "Surgery was consulted for potential Chilaiditi syndrome.", + "The patient refused to undergo any surgery.", + "The patient preferred to be discharged from the hospital.", + "The patient was discharged with guidelines for long-term medical treatment for heart failure.", + "The patient was discharged with Lasix 40mg by mouth twice daily.", + "The patient was discharged with carvedilol 3.125 mg twice daily.", + "The patient was discharged with Losartan 25mg daily.", + "The patient was discharged with aspirin 81mg.", + "The patient was discharged with albuterol inhaler as needed.", + "The patient was discharged with montelukast 10mg daily." + ], + "summary": "In this interesting case, we discover lingering dyspnea in our 79 year old male with a past medical history of asthma and heart failure with preserved ejection fraction admitted for acute heart failure exacerbation with reduced ejection fraction along with a new incidental finding of Chilaiditi's sign on chest radiograph. Patient received optimal diuretics and guideline-directed medical treatment for heart failure exacerbation, but mild dyspnea with pleuritic chest pain persisted. Dyspnea with pleurisy was likely attributed to a structural anatomical defect (Chilaiditi's sign) that can be picked up on imaging.", + "summary_subclaims": [ + "The patient is a 79 year old male.", + "The patient has a past medical history of asthma.", + "The patient has a past medical history of heart failure with preserved ejection fraction.", + "The patient was admitted for acute heart failure exacerbation with reduced ejection fraction.", + "A new incidental finding of Chilaiditi's sign was noted on chest radiograph.", + "The patient received optimal diuretics.", + "The patient received guideline-directed medical treatment for heart failure exacerbation.", + "Mild dyspnea with pleuritic chest pain persisted.", + "Dyspnea with pleurisy was likely attributed to a structural anatomical defect.", + "Chilaiditi's sign can be picked up on imaging." + ] + }, + { + "id": "multiclinsum_test_3216_en.txt", + "fulltext": "A male neonate with a birth weight of 2800g, body length of 47cm, and Apgar scores of 9–10-10 was born via cesarean section delivery to a 33-year-old G4P2+1L1 mother at 38+5-week gestation in hospital in a nonconsanguineous marriage with 4000mL of II° meconium-stained amniotic fluid in a tertiary first-class hospital in Chengdu, western China, in 2019.\n\nThe mother had a history of one intrauterine fetal loss at 7 months’ gestation for undetermined cause, gave birth to a healthy male infant two years previously, and experienced a spontaneous abortion during her third pregnancy with specific details unavailable. This was her fourth pregnancy, and she underwent routine prenatal examination in the local county-level hospital during the mid-term of pregnancy. Given the history of previous stillbirths, the pregnant woman underwent comprehensive genetic screenings, including thalassemia gene screening, amniocentesis, and examinations of fetal chromosomal number chromosomal aneuploidy, and gene copy number variations at gestational age of 22+5 weeks at the most authoritative hospital in the province. However, all these investigations failed to reveal any abnormalities. At 35+6-week gestation, the local hospital detected a serum alpha-fetoprotein (AFP) level in the pregnant women exceeding 1000 ng/mL. At 36+5-week gestation, upon transferring to our hospital in preparation for delivery, ultrasound revealed mild polyhydramnios (Amniotic fluid index of 33.5 cm.), chorioamniotic membrane separation(CMS), and an enlarged fetal gastric bubble (7.2cm×3.0cm), and the pregnant woman was diagnosed with gestational diabetes (GDM) and suspected fetal digestive tract obstruction by the outpatient obstetrician.\n\nOn physical examination, the neonate was found tachypnea (with respiration rate of 55/min) and absence of skin along Blaschko’s lines over the anteromedial aspect of both lower legs almost symmetrically, and also skin absence on the nasal tip, ears, right neck, the right hip, and mucosa absence in the oral cavity, and totally the skin missing covered about 17% of the whole body surface (Roughly, calves, feet, buttocks, and neck accounted for 10%, 3.5%, 2.5%, and 1% respectively), with scattered blisters. The skin and mucous membrane adjacent to these defects appeared “normal” but showed a strongly positive Nikolsky test. Moreover, there was bilateral ear maldevelopment.\n\nRight after the delivery, routine airway sputum suctioning was performed on the neonate. Subsequently, the neonate was transferred to the Neonatal Intensive Care Unit (NICU) laminar flow ward due to extensive skin lesion and pneumonia, placed in reverse isolation in a 34°C temperature-controlled incubator with humidity of 55%, aiming to minimize insensible water loss. The neonate received immediate thermoregulation and total parenteral nutrition, along with vitamin K1 for vitamin K deficiency bleeding (VKDB) prevention, analgesia, sedation, and cefuroxime anti-infective treatment. In terms of care, continuous electrocardiographic monitoring, oxygen inhalation, and fasting were initiated promptly.\n\nFor skin care, given the extensive abnormal skin area of the patient, to alleviate pain and reduce the duration of dressing changes, we planned an alternate-day dressing change strategy, alternating between the trunk and limbs. The dressing sequence involved moistening and softening, wound cleaning, medication application, covering with petrolatum gauze, non-adherent foam dressing, and self-adhesive elastic bandage wrapping.\n\nThe neonatologist requested urgent consultations. Given absence of skin and scattered blisters of the skin, the dermatologist suspected “Bart Syndrome”. A subsequent plain abdominal radiograph was performed and it revealed a large gastric air bubble with no gas distally, indicating PA. Consequently, the pediatric surgeon made a supplementary diagnosis of CPA. After 26 hours and 53 minutes of hospitalization, the neonate’s family decided to discontinue treatment, and the neonate passed away approximately 30 hours after birth. Despite departmental discussions mentioning the possibility of EB and/or ACC in the neonate and proposing the need for pathological and genetic examinations, these planned investigations were not implemented due to the neonate’s short lifespan, lack of family support, and other factors.", + "fulltext_subclaims": [ + "The neonate was a male.", + "The neonate had a birth weight of 2800g.", + "The neonate had body length of 47cm.", + "The neonate had Apgar scores of 9–10-10.", + "The neonate was born via cesarean section.", + "The mother was 33 years old.", + "The mother was G4P2+1L1.", + "The delivery occurred at 38+5-week gestation.", + "The delivery occurred in a tertiary first-class hospital in Chengdu, western China.", + "The delivery occurred in 2019.", + "The mother had a history of one intrauterine fetal loss at 7 months’ gestation for undetermined cause.", + "The mother gave birth to a healthy male infant two years previously.", + "The mother experienced a spontaneous abortion during her third pregnancy.", + "This was the mother’s fourth pregnancy.", + "The mother underwent routine prenatal examination in the local county-level hospital during the mid-term of pregnancy.", + "The mother underwent comprehensive genetic screenings, including thalassemia gene screening, amniocentesis, and examinations of fetal chromosomal number chromosomal aneuploidy, and gene copy number variations at gestational age of 22+5 weeks.", + "All these investigations failed to reveal any abnormalities.", + "At 35+6-week gestation, the local hospital detected a serum alpha-fetoprotein (AFP) level in the pregnant woman exceeding 1000 ng/mL.", + "At 36+5-week gestation, ultrasound revealed mild polyhydramnios (Amniotic fluid index of 33.5 cm.).", + "At 36+5-week gestation, ultrasound revealed chorioamniotic membrane separation.", + "At 36+5-week gestation, ultrasound revealed an enlarged fetal gastric bubble (7.2cm×3.0cm).", + "The pregnant woman was diagnosed with gestational diabetes.", + "The pregnant woman was diagnosed with suspected fetal digestive tract obstruction.", + "On physical examination, the neonate was found to have tachypnea (with respiration rate of 55/min).", + "On physical examination, the neonate had absence of skin along Blaschko’s lines over the anteromedial aspect of both lower legs.", + "On physical examination, the neonate had skin absence on the nasal tip.", + "On physical examination, the neonate had skin absence on the ears.", + "On physical examination, the neonate had skin absence on the right neck.", + "On physical examination, the neonate had skin absence on the right hip.", + "On physical examination, the neonate had mucosa absence in the oral cavity.", + "The total skin missing covered about 17% of the whole body surface.", + "The skin and mucous membrane adjacent to these defects appeared “normal”.", + "The skin and mucous membrane adjacent to these defects showed a strongly positive Nikolsky test.", + "There was bilateral ear maldevelopment.", + "Right after the delivery, routine airway sputum suctioning was performed on the neonate.", + "The neonate was transferred to the Neonatal Intensive Care Unit (NICU) laminar flow ward.", + "The neonate was placed in reverse isolation in a 34°C temperature-controlled incubator.", + "The neonate received immediate thermoregulation.", + "The neonate received total parenteral nutrition.", + "The neonate received vitamin K1 for vitamin K deficiency bleeding (VKDB) prevention.", + "The neonate received analgesia.", + "The neonate received sedation.", + "The neonate received cefuroxime anti-infective treatment.", + "The neonate had continuous electrocardiographic monitoring.", + "The neonate had oxygen inhalation.", + "The neonate had fasting initiated promptly.", + "For skin care, an alternate-day dressing change strategy was planned.", + "The dressing sequence involved moistening and softening.", + "The dressing sequence involved wound cleaning.", + "The dressing sequence involved medication application.", + "The dressing sequence involved covering with petrolatum gauze.", + "The dressing sequence involved non-adherent foam dressing.", + "The dressing sequence involved self-adhesive elastic bandage wrapping.", + "The dermatologist suspected “Bart Syndrome”.", + "A plain abdominal radiograph revealed a large gastric air bubble with no gas distally.", + "The pediatric surgeon made a supplementary diagnosis of CPA.", + "After 26 hours and 53 minutes of hospitalization, the neonate’s family decided to discontinue treatment.", + "The neonate passed away approximately 30 hours after birth.", + "Departmental discussions mentioned the possibility of EB and/or ACC in the neonate.", + "Departmental discussions proposed the need for pathological and genetic examinations.", + "These planned investigations were not implemented due to the neonate’s short lifespan.", + "These planned investigations were not implemented due to lack of family support." + ], + "summary": "Carmi Syndrome is an extremely rare autosomal recessive genetic disorder characterized the coexistence of pyloric atresia and junctional epidermolysis bullosa, and with aplasia cutis congenita in approximately 28% patients. In this case, a full-term male neonate was born to a G4P2+1L1 multipara through cesarean section delivery in hospital in a non-consanguineous marriage with 4000mL of II°meconium-stained amniotic fluid. He was found extensive skin loss over lower legs and other parts, with scattered blisters and bilateral microtia. Plain abdominal X-ray revealed a large gastric air bubble with no gas distally. The mother had an intrauterine fetal loss previously for reasons unknown. The dermatologist diagnosed the newborn with Bart Syndrome, while the pediatric surgeon diagnosed congenital pyloric atresia(CPA). The parents refused further treatment and the neonate passed away about 30 hours after birth.\n\nOutcome: The neonate passed away about 30 hours after birth.", + "summary_subclaims": [ + "Carmi Syndrome is an extremely rare autosomal recessive genetic disorder.", + "Carmi Syndrome is characterized by the coexistence of pyloric atresia and junctional epidermolysis bullosa.", + "Aplasia cutis congenita is present in approximately 28% of patients with Carmi Syndrome.", + "The patient was a full-term male neonate.", + "The neonate was born to a G4P2+1L1 multipara.", + "The delivery was via cesarean section in a hospital.", + "The neonate's parents were in a non-consanguineous marriage.", + "The amniotic fluid was 4000mL of II° meconium-stained.", + "The neonate had extensive skin loss over the lower legs and other parts.", + "The neonate had scattered blisters.", + "The neonate had bilateral microtia.", + "Plain abdominal X-ray revealed a large gastric air bubble with no gas distally.", + "The mother had an intrauterine fetal loss previously for reasons unknown.", + "The dermatologist diagnosed the newborn with Bart Syndrome.", + "The pediatric surgeon diagnosed congenital pyloric atresia (CPA).", + "The parents refused further treatment.", + "The neonate passed away about 30 hours after birth." + ] + }, + { + "id": "multiclinsum_test_2935_en.txt", + "fulltext": "A 52-year-old gentleman was admitted electively for his third redo debulking of right occipital parafalcine meningioma in November 2017. At the time of anesthetic induction, he desaturated and required high ventilator pressure support and high FiO2 requirements to maintain oxygen saturation over 90%. An urgent chest X-ray (CXR) revealed that the endotracheal tube was appropriately positioned, and an incidental large well-delineated left upper lobe nodule was noted. The lung fields were otherwise clear, and there was no associated lung parenchymal abnormality. The following day, a formal CXR was performed , the patient was back to his baseline and the surgery was postponed. A CXR performed in 2016 revealed no lung lesions.\nA subsequent chest computed tomography (CT) was arranged and confirmed the presence of a 19-mm left upper lobe nodule and a total of five other smaller bilateral pulmonary nodules ranging from 4 to 13 mm, giving a cannonball appearance [Figures and ]. As these nodules were very well circumscribed and appeared benign, the respiratory and multidisciplinary teams felt that the best course of action in this patient would be a repeat chest CT in 6 months.\nThis patient's medical history included right occipital parafalcine meningioma diagnosed in 1994 which was surgically resected in Auckland, New Zealand. This was followed by the insertion of a left-sided ventriculoperitoneal shunt for postoperative hydrocephalus. Histopathology confirmed WHO Grade I meningioma. On surveillance imaging in Melbourne, Australia, in 2013, he was found to have a recurrence, leading to the first redo craniotomy and debulking. Histopathology in this instance revealed transformation to atypical WHO Grade II meningioma. In February 2016, he developed intractable seizures which lead to his second redo debulking at the same unit. The histopathology remained unchanged.\nThis patient's third redo debulking procedure was rescheduled to February 2018, approximately 3 months after the diagnosis of the multiple pulmonary lesions. A Simpson Grade 2 resection of recurrent right occipital parafalcine meningioma was performed. Histopathology again showed features consistent with atypical WHO Grade II meningioma ; however, although it did not fulfill criteria for anaplastic WHO Grade III meningioma, the higher Ki-67 proliferation index suggested that it may behave more aggressively than the conventional WHO Grade II meningioma. Postoperatively, he developed no new focal neurology and had significant improvement in seizure-free periods. He was treated with postoperative radiation therapy 60 Gy in 30 fractions and had no symptoms to suggest residual acute radiation toxicity.\nA repeat chest CT was performed in May 2018 and revealed all six lung lesions with interval increase in size, the largest now measuring 27 mm. A chest CT-guided core biopsy of the largest lesion was performed. This confirmed histopathological features consistent with metastatic meningioma .", + "fulltext_subclaims": [ + "The patient was admitted electively for his third redo debulking of right occipital parafalcine meningioma in November 2017.", + "At the time of anesthetic induction, he desaturated and required high ventilator pressure support and high FiO2 requirements to maintain oxygen saturation over 90%.", + "An urgent chest X-ray (CXR) revealed that the endotracheal tube was appropriately positioned.", + "An incidental large well-delineated left upper lobe nodule was noted.", + "The lung fields were otherwise clear, and there was no associated lung parenchymal abnormality.", + "The following day, a formal CXR was performed.", + "The patient was back to his baseline.", + "The surgery was postponed.", + "A CXR performed in 2016 revealed no lung lesions.", + "A subsequent chest computed tomography (CT) was arranged.", + "The chest CT confirmed the presence of a 19-mm left upper lobe nodule.", + "The chest CT showed a total of five other smaller bilateral pulmonary nodules ranging from 4 to 13 mm.", + "The nodules gave a cannonball appearance.", + "The nodules were very well circumscribed and appeared benign.", + "The respiratory and multidisciplinary teams felt that the best course of action in this patient would be a repeat chest CT in 6 months.", + "The patient's medical history included right occipital parafalcine meningioma diagnosed in 1994.", + "The meningioma was surgically resected in Auckland, New Zealand.", + "A left-sided ventriculoperitoneal shunt was inserted for postoperative hydrocephalus.", + "Histopathology confirmed WHO Grade I meningioma.", + "On surveillance imaging in Melbourne, Australia, in 2013, he was found to have a recurrence.", + "This led to the first redo craniotomy and debulking.", + "Histopathology in this instance revealed transformation to atypical WHO Grade II meningioma.", + "In February 2016, he developed intractable seizures.", + "This led to his second redo debulking at the same unit.", + "The histopathology remained unchanged.", + "The third redo debulking procedure was rescheduled to February 2018.", + "The third redo debulking was approximately 3 months after the diagnosis of the multiple pulmonary lesions.", + "A Simpson Grade 2 resection of recurrent right occipital parafalcine meningioma was performed.", + "Histopathology again showed features consistent with atypical WHO Grade II meningioma.", + "The higher Ki-67 proliferation index suggested that it may behave more aggressively than the conventional WHO Grade II meningioma.", + "Postoperatively, he developed no new focal neurology.", + "He had significant improvement in seizure-free periods.", + "He was treated with postoperative radiation therapy 60 Gy in 30 fractions.", + "He had no symptoms to suggest residual acute radiation toxicity.", + "A repeat chest CT was performed in May 2018.", + "The repeat chest CT revealed all six lung lesions with interval increase in size.", + "The largest lesion now measured 27 mm.", + "A chest CT-guided core biopsy of the largest lesion was performed.", + "The biopsy confirmed histopathological features consistent with metastatic meningioma." + ], + "summary": "We present a case of multiple pulmonary meningioma metastases developing 13 years after initial resection of left occipital parafalcine World Health Organization Grade I intracranial meningioma.", + "summary_subclaims": [ + "The patient had multiple pulmonary meningioma metastases.", + "The pulmonary metastases developed 13 years after the initial resection.", + "The initial tumor was a left occipital parafalcine World Health Organization Grade I intracranial meningioma." + ] + }, + { + "id": "multiclinsum_test_1186_en.txt", + "fulltext": "A 35-year-old woman from Haryana presented with generalized tonic-clonic seizures. She was treated with antiepileptics and became seizure-free. She had also noticed swellings all over her body which had gradually increased in number and size over the previous year, and there was proptosis of her right eyeball. She also had fever and arthralgia. On examination there was symmetrical generalized hypertrophy of the limbs, most prominent in the calf muscles, and also affecting trunk, neck and facial muscles. There was muscle tenderness with increased pain on movement of the joints.\nInvestigations revealed hemoglobin of 12.5 gm%, total lymphocyte count (TLC) of 12,800 and differential leucocyte count (DLC) of P80%:L20%. The erythrocyte sedimentation rate (ESR) was 40 mm/hour. The level of serum creatinine phosphokinase was 150 (normal value 200). In addition, urine tests showed the presence of proteinuria without any active sediment on microscopy. Routine biochemical investigations revealed normal glucose, renal and liver function tests. The tests for rheumatoid arthritis (RA) factor and antinuclear antibodies were positive but the patient did not have any other symptoms to suggest a diagnosis of rheumatoid arthritis or lupus. Tests for HIV using enzyme-linked immunosorbent assay (ELISA) were negative for both HIV 1 and 2. Electrocardiogram (ECG) examination revealed a right bundle branch block and a right axis deviation. An echocardiogram failed to show cysticerci in the heart. X-rays of the skull and extremities were normal. There was no radiographic evidence of calcification in the muscles. Ultrasound examination of the orbit and neck was performed, revealing multiple swellings in the orbit, thyroid gland and strap muscles of the neck. Fundus examination was normal. Perimetry was also within normal limits. Magnetic resonance imaging (MRI) scan showed multiple cysts in the brain, scalp tissue, orbit and neck muscles. There was no evidence of hydrocephalus. Biopsy of a subcutaneous swelling was taken from the right forearm. Cysts poured out as soon as the skin was incised. Histopathological examination confirmed that the cysts were of C. cellulosae.\nThe patient was treated with prednisolone 1 mg/kg of body weight 1 week prior to the initiation of albendazole therapy instituted at a dose of 15 mg/kg. The patient was observed for 5 days prior to discharge. The symptoms improved and albendazole was continued for a total duration of 30 days. There was objective evidence of improvement with reduction in the size of the swellings. There was no deterioration in neurological or intellectual status and no appearance of new crops of cysticerci. To our surprise her fever and arthralgia disappeared without the use of anti-inflammatory agents. This improvement lasted for 6 months, at which time there was an increase in the size of existing swellings plus development of new crops of swelling. The fever and arthralgia reappeared. The patient was again primed with steroids and given praziquantel therapy. The patient responded and was discharged after 10 days of observation in hospital. Antiepileptic treatment was continued.\nOn followup after 1 year, no new swellings or any apparent increase in the size of the residual swellings were reported, there was no further fever or arthralgia and the patient remained seizure-free.", + "fulltext_subclaims": [ + "The patient was a 35-year-old woman from Haryana.", + "She presented with generalized tonic-clonic seizures.", + "She was treated with antiepileptics and became seizure-free.", + "She had swellings all over her body that had gradually increased in number and size over the previous year.", + "There was proptosis of her right eyeball.", + "She had fever and arthralgia.", + "On examination, there was symmetrical generalized hypertrophy of the limbs, most prominent in the calf muscles.", + "There was muscle tenderness with increased pain on movement of the joints.", + "Investigations revealed hemoglobin of 12.5 gm%.", + "The total lymphocyte count (TLC) was 12,800.", + "The differential leucocyte count (DLC) was P80%:L20%.", + "The erythrocyte sedimentation rate (ESR) was 40 mm/hour.", + "The level of serum creatinine phosphokinase was 150.", + "Urine tests showed the presence of proteinuria without any active sediment on microscopy.", + "Routine biochemical investigations revealed normal glucose, renal and liver function tests.", + "Tests for rheumatoid arthritis (RA) factor and antinuclear antibodies were positive.", + "The patient did not have any other symptoms to suggest a diagnosis of rheumatoid arthritis or lupus.", + "Tests for HIV using enzyme-linked immunosorbent assay (ELISA) were negative for both HIV 1 and 2.", + "Electrocardiogram (ECG) examination revealed a right bundle branch block and a right axis deviation.", + "An echocardiogram failed to show cysticerci in the heart.", + "X-rays of the skull and extremities were normal.", + "There was no radiographic evidence of calcification in the muscles.", + "Ultrasound examination of the orbit and neck revealed multiple swellings in the orbit, thyroid gland and strap muscles of the neck.", + "Fundus examination was normal.", + "Perimetry was also within normal limits.", + "Magnetic resonance imaging (MRI) scan showed multiple cysts in the brain, scalp tissue, orbit and neck muscles.", + "There was no evidence of hydrocephalus.", + "Biopsy of a subcutaneous swelling was taken from the right forearm.", + "Cysts poured out as soon as the skin was incised.", + "Histopathological examination confirmed that the cysts were of C. cellulosae.", + "The patient was treated with prednisolone 1 mg/kg of body weight 1 week prior to the initiation of albendazole therapy.", + "Albendazole therapy was instituted at a dose of 15 mg/kg.", + "The patient was observed for 5 days prior to discharge.", + "The symptoms improved and albendazole was continued for a total duration of 30 days.", + "There was objective evidence of improvement with reduction in the size of the swellings.", + "There was no deterioration in neurological or intellectual status.", + "There was no appearance of new crops of cysticerci.", + "Her fever and arthralgia disappeared without the use of anti-inflammatory agents.", + "This improvement lasted for 6 months.", + "At 6 months, there was an increase in the size of existing swellings plus development of new crops of swelling.", + "The fever and arthralgia reappeared.", + "The patient was again primed with steroids and given praziquantel therapy.", + "The patient responded and was discharged after 10 days of observation in hospital.", + "Antiepileptic treatment was continued.", + "On followup after 1 year, no new swellings or any apparent increase in the size of the residual swellings were reported.", + "There was no further fever or arthralgia.", + "The patient remained seizure-free." + ], + "summary": "We report an immunocompetent patient with disseminated cysticercosis, who had involvement of the brain, subcutaneous tissues, skeletal muscles, right orbit and thyroid gland. In addition, this patient developed a serum sickness which responded to therapy.", + "summary_subclaims": [ + "The patient was immunocompetent.", + "The patient had disseminated cysticercosis.", + "The patient had involvement of the brain.", + "The patient had involvement of the subcutaneous tissues.", + "The patient had involvement of the skeletal muscles.", + "The patient had involvement of the right orbit.", + "The patient had involvement of the thyroid gland.", + "The patient developed a serum sickness.", + "The serum sickness responded to therapy." + ] + }, + { + "id": "multiclinsum_test_1594_en.txt", + "fulltext": "A 53-year-old Caucasian man with FD presented to our cardiology department for regular follow-up. He reported symptomatic ventricular extrasystoles with palpitations for over ten years while he has been in good physical shape. Moreover, he complained of pain and cramps in the lower limbs. In the past, he had two operations (retractile testicles, operation of his knee), but denied further comorbidities. The family history for FD was negative. The physical examination revealed an arrhythmic pulse and a mild atrial hypertension. The ECG showed a shortened PendQ interval, i. e. PQ interval minus P-wave, of 40 ms and negative T-waves . The echocardiographic examination presented LVH about 15 mm and a mildly reduced global longitudinal strain (, Video 1). The left ventricular ejection fraction was in a normal range and no valvular damage was observed. N-terminal prohormone of brain natriuretic peptide (NT-proBNP) was mildly elevated (160 ng/L, normal range <121 ng/L).\nFD was suspected in 2018 after performing a CMR. The CMR presented LVH [left ventricular mass (LVM) 146 g] and short T1 relaxation time, which is indicative of sphingolipid storage in an early FD. Moreover, it showed prolonged T1 time with an intramural hyperenhancement in the inferolateral wall in late enhancement sequences as a sign for fibrosis (, Video 2). Biochemical testing revealed a reduced GLA activity [<2.8 µmol/L/h (limit of quantification), normal range ≥15.3 µmol/L/h] and an increased concentration of lyso-globotriaosylceramide (lyso-Gb3, 20.0 ng/mL, normal range ≤1.8 ng/mL). The diagnosis was confirmed by a hemizygous pathogenetic mutation in exon 6 of the GLA gene [c.902G>A, p.(Arg301Gln)]. Afterwards, the patient was admitted to the Department of Nephrology to evaluate organ involvement in a multidisciplinary approach. Arterial hypertension was treated with an angiotensin receptor blocker. Kidney biopsy was performed due to unclear aetiology of proteinuria in the presence of arterial hypertension. It showed ‘zebra bodies’ and vacuoles in podocytes as a renal involvement of FD. Neurological examination detected bilateral carpal tunnel syndrome and cerebrovascular magnetic resonance showed microbleeds and white matter lesions. According to the detected mutation, an ERT with Agalsidase Beta was started in 2018. The patient presented regularly for follow-up examinations in our Fabry Centrum (CeRKiD). In 2019, CMR detected increased T1 relaxation time (1079 ms in 2019 vs. 1060 ms in 2018) and reduced LVM (−14 g) and, in 2020, lyso-Gb3 concentration decreased to a level of 9 ng/mL.\nIn retrospective analysis, ECG characteristics of FD have already been present in 2008 and progressed over time . In particular, the first ECG (2008) showed a sinus rhythm with a PendQ interval of 40 ms, a PQ interval of 160 ms, a QT interval of 360 ms, and negative T-waves in II, III, aVF, V5, and V6. ST elevations were present in V1-V4 with a maximum of 0.2 mV in V2 and V3. Seven years later, the ECG showed additional negative T-waves in I and V4. The duration of the PQ interval remained stable over time while PendQ decreased. The ECG findings correlated well with echocardiographic measurements. While the diameter of the interventricular septum was constant with 15-16mm, the posterior wall exhibited an increasing thickness from 11 mm (2008) to 14 mm (2018, before ERT) and up to 15 mm (2020, two years after ERT was started). In addition, in 2020, lateral and posterior longitudinal left ventricular function was reduced.", + "fulltext_subclaims": [ + "The patient is a 53-year-old Caucasian man with FD.", + "He reported symptomatic ventricular extrasystoles with palpitations for over ten years.", + "He complained of pain and cramps in the lower limbs.", + "He had two operations: retractile testicles and knee operation.", + "The family history for FD was negative.", + "The physical examination revealed an arrhythmic pulse.", + "The ECG showed a shortened PendQ interval of 40 ms.", + "The ECG showed negative T-waves.", + "The echocardiographic examination presented LVH about 15 mm.", + "The left ventricular ejection fraction was in a normal range.", + "No valvular damage was observed.", + "NT-proBNP was 160 ng/L.", + "FD was suspected in 2018 after performing a CMR.", + "The CMR showed LVH with LVM 146 g.", + "The CMR showed short T1 relaxation time, indicative of sphingolipid storage in early FD.", + "The CMR showed prolonged T1 time with intramural hyperenhancement in the inferolateral wall as a sign for fibrosis.", + "Biochemical testing revealed a reduced GLA activity [<2.8 µmol/L/h].", + "The diagnosis was confirmed by a hemizygous pathogenetic mutation in exon 6 of the GLA gene [c.902G>A, p.(Arg301Gln)].", + "The patient was admitted to the Department of Nephrology.", + "Arterial hypertension was treated with an angiotensin receptor blocker.", + "Kidney biopsy showed ‘zebra bodies’ and vacuoles in podocytes as a renal involvement of FD.", + "Neurological examination detected bilateral carpal tunnel syndrome.", + "Cerebrovascular magnetic resonance showed microbleeds and white matter lesions.", + "ERT with Agalsidase Beta was started in 2018.", + "In 2019, CMR detected increased T1 relaxation time (1079 ms).", + "In 2019, LVM was reduced by 14 g.", + "In 2020, lyso-Gb3 concentration decreased to 9 ng/mL.", + "In 2008, the first ECG showed a PendQ interval of 40 ms.", + "In 2008, the ECG showed negative T-waves in II, III, aVF, V5, and V6.", + "In 2008, ST elevations were present in V1-V4 with a maximum of 0.2 mV in V2 and V3.", + "Seven years later, the ECG showed additional negative T-waves in I and V4.", + "The duration of the PQ interval remained stable over time.", + "The posterior wall thickness increased from 11 mm (2008) to 15 mm (2020)." + ], + "summary": "A 53-year-old man with FD presented to our outpatient department. He suffered from symptomatic ventricular extrasystoles. Echocardiography detected LVH and reduced global longitudinal strain. Twelve years ago, first examination was conducted due to ventricular arrhythmias. Electrocardiogram showed a short PQ minus P-wave (PendQ) interval and negative T-waves. Over time, the number of leads with negative T-waves increased. Moreover, the echocardiography revealed a thickened left ventricular wall. Without any further examinations at that time, the patient was treated for arterial hypertension with proteinuria. Ten years after first symptoms appeared, FD was diagnosed utilizing cardiac magnetic resonance imaging and genetic tests. Hence, enzyme replacement therapy was initiated.", + "summary_subclaims": [ + "The patient is a 53-year-old man with FD.", + "He suffered from symptomatic ventricular extrasystoles.", + "Echocardiography detected LVH.", + "Echocardiography detected reduced global longitudinal strain.", + "Twelve years ago, first examination was conducted due to ventricular arrhythmias.", + "Electrocardiogram showed a short PQ minus P-wave (PendQ) interval.", + "Electrocardiogram showed negative T-waves.", + "Over time, the number of leads with negative T-waves increased.", + "Echocardiography revealed a thickened left ventricular wall.", + "The patient was treated for arterial hypertension with proteinuria.", + "Ten years after first symptoms appeared, FD was diagnosed.", + "FD was diagnosed utilizing cardiac magnetic resonance imaging.", + "FD was diagnosed utilizing genetic tests.", + "Enzyme replacement therapy was initiated." + ] + }, + { + "id": "multiclinsum_test_1571_en.txt", + "fulltext": "A 28-year-old woman was transported to the emergency unit of Ayatollah Rouhani Hospital in Babol in January 2013 due to generalized muscle paralysis and respiratory failure. The patient underwent intubation and was transferred to the medical intensive care unit.\nThe patient had a history of severe headache and fever was reported a week ago. She was reported to have had dysphagia, dyspnea, ptosis, diplopia, dry mouth and weakness of extremities 12 hours before respiratory failure. Weakness of muscle initially occurred in the upper extremities and then in the lower extremities. Vital signs include: blood pressure: 130/80 mmHg, heart rate: 120/min, respiratory rate: 12 (on ventilator without any trigger and assist), temperature: 38.2 oC and saturation of peripheral oxygen: 100%.\nOn examination, the patient was alert; pupils were bilaterally midriatic but with absent corneal reflux absent. There was no papilledema seen using an ophthalmoscope. Swallowing reflex was absent.\nThe patient’s extremities were quadriplegic and are areflexic in all four limbs. There was not any movement on the eyelids, cheeks, chin, head and neck. Facial and frontal folds were completely omitted . She had mild abdominal distension.\nOn respiratory system, the patient had apnea and on ventilator with ACMV, TV=550 ml, RR: 12 / min, PEEP = 3 Cm / H2O, Fio2= 50% did not need any assistance (, ). Initial tests: WBC: 13500 μL, PLT: 23600 μL , Hb: 11.7 gr/dl, HCT: 34.8%, Bun: 13 mg/dl, Cr: 0.6 mg/dl, BS: 127 mg/dl, Ferritin: 196 ng/mL, Na: 131 mEq/L, K: 3.7 mEq/L, CL: 97 mEq/L, Mg: 1.8 mEq/L, SGOT: 17 U/L, SGPT: 10 U/L, ALP: 176 U/L, PT: 13.2, PTT: 35, INR: 1.3, urine analysis and urine culture were normal.\nBiochemical analysis of CSF was normal. In addition, the culture was negative; PCR was negative for mycobacterium tuberculosis. Qualitive test for HSV-I and HSV -2 are negative. Chest x-ray and brain CT scan was normal .\nThere were pansinusitis in the paranasal sinus scan .\nParameters of arterial blood gases in the first hour after the start of mechanical ventilation were, PH: 7.33, PCo2: 47 mmHg, PO2: 119 mmHg, HCO3: 23.7 mmol/L. Arterial blood gas was checked at least once daily during hospitalization and if necessary, was corrected. Due to the complete relaxation, Botulinum antitoxin was administered. Other treatments include antibiotics for acute sinusitis (amikacin 1 g IV daily, vancomycin 1 g intravenously twice daily, meropenem (IV) 1 g every 8 hours) pantoprazole 40 mg IV twice daily, subcutaneous enoxaparin 40 mg daily. Neurology consultation revealed bilateral exophthalmos, chemosis, proptosis, and lack of vertical and horizontal movement of both eyes. The neurologist diagnosed venous thrombosis based on clinical examination and then started subcutaneous enoxaparin 40 mg twice per day, dexamethasone 8 mg IV every 8 hours and antibiotics. Na, K, Mg, Ca, P were checked in the the ICU, and if necessary, were corrected.\nOn the seventh day of hospitalization, functional endoscopic sinus surgery (FESS) was carried out and purulent sinus drainage was evacuated .\nOn the ninth day, the first signs of spontaneous respiration of the brain stem (MIP=-2 cm / H20) was observed. Then, the patient's spontaneous breathing was assisted by ventilator. A tracheostomy was performed on the thirteenth day. Then, gradually the movement of the upper limbs (15th day), chest wall (20th day), abdomen (25th day) and the lower extremities (32nd day) were restored.\nOn the 37th day of admission, the patient tolerated the mode of pressure support ventilation (PSV=14 cm/ H2o). The pressure level gradually decreased based on the patient’s respiratory rate and tidal volume (6, 7). On the 41st day, the patient was completely disconnected from the ventilator and better tolerated T-tube with 5 liters oxygen per minute. Then after 72 hours (44th day), tracheostomy tube was removed. Arterial blood gases were normal during mechanical ventilation. Joint movement and muscular strength gradually were restored after two months of therapy and became relatively normal. After 6 months, muscle strength was completely normal. For now, the patient’s activity and function of other organs are normal.", + "fulltext_subclaims": [ + "A 28-year-old woman was transported to the emergency unit of Ayatollah Rouhani Hospital in Babol in January 2013 due to generalized muscle paralysis and respiratory failure.", + "The patient underwent intubation and was transferred to the medical intensive care unit.", + "The patient had a history of severe headache and fever was reported a week ago.", + "She was reported to have had dysphagia, dyspnea, ptosis, diplopia, dry mouth and weakness of extremities 12 hours before respiratory failure.", + "Weakness of muscle initially occurred in the upper extremities and then in the lower extremities.", + "Vital signs include: blood pressure: 130/80 mmHg, heart rate: 120/min, respiratory rate: 12 (on ventilator without any trigger and assist), temperature: 38.2 oC and saturation of peripheral oxygen: 100%.", + "On examination, the patient was alert; pupils were bilaterally midriatic but with absent corneal reflux absent.", + "There was no papilledema seen using an ophthalmoscope.", + "Swallowing reflex was absent.", + "The patient’s extremities were quadriplegic and are areflexic in all four limbs.", + "There was not any movement on the eyelids, cheeks, chin, head and neck.", + "Facial and frontal folds were completely omitted.", + "She had mild abdominal distension.", + "On respiratory system, the patient had apnea and on ventilator with ACMV, TV=550 ml, RR: 12 / min, PEEP = 3 Cm / H2O, Fio2= 50% did not need any assistance.", + "Initial tests: WBC: 13500 μL, PLT: 23600 μL , Hb: 11.7 gr/dl, HCT: 34.8%, Bun: 13 mg/dl, Cr: 0.6 mg/dl, BS: 127 mg/dl, Ferritin: 196 ng/mL, Na: 131 mEq/L, K: 3.7 mEq/L, CL: 97 mEq/L, Mg: 1.8 mEq/L, SGOT: 17 U/L, SGPT: 10 U/L, ALP: 176 U/L, PT: 13.2, PTT: 35, INR: 1.3, urine analysis and urine culture were normal.", + "Biochemical analysis of CSF was normal.", + "The culture was negative; PCR was negative for mycobacterium tuberculosis.", + "Qualitive test for HSV-I and HSV -2 are negative.", + "Chest x-ray and brain CT scan was normal.", + "There were pansinusitis in the paranasal sinus scan.", + "Parameters of arterial blood gases in the first hour after the start of mechanical ventilation were, PH: 7.33, PCo2: 47 mmHg, PO2: 119 mmHg, HCO3: 23.7 mmol/L.", + "Arterial blood gas was checked at least once daily during hospitalization and if necessary, was corrected.", + "Due to the complete relaxation, Botulinum antitoxin was administered.", + "Other treatments include antibiotics for acute sinusitis (amikacin 1 g IV daily, vancomycin 1 g intravenously twice daily, meropenem (IV) 1 g every 8 hours) pantoprazole 40 mg IV twice daily, subcutaneous enoxaparin 40 mg daily.", + "Neurology consultation revealed bilateral exophthalmos, chemosis, proptosis, and lack of vertical and horizontal movement of both eyes.", + "The neurologist diagnosed venous thrombosis based on clinical examination and then started subcutaneous enoxaparin 40 mg twice per day, dexamethasone 8 mg IV every 8 hours and antibiotics.", + "Na, K, Mg, Ca, P were checked in the the ICU, and if necessary, were corrected.", + "On the seventh day of hospitalization, functional endoscopic sinus surgery (FESS) was carried out and purulent sinus drainage was evacuated.", + "On the ninth day, the first signs of spontaneous respiration of the brain stem (MIP=-2 cm / H20) was observed.", + "Then, the patient's spontaneous breathing was assisted by ventilator.", + "A tracheostomy was performed on the thirteenth day.", + "Then, gradually the movement of the upper limbs (15th day), chest wall (20th day), abdomen (25th day) and the lower extremities (32nd day) were restored.", + "On the 37th day of admission, the patient tolerated the mode of pressure support ventilation (PSV=14 cm/ H2o).", + "The pressure level gradually decreased based on the patient’s respiratory rate and tidal volume.", + "On the 41st day, the patient was completely disconnected from the ventilator and better tolerated T-tube with 5 liters oxygen per minute.", + "Then after 72 hours (44th day), tracheostomy tube was removed.", + "Arterial blood gases were normal during mechanical ventilation.", + "Joint movement and muscular strength gradually were restored after two months of therapy and became relatively normal.", + "After 6 months, muscle strength was completely normal.", + "For now, the patient’s activity and function of other organs are normal." + ], + "summary": "A 28-year-old woman presented with severe generalized ascending symmetrical muscle paralysis. The patient was intubated and transferred to the medical intensive care unit with several symptoms including: severe headache, dysphagia, dyspnea, ptosis, diplopia, and dry mouth. Despite being alert, pupils were bilaterally midriatic and had absent corneal reflux. Pansinusitis was seen in the paranasal sinus scan. At first, the movement of eyelids, head and neck were restored. The movement of the upper limbs (15th day) and chest wall (20th day), abdomen (25th day) and the lower extremities (32nd day) were then gradually restored. On 41st day, the patient was completely disconnected from the ventilator.", + "summary_subclaims": [ + "The patient was a 28-year-old woman.", + "She presented with severe generalized ascending symmetrical muscle paralysis.", + "The patient was intubated.", + "She was transferred to the medical intensive care unit.", + "She had several symptoms including severe headache, dysphagia, dyspnea, ptosis, diplopia, and dry mouth.", + "Pupils were bilaterally midriatic.", + "Corneal reflex was absent.", + "Pansinusitis was seen in the paranasal sinus scan.", + "The movement of eyelids, head, and neck were restored at first.", + "The movement of the upper limbs was restored on the 15th day.", + "The movement of the chest wall was restored on the 20th day.", + "The movement of the abdomen was restored on the 25th day.", + "The movement of the lower extremities was restored on the 32nd day.", + "On the 41st day, the patient was completely disconnected from the ventilator." + ] + }, + { + "id": "multiclinsum_test_2085_en.txt", + "fulltext": "Our case was a 65-year-old elderly woman with an ongoing scene of jaundice and abdominal pain which was settled with medical therapy. The transabdominal ultrasound was indicative of the presence of stone inside the dilated common bile duct (CBD) and she was alluded to an elective outpatient ERCP owing to choledocholithiasis. The assessment was average; in addition, aspartate aminotransferase, alanine aminotransferase, and bilirubin were seen to be inside the ordinary range. Nonetheless, alkaline phosphatase was elevated (659 IU/dl). Her vital sign was stable, oxygen therapy with nasal cannula was established and oxygen saturation was 98%.The patient underwent general anesthesia with midazolam, fentanyl, and ketamin at the proneposition.\nThe side view endoscope was inserted slowly and easily into the duodenum, and a papilla with a normal appearance was seen next to a small diverticulum anfistolotomy was performed using a kindle knife following technically unsuccessful cannulation of CBD with a standard sphincterotome. Meanwhile, pulse oximetry dropped to 80% and the procedure was interrupted. The patient was released from pronepositin and auxiliary oxygen was applied with bag mask ventilation; nonetheless,the pulse oxymetry did not exceed 82% and there was no obvious reduction in lung sounds at that moment. Also, the patient developed abdominal distension. Therefore, duodenum perforation was suspected and abdominal radiography was performed which disclosed a large area of mottled air in the retroperitoneal area (around the kidney) . The physicians made the patient NPO and Iv administration of metronidazole and ceftriaxone was started. Subsequently, facial, cervical, and thoracic subcutaneous emphysema occurred. Oxygen therapy continued with the reservoir bag mask, pulseoxymetry dropped to 75% and bilateral lung sounds decreased. Abdominal computed tomography indicated the evidence of duodenal rupture, including retroperitoneal air, intra-abdominal free fluid, bilateral pneumothorax, Pneumomediastinum and subcutaneous emphysema (-).\nBilateral chest tube was inserted instantly and the patient created indications of peritonitis. Laprotomy and repair of a lease (2 cm) situated in the posterolateral mass of the second segment of duodenum (Stapfer type 1 perforation) was performed. At long last, the patient was moved to the ICU, and after 4 days she was moved from the emergency unit to the ordinary ward. She bit by bit improved and was released from the clinic 8 days after the procedure.", + "fulltext_subclaims": [ + "The patient was a 65-year-old elderly woman.", + "She had an ongoing scene of jaundice and abdominal pain.", + "The pain was settled with medical therapy.", + "The transabdominal ultrasound was indicative of the presence of stone inside the dilated common bile duct.", + "She was alluded to an elective outpatient ERCP owing to choledocholithiasis.", + "Aspartate aminotransferase, alanine aminotransferase, and bilirubin were seen to be inside the ordinary range.", + "Alkaline phosphatase was elevated to 659 IU/dl.", + "Her vital sign was stable.", + "Oxygen therapy with nasal cannula was established.", + "Oxygen saturation was 98%.", + "The patient underwent general anesthesia with midazolam, fentanyl, and ketamine at the prone position.", + "The side view endoscope was inserted slowly and easily into the duodenum.", + "A papilla with a normal appearance was seen next to a small diverticulum.", + "An anfistolotomy was performed using a kindle knife.", + "Cannulation of CBD with a standard sphincterotome was technically unsuccessful.", + "Pulse oximetry dropped to 80%.", + "The procedure was interrupted.", + "The patient was released from prone position.", + "Auxiliary oxygen was applied with bag mask ventilation.", + "Pulse oximetry did not exceed 82%.", + "There was no obvious reduction in lung sounds.", + "The patient developed abdominal distension.", + "Duodenum perforation was suspected.", + "Abdominal radiography was performed.", + "The radiography disclosed a large area of mottled air in the retroperitoneal area around the kidney.", + "The physicians made the patient NPO.", + "Intravenous administration of metronidazole and ceftriaxone was started.", + "Facial, cervical, and thoracic subcutaneous emphysema occurred.", + "Oxygen therapy continued with the reservoir bag mask.", + "Pulse oximetry dropped to 75%.", + "Bilateral lung sounds decreased.", + "Abdominal computed tomography indicated evidence of duodenal rupture.", + "The computed tomography showed retroperitoneal air.", + "The computed tomography showed intra-abdominal free fluid.", + "The computed tomography showed bilateral pneumothorax.", + "The computed tomography showed pneumomediastinum.", + "The computed tomography showed subcutaneous emphysema.", + "Bilateral chest tube was inserted instantly.", + "The patient created indications of peritonitis.", + "Laparotomy and repair of a lease (2 cm) situated in the posterolateral mass of the second segment of duodenum was performed.", + "The perforation was classified as Stapfer type 1.", + "The patient was moved to the ICU.", + "After 4 days, the patient was moved from the emergency unit to the ordinary ward.", + "She bit by bit improved.", + "She was released from the clinic 8 days after the procedure." + ], + "summary": "In the present study, we report a 65-year-old woman who develops hypoxemia during the ERCP. Based on the obtained results, it was revealed that this patient had perforation-related bilateral pneumothorax and hypoxemia.", + "summary_subclaims": [ + "The patient is a 65-year-old woman.", + "The patient develops hypoxemia during the ERCP.", + "The patient had perforation-related bilateral pneumothorax.", + "The patient had hypoxemia." + ] + }, + { + "id": "multiclinsum_test_2989_en.txt", + "fulltext": "A 14-year-old male of Eastern European descent was referred to pediatric gastroenterology for severe malnutrition and epigastric abdominal pain initially attributed to gastroesophageal reflux disease. He had been experiencing eight months of daily postprandial periumbilical abdominal pain. At the time of the initial GI assessment in clinic, he was taking omeprazole for the past few months with some improvement in abdominal pain, but he had experienced a 9% weight loss over the past six months with his weight below the 3rd percentile (Z-score < -6). His past medical history is notable for NBS that was diagnosed at six months of age, with combined immunodeficiency phenotype with low B cell and poor T cell function. He was diagnosed after his older sister underwent genetic testing and was found to have a NBS1 657del5 mutation. His family history is notable for two siblings with NBS along with a first cousin. He has associated microcephaly, short stature with height below the 3rd percentile (Z-score < -2), bronchiectasis, and lymphopenia with IgG deficiency, requiring routine IVIG infusions. He has a history of diffuse large B-cell lymphoma that was diagnosed at age eight during a hospitalization for pneumonia and pleural effusion. On initial labs, he was noted to have an elevated uric acid of 7.2 mg/dL and LDH of 2711 U/L, leading to further diagnostic work-up. MRI of the chest revealed a large right chest mass and multiple lesions in his kidneys, spleen, pelvis, and tibias. Bone marrow biopsies revealed patchy tumor involvement and he was treated with the ANHL1131 protocol at reduced dose given his chromosomal instability and has been in remission for 6 years.\nOn presentation to the pediatric GI clinic, the physical exam was unremarkable. The abdomen was soft, non-distended, and non-tender with no masses appreciable. The oropharynx was clear and there was no significant cervical, axillary, or inguinal adenopathy. Initial laboratory workup for abdominal pain and weight loss included a complete blood count, complete metabolic panel, c-reactive protein, and celiac antibodies which were all within normal limits. Additional diagnostic work-up to look for inflammatory or malabsorption etiologies of his symptoms were pursued due to the extent of his weight loss. His fecal calprotectin was elevated to 318.2 mcg/g (normal < 50 mcg/g) and given his constellation of symptoms, an endoscopy and colonoscopy were performed. Endoscopy revealed white nummular lesions , chronic gastritis without evidence of H. pylori, and focal active ileitis. Colonoscopy showed a < 5 mm tubular adenoma in the sigmoid colon.\nPathology of this lesion showed Reed-Sternberg cells and neoplastic cells strongly/diffusely positive for CD30 and CD15, and with dim/partial positivity for CD20, PAX5, CD79a, and BCL6 . CD19, CD22, CD43, CD45, and ALK were negative. CD10 stain was predominately negative and testing for cytomegalovirus and Epstein-Barr virus were negative. MRI of the chest, abdomen, and pelvis was used for staging of disease and showed lymphadenopathy of the lesser sac and gastric cardia . A lumbar puncture and bone marrow were performed and were negative for disease. He was diagnosed with stage IIB Classical Hodgkin’s disease of stomach.\nHe underwent two cycles of OEPA chemotherapy (vincristine, etoposide, prednisone, and doxorubicin) at 30% and 40% full dose. The remainder of standard Hodgkin’s treatment consisting of two cycles of COPDAC (cyclophosphamide, vincristine, prednisone, and dacarbazine) was not recommended to avoid alkylating agents in a patient prone to malignancy. He tolerated the treatment well without any complications and achieved complete remission. Unfortunately, 9 months later, he was admitted for a bowel perforation and found to have recurrent Hodgkin disease. He completed one cycle of OEPA chemotherapy at 30% dosing and transitioned to pembrolizumab while considering a bone marrow transplant.", + "fulltext_subclaims": [ + "The patient is a 14-year-old male of Eastern European descent.", + "He was referred to pediatric gastroenterology for severe malnutrition and epigastric abdominal pain.", + "The abdominal pain was initially attributed to gastroesophageal reflux disease.", + "He had eight months of daily postprandial periumbilical abdominal pain.", + "He was taking omeprazole for the past few months.", + "He had some improvement in abdominal pain with omeprazole.", + "He had a 9% weight loss over the past six months.", + "His weight was below the 3rd percentile.", + "His weight Z-score was < -6.", + "He had a history of neonatal screening (NBS) diagnosed at six months of age.", + "He had combined immunodeficiency phenotype with low B cell and poor T cell function.", + "He was diagnosed after his older sister underwent genetic testing.", + "His older sister was found to have a NBS1 657del5 mutation.", + "He had a history of diffuse large B-cell lymphoma diagnosed at age eight.", + "The lymphoma was diagnosed during a hospitalization for pneumonia and pleural effusion.", + "On initial labs, he had an elevated uric acid of 7.2 mg/dL.", + "On initial labs, he had an elevated LDH of 2711 U/L.", + "MRI of the chest revealed a large right chest mass.", + "MRI showed multiple lesions in his kidneys, spleen, pelvis, and tibias.", + "Bone marrow biopsies revealed patchy tumor involvement.", + "He was treated with the ANHL1131 protocol at reduced dose.", + "He has been in remission for 6 years.", + "On presentation to the pediatric GI clinic, the physical exam was unremarkable.", + "The abdomen was soft, non-distended, and non-tender.", + "There were no masses appreciable on abdominal exam.", + "Initial laboratory workup included a complete blood count, complete metabolic panel, c-reactive protein, and celiac antibodies.", + "All initial laboratory tests were within normal limits.", + "Fecal calprotectin was elevated to 318.2 mcg/g.", + "Endoscopy revealed white nummular lesions.", + "Endoscopy showed chronic gastritis without evidence of H. pylori.", + "Endoscopy showed focal active ileitis.", + "Colonoscopy showed a < 5 mm tubular adenoma in the sigmoid colon.", + "Pathology showed Reed-Sternberg cells.", + "Neoplastic cells were strongly/diffusely positive for CD30 and CD15.", + "Neoplastic cells showed dim/partial positivity for CD20, PAX5, CD79a, and BCL6.", + "CD19, CD22, CD43, CD45, and ALK were negative.", + "CD10 stain was predominately negative.", + "Testing for cytomegalovirus and Epstein-Barr virus were negative.", + "MRI showed lymphadenopathy of the lesser sac and gastric cardia.", + "A lumbar puncture was performed and was negative for disease.", + "A bone marrow biopsy was performed and was negative for disease.", + "He was diagnosed with stage IIB Classical Hodgkin’s disease of the stomach.", + "He underwent two cycles of OEPA chemotherapy at 30% and 40% full dose.", + "The remainder of standard Hodgkin’s treatment was not recommended.", + "He achieved complete remission.", + "Nine months later, he was admitted for a bowel perforation.", + "He was found to have recurrent Hodgkin disease.", + "He completed one cycle of OEPA chemotherapy at 30% dosing.", + "He transitioned to pembrolizumab.", + "A bone marrow transplant was considered." + ], + "summary": "A 14-year-old male with NBS presented with persistent abdominal pain and was diagnosed with primary Hodgkin disease of the stomach.", + "summary_subclaims": [ + "The patient is a 14-year-old male.", + "The patient has NBS.", + "The patient presented with persistent abdominal pain.", + "The patient was diagnosed with primary Hodgkin disease of the stomach." + ] + }, + { + "id": "multiclinsum_test_1812_en.txt", + "fulltext": "A 38-year-old multigravida (gravida V para IV) woman of Amhara ethnicity was referred from a health center to our hospital due to prolonged second stage of labor at 42+1 weeks. She felt that her pregnancy did not differ from her previous pregnancies. She had been taking injectable contraception for 2 years.\nShe had no family history of any congenital anomalies. She had four healthy live births at term and all are healthy. She had antenatal follow up for four visits where she was screened for human immunodeficiency virus (HIV), syphilis, hepatitis B virus (HBV), and for diabetes (only a random blood sugar test) but not sonographic screening. She received tetanus vaccination and iron supplementation. She did not take any other medication during her pregnancy. She presented to our hospital after laboring for approximately 35 hours both at home and at the health center. She was evaluated on arrival at our hospital; she had contraction, term-sized gravid uterus, and fetal heart beat was 112. On digital pelvic examination her cervix was fully dilated, the station of the head was high, and the pulsating umbilical cord was in front of the presenting part with ruptured membrane, which indicated a difficult transvaginal delivery. For this reason, the team rushed for emergency cesarean section.\nA cesarean section was done under general anesthesia and a live baby girl weighing 4200 g was delivered. The placenta was single and normal. Her Appearance, Pulse, Grimace, Activity, and Respiration (APGAR) scores were 7 and 9 at 1 and 5 minutes, respectively. She appeared to be grossly normal except her parasitic co-twin was attached at the temporal area of her cranium (see Figs. , , , , and ). Her twin was an incidental finding and during the difficult extraction her left uterine artery was severed and repaired.\nThe baby girl was further evaluated with a skull X-ray; an ultrasound of the co-twin and the abdomen of the normal twin (autosite) by Doppler ultrasound confirmed that the parasitic conjoined twin had communication with the normal twin only in soft tissue and vessel arising from carotid vessels but no connection with the brain or related structures.\nA detailed clinical examination of the normal twin revealed normal findings except for her parasitic twin at her cranial region. All four limbs of the normal twin were moving freely but no movement was detected at the parasitic twin. Auscultation to the heart of the normal twin was normal. The parasitic twin contained disproportionately developed lower limbs that had four toes on each limb. The parasitic twin had no distinctly separable abdomen, chest, or cranium. The parents were counselled and informed by a multidisciplinary team of nurses, anesthesiologists, pediatricians, gynecologists, and surgeons as to the subsequent plan of management.\nSurgery was performed to the baby 1 week after her delivery after the necessary investigation and preparation was done. The parasitic co-twin was totally excised in the operation that took approximately 6 hours. Her postoperative period was smooth and uneventful; she comfortably suckled on the breast well. She was transfused with a calculated two units of fresh whole blood. Two weeks after the surgery she was discharged healthy with an arrangement for postnatal follow up.\nAfter separation, a pathologic examination demonstrated that skin covered the body of the parasitic twin. The parasitic twin had two deformed lower limbs, one of which was rudimentary. After dissection of the mass of the body, the intestine was seen but there were no chest organs or abdominal organs. The long bones of the bilateral lower limbs and some pelvic bone were seen in the limbs of the parasitic twin. There was also a rudimentary labium but no vaginal opening.", + "fulltext_subclaims": [ + "The patient is a 38-year-old multigravida woman of Amhara ethnicity.", + "She was referred due to prolonged second stage of labor at 42+1 weeks.", + "She had been taking injectable contraception for 2 years.", + "She had four healthy live births at term.", + "She had antenatal follow up for four visits.", + "She was screened for HIV, syphilis, HBV, and for diabetes.", + "She received tetanus vaccination and iron supplementation.", + "She did not take any other medication during her pregnancy.", + "She presented after laboring for approximately 35 hours.", + "On digital pelvic examination, her cervix was fully dilated.", + "The station of the head was high.", + "The pulsating umbilical cord was in front of the presenting part.", + "The ruptured membrane indicated a difficult transvaginal delivery.", + "An emergency cesarean section was done under general anesthesia.", + "A live baby girl weighing 4200 g was delivered.", + "The placenta was single and normal.", + "The APGAR scores were 7 at 1 minute and 9 at 5 minutes.", + "The baby girl had a parasitic co-twin attached at the temporal area of her cranium.", + "The parasitic co-twin was an incidental finding.", + "During the difficult extraction, her left uterine artery was severed and repaired.", + "A skull X-ray was performed.", + "An ultrasound confirmed that the parasitic twin had communication with the normal twin only in soft tissue.", + "The parasitic twin had no connection with the brain or related structures.", + "The normal twin had all four limbs moving freely.", + "No movement was detected at the parasitic twin.", + "The parasitic twin had disproportionately developed lower limbs with four toes on each limb.", + "The parasitic twin had no distinctly separable abdomen, chest, or cranium.", + "The parents were counselled by a multidisciplinary team.", + "Surgery to excise the parasitic co-twin was performed 1 week after delivery.", + "The operation took approximately 6 hours.", + "The postoperative period was smooth and uneventful.", + "She was transfused with two units of fresh whole blood.", + "She was discharged two weeks after the surgery.", + "A pathologic examination demonstrated that skin covered the body of the parasitic twin.", + "The parasitic twin had two deformed lower limbs, one of which was rudimentary.", + "The parasitic twin had no chest organs or abdominal organs.", + "The long bones of the bilateral lower limbs and some pelvic bone were seen.", + "The parasitic twin had a rudimentary labium but no vaginal opening." + ], + "summary": "A 38-year-old multigravida (gravida V para IV) woman of Amhara ethnicity was referred from a rural health center to our hospital due to prolonged second stage of labor at 42+1 weeks. On her arrival at our hospital, an obstetrician decided to do a caesarean section because she was unable to deliver vaginally. A live baby girl weighing 4200 g was delivered. The placenta was single and normal. Her Appearance, Pulse, Grimace, Activity, and Respiration scores were 7 and 9 at 1 and 5 minutes, respectively. She appeared to be grossly normal except for the parasitic co-twin attached to her cranium. After a week of extensive counselling and investigation, a successful separation operation was done. Postoperation, she comfortably suckled on the breast and had no neurological deficit. Two weeks after separation she was discharged in a good healthy condition with an arrangement for postnatal follow up.", + "summary_subclaims": [ + "The woman was referred to the hospital due to prolonged second stage of labor at 42+1 weeks.", + "An obstetrician decided to do a caesarean section because she was unable to deliver vaginally.", + "A live baby girl weighing 4200 g was delivered.", + "The placenta was single and normal.", + "Her Appearance, Pulse, Grimace, Activity, and Respiration scores were 7 at 1 minute.", + "Her Appearance, Pulse, Grimace, Activity, and Respiration scores were 9 at 5 minutes.", + "The baby appeared to be grossly normal except for the parasitic co-twin attached to her cranium.", + "After a week of extensive counselling and investigation, a successful separation operation was done.", + "Postoperation, she comfortably suckled on the breast.", + "Postoperation, she had no neurological deficit.", + "Two weeks after separation she was discharged in a good healthy condition." + ] + }, + { + "id": "multiclinsum_test_360_en.txt", + "fulltext": "A 14-year-old boy, with nothing relevant in his medical history, came to our observation for a strong back pain associated to a right lumbar scoliosis and a severe coronal imbalance . The pain started almost 1 year before, after a playing soccer. He was first treated by a physiatrist, who prescribed postural gymnastics, swimming, and physiotherapy. Then, a thoracolumbosacral orthosis (TLSO) was prescribed too (after the scoliosis was diagnosed).\nAs he was referred to us, an MRI and a CT scan were prescribed, and the radiological report stated as follows: “Findings orientate to a slow-growing expansive lesion with wear of the L2-L3 arcal structures on the left. It could be an osteoblastoma of the left neural hemiarch of L2 with associated cyst-type hematological lesion ABC (secondary ABC) in intraforaminal development with compression of the L2 root in the intraforaminal area” ( and ).\nClinically, he presented an important trunk imbalance , a severe lumbar pain with irradiation to the proximal third of the thigh.\nThe patient has been operated by posterior approach wide excision of the lesion with removal of left inferior L1 articular process, of left L2 hemilamina to the basis of the left L2 pedicle, and of left L3 superior articular process; excision interested whole bone cyst compressing intraforaminal tract of the left L2 nervous root; wide excision of bony structures with excision margins within healthy bone tissue assures best chance of removing the entire lesion minimizing local recurrence risks.\nAfter bone structures excision, soft tissues that surrounded left L2 nervous root have been removed too, as to completely free the root, leaving nervous structure without any compression.\nThe patient experienced no post-surgical complications and was discharged after 2 days from the procedure. A TLSO was prescribed for the first 6 weeks.\nAt the 6 months follow-up control, the patient was completely pain free, he returned to all his previous sport activity. The trunk imbalance was still slightly noticeable and the X-rays showed a similar lumbar curve with a small compensatory thoracic curve that reduced the coronal imbalance .", + "fulltext_subclaims": [ + "The patient is a 14-year-old boy.", + "He has nothing relevant in his medical history.", + "He came to the observation for strong back pain associated with right lumbar scoliosis and severe coronal imbalance.", + "The pain started almost 1 year before after playing soccer.", + "He was first treated by a physiatrist.", + "The physiatrist prescribed postural gymnastics, swimming, and physiotherapy.", + "A thoracolumbosacral orthosis (TLSO) was prescribed after the scoliosis was diagnosed.", + "An MRI and a CT scan were prescribed.", + "The radiological report stated findings orientate to a slow-growing expansive lesion with wear of the L2-L3 arcal structures on the left.", + "The radiological report suggested it could be an osteoblastoma of the left neural hemiarch of L2.", + "The radiological report mentioned an associated cyst-type hematological lesion ABC in intraforaminal development.", + "The lesion was compressing the L2 root in the intraforaminal area.", + "The patient presented an important trunk imbalance.", + "He had severe lumbar pain with irradiation to the proximal third of the thigh.", + "The patient was operated on by posterior approach wide excision of the lesion.", + "The excision included removal of the left inferior L1 articular process.", + "The excision included removal of the left L2 hemilamina to the basis of the left L2 pedicle.", + "The excision included removal of the left L3 superior articular process.", + "The excision included removal of the whole bone cyst compressing the intraforaminal tract of the left L2 nervous root.", + "Wide excision of bony structures with excision margins within healthy bone tissue was performed.", + "Soft tissues surrounding the left L2 nervous root were removed.", + "The patient experienced no post-surgical complications.", + "He was discharged after 2 days from the procedure.", + "A TLSO was prescribed for the first 6 weeks.", + "At the 6 months follow-up, the patient was completely pain free.", + "He returned to all his previous sport activity.", + "The trunk imbalance was still slightly noticeable.", + "The X-rays showed a similar lumbar curve with a small compensatory thoracic curve.", + "The small compensatory thoracic curve reduced the coronal imbalance." + ], + "summary": "We report a case of a 14-year-old boy, soccer player, with an osteoblastoma of the left posterior neural arc of L2 and a secondary aneurismal bone cyst compressing the left L2 nerve root, causing severe antalgic scoliosis and back pain with radiculopathy. A complete surgical excision with radicular decompression has been performed, and the histologic examination confirmed the diagnostic hypothesis (osteoblastoma + ABC). At 6 months follow-up, the patient presented a complete resolution of symptoms, but the trunk imbalance was not completely resolved.", + "summary_subclaims": [ + "The patient is a 14-year-old boy.", + "The patient is a soccer player.", + "The patient had an osteoblastoma of the left posterior neural arc of L2.", + "The patient had a secondary aneurismal bone cyst.", + "The aneurismal bone cyst was compressing the left L2 nerve root.", + "The patient had severe antalgic scoliosis.", + "The patient had back pain with radiculopathy.", + "A complete surgical excision with radicular decompression has been performed.", + "The histologic examination confirmed the diagnostic hypothesis.", + "The diagnostic hypothesis was osteoblastoma + ABC.", + "At 6 months follow-up, the patient presented a complete resolution of symptoms.", + "The trunk imbalance was not completely resolved." + ] + }, + { + "id": "multiclinsum_test_3162_en.txt", + "fulltext": "The patient was a 33-year-old Caucasian man with a history of untreated AIDS for 1 year who presented to the emergency department with progressive dyspnoea for 3 weeks followed by treatment with levofloxacin for 5 days and amoxicillin + clavulanic acid for 7 days with no adequate response. On admission, he presented with tachypnoea, fever of 39.1ºC, dry cough and hypoxaemia. Chest radiography and computed tomography revealed bilateral pulmonary infiltrates with no localized alveolar opacities. Non-invasive ventilation (NIV) was immediately established and sputum, blood and urine samples were collected and empirical antibiotic therapy was initiated.\n\nThe patient was admitted to the intensive care unit (ICU) on NIV with a Glasgow Coma Scale of 15/15, respiratory rate of 28-34 breaths per minute (bpm), dyspnea score of 8/10 (zero for no dyspnea and ten for worst possible dyspnea), comfort 8/10, accessory muscle use and a four-point Heart Rate, Acidosis, Consciousness, Oxygenation, and Respiratory Rate (HACOR) score. After 1 hour on NIV, arterial blood gas revealed a pH of 7.38, carbon dioxide partial pressure (PaCO2) of 38 mmHg, oxygen partial pressure (PaO2) of 78.1 mmHg, bicarbonate (HCO3) of 22.2 mEq/L, base excess (BE) of -2.4 mEq/L, and PaO2/FiO2 ratio of 156.2 mmHg.\n\nConsidering the initial clinical picture, it was decided to change from NIV to nasal cannula of high flow (NCHF) using flow of 60L/minute with FiO2 of 0.50. Initially the patient had a decrease in respiratory rate to 23rpm and improvement in oxygenation, dyspnea and comfort. The ROX index after 1 hour of NCHF was 8.33.\n\nAfter 48 hours with CNAF, the patient had increased RT and worsened oxygenation, requiring endotracheal intubation and invasive MV.\n\nFirst period of ventilation in controlled mode\nAdvanced monitoring of SR mechanics was performed during the time of invasive VM by esophageal manometry. Initially, protective VM was instituted with use of tidal volume (TV) of 4-6L/kg predicted body weight (PBW), titration of end-expiratory positive pressure (PEEP) to best SR compliance (Crs), target plateau pressure (Pplat) > 30cmH2O, driving pressure in the airways (∆Paw) < a 15cmH2O, driving transpulmonary pressure (∆PL) < a 12cmH2O, deep sedation, use of neuromuscular blocking agents (BNM) and prone position (PP).\n\nOn day 4 of invasive VM, after a marked improvement in oxygenation, the sedation levels were reduced in an attempt to initiate the partial ventilatory support phase, with ventilation changed from controlled VM to pressure support ventilation (VPS).\n\nFirst period of partial ventilatory support\nAn attempt was made to titrate PEEP down to optimize the ventilatory strategy. It was observed that higher levels of PEEP did not improve the esophageal pressure oscillation (∆Pes) or ∆PL and even seemed to increase them; thus, low PEEP values were given priority to reduce the stress and mechanical energy applied to the lungs.\n\nOn the sixth day of invasive MV, the patient met the classic criteria for weaning; thus, a spontaneous breath test (SBT) was performed with a support pressure level of 5 cm H2O to assess the chance of extubation. The patient failed the SBT after 20 minutes due to hypoxemia.\n\nOn the 7th day of invasive VM, due to persistent worsening of oxygenation, a new computed tomography was performed, which showed clear progression of the pulmonary lesion, with the appearance of bilateral diffuse alveolar infiltrate, primarily in pulmonary regions. In this context, it was decided to reinstitute controlled VM and deep levels of sedation.\n", + "fulltext_subclaims": [ + "The patient was a 33-year-old Caucasian man.", + "He had a history of untreated AIDS for 1 year.", + "He presented to the emergency department with progressive dyspnoea for 3 weeks.", + "He received treatment with levofloxacin for 5 days.", + "He received treatment with amoxicillin + clavulanic acid for 7 days.", + "The treatment with levofloxacin and amoxicillin + clavulanic acid did not result in an adequate response.", + "On admission, he had tachypnoea.", + "On admission, he had a fever of 39.1ºC.", + "Chest radiography revealed bilateral pulmonary infiltrates.", + "Computed tomography revealed bilateral pulmonary infiltrates.", + "Non-invasive ventilation (NIV) was immediately established.", + "Sputum, blood, and urine samples were collected.", + "Empirical antibiotic therapy was initiated.", + "The patient was admitted to the ICU on NIV.", + "The Glasgow Coma Scale was 15/15.", + "The respiratory rate was 28-34 breaths per minute.", + "The dyspnea score was 8/10.", + "The comfort score was 8/10.", + "The patient had accessory muscle use.", + "A four-point HACOR score was recorded.", + "After 1 hour on NIV, the PaO2/FiO2 ratio was 156.2 mmHg.", + "It was decided to change from NIV to nasal cannula of high flow (NCHF) using flow of 60L/minute with FiO2 of 0.50.", + "After 1 hour of NCHF, the patient had a decrease in respiratory rate to 23rpm.", + "After 1 hour of NCHF, the patient had improvement in oxygenation.", + "After 1 hour of NCHF, the ROX index was 8.33.", + "After 48 hours with NCHF, the patient had increased respiratory rate.", + "After 48 hours with NCHF, the patient had worsened oxygenation.", + "Endotracheal intubation and invasive mechanical ventilation were required.", + "Advanced monitoring of SR mechanics was performed during invasive mechanical ventilation.", + "Protective mechanical ventilation was instituted with tidal volume of 4-6L/kg predicted body weight.", + "End-expiratory positive pressure was titrated to best SR compliance.", + "The target plateau pressure was > 30cmH2O.", + "The target driving pressure in the airways was < 15cmH2O.", + "The target driving transpulmonary pressure was < 12cmH2O.", + "Deep sedation was used.", + "Neuromuscular blocking agents were used.", + "Prone position was used.", + "On day 4 of invasive mechanical ventilation, the patient met the criteria for weaning.", + "A spontaneous breath test was performed with a support pressure level of 5 cm H2O.", + "The patient failed the spontaneous breath test after 20 minutes due to hypoxemia.", + "On the 7th day of invasive mechanical ventilation, a new computed tomography showed clear progression of the pulmonary lesion.", + "The computed tomography showed bilateral diffuse alveolar infiltrate.", + "It was decided to reinstitute controlled mechanical ventilation and deep levels of sedation." + ], + "summary": "The patient was a 33-year-old Caucasian man with a history of AIDS who developed acute respiratory distress syndrome and required invasive mechanical ventilation after failure of noninvasive ventilatory support. During the periods of controlled ventilation, a protective ventilation strategy was adopted and the patient showed marked clinical and radiographic improvement. However, during each period of spontaneous respiration under pressure support ventilation, despite adequate initial parameters, strict setting and close monitoring, the patient developed progressive hypoxemia and respiratory mechanics deterioration with a clearly correlated radiographic lesion (self-inflicted pulmonary injury). After failure of three attempts of spontaneous respiration, the patient died of refractory hypoxemia on day 29.\n", + "summary_subclaims": [ + "The patient was a 33-year-old Caucasian man.", + "The patient had a history of AIDS.", + "The patient developed acute respiratory distress syndrome.", + "The patient required invasive mechanical ventilation after failure of noninvasive ventilatory support.", + "During the periods of controlled ventilation, a protective ventilation strategy was adopted.", + "The patient showed marked clinical and radiographic improvement during controlled ventilation.", + "During each period of spontaneous respiration under pressure support ventilation, the patient developed progressive hypoxemia.", + "During each period of spontaneous respiration under pressure support ventilation, the patient developed respiratory mechanics deterioration.", + "During each period of spontaneous respiration under pressure support ventilation, the patient had a clearly correlated radiographic lesion.", + "The radiographic lesion was labeled as self-inflicted pulmonary injury.", + "After failure of three attempts of spontaneous respiration, the patient died.", + "The patient died of refractory hypoxemia on day 29." + ] + }, + { + "id": "multiclinsum_test_2810_en.txt", + "fulltext": "A 58-year-old female presented with right facial and neck swelling and respiratory distress after a recent dental infection treated with clindamycin. On examination, there were grossly decayed teeth with a firm floor of mouth and diffuse erythema of the right neck, lower and mid-face. She was diagnosed with Ludwig’s Angina and immediately intubated due to stridor and pending airway compromise. Imaging revealed extensive infection and abscess formation involving the submandibular, pterygomandibular, and buccal spaces, and she was taken to the operating room for dental extraction and abscess drainage by the oral surgery team and started on broad spectrum antibiotics. Cultures from this operation were polymicrobial and consistent with oral microbes. On postoperative day 1, she developed rapidly expanding erythema and swelling of the right hemiface and neck with gross necrosis of the skin throughout the right neck and face. The Otolaryngology team was consulted for possible necrotizing fasciitis.\nThe patient was taken to the operating room for urgent debridement, which included the skin of the right neck and face up to lower eyelid, devascularized orbicularis oculi, mylohyoid, superficial muscular aponeurotic system in the midface, masseter, and all branches of the facial nerve. The debridement ultimately required removal of a 20x30cm segment of the right and central neck and a 20x20cm segment of the right face .\nSubsequent debridement 2 days later required excision of soft tissue to the level of the zygoma and infraorbital rim. Penrose drains were placed to assist with drainage and irrigation of deeper spaces communicating with the open wound, including the pretracheal space. Antibiotics were transitioned to vancomycin, ampicillin-sulbactam, and fluconazole for a planned duration of 4 weeks, as was appropriate per bacterial culture susceptibilities.\nThe decision was made to proceed with twice daily local wound care with Dakins irrigations through the Penrose drains into the deep spaces, and placement of wet-to-dry Dakins-soaked gauze over exposed soft tissue between operative debridements. Ophthalmology was consulted for assistance with progressive ocular and lower eyelid involvement. Due to the extent of the wound, heavy sedation was required for dressing changes. However, due to open wound without overlying skin in the pretracheal space, a tracheostomy was not offered, as secretions would have saturated the wound bed and prolonged infection, resulting in a prolonged endotracheal intubation. Despite aggressive wound care, 12 days after initial aggressive debridement, purulent drainage continued to be encountered with irrigations, with concern for spread of infection threatening the right orbit and mediastinum. Furthermore, new areas of devitalized tissue were encountered routinely throughout the wound bed and debrided at bedside. The white blood cell count was persistently elevated throughout this time and the patient remained septic.\nSeveral case reports and review articles have demonstrated success with NPWT in decreasing bacterial burden and stabilizing wounds in patients with NF, even within the head and neck regions [–]. Unfortunately, given the proximity of the wound bed to the lower eyelid and conjunctiva and surgical absence of the majority of the soft tissue of the eyelid including the orbicularis oculi, negative pressure wound therapy was contraindicated due to risk of traction injury to the globe and/or eyelid. To address this problem, a 3D-printed, patient-specific wound splint was designed at the point-of-care using the patient’s anatomy to facilitate NPWT. It was determined that the patient’s circumstances met the criteria for the FDA Expanded Access for Medical Devices Emergency Use mechanism (EAEU) with concurrence from the Institutional Review Board (IRB) . A follow-up report was sent to the FDA within 5 days on the use of the device as required.\nA facial CT was obtained and Digital Imaging and Communications in Medicine (DICOM) images were uploaded to Materialise Mimics (Materalise, Leuven, Belgium). These were segmented to include the remaining soft tissue and bony structures in the nasofacial sulcus, periorbital, and malar regions. The native anatomy was then imported into Materalise 3-Matic (Materalise, Leuven, Belgium) and a 3-Dimensional (3D) surface was formed through the offset of the soft tissue and bony structures within the wound and extruded to provide additional surface and contact area. This process was performed with both clinician and engineering input to ensure correct design and adequate contact area for both the wound-vac device as well as the mount sutures. The resulting model was then smoothed with additional surface post processing to ensure fitment would be exactly along the contour of the wound and as well as provide a wide and flat surface on the outside upon which the NPWT could be secured . An open-faced mold was then designed in 3-matic to allow for a naturally smooth surface for the NPWT film to attach. The mold was printed on a FormLabs Form 3B in FormLabs Biomed Amber resin (FormLabs, Somerville, MA, USA) and post-processed following the recommended Form Wash and Cure time and temperatures for clinical applications . Factor II VST-50HD (FactorII, Inc., Lakeside, AZ, USA) platinum cure two part medical grade silicone was selected for its shore hardness of 38A and safe skin contact properties and was mixed in ratio of 10:1 A:B, degassed, and gravity poured into the mold . The mold and poured silicone were allowed to cure at 60 °C for 3 hours and the splint was extracted from the mold. The splint alone underwent an additional cure in at 150 °C for 2 h to ensure complete cure. The wound splint was then cleansed in 99% IPA for 5 minutes, before being ready for patient application .\nAn EAEU was submitted to the FDA on the basis of a life threatening infection requiring prolonged intubation that was necessary due to heavy sedation requirements with dressing changes. Additional concerns of development of orbital involvement and vision loss were cited if the wound did not begin to rapidly heal, and failure of other treatment options (wet-to-dry dressing changes). Concurrence was obtained from our IRB.\nThe wound splint was then placed at the superior edge of the wound bed, just below the remnant eyelid and sutured in place. A NPWT sponge was placed in the remaining wound bed. The NPWT film was applied directly to the splint, and ophthalmology confirmed that there was no traction on the lower lid .\nSince bedside dressing changes were no longer necessary, the patient was weaned from sedation, although she remained intubated. Two days following placement, the NPWT was exchanged in the operating room. The wound was noted to have stabilized, with well-healing granulation tissue present in > 50% of the wound bed, active bleeding throughout, and no evidence of devascularized areas or additional further purulence. The erythema of the mediastinal skin had improved, and the WBC count normalized. Five days later, the NPWT was again exchanged, and the dead space between the skin and trachea was noted to have healed and seated down, allowing for tracheostomy and removal of the endotracheal tube 2 weeks following initial placement . Now fully weaned from sedation, the patient was transferred out of the intensive care unit and continued to express appreciation for her customized care and device.\nWith each exchange of NPWT, the wound continued to demonstrate contraction and healthy granulation tissue formation, with no evidence of ongoing infection. Four weeks after initial placement, the NPWT was removed, and the defect was reconstructed with a pectoralis muscle flap, split thickness skin graft, and right paramedian forehead flap .\nA second stage surgery for division and inset was performed 4 weeks after the initial reconstruction . Following completion of reconstruction, vision testing and patient-reported vision were at baseline from prior to infection, with minimal lagophthalmos, no exposure keratopathy and no damage to the globe.", + "fulltext_subclaims": [ + "The patient was a 58-year-old female.", + "She presented with right facial and neck swelling and respiratory distress.", + "She had a recent dental infection treated with clindamycin.", + "On examination, there were grossly decayed teeth.", + "There was a firm floor of mouth and diffuse erythema of the right neck, lower and mid-face.", + "She was diagnosed with Ludwig’s Angina.", + "She was immediately intubated due to stridor and pending airway compromise.", + "Imaging revealed extensive infection and abscess formation involving the submandibular, pterygomandibular, and buccal spaces.", + "She was taken to the operating room for dental extraction and abscess drainage.", + "Cultures from this operation were polymicrobial and consistent with oral microbes.", + "On postoperative day 1, she developed rapidly expanding erythema and swelling of the right hemiface and neck.", + "There was gross necrosis of the skin throughout the right neck and face.", + "The Otolaryngology team was consulted for possible necrotizing fasciitis.", + "The patient was taken to the operating room for urgent debridement.", + "Debridement included the skin of the right neck and face up to lower eyelid.", + "Debridement included devascularized orbicularis oculi, mylohyoid, superficial muscular aponeurotic system in the midface, masseter, and all branches of the facial nerve.", + "The debridement required removal of a 20x30cm segment of the right and central neck.", + "The debridement required removal of a 20x20cm segment of the right face.", + "Subsequent debridement 2 days later required excision of soft tissue to the level of the zygoma and infraorbital rim.", + "Penrose drains were placed to assist with drainage and irrigation of deeper spaces communicating with the open wound.", + "Antibiotics were transitioned to vancomycin, ampicillin-sulbactam, and fluconazole.", + "The planned duration of antibiotics was 4 weeks.", + "The decision was made to proceed with twice daily local wound care with Dakins irrigations through the Penrose drains.", + "Placement of wet-to-dry Dakins-soaked gauze over exposed soft tissue between operative debridements was planned.", + "Ophthalmology was consulted for assistance with progressive ocular and lower eyelid involvement.", + "Heavy sedation was required for dressing changes.", + "A tracheostomy was not offered due to open wound without overlying skin in the pretracheal space.", + "Secretions would have saturated the wound bed and prolonged infection.", + "Despite aggressive wound care, 12 days after initial aggressive debridement, purulent drainage continued to be encountered with irrigations.", + "There was concern for spread of infection threatening the right orbit and mediastinum.", + "New areas of devitalized tissue were encountered routinely throughout the wound bed.", + "The white blood cell count was persistently elevated.", + "The patient remained septic.", + "Several case reports and review articles have demonstrated success with NPWT in decreasing bacterial burden and stabilizing wounds in patients with NF.", + "Negative pressure wound therapy was contraindicated due to risk of traction injury to the globe and/or eyelid.", + "A 3D-printed, patient-specific wound splint was designed at the point-of-care.", + "The patient’s circumstances met the criteria for the FDA Expanded Access for Medical Devices Emergency Use mechanism.", + "Concurrence was obtained from the Institutional Review Board.", + "A follow-up report was sent to the FDA within 5 days on the use of the device.", + "A facial CT was obtained.", + "DICOM images were uploaded to Materialise Mimics.", + "The native anatomy was imported into Materalise 3-Matic.", + "A 3D surface was formed through the offset of the soft tissue and bony structures within the wound.", + "The mold was printed on a FormLabs Form 3B.", + "Factor II VST-50HD platinum cure two part medical grade silicone was selected.", + "The wound splint was cleansed in 99% IPA for 5 minutes.", + "An EAEU was submitted to the FDA.", + "The wound splint was placed at the superior edge of the wound bed.", + "The NPWT film was applied directly to the splint.", + "Ophthalmology confirmed that there was no traction on the lower lid.", + "The patient was weaned from sedation.", + "Two days following placement, the NPWT was exchanged in the operating room.", + "The wound was noted to have stabilized.", + "The wound had well-healing granulation tissue present in > 50% of the wound bed.", + "There was no evidence of devascularized areas or additional further purulence.", + "The erythema of the mediastinal skin had improved.", + "The WBC count normalized.", + "Five days later, the NPWT was again exchanged.", + "The dead space between the skin and trachea was noted to have healed.", + "A tracheostomy was performed.", + "The endotracheal tube was removed 2 weeks following initial placement.", + "The patient was transferred out of the intensive care unit.", + "The NPWT was removed four weeks after initial placement.", + "The defect was reconstructed with a pectoralis muscle flap, split thickness skin graft, and right paramedian forehead flap.", + "A second stage surgery for division and inset was performed four weeks after the initial reconstruction.", + "Vision testing and patient-reported vision were at baseline.", + "There was minimal lagophthalmos.", + "There was no exposure keratopathy.", + "There was no damage to the globe." + ], + "summary": "A 58-year-old female presented with necrotizing fasciitis of the neck and hemiface. After multiple debridements, she remained critically ill with poor vascularity of tissue in the wound bed and no evidence of healthy granulation tissue and concern for additional breakdown towards the right orbit, mediastinum, and pretracheal soft tissues, precluding tracheostomy placement despite prolonged intubation. A negative pressure wound vacuum was considered for improved healing, but proximity to the eye raised concern for vision loss due to traction injury. As a solution, under the Food and Drug Administration's Expanded Access for Medical Devices Emergency Use mechanism, we designed a three-dimensional printed, patient-specific silicone wound splint from a CT scan, allowing the wound vacuum to be secured to the splint rather than the eyelid. After 5 days of splint-assisted vacuum therapy, the wound bed stabilized with no residual purulence and developed healthy granulation tissue, without injury to the eye or lower lid. With continued vacuum therapy, the wound contracted to allow for safe tracheostomy placement, ventilator liberation, oral intake, and hemifacial reconstruction with a myofascial pectoralis muscle flap and a paramedian forehead flap 1 month later. She was eventually decannulated and at six-month follow-up has excellent wound healing and periorbital function.", + "summary_subclaims": [ + "The patient was a 58-year-old female.", + "She presented with necrotizing fasciitis of the neck and hemiface.", + "After multiple debridements, she remained critically ill.", + "There was poor vascularity of tissue in the wound bed.", + "There was no evidence of healthy granulation tissue.", + "There was concern for additional breakdown towards the right orbit, mediastinum, and pretracheal soft tissues.", + "Tracheostomy placement was precluded despite prolonged intubation.", + "A negative pressure wound vacuum was considered for improved healing.", + "Proximity to the eye raised concern for vision loss due to traction injury.", + "A three-dimensional printed, patient-specific silicone wound splint was designed.", + "The splint was based on a CT scan.", + "The wound vacuum was secured to the splint rather than the eyelid.", + "After 5 days of splint-assisted vacuum therapy, the wound bed stabilized.", + "There was no residual purulence.", + "Healthy granulation tissue developed.", + "There was no injury to the eye or lower lid.", + "The wound contracted to allow for safe tracheostomy placement.", + "The patient was ventilator liberated.", + "The patient achieved oral intake.", + "Hemifacial reconstruction was performed with a myofascial pectoralis muscle flap and a paramedian forehead flap 1 month later.", + "She was eventually decannulated.", + "At six-month follow-up, she had excellent wound healing.", + "At six-month follow-up, she had excellent periorbital function." + ] + }, + { + "id": "multiclinsum_test_892_en.txt", + "fulltext": "A 34-year-old female patient was admitted to the rheumatology department in July 2017 with complaints of nausea, joint pain, and swelling in the neck.\nHer medical history was notable for asthma, rheumatoid arthritis (RA), SS, and sialadenitis.\nShe had been undergoing follow-up for RA and SS in the rheumatology department since 2015. Her last follow-up was in November 2016, and laboratory results revealed a rheumatoid factor of 273 IU/mL [reference range (RR) 0-20], anti-cyclic citrullinated peptide (anti-CCP) of < 1.5 U/mL (RR 1.5-1.93), creatinine of 0.74 mg/dL (RR 0.5-0.9 mg/dL), erythrocyte sedimentation rate (ESR) of 109 mm/h (RR 0-20), and C-reactive protein (CRP) of 55.6 mg/L (RR 0–6).\nUpon initial physical examination, a 2-3 cm palpable cervical lymphadenomegaly was detected. She had clear lungs and normal heart sounds with no murmurs or gallops upon auscultation. Her current medication upon admission included methotrexate (15 mg once weekly injection), methylprednisolone (16 mg once daily), calcium carbonate (2500 mg) plus cholecalciferol/vitamin D3 (880 IU once daily).\nLaboratory results revealed several abnormal findings: Hemoglobin: 10.8 g/dL (RR 14-18 g/dL); blood urea nitrogen 33 mg/dL (RR 8-23 mg/dL); creatinine 4.4 mg/dL (RR 0.5-0.9 mg/dl); K: 5.6 mmol/L (3.5-5.1 mmol/L); phosphorus 4.6 mmol/L (RR 2.5-4.5 mmol/L); uric acid: 8.4 mg/dL (RR 2.4-5.7 mg/dL); ferritin: 221.8 ng/mL (RR 15-150 ng/mL); ESR: 84 mm/h (RR 0-20); and CRP: 23 mg/L (RR 0-6 mg/L). All laboratory results are depicted in Table . The patient was referred to the nephrology department. A urine stick test revealed one positive protein. Urine microscopy was negative for casts. The 24-h urine protein level was 0.8 g. Anti-nuclear antibody, anti-double-stranded DNA (dsDNA), anti-glomerular basement membrane, and antineutrophil cytoplasmic antibodies profiles were all negative. The C3 level was 60 mg/dL (RR 90-180 mg/dL), and the C4 level was 15.3 (RR 10-40).\nHypereosinophilia was detected on a peripheral blood smear (eosinophil count was 3.99 × 103/L; RR is 0-0.2 × 103/L), eosinophil percentage was 37.3% (RR 0.9%-2.9%), and the IgG4 level was 2602 mg/dL (RR 3-201 mg/dL).\nRenal ultrasonography indicated enlarged bilateral kidneys. The right and left kidneys had long axes of 159 and 181 mm, respectively. Bilateral renal echoes were significantly decreased, and hypoechoic areas were observed in both kidneys. Among the enlarged area, the largest one was 54 mm × 42 mm in the lower middle section of the left kidney.\nComputed tomography (CT) revealed nodular lesions in the liver, a pancreatic mass, cervical and mediastinal lymph nodes of 2 to 3 cm in diameter.\nPositron emission tomography/CT (PET-CT) screening was used based on suspicion of metastatic malignancy or lymphoma. It has been revealed that cervical and mediastinal lymph nodes had high metabolic activity. Infiltrative soft tissue masses were observed ranging from 2 to 4 cm in size in both kidneys. These masses have showed intense hypermetabolic activity in the cortical areas of the kidney parenchyma (standardized uptake value max: 8.01) .\nA kidney biopsy was performed. The biopsy showed intense, connective tissue infiltration between the glomerular and tubular structures. Lymphoplasmacytic and eosinophilic cell infiltrations were observed. IgG4-stained cells were detected on the biopsy specimen .", + "fulltext_subclaims": [ + "The patient was a 34-year-old female.", + "She was admitted to the rheumatology department in July 2017.", + "She had complaints of nausea, joint pain, and swelling in the neck.", + "Her medical history was notable for asthma.", + "Her medical history was notable for rheumatoid arthritis.", + "Her medical history was notable for SS.", + "Her medical history was notable for sialadenitis.", + "She had been undergoing follow-up for rheumatoid arthritis and SS in the rheumatology department since 2015.", + "Her last follow-up was in November 2016.", + "Her rheumatoid factor was 273 IU/mL.", + "The reference range for rheumatoid factor is 0-20 IU/mL.", + "Her anti-cyclic citrullinated peptide was < 1.5 U/mL.", + "The reference range for anti-cyclic citrullinated peptide is 1.5-1.93 U/mL.", + "Her creatinine was 0.74 mg/dL.", + "The reference range for creatinine is 0.5-0.9 mg/dL.", + "Her erythrocyte sedimentation rate was 109 mm/h.", + "The reference range for erythrocyte sedimentation rate is 0-20 mm/h.", + "Her C-reactive protein was 55.6 mg/L.", + "The reference range for C-reactive protein is 0–6 mg/L.", + "A 2-3 cm palpable cervical lymphadenomegaly was detected.", + "She had clear lungs.", + "Her current medication upon admission included methotrexate (15 mg once weekly injection).", + "Her current medication upon admission included methylprednisolone (16 mg once daily).", + "Her current medication upon admission included calcium carbonate (2500 mg) plus cholecalciferol/vitamin D3 (880 IU once daily).", + "Her hemoglobin was 10.8 g/dL.", + "The reference range for hemoglobin is 14-18 g/dL.", + "Her blood urea nitrogen was 33 mg/dL.", + "The reference range for blood urea nitrogen is 8-23 mg/dL.", + "Her creatinine was 4.4 mg/dL.", + "The reference range for creatinine is 0.5-0.9 mg/dL.", + "Her potassium was 5.6 mmol/L.", + "The reference range for potassium is 3.5-5.1 mmol/L.", + "Her phosphorus was 4.6 mmol/L.", + "The reference range for phosphorus is 2.5-4.5 mmol/L.", + "Her uric acid was 8.4 mg/dL.", + "The reference range for uric acid is 2.4-5.7 mg/dL.", + "Her ferritin was 221.8 ng/mL.", + "The reference range for ferritin is 15-150 ng/mL.", + "Her erythrocyte sedimentation rate was 84 mm/h.", + "The reference range for erythrocyte sedimentation rate is 0-20 mm/h.", + "Her C-reactive protein was 23 mg/L.", + "The reference range for C-reactive protein is 0-6 mg/L.", + "A urine stick test revealed one positive protein.", + "The 24-h urine protein level was 0.8 g.", + "Anti-nuclear antibody was negative.", + "Anti-double-stranded DNA was negative.", + "Anti-glomerular basement membrane was negative.", + "Antineutrophil cytoplasmic antibodies were negative.", + "Her C3 level was 60 mg/dL.", + "The reference range for C3 is 90-180 mg/dL.", + "Her C4 level was 15.3.", + "The reference range for C4 is 10-40.", + "Hypereosinophilia was detected on a peripheral blood smear.", + "Her eosinophil count was 3.99 × 103/L.", + "The reference range for eosinophil count is 0-0.2 × 103/L.", + "Her eosinophil percentage was 37.3%.", + "The reference range for eosinophil percentage is 0.9%-2.9%.", + "Her IgG4 level was 2602 mg/dL.", + "The reference range for IgG4 is 3-201 mg/dL.", + "Renal ultrasonography indicated enlarged bilateral kidneys.", + "The right kidney had a long axis of 159 mm.", + "The left kidney had a long axis of 181 mm.", + "Bilateral renal echoes were significantly decreased.", + "Hypoechoic areas were observed in both kidneys.", + "The largest hypoechoic area was 54 mm × 42 mm in the lower middle section of the left kidney.", + "Computed tomography revealed nodular lesions in the liver.", + "Computed tomography revealed a pancreatic mass.", + "Computed tomography revealed cervical and mediastinal lymph nodes of 2 to 3 cm in diameter.", + "Positron emission tomography/CT screening was used based on suspicion of metastatic malignancy or lymphoma.", + "Cervical and mediastinal lymph nodes had high metabolic activity.", + "Infiltrative soft tissue masses were observed in both kidneys.", + "The masses were ranging from 2 to 4 cm in size.", + "The masses showed intense hypermetabolic activity in the cortical areas of the kidney parenchyma.", + "The standardized uptake value max was 8.01.", + "A kidney biopsy was performed.", + "The biopsy showed intense, connective tissue infiltration between the glomerular and tubular structures.", + "Lymphoplasmacytic and eosinophilic cell infiltrations were observed.", + "IgG4-stained cells were detected on the biopsy specimen." + ], + "summary": "Herein, we reported a 34-year-old woman whom previously had diagnosed with asthma, rheumatoid arthritis and Sjögren's syndrome (SS) referred our nephrology department due to acute kidney failure development at the last rheumatology visit. After kidney biopsy she has been diagnosed with IgG4-RD and tubuluointerstitial nephritis. She had been accepted resistant to steroid, mycophenolate mofetil, methotrexate and azathioprine therapies due to receiving in last two years. She refused to receive cyclophosphamide due to potential gonadotoxicity of the drug. Thus, rituximab therapy was considered. She received 1000 mg infusion, 15 d apart and 6 mo later it has been administered same protocol. After one year from the last rituximab dose serum creatinine decreased from 4.4 mg/dL to 1.6 mg/dL, erythrocyte sedimentation rate decreased from 109 mm/h to 13 mm/h", + "summary_subclaims": [ + "The patient was a 34-year-old woman.", + "She had previously been diagnosed with asthma.", + "She had previously been diagnosed with rheumatoid arthritis.", + "She had previously been diagnosed with Sjögren's syndrome.", + "She was referred to the nephrology department due to acute kidney failure.", + "After kidney biopsy, she was diagnosed with IgG4-RD.", + "After kidney biopsy, she was diagnosed with tubulointerstitial nephritis.", + "She was resistant to steroid therapy.", + "She was resistant to mycophenolate mofetil therapy.", + "She was resistant to methotrexate therapy.", + "She was resistant to azathioprine therapy.", + "She had received these therapies in the last two years.", + "She refused to receive cyclophosphamide due to potential gonadotoxicity.", + "Rituximab therapy was considered.", + "She received a 1000 mg infusion.", + "The infusions were 15 days apart.", + "Six months later, the same protocol was administered.", + "After one year from the last rituximab dose, serum creatinine decreased from 4.4 mg/dL to 1.6 mg/dL.", + "After one year from the last rituximab dose, erythrocyte sedimentation rate decreased from 109 mm/h to 13 mm/h." + ] + }, + { + "id": "multiclinsum_test_1883_en.txt", + "fulltext": "A 32-year-old Iranian man with an unremarkable medical history presented with the chief complaint of a lump on the dorsal ulnar side of his right hand and wrist. He first noticed his symptoms approximately one month earlier. The patient reported that the mass had been there for one month and had been growing steadily over the previous month. There was no prior trauma history or constitutional symptoms, and his past medical, and family history was otherwise unremarkable. He noted some swelling in the left dorsal area but no fever, chills, or pain. Furthermore, in part of his social history, he did not abuse alcohol, drugs, or cigarettes. Also, at the time of admission, his vital signs were in normal range (pulse rate = 75, blood pressure = 118/83, temperature = 36.7, O2 saturation = 98%). In addition, as Table depict all patient’s laboratory findings except 25-Hydroxy Vitamin D3 were normal. Thus, for his low level of 25-Hydroxy Vitamin D3, supplement medication (a tablet of Vitamin D3 1000 mg daily) was started.\nStandard hand-wrist radiographs were taken to rule out any foreign body or fracture.\nThere was no evidence of bone involvement, and no foreign bodies or breaks in any cortical margins were noted. The primary physician clinically suspected the case as a ganglion cyst during that period. After receiving conservative treatment (a tablet of Naproxen 500 mg when he suffers from pain) for 2 months, the size of the lesion gradually increased. On clinical examination, a mass of size 30 × 20 mm was found between the second and third metacarpal bones of the dorsal surface of the left hand, extending up to the proximal of the metacarpal bones and the distal part of the wrist joint. Moreover, in terms of neurovascular examination patient did not have any significant abnormalities, despite the tumor size. The patient could flex and extend his wrist suitably. His deep tendon reflex was normal. Moreover, his sensation and precipitation were literally acceptable. As well, his muscle power was 5 out of 5. In addition, Magnetic Resonance Imaging (MRI) was performed, and the image was reviewed by a radiologist. The image revealed a hypersignal lesion in T2 that was iso to a hypersignal lesion in T1 in the deep soft tissue of the middle and medial side of the hand in the 3rd and 4th web with encasement of the 4th metacarpal bone. The lesion was suggestive of a cystic structure with fine internal septation and heterogeneous signal intensity. A deviation of the flexor tendon was observed due to the mass effect of this lesion. Additionally, displacement of the extensor tendon of the hand was observed in the 3rd, 4th, and 5th fingers .\nWith the patient under local anesthesia, an excisional biopsy was performed, which revealed a gray gelatinous, loose mass adhering to the lumbrical and interosseous muscles and invading the carpometacarpal joint. The mass was excised in total and sent to the pathology laboratory for review.\nUnfortunately, the patient had poor follow-up and did not return to the clinic after 2 months when he reported a recurrent lesion at the same location . Furthermore, in that follow-up, he brought the pathology report which revealed synovial sarcoma (biphasic). Considering the pathology report, abdominal—pelvic, and thoracic CT scans were requested for him and the result of the aforementioned images was literally normal. The patient was referred to an orthopedic oncologist. As a part of patient treatment, amputation was also suggested to the patient However, the patient refused to start his treatment and had no more follow-ups.", + "fulltext_subclaims": [ + "The patient is a 32-year-old Iranian man.", + "The patient's chief complaint was a lump on the dorsal ulnar side of his right hand and wrist.", + "The patient reported that the mass had been there for one month.", + "The patient reported that the mass had been growing steadily over the previous month.", + "There was no prior trauma history.", + "The patient noted some swelling in the left dorsal area.", + "The patient did not have fever, chills, or pain.", + "The patient did not abuse alcohol, drugs, or cigarettes.", + "The patient's vital signs were in normal range at the time of admission.", + "The patient's laboratory findings were normal except for 25-Hydroxy Vitamin D3.", + "The patient was started on a tablet of Vitamin D3 1000 mg daily.", + "Standard hand-wrist radiographs were taken.", + "There was no evidence of bone involvement.", + "The primary physician clinically suspected the case as a ganglion cyst.", + "The patient received conservative treatment with a tablet of Naproxen 500 mg when he suffered from pain.", + "After 2 months of conservative treatment, the size of the lesion gradually increased.", + "A mass of size 30 × 20 mm was found between the second and third metacarpal bones of the dorsal surface of the left hand.", + "The lesion extended up to the proximal of the metacarpal bones and the distal part of the wrist joint.", + "The patient's neurovascular examination did not have any significant abnormalities.", + "The patient could flex and extend his wrist suitably.", + "The patient's deep tendon reflex was normal.", + "The patient's sensation and precipitation were literally acceptable.", + "The patient's muscle power was 5 out of 5.", + "Magnetic Resonance Imaging (MRI) was performed.", + "The MRI image revealed a hypersignal lesion in T2.", + "The MRI image revealed an iso to hypersignal lesion in T1.", + "The lesion was in the deep soft tissue of the middle and medial side of the hand in the 3rd and 4th web.", + "The lesion encased the 4th metacarpal bone.", + "The lesion was suggestive of a cystic structure with fine internal septation.", + "The lesion had heterogeneous signal intensity.", + "A deviation of the flexor tendon was observed due to the mass effect of this lesion.", + "Displacement of the extensor tendon of the hand was observed in the 3rd, 4th, and 5th fingers.", + "An excisional biopsy was performed under local anesthesia.", + "The excised mass was gray gelatinous and loose.", + "The mass adhered to the lumbrical and interosseous muscles.", + "The mass invaded the carpometacarpal joint.", + "The mass was excised in total.", + "The patient did not return to the clinic after 2 months.", + "The patient reported a recurrent lesion at the same location.", + "The pathology report revealed synovial sarcoma (biphasic).", + "Abdominal-pelvic and thoracic CT scans were requested.", + "The results of the CT scans were literally normal.", + "The patient was referred to an orthopedic oncologist.", + "Amputation was suggested to the patient.", + "The patient refused to start his treatment.", + "The patient had no more follow-ups." + ], + "summary": "This study reports a case of metacarpal synovial sarcoma occurring in the hand-wrist of a 32-year-old Iranian man presented with the chief complaint of a lump on the dorsal ulnar side of his left hand and wrist. Initially, the first physician suspected the case to be a ganglion cyst. After two months of conservative treatment, the size of the lesion gradually increased. Magnetic resonance imaging (MRI) was performed and after an excisional biopsy and a postoperative histological analysis, the tumor was identified as a synovial sarcoma. The patient underwent a scheduled surgical procedure. Unfortunately, he had poor follow-ups and brought the pathologic results two months later when, the tumor had incredible growth, which makes this presentation rare.", + "summary_subclaims": [ + "The patient is a 32-year-old Iranian man.", + "The patient had a lump on the dorsal ulnar side of his left hand and wrist.", + "The first physician suspected the case to be a ganglion cyst.", + "The lesion size gradually increased after two months of conservative treatment.", + "Magnetic resonance imaging (MRI) was performed.", + "An excisional biopsy was performed.", + "A postoperative histological analysis identified the tumor as a synovial sarcoma.", + "The patient underwent a scheduled surgical procedure.", + "The patient had poor follow-ups.", + "The patient brought the pathologic results two months later.", + "The tumor had incredible growth when the pathologic results were brought.", + "This presentation is rare." + ] + }, + { + "id": "multiclinsum_test_2360_en.txt", + "fulltext": "A 47-year-old male was brought to the emergency department from his primary care physician’s office after complaining of blurred vision and pain in his left eye for the prior four weeks. The patient initially dismissed these symptoms as a headache or optic neuritis, which he had previously experienced due to his medical history of multiple sclerosis. However, his vision gradually deteriorated over time, with the appearance of floaters and a significant increase in pain two weeks prior to presentation. On physical examination, the patient’s left eye had a visual acuity of 20/60 and a superior temporal field cut. Unfortunately, his right eye had previously suffered vision loss due to optic neuritis and could only perceive light. The intraocular pressure in the left eye was 14 millimeters of mercury (mm Hg), while the right eye’s pressure was 11 mm Hg. The patient’s neurologic examination was otherwise unremarkable.\nThe ophthalmologic exam revealed left conjunctival injection and ciliary flush. Dilated ophthalmic examination showed peripheral retinal whitening in the superonasal area of the left eye, as well as high-grade inflammation in the anterior chamber (3+ cell) and vitreous cavity (2+ cell) . Laboratory testing revealed a rapid plasma reagin titer of 1:256, with the patient testing negative for HIV. He was treated with intravenous penicillin 4 million units every 4 hours for 14 days. Ultrasonography of the eye revealed echogenic particles within the vitreous, with a possible undulating membrane that moved freely and swirled on dynamic exam . The patient’s retina was attached, and the diameter of the optic nerve was within normal limits.", + "fulltext_subclaims": [ + "The patient is a 47-year-old male.", + "The patient was brought to the emergency department from his primary care physician’s office.", + "The patient had complained of blurred vision and pain in his left eye for the prior four weeks.", + "The patient initially dismissed these symptoms as a headache or optic neuritis.", + "The patient has a medical history of multiple sclerosis.", + "The patient’s vision gradually deteriorated over time.", + "The patient had the appearance of floaters two weeks prior to presentation.", + "The patient had a significant increase in pain two weeks prior to presentation.", + "On physical examination, the patient’s left eye had a visual acuity of 20/60.", + "The patient’s right eye could only perceive light.", + "The intraocular pressure in the left eye was 14 millimeters of mercury (mm Hg).", + "The intraocular pressure in the right eye was 11 mm Hg.", + "The ophthalmologic exam revealed left conjunctival injection.", + "The ophthalmologic exam revealed left ciliary flush.", + "Dilated ophthalmic examination showed peripheral retinal whitening in the superonasal area of the left eye.", + "Dilated ophthalmic examination showed high-grade inflammation in the anterior chamber (3+ cell).", + "Dilated ophthalmic examination showed vitreous cavity inflammation (2+ cell).", + "Laboratory testing revealed a rapid plasma reagin titer of 1:256.", + "The patient tested negative for HIV.", + "The patient was treated with intravenous penicillin 4 million units every 4 hours for 14 days.", + "Ultrasonography of the eye revealed echogenic particles within the vitreous.", + "Ultrasonography showed a possible undulating membrane that moved freely and swirled on dynamic exam.", + "The patient’s retina was attached.", + "The diameter of the optic nerve was within normal limits." + ], + "summary": "We report a rare case of unilateral syphilitic uveitis in an individual who had been sexually abstinent for 13 years. Using ocular point-of-care ultrasound in the ED, we successfully diagnosed this uncommon ocular manifestation.", + "summary_subclaims": [ + "The patient had been sexually abstinent for 13 years.", + "Unilateral syphilitic uveitis was diagnosed.", + "Ocular point-of-care ultrasound was used in the ED.", + "This was an uncommon ocular manifestation." + ] + }, + { + "id": "multiclinsum_test_275_en.txt", + "fulltext": "A 21-year-old female patient without any known adverse medical background presented with a 1 month history of headache, nausea, fatigue and blurred vision. Physical examination and computer tomographic (CT) scan showed pericardial inflammation and splenomegaly (2 cm). Ophthalmoscopy of the right eye revealed papillary edema, retinal hemorrhages (Roth’s spots) and arteriovenous nickings (for further details see Fig. and Table ). Initial laboratory evaluation of peripheral blood (PB) revealed a white blood cells (WBC) of 113.2 × 109/l (72% were blasts), red blood cells (RBC) count was 2.53 × 106/mm3, with a hemoglobin level of 9 g/dl and a platelet count (Plt) of 61 × 109/l. Prothrombine time was 15.1 s (normal value 10.0–13.0 s) while partial thromboplastin time (PTT) was 25.8 s (normal value 29 ± 3.5 s). Creatinine value showed 38.7 μmol/l (normal 45–120) and uric acid value 498.2 μmol/l (normal 150–450). Bone marrow (BM) aspiration revealed 70% of blasts .\nAt this point the first cytogenetic and immunophenotypic data were determined. Flow cytometric (FCM) analysis classified this case as AML-M1. The patient was given standard treatment for AML including (3 + 7) induction chemotherapy (Daunorubicin 60 mg/m2 for 3 days and Cytarabine 200 mg/m2 for 7 days). On day + 28 of treatment with (3 + 7) protocol, the patient had not responded as expected to the treatment, i.e. her PB revealed pancytopenia/cytopenia (WBC 0.4 × 109/l), anemia (hemoglobin level = Hgb: 9.5 g/dl); thrombocytopenia (Plt 12 × 109/l) and less than 7% blasts in BM aspiration. The patient was given re-induction chemotherapy (ICE protocol: Cytrabin 200 mg/day: day 1 ➔ day 7, Etobside 100 mg/day: day 1 ➔ day 5, and Idarubicin 20 mg/day: day 1 ➔ day 3) and she achieved complete remission on day 30 of ICE protocol treatment (WBC 7.4 × 109/l; Hgb 11.6 g/dl; Plt 183 × 109/l), with less than 4% blasts in BM aspiration. Still the patient suffered from blurred vision in the right eye (retinal detachment sensory serous) during ICE protocol treatment but her karyotype was normal. The patient was given consolidation I chemotherapy (High dose Ara-C = HIDAC: Cytarabine 3 g/m2/day; day 1 ➔ day 3; and Methoxantron 20 mg/day; day 1 ➔day 2). Afterwards the patient did not return to the hospital to continue the treatment for 6 weeks. Then she was referred to the hospital again for blurred vision in the right eye and a mass under the vascular arch with splint edema of optical nerve of the right eye was diagnosed, being the cause of her severe decrease in vision. While cerebrospinal fluid (CSF) test was negative, BM aspiration revealed 20–30% of blasts. In PB WBC was 5.6 × 109/l (98.5% of neutrophils), Hgb was 11.6 g/dl, Plt of 70 × 109/l indicated for thrombocytopenia while CT scan of brain was normal. Now she treated with consolidation II chemotherapy (HIDAC), 2 weeks later her PB had WBC 0.1 × 109/l, Hgb 8.4 g/dl and Plt still 20 × 109/l; the mass behind the retina of the right eye was still present.\nAbout 2 months later the patient relapsed and the following values were found: in PB WBC was 7.5 × 109/l with 77.7% of neutrophils, Hgb 12 was g/dl and Plt was 178 × 109/l; BM aspiration revealed 15% of blasts. The MD’s suggested to apply now the Flag-Ida protocol; however, due to the political situation in her home country only available treatment at this point was treatment with Cytrabin 100 mg/day. Again 2 weeks later the patient suffered from blurred vision of the right eye due to serious central retinal detachment; her PB revealed a WBC of 60 × 109/l (70% of them were blasts), Hgb of 13.3 g/dl; thrombocytopenia with Plt of 13 × 109/l was present with a normal brain MRI. Now the patient treated with Cytrabin 1 g/day: day 1 ➔ day 3, Etoposide 100 mg/day: day 1 ➔ day 3, and Methoxantron 20 mg/day: day 1 ➔day 2).\nTen days later, the patient relapsed; her PB shows cytopenia [WBC 1.5 × 109/l with 44% blasts)], anemia (Hgb 9.6 g/dl) and thrombocytopenia (Plt 17 × 109/l). Now the patient stopped the treatment on her own request for 1 month. Afterwards she suffered from fever (more than 40 °C for more than 3 days), menorrhagia and blurred vision in the right eye. Approximately 8.5 months after initial diagnosis she died in her house and no autopsy was performed. Her husband agreed with scientific evaluation of her case and the study was approved by the ethical committee of the Atomic Energy Commission, Damascus, Syria.\nConventional cytogenetics analysis on unstimulated BM sample according to standard procedures was performed prior and post chemotherapy treatments. Karyotypes according to the International System for Human Cytogenetic Nomenclature were classified .\nPrior to chemotherapy treatment: GTG-banding cytogenetics revealed the following karyotype:48–50,X,- X,der(1)t(1;2)(?;?),der(1)t(1;3)(?;?),+ 4,+ 4,+ 4,+ 6,t(8;11)(?;?),t(10;12)(?;?),dic(12;17)(?;?)× 2 , which was further specified by molecular cytogenetic studies . Fluorescence in situ hybridization (FISH) using (WCP) probes for chromosomes 1, 2, 3, 4, 5, 6, 9, 12, 17 and X (MetaSystems, Altlussheim, Germany), a specific probe for ETV6 break apart probe and a specific probe for 17p13 (TP53) (Q-Biogene, USA) were applied according to manufacturer’s instructions. Array-proven multicolor banding (aMCB) probes sets for chromosomes 1, 2, 3, 8, 10, 11, 12 and 17 were used . Thus, the following final karyotype prior to chemotherapeutic treatment was determined using a fluorescence microscope . 48–50,X,-X,der(1)t(1;2)(p35;p22),der(1)t(1;3)(p36.21;p26.2),der(2)(:1p36.21- > 1p35::2p22- > 2qter),+ 4,+ 4,+ 4,+ 6,der(8)t(8;11)(q24.3;q13.4),der(10)t(10;12)(p15.3;q24.11),del(10)(q21q21),dic(12;17)(p11.2;p11.2),del(15)(q14q14),del(15)(q21.1q21.1),del(15)(q22.32q24)del(17)(q12q12) .\nGenomic DNA was extracted from BM cells prior to chemotherapy treatment as previously reported . aCGH was performed using the Agilent Sure Print G3 Human Genome Microarray 180 K as previously described . The aCGH analysis revealed different genomic imbalances . Thus, copy number alterations (CNAs) could be grouped according to their sizes as follows:\nFocal CNAs (e.g. deletion on 14q14.3); CNAs involving variable numbers of genes (e.g. deletion on 17q21.3); CNAs involving large parts of chromosomal p or q arms (e.g. duplication of 3q26.1q29) and CNAs of whole chromosomes (e.g. trisomy # 6 -Table ).\nImmunophenotyping was performed on BM specimen prior and after chemotherapy treatment using a general panel of fluorescent antibodies against antigens typical for different cell lineages and cell types : CD1a, CD2, CD3, CD4, CD5, CD8, CD10, CD11b, CD11c, CD13, CD14, CD15, CD16, CD19, CD20, CD22, CD23, CD32, CD33, CD34, CD36, CD38, CD41a, CD45, CD56, CD57, CD64, CD79a, CD103, CD117, CD123, CD138, CD209, CD235a and CD243; In addition to antibodies to Kappa and Lambda light Chains, IgD, sIgM, and HLADr. All antibodies were from BD Biosciences. Flow cytometric data acquisition and analysis were conducted . FCM analysis of BM specimen prior to chemotherapy treatment characterized this case as AML-M1 according to WHO classifications. The abnormal cell population (60% of tested cells) was positive for CD45dim, CD34, HLADr, CD33, CD117, and CD13. Blast cell population was negative for CD3, CD79a, CD14, CD64, CD32, CD7, CD19, CD10 and CD5.\nAfter chemotherapy and relapse GTG-banding revealed a mosaic of tetraploidy and HH as 92,XXXX /62,XX,+ 1,+ 4,+ 5,+ 5,+ 6,+ 6,+ 11,+ 15,+ 16,+ 17,+ 19,+ 19,+ 20,+ 20,+ 21,+ 22 /46,XX .\nFCM analysis of BM specimen post to chemotherapy treatment characterized this case as AML-M6 according to WHO classifications. The abnormal cell population (15%) was positive for CD45dim, CD36, HLADr, CD33, CD34, CD117, CD13, CD235a and MPO. Those blasts were negative for: CD10, CD19, CD20, CD22, CD5, CD7, CD2, CD3, CD16, CD56, CD1a, CD14, CD64, CD32, TdT, cyCD3 and cyCD79a.", + "fulltext_subclaims": [ + "The patient was a 21-year-old female.", + "The patient had no known adverse medical background.", + "The patient had a 1 month history of headache, nausea, fatigue, and blurred vision.", + "Physical examination and CT scan showed pericardial inflammation.", + "Ophthalmoscopy of the right eye revealed papillary edema.", + "Ophthalmoscopy of the right eye revealed retinal hemorrhages (Roth’s spots).", + "Initial laboratory evaluation showed a white blood cell count of 113.2 × 109/l.", + "Initial laboratory evaluation showed 72% blasts in the white blood cell differential.", + "Bone marrow aspiration revealed 70% blasts.", + "Flow cytometric analysis classified the case as AML-M1.", + "The patient was given standard treatment for AML including (3 + 7) induction chemotherapy.", + "On day + 28 of treatment with the (3 + 7) protocol, the patient had not responded as expected.", + "The patient was given re-induction chemotherapy with the ICE protocol.", + "The patient achieved complete remission on day 30 of ICE protocol treatment.", + "The patient suffered from blurred vision in the right eye during ICE protocol treatment.", + "The patient was given consolidation I chemotherapy with HIDAC.", + "The patient did not return to the hospital to continue treatment for 6 weeks.", + "The patient was referred to the hospital again for blurred vision in the right eye.", + "A mass under the vascular arch with splint edema of the optical nerve of the right eye was diagnosed.", + "Cerebrospinal fluid test was negative.", + "Bone marrow aspiration revealed 20–30% blasts.", + "The patient was treated with consolidation II chemotherapy with HIDAC.", + "Two weeks later, the patient's peripheral blood showed WBC 0.1 × 109/l.", + "The mass behind the retina of the right eye was still present.", + "About 2 months later, the patient relapsed.", + "The patient's peripheral blood showed WBC 7.5 × 109/l with 77.7% neutrophils.", + "Bone marrow aspiration revealed 15% blasts.", + "The patient was treated with Cytrabin 100 mg/day.", + "Two weeks later, the patient suffered from blurred vision of the right eye due to serious central retinal detachment.", + "The patient's peripheral blood showed WBC 60 × 109/l with 70% blasts.", + "The patient was treated with Cytrabin 1 g/day, Etoposide 100 mg/day, and Methoxantron 20 mg/day.", + "Ten days later, the patient relapsed.", + "The patient's peripheral blood showed WBC 1.5 × 109/l with 44% blasts.", + "The patient stopped treatment on her own request for 1 month.", + "The patient suffered from fever (more than 40 °C for more than 3 days).", + "Approximately 8.5 months after initial diagnosis, the patient died in her house.", + "No autopsy was performed.", + "The patient's husband agreed with scientific evaluation of her case.", + "The study was approved by the ethical committee of the Atomic Energy Commission, Damascus, Syria.", + "GTG-banding cytogenetics prior to chemotherapy treatment revealed the karyotype: 48–50,X,-X,der(1)t(1;2)(p35;p22),der(1)t(1;3)(p36.21;p26.2),der(2)(:1p36.21- > 1p35::2p22- > 2qter),+ 4,+ 4,+ 4,+ 6,der(8)t(8;11)(q24.3;q13.4),der(10)t(10;12)(p15.3;q24.11),del(10)(q21q21),dic(12;17)(p11.2;p11.2),del(15)(q14q14),del(15)(q21.1q21.1),del(15)(q22.32q24)del(17)(q12q12).", + "Array-proven multicolor banding (aMCB) probes sets were used for chromosomes 1, 2, 3, 8, 10, 11, 12, and 17.", + "aCGH analysis revealed different genomic imbalances.", + "Copy number alterations (CNAs) could be grouped according to their sizes.", + "Focal CNAs were observed, such as deletion on 14q14.3.", + "CNAs involving variable numbers of genes were observed, such as deletion on 17q21.3.", + "CNAs involving large parts of chromosomal p or q arms were observed, such as duplication of 3q26.1q29.", + "CNAs of whole chromosomes were observed, such as trisomy # 6.", + "Immunophenotyping was performed on BM specimen prior and after chemotherapy treatment.", + "FCM analysis of BM specimen prior to chemotherapy treatment characterized the case as AML-M1.", + "The abnormal cell population (60% of tested cells) was positive for CD45dim, CD34, HLADr, CD33, CD117, and CD13.", + "The blast cell population was negative for CD3, CD79a, CD14, CD64, CD32, CD7, CD19, CD10, and CD5.", + "After chemotherapy and relapse, GTG-banding revealed a mosaic of tetraploidy and HH as 92,XXXX /62,XX,+ 1,+ 4,+ 5,+ 5,+ 6,+ 6,+ 11,+ 15,+ 16,+ 17,+ 19,+ 19,+ 20,+ 20,+ 21,+ 22 /46,XX.", + "FCM analysis of BM specimen post to chemotherapy treatment characterized the case as AML-M6.", + "The abnormal cell population (15%) was positive for CD45dim, CD36, HLADr, CD33, CD34, CD117, CD13, CD235a, and MPO.", + "Those blasts were negative for: CD10, CD19, CD20, CD22, CD5, CD7, CD2, CD3, CD16, CD56, CD1a, CD14, CD64, CD32, TdT, cyCD3, and cyCD79a." + ], + "summary": "Here we report a case of 21-year-old female, diagnosed with a de novo AML-M1 according to WHO classification and a CK at diagnosis. Cytogenetic, molecular cytogenetic approaches (standard fluorescence in situ hybridization (FISH), array-proven multicolor banding (aMCB)) and high resolution array comparative genomic hybridization (aCGH) analyses revealed a unique complex but still near diploid karyotype involving eleven chromosomes was identified. It included pentasomy 4, three yet unreported chromosomal aberrations t(1;2)(p35;p22), t(1;3)(p36.2;p26.2), and t(10;12)(p15.2;q24.11), and a combination of two cytogenetic events, yet unreported to appear in together, i.e. a reciprocal translocation t(1;3)(p36.2;p26.2) leading to EVI1/PRDM16 gene fusion, and monoallelic loss of tumor suppressor gene TP53. After successful chemotherapeutic treatment the patient experienced a relapse to AML-M1, and she developed secondary AML-M6 with tetraploidy and HH. Unfortunately, the young woman died 8.5 months after initial diagnosis.", + "summary_subclaims": [ + "The patient was a 21-year-old female.", + "She was diagnosed with a de novo AML-M1 according to WHO classification.", + "She had a complex but near diploid karyotype involving eleven chromosomes.", + "The karyotype included pentasomy 4.", + "Three chromosomal aberrations were identified: t(1;2)(p35;p22), t(1;3)(p36.2;p26.2), and t(10;12)(p15.2;q24.11).", + "A reciprocal translocation t(1;3)(p36.2;p26.2) leading to EVI1/PRDM16 gene fusion was identified.", + "Monoallelic loss of tumor suppressor gene TP53 was identified.", + "The patient experienced a relapse to AML-M1.", + "She developed secondary AML-M6 with tetraploidy and HH.", + "The patient died 8.5 months after initial diagnosis." + ] + }, + { + "id": "multiclinsum_test_1443_en.txt", + "fulltext": "Then, a 13-year-old right-hand dominant boy sustained a bony mallet injury to his right long finger while jumping on a fumbled football. Injury radiographs revealed an avulsion-type fracture of the base of the right long finger distal phalanx involving 30% of the joint, in which the distal fragment was subluxed volarly . The patient’s examination was significant for loss of active extension at the long finger DIP joint as well as generalized ligamentous laxity. The patient had hyperextension of both his elbows and knees, could extend his thumb back to his forearm, and hyperextend his 2nd metacarpal phalangeal (MCP) joint to 90°. Several family members had similar traits but no formal diagnosis had been made.\nHe was offered surgical treatment based on the amount of joint subluxation and underwent closed reduction, percutaneous pinning of the right long finger DIP joint 9 days from injury. A two-pin technique was used, one across the DIP joint and the other to block the bone fragment from retracting . The pin was left in place for 6 weeks and removed without complication. He went on to heal with residual DIP joint stiffness and only 20° residual motion that was noted on follow-up 2 years later during an examination for an injury to the opposite hand .\nThe patient was seen for an unrelated injury 7 years later and was found to have no motion at the right long finger DIP joint. X-rays of his right long finger showed a complete fusion of bone across the DIP joint . He reported unrestricted use of his right hand despite the DIP fusion and even played collegiate baseball for 4 years.", + "fulltext_subclaims": [ + "A 13-year-old right-hand dominant boy sustained a bony mallet injury to his right long finger while jumping on a fumbled football.", + "Injury radiographs revealed an avulsion-type fracture of the base of the right long finger distal phalanx involving 30% of the joint.", + "The distal fragment was subluxed volarly.", + "The patient had loss of active extension at the long finger DIP joint.", + "The patient had generalized ligamentous laxity.", + "The patient had hyperextension of both his elbows and knees.", + "The patient could extend his thumb back to his forearm.", + "The patient had hyperextension of his 2nd metacarpal phalangeal (MCP) joint to 90°.", + "Several family members had similar traits.", + "No formal diagnosis had been made.", + "The patient was offered surgical treatment based on the amount of joint subluxation.", + "The patient underwent closed reduction, percutaneous pinning of the right long finger DIP joint 9 days from injury.", + "A two-pin technique was used.", + "One pin was across the DIP joint.", + "One pin was used to block the bone fragment from retracting.", + "The pin was left in place for 6 weeks.", + "The pin was removed without complication.", + "He went on to heal with residual DIP joint stiffness.", + "He had 20° residual motion noted on follow-up 2 years later.", + "The follow-up was during an examination for an injury to the opposite hand.", + "The patient was seen for an unrelated injury 7 years later.", + "X-rays of his right long finger showed a complete fusion of bone across the DIP joint.", + "He reported unrestricted use of his right hand despite the DIP fusion.", + "He played collegiate baseball for 4 years." + ], + "summary": "We present a case of a 13-year-old right-hand dominant boy who sustained a right long finger bony mallet injury while playing football. Treatment consisted of closed reduction, percutaneous pinning of the right long finger distal interphalangeal (DIP) joint. He went on to heal with residual DIP joint stiffness and only 20° of residual motion that were noted on the early follow-up. Seven years later, he presented with no motion at the right long finger DIP joint. X-rays of his right long finger showed a complete fusion of bone across the DIP joint.", + "summary_subclaims": [ + "The patient is a 13-year-old right-hand dominant boy.", + "He sustained a right long finger bony mallet injury while playing football.", + "Treatment consisted of closed reduction.", + "Treatment consisted of percutaneous pinning of the right long finger distal interphalangeal (DIP) joint.", + "He went on to heal with residual DIP joint stiffness.", + "He had 20° of residual motion noted on the early follow-up.", + "Seven years later, he presented with no motion at the right long finger DIP joint.", + "X-rays of his right long finger showed a complete fusion of bone across the DIP joint." + ] + }, + { + "id": "multiclinsum_test_1230_en.txt", + "fulltext": "A 53 year old Pakistani lady presented to the Medicine clinic of a local hospital in 2004 with a history of heel pain and lower back pain for 5 months. In this period, the patient had sustained a rib fracture and left humeral fracture. There was no history of diabetes, hypertension or any other chronic disease. She had not been on any form of medication, including steroids and traditional drugs widely available and prescribed in the region, prior to the onset of pain. At the time of the fractures, she had been placed on non steroidal anti inflammatory agents, acetaminophen and tramadol. There was no history of illicit drug use and she was a non smoker. Family history was unremarkable, particularly in the context of bone disease, and malignancy.\nInitial laboratory investigations had shown a mildly elevated total calcium level of 10.8 mg/dL {2.7 mmol/L}-(no albumin level result available from that time for correction). Parathormone levels (PTH) had not been determined. There was no vitamin d or renal function report available from that time. X-Ray pelvis revealed lytic lesions in the right iliac bone . A magnetic resonance imaging (MRI) of the lumbosacral spine showed some signal changes. The differentials based on the MRI were metastatic bone disease or multiple myeloma.\nSerum protein electrophoresis was normal. The patient then got lost to follow-up. Her work up was resumed 4 years later when her bone pains had started flaring up. Bone marrow examinations done back in 2007, and later in 2009, were negative for multiple myeloma. A bone scan in November 2009 showed generalized increased tracer uptake over the skull and both the axial and appendicular skeletons- findings in favor of metabolic bone disease . An initial planar parathyroid sestamibi scan requested by a general practitioner in November 2009 was negative for any functioning parathyroid adenoma in the neck or superior mediastinum. No serum PTH report was available from this time either. Following this workup, the patient was treated empirically for bone pains with calcium supplements, an empiric vitamin d injection, and intravenous zoledronic acid 5 mg (without prior bone mineral density assessment via DXA scan). This empiric treatment was instituted by an orthopedic surgeon whom she had been referred to. The patient experienced only a slight improvement in bone pains with this treatment and also developed nausea, vomiting and anorexia. Subsequently, she sought care at the National Institute of Diabetes and Endocrinology, Dow University Health Sciences, Karachi, Pakistan.\nAt presentation, the patient was well oriented and of functional class 3 (wheel chair bound, able to walk only with support). Her blood pressure was 110/70 mmHg. Neck examination revealed no mass or lymphadenopathy. She had a significant proximal myopathy as well as curved thighs. She had shortened fingers, and spinal scoliosis was evident. Severe generalized bone tenderness was elicited. There was no focal deficit. Laboratory investigations at this time showed a calcium level of 15.1 mg/dL{3.775 mmol/L}, (corrected for albumin of 3.6 mg/dL{36 g/L}); Vitamin D3 level of 33.92 ng/mL{84.664 nmol/L}; phosphorus 2.3 mg/dL {0.743 mmol/L}and alkaline phosphatase of 1298 IU/L {21.633 µkat/L}. Her 24 h urine calcium was 155 mg/day {3.875 mmol/day}, with urine calcium to creatinine ratio of 0.02. Her creatinine level was 1.3 mg/dL {114.92 µmol/L}. The estimated glomerular filtration rate (calculated through Cockcroft-Gault equation) was 50 mL/min {0.835 mL/second).\nFollowing these tests, the patient’s PTH level was ordered and determined to be 2105 pg/mL {2105 ng/L} [Table ]. Ultrasonography of the neck showed a solid hypo echoic, well-circumscribed mass lesion, measuring 1.8 × 1.2 cm at the lower pole of the right lobe of thyroid. There were no calcifications or lymphadenopathy. Appearances were suggestive of parathyroid adenoma. Both lobes of the thyroid appeared normal. A repeat planar sestamibi scan, (requested from a different institute in the city), revealed areas of tracer retention over upper and lower poles of the right lobe of thyroid. The intensity of retained tracer was more over the right inferior parathyroid gland. The findings were highly suggestive of hyperparathyroidism .\nA bone mineral density scan showed a T score of − 2.9 in the spine, − 3.8 in the hip and − 4.5 in the distal forearm, consistent with severe osteoporosis. The Z scores at the spine, hip and distal forearm were − 2.0, − 3.1 and − 3.6, respectively .\nUltrasonography of the kidneys revealed a single renal stone (0.6 cm) and no neprocalcinosis.\nBased on the biochemistry results of hypercalcemia, associated with elevated PTH levels, a diagnosis of primary hyperparathyroidism was made. Subsequent sestamibi scan and neck imaging facilitated us to localize the abnormal parathyroid gland. The DXA scan was useful for evaluation of the bone mineral density. In view of the phenomenally high levels of parathyroid hormone, (more than 10 times upper limit of normal), the pre-operative suspicion of parathyroid cancer was high [, ]. The patient was rehydrated with intravenous fluids. Subcutaneous calcitonin injections at a dose of 4 units/kg every 12 h were administered to tide her over until the surgery. Once her calcium levels had come down to 10.5 mg/dL {2.625 nmol/L}L, she was operated upon. At surgery, right hemithyroidectomy and inferior parathyroidectomy with level six lymph node resection was done. The lymphadenectomy was performed as there was evidence of enlarged lymph nodes at neck exploration. The size of the lesion was measured as 2.5 × 1.5 × 1 cm. Histopathology showed features consistent with parathyroid cancer . Capsular invasion and focal vascular invasion were noted. However, margins of excision were tumor free. The excised lymph nodes did not show evidence of tumour infiltration. The patient was not given external radiation therapy postoperatively. Literature review revealed that post operative adjuvant radiation therapy may only have a role in the management of patients with a histologically positive margin following en bloc resection, or in those with lymph node metastases [, , ].\nPostoperative PTH level, performed on the second day of surgery, was 59 pg/mL {59 ng/L} (16–87). On the third postoperative day, the patient’s serum corrected calcium declined to 6 mg/dL {1.5 mmol/L}. This was associated with paresthesias around her mouth and carpo-pedal spasm. There were no seizures, although there was some confusion in terms of time and place. Intravenous calcium (2 g calcium gluconate, equivalent to 180 mg elemental calcium, in 50 mL 5% dextrose water) was infused over 20 min. Re-monitoring of calcium levels revealed persistent hypocalcemia. A slow infusion of calcium was initiated at an initial rate of 50 mL/h. This was prepared by adding 100 mL of 10% calcium gluconate (equivalent to 900 mg elemental calcium) to 1000 mL 5% dextrose water. The infusion rate was adjusted, with a goal to maintain calcium levels at lower end of normal range. On the fifth post-operative day, the calcium level had risen to 9.0 mg/dL {2.25 nmol/L}. Neurologic examination was normal and she was tolerating oral diet. Oral calcium supplementation was initiated (Qalsan D four times daily-equivalent to 2 g elemental calcium per day). She was discharged on oral calcium and vitamin D supplementation with active vitamin D, (calcitriol) 0.25 µg twice daily, in a stable condition.\nAt follow-up, her appetite and mobility had improved significantly, although she continued to experience bone pains. Corrected calcium was 9.5 mg/dL {2.375 nmol/L}. A repeat skeletal scintigraphy done 3 months after parathyroidectomy did not demonstrate a significant change in the lytic lesions . A repeat DXA scan 2 years down the line revealed a significant improvement in bone mineral density at all sites, though more so at the spine and hip, than at the forearm . Thereafter, we followed her clinically, as she was not keen to have further radiologic testing done. We have been monitoring her calcium and PTH levels on an annual basis. They have remained within their normal range till date (2018). She is now functional class 2, (no longer wheel chair bound), and on regular calcium and vitamin D supplements (patient perspective, attached as Additional file ).", + "fulltext_subclaims": [ + "The patient was a 53 year old Pakistani lady.", + "She presented to the Medicine clinic of a local hospital in 2004.", + "She had a history of heel pain and lower back pain for 5 months.", + "In this period, the patient had sustained a rib fracture.", + "In this period, the patient had sustained a left humeral fracture.", + "There was no history of diabetes.", + "There was no history of hypertension.", + "She had not been on any form of medication, including steroids and traditional drugs widely available and prescribed in the region, prior to the onset of pain.", + "At the time of the fractures, she had been placed on non steroidal anti inflammatory agents.", + "At the time of the fractures, she had been placed on acetaminophen.", + "At the time of the fractures, she had been placed on tramadol.", + "There was no history of illicit drug use.", + "She was a non smoker.", + "Family history was unremarkable, particularly in the context of bone disease.", + "Family history was unremarkable, particularly in the context of malignancy.", + "Initial laboratory investigations had shown a mildly elevated total calcium level of 10.8 mg/dL.", + "Parathormone levels (PTH) had not been determined.", + "There was no vitamin d or renal function report available from that time.", + "X-Ray pelvis revealed lytic lesions in the right iliac bone.", + "A magnetic resonance imaging (MRI) of the lumbosacral spine showed some signal changes.", + "The differentials based on the MRI were metastatic bone disease.", + "The differentials based on the MRI were multiple myeloma.", + "Serum protein electrophoresis was normal.", + "The patient then got lost to follow-up.", + "Her work up was resumed 4 years later when her bone pains had started flaring up.", + "Bone marrow examinations done back in 2007 were negative for multiple myeloma.", + "Bone marrow examinations done back in 2009 were negative for multiple myeloma.", + "A bone scan in November 2009 showed generalized increased tracer uptake over the skull.", + "A bone scan in November 2009 showed generalized increased tracer uptake over both the axial and appendicular skeletons.", + "An initial planar parathyroid sestamibi scan requested by a general practitioner in November 2009 was negative for any functioning parathyroid adenoma in the neck.", + "An initial planar parathyroid sestamibi scan requested by a general practitioner in November 2009 was negative for any functioning parathyroid adenoma in the superior mediastinum.", + "No serum PTH report was available from this time either.", + "Following this workup, the patient was treated empirically for bone pains with calcium supplements.", + "Following this workup, the patient was treated empirically for bone pains with an empiric vitamin d injection.", + "Following this workup, the patient was treated empirically for bone pains with intravenous zoledronic acid 5 mg.", + "This empiric treatment was instituted by an orthopedic surgeon.", + "The patient experienced only a slight improvement in bone pains with this treatment.", + "The patient also developed nausea, vomiting and anorexia.", + "She sought care at the National Institute of Diabetes and Endocrinology, Dow University Health Sciences, Karachi, Pakistan.", + "At presentation, the patient was well oriented.", + "Her blood pressure was 110/70 mmHg.", + "Neck examination revealed no mass.", + "Neck examination revealed no lymphadenopathy.", + "She had a significant proximal myopathy.", + "She had curved thighs.", + "She had shortened fingers.", + "Spinal scoliosis was evident.", + "Severe generalized bone tenderness was elicited.", + "There was no focal deficit.", + "Laboratory investigations at this time showed a calcium level of 15.1 mg/dL.", + "Laboratory investigations at this time showed a Vitamin D3 level of 33.92 ng/mL.", + "Laboratory investigations at this time showed a phosphorus of 2.3 mg/dL.", + "Laboratory investigations at this time showed an alkaline phosphatase of 1298 IU/L.", + "Her 24 h urine calcium was 155 mg/day.", + "Her creatinine level was 1.3 mg/dL.", + "The estimated glomerular filtration rate was 50 mL/min.", + "Following these tests, the patient’s PTH level was ordered and determined to be 2105 pg/mL.", + "Ultrasonography of the neck showed a solid hypo echoic, well-circumscribed mass lesion, measuring 1.8 × 1.2 cm at the lower pole of the right lobe of thyroid.", + "There were no calcifications.", + "There were no lymphadenopathy.", + "Appearances were suggestive of parathyroid adenoma.", + "Both lobes of the thyroid appeared normal.", + "A repeat planar sestamibi scan revealed areas of tracer retention over upper and lower poles of the right lobe of thyroid.", + "The intensity of retained tracer was more over the right inferior parathyroid gland.", + "The findings were highly suggestive of hyperparathyroidism.", + "A bone mineral density scan showed a T score of − 2.9 in the spine.", + "A bone mineral density scan showed a T score of − 3.8 in the hip.", + "A bone mineral density scan showed a T score of − 4.5 in the distal forearm.", + "The Z scores at the spine, hip and distal forearm were − 2.0, − 3.1 and − 3.6, respectively.", + "Ultrasonography of the kidneys revealed a single renal stone (0.6 cm).", + "Ultrasonography of the kidneys revealed no nephrocalcinosis.", + "Based on the biochemistry results of hypercalcemia, associated with elevated PTH levels, a diagnosis of primary hyperparathyroidism was made.", + "Subsequent sestamibi scan and neck imaging facilitated us to localize the abnormal parathyroid gland.", + "The DXA scan was useful for evaluation of the bone mineral density.", + "In view of the phenomenally high levels of parathyroid hormone, the pre-operative suspicion of parathyroid cancer was high.", + "The patient was rehydrated with intravenous fluids.", + "Subcutaneous calcitonin injections at a dose of 4 units/kg every 12 h were administered to tide her over until the surgery.", + "Once her calcium levels had come down to 10.5 mg/dL, she was operated upon.", + "At surgery, right hemithyroidectomy and inferior parathyroidectomy with level six lymph node resection was done.", + "The lymphadenectomy was performed as there was evidence of enlarged lymph nodes at neck exploration.", + "The size of the lesion was measured as 2.5 × 1.5 × 1 cm.", + "Histopathology showed features consistent with parathyroid cancer.", + "Capsular invasion and focal vascular invasion were noted.", + "However, margins of excision were tumor free.", + "The excised lymph nodes did not show evidence of tumour infiltration.", + "The patient was not given external radiation therapy postoperatively.", + "Literature review revealed that post operative adjuvant radiation therapy may only have a role in the management of patients with a histologically positive margin following en bloc resection.", + "Literature review revealed that post operative adjuvant radiation therapy may only have a role in the management of patients with lymph node metastases.", + "Postoperative PTH level, performed on the second day of surgery, was 59 pg/mL.", + "On the third postoperative day, the patient’s serum corrected calcium declined to 6 mg/dL.", + "This was associated with paresthesias around her mouth and carpo-pedal spasm.", + "There were no seizures.", + "There was some confusion in terms of time and place.", + "Intravenous calcium (2 g calcium gluconate, equivalent to 180 mg elemental calcium, in 50 mL 5% dextrose water) was infused over 20 min.", + "Re-monitoring of calcium levels revealed persistent hypocalcemia.", + "A slow infusion of calcium was initiated at an initial rate of 50 mL/h.", + "This was prepared by adding 100 mL of 10% calcium gluconate (equivalent to 900 mg elemental calcium) to 1000 mL 5% dextrose water.", + "The infusion rate was adjusted, with a goal to maintain calcium levels at lower end of normal range.", + "On the fifth post-operative day, the calcium level had risen to 9.0 mg/dL.", + "Neurologic examination was normal.", + "She was tolerating oral diet.", + "Oral calcium supplementation was initiated (Qalsan D four times daily-equivalent to 2 g elemental calcium per day).", + "She was discharged on oral calcium and vitamin D supplementation with active vitamin D, (calcitriol) 0.25 µg twice daily, in a stable condition.", + "At follow-up, her appetite and mobility had improved significantly.", + "Corrected calcium was 9.5 mg/dL.", + "A repeat skeletal scintigraphy done 3 months after parathyroidectomy did not demonstrate a significant change in the lytic lesions.", + "A repeat DXA scan 2 years down the line revealed a significant improvement in bone mineral density at all sites.", + "We have been monitoring her calcium and PTH levels on an annual basis.", + "They have remained within their normal range till date (2018).", + "She is now functional class 2.", + "She is on regular calcium and vitamin D supplements." + ], + "summary": "A middle aged lady of Asian descent presented with backache. Initial work up revealed mild hypercalcemia, negative work up for multiple myeloma, negative sestamibi scan for parathyroid pathology. A phenomenally elevated parathormone (PTH) level-2105 pg/mL (16-87 pg/mL), and rising serum calcium, 15.1 mg/dL, (8.6-10.5 mg/dL), ordered years later prompted a repeat sestamibi scan and ultrasonography of neck. Based on these investigations, a diagnosis of primary hyperparathyroidism, with high suspicion of parathyroid cancer was made. The patient underwent surgical tumour resection, with subsequent histopathological confirmation of diagnosis.", + "summary_subclaims": [ + "A middle aged lady of Asian descent presented with backache.", + "Initial work up revealed mild hypercalcemia.", + "Work up was negative for multiple myeloma.", + "Sestamibi scan was negative for parathyroid pathology.", + "Parathormone level was 2105 pg/mL.", + "Serum calcium was 15.1 mg/dL.", + "A repeat sestamibi scan was ordered.", + "Ultrasonography of the neck was performed.", + "A diagnosis of primary hyperparathyroidism was made.", + "There was high suspicion of parathyroid cancer.", + "The patient underwent surgical tumour resection.", + "Histopathological confirmation of the diagnosis was obtained." + ] + }, + { + "id": "multiclinsum_test_1644_en.txt", + "fulltext": "A 55-year-old postmenopausal woman had intermittent chest pain for 3 years.\nThree years ago (on January 20, 2016), the patient experienced chest pain following an emotionally stressful event (quarrel with her husband) without any signs of infection, such as cough or diarrhea. Twelve-lead electrocardiograms (ECGs) indicated ST-segment and T-wave dynamic changes in the inferior and anterior leads. The peak troponin I level was 0.81 ng/mL (normal range < 0.03). A transthoracic echocardiogram (TTE) showed hypokinesis of the apical and mid-distal segments of the left ventricle with a reduced ejection fraction of 48%. A coronary angiogram showed no evidence of coronary artery disease. The patient was discharged home on diltiazem and an angiotensin-converting-enzyme inhibitor (perindopril) with a suspected diagnosis of coronary artery spasm. The TTE demonstrated completely normal cardiac structure and function with an ejection fraction of 68% on July 27, 2018. On August 9, 2018, the patient presented with chest pain again following the same emotionally stressful event (quarrel with her husband). The peak troponin I level was 0.338 ng/mL. The 12-lead ECG indicated ST-segment depression in the inferior leads and T-wave inversion in the inferior and anterior leads. The TTE showed hypokinesis of the apical and mid-distal segments of the left ventricle (ejection fraction of 52%). A coronary angiogram was performed again without evidence of coronary artery disease. A left ventriculogram was not performed again. The patient was discharged with trimetazidine and an angiotensin-converting-enzyme inhibitor (perindopril). On February 9, 2019, the patient presented with similar chest pain following another stressful event (business failure) without any signs of infection.\nThe patient had a history of pacemaker implantation.\nThe patient had a free personal history. The patient had no family history of premature coronary artery disease.\nVital signs were stable. There was no obvious abnormality during pulmonary or cardiac examination. There was no jugular vein engorgement or peripheral edema.\nThe peak troponin I level was 2.228 ng/mL (normal range < 0.03), and the peak B-type natriuretic peptide level was 166 pg/mL (normal range < 76).\nTwelve-lead ECGs indicated ST-segment and T-wave changes in the inferior and anterior leads . The TTE showed hypokinesis of the apical and mid-distal segments and a hyperdynamic basal segment of the left ventricle with a depressed ejection fraction of 47% . Myocardial perfusion single photon emission computed tomography imaging (resting state) demonstrated decreased uptake in the left ventricular apical, anterior, inferior and lateral walls of the myocardium . Adrenal computed tomography and hormone results excluded pheochromocytoma. She had no evidence of coronary artery disease detected by the coronary angiogram; however, the left ventriculogram revealed apical akinesia with ballooning of the apical region and hypercontractile basal segments consistent with the typical diagnosis of TCM .", + "fulltext_subclaims": [ + "The patient is a 55-year-old postmenopausal woman.", + "She had intermittent chest pain for 3 years.", + "Three years ago, on January 20, 2016, she experienced chest pain following an emotionally stressful event.", + "The chest pain occurred without signs of infection, such as cough or diarrhea.", + "Twelve-lead electrocardiograms indicated ST-segment and T-wave dynamic changes in the inferior and anterior leads.", + "The peak troponin I level was 0.81 ng/mL.", + "A transthoracic echocardiogram showed hypokinesis of the apical and mid-distal segments of the left ventricle.", + "The ejection fraction was 48%.", + "A coronary angiogram showed no evidence of coronary artery disease.", + "The patient was discharged home on diltiazem and perindopril.", + "The suspected diagnosis was coronary artery spasm.", + "The TTE demonstrated completely normal cardiac structure and function with an ejection fraction of 68% on July 27, 2018.", + "On August 9, 2018, the patient presented with chest pain again following the same emotionally stressful event.", + "The peak troponin I level was 0.338 ng/mL.", + "The 12-lead ECG indicated ST-segment depression in the inferior leads and T-wave inversion in the inferior and anterior leads.", + "The TTE showed hypokinesis of the apical and mid-distal segments of the left ventricle.", + "The ejection fraction was 52%.", + "A coronary angiogram was performed again without evidence of coronary artery disease.", + "A left ventriculogram was not performed again.", + "The patient was discharged with trimetazidine and perindopril.", + "On February 9, 2019, the patient presented with similar chest pain following another stressful event.", + "The chest pain occurred without signs of infection.", + "The patient had a history of pacemaker implantation.", + "The patient had no family history of premature coronary artery disease.", + "There was no jugular vein engorgement or peripheral edema.", + "The peak troponin I level was 2.228 ng/mL.", + "The peak B-type natriuretic peptide level was 166 pg/mL.", + "Twelve-lead ECGs indicated ST-segment and T-wave changes in the inferior and anterior leads.", + "The TTE showed hypokinesis of the apical and mid-distal segments and a hyperdynamic basal segment of the left ventricle.", + "The ejection fraction was 47%.", + "Myocardial perfusion single photon emission computed tomography imaging demonstrated decreased uptake in the left ventricular apical, anterior, inferior, and lateral walls.", + "Adrenal computed tomography and hormone results excluded pheochromocytoma.", + "She had no evidence of coronary artery disease detected by the coronary angiogram.", + "The left ventriculogram revealed apical akinesia with ballooning of the apical region and hypercontractile basal segments.", + "The findings were consistent with the typical diagnosis of TCM." + ], + "summary": "A 55-year-old postmenopausal woman had intermittent chest pain following emotionally stressful events three times in the past 3 years. Cardiac troponin levels increased after each instance of symptom onset. A transthoracic echocardiogram showed reversible left ventricular dysfunction. The patient underwent three coronary angiograms without evidence of coronary artery disease. A left ventriculogram was first performed at the third hospitalization and revealed apical akinesia with ballooning of the apical region and consistent hypercontractile basal segments. The diagnosis of TCM was confirmed. The patient was treated with an angiotensin-converting-enzyme inhibitor (perindopril) and a β-blocker (metoprolol). No complications occurred during the patient's hospitalization. The patient was told to avoid stressful events. During the 9-mo follow-up visit, the patient was asymptomatic with an ejection fraction of 55%.", + "summary_subclaims": [ + "The patient is a 55-year-old postmenopausal woman.", + "She had intermittent chest pain following emotionally stressful events three times in the past 3 years.", + "Cardiac troponin levels increased after each instance of symptom onset.", + "A transthoracic echocardiogram showed reversible left ventricular dysfunction.", + "The patient underwent three coronary angiograms without evidence of coronary artery disease.", + "A left ventriculogram was first performed at the third hospitalization.", + "The left ventriculogram revealed apical akinesia with ballooning of the apical region.", + "The left ventriculogram showed consistent hypercontractile basal segments.", + "The diagnosis of TCM was confirmed.", + "The patient was treated with an angiotensin-converting-enzyme inhibitor (perindopril).", + "The patient was treated with a β-blocker (metoprolol).", + "No complications occurred during the patient's hospitalization.", + "The patient was told to avoid stressful events.", + "During the 9-mo follow-up visit, the patient was asymptomatic.", + "During the 9-mo follow-up visit, the patient had an ejection fraction of 55%." + ] + }, + { + "id": "multiclinsum_test_1164_en.txt", + "fulltext": "A 15-year-old male presented with gradually progressive painful low back swelling of 4 months’ duration without any neurological deficit. Plain lumbosacral X-rays showed an enlarged lytic lesion involving predominantly the left side of the sacrum and lower lumbar vertebrae L4-S2 . The MR demonstrated a large, multi-loculated, expansile mass with a soap-bubble-like appearance from L4-S2, which extended to the neural foramina, sacroiliac joints, and paravertebral muscles; findings were consistent with the diagnosis of an ABC . The lumbosacral CT showed a lytic lesion involving the sacral alae, part of the S1and S2 vertebral bodies, and destruction of the left L5 pedicle .\nAn arterial angiogram confirmed the vascularity of the ABC mass. The patient underwent preoperative selective arterial embolization on the day of surgery, followed by an extended curettage . This was followed by a posterior pedicle screw and rod lumbopelvic reconstruction (i.e. L4-S2) .\nThe histopathological examination confirmed the diagnosis of an ABC lesion: osteoid foci, spindle cells, multinucleated giant cells, and reactive changes.\nTwo years later, the patient remained asymptomatic without evidence of ABC lesion recurrence. The only focal asymptomatic finding on radiography was the loosening of the set screw on the left side inferiorly .", + "fulltext_subclaims": [ + "A 15-year-old male presented with gradually progressive painful low back swelling of 4 months’ duration without any neurological deficit.", + "Plain lumbosacral X-rays showed an enlarged lytic lesion involving predominantly the left side of the sacrum and lower lumbar vertebrae L4-S2.", + "The MR demonstrated a large, multi-loculated, expansile mass with a soap-bubble-like appearance from L4-S2.", + "The mass extended to the neural foramina, sacroiliac joints, and paravertebral muscles.", + "Findings were consistent with the diagnosis of an ABC.", + "The lumbosacral CT showed a lytic lesion involving the sacral alae, part of the S1 and S2 vertebral bodies, and destruction of the left L5 pedicle.", + "An arterial angiogram confirmed the vascularity of the ABC mass.", + "The patient underwent preoperative selective arterial embolization on the day of surgery.", + "The patient underwent extended curettage.", + "The patient underwent posterior pedicle screw and rod lumbopelvic reconstruction (i.e. L4-S2).", + "The histopathological examination confirmed the diagnosis of an ABC lesion.", + "The histopathological findings included osteoid foci, spindle cells, multinucleated giant cells, and reactive changes.", + "Two years later, the patient remained asymptomatic without evidence of ABC lesion recurrence.", + "The only focal asymptomatic finding on radiography was the loosening of the set screw on the left side inferiorly." + ], + "summary": "A 15-year-old male, presented with gradually progressive painful lower back swelling of 4 months' duration. Once the diagnosis of an ABC was established based on a combination of X-ray, MR, and CT studies, he underwent selective arterial embolization, extended surgical excision (i.e. curettage), with a posterior fusion. Two years postoperatively, the patient remained neurologically intact without radiographic evidence of lesion recurrence.", + "summary_subclaims": [ + "The patient is a 15-year-old male.", + "He had gradually progressive painful lower back swelling.", + "The swelling had been present for 4 months.", + "The diagnosis of an ABC was established.", + "The diagnosis was based on a combination of X-ray, MR, and CT studies.", + "He underwent selective arterial embolization.", + "He underwent extended surgical excision.", + "The surgical excision was described as curettage.", + "He had a posterior fusion.", + "Two years postoperatively, the patient remained neurologically intact.", + "There was no radiographic evidence of lesion recurrence." + ] + }, + { + "id": "multiclinsum_test_2814_en.txt", + "fulltext": "A 73-year-old man was admitted in our hospital with abdominal pain and fatigue lasting 1 mo.\nOne month before his admission, the patient developed persistent abdominal pain without obvious incentives, such as tolerable dull pain on the left side, without abdominal distension, lethargy, cold sensitivity, itchy skin, and change in skin color, among other symptoms. Since the start of the symptoms, the patient had poor appetite and spirit, and lost more than 10 kg weight.\nThe patient had no history of surgery, trauma, or other diseases.\nThere was no history of hereditary diseases. No family members had similar symptoms.\nThe physical examination of the patient was unremarkable.\nRoutine blood tests, liver and kidney function test, blood coagulation function test, hormone-related examination, and tumor marker analysis showed no obvious abnormalities. In addition, the level of serum potassium was normal.\nThe adrenal enhancement computed tomography (CT) scan showed the presence of irregular masses in the adrenal glands on both sides, with the larger one being located on the left side. Its size was approximately 8.0 cm × 4.3 cm, its border was irregular, and the surrounding tissues were compressed. We did not observe any obvious enhancement in the arterial phase, nor any obvious swollen lymph nodes were noted later on .", + "fulltext_subclaims": [ + "A 73-year-old man was admitted in our hospital with abdominal pain and fatigue lasting 1 mo.", + "One month before his admission, the patient developed persistent abdominal pain without obvious incentives.", + "The patient had tolerable dull pain on the left side.", + "The patient did not have abdominal distension.", + "The patient did not have cold sensitivity.", + "The patient did not have itchy skin.", + "The patient did not have a change in skin color.", + "Since the start of the symptoms, the patient had poor appetite.", + "Since the start of the symptoms, the patient had poor spirit.", + "The patient had lost more than 10 kg weight.", + "The patient had no history of surgery.", + "The patient had no history of trauma.", + "The patient had no history of other diseases.", + "There was no history of hereditary diseases.", + "No family members had similar symptoms.", + "The physical examination of the patient was unremarkable.", + "Routine blood tests showed no obvious abnormalities.", + "Liver and kidney function tests showed no obvious abnormalities.", + "Blood coagulation function tests showed no obvious abnormalities.", + "Hormone-related examinations showed no obvious abnormalities.", + "Tumor marker analysis showed no obvious abnormalities.", + "The level of serum potassium was normal.", + "The adrenal enhancement CT scan showed the presence of irregular masses in the adrenal glands on both sides.", + "The larger mass was located on the left side.", + "The size of the larger mass was approximately 8.0 cm × 4.3 cm.", + "The border of the larger mass was irregular.", + "The surrounding tissues were compressed.", + "We did not observe any obvious enhancement in the arterial phase.", + "No obvious swollen lymph nodes were noted." + ], + "summary": "A 73-year-old man was admitted with abdominal pain and fatigue. After admission, enhanced adrenal computed tomography indicated irregular masses on both adrenal glands, with the larger one on the left side, approximately 8.0 cm × 4.3 cm in size. The boundary was irregular, and surrounding tissues were compressed. No obvious enhancement was observed in the arterial phase. Resection of the left adrenal gland was performed. Pathological diagnosis revealed diffuse large B-cell lymphoma. After surgery, the patient received R-CHOP immunochemotherapy. During the fourth immunochemotherapy, patient condition deteriorated, and he eventually died of respiratory failure.", + "summary_subclaims": [ + "The patient was a 73-year-old man.", + "The patient was admitted with abdominal pain and fatigue.", + "Enhanced adrenal computed tomography indicated irregular masses on both adrenal glands.", + "The larger mass was on the left side.", + "The larger mass was approximately 8.0 cm × 4.3 cm in size.", + "The boundary of the mass was irregular.", + "Surrounding tissues were compressed.", + "No obvious enhancement was observed in the arterial phase.", + "Resection of the left adrenal gland was performed.", + "Pathological diagnosis revealed diffuse large B-cell lymphoma.", + "The patient received R-CHOP immunochemotherapy.", + "During the fourth immunochemotherapy, the patient's condition deteriorated.", + "The patient eventually died of respiratory failure." + ] + }, + { + "id": "multiclinsum_test_734_en.txt", + "fulltext": "A 61-year-old man was affected by rectal cancer and underwent a robotic, high-anterior resection with lymph node dissection. Histopathologically, well-differentiated adenocarcinoma was suggested. The pathological stage was evaluated as I (pT2N0M0) according to the 8th edition of the Union for International Cancer Control. He presented with a 1-month history of a growing mass in his right abdomen, at the surgical port site, 1.5 years after the robotic surgery. This mass was asymptomatic and non-tender. When first noticed 1 month prior to his complaint, the mass lesion was soft and mobile. He had a medical history of an appendectomy for appendicitis and a procedure for inflammation of the paranasal sinuses. There were no overlying skin changes, the swelling was firm, and the mass was not tethered to the overlying skin. An abdominal CT examination revealed a tumor in the upper right abdominal wall, at the surgical port site, that measured 45 mm .\nAn MRI was performed, which showed a solitary lesion measuring 39 mm within the right straight muscle of the abdomen . The mass was hypo-intense to muscle on T1 imaging, and hyper-intense on T2 imaging. Some restricted diffusion was seen around the lesion. This lesion was believed to represent a malignancy process, such as a recurrence of rectal cancer. Due to the malignancy appearance on both the CT and MRI, a decision was made to perform an excisional biopsy of this lesion.\nDue to a suspicion of port site recurrence following the robotic surgery for rectal cancer, an ultrasound-guided, fine-needle aspiration (FNA) was performed. The examination revealed this lesion as either a low-grade myofibroblastic tumor or a benign neoplasm, but was inconclusive.\nThe patient decided to undergo surgery to excise the lesion. Through laparoscopic surgery and a pedicled flap at the right fascia lata, the defect was covered with mesh to create an artificial fascia from the intraperitoneal side . The patient recovered without any complications at 1 month, and continues to be monitored for recurrence. He has no functional deficits or signs of recurrence.", + "fulltext_subclaims": [ + "The patient is a 61-year-old man.", + "The patient was affected by rectal cancer.", + "The patient underwent a robotic, high-anterior resection with lymph node dissection.", + "Histopathologically, well-differentiated adenocarcinoma was suggested.", + "The pathological stage was evaluated as I (pT2N0M0) according to the 8th edition of the Union for International Cancer Control.", + "The patient had a 1-month history of a growing mass in his right abdomen.", + "The mass was at the surgical port site.", + "The mass was 1.5 years old.", + "The mass was asymptomatic.", + "The mass was non-tender.", + "When first noticed 1 month prior to his complaint, the mass lesion was soft and mobile.", + "The patient had a medical history of an appendectomy for appendicitis.", + "The patient had a procedure for inflammation of the paranasal sinuses.", + "There were no overlying skin changes.", + "The swelling was firm.", + "The mass was not tethered to the overlying skin.", + "An abdominal CT examination revealed a tumor in the upper right abdominal wall, at the surgical port site.", + "The tumor measured 45 mm.", + "An MRI showed a solitary lesion within the right straight muscle of the abdomen.", + "The lesion measured 39 mm.", + "The mass was hypo-intense to muscle on T1 imaging.", + "The mass was hyper-intense on T2 imaging.", + "Some restricted diffusion was seen around the lesion.", + "The lesion was believed to represent a malignancy process.", + "The lesion was believed to represent a recurrence of rectal cancer.", + "An excisional biopsy of this lesion was decided.", + "An ultrasound-guided, fine-needle aspiration (FNA) was performed.", + "The FNA was inconclusive.", + "The lesion was either a low-grade myofibroblastic tumor or a benign neoplasm.", + "The patient decided to undergo surgery to excise the lesion.", + "The surgery was laparoscopic.", + "A pedicled flap at the right fascia lata was used.", + "The defect was covered with mesh to create an artificial fascia from the intraperitoneal side.", + "The patient recovered without any complications at 1 month.", + "The patient continues to be monitored for recurrence.", + "The patient has no functional deficits.", + "The patient has no signs of recurrence." + ], + "summary": "A 61-year-old man was affected by rectal cancer. We performed a robotic, high-anterior resection with lymph node dissection. According to the 8th edition of Union for International Cancer Control, the diagnosis was stage I pT2N0M0. During a routine follow-up 1.5 years after the robotic surgery, a computed tomography examination revealed a tumor in the upper right abdominal wall, at the site of the surgical port, that measured 45 mm. Magnetic resonance imaging indicated a hypo-intensive mass within the right straight muscle of the abdomen. Port site recurrence following the robotic surgery for rectal cancer was suspected, and an ultrasound-guided fine-needle aspiration was performed; it revealed a low-grade myofibroblastic tumor or benign neoplasm, but was inconclusive. We performed an excision of the lesion, and histopathology confirmed NF, seen as a solid, nodular, spindle-cell lesion. The patient was postoperatively followed for more than 1 year without any sign of recurrence of either cancer or NF.", + "summary_subclaims": [ + "The patient was a 61-year-old man.", + "The patient was affected by rectal cancer.", + "A robotic, high-anterior resection with lymph node dissection was performed.", + "According to the 8th edition of Union for International Cancer Control, the diagnosis was stage I pT2N0M0.", + "A computed tomography examination revealed a tumor in the upper right abdominal wall, at the site of the surgical port, that measured 45 mm.", + "Magnetic resonance imaging indicated a hypo-intensive mass within the right straight muscle of the abdomen.", + "Port site recurrence following the robotic surgery for rectal cancer was suspected.", + "An ultrasound-guided fine-needle aspiration was performed.", + "The fine-needle aspiration revealed a low-grade myofibroblastic tumor or benign neoplasm, but was inconclusive.", + "An excision of the lesion was performed.", + "Histopathology confirmed NF, seen as a solid, nodular, spindle-cell lesion.", + "The patient was postoperatively followed for more than 1 year without any sign of recurrence of either cancer or NF." + ] + }, + { + "id": "multiclinsum_test_1630_en.txt", + "fulltext": "An 11-year-old girl was referred to our hospital with the chief complaint of a swollen left-sided neck mass. Two days prior, hoarseness began in the morning, followed by fever and sore throat in the afternoon. On the next day, neck discomfort with tenderness occurred. On admission, she had a fever of 38.2 °C, hoarseness, and an elastic soft mass with mild tenderness on the left anterior neck . Pharyngeal redness or swollen tonsils were not observed. Laboratory data indicated mild inflammation and thyrotoxicosis; increased white blood cell of 17,500/mm3 (neutrophils, 86.6% and lymphocytes, 8.6%) and C-reactive protein level of 3.4 mg/dL; increased free T4 of 1.98 ng/dL [reference 1.02~1.52 ng/dL], decreased free T3 and thyroid-stimulating hormone (TSH) level of 2.71 pg/mL [reference 2.78~4.90 pg/mL] and 0.009 μIU/mL [reference 0.62~3.36 μIU/mL] respectively; and an elevated thyroglobulin level of 308 ng/mL [reference 0~33.7 ng/mL]. Contrast-enhanced computed tomography (CT) of the cervical region revealed an abscess partially infiltrating the thyroid gland and an air pocket near the piriform sinus . Pharyngoscopy revealed swelling of the arytenoid region, with purulent retention . From the purulent discharge, Klebsiella oxytoca was isolated. The left vocal cord was swollen but not paralyzed. No evidence of airway narrowing was identified. Suspecting PSF infection, parenteral treatment with cefotaxime at 100 mg/kg/day and dexamethasone (DEX) at 0.16 mg/kg/day was initiated . On the day after admission, the hoarseness disappeared, and the fever resolved. On the third day of admission, pharyngoscopy revealed that the swelling had disappeared . DEX was tapered off within 5 days. On the seventh day of admission, a subsequent contrast-enhanced CT of the cervical region revealed a prominent reduction in the abscess. The patient was discharged on the eighth day of admission, and the antibiotic was switched to oral cefdinir 10 mg/kg/day.\nThree weeks after discharge, a barium esophagogram revealed residual contrast in the left pyriform sinus, and PSF was diagnosed . However, abscess was not detected by ultrasonography. At that time, thyroid function returned to the normal range (FT3, 4.19 pg/ml; FT4, 1.19 ng/dl; TSH level, 2.63 μIU/mL; and thyroglobulin level, 16.4 ng/mL). Chemocauterization was proposed to the patient’s family because this was the first episode of a neck abscess. However, the family did not opt for this method, and the patient is currently under observation without recurrence for a year.", + "fulltext_subclaims": [ + "An 11-year-old girl was referred to our hospital with the chief complaint of a swollen left-sided neck mass.", + "Two days prior, hoarseness began in the morning.", + "On the next day, neck discomfort with tenderness occurred.", + "On admission, she had a fever of 38.2 °C.", + "Pharyngeal redness or swollen tonsils were not observed.", + "Laboratory data indicated increased white blood cell count of 17,500/mm3.", + "C-reactive protein level was 3.4 mg/dL.", + "Free T4 was 1.98 ng/dL.", + "Free T3 was decreased.", + "Thyroid-stimulating hormone (TSH) level was 0.009 μIU/mL.", + "Contrast-enhanced computed tomography (CT) of the cervical region revealed an abscess partially infiltrating the thyroid gland.", + "An air pocket near the piriform sinus was observed.", + "Pharyngoscopy revealed swelling of the arytenoid region.", + "Purulent retention was observed.", + "Klebsiella oxytoca was isolated from the purulent discharge.", + "The left vocal cord was swollen but not paralyzed.", + "No evidence of airway narrowing was identified.", + "Parenteral treatment with cefotaxime at 100 mg/kg/day was initiated.", + "Dexamethasone (DEX) at 0.16 mg/kg/day was initiated.", + "On the day after admission, the hoarseness disappeared.", + "On the third day of admission, pharyngoscopy revealed that the swelling had disappeared.", + "DEX was tapered off within 5 days.", + "On the seventh day of admission, contrast-enhanced CT of the cervical region revealed a prominent reduction in the abscess.", + "The patient was discharged on the eighth day of admission.", + "The antibiotic was switched to oral cefdinir 10 mg/kg/day.", + "Three weeks after discharge, a barium esophagogram revealed residual contrast in the left pyriform sinus.", + "PSF was diagnosed.", + "Abscess was not detected by ultrasonography.", + "Thyroid function returned to the normal range.", + "Chemocauterization was proposed to the patient’s family.", + "The family did not opt for this method.", + "The patient is currently under observation without recurrence for a year." + ], + "summary": "This report describes an 11-year-old girl presenting with hoarseness as the first symptom of PSF. Hoarseness occurred 2 days prior to admission. On admission, she had fever, hoarseness, and an elastic soft mass on her left anterior neck. Contrast-enhanced computed tomography of the cervical region demonstrated an abscess partially infiltrating the thyroid gland and an air pocket near the pyriform sinus. Pharyngoscopy revealed swelling of the left arytenoid region, with purulent retention. The left vocal cord was swollen but not paralyzed. Additionally, the laboratory data indicated thyrotoxicosis. Suspecting a PSF infection, parenteral treatment with cefotaxime and dexamethasone was initiated. On the following day, the hoarseness disappeared, and the fever resolved. Four weeks after onset, the thyroid hormone levels returned to the normal range, and a barium esophagogram revealed residual contrast in the left pyriform sinus, leading to a diagnosis of PSF.", + "summary_subclaims": [ + "The patient is an 11-year-old girl.", + "Hoarseness was the first symptom of PSF.", + "Hoarseness occurred 2 days prior to admission.", + "On admission, she had fever.", + "On admission, she had an elastic soft mass on her left anterior neck.", + "Contrast-enhanced computed tomography of the cervical region demonstrated an abscess partially infiltrating the thyroid gland.", + "Contrast-enhanced computed tomography showed an air pocket near the pyriform sinus.", + "Pharyngoscopy revealed swelling of the left arytenoid region.", + "Pharyngoscopy showed purulent retention.", + "The left vocal cord was swollen.", + "The left vocal cord was not paralyzed.", + "Laboratory data indicated thyrotoxicosis.", + "Parenteral treatment with cefotaxime and dexamethasone was initiated.", + "On the following day, the hoarseness disappeared.", + "On the following day, the fever resolved.", + "Four weeks after onset, the thyroid hormone levels returned to the normal range.", + "A barium esophagogram revealed residual contrast in the left pyriform sinus.", + "The diagnosis was PSF." + ] + }, + { + "id": "multiclinsum_test_750_en.txt", + "fulltext": "The patient was a 65-year-old woman (height: 1.65 m; weight: 50 kg; body mass index: 18.4 kg/m2), who presented with a 2-year history of intermittent diarrhea.\nA 2-year history of intermittent diarrhea.\nThe patient had a history of hypertension (diagnosed 2 years prior) and no history of surgery.\nFamily history: The patient had a free family history.\nObstetric history: The patient had an uneventful obstetric history (gravidity: 1, parity: 1).\nFindings from the physical examination upon admission were unremarkable.\nRoutine blood examination, serum biochemistry tests, and measurement of tumor markers and coagulation function yielded results within normal range. The level of carcinoembryonic antigen (commonly referred to as CEA) was normal (at 0.96 ng/mL) as was that of the carbohydrate antigen 19-9 (commonly referred to as CA 19-9; at 7.99 U/mL).\nA 2.5 cm ulcerative mass was found in the ascending colon near the ileocecal region by colonoscopy, and adenocarcinoma was confirmed by biopsy. Chest-abdomen-pelvis contrast-enhanced computed tomography (CT) revealed a thickened wall of the ascending colon, without obvious enlarged lymph nodes around the mass. No distant metastases were found.", + "fulltext_subclaims": [ + "The patient was a 65-year-old woman.", + "The patient's height was 1.65 m.", + "The patient's weight was 50 kg.", + "The patient's body mass index was 18.4 kg/m2.", + "The patient had a 2-year history of intermittent diarrhea.", + "The patient had a history of hypertension.", + "The patient's hypertension was diagnosed 2 years prior.", + "The patient had no history of surgery.", + "The patient had a free family history.", + "The patient had an uneventful obstetric history.", + "The patient's gravidity was 1.", + "The patient's parity was 1.", + "Findings from the physical examination upon admission were unremarkable.", + "Routine blood examination yielded results within normal range.", + "Serum biochemistry tests yielded results within normal range.", + "Measurement of tumor markers yielded results within normal range.", + "Measurement of coagulation function yielded results within normal range.", + "The level of carcinoembryonic antigen was normal.", + "The level of carcinoembryonic antigen was 0.96 ng/mL.", + "The level of carbohydrate antigen 19-9 was 7.99 U/mL.", + "A 2.5 cm ulcerative mass was found in the ascending colon near the ileocecal region by colonoscopy.", + "Adenocarcinoma was confirmed by biopsy.", + "Chest-abdomen-pelvis contrast-enhanced computed tomography revealed a thickened wall of the ascending colon.", + "No obvious enlarged lymph nodes were found around the mass.", + "No distant metastases were found." + ], + "summary": "A 65-year-old woman with a 2-year history of intermittent diarrhea was diagnosed with ascending colon adenocarcinoma by colonoscopy and biopsy. Pure vNOTES right hemicolectomy was performed with complete mesocolic excision by well-experienced surgeons. The operative time was 200 min and the estimated blood loss was 30 mL. No intraoperative or postoperative complications occurred within 30 d after the surgery. The visual analog scale pain score on postoperative day 1 was 1 and dropped to 0 on postoperative days 2 and 3. The patient was discharged at postoperative day 6. The pathologic specimen had sufficient clear resection margins and 14 negative harvested lymph nodes.", + "summary_subclaims": [ + "The patient is a 65-year-old woman.", + "The patient had a 2-year history of intermittent diarrhea.", + "The patient was diagnosed with ascending colon adenocarcinoma by colonoscopy and biopsy.", + "Pure vNOTES right hemicolectomy was performed.", + "Complete mesocolic excision was performed.", + "The surgery was performed by well-experienced surgeons.", + "The operative time was 200 min.", + "The estimated blood loss was 30 mL.", + "No intraoperative complications occurred.", + "No postoperative complications occurred within 30 d after the surgery.", + "The visual analog scale pain score on postoperative day 1 was 1.", + "The visual analog scale pain score dropped to 0 on postoperative days 2 and 3.", + "The patient was discharged at postoperative day 6.", + "The pathologic specimen had sufficient clear resection margins.", + "14 lymph nodes were harvested.", + "The harvested lymph nodes were negative." + ] + } +] \ No newline at end of file