diff --git "a/data/extracting_subclaim/subset_testset/extracted_subclaims_multiclinsum_test_en_500_1000.json" "b/data/extracting_subclaim/subset_testset/extracted_subclaims_multiclinsum_test_en_500_1000.json" new file mode 100644--- /dev/null +++ "b/data/extracting_subclaim/subset_testset/extracted_subclaims_multiclinsum_test_en_500_1000.json" @@ -0,0 +1,34197 @@ +[ + { + "id": "multiclinsum_test_3264_en.txt", + "fulltext": "24-month-old male patient with no significant perinatal history. During growth he achieved motor milestones up to crawling on his own, but at 8 months of age he began to develop floppy hypotonia of the lower limbs associated with marked weakness, with loss of the ability to crawl and subsequently required support to sit. Therefore, neurological evaluation was performed and multiplex ligation-dependent probe amplification (MLPA) was performed to detect the number of copies present or deletion of multiple genes for SMN1, SMN2 and NAIP in the samples. The result of the test showed homozygous deletion of the SMN1 gene and presence of only three copies of the SMN2 gene, as well as deletion of the NAIP gene. To evaluate the clinical response, three main outcomes were measured: motor function, respiratory function and swallowing function. For motor function, the CHOP INTEND scale and the extended Hammersmith scale (HFSME) were used. Also, measurement of respiratory function with pCO2 values, clinical symptoms and complex pulmonary function tests could not be performed due to the patient's age limitations. Swallowing function was evaluated by swallowing tests with water-soluble contrast.\n\nTherapy\nInitial treatment at the center was with nusinersen (Spinraza, Biogen, MA USA) at 18 months. Administration was intrathecal, 12 mg/5mL in four occasions, for drug impregnation every 14 days. The patient subsequently increased baseline scores in the CHOP INTEND scale by 30 points and in the HFMSE scale by 17 points.\n\nFollowing administration of intrathecal nusinersen, the patient did not experience any adverse effects related to the medication and two months after administration of this medication, the patient showed a significant increase in CHOP INTEND and HFMSE scores.\n\nIn December 2020, when the patient was 23 months old, after evaluating the progress in motor function, the possibility of having an additional improvement with the application of onasemnogene abeparvovec-xioi was agreed with the parents. They were explained the absence of evidence and the possible adverse effects. After evaluating the risk and the benefit, it was decided to administer onasemnogene abeparvovec-xioi (Zolgensma, Novartis, Switzerland), 1.1 x 1014 of viral particles per kilogram of weight, 5.5 mL/kg in infusion for 60 minutes. The application of the therapy was performed in hospital and the patient presented as adverse effects fever, thrombocytopenia and elevation of AST and ALT twice in their normal value.\n\nSubsequently, monthly assessments of motor function were performed using the CHOP INTEND and HFMSE scales and the patient progressed very favourably to being able to walk with support.\n\nFollow-up and outcomes\nThe patient is currently in the process of normalizing AST and ALT and intrathecal nusinersen is planned to be continued in the coming months; the patient continues to gain motor skills over time.\n", + "fulltext_subclaims": [ + "The patient is a 24-month-old male.", + "The patient had no significant perinatal history.", + "The patient achieved motor milestones up to crawling on his own.", + "At 8 months of age, the patient began to develop floppy hypotonia of the lower limbs.", + "The hypotonia was associated with marked weakness.", + "The patient lost the ability to crawl.", + "The patient required support to sit.", + "Neurological evaluation was performed.", + "MLPA was performed to detect copy number or deletion of multiple genes for SMN1, SMN2, and NAIP.", + "The test result showed homozygous deletion of the SMN1 gene.", + "The test result showed the presence of only three copies of the SMN2 gene.", + "The test result showed deletion of the NAIP gene.", + "Three main outcomes were measured: motor function, respiratory function, and swallowing function.", + "The CHOP INTEND scale was used to evaluate motor function.", + "The extended Hammersmith scale (HFSME) was used to evaluate motor function.", + "Measurement of respiratory function with pCO2 values could not be performed due to the patient's age limitations.", + "Clinical symptoms were used to evaluate respiratory function.", + "Complex pulmonary function tests could not be performed due to the patient's age limitations.", + "Swallowing function was evaluated by swallowing tests with water-soluble contrast.", + "Initial treatment at the center was with nusinersen.", + "Nusinersen was administered intrathecally.", + "Nusinersen was administered at 12 mg/5mL.", + "Nusinersen was administered in four occasions.", + "Nusinersen was administered every 14 days.", + "The patient increased baseline scores in the CHOP INTEND scale by 30 points.", + "The patient increased baseline scores in the HFMSE scale by 17 points.", + "Following administration of intrathecal nusinersen, the patient did not experience any adverse effects related to the medication.", + "Two months after administration of nusinersen, the patient showed a significant increase in CHOP INTEND and HFMSE scores.", + "In December 2020, when the patient was 23 months old, the possibility of additional improvement with onasemnogene abeparvovec-xioi was agreed with the parents.", + "The parents were explained the absence of evidence and the possible adverse effects.", + "Onasemnogene abeparvovec-xioi was administered at 1.1 x 10^14 viral particles per kilogram of weight.", + "Onasemnogene abeparvovec-xioi was administered in 5.5 mL/kg.", + "Onasemnogene abeparvovec-xioi was administered in infusion for 60 minutes.", + "The application of onasemnogene abeparvovec-xioi was performed in hospital.", + "The patient presented fever as an adverse effect.", + "The patient presented thrombocytopenia as an adverse effect.", + "The patient presented elevation of AST and ALT twice their normal value.", + "Monthly assessments of motor function were performed using the CHOP INTEND and HFMSE scales.", + "The patient progressed to being able to walk with support.", + "The patient is currently in the process of normalizing AST and ALT.", + "Intrathecal nusinersen is planned to be continued in the coming months.", + "The patient continues to gain motor skills over time." + ], + "summary": "24-month-old male patient diagnosed with SMA at 18 months of age who was initially treated with intrathecal nusinersen and subsequently OAX. The patient showed an increase in motor function performance when assessed on the CHOP INTEND and HFSME function scales.\n", + "summary_subclaims": [ + "The patient is a 24-month-old male.", + "The patient was diagnosed with SMA at 18 months of age.", + "The patient was initially treated with intrathecal nusinersen.", + "The patient was subsequently treated with OAX.", + "The patient showed an increase in motor function performance.", + "The increase in motor function was assessed on the CHOP INTEND function scale.", + "The increase in motor function was assessed on the HFSME function scale." + ] + }, + { + "id": "multiclinsum_test_1598_en.txt", + "fulltext": "A 76-year-old female patient was diagnosed with a left polycystic VS Koos grade D in the cerebellopontine angle in 2011 [Figure and ]. The patient suffered from severe hearing loss, which was also the presenting symptom. Because of advanced age and serious cardiovascular comorbidity, a wait and scan policy was followed.\nThe medical history of the patient included hypertension, hypercholesterolemia, thrombosis of the right carotid artery, acute myocardial infarction, total knee replacement, thoracic and lumbar fractures, diabetic retinopathy, aortic valve replacement, coronary artery bypass surgery, and postoperative arterial fibrillation. The patient used an extensive list of medications, which included anti-coagulants.\nThe VS remained stable on follow-up. In May 2016, the patient presented with a severe headache and a facial palsy House and Brackmann (HB) grade 5. Computerized tomography (CT) scan showed an ITH . The patient was then hospitalized in a peripheral hospital. The anti-coagulant therapy was stopped accordingly. After a couple of days, the facial palsy improved to a HB grade 3 and the patient was discharged. However, 1 week later, the partial facial palsy progressed to a HB grade 6. The CT scan revealed a second hemorrhage in the tumor . The patient was then referred to the Maastricht University Medical Centre for treatment. Neurological examination upon arrival revealed an optimal EMV score with a facial palsy HB grade 6. Other cranial nerves were intact. A few days later, the patient deteriorated to a score of E3M6V3. The CT scan showed another bleeding resulting in a strong mass effect on the brainstem . In addition, there was a bilateral dilation of the lateral ventricles and the third ventricle consistent with hydrocephalus. An emergency retrosigmoid approach was employed to evacuate the hematoma and resect the VS as much as possible. In addition to these measures, an occipital external ventricular drainage was applied. During surgery, the tumor appeared very necrotic. One day following surgery, the patient recovered to an optimal EMV score. Approximately 36 hours after surgery, the patient deteriorated rapidly. A CT scan showed another hemorrhage in the same area, however, more directed toward the brainstem . Unfortunately, the condition of the patient worsened quickly and the patient deceased.\nHistopathological examination confirmed the diagnosis of VS. Furthermore, it showed an extensive hemorrhage with small focal fragments of fusiform proliferation and thick-walled dilated blood vessels. Immunological examination showed a positive S100 and a low mitotic activity (MIB1) in tumor areas. Glial fibrillary acidic protein (GFAP) staining was negative. The tumor area showed inflammation and contained eosinophil cytoplasm with elongated nuclei.", + "fulltext_subclaims": [ + "A 76-year-old female patient was diagnosed with a left polycystic VS Koos grade D in the cerebellopontine angle in 2011.", + "The patient suffered from severe hearing loss, which was also the presenting symptom.", + "Because of advanced age and serious cardiovascular comorbidity, a wait and scan policy was followed.", + "The medical history of the patient included hypertension, hypercholesterolemia, thrombosis of the right carotid artery, acute myocardial infarction, total knee replacement, thoracic and lumbar fractures, diabetic retinopathy, aortic valve replacement, coronary artery bypass surgery, and postoperative arterial fibrillation.", + "The patient used an extensive list of medications, which included anti-coagulants.", + "The VS remained stable on follow-up.", + "In May 2016, the patient presented with a severe headache and a facial palsy House and Brackmann (HB) grade 5.", + "Computerized tomography (CT) scan showed an ITH.", + "The patient was hospitalized in a peripheral hospital.", + "The anti-coagulant therapy was stopped accordingly.", + "After a couple of days, the facial palsy improved to a HB grade 3 and the patient was discharged.", + "However, 1 week later, the partial facial palsy progressed to a HB grade 6.", + "The CT scan revealed a second hemorrhage in the tumor.", + "The patient was then referred to the Maastricht University Medical Centre for treatment.", + "Neurological examination upon arrival revealed an optimal EMV score with a facial palsy HB grade 6.", + "Other cranial nerves were intact.", + "A few days later, the patient deteriorated to a score of E3M6V3.", + "The CT scan showed another bleeding resulting in a strong mass effect on the brainstem.", + "There was a bilateral dilation of the lateral ventricles and the third ventricle consistent with hydrocephalus.", + "An emergency retrosigmoid approach was employed to evacuate the hematoma and resect the VS as much as possible.", + "An occipital external ventricular drainage was applied.", + "During surgery, the tumor appeared very necrotic.", + "One day following surgery, the patient recovered to an optimal EMV score.", + "Approximately 36 hours after surgery, the patient deteriorated rapidly.", + "A CT scan showed another hemorrhage in the same area, however, more directed toward the brainstem.", + "The condition of the patient worsened quickly and the patient deceased.", + "Histopathological examination confirmed the diagnosis of VS.", + "It showed an extensive hemorrhage with small focal fragments of fusiform proliferation and thick-walled dilated blood vessels.", + "Immunological examination showed a positive S100 and a low mitotic activity (MIB1) in tumor areas.", + "Glial fibrillary acidic protein (GFAP) staining was negative.", + "The tumor area showed inflammation and contained eosinophil cytoplasm with elongated nuclei." + ], + "summary": "A 76-year-old woman presented with hearing loss due to polycystic VS on the left side. Five years later, the patient was presented with facial palsy caused by hemorrhage in the VS. The patient had an eventful medical history that necessitated the use of anti-coagulants. The patient suffered from three subsequent hemorrhages preoperatively and one hemorrhage 36 h postoperatively.", + "summary_subclaims": [ + "The patient is a 76-year-old woman.", + "The patient had hearing loss due to polycystic VS on the left side.", + "Five years later, the patient was presented with facial palsy caused by hemorrhage in the VS.", + "The patient had an eventful medical history that necessitated the use of anti-coagulants.", + "The patient suffered from three subsequent hemorrhages preoperatively.", + "The patient had one hemorrhage 36 h postoperatively." + ] + }, + { + "id": "multiclinsum_test_3314_en.txt", + "fulltext": "A 60-year-old female sheep herder from Eritrea presented to St. Paul’s Hospital Millennium Medical College ophthalmology department with a 3-month history of painless left eye protrusion associated with progressive decreased vision of the left eye. Otherwise, she had an unremarkable history. Visual acuity in the right eye was 6/18 and counting finger in front of the eye on the left eye. Physical examination revealed a 4 mm discrepancy on exophthalmometry between the two eyes with a proptosis of 21 mm on the left eye. On fundus examination, there was a tortuous temporal arcade and grade 4 papilledema in the left eye. Otherwise, there was an unremarkable finding. Laboratory investigation revealed a normal complete blood count. Computerized tomography (CT) of the brain and orbit showed a well-defined thin-walled non-enhancing fluid density cystic mass in the left orbital cavity measuring 2.6 cm by 2.0 cm by 1.9 cm with compression and lateral displacement of the globe as well as compression and stretching of the optic nerve. The left medial rectus muscle was not clearly and separately visualized from the lesion. There were no osseous lytic or sclerotic changes of the bony orbit. The CT scan was suggestive of a hydatid cyst of the orbit. Abdominal ultrasound and chest X-ray findings were unremarkable.\n\nThe patient was given albendazole 400mg orally twice per day for 2 weeks and re-evaluated. Subsequently, she was taken to the operating room with an impression of a left medial mass secondary to Hydatid cyst. The cyst was approached through a medial anterior orbitotomy. Intraoperatively, a cystic mass attached to the inferior aspect of the medial rectus (MR) was identified. The cyst ruptured during manipulation and a clear fluid came out. A paper white cyst lining was removed in piecemeal and the external capsule was excised with care not to severely damage the MR muscle. Then, the surgical field was irrigated with 3% hydrogen peroxide solution followed by copious normal saline solution, and the tissue was sent for histopathological examination. Biopsy result revealed an acellular laminated membrane with germinal epithelium and a daughter cyst with protoscolices and surrounding soft tissue consisting of chronic inflammatory cells confirming the diagnosis of hydatid cyst. Cytology from cyst fluid showed a hemorrhagic background with no cells.\n\nOn her first postoperative day, she had lid edema with limited adduction of the left eye and mild ocular pain. Oral albendazole 400mg twice daily was continued postoperatively. Follow-up on her 7th post-operative day showed that there was mild improvement in the adduction deficit and lid swelling had resolved. Subsequent follow-up on her 21st postoperative day showed left eye visual acuity of counting fingers at two meters and the adduction deficit improved to −2. Furthermore, the optic disc edema also resolved to grade 1. However, the patient moved back to Eritrea, and we were not able to follow the subsequent progress of the patient beyond the first 3 weeks.", + "fulltext_subclaims": [ + "The patient was a 60-year-old female sheep herder from Eritrea.", + "She presented with a 3-month history of painless left eye protrusion.", + "She had progressive decreased vision of the left eye.", + "Visual acuity in the right eye was 6/18.", + "Visual acuity in the left eye was counting fingers in front of the eye.", + "Physical examination revealed a 4 mm discrepancy on exophthalmometry between the two eyes.", + "The left eye had a proptosis of 21 mm.", + "Fundus examination showed a tortuous temporal arcade in the left eye.", + "Fundus examination showed grade 4 papilledema in the left eye.", + "Computerized tomography showed a well-defined thin-walled non-enhancing fluid density cystic mass in the left orbital cavity.", + "The cyst measured 2.6 cm by 2.0 cm by 1.9 cm.", + "The CT scan was suggestive of a hydatid cyst of the orbit.", + "The patient was given albendazole 400mg orally twice per day for 2 weeks.", + "The patient was taken to the operating room with an impression of a left medial mass secondary to Hydatid cyst.", + "The cyst was approached through a medial anterior orbitotomy.", + "Intraoperatively, a cystic mass attached to the inferior aspect of the medial rectus was identified.", + "The cyst ruptured during manipulation and clear fluid came out.", + "A paper white cyst lining was removed in piecemeal.", + "The external capsule was excised with care not to severely damage the MR muscle.", + "The surgical field was irrigated with 3% hydrogen peroxide solution.", + "The surgical field was irrigated with copious normal saline solution.", + "Biopsy result revealed an acellular laminated membrane with germinal epithelium.", + "Biopsy result revealed a daughter cyst with protoscolices.", + "Biopsy result showed surrounding soft tissue consisting of chronic inflammatory cells.", + "Cytology from cyst fluid showed a hemorrhagic background with no cells.", + "On the first postoperative day, she had lid edema with limited adduction of the left eye.", + "On the first postoperative day, she had mild ocular pain.", + "Oral albendazole 400mg twice daily was continued postoperatively.", + "Follow-up on the 7th post-operative day showed mild improvement in the adduction deficit.", + "Follow-up on the 7th post-operative day showed lid swelling had resolved.", + "Follow-up on the 21st postoperative day showed left eye visual acuity of counting fingers at two meters.", + "Follow-up on the 21st postoperative day showed the adduction deficit improved to −2.", + "Follow-up on the 21st postoperative day showed optic disc edema resolved to grade 1.", + "The patient moved back to Eritrea.", + "We were not able to follow the subsequent progress of the patient beyond the first 3 weeks." + ], + "summary": "A 60-year-old female Eritrean woman presented with 3-month history of painless protrusion of the left eye. Physical examination showed significantly decreased visual acuity of the left eye, left eye proptosis, and papilledema. Laboratory investigations were normal and orbital CT scan examination was suggestive of orbital hydatid cyst. After giving two weeks course of oral Albendazole, anterior orbitotomy and cyst excision was done. Post-op biopsy was conclusive of orbital hydatid cyst. She had mild lid swelling and adduction deficit on her post-operative follow-up. Subsequent longer duration of follow-up of the patient was not possible since the patient relocated back to Eritrea.", + "summary_subclaims": [ + "The patient is a 60-year-old female Eritrean woman.", + "She had a 3-month history of painless protrusion of the left eye.", + "Physical examination showed significantly decreased visual acuity of the left eye.", + "Physical examination showed left eye proptosis.", + "Physical examination showed papilledema.", + "Laboratory investigations were normal.", + "Orbital CT scan examination was suggestive of orbital hydatid cyst.", + "She received a two weeks course of oral Albendazole.", + "Anterior orbitotomy and cyst excision was done.", + "Post-op biopsy was conclusive of orbital hydatid cyst.", + "She had mild lid swelling on her post-operative follow-up.", + "She had adduction deficit on her post-operative follow-up.", + "Subsequent longer duration of follow-up of the patient was not possible since the patient relocated back to Eritrea." + ] + }, + { + "id": "multiclinsum_test_2315_en.txt", + "fulltext": "A 29-year-old woman with systemic lupus erythematosus (SLE) diagnosed at age 12 years with severe idiopathic thrombocytopaenic purpura (ITP), presented acutely while visiting her baby in the Neonatal Intensive Care Unit with sudden onset chest pain and shortness of breath. Her SLE was complicated by spontaneous deep vein thrombosis, triple positive antiphospholipid syndrome (APLS), and Class IV lupus nephritis. This triggered an emergency call to the neonatal ward, with examination notable for tachycardia, but normotensive and normal oxygen saturation initially. Her chest was clear with dual heart sounds and no oedema. Her medications at presentation were enoxaparin 100 mg and aspirin 100 mg daily, transition to warfarin was planned at 2 weeks’ postpartum. Her immunosuppression regime was hydroxychloroquine 400 mg daily, azathioprine 150 mg daily, and prednisone 5 mg daily, other medications included calcitriol 0.25 μg daily and calcium carbonate 1.25 g daily.\nElectrocardiogram (ECG) showed sinus tachycardia with no ischaemic changes. Initial blood results shown in . Chest X-ray showed cardiomegaly with increased interstitial markings . She deteriorated rapidly over the next hour with climbing oxygen requirements and hypotension and was investigated for pulmonary embolism (PE) and treated with morphine and enoxaparin. She was escorted to radiology from the neonatal ward for the CT pulmonary angiography (CTPA) which showed pulmonary oedema and no PE and was admitted to cardiovascular intensive care (CVICU). On arrival, she was intubated for respiratory distress and, as no transthoracic echocardiogram had been performed, she had a transoesophageal echocardiogram. This demonstrated the posterolateral papillary muscle rupture and flail anterior leaflet with torrential MR and preserved left ventricular (LV) function (see ).\nShe proceeded to emergency mitral valve (MV) replacement, on transfer to the operating table she had a pulseless electrical activity (PEA) arrest, resuscitated with adrenaline and CPR before return of circulation and the start of operative intervention. The posterolateral papillary muscle was pale and sheared directly off the ventricular wall. The MV was replaced by a 29-mm St Jude’s Mechanical valve. At the end of the procedure, VA ECMO was instituted due to persistent severe pulmonary oedema and biventricular failure despite maximal ionotropic support.\nThe histology of the valve revealed preserved architecture with scattered fibrinous deposits and a focal larger fibrinous vegetation with occasional inflammatory cells, with no organisms, consistent with chronic Libman -Sacks endocarditis . The papillary muscle showed extensive central necrosis with a surrounding rim of acute inflammation consistent with infarction several days old, thrombi were seen within the intramyocardial arteries . The endocardial surface had mixed inflammatory infiltrates and focally fibrinous material with granuloma-like appearance, in keeping with Libman–Sacks.\nECMO was required for 2 days, on decannulation and desedation, she had some abnormal movements so magnetic resonance imaging (MRI) brain was performed which showed widespread hypoxic injury. She had paroxysmal atrial fibrillation and mild LV impairment so was commenced on metoprolol CR 166.25mg and cilazapril 1 mg daily and transitioned from heparin back to warfarin and aspirin 100 mg daily. She underwent inpatient rehabilitation after 4 weeks in CVICU before discharge. At this point, her neurological function was normal.\nShe continued the same immunosuppression regime from admission on discharge as well as the medications mentioned above. She was planned to continue both aspirin and warfarin given the recurrent thrombosis previously.", + "fulltext_subclaims": [ + "The patient is a 29-year-old woman.", + "She has systemic lupus erythematosus (SLE) diagnosed at age 12 years.", + "She has severe idiopathic thrombocytopaenic purpura (ITP).", + "She presented with sudden onset chest pain and shortness of breath.", + "Her SLE was complicated by spontaneous deep vein thrombosis.", + "She has triple positive antiphospholipid syndrome (APLS).", + "She has Class IV lupus nephritis.", + "She was on enoxaparin 100 mg daily.", + "She was on aspirin 100 mg daily.", + "She was on hydroxychloroquine 400 mg daily.", + "She was on azathioprine 150 mg daily.", + "She was on prednisone 5 mg daily.", + "The ECG showed sinus tachycardia with no ischaemic changes.", + "The chest X-ray showed cardiomegaly with increased interstitial markings.", + "She deteriorated rapidly over the next hour.", + "She was investigated for pulmonary embolism (PE).", + "She was treated with morphine and enoxaparin.", + "The CT pulmonary angiography (CTPA) showed pulmonary oedema and no PE.", + "She was admitted to cardiovascular intensive care (CVICU).", + "She was intubated for respiratory distress.", + "A transoesophageal echocardiogram demonstrated the posterolateral papillary muscle rupture and flail anterior leaflet.", + "The echocardiogram showed torrential MR and preserved left ventricular (LV) function.", + "She proceeded to emergency mitral valve (MV) replacement.", + "On transfer to the operating table, she had a pulseless electrical activity (PEA) arrest.", + "She was resuscitated with adrenaline and CPR.", + "The posterolateral papillary muscle was pale and sheared directly off the ventricular wall.", + "The MV was replaced by a 29-mm St Jude’s Mechanical valve.", + "VA ECMO was instituted due to persistent severe pulmonary oedema.", + "The histology of the valve revealed preserved architecture with scattered fibrinous deposits.", + "The histology showed a focal larger fibrinous vegetation with occasional inflammatory cells.", + "The histology showed no organisms.", + "The histology was consistent with chronic Libman–Sacks endocarditis.", + "The papillary muscle showed extensive central necrosis with a surrounding rim of acute inflammation.", + "The papillary muscle showed thrombi within the intramyocardial arteries.", + "The endocardial surface had mixed inflammatory infiltrates.", + "The endocardial surface had focally fibrinous material with granuloma-like appearance.", + "The endocardial surface was in keeping with Libman–Sacks.", + "ECMO was required for 2 days.", + "She had some abnormal movements after decannulation and desedation.", + "Magnetic resonance imaging (MRI) brain showed widespread hypoxic injury.", + "She had paroxysmal atrial fibrillation.", + "She had mild LV impairment.", + "She was commenced on metoprolol CR 166.25mg daily.", + "She was commenced on cilazapril 1 mg daily.", + "She was transitioned back to warfarin.", + "She was on aspirin 100 mg daily.", + "She underwent inpatient rehabilitation after 4 weeks in CVICU.", + "At discharge, her neurological function was normal.", + "She continued the same immunosuppression regime on discharge.", + "She was planned to continue both aspirin and warfarin." + ], + "summary": "A 29-year-old woman presented with acute heart failure 2 weeks' postpartum and was found to have acute MR due to a flail leaflet caused by papillary muscle rupture. She proceeded to emergency surgery with mitral valve (MV) replacement and the histology revealed evidence of chronic Libman-Sacks endocarditis and papillary muscle infarction with thrombi in the intramyocardial arteries.", + "summary_subclaims": [ + "The patient is a 29-year-old woman.", + "She presented with acute heart failure 2 weeks' postpartum.", + "She was found to have acute MR due to a flail leaflet.", + "The flail leaflet was caused by papillary muscle rupture.", + "She proceeded to emergency surgery with mitral valve replacement.", + "The histology revealed evidence of chronic Libman-Sacks endocarditis.", + "The histology showed papillary muscle infarction.", + "Thrombi were found in the intramyocardial arteries." + ] + }, + { + "id": "multiclinsum_test_3094_en.txt", + "fulltext": "Our patient was a girl who was 40 weeks in utero and born through natural vaginal delivery as the first child of a Japanese couple. Her birth weight, height, and head circumference were 3244 g (+0.67 standard deviation [SD]), 46.8 cm (−0.77 SD), and normal, respectively. Neonatal asphyxia was not observed at birth. Her family history lacked evidence regarding consanguineous marriage, epilepsy, or neuromuscular disease. At 15 days old, she presented with bilateral tonic–clonic seizures that lasted for a few minutes, which started in the left or right upper extremity. The seizure frequency increased to approximately 10 per day; the patient was admitted to the hospital by her previous doctor. Interictal electroencephalography (EEG) revealed multifocal spontaneous spikes. The EEG showed isolated spike waves in the right frontal, central, and occipital regions that did not spread widely. It was not a suppression-burst or hypsarrhythmia pattern. General blood tests, plasma amino acid analysis, general spinal fluid tests, spinal fluid virus isolation, and urinary organic acid analysis revealed no abnormalities. Brain magnetic resonance imaging (MRI) revealed no obvious epilepsy-inducing structural abnormalities. She was started on phenobarbital for neonatal-onset epilepsy of unknown classification; however, she showed no improvement. She was referred to our hospital at the age of 75 days.\n\nPhysical examination and general neurological findings revealed no obvious facial abnormalities or deformities. Eye-tracking and smiling when someone touched or held her were appropriate for infant age. Interictal EEG revealed normal sleep waves; however, there were frequent localized spike waves and spike–slow wave complexes. A tentative diagnosis of symptomatic localization-related epilepsy was made, and treatment was initiated. She continued to experience seizures approximately 10 times a day; therefore, phenobarbital was discontinued and carbamazepine was started at 78 days old. However, it was discontinued after a few days due to an increase in seizure frequency. Oral sodium valproate and zonisamide were initiated at 81 and 88 days old, respectively. Vitamin B6 was administered; however, it was discontinued after having no effect. After starting sodium valproate and zonisamide, there was a gradual decrease in the seizure frequency; however, even at the maximum dose, seizures were still observed 3–4 times a day. Initially, the seizures were generalized tonic convulsions starting from the left upper extremity. However, around the age of 88 days, she displayed a series of nodding spasms. After adjustment of medications, oral intake was decreased, and tube feeding was initiated. At 108 days old, the patient underwent examination for primary disease according to the Department of Child Neurology, National Center of Neurology and Psychiatry. Long-term EEG monitoring revealed frequent irregular high-amplitude spikes and slow waves without left-right synchrony during sleep and wakefulness, which indicated a hypsarrhythmia. Ictal EEG revealed a fast-wave rhythm and positive slow waves preceding the spasm. Eye tracking and chuckling during the early disease stage were no longer observed. Further, she was considered to be developmentally regressing and was diagnosed with West syndrome. Brain MRI revealed no structural abnormalities presenting as obvious epileptic foci, including focal cortical dysplasia. The patient was started on adrenocorticotropic hormone (ACTH) therapy at 114 days old, which was administered daily for two weeks.\n\nThe seizures disappeared the day after starting ACTH therapy. Recurrent spasms were observed 8 days after initiating ACTH therapy. Subsequently, sodium valproate and zonisamide were continued; however, there was no change in seizure frequency. Nitrazepam was started at the age of 4 months, which decreased the seizure frequency to 1–2 per day. EEG revealed multifocal spikes; however, the typical hypsarrhythmia disappeared and there was improved background activity. Cerebral cortical atrophy occurred as a side effect of ACTH therapy. Development remained regressive, without evidence of head control, eye tracking, or chuckling. Due to aspiration pneumonia, nutrition was maintained by tube feeding. The patient was discharged from the hospital at 6 months old. After 7 months old, the patient lacked obvious clinical seizures. At 10 months old, genetic testing for West syndrome was performed. Subsequently, she was hospitalized for a urinary tract infection and pneumonia at 10 months and 1.3 years old, respectively.\n\nAt approximately 1.2 years old, she began experiencing a series of seizures involving the twitching of her right leg during sleep for 2–3 min at a time. Ictal EEG revealed series-forming myoclonus seizures. Interictal EEG showed multifocal spikes and slow waves at sleep onset without hypsarrhythmia. Moreover, background activity during wakefulness revealed continuous slow waves. Brain MRI showed diffuse cerebral atrophy and corpus callosum thinning; however, there were no obvious abnormal structures. Despite the observation of a new seizure type, three antiepileptic drugs were administered at extreme doses and no indication for active surgery was indicated.\n\nAt 1.5 years old, she underwent further genetic testing. Target capture sequencing was performed to screen 114 epilepsy-related genes in the proband of the Department of Pediatrics at Fukuoka. We identified a missense variant (RefSeq accession number NM_003165: c.875G > A [p.Arg292His] available at https://www.ncbi.nlm.nih.gov/refseq/ (accessed on 27 July 2022)) in the STXBP1 gene. Sanger sequencing confirmed the variant in the proband. A search for this variant in her parents through Sanger sequencing revealed that the variant was de novo. Finally, she was diagnosed with developmental and epileptic encephalopathies exhibiting clinical characteristics of West syndrome due to STXBP1 gene mutation (c.875G > A [p.Arg292His], previously reported in ClinVar [rs796053361] as a pathogenic variant). Other unidentified variants in addition to STXBP1-p.Arg292His may have contributed to her clinical phenotype; since she did not undergo whole genome or whole exome sequencing, we continue to investigate this possibility.\n\nThe patient is currently 2.1 years old. Although the frequency of epileptic seizures has decreased, her development remains regressive, and she has a severe intellectual disability. At the time of writing, apart from the neurological phenotype, the patient had no other symptoms, such as metabolic disease, primary immunodeficiency, or hyperinflammatory condition. She continues to receive medical treatment. Should the seizures worsen in the future, we will review the choice of drug according to the seizure type and consider palliative epilepsy surgical treatment to reduce seizure frequency.", + "fulltext_subclaims": [ + "The patient was a girl who was 40 weeks in utero and born through natural vaginal delivery.", + "She was the first child of a Japanese couple.", + "Her birth weight was 3244 g (+0.67 standard deviation).", + "Her birth height was 46.8 cm (−0.77 standard deviation).", + "Neonatal asphyxia was not observed at birth.", + "Her family history lacked evidence of consanguineous marriage.", + "At 15 days old, she presented with bilateral tonic–clonic seizures that lasted for a few minutes.", + "The seizure frequency increased to approximately 10 per day.", + "Interictal electroencephalography (EEG) revealed multifocal spontaneous spikes.", + "The EEG showed isolated spike waves in the right frontal, central, and occipital regions.", + "It was not a suppression-burst or hypsarrhythmia pattern.", + "General blood tests revealed no abnormalities.", + "Brain magnetic resonance imaging (MRI) revealed no obvious epilepsy-inducing structural abnormalities.", + "She was started on phenobarbital for neonatal-onset epilepsy of unknown classification.", + "She showed no improvement with phenobarbital.", + "She was referred to our hospital at the age of 75 days.", + "Interictal EEG revealed normal sleep waves.", + "There were frequent localized spike waves and spike–slow wave complexes.", + "A tentative diagnosis of symptomatic localization-related epilepsy was made.", + "She continued to experience seizures approximately 10 times a day.", + "Phenobarbital was discontinued and carbamazepine was started at 78 days old.", + "Carbamazepine was discontinued after a few days due to an increase in seizure frequency.", + "Oral sodium valproate was initiated at 81 days old.", + "Oral zonisamide was initiated at 88 days old.", + "Vitamin B6 was administered.", + "Vitamin B6 was discontinued after having no effect.", + "After starting sodium valproate and zonisamide, there was a gradual decrease in the seizure frequency.", + "Even at the maximum dose, seizures were still observed 3–4 times a day.", + "Initially, the seizures were generalized tonic convulsions starting from the left upper extremity.", + "Around the age of 88 days, she displayed a series of nodding spasms.", + "Long-term EEG monitoring revealed frequent irregular high-amplitude spikes and slow waves without left-right synchrony.", + "This indicated a hypsarrhythmia.", + "She was diagnosed with West syndrome.", + "Brain MRI revealed no structural abnormalities presenting as obvious epileptic foci.", + "The patient was started on adrenocorticotropic hormone (ACTH) therapy at 114 days old.", + "The seizures disappeared the day after starting ACTH therapy.", + "Recurrent spasms were observed 8 days after initiating ACTH therapy.", + "Nitrazepam was started at the age of 4 months.", + "Nitrazepam decreased the seizure frequency to 1–2 per day.", + "EEG revealed multifocal spikes.", + "The typical hypsarrhythmia disappeared.", + "Cerebral cortical atrophy occurred as a side effect of ACTH therapy.", + "Development remained regressive.", + "Nutrition was maintained by tube feeding due to aspiration pneumonia.", + "The patient was discharged from the hospital at 6 months old.", + "At 10 months old, genetic testing for West syndrome was performed.", + "She was hospitalized for a urinary tract infection at 10 months old.", + "She was hospitalized for pneumonia at 1.3 years old.", + "At approximately 1.2 years old, she began experiencing a series of seizures involving the twitching of her right leg during sleep.", + "Ictal EEG revealed series-forming myoclonus seizures.", + "Interictal EEG showed multifocal spikes and slow waves at sleep onset without hypsarrhythmia.", + "Brain MRI showed diffuse cerebral atrophy and corpus callosum thinning.", + "She underwent further genetic testing at 1.5 years old.", + "Target capture sequencing was performed to screen 114 epilepsy-related genes.", + "A missense variant (c.875G > A [p.Arg292His]) in the STXBP1 gene was identified.", + "Sanger sequencing confirmed the variant in the proband.", + "The variant was de novo.", + "She was diagnosed with developmental and epileptic encephalopathies exhibiting clinical characteristics of West syndrome due to STXBP1 gene mutation.", + "The variant was previously reported in ClinVar as a pathogenic variant.", + "Other unidentified variants may have contributed to her clinical phenotype.", + "She did not undergo whole genome or whole exome sequencing.", + "The patient is currently 2.1 years old.", + "Her development remains regressive.", + "She has a severe intellectual disability.", + "She continues to receive medical treatment.", + "Should the seizures worsen in the future, palliative epilepsy surgical treatment may be considered." + ], + "summary": "erein, we present the case of a Japanese girl with a mutation in the STXBP1 gene, who was born at 40 weeks without neonatal asphyxia. At 15 days old, she developed epilepsy and generalized seizures. Around 88 days old, she presented with a series of nodding spasms, with the seizure frequency gradually increasing. Interictal EEG indicated hypsarrhythmia and she presented with developmental regression. At 1.5 years old, genetic testing was performed and mutational analysis revealed an STXBP1 gene mutation (c.875G > A: p.Arg292His). Accordingly, she was diagnosed with developmental and epileptic encephalopathy, presenting West syndrome’s clinical characteristics caused by the STXBP1 gene mutation. Although drug treatment has reduced the frequency of epileptic seizures, her development has remained regressive.", + "summary_subclaims": [ + "The patient is a Japanese girl.", + "She has a mutation in the STXBP1 gene.", + "She was born at 40 weeks.", + "She was born without neonatal asphyxia.", + "At 15 days old, she developed epilepsy.", + "At 15 days old, she had generalized seizures.", + "Around 88 days old, she presented with a series of nodding spasms.", + "The seizure frequency gradually increased.", + "Interictal EEG indicated hypsarrhythmia.", + "She presented with developmental regression.", + "At 1.5 years old, genetic testing was performed.", + "Mutational analysis revealed an STXBP1 gene mutation (c.875G > A: p.Arg292His).", + "She was diagnosed with developmental and epileptic encephalopathy.", + "She presented West syndrome’s clinical characteristics.", + "The West syndrome was caused by the STXBP1 gene mutation.", + "Drug treatment has reduced the frequency of epileptic seizures.", + "Her development has remained regressive." + ] + }, + { + "id": "multiclinsum_test_2090_en.txt", + "fulltext": "The patient was a 67-year-old man with no significant medical history. He presented to the Nanjing Brain Hospital for the first time on July 4, 2016 with new onset frequent attacks of left limb convulsions without loss of consciousness nor incontinence for 6 days. The brain MRI from another hospital on June 30, 2016 showed abnormal signals in the left cingulate gyrus. During the hospitalization, the patient presented with frequent attacks (ten or more ictal attacks a day) of the left limb convulsions. Duration of attacks ranged from dozens of seconds to several minutes. There was no abnormality during the interval of the seizures. In the interictal period, the patient had no fever or headache, no mental or behavioral abnormalities, no dysphagia, no weakness of limbs, or other complications of nervous system.\nRoutine laboratory studies including blood and urine routine tests, coagulation tests, liver and renal function, blood sugar, glycosylated hemoglobin, antinuclear antibody, erythrocyte sedimentation rate, anti-cardiolipin antibodies, phospholipase A2, thyroid function, HIV and syphilis, were all unremarkable. Anti-glutamic acid decarboxylase (GAD) antibody was negative. Serum carbohydrate antigen 72–4 was 17.56 IU / ml (normal < 6.00 IU / ml), more than normal. Lumbar puncture revealed the CSF pressure of 100 mmH2O. Examination of the CSF showed white blood cells of 4/μl, protein levels of 0.45 g/L (normal 0.2 ~ 0.4 g / L). The concentrations of glucose and chlorine in the CSF were normal. Anti-NMDAR antibodies were detected in CSF and serum using a commercial kit (Euroimmune, Germany) by indirect immunofluorescence testing (IIFT) according to the manufacturer’s instructions for twice. Anti-NMDAR titers were 1:10(++) in CSF and 1:32(++) in serum. Anti-AMPA1, AMPA2, LG1, ASPR2 and GABAB receptor antibodies in CSF and serum were negative. Tests for paraneoplastic antibodies (Hu, Yo, Ri, Ma2, CV2, Amphiphysin, ANNA-3, Tr, PCA-2, GAD) in CSF were all negative. Chest CT did not reveal any lesions concerning for malignancy. Video-EEG showed slight abnormality (all visible more low amplitude fast wave guide, especially the front head). Brain MRI scan and enhanced scan showed long T1 and long T2 abnormal signal on the bilateral frontal parietal, proximal midline, diffusion weighted imaging (DWI): high signal intensity, patchy eccentric mild enhancement . MRS showed N-acetyl aspartate (NAA) peak decreased and no increase in choline compounds (Cho) peak. Therefore, lesions were considered the possibility of non-neoplastic lesions.\nWith a presumed diagnosis of anti-NMDAR encephalitis, the patient was treated with intravenous dexamethasone 10 mg/d × 11d → methylprednisolone 200 mg/d × 3d → methylprednisolone 80 mg/d × 3d → gamma globulin (20 g/d × 5d), oral prednisolone acetate tablets (40 mg qd) and antiepileptic (oxcarbazepine 300 mg bid). The epileptic seizures were slightly alleviated after treatment. The main manifestation was the twitching with spasms of the left upper and lower extremities, each lasting several seconds to more than ten seconds, attacking several times a day, without alteration of consciousness. Then the patient was discharged home.\nTwo months later, the patient presented to the hospital for a second time. He had suffered from frequent attacks of the left limb. Physical examination showed no abnormalities in the nervous system. Results from routine biochemical and cytological examination of the cerebrospinal fluid were normal. Anti-NMDAR titers were 1:32(+++) in CSF and 1:32(++) in serum. The brain MRI showed bilateral frontal parietal lesions enlarged slightly and the enhancement became more obvious than before . The patient was treated for a second time with intravenous injection of methylprednisolone (80 mg/d × 15d) → oral prednisolone acetate tablets (40 mg qd), immunoglobulins (25 g/d × 5d), oral azathioprine (50 mg qd), oral antiepileptic (oxcarbazepine 600 mg bid, Debakin 250 mg qm, 500 mg qn) treatment. The epileptic seizures were slightly alleviated after the treatment, 2~3 times a day, the twitching with spasms of the left limb typically lasts a few seconds, without loss of consciousness. Then the patient was discharged home.\nFour months later, the patient presented at the hospital for a third time. He complained of weakness after frequent partial seizures in his right limb. Muscle Strength Grading Scale of the right lower extremity was 4/5 and physical examination of the remaining nervous system showed no significant abnormalities. The diagnosis was simple partial status epilepticus and Todd’s Paralysis. Epilepsy was controlled on diazepam injection therapy and the muscle strength of the right lower extremity returned to normal. The brain MRI reexamination indicated that the frontal parietal lesions enlarged and one new lesion appeared in the left basal ganglia with some mild mass effect, significantly enhanced . Diffusion tensor imaging (DTI) showed partial ablation of white matter fibro tracts in the bilateral frontal parietal lobe and the left basal ganglia lesion, reduction of FA and the surrounding fibro tracts slightly compressed . Arterial spin labeling (ASL) MR imaging showed that bilateral frontoparietal and left basal ganglia lesions had abnormally high perfusion . Surgical biopsy of the right parietal lesion was performed under general anesthesia on November 21, 2016. The lesions were pale red, slightly tough, abundant blood supply and without clear border. The size of the removed lesion was about 1.5 × 1.5 × 1.0 cm. The astrocytoma (WHO II-III) was confirmed on histopathologic findings. Patients transferred to the oncology department for further radiotherapy and chemotherapy. One month later, the patient died.", + "fulltext_subclaims": [ + "The patient was a 67-year-old man with no significant medical history.", + "He presented to the Nanjing Brain Hospital for the first time on July 4, 2016.", + "He had new onset frequent attacks of left limb convulsions without loss of consciousness nor incontinence for 6 days.", + "The brain MRI from another hospital on June 30, 2016 showed abnormal signals in the left cingulate gyrus.", + "During the hospitalization, the patient presented with frequent attacks (ten or more ictal attacks a day) of the left limb convulsions.", + "Duration of attacks ranged from dozens of seconds to several minutes.", + "There was no abnormality during the interval of the seizures.", + "In the interictal period, the patient had no fever or headache.", + "In the interictal period, the patient had no mental or behavioral abnormalities.", + "In the interictal period, the patient had no dysphagia.", + "In the interictal period, the patient had no weakness of limbs.", + "In the interictal period, the patient had no other complications of nervous system.", + "Routine laboratory studies including blood and urine routine tests, coagulation tests, liver and renal function, blood sugar, glycosylated hemoglobin, antinuclear antibody, erythrocyte sedimentation rate, anti-cardiolipin antibodies, phospholipase A2, thyroid function, HIV and syphilis, were all unremarkable.", + "Anti-glutamic acid decarboxylase (GAD) antibody was negative.", + "Serum carbohydrate antigen 72–4 was 17.56 IU / ml (normal < 6.00 IU / ml), more than normal.", + "Lumbar puncture revealed the CSF pressure of 100 mmH2O.", + "Examination of the CSF showed white blood cells of 4/μl.", + "Examination of the CSF showed protein levels of 0.45 g/L (normal 0.2 ~ 0.4 g / L).", + "The concentrations of glucose and chlorine in the CSF were normal.", + "Anti-NMDAR antibodies were detected in CSF and serum using a commercial kit (Euroimmune, Germany) by indirect immunofluorescence testing (IIFT) according to the manufacturer’s instructions for twice.", + "Anti-NMDAR titers were 1:10(++) in CSF and 1:32(++) in serum.", + "Anti-AMPA1, AMPA2, LG1, ASPR2 and GABAB receptor antibodies in CSF and serum were negative.", + "Tests for paraneoplastic antibodies (Hu, Yo, Ri, Ma2, CV2, Amphiphysin, ANNA-3, Tr, PCA-2, GAD) in CSF were all negative.", + "Chest CT did not reveal any lesions concerning for malignancy.", + "Video-EEG showed slight abnormality (all visible more low amplitude fast wave guide, especially the front head).", + "Brain MRI scan and enhanced scan showed long T1 and long T2 abnormal signal on the bilateral frontal parietal, proximal midline.", + "Diffusion weighted imaging (DWI) showed high signal intensity, patchy eccentric mild enhancement.", + "MRS showed N-acetyl aspartate (NAA) peak decreased.", + "MRS showed no increase in choline compounds (Cho) peak.", + "Lesions were considered the possibility of non-neoplastic lesions.", + "With a presumed diagnosis of anti-NMDAR encephalitis, the patient was treated with intravenous dexamethasone 10 mg/d × 11d.", + "With a presumed diagnosis of anti-NMDAR encephalitis, the patient was treated with methylprednisolone 200 mg/d × 3d.", + "With a presumed diagnosis of anti-NMDAR encephalitis, the patient was treated with methylprednisolone 80 mg/d × 3d.", + "With a presumed diagnosis of anti-NMDAR encephalitis, the patient was treated with gamma globulin (20 g/d × 5d).", + "With a presumed diagnosis of anti-NMDAR encephalitis, the patient was treated with oral prednisolone acetate tablets (40 mg qd).", + "With a presumed diagnosis of anti-NMDAR encephalitis, the patient was treated with antiepileptic (oxcarbazepine 300 mg bid).", + "The epileptic seizures were slightly alleviated after treatment.", + "The main manifestation was the twitching with spasms of the left upper and lower extremities.", + "Each twitching with spasms lasted several seconds to more than ten seconds.", + "The twitching with spasms attacked several times a day.", + "The twitching with spasms occurred without alteration of consciousness.", + "The patient was discharged home.", + "Two months later, the patient presented to the hospital for a second time.", + "He had suffered from frequent attacks of the left limb.", + "Physical examination showed no abnormalities in the nervous system.", + "Results from routine biochemical and cytological examination of the cerebrospinal fluid were normal.", + "Anti-NMDAR titers were 1:32(+++) in CSF and 1:32(++) in serum.", + "The brain MRI showed bilateral frontal parietal lesions enlarged slightly.", + "The enhancement became more obvious than before.", + "The patient was treated for a second time with intravenous injection of methylprednisolone (80 mg/d × 15d).", + "The patient was treated for a second time with oral prednisolone acetate tablets (40 mg qd).", + "The patient was treated for a second time with immunoglobulins (25 g/d × 5d).", + "The patient was treated for a second time with oral azathioprine (50 mg qd).", + "The patient was treated for a second time with oral antiepileptic (oxcarbazepine 600 mg bid, Debakin 250 mg qm, 500 mg qn).", + "The epileptic seizures were slightly alleviated after the treatment.", + "The twitching with spasms of the left limb occurred 2~3 times a day.", + "The twitching with spasms of the left limb typically lasts a few seconds.", + "The twitching with spasms occurred without loss of consciousness.", + "The patient was discharged home.", + "Four months later, the patient presented at the hospital for a third time.", + "He complained of weakness after frequent partial seizures in his right limb.", + "Muscle Strength Grading Scale of the right lower extremity was 4/5.", + "Physical examination of the remaining nervous system showed no significant abnormalities.", + "The diagnosis was simple partial status epilepticus and Todd’s Paralysis.", + "Epilepsy was controlled on diazepam injection therapy.", + "The muscle strength of the right lower extremity returned to normal.", + "The brain MRI reexamination indicated that the frontal parietal lesions enlarged.", + "One new lesion appeared in the left basal ganglia with some mild mass effect, significantly enhanced.", + "Diffusion tensor imaging (DTI) showed partial ablation of white matter fibro tracts in the bilateral frontal parietal lobe and the left basal ganglia lesion.", + "Diffusion tensor imaging (DTI) showed reduction of FA and the surrounding fibro tracts slightly compressed.", + "Arterial spin labeling (ASL) MR imaging showed that bilateral frontoparietal and left basal ganglia lesions had abnormally high perfusion.", + "Surgical biopsy of the right parietal lesion was performed under general anesthesia on November 21, 2016.", + "The lesions were pale red, slightly tough, abundant blood supply and without clear border.", + "The size of the removed lesion was about 1.5 × 1.5 × 1.0 cm.", + "The astrocytoma (WHO II-III) was confirmed on histopathologic findings.", + "Patients transferred to the oncology department for further radiotherapy and chemotherapy.", + "One month later, the patient died." + ], + "summary": "A 67-year-old man presented with new-onset focal seizures. The brain magnetic resonance imaging (MRI) plain scan and enhanced scan showed abnormal signal on the proximal midline frontoparietal junction region. Anti-NMDAR antibody was detected in cerebrospinal fluid (CSF) and serum using a commercial kit (Euroimmune, Germany) by indirect immunofluorescence testing (IIFT) according to the manufacturer's instructions for twice. Both of the test results were positive in CSF and serum. The patient was diagnosed as anti-NMDAR encephalitis and then was treated repeatedly with large dose of intravenous corticosteroids and gamma globulin. Accordingly, the refractory nature of seizures in this case may be attributed to NMDAR autoantibodies. When the patient presented at the hospital for the third time, the brain MRI revealed an increase in the size of the frontal parietal lesion and one new lesion in the left basal ganglia. The patient underwent a surgical biopsy and astrocytoma was confirmed by histopathology.", + "summary_subclaims": [ + "A 67-year-old man presented with new-onset focal seizures.", + "The brain magnetic resonance imaging (MRI) plain scan and enhanced scan showed abnormal signal on the proximal midline frontoparietal junction region.", + "Anti-NMDAR antibody was detected in cerebrospinal fluid (CSF) and serum using a commercial kit (Euroimmune, Germany) by indirect immunofluorescence testing (IIFT) according to the manufacturer's instructions for twice.", + "Both of the test results were positive in CSF and serum.", + "The patient was diagnosed as anti-NMDAR encephalitis.", + "The patient was treated repeatedly with large dose of intravenous corticosteroids and gamma globulin.", + "The refractory nature of seizures in this case may be attributed to NMDAR autoantibodies.", + "When the patient presented at the hospital for the third time, the brain MRI revealed an increase in the size of the frontal parietal lesion and one new lesion in the left basal ganglia.", + "The patient underwent a surgical biopsy.", + "Astrocytoma was confirmed by histopathology." + ] + }, + { + "id": "multiclinsum_test_1723_en.txt", + "fulltext": "A 70-year-old male patient visited our clinic because of poor cognitive function and gait disturbance.\nHe was diagnosed with encephalitis following scrub typhus 23 years ago. The patient complained of poor memory. The patient was initially admitted to a local hospital with a high fever and headache 23 years ago. He developed neurological symptoms as mental change, visual disturbance, and weakness, according to medical history. The first MRI was conducted 7-d after onset. He was then transferred to a tertiary hospital to treat his symptoms, and the diagnosis of scrub typhus encephalitis was confirmed.\nNo special previous medical history was reported.\nNo special personal and family histories were found.\nPhysical examination revealed narrow visual fields; however, he could read books and newspapers. His motor power on both extremities was intact without any pain. But fine movements of the left hand were poor, and he could only manage to walk indoors because of sensory impairment.\nMotor and sensory findings tested using objective tools were as follows: handgrip strength (right/left, kg), 32.3/31.3; two-point discrimination test (right/left, mm), 5/absence; and monofilament test (right/left, mm), 3.22/absence. The patient had impaired cognition, with a mini-mental status examination score of 14 and a Montreal cognitive assessment score of 10[-]. For a more detailed evaluation of cognition, we performed a computerized neuropsychological test .\nDTI data were acquired with a 3.0 T scanner Intera (Philips, Ltd., Best, The Netherlands) with a six-channel head coil and single-shot echo-planar imaging. For each of the 32 non-collinear diffusion-sensitizing gradients, we acquired 80 contiguous slices parallel to the anterior commissure-posterior commissure line. The imaging parameters were as follows: acquisition matrix = 112 × 112, field of view = 224 mm × 224 mm, TR/TE = 8973/80 ms, parallel imaging reduction factor (SENSE factor) = 2, EPI factor = 49, b = 1000 s/mm2, NEX = 2, and slice thickness = 2.0 mm (acquired voxel size = 2 mm × 2 mm × 2 mm). Analysis of the DTI data was performed using the Oxford Centre for Functional Magnetic Resonance Imaging of the Brain (FMRIB) Software Library (FSL: ) based on the probabilistic tractography method. Head motion artifacts and image distortion due to eddy current were corrected by affine multiscale two-dimensional registration. To reconstruct the Papez circuit, the following locations were considered as the regions of interest (ROIs): The thalamocortical tract-cingulate gyrus (seed ROI), the anterior limb of the internal capsule (target ROI 1) and the anterior thalamic nuclei (target ROI 2) on axial images; the fornix - mammillary body (seed ROI) on axial images and the crus of the fornix (target ROI) on coronal images; the mammillothalamic tract-anterior thalamic nucleus (seed ROI) and the portion of the isolated mammillothalamic tract (target ROI 1), and the mammillary body (target ROI 2) on axial images; the cingulum - the middle portion of the cingulum (seed ROI) and the posterior portion of the cingulum (target ROI) on coronal images. Additionally, we reconstructed the corticospinal tract (CST) as described in a previous study as we believed it would help to confirm whether specific neural tracts can reflect their related functions.\nThe 7-d MRI onset showed small lesions in the left frontal and parietal lobes, and large lesions in the right superior parietal lobule and both occipital lobes. Compared with the 7-d MRI, the 23-year MRI findings indicated expanded lesions of encephalomalacia with marked dilation of both ventricles . Probabilistic DTT of the Papez circuit revealed that the left thalamocortical tract and right mammillothalamic tract could not be reconstructed; however, the anterior part of the fornix was found to be injured. Both CSTs were well preserved .", + "fulltext_subclaims": [ + "A 70-year-old male patient visited our clinic because of poor cognitive function and gait disturbance.", + "He was diagnosed with encephalitis following scrub typhus 23 years ago.", + "The patient complained of poor memory.", + "He was initially admitted to a local hospital with a high fever and headache 23 years ago.", + "He developed neurological symptoms as mental change, visual disturbance, and weakness, according to medical history.", + "The first MRI was conducted 7-d after onset.", + "The diagnosis of scrub typhus encephalitis was confirmed.", + "No special previous medical history was reported.", + "No special personal and family histories were found.", + "Physical examination revealed narrow visual fields.", + "He could read books and newspapers.", + "His motor power on both extremities was intact without any pain.", + "Fine movements of the left hand were poor.", + "He could only manage to walk indoors because of sensory impairment.", + "Handgrip strength (right/left, kg) was 32.3/31.3.", + "Two-point discrimination test (right/left, mm) was 5/absence.", + "Monofilament test (right/left, mm) was 3.22/absence.", + "The patient had impaired cognition, with a mini-mental status examination score of 14.", + "The patient had impaired cognition, with a Montreal cognitive assessment score of 10[-].", + "We performed a computerized neuropsychological test.", + "DTI data were acquired with a 3.0 T scanner Intera (Philips, Ltd., Best, The Netherlands) with a six-channel head coil and single-shot echo-planar imaging.", + "For each of the 32 non-collinear diffusion-sensitizing gradients, we acquired 80 contiguous slices parallel to the anterior commissure-posterior commissure line.", + "The imaging parameters were as follows: acquisition matrix = 112 × 112, field of view = 224 mm × 224 mm, TR/TE = 8973/80 ms, parallel imaging reduction factor (SENSE factor) = 2, EPI factor = 49, b = 1000 s/mm2, NEX = 2, and slice thickness = 2.0 mm (acquired voxel size = 2 mm × 2 mm × 2 mm).", + "Analysis of the DTI data was performed using the Oxford Centre for Functional Magnetic Resonance Imaging of the Brain (FMRIB) Software Library (FSL: ) based on the probabilistic tractography method.", + "Head motion artifacts and image distortion due to eddy current were corrected by affine multiscale two-dimensional registration.", + "The 7-d MRI onset showed small lesions in the left frontal and parietal lobes, and large lesions in the right superior parietal lobule and both occipital lobes.", + "Compared with the 7-d MRI, the 23-year MRI findings indicated expanded lesions of encephalomalacia with marked dilation of both ventricles.", + "Probabilistic DTT of the Papez circuit revealed that the left thalamocortical tract and right mammillothalamic tract could not be reconstructed.", + "The anterior part of the fornix was found to be injured.", + "Both CSTs were well preserved." + ], + "summary": "A 70-year-old male patient was affected by encephalitis caused by scrub typhus that occurred 23 years ago. He had poor cognition and his clinical examination findings were as follows: Mini-Mental Status Examination score, 14; and handgrip strength (right/left, kg), 32.3/31.3. DTT revealed serious injuries of the left thalamocingulate tract and right mammillothalamic tract in the Papez circuit, and a partial injury of the anterior part of the fornix.", + "summary_subclaims": [ + "The patient was affected by encephalitis caused by scrub typhus that occurred 23 years ago.", + "The patient had poor cognition.", + "The Mini-Mental Status Examination score was 14.", + "Handgrip strength was 32.3 kg on the right and 31.3 kg on the left.", + "DTT revealed serious injuries of the left thalamocingulate tract.", + "DTT revealed serious injuries of the right mammillothalamic tract in the Papez circuit.", + "DTT showed a partial injury of the anterior part of the fornix." + ] + }, + { + "id": "multiclinsum_test_1469_en.txt", + "fulltext": "The patient is a 57 years old never smoker female who initially received a clinical diagnosis of pneumonia. As symptoms failed to resolve with antimicrobials, a subsequent CT scan of the chest revealed a partially cavitary mass in the right lower lung lobe. This imaging finding was followed with CT scans for two years at an outside facility showing slow growth. Eventually, a CT guided biopsy revealed mucinous adenocarcinoma of the lung with predominant lepidic pattern. A PET CT and MRI of the brain at the time did not show any other disease sites and she received a right lower lobectomy which confirmed the diagnosis and the stage as pT2bpN0M0 (IIA). Following surgery, the patient received adjuvant chemotherapy with carboplatin and paclitaxel for four cycles.\nShe carried a diagnosis of idiopathic autoimmune hearing loss, that had been successfully treated with mycophenolate mofetil. Her family history included lung cancer in both of her parents and her sister, all smoking related, as well as breast cancer in her maternal aunt.\nA year after her surgery, disease recurrence was documented on imaging in the right pleura. The same neoplasm was identified upon pathology review of a right pleural biopsy and she received local radiation therapy as salvage treatment. Follow up imaging in 3 months identified new lung nodules and the patient was referred to our institution. Figure shows the metabolically avid right pleural thickening that was radiated and one of the lung nodules at the time of disease recurrence following radiation. Molecular analysis of the original lobectomy material with next generation sequencing revealed a BRAF V600E mutation. Subsequently, she was initiated on combination of dabrafenib and trametinib treatment in the context of a clinical trial.\nWhile on the experimental drugs for two weeks, she experienced significant fatigue, persistent fevers up to 38 °C and generalized myalgias necessitating holding dabrafenib and trametinib. Nevertheless, symptoms persisted and infectious and rheumatology workups were initiated at the time. In addition, three weeks after stopping dabrafenib and trametinib, she was admitted for left eye vision loss and acute kidney injury. An ophthalmology exam with eye dilation indicated left central artery occlusion. Additional data from her history, exam and laboratory evaluation revealed the following: a history of recurrent sinusitis, acute onset visual loss and renal insufficiency during the current admission, and evidence of a saddle-nose deformity on exam which the patient believed was present for several years prior. She subsequently received a unifying diagnosis of granulomatosis with polyangiitis (GPA) on the basis of these findings as well as high-titer characteristic antibodies (p-ANCA titer 1:640, myeloperoxidase antibody > 30). Other lab results including rheumatology workup are shown in Table . Due to acute vision loss, giant cell arteritis was considered and a temporal artery biopsy was obtained and found negative. Her acute vision loss and creatinine elevation were thought secondary to retinal and renal vascular involvement by GPA. Nevertheless, review of the pleural biopsy and the resection specimen by pathology in retrospect, did not reveal any granulomatous change or vasculitis. She was initiated on rituximab, corticosteroids were successfully tapered, and further anti-neoplastic drugs were held. Lung cancer was followed clinically with scans.\nA year after diagnosis of GPA, a growing lung nodule was proven with biopsy to be malignant and was treated with SBRT. To-date, three years following GPA diagnosis and lung cancer recurrence, both conditions remain controlled without any further systemic therapy for lung cancer and while she continues on rituximab for GPA.", + "fulltext_subclaims": [ + "The patient is a 57 years old never smoker female.", + "The patient initially received a clinical diagnosis of pneumonia.", + "A CT scan of the chest revealed a partially cavitary mass in the right lower lung lobe.", + "CT scans for two years showed slow growth.", + "A CT guided biopsy revealed mucinous adenocarcinoma of the lung with predominant lepidic pattern.", + "A PET CT and MRI of the brain did not show any other disease sites.", + "The patient received a right lower lobectomy.", + "The stage was pT2bpN0M0 (IIA).", + "The patient received adjuvant chemotherapy with carboplatin and paclitaxel for four cycles.", + "The patient carried a diagnosis of idiopathic autoimmune hearing loss.", + "The patient had been successfully treated with mycophenolate mofetil.", + "The patient's family history included lung cancer in both parents and her sister.", + "The patient's family history included breast cancer in her maternal aunt.", + "Disease recurrence was documented on imaging in the right pleura a year after surgery.", + "A right pleural biopsy identified the same neoplasm.", + "The patient received local radiation therapy as salvage treatment.", + "Follow up imaging in 3 months identified new lung nodules.", + "Molecular analysis of the original lobectomy material with next generation sequencing revealed a BRAF V600E mutation.", + "The patient was initiated on combination of dabrafenib and trametinib treatment in the context of a clinical trial.", + "While on the experimental drugs for two weeks, she experienced significant fatigue.", + "She experienced persistent fevers up to 38 °C.", + "She experienced generalized myalgias.", + "Dabrafenib and trametinib were held.", + "Infectious and rheumatology workups were initiated.", + "Three weeks after stopping dabrafenib and trametinib, she was admitted for left eye vision loss.", + "She was admitted for acute kidney injury.", + "An ophthalmology exam with eye dilation indicated left central artery occlusion.", + "She had a history of recurrent sinusitis.", + "She had acute onset visual loss during the current admission.", + "She had renal insufficiency during the current admission.", + "She had evidence of a saddle-nose deformity on exam.", + "She received a unifying diagnosis of granulomatosis with polyangiitis (GPA).", + "She had high-titer characteristic antibodies (p-ANCA titer 1:640, myeloperoxidase antibody > 30).", + "Giant cell arteritis was considered.", + "A temporal artery biopsy was obtained.", + "The temporal artery biopsy found negative.", + "Her acute vision loss and creatinine elevation were thought secondary to retinal and renal vascular involvement by GPA.", + "Review of the pleural biopsy and the resection specimen by pathology did not reveal any granulomatous change or vasculitis.", + "She was initiated on rituximab.", + "Corticosteroids were successfully tapered.", + "Further anti-neoplastic drugs were held.", + "A year after diagnosis of GPA, a growing lung nodule was proven with biopsy to be malignant.", + "The lung nodule was treated with SBRT.", + "Three years following GPA diagnosis and lung cancer recurrence, both conditions remain controlled.", + "She continues on rituximab for GPA." + ], + "summary": "A 57 years old female patient was diagnosed with recurrent lung adenocarcinoma following initial lobectomy for early stage disease. A BRAF V600E mutation was identified at the time of recurrence and she received combination dabrafenib and trametinib therapy. Shortly after commencement of treatment, she developed persistent fevers necessitating withholding both drugs. Pyrexia continued and was followed by left vision loss and acute kidney injury. Further rheumatological workup led to the unifying diagnosis of GPA. The patient was then treated with rituximab for GPA to the present date while all antineoplastic drugs were held. Lung cancer oligoprogression was addressed with radiation therapy and has not required further systemic treatment whereas GPA has been controlled to-date with rituximab.", + "summary_subclaims": [ + "The patient is a 57 years old female.", + "She was diagnosed with recurrent lung adenocarcinoma.", + "A BRAF V600E mutation was identified at the time of recurrence.", + "She received combination dabrafenib and trametinib therapy.", + "She developed persistent fevers necessitating withholding both drugs.", + "Pyrexia continued and was followed by left vision loss.", + "Acute kidney injury occurred.", + "Further rheumatological workup led to the unifying diagnosis of GPA.", + "The patient was treated with rituximab for GPA.", + "All antineoplastic drugs were held.", + "Lung cancer oligoprogression was addressed with radiation therapy.", + "Lung cancer has not required further systemic treatment.", + "GPA has been controlled to-date with rituximab." + ] + }, + { + "id": "multiclinsum_test_1490_en.txt", + "fulltext": "A 23-year-old Arabic single woman was brought to our emergency department (ED) by her family around 4 hours after intentional metformin ingestion. She was on metformin for weight reduction (her body mass index was 28), as she was found to have polycystic ovarian syndrome (PCOS). She ingested around 60 tablets of 500 mg metformin as a suicide attempt after she experienced a stressful social event. Four years prior, she had undergone a kidney donation to her brother, who had renal failure due to an unknown cause, and otherwise she was healthy. She was not known to have any psychiatric illness or previous suicidal ideation or attempt. There was no history of smoking or alcohol intake. She does not have any family history of diabetes mellitus or mental illnesses. On examination, she was alert and well-nourished but generally fatigued, with no pallor, jaundice, or cyanosis. Her vital signs were as follows: blood pressure 119/65 mmHg, heart rate 122 beat/min, respiratory rate 20 breaths/min, pulse oximetry oxygen saturation 100% on room air, and oral temperature 36.9 °C. She had dry and cool skin, and bilaterally mid-sized pupils, equal and reactive. The rest of her physical examination was unremarkable.\nHer bedside point-of-care capillary blood glucose level was checked, and it was low. A peripheral intravenous cannula was inserted, and blood extracted followed by administration of 50 ml (25 g) of 50% dextrose (D50) solution. Her blood glucose level was 6.3 mg/dL in serum chemistry; however, it increased to 106 mg/dL after the D50. After that, 5% dextrose-water solution was initiated as a maintenance infusion. Her blood investigation results are summarized in Table . They were unremarkable except for a very low blood glucose level, leukocytosis, hypocalcemia, hyperphosphatemia, and mild creatinine elevation. An initial venous blood gases reading revealed pH: 7.18; PO2: 76.9 mmHg; PCO2: 40.3 mmHg; and bicarbonate of 14.3 mmol/L. Her first lactate level was elevated (8.4 mmol/L), and so a 1 L bolus of Ringer lactate solution was given. Her serial venous blood gases and lactate measurements are shown in Table . Results of analyses of her acetaminophen and aspirin levels were negative. In addition, urine analysis as well as urine pregnancy test results were negative.\nTwo hours later, her capillary blood glucose dropped to 38 mg/dL, and another 50 mL ampule of D50 was infused, which increased her glucose level to 319 mg/dL. During the hospital stay, her blood sugar was monitored frequently . As our patient had worsening lactic acidosis, a nephrologist was urgently consulted, and she was admitted to the intensive care unit (ICU). She had a drop in her blood pressure, and so norepinephrine infusion was initiated. After that, continuous renal replacement therapy (CRRT) was started. At around 3 hours later, her blood sugar dropped to 42 mg/dL, and another dextrose bolus was given. After 13 hours of CRRT initiation, the norepinephrine infusion was discontinued, and our patient was hemodynamically stable. The CRRT was continued for 24 hours. Our patient’s renal and liver function tests did not worsen and remained within normal limits till hospital discharge.\nOn day 3, she was transferred to the ward with normal mental status and vital signs. She was tolerating oral intake and did not develop any more hypoglycemic attacks. The psychiatrist was consulted for further assessment and treatment. On the fifth day of hospitalization, our patient was discharged home with a good health status. This patient was provided, as a part of our multidisciplinary discharge planning, with follow-up appointments within 1 month for internal medicine, nephrology, and psychiatry. As per our medical records, this patient did not show up for any of these outpatient follow-up appointments.", + "fulltext_subclaims": [ + "The patient is a 23-year-old Arabic single woman.", + "She was brought to the emergency department four hours after intentional metformin ingestion.", + "She was on metformin for weight reduction.", + "She was found to have polycystic ovarian syndrome.", + "She ingested around 60 tablets of 500 mg metformin.", + "The ingestion was a suicide attempt.", + "The suicide attempt occurred after she experienced a stressful social event.", + "She had undergone a kidney donation to her brother four years prior.", + "She was not known to have any psychiatric illness.", + "She did not have any previous suicidal ideation or attempt.", + "She does not have a family history of diabetes mellitus.", + "She does not have a family history of mental illnesses.", + "On examination, she was alert and well-nourished.", + "Her heart rate was 122 beats per minute.", + "Her blood glucose level was 6.3 mg/dL in serum chemistry.", + "After administration of 50 ml of 50% dextrose, her blood glucose increased to 106 mg/dL.", + "A 5% dextrose-water solution was initiated as a maintenance infusion.", + "Her initial venous blood gases revealed a pH of 7.18.", + "Her first lactate level was 8.4 mmol/L.", + "A 1 L bolus of Ringer lactate solution was given.", + "Her blood pressure dropped during the hospital stay.", + "Norepinephrine infusion was initiated.", + "Continuous renal replacement therapy was started.", + "After 13 hours of CRRT, the norepinephrine infusion was discontinued.", + "The patient was hemodynamically stable after 13 hours of CRRT.", + "The CRRT was continued for 24 hours.", + "The patient was transferred to the ward on day 3.", + "She was tolerating oral intake on day 3.", + "She did not develop any more hypoglycemic attacks.", + "The psychiatrist was consulted for further assessment and treatment.", + "The patient was discharged home on the fifth day of hospitalization.", + "She was provided with follow-up appointments within 1 month for internal medicine, nephrology, and psychiatry.", + "She did not show up for any of these outpatient follow-up appointments." + ], + "summary": "A 23-year-old Arabic woman took 30 g of metformin. In the emergency department, 4 hours after of the event, she was fatigued but vitally stable. During her hospitalization, she had severe lactic acidosis, hypotension corrected with fluid boluses and vasopressors, and multiple episodes of hypoglycemia (6.3 mg/dL, 38 mg/dL, and 42 mg/dL), requiring multiple 50% dextrose-water boluses. The three hypoglycemic episodes occurred coincident with severe lactic acidosis. She improved after 24 hours of continuous renal replacement therapy.", + "summary_subclaims": [ + "The patient is a 23-year-old Arabic woman.", + "She took 30 g of metformin.", + "In the emergency department, 4 hours after the event, she was fatigued.", + "In the emergency department, 4 hours after the event, she was vitally stable.", + "During her hospitalization, she had severe lactic acidosis.", + "During her hospitalization, she had hypotension corrected with fluid boluses and vasopressors.", + "During her hospitalization, she had multiple episodes of hypoglycemia.", + "The hypoglycemia episodes were 6.3 mg/dL, 38 mg/dL, and 42 mg/dL.", + "The three hypoglycemic episodes occurred coincident with severe lactic acidosis.", + "She improved after 24 hours of continuous renal replacement therapy." + ] + }, + { + "id": "multiclinsum_test_2423_en.txt", + "fulltext": "A 12-year-old Amhara boy from the Northwest Gondar Amhara regional state complained of left flank swelling for the last 3 months. Three days before admission he started to experience pain in his left flank, which was associated with high grade fever, chills, rigor, and vomiting. At the time he had no urinary or respiratory symptoms. Maternal pregnancy course and medical history were noncontributory, and he had an attended birth at a health center; his past medical history was unremarkable. He has seven siblings, none of whom had similar symptoms. His mother had no history of radiation exposure, use of traditional medicine, or chemotherapy during pregnancy.\nNo dysmorphisms were noted in his general appearance. His vital signs were: pulse rate (PR) 142 beats/min, respiratory rate (RR) 33 breaths/min, temperature (T) 38.5 °C, and blood pressure (BP) 105/65 mmHg. Anthropometric measurements showed severe stunting. An abdominal examination revealed distended abdomen, asymmetric with bulging left flank, visible horizontal line, upward umbilical slit, and absent rectus abdominis muscles. His abdomen was soft with a tender cystic, bimanually palpable mass on the left flank measuring 13 × 11 cm. Both testes were undescended . He also had scoliosis and developmental dysplasia of the hips with waddling gate.\nUrinary analysis demonstrated many red blood cells (RBCs) and positive leukocyte esterase. He had a normal renal function test with creatinine of 0.72 mg/dl and blood urea nitrogen (BUN) of 44 mg/dl, normal hemoglobin of 12.7 gm/dl, and normal electrolyte. Ultrasound showed a large cystic mass in his left kidney area with echo debris. His right kidney had normal echo texture and size. An X-ray of his hips showed bilateral developmental dysplasia of the hip (DDH; Fig. ). Our facility does not have the capacity to perform a genetic study to support the diagnosis of PBS.\nHis left kidney is cystic and enlarged; there is no parenchyma tissue, both testes are intraperitoneal just below the kidneys, tortuous left renal vein, enlarged bladder reaching above umbilicus, and left megaureter . A bilateral orchidectomy and left nephrectomy were done.\nAfter surgical removal of cystic mass and testes, he was given intravenously administered antibiotics for treatment of pyelonephritis for 14 days. Subsequently he showed significant improvement and was discharged home with an appointment for follow up to consider hormonal replacement therapy and possible abdominoplasty. His parents were also counseled about the PBS and the care they can give him at home.", + "fulltext_subclaims": [ + "The patient is a 12-year-old Amhara boy from the Northwest Gondar Amhara regional state.", + "He complained of left flank swelling for the last 3 months.", + "Three days before admission he started to experience pain in his left flank.", + "The pain was associated with high grade fever, chills, rigor, and vomiting.", + "At the time he had no urinary or respiratory symptoms.", + "Maternal pregnancy course and medical history were noncontributory.", + "He had an attended birth at a health center.", + "His past medical history was unremarkable.", + "He has seven siblings, none of whom had similar symptoms.", + "His mother had no history of radiation exposure, use of traditional medicine, or chemotherapy during pregnancy.", + "No dysmorphisms were noted in his general appearance.", + "His pulse rate was 142 beats/min.", + "His temperature was 38.5 °C.", + "Anthropometric measurements showed severe stunting.", + "An abdominal examination revealed distended abdomen, asymmetric with bulging left flank.", + "There was a tender cystic, bimanually palpable mass on the left flank measuring 13 × 11 cm.", + "Both testes were undescended.", + "He also had scoliosis and developmental dysplasia of the hips with waddling gate.", + "Urinary analysis demonstrated many red blood cells and positive leukocyte esterase.", + "He had a normal renal function test with creatinine of 0.72 mg/dl.", + "An ultrasound showed a large cystic mass in his left kidney area with echo debris.", + "His right kidney had normal echo texture and size.", + "An X-ray of his hips showed bilateral developmental dysplasia of the hip.", + "Our facility does not have the capacity to perform a genetic study to support the diagnosis of PBS.", + "A bilateral orchidectomy and left nephrectomy were done.", + "After surgical removal of cystic mass and testes, he was given intravenously administered antibiotics for treatment of pyelonephritis for 14 days.", + "Subsequently he showed significant improvement and was discharged home.", + "He was given an appointment for follow up to consider hormonal replacement therapy and possible abdominoplasty." + ], + "summary": "A 12-year-old Amhara boy from the Northwest Gondar Amhara regional state presented to our referral hospital with a complaint of swelling over his left flank for the past 3 months. Maternal pregnancy course and medical history were noncontributory, and he had an attended birth at a health center. He has seven siblings, none of whom had similar symptoms. On examination he had a distended abdomen, asymmetric with bulging left flank, visible horizontal line, upward umbilical slit, and absent rectus abdominis muscles. His abdomen was soft with a tender cystic, bimanually palpable mass on the left flank measuring 13 × 11 cm. Both testes were undescended and he also has developmental dysplasia of the hips. An abdominal ultrasound revealed a large cystic mass in his left kidney area with echo debris and a hip X-ray showed bilateral developmental dysplasia of the hip. Intraoperative findings were cystic left kidney, both testes were intraperitoneal, tortuous left renal vein, enlarged bladder reaching above umbilicus, and left megaureter.", + "summary_subclaims": [ + "The patient is a 12-year-old Amhara boy.", + "He is from the Northwest Gondar Amhara regional state.", + "He presented with swelling over his left flank for the past 3 months.", + "Maternal pregnancy course and medical history were noncontributory.", + "He had an attended birth at a health center.", + "He has seven siblings.", + "None of his siblings had similar symptoms.", + "On examination, he had a distended abdomen.", + "The distension was asymmetric with bulging left flank.", + "A visible horizontal line was noted.", + "An upward umbilical slit was noted.", + "Absent rectus abdominis muscles were noted.", + "The abdomen was soft.", + "A tender cystic, bimanually palpable mass was found on the left flank.", + "The mass measured 13 × 11 cm.", + "Both testes were undescended.", + "He has developmental dysplasia of the hips.", + "An abdominal ultrasound revealed a large cystic mass in his left kidney area.", + "The ultrasound showed echo debris.", + "A hip X-ray showed bilateral developmental dysplasia of the hip.", + "Intraoperative findings included a cystic left kidney.", + "Both testes were intraperitoneal.", + "A tortuous left renal vein was found.", + "An enlarged bladder reaching above the umbilicus was found.", + "A left megaureter was found." + ] + }, + { + "id": "multiclinsum_test_105_en.txt", + "fulltext": "A 37-year-old Chinese woman presented to our department four years and 11 months ago with bilateral lower limb crush injuries sustained in a traffic accident. The lower limb injuries were at different anatomic levels . On the right side, her lower limb was crushed from her hip joint to 16cm below her knee joint, but the bones and soft tissues of the lower one-third of her leg were intact with only slight injury to the skin. On the left side, the distal portion of her leg was crushed. Our patient was in serious hypovolemic shock on arrival, with a heart rate of 150 beats per minute and blood pressure of 80/60mmHg.\nAfter rapid infusion of intravenous fluids, our patient rapidly recovered from shock and did not develop acute renal failure or acute respiratory distress syndrome. Emergency surgery was performed. Bilateral lower limb amputations were necessary. Her lower left leg was unsalvageable, but her lower right leg was suitable for replantation to the left leg stump after debridement. We decided to perform crossover replantation of her right lower leg to the left leg stump to provide our patient with a sensate weight-bearing extremity. Her amputated right lower leg was wrapped in sterile dressings, placed on a sterile tray and stored in the refrigerator at 4°C during fixation of the left leg fracture.\nAfter amputation and debridement of her right hip joint, her right lower tibia was fixed to her left upper tibia . The fibula was not fixed. The tendons, blood vessels and nerves of her left leg were anastomosed to the amputated lower right leg structures. The anterior tibial artery and posterior tibial artery were anastomosed crosswise, and the ends of the great saphenous vein, small saphenous vein and four deep veins were anastomosed without crossover. The sural nerve and saphenous nerve were anastomosed crosswise, and the anterior and posterior tibial nerves were anastomosed without crossover. Heterotopic replantation of her right lower leg to the left leg stump was thus completed. A stump was created on the right side at her hip joint. Routine antibiotic, anti-coagulant, and anti-angiospasm treatments were administered post-operatively. In a second operation, a soft tissue defect of the replanted limb was covered by a microvascular-free latissimus dorsi muscle flap. The post-operative anti-coagulation regime was as follows: dextran 40 (500mL) twice a day for seven days; aspirin (100mg) orally three times a day for three days; narceine (30mg) four times a day for seven days; and tolazoline (25mg) three times a day for seven days. Routine post-operative blood tests, including coagulation tests, were performed for seven days.\nThe replantation was successful and our patient was discharged after two months . She was rehabilitated with a contralateral prosthesis and ambulates with a walking stick. One year post-operatively, X-ray examination showed perfect union of the tibia . There was no ulceration of the replanted extremity or the right-sided amputation stump at 39 months post-operatively. The sole of her foot on the left side regained complete protective sensation . Our patient described the functional result of the replantation as satisfying, and found that the prosthesis on the right side caused more problems than the replanted left lower limb. She had no complaints about the cosmetic result. In addition, she experienced restoration of perceived body height with the crossover replantation.", + "fulltext_subclaims": [ + "A 37-year-old Chinese woman presented to our department four years and 11 months ago with bilateral lower limb crush injuries sustained in a traffic accident.", + "The lower limb injuries were at different anatomic levels.", + "On the right side, her lower limb was crushed from her hip joint to 16cm below her knee joint.", + "The bones and soft tissues of the lower one-third of her right leg were intact with only slight injury to the skin.", + "On the left side, the distal portion of her leg was crushed.", + "Our patient was in serious hypovolemic shock on arrival, with a heart rate of 150 beats per minute and blood pressure of 80/60mmHg.", + "After rapid infusion of intravenous fluids, our patient rapidly recovered from shock.", + "Our patient did not develop acute renal failure.", + "Our patient did not develop acute respiratory distress syndrome.", + "Emergency surgery was performed.", + "Bilateral lower limb amputations were necessary.", + "Her lower left leg was unsalvageable.", + "Her lower right leg was suitable for replantation to the left leg stump after debridement.", + "We decided to perform crossover replantation of her right lower leg to the left leg stump.", + "Her amputated right lower leg was wrapped in sterile dressings.", + "Her amputated right lower leg was placed on a sterile tray.", + "Her amputated right lower leg was stored in the refrigerator at 4°C during fixation of the left leg fracture.", + "After amputation and debridement of her right hip joint, her right lower tibia was fixed to her left upper tibia.", + "The fibula was not fixed.", + "The tendons, blood vessels and nerves of her left leg were anastomosed to the amputated lower right leg structures.", + "The anterior tibial artery and posterior tibial artery were anastomosed crosswise.", + "The ends of the great saphenous vein, small saphenous vein and four deep veins were anastomosed without crossover.", + "The sural nerve and saphenous nerve were anastomosed crosswise.", + "The anterior and posterior tibial nerves were anastomosed without crossover.", + "Heterotopic replantation of her right lower leg to the left leg stump was thus completed.", + "A stump was created on the right side at her hip joint.", + "Routine antibiotic, anti-coagulant, and anti-angiospasm treatments were administered post-operatively.", + "In a second operation, a soft tissue defect of the replanted limb was covered by a microvascular-free latissimus dorsi muscle flap.", + "The post-operative anti-coagulation regime was as follows: dextran 40 (500mL) twice a day for seven days.", + "The post-operative anti-coagulation regime was as follows: aspirin (100mg) orally three times a day for three days.", + "The post-operative anti-coagulation regime was as follows: narceine (30mg) four times a day for seven days.", + "The post-operative anti-coagulation regime was as follows: tolazoline (25mg) three times a day for seven days.", + "Routine post-operative blood tests, including coagulation tests, were performed for seven days.", + "The replantation was successful.", + "Our patient was discharged after two months.", + "She was rehabilitated with a contralateral prosthesis.", + "She ambulates with a walking stick.", + "One year post-operatively, X-ray examination showed perfect union of the tibia.", + "There was no ulceration of the replanted extremity at 39 months post-operatively.", + "There was no ulceration of the right-sided amputation stump at 39 months post-operatively.", + "The sole of her foot on the left side regained complete protective sensation.", + "Our patient described the functional result of the replantation as satisfying.", + "She found that the prosthesis on the right side caused more problems than the replanted left lower limb.", + "She had no complaints about the cosmetic result.", + "She experienced restoration of perceived body height with the crossover replantation." + ], + "summary": "We treated a 37-year-old Chinese woman with bilateral lower limb crush injuries sustained in a traffic accident. Her lower limb injuries were at different anatomic levels. We performed emergency bilateral amputations followed by crossover replantation. Five years later, the woman had recovered well, and had perfect movement and stability in her replanted leg. After reviewing the literature, we thought that presentation of our patient's case might provide useful information for clinicians.", + "summary_subclaims": [ + "We treated a 37-year-old Chinese woman with bilateral lower limb crush injuries sustained in a traffic accident.", + "Her lower limb injuries were at different anatomic levels.", + "We performed emergency bilateral amputations followed by crossover replantation.", + "Five years later, the woman had recovered well.", + "She had perfect movement and stability in her replanted leg.", + "After reviewing the literature, we thought that presentation of our patient's case might provide useful information for clinicians." + ] + }, + { + "id": "multiclinsum_test_1823_en.txt", + "fulltext": "A 17-year-old female with a history of allergy and systemic reactions to peanuts unknowingly ate a plate of Spaghetti in a Chinese restaurant cooked with groundnut oil. She immediately developed an anaphylactic shock with dyspnea, agitation and cardiac arrest. Cardiopulmonary resuscitation (CPR) was begun upon arrival of the medical emergency team, 10 minutes after collapse-the first rhythm was asystole. Intravenous Epinephrine (total dose 10 mg) and fluid administration (total 2.5 L) were administered and although transient return to spontaneous circulation was achieved at 22 minutes, the patient rearrested with recurrent pulseless electrical activity and then asystole. Only mild laryngeal edema was noted on intubation. She was transferred to our tertiary care facility, under continuous CPR with the Lund University Cardiac Arrest System–Version 2 device (LUCAS 2; Jolife AB, Lund, Sweden). Immediate femoro-femoral, veno-arterial extra-corporeal life support (ECLS) was surgically implanted (RotaFlow, Maquet, Hirrlingen, Germany). No-flow was estimated to be 10 minutes and total low-flow from CPR initiation to full ECLS support 95 minutes. Soon after the establishment of the VA-ECLS, the patient regained an effective sinus rhythm. However, the transesophageal echocardiography performed during the implantation procedure showed a bilateral ventricular dysfunction with global hypokinesia (Additional file ). In order to maintain both a left ventricular drainage and a mean arterial pressure (MAP) above 65 mmHg, a hemodynamic support with dobutamine and norepinephrine was necessary during the first 12 hours. There was no sedative or analgesic administration at any point during pre- or in-hospital care.\nClinically, the patient was deeply comatose-Glasgow Coma Scale 3–with bilaterally dilated pupils unresponsive to light. Complete clinical examination and brain death assessment were performed according to the guidelines of the Swiss Academy of Medical Sciences . The apnea test was carried out in accordance with previously published data on apnea test and brain death testing in patients under ECLS . The clinical diagnosis of brain death was established 16 h after hospital admission and the parents consented to organ donation. Thyroid hormones, low dose corticosteroids and desmopressin were administered for the organ preservation and diabetes insipidus.\nCardiac assessment for heart donation was made by transthoracic echocardiography (TTE). Given the young age, coronary angiography was not performed. TTE displayed normal findings with no inotropic or vasoactive support and ECMO flow lowered to 1.5 L / min (Additional file ). Left ventricular function was assessed by measuring the left ventricular outflow tract velocity time-integral (16 cm), visual assessment of the left ventricular ejection fraction (60 %) and measurement of the systolic peak velocity of the mitral annulus (TDSa) (> 6 cm/s). Right ventricular function was assessed visually and by tricuspid annular plane systolic excursion (TAPSE) (18 mm). There were no segmental anomalies as well as normal valves. The heart was retrieved 50 h after hospital admission (total ECLS support of 50 h, ECLS support prior to organ assessment 16 h and time from assessment to transplant 34 h). Warm and cold ischemia times were 23 and 202 minutes respectively. The heart was transplanted in an 11-year-old female with anthracyclin-induced cardiomyopathy following treatment for high-grade osteosarcoma of the tibia. The immediate post-operative course was favourable allowing extubation on day 2, she required milrinone but no mechanical support for a total intensive care length of stay of 21 days. The patient was discharged 56 days post transplantation, she is symptom-free at 6-month follow-up with normal cardiac function.", + "fulltext_subclaims": [ + "The patient is a 17-year-old female.", + "She has a history of allergy and systemic reactions to peanuts.", + "She unknowingly ate a plate of Spaghetti in a Chinese restaurant cooked with groundnut oil.", + "She immediately developed an anaphylactic shock.", + "She had dyspnea.", + "She had agitation.", + "She had cardiac arrest.", + "Cardiopulmonary resuscitation (CPR) was begun 10 minutes after collapse.", + "The first rhythm was asystole.", + "Intravenous Epinephrine (total dose 10 mg) was administered.", + "Fluid administration (total 2.5 L) was given.", + "Transient return to spontaneous circulation was achieved at 22 minutes.", + "The patient rearrested with recurrent pulseless electrical activity.", + "The patient then had asystole.", + "Only mild laryngeal edema was noted on intubation.", + "She was transferred to a tertiary care facility under continuous CPR with the LUCAS 2 device.", + "Immediate femoro-femoral, veno-arterial extra-corporeal life support (ECLS) was surgically implanted.", + "The RotaFlow device was used for ECLS.", + "No-flow was estimated to be 10 minutes.", + "Total low-flow from CPR initiation to full ECLS support was 95 minutes.", + "Soon after the establishment of VA-ECLS, the patient regained an effective sinus rhythm.", + "Transesophageal echocardiography showed bilateral ventricular dysfunction with global hypokinesia.", + "Hemodynamic support with dobutamine and norepinephrine was necessary during the first 12 hours.", + "There was no sedative or analgesic administration at any point during pre- or in-hospital care.", + "The patient was deeply comatose with a Glasgow Coma Scale of 3.", + "The clinical diagnosis of brain death was established 16 h after hospital admission.", + "The parents consented to organ donation.", + "Thyroid hormones, low dose corticosteroids, and desmopressin were administered.", + "Cardiac assessment for heart donation was made by transthoracic echocardiography.", + "Given the young age, coronary angiography was not performed.", + "TTE displayed normal findings with no inotropic or vasoactive support.", + "ECMO flow was lowered to 1.5 L/min.", + "Left ventricular function was assessed by measuring the left ventricular outflow tract velocity time-integral (16 cm).", + "Left ventricular ejection fraction was visually assessed as 60%.", + "The systolic peak velocity of the mitral annulus (TDSa) was > 6 cm/s.", + "Right ventricular function was assessed visually and by tricuspid annular plane systolic excursion (TAPSE) (18 mm).", + "There were no segmental anomalies.", + "The valves were normal.", + "The heart was retrieved 50 h after hospital admission.", + "Total ECLS support was 50 h.", + "ECLS support prior to organ assessment was 16 h.", + "Time from assessment to transplant was 34 h.", + "Warm ischemia time was 23 minutes.", + "Cold ischemia time was 202 minutes.", + "The heart was transplanted in an 11-year-old female.", + "The recipient had anthracyclin-induced cardiomyopathy.", + "The recipient had high-grade osteosarcoma of the tibia.", + "The immediate post-operative course was favorable.", + "Extubation occurred on day 2.", + "The recipient required milrinone.", + "The recipient did not require mechanical support.", + "The total intensive care length of stay was 21 days.", + "The patient was discharged 56 days post transplantation.", + "The patient is symptom-free at 6-month follow-up.", + "The patient has normal cardiac function." + ], + "summary": "The present case reports a successful heart transplantation after prolonged donor cardiac arrest (total lowflow time of 95 minutes) due to anaphylactic shock necessitating extracorporeal life support. We further provide an overview of the current evidence and outcomes of heart transplantation in cases of donor cardiac arrest.", + "summary_subclaims": [ + "The present case reports a successful heart transplantation after prolonged donor cardiac arrest.", + "The total lowflow time was 95 minutes.", + "The donor cardiac arrest was due to anaphylactic shock.", + "Extracorporeal life support was necessitated.", + "An overview of the current evidence is provided.", + "Outcomes of heart transplantation in cases of donor cardiac arrest are discussed." + ] + }, + { + "id": "multiclinsum_test_2216_en.txt", + "fulltext": "A 36-year-old female patient with a history of “cardiac cyst (70 × 30 mm)” presented to our hospital for treatment of recurrent episodes of chest pain. The “cardiac cyst” was discovered 3 years earlier by echocardiography when the patient experienced slight dyspnea and palpitation at 37 weeks’ gestation. At that time, the electrocardiogram was normal, and blood coagulation function tests revealed slightly increased fibrinogen and D-dimer levels (4.10 g/L and 1252 μg/L, respectively). Before parturition, these values were 4.07 g/L and 1875 μg/L, respectively. Because uterine inertia could not be resolved during natural delivery, cesarean section was performed. Delivery was successful, and the patient was asymptomatic. Annual check-ups during the following 3 years revealed no abnormity other than an enlarged heart shadow on chest radiographs. Anticoagulation therapy was not administered during the 3-year follow-up period.\nTwo months before presentation at our hospital, the patient developed gradually worsening chest pain. The electrocardiogram remained normal; however, transthoracic echocardiography (iE Elite, Philips Healthcare, Bothell, WA, USA) revealed a long oval structure attached to the left atrium (LA) adjacent to the left ventricle (LV) and compressing the anterolateral left ventricular wall during the entire cardiac cycle . No other structural abnormalities were observed. Contrast echocardiography showed that the long oval structure and the LA were enhanced simultaneously with no filling defect . Transesophageal study confirmed a 3.9-cm2 channel between the LA and the structure, which measured 96 mm in length and 55 mm wide . Migration of blood along the channel was observed with Doppler imaging . LAAA was diagnosed definitively, with no thrombi or spontaneous echo contrast observed. Computed tomography (CT) was performed to evaluate the status of the pulmonary veins and other surrounding structures .\nThe patient was hospitalized and scheduled to undergo cardiac surgery. Preoperative blood testing, including coagulation function tests, were normal. Median sternotomy was performed, exposing the giant LAAA with intact overlying pericardium. During cardiopulmonary bypass, the base of the LAAA was simply clamped and then resected with a stapler (Echelon 60, Johnson & Johnson, Guaynabo, Puerto Rico, USA). No thrombus within the LAAA or other cardiac anomaly was detected. Anatomical pathology identified the LAAA as a thin-walled and dilated aneurysm of the left atrial appendage. Histopathology described the wall as being composed of myocardium and fibrotic tissue, indicating a true atrial aneurysm . The patient’s postoperative course was uneventful. At the 6-month follow-up, the patient remained asymptomatic and in sinus rhythm, and transthoracic echocardiography (Vivid E9; GE Healthcare, Strandpromenaden, Horten, Norway) revealed good correction of the LAAA and a normal size for the LA, with no evidence of abnormality .", + "fulltext_subclaims": [ + "The patient is a 36-year-old female.", + "The patient has a history of a cardiac cyst measuring 70 × 30 mm.", + "The patient presented for treatment of recurrent episodes of chest pain.", + "The cardiac cyst was discovered 3 years earlier by echocardiography.", + "At the time of discovery, the patient experienced slight dyspnea and palpitation at 37 weeks’ gestation.", + "The electrocardiogram was normal at the time of discovery.", + "Blood coagulation function tests revealed slightly increased fibrinogen and D-dimer levels (4.10 g/L and 1252 μg/L, respectively).", + "Before parturition, fibrinogen and D-dimer levels were 4.07 g/L and 1875 μg/L, respectively.", + "Cesarean section was performed due to uterine inertia.", + "The patient was asymptomatic after delivery.", + "Annual check-ups during the following 3 years revealed no abnormity other than an enlarged heart shadow on chest radiographs.", + "Anticoagulation therapy was not administered during the 3-year follow-up period.", + "Two months before presentation at our hospital, the patient developed gradually worsening chest pain.", + "The electrocardiogram remained normal.", + "Transthoracic echocardiography revealed a long oval structure attached to the left atrium adjacent to the left ventricle.", + "The structure compressed the anterolateral left ventricular wall during the entire cardiac cycle.", + "Contrast echocardiography showed that the long oval structure and the left atrium were enhanced simultaneously with no filling defect.", + "Transesophageal study confirmed a 3.9-cm2 channel between the left atrium and the structure.", + "The structure measured 96 mm in length and 55 mm wide.", + "Migration of blood along the channel was observed with Doppler imaging.", + "LAAA was diagnosed definitively.", + "Computed tomography was performed to evaluate the status of the pulmonary veins and other surrounding structures.", + "The patient was hospitalized and scheduled to undergo cardiac surgery.", + "Preoperative blood testing, including coagulation function tests, were normal.", + "Median sternotomy was performed, exposing the giant LAAA with intact overlying pericardium.", + "During cardiopulmonary bypass, the base of the LAAA was simply clamped and then resected with a stapler.", + "No thrombus within the LAAA or other cardiac anomaly was detected.", + "Anatomical pathology identified the LAAA as a thin-walled and dilated aneurysm of the left atrial appendage.", + "Histopathology described the wall as being composed of myocardium and fibrotic tissue, indicating a true atrial aneurysm.", + "The patient’s postoperative course was uneventful.", + "At the 6-month follow-up, the patient remained asymptomatic and in sinus rhythm.", + "Transthoracic echocardiography revealed good correction of the LAAA and a normal size for the left atrium, with no evidence of abnormality." + ], + "summary": "We present a case of congenital giant LAAA in a female patient who successfully completed pregnancy and underwent caesarean section with no obvious complications. Surgical resection of the LAAA was performed 3 years later, at the onset of chest pain resulting from compression of adjacent cardiac structures by the LAAA.", + "summary_subclaims": [ + "The patient had congenital giant LAAA.", + "The patient successfully completed pregnancy.", + "The patient underwent caesarean section.", + "The caesarean section was performed with no obvious complications.", + "Surgical resection of the LAAA was performed 3 years after the caesarean section.", + "The surgical resection was performed at the onset of chest pain.", + "The chest pain resulted from compression of adjacent cardiac structures by the LAAA." + ] + }, + { + "id": "multiclinsum_test_1965_en.txt", + "fulltext": "A 68-year-old man was scheduled for elective coronary artery bypass graft surgery. He had a past history of hypertension, bronchial asthma, cerebral infarction, and myelodysplastic syndrome and has been on hemodialysis because of autosomal dominant polycystic kidney disease. He was alert and preoperative laboratory data were unremarkable except white blood cell count 2.24 × 103/μL, red blood cell count 3.83 × 103/μL, platelet count 9.1× 104/μL, creatinine 4.15 mg/dL, and B-type natriuretic peptide 161.9 pg/mL. Echocardiography demonstrated left ventricular ejection fraction 34%, mild aortic regurgitation, mild aortic stenosis, and mild mitral regurgitation. An IABP catheter (TRANS-RAY®, 7.5 Fr, 34 mL, Getinge AB, Lindholmspiren, Göteborg, Sweden) was inserted via the right femoral artery and connected to the console (Cardiosave® IABP Hybrid, Getinge AB), and circulatory support was started before surgery.\nIn the operating room, a radial arterial catheter was inserted and an electrode for monitoring PSI was placed on the forehead in addition to routine monitors. General anesthesia was induced with midazolam 3 mg and remifentanil 0.3 μg/kg/min and was maintained using sevoflurane in an air–oxygen mix after tracheal intubation. PSI value prior to CPB was between 30 and 50. Propofol was continuously infused with a target concentration of 3 μg/mL using an infusion pump (TERUMO TE-371, Diprifuser™, TERUMO, Tokyo, Japan), and heart rate was approximately 60 bpm during CPB. IABP was continuously operated using electrocardiogram-triggered mode (1:1) in order to provide pulsatile flow.\nPSI value was increased from 30 to 50 immediately after starting CPB and remarkably decreased after stopping IABP before partial clamping of the ascending aorta for anastomosis with the saphenous vein . PSI was increased to approximately 70 abruptly after resuming IABP, which did not respond to an increase of infusion rate of propofol and remifentanil and to a bolus administration of fentanyl 100 μg or midazolam 10 mg. PSI values varied between 6 and 88 in accordance with the stopping and restarting of IABP. It decreased to 14 after stopping IABP for hemostasis around the anastomosis and again rapidly increased to 80 corresponding to restart of IABP before weaning from CPB . EEG remained almost electrically silent, mean arterial blood pressure was around 40 mmHg, and rectal temperature was 35.3 °C during CPB with a flow rate of 2.5 L/min. Based on the EEG findings, we were certain that the patient was adequately anesthetized. After weaning the patient from CPB, the PSI value and EEG pattern spontaneously showed sedative status. Postoperatively, there was no evidence of intraoperative awareness, anesthetic drug delivery, or instrument trouble.", + "fulltext_subclaims": [ + "The patient was a 68-year-old man.", + "He was scheduled for elective coronary artery bypass graft surgery.", + "He had a past history of hypertension.", + "He had a past history of bronchial asthma.", + "He had a past history of cerebral infarction.", + "He had a past history of myelodysplastic syndrome.", + "He has been on hemodialysis because of autosomal dominant polycystic kidney disease.", + "Preoperative white blood cell count was 2.24 × 103/μL.", + "Preoperative red blood cell count was 3.83 × 103/μL.", + "Preoperative platelet count was 9.1 × 104/μL.", + "Preoperative creatinine was 4.15 mg/dL.", + "Preoperative B-type natriuretic peptide was 161.9 pg/mL.", + "Echocardiography demonstrated left ventricular ejection fraction 34%.", + "Echocardiography showed mild aortic regurgitation.", + "Echocardiography showed mild aortic stenosis.", + "Echocardiography showed mild mitral regurgitation.", + "An IABP catheter (TRANS-RAY®, 7.5 Fr, 34 mL, Getinge AB) was inserted via the right femoral artery.", + "The IABP catheter was connected to the console (Cardiosave® IABP Hybrid, Getinge AB).", + "Circulatory support was started before surgery.", + "In the operating room, a radial arterial catheter was inserted.", + "An electrode for monitoring PSI was placed on the forehead.", + "General anesthesia was induced with midazolam 3 mg.", + "General anesthesia was induced with remifentanil 0.3 μg/kg/min.", + "General anesthesia was maintained using sevoflurane in an air–oxygen mix after tracheal intubation.", + "PSI value prior to CPB was between 30 and 50.", + "Propofol was continuously infused with a target concentration of 3 μg/mL.", + "Heart rate was approximately 60 bpm during CPB.", + "IABP was operated using electrocardiogram-triggered mode (1:1).", + "PSI value was increased from 30 to 50 immediately after starting CPB.", + "PSI value remarkably decreased after stopping IABP before partial clamping of the ascending aorta.", + "PSI was increased to approximately 70 abruptly after resuming IABP.", + "PSI did not respond to an increase of infusion rate of propofol.", + "PSI did not respond to an increase of infusion rate of remifentanil.", + "PSI did not respond to a bolus administration of fentanyl 100 μg.", + "PSI did not respond to a bolus administration of midazolam 10 mg.", + "PSI values varied between 6 and 88 in accordance with the stopping and restarting of IABP.", + "PSI decreased to 14 after stopping IABP for hemostasis around the anastomosis.", + "PSI rapidly increased to 80 corresponding to restart of IABP before weaning from CPB.", + "EEG remained almost electrically silent during CPB.", + "Mean arterial blood pressure was around 40 mmHg during CPB.", + "Rectal temperature was 35.3 °C during CPB.", + "CPB was performed with a flow rate of 2.5 L/min.", + "Based on the EEG findings, the patient was adequately anesthetized.", + "After weaning from CPB, the PSI value and EEG pattern spontaneously showed sedative status.", + "Postoperatively, there was no evidence of intraoperative awareness.", + "Postoperatively, there was no evidence of anesthetic drug delivery.", + "Postoperatively, there was no evidence of instrument trouble." + ], + "summary": "A 68-year-old man was scheduled for coronary artery bypass graft surgery with IABP. General anesthesia was maintained using sevoflurane. Initial PSI was between 30 and 50 before CPB. Propofol was administered during CPB, and IABP provided pulsatile flow. IABP was stopped soon after the initiation of CPB, and the ascending aorta was partially clamped to anastomose the saphenous vein graft to the ascending aorta. The PSI value decreased drastically, but with resumption of IABP, the value increased to approximately 80, despite increasing the dose of anesthetics. Meanwhile, the EEG waveform was nearly flat. After discontinuing CPB, the PSI value returned to being extremely low. There was no evidence of intraoperative awareness or instrument trouble. After reviewing the anesthesia record, the high PSI value was almost consistent with ongoing IABP during CPB. We suspect that the oscillation noise created by IABP during CPB erroneously influences the PSI algorithm, resulting in a falsely high PSI.", + "summary_subclaims": [ + "A 68-year-old man was scheduled for coronary artery bypass graft surgery with IABP.", + "General anesthesia was maintained using sevoflurane.", + "Initial PSI was between 30 and 50 before CPB.", + "Propofol was administered during CPB.", + "IABP provided pulsatile flow.", + "IABP was stopped soon after the initiation of CPB.", + "The ascending aorta was partially clamped to anastomose the saphenous vein graft to the ascending aorta.", + "The PSI value decreased drastically.", + "With resumption of IABP, the value increased to approximately 80.", + "The EEG waveform was nearly flat.", + "After discontinuing CPB, the PSI value returned to being extremely low.", + "There was no evidence of intraoperative awareness.", + "There was no evidence of instrument trouble.", + "After reviewing the anesthesia record, the high PSI value was almost consistent with ongoing IABP during CPB.", + "We suspect that the oscillation noise created by IABP during CPB erroneously influences the PSI algorithm, resulting in a falsely high PSI." + ] + }, + { + "id": "multiclinsum_test_1139_en.txt", + "fulltext": "An 86-year-old male came to our attention seeking medical treatment for a growing lesion of the lower lip. The patient previously treated the lesion with topical antibiotics and steroids, with no improvement in the condition. The lesion was exophytic and with a warty appearance . Suspecting an SCC, the surgeon performed an excisional biopsy on the lesion. . A total body computerized tomography and an echography of neck and mandibular nodes were performed before surgery, showing no presence of suspect secondarisms.\nThe histopathological examination confirmed the diagnosis of SCC, describing a histologically well-differentiated lesion. HPV typization of the lesion showed positivity for HPV 16 after a conventional polymerase chain reaction assay. The margins of the lesions were not microscopically clear. Considering the patient’s old age and the unwillingness to undergo another surgical procedure, the patient, one month after surgery, was sent to the Dermatological Unit of Magna Graecia University, Catanzaro, for examination . The patient was there treated with topical 5% imiquimod (Aldara, Meda Pharma S.p.A, Milan, Italy) application on the affected area once a day for two weeks, then once a week. The patient performed another total body computerized tomography one and a half years after surgery due to the follow-up of internal malignancy. No signs of SCC-related manifestations were assessed. Two years after the initial surgical procedure, the patient has not developed any sign of systemic or local relapse of the condition .", + "fulltext_subclaims": [ + "The patient is an 86-year-old male.", + "The patient sought medical treatment for a growing lesion of the lower lip.", + "The lesion was exophytic and with a warty appearance.", + "The surgeon performed an excisional biopsy on the lesion.", + "A total body computerized tomography and an echography of neck and mandibular nodes were performed before surgery.", + "The histopathological examination confirmed the diagnosis of SCC.", + "The histopathological examination described a histologically well-differentiated lesion.", + "HPV typization of the lesion showed positivity for HPV 16 after a conventional polymerase chain reaction assay.", + "The margins of the lesions were not microscopically clear.", + "The patient was sent to the Dermatological Unit of Magna Graecia University, Catanzaro, for examination.", + "The patient was treated with topical 5% imiquimod (Aldara, Meda Pharma S.p.A, Milan, Italy) application on the affected area once a day for two weeks, then once a week.", + "The patient performed another total body computerized tomography one and a half years after surgery.", + "No signs of SCC-related manifestations were assessed.", + "Two years after the initial surgical procedure, the patient has not developed any sign of systemic or local relapse of the condition." + ], + "summary": "In this paper, we report the case of an 86-year-old patient with a well-differentiated SCC of the lower lip associated with HPV treated with surgery with a non-complete histological resolution. Imiquimod 5% cream was applied on the surgical scar once a day for two weeks and then once a week. Two years after SCC removal, no relapse has occurred.", + "summary_subclaims": [ + "The patient was an 86-year-old individual.", + "The patient had a well-differentiated SCC of the lower lip associated with HPV.", + "The SCC was treated with surgery.", + "The histological resolution after surgery was non-complete.", + "Imiquimod 5% cream was applied on the surgical scar once a day for two weeks.", + "After two weeks, Imiquimod 5% cream was applied once a week.", + "Two years after SCC removal, no relapse has occurred." + ] + }, + { + "id": "multiclinsum_test_176_en.txt", + "fulltext": "A 38-year-old woman with a medical history of type I diabetes mellitus and SPS initially presented to inpatient rehabilitation with intractable and painful muscle spasms due to SPS. The diagnosis of SPS was confirmed by elevated anti-glutamic acid decarboxylase antibody levels (>250 IU/mL). Her symptoms were episodic in nature and triggered by light palpation along the lower limbs. Emotional distress also worsened symptoms. Episodes would last up to 8 h per day. Examination was notable for severe and painful muscle flexor spasms, which were clonic and diffuse. The spasms were particularly notable in her left lower limb with corresponding left ankle inversion, and right upper limb with elbow flexion and forearm supination. The patient underwent serial up-titration of oral baclofen up to 15 mg 3 times a day and diazepam up to 20 mg every 6 h, with concurrent IVIG cycles, with only transient symptom control. Her symptoms made her non-ambulatory and limited her tolerance to using a wheelchair for mobility. She also required moderate-to-maximum assistance for bed mobility, transfers and lower limb dressing. The patient was subsequently referred to the spasticity clinic to be assessed for ITB therapy. She underwent a trial of a single bolus of 50 μg baclofen via a lumbar puncture at the L3–L4 interspace , resulting in a significant decrease in spontaneous spasms, which lasted for hours. She demonstrated modified independence on transfers and ambulation following the test dose procedure, without requiring an assistive device. The patient was then referred to neurosurgery and ultimately implanted with a SynchroMed II intrathecal delivery system (Medtronic, Inc. Minneapolis, Minnesota, USA), with the catheter tip placed at the T8 spinal level. Her post-procedural course was complicated only by a transient post-dural puncture headache. To date, her ITB has been titrated to 186 μg per day with simple continuous delivery. The patient was weaned off oral baclofen and required only intermittent oral diazepam, with 5 mg once or twice daily. To date, she has mild allodynia in the left lower limb. She attained complete functional independence with ambulation and continues ambulating without needing an assistive device. She remains independent in bed mobility, lower limb dressing, and transfers. She continues ITB therapy with occasional IVIG cycles, directed by neurology. Her baclofen dose has been stable for 36 months following the titration phase of therapy. She has experienced no lasting adverse effects from ITB therapy.", + "fulltext_subclaims": [ + "The patient is a 38-year-old woman.", + "She has a medical history of type I diabetes mellitus.", + "She has a medical history of stiff-person syndrome.", + "She presented with intractable and painful muscle spasms due to stiff-person syndrome.", + "The diagnosis of stiff-person syndrome was confirmed by elevated anti-glutamic acid decarboxylase antibody levels.", + "The anti-glutamic acid decarboxylase antibody levels were >250 IU/mL.", + "Her symptoms were episodic in nature.", + "Her symptoms were triggered by light palpation along the lower limbs.", + "Emotional distress worsened her symptoms.", + "Episodes lasted up to 8 h per day.", + "Examination was notable for severe and painful muscle flexor spasms.", + "The spasms were clonic and diffuse.", + "The spasms were particularly notable in her left lower limb.", + "The spasms were associated with left ankle inversion.", + "The spasms were particularly notable in her right upper limb.", + "The spasms were associated with elbow flexion and forearm supination.", + "She underwent serial up-titration of oral baclofen up to 15 mg 3 times a day.", + "She underwent serial up-titration of diazepam up to 20 mg every 6 h.", + "She received concurrent IVIG cycles.", + "She had only transient symptom control.", + "Her symptoms made her non-ambulatory.", + "She required moderate-to-maximum assistance for bed mobility.", + "She required moderate-to-maximum assistance for transfers.", + "She required moderate-to-maximum assistance for lower limb dressing.", + "She was referred to the spasticity clinic to be assessed for intrathecal baclofen therapy.", + "She underwent a trial of a single bolus of 50 μg baclofen via a lumbar puncture.", + "The lumbar puncture was performed at the L3–L4 interspace.", + "The trial resulted in a significant decrease in spontaneous spasms.", + "The decrease in spasms lasted for hours.", + "She demonstrated modified independence on transfers following the test dose procedure.", + "She demonstrated modified independence on ambulation following the test dose procedure.", + "She did not require an assistive device following the test dose procedure.", + "She was implanted with a SynchroMed II intrathecal delivery system.", + "The catheter tip was placed at the T8 spinal level.", + "Her post-procedural course was complicated only by a transient post-dural puncture headache.", + "Her intrathecal baclofen has been titrated to 186 μg per day.", + "She was weaned off oral baclofen.", + "She required only intermittent oral diazepam.", + "She took 5 mg of diazepam once or twice daily.", + "She has mild allodynia in the left lower limb.", + "She attained complete functional independence with ambulation.", + "She continues ambulating without needing an assistive device.", + "She remains independent in bed mobility.", + "She remains independent in lower limb dressing.", + "She remains independent in transfers.", + "She continues intrathecal baclofen therapy.", + "She receives occasional IVIG cycles.", + "Her baclofen dose has been stable for 36 months following the titration phase of therapy.", + "She has experienced no lasting adverse effects from intrathecal baclofen therapy." + ], + "summary": "A 38-year-old woman with stiff- person syndrome initially presented to inpatient rehabilitation for intractable muscle spasms. The symptoms made her non-ambulatory and limited her tolerance to wheelchair use for mobility. The patient underwent up-titration of oral baclofen and diazepam, with concurrent intravenous immunoglobulin cycles, leading to transient symptom relief. She agreed to explore intrathecal baclofen therapy. An initial trial of a single bolus of 50 μg intrathecal baclofen resulted in a significant decrease in spontaneous spasms, enabling modified independence in transfers and ambulation. The patient was subsequently implanted with a permanent intrathecal delivery system. To date, the intrathecal baclofen had been titrated to 186 μg per day with simple continuous delivery. The patient was weaned off oral baclofen. She attained complete functional independence with ambulation without the need for assistive devices, and has had no lasting post-procedural complications to date.", + "summary_subclaims": [ + "The patient is a 38-year-old woman with stiff-person syndrome.", + "She initially presented to inpatient rehabilitation for intractable muscle spasms.", + "The symptoms made her non-ambulatory.", + "The symptoms limited her tolerance to wheelchair use for mobility.", + "The patient underwent up-titration of oral baclofen.", + "The patient underwent up-titration of oral diazepam.", + "The patient had concurrent intravenous immunoglobulin cycles.", + "The treatment led to transient symptom relief.", + "She agreed to explore intrathecal baclofen therapy.", + "An initial trial of a single bolus of 50 μg intrathecal baclofen resulted in a significant decrease in spontaneous spasms.", + "The trial enabled modified independence in transfers.", + "The trial enabled modified independence in ambulation.", + "The patient was implanted with a permanent intrathecal delivery system.", + "Intrathecal baclofen had been titrated to 186 μg per day with simple continuous delivery.", + "The patient was weaned off oral baclofen.", + "She attained complete functional independence with ambulation without the need for assistive devices.", + "She has had no lasting post-procedural complications to date." + ] + }, + { + "id": "multiclinsum_test_3383_en.txt", + "fulltext": "Patient information: A 64-year-old housewife with no significant medical history presented with dysphagia to solids accompanied by a foreign body sensation in the pharynx for one month, which had not improved with symptomatic treatment. She had no respiratory difficulties or dysphonia. Her general condition was stable and she had no fever.\n\nClinical findings: On clinical examination, no abnormality or peripheral adenopathy was found. Nasofibroscopy showed a pink polypoid tumour with a smooth surface and healthy mucosa, located on the left ary-epiglottic fold and its attached pedicle in the left retro-crico-arytenoid region.\n\nDiagnostic evaluation: cervical-thoracic CT scan revealed a well-defined polyploid mass of homogeneous tissue density that was enhanced in the post-contrast phase, located at the posterior wall of the hypopharynx. It extended anteriorly to the supraglottic level and was in contact with the laryngeal aspect of the epiglottis. Direct laryngoscopy under general anesthesia with multiple biopsies revealed a pink polyploid mass at the supraglottic level. Histological analysis revealed a large lymphoid cell infiltrate with irregular nuclear outlines and multiple prominent nucleoli. Immunohistochemical analysis of the tumor cells showed a positive expression of CD20, but not CD5, CD7, CD23, CD10, cyclin D1, LEF1, and Bcl6. Scattered plasma cells were identified, which retained CD138, but were present in a limited number. Proliferation index, evaluated with Ki67 marker, was 25%. Based on these findings, a diagnosis of a low-grade B lymphoma, consistent with a marginal zone lymphoma, was made. The laboratory findings were normal, including a complete blood count, inflammatory markers, and LDH. Extensive examinations, including a thoraco-abdomino-pelvic CT scan and a bone marrow biopsy, revealed no abnormalities, which allowed the disease stage to be determined as IEBa according to the Ann Arbor classification.\n\nTherapeutic intervention: The patient received four courses of R-CEOP chemotherapy, which consists of a mixture of rituximab and various products, including cyclophosphamide, etoposide, vincristine and prednisone. After each course, appropriate intervals were observed, followed by radiotherapy. Radiotherapy was administered over a period of four weeks, with a total dose of 40 Gy. It was divided into five sessions of 2 Gy per week, targeting the tumour site as well as the adjacent lymph nodes, including the upper mediastinum.\n\nFollow-up and results: the side effects of the treatment were minimal. After three months of treatment, the dysphagia had completely disappeared. The endoscopic and tomodensitometric control examinations performed six months later revealed normal results. The evolution was favorable, without any sign of local recurrence. The follow-up period extends over two years.\n", + "fulltext_subclaims": [ + "The patient is a 64-year-old housewife with no significant medical history.", + "She presented with dysphagia to solids and a foreign body sensation in the pharynx for one month.", + "The symptoms had not improved with symptomatic treatment.", + "She had no respiratory difficulties or dysphonia.", + "Her general condition was stable.", + "She had no fever.", + "On clinical examination, no abnormality or peripheral adenopathy was found.", + "Nasofibroscopy showed a pink polypoid tumour with a smooth surface and healthy mucosa.", + "The tumour was located on the left ary-epiglottic fold and its attached pedicle in the left retro-crico-arytenoid region.", + "Cervical-thoracic CT scan revealed a well-defined polyploid mass of homogeneous tissue density.", + "The mass was enhanced in the post-contrast phase.", + "The mass was located at the posterior wall of the hypopharynx.", + "It extended anteriorly to the supraglottic level.", + "It was in contact with the laryngeal aspect of the epiglottis.", + "Direct laryngoscopy under general anesthesia with multiple biopsies revealed a pink polyploid mass at the supraglottic level.", + "Histological analysis revealed a large lymphoid cell infiltrate with irregular nuclear outlines and multiple prominent nucleoli.", + "Immunohistochemical analysis of the tumor cells showed positive expression of CD20.", + "The tumor cells did not express CD5, CD7, CD23, CD10, cyclin D1, LEF1, and Bcl6.", + "Scattered plasma cells were identified, which retained CD138.", + "The plasma cells were present in a limited number.", + "The proliferation index, evaluated with Ki67 marker, was 25%.", + "A diagnosis of a low-grade B lymphoma, consistent with a marginal zone lymphoma, was made.", + "The laboratory findings were normal, including a complete blood count, inflammatory markers, and LDH.", + "Extensive examinations, including a thoraco-abdomino-pelvic CT scan and a bone marrow biopsy, revealed no abnormalities.", + "The disease stage was determined as IEBa according to the Ann Arbor classification.", + "The patient received four courses of R-CEOP chemotherapy.", + "R-CEOP chemotherapy consists of a mixture of rituximab, cyclophosphamide, etoposide, vincristine, and prednisone.", + "After each course, appropriate intervals were observed, followed by radiotherapy.", + "Radiotherapy was administered over a period of four weeks.", + "The total dose of radiotherapy was 40 Gy.", + "Radiotherapy was divided into five sessions of 2 Gy per week.", + "Radiotherapy targeted the tumour site as well as the adjacent lymph nodes, including the upper mediastinum.", + "The side effects of the treatment were minimal.", + "After three months of treatment, the dysphagia had completely disappeared.", + "Endoscopic and tomodensitometric control examinations performed six months later revealed normal results.", + "The evolution was favorable, without any sign of local recurrence.", + "The follow-up period extends over two years." + ], + "summary": "We present the exceptional case of a 64-year-old non-smoking woman with dysphagia to solids and a foreign body sensation. Laryngoscopy and biopsies revealed a polyploid tumour on the left ary-epiglottic fold, confirmed as a diffuse large cell non-Hodgkin's B-cell lymphoma. The patient received chemotherapy followed by radiotherapy, with a marked improvement in the 2 years of follow-up, without local recurrence. Because of its rarity and the variety of symptoms, the optimal management of this type of cancer remains controversial, requiring a specific diagnostic and therapeutic approach, which makes it an interesting case to publish.\n", + "summary_subclaims": [ + "The patient is a 64-year-old non-smoking woman.", + "The patient had dysphagia to solids.", + "The patient had a foreign body sensation.", + "Laryngoscopy and biopsies revealed a polyploid tumour on the left ary-epiglottic fold.", + "The tumour was confirmed as a diffuse large cell non-Hodgkin's B-cell lymphoma.", + "The patient received chemotherapy.", + "The patient received radiotherapy.", + "There was a marked improvement in the 2 years of follow-up.", + "There was no local recurrence.", + "The optimal management of this type of cancer remains controversial.", + "A specific diagnostic and therapeutic approach is required.", + "This case is considered interesting to publish." + ] + }, + { + "id": "multiclinsum_test_898_en.txt", + "fulltext": "A Chinese 3-year-old girl, who had normal intelligence and an unremarkable medical history and family history, was hospitalized in June 2022 because she was suffering from the terrible pain in the lower limbs and abnormal gait for 4 days. She had no recent vaccination, obvious digestive, or respiratory symptoms before the onset of the symptoms. On admission, physical examinations showed positivity for the following main nervous system signs: nuchal rigidity; bilateral ptosis; facial nerve weakness (showing complete disappearances of frontal wrinkles and a decrease depth of the bilateral nasolabial sulcus), which was slightly more prominent on the right side; hand tremors and severe truncal ataxia resulting in poor balance and head control; low muscular tension; areflexia in all limbs; and Romberg’s sign. The muscle strength of the bilateral distal and proximal limbs was grade II and grade III, respectively. In the hospital for 5 days, she had hoarseness, ptyalism, and dysphagia, with no influence on slowly drinking and eating fluid food. In the 11 days of her illness, her condition becomes worse, with undergoing urinary and fecal incontinence and excessive sweating. The findings of cranial MRI and cervical and thoracic spinal MRI were normal. Early in the disease course, nerve conduction studies (NCS) findings showed that the absence of compound muscle action potentials (CMAP) in the right facial nerve, the amplitude of the distal CMAPs was obviously decayed in the left facial nerve, and the bilateral tibial and common fibular nerves, the CMAP amplitude was reduced, the motor nerve conduction velocity (m-NCV) was slowed, sensory nerve action potentials (SNAPs) could not be detected in the common fibular nerve, and F-wave latency and H-wave absence were observed . Lumbar puncture was performed 1 week after onset, and cerebrospinal fluid (CSF) analysis showed that the protein level was 1.2 g/L (normal values 0.2–0.4 g/L), while the white blood cell count was 3 × 106/L (normal values 0–5 × 106/L). Her acute-phase serum and CSF samples were investigated by enzyme-linked immunosorbent assay for anti-ganglioside antibodies (for sulfatides, GM1, GM2, GM3, GM4, GD1a, GD1b, GD2, GD3, GT1a, GT1b, and GQ1b), including IgG and IgM. Only anti-GM4 IgG antibodies were detected, and the other 11 antigen tests had negative results. A clinical diagnosis of overlapping MFS/GBS was made based on the patient’s clinical presentation. Intravenous immunoglobulin (IVIG) therapy at the dosage of 2.0 g/kg was immediately initiated on the seventh day of the course of disease, followed by rehabilitation therapy. The neurological symptoms were gradually resolved by 1 month from the onset of symptoms in the sequence of neuropathic pain, ataxia, autonomic dysfunction, cranial nerve palsy, peripheral nerve paralysis. During an ill period of 3 months, her motor strength was 4/5 bilaterally in all limbs, with a complete improvement in her multiple cranial nerve palsies.", + "fulltext_subclaims": [ + "The patient was a Chinese 3-year-old girl.", + "She had normal intelligence.", + "She had an unremarkable medical history.", + "She had an unremarkable family history.", + "She was hospitalized in June 2022.", + "She was suffering from pain in the lower limbs.", + "She had abnormal gait.", + "The symptoms had been present for 4 days.", + "She had no recent vaccination.", + "She had no obvious digestive symptoms.", + "She had no obvious respiratory symptoms.", + "On admission, physical examinations showed positivity for nuchal rigidity.", + "On admission, physical examinations showed bilateral ptosis.", + "On admission, physical examinations showed facial nerve weakness.", + "Facial nerve weakness showed complete disappearances of frontal wrinkles.", + "Facial nerve weakness showed a decrease depth of the bilateral nasolabial sulcus.", + "Facial nerve weakness was slightly more prominent on the right side.", + "On admission, physical examinations showed hand tremors.", + "On admission, physical examinations showed severe truncal ataxia.", + "Severe truncal ataxia resulted in poor balance.", + "Severe truncal ataxia resulted in poor head control.", + "On admission, physical examinations showed low muscular tension.", + "On admission, physical examinations showed areflexia in all limbs.", + "On admission, physical examinations showed Romberg’s sign.", + "The muscle strength of the bilateral distal limbs was grade II.", + "The muscle strength of the bilateral proximal limbs was grade III.", + "In the hospital for 5 days, she had hoarseness.", + "In the hospital for 5 days, she had ptyalism.", + "In the hospital for 5 days, she had dysphagia.", + "In the hospital for 5 days, she could slowly drink and eat fluid food.", + "In the 11 days of her illness, her condition becomes worse.", + "In the 11 days of her illness, she underwent urinary and fecal incontinence.", + "In the 11 days of her illness, she had excessive sweating.", + "The findings of cranial MRI were normal.", + "The findings of cervical spinal MRI were normal.", + "The findings of thoracic spinal MRI were normal.", + "Early in the disease course, nerve conduction studies showed the absence of compound muscle action potentials in the right facial nerve.", + "Early in the disease course, nerve conduction studies showed the amplitude of the distal CMAPs was obviously decayed in the left facial nerve.", + "Early in the disease course, nerve conduction studies showed the CMAP amplitude was reduced in the bilateral tibial and common fibular nerves.", + "Early in the disease course, nerve conduction studies showed the motor nerve conduction velocity was slowed.", + "Early in the disease course, nerve conduction studies showed sensory nerve action potentials could not be detected in the common fibular nerve.", + "Early in the disease course, nerve conduction studies showed F-wave latency.", + "Early in the disease course, nerve conduction studies showed H-wave absence.", + "Lumbar puncture was performed 1 week after onset.", + "Cerebrospinal fluid analysis showed the protein level was 1.2 g/L.", + "Cerebrospinal fluid analysis showed the white blood cell count was 3 × 106/L.", + "Acute-phase serum and CSF samples were investigated by enzyme-linked immunosorbent assay for anti-ganglioside antibodies.", + "Only anti-GM4 IgG antibodies were detected.", + "The other 11 antigen tests had negative results.", + "A clinical diagnosis of overlapping MFS/GBS was made.", + "Intravenous immunoglobulin therapy at the dosage of 2.0 g/kg was initiated on the seventh day of the course of disease.", + "Neurological symptoms were gradually resolved by 1 month from the onset.", + "Neurological symptoms resolved in the sequence of neuropathic pain, ataxia, autonomic dysfunction, cranial nerve palsy, peripheral nerve paralysis.", + "During an ill period of 3 months, her motor strength was 4/5 bilaterally in all limbs.", + "During an ill period of 3 months, there was a complete improvement in her multiple cranial nerve palsies." + ], + "summary": "Here, we report a Chinese girl who was diagnosed with overlapping MFS/GBS showing acute flaccid paralysis of all four limbs, sensory symptoms, cranial nerve dysfunction, autonomic involvement, ophthalmoplegia, and ataxia. She had high serum and cerebrospinal fluid titres of monospecific anti-GM4 IgG antibody instead of anti-GQ1b antibody in the acute phase.", + "summary_subclaims": [ + "The patient was diagnosed with overlapping MFS/GBS.", + "The patient showed acute flaccid paralysis of all four limbs.", + "The patient had sensory symptoms.", + "The patient had cranial nerve dysfunction.", + "The patient had autonomic involvement.", + "The patient had ophthalmoplegia.", + "The patient had ataxia.", + "The patient had high serum titres of monospecific anti-GM4 IgG antibody in the acute phase.", + "The patient had high cerebrospinal fluid titres of monospecific anti-GM4 IgG antibody in the acute phase.", + "The patient did not have anti-GQ1b antibody in the acute phase." + ] + }, + { + "id": "multiclinsum_test_3359_en.txt", + "fulltext": "67-year-old woman with a history of hypertension, obesity, former smoker of 20 packs/year and pulmonary thromboembolism in 2020. She had no known history of immunosuppression, nor regular consumption of antibiotics or corticosteroids. She consulted the emergency room for abdominal pain of 4 days' evolution, located in the epigastrium and right hypochondrium, of a colic type. She also had nausea and vomiting. In the 24 hours before the consultation, she added jaundice, coluria and acolia. In the physical examination, she had jaundice, painful abdomen in the right hypochondrium, without peritoneal reaction. The laboratory analyses showed a normal white blood cell count and hyperbilirubinaemia with a direct predominance (total bilirubin 2.7 mg/dl). An abdominal ultrasound was performed, which reported a thin-walled gallbladder with a 17 mm stone and an endoscopic retrograde cholangiopancreatography (ERCP), which reported a lithogenic image embedded in the mouth of the common bile duct of 6 mm, associated with mild dilation. With a diagnosis of mild cholangitis, the patient initiated treatment with ampicillin sulbactam. She evolved with leukocytosis, febrile records, increased bilirubin, as well as oligoanuria and altered level of consciousness, so the treatment was changed to piperacillin tazobactam and an endoscopic retrograde cholangiopancreatography (ERCP) was performed, in which a dilation of the extrahepatic bile duct was observed (9 mm) with lithogenic images inside, the sphincteropylothomy was performed, and the exit of purulent material and lithogenic fragments was observed. A biliary stent was placed. Blood cultures were taken, which were negative. After the procedure, the patient evolved afebrile, with an improvement in the clinical picture. Gram-negative bacilli and yeasts were identified in the direct microscopic examination of the bile liquid, and Klebsiella pneumoniae BLEE and Candida glabrata were isolated in the culture. The patient completed 7 days of treatment with piperacillin tazobactam and anidulafungin, with a good evolution and subsequent hospital discharge. The patient signed the corresponding informed consent.\n", + "fulltext_subclaims": [ + "The patient is a 67-year-old woman.", + "She has a history of hypertension.", + "She has a history of obesity.", + "She is a former smoker with a 20 pack-year history.", + "She had a pulmonary thromboembolism in 2020.", + "She had no known history of immunosuppression.", + "She had no regular consumption of antibiotics.", + "She had no regular consumption of corticosteroids.", + "She consulted the emergency room for abdominal pain of 4 days' evolution.", + "The abdominal pain was located in the epigastrium and right hypochondrium.", + "The abdominal pain was of a colic type.", + "She had nausea and vomiting.", + "In the 24 hours before the consultation, she added jaundice.", + "In the 24 hours before the consultation, she had coluria.", + "In the 24 hours before the consultation, she had acolia.", + "In the physical examination, she had jaundice.", + "In the physical examination, she had a painful abdomen in the right hypochondrium.", + "The laboratory analyses showed a normal white blood cell count.", + "The laboratory analyses showed hyperbilirubinaemia with a direct predominance.", + "The total bilirubin was 2.7 mg/dl.", + "An abdominal ultrasound was performed.", + "The abdominal ultrasound reported a thin-walled gallbladder.", + "The abdominal ultrasound reported a 17 mm stone.", + "An endoscopic retrograde cholangiopancreatography (ERCP) was performed.", + "The ERCP reported a lithogenic image embedded in the mouth of the common bile duct.", + "The lithogenic image was 6 mm.", + "The ERCP reported mild dilation.", + "The diagnosis was mild cholangitis.", + "The patient initiated treatment with ampicillin sulbactam.", + "The patient evolved with leukocytosis.", + "The patient had febrile records.", + "The patient had increased bilirubin.", + "The patient had oligoanuria.", + "The patient had an altered level of consciousness.", + "The treatment was changed to piperacillin tazobactam.", + "An endoscopic retrograde cholangiopancreatography (ERCP) was performed.", + "The ERCP observed a dilation of the extrahepatic bile duct.", + "The dilation was 9 mm.", + "The ERCP observed lithogenic images inside.", + "Sphincterotomy was performed.", + "The exit of purulent material was observed.", + "The exit of lithogenic fragments was observed.", + "A biliary stent was placed.", + "Blood cultures were taken.", + "The blood cultures were negative.", + "After the procedure, the patient evolved afebrile.", + "After the procedure, the patient had an improvement in the clinical picture.", + "Gram-negative bacilli were identified in the direct microscopic examination of the bile liquid.", + "Yeasts were identified in the direct microscopic examination of the bile liquid.", + "Klebsiella pneumoniae BLEE was isolated in the culture.", + "Candida glabrata was isolated in the culture.", + "The patient completed 7 days of treatment with piperacillin tazobactam.", + "The patient completed 7 days of treatment with anidulafungin.", + "The patient had a good evolution.", + "The patient was subsequently discharged from the hospital.", + "The patient signed the corresponding informed consent." + ], + "summary": "We present the case of a 67-year-old woman with no history of the above, who presented with fever, abdominal pain and jaundice. Magnetic resonance imaging of the abdomen showed a stony image in the common bile duct with dilation of the bile duct. She required endoscopic drainage of the biliary tract. Direct microscopic examination of the bile fluid showed yeast and Gram-negative bacilli, and the culture isolated Klebsiella pneumoniae producing extended spectrum beta-lactamase (ESBL) and Candida glabrata. The patient completed the antibiotic treatment with piperacillin tazobactam and anidulafungin with good evolution.\n", + "summary_subclaims": [ + "The patient is a 67-year-old woman.", + "The patient had no history of the above.", + "The patient presented with fever.", + "The patient presented with abdominal pain.", + "The patient presented with jaundice.", + "Magnetic resonance imaging of the abdomen showed a stony image in the common bile duct.", + "Magnetic resonance imaging of the abdomen showed dilation of the bile duct.", + "The patient required endoscopic drainage of the biliary tract.", + "Direct microscopic examination of the bile fluid showed yeast.", + "Direct microscopic examination of the bile fluid showed Gram-negative bacilli.", + "The culture isolated Klebsiella pneumoniae producing extended spectrum beta-lactamase (ESBL).", + "The culture isolated Candida glabrata.", + "The patient completed the antibiotic treatment with piperacillin tazobactam.", + "The patient completed the antibiotic treatment with anidulafungin.", + "The patient had good evolution." + ] + }, + { + "id": "multiclinsum_test_3033_en.txt", + "fulltext": "Patient and observation\nA 36-year-old female patient with obesity (Body Mass Index: 34) presented to our service after a fall down the stairs, causing an indirect injury to her right elbow.\n\nThe initial clinical examination showed signs of trauma to the upper limb, without any distal neurovascular deficit.\n\nRadiographs revealed a 2R2A2 radial diaphyseal fracture and a 2R1A2 radial neck fracture with approximately 15° of angulation, along with a posterolateral humeroulnar dislocation.\n\nThe first step was an emergency reduction of the humeroulnar dislocation. Ligament testing was difficult due to the diaphyseal fracture. The patient was immobilized in a BABP splint, and a computed tomography (CT) scan was performed to assess the potential involvement of the stabilizing structures of the elbow. No coronoid involvement was noted.\n\nThe second step involved osteosynthesis of the radial diaphysis under regional anesthesia using a compression plate (Synthes), with a working length two screw holes and a lever arm spanning six contiguous cortices on both sides.\n\nThe third step involved elbow testing, which showed no recurrence of dislocation up to −40° extension, but a persistent displacement of the radial neck fracture.\n\nThe fourth step included a reduction and osteosynthesis via a Cadenat approach (between the ulnar extensor and the anconeus muscle), exposing the fracture, particularly the metaphyseal shift, while protecting the motor branch of the radial nerve by keeping the elbow in pronation. The fracture was then stabilized using an anatomical radial head plate (Trilock Radial Head Plates, Medartis), and the posterolateral structure was reattached. Given the good stability of the elbow, no additional medial procedure was performed.\n\nThe patient was immobilized for 6 weeks in a brachio-antebrachial-palmar splint, with immediate rehabilitation for flexion and extension. Pronation and supination were allowed starting from the third week.\n\nAt 6 weeks, the patient's range of motion was as follows (in degrees): Flexion-extension: 10°/0°/20°; Pronation-supination: 0°/0°/10°, with a deficit in thumb flexion. At 3 months, the range of motion was: Flexion-extension: 0°/40°/120°; Pronation-supination: 0°/60°/110°, with radial hypoesthesia but no motor deficit. At 5 months, the range of motion improved to: Flexion-extension: 0°/10°/140°; Pronation-supination: 0°/20°/180°, with complete recovery of thumb flexion and partial hypoesthesia in the radial nerve territory. The patient was able to resume her professional activities at 5 months postoperatively, working as a funeral director.", + "fulltext_subclaims": [ + "The patient is a 36-year-old female with obesity (Body Mass Index: 34).", + "She presented after a fall down the stairs, causing an indirect injury to her right elbow.", + "The initial clinical examination showed signs of trauma to the upper limb.", + "There was no distal neurovascular deficit.", + "Radiographs revealed a 2R2A2 radial diaphyseal fracture.", + "Radiographs revealed a 2R1A2 radial neck fracture with approximately 15° of angulation.", + "Radiographs showed a posterolateral humeroulnar dislocation.", + "The first step was an emergency reduction of the humeroulnar dislocation.", + "Ligament testing was difficult due to the diaphyseal fracture.", + "The patient was immobilized in a BABP splint.", + "A computed tomography (CT) scan was performed.", + "No coronoid involvement was noted.", + "The second step involved osteosynthesis of the radial diaphysis under regional anesthesia.", + "A compression plate (Synthes) was used.", + "The plate had a working length two screw holes.", + "The lever arm spanned six contiguous cortices on both sides.", + "The third step involved elbow testing.", + "Elbow testing showed no recurrence of dislocation up to −40° extension.", + "There was a persistent displacement of the radial neck fracture.", + "The fourth step included a reduction and osteosynthesis via a Cadenat approach.", + "The Cadenat approach was between the ulnar extensor and the anconeus muscle.", + "The fracture was stabilized using an anatomical radial head plate (Trilock Radial Head Plates, Medartis).", + "The posterolateral structure was reattached.", + "No additional medial procedure was performed.", + "The patient was immobilized for 6 weeks in a brachio-antebrachial-palmar splint.", + "Immediate rehabilitation for flexion and extension was started.", + "Pronation and supination were allowed starting from the third week.", + "At 6 weeks, the range of motion was: Flexion-extension: 10°/0°/20°.", + "At 6 weeks, Pronation-supination: 0°/0°/10°.", + "At 6 weeks, there was a deficit in thumb flexion.", + "At 3 months, the range of motion was: Flexion-extension: 0°/40°/120°.", + "At 3 months, Pronation-supination: 0°/60°/110°.", + "At 3 months, there was radial hypoesthesia but no motor deficit.", + "At 5 months, the range of motion improved to: Flexion-extension: 0°/10°/140°.", + "At 5 months, Pronation-supination: 0°/20°/180°.", + "At 5 months, there was complete recovery of thumb flexion.", + "At 5 months, there was partial hypoesthesia in the radial nerve territory.", + "The patient was able to resume her professional activities at 5 months postoperatively.", + "The patient works as a funeral director." + ], + "summary": "A 36-year-old obese female patient was admitted to our service after a low-energy fall in stairs. She presented with a radial diaphyseal fracture, a radial neck fracture with approximately 15° angulation, and a posterolateral elbow dislocation. The first procedure involved an urgent reduction of the elbow dislocation, followed by surgical fixation of the bifocal radial fractures and reattachment of the external and posterolateral elbow structures.", + "summary_subclaims": [ + "The patient is a 36-year-old obese female.", + "The patient was admitted after a low-energy fall in stairs.", + "The patient presented with a radial diaphyseal fracture.", + "The patient presented with a radial neck fracture with approximately 15° angulation.", + "The patient presented with a posterolateral elbow dislocation.", + "The first procedure involved an urgent reduction of the elbow dislocation.", + "The first procedure involved surgical fixation of the bifocal radial fractures.", + "The first procedure involved reattachment of the external and posterolateral elbow structures." + ] + }, + { + "id": "multiclinsum_test_1843_en.txt", + "fulltext": "A 56-year-old woman had been followed up for two years before the initial visit with suspected age-related macular degeneration oculus sinister (OS) at a previous clinic. One year before the initial visit, her best-corrected visual acuity (BCVA) was 0.9 OS, and fluorescence angiography (FA) showed leakage of fluorescence at the macula, which indicated the possibility of central serous chorioretinopathy at the clinic. One month before the initial visit, SRD was observed with BCVA of 0.5 OS, and local photocoagulation was performed. However, due to residual SRD and worsening visual impairment OS, she was referred to our hospital. Her medical history was limited to the inguinal hernia surgery 20 years ago, and she had neither a smoking habit nor family history. At the initial examination, her BCVA was 1.5 oculus dexter (OD) and 0.8 OS, with normal intraocular pressure oculi uterque (OU). Slit-lamp microscopy did not detect any findings OU. Color fundus photography (CFP) showed no abnormality OD , while an irregular brownish lesion was noted around the macula OS . Therefore, coloration of the posterior pole in the left eye was generally more yellowish-brown than the right eye. Although swept-source (SS)-OCT images (DRI OCT Triton; Topcon Inc., Tokyo, Japan) demonstrated no abnormalities of retino-choroidal structures OD , SS-OCT showed the markedly hyporeflective choroidal structure OS as well as SRD where the retinal thickness was preserved. Moreover, the lumen of the choriocapillaris was suggested to be compressed beneath the RPE layer OS . FAF indicated enlarged macular hypoautofluorescence suggesting chronic RPE damage OS . There was no choroidal elevation on B-mode echography OU . FA revealed reduced choroidal perfusion in the macula in the early phase and scattered focal hyperfluorescent spots that intensified from early to late phase OS . Indocyanine green angiography (ICGA) demonstrated serpiginous-like fluorescence blockade throughout OS . There was no obvious abnormal shadow on orbital magnetic resonance imaging. Based on the clinical findings, her left eye was diagnosed with choroidal melanocytosis together with SRD. Central serous chorioretinopathy was ruled out by the absence of choroidal thickening on SS-OCT, descending tract on FAF, and choroidal vascular hyperpermeability on ICGA. The absence of choroidal elevation observed by fundus examination and echography, and irregular melanin pigmentation of the choroid supported the diagnosis of choroidal melanocytosis rather than choroidal nevus. She was observed without any treatment. Fifty-eight months after the initial diagnosis, her BCVA was 0.5, CFP showed slightly darker macular pigmentation, and SRD persisted on SS-OCT.\nThe institutional review board of Hokkaido University waived the need for ethical assessment of this clinical study because of it being a single case report with a non-invasive study. This study adhered to the tenets of the Declaration of Helsinki.\nThis study evaluated the alterations of choroidal blood flow of choroidal melanocytosis using LSFG. Relative blood flow values were obtained as the mean blur rate (MBR) after quantitative measurement of blood flow velocity by LSFG software (LSFG-NAVI, version 3.1.39.2, Softcare Ltd., Fukuoka, Japan) according to previous reports [, ]. The pupils of the patient were dilated with 0.4% tropicamide (Mydrin-M; Santen Pharmaceutical Co., Ltd., Osaka) before examination. Ophthalmic examinations were conducted after pupils of both eyes had completely lost their light reflex. The macula in the LSFG images was manually marked and vessels were automatically segmented using threshold values defined by the system software (LSFG Analyzer, version 3.0.47.0). The macular area was identified by an experienced examiner by comparing the initial FA images and FAF images. Since LSFG images also show retinal blood vessels, the macular area was determined by comparing their length and vascular runways with the FA images. A circle of about 750 μm in diameter to the fovea was defined as the region of interest on LSFG , based on FA findings. Four to five consecutive measurements were taken for each circle, and the mean values were used for analysis. All examinations were conducted by a single experienced operator. Ocular perfusion pressure (OPP) was calculated using the patient’s blood pressure and intraocular pressure, as previously described [, ].\nThe MBR values OD are shown in Fig. B as follows: 10.9, 10.6, 10.1, and 9.0 arbitrary units (AU) at 18, 24, 36, and 58 months after the initial visit, respectively. The MBR values OS are shown in Fig. B as follows: 1.24, 1.30, 1.32, 1.28, and 1.42 AU at 12, 18, 24, 36, and 58 months after the initial visit, respectively. The MBR (mean ± standard deviation) for 58 months was 10.15 ± 0.72 AU OD and 1.31 ± 0.06 AU OS. OPP was 82.2, 76.2, 82.9, 73.0, and 68.0 mmHg OD, and 83.2, 78.2, 82.9, 72.0, and 69.0 mmHg OS at 12, 18, 24, 36, and 58 months after the initial visit OS, respectively, revealing no significant changes in either eye.", + "fulltext_subclaims": [ + "The patient was a 56-year-old woman.", + "She had been followed up for two years before the initial visit with suspected age-related macular degeneration oculus sinister (OS) at a previous clinic.", + "One year before the initial visit, her best-corrected visual acuity (BCVA) was 0.9 OS.", + "Fluorescence angiography (FA) showed leakage of fluorescence at the macula.", + "The leakage of fluorescence at the macula indicated the possibility of central serous chorioretinopathy.", + "One month before the initial visit, subretinal fluid (SRD) was observed with BCVA of 0.5 OS.", + "Local photocoagulation was performed one month before the initial visit.", + "Due to residual SRD and worsening visual impairment OS, she was referred to our hospital.", + "Her medical history was limited to inguinal hernia surgery 20 years ago.", + "She had neither a smoking habit nor family history.", + "At the initial examination, her BCVA was 1.5 oculus dexter (OD) and 0.8 OS.", + "Intraocular pressure was normal oculi uterque (OU).", + "Slit-lamp microscopy did not detect any findings OU.", + "Color fundus photography (CFP) showed no abnormality OD.", + "An irregular brownish lesion was noted around the macula OS.", + "Coloration of the posterior pole in the left eye was generally more yellowish-brown than the right eye.", + "Swept-source (SS)-OCT images demonstrated no abnormalities of retino-choroidal structures OD.", + "SS-OCT showed the markedly hyporeflective choroidal structure OS.", + "SS-OCT showed subretinal fluid where the retinal thickness was preserved.", + "The lumen of the choriocapillaris was suggested to be compressed beneath the RPE layer OS.", + "Fundus autofluorescence (FAF) indicated enlarged macular hypoautofluorescence suggesting chronic RPE damage OS.", + "There was no choroidal elevation on B-mode echography OU.", + "FA revealed reduced choroidal perfusion in the macula in the early phase OS.", + "FA showed scattered focal hyperfluorescent spots that intensified from early to late phase OS.", + "Indocyanine green angiography (ICGA) demonstrated serpiginous-like fluorescence blockade throughout OS.", + "There was no obvious abnormal shadow on orbital magnetic resonance imaging.", + "Her left eye was diagnosed with choroidal melanocytosis together with SRD.", + "Central serous chorioretinopathy was ruled out by the absence of choroidal thickening on SS-OCT.", + "Central serous chorioretinopathy was ruled out by the absence of a descending tract on FAF.", + "Central serous chorioretinopathy was ruled out by the absence of choroidal vascular hyperpermeability on ICGA.", + "The absence of choroidal elevation observed by fundus examination and echography supported the diagnosis of choroidal melanocytosis.", + "Irregular melanin pigmentation of the choroid supported the diagnosis of choroidal melanocytosis.", + "She was observed without any treatment.", + "Fifty-eight months after the initial diagnosis, her BCVA was 0.5.", + "Fifty-eight months after the initial diagnosis, CFP showed slightly darker macular pigmentation.", + "Fifty-eight months after the initial diagnosis, SRD persisted on SS-OCT.", + "The institutional review board of Hokkaido University waived the need for ethical assessment of this clinical study.", + "This study adhered to the tenets of the Declaration of Helsinki.", + "This study evaluated the alterations of choroidal blood flow of choroidal melanocytosis using laser speckle flowgraphy (LSFG).", + "Relative blood flow values were obtained as the mean blur rate (MBR) after quantitative measurement of blood flow velocity by LSFG software.", + "The pupils of the patient were dilated with 0.4% tropicamide before examination.", + "Ophthalmic examinations were conducted after pupils of both eyes had completely lost their light reflex.", + "The macula in the LSFG images was manually marked and vessels were automatically segmented using threshold values defined by the system software.", + "The macular area was identified by an experienced examiner by comparing the initial FA images and FAF images.", + "A circle of about 750 μm in diameter to the fovea was defined as the region of interest on LSFG.", + "Four to five consecutive measurements were taken for each circle, and the mean values were used for analysis.", + "All examinations were conducted by a single experienced operator.", + "Ocular perfusion pressure (OPP) was calculated using the patient’s blood pressure and intraocular pressure.", + "The MBR values OD were 10.9, 10.6, 10.1, and 9.0 arbitrary units (AU) at 18, 24, 36, and 58 months after the initial visit, respectively.", + "The MBR values OS were 1.24, 1.30, 1.32, 1.28, and 1.42 AU at 12, 18, 24, 36, and 58 months after the initial visit, respectively.", + "The MBR (mean ± standard deviation) for 58 months was 10.15 ± 0.72 AU OD.", + "The MBR (mean ± standard deviation) for 58 months was 1.31 ± 0.06 AU OS.", + "OPP was 82.2, 76.2, 82.9, 73.0, and 68.0 mmHg OD at 12, 18, 24, 36, and 58 months after the initial visit, respectively.", + "OPP was 83.2, 78.2, 82.9, 72.0, and 69.0 mmHg OS at 12, 18, 24, 36, and 58 months after the initial visit, respectively.", + "There were no significant changes in OPP in either eye." + ], + "summary": "A 56-year-old woman was referred to our hospital because of serous retinal detachment (SRD) in her left eye. At the initial examination, her best-corrected visual acuity (BCVA) was 1.5 oculus dexter (OD) and 0.8 oculus sinister (OS). An irregular, flat, brownish lesion was noted around the macula OS. Optical coherence tomography showed a choroidal structure with marked hyporeflectivity and SRD where the retinal thickness was preserved. Indocyanine green angiography demonstrated fluorescence blockade throughout. Fundus autofluorescence revealed enlarged macular hypofluorescence, suggesting chronic retinal pigment epithelium damage associated with prolonged SRD. B-mode echography showed no choroidal elevation. Based on the clinical findings, the left eye was diagnosed with choroidal melanocytosis. Four years and 10 months after the initial visit, her BCVA was 0.5 and SRD remained. During the entire period of observation, the mean blur rate (MBR) (mean ± standard deviation) of choroidal blood flow velocity on LSFG was 10.15 ± 0.72 arbitrary units (AU) OD and 1.31 ± 0.06 AU OS.", + "summary_subclaims": [ + "A 56-year-old woman was referred to our hospital because of serous retinal detachment (SRD) in her left eye.", + "At the initial examination, her best-corrected visual acuity (BCVA) was 1.5 oculus dexter (OD).", + "At the initial examination, her best-corrected visual acuity (BCVA) was 0.8 oculus sinister (OS).", + "An irregular, flat, brownish lesion was noted around the macula OS.", + "Optical coherence tomography showed a choroidal structure with marked hyporeflectivity.", + "Optical coherence tomography showed SRD where the retinal thickness was preserved.", + "Indocyanine green angiography demonstrated fluorescence blockade throughout.", + "Fundus autofluorescence revealed enlarged macular hypofluorescence.", + "Fundus autofluorescence findings suggested chronic retinal pigment epithelium damage associated with prolonged SRD.", + "B-mode echography showed no choroidal elevation.", + "The left eye was diagnosed with choroidal melanocytosis.", + "Four years and 10 months after the initial visit, her BCVA was 0.5.", + "During the entire period of observation, the mean blur rate (MBR) of choroidal blood flow velocity on LSFG was 10.15 ± 0.72 arbitrary units (AU) OD.", + "During the entire period of observation, the mean blur rate (MBR) of choroidal blood flow velocity on LSFG was 1.31 ± 0.06 arbitrary units (AU) OS." + ] + }, + { + "id": "multiclinsum_test_351_en.txt", + "fulltext": "A 70-year-old Asian woman presented to the emergency ward with acute kidney injury after having been diagnosed recently with a non-small cell lung carcinoma (NSCLC). She had a history of hypertension, hypercholesterolemia, and type 2 diabetes for which she used metformin and enalapril. She was of Asian descent, born in Thailand, and lived in the Netherlands for approximately 20 years. For the largest part of her life, she was a stay-at-home mother of two children and had no known occupational exposure to toxins or chemicals. She had a negative family history for pulmonary disease or kidney diseases, never smoked, and consumed no alcohol. She was analyzed for lung cancer after a large lung mass was seen on a chest X-ray carried out for complaints of dyspnea . The fluorodeoxyglucose (18F-FDG) positron emission tomography (PET) with low-dose computed tomography (CT) scan showed an FDG-avid mass in the left lower quadrant of 11 × 6.8 cm with multiple small FDG-avid lesions in all lung quadrants, pathological lymphadenopathy subcarinal in the hili and in the mediastinum, and multiple FDG-avid liver and bone lesions all suspected of being metastases. A bronchoscopy showed an exophytic tumor in the left main bronchus extending to the left upper lobe closing of the main bronchus as well as a tumor in the left lower lobe. The bronchoscopy samples showed NSCLC with EML4–ALK rearrangement. A multidisciplinary team (pulmonary oncologists, surgeons, nurses, pathologist, radiologist, and nuclear radiologist) discussed the patient in accordance with local guidelines and came to a diagnosis of NSCLC, cT4N3M1c, stage IV with EML4–ALK rearrangement. She started treatment with alectinib 600 mg twice daily and used naproxen for pain complaints from her bone metastases. Prior to start of alectinib, she had a blood pressure of 143/69 mmHg, serum creatinine of 69 µmol/L [0.78 mg/dL; estimated glomerular filtration rate (eGFR) of 77 mL/min/1.73 m2].\nAt presentation, 11 days after initiation of alectinib, she had complaints of reduced appetite, vomiting, and oliguria. On examination, we found a blood pressure of 120/68 mmHg with a pulse of 81 beats per minute. She had capillary refill time of 4–5 seconds and reduced skin turgor. Her temperature was 36.1 °C (97 °F). Heart auscultation revealed normal hearts sounds without murmurs. Lung auscultation revealed sharpened breath sounds, but no crackles or rhonchi. Examination of the abdomen showed no visible pathology, normal bowel sounds, and no signs of acute abdominal or surgical pathology. Basic neurological examination revealed no impaired mental status, no cranial nerve pathology, normal gait and coordination, and no abnormalities on motor and sensory examination. Further physical examination revealed no other abnormalities. A chest X-ray showed a reduction of the lung cancer mass compared with the initial staging imaging. Laboratory evaluation revealed a creatinine level of 424 µmol/L (4.79 mg/dL; eGFR 8 mL/min/1.73 m2), and a urea level of 15.3 mmol/L (91.8 mg/dL). Other lab results showed anemia (hemoglobin 6.6 mmol/L, 10.6 g/dL), thrombocytosis (691 × 109/L), and leukocytosis (14.9 × 109/L). She had hyponatremia (127 mmol/L; 127 mEq/L), hyperkalemia (6.0 mmol/L, 6 mEq/L), and hypercalcemia (2.61 mmol/L, 10.46 mg/dL) that was normal when corrected for albumin (31 g/L, 3.1 g/dL). She had normal alanine transaminase and aspartate transaminase, but alkaline phosphatase and gamma-glutamyl transferase were slightly above the upper limit of normal (170 U/L and 91 U/L, respectively). The C-reactive protein was slightly above the upper limit of normal (7 mg/L, 0.7 mg/dL). Her glucose at presentation was 8.3 mmol/L (149.5 mg/dL). Urine analysis showed leukocyturia (66/µL) without hematuria and no bacteriuria. Urinary sodium concentration was 73 mEq/L (167.9 mg/dL) and the fractional excretion of sodium was 11%, suggesting renal tubular etiology. Ultrasound of the kidneys showed no abnormalities. No serologic or microbiological tests were performed.\nThe patient was admitted to the pulmonology ward and received sodium chloride 0.9% fluid therapy, 1 L in 4 hours followed by 3 L/24 hours. All medication was discontinued. For pain complaints, acetaminophen was prescribed (four times 1000 mg daily) and fentanyl was started, as both transdermal patch (12.5 µg/hour) and tablets for sublingual that the patient used at her own discretion with a maximum of 200 µg per day. For nausea, metoclopramide 10 mg tablets were started, taken at the patient’s discretion with a maximum of three times daily. Because of constipation, macrogol and lactulose were started, and during the hospital admission a sodium phosphate enema was administered. Temazepam 10 mg was used at the patient’s discretion before sleeping, with a maximum of once daily. Nadroparin 2850 IU was started to prevent venous thromboembolisms. During the admission, insulin aspart was given for hyperglycemia when necessary (0–10 IE based on glucose levels and intake). The patient’s diuresis during the first 24 hours was 1860 mL, which further suggested tubulopathy as a possible cause of her acute kidney injury. After 2 days of fluid therapy, there was no improvement of renal function, and a biopsy was performed. Light microscopy revealed massive vacuolar alterations of the cytoplasm of proximal tubular epithelial cells , representing proximal tubular toxicity. Glomerular, interstitial, and vascular structures were normal. No tubular cell sloughing, necrosis, cast formation, or interstitial edema was seen.\nOn the fourth day, intravenous prednisolone 40 mg daily was started for 7 days. In the days thereafter, renal function recovered rapidly, blood pressure rose to 148/80 mmHg, and the patient was discharged 9 days after admission with an eGFR of 70 mL/min/1.73 m2. Alectinib was reintroduced 1 week after discharge at 300 mg twice daily and 2 weeks later increased to 450 mg twice daily without decrease in kidney function until she died 2 months after discharge. Metformin, enalapril, and naproxen were withheld completely during the follow-up. During follow-up, the patient continued using metoclopramide and temazepam when necessary, and the fentanyl dose was increased step by step to a dose of 50 µg/hour in the weeks leading up to her death. In the palliative phase, no other medication was started. In a final staging 18F-FDG PET scan before her death, a reduction of size and activity of the primary tumor and the pathological lymph nodes was seen, but the patient had developed new pathological vertebral and pelvic fractures. She died of complications of her non-small cell lung carcinoma 2 months after discharge. No autopsy was performed.", + "fulltext_subclaims": [ + "The patient was a 70-year-old Asian woman.", + "She presented to the emergency ward with acute kidney injury.", + "She had recently been diagnosed with non-small cell lung carcinoma.", + "She had a history of hypertension.", + "She had a history of hypercholesterolemia.", + "She had type 2 diabetes.", + "She used metformin.", + "She used enalapril.", + "She was born in Thailand.", + "She lived in the Netherlands for approximately 20 years.", + "She had no known occupational exposure to toxins or chemicals.", + "She had a negative family history for pulmonary disease.", + "She had a negative family history for kidney diseases.", + "She never smoked.", + "She consumed no alcohol.", + "A chest X-ray showed a large lung mass.", + "The PET/CT scan showed an FDG-avid mass in the left lower quadrant.", + "The PET/CT scan showed multiple small FDG-avid lesions in all lung quadrants.", + "The PET/CT scan showed pathological lymphadenopathy subcarinal in the hili.", + "The PET/CT scan showed multiple FDG-avid liver and bone lesions.", + "The bronchoscopy showed an exophytic tumor in the left main bronchus.", + "The bronchoscopy showed a tumor in the left lower lobe.", + "The bronchoscopy samples showed NSCLC with EML4–ALK rearrangement.", + "The multidisciplinary team diagnosed NSCLC, cT4N3M1c, stage IV.", + "She started treatment with alectinib 600 mg twice daily.", + "She used naproxen for pain complaints from bone metastases.", + "Prior to alectinib, her serum creatinine was 69 µmol/L.", + "Prior to alectinib, her eGFR was 77 mL/min/1.73 m2.", + "At presentation, 11 days after alectinib, she had reduced appetite.", + "At presentation, she had vomiting.", + "At presentation, she had oliguria.", + "On examination, her blood pressure was 120/68 mmHg.", + "On examination, her pulse was 81 beats per minute.", + "Laboratory evaluation revealed a creatinine level of 424 µmol/L.", + "Laboratory evaluation revealed an eGFR of 8 mL/min/1.73 m2.", + "She had anemia (hemoglobin 6.6 mmol/L).", + "She had thrombocytosis (691 × 109/L).", + "She had leukocytosis (14.9 × 109/L).", + "She had hyponatremia (127 mmol/L).", + "She had hyperkalemia (6.0 mmol/L).", + "She had hypercalcemia (2.61 mmol/L).", + "Urinary sodium concentration was 73 mEq/L.", + "The fractional excretion of sodium was 11%.", + "Ultrasound of the kidneys showed no abnormalities.", + "The patient received sodium chloride 0.9% fluid therapy.", + "All medication was discontinued.", + "Acetaminophen was prescribed for pain complaints.", + "Fentanyl was started as a transdermal patch.", + "Fentanyl was started as sublingual tablets.", + "Metoclopramide was started for nausea.", + "Macrogol and lactulose were started for constipation.", + "A sodium phosphate enema was administered.", + "Temazepam was used before sleeping.", + "Nadroparin was started to prevent venous thromboembolisms.", + "Insulin aspart was given for hyperglycemia.", + "The patient’s diuresis during the first 24 hours was 1860 mL.", + "A biopsy was performed.", + "Light microscopy revealed massive vacuolar alterations of the cytoplasm of proximal tubular epithelial cells.", + "Intravenous prednisolone 40 mg daily was started for 7 days.", + "After 2 days of fluid therapy, there was no improvement of renal function.", + "After 9 days of hospitalization, the patient was discharged.", + "At discharge, her eGFR was 70 mL/min/1.73 m2.", + "Alectinib was reintroduced 1 week after discharge at 300 mg twice daily.", + "Alectinib was increased to 450 mg twice daily 2 weeks after discharge.", + "Metformin was withheld during follow-up.", + "Enalapril was withheld during follow-up.", + "Naproxen was withheld during follow-up.", + "The patient continued using metoclopramide when necessary.", + "The patient continued using temazepam when necessary.", + "The fentanyl dose was increased to 50 µg/hour.", + "In a final staging PET scan, a reduction of size and activity of the primary tumor was seen.", + "The patient had developed new pathological vertebral and pelvic fractures.", + "She died of complications of her non-small cell lung carcinoma.", + "No autopsy was performed." + ], + "summary": "A 70-year-old Asian woman was diagnosed with metastasized non-small cell lung carcinoma (cT4N3M1c, stage IV) with echinoderm microtubule-associated protein-like 4 and anaplastic lymphoma kinase gene rearrangement and received alectinib, in two daily doses of 600 mg. Eleven days after the initiation of therapy, she was seen at the emergency department with acute kidney injury. Renal biopsy showed lesions in the proximal tubular epithelial cells. Nine days after alectinib cessation, renal function recovered quickly and reintroduction of alectinib in a reduced dose was tolerated, while withholding metformin, enalapril, and naproxen. In seven other patients, data on estimated glomerular filtration rate showed decreased kidney function at 3 months with stabilization at 6 months. Serum sodium at 3 months increased during alectinib treatment and increased further at 6 months.", + "summary_subclaims": [ + "The patient was a 70-year-old Asian woman.", + "She was diagnosed with metastasized non-small cell lung carcinoma.", + "The tumor stage was cT4N3M1c, stage IV.", + "The tumor had echinoderm microtubule-associated protein-like 4 and anaplastic lymphoma kinase gene rearrangement.", + "She received alectinib in two daily doses of 600 mg.", + "Eleven days after initiation of therapy, she was seen at the emergency department with acute kidney injury.", + "Renal biopsy showed lesions in the proximal tubular epithelial cells.", + "Nine days after alectinib cessation, renal function recovered quickly.", + "Reintroduction of alectinib in a reduced dose was tolerated.", + "Metformin, enalapril, and naproxen were withheld.", + "In seven other patients, data on estimated glomerular filtration rate showed decreased kidney function at 3 months.", + "Estimated glomerular filtration rate stabilized at 6 months.", + "Serum sodium at 3 months increased during alectinib treatment.", + "Serum sodium increased further at 6 months." + ] + }, + { + "id": "multiclinsum_test_2418_en.txt", + "fulltext": "A 53-year-old Chinese female presented to the Emergency Department of our hospital for persistent abdominal pain and distension for over two months. Two months ago, the patient went to a local hospital and obtained a transvaginal ultrasound that revealed thickened bilateral fallopian, suggesting adnexitis. She was treated with antibiotics, but the pain persisted. The serum CA125 and CA724 levels were elevated (469U/ml and 33.4U/ml, respectively). Abdomen and pelvis computed tomography (CT) showed heterogeneous stomach and bilateral adnexal masses, suggesting adnexal lesions or the Krukenberg tumor. She was then referred to the emergency room of our hospital.\nIn our hospital, she received thorough examinations. A gynecological examination revealed an abdominopelvic mass with an unclear boundary. The transvaginal ultrasound showed a 3.9×2.3cm solid pelvic mass with ascites . The abdominal and pelvic enhanced CT, the pelvic magnetic resonance imaging (MRI), and the positron emission computed tomography (PET-CT) all revealed irregular, heterogeneous, and plump bilateral adnexal masses with diffusely thickened peritoneum, omentum, and mesangium, multiple soft-tissue nodules, slightly thickened intestinal wall, abdominal and pelvic effusion, and multiple enlarged lymph nodes . The serum CA125 level was 439U/mL. The chest X-ray showed no abnormality. The patient underwent bilateral tubal sterilization more than 20 years ago and was found with a Helicobacter pylori infection two months ago. She went into natural menopause for one year and gave birth to two children. Personal and family history were unremarkable.\nConsidering the possibility of ovarian or gastrointestinal malignancies, the patient was admitted to our hospital. After admission, the patient developed aggravated abdominal distension with an increase in body temperature to 39℃. After four days of intravenous anti-inflammatory, the patient underwent diagnostic laparoscopy with omentum and peritoneum biopsies in a stable condition, which suggested poorly differentiated carcinoma according to intraoperative consultation. About 2 liters of tawny ascites were drained for cytology confirmation during the operation, which revealed no tumor cells. The surgical findings showed multiple white granular tumor implants studding the omentum, peritoneum, and the surface of the diaphragm, liver, intestine, and uterus. A 9×9×3cm omental cake enclosed part of the intestine and was fixed. The omentum and intestine obscured bilateral ovaries and fallopian tubes. Combined with laboratory, imaging, and surgical findings, the possibility of advanced (stage IV) ovarian cancer was considered. Given the difficulty in performing satisfactory cytoreductive surgery, the patient was treated with three cycles of neoadjuvant chemotherapy with Paclitaxel-albumin, Carboplatin, and Bevacizumab.\nAfter chemotherapy, the patient’s serum CA125 level was reduced to 107 U/mL. Imaging examination showed reduced abdominal and pelvic effusion, while abdominopelvic lesions were roughly the same as before . The pathological findings of the previous operation excluded the common types of epithelial ovarian carcinoma, breast carcinoma, and neuroendocrine neoplasm. Still, the diagnosis could not be confirmed due to the poor differentiation characteristics of the tumor cells. Upper GI endoscopy and colonoscopy were performed to distinguish gastrointestinal tumors, but no mucosal lesions were identified . The patient further underwent cytoreductive surgery, which showed a 20×10×4cm extensive gritty nodular omental cake densely adhered to the pelvic wall and part of the intestine and mesentery . The mesostenium and mesocolon were extensively thickened with contracture and stiff morphology. A heterogeneous mass about 2.5cm in diameter was found on the surface of the small intestine. The posterior wall of the uterus closely adhered to the rectum, and bilateral ovaries were enlarged with a solid nodular appearance . Total hysterectomy and bilateral salpingo-oophorectomy were performed. The omentum, small intestinal mass, and left pelvic lymph nodes were also removed. All specimen was submitted for pathological confirmation. It was an unsatisfactory cytoreductive surgery (R2), with the postoperative residuals being the diffuse thickened malignancy lesions in the mesentery. The patient recovered in a stable condition without any complications and was discharged home 13 days after surgery.\nMicroscopic examination showed malignancy infiltration in bilateral ovaries involving the omentum, peritoneum, mass on the small intestine surface, and the serosa of the uterus and bilateral fallopian tubes. The tumor cells were uniform monotonous medium-sized round and oval with small-to-moderate eosinophilic cytoplasm, enlarged nuclei, high nuclear/cytoplasmic ratio, and uneven chromatin . Lymphatic vascular involvement and lymph node metastases were frequently observed . Solid sheets and nests of typically undifferentiated cells infiltrating surrounding normal omental tissue were present, with no abrupt keratinization . Comparing the two surgical specimens, there was no significant regression of tumor cells after neoadjuvant chemotherapy . Malignancy infiltration was found on the serosa of the uterus, while typical structures of the endometrium and myometrium remained, suggesting that it was not a primary uterine neoplasm . It is noteworthy that although the malignancies significantly infiltrated the ovary, most of the ovarian cortical and corpus albicans were intact. The lesions were mainly close to the ovarian hilus and surrounded by large blood vessels , so the possibility of secondary ovarian malignancy cannot be excluded.\nIHC was conducted to help confirm the diagnosis . Tumor cells positively expressed monoclonal ER, INI1(SMARCB1), BRG1(SMARCA4), and ARID1a, with patchy expressions of monoclonal PR, P16, Syn, SATB2, and CK8/18. The β-Catenin and P120 were positive in the cytoplasm. The Ki-67 labeling index was approximately 30%. There was no expression of CK pan , p40 , p63 , and other IHC markers (i.e., CD56, CK7, WT-1, TTF-1, Desmin, C-myc, CgA, CDX2, INSM1, SSTR2, SSTR5). Details of all the IHC results were listed in . Based on the morphological and IHC features, 14 malignancies with similar morphology were compared, including ovarian serous carcinoma, ovarian clear cell carcinoma, ovarian germ cell neoplasms, ovarian sex cord-stromal neoplasms, neoplasms associated with the SWI/SNF complex, colorectal carcinoma, invasive lobular carcinoma of the breast, poorly differentiated hepatic cholangiocarcinoma, low grade endometrial stromal sarcoma, high grade endometrial stromal sarcoma, rhabdomyosarcoma, malignant peripheral nerve sheath tumors, histiocytic sarcoma, and plasmacytoma . Additionally, to distinguish it from Ewing sarcoma, dual-color break-apart FISH was conducted to test for EWSR1 gene rearrangements, which revealed a negative result.\nFinally, we conducted NUT immunostaining (clone C52B1) and revealed diffusely positive expression in the nucleus of tumor cells . However, the FISH experiment found no disruption or translocation of the NUTM1 gene locus . We subsequently identified the gene fusion of MXI1 exon 5 (NM_130439.3) to NUTM1 exon 3 (NM_175741.3) via a targeted RNA-based NGS platform (DA8600, Daan Gene, Guangzhou, China) on tissue samples, which finally confirmed NUT carcinoma two months after cytoreductive surgery . Besides, we also identified the gene fusion of MTMR3 exon 5 (NM_021090.4) to SFI1 exon 3 (NM_001007467.3).\nOne week after diagnosis, the patient developed fever and an increased burden of malignancy, with imaging of advanced diffusely thickened peritoneum, omentum, and mesangium, progressed multiple metastatic lymph nodes, and newly developed abdomino pelvic effusion. Unfortunately, although the patient was adequately informed and the potential feasibility of antitumor therapy was introduced, the patient refused further treatment due to financial difficulties and decided to be discharged to a local hospital for symptomatic relief and supportive treatment. She developed systemic symptoms and passed away four months and 18 days after cytoreductive surgery .", + "fulltext_subclaims": [ + "The patient is a 53-year-old Chinese female.", + "She presented with persistent abdominal pain and distension for over two months.", + "A transvaginal ultrasound at a local hospital revealed thickened bilateral fallopian tubes, suggesting adnexitis.", + "She was treated with antibiotics, but the pain persisted.", + "The serum CA125 and CA724 levels were elevated (469U/ml and 33.4U/ml, respectively).", + "Abdomen and pelvis CT showed heterogeneous stomach and bilateral adnexal masses, suggesting adnexal lesions or the Krukenberg tumor.", + "She was referred to the emergency room of our hospital.", + "A gynecological examination revealed an abdominopelvic mass with an unclear boundary.", + "Transvaginal ultrasound showed a 3.9×2.3cm solid pelvic mass with ascites.", + "Abdominal and pelvic enhanced CT, pelvic MRI, and PET-CT revealed irregular, heterogeneous, and plump bilateral adnexal masses.", + "The serum CA125 level was 439U/mL.", + "The chest X-ray showed no abnormality.", + "The patient underwent bilateral tubal sterilization more than 20 years ago.", + "She was found with a Helicobacter pylori infection two months ago.", + "She went into natural menopause for one year.", + "Personal and family history were unremarkable.", + "The patient was admitted to the hospital considering the possibility of ovarian or gastrointestinal malignancies.", + "After four days of intravenous anti-inflammatory treatment, she underwent diagnostic laparoscopy with omentum and peritoneum biopsies.", + "Intraoperative consultation suggested poorly differentiated carcinoma.", + "About 2 liters of tawny ascites were drained for cytology confirmation during the operation.", + "Cytology of the ascites revealed no tumor cells.", + "Surgical findings showed multiple white granular tumor implants on the omentum, peritoneum, and the surface of the diaphragm, liver, intestine, and uterus.", + "A 9×9×3cm omental cake enclosed part of the intestine and was fixed.", + "The omentum and intestine obscured bilateral ovaries and fallopian tubes.", + "The possibility of advanced (stage IV) ovarian cancer was considered.", + "Given the difficulty in performing satisfactory cytoreductive surgery, the patient was treated with three cycles of neoadjuvant chemotherapy with Paclitaxel-albumin, Carboplatin, and Bevacizumab.", + "After chemotherapy, the serum CA125 level was reduced to 107 U/mL.", + "Imaging examination showed reduced abdominal and pelvic effusion, while abdominopelvic lesions were roughly the same as before.", + "The pathological findings of the previous operation excluded the common types of epithelial ovarian carcinoma, breast carcinoma, and neuroendocrine neoplasm.", + "The diagnosis could not be confirmed due to the poor differentiation characteristics of the tumor cells.", + "Upper GI endoscopy and colonoscopy were performed to distinguish gastrointestinal tumors, but no mucosal lesions were identified.", + "The patient further underwent cytoreductive surgery.", + "The surgical specimen showed a 20×10×4cm extensive gritty nodular omental cake densely adhered to the pelvic wall and part of the intestine and mesentery.", + "The mesostenium and mesocolon were extensively thickened with contracture and stiff morphology.", + "A heterogeneous mass about 2.5cm in diameter was found on the surface of the small intestine.", + "The posterior wall of the uterus closely adhered to the rectum, and bilateral ovaries were enlarged with a solid nodular appearance.", + "Total hysterectomy and bilateral salpingo-oophorectomy were performed.", + "The omentum, small intestinal mass, and left pelvic lymph nodes were also removed.", + "All specimens were submitted for pathological confirmation.", + "It was an unsatisfactory cytoreductive surgery (R2), with the postoperative residuals being the diffuse thickened malignancy lesions in the mesentery.", + "The patient recovered in a stable condition without any complications and was discharged home 13 days after surgery.", + "Microscopic examination showed malignancy infiltration in bilateral ovaries involving the omentum, peritoneum, mass on the small intestine surface, and the serosa of the uterus and bilateral fallopian tubes.", + "The tumor cells were uniform monotonous medium-sized round and oval with small-to-moderate eosinophilic cytoplasm, enlarged nuclei, high nuclear/cytoplasmic ratio, and uneven chromatin.", + "Lymphatic vascular involvement and lymph node metastases were frequently observed.", + "Solid sheets and nests of typically undifferentiated cells infiltrating surrounding normal omental tissue were present, with no abrupt keratinization.", + "There was no significant regression of tumor cells after neoadjuvant chemotherapy.", + "Malignancy infiltration was found on the serosa of the uterus, while typical structures of the endometrium and myometrium remained.", + "The possibility of secondary ovarian malignancy cannot be excluded.", + "IHC was conducted to help confirm the diagnosis.", + "Tumor cells positively expressed monoclonal ER, INI1(SMARCB1), BRG1(SMARCA4), and ARID1a.", + "The Ki-67 labeling index was approximately 30%.", + "There was no expression of CK pan, p40, p63, and other IHC markers.", + "NUT immunostaining (clone C52B1) revealed diffusely positive expression in the nucleus of tumor cells.", + "The FISH experiment found no disruption or translocation of the NUTM1 gene locus.", + "The gene fusion of MXI1 exon 5 to NUTM1 exon 3 was identified via targeted RNA-based NGS.", + "This confirmed NUT carcinoma two months after cytoreductive surgery.", + "The gene fusion of MTMR3 exon 5 to SFI1 exon 3 was also identified.", + "One week after diagnosis, the patient developed fever and an increased burden of malignancy.", + "Imaging showed advanced diffusely thickened peritoneum, omentum, and mesangium, progressed multiple metastatic lymph nodes, and newly developed abdomino pelvic effusion.", + "The patient refused further treatment due to financial difficulties.", + "She decided to be discharged to a local hospital for symptomatic relief and supportive treatment.", + "She developed systemic symptoms and passed away four months and 18 days after cytoreductive surgery." + ], + "summary": "We report a case of NUT carcinoma in a 53-year-old female who presented with extensive abdominopelvic lesions and bilateral ovarian masses suggestive of advanced ovarian cancer. This patient was admitted to our hospital due to abdominal pain and distension for over two months. Imaging examinations suggested a possible malignancy of bilateral adnexal origin. This patient first underwent diagnostic laparoscopy. After receiving neoadjuvant chemotherapy, she underwent cytoreductive surgery. Surgical pathology showed infiltration of monotonous round tumor cells with no apparent differentiation characteristics. Immunohistochemistry (IHC) revealed nuclear expression of the NUT protein. And MXI1::NUTM1 fusion was identified by next-generation sequencing (NGS). Herein, we introduce an unusual NUT carcinoma and describe the clinical, imaging, and pathological features. In addition, we briefly reviewed the published literature and discussed the possibility of primary gynecological NUT carcinoma.", + "summary_subclaims": [ + "The patient was a 53-year-old female.", + "The patient presented with extensive abdominopelvic lesions.", + "The patient had bilateral ovarian masses.", + "The patient had abdominal pain and distension for over two months.", + "Imaging examinations suggested a possible malignancy of bilateral adnexal origin.", + "The patient first underwent diagnostic laparoscopy.", + "The patient received neoadjuvant chemotherapy.", + "The patient underwent cytoreductive surgery.", + "Surgical pathology showed infiltration of monotonous round tumor cells.", + "Immunohistochemistry revealed nuclear expression of the NUT protein.", + "MXI1::NUTM1 fusion was identified by next-generation sequencing.", + "The case is described as an unusual NUT carcinoma.", + "The clinical, imaging, and pathological features are described.", + "A brief review of the published literature is included.", + "The possibility of primary gynecological NUT carcinoma is discussed." + ] + }, + { + "id": "multiclinsum_test_296_en.txt", + "fulltext": "A 65-year-old man was referred to our hospital in October 2006 with a huge abdominal tumor. A firm mass was palpated extending from the epigastrium to the left hypogastrium. There were no laboratory abnormalities, except a slight elevation of the total bilirubin (1.3 mg/dl) and lactate dehydrogenase (LDH: 217 IU/L) levels in the serum. The tumor markers carcinoembryonic antigen (CEA) and carbohydrate antigen (CA19-9) were within the normal range. Ultrasonography showed that the mass occupied almost the entire upper abdomen anterior to the bowel loops. On computed tomography (CT), a mass behind the left hepatic lobe showed heterogeneous low density with faint enhancement . Abdominal angiography revealed that the tumor was vascularized mainly from the right epigastric artery . We suspected liposarcoma, leiomyosarcoma, mesothelioma, or gastric GIST. At laparotomy on October 2006, a well-encapsulated tumor was found in the greater omentum. There was no adhesion to adjacent organs and structures but a pinpoint adhesion to the stomach. The right gastroepiploic artery and vein were prominent and stretched by the tumor, and a major supply vessel diverged from it in one stalk . There was no evidence of metastasis in the abdominal cavity. Grossly, a well-demarcated reddish-gray solid tumor, 20 × 17 × 6 cm in size, showed irregular modularity . The cut surfaces were tan-colored and contained focally necrotic areas and a cystic nodule. Histopathologically, the tumor was composed of proliferating epithelioid cells and myxoid cells with an interlacing bundle pattern . The cellularity was relatively high and the frequency of mitotic figures was 2 of 50 high power fields (HPF). The MIB-1 index was 4.4% . The tumor cells were diffusely immunoreactive for myeloid stem cell antigen (CD34), weakly or focally positive for c-kit proto-oncogene protein product (CD117) and slightly positive for neuron-specific enolase (NSE). However, there was no staining for cytokeratin (CK), alpha-smooth muscle actin (SMA) or S-100 protein. Direct sequencing demonstrated mutations in the platelet-derived growth factor alpha (PDGFRA) gene exon 12, codon 561, encoding a thymine to adenine substitution . These findings were consistent with a myxoid epithelioid GIST lacking myogenic features and neural attributes. The patient had a complete tumor resection and an uneventful postoperative course. He was treated by per os administration of Glevec® 300 mg/day as an adjuvant postoperative molecular targeting chemotherapy and has been living disease-free for 6 months.", + "fulltext_subclaims": [ + "The patient was a 65-year-old man.", + "He was referred to the hospital in October 2006.", + "He had a huge abdominal tumor.", + "A firm mass was palpated extending from the epigastrium to the left hypogastrium.", + "The total bilirubin was slightly elevated at 1.3 mg/dl.", + "The lactate dehydrogenase (LDH) level was 217 IU/L.", + "The tumor markers carcinoembryonic antigen (CEA) and carbohydrate antigen (CA19-9) were within the normal range.", + "Ultrasonography showed the mass occupied almost the entire upper abdomen anterior to the bowel loops.", + "On CT, a mass behind the left hepatic lobe showed heterogeneous low density with faint enhancement.", + "Abdominal angiography revealed that the tumor was vascularized mainly from the right epigastric artery.", + "We suspected liposarcoma, leiomyosarcoma, mesothelioma, or gastric GIST.", + "At laparotomy in October 2006, a well-encapsulated tumor was found in the greater omentum.", + "There was no adhesion to adjacent organs and structures but a pinpoint adhesion to the stomach.", + "The right gastroepiploic artery and vein were prominent and stretched by the tumor.", + "A major supply vessel diverged from the right gastroepiploic artery in one stalk.", + "There was no evidence of metastasis in the abdominal cavity.", + "Grossly, the tumor was 20 × 17 × 6 cm in size.", + "The cut surfaces were tan-colored and contained focally necrotic areas and a cystic nodule.", + "Histopathologically, the tumor was composed of proliferating epithelioid cells and myxoid cells with an interlacing bundle pattern.", + "The frequency of mitotic figures was 2 of 50 high power fields (HPF).", + "The MIB-1 index was 4.4%.", + "The tumor cells were diffusely immunoreactive for myeloid stem cell antigen (CD34).", + "The tumor cells were weakly or focally positive for c-kit proto-oncogene protein product (CD117).", + "The tumor cells were slightly positive for neuron-specific enolase (NSE).", + "There was no staining for cytokeratin (CK).", + "There was no staining for alpha-smooth muscle actin (SMA).", + "There was no staining for S-100 protein.", + "Direct sequencing demonstrated mutations in the platelet-derived growth factor alpha (PDGFRA) gene exon 12, codon 561, encoding a thymine to adenine substitution.", + "The findings were consistent with a myxoid epithelioid GIST lacking myogenic features and neural attributes.", + "The patient had a complete tumor resection.", + "He was treated by per os administration of Glevec® 300 mg/day as an adjuvant postoperative molecular targeting chemotherapy.", + "He has been living disease-free for 6 months." + ], + "summary": "A 65 year-old man was referred to our hospital with a huge abdominal mass occupying the entire left upper abdomen as shown by sonography. On computed tomography (CT), this appeared as a heterogeneous low-density mass with faint enhancement. Abdominal angiography revealed that the right gastroepiploic artery supplied the tumor. With such an indication of gastric GIST, liposarcoma, leiomyosarcoma or mesothelioma laparotomy was performed and revealed that this large mass measured 20 x 17 x 6 cm, arising from the greater omentum. It was completely resected. Histopathologically, it was composed of proliferating spindle and epithelioid cells with an interlacing bundle pattern. Immunohistochemically, the tumor was positive for myeloid stem cell antigen (CD34), weakly positive for c-KIT (CD117) and slightly positive for neuron-specific enolase (NSE), but negative for cytokeratin (CK), alpha-smooth muscle actin (SMA) and S-100 protein. A mutation was identified in the platelet-derived growth factor alpha (PDGFRA) juxtamembrane domain (exon 12, codon561) and the tumor was diagnosed as an omental GIST. The postoperative course was uneventful. The patient is treated by Glevec(R) and is alive well with no sign of relapse.", + "summary_subclaims": [ + "The patient was a 65 year-old man.", + "The patient was referred to the hospital with a huge abdominal mass.", + "Sonography showed the mass occupied the entire left upper abdomen.", + "Computed tomography showed a heterogeneous low-density mass with faint enhancement.", + "Abdominal angiography revealed the right gastroepiploic artery supplied the tumor.", + "Laparotomy was performed.", + "The mass measured 20 x 17 x 6 cm.", + "The mass arose from the greater omentum.", + "The mass was completely resected.", + "Histopathology showed proliferating spindle and epithelioid cells with an interlacing bundle pattern.", + "The tumor was positive for myeloid stem cell antigen (CD34).", + "The tumor was weakly positive for c-KIT (CD117).", + "The tumor was slightly positive for neuron-specific enolase (NSE).", + "The tumor was negative for cytokeratin (CK).", + "The tumor was negative for alpha-smooth muscle actin (SMA).", + "The tumor was negative for S-100 protein.", + "A mutation was identified in the platelet-derived growth factor alpha (PDGFRA) juxtamembrane domain (exon 12, codon561).", + "The tumor was diagnosed as an omental GIST.", + "The postoperative course was uneventful.", + "The patient is treated by Glevec(R).", + "The patient is alive well with no sign of relapse." + ] + }, + { + "id": "multiclinsum_test_902_en.txt", + "fulltext": "On 23 January 2020, a 46-year-old man was transferred to our hospital with 11-days history of fever of 38 °C and coughing. The patient permanently resides in Yili Development Zone, Xinjiang, China. He started low fever with dry cough, muscle ache and fatigue without known causes in Yili on 12 January. The patient disclosed that he had been in close contact with a person from Wuhan in Yili on 10 January and had a travel history with flights to Shanghai on 16 January 2020, from Shanghai to Ningbo on 17 January 2020, and from Ningbo to Shenzhen on January 19, 2020, without traveling or living history to Wuhan. On 18 January, there was onset of symptoms including chest tightness without chest pain and hemoptysis. Unknown medication was taken by the patient without symptomatic improvement. He was considered as a pneumonia patient and admitted to the University of Hong Kong-Shenzhen Hospital on 19 January. Results of blood gas analysis showed a pH of 7.445, carbon dioxide partial pressure of 4.72 KPa and oxygen partial pressure of 7.82 KPa. He was tested negative for influenza A/B virus and respiratory syncytial virus (RSV), Mycoplasma pneumoniae, Cryptococcus haemolyticus antigen, Aspergillus antigen, Epstein-Barr virus capsid antigen IgM, Epstein-Barr virus DNA, Cytomegalovirus DNA and antigen IgM. He was isolated in a single ward and received oxygen support and levofloxacin treatment. On 22 January, the patient was still having fever of 38.5 °C with chest tightness and shortness of breath. BALF was tested negative for Aspergillus, Legionella, Pneumocystis carinii, acid-fast Bacilli, Mycobacterium tuberculosis. He was diagnosed with severe bilateral community-acquired pneumonia (not excluding the possibility of COVID-19 pneumonia) and hypoxemia. Levofloxacin treatment was thus stopped and changed to combined anti-infection treatment of amoxicillin and clavulanate potassium and doxycycline. He was transferred to the Third People’s hospital of Shenzhen for further treatment on 23 January. The patient has no history of other diseases, surgical trauma, food and drug allergy. There was no headache, dizziness, vomiting, abdominal pain, diarrhea, frequent urination, urgent urination, or urination pain claimed by the patient.\nThe results of physical examination on 23 January showed a body temperature of 36.1 °C, pulse of 94 times/min, respiratory rate of 26 breaths/min and blood pressure of 127/87 mmHg. Clinical laboratory test results revealed negative results for mycoplasma, chlamydia, cytomegalovirus-IgM, influenza A/B virus and RSV. Throughout the whole period of hospitalization, the patient was isolated in a single ward and given 60 μg of interferonalf-a1b (Beijing Tri-Prime Gene Pharmaceutical Co., Ltd., China; Shenzhen Kexing Biopharm, China) inhalation for antiviral purpose, 0.4 g of Bio-Three tablets (Huizhou Jiuhui Pharmaceutical Co., Ltd., China; Toa Pharmaceutical Co.,Ltd.Tatebayashi Plant, Japan) and 420 mg Bifid-triple viable capsule (Inner Mongolia Shuangqi Pharmaceutical Co., Ltd., China) three times a day for regulation of intestinal microbiome, and 30 mg mucosolvan (Boehringer Ingelheim Espana,S,A.) intravenous injection twice per day for phlegm elimination. A 3-day course of 0.5 g ribavirin (Jiangsu Lianshui Pharmaceutical Co., Ltd., China) intravenous injection starting from 23 January was also given to the patient in combination with Interferonalfa-1b twice a day for 3 days for antiviral treatment of RNA virus. .\nOn 24 January, the patient was reported to have shortness of breath with respiratory rate of 38 times/min and heart rate of 90 times/min. Blood gas analysis revealed a pH value of 7.428, carbon dioxide partial pressure of 43.0 mmHg, oxygen partial pressure of 64.4 mmHg, actual bicarbonate level of 28.4 mmol/L, oxygen saturation of 92% and fractional concentration of inspired oxygen (FiO2) of 41.0%. Supplemental oxygen was applied to the patient with non-invasive BIPAP ventilator using IPAP 14cmH2O and EPAP 7cmH2O with oxygen concentration of 45%. His respiratory rate was 16 times/min after receiving oxygen supplement. Shortness of breath was gradually relieved and patient’s oxygen saturation values of peripheral blood reached 99 to 100%. Routine blood test revealed a white blood cell count of 5.61 × 109/L with 80.40% neutrophil and 14.80% lymphocyte, hemoglobin concentration of 158 g/L, platelet count of 207 × 109/L and erythrocyte sedimentation rate (ESR) of 71 mm/h. Biochemical test results showed an elevated D-Dimer (diffuse intravascular coagulation, DIC) level which may induce thrombus. 0.4 ml of nadroparin calcium (ASPEN Notre Dame de Bondeville, France) subcutaneous injection was given to the patient once per day for anti-coagulation until 31 January. D-DIC level decreased to normal range at 26 January. The patient also received 40 mg of esomeprazole sodium (AstraZeneca Pharmaceutical Co.,Ltd.) intravenous injection once per day for gastro-esophageal reflux suppression until 30 January and 30 mg of methylprednisolone (Pfizer Manufacturing Belgium NV) intravenous injection once every 12 h until 28 January for anti-inflammation treatment. The increase in white blood cells during this period may be due to the effect of methylprednisolone. However, COVID-19 ribonucleic acid test was negative using nasopharyngeal swabs done by Shenzhen Center for Disease Control (Shenzhen CDC). Treatment scheme and viral detection time points are illustrated in Fig. .\nFrom 25 January onward, the patient’s syndromes had gradually resolved with only occasional dry cough. Computed tomography (CT) scan of the lungs was performed on 25th, 29th January and 12th February . Evidence of severe pneumonia, including multiple lesions and swollen lymph nodes, could be seen from both of the lungs on 25th January. The patient was then given 500 mg lopinavir and ritonavir tablets (Abbott S.P.A., Italy) every 12 h until 6 Feb as a combination treatment for antiviral effect. SARS-COV-2 ribonucleic acid test was negative using nasopharyngeal swabs done by our hospital on 26 January. To confirm the presence of SARS-COV-2, the patient’s BALF sample was sent to Shenzhen CDC for viral nucleic acid detection. SARS-COV-2 ribonucleic acid was tested positive for BALF sample on 27 January. Oxygen supplement by non-invasive BIPAP was replaced by high-flow humidification oxygen therapy instrument for higher oxygen flow of 45 L/min and oxygen concentration of 40% on 28 January. Biochemical test results indicated an increased level of alanine aminotransferase (ALT) since 29 January. The patient was diagnosed to have toxipathic hepatitis which was possibly induced by SARS-COV-2. The patient then received 50 mg compound glycyrrhizin tablets (Akiyama Jozai Co., Ltd., Japan) three times per day from 29 January to 13 February and 50 mg bicyclol tablets (Beijing Union Pharmaceutical Factory, China) three times per day from 31 January to 13 February for liver protection. ALT level resumed to the normal range on 13 February. To prevent pulmonary fibrosis, the patient was given 7-day course of 0.2 g acetylcysteine granules (Bio Pharmacceutical, China) three times per day from 7 February. Obvious improvements could be seen from the subsequent CT scanning results of the lungs on 29th January and 12 February . Oxygen supplement by high-flow humidification oxygen therapy instrument was discontinued on 31 January and the patient was given nasal catheter for oxygen inhalation with a flow rate of 4 L/min. His clinical conditions was stable with fractional concentration of inspired oxygen (FiO2) value fluctuating within the normal range. On 2 February, the patient stated that there was obvious improvement of his symptoms. CT scanning of the lungs on 12 February confirmed the improvement and the patient was discharged on the following day.", + "fulltext_subclaims": [ + "The patient was a 46-year-old man.", + "He was transferred to the hospital on 23 January 2020.", + "He had an 11-day history of fever of 38 °C and coughing.", + "He permanently resides in Yili Development Zone, Xinjiang, China.", + "He started low fever with dry cough, muscle ache, and fatigue on 12 January.", + "He had been in close contact with a person from Wuhan in Yili on 10 January.", + "He had a travel history with flights to Shanghai on 16 January 2020.", + "He had a travel history with flights from Shanghai to Ningbo on 17 January 2020.", + "He had a travel history with flights from Ningbo to Shenzhen on 19 January 2020.", + "He did not have a travel or living history to Wuhan.", + "On 18 January, he had chest tightness without chest pain.", + "On 18 January, he had hemoptysis.", + "He took unknown medication without symptomatic improvement.", + "He was admitted to the University of Hong Kong-Shenzhen Hospital on 19 January.", + "Blood gas analysis showed a pH of 7.445.", + "Blood gas analysis showed a carbon dioxide partial pressure of 4.72 KPa.", + "Blood gas analysis showed an oxygen partial pressure of 7.82 KPa.", + "He was tested negative for influenza A/B virus.", + "He was tested negative for respiratory syncytial virus (RSV).", + "He was tested negative for Mycoplasma pneumoniae.", + "He was tested negative for Cryptococcus haemolyticus antigen.", + "He was tested negative for Aspergillus antigen.", + "He was tested negative for Epstein-Barr virus capsid antigen IgM.", + "He was tested negative for Epstein-Barr virus DNA.", + "He was tested negative for Cytomegalovirus DNA and antigen IgM.", + "He was isolated in a single ward.", + "He received oxygen support.", + "He received levofloxacin treatment.", + "On 22 January, he had fever of 38.5 °C.", + "On 22 January, he had chest tightness.", + "On 22 January, he had shortness of breath.", + "BALF was tested negative for Aspergillus.", + "BALF was tested negative for Legionella.", + "BALF was tested negative for Pneumocystis carinii.", + "BALF was tested negative for acid-fast Bacilli.", + "BALF was tested negative for Mycobacterium tuberculosis.", + "He was diagnosed with severe bilateral community-acquired pneumonia.", + "The diagnosis did not exclude the possibility of COVID-19 pneumonia.", + "He was diagnosed with hypoxemia.", + "Levofloxacin treatment was stopped.", + "He received combined anti-infection treatment of amoxicillin and clavulanate potassium.", + "He received combined anti-infection treatment of doxycycline.", + "He was transferred to the Third People’s Hospital of Shenzhen on 23 January.", + "He had no history of other diseases.", + "He had no history of surgical trauma.", + "He had no history of food and drug allergy.", + "He did not report headache.", + "He did not report dizziness.", + "He did not report vomiting.", + "He did not report abdominal pain.", + "He did not report diarrhea.", + "He did not report frequent urination.", + "He did not report urgent urination.", + "He did not report urination pain.", + "Physical examination on 23 January showed a body temperature of 36.1 °C.", + "Physical examination on 23 January showed a pulse of 94 times/min.", + "Physical examination on 23 January showed a respiratory rate of 26 breaths/min.", + "Physical examination on 23 January showed a blood pressure of 127/87 mmHg.", + "Clinical laboratory test results revealed negative results for mycoplasma.", + "Clinical laboratory test results revealed negative results for chlamydia.", + "Clinical laboratory test results revealed negative results for cytomegalovirus-IgM.", + "Clinical laboratory test results revealed negative results for influenza A/B virus.", + "Clinical laboratory test results revealed negative results for RSV.", + "The patient was isolated in a single ward.", + "He received 60 μg of interferonalfa-1b inhalation.", + "He received 0.4 g of Bio-Three tablets three times a day.", + "He received 420 mg Bifid-triple viable capsule three times a day.", + "He received 30 mg mucosolvan intravenous injection twice per day.", + "He received 0.5 g ribavirin intravenous injection for 3 days.", + "On 24 January, he had shortness of breath.", + "On 24 January, his respiratory rate was 38 times/min.", + "On 24 January, his heart rate was 90 times/min.", + "Blood gas analysis on 24 January showed a pH value of 7.428.", + "Blood gas analysis on 24 January showed a carbon dioxide partial pressure of 43.0 mmHg.", + "Blood gas analysis on 24 January showed an oxygen partial pressure of 64.4 mmHg.", + "Blood gas analysis on 24 January showed an actual bicarbonate level of 28.4 mmol/L.", + "Blood gas analysis on 24 January showed an oxygen saturation of 92%.", + "Blood gas analysis on 24 January showed an FiO2 of 41.0%.", + "Supplemental oxygen was applied with non-invasive BIPAP ventilator.", + "The BIPAP settings were IPAP 14cmH2O and EPAP 7cmH2O.", + "The BIPAP oxygen concentration was 45%.", + "His respiratory rate was 16 times/min after receiving oxygen supplement.", + "Shortness of breath was gradually relieved.", + "Oxygen saturation values of peripheral blood reached 99 to 100%.", + "Routine blood test showed a white blood cell count of 5.61 × 109/L.", + "Routine blood test showed 80.40% neutrophil.", + "Routine blood test showed 14.80% lymphocyte.", + "Routine blood test showed hemoglobin concentration of 158 g/L.", + "Routine blood test showed platelet count of 207 × 109/L.", + "Routine blood test showed ESR of 71 mm/h.", + "Biochemical test showed an elevated D-Dimer level.", + "The elevated D-Dimer level may induce thrombus.", + "He received 0.4 ml of nadroparin calcium subcutaneous injection once per day.", + "D-DIC level decreased to normal range on 26 January.", + "He received 40 mg of esomeprazole sodium intravenous injection once per day.", + "He received 30 mg of methylprednisolone intravenous injection once every 12 h.", + "The increase in white blood cells may be due to the effect of methylprednisolone.", + "The patient’s syndromes had gradually resolved from 25 January onward.", + "Computed tomography (CT) scan of the lungs was performed on 25th January.", + "Computed tomography (CT) scan of the lungs was performed on 29th January.", + "Computed tomography (CT) scan of the lungs was performed on 12th February.", + "Evidence of severe pneumonia, including multiple lesions and swollen lymph nodes, was seen on 25th January.", + "He received 500 mg lopinavir and ritonavir tablets every 12 h until 6 Feb.", + "SARS-COV-2 ribonucleic acid test was negative using nasopharyngeal swabs on 26 January.", + "The patient’s BALF sample was sent to Shenzhen CDC for viral nucleic acid detection.", + "SARS-COV-2 ribonucleic acid was tested positive for BALF sample on 27 January.", + "Oxygen supplement by non-invasive BIPAP was replaced by high-flow humidification oxygen therapy on 28 January.", + "The high-flow humidification oxygen therapy had an oxygen flow of 45 L/min.", + "The high-flow humidification oxygen therapy had an oxygen concentration of 40%.", + "Biochemical test results indicated an increased level of alanine aminotransferase (ALT) since 29 January.", + "The patient was diagnosed to have toxipathic hepatitis.", + "The toxipathic hepatitis was possibly induced by SARS-COV-2.", + "He received 50 mg compound glycyrrhizin tablets three times per day from 29 January to 13 February.", + "He received 50 mg bicyclol tablets three times per day from 31 January to 13 February.", + "ALT level resumed to the normal range on 13 February.", + "He received 0.2 g acetylcysteine granules three times per day from 7 February.", + "The acetylcysteine granules were given for 7 days.", + "Obvious improvements could be seen from the CT scanning results on 29th January.", + "Obvious improvements could be seen from the CT scanning results on 12 February.", + "Oxygen supplement by high-flow humidification oxygen therapy was discontinued on 31 January.", + "The patient was given nasal catheter for oxygen inhalation with a flow rate of 4 L/min.", + "His clinical conditions were stable with FiO2 value fluctuating within the normal range.", + "On 2 February, the patient stated there was obvious improvement of his symptoms.", + "CT scanning of the lungs on 12 February confirmed the improvement.", + "The patient was discharged on 13 February." + ], + "summary": "We present a case of severely ill SARS-COV-2 infected 46-year-old man with fever, coughing and chest tightness. We performed viral detection using his BALF samples and imaging method (CT) for confirmation. The patient received combination of interferonalfa-1b and ribavirin, lopinavir and ritonavir for antiviral treatment at different stages. Other medication was also given to him in combination for anti-inflammation, intestinal microbial regulation, phlegm elimination, liver protection and pulmonary fibrosis prevention purposes. We provided oxygen supply to him using BIPAP ventilator and high-flow humidification oxygen therapy instrument to facilitate respiration. The patient was cured and discharged.", + "summary_subclaims": [ + "The patient was a 46-year-old man.", + "The patient had SARS-COV-2 infection.", + "The patient had fever.", + "The patient had coughing.", + "The patient had chest tightness.", + "Viral detection was performed using BALF samples.", + "CT imaging was used for confirmation.", + "The patient received interferonalfa-1b and ribavirin.", + "The patient received lopinavir and ritonavir.", + "The patient received medication for anti-inflammation.", + "The patient received medication for intestinal microbial regulation.", + "The patient received medication for phlegm elimination.", + "The patient received medication for liver protection.", + "The patient received medication for pulmonary fibrosis prevention.", + "The patient received oxygen supply using a BIPAP ventilator.", + "The patient received oxygen supply using a high-flow humidification oxygen therapy instrument.", + "The patient was cured and discharged." + ] + }, + { + "id": "multiclinsum_test_1848_en.txt", + "fulltext": "A 20-year-old woman was admitted to our hospital (Imam Reza Hospital, Mashhad, Iran) with neck pain, fever, cough, and dyspnea. She had been diagnosed with dematomyositis 21 months prior. Her symptoms began in March 2014 with polyarthralgia and skin rash. Examination at that time showed presence of heliotrope rash, malar rash, and Gottron’s papules. Muscle forces were intact. Laboratory tests showed a hemoglobin level of 11.9 g/dL (12-16 g/dL), a white blood cell count of 6800/mm3 (4000-10000/mm3), a platelet count of 261×103/mm3 (150-450×103/mm3). Blood chemistry showed a glutamate-oxaloacetate transaminase level of 118 IU/L (5-40 IU/L), a glutamate-pyruvate transaminase level of 78 IU/L (5-40 IU/L), a creatine kinase level of 293 IU/L (50-190 IU/L), and an aldolase level of 5.1 IU/ml (＜7.6 IU/ml).\nUrine analysis was normal. Antinuclear antibodies, anti-double stranded DNA, and anti-Jo-1 were all negative. Electromyography was normal. Biopsy of the quadriceps femoris muscle showed no abnormal findings. She was diagnosed with possible DM based on cutaneous manifestations and elevated muscle enzymes. She was treated with prednisolone 50 mg daily and azathioprine 100 mg daily. Two months later, her arthralgia improved, but cutaneous manifestations had not changed. Laboratory tests showed the serum CK level had increased to 727 IU/L. Hydroxychloroquine was added to the previous regime.\nTwo months later she was asymptomatic and the serum CK level was normal. Thus, prednisolone was tapered. She felt well until July 2015 when she complained of dyspnea. During chest examination, bilateral fine crackles were heard. Chest x-ray showed bilateral opacities and computed tomography (CT) scan showed bilateral ground glass opacities. Prednisolone dose was increased to 50 mg/day and a cyclophosphamide regimen of 1000 mg per month was initiated. After 2 months, she did not feel better and chest x-ray showed progression of fibrosis. An intravenous immunoglobulin (IVIG) regimen of 400 mg/kg/day for 5 days was prescribed. One month later, she was admitted for neck pain and increased dyspnea. She reported chills and fever for 10 days. Upon physical examination, she was febrile (T=38.2 °C) and her blood pressure was 120/90mmHg. A subcutaneous crepitus around her neck was detected. Muscle power was normal in all four limbs.\nLaboratory examination only revealed leukocytosis (23000, PMN 85%) and other laboratory tests (including CK and aldolase) were normal. Chest radiograph and CT scan of the thorax showed a progression lung involvement with subcutaneous emphysema, pneumomediastinum, thickening of interlobular septa, and a reticulonodular pattern (,).\nCT scan of paranasal sinuses also showed emphysema in parietal, temporal and occipital soft tissue. Furthermore, emphysema was seen in retropharyngeal space .\nThe smear and culture of sputum were negative for infectious agents. Flexible bronchoscopy showed severe erythema in bronchial tree, but there was no apparent fistula or rupture. Bronchoalveolar lavage fluid was negative for infectious agents. Echocardiography and esophagoscopy were normal. Intravenous cefteriaxon (1g twice daily) and oral aziothromycin were initiated. On the third day of admission, her shortness of breath worsened. The blood O2 saturation was 82%. High-dose steroid pulse therapy (1g IV methylprednisolone for 3 days) and rituximab 500 mg per week for 4 weeks were initiated. Oxygen therapy and complete bed rest were prescribed.\nOn the 5th day of admission, she transferred to the intensive care unit (ICU) due to severe hypoxemia. She developed bilateral severe pneumothrox. A chest tube was inserted into both pleural spaces. The patient was intubated andmechanical ventilation was initiated. After one week, percutaneous tracheostomy was done.\nIx weeks after immunosuppressive therapy, emphysema and pneumomediastinum were restricted and the chest tube was disconnected (first right, then left). However, the patient died because of severe hypoxemia despite intensive immunosuppressive therapy and mechanical ventilation.", + "fulltext_subclaims": [ + "A 20-year-old woman was admitted to Imam Reza Hospital, Mashhad, Iran.", + "She had been diagnosed with dematomyositis 21 months prior.", + "Her symptoms began in March 2014 with polyarthralgia and skin rash.", + "Examination at that time showed presence of heliotrope rash, malar rash, and Gottron’s papules.", + "Muscle forces were intact.", + "Laboratory tests showed a hemoglobin level of 11.9 g/dL.", + "Blood chemistry showed a creatine kinase level of 293 IU/L.", + "Antinuclear antibodies, anti-double stranded DNA, and anti-Jo-1 were all negative.", + "She was diagnosed with possible DM based on cutaneous manifestations and elevated muscle enzymes.", + "She was treated with prednisolone 50 mg daily and azathioprine 100 mg daily.", + "Two months later, her arthralgia improved, but cutaneous manifestations had not changed.", + "Laboratory tests showed the serum CK level had increased to 727 IU/L.", + "Hydroxychloroquine was added to the previous regime.", + "Two months later she was asymptomatic and the serum CK level was normal.", + "Prednisolone was tapered.", + "She felt well until July 2015 when she complained of dyspnea.", + "Chest x-ray showed bilateral opacities.", + "Computed tomography (CT) scan showed bilateral ground glass opacities.", + "An intravenous immunoglobulin (IVIG) regimen of 400 mg/kg/day for 5 days was prescribed.", + "One month later, she was admitted for neck pain and increased dyspnea.", + "She reported chills and fever for 10 days.", + "Upon physical examination, she was febrile (T=38.2 °C).", + "A subcutaneous crepitus around her neck was detected.", + "Muscle power was normal in all four limbs.", + "Laboratory examination only revealed leukocytosis (23000, PMN 85%).", + "Chest radiograph and CT scan of the thorax showed progression lung involvement with subcutaneous emphysema, pneumomediastinum, thickening of interlobular septa, and a reticulonodular pattern.", + "CT scan of paranasal sinuses also showed emphysema in parietal, temporal and occipital soft tissue.", + "Emphysema was seen in retropharyngeal space.", + "The smear and culture of sputum were negative for infectious agents.", + "Flexible bronchoscopy showed severe erythema in bronchial tree, but there was no apparent fistula or rupture.", + "Bronchoalveolar lavage fluid was negative for infectious agents.", + "Echocardiography and esophagoscopy were normal.", + "Intravenous cefteriaxon (1g twice daily) and oral aziothromycin were initiated.", + "On the third day of admission, her shortness of breath worsened.", + "The blood O2 saturation was 82%.", + "High-dose steroid pulse therapy (1g IV methylprednisolone for 3 days) and rituximab 500 mg per week for 4 weeks were initiated.", + "Oxygen therapy and complete bed rest were prescribed.", + "On the 5th day of admission, she transferred to the intensive care unit (ICU) due to severe hypoxemia.", + "She developed bilateral severe pneumothorax.", + "A chest tube was inserted into both pleural spaces.", + "The patient was intubated and mechanical ventilation was initiated.", + "After one week, percutaneous tracheostomy was done.", + "Ix weeks after immunosuppressive therapy, emphysema and pneumomediastinum were restricted and the chest tube was disconnected (first right, then left).", + "However, the patient died because of severe hypoxemia despite intensive immunosuppressive therapy and mechanical ventilation." + ], + "summary": "A 20-year-old woman was admitted with neck pain, dyspnea, cough, and fever. She had been diagnosed with dermatomyositis 21 months prior. A thorax computed tomography (CT) scan revealed ground glass opacities in her lungs, pneumomediastinum, pneumothorax, and subcutaneous emphysema. Despite intensive immunosuppressive therapy, clinical deterioration and radiological progression were observed, ultimately the patient died.", + "summary_subclaims": [ + "The patient was a 20-year-old woman.", + "She was admitted with neck pain.", + "She was admitted with dyspnea.", + "She was admitted with cough.", + "She was admitted with fever.", + "She had been diagnosed with dermatomyositis 21 months prior.", + "A thorax CT scan revealed ground glass opacities in her lungs.", + "A thorax CT scan revealed pneumomediastinum.", + "A thorax CT scan revealed pneumothorax.", + "A thorax CT scan revealed subcutaneous emphysema.", + "Clinical deterioration was observed.", + "Radiological progression was observed.", + "The patient died." + ] + }, + { + "id": "multiclinsum_test_3168_en.txt", + "fulltext": "A 32-year-old previously healthy female patient from the North Central Province of Sri Lanka presented with gradual onset of visual impairment in both eyes for 2 months. The blurred vision was initially unilateral, involving the right eye, and within the next few weeks, it progressed to involve the left eye. Both near and far visions were impaired, however, her color vision remained unimpaired. It was later associated with persistent, mild frontal headache without aura, photophobia, or focal neurological deficits. There was no redness or pain in the eyes. Over the following weeks, her symptoms progressively worsened to a degree that affected her instrumental activities of daily living.\n\nEye examination revealed a best corrected visual acuity (BCVA) of 6/36 in both eyes. Fundoscopic examination revealed bilateral cotton wool spots, predominantly over the posterior pole and along the vascular arcades; arteriolar narrowing; venous segmentation; and a few areas of flame-shaped hemorrhages. The pupils were normal in size without evidence of relative afferent pupillary defects. The visual fields and color vision were normal. The rest of the neurological examination results were normal. A fundal fluorescein angiogram (FFA) revealed retinal vasculitis with occlusive retinal arteriolitis and phlebitis.\n\nA total of 2 months after the onset of her initial symptoms, while undergoing evaluation for retinal vasculitis, the patient developed a constellation of constitutional and musculoskeletal complaints. This included low-grade fever (101 °F) with chills, fatigue, and loss of appetite. She also experienced arthralgia, involving both small and large joints bilaterally, without objective signs of joint inflammation. Then, 1 week later, the patient developed an erythematous malar rash and a painless ulcer on the hard palate. It was then followed by bilateral periorbital and ankle swelling, which were worse in the morning.\n\nShe did not have a history of chronic cough, hemoptysis, or a past or contact history of tuberculosis. She had no history of valvular or congenital heart disease, and she did not have a history to suggest inflammatory bowel disease. She denied a history of contact with household pets or livestock or recent foreign travel. She also denied high-risk sexual behaviour, unhygienic tattooing, or intravenous drug abuse.\n\nShe also did not have photosensitive rashes, increased hair loss, Raynaud’s phenomenon, proximal muscle weakness, sicca symptoms, painful or red eyes, recurrent oral or genital ulcers, neck pain, or limb claudication. She had no symptoms suggesting thyrotoxicosis or diabetes mellitus. She had regular menstruation since menarche. She experienced an uneventful pregnancy 1 year prior. She did not have a history of recurrent miscarriages or intrauterine death. There was no family history of autoimmune diseases. She is a non-smoking teetotaler. She had good family support and no significant psychosocial stressors.\n\nOn examination, her body mass index was 19 kg/m2. She was febrile but not pale. There were bilateral erythematous rashes over the malar area of the face sparing the nasolabial folds suggestive of acute cutaneous lupus. Oral examination revealed an oral ulcer over the hard palate of the mouth. She did not have redness in her eyes. Mild periorbital swelling was noted along with bilateral pitting ankle edema. Examination of the neck revealed a few subcentimeter, nontender, enlarged lymph nodes. There were no clubbing or peripheral stigmata of infective endocarditis. None of the joints were actively inflamed, nor were there any joint deformities.\n\nHer blood pressure was 112/78 mmHg, and her pulse rate was 82 beats per minute and regular. The radial, carotid, and femoral pulses were palpable in normal volume, and there were no audible bruits or radio-radial or radio-femoral delays. The rest of the peripheral pulses were palpable. There was no tenderness in the carotid artery. Cardiac examination was normal, with no audible murmurs or pericardial rubs. The lung fields were clear. Abdominal and neurological examinations were unremarkable. There were no genital ulcers.\n\nRheumatological work-up revealed a high antinuclear antibody (ANA) and anti-double stranded DNA (anti-dsDNA) titers with low complement levels.\n\nThe urine-protein-to-creatinine ratio (UPCR) showed a nephrotic range proteinuria. The renal biopsy confirmed class III LN. Blood and urine cultures were sterile. A transthoracic echocardiogram excluded infective endocarditis. A comprehensive workup was undertaken to exclude infectious and inflammatory aetiologies of retinal vasculitis. This included evaluation for Epstein–Barr virus (EBV), cytomegalovirus (CMV), human immunodeficiency virus (HIV), hepatitis B and C viruses, toxoplasmosis, syphilis, and tuberculosis. Additionally, the rheumatologic workup excluded Behçet's disease, antineutrophil cytoplasmic antibodies (ANCA)-associated vasculitis, sarcoidosis, Sjögren's syndrome, and rheumatoid arthritis.\n\nThe patient fulfilled the 2019 European League Against Rheumatism/American College of Rheumatology (EULAR/ACR) classification criteria for SLE with a score of 37 points on the basis of the constellation of fever, leukopenia, oral ulcers, acute cutaneous lupus, arthralgia, class III LN on biopsy, low C3 and C4 levels, and anti-dsDNA antibody positivity. Furthermore, the Systemic Lupus Erythematosus Disease Activity Index 2000 (SLEDAI-2 K) score of 29 points, driven by fever, visual disturbance, evidence of vasculitis, proteinuria, inflammatory rash, oral ulcers, low complement levels, and high DNA binding, categorized the disease activity as severe.\n\nThe patient was started on pulsed intravenous methylprednisolone (1 g per day) for 3 days followed by oral prednisolone (1 mg/kg/day) with a tapering regime. She was simultaneously treated with hydroxychloroquine (HCQ) and mycophenolate mofetil (MMF) at the discretion of the rheumatology, ophthalmology, and nephrology teams. Treatment resulted in a favorable clinical response within 1 month. The patient experienced an improvement in systemic symptoms and proteinuria, with UPCR falling below 2.5 mg/kg. Additionally, BCVA improved from 6/36 to 6/12 at 2 months, accompanied by a corresponding resolution of retinal changes. A total of 3 months after initiating treatment, the patient achieved disease remission, as evidenced by a SLEDAI-2 K score of two points. Following the initial management, steroid dosages were gradually tapered off. MMF and HCQ were continued for long-term disease control. The patient underwent regular monitoring for HCQ-induced retinal toxicity. At the 1-year follow-up, the patient demonstrated excellent long-term disease control, with significant improvement in vision (BCVA improving to 6/6) and no evidence of HCQ-induced retinal toxicity. Additionally, LN remained in remission.", + "fulltext_subclaims": [ + "The patient is a 32-year-old previously healthy female.", + "She is from the North Central Province of Sri Lanka.", + "She presented with gradual onset of visual impairment in both eyes for 2 months.", + "The blurred vision was initially unilateral, involving the right eye.", + "Within the next few weeks, it progressed to involve the left eye.", + "Both near and far visions were impaired.", + "Her color vision remained unimpaired.", + "It was later associated with persistent, mild frontal headache.", + "There was no redness or pain in the eyes.", + "Her symptoms progressively worsened to a degree that affected her instrumental activities of daily living.", + "Eye examination revealed a best corrected visual acuity (BCVA) of 6/36 in both eyes.", + "Fundoscopic examination revealed bilateral cotton wool spots.", + "The cotton wool spots were predominantly over the posterior pole and along the vascular arcades.", + "Arteriolar narrowing was noted.", + "Venous segmentation was noted.", + "A few areas of flame-shaped hemorrhages were noted.", + "The pupils were normal in size without evidence of relative afferent pupillary defects.", + "The visual fields and color vision were normal.", + "The rest of the neurological examination results were normal.", + "A fundal fluorescein angiogram (FFA) revealed retinal vasculitis.", + "The FFA showed occlusive retinal arteriolitis.", + "The FFA showed phlebitis.", + "The patient developed low-grade fever (101 °F) with chills.", + "She experienced arthralgia involving both small and large joints bilaterally.", + "There were no objective signs of joint inflammation.", + "She developed an erythematous malar rash.", + "She had a painless ulcer on the hard palate.", + "She had bilateral periorbital and ankle swelling.", + "The swelling was worse in the morning.", + "She did not have a history of chronic cough, hemoptysis, or a past or contact history of tuberculosis.", + "She had no history of valvular or congenital heart disease.", + "She did not have a history to suggest inflammatory bowel disease.", + "She denied a history of contact with household pets or livestock.", + "She denied recent foreign travel.", + "She denied high-risk sexual behaviour, unhygienic tattooing, or intravenous drug abuse.", + "She did not have photosensitive rashes, increased hair loss, Raynaud’s phenomenon, proximal muscle weakness, sicca symptoms, painful or red eyes, recurrent oral or genital ulcers, neck pain, or limb claudication.", + "She had no symptoms suggesting thyrotoxicosis or diabetes mellitus.", + "She had regular menstruation since menarche.", + "She experienced an uneventful pregnancy 1 year prior.", + "There was no family history of autoimmune diseases.", + "She is a non-smoking teetotaler.", + "On examination, her body mass index was 19 kg/m2.", + "There were bilateral erythematous rashes over the malar area of the face.", + "The rash spared the nasolabial folds.", + "Oral examination revealed an oral ulcer over the hard palate.", + "Mild periorbital swelling was noted.", + "Bilateral pitting ankle edema was noted.", + "Examination of the neck revealed a few subcentimeter, nontender, enlarged lymph nodes.", + "There were no clubbing or peripheral stigmata of infective endocarditis.", + "None of the joints were actively inflamed.", + "There were no joint deformities.", + "Rheumatological work-up revealed a high antinuclear antibody (ANA) titer.", + "Rheumatological work-up revealed a high anti-double stranded DNA (anti-dsDNA) titer.", + "Rheumatological work-up showed low complement levels.", + "The urine-protein-to-creatinine ratio (UPCR) showed a nephrotic range proteinuria.", + "The renal biopsy confirmed class III lupus nephritis (LN).", + "Blood and urine cultures were sterile.", + "A transthoracic echocardiogram excluded infective endocarditis.", + "A comprehensive workup was undertaken to exclude infectious and inflammatory aetiologies of retinal vasculitis.", + "The patient fulfilled the 2019 EULAR/ACR classification criteria for SLE with a score of 37 points.", + "The SLEDAI-2 K score was 29 points.", + "The disease activity was categorized as severe.", + "The patient was started on pulsed intravenous methylprednisolone (1 g per day) for 3 days.", + "She was treated with oral prednisolone (1 mg/kg/day) with a tapering regime.", + "She was treated with hydroxychloroquine (HCQ).", + "She was treated with mycophenolate mofetil (MMF).", + "Treatment resulted in a favorable clinical response within 1 month.", + "The patient experienced an improvement in systemic symptoms and proteinuria.", + "The UPCR fell below 2.5 mg/kg.", + "BCVA improved from 6/36 to 6/12 at 2 months.", + "Retinal changes resolved.", + "At 3 months after initiating treatment, the patient achieved disease remission.", + "The SLEDAI-2 K score was two points.", + "Steroid dosages were gradually tapered off.", + "MMF and HCQ were continued for long-term disease control.", + "The patient underwent regular monitoring for HCQ-induced retinal toxicity.", + "At the 1-year follow-up, the patient demonstrated excellent long-term disease control.", + "Vision improved to 6/6.", + "There was no evidence of HCQ-induced retinal toxicity.", + "LN remained in remission." + ], + "summary": "We report the case of a 32-year-old female patient from Sri Lanka who presented with progressive visual impairment, followed by fatigue, malaise, and arthralgia. She was initially diagnosed with retinal vasculitis. Later, she developed constitutional symptoms followed by mucocutaneous and renal manifestations consistent with systemic lupus erythematosus. Laboratory findings supported the diagnosis of systemic lupus erythematosus with positive antinuclear antibody and anti-double stranded DNA, as well as low complement levels. Renal biopsy confirmed class III lupus nephritis. The patient received treatment with corticosteroids, mycophenolate mofetil, and hydroxychloroquine, which resulted in significant improvements in visual, renal, and other clinical symptoms.", + "summary_subclaims": [ + "The patient is a 32-year-old female from Sri Lanka.", + "The patient presented with progressive visual impairment.", + "The patient had fatigue.", + "The patient had malaise.", + "The patient had arthralgia.", + "The patient was initially diagnosed with retinal vasculitis.", + "The patient later developed constitutional symptoms.", + "The patient later developed mucocutaneous manifestations consistent with systemic lupus erythematosus.", + "The patient later developed renal manifestations consistent with systemic lupus erythematosus.", + "Laboratory findings supported the diagnosis of systemic lupus erythematosus.", + "The patient had positive antinuclear antibody.", + "The patient had positive anti-double stranded DNA.", + "The patient had low complement levels.", + "Renal biopsy confirmed class III lupus nephritis.", + "The patient received treatment with corticosteroids.", + "The patient received treatment with mycophenolate mofetil.", + "The patient received treatment with hydroxychloroquine.", + "Treatment resulted in significant improvements in visual symptoms.", + "Treatment resulted in significant improvements in renal symptoms.", + "Treatment resulted in significant improvements in other clinical symptoms." + ] + }, + { + "id": "multiclinsum_test_2909_en.txt", + "fulltext": "A 78-year-old Chinese woman had an isolated mass that was found in her right breast during a health checkup, and a pulmonary CT scan revealed multiple lesions in both of her lungs. She had a history of cough and expectoration for two months without fever, chest pain, dyspnea, or other complaints. During a physical examination, a nearly 2.0×2.0cm, firm nodule without tenderness was found in the lateral superior quadrant of the right breast. In a routine blood test and tumor marker screen, no remarkable abnormalities were reported. However, the anti-SS-A and anti-SS-B antibodies were positive. Our patient had high concentrations of polyclonal serum immunoglobulins (Igs): IgA 485.00mg/dL (reference range: 70 to 400mg/dL), IgG 2030.00mg/dL (reference range: 700 to 1600mg/dL), Ig light-chain kappa 432.00mg/dL (reference range: 170 to 370mg/dL), and Ig light-chain lambda 249.00mg/dL (reference range: 90 to 210mg/dL).\nPrior to a surgical resection of the mammary nodule, a whole-body PET/CT scan was suggested for the purpose of staging the possible malignant breast lesion. The scan was performed on a PET/CT system (Siemens Biograph TruePoint™ 64; Siemens Healthcare, Erlangen, Germany) at 60 minutes after intravenous injection of 6.5mCi (240MBq) of 18F-FDG and covered the range of the bottom of the skull to the mid thigh. On the PET maximum intensity projection image , an obviously hypermetabolic nodule in the right breast and slightly increased FDG uptake of the lymph nodes (LNs) at the hilus of the lungs and posterior cervical region bilaterally were revealed. On transverse images of PET/CT, the right breast lesion was a 2.3×1.9cm, round, well-circumscribed homogenous isodense nodule with a maximum standardized uptake value (SUVmax) of 7.30 . Multiple irregular nodules with slight to mild FDG uptake were observed in the lungs, and the largest lesion was a 2.7×2.5cm, round, well-defined solid nodule in the right lower lobe and had an SUVmax of 2.96 . In addition, the bilateral posterior cervical LNs were normal in size and had an SUVmax of 4.48. Given the multiple FDG-avid foci in a woman of our patient’s age, a primary breast malignant tumor lesion with pulmonary metastasis was considered first and surgery on the mammary lesion was performed three days later.\nTissues of the mammary lesion were reviewed for histopathological features, and formalin-fixed and paraffin-embedded tissues were immunostained with antibodies to IgG4 (1:300, clone HP6025; Zymed, now part of Invitrogen Corporation, Carlsbad, CA, USA), IgG (1:200, clone A57H; Dako, Glostrup, Denmark), S-100 protein (1:1000, polyclonal; Dako), and CD68 protein (1:100, clone KP1; Dako). Congo red stain was used to test amyloid deposits. Pathologically, the mammary lesion showed abundant plasma cells and sinus histiocytes, including large pale pathognomonic histiocytes that exhibited emperipolesis . In addition, lymphoid follicle formation, patchy fibrosis, and obliterative phlebitis, accompanied by atrophy and loss of mammary lobules, were observed. Further immunohistochemical staining showed large histiocytes positive for S-100 protein and CD-68 protein but negative for CD1a. The average number of IgG4+ cells was 118 per high-powered field, and the ratio of IgG4+ to IgG+ cells was 65%.\nThe lesion in the upper lobe of the right lung and the LN at the right carotid sheath were biopsied. Histology revealed deposition of strongly Congo red-positive materials with few histiocytes and fibrotic cell infiltration in the lung tissue. Reactive lymphoproliferation and deposition of Congo red-positive materials within the adjacent connective tissue were observed in the cervical LN.", + "fulltext_subclaims": [ + "A 78-year-old Chinese woman had an isolated mass found in her right breast during a health checkup.", + "A pulmonary CT scan revealed multiple lesions in both of her lungs.", + "She had a history of cough and expectoration for two months.", + "During a physical examination, a nearly 2.0×2.0cm, firm nodule without tenderness was found in the lateral superior quadrant of the right breast.", + "In a routine blood test and tumor marker screen, no remarkable abnormalities were reported.", + "The anti-SS-A and anti-SS-B antibodies were positive.", + "The patient had high concentrations of polyclonal serum immunoglobulins.", + "IgA was 485.00mg/dL.", + "IgG was 2030.00mg/dL.", + "Ig light-chain kappa was 432.00mg/dL.", + "Ig light-chain lambda was 249.00mg/dL.", + "A whole-body PET/CT scan was suggested for staging the possible malignant breast lesion.", + "The PET/CT scan was performed on a Siemens Biograph TruePoint™ 64 system.", + "The scan was performed 60 minutes after intravenous injection of 6.5mCi of 18F-FDG.", + "The PET maximum intensity projection image showed an obviously hypermetabolic nodule in the right breast.", + "The PET maximum intensity projection image showed slightly increased FDG uptake of the lymph nodes at the hilus of the lungs and posterior cervical region bilaterally.", + "On transverse images, the right breast lesion was a 2.3×1.9cm, round, well-circumscribed homogenous isodense nodule with an SUVmax of 7.30.", + "Multiple irregular nodules with slight to mild FDG uptake were observed in the lungs.", + "The largest lung lesion was a 2.7×2.5cm, round, well-defined solid nodule in the right lower lobe with an SUVmax of 2.96.", + "The bilateral posterior cervical lymph nodes had an SUVmax of 4.48.", + "Given the multiple FDG-avid foci in a woman of the patient’s age, a primary breast malignant tumor lesion with pulmonary metastasis was considered first.", + "Surgery on the mammary lesion was performed three days later.", + "Tissues of the mammary lesion were immunostained with antibodies to IgG4, IgG, S-100 protein, and CD68 protein.", + "Congo red stain was used to test amyloid deposits.", + "The mammary lesion showed abundant plasma cells and sinus histiocytes, including large pale pathognomonic histiocytes that exhibited emperipolesis.", + "Lymphoid follicle formation, patchy fibrosis, and obliterative phlebitis were observed.", + "Further immunohistochemical staining showed large histiocytes positive for S-100 protein and CD-68 protein but negative for CD1a.", + "The average number of IgG4+ cells was 118 per high-powered field.", + "The ratio of IgG4+ to IgG+ cells was 65%.", + "The lesion in the upper lobe of the right lung and the LN at the right carotid sheath were biopsied.", + "Histology revealed deposition of strongly Congo red-positive materials with few histiocytes and fibrotic cell infiltration in the lung tissue.", + "Reactive lymphoproliferation and deposition of Congo red-positive materials within the adjacent connective tissue were observed in the cervical LN." + ], + "summary": "We reviewed the 18F-fluoro-deoxyglucose positron emission tomography/computed tomography scan of a 78-year-old Chinese woman with a solid mass that was found in her right breast during a health checkup. 18F-fluoro-deoxyglucose positron emission tomography/computed tomography showed a hypermetabolic nodule in her right breast and slightly heterogeneous increased fluoro-deoxyglucose uptake of the pulmonary nodules, which were histologically proven to be mammary Rosai-Dorfman disease with IgG4+ plasma cell infiltration and pulmonary amyloidosis, respectively. A literature review was performed to gather information on this rare disease process.", + "summary_subclaims": [ + "The patient is a 78-year-old Chinese woman.", + "The patient had a solid mass found in her right breast during a health checkup.", + "An 18F-fluoro-deoxyglucose positron emission tomography/computed tomography scan was reviewed.", + "The 18F-fluoro-deoxyglucose positron emission tomography/computed tomography showed a hypermetabolic nodule in her right breast.", + "The 18F-fluoro-deoxyglucose positron emission tomography/computed tomography showed slightly heterogeneous increased fluoro-deoxyglucose uptake of the pulmonary nodules.", + "The pulmonary nodules were histologically proven to be pulmonary amyloidosis.", + "A literature review was performed to gather information on this rare disease process." + ] + }, + { + "id": "multiclinsum_test_1476_en.txt", + "fulltext": "A 79-year-old male complained of persistent diffuse abdominal pain for 4 d.\nInitially, the abdominal pain occurred abruptly after eating a big meal, 4 d prior to admission. The initial abdominal pain was mainly located in the right upper quarter abdominal area and then migrated to the whole abdomen. Additionally, the patient experienced nausea, vomiting, constipation, and fever. Recurrent abdominal pain was noted for the 4 d as well. Sonography-guided percutaneous catheter drainage of the left subphrenic abscess, as shown by contrast computed tomography (CT) of the abdomen, was performed. The bilirubin level was 76.0 mg/dL and volume of abscess drainage was around 600 mL. The abscess culture yielded Enterococcus faecalis and Enterobacter cloacae complex. The blood culture yielded no pathogen isolates. Biloma was confirmed. However, the patient still complained of epigastric pain after drainage.\nThe patient had a medical history of hypertension and had taken an antihypertensive drug regularly.\nThe patient’s personal and family histories were unremarkable.\nInitial vital signs were a temperature of 37.8 °C, heart rate of 126 beats/min, blood pressure of 163/93 mmHg, and respiratory rate of 32 breaths/min. There was no apparent loss of consciousness. Physical examination showed icteric sclera, abdominal fullness, diffuse tenderness, and muscle guarding. Follow-up vital signs before repeat abdominal CT for persistent abdominal pain were a temperature of 37.5 °C, heart rate of 116 beats/min, blood pressure of 162/84 mmHg, and respiratory rate of 20 breaths/min. Severe muscle guarding and diffuse tenderness were observed.\nAbnormal laboratory findings included hyperbilirubinemia (total bilirubin: 3.0 mg/dL; reference range: ≤ 1.2 mg/dL), mildly elevated alkaline phosphatase (138 U/L; reference range: 40-129 U/L), hyponatremia (sodium: 127 mmol/L; reference range: 136-145 mmol/L), impaired renal function (creatinine: 1.59 mg/dL; reference range: 0.70-1.20 mg/dL), white blood cell count of 3200/μL (reference range: 3400-9500/μL), and 8% band form of white blood cells (reference range: 0.0%-4.2%).\nPlain abdominal radiography showed ileus and contrast abdominal CT showed a dilated common bile duct (CBD) and left subphrenic abscess . Repeat contrast CT of the abdomen was performed for persistent abdominal pain after biloma drainage and showed bile leakage and gastric wall thickening . Esophagogastroduodenoscopy (EGD) showed an edematous, hyperemic gastric mucosa with poor distensibility . Endoscopic retrograde cholangiopancreatography after EGD showed a dilated CBD with one filling defect of about 10 mm in size .\nThe gastric mucosal culture yielded Enterococcus faecalis and the biopsy showed that the gastric submucosa and mucosa were infiltrated by clusters of lymphocytes, neutrophils, and plasma cells . According to initial CT and endoscopic retrograde cholangiopancreatography, the etiology of the initial abdominal pain with fever was a CBD stone with cholangitis and spontaneous biloma. However, according to serial CT images and gastric mucosal culture, the persistent pain after biloma drainage was caused by PG. The etiology of PG was bile leakage after biloma drainage.", + "fulltext_subclaims": [ + "The patient is a 79-year-old male.", + "The patient complained of persistent diffuse abdominal pain for 4 d.", + "The initial abdominal pain occurred abruptly after eating a big meal.", + "The initial abdominal pain was mainly located in the right upper quarter abdominal area.", + "The patient experienced nausea.", + "The patient experienced vomiting.", + "The patient experienced constipation.", + "The patient experienced fever.", + "Sonography-guided percutaneous catheter drainage of the left subphrenic abscess was performed.", + "The bilirubin level was 76.0 mg/dL.", + "The volume of abscess drainage was around 600 mL.", + "The abscess culture yielded Enterococcus faecalis.", + "The abscess culture yielded Enterobacter cloacae complex.", + "The blood culture yielded no pathogen isolates.", + "Biloma was confirmed.", + "The patient still complained of epigastric pain after drainage.", + "The patient had a medical history of hypertension.", + "The patient’s personal and family histories were unremarkable.", + "Initial vital signs were a temperature of 37.8 °C.", + "Initial vital signs were a heart rate of 126 beats/min.", + "Initial vital signs were a blood pressure of 163/93 mmHg.", + "Initial vital signs were a respiratory rate of 32 breaths/min.", + "Physical examination showed icteric sclera.", + "Physical examination showed abdominal fullness.", + "Physical examination showed diffuse tenderness.", + "Physical examination showed muscle guarding.", + "Follow-up vital signs before repeat abdominal CT were a temperature of 37.5 °C.", + "Follow-up vital signs before repeat abdominal CT were a heart rate of 116 beats/min.", + "Follow-up vital signs before repeat abdominal CT were a blood pressure of 162/84 mmHg.", + "Follow-up vital signs before repeat abdominal CT were a respiratory rate of 20 breaths/min.", + "Severe muscle guarding was observed.", + "Severe diffuse tenderness was observed.", + "Hyperbilirubinemia was present (total bilirubin: 3.0 mg/dL).", + "Alkaline phosphatase was mildly elevated (138 U/L).", + "Hyponatremia was present (sodium: 127 mmol/L).", + "Impaired renal function was present (creatinine: 1.59 mg/dL).", + "White blood cell count was 3200/μL.", + "Band form of white blood cells was 8%.", + "Plain abdominal radiography showed ileus.", + "Contrast abdominal CT showed a dilated common bile duct.", + "Contrast abdominal CT showed a left subphrenic abscess.", + "Repeat contrast CT of the abdomen was performed for persistent abdominal pain after biloma drainage.", + "Repeat contrast CT showed bile leakage.", + "Repeat contrast CT showed gastric wall thickening.", + "Esophagogastroduodenoscopy showed an edematous, hyperemic gastric mucosa.", + "Esophagogastroduodenoscopy showed poor distensibility.", + "Endoscopic retrograde cholangiopancreatography showed a dilated common bile duct.", + "Endoscopic retrograde cholangiopancreatography showed one filling defect of about 10 mm in size.", + "The gastric mucosal culture yielded Enterococcus faecalis.", + "The gastric biopsy showed infiltration by clusters of lymphocytes.", + "The gastric biopsy showed infiltration by clusters of neutrophils.", + "The gastric biopsy showed infiltration by clusters of plasma cells.", + "According to initial CT and endoscopic retrograde cholangiopancreatography, the etiology of the initial abdominal pain with fever was a CBD stone with cholangitis and spontaneous biloma.", + "According to serial CT images and gastric mucosal culture, the persistent pain after biloma drainage was caused by PG.", + "The etiology of PG was bile leakage after biloma drainage." + ], + "summary": "A 79-year-old man with a medical history of hypertension had persistent diffuse abdominal pain for 4 d. Physical examination showed stable vital signs, icteric sclera, diffuse abdominal tenderness, and muscle guarding. Laboratory tests showed hyperbilirubinemia and bandemia. Contrast computed tomography (CT) of the abdomen showed a dilated common bile duct and left subphrenic abscess. Left subphrenic abscess drainage revealed bilious fluid, and infected biloma was confirmed. Repeated abdominal CT for persistent epigastralgia after drainage showed gastric wall thickening. Esophagogastroduodenoscopy (EGD) showed an edematous, hyperemic gastric mucosa with poor distensibility. The gastric mucosal culture yielded Enterococcus faecalis. PG was diagnosed based on imaging, EGD findings, and gastric mucosal culture. The patient recovered successfully with antibiotic treatment.", + "summary_subclaims": [ + "The patient is a 79-year-old man.", + "The patient had a medical history of hypertension.", + "The patient had persistent diffuse abdominal pain for 4 d.", + "Physical examination showed stable vital signs.", + "Physical examination showed icteric sclera.", + "Physical examination showed diffuse abdominal tenderness.", + "Physical examination showed muscle guarding.", + "Laboratory tests showed hyperbilirubinemia.", + "Laboratory tests showed bandemia.", + "Contrast computed tomography (CT) of the abdomen showed a dilated common bile duct.", + "Contrast CT of the abdomen showed a left subphrenic abscess.", + "Left subphrenic abscess drainage revealed bilious fluid.", + "Infected biloma was confirmed.", + "Repeated abdominal CT for persistent epigastralgia after drainage showed gastric wall thickening.", + "Esophagogastroduodenoscopy (EGD) showed an edematous, hyperemic gastric mucosa with poor distensibility.", + "The gastric mucosal culture yielded Enterococcus faecalis.", + "PG was diagnosed based on imaging, EGD findings, and gastric mucosal culture.", + "The patient recovered successfully with antibiotic treatment." + ] + }, + { + "id": "multiclinsum_test_1047_en.txt", + "fulltext": "The proband (II-2 in Fig. ) is a 45-year old woman, who first presented to our university hospital at the age of 35 and was referred to us because of her pregnancy. She has congenital deafness, first experienced syncope at the age of 3, and was diagnosed with epilepsy. She was treated with anti-epilepsy medications; however, she subsequently experienced several instances of syncope. At the age of 13, she had a syncope event, and was suspected of having JLNS because of her congenital deafness and prolonged QT interval. Her syncope was diagnosed as an arrhythmic episode when she was aware of tachycardia and as epilepsy when she was not. She also had a subarachnoid hemorrhage at the age of 29.\nWhen she first presented at our hospital, she was not taking beta-blockers, because of a history of asthma, but was taking mexiletine in addition to phenytoin. Her QTc was found to be prolonged (584 ms) at presentation and administration of atenolol was initiated. She delivered her baby (III-1 in Fig. ) through Caesarean operation at our hospital at the age of 35. At 37, she delivered her second baby (III-2 in Fig. ) through Caesarean operation at our hospital. Despite administration of beta-blockers, her QTc remained prolonged (600 msec at the age of 37, 780 msec at 44) , which is not unexpected because treatment with beta-blockers in LQTS1 is not expected to overtly reduce QTc . However, she continued to experience occasional syncope and finally underwent an implantable cardioverter defibrillator (ICD) operation at 38 years of age. Subsequently, she is in a stable clinical condition. Because the proband was suspected of JLNS and both infants had a measured QTc of 500 ms or greater within 1 month after birth, beta blockers were initiated and both children remain in stable condition at ages 10 and 8 . QTc of the son (III-1 in Fig. ) was measured as 500 ms one month after birth, while the QTc of his sister (III-2) was 530 ms at birth.\nThe father (I-1) and mother (I-2) of the proband were first cousins. There is no history of sudden unexplained syncope or death of children or adults in the immediate family members, despite the prolonged QTc of the children.\nClinical evaluation and consultation of the proband and her family members were performed at Chiba University Hospital. Clinical phenotypes were deduced from the clinical history, physical examinations, and ECG. Blood samples were collected from the proband and her family members following genetic counseling, and written informed consent was obtained prior to sample collection.\nGenomic DNA was isolated from peripheral blood lymphocytes according to established protocols at our laboratory . Entire coding exons, including the intronic boundaries of the genes, of KCNQ1 (NCBI ref: NM_000218) and other LQT causative genes (KCNH2, SCN5A, KCNE1, KCNE2, KCNJ2, SCN4B, KCNJ5) were amplified by polymerase chain reaction (PCR), according to established protocols in our laboratory. Briefly, 30–100 ng of genomic DNA was subjected to PCR amplification with DNA polymerase (PrimeSTAR GXL DNA Polymerase; Takara Bio Inc., Kusatsu, Japan) and primer sets.\nThe amplicons were subjected to conventional sequencing with Sanger sequencers (Applied Biosystems 3730/3130 DNA analyzers; Thermo Fisher Scientific, Waltham, MA, USA). The sequence data were processed with Gene Codes Sequencher Software (Takara Bio Inc.) and mapped to the human genome sequence (build GRCh37/hg19).\nGenetic analysis was performed to screen all coding exons and the exon–intron boundaries of the KCNQ1 gene (NCBI ref: NM_000218.2, NP_000209.2) with concurrent screening of other LQT causative genes (KCNH2, SCN5A, KCNE1, KCNE2, KCNJ2, SCN4B, KCNJ5). We detected a novel homozygous nonsense variant, NM_000218.2:c.115G > T (p.Glu39X, in exon 1a), in the KCNQ1 gene of the proband, as well as a homozygous common variant (NM_000218.2:c.1343C > G, p.Pro448Arg) (Additional file : Table S1). Genetic screening of her mother (I-2) and children (III-1 and III-2) revealed that they were heterozygous for the nonsense variant . Her husband (II-3) was also screened and found to be heterozygous for the common variant (NM_000218.2:c.1343C > G, p.Pro448Arg). The proband is a child from a first-cousin marriage, and we have concluded the homozygous nonsense variant in the proband is the cause of her JLNS1. The proband was negative for pathogenic variants in other LQT causative genes, including the KCNE1 gene (Additional file : Table S1).", + "fulltext_subclaims": [ + "The proband is a 45-year-old woman.", + "The proband first presented to the university hospital at the age of 35.", + "The proband was referred to the hospital because of her pregnancy.", + "The proband has congenital deafness.", + "The proband first experienced syncope at the age of 3.", + "The proband was diagnosed with epilepsy.", + "The proband was treated with anti-epilepsy medications.", + "The proband experienced several instances of syncope.", + "At the age of 13, the proband had a syncope event.", + "The proband was suspected of having JLNS because of her congenital deafness and prolonged QT interval.", + "The proband's syncope was diagnosed as an arrhythmic episode when she was aware of tachycardia.", + "The proband's syncope was diagnosed as epilepsy when she was not aware of tachycardia.", + "The proband had a subarachnoid hemorrhage at the age of 29.", + "When she first presented at the hospital, she was not taking beta-blockers.", + "She was taking mexiletine in addition to phenytoin.", + "Her QTc was found to be prolonged (584 ms) at presentation.", + "Administration of atenolol was initiated.", + "She delivered her baby (III-1) through Caesarean operation at the age of 35.", + "At 37, she delivered her second baby (III-2) through Caesarean operation.", + "Despite administration of beta-blockers, her QTc remained prolonged (600 msec at the age of 37, 780 msec at 44).", + "Treatment with beta-blockers in LQTS1 is not expected to overtly reduce QTc.", + "She continued to experience occasional syncope.", + "She finally underwent an implantable cardioverter defibrillator (ICD) operation at 38 years of age.", + "She is in a stable clinical condition.", + "Because the proband was suspected of JLNS and both infants had a measured QTc of 500 ms or greater within 1 month after birth, beta blockers were initiated.", + "Both children remain in stable condition at ages 10 and 8.", + "The QTc of the son (III-1) was measured as 500 ms one month after birth.", + "The QTc of his sister (III-2) was 530 ms at birth.", + "The father (I-1) and mother (I-2) of the proband were first cousins.", + "There is no history of sudden unexplained syncope or death of children or adults in the immediate family members.", + "Clinical evaluation and consultation of the proband and her family members were performed at Chiba University Hospital.", + "Clinical phenotypes were deduced from the clinical history, physical examinations, and ECG.", + "Blood samples were collected from the proband and her family members following genetic counseling.", + "Written informed consent was obtained prior to sample collection.", + "Genomic DNA was isolated from peripheral blood lymphocytes according to established protocols at the laboratory.", + "Entire coding exons, including the intronic boundaries of the genes, of KCNQ1 and other LQT causative genes were amplified by polymerase chain reaction.", + "The amplicons were subjected to conventional sequencing with Sanger sequencers.", + "The sequence data were processed with Gene Codes Sequencher Software.", + "The sequence data were mapped to the human genome sequence (build GRCh37/hg19).", + "Genetic analysis was performed to screen all coding exons and the exon–intron boundaries of the KCNQ1 gene.", + "A novel homozygous nonsense variant, NM_000218.2:c.115G > T (p.Glu39X, in exon 1a), was detected in the KCNQ1 gene of the proband.", + "A homozygous common variant (NM_000218.2:c.1343C > G, p.Pro448Arg) was detected.", + "Genetic screening of her mother (I-2) and children (III-1 and III-2) revealed that they were heterozygous for the nonsense variant.", + "Her husband (II-3) was also screened and found to be heterozygous for the common variant (NM_000218.2:c.1343C > G, p.Pro448Arg).", + "The proband is a child from a first-cousin marriage.", + "The homozygous nonsense variant in the proband is the cause of her JLNS1.", + "The proband was negative for pathogenic variants in other LQT causative genes, including the KCNE1 gene." + ], + "summary": "Here, we report a novel nonsense KCNQ1 variant causing not only JLNS, but also significant QTc prolongation identical to RWS in an autosomal dominant manner. Our case study supports that haploinsufficiency in the KCNQ1 gene is causative of significant QTc prolongation identical to RWS. Interestingly, the nonsense variant (NM_000218.2:c.115G > T", + "summary_subclaims": [ + "A novel nonsense KCNQ1 variant causes not only JLNS, but also significant QTc prolongation identical to RWS in an autosomal dominant manner.", + "The case study supports that haploinsufficiency in the KCNQ1 gene is causative of significant QTc prolongation identical to RWS.", + "The nonsense variant is NM_000218.2:c.115G > T." + ] + }, + { + "id": "multiclinsum_test_236_en.txt", + "fulltext": "A 3-year-old girl was referred to the neurogenetics clinic, National Research Center, Egypt because of the delayed milestones of development and unusual facies. She was the offspring of a non-consanguineous marriage with no similarly affected family members. The pregnancy and delivery histories were uneventful, however small head and dysmorphic facies were noted at birth. Delayed milestones and failure to gain weight were noted since early life. Seizures were developed at the age of 9 months as myoclonic and the focal seizures were fairly controlled on a combination of valproate and levetiracetam. Evaluation of the motor and mental developmental milestones was remarkably delayed; she could only sit supported, had impaired cognitive functions with obvious autistic features, had the inability to maintain holding objects, and didn’t acquire any speech skills. Her main anthropometric measurements revealed head circumference 40 cm (−6 SD), length 79 cm (−3.6 SD) and weight 7.200 kg (−3 SD). Clinical examination showed dysmorphic facies including, round face with full cheek, narrow forehead, thick bow shaped eyebrows, hypertelorism, long smooth philtrum, downturned corners of the mouth, low set ears, retro-micrognathia and short neck . She had bilateral simian creases, vascular markings on the palm, tapering fingers, and clitoromegaly on genital assessment. Neurological evaluation showed hypotonia with elicited reflexes. Table shows a comparison of the main clinical presentation, involving cytobands, size of 1q deletion, smallest region of overlap (SRO) in the previously reported patients with pure 1q43q44 submicroscopic deletion and our patient.\nElectroencephalogram showed frontotemporal epileptogenic focus. CT brain displayed abnormal gyral pattern, hypogenesis of corpus callosum and bilateral deep Sylvian fissure . Echocardiogram, fundus examination, abdominal and renal ultrasonography revealed no abnormalities. Psychomotor assessment using Stanford Binet International Scale method showed profound retardation.\nThis study was carried out in compliance with the Declaration of Helsinki and approved by the National Research Centre Ethical Research Committee.. Informed consent was obtained from the parents for genetic testing and publication of this case report.", + "fulltext_subclaims": [ + "The patient is a 3-year-old girl.", + "She was referred to the neurogenetics clinic at the National Research Center, Egypt.", + "The referral was due to delayed developmental milestones and unusual facies.", + "She is the offspring of a non-consanguineous marriage.", + "There are no similarly affected family members.", + "The pregnancy and delivery histories were uneventful.", + "Small head and dysmorphic facies were noted at birth.", + "Delayed milestones and failure to gain weight were noted since early life.", + "Seizures developed at the age of 9 months as myoclonic and focal seizures.", + "The seizures were fairly controlled on a combination of valproate and levetiracetam.", + "Evaluation of motor and mental developmental milestones was remarkably delayed.", + "She could only sit supported.", + "She had impaired cognitive functions with obvious autistic features.", + "She had the inability to maintain holding objects.", + "She did not acquire any speech skills.", + "Her head circumference was 40 cm (−6 SD).", + "Her length was 79 cm (−3.6 SD).", + "Her weight was 7.200 kg (−3 SD).", + "Clinical examination showed dysmorphic facies including round face with full cheek.", + "Clinical examination showed narrow forehead.", + "Clinical examination showed thick bow shaped eyebrows.", + "Clinical examination showed hypertelorism.", + "Clinical examination showed long smooth philtrum.", + "Clinical examination showed downturned corners of the mouth.", + "Clinical examination showed low set ears.", + "Clinical examination showed retro-micrognathia.", + "Clinical examination showed short neck.", + "She had bilateral simian creases.", + "She had vascular markings on the palm.", + "She had tapering fingers.", + "Genital assessment showed clitoromegaly.", + "Neurological evaluation showed hypotonia with elicited reflexes.", + "Electroencephalogram showed frontotemporal epileptogenic focus.", + "CT brain showed abnormal gyral pattern.", + "CT brain showed hypogenesis of corpus callosum.", + "CT brain showed bilateral deep Sylvian fissure.", + "Echocardiogram revealed no abnormalities.", + "Fundus examination revealed no abnormalities.", + "Abdominal and renal ultrasonography revealed no abnormalities.", + "Psychomotor assessment using Stanford Binet International Scale method showed profound retardation.", + "This study was carried out in compliance with the Declaration of Helsinki.", + "The study was approved by the National Research Centre Ethical Research Committee.", + "Informed consent was obtained from the parents for genetic testing.", + "Informed consent was obtained from the parents for publication of this case report." + ], + "summary": "We report on a 3 year-old female patient with delayed motor and mental milestones, MIC and facial dysmorphism. She is a child of non-consanguineous parents and no similarly affected family members. CT brain showed abnormal gyral patterns, hypogenesis of corpus callosum and bilateral deep Sylvian fissure. Electroencephalogram showed frontotemporal epileptogenic focus. Her karyotype was revealed as 46,XX,add(1)(q44). Fluorescence in situ hybridization (FISH) using whole chromosome paint (WCP1) and subtelomere 1q revealed that the add segment was not derived from chromosome 1 and there was the deletion of subtelomere 1q. Multiple ligation probe amplification (MLPA) subtelomere kit revealed the deletion of 1q and duplication of 4q. Array CGH demonstrated the 6.5 Mb deletion of 1q and 31 Mb duplication of chromosome 4q.", + "summary_subclaims": [ + "The patient is a 3 year-old female.", + "The patient has delayed motor and mental milestones.", + "The patient has facial dysmorphism.", + "The patient is a child of non-consanguineous parents.", + "CT brain showed abnormal gyral patterns.", + "CT brain showed hypogenesis of corpus callosum.", + "CT brain showed bilateral deep Sylvian fissure.", + "Electroencephalogram showed frontotemporal epileptogenic focus.", + "Her karyotype was revealed as 46,XX,add(1)(q44).", + "FISH using WCP1 revealed that the add segment was not derived from chromosome 1.", + "FISH using subtelomere 1q revealed deletion of subtelomere 1q.", + "MLPA subtelomere kit revealed deletion of 1q.", + "MLPA subtelomere kit revealed duplication of 4q.", + "Array CGH demonstrated 6.5 Mb deletion of 1q.", + "Array CGH demonstrated 31 Mb duplication of chromosome 4q." + ] + }, + { + "id": "multiclinsum_test_2614_en.txt", + "fulltext": "A 70-year-old Greek-Caucasian man was admitted to our hospital with diffuse abdominal pain of sudden onset three hours prior to his admission. The patient did not complain of nausea, vomiting or diarrhea and his temperature and arterial pressure were normal despite an elevated pulse rate (90 ppm.). His latest stool passage was blood-free and a digital rectal examination revealed nothing pathological.\nDuring physical examination, the patient's abdomen was mildly distended with diffuse guarding and marked rebound tenderness. Abdominal sounds were diminished during auscultation.\nLaboratory investigations revealed normal values for his hematocrit, hemoglobin, white blood cell count, and platelets. Renal and hepatic function tests were also normal and his blood glucose was a little elevated at 167.8 mg/dl (normal 70 to 110 mg/dl).\nThe patient's medical history included colonic diverticular disease, an endoscopic excision of benign rectal polyps four years prior to his presentation, and ongoing arterial hypertension and osteoporosis treatment. Ten years prior to presentation in a random ultrasound examination, the patient was found to have several simple liver cysts including two large hepatic cysts and other smaller ones. The largest cyst had a size of 13 cm. At the time, his pancreas, spleen and kidneys were normal . A second ultrasound examination was performed nine years after the first one (and just 13 months prior to his present admission) due to the patient being admitted after an accidental fall. A reduction in the size of the largest cyst form 13 cm to 4.6 cm and a small amount of free liquid in the patient's right abdominal fossa were identified as the only difference from the previous ultrasound report.\nDuring the patient's present admission, there was no free air in his abdomen. An abdominal X-ray examination did not show bowel air-fluid levels. Abdominal ultrasound examination showed a significant quantity of free liquid in his abdominal cavity, around the spleen and liver, as well as in the Douglas pouch. Since the patient's general condition was deteriorating and he was already showing symptoms of paleness, sweating, increased abdominal guarding and marked rebound tenderness in the whole abdominal area, we decided to perform an exploratory laparoscopy.\nThe laparoscopy revealed a vast amount of opaque-yellowish peritoneal fluid occupying majority of his abdominal cavity without any obvious origin, so the operation was converted to laparotomy.\nThe exploration of the patient's abdominal cavity revealed a ruptured liver cyst that originated from the lower surface of his right liver lobe . Unroofing of the cyst using LigaSure to the liver parenchyma margin, plus omentoplasty and cholecystectomy, were performed as the gallbladder was part of the anterior cystic wall. Intraoperative frozen sections of multiple specimens from the cystic wall showed no evidence of malignancy, while cytology and cultures of the cystic fluid were negative. Serological tests for Echinococcus and tumor markers, CEA and CA 19-9, all showed negative results.\nTwo drains were positioned, one at the patient's cystic cavity area and the other at his Douglas pouch. The postoperative course of the patient was uneventful and three days later the drainages were removed. The patient was discharged in excellent general condition eight days after his admission.", + "fulltext_subclaims": [ + "The patient was a 70-year-old Greek-Caucasian man.", + "He was admitted with diffuse abdominal pain of sudden onset three hours prior to admission.", + "He did not complain of nausea, vomiting, or diarrhea.", + "His temperature and arterial pressure were normal.", + "His pulse rate was 90 ppm.", + "His latest stool passage was blood-free.", + "A digital rectal examination revealed nothing pathological.", + "The abdomen was mildly distended with diffuse guarding.", + "There was marked rebound tenderness.", + "Abdominal sounds were diminished during auscultation.", + "Hematocrit, hemoglobin, white blood cell count, and platelets were normal.", + "Renal and hepatic function tests were normal.", + "Blood glucose was 167.8 mg/dl.", + "The patient had a history of colonic diverticular disease.", + "He had an endoscopic excision of benign rectal polyps four years prior.", + "He was on treatment for arterial hypertension and osteoporosis.", + "Ten years prior, he was found to have several simple liver cysts, including two large hepatic cysts.", + "The largest cyst was 13 cm in size.", + "At the time, his pancreas, spleen, and kidneys were normal.", + "A second ultrasound was performed nine years after the first one.", + "The largest cyst had reduced in size from 13 cm to 4.6 cm.", + "A small amount of free liquid was found in the right abdominal fossa.", + "There was no free air in the abdomen.", + "An abdominal X-ray did not show bowel air-fluid levels.", + "An abdominal ultrasound showed a significant quantity of free liquid in the abdominal cavity.", + "The patient was showing symptoms of paleness, sweating, increased abdominal guarding, and marked rebound tenderness.", + "An exploratory laparoscopy was performed.", + "The laparoscopy revealed a vast amount of opaque-yellowish peritoneal fluid.", + "The operation was converted to laparotomy.", + "A ruptured liver cyst was found originating from the lower surface of the right liver lobe.", + "Unroofing of the cyst using LigaSure to the liver parenchyma margin was performed.", + "Omentoplasty and cholecystectomy were performed.", + "Intraoperative frozen sections showed no evidence of malignancy.", + "Cytology and cultures of the cystic fluid were negative.", + "Serological tests for Echinococcus and tumor markers CEA and CA 19-9 were negative.", + "Two drains were positioned, one at the cystic cavity area and the other at the Douglas pouch.", + "The postoperative course was uneventful.", + "The drains were removed three days after surgery.", + "The patient was discharged eight days after admission." + ], + "summary": "We present the case of a 70-year-old Greek-Caucasian man with a large, asymptomatic and non-parasitic liver cyst that presented as an acute surgical abdominal emergency after spontaneous rupture into the peritoneal cavity.", + "summary_subclaims": [ + "The patient is a 70-year-old Greek-Caucasian man.", + "The patient had a large, asymptomatic and non-parasitic liver cyst.", + "The liver cyst presented as an acute surgical abdominal emergency.", + "The liver cyst ruptured spontaneously into the peritoneal cavity." + ] + }, + { + "id": "multiclinsum_test_3318_en.txt", + "fulltext": "47-year-old female patient, housewife, no financial resources and no medical services. The patient presented with pain, functional limitation and deformity of the left wrist. She reported a history of TCG resection, treated with curettage and obturation of the defect with autograft of the iliac crest 4 years ago. Physical examination revealed deformity of the left distal radius with pain on palpation and significant limitation of flexion-extension movements, with no evidence of distal neurovascular involvement and normal mobility of the fingers. Radiologically, an expansive lytic lesion was observed with thinning of the lateral cortical and rupture of the anteromedial cortical of the left distal radius, classified as grade III of Campanacci for TCG. Surgery was performed with a dorsal approach, dissecting planes until the tumor tissue was found with destruction of the anteromedial cortical at the distal third of the radius. Extensor tendons were removed from the tumor tissue and a 7 cm block resection was performed, preserving the carpal bones. Simultaneously, an autologous graft of about 9 cm from the distal third of the fibula was taken and a 7 cm molded block was placed in the area where the resection was performed. Subsequently, a pre-molded 12-hole 3.5 mm compression plate with a dorsal curvature of 10° dorsiflexion was placed to provide an optimal hand position; a metacarpo-carpo-radial arthrodesis was performed with distal fixation in the third metacarpal with three locking pins, a 3.5 mm cortical screw to the greater bone, two locking pins for the graft and three proximal locking pins. The cubito-carpo joint was stabilized and fixed with a 2.0 mm Kirschner wire, the wound was washed and the remaining autologous graft in the radiocarpal space was fragmented. Extensor tendons were rearranged and a flat closure was performed. Finally, a splint was placed on the forearm. The diagnosis of TCG was confirmed by pathology. There were no complications during surgery.\n\nAt 18 months of follow-up, clinical results were very encouraging and the patient reported being very satisfied. She had no pain or paresthesia and performed her daily activities; the patient had good grip strength (80% compared to the healthy side) and had fine motor function in the hand. The wrist was stable with pronation of 85°, supination of 80°, flexion-extension of 0°, and a DASH (Disabilities of the Arm, Shoulder, and Hand) functional outcome assessment questionnaire score of 6.7. Radiologically, the autograft was integrated at the distal end and not integrated at the proximal end. The patient was evaluated radiologically five years after surgery and continued to have no evidence of local recurrence and pulmonary involvement.\n", + "fulltext_subclaims": [ + "The patient is a 47-year-old female.", + "The patient is a housewife.", + "The patient has no financial resources.", + "The patient has no medical services.", + "The patient presented with pain, functional limitation, and deformity of the left wrist.", + "The patient reported a history of TCG resection.", + "The patient was treated with curettage and obturation of the defect with autograft of the iliac crest 4 years ago.", + "Physical examination revealed deformity of the left distal radius.", + "Physical examination showed pain on palpation.", + "Physical examination showed significant limitation of flexion-extension movements.", + "There was no evidence of distal neurovascular involvement.", + "Radiologically, an expansive lytic lesion was observed.", + "The lesion showed thinning of the lateral cortical.", + "The lesion showed rupture of the anteromedial cortical of the left distal radius.", + "The lesion was classified as grade III of Campanacci for TCG.", + "Surgery was performed with a dorsal approach.", + "A 7 cm block resection was performed, preserving the carpal bones.", + "An autologous graft of about 9 cm from the distal third of the fibula was taken.", + "A 7 cm molded block was placed in the area where the resection was performed.", + "A pre-molded 12-hole 3.5 mm compression plate with a dorsal curvature of 10° dorsiflexion was placed.", + "A metacarpo-carpo-radial arthrodesis was performed with distal fixation in the third metacarpal.", + "The cubito-carpo joint was stabilized and fixed with a 2.0 mm Kirschner wire.", + "The diagnosis of TCG was confirmed by pathology.", + "There were no complications during surgery.", + "At 18 months of follow-up, clinical results were very encouraging.", + "The patient reported being very satisfied.", + "The patient had no pain or paresthesia.", + "The patient performed her daily activities.", + "The patient had good grip strength (80% compared to the healthy side).", + "The patient had fine motor function in the hand.", + "The wrist was stable with pronation of 85°.", + "The wrist had supination of 80°.", + "The wrist had flexion-extension of 0°.", + "The DASH score was 6.7.", + "Radiologically, the autograft was integrated at the distal end.", + "Radiologically, the autograft was not integrated at the proximal end.", + "The patient was evaluated radiologically five years after surgery.", + "The patient continued to have no evidence of local recurrence.", + "The patient continued to have no evidence of pulmonary involvement." + ], + "summary": "47-year-old female patient with no financial resources and no medical insurance. Treatment included a block resection, reconstruction with autograft of the distal fibula, and radiocarpal arthrodesis with locked compression plate. Eighteen months later, the patient had good grip strength (80% compared to the healthy side) and had fine motor function in the hand. The wrist was stable with 85° pronation, 80° supination, 0° flexion-extension, and a DASH functional outcome assessment questionnaire score of 6.7. Her radiological evolution five years after surgery continued without evidence of local recurrence and pulmonary involvement.\n", + "summary_subclaims": [ + "The patient is a 47-year-old female.", + "The patient has no financial resources.", + "The patient has no medical insurance.", + "Treatment included a block resection.", + "Treatment included reconstruction with autograft of the distal fibula.", + "Treatment included radiocarpal arthrodesis with locked compression plate.", + "Eighteen months later, the patient had good grip strength.", + "Eighteen months later, the patient's grip strength was 80% compared to the healthy side.", + "Eighteen months later, the patient had fine motor function in the hand.", + "The wrist was stable with 85° pronation.", + "The wrist was stable with 80° supination.", + "The wrist was stable with 0° flexion-extension.", + "The DASH functional outcome assessment questionnaire score was 6.7.", + "Radiological evolution five years after surgery continued without evidence of local recurrence.", + "Radiological evolution five years after surgery continued without pulmonary involvement." + ] + }, + { + "id": "multiclinsum_test_1574_en.txt", + "fulltext": "A 37-year-old Caucasian female nonsmoker with no known past medical history presented to our emergency department with 4 months of dyspnea and back pain. At her initial presentation 4 months prior to an outside facility, she underwent a chest C-ray and chest computed tomography (CT) scan, which showed a right upper lobe consolidation. She had been treated for and discharged with a diagnosis of pneumonia. Two months after her initial presentation, she underwent an outpatient bronchoscopy with bronchoalveolar lavage (BAL) and transbronchial right upper lobe biopsy owing to persistent symptoms and a concern for malignancy. Fungal studies and acid-fast bacilli fluorochrome smears were negative, and biopsy results were negative for malignant cells; the pathology results were consistent with chronic inflammation. Upon arrival to our emergency room, she again reported similar symptoms. Physical examination was notable for neck pain on palpation and tachypnea. A chest CT with intravenous (IV) contrast was performed, revealing near-complete right upper lobe collapse, right upper lobe consolidation, enlarged subcarinal lymph node, and enlarged station 6 lymph node . Magnetic resonance imaging (MRI) of the spine was performed, demonstrating a C7 50% compression fracture and lytic lesions throughout the spinal vertebrae, concerning for metastatic disease. A CT of the abdomen and pelvis was also performed, revealing a single 15-mm hypodense nodule on the liver .\nThe patient subsequently underwent a transthoracic right upper lobe biopsy, which showed dense fibrous pleural bits, samples of alveolar parenchyma showing interstitial fibrosis, and a patchy dense lymphocytic infiltrate; no malignant cells were seen on histopathological examination. Next, the patient underwent bronchoscopy and endobronchial ultrasound with transbronchial lymph node sampling, as well as brushing and BAL of the right upper lobe. Most studies were unremarkable except the BAL cytology exhibit, which was positive for poorly differentiated neoplastic cells, raising the possibility of a poorly differentiated carcinoma; however, the material on the cell block was insufficient to run immunostains. As the concern for metastatic disease remained high on our differential diagnosis, we pursued a liver biopsy to better characterize the malignancy. The patient underwent a fluoroscopy-guided liver biopsy of the aforementioned liver nodule, which demonstrated a malignant undifferentiated neoplasm with epithelioid morphology and weak neuroendocrine differentiation.\nThe cells formed nests/cords in a background of hyalinized sclerotic stroma, frequently demonstrating eosinophilic cytoplasm and round-to-ovoid nuclei . These ancillary studies were insufficient to rule out epithelioid synovial sarcoma, breast malignancy, renal malignancy, thyroid malignancy, gynecologic primary tumors, and epithelioid osteosarcoma. The neoplastic cells were weakly reactive for synaptophysin, and CD99 staining showed a membranous pattern . In a subset, GATA-3 was positive and PAX-8 was weakly positive . However, the neoplastic cells were nonreactive to ER (breast marker) and SATB2 (lower gastrointestinal and osteosarcoma marker). Moreover, the tumor cells were negative for Oscar pankeratin, CK7, CK20, Moc-31, TTF-1, WT-1, HMB45, Melan-A, SOX-10, S100, Inhibin, SMA, MyoD1, CD117, CD45, CD30, and CD34. Thus, the liver tissue was sent for a second opinion for evaluation by a pathologist with expertise in gastrointestinal, liver, soft tissue, and cardiothoracic pathology in a state-of-the-art center at the national and international levels. They found that a specialized panel of immunohistochemical stains revealed that the tumor cells were reactive to MUC4 expression. BRG1 and INI1 immunostains revealed preserved nuclear staining; however, claudin-4, ERG, CD31, CAMTA1, P40, ETV-4, and NUT stains were negative. Subsequently, a diagnosis of sclerosing epithelioid fibrosarcoma was concluded.\nBased on our diagnostic workup, the patient was promptly started on doxorubicin therapy. The patient ultimately joined a genetic research protocol at a major cancer research center. Next-generation sequencing (Tempus genetic testing) was completed to evaluate for any variant known to increase her risk for cancer. There were no genes identified that would increase her risk for cancer. However, there was an identified variant of unknown significance of the WRN gene, an autosomal recessive gene associated with Werner syndrome (WS). She has not had any clear manifestations of WS other than malignancy and has yet to be assessed for osteoporosis. At 3-month follow-up, she is in the early stages of her treatment course and has tolerated her regimen without issues.", + "fulltext_subclaims": [ + "The patient is a 37-year-old Caucasian female nonsmoker with no known past medical history.", + "She presented with 4 months of dyspnea and back pain.", + "At her initial presentation 4 months prior, she underwent a chest C-ray and chest CT scan.", + "The chest CT scan showed a right upper lobe consolidation.", + "She had been treated for and discharged with a diagnosis of pneumonia.", + "Two months after her initial presentation, she underwent an outpatient bronchoscopy with bronchoalveolar lavage and transbronchial right upper lobe biopsy.", + "Fungal studies and acid-fast bacilli fluorochrome smears were negative.", + "Biopsy results were negative for malignant cells.", + "The pathology results were consistent with chronic inflammation.", + "Upon arrival to the emergency room, she again reported similar symptoms.", + "Physical examination was notable for neck pain on palpation and tachypnea.", + "A chest CT with IV contrast was performed, revealing near-complete right upper lobe collapse.", + "The chest CT showed right upper lobe consolidation.", + "The chest CT showed enlarged subcarinal lymph node.", + "The chest CT showed enlarged station 6 lymph node.", + "MRI of the spine demonstrated a C7 50% compression fracture.", + "MRI showed lytic lesions throughout the spinal vertebrae, concerning for metastatic disease.", + "CT of the abdomen and pelvis revealed a single 15-mm hypodense nodule on the liver.", + "The patient underwent a transthoracic right upper lobe biopsy.", + "The biopsy showed dense fibrous pleural bits.", + "The biopsy showed samples of alveolar parenchyma showing interstitial fibrosis.", + "The biopsy showed a patchy dense lymphocytic infiltrate.", + "No malignant cells were seen on histopathological examination.", + "The patient underwent bronchoscopy and endobronchial ultrasound with transbronchial lymph node sampling.", + "The patient underwent brushing and BAL of the right upper lobe.", + "Most studies were unremarkable.", + "BAL cytology exhibit was positive for poorly differentiated neoplastic cells.", + "The BAL cytology raised the possibility of a poorly differentiated carcinoma.", + "The material on the cell block was insufficient to run immunostains.", + "The patient underwent a fluoroscopy-guided liver biopsy of the liver nodule.", + "The liver biopsy demonstrated a malignant undifferentiated neoplasm with epithelioid morphology.", + "The neoplasm showed weak neuroendocrine differentiation.", + "The cells formed nests/cords in a background of hyalinized sclerotic stroma.", + "The cells frequently demonstrated eosinophilic cytoplasm and round-to-ovoid nuclei.", + "Ancillary studies were insufficient to rule out epithelioid synovial sarcoma.", + "Ancillary studies were insufficient to rule out breast malignancy.", + "Ancillary studies were insufficient to rule out renal malignancy.", + "Ancillary studies were insufficient to rule out thyroid malignancy.", + "Ancillary studies were insufficient to rule out gynecologic primary tumors.", + "Ancillary studies were insufficient to rule out epithelioid osteosarcoma.", + "The neoplastic cells were weakly reactive for synaptophysin.", + "CD99 staining showed a membranous pattern.", + "A subset of neoplastic cells was positive for GATA-3.", + "A subset of neoplastic cells was weakly positive for PAX-8.", + "The neoplastic cells were nonreactive to ER.", + "The neoplastic cells were nonreactive to SATB2.", + "The tumor cells were negative for Oscar pankeratin.", + "The tumor cells were negative for CK7.", + "The tumor cells were negative for CK20.", + "The tumor cells were negative for Moc-31.", + "The tumor cells were negative for TTF-1.", + "The tumor cells were negative for WT-1.", + "The tumor cells were negative for HMB45.", + "The tumor cells were negative for Melan-A.", + "The tumor cells were negative for SOX-10.", + "The tumor cells were negative for S100.", + "The tumor cells were negative for Inhibin.", + "The tumor cells were negative for SMA.", + "The tumor cells were negative for MyoD1.", + "The tumor cells were negative for CD117.", + "The tumor cells were negative for CD45.", + "The tumor cells were negative for CD30.", + "The tumor cells were negative for CD34.", + "The liver tissue was sent for a second opinion.", + "A specialized panel of immunohistochemical stains revealed that the tumor cells were reactive to MUC4 expression.", + "BRG1 immunostains revealed preserved nuclear staining.", + "INI1 immunostains revealed preserved nuclear staining.", + "Claudin-4 stains were negative.", + "ERG stains were negative.", + "CD31 stains were negative.", + "CAMTA1 stains were negative.", + "P40 stains were negative.", + "ETV-4 stains were negative.", + "NUT stains were negative.", + "A diagnosis of sclerosing epithelioid fibrosarcoma was concluded.", + "The patient was promptly started on doxorubicin therapy.", + "The patient joined a genetic research protocol at a major cancer research center.", + "Next-generation sequencing (Tempus genetic testing) was completed.", + "No genes were identified that would increase her risk for cancer.", + "An identified variant of unknown significance of the WRN gene was found.", + "The WRN gene is an autosomal recessive gene associated with Werner syndrome.", + "She has not had any clear manifestations of Werner syndrome other than malignancy.", + "She has yet to be assessed for osteoporosis.", + "At 3-month follow-up, she is in the early stages of her treatment course.", + "She has tolerated her regimen without issues." + ], + "summary": "A 37-year-old Caucasian female presented to the emergency department with 4 months of dyspnea and back pain. She had been treated for pneumonia but had persistent symptoms. A chest, abdomen, and pelvis computed tomography showed near-complete right upper lobe collapse and consolidation, mediastinal lymphadenopathy, lytic spinal lesions, and a single 15-mm hypodense liver nodule. The patient underwent a transthoracic right upper lobe biopsy, bronchoscopy, endobronchial ultrasound with transbronchial lymph node sampling, and bronchoalveolar lavage of the right upper lobe. The bronchoalveolar lavage cytology was positive for malignant cells compatible with poorly differentiated non-small cell carcinoma; however, the cell block materials were insufficient to run immunostains for further investigation of the bronchoalveolar lavage results. Consequently, the patient also underwent a liver biopsy of the liver nodule, which later confirmed a diagnosis of sclerosing epithelioid fibrosarcoma. Next-generation sequencing revealed a variant of unknown significance in the WRN gene. She was subsequently started on doxorubicin.", + "summary_subclaims": [ + "The patient is a 37-year-old Caucasian female.", + "She presented with 4 months of dyspnea and back pain.", + "She had been treated for pneumonia.", + "A chest, abdomen, and pelvis computed tomography showed near-complete right upper lobe collapse and consolidation.", + "The computed tomography showed mediastinal lymphadenopathy.", + "The computed tomography showed lytic spinal lesions.", + "The computed tomography showed a single 15-mm hypodense liver nodule.", + "The patient underwent a transthoracic right upper lobe biopsy.", + "The patient underwent bronchoscopy.", + "The patient underwent endobronchial ultrasound with transbronchial lymph node sampling.", + "The patient underwent bronchoalveolar lavage of the right upper lobe.", + "The bronchoalveolar lavage cytology was positive for malignant cells compatible with poorly differentiated non-small cell carcinoma.", + "The cell block materials were insufficient to run immunostains for further investigation of the bronchoalveolar lavage results.", + "The patient underwent a liver biopsy of the liver nodule.", + "The liver biopsy confirmed a diagnosis of sclerosing epithelioid fibrosarcoma.", + "Next-generation sequencing revealed a variant of unknown significance in the WRN gene.", + "She was started on doxorubicin." + ] + }, + { + "id": "multiclinsum_test_389_en.txt", + "fulltext": "A one-year-nine-month old Chinese girl with symptoms of hearing loss and retrogression of speech and movement since one-year-old presented in our out-patient service. The patient was responsible to teasing, and her neck stood firmly at the age of 5 months. She was able to flip over her body at the age of 8 months, responded when her name was called, and was able to call mom and dad at the age of 9 months. However, her motor development lagged behind her peers obviously. She was not able to sit and crawl independently at one-year-old. Since then, the patient gradually lost her response to surroundings and had lack of facial expression and hypotonia, especially weakness in upper limbs, including loss of hand agility and lack of grabbing. Other symptoms included choking when drinking and swallowing difficulty, but seizure was not observed. Her body weight decreased from 10.5 kg to 8 kg after the symptoms manifested. She started holding her breath for 1–2 min frequently after crying, starting at the age of 10 months. Cyanotic breath holding spells (BHS) occurred on an average of 10 times/day. She was the first child of non-consanguineous parents. The first and second pregnancies were ceased by her parents, and the 3rd pregnancy was aborted because the embryo stopped developing. She was born at 32+ 6 weeks of gestation through cesarean section because her mother suffered from pregnancy-induced hypertension. Her birth weight was 1.36 kg, and her newborn hearing screening result was unremarkable. When she came to the clinic at one-year-nine-month, her height was 77 cm, her weight was 8 kg, and her head circumference was 45 cm, all lagging behind children of the same age. She could only control her head, and she showed poor visual fixation and sound tracking. Physical examination showed generalized weakness, especially the upper extremities, hypotonia of limbs, weak gag reflex, absent of patellar tendon reflex, and negative bilateral Babinski sign. Ammonia, serum lactic acid, hepatorenal function, microelements, and serum amino acids were normal. Acylcarnitine profile showed mild abnormalities including mild elevation of octanoyl carnitine (C8): 0.33 μmol/L (0.01–0.30 μmol/L) and decanoyl carnitine (C10): 0.50 μmol/L (0.01–0.35 μmol/L). Other acylcarnitine species were within the normal ranges. Her urine organic acid analysis showed mild elevated pyruvic acid and lactic acid.\nMagnetic resonance imaging (MRI) of the brain showed no contrast and visual-evoked response. Video electroencephalogram and echocardiography were normal. Electromyogram was neurogenic with fibrillation activity. Nerve conduction studies showed denervation without sensory response of the sural and median nerves but normal motor velocities. Brainstem auditory-evoked responses revealed severe sensorineural hearing loss. The ophthalmologic examination was normal. With the consent of the child’s parents, genetic testing was performed. No variant was found in the SMN (survival motor neuron) gene, which encodes survival motor neuron protein. Her karyotype analysis was normal.", + "fulltext_subclaims": [ + "The patient is a one-year-nine-month old Chinese girl.", + "She had symptoms of hearing loss and retrogression of speech and movement since one-year-old.", + "She was able to flip over her body at the age of 8 months.", + "She was able to call mom and dad at the age of 9 months.", + "Her motor development lagged behind her peers obviously.", + "She was not able to sit and crawl independently at one-year-old.", + "She gradually lost her response to surroundings.", + "She had lack of facial expression.", + "She had hypotonia, especially weakness in upper limbs.", + "She had loss of hand agility and lack of grabbing.", + "She had choking when drinking.", + "She had swallowing difficulty.", + "Seizure was not observed.", + "Her body weight decreased from 10.5 kg to 8 kg after the symptoms manifested.", + "She started holding her breath for 1–2 min frequently after crying at the age of 10 months.", + "Cyanotic breath holding spells occurred on an average of 10 times/day.", + "She was the first child of non-consanguineous parents.", + "The first and second pregnancies were ceased by her parents.", + "The 3rd pregnancy was aborted because the embryo stopped developing.", + "She was born at 32+6 weeks of gestation through cesarean section.", + "Her mother suffered from pregnancy-induced hypertension.", + "Her birth weight was 1.36 kg.", + "Her newborn hearing screening result was unremarkable.", + "When she came to the clinic at one-year-nine-month, her height was 77 cm.", + "When she came to the clinic at one-year-nine-month, her weight was 8 kg.", + "When she came to the clinic at one-year-nine-month, her head circumference was 45 cm.", + "She could only control her head.", + "She showed poor visual fixation and sound tracking.", + "Physical examination showed generalized weakness, especially the upper extremities.", + "Physical examination showed hypotonia of limbs.", + "Physical examination showed weak gag reflex.", + "Physical examination showed absent patellar tendon reflex.", + "Physical examination showed negative bilateral Babinski sign.", + "Ammonia, serum lactic acid, hepatorenal function, microelements, and serum amino acids were normal.", + "Acylcarnitine profile showed mild elevation of octanoyl carnitine (C8): 0.33 μmol/L.", + "Acylcarnitine profile showed mild elevation of decanoyl carnitine (C10): 0.50 μmol/L.", + "Other acylcarnitine species were within the normal ranges.", + "Urine organic acid analysis showed mild elevated pyruvic acid.", + "Urine organic acid analysis showed mild elevated lactic acid.", + "Magnetic resonance imaging (MRI) of the brain showed no contrast.", + "Magnetic resonance imaging (MRI) of the brain showed no visual-evoked response.", + "Video electroencephalogram was normal.", + "Echocardiography was normal.", + "Electromyogram was neurogenic with fibrillation activity.", + "Nerve conduction studies showed denervation without sensory response of the sural and median nerves.", + "Nerve conduction studies showed normal motor velocities.", + "Brainstem auditory-evoked responses revealed severe sensorineural hearing loss.", + "The ophthalmologic examination was normal.", + "Genetic testing was performed with the consent of the child’s parents.", + "No variant was found in the SMN gene.", + "Her karyotype analysis was normal." + ], + "summary": "We report the novel compound heterozygous variants c.1328G>A p.(Cys443Tyr) and c.1022_1023insC p. (Leu341Profs*103) of SLC52A2 gene in a female proband who presented in our out-patient clinic at the age of one-year-old with progressive mental and motor regression, breath holding, and brain stem dysfunction including facial weakness, hearing loss, dysphagia. Following high-dose riboflavin supplementation, the respiratory insufficiency and mental, motor, and bulbar function improved. However, sensorineural hearing loss was not improved. The missense variant site was highly conserved. Both variants were not found in the population database gnomAD. The two variants were inherited from her mother and father, respectively. Both variants were predicted to be deleterious by Polyphen2, Mutation taster, and SIFT and were classified as likely pathogenic according to the ACMG guideline.", + "summary_subclaims": [ + "The proband is a female.", + "The proband presented at the age of one-year-old.", + "The proband had progressive mental and motor regression.", + "The proband had breath holding.", + "The proband had brain stem dysfunction.", + "The proband had facial weakness.", + "The proband had hearing loss.", + "The proband had dysphagia.", + "The proband had compound heterozygous variants c.1328G>A p.(Cys443Tyr) and c.1022_1023insC p.(Leu341Profs*103) of the SLC52A2 gene.", + "Following high-dose riboflavin supplementation, the respiratory insufficiency improved.", + "Following high-dose riboflavin supplementation, the mental function improved.", + "Following high-dose riboflavin supplementation, the motor function improved.", + "Following high-dose riboflavin supplementation, the bulbar function improved.", + "Sensorineural hearing loss was not improved.", + "The missense variant site was highly conserved.", + "Both variants were not found in the population database gnomAD.", + "The two variants were inherited from her mother and father, respectively.", + "Both variants were predicted to be deleterious by Polyphen2.", + "Both variants were predicted to be deleterious by Mutation taster.", + "Both variants were predicted to be deleterious by SIFT.", + "Both variants were classified as likely pathogenic according to the ACMG guideline." + ] + }, + { + "id": "multiclinsum_test_2700_en.txt", + "fulltext": "A 19-year-old Iranian male of Caucasian ethnicity sought treatment at a tertiary centre specializing in cardiovascular diseases. The patient’s chief complaint was dyspnoea on exertion, which he had been experiencing for the past 2 months. His condition corresponded to New York Heart Association functional Class II (NYHA Class II).\nThe patient denied any additional symptoms. His medical history revealed a diagnosis of hypothyroidism, and he reported no known genetic or congenital disorders in his parents. During the initial physical examination, the patient exhibited short stature (height: 135 cm and weight: 53 kg), but his blood pressure, heart rate, oxygen saturation, and body temperature were within the normal range.\nUpon auscultation, a characteristic murmur consistent with aortic stenosis was detected. The murmur was described as high-pitched, crescendo–decrescendo in nature, and exhibited a mid-systolic ejection pattern. It was graded as III/VI and best heard at the heart base. Additionally, a Grade IV/VI holosystolic (pansystolic) murmur was noted, audible at the apex with the diaphragm of the stethoscope, particularly when the patient assumed the left lateral decubitus position. This finding was suggestive of mitral regurgitation (MR). Symmetrical pulses were observed in both the upper and lower limbs, and a palpable spleen was detected ∼4 cm below the costal margin. No other significant abnormalities were identified during the examination. The patient was on a regular daily dosage of levothyroxine (0.1 mg).\nAt the time of presentation, the electrocardiogram (ECG) exhibited changes indicative of left ventricular hypertrophy (LVH) .\nThe patient underwent trans-thoracic echocardiography (TTE) initially, and subsequently, trans-oesophageal echocardiography (TEE) was performed due to abnormal findings observed in the TTE ( and ). Trans-thoracic echocardiography and the complementary TEE examinations revealed a LV ejection fraction of ∼65% and moderate LVH. Furthermore, the AV was observed to be thickened with severe calcification of the AV cusps, resulting in severe AV stenosis. The maximum velocity (Vmax) across the AV was measured at 5.6 m/s, and the AV area was determined to be 0.84 cm2.\nThe severe calcification observed in the proximal region of the under-developed ascending aorta and aortic arch led to the presence of severe supra-valvular aortic stenosis. Additionally, the calcification extended to the aortomitral continuity and anterior MV leaflet, resulting in moderate mitral stenosis and severe degenerative MR. The echocardiographic findings indicated a mean gradient across the MV of 10 mmHg, a vena contracta of 7.4 mm, a regurgitant volume of 84 mL/beat, and an effective regurgitant orifice area (EROA) of 0.43 cm2. It is noteworthy that the patient’s heart rate during the echocardiographic examination for the assessment of the MV gradient was recorded as 82 b.p.m. The initial laboratory investigations revealed normal results, except for thrombocytopaenia, with a platelet count of 62 000 × 103/µL (150 000–450 000 × 103/µL). Thyroid function tests were within normal limits. Microscopic examination of the peripheral blood smear showed thrombocytopaenia, along with a few foci of platelet aggregation. The red blood cell count and white blood cell count appeared normal, both in terms of count and morphology.\nAbdominal ultrasound revealed an abnormal finding of splenomegaly, with a span measuring 180 mm. Further imaging with multi-detector computed tomography (CT) of the aorta, cervical, and cerebral arteries confirmed the previously visualized findings from the echocardiography examination (see , ). It was observed that the aortic arch and descending aorta also exhibited hypoplasia, similar to the under-developed ascending aorta with an average diameter of 15 mm. The assessment of the patient’s cardiovascular system included the examination of the aortic arch branches, abdominal aorta, and its branches, as well as the cervical and cerebral arteries. These blood vessels were found to be patent and exhibited a normal anatomical structure. Additionally, the coronary CT angiography (CTA) scan indicated a normal course and no significant luminal stenosis in the coronary arteries. However, it was noted that there was calcification present in the left circumflex artery.\nConsidering the extensive cardiovascular involvement in the patient and the scarcity of similar cases documented in the literature, a heart team was convened. After careful deliberation, it was decided that surgical intervention was necessary due to the worsening dyspnoea experienced by the patient. Prior to the open-heart surgery, a bone marrow aspiration and biopsy were performed. The results of the bone marrow biopsy and aspiration revealed the presence of clusters of eosinophilic histiocytes exhibiting a fibrillar or striated appearance and characterized by thin nuclei. These findings were consistent with Gaucher cells, indicative of GD .\nThe patient underwent surgery, which the Bentall procedure was performed by the surgeon using a mechanical composite St-Jude #21 valve. Additionally, MV replacement was carried out using a mechanical St-Jude #27 valve. Septal myectomy was also performed, due to the high LV outflow tract pressure gradient (LVOT PG) and high LV end-diastolic pressure. Following the operation, a post-operative echocardiography examination revealed preserved LV systolic function, as well as well-functioning prosthetic valves in both the AV and MV. The echocardiogram also indicated good leaflet motion and acceptable gradients across the prosthetic valves.\nUpon discharge, the patient has prescribed warfarin, aspirin 80 mg daily, and bisoprolol 1.25 mg daily as part of their post-operative management. However, 1 month after the surgery, the patient contracted a COVID-19 infection. Fortunately, they recovered after receiving a course of intravenous glucocorticoid therapy. During the follow-up visits at 1, 3, and 6 months, the patient’s symptoms improved, and they were in good overall condition. It is important to note that the patient underwent enzyme replacement therapy with imiglucerase (Cerezyme) at a monthly dosage of 1200 units. As a result of this treatment, the patient’s platelet count remained within the range of 100 000–130 000 × 103/µL. Therefore, splenectomy was not deemed necessary in this case.", + "fulltext_subclaims": [ + "The patient is a 19-year-old Iranian male of Caucasian ethnicity.", + "The patient sought treatment at a tertiary centre specializing in cardiovascular diseases.", + "The patient’s chief complaint was dyspnoea on exertion.", + "The patient had been experiencing dyspnoea on exertion for the past 2 months.", + "The patient’s condition corresponded to New York Heart Association functional Class II.", + "The patient denied any additional symptoms.", + "The patient’s medical history revealed a diagnosis of hypothyroidism.", + "The patient reported no known genetic or congenital disorders in his parents.", + "During the initial physical examination, the patient exhibited short stature (height: 135 cm and weight: 53 kg).", + "The patient’s blood pressure, heart rate, oxygen saturation, and body temperature were within the normal range.", + "A characteristic murmur consistent with aortic stenosis was detected.", + "The murmur was described as high-pitched, crescendo–decrescendo in nature, and exhibited a mid-systolic ejection pattern.", + "The murmur was graded as III/VI and best heard at the heart base.", + "A Grade IV/VI holosystolic murmur was noted, audible at the apex with the diaphragm of the stethoscope.", + "The murmur was particularly audible when the patient assumed the left lateral decubitus position.", + "This finding was suggestive of mitral regurgitation.", + "Symmetrical pulses were observed in both the upper and lower limbs.", + "A palpable spleen was detected ∼4 cm below the costal margin.", + "The patient was on a regular daily dosage of levothyroxine (0.1 mg).", + "The electrocardiogram exhibited changes indicative of left ventricular hypertrophy.", + "The patient underwent trans-thoracic echocardiography.", + "Trans-oesophageal echocardiography was performed due to abnormal findings observed in the trans-thoracic echocardiography.", + "The echocardiographic examinations revealed a left ventricular ejection fraction of ∼65%.", + "The echocardiographic examinations revealed moderate left ventricular hypertrophy.", + "The aortic valve was observed to be thickened with severe calcification of the aortic valve cusps.", + "The aortic valve area was determined to be 0.84 cm2.", + "The maximum velocity across the aortic valve was measured at 5.6 m/s.", + "Severe calcification was observed in the proximal region of the under-developed ascending aorta and aortic arch.", + "This calcification led to the presence of severe supra-valvular aortic stenosis.", + "The calcification extended to the aortomitral continuity and anterior mitral valve leaflet.", + "This resulted in moderate mitral stenosis and severe degenerative mitral regurgitation.", + "The echocardiographic findings indicated a mean gradient across the mitral valve of 10 mmHg.", + "The echocardiographic findings indicated a vena contracta of 7.4 mm.", + "The echocardiographic findings indicated a regurgitant volume of 84 mL/beat.", + "The echocardiographic findings indicated an effective regurgitant orifice area of 0.43 cm2.", + "The patient’s heart rate during the echocardiographic examination for the assessment of the mitral valve gradient was recorded as 82 b.p.m.", + "The initial laboratory investigations revealed normal results, except for thrombocytopaenia.", + "The platelet count was 62 000 × 103/µL.", + "Thyroid function tests were within normal limits.", + "Microscopic examination of the peripheral blood smear showed thrombocytopaenia.", + "Microscopic examination of the peripheral blood smear showed a few foci of platelet aggregation.", + "The red blood cell count and white blood cell count appeared normal.", + "Abdominal ultrasound revealed splenomegaly with a span measuring 180 mm.", + "Multi-detector computed tomography of the aorta, cervical, and cerebral arteries confirmed the previously visualized findings from the echocardiography.", + "The aortic arch and descending aorta exhibited hypoplasia.", + "The under-developed ascending aorta had an average diameter of 15 mm.", + "The coronary CT angiography scan indicated a normal course and no significant luminal stenosis in the coronary arteries.", + "It was noted that there was calcification present in the left circumflex artery.", + "A heart team was convened due to the extensive cardiovascular involvement.", + "It was decided that surgical intervention was necessary due to the worsening dyspnoea.", + "A bone marrow aspiration and biopsy were performed prior to the open-heart surgery.", + "The bone marrow biopsy revealed the presence of clusters of eosinophilic histiocytes.", + "These histiocytes exhibited a fibrillar or striated appearance.", + "These histiocytes were characterized by thin nuclei.", + "These findings were consistent with Gaucher cells.", + "The patient underwent surgery, and the Bentall procedure was performed.", + "The Bentall procedure was performed using a mechanical composite St-Jude #21 valve.", + "MV replacement was carried out using a mechanical St-Jude #27 valve.", + "Septal myectomy was performed due to the high LV outflow tract pressure gradient.", + "Septal myectomy was performed due to the high LV end-diastolic pressure.", + "Post-operative echocardiography revealed preserved LV systolic function.", + "Post-operative echocardiography revealed well-functioning prosthetic valves in both the aortic and mitral valves.", + "The echocardiogram indicated good leaflet motion and acceptable gradients across the prosthetic valves.", + "The patient was prescribed warfarin, aspirin 80 mg daily, and bisoprolol 1.25 mg daily upon discharge.", + "One month after the surgery, the patient contracted a COVID-19 infection.", + "The patient recovered after receiving a course of intravenous glucocorticoid therapy.", + "During follow-up visits at 1, 3, and 6 months, the patient’s symptoms improved.", + "The patient was in good overall condition during follow-up visits.", + "The patient underwent enzyme replacement therapy with imiglucerase at a monthly dosage of 1200 units.", + "As a result of this treatment, the patient’s platelet count remained within the range of 100 000–130 000 × 103/µL.", + "Splenectomy was not deemed necessary in this case." + ], + "summary": "A 19-year-old Caucasian male presented with exertional dyspnoea. Physical examination revealed a Grade III/VI systolic diamond murmur at the heart base and a Grade IV/VI systolic murmur at the apex. Electrocardiogram showed signs of left ventricular hypertrophy (LVH). Trans-thoracic echocardiography (TTE) and trans-oesophageal echocardiography (TEE) demonstrated moderate LVH, severe aortic valve stenosis, severe supra-valvular aortic stenosis, and moderate mitral stenosis with severe degenerative mitral valve regurgitation. Bone marrow biopsy and aspiration confirmed the presence of characteristic Gaucher's cells. The patient underwent the Bentall procedure and mitral valve replacement and was discharged in good condition.", + "summary_subclaims": [ + "The patient is a 19-year-old Caucasian male.", + "The patient presented with exertional dyspnoea.", + "Physical examination revealed a Grade III/VI systolic diamond murmur at the heart base.", + "Physical examination revealed a Grade IV/VI systolic murmur at the apex.", + "Electrocardiogram showed signs of left ventricular hypertrophy.", + "Trans-thoracic echocardiography and trans-oesophageal echocardiography demonstrated moderate left ventricular hypertrophy.", + "Trans-thoracic echocardiography and trans-oesophageal echocardiography demonstrated severe aortic valve stenosis.", + "Trans-thoracic echocardiography and trans-oesophageal echocardiography demonstrated severe supra-valvular aortic stenosis.", + "Trans-thoracic echocardiography and trans-oesophageal echocardiography demonstrated moderate mitral stenosis.", + "Trans-thoracic echocardiography and trans-oesophageal echocardiography demonstrated severe degenerative mitral valve regurgitation.", + "Bone marrow biopsy and aspiration confirmed the presence of characteristic Gaucher's cells.", + "The patient underwent the Bentall procedure.", + "The patient underwent mitral valve replacement.", + "The patient was discharged in good condition." + ] + }, + { + "id": "multiclinsum_test_1760_en.txt", + "fulltext": "A 55-year-old man was admitted to hospital as a stroke call, presenting with sudden-onset left sided cheek, arm and hand sensory loss, visual blurring, and worsening headache. The National Institutes of Health Stroke Scale (NIHSS) score was 3. His past medical history was significant for multiple co-morbidities including coronary artery bypass graft (CABG) surgery, hypertension, type 2 diabetes, and hypercholesterolemia. An urgent head CT excluded intracranial haemorrhage , and intravenous thrombolysis with alteplase was administered. Within 2 hours of thrombolysis, his features of visual disturbance and headache worsened, with increasing confusion. A repeat CT of the head showed multiple areas of intracerebral haemorrhage, mainly in the bilateral posterior regions . No benefit from neurosurgical intervention was expected. Despite intensive multiple organ support therapy, he deteriorated over his admission, developed chest infection, and died 4 days after the initial presentation. The case was referred to HM Coroner and detailed neuropathological examination was performed.\nInformed consent was obtained from the relatives for research and medical education. Post-mortem examination confirmed marked cardiovascular disease, demonstrated by severe coronary artery sclerosis evident in the left main stem and right coronary arteries with associated critical stenosis (luminal diameter < 1 mm). The right coronary artery bypass graft was patent. There were no acute or healed myocardial infarcts. There was mild concentric left ventricular hypertrophy consistent with the history of hypertension. Examination of the lungs revealed an area of possible bronchopneumonia. Other internal organs showed no relevant alterations.\nThe brain was fixed in buffered formalin for 4 weeks and weighed 1466 g. On external examination, the brain was swollen and smooth with shallowed sulci and mild subarachnoid haemorrhages in the right anterior frontal pole, the right middle temporal and the right posterior parieto-occipital lobes. At the base of the brain both unci were bulged with prominent grooving, petechial haemorrhages on the right side and soft necrotic brain fragments on the left side. The cerebellar tonsils were also prominently grooved but without haemorrhages or softening. There was moderate calcifying atherosclerosis in the right vertebral artery without luminal narrowing. The rest of the basal arteries were normal with no evidence of thrombotic occlusion, vascular malformation or aneurysm.\nCoronal sections of the cerebral hemispheres revealed mild midline shift to the left associated with compressed ventricles in the anterior and central parts . The right inferior horn and the posterior horns were filled with blood clots . There were multiple recent intracerebral parenchymal haemorrhages, various in size and widespread in distribution, affecting the right frontobasal area, the right temporo-occipital lobe, left superior parietal lobe, both posterior occipital lobe areas and the left cerebellar hemisphere. These haemorrhages probably occurred at the same time, and the atypical distribution suggested that they were secondary to the thrombolysis. Furthermore, a soft, cavitating area was identified in the subcortical white matter of the superior temporal gyrus and the insula slightly extending to the putamen, measuring 20x10x10mm. Timing was uncertain but appeared to be older than the haemorrhages, probably representing an ischaemic infarct. The hippocampi, the inferior part of the thalamus and the midbrain were haemorrhagic, soft and fragmented. Typical Duret’s haemorrhages were noted in the central part of the pons. The fourth ventricle contained a moderate amount of clotted blood. Summarizing the macroscopical findings, the direct cause of the death was given as brainstem herniation secondary to widespread recent intraparenchymal haemorrhages, probably related to thrombolysis. Alternative causes of the haemorrhages were also considered and further histological examination was performed.\nMicroscopic evaluation confirmed extensive recent intracerebral haemorrhages, most of them thought to be due to the thrombolysis therapy, surrounded by marked oedema and hypereosinophilic (red) neurons. Haemorrhages were also detected in the subarachnoid space and the ventricles, in keeping with secondary propagation of parenchymal haemorrhages. In addition, the histology examination also revealed severe CAA (Vonsattel grade 3), which was confirmed by Aβ immunostaining . The CAA was particularly prominent in the occipital lobe and was associated with focal, perivascular and vaguely granulomatous inflammation, in keeping with ABRA . Further, probably subclinical, complications of CAA were noted in the left occipital lobe and in the white matter between the insular cortex and the putamen in form of old (at least 6 months) haemorrhagic microinfarcts . In addition, there were also two separate acute ischaemic lesions, estimated between 3 to 5 days old, in the right insular cortex and the basal ganglia and in the right occipital lobe, which might have caused the new onset neurological symptoms prior to hospitalisation. The parenchymal β-amyloid pathology was not significant, consisting of sparse mainly diffuse and fleece-like plaques throughout the neocortex. No characteristic cored plaques were identified and there were no neurofibrillary tangles by hyperphosphorylated tau, which excluded the possibility of underlying AD. Histological examination of the lung confirmed extensive bronchopneumonia which developed in the terminal stage and also contributed to death.", + "fulltext_subclaims": [ + "The patient was a 55-year-old man.", + "He was admitted to hospital as a stroke call.", + "He presented with sudden-onset left sided cheek, arm and hand sensory loss.", + "He had visual blurring.", + "He had worsening headache.", + "The NIHSS score was 3.", + "His past medical history was significant for multiple co-morbidities.", + "He had a history of coronary artery bypass graft (CABG) surgery.", + "He had hypertension.", + "He had type 2 diabetes.", + "He had hypercholesterolemia.", + "An urgent head CT excluded intracranial haemorrhage.", + "Intravenous thrombolysis with alteplase was administered.", + "Within 2 hours of thrombolysis, his features of visual disturbance and headache worsened.", + "He developed increasing confusion.", + "A repeat CT of the head showed multiple areas of intracerebral haemorrhage.", + "The haemorrhages were mainly in the bilateral posterior regions.", + "No benefit from neurosurgical intervention was expected.", + "Despite intensive multiple organ support therapy, he deteriorated over his admission.", + "He developed chest infection.", + "He died 4 days after the initial presentation.", + "The case was referred to HM Coroner.", + "Detailed neuropathological examination was performed.", + "Informed consent was obtained from the relatives for research and medical education.", + "Post-mortem examination confirmed marked cardiovascular disease.", + "Severe coronary artery sclerosis was evident in the left main stem and right coronary arteries.", + "The right coronary artery bypass graft was patent.", + "There were no acute or healed myocardial infarcts.", + "There was mild concentric left ventricular hypertrophy.", + "The left ventricular hypertrophy was consistent with the history of hypertension.", + "Examination of the lungs revealed an area of possible bronchopneumonia.", + "Other internal organs showed no relevant alterations.", + "The brain was fixed in buffered formalin for 4 weeks.", + "The brain weighed 1466 g.", + "On external examination, the brain was swollen and smooth.", + "There were shallowed sulci.", + "There were mild subarachnoid haemorrhages in the right anterior frontal pole.", + "There were mild subarachnoid haemorrhages in the right middle temporal lobe.", + "There were mild subarachnoid haemorrhages in the right posterior parieto-occipital lobes.", + "At the base of the brain, both unci were bulged with prominent grooving.", + "There were petechial haemorrhages on the right side of the unci.", + "There were soft necrotic brain fragments on the left side of the unci.", + "The cerebellar tonsils were prominently grooved.", + "There were no haemorrhages in the cerebellar tonsils.", + "There was moderate calcifying atherosclerosis in the right vertebral artery.", + "There was no luminal narrowing in the right vertebral artery.", + "The rest of the basal arteries were normal.", + "There was no evidence of thrombotic occlusion.", + "There was no evidence of vascular malformation.", + "There was no evidence of aneurysm.", + "Coronal sections of the cerebral hemispheres revealed mild midline shift to the left.", + "The right inferior horn and the posterior horns were filled with blood clots.", + "There were multiple recent intracerebral parenchymal haemorrhages.", + "The haemorrhages were various in size.", + "The haemorrhages were widespread in distribution.", + "The haemorrhages affected the right frontobasal area.", + "The haemorrhages affected the right temporo-occipital lobe.", + "The haemorrhages affected the left superior parietal lobe.", + "The haemorrhages affected both posterior occipital lobe areas.", + "The haemorrhages affected the left cerebellar hemisphere.", + "The haemorrhages probably occurred at the same time.", + "The atypical distribution suggested that the haemorrhages were secondary to the thrombolysis.", + "A soft, cavitating area was identified in the subcortical white matter of the superior temporal gyrus.", + "The cavitating area slightly extended to the putamen.", + "The cavitating area measured 20x10x10mm.", + "The timing of the cavitating area was uncertain.", + "The cavitating area appeared to be older than the haemorrhages.", + "The cavitating area probably represented an ischaemic infarct.", + "The hippocampi were haemorrhagic, soft and fragmented.", + "The inferior part of the thalamus was haemorrhagic, soft and fragmented.", + "The midbrain was haemorrhagic, soft and fragmented.", + "Typical Duret’s haemorrhages were noted in the central part of the pons.", + "The fourth ventricle contained a moderate amount of clotted blood.", + "The direct cause of the death was given as brainstem herniation.", + "The brainstem herniation was secondary to widespread recent intraparenchymal haemorrhages.", + "The haemorrhages were probably related to thrombolysis.", + "Alternative causes of the haemorrhages were also considered.", + "Further histological examination was performed.", + "Microscopic evaluation confirmed extensive recent intracerebral haemorrhages.", + "Most of the haemorrhages were thought to be due to the thrombolysis therapy.", + "The haemorrhages were surrounded by marked oedema.", + "The haemorrhages were surrounded by hypereosinophilic (red) neurons.", + "Haemorrhages were also detected in the subarachnoid space.", + "The subarachnoid haemorrhages were in keeping with secondary propagation of parenchymal haemorrhages.", + "Haemorrhages were also detected in the ventricles.", + "The ventricular haemorrhages were in keeping with secondary propagation of parenchymal haemorrhages.", + "The histology examination also revealed severe CAA (Vonsattel grade 3).", + "The CAA was confirmed by Aβ immunostaining.", + "The CAA was particularly prominent in the occipital lobe.", + "The CAA was associated with focal, perivascular and vaguely granulomatous inflammation.", + "The inflammation was in keeping with ABRA.", + "Further, probably subclinical, complications of CAA were noted in the left occipital lobe.", + "Further, probably subclinical, complications of CAA were noted in the white matter between the insular cortex and the putamen.", + "The complications were in form of old (at least 6 months) haemorrhagic microinfarcts.", + "There were also two separate acute ischaemic lesions.", + "The ischaemic lesions were estimated between 3 to 5 days old.", + "The ischaemic lesions were in the right insular cortex and the basal ganglia.", + "The ischaemic lesions were in the right occipital lobe.", + "The ischaemic lesions might have caused the new onset neurological symptoms prior to hospitalisation.", + "The parenchymal β-amyloid pathology was not significant.", + "The β-amyloid pathology consisted of sparse mainly diffuse and fleece-like plaques throughout the neocortex.", + "No characteristic cored plaques were identified.", + "There were no neurofibrillary tangles by hyperphosphorylated tau.", + "The absence of neurofibrillary tangles excluded the possibility of underlying AD.", + "Histological examination of the lung confirmed extensive bronchopneumonia.", + "The bronchopneumonia developed in the terminal stage.", + "The bronchopneumonia also contributed to death." + ], + "summary": "A 55-year-old man was admitted to hospital with sudden onset left-sided cheek, arm and hand sensory loss, blurred vision, and worsening headache, with a National Institutes of Health Stroke Scale (NIHSS) score of 3. An acute CT head scan showed no contraindications, and therefore the decision was made to give intravenous thrombolysis. Post-thrombolysis, he showed rapid deterioration with visual disturbances, headache and confusion, and a repeat CT head scan confirmed several areas of intracerebral haemorrhage. No benefit from surgical intervention was expected, and the patient died four days after the first presentation. Neuropathological examination found acute ischemic infarcts of three to five days duration in the basal ganglia, insular cortex and occipital lobe, correlating with the initial clinical symptoms. There were also extensive recent intracerebral haemorrhages most likely secondary to thrombolysis. Furthermore, the histological examination revealed severe cerebral amyloid angiopathy associated with granulomatous inflammatory reaction, consistent with ABRA.", + "summary_subclaims": [ + "The patient was a 55-year-old man.", + "He was admitted to hospital with sudden onset left-sided cheek, arm and hand sensory loss.", + "He had blurred vision.", + "He had worsening headache.", + "His NIHSS score was 3.", + "An acute CT head scan showed no contraindications.", + "The decision was made to give intravenous thrombolysis.", + "Post-thrombolysis, he showed rapid deterioration with visual disturbances.", + "Post-thrombolysis, he showed rapid deterioration with headache.", + "Post-thrombolysis, he showed rapid deterioration with confusion.", + "A repeat CT head scan confirmed several areas of intracerebral haemorrhage.", + "No benefit from surgical intervention was expected.", + "The patient died four days after the first presentation.", + "Neuropathological examination found acute ischemic infarcts of three to five days duration in the basal ganglia.", + "Neuropathological examination found acute ischemic infarcts of three to five days duration in the insular cortex.", + "Neuropathological examination found acute ischemic infarcts of three to five days duration in the occipital lobe.", + "The infarcts correlated with the initial clinical symptoms.", + "There were extensive recent intracerebral haemorrhages most likely secondary to thrombolysis.", + "The histological examination revealed severe cerebral amyloid angiopathy.", + "The histological examination revealed granulomatous inflammatory reaction.", + "The findings were consistent with ABRA." + ] + }, + { + "id": "multiclinsum_test_2449_en.txt", + "fulltext": "We present the case of a 72-year-old Caucasian woman with a history of childhood encephalitis with motor sequelae, who presented with a 10-year history of full-thickness rectal prolapse that had progressively worsened despite two surgical procedures, namely, anal encirclement 13 years before presentation and a new encirclement associated with stapler mucous prolapsectomy 6 years before presentation. For 2 years, severe fecal incontinence associated with repeated rectal bleeding had prevented her from sitting down, had severely impeded her walking and induced pain. The patient's Wexner incontinence score was 19, and anorectal manometry showed marked hypotonia of the anal canal at rest (20 mmHg) and during contraction (40 mmHg). Endorectal ultrasonographic examination revealed no documentable sphincter lesions although the muscle fibers appeared markedly thinned. Electromyographic (EMG) recordings disclosed severe neurogenic damage to her external anal sphincter. The patient declined to undergo construction of a definitive colostomy.\nThe operation proceeded in three steps. First, the full-thickness rectal wall was incised circumferentially at 2 cm from the pectinate line. The pouch of Douglas was opened and about 20 cm of bowel was prepared before the peritoneal fossa was reconstructed. Once the bowel was resected a coloanal anastomosis was constructed with a 29 circular stapler. The operation proceeded with dynamic graciloplasty. Through two longitudinal incisions on the medial face of the right thigh, the gracile muscle was mobilized down to its insertion on the tibial tuberosity. Once the muscle was prepared for tunneling, electrical stimuli were delivered to identify the neurovascular peduncle. This step is crucial to identify the site for definitive intramuscular electrode implantation that guarantees an effective gracilis muscle contraction.\nSecond, the gracile muscle was tunnelled and wrapped around the sigmoid colon anastomosed to the residual rectum after preparing the peri-anastomotic space using two longitudinal perianal incisions. This fixed the muscle tendon on the perineal skin.\nFinally, a subcutaneous pouch was created in the right iliac fossa to house the neurostimulator. The leads connecting the neurostimulator to the gracile muscle were then tunnelled subcutaneously. This entailed constructing a temporary transverse colostomy to minimize the risk of infections involving the perianal accesses that can damage the neosphincter or cause its disinsertion.\nThe patient had an uneventful postoperative course, and on day 7 began regular leg gymnastics with a soft balloon placed between her knees. Neurostimulation delivered at low frequency began on day 20 and continued for about 2 months before the frequency was increased. In the sixth month, clinical examination and manometric evaluation showed a slight improvement in sphincter tone, that is, pressure at 30 mmHg without electrical stimulation and 55 mmHg with electrical stimulation. One year after the operation, the colostomy was closed under manometric evaluation (pressure at 40 mmHg without electrical stimulation and 65 mmHg with electrical stimulation).\nTwo years after the combined operation, no further recurrent rectal prolapse was visible. The patient was already continent for solids (Wexner incontinence score 9) and could switch the pacemaker device on and off without help.", + "fulltext_subclaims": [ + "The patient was a 72-year-old Caucasian woman.", + "She had a history of childhood encephalitis with motor sequelae.", + "She had a 10-year history of full-thickness rectal prolapse.", + "The rectal prolapse had progressively worsened despite two surgical procedures.", + "The first surgical procedure was anal encirclement 13 years before presentation.", + "The second surgical procedure was an encirclement associated with stapler mucous prolapsectomy 6 years before presentation.", + "She had severe fecal incontinence associated with repeated rectal bleeding for 2 years.", + "The patient's Wexner incontinence score was 19.", + "Anorectal manometry showed marked hypotonia of the anal canal at rest (20 mmHg).", + "Anorectal manometry showed marked hypotonia of the anal canal during contraction (40 mmHg).", + "Endorectal ultrasonographic examination revealed no documentable sphincter lesions.", + "The muscle fibers appeared markedly thinned on endorectal ultrasonographic examination.", + "Electromyographic recordings disclosed severe neurogenic damage to her external anal sphincter.", + "The patient declined to undergo construction of a definitive colostomy.", + "The operation proceeded in three steps.", + "The full-thickness rectal wall was incised circumferentially at 2 cm from the pectinate line.", + "The pouch of Douglas was opened.", + "About 20 cm of bowel was prepared.", + "The peritoneal fossa was reconstructed.", + "A coloanal anastomosis was constructed with a 29 circular stapler.", + "The operation proceeded with dynamic graciloplasty.", + "The gracile muscle was mobilized down to its insertion on the tibial tuberosity.", + "Electrical stimuli were delivered to identify the neurovascular peduncle.", + "This step is crucial to identify the site for definitive intramuscular electrode implantation.", + "The gracile muscle was tunnelled and wrapped around the sigmoid colon anastomosed to the residual rectum.", + "The muscle tendon was fixed on the perineal skin.", + "A subcutaneous pouch was created in the right iliac fossa to house the neurostimulator.", + "The leads connecting the neurostimulator to the gracile muscle were tunnelled subcutaneously.", + "A temporary transverse colostomy was constructed.", + "The patient had an uneventful postoperative course.", + "On day 7, the patient began regular leg gymnastics with a soft balloon placed between her knees.", + "Neurostimulation delivered at low frequency began on day 20.", + "Neurostimulation continued for about 2 months before the frequency was increased.", + "In the sixth month, clinical examination showed a slight improvement in sphincter tone.", + "In the sixth month, manometric evaluation showed pressure at 30 mmHg without electrical stimulation.", + "In the sixth month, manometric evaluation showed pressure at 55 mmHg with electrical stimulation.", + "One year after the operation, the colostomy was closed under manometric evaluation.", + "One year after the operation, manometric evaluation showed pressure at 40 mmHg without electrical stimulation.", + "One year after the operation, manometric evaluation showed pressure at 65 mmHg with electrical stimulation.", + "Two years after the combined operation, no further recurrent rectal prolapse was visible.", + "The patient was continent for solids (Wexner incontinence score 9).", + "The patient could switch the pacemaker device on and off without help." + ], + "summary": "We report the case of a 72-year-old Caucasian woman with full-thickness rectal prolapse associated with fecal incontinence from severe neuromuscular damage.", + "summary_subclaims": [ + "The patient is a 72-year-old Caucasian woman.", + "The patient had full-thickness rectal prolapse.", + "The patient had fecal incontinence.", + "The fecal incontinence was associated with full-thickness rectal prolapse.", + "The fecal incontinence was from severe neuromuscular damage." + ] + }, + { + "id": "multiclinsum_test_2787_en.txt", + "fulltext": "A 40-year-old man, a building worker, presented with acute right-sided body weakness without obvious inducement for 6 days. Weakness of the right limb occurred 16 h prior to admission to the hospital, presenting as inability to lift the right upper limb and inability to stand on the right lower limb.\nThere was no history of trauma and neck massage, no surgical history, and no previous infectious symptoms. He did not have diabetes and he was normotensive. The patient was a smoker for 10 years.\nNeurologic examination showed that the patient’s consciousness and speech were normal. Cranial nerve examination was normal. According to the Medical Research Council muscle scale, the right upper proximal limb had muscle power grade 4/5; distal limb, muscle power grade 2/5; right lower limb, muscle power grade 0/5; and contralateral upper and lower limbs, muscle power grade 5/5. Joint position and vibration disappeared in the right lower limb, and position was weakened in the right hand. Deep sensation was normal in the left side of the body. The right ankle reflex was weakened. Pain and temperature sensation were decreased on the left below the level of C3. The patient tested negative for the Kernig sign. These results indicated Brown-Séquard syndrome on the right at the level of C3.\nLaboratory studies, including hematologic, biochemical, and immunologic investigations were normal. Lumbar puncture cerebrospinal fluid was unremarkable.\nThere were no obvious abnormalities on head computed tomography (CT) and MRI examinations.\nSagittal T2-weighted MRI of cervical spine revealed spinal cord swelling with hyperintense lesion at the level of C1–3 . T2 axial scan showed hyperintensity of right spinal cord, consistent with SCI . Further, high-resolution MRI volumetric isotropic turbo spin echo acquisition (HR-MRI VISTA) showed narrowing of the right vertebral artery at the level of C1–3 with eccentric high signal parallel to the narrowed lumen resulting from VAD with intramural hematoma . Therefore, we diagnosed this condition as SCI resulting from VAD.\nThe patient underwent anticoagulant (AC) and antiplatelet (AP) therapy for 3 months. MRI reexamination showed a diminished range of abnormal signals of the spinal cord , and HR-MR VISTA sequence revealed lumen recanalization of the right vertebral artery . The patient recovered well and was discharged with a modified Rankin scale score of 1. We advised the patient to keep following up, but he refused.", + "fulltext_subclaims": [ + "A 40-year-old man, a building worker, presented with acute right-sided body weakness without obvious inducement for 6 days.", + "Weakness of the right limb occurred 16 h prior to admission to the hospital.", + "There was no history of trauma and neck massage.", + "The patient was a smoker for 10 years.", + "Neurologic examination showed that the patient’s consciousness and speech were normal.", + "Cranial nerve examination was normal.", + "According to the Medical Research Council muscle scale, the right upper proximal limb had muscle power grade 4/5.", + "According to the Medical Research Council muscle scale, the right upper distal limb had muscle power grade 2/5.", + "According to the Medical Research Council muscle scale, the right lower limb had muscle power grade 0/5.", + "Joint position and vibration disappeared in the right lower limb.", + "Pain and temperature sensation were decreased on the left below the level of C3.", + "The patient tested negative for the Kernig sign.", + "These results indicated Brown-Séquard syndrome on the right at the level of C3.", + "Laboratory studies, including hematologic, biochemical, and immunologic investigations were normal.", + "Lumbar puncture cerebrospinal fluid was unremarkable.", + "There were no obvious abnormalities on head computed tomography (CT) and MRI examinations.", + "Sagittal T2-weighted MRI of cervical spine revealed spinal cord swelling with hyperintense lesion at the level of C1–3.", + "T2 axial scan showed hyperintensity of right spinal cord, consistent with SCI.", + "High-resolution MRI volumetric isotropic turbo spin echo acquisition (HR-MRI VISTA) showed narrowing of the right vertebral artery at the level of C1–3 with eccentric high signal parallel to the narrowed lumen resulting from VAD with intramural hematoma.", + "We diagnosed this condition as SCI resulting from VAD.", + "The patient underwent anticoagulant (AC) and antiplatelet (AP) therapy for 3 months.", + "MRI reexamination showed a diminished range of abnormal signals of the spinal cord.", + "HR-MR VISTA sequence revealed lumen recanalization of the right vertebral artery.", + "The patient recovered well and was discharged with a modified Rankin scale score of 1.", + "We advised the patient to keep following up, but he refused." + ], + "summary": "An otherwise healthy 40-year-old man presented with acute right-sided body weakness. Six days earlier, he had experienced posterior neck pain without obvious inducement. Neurologic examination revealed a right Brown-Séquard syndrome. Magnetic resonance imaging (MRI) of the head was normal. Further, cervical spine MRI showed spinal cord infarction (SCI) on the right at the C1-C3 level. Three-dimensional high-resolution MRI (3D HR-MRI) volumetric isotropic turbo spin echo acquisition (VISTA) scan showed evidence of vertebral artery dissection (VAD). The patient was significantly relieved of symptoms and demonstrated negative imaging findings after therapy with anticoagulation (AC) and antiplatelets (AP) for 3 months.", + "summary_subclaims": [ + "The patient is an otherwise healthy 40-year-old man.", + "He presented with acute right-sided body weakness.", + "Six days earlier, he had experienced posterior neck pain without obvious inducement.", + "Neurologic examination revealed a right Brown-Séquard syndrome.", + "Magnetic resonance imaging (MRI) of the head was normal.", + "Cervical spine MRI showed spinal cord infarction on the right at the C1-C3 level.", + "3D HR-MRI VISTA scan showed evidence of vertebral artery dissection.", + "The patient was significantly relieved of symptoms after therapy with anticoagulation and antiplatelets for 3 months." + ] + }, + { + "id": "multiclinsum_test_3265_en.txt", + "fulltext": "A 24-year-old para 1 woman of African descent gave birth to a normal 3100 g female baby at 40 weeks’ gestation in a district hospital. Five months later, the patient, who was self-referred, presented to the outpatient gynaecology clinic of a regional hospital with a painful growth at the site of the left mediolateral episiotomy. She had no obvious puerperal sepsis. The patient had tertiary education, but no history of allergy, nor personal/family history of poor wound healing. The pain made it difficult for her to attempt coitus after birth. She used topical povidone-iodine ointment with no success. Physical examination revealed an exuberant tissue on the episiotomy scar at the 5 o’clock position of the introitus that extended superiorly into the lower third of the vagina and inferiorly into the upper part of the thigh. The lesion was also present in the fourchette from the 5 to 7 o’clock position. No obvious risk factor for exuberant granulation was identified, except for being an African.\n\nThe differential diagnoses were exuberant granulation tissue, granulomatous disorder (such as foreign body granulomas), pyogenic granuloma (lobular capillary hemangioma) that develops due to irritation, chronic graft-versus-host disease (cGVHD), keloid, and malignant lesions such as aggressive fibromatoses. cGVHD was excluded because there was no history of tissue grafting. The lack of epithelization excluded keloid. She was counseled, consented to, and underwent a cold knife excision biopsy aided by local bupivacaine hydrochloride (Marcaine) infiltration to minimize bleeding, and the surgical sites were sutured using polyglactin 2–0. During suturing, the vaginal epithelium in the vicinity of the lesion was thin and friable, as the stitches easily cut through the vaginal mucosa. There were no other features of hypoestrogenism. The lesions were discrete and sessile in attachment with a maximum diameter of 1.5 cm. Postoperatively and after discussion with a multidisciplinary team that included a urogynecologist, to treat the atrophic vaginal mucosa, she was prescribed topical conjugated equine estrogen vaginal cream 0.625 mg per 1 g, using 0.5 g per intravaginal application. This was the most appropriate available medication to assist with rejuvenation of the friable vaginal tissue. The patient applied the cream intravaginally twice a week for two weeks and then once a week for one week. This was an intermediate dose (which ranges from 0.3 to 0.5 mg of conjugated equine estrogen). The therapy was intermittent and of a short duration to minimize the effects of any systemic absorption. There is no specific dose recommended for premenopausal women,9 making its use controversial. Despite the controversy, data from a recent Danish study show a reassuring safety profile. Therefore, conjugated equine estrogen remains a recommended treatment option for vulvovaginal atrophy in women.\n\nThe histological report confirmed exuberant granulation tissue. No foreign body or residual surgical suture was identified in the specimen. A follow-up review at 12 weeks and 6 months confirmed normal wound healing and genitalia function.", + "fulltext_subclaims": [ + "The patient is a 24-year-old para 1 woman of African descent.", + "She gave birth to a 3100 g female baby at 40 weeks’ gestation.", + "The birth occurred in a district hospital.", + "Five months later, she presented to the outpatient gynaecology clinic of a regional hospital.", + "She had a painful growth at the site of the left mediolateral episiotomy.", + "She had no obvious puerperal sepsis.", + "She had tertiary education.", + "She had no history of allergy.", + "She had no personal/family history of poor wound healing.", + "The pain made it difficult for her to attempt coitus after birth.", + "She used topical povidone-iodine ointment with no success.", + "Physical examination revealed an exuberant tissue on the episiotomy scar at the 5 o’clock position of the introitus.", + "The lesion extended superiorly into the lower third of the vagina.", + "The lesion extended inferiorly into the upper part of the thigh.", + "The lesion was also present in the fourchette from the 5 to 7 o’clock position.", + "No obvious risk factor for exuberant granulation was identified, except for being an African.", + "The differential diagnoses included exuberant granulation tissue.", + "The differential diagnoses included granulomatous disorder.", + "The differential diagnoses included pyogenic granuloma.", + "The differential diagnoses included chronic graft-versus-host disease.", + "The differential diagnoses included keloid.", + "The differential diagnoses included aggressive fibromatoses.", + "cGVHD was excluded because there was no history of tissue grafting.", + "The lack of epithelization excluded keloid.", + "She underwent a cold knife excision biopsy.", + "The surgical sites were sutured using polyglactin 2–0.", + "The vaginal epithelium in the vicinity of the lesion was thin and friable.", + "The lesions were discrete and sessile in attachment.", + "The maximum diameter of the lesions was 1.5 cm.", + "She was prescribed topical conjugated equine estrogen vaginal cream 0.625 mg per 1 g.", + "The patient applied the cream intravaginally twice a week for two weeks.", + "The patient applied the cream intravaginally once a week for one week.", + "The therapy was intermittent and of a short duration.", + "There is no specific dose recommended for premenopausal women.", + "Data from a recent Danish study show a reassuring safety profile.", + "Conjugated equine estrogen remains a recommended treatment option for vulvovaginal atrophy in women.", + "The histological report confirmed exuberant granulation tissue.", + "No foreign body or residual surgical suture was identified in the specimen.", + "A follow-up review at 12 weeks confirmed normal wound healing.", + "A follow-up review at 6 months confirmed normal genitalia function." + ], + "summary": "A 24-year-old para 1 had spontaneous vaginal birth of a normal baby at term in a district hospital. Five months later, she presented to a regional hospital with complaints of pain and incomplete wound healing at the episiotomy site. She had used topical povidone-iodine ointment with no success. Following a physical examination, an exuberant granulation at the episiotomy wound was diagnosed. The lesions were located mostly at 5 to 7 o'clock position in the vagina which had a thin and friable mucosa. The patient was treated with surgical excision and postoperative topical conjugated equine estrogen vaginal cream 0.625 mg per 1 g at a dose of 0.5 g per intravaginal application twice weekly for two weeks, and thereafter once weekly for one week. A review after 6 weeks, 12 weeks, and 6 months confirmed complete wound healing and normal function of the genitalia.", + "summary_subclaims": [ + "The patient is a 24-year-old para 1.", + "She had a spontaneous vaginal birth of a normal baby at term.", + "The birth occurred in a district hospital.", + "Five months later, she presented to a regional hospital.", + "She had pain and incomplete wound healing at the episiotomy site.", + "She had used topical povidone-iodine ointment with no success.", + "An exuberant granulation at the episiotomy wound was diagnosed.", + "The lesions were located mostly at 5 to 7 o'clock position in the vagina.", + "The vaginal mucosa was thin and friable.", + "The patient was treated with surgical excision.", + "Postoperative treatment included topical conjugated equine estrogen vaginal cream 0.625 mg per 1 g.", + "The dose was 0.5 g per intravaginal application twice weekly for two weeks.", + "Thereafter, the dose was once weekly for one week.", + "A review after 6 weeks confirmed complete wound healing.", + "A review after 12 weeks confirmed complete wound healing.", + "A review after 6 months confirmed complete wound healing.", + "A review after 6 months confirmed normal function of the genitalia." + ] + }, + { + "id": "multiclinsum_test_999_en.txt", + "fulltext": "A 67-year-old White male with no past medical history presented to the gastroenterology clinic in February 2017 with a complaint of persistent intermittent mid-chest discomfort over the past year. Prior to presentation, the patient underwent a negative coronary workup for intermittent mid-chest discomfort of unclear etiology. The patient described a retrosternal chest pressure that only later became associated with food intake. He denied heartburn, regurgitation, dysphagia, nausea, vomiting, abdominal pain, bleeding, dyspepsia, fevers, dark stools, night sweats, or weight loss. The patient did not use any medications, was never a smoker, did not drink alcohol, and denied a significant familial medical history. On physical exam, the patient appeared in no acute distress and had a normal exam of his oral cavity, along with a soft, non-tender, non-distended abdomen and no apparent organomegaly or lymphadenopathy. His initial complete blood count, basic metabolic panel, and liver function tests were within normal ranges. His negative workup and persistent symptoms, which were refractory to conservative measures, warranted further evaluation. He was referred for endoscopy, which revealed an ulcerative mass and a stricture in the distal third of his esophagus—concerns for malignancy .\nEndoscopic ultrasound (EUS) examination further characterized the mass as 5 cm in length, 16–18 mm in thickness, and as a partially circumferential mass contained within the submucosal area, with evidence suggesting muscularis propria invasion . It was staged T3N0M0 as per endosonographic criteria. The mass appeared to be primarily below the diaphragmatic hiatus and its center within 0.5 cm of the gastroesophageal (GE) junction. Positron emission tomography (PET) scans demonstrated fluorodeoxyglucose (FDG) avidity involving the GE junction and extending to the lesser junction, but no signs of FDG avidity elsewhere. Biopsy obtained from EUS suggested a poorly differentiated carcinoma of suggested large cell neuroendocrine histology . As such, immunohistochemical staining followed, and it showed strong immunoreactivity for both synaptophysin and CD56, but showed negative chromogranin immunoreactivity. Serum chromogranin A was mildly elevated at 16 ng/ml (normal < 15 ng/ml), while serum serotonin at 154 ng/ml and 24-h urine 5-hydroxyindoleacetic acid (5-HIAA) at 3.1 mg were normal (normal ranges < 230 ng/ml and < 8 mg/24 h, respectively). These findings confirmed the diagnosis of a stage IIA poorly differentiated large cell neuroendocrine tumor.\nThe patient was started on neoadjuvant chemoradiation in June 2017, consisting of weekly carboplatin with target area under the curve 2 (AUC2), and paclitaxel 50 mg, along with radiotherapy, ahead of surgical resection. He tolerated four cycles of chemotherapy and seven sessions of radiotherapy, which helped in shrinking his tumor size. This was followed by a successful and noncomplicated robotic-assisted, laparoscopic esophagectomy in July 2017. Surgical biopsies and lymph node dissection revealed metastatic involvement in 1 of 3 diaphragmatic lymph nodes and no tumor invasion beyond the muscularis propria, further fine-tuning staging as T2N1M0. The patient has been under active surveillance, with yearly EGD and computed tomography (CT) scans every 6 months.", + "fulltext_subclaims": [ + "The patient is a 67-year-old White male.", + "The patient had no past medical history.", + "The patient presented to the gastroenterology clinic in February 2017.", + "The patient reported persistent intermittent mid-chest discomfort over the past year.", + "The patient underwent a negative coronary workup for intermittent mid-chest discomfort of unclear etiology.", + "The patient described retrosternal chest pressure that became associated with food intake.", + "The patient denied heartburn, regurgitation, dysphagia, nausea, vomiting, abdominal pain, bleeding, dyspepsia, fevers, dark stools, night sweats, or weight loss.", + "The patient did not use any medications.", + "The patient was never a smoker.", + "The patient did not drink alcohol.", + "The patient denied a significant familial medical history.", + "On physical exam, the patient appeared in no acute distress.", + "The patient's initial complete blood count, basic metabolic panel, and liver function tests were within normal ranges.", + "The patient was referred for endoscopy.", + "Endoscopy revealed an ulcerative mass and a stricture in the distal third of the esophagus.", + "Endoscopic ultrasound (EUS) characterized the mass as 5 cm in length.", + "EUS showed the mass was 16–18 mm in thickness.", + "EUS showed the mass was partially circumferential and contained within the submucosal area.", + "EUS suggested muscularis propria invasion.", + "The mass was staged T3N0M0 as per endosonographic criteria.", + "The mass was primarily below the diaphragmatic hiatus.", + "The center of the mass was within 0.5 cm of the gastroesophageal (GE) junction.", + "PET scans showed FDG avidity involving the GE junction and extending to the lesser junction.", + "PET scans showed no signs of FDG avidity elsewhere.", + "Biopsy obtained from EUS suggested a poorly differentiated carcinoma of suggested large cell neuroendocrine histology.", + "Immunohistochemical staining showed strong immunoreactivity for synaptophysin.", + "Immunohistochemical staining showed strong immunoreactivity for CD56.", + "Immunohistochemical staining showed negative chromogranin immunoreactivity.", + "Serum chromogranin A was 16 ng/ml.", + "Serum chromogranin A was mildly elevated.", + "Serum serotonin was 154 ng/ml.", + "24-h urine 5-HIAA was 3.1 mg.", + "The diagnosis was confirmed as a stage IIA poorly differentiated large cell neuroendocrine tumor.", + "The patient was started on neoadjuvant chemoradiation in June 2017.", + "Neoadjuvant chemoradiation consisted of weekly carboplatin with target AUC2.", + "Neoadjuvant chemoradiation consisted of paclitaxel 50 mg.", + "Neoadjuvant chemoradiation was followed by radiotherapy.", + "The patient tolerated four cycles of chemotherapy.", + "The patient tolerated seven sessions of radiotherapy.", + "The tumor size was reduced by chemoradiation.", + "The patient underwent a successful and noncomplicated robotic-assisted, laparoscopic esophagectomy in July 2017.", + "Surgical biopsies revealed metastatic involvement in 1 of 3 diaphragmatic lymph nodes.", + "Surgical biopsies showed no tumor invasion beyond the muscularis propria.", + "The staging was further fine-tuned as T2N1M0.", + "The patient has been under active surveillance.", + "The patient has yearly EGD.", + "The patient has CT scans every 6 months." + ], + "summary": "A 67-year-old previously healthy White male presented with a year-long intermittent nonspecific retrosternal discomfort, with the absence of any other symptoms. Esophagogastroduodenoscopy revealed an ulcerative mass in his lower esophagus, with concern of malignancy. Endoscopic ultrasound-guided biopsy revealed poorly differentiated neuroendocrine carcinoma of the esophagus with metastasis to a diaphragmatic lymph node. He was treated with neoadjuvant chemoradiation followed by surgery, and he has been in remission for over 5 years.", + "summary_subclaims": [ + "The patient is a 67-year-old previously healthy White male.", + "He presented with a year-long intermittent nonspecific retrosternal discomfort.", + "He had the absence of any other symptoms.", + "Esophagogastroduodenoscopy revealed an ulcerative mass in his lower esophagus.", + "There was concern of malignancy.", + "Endoscopic ultrasound-guided biopsy revealed poorly differentiated neuroendocrine carcinoma of the esophagus.", + "The biopsy showed metastasis to a diaphragmatic lymph node.", + "He was treated with neoadjuvant chemoradiation followed by surgery.", + "He has been in remission for over 5 years." + ] + }, + { + "id": "multiclinsum_test_336_en.txt", + "fulltext": "In April 2006, a 75-year old man who had been successfully treated for colon cancer 13 years ago, thyroid cancer 12 years ago, and was receiving endocrine therapy for prostate cancer from last year was transferred to our hospital for a fracture of his left proximal femur. The chest radiograph showed a solid mass in the hilum of left lung, and the thallium scintigram demonstrated abnormal uptake at the left proximal thigh and the hilum of left lung. In addition, the screening of tumor markers revealed extremely high level of CEA (1250 ng/ml), slightly high level of NSE (16.6 ng/ml) and SCC (2.2 ng/ml), and low level of thyroglobulin (0.3 ng/ml) and PSA (0.009 ng/ml). Thus the fracture was considered to be a bone metastasis from his fourth primary pulmonary cancer. Physical examination showed no hyperpigmentation of his all body surface. Laboratory investigation revealed serum sodium of 134 mmol/l, potassium 4.7 mmol/l, and plasma glucose 110 mg/dl, with normal renal and liver function.\nHe uneventfully underwent local excision and proximal femur replacement with a mega-prosthesis under general anesthesia. The bone tumor was pathologically diagnosed to be moderately differentiated adenocarcinoma. Later, the immunohistochemical examination revealed that cytokeratin 7 (CK7) and thyroid transcription factor 1 (TTF-1) were distinctly detected but cytokeratin 20 (CK20) never expressed. Recently, Chhieng et al. described that an adenocarcinoma was likely a primary lung tumor when it was of the CK7 positive/CK20 negative and TTF-1 positive phenotype . Thus, the bone tumor was finally diagnosed to be a metastatic lung cancer.\nThe estimated intraoperative blood loss was 400 ml. The patient was extubated as usual, but the level of awakening was very poor. Postoperative laboratory examination demonstrated anemia and severe hyponatremia (126 mmol/l), but showed normokalemia (4.3 mmol/l) and normoglycemia (92 mg/dl). Despite the transfusion of blood and the administration of normal saline, the patient subsequently became hypotensive (SBP 60–70 mmHg), tachycardic, hypoxic, febrile (40.5°C) and confused. Re-intubation was required for respiratory distress. A chest radiograph showed diffuse pulmonary edema. We initially suspected this condition of acute pulmonary emboli. Immediately, the patient underwent CT examination from head to abdomen. Enhanced chest CT revealed a left hilar mass suggesting a primary lung cancer but no pulmonary embolus. A ventilation/perfusion scan performed on the next day showed no perfusion defect and confirmed definitely no evidence of pulmonary embolism. Concomitant brain and abdominal CT scan also demonstrated a low density area in the parietal lobe of the left brain and massively enlarged bilateral adrenal glands consistent with metastases . After the CT evaluation, we finally diagnosed adrenal crisis due to extensive destruction of adrenal tissue caused by metastases. Blood was drawn at 8:00 on the first postoperative day for serum cortisol levels that were found to be 2.0 μg/dl on the third postoperative day. Betamethasone (2 mg) was given to the patient at first, and switched to hydrocortisone, 100 mg administered intravenously every 8 hours. Dramatic improvement occurred in the subsequent hours following administration of hydrocortisone. The fever and hypotension promptly subsided and hyponatremia instantly disappeared. The patient recovered his consciousness and could be successfully extubated. On postoperative day 3, he was started on early remobilization by physical therapy. On postoperative day 7, the patient could sit down on the edge of a bed without assistance, followed by transfer exercise to a wheelchair. Although he could not undergo a CT-guided biopsy of the adrenal gland due to the flat refusal of his family, the following CT examination on postoperative day 35 demonstrated that bilateral adrenal glands neither decreased in size nor showed atrophic change, suggesting that adrenal enlargement was mainly caused by metastasis rather than hemorrhagic complication. The patient was transferred to the related hospital for further rehabilitation on postoperative day 39.", + "fulltext_subclaims": [ + "The patient was a 75-year-old man.", + "He had been successfully treated for colon cancer 13 years ago.", + "He had been successfully treated for thyroid cancer 12 years ago.", + "He was receiving endocrine therapy for prostate cancer from last year.", + "He was transferred to the hospital for a fracture of his left proximal femur.", + "The chest radiograph showed a solid mass in the hilum of the left lung.", + "The thallium scintigram demonstrated abnormal uptake at the left proximal thigh.", + "The thallium scintigram demonstrated abnormal uptake at the hilum of the left lung.", + "The screening of tumor markers revealed an extremely high level of CEA (1250 ng/ml).", + "The screening of tumor markers revealed a slightly high level of NSE (16.6 ng/ml).", + "The screening of tumor markers revealed a slightly high level of SCC (2.2 ng/ml).", + "The screening of tumor markers revealed a low level of thyroglobulin (0.3 ng/ml).", + "The screening of tumor markers revealed a low level of PSA (0.009 ng/ml).", + "The fracture was considered to be a bone metastasis from his fourth primary pulmonary cancer.", + "Physical examination showed no hyperpigmentation of his all body surface.", + "Laboratory investigation revealed serum sodium of 134 mmol/l.", + "Laboratory investigation revealed potassium of 4.7 mmol/l.", + "Laboratory investigation revealed plasma glucose of 110 mg/dl.", + "Renal and liver function were normal.", + "He underwent local excision and proximal femur replacement with a mega-prosthesis under general anesthesia.", + "The bone tumor was pathologically diagnosed to be moderately differentiated adenocarcinoma.", + "The immunohistochemical examination revealed that cytokeratin 7 (CK7) was distinctly detected.", + "The immunohistochemical examination revealed that thyroid transcription factor 1 (TTF-1) was distinctly detected.", + "The immunohistochemical examination revealed that cytokeratin 20 (CK20) was never expressed.", + "Chhieng et al. described that an adenocarcinoma was likely a primary lung tumor when it was of the CK7 positive/CK20 negative and TTF-1 positive phenotype.", + "The bone tumor was finally diagnosed to be a metastatic lung cancer.", + "The estimated intraoperative blood loss was 400 ml.", + "The patient was extubated as usual.", + "The level of awakening was very poor.", + "Postoperative laboratory examination demonstrated anemia.", + "Postoperative laboratory examination demonstrated severe hyponatremia (126 mmol/l).", + "Postoperative laboratory examination showed normokalemia (4.3 mmol/l).", + "Postoperative laboratory examination showed normoglycemia (92 mg/dl).", + "The patient became hypotensive (SBP 60–70 mmHg).", + "The patient became tachycardic.", + "The patient became hypoxic.", + "The patient became febrile (40.5°C).", + "The patient became confused.", + "Re-intubation was required for respiratory distress.", + "A chest radiograph showed diffuse pulmonary edema.", + "We initially suspected this condition of acute pulmonary emboli.", + "The patient underwent CT examination from head to abdomen.", + "Enhanced chest CT revealed a left hilar mass suggesting a primary lung cancer.", + "Enhanced chest CT revealed no pulmonary embolus.", + "A ventilation/perfusion scan performed on the next day showed no perfusion defect.", + "A ventilation/perfusion scan confirmed definitely no evidence of pulmonary embolism.", + "Concomitant brain and abdominal CT scan demonstrated a low density area in the parietal lobe of the left brain.", + "Concomitant brain and abdominal CT scan demonstrated massively enlarged bilateral adrenal glands consistent with metastases.", + "Blood was drawn at 8:00 on the first postoperative day for serum cortisol levels.", + "Serum cortisol levels were found to be 2.0 μg/dl on the third postoperative day.", + "Betamethasone (2 mg) was given to the patient at first.", + "Betamethasone was switched to hydrocortisone, 100 mg administered intravenously every 8 hours.", + "Dramatic improvement occurred in the subsequent hours following administration of hydrocortisone.", + "The fever and hypotension promptly subsided.", + "Hyponatremia instantly disappeared.", + "The patient recovered his consciousness.", + "The patient could be successfully extubated.", + "On postoperative day 3, he was started on early remobilization by physical therapy.", + "On postoperative day 7, the patient could sit down on the edge of a bed without assistance.", + "On postoperative day 7, the patient could transfer to a wheelchair.", + "The patient could not undergo a CT-guided biopsy of the adrenal gland due to the flat refusal of his family.", + "The following CT examination on postoperative day 35 demonstrated that bilateral adrenal glands neither decreased in size nor showed atrophic change.", + "The CT examination suggested that adrenal enlargement was mainly caused by metastasis rather than hemorrhagic complication.", + "The patient was transferred to the related hospital for further rehabilitation on postoperative day 39." + ], + "summary": "We report a 75-year-old man who presented with shock immediately after surgery for a femoral fracture from lung cancer metastasis. Anemia and severe hyponatremia were detected. Despite adequate fluid resuscitation, nonspecific symptoms including hypotension, tachycardia, hypoxia, fever and confusion occurred. Emergent CT revealed enlarged bilateral adrenal glands. Under the diagnosis of adrenal crisis due to metastatic infiltration of adrenal glands, the patient was treated with appropriate steroid replacement resulting in rapid improvement and recovery.", + "summary_subclaims": [ + "The patient was a 75-year-old man.", + "He presented with shock immediately after surgery for a femoral fracture.", + "The femoral fracture was due to lung cancer metastasis.", + "Anemia was detected.", + "Severe hyponatremia was detected.", + "Nonspecific symptoms occurred despite adequate fluid resuscitation.", + "The nonspecific symptoms included hypotension, tachycardia, hypoxia, fever, and confusion.", + "Emergent CT revealed enlarged bilateral adrenal glands.", + "The diagnosis was adrenal crisis due to metastatic infiltration of adrenal glands.", + "The patient was treated with appropriate steroid replacement.", + "The treatment resulted in rapid improvement and recovery." + ] + }, + { + "id": "multiclinsum_test_2414_en.txt", + "fulltext": "A 28-year-old male with normal BMI presented to a surgical department clinic with complaint of a pain and swelling in the right inguinal region for the past two weeks initially it was small and gradually increase in size and associated with pain. This swelling was present for the last 8 years causing no symptoms, so the patient did not seek any medical advice for it. There was no history of abdominal pain and vomiting. The patient is an engineer by profession, suffering from Hepatitis C, for which he took treatment.\nOn examination, there was an indirect right inguinal hernia incomplete, and reducible type with positive cough impulse.\nPatient was diagnosed clinically as indirect inguinal hernia. Hematological workup was within normal limits.\nA Preoperative diagnosis of right inguinal hernia was made and was planned for hernia mesh repair, during surgery under spinal anesthesia, the hernia sac was found to contain an appendix. The appendix was slightly congested, not inflamed but there were dense adhesions within the sac and so adhesiolysis and appendectomy along with excision of the sac and Lichtenstein mesh hernioplasty was done. The postoperative period was uneventful. The patient postoperatively received fluid therapy, Oral fluids were administrated after 6 h along with soft diet and was discharged on postoperative day 2.\nThe patient was discharged on second post-operative day with complications on oral anti-biotics and followed up after one week of surgery (, , ).", + "fulltext_subclaims": [ + "The patient is a 28-year-old male.", + "The patient has a normal BMI.", + "The patient presented with pain and swelling in the right inguinal region for the past two weeks.", + "The swelling was initially small and gradually increased in size.", + "The swelling was associated with pain.", + "The swelling had been present for the last 8 years.", + "The patient did not seek medical advice for the swelling.", + "There was no history of abdominal pain.", + "There was no history of vomiting.", + "The patient is an engineer by profession.", + "The patient has Hepatitis C.", + "The patient took treatment for Hepatitis C.", + "On examination, there was an indirect right inguinal hernia.", + "The hernia was incomplete and reducible.", + "There was a positive cough impulse.", + "The patient was diagnosed clinically as having an indirect inguinal hernia.", + "Hematological workup was within normal limits.", + "A preoperative diagnosis of right inguinal hernia was made.", + "Hernia mesh repair was planned.", + "The surgery was performed under spinal anesthesia.", + "The hernia sac was found to contain an appendix.", + "The appendix was slightly congested.", + "The appendix was not inflamed.", + "There were dense adhesions within the sac.", + "Adhesiolysis was performed.", + "Appendectomy was performed.", + "Excision of the sac was performed.", + "Lichtenstein mesh hernioplasty was performed.", + "The postoperative period was uneventful.", + "The patient received fluid therapy.", + "Oral fluids were administered after 6 hours.", + "A soft diet was provided.", + "The patient was discharged on postoperative day 2.", + "The patient was discharged with complications.", + "The patient was prescribed oral antibiotics.", + "The patient was followed up after one week of surgery." + ], + "summary": "A 28 year's old man with normal body mass index (BMI) who had a history of right-side reducible linguino-scrotal swelling for 8 years, was admitted for elective right inguinal hernia repair. Two weeks back before admission, he noticed that swelling was slightly painful. Ultrasound of the abdomen reported normal findings. There was no history of abdominal pain and vomiting. Laboratory parameters were within normal limit. So, with a diagnosis of right sided partially reducible, incomplete, and indirect inguinal hernia, patient was operated for open hernia repair surgery, intra operatively we found dense adhesions within the sac, adhesions were released which revealed herniation of appendix into the inguinal canal. Appendix was mildly congested without gross evidence of inflammation. Hence, in view of noninflamed appendix, preperitoneal mesh (polypropylene) hernioplasty from Lichtenstein tension-free mesh repair was performed with appendicectomy. Postoperative period was uneventful, patient discharged at second day.", + "summary_subclaims": [ + "The patient is a 28-year-old man.", + "The patient had a history of right-side reducible linguino-scrotal swelling for 8 years.", + "The patient was admitted for elective right inguinal hernia repair.", + "Two weeks before admission, he noticed that the swelling was slightly painful.", + "Ultrasound of the abdomen reported normal findings.", + "There was no history of abdominal pain.", + "There was no history of vomiting.", + "Laboratory parameters were within normal limits.", + "The diagnosis was right-sided partially reducible, incomplete, and indirect inguinal hernia.", + "The patient was operated for open hernia repair surgery.", + "Intraoperatively, dense adhesions within the sac were found.", + "Adhesions were released, which revealed herniation of appendix into the inguinal canal.", + "The appendix was mildly congested.", + "There was no gross evidence of inflammation on the appendix.", + "In view of the noninflamed appendix, preperitoneal mesh hernioplasty was performed.", + "The mesh used was polypropylene from Lichtenstein tension-free mesh repair.", + "Appendicectomy was performed.", + "The postoperative period was uneventful.", + "The patient was discharged on the second day." + ] + }, + { + "id": "multiclinsum_test_2502_en.txt", + "fulltext": "A 57 year-old woman presented with sudden onset chest pain/ventricular fibrillation after hearing of her brother’s death. The electrocardiography indicated “anterior wall ST segment elevation myocardial infarction”. Laboratory data was notable for cTnT 1.12 ng/mL. Coronary angiography ruled out obstructive lesion in the major coronary arteries, but revealed a tapering and long narrowing distal left anterior descending artery (LAD, Fig. ), which was consistent with angiographic feature of coronary artery fibromuscular dysplasia . The ventriculography showed remarkable ventricular dilation, which affected much broader myocardium than the culprit vessel supplied . In a subsequent cardiac magnetic resonance (CMR) study, left ventricular (LV) remained dilated . Delayed contrast (gadolinium) image confirmed a localized mayocardial infarction in the inferoapical wall .\nOne week later, repeated transthoracic echocardiography (TTE) showed nearly normalized LV systolic function except for a residual apical hypokinesis compared with original episode . Nine months later, when she was laid off, she developed recurrent chest pain and significant LV dilation, with different contractile pattern . With only supportive therapy, both her symptoms and LV dysfunction spontaneously improved quickly.", + "fulltext_subclaims": [ + "A 57 year-old woman presented with sudden onset chest pain/ventricular fibrillation after hearing of her brother’s death.", + "The electrocardiography indicated “anterior wall ST segment elevation myocardial infarction”.", + "Laboratory data was notable for cTnT 1.12 ng/mL.", + "Coronary angiography ruled out obstructive lesion in the major coronary arteries.", + "Coronary angiography revealed a tapering and long narrowing distal left anterior descending artery.", + "The ventriculography showed remarkable ventricular dilation.", + "In a subsequent cardiac magnetic resonance (CMR) study, left ventricular (LV) remained dilated.", + "Delayed contrast (gadolinium) image confirmed a localized myocardial infarction in the inferoapical wall.", + "One week later, repeated transthoracic echocardiography (TTE) showed nearly normalized LV systolic function except for a residual apical hypokinesis compared with original episode.", + "Nine months later, when she was laid off, she developed recurrent chest pain and significant LV dilation, with different contractile pattern.", + "With only supportive therapy, both her symptoms and LV dysfunction spontaneously improved quickly." + ], + "summary": "A 57 year-old woman presented with sudden onset chest pain and ventricular fibrillation after hearing of her brother's death. The electrocardiography indicated \"anterior wall ST segment elevation myocardial infarction\". Coronary angiography ruled out obstructive lesion in the major coronary arteries, but revealed fibromuscular dysplasia of the distal left anterior descending artery. The ventriculography showed remarkable ventricular dilation, which affected much broader myocardium than the culprit vessel supplied. In a subsequent cardiac magnetic resonance study, delayed contrast (gadolinium) image revealed a focal left ventricular (LV) apical infarction. Her LV systolic function normalized within 1 week, except for a residual apical hypokinesis. She developed recurrent chest pain and LV dilation when she was laid off 9 months later. After supportive therapy, her symptoms improved and LV dysfunction normalized again.", + "summary_subclaims": [ + "The patient is a 57 year-old woman.", + "She presented with sudden onset chest pain.", + "She had ventricular fibrillation after hearing of her brother's death.", + "Electrocardiography indicated anterior wall ST segment elevation myocardial infarction.", + "Coronary angiography ruled out obstructive lesion in the major coronary arteries.", + "Coronary angiography revealed fibromuscular dysplasia of the distal left anterior descending artery.", + "Ventriculography showed remarkable ventricular dilation.", + "The ventricular dilation affected much broader myocardium than the culprit vessel supplied.", + "A cardiac magnetic resonance study was performed.", + "Delayed contrast (gadolinium) image revealed a focal left ventricular apical infarction.", + "Her LV systolic function normalized within 1 week.", + "There was residual apical hypokinesis.", + "She developed recurrent chest pain 9 months later.", + "She developed LV dilation when she was laid off 9 months later.", + "After supportive therapy, her symptoms improved.", + "LV dysfunction normalized again after supportive therapy." + ] + }, + { + "id": "multiclinsum_test_427_en.txt", + "fulltext": "A 68-year-old man presented to his primary care physician with a complaint of abdominal pain. He had a medical history of reflux esophagitis and benign prostatic hyperplasia. Esophagogastroduodenoscopy was performed, which showed a submucosal mass in the second portion of the duodenum with central ulceration. Upon admission, his carcinoembryonic antigen (CEA) and carbohydrate antigen (CA) 19-9 levels were within normal limits.\nDynamic CT showed a circumscribed tumor measuring 26 mm in diameter in the second portion of the duodenum with ulceration. On the arterial and portal phase contrast-enhanced CT, the mass was greatly enhanced with, persistent enhancement on the equilibrium phase . The mass was in contact with the pancreatic head, and pancreatic invasion was suspected. However, there was no dilatation of the central common bile duct and middle pancreatic duct.\nThe T1-weighted image showed the tumor as a hypo-intensity , and the T2-weighted image showed a tumor with modestly high intensity . The tumor showed a slightly high intensity on diffusion-weighted imaging (DWI) , and the apparent diffusion coefficient (ADC) map displayed slight visual intensity.\nEndoscopy showed a round, smooth, elevated mass in the second portion of the duodenum with central ulceration . Endoscopic ultrasonography of the lesion confirmed a hypoechoic mass arising from the fourth layer of the duodenal wall . A biopsy was performed from the central ulceration, but the cytological findings revealed no malignancy. Immunochemical studies were positive for smooth muscle actin (SMA) and negative for S100, C-Kit, and CD34.\nPreoperatively, we diagnosed the tumor as a leiomyoma or gastrointestinal stromal tumor (GIST). Therefore, after informed consent was obtained, pancreatoduodenectomy (PD) was performed.\nThe resected specimen showed a yellowish-white tumor, 24 × 24 × 19 mm in diameter, arising from the submucosa of the duodenal wall with deep ulceration . The tumor was located at the oral site from the papilla of Vater and showed transmural growth in the duodenal wall.\nThe tumor was a vascular-rich tumor without capsular and deep ulceration . The lesion was shown by the nested or perivascular proliferation of mildly atypical cells with round-to-oval nuclei and eosinophilic cytoplasm (glomus cell), accompanied by prominent small blood vessels, hemorrhage and hyalinized stroma . The resected pancreas was free of tumor cells. No mitosis was observed. Immunochemical studies showed that the tumor was positive for SMA and collagen type IV, and negative for C-Kit, CD34, desmin, and S100. The Ki-67 labeling index was 4% in the hot spot . As a result, the tumor was diagnosed as GT arising from the duodenum. There was no evidence of malignancy.\nThe patient was discharged from the hospital 38 days after the surgery. No sign of recurrence was found after a year of surgery.", + "fulltext_subclaims": [ + "The patient is a 68-year-old man.", + "He presented with a complaint of abdominal pain.", + "He had a medical history of reflux esophagitis.", + "He had a medical history of benign prostatic hyperplasia.", + "Esophagogastroduodenoscopy showed a submucosal mass in the second portion of the duodenum with central ulceration.", + "His carcinoembryonic antigen (CEA) levels were within normal limits.", + "His carbohydrate antigen (CA) 19-9 levels were within normal limits.", + "Dynamic CT showed a circumscribed tumor measuring 26 mm in diameter in the second portion of the duodenum with ulceration.", + "The mass was greatly enhanced on the arterial and portal phase contrast-enhanced CT.", + "The mass showed persistent enhancement on the equilibrium phase.", + "The mass was in contact with the pancreatic head.", + "Pancreatic invasion was suspected.", + "There was no dilatation of the central common bile duct.", + "There was no dilatation of the middle pancreatic duct.", + "The T1-weighted image showed the tumor as hypo-intensity.", + "The T2-weighted image showed the tumor with modestly high intensity.", + "The tumor showed a slightly high intensity on diffusion-weighted imaging (DWI).", + "The apparent diffusion coefficient (ADC) map displayed slight visual intensity.", + "Endoscopy showed a round, smooth, elevated mass in the second portion of the duodenum with central ulceration.", + "Endoscopic ultrasonography confirmed a hypoechoic mass arising from the fourth layer of the duodenal wall.", + "A biopsy was performed from the central ulceration.", + "The cytological findings revealed no malignancy.", + "Immunochemical studies were positive for smooth muscle actin (SMA).", + "Immunochemical studies were negative for S100.", + "Immunochemical studies were negative for C-Kit.", + "Immunochemical studies were negative for CD34.", + "Preoperatively, the tumor was diagnosed as a leiomyoma or gastrointestinal stromal tumor (GIST).", + "Pancreatoduodenectomy (PD) was performed after informed consent was obtained.", + "The resected specimen showed a yellowish-white tumor, 24 × 24 × 19 mm in diameter, arising from the submucosa of the duodenal wall with deep ulceration.", + "The tumor was located at the oral site from the papilla of Vater.", + "The tumor showed transmural growth in the duodenal wall.", + "The tumor was a vascular-rich tumor without capsular and deep ulceration.", + "The lesion showed nested or perivascular proliferation of mildly atypical cells with round-to-oval nuclei and eosinophilic cytoplasm.", + "The lesion was accompanied by prominent small blood vessels, hemorrhage, and hyalinized stroma.", + "The resected pancreas was free of tumor cells.", + "No mitosis was observed.", + "The tumor was positive for SMA and collagen type IV.", + "The tumor was negative for C-Kit, CD34, desmin, and S100.", + "The Ki-67 labeling index was 4% in the hot spot.", + "The tumor was diagnosed as glomus tumor (GT) arising from the duodenum.", + "There was no evidence of malignancy.", + "The patient was discharged from the hospital 38 days after the surgery.", + "No sign of recurrence was found after a year of surgery." + ], + "summary": "A 68-year-old man was admitted due to abdominal pain. Endoscopy showed a round, smooth, elevated mass in the second portion of the duodenum with central ulceration. Abdominal contrast computed tomography showed a hypervascular tumor measuring 26 mm in diameter in the second portion of the duodenum, and pancreatic invasion was suspected. Endoscopic ultrasonography of the lesion confirmed a hypoechoic mass arising from the fourth layer of the duodenal wall. A biopsy was performed for central ulceration, and immunochemical studies showed positive results for smooth muscle actin (SMA) and negative results for S100, C-Kit, and CD34. Leiomyoma or gastrointestinal stromal tumor was suspected and pancreatoduodenectomy was performed. The specimen exhibited a vascular-rich tumor, 24 × 24 × 19 mm in size, with deep ulceration in the duodenum. Histological examination showed uniform small round cells with central nuclei and a pale cytoplasm (glomus cell) with perivascular proliferation. Immunochemical studies showed that the tumor was positive for SMA and collagen type IV, and negative for C-Kit, CD34, desmin, and S100. We diagnosed the tumor as a GT of the duodenum.", + "summary_subclaims": [ + "The patient was a 68-year-old man.", + "The patient was admitted due to abdominal pain.", + "Endoscopy showed a round, smooth, elevated mass in the second portion of the duodenum with central ulceration.", + "Abdominal contrast computed tomography showed a hypervascular tumor measuring 26 mm in diameter in the second portion of the duodenum.", + "Pancreatic invasion was suspected.", + "Endoscopic ultrasonography of the lesion confirmed a hypoechoic mass arising from the fourth layer of the duodenal wall.", + "A biopsy was performed for central ulceration.", + "Immunochemical studies showed positive results for smooth muscle actin (SMA).", + "Immunochemical studies showed negative results for S100.", + "Immunochemical studies showed negative results for C-Kit.", + "Immunochemical studies showed negative results for CD34.", + "Leiomyoma or gastrointestinal stromal tumor was suspected.", + "Pancreatoduodenectomy was performed.", + "The specimen exhibited a vascular-rich tumor, 24 × 24 × 19 mm in size, with deep ulceration in the duodenum.", + "Histological examination showed uniform small round cells with central nuclei and a pale cytoplasm (glomus cell) with perivascular proliferation.", + "Immunochemical studies showed that the tumor was positive for SMA.", + "Immunochemical studies showed that the tumor was positive for collagen type IV.", + "Immunochemical studies showed that the tumor was negative for C-Kit.", + "Immunochemical studies showed that the tumor was negative for CD34.", + "Immunochemical studies showed that the tumor was negative for desmin.", + "Immunochemical studies showed that the tumor was negative for S100.", + "The tumor was diagnosed as a GT of the duodenum." + ] + }, + { + "id": "multiclinsum_test_1585_en.txt", + "fulltext": "A 56-year-old female was referred for a painless tongue lesion of three-month duration. The patient had unremarkable medical history, was normolipemic, nonalcohol drinker, smoker (6–19 cigarettes/day) for 30 years, and was taking no medications. On clinical examination, an asymptomatic pink-white, well-demarcated, sessile lesion with a granular surface and slightly raised margins measuring 1 × 0.5 × 0.3 cm was observed in the left lateral lingual border which extended to the ventral surface of the tongue. The lesion was soft in consistency on palpation and closely related to an area of combined white plaque and striae . Similar white striae in a reticular pattern were also observed in the right and left buccal mucosa consistent with the clinical diagnosis of OLP . There was no evidence of cervical lymph node enlargement. The extraoral examination performed by a dermatologist did not reveal any skin or genital lesions. Regarding the tongue lesion, the possibility of malignancy arising within OLP of the reticular/hypertrophic type was taken under consideration. An incisional biopsy was performed under local anesthesia from a region that included both the granular and the whitish tongue lesions.\nMicroscopic examination showed hyperparakeratosis and acanthosis with projections of the surface epithelium in a verrucous pattern, intense orange parakeratin plugs, and elongated thickened rete ridges . Epithelial cell atypia was not evident. Accumulation of foamy cells in the subepithelial connective tissue confined in the lamina propria papillae was noted with sparse inflammatory infiltrates . The oral mucosa adjacent to the lesion demonstrated histopathological features consistent with lichen planus. Specifically, the epithelial hyperplastic pattern in a transitional manner changed into a relatively thinner squamous epithelium that exhibited parakeratosis, basal cell hydropic degeneration, and a band-like subepithelial dense chronic inflammatory infiltrate mainly by lymphocytes (, inset). Based on the clinical and histopathological findings, a final diagnosis of VX with concomitant oral lichen planus features was rendered using the accepted diagnostic criteria for OLP .\nImmunohistochemical evaluation on formalin-fixed paraffin-embedded tissue sections was performed using CD68 antibody (Dako, Glostrup, Denmark) on a Ventana NexES automated immunohistochemistry system (Ventana Medical Systems, Tucson, AZ). The foamy cells exhibited strong immunostaining for CD68 .\nThe postsurgical healing was satisfactory, and complete removal was performed approximately two weeks after the incisional biopsy. Since OLP lesions remained unchanged and asymptomatic, no medications were prescribed, but follow-up was recommended. There was no evidence of recurrence after excision in a 7-year follow-up period, whereas the bilateral reticular OLP lesions on the buccal mucosa remained unchanged after the initial presentation.", + "fulltext_subclaims": [ + "The patient was a 56-year-old female.", + "The patient had a painless tongue lesion of three-month duration.", + "The patient was a smoker (6–19 cigarettes/day) for 30 years.", + "The patient was taking no medications.", + "An asymptomatic pink-white, well-demarcated, sessile lesion with a granular surface and slightly raised margins measuring 1 × 0.5 × 0.3 cm was observed in the left lateral lingual border.", + "The lesion extended to the ventral surface of the tongue.", + "The lesion was soft in consistency on palpation.", + "The lesion was closely related to an area of combined white plaque and striae.", + "Similar white striae in a reticular pattern were observed in the right and left buccal mucosa.", + "The clinical diagnosis was OLP.", + "There was no evidence of cervical lymph node enlargement.", + "The extraoral examination did not reveal any skin or genital lesions.", + "The possibility of malignancy arising within OLP of the reticular/hypertrophic type was taken under consideration.", + "An incisional biopsy was performed under local anesthesia.", + "Microscopic examination showed hyperparakeratosis and acanthosis with projections of the surface epithelium in a verrucous pattern.", + "Intense orange parakeratin plugs were noted.", + "Elongated thickened rete ridges were observed.", + "Epithelial cell atypia was not evident.", + "Accumulation of foamy cells in the subepithelial connective tissue confined in the lamina propria papillae was noted.", + "Sparse inflammatory infiltrates were observed.", + "The oral mucosa adjacent to the lesion demonstrated histopathological features consistent with lichen planus.", + "The epithelial hyperplastic pattern changed into a relatively thinner squamous epithelium.", + "The epithelium exhibited parakeratosis, basal cell hydropic degeneration, and a band-like subepithelial dense chronic inflammatory infiltrate mainly by lymphocytes.", + "A final diagnosis of VX with concomitant oral lichen planus features was rendered.", + "Immunohistochemical evaluation was performed using CD68 antibody.", + "The foamy cells exhibited strong immunostaining for CD68.", + "Complete removal was performed approximately two weeks after the incisional biopsy.", + "No medications were prescribed.", + "Follow-up was recommended.", + "There was no evidence of recurrence after excision in a 7-year follow-up period.", + "The bilateral reticular OLP lesions on the buccal mucosa remained unchanged after the initial presentation." + ], + "summary": "A case of verruciform xanthoma on the tongue of a 56-year-old female with oral lichen planus is reported. An asymptomatic pink-white lesion with a granular surface was observed in the left lateral lingual border, which was closely associated with a white plaque and striae. An incisional biopsy was performed, and histologically, epithelial projections in a verrucous pattern were observed. In the subepithelial connective tissue, aggregates of foamy cells that exhibited immunoreactivity for CD68 were noted. The final diagnosis was verruciform xanthoma. The mucosa adjacent to the lesion demonstrated histopathological features consistent with lichen planus.", + "summary_subclaims": [ + "A 56-year-old female had a case of verruciform xanthoma on the tongue.", + "The patient had oral lichen planus.", + "An asymptomatic pink-white lesion with a granular surface was observed in the left lateral lingual border.", + "The lesion was closely associated with a white plaque and striae.", + "An incisional biopsy was performed.", + "Histologically, epithelial projections in a verrucous pattern were observed.", + "In the subepithelial connective tissue, aggregates of foamy cells were noted.", + "The foamy cells exhibited immunoreactivity for CD68.", + "The final diagnosis was verruciform xanthoma.", + "The mucosa adjacent to the lesion demonstrated histopathological features consistent with lichen planus." + ] + }, + { + "id": "multiclinsum_test_1683_en.txt", + "fulltext": "A 3-year-old girl was referred to our hospital 5 days after the trauma, complaining of right elbow joint restriction and pain. She fell onto her outstretched hand while playing at home from a low chair. Her hand was put into a sling by her grandmother, but she hadn't received any other medical care.\nOn our examination, there was mild swelling over the elbow and tenderness over the radial head. On palpation, the radial head appeared to be anteriorly dislocated. She had pain in her elbow and could not do the active motion. The passive movement of the injured elbow was: 100º of flexion, 20º lack of full extension, 70º of pronation, and 50º of supination.\nRadiographs confirmed an anterior dislocation of the radial head with plastic bowing of the ulna, no evidence of fracture . Ultrasound detected fluid in the joint and soft tissue interposed in the humeroradial joint, so we anticipated that closed reduction would be unsuccessful. The patient was brought to the imaging department the following day. Under anesthesia using a laryngeal mask airway, closed reduction was initially attempted; however, that was unsuccessful as we anticipated. Then, a magnetic resonance imaging (MRI) film was done that showed that a structure of low signal intensity (annular ligament) was stuck in the humeroradial joint .\nThe patient was moved to the operative room the following day (7 days after injury). Closed reduction was attempted a second time, but it also proved unsuccessful verified by intraoperative X-ray fluoroscopy. Open reduction through a posterolateral approach was performed. We found the annular ligament was what stopped the radial head from returning to its anatomical location. The annular ligament wasn't damaged but was very stretched. The radial head was found to be protruding below the annular ligament and was incarcerated between the ligament and anterior capsule, similar to a kind of buttonhole effect . The ligament could not be pulled over the radial head when still intact as that made the joint irreducible. We decided to transect the ligament and repaired it subsequently. By pushing the radial head distally and pulling the interposed ligament anteriorly, it returned to its normal anatomical position immediately. After reduction, the elbow seems to be stable in the proper position during elbow joint movement and forearm rotation, so we finished the operation.\nActive range-of-motion exercises were allowed following 3 weeks of immobilization by a long arm plaster splint. At 3-week, 6-week, 3-month follow-up checkups, the movement range of the operated arm gradually improved, and at 6 months after surgery, it was 135º of flexion, full of extension, 90º of pronation, 90º of supination. This was compared to normal, which was 145º of flexion, full of extension, 90º of pronation, 90º of supination . The result was excellent according to the Mayo elbow performance score (100 scores).", + "fulltext_subclaims": [ + "A 3-year-old girl was referred to our hospital 5 days after the trauma.", + "She complained of right elbow joint restriction and pain.", + "She fell onto her outstretched hand while playing at home from a low chair.", + "Her hand was put into a sling by her grandmother.", + "She hadn't received any other medical care.", + "On our examination, there was mild swelling over the elbow.", + "There was tenderness over the radial head.", + "On palpation, the radial head appeared to be anteriorly dislocated.", + "She had pain in her elbow and could not do the active motion.", + "The passive movement of the injured elbow was: 100º of flexion, 20º lack of full extension, 70º of pronation, and 50º of supination.", + "Radiographs confirmed an anterior dislocation of the radial head.", + "Radiographs showed plastic bowing of the ulna.", + "Radiographs showed no evidence of fracture.", + "Ultrasound detected fluid in the joint.", + "Ultrasound detected soft tissue interposed in the humeroradial joint.", + "We anticipated that closed reduction would be unsuccessful.", + "The patient was brought to the imaging department the following day.", + "Closed reduction was initially attempted under anesthesia using a laryngeal mask airway.", + "That was unsuccessful as we anticipated.", + "A magnetic resonance imaging (MRI) film was done that showed a structure of low signal intensity (annular ligament) was stuck in the humeroradial joint.", + "The patient was moved to the operative room the following day.", + "Closed reduction was attempted a second time.", + "It also proved unsuccessful verified by intraoperative X-ray fluoroscopy.", + "Open reduction through a posterolateral approach was performed.", + "We found the annular ligament was what stopped the radial head from returning to its anatomical location.", + "The annular ligament wasn't damaged but was very stretched.", + "The radial head was found to be protruding below the annular ligament.", + "The radial head was incarcerated between the ligament and anterior capsule, similar to a kind of buttonhole effect.", + "The ligament could not be pulled over the radial head when still intact as that made the joint irreducible.", + "We decided to transect the ligament and repaired it subsequently.", + "By pushing the radial head distally and pulling the interposed ligament anteriorly, it returned to its normal anatomical position immediately.", + "After reduction, the elbow seems to be stable in the proper position during elbow joint movement and forearm rotation.", + "Active range-of-motion exercises were allowed following 3 weeks of immobilization by a long arm plaster splint.", + "At 3-week, 6-week, 3-month follow-up checkups, the movement range of the operated arm gradually improved.", + "At 6 months after surgery, it was 135º of flexion, full of extension, 90º of pronation, 90º of supination.", + "This was compared to normal, which was 145º of flexion, full of extension, 90º of pronation, 90º of supination.", + "The result was excellent according to the Mayo elbow performance score (100 scores)." + ], + "summary": "This study presents a relatively rare case of traumatic radial head dislocation with ulnar plastic deformation in a 3-year-old child, which was successfully treated by open reduction. The examined case did not require osteotomy and ligamentous reconstruction. The initial attempt of closed reduction failed due to annular ligament interposition, which has been detected on MRI. After 3 months of treatment, the range of motion of the operated arm gradually improved. At the 6-month follow-up, the Mayo elbow-performance score indicated an excellent treatment outcome.", + "summary_subclaims": [ + "This study presents a relatively rare case of traumatic radial head dislocation with ulnar plastic deformation in a 3-year-old child.", + "The case was successfully treated by open reduction.", + "The examined case did not require osteotomy and ligamentous reconstruction.", + "The initial attempt of closed reduction failed due to annular ligament interposition.", + "Annular ligament interposition has been detected on MRI.", + "After 3 months of treatment, the range of motion of the operated arm gradually improved.", + "At the 6-month follow-up, the Mayo elbow-performance score indicated an excellent treatment outcome." + ] + }, + { + "id": "multiclinsum_test_3079_en.txt", + "fulltext": "We report the case of a 67-year-old man who presented to the services of Manatí Medical Center with a chief complaint of fatigue upon exertion, dyspnea, and lower-extremity edema that had been progressively worsening for 2 weeks. His medical history was significant for a 30-year history of hidradenitis suppurativa (HS) Hurley stage III, hypertension, major depressive disorder, and a positive Mantoux test, treated with isoniazid 12 years ago. On physical exam, he was hypotensive, tachycardic, and tachypneic. On auscultation, a mild holosystolic murmur with S3 gallop was heard at the apex. Crackles and rales were appreciated in all lung fields, as well as bilateral lower-extremity edema. Additionally, there was mild ascites without abdominal tenderness or guarding. The patient was not confused at any point during history taking or physical exam.\n\nTroponin levels remained constant at less than 0.015 ng/mL, CK-MB less than 1.00 mg/mL, and total creatinine kinase at 15 IU/L, all within normal limits. However, Pro-B natriuretic peptide was elevated at 77 660 pg/mL (normal levels are 5–125 pg/mL). The electrocardiogram showed sinus rhythm with no indication of acute ischemic changes or arrythmia. A chest X-ray showed marked Kerley B lines, enlarged cardiac silhouette, and bilateral pleural effusion, suggesting exacerbated congestive heart failure. He was admitted to the hospital the same day for clinical stabilization and further treatment.\n\nDuring the hospital stay, various studies were performed to find the etiology of his CHF. The patient’s echocardiogram showed an ejection fraction (EF) of 20–25%, significantly different from a previous study done 2 months ago, which reported an EF of 50%, which also mentioned findings of global hypokinesis of the left ventricle with enlarged atria, left worse than right, and present mitral regurgitation. There were no changes indicating possible myocarditis or pericarditis. Findings of this study suggested new-onset decompensated congestive heart failure (CHF). Other diagnostic tools looking for ischemic and infectious etiology yielded negative results.\n\nA chest CT scan without contrast showed bilateral pleural effusions with bibasilar compressive atelectasis and no evidence of pulmonary or infectious processes. There was also no evidence of an intra-abdominal emergent process on abdominal imaging. The patient did not have significant leukocytosis, with negative blood cultures and pleural fluid culture, suggesting there was no systemic infection or sepsis that may have caused the heart failure. The patient had no coronary disease or cardiovascular risk factors that could explain his symptoms’ severity and rapid progression. However, his clinical history revealed that he was re-initiated on adalimumab 2 months before this presentation. Therefore, adalimumab was discontinued as a precaution of potential cause, with an adverse drug reaction probability of 5.\n\nFurther investigation with his dermatologist revealed he first started adalimumab treatment 3 years ago with the standard HS regimen, beginning with subcutaneous 160 mg on the first day, and 80 mg on day 15. On day 29 and weekly thereafter, the dose was maintained at 40 mg. After 2 years of utilizing the medication with no complications, it was discontinued due to his lesions’ progression. However, even with alternate standard treatments and procedures, his condition had not stabilized. After various hospital admissions, adalimumab was re-initiated with the standard-dose regimen, as previously described. Once adalimumab was discontinued during this hospital stay, his health continued to decline, with worsening of symptoms. Unfortunately, the patient’s condition continued to worsen, increasing his hospital visits for symptom management. On the 8th day of hospitalization, he died due to de-compensated heart failure and septicemia.", + "fulltext_subclaims": [ + "The patient was a 67-year-old man.", + "He presented with fatigue upon exertion, dyspnea, and lower-extremity edema.", + "His symptoms had been progressively worsening for 2 weeks.", + "He had a 30-year history of hidradenitis suppurativa Hurley stage III.", + "He had a positive Mantoux test, treated with isoniazid 12 years ago.", + "On physical exam, he was hypotensive, tachycardic, and tachypneic.", + "A mild holosystolic murmur with S3 gallop was heard at the apex.", + "Crackles and rales were appreciated in all lung fields.", + "There was bilateral lower-extremity edema.", + "There was mild ascites without abdominal tenderness or guarding.", + "The patient was not confused at any point during history taking or physical exam.", + "Troponin levels remained constant at less than 0.015 ng/mL.", + "CK-MB was less than 1.00 mg/mL.", + "Total creatinine kinase was 15 IU/L.", + "Pro-B natriuretic peptide was elevated at 77 660 pg/mL.", + "The electrocardiogram showed sinus rhythm with no indication of acute ischemic changes or arrythmia.", + "A chest X-ray showed marked Kerley B lines, enlarged cardiac silhouette, and bilateral pleural effusion.", + "The chest X-ray findings suggested exacerbated congestive heart failure.", + "He was admitted to the hospital the same day for clinical stabilization and further treatment.", + "The echocardiogram showed an ejection fraction of 20–25%.", + "A previous echocardiogram 2 months ago reported an ejection fraction of 50%.", + "The echocardiogram findings suggested new-onset decompensated congestive heart failure.", + "There were no changes indicating possible myocarditis or pericarditis.", + "A chest CT scan without contrast showed bilateral pleural effusions with bibasilar compressive atelectasis.", + "There was no evidence of pulmonary or infectious processes on the chest CT scan.", + "There was no evidence of an intra-abdominal emergent process on abdominal imaging.", + "The patient did not have significant leukocytosis.", + "Blood cultures and pleural fluid culture were negative.", + "The patient had no coronary disease or cardiovascular risk factors.", + "The patient was re-initiated on adalimumab 2 months before this presentation.", + "Adalimumab was discontinued as a precaution of potential cause, with an adverse drug reaction probability of 5.", + "The patient first started adalimumab treatment 3 years ago.", + "He initially received subcutaneous 160 mg on the first day.", + "He received 80 mg on day 15.", + "On day 29 and weekly thereafter, the dose was maintained at 40 mg.", + "After 2 years of utilizing the medication with no complications, it was discontinued due to his lesions’ progression.", + "Adalimumab was re-initiated with the standard-dose regimen.", + "Once adalimumab was discontinued during this hospital stay, his health continued to decline.", + "The patient’s condition continued to worsen, increasing his hospital visits for symptom management.", + "On the 8th day of hospitalization, he died due to de-compensated heart failure and septicemia." + ], + "summary": "We report the case of a 67-year-old man with a history of severe HS and major depressive disorder who came to our hospital complaining of dyspnea, fatigue upon exertion, and lower-extremity edema of 2 weeks’ evolution. Symptoms began after the re-initiation of adalimumab for his severe HS. During hospitalization, he was diagnosed with decompensated congestive heart failure (CHF). Extensive studies, looking for ischemic or infectious etiology, yielded negative results. Being aware of adalimumab’s potential adverse effects, the team discontinued the medication as a probable cause of his condition. Unfortunately, the patient died secondary to heart failure and septicemia.", + "summary_subclaims": [ + "The patient was a 67-year-old man.", + "The patient had a history of severe HS.", + "The patient had a history of major depressive disorder.", + "The patient came to the hospital complaining of dyspnea.", + "The patient came to the hospital complaining of fatigue upon exertion.", + "The patient came to the hospital complaining of lower-extremity edema.", + "The symptoms had a 2-week evolution.", + "The symptoms began after the re-initiation of adalimumab.", + "The patient was diagnosed with decompensated congestive heart failure.", + "Extensive studies looking for ischemic etiology yielded negative results.", + "Extensive studies looking for infectious etiology yielded negative results.", + "The team discontinued adalimumab as a probable cause of the condition.", + "The patient died secondary to heart failure.", + "The patient died secondary to septicemia." + ] + }, + { + "id": "multiclinsum_test_1262_en.txt", + "fulltext": "A 27-year-old woman, gravida 2, para 0, with no history of previous disease and no family history of congenital anomalies, smoker and with a BMI of 18.3 received a diagnosis of spontaneous twin pregnancy at 12 weeks. The assessment of chorionicity in this gestational age was however hampered by the presence of an hematoma measuring 44 × 38 mm separating the two membranes, thus preventing the identification of the “lambda” or “T” sign.\nThe anatomy scan at 20 weeks revealed two female fetuses, both presenting isolated levocardia (IL) with normal heart and situs inversus abdominalis with a left-sided liver and right-sided stomach and spleen . Noteworthy, in one fetus (A) the gallbladder was not visible.\nAn amniocentesis was performed, with conventional cytogenetic evaluation indicating normal karyotype 46XX for both fetuses. No genetic anomaly was reported with the Chromosomal Microarray Analysis (CMA). Zygosity was assessed by microsatellite analysis; as shown in Table , twins share only a fraction of paternal and maternal alleles, indicating dizygosity.\nAt 36 weeks one fetus was diagnosed to be growth restricted, having an abdominal circumference and an estimated fetal weight less than 3rd centile. At 37 weeks and 1 day, the pulsatility index (PI) of the umbilical artery of the growth restricted fetus, with an estimated fetal weight of 2171 g (below the 3rd centile, according to Hadlock growth chart), was 0.89 (corresponding to 46° centile), while the PI of the middle cerebral artery was 1.45 (26° centile). By contrast, the other twin had an estimated fetal weight of 2521 g with normal Doppler parameters. At 37 weeks and 3 days the mother underwent a scheduled cesarean delivery. The birthweight of the two female neonates were 2430 g and 2185 g.\nThe histological analysis of the placenta confirmed the monochorionicity of the twin pregnancy, revealing the juxtaposition of an amnion on each surface of the dividing membrane . The chorion was not visible between the two amnion surfaces, thus excluding the rare occurrence of partially fused placentas [, ]. Postnatally, by using DNA extracted from blood samples, the molecular analysis confirmed the dizygosity of the twins, as already previously determined through amniocentesis.\nMoreover, the two babies turned out to have the same situs anomaly, with IL and situs inversus, thus confirming the prenatal diagnosis. In order to identify possible genetic causes of such a concordant abnormal phenotype, the twins were subjected to clinical exome analysis with evaluation of 17 genes known to be associated to situs inversus. However, according to the variant classification ACMG (The American College of Medical Genetics and Genomics), no pathogenic or probably pathogenetic variants have been identified. By opening the analysis to the whole clinical exome (4490 genes), the twins did not share pathogenic or probably pathogenetic variants. In addition, the twin whose gallbladder was not visualized prenatally, developed jaundice with acholic stool in her neonatal period.\nThe complete abdominal scan performed at 20 days of extrauterine life showed a left sided, damage-free liver with regular size (lateral diameter of 6,3 cm), a reversed relation between superior mesenteric vein and artery and right-placed inferior vena cava in relation to the aorta. These findings perfectly fit with abdominalis situs inversus with isolated levocardia. The scan revealed for the first time a shriveled gallbladder, which led to the diagnosis of biliary atresia type IV associated with splenic malformations syndrome . The clinical exome analysis was unable to identify the genetic cause of these abdominal abnormalities.\nThe twin with BASM at 38 days of extrauterine life underwent Kasai portoenterostomy, second-hand appendectomy and Ladd bridle dissection. Later, during the fifth month of extrauterine life, the baby was diagnosed to have a subclinical acute cholangitis, which was treated with continuous infusion of piperacillin tazobactam during hospitalization. Unfortunately, the baby had recurrent cholangitis during the whole first year of extrauterine life, and these are still occurring.", + "fulltext_subclaims": [ + "The patient is a 27-year-old woman, gravida 2, para 0.", + "The patient received a diagnosis of spontaneous twin pregnancy at 12 weeks.", + "The assessment of chorionicity was hampered by the presence of an hematoma measuring 44 × 38 mm separating the two membranes.", + "The anatomy scan at 20 weeks revealed two female fetuses.", + "Both fetuses presented isolated levocardia.", + "Both fetuses had normal heart and situs inversus abdominalis.", + "In one fetus (A), the gallbladder was not visible.", + "Amniocentesis indicated normal karyotype 46XX for both fetuses.", + "No genetic anomaly was reported with the Chromosomal Microarray Analysis.", + "Zygosity was assessed by microsatellite analysis.", + "Twins share only a fraction of paternal and maternal alleles, indicating dizygosity.", + "At 36 weeks, one fetus was diagnosed to be growth restricted.", + "The estimated fetal weight of the growth restricted fetus was less than 3rd centile.", + "The pulsatility index (PI) of the umbilical artery of the growth restricted fetus was 0.89.", + "The PI of the middle cerebral artery of the growth restricted fetus was 1.45.", + "The other twin had an estimated fetal weight of 2521 g.", + "The mother underwent a scheduled cesarean delivery at 37 weeks and 3 days.", + "The birthweight of the two female neonates were 2430 g and 2185 g.", + "The histological analysis of the placenta confirmed the monochorionicity of the twin pregnancy.", + "The chorion was not visible between the two amnion surfaces.", + "Postnatally, molecular analysis confirmed the dizygosity of the twins.", + "The two babies had the same situs anomaly, with IL and situs inversus.", + "The twins were subjected to clinical exome analysis with evaluation of 17 genes known to be associated to situs inversus.", + "No pathogenic or probably pathogenetic variants have been identified.", + "The twins did not share pathogenic or probably pathogenetic variants in the whole clinical exome.", + "The twin whose gallbladder was not visualized prenatally, developed jaundice with acholic stool in her neonatal period.", + "The complete abdominal scan at 20 days showed a left sided, damage-free liver.", + "The scan revealed a shriveled gallbladder, which led to the diagnosis of biliary atresia type IV associated with splenic malformations syndrome.", + "The clinical exome analysis was unable to identify the genetic cause of these abdominal abnormalities.", + "The twin with BASM at 38 days of extrauterine life underwent Kasai portoenterostomy.", + "The baby was diagnosed to have a subclinical acute cholangitis during the fifth month of extrauterine life.", + "The baby had recurrent cholangitis during the whole first year of extrauterine life." + ], + "summary": "We report a case of spontaneous monochorionic dizygotic twins sharing situs inversus abdominalis and isolated levocardia, with only one twin affected by biliary atresia with splenic malformation syndrome. We also conducted a literature review of the 14 available documented monochorionic dizygotic twin gestations spontaneously conceived.", + "summary_subclaims": [ + "We report a case of spontaneous monochorionic dizygotic twins.", + "The twins shared situs inversus abdominalis.", + "The twins had isolated levocardia.", + "Only one twin was affected by biliary atresia with splenic malformation syndrome.", + "A literature review was conducted of the 14 available documented monochorionic dizygotic twin gestations.", + "The gestations were spontaneously conceived." + ] + }, + { + "id": "multiclinsum_test_1592_en.txt", + "fulltext": "A 53-year-old homeless man was admitted to the hospital due to a right femoral neck fracture. His medical history included noninsulin-dependent diabetes mellitus. A physical examination performed at admission was unremarkable. There was no fever, lymphadenopathy, or other neurological defects. Laboratory tests revealed the following results: white blood cells, 4330 cells/mL; hemoglobin, 9.2 g/dL; and platelet count, 29,900 platelets/mL. C-reactive protein was negative, and only normochromic-normocytic anemia was present. He successfully underwent surgery for the femoral neck fracture, which was performed by an orthopedic surgeon. However, he had an episode of generalized seizures during the postoperative course, and phenytoin was administered. After this episode of generalized seizures, he was referred to our department for further examination and treatment.\nA computed tomography (CT) examination of the head that was conducted without contrast showed a high-density and extraaxial mass in the right parietal convexity, and peritumoral brain edema was clearly observed . Enhanced magnetic resonance imaging (MRI) revealed an extraaxial, dural-based, and homogeneously enhanced mass with clear borders that was compatible with a meningioma en plaque . The mass was iso- to hypointense on fluid-attenuated inversion recovery and T2 imaging sequences and iso- to hyperintense on T1 imaging. It was strongly suspected that the patient had a meningioma en plaque.The mass was exposed with a right frontotemporal craniotomy. The tumor appeared to be a meningioma en plaque, and it was extraaxial, xanthochromic, firm, nonaspiratable, and it seemed to have a high vascularity and was dural based. The tumor was tightly adhered to the adjacent cerebral cortex and was permeated by many pial arteries and veins of the brain surface. It is very difficult to preserve these pial vessels during the total removal of a tumor.\nA frozen section of the lesion showed inflammatory cell infiltration, which mainly consisted of lymphocytes and plasma cells, and the presence of these cells was initially interpreted as some kind of hematologic disorder or inflammatory pseudotumor . Paraffin-embedded sections, however, showed a hypercellular pattern with features of polymorphous and mixed inflammatory infiltrates that were composed mainly of histiocytes in a background of collagen fibers . The cytoplasm in some histiocytes was foamy and eosinophilic. Some histiocytes were seen to engulf viable lymphocytes, which was thought to reflect emperipolesis (lymphophagocytosis) .\nThese histiocytes were immunopositive for S-100 protein and CD68, but negative for CD1α . All of these findings were consistent with extranodal RDD.\nThe patient had incomplete left hemiparesis after surgery. A brain CT examination conducted without contrast revealed postoperative hemorrhage and a low-density lesion in the right frontal lobe, which seemed to be due to the sacrificed pial arteries from the brain-tumor interface. His seizures completely ceased.\nIn order to find evidence of extra-CNS RDD, we performed a whole-body CT examination postoperatively, and findings of lymphadenopathy or other extranodal involvements were not found. The patient has been free of seizures since the surgery, and he recovered from his hemiparesis 6 months after the surgery.", + "fulltext_subclaims": [ + "The patient was a 53-year-old homeless man.", + "He was admitted to the hospital due to a right femoral neck fracture.", + "His medical history included noninsulin-dependent diabetes mellitus.", + "A physical examination performed at admission was unremarkable.", + "There was no fever.", + "There was no lymphadenopathy.", + "There were no other neurological defects.", + "Laboratory tests revealed white blood cells of 4330 cells/mL.", + "Laboratory tests revealed hemoglobin of 9.2 g/dL.", + "Laboratory tests revealed platelet count of 29,900 platelets/mL.", + "C-reactive protein was negative.", + "Only normochromic-normocytic anemia was present.", + "He successfully underwent surgery for the femoral neck fracture.", + "The surgery was performed by an orthopedic surgeon.", + "He had an episode of generalized seizures during the postoperative course.", + "Phenytoin was administered.", + "After this episode of generalized seizures, he was referred to our department.", + "A computed tomography (CT) examination of the head without contrast showed a high-density and extraaxial mass in the right parietal convexity.", + "Peritumoral brain edema was clearly observed.", + "Enhanced magnetic resonance imaging (MRI) revealed an extraaxial, dural-based, and homogeneously enhanced mass with clear borders.", + "The mass was compatible with a meningioma en plaque.", + "The mass was iso- to hypointense on fluid-attenuated inversion recovery and T2 imaging sequences.", + "The mass was iso- to hyperintense on T1 imaging.", + "It was strongly suspected that the patient had a meningioma en plaque.", + "The mass was exposed with a right frontotemporal craniotomy.", + "The tumor appeared to be a meningioma en plaque.", + "The tumor was extraaxial, xanthochromic, firm, nonaspiratable, and had high vascularity.", + "The tumor was dural based.", + "The tumor was tightly adhered to the adjacent cerebral cortex.", + "The tumor was permeated by many pial arteries and veins of the brain surface.", + "It is very difficult to preserve these pial vessels during the total removal of a tumor.", + "A frozen section of the lesion showed inflammatory cell infiltration.", + "The inflammatory cell infiltration mainly consisted of lymphocytes and plasma cells.", + "The presence of these cells was initially interpreted as some kind of hematologic disorder or inflammatory pseudotumor.", + "Paraffin-embedded sections showed a hypercellular pattern with features of polymorphous and mixed inflammatory infiltrates.", + "The infiltrates were composed mainly of histiocytes in a background of collagen fibers.", + "Some histiocytes had foamy and eosinophilic cytoplasm.", + "Some histiocytes were seen to engulf viable lymphocytes.", + "This was thought to reflect emperipolesis (lymphophagocytosis).", + "The histiocytes were immunopositive for S-100 protein and CD68.", + "The histiocytes were negative for CD1α.", + "All of these findings were consistent with extranodal RDD.", + "The patient had incomplete left hemiparesis after surgery.", + "A brain CT examination conducted without contrast revealed postoperative hemorrhage.", + "A low-density lesion in the right frontal lobe was observed.", + "The low-density lesion seemed to be due to the sacrificed pial arteries from the brain-tumor interface.", + "His seizures completely ceased.", + "A whole-body CT examination postoperatively was performed.", + "Findings of lymphadenopathy or other extranodal involvements were not found.", + "The patient has been free of seizures since the surgery.", + "He recovered from his hemiparesis 6 months after the surgery." + ], + "summary": "We report a case of an isolated intracranial RDD in a 53-year-old man. The patient had an episode of generalized seizures. Imaging studies of the brain were compatible with a meningioma en plaque. The mass was exposed by a right frontotemporal craniotomy. The tumor was adhered tightly to the adjacent cerebral cortex and was permeated by pial arteries of the brain surface. The sacrificing of these arteries was inevitable in order to achieve the total removal of the tumor. The patient had incomplete left hemiparesis after the surgery. Brain computed tomography (CT) imaging revealed a postoperative hemorrhage and a low-density lesion in the right frontal lobe. The patient was postoperatively diagnosed with isolated central nervous system RDD.", + "summary_subclaims": [ + "The patient was a 53-year-old man.", + "The patient had an episode of generalized seizures.", + "Imaging studies of the brain were compatible with a meningioma en plaque.", + "The mass was exposed by a right frontotemporal craniotomy.", + "The tumor was adhered tightly to the adjacent cerebral cortex.", + "The tumor was permeated by pial arteries of the brain surface.", + "The sacrificing of these arteries was inevitable in order to achieve the total removal of the tumor.", + "The patient had incomplete left hemiparesis after the surgery.", + "Brain computed tomography (CT) imaging revealed a postoperative hemorrhage.", + "Brain computed tomography (CT) imaging revealed a low-density lesion in the right frontal lobe.", + "The patient was postoperatively diagnosed with isolated central nervous system RDD." + ] + }, + { + "id": "multiclinsum_test_1671_en.txt", + "fulltext": "A 45-year-old man presented to the outpatient clinic at our hospital with abnormal electrocardiogram (ECG) findings.\nThe patient underwent ECG as part of a regular health check, and had no cardiac symptoms such as chest pain or shortness of breath.\nHe had no specific comorbidities and no history of trauma.\nThe patient had a smoking history of 20 pack-years and an alcohol consumption history of 3–4 bottles of soju per week. His younger brother was diagnosed with a myocardial bridge, and there was no other family history of cardiovascular disease.\nThe patient had a height of 176 cm and weight of 73 kg, and his vital signs were stable, with a blood pressure of 121/74 mmHg and pulse of 100 beats/min. There were no other significant findings on physical examination.\nBlood tests revealed no abnormalities, and cardiac markers were normal. The ECG showed T wave inversion in the anterior lead, and chest radiography findings were unremarkable.\nEchocardiography revealed that the LV was divided into two compartments by myocardial muscle fibers, along with tears in the apical lateral and inferior segments . There were no other significant abnormalities. Based on these findings, LV aneurysm dissection or LV pseudoaneurysm secondary to myocardial infarction (MI) were suspected.\nCoronary angiography was performed to assess for coronary artery disease (CAD) such as MI. However, no significant luminal narrowing was observed. Although the findings regarding CAD did not appear, treatment was discussed with a thoracic surgeon in light of the possibility of aneurysmal dissection. After consulting with the surgeon, it was decided to prioritize a definitive diagnosis because surgical treatment in cases of asymptomatic aneurysm dissection is not urgent.\nCCTA was performed for a more detailed evaluation of the anatomy and myocardial condition. On CCTA, it was shown that the LV was divided into two. A separated accessory chamber (AC) was connected to the LV by a narrow slit-like communication in the LV apical-mid posterolateral wall . No other abnormal findings, such as coronary artery anomaly, were seen, and no findings were suggestive of myocardial ischemia. Together, these findings indicated DCLV as a more likely diagnosis than LV pseudoaneurysm or aneurysm.", + "fulltext_subclaims": [ + "A 45-year-old man presented to the outpatient clinic at our hospital with abnormal electrocardiogram (ECG) findings.", + "The patient underwent ECG as part of a regular health check.", + "The patient had no cardiac symptoms such as chest pain or shortness of breath.", + "The patient had a smoking history of 20 pack-years.", + "The patient had an alcohol consumption history of 3–4 bottles of soju per week.", + "The patient's younger brother was diagnosed with a myocardial bridge.", + "The patient's height was 176 cm and weight was 73 kg.", + "The patient's blood pressure was 121/74 mmHg.", + "The patient's pulse was 100 beats/min.", + "Blood tests revealed no abnormalities.", + "The ECG showed T wave inversion in the anterior lead.", + "Echocardiography revealed that the LV was divided into two compartments by myocardial muscle fibers.", + "Echocardiography showed tears in the apical lateral and inferior segments.", + "LV aneurysm dissection or LV pseudoaneurysm secondary to myocardial infarction (MI) were suspected.", + "Coronary angiography was performed to assess for coronary artery disease (CAD) such as MI.", + "No significant luminal narrowing was observed.", + "Treatment was discussed with a thoracic surgeon in light of the possibility of aneurysmal dissection.", + "It was decided to prioritize a definitive diagnosis because surgical treatment in cases of asymptomatic aneurysm dissection is not urgent.", + "CCTA was performed for a more detailed evaluation of the anatomy and myocardial condition.", + "On CCTA, it was shown that the LV was divided into two.", + "A separated accessory chamber (AC) was connected to the LV by a narrow slit-like communication in the LV apical-mid posterolateral wall.", + "No other abnormal findings, such as coronary artery anomaly, were seen.", + "No findings were suggestive of myocardial ischemia.", + "Together, these findings indicated DCLV as a more likely diagnosis than LV pseudoaneurysm or aneurysm." + ], + "summary": "A 45-year-old man presented to our hospital due to abnormal findings on an electrocardiogram recorded during a health check. He had no specific cardiac symptoms, comorbidities or relevant past medical history. Echocardiography revealed that the LV was divided into two by muscle fibers. There were no findings of ischemia on coronary angiography and coronary computed tomography angiography performed to exclude differential diagnoses. After comprehensive analysis of the images, DCLV was diagnosed. As it seemed to be asymptomatic DCLV, we decided the patient was to be observed without administering any medication. However, follow-up echocardiography revealed a thrombus in the accessory chamber (AC). Anticoagulant medication was initiated, the thrombus resolved, and the patient is currently undergoing follow-up without any specific symptoms.", + "summary_subclaims": [ + "A 45-year-old man presented to our hospital due to abnormal findings on an electrocardiogram recorded during a health check.", + "He had no specific cardiac symptoms.", + "Echocardiography revealed that the LV was divided into two by muscle fibers.", + "There were no findings of ischemia on coronary angiography.", + "There were no findings of ischemia on coronary computed tomography angiography.", + "After comprehensive analysis of the images, DCLV was diagnosed.", + "We decided the patient was to be observed without administering any medication.", + "Follow-up echocardiography revealed a thrombus in the accessory chamber.", + "Anticoagulant medication was initiated.", + "The thrombus resolved.", + "The patient is currently undergoing follow-up without any specific symptoms." + ] + }, + { + "id": "multiclinsum_test_330_en.txt", + "fulltext": "A 46-year-old man, former professional athlete, presented with a hypertensive stroke secondary to use of intravenous (IV) drugs, including heroin and cocaine. While admitted to the hospital, it was discovered that he was human immunodeficiency virus (HIV) positive. The patient's stroke resulted in hypoxic-ischemic brain damage leading to severe spasticity. He developed 4/5 bilateral lower extremity spastic diplegia as per the Ashworth scale. Weakness of his right arm and face were additionally noted. The patient's speech was dysarthric but understandable.\nFor 7 years poststroke, the patient underwent physical therapy, botulinum toxin injections, and took oral baclofen for his increased tone without relief. The patient was wheelchair bound due to the increased tightness and loss of strength in both of his legs. He was unable to stand up or mobilize independently, and needed assistance with daily activities such as bathing and dressing. The goals of his spasticity management included improvement in mobility and gait, as well as a better range of motion. Unable to achieve these goals with pharmacological treatment, his physiatrist administered an intrathecal test dose of baclofen through a lumbar puncture. A test dosage of 75 ug of ITB was administered. The patient responded positively and underwent surgical implantation of a 40 ml SynchroMed II pump with a T10 level catheter. Postoperatively, the patient did well and was transferred back to inpatient rehabilitation after 48 hours of flat bed rest and IV cefazolin.\nTwo weeks postoperatively, the patient developed leakage of CSF from the lumbar incision and was subsequently transferred back to the neurosurgical service. The lumbar incision was oversewn and a lumbar puncture below the level of the catheter was done. A pressure of 24 cm H2O was documented. A computed tomography scan of the head showed mild to moderate ventricular enlargement. The next day, a right frontal Codman ventriculo-pleural shunt was placed. The patient's ventricular CSF did not initially show any bacteria. However, the following day the lumbar puncture CSF grew Staphylococcus epidermidis, sensitive to oxacillin. The patient was placed on IV antibiotics to prevent infection of the newly placed pump.\nAfter finishing 8 weeks of IV antibiotics, another area of the patient's incision site opened. Subsequently, the patient received a peripherally inserted central catheter line for another round of IV antibiotics. Due to these recurrent infections, it was decided to remove the patient's right-sided pump, and replace it with a new pump and spinal catheter on the left-side of his body. Postoperatively, the patient developed an infection at the abdominal incision site of the second pump, and the device was removed. At this time, the patient developed deep vein thrombosis and sepsis, and received 45 days of IV antibiotics through long-term IV access. Although the HIV was under control and the viral load was undetectable, it was believed that the patient's recurrent infections were due to his immunocompromised status. In addition, his urinary and fecal incontinence may have contributed to recurrent lower abdominal infections, secondary to contamination from his diaper.\nAt this time, botulinum toxin injections were re-instituted as the primary treatment for the patient's spasticity: 600 units of botulinum toxin were administered in the adductors, plantar flexors, and hamstrings every 3 months. He reported improvement of his gait 2 weeks after each injection, and experienced maximum effect of the treatment 4 weeks postinjection. The patient was able to walk with a rolling walker; however, he noted difficulty with balance while standing. The effect of the botulinum toxin lasted approximately 2.5 months before wearing off. The patient became septic with a Staphylococcus infection secondary to multiple, recurrent intramuscular botulinum toxin injections.\nAt this point, almost all options were exhausted, and the neurosurgeon proposed a SDR. The patient was explained the risks and unknown but potential benefits of SDR. The surgery would reduce the patient's tone, but could make it difficult for him to walk postprocedure if he was currently using his tone to ambulate. The risk of numbness in lower extremities, neurogenic bladder, and CSF leak were also discussed. The patient agreed to the procedure in an attempt to eliminate or decrease the frequency of the botulinum toxin injections.\nThe patient underwent selective dorsal rhizotomies at levels L2-S1 bilaterally. Osteoplastic laminectomies were performed from L1 to L5. The dura was retracted laterally. The L2 nerve root on the left was dissected out and confirmed electrically. The nerve root was separated out into the ventral motor and the sensory dorsal portions. Each dorsal sensory nerve was isolated using intraoperative microscopic dissection, and the rootlets were separated into thirds or quarters. Each motor nerve was stimulated, and then each sensory rootlet was stimulated. Rootlets were sectioned if stimulation of the rootlet was associated with clonus and prolonged contraction of the involved muscle groups. This was repeated for L2 through S1 bilaterally based on electrophysiological stimulation and the observed and recorded results. Approximately 50–75% of each dorsal sensory nerve on each side was sectioned.\nSpinal nerve root function was tested in this procedure by recording spontaneous and electrically-triggered EMG activity from iliopsoas, adductor, quadriceps, tibialis anterior, gastrocnemius, biceps femoris, and external anal sphincter muscles innervated by these roots. Portions of these roots were selectively sectioned based on triggered EMG discharge patterns.\nAt completion of the dorsal rhizotomy, the dura was sewn closed with a 6–0 Nurolon. The lamina of L1 through L5 was put back into position and laminar fusion was done using the Synthes laminar plating system. An epidural spinal catheter was placed for pain management control. There were no intraoperative complications.\nPostoperatively, the patient did well and was transferred back to inpatient rehabilitation. His spasticity was significantly reduced according to the Ashworth scale. Prior to his SDR, his lower extremity spasticity was 4/5. Postoperatively after SDR, this patient's Ashworth scale is consistently 1/5 bilaterally. The patient experienced no numbness or change in bowel and bladder control postsurgically.\nAt the present time, 3 years postsurgery, the patient attends physical therapy twice a week. The patient has no spasticity. Although he still requires assistance to ambulate, he experiences increased comfort due to the reduction of his tone and associated pain. The patient continues to present with lower extremity weakness and cannot stand without support. His muscular strength is about 3/5 in both legs proximally and 2/5 distally. This weakness resulting from the stroke is permanent and cannot be improved via a dorsal rhizotomy, as most poststroke paresis is irreversible after 6 months. His hydrocephalus is well-controlled with his shunt set at 180 mm H2O. His HIV viral load is undetectable. The patient is extremely satisfied with the outcome of his dorsal rhizotomy.", + "fulltext_subclaims": [ + "The patient is a 46-year-old man.", + "The patient had a hypertensive stroke.", + "The stroke was secondary to use of intravenous drugs.", + "The intravenous drugs included heroin and cocaine.", + "The patient was HIV positive.", + "The stroke resulted in hypoxic-ischemic brain damage.", + "The hypoxic-ischemic brain damage led to severe spasticity.", + "The patient developed 4/5 bilateral lower extremity spastic diplegia as per the Ashworth scale.", + "The patient had weakness of his right arm and face.", + "The patient's speech was dysarthric.", + "The patient's speech was understandable.", + "The patient underwent physical therapy for 7 years.", + "The patient received botulinum toxin injections for 7 years.", + "The patient took oral baclofen for 7 years.", + "The patient was wheelchair bound.", + "The patient was unable to stand up independently.", + "The patient needed assistance with daily activities.", + "The goals of spasticity management included improvement in mobility and gait.", + "The goals of spasticity management included a better range of motion.", + "The patient did not achieve these goals with pharmacological treatment.", + "The physiatrist administered an intrathecal test dose of baclofen.", + "The test dosage was 75 ug of ITB.", + "The patient responded positively to the test dose.", + "The patient underwent surgical implantation of a 40 ml SynchroMed II pump.", + "The pump had a T10 level catheter.", + "The patient was transferred back to inpatient rehabilitation after 48 hours.", + "The patient received IV cefazolin.", + "Two weeks postoperatively, the patient developed leakage of CSF from the lumbar incision.", + "The lumbar incision was oversewn.", + "A lumbar puncture below the level of the catheter was done.", + "A pressure of 24 cm H2O was documented.", + "A computed tomography scan of the head showed mild to moderate ventricular enlargement.", + "A right frontal Codman ventriculo-pleural shunt was placed.", + "The ventricular CSF did not initially show any bacteria.", + "The lumbar puncture CSF grew Staphylococcus epidermidis.", + "The Staphylococcus epidermidis was sensitive to oxacillin.", + "The patient was placed on IV antibiotics.", + "The patient received 8 weeks of IV antibiotics.", + "Another area of the incision site opened.", + "The patient received a peripherally inserted central catheter line.", + "The patient's HIV viral load was undetectable.", + "It was believed that the patient's recurrent infections were due to his immunocompromised status.", + "The patient's urinary and fecal incontinence may have contributed to recurrent lower abdominal infections.", + "Botulinum toxin injections were re-instituted as the primary treatment.", + "600 units of botulinum toxin were administered every 3 months.", + "The botulinum toxin was administered in the adductors, plantar flexors, and hamstrings.", + "The patient reported improvement of his gait 2 weeks after each injection.", + "The maximum effect of the treatment was 4 weeks postinjection.", + "The effect of the botulinum toxin lasted approximately 2.5 months.", + "The patient became septic with a Staphylococcus infection.", + "The Staphylococcus infection was secondary to multiple, recurrent intramuscular botulinum toxin injections.", + "The neurosurgeon proposed a SDR.", + "The patient agreed to the SDR.", + "The SDR would reduce the patient's tone.", + "The SDR could make it difficult for the patient to walk postprocedure.", + "The risk of numbness in lower extremities was discussed.", + "The risk of neurogenic bladder was discussed.", + "The risk of CSF leak was discussed.", + "The patient underwent selective dorsal rhizotomies at levels L2-S1 bilaterally.", + "Osteoplastic laminectomies were performed from L1 to L5.", + "The dura was retracted laterally.", + "The L2 nerve root on the left was dissected out.", + "The nerve root was separated into the ventral motor and the sensory dorsal portions.", + "Each dorsal sensory nerve was isolated using intraoperative microscopic dissection.", + "The rootlets were separated into thirds or quarters.", + "Each motor nerve was stimulated.", + "Each sensory rootlet was stimulated.", + "Rootlets were sectioned if stimulation was associated with clonus and prolonged contraction.", + "This was repeated for L2 through S1 bilaterally.", + "Approximately 50–75% of each dorsal sensory nerve on each side was sectioned.", + "Spinal nerve root function was tested by recording EMG activity.", + "The EMG activity was recorded from iliopsoas, adductor, quadriceps, tibialis anterior, gastrocnemius, biceps femoris, and external anal sphincter muscles.", + "Portions of these roots were selectively sectioned based on triggered EMG discharge patterns.", + "The dura was sewn closed with a 6–0 Nurolon.", + "The lamina of L1 through L5 was put back into position.", + "Laminar fusion was done using the Synthes laminar plating system.", + "An epidural spinal catheter was placed for pain management.", + "There were no intraoperative complications.", + "Postoperatively, the patient was transferred back to inpatient rehabilitation.", + "The patient's spasticity was significantly reduced.", + "Prior to SDR, the lower extremity spasticity was 4/5.", + "Postoperatively, the lower extremity spasticity was 1/5 bilaterally.", + "The patient experienced no numbness postsurgically.", + "The patient experienced no change in bowel and bladder control postsurgically.", + "Three years postsurgery, the patient has no spasticity.", + "The patient still requires assistance to ambulate.", + "The patient experiences increased comfort due to the reduction of tone and associated pain.", + "The patient continues to present with lower extremity weakness.", + "The patient cannot stand without support.", + "The patient's muscular strength is about 3/5 in both legs proximally.", + "The patient's muscular strength is about 2/5 distally.", + "The weakness resulting from the stroke is permanent.", + "The weakness cannot be improved via a dorsal rhizotomy.", + "Most poststroke paresis is irreversible after 6 months.", + "The patient's hydrocephalus is well-controlled.", + "The shunt is set at 180 mm H2O.", + "The patient's HIV viral load is undetectable.", + "The patient is extremely satisfied with the outcome of his dorsal rhizotomy." + ], + "summary": "The authors describe a patient who underwent a SDR with a successful postoperative outcome. This man suffered a hypertensive and hemorrhagic stroke secondary to intravenous drug abuse at age 46. A SDR was performed after two failed intrathecal baclofen pump placements due to recurrent infections, likely resulting from his immunocompromised status. The patient underwent lumbar laminectomies and dorsal rhizotomies at levels L1-S1 bilaterally. Postoperatively, the patient's spasticity was significantly reduced. His Ashworth spasticity score decreased from 4/5 to 1/5, and the reduction in tone has been durable over 3 years.", + "summary_subclaims": [ + "The authors describe a patient who underwent a SDR with a successful postoperative outcome.", + "This man suffered a hypertensive and hemorrhagic stroke secondary to intravenous drug abuse at age 46.", + "A SDR was performed after two failed intrathecal baclofen pump placements due to recurrent infections.", + "The recurrent infections were likely resulting from his immunocompromised status.", + "The patient underwent lumbar laminectomies and dorsal rhizotomies at levels L1-S1 bilaterally.", + "Postoperatively, the patient's spasticity was significantly reduced.", + "His Ashworth spasticity score decreased from 4/5 to 1/5.", + "The reduction in tone has been durable over 3 years." + ] + }, + { + "id": "multiclinsum_test_465_en.txt", + "fulltext": "A 33-year-old healthy female patient presented with fever, myalgia, and skin rash lasting 3 days before visiting Korea University Guro Hospital . The patient had a history of trip to Thailand, and she came back to Koreaeight days ago. Except for conjunctiva hemorrhage and mild splenomegaly, the physical findings were unremarkable.\nInitial laboratory tests showed mild neutropenia (1251/μL), thrombocytopenia (75,000/μL), elevated level of lactate dehydrogenase (LDH, 1775 IU/L), and elevated levels of alanine aminotransferase (ALT, 116 IU/L) and aspartate transaminase (AST,74 IU/L). Prothrombin time (PT, 13.1 sec) and activated partial thromboplastin time (aPTT, 33.3 sec) were within the normal range. Despite conservative treatment, sustained high fever was observed.\nOn hospital day 3, the patient appeared lethargic and fever persisted. With suspicion for secondary HLH after dengue infection, diagnostic tests were performed. Although bone marrow examination did not show typical findings of hemophagocytosis, diagnostic criteria of HLH were met: fever, splenomegaly, cytopenia, hypertriglyceridaemia (fasting TG 308 mg/dL), and hyperferritinaemia (ferritin 25,107 ng/mL) . Intravenous dexamethasone (10 mg/m2) was initiated on day 3 . Dengue virus PCR was positive and reported as a serotype 3 on hospital day 8. The dose of dexamethasone was tapered down after 2 weeks of treatment, and all results of blood tests were normalized . The patient was discharged from the hospital on hospital day 18 without any sequelae.", + "fulltext_subclaims": [ + "The patient is a 33-year-old healthy female.", + "The patient presented with fever, myalgia, and skin rash.", + "The symptoms lasted 3 days before visiting Korea University Guro Hospital.", + "The patient had a history of a trip to Thailand.", + "The patient returned to Korea eight days before presentation.", + "The physical findings were unremarkable except for conjunctiva hemorrhage and mild splenomegaly.", + "Initial laboratory tests showed mild neutropenia (1251/μL).", + "Initial laboratory tests showed thrombocytopenia (75,000/μL).", + "Initial laboratory tests showed elevated lactate dehydrogenase (1775 IU/L).", + "Initial laboratory tests showed elevated alanine aminotransferase (116 IU/L).", + "Initial laboratory tests showed elevated aspartate transaminase (74 IU/L).", + "Prothrombin time was within the normal range.", + "Activated partial thromboplastin time was within the normal range.", + "Despite conservative treatment, sustained high fever was observed.", + "On hospital day 3, the patient appeared lethargic.", + "Fever persisted on hospital day 3.", + "Diagnostic tests were performed with suspicion for secondary HLH after dengue infection.", + "Bone marrow examination did not show typical findings of hemophagocytosis.", + "The diagnostic criteria of HLH were met.", + "The diagnostic criteria included fever.", + "The diagnostic criteria included splenomegaly.", + "The diagnostic criteria included cytopenia.", + "The diagnostic criteria included hypertriglyceridaemia (fasting TG 308 mg/dL).", + "The diagnostic criteria included hyperferritinaemia (ferritin 25,107 ng/mL).", + "Intravenous dexamethasone (10 mg/m2) was initiated on day 3.", + "Dengue virus PCR was positive.", + "Dengue virus PCR reported as serotype 3 on hospital day 8.", + "The dose of dexamethasone was tapered down after 2 weeks of treatment.", + "All results of blood tests were normalized.", + "The patient was discharged from the hospital on hospital day 18.", + "The patient was discharged without any sequelae." + ], + "summary": "A 33-year-old healthy female patient presented with 3 days of fever, myalgia, and skin rash. Serotype 3 dengue virus was isolated. Clinical and laboratory findings fulfilled the criteria of HLH. After the initiation of corticosteroid therapy, the patient recovered and laboratory findings were normalized.", + "summary_subclaims": [ + "The patient is a 33-year-old healthy female.", + "The patient had 3 days of fever.", + "The patient had myalgia.", + "The patient had a skin rash.", + "Serotype 3 dengue virus was isolated.", + "Clinical and laboratory findings fulfilled the criteria of HLH.", + "Corticosteroid therapy was initiated.", + "The patient recovered.", + "Laboratory findings were normalized." + ] + }, + { + "id": "multiclinsum_test_1832_en.txt", + "fulltext": "A 37-year-old woman, G1P1, was referred to our hospital due to an increase in size of a tumor in her vulva. The mass was first pointed out to her during her delivery one year earlier. The patient had no apparent symptoms. Magnetic resonance imaging (MRI) of the pelvis showed a well-circumscribed mass in the vulva . The patient underwent resection of the tumor, and the tumor was subjected to histological examination. There was no apparent evidence of recurrence one year after the resection.\nGrossly, the tumor mass was located in the subcutis and measured 73×29 mm. There was no fibrous capsule, but the tumor was well circumscribed. The cut surface showed a yellowish-white mass with gelatinous change. No hemorrhage or necrosis was observed.\nOn histopathological examination , the boundary between tumor and adjacent tissue was clear. Tumor cells were short and spindle-shaped without prominent atypia, arranged in no overt architecture. No necrosis or mitoses were identified. The stroma was edematous and myxoid; fine collagen as well as dense collagen was detected in some regions. The vast majority of blood vessels were small-sized with thin walls. Some medium-sized blood vessels were also identified within the lesion . There was no specific distribution pattern of the vascularity. Immunohistochemical studies were performed using the primary antibodies listed in . On immunohistochemical analysis, most tumor cells showed positivity for vimentin, ER, PgR, and desmin. Some tumor cells showed positive for alpha-SMA and CD34. The tumor cells were uniformly negative for S100 protein . The Ki-67 labeling index was less than 2%.", + "fulltext_subclaims": [ + "The patient is a 37-year-old woman.", + "The patient was referred to the hospital due to an increase in size of a tumor in her vulva.", + "The mass was first pointed out to her during her delivery one year earlier.", + "The patient had no apparent symptoms.", + "MRI of the pelvis showed a well-circumscribed mass in the vulva.", + "The patient underwent resection of the tumor.", + "The tumor was subjected to histological examination.", + "There was no apparent evidence of recurrence one year after the resection.", + "Grossly, the tumor mass was located in the subcutis.", + "The tumor measured 73×29 mm.", + "There was no fibrous capsule.", + "The tumor was well circumscribed.", + "The cut surface showed a yellowish-white mass with gelatinous change.", + "No hemorrhage was observed.", + "No necrosis was observed.", + "On histopathological examination, the boundary between tumor and adjacent tissue was clear.", + "Tumor cells were short and spindle-shaped without prominent atypia.", + "Tumor cells were arranged in no overt architecture.", + "No necrosis was identified.", + "No mitoses were identified.", + "The stroma was edematous and myxoid.", + "Fine collagen as well as dense collagen was detected in some regions.", + "The vast majority of blood vessels were small-sized with thin walls.", + "Some medium-sized blood vessels were also identified within the lesion.", + "There was no specific distribution pattern of the vascularity.", + "Immunohistochemical studies were performed using the primary antibodies listed.", + "Most tumor cells showed positivity for vimentin.", + "Most tumor cells showed positivity for ER.", + "Most tumor cells showed positivity for PgR.", + "Most tumor cells showed positivity for desmin.", + "Some tumor cells showed positive for alpha-SMA.", + "Some tumor cells showed positive for CD34.", + "The tumor cells were uniformly negative for S100 protein.", + "The Ki-67 labeling index was less than 2%." + ], + "summary": "a 37-year-old woman presented with a painless mass in the vulva. Magnetic resonance imaging (MRI) showed a well-circumscribed 7 cm mass in the subcutis of the vulva. The tumor was resected. Histopathologically, the tumor was characterized by sparsely populated spindle-shaped cells in the fibromyxoid stroma. Thin-walled blood vessels were detected. Mitoses or pleomorphism was not found. Tumor cells were positive for vimentin, ER, PgR, and desmin. Some cells were positive for alpha-SMA and CD34. All cells were negative for S100 protein.", + "summary_subclaims": [ + "The patient is a 37-year-old woman.", + "She presented with a painless mass in the vulva.", + "Magnetic resonance imaging showed a well-circumscribed 7 cm mass in the subcutis of the vulva.", + "The tumor was resected.", + "Histopathologically, the tumor was characterized by sparsely populated spindle-shaped cells in the fibromyxoid stroma.", + "Thin-walled blood vessels were detected.", + "Mitoses or pleomorphism was not found.", + "Tumor cells were positive for vimentin.", + "Tumor cells were positive for ER.", + "Tumor cells were positive for PgR.", + "Tumor cells were positive for desmin.", + "Some cells were positive for alpha-SMA.", + "Some cells were positive for CD34.", + "All cells were negative for S100 protein." + ] + }, + { + "id": "multiclinsum_test_3222_en.txt", + "fulltext": "A 73-year-old male patient without any comorbidities presented with breathlessness for the last 12 h along with bipedal pitting edema and scrotal edema for the last 1 month with no features suggesting orthopnea or paroxysmal nocturnal dyspnea. There was no history of any medication intake, prolonged steroid abuse, altered bowel habits, recent surgery, or prolonged immobilization. Physical examination revealed tachypnea (respiratory rate—44/min), tachycardia (heart rate—140 beats/min), mild pallor, hypotension (BP 70/40 mmHg) with SpO2 80% in room air and 96% with 8 liters of O2/min via face mask. Peripheral extremities were cold and clammy. Bilateral pitting pedal edema, and scrotal edema along with leukonychia were present. Jugular venous pressure was not raised. Cardiovascular, respiratory, gastrointestinal, and lymphoreticular system examinations were within normal limits. For shock, vasopressor (noradrenaline) support and intravenous fluid resuscitation were carried on. The patient survived the episode of shock. 12-lead electrocardiogram showing sinus tachycardia and negative cardiac biomarkers ruled out acute coronary syndrome. Chest X-ray was performed which was normal. 8 a.m. serum cortisol was found to be normal (11.2 mcg/dl). On evaluation, the patient was found to have iron deficiency anemia (transferrin saturation 10%) with normal vitamin B12 levels. Fasting blood glucose was 93 mg/dl with a Glycated hemoglobin (HbA1C) of 5.4. Serology for Human Immunodeficiency virus (HIV)- 1,2; Hepatitis C virus (HCV); and Hepatitis B virus (HBV) was non-reactive. The Mantoux test was negative. Hypoproteinemia (4.4 mg/dl) along with hypoalbuminemia (2.4 mg/dl) was evident with normal renal function test. Markers of inflammation were elevated [erythrocyte sedimentation rate (ESR)-64, Ferritin-732 mcg/L, C-reactive protein (CRP)-12.6 mg/dl]. 24 h of urinary protein was 119 mg/24-h urine. No dyslipidemia was present. Ultrasonography of the whole abdomen revealed no evidence of chronic liver disease or any kidney disease. 2D echocardiography revealed an ejection fraction of 60% with right ventricular free wall hypokinesia without any pericardial effusion. Raising the suspicion of pulmonary thromboembolism, computed tomography of pulmonary angiography was performed where pulmonary thromboembolism was noted in bilateral lower lobe pulmonary arterial branches and right-sided upper lobe pulmonary arterial branches with dilated pulmonary trunk and both main pulmonary artery (MPA) [MPA 29 mm, right-22 mm, left-18 mm]. During the hospital stay, the patient was gradually developing asymmetrical right leg swelling for which an ultrasonography color doppler of bilateral lower limbs was performed where a long segment thrombus was noted extending from the popliteal vein to complete involvement of the external iliac vein. Antiphospholipid syndrome was ruled out. Protein, C, S, antithrombin III, and Serum homocysteine were within normal limits. Factor V mutation was not detected. Paroxysmal Nocturnal Hemoglobinuria (PNH) profile was negative. No Monoclonal protein band was detected on serum protein electrophoresis (SPEP). A computed tomography scan of the neck, thorax, and abdomen revealed no evidence of internal solid organ malignancy. Anticoagulation was started with low molecular weight Heparin (LMWH) and Warfarin and INR were monitored. To unveil the etiology of iron deficiency anemia and hypoproteinemia, stool examination, and upper gastrointestinal endoscopy were planned which revealed erythematous duodenal mucosa. D2 biopsy was taken which revealed chronic inflammatory cell infiltration in lamina propria consisting of eosinophils, plasma cells, and lymphocytes along with the presence of a parasite within the lumen of duodenal crypts morphologically resembling Strongyloides stercoralis. The stool was positive for occult blood and Strongyloides stercoralis larva was seen on wet moun. Bronchoscopy was done where the larval stage of the parasite was seen. Ivermectin (200 μg/kg orally) was started with Albendazole (400 mg orally two times a day). On continuation of the treatment with anticoagulant and anthelmintic, target INR was achieved (INR 2.2). The patient’s general well-being and appetite were improved within 2 days of therapy.", + "fulltext_subclaims": [ + "The patient is a 73-year-old male.", + "The patient had breathlessness for the last 12 h.", + "The patient had bipedal pitting edema for the last 1 month.", + "The patient had scrotal edema for the last 1 month.", + "There were no features suggesting orthopnea.", + "There were no features suggesting paroxysmal nocturnal dyspnea.", + "There was no history of prolonged steroid abuse.", + "There was no history of recent surgery.", + "There was no history of prolonged immobilization.", + "Physical examination revealed tachypnea (respiratory rate—44/min).", + "Physical examination revealed tachycardia (heart rate—140 beats/min).", + "Physical examination revealed hypotension (BP 70/40 mmHg).", + "SpO2 was 80% in room air.", + "SpO2 was 96% with 8 liters of O2/min via face mask.", + "Peripheral extremities were cold and clammy.", + "Bilateral pitting pedal edema was present.", + "Scrotal edema was present.", + "Leukonychia was present.", + "Jugular venous pressure was not raised.", + "A 12-lead electrocardiogram showed sinus tachycardia.", + "Cardiac biomarkers were negative.", + "Chest X-ray was normal.", + "8 a.m. serum cortisol was 11.2 mcg/dl.", + "The patient was found to have iron deficiency anemia.", + "Transferrin saturation was 10%.", + "Fasting blood glucose was 93 mg/dl.", + "HbA1C was 5.4.", + "Serology for HIV-1,2 was non-reactive.", + "Serology for HCV was non-reactive.", + "Serology for HBV was non-reactive.", + "The Mantoux test was negative.", + "Hypoproteinemia was evident.", + "Hypoalbuminemia was evident.", + "Erythrocyte sedimentation rate was 64.", + "Ferritin was 732 mcg/L.", + "C-reactive protein was 12.6 mg/dl.", + "24 h of urinary protein was 119 mg/24-h urine.", + "No dyslipidemia was present.", + "Ultrasonography of the whole abdomen revealed no evidence of chronic liver disease.", + "2D echocardiography revealed an ejection fraction of 60%.", + "2D echocardiography showed right ventricular free wall hypokinesia.", + "Computed tomography of pulmonary angiography showed pulmonary thromboembolism in bilateral lower lobe pulmonary arterial branches.", + "Computed tomography of pulmonary angiography showed pulmonary thromboembolism in right-sided upper lobe pulmonary arterial branches.", + "Anticoagulation was started with low molecular weight Heparin.", + "Anticoagulation was started with Warfarin.", + "D2 biopsy revealed chronic inflammatory cell infiltration in lamina propria.", + "The stool was positive for occult blood.", + "Strongyloides stercoralis larva was seen on wet mount.", + "Ivermectin (200 μg/kg orally) was started.", + "Albendazole (400 mg orally two times a day) was started.", + "Target INR was achieved (INR 2.2).", + "The patient’s general well-being improved within 2 days of therapy." + ], + "summary": "Here we report a case of a 73-year-old patient presenting with obstructive shock with bipedal edema without any evidence of adrenal insufficiency. An upper gastrointestinal endoscopy revealed Strongyloides larva in the lumen of duodenal crypts. Stool examination and broncho-alveolar lavage revealed the presence of S. stercoralis larva. Computed tomography of pulmonary angiography revealed pulmonary thromboembolism. A long segment thrombus was also noted in the right external iliac vein on color Doppler with negative screening for malignancy on computed tomography scan.", + "summary_subclaims": [ + "The patient is a 73-year-old.", + "The patient presented with obstructive shock.", + "The patient had bipedal edema.", + "There was no evidence of adrenal insufficiency.", + "An upper gastrointestinal endoscopy revealed Strongyloides larva in the lumen of duodenal crypts.", + "Stool examination revealed the presence of S. stercoralis larva.", + "Broncho-alveolar lavage revealed the presence of S. stercoralis larva.", + "Computed tomography of pulmonary angiography revealed pulmonary thromboembolism.", + "A long segment thrombus was noted in the right external iliac vein on color Doppler.", + "Computed tomography scan showed negative screening for malignancy." + ] + }, + { + "id": "multiclinsum_test_291_en.txt", + "fulltext": "A 5.5-year old girl had undergone surgical patch closure of a large secundum atrial septal defect with valvotomy of a moderate pulmonary stenosis at the age of 2 months; a mild aortic stenosis with a thickened tricuspid aortic valve was not corrected. She was born as the first child to non-consanguineous parents. The family history was negative for sudden cardiac death, but the maternal grandfather had epileptic seizures without fever in his youth. At the age of 12 months the girl suffered from a first afebrile seizure and at the age of 23 months from a first febrile seizure. Four months later she suffered from a series of afebrile seizures. Therefore valproic acid was started and maintained for 2 years. During this treatment she was seizure-free with normal electroencephalogram (EEG). After tapering valproic acid over a period of 2 months, short generalized paroxysmal discharges appeared on the EEG for the first time without clinical correlate. One year later she suffered from two further uncomplicated febrile seizures. Since then she is seizure-free without anticonvulsive treatment but the 24 h-EEG persistently shows subclinical absences. Since the intellectual and physical development of the patient is normal it was decided together with the parents not to restart the antiepileptic medication but to follow her up closely. Cerebral magnetic resonance imaging was normal. Clinical cardiologic, echocardiographic and neurologic examinations of the first degree relatives were normal except for the mother who showed epicanthic folds and hypertelorism. Unfortunately, the maternal grandfather did not consent with any investigations.\nAt inspection, she had bilateral epicanthic folds; broad eyebrows, a broad nasal tip and hypertelorism, however no ptosis or low-set ears (Figures and ). Her body weight was 18 kg (25th percentile), head circumference 51 cm (50th percentile) and height 115 cm (75th percentile). She did not complain about any cardiac symptoms and did not suffer from heart failure. Twelve-lead electrocardiogram showed normal sinus rhythm alternating with an atrio-ventricular-nodal rhythm and an incomplete right-bundle-branch-block. Twenty-four-hour electrocardiogram showed sporadic ventricular and supraventricular ectopic beats. Echocardiography revealed a mild residual valvular pulmonary stenosis with moderate pulmonary valve regurgitation and mild aortic valve stenosis with mild aortic regurgitation. Left ventricular function was normal, however, extensive hypertrabeculation resulting in a two-layered structure of the myocardium was visible in the mid-ventricular and apical segments of the left ventricle, consistent with the diagnosis of LVHT (Figures and ). Review of previous echocardiographic examinations disclosed that LVHT had been present already at age 2 years. As a primary prophylaxis for cardiac embolism aspirin 50 mg/d was started. Since she was symptom-free, no further cardiac medication was prescribed. At the latest follow-up investigation in September 2011, she was in a good cardiac and neurologic condition, no seizures had recurred and her intellectual development was normal. Echocardiography was unchanged.\nMolecular genetic analyses of the PTPN11, KRAS, RAF1 and SOS1 genes were negative. Array CGH using a 1 M oligonucleotide microarray platform (Agilent Technologies, Santa Clara, CA) was performed to screen genome-wide for submicroscopic deletions and duplications . Genomic positions are given according to genome-build hg18. Array CGH detected five previously not described CNVs as listed in Table . FISH analyses were not carried out because of the size of the CNVs. Regarding the duplications it could not be assessed whether they were tandem-duplications on the same locus or whether the duplicated fragment was inserted or translocated in another chromosome. By application of quantitative Real-Time PCR (qPCR) we could show, however, that none of the changes had developed de novo. All five CNVs are currently not listed in the Toronto Database of Genomic Variants (DGV), therefore, have to be considered as non-frequent variants in normal controls. Follow-up and testing of the index patient and her parents by qPCR revealed that all CNVs were inherited from one of the unaffected parents (maternal: deletion 1q42.3, duplication 3q26.32q26.33; paternal: duplication 14q32.11, deletion and duplication 20q13.33). We thus conclude that these changes are most likely not clinically significant CNVs but rare benign variants, although a reduced penetrance of inherited CNVs cannot be excluded.", + "fulltext_subclaims": [ + "The patient is a 5.5-year-old girl.", + "She had surgical patch closure of a large secundum atrial septal defect at the age of 2 months.", + "She had valvotomy of a moderate pulmonary stenosis at the age of 2 months.", + "A mild aortic stenosis with a thickened tricuspid aortic valve was not corrected.", + "The family history was negative for sudden cardiac death.", + "The maternal grandfather had epileptic seizures without fever in his youth.", + "At the age of 12 months, the girl suffered from a first afebrile seizure.", + "At the age of 23 months, she suffered from a first febrile seizure.", + "Four months after the first febrile seizure, she suffered from a series of afebrile seizures.", + "Valproic acid was started and maintained for 2 years.", + "During valproic acid treatment, she was seizure-free with a normal electroencephalogram.", + "After tapering valproic acid over 2 months, short generalized paroxysmal discharges appeared on the EEG without clinical correlate.", + "One year later, she suffered from two further uncomplicated febrile seizures.", + "Since then, she is seizure-free without anticonvulsive treatment.", + "The 24 h-EEG persistently shows subclinical absences.", + "The intellectual and physical development of the patient is normal.", + "It was decided not to restart antiepileptic medication.", + "Cerebral magnetic resonance imaging was normal.", + "The mother showed epicanthic folds and hypertelorism.", + "The maternal grandfather did not consent to any investigations.", + "The patient had bilateral epicanthic folds.", + "The patient had broad eyebrows, a broad nasal tip, and hypertelorism.", + "Her body weight was 18 kg (25th percentile).", + "Her head circumference was 51 cm (50th percentile).", + "Her height was 115 cm (75th percentile).", + "She did not suffer from heart failure.", + "Twelve-lead electrocardiogram showed normal sinus rhythm alternating with an atrio-ventricular-nodal rhythm.", + "Echocardiography revealed a mild residual valvular pulmonary stenosis with moderate pulmonary valve regurgitation.", + "Echocardiography revealed mild aortic valve stenosis with mild aortic regurgitation.", + "Left ventricular function was normal.", + "Extensive hypertrabeculation resulting in a two-layered structure of the myocardium was visible in the mid-ventricular and apical segments of the left ventricle.", + "The diagnosis of LVHT was made.", + "Review of previous echocardiographic examinations disclosed that LVHT had been present already at age 2 years.", + "As a primary prophylaxis for cardiac embolism, aspirin 50 mg/d was started.", + "No further cardiac medication was prescribed.", + "At the latest follow-up in September 2011, she was in a good cardiac and neurologic condition.", + "No seizures had recurred.", + "Her intellectual development was normal.", + "Echocardiography was unchanged.", + "Molecular genetic analyses of the PTPN11, KRAS, RAF1, and SOS1 genes were negative.", + "Array CGH using a 1 M oligonucleotide microarray platform was performed.", + "Array CGH detected five previously not described CNVs.", + "FISH analyses were not carried out because of the size of the CNVs.", + "Quantitative Real-Time PCR showed that none of the changes had developed de novo.", + "All five CNVs are not listed in the Toronto Database of Genomic Variants.", + "Follow-up and testing of the index patient and her parents by qPCR revealed that all CNVs were inherited from one of the unaffected parents.", + "The maternal parent contributed deletion 1q42.3 and duplication 3q26.32q26.33.", + "The paternal parent contributed duplication 14q32.11, deletion, and duplication 20q13.33.", + "These changes are most likely not clinically significant CNVs but rare benign variants.", + "A reduced penetrance of inherited CNVs cannot be excluded." + ], + "summary": "A unique combination of LVHT, atrial septal defect, pulmonary valve stenosis, aortic stenosis, epilepsy and minor facial anomalies is presented in a 5.5 years old girl. Microarray-based genomic hybridization (array-CGH) detected six previously not described copy number variants (CNVs) inherited from a clinically unaffected father and minimally affected mother, thus, most likely, not clinically significant but rare benign variants.", + "summary_subclaims": [ + "The patient is a 5.5 years old girl.", + "The patient has LVHT.", + "The patient has an atrial septal defect.", + "The patient has pulmonary valve stenosis.", + "The patient has aortic stenosis.", + "The patient has epilepsy.", + "The patient has minor facial anomalies.", + "Microarray-based genomic hybridization detected six previously not described copy number variants.", + "The copy number variants were inherited from a clinically unaffected father.", + "The copy number variants were inherited from a minimally affected mother.", + "The copy number variants are most likely not clinically significant.", + "The copy number variants are rare benign variants." + ] + }, + { + "id": "multiclinsum_test_2897_en.txt", + "fulltext": "A 68-year-old woman, who had a history of hypertension, hyperlipidemia, and diabetes mellitus, underwent laparoscopic low anterior resection (LLAR) for treatment of her rectal cancer in December 2011. Histological examination revealed a well differentiated tubular adenocarcinoma, pT3N0M0 stage II A according to the Union for International Cancer Control (UICC) TNM classification system . The surgical margin was negative, and there was no vascular or lymphatic invasion. No adjuvant therapy was given, and there was no evidence of recurrence for 3 years.\nThree years after the LLAR, the follow-up computed tomography (CT) scan revealed liver metastasis in Couinaud segment V . A diagnosis of liver metastasis of rectal cancer was made, and she therefore underwent a laparoscopic anterior segment liver resection in February 2015. Histological examination revealed a moderately differentiated tubular adenocarcinoma without vascular or bile duct invasion, and with a preserved surgical margin .\nTwo years after undergoing hepatectomy, the follow-up CT scan revealed dilation of the left intrahepatic bile duct and a high-density mass in the common trunk of segment II and segment III (B23). Magnetic resonance cholangiopancreatography (MRCP) and endoscopic retrograde cholangiopancreatography (ERCP) also revealed a mass in B23 . The biopsy findings from ERCP confirmed adenocarcinoma. Therefore, she underwent left and caudal lobectomy with extrahepatic bile duct resection in April 2017. Histological examination revealed a moderately differentiated tubular adenocarcinoma in segments II and III that invaded into the left hepatic duct and the liver parenchyma, forming a 20 mm nodule. There was no vascular invasion, and the surgical margin was preserved . The postoperative diagnosis was intrahepatic cholangiocarcinoma, pT2N0M0 stage II according to the American Joint Committee on Cancer (AJCC) 8th edition.\nIn October 2017, a follow-up CT scan revealed a 15 mm mass with enhancement in the early phase in the common bile duct, and lymphadenopathy at 8a. MRCP also revealed a 15 × 6 mm low intensity mass at the end of the common bile duct, and a slightly high diffusion-weighted imaging (DWI) but no corresponding low signal on the apparent diffusion coefficient (ADC) map . A diagnosis of lower bile duct cancer was made. Consequently, she received pylorus-preserving pancreatoduodenectomy in November 2017. Histological examination revealed a well to moderately differentiated tubular adenocarcinoma with preserved surgical margin. Although there was no vascular invasion, lymph node (LN) 8a metastasis (2/2) was observed .\nUpon comparison, the histology of the current surgical specimen was found to be similar to those from the earlier surgeries. Immunological findings also revealed similar cytokeratin (CK) expression patterns of the specimens, which were negative for CK7 and positive for CK20 , indicating that the tumor originated from the colon or rectum. Based on these findings, a definitive diagnosis of rectal cancer with metastases to the liver, intrahepatic bile duct, and lower bile duct was made. The patient was followed up as an outpatient for 2 years, and no apparent recurrence or metastasis was observed.", + "fulltext_subclaims": [ + "The patient is a 68-year-old woman.", + "She had a history of hypertension.", + "She had a history of hyperlipidemia.", + "She had a history of diabetes mellitus.", + "She underwent laparoscopic low anterior resection (LLAR) in December 2011.", + "The LLAR was for treatment of rectal cancer.", + "Histological examination revealed a well differentiated tubular adenocarcinoma.", + "The tumor was pT3N0M0 stage II A according to the UICC TNM classification system.", + "The surgical margin was negative.", + "There was no vascular or lymphatic invasion.", + "No adjuvant therapy was given.", + "There was no evidence of recurrence for 3 years.", + "Three years after the LLAR, the follow-up CT scan revealed liver metastasis in Couinaud segment V.", + "A diagnosis of liver metastasis of rectal cancer was made.", + "She underwent a laparoscopic anterior segment liver resection in February 2015.", + "Histological examination revealed a moderately differentiated tubular adenocarcinoma.", + "There was no vascular or bile duct invasion.", + "The surgical margin was preserved.", + "Two years after undergoing hepatectomy, the follow-up CT scan revealed dilation of the left intrahepatic bile duct.", + "The CT scan also revealed a high-density mass in the common trunk of segment II and segment III (B23).", + "MRCP and ERCP also revealed a mass in B23.", + "The biopsy findings from ERCP confirmed adenocarcinoma.", + "She underwent left and caudal lobectomy with extrahepatic bile duct resection in April 2017.", + "Histological examination revealed a moderately differentiated tubular adenocarcinoma in segments II and III.", + "The tumor invaded into the left hepatic duct and the liver parenchyma, forming a 20 mm nodule.", + "There was no vascular invasion.", + "The surgical margin was preserved.", + "The postoperative diagnosis was intrahepatic cholangiocarcinoma, pT2N0M0 stage II according to the AJCC 8th edition.", + "In October 2017, a follow-up CT scan revealed a 15 mm mass with enhancement in the early phase in the common bile duct.", + "Lymphadenopathy at 8a was observed.", + "MRCP revealed a 15 × 6 mm low intensity mass at the end of the common bile duct.", + "A diagnosis of lower bile duct cancer was made.", + "She received pylorus-preserving pancreatoduodenectomy in November 2017.", + "Histological examination revealed a well to moderately differentiated tubular adenocarcinoma.", + "The surgical margin was preserved.", + "There was no vascular invasion.", + "Lymph node (LN) 8a metastasis (2/2) was observed.", + "The histology of the current surgical specimen was found to be similar to those from the earlier surgeries.", + "Immunological findings revealed similar CK expression patterns of the specimens.", + "The specimens were negative for CK7.", + "The specimens were positive for CK20.", + "The tumor originated from the colon or rectum.", + "A definitive diagnosis of rectal cancer with metastases to the liver, intrahepatic bile duct, and lower bile duct was made.", + "The patient was followed up as an outpatient for 2 years.", + "No apparent recurrence or metastasis was observed." + ], + "summary": "The patient had undergone laparoscopic low anterior resection for rectal cancer (pT3N0M0 stage IIA) 6 years ago, laparoscopic anterior liver resection for liver metastasis (Couinaud segment V) 3 years ago, and left and caudal lobectomy with extrahepatic bile duct resection for left intrahepatic bile duct metastasis 6 months ago. A follow-up examination showed a 15 mm mass in the common bile duct, for which she underwent pylorus-preserving pancreatoduodenectomy. Histological and immunohistological examination of the specimens revealed similar cytokeratin (CK) expression patterns, which were negative for CK7 and positive for CK20. Therefore, the definitive diagnosis was metastasis from rectal cancer.", + "summary_subclaims": [ + "The patient had undergone laparoscopic low anterior resection for rectal cancer 6 years ago.", + "The rectal cancer was staged as pT3N0M0 stage IIA.", + "The patient had undergone laparoscopic anterior liver resection for liver metastasis in Couinaud segment V 3 years ago.", + "The patient had undergone left and caudal lobectomy with extrahepatic bile duct resection for left intrahepatic bile duct metastasis 6 months ago.", + "A follow-up examination showed a 15 mm mass in the common bile duct.", + "The patient underwent pylorus-preserving pancreatoduodenectomy.", + "Histological and immunohistological examination of the specimens revealed similar cytokeratin (CK) expression patterns.", + "The specimens were negative for CK7.", + "The specimens were positive for CK20.", + "The definitive diagnosis was metastasis from rectal cancer." + ] + }, + { + "id": "multiclinsum_test_575_en.txt", + "fulltext": "The patient was a 71-year-old woman. She did not keep any birds or animals, and had been treated for diabetes for over 30 years. She was on diet therapy and insulin therapy, but her diet appeared inadequate and her hemoglobin (Hb)A1c levels were within the range of 7.9%–8.5%. She was therefore admitted to her family hospital for dietary and lifestyle guidance in April 2019. During that hospitalization, she repeatedly developed pneumonia and bronchitis. In addition, findings of moon face, central obesity, and red skin lines led to a suspicion of Cushing's syndrome. During early morning fasting, plasma ACTH increased to 104 pg/mL (normal, 7.2–63.3 pg/mL) and serum cortisol increased to 23.5 μg/dL (normal, 6.2–19.4 μg/dL). In August 2019, at the time of consultation at our hospital (Fukushima Medical University Hospital), the patient showed: weight, 52.1 kg; height, 139.9 cm; body mass index, 26.6 kg/m2; blood pressure, 125/60 mmHg; and heart rate, 81 beats/min with regular rhythm. At this time, 24-h urinary free cortisol (UFC) was slightly increased to 128 μg (normal, 20–100 μg).\nWe performed screening tests for Cushing's syndrome. No diurnal variation was seen in serum cortisol (values on 1 day: 8.15 μg/dL at 08:00; 12.30 μg/dL at 16:00; and 11.85 μg/dL at 23:00), and after a 0.5-mg overnight dexamethasone suppression test, serum ACTH and cortisol were not suppressed (ACTH: 67.80 pg/mL; cortisol: 11.28 μg/dL). Based on these findings, ACTH-dependent Cushing's syndrome was suspected and we performed testing to confirm the diagnosis. After 8-mg overnight dexamethasone suppression testing, serum cortisol was suppressed (ACTH: 31.79 pg/mL; cortisol: 4.12 μg/dL). No response to ACTH was seen in the corticotropin-releasing hormone (CRH) loading test (after CRH loading: basal plasma ACTH, 85.84 pg/mL; peak plasma ACTH, 87.18 pg/mL). Magnetic resonance imaging of the brain showed no abnormal enhancement of the pituitary gland.\nHigh-resolution computed tomography (CT) showed two pulmonary nodules in the left lung apex and lingual regions . The results of blood tests were normal, showing: white blood cell count, 5.2 × 103/μL; C-reactive protein, 0.04 mg/dL; carcinoembryonic antigen, 4.9 ng/mL; squamous cell carcinoma antigen, 0.5 ng/mL; cytokeratin 19 fragment (CYFRA 21-1), 3.09 ng/mL; and neuron-specific enolase (NSE), 208 pg/mL. Only NSE was elevated. Positron emission tomography/CT showed no significant accumulations of 18F-fluorodeoxyglucose in those lung nodules or other sites. SRS was performed using 111In-octreotide, and no positive lesions were found throughout the entire body.\nAlthough serum cortisol was suppressed in the high-dose dexamethasone suppression test, Cushing's syndrome due to an ectopic ACTH-producing tumor was suspected. However, the patient did not agree to selective venous sinus blood sampling from the cavernous sinuses or inferior petrosal sinus due to the invasiveness of the procedures. In addition, the possibility of ectopic ACTH-producing tumor could not be ruled out due to the presence of lung tumors. However, CT findings suggested these tumors would be difficult to sample by bronchoscopic lung biopsy and we therefore performed surgical biopsy in December 2019.\nWith the patient under general anesthesia, two nodules in the left lung underwent wedge resection with free margins under thoracoscopy. Intraoperatively, the easily resectable pulmonary apex lesion underwent wedge resection first, and frozen section diagnosis revealed pyogenic granuloma. We therefore determined that the entire left lung was infected, and surgery was finished after adding only wedge resection of the lingual region.\nIn the definitive diagnosis on histopathological examination of the resected specimens, the lesion in the left lung apex showed caseous necrosis, and no mycobacteria were observed on Ziehl–Neelsen staining. Grocott staining and periodic acid-Schiff staining showed numerous oval-shaped fungi positive for mucicarmine staining, indicating fungal infection by Cryptococcus. Lesions in the lingular segment comprised spindle cells proliferating in ribbons and foci , and immunohistochemistry showed strong positivity for chromogranin A, synaptophysin, CD56, and ACTH . No necrosis was present in the tumor, and the mitosis count was 1/2 mm2. The patient was diagnosed with ACTH-producing pulmonary typical carcinoid (p-T1bN0M stage IA2) with pulmonary cryptococcosis. Although this was before the diagnosis of ACTH-producing tumor, hydrocortisone was started at 50 mg/day immediately after surgery as a precaution. On postoperative day 4, basal plasma ACTH decreased to 6.67 pg/mL and serum cortisol levels decreased to 3.64 μg/dL. Although hydrocortisone might have had some effect, ACTH and cortisol remained at normal levels. Hydrocortisone dosage was gradually decreased to 20 mg/day, and the patient was discharged 15 days postoperatively. Subsequently, 24-h UFC levels were also normal, diabetes control was improved, and clinical symptoms resolved. Finally, at 6 months postoperatively and on hydrocortisone at 15 mg/day, the 0.5-mg dexamethasone suppression test suppressed ACTH and cortisol levels (ACTH: 14.55 pg/mL; cortisol: 0.288 μg/dL), confirming improvement of Cushing's syndrome. Furthermore, basal plasma concentration of ACTH was 20.05 pg/mL and cortisol was 10.32 μg/dL, so secretions were considered to be adequately maintained and hydrocortisone dose was further tapered and terminated 2 years postoperatively. Preoperatively, we did not test for cryptococcal antigen in the serum because we did not strongly suspect infection. Results for cryptococcal antigen in the serum examined 2 days postoperatively were negative. Cerebrospinal fluid was also examined after discharge, but no cryptococcus was found. The patient did not request additional lobectomy. As of July 2022, 18 months postoperatively, the patient was alive with no tumor recurrence and no clinical or laboratory evidence of elevated ACTH or Cushing's syndrome. She remains on insulin therapy for diabetes, but HbA1c is hovering around 7%. She patient is living independently and we will continue careful observation with laboratory data and CT.", + "fulltext_subclaims": [ + "The patient was a 71-year-old woman.", + "She did not keep any birds or animals.", + "She had been treated for diabetes for over 30 years.", + "She was on diet therapy and insulin therapy.", + "Her hemoglobin (Hb)A1c levels were within the range of 7.9%–8.5%.", + "She was admitted to her family hospital for dietary and lifestyle guidance in April 2019.", + "During that hospitalization, she repeatedly developed pneumonia and bronchitis.", + "Findings of moon face, central obesity, and red skin lines led to a suspicion of Cushing's syndrome.", + "During early morning fasting, plasma ACTH increased to 104 pg/mL.", + "Serum cortisol increased to 23.5 μg/dL.", + "In August 2019, at the time of consultation at our hospital, the patient showed a body mass index of 26.6 kg/m2.", + "24-h urinary free cortisol was slightly increased to 128 μg.", + "No diurnal variation was seen in serum cortisol on one day.", + "After a 0.5-mg overnight dexamethasone suppression test, serum ACTH and cortisol were not suppressed.", + "After 8-mg overnight dexamethasone suppression testing, serum cortisol was suppressed.", + "No response to ACTH was seen in the corticotropin-releasing hormone loading test.", + "Magnetic resonance imaging of the brain showed no abnormal enhancement of the pituitary gland.", + "High-resolution computed tomography showed two pulmonary nodules in the left lung apex and lingual regions.", + "Positron emission tomography/CT showed no significant accumulations of 18F-fluorodeoxyglucose in those lung nodules or other sites.", + "SRS using 111In-octreotide showed no positive lesions throughout the entire body.", + "The patient did not agree to selective venous sinus blood sampling from the cavernous sinuses or inferior petrosal sinus.", + "The possibility of ectopic ACTH-producing tumor could not be ruled out due to the presence of lung tumors.", + "CT findings suggested these tumors would be difficult to sample by bronchoscopic lung biopsy.", + "Surgical biopsy was performed in December 2019.", + "Two nodules in the left lung underwent wedge resection with free margins under thoracoscopy.", + "Frozen section diagnosis of the pulmonary apex lesion revealed pyogenic granuloma.", + "The lesion in the left lung apex showed caseous necrosis.", + "No mycobacteria were observed on Ziehl–Neelsen staining.", + "Grocott staining showed numerous oval-shaped fungi positive for mucicarmine staining.", + "Lesions in the lingular segment comprised spindle cells proliferating in ribbons and foci.", + "Immunohistochemistry showed strong positivity for chromogranin A, synaptophysin, CD56, and ACTH.", + "The patient was diagnosed with ACTH-producing pulmonary typical carcinoid (p-T1bN0M stage IA2) with pulmonary cryptococcosis.", + "Hydrocortisone was started at 50 mg/day immediately after surgery.", + "On postoperative day 4, basal plasma ACTH decreased to 6.67 pg/mL.", + "Serum cortisol levels decreased to 3.64 μg/dL.", + "Hydrocortisone dosage was gradually decreased to 20 mg/day.", + "The patient was discharged 15 days postoperatively.", + "24-h UFC levels were also normal.", + "Diabetes control was improved.", + "Clinical symptoms resolved.", + "At 6 months postoperatively and on hydrocortisone at 15 mg/day, the 0.5-mg dexamethasone suppression test suppressed ACTH and cortisol levels.", + "Basal plasma concentration of ACTH was 20.05 pg/mL.", + "Cortisol was 10.32 μg/dL.", + "Hydrocortisone dose was further tapered and terminated 2 years postoperatively.", + "Preoperatively, we did not test for cryptococcal antigen in the serum.", + "Results for cryptococcal antigen in the serum examined 2 days postoperatively were negative.", + "Cerebrospinal fluid was also examined after discharge, but no cryptococcus was found.", + "The patient did not request additional lobectomy.", + "As of July 2022, 18 months postoperatively, the patient was alive with no tumor recurrence.", + "There was no clinical or laboratory evidence of elevated ACTH or Cushing's syndrome.", + "She remains on insulin therapy for diabetes.", + "HbA1c is hovering around 7%.", + "She is living independently.", + "We will continue careful observation with laboratory data and CT." + ], + "summary": "The patient was a 71-year-old woman with refractory diabetes. She showed clinical symptoms of Cushing's syndrome during treatment for diabetes and ectopic ACTH production was suspected based on biochemical and imaging tests. Nodules were identified in the left lung apex and lingual segment. Examination of resected nodules revealed that the nodule in the apex was pulmonary cryptococcosis, while the nodule in the lingual segment represented typical carcinoid. After surgery, clinical symptoms, laboratory findings, and diabetes all improved.", + "summary_subclaims": [ + "The patient was a 71-year-old woman with refractory diabetes.", + "She showed clinical symptoms of Cushing's syndrome during treatment for diabetes.", + "Ectopic ACTH production was suspected based on biochemical and imaging tests.", + "Nodules were identified in the left lung apex and lingual segment.", + "Examination of resected nodules revealed that the nodule in the apex was pulmonary cryptococcosis.", + "The nodule in the lingual segment represented typical carcinoid.", + "After surgery, clinical symptoms improved.", + "After surgery, laboratory findings improved.", + "After surgery, diabetes improved." + ] + }, + { + "id": "multiclinsum_test_710_en.txt", + "fulltext": "Fatigue and weight loss for more than 1 mo.\nA 62-year-old male farmer was hospitalized for fatigue and weight loss for more than 1 mo, without fever or bone pain. The peripheral blood examination in a local hospital indicated severe anemia with a hemoglobin level of 54 g/L and a potentially malignant tumor from the blood system. Therefore, he was admitted to Huaihe Hospital of Henan University.\nNo particular previous medical history.\nThe patient had no history of exposure to industrial poisons or radioactive substances, and was not smoking or drinking alcohol. The family history was unremarkable.\nThe patient presented an anemic face; the percussion of the lungs presented a little dullness, a few moist rales were heard at the left lung base, and mild concave edema was seen in both lower extremities.\nLaboratory evaluation at the Huaihe Hospital of Henan University showed a medium degree of anemia with a hemoglobin level of 61 g/L. Further blood examination indicated renal dysfunction and elevated erythrocyte sedimentation rate and N-terminal pro-brain natriuretic peptide (NT-PROBNP) . The other laboratory findings, including blood coagulation functions, stool for routine, blood lipids, and blood sugar, were normal.\nSerum protein electrophoresis on agarose gel suggested an elevation of α2-globulin and γ-globulin, and two slight M-spikes appeared and a band within the γ fraction (the other band within α2 fraction was obscure) was seen. To categorize the M protein, we conducted serum IFE, which consisted of antisera to IgA, IgM, IgG, κ, and λ, and the results yielded two monoclonal bands in the λ region without corresponding heavy chain bands, corresponding to the distinct elevation of serum λ FLC . Thus, we highly suspected the possibility of type IgD or IgE or FLC M protein component. Subsequently, we implemented a second serum IFE with antisera to IgD, IgE, κ, and λ. The results showed two monoclonal bands in antisera to λ but only one corresponding heavy chain band in antisera to IgD, which indicated a diagnosis of IgD-λ/λ myeloma by correlating the clinical manifestation and laboratory examinations.\nBM cytomorphologic (anterior superior spine) examination found a marked increment of plasma cells, mainly immature plasma cells, which accounted for 82% of the BM nucleated cells . Flow cytometry suggested positivity of monoclonal plasma cells (70.12% of total nucleated red blood cells) with the following immunophenotype: CD38, cytoplasmic lambda, and CD229. All of the monoclonal plasma cells expressed CD229, CD38, and cytoplasmic lambda and partly expressed CD138 . Undoubtedly, BM cytomorphologic examination and flow cytometry supported the diagnosis of plasma cell myeloma. Furthermore, analysis of chromosome karyotype was as follows: 46,XY;46,Y,t(X;4)(p11.2;q21), no abnormal cloning. Gene analysis of the blood tumor mutant group was mainly normal.\nCombined with the clinical, and laboratory data above, the patient was diagnosed with stage ISS III myeloma.", + "fulltext_subclaims": [ + "The patient was a 62-year-old male farmer.", + "He was hospitalized for fatigue and weight loss for more than 1 mo.", + "He had no fever or bone pain.", + "The peripheral blood examination in a local hospital indicated severe anemia with a hemoglobin level of 54 g/L.", + "The peripheral blood examination suggested a potentially malignant tumor from the blood system.", + "He was admitted to Huaihe Hospital of Henan University.", + "The patient had no history of exposure to industrial poisons or radioactive substances.", + "The patient was not smoking or drinking alcohol.", + "The family history was unremarkable.", + "The patient presented an anemic face.", + "The percussion of the lungs presented a little dullness.", + "A few moist rales were heard at the left lung base.", + "Mild concave edema was seen in both lower extremities.", + "Laboratory evaluation at the Huaihe Hospital showed a hemoglobin level of 61 g/L.", + "Further blood examination indicated renal dysfunction.", + "Erythrocyte sedimentation rate was elevated.", + "NT-PROBNP was elevated.", + "Serum protein electrophoresis suggested an elevation of α2-globulin and γ-globulin.", + "Two slight M-spikes appeared.", + "A band within the γ fraction was seen.", + "The other band within α2 fraction was obscure.", + "Serum IFE showed two monoclonal bands in the λ region without corresponding heavy chain bands.", + "The results corresponded to the distinct elevation of serum λ FLC.", + "A second serum IFE showed two monoclonal bands in antisera to λ.", + "A second serum IFE showed one corresponding heavy chain band in antisera to IgD.", + "The diagnosis was IgD-λ/λ myeloma.", + "BM cytomorphologic examination found 82% plasma cells, mainly immature, of the BM nucleated cells.", + "Flow cytometry suggested positivity of monoclonal plasma cells at 70.12% of total nucleated red blood cells.", + "The immunophenotype was CD38, cytoplasmic lambda, and CD229.", + "All monoclonal plasma cells expressed CD229, CD38, and cytoplasmic lambda.", + "BM cytomorphologic examination and flow cytometry supported the diagnosis of plasma cell myeloma.", + "Chromosome karyotype analysis showed 46,XY;46,Y,t(X;4)(p11.2;q21).", + "Gene analysis of the blood tumor mutant group was mainly normal.", + "The patient was diagnosed with stage ISS III myeloma." + ], + "summary": "A 62-year-old man diagnosed as IgD-λ/λ myeloma (ISS stage III) was admitted with fatigue and weight loss. The physical examination suggested an anemic face, a few moist rales at the left lung base, and mild concave edema in both lower extremities. Laboratory examinations showed the elevated creatinine levels, β2-microglobulin, lactic dehydrogenase, and erythrocyte sedimentation rate, while the decreased neutrophils, granulocytes, and hemoglobin. In the serum protein electrophoresis, there appeared two inconspicuous M-spikes. Serum IFE indicated an over-representation of lambda light chain and yielded two monoclonal bands in λ region, but only one corresponding heavy chain band in the antisera to IgD region. The BM histology and BM cytology both supported the diagnosis of IgD-λ/λ myeloma.", + "summary_subclaims": [ + "The patient is a 62-year-old man.", + "The patient was diagnosed as IgD-λ/λ myeloma.", + "The patient was admitted with fatigue.", + "The patient was admitted with weight loss.", + "The physical examination suggested an anemic face.", + "The physical examination found a few moist rales at the left lung base.", + "The physical examination found mild concave edema in both lower extremities.", + "Laboratory examinations showed elevated creatinine levels.", + "Laboratory examinations showed elevated β2-microglobulin.", + "Laboratory examinations showed elevated lactic dehydrogenase.", + "Laboratory examinations showed elevated erythrocyte sedimentation rate.", + "Laboratory examinations showed decreased neutrophils.", + "Laboratory examinations showed decreased granulocytes.", + "Laboratory examinations showed decreased hemoglobin.", + "Serum protein electrophoresis showed two inconspicuous M-spikes.", + "Serum IFE indicated an over-representation of lambda light chain.", + "Serum IFE yielded two monoclonal bands in λ region.", + "Serum IFE yielded one corresponding heavy chain band in the antisera to IgD region.", + "BM histology supported the diagnosis of IgD-λ/λ myeloma.", + "BM cytology supported the diagnosis of IgD-λ/λ myeloma." + ] + }, + { + "id": "multiclinsum_test_152_en.txt", + "fulltext": "An eight-year-old girl was admitted to the emergency department with an acute primary episode of bilateral lower limb paralysis that had begun approximately 9 h prior. There was no history of trauma, loss of consciousness, rapid breathing, fever, seizure, spasm, gastrointestinal tract losses, polyuria, paresthesia, or pain. She had a normal developmental history, normal auditory function, and experienced no leg weakness or sensory loss previously. No family members reported similar medical history or kidney diseases, and her parents were not close relatives. Her physical examination revealed that she was fully alert with normal vital signs. She was well nourished with short stature (height < 3rd percentile) consistent with her genetic potential. She had normal physiological reflexes. Muscle strength was 4/5 for the upper limbs and 3/5 for the lower limbs. No pathological reflexes, clonus, spasticity, or rigidity was found.\nThe patient had a history of anal atresia with a rectovaginal fistula that was fully corrected when she was 1 year old. She had recurrent urinary tract infections (UTIs) caused by high-grade vesicoureteral reflux (VUR) and severe bilateral hydronephrosis. She was treated with prophylactic antibiotics. When she was 6 years old, a bulking agent was used to treat bilateral VUR. She also received tamsulosin (α-1 blocker) at the age of 6 years which was then discontinued after 3 months due to no improvements. Urodynamics were performed and suggested bladder outlet obstruction with a residual urine volume of 150 mL. Magnetic resonance imaging (MRI) of the spinal cord revealed syringomyelia extending from thoracic spine Th2 to Th7 . Clean intermittent catheterization (CIC) was initiated and maintained until admission. No breakthrough UTIs were noted. After a 2-year follow-up, the hydronephrosis persisted.\nInitial laboratory investigations revealed a normal complete blood count and electrolyte imbalances, notably hypokalemia (K 2.4 mEq/L). Urinalysis revealed a UTI . The electrocardiogram (ECG) indicated a normal heart rate and T wave inversions. The patient had decreased kidney function corresponding to an estimated glomerular filtration rate (eGFR) of 25 mL/min per 1.73 m2 . She was treated with intravenous (IV) potassium chloride, sodium chloride, and cefotaxime and investigated for possible etiologies of hypokalemic paralysis. On the third day of hospitalization, her venous blood gasses and electrolytes indicated hyperchloremic metabolic acidosis with hypokalemia and a normal anion gap. The urine pH was 6.5 with a positive urine anion gap. Her urinary pH before this admission has ranged from 7.0 to 7.5. The urinary calcium creatinine ratio was 0.19 mg/g. Thyroid function was within the normal range. Urine osmolal gap (UOG) when she was free from UTI was 1.9 mOsmol/kg . Kidney ultrasonography (US) did not document any nephrocalcinosis.\ndRTA was therefore diagnosed. The paralysis resolved completely, the urinalysis normalized, and the patient was discharged with oral bicarbonate 500 mg every 8 h and potassium slow release (KSR) 1200 mg every 12 h.", + "fulltext_subclaims": [ + "An eight-year-old girl was admitted to the emergency department with an acute primary episode of bilateral lower limb paralysis that had begun approximately 9 h prior.", + "There was no history of trauma, loss of consciousness, rapid breathing, fever, seizure, spasm, gastrointestinal tract losses, polyuria, paresthesia, or pain.", + "She had a normal developmental history.", + "She had no leg weakness or sensory loss previously.", + "No family members reported similar medical history or kidney diseases.", + "Her physical examination revealed that she was fully alert with normal vital signs.", + "She was well nourished with short stature (height < 3rd percentile) consistent with her genetic potential.", + "Muscle strength was 4/5 for the upper limbs and 3/5 for the lower limbs.", + "The patient had a history of anal atresia with a rectovaginal fistula that was fully corrected when she was 1 year old.", + "She had recurrent urinary tract infections (UTIs) caused by high-grade vesicoureteral reflux (VUR) and severe bilateral hydronephrosis.", + "She was treated with prophylactic antibiotics.", + "When she was 6 years old, a bulking agent was used to treat bilateral VUR.", + "She also received tamsulosin (α-1 blocker) at the age of 6 years which was then discontinued after 3 months due to no improvements.", + "Urodynamics were performed and suggested bladder outlet obstruction with a residual urine volume of 150 mL.", + "Magnetic resonance imaging (MRI) of the spinal cord revealed syringomyelia extending from thoracic spine Th2 to Th7.", + "Clean intermittent catheterization (CIC) was initiated and maintained until admission.", + "No breakthrough UTIs were noted.", + "After a 2-year follow-up, the hydronephrosis persisted.", + "Initial laboratory investigations revealed a normal complete blood count.", + "Initial laboratory investigations revealed electrolyte imbalances, notably hypokalemia (K 2.4 mEq/L).", + "Urinalysis revealed a UTI.", + "The electrocardiogram (ECG) indicated a normal heart rate and T wave inversions.", + "The patient had decreased kidney function corresponding to an estimated glomerular filtration rate (eGFR) of 25 mL/min per 1.73 m2.", + "She was treated with intravenous (IV) potassium chloride, sodium chloride, and cefotaxime.", + "On the third day of hospitalization, her venous blood gasses and electrolytes indicated hyperchloremic metabolic acidosis with hypokalemia and a normal anion gap.", + "The urine pH was 6.5 with a positive urine anion gap.", + "Her urinary pH before this admission has ranged from 7.0 to 7.5.", + "The urinary calcium creatinine ratio was 0.19 mg/g.", + "Thyroid function was within the normal range.", + "Urine osmolal gap (UOG) when she was free from UTI was 1.9 mOsmol/kg.", + "Kidney ultrasonography (US) did not document any nephrocalcinosis.", + "dRTA was therefore diagnosed.", + "The paralysis resolved completely.", + "The urinalysis normalized.", + "The patient was discharged with oral bicarbonate 500 mg every 8 h and potassium slow release (KSR) 1200 mg every 12 h." + ], + "summary": "An eight-year-old girl presented with an acute first episode of paralysis. A physical examination revealed normal vital signs, short stature consistent with her genetic potential, and decreased muscle strength of her upper and lower extremities. Preexisting conditions included stage 4 CKD due to recurrent UTIs, severe vesicoureteral reflux and bilateral hydronephrosis, neurogenic bladder, and multisegment thoracic syringomyelia. Her laboratory work-up revealed hypokalemic, hyperchloremic metabolic acidosis with a normal anion gap. She also had a urine osmolal gap of 1.9 mOsmol/kg with a high urine pH. Intravenous potassium replacement resulted in a complete resolution of her paralysis. She was diagnosed with dRTA and discharged with oral bicarbonate and slow-release potassium supplementation.", + "summary_subclaims": [ + "An eight-year-old girl presented with an acute first episode of paralysis.", + "A physical examination revealed normal vital signs.", + "A physical examination revealed short stature consistent with her genetic potential.", + "A physical examination revealed decreased muscle strength of her upper and lower extremities.", + "Preexisting conditions included stage 4 CKD due to recurrent UTIs.", + "Preexisting conditions included severe vesicoureteral reflux.", + "Preexisting conditions included bilateral hydronephrosis.", + "Preexisting conditions included neurogenic bladder.", + "Preexisting conditions included multisegment thoracic syringomyelia.", + "Her laboratory work-up revealed hypokalemic, hyperchloremic metabolic acidosis with a normal anion gap.", + "She had a urine osmolal gap of 1.9 mOsmol/kg.", + "She had a high urine pH.", + "Intravenous potassium replacement resulted in a complete resolution of her paralysis.", + "She was diagnosed with dRTA.", + "She was discharged with oral bicarbonate.", + "She was discharged with slow-release potassium supplementation." + ] + }, + { + "id": "multiclinsum_test_2887_en.txt", + "fulltext": "In March 2018, an 85-year-old man with no medical history was admitted after a 6-month history of worsening pain and swelling in the right wrist. Magnetic resonance imaging showed a large region of tenosynovitis from the distal forearm to the palm, and a biopsy of the synovial membrane was performed. Histological testing showed granulomatous inflammation. After nine weeks of culture on Ogawa medium (Kyokuto Pharmaceutical Industrial CO., Japan), smooth non-pigmented colonies were observed. The colony was positive for Ziehl Neelsen stain, suggesting acid fast bacilli. Initial testing with AccuProbe (Hologic, Marlborough, MA) was positive for MAC, with a value of 197,546 relative light units (RLU). COBAS TaqMan MTB/MAI (Roche Diagnostics, Switzerland), another real-time PCR test, was positive for M. intracellulare as well. However, further identification of the isolate using matrix-assisted laser desorption ionization–time of flight mass spectrometry (MALDI-TOF MS; MALDI Biotyper Version 2.0, Bruker Daltonics, US) suggested that the isolate was M. marseillense, with a score of 2.023 indicating a probable species identification. Because of this discordance, the rpoB and hsp65 regions were sequenced [, ]. In the Basic Logical Alignment Search Tool (BLAST) analysis, both sequences showed a 99.7% (E value, 0.0) and 100.0% (E value, 0.0) alignment respectively with those of Mycobacterium marseillense (GenBank accession number CP023147.1).\nDrug susceptibility testing was performed by a broth microdilution test, BrothMIC NTM (Kyokuto Pharmaceutical Industrial Co., Japan). Based on the breakpoints proposed by the Clinical and Laboratory Standards Institute , the isolate was sensitive to clarithromycin and amikacin. Subsequently, clarithromycin, ethambutol and rifampicin were initiated, and symptoms subsided gradually over the following month. Rifampicin was discontinued due to neutropenia after 2 months. Unfortunately, the patient died from an unrelated cause six months after the initiation of treatment.", + "fulltext_subclaims": [ + "An 85-year-old man with no medical history was admitted in March 2018.", + "He had a 6-month history of worsening pain and swelling in the right wrist.", + "Magnetic resonance imaging showed a large region of tenosynovitis from the distal forearm to the palm.", + "A biopsy of the synovial membrane was performed.", + "Histological testing showed granulomatous inflammation.", + "After nine weeks of culture on Ogawa medium, smooth non-pigmented colonies were observed.", + "The colony was positive for Ziehl Neelsen stain, suggesting acid fast bacilli.", + "Initial testing with AccuProbe was positive for MAC, with a value of 197,546 relative light units.", + "COBAS TaqMan MTB/MAI was positive for M. intracellulare.", + "Further identification using MALDI-TOF MS suggested the isolate was M. marseillense, with a score of 2.023.", + "The rpoB and hsp65 regions were sequenced.", + "BLAST analysis showed 99.7% alignment with Mycobacterium marseillense for the rpoB region.", + "BLAST analysis showed 100.0% alignment with Mycobacterium marseillense for the hsp65 region.", + "Drug susceptibility testing was performed by a broth microdilution test.", + "The isolate was sensitive to clarithromycin and amikacin.", + "Clarithromycin, ethambutol, and rifampicin were initiated.", + "Symptoms subsided gradually over the following month.", + "Rifampicin was discontinued due to neutropenia after 2 months.", + "The patient died from an unrelated cause six months after the initiation of treatment." + ], + "summary": "We report a case of tenosynovitis caused by M. marseillense in an immunocompetent adult in Japan. The isolate was initially identified as M. intracellulare using commercial real time polymerase chain reaction assays and later identified as M. marseillense with sequencing of the the rpoB and hsp65 regions, and matrix-assisted laser desorption ionization-time of flight mass spectrometry (MALDI-TOF MS).", + "summary_subclaims": [ + "We report a case of tenosynovitis caused by M. marseillense in an immunocompetent adult in Japan.", + "The isolate was initially identified as M. intracellulare using commercial real time polymerase chain reaction assays.", + "The isolate was later identified as M. marseillense with sequencing of the rpoB and hsp65 regions.", + "The isolate was later identified as M. marseillense with matrix-assisted laser desorption ionization-time of flight mass spectrometry." + ] + }, + { + "id": "multiclinsum_test_2047_en.txt", + "fulltext": "A 53-year-old man reported to the emergency room with a 2-day history of sudden-onset left chest pain radiating to his left back. The pain was intermittent over the 48 h and felt similar to the pain he experienced in a prior episode of pleurisy. It did not localize to any specific region of the chest and did not involve the left arm. It was partially relieved with NSAID use and resting on his left side. The patient had a 30 pack year smoking history as well as a history of illicit drug use. He had history of hypertension that was controlled with lifestyle changes and did not show any signs of end organ damage. The previous clinic visits showed his blood pressure to be under control and on admission it was 100/78. A review of systems and physical examination did not show any signs of paresthesias, numbness, weakness, or ataxia. Cardiovascular, respiratory, and neurologic physical exams were normal. The patient was given nitroglycerin and fentanyl, which eased the pain. Because of both his history of smoking and hypertension as well as his clinical presentation, a chest X-ray, EKG, and blood work-up including troponin I and D-dimer were performed which returned normal results.\nDue to high suspicion for coronary ischemia and other cardiac etiologies related to his history of smoking, hypertension, and illicit drug use, the patient was admitted to further investigate his chest pain. At this point, his pain was completely resolved with fentanyl. As part of expanding the differential diagnosis for chest pain, to rule out pulmonary embolism and aortic dissection, a CT angiogram of the chest was performed and revealed a 4.4 × 2 × 2.1 cm soft-tissue mass compressing the spinal cord at the level of T8-T9. To further characterize the spinal lesion, MRI imaging was obtained and confirmed the presence of a heterogeneous mass at the left T8 that was hyperintense on T2-weighted and hypointense on T1-weighted images . Axial scans showed an intradural extramedullary dumbbell-shaped tumor, characteristic of a spinal schwannoma, at the level of spinal nerve T8.\nGiven the significant mass effect of the mid-thoracic spinal cord and pain symptoms, the patient underwent an open laminectomy and partial facetectomy of T8 and T9. A dark, dumbbell-shaped mass could be seen extending from the left spinal column grossly . There also appeared to be a hemorrhage within the dural sac near the T8 nerve root. GTR of the lesion was accomplished with sparing of the nerve root. Post-operative histological examination showed fascicles and nests of plump spindle cells, consistent with schwannoma . Variable amounts of melanin were also seen within tumor cells , leading to further immunohistochemical staining. Tumor sections showed positive expression of S100, SOX10, HMB-45, and MART-1 , compatible with a diagnosis of MS.\nA complete history and review of systems did not reveal any family history or clinical signs of Carney complex in this patient. He was discharged 1 day after surgery. We followed up with the patient 2 months after surgery. He was doing well other than some persisting incisional pain. Imaging did not show any local recurrence of the tumor . He was counseled on his options regarding radiation and referred to another institution for a second opinion due to the rarity of this diagnosis. He has subsequently been lost to follow-up 6 months after surgery.", + "fulltext_subclaims": [ + "The patient is a 53-year-old man.", + "He reported to the emergency room with a 2-day history of sudden-onset left chest pain.", + "The pain radiated to his left back.", + "The pain was intermittent over the 48 hours.", + "The pain was similar to the pain he experienced in a prior episode of pleurisy.", + "The pain did not localize to any specific region of the chest.", + "The pain did not involve the left arm.", + "The pain was partially relieved with NSAID use.", + "The pain was partially relieved with resting on his left side.", + "He had a 30 pack year smoking history.", + "He had a history of illicit drug use.", + "He had a history of hypertension controlled with lifestyle changes.", + "He did not show any signs of end organ damage.", + "The patient's blood pressure on admission was 100/78.", + "A review of systems and physical examination did not show any signs of paresthesias, numbness, weakness, or ataxia.", + "Cardiovascular, respiratory, and neurologic physical exams were normal.", + "The patient was given nitroglycerin and fentanyl, which eased the pain.", + "A chest X-ray, EKG, and blood work-up including troponin I and D-dimer were performed.", + "The chest X-ray, EKG, and blood work-up returned normal results.", + "The patient was admitted due to high suspicion for coronary ischemia.", + "The patient's pain was completely resolved with fentanyl.", + "A CT angiogram of the chest was performed.", + "The CT angiogram revealed a 4.4 × 2 × 2.1 cm soft-tissue mass compressing the spinal cord at the level of T8-T9.", + "MRI imaging confirmed the presence of a heterogeneous mass at the left T8.", + "The mass was hyperintense on T2-weighted and hypointense on T1-weighted images.", + "Axial scans showed an intradural extramedullary dumbbell-shaped tumor at the level of spinal nerve T8.", + "The tumor was characteristic of a spinal schwannoma.", + "The patient underwent an open laminectomy and partial facetectomy of T8 and T9.", + "A dark, dumbbell-shaped mass could be seen extending from the left spinal column grossly.", + "There appeared to be a hemorrhage within the dural sac near the T8 nerve root.", + "GTR of the lesion was accomplished with sparing of the nerve root.", + "Post-operative histological examination showed fascicles and nests of plump spindle cells, consistent with schwannoma.", + "Variable amounts of melanin were also seen within tumor cells.", + "Tumor sections showed positive expression of S100, SOX10, HMB-45, and MART-1.", + "The diagnosis was compatible with a melanotic schwannoma.", + "A complete history and review of systems did not reveal any family history or clinical signs of Carney complex.", + "The patient was discharged 1 day after surgery.", + "The patient was followed up 2 months after surgery.", + "He was doing well other than some persisting incisional pain.", + "Imaging did not show any local recurrence of the tumor.", + "He was referred to another institution for a second opinion due to the rarity of this diagnosis.", + "He has been lost to follow-up 6 months after surgery." + ], + "summary": "We describe a case of hemorrhagic MS presenting as acute chest pain mimicking myocardial infarction, a presentation which has not yet been described in the literature. Neurologic examination did not reveal any abnormalities. Myocardial infarction was ruled out in the ER, and a chest CT angiogram was ordered for evaluation of PE or aortic dissection which revealed an intradural extramedullary dumbbell-shaped mass extending through the left vertebral foramen at the level of T8. MRI revealed a heterogenous mass that was hyperintense with T2 and hypointense with T1-weighted imaging. The patient underwent an open laminectomy of the left T8 and T9 vertebrae and gross total resection (GTR) of a hemorrhagic black tumor. Microscopic examination showed fascicles and nests of plump spindle cells with variable intracellular melanin. Immunohistochemistry showed the cells to be positive for S100, SOX10, HMB-45, and MART-1, confirming diagnosis of MS. Two months after the operation, the patient was doing well and is free of recurrence.", + "summary_subclaims": [ + "We describe a case of hemorrhagic MS presenting as acute chest pain mimicking myocardial infarction.", + "This presentation has not yet been described in the literature.", + "Neurologic examination did not reveal any abnormalities.", + "Myocardial infarction was ruled out in the ER.", + "A chest CT angiogram was ordered for evaluation of PE or aortic dissection.", + "The CT revealed an intradural extramedullary dumbbell-shaped mass extending through the left vertebral foramen at the level of T8.", + "MRI revealed a heterogenous mass that was hyperintense with T2 and hypointense with T1-weighted imaging.", + "The patient underwent an open laminectomy of the left T8 and T9 vertebrae.", + "The patient underwent gross total resection (GTR) of a hemorrhagic black tumor.", + "Microscopic examination showed fascicles and nests of plump spindle cells with variable intracellular melanin.", + "Immunohistochemistry showed the cells to be positive for S100, SOX10, HMB-45, and MART-1.", + "The diagnosis of MS was confirmed.", + "Two months after the operation, the patient was doing well.", + "The patient is free of recurrence." + ] + }, + { + "id": "multiclinsum_test_331_en.txt", + "fulltext": "The proband was a 12-years-old girl presenting with chronic compensated hemolysis, Gilbert syndrome, and recurrent abdominal pain. The blood count showed: hemoglobin 13 g/dL, red blood cell counts 4.020.000/mm3, Mean Corpuscular Volume (MCV) 90.3 fL, Mean Content Hemoglobin (MCH) 32.1 pg, mean corpuscular hemoglobin concentration (MCHC) 38.3 g/dL, reticulocytosis, and indirect hyperbilirubinemia. The complete blood work-up is shown in Table . The ultrasound of the abdomen did not show gallstones, hepatomegaly and splenomegaly.\nThe patient was a single-born from non-consanguineous Italian parents . The remote case history reported neonatal jaundice treated with phototherapy. The family anamnesis revealed that the father presented jaundice during his childhood, recurrent episodes of abdominal pain resolved after splenectomy (performed at the age of 23 years-old) and gallstones for which he had undergone a cholecystectomy. The paternal uncle also had gallbladder stones. To investigate the cause of hemolysis in our patient, laboratory investigations were carried out. The peripheral blood smear showed anisocytosis with the presence of red blood cells with specific shape: stomatocytes (5%), ovalocytes (4%), schistocytes (3%) and rare spherocytes . The direct antiglobulin test (DAT) was negative, thus excluding an autoimmune origin of the hemolysis. Structural hemoglobin alterations have also been excluded performing electrophoresis and molecular assessment of the genes encoding beta and alpha-globin chains. The activity of red blood cell metabolism enzymes (Hexokinase, Glucose-6-phosphate isomerase, 6-Phosphofruttochinase, Glyceraldehyde phosphate dehydrogenase, Phosphoglycerate kinase, Pyruvate kinase, Glucose 6 phosphate dehydrogenase, Adenylate 6-Phosphogluconate dehydrogenase kinase) was normal.\nThe family history showed an autosomal dominant inheritance of the condition. To investigate the possible presence of a spherocytosis condition, the most frequent erythrocyte structural defect, a combination of tests was performed. First, the eosin-5′-maleimide binding test (EMA test), a cytometric analysis in which a fluoresceinated (eosin-5′-maleimide) substance binds to the plasma membrane proteins of red blood cells, mainly to the band 3 protein [, ]. The average fluorescence of RBCs with EMA staining in patients with spherocytosis is lower than that of control RBCs due to the decrease in the number of target proteins. In our case, this examination was in the normal range with a value of 12% (normal test value> 11%). The other complementary investigations carried out were the osmotic resistance tests such as the glycerol lysis test (AGLT50) and the Pink test. These tests were normal in our patient. Furthermore, quantitative analysis of membrane proteins was carried out using Sodium Dodecyl Sulphate-PolyAcrylamide Gel Electrophoresis (SDS-PAGE), and resulted not altered. We also performed the ektacytometry that evaluates the erythrocyte deformability by subjecting them to an increasing osmotic gradient with constant shear stress . Ektacytometry showed a left shift of the osmolarity curve suggestive of DHS. In agreement with the clinical suspicion, genetic testing was carried out both in the patient and in the parents by a targeted-NGS custom panel composed of 86 causative genes of hereditary anemias. This panel is an updated version of a similar previously published one . We found in both subjects the missense variant c.1815G > A, p.Met605Ile in PIEZO1 gene (NM_001142864, CCDS54058) in heterozygous state. According to the guidelines of American College of Medical Genetics and Genomics (ACMG), we evaluated the pathogenicity of this variant by gathering evidence from various sources: population data, computational and predictive data, functional data, and segregation data . First, the variant segregated in the affected father . Currently, this variant is annotated neither in population databases nor in databases of known variant. Moreover, it is predicted by several tools as probably damaging (MutationTaster score 0.999 Disease causing; FATHMM Score − 1.59; LRT prediction Deleterious; PolyPhen2 score HumVar 0.968 Probably damaging; PROVEAN Score-2.95 Damaging).", + "fulltext_subclaims": [ + "The proband was a 12-years-old girl.", + "The proband had chronic compensated hemolysis.", + "The proband had Gilbert syndrome.", + "The proband had recurrent abdominal pain.", + "The blood count showed hemoglobin 13 g/dL.", + "The blood count showed red blood cell counts 4.020.000/mm3.", + "The blood count showed Mean Corpuscular Volume (MCV) 90.3 fL.", + "The blood count showed Mean Content Hemoglobin (MCH) 32.1 pg.", + "The blood count showed mean corpuscular hemoglobin concentration (MCHC) 38.3 g/dL.", + "The blood count showed reticulocytosis.", + "The blood count showed indirect hyperbilirubinemia.", + "The ultrasound of the abdomen did not show gallstones.", + "The ultrasound of the abdomen did not show hepatomegaly.", + "The ultrasound of the abdomen did not show splenomegaly.", + "The patient was a single-born from non-consanguineous Italian parents.", + "The remote case history reported neonatal jaundice treated with phototherapy.", + "The family anamnesis revealed that the father presented jaundice during his childhood.", + "The father had recurrent episodes of abdominal pain resolved after splenectomy.", + "The father had gallstones for which he had undergone a cholecystectomy.", + "The paternal uncle also had gallbladder stones.", + "The peripheral blood smear showed anisocytosis.", + "The peripheral blood smear showed stomatocytes (5%).", + "The peripheral blood smear showed ovalocytes (4%).", + "The peripheral blood smear showed schistocytes (3%).", + "The peripheral blood smear showed rare spherocytes.", + "The direct antiglobulin test (DAT) was negative.", + "Structural hemoglobin alterations were excluded.", + "The activity of red blood cell metabolism enzymes was normal.", + "The family history showed an autosomal dominant inheritance of the condition.", + "The eosin-5′-maleimide binding test (EMA test) was in the normal range with a value of 12%.", + "The glycerol lysis test (AGLT50) was normal.", + "The Pink test was normal.", + "Quantitative analysis of membrane proteins using SDS-PAGE was not altered.", + "Ektacytometry showed a left shift of the osmolarity curve suggestive of DHS.", + "Genetic testing was carried out both in the patient and in the parents.", + "The missense variant c.1815G > A, p.Met605Ile in PIEZO1 gene was found in heterozygous state in both subjects.", + "The variant segregated in the affected father.", + "The variant is annotated neither in population databases nor in databases of known variants.", + "The variant is predicted by several tools as probably damaging." + ], + "summary": "We describe the case of a 12-years-old girl with well-compensated chronic hemolysis, increased MCHC and a father who had the same hematological characteristics. After excluding secondary causes of chronic hemolysis and enzymatic defects of the RBCs, microscopic observation of the peripheral blood smear, tests of RBC lysis, ektacytometry, SDS-PAGE and in last instance genetic analysis has been performed. This complex diagnostic workup identified a new variant in the PIEZO1 gene, never described in literature, causative of DHS. This pathogenetic variant was also detected in the father.", + "summary_subclaims": [ + "The patient is a 12-years-old girl.", + "The patient has well-compensated chronic hemolysis.", + "The patient has increased MCHC.", + "The patient's father had the same hematological characteristics.", + "Secondary causes of chronic hemolysis were excluded.", + "Enzymatic defects of the RBCs were excluded.", + "Microscopic observation of the peripheral blood smear was performed.", + "Tests of RBC lysis were performed.", + "Ektacytometry was performed.", + "SDS-PAGE was performed.", + "Genetic analysis was performed.", + "A new variant in the PIEZO1 gene was identified.", + "The variant in the PIEZO1 gene was never described in literature.", + "The variant in the PIEZO1 gene is causative of DHS.", + "The pathogenetic variant was also detected in the father." + ] + }, + { + "id": "multiclinsum_test_108_en.txt", + "fulltext": "An asymptomatic 41-year-old man underwent evaluation for employment health assessment and was accidentally discovered to have significant aortic dilatation. He reported a history of total repair of TOF with transannular patching at 2 years of age. Postoperatively, he underwent ambulatory follow-up for 21 years without any difficulty until he discontinued follow-up on his own because he was asymptomatic. Last transthoracic echocardiography (TTE) reports in his pediatric medical records at that time showed only trivial aortic regurgitation (AR) without any aortic root abnormality. On physical examination, he was 173 cm tall, weighed 65.6 kg, and his blood pressure was elevated to 165/60 mmHg; however, he had not received any medication. Contrast-enhanced computed tomography (CT) revealed significant aneurysmal aortic dilatation (maximum diameter of 88 mm at the sinus of Valsalva) . TTE revealed severe AR, without significant pulmonary regurgitation or residual VSD, and transesophageal echocardiography showed a slight shortening of the noncoronary cusp and poor coaptation of leaflets of the aortic valve at the central portion where a massive AR, which had 0.9 cm2 of regurgitant orifice area, could be seen. Cardiac magnetic resonance imaging revealed that significant pulmonary regurgitation flow and residual VSD could not be detected and that right ventricular (RV) ejection fraction was 37%, end-diastolic RV volume index was 201 ml/m2. He was referred to our department for surgical treatment of aortic root dilatation and AR.\nThe procedure was performed through a midline sternotomy, after taping the left femoral artery and vein. Cardiopulmonary bypass was established after femoral arterial and bicaval cannulation. Left ventricular venting was initiated using a venting tube inserted through the right upper pulmonary vein. Exacerbation of AR and onset of ventricular fibrillation were observed after initiation of cooling, necessitating aortic clamping, and antegrade cardioplegic arrest. Inspection through the aortotomy revealed a dilatated aortic annulus (diameter 35 mm) and floppy aortic annulus and leaflets. All leaflets were thin and flail, and had irregular thickening which implied myxomatous degeneration. There was a stiff portion in the left ventricular outflow tract under the noncoronary and right coronary sinus, as a result of the VSD patch. Because we considered that valve-sparing aortic root replacement (VSARR) could be difficult, we performed the Bentall procedure using a 27-mm SJM Masters series Aortic Valved Graft (St. Jude Medical, Cardiology Division Inc., Minnesota), using felt strips in order to reinforce the aortic annulus. After cooling below 20 °C, we performed distal aortic anastomosis using a 28-mm J-Graft Shield Noe (27 mm ) (Japan Lifeline Co. Ltd., Japan) under deep hypothermic circulatory arrest with antegrade cerebral perfusion. After graft-to-graft anastomosis was performed, the patient was easily weaned from the bypass and showed an uneventful course except for the onset of ventricular fibrillation, which was controlled after short-termed assisted circulatory support.\nHistopathological examination of the ascending aorta specimens revealed cystic medial degeneration with some areas of mucopolysaccharides accumulation, collagen deposition, fragmentation, and loss of elastic lamellae across large areas of the media . The aortic valve showed mucoid degeneration with fragmentation of elastic fibers . The patient’s postoperative course was uneventful, and he was discharged on the 26th postoperative day.", + "fulltext_subclaims": [ + "The patient is a 41-year-old man.", + "He was asymptomatic.", + "He underwent evaluation for employment health assessment.", + "He was accidentally discovered to have significant aortic dilatation.", + "He reported a history of total repair of TOF with transannular patching at 2 years of age.", + "He discontinued follow-up on his own because he was asymptomatic.", + "Last transthoracic echocardiography reports showed only trivial aortic regurgitation.", + "Contrast-enhanced computed tomography revealed significant aneurysmal aortic dilatation.", + "The maximum diameter of the aortic dilatation was 88 mm at the sinus of Valsalva.", + "TTE revealed severe aortic regurgitation.", + "Transesophageal echocardiography showed a slight shortening of the noncoronary cusp.", + "The regurgitant orifice area was 0.9 cm2.", + "Cardiac magnetic resonance imaging revealed that significant pulmonary regurgitation flow could not be detected.", + "The right ventricular ejection fraction was 37%.", + "The end-diastolic RV volume index was 201 ml/m2.", + "The procedure was performed through a midline sternotomy.", + "Cardiopulmonary bypass was established after femoral arterial and bicaval cannulation.", + "Exacerbation of AR and onset of ventricular fibrillation were observed after initiation of cooling.", + "Aortic clamping and antegrade cardioplegic arrest were performed.", + "The aortic annulus diameter was 35 mm.", + "All leaflets were thin and flail.", + "There was a stiff portion in the left ventricular outflow tract under the noncoronary and right coronary sinus.", + "The Bentall procedure was performed using a 27-mm SJM Masters series Aortic Valved Graft.", + "Distal aortic anastomosis was performed under deep hypothermic circulatory arrest.", + "The patient was easily weaned from the bypass.", + "Histopathological examination revealed cystic medial degeneration.", + "The aortic valve showed mucoid degeneration.", + "The patient was discharged on the 26th postoperative day." + ], + "summary": "We describe an asymptomatic 41-year-old man with hypertension in whom aortic dilatation was accidentally discovered 39 years after TOF repair. He underwent ambulatory follow-up without any difficulty for 21 years after the repair. Contrast-enhanced computed tomography revealed significant aortic dilatation (maximum diameter of 88 mm at the sinus of Valsalva), and echocardiography revealed severe aortic regurgitation, which seemed to progress during the last 18 years without any evaluation or follow-up. The Bentall procedure was successfully performed using a valved graft, under deep hypothermic circulatory arrest with antegrade cerebral perfusion, and his postoperative course was uneventful. Histopathological examination of ascending aorta specimens revealed severe cystic medial degeneration.", + "summary_subclaims": [ + "The patient is a 41-year-old man.", + "He has hypertension.", + "Aortic dilatation was accidentally discovered 39 years after TOF repair.", + "He underwent ambulatory follow-up without any difficulty for 21 years after the repair.", + "Contrast-enhanced computed tomography revealed significant aortic dilatation.", + "The maximum diameter of the aortic dilatation was 88 mm at the sinus of Valsalva.", + "Echocardiography revealed severe aortic regurgitation.", + "The severe aortic regurgitation seemed to progress during the last 18 years.", + "The Bentall procedure was successfully performed using a valved graft.", + "The procedure was performed under deep hypothermic circulatory arrest with antegrade cerebral perfusion.", + "His postoperative course was uneventful.", + "Histopathological examination of ascending aorta specimens revealed severe cystic medial degeneration." + ] + }, + { + "id": "multiclinsum_test_650_en.txt", + "fulltext": "A 56-year-old woman reported to our orthopedic hospital with a complaint of severe pain in the left hip and inability to stand or walk. The family reported that the patient had a fall on the same day. Routine investigation revealed a fracture in the neck region of the left femur. There was no history of any comorbid condition. The patient was taken up for a surgical intervention following standard of care compression fixation. The patient’s condition on day 3 post-surgery was satisfactory and the patient was discharged, with recommendation for regular follow-up.\nAfter about 8-month post-discharge, the patient visited our unit complaining of recurring severe pain in the left hip. Radiological investigation revealed a non-union of the previous fracture.\nTreatment using a novel bone cell therapy product (OSSGROW®) that is available in the India was considered given the age and lifestyle of the patient. The patient and her family were counseled about the cell therapy option and an appropriate consent was taken.\nOsteoblast cell therapy is a two-step process. The first step involves bone marrow harvest and the second step involves implantation of the ex vivo cultured autologous osteoblast cells from the bone marrow. First, an adequate quantity (4–5 ml) of bone marrow from the patient’s iliac crest was aspirated and collected in transport media containing an anticoagulant. The collection kit was transported under temperature-monitored conditions and the collected bone marrow was processed at the GMP-certified cell processing facility (Regrow Biosciences Pvt. Ltd.). Mesenchymal progenitor cells were isolated from the bone marrow of the patient. These progenitor cells were differentiated into bone forming cells or osteoblasts . Immunophenotypic characterization was done to ensure that the cultured cells test positive for osteoblast biomarkers. Osteoblasts were expanded for approximately 4 weeks under stringent laboratory conditions and multiplied to more than 50 million osteoblasts. The personalized autologous osteoblast product OSSGROW® was made available by the 5th week and the cell implantation was planned. In a short surgery, a small incision was made on the lateral cortex of femur shaft to expose the non-union region and the cultured osteoblast cells mixed with a gel (Tisseel kit from Baxter) was injected into the region of non-union.\nThe patient was advised a rehabilitation protocol to be followed for about 6 weeks. With initial 48 h of immobilization, the patient started with non-weight-bearing exercises; with gradual partial weight-bearing followed by full weight-bearing exercises.\nAt week 10 post-OSSGROW® treatment, radiological evaluation of the patient showed completely united femoral neck. shows radiological evidence of non-union of the fracture in the left hip and shows post-operative at 10 weeks with united bone at the femoral neck. The patient had no pain and other symptoms. At 10 months post-implantation, the patient can perform all routine chores, walks without support, and is experiencing very good quality of life.", + "fulltext_subclaims": [ + "A 56-year-old woman reported to our orthopedic hospital with a complaint of severe pain in the left hip and inability to stand or walk.", + "The family reported that the patient had a fall on the same day.", + "Routine investigation revealed a fracture in the neck region of the left femur.", + "There was no history of any comorbid condition.", + "The patient was taken up for a surgical intervention following standard of care compression fixation.", + "The patient’s condition on day 3 post-surgery was satisfactory and the patient was discharged.", + "After about 8-month post-discharge, the patient visited our unit complaining of recurring severe pain in the left hip.", + "Radiological investigation revealed a non-union of the previous fracture.", + "Treatment using a novel bone cell therapy product (OSSGROW®) that is available in the India was considered given the age and lifestyle of the patient.", + "The patient and her family were counseled about the cell therapy option and an appropriate consent was taken.", + "Osteoblast cell therapy is a two-step process.", + "The first step involves bone marrow harvest.", + "The second step involves implantation of the ex vivo cultured autologous osteoblast cells from the bone marrow.", + "An adequate quantity (4–5 ml) of bone marrow from the patient’s iliac crest was aspirated and collected in transport media containing an anticoagulant.", + "The collection kit was transported under temperature-monitored conditions.", + "The collected bone marrow was processed at the GMP-certified cell processing facility (Regrow Biosciences Pvt. Ltd.).", + "Mesenchymal progenitor cells were isolated from the bone marrow of the patient.", + "These progenitor cells were differentiated into bone forming cells or osteoblasts.", + "Immunophenotypic characterization was done to ensure that the cultured cells test positive for osteoblast biomarkers.", + "Osteoblasts were expanded for approximately 4 weeks under stringent laboratory conditions and multiplied to more than 50 million osteoblasts.", + "The personalized autologous osteoblast product OSSGROW® was made available by the 5th week and the cell implantation was planned.", + "In a short surgery, a small incision was made on the lateral cortex of femur shaft to expose the non-union region.", + "The cultured osteoblast cells mixed with a gel (Tisseel kit from Baxter) was injected into the region of non-union.", + "The patient was advised a rehabilitation protocol to be followed for about 6 weeks.", + "With initial 48 h of immobilization, the patient started with non-weight-bearing exercises.", + "With gradual partial weight-bearing followed by full weight-bearing exercises.", + "At week 10 post-OSSGROW® treatment, radiological evaluation of the patient showed completely united femoral neck.", + "The patient had no pain and other symptoms.", + "At 10 months post-implantation, the patient can perform all routine chores.", + "The patient walks without support.", + "The patient is experiencing very good quality of life." + ], + "summary": "We present a case of a middle-aged woman with femoral neck non-union, treated with a novel bone cell therapy. Fracture union was achieved within 75 days post-cell implantation. At 10-month post-cell therapy, clinical outcome in our patient was quite satisfactory and the patient is doing very well without pain or any symptoms. and reports excellent quality of life.", + "summary_subclaims": [ + "We present a case of a middle-aged woman with femoral neck non-union.", + "The patient was treated with a novel bone cell therapy.", + "Fracture union was achieved within 75 days post-cell implantation.", + "At 10-month post-cell therapy, clinical outcome in our patient was quite satisfactory.", + "The patient is doing very well without pain or any symptoms.", + "The patient reports excellent quality of life." + ] + }, + { + "id": "multiclinsum_test_2407_en.txt", + "fulltext": "A 57-year-old Chinese man presented to our hospital for further management of a laterally spreading tumor (LST)-like lesion in the proximal rectum accidently discovered on colonoscopy over 1 mo prior.\nThe biopsy results indicated an inflammatory hyperplastic polyp. The patient had no obvious symptoms and received screening endoscopy as part of a routine health examination. Gastroscopy showed chronic atrophic gastritis and inflammation of the cardia.\nThe patient had a history of diabetes mellitus for more than 6 mo and was administered metformin and other drugs to control his blood sugar. He also had a history of hypertension for more than 1 mo without medication.\nHe had a long smoking history of over 30 years, with an average of 20 cigarettes per day. He also had a drinking history for more than 30 years, with half a catty of liquor per day.\nPhysical examination upon admission showed that the patient was 1.82 m in height and 94 kg in weight. He had a blood pressure of 139/84 mmHg with a heart rate of 68 beat/min. He had clear lungs and normal heart sounds with no murmurs or gallops on auscultation. There were no obvious pathognomonic signs during physical examination of the abdomen.\nNo significant abnormal laboratory results were recorded in this patient.\nColonoscopy in our hospital also revealed a 25 mm × 20 mm, LST-like slightly elevated lesion in the proximal rectum with a red color . To observe the microstructure and capillaries of the lesion, magnifying endoscopy with narrow-band imaging (NBI) was carried out. It showed enlarged and dilated branch-like vessels on the surface of the tumor similar to those of gastric MALT lymphoma . The margin of the lesion became clearer, and a type II pit pattern was observed on magnifying endoscopy after indigo carmine staining . Gastroscopy revealed atrophic gastritis and cardia mucosa erosion with irregular microstructure and capillaries on magnifying endoscopy. The biopsy pathology indicated cardia inflammation with mild glandular atypia in the absence of H. pylori. Therefore, there were no endoscopic and pathological findings indicating gastric MALT lymphoma. Abdominal computed tomography showed no obvious abnormalities.", + "fulltext_subclaims": [ + "A 57-year-old Chinese man presented to our hospital for further management of a laterally spreading tumor (LST)-like lesion in the proximal rectum.", + "The LST-like lesion was accidently discovered on colonoscopy over 1 mo prior.", + "The biopsy results indicated an inflammatory hyperplastic polyp.", + "The patient had no obvious symptoms.", + "The patient received screening endoscopy as part of a routine health examination.", + "Gastroscopy showed chronic atrophic gastritis.", + "Gastroscopy showed inflammation of the cardia.", + "The patient had a history of diabetes mellitus for more than 6 mo.", + "The patient was administered metformin and other drugs to control his blood sugar.", + "The patient had a history of hypertension for more than 1 mo without medication.", + "He had a long smoking history of over 30 years, with an average of 20 cigarettes per day.", + "He had a drinking history for more than 30 years, with half a catty of liquor per day.", + "Physical examination showed the patient was 1.82 m in height and 94 kg in weight.", + "Colonoscopy in our hospital revealed a 25 mm × 20 mm, LST-like slightly elevated lesion in the proximal rectum with a red color.", + "Magnifying endoscopy with narrow-band imaging (NBI) showed enlarged and dilated branch-like vessels on the surface of the tumor similar to those of gastric MALT lymphoma.", + "The margin of the lesion became clearer after indigo carmine staining.", + "A type II pit pattern was observed on magnifying endoscopy after indigo carmine staining.", + "Gastroscopy revealed atrophic gastritis and cardia mucosa erosion with irregular microstructure and capillaries on magnifying endoscopy.", + "The biopsy pathology indicated cardia inflammation with mild glandular atypia in the absence of H. pylori.", + "There were no endoscopic and pathological findings indicating gastric MALT lymphoma.", + "Abdominal computed tomography showed no obvious abnormalities." + ], + "summary": "We report a case of rectal MALT in a 57-year-old Chinese man with no symptoms who received endoscopy as part of a routine physical examination, which incidentally found a 25 mm × 20 mm, laterally spreading tumor (LST)-like elevated lesion in the rectum. Therefore, he was referred to our hospital for further endoscopic treatment. Complete and curable removal of the tumor was performed by endoscopic submucosal dissection. We observed enlarged and dilated branch-like vessels similar to those of gastric MALT lymphoma on magnifying endoscopy with narrow-band imaging. And immunopathological staining showed hyperplastic capillaries in the mucosa. Histopathological findings revealed diffusely hyperplastic lymphoid tissue in the lamina propria, with a visible lymphoid follicle structure surrounded by a large number of diffusely infiltrated lymphoid cells that had a relatively simple morphology and clear cytoplasm. In addition, immunohistochemical analysis suggested strongly positive expression for CD20 and Bcl-2. Gene rearrangement results showed positivity for IGH-A, IGH-C, IGK-B, and IGL. Taking all the above findings together, we arrived at a diagnosis of extranodal marginal zone B-cell lymphoma of MALT lymphoma. Positron emission tomography-computed tomography examination showed no other lesions involved. The patient will be followed by periodic endoscopic observation.", + "summary_subclaims": [ + "The patient is a 57-year-old Chinese man.", + "The patient had no symptoms.", + "The patient received endoscopy as part of a routine physical examination.", + "The endoscopy incidentally found a 25 mm × 20 mm, laterally spreading tumor (LST)-like elevated lesion in the rectum.", + "The patient was referred to the hospital for further endoscopic treatment.", + "Complete and curable removal of the tumor was performed by endoscopic submucosal dissection.", + "Magnifying endoscopy with narrow-band imaging showed enlarged and dilated branch-like vessels similar to those of gastric MALT lymphoma.", + "Immunopathological staining showed hyperplastic capillaries in the mucosa.", + "Histopathological findings revealed diffusely hyperplastic lymphoid tissue in the lamina propria.", + "The lymphoid tissue had a visible lymphoid follicle structure.", + "The lymphoid tissue was surrounded by a large number of diffusely infiltrated lymphoid cells.", + "The lymphoid cells had a relatively simple morphology.", + "The lymphoid cells had clear cytoplasm.", + "Immunohistochemical analysis suggested strongly positive expression for CD20.", + "Immunohistochemical analysis suggested strongly positive expression for Bcl-2.", + "Gene rearrangement results showed positivity for IGH-A.", + "Gene rearrangement results showed positivity for IGH-C.", + "Gene rearrangement results showed positivity for IGK-B.", + "Gene rearrangement results showed positivity for IGL.", + "The diagnosis was extranodal marginal zone B-cell lymphoma of MALT lymphoma.", + "Positron emission tomography-computed tomography showed no other lesions involved.", + "The patient will be followed by periodic endoscopic observation." + ] + }, + { + "id": "multiclinsum_test_1151_en.txt", + "fulltext": "A 67-year-old Caucasian man presented to the emergency room because of a 4 days’ history of abdominal pain, with one episode of vomiting.\nThe patient’s past medical history was significant for colonic diverticulosis and an episode of gastrointestinal bleeding one year before. The event had been investigated by two different gastroscopies, a colonoscopy and a MDCT, which produced inconclusive results. Ten months later he was newly admitted because of abdominal pain and fever at 38.0 C°, with valid urination and defecation. A CT of the abdomen was performed, which confirmed the colonic diverticulosis and revealed the presence of multiple diverticula of the small intestine, fat stranding, signs of inflammation as well as a small amount of free liquid in the abdomen. The patient was hence diagnosed with jejunal diverticulitis and managed conservatively with intra-venous antibiotics, with an apparent complete recovery.\nHe re-presented to the emergency department two months later with acute abdominal pain. The pain was described as severe and constant, localized mainly in the lower abdomen with clinical signs of peritonitis. No change in bowel habits nor urinary symptoms were complained. His vital signs were stable, with a temperature of 37.2 C°; he appeared fully oriented and not in any acute distress. Laboratory examination reported a hemoglobin of 121 g/dL, a WBC count of 12.2 × 10E9/L and a CRP of 249 mg/L. Other laboratory data were within normal limit. An abdominal and pelvic contrast-enhanced computed tomography, with administration of oral contrast, was performed. Jejunum and ileum showed several diverticula as well as an inflammatory thick-walled mass involving different loops of the intestine. In addition, free fluid in the abdomen and a small amount of subdiaphragmatic air were reported (, ). On the basis of these findings, the diagnosis of perforated diverticulitis was hereby proposed.\nThe patient underwent a diagnostic laparoscopy which revealed plenty of purulent yellowish liquid collected in the right abdomen and a conglomerate of intestinal inflamed loops. We hence decided to convert immediately the procedure to laparotomy. Large multiple diverticula were found covering a section of small intestine approximately 2.5 m long, without signs of obvious macro perforation. Among the middle distal tract of the jejunum and the middle distal tract of ileum, strong adhesions were identified . The involved segments of jejunum and ileum were connected by an intestinal loop free of signs of diverticulosis . There were no signs of bowel ischemia. Adhesiolisis was partially carried out, however, because of difficulties associated with the procedure, we opt to perform a double enterectomy, removing only those segments involved in the intestinal conglomerate and deeply affected by the pathology. Roughly 25 cm of ileum and 80 cm of jejunum were resected. Bowel continuity was restored with an ileo-ileal and a jejuno-jejunal anastomosis. Almost 700 cl of pus were drained and the peritoneal cavity was washed with 10 L of saline solution. The postoperative recovery was uneventful and the patient was discharged 8 days later. There were no signs of malignancy in the resected intestine.", + "fulltext_subclaims": [ + "The patient is a 67-year-old Caucasian man.", + "He presented to the emergency room with a 4 days’ history of abdominal pain.", + "He had one episode of vomiting.", + "His past medical history was significant for colonic diverticulosis.", + "He had an episode of gastrointestinal bleeding one year before.", + "The event had been investigated by two different gastroscopies.", + "The event had been investigated by a colonoscopy.", + "The event had been investigated by a MDCT.", + "The investigations produced inconclusive results.", + "Ten months later he was newly admitted because of abdominal pain and fever at 38.0 C°.", + "A CT of the abdomen was performed.", + "The CT confirmed the colonic diverticulosis.", + "The CT revealed the presence of multiple diverticula of the small intestine.", + "The CT showed fat stranding.", + "The CT showed signs of inflammation.", + "The CT showed a small amount of free liquid in the abdomen.", + "The patient was diagnosed with jejunal diverticulitis.", + "The patient was managed conservatively with intra-venous antibiotics.", + "The patient had an apparent complete recovery.", + "He re-presented to the emergency department two months later with acute abdominal pain.", + "The pain was described as severe and constant.", + "The pain was localized mainly in the lower abdomen.", + "Clinical signs of peritonitis were present.", + "No change in bowel habits was complained.", + "No urinary symptoms were complained.", + "His vital signs were stable.", + "His temperature was 37.2 C°.", + "He appeared fully oriented.", + "He was not in any acute distress.", + "Laboratory examination reported a hemoglobin of 121 g/dL.", + "Laboratory examination reported a WBC count of 12.2 × 10E9/L.", + "Laboratory examination reported a CRP of 249 mg/L.", + "Other laboratory data were within normal limit.", + "An abdominal and pelvic contrast-enhanced computed tomography was performed.", + "Jejunum and ileum showed several diverticula.", + "An inflammatory thick-walled mass involving different loops of the intestine was reported.", + "Free fluid in the abdomen was reported.", + "A small amount of subdiaphragmatic air was reported.", + "The diagnosis of perforated diverticulitis was proposed.", + "The patient underwent a diagnostic laparoscopy.", + "Plenty of purulent yellowish liquid was collected in the right abdomen.", + "A conglomerate of intestinal inflamed loops was found.", + "The procedure was converted to laparotomy.", + "Large multiple diverticula were found covering a section of small intestine approximately 2.5 m long.", + "There were no signs of obvious macro perforation.", + "Strong adhesions were identified among the middle distal tract of the jejunum and the middle distal tract of ileum.", + "The involved segments of jejunum and ileum were connected by an intestinal loop free of signs of diverticulosis.", + "There were no signs of bowel ischemia.", + "Adhesiolysis was partially carried out.", + "A double enterectomy was performed.", + "Roughly 25 cm of ileum was resected.", + "Roughly 80 cm of jejunum was resected.", + "Bowel continuity was restored with an ileo-ileal and a jejuno-jejunal anastomosis.", + "Almost 700 cl of pus was drained.", + "The peritoneal cavity was washed with 10 L of saline solution.", + "The postoperative recovery was uneventful.", + "The patient was discharged 8 days later.", + "There were no signs of malignancy in the resected intestine." + ], + "summary": "We are presenting a case of a 67-year-old patient who presented to our department with abdominal pain and signs of peritonitis. The CT scan displayed an inflammatory mass with a fair amount of free liquid in the abdomen, as well as multiple diverticula at different levels of the intestine. The patient had to underwent immediate surgery, during which a resection of 25 cm jejunum and 80 cm of ileum has been performed.", + "summary_subclaims": [ + "The patient is a 67-year-old.", + "The patient presented with abdominal pain.", + "The patient had signs of peritonitis.", + "The CT scan displayed an inflammatory mass.", + "The CT scan showed a fair amount of free liquid in the abdomen.", + "The CT scan showed multiple diverticula at different levels of the intestine.", + "The patient underwent immediate surgery.", + "A resection of 25 cm jejunum was performed.", + "A resection of 80 cm of ileum was performed." + ] + }, + { + "id": "multiclinsum_test_1906_en.txt", + "fulltext": "A 51-year-old female, who is known to have hypertension, presented to our outpatient department with a complaint of left breast mass for 2 months duration. According to the patient, the mass was not associated with any pain, discharge from the nipple or skin changes. She is a mother of 7 children and had her first menarche at the age of 13. Her family history was unremarkable for any malignancies. She utilized oral contraceptive pills for 13 years. Her past surgical history was significant for subtotal thyroidectomy performed for goiter 15 years back, and was kept on replacement therapy since then. Menstrual history confirmed a regular and non-heavy menstruation. Upon examination, a mass was detected in the left breast, measuring around 4 x 3 cm, located at 2 o’clock, 7 cm away from the nipple, with no attachment to the skin or muscles. Examination of the right breast along with the axilla bilaterally was unremarkable.\nA diagnostic mammography was performed and illustrated the presence of an irregular mass with obscured margins measuring around 4.5 cm x 2 cm, occupying the upper lateral quadrant of the left breast, 5 cm away from the nipple, with fine pleomorphic suspicious calcifications, as shown in . No suspicious axillary lymph nodes were identified, and the right breast was demonstrated with no architectural distortion or suspicious masses. A core-needle biopsy was obtained and was consistent with grade three metaplastic carcinoma with squamous differentiation. The lesion was triple negative with a Ki-67 score of 90%. The decision was made to proceed with neoadjuvant chemotherapy to be followed by breast-conserving surgery, or total mastectomy, with sentinel lymph node biopsy based on the cells’ response to neoadjuvant agents.", + "fulltext_subclaims": [ + "The patient is a 51-year-old female.", + "The patient has a history of hypertension.", + "The patient reported a left breast mass for 2 months.", + "The mass was not associated with pain.", + "The mass was not associated with discharge from the nipple.", + "The mass was not associated with skin changes.", + "The patient is a mother of 7 children.", + "The patient had her first menarche at the age of 13.", + "The patient's family history was unremarkable for malignancies.", + "The patient used oral contraceptive pills for 13 years.", + "The patient had a subtotal thyroidectomy 15 years ago.", + "The patient is on thyroid replacement therapy.", + "A mass was detected in the left breast, measuring around 4 x 3 cm.", + "The mass was located at 2 o'clock, 7 cm away from the nipple.", + "The mass was not attached to the skin or muscles.", + "A diagnostic mammography showed an irregular mass with obscured margins.", + "The mass measured around 4.5 cm x 2 cm.", + "The mass was located in the upper lateral quadrant of the left breast.", + "The mass was 5 cm away from the nipple.", + "Fine pleomorphic suspicious calcifications were present.", + "No suspicious axillary lymph nodes were identified.", + "The right breast showed no architectural distortion.", + "The right breast had no suspicious masses.", + "A core-needle biopsy was obtained.", + "The biopsy was consistent with grade three metaplastic carcinoma with squamous differentiation.", + "The lesion was triple negative.", + "The Ki-67 score was 90%.", + "The decision was made to proceed with neoadjuvant chemotherapy.", + "The plan was to follow neoadjuvant chemotherapy with breast-conserving surgery or total mastectomy.", + "Sentinel lymph node biopsy was planned based on the response to neoadjuvant agents." + ], + "summary": "The patient presented to our outpatient department with a complaint of left breast mass for 2 months duration with a diagnostic workup found to be grade three metaplastic carcinoma with squamous differentiation. The management decision was to proceed with neoadjuvant chemotherapy, followed by surgical intervention based on the tumor cell response to neoadjuvant therapy.", + "summary_subclaims": [ + "The patient presented to our outpatient department with a complaint of left breast mass for 2 months duration.", + "A diagnostic workup found grade three metaplastic carcinoma with squamous differentiation.", + "The management decision was to proceed with neoadjuvant chemotherapy.", + "Surgical intervention was planned based on the tumor cell response to neoadjuvant therapy." + ] + }, + { + "id": "multiclinsum_test_2767_en.txt", + "fulltext": "A 26-year-old male presented with 1 week of fevers, chills, headache, nausea, vomiting and diarrhea. Upon evaluation in the emergency department, he was febrile to 39.2 C, hypotensive to 75/35 mmHg, tachycardic at 126 beats per minute, with an oxygen saturation of 96% on 6 L nasal cannula. His labs were notable for leukocytosis (white blood cell count 17.1/nL), lymphopenia (absolute lymphocyte count 0.73/nL), acute kidney injury (creatinine 1.9 mg/dL), lactic acidosis (lactate 4.1 mmol/L), and elevated troponin levels (troponin T 0.218 µg/L, normal range < 0.09 µg/L). SARS-CoV-2 PCR was negative but SARS-CoV-2 IgG was positive. Point of care ultrasound showed severely reduced biventricular function. He was admitted to the cardiac care unit and given intravenous diuresis and inotropes for the management of cardiogenic shock (Additional file ).\nFurther admission laboratory assessment was notable for elevations in transaminases, procalcitonin, NT-proBNP, ferritin, D-dimer, ESR, and C-reactive protein . Chest x-ray showed opacification of the right lower lung field, a left lower lobe opacity, and borderline enlarged cardiac silhouette . Electrocardiogram showed sinus tachycardia with right axis deviation . An echocardiogram demonstrated a left ventricular ejection fraction of 20% with global hypokinesis, mildly dilated left ventricle, biatrial enlargement, hypokinetic and dilated right ventricle, moderate to severe mitral regurgitation due to leaflet tethering, severe tricuspid regurgitation, small pericardial effusion, and an estimated pulmonary artery systolic pressure of 53 mmHg with a right atrial pressure of 15 mmHg (Additional files and : Video 1).) .\nOn the evening of admission, bedside pulmonary artery catheter was placed with the following hemodynamics: RA 17 mmHg, RV 36/15 mmHg, PA 35/24 mmHg with mean 28 mmHg, PCWP 24 mmHg, mixed venous O2 saturation 53%, cardiac output 3.5 L/min, cardiac index 1.9 L/min/m2, system vascular resistance of 1440 dynes/s/cm−5. Cardiac output was calculated based on Fick’s formula using an assumed oxygen consumption. Pulmonary Artery Pulsatility Index (PAPi) was 0.7 (normal PAPi > 1.0 ), consistent with right ventricular dysfunction and biventricular shock.\nMilrinone was initiated after PA catheter measurements were consistent with biventricular shock and intravenous diuretics were continued. In light of his ongoing hypotension, norephinephrine was initiated to maintain a MAP ≥ 65 mmHg. Given the patient’s ongoing cardiogenic shock and rapid decline, the decision was made to treat empirically for fulminant giant cell myocarditis and MIS-A as his COVID-19 diagnosis was 5 weeks prior. As such, he was empirically treated with 1000 mg of solumedrol and intravenous immunoglobulin (IVIg) therapy.\nAn endomyocardial biopsy was subsequently performed . Histologic assessment showed interstitial edema and inflammatory infiltrate consisting predominantly of interstitial macrophages with scant T lymphocytes. Rare subendocardial myocytes with ischemic injury as highlighted by immunostain for C4d were seen. No eosinophils, giant cells or vascular thrombi were present. Given the macrophage predominant histology in combination with the remainder of his findings, a diagnosis of MIS-A was made. Steroid dosing was de-escalated to 2 mg/kg daily and IVIg was continued for 2 days.\nDespite antibiotic therapy and improving hemodynamics, the patient remained hypoxemic on 6 L nasal cannula with a rising D-Dimer (8147 ng/mL). A computed tomography scan was performed on hospital day 6 demonstrating multiple bilateral segmental and subsegmental pulmonary thromboemboli. The patient was transitioned from prophylactic to therapeutic heparin with rapid resolution of hypoxemia. Bilateral lower extremity venous duplexes showed no evidence of deep venous thrombosis.\nBy hospital day 7, the patient was tapered off milrinone. He was transitioned to apixaban, and guideline-directed medical therapy was initiated with metoprolol succinate, sacubitril-valsartan and spironolactone. Repeat echocardiogram prior to discharge showed an LVEF 75% with normal RV size and function, no more than trace valvular regurgitation and a small pericardial effusion (Additional files and : Video 2). His renal function returned to normal (0.9 mg/dL) without requiring renal replacement therapy and liver enzymes continued to downtrend.\nThe patient is doing well following discharge at 1 and 3 months with unlimited exercise tolerance and no evidence of arrhythmias or hemodynamic compromise. Repeat echocardiogram showed preserved biventricular function. He will have a cardiac MRI to further characterize the effect of myocardial injury and he is restricting vigorous exercise. He was referred to cardiac rehabilitation and remains on the same medications.", + "fulltext_subclaims": [ + "A 26-year-old male presented with 1 week of fevers, chills, headache, nausea, vomiting and diarrhea.", + "Upon evaluation in the emergency department, he was febrile to 39.2 C.", + "He was hypotensive to 75/35 mmHg.", + "He was tachycardic at 126 beats per minute.", + "His oxygen saturation was 96% on 6 L nasal cannula.", + "His labs were notable for leukocytosis (white blood cell count 17.1/nL).", + "He had lymphopenia (absolute lymphocyte count 0.73/nL).", + "He had acute kidney injury (creatinine 1.9 mg/dL).", + "He had lactic acidosis (lactate 4.1 mmol/L).", + "He had elevated troponin levels (troponin T 0.218 µg/L, normal range < 0.09 µg/L).", + "SARS-CoV-2 PCR was negative.", + "SARS-CoV-2 IgG was positive.", + "Point of care ultrasound showed severely reduced biventricular function.", + "He was admitted to the cardiac care unit.", + "He was given intravenous diuresis and inotropes for the management of cardiogenic shock.", + "Further admission laboratory assessment was notable for elevations in transaminases.", + "Chest x-ray showed opacification of the right lower lung field.", + "Chest x-ray showed a left lower lobe opacity.", + "Chest x-ray showed a borderline enlarged cardiac silhouette.", + "Electrocardiogram showed sinus tachycardia with right axis deviation.", + "An echocardiogram demonstrated a left ventricular ejection fraction of 20% with global hypokinesis.", + "He was empirically treated with 1000 mg of solumedrol and intravenous immunoglobulin (IVIg) therapy.", + "An endomyocardial biopsy was subsequently performed.", + "Histologic assessment showed interstitial edema and inflammatory infiltrate consisting predominantly of interstitial macrophages with scant T lymphocytes.", + "No eosinophils, giant cells or vascular thrombi were present.", + "A diagnosis of MIS-A was made.", + "Steroid dosing was de-escalated to 2 mg/kg daily.", + "IVIg was continued for 2 days.", + "A computed tomography scan was performed on hospital day 6 demonstrating multiple bilateral segmental and subsegmental pulmonary thromboemboli.", + "The patient was transitioned from prophylactic to therapeutic heparin.", + "By hospital day 7, the patient was tapered off milrinone.", + "He was transitioned to apixaban.", + "Guideline-directed medical therapy was initiated with metoprolol succinate, sacubitril-valsartan and spironolactone.", + "Repeat echocardiogram prior to discharge showed an LVEF 75% with normal RV size and function.", + "His renal function returned to normal (0.9 mg/dL).", + "The patient is doing well following discharge at 1 and 3 months.", + "Repeat echocardiogram showed preserved biventricular function.", + "He will have a cardiac MRI to further characterize the effect of myocardial injury.", + "He is restricting vigorous exercise.", + "He was referred to cardiac rehabilitation.", + "He remains on the same medications." + ], + "summary": "A 26-year-old male presented with fevers, chills, headache, nausea, vomiting, and diarrhea 5 weeks after his COVID-19 infection. His SARS-CoV-2 PCR was negative and IgG was positive, consistent with prior infection. He was found to be in cardiogenic shock with biventricular failure, requiring inotropes and diuretics. Given concern for acute fulminant myocarditis, an endomyocardial biopsy (EMB) was performed, showing an inflammatory infiltrate consisting predominantly of interstitial macrophages with scant T lymphocytes. The histologic pattern was similar to that of cardiac specimens from COVID-19 patients, helping rule out myocarditis as the prevailing diagnosis. His case was complicated by persistent hypoxemia, and a computed tomography scan revealed pulmonary emboli. He received IVIg, steroids, and anticoagulation with rapid recovery of biventricular function.", + "summary_subclaims": [ + "The patient was a 26-year-old male.", + "He presented with fevers, chills, headache, nausea, vomiting, and diarrhea.", + "He had these symptoms 5 weeks after his COVID-19 infection.", + "His SARS-CoV-2 PCR was negative.", + "His SARS-CoV-2 IgG was positive.", + "The IgG result was consistent with prior infection.", + "He was found to be in cardiogenic shock.", + "He had biventricular failure.", + "He required inotropes and diuretics.", + "An endomyocardial biopsy was performed.", + "The biopsy showed an inflammatory infiltrate consisting predominantly of interstitial macrophages.", + "The biopsy showed scant T lymphocytes.", + "The histologic pattern was similar to that of cardiac specimens from COVID-19 patients.", + "The histologic pattern helped rule out myocarditis as the prevailing diagnosis.", + "He received IVIg.", + "He received steroids.", + "He received anticoagulation.", + "He had rapid recovery of biventricular function." + ] + }, + { + "id": "multiclinsum_test_1808_en.txt", + "fulltext": "A 50-year-old female patient presented to the emergency department (ED) in significant respiratory distress. She had a known past medical history of tobacco dependence, chronic obstructive pulmonary disease (COPD), gastroesophageal reflux disease, and hypertension. On arrival, the patient was noted to be apneic and was actively being ventilated with a bag-valve-mask ventilation. She rapidly progressed from an irregularly irregular cardiac rhythm to sinus bradycardia, and then into a pulseless electrical activity (PEA) arrest within minutes of arrival. She underwent approximately 30 minutes of cardiopulmonary resuscitation, with endotracheal intubation performed via video laryngoscopy. She was noted to have significant resistance to bagging after intubation, and after return of spontaneous circulation, was noted to have high peak pressures on the ventilator and was persistently hypotensive.\nOn examination, the patient was noted to have distant, rhonchorous, and wheezy breath sounds bilaterally, and she was treated for her bronchospasm with nebulized albuterol-ipratropium solution, continuous nebulized albuterol, magnesium sulfate, methylprednisolone, subcutaneous terbutaline, and titratable epinephrine (to also assist with her hypotension). She was noted to have continuously high peak pressures; so, an intravenous push of vecuronium was given without improvement in ventilation and with continuously high peak airway pressures noted on the ventilator. She had an electrocardiogram concerning for new-onset atrial fibrillation with rapid ventricular response, left axis deviation, a new right bundle branch block, and a left anterior fascicular block with signs of right heart strain. Given her difficulty with ventilation with high peak pressures and hypotension, she was taken for a computed tomography (CT) with pulmonary embolism protocol as there was concern that the etiology of her arrest may have been a massive pulmonary embolism.\nThis revealed no evidence of pulmonary embolism; however, it did show evidence of alveolar rupture with pneumomediastinum consistent with the Macklin effect and a small left-sided pneumothorax with associated medial left hemi diaphragmatic rupture with pneumoretroperitoneum tracking along the left upper abdomen and left perinephric space with left-sided nondisplaced rib fractures of the fifth and sixth ribs . A CT of the abdomen and pelvis was then performed, which showed a small amount of free air consistent with pneumoretroperitoneum adjacent to the gastric cardia, left kidney, and left adrenal gland, but with no definitively identified intra-abdominal traumatic injury.\nFurther history from the family, who arrived several hours after the patient’s initial presentation, revealed she had been complaining of difficulty breathing earlier in the day, and she subsequently suffered a witnessed fall down a flight of stairs with head trauma and apparent loss of consciousness. The patient’s physical examination revealed no external signs of trauma on initial arrival.\nThe patient was admitted to the medical intensive care unit in the setting of cardiac arrest with prolonged down time, with improvement in her pneumomediastinum and pneumoretroperitoneum with lung-protective ventilation strategies and paralytics. The patient’s treatment for her COPD exacerbation was extensive and included continuous albuterol nebulization of 40 milligrams (mg) over four hours, intermittent scheduled three-milliliter ipratroprium-albuterol nebulizers every six hours, 0.25 mg of budesonide twice daily, 0.5 mg of ipratroprium four times daily, isolated two mg of magnesium sulfate administration daily if worsening wheeze on examination, 80 mg of methylprednisolone daily, a one-time dose of 0.25 mg of subcutaneous terbutaline, and a one-time dose of one microgram (μg) of epinephrine. Sedation was maintained with both ketamine at 1.5 mg per kilogram (kg) per hour and propofol at 20 μg/kg per minute. For the patient’s hypotension, she was treated with epinephrine as the first-line vasopressor choice given its underlying beta adrenergic effects in the setting of her profound bronchospasm.\nHowever, the patient’s cardiac arrest resulted in severe hypoxic brain injury, leading to subsequent diffuse cerebral edema with effacement of the basal cisterns and tonsillar herniation seen on CT of her head. She became increasingly hypertensive and was weaned off vasopressors and started on titratable nicardipine at a maximum of 12.5 mg per hour and was given a hypertonic saline bolus. The patient lost all evidence of brainstem reflexes five days after suffering cardiac arrest but continued to trigger some spontaneous breaths on the ventilator. Multiple family meetings were held regarding patient prognosis, and ultimately the patient was palliatively extubated with subsequent demise 26 days after arrival.", + "fulltext_subclaims": [ + "The patient was a 50-year-old female.", + "She presented to the emergency department in significant respiratory distress.", + "She had a known past medical history of tobacco dependence.", + "She had a known past medical history of chronic obstructive pulmonary disease.", + "She had a known past medical history of hypertension.", + "On arrival, the patient was noted to be apneic.", + "She was actively being ventilated with a bag-valve-mask ventilation.", + "She rapidly progressed from an irregularly irregular cardiac rhythm to sinus bradycardia.", + "She then progressed into a pulseless electrical activity (PEA) arrest within minutes of arrival.", + "She underwent approximately 30 minutes of cardiopulmonary resuscitation.", + "Endotracheal intubation was performed via video laryngoscopy.", + "After intubation, she was noted to have significant resistance to bagging.", + "After return of spontaneous circulation, she was noted to have high peak pressures on the ventilator.", + "She was persistently hypotensive.", + "On examination, she was noted to have distant, rhonchorous, and wheezy breath sounds bilaterally.", + "She was treated for her bronchospasm with nebulized albuterol-ipratropium solution.", + "She was treated with continuous nebulized albuterol.", + "She was treated with magnesium sulfate.", + "She was treated with methylprednisolone.", + "She was treated with subcutaneous terbutaline.", + "She was treated with titratable epinephrine.", + "She was noted to have continuously high peak pressures.", + "An intravenous push of vecuronium was given.", + "There was no improvement in ventilation after vecuronium.", + "There were continuously high peak airway pressures noted on the ventilator.", + "She had an electrocardiogram concerning for new-onset atrial fibrillation with rapid ventricular response.", + "She had an electrocardiogram showing left axis deviation.", + "She had an electrocardiogram showing a new right bundle branch block.", + "She had an electrocardiogram showing a left anterior fascicular block.", + "The electrocardiogram showed signs of right heart strain.", + "Given her difficulty with ventilation and hypotension, she was taken for a computed tomography (CT) with pulmonary embolism protocol.", + "The CT revealed no evidence of pulmonary embolism.", + "The CT showed evidence of alveolar rupture with pneumomediastinum consistent with the Macklin effect.", + "The CT showed a small left-sided pneumothorax.", + "The CT showed associated medial left hemi diaphragmatic rupture.", + "The CT showed pneumoretroperitoneum tracking along the left upper abdomen.", + "The CT showed pneumoretroperitoneum tracking along the left perinephric space.", + "The CT showed left-sided nondisplaced rib fractures of the fifth and sixth ribs.", + "A CT of the abdomen and pelvis showed a small amount of free air consistent with pneumoretroperitoneum.", + "The CT of the abdomen and pelvis showed free air adjacent to the gastric cardia.", + "The CT of the abdomen and pelvis showed free air adjacent to the left kidney.", + "The CT of the abdomen and pelvis showed free air adjacent to the left adrenal gland.", + "There was no definitively identified intra-abdominal traumatic injury.", + "Further history from the family revealed she had been complaining of difficulty breathing earlier in the day.", + "She subsequently suffered a witnessed fall down a flight of stairs.", + "The fall was associated with head trauma.", + "The fall was associated with apparent loss of consciousness.", + "The patient’s physical examination revealed no external signs of trauma on initial arrival.", + "The patient was admitted to the medical intensive care unit.", + "The admission was in the setting of cardiac arrest with prolonged down time.", + "The patient’s pneumomediastinum improved with lung-protective ventilation strategies.", + "The patient’s pneumoretroperitoneum improved with lung-protective ventilation strategies.", + "The patient was treated with paralytics.", + "The patient’s treatment for her COPD exacerbation included continuous albuterol nebulization of 40 milligrams (mg) over four hours.", + "The patient’s treatment included intermittent scheduled three-milliliter ipratroprium-albuterol nebulizers every six hours.", + "The patient’s treatment included 0.25 mg of budesonide twice daily.", + "The patient’s treatment included 0.5 mg of ipratroprium four times daily.", + "The patient’s treatment included isolated two mg of magnesium sulfate administration daily if worsening wheeze on examination.", + "The patient’s treatment included 80 mg of methylprednisolone daily.", + "The patient received a one-time dose of 0.25 mg of subcutaneous terbutaline.", + "The patient received a one-time dose of one microgram (μg) of epinephrine.", + "Sedation was maintained with ketamine at 1.5 mg per kilogram (kg) per hour.", + "Sedation was maintained with propofol at 20 μg/kg per minute.", + "The patient was treated with epinephrine as the first-line vasopressor choice.", + "The patient’s cardiac arrest resulted in severe hypoxic brain injury.", + "The patient had subsequent diffuse cerebral edema.", + "The patient had effacement of the basal cisterns.", + "The patient had tonsillar herniation seen on CT of her head.", + "The patient became increasingly hypertensive.", + "The patient was weaned off vasopressors.", + "The patient was started on titratable nicardipine at a maximum of 12.5 mg per hour.", + "The patient was given a hypertonic saline bolus.", + "The patient lost all evidence of brainstem reflexes five days after suffering cardiac arrest.", + "The patient continued to trigger some spontaneous breaths on the ventilator.", + "Multiple family meetings were held regarding patient prognosis.", + "The patient was palliatively extubated.", + "The patient died 26 days after arrival." + ], + "summary": "We present a case of a patient who suffered a cardiac arrest after a fall during a chronic obstructive pulmonary disease exacerbation, leading to pneumoretroperitoneum.", + "summary_subclaims": [ + "The patient suffered a cardiac arrest after a fall.", + "The cardiac arrest occurred during a chronic obstructive pulmonary disease exacerbation.", + "The patient had pneumoretroperitoneum." + ] + }, + { + "id": "multiclinsum_test_2807_en.txt", + "fulltext": "A fourty-year-old man with DEB diagnosed at the age of eight was admitted to the department of gastroenterology because of the dysphagia for two previous months. The diagnosis of DEB was established due to the presence of single blisters on the whole body since the sixth month of life. His sister was also diagnosed with DEB and had similar symptoms of the disease. To our knowledge, the presented patient and his sister are the oldest diagnosed with EB living in Poland. At the age of four the patient started experiencing heartburn occasionally. Five years later dysphagia appeared for the first time. It was an episodal and periodical ailment. He reported a deterioration of dysphagia at the age of nineteen; he mostly consumed liquids and soft consistency meals during that time. Nonetheless, the patient admitted that this esophageal discomfort still was not a constant one and there were time intervals without this ailment. In the past there were also episodes of mild esophageal bleeding. The only one endoscopic esophageal dilatation in this patient took place in 1997; a stenosis was located then approximately 18 cm from incisors. The performed procedure ameliorated swallowing difficulty. A barium swallow test obtained one year after the endoscopic dilatation of the esophagus also revealed esophageal constriction on the same level. In 2014 the patient was diagnosed because of hematochezia and pain in hypogastrium. Tissue samples obtained in colonoscopy revealed the presence of nonspecific inflammatory infiltration in the ascending colon and terminal part of the ileum. Interestingly, 3 years ago he complained of hemoptysis and there was a suspicion of bleeding to pulmonary alveoli in the course of DEB. However, a CT scan did not confirm bleeding. On admission to our department the patient was complaining of painful swallowing of solids. Two months earlier he was diagnosed in the cardiology unit because of the chest pain and elevated level of troponin I. An electrocardiogram did not show any abnormalities. The patient refused to undergo coronarography and no more cardiological diagnostic procedures were performed Additional file . On admission to our unit he did not complain of the chest pain. On physical examination he appeared comfortable, afebrile with pulse 90 beats per minute, blood pressure 125/90 mmHg, respiratory rate 19 per minute and the body mass index (BMI) was 24.7 kg/m2. The patient presented blisters, skin reddening and crust formation on the upper and lower limbs. There were also contractures and disabled movement in his hand joints together with a loss of a finger and toenails . The apex of the tongue and left palatine arch were covered by superficial ulcerations. During his hospital stay, performed laboratory tests did not reveal any abnormalities. A CT scan of the chest and abdomen showed a thickening of the esophageal wall at maximum to 7 mm on the level from the fourth cervical vertebra to the fourth thoracic vertebra . A probe of gastroscopy under sedation with benzodiazepine failed due to an esophageal stenosis. An attempt of examination with paediatric endoscope was also unsuccessful. A barium swallow test revealed a narrowing of upper esophageal lumen to 7 mm along the length of 4 cm together with two diverticula on the right side not emptying of contrast. During swallowing other two diverticula appeared which were emptying of contrast . A barium swallow test also showed a noticeable weakening of the esophageal mucous membrane. After the performed investigation the patient was qualified to endoscopic dilatation of esophageal stenosis and endoscopic management of diverticula. However, he did not agree to undergo this procedure during current hospital stay. In our unit the patient was treated with proton pump inhibitor (PPI) and prokinetic drugs administered intravenously, which caused an amelioration of esophageal discomfort. He was discharged in a good general condition with a recommendation of a diet based on soft consistency meals, oral PPI and prokinetic drugs administration and the next follow-up in a month.", + "fulltext_subclaims": [ + "The patient is a fourty-year-old man.", + "The patient has DEB.", + "The diagnosis of DEB was established due to the presence of single blisters on the whole body since the sixth month of life.", + "The patient's sister was also diagnosed with DEB.", + "The patient and his sister are the oldest diagnosed with EB living in Poland.", + "The patient started experiencing heartburn occasionally at the age of four.", + "Dysphagia appeared for the first time five years after the age of four.", + "The dysphagia was an episodal and periodical ailment.", + "The patient reported a deterioration of dysphagia at the age of nineteen.", + "The patient mostly consumed liquids and soft consistency meals at the age of nineteen.", + "The patient admitted that esophageal discomfort was not constant.", + "There were episodes of mild esophageal bleeding in the past.", + "The only one endoscopic esophageal dilatation in this patient took place in 1997.", + "A stenosis was located approximately 18 cm from incisors in 1997.", + "The performed procedure ameliorated swallowing difficulty.", + "A barium swallow test one year after the endoscopic dilatation revealed esophageal constriction on the same level.", + "In 2014, the patient was diagnosed because of hematochezia and pain in hypogastrium.", + "Tissue samples obtained in colonoscopy revealed the presence of nonspecific inflammatory infiltration in the ascending colon and terminal part of the ileum.", + "Three years ago, the patient complained of hemoptysis.", + "There was a suspicion of bleeding to pulmonary alveoli in the course of DEB.", + "A CT scan did not confirm bleeding.", + "On admission to the department, the patient was complaining of painful swallowing of solids.", + "Two months earlier, the patient was diagnosed in the cardiology unit because of chest pain and elevated level of troponin I.", + "An electrocardiogram did not show any abnormalities.", + "The patient refused to undergo coronarography.", + "No more cardiological diagnostic procedures were performed.", + "On admission to the department, the patient did not complain of chest pain.", + "The patient appeared comfortable, afebrile with pulse 90 beats per minute.", + "The patient's blood pressure was 125/90 mmHg.", + "The patient's BMI was 24.7 kg/m2.", + "The patient presented blisters, skin reddening and crust formation on the upper and lower limbs.", + "There were contractures and disabled movement in his hand joints.", + "There was a loss of a finger and toenails.", + "The apex of the tongue and left palatine arch were covered by superficial ulcerations.", + "A CT scan of the chest and abdomen showed a thickening of the esophageal wall at maximum to 7 mm.", + "A probe of gastroscopy under sedation with benzodiazepine failed due to an esophageal stenosis.", + "An attempt of examination with paediatric endoscope was also unsuccessful.", + "A barium swallow test revealed a narrowing of upper esophageal lumen to 7 mm along the length of 4 cm.", + "A barium swallow test showed two diverticula on the right side not emptying of contrast.", + "During swallowing, other two diverticula appeared which were emptying of contrast.", + "A barium swallow test also showed a noticeable weakening of the esophageal mucous membrane.", + "The patient was qualified to endoscopic dilatation of esophageal stenosis and endoscopic management of diverticula.", + "The patient did not agree to undergo this procedure during the current hospital stay.", + "The patient was treated with proton pump inhibitor (PPI) and prokinetic drugs administered intravenously.", + "The treatment caused an amelioration of esophageal discomfort.", + "The patient was discharged in a good general condition.", + "The patient was recommended a diet based on soft consistency meals.", + "The patient was recommended oral PPI and prokinetic drugs administration.", + "The patient was recommended a next follow-up in a month." + ], + "summary": "Here we present a case of a man with dystrophic EB and dysphagia, skin blistering, joints contractures and missing nails. To our knowledge, the presented man is the oldest one diagnosed with EB living in Poland.", + "summary_subclaims": [ + "The man has dystrophic EB.", + "The man has dysphagia.", + "The man has skin blistering.", + "The man has joint contractures.", + "The man has missing nails.", + "The man is the oldest one diagnosed with EB living in Poland." + ] + }, + { + "id": "multiclinsum_test_759_en.txt", + "fulltext": "A 52-year-old White man presented with intermittent constipation and back pain, with a history of a decrease in lymphocyte count (documented two months prior). The patient was a never smoker and had no family history of cancer or other cancer risk factors. Initial computed tomography scans revealed stage T4 prostatic adenocarcinoma with invasion into adjacent structures, metastasis to regional lymph nodes (stage N1), and metastases to the liver, bone, and a distant lymph node (stage M1) (, ). A retroperitoneal lymph node was biopsied to confirm histology. His prostate-specific antigen (PSA) level was 1291ng/mL.\nThe patient started the antiandrogen bicalutamide (oral) shortly after confirmed diagnosis and a gonadotrophin-releasing hormone agonist, leuprorelin (depot injection), was subsequently initiated to affect androgen deprivation. The patient received treatment until PSA values began to rise ≈15 weeks later and the patient discontinued bicalutamide. Docetaxel (intravenous infusion; 4 cycles) plus prednisone (oral; continuous dosing) was administered as standard of care; prednisone was continued for 1 week after the end of docetaxel treatment for symptom control. The patient ultimately discontinued docetaxel/prednisone due to radiographic disease progression and PSA progression and immediately started on abiraterone as an androgen receptor targeting therapy, which continued for 7 weeks until radiographic disease progression and PSA progression. The patient also received palliative radiation of the right femur and acetabula around the time abiraterone was initiated.\nAfter discontinuing abiraterone, the patient was enrolled in the TRITON2 study based on results of local genomic testing of an archival tissue biopsy (retroperitoneal lymph node metastasis, 90% tumor purity) obtained at initial diagnosis. Local testing utilized the Oncomine™ Comprehensive Assay v3 (Thermo Fisher Scientific Inc., Waltham, MA, USA), which can detect single-nucleotide variants, copy-number variations, gene fusions, and insertions/deletions in 161 cancer-related genes. This local test indicated the presence of a BRCA1 T1399I (allelic fraction [AF], 19%) mutation , a novel variant of uncertain significance within a coiled-coil domain which bioinformatics analyses predicted to have a deleterious effect on the BRCA1-PALB2 interaction. A deleterious or probably damaging ATM G1663C mutation, a damaging TP53 P191del mutation, and an oncogenic, activating BRAF K601E mutation were also detected; no gene amplifications or gene fusions were detected. TRITON2 patients provided plasma samples for central genomic analysis prior to starting rucaparib. Analysis of the patient’s pre-rucaparib plasma sample was conducted using the FoundationOne Liquid CDx assay, which analyzes 324 cancer-related genes and identifies the same classes of BRCA alterations, including homozygous deletions. The FoundationOne Liquid CDx assay detected the same alterations as the Oncomine analysis of the archival tissue biopsy but also revealed the presence of a BRCA2 homozygous loss (whole gene, 26 of 26 exons) and several other alterations of unknown functional impact in a plasma sample with 28% tumor content .\nThe patient started at the recommended dose of rucaparib, 600 mg twice daily, but the dose was reduced to 500 mg twice daily due to nausea/fatigue, with the patient ultimately receiving rucaparib for 32 weeks . At enrollment into TRITON2, the patient had >21 bone-associated lesions and multiple liver lesions. Treatment with rucaparib resulted in a confirmed partial response per modified Response Evaluation Criteria In Solid Tumors, version 1.1 (51% decrease in liver metastasis target lesion diameters; ) lasting 13 weeks, ongoing as of the last radiographic assessment before subsequent anti-cancer therapy, resulting in a rPFS of 29 weeks, with no confirmed progression in bone. The patient also had a confirmed PSA response (maximum decrease, 95%; ) lasting 28 weeks from the first dose of rucaparib. The patient discontinued rucaparib treatment due to clinical disease progression after 32 weeks on study and subsequently received palliative radiotherapy due to painful bone lesions.\nFollowing discontinuation from the rucaparib treatment, the patient received carboplatin and cabazitaxel for 2 cycles (intravenous infusion) until subsequent scans indicated progressive disease in nontarget liver lesions two months later. The patient discontinued carboplatin/cabazitaxel and did not receive any further anticancer therapies. The patient died ≈23 months after initial diagnosis due to progression of his disease.", + "fulltext_subclaims": [ + "The patient was a 52-year-old White man.", + "The patient presented with intermittent constipation.", + "The patient had a history of a decrease in lymphocyte count two months prior.", + "Initial computed tomography scans revealed stage T4 prostatic adenocarcinoma.", + "The tumor had invasion into adjacent structures.", + "The tumor had metastasis to regional lymph nodes (stage N1).", + "The tumor had metastases to the liver, bone, and a distant lymph node (stage M1).", + "A retroperitoneal lymph node was biopsied to confirm histology.", + "The patient's prostate-specific antigen (PSA) level was 1291ng/mL.", + "The patient started the antiandrogen bicalutamide (oral) shortly after confirmed diagnosis.", + "A gonadotrophin-releasing hormone agonist, leuprorelin (depot injection), was subsequently initiated.", + "The patient received treatment until PSA values began to rise ≈15 weeks later.", + "The patient discontinued bicalutamide.", + "Docetaxel (intravenous infusion; 4 cycles) plus prednisone (oral; continuous dosing) was administered as standard of care.", + "Prednisone was continued for 1 week after the end of docetaxel treatment for symptom control.", + "The patient discontinued docetaxel/prednisone due to radiographic disease progression and PSA progression.", + "The patient immediately started on abiraterone as an androgen receptor targeting therapy.", + "The patient received palliative radiation of the right femur and acetabula around the time abiraterone was initiated.", + "After discontinuing abiraterone, the patient was enrolled in the TRITON2 study.", + "Local genomic testing of an archival tissue biopsy (retroperitoneal lymph node metastasis, 90% tumor purity) was obtained at initial diagnosis.", + "Local testing utilized the Oncomine™ Comprehensive Assay v3.", + "The local test indicated the presence of a BRCA1 T1399I (allelic fraction [AF], 19%) mutation.", + "A deleterious or probably damaging ATM G1663C mutation was also detected.", + "A damaging TP53 P191del mutation was also detected.", + "An oncogenic, activating BRAF K601E mutation was also detected.", + "No gene amplifications were detected.", + "No gene fusions were detected.", + "TRITON2 patients provided plasma samples for central genomic analysis prior to starting rucaparib.", + "The patient’s pre-rucaparib plasma sample was analyzed using the FoundationOne Liquid CDx assay.", + "The FoundationOne Liquid CDx assay detected the same alterations as the Oncomine analysis of the archival tissue biopsy.", + "The FoundationOne Liquid CDx assay also revealed the presence of a BRCA2 homozygous loss (whole gene, 26 of 26 exons).", + "The patient started at the recommended dose of rucaparib, 600 mg twice daily.", + "The dose was reduced to 500 mg twice daily due to nausea/fatigue.", + "The patient ultimately received rucaparib for 32 weeks.", + "At enrollment into TRITON2, the patient had >21 bone-associated lesions.", + "The patient had multiple liver lesions.", + "Treatment with rucaparib resulted in a confirmed partial response per modified Response Evaluation Criteria In Solid Tumors, version 1.1.", + "The partial response lasted 13 weeks.", + "The partial response was ongoing as of the last radiographic assessment before subsequent anti-cancer therapy.", + "The rPFS was 29 weeks.", + "There was no confirmed progression in bone.", + "The patient had a confirmed PSA response (maximum decrease, 95%).", + "The PSA response lasted 28 weeks from the first dose of rucaparib.", + "The patient discontinued rucaparib treatment due to clinical disease progression after 32 weeks on study.", + "The patient received carboplatin and cabazitaxel for 2 cycles.", + "Subsequent scans indicated progressive disease in nontarget liver lesions two months later.", + "The patient discontinued carboplatin/cabazitaxel.", + "The patient did not receive any further anticancer therapies.", + "The patient died ≈23 months after initial diagnosis due to progression of his disease." + ], + "summary": "A patient from TRITON2 with BRCA-mutated mCRPC had a response to the PARP inhibitor rucaparib and remained on treatment for 32 weeks, which was >2 times longer than the duration of each of his prior therapies (bicalutamide, docetaxel, abiraterone). The patient enrolled in TRITON2 based on results of local genomic testing of an archival biopsy that indicated the presence of a BRCA1 T1399I (allelic fraction, 19%) mutation. Local testing also identified an ATM G1663C mutation, a TP53 P191del mutation, and a BRAF K601E mutation. Analysis of a plasma sample obtained before the patient started rucaparib detected the same alterations as those in the archival biopsy, but it also revealed the presence of a BRCA2 homozygous loss (whole gene, 26 of 26 exons) and several other alterations of unknown functional impact. We hypothesize the response of the patient's tumor to rucaparib was likely driven by DNA damage repair deficiency caused by homozygous loss of all BRCA2 exons. Following discontinuation from rucaparib due to clinical disease progression, the patient received carboplatin and cabazitaxel for ≈3 weeks. The patient died due to progression of his disease.", + "summary_subclaims": [ + "The patient had BRCA-mutated metastatic castration-resistant prostate cancer.", + "The patient had a response to the PARP inhibitor rucaparib.", + "The patient remained on rucaparib for 32 weeks.", + "The duration of treatment with rucaparib was >2 times longer than the duration of each of his prior therapies.", + "The patient's prior therapies included bicalutamide, docetaxel, and abiraterone.", + "The patient enrolled in TRITON2 based on results of local genomic testing of an archival biopsy.", + "Local genomic testing indicated the presence of a BRCA1 T1399I mutation.", + "The allelic fraction of the BRCA1 T1399I mutation was 19%.", + "Local testing also identified an ATM G1663C mutation.", + "Local testing also identified a TP53 P191del mutation.", + "Local testing also identified a BRAF K601E mutation.", + "Analysis of a plasma sample obtained before starting rucaparib detected the same alterations as those in the archival biopsy.", + "Analysis of the plasma sample also revealed the presence of a BRCA2 homozygous loss.", + "The BRCA2 homozygous loss involved the whole gene, 26 of 26 exons.", + "The plasma sample analysis also revealed several other alterations of unknown functional impact.", + "We hypothesize the response of the patient's tumor to rucaparib was likely driven by DNA damage repair deficiency.", + "The DNA damage repair deficiency was caused by homozygous loss of all BRCA2 exons.", + "The patient discontinued rucaparib due to clinical disease progression.", + "Following discontinuation from rucaparib, the patient received carboplatin and cabazitaxel.", + "The patient received carboplatin and cabazitaxel for ≈3 weeks.", + "The patient died due to progression of his disease." + ] + }, + { + "id": "multiclinsum_test_1268_en.txt", + "fulltext": "A 30-year-old Chinese woman came to the dermatology clinic with a two-year history of progressing, diffuse, lattice-like hyperpigmentation of the face and neck. Significant sunlight, chemical materials, medicine, and cosmetic exposures were denied. She had no notable family history of similar conditions. On further questioning, she admitted that she had experienced hair loss and ankle joint pain for two years, and these had worsened in the last two months.\nDiffuse, symmetric, and reticular gray brown hyperpigmentation was observed all over the face and neck, especially the cheeks and the area around the mouth . Slight hyperpigmentation was seen on her upper limbs. No similar change can be seen on the rest of her skin and mucosa.\nUnder skin microscopy, diffuse black-pepper-like changes separated by hair follicles with sweat glands and telangiectasias were seen . The reflectance confocal microscopy showed abundant melanin in the epidermis and dermis, local liquefactive degeneration of basal layer cells, and the presence of melanophages in the dermis ( and ). Histopathology of neck lesions (HE staining) showed punctiform epidermal atrophy, punctate liquefactive degeneration of basal layer cells, melanophages in the dermis, and a few lymphocytes infiltrating around the dermal adnexa . Masson-Fontana silver staining showed amounts of melanin in the epidermis and dermis . Laboratory investigations revealed the following: peripheral white blood cell (WBC) count 2.73 × 109/L (3.5–9.5 × 109/L), antinuclear antibody (ANA) (+++), anti-dsDNA antibody (dsDNA) (+), anti-Sjögren’s-syndrome-related antigen antibody A (+++), C3 0.48 g/L (0.90–1.80 g/L), C4 0.06 g/L (0.10–0.40 g/L), anti-thyroglobulin antibody (TGAb) >4000 IU/mL (0.00–115.00 IU/mL), and anti-thyroid peroxidase (ATPO) >600 IU/mL (0.00–34.00 IU/mL), thyroid stimulating hormone (TSH) 92 mIU/L (0.550–4.780 mIU/L), Thyronine-4 (T4) 2.5 μg/dl (4.5–10.9 μg/dl). Serum-free thyroxine (FT4), free triiodothyronine (FT3), thyronine-3 (T3), and adrenocorticotrophic hormone (ACTH) were all within normal range. Anti-TSH receptor antibody (TRab) was negative. Doppler ultrasonography of the thyroid showed hypothyroidism changes and a nodular thyroid cyst. Serum sex hormone, adrenal hormone, and the computed tomography scanning of the adrenal glands were all normal.\nDiagnoses of RM accompanied with SLE and Hashimoto’s thyroiditis of primary hypothyroidism were made via the clinical features and laboratory investigations.\nPrednisone (20 mg/day), hydroxychloroquine (400 mg/day), and L-thyroxine (100 μg/day) were administered orally. The prednisone was withdrawn gradually over the course of 7 months.\nSignificant improvement was observed after 14 months of treatment. The hyperpigmentation has turned much lighter ( and ). Under reflectance confocal microscopy, the melanin in the epidermis was found to have decreased significantly, the local liquefactive degeneration of basal layer cells showed improvement, and the melanophages in dermis was found to have decreased in number . WBC, C3, C4, and T4 returned to normal. The TSH decreased to 5.667 mIU/L.", + "fulltext_subclaims": [ + "The patient is a 30-year-old Chinese woman.", + "She had a two-year history of progressing, diffuse, lattice-like hyperpigmentation of the face and neck.", + "She denied significant sunlight, chemical materials, medicine, and cosmetic exposures.", + "She had no notable family history of similar conditions.", + "She admitted to experiencing hair loss and ankle joint pain for two years.", + "The hyperpigmentation was diffuse, symmetric, and reticular gray brown.", + "It was observed all over the face and neck, especially the cheeks and the area around the mouth.", + "Slight hyperpigmentation was seen on her upper limbs.", + "No similar change can be seen on the rest of her skin and mucosa.", + "Under skin microscopy, diffuse black-pepper-like changes separated by hair follicles with sweat glands and telangiectasias were seen.", + "The reflectance confocal microscopy showed abundant melanin in the epidermis and dermis.", + "Local liquefactive degeneration of basal layer cells was observed.", + "The presence of melanophages in the dermis was noted.", + "Histopathology of neck lesions showed punctiform epidermal atrophy.", + "Punctate liquefactive degeneration of basal layer cells was observed.", + "Melanophages in the dermis were present.", + "A few lymphocytes infiltrated around the dermal adnexa.", + "Masson-Fontana silver staining showed amounts of melanin in the epidermis and dermis.", + "The peripheral white blood cell (WBC) count was 2.73 × 109/L.", + "The antinuclear antibody (ANA) was (+++).", + "The anti-dsDNA antibody (dsDNA) was (+).", + "The anti-Sjögren’s-syndrome-related antigen antibody A was (+++).", + "C3 was 0.48 g/L.", + "C4 was 0.06 g/L.", + "Anti-thyroglobulin antibody (TGAb) was >4000 IU/mL.", + "Anti-thyroid peroxidase (ATPO) was >600 IU/mL.", + "Thyroid stimulating hormone (TSH) was 92 mIU/L.", + "Thyronine-4 (T4) was 2.5 μg/dl.", + "Doppler ultrasonography of the thyroid showed hypothyroidism changes and a nodular thyroid cyst.", + "Diagnoses of RM accompanied with SLE and Hashimoto’s thyroiditis of primary hypothyroidism were made.", + "Prednisone (20 mg/day), hydroxychloroquine (400 mg/day), and L-thyroxine (100 μg/day) were administered orally.", + "The prednisone was withdrawn gradually over the course of 7 months.", + "Significant improvement was observed after 14 months of treatment.", + "The hyperpigmentation has turned much lighter.", + "Under reflectance confocal microscopy, the melanin in the epidermis was found to have decreased significantly.", + "The local liquefactive degeneration of basal layer cells showed improvement.", + "The melanophages in dermis was found to have decreased in number.", + "WBC, C3, C4, and T4 returned to normal.", + "The TSH decreased to 5.667 mIU/L." + ], + "summary": "We report a case of RM patient accompanied with SLE and Hashimoto's thyroiditis of primary hypothyroidism. Progressing, diffuse, symmetric, and reticular hyperpigmentation was seen on the face, neck, and upper limbs, manifesting as typical melanosis. Skin microscopy showed diffuse black-pepper-like changes and telangiectasias. The diagnosis of SLE and primary hypothyroidism were confirmed by follow-up investigations. The hyperpigmentation turned notably lighter after 14 months of treatment with prednisone, hydroxychloroquine, and L-thyroxine.", + "summary_subclaims": [ + "The patient had a case of RM accompanied with SLE and Hashimoto's thyroiditis of primary hypothyroidism.", + "The patient had progressing, diffuse, symmetric, and reticular hyperpigmentation on the face, neck, and upper limbs.", + "The hyperpigmentation was described as typical melanosis.", + "Skin microscopy showed diffuse black-pepper-like changes.", + "Skin microscopy showed telangiectasias.", + "The diagnosis of SLE and primary hypothyroidism were confirmed by follow-up investigations.", + "The hyperpigmentation turned notably lighter after 14 months of treatment.", + "The treatment included prednisone.", + "The treatment included hydroxychloroquine.", + "The treatment included L-thyroxine." + ] + }, + { + "id": "multiclinsum_test_2654_en.txt", + "fulltext": "Our patient was a 71-year-old Caucasian non-Hispanic male who presented with chronic left knee pain after undergoing a TKA 18 months prior. He had an uncomplicated past medical history of hypertension, hyperlipidemia, and reflux, which were well controlled with medical management. He was 70 inches tall and weighed 215 lbs. He had no history of any additional surgeries. He was married and lived at home with his wife. He was now retired and prior to his surgery maintained an active lifestyle including exercise and daily life activities. His social history included social alcohol consumption and was negative for tobacco use .\nFollowing his TKA, the patient complained of persistent and progressively worsening post-operative pain of his knee. Orthopedic evaluation determined his implant to be normally functioning without evidence of hardware loosening or infection. On presentation, he described the pain as sharp, 7/10 (VAS) in severity though poorly defined, with radiation to the left ankle, and associated paresthesias in the same distribution. On physical exam, he experienced symptoms of hyperesthesia and allodynia along the anterior aspect of his knee. His postsurgical incision was well healed, without evidence of erythema, swelling, or gross changes in color. Strength was 5/5 with flexion and extension of the lower left leg, but was limited by guarding due to pain. His right lower extremity had 5/5 strength in all myotomes, and otherwise he had 5/5 strength in the left leg with flexion and extension of the thigh, inversion, eversion, plantar flexion, and dorsiflexion of his left foot.\nGiven his symptomatology of hyperesthesia, allodynia, preserved strength, and absence of orthopedic aberrancy, a diagnosis of postsurgical CRPS of the left lower extremity was made. Initial management of his pain was conservative including physical therapy, non-steroidal anti-inflammatory, muscle relaxant, neuropathic, and opioid medications, which provided little or no relief of symptoms. Following a trial of lumbar sympathetic block, he reported improvement in pain, with a reduction on VAS to 3/10, lasting approximately 1 month in duration. Given a dramatic improvement in his knee symptoms, he subsequently underwent a successful SCS trial and uneventful implantation of two 16-contact Boston Scientific leads with a Boston Scientific Spectra WaveWriter™ SCS system. His generator was programmed to provide simultaneous traditional paresthesia-based therapy at a frequency of 50 Hz along with the combination of burst therapy at a frequency of 450 Hz, with six pulses per burst, as well as sub perception stimulation therapy at a frequency of 1.2 kHz. Upon first post-procedural follow-up, the patient experienced dramatic pain relief, reporting complete resolution of his symptoms. Moreover, at 6 months post SCS implantation, he continued to experience complete resolution and had successfully completed an opioid wean to discontinuation.", + "fulltext_subclaims": [ + "The patient was a 71-year-old Caucasian non-Hispanic male.", + "He had a total knee arthroplasty 18 months prior.", + "He had an uncomplicated past medical history of hypertension, hyperlipidemia, and reflux.", + "He was 70 inches tall and weighed 215 lbs.", + "He had no history of any additional surgeries.", + "He was married and lived at home with his wife.", + "He was now retired.", + "He had social alcohol consumption.", + "He was negative for tobacco use.", + "Following his TKA, the patient complained of persistent and progressively worsening post-operative pain of his knee.", + "Orthopedic evaluation determined his implant to be normally functioning without evidence of hardware loosening or infection.", + "On presentation, he described the pain as sharp, 7/10 (VAS) in severity though poorly defined, with radiation to the left ankle, and associated paresthesias in the same distribution.", + "On physical exam, he experienced symptoms of hyperesthesia and allodynia along the anterior aspect of his knee.", + "His postsurgical incision was well healed, without evidence of erythema, swelling, or gross changes in color.", + "Strength was 5/5 with flexion and extension of the lower left leg, but was limited by guarding due to pain.", + "His right lower extremity had 5/5 strength in all myotomes.", + "Otherwise, he had 5/5 strength in the left leg with flexion and extension of the thigh, inversion, eversion, plantar flexion, and dorsiflexion of his left foot.", + "A diagnosis of postsurgical CRPS of the left lower extremity was made.", + "Initial management of his pain was conservative including physical therapy, non-steroidal anti-inflammatory, muscle relaxant, neuropathic, and opioid medications, which provided little or no relief of symptoms.", + "Following a trial of lumbar sympathetic block, he reported improvement in pain, with a reduction on VAS to 3/10, lasting approximately 1 month in duration.", + "Given a dramatic improvement in his knee symptoms, he subsequently underwent a successful SCS trial and uneventful implantation of two 16-contact Boston Scientific leads with a Boston Scientific Spectra WaveWriter™ SCS system.", + "His generator was programmed to provide simultaneous traditional paresthesia-based therapy at a frequency of 50 Hz along with the combination of burst therapy at a frequency of 450 Hz, with six pulses per burst, as well as sub perception stimulation therapy at a frequency of 1.2 kHz.", + "Upon first post-procedural follow-up, the patient experienced dramatic pain relief, reporting complete resolution of his symptoms.", + "At 6 months post SCS implantation, he continued to experience complete resolution and had successfully completed an opioid wean to discontinuation." + ], + "summary": "We present a 71-year-old Caucasian non-Hispanic male who presented with chronic left knee pain after undergoing a total knee arthroplasty (TKA) 18 months prior. Following his TKA, he reported doing well in the acute post-operative period but began to develop progressively worsening left knee pain at approximately the third post-operative week. He underwent a successful spinal cord stimulator (SCS) trial and subsequent implantation of two 16-contact Boston Scientific leads with a Boston Scientific Spectra WaveWriterTM SCS system. Upon first post-procedural follow-up, and moreover at his 6-month follow-up, the patient reported complete resolution of his symptoms.", + "summary_subclaims": [ + "The patient is a 71-year-old Caucasian non-Hispanic male.", + "The patient had a total knee arthroplasty 18 months prior.", + "He reported doing well in the acute post-operative period.", + "He began to develop progressively worsening left knee pain at approximately the third post-operative week.", + "He underwent a successful spinal cord stimulator trial.", + "He had implantation of two 16-contact Boston Scientific leads.", + "He received a Boston Scientific Spectra WaveWriterTM SCS system.", + "Upon first post-procedural follow-up, the patient reported complete resolution of his symptoms.", + "At his 6-month follow-up, the patient reported complete resolution of his symptoms." + ] + }, + { + "id": "multiclinsum_test_434_en.txt", + "fulltext": "The patient was a 40-year-old Moroccan man who had been vaccinated with bacillus Calmette–Guérin (BCG). He did not have any signs of previous TB infection or a history of sexually transmitted infections. The patient visited our hospital for a urology consultation and presented with dysuria, purulent discharge and a meatic penoscrotal fistula that had developed over a one-year period. The physical examination at admission found nodular lesions, urethral induration on the urethral path extending laterally to the cavernous bodies with multiple fistulas, and penoscrotal pus excretion . The external genitalia examination, testis, epididymis and ductus deferens, were without remarkable signs. His prostate volume was normal with a soft consistency. His prostate volume was normal with a soft consistency.\nThe initial biological assessment revealed an inflammatory syndrome corresponding to a sedimentation speed of 80 associated with a urinary tract infection with Escherichia coli susceptible to fluoroquinolones. First, the patient received antibiotherapy based on ciprofloxacin and benefited from urinary drainage by suprapubic catheter. A retrograde and voiding urethrocystography (UCG) was then performed and revealed an extended narrowing of the whole anterior urethra associated with multiple fistulous portions toward the scrotum and perineum. The bladder control showed a bilateral secondary vesico-ureteric reflux . At this stage, we reached a diagnosis of nonspecific sclero-inflammatory urethral stricture with complicating fistulas. After six weeks of urinary drainage and antibiotherapy, we decided to perform a urethroplasty enlargement to clear the narrowing urethral sinus tracts .\nThe evolution was marked by delayed wound healing associated with the persistence of fistulas extending into the corpus cavernosum with purulent discharge. It was at this point of the treatment that we suspected TB and we carried out a biological assessment in this regard. His test result for Koch bacillus (BK) in the urine was negative. His tuberculin assessment result was positive. Multiple biopsies were then performed on the periurethral tissue and fistula tracts.\nThe histological examination confirmed urethral TB and showed the presence of giant cell epithelial lesions with caseous necrosis characteristic of TB. The treatment for TB was immediately established and marked by a localized, rapid and significant improvement. A second-stage urethroplasty was scheduled for two months after the start of his anti-TB treatment.", + "fulltext_subclaims": [ + "The patient was a 40-year-old Moroccan man.", + "He had been vaccinated with bacillus Calmette–Guérin (BCG).", + "He did not have any signs of previous TB infection.", + "He did not have a history of sexually transmitted infections.", + "The patient visited our hospital for a urology consultation.", + "He presented with dysuria.", + "He presented with purulent discharge.", + "He presented with a meatic penoscrotal fistula that had developed over a one-year period.", + "The physical examination at admission found nodular lesions.", + "The physical examination at admission found urethral induration on the urethral path extending laterally to the cavernous bodies.", + "The physical examination at admission found multiple fistulas.", + "The physical examination at admission found penoscrotal pus excretion.", + "The external genitalia examination, testis, epididymis and ductus deferens were without remarkable signs.", + "His prostate volume was normal with a soft consistency.", + "The initial biological assessment revealed an inflammatory syndrome.", + "The initial biological assessment revealed a sedimentation speed of 80.", + "The initial biological assessment revealed a urinary tract infection with Escherichia coli.", + "The Escherichia coli was susceptible to fluoroquinolones.", + "The patient received antibiotherapy based on ciprofloxacin.", + "The patient benefited from urinary drainage by suprapubic catheter.", + "A retrograde and voiding urethrocystography (UCG) was performed.", + "The UCG revealed an extended narrowing of the whole anterior urethra.", + "The UCG revealed multiple fistulous portions toward the scrotum and perineum.", + "The bladder control showed a bilateral secondary vesico-ureteric reflux.", + "At this stage, we reached a diagnosis of nonspecific sclero-inflammatory urethral stricture with complicating fistulas.", + "After six weeks of urinary drainage and antibiotherapy, we decided to perform a urethroplasty enlargement.", + "The evolution was marked by delayed wound healing.", + "The evolution was marked by the persistence of fistulas extending into the corpus cavernosum.", + "The evolution was marked by purulent discharge.", + "It was at this point of the treatment that we suspected TB.", + "We carried out a biological assessment in this regard.", + "His test result for Koch bacillus (BK) in the urine was negative.", + "His tuberculin assessment result was positive.", + "Multiple biopsies were performed on the periurethral tissue.", + "Multiple biopsies were performed on the fistula tracts.", + "The histological examination confirmed urethral TB.", + "The histological examination showed the presence of giant cell epithelial lesions.", + "The histological examination showed caseous necrosis characteristic of TB.", + "The treatment for TB was immediately established.", + "The treatment for TB marked a localized, rapid and significant improvement.", + "A second-stage urethroplasty was scheduled for two months after the start of his anti-TB treatment." + ], + "summary": "The patient, a Moroccan man, was 40 years old. He visited our hospital for a urology consultation and presented with dysuria, purulent discharge and a meatic penoscrotal fistula. A retrograde and voiding urethrocystography was performed and revealed an extended narrowing of the whole anterior urethra associated with multiple fistulous portions toward the scrotum and perineum. At this stage, we reached a diagnosis of nonspecific sclero-inflammatory urethral stricture with complicating fistulas. We decided to perform a urethroplasty enlargement to clear the narrowing urethral sinus tracts. The evolution was marked by delayed wound healing associated with the persistence of fistulas extending into the corpus cavernosum with purulent discharge. It was at this point in the treatment that we suspected tuberculosis. Multiple biopsies were then performed on the periurethral tissue and fistula tracts. The histological examination confirmed urethral tuberculosis and showed the presence of giant cell epithelial lesions with caseous necrosis characteristic of tuberculosis. The treatment for tuberculosis was immediately established and the evolution was marked by a localized, rapid and significant improvement. A second-stage urethroplasty was scheduled for two months after the start of his antituberculous treatment.", + "summary_subclaims": [ + "The patient was a 40-year-old Moroccan man.", + "He visited the hospital for a urology consultation.", + "He presented with dysuria.", + "He had a purulent discharge.", + "He had a meatic penoscrotal fistula.", + "A retrograde and voiding urethrocystography was performed.", + "The imaging revealed an extended narrowing of the whole anterior urethra.", + "The imaging showed multiple fistulous portions toward the scrotum and perineum.", + "The diagnosis was nonspecific sclero-inflammatory urethral stricture with complicating fistulas.", + "A urethroplasty enlargement was decided to clear the narrowing urethral sinus tracts.", + "The evolution was marked by delayed wound healing.", + "The evolution was marked by the persistence of fistulas extending into the corpus cavernosum.", + "The fistulas were associated with purulent discharge.", + "Tuberculosis was suspected at this point in the treatment.", + "Multiple biopsies were performed on the periurethral tissue and fistula tracts.", + "The histological examination confirmed urethral tuberculosis.", + "The histological examination showed the presence of giant cell epithelial lesions.", + "The histological examination showed caseous necrosis characteristic of tuberculosis.", + "The treatment for tuberculosis was immediately established.", + "The evolution was marked by a localized, rapid, and significant improvement.", + "A second-stage urethroplasty was scheduled for two months after the start of antituberculous treatment." + ] + }, + { + "id": "multiclinsum_test_3019_en.txt", + "fulltext": "Past Medical History\nThe patient had end-stage renal disease treated with hemodialysis, bilateral hip osteoarthritis with a previous right hip arthroplasty, hypertension, atrial fibrillation treated with warfarin (Coumadin), previous myocardial infarction requiring coronary artery bypass grafting, and monomorphic ventricular tachycardia (VT) arrest requiring a dual-chamber, single-coil ICD 9 months earlier. Lead models included a Medtronic 5076 CapSureFix Novus magnetic resonance imaging (MRI) SureScan right atrial lead and a Medtronic 6935M Sprint Quattro Secure S MRI SureScan right ventricular lead. Two months earlier, he had experienced fevers during dialysis and recurrent S. maltophilia bacteremia, presumed to be from infected tunneled hemodialysis catheters. He had undergone 3 hemodialysis catheter replacements and had received intravenous (IV) antibiotics. However, before a planned left hip arthroplasty, preoperative blood cultures regrew S. maltophilia. He was admitted to an outside hospital and started on IV ceftazidime. Given his ongoing fevers, he left the outside hospital against medical advice for a second opinion at our hospital.\n\nDifferential Diagnosis\nIt was reasonable to suspect that hemodialysis catheters were the source of bacteremia because of frequent venous access and fevers during dialysis. According to Heart Rhythm Society (HRS), European Heart Rhythm Association (EHRA),2 and American Heart Association (AHA) guidelines, in cases of nonstaphylococcal bacteremia without evidence of cardiac implantable electronic device (CIED) infection, eliminating accessible non-CIED sources of infection comes first. Persistent bacteremia, despite appropriate IV antibiotic treatment and removal of alternative sources, should raise concern for ICD seeding.\n\n\nInvestigations\n\nHospitalization for second opinion and initial fluorodeoxyglucose positron emission tomography screening\n\nThis strain of S. maltophilia was susceptible to ceftazidime, trimethoprim-sulfamethoxazole (TMP-SMX), and levofloxacin. However, the patient was switched from IV ceftazidime to IV TMP-SMX upon arrival to our hospital because of his recent fevers and recommendations to avoid ceftazidime monotherapy for S. maltophilia, according to Infectious Disease Society of America (IDSA) guidelines. Infectious disease specialists recommended a fluorine-18 fluorodeoxyglucose positron emission tomography with computed tomography (18F-FDG PET/CT) scan, which demonstrated increased activity around the left hip joint but no ICD involvement. Orthopedic surgery ruled out septic arthritis in view of the absence of clinical symptoms. Results of 2 blood cultures obtained during the current admission remained negative for 72 hours. Given the low association of gram-negative organisms with device seeding and clearance of blood cultures following a hemodialysis catheter removal (2 days earlier), the ICD was left in place. The patient was discharged with 6 weeks of IV TMP-SMX at 5 mg/kg every 24 hours.1 Oral levofloxacin was prescribed for synergistic effect, but the patient never filled the prescription.\n\nReadmission and Repeat FDG PET/CT Screening\nAfter the IV TMP-SMX course, the patient had clinical improvement and began using an arteriovenous fistula for dialysis. Two months later, he developed superficial pocket erythema and was started on oral cephalexin (Keflex). One month afterward, he had recurrent S. maltophilia bacteremia and was restarted on IV ceftazidime through dialysis. Because of his persistent bacteremia, he was readmitted for further diagnostic work-up.\n\nThere was again no evidence of pocket infection. Transesophageal echocardiography showed no lead or valvular vegetations (Figures 2A to 2E). Computed tomography of the chest was clear. Whole-body FDG PET/CT was repeated to screen for occult sources of infection before proceeding with device extraction. FDG PET/CT revealed uptake along device leads, a finding suggesting CIED infection.\n\nManagement\nThe patient’s antibiotics were again switched from ceftazidime to IV TMP-SMX, 5 mg/kg daily. Oral levofloxacin, 500 mg every 48 hours, was added for synergistic effects. Electrophysiology was consulted for ICD removal. ICD interrogation revealed sinus bradycardia at 57 beats/min, minimal pacing, and no recent arrhythmias or shocks. The ICD was successfully extracted percutaneously. Extraction proved moderately challenging because the device’s active fixation mechanism failed to retract. With careful traction and countertraction, the right atrial and right ventricular leads were removed intact without complications.\nDevice lead cultures grew S. maltophilia. Given his history of sudden cardiac death and the need for an ICD for secondary prevention, the patient was discharged with a wearable defibrillator. Despite blood culture clearance at 72 hours, device reimplantation was deferred pending 8 weeks of oral TMP-SMX double strength 3 tablets daily and oral levofloxacin, 500 mg every 48 hours, to ensure bacteremia resolution.", + "fulltext_subclaims": [ + "The patient had end-stage renal disease treated with hemodialysis.", + "The patient had bilateral hip osteoarthritis with a previous right hip arthroplasty.", + "The patient had atrial fibrillation treated with warfarin.", + "The patient had a previous myocardial infarction requiring coronary artery bypass grafting.", + "The patient had monomorphic ventricular tachycardia (VT) arrest requiring a dual-chamber, single-coil ICD 9 months earlier.", + "The patient had fevers during dialysis.", + "The patient had recurrent S. maltophilia bacteremia.", + "The patient had undergone 3 hemodialysis catheter replacements.", + "The patient had received intravenous antibiotics.", + "Preoperative blood cultures regrew S. maltophilia.", + "The patient was admitted to an outside hospital and started on IV ceftazidime.", + "The patient left the outside hospital against medical advice.", + "It was reasonable to suspect that hemodialysis catheters were the source of bacteremia.", + "According to HRS, EHRA, and AHA guidelines, eliminating accessible non-CIED sources of infection comes first.", + "Persistent bacteremia, despite appropriate IV antibiotic treatment and removal of alternative sources, should raise concern for ICD seeding.", + "This strain of S. maltophilia was susceptible to ceftazidime, trimethoprim-sulfamethoxazole, and levofloxacin.", + "The patient was switched from IV ceftazidime to IV TMP-SMX.", + "Infectious disease specialists recommended an 18F-FDG PET/CT scan.", + "The PET/CT scan demonstrated increased activity around the left hip joint.", + "Orthopedic surgery ruled out septic arthritis.", + "Results of 2 blood cultures obtained during the current admission remained negative for 72 hours.", + "The ICD was left in place.", + "The patient was discharged with 6 weeks of IV TMP-SMX.", + "Oral levofloxacin was prescribed for synergistic effect.", + "The patient never filled the prescription.", + "The patient had clinical improvement and began using an arteriovenous fistula for dialysis.", + "Two months later, the patient developed superficial pocket erythema.", + "The patient was started on oral cephalexin.", + "One month afterward, the patient had recurrent S. maltophilia bacteremia.", + "The patient was restarted on IV ceftazidime through dialysis.", + "There was again no evidence of pocket infection.", + "Transesophageal echocardiography showed no lead or valvular vegetations.", + "Computed tomography of the chest was clear.", + "Whole-body FDG PET/CT was repeated.", + "FDG PET/CT revealed uptake along device leads.", + "The patient’s antibiotics were again switched from ceftazidime to IV TMP-SMX.", + "Oral levofloxacin was added for synergistic effects.", + "Electrophysiology was consulted for ICD removal.", + "ICD interrogation revealed sinus bradycardia at 57 beats/min.", + "The ICD was successfully extracted percutaneously.", + "Device lead cultures grew S. maltophilia.", + "The patient was discharged with a wearable defibrillator.", + "Device reimplantation was deferred.", + "The patient was prescribed 8 weeks of oral TMP-SMX double strength.", + "The patient was prescribed oral levofloxacin, 500 mg every 48 hours." + ], + "summary": "A 57-year-old man with end-stage renal disease and an implantable cardioverter-defibrillator (ICD) for secondary prevention developed persistent Stenotrophomonas maltophilia bacteremia despite intravenous antibiotics and elimination of alternative infection sources. He had no pocket infection or echocardiographic evidence of endocarditis. Serial fluorine-18 fluorodeoxyglucose positron emission tomography combined with-computed tomography (18F-FDG PET/CT) demonstrated ICD seeding. The device was extracted, and the patient was treated with trimethoprim-sulfamethoxazole and levofloxacin, with bacteremia resolution. Results of intraoperative cultures confirmed device infection with S. maltophilia, a multidrug-resistant, biofilm-forming, gram-negative pathogen. The ICD was later reimplanted subcutaneously to lower the infection risk.", + "summary_subclaims": [ + "The patient is a 57-year-old man with end-stage renal disease.", + "The patient has an implantable cardioverter-defibrillator (ICD) for secondary prevention.", + "The patient developed persistent Stenotrophomonas maltophilia bacteremia.", + "The patient received intravenous antibiotics.", + "Alternative infection sources were eliminated.", + "The patient had no pocket infection.", + "There was no echocardiographic evidence of endocarditis.", + "Serial fluorine-18 fluorodeoxyglucose positron emission tomography combined with-computed tomography (18F-FDG PET/CT) demonstrated ICD seeding.", + "The ICD was extracted.", + "The patient was treated with trimethoprim-sulfamethoxazole and levofloxacin.", + "The bacteremia resolved.", + "Intraoperative cultures confirmed device infection with S. maltophilia.", + "Stenotrophomonas maltophilia is a multidrug-resistant, biofilm-forming, gram-negative pathogen.", + "The ICD was later reimplanted subcutaneously." + ] + }, + { + "id": "multiclinsum_test_408_en.txt", + "fulltext": "A 19-month-old Ethiopian baby boy from Addis Ababa, Ethiopia, presented with a left-sided body weakness of 4 days’ duration to Tikur Anbessa Specialized Hospital. The weakness of his left upper and lower extremities was noted by his mother upon awakening from sleep. He also had a low grade intermittent fever and weight loss (not quantified) for the preceding 1 month. His mother had symptoms of cough, sweating, and weight loss for the past 3 months for which she did not seek medical attention.\nHe was born at term to a primiparous woman, diagnosed as having HIV infection since her second month of pregnancy. Antiretroviral treatment (ART) was initiated along with diagnosis and she delivered via caesarean section. She opted for exclusive breast feeding. The newborn was given nevirapine prophylaxis immediately after delivery but both the mother’s and neonate’s ART were discontinued on the third day of life due to poor social support for the family. The child did not receive any further care for exposure to HIV infection. He had received all the vaccines of the national immunization schedule. His developmental milestones were optimal.\nOn physical examination, his vital signs were within normal limits. He was stunted with height measuring 71 cm (less than 5th centile for age). He had pale conjunctivae with 1.5 by 1 cm right and left axillary lymphadenopathies. He was fully conscious. A neurologic examination revealed left-sided hypertonia, hyper-reflexia, and weakness (left upper extremity 0/5 and left lower extremity 3/5).\nA complete blood count showed white blood cell (WBC) of 5700/mm3 with 64% neutrophils and 23% lymphocytes. His hemoglobin was 7.6 gm/dl, mean corpuscular volume (MCV) 66.1 fl, and platelets 261,000/mm3. Erythrocyte sedimentation rate (ESR) was 107 mm/hour and HIV serology test was reactive. Baseline tests showed a CD4 count of 320/mm3, CD4 percentage of 14%, and a viral load of 690,000 copies/ml. Serum Venereal Disease Research Laboratory (VDRL) test was non-reactive. Cerebrospinal fluid (CSF) analysis had no cells, with normal CSF glucose and protein. CSF VDRL was non-reactive. Organ function tests and lipid profiles were within normal limits. Coagulation profile tests showed a prothrombin time (PT) of 14.4 seconds, activated partial thromboplastin time (PTT) of 23.1 seconds, and international normalized ratio (INR) of 1.13. Testing for serum protein C and protein S levels was not possible in our hospital.\nA chest X-ray revealed bilateral, mainly central, nodular opacities. Echocardiography was normal. Multiple hypoechoic splenic lesions and periportal lymphadenopathy were evident on an abdominal ultrasound. A computed tomography (CT) scan of his brain showed right temporoparietal M1 segment of middle cerebral artery territory acute ischemic infarct.\nA CT angiography of his brain confirmed the above findings along with hemorrhagic transformation.\nA diagnoses list of stunted, disseminated TB (lung, spleen, abdominal lymph nodes, and brain), iron deficiency anemia, left-sided hemiparesis due to ischemic stroke possibly due to tuberculous vasculitis, and a newly diagnosed HIV infection was made. Co-trimoxazole prophylaxis, anti-TB treatment (isoniazid, rifampicin, pyrazinamide, and ethambutol) along with steroids and pyridoxine, aspirin, and iron supplementation were initiated as well as physiotherapy. Within 2 weeks of starting treatment, ART with abacavir, lamivudine and lopinavir/ritonavir was started.\nHe has currently completed his anti-TB treatment (2 months of isoniazid, rifampicin, pyrazinamide, and ethambutol and 10 months of isoniazid and rifampicin) as well as being on ART. His examination shows normal tone and reflexes with his left upper extremity having a power of 3/5 but his left lower extremity having a power of 5/5.", + "fulltext_subclaims": [ + "A 19-month-old Ethiopian baby boy from Addis Ababa, Ethiopia, presented with a left-sided body weakness of 4 days’ duration to Tikur Anbessa Specialized Hospital.", + "The weakness of his left upper and lower extremities was noted by his mother upon awakening from sleep.", + "He had a low grade intermittent fever and weight loss for the preceding 1 month.", + "His mother had symptoms of cough, sweating, and weight loss for the past 3 months.", + "The mother did not seek medical attention.", + "He was born at term to a primiparous woman.", + "The mother was diagnosed as having HIV infection since her second month of pregnancy.", + "Antiretroviral treatment (ART) was initiated along with diagnosis.", + "She delivered via caesarean section.", + "The newborn was given nevirapine prophylaxis immediately after delivery.", + "Both the mother’s and neonate’s ART were discontinued on the third day of life due to poor social support for the family.", + "The child did not receive any further care for exposure to HIV infection.", + "He had received all the vaccines of the national immunization schedule.", + "His developmental milestones were optimal.", + "On physical examination, his vital signs were within normal limits.", + "He was stunted with height measuring 71 cm (less than 5th centile for age).", + "He had pale conjunctivae with 1.5 by 1 cm right and left axillary lymphadenopathies.", + "A neurologic examination revealed left-sided hypertonia, hyper-reflexia, and weakness (left upper extremity 0/5 and left lower extremity 3/5).", + "A complete blood count showed white blood cell (WBC) of 5700/mm3 with 64% neutrophils and 23% lymphocytes.", + "His hemoglobin was 7.6 gm/dl, mean corpuscular volume (MCV) 66.1 fl, and platelets 261,000/mm3.", + "Erythrocyte sedimentation rate (ESR) was 107 mm/hour.", + "HIV serology test was reactive.", + "Baseline tests showed a CD4 count of 320/mm3, CD4 percentage of 14%, and a viral load of 690,000 copies/ml.", + "Serum Venereal Disease Research Laboratory (VDRL) test was non-reactive.", + "Cerebrospinal fluid (CSF) analysis had no cells, with normal CSF glucose and protein.", + "CSF VDRL was non-reactive.", + "A chest X-ray revealed bilateral, mainly central, nodular opacities.", + "A computed tomography (CT) scan of his brain showed right temporoparietal M1 segment of middle cerebral artery territory acute ischemic infarct.", + "A CT angiography of his brain confirmed the above findings along with hemorrhagic transformation.", + "A diagnoses list of stunted, disseminated TB (lung, spleen, abdominal lymph nodes, and brain), iron deficiency anemia, left-sided hemiparesis due to ischemic stroke possibly due to tuberculous vasculitis, and a newly diagnosed HIV infection was made.", + "Co-trimoxazole prophylaxis, anti-TB treatment (isoniazid, rifampicin, pyrazinamide, and ethambutol) along with steroids and pyridoxine, aspirin, and iron supplementation were initiated as well as physiotherapy.", + "Within 2 weeks of starting treatment, ART with abacavir, lamivudine and lopinavir/ritonavir was started.", + "He has currently completed his anti-TB treatment (2 months of isoniazid, rifampicin, pyrazinamide, and ethambutol and 10 months of isoniazid and rifampicin) as well as being on ART.", + "His examination shows normal tone and reflexes with his left upper extremity having a power of 3/5 but his left lower extremity having a power of 5/5." + ], + "summary": "We report the case of a 19-month-old Ethiopian boy who presented with a left-sided body weakness of sudden onset. He was also diagnosed as having human immunodeficiency virus infection. Laboratory tests showed an iron deficiency anemia and imaging revealed tuberculosis of his lungs, spleen, and abdominal lymph nodes as well as an acute ischemic stroke of the right middle cerebral artery region. His symptoms improved after anti-tuberculosis drugs, antiretroviral treatment, and iron supplementation were initiated.", + "summary_subclaims": [ + "The patient is a 19-month-old Ethiopian boy.", + "He presented with a left-sided body weakness of sudden onset.", + "He was diagnosed as having human immunodeficiency virus infection.", + "Laboratory tests showed an iron deficiency anemia.", + "Imaging revealed tuberculosis of his lungs.", + "Imaging revealed tuberculosis of his spleen.", + "Imaging revealed tuberculosis of his abdominal lymph nodes.", + "Imaging revealed an acute ischemic stroke of the right middle cerebral artery region.", + "His symptoms improved after anti-tuberculosis drugs were initiated.", + "His symptoms improved after antiretroviral treatment was initiated.", + "His symptoms improved after iron supplementation was initiated." + ] + }, + { + "id": "multiclinsum_test_77_en.txt", + "fulltext": "A 65-year-old Japanese woman was admitted to our hospital with dysphagia and was diagnosed with clinical T2N0M0 stage IIA [Union for International Cancer Control (UICC), 8th edition] esophageal squamous cell carcinoma. She was treated with concurrent chemoradiotherapy (CRT). The chemoradiotherapy protocol was consistent with that of the Japan Clinical Oncology Group trial 9906; the patient received two cycles of intravenous cisplatin infusions with continuous 5-fluorouracil (5-FU) infusion and concurrent radiotherapy of 60 Gy (30 fractions of 2 Gy) . Two months after the entire course of CRT, esophagoscopy revealed a residual tumor and salvage esophagectomy was performed. Right thoracoscopic access for esophagectomy was achieved in the prone position, and hand-assisted laparoscopic technique was performed in the supine position. After the hiatus was dilated by manual blunt force through four fingerbreadths, gastric reconstruction was performed through the posterior mediastinal route and by cervical esophagogastric anastomosis. The gastric conduit was fixed to the hiatus with two non-absorbable sutures. The postoperative course was uneventful, and the patient was discharged on the 21st postoperative day and diagnosed with pathological stage IB (T1bN0M0) squamous cell carcinoma. Three years after esophagectomy, two metastatic nodules in the lateral and posterior segments of the liver were detected on follow-up CT. As the postoperative performance status of the patient had worsened, she was then treated with only oral anticancer drugs (tegafur-gimeracil-oteracil potassium).\nSix months later, the patient was readmitted for anorexia of a few weeks’ duration. On admission, heart rate and mean blood pressure were 98/min and 59 mmHg, respectively, suggesting a state of shock. Peripheral blood examination showed that the white blood cells were in the normal range; however, the C-reactive protein (CRP) level was elevated to 32.1 mg/dL. Arterial blood gas analysis on room air showed acidosis. Blood urea nitrogen and creatinine levels were elevated to 91 mg/dL and 4.99 mg/dL, respectively, suggesting renal dysfunction or severe dehydration . Non-contrast computed tomography revealed digestive tract prolapsing into the right side of the mediastinum, which was distended with air and fluid . The patient was diagnosed with postoperative hiatal hernia with incarcerated digestive tract, and emergency operative repair was performed with open surgery through the abdomen. The distal transverse colon was incarcerated through the left side of diaphragmatic hiatal defect into the right mediastinum around the back of the gastric conduit . When a part of the adhesion around the hiatus was exposed, digestive fluid was eluted from the mediastinum. It was difficult to expose the colon safely due to the strength of the adhesion in the mediastinum. In addition, the gastroepiploic artery, preserved as the feeding artery and located on the left side of the gastric conduit, made it difficult to pull the transverse colon and expose the adhesion in the mediastinum. Finally, after manual repositioning of the herniated content, the transverse colon, incarcerated into the mediastinum, was resected due to perforation and a transverse colostomy was performed. After reduction of the herniated bowels, the mediastinum and abdominal cavity were manually lavaged and the drainage tube was placed in the mediastinum via the hiatus. The right side of the pleural cavity was also lavaged through the widened hiatus, without thoracotomy, which would have been invasive for the patient. The dilated diaphragmatic hiatal defect was closed with sutures, and the gastric conduit was fixed to the crus with 2–0 non-absorbable sutures. The total operation time was 233 min, and the intraoperative blood loss was 770 mL. Macroscopic analysis of the resected specimen revealed perforation in the edematous lesion of the colon without necrosis . Postoperatively, the patient was transferred to the intensive care unit (ICU) and was on a ventilator. The patient was diagnosed with septic shock due to acute mediastinitis, and broad-spectrum antibiotics and vasopressor agents were administered. Continuous hemodiafiltration and polymyxin B hemoperfusion were administered for the first 3 days. The patient stayed in the ICU for 16 days, and oral intake was initiated on the 18th postoperative day. The patient was discharged from the hospital on the 53rd postoperative day. The patient’s condition deteriorated following surgery, and she did not receive any further chemotherapy or radiotherapy. Only palliative care services were provided, and she is alive one and half years after surgery.", + "fulltext_subclaims": [ + "A 65-year-old Japanese woman was admitted to our hospital with dysphagia.", + "She was diagnosed with clinical T2N0M0 stage IIA esophageal squamous cell carcinoma.", + "The staging was according to the Union for International Cancer Control (UICC), 8th edition.", + "She was treated with concurrent chemoradiotherapy (CRT).", + "The chemoradiotherapy protocol was consistent with that of the Japan Clinical Oncology Group trial 9906.", + "The patient received two cycles of intravenous cisplatin infusions with continuous 5-fluorouracil (5-FU) infusion.", + "The patient received concurrent radiotherapy of 60 Gy (30 fractions of 2 Gy).", + "Two months after the entire course of CRT, esophagoscopy revealed a residual tumor.", + "Salvage esophagectomy was performed.", + "Right thoracoscopic access for esophagectomy was achieved in the prone position.", + "Hand-assisted laparoscopic technique was performed in the supine position.", + "After the hiatus was dilated by manual blunt force through four fingerbreadths, gastric reconstruction was performed.", + "The gastric reconstruction was through the posterior mediastinal route.", + "The gastric reconstruction was by cervical esophagogastric anastomosis.", + "The gastric conduit was fixed to the hiatus with two non-absorbable sutures.", + "The postoperative course was uneventful.", + "The patient was discharged on the 21st postoperative day.", + "The patient was diagnosed with pathological stage IB (T1bN0M0) squamous cell carcinoma.", + "Three years after esophagectomy, two metastatic nodules in the lateral and posterior segments of the liver were detected on follow-up CT.", + "The patient was treated with only oral anticancer drugs (tegafur-gimeracil-oteracil potassium).", + "Six months later, the patient was readmitted for anorexia of a few weeks’ duration.", + "On admission, heart rate was 98/min.", + "On admission, mean blood pressure was 59 mmHg.", + "The C-reactive protein (CRP) level was elevated to 32.1 mg/dL.", + "Arterial blood gas analysis on room air showed acidosis.", + "Blood urea nitrogen was elevated to 91 mg/dL.", + "Creatinine was elevated to 4.99 mg/dL.", + "Non-contrast computed tomography revealed digestive tract prolapsing into the right side of the mediastinum.", + "The patient was diagnosed with postoperative hiatal hernia with incarcerated digestive tract.", + "Emergency operative repair was performed with open surgery through the abdomen.", + "The distal transverse colon was incarcerated through the left side of diaphragmatic hiatal defect into the right mediastinum around the back of the gastric conduit.", + "Digestive fluid was eluted from the mediastinum.", + "Manual repositioning of the herniated content was performed.", + "The transverse colon, incarcerated into the mediastinum, was resected due to perforation.", + "A transverse colostomy was performed.", + "The mediastinum and abdominal cavity were manually lavaged.", + "The right side of the pleural cavity was also lavaged through the widened hiatus, without thoracotomy.", + "The dilated diaphragmatic hiatal defect was closed with sutures.", + "The gastric conduit was fixed to the crus with 2–0 non-absorbable sutures.", + "The total operation time was 233 min.", + "The intraoperative blood loss was 770 mL.", + "Macroscopic analysis of the resected specimen revealed perforation in the edematous lesion of the colon without necrosis.", + "The patient was transferred to the intensive care unit (ICU) and was on a ventilator.", + "The patient was diagnosed with septic shock due to acute mediastinitis.", + "Broad-spectrum antibiotics and vasopressor agents were administered.", + "Continuous hemodiafiltration and polymyxin B hemoperfusion were administered for the first 3 days.", + "The patient stayed in the ICU for 16 days.", + "Oral intake was initiated on the 18th postoperative day.", + "The patient was discharged from the hospital on the 53rd postoperative day.", + "The patient’s condition deteriorated following surgery.", + "The patient did not receive any further chemotherapy or radiotherapy.", + "Only palliative care services were provided.", + "The patient is alive one and a half years after surgery." + ], + "summary": "The patient underwent definitive chemoradiotherapy for clinical stage IIA esophageal squamous cell carcinoma and salvage esophagectomy with gastric tube reconstruction through a posterior mediastinum route for residual carcinoma. Three years after the initial surgery, two metastatic nodules in the lateral and posterior segments of the liver were detected on follow-up CT and were treated with oral anticancer drugs. After 6 months, the patient was readmitted for anorexia. Upon admission, computed tomography revealed an ileus caused by a hiatal hernia. Emergent operative repair was performed; an incarcerated herniation of the transverse colon was perforated in the mediastinum, and partial transverse colon resection and colostomy were performed. Intensive care was required to control septic shock after surgery, and the patient was discharged on the 53rd postoperative day.", + "summary_subclaims": [ + "The patient underwent definitive chemoradiotherapy for clinical stage IIA esophageal squamous cell carcinoma.", + "The patient underwent salvage esophagectomy with gastric tube reconstruction through a posterior mediastinum route for residual carcinoma.", + "Three years after the initial surgery, two metastatic nodules in the lateral and posterior segments of the liver were detected on follow-up CT.", + "The two metastatic nodules were treated with oral anticancer drugs.", + "After 6 months, the patient was readmitted for anorexia.", + "Computed tomography revealed an ileus caused by a hiatal hernia.", + "Emergent operative repair was performed.", + "An incarcerated herniation of the transverse colon was perforated in the mediastinum.", + "Partial transverse colon resection and colostomy were performed.", + "Intensive care was required to control septic shock after surgery.", + "The patient was discharged on the 53rd postoperative day." + ] + }, + { + "id": "multiclinsum_test_1726_en.txt", + "fulltext": "A 32-year-old man who experienced a recurrent fracture after sudden syncope was admitted to the First Hospital of China Medical University. Six months before the current time, he had sudden syncope while lying in bed; he felt low back pain after regaining consciousness. A computed tomography (CT) scan in the local hospital indicated multiple thoracolumbar fractures, and he was treated with external belt fixation. One month prior, he experienced another sudden syncope episode when he while sitting in the driver’s seat but before driving; he felt pain in his left shoulder upon waking. X-ray analysis indicated multiple fractures of the left proximal humerus, and he was treated with external fixation. He was then admitted to our hospital for further examination.\nLaboratory assessment revealed elevated β-C-terminal telopeptides of type I collagen (β-CTX) (981.8 pg/ml; normal range<584 pg/ml) and N-terminal propeptides of type I collagen (P1NP) (81.93 ng/ml; normal range 20.00–80.00 ng/ml) and decreased 25(OH)D3 (12.99 ng/ml); serum calcium (2.3 mmol/L), phosphorus (1.27 mmol/L), magnesium (0.96 mmol/L), alkaline phosphatase (ALP) (93 U/L; normal range 35–100 U/L) and parathyroid hormone (PTH) (24.92 pg/ml; normal range 15.00–65.00 pg/ml) levels were normal. HLA-B27, arterial blood gas, kidney function, and liver function were all within normal ranges.\nX-ray radiographs of the skull, bilateral hands, left shoulder joint, and bilateral hips were performed. The skull image revealed a suspicious light transmission shadow at the left frontal bone. A bone island was detected in the left thumb proximal phalanx. The bilateral hips showed mild degenerative changes, and a comminuted fracture of the left greater tuberosity of the humerus were observed on X-ray and CT scans of the left shoulder joint. Magnetic resonance imaging (MRI) of thoracic and lumbar vertebrae is shown in Fig. , revealing L3 vertebral compression fracture, local kyphosis, spinal canal stenosis, and cauda equina compression. Vertebral endplate alterations were found in L1 to S1, and L2-S1 disc bulges and slight L4-S1 disc protrusions were noted. Schmorl’s nodes were observed in multiple thoracic and lumbar vertebrae (T8, T12, L1, and L5). Although bone mineral density (BMD) examined by dual-energy X-ray absorptiometry (DXA) of the hip joint was normal, the L2 (0.820 g/cm2, Z-score − 1.4) and L4 (0.877 g/cm2, Z-score − 1.7) BMD values were low.\nThe electrocardiogram performed indicated sinus tachycardia, and his heart rate was 107 beats/min. Cardiac ultrasound showed ventricular septum hypertrophy (9–11 mm), but left ventricular systolic function was normal in the resting state. CT angiography of the head and neck arteries indicated thinning of the right vertebral artery.\nThe patient had a 4-year history of hypertension. The patient had not suffered from any fracture in the past. His father had hypertension and cerebral thrombosis, and he had a 9-year-old son with Kawasaki disease. His mother and sister were healthy. The patient presented with normal stature and appearance (height, 173 cm; weight, 72 kg; BMI, 24 kg/m2; lack of blue sclera). The patient also had normal teeth and hearing, and no obvious kyphosis was observed.\nBlood samples were collected from the patient and his family members, and genomic DNA was extracted using a blood extraction kit (Tian Jing Biochemical Technology Beijing, Ltd.). Gene regions, including splicing and coding regions of exons, of a panel of genes associated with bone metabolism were amplified by PCR and then sequenced using the Illumina NextSeq 500 system (Illumina, San Diego, CA, USA). Variations were confirmed by Sanger sequencing (ABI 3730, Applied Biosystems, Foster City, CA, USA). This analysis revealed a heterozygous mutation in COL1A2 (NM_000089; c.4048G > A, (p.G1350S)) in the proband. Family investigation revealed that the proband’s sister and her daughter (his niece) carry this mutation. The proband’s sister was found to be an asymptomatic heterozygous carrier, and the niece previously experienced a fracture of the ankle and had mild dentinogenesis imperfecta without blue sclera . Predictions for the c.4048G > A mutation in COL1A2 are as follows: PolyPhen2 (Probably damaging, score = 1), FATHMM (Tolerated, score=-1.11), SIFT (Deleterious, score = 0.002) and PROVEAN (Deleterious, score=-4.84).", + "fulltext_subclaims": [ + "The patient is a 32-year-old man.", + "He experienced a recurrent fracture after sudden syncope.", + "He was admitted to the First Hospital of China Medical University.", + "Six months before the current time, he had sudden syncope while lying in bed.", + "A CT scan in the local hospital indicated multiple thoracolumbar fractures.", + "He was treated with external belt fixation.", + "One month prior, he experienced another sudden syncope episode when he was sitting in the driver’s seat.", + "X-ray analysis indicated multiple fractures of the left proximal humerus.", + "He was treated with external fixation.", + "He was admitted to our hospital for further examination.", + "β-CTX was 981.8 pg/ml.", + "The normal range for β-CTX is <584 pg/ml.", + "P1NP was 81.93 ng/ml.", + "The normal range for P1NP is 20.00–80.00 ng/ml.", + "25(OH)D3 was 12.99 ng/ml.", + "Serum calcium was 2.3 mmol/L.", + "Serum phosphorus was 1.27 mmol/L.", + "Serum magnesium was 0.96 mmol/L.", + "ALP was 93 U/L.", + "The normal range for ALP is 35–100 U/L.", + "PTH was 24.92 pg/ml.", + "The normal range for PTH is 15.00–65.00 pg/ml.", + "X-ray radiographs of the skull, bilateral hands, left shoulder joint, and bilateral hips were performed.", + "The skull image revealed a suspicious light transmission shadow at the left frontal bone.", + "A bone island was detected in the left thumb proximal phalanx.", + "The bilateral hips showed mild degenerative changes.", + "A comminuted fracture of the left greater tuberosity of the humerus was observed.", + "MRI of thoracic and lumbar vertebrae revealed L3 vertebral compression fracture.", + "Vertebral endplate alterations were found in L1 to S1.", + "Schmorl’s nodes were observed in multiple thoracic and lumbar vertebrae.", + "DXA of the hip joint showed normal BMD.", + "The L2 BMD value was 0.820 g/cm2.", + "The L4 BMD value was 0.877 g/cm2.", + "The electrocardiogram indicated sinus tachycardia.", + "His heart rate was 107 beats/min.", + "Cardiac ultrasound showed ventricular septum hypertrophy.", + "CT angiography of the head and neck arteries indicated thinning of the right vertebral artery.", + "The patient had a 4-year history of hypertension.", + "The patient had not suffered from any fracture in the past.", + "His father had hypertension and cerebral thrombosis.", + "His 9-year-old son had Kawasaki disease.", + "The patient’s height was 173 cm.", + "The patient’s weight was 72 kg.", + "The patient’s BMI was 24 kg/m2.", + "The patient had no blue sclera.", + "Genomic DNA was extracted using a blood extraction kit.", + "Gene regions of a panel of genes associated with bone metabolism were amplified by PCR.", + "Sequencing revealed a heterozygous mutation in COL1A2 (NM_000089; c.4048G > A, (p.G1350S)).", + "The proband’s sister and niece carry this mutation.", + "The proband’s sister was found to be an asymptomatic heterozygous carrier.", + "The niece previously experienced a fracture of the ankle.", + "The niece had mild dentinogenesis imperfecta.", + "The niece did not have blue sclera.", + "The c.4048G > A mutation in COL1A2 was predicted as Probably damaging by PolyPhen2.", + "The c.4048G > A mutation in COL1A2 was predicted as Tolerated by FATHMM.", + "The c.4048G > A mutation in COL1A2 was predicted as Deleterious by SIFT.", + "The c.4048G > A mutation in COL1A2 was predicted as Deleterious by PROVEAN." + ], + "summary": "Here, we report a 32-year-old male patient who experienced multiple brittle fractures. Gene sequencing revealed a heterozygous mutation, c.4048G > A (p.G1350S), in the COL1A2 gene, and the patient was diagnosed with OI. Magnetic resonance imaging of his thoracolumbar spine revealed multiple Schmorl's nodes.", + "summary_subclaims": [ + "The patient is a 32-year-old male.", + "The patient experienced multiple brittle fractures.", + "Gene sequencing revealed a heterozygous mutation, c.4048G > A (p.G1350S), in the COL1A2 gene.", + "The patient was diagnosed with OI.", + "Magnetic resonance imaging of his thoracolumbar spine revealed multiple Schmorl's nodes." + ] + }, + { + "id": "multiclinsum_test_2778_en.txt", + "fulltext": "A 68-year-old woman patient presented arrhythmias with hypotension requiring electrical cardioversion. Her electrocardiogram (ECG) was interpreted as atrial fibrillation (AF) by AP. She was brought urgently to our electrophysiology laboratory, where we are trained for electroanatomical mapping but it is not available. The ECG suggested the presence of posterior or right postero-septal AP ;\nIn this case, with recurrent AF by AP and hypotension we did not decide to perform the electrophysiological study to determine the AP insertion sites due to the patient's clinical condition. Cardiologists who was in charge of the patient requested our intervention due to despite the group I-C antiarrhythmic drugs treatment (at recommended doses) the patient continued suffering AF by AP. Once in the electrophysiology laboratory secondary to catheters movement into the heart AF by AP began with hypotension and it was necessary to perform electrical cardioversión (2 Joules per kilogram of weight was calculated, discharge was synchronized with QRS of the electrocardiogram). A deep sedation was performed with midazolam (10 mg ampules in 2 ml), initial dose of 0.5 mg. A single shock was required to recover sinus rhythm.\nConsidering the above we proceeded with the protocol of ablation stablished in our laboratory: two punctures on the right femoral vein with placement of introducers (8F and 7F) by Seldigner technique and one puncture on the left femoral vein (7F). The study was performed with BIOTRONIK technology (Multicath study catheter), a non-deflectable 7F quadripolar catheter with 2 mm tip electrode to record the His electrogram, a non-deflectable decapolar catheter with 5 pairs of CS electrodes. All electrograms into CS showed short AV from proximal to distal CS .\nUsing a BIOTRONIK ablation catheter (Alcath gold fullcircle) through the 8F introducer. Delta wave in V1 showed negative suggesting the septal region accessory pathway.\nIt seemed ventricular electrogram CS proximal (CP 9–10) was earliest during sinus rhythm in Fig. B. It is important to validate the electrogram component between atrium and ventricle. Nevertheless, AP mapping on the right posterior septal region showed no accessory pathway recordings. That is why we decided to perform anterograde mapping of the AP into the left cavities, using a St Jude deflectable sheath (Agilis 8.5 F) and by transseptal puncture we accessed to the left atrium. Mapping with the ablation catheter of the entire posteroseptal, posterior, posterolateral and lateral region of the mitral annulus, we never saw an AV shorter than those observed in the CS; the shorter AV into left chambers was observed on posteriorseptal región (delta-V of 5 ms), then we decided to apply radiofrecuency (RF) on there (temperature of 60 degrees, 55 watts and 60 s of application); finally it was not successful.\nWe returned to the right cavities decided to map in sinus rhythm the entire CS from its proximal to the most distal portion, observing AP recordings with very short AV along the CS, the shortest delta-V was − 20 ms, always on proximal CS (CS 9–10), Fig. B. Nevertheless, the AP electrogram was not found nearby of it. Finally we decided to map into the CS finding the a continuous electrogram on ablation catheter, with intermediate accessory pathway potential spike into of the left posterior coronary vein (PCV) considering its probable radiological projection and here was applied RF with 50 watts and 50 Celsius degrees on the PCV anatomical region . During the first seconds of radiofrequency application the patient referred intense pain, so we decided a deep sedation with midazolam newly, this time 1 mg to achieve deep sedation. A trained specialist was in charge of the patient's airway management. This allowed us to gradually increase the temperature for ablation and fortunately there were no impedance increases in the ablation channel. It allowed us to continue and end the procedure.\nAfter we decided to increase 55 watts and 60 Celsius degrees; a junctional rhythm started and we moved the His recording catheter to the right atrium and started to pace with a higher cycle length than the junctional rhythm after 60 consecutive seconds of RF the AP was ablated on the ventricular site. We could recognize the accessory pathway was ablated because during pacing from the right atrium a normal PR segment can be observed on the surface electrocardiogram, without the presence of a delta wave . If accessory pathway were still present, pacing from the atrium at a basic cycle higher than junctional rhythm would reveal the presence of the accessory pathway (delta wave on electrocardiogram).\nThe radiological projection suggests we were probably in the posterior coronary vein; however, a venography should have been performed to identify that site; there is a anatomical variation of the CS ostium. Some of the patients showed large ostium with trumpet-shape. It is still unclear the shortest delta-V was located at left posterior vein without CS venography or Geometry with 3D mapping system. In our laboratory we have not a 3D system, we should have performed CS venography and it was not performed. It was a limitation to diagnosis the anatomical site of ablation.\nAccording to our laboratory protocols, we waited ten minutes after ablation and administered adenosine, 12 mg intravenously for verification of AP ablation. After the administration of adenosine an electrocardiographic pattern reappears with the presence of delta wave ; however, compared to the initial ECG, a small R wave appears in DII and CS recording has been modified with shorter AV on CS 1–2 and 3–4 . Upon observing a new site where the CS 3–4 accessory pathway would be passing through, we decided to stimulate from that point of the atrium (CS 3–4) and observed maximum pre-excitation. We also stimulated from 9–10 CS and there was no change in the magnitude of the surface electrocardiogram delta wave. When pacing from the right ventricle, the first retrograde atrium was observed at CS 3–4. Considering that initially left intracavitary mapping had been performed, we decided to go directly through the CS.\nMapping within CS with ablation catheter up to anatomical and fluoroscopic region where the CS catheter recording 3–4 was located (it was removed) . Successful ablation was achieved at this second point, on the mitral annulus. After waiting 10 min and administration of adenosine, ablation was successful at two distant epicardial points and the ECG was in sinus rhythm with normal PR .", + "fulltext_subclaims": [ + "The patient was a 68-year-old woman.", + "She presented arrhythmias with hypotension requiring electrical cardioversion.", + "Her electrocardiogram (ECG) was interpreted as atrial fibrillation (AF) by AP.", + "She was brought urgently to the electrophysiology laboratory.", + "We are trained for electroanatomical mapping but it is not available.", + "The ECG suggested the presence of posterior or right postero-septal AP.", + "We did not decide to perform the electrophysiological study to determine the AP insertion sites.", + "The decision was due to the patient's clinical condition.", + "Cardiologists requested our intervention.", + "The patient continued suffering AF by AP despite group I-C antiarrhythmic drugs treatment at recommended doses.", + "Once in the electrophysiology laboratory, secondary to catheters movement into the heart AF by AP began with hypotension.", + "Electrical cardioversion was performed.", + "2 Joules per kilogram of weight was calculated.", + "Discharge was synchronized with QRS of the electrocardiogram.", + "A single shock was required to recover sinus rhythm.", + "A deep sedation was performed with midazolam.", + "The initial dose of midazolam was 0.5 mg.", + "We proceeded with the protocol of ablation established in our laboratory.", + "Two punctures on the right femoral vein with placement of introducers (8F and 7F) by Seldinger technique were performed.", + "One puncture on the left femoral vein (7F) was performed.", + "The study was performed with BIOTRONIK technology.", + "A Multicath study catheter was used.", + "A non-deflectable 7F quadripolar catheter with 2 mm tip electrode was used to record the His electrogram.", + "A non-deflectable decapolar catheter with 5 pairs of CS electrodes was used.", + "All electrograms into CS showed short AV from proximal to distal CS.", + "A BIOTRONIK ablation catheter (Alcath gold fullcircle) was used through the 8F introducer.", + "Delta wave in V1 showed negative suggesting the septal region accessory pathway.", + "It seemed ventricular electrogram CS proximal (CP 9–10) was earliest during sinus rhythm.", + "AP mapping on the right posterior septal region showed no accessory pathway recordings.", + "We decided to perform anterograde mapping of the AP into the left cavities.", + "A St Jude deflectable sheath (Agilis 8.5 F) was used.", + "By transseptal puncture we accessed to the left atrium.", + "Mapping with the ablation catheter of the entire posteroseptal, posterior, posterolateral and lateral region of the mitral annulus was performed.", + "We never saw an AV shorter than those observed in the CS.", + "The shorter AV into left chambers was observed on posteriorseptal región (delta-V of 5 ms).", + "We decided to apply radiofrequency (RF) on there.", + "RF was applied with temperature of 60 degrees, 55 watts and 60 s of application.", + "The RF application was not successful.", + "We returned to the right cavities and decided to map in sinus rhythm the entire CS from its proximal to the most distal portion.", + "AP recordings with very short AV along the CS were observed.", + "The shortest delta-V was − 20 ms, always on proximal CS (CS 9–10).", + "The AP electrogram was not found nearby of it.", + "We decided to map into the CS finding a continuous electrogram on ablation catheter.", + "An intermediate accessory pathway potential spike was observed into the left posterior coronary vein (PCV).", + "RF was applied with 50 watts and 50 Celsius degrees on the PCV anatomical region.", + "During the first seconds of radiofrequency application the patient referred intense pain.", + "We decided a deep sedation with midazolam newly, this time 1 mg.", + "A trained specialist was in charge of the patient's airway management.", + "There were no impedance increases in the ablation channel.", + "We increased 55 watts and 60 Celsius degrees.", + "A junctional rhythm started.", + "The His recording catheter was moved to the right atrium.", + "Pacing with a higher cycle length than the junctional rhythm was started.", + "After 60 consecutive seconds of RF the AP was ablated on the ventricular site.", + "The accessory pathway was ablated because during pacing from the right atrium a normal PR segment can be observed on the surface electrocardiogram, without the presence of a delta wave.", + "Radiological projection suggests we were probably in the posterior coronary vein.", + "A venography should have been performed to identify that site.", + "There is anatomical variation of the CS ostium.", + "Some patients showed large ostium with trumpet-shape.", + "It is still unclear the shortest delta-V was located at left posterior vein without CS venography or Geometry with 3D mapping system.", + "We have not a 3D system.", + "CS venography was not performed.", + "It was a limitation to diagnosis the anatomical site of ablation.", + "We waited ten minutes after ablation and administered adenosine, 12 mg intravenously for verification of AP ablation.", + "After the administration of adenosine an electrocardiographic pattern reappears with the presence of delta wave.", + "Compared to the initial ECG, a small R wave appears in DII.", + "CS recording has been modified with shorter AV on CS 1–2 and 3–4.", + "We decided to stimulate from the point of the atrium (CS 3–4) and observed maximum pre-excitation.", + "We also stimulated from 9–10 CS and there was no change in the magnitude of the surface electrocardiogram delta wave.", + "When pacing from the right ventricle, the first retrograde atrium was observed at CS 3–4.", + "We decided to go directly through the CS.", + "Mapping within CS with ablation catheter up to anatomical and fluoroscopic region where the CS catheter recording 3–4 was located was performed.", + "Successful ablation was achieved at this second point, on the mitral annulus.", + "After waiting 10 min and administration of adenosine, ablation was successful at two distant epicardial points.", + "The ECG was in sinus rhythm with normal PR." + ], + "summary": "A 68-year-old woman patient presented arrhythmias with hypotension requiring electrical cardioversion. Her electrocardiogram (ECG) was interpreted as atrial fibrillation by accessory pathway. We performed with the protocol of ablation stablished in our laboratory: two punctures on the right femoral vein with placement of introducers (8F and 7F) by Seldigner technique and one puncture on the left femoral vein (7F). The study was performed with BIOTRONIK technology (Multicath study catheter), a non-deflectable 7F quadripolar catheter with 2 mm tip electrode to record the His electrogram, a non-deflectable decapolar catheter with 5 pairs of coronary sinus (CS) electrodes. Accessory pathway mapping was performed in right and left cavities and within the CS. All electrograms into CS showed short AV from proximal to distal CS. Finally, ablation of two accessory pathway recordings was achieved at two distant epicardial points within the CS.", + "summary_subclaims": [ + "The patient is a 68-year-old woman.", + "The patient presented arrhythmias with hypotension requiring electrical cardioversion.", + "The ECG was interpreted as atrial fibrillation by accessory pathway.", + "The ablation protocol used two punctures on the right femoral vein with placement of introducers (8F and 7F) by Seldinger technique.", + "The ablation protocol used one puncture on the left femoral vein (7F).", + "The study was performed with BIOTRONIK technology (Multicath study catheter).", + "The study used a non-deflectable 7F quadripolar catheter with 2 mm tip electrode to record the His electrogram.", + "The study used a non-deflectable decapolar catheter with 5 pairs of coronary sinus (CS) electrodes.", + "Accessory pathway mapping was performed in right and left cavities and within the CS.", + "All electrograms into CS showed short AV from proximal to distal CS.", + "Ablation of two accessory pathway recordings was achieved at two distant epicardial points within the CS." + ] + }, + { + "id": "multiclinsum_test_736_en.txt", + "fulltext": "A 30-year-old Caucasian woman presented to the emergency department (ED) with right-sided facial and lower limb twitching. She also reported a headache for the past 5 days, similar to her previous migraines. She had taken a dose of sumatriptan approximately 6–8 hours prior to presentation to alleviate the pain. This medication had been newly prescribed by her general practitioner with no history of prior use by the patient. Shortly after taking the sumatriptan, the patient developed gradually worsening right-sided facial and lower limb twitching, with discomfort in the right arm and right leg and associated difficulty with speech. She had taken paracetamol at home prior to this event and denied ingestion of any other medications, including prescription medications as well as herbal and over-the-counter supplements. She also denied any recent alcohol or illicit drug use.\nHer past medical history was significant for longstanding depression for which she was on regular fluvoxamine 100 mg once daily, as well as hemiplegic migraines (usually managed with simple analgesia), endometriosis, and paroxysmal supraventricular tachycardia. She denied any recent changes in her fluvoxamine dose. Her other regular medications included pregabalin and tranexamic acid, which she did not take on the day of presentation. She had no significant family history and denied regular alcohol or drug use. She denied any regular smoking history.\nOn initial assessment, she had a heart rate of 120 beats per minute and blood pressure of 144/96 mmHg, but otherwise normal vital signs and a Glasgow Coma Scale (GCS) score of 15. Temperature was normal at 36.5 °C. She had notably diaphoretic palms and a resting tremor in her right arm and leg. Initial ophthalmic assessment showed bilaterally sluggish and dilated pupils with ocular clonus. She had bilateral lower limb hypertonicity and hyperreflexia with six to seven beats of inducible clonus in both ankles. Power and sensation were normal in all four limbs, and full neurological examination was otherwise unremarkable. There were no other significant findings on physical examination.\nInitial electrocardiogram (ECG) showed sinus tachycardia with a QT interval below the treatment line on QT nomogram. Full blood count, electrolytes, liver function tests, and serum beta human chorionic gonadotropin (HCG) were unremarkable. Computed tomography (CT) scan of her head showed no evidence of intracranial lesion and was grossly normal for age.\nBased on her clinical presentation and history of SSRI use, the patient was diagnosed with serotonin toxicity. Differential diagnoses at the time included atypical focal seizure, alternate drug toxidrome (such as anticholinergic or sympathomimetic toxicity) or withdrawal phenomenon.\nThe patient was placed on telemetry and was given supportive treatment with slow intravenous fluids as well as a dose of 12 mg oral cyproheptadine, a potent antihistamine and serotonin antagonist. Her fluvoxamine and sumatriptan were withheld, and she was kept in the ED short-stay unit overnight for a prolonged period of observation. Periodic reviews throughout her admission showed an incremental improvement in her serotonergic symptoms, with improvement in her motor symptoms and agitation, as well as her ocular and lower limb clonus.\nOn her morning review, the patient had returned to baseline with resolution of her clonus and tremor and a completely normal repeat neurological examination, aside from some mild residual lower limb hyperreflexia. She was discharged home with instructions to withhold her fluvoxamine for 24 hours and to avoid taking any further concomitant triptan medications in the future, to be followed up by her usual general practitioner.", + "fulltext_subclaims": [ + "The patient is a 30-year-old Caucasian woman.", + "She presented to the emergency department with right-sided facial and lower limb twitching.", + "She reported a headache for the past 5 days.", + "She had taken a dose of sumatriptan approximately 6–8 hours prior to presentation.", + "The sumatriptan had been newly prescribed by her general practitioner.", + "She had no history of prior use of sumatriptan.", + "She developed gradually worsening right-sided facial and lower limb twitching after taking the sumatriptan.", + "She had discomfort in the right arm and right leg.", + "She had associated difficulty with speech.", + "She had taken paracetamol at home prior to this event.", + "She denied ingestion of any other medications, including prescription medications.", + "She denied ingestion of herbal and over-the-counter supplements.", + "She denied any recent alcohol or illicit drug use.", + "Her past medical history was significant for longstanding depression.", + "She was on regular fluvoxamine 100 mg once daily.", + "She had a history of hemiplegic migraines.", + "She had no recent changes in her fluvoxamine dose.", + "She had no significant family history.", + "She denied regular alcohol or drug use.", + "She denied any regular smoking history.", + "On initial assessment, she had a heart rate of 120 beats per minute.", + "Her blood pressure was 144/96 mmHg.", + "Her Glasgow Coma Scale score was 15.", + "She had diaphoretic palms.", + "She had a resting tremor in her right arm and leg.", + "Initial ophthalmic assessment showed bilaterally sluggish and dilated pupils.", + "She had ocular clonus.", + "She had bilateral lower limb hypertonicity.", + "She had bilateral lower limb hyperreflexia.", + "She had six to seven beats of inducible clonus in both ankles.", + "Power and sensation were normal in all four limbs.", + "Computed tomography of her head showed no evidence of intracranial lesion.", + "The CT scan was grossly normal for age.", + "The patient was diagnosed with serotonin toxicity.", + "Differential diagnoses included atypical focal seizure.", + "Differential diagnoses included alternate drug toxidrome.", + "The patient was given 12 mg oral cyproheptadine.", + "Her fluvoxamine and sumatriptan were withheld.", + "She was kept in the ED short-stay unit overnight.", + "Periodic reviews showed incremental improvement in her serotonergic symptoms.", + "On her morning review, she had returned to baseline.", + "She was discharged home with instructions to withhold her fluvoxamine for 24 hours.", + "She was instructed to avoid taking any further concomitant triptan medications in the future." + ], + "summary": "A 30-year-old Caucasian woman with a history of depression on regular fluvoxamine presented to the emergency department with right-sided facial and lower limb twitching. The patient had recently been prescribed sumatriptan for migraines and had taken her first ever dose shortly prior to the onset of symptoms. She was tachycardic, diaphoretic, and hypertonic on initial assessment with bilateral lower limb and ocular clonus. Electrocardiogram showed sinus tachycardia with QT interval under the treatment interval, and pathology and imaging findings were unremarkable. Her symptoms improved with supportive management and cyproheptadine.", + "summary_subclaims": [ + "The patient is a 30-year-old Caucasian woman.", + "She has a history of depression.", + "She is on regular fluvoxamine.", + "She presented with right-sided facial and lower limb twitching.", + "She had recently been prescribed sumatriptan for migraines.", + "She had taken her first ever dose of sumatriptan shortly prior to the onset of symptoms.", + "She was tachycardic on initial assessment.", + "She was diaphoretic on initial assessment.", + "She was hypertonic on initial assessment.", + "She had bilateral lower limb and ocular clonus.", + "Electrocardiogram showed sinus tachycardia.", + "Electrocardiogram showed QT interval under the treatment interval.", + "Pathology findings were unremarkable.", + "Imaging findings were unremarkable.", + "Her symptoms improved with supportive management.", + "Her symptoms improved with cyproheptadine." + ] + }, + { + "id": "multiclinsum_test_2591_en.txt", + "fulltext": "A ten-year-old girl with a history of cystic fibrosis (CF) with gastrointestinal and pulmonary involvement, presented to her pediatrician with newly diagnosed growth retardation, fatigue and frequent headache. An arginine growth hormone-releasing hormone test confirmed growth hormone (GH) deficiency, and after further laboratory analysis, a central hypothyroidism and hypercortisolism was diagnosed. Substitutional therapy with levothyroxine and hydrocortisone was initiated, which improved the patient’s headache and fatigue. Ophthalmologic examination revealed bitemporal hemianopia. Further work-up with magnetic resonance imaging (MRI) revealed a 3 × 3 × 2.5 cm cystic space-occupying lesion in the sellar and suprasellar compartment with compression of the optic chiasm, with partial calcifications in computed tomography (CT), highly suspicious of a craniopharyngioma (CP) . Hydrocephalus was not present at the time of presentation. Due to the compression of the chiasm causing clinical hemianopia, the indication for surgical decompression was given. We weighed the possibilities of a neuroendoscopic transventricular (NET) cyst fenestration and partial tumor resection versus an endonasal endoscopic approach (EEA) or an open transcranial approach. The advantage for the transventricular neuroendoscopic approach is its minimal-invasive nature and straight-forward decompression of the cyst, which is causing compression of the optic chiasm. However, the patient presented with very small ventricles, making neuroendoscopy cumbersome, and the neuroendoscopic approach would only allow a partial tumor resection. EEA shares the advantage of being minimal-invasive. However, due to her age and the concomitant diagnosis of CF, known to be associated with hypoplasia and markedly reduced pneumatization of the paranasal sinuses, a non-pneumatized (conchal type) sphenoid was present , making the AAE more challenging . In addition, gross total resection (GTR) was not considered achievable through an EEA, due to a supra-chiasmatic tumor extension. Still, both an NET or EEA seemed superior to an open approach (e.g. subfrontal or interhemispheric) given the invasiveness and associated morbidity of such approaches, while similar to the EEA and NET approach, GTR would most probably not be achieved either [–]. We ultimately decided to perform an EEA together with our colleagues from ENT. The conchal configuration of the sphenoid sinus required meticulous drilling of squamous intrasphenoidal bone, exposure of the harder sellar bone, and a superior trans-chiasmatic sulcus extension to achieve satisfactory exposure of the suprasellar tumor cyst . Intraoperatively, crystals and cystic fluid, suspicious of CP, were drained from the cyst, and the cyst was dissected from the cavernous sinus walls, the sellar diaphragm, and the dorsum sellae without risking injury of adjacent structures. At the end of the operation, a symmetrical diaphragmal descent was achieved as indirect sign for the decompression of the optic chiasm . Postoperative MRI showed the expected near total tumor removal. While the cyst was completely drained, tumor remnants extending posteriorly to the superiorly displaced chiasm remained as expected . Postoperatively, the patient developed diabetes insipidus (DI) for which she received desmopressin under the supervision of the pediatric endocrinologists. During her inpatient stay, she recovered from her DI with stable sodium levels but required vasopressin substitution. Overall recovery was good, while the hemianopia persisted. No signs of rhinorrhea resulting from cerebrospinal fluid (CSF) fistula were noted. We were able to discharge the patient to her home 11 days after surgery. Unexpectedly, the histopathologic analysis found conspicuous areas of skin with formation of hairs and squamous epithelia, compatible with a mature teratoma . The cytokeratin staining was positive for epithelial cells consistent with the finding in a mature teratoma . These findings led to the diagnosis of a rare case of infantile mature teratoma originating from the sellar region After discussion in our interdisciplinary pediatric neuro-tumor-board, no further treatments (e.g. chemotherapy, radiation therapy) were indicated and a clinical and radiological follow up was initiated.\nAt her first postoperative follow-up appointment after 6 weeks the patient was back in school, without any complaints. The hemianopia remained unchanged, and cortisol, vasopressin and thyroxin substitution was still required one year postoperatively. She was also started on growth hormone (GH) replacement therapy 6 months postoperatively. MRI follow-up one year after surgery showed stable appearances without any sign of progression .", + "fulltext_subclaims": [ + "A ten-year-old girl with a history of cystic fibrosis (CF) with gastrointestinal and pulmonary involvement presented to her pediatrician with newly diagnosed growth retardation, fatigue, and frequent headache.", + "An arginine growth hormone-releasing hormone test confirmed growth hormone (GH) deficiency.", + "Further laboratory analysis diagnosed central hypothyroidism and hypercortisolism.", + "Substitutional therapy with levothyroxine and hydrocortisone was initiated.", + "Ophthalmologic examination revealed bitemporal hemianopia.", + "Magnetic resonance imaging (MRI) revealed a 3 × 3 × 2.5 cm cystic space-occupying lesion in the sellar and suprasellar compartment.", + "The lesion was highly suspicious of a craniopharyngioma (CP).", + "Hydrocephalus was not present at the time of presentation.", + "The indication for surgical decompression was given due to the compression of the chiasm causing clinical hemianopia.", + "The neuroendoscopic transventricular (NET) cyst fenestration and partial tumor resection was considered.", + "The patient presented with very small ventricles, making neuroendoscopy cumbersome.", + "The neuroendoscopic approach would only allow a partial tumor resection.", + "The endonasal endoscopic approach (EEA) was considered.", + "The patient had a conchal type sphenoid, making the EEA more challenging.", + "Gross total resection (GTR) was not considered achievable through an EEA due to a supra-chiasmatic tumor extension.", + "An EEA was ultimately decided upon.", + "The conchal configuration of the sphenoid sinus required meticulous drilling of squamous intrasphenoidal bone.", + "Intraoperatively, crystals and cystic fluid, suspicious of CP, were drained from the cyst.", + "The cyst was dissected from the cavernous sinus walls, the sellar diaphragm, and the dorsum sellae.", + "A symmetrical diaphragmal descent was achieved as an indirect sign for the decompression of the optic chiasm.", + "Postoperative MRI showed the expected near total tumor removal.", + "Tumor remnants extending posteriorly to the superiorly displaced chiasm remained.", + "The patient developed diabetes insipidus (DI) postoperatively.", + "The patient received desmopressin under the supervision of the pediatric endocrinologists.", + "The patient recovered from her DI with stable sodium levels.", + "The patient required vasopressin substitution.", + "No signs of rhinorrhea resulting from cerebrospinal fluid (CSF) fistula were noted.", + "The patient was discharged 11 days after surgery.", + "Histopathologic analysis found areas of skin with formation of hairs and squamous epithelia, compatible with a mature teratoma.", + "Cytokeratin staining was positive for epithelial cells consistent with the finding in a mature teratoma.", + "The diagnosis was a rare case of infantile mature teratoma originating from the sellar region.", + "No further treatments were indicated after discussion in the interdisciplinary pediatric neuro-tumor-board.", + "A clinical and radiological follow-up was initiated.", + "At her first postoperative follow-up appointment after 6 weeks, the patient was back in school without any complaints.", + "The hemianopia remained unchanged.", + "Cortisol, vasopressin, and thyroxin substitution was still required one year postoperatively.", + "The patient was started on growth hormone (GH) replacement therapy 6 months postoperatively.", + "MRI follow-up one year after surgery showed stable appearances without any sign of progression." + ], + "summary": "A 10-year-old girl presented with newly diagnosed growth retardation, fatigue, cephalgia and bilateral hemianopia. Further laboratory analysis confirmed central hypothyroidism and hypercortisolism. Cranial magnetic resonance imaging showed a cystic space-occupying lesion in the sellar and suprasellar compartment with compression of the optic chiasm without hydrocephalus present, suspicious of craniopharyngioma. Subsequently, an endonasal endoscopic transsphenoidal near-total tumor resection with decompression of the optic chiasm was performed. During postoperative recovery the patient developed transient diabetes insipidus, the bilateral hemianopia remained unchanged. The patient could be discharged in a stable condition, while hormone replacement for multiple pituitary hormone deficiency was required. Surprisingly, histopathology revealed conspicuous areas of skin with formation of hairs and squamous epithelia, compatible with a mature teratoma.", + "summary_subclaims": [ + "The patient is a 10-year-old girl.", + "The patient had newly diagnosed growth retardation.", + "The patient had fatigue.", + "The patient had cephalgia.", + "The patient had bilateral hemianopia.", + "Laboratory analysis confirmed central hypothyroidism.", + "Laboratory analysis confirmed hypercortisolism.", + "Cranial magnetic resonance imaging showed a cystic space-occupying lesion in the sellar and suprasellar compartment.", + "The lesion caused compression of the optic chiasm.", + "Hydrocephalus was not present.", + "The lesion was suspicious of craniopharyngioma.", + "An endonasal endoscopic transsphenoidal near-total tumor resection was performed.", + "The optic chiasm was decompressed.", + "The patient developed transient diabetes insipidus during postoperative recovery.", + "The bilateral hemianopia remained unchanged.", + "The patient was discharged in a stable condition.", + "Hormone replacement for multiple pituitary hormone deficiency was required.", + "Histopathology revealed conspicuous areas of skin with formation of hairs and squamous epithelia.", + "The histopathology findings were compatible with a mature teratoma." + ] + }, + { + "id": "multiclinsum_test_639_en.txt", + "fulltext": "A 74-year-old man with sick sinus syndrome and a St. Jude Abbott DCPPM, placed 8 months prior, presented for routine device check. Presenting rhythm was atrial paced (AP) ventricular sensed (VS) at 70 b.p.m. Atrial and ventricular impedance, sensing, and thresholds were appropriate and consistent with prior values. Device settings were DDDR with base rate 70 b.p.m., maximum tracking rate 105 b.p.m., and maximum sensor rate 130 b.p.m., and paced and sensed AV delays were 250 ms. Ventricular intrinsic preference was enabled, allowing intermittent AV delay to promote intrinsic conduction and mitigate ventricular pacing. A ventricular high rate episode with corresponding electrogram (EGM) was noted . This episode commenced with a 1:1 atrial tachycardia (AT) at a rate of 150 b.p.m. with prolonged AV conduction, prompting AMS from DDDR to DDIR. Unexpectedly, this was followed by a period of rapid atrial pacing at 180–190 b.p.m., well exceeding the maximum tracking and sensor rates. Notably, there was no atrial anti-tachycardia pacing programmed on this device, and the native AV conduction was longer than the programmed AV delay. In addition, the observed AV interval during rapid atrial pacing appeared implausibly short. To understand the mechanism for this phenomenon, one must consider how pacemaker timing cycle parameters determine the pacing rate.\nIn ventricular-based timing modes, the cycle length between two atrial-paced events is determined by the calculated VAI, not the A–A interval as in atrial-based timing. This calculation depends on the base rate, or sensor indicated rate, and the programmed paced AV delay. This patient’s device was initially set to DDDR. While in an episode of AT, the device mode switched from atrial-based timing mode to a ventricular-based timing mode (DDIR). As shown in , the initial AT cycle length was ∼395 ms triggering AMS to DDIR, and intrinsic AV time was prolonged at 285 ms. Then, a perfectly timed premature atrial complex (PAC) fell within the post-ventricular atrial blanking period (PVAB) and was not sensed, thus failing to reset the VAI timer. With further AV nodal decrement, this PAC conducted with an AV time of 320 ms. However, the calculated VAI (atrial escape interval) had already elapsed at 258 ms, leading to an AP beat just before the PAC conducted to a ventricular-sensed event. This ‘pacemaker crossover’ created a short ‘pseudo-AV interval’ of 66 ms, and the ventricular-sensed event from the conducted PAC resets the VAI timer just after the AP beat. Ventriculo-atrial interval was then reached again at ∼260 ms, triggering another AP event with even slower AV time of 398 ms, once again ‘crossing over’ with AP occurring before VS event from the preceding paced beat. This consistent but prolonged AV conduction led to repetitive crossover with short pseudo-AV intervals resetting VAI. The VAI was calculated based on sensed activity, due to enabled rate responsive pacing, and an assumed paced AV time of 250 ms, leading to atrial pacing well above the max sensor rate.\nThis event was stored as a ventricular high rate episode because the ventricular rate exceeded 175 b.p.m.; however, it lasted <20 s, and the stored EGM did not capture the termination. Presumably, it terminated with an atrial-paced beat that failed to conduct, or due to a spontaneous PAC or pemature ventricular contraction. Importantly, there were no associated symptoms with this brief episode, nor were there any other similar episodes recorded before or within 6 months following. To prevent this episode from happening again, multiple programming changes could be made including changing the AMS from DDIR to a non-sensor setting such as DDI or VVI; reducing the maximum sensor driven rate, or shortening the programmed AV delay. However, each of these changes would have other implications. Therefore, another option would be to make no programming changes given that this was a single short episode with no associated symptoms. Even if lightning did strike twice, these episodes would be unlikely to sustain for any significant length of time given reliance on extremely long yet necessarily fixed 1:1 AV conduction. In the case of this patient, the company representative was contacted and agreed with our proposed mechanism and potential programming changes to prevent recurrence. However, ultimately no changes were made, and the phenomenon has not recurred since this initial episode.", + "fulltext_subclaims": [ + "The patient is a 74-year-old man with sick sinus syndrome.", + "The patient has a St. Jude Abbott DCPPM placed 8 months prior.", + "The presenting rhythm was atrial paced (AP) ventricular sensed (VS) at 70 b.p.m.", + "Atrial and ventricular impedance, sensing, and thresholds were appropriate and consistent with prior values.", + "Device settings were DDDR with base rate 70 b.p.m., maximum tracking rate 105 b.p.m., and maximum sensor rate 130 b.p.m.", + "Paced and sensed AV delays were 250 ms.", + "Ventricular intrinsic preference was enabled.", + "A ventricular high rate episode with corresponding electrogram (EGM) was noted.", + "The episode commenced with a 1:1 atrial tachycardia (AT) at a rate of 150 b.p.m.", + "The AT was associated with prolonged AV conduction.", + "AMS occurred from DDDR to DDIR.", + "This was followed by a period of rapid atrial pacing at 180–190 b.p.m.", + "The rapid atrial pacing exceeded the maximum tracking and sensor rates.", + "There was no atrial anti-tachycardia pacing programmed on this device.", + "The native AV conduction was longer than the programmed AV delay.", + "The observed AV interval during rapid atrial pacing appeared implausibly short.", + "In ventricular-based timing modes, the cycle length between two atrial-paced events is determined by the calculated VAI.", + "The patient’s device was initially set to DDDR.", + "During the AT episode, the device mode switched to DDIR.", + "The initial AT cycle length was ∼395 ms.", + "Intrinsic AV time was prolonged at 285 ms.", + "A premature atrial complex (PAC) fell within the post-ventricular atrial blanking period (PVAB) and was not sensed.", + "The PAC conducted with an AV time of 320 ms.", + "The calculated VAI (atrial escape interval) had already elapsed at 258 ms.", + "An atrial-paced beat occurred just before the PAC conducted to a ventricular-sensed event.", + "This created a short 'pseudo-AV interval' of 66 ms.", + "The ventricular-sensed event from the conducted PAC reset the VAI timer just after the AP beat.", + "The ventriculo-atrial interval was reached again at ∼260 ms, triggering another AP event.", + "The AV time from the second AP event was 398 ms.", + "This led to another 'crossover' with AP occurring before the VS event from the preceding paced beat.", + "The VAI was calculated based on sensed activity.", + "Rate responsive pacing was enabled.", + "An assumed paced AV time of 250 ms was used in the calculation.", + "This led to atrial pacing well above the max sensor rate.", + "The event was stored as a ventricular high rate episode because the ventricular rate exceeded 175 b.p.m.", + "The event lasted <20 s.", + "The stored EGM did not capture the termination.", + "It presumably terminated with an atrial-paced beat that failed to conduct.", + "There were no associated symptoms with this brief episode.", + "There were no other similar episodes recorded before or within 6 months following.", + "Multiple programming changes could be made to prevent recurrence.", + "Options included changing AMS from DDIR to a non-sensor setting such as DDI or VVI.", + "Options also included reducing the maximum sensor driven rate or shortening the programmed AV delay.", + "Each of these changes would have other implications.", + "Another option was to make no programming changes.", + "The company representative was contacted.", + "The company representative agreed with the proposed mechanism and potential programming changes.", + "Ultimately, no changes were made.", + "The phenomenon has not recurred since the initial episode." + ], + "summary": "We present a very unusual case of rapid atrial pacing at >180 b.p.m. due to a perfect storm of events that we believe has not been previously reported. A patient with a St. Jude Abbott DCPPM set DDDR had an atrial tachyarrhythmia causing a mode switch to DDIR, which uses ventricular-based timing. This was followed by a period of rapid atrial pacing that terminated spontaneously.", + "summary_subclaims": [ + "We present a very unusual case of rapid atrial pacing at >180 b.p.m. due to a perfect storm of events that we believe has not been previously reported.", + "A patient with a St. Jude Abbott DCPPM set DDDR had an atrial tachyarrhythmia causing a mode switch to DDIR, which uses ventricular-based timing.", + "This was followed by a period of rapid atrial pacing that terminated spontaneously." + ] + }, + { + "id": "multiclinsum_test_1477_en.txt", + "fulltext": "A 47-year-old male patient who had HBV infection for 25 years and underwent hepatectomy for HCC 4 years ago was admitted to our institution.\nThe patient was found to have HBV infection 25 years ago with normal liver function during follow-up. In 2000, he developed abnormal liver function and was diagnosed with HBeAg-positive chronic hepatitis B, for which he was administered lamivudine (LAM) antiviral therapy; however, he discontinued the antiviral therapy after 2 years. In 2006, he was administered ETV antiviral therapy. In 2009, HBeAg seroconversion was achieved, and HBV DNA (Cobas) was maintained at < 20 IU/mL. In October 2016, color Doppler ultrasonography showed a space-occupying hepatic lesion, and it was confirmed to be an HCC (5.3 cm × 5 cm × 5 cm) by enhanced magnetic resonance imaging (MRI) of the liver at Zhongshan Hospital Affiliated to Fudan University . Subsequently, special segmental hepatectomy was performed. Intraoperatively, a tumor was found in segment V, with a complete capsule, clear boundary, and soft texture; moreover, no tumor thrombus was found in the hepatic and portal veins or bile ducts. Postoperative pathological examination confirmed a grade II HCC with no nodular cirrhosis (G1S3, Figure ). Postoperatively, the patient continued taking ETV, regular follow-ups revealed normal liver function, and MRI findings did not change significantly.\nThe patient had no previous noteworthy medical history.\nThe patient did not smoke tobacco or consume alcohol. His father died of HCC in 1974.\nThe patient’s height and weight were 176 cm and 76 kg, respectively. The patient had a body temperature of 36.2 °C, blood pressure of 145/78 mmHg, and pulse rate of 76 beats/min. The abdomen was soft and flat, with no pain or tenderness. No edema of the lower extremities was observed.\nThe results of the analyses performed on February 27, 2019 before the initial treatment, were as follows: For serology (Abbott), HBsAg, 572.03 IU/mL; HBeAb, 0.79 S/CO; HBcAb, 1.13 S/CO; and alpha-fetoprotein (AFP), 3.06 ng/mL; for biochemistry, alanine aminotransferase (ALT), 22 U/L; and aspartate aminotransferase (AST), 25 U/L; for virology, HBV DNA (cobas), < 20 IU/mL; and for the blood routine test, white blood cell count, 6.38 × 109/L; neutrophil count, 2.21 × 109/L; and platelet count, 156 × 109/L. The results of the thyroid function tests (TSH, FT3, and FT4) were normal; autoimmune liver disease-related antibodies were all negative.\nElectrocardiography was normal, and abdominal color Doppler ultrasonography and liver ultrasound scans showed slightly coarse images, with no nodules or space-occupying lesions.", + "fulltext_subclaims": [ + "The patient is a 47-year-old male.", + "The patient had HBV infection for 25 years.", + "The patient underwent hepatectomy for HCC 4 years ago.", + "The patient was found to have HBV infection 25 years ago.", + "The patient had normal liver function during follow-up.", + "In 2000, the patient developed abnormal liver function.", + "In 2000, the patient was diagnosed with HBeAg-positive chronic hepatitis B.", + "In 2000, the patient was administered lamivudine (LAM) antiviral therapy.", + "The patient discontinued lamivudine antiviral therapy after 2 years.", + "In 2006, the patient was administered ETV antiviral therapy.", + "In 2009, HBeAg seroconversion was achieved.", + "HBV DNA (Cobas) was maintained at < 20 IU/mL.", + "In October 2016, color Doppler ultrasonography showed a space-occupying hepatic lesion.", + "Enhanced MRI confirmed an HCC (5.3 cm × 5 cm × 5 cm).", + "The HCC was confirmed at Zhongshan Hospital Affiliated to Fudan University.", + "Special segmental hepatectomy was performed.", + "Intraoperatively, a tumor was found in segment V.", + "The tumor had a complete capsule.", + "The tumor had clear boundary.", + "The tumor had soft texture.", + "No tumor thrombus was found in the hepatic and portal veins.", + "No tumor thrombus was found in the bile ducts.", + "Postoperative pathological examination confirmed grade II HCC.", + "Postoperative pathological examination found no nodular cirrhosis.", + "The patient continued taking ETV postoperatively.", + "Regular follow-ups revealed normal liver function.", + "MRI findings did not change significantly.", + "The patient had no previous noteworthy medical history.", + "The patient did not smoke tobacco.", + "The patient did not consume alcohol.", + "The patient’s father died of HCC in 1974.", + "The patient’s height was 176 cm.", + "The patient’s weight was 76 kg.", + "The patient’s body temperature was 36.2 °C.", + "The patient’s blood pressure was 145/78 mmHg.", + "The patient’s pulse rate was 76 beats/min.", + "The abdomen was soft and flat.", + "There was no pain or tenderness.", + "No edema of the lower extremities was observed.", + "HBsAg was 572.03 IU/mL.", + "HBeAb was 0.79 S/CO.", + "HBcAb was 1.13 S/CO.", + "Alpha-fetoprotein (AFP) was 3.06 ng/mL.", + "Alanine aminotransferase (ALT) was 22 U/L.", + "Aspartate aminotransferase (AST) was 25 U/L.", + "HBV DNA (cobas) was < 20 IU/mL.", + "White blood cell count was 6.38 × 109/L.", + "Neutrophil count was 2.21 × 109/L.", + "Platelet count was 156 × 109/L.", + "Thyroid function tests (TSH, FT3, and FT4) were normal.", + "Autoimmune liver disease-related antibodies were all negative.", + "Electrocardiography was normal.", + "Abdominal color Doppler ultrasonography showed slightly coarse images.", + "Liver ultrasound scans showed slightly coarse images.", + "No nodules were found on liver ultrasound.", + "No space-occupying lesions were found on liver ultrasound." + ], + "summary": "A 47-year-old man with a family history of HCC was found to have hepatitis B virus (HBV) infection 25 years ago. In 2000, he was administered lamivudine for 2 years, and entecavir (ETV 0.5 mg) was administered in 2006. In October 2016, magnetic resonance imaging revealed a tumor in the liver (5.3 cm × 5 cm × 5 cm); no intraoperative hepatic and portal vein and bile duct tumor thrombi were found; and postoperative pathological examination confirmed a grade II HCC with no nodular cirrhosis (G1S3). ETV was continued, and no significant changes were observed on imaging. After receiving pegylated interferon alfa-2b (PEG IFNα-2b) (180 μg) + ETV in February 2019, the HBsAg titer decreased significantly within 12 wk. After receiving hepatitis B vaccine (60 μg) in 12 wk, HBsAg serological conversion was realized at 48 wk. During the treatment, no obvious adverse reactions were observed, except for early alanine aminotransferase flares. The reexamination results of liver pathology were G2S1, and reversal of liver fibrosis was achieved.", + "summary_subclaims": [ + "The patient is a 47-year-old man.", + "The patient has a family history of HCC.", + "The patient was found to have hepatitis B virus (HBV) infection 25 years ago.", + "In 2000, the patient was administered lamivudine for 2 years.", + "Entecavir (ETV 0.5 mg) was administered in 2006.", + "In October 2016, magnetic resonance imaging revealed a tumor in the liver (5.3 cm × 5 cm × 5 cm).", + "No intraoperative hepatic and portal vein and bile duct tumor thrombi were found.", + "Postoperative pathological examination confirmed a grade II HCC with no nodular cirrhosis (G1S3).", + "ETV was continued after the surgery.", + "No significant changes were observed on imaging after ETV was continued.", + "The patient received pegylated interferon alfa-2b (PEG IFNα-2b) (180 μg) + ETV in February 2019.", + "The HBsAg titer decreased significantly within 12 wk after receiving PEG IFNα-2b + ETV.", + "The patient received hepatitis B vaccine (60 μg) in 12 wk.", + "HBsAg serological conversion was realized at 48 wk.", + "No obvious adverse reactions were observed during the treatment, except for early alanine aminotransferase flares.", + "The reexamination results of liver pathology were G2S1.", + "Reversal of liver fibrosis was achieved." + ] + }, + { + "id": "multiclinsum_test_1223_en.txt", + "fulltext": "A 43-year-old Caucasian woman presented to our clinic with a mild itching sensation in her arms and legs. She was referred by her physician for contact eczema. A physical examination revealed erythematous papular lesions over her metacarpophalangeal and proximal interphalangeal joints together with a periungual involvement with redness, hyperkeratosis, and capillary telangiectasia along the distal nailfolds on both her hands . No other skin findings such as heliotrope rash or erythema on the extensor surface of her extremity joints were present.\nShe complained about pain and weakness in the muscles of her proximal extremities and neck flexor muscles with difficulty raising her arms and climbing stairs. At the same time she experienced swallowing difficulties and reported an uncharacteristic weight loss of 10 kg in the last 3 months. She had a 30 pack-year history of cigarette smoking with persistent nicotine use at the time of presentation in our clinic. A neurological examination showed symmetrical mild proximal muscle weakness. The rest of her physical examination including auscultation of her lungs, body temperature and lymph nodes status was normal.\nThe laboratory findings revealed elevated serum levels of myoglobin 397 μg/l (normal range 25 to 58), creatine phosphokinase (CK) 881 IU/L (normal range 0 to 145 IU/L) and aldolase 11.8 U/l (normal range up to 7.6 U/l). Her liver enzymes were slightly elevated as were aspartate transaminase (AST) 69 U/l (normal range up to 31 U/l) and alanine transaminase (ALT) 50 U/l (normal range up to 34 U/l). Antinuclear antibody (ANA 1/160) was weakly positive while extractable nuclear antigens (ENAs) including anti-Jo-1 antibody were negative. Other laboratory parameters such as C-reactive protein (CRP) and lactate dehydrogenase (LDH) were normal. A histopathologic examination of the skin/muscle biopsy showed vacuolar degeneration of the basal membrane with perivascular inflammatory infiltration together with a lymphohistiocytic infiltration. In addition, an extensive mucin deposition in her dermis and linear atrophy of her muscle layer were detected. The morphologic features were compatible with dermatomyositis. An electromyogram and magnetic resonance imaging (MRI) of the muscles of her extremities showed a symmetric moderate myopathy mainly of proximal muscles which confirmed the diagnosis of dermatomyositis. A chest X-ray showed an unspecific pulmonary nodule in the upper field of her right lung. Computed tomography (CT) of her chest revealed a nodule of 20×22 mm in her right upper pulmonary field without mediastinal or axillar lymphadenopathy . A CT-guided biopsy of the lung nodule revealed a lung adenocarcinoma of moderate differentiation. After diagnosis of the lung tumor was made, she underwent a thorough screening including CT of her abdomen and MRI of her head/neck in order to exclude other tumors, lymph metastases or organ metastases. Furthermore we performed an endoscopy of her upper digestive tract and a gynecological control to exclude any other types of cancer. All of them were negative. Her pulmonary function tests and echocardiography were normal as well.\nShe was given a presumed diagnosis of a lung adenocarcinoma with clinical manifestations of paraneoplastic dermatomyositis. No metastatic lesions were found, and there were no abdominal or cerebral abnormalities. A corticosteroid treatment with prednisolone 1 mg/kg/day was administered. In the absence of cardiologic or anesthesiologic contraindications she was assessed to be eligible for surgery. She underwent a right upper lobectomy. The histopathology showed a moderately differentiated adenocarcinoma that was pathologically staged as T1b N0 M0. In the postoperative period, she presented partial improvement of her skin lesions, muscle weakness and dysphagia.", + "fulltext_subclaims": [ + "The patient is a 43-year-old Caucasian woman.", + "She presented with a mild itching sensation in her arms and legs.", + "She was referred by her physician for contact eczema.", + "A physical examination revealed erythematous papular lesions over her metacarpophalangeal and proximal interphalangeal joints.", + "There was periungual involvement with redness, hyperkeratosis, and capillary telangiectasia along the distal nailfolds on both her hands.", + "No other skin findings such as heliotrope rash or erythema on the extensor surface of her extremity joints were present.", + "She complained about pain and weakness in the muscles of her proximal extremities and neck flexor muscles.", + "She had difficulty raising her arms and climbing stairs.", + "She experienced swallowing difficulties.", + "She reported an uncharacteristic weight loss of 10 kg in the last 3 months.", + "She had a 30 pack-year history of cigarette smoking.", + "She was using nicotine at the time of presentation.", + "A neurological examination showed symmetrical mild proximal muscle weakness.", + "The rest of her physical examination including auscultation of her lungs, body temperature and lymph nodes status was normal.", + "The laboratory findings revealed elevated serum levels of myoglobin 397 μg/l.", + "The normal range for myoglobin is 25 to 58 μg/l.", + "The laboratory findings revealed elevated creatine phosphokinase (CK) 881 IU/L.", + "The normal range for CK is 0 to 145 IU/L.", + "The laboratory findings revealed elevated aldolase 11.8 U/l.", + "The normal range for aldolase is up to 7.6 U/l.", + "Her liver enzymes were slightly elevated.", + "Aspartate transaminase (AST) was 69 U/l.", + "The normal range for AST is up to 31 U/l.", + "Alanine transaminase (ALT) was 50 U/l.", + "The normal range for ALT is up to 34 U/l.", + "Antinuclear antibody (ANA) was weakly positive at 1/160.", + "Extractable nuclear antigens (ENAs) including anti-Jo-1 antibody were negative.", + "Other laboratory parameters such as C-reactive protein (CRP) and lactate dehydrogenase (LDH) were normal.", + "A histopathologic examination of the skin/muscle biopsy showed vacuolar degeneration of the basal membrane with perivascular inflammatory infiltration.", + "A histopathologic examination showed a lymphohistiocytic infiltration.", + "An extensive mucin deposition in her dermis was detected.", + "Linear atrophy of her muscle layer was detected.", + "The morphologic features were compatible with dermatomyositis.", + "An electromyogram and magnetic resonance imaging (MRI) of the muscles of her extremities showed a symmetric moderate myopathy mainly of proximal muscles.", + "The diagnosis of dermatomyositis was confirmed.", + "A chest X-ray showed an unspecific pulmonary nodule in the upper field of her right lung.", + "Computed tomography (CT) of her chest revealed a nodule of 20×22 mm in her right upper pulmonary field.", + "There was no mediastinal or axillar lymphadenopathy.", + "A CT-guided biopsy of the lung nodule revealed a lung adenocarcinoma of moderate differentiation.", + "After diagnosis of the lung tumor was made, she underwent a thorough screening including CT of her abdomen and MRI of her head/neck.", + "An endoscopy of her upper digestive tract and a gynecological control were performed.", + "All of them were negative.", + "Her pulmonary function tests and echocardiography were normal.", + "She was given a presumed diagnosis of a lung adenocarcinoma with clinical manifestations of paraneoplastic dermatomyositis.", + "No metastatic lesions were found.", + "There were no abdominal or cerebral abnormalities.", + "A corticosteroid treatment with prednisolone 1 mg/kg/day was administered.", + "In the absence of cardiologic or anesthesiologic contraindications she was assessed to be eligible for surgery.", + "She underwent a right upper lobectomy.", + "The histopathology showed a moderately differentiated adenocarcinoma.", + "The tumor was pathologically staged as T1b N0 M0.", + "In the postoperative period, she presented partial improvement of her skin lesions.", + "In the postoperative period, she presented partial improvement of her muscle weakness.", + "In the postoperative period, she presented partial improvement of her dysphagia." + ], + "summary": "Here we report a case of a woman with dermatomyositis who was diagnosed with lung adenocarcinoma in the setting of weight loss, progressive fatigue and muscle weakness. A 43-year-old Caucasian woman was referred to our hospital by her physician for suspected contact dermatitis since she described mild itching sensations in her arms and legs as her major symptom. A physical examination revealed erythematous papular lesions over her metacarpophalangeal and proximal interphalangeal joints together with a periungual involvement with redness, hyperkeratosis and capillary telangiectasia along the distal nailfolds on her hands. She was unaware of these features and they did not seem to bother her. A thorough examination of her medical history, however, revealed more symptoms. Pain and weakness in the muscles of her proximal extremities and neck flexor muscles led to difficulty in raising her arms and climbing stairs. At the same time she experienced swallowing difficulties and reported an uncharacteristic weight loss of 10 kg in the last 3 months. The results of laboratory tests showed increased values of serum creatine kinase and myoglobin. An electromyogram, a skin biopsy and a muscle biopsy confirmed the diagnosis of dermatomyositis. A computed tomography of her thorax showed a nodular mass in the upper lobe of her right lung. A histological examination of the lung biopsy showed an adenocarcinoma of moderate differentiation. She was diagnosed with paraneoplastic dermatomyositis as the first sign of a lung adenocarcinoma.", + "summary_subclaims": [ + "A 43-year-old Caucasian woman was referred to the hospital by her physician for suspected contact dermatitis.", + "The patient described mild itching sensations in her arms and legs as her major symptom.", + "A physical examination revealed erythematous papular lesions over her metacarpophalangeal and proximal interphalangeal joints.", + "There was periungual involvement with redness, hyperkeratosis, and capillary telangiectasia along the distal nailfolds on her hands.", + "The patient was unaware of these features and they did not seem to bother her.", + "The patient had pain and weakness in the muscles of her proximal extremities and neck flexor muscles.", + "She had difficulty raising her arms and climbing stairs.", + "She experienced swallowing difficulties.", + "She reported an uncharacteristic weight loss of 10 kg in the last 3 months.", + "Laboratory tests showed increased values of serum creatine kinase and myoglobin.", + "An electromyogram, a skin biopsy, and a muscle biopsy confirmed the diagnosis of dermatomyositis.", + "A computed tomography of the thorax showed a nodular mass in the upper lobe of the right lung.", + "A histological examination of the lung biopsy showed an adenocarcinoma of moderate differentiation.", + "She was diagnosed with paraneoplastic dermatomyositis as the first sign of a lung adenocarcinoma." + ] + }, + { + "id": "multiclinsum_test_3376_en.txt", + "fulltext": "A 27-year-old woman with no relevant medical history presented to the emergency department with 15 days of lower limb oedema and a history of oliguria. She reported a weight gain of approximately 5 kg in the past 15 days. On physical examination, she presented hypertensive crisis with bilateral oedema, jugular engorgement, basal crepitations in both pulmonary bases, and stage II oedema with pitting in all four limbs. The admission test showed metabolic acidosis with elevated anion gap, leukocytosis, neutrophilia, normocytic/normchromic anaemia without transfusion criteria, severe hyperkalaemia, KDIGO 3 acute renal injury, and hyperkalaemia electrocardiographic changes. Given the initial approach of hypertensive emergency with a compromised kidney versus a nephritic syndrome, medical management was initiated and, due to refractoriness, haemodialysis was decided in the nephrology department. Further studies with renal ultrasound showed chronic parenchymal process with signs of exacerbation. The patient also had an increase in calcium and phosphorus profile with increased PTH, autoimmune profile with only one positive P-ANCA result (1/160), and negative infectious profile. Clinical evolution showed persistent signs of overload and progressive deterioration of renal function, and glomerulonephritis was considered rapidly progressive. Treatment started with intravenous corticosteroid pulses for 3 days, plasmapheresis (7 sessions) and continuation of renal replacement therapy. Renal biopsy showed glomerulonephritis with increasing and extracapillary proliferation mediated by P-ANCA, and immune complex mediated glomerulonephritis with membranoproliferative pattern superimposed, which is consistent with full-house disease. Due to satisfactory clinical evolution after the first dose of cyclophosphamide, she was discharged for continuation of immunosuppressive treatment and renal replacement therapy with haemodialysis.\n\nFive days after leaving the hospital, the patient was readmitted with a cough with purulent expectoration associated with fever, asthenia and adynamia. The physical examination showed crepitations in both pulmonary bases and stage I edema in the lower limbs. The patient suffered progressive deterioration of the respiratory pattern, had anemia requiring transfusion, findings in the imaging examinations with areas of glass-like opacity and multilobular infiltrates. Antibiotic coverage (cefepime) was initiated and a bronchial brush was performed that detected macroscopic alveolar hemorrhage. The patient presented progressive deterioration of the ventilatory pattern, with the need for orotracheal intubation and transfer to the intensive care unit. After presenting a poor clinical evolution, the patient died.\n\nMicrobiological screening studies (blood culture, urine culture, bronchoalveolar lavage culture) were negative. The family did not authorize an autopsy.\n", + "fulltext_subclaims": [ + "The patient was a 27-year-old woman.", + "She had no relevant medical history.", + "She presented with 15 days of lower limb oedema.", + "She had a history of oliguria.", + "She reported a weight gain of approximately 5 kg in the past 15 days.", + "On physical examination, she presented hypertensive crisis.", + "She had bilateral oedema.", + "She had jugular engorgement.", + "She had basal crepitations in both pulmonary bases.", + "She had stage II oedema with pitting in all four limbs.", + "The admission test showed metabolic acidosis with elevated anion gap.", + "The admission test showed leukocytosis.", + "The admission test showed neutrophilia.", + "The admission test showed normocytic/normochromic anaemia.", + "The admission test showed no transfusion criteria.", + "The admission test showed severe hyperkalaemia.", + "The admission test showed KDIGO 3 acute renal injury.", + "The admission test showed hyperkalaemia electrocardiographic changes.", + "The initial approach considered a hypertensive emergency with a compromised kidney.", + "The initial approach considered a nephritic syndrome.", + "Medical management was initiated.", + "Haemodialysis was decided in the nephrology department.", + "Renal ultrasound showed chronic parenchymal process with signs of exacerbation.", + "The patient had an increase in calcium and phosphorus profile.", + "The patient had increased PTH.", + "The autoimmune profile showed one positive P-ANCA result (1/160).", + "The infectious profile was negative.", + "Clinical evolution showed persistent signs of overload.", + "Clinical evolution showed progressive deterioration of renal function.", + "Glomerulonephritis was considered rapidly progressive.", + "Treatment started with intravenous corticosteroid pulses for 3 days.", + "Plasmapheresis (7 sessions) was started.", + "Renal biopsy showed glomerulonephritis with increasing and extracapillary proliferation mediated by P-ANCA.", + "Renal biopsy showed immune complex mediated glomerulonephritis with membranoproliferative pattern superimposed.", + "The renal biopsy findings were consistent with full-house disease.", + "The patient was discharged for continuation of immunosuppressive treatment.", + "The patient was discharged for continuation of renal replacement therapy with haemodialysis.", + "Five days after leaving the hospital, the patient was readmitted.", + "The readmission was due to cough with purulent expectoration.", + "The readmission was associated with fever.", + "The readmission was associated with asthenia and adynamia.", + "Physical examination showed crepitations in both pulmonary bases.", + "Physical examination showed stage I edema in the lower limbs.", + "The patient had progressive deterioration of the respiratory pattern.", + "The patient had anemia requiring transfusion.", + "Imaging examinations showed areas of glass-like opacity.", + "Imaging examinations showed multilobular infiltrates.", + "Antibiotic coverage (cefepime) was initiated.", + "A bronchial brush detected macroscopic alveolar hemorrhage.", + "The patient had progressive deterioration of the ventilatory pattern.", + "The patient required orotracheal intubation.", + "The patient was transferred to the intensive care unit.", + "The patient died.", + "Microbiological screening studies were negative.", + "The family did not authorize an autopsy." + ], + "summary": "We present the case of a 27-year-old woman with symptoms consistent with rapidly progressive glomerulonephritis and biopsy findings of a full-house pattern nephropathy that progressed to an early fatal outcome. The association of a full-house pattern, which has a low incidence, with a negative autoimmune profile for systemic lupus erythematosus makes this a rare case. ANCA-associated vasculitis with a full-house pattern renal disease was diagnosed.\n", + "summary_subclaims": [ + "The patient was a 27-year-old woman.", + "The patient had symptoms consistent with rapidly progressive glomerulonephritis.", + "The biopsy findings showed a full-house pattern nephropathy.", + "The case progressed to an early fatal outcome.", + "The full-house pattern has a low incidence.", + "The autoimmune profile for systemic lupus erythematosus was negative.", + "ANCA-associated vasculitis with a full-house pattern renal disease was diagnosed." + ] + }, + { + "id": "multiclinsum_test_642_en.txt", + "fulltext": "A 52 year-old woman collapsed at her home in front of an acquaintance. “Bloody vomit” was noted. An ambulance was called and cardiopulmonary resuscitation (CPR) was begun by paramedics. The patient was transported to hospital, but she remained in cardiorespiratory arrest despite ongoing CPR. Resuscitation efforts were finally stopped.\nIt was later learned that several days prior to her death she had complained of unspecified upper digestive symptoms, but had steadfastly refused to seek medical advice. The medical history included bipolar disorder for which she was apparently compliant in taking her medications. She also smoked and had type II diabetes. Her medications were the following: quetiapine, lorazepam, baclofen, glickazide, metformin, and esomeprazole.\nThe coroner was notified and an autopsy was requested.\nA complete autopsy was performed. The pertinent anatomic findings were confined to the gastrointestinal tract. The middle portion of the esophagus showed a prominent brownish 9 cm longitudinal ulcer, with a maximal width of 0.5 cm, situated 12 cm from the esophago-gastric junction . The esophago-gastric junction itself showed brownish steaks without ulceration, induration or a mass lesion. The stomach contained approximately 750 ml of dark blood; the small bowel and colon contained dark, tarry blood. There was no identifiable mucosal lesion beyond the esophagus.\nMicroscopic examination of numerous sections (>30) from all levels of the esophagus, including the ulcer, showed complete sloughing of the epithelium with a striking subepithelial lichenoid lymphocytic infiltrate extending into the muscularis mucosae . Sections of the esophago-gastric junction showed no evidence of varices. Fungal elements and viral inclusions were absent; Periodic acid-Schiff staining for identification of fungi and immunohistochemical staining for Cytomegalovirus and Herpes simplex viruses I and II were negative.\nAn extensive immunohistochemical study was performed in order to characterize the immunophenotype of the lymphocytic infiltration. The following antibodies were used: CD20, CD2, CD3, CD4, CD5, CD7, CD8 and CD43. Unfortunately, marked post-mortem autolysis rendered interpretation difficult. Only CD43 staining was well preserved , showing diffuse positivity, thus demonstrating that the lymphocytic infiltrate was essentially composed of T-cells. For the other antibodies the results were less reliable, although better antigen preservation of the deeper situated lymphocytes in the muscularis mucosae was noted. Here, a high CD8/CD4 ratio was found. CD2, CD5, CD7 and CD20 were negative, but, given the absence of positive controls for these markers, interpretation was essentially impossible.\nA representative formalin-fixed, paraffin-embedded tissue block was submitted for evaluation of T-cell receptor gamma chain rearrangement by polymerase chain reaction. However, amplification was not possible for technical reasons.\nLaboratory results were the following: lorazepam at a therapeutic blood level; tetrahydrocannabinol metabolites were also present. Ethanol was absent. Blood acetone: 10 mmol/L (normal: 0–0.34), ocular liquid glucose: 640 mg/dL, ocular liquid lactic acid: 230 mg/dL, and ocular liquid acetone: 12 mmol/L. The results were compatible with diabetic ketoacidosis (DKA).\nThe final autopsy diagnoses were: 1) fatal upper gastrointestinal bleeding due to lichenoid esophagitis with diffuse mucosal sloughing and a large ulcer of the mid-esophagus, and 2) diabetic ketoacidosis.", + "fulltext_subclaims": [ + "The patient was a 52 year-old woman.", + "She collapsed at her home in front of an acquaintance.", + "Bloody vomit was noted.", + "An ambulance was called.", + "CPR was begun by paramedics.", + "The patient was transported to hospital.", + "She remained in cardiorespiratory arrest despite ongoing CPR.", + "Resuscitation efforts were finally stopped.", + "Several days prior to her death, she had complained of unspecified upper digestive symptoms.", + "She had steadfastly refused to seek medical advice.", + "The medical history included bipolar disorder.", + "She was apparently compliant in taking her medications.", + "She smoked.", + "She had type II diabetes.", + "Her medications included quetiapine, lorazepam, baclofen, gliclazide, metformin, and esomeprazole.", + "The coroner was notified.", + "An autopsy was requested.", + "A complete autopsy was performed.", + "The pertinent anatomic findings were confined to the gastrointestinal tract.", + "The middle portion of the esophagus showed a prominent brownish 9 cm longitudinal ulcer.", + "The ulcer had a maximal width of 0.5 cm.", + "The ulcer was situated 12 cm from the esophago-gastric junction.", + "The esophago-gastric junction showed brownish steaks without ulceration, induration or a mass lesion.", + "The stomach contained approximately 750 ml of dark blood.", + "The small bowel and colon contained dark, tarry blood.", + "There was no identifiable mucosal lesion beyond the esophagus.", + "Microscopic examination of numerous sections from all levels of the esophagus showed complete sloughing of the epithelium.", + "There was a striking subepithelial lichenoid lymphocytic infiltrate extending into the muscularis mucosae.", + "Sections of the esophago-gastric junction showed no evidence of varices.", + "Fungal elements and viral inclusions were absent.", + "Periodic acid-Schiff staining for identification of fungi and immunohistochemical staining for Cytomegalovirus and Herpes simplex viruses I and II were negative.", + "An extensive immunohistochemical study was performed.", + "The following antibodies were used: CD20, CD2, CD3, CD4, CD5, CD7, CD8 and CD43.", + "Marked post-mortem autolysis rendered interpretation difficult.", + "Only CD43 staining was well preserved, showing diffuse positivity.", + "The lymphocytic infiltrate was essentially composed of T-cells.", + "For the other antibodies, the results were less reliable.", + "A representative formalin-fixed, paraffin-embedded tissue block was submitted for evaluation of T-cell receptor gamma chain rearrangement by polymerase chain reaction.", + "Amplification was not possible for technical reasons.", + "Lorazepam was at a therapeutic blood level.", + "Tetrahydrocannabinol metabolites were also present.", + "Ethanol was absent.", + "Blood acetone was 10 mmol/L.", + "The results were compatible with diabetic ketoacidosis.", + "The final autopsy diagnoses were: 1) fatal upper gastrointestinal bleeding due to lichenoid esophagitis with diffuse mucosal sloughing and a large ulcer of the mid-esophagus, and 2) diabetic ketoacidosis." + ], + "summary": "A 52 year-old diabetic woman collapsed at her home in front of an acquaintance. \"Bloody vomit\" was noted. Despite resuscitation efforts, the patient died. A complete autopsy was performed. The middle portion of the esophagus showed a 9 cm longitudinal ulcer situated 12 cm from the esophago-gastric junction. Microscopic examination showed complete sloughing of the esophageal epithelium with a striking subepithelial lichenoid lymphocytic infiltrate extending into the muscularis mucosae. The findings were considered compatible with lichenoid esophagitis. Laboratory studies also showed the presence of diabetic ketoacidosis.", + "summary_subclaims": [ + "The patient was a 52-year-old diabetic woman.", + "The patient collapsed at her home in front of an acquaintance.", + "Bloody vomit was noted.", + "The patient died despite resuscitation efforts.", + "A complete autopsy was performed.", + "The middle portion of the esophagus showed a 9-cm longitudinal ulcer situated 12 cm from the esophago-gastric junction.", + "Microscopic examination showed complete sloughing of the esophageal epithelium.", + "A striking subepithelial lichenoid lymphocytic infiltrate extending into the muscularis mucosae was observed.", + "The findings were considered compatible with lichenoid esophagitis.", + "Laboratory studies showed the presence of diabetic ketoacidosis." + ] + }, + { + "id": "multiclinsum_test_3056_en.txt", + "fulltext": "A 56-year-old male was involved in a motorbike accident. He was struck by another motorcycle attempting to overtake a car, causing him to be thrown and impact his face on a road divider. Despite wearing a half-face helmet, he remained conscious but experienced significant pain in his cheek, lip, and left eye area, along with bleeding from his nose and mouth. He was initially transported to Krakatau Hospital for facial surgery but was referred to Cipto Mangunkusumo General Hospital (RSCM) due to difficulties with intubation.\n\nUpon assessment at RSCM, the patient was conscious, cooperative, and oriented, with a Glasgow Coma Scale score of 15. Clinical examination revealed generalized facial edema, bilateral lagophthalmos (2 mm in the right eye, 1 mm in the left), orthophoria, and a visual acuity of 3/60. Subconjunctival bleeding was noted in the left eye, along with malar depression in both nasal regions. The right maxilla showed edema, crepitus, and a floating sensation, while the mandibular area exhibited lacerations and crepitus. Intraoral examination revealed anterior and posterior open-bite malocclusion, with a laceration near the right lip and a separation of the palate. Laboratory results indicated leukocytosis (15,500/mm3). A pre-operative CT scan revealed bilateral Le Fort type I fractures, septal fractures, bilateral condyle fractures, a mandibular symphysis fracture, and zygomatic fractures.\n\nThe operation involved multiple specialties, including ENT Plastic Reconstruction, ENT Larynx Pharynx, Oral-Maxillofacial Surgery, and Anesthesia, requiring submental intubation. The Oral-Maxillofacial Surgery Division initiated maxillomandibular fixation (MMF) with arch bars, followed by dental procedure including debridement and extraction of the left central maxillary and mandibular incisors due to indication of Le Fort I fracture. Additionally, the right maxillary lateral incisor and right maxillary canine were intruded and, due to extensive damage we extracted. The left maxillary central incisor was avulsed. Tooth vitality of the remaining undisturbed teeth was found to be normal on physical examination. Following this, open reduction internal fixation (ORIF) of the mandible using plates and screws (numbers 8, 10, and 12). Arch bars were secured with wires to maintain occlusion during reconstruction.\n\nOnce occlusion was achieved, an incision was made from the preauricular region, and blunt dissection revealed fractures in the left condyle region, where two plates and screws (numbers 6 and 8) were installed. The same procedure was performed on the right condyle. ENT Plastic Reconstruction then performed open reduction internal fixation of the maxilla with miniplates, with the arch bar locked in place using wires. Incisions were made from the gingivobuccal mucosa to the maxillary periosteum, followed by mucoperiosteal flap elevation. Multiple plates and screws (numbers 4, 5, and 6) were used to stabilize comminuted fractures in the maxilla and zygoma.\n\nFive days post-operatively, the submental anesthetic tube was removed, and a tracheostomy was performed due to silent aspiration and sputum retention. Eighteen days later, the tracheostomy cannula was accidentally dislodged by the patient. Fortunately, the patient's condition remained stable, and there was no desaturation. The patient was treated in the ICU for 25 days. On the third post-operative day, the wire fixation was removed due to airway issues and poor oral hygiene, but the arch bar was maintained until six weeks post-operatively.\n\nOne month and eight months after surgery, the patient's face appeared symmetrical, with no facial edema or malocclusion, and no abnormalities were found in either eye.", + "fulltext_subclaims": [ + "The patient was involved in a motorbike accident.", + "He was struck by another motorcycle attempting to overtake a car.", + "He was thrown and impacted his face on a road divider.", + "He was wearing a half-face helmet.", + "He remained conscious after the accident.", + "He experienced significant pain in his cheek, lip, and left eye area.", + "He had bleeding from his nose and mouth.", + "He was initially transported to Krakatau Hospital for facial surgery.", + "He was referred to Cipto Mangunkusumo General Hospital due to difficulties with intubation.", + "Upon assessment at RSCM, the patient was conscious.", + "The patient was cooperative and oriented.", + "The patient had a Glasgow Coma Scale score of 15.", + "Clinical examination revealed generalized facial edema.", + "Bilateral lagophthalmos was noted.", + "Subconjunctival bleeding was noted in the left eye.", + "Malar depression was noted in both nasal regions.", + "The right maxilla showed edema, crepitus, and a floating sensation.", + "The mandibular area exhibited lacerations and crepitus.", + "Intraoral examination revealed anterior and posterior open-bite malocclusion.", + "A laceration near the right lip was noted.", + "A separation of the palate was noted.", + "Laboratory results indicated leukocytosis (15,500/mm3).", + "A pre-operative CT scan revealed bilateral Le Fort type I fractures.", + "A pre-operative CT scan revealed septal fractures.", + "A pre-operative CT scan revealed bilateral condyle fractures.", + "A pre-operative CT scan revealed a mandibular symphysis fracture.", + "A pre-operative CT scan revealed zygomatic fractures.", + "The operation involved multiple specialties.", + "Submental intubation was required.", + "The Oral-Maxillofacial Surgery Division initiated maxillomandibular fixation with arch bars.", + "Dental procedures included debridement and extraction of the left central maxillary and mandibular incisors.", + "The right maxillary lateral incisor and right maxillary canine were intruded and extracted.", + "The left maxillary central incisor was avulsed.", + "Tooth vitality of the remaining undisturbed teeth was found to be normal.", + "Open reduction internal fixation of the mandible was performed using plates and screws.", + "Arch bars were secured with wires to maintain occlusion.", + "An incision was made from the preauricular region.", + "Fractures in the left condyle region were repaired with two plates and screws.", + "The same procedure was performed on the right condyle.", + "Open reduction internal fixation of the maxilla was performed with miniplates.", + "Incisions were made from the gingivobuccal mucosa to the maxillary periosteum.", + "Multiple plates and screws were used to stabilize comminuted fractures in the maxilla and zygoma.", + "Five days post-operatively, the submental anesthetic tube was removed.", + "A tracheostomy was performed due to silent aspiration and sputum retention.", + "Eighteen days later, the tracheostomy cannula was accidentally dislodged by the patient.", + "The patient's condition remained stable after the tracheostomy cannula dislodgement.", + "There was no desaturation after the tracheostomy cannula dislodgement.", + "The patient was treated in the ICU for 25 days.", + "On the third post-operative day, wire fixation was removed due to airway issues and poor oral hygiene.", + "The arch bar was maintained until six weeks post-operatively.", + "One month after surgery, the patient's face appeared symmetrical.", + "One month after surgery, there was no facial edema.", + "One month after surgery, there was no malocclusion.", + "One month after surgery, no abnormalities were found in either eye.", + "Eight months after surgery, the patient's face appeared symmetrical.", + "Eight months after surgery, there was no facial edema.", + "Eight months after surgery, there was no malocclusion.", + "Eight months after surgery, no abnormalities were found in either eye." + ], + "summary": "This article presents the case of a 56-year-old male who sustained panfacial fractures following a road accident, exhibiting symptoms including facial pain and nosebleeds. The treatment involved the use of arch bars for dental occlusion. Post-operative recovery was complicated by silent aspiration, successfully managed with a tracheostomy. After one month, the patient showed symmetrical facial features with no abnormalities.", + "summary_subclaims": [ + "This article presents the case of a 56-year-old male.", + "The patient sustained panfacial fractures following a road accident.", + "The patient exhibited symptoms including facial pain and nosebleeds.", + "The treatment involved the use of arch bars for dental occlusion.", + "Post-operative recovery was complicated by silent aspiration.", + "The silent aspiration was successfully managed with a tracheostomy.", + "After one month, the patient showed symmetrical facial features.", + "After one month, the patient had no abnormalities." + ] + }, + { + "id": "multiclinsum_test_1830_en.txt", + "fulltext": "We present the case of an 81-year-old male patient with a history of a CABG using the RGEA. He had a past medical history of diabetes mellitus and the lower extremity arteriosclerosis obliterans. Preoperative enhanced computed tomography (CT) imaging revealed an enlarged hepatic tumor and a patent RGEA graft was observed on the left lobe of the liver . Subsequent liver biopsy confirmed the diagnosis of hepatocellular carcinoma as a consequence of nonalcoholic steatohepatitis. The tumor was located near the bifurcation of the anterior and posterior hepatic branches , warranting a right hepatectomy. As the percentage of the remaining liver was only 41%, preoperative transhepatic portal vein embolization (PTPE) was initially performed to promote enlargement of the left lobe. This procedure increased the proportion of the remaining liver to 45%, after which an open right hepatectomy was planned. The Child-Pugh classification, which reflects preoperative liver function, was A (5 points), and the indocyanine green(ICG) retention test after 15 minuets was 1.0%.\nA median skin incision with right transverse extension was performed. A wound protector was not used to prevent potential damage to the RGEA. The RGEA graft coursed past the ventral side of the stomach to the left of the hepatic falciform ligament and proceeded along the ventral side of the liver into the heart. The RGEA graft tightly adhered to the falciform ligament, meticulously separated from the liver’s surface, and was secured . The RGEA graft was taped, taking the utmost care not only to prevent any intraoperative damage but also to ensure that no unnecessary tension was applied.\nFollowing the detachment of the RGEA graft from the liver, a right hepatectomy was performed . The left lobe was retracted to the new space of the right temporal side, which might have exerted tension on the RGEA graft; therefore, the falciform ligament was anchored to the abdominal wall . Consequently, traction on the RGEA graft was avoided. No cardiac events occurred during the right hepatectomy, with a total intraoperative blood loss of 175 ml over a total operative time of 268 min. The resected specimen weighed 600 g, and the tumor measured 6.0 × 5.0 cm. Histopathological examination revealed a moderately differentiated hepatocellular carcinoma . Continuous preoperative heparin was administered to ensure optimal circulation through the RGEA graft. Heparin was discontinued 6 h before surgery and resumed the day following the procedure. The patient’s postoperative course was uneventful, except that diuretics were started due to ascites. The patient was discharged on the 19th postoperative day. One and a half years after the surgery, the patient showed no recurrence of hepatocellular carcinoma or cardiovascular events.", + "fulltext_subclaims": [ + "The patient was an 81-year-old male.", + "The patient had a history of CABG using the RGEA.", + "The patient had a past medical history of diabetes mellitus.", + "The patient had a past medical history of lower extremity arteriosclerosis obliterans.", + "Preoperative enhanced CT imaging revealed an enlarged hepatic tumor.", + "A patent RGEA graft was observed on the left lobe of the liver.", + "Subsequent liver biopsy confirmed the diagnosis of hepatocellular carcinoma.", + "The hepatocellular carcinoma was a consequence of nonalcoholic steatohepatitis.", + "The tumor was located near the bifurcation of the anterior and posterior hepatic branches.", + "A right hepatectomy was planned.", + "The percentage of the remaining liver was 41%.", + "Preoperative transhepatic portal vein embolization was initially performed.", + "The procedure increased the proportion of the remaining liver to 45%.", + "An open right hepatectomy was planned.", + "The Child-Pugh classification was A (5 points).", + "The ICG retention test after 15 minutes was 1.0%.", + "A median skin incision with right transverse extension was performed.", + "A wound protector was not used to prevent potential damage to the RGEA.", + "The RGEA graft coursed past the ventral side of the stomach to the left of the hepatic falciform ligament.", + "The RGEA graft proceeded along the ventral side of the liver into the heart.", + "The RGEA graft tightly adhered to the falciform ligament.", + "The RGEA graft was meticulously separated from the liver’s surface.", + "The RGEA graft was secured.", + "The RGEA graft was taped.", + "Care was taken to prevent intraoperative damage to the RGEA graft.", + "Care was taken to ensure no unnecessary tension was applied to the RGEA graft.", + "Following the detachment of the RGEA graft from the liver, a right hepatectomy was performed.", + "The left lobe was retracted to the new space of the right temporal side.", + "The falciform ligament was anchored to the abdominal wall.", + "Traction on the RGEA graft was avoided.", + "No cardiac events occurred during the right hepatectomy.", + "The total intraoperative blood loss was 175 ml.", + "The total operative time was 268 min.", + "The resected specimen weighed 600 g.", + "The tumor measured 6.0 × 5.0 cm.", + "Histopathological examination revealed a moderately differentiated hepatocellular carcinoma.", + "Continuous preoperative heparin was administered.", + "Heparin was discontinued 6 h before surgery.", + "Heparin was resumed the day following the procedure.", + "The patient’s postoperative course was uneventful.", + "Diuretics were started due to ascites.", + "The patient was discharged on the 19th postoperative day.", + "One and a half years after the surgery, the patient showed no recurrence of hepatocellular carcinoma.", + "One and a half years after the surgery, the patient showed no cardiovascular events." + ], + "summary": "We describe a case in which a right hepatectomy for an 81-year-old male patient with hepatocellular carcinoma was safely performed after CABG using a RGEA graft. Preoperatively, three-dimensional computed tomography (3D- CT) images were constructed to confirm the run of the RGEA graft. The operation was conducted with the standby of a cardiovascular surgeon if there was a problem with the RGEA graft. The RGEA graft had formed adhesions with the hepatic falciform ligament, necessitating meticulous dissection. After the right hepatectomy, the left hepatic lobe descended into the vacated space, exerting traction on the RGEA. However, this traction was mitigated by suturing the hepatic falciform ligament to the abdominal wall, ensuring stability of the RGEA. There were no intraoperative or postoperative complications.", + "summary_subclaims": [ + "A right hepatectomy for an 81-year-old male patient with hepatocellular carcinoma was safely performed after CABG using a RGEA graft.", + "Preoperatively, three-dimensional computed tomography (3D-CT) images were constructed to confirm the run of the RGEA graft.", + "The operation was conducted with the standby of a cardiovascular surgeon if there was a problem with the RGEA graft.", + "The RGEA graft had formed adhesions with the hepatic falciform ligament.", + "Meticulous dissection was necessitated by the adhesions of the RGEA graft with the hepatic falciform ligament.", + "After the right hepatectomy, the left hepatic lobe descended into the vacated space.", + "The descent of the left hepatic lobe exerted traction on the RGEA.", + "The traction on the RGEA was mitigated by suturing the hepatic falciform ligament to the abdominal wall.", + "There were no intraoperative or postoperative complications." + ] + }, + { + "id": "multiclinsum_test_1392_en.txt", + "fulltext": "A 72-year-old right handed male diagnosed with poorly-differentiated, stage IIIB neuroendocrine carcinoma of the colon s/p hemicolectomy, small bowel resection and carboplatin-etoposide × 3 cycles presented to the emergency department with acute altered mental status and right facial droop.\nFour months prior, he presented with constipation and anemia. Colonoscopy revealed a large raised flat lesion in the transverse colon and CT abdomen demonstrated RLQ mesenteric lymphadenopathy. He underwent right hemicolectomy and small bowel resection weeks later. Pathology was significant for poorly-differentiated grade 3, neuroendocrine carcinoma with focal lymphovascular invasion and tumor invasion through the muscularis propria into the subserosa. Margins were negative, no perineural invasion and 1/33 lymph nodes were positive for carcinoma. There was an absence of non-neuroendocrine component. Immunohistochemical stains were positive for: AE1/AE3, CD56, chromogranin, and synaptophysin; Ki-67 of 60% proliferative index. He was staged as pathologic T3N1a, stage IIIB.\nIn the emergency department, head CT was negative for an acute hemorrhagic process and did not demonstrate any suspicious lesions. Within one day of admission, the facial droop resolved. Further imaging, CT chest abdomen pelvis, revealed stable enlarged mediastinal lymphadenopathy and a subcentimeter retroperitoneal lymph node but no progression was evident. Two days into the hospital stay, the patient developed fever and subsequently neck stiffness. His chest x-ray and urinalysis were non-diagnostic; EEG showed diffuse slowing but no seizure activity. A lumbar puncture was performed with cytopathology of the CSF suggesting metastatic disease to the central nervous system , along with lymphocytic pleocytosis, normal glucose, and significantly elevated protein and lactic acid. Cytologic analysis showed tumor cells with characteristically-high nuclear to cytoplasmic ratio, relatively round nuclei with stippled “salt and pepper” nuclear chromatin and minimal cytoplasm, features consistent with metastatic neuroendocrine carcinoma . Immunohistochemistry showed the tumor cells were strongly positive for synaptophysin and Cytokeratin AE1/AE3 with a typical perinuclear dot pattern.\nMedical oncology and radiation oncology were consulted. No further chemotherapy was recommended as he had progressed after completing 3 of 6 cycles of carboplatin-etoposide. Enrollment in an erlotinib trial was discussed vs palliative therapy. While radiation was considered to be potentially palliative for his symptoms, radiation oncology deemed it would be unlikely to change his overall survival. He was started on palliative high-dose steroids and ultimately transferred to inpatient hospice care. The patient passed away within a week of entering hospice.", + "fulltext_subclaims": [ + "The patient is a 72-year-old right handed male.", + "He was diagnosed with poorly-differentiated, stage IIIB neuroendocrine carcinoma of the colon.", + "He had a hemicolectomy, small bowel resection, and three cycles of carboplatin-etoposide.", + "He presented to the emergency department with acute altered mental status and right facial droop.", + "Four months prior, he presented with constipation and anemia.", + "Colonoscopy revealed a large raised flat lesion in the transverse colon.", + "CT abdomen demonstrated RLQ mesenteric lymphadenopathy.", + "He underwent right hemicolectomy and small bowel resection weeks later.", + "Pathology showed poorly-differentiated grade 3, neuroendocrine carcinoma with focal lymphovascular invasion.", + "Tumor invasion was through the muscularis propria into the subserosa.", + "Margins were negative.", + "One of 33 lymph nodes was positive for carcinoma.", + "There was an absence of non-neuroendocrine component.", + "Immunohistochemical stains were positive for AE1/AE3, CD56, chromogranin, and synaptophysin.", + "Ki-67 showed a 60% proliferative index.", + "He was staged as pathologic T3N1a, stage IIIB.", + "Head CT was negative for an acute hemorrhagic process.", + "Head CT did not demonstrate any suspicious lesions.", + "The facial droop resolved within one day of admission.", + "CT chest abdomen pelvis showed stable enlarged mediastinal lymphadenopathy.", + "A subcentimeter retroperitoneal lymph node was noted.", + "The patient developed fever and neck stiffness two days into the hospital stay.", + "Chest x-ray and urinalysis were non-diagnostic.", + "EEG showed diffuse slowing but no seizure activity.", + "Lumbar puncture cytopathology suggested metastatic disease to the central nervous system.", + "CSF showed lymphocytic pleocytosis.", + "CSF glucose was normal.", + "CSF protein was significantly elevated.", + "CSF lactic acid was significantly elevated.", + "Cytologic analysis showed tumor cells with a high nuclear to cytoplasmic ratio.", + "Tumor cells had relatively round nuclei with stippled 'salt and pepper' nuclear chromatin.", + "Tumor cells had minimal cytoplasm.", + "Features were consistent with metastatic neuroendocrine carcinoma.", + "Immunohistochemistry showed tumor cells were strongly positive for synaptophysin.", + "Immunohistochemistry showed tumor cells were positive for Cytokeratin AE1/AE3 with a typical perinuclear dot pattern.", + "Medical oncology and radiation oncology were consulted.", + "No further chemotherapy was recommended.", + "Enrollment in an erlotinib trial was discussed.", + "Palliative therapy was discussed.", + "Radiation was considered potentially palliative for his symptoms.", + "Radiation oncology deemed it would be unlikely to change his overall survival.", + "He was started on palliative high-dose steroids.", + "He was transferred to inpatient hospice care.", + "The patient passed away within a week of entering hospice." + ], + "summary": "A 72-year-old male with poorly-differentiated stage IIIB neuroendocrine carcinoma of the colon presented with acute altered mental status and right facial droop. Head CT was negative for an acute hemorrhagic process without evidence of suspicious lesions. Several days later, the patient developed fever and neck stiffness suspicious for bacterial meningitis. A lumbar puncture procedure was performed. Cytology of the CSF demonstrated metastatic disease to the central nervous system and the final diagnosis of carcinomatous meningitis secondary to metastatic neuroendocrine carcinoma of the colon was made.", + "summary_subclaims": [ + "The patient is a 72-year-old male.", + "The patient has poorly-differentiated stage IIIB neuroendocrine carcinoma of the colon.", + "The patient presented with acute altered mental status.", + "The patient presented with right facial droop.", + "Head CT was negative for an acute hemorrhagic process.", + "Head CT showed no evidence of suspicious lesions.", + "The patient developed fever several days later.", + "The patient developed neck stiffness.", + "The clinical presentation was suspicious for bacterial meningitis.", + "A lumbar puncture procedure was performed.", + "Cytology of the CSF demonstrated metastatic disease to the central nervous system.", + "The final diagnosis was carcinomatous meningitis secondary to metastatic neuroendocrine carcinoma of the colon." + ] + }, + { + "id": "multiclinsum_test_1394_en.txt", + "fulltext": "A 62-year-old hypertentive man was admitted to a local hospital for persistent chest pain lasting 1 h. The patient said he had a heart murmur during a physical examination at age 8 but was misdiagnosed with mitral insufficiency, so he was not further treated. The electrocardiograph (ECG) demonstrated a significant ST-segment elevation in II,III,avF and V7–9 . A diagnosis of acute inferior-posterior myocardial infarction was made. The patient was given 300 mg aspirin,300 mg clopidogrel and then intravenous thrombolysis treatment (Reteplase 18 mg*2). However he still had chest pain and ST-segment elevation 2 h after treatment. Then, he was transferred to a regional percutaneous coronary intervention (PCI)-capable hospital.\nAt admission, his blood pressure was 126/62 mmHg, and his heart rate was regular at 122 beats/min without cardiac murmurs. There was no systemic or pulmonary oedema. The cTNI was 6.64 mmol/L, NT-proBNP was 664.8 pg/mL, and D-dimer was 37,180 ng/mL.\nEmergence coronary angiography was performed and showed a 50–60% stenosis in the middle left anterior descending artery (mLAD), and the left circumflex artery (LCX) was normal . When they tried to perform right coronary artery (RCA) angiography, the catheter could not enter the RCA. Ultimately, the physicians were still unable to observe the ostia of the RCA .\nEchocardiography revealed a giant right coronary artery- right ventricle fistula. A computed tomography angiography (CTA) scan 7 days after admission showed that the dilated RCA opening was approximately 30 mm , and the widest segment was about 97 mm . The thrombus blocked the artery flow, and the contrast medium filling in the distal region was defective . 3D reconstruction of the heart showed a dilated and tortuous RCA originating from the ascending aorta and traversing through the right front the heart, but its development stopped because the flow was blocked . The 3D reconstruction of the heart and great vessels showed that the diameter of the RCA was almost equal to that of the descending aorta .\nTherefore, a diagnosis of congenital right coronary artery-right ventricular fistula complicated with coronary artery aneurysm and acute myocardial infarction was made. The patient had discovered a cardiac murmur at age 8 but had been was asymptomatic for 62 years before the acute myocardial infarction occurred. After tortuous treatments, including intravenous thrombolysis treatment at a local hospital, coronary angiography was performed at a regional hospital. He was ultimately transferred to our hospital for complex surgical treatment.\nAfter 1 month of medication, he was admitted to our hospital and underwent surgery for coronary artery fistula repair + coronary aneurysm resection + coronary aneurysm thrombectomy + aortic sinus plasty. During the operation, the RCA was tortuously dilated, with the widest point > 100 mm located in the right atrioventricular groove at 120 mm in length, causing compression on the right lung. Many red thrombi intermingled with white blood clots in the lumen were observed after the RCA was cut open. The dilated segment of the RCA was cut and removed, followed by opening of the RCA and the long axis to the aortic root. The ostia of the RCA was expanded approximately 30 mm, with a longitudinal suture line, cutting and forming the right coronary sinus. The distal RCA in the right ventricle was stitched. The right crown was small, the lumen was approximately 1 mm, and it was not treated.\nThe occluded part of the middle of the RCA was sent for pathological examination. Images show the formation of atherosclerotic plaques in the intima and partial organization of the mural thrombus, and lymphocyte infiltration was observed in the grossly dilated segment . The three layers in the relatively normal coronary artery wall segment are shown in Fig. b. The middle membrane of the artery was hypertrophic and atrophic, with partial replacement of collagen fibres and fibrous thickening of the outer membrane . The internal elastic lamina and external elastic membrane in the relatively normal coronary artery wall segment are shown in Fig. d.\nThe patient was satisfied with his treatment and outcome. He had taken aspirin 100 mg once a day, atorvastatin 20 mg once a day, isosorbide 20 mg twice a day, and atenolol 25 mg three times a day. After a 3-year follow-up, he had no angina pectoris, myocardial infarction or heart failure.", + "fulltext_subclaims": [ + "The patient was a 62-year-old hypertensive man.", + "He was admitted to a local hospital for persistent chest pain lasting 1 h.", + "The patient said he had a heart murmur during a physical examination at age 8.", + "He was misdiagnosed with mitral insufficiency.", + "The electrocardiograph demonstrated a significant ST-segment elevation in II, III, avF, and V7–9.", + "A diagnosis of acute inferior-posterior myocardial infarction was made.", + "The patient was given 300 mg aspirin.", + "The patient was given 300 mg clopidogrel.", + "He received intravenous thrombolysis treatment (Reteplase 18 mg*2).", + "He still had chest pain 2 h after treatment.", + "He was transferred to a regional PCI-capable hospital.", + "At admission, his blood pressure was 126/62 mmHg.", + "His heart rate was regular at 122 beats/min.", + "There were no cardiac murmurs.", + "The cTNI was 6.64 mmol/L.", + "The NT-proBNP was 664.8 pg/mL.", + "The D-dimer was 37,180 ng/mL.", + "Emergence coronary angiography showed a 50–60% stenosis in the middle left anterior descending artery.", + "The left circumflex artery was normal.", + "The catheter could not enter the right coronary artery during angiography.", + "The physicians were unable to observe the ostia of the right coronary artery.", + "Echocardiography revealed a giant right coronary artery-right ventricle fistula.", + "A CTA scan 7 days after admission showed the dilated RCA opening was approximately 30 mm.", + "The widest segment of the RCA was about 97 mm.", + "The thrombus blocked the artery flow.", + "The contrast medium filling in the distal region was defective.", + "3D reconstruction showed a dilated and tortuous RCA originating from the ascending aorta.", + "The diameter of the RCA was almost equal to that of the descending aorta.", + "A diagnosis of congenital right coronary artery-right ventricular fistula complicated with coronary artery aneurysm and acute myocardial infarction was made.", + "The patient had discovered a cardiac murmur at age 8.", + "He had been asymptomatic for 62 years before the acute myocardial infarction.", + "He underwent surgery for coronary artery fistula repair.", + "He underwent coronary aneurysm resection.", + "He underwent coronary aneurysm thrombectomy.", + "He underwent aortic sinus plasty.", + "The occluded part of the middle of the RCA was sent for pathological examination.", + "Images showed the formation of atherosclerotic plaques in the intima.", + "Partial organization of the mural thrombus was observed.", + "Lymphocyte infiltration was observed in the grossly dilated segment.", + "The patient was satisfied with his treatment and outcome.", + "He took aspirin 100 mg once a day.", + "He took atorvastatin 20 mg once a day.", + "He took isosorbide 20 mg twice a day.", + "He took atenolol 25 mg three times a day.", + "After a 3-year follow-up, he had no angina pectoris.", + "After a 3-year follow-up, he had no myocardial infarction.", + "After a 3-year follow-up, he had no heart failure." + ], + "summary": "We present here a 62-year-old man diagnosed with giant coronary artery fistula complicated with gross coronary artery aneurysm and acute myocardial infarction. He underwent intravenous thrombolysis treatment at a local hospital, coronary angiography at a regional hospital and complex surgery at a national centre for cardiovascular disease. The patient had no major adverse cardiac events during the 3-year follow-up.", + "summary_subclaims": [ + "The patient is a 62-year-old man.", + "The patient was diagnosed with giant coronary artery fistula.", + "The patient had gross coronary artery aneurysm.", + "The patient had acute myocardial infarction.", + "The patient underwent intravenous thrombolysis treatment at a local hospital.", + "The patient had coronary angiography at a regional hospital.", + "The patient had complex surgery at a national centre for cardiovascular disease.", + "The patient had no major adverse cardiac events during the 3-year follow-up." + ] + }, + { + "id": "multiclinsum_test_1827_en.txt", + "fulltext": "The patient was a 40-year-old man who was admitted to hospital because of increased pain in the metatarsal joints and renal impairment.\nAround 15 years previously, the patient was diagnosed with gout.\nThe patient had a free previous medical history.\nThe proband had a family history of hyperuricemia as his grandmother, father, two of his aunts, and two of his female cousins were diagnosed with hyperuricemia and gout. The grandmother, father, one aunt, and one female cousin had been undergoing hemodialysis and died between the ages of 30 and 50 years. In addition, the patient’s 9-year-old daughter had also been diagnosed with hyperuricemia based on her 5.6 mg/dL serum uric acid level (normal range for children aged 1–10 years: < 5.3 mg/dL) .\nThe patient’s temperature was 36.7 ℃, heart rate 88 bpm, respiratory rate 14 breaths/min, blood pressure 132/78 mmHg, and oxygen saturation in room air 100%. Physical examination indicated the presence of a mildly painful nodule behind the auricle, slight pain and swelling of the knee joints, serious pain and deformity of the interphalangeal joints, and gout stones on the 1 s metatarsal joints in the feet of the patient .\nThe patient had respective blood urea nitrogen and serum creatinine levels of 50.5 mg/dL and 6.2 mg/dL (normal ranges: 7.30–21.06 mg/dL and 0.46–0.82 mg/dL, respectively). The patient had a serum uric acid level of 13.2 mg/dL (normal range: 2.6–6.0 mg/dL), whereas fractional uric acid excretion was reduced by 3.43%. Other laboratory test results were within normal ranges.\nRenal ultrasonography showed that the patient’s kidneys were relatively atrophic (longitudinal image; 8.1 and 8.7 cm in the major axis of right and left kidneys), indicating the presence of cysts and suggestive of ESRD . Analysis of the knee joints by computed tomography showed high bone density, the presence of high-density shadows, narrowing of the joint space, and soft tissue swelling, which were consistent with the patient’s gout/arthritic symptoms .\nConsidering the family history of kidney disease, juvenile-onset of hyperuricemia, symptoms of gout/arthritis, and progressive renal impairment beginning at an early age, ADTKD-UMOD was considered highly probable. After receiving written informed consent from the four affected living members of the patient’s family, DNA analyses, clinical data collection, and image publication were performed for these individuals. The peripheral blood was sent to CIPHER gene to perform the whole exome sequencing by Illumina HiSeq (the specific method can be consulted in the Supplementary Material). Genetic analyses revealed the presence of a novel heterozygous missense mutation in UMOD exon 3 of the patient, his daughter, aunt, and younger female cousin . The conclusion of the genetic test was variants of unknown clinical significance. According to the American College of Medical Genetics and Genomics genetic variation classification standards and guidelines, the variation site was heterozygous, and the zygote type could explain the patient’s disease. Furthermore, this missense mutation was the result of nucleotide exchange at position c.554 (c.554G>T), in which leucine was replaced by arginine at position 185 in the final protein (p.Arg185Leu). This resulted in abnormal folding of uromodulin protein, leading to its accumulation within the endoplasmic reticulum and impaired trafficking through the cell.", + "fulltext_subclaims": [ + "The patient was a 40-year-old man.", + "The patient was admitted to hospital because of increased pain in the metatarsal joints and renal impairment.", + "Around 15 years previously, the patient was diagnosed with gout.", + "The patient had a free previous medical history.", + "The proband had a family history of hyperuricemia.", + "The patient’s 9-year-old daughter had also been diagnosed with hyperuricemia based on her 5.6 mg/dL serum uric acid level.", + "The patient’s temperature was 36.7 ℃.", + "The patient’s blood pressure was 132/78 mmHg.", + "Physical examination indicated the presence of a mildly painful nodule behind the auricle.", + "Physical examination indicated slight pain and swelling of the knee joints.", + "Physical examination indicated serious pain and deformity of the interphalangeal joints.", + "Physical examination indicated gout stones on the 1 s metatarsal joints in the feet of the patient.", + "The patient had a serum uric acid level of 13.2 mg/dL.", + "The patient had a fractional uric acid excretion reduced by 3.43%.", + "Renal ultrasonography showed that the patient’s kidneys were relatively atrophic.", + "Renal ultrasonography showed the presence of cysts.", + "Renal ultrasonography was suggestive of ESRD.", + "Computed tomography showed high bone density.", + "Computed tomography showed the presence of high-density shadows.", + "Computed tomography showed narrowing of the joint space.", + "Computed tomography showed soft tissue swelling.", + "ADTKD-UMOD was considered highly probable.", + "DNA analyses, clinical data collection, and image publication were performed for four affected living members of the patient’s family.", + "Genetic analyses revealed the presence of a novel heterozygous missense mutation in UMOD exon 3 of the patient.", + "Genetic analyses revealed the presence of a novel heterozygous missense mutation in UMOD exon 3 of the patient’s daughter.", + "Genetic analyses revealed the presence of a novel heterozygous missense mutation in UMOD exon 3 of the patient’s aunt.", + "Genetic analyses revealed the presence of a novel heterozygous missense mutation in UMOD exon 3 of the patient’s younger female cousin.", + "The conclusion of the genetic test was variants of unknown clinical significance.", + "The variation site was heterozygous.", + "The zygote type could explain the patient’s disease.", + "The missense mutation was the result of nucleotide exchange at position c.554 (c.554G>T).", + "This resulted in leucine being replaced by arginine at position 185 in the final protein (p.Arg185Leu).", + "This resulted in abnormal folding of uromodulin protein.", + "This resulted in the accumulation of uromodulin protein within the endoplasmic reticulum.", + "This resulted in impaired trafficking of uromodulin protein through the cell." + ], + "summary": "We report a 40-year-old man harboring a novel heterozygous missense mutation in UMOD (c.554G>T; p. Arg185Leu). The patient had hyperuricemia, gout, and chronic kidney disease. The same mutation was detected in his daughter, aunt and cousin.", + "summary_subclaims": [ + "The patient is a 40-year-old man.", + "The patient harbors a novel heterozygous missense mutation in UMOD (c.554G>T; p. Arg185Leu).", + "The patient had hyperuricemia.", + "The patient had gout.", + "The patient had chronic kidney disease.", + "The same mutation was detected in his daughter.", + "The same mutation was detected in his aunt.", + "The same mutation was detected in his cousin." + ] + }, + { + "id": "multiclinsum_test_2149_en.txt", + "fulltext": "A 4-year- and 8-month-old boy was brought to our hospital with fatigue, polyuria, and excessive drinking for one month. There was no recent history of fever, hair loss, facial erythema, oral ulcers, vomiting or diarrhea. There was no consanguineal marriage history, no family history of kidney disease and other genetic diseases. He was born spontaneously at 39 weeks, weighed 2.8 kg at birth, was 50 cm long, and had no history of asphyxia (Apgar score unknown). The family thought that he was shorter than other children of the same age and gender, but he was not lagging behind in motor, language and intellectual development. At the age of 1, he was 72 cm tall (−2SD∼−1SD) and weighed 8.5 kg (−2SD∼−1SD); he was 103 cm tall and weighed 12 kg at the time of consultation, and his physical examination height and weight were less than 2 standard deviations of the standard value, his intellectual development was normal, and he could talk and express needs normally. Blood pressure was normal, and there was no edema throughout the body except a ∼3 cm × 3 cm area of cafe au lait spoton the skin of the left lower limb. No other abnormalities were found on physical examinations. Urinary examination showed alkaline urine (urine pH >5.5), glycosuria and highly positive proteinuria, but no hematuria was detected by high-power microscopy. Blood gas analysis and biochemical tests indicated metabolic acidosis and electrolyte disorders, mainly manifested as hyponatremia, hypokalemia, hypocalcemia, hypophosphatemia, and hyperchloremia. The complication of Fanconi syndrome was considered. Further, we carried out humoral immunity test which revealed a decrease in complement C3 (0.38 g/L; the levels of C3 with the normal range was 0.70–2.06 g/L), and the complement C4 was normal (the normal range of C4 level was 0.11–0.61 g/L). Autoantibody ANA was positive, with the highest titer >1:3,200. Thyroid function was normal. Recent laboratory results were shown in . Urinary ultrasound indicated enhanced renal parenchymal echoes with unclear corticomedullary boundary, hydronephrosis in both kidneys, and no renal calcification or stones. The bone age was relatively below the standard, equivalent to 3.6-year-old or 10–25 percentiles. The contrast-enhanced voiding urosonography (VUS), CT urography (CTU), axial enhanced MRI of the sella turcica, conventional MRI of the lower limbs, and electromyography examination revealed no abnormalities. The whole-exome sequencing of the child did not found any suspected pathogenic gene mutations. After excluding diseases such as tuberculosis, hepatitis B, diabetes, genetic diseases and tumors, the patients were treated with sufficient oral methylprednisolone, captopril, potassium citrate, sodium citrate, potassium dihydrogen phosphate, and sodium dihydrogen phosphate for 28 days, but there was no improvement in proteinuria. Then renal biopsy was performed, and hematoxylin-eosin and other specific staining revealed 1/4 glomerular glomerulosclerosis. The remaining glomeruli showed mesangial cell and stroma mild hyperplasia, with thickening of the basement membrane and a small amount of spike like structures. Subepithelial deposition of immune complexes was observed. The staining also revealed granular and vacuolar degeneration of renal tubular epithelial cells, occasional protein tubular type, focal renal tubular lumen dilation accompanied by segmental epithelial cell detachment, brush border detachment, a few renal tubular atrophy, renal interstitial edema, small focal lymphoid and monocyte infiltration. There was no obvious lesion on the small artery wall. Immunofluorescence showed that IgG was deposited (++) in fine particles along the capillary loop. The electromicroscopic examination of ultrastructures showed mild irregular thickening of the basement membrane with a thickness of about 300–700 nm, diffused fusion of the foot processes, deposition of a large amount of electronic dense materials in the subepithelial and basement membranes, vacuolization and degeneration of the epithelial cells of the renal tubules, and no special changes in the renal interstitium. The pathological diagnosis was stage II membranous nephropathy with acute tubulointerstitial lesions. Paraffin section fluorescence staining showed IgG1 subtype+, IgG4++, while negative in IgG2, IgG3, PLA2R, and THSD7A staining, consistent with stage II membranous nephropathy (–). Clinical diagnosis of lupus nephritis (nephrotic syndrome type, V-type) was made, with a SLE disease activity index (SLEDAI) score of 14. After receiving a sufficient oral dose of methylprednisolone (12 mg, bid) for 60 days with the subsequent dosage tapered, and sequential anti-inflammatory treatment with prednisone acetate (10 mg, qd), immune suppression with mycophenolate mofetil (0.166 g, bid), 5 times of plasma exchange, captopril, and dipyridamole, the patient was discharged. A follow-up after taking the above oral drugs for 11 months showed that the symptoms of fatigue, excessive drinking, and polyuria improved, the complement C3 returned to normal levels, but there were still persistent proteinuria (2 + to 3+) and glycosuria (2 + to 4+); no hematuria was detected under high-power microscopy; SLEDAI score was 12; autoantibody ANA was positive with a titer of 1:320; and eGFR was calculated to be >30 ml/min/1.73 m2 (The eGFR at initial presentation was 53.1 ml/min/1.73 m2). Then the treatment with belimumab monoclonal antibody was added. After 9 times of regular use of belimumab, the clinical symptoms of the patient achieved complete remission; blood electrolytes, complement C3 and C4 returned to normal levels; and ANA titer was maintained at a relatively low level (1:320); urinary protein fluctuated between+to ∼+; urinary glucose fluctuated between+to 3+, the UTP was 0.785 g/24 h (24 h urine output of 1,700 ml), and eGFR was calculated to be 32.8 ml/min/1.73 m2, recent laboratory results were shown in . The dose of prednisone was reduced to 7.5 mg, qd. The follow-up examination showed a body-weight increase to the 50th percentile of the same age and gender, a height of the 3th percentile, and a SLEDAI score decrease to 4.", + "fulltext_subclaims": [ + "The patient was a 4-year- and 8-month-old boy.", + "He was brought to the hospital with fatigue, polyuria, and excessive drinking for one month.", + "There was no recent history of fever, hair loss, facial erythema, oral ulcers, vomiting, or diarrhea.", + "There was no consanguineal marriage history.", + "There was no family history of kidney disease.", + "He was born spontaneously at 39 weeks.", + "He weighed 2.8 kg at birth.", + "He was 50 cm long at birth.", + "He had no history of asphyxia.", + "The family thought he was shorter than other children of the same age and gender.", + "He was 72 cm tall at age 1.", + "He weighed 8.5 kg at age 1.", + "He was 103 cm tall at the time of consultation.", + "He weighed 12 kg at the time of consultation.", + "His physical examination height and weight were less than 2 standard deviations of the standard value.", + "His intellectual development was normal.", + "He could talk and express needs normally.", + "There was a ∼3 cm × 3 cm area of cafe au lait spot on the skin of the left lower limb.", + "Urinary examination showed alkaline urine (urine pH >5.5).", + "Urinary examination showed glycosuria.", + "Urinary examination showed highly positive proteinuria.", + "No hematuria was detected by high-power microscopy.", + "Blood gas analysis and biochemical tests indicated metabolic acidosis.", + "Blood gas analysis and biochemical tests indicated electrolyte disorders.", + "The electrolyte disorders were mainly hyponatremia, hypokalemia, hypocalcemia, hypophosphatemia, and hyperchloremia.", + "The complication of Fanconi syndrome was considered.", + "Humoral immunity test revealed a decrease in complement C3 (0.38 g/L).", + "The normal range of C3 was 0.70–2.06 g/L.", + "The complement C4 was normal.", + "The normal range of C4 was 0.11–0.61 g/L.", + "Autoantibody ANA was positive, with the highest titer >1:3,200.", + "Thyroid function was normal.", + "Urinary ultrasound indicated enhanced renal parenchymal echoes.", + "Urinary ultrasound showed hydronephrosis in both kidneys.", + "The bone age was relatively below the standard.", + "The bone age was equivalent to 3.6-year-old or 10–25 percentiles.", + "The contrast-enhanced voiding urosonography (VUS), CT urography (CTU), axial enhanced MRI of the sella turcica, conventional MRI of the lower limbs, and electromyography examination revealed no abnormalities.", + "The whole-exome sequencing of the child did not find any suspected pathogenic gene mutations.", + "After excluding diseases such as tuberculosis, hepatitis B, diabetes, genetic diseases, and tumors, the patient was treated with sufficient oral methylprednisolone, captopril, potassium citrate, sodium citrate, potassium dihydrogen phosphate, and sodium dihydrogen phosphate for 28 days.", + "There was no improvement in proteinuria after 28 days of treatment.", + "Renal biopsy was performed.", + "Hematoxylin-eosin and other specific staining revealed 1/4 glomerular glomerulosclerosis.", + "The remaining glomeruli showed mesangial cell and stroma mild hyperplasia.", + "The basement membrane was thickened.", + "A small amount of spike-like structures were observed.", + "Subepithelial deposition of immune complexes was observed.", + "The staining also revealed granular and vacuolar degeneration of renal tubular epithelial cells.", + "Occasional protein tubular type was observed.", + "Focal renal tubular lumen dilation accompanied by segmental epithelial cell detachment was observed.", + "Brush border detachment was observed.", + "A few renal tubular atrophy was observed.", + "Renal interstitial edema was observed.", + "Small focal lymphoid and monocyte infiltration was observed.", + "There was no obvious lesion on the small artery wall.", + "Immunofluorescence showed that IgG was deposited (++) in fine particles along the capillary loop.", + "Electromicroscopic examination of ultrastructures showed mild irregular thickening of the basement membrane.", + "The basement membrane thickness was about 300–700 nm.", + "Diffused fusion of the foot processes was observed.", + "A large amount of electronic dense materials was deposited in the subepithelial and basement membranes.", + "Vacuolization and degeneration of the epithelial cells of the renal tubules was observed.", + "No special changes in the renal interstitium were observed.", + "The pathological diagnosis was stage II membranous nephropathy with acute tubulointerstitial lesions.", + "Paraffin section fluorescence staining showed IgG1 subtype+.", + "Paraffin section fluorescence staining showed IgG4++.", + "IgG2, IgG3, PLA2R, and THSD7A staining were negative.", + "The clinical diagnosis was lupus nephritis (nephrotic syndrome type, V-type).", + "The SLE disease activity index (SLEDAI) score was 14.", + "The patient received a sufficient oral dose of methylprednisolone (12 mg, bid) for 60 days.", + "The subsequent dosage of methylprednisolone was tapered.", + "Sequential anti-inflammatory treatment with prednisone acetate (10 mg, qd) was given.", + "Immune suppression with mycophenolate mofetil (0.166 g, bid) was given.", + "Five times of plasma exchange were performed.", + "Captopril and dipyridamole were given.", + "The patient was discharged.", + "A follow-up after taking the above oral drugs for 11 months showed that the symptoms of fatigue, excessive drinking, and polyuria improved.", + "The complement C3 returned to normal levels.", + "There were still persistent proteinuria (2 + to 3+).", + "There were still persistent glycosuria (2 + to 4+).", + "No hematuria was detected under high-power microscopy.", + "The SLEDAI score was 12.", + "Autoantibody ANA was positive with a titer of 1:320.", + "The eGFR was calculated to be >30 ml/min/1.73 m2.", + "The eGFR at initial presentation was 53.1 ml/min/1.73 m2.", + "Treatment with belimumab monoclonal antibody was added.", + "After 9 times of regular use of belimumab, the clinical symptoms of the patient achieved complete remission.", + "Blood electrolytes returned to normal levels.", + "Complement C3 and C4 returned to normal levels.", + "ANA titer was maintained at a relatively low level (1:320).", + "Urinary protein fluctuated between + to ∼+.", + "Urinary glucose fluctuated between + to 3+.", + "The UTP was 0.785 g/24 h.", + "The 24 h urine output was 1,700 ml.", + "The eGFR was calculated to be 32.8 ml/min/1.73 m2.", + "The dose of prednisone was reduced to 7.5 mg, qd.", + "The follow-up examination showed a body-weight increase to the 50th percentile of the same age and gender.", + "The follow-up examination showed a height of the 3th percentile.", + "The SLEDAI score decreased to 4." + ], + "summary": "This article reports a preschool boy with SLE who presented with renal tubular acidosis, accompanied by weakness in both lower limbs, delayed growth, and malnutrition. It was later found that the patient had the complication of Fanconi syndrome with renal tubular acidosis. Ultimately, renal biopsy confirmed lupus nephritis. The patient was treated with corticosteroid combined with mycophenolate mofetil, hydroxychloroquine, and belimumab. The symptoms of the child were relieved.", + "summary_subclaims": [ + "This article reports a preschool boy with SLE.", + "The boy presented with renal tubular acidosis.", + "The boy had weakness in both lower limbs.", + "The boy had delayed growth.", + "The boy had malnutrition.", + "The patient had the complication of Fanconi syndrome with renal tubular acidosis.", + "Renal biopsy confirmed lupus nephritis.", + "The patient was treated with corticosteroid combined with mycophenolate mofetil.", + "The patient was treated with hydroxychloroquine.", + "The patient was treated with belimumab.", + "The symptoms of the child were relieved." + ] + }, + { + "id": "multiclinsum_test_2592_en.txt", + "fulltext": "An 8-year-old boy (height, 122 cm; body weight 26.9 kg; ASA physical status class I) with Perthes’ disease was scheduled for osteotomy. He had no significant medical history other than amblyopia. He had no family history of metabolic diseases and none of his family members had received general anesthesia. His blood pressure in the ward was approximately 100/60 mmHg.\nAnesthesia was induced using a propofol bolus of 2 mg/kg, followed by rocuronium 0.8 mg/kg and fentanyl 0.2 μg/kg. After intubation, a radial artery catheter was placed to monitor blood pressure and hemoglobin (Hb). The patient was placed in the right-lateral recumbent position. Anesthesia was maintained with 40% oxygen and 2% sevoflurane in combination with the continuous infusion of 0.2–0.4 μg/kg/min of remifentanil. The intravenous fluids administered included Ringer’s solution with acetate, bicarbonate Ringer’s solution, and a colloidal solution; lactated Ringer’s solution was not used. Blood loss was recorded as 150 mL, and 200 mL of autologous blood was used intraoperatively. Blood gas parameters including pH, partial pressure of carbon dioxide (pCO2), bicarbonate (HCO3), Hb, and lactate levels were closely monitored. Throughout anesthesia, there was a progressive increase in lactate levels, indicative of high anion gap metabolic acidosis . The duration of surgery was 5.5 h, and the duration of anesthesia was 8 h. No intraoperative tourniquet was used, and the systolic blood pressure remained at 80–100 mmHg. There was no increase in partial pressure of exhaled carbon dioxide and no muscle rigidity, and the patient’s temperature remained around 37.5 °C. The lactate dehydrogenase level measured intraoperatively was 116 U/L. The intraoperative fluid balance was + 2050 mL, and the urine output was maintained at 1.8 mL/kg/h (400 mL).\nThe postoperative arousal was uneventful, and the patient was extubated without complications. His laboratory data showed lactate levels within reference limits, with pH 7.4 and lactate 0.94 mmol/L the day after the surgery.\nThe patient was referred to the pediatric department for a thorough examination of his metabolic disease. Blood samples were collected on postoperative day 49. Laboratory analyses included fasting blood glucose, lactate/pyruvate (L/P) ratio, ketone and amino acid fractions, urinary lactate, and vitamin B1 levels. None of the differences were significant. Laboratory data suggested that the patient was unlikely to have congenital metabolic abnormalities and that it could be drug-induced or as a result of surgical invasion. We suggested muscle biopsy and genetic testing for a close examination of malignant hyperthermia and mitochondrial disease, which remained differential diagnoses; however, his parents did not wish to do so.\nThe patient was scheduled for nail extraction 6 months after the initial surgery. Hyperlactatemia due to hypoperfusion could not be completely ruled out; however, because it could be drug-related, an anesthesia plan was discussed in our department.\nHyperlactatemia, an initial symptom of malignant hyperthermia and PRIS, is rare, but can be fatal. Therefore, we decided not to use propofol or inhalational anesthesia. Midazolam could be a choice, but its long half-life can cause delayed emergence and respiratory depression . To avoid its disadvantages and avoid the use of propofol and inhaled anesthesia, induction and maintenance of anesthesia with remimazolam were planned.\nThe appropriate dosage of remimazolam in pediatric patients is yet to be established, and dosages differ in each report [, ]. Based on these reports, we determined the dosage based on the per-body weight dosage for adults indicated in the package insert.\nRemimazolam 12 mg/kg/h until sleep onset, remifentanil, and rocuronium were administered to induce general anesthesia. After intubation, the patient was placed in the right-lateral recumbent position. Anesthesia was maintained using remimazolam 1 mg/kg/h and remifentanil 0.2–0.5 μg/kg/min. Intraoperative infusions included Ringer’s acetate and bicarbonate Ringer’s solutions; no lactate Ringer’s solution was used. The duration of surgery was 82 min and the duration of anesthesia was 153 min. The intraoperative fluid balance was + 740 mL, and the urine output was 4.22 mL/kg/h (230 mL). Although the operative time was shorter than that of the initial surgery, increased lactate levels were observed . The day after surgery, the patient’s lactate level was within the reference limits, and he was discharged from the hospital without any postoperative problems.", + "fulltext_subclaims": [ + "The patient was an 8-year-old boy with Perthes’ disease.", + "He was scheduled for osteotomy.", + "He had no significant medical history other than amblyopia.", + "He had no family history of metabolic diseases.", + "His blood pressure in the ward was approximately 100/60 mmHg.", + "Anesthesia was induced using a propofol bolus of 2 mg/kg.", + "Rocuronium 0.8 mg/kg was administered.", + "Fentanyl 0.2 μg/kg was administered.", + "A radial artery catheter was placed to monitor blood pressure and hemoglobin.", + "The patient was placed in the right-lateral recumbent position.", + "Anesthesia was maintained with 40% oxygen and 2% sevoflurane.", + "A continuous infusion of 0.2–0.4 μg/kg/min of remifentanil was used.", + "Ringer’s solution with acetate was administered.", + "Bicarbonate Ringer’s solution was administered.", + "A colloidal solution was administered.", + "Lactated Ringer’s solution was not used.", + "Blood loss was recorded as 150 mL.", + "200 mL of autologous blood was used intraoperatively.", + "Blood gas parameters including pH, pCO2, HCO3, Hb, and lactate levels were monitored.", + "There was a progressive increase in lactate levels, indicative of high anion gap metabolic acidosis.", + "The duration of surgery was 5.5 h.", + "The duration of anesthesia was 8 h.", + "No intraoperative tourniquet was used.", + "The systolic blood pressure remained at 80–100 mmHg.", + "There was no increase in partial pressure of exhaled carbon dioxide.", + "There was no muscle rigidity.", + "The patient’s temperature remained around 37.5 °C.", + "The lactate dehydrogenase level measured intraoperatively was 116 U/L.", + "The intraoperative fluid balance was + 2050 mL.", + "The urine output was maintained at 1.8 mL/kg/h (400 mL).", + "The postoperative arousal was uneventful.", + "The patient was extubated without complications.", + "The patient’s lactate levels were within reference limits the day after surgery.", + "The patient was referred to the pediatric department for a thorough examination of his metabolic disease.", + "Blood samples were collected on postoperative day 49.", + "Laboratory analyses included fasting blood glucose, lactate/pyruvate ratio, ketone and amino acid fractions, urinary lactate, and vitamin B1 levels.", + "None of the differences were significant.", + "Laboratory data suggested the patient was unlikely to have congenital metabolic abnormalities.", + "The patient was scheduled for nail extraction 6 months after the initial surgery.", + "Hyperlactatemia due to hypoperfusion could not be completely ruled out.", + "We decided not to use propofol or inhalational anesthesia.", + "Induction and maintenance of anesthesia with remimazolam were planned.", + "The appropriate dosage of remimazolam in pediatric patients is yet to be established.", + "Dosages differ in each report.", + "The dosage was determined based on the per-body weight dosage for adults indicated in the package insert.", + "Remimazolam 12 mg/kg/h until sleep onset was administered.", + "Remifentanil and rocuronium were administered to induce general anesthesia.", + "Anesthesia was maintained using remimazolam 1 mg/kg/h.", + "Anesthesia was maintained using remifentanil 0.2–0.5 μg/kg/min.", + "Ringer’s acetate and bicarbonate Ringer’s solutions were used intraoperatively.", + "Lactate Ringer’s solution was not used.", + "The duration of surgery was 82 min.", + "The duration of anesthesia was 153 min.", + "The intraoperative fluid balance was + 740 mL.", + "The urine output was 4.22 mL/kg/h (230 mL).", + "Increased lactate levels were observed.", + "The patient’s lactate level was within the reference limits the day after surgery.", + "The patient was discharged from the hospital without any postoperative problems." + ], + "summary": "An 8-year-old boy with Perthes disease and no remarkable past or family history was scheduled for an osteotomy. Anesthesia was induced with propofol and rocuronium and then maintained with sevoflurane and remifentanil. The patient developed lactic acidosis without hemodynamic instability during anesthesia, with a normal lactate/pyruvate ratio after surgery, suggesting a lack of hypoperfusion. We used remimazolam instead of propofol during the second surgery 6 months later, considering the possibility of drug-induced lactic acidosis, including malignant hyperthermia and propofol infusion syndrome, where the unexplained hyperlactatemia recurred.", + "summary_subclaims": [ + "The patient was an 8-year-old boy.", + "The patient had Perthes disease.", + "The patient had no remarkable past or family history.", + "An osteotomy was scheduled.", + "Anesthesia was induced with propofol and rocuronium.", + "Anesthesia was maintained with sevoflurane and remifentanil.", + "The patient developed lactic acidosis during anesthesia.", + "The patient did not have hemodynamic instability during anesthesia.", + "The lactate/pyruvate ratio was normal after surgery.", + "The normal lactate/pyruvate ratio suggested a lack of hypoperfusion.", + "Remimazolam was used instead of propofol during the second surgery.", + "The second surgery occurred 6 months later.", + "The possibility of drug-induced lactic acidosis was considered.", + "Malignant hyperthermia was considered as a possibility.", + "Propofol infusion syndrome was considered as a possibility.", + "The unexplained hyperlactatemia recurred." + ] + }, + { + "id": "multiclinsum_test_2220_en.txt", + "fulltext": "A Hispanic 64-year-old woman was admitted with headaches, vomiting and confusion. A month earlier, the patient presented with subacute new-onset headaches, nausea, vomiting, gait impairment, and anorexia. There was no history of fever, cough, abdominal pain, previous medical disease or immunosuppressant drug use. Blood pressure was normal. Physical examination was unremarkable. Neurologic examination showed an unsteady gait, without motor weakness or ataxia. Cognitive tests showed a Mini-Mental Status Exam (MMSE) score of 18/30, impaired attention, executive functions, verbal fluency and episodic memory .\nBrain MRI disclosed diffuse and symmetric confluent nonenhancing white matter lesions, that were hyperintense in T2/FLAIR images . Corresponding apparent diffusion coefficients (ADC) maps suggested vasogenic edema . MRI angiography was unremarkable (not shown). Multivoxel spectroscopy, dynamic susceptibility contrast (DSC) perfusion (T2*) and dynamic contrast-enhanced (DCE) permeability (T1) did not disclose relevant abnormalities . Cerebrospinal fluid analysis showed a normal cell count (4 cells/mm3), protein (32 mg/dL) and glucose (80 mg/dL) levels, normal protein electrophoresis values, negative oligoclonal bands and polymerase chain reaction for infectious agents (including tuberculosis). Systemic evaluation was negative for cancer, autoimmune diseases (Anti-nuclear antibodies = negative, Anti-neutrophil cytoplasmic antibodies = negative), and infectious diseases. Thoracic computed tomography (CT) showed nonspecific patchy lung infiltrates. Blood laboratory tests were normal (i.e. Erythrocyte sedimentation rate = 2 mm; C-reactive protein = 1,3 mg/L; Leucocytes = 6,880/mm3). Electroencephalogram EEG showed mild diffuse slowing and brief bursts of diffuse delta waves. The patient underwent two brain biopsies that showed tissue rarefaction with vacuolation, very mild inflammatory cell and macrophage infiltrates, absence of demyelination, malignant cells or granulomas, and no signs of tissue infarction or hemorrhagic changes . Immunostaining showed scarce CD45+ lymphocytes and CD68+ macrophages, without axonal or myelin damage, with few reactive astrocytes and low aquaporin-4 staining in the lesion compared to the normal surrounding areas. Aquaporin-1 staining was also reduced in the lesion, less extensively than aquaporin-4.\nThe patient was treated initially with intravenous methylprednisolone (1 g/day for three days), followed by oral dexamethasone (10 mg/day) for six months. Clinical and neurologic status and brain MRI remained unchanged. Activities of daily living were impaired, with a Functional Activity Questionnaire (FAQ) score of 25 and MMSE score of 18. Whole body positron emission tomography-computed tomography obtained at this point revealed a hypermetabolic right pulmonary mass. Lesion histology showed granulomas containing Mycobacterium abscessus. The patient was treated with levofloxacin, clarithromycin and amycacin. Steroids were tapered and discontinued. A year later, cognitive functions and functional status were improved (MMSE = 21; FAQ score = 10) , and brain MRI disclosed remarkable resolution of white matter changes .", + "fulltext_subclaims": [ + "The patient was a 64-year-old Hispanic woman.", + "The patient was admitted with headaches, vomiting, and confusion.", + "A month earlier, the patient presented with subacute new-onset headaches.", + "The patient had no history of fever.", + "The patient had no history of cough.", + "The patient had no history of abdominal pain.", + "The patient had no history of previous medical disease.", + "The patient had no history of immunosuppressant drug use.", + "Blood pressure was normal.", + "Physical examination was unremarkable.", + "Neurologic examination showed an unsteady gait.", + "Cognitive tests showed a Mini-Mental Status Exam (MMSE) score of 18/30.", + "Brain MRI disclosed diffuse and symmetric confluent nonenhancing white matter lesions.", + "Corresponding apparent diffusion coefficients (ADC) maps suggested vasogenic edema.", + "MRI angiography was unremarkable.", + "Multivoxel spectroscopy did not disclose relevant abnormalities.", + "Cerebrospinal fluid analysis showed a normal cell count (4 cells/mm3).", + "Cerebrospinal fluid analysis showed protein levels of 32 mg/dL.", + "Cerebrospinal fluid analysis showed glucose levels of 80 mg/dL.", + "Cerebrospinal fluid analysis showed negative polymerase chain reaction for infectious agents.", + "Systemic evaluation was negative for cancer.", + "Thoracic computed tomography showed nonspecific patchy lung infiltrates.", + "Electroencephalogram showed mild diffuse slowing.", + "The patient underwent two brain biopsies.", + "Brain biopsies showed tissue rarefaction with vacuolation.", + "Brain biopsies showed absence of demyelination.", + "Brain biopsies showed absence of granulomas.", + "Brain biopsies showed no signs of tissue infarction.", + "Immunostaining showed scarce CD45+ lymphocytes.", + "Immunostaining showed CD68+ macrophages.", + "The patient was treated with intravenous methylprednisolone (1 g/day for three days).", + "The patient was treated with oral dexamethasone (10 mg/day) for six months.", + "Clinical and neurologic status remained unchanged.", + "Brain MRI remained unchanged.", + "Activities of daily living were impaired.", + "Functional Activity Questionnaire (FAQ) score was 25.", + "Whole body positron emission tomography-computed tomography revealed a hypermetabolic right pulmonary mass.", + "Lesion histology showed granulomas containing Mycobacterium abscessus.", + "The patient was treated with levofloxacin.", + "The patient was treated with clarithromycin.", + "The patient was treated with amycacin.", + "Steroids were tapered and discontinued.", + "A year later, cognitive functions were improved.", + "A year later, brain MRI disclosed remarkable resolution of white matter changes." + ], + "summary": "We report the case of a Hispanic 64-year-old woman with cognitive decline and extensive leukoencephalopathy. Magnetic resonance imaging revealed white-matter lesions with increased water diffusivity, without blood-brain-barrier disruption. Brain biopsy showed tissue rarefaction with vacuolation, mild inflammation, few reactive astrocytes and decreased aquaporin water-channel expression in the lesions. Six months later, she was diagnosed with atypical mycobacterial pulmonary infection. Brain lesions resolved after antimycobacterial treatment.", + "summary_subclaims": [ + "The patient is a 64-year-old Hispanic woman.", + "The patient had cognitive decline.", + "The patient had extensive leukoencephalopathy.", + "Magnetic resonance imaging revealed white-matter lesions.", + "White-matter lesions showed increased water diffusivity.", + "There was no blood-brain-barrier disruption.", + "Brain biopsy showed tissue rarefaction.", + "Brain biopsy showed vacuolation.", + "Brain biopsy showed mild inflammation.", + "Brain biopsy showed few reactive astrocytes.", + "Brain biopsy showed decreased aquaporin water-channel expression in the lesions.", + "Six months later, she was diagnosed with atypical mycobacterial pulmonary infection.", + "Brain lesions resolved after antimycobacterial treatment." + ] + }, + { + "id": "multiclinsum_test_1988_en.txt", + "fulltext": "A 3-month-old male Chinchilla cat weighing 0.8 kg was admitted for pain in the right hindlimb. Radiographs revealed an oblique diaphyseal fracture of the right femur. After closed reduction, two Kirschner (K)-wires of 1.5 mm diameter were inserted in a normograde fashion. The inserted K-wires were removed 1 month after the surgery. Several days after removing the implants, the patient was presented with a fracture of the distal metaphysis of the right tibia after falling from a low height. Surgical repair was performed in the same way using two K-wires 1.6 mm in diameter. After the second operation, as additional fractures occurred owing to unknown reasons or suspected slipping events, several additional surgeries were carried out inserting K-wires into intact long bones to aid stress distribution on those bones. K-wires with a diameter of 1.2 to 2.0 mm were used and applied in a normograde fashion after closed reduction .Blood tests were performed to identify other diseases that could cause pathological fractures. Complete blood count revealed no particular abnormality. Serum total calcium, serum total phosphorus, ionised calcium, parathyroid hormone and 25-hydroxy vitamin D levels were all normal . As blood urea nitrogen and creatinine levels were within the reference intervals and renal ultrasonography confirmed no specific findings, secondary renal hyperparathyroidism was deemed improbable. Trabecular bone mineral density was measured from the 12th thoracic vertebra and the fourth lumbar vertebra using CT (Hi Speed QX/I; GE Medical). Relatively low trabecular bone mineral density was confirmed in the patient (219.8 Hounsfield units [HU] at the 12th thoracic vertebra and 169.46 HU at the fourth lumbar vertebra), compared with normal cats of a similar age. Bone biopsy was performed from the patient’s humerus during surgery and the sample was submitted for histopathological examination. Irregular and thin cortical bone with increased diameter of Haversian canals and replicated cement lines was identified . Based on these results, OI was tentatively diagnosed.Radiography was performed for follow-up or when the patient showed clinical signs. Follow-up radiographs were taken for 2 years. The patient showed spinous process fractures on several thoracic vertebrae 3 months after the first operation. After 5 months, the patient showed fractures on the ribs. As alignment was unchanged, no additional surgery was performed. Seven months later, a pelvic fracture not disrupting the pelvic cavity was revealed. The patient showed a fracture of the proximal ulna which had the K-wire inserted, luxation of thoracic vertebrae 4–5, changes in the morphology of the thoracic cavity and a fracture of the canine tooth of the right mandible, implying dentinogenesis imperfecta 1 year after surgery. Loosening of an inserted pin often occurred and irritated the adjacent joint and soft tissues, which then required cutting of the pin and/or re-insertion. The last radiographs taken 2 years postoperatively suggested repeated fractures and bone unions . Follow-up complete blood count and serum chemistry, except parathyroid hormone and 25-hydroxy vitamin D, were performed regularly but failed to reveal any abnormalities. During the 3-year follow-up period, although the patient often showed lameness or ataxia due to fractures and required medical management using tramadol (Tridol 2 mg/kg q12h; Yuhan Corporation) and/or meloxicam (Metacam 0.05 mg/kg q24h; Boehringer Ingelheim), it was able to walk until it died due to undetermined reasons.", + "fulltext_subclaims": [ + "A 3-month-old male Chinchilla cat weighing 0.8 kg was admitted for pain in the right hindlimb.", + "Radiographs revealed an oblique diaphyseal fracture of the right femur.", + "After closed reduction, two Kirschner (K)-wires of 1.5 mm diameter were inserted in a normograde fashion.", + "The inserted K-wires were removed 1 month after the surgery.", + "Several days after removing the implants, the patient was presented with a fracture of the distal metaphysis of the right tibia after falling from a low height.", + "Surgical repair was performed in the same way using two K-wires 1.6 mm in diameter.", + "After the second operation, as additional fractures occurred owing to unknown reasons or suspected slipping events, several additional surgeries were carried out inserting K-wires into intact long bones to aid stress distribution on those bones.", + "K-wires with a diameter of 1.2 to 2.0 mm were used and applied in a normograde fashion after closed reduction.", + "Blood tests were performed to identify other diseases that could cause pathological fractures.", + "Complete blood count revealed no particular abnormality.", + "Serum total calcium, serum total phosphorus, ionised calcium, parathyroid hormone and 25-hydroxy vitamin D levels were all normal.", + "As blood urea nitrogen and creatinine levels were within the reference intervals and renal ultrasonography confirmed no specific findings, secondary renal hyperparathyroidism was deemed improbable.", + "Trabecular bone mineral density was measured from the 12th thoracic vertebra and the fourth lumbar vertebra using CT.", + "Relatively low trabecular bone mineral density was confirmed in the patient (219.8 Hounsfield units [HU] at the 12th thoracic vertebra and 169.46 HU at the fourth lumbar vertebra), compared with normal cats of a similar age.", + "Bone biopsy was performed from the patient’s humerus during surgery and the sample was submitted for histopathological examination.", + "Irregular and thin cortical bone with increased diameter of Haversian canals and replicated cement lines was identified.", + "Based on these results, OI was tentatively diagnosed.", + "Radiography was performed for follow-up or when the patient showed clinical signs.", + "Follow-up radiographs were taken for 2 years.", + "The patient showed spinous process fractures on several thoracic vertebrae 3 months after the first operation.", + "After 5 months, the patient showed fractures on the ribs.", + "As alignment was unchanged, no additional surgery was performed.", + "Seven months later, a pelvic fracture not disrupting the pelvic cavity was revealed.", + "The patient showed a fracture of the proximal ulna which had the K-wire inserted, luxation of thoracic vertebrae 4–5, changes in the morphology of the thoracic cavity and a fracture of the canine tooth of the right mandible, implying dentinogenesis imperfecta 1 year after surgery.", + "Loosening of an inserted pin often occurred and irritated the adjacent joint and soft tissues, which then required cutting of the pin and/or re-insertion.", + "The last radiographs taken 2 years postoperatively suggested repeated fractures and bone unions.", + "Follow-up complete blood count and serum chemistry, except parathyroid hormone and 25-hydroxy vitamin D, were performed regularly but failed to reveal any abnormalities.", + "During the 3-year follow-up period, although the patient often showed lameness or ataxia due to fractures and required medical management using tramadol (Tridol 2 mg/kg q12h; Yuhan Corporation) and/or meloxicam (Metacam 0.05 mg/kg q24h; Boehringer Ingelheim), it was able to walk until it died due to undetermined reasons." + ], + "summary": "Osteogenesis imperfecta (OI) is an inherited disorder related to the synthesis of type 1 collagen. Clinical signs of pain from the fracture of fragile bones are common. A 3-month-old male Chinchilla cat was presented for lameness and pain from a right femoral fracture. After surgical repair using intramedullary pins, and since repeated fractures occurred and there is little information about genes causing OI in cats, various examinations were performed to discriminate other diseases that could cause the pathological fracture. Primary hyperparathyroidism and nutritional or renal secondary hyperparathyroidism were ruled out through blood tests and ultrasonography. Quantitative CT confirmed low trabecular bone mineral density compared with normal cats. Radiography and histopathological examination revealed thin cortical bone. OI was tentatively diagnosed and long-term follow-up of the surgical repair was reviewed. Fractures were treated using intramedullary Kirschner wires. The same method of intramedullary pinning was then applied preventively to protect several other long bones by improving stress distribution and bending resistance. Follow-up was performed for 3 years until the patient's death due to undetermined reasons.", + "summary_subclaims": [ + "Osteogenesis imperfecta (OI) is an inherited disorder related to the synthesis of type 1 collagen.", + "Clinical signs of pain from the fracture of fragile bones are common.", + "A 3-month-old male Chinchilla cat was presented for lameness and pain from a right femoral fracture.", + "Surgical repair using intramedullary pins was performed.", + "Repeated fractures occurred.", + "There is little information about genes causing OI in cats.", + "Various examinations were performed to discriminate other diseases that could cause the pathological fracture.", + "Primary hyperparathyroidism was ruled out through blood tests and ultrasonography.", + "Nutritional or renal secondary hyperparathyroidism was ruled out through blood tests and ultrasonography.", + "Quantitative CT confirmed low trabecular bone mineral density compared with normal cats.", + "Radiography and histopathological examination revealed thin cortical bone.", + "OI was tentatively diagnosed.", + "Long-term follow-up of the surgical repair was reviewed.", + "Fractures were treated using intramedullary Kirschner wires.", + "The same method of intramedullary pinning was then applied preventively to protect several other long bones.", + "Follow-up was performed for 3 years until the patient's death due to undetermined reasons." + ] + }, + { + "id": "multiclinsum_test_2615_en.txt", + "fulltext": "A 77-year-old Chinese female was admitted to hospital with high-grade fever, sore throat, and swelling of the right knee. The intermittent high fever(> 40 °C), which started 20 days ago, had no obvious cause,and was accompanied by chills, redness, pain and swelling of the left ankle. The severe and unbearable pain often occurred during fever, and was slightly relieved after the fever subsided. However, a few days later, these syptoms disappeared while the right knee showed the same symptoms. The patient initially underwent bilateral TKA six years ago and recovered uneventfully and had well functioning TKAs. She also had a history of Alzheimer’s disease.\nHer initial body temperature was 39.2 °C in the evening of admission. The right knee was swollen, and she experienced pain with tenderness. The floating patellar test was positive on the right knee; and negative on the left. The range of motion was 0–100° for the right knee and 0–120° for the left. There was no obvious instability in either knee joint.\nLaboratory examination results are shown in Table . The abdominal ultrasound showed no signs of hepatosplenomegaly and the X-ray showed no obvious abnormality in both knee joints and chest.\nThe right knee was aspirated upon admission, and the aspiration fluid showed a yellowish-green turbid character . Routine examination of the fluid showed inflammatory characteristics . No fungi or bacteria were found in the aspiration fluid. Venous blood culture was negative. Thereafter, blood culture was carried out every time the temperature increased significantly (a total of five times), and the results were all negative. After consultation, the pharmacy department provided diagnoses of erysipelas and knee arthritis, and treated the patient with penicillin. However, the patient’s body temperature still fluctuated above 38 °C over the next two days, so treatment was changed to vancomycin and levofloxacin.\nConsidering the patient’s symptoms and test results, acute PJI could not be ruled out. We performed debridement, antibiotics, implant retention (DAIR) for the right knee five days after admission. The grinding tissue fluid was taken for culture and biochemical examination .\nThe symptoms and laboratory results were slightly improved postoperatively. But on the fourth day after the operation, the patient’s temperature spiked again, reaching over 39.0 °C. A punctate congestive rash was distributed symmetrically over the neck and trunk. At the same time, the patient developed a cough, expectoration, and wheezing. The leukocytes level and the percentage of neutrophils increased significantly. CT scan showed bilateral lung infection with pleural effusion. It also showed enlargement of mediastinal and bilateral axillary lymph nodes. Echocardiography showed a small amount of pericardial effusion and decreased left ventricular diastolic function. We treated it as pulmonary infection, cardiac insufficiency and drug-borne allergy. The previous antibiotics were replaced with linezolid cefoperazone/sulbactam and furosemide, followed by an intravenous drip of dexamethasone 10 mg for three days. During the use of dexamethasone, the patient’s temperature was normal. The respiratory symptoms improved significantly, and the rash gradually subsided. However, her temperature rose above 37.5 °C again after stopping dexamethasone. The left knee displayed redness, swelling, and pain, and the floating patellar test was positive. Both 1,3-β-D-glucan test (G test) and galactomannan test (GM test) were negative, and the sputum culture showed presence of acinetobacter pittii. Treated with an intravenous infusion of imipenem, linezolid, and fluconazole, the patient reported that pain in both knees and the rash intensified. The aspiration fluid collected from both knees showed no bacteria in the culture but the possibility of suppurative arthritis once again .\nConsidering that the infection remained uncontrolled, we removed the right prosthesis again, placed the antibiotic bone cement spacer, and performed DAIR for the left knee. We took synovial grinding tissue fluid from both knees for culture, and found Human staphylococci and Staphylococcus cohnii in the left. The temperature remained abnormal postoperatively and even gradually increased over the next few days, peaking around 14:00 each day. Two weeks later, the patient’s right knee swelled again with sticky secretions, but the culture of the joint aspiration fluid was negative. Subsequent mycoplasma pneumoniae and tuberculosis antibody tests were negative. T-SPOT test was positive, so oral isoniazid was given for treatment. A few days later, the right knee’s symptoms worsened, and a rash appeared.\nThen, the spacer in the right knee was removed, and the knee was fixed by bracing. However, the result of articular fluid analysis remained negative. On the third day after operation, the rash had spread all over the body, and the temperature rose again. After four operations on both knees, the fever and rash got worse and worse, so we thought it might not be a simple PJI and consulted the rheumatic immunology department. After excluding the possibilities of malignancies and hematological diseases, they found the patient’s symptoms matched those of AOSD. According to the Yamaguchi criteria , our patient had four major features (spiking fever, arthralgia, rash, and leukocytosis) and four minor features (sore throat, abnormal liver function, lymph nodes enlargement and negative ANA/RF). Using a combination with antibiotics, we continued to prescribe intravenous infusion of methylprednisolone powder 40 mg once a day for three days, then changed the medication to oral prednisone 50 mg. After treatment, the patient’s temperature returned to normal. Both the rash and symptoms of bilateral knees disappeared. A week later, the CRP level decreased to normal (5.06 mg/L) while ESR level was slightly higher (30 mm/h). The patient was discharged. A brief diagram of the patient’s disease changes is shown in Fig. .\nAfter discharge, the patient’s right lower limb was fixed with a brace, and she continued taking prednisone 50 mg once a day. The symptoms were well-controlled, and the medication dose decreased gradually after a month. The patient was re-admitted four months later and was re-examined . The X-ray of the knee showed bone defects and reduced space in the distal femur and tibial plateau . We performed a revision of the right knee with ACCK prosthesis (ACCK Knee Prosthesis; AK; Beijing, China).\nAt one year follow-up after the operation, her right knee flexion was 100° with 15° extension lag and the HSS score was 76. The patient had discontinued prednisone for one month without any systemic or local symptoms.", + "fulltext_subclaims": [ + "The patient was a 77-year-old Chinese female.", + "She was admitted to hospital with high-grade fever, sore throat, and swelling of the right knee.", + "The intermittent high fever (> 40 °C) started 20 days ago.", + "The fever was accompanied by chills, redness, pain, and swelling of the left ankle.", + "The severe and unbearable pain often occurred during fever.", + "The pain was slightly relieved after the fever subsided.", + "A few days later, these symptoms disappeared while the right knee showed the same symptoms.", + "The patient had undergone bilateral TKA six years ago.", + "She had well functioning TKAs.", + "She had a history of Alzheimer’s disease.", + "Her initial body temperature was 39.2 °C in the evening of admission.", + "The right knee was swollen.", + "She experienced pain with tenderness.", + "The floating patellar test was positive on the right knee.", + "The floating patellar test was negative on the left.", + "The range of motion was 0–100° for the right knee.", + "The range of motion was 0–120° for the left.", + "There was no obvious instability in either knee joint.", + "The abdominal ultrasound showed no signs of hepatosplenomegaly.", + "The X-ray showed no obvious abnormality in both knee joints.", + "The right knee was aspirated upon admission.", + "The aspiration fluid showed a yellowish-green turbid character.", + "Routine examination of the fluid showed inflammatory characteristics.", + "No fungi or bacteria were found in the aspiration fluid.", + "Venous blood culture was negative.", + "Blood culture was carried out every time the temperature increased significantly.", + "The results were all negative.", + "The pharmacy department provided diagnoses of erysipelas and knee arthritis.", + "The patient was treated with penicillin.", + "The patient’s body temperature still fluctuated above 38 °C over the next two days.", + "Treatment was changed to vancomycin and levofloxacin.", + "Acute PJI could not be ruled out.", + "DAIR was performed for the right knee five days after admission.", + "The symptoms and laboratory results were slightly improved postoperatively.", + "On the fourth day after the operation, the patient’s temperature spiked again, reaching over 39.0 °C.", + "A punctate congestive rash was distributed symmetrically over the neck and trunk.", + "The patient developed a cough, expectoration, and wheezing.", + "The leukocytes level and the percentage of neutrophils increased significantly.", + "CT scan showed bilateral lung infection with pleural effusion.", + "CT scan showed enlargement of mediastinal and bilateral axillary lymph nodes.", + "Echocardiography showed a small amount of pericardial effusion.", + "Echocardiography showed decreased left ventricular diastolic function.", + "The previous antibiotics were replaced with linezolid, cefoperazone/sulbactam, and furosemide.", + "An intravenous drip of dexamethasone 10 mg was given for three days.", + "During the use of dexamethasone, the patient’s temperature was normal.", + "The respiratory symptoms improved significantly.", + "The rash gradually subsided.", + "Her temperature rose above 37.5 °C again after stopping dexamethasone.", + "The left knee displayed redness, swelling, and pain.", + "The floating patellar test was positive.", + "Both 1,3-β-D-glucan test and galactomannan test were negative.", + "The sputum culture showed presence of acinetobacter pittii.", + "The patient was treated with intravenous infusion of imipenem, linezolid, and fluconazole.", + "The patient reported that pain in both knees and the rash intensified.", + "The aspiration fluid collected from both knees showed no bacteria in the culture.", + "The possibility of suppurative arthritis was once again considered.", + "The right prosthesis was removed again.", + "An antibiotic bone cement spacer was placed.", + "DAIR was performed for the left knee.", + "Synovial grinding tissue fluid from both knees was taken for culture.", + "Human staphylococci and Staphylococcus cohnii were found in the left.", + "The temperature remained abnormal postoperatively.", + "The temperature gradually increased over the next few days.", + "The temperature peaked around 14:00 each day.", + "Two weeks later, the right knee swelled again with sticky secretions.", + "The culture of the joint aspiration fluid was negative.", + "Subsequent mycoplasma pneumoniae and tuberculosis antibody tests were negative.", + "T-SPOT test was positive.", + "Oral isoniazid was given for treatment.", + "A few days later, the right knee’s symptoms worsened, and a rash appeared.", + "The spacer in the right knee was removed.", + "The knee was fixed by bracing.", + "The result of articular fluid analysis remained negative.", + "On the third day after operation, the rash had spread all over the body.", + "The temperature rose again.", + "After four operations on both knees, the fever and rash got worse and worse.", + "It was thought it might not be a simple PJI.", + "The rheumatic immunology department was consulted.", + "The possibilities of malignancies and hematological diseases were excluded.", + "The patient’s symptoms matched those of AOSD.", + "According to the Yamaguchi criteria, the patient had four major features.", + "According to the Yamaguchi criteria, the patient had four minor features.", + "Intravenous infusion of methylprednisolone powder 40 mg once a day was prescribed for three days.", + "The medication was changed to oral prednisone 50 mg.", + "After treatment, the patient’s temperature returned to normal.", + "Both the rash and symptoms of bilateral knees disappeared.", + "A week later, the CRP level decreased to normal (5.06 mg/L).", + "The ESR level was slightly higher (30 mm/h).", + "The patient was discharged.", + "After discharge, the right lower limb was fixed with a brace.", + "She continued taking prednisone 50 mg once a day.", + "The symptoms were well-controlled.", + "The medication dose decreased gradually after a month.", + "The patient was re-admitted four months later.", + "The X-ray of the knee showed bone defects.", + "The X-ray showed reduced space in the distal femur and tibial plateau.", + "A revision of the right knee with ACCK prosthesis was performed.", + "At one year follow-up after the operation, her right knee flexion was 100°.", + "There was 15° extension lag.", + "The HSS score was 76.", + "The patient had discontinued prednisone for one month.", + "There were no systemic or local symptoms." + ], + "summary": "A 77-year-old female who underwent bilateral total knee arthroplasty 6 years ago was admitted to our hospital with high fever, right knee effusion and painful knee. Based on the results of joint fluid aspiration and culture, we treated the right knee as acute hematogenous prosthetic joint infection. After three debridement and revision surgeries, the patient's symptoms continued to persist. Subsequent manifestations of other symptoms such as typical rash and sore throat and laboratory examination suggested the possibility of adult-onset Still's disease. So she underwent diagnostic steroid hormone therapy at the recommendation of a rheumatologist, and a final revision was performed after symptom was controlled. At the one-year follow-up, the patient's symptoms completely resolved and the knee revision was functioning well.", + "summary_subclaims": [ + "The patient is a 77-year-old female.", + "She underwent bilateral total knee arthroplasty 6 years ago.", + "She was admitted to our hospital with high fever, right knee effusion and painful knee.", + "Based on the results of joint fluid aspiration and culture, we treated the right knee as acute hematogenous prosthetic joint infection.", + "After three debridement and revision surgeries, the patient's symptoms continued to persist.", + "Subsequent manifestations of other symptoms such as typical rash and sore throat and laboratory examination suggested the possibility of adult-onset Still's disease.", + "She underwent diagnostic steroid hormone therapy at the recommendation of a rheumatologist.", + "A final revision was performed after symptom was controlled.", + "At the one-year follow-up, the patient's symptoms completely resolved.", + "The knee revision was functioning well." + ] + }, + { + "id": "multiclinsum_test_2888_en.txt", + "fulltext": "A 55-year-old man experienced allergic rhinitis for 2.5 years with no hepatitis or kidney disease. He became ill at the sight of greasy food on January 12, 2022 and sought care at a local health center on January 13, 2022. The specific therapeutical program he received was unknown, and the effect was unhelpful. His daily urination frequency and volume gradually decreased. He also had epigastric pain, generalized weakness, and hiccups and was admitted to a local hospital on January 16, 2022. The laboratory test results were as follows: white blood cell (WBC) count, 8.95 × 109/L (reference value 3.5–9.5 × 109/L); platelets (PLTs), 9 × 109/L (reference value 125–350 × 109/L); direct bilirubin (DBIL), 135.07 µmol/L; indirect bilirubin (IBIL), 20.99 µmol/L; albumin (ALB), 36.5 g/L(reference value 40–55 g/L); alanine transaminase (ALT), 8,453 U/L (reference value 9–50 U/L); aspartate aminotransferase (AST), 3,515 U/L (reference value 15–45 U/L); serum ammonia (AMON) 435.79 µmol/L (reference value 18–72 µmol/L); creatinine (Cr), 809 µmol/L (reference value 40–115 µmol/L); blood urea nitrogen, 32.82 mmol/L(reference value 2.00–6.90 mmol/L); amylase (AMYL), 184 U/L(reference value 0–96 U/L); prothrombin time (PT), 55.1 s (reference value 8.80–13.80 mmol/L); and activated partial thromboplastin time (APTT), 64.50 s (reference value 26.00–42.00 mmol/L). No obvious abnormality was observed in the remaining parameters. The local hospital made a diagnosis of acute renal failure, acute liver failure, coagulation dysfunction. Considering the seriousness of the patient’s condition, he was transferred to the intensive care unit of the local city hospital. And symptomatic and supportive treatment was given (specific therapeutic schemes were unknown). After 5 days of treatment, the patient continued to experience abdominal pain, abdominal distention, and anuria. Transaminase levels decreased significantly, but serum creatinine and bilirubin levels remained unchanged. The laboratory test results after treatment were as follows: DBIL, 176.70 µmol/L; IBIL, 17.08 µmol/L; ALB, 35.1 g/L; ALT, 637 U/L; AST, 87 U/L; AMON, 47.79 µmol/L; Cr, 681 µmol/L .\nFor further diagnosis and treatment, he was transferred to our department at on January 22, 2022. To determine the cause of the disease, the doctor repeatedly asked the patient’s history. It was then revealed that the patient had followed folk medication and consumed Xanthii Fructus for 2 months, approximately 20 g (35–40 particles), once daily (at night, before going to bed). During the same period, no other drugs were taken, and no toxic animals, plants, or chemicals were consumed. Upon admission to our hospital, his vital signs were as follows: temperature, 36.6 °C; heart rate, 79 beats/min; respiratory rate, 20 breaths/min; blood pressure, 131/75 mmHg; and oxygen saturation, 99%. He appeared to be in severe pain and severe yellowing of the skin and white of the eyes . Heart and lung examinations showed normal findings. He also had a soft abdomen, tenderness of the upper abdomen, no rebound pain, and muscle tension, and the liver was palpable 2 cm under the rib margin. The spleen was not palpable under the ribs. Normal borborygmus was noted. Physiological reflexes were present, but no pathological reflexes, such as Babinski’s sign, were induced. The laboratory test results obtained in our department were as follows: WBC count, 14.05 × 109/L; PLT, 57 × 109/L; ALT, 573 U/L; AST, 138 U/L; AMON, 59 µmol/L; Cr, 514 µmol/L; serum myoglobin (MYO), 856.20 ng/mL (reference value 0–70 ng/mL), serum high-sensitivity troponin I (hs-CTNI), 22.70 ng/L; NT-PROBNP (BNP), 4,718 pg/mL; PT, 18.90 s, APTT, 43.90. No significant changes in electrocardiogram findings were observed. Chest computed tomography revealed inflammation of both lungs and manifestations of bilateral pleural effusion and hypoexpansion of the adjacent lung tissues. Abdominal computed tomography particularly revealed ascites and thickening of the gastric wall and part of the intestinal wall. Xanthii Fructus-related multiple organ dysfunction syndrome was diagnosed, and the treatment included nutritional support and daily administration of medications including lansoprazole (30 mg bid), magnesium isoglycyrrhizinate injection (Chinese Medicine Approval: H20051942, CTTQ, Lianyungang, Jiangsu Province, China) (0.2 g), furosemide (100 mg bid). Fresh plasma (200 mL) and cryoprecipitate (12 u) were also given. Continuous venovenous hemodialysis (Prismaflex ST100) was also administered.\nOn day 2, his heart rate was 146 beats/min, and blood pressure was 112/67 mmHg. The patient was irritable. He continuously had a stomachache, which did not improve, but, instead, gradually worsened. The patient was administered phloroglucinol (40 mg IM) for pain relief and esmolol micropump for heart rate control.\nOn day 3, the patient was delirious, drowsy and continued to have anuria. He developed sighing and open-mouth breathing. His blood pressure continued to drop to 38/21 mmHg, heart rate was 86 beats/min, and respiratory rate was 24 breaths/min, with 89% oxygen saturation. The laboratory test results were as follows: pH, 6.82; partial carbon dioxide pressure (PCO2), 64 mmHg; partial oxygen pressure (PO2), 277 mmHg; lactic acid (Lac), 7.80 mmol/L; K+, 7.5 mmol/L; WBC count, 17.44 × 109/L; PLT count, 56 × 109/L; DBIL, 233.6 µmol/L; IBIL, 94.1 µmol/L; ALB, 33.5 g/L; ALT, 338 U/L; AST, 101 U/L; Cr, 719 µmol/L; MYO, 6,114.00 ng/mL; hs-CTNI, 96.14 ng/L; BNP, 24,049 pg/mL; PT, 21.70 s; APTT, 43.50 s; Fib, 2.75 g/L; DD-i, 23.81 µg/mL. High-flow oxygen was administered, and IV norepinephrine was provided via micropump to increase blood pressure; additionally, the patient received an intravenous drip of nikethamide and lobeline to maintain breathing, intravenous drip of sodium bicarbonate to correct acidosis, and intravenous injection of calcium gluconate to reduce potassium levels. The pumping esmolol micropump was then stopped. After 30 min, the patient was still in coma (Glasgow Coma Scale score: 3 points), with blood pressure of 107/76 mmHg, heart rate of 113 beats/min, respiratory rate of 22 beats/min, and 100% oxygen saturation. Arterial blood gas analysis revealed the following: pH, 6.93; PCO2, 62 mmHg; PO2, 212 mmHg; Lac, 7.0 mmol/L; and K+, 6.90 mmol/L. The patient’s family gave up further treatment and arranged for discharge from the hospital. The patient died on the day of discharge .", + "fulltext_subclaims": [ + "The patient is a 55-year-old man.", + "He experienced allergic rhinitis for 2.5 years.", + "He had no hepatitis or kidney disease.", + "He became ill at the sight of greasy food on January 12, 2022.", + "He sought care at a local health center on January 13, 2022.", + "The specific therapeutical program he received was unknown.", + "The effect of the treatment was unhelpful.", + "His daily urination frequency and volume gradually decreased.", + "He had epigastric pain.", + "He had generalized weakness.", + "He had hiccups.", + "He was admitted to a local hospital on January 16, 2022.", + "The white blood cell count was 8.95 × 109/L.", + "The platelet count was 9 × 109/L.", + "The direct bilirubin was 135.07 µmol/L.", + "The indirect bilirubin was 20.99 µmol/L.", + "The albumin was 36.5 g/L.", + "The alanine transaminase was 8,453 U/L.", + "The aspartate aminotransferase was 3,515 U/L.", + "The serum ammonia was 435.79 µmol/L.", + "The creatinine was 809 µmol/L.", + "The blood urea nitrogen was 32.82 mmol/L.", + "The amylase was 184 U/L.", + "The prothrombin time was 55.1 s.", + "The activated partial thromboplastin time was 64.50 s.", + "The local hospital diagnosed acute renal failure.", + "The local hospital diagnosed acute liver failure.", + "The local hospital diagnosed coagulation dysfunction.", + "He was transferred to the intensive care unit of the local city hospital.", + "Symptomatic and supportive treatment was given.", + "After 5 days of treatment, the patient continued to experience abdominal pain.", + "After 5 days of treatment, the patient continued to experience abdominal distention.", + "After 5 days of treatment, the patient continued to experience anuria.", + "Transaminase levels decreased significantly.", + "Serum creatinine levels remained unchanged.", + "Serum bilirubin levels remained unchanged.", + "The direct bilirubin after treatment was 176.70 µmol/L.", + "The indirect bilirubin after treatment was 17.08 µmol/L.", + "The albumin after treatment was 35.1 g/L.", + "The alanine transaminase after treatment was 637 U/L.", + "The aspartate aminotransferase after treatment was 87 U/L.", + "The serum ammonia after treatment was 47.79 µmol/L.", + "The creatinine after treatment was 681 µmol/L.", + "He was transferred to our department on January 22, 2022.", + "The patient had followed folk medication and consumed Xanthii Fructus for 2 months.", + "He consumed approximately 20 g of Xanthii Fructus once daily.", + "He consumed Xanthii Fructus at night, before going to bed.", + "During the same period, no other drugs were taken.", + "During the same period, no toxic animals, plants, or chemicals were consumed.", + "Upon admission to our hospital, his temperature was 36.6 °C.", + "Upon admission to our hospital, his heart rate was 79 beats/min.", + "Upon admission to our hospital, his respiratory rate was 20 breaths/min.", + "Upon admission to our hospital, his blood pressure was 131/75 mmHg.", + "Upon admission to our hospital, his oxygen saturation was 99%.", + "He appeared to be in severe pain.", + "He had severe yellowing of the skin and white of the eyes.", + "Heart and lung examinations showed normal findings.", + "He had a soft abdomen.", + "He had tenderness of the upper abdomen.", + "The liver was palpable 2 cm under the rib margin.", + "The spleen was not palpable under the ribs.", + "Normal borborygmus was noted.", + "Physiological reflexes were present.", + "No pathological reflexes were induced.", + "The white blood cell count was 14.05 × 109/L.", + "The platelet count was 57 × 109/L.", + "The alanine transaminase was 573 U/L.", + "The aspartate aminotransferase was 138 U/L.", + "The serum ammonia was 59 µmol/L.", + "The creatinine was 514 µmol/L.", + "The serum myoglobin was 856.20 ng/mL.", + "The serum high-sensitivity troponin I was 22.70 ng/L.", + "The NT-PROBNP was 4,718 pg/mL.", + "The prothrombin time was 18.90 s.", + "The activated partial thromboplastin time was 43.90 s.", + "Chest computed tomography revealed inflammation of both lungs.", + "Chest computed tomography showed bilateral pleural effusion.", + "Chest computed tomography showed hypoexpansion of the adjacent lung tissues.", + "Abdominal computed tomography revealed ascites.", + "Abdominal computed tomography showed thickening of the gastric wall.", + "Abdominal computed tomography showed thickening of part of the intestinal wall.", + "Xanthii Fructus-related multiple organ dysfunction syndrome was diagnosed.", + "The treatment included nutritional support.", + "The treatment included daily administration of lansoprazole.", + "The treatment included daily administration of magnesium isoglycyrrhizinate injection.", + "The treatment included daily administration of furosemide.", + "Fresh plasma was given.", + "Cryoprecipitate was given.", + "Continuous venovenous hemodialysis was administered.", + "On day 2, his heart rate was 146 beats/min.", + "On day 2, his blood pressure was 112/67 mmHg.", + "The patient was irritable.", + "The patient had continuous stomachache.", + "The stomachache did not improve.", + "The stomachache gradually worsened.", + "Phloroglucinol was administered for pain relief.", + "Esmolol micropump was administered for heart rate control.", + "On day 3, the patient was delirious.", + "On day 3, the patient was drowsy.", + "On day 3, the patient continued to have anuria.", + "On day 3, the patient developed sighing and open-mouth breathing.", + "On day 3, his blood pressure dropped to 38/21 mmHg.", + "On day 3, his heart rate was 86 beats/min.", + "On day 3, his respiratory rate was 24 breaths/min.", + "On day 3, his oxygen saturation was 89%.", + "The pH was 6.82.", + "The partial carbon dioxide pressure was 64 mmHg.", + "The partial oxygen pressure was 277 mmHg.", + "The lactic acid was 7.80 mmol/L.", + "The potassium was 7.5 mmol/L.", + "The white blood cell count was 17.44 × 109/L.", + "The platelet count was 56 × 109/L.", + "The direct bilirubin was 233.6 µmol/L.", + "The indirect bilirubin was 94.1 µmol/L.", + "The albumin was 33.5 g/L.", + "The alanine transaminase was 338 U/L.", + "The aspartate aminotransferase was 101 U/L.", + "The creatinine was 719 µmol/L.", + "The serum myoglobin was 6,114.00 ng/mL.", + "The high-sensitivity troponin I was 96.14 ng/L.", + "The BNP was 24,049 pg/mL.", + "The prothrombin time was 21.70 s.", + "The activated partial thromboplastin time was 43.50 s.", + "The fibrinogen was 2.75 g/L.", + "The D-dimer was 23.81 µg/mL.", + "High-flow oxygen was administered.", + "Intravenous norepinephrine was provided via micropump.", + "Intravenous drip of nikethamide and lobeline was provided.", + "Intravenous drip of sodium bicarbonate was provided.", + "Intravenous injection of calcium gluconate was provided.", + "The pumping esmolol micropump was stopped.", + "After 30 min, the patient was still in coma.", + "The Glasgow Coma Scale score was 3 points.", + "The blood pressure was 107/76 mmHg.", + "The heart rate was 113 beats/min.", + "The respiratory rate was 22 breaths/min.", + "The oxygen saturation was 100%.", + "The pH was 6.93.", + "The partial carbon dioxide pressure was 62 mmHg.", + "The partial oxygen pressure was 212 mmHg.", + "The lactic acid was 7.0 mmol/L.", + "The potassium was 6.90 mmol/L.", + "The patient’s family gave up further treatment.", + "The patient was arranged for discharge from the hospital.", + "The patient died on the day of discharge." + ], + "summary": "We reported on a 55-year-old man who experienced allergic rhinitis for 2.5 years. He ingested unprocessed Xanthii Fructus for 2 months as treatment. However, he developed anorexia; nausea; abdominal pain; general weakness; hiccups; oliguria and anuria; significantly elevated serum alanine aminotransferase, aspartate aminotransferase, and creatinine levels; and abnormalities in blood coagulation series. Nutritional support; daily drugs for liver protection, gastric protection, inflammation reduction; fresh plasma; and cryoprecipitate infusion were administered. Continuous venovenous hemodialysis (Prismaflex ST100) was also administered. However, the patient's multiple organ failure gradually worsened, ultimately leading to death.", + "summary_subclaims": [ + "The patient was a 55-year-old man.", + "He experienced allergic rhinitis for 2.5 years.", + "He ingested unprocessed Xanthii Fructus for 2 months.", + "He developed anorexia.", + "He developed nausea.", + "He developed abdominal pain.", + "He developed general weakness.", + "He developed hiccups.", + "He developed oliguria and anuria.", + "Serum alanine aminotransferase levels were significantly elevated.", + "Serum aspartate aminotransferase levels were significantly elevated.", + "Serum creatinine levels were significantly elevated.", + "Abnormalities were present in the blood coagulation series.", + "Nutritional support was administered.", + "Daily drugs for liver protection were administered.", + "Daily drugs for gastric protection were administered.", + "Daily drugs for inflammation reduction were administered.", + "Fresh plasma was administered.", + "Cryoprecipitate infusion was administered.", + "Continuous venovenous hemodialysis (Prismaflex ST100) was administered.", + "The patient's multiple organ failure gradually worsened.", + "The patient ultimately died." + ] + }, + { + "id": "multiclinsum_test_1403_en.txt", + "fulltext": "A healthy 19-year-old male college student presented to the emergency department with acute pain in the left foot after sustaining a sledding injury. While sledding in the sitting position and with legs extended, the plantar aspect of his left foot struck a tree limb at high speed. The pain was throbbing and did not radiate. Weight bearing was impossible. Previous medical and surgical records were unremarkable.\nOn physical examination, localized swelling and tenderness of the dorsal aspect of the midfoot prevented weight-bearing or movement of the foot and ankle. Circulation and neurological examinations were normal. The skin was intact.\nFoot radiograph demonstrated a Lisfranc fracture dislocation . A subsequent CT scan is shown .\nThis patient underwent an immediate open reduction and internal fixation of the Lisfranc fracture-dislocation. A postoperative radiograph is shown . He was treated with a non-weight-bearing cast followed by a weight-bearing boot. He was advised to refrain from strenuous physical activity for 6 weeks after removal of the boot, after which time, normal physical activity was resumed. A non-steroidal anti-inflammatory drug was prescribed for pain. The patient had only mild pain with weight-bearing at 6 months and was ambulating without difficulty; he was pain-free at 2 years.", + "fulltext_subclaims": [ + "A healthy 19-year-old male college student presented to the emergency department with acute pain in the left foot after sustaining a sledding injury.", + "While sledding in the sitting position and with legs extended, the plantar aspect of his left foot struck a tree limb at high speed.", + "The pain was throbbing and did not radiate.", + "Weight bearing was impossible.", + "Previous medical and surgical records were unremarkable.", + "On physical examination, localized swelling and tenderness of the dorsal aspect of the midfoot prevented weight-bearing or movement of the foot and ankle.", + "Circulation and neurological examinations were normal.", + "The skin was intact.", + "Foot radiograph demonstrated a Lisfranc fracture dislocation.", + "A subsequent CT scan is shown.", + "This patient underwent an immediate open reduction and internal fixation of the Lisfranc fracture-dislocation.", + "A postoperative radiograph is shown.", + "He was treated with a non-weight-bearing cast followed by a weight-bearing boot.", + "He was advised to refrain from strenuous physical activity for 6 weeks after removal of the boot.", + "A non-steroidal anti-inflammatory drug was prescribed for pain.", + "The patient had only mild pain with weight-bearing at 6 months and was ambulating without difficulty.", + "He was pain-free at 2 years." + ], + "summary": "A 19-year-old male college student presented to the emergency department with a Lisfranc fracture dislocation of the foot as a result of a high-velocity sledding injury. The patient underwent an immediate open reduction and internal fixation.", + "summary_subclaims": [ + "The patient is a 19-year-old male college student.", + "The patient presented to the emergency department.", + "The patient had a Lisfranc fracture dislocation of the foot.", + "The injury was a result of a high-velocity sledding injury.", + "The patient underwent an immediate open reduction and internal fixation." + ] + }, + { + "id": "multiclinsum_test_2604_en.txt", + "fulltext": "A 50-year-old woman with a history of fatigue, worsening exertional dyspnoea, and\nweight increase (8 kg) in the last 3 months was referred to our\nCardiovascular Department by her general practitioner. Clinical examination detected\nhypotension (90/60 mmHg), an holosystolic murmur best heard at the cardiac\napex, bilateral pulmonary rales, lower extremity oedema, and macroglossia. Her past\nmedical history was unremarkable except for bilateral carpal tunnel (CT) surgery\nsome years before. She denied suffering from arterial hypertension, and an\nelectrocardiogram (ECG) obtained 1 year earlier was reported normal (not\navailable).\nThe patient is a previously asymptomatic young adult without comorbidities,\npresenting with severe new-onset HF. The differential diagnosis includes\ncardiomyopathies, hypertensive, ischaemic, and valvular heart diseases. Macroglossia\nand CT syndrome suggest an infiltrative disease, while the heart murmur endorses the\npossibility of a severe valve disease precipitating acute HF. The absence of any\ncardiovascular risk factor makes the diagnosis of ischaemic heart disease\nunlikely.\nThe ECG showed sinus rhythm with normal QRS voltages and Q-waves in anterior and\ninferior leads not consistent with the degree of left ventricle (LV)\nhypertrophy (max 17 mm) and normal wall motion evident at echocardiography\n.\nIn addition, grade III diastolic dysfunction, reduced LV global longitudinal strain\n(GLS –14%) with an ‘apical sparing’ pattern, thickened\nmitral valve leaflets, right ventricle hypertrophy and dilated inferior vena cava\nwere found (Video 1). Laboratory tests revealed high brain natriuretic peptide\n(BNP) levels (618 pg/L, normal reference value <100 pg/L) and\npersistent mild increase in troponin T (0.34 ng/mL, normal reference value\n<0.25 ng/mL). An invasive angiography excluded coronary artery\ndisease. Clinical and instrumental findings rose the suspicion of CA, and the\nGillmore’s algorithm was followed: serum λ free light chains (FLCs) returned\npathologically increased (108 mg/dL, delta FLCs 93 mg/dL) and Perugini\ngrade 1 myocardial uptake was found at diphosphonate scintigraphy . The diagnosis of\nAL-CA was confirmed through detection and typing of amyloid fibrils at Congo red\nstaining and electron microscopy of abdominal fat specimen. A concomitant diagnosis\nof a smouldering micromolecular λ-type myeloma was made on the basis of\n22% clonal plasma cell in the bone marrow biopsy (BMB) without signs of\nend-organ (classic ‘calcium elevation, renal insufficiency, anemia, and bone\nabnormalities’ criteria) damage .\nThe advanced heart involvement (Mayo cardiac stage III) and the micromolecular myeloma\ncontraindicated ASCT as up-front therapy. Therefore, low-dose cytoreductive therapy\nwith cyclophosphamide, bortezomib, and dexamethasone (CyBorD) was started, halving\nthe standard dose of the proteasome inhibitor and monitoring troponin serum\nconcentrations and fluid status on a daily basis. Up-titration of diuretic dose up\nto 200 mg/die of furosemide was necessary due to frequent readmissions for\ndecompensated HF with haemodynamic deterioration. No other HF medications were\nstarted. Low cardiac index (2.5 l/min/m2) at right heart\ncatheterization and severely reduced maximal oxygen consumption during exercise\n(VO2) peak (15.4 ml/kg/min, 50% predicted value) with\nimpaired ventilatory efficiency at cardiopulmonary exercise test (CPET) were\ndocumented. After one CyBorD cycle, therapeutic strategies were collegially\ndiscussed in a multidisciplinary team, considering three main variables: young age,\nsevere cardiac involvement with ominous prognosis, and absence of significant\nextra-cardiac involvement, which was systematically investigated. The patient was\njudged a good candidate for HTx followed by ASCT. Thus, she entered on the HTx\nwaiting list within 2 months from HF diagnosis. She experienced two syncopal\nepisodes without clear prodromal symptoms and received an implantable cardioverter\ndefibrillator for the prevention of arrhythmic death as bridge to HTx.\nDespite fragile conditions, she succeeded in having a full course of chemotherapy\nwith unexpected progressive reduction in serum values of BNP and FLCs. After 1 year\nof CyBorD therapy (6 cycles), serum FLCs normalized without residual hematological\ndisease at BMB. At cardiological evaluation, the patient was in New York Heart\nFailure (NYHA) I functional class with normal BNP value (70 pg/L), lower diuretic\ndose (125 mg/die), recovered LV systolic function (GLS −20%)\n,\nincreased exercise capacity (VO2 peak of 20.8 ml/kg/min,\n76% predicted value), and normalization of ventilation and carbon dioxide\nproduction slope at CPET . Due to significantly improved\ncardiac performance and the complete hematological response, CyBorD therapy was\ndiscontinued, and the patient was withdrawn from HTx waiting list and the planned\nASCT. She underwent apheresis and cryopreservation of hematopoietic stem cells in\ncase of future need of ASCT. At device interrogations, no record of ventricular\narrhythmic events or ICD discharge was found. She remained stable in NYHA I\nfunctional class after >3 years from HF onset under regular cardiological and\nhematological follow-up.", + "fulltext_subclaims": [ + "The patient is a 50-year-old woman.", + "She had a weight increase of 8 kg in the last 3 months.", + "Clinical examination detected hypotension (90/60 mmHg).", + "Clinical examination detected bilateral pulmonary rales.", + "Clinical examination detected lower extremity oedema.", + "Clinical examination detected macroglossia.", + "She had bilateral carpal tunnel surgery some years before.", + "She denied suffering from arterial hypertension.", + "An electrocardiogram obtained 1 year earlier was reported normal.", + "The ECG showed sinus rhythm with normal QRS voltages.", + "The ECG showed Q-waves in anterior and inferior leads.", + "The Q-waves were not consistent with the degree of left ventricle hypertrophy.", + "Echocardiography showed normal wall motion.", + "Echocardiography showed grade III diastolic dysfunction.", + "Echocardiography showed reduced LV global longitudinal strain (GLS –14%).", + "Echocardiography showed an ‘apical sparing’ pattern.", + "Echocardiography showed thickened mitral valve leaflets.", + "Echocardiography showed right ventricle hypertrophy.", + "Echocardiography showed a dilated inferior vena cava.", + "Laboratory tests revealed high brain natriuretic peptide (BNP) levels (618 pg/L).", + "Laboratory tests revealed persistent mild increase in troponin T (0.34 ng/mL).", + "Invasive angiography excluded coronary artery disease.", + "Serum λ free light chains (FLCs) were pathologically increased (108 mg/dL).", + "Perugini grade 1 myocardial uptake was found at diphosphonate scintigraphy.", + "The diagnosis of AL-CA was confirmed through detection and typing of amyloid fibrils at Congo red staining.", + "The diagnosis of AL-CA was confirmed through detection and typing of amyloid fibrils at electron microscopy of abdominal fat specimen.", + "A concomitant diagnosis of a smouldering micromolecular λ-type myeloma was made.", + "The bone marrow biopsy showed 22% clonal plasma cell.", + "The bone marrow biopsy showed no signs of end-organ damage.", + "The advanced heart involvement (Mayo cardiac stage III) and the micromolecular myeloma contraindicated ASCT as up-front therapy.", + "Low-dose cytoreductive therapy with cyclophosphamide, bortezomib, and dexamethasone (CyBorD) was started.", + "The standard dose of the proteasome inhibitor was halved.", + "Troponin serum concentrations and fluid status were monitored on a daily basis.", + "Up-titration of diuretic dose up to 200 mg/die of furosemide was necessary.", + "No other HF medications were started.", + "Low cardiac index (2.5 l/min/m2) was documented at right heart catheterization.", + "Severely reduced maximal oxygen consumption during exercise (VO2 peak 15.4 ml/kg/min) was documented.", + "After one CyBorD cycle, the patient was judged a good candidate for HTx followed by ASCT.", + "She entered on the HTx waiting list within 2 months from HF diagnosis.", + "She experienced two syncopal episodes without clear prodromal symptoms.", + "She received an implantable cardioverter defibrillator for the prevention of arrhythmic death as bridge to HTx.", + "She succeeded in having a full course of chemotherapy.", + "After 1 year of CyBorD therapy (6 cycles), serum FLCs normalized.", + "At cardiological evaluation, the patient was in New York Heart Failure (NYHA) I functional class.", + "At cardiological evaluation, BNP value was 70 pg/L.", + "At cardiological evaluation, the diuretic dose was 125 mg/die.", + "At cardiological evaluation, LV systolic function was recovered (GLS −20%).", + "At cardiological evaluation, VO2 peak was 20.8 ml/kg/min.", + "At cardiological evaluation, ventilation and carbon dioxide production slope normalized at CPET.", + "Due to significantly improved cardiac performance and the complete hematological response, CyBorD therapy was discontinued.", + "The patient was withdrawn from HTx waiting list.", + "The planned ASCT was not performed.", + "She underwent apheresis and cryopreservation of hematopoietic stem cells.", + "At device interrogations, no record of ventricular arrhythmic events or ICD discharge was found.", + "She remained stable in NYHA I functional class after >3 years from HF onset." + ], + "summary": "A previously healthy 50-year-old woman presented with severely symptomatic new-onset heart with preserved ejection fraction, significant cardiac hypertrophy, and an 'apical sparing' pattern. Bone marrow and abdominal fat biopsy revealed AL amyloidosis due to a smouldering micromolecular λ-type myeloma with severe cardiac involvement, and the patient was judged a good candidate to HTx followed by ASCT. Despite fragile conditions, she tolerated a full course of low-dose combination therapy with bortezomib and was withdrawn from HTx list because of unexpected persistent complete hematologic response and major cardiac improvement. Disease remission was achieved in the long term (>3 years).", + "summary_subclaims": [ + "The patient is a previously healthy 50-year-old woman.", + "She presented with severely symptomatic new-onset heart with preserved ejection fraction.", + "She had significant cardiac hypertrophy.", + "She had an 'apical sparing' pattern.", + "Bone marrow and abdominal fat biopsy revealed AL amyloidosis.", + "The AL amyloidosis was due to a smouldering micromolecular λ-type myeloma.", + "The patient had severe cardiac involvement.", + "The patient was judged a good candidate to HTx followed by ASCT.", + "She tolerated a full course of low-dose combination therapy with bortezomib.", + "She was withdrawn from the HTx list because of unexpected persistent complete hematologic response.", + "She was withdrawn from the HTx list because of major cardiac improvement.", + "Disease remission was achieved in the long term (>3 years)." + ] + }, + { + "id": "multiclinsum_test_632_en.txt", + "fulltext": "The patient was a 62-year-old man who had undergone combined phacovitrectomy for the epiretinal membrane of the left eye performed by a local ophthalmologist 4 years previously. Postoperative refractive values did not differ between the right and left eyes. The patient was referred to our department after complaining several months prior that the power of his left eyeglasses was out of alignment. Ocular examination revealed an uncorrected distance visual acuity of 20/100 in the right eye and 20/200 in the left eye. The corrected distance visual acuity was 20/20 in both eyes, and the subjective refraction was −4.50 diopters sphere (DS)/−2.00 diopters cylinder (DC) × 90° in the right eye and −7.00 DS/−0.50 DC × 80° in the left eye. No abnormalities were observed in the corneas of either eye; the fundus of the right eye was normal, with only a mild cataract. The left eye was vitrectomized and showed no recurrence of epiretinal membrane; however, a slightly protruding milky white opacity in the shape of a convex lens was observed between the IOL and posterior capsule (shown in a). After the ocular examination, when the Nd-YAG laser treatment was performed, a milky white fluid drained into the vitreous cavity, resulting in the disappearance of the milky white contents (shown in b). The IOL depth in the left eye was measured using a swept-source AS-OCT device (CASIA2; Tomey, Nagoya, Japan). The IOL depth in the left eye was 4.553 mm in horizontal sections and 4.530 mm in vertical sections before, and 4.607 mm and 4.559 mm after, the Nd-YAG laser posterior capsulotomy, respectively (shown in a–d). Objective refraction of the left eye before and after the Nd-YAG laser treatment changed from −7.23 DS/−0.88 DC × 81° to −5.92 DS/−1.18 DC × 71° in normal pupil condition. Two weeks after the Nd-YAG laser treatment was administered, the left corrected distance visual acuity was 25/20 and the subjective refraction was −5.50 DS/−1.00 DC × 70°, indicating that the myopia improved.", + "fulltext_subclaims": [ + "The patient was a 62-year-old man.", + "The patient had undergone combined phacovitrectomy for the epiretinal membrane of the left eye.", + "The surgery was performed by a local ophthalmologist 4 years previously.", + "Postoperative refractive values did not differ between the right and left eyes.", + "The patient was referred to our department after complaining several months prior that the power of his left eyeglasses was out of alignment.", + "Ocular examination revealed an uncorrected distance visual acuity of 20/100 in the right eye.", + "Ocular examination revealed an uncorrected distance visual acuity of 20/200 in the left eye.", + "The corrected distance visual acuity was 20/20 in both eyes.", + "The subjective refraction was −4.50 diopters sphere (DS)/−2.00 diopters cylinder (DC) × 90° in the right eye.", + "The subjective refraction was −7.00 DS/−0.50 DC × 80° in the left eye.", + "No abnormalities were observed in the corneas of either eye.", + "The fundus of the right eye was normal, with only a mild cataract.", + "The left eye was vitrectomized.", + "The left eye showed no recurrence of epiretinal membrane.", + "A slightly protruding milky white opacity in the shape of a convex lens was observed between the IOL and posterior capsule.", + "After the ocular examination, when the Nd-YAG laser treatment was performed, a milky white fluid drained into the vitreous cavity.", + "The milky white contents disappeared after the Nd-YAG laser treatment.", + "The IOL depth in the left eye was measured using a swept-source AS-OCT device (CASIA2; Tomey, Nagoya, Japan).", + "The IOL depth in the left eye was 4.553 mm in horizontal sections before the Nd-YAG laser posterior capsulotomy.", + "The IOL depth in the left eye was 4.530 mm in vertical sections before the Nd-YAG laser posterior capsulotomy.", + "The IOL depth in the left eye was 4.607 mm in horizontal sections after the Nd-YAG laser posterior capsulotomy.", + "The IOL depth in the left eye was 4.559 mm in vertical sections after the Nd-YAG laser posterior capsulotomy.", + "Objective refraction of the left eye before the Nd-YAG laser treatment was −7.23 DS/−0.88 DC × 81°.", + "Objective refraction of the left eye after the Nd-YAG laser treatment was −5.92 DS/−1.18 DC × 71°.", + "Two weeks after the Nd-YAG laser treatment was administered, the left corrected distance visual acuity was 25/20.", + "Two weeks after the Nd-YAG laser treatment was administered, the subjective refraction was −5.50 DS/−1.00 DC × 70°.", + "The myopia improved after the Nd-YAG laser treatment." + ], + "summary": "We report a case of a 62-year-old male patient having CBS with myopia. The patient was treated with neodymium-yttrium aluminum garnet (Nd-YAG) laser posterior capsulotomy. We measured and compared the depth of the intraocular lens using anterior segment optical coherence tomography (AS-OCT) before and after laser treatment. Treatment resulted in refraction improvement of more than 1.0 diopters. The intraocular lens depth before and after Nd-YAG laser irradiation had very mild changes of less than 0.05 mm, which did not explain the refractive changes.", + "summary_subclaims": [ + "The patient was a 62-year-old male.", + "The patient had CBS with myopia.", + "The patient was treated with neodymium-yttrium aluminum garnet (Nd-YAG) laser posterior capsulotomy.", + "The depth of the intraocular lens was measured using anterior segment optical coherence tomography (AS-OCT).", + "The measurements were taken before and after laser treatment.", + "Treatment resulted in refraction improvement of more than 1.0 diopters.", + "The intraocular lens depth before and after Nd-YAG laser irradiation had very mild changes of less than 0.05 mm.", + "The intraocular lens depth changes did not explain the refractive changes." + ] + }, + { + "id": "multiclinsum_test_512_en.txt", + "fulltext": "An 18-year-old Saudi male was referred to our hospital with a 3-month history of upper abdominal pain and yellowish discoloration of the sclera. The pain was colicky and non-radiating, with a severity of 3/10, and was not related to food intake or position. Six months prior to the presentation, the patient was diagnosed with diabetes mellitus type 1 and started on insulin aspart 14/16/8 units and glargine 38 units HS. There was no family history of hepatobiliary, hemoglobinopathy, or gastrointestinal malignancy. Two weeks prior to the presentation, the patient was admitted to another hospital during which magnetic resonance cholangiopancreatography (MRCP) was performed and showed a filling defect in the distal common bile duct (CBD). Endoscopic retrograde cholangiopancreatography (ERCP) could not be done there due to unavailability.\nHis physical examination was unremarkable, apart from scleral jaundice. Liver function test revealed a total bilirubin of 6 mg/dL, alanine aminotransferase 70 U/L, alkaline phosphatase 258 U/L, and gamma-glutamyl transferase 474 U/L. Complete blood count, renal function test, calcium level, amylase, and lipase levels were normal. The parathyroid hormone was elevated (171 pg/mL); however, TSH, free T4, LH, FSH, prolactin, ACTH, cortisol, and testosterone levels were normal.\nAbdominal ultrasound revealed a dilated CBD of 8 mm and a single gallbladder stone . During the ERCP, two duodenal polypoid lesions were noted, one of them overlying the ampulla of Vater, with erythematous and ulcerated surface . The common bile duct was cannulated, and the cholangiogram revealed dilated extra and intrahepatic bile ducts and a lower CBD filling defect . Multiple biopsies were obtained from both the duodenal lesions, and a plastic stent was inserted in the CBD. CT scan of the abdomen with IV contrast showed multiple enhanced well-defined lesions in the peri-ampullary area as well as the pancreaticoduodenal groove. No distant metastasis was detected .\nThe histopathological evaluation revealed infiltration of the intestinal mucosa by a few small solid nodules. These nodules were composed of cells with round uniform nuclei and stippled chromatin. Immunohistochemical studies of the nodules showed positive reactivity for CK7, CDX2, CD56, chromogranin A, and synaptophysin and stained negative for CD20 . Less than 2% of the cells were labeled with the proliferation marker Ki-67, and the mitotic rate was 1/2 mm2. Accordingly, a histopathological diagnosis of NET grade 1 was made.\nTc-Octreotide scan showed multiple large intraluminal and extraluminal duodenal masses with no radiotracer uptake due to necrotic component. Two left para-aortic lymph nodes, the larger one measuring 2.6 cm × 2.8 cm, showed intense radiotracer uptake . There was no abnormal focus of activity in the liver, bones, and rest of the body.\nFurther workup showed an elevated 24-h urinary normetanephrine of 4,394 μg/24 h; however, the 24-h urinary metanephrine was normal as was the chromogranin (52 ng/mL; reference value <93), urine 5-hydroxyindoleacetic acid, gastrin, somatomedin, and glucagon. Tumor markers including carcinoembryonic antigen, alpha-feto protein, and CA19-9 were normal. Colonoscopy, MRI pituitary, and parathyroid ultrasound were unremarkable. Sequence analysis of MEN1 gene was negative for any pathogenic variants.\nAfter a multidisciplinary team discussion, the patient underwent a conventional Whipple procedure followed by para-aortic lymph node dissection. Lymph nodes draining the head of the pancreas and duodenum were dissected, and the surgeon was keen on removing as many lymph nodes as possible. Gastrointestinal reconstruction was done as follows: pancreaticojejunostomy was performed as a two-layer end-to-side full-thickness pancreatic neck inside the jejunum; hepaticojejunostomy was done with end-to-side common hepatic duct to antimesenteric border of the jejunum 15 cm distal to pancreaticojejunostomy, and gastrojejunostomy was done using handsewn anastomosis. Jejunojejunostomy was created around 60 cm from the biliary-enteric anastomosis. All the surgical margins were negative for tumor, and among the 39 lymph nodes excised, 12 lymph nodes showed metastatic NET. The tumor was confirmed to be NET grade 2. Two presumed para-aortic lymph nodes turned out to be paragangliomas.\nAfter the surgery, the patient had improved apart from diarrhea responding to pancreatic enzymes. The patient was started on intramuscular octreotide 30 mg monthly based on the oncology recommendation and considering the presence of lymph node metastasis. Gallium-68 DOTATATE showed no residual uptake in the postoperative bed, and apart from an avid left para-aortic lymph node, no other DOTATATE-avid lymph node was noted. Over the 18-month follow-up, gallium-68 DOTATAE and CT scan have been showing the stability of the avid left para-aortic lymph node with no local recurrence.", + "fulltext_subclaims": [ + "The patient was an 18-year-old Saudi male.", + "The patient had a 3-month history of upper abdominal pain.", + "The pain was colicky and non-radiating.", + "The pain had a severity of 3/10.", + "The pain was not related to food intake.", + "The pain was not related to position.", + "The patient had yellowish discoloration of the sclera.", + "Six months prior to the presentation, the patient was diagnosed with diabetes mellitus type 1.", + "The patient was started on insulin aspart 14/16/8 units.", + "The patient was started on glargine 38 units HS.", + "There was no family history of hepatobiliary disease.", + "There was no family history of hemoglobinopathy.", + "There was no family history of gastrointestinal malignancy.", + "Two weeks prior to the presentation, the patient was admitted to another hospital.", + "Magnetic resonance cholangiopancreatography (MRCP) was performed.", + "MRCP showed a filling defect in the distal common bile duct.", + "Endoscopic retrograde cholangiopancreatography (ERCP) could not be done due to unavailability.", + "Physical examination showed scleral jaundice.", + "Liver function test showed a total bilirubin of 6 mg/dL.", + "Liver function test showed an alanine aminotransferase of 70 U/L.", + "Liver function test showed an alkaline phosphatase of 258 U/L.", + "Liver function test showed a gamma-glutamyl transferase of 474 U/L.", + "The parathyroid hormone was elevated to 171 pg/mL.", + "TSH, free T4, LH, FSH, prolactin, ACTH, cortisol, and testosterone levels were normal.", + "Abdominal ultrasound revealed a dilated CBD of 8 mm.", + "Abdominal ultrasound showed a single gallbladder stone.", + "During the ERCP, two duodenal polypoid lesions were noted.", + "One of the duodenal lesions overlaid the ampulla of Vater.", + "The duodenal lesions had an erythematous and ulcerated surface.", + "The cholangiogram revealed dilated extra and intrahepatic bile ducts.", + "The cholangiogram showed a lower CBD filling defect.", + "Multiple biopsies were obtained from both the duodenal lesions.", + "A plastic stent was inserted in the CBD.", + "CT scan showed multiple enhanced well-defined lesions in the peri-ampullary area.", + "CT scan showed multiple enhanced well-defined lesions in the pancreaticoduodenal groove.", + "No distant metastasis was detected.", + "Histopathological evaluation revealed infiltration of the intestinal mucosa by small solid nodules.", + "The nodules were composed of cells with round uniform nuclei and stippled chromatin.", + "Immunohistochemical studies showed positive reactivity for CK7.", + "Immunohistochemical studies showed positive reactivity for CDX2.", + "Immunohistochemical studies showed positive reactivity for CD56.", + "Immunohistochemical studies showed positive reactivity for chromogranin A.", + "Immunohistochemical studies showed positive reactivity for synaptophysin.", + "Immunohistochemical studies showed negative reactivity for CD20.", + "Less than 2% of the cells were labeled with Ki-67.", + "The mitotic rate was 1/2 mm2.", + "A histopathological diagnosis of NET grade 1 was made.", + "Tc-Octreotide scan showed multiple large intraluminal and extraluminal duodenal masses.", + "The Tc-Octreotide scan showed no radiotracer uptake due to necrotic component.", + "Two left para-aortic lymph nodes showed intense radiotracer uptake.", + "The larger left para-aortic lymph node measured 2.6 cm × 2.8 cm.", + "There was no abnormal focus of activity in the liver.", + "There was no abnormal focus of activity in the bones.", + "There was no abnormal focus of activity in the rest of the body.", + "24-h urinary normetanephrine was 4,394 μg/24 h.", + "24-h urinary metanephrine was normal.", + "Chromogranin was 52 ng/mL.", + "Urine 5-hydroxyindoleacetic acid was normal.", + "Gastrin, somatomedin, and glucagon were normal.", + "Tumor markers including carcinoembryonic antigen, alpha-feto protein, and CA19-9 were normal.", + "Colonoscopy was unremarkable.", + "MRI pituitary was unremarkable.", + "Parathyroid ultrasound was unremarkable.", + "Sequence analysis of MEN1 gene was negative for any pathogenic variants.", + "The patient underwent a conventional Whipple procedure.", + "Para-aortic lymph node dissection was performed.", + "Lymph nodes draining the head of the pancreas and duodenum were dissected.", + "The surgeon was keen on removing as many lymph nodes as possible.", + "Pancreaticojejunostomy was performed as a two-layer end-to-side full-thickness pancreatic neck inside the jejunum.", + "Hepaticojejunostomy was done with end-to-side common hepatic duct to antimesenteric border of the jejunum.", + "Gastrojejunostomy was done using handsewn anastomosis.", + "Jejunojejunostomy was created around 60 cm from the biliary-enteric anastomosis.", + "All the surgical margins were negative for tumor.", + "Among the 39 lymph nodes excised, 12 lymph nodes showed metastatic NET.", + "The tumor was confirmed to be NET grade 2.", + "Two presumed para-aortic lymph nodes turned out to be paragangliomas.", + "The patient had improved apart from diarrhea responding to pancreatic enzymes.", + "The patient was started on intramuscular octreotide 30 mg monthly.", + "Gallium-68 DOTATATE showed no residual uptake in the postoperative bed.", + "An avid left para-aortic lymph node was noted.", + "No other DOTATATE-avid lymph node was noted.", + "Over the 18-month follow-up, gallium-68 DOTATAE showed stability of the avid left para-aortic lymph node.", + "Over the 18-month follow-up, CT scan showed stability of the avid left para-aortic lymph node.", + "There was no local recurrence." + ], + "summary": "An 18-year-old man presented with a 3-month history of upper abdominal pain and jaundice. Abdominal ultrasound showed a dilated common bile duct, and endoscopic retrograde cholangiopancreatography revealed two duodenal polypoid lesions, one of them overlying the ampulla of Vater, with an erythematous and ulcerated surface. Histopathological examination confirmed the diagnosis of NET grade 1. Octreotide scan revealed 2 para-aortic lymph nodes with intense radiotracer uptake. The patient had undergone Whipple surgery with para-aortic lymph node dissection. Histopathological examination of the surgical specimens was confirmatory of NET grade 2 and paraganglioma in a few of the dissected lymph nodes. Postoperatively, the patient was kept on monthly intramuscular octreotide. Follow-up gallium-68 DOTATATE is unremarkable apart from an avid left para-aortic lymph node which is showing stability over 12 months of follow-up.", + "summary_subclaims": [ + "The patient is an 18-year-old man.", + "The patient had a 3-month history of upper abdominal pain.", + "The patient had jaundice.", + "Abdominal ultrasound showed a dilated common bile duct.", + "Endoscopic retrograde cholangiopancreatography revealed two duodenal polypoid lesions.", + "One of the duodenal polypoid lesions overlaid the ampulla of Vater.", + "The lesions had an erythematous and ulcerated surface.", + "Histopathological examination confirmed the diagnosis of NET grade 1.", + "Octreotide scan revealed 2 para-aortic lymph nodes with intense radiotracer uptake.", + "The patient had undergone Whipple surgery with para-aortic lymph node dissection.", + "Histopathological examination of the surgical specimens was confirmatory of NET grade 2.", + "Histopathological examination of the surgical specimens was confirmatory of paraganglioma in a few of the dissected lymph nodes.", + "The patient was kept on monthly intramuscular octreotide.", + "Follow-up gallium-68 DOTATATE is unremarkable apart from an avid left para-aortic lymph node.", + "The left para-aortic lymph node is showing stability over 12 months of follow-up." + ] + }, + { + "id": "multiclinsum_test_140_en.txt", + "fulltext": "A 43-year-old male patient with a past medical history of MCD and ADHD since childhood presented to the emergency department with shortness of breath, generalized oedema, and foamy urine without haematuria for the last few months. The patient was taking Adderall (mixed amphetamine salts with dextroamphetamine and amphetamine) for ADHD since childhood and have undocumented history of inadequately treated MCD. He was evaluated for chronic kidney disease which revealed nephrotic range proteinuria, hypoalbuminemia, and an elevated brain natriuretic peptide. Urine drug sample was positive for amphetamine and cannabinoids. An extensive work-up was negative for secondary causes of nephrotic syndrome and kidney biopsy findings were consistent with MCD.\nElectrocardiography was performed that showed right bundle branch block and echocardiography revealed grade 1 diastolic dysfunction, severe dilation of the main right ventricle (RV) and RV outflow tract, significant RV hypertrophy, severely reduced RV systolic function, severe right atrial dilation, severe tricuspid regurgitation, and elevated central pressures. Chest X-ray showed cardiomegaly with a prominent pulmonary trunk suggestive of pulmonary hypertension. Cardiac catheterization revealed a mean pulmonary artery pressure of 43 mmHg and a pulmonary vascular resistance of 14.3 Wood units, consistent with moderate to severe PH, which was not reversible with the adenosine challenge. The patient commenced on high dose prednisone, lasix, and losartan. Adderall was discontinued as a possible contributing factor to PAH. The patient responded well to the treatment with the improvement in symptoms such as oedema and shortness of breath. Over the next 3 months, a gradual normalization of proteinuria, hypoalbuminemia, and urine protein-to-creatinine ratio was observed.", + "fulltext_subclaims": [ + "The patient is a 43-year-old male.", + "The patient has a past medical history of MCD.", + "The patient has a past medical history of ADHD.", + "The patient presented with shortness of breath.", + "The patient presented with generalized oedema.", + "The patient presented with foamy urine.", + "The patient was taking Adderall for ADHD since childhood.", + "The patient had an undocumented history of inadequately treated MCD.", + "The patient had nephrotic range proteinuria.", + "The patient had hypoalbuminemia.", + "The patient had an elevated brain natriuretic peptide.", + "The urine drug sample was positive for amphetamine.", + "The urine drug sample was positive for cannabinoids.", + "The kidney biopsy findings were consistent with MCD.", + "Electrocardiography showed right bundle branch block.", + "Echocardiography revealed grade 1 diastolic dysfunction.", + "Echocardiography showed severe dilation of the main right ventricle.", + "Echocardiography showed severely reduced right ventricular systolic function.", + "Chest X-ray showed cardiomegaly.", + "Chest X-ray showed a prominent pulmonary trunk.", + "Cardiac catheterization revealed a mean pulmonary artery pressure of 43 mmHg.", + "Cardiac catheterization revealed a pulmonary vascular resistance of 14.3 Wood units.", + "The pulmonary hypertension was not reversible with the adenosine challenge.", + "The patient was started on high dose prednisone.", + "The patient was started on lasix.", + "The patient was started on losartan.", + "Adderall was discontinued as a possible contributing factor to PAH.", + "The patient responded well to the treatment.", + "The patient had improvement in symptoms such as oedema.", + "The patient had improvement in symptoms such as shortness of breath.", + "Over the next 3 months, a gradual normalization of proteinuria was observed.", + "Over the next 3 months, a gradual normalization of hypoalbuminemia was observed.", + "Over the next 3 months, a gradual normalization of the urine protein-to-creatinine ratio was observed." + ], + "summary": "In this report, the authors present an interesting case of a 43-year-old male, diagnosed with nephrotic syndrome secondary to minimal change disease, as well as currently presenting with PAH secondary to amphetamine.", + "summary_subclaims": [ + "The patient is a 43-year-old male.", + "The patient was diagnosed with nephrotic syndrome.", + "The nephrotic syndrome is secondary to minimal change disease.", + "The patient is currently presenting with PAH.", + "The PAH is secondary to amphetamine." + ] + }, + { + "id": "multiclinsum_test_2145_en.txt", + "fulltext": "The patient is a previously healthy 44-year-old man who presented with a painless enlarging mass in his left groin. He was observed initially for three months and eventually was referred for an excisional lymph node biopsy. Histologic examination showed a high-grade malignant neoplasm that was diagnosed as BPDCN. He was then referred to our institution. BM evaluation included a trephine biopsy and aspiration. There was no evidence of BPDCN in BM by morphology or immunohistochemistry. Flow cytometry was also negative for BPDCN in BM. However, conventional cytogenetic analysis performed on the BM aspirate sample showed karyotypic aberrations involving chromosomes 12 and 22, which were further characterized by fluorescence in situ hybridization (FISH) analysis (see details below). The patient was treated with a hyper-CVAD-Bortezomib regimen (hyperfractioned cyclophosphamide, vincristine, doxorubicin, dexamethasone alternating with high dose of methotrexate and cytarabine, plus bortezomib) regimen. He also received prophylactic intrathecal chemotherapy with methotrexate for 3 cycles and achieved a complete remission.", + "fulltext_subclaims": [ + "The patient is a previously healthy 44-year-old man.", + "He presented with a painless enlarging mass in his left groin.", + "He was observed initially for three months.", + "He was referred for an excisional lymph node biopsy.", + "Histologic examination showed a high-grade malignant neoplasm.", + "The neoplasm was diagnosed as BPDCN.", + "He was referred to our institution.", + "BM evaluation included a trephine biopsy and aspiration.", + "There was no evidence of BPDCN in BM by morphology or immunohistochemistry.", + "Flow cytometry was also negative for BPDCN in BM.", + "Conventional cytogenetic analysis performed on the BM aspirate sample showed karyotypic aberrations involving chromosomes 12 and 22.", + "The karyotypic aberrations were further characterized by fluorescence in situ hybridization.", + "The patient was treated with a hyper-CVAD-Bortezomib regimen.", + "The regimen included hyperfractioned cyclophosphamide, vincristine, doxorubicin, dexamethasone alternating with high dose of methotrexate and cytarabine, plus bortezomib.", + "He received prophylactic intrathecal chemotherapy with methotrexate for 3 cycles.", + "He achieved a complete remission." + ], + "summary": "In this report, we present a case of BPDCN with complicated chromosomal abnormalities involving chromosomes 12 and 22 and resulting in a simultaneous partial deletion of ETV6 and EWSR1. Notably, these aberrations were identified in bone marrow myeloid precursors in the absence of bone marrow involvement by BPDCN.", + "summary_subclaims": [ + "The case involves BPDCN with complicated chromosomal abnormalities.", + "The chromosomal abnormalities involve chromosomes 12 and 22.", + "The abnormalities resulted in a simultaneous partial deletion of ETV6 and EWSR1.", + "The aberrations were identified in bone marrow myeloid precursors.", + "There was no bone marrow involvement by BPDCN." + ] + }, + { + "id": "multiclinsum_test_1271_en.txt", + "fulltext": "Our patient is a 39-year-old Caucasian woman, with family history of hypertension and with hypertension herself since her late 20s, well controlled on amlodipine 10 mg once daily. In addition, her non-cardiac history includes keratosis follicularis (Darier disease), with frequent skin infections, treated empirically with minocycline. She suffered an acute aortic dissection type A 3.5 years ago and underwent surgery for aorta repair with a 34 mm Dacron graft. Her immediate post-operative course was uncomplicated and she was discharged a week later.\nTwenty-five days after surgery she presented to our institution with fever; clinical examination was remarkable for red keratotic papules of forehead, neck, and presternal area, in addition, fine left lower lobe crackles were present. Her fundi were normal. Leucocytosis with granulocytosis was observed; renal and liver functions tests were within normal limits. A chest X-ray revealed left lower lobe pneumonia with ipsilateral pleural effusion and an echocardiogram showed moderate pericardial effusion. Her blood cultures and Bronchoalveolar Lavage were positive for staph hominis and ciprofloxacin 500 mg BID was administered for 4 weeks. One week after completion of antibiotic therapy, she was re-admitted with fever and malaise and had negative blood cultures, but PCR was positive for Coagulase Negative Staphylococci and ciprofloxacin 500 mg BID and vancomycin 1 g IV BID were given for 4 weeks. With the suspicion of graft infection,—relapse of fever, despite previous appropriate antibiotic treatment, soon after urgent surgery, in a patient with skin disease—an 18F-fluorodeoxyglucose Positron Emission Tomography Computerized Tomography (FDG PET-CT scan) was done and showed uptake in the aortic graft . Daptomycin 500 mg IV OD was initiated for another 6 weeks and fever and inflammatory markers subsided. During a 6-month period, however, multiple relapses occurred, each time following completion of antibiotics and a subsequent FDG PET-CT scan showed increased metabolic activity in the graft, pleura, pericardium, sternum and substernal fat, lymph nodes and spleen . The decision to re-operate was then made; the infected Dacron graft was removed and a bovine pericardium graft was inserted, 9 months after the first operation. Methicillin Resistant Staphylococcus epidermidis (MRSE) was isolated in graft’s cultures and IV daptomycin was administered for 6 weeks post-operatively. Patient remained asymptomatic at 22 months follow-up after second surgery and 18F-FDG PET/CT scan showed significant reduction in FDG uptake.", + "fulltext_subclaims": [ + "The patient is a 39-year-old Caucasian woman.", + "She has a family history of hypertension.", + "She has had hypertension since her late 20s.", + "Her hypertension is well controlled on amlodipine 10 mg once daily.", + "She has keratosis follicularis (Darier disease).", + "She has frequent skin infections.", + "She was treated empirically with minocycline.", + "She suffered an acute aortic dissection type A 3.5 years ago.", + "She underwent surgery for aorta repair with a 34 mm Dacron graft.", + "Her immediate post-operative course was uncomplicated.", + "She was discharged a week after surgery.", + "Twenty-five days after surgery she presented with fever.", + "Clinical examination showed red keratotic papules of forehead, neck, and presternal area.", + "Fine left lower lobe crackles were present.", + "Her fundi were normal.", + "Leucocytosis with granulocytosis was observed.", + "Renal and liver function tests were within normal limits.", + "A chest X-ray revealed left lower lobe pneumonia with ipsilateral pleural effusion.", + "An echocardiogram showed moderate pericardial effusion.", + "Her blood cultures and bronchoalveolar lavage were positive for staph hominis.", + "Ciprofloxacin 500 mg BID was administered for 4 weeks.", + "One week after completion of antibiotic therapy, she was re-admitted with fever and malaise.", + "Her blood cultures were negative.", + "PCR was positive for Coagulase Negative Staphylococci.", + "Ciprofloxacin 500 mg BID and vancomycin 1 g IV BID were given for 4 weeks.", + "With the suspicion of graft infection, an 18F-fluorodeoxyglucose Positron Emission Tomography Computerized Tomography (FDG PET-CT scan) was done.", + "The FDG PET-CT scan showed uptake in the aortic graft.", + "Daptomycin 500 mg IV OD was initiated for another 6 weeks.", + "Fever and inflammatory markers subsided.", + "During a 6-month period, multiple relapses occurred.", + "Each relapse occurred after completion of antibiotics.", + "A subsequent FDG PET-CT scan showed increased metabolic activity in the graft, pleura, pericardium, sternum and substernal fat, lymph nodes and spleen.", + "The decision to re-operate was made.", + "The infected Dacron graft was removed.", + "A bovine pericardium graft was inserted.", + "The second surgery was 9 months after the first operation.", + "Methicillin Resistant Staphylococcus epidermidis (MRSE) was isolated in graft’s cultures.", + "IV daptomycin was administered for 6 weeks post-operatively.", + "The patient remained asymptomatic at 22 months follow-up after second surgery.", + "An 18F-FDG PET/CT scan showed significant reduction in FDG uptake." + ], + "summary": "A 39-year-old woman with hypertension and Darier disease suffered an acute type A aortic dissection, requiring emergency operation with a Dacron graft. Twenty-five days post-operatively, she developed pneumonia and staph hominis was isolated in blood cultures and Bronchoalveolar Lavage. Following completion of antibiotics, multiple relapses occurred during a 6-month period, each time treated with appropriate antibiotic therapy. An 18F-fluorodeoxyglucose positron emission tomography computerized tomography showed persistent graft uptake and re-operation was performed. At 22 months of follow-up, the patient remains asymptomatic and the 18F-FDG PET/CT shows significant reduction in FDG uptake.", + "summary_subclaims": [ + "The patient is a 39-year-old woman.", + "The patient has hypertension.", + "The patient has Darier disease.", + "The patient suffered an acute type A aortic dissection.", + "The patient required emergency operation with a Dacron graft.", + "Twenty-five days post-operatively, she developed pneumonia.", + "Staph hominis was isolated in blood cultures.", + "Staph hominis was isolated in Bronchoalveolar Lavage.", + "Multiple relapses occurred during a 6-month period.", + "Each relapse was treated with appropriate antibiotic therapy.", + "An 18F-fluorodeoxyglucose positron emission tomography computerized tomography showed persistent graft uptake.", + "Re-operation was performed.", + "At 22 months of follow-up, the patient remains asymptomatic.", + "The 18F-FDG PET/CT shows significant reduction in FDG uptake." + ] + }, + { + "id": "multiclinsum_test_405_en.txt", + "fulltext": "A 43-year-old man with mild type 2 diabetes mellitus visited the hospital where he received his medications for diabetes mellitus, owing to persistent dizziness, anorexia and general fatigue for 1 month before the consultation. He showed significant weight loss of 15 kg during that 1 month. Approximately 2 weeks before the emergence of his clinical symptoms, he walked around a cave where he encountered a lot of bird droppings and feathers. Since abdominal CT revealed bilateral adrenal masses, he was introduced to a larger hospital for advanced examination. On admission, physical examination revealed a height of 167 cm and a weight of 62 kg. The remainder of the examination findings were normal without signs of meningitis. Laboratory data included white blood cell count of 7,390/μL with 61.7% neutrophils, 23.9% lymphocytes, 2.4% eosinophils, 0.5% basophils and 9.4% monocytes, hemoglobin of 12.6 g/dL and platelet count of 313,000/μL. Although the serum sodium level (133 mEq/L) was slightly decreased, the serum levels of potassium, chloride, creatinine and fasting glucose were normal. The HbA1c was 6.2%. The level of γ-gamma glutamyl transpeptidase was elevated to 116 U/L without increased levels of aspartate aminotransferase, alanine aminotransferase and alkaline phosphatase. The serum C-reactive protein level was elevated (5.04 mg/dL). On endocrinological examination, low basal serum cortisol (2.3 μg/dL; normal: 4.0-18.3) with high serum adrenocorticotropic hormone (ACTH) (843 pg/mL; normal: 7.2-63.3) was observed, indicating primary adrenal insufficiency. In addition to the low blood levels of aldosterone (28.5 pg/mL; normal: 38.9-307) and dehydroepiandrosterone sulfate (55 μg/dL; normal: 70-495) synthesized and released by the adrenal cortex, the 24-hour urine adrenaline (1.6 μg/day: normal: 3.4-26.9) and epinephrine (< 0.01 mg/day; normal: 0.04-0.19) levels were markedly reduced, indicating that the adrenal medulla was also devastated. Rapid ACTH (Cortrosyn) stimulation revealed the absence of a serum cortisol response (baselines of 1.1 μg/dL to 1.1 μg/dL and 1.1 μg/dL at 30 and 60 minutes after the ACTH challenge, respectively). Primary adrenal insufficiency was diagnosed and a regimen of oral hydrocortisone (20 mg/day) was prescribed.\nContrast-enhanced abdominal CT showed bilateral adrenal masses (right: 5.2 × 2.7 cm; left: 3.7 × 3.6 cm) . The differential diagnosis of the adrenal masses included metastatic carcinoma, tuberculosis, fungal infections, bilateral adrenal hyperplasia and sarcoidosis. An intensive whole-body examination failed to detect a primary lesion for malignancy. The QuantiFERON-TB test and serum human immunodeficiency virus (HIV) antibody enzyme immunoassay were negative. Re-examination of the abdominal CT at 1 month after admission revealed a liver abscess that was thought to be an invasion from the right adrenal mass . Whole-body 18 F-FDG PET showed intense uptake by the bilateral adrenal glands and liver.\nTo make a diagnosis, a fine-needle aspiration biopsy of the liver mass was performed. The pathological diagnosis of the liver abscess showed multiple foci of necrotic and degenerative cells with infiltration of neutrophils. No malignant cells or epithelioid granulomas were observed in this specimen. Alcian blue staining demonstrated the presence of 5-μm spherical yeast-like organisms, such as Cryptococcus spp., interspersed within the foci. Since the serum cryptococcal antigen titer was 1:256, cryptococcosis of the bilateral adrenal glands and liver was diagnosed. A lumbar puncture revealed clear cerebrospinal fluid with a white blood cell count of 1/μL, normal levels of protein and glucose and negative cryptococcal antigen titer.\nAfter 4 months of fluconazole treatment at a daily dose of 400 mg, the size of the liver abscess was reduced, but no significant changes were observed in the bilateral adrenal masses and the serum cryptococcal antigen titer was still elevated at 1:128. Additional treatment with liposomal amphotericin B at 150 mg daily for 6 weeks (a cumulative dose of 6.3 g) was not effective.\nSince it was conceivable that the bilateral adrenal glands were the apparent foci of the persistent fungemia, the patient was referred to our hospital and a laparoscopic left adrenalectomy was performed to control the cryptococcosis. Resection of the right adrenal mass was not executed as the first operation to avoid injury to the adjacent liver. The size of the resected mass was 5 × 4 cm . Histological analysis revealed that the adrenal tissue was widely replaced by massively necrotizing granulomas and fibrous tissue. Many fungi structures, similar to Cryptococcus spp. cells were detected by PAS and Grocott staining .\nFluconazole therapy was continued after the adrenalectomy. At 3 months after the adrenalectomy, a significant size reduction of the right adrenal mass was observed by abdominal CT . The serum cryptococcal antigen titer also decreased to 1:16 at 2 months after the adrenalectomy, and 1:4 at 5 months after the operation. There were no signs of relapse in imaging analyses and the serum cryptococcal antigen titer remained at 1:4 for the subsequent 9 months .", + "fulltext_subclaims": [ + "The patient is a 43-year-old man with mild type 2 diabetes mellitus.", + "He had persistent dizziness, anorexia, and general fatigue for 1 month before the consultation.", + "He had significant weight loss of 15 kg during that 1 month.", + "Approximately 2 weeks before the emergence of his clinical symptoms, he walked around a cave where he encountered a lot of bird droppings and feathers.", + "Abdominal CT revealed bilateral adrenal masses.", + "On admission, physical examination revealed a height of 167 cm and a weight of 62 kg.", + "The remainder of the examination findings were normal without signs of meningitis.", + "The white blood cell count was 7,390/μL.", + "The neutrophil percentage was 61.7%.", + "The lymphocyte percentage was 23.9%.", + "The eosinophil percentage was 2.4%.", + "The basophil percentage was 0.5%.", + "The monocyte percentage was 9.4%.", + "The hemoglobin was 12.6 g/dL.", + "The platelet count was 313,000/μL.", + "The serum sodium level was 133 mEq/L.", + "The serum potassium, chloride, creatinine, and fasting glucose levels were normal.", + "The HbA1c was 6.2%.", + "The γ-gamma glutamyl transpeptidase level was elevated to 116 U/L.", + "The serum C-reactive protein level was elevated to 5.04 mg/dL.", + "The basal serum cortisol was 2.3 μg/dL.", + "The serum adrenocorticotropic hormone (ACTH) was 843 pg/mL.", + "The aldosterone level was 28.5 pg/mL.", + "The dehydroepiandrosterone sulfate level was 55 μg/dL.", + "The 24-hour urine adrenaline level was 1.6 μg/day.", + "The 24-hour urine epinephrine level was < 0.01 mg/day.", + "Rapid ACTH (Cortrosyn) stimulation revealed the absence of a serum cortisol response.", + "Primary adrenal insufficiency was diagnosed.", + "A regimen of oral hydrocortisone (20 mg/day) was prescribed.", + "Contrast-enhanced abdominal CT showed bilateral adrenal masses (right: 5.2 × 2.7 cm; left: 3.7 × 3.6 cm).", + "The differential diagnosis of the adrenal masses included metastatic carcinoma, tuberculosis, fungal infections, bilateral adrenal hyperplasia, and sarcoidosis.", + "An intensive whole-body examination failed to detect a primary lesion for malignancy.", + "The QuantiFERON-TB test was negative.", + "The serum human immunodeficiency virus (HIV) antibody enzyme immunoassay was negative.", + "Re-examination of the abdominal CT at 1 month after admission revealed a liver abscess.", + "The liver abscess was thought to be an invasion from the right adrenal mass.", + "Whole-body 18 F-FDG PET showed intense uptake by the bilateral adrenal glands and liver.", + "A fine-needle aspiration biopsy of the liver mass was performed.", + "The pathological diagnosis of the liver abscess showed multiple foci of necrotic and degenerative cells with infiltration of neutrophils.", + "No malignant cells or epithelioid granulomas were observed in this specimen.", + "Alcian blue staining demonstrated the presence of 5-μm spherical yeast-like organisms, such as Cryptococcus spp., interspersed within the foci.", + "The serum cryptococcal antigen titer was 1:256.", + "Cryptococcosis of the bilateral adrenal glands and liver was diagnosed.", + "A lumbar puncture revealed clear cerebrospinal fluid with a white blood cell count of 1/μL.", + "The cerebrospinal fluid protein and glucose levels were normal.", + "The cerebrospinal fluid cryptococcal antigen titer was negative.", + "After 4 months of fluconazole treatment at a daily dose of 400 mg, the size of the liver abscess was reduced.", + "No significant changes were observed in the bilateral adrenal masses.", + "The serum cryptococcal antigen titer was still elevated at 1:128.", + "Additional treatment with liposomal amphotericin B at 150 mg daily for 6 weeks (a cumulative dose of 6.3 g) was not effective.", + "A laparoscopic left adrenalectomy was performed.", + "Resection of the right adrenal mass was not executed as the first operation.", + "The size of the resected mass was 5 × 4 cm.", + "Histological analysis revealed that the adrenal tissue was widely replaced by massively necrotizing granulomas and fibrous tissue.", + "Many fungi structures, similar to Cryptococcus spp. cells, were detected by PAS and Grocott staining.", + "Fluconazole therapy was continued after the adrenalectomy.", + "At 3 months after the adrenalectomy, a significant size reduction of the right adrenal mass was observed by abdominal CT.", + "The serum cryptococcal antigen titer decreased to 1:16 at 2 months after the adrenalectomy.", + "The serum cryptococcal antigen titer decreased to 1:4 at 5 months after the adrenalectomy.", + "There were no signs of relapse in imaging analyses.", + "The serum cryptococcal antigen titer remained at 1:4 for the subsequent 9 months." + ], + "summary": "We present a case of primary adrenal insufficiency with bilateral adrenal masses and liver invasion in a 43-year-old man with mild type 2 diabetes mellitus. Cryptococcosis was diagnosed by fine-needle aspiration biopsy of the liver mass. The serum cryptococcal antigen titer was elevated to 1:256. After 6 months of antifungal therapy with fluconazole and amphotericin B, the size of the liver mass was decreased, but no significant changes were observed in the bilateral adrenal masses and the serum cryptococcal antigen titer remained elevated at 1:128. To control the cryptococcosis, a laparoscopic left adrenalectomy was performed, followed by antifungal therapy. After the unilateral adrenalectomy, the size of the remaining right adrenal mass was reduced and the serum cryptococcal antigen titer declined to 1:4.", + "summary_subclaims": [ + "The patient is a 43-year-old man.", + "The patient had mild type 2 diabetes mellitus.", + "The patient had bilateral adrenal masses.", + "The patient had liver invasion.", + "Cryptococcosis was diagnosed by fine-needle aspiration biopsy of the liver mass.", + "The serum cryptococcal antigen titer was elevated to 1:256.", + "After 6 months of antifungal therapy with fluconazole and amphotericin B, the size of the liver mass was decreased.", + "No significant changes were observed in the bilateral adrenal masses after 6 months of antifungal therapy.", + "The serum cryptococcal antigen titer remained elevated at 1:128 after 6 months of antifungal therapy.", + "A laparoscopic left adrenalectomy was performed.", + "After the unilateral adrenalectomy, the size of the remaining right adrenal mass was reduced.", + "After the unilateral adrenalectomy, the serum cryptococcal antigen titer declined to 1:4." + ] + }, + { + "id": "multiclinsum_test_1087_en.txt", + "fulltext": "A 62-year-old man with SIT, intestinal malrotation, and type 2 diabetes underwent gastroduodenal endoscopy for investigation of epigastric discomfort. A 5-cm type 2 tumor was found at the cardia side of the EGJ . A biopsy confirmed moderately differentiated adenocarcinoma, and the patient was diagnosed with Siewert type II EGJ cancer with 2.5 cm of esophageal involvement. Computed tomography (CT) revealed SIT, intestinal malrotation, multiple spleens, and irregular thickening of the gastric wall. No swollen lymph nodes (LNs) or distant metastases were observed . The patient was diagnosed with EGJ cancer (T3N0M0 Stage IIA according to the 8th edition of the Union for International Cancer Control (UICC)-TNM classification). In addition, three-dimensional (3D) reconstruction of a CT angiogram showed that the common hepatic artery was absent, the proper hepatic artery was derived from the superior mesenteric artery through the gastroduodenal artery, and an accessory left hepatic artery (ALHA) arose from the left gastric artery (LGA) . We planned a robot-assisted transhiatal lower esophagectomy and proximal gastrectomy with D2 LN dissection, including lower mediastinal lymphadenectomy.\nThe patient was placed in a spinal position and the port placement mirrored our conventional settings . The patient’s position was changed in a reverse Trendelenburg position with 15 degrees before the da Vinci Xi Surgical System (Intuitive Surgical, Inc., Sunnyvale, CA, USA) rolled in. The first and second arms were placed on the right side of the abdomen for Cadiere forceps and Maryland bipolar forceps, respectively. The fourth arm was placed on the left side of the abdomen for fenestrated bipolar forceps. The assistant port was also placed on the left side of the abdomen. Robotic bipolar vessel-sealing tools were attached to the second arm or fourth arm depending on the surgical site.\nAfter laparoscopic inspections, the lesser omentum was opened and suprapancreatic LN dissection was started. The two left gastric veins draining into the splenic vein (SPV) were clipped and cut . The LGA branched an ALHA and was itself divided into three branches. The branches of the LGA were clipped and cut, preserving the root itself . Station 11p and 11d LNs were dissected, tracing the splenic artery behind the SPV. Next, the greater omentum was dissected from the middle part toward the lower pole of the spleen, and station 4sa LNs were dissected. The rest of the suprapancreatic LN dissection was then completed toward the crus of the diaphragm. On the right side of the patient, the left gastroepiploic vessels and the short gastric vessels were divided by a sealing device attached to the second arm or fourth arm depending on the working angle. Transhiatal lower mediastinal lymphadenectomy was then performed (station 110 LNs) . We decided to secure a safety margin of at least 2 cm from the tumor. It was 4 cm from the angle of His based on preoperative esophagogastric fluoroscopy, where was transected with an EndoWrist Stapler (Intuitive Surgical, Inc., Sunnyvale, CA, USA) . The stomach was transected at the upper one-third level. The resected specimen was extracted through an umbilical incision.\nAfter checking the margin of softy on the back table, esophagogastrostomy was performed according to the side overlap with fundoplication by Yamashita (SOFY) method as follows . The central apex and left edges of the remnant stomach stump were fixated by suture to the crus of the diaphragm. The esophagus was pulled caudally, and the most proximal dorsal side of the esophagus was fixated by suture to the apex of the remnant stomach stump to prevent the esophagus from being pulled into the mediastinum. Small incisions for a stapler were made in the center of the anterior gastric wall and left side of the esophageal stump, respectively. A 45-mm EndoWrist Stapler was inserted into both holes. The esophagus was then rotated 45 degrees clockwise and stapled to suture the left wall of the esophagus to the stomach. The entry hole was closed using 3–0 absorbable barbed sutures. The esophagus was rotated back 45 degrees, and the posterior wall was placed parallel to the stomach wall. The right side of the esophagus was fixated by suture, completing the valvuloplasty .\nThe surgical time was 296 min, and the amount of blood loss was small. Histopathological diagnosis revealed a Siewert type II tumor measuring 50 × 37 mm in diameter and moderately differentiated adenocarcinoma with subserosal invasion . Three metastatic LNs were present around the cardia. The final stage was pT3N2 pStage IIIB according to the 8th edition of the UICC-TNM classification. The patient had an uneventful postoperative course and was discharged 11 days after surgery.", + "fulltext_subclaims": [ + "The patient is a 62-year-old man.", + "The patient has short intestinal tract (SIT).", + "The patient has intestinal malrotation.", + "The patient has type 2 diabetes.", + "A gastroduodenal endoscopy was performed.", + "The endoscopy was for investigation of epigastric discomfort.", + "A 5-cm type 2 tumor was found at the cardia side of the EGJ.", + "A biopsy confirmed moderately differentiated adenocarcinoma.", + "The patient was diagnosed with Siewert type II EGJ cancer.", + "The tumor had 2.5 cm of esophageal involvement.", + "Computed tomography (CT) revealed SIT.", + "Computed tomography (CT) revealed intestinal malrotation.", + "Computed tomography (CT) revealed multiple spleens.", + "Computed tomography (CT) showed irregular thickening of the gastric wall.", + "No swollen lymph nodes (LNs) were observed.", + "No distant metastases were observed.", + "The patient was diagnosed with EGJ cancer T3N0M0 Stage IIA.", + "The diagnosis was based on the 8th edition of the UICC-TNM classification.", + "Three-dimensional (3D) reconstruction showed the common hepatic artery was absent.", + "The proper hepatic artery was derived from the superior mesenteric artery through the gastroduodenal artery.", + "An accessory left hepatic artery (ALHA) arose from the left gastric artery (LGA).", + "A robot-assisted transhiatal lower esophagectomy was planned.", + "A proximal gastrectomy was planned.", + "A D2 LN dissection was planned.", + "A lower mediastinal lymphadenectomy was planned.", + "The patient was placed in a spinal position.", + "The port placement mirrored conventional settings.", + "The patient’s position was changed to a reverse Trendelenburg position with 15 degrees.", + "The da Vinci Xi Surgical System was used.", + "The first and second arms were placed on the right side of the abdomen.", + "The fourth arm was placed on the left side of the abdomen.", + "The assistant port was placed on the left side of the abdomen.", + "Robotic bipolar vessel-sealing tools were attached to the second arm or fourth arm.", + "The lesser omentum was opened.", + "Suprapancreatic LN dissection was started.", + "The two left gastric veins draining into the splenic vein were clipped and cut.", + "The LGA branched an ALHA.", + "The LGA was divided into three branches.", + "The branches of the LGA were clipped and cut, preserving the root itself.", + "Station 11p and 11d LNs were dissected.", + "The greater omentum was dissected from the middle part toward the lower pole of the spleen.", + "Station 4sa LNs were dissected.", + "The rest of the suprapancreatic LN dissection was completed toward the crus of the diaphragm.", + "The left gastroepiploic vessels and the short gastric vessels were divided by a sealing device.", + "Transhiatal lower mediastinal lymphadenectomy was performed (station 110 LNs).", + "A safety margin of at least 2 cm from the tumor was secured.", + "The tumor was 4 cm from the angle of His based on preoperative esophagogastric fluoroscopy.", + "The stomach was transected at the upper one-third level.", + "The resected specimen was extracted through an umbilical incision.", + "The margin was checked on the back table.", + "Esophagogastrostomy was performed according to the SOFY method.", + "The central apex and left edges of the remnant stomach stump were fixated by suture to the crus of the diaphragm.", + "The esophagus was pulled caudally.", + "The most proximal dorsal side of the esophagus was fixated by suture to the apex of the remnant stomach stump.", + "Small incisions for a stapler were made in the center of the anterior gastric wall and left side of the esophageal stump.", + "A 45-mm EndoWrist Stapler was inserted into both holes.", + "The esophagus was rotated 45 degrees clockwise and stapled to suture the left wall of the esophagus to the stomach.", + "The entry hole was closed using 3–0 absorbable barbed sutures.", + "The esophagus was rotated back 45 degrees.", + "The posterior wall was placed parallel to the stomach wall.", + "The right side of the esophagus was fixated by suture, completing the valvuloplasty.", + "The surgical time was 296 min.", + "The amount of blood loss was small.", + "Histopathological diagnosis revealed a Siewert type II tumor measuring 50 × 37 mm in diameter.", + "The tumor was moderately differentiated adenocarcinoma with subserosal invasion.", + "Three metastatic LNs were present around the cardia.", + "The final stage was pT3N2 pStage IIIB.", + "The diagnosis was based on the 8th edition of the UICC-TNM classification.", + "The patient had an uneventful postoperative course.", + "The patient was discharged 11 days after surgery." + ], + "summary": "A 62-year-old man with SIT and intestinal malrotation was diagnosed with T3N0M0 Stage IIA EGJ cancer. Three-dimensional reconstruction of a computed tomography angiogram showed that the common hepatic artery was absent, the proper hepatic artery was derived from the superior mesenteric artery through the gastroduodenal artery, and an accessary left hepatic artery arose from the left gastric artery. The patient underwent robot-assisted transhiatal lower esophagectomy and proximal gastrectomy with D2 lymph node dissection, including lower mediastinal lymphadenectomy. Intraoperative examination revealed minor vascular abnormalities, including three branches of the left gastric artery and two left gastric veins, that had not been recognized preoperatively. The surgery was performed safely, and the patient had an uneventful postoperative course.", + "summary_subclaims": [ + "The patient is a 62-year-old man.", + "The patient has short bowel syndrome.", + "The patient has intestinal malrotation.", + "The patient was diagnosed with T3N0M0 Stage IIA EGJ cancer.", + "Three-dimensional reconstruction of a computed tomography angiogram showed that the common hepatic artery was absent.", + "The proper hepatic artery was derived from the superior mesenteric artery through the gastroduodenal artery.", + "An accessory left hepatic artery arose from the left gastric artery.", + "The patient underwent robot-assisted transhiatal lower esophagectomy.", + "The patient underwent proximal gastrectomy.", + "The patient underwent D2 lymph node dissection.", + "The patient underwent lower mediastinal lymphadenectomy.", + "Intraoperative examination revealed three branches of the left gastric artery.", + "Intraoperative examination revealed two left gastric veins.", + "The surgery was performed safely.", + "The patient had an uneventful postoperative course." + ] + }, + { + "id": "multiclinsum_test_2881_en.txt", + "fulltext": "A 45-year-old black Ethiopian man presented to our COVID-19 isolation center with intermittent dry cough and dyspnea for 05 days associated with new onset mild holocranial headache, low grade fever, myalgia and arthralgia. One day after his admission to the center, he started to develop blurring of vision associated with worsening of the headache. He also had one episode of projectile vomiting of ingested matter. He had no known chronic medical illnesses and no history of drug intake including vitamin A derivatives and tetracycline before the onset of the aforementioned symptoms.\nPhysical examination revealed blood pressure of 127/91 mmHg, pulse rate of 98 beats per minute, respiratory rate of 28 breaths per minute, oxygen saturation of 86% without oxygen and 92% with 2 L/min intranasal oxygen and body mass index (BMI) of 22.8 kg/m2. He had bilateral coarse crepitation over his lower lung fields. He was conscious with Glasgow Coma Scale (GCS) of 15/15 and all the cranial nerves were intact with normal visual acuity (20/20) and visual fields. Meningeal signs were negative and there were no sensory or motor deficits.\nUpon investigations, he tested positive for SARS-CoV-2 with nasopharyngeal swab polymerase chain reaction (PCR) and he had mild leukocytosis with left shift and lymphopenia. Lumbar puncture was performed after doing brain magnetic resonance imaging (MRI) and cerebrospinal fluid (CSF) opening pressure appeared high, though it was not measured. The other laboratory results were non-remarkable .\nBrain MRI revealed prominent subarachnoid space around the optic nerves and bilateral papilledema, but didn’t show any mass lesion, hemorrhage, or cerebrovascular lesion and brain magnetic resonance venography (MRV) was normal . Chest x-ray revealed bilateral ground glass opacities mainly in the middle and lower lung zones with right side blunted costophrenic angle which was suggestive of COVID-19 pneumonia .\nThe patient initially received supportive therapies for severe COVID-19 infection including IV antibiotics, dexamethasone 6 mg IV daily, intranasal oxygen, and prophylactic dose of unfractionated heparin. Acetazolamide 250 mg three times daily was added after establishing the diagnosis of idiopathic intracranial hypertension. He was then followed clinically if he could have an indication for ventriculoperitoneal shunt but his headache and blurring of vision improved and he did not require any surgical intervention. He was finally discharged after 10 days of inpatient supportive medical treatment with significant improvement except occasional cough and mild headache. He did not have any complaint upon reevaluation on the second week of discharge and the acetazolamide was discontinued. He was then doing well throughout his follow up over 6 months in the outpatient department.", + "fulltext_subclaims": [ + "The patient is a 45-year-old black Ethiopian man.", + "He presented to the isolation center with intermittent dry cough and dyspnea for 05 days.", + "He had new onset mild holocranial headache.", + "He had low grade fever.", + "He had myalgia and arthralgia.", + "One day after admission, he developed blurring of vision.", + "He had one episode of projectile vomiting of ingested matter.", + "He had no known chronic medical illnesses.", + "He had no history of drug intake including vitamin A derivatives and tetracycline.", + "Physical examination revealed oxygen saturation of 86% without oxygen.", + "Physical examination revealed oxygen saturation of 92% with 2 L/min intranasal oxygen.", + "He had bilateral coarse crepitation over his lower lung fields.", + "He was conscious with GCS of 15/15.", + "All cranial nerves were intact.", + "Visual acuity was 20/20.", + "Meningeal signs were negative.", + "He tested positive for SARS-CoV-2 with nasopharyngeal swab PCR.", + "He had mild leukocytosis with left shift.", + "He had lymphopenia.", + "Lumbar puncture was performed after brain MRI.", + "CSF opening pressure appeared high, though it was not measured.", + "Brain MRI revealed prominent subarachnoid space around the optic nerves.", + "Brain MRI revealed bilateral papilledema.", + "Brain MRI did not show any mass lesion.", + "Brain MRI did not show any hemorrhage.", + "Brain MRI did not show any cerebrovascular lesion.", + "Brain MRV was normal.", + "Chest x-ray revealed bilateral ground glass opacities mainly in the middle and lower lung zones.", + "The right side blunted costophrenic angle was suggestive of COVID-19 pneumonia.", + "The patient received IV antibiotics.", + "The patient received dexamethasone 6 mg IV daily.", + "The patient received intranasal oxygen.", + "The patient received prophylactic dose of unfractionated heparin.", + "Acetazolamide 250 mg three times daily was added after establishing the diagnosis of idiopathic intracranial hypertension.", + "He was followed clinically for possible ventriculoperitoneal shunt.", + "His headache and blurring of vision improved.", + "He did not require any surgical intervention.", + "He was discharged after 10 days of inpatient supportive medical treatment.", + "He had occasional cough and mild headache at discharge.", + "He did not have any complaint upon reevaluation on the second week of discharge.", + "Acetazolamide was discontinued.", + "He was doing well throughout his follow up over 6 months." + ], + "summary": "A 45-year-old black man presented with dyspnea, cough, fever and headache for 05 days followed by blurring of vision associated with worsening of the headache. Physical examination was significant for tachypnea and oxygen desaturation and there were no abnormal neurologic findings. He tested positive for SARS-CoV-2 with nasopharyngeal swab PCR. His CSF opening pressure appeared high with normal CSF analysis and brain magnetic resonance imaging (MRI) revealed prominent subarachnoid space around the optic nerves and bilateral papilledema. He had significant improvement with medical therapy alone.", + "summary_subclaims": [ + "The patient is a 45-year-old black man.", + "He presented with dyspnea, cough, fever, and headache for 05 days.", + "He had blurring of vision associated with worsening of the headache.", + "Physical examination was significant for tachypnea and oxygen desaturation.", + "There were no abnormal neurologic findings.", + "He tested positive for SARS-CoV-2 with nasopharyngeal swab PCR.", + "His CSF opening pressure appeared high.", + "His CSF analysis was normal.", + "Brain MRI revealed prominent subarachnoid space around the optic nerves.", + "Brain MRI showed bilateral papilledema.", + "He had significant improvement with medical therapy alone." + ] + }, + { + "id": "multiclinsum_test_1323_en.txt", + "fulltext": "A 14-year-10-month-old Han Taiwanese boy was presented to the pediatric out-patient clinic with a 3-month history of swelling of the left clavicle. His family history included his father’s ankylosing spondylitis and his mother’s uveitis. Physical examination revealed mild tenderness. An erythematous immobile firm mass measuring approximately 2 × 2.5 cm was found overlying the left proximal clavicle, immediately lateral to the SCJ. Furthermore, he expressed pain when the clinician pressed down on his right hip and bilateral ankles. We did not perform modified Schober test in our patient because LBP was not obvious and he was a suspicious case of JIA.\nThe patient had right hip arthritis and bilateral Achilles enthesitis. White blood cells count was 7.8 × 103 /μl, with 57% neutrophils and 32% lymphocytes (normal 3.9–10.6 × 103 /μl; neutrophils 42–74%; lymphocytes 20–56%). Biological inflammatory syndrome was observed with elevated erythrocyte sedimentation rate (33 mm/hr.; normal < 17 mm/hr) and C-reactive protein (22.6 mg/l; normal < 5 mg/L). Human leucocyte antigen (HLA) typing was positive for B27. Meanwhile, uric acid, rheumatoid factor, complements C3 and C4, anti-nuclear antibody, and anti-double-strand DNA were all normal. Furthermore, his renal and liver function, urine analysis, and muscle enzyme tests results were all normal.\nThe patient was initially treated empirically with oral augmentin (amoxicillin trihydrate + clavulanate potassium) and cefixime for 1 week, but did not respond favorably to the antibacterial treatment. We then treated the patient with naproxen (500 mg/day), a non-steroidal anti-inflammatory agent, and followed up. He claimed to have no history of trauma, fever, weight loss, loss of appetite, or intravenous drug abuse. We observed no skin lesions, such as acne or pustulosis palmaris et plantaris. Ultrasonography examination revealed a heterogeneous hypoechoic mass in the left SCJ (2 × 2.5 cm; Fig. ), and he was hospitalized to our pediatric ward. A computed tomography (CT) scan of the chest further indicated a turbid collection at the left SCJ . Bone window testing demonstrated irregular bone surfaces on the SCJ due to erosion, thus suggesting arthritis. Bone scintigraphy (MDP Tc-99 m) showed a focal area of increased uptake in the trochanteric region of the right proximal femur .\nWe performed a left SCJ arthrotomy on the patient, in which the clavicular head was excised and the left SCJ was debrided. Due to suspicion of malignant infiltration, we performed a histopathological examination, but no malignant cells were observed. A histologic examination of the tissue exposed acute and chronic inflammatory cell infiltration. Aspirated joint fluid cultures were negative; therefore, diagnosis of infection could be excluded.\nIn view of the historical facts and clinico-radiological correlation, including CT findings, we made a working diagnosis of JIA of the medial end of the left clavicle and initiated JIA therapy. The onset of arthritis and enthesitis after 6 years of age in a boy with HLA-B27 and a family history allowed him to meet the strict diagnostic criteria of the JIA subtype enthesitis-related arthritis. Given that SCJ disorders are rare, there is a probability that many clinicians do not have substantial training or experience injecting the SCJ with corticosteroids . This lack of experience, combined with a complex and frequently distorted SCJ anatomy, may result in poor injection accuracy. After surgical debridement, we prescribed a naproxen, sulfasalazine 1000 mg/day (4 months before prednisolone), and prednisolone 0.6 mg/kg/day combination for 4 weeks, followed by naproxen + oral methotrexate (MTX) 10 mg/m2/week + prednisolone for the next 3.5 months. Due to persistent high disease activity under salfasalazine, an alternate immunomodulator therapy MTX was selected. Etanercept has been indicated in the treatment of refractory JIA . He achieved full remission from the JIA with etanercept 25 mg twice a week within 4 weeks , and tolerated etanercept with good adherence. The patient reported complete cessation of pain and no longer needed analgesics, MTX, or prednisolone after 3 months. The aim of our treatment was to achieve maximum effectiveness and reduce the dosage of concomitant therapy because concomitant therapy substantially elevates the risk of side effects. A prospective study also revealed the effectiveness of etanercept therapy . Furthermore, 38.3% of patients with JIA treated with etanercept in combination with any medication could completely discontinue these concomitant drugs. Our patient continued the etanercept treatment 25 mg twice a week for at least 2 years to maintain a stable condition without any relapse during the outpatient follow-up. We repeated the ultrasound of the left clavicle, which revealed complete healing of the initial findings after 13 months of etanercept treatment.", + "fulltext_subclaims": [ + "The patient is a 14-year-10-month-old Han Taiwanese boy.", + "He had a 3-month history of swelling of the left clavicle.", + "His father has ankylosing spondylitis.", + "His mother has uveitis.", + "Physical examination revealed mild tenderness.", + "An erythematous immobile firm mass measuring approximately 2 × 2.5 cm was found overlying the left proximal clavicle, immediately lateral to the SCJ.", + "He expressed pain when the clinician pressed down on his right hip and bilateral ankles.", + "We did not perform modified Schober test in our patient because LBP was not obvious and he was a suspicious case of JIA.", + "The patient had right hip arthritis and bilateral Achilles enthesitis.", + "White blood cells count was 7.8 × 103 /μl.", + "Neutrophils were 57%.", + "Lymphocytes were 32%.", + "Erythrocyte sedimentation rate was 33 mm/hr.", + "C-reactive protein was 22.6 mg/l.", + "Human leucocyte antigen typing was positive for B27.", + "Uric acid, rheumatoid factor, complements C3 and C4, anti-nuclear antibody, and anti-double-strand DNA were all normal.", + "Renal and liver function, urine analysis, and muscle enzyme tests results were all normal.", + "The patient was initially treated empirically with oral augmentin and cefixime for 1 week.", + "He did not respond favorably to the antibacterial treatment.", + "He claimed to have no history of trauma, fever, weight loss, loss of appetite, or intravenous drug abuse.", + "Ultrasonography examination revealed a heterogeneous hypoechoic mass in the left SCJ.", + "A computed tomography scan of the chest indicated a turbid collection at the left SCJ.", + "Bone window testing demonstrated irregular bone surfaces on the SCJ due to erosion.", + "Bone scintigraphy showed a focal area of increased uptake in the trochanteric region of the right proximal femur.", + "We performed a left SCJ arthrotomy, in which the clavicular head was excised and the left SCJ was debrided.", + "Histopathological examination did not observe malignant cells.", + "A histologic examination of the tissue exposed acute and chronic inflammatory cell infiltration.", + "Aspirated joint fluid cultures were negative.", + "We made a working diagnosis of JIA of the medial end of the left clavicle.", + "The onset of arthritis and enthesitis after 6 years of age in a boy with HLA-B27 and a family history allowed him to meet the strict diagnostic criteria of the JIA subtype enthesitis-related arthritis.", + "After surgical debridement, we prescribed a naproxen, sulfasalazine 1000 mg/day, and prednisolone 0.6 mg/kg/day combination for 4 weeks.", + "Due to persistent high disease activity under sulfasalazine, an alternate immunomodulator therapy MTX was selected.", + "Etanercept has been indicated in the treatment of refractory JIA.", + "He achieved full remission from the JIA with etanercept 25 mg twice a week within 4 weeks.", + "The patient reported complete cessation of pain and no longer needed analgesics, MTX, or prednisolone after 3 months.", + "The aim of our treatment was to achieve maximum effectiveness and reduce the dosage of concomitant therapy.", + "A prospective study also revealed the effectiveness of etanercept therapy.", + "38.3% of patients with JIA treated with etanercept in combination with any medication could completely discontinue these concomitant drugs.", + "Our patient continued the etanercept treatment 25 mg twice a week for at least 2 years.", + "We repeated the ultrasound of the left clavicle, which revealed complete healing of the initial findings after 13 months of etanercept treatment." + ], + "summary": "In this study, we describe an unusual case of a child with juvenile idiopathic arthritis with an initial presentation of sternoclavicular mass. The patient (age, 14 years 10 months) presented with an insidious onset atraumatic swelling of the left SCJ and complained of right hip and bilateral ankle tenderness without an apparent cause. Initial ultrasonography indicated a heterogeneous mass in the left SCJ, while computed tomography identified mild swelling of the left SCJ with a thickened synovial lining, mild bone erosion, and some turbid fluid. The patient ultimately underwent left SCJ arthrotomy, during which tapping of the SCJ revealed 2 cc of yellowish fluid, inflammation and necrosis of tissues within the SCJ. A clear yellow joint fluid was aspirated, and testing revealed a negative culture result. The patient was diagnosed with JIA. The joint tenderness improved and erythrocyte sedimentation rate decreased after administering anti-tumor necrosis factor etanercept. An additional ultrasonography demonstrated that the initial imaging findings have been resolved. At the end of a 2-year follow-up period, the patient was completely symptom-free.", + "summary_subclaims": [ + "This study describes an unusual case of a child with juvenile idiopathic arthritis with an initial presentation of sternoclavicular mass.", + "The patient was 14 years 10 months old.", + "The patient presented with an insidious onset atraumatic swelling of the left sternoclavicular joint.", + "The patient complained of right hip and bilateral ankle tenderness without an apparent cause.", + "Initial ultrasonography indicated a heterogeneous mass in the left sternoclavicular joint.", + "Computed tomography identified mild swelling of the left sternoclavicular joint with a thickened synovial lining.", + "Computed tomography identified mild bone erosion in the left sternoclavicular joint.", + "Computed tomography identified some turbid fluid in the left sternoclavicular joint.", + "The patient underwent left sternoclavicular joint arthrotomy.", + "Tapping of the sternoclavicular joint revealed 2 cc of yellowish fluid.", + "Inflammation and necrosis of tissues within the sternoclavicular joint were observed.", + "A clear yellow joint fluid was aspirated.", + "Testing of the aspirated fluid revealed a negative culture result.", + "The patient was diagnosed with juvenile idiopathic arthritis.", + "The joint tenderness improved after administering anti-tumor necrosis factor etanercept.", + "The erythrocyte sedimentation rate decreased after administering anti-tumor necrosis factor etanercept.", + "An additional ultrasonography demonstrated that the initial imaging findings have been resolved.", + "At the end of a 2-year follow-up period, the patient was completely symptom-free." + ] + }, + { + "id": "multiclinsum_test_2306_en.txt", + "fulltext": "A 94-year-old man, who suffered dark urine, epigastric pain, and loss of appetite, was admitted for evaluation and treatment of bile duct cancer. He has a past history of hypertension and paroxysmal atrial fibrillation. Computed tomography (CT) showed a nodule in the lower bile duct, which was slowly enhanced by dynamic CT . Tumor markers were as follows: carcinoembryonic antigen of 7.2 ng/mL, carbohydrate antigen 19–9 of 22 U/mL, respectively. Endoscopic retrograde cholangiopancreatography revealed biliary obstruction and biliary drainage was performed . Cytopathological examination revealed adenocarcinoma of the bile duct. The patient was carefully evaluated whether he overcame pancreatoduodenectomy by cardiac ultrasonography, brain magnetic resonance angiography, nutritional evaluation by rapid turnover proteins (RTPs) (retinol-binding protein of 2.4 mg/dL, pre-albumin of 19.9 mg/dL, transferrin of 196 mg/dL), and CT-based assessment, including osteopenia and sarcopenia. Sarcopenia was evaluated by the area of the psoas muscle at the caudal end of the third lumbar vertebra by measurement of the lengths of the major and minor axes of the psoas muscle . We then evaluated sarcopenia by comparing the area of psoas muscle with previously reported sex-specific average . Osteopenia was defined as actual bone mineral density (BMD) below the calculated standard BMD, which was calculated as previously reported (308.82–2.49 × age in men and 311.84–2.41 × age in women) . BMD was measured in trabecular bone by calculating average pixel density within a circle in midvertebral core at the bottom of 11th thoracic vertebra (Th11) on preoperative computed tomography. The patient was independent in activities of daily living and was graded as performance status 1 and American Society of Anesthesiologists physical status (ASA-PS) 2. He had enough ejection fraction of 65%, and examinations revealed no impairment of cognitive function and neither of osteopenia and sarcopenia .\nWith a diagnosis of bile duct cancer with no distant metastasis, the patient underwent subtotal stomach-preserving pancreaticoduodenectomy with lymph node dissection . Operation time was 299 min and estimated blood loss was 100 ml. Pancreatic duct stent (6Fr), external biliary stent (7.5Fr), jejunostomy, and 2 drain tubes (Winslow and anastomosis of pancreatojejunostomy) were placed after operation. The resected specimens showed a tumor in the lower bile duct . Pathological examination revealed papillary adenocarcinoma of the bile duct (pT3N1M0 Stage IIIB) and the surgical margin was negative. Enteral nutrition (ENEVO®, Abbott, Japan) was given through jejunostomy and then the patient started oral intake after an evaluation of swallowing function on the postoperative day 7. Although RTPs were decreased on the postoperative day 7 (retinol-binding protein of 0.8 mg/dL, pre-albumin of 8.1 mg/dL, transferrin of 115 mg/dL), those were recovered after 1 month (retinol-binding protein of 1.6 mg/dL, pre-albumin of 13.7 mg/dL, transferrin of 208 mg/dL) with careful nutritional support and rehabilitation. The patient discharged on postoperative day 65 without any complications. He remains well with no evidence of tumor recurrence as of 1 year after resection.", + "fulltext_subclaims": [ + "The patient is a 94-year-old man.", + "He had dark urine.", + "He had epigastric pain.", + "He had loss of appetite.", + "He was admitted for evaluation and treatment of bile duct cancer.", + "He has a past history of hypertension.", + "He has a past history of paroxysmal atrial fibrillation.", + "Computed tomography showed a nodule in the lower bile duct.", + "The nodule was slowly enhanced by dynamic CT.", + "Carcinoembryonic antigen was 7.2 ng/mL.", + "Carbohydrate antigen 19–9 was 22 U/mL.", + "Endoscopic retrograde cholangiopancreatography revealed biliary obstruction.", + "Biliary drainage was performed.", + "Cytopathological examination revealed adenocarcinoma of the bile duct.", + "The patient was evaluated whether he overcame pancreatoduodenectomy.", + "Cardiac ultrasonography was part of the evaluation.", + "Brain magnetic resonance angiography was part of the evaluation.", + "Nutritional evaluation was performed by rapid turnover proteins.", + "Retinol-binding protein was 2.4 mg/dL.", + "Pre-albumin was 19.9 mg/dL.", + "Transferrin was 196 mg/dL.", + "Sarcopenia was evaluated by the area of the psoas muscle at the caudal end of the third lumbar vertebra.", + "The area of the psoas muscle was measured by the lengths of the major and minor axes.", + "Sarcopenia was evaluated by comparing the area of psoas muscle with previously reported sex-specific average.", + "Osteopenia was defined as actual bone mineral density below the calculated standard BMD.", + "The standard BMD was calculated as previously reported.", + "Bone mineral density was measured in trabecular bone.", + "The patient was independent in activities of daily living.", + "He was graded as performance status 1.", + "He was graded as American Society of Anesthesiologists physical status 2.", + "Ejection fraction was 65%.", + "Examinations revealed no impairment of cognitive function.", + "Examinations revealed neither osteopenia nor sarcopenia.", + "The patient had a diagnosis of bile duct cancer with no distant metastasis.", + "He underwent subtotal stomach-preserving pancreaticoduodenectomy with lymph node dissection.", + "Operation time was 299 minutes.", + "Estimated blood loss was 100 ml.", + "A pancreatic duct stent (6Fr) was placed after operation.", + "An external biliary stent (7.5Fr) was placed after operation.", + "Jejunostomy was performed after operation.", + "Two drain tubes were placed after operation.", + "The resected specimens showed a tumor in the lower bile duct.", + "Pathological examination revealed papillary adenocarcinoma of the bile duct.", + "The tumor was classified as pT3N1M0 Stage IIIB.", + "The surgical margin was negative.", + "Enteral nutrition was given through jejunostomy.", + "The patient started oral intake after an evaluation of swallowing function on postoperative day 7.", + "Rapid turnover proteins were decreased on postoperative day 7.", + "Retinol-binding protein was 0.8 mg/dL on postoperative day 7.", + "Pre-albumin was 8.1 mg/dL on postoperative day 7.", + "Transferrin was 115 mg/dL on postoperative day 7.", + "Rapid turnover proteins were recovered after 1 month.", + "Retinol-binding protein was 1.6 mg/dL after 1 month.", + "Pre-albumin was 13.7 mg/dL after 1 month.", + "Transferrin was 208 mg/dL after 1 month.", + "The patient was discharged on postoperative day 65.", + "There were no complications.", + "He remains well with no evidence of tumor recurrence as of 1 year after resection." + ], + "summary": "A 94-year-old man, who suffered dark urine, epigastric pain, and loss of appetite, was diagnosed as bile duct cancer and underwent endoscopic retrograde biliary drainage. He has past history of hypertension and paroxysmal atrial fibrillation. Computed tomography (CT) showed a nodule in the lower bile duct, which was slowly enhanced by dynamic CT. The patient was evaluated whether he overcomes pancreatoduodenectomy by cardiac ultrasonography, brain magnetic resonance angiography, nutritional evaluation (rapid turnover proteins), and CT-based general assessment, including sarcopenia and osteopenia. The patient was independent in activities of daily living and has enough ejection fraction of 65%, and examinations revealed no impairment of cognitive function, sarcopenia, and osteopenia. With a diagnosis of bile duct cancer with no distant metastasis, the patient underwent subtotal stomach-preserving pancreatoduodenectomy with lymph node dissection. Operation time was 299 min and estimated blood loss was 100 ml. Pathological examination revealed papillary adenocarcinoma of the bile duct (pT3N1M0 Stage IIIB). Enteral nutrition was given through jejunostomy and then the patient started oral intake after an evaluation of swallowing function. Postoperative course was uneventful and all drains including pancreatic duct stent, biliary stent, and jejunostomy were removed by 3 weeks after operation. The levels of rapid turnover proteins dropped at postoperative day 7, but recovered at 1 month after operation via appropriate nutrition and rehabilitation. He remains well with no evidence of tumor recurrence as of 1 year after resection.", + "summary_subclaims": [ + "The patient is a 94-year-old man.", + "He had dark urine.", + "He had epigastric pain.", + "He had loss of appetite.", + "He was diagnosed as bile duct cancer.", + "He underwent endoscopic retrograde biliary drainage.", + "He has past history of hypertension.", + "He has past history of paroxysmal atrial fibrillation.", + "Computed tomography showed a nodule in the lower bile duct.", + "The nodule was slowly enhanced by dynamic CT.", + "The patient was evaluated whether he overcomes pancreatoduodenectomy.", + "The evaluation included cardiac ultrasonography.", + "The evaluation included brain magnetic resonance angiography.", + "The evaluation included nutritional evaluation (rapid turnover proteins).", + "The evaluation included CT-based general assessment.", + "The patient was independent in activities of daily living.", + "The patient had an ejection fraction of 65%.", + "Examinations revealed no impairment of cognitive function.", + "Examinations revealed no sarcopenia.", + "Examinations revealed no osteopenia.", + "The patient was diagnosed with bile duct cancer with no distant metastasis.", + "The patient underwent subtotal stomach-preserving pancreatoduodenectomy.", + "The operation time was 299 minutes.", + "Estimated blood loss was 100 ml.", + "Pathological examination revealed papillary adenocarcinoma of the bile duct.", + "The stage was pT3N1M0 Stage IIIB.", + "Enteral nutrition was given through jejunostomy.", + "The patient started oral intake after an evaluation of swallowing function.", + "Postoperative course was uneventful.", + "All drains were removed by 3 weeks after operation.", + "The levels of rapid turnover proteins dropped at postoperative day 7.", + "The levels of rapid turnover proteins recovered at 1 month after operation.", + "He remains well with no evidence of tumor recurrence as of 1 year after resection." + ] + }, + { + "id": "multiclinsum_test_1976_en.txt", + "fulltext": "Our patient is a nonsmoker, 73-year-old male who came to our attention after presenting to a medical outpatient clinic with the chief complaint of right shoulder pain with a 2-week duration. The patient describes his pain as excruciating in nature, mostly occurring at night and awakening him from sleep. He experienced two episodes of the same complaint lasting about 3–5 days in the last 6 months, both with spontaneous resolution. Nowadays, the patient is seeking medical attention due to the persistence of the pain without any improvement. He mentioned that he is consuming large and frequent meals of red meats and some kinds of seafood such as tuna. Past medical history is positive for controlled hypertension, diabetes mellitus, and mild chronic kidney disease. The patient reported no personal and/or family history of cancer, any acute, repeat, or discontinued medications, any allergies, autoinflammatory diseases, any genetic or psychosocial issues, and a significant past surgical history for coronary artery bypass graft. He denies any history of trauma in general or specifically to the shoulder. Upon admission, the physical assessment was unremarkable except for right shoulder pain and tenderness with movement in the absence of redness, swelling, and hotness. Laboratory evaluation revealed C-reactive protein of 111 mg/l (normal range 0–10 mg/l), erythrocyte sedimentation rate of 122 mm/h (normal range 0–15 mm/h), blood urea nitrogen of 32 mg/dl (normal range 8–23 mg/dl), creatinine of 1.4 mg/dl (normal range 0.7–1.2 mg/dl), uric acid of 15 mg/dl (normal range 3.7–7.1 mg/dl), and a normal white blood cell count. Radiological imaging of the right shoulder was normal. An arthrocentesis was performed, and analysis of the aspirated synovial fluid revealed the presence of yellow needle-shaped monosodium urate crystals under a light microscope along with a white blood cell count of 2500 cell/μl. A diagnosis of gout with right shoulder involvement was established. The patient was prescribed prednisolone 40 mg/day for 10 days, allopurinol 300 mg/day, and colchicine 0.5 mg/day. The patient was followed up for 6 months with significant improvement. The patient also had a good tolerance for pharmacological agents without any reported complications or adverse events.", + "fulltext_subclaims": [ + "The patient is a 73-year-old male.", + "The patient is a nonsmoker.", + "The patient presented with right shoulder pain.", + "The pain has been present for 2 weeks.", + "The patient describes the pain as excruciating.", + "The pain occurs at night and awakens him from sleep.", + "The patient experienced two episodes of the same complaint in the last 6 months.", + "Each prior episode lasted 3–5 days.", + "Each prior episode resolved spontaneously.", + "The patient is consuming large and frequent meals of red meats.", + "The patient consumes some kinds of seafood such as tuna.", + "Past medical history is positive for controlled hypertension.", + "Past medical history is positive for diabetes mellitus.", + "Past medical history is positive for mild chronic kidney disease.", + "The patient reported no personal and/or family history of cancer.", + "The patient reported no acute, repeat, or discontinued medications.", + "The patient reported no allergies.", + "The patient reported no autoinflammatory diseases.", + "The patient reported no genetic or psychosocial issues.", + "The patient had a significant past surgical history for coronary artery bypass graft.", + "The patient denies any history of trauma.", + "The patient denies any history of shoulder trauma.", + "Physical assessment was unremarkable except for right shoulder pain and tenderness with movement.", + "There was no redness, swelling, or hotness in the right shoulder.", + "C-reactive protein was 111 mg/l.", + "Erythrocyte sedimentation rate was 122 mm/h.", + "Blood urea nitrogen was 32 mg/dl.", + "Creatinine was 1.4 mg/dl.", + "Uric acid was 15 mg/dl.", + "White blood cell count was normal.", + "Radiological imaging of the right shoulder was normal.", + "An arthrocentesis was performed.", + "Analysis of the aspirated synovial fluid revealed yellow needle-shaped monosodium urate crystals.", + "The white blood cell count in the synovial fluid was 2500 cell/μl.", + "A diagnosis of gout with right shoulder involvement was established.", + "The patient was prescribed prednisolone 40 mg/day for 10 days.", + "The patient was prescribed allopurinol 300 mg/day.", + "The patient was prescribed colchicine 0.5 mg/day.", + "The patient was followed up for 6 months.", + "The patient had significant improvement.", + "The patient had good tolerance for pharmacological agents.", + "There were no reported complications or adverse events." + ], + "summary": "A 73-year-old man who visited an outpatient clinic with the main complaint of a right shoulder ache lasting 2 weeks came to our attention. The patient reports his discomfort as being of an unbearable character, happening largely at night and preventing him from falling asleep. In the previous 6 months, he had two episodes of the same ailment that lasted around 3-5 days each and spontaneously resolved. Due to the pain's continuance without improvement, the patient now seeks medical assistance. Gout with right shoulder involvement was identified as the cause. Prednisolone 40 mg/day for 10 days, allopurinol 300 mg/day, and colchicine 0.5 mg/day were all prescribed for the patient. After 6 months of follow-up, the patient had significantly improved.", + "summary_subclaims": [ + "A 73-year-old man visited an outpatient clinic with a right shoulder ache lasting 2 weeks.", + "The patient reports his discomfort as being of an unbearable character.", + "The pain happens largely at night and prevents him from falling asleep.", + "In the previous 6 months, he had two episodes of the same ailment that lasted around 3-5 days each.", + "The two episodes spontaneously resolved.", + "The patient now seeks medical assistance due to the pain's continuance without improvement.", + "Gout with right shoulder involvement was identified as the cause.", + "Prednisolone 40 mg/day for 10 days was prescribed.", + "Allopurinol 300 mg/day was prescribed.", + "Colchicine 0.5 mg/day was prescribed.", + "After 6 months of follow-up, the patient had significantly improved." + ] + }, + { + "id": "multiclinsum_test_3394_en.txt", + "fulltext": "A 52-year-old patient was admitted to the Cardiology Department for the diagnosis of arrhythmia in the course of the Holt-Oram syndrome. Having a hereditary burden of Holt-Oram syndrome on his father’s side, the patient was diagnosed with the syndrome in early childhood.\nAt the time of admission to the hospital, the main problem of the patient was symptomatic bradycardia. So far, he has not been treated for chronic diseases. In childhood, he underwent atrial septal defect (ASD) closure. Despite symptomatic cardiac conduction disturbances, a pacemaker was not implanted in the past due to the patient’s refusal of informed consent for the procedure. The patient was explaining the lack of consent with the fear of worsening heart function caused by ventricular pacing and his father’s history (multiple hospitalizations and device replacements).\nAt the time of admission to the hospital, the patient was in good general condition. His blood pressure was 144/83 mmHg. Temperature and oxygen saturation were normal. The heart rate was 41 beats/min. Moreover, a physical examination revealed distortions of the upper limbs and a chest– typical for Holt-Oram syndrome. Abnormal laboratory results included a slightly elevated level of N-terminal prohormone of brain natriuretic peptide (NT-pro-BNP), a slightly decreased level of platelets (PLT), and an ab- normal lipid profile. Electrocardiography (ECG) showed atrial flutter (AFI) and third-degree atrio- ventricular block (complete heart block) with a heart rate of about 40 beats/min. In echocardiography (ECHO), normal systolic left ventricle function with left ventricular ejection fraction (LVEF) about 60%, enlargement of a left ventricle and enlargement of both atria [left ventricular end-diastolic dimension (LVEDd) about 6.1 cm, left atrial dimension (LAD) about 4.9 cm, left atrial area (LAAr) about 53 cm 2 , right atrial area (RAAr) about 54 cm 2] were stated. In the Cardiology Department, Holter’s EKG confirmed AFI and complete heart block. The patient was qualified for the implantation of a pacemaker.\nThe computed tomography angiography (CTA) did not reveal new heart malformations, but the radiologist suggested the presence of an abnormal structure in the auricle of the left atrium. Trans- esophageal echocardiography (TEE) did not confirm the presence of a thrombus in the left auricle.\nBased on the CHA 2 DS2 -VASc score, the patient did not get any points, so he was not qualified for anticoagulation therapy.\nDuring the next hospitalization, it was decided to implant the His-bundle pacemaker (HBP), giving the patient a chance for electrotherapy using the physiological conduction pathway. The implantation was successful, and the patient left the Cardiology Department in good condition. Accurate presentation of the indications for the procedure, as well as its course allowed to obtain informed consent from the patient for implantation of the pacemaker.\nAfter one year, the man remains in good condition. The pacing was over 90%, and a LVEF was stable (60%).", + "fulltext_subclaims": [ + "The patient was admitted to the Cardiology Department for the diagnosis of arrhythmia in the course of the Holt-Oram syndrome.", + "The patient was diagnosed with Holt-Oram syndrome in early childhood.", + "The patient had a hereditary burden of Holt-Oram syndrome on his father’s side.", + "The patient’s main problem at admission was symptomatic bradycardia.", + "The patient had not been treated for chronic diseases.", + "In childhood, the patient underwent atrial septal defect (ASD) closure.", + "A pacemaker was not implanted in the past due to the patient’s refusal of informed consent.", + "The patient refused the pacemaker implantation because of fear of worsening heart function caused by ventricular pacing.", + "The patient’s father had multiple hospitalizations and device replacements.", + "At admission, the patient was in good general condition.", + "The patient’s blood pressure was 144/83 mmHg.", + "The patient’s heart rate was 41 beats/min.", + "A physical examination revealed distortions of the upper limbs and a chest typical for Holt-Oram syndrome.", + "NT-pro-BNP was slightly elevated.", + "Platelet count was slightly decreased.", + "The lipid profile was abnormal.", + "Electrocardiography showed atrial flutter and third-degree atrioventricular block with a heart rate of about 40 beats/min.", + "Echocardiography showed normal systolic left ventricle function with left ventricular ejection fraction about 60%.", + "Echocardiography showed enlargement of the left ventricle.", + "Echocardiography showed enlargement of both atria.", + "Holter’s EKG confirmed atrial flutter and complete heart block.", + "The patient was qualified for the implantation of a pacemaker.", + "Computed tomography angiography did not reveal new heart malformations.", + "The radiologist suggested the presence of an abnormal structure in the auricle of the left atrium.", + "Transesophageal echocardiography did not confirm the presence of a thrombus in the left auricle.", + "Based on the CHA2DS2-VASc score, the patient did not get any points.", + "The patient was not qualified for anticoagulation therapy.", + "It was decided to implant a His-bundle pacemaker.", + "The implantation of the His-bundle pacemaker was successful.", + "The patient left the Cardiology Department in good condition.", + "Accurate presentation of the indications for the procedure allowed obtaining informed consent from the patient.", + "After one year, the man remains in good condition.", + "Pacing was over 90%.", + "Left ventricular ejection fraction was stable at 60%." + ], + "summary": "We present the case of a patient with HOS qualified for pacemaker implantation due to overt bradycardia. To prevent the development of heart failure in the future, the His-bundle pacing technique was used. The implantation was successful. In the control, after one year, the man remains in good condition. The pacing was over 90%, and the left ventricular ejection fraction (LVEF) was stable (60%).", + "summary_subclaims": [ + "The patient had HOS.", + "The patient was qualified for pacemaker implantation due to overt bradycardia.", + "The His-bundle pacing technique was used.", + "The implantation was successful.", + "After one year, the man remains in good condition.", + "The pacing was over 90%.", + "The left ventricular ejection fraction (LVEF) was stable (60%)." + ] + }, + { + "id": "multiclinsum_test_1931_en.txt", + "fulltext": "A 20-year-old woman, gravida 7 para 0060, at 14+3/7 weeks gestation by 8-week ultrasonography with history of depression and bipolar disorder presented to the emergency department (ED) complaining of unremitting nausea and vomiting, exacerbated by oral intake, for the past several weeks. She also reported intermittent hematemesis, epigastric abdominal pain, and mild diarrhea. However, she denied headache, fever, chills, chest pain, shortness of breath, palpitations, or dizziness. She also denied vaginal bleeding and discharge, vaginal bleeding, leakage of fluid, contractions, suprapubic or pelvic pain. She was given IV hydration, ondansetron, famotidine, and metoclopramide but continued to vomit without visible blood. She had mild hypokalemia, which was replaced with intravenous (IV) and oral potassium. She slowly improved throughout her hospital course and was able to tolerate oral intake by hospital day 6. The patient had a two-year history of multiple ED visits for the same issue, for which she was diagnosed with hyperemesis gravidarum and managed with hydration and antiemetics.\nDuring the following month, the patient returned several times with the same complaints. She was treated again with IV hydration and antiemetics (oral ondansetron and promethazine suppositories), which resolved her symptoms. She was instructed to continue her home doxylamine succinate-pyridoxine hydrochloride and prescribed ondansetron and promethazine prophylactically.\nAt 22+4/7 weeks gestation, the patient presented to labor and delivery again with complaint of nausea and vomiting. She reported that she remained free of symptoms for approximately a month with home medications but began vomiting again with inability to keep fluids or solids down for the past 12 hours following consumption of contaminated food. She denied any fever, chills, diarrhea, headache, or blurred vision. She reported good fetal movement and no vaginal bleeding or discharge or contractions. While on the labor and delivery, she continued to vomit with antiemetics (IV ondansetron and promethazine). On the hospital day 2, patient was found in the shower and reported that warm showers are the only relieving factor for nausea and vomiting—concerning for CHS. Urine drug screening (UDS) was performed and was positive for cannabinoids. The patient was informed that this was possibly related to her cannabis exposure. She remained abstinent throughout the hospital stay and was continued on IV fluids and antiemetics. On the hospital day 3, she noted vast improvement and was able to tolerate regular diet. Patient was discharged home with promethazine, ondansetron, and doxylamine succinate-pyridoxine hydrochloride. Patient was counseled on completely discontinuing all exposure to cannabis and voiced understanding. UDS remained negative at subsequent prenatal visits.\nAt 40+1/7 weeks gestation, the patient delivered vaginally a live female infant weighing 3.19 kg with APGAR score of 8/9 without any complications. The mother and baby were discharged home on the second postpartum day.", + "fulltext_subclaims": [ + "The patient is a 20-year-old woman.", + "She is gravida 7 para 0060.", + "She is at 14+3/7 weeks gestation by 8-week ultrasonography.", + "She has a history of depression and bipolar disorder.", + "She presented to the emergency department complaining of unremitting nausea and vomiting.", + "She reported intermittent hematemesis.", + "She reported epigastric abdominal pain.", + "She denied headache.", + "She denied fever.", + "She denied chest pain.", + "She denied shortness of breath.", + "She denied vaginal bleeding.", + "She denied leakage of fluid.", + "She denied contractions.", + "She was given IV hydration.", + "She was given ondansetron.", + "She was given famotidine.", + "She was given metoclopramide.", + "She continued to vomit without visible blood.", + "She had mild hypokalemia.", + "She was able to tolerate oral intake by hospital day 6.", + "She had a two-year history of multiple ED visits for the same issue.", + "She was diagnosed with hyperemesis gravidarum.", + "She was managed with hydration and antiemetics.", + "During the following month, she returned several times with the same complaints.", + "She was treated again with IV hydration and antiemetics.", + "She was instructed to continue her home doxylamine succinate-pyridoxine hydrochloride.", + "She was prescribed ondansetron and promethazine prophylactically.", + "At 22+4/7 weeks gestation, she presented to labor and delivery again with complaint of nausea and vomiting.", + "She reported that she remained free of symptoms for approximately a month with home medications.", + "She began vomiting again with inability to keep fluids or solids down for the past 12 hours.", + "She denied any fever.", + "She reported good fetal movement.", + "She reported no vaginal bleeding.", + "She continued to vomit with antiemetics (IV ondansetron and promethazine).", + "Urine drug screening (UDS) was performed and was positive for cannabinoids.", + "The patient was informed that this was possibly related to her cannabis exposure.", + "She remained abstinent throughout the hospital stay.", + "She was discharged home with promethazine, ondansetron, and doxylamine succinate-pyridoxine hydrochloride.", + "She was counseled on completely discontinuing all exposure to cannabis.", + "UDS remained negative at subsequent prenatal visits.", + "At 40+1/7 weeks gestation, she delivered vaginally a live female infant.", + "The infant weighed 3.19 kg.", + "The infant had an APGAR score of 8/9.", + "The mother and baby were discharged home on the second postpartum day." + ], + "summary": "We report a 20-year-old pregnant woman with multiple admissions for recurrent nausea and vomiting who was observed to be taking frequent hot showers. Without other identifiable causes, she was diagnosed with cannabinoid hyperemesis syndrome and managed with antiemetics and abstinence.", + "summary_subclaims": [ + "The patient is a 20-year-old pregnant woman.", + "She had multiple admissions for recurrent nausea and vomiting.", + "She was observed to be taking frequent hot showers.", + "There were no other identifiable causes.", + "She was diagnosed with cannabinoid hyperemesis syndrome.", + "She was managed with antiemetics.", + "She was advised to abstain from cannabinoids." + ] + }, + { + "id": "multiclinsum_test_3372_en.txt", + "fulltext": "A 71-year-old man underwent a robot-assisted partial nephrectomy in 2022 at Azienda sanitaria territoriale Pesaro-Urbino, Italy, to treat a 5 cm mass located at the upper pole of his left kidney (7a according to the RENAL Nephrometry Score).8 Following appropriate preoperative preparation, the mass was enucleated with a clamp of renal artery of 21 minutes. Care was taken to close the renal wound meticulously using absorbable sutures and covered with sealing matrix (made by human fibrinogen and thrombin), and perirenal fat. Post-surgery, pathological analysis of the surgical specimens revealed stage pT1a, grade 2 renal cell carcinoma (RCC). The patient recovered well, with the temporary drainage tube removed on the fourth postoperative day, and he was discharged on the fifth day. However, six months later, was re-admitted with fever and elevated inflammatory markers, she had no history of urinary stones and did not report any recent trauma. CT urography showed a 8 cm perirenal collection at the upper pole of the left kidney, with contrast leakage from the upper calyx into the perirenal space. Subsequent retrograde pyelography confirmed the presence of a urinary fistula between the urinoma and the upper urinary calyx. To address this complication, a retrograde double pig-tail stent was inserted in the collecting system and percutaneous US drainage was positioned by interventional radiologist in the perirenal collection. Cultural examination of urine and drainage fluid yielded negative results. However, at the one-month follow-up, the urinary fistula persisted. Along with the interventional radiologist, despite the non-dilatated collection system a US guided percutaneous access into the lower calyx was obtained with a vascular introducer sheat. After confirming the presence of the fistula from the upper calyx with contrast injection, a catheterization of the fistula was obtained with a Bern catheter and a microcatheter (Progreate 2.7 F Terumo). Adhesive fibrin, a solution comprising frozen aprotinin and thrombin-calcium chloride, was then introduced via the microcatheter in the fistula, following a sudden closure of the fistula, as indicated by the urogram. The percutaneous nephrostomy was left with the distal tip within the upper calyx group after the procedure along with the double pig-tail stent, in order to optimize the drainage of the entire collecting system of the kidney. After three days, a pyelography control showed no contrast leakage in the upper calyx, which remained absent on subsequent controls at nine days and after a further 15-day period. With the urinary fistula resolved, the percutaneous drainage and nephrostomy were removed, while the double pig-tail stent remained. A final pyelography conducted one month after nephrostomy removal confirmed the sustained absence of the urinary fistula, prompting the decision to remove the double pig-tail ureteral stent.", + "fulltext_subclaims": [ + "The patient is a 71-year-old man.", + "The patient underwent a robot-assisted partial nephrectomy in 2022 at Azienda sanitaria territoriale Pesaro-Urbino, Italy.", + "The procedure was performed to treat a 5 cm mass located at the upper pole of his left kidney.", + "The mass was classified as 7a according to the RENAL Nephrometry Score.", + "The mass was enucleated with a clamp of renal artery of 21 minutes.", + "The renal wound was closed with absorbable sutures.", + "The wound was covered with sealing matrix made by human fibrinogen and thrombin.", + "The wound was covered with perirenal fat.", + "Pathological analysis revealed stage pT1a, grade 2 renal cell carcinoma.", + "The temporary drainage tube was removed on the fourth postoperative day.", + "The patient was discharged on the fifth postoperative day.", + "Six months later, the patient was re-admitted with fever and elevated inflammatory markers.", + "CT urography showed an 8 cm perirenal collection at the upper pole of the left kidney.", + "CT urography showed contrast leakage from the upper calyx into the perirenal space.", + "Retrograde pyelography confirmed a urinary fistula between the urinoma and the upper urinary calyx.", + "A retrograde double pig-tail stent was inserted in the collecting system.", + "Percutaneous US drainage was positioned by interventional radiologist in the perirenal collection.", + "Cultural examination of urine and drainage fluid yielded negative results.", + "At the one-month follow-up, the urinary fistula persisted.", + "A US guided percutaneous access into the lower calyx was obtained with a vascular introducer sheath.", + "Contrast injection confirmed the presence of the fistula from the upper calyx.", + "A catheterization of the fistula was obtained with a Bern catheter and a microcatheter.", + "Adhesive fibrin, a solution comprising frozen aprotinin and thrombin-calcium chloride, was introduced via the microcatheter.", + "The urogram indicated a sudden closure of the fistula.", + "The percutaneous nephrostomy was left with the distal tip within the upper calyx group.", + "A pyelography control after three days showed no contrast leakage in the upper calyx.", + "The absence of contrast leakage remained on subsequent controls at nine days and after a further 15-day period.", + "The percutaneous drainage and nephrostomy were removed.", + "The double pig-tail stent remained after removal of the percutaneous drainage and nephrostomy.", + "A final pyelography conducted one month after nephrostomy removal confirmed the sustained absence of the urinary fistula.", + "The decision was made to remove the double pig-tail ureteral stent." + ], + "summary": "71-year-old male patient who developed a urinary fistula six months following a robot-assisted partial nephrectomy. Initial efforts to address the fistula through the placement of a double pigtail ureteral stent proved ineffective. Subsequent interventional radiology procedures successfully achieved fistula closure by administering adhesive fibrin directly within the fistulous tract.", + "summary_subclaims": [ + "The patient is a 71-year-old male.", + "The patient developed a urinary fistula six months after a robot-assisted partial nephrectomy.", + "A double pigtail ureteral stent was placed to address the fistula.", + "The placement of a double pigtail ureteral stent proved ineffective.", + "Interventional radiology procedures were performed.", + "Fistula closure was achieved by administering adhesive fibrin directly within the fistulous tract." + ] + }, + { + "id": "multiclinsum_test_715_en.txt", + "fulltext": "A 55-year-old man was admitted to our hospital with unexplained abdominal distension and anorexia 3 mo ago.\nThe patient suffered from unexplained abdominal distension and anorexia for 3 mo. The patient developed darkened urine 2 mo ago. He experienced a weight loss of 5 kg over the course of the disease. He underwent contrast-enhanced computed tomography (CECT) examination at a local hospital, and a lesion was found in the extrahepatic bile duct, which was believed to be a tumor.\nThe patient underwent cholecystectomy for gallbladder stones with an uneventful postoperative recovery 4 years ago. He had a 10-year history of hypertension.\nThere was no other personal or family history of acute or chronic disease.\nThe patient showed no tenderness, rebound tenderness or muscle tension on abdominal palpation.\nThe liver function tests demonstrated increased levels of alanine aminotransferase (185 IU/L, normal range: < 50 IU/L), aspartate aminotransferase (148 IU/L, normal range: < 40 IU/L) and total bilirubin (37.0 μmol/L, normal range: 5 µmol/L to 28 µmol/L). Tumor markers included carbohydrate antigen 19-9 (98.6 U/mL, normal range: < 22 U/mL), carcinoembryonic antigen (0.97 ng/mL, normal range: < 5 ng/mL), and alpha-fetoprotein (4.67 ng/mL, normal range: < 7 ng/mL).\nThe patient underwent an abdominal ultrasound (US) examination by a Resona7 US system (Mindray Medical International, Shenzhen, Guangdong Province, China) equipped with an SC6-1U (1-6 MHz) transducer. The US revealed mild to moderate dilatation of the intrahepatic bile duct, and the diameter of the upper extrahepatic bile duct was 1.2 cm . A hyperechoic nodule sized 0.8 cm × 0.6 cm was found in the upper extrahepatic bile duct with an almost regular shape and slightly clear margins . The patient underwent CEUS with the patient’s consent for further diagnosis. A 2.4-mL US contrast agent SonoVue (Bracco, Milan, Italy) suspension was injected through the left cubital vein followed by a flush with 5 mL saline. In the arterial phase, the nodule showed slight heterogeneous hyperenhancement without rim-like enhancement . The nodule appeared heterogeneous isoenhancement in the venous phase . Additional CECT in our hospital showed a hypoenhancement nodule approximately 1.3 cm × 1.0 cm in size in the upper extrahepatic bile duct .", + "fulltext_subclaims": [ + "The patient was a 55-year-old man.", + "The patient was admitted to the hospital with unexplained abdominal distension and anorexia 3 mo ago.", + "The patient had unexplained abdominal distension and anorexia for 3 mo.", + "The patient developed darkened urine 2 mo ago.", + "The patient experienced a weight loss of 5 kg over the course of the disease.", + "The patient underwent contrast-enhanced computed tomography (CECT) at a local hospital.", + "A lesion was found in the extrahepatic bile duct.", + "The lesion was believed to be a tumor.", + "The patient underwent cholecystectomy for gallbladder stones 4 years ago.", + "The patient had an uneventful postoperative recovery after cholecystectomy.", + "The patient had a 10-year history of hypertension.", + "There was no other personal or family history of acute or chronic disease.", + "The patient showed no tenderness on abdominal palpation.", + "The patient showed no rebound tenderness on abdominal palpation.", + "The patient showed no muscle tension on abdominal palpation.", + "Alanine aminotransferase was 185 IU/L.", + "The normal range for alanine aminotransferase is < 50 IU/L.", + "Aspartate aminotransferase was 148 IU/L.", + "The normal range for aspartate aminotransferase is < 40 IU/L.", + "Total bilirubin was 37.0 μmol/L.", + "The normal range for total bilirubin is 5 µmol/L to 28 µmol/L.", + "Carbohydrate antigen 19-9 was 98.6 U/mL.", + "The normal range for carbohydrate antigen 19-9 is < 22 U/mL.", + "Carcinoembryonic antigen was 0.97 ng/mL.", + "The normal range for carcinoembryonic antigen is < 5 ng/mL.", + "Alpha-fetoprotein was 4.67 ng/mL.", + "The normal range for alpha-fetoprotein is < 7 ng/mL.", + "The patient underwent an abdominal ultrasound examination using a Resona7 US system.", + "The US revealed mild to moderate dilatation of the intrahepatic bile duct.", + "The diameter of the upper extrahepatic bile duct was 1.2 cm.", + "A hyperechoic nodule sized 0.8 cm × 0.6 cm was found in the upper extrahepatic bile duct.", + "The nodule had an almost regular shape.", + "The nodule had slightly clear margins.", + "The patient underwent contrast-enhanced ultrasound (CEUS) with consent.", + "A 2.4-mL US contrast agent SonoVue suspension was injected through the left cubital vein.", + "The nodule showed slight heterogeneous hyperenhancement in the arterial phase.", + "The nodule showed heterogeneous isoenhancement in the venous phase.", + "Additional CECT showed a hypoenhancement nodule approximately 1.3 cm × 1.0 cm in size in the upper extrahepatic bile duct." + ], + "summary": "A 55-year-old male patient presented to our hospital with a 3-mo history of abdominal distension and anorexia and history of cholecystectomy 4 years ago. Grayscale ultrasound demonstrated mild to moderate intrahepatic bile duct dilatation. Meanwhile, a hyperechoic nodule was found in the upper extrahepatic bile duct. The lesion approximately 0.8 cm × 0.6 cm with a regular shape and clear margins. The nodule of the bile duct showed slight hyperenhancement in the arterial phase and isoenhancement in the venous phase on CEUS. Laboratory tests showed that alanine aminotransferase and aspartate aminotransferase were increased significantly, while the tumor marker carbohydrate antigen 19-9 was increased slightly. Then, hilar bile duct resection and end-to-end bile ductal anastomosis were performed. The histological examination revealed traumatic neuroma of the extrahepatic bile duct. The patient had an uneventful recovery after surgery.", + "summary_subclaims": [ + "The patient is a 55-year-old male.", + "The patient had a 3-month history of abdominal distension.", + "The patient had a 3-month history of anorexia.", + "The patient had a cholecystectomy 4 years ago.", + "Grayscale ultrasound demonstrated mild to moderate intrahepatic bile duct dilatation.", + "A hyperechoic nodule was found in the upper extrahepatic bile duct.", + "The lesion was approximately 0.8 cm × 0.6 cm.", + "The lesion had a regular shape.", + "The lesion had clear margins.", + "The nodule showed slight hyperenhancement in the arterial phase on CEUS.", + "The nodule showed isoenhancement in the venous phase on CEUS.", + "Alanine aminotransferase was increased significantly.", + "Aspartate aminotransferase was increased significantly.", + "Carbohydrate antigen 19-9 was increased slightly.", + "Hilar bile duct resection was performed.", + "End-to-end bile ductal anastomosis was performed.", + "Histological examination revealed traumatic neuroma of the extrahepatic bile duct.", + "The patient had an uneventful recovery after surgery." + ] + }, + { + "id": "multiclinsum_test_1601_en.txt", + "fulltext": "A 40-year-old pregnant woman at 28th week of pregnancy was admitted to an obstetric emergency department in Isfahan, Iran, with chief complaints of epistaxis and gingival bleeding that were manifested about a week before admission.\nShe had no previous family history of bleeding disorders. But in her past medical history, it is highly notable that she had several hours of bleeding after eyebrow tattooing about 5 years before admission and two episodes of abortion in the first pregnancy trimester, 4 and 2 years before the current pregnancy. Moreover, her first pregnancy was successful. There were no abnormal data pertaining to her first labor.\nHer medications were aspirin due to previous pregnancy losses, daily perinatal multivitamins, and iron supplements. She did not smoke or drink alcohol. Considering the patient’s condition, aspirin administration was discontinued and her symptoms reduced in intensity.\nOn admission, her vital signs were blood pressure 120/70, pulse 82, temperature 37 degrees C, respiratory rate 17. A detailed physical examination was performed but all findings were normal and no evidence of bleeding was found.\nIn her laboratory data, platelet count was in the normal range but prothrombin time (PT) and partial thromboplastin time (PTT) were both significantly elevated, so a mixing test was done. In the mixing test, both PT and PTT corrected instantly and after two hours of incubation at room temperature. Based on these results, the patient was suspected of having a deficiency of one or more coagulation factors. Thus, the activity level of coagulation factors were tested . Laboratory results showed that the activity level of factor V was decreased significantly and the patient was diagnosed with factor V deficiency. In accordance with the mixing test result, the congenital form of FVD was approved.\nThe patient had a history of two unsuccessful pregnancies and some complications were possible due to significantly elevated PT and PTT. Thus, the patient was started on fresh frozen plasma (FFP) every three days -two units each time (15–20 ml/kg bodyweight)- from week 30 of pregnancy until the parturition and she responded well with increase in FV activity to the normal range. At 40 + 2 weeks gestation, the vaginal delivery was done successfully and the baby was born with 3820 gr weight and Apgar score of 9 and 10 in 1st and 5th minute respectively. The newborn was tested for bleeding disorders and diagnosed with congenital FVD. As the patient and her husband were cousins, the infant was a case of congenital FVD with parental consanguinity.", + "fulltext_subclaims": [ + "A 40-year-old pregnant woman at 28th week of pregnancy was admitted to an obstetric emergency department in Isfahan, Iran.", + "She had chief complaints of epistaxis and gingival bleeding that were manifested about a week before admission.", + "She had no previous family history of bleeding disorders.", + "She had several hours of bleeding after eyebrow tattooing about 5 years before admission.", + "She had two episodes of abortion in the first pregnancy trimester, 4 and 2 years before the current pregnancy.", + "Her first pregnancy was successful.", + "Her medications were aspirin due to previous pregnancy losses, daily perinatal multivitamins, and iron supplements.", + "Aspirin administration was discontinued and her symptoms reduced in intensity.", + "On admission, her vital signs were blood pressure 120/70, pulse 82, temperature 37 degrees C, respiratory rate 17.", + "A detailed physical examination was performed but all findings were normal and no evidence of bleeding was found.", + "Platelet count was in the normal range.", + "Prothrombin time (PT) and partial thromboplastin time (PTT) were both significantly elevated.", + "A mixing test was done.", + "In the mixing test, both PT and PTT corrected instantly and after two hours of incubation at room temperature.", + "The patient was suspected of having a deficiency of one or more coagulation factors.", + "The activity level of coagulation factors were tested.", + "The activity level of factor V was decreased significantly.", + "The patient was diagnosed with factor V deficiency.", + "In accordance with the mixing test result, the congenital form of FVD was approved.", + "The patient was started on fresh frozen plasma (FFP) every three days - two units each time (15–20 ml/kg bodyweight)- from week 30 of pregnancy until the parturition.", + "She responded well with increase in FV activity to the normal range.", + "At 40 + 2 weeks gestation, the vaginal delivery was done successfully.", + "The baby was born with 3820 gr weight.", + "The newborn was tested for bleeding disorders and diagnosed with congenital FVD.", + "As the patient and her husband were cousins, the infant was a case of congenital FVD with parental consanguinity." + ], + "summary": "We report a 40-year-old pregnant woman with prolonged gingival bleeding and epistaxis at 28 weeks of pregnancy. Her past medical history included two unexplained abortions. Physical examination was unremarkable, but the blood test showed elevated PT and PTT with a considerable decrease in factor V activity, while other factors were within normal range. Subsequently, the patient was diagnosed with congenital factor V deficiency. After treatment with fresh frozen plasma, she underwent vaginal delivery and a baby with factor V deficiency was born.", + "summary_subclaims": [ + "The patient is a 40-year-old pregnant woman.", + "She had prolonged gingival bleeding and epistaxis at 28 weeks of pregnancy.", + "Her past medical history included two unexplained abortions.", + "Physical examination was unremarkable.", + "The blood test showed elevated PT.", + "The blood test showed elevated PTT.", + "The blood test showed a considerable decrease in factor V activity.", + "Other factors were within normal range.", + "The patient was diagnosed with congenital factor V deficiency.", + "After treatment with fresh frozen plasma, she underwent vaginal delivery.", + "A baby with factor V deficiency was born." + ] + }, + { + "id": "multiclinsum_test_337_en.txt", + "fulltext": "A 56-year-old previously healthy Chinese female was admitted to our medical center because of detection of a malignancy-suspected nodule in the right lobe of the thyroid by a routine ultrasonography examination two months ago, which displayed a 1.28 cm*1.14 cm hypoechoic nodule inside the right lobe of thyroid with irregular shape and fairly clear margins close to the posterior capsule, and the Color-flow Doppler imaging showed short-trip blood flows inside . There were no complaints of palpitation, hyperhidrosis, hoarseness, dyspnea, dysphagia, osteoporosis or convulsion of limbs. The patient was soon scheduled for surgery, before which a preoperative assay of level of serum calcium (Ca) and phosphorus (P) showed normal (Ca 2.50 mmol per liter, P 0.94 mmol per liter).\nDuring the operation, it was found that the tumor was completely located inside the right lobe of thyroid, the texture of which was soft, and the thyroid membrane was intact while no infiltration of adjacent structures was seen. The intraoperative rapid pathology highly suspected malignancy while no characteristic papillary pathological structure was detected, remaining further classification still in need of postoperative paraffin pathology. In addition, during the operation, we detected that some right VI lymph nodes were abnormal swell and hyperplasia, consequently, we finally performed right thyroid lobectomy combined with right VI lymphadenectomy.\nThe patient was sent back to ward in generally good condition after a smooth surgery and an immediate postoperative assay of calcitonin (CT) and carcinoembryonic(CEA)antigen showed no abnormality (CT < 1.5 pg per milliliter, CEA 2.32 ng per milliliter). After three days of medical care, the patient recovered well and was discharged smoothly. The postoperative paraffin pathological diagnosis revealed adenocarcinoma of parathyroid and the level of serum parathormone (PTH), Ca and P showed no abnormality (PTH 66.1 pg per milliliter, Ca 2.31 mmol per liter, P 1.17 mmol per liter). In addition, 99 m-Tc-MIBI-Pertechnetate imaging showed that the rest parathyroid appeared no abnormality. At a six-month follow up visit after operation, no discomforts or side effects were complained by the patient as well as no obvious locally recurrence were indicated by ultrasonography and the patient is still under regular routine follow up.", + "fulltext_subclaims": [ + "A 56-year-old previously healthy Chinese female was admitted to our medical center.", + "The admission was due to detection of a malignancy-suspected nodule in the right lobe of the thyroid by a routine ultrasonography examination two months ago.", + "The nodule was 1.28 cm*1.14 cm hypoechoic.", + "The nodule was located inside the right lobe of the thyroid.", + "The nodule had an irregular shape.", + "The nodule had fairly clear margins close to the posterior capsule.", + "Color-flow Doppler imaging showed short-trip blood flows inside the nodule.", + "The patient had no complaints of palpitation.", + "The patient had no complaints of hyperhidrosis.", + "The patient had no complaints of hoarseness.", + "The patient had no complaints of dyspnea.", + "The patient had no complaints of dysphagia.", + "The patient had no complaints of osteoporosis.", + "The patient had no complaints of convulsion of limbs.", + "A preoperative assay of serum calcium showed Ca 2.50 mmol per liter.", + "A preoperative assay of serum phosphorus showed P 0.94 mmol per liter.", + "During the operation, the tumor was found to be completely located inside the right lobe of the thyroid.", + "The tumor had a soft texture.", + "The thyroid membrane was intact.", + "No infiltration of adjacent structures was seen.", + "The intraoperative rapid pathology highly suspected malignancy.", + "No characteristic papillary pathological structure was detected.", + "Further classification was still in need of postoperative paraffin pathology.", + "Some right VI lymph nodes were detected as abnormal swell and hyperplasia.", + "Right thyroid lobectomy combined with right VI lymphadenectomy was performed.", + "The patient was sent back to the ward in generally good condition after a smooth surgery.", + "An immediate postoperative assay of calcitonin showed CT < 1.5 pg per milliliter.", + "An immediate postoperative assay of carcinoembryonic antigen showed CEA 2.32 ng per milliliter.", + "The postoperative paraffin pathological diagnosis revealed adenocarcinoma of parathyroid.", + "The level of serum parathormone showed PTH 66.1 pg per milliliter.", + "The level of serum calcium showed Ca 2.31 mmol per liter.", + "The level of serum phosphorus showed P 1.17 mmol per liter.", + "99 m-Tc-MIBI-Pertechnetate imaging showed that the rest parathyroid appeared no abnormality.", + "At a six-month follow up visit after operation, no discomforts or side effects were complained by the patient.", + "No obvious local recurrence was indicated by ultrasonography.", + "The patient is still under regular routine follow up." + ], + "summary": "We describe a patient diagnosed with intrathyroidal normocalcemic parathyroid carcinoma, whose preoperative ultrasonography suggests that the tumor is located inside the thyroid gland and present without obvious clinical manifestations, which makes it more challenging for diagnosis.", + "summary_subclaims": [ + "The patient was diagnosed with intrathyroidal normocalcemic parathyroid carcinoma.", + "Preoperative ultrasonography suggests that the tumor is located inside the thyroid gland.", + "The tumor is present without obvious clinical manifestations.", + "The absence of obvious clinical manifestations makes it more challenging for diagnosis." + ] + }, + { + "id": "multiclinsum_test_1014_en.txt", + "fulltext": "The patient was a 53-year-old woman with no relevant medical history. She experienced discomfort and pain in the anal region, and a colonoscopy detected a tumor in the colon. On the basis of imaging and endometrial sampling cytology with conventional biopsy findings, she was diagnosed with International Federation of Gynecology and Obstetrics stage IVB endometrial cancer (endometrioid adenocarcinoma Grade 1) with colon metastasis and lymphadenopathy in the bilateral obturator lymph nodes and sacrum. She received neoadjuvant chemotherapy (four cycles of paclitaxel 175 mg/m2 and carboplatin area under curve 6). Two months later, Hartmann surgery was performed to prevent the tumor from occluding the colon. Pathological evaluation of the tumor specimen confirmed endometrial cancer, surgical stage IVB. MSI testing revealed the tumor was MSI-H.\nAfter the surgery, computed tomography (CT) showed an enlarged recurrent tumor in the colon, with peritoneal dissemination and multiple metastases in the paraaortic lymph nodes. Hence, she was started on a combination of lenvatinib (20 mg, administered orally once daily) and pembrolizumab (200 mg, administered intravenously as a 30-minute infusion every 3 weeks). On day 11 after the LEAP therapy, she received 4 units of red blood cells due to a fall in her hemoglobin level to 7.3 g/dL. She was discharged on day 12. On day 15, she developed a gait disorder and tremors. Hypothyroidism (thyroid stimulating hormone [TSH] level: 5.350 ng/mL, free thyroxine 4 [FT4] level: 0.99 pg/mL, free thyroxine 3 [FT3] level: 2.08 pg/mL) was also detected on the same day on consultation with endocrinologists.\nOn day 18, she was referred to the emergency room for an altered sensorium. On arrival, her Glasgow Coma Scale score was E3V4M6. Her blood pressure showed a continued increase . There was no electrolyte imbalance or renal or liver failure . An emergency CT scan found no brain metastasis or intracranial hemorrhage . Magnetic resonance imaging (MRI) showed a slightly high signal intensity in the left occipital lobe, with no apparent cerebral infarction . LEAP therapy was discontinued. Although there were no visual complaints or findings given the location of the MRI abnormalities and electroencephalogram was normal, her consciousness level gradually worsened, resulting in convulsions, which were suppressed by an intravenous injection of diazepam (5 mg). She was started on levetiracetam (200 mg) to prevent convulsions. For further investigation, additional blood tests and multiple lumbar taps were performed. While serum vitamin B1, TSH, FT4, and FT3 levels were normal, a slight increase was seen in the anti-thyroid peroxidase antibody levels . The blood glucose level was 110 mg/dL. Analysis of the cerebrospinal fluid found cells (5/µL), protein (154 mg/dL), and glucose (50 mg/dL) , suggesting that meningitis was unlikely. The disturbance in consciousness gradually improved with time, indicating the low probability of Hashimoto encephalopathy.\nPrevious clinical trials have revealed that the incidence of adverse effects of lenvatinib and pembrolizumab on the central nervous system was 0.4% and less than 0.1% , respectively, and could have caused PRES and encephalitis, respectively. The absence of markers of inflammation in the cerebrospinal fluid and a high signal intensity in the left occipital lobe on MRI suggested PRES, rather than encephalitis. Therefore, it was concluded that these symptoms were caused by lenvatinib, not pembrolizumab. She was resumed on treatment with pembrolizumab. Although no long-term sequalae of PRES were observed, unfortunately, CT showed multiple lymph node metastases after four cycles of pembrolizumab monotherapy, indicative of further disease progression. Pembrolizumab was discontinued, and she is now enrolled in another clinical trial in Japan.", + "fulltext_subclaims": [ + "The patient was a 53-year-old woman with no relevant medical history.", + "She experienced discomfort and pain in the anal region.", + "A colonoscopy detected a tumor in the colon.", + "She was diagnosed with International Federation of Gynecology and Obstetrics stage IVB endometrial cancer.", + "The tumor was endometrioid adenocarcinoma Grade 1.", + "The tumor had colon metastasis.", + "Lymphadenopathy was present in the bilateral obturator lymph nodes.", + "Lymphadenopathy was present in the sacrum.", + "She received neoadjuvant chemotherapy.", + "The chemotherapy consisted of four cycles of paclitaxel 175 mg/m2 and carboplatin area under curve 6.", + "Hartmann surgery was performed.", + "Pathological evaluation of the tumor specimen confirmed endometrial cancer.", + "The surgical stage was IVB.", + "MSI testing revealed the tumor was MSI-H.", + "Computed tomography showed an enlarged recurrent tumor in the colon.", + "Peritoneal dissemination was present.", + "Multiple metastases were present in the paraaortic lymph nodes.", + "She was started on a combination of lenvatinib and pembrolizumab.", + "Lenvatinib was administered at 20 mg, orally once daily.", + "Pembrolizumab was administered at 200 mg, intravenously as a 30-minute infusion every 3 weeks.", + "On day 11 after the LEAP therapy, she received 4 units of red blood cells.", + "Her hemoglobin level fell to 7.3 g/dL.", + "On day 15, she developed a gait disorder.", + "On day 15, she developed tremors.", + "Hypothyroidism was detected.", + "Her TSH level was 5.350 ng/mL.", + "Her FT4 level was 0.99 pg/mL.", + "Her FT3 level was 2.08 pg/mL.", + "On day 18, she was referred to the emergency room for an altered sensorium.", + "Her Glasgow Coma Scale score was E3V4M6.", + "Her blood pressure showed a continued increase.", + "There was no electrolyte imbalance.", + "There was no renal or liver failure.", + "An emergency CT scan found no brain metastasis.", + "An emergency CT scan found no intracranial hemorrhage.", + "MRI showed a slightly high signal intensity in the left occipital lobe.", + "MRI showed no apparent cerebral infarction.", + "LEAP therapy was discontinued.", + "An intravenous injection of diazepam (5 mg) was given.", + "She was started on levetiracetam (200 mg) to prevent convulsions.", + "Serum vitamin B1 levels were normal.", + "TSH levels were normal.", + "FT4 levels were normal.", + "FT3 levels were normal.", + "A slight increase was seen in the anti-thyroid peroxidase antibody levels.", + "The blood glucose level was 110 mg/dL.", + "Cerebrospinal fluid analysis found cells (5/µL).", + "Cerebrospinal fluid analysis found protein (154 mg/dL).", + "Cerebrospinal fluid analysis found glucose (50 mg/dL).", + "The disturbance in consciousness gradually improved.", + "The incidence of adverse effects of lenvatinib on the central nervous system was 0.4%.", + "The incidence of adverse effects of pembrolizumab on the central nervous system was less than 0.1%.", + "The absence of markers of inflammation in the cerebrospinal fluid suggested PRES.", + "A high signal intensity in the left occipital lobe on MRI suggested PRES.", + "It was concluded that these symptoms were caused by lenvatinib.", + "She was resumed on treatment with pembrolizumab.", + "CT showed multiple lymph node metastases after four cycles of pembrolizumab monotherapy.", + "Pembrolizumab was discontinued.", + "She is now enrolled in another clinical trial in Japan." + ], + "summary": "A 53-year-old patient with stage IVB endometrial cancer having rectal metastases, after four cycles of paclitaxel-carboplatin therapy, was found to have increased rectal invasion, peritoneal dissemination, and multiple paraaortic lymph node metastases. She was treated with LEAP therapy and discharged on day 12 without adverse events, except for mild anemia on day 11 of treatment. She was carefully managed in the outpatient department, but on day 18, she was admitted to the emergency department with severely impaired consciousness and generalized seizures. Computed tomography of the head and lumbar tap showed no abnormal findings, and the seizures resolved with anticonvulsant medication alone. Based on a thorough physical examination and findings on magnetic resonance imaging (MRI), which showed high signal intensity in the left occipital lobe, encephalopathy, rather than encephalitis, was the likely diagnosis. Symptomatic improvement was observed, and pembrolizumab monotherapy was resumed.", + "summary_subclaims": [ + "The patient is a 53-year-old woman.", + "The patient has stage IVB endometrial cancer.", + "The patient has rectal metastases.", + "The patient received four cycles of paclitaxel-carboplatin therapy.", + "After four cycles of paclitaxel-carboplatin therapy, the patient was found to have increased rectal invasion.", + "After four cycles of paclitaxel-carboplatin therapy, the patient was found to have peritoneal dissemination.", + "After four cycles of paclitaxel-carboplatin therapy, the patient was found to have multiple paraaortic lymph node metastases.", + "The patient was treated with LEAP therapy.", + "The patient was discharged on day 12.", + "The patient had no adverse events during LEAP therapy.", + "The patient had mild anemia on day 11 of treatment.", + "The patient was managed in the outpatient department.", + "On day 18, the patient was admitted to the emergency department with severely impaired consciousness.", + "On day 18, the patient had generalized seizures.", + "Computed tomography of the head showed no abnormal findings.", + "Lumbar tap showed no abnormal findings.", + "The seizures resolved with anticonvulsant medication alone.", + "Magnetic resonance imaging showed high signal intensity in the left occipital lobe.", + "Encephalopathy, rather than encephalitis, was the likely diagnosis.", + "Symptomatic improvement was observed.", + "Pembrolizumab monotherapy was resumed." + ] + }, + { + "id": "multiclinsum_test_2079_en.txt", + "fulltext": "The patient is a 45-year old woman of Japanese descent with urothelial carcinoma of the right renal pelvis. The family history was negative for any malignancies in first-degree relatives. She has been a life-long non-smoker and has no occupational exposure to aniline dyes, radiation, or other chemicals. After presenting with gross hematuria in November 2013, a CT-IVP showed an abnormal, mass-like infiltration measuring 2.9 x 2.4 x 3 cm of the middle to lower right renal collecting system involving the renal parenchyma and invading the sinus fat. Ureteroscopy and biopsy revealed a transitional cell malignancy of the right lower pole renal calyx. In December 2013, she underwent a hand-assisted right nephroureterectomy.\nPathology revealed high-grade urothelial carcinoma invading the renal parenchyma and peripelvic fat without a significant inflammatory component . The resection margins were negative. She was deemed as having G3 pT3N0M0, AJCC Stage III cancer. Post-operatively, she received 6 cycles of adjuvant gemcitabine-cisplatin chemotherapy and completed the treatment by July 2014. A CT scan immediately following adjuvant treatment revealed a new contralateral lymphadenopathy measuring 1.2 cm. Subsequently, a repeat scan revealed a new nodular lesion in the right renal bed and an increase in the dimensions of the left sided lymph node to 2.3 cm including two additional areas of metastatic disease: a lesion overlying the right iliopsoas muscle and the left para-aortic adenopathy. PET scanning disclosed that the 3 lesions seen on CT were hypermetabolic. A CT-guided biopsy confirmed metastatic urothelial carcinoma.\nMolecular profiling was performed at Foundation Medicine, Inc. utilizing next generation DNA sequencing to identify actionable genomic alterations in key oncogenes and tumor suppressor genes [exonic regions of 315 genes]. This testing revealed 73 mutations among 62 genes . Additionally, 340 variants of unknown significance [VUS] abnormalities were also identified among 166 genes (not shown). Three deleterious mutations were identified in MSH2 (A913fs*2, E226*, E580*) and one in MSH6 (R361H) .\nThe hypermutant genotype was phenotypically evaluated with 4-gene MMR IHC testing that showed loss of expression of both MSH2 and MSH6 .\nGermline DNA testing at Myriad Inc. was negative for all known Lynch mutations. Subsequently, the patient’s primary tumor was tested at Clarient GE, Inc. [Aliso Viejo, CA] for PD-L1 expression and found 2+ staining in 80 % of cells .\nThe patient enrolled on a phase I clinical trial of an anti-PD-L1 inhibitor MEDI4736 and MEDI0680, [MedImmune Inc., Gaithersburg, MD] in Los Angeles [Clinical trial #: NCT02118337]. Within 2 months at the first radiographic evaluation, she had a complete disappearance of all cancer . After 10 months of treatment, she developed grade 1–2 uritcarial rash and polyarthralgias in her hands and a positive ANA 1:160, but has no signs of severe or life-threatening autoimmunity or other criteria for a diagnosis of SLE. She has a confirmed continuous complete remission at 11 months and continues to participate on study.", + "fulltext_subclaims": [ + "The patient is a 45-year old woman of Japanese descent.", + "The patient has urothelial carcinoma of the right renal pelvis.", + "The family history was negative for any malignancies in first-degree relatives.", + "She has been a life-long non-smoker.", + "She has no occupational exposure to aniline dyes.", + "She has no occupational exposure to radiation.", + "She has no occupational exposure to other chemicals.", + "After presenting with gross hematuria in November 2013, a CT-IVP showed an abnormal, mass-like infiltration measuring 2.9 x 2.4 x 3 cm of the middle to lower right renal collecting system.", + "The mass involved the renal parenchyma.", + "The mass invaded the sinus fat.", + "Ureteroscopy and biopsy revealed a transitional cell malignancy of the right lower pole renal calyx.", + "In December 2013, she underwent a hand-assisted right nephroureterectomy.", + "Pathology revealed high-grade urothelial carcinoma invading the renal parenchyma.", + "Pathology revealed high-grade urothelial carcinoma invading the peripelvic fat.", + "The resection margins were negative.", + "She was deemed as having G3 pT3N0M0, AJCC Stage III cancer.", + "Post-operatively, she received 6 cycles of adjuvant gemcitabine-cisplatin chemotherapy.", + "She completed the treatment by July 2014.", + "A CT scan immediately following adjuvant treatment revealed a new contralateral lymphadenopathy measuring 1.2 cm.", + "A repeat scan revealed a new nodular lesion in the right renal bed.", + "The left sided lymph node increased in dimensions to 2.3 cm.", + "There were two additional areas of metastatic disease: a lesion overlying the right iliopsoas muscle and the left para-aortic adenopathy.", + "PET scanning disclosed that the 3 lesions seen on CT were hypermetabolic.", + "A CT-guided biopsy confirmed metastatic urothelial carcinoma.", + "Molecular profiling was performed at Foundation Medicine, Inc.", + "Next generation DNA sequencing was used to identify actionable genomic alterations in key oncogenes and tumor suppressor genes.", + "The testing revealed 73 mutations among 62 genes.", + "Three deleterious mutations were identified in MSH2 (A913fs*2, E226*, E580*).", + "One deleterious mutation was identified in MSH6 (R361H).", + "The hypermutant genotype was phenotypically evaluated with 4-gene MMR IHC testing.", + "The 4-gene MMR IHC testing showed loss of expression of both MSH2 and MSH6.", + "Germline DNA testing at Myriad Inc. was negative for all known Lynch mutations.", + "The primary tumor was tested at Clarient GE, Inc. for PD-L1 expression.", + "The PD-L1 expression was 2+ staining in 80 % of cells.", + "The patient enrolled on a phase I clinical trial of an anti-PD-L1 inhibitor MEDI4736 and MEDI0680.", + "Within 2 months at the first radiographic evaluation, she had a complete disappearance of all cancer.", + "After 10 months of treatment, she developed grade 1–2 urticarial rash.", + "After 10 months of treatment, she developed polyarthralgias in her hands.", + "After 10 months of treatment, she had a positive ANA 1:160.", + "She has no signs of severe or life-threatening autoimmunity.", + "She has no signs of other criteria for a diagnosis of SLE.", + "She has a confirmed continuous complete remission at 11 months.", + "She continues to participate on study." + ], + "summary": "Molecular profiling was performed using next generation DNA sequencing and (IHC) testing for MMR and PD-L1. A patient with sporadic, high grade urothelial carcinoma of the renal pelvis was found to have a hypermutator genotype with 73 mutations occurring amidst 62 known drivers of malignancy, and 340 VUS alterations. MMR deficiency phenotype was confirmed by the absence of MSH2 and MSH6 as well as deleterious mutations in these genes. IHC staining for programmed cell death ligand-1", + "summary_subclaims": [ + "Molecular profiling was performed using next generation DNA sequencing.", + "Molecular profiling was performed using immunohistochemistry testing for MMR and PD-L1.", + "The patient had sporadic, high grade urothelial carcinoma of the renal pelvis.", + "The patient was found to have a hypermutator genotype.", + "The patient had 73 mutations occurring amidst 62 known drivers of malignancy.", + "The patient had 340 VUS alterations.", + "MMR deficiency phenotype was confirmed by the absence of MSH2 and MSH6.", + "MMR deficiency phenotype was confirmed by deleterious mutations in MSH2 and MSH6." + ] + }, + { + "id": "multiclinsum_test_502_en.txt", + "fulltext": "An elderly 88-year-old female patient suffering from an actively bleeding upper GIB due to a duodenal ulcer was treated with coil embolization of the GDA. Endovascular therapy was indicated after endoscopic management using three metal clips and the injection of 4 ml Suprarenin 1:100.000 failed to stop the bleeding. Embolization was carried out using pushable coils of various sizes in the usual “front door – back door” technique over a 2.7 French (F) Progreat microcatheter (Terumo, Tokyo, Japan) which is routinely used in our institute for such embolization procedures. During embolization, the last VortX-Diamond-18 pushable coil (Boston Scientific, Massachusetts, USA) measuring 6 × 6.7 mm was dislocated into the CHA causing a subsequent slowing down of the blood flow in the vessel. A decision was thereby made to remove the coil by retrieving it through the 5F SIM1-Catheter (Boston Scientific, Massachusetts, USA), which was already positioned in the coeliac trunk as a guiding catheter for the initial embolization of the GDA. An initial trial to remove the coil using a 4 mm Amplatz GOOSE-NECK® Microsnare Kit (ev3, Minneapolis, USA) was unsuccessful. Consequently, the decision was made to retrieve the dislocated coil using a cerebral pRESET stent retriever (4 × 20 mm). For this procedure, the initially used 2.7F Progreat microcatheter was brought distal to the dislocated coil and the pRESET was placed in the CHA covering the dislocated coil . The coil was easily pulled back all the way to the SIM1-Catheter. The first trial to retrieve the coil into the lumen of the SIM1-Catheter was however unsuccessful, with the coil dislocating back into the periphery of the CHA. In the second trial, an extra step to lock the dislocated coil within the meshwork of the pRESET was performed by carefully pushing the microcatheter to the position of the dislocated coil while pulling the stent retriever . The coil was then carefully retrieved by pulling back the pRESET together with the microcatheter into the SIM1-Catheter using gentle repetitive pulling movements. A postinterventional series showed a restoration of the normal flow without perforation or thrombosis of the CHA . The patient was symptom-free and stable with improvement of the Hemoglobin-level and with no changes in the liver enzymes.", + "fulltext_subclaims": [ + "The patient was an 88-year-old female.", + "The patient had an actively bleeding upper GIB due to a duodenal ulcer.", + "Endovascular therapy was indicated after endoscopic management using three metal clips and the injection of 4 ml Suprarenin 1:100.000 failed to stop the bleeding.", + "Embolization was carried out using pushable coils of various sizes in the usual “front door – back door” technique.", + "The embolization was performed over a 2.7 French Progreat microcatheter.", + "The last VortX-Diamond-18 pushable coil measuring 6 × 6.7 mm was dislocated into the CHA.", + "The dislocated coil caused a subsequent slowing down of the blood flow in the vessel.", + "The decision was made to remove the coil by retrieving it through the 5F SIM1-Catheter.", + "An initial trial to remove the coil using a 4 mm Amplatz GOOSE-NECK® Microsnare Kit was unsuccessful.", + "The decision was made to retrieve the dislocated coil using a cerebral pRESET stent retriever (4 × 20 mm).", + "The initially used 2.7F Progreat microcatheter was brought distal to the dislocated coil.", + "The pRESET was placed in the CHA covering the dislocated coil.", + "The coil was easily pulled back all the way to the SIM1-Catheter.", + "The first trial to retrieve the coil into the lumen of the SIM1-Catheter was unsuccessful.", + "The coil dislocated back into the periphery of the CHA.", + "An extra step to lock the dislocated coil within the meshwork of the pRESET was performed.", + "The coil was then carefully retrieved by pulling back the pRESET together with the microcatheter into the SIM1-Catheter.", + "A postinterventional series showed a restoration of the normal flow without perforation or thrombosis of the CHA.", + "The patient was symptom-free and stable with improvement of the Hemoglobin-level.", + "There were no changes in the liver enzymes." + ], + "summary": "An 88-year-old female patient was referred to our hospital to get an emergency embolization of the GDA causing an UGIB with a relevant drop of the hemoglobin level. During the routine embolization of the GDA using pushable coils, a complete dislocation of the last coil into the CHA took place leading to a relevant slowing down of the arterial blood flow to the liver. A decision was thereby made to remove the dislocated coil to avoid further possible complications which was successfully achieved.", + "summary_subclaims": [ + "An 88-year-old female patient was referred to our hospital to get an emergency embolization of the GDA causing an UGIB with a relevant drop of the hemoglobin level.", + "During the routine embolization of the GDA using pushable coils, a complete dislocation of the last coil into the CHA took place leading to a relevant slowing down of the arterial blood flow to the liver.", + "A decision was thereby made to remove the dislocated coil to avoid further possible complications.", + "The dislocated coil was successfully achieved." + ] + }, + { + "id": "multiclinsum_test_2762_en.txt", + "fulltext": "A 73-year-old, 153-cm, 50-kg female was scheduled to undergo a robot-assisted right upper lobectomy for lung cancer. She had undergone a lingula-sparing left upper lobectomy 5 years before. A chest X-ray revealed angulation of the left main bronchus with a 3.4-cm distance from the trachea to the angulation point, 127° T-MB angle, and 132° PL-DL angle , which did not meet the angle criteria for remarkable angulation. Therefore, a standard left-sided DLT was selected.\nA thoracic epidural catheter was placed. After induction of general anesthesia with propofol, remifentanil, and rocuronium, a standard 35-Fr left-sided DLT (Portex Blue Line®, Smith Medical, Minneapolis, MN) was correctly placed with the video-assisted laryngoscope (McGrath MAC®, Medtronic, Minneapolis, MN) and a bronchoscope. The outlet of the bronchial port was partly faced with the bronchial wall. Test OLV with pressure-controlled ventilation with a peak pressure 20 cm H2O and positive end-expiratory pressure 4 cm H2O achieved a tidal volume above 250 mL while she was placed in the supine position. After placement in the left lateral position, test OLV could achieve a tidal volume above 200 mL. Although the tube outlet seemed almost fully faced with the bronchial wall, the bronchoscope could be advanced into the bronchus by flexing its tip. However, as soon as OLV was attempted after she was repositioned in the lateral jackknife position with the lowest chest raised and the lower trunk lowered by a flexed operating table , the tidal volume decreased to less than 50 mL. Adequate manual OLV was impossible. Bronchoscopically, the outlet was obstructed by the bronchial wall, and the bronchoscope could not be advanced beyond the tube outlet.\nImmediately, the jackknife position was released, and adequate manual OLV became possible. The tube was exchanged for a 37-Fr left-sided DLT with a flexible wire-reinforced tip and a narrow bronchial cuff (Silbroncho®, Fuji Systems, Tokyo, Japan) , using an airway exchange catheter and the video-assisted laryngoscope while she remained in the lateral position. Further, under bronchoscopic guidance, the tube tip was placed below the angulation point and above the secondary carina so that the secondary carina was seen in front of the tube outlet. Thereafter, a tidal volume during OLV remained above 250 mL even after repositioning in the lateral jackknife position. The scheduled robotic surgery was completed within 146 min under combined general and epidural anesthesia. She was extubated 9 min after the surgery and discharged from the hospital on the fourth postoperative day.", + "fulltext_subclaims": [ + "The patient was a 73-year-old, 153-cm, 50-kg female.", + "She was scheduled to undergo a robot-assisted right upper lobectomy for lung cancer.", + "She had undergone a lingula-sparing left upper lobectomy 5 years before.", + "A chest X-ray revealed angulation of the left main bronchus.", + "The distance from the trachea to the angulation point was 3.4 cm.", + "The T-MB angle was 127°.", + "The PL-DL angle was 132°.", + "The chest X-ray findings did not meet the angle criteria for remarkable angulation.", + "A standard left-sided DLT was selected.", + "A thoracic epidural catheter was placed.", + "General anesthesia was induced with propofol, remifentanil, and rocuronium.", + "A standard 35-Fr left-sided DLT (Portex Blue Line®) was placed.", + "The DLT was placed with a video-assisted laryngoscope (McGrath MAC®) and a bronchoscope.", + "The outlet of the bronchial port was partly faced with the bronchial wall.", + "Test OLV with pressure-controlled ventilation achieved a tidal volume above 250 mL in the supine position.", + "Test OLV achieved a tidal volume above 200 mL in the left lateral position.", + "The tube outlet seemed almost fully faced with the bronchial wall.", + "The bronchoscope could be advanced into the bronchus by flexing its tip.", + "OLV was attempted after repositioning in the lateral jackknife position.", + "The tidal volume decreased to less than 50 mL during OLV in the lateral jackknife position.", + "Adequate manual OLV was impossible.", + "The outlet was obstructed by the bronchial wall.", + "The bronchoscope could not be advanced beyond the tube outlet.", + "The jackknife position was released.", + "Adequate manual OLV became possible after releasing the jackknife position.", + "The tube was exchanged for a 37-Fr left-sided DLT with a flexible wire-reinforced tip and a narrow bronchial cuff (Silbroncho®).", + "The exchange was performed using an airway exchange catheter and the video-assisted laryngoscope.", + "The tube tip was placed below the angulation point and above the secondary carina.", + "The secondary carina was seen in front of the tube outlet.", + "A tidal volume during OLV remained above 250 mL after repositioning in the lateral jackknife position.", + "The scheduled robotic surgery was completed within 146 min.", + "The surgery was performed under combined general and epidural anesthesia.", + "The patient was extubated 9 min after the surgery.", + "The patient was discharged from the hospital on the fourth postoperative day." + ], + "summary": "A 73-year-old female after lingula-sparing left upper lobectomy without remarkable angulation was scheduled for robot-assisted right upper lobectomy. Ventilation failure with a standard left-sided double-lumen tube occurred when she was placed not in the lateral position but in the lateral jackknife position required for robotic surgery. After replacement by the Silbroncho® left-sided double-lumen tube, adequate one-lung ventilation became possible.", + "summary_subclaims": [ + "The patient was a 73-year-old female.", + "The patient had undergone a lingula-sparing left upper lobectomy.", + "The patient was scheduled for robot-assisted right upper lobectomy.", + "Ventilation failure with a standard left-sided double-lumen tube occurred.", + "The ventilation failure occurred when she was placed in the lateral jackknife position.", + "The lateral jackknife position is required for robotic surgery.", + "After replacement by the Silbroncho® left-sided double-lumen tube, adequate one-lung ventilation became possible." + ] + }, + { + "id": "multiclinsum_test_277_en.txt", + "fulltext": "Male patient aged 45 years at the time of diagnosis.\nChronic fatigue and pain in both shoulders and the lower back.\nThe patient visited a local clinic due to headache, dizziness, malaise, fatigue, and pain in both shoulders and the lower back. Symptoms persisted for several days and did not ease with medication. The patient underwent a complete blood count test; his white blood cell count was elevated to 34,100/mm3. The vital signs of the patient were normal, and the patient was stable without any fever. The clinical impression was leukemia, and the patient was referred to the hemato-oncology department of a university hospital. After admission, he underwent a bone marrow biopsy and a cytology exam. The results are reported in Table . Based on the biopsy results, he was diagnosed with CML and was started on chemotherapy.\nThe patient had never smoked and rarely drank alcohol.\nThe patient did not have hypertension, diabetes, tuberculosis, viral hepatitis, or human immunodeficiency virus infection.\nThere was no family history of hemato-oncologic diseases.\nThe patient started his job as a diagnostic radiographer in November 1990 and had continued working until he was diagnosed with CML. His job history is summarized in Table .\nThe patient’s main jobs involved obtaining simple radiographs, including chest and abdominal radiographs. He also performed special radiography such as gastrointestinal series radiography and measuring bone marrow density. The working environment and the equipment he used are shown in Figures and . The one-time exposure amount of the relevant diagnostic tools are listed in Table .\nThe patient’s work profile also included fixation and development of the exposed films. We investigated the chemicals used to fix and develop the film, but we found no known compound that could be considered to have initiated oncogenesis.\nRecords of the patient’s personal exposure dose from 1997 to 2012, measured by the TLD, were available. This is the official record provided by the Korea Workers’ Compensation and Welfare Service .\nThe patient mentioned that he was very stressed specifically from 2002 to 2006 because several cases of radiography had to be performed and there was no assistant to help with the workload. With regards to the missing records from 1990 to 1996, the patient estimated that the accumulated radiation would be comparable to that of 2003 to 2005, or even higher. Conventionally, younger workers tend to take more jobs than senior workers. Furthermore, the working environment then was worse than the present working conditions, and past radiologic shield methods were not as effective .\nBased on these assumptions, the PC was calculated by applying both the highest value (17.48 mSv) and the mean value (6.02 mSv) of annual radiation for the period of 1997–2012 . The PC was calculated by the Radiation Health Research Institute-Program for Estimating the Probability of Causation (RHRI-PEPC), under the consultation of the Korea Hydro and Nuclear Power Company. The results showed that the point estimation of PC, i.e., the 50th percentile, was 58.83% for the highest estimation, and 57.28%, using the assumed mean value for the missing records.", + "fulltext_subclaims": [ + "The patient is a 45-year-old male.", + "The patient had chronic fatigue and pain in both shoulders and the lower back.", + "The patient visited a local clinic due to headache, dizziness, malaise, fatigue, and pain in both shoulders and the lower back.", + "The symptoms persisted for several days and did not ease with medication.", + "The patient underwent a complete blood count test.", + "The patient's white blood cell count was 34,100/mm3.", + "The patient's vital signs were normal.", + "The patient was stable without any fever.", + "The clinical impression was leukemia.", + "The patient was referred to the hemato-oncology department of a university hospital.", + "The patient underwent a bone marrow biopsy.", + "The patient underwent a cytology exam.", + "Based on the biopsy results, the patient was diagnosed with CML.", + "The patient was started on chemotherapy.", + "The patient had never smoked.", + "The patient rarely drank alcohol.", + "The patient did not have hypertension.", + "The patient did not have diabetes.", + "The patient did not have tuberculosis.", + "The patient did not have viral hepatitis.", + "The patient did not have human immunodeficiency virus infection.", + "There was no family history of hemato-oncologic diseases.", + "The patient started his job as a diagnostic radiographer in November 1990.", + "The patient continued working until he was diagnosed with CML.", + "The patient’s main jobs involved obtaining simple radiographs, including chest and abdominal radiographs.", + "The patient performed special radiography such as gastrointestinal series radiography.", + "The patient performed measuring bone marrow density.", + "The patient’s work profile included fixation and development of the exposed films.", + "The chemicals used to fix and develop the film were investigated.", + "No known compound used for film fixation and development was considered to have initiated oncogenesis.", + "Records of the patient’s personal exposure dose from 1997 to 2012, measured by the TLD, were available.", + "The records were provided by the Korea Workers’ Compensation and Welfare Service.", + "The patient mentioned being very stressed from 2002 to 2006.", + "The patient estimated that the accumulated radiation from 1990 to 1996 was comparable to that of 2003 to 2005, or even higher.", + "The PC was calculated by applying both the highest value (17.48 mSv) and the mean value (6.02 mSv) of annual radiation for the period of 1997–2012.", + "The PC was calculated by the Radiation Health Research Institute-Program for Estimating the Probability of Causation (RHRI-PEPC).", + "The calculation was done under the consultation of the Korea Hydro and Nuclear Power Company.", + "The point estimation of PC, i.e., the 50th percentile, was 58.83% for the highest estimation.", + "The point estimation of PC, i.e., the 50th percentile, was 57.28% using the assumed mean value for the missing records." + ], + "summary": "A 45-year-old man complained of chronic fatigue and myalgia for several days. He was diagnosed with chronic myeloid leukemia. The patient was a diagnostic radiographer at a diagnostic radiation department and was exposed to ionizing radiation for 21 years before chronic myeloid leukemia was diagnosed. His job involved taking simple radiographs, computed tomography scans, and measuring bone marrow density.", + "summary_subclaims": [ + "The patient is a 45-year-old man.", + "The patient complained of chronic fatigue.", + "The patient complained of myalgia.", + "The symptoms lasted for several days.", + "The patient was diagnosed with chronic myeloid leukemia.", + "The patient was a diagnostic radiographer.", + "The patient worked in a diagnostic radiation department.", + "The patient was exposed to ionizing radiation for 21 years.", + "Chronic myeloid leukemia was diagnosed after 21 years of ionizing radiation exposure.", + "The patient's job involved taking simple radiographs.", + "The patient's job involved computed tomography scans.", + "The patient's job involved measuring bone marrow density." + ] + }, + { + "id": "multiclinsum_test_1277_en.txt", + "fulltext": "A 68-year-old female with a history of hypertension, hyperlipidemia, type 2 diabetes mellitus, gout, rheumatoid arthritis, and bilateral knee replacements on clindamycin prophylaxis for past infections presented to our emergency department with 3 weeks of worsening left lower extremity pain. She was initially seen at an urgent care for erythema and swelling of the left shin. Plain radiographs were unremarkable at that time and she was treated for cellulitis with intramuscular ceftriaxone for 10 days without improvement. On arrival, she was well-appearing, afebrile, and hemodynamically stable with erythema, swelling, and tenderness of the left pretibial soft tissues . The area of erythema and swelling appeared to terminate before the knee joint and there was no appreciable joint effusion or limitation in range of motion on exam. Her pain was worse with ambulation, but she was able to bear weight on the affected leg. Repeat plain radiographs were performed and showed focal soft tissue swelling overlying the anterior aspect of the tibia . A point-of-care ultrasound was performed by sliding the linear probe over the area of erythema in orthogonal transverse and longitudinal planes. Ultrasound demonstrated a large heterogeneous fluid collection adjacent to the tibial cortex . There was a focal defect in the cortex and pulsatile fluid communicating with the medullary cavity. Alternating bidirectional flow was visualized with color flow and pulsed wave spectral Doppler . The WBC count was normal (7.7), and systemic inflammatory markers were elevated (CRP 38 mg/dL, ESR 91 mm/hr). CT was obtained and demonstrated a 5.7 × 2.4 × 7.1 cm fluid collection adjacent to the tibial cortex with sinus tracts into the medullary cavity concerning for abscess with adjacent cellulitis and osteomyelitis . She was given vancomycin and Piperacillin/Tazobactam, orthopedics was consulted, and she was admitted to the internal medicine service. An incision and drainage of the left pretibial abscess was performed. Neither wound nor blood cultures yielded any growth. Infectious Diseases was consulted and recommended treatment with vancomycin for 6 weeks.", + "fulltext_subclaims": [ + "The patient is a 68-year-old female.", + "She has a history of hypertension.", + "She has a history of hyperlipidemia.", + "She has a history of type 2 diabetes mellitus.", + "She has a history of gout.", + "She has a history of rheumatoid arthritis.", + "She has bilateral knee replacements.", + "She is on clindamycin prophylaxis for past infections.", + "She presented with 3 weeks of worsening left lower extremity pain.", + "She was initially seen at an urgent care for erythema and swelling of the left shin.", + "Plain radiographs were unremarkable at that time.", + "She was treated for cellulitis with intramuscular ceftriaxone for 10 days.", + "She had no improvement with the 10-day course of ceftriaxone.", + "On arrival, she was well-appearing.", + "On arrival, she was afebrile.", + "On arrival, she was hemodynamically stable.", + "There was erythema, swelling, and tenderness of the left pretibial soft tissues.", + "The area of erythema and swelling appeared to terminate before the knee joint.", + "There was no appreciable joint effusion on exam.", + "There was no limitation in range of motion on exam.", + "Her pain was worse with ambulation.", + "She was able to bear weight on the affected leg.", + "Repeat plain radiographs showed focal soft tissue swelling overlying the anterior aspect of the tibia.", + "A point-of-care ultrasound was performed.", + "Ultrasound demonstrated a large heterogeneous fluid collection adjacent to the tibial cortex.", + "There was a focal defect in the cortex.", + "There was pulsatile fluid communicating with the medullary cavity.", + "Alternating bidirectional flow was visualized with color flow and pulsed wave spectral Doppler.", + "The WBC count was normal (7.7).", + "The CRP was 38 mg/dL.", + "The ESR was 91 mm/hr.", + "CT demonstrated a 5.7 × 2.4 × 7.1 cm fluid collection adjacent to the tibial cortex.", + "CT showed sinus tracts into the medullary cavity.", + "CT findings were concerning for abscess with adjacent cellulitis and osteomyelitis.", + "She was given vancomycin.", + "She was given Piperacillin/Tazobactam.", + "Orthopedics was consulted.", + "She was admitted to the internal medicine service.", + "An incision and drainage of the left pretibial abscess was performed.", + "Neither wound nor blood cultures yielded any growth.", + "Infectious Diseases was consulted.", + "Infectious Diseases recommended treatment with vancomycin for 6 weeks." + ], + "summary": "A 68-year-old female presented to the emergency department with 3 weeks of worsening left lower extremity pain. She was initially seen by urgent care for left shin erythema and swelling and treated for cellulitis with intramuscular ceftriaxone without improvement. On presentation, she was afebrile and hemodynamically stable with erythema, swelling, and tenderness of the left pretibial soft tissues. Her labs revealed leukocytosis and elevated inflammatory markers. Point-of-care ultrasound demonstrated a bidirectional flow of fluid through a disruption in the bone cortex visualized on greyscale imaging and confirmed with color and spectral Doppler. The patient was diagnosed with osteomyelitis and treated with antibiotics and incision and drainage by orthopedic surgery.", + "summary_subclaims": [ + "The patient is a 68-year-old female.", + "She presented to the emergency department with 3 weeks of worsening left lower extremity pain.", + "She was initially seen by urgent care for left shin erythema and swelling.", + "She was treated for cellulitis with intramuscular ceftriaxone.", + "She had no improvement with intramuscular ceftriaxone.", + "On presentation, she was afebrile.", + "She was hemodynamically stable.", + "She had erythema, swelling, and tenderness of the left pretibial soft tissues.", + "Her labs revealed leukocytosis.", + "Her labs revealed elevated inflammatory markers.", + "Point-of-care ultrasound demonstrated a bidirectional flow of fluid through a disruption in the bone cortex.", + "The disruption in the bone cortex was visualized on greyscale imaging.", + "The disruption in the bone cortex was confirmed with color and spectral Doppler.", + "The patient was diagnosed with osteomyelitis.", + "The patient was treated with antibiotics.", + "The patient underwent incision and drainage by orthopedic surgery." + ] + }, + { + "id": "multiclinsum_test_1721_en.txt", + "fulltext": "A 13-year-old young man was admitted to our hospital with non-sustained ventricular tachycardia episode, noticed during routine athletic evaluation.\nResting ECG was normal, with sinus rhythm, normal heart rate in the absence of significant alterations of the ventricular repolarization phase (QTma × 413 ms, QTmin 383 ms, QTd 39 ms, QTcd 44 ms). Exercise stress test (treadmill) didn’t show signs of inducible ischemia through maximal effort (METS 21, HR max 194 beats per minutes), but induced asymptomatic non sustained ventricular tachycardia, with left bundle branch morphology an inferior axis with a rate of 150 beats per minute during the second minute of the recovery phase .\nStandard echocardiographic views showed a not clearly normal coronary pattern. Indeed, the right coronary artery appeared with high take-off from the aortic wall, without clear identification of right coronary artery ostium.\nAs a result of genetic screening for catecholaminergic tachycardia, beta-blocking therapy with nadolol was started and continued until the first cardiological follow up.\nIn order to exclude the presence of a possible coronary artery anomaly and disease, coronary computed tomography angiography was performed.\nThe scan showed anomalous origin of the all three branches of coronary arteries of a single origin from left coronary sinus with malignant course of the right coronary artery, squeezed between the pulmonary trunk and the proximal ascending aorta. The distal part of the artery took its normal course. The left anterior descending artery and the circumflex artery calibers appeared to be normal. All the data were confirmed by cardiac magnetic resonance .\nMyocardial scintigraphy with protocol of two days steps and treadmill stress test (exercise) was performed, without significant evidences of perfusion defects. Catheter coronary angiography was performed to decide the tailored treatment plan. The coronary angiography showed the rare coronary anomaly pattern .\nFurthermore, the exam showed a significant milking effect at the middle segment of the left anterior descending artery, with borderline value of indices of intracoronary pressure and coronary flow reserve measured by Fractional Flow Reserve (FFR 0,74) and invasive Fractional Flow Reserve (iFFR 0,83) analysis.\nOn intravascular ultrasound (IVUS) both a slit like right coronary ostium and eccentric systolic compression in the proximal bridge segment of vessel were evident.\nThe depth and the length of the bridging muscle segment were measured as 16 mm and 25 mm, respectively .\nPlanned on pump surgery was discussed. We performed a surgical unroofing of the right coronary artery intramural section and resuspension of the intercoronary commissure, that resulted in relocation of the coronary artery into the appropriate aortic sinus. Surgical myotomy involving resection of the overlying muscle fibers on middle segment of the left anterior descending artery was performed.\nThe patient's postoperative course was uneventful. He stayed overnight in the intensive care unit and left the hospital on postoperative day 7. No complications occurred during the first six months of follow-up.", + "fulltext_subclaims": [ + "A 13-year-old young man was admitted to our hospital with non-sustained ventricular tachycardia episode.", + "The non-sustained ventricular tachycardia episode was noticed during routine athletic evaluation.", + "Resting ECG was normal, with sinus rhythm.", + "The heart rate on resting ECG was normal.", + "There were no significant alterations of the ventricular repolarization phase on resting ECG.", + "QTma was 413 ms.", + "QTmin was 383 ms.", + "QTd was 39 ms.", + "QTcd was 44 ms.", + "Exercise stress test (treadmill) didn’t show signs of inducible ischemia through maximal effort.", + "The METS achieved during the treadmill test were 21.", + "The maximal heart rate during the treadmill test was 194 beats per minute.", + "The treadmill test induced asymptomatic non-sustained ventricular tachycardia.", + "The non-sustained ventricular tachycardia had left bundle branch morphology.", + "The non-sustained ventricular tachycardia had an inferior axis.", + "The rate of the non-sustained ventricular tachycardia was 150 beats per minute.", + "The non-sustained ventricular tachycardia occurred during the second minute of the recovery phase.", + "Standard echocardiographic views showed a not clearly normal coronary pattern.", + "The right coronary artery appeared with high take-off from the aortic wall.", + "The right coronary artery ostium was not clearly identified.", + "Genetic screening for catecholaminergic tachycardia was performed.", + "Beta-blocking therapy with nadolol was started.", + "Beta-blocking therapy with nadolol was continued until the first cardiological follow up.", + "Coronary computed tomography angiography was performed.", + "The scan showed anomalous origin of all three branches of coronary arteries from a single origin from the left coronary sinus.", + "The right coronary artery had a malignant course, squeezed between the pulmonary trunk and the proximal ascending aorta.", + "The distal part of the right coronary artery took its normal course.", + "The left anterior descending artery caliber appeared to be normal.", + "The circumflex artery caliber appeared to be normal.", + "All the data from coronary computed tomography angiography were confirmed by cardiac magnetic resonance.", + "Myocardial scintigraphy with protocol of two days steps and treadmill stress test (exercise) was performed.", + "Myocardial scintigraphy showed no significant evidences of perfusion defects.", + "Catheter coronary angiography was performed.", + "The coronary angiography showed the rare coronary anomaly pattern.", + "The exam showed a significant milking effect at the middle segment of the left anterior descending artery.", + "Fractional Flow Reserve (FFR) was 0.74.", + "Invasive Fractional Flow Reserve (iFFR) was 0.83.", + "Intravascular ultrasound (IVUS) showed a slit like right coronary ostium.", + "Intravascular ultrasound (IVUS) showed eccentric systolic compression in the proximal bridge segment of the right coronary artery.", + "The depth of the bridging muscle segment was 16 mm.", + "The length of the bridging muscle segment was 25 mm.", + "Planned on pump surgery was discussed.", + "A surgical unroofing of the right coronary artery intramural section was performed.", + "Resuspension of the intercoronary commissure was performed.", + "The resuspension resulted in relocation of the coronary artery into the appropriate aortic sinus.", + "Surgical myotomy involving resection of the overlying muscle fibers on the middle segment of the left anterior descending artery was performed.", + "The patient's postoperative course was uneventful.", + "The patient stayed overnight in the intensive care unit.", + "The patient left the hospital on postoperative day 7.", + "No complications occurred during the first six months of follow-up." + ], + "summary": "We report an unusual case in which both anomalous origin of the right coronary artery and myocardial bridge on left anterior descending artery were detected concurrently.", + "summary_subclaims": [ + "Both anomalous origin of the right coronary artery and myocardial bridge on left anterior descending artery were detected concurrently." + ] + }, + { + "id": "multiclinsum_test_1963_en.txt", + "fulltext": "A 62-year-old Asian man consulted a doctor because of asthmatoid wheeze, anarthria, purpura and gait disturbance. He has no history of hypertension. He pointed out proteinuria for the first time two months ago before the consultation. He was diagnosed with a cerebral hemorrhage following a computerized tomography scan . His laboratory findings revealed that his serum creatinine concentration was 0.66 mg/dl, his serum IgE concentration was 18230 IU/ml (normal: <170 IU/ml), and his eosinophil count was 18900/μl. His urinary analysis revealed 1.61 g/gCr of proteinuria. Coagulation tests revealed a prolonged activated partial thromboplastin time at 61.2 seconds and a prothrombin time of 25.5 seconds. In addition, FV activity alone severely decreased to 4.4% of normal, and an FV inhibitor was present at a titer of 2.5 BU/ml, suggesting the presence of antibody-mediated circulating inhibitors specific for FV . The patient was diagnosed with a cerebral hemorrhage, eosinophilia, hyper IgE syndrome and acquired FV inhibitors. Steroid therapy with prednisolone (1 mg/kg) for the treatment of purpura and acquired FV inhibitors was administered. Treatment with steroid led to the improvement of his clinical symptoms including purpura, normalization of the coagulation tests, and disappearance of eosinophilia. To confirm the diagnosis of proteinuria, we performed a renal biopsy. Fine granular depositions were observed at the subepithelial layer in the glomerulus upon IgG fluorescent staining . Spike formations were partially observed at the subepithelial layer upon Periodic acid-methenamine-silver (PAM) staining . An impaired lamina rara layer and endothelial cell swelling and detachment were observed with high-density deposits at the lamina rara externa upon electron microscopic analysis . We determined that the patient had developed MN with glomerular endothelial cell damage. After the administration of steroid therapy, the proteinuria improved gradually.", + "fulltext_subclaims": [ + "The patient is a 62-year-old Asian man.", + "The patient had asthmatoid wheeze.", + "The patient had anarthria.", + "The patient had purpura.", + "The patient had gait disturbance.", + "The patient had no history of hypertension.", + "The patient had proteinuria for the first time two months before the consultation.", + "The patient was diagnosed with a cerebral hemorrhage following a computerized tomography scan.", + "The patient's serum creatinine concentration was 0.66 mg/dl.", + "The patient's serum IgE concentration was 18230 IU/ml.", + "The patient's eosinophil count was 18900/μl.", + "The patient's urinary analysis revealed 1.61 g/gCr of proteinuria.", + "The patient's activated partial thromboplastin time was 61.2 seconds.", + "The patient's prothrombin time was 25.5 seconds.", + "The patient's FV activity was 4.4% of normal.", + "The patient had an FV inhibitor titer of 2.5 BU/ml.", + "The patient was diagnosed with acquired FV inhibitors.", + "The patient was diagnosed with cerebral hemorrhage.", + "The patient was diagnosed with eosinophilia.", + "The patient was diagnosed with hyper IgE syndrome.", + "The patient received steroid therapy with prednisolone (1 mg/kg).", + "The patient's purpura improved with steroid therapy.", + "The patient's coagulation tests normalized with steroid therapy.", + "The patient's eosinophilia disappeared with steroid therapy.", + "A renal biopsy was performed to confirm the diagnosis of proteinuria.", + "Fine granular depositions were observed at the subepithelial layer in the glomerulus upon IgG fluorescent staining.", + "Spike formations were partially observed at the subepithelial layer upon Periodic acid-methenamine-silver staining.", + "An impaired lamina rara layer was observed upon electron microscopic analysis.", + "Endothelial cell swelling and detachment were observed upon electron microscopic analysis.", + "High-density deposits were observed at the lamina rara externa upon electron microscopic analysis.", + "The patient was diagnosed with membranous nephropathy with glomerular endothelial cell damage.", + "The patient's proteinuria improved gradually after the administration of steroid therapy." + ], + "summary": "A 62-year-old Asian man with a history of cerebral hemorrhage, purpura, eosinophilia and hyper immunoglobulin E syndrome developed proteinuria. The bleeding disorder was diagnosed with acquired factor V inhibitors. A renal biopsy revealed that he suffered from membranous nephropathy with glomerular endothelial damage which is reported to be involved in another factor disorder. After the steroid administration, the coagulation test and proteinuria were improved.", + "summary_subclaims": [ + "The patient is a 62-year-old Asian man.", + "The patient has a history of cerebral hemorrhage.", + "The patient has a history of purpura.", + "The patient has a history of eosinophilia.", + "The patient has a history of hyper immunoglobulin E syndrome.", + "The patient developed proteinuria.", + "The bleeding disorder was diagnosed with acquired factor V inhibitors.", + "A renal biopsy revealed membranous nephropathy.", + "A renal biopsy revealed glomerular endothelial damage.", + "Membranous nephropathy with glomerular endothelial damage is reported to be involved in another factor disorder.", + "After steroid administration, the coagulation test improved.", + "After steroid administration, the proteinuria improved." + ] + }, + { + "id": "multiclinsum_test_1874_en.txt", + "fulltext": "A 25-year-old male presented to our hospital in drowsy state with history of headache for 3 years progressively worsening for 6 months. His Glasgow Coma Scale was 13/15, magnetic resonance imaging (MRI) brain revealed giant left lateral sphenoid wing meningioma measuring 8 × 7 × 5 cm3 with no encasement of major blood vessels . Preoperative embolization was not feasible. Hence left external carotid artery (ECA) was exposed in the neck and kept occluded. Large fronto-temporal scalp flap was raised after adequate infiltration of local anesthetic with adrenaline, and use of Raney's clips. Large fronto-temporal free bone flap was raised with craniotome and temporal bone rongeured flush with middle cranial fossa. Profuse bleeding of bone edges was controlled with bone wax. Bipolar coagulation of middle meningeal artery and other vessels over the dura was carried out. Dura was opened just around the tumor, and reflected as a flap detaching it from the underlying tumor. The tumor surface was studded with blood vessels. Bipolar coagulation was performed all around the exposed tumor surface thereby devascularizing and shrinking the tumor. Gradually the tumor started to separate from the arachnoid plane and started to bulge in a pulsatile manner . Progressively deeper circumferential dissection carried out with placement of patties protecting the adjacent arachnoid layer. It appeared as if the brain pulsations were gently pushing the tumor out of the dural defect. No retractor or tumor manipulation was used throughout the procedure and finally, the whole tumor was delivered en bloc . The blood loss was around 500 ml, most of which occurred during craniotomy. Patch duraplasty was carried out using pericranium, and layered closure performed. Postoperatively the patient had improved remarkably, contrast enhanced computed tomography (CECT) showing no residual tumor, and was discharged in good functional status on fourth day . This ‘en bloc’ technique, as elaborated below, has been utilized in a series of seven more large meningiomas (>5 cm) safely with less blood loss.\nPatients with meningioma were positioned intraoperatively so that tumor was more superficial than brain. Sufficiently large basal craniotomy was carried out. Meningiomas with suspected encasement of neurovascular structures and significant interposition of brain around the tumor attachment were considered for internal decompression before dissection of tumor capsule. However, meningiomas with no contraindication as above were taken up for surgery with the rule of 4 D's: Devascularization, Diminutive dural opening, Detachment, and either Debulking followed by dissection or Dissection without debulking. After extensive coagulation of dural surface vessels, dural opening was made just at the tumor margin, so that surrounding brain was not exposed. The decision on performing internal decompression was made following early severance of dural attachment. Whenever arachnoid plane appeared favorable, dissection was carried out without debulking, and nearly always the tumor was pushed gradually by the underlying brain pulsations and edema so that the tumor gets delivered en bloc. The main advantages of ‘en bloc’ removal appear to be lesser bleeding and shorter operative time. The limited dural opening cannot be overemphasized to avoid herniation of the edematous brain being pushed out by the tumor. Also if tumor cannot be freed of its attachment in the initial phase of surgery internal debulking becomes unavoidable.\nOf the total 35 large meningiomas (>5 cm) operated by us in 2 years, 8 patients had en bloc removal while the rest had initial debulking. The mean blood loss in en bloc removal was around 400 ml, with no patient having new neurological deficit, new onset seizures, or postoperative hematomas.", + "fulltext_subclaims": [ + "A 25-year-old male presented to our hospital in a drowsy state.", + "He had a history of headache for 3 years.", + "The headache had been progressively worsening for 6 months.", + "His Glasgow Coma Scale was 13/15.", + "MRI brain revealed a giant left lateral sphenoid wing meningioma measuring 8 × 7 × 5 cm3.", + "The meningioma had no encasement of major blood vessels.", + "Preoperative embolization was not feasible.", + "The left external carotid artery was exposed in the neck and kept occluded.", + "A large fronto-temporal scalp flap was raised after adequate infiltration of local anesthetic with adrenaline.", + "Raney's clips were used.", + "A large fronto-temporal free bone flap was raised with craniotome.", + "The temporal bone was rongeured flush with the middle cranial fossa.", + "Profuse bleeding of bone edges was controlled with bone wax.", + "Bipolar coagulation of the middle meningeal artery and other vessels over the dura was carried out.", + "The dura was opened just around the tumor.", + "The dura was reflected as a flap detaching it from the underlying tumor.", + "The tumor surface was studded with blood vessels.", + "Bipolar coagulation was performed all around the exposed tumor surface.", + "The tumor started to separate from the arachnoid plane.", + "The tumor started to bulge in a pulsatile manner.", + "Progressive deeper circumferential dissection was carried out.", + "Patties were placed to protect the adjacent arachnoid layer.", + "The brain pulsations appeared to gently push the tumor out of the dural defect.", + "No retractor or tumor manipulation was used throughout the procedure.", + "The whole tumor was delivered en bloc.", + "The blood loss was around 500 ml.", + "Most of the blood loss occurred during craniotomy.", + "Patch duraplasty was carried out using pericranium.", + "Layered closure was performed.", + "Postoperatively, the patient improved remarkably.", + "Contrast-enhanced computed tomography showed no residual tumor.", + "The patient was discharged in good functional status on the fourth day.", + "This ‘en bloc’ technique has been utilized in a series of seven more large meningiomas (>5 cm) safely.", + "The ‘en bloc’ technique resulted in less blood loss.", + "Patients with meningioma were positioned intraoperatively so that the tumor was more superficial than the brain.", + "Sufficiently large basal craniotomy was carried out.", + "Meningiomas with suspected encasement of neurovascular structures were considered for internal decompression.", + "Meningiomas with significant interposition of brain around the tumor attachment were considered for internal decompression.", + "Meningiomas with no contraindications were taken up for surgery with the rule of 4 D's.", + "The rule of 4 D's includes Devascularization, Diminutive dural opening, Detachment, and either Debulking followed by dissection or Dissection without debulking.", + "After extensive coagulation of dural surface vessels, dural opening was made just at the tumor margin.", + "The decision on performing internal decompression was made following early severance of dural attachment.", + "Whenever the arachnoid plane appeared favorable, dissection was carried out without debulking.", + "The tumor was pushed gradually by the underlying brain pulsations and edema.", + "The tumor was delivered en bloc.", + "The main advantages of ‘en bloc’ removal appear to be lesser bleeding and shorter operative time.", + "The limited dural opening cannot be overemphasized to avoid herniation of the edematous brain.", + "If the tumor cannot be freed of its attachment in the initial phase of surgery, internal debulking becomes unavoidable.", + "Of the total 35 large meningiomas (>5 cm) operated by us in 2 years, 8 patients had en bloc removal.", + "The mean blood loss in en bloc removal was around 400 ml.", + "No patient had new neurological deficit.", + "No patient had new onset seizures.", + "No patient had postoperative hematomas." + ], + "summary": "We present an illustrative case of 'en bloc' excision of a highly vascular giant lateral sphenoid wing meningioma using the technique of 4 D's. After ruling out neurovascular encasement and significant brain interposition, our technique consisted of devascularization, diminutive dural opening, early detachment, and progressively deeper circumferential dissection. \"En bloc\" delivery was aided by the underlying brain pulsations and edema with no retraction or manipulation. This was successfully employed in a series of seven more patients with large meningiomas with less blood loss. All the patients recovered well with no clinical or radiological sequelae.", + "summary_subclaims": [ + "We present an illustrative case of 'en bloc' excision of a highly vascular giant lateral sphenoid wing meningioma using the technique of 4 D's.", + "After ruling out neurovascular encasement and significant brain interposition, our technique consisted of devascularization, diminutive dural opening, early detachment, and progressively deeper circumferential dissection.", + "'En bloc' delivery was aided by the underlying brain pulsations and edema with no retraction or manipulation.", + "This was successfully employed in a series of seven more patients with large meningiomas with less blood loss.", + "All the patients recovered well with no clinical or radiological sequelae." + ] + }, + { + "id": "multiclinsum_test_3228_en.txt", + "fulltext": "A 30-year-old male presented with grade 3 phimosis with no other relevant personal or family history. On physical examination, a mobile, painless, elastic, 20 mm diameter, solid, nodular mass was found in the right scrotum, with a one-year history. On ultrasound, a right paratesticular solid mass was found, 20 mm in diameter, predominantly hypoechoic, heterogeneous, with well-defined borders. Surgical resection was performed and the material was sent to the pathology department, fixed in 10% formalin. Macroscopically, a 2.5 x 1.5 x 0.7 cm skin fragment was received, which showed a 2 cm diameter nodule, poorly circumscribed, brown-grey, soft, gelatinous. Total processing of the sample was decided according to the routine protocol. Histological examination showed a dermo-hypodermic multilobulated proliferation, poorly circumscribed, partially subdivided by fibrous septa, consisting of a vascularised myxoid matrix with the presence of stromal cells of spindle-shaped fibroblasts and some stellate cells. The vascular structures had a thin wall and formed a tree-like network in some areas. A mononuclear inflammatory infiltrate and isolated polymorphonuclear neutrophils were detected at the intra-lesional level. In addition, there were elongated epithelial cords located in the periphery, but no mitosis or atypia was observed. Complementary histochemical (periodic acid-Schiff PAS; alcian blue and mucicarmine) and immunohistochemical techniques were used. The first highlighted the myxoid stromal matrix rich in mucin. The immunomarking profile was positive for vimentin and CD34 in some stromal cells and blood vessels, and negative for pan-keratin, S-100 protein, desmin, smooth muscle actin and estrogen and progesterone receptors. Clinical and morphological findings allowed the diagnosis of AS to be made. The section margins contacted the lesion. To rule out the Carney complex, extensive consultations and evaluations were performed. A detailed medical history and physical examination was performed, including a review of personal and family medical history. An echocardiogram ruled out the presence of cardiac myxoma. Possible skin lesions and laboratory blood tests were investigated. After these studies, no lesions or findings characteristic of the Carney complex were found, so this entity was ruled out. The patient signed the corresponding informed consent for the publication of the case.\n", + "fulltext_subclaims": [ + "The patient is a 30-year-old male.", + "He presented with grade 3 phimosis.", + "He had no other relevant personal or family history.", + "A mobile, painless, elastic, 20 mm diameter, solid, nodular mass was found in the right scrotum.", + "The mass had a one-year history.", + "On ultrasound, a right paratesticular solid mass was found.", + "The mass was 20 mm in diameter.", + "The mass was predominantly hypoechoic.", + "The mass was heterogeneous.", + "The mass had well-defined borders.", + "Surgical resection was performed.", + "The material was sent to the pathology department.", + "The material was fixed in 10% formalin.", + "Macroscopically, a 2.5 x 1.5 x 0.7 cm skin fragment was received.", + "The fragment showed a 2 cm diameter nodule.", + "The nodule was poorly circumscribed.", + "The nodule was brown-grey.", + "The nodule was soft and gelatinous.", + "Total processing of the sample was decided.", + "Histological examination showed a dermo-hypodermic multilobulated proliferation.", + "The proliferation was poorly circumscribed.", + "The proliferation was partially subdivided by fibrous septa.", + "The proliferation consisted of a vascularised myxoid matrix.", + "The matrix had the presence of stromal cells of spindle-shaped fibroblasts.", + "The matrix had some stellate cells.", + "The vascular structures had a thin wall.", + "The vascular structures formed a tree-like network in some areas.", + "A mononuclear inflammatory infiltrate was detected at the intra-lesional level.", + "Isolated polymorphonuclear neutrophils were detected at the intra-lesional level.", + "Elongated epithelial cords were located in the periphery.", + "No mitosis was observed.", + "No atypia was observed.", + "Complementary histochemical techniques were used.", + "Complementary immunohistochemical techniques were used.", + "The histochemical techniques highlighted the myxoid stromal matrix rich in mucin.", + "The immunomarking profile was positive for vimentin in some stromal cells.", + "The immunomarking profile was positive for CD34 in some stromal cells.", + "The immunomarking profile was positive for CD34 in some blood vessels.", + "The immunomarking profile was negative for pan-keratin.", + "The immunomarking profile was negative for S-100 protein.", + "The immunomarking profile was negative for desmin.", + "The immunomarking profile was negative for smooth muscle actin.", + "The immunomarking profile was negative for estrogen receptors.", + "The immunomarking profile was negative for progesterone receptors.", + "Clinical and morphological findings allowed the diagnosis of AS to be made.", + "The section margins contacted the lesion.", + "To rule out the Carney complex, extensive consultations and evaluations were performed.", + "A detailed medical history and physical examination was performed.", + "An echocardiogram ruled out the presence of cardiac myxoma.", + "Possible skin lesions and laboratory blood tests were investigated.", + "No lesions or findings characteristic of the Carney complex were found.", + "The patient signed the corresponding informed consent for the publication of the case." + ], + "summary": "We report a young patient who presented with a nodular mass in the right scrotum. Microscopic examination showed a proliferation of stromal cells embedded in a mucinous rich myxoid matrix with abundant thin-walled vessels and polymorphonuclear inflammatory infiltrate. Immunohistochemical techniques were positive for vimentin and CD34 in vascular structures; negative for pan-keratin, S-100 protein, desmin, smooth muscle actin, and estrogen and progesterone receptors. A superficial angiomixoma of the scrotal location was diagnosed.\n", + "summary_subclaims": [ + "The patient presented with a nodular mass in the right scrotum.", + "Microscopic examination showed a proliferation of stromal cells embedded in a mucinous rich myxoid matrix.", + "The matrix contained abundant thin-walled vessels.", + "The matrix contained polymorphonuclear inflammatory infiltrate.", + "Immunohistochemical techniques were positive for vimentin.", + "Immunohistochemical techniques were positive for CD34 in vascular structures.", + "Immunohistochemical techniques were negative for pan-keratin.", + "Immunohistochemical techniques were negative for S-100 protein.", + "Immunohistochemical techniques were negative for desmin.", + "Immunohistochemical techniques were negative for smooth muscle actin.", + "Immunohistochemical techniques were negative for estrogen receptors.", + "Immunohistochemical techniques were negative for progesterone receptors.", + "A superficial angiomixoma of the scrotal location was diagnosed." + ] + }, + { + "id": "multiclinsum_test_1694_en.txt", + "fulltext": "A 72-year-old White man with an 8-year history of CLL previously treated with four cycles of fludarabine, cyclophosphamide, rituximab in 2012, and ibrutinib since 2014, presented to the oncology clinic with 2 weeks of low-grade fever and chills, night sweats, fatigue, dysphagia, and new-onset rapidly increasing cervical lymphadenopathy. The interval workup revealed worsening of lymphocytosis (61% at presentation vs. 40.2% at 6 months before the presentation) and thrombocytopenia (42 vs. 92 K/mm3). A positron emission tomography scan showed bulky confluent hypermetabolic adenopathy throughout all bilateral neck, chest, abdomen, and pelvis portions. The patient was subsequently admitted to the hospital with suspected CLL progression and possible transformation to a more aggressive type. Lymph node biopsy revealed that high-grade diffuse large B-cell lymphoma (DLBCL) had transformed from CLL (Richter syndrome; Fig. ). The patient was started on DA-R-EPOCH chemotherapy. However, the patient's course was complicated by tumor lysis syndrome, acute kidney injury, and neutropenic fever with Pseudomonas aeruginosa bacteremia. Therapy with broad-spectrum antibacterials and antifungals and with granulocyte colony-stimulating factor (G-CSF) was initiated.\nDespite an improvement in cervical lymphadenopathy, on day 9 of hospitalization, the patient developed severe airway obstruction and immediately underwent emergency intubation for airway protection, following which he was transferred to the intensive care unit (ICU). Magnetic resonance imaging (MRI) of the neck demonstrated significant neck soft-tissue edema, for which he received high doses of hydrocortisone, but with no improvement. On day 10, the patient remained unresponsive after sedation was weaned off, and he subsequently developed two episodes of generalized seizures. Computed tomography of the head showed no acute abnormalities. An electroencephalogram did not demonstrate any signs of focal or generalized seizure activity. Brain MRI revealed edema in the cortical gray and subcortical white matter of the bilateral occipital and inferior temporal lobes, consistent with posterior reversible encephalopathy syndrome . The patient experienced recurrent seizure episodes refractory to lorazepam, levetiracetam, valproate, but responsive to midazolam and propofol. Of note, additional blood cultures became positive for Klebsiella oxytoca; thus, tigecycline was added to the antibiotic regimen. However, considering the overall grim prognosis, the decision was made, in conjunction with the family, not to escalate care. Unfortunately, the patient's condition deteriorated further, resulting in cardiac arrest. We concluded that the nature of PRES, in this case, was multifactorial and related to the recently initiated combination chemotherapy, with acute kidney injury and sepsis being essential additional risk factors.", + "fulltext_subclaims": [ + "The patient is a 72-year-old White man.", + "The patient has an 8-year history of CLL.", + "The patient was previously treated with four cycles of fludarabine, cyclophosphamide, rituximab in 2012.", + "The patient received ibrutinib since 2014.", + "The patient presented with 2 weeks of low-grade fever and chills.", + "The patient had night sweats.", + "The patient had fatigue.", + "The patient had dysphagia.", + "The patient had new-onset rapidly increasing cervical lymphadenopathy.", + "The interval workup revealed worsening of lymphocytosis (61% at presentation vs. 40.2% at 6 months before the presentation).", + "The interval workup revealed thrombocytopenia (42 vs. 92 K/mm3).", + "A positron emission tomography scan showed bulky confluent hypermetabolic adenopathy throughout all bilateral neck, chest, abdomen, and pelvis portions.", + "The patient was admitted to the hospital with suspected CLL progression.", + "The patient was admitted to the hospital with possible transformation to a more aggressive type.", + "Lymph node biopsy revealed that high-grade diffuse large B-cell lymphoma (DLBCL) had transformed from CLL.", + "The patient was started on DA-R-EPOCH chemotherapy.", + "The patient's course was complicated by tumor lysis syndrome.", + "The patient's course was complicated by acute kidney injury.", + "The patient's course was complicated by neutropenic fever with Pseudomonas aeruginosa bacteremia.", + "Therapy with broad-spectrum antibacterials was initiated.", + "Therapy with antifungals was initiated.", + "Therapy with granulocyte colony-stimulating factor (G-CSF) was initiated.", + "Despite an improvement in cervical lymphadenopathy, on day 9 of hospitalization, the patient developed severe airway obstruction.", + "The patient underwent emergency intubation for airway protection.", + "The patient was transferred to the intensive care unit (ICU).", + "Magnetic resonance imaging (MRI) of the neck demonstrated significant neck soft-tissue edema.", + "The patient received high doses of hydrocortisone.", + "On day 10, the patient remained unresponsive after sedation was weaned off.", + "The patient developed two episodes of generalized seizures.", + "Computed tomography of the head showed no acute abnormalities.", + "An electroencephalogram did not demonstrate any signs of focal or generalized seizure activity.", + "Brain MRI revealed edema in the cortical gray and subcortical white matter of the bilateral occipital and inferior temporal lobes.", + "The brain MRI findings were consistent with posterior reversible encephalopathy syndrome.", + "The patient experienced recurrent seizure episodes refractory to lorazepam, levetiracetam, valproate.", + "The patient's seizures were responsive to midazolam and propofol.", + "Additional blood cultures became positive for Klebsiella oxytoca.", + "Tigecycline was added to the antibiotic regimen.", + "The decision was made, in conjunction with the family, not to escalate care.", + "The patient's condition deteriorated further, resulting in cardiac arrest.", + "The nature of PRES, in this case, was multifactorial.", + "The PRES was related to the recently initiated combination chemotherapy.", + "Acute kidney injury was an essential additional risk factor for PRES.", + "Sepsis was an essential additional risk factor for PRES." + ], + "summary": "A 72-year-old White man presented with 2 weeks of low-grade fever and chills, night sweats, fatigue, dysphagia, and new-onset rapidly increasing cervical lymphadenopathy. He had a history of chronic lymphocytic leukemia with transformation to diffuse large B-cell lymphoma for which he was started on dose-adjusted rituximab, etoposide, prednisone vincristine, cyclophosphamide, and doxorubicin (DA-R-EPOCH). Shortly after treatment initiation, the patient developed severe airway obstruction due to cervical lymphadenopathy that required emergency intubation. A few days later, the cervical lymphadenopathy and the status of the airway improved, and sedation was consequently weaned off to plan for extubation. However, the patient did not recover consciousness and developed generalized refractory seizures. Brain magnetic resonance imaging revealed edema in the cortical gray and subcortical white matter of the bilateral occipital and inferior temporal lobes, consistent with PRES.", + "summary_subclaims": [ + "The patient is a 72-year-old White man.", + "He had 2 weeks of low-grade fever and chills.", + "He had night sweats.", + "He had fatigue.", + "He had dysphagia.", + "He had new-onset rapidly increasing cervical lymphadenopathy.", + "He had a history of chronic lymphocytic leukemia.", + "He had transformation to diffuse large B-cell lymphoma.", + "He was started on dose-adjusted rituximab, etoposide, prednisone vincristine, cyclophosphamide, and doxorubicin (DA-R-EPOCH).", + "He developed severe airway obstruction due to cervical lymphadenopathy.", + "The airway obstruction required emergency intubation.", + "The cervical lymphadenopathy and airway status improved a few days later.", + "Sedation was weaned off to plan for extubation.", + "The patient did not recover consciousness.", + "He developed generalized refractory seizures.", + "Brain magnetic resonance imaging revealed edema in the cortical gray and subcortical white matter of the bilateral occipital and inferior temporal lobes.", + "The imaging findings were consistent with PRES." + ] + }, + { + "id": "multiclinsum_test_890_en.txt", + "fulltext": "The patient was an 81-year-old Japanese man. He was diagnosed with a recurrence of UC with multiple lymph node metastases, originating from the left renal pelvis, 1 year after laparoscopic radical nephroureterectomy. In addition, his renal function worsened 1 month before the above diagnosis; a shunt was created surgically for hemodialysis initiation. Thus, chemotherapy was planned while the patient continued hemodialysis.\nBefore the commencement of chemotherapy, the patient’s Eastern Cooperative Oncology Group performance status was 1. His height was 163.5 cm, dry weight was 51.90 kg, and body surface area (BSA) was 1.55 m2. Laboratory findings were as follows: white blood count, 3700/μL; hemoglobin, 11.0 g/dL; platelet count, 168 × 103/μL; blood urea nitrogen, 24.2 mg/dL; and creatinine, 3.38 mg/dL. The patient had residual renal function, with daily urine volume > 500 mL and a 24-h creatinine clearance of 7.3 mL/min.\nThe GEM dose was reduced by 25% (750 mg/m2) and was administered by intravenous infusion for 30 min on days 1 and 8 of a 21-day cycle. CBDCA was administered by intravenous infusion for 60 min on day 1, followed by infusion of GEM. The initial CBDCA dose was calculated according to the Calvert’s formula (target AUC: 5.0 mg/ml min, GFR: 6.1 mL/min). GFR was calculated based on knowledge that 24-h creatinine clearance is generally approximately 20% higher than GFR . Therefore, the CBDCA dose was calculated as 160 mg.\nHemodialysis commenced 2 h after the end of CBDCA infusion on day 1 and was performed for 3 h, with a blood flow rate of 200 mL/min and a continuous infusion of heparin as an anticoagulant. The dialyzer membrane was made of polymethyl methacrylate, with a surface area of 1.6 m2 (BK1.6P, TORAY Inc., Tokyo, Japan). Subsequent hemodialysis was performed on days 3 and 5.\nA pharmacokinetic study was performed to monitor the measured AUC of CBDCA. This study was approved by the ethical review board at Nagoya City University Graduate School of Medical Sciences. Informed consent was obtained from the patient. Blood samples were collected during the first 2 cycles of chemotherapy. Sampling points were as follows: immediately after CBDCA infusion, before starting and ending hemodialysis, and 20 and 48 h after CBDCA infusion on day 1 . The plasma was stored at − 80 °C until analysis. The plasma platinum level was measured by inductively coupled plasma mass spectrometry. The CBDCA level was calculated using the molar ratio of platinum: CBDCA (371.25/195.08). The measured AUC of plasma CBDCA was calculated using the trapezoidal method according to the intervals before, during, and after hemodialysis, with extrapolation to infinity.\nThe measured AUC of CBDCA in the first cycle was 5.96 mg/mL min, which was 19.2% higher than the target AUC . Consequently, grade 4 neutropenia and grade 3 thrombocytopenia were observed, according to the National Cancer Institute’s Common Toxicity Criteria for Adverse Events version 4.0 . To match the target AUC more closely in the subsequent cycle, we performed a pharmacokinetic study using parameters obtained in the first cycle. Consequently, the CBDCA dose was reduced to 135 mg, and the time interval between the CBDCA infusion and hemodialysis initiation was shortened to 1 h in the second cycle. The hemodialysis duration and conditions, such as the dialyzer and blood or dialysate flow rates, were unchanged. The measured AUC of CBDCA in the second cycle was 4.97 mg/mL min . The CBDCA dose and administration procedure in the third cycle were the same as that in the second cycle. In the second and third cycles, neutropenia severities were grades 2 and 3 and thrombocytopenia severities were grades 2 and 1, respectively . In addition, no other serious adverse events, including nausea and vomiting, were observed by the supportive care. Serum creatinine levels immediately prior to starting the second and third cycles were 3.12 mg/dL and 2.84 mg/dL, respectively; the 24-h creatinine clearance was only measured prior to the first cycle. The CBDCA removal rates by hemodialysis in the first and second cycles were calculated at 56.9 and 59.3%, respectively, though the redistribution phenomenon in the post hemodialysis period could not be considered due to the small number of blood sampling points. Other pharmacokinetic parameters in the first and second cycles are shown in Table . Total clearance of CBDCA was slightly higher in the second cycle than in the first cycle. Stable disease (according to Response Evaluation Criteria in Solid Tumors) was demonstrated by computed tomography after the second and third cycles.\nThe patient’s QOL before treatment and after 2 cycles of treatment was evaluated using the Medical Outcomes Study 36-Item Short Form Survey (SF-36, iHope International Inc., Kyoto, Japan), which is a questionnaire used to measure general health status . Mean norm-based score (NBS) is an international common score recalculated on the basis of the score of 8 items of the SF-36. Our patient’s NBS did not significantly decrease after 2 cycles of chemotherapy compared with his NBS before treatment .", + "fulltext_subclaims": [ + "The patient was an 81-year-old Japanese man.", + "He was diagnosed with a recurrence of UC with multiple lymph node metastases, originating from the left renal pelvis, 1 year after laparoscopic radical nephroureterectomy.", + "A shunt was created surgically for hemodialysis initiation.", + "Chemotherapy was planned while the patient continued hemodialysis.", + "The patient’s Eastern Cooperative Oncology Group performance status was 1 before the commencement of chemotherapy.", + "The patient’s body surface area was 1.55 m2.", + "The patient’s creatinine was 3.38 mg/dL.", + "The patient had residual renal function, with daily urine volume > 500 mL.", + "The patient’s 24-h creatinine clearance was 7.3 mL/min.", + "The GEM dose was reduced by 25% (750 mg/m2).", + "GEM was administered by intravenous infusion for 30 min on days 1 and 8 of a 21-day cycle.", + "CBDCA was administered by intravenous infusion for 60 min on day 1, followed by infusion of GEM.", + "The initial CBDCA dose was calculated according to the Calvert’s formula (target AUC: 5.0 mg/ml min, GFR: 6.1 mL/min).", + "The CBDCA dose was calculated as 160 mg.", + "Hemodialysis commenced 2 h after the end of CBDCA infusion on day 1.", + "Hemodialysis was performed for 3 h, with a blood flow rate of 200 mL/min.", + "The dialyzer membrane was made of polymethyl methacrylate, with a surface area of 1.6 m2.", + "Subsequent hemodialysis was performed on days 3 and 5.", + "A pharmacokinetic study was performed to monitor the measured AUC of CBDCA.", + "The study was approved by the ethical review board at Nagoya City University Graduate School of Medical Sciences.", + "Informed consent was obtained from the patient.", + "Blood samples were collected during the first 2 cycles of chemotherapy.", + "Sampling points were immediately after CBDCA infusion, before starting and ending hemodialysis, and 20 and 48 h after CBDCA infusion on day 1.", + "The plasma was stored at −80 °C until analysis.", + "The plasma platinum level was measured by inductively coupled plasma mass spectrometry.", + "The CBDCA level was calculated using the molar ratio of platinum: CBDCA (371.25/195.08).", + "The measured AUC of plasma CBDCA was calculated using the trapezoidal method.", + "The measured AUC of CBDCA in the first cycle was 5.96 mg/mL min.", + "The measured AUC of CBDCA in the first cycle was 19.2% higher than the target AUC.", + "Grade 4 neutropenia was observed.", + "Grade 3 thrombocytopenia was observed.", + "The CBDCA dose was reduced to 135 mg in the second cycle.", + "The time interval between the CBDCA infusion and hemodialysis initiation was shortened to 1 h in the second cycle.", + "The hemodialysis duration and conditions were unchanged.", + "The measured AUC of CBDCA in the second cycle was 4.97 mg/mL min.", + "The CBDCA dose and administration procedure in the third cycle were the same as that in the second cycle.", + "Neutropenia severity in the second cycle was grade 2.", + "Thrombocytopenia severity in the second cycle was grade 2.", + "Neutropenia severity in the third cycle was grade 3.", + "Thrombocytopenia severity in the third cycle was grade 1.", + "No other serious adverse events, including nausea and vomiting, were observed.", + "Serum creatinine levels immediately prior to starting the second cycle were 3.12 mg/dL.", + "Serum creatinine levels immediately prior to starting the third cycle were 2.84 mg/dL.", + "The CBDCA removal rates by hemodialysis in the first and second cycles were calculated at 56.9 and 59.3%, respectively.", + "Stable disease was demonstrated by computed tomography after the second and third cycles.", + "The patient’s QOL was evaluated using the Medical Outcomes Study 36-Item Short Form Survey (SF-36).", + "The patient’s NBS did not significantly decrease after 2 cycles of chemotherapy compared with his NBS before treatment." + ], + "summary": "The optimal CBDCA dose and hemodialysis timing were determined by monitoring the measured area under the concentration-time curve (AUC) of CBDCA. This was used because the AUC of CBDCA is correlated with hematologic toxicities, especially nadir thrombocytopenia, and CBDCA is easily dialyzed during hemodialysis. In the first cycle, a 160 mg CBDCA dose, calculated using Calvert's formula (target-AUC: 5), was administered on day 1. Hemodialysis was performed for 3 h, starting 2 h after the end of the CBDCA infusion. The measured-AUC was 5.96 mg/mL min in the first cycle, after which the patient developed grade 3/4 hematologic toxicities. Thus, in the second cycle, the CBDCA dose was reduced to 135 mg and the time interval between CBDCA infusion and hemodialysis was shortened to 1 h, according to the results of a pharmacokinetic study performed using parameters from the first cycle. The measured-AUC in the second cycle was 4.97 mg/mL min, and hematologic toxic effects decreased to grade 2. Stable disease according to the Response Evaluation Criteria in Solid Tumors was demonstrated after the second and third cycles. QOL scores determined using a short-form questionnaire (SF-36) after 2 cycles were not significantly lower than pretreatment values.", + "summary_subclaims": [ + "The optimal CBDCA dose and hemodialysis timing were determined by monitoring the measured area under the concentration-time curve (AUC) of CBDCA.", + "The AUC of CBDCA is correlated with hematologic toxicities, especially nadir thrombocytopenia.", + "CBDCA is easily dialyzed during hemodialysis.", + "In the first cycle, a 160 mg CBDCA dose was administered on day 1.", + "The CBDCA dose was calculated using Calvert's formula with a target-AUC of 5.", + "Hemodialysis was performed for 3 h, starting 2 h after the end of the CBDCA infusion.", + "The measured-AUC was 5.96 mg/mL min in the first cycle.", + "The patient developed grade 3/4 hematologic toxicities after the first cycle.", + "In the second cycle, the CBDCA dose was reduced to 135 mg.", + "The time interval between CBDCA infusion and hemodialysis was shortened to 1 h in the second cycle.", + "The measured-AUC in the second cycle was 4.97 mg/mL min.", + "Hematologic toxic effects decreased to grade 2 in the second cycle.", + "Stable disease according to the Response Evaluation Criteria in Solid Tumors was demonstrated after the second and third cycles.", + "QOL scores after 2 cycles were not significantly lower than pretreatment values." + ] + }, + { + "id": "multiclinsum_test_2801_en.txt", + "fulltext": "A 28 year old male while attempting to slaughter a calf holding its head between his thighs accidentally shot himself with bolt gun to right thigh and sustained Grade II open fracture of distal one third shaft of femur . He had an entry wound measuring 2 cm in length and 1 cm in breadth over anterior aspect of his right thigh .\nThe wound was explored and debrided on the day of admission. Wound swab grew Pseudomonas, Proteus and Anaerobes. He was started on intra venous Augmentin. After five days, patient developed fever with chills and rigors. He also had purulent discharge from the wound. Inflammatory markers were raised with C reactive protein of 450. MRI confirmed there was no collection of pus in the posterior compartment of thigh. He underwent another wound exploration and debridement on fifth day of admission. Pus collection was found in the subcutaneous and sub muscular layers of right thigh. The wound was communicating with knee joint through the supra patellar pouch. Knee was washed out under arthroscopic guidance.\nThe wound was treated with negative pressure wound therapy. He had a further wound debridement andsecondary wound closure after eleven days of injury and then discharged to home. The limb was immobilized in an above knee cast for four weeks and knee was later mobilized using a knee ranger splint.\nHe had three weeks of intravenous Ertepenem based on wound swab culture and sensitivity. At 12 months of follow up the wound healed with no signs of infection. He had full range of knee movements.", + "fulltext_subclaims": [ + "The patient is a 28 year old male.", + "He sustained a Grade II open fracture of the distal one third shaft of the femur.", + "He had an entry wound measuring 2 cm in length and 1 cm in breadth over the anterior aspect of his right thigh.", + "The wound was explored and debrided on the day of admission.", + "Wound swab grew Pseudomonas, Proteus and Anaerobes.", + "He was started on intra venous Augmentin.", + "After five days, the patient developed fever with chills and rigors.", + "He had purulent discharge from the wound.", + "Inflammatory markers were raised with C reactive protein of 450.", + "MRI confirmed there was no collection of pus in the posterior compartment of the thigh.", + "He underwent another wound exploration and debridement on the fifth day of admission.", + "Pus collection was found in the subcutaneous and sub muscular layers of the right thigh.", + "The wound was communicating with the knee joint through the supra patellar pouch.", + "The knee was washed out under arthroscopic guidance.", + "The wound was treated with negative pressure wound therapy.", + "He had a further wound debridement and secondary wound closure after eleven days of injury.", + "The limb was immobilized in an above knee cast for four weeks.", + "He had three weeks of intravenous Ertepenem based on wound swab culture and sensitivity.", + "At 12 months of follow up, the wound healed with no signs of infection.", + "He had full range of knee movements." + ], + "summary": "A 28 years old male presented to our Accident and Emergency department after accidental injury to his right thigh with bolt gun. He had an entry wound measuring 2 cm in length and 1 cm in breadth over anterior aspect of lower one third of thigh at lower and sustained Grade II compound fracture of right femur shaft at distal one third. The wound was treated with multiple debridements, negative pressure wound therapy and intravenous antibiotics based on culture and sensitivity.", + "summary_subclaims": [ + "The patient is a 28 years old male.", + "He presented to the Accident and Emergency department after an accidental injury to his right thigh with a bolt gun.", + "He had an entry wound measuring 2 cm in length and 1 cm in breadth over the anterior aspect of the lower one third of the thigh.", + "He sustained a Grade II compound fracture of the right femur shaft at the distal one third.", + "The wound was treated with multiple debridements.", + "Negative pressure wound therapy was used.", + "Intravenous antibiotics were administered based on culture and sensitivity." + ] + }, + { + "id": "multiclinsum_test_2507_en.txt", + "fulltext": "A 68-year-old male presented to the outpatient clinic complaining of drowsiness and fatigue for 2 weeks. He had a history of left-sided cerebral infarction 5 months ago and no hypertension, diabetes, coronary artery disease or atrial fibrillation. Since then, dual antiplatelet and statin therapy was taken and there was no transient ischemic attack. Neurological examination showed right limb dyskinesia along with aphasia. The admission low-density lipoprotein cholesterol was 1.64 mmol/L, preoperative coagulation was normal with prothrombin time (PT) of 11.9 s, activated partial thromboplastin time (APTT) of 27.3 s, international normalized ratio (INR) of 1.04, thromboelastography arachidonic acid (AA) inhibition rate of 96 % and adenosine diphosphate (ADP) inhibition rate of 90 %. The electrocardiogram showed sinus tachycardia. Because of claustrophobia, only computed tomography (CT) images could be provided. After admission, one-stop computed tomography angiography (CTA)/computed tomography perfusion (CTP) was performed. CTA showed that the Willis circle was well developed . CTP showed that cerebral blood volume (CBV) and cerebral blood flow (CBF) in the left hemisphere were lower than those in the right hemisphere, while time to peak (TTP) was significantly higher .\nDigital subtraction angiography (DSA) revealed occlusion at the beginning of the left ICA and 75 % stenosis in the right ICA according to the North American Symptomatic Carotid Endarterectomy Trial criteria . The right ICA stent (XACT 6–8*40 mm, Abbott) implantation was performed after DSA . During the procedure, there was no significant decrease in blood pressure or heart rate, nor any neurological deterioration. Unfortunately, 8 h after CAS, the patient developed restlessness, accompanied by a marked increase in blood pressure (170/100 mmHg). After the exclusion of intracranial hemorrhage by CT, sedation and antihypertensive treatment were used, and the blood pressure was controlled below 120/80 mmHg. However, the patient developed left limb hemiplegia 24 h after the procedure. Then one-stop CTA/CTP was performed again. Intracranial vessels were comparable to that before CAS . CTP showed CBV and CBF in the left hemisphere were improved and TTP was reduced significantly. But CBV and CBF in the right hemisphere were not only lower than pre-operation, but also lower than that in the left hemisphere . Dynamic Transcranial Doppler (TCD) was also performed. Flow velocity of the right middle cerebral artery (MCA) decreased 24 h after CAS, while that of the right anterior cerebral artery (ACA) increased significantly . We supposed that hypoperfusion in the right hemisphere might be caused by left-to-right blood theft. Then hypervolemic treatment (intravenous infusion of saline 3000 ml per day) was accepted and the blood pressure was maintained above 140/90 mmHg. After 3 days, the patient’s restlessness and left limb hemiplegia were completely relieved. No recurrence of cerebral ischemia occurred during 3 months of telephone follow-up.", + "fulltext_subclaims": [ + "The patient is a 68-year-old male.", + "He presented with drowsiness and fatigue for 2 weeks.", + "He had a history of left-sided cerebral infarction 5 months ago.", + "He had no history of hypertension, diabetes, coronary artery disease, or atrial fibrillation.", + "Dual antiplatelet and statin therapy was taken since the cerebral infarction.", + "There was no transient ischemic attack.", + "Neurological examination showed right limb dyskinesia.", + "Neurological examination showed aphasia.", + "The admission low-density lipoprotein cholesterol was 1.64 mmol/L.", + "The prothrombin time was 11.9 s.", + "The activated partial thromboplastin time was 27.3 s.", + "The international normalized ratio was 1.04.", + "The thromboelastography arachidonic acid inhibition rate was 96%.", + "The thromboelastography adenosine diphosphate inhibition rate was 90%.", + "The electrocardiogram showed sinus tachycardia.", + "Computed tomography images were provided because of claustrophobia.", + "One-stop computed tomography angiography/perfusion was performed.", + "Computed tomography angiography showed that the Willis circle was well developed.", + "Computed tomography perfusion showed cerebral blood volume in the left hemisphere was lower than in the right hemisphere.", + "Computed tomography perfusion showed cerebral blood flow in the left hemisphere was lower than in the right hemisphere.", + "Computed tomography perfusion showed time to peak was significantly higher in the left hemisphere.", + "Digital subtraction angiography revealed occlusion at the beginning of the left internal carotid artery.", + "Digital subtraction angiography showed 75% stenosis in the right internal carotid artery according to the North American Symptomatic Carotid Endarterectomy Trial criteria.", + "Right internal carotid artery stent implantation was performed after digital subtraction angiography.", + "During the procedure, there was no significant decrease in blood pressure.", + "During the procedure, there was no significant decrease in heart rate.", + "During the procedure, there was no neurological deterioration.", + "Eight hours after carotid artery stenting, the patient developed restlessness.", + "Eight hours after carotid artery stenting, blood pressure was 170/100 mmHg.", + "Intracranial hemorrhage was excluded by computed tomography.", + "Sedation and antihypertensive treatment were used.", + "Blood pressure was controlled below 120/80 mmHg.", + "The patient developed left limb hemiplegia 24 hours after the procedure.", + "One-stop computed tomography angiography/perfusion was performed again.", + "Intracranial vessels were comparable to those before carotid artery stenting.", + "Computed tomography perfusion showed cerebral blood volume in the left hemisphere was improved.", + "Computed tomography perfusion showed cerebral blood flow in the left hemisphere was improved.", + "Computed tomography perfusion showed time to peak in the left hemisphere was reduced significantly.", + "Computed tomography perfusion showed cerebral blood volume in the right hemisphere was lower than pre-operation.", + "Computed tomography perfusion showed cerebral blood flow in the right hemisphere was lower than pre-operation.", + "Computed tomography perfusion showed cerebral blood volume in the right hemisphere was lower than in the left hemisphere.", + "Computed tomography perfusion showed cerebral blood flow in the right hemisphere was lower than in the left hemisphere.", + "Dynamic transcranial Doppler was performed.", + "Flow velocity of the right middle cerebral artery decreased 24 hours after carotid artery stenting.", + "Flow velocity of the right anterior cerebral artery increased significantly 24 hours after carotid artery stenting.", + "Hypoperfusion in the right hemisphere was supposed to be caused by left-to-right blood theft.", + "Hypervolemic treatment with intravenous infusion of saline 3000 ml per day was accepted.", + "Blood pressure was maintained above 140/90 mmHg.", + "After 3 days, the patient’s restlessness was completely relieved.", + "After 3 days, the patient’s left limb hemiplegia was completely relieved.", + "No recurrence of cerebral ischemia occurred during 3 months of telephone follow-up." + ], + "summary": "A 68-year-old male with severe right internal carotid artery stenosis and left internal carotid artery occlusion underwent right stenosis stent implantation. Restlessness and left limb hemiplegia occurred within 24 h after the procedure, which was similar to hyperperfusion syndrome. However, postoperative computerized tomography perfusion (CTP) revealed abnormal hypoperfusion in the right hemisphere. Transcranial Doppler (TCD) also showed decreased flow velocity in the right middle cerebral artery, and increased flow velocity in the right anterior cerebral artery. We considered that intracerebral steal phenomenon might be the cause, then hypervolemic therapy was accepted and the symptoms completely resolved after 3 days.", + "summary_subclaims": [ + "The patient is a 68-year-old male.", + "The patient had severe right internal carotid artery stenosis.", + "The patient had left internal carotid artery occlusion.", + "The patient underwent right stenosis stent implantation.", + "Restlessness occurred within 24 h after the procedure.", + "Left limb hemiplegia occurred within 24 h after the procedure.", + "The symptoms were similar to hyperperfusion syndrome.", + "Postoperative computerized tomography perfusion revealed abnormal hypoperfusion in the right hemisphere.", + "Transcranial Doppler showed decreased flow velocity in the right middle cerebral artery.", + "Transcranial Doppler showed increased flow velocity in the right anterior cerebral artery.", + "Intracerebral steal phenomenon was considered to be the cause.", + "Hypervolemic therapy was accepted.", + "The symptoms completely resolved after 3 days." + ] + }, + { + "id": "multiclinsum_test_82_en.txt", + "fulltext": "A 4-year-old girl was brought by her mother from Saravan city to the emergency department of gynecology in Ali-Ibn-Abitaleb Hospital of Zahedan University of Medical Sciences in May 2012, with the complaints of a foreign body in her vagina and lower abdominal pain for eight hours. The clinicians did a pelvic X-Ray in Saravan city hospital that showed a big metal nail in the child`s vagina . In physical examination of the girl in frog-leg position and by tension of her vulvae labials major, a black point in depth of her vagina through the orifice of hymen was observed, it was the tail of a nail, the hymen was intact and her mother entreated that we discharge the nail without trauma to child hymen. Fortunately the cooperation of child was very good and we could discharge the nail by doing the TR (rectal exam with finger) and pushing the nail to midline of vaginal canal and extraction of nail out of vagina by use of a magnetic mag . In this case, it could not be established whether the nail had been inserted by the child herself or by another child or an adult.", + "fulltext_subclaims": [ + "A 4-year-old girl was brought by her mother from Saravan city to the emergency department of gynecology in Ali-Ibn-Abitaleb Hospital of Zahedan University of Medical Sciences in May 2012.", + "The girl had complaints of a foreign body in her vagina and lower abdominal pain for eight hours.", + "The clinicians did a pelvic X-Ray in Saravan city hospital that showed a big metal nail in the child's vagina.", + "In physical examination, a black point in depth of her vagina through the orifice of hymen was observed.", + "The hymen was intact.", + "The mother entreated that the nail be discharged without trauma to the child's hymen.", + "The child's cooperation was very good.", + "The nail was discharged by doing a rectal exam with a finger.", + "The nail was pushed to the midline of the vaginal canal.", + "The nail was extracted out of the vagina by use of a magnetic mag.", + "It could not be established whether the nail had been inserted by the child herself or by another child or an adult." + ], + "summary": "This problem may produce symptoms or be asymptomatic for long periods of time and may result from ignorance, accident, malice, psychotic tendencies, attempts at sexual stimulation or sexual abuse. The current report presents the case of a girl that had inserted a foreign body in her vagina probably due to childish prank.", + "summary_subclaims": [ + "This problem may produce symptoms or be asymptomatic for long periods of time.", + "This problem may result from ignorance.", + "This problem may result from accident.", + "This problem may result from malice.", + "This problem may result from psychotic tendencies.", + "This problem may result from attempts at sexual stimulation.", + "This problem may result from sexual abuse.", + "The current report presents the case of a girl that had inserted a foreign body in her vagina.", + "The girl probably inserted the foreign body due to childish prank." + ] + }, + { + "id": "multiclinsum_test_618_en.txt", + "fulltext": "A 57-year-old gentleman with a history of active smoking, insulin dependent diabetes mellito (IDDM), hypertension, dyslipidaemia, and chronic coronary artery disease (CAD), presented complaining of severe ED. He underwent percutaneous coronary intervention (PCI) in 2010 with implantation of three DES on left anterior descending artery, OM1, and right coronary artery. He was asymptomatic for chest pain, and echocardiography demonstrated normal cardiac function. He had normal external genitalia and secondary sexual characteristics. Sexual hormones analyses were in the reference range (total testosterone 7.34 ng/dL; free testosterone 17 pg/mL; sex hormone binding globulin 54 nmol/L; DHEA-S 394 g/dL). Ultrasound evaluation revealed normal prostate. Patient was taking 1 tablet of Bisoprolol 1.25 mg in the morning. He showed no response to increasing doses of different oral PDE5i drugs as well as no response to intra-cavernosal injections to prostaglandin E1 (IC-PDE1) over a 1-year period. Libido was normal. Dynamic Doppler Ultrasound with IC injection of PDE1 (Caverject® 10 mcg and after 10 min additional 10 mcg) showed a peak systolic velocity (PSV) of 12 cm/s on the left cavernosal artery and a PSV of 6 cm/s on the right cavernosal artery suggestive of a bilateral severe vasculogenic ED (normal response after Caverject > 25 cm/s). International Index of Erectile Dysfunction-5 questionnaire (IIEF) score was 3 points (normal 26–30; severe ED 6–10; moderate ED 11–16; mild ED 17–25). Selective angiography showed significant and diffuse atherosclerotic disease of the right mid and distal internal pudendal artery (IPA) associated with absence opacification of distal vascularization of the cavernous bodies and critical stenosis of the left internal iliac artery (IIA) ( and ). By utilization of a 6 Fr. left internal mammary guiding catheter (Cordis, Milan, Italy), the left IIA was engaged, and a 0.014' BMW wire (Abbott, Milan, Italy) was utilized to cross the stenosis. After non-compliant 5 mm × 40 mm balloon pre-dilatation at 10 atm (Sequent Neo NC, B.Braun), a self-expandable 6 mm × 18 mm bare-metal stent (Vascuflex® – B.Braun,) was precisely placed at the ostium of the vessel with no residual stenosis . Then, the IPA was engaged, and stenosis crossed by a Sion Blu 0.014' wire (Asahi Intecc Co. Japan) followed by semi-compliant balloon 2.0 mm × 20 mm (Sequent Neo, B. Braun) inflation at 10 atm in the proximal, mid, and distal segments and subsequently by sirolimus-eluting balloon 2.5 mm × 30 mm inflation (Magic Touch ED, Concept Medical) at proximal and middle segments followed by 2.0 mm × 20 mm sirolimus balloon inflation at the distal segment for 2 min at 8 atm, respectively. After waiting for 10 min to rule out elastic recoil, a 2 × 18 drug-eluting stent (DES; Supraflex Cruz, SMT) was implanted in the mid-segment of the IPA due to >30% residual stenosis with an optimal final acute result at control angiography . Femoral access was closed by a 6 Fr Angioseal VIP closure device (Terumo Europe).\nOne hundred and twenty millilitre volume of peripheral blood was utilized to concentrate 12 mL of autologous mononuclear cells by point-of-care device (Hematrate® Blood Filtration System, Cook Regentec), designed to obtain an autologous concentration of mononuclear cells (MNCs) utilizing whole-blood selective filtration . Mononuclear cells were immediately injected into the cavernous bodies under echo-guidance . This procedure was repeated at 35 and 70 days after the index procedure, following the same protocol used for critical limb ischaemia non-option patients.\nThe patient's hospital course was without complications. He was discharged with aspirin 100 mg lifelong, clopidogrel 75 mg for 1 year (choice related to the presence of multiple risk factors, previous coronary revascularization and multiple stents placement in the pudendal arteries usually considered a low flow district), rosuvastatin 20 mg, and fenofibrate 200 mg, Tadalafil 5 mg/daily, and vitamin E supplementation. After 3-months from the procedure, the patient reported an excellent response to PDE5i. At 6-month, the patient underwent Dynamic Doppler ultrasound with 10 mcg of IC-PDE1, which showed peak systolic velocity of 27 cm/s on the left and 32 cm/s on the right cavernosal arteries. IEF-5 score was 16 (delta IEF 13), suggestive of an excellent mid-term result. No complication was observed at the site of MNCs injection at the time of out-patient visit. At 1-year follow-up, the patient reported stable improvement in sexual function with an IEF-5 score of 18. He underwent control angiography demonstrating complete stent patency of the left IIA and excellent result on the right IPA with a marked increase in vascularization of the distal IPA and common penile artery ( and —arrows).", + "fulltext_subclaims": [ + "The patient is a 57-year-old gentleman.", + "He has a history of active smoking.", + "He has insulin dependent diabetes mellito (IDDM).", + "He has hypertension.", + "He has dyslipidaemia.", + "He has chronic coronary artery disease (CAD).", + "He presented complaining of severe ED.", + "He underwent percutaneous coronary intervention (PCI) in 2010.", + "Three DES were implanted on the left anterior descending artery, OM1, and right coronary artery.", + "He was asymptomatic for chest pain.", + "Echocardiography demonstrated normal cardiac function.", + "Sexual hormones analyses were in the reference range.", + "Total testosterone was 7.34 ng/dL.", + "Free testosterone was 17 pg/mL.", + "Sex hormone binding globulin was 54 nmol/L.", + "DHEA-S was 394 g/dL.", + "Ultrasound evaluation revealed a normal prostate.", + "He was taking 1 tablet of Bisoprolol 1.25 mg in the morning.", + "He showed no response to increasing doses of different oral PDE5i drugs.", + "He showed no response to intra-cavernosal injections to prostaglandin E1 (IC-PDE1) over a 1-year period.", + "Libido was normal.", + "Dynamic Doppler Ultrasound with IC injection of PDE1 showed a peak systolic velocity (PSV) of 12 cm/s on the left cavernosal artery.", + "Dynamic Doppler Ultrasound with IC injection of PDE1 showed a PSV of 6 cm/s on the right cavernosal artery.", + "The PSV was suggestive of a bilateral severe vasculogenic ED.", + "The IIEF score was 3 points.", + "Selective angiography showed significant and diffuse atherosclerotic disease of the right mid and distal internal pudendal artery (IPA).", + "Selective angiography showed absence of opacification of distal vascularization of the cavernous bodies.", + "Selective angiography showed critical stenosis of the left internal iliac artery (IIA).", + "A 6 Fr. left internal mammary guiding catheter was used.", + "A 0.014' BMW wire was utilized to cross the stenosis.", + "A non-compliant 5 mm × 40 mm balloon was used for pre-dilatation at 10 atm.", + "A self-expandable 6 mm × 18 mm bare-metal stent was placed at the ostium of the vessel.", + "The IPA was engaged, and stenosis was crossed by a Sion Blu 0.014' wire.", + "A semi-compliant balloon 2.0 mm × 20 mm was inflated at 10 atm in the proximal, mid, and distal segments.", + "A sirolimus-eluting balloon 2.5 mm × 30 mm was inflated at the proximal and middle segments.", + "A 2 × 18 drug-eluting stent was implanted in the mid-segment of the IPA.", + "A 2.0 mm × 20 mm sirolimus balloon was inflated at the distal segment.", + "Femoral access was closed by a 6 Fr Angioseal VIP closure device.", + "120 mL of peripheral blood was used to concentrate 12 mL of autologous mononuclear cells.", + "Mononuclear cells were injected into the cavernous bodies under echo-guidance.", + "The procedure was repeated at 35 and 70 days after the index procedure.", + "The patient's hospital course was without complications.", + "He was discharged with aspirin 100 mg lifelong.", + "He was discharged with clopidogrel 75 mg for 1 year.", + "He was discharged with rosuvastatin 20 mg.", + "He was discharged with fenofibrate 200 mg.", + "He was discharged with Tadalafil 5 mg/daily.", + "He was discharged with vitamin E supplementation.", + "After 3 months, the patient reported an excellent response to PDE5i.", + "At 6 months, Dynamic Doppler ultrasound showed a PSV of 27 cm/s on the left cavernosal artery.", + "At 6 months, Dynamic Doppler ultrasound showed a PSV of 32 cm/s on the right cavernosal artery.", + "The IEF-5 score was 16.", + "At 1 year, the patient reported stable improvement in sexual function.", + "The IEF-5 score was 18.", + "Control angiography demonstrated complete stent patency of the left IIA.", + "Control angiography showed an excellent result on the right IPA.", + "No complication was observed at the site of MNCs injection." + ], + "summary": "We report a case of a young insulin dependent (ID) diabetic patients who suffered of severe vasculogenic erectile dysfunction associated with a poor response for more than 1 year to oral phosphodiesterase-5 inhibitors (PDE5i) and intracavernous (IC) phosphodiesterase type 1 (PDE1) therapy. At selective angiography of the pelvic district, a severe atherosclerotic disease of the internal iliac and pudendal artery was evident with absence of distal vascularization of the cavernous bodies. The patient was treated by mechanical revascularization with drug-coated balloon and drug-eluting stent placement associated with IC injection of autologous PBMNCs. Immediate and 1-year clinical and angiographic follow-up are described.", + "summary_subclaims": [ + "The patient is a young insulin dependent diabetic.", + "The patient had severe vasculogenic erectile dysfunction.", + "The patient had a poor response for more than 1 year to oral phosphodiesterase-5 inhibitors.", + "The patient had a poor response to intracavernous phosphodiesterase type 1 therapy.", + "Selective angiography showed severe atherosclerotic disease of the internal iliac and pudendal artery.", + "There was absence of distal vascularization of the cavernous bodies.", + "The patient was treated by mechanical revascularization with drug-coated balloon.", + "The patient received drug-eluting stent placement.", + "The patient had intracavernous injection of autologous PBMNCs.", + "Immediate and 1-year clinical and angiographic follow-up are described." + ] + }, + { + "id": "multiclinsum_test_353_en.txt", + "fulltext": "The patient, a 58-year-old male, was admitted to the hospital on November 10, 2021, due complaining of fever for 7 days. There was no family history. On November 2019, he was diagnosed with B-cell acute lymphoblastic leukemia and received multiple chemotherapy sessions, during which his bone marrow was retested as minimal residual disease-negative complete remission (MRD-negative CR). On November 26, 2020, the patient underwent allogeneic HSCT and received treatment such as leukocytosis, GVHD prophylaxis, and infection prophylaxis. On December 29, 2020, he developed thrombocytopenia and was treated with platelet transfusion after repeatedly rechecking bone marrow CR and MDR, and the results were negative and complete implantation of FISH donor. Fever occurred repeatedly in February, March, and May 2021, and after anti-infection, anti-fungal, and anti-viral treatment, the patient improved and was discharged.\n7 days before admission, the patient developed a fever with the highest temperature of 39.3°C. He was hospitalized again in a tertiary hospital in Guangzhou, and the chest CT showed multiple inflammations in both lungs . He was given anti-infections such as imipenem/cilastatin, caspofungin, and liposomal amphotericin B, but he still had recurrent fevers. After completing the tracheoscopy, the bronchial fluid was found positive for MTB complex nucleic acid, and MTB was detected again in the NGS. Based on the above clinical data, the patient was considered to be post-HSCT TB, and he was admitted to our hospital after consultation.", + "fulltext_subclaims": [ + "The patient is a 58-year-old male.", + "The patient was admitted to the hospital on November 10, 2021.", + "The patient was admitted due to complaining of fever for 7 days.", + "There was no family history.", + "On November 2019, he was diagnosed with B-cell acute lymphoblastic leukemia.", + "He received multiple chemotherapy sessions.", + "His bone marrow was retested as minimal residual disease-negative complete remission.", + "On November 26, 2020, the patient underwent allogeneic HSCT.", + "He received treatment such as leukocytosis.", + "He received GVHD prophylaxis.", + "He received infection prophylaxis.", + "On December 29, 2020, he developed thrombocytopenia.", + "He was treated with platelet transfusion.", + "Bone marrow CR and MDR were repeatedly rechecked.", + "The results were negative.", + "The results showed complete implantation of FISH donor.", + "Fever occurred repeatedly in February, March, and May 2021.", + "After anti-infection, anti-fungal, and anti-viral treatment, the patient improved.", + "The patient was discharged.", + "7 days before admission, the patient developed a fever.", + "The highest temperature was 39.3°C.", + "The patient was hospitalized in a tertiary hospital in Guangzhou.", + "The chest CT showed multiple inflammations in both lungs.", + "He was given imipenem/cilastatin.", + "He was given caspofungin.", + "He was given liposomal amphotericin B.", + "He still had recurrent fevers.", + "The tracheoscopy was completed.", + "The bronchial fluid was found positive for MTB complex nucleic acid.", + "MTB was detected again in the NGS.", + "The patient was considered to be post-HSCT TB.", + "He was admitted to our hospital after consultation." + ], + "summary": "We reported a patient with acute lymphoblastic leukemia suffered from pulmonary TB infection after HSCT. During anti-TB treatment, the patient had a poor response to linezolid-containing regimen, and developed side effects such as gingival bleeding and thrombocytopenia, so the administration was switched to contezolid. After 15 days of continuous treatment, the patient's platelet increased to 58×109/L, and he was discharged in stable condition. During subsequent anti-TB treatment with contezolid for more than 7 months, the platelets remained stable, and no hematological adverse reactions and no symptoms of peripheral neuropathy were observed. Moreover, repeat imaging showed that the bilateral lung lesions were significantly reduced, indicating a good outcome for the patient.", + "summary_subclaims": [ + "The patient had acute lymphoblastic leukemia.", + "The patient suffered from pulmonary TB infection after HSCT.", + "The patient had a poor response to linezolid-containing regimen.", + "The patient developed side effects such as gingival bleeding and thrombocytopenia.", + "The administration was switched to contezolid.", + "After 15 days of continuous treatment, the patient's platelet increased to 58×109/L.", + "The patient was discharged in stable condition.", + "During subsequent anti-TB treatment with contezolid for more than 7 months, the platelets remained stable.", + "No hematological adverse reactions were observed.", + "No symptoms of peripheral neuropathy were observed.", + "Repeat imaging showed that the bilateral lung lesions were significantly reduced." + ] + }, + { + "id": "multiclinsum_test_2049_en.txt", + "fulltext": "A 56-year-old male patient received coronary angiography via the right radial route in a local hospital due to sudden onset of unstable angina pectoris. During the procedure, the cardiologist found that the right brachial artery was tortuous, and the guide wire was unable to pass through that region. Then, the cardiologist used the left radial artery to complete the angiography. The result showed tri-vessel disease suitable for coronary artery bypass grafting surgery. When they were removing the guide wire from the right radial artery, the guide wire broke and became stuck in the right brachial artery because of arterial spasm. They immediately infused heparin through the right radial artery to prevent thrombosis. Afterwards, they tried to pull the broken guide wire out through the femoral artery with a wire loop snare, but failed. The length of the broken wire was approximately from the distal radial artery to the brachiocephalic artery . The patient was referred to our hospital for emergency surgery.\nThe patient received OPCABG concomitant with the retrieval of the broken guide wire stuck in the brachial artery under general anesthesia. First, the right brachial artery was dissected and exposed. After clamping the proximal brachial artery, we incised it and removed the broken guide wire completely . Then the incision was closed as routine, and the emergency OPCABG was performed, including one arterial graft (left internal mammary artery to the left anterior descending artery) and one sequential great saphenous vein (aortic top end to the first diagonal branch to the obtuse margin branch to the posterior descending artery). The whole procedure was carried out smoothly, and no obvious guide wire residue was observed by postoperative chest X-ray. The patient was discharged uneventfully, and the 12 month follow-up showed an excellent surgical outcome.", + "fulltext_subclaims": [ + "The patient received coronary angiography via the right radial route.", + "The right brachial artery was tortuous.", + "The guide wire was unable to pass through the tortuous region of the right brachial artery.", + "The cardiologist used the left radial artery to complete the angiography.", + "The result showed tri-vessel disease suitable for coronary artery bypass grafting surgery.", + "The guide wire broke and became stuck in the right brachial artery because of arterial spasm.", + "Heparin was infused through the right radial artery to prevent thrombosis.", + "They tried to pull the broken guide wire out through the femoral artery with a wire loop snare, but failed.", + "The length of the broken wire was approximately from the distal radial artery to the brachiocephalic artery.", + "The patient was referred to our hospital for emergency surgery.", + "The patient received OPCABG concomitant with the retrieval of the broken guide wire under general anesthesia.", + "The right brachial artery was dissected and exposed.", + "After clamping the proximal brachial artery, the artery was incised and the broken guide wire was removed completely.", + "The incision was closed as routine.", + "The emergency OPCABG included one arterial graft (left internal mammary artery to the left anterior descending artery).", + "The emergency OPCABG included one sequential great saphenous vein (aortic top end to the first diagonal branch to the obtuse margin branch to the posterior descending artery).", + "No obvious guide wire residue was observed by postoperative chest X-ray.", + "The patient was discharged uneventfully.", + "The 12 month follow-up showed an excellent surgical outcome." + ], + "summary": "In this report, we describe our experience with a case of off-pump coronary artery bypass (OPCABG) concomitant with the retrieval of a broken guide wire stuck in the brachial artery: a 56-year-old male patient was referred to our hospital because of tri-vessel disease and a broken guide wire stuck in the right brachial artery. He received OPCABG concomitant with the retrieval of the broken guide wire stuck in the brachial artery under general anesthesia. The patient was discharged uneventfully, and 12 months follow-up showed an excellent surgical outcome.", + "summary_subclaims": [ + "We describe our experience with a case of off-pump coronary artery bypass (OPCABG) concomitant with the retrieval of a broken guide wire stuck in the brachial artery.", + "The patient was a 56-year-old male.", + "He was referred to our hospital because of tri-vessel disease.", + "He had a broken guide wire stuck in the right brachial artery.", + "He received OPCABG concomitant with the retrieval of the broken guide wire stuck in the brachial artery under general anesthesia.", + "The patient was discharged uneventfully.", + "12 months follow-up showed an excellent surgical outcome." + ] + }, + { + "id": "multiclinsum_test_2422_en.txt", + "fulltext": "A 69-year-old Caucasian woman presented to our emergency department with a 2-h history of dyspnoea, following a family quarrel. Her past medical history included mitral valve prolapse with mild mitral regurgitation diagnosed in young age and colon cancer successfully treated by surgery and chemotherapy 3 years before. The patient suffered from anxiety, occasionally treated with anxiolytic drugs. Physical exam revealed apical systolic murmur 2/6 Levine scale with systolic click and crackles at both lung bases. Blood pressure was 110/70 mmHg, heart rate 73 b.p.m., respiratory rate 22 b.p.m., and O2 saturation 96%. The ECG showed sinus rhythm, ST-segment elevation up to 1.5 mm in lateral and anterior leads and prolonged QTc interval (496 ms). Increased high-sensitivity cardiac troponin (937 ng/L—URL 20 ng/L) and no other abnormalities were detected on blood sample analysis. Haemoglobin (13.8 g/dL), white blood cells (7.8 × 103/µL), platelets (189 × 103/µL), prothrombin time (12.3 s), and activated partial thromboplastin time (31 s) were within normal range. Transthoracic echocardiography (TTE) showed reduced left ventricular ejection fraction (LVEF, 38%) due to akinesia of cardiac apex . The patient was immediately referred to the cath lab with an initial diagnosis of ST-elevation myocardial infarction and treated with unfractionated heparin 5000 IU i.v. and dual antiplatelet therapy (aspirin 250 mg i.v. and ticagrelor 180 mg per os) according to current guidelines. Unexpectedly, coronary angiography revealed normal coronary arteries while left ventriculography confirmed the echo finding of extensive systolic dysfunction of the apical segments with hyperkinesia of the basal segments resembling ‘takotsubo’ morphology . Considering the preceding trigger event and the apical akinesia despite normal coronary arteries, the suspicion of typical TTS arose. This hypothesis was reinforced by an InterTAK diagnostic score value of >70. The patient remained under close clinical observation in the intensive care unit for 2 days receiving the following therapy: low molecular weight heparin (LMWH) 6000 IU s.c. twice daily, aspirin 100 mg/day, metoprolol 50 mg twice daily, ramipril 2.5 mg/day. Due to signs of heart failure, furosemide 20 mg i.v. twice daily was added. On the 4th day of hospitalization, the patient was transferred to the cardiology unit. Therapy remained unchanged, except for LMWH which was withdrawn. Two days later, the patient developed dysarthria and right hemiparesis. Head computed tomography (CT) scan revealed a small hypodense area at the cortico-subcortical site of the left parietal lobe. The day after, due to sudden disappearance of spontaneous speech, a new head CT was performed, revealing an additional ischaemic hypodense area localized at the cortex of the precentral gyrus, whilst no hyperdense area suggestive of ongoing intracranial haemorrhage was detected. TTE showed persisting apical akinesia and detected a small apical thrombus (1.2 mm × 3.2 mm) attached to the apical segment of the left ventricular (LV) lateral wall . Therefore, anticoagulation therapy with acenocoumarol per os was started, with dose adjustment according to periodic laboratory testing of international normalized ratio. At 72 h from the onset of neurological symptoms, head magnetic resonance imaging (MRI) confirmed the diagnosis of ischaemic stroke showing diffuse cardioembolic lesions mainly involving the left parietal and frontal lobes . Ten days after hospitalization, LV systolic function improved significatively (LVEF 48%) and the size of the apical thrombus appeared reduced . Owing to the persistence of the neurological disorders, the patient was transferred 3 days later to a neurological rehabilitation institute, in stable haemodynamic conditions. At 1-month follow-up, she was asymptomatic, hemiparesis was no more detectable and dysarthria was slowly but significantly improving. The ECG showed only diffuse negative T-waves. TTE showed normal LVEF (58%) and no apical thrombus . At 3-month follow-up, the patient was in good clinical conditions. Speech had further improved, albeit still slower than normal. No more ST-T segment abnormalities were identifiable at ECG. Cardiac MRI confirmed the complete recovery of LV systolic function and the absence of thrombi . No areas of oedema or late gadolinium enhancement were appreciated . Therefore, anticoagulation therapy was withdrawn. At 5-month follow-up, the patient fully recovered speech without any relevant symptoms.", + "fulltext_subclaims": [ + "The patient was a 69-year-old Caucasian woman.", + "She presented with a 2-h history of dyspnoea.", + "The dyspnoea followed a family quarrel.", + "Her past medical history included mitral valve prolapse with mild mitral regurgitation.", + "The mitral valve prolapse was diagnosed in young age.", + "She had colon cancer successfully treated by surgery and chemotherapy 3 years before.", + "She suffered from anxiety.", + "Anxiety was occasionally treated with anxiolytic drugs.", + "Physical exam revealed an apical systolic murmur 2/6 on the Levine scale.", + "Physical exam revealed a systolic click.", + "Physical exam revealed crackles at both lung bases.", + "Blood pressure was 110/70 mmHg.", + "Heart rate was 73 b.p.m.", + "Respiratory rate was 22 b.p.m.", + "O2 saturation was 96%.", + "The ECG showed sinus rhythm.", + "The ECG showed ST-segment elevation up to 1.5 mm in lateral and anterior leads.", + "The ECG showed a prolonged QTc interval of 496 ms.", + "High-sensitivity cardiac troponin was 937 ng/L.", + "The upper reference limit for high-sensitivity cardiac troponin was 20 ng/L.", + "Transthoracic echocardiography showed reduced left ventricular ejection fraction of 38%.", + "The reduced ejection fraction was due to akinesia of the cardiac apex.", + "The patient was immediately referred to the cath lab with an initial diagnosis of ST-elevation myocardial infarction.", + "The patient was treated with unfractionated heparin 5000 IU i.v.", + "The patient was treated with dual antiplatelet therapy.", + "The dual antiplatelet therapy included aspirin 250 mg i.v.", + "The dual antiplatelet therapy included ticagrelor 180 mg per os.", + "Coronary angiography revealed normal coronary arteries.", + "Left ventriculography confirmed apical akinesia.", + "Left ventriculography showed extensive systolic dysfunction of the apical segments.", + "Left ventriculography showed hyperkinesia of the basal segments resembling ‘takotsubo’ morphology.", + "The suspicion of typical TTS arose.", + "The suspicion was based on the preceding trigger event.", + "The suspicion was based on apical akinesia despite normal coronary arteries.", + "The InterTAK diagnostic score was >70.", + "The patient remained in the intensive care unit for 2 days.", + "The patient received low molecular weight heparin 6000 IU s.c. twice daily.", + "The patient received metoprolol 50 mg twice daily.", + "The patient received ramipril 2.5 mg/day.", + "Furosemide 20 mg i.v. twice daily was added due to signs of heart failure.", + "On the 4th day of hospitalization, the patient was transferred to the cardiology unit.", + "LMWH was withdrawn.", + "Two days later, the patient developed dysarthria.", + "Two days later, the patient developed right hemiparesis.", + "Head CT scan revealed a small hypodense area at the cortico-subcortical site of the left parietal lobe.", + "A new head CT showed an additional ischaemic hypodense area at the cortex of the precentral gyrus.", + "No hyperdense area suggestive of ongoing intracranial haemorrhage was detected.", + "TTE detected a small apical thrombus (1.2 mm × 3.2 mm) attached to the apical segment of the left ventricular lateral wall.", + "Anticoagulation therapy with acenocoumarol per os was started.", + "Anticoagulation therapy was adjusted according to periodic laboratory testing of international normalized ratio.", + "Head MRI confirmed the diagnosis of ischaemic stroke.", + "MRI showed diffuse cardioembolic lesions mainly involving the left parietal and frontal lobes.", + "At 72 h from the onset of neurological symptoms, the diagnosis of ischaemic stroke was confirmed.", + "Ten days after hospitalization, LV systolic function improved significantly (LVEF 48%).", + "The size of the apical thrombus appeared reduced.", + "The patient was transferred to a neurological rehabilitation institute.", + "The transfer occurred 3 days after hospitalization.", + "The patient was in stable haemodynamic conditions at transfer.", + "At 1-month follow-up, the patient was asymptomatic.", + "Hemiparesis was no more detectable at 1-month follow-up.", + "Dysarthria was slowly but significantly improving at 1-month follow-up.", + "The ECG showed only diffuse negative T-waves at 1-month follow-up.", + "TTE showed normal LVEF (58%) at 1-month follow-up.", + "TTE showed no apical thrombus at 1-month follow-up.", + "At 3-month follow-up, the patient was in good clinical conditions.", + "Speech had further improved at 3-month follow-up.", + "Speech was still slower than normal at 3-month follow-up.", + "No more ST-T segment abnormalities were identifiable at ECG at 3-month follow-up.", + "Cardiac MRI confirmed complete recovery of LV systolic function at 3-month follow-up.", + "Cardiac MRI showed absence of thrombi at 3-month follow-up.", + "No areas of oedema were appreciated at 3-month follow-up.", + "No late gadolinium enhancement was appreciated at 3-month follow-up.", + "Anticoagulation therapy was withdrawn at 3-month follow-up.", + "At 5-month follow-up, the patient fully recovered speech.", + "At 5-month follow-up, the patient had no relevant symptoms." + ], + "summary": "A 69-year-old woman presented to our emergency department for dyspnoea after a family quarrel. Electrocardiogram revealed ST-segment elevation in anterolateral leads and laboratory exams showed a slight elevation of high-sensitivity cardiac troponin. The patient was treated according to current guidelines on ST-elevation myocardial infarction and referred to the cath lab. Urgent coronary angiography revealed normal coronary arteries. Based on the patient profile and instrumental findings, a diagnosis of TTS was hypothesized. After 6 days, the patient developed dysarthria and right hemiparesis under therapy with aspirin, whilst low molecular weight heparin had been previously withdrawn. Transthoracic echocardiography (TTE) revealed persisting apical akinesia and a subtle intraventricular thrombus. Head computed tomography and magnetic resonance imaging detected focal areas of ischaemic necrosis resembling diffuse cardioembolic lesions. Anticoagulation therapy was started and regular TTE showed complete recovery of myocardial systolic function and absence of ventricular thrombi at 1-month follow-up. The patient fully recovered speech after 5 months.", + "summary_subclaims": [ + "The patient was a 69-year-old woman.", + "She presented to the emergency department for dyspnoea after a family quarrel.", + "Electrocardiogram revealed ST-segment elevation in anterolateral leads.", + "Laboratory exams showed a slight elevation of high-sensitivity cardiac troponin.", + "The patient was treated according to current guidelines on ST-elevation myocardial infarction.", + "Urgent coronary angiography revealed normal coronary arteries.", + "A diagnosis of TTS was hypothesized.", + "After 6 days, the patient developed dysarthria and right hemiparesis under therapy with aspirin.", + "Low molecular weight heparin had been previously withdrawn.", + "Transthoracic echocardiography revealed persisting apical akinesia and a subtle intraventricular thrombus.", + "Head computed tomography and magnetic resonance imaging detected focal areas of ischaemic necrosis resembling diffuse cardioembolic lesions.", + "Anticoagulation therapy was started.", + "Regular TTE showed complete recovery of myocardial systolic function and absence of ventricular thrombi at 1-month follow-up.", + "The patient fully recovered speech after 5 months." + ] + }, + { + "id": "multiclinsum_test_2395_en.txt", + "fulltext": "A 43-year-old man, with blunt neck trauma after being hardly hit by a crane lifting hook , was referred to the Shahid Beheshti Hospital Emergency Department (affiliated to Yasuj University of Medical Sciences, Yasuj, Iran). At the initial visit, the cervical collar was fixed first. The patient was evaluated in the primary survey and findings were as below: A: The airway system was open without any tracheal deviation, and the respiratory rate was 18 breaths/min with the oxygen saturation value of 98% estimated by pulse oximetry, while oxygen was administered at a rate of 3 L/min. B: Breathing was spontaneous without decreased breathing sound in bilateral auscultation of the lungs (no pneumothorax), but there was stridor, and the chest had bilateral symmetrical expansion, and there was no or subcutaneous emphysema. C: His blood pressure and pulse rate were 100/70 mm Hg and 92 beats/min respectively. Carotid pulses were present bilaterally. There was no ecchymosis, bruising, hematoma, and external bleeding in the trauma site at the neck . D: The patient was alert with the Glasgow Coma Scale/Score (GCS) of 15/15, and there was no cervical spine pain and tenderness, while the cervical collar was fixed. E: The patient was exposed while kept warm, and there were no other findings in the physical examinations. There was no abnormality in the simple radiography of the cervical spine. Color Doppler sonography (CDS) of the carotid and vertebral arteries and jugular vein showed normal flow velocity and spectral waveforms in the common carotid artery (CCA), internal carotid artery (ICA), external carotid artery (ECA), and vertebral arteries, and there was normal flow in both internal jugular veins. While the patient’s hoarseness and dyspnea got worse with time, neck and chest CT scans were performed to rule out laryngeal and other chest trauma. The CT scans showed no pathology in the chest but comminuted fracture of the left anterior arch of the cricoid cartilage with left-sided mucosal thickening, inflammation, and edema which was extended to the glottis, causing a narrowing of the airway (transverse inner diameter of the cricoid = 3.7 mm) .\nThe cervical spine had no fracture. Direct fiber-optic laryngoscopy revealed swelling and congestion in the epiglottis and swelling at the level of the left vocal cord. The arterial oxygen saturation value was sustained at > 98% by administration of oxygen at a rate of 3–5 L/min with the use of a mask. As the patient’s vital sign was stable, and the arterial oxygen saturation value through the pulse oximetry did not decrease with time, orotracheal intubation and tracheotomy were not performed. The patient tolerated the treatment and had good intervention adherence. There were no adverse and unanticipated events during the study.\nDysphonia and dyspnea alleviated gradually, and on the 4th day after the admission, the patient was discharged. The patient visited again on the 7th day after the discharge, and there was no dyspnea but very mild and fading dysphonia (clinically improved). The patient was optimistic about his well-being and coming back to his work again in the future. One of the limitations of this study was that we could not follow the patient with the next-up laryngoscopy.", + "fulltext_subclaims": [ + "The patient was a 43-year-old man.", + "The patient had blunt neck trauma after being hardly hit by a crane lifting hook.", + "The patient was referred to the Shahid Beheshti Hospital Emergency Department.", + "The emergency department is affiliated to Yasuj University of Medical Sciences.", + "The emergency department is located in Yasuj, Iran.", + "At the initial visit, the cervical collar was fixed first.", + "The patient was evaluated in the primary survey.", + "The airway system was open without any tracheal deviation.", + "The respiratory rate was 18 breaths/min.", + "The oxygen saturation value was 98% estimated by pulse oximetry.", + "Oxygen was administered at a rate of 3 L/min.", + "Breathing was spontaneous.", + "There was no decreased breathing sound in bilateral auscultation of the lungs.", + "There was stridor.", + "The chest had bilateral symmetrical expansion.", + "There was no subcutaneous emphysema.", + "The blood pressure was 100/70 mm Hg.", + "The pulse rate was 92 beats/min.", + "Carotid pulses were present bilaterally.", + "There was no ecchymosis, bruising, hematoma, and external bleeding in the trauma site at the neck.", + "The patient was alert with the Glasgow Coma Scale/Score (GCS) of 15/15.", + "There was no cervical spine pain and tenderness while the cervical collar was fixed.", + "There was no abnormality in the simple radiography of the cervical spine.", + "Color Doppler sonography showed normal flow velocity and spectral waveforms in the common carotid artery.", + "Color Doppler sonography showed normal flow velocity and spectral waveforms in the internal carotid artery.", + "Color Doppler sonography showed normal flow velocity and spectral waveforms in the external carotid artery.", + "Color Doppler sonography showed normal flow velocity and spectral waveforms in the vertebral arteries.", + "There was normal flow in both internal jugular veins.", + "The patient’s hoarseness and dyspnea got worse with time.", + "Neck and chest CT scans were performed to rule out laryngeal and other chest trauma.", + "The CT scans showed no pathology in the chest.", + "The CT scans showed comminuted fracture of the left anterior arch of the cricoid cartilage.", + "The CT scans showed left-sided mucosal thickening, inflammation, and edema.", + "The edema was extended to the glottis.", + "The edema caused a narrowing of the airway.", + "The transverse inner diameter of the cricoid was 3.7 mm.", + "The cervical spine had no fracture.", + "Direct fiber-optic laryngoscopy revealed swelling and congestion in the epiglottis.", + "Direct fiber-optic laryngoscopy revealed swelling at the level of the left vocal cord.", + "The arterial oxygen saturation value was sustained at > 98% by administration of oxygen at a rate of 3–5 L/min with the use of a mask.", + "The patient’s vital signs were stable.", + "The arterial oxygen saturation value through the pulse oximetry did not decrease with time.", + "Orotracheal intubation was not performed.", + "Tracheotomy was not performed.", + "The patient tolerated the treatment.", + "The patient had good intervention adherence.", + "There were no adverse and unanticipated events during the study.", + "Dysphonia and dyspnea alleviated gradually.", + "On the 4th day after the admission, the patient was discharged.", + "The patient visited again on the 7th day after the discharge.", + "There was no dyspnea on the 7th day after the discharge.", + "There was very mild and fading dysphonia on the 7th day after the discharge.", + "The patient was optimistic about his well-being.", + "The patient was optimistic about coming back to his work again in the future.", + "One of the limitations of this study was that we could not follow the patient with the next-up laryngoscopy." + ], + "summary": "A 43-year-old man, with blunt neck trauma after being hardly hit by a crane lifting hook, was referred to the Shahid Beheshti Hospital. The patient complained of dysphonia (hoarseness) and dyspnea. The CT scans showed a comminuted fracture of the left anterior arch of the cricoid cartilage with left-sided mucosal thickening, inflammation, and edema which was extended to the glottis, causing a narrowing of the airway. Direct fiber-optic laryngoscopy revealed swelling and congestion in the epiglottis and swelling at the level of the left vocal cord.", + "summary_subclaims": [ + "The patient is a 43-year-old man.", + "The patient had blunt neck trauma after being hardly hit by a crane lifting hook.", + "The patient complained of dysphonia.", + "The patient complained of dyspnea.", + "CT scans showed a comminuted fracture of the left anterior arch of the cricoid cartilage.", + "CT scans showed left-sided mucosal thickening.", + "CT scans showed inflammation.", + "CT scans showed edema.", + "The edema was extended to the glottis.", + "The edema caused a narrowing of the airway.", + "Direct fiber-optic laryngoscopy revealed swelling and congestion in the epiglottis.", + "Direct fiber-optic laryngoscopy revealed swelling at the level of the left vocal cord." + ] + }, + { + "id": "multiclinsum_test_2893_en.txt", + "fulltext": "A 66-year-old Caucasian woman presented with vertical double vision for the previous 3 weeks. Diplopia was binocular and noticed after she banged her head against the shower screen. She was healthy and had no symptoms suggestive of giant cell arteritis (GCA). A clinical examination showed right fourth cranial nerve palsy. Her magnetic resonance imaging (MRI) scan was normal. Her erythrocyte sedimentation rate (ESR) was 77mm/hour and C-reactive protein 68mg/L. She was commenced on oral steroids while awaiting temporal artery biopsy to rule out GCA. TAB revealed normal histology. As there was no clinical suspicion of GCA, her steroids were stopped. The medics investigated her further for raised inflammatory parameters and no cause was identified.\nShe then sought medical attention for a breast lump that she had noticed for the past few months. This was clinically diagnosed as breast cancer. She subsequently underwent right wide local excision of the mass and axillary clearance. Histology revealed 28mm grade 3 oestrogen receptor positive, human epidermal growth factor receptor 2 negative ductal carcinoma involving 12 of 14 axillary nodes. An oncology referral was made.\nMeanwhile, she complained of a droopy right eyelid. Orthoptic examination showed pupil-sparing third nerve paresis and mild sixth nerve involvement. The fourth nerve paresis had resolved. Neuroimaging to rule out cavernous sinus pathology was requested. A MRI scan with contrast showed meningeal thickening in frontal, parietal and occipital lobes and no abnormality in the cavernous sinus territory. This was consistent with carcinomatous meningitis .\nBy the time of her oncology appointment, she had developed numbness in the ophthalmic division of her right trigeminal nerve. A bone scan showed bone metastases; computed tomography revealed bone spread and abnormal mediastinal lymphadenopathy. Cerebrospinal fluid (CSF) cytology was negative but protein was slightly raised. Palliative hormone therapy was commenced for metastatic breast cancer. She responded quickly with complete resolution of diplopia, ptosis and numbness on her right anterior scalp within 8 weeks of starting anastrozole.", + "fulltext_subclaims": [ + "A 66-year-old Caucasian woman presented with vertical double vision for the previous 3 weeks.", + "Diplopia was binocular.", + "Diplopia was noticed after she banged her head against the shower screen.", + "She was healthy.", + "She had no symptoms suggestive of giant cell arteritis.", + "A clinical examination showed right fourth cranial nerve palsy.", + "Her MRI scan was normal.", + "Her ESR was 77mm/hour.", + "Her C-reactive protein was 68mg/L.", + "She was commenced on oral steroids.", + "A temporal artery biopsy was requested.", + "TAB revealed normal histology.", + "There was no clinical suspicion of GCA.", + "Her steroids were stopped.", + "The medics investigated her further for raised inflammatory parameters.", + "No cause was identified.", + "She sought medical attention for a breast lump that she had noticed for the past few months.", + "This was clinically diagnosed as breast cancer.", + "She underwent right wide local excision of the mass.", + "She underwent axillary clearance.", + "Histology revealed 28mm grade 3 oestrogen receptor positive ductal carcinoma.", + "Histology showed human epidermal growth factor receptor 2 negative ductal carcinoma.", + "Histology showed involvement of 12 of 14 axillary nodes.", + "An oncology referral was made.", + "She complained of a droopy right eyelid.", + "Orthoptic examination showed pupil-sparing third nerve paresis.", + "Orthoptic examination showed mild sixth nerve involvement.", + "The fourth nerve paresis had resolved.", + "Neuroimaging to rule out cavernous sinus pathology was requested.", + "A MRI scan with contrast showed meningeal thickening in frontal, parietal and occipital lobes.", + "The MRI scan showed no abnormality in the cavernous sinus territory.", + "This was consistent with carcinomatous meningitis.", + "By the time of her oncology appointment, she had developed numbness in the ophthalmic division of her right trigeminal nerve.", + "A bone scan showed bone metastases.", + "Computed tomography revealed bone spread.", + "Computed tomography showed abnormal mediastinal lymphadenopathy.", + "Cerebrospinal fluid cytology was negative.", + "Cerebrospinal fluid protein was slightly raised.", + "Palliative hormone therapy was commenced for metastatic breast cancer.", + "She responded quickly with complete resolution of diplopia.", + "She responded quickly with complete resolution of ptosis.", + "She responded quickly with complete resolution of numbness on her right anterior scalp.", + "The resolution occurred within 8 weeks of starting anastrozole." + ], + "summary": "A 66-year-old Caucasian woman presented with vertical double vision for the previous 3 weeks. At 6-weeks follow up this had resolved. However, she presented with a new third and sixth cranial nerve palsy. Neuroimaging with contrast revealed carcinomatous meningitis.", + "summary_subclaims": [ + "The patient is a 66-year-old Caucasian woman.", + "She presented with vertical double vision for the previous 3 weeks.", + "At 6-weeks follow up the double vision had resolved.", + "She presented with a new third and sixth cranial nerve palsy.", + "Neuroimaging with contrast revealed carcinomatous meningitis." + ] + }, + { + "id": "multiclinsum_test_2158_en.txt", + "fulltext": "A 36-year-old Japanese female was referred to our hospital with morbid obesity and T1DM. She was diagnosed with T1DM at the age of 6 years, thereafter, treatment with multiple daily insulin was started. By the age of 20 years, she had a body weight of 70 kg, increasing to > 100 kg at the age of 34 years. Her required daily dose of insulin increased as a function of her body weight. At her initial assessment, she required 45 units of insulin aspart and 30 units of insulin glargine per day. Although a temporary weight loss and reduction in daily insulin dose was achieved with an in-hospital treatment, her weight rebounded shortly after discharge and the patient experienced difficulty in controlling her body weight. The patient expressed her intention for surgical treatment for weight loss, and she was referred to our department.\nAt the time of admission, her height was 159 cm and her weight 106.7 kg, BMI of 42.2 kg/m2. Blood analyses indicated HbA1c of 9.0%, and blood C-peptide levels were undetectable (< 0.01 ng/mL), suggesting her insulin secretion capacity was completely depleted. With medication, her blood lipid levels were within normal range. On computed tomography (CT) examination, the calculated visceral fat area was 162.6 cm2, with a subcutaneous fat area of 527.9 cm2, measured at level of the umbilicus . Upper gastrointestinal endoscopy revealed no abnormalities in the esophagus, stomach, or duodenum.\nTo prevent complications associated with rapid postoperative blood glucose improvement, she was admitted to our hospital 2 weeks before operation for strict glycemic control, dietary restrictions, and exercise therapy. As a result, preoperative HbA1c was reduced to 7.8% and body weight was reduced to 101.1 kg.\nWe performed a laparoscopic sleeve gastrectomy (LSG) , using five ports,, as shown in Fig. a. The blood vessel along the wall of the greater curvature of the stomach was first dissected. We then inserted a 36 Fr (12 mm) bougie into the stomach and resected the greater curvature of the stomach, from a point, on the oral side, 4 cm from the pylorus to the His angle, using a linear stapler. The staple line was reinforced with continuous seromuscular sutures using non-absorbable stitches .\nAfter the operation, a unit of insulin aspart was mixed with 5 g of glucose contained in the infusion solution and sliding scale insulin was added as needed. From postoperative day 2, insulin glargine was administered. Sliding scale insulin was added depending on fasting blood sugar level and oral intake and her daily insulin dose was determined accordingly.\nThere were no postoperative complications, including severe hypoglycemic episodes. One year after the procedure, her body weight had decreased to 81.0 kg, with a BMI of 32.2 kg/m2, with this decrease being mainly due to a decrease in the body fat mass. Her HbA1c level improved to 7.7%, and her daily required insulin dose had been reduced to 24 units (10 units of insulin aspart and 14 units of insulin glargine per day: Fig. a–d). On abdominal CT images, the visceral fat area, measured at level of the umbilicus, was 44.8 cm2, with a subcutaneous fat area of 408.8 cm2 . Therefore, there was a marked decrease in both visceral and subcutaneous fat.", + "fulltext_subclaims": [ + "The patient is a 36-year-old Japanese female.", + "She was referred to the hospital with morbid obesity and T1DM.", + "She was diagnosed with T1DM at the age of 6 years.", + "Treatment with multiple daily insulin was started.", + "By the age of 20 years, she had a body weight of 70 kg.", + "Her required daily dose of insulin increased as a function of her body weight.", + "At her initial assessment, she required 45 units of insulin aspart and 30 units of insulin glargine per day.", + "A temporary weight loss and reduction in daily insulin dose was achieved with an in-hospital treatment.", + "Her weight rebounded shortly after discharge.", + "The patient expressed her intention for surgical treatment for weight loss.", + "At the time of admission, her height was 159 cm.", + "At the time of admission, her weight was 106.7 kg.", + "At the time of admission, her BMI was 42.2 kg/m2.", + "Blood analyses indicated HbA1c of 9.0%.", + "Blood C-peptide levels were undetectable (< 0.01 ng/mL).", + "With medication, her blood lipid levels were within normal range.", + "On CT examination, the calculated visceral fat area was 162.6 cm2.", + "On CT examination, the subcutaneous fat area was 527.9 cm2.", + "Upper gastrointestinal endoscopy revealed no abnormalities in the esophagus, stomach, or duodenum.", + "She was admitted to the hospital 2 weeks before operation.", + "Preoperative HbA1c was reduced to 7.8%.", + "Preoperative body weight was reduced to 101.1 kg.", + "We performed a laparoscopic sleeve gastrectomy (LSG).", + "The blood vessel along the wall of the greater curvature of the stomach was first dissected.", + "A 36 Fr (12 mm) bougie was inserted into the stomach.", + "The greater curvature of the stomach was resected from a point 4 cm from the pylorus to the His angle.", + "The staple line was reinforced with continuous seromuscular sutures using non-absorbable stitches.", + "After the operation, a unit of insulin aspart was mixed with 5 g of glucose contained in the infusion solution.", + "Sliding scale insulin was added as needed.", + "From postoperative day 2, insulin glargine was administered.", + "There were no postoperative complications, including severe hypoglycemic episodes.", + "One year after the procedure, her body weight had decreased to 81.0 kg.", + "One year after the procedure, her BMI was 32.2 kg/m2.", + "The decrease in body weight was mainly due to a decrease in body fat mass.", + "Her HbA1c level improved to 7.7%.", + "Her daily required insulin dose had been reduced to 24 units.", + "On abdominal CT images, the visceral fat area was 44.8 cm2.", + "On abdominal CT images, the subcutaneous fat area was 408.8 cm2." + ], + "summary": "A 36-year-old woman with morbid obesity and T1DM, diagnosed when she was 6 years, was admitted for bariatric surgery. At her first consultation, she had a body weight of 106.7 kg and a body mass index of 42.2 kg/m2. Her HbA1c level was 9.0%, with a required daily insulin dose of 75 units. She underwent laparoscopic sleeve gastrectomy. At 1 year after surgery, her body weight had decreased to 81.0 kg and her body mass index to 32.2 kg/m2. In addition, her daily required dose of insulin had decreased to 24 units, with an improvement in her HbA1c level to 7.7%.", + "summary_subclaims": [ + "The patient is a 36-year-old woman.", + "She has morbid obesity.", + "She has type 1 diabetes mellitus.", + "She was diagnosed with type 1 diabetes mellitus when she was 6 years old.", + "She was admitted for bariatric surgery.", + "She underwent laparoscopic sleeve gastrectomy.", + "At 1 year after surgery, her body weight had decreased to 81.0 kg.", + "At 1 year after surgery, her body mass index was 32.2 kg/m2.", + "Her daily required insulin dose had decreased to 24 units.", + "Her HbA1c level improved to 7.7%." + ] + }, + { + "id": "multiclinsum_test_387_en.txt", + "fulltext": "A 33-year-old woman, a nurse, was referred to our hospital due to headache for 10 days. She had a brain CT scan at a local hospital on June 5, 2018, which revealed a hypodensity lesion in the right frontal lobe . Brain MRI was also performed on the same day. An irregular lesion, hypointense on T1-weighted imaging (T1WI) and hyperintense on T2-weighted imaging (T2WI), was observed. Enhanced scans showed irregular enhancement with perifocal edema . Besides, tunnel-shaped focus was observed, involving the bilateral brain . The patient was suspected to have demyelinating pseudotumor and was treated with 10 mg dexamethasone for 5 days. After the treatment, her headache relieved.\nWhen she was admitted to our hospital on June 12, 2018, the general physical examination and neurological examination revealed no abnormality. Routine haematological and biochemical investigations were normal. The brain MRI performed in our hospital on June 15 revealed similar findings to that performed on June 6. Lumbar puncture revealed normal cranial pressure. CSF analysis disclosed 166 cells/μL and protein concentration of 0.742 g/L. The levels of glucose and chloride were normal. Bacterial and fungal cultures were negative. A postcontrast MRI was ordered. The tunnel-shaped lesion involving the contralateral hemisphere caused our attention, which was clearly seen in the body of corpus callosum. Based on her CSF and imaging findings, parasitic infection was suspected. ELISA showed positive anti-sparganum antibody in both blood and CSF.\nThe patient was thus diagnosed as cerebral sparganosis. However, it remained unclear how she got infected by this rare parasite. She denied having drunk contaminated water, eaten raw or undercooked frog, snake, chicken, or pork meat, or used the flesh of them as a poultice to open wounds. The patient refused to have the surgery. She received praziquantel 25 mg/kg/dose 3 times daily for 2 days. Lumbar puncture and brain MRI were performed again to evaluate the treatment effects 1 week later. CSF analysis showed 120 cells/μL and protein concentration of 0.264 g/L, which was better than before. MRI showed that the lesion size was markedly reduced. The two-day course of praziquantel treatment was repeated, and she was then discharged with no signs or symptoms. A follow-up brain MRI on July 25 showed that the punctate enhancement was further reduced and the tunnel sign almost disappeared, indicating significant therapeutic effect of the treatment . No headache relapse or other neurological deficits were observed during six-month follow-up.", + "fulltext_subclaims": [ + "The patient is a 33-year-old woman.", + "She was referred to the hospital due to headache for 10 days.", + "A brain CT scan on June 5, 2018, revealed a hypodensity lesion in the right frontal lobe.", + "Brain MRI was performed on June 5, 2018.", + "An irregular lesion, hypointense on T1WI and hyperintense on T2WI, was observed.", + "Enhanced scans showed irregular enhancement with perifocal edema.", + "Tunnel-shaped focus was observed, involving the bilateral brain.", + "The patient was suspected to have demyelinating pseudotumor.", + "She was treated with 10 mg dexamethasone for 5 days.", + "After treatment, her headache relieved.", + "She was admitted to the hospital on June 12, 2018.", + "General physical and neurological examinations revealed no abnormality.", + "Routine haematological and biochemical investigations were normal.", + "Brain MRI performed on June 15 showed similar findings to that on June 6.", + "Lumbar puncture revealed normal cranial pressure.", + "CSF analysis disclosed 166 cells/μL and protein concentration of 0.742 g/L.", + "The levels of glucose and chloride were normal.", + "Bacterial and fungal cultures were negative.", + "A postcontrast MRI was ordered.", + "The tunnel-shaped lesion involving the contralateral hemisphere was clearly seen in the body of corpus callosum.", + "Based on CSF and imaging findings, parasitic infection was suspected.", + "ELISA showed positive anti-sparganum antibody in both blood and CSF.", + "The patient was diagnosed as cerebral sparganosis.", + "It remained unclear how she got infected by this rare parasite.", + "She denied having drunk contaminated water.", + "She denied having eaten raw or undercooked frog, snake, chicken, or pork meat.", + "She denied having used the flesh of them as a poultice to open wounds.", + "She refused to have the surgery.", + "She received praziquantel 25 mg/kg/dose 3 times daily for 2 days.", + "Lumbar puncture and brain MRI were performed again 1 week later.", + "CSF analysis showed 120 cells/μL and protein concentration of 0.264 g/L.", + "MRI showed that the lesion size was markedly reduced.", + "The two-day course of praziquantel treatment was repeated.", + "She was discharged with no signs or symptoms.", + "A follow-up brain MRI on July 25 showed that the punctate enhancement was further reduced.", + "The tunnel sign almost disappeared, indicating significant therapeutic effect of the treatment.", + "No headache relapse or other neurological deficits were observed during six-month follow-up." + ], + "summary": "A 33-year-old woman presented with a 10-day history of headache. Postcontrast magnetic resonance imaging (MRI) revealed an irregular lesion with enhancement and the tunnel-shaped focus extending to the contralateral hemiphere. Cerebrospinal fluid (CSF) analysis disclosed pleocytosis (166 cells/μL) and an elevated protein concentration (0.742 g/L). Enzyme-linked immunosorbent assay (ELISA) revealed positive sparganum-specific antibody in both blood and CSF. Finally, the diagnosis of cerebral sparganosis was comfirmed. She received praziquantel treatment and got a favorable outcome during six-month follow-up.", + "summary_subclaims": [ + "The patient is a 33-year-old woman.", + "She presented with a 10-day history of headache.", + "Postcontrast MRI revealed an irregular lesion with enhancement.", + "The MRI showed a tunnel-shaped focus extending to the contralateral hemisphere.", + "CSF analysis disclosed pleocytosis (166 cells/μL).", + "CSF analysis showed an elevated protein concentration (0.742 g/L).", + "ELISA revealed positive sparganum-specific antibody in both blood and CSF.", + "The diagnosis of cerebral sparganosis was confirmed.", + "She received praziquantel treatment.", + "She had a favorable outcome during six-month follow-up." + ] + }, + { + "id": "multiclinsum_test_72_en.txt", + "fulltext": "A 75-year-old man presented to our hospital with dyspnea.\nHe was diagnosed with interstitial pneumonia 11 years ago. He had been treated with prednisolone (5 mg/d) and home oxygen therapy (3 L/min) for 1 year. However, between November of the same year to January of the following year, his lung function deteriorated, leading to hospitalization for 10 times over the next 13 mo for acute type 1 respiratory failure. The maximum length of stay at home between hospitalization was 30 d. Before his final admission to our hospital (his eleventh admission), the patient was at home for 6 d. At that time, hospitalization until the very end of life was proposed to the patient.\nThe patient had type 2 diabetes.\nAt home he lived with his wife, and while he could consume food independently, he required assistance in changing clothes. Furthermore, excretion was done on the floor, and bathing was not possible due to restricted movements caused by exertion dyspnea. His modified Medical Research Council grade was 4. He smoked 80 cigarettes a day between the ages of 20 and 50.\nThe patient’s was thin during the final admission. He was fully conscious, with a body temperature of 38.4 ºC and a respiratory rate of 57 breaths/min. His SpO2 was 60% at 15 L oxygen/min with a mask with reservoir and 94% with non-invasive positive pressure ventilation [inspiratory positive airway pressure, 8 cmH2O; expiratory positive airway pressure, 4 cmH2O, and fraction of inspired oxygen (FiO2) 100%]. Fine crackles were heard bilaterally on the chest.\nBlood tests showed increases in his white blood cell count [32100 cells/µL, (neutrophils: 48.2%)] and C-reactive protein level (9.12 mg/L); no abnormalities were detected in the patient’s urinalysis.\nChest X-rays showed reticular shadows on both sides of the lungs, and the computed tomography scan displayed a mixture of frosted glass shadows, reticular shadows, and tractive bronchodilation on both lungs .", + "fulltext_subclaims": [ + "A 75-year-old man presented to our hospital with dyspnea.", + "He was diagnosed with interstitial pneumonia 11 years ago.", + "He had been treated with prednisolone (5 mg/d) and home oxygen therapy (3 L/min) for 1 year.", + "Between November of the same year to January of the following year, his lung function deteriorated.", + "He was hospitalized 10 times over the next 13 mo for acute type 1 respiratory failure.", + "The maximum length of stay at home between hospitalization was 30 d.", + "Before his final admission to our hospital, the patient was at home for 6 d.", + "Hospitalization until the very end of life was proposed to the patient.", + "The patient had type 2 diabetes.", + "At home he lived with his wife.", + "He could consume food independently.", + "He required assistance in changing clothes.", + "Excretion was done on the floor.", + "Bathing was not possible due to restricted movements caused by exertion dyspnea.", + "His modified Medical Research Council grade was 4.", + "He smoked 80 cigarettes a day between the ages of 20 and 50.", + "The patient was thin during the final admission.", + "He was fully conscious.", + "His body temperature was 38.4 ºC.", + "His respiratory rate was 57 breaths/min.", + "His SpO2 was 60% at 15 L oxygen/min with a mask with reservoir.", + "His SpO2 was 94% with non-invasive positive pressure ventilation.", + "Fine crackles were heard bilaterally on the chest.", + "Blood tests showed increases in his white blood cell count [32100 cells/µL, (neutrophils: 48.2%)] and C-reactive protein level (9.12 mg/L).", + "No abnormalities were detected in the patient’s urinalysis.", + "Chest X-rays showed reticular shadows on both sides of the lungs.", + "The computed tomography scan displayed a mixture of frosted glass shadows, reticular shadows, and tractive bronchodilation on both lungs." + ], + "summary": "Here, we report a case of a 75-year-old man who was diagnosed with interstitial pneumonia 11 years ago and was successfully nursed at home during his terminal phase for over 10 mo without hospitalization, by introducing domiciliary uses of HFNC and morphine CSI with a patient-controlled analgesia device.", + "summary_subclaims": [ + "The patient was a 75-year-old man.", + "The patient was diagnosed with interstitial pneumonia 11 years ago.", + "The patient was successfully nursed at home during his terminal phase.", + "The home care lasted for over 10 mo without hospitalization.", + "Domiciliary uses of HFNC were introduced.", + "Morphine CSI with a patient-controlled analgesia device was used." + ] + }, + { + "id": "multiclinsum_test_2124_en.txt", + "fulltext": "A 45-year-old Caucasian male presented to the Emergency Department following 3 days of progressively worsening right lower quadrant abdominal pain and headaches. His past medical history was remarkable for long-standing back pain and erectile dysfunction. The patient was a social drinker and occasionally smoked. Initial clinical workup was unremarkable with normal blood pressure and renal function (BP 124/86; serum creatinine was 1.0 mg/dL with an eGFR of 90 mL/min/1.73 m2). A CT scan of the abdomen and pelvis was performed with intravenous contrast was performed per local protocol, revealing a right lower pole renal infarct. There was also perivascular inflammation involving the celiac artery. Initially a thrombotic/hypercoagulable state was hypothesized as the etiology. An ECG, transthoracic echocardiography bubble studies, d-dimer and coagulation studies were performed with no abnormal findings. Serologic studies evaluating for systemic vasculitis including ESR, CRP, ANCA and ANA were also negative. The patient was admitted for 3 days and was discharged on apixaban 5 mg once daily with stable creatinine and eGFR.\nThe patient represented to the ED 16 days later with recurrent right flank pain, blood pressure 151/88 mmHg, temperature 36.7°C, serum creatinine of 1.3 mg/dL, eGFR 65.7 mL/min/1.73 m2, ESR 32 mm/h, CRP 12.32 mg/dL. Urinalysis was bland with no granular or epithelial casts. A CT angiogram of the aorta was performed to evaluate for aortic dissection, which revealed progression of the previously seen right renal infarct, now extending into the mid pole. There was also an acute dissection of the anterior and posterior divisions of the right renal artery, with several smaller branch occlusions in the mid and lower pole. In addition, there was new perivascular inflammation involving the main right renal artery and persistent inflammation involving the celiac artery, but no dissection or end organ damage. Interventional radiology was consulted for management of the renal artery thrombus to prevent worsening of the infarct. The patient was taken for a renal artery angiogram which confirmed the presence of a dissection and multiple segmental and smaller branch occlusion in the mid to lower right kidney. A decision was made to initiate catheter-directed thrombolysis, and the patient was monitored in the ICU overnight per protocol. Within 48 hours after the initiation of catheter directed thrombolysis, suffered fever and urinalysis was leukocyte esterase and nitrite positive and had 2+ blood and 2+ protein and was subsequently managed with Cefepime for urinary tract infection although urine culture ultimately showed no growth. The following day, the patient returned to IR for a repeat angiogram which revealed no significant reduction in arterial thrombus burden and a persistent dissection. Due to the patient having normal blood pressure, and significant pain improvement, thrombolytic therapy was discontinued and the patient was initiated on dual antiplatelet therapy with aspirin (81 mg daily) and clopidogrel (75 mg daily). At the point of discharge, the sCr was 1.0 mg/dL, eGFR 89.0 mL/min/1.73 m2.\nTwelve days later, the patient was readmitted, at that time complaining of gross hematuria and passing tissue on urination with elevated creatinine (1.63 mg/dL) and eGFR (50.1 mL/min/1.73 m2). A CT angiogram of the renal arteries was performed, showing a new left lower pole renal infarct and a left renal artery segmental branch dissection . There was a similar appearance to the perivascular inflammation involving the celiac and right renal artery branches with no increase in right renal infarct size. Genetic testing panels including COL3A1 for collagen disorders yielded nothing.\nAt that time other contributors to the acute kidney injury and gross hematuria, including variously: hypovolemia; post-renal obstructive causes; glomerular and tubulointerstitial nephropathies (eg, contrast-induced nephropathy, acute interstitial nephropathy, acute tubular necrosis; were considered but appeared unlikely given lack of obstruction found on imaging (renal ultrasound and CT) as well as profuse red blood cells and protein on urinalysis but otherwise bland urine microscopy). There was no albuminuria. Throughout his presentation, the patient maintained adequate urine output ~120–200 mL/hour (body mass 95.7 kg). At this stage and in light of the radiographic abnormalities including inflammatory changes involving the celiac and renal arteries with associated bilateral renal artery dissections and the absence of vasculitic-, collagen defect-, or thrombophilia-markers, the provisional diagnosis was a non-atherosclerotic non-inflammatory vasculopathy.\nAs there was no indication for surgical or additional endovascular management, the multidisciplinary team decided to manage the patient medically with atorvastatin (80 mg daily), Aspirin (81 mg daily), clopidogrel (75 mg daily), metoprolol (25 mg daily), amlodipine (5 mg daily) with blood pressure goals of <130/80 and counseling to adhere to a low sodium diet, home blood pressure monitoring and avoidance non-steroidal anti-inflammatories.\nWithin 2 weeks of this latter presentation, hematuria had been resolved, there was no proteinuria or albuminuria on urinalysis; however, serum creatinine remained elevated and eGFR depressed. At 15-month follow-up, his kidney function had stabilized with elevated creatinine (1.3–1.5 mg/dL) and eGR (58–63 mL/min/1.73 m2) levels meeting the KDIGO criterion for CKD stage G2/3. A Renal CTA at this time demonstrated chronic bilateral infarcts and persistent, but improved perivascular inflammatory changes of the celiac and renal arteries without recurrent or new dissection .", + "fulltext_subclaims": [ + "The patient was a 45-year-old Caucasian male.", + "He presented with 3 days of progressively worsening right lower quadrant abdominal pain and headaches.", + "His past medical history was remarkable for long-standing back pain and erectile dysfunction.", + "He was a social drinker and occasionally smoked.", + "Initial clinical workup was unremarkable with normal blood pressure and renal function.", + "A CT scan of the abdomen and pelvis with intravenous contrast was performed.", + "The CT scan revealed a right lower pole renal infarct.", + "There was also perivascular inflammation involving the celiac artery.", + "An ECG, transthoracic echocardiography bubble studies, d-dimer, and coagulation studies were performed with no abnormal findings.", + "Serologic studies evaluating for systemic vasculitis including ESR, CRP, ANCA, and ANA were also negative.", + "The patient was admitted for 3 days and was discharged on apixaban 5 mg once daily.", + "The patient represented to the ED 16 days later with recurrent right flank pain.", + "Serum creatinine was 1.3 mg/dL.", + "eGFR was 65.7 mL/min/1.73 m2.", + "A CT angiogram of the aorta was performed.", + "The CT angiogram revealed progression of the previously seen right renal infarct, now extending into the mid pole.", + "There was an acute dissection of the anterior and posterior divisions of the right renal artery.", + "There were several smaller branch occlusions in the mid and lower pole.", + "There was new perivascular inflammation involving the main right renal artery.", + "There was persistent inflammation involving the celiac artery.", + "Interventional radiology was consulted for management of the renal artery thrombus.", + "The patient was taken for a renal artery angiogram.", + "A decision was made to initiate catheter-directed thrombolysis.", + "The patient was monitored in the ICU overnight per protocol.", + "Within 48 hours after the initiation of catheter-directed thrombolysis, the patient suffered fever.", + "Urinalysis was leukocyte esterase and nitrite positive.", + "The patient was managed with Cefepime for urinary tract infection.", + "Urine culture ultimately showed no growth.", + "The following day, the patient returned to IR for a repeat angiogram.", + "The repeat angiogram revealed no significant reduction in arterial thrombus burden.", + "Thrombolytic therapy was discontinued.", + "The patient was initiated on dual antiplatelet therapy with aspirin (81 mg daily) and clopidogrel (75 mg daily).", + "At the point of discharge, serum creatinine was 1.0 mg/dL.", + "eGFR was 89.0 mL/min/1.73 m2.", + "Twelve days later, the patient was readmitted.", + "He complained of gross hematuria and passing tissue on urination.", + "Serum creatinine was 1.63 mg/dL.", + "eGFR was 50.1 mL/min/1.73 m2.", + "A CT angiogram of the renal arteries was performed.", + "The CT angiogram showed a new left lower pole renal infarct.", + "There was a left renal artery segmental branch dissection.", + "There was a similar appearance to the perivascular inflammation involving the celiac and right renal artery branches.", + "Genetic testing panels including COL3A1 for collagen disorders yielded nothing.", + "Other contributors to the acute kidney injury and gross hematuria were considered.", + "There was no indication for surgical or additional endovascular management.", + "The multidisciplinary team decided to manage the patient medically.", + "The provisional diagnosis was a non-atherosclerotic non-inflammatory vasculopathy.", + "The patient was managed medically with atorvastatin (80 mg daily), Aspirin (81 mg daily), clopidogrel (75 mg daily), metoprolol (25 mg daily), and amlodipine (5 mg daily).", + "Blood pressure goals were <130/80.", + "Within 2 weeks of this latter presentation, hematuria had been resolved.", + "There was no proteinuria or albuminuria on urinalysis.", + "Serum creatinine remained elevated.", + "eGFR was depressed.", + "At 15-month follow-up, kidney function had stabilized.", + "Serum creatinine levels were 1.3–1.5 mg/dL.", + "eGFR levels were 58–63 mL/min/1.73 m2.", + "A Renal CTA at this time demonstrated chronic bilateral infarcts.", + "There was persistent, but improved perivascular inflammatory changes of the celiac and renal arteries.", + "There was no recurrent or new dissection." + ], + "summary": "In this case report, we describe a case of a 45-year-old male with erectile dysfunction but without any readily identifiable risk factors for chronic kidney disease (CKD) or vasculopathy, who presented with bilateral renal infarction and parenchymal infarcts due to SAM and who subsequently developed CKD at follow-up. We conduct a mini-literature review that discusses the pathogenesis of SAM in the context of vasospastic diseases, as well as compares the outcomes of observation-only, versus medical-management, versus endovascular-interventions in patients with SAM.", + "summary_subclaims": [ + "The patient was a 45-year-old male.", + "The patient had erectile dysfunction.", + "The patient did not have any readily identifiable risk factors for chronic kidney disease.", + "The patient did not have any readily identifiable risk factors for vasculopathy.", + "The patient presented with bilateral renal infarction.", + "The patient presented with parenchymal infarcts due to SAM.", + "The patient subsequently developed chronic kidney disease at follow-up.", + "A mini-literature review was conducted.", + "The mini-literature review discussed the pathogenesis of SAM in the context of vasospastic diseases.", + "The mini-literature review compared the outcomes of observation-only, versus medical-management, versus endovascular-interventions in patients with SAM." + ] + }, + { + "id": "multiclinsum_test_143_en.txt", + "fulltext": "A 63-year-old right-handed woman attended her local hospital with a left hemiparesis of sudden onset 24 hours after a RTA. Her motor vehicle had collided with a parked vehicle. There was neither loss of consciousness nor any definite head or whiplash injury. Within a further 24 hours she developed right leg weakness. Computed tomography (CT) brain scan revealed a small low-density area in the right fronto-parietal region only; a CT scan of her cervical spine was normal. Given her progressive triplegia, immediate transfer to our centre was made, to exclude cervical spinal cord injury.\nInitial assessment revealed her to be orientated with fluent speech. However, she had evidence of cognitive impairment with an inappropriate jovial affect, poor cognitive estimates and concrete thinking, bradyphrenia and was unable to provide a reliable history. Additional history was obtained from her husband and family. There was no preceding history of cognitive decline but some reduced self-care and hygiene, weight loss of approximately 8 kilograms over three months, and altered bowel habit. Her family had witnessed three episodes of left arm monoparesis, lasting between minutes and 1–2 hours, in the 48 hours preceding her accident. Twenty-four hours after her accident she developed a dense left hemiparesis of sudden onset.\nShe consumed less than 2 units of alcohol per week, was an ex-smoker, and had no other past medical history of note. She had a family history of ischaemic heart disease.\nGeneral examination was unremarkable and she was in sinus rhythm. Neurological examination revealed impaired volitional saccades to the left, but normal targeted saccades. Snout and palmomental reflexes were present. Mild left sided visuospatial dysfunction was present. No sensory inattention was demonstrated. She had a dense left hemiparesis (MRC grade 0 arm and leg) and mild right leg monoparesis (MRC grade 4). Deep tendon reflexes were brisk bilaterally, and both plantar responses were extensor. There was no sensory level.\nFormal neuropsychological assessment later confirmed specific difficulties with visual memory, executive functioning and perceptual/constructional abilities.\nUrgent brain and cervical spine MRI, revealed an ischaemic lesion in the right fronto-parietal region but no structural cervical cord pathology. Diffusion weighted images were not obtained. A repeat MRI brain scan, 8 days after the onset of left hemiparesis showed additional infarction in the distal left anterior cerebral artery territory.\nComprehensive serial blood tests revealed the following abnormal results (normal ranges and units in brackets): white blood cell count between 11.6 and 13.9 (4 to 11 × 109/L), C-reactive protein between 17.8 and 49.5 (< 8 mg/L), erythrocyte sedimentation rate between 54 and 65 (5 to 15 mm/h), total serum cholesterol 5.7 (<5 mmol/L), carcinoembryonic antigen (CEA) 15.7 (0 to 3.5 ng/mL). Carotid ultrasound examination revealed a right internal carotid artery (ICA) stenosis >85%, whilst all other vessels were normal. Routine cerebrospinal fluid examination was normal. CTA neck confirmed the right ICA stenosis, but no significant left ICA disease. CTA circle of Willis (CoW) showed the right A1 anterior cerebral artery (ACA) segment to be dominant, the left A1 ACA segment to be absent, and an anterior communicating artery (AcoA) aneurysm . The remainder of the CoW was considered to be normal. A transthoracic echocardiogram demonstrated no cardiac embolic source. A colonoscopy revealed a rectal tumour, confirmed on biopsy to be a moderately differentiated adenocarcinoma.\nPharmacological treatment included aspirin, pravastatin and perindopril. She also received care from a multi-disciplinary rehabilitation team including physiotherapy. By 10 days after the onset of the left hemiparesis, improvement was noted in all of her deficits, and by 18 days she was regaining power in the left hand and wrist. She was transferred back to her referring hospital for management of her rectal tumour.\nThe neurological formulation at discharge was one of symptomatic right internal carotid artery stenosis and embolic stroke. It is possible that the RTA was a complication of left-sided visuospatial dysfunction. The subsequent presentation is consistent with multiple bilateral embolic strokes, secondary to CoW variation.", + "fulltext_subclaims": [ + "The patient is a 63-year-old right-handed woman.", + "She had a left hemiparesis of sudden onset 24 hours after a RTA.", + "Her motor vehicle had collided with a parked vehicle.", + "There was neither loss of consciousness nor any definite head or whiplash injury.", + "Within a further 24 hours she developed right leg weakness.", + "Computed tomography (CT) brain scan revealed a small low-density area in the right fronto-parietal region only.", + "A CT scan of her cervical spine was normal.", + "Given her progressive triplegia, immediate transfer to our centre was made.", + "Initial assessment revealed her to be orientated with fluent speech.", + "She had evidence of cognitive impairment with an inappropriate jovial affect, poor cognitive estimates and concrete thinking.", + "She was unable to provide a reliable history.", + "There was no preceding history of cognitive decline.", + "There was some reduced self-care and hygiene.", + "There was weight loss of approximately 8 kilograms over three months.", + "Her family had witnessed three episodes of left arm monoparesis, lasting between minutes and 1–2 hours, in the 48 hours preceding her accident.", + "Twenty-four hours after her accident she developed a dense left hemiparesis of sudden onset.", + "She consumed less than 2 units of alcohol per week.", + "She had a family history of ischaemic heart disease.", + "Neurological examination revealed impaired volitional saccades to the left, but normal targeted saccades.", + "Snout and palmomental reflexes were present.", + "Mild left sided visuospatial dysfunction was present.", + "No sensory inattention was demonstrated.", + "She had a dense left hemiparesis (MRC grade 0 arm and leg) and mild right leg monoparesis (MRC grade 4).", + "Deep tendon reflexes were brisk bilaterally, and both plantar responses were extensor.", + "There was no sensory level.", + "Urgent brain and cervical spine MRI revealed an ischaemic lesion in the right fronto-parietal region.", + "A repeat MRI brain scan, 8 days after the onset of left hemiparesis showed additional infarction in the distal left anterior cerebral artery territory.", + "Comprehensive serial blood tests revealed a white blood cell count between 11.6 and 13.9 (4 to 11 × 109/L).", + "C-reactive protein was between 17.8 and 49.5 (< 8 mg/L).", + "Erythrocyte sedimentation rate was between 54 and 65 (5 to 15 mm/h).", + "Total serum cholesterol was 5.7 (<5 mmol/L).", + "Carcinoembryonic antigen (CEA) was 15.7 (0 to 3.5 ng/mL).", + "Carotid ultrasound examination revealed a right internal carotid artery (ICA) stenosis >85%.", + "CTA neck confirmed the right ICA stenosis, but no significant left ICA disease.", + "CTA circle of Willis (CoW) showed the right A1 anterior cerebral artery (ACA) segment to be dominant.", + "The left A1 ACA segment was absent.", + "An anterior communicating artery (AcoA) aneurysm was present.", + "A colonoscopy revealed a rectal tumour, confirmed on biopsy to be a moderately differentiated adenocarcinoma.", + "Pharmacological treatment included aspirin, pravastatin and perindopril.", + "She received care from a multi-disciplinary rehabilitation team including physiotherapy.", + "By 10 days after the onset of the left hemiparesis, improvement was noted in all of her deficits.", + "By 18 days she was regaining power in the left hand and wrist.", + "The neurological formulation at discharge was one of symptomatic right internal carotid artery stenosis and embolic stroke.", + "It is possible that the RTA was a complication of left-sided visuospatial dysfunction.", + "The subsequent presentation is consistent with multiple bilateral embolic strokes, secondary to CoW variation." + ], + "summary": "A 63-year-old right-handed woman developed a left hemiparesis and right leg weakness sequentially following a road traffic accident (RTA). Despite initial concern about the possibility of cervical spinal cord injury, the final diagnosis was bilateral artery-to-artery embolic cerebral infarction with dominant right internal carotid artery.", + "summary_subclaims": [ + "The patient is a 63-year-old right-handed woman.", + "She developed a left hemiparesis following a road traffic accident.", + "She developed right leg weakness following the road traffic accident.", + "There was initial concern about the possibility of cervical spinal cord injury.", + "The final diagnosis was bilateral artery-to-artery embolic cerebral infarction.", + "The dominant right internal carotid artery was involved." + ] + }, + { + "id": "multiclinsum_test_2556_en.txt", + "fulltext": "A previously healthy 29-year-old Arab female was brought by her father to the emergency department of Aster Sanad Hospital for severe upper abdominal pain. The pain started 1 week previously and progressed, becoming severe at the time of admission. It was radiating to the left shoulder and was associated with nausea, anorexia, low-grade fever, and vomiting. Moreover, the pain was reduced upon lying flat and exacerbated by movement. The patient mentioned that she went to see her family in a nearby village where she was in indirect contact with domestic animals. Past medical history and systemic review analysis were unremarkable. Normal saline 0.9% NaCl (500 mL) and intravenous acetaminophen 1 g were given to the patient in the emergency room.\nInitial general physical examination showed hemodynamic stability as per the following: pulse rate 97 beats/minute, respiratory rate 18 breaths/minute, blood pressure 113/95 mmHg, oxygen saturation 96%, and temperature 38 °C. On admission, the Glasgow Coma Scale (GCS) score was 13. Abdominal examination showed generalized abdominal tenderness, muscle guarding, and rigidity in the upper part of the abdomen, eliciting the findings of acute peritonitis. Hypoactive bowel sounds were heard on auscultation. Cardiopulmonary and peripheral vascular examinations were unremarkable.\nAn emergency computerized tomography (CT) scan with contrast was ordered upon admission . Evidence of multiple variable-sided hypodense lesions was seen scattered in the spleen. Evidence of mild to moderate intraperitoneal hyperdense free fluid collection was seen at the perisplenic, perihepatic, lower abdominal, and pelvic regions; probably hemorrhagic fluid. Normal CT appearance of the intra- and extrahepatic biliary radicles was observed. Normal appearance of the pancreas was observed, with preserved surrounding fat planes. Both kidneys were of normal size. No masses, stones, or back pressure changes were detected. Normal appearance of both adrenal glands, and all of the different segments of the small and large bowel loops, was noted.\nComplete blood count (CBC), coagulation profile, and creatinine tests were ordered upon admission. The CBC showed the following: red blood cell (RBC) count 3.67 × 106/UL (low), hemoglobin 9.8 g/dL (low), hematocrit 29.5% (low), red cell distribution width–coefficient of variation (RDW–CV) 16.3% (high), and red cell distribution width–standard deviation (RDW-SD) 48.8 FL (high). Coagulation profile results were normal. Creatinine level was 41 µmol/L (low).\nAn emergent explorative laparotomy with splenectomy was performed. Before the surgery, pneumo-meningococcal and flu vaccine was given. Under general anesthesia and aseptic technique, the skin was draped. A midline skin incision was done. Upon exploration, blood was found to be all over the abdomen. There were ruptured bleeding cysts in the spleen, as shown in Fig. . Hence, ligation of splenic vessels was done followed by the removal of the spleen. Omentoplasty in the cyst space was performed. A drain was inserted in the pelvis and fixed. Finally, the dissected spleen was sent for pathological examination.\nPathological examination of the splenectomy specimen revealed a spleen weighing 900 g and measuring 18 cm × 4 cm × 6 cm, with an intact capsule, smooth surface with focal laceration, and preserved hilum. Cut section of the spleen revealed dark brown homogeneous splenic tissue with no nodules or masses detected.\nMicroscopic examination of sections prepared from the submitted spleen revealed splenic tissue with marked congestion in cords, with dilated sinusoids, and packed with RBCs. There were numerous cystic lesions lined by fibrous tissue with no identified epithelial or endothelial cell lining, and containing blood and fibrinous debris, with adjacent chronic inflammatory cell infiltrate. There were other foci in the spleen that showed proliferation of sinusoid-like channels, lined with plump endothelial cells and filled with blood. Diagnosis of congestive splenomegaly, with splenic peliosis and splenic vascular hamartoma, was established.\nThe patient was discharged with the following medications: amoxicillin/clavulanic acid 1 g [twice daily (BID) for 1 week], diclofenac 50 mg (every 12 hours for 1 week), paracetamol 1 g [three times daily (TID) for 1 week], pantoprazole 40 mg (once daily for 1 week), and enoxaparin 40 mg injection subcutaneously (once daily for 7 days). There were no postsurgical complications. On follow-up after 1 week from discharge, the patient was well but displayed thrombocytosis with a platelet count of 1,000,000/μL. Thus, she was prescribed low-dose aspirin of 81 mg.", + "fulltext_subclaims": [ + "The patient is a 29-year-old Arab female.", + "She was brought to the emergency department for severe upper abdominal pain.", + "The pain started 1 week previously.", + "The pain was radiating to the left shoulder.", + "The pain was associated with nausea.", + "The pain was associated with anorexia.", + "The pain was associated with low-grade fever.", + "The pain was associated with vomiting.", + "The pain was reduced upon lying flat.", + "The pain was exacerbated by movement.", + "She went to see her family in a nearby village.", + "She was in indirect contact with domestic animals.", + "Past medical history was unremarkable.", + "Systemic review analysis was unremarkable.", + "Intravenous acetaminophen 1 g was given in the emergency room.", + "The Glasgow Coma Scale (GCS) score was 13.", + "Abdominal examination showed generalized abdominal tenderness.", + "Abdominal examination showed muscle guarding.", + "Abdominal examination showed rigidity in the upper part of the abdomen.", + "The findings of acute peritonitis were elicited.", + "An emergency CT scan with contrast was ordered.", + "Multiple variable-sided hypodense lesions were seen scattered in the spleen.", + "Mild to moderate intraperitoneal hyperdense free fluid collection was seen.", + "The fluid was probably hemorrhagic.", + "The CT appearance of the intra- and extrahepatic biliary radicles was normal.", + "The CT appearance of the pancreas was normal.", + "Both kidneys were of normal size.", + "No masses, stones, or back pressure changes were detected.", + "The CT appearance of both adrenal glands was normal.", + "An emergent explorative laparotomy with splenectomy was performed.", + "Pneumo-meningococcal and flu vaccine was given before the surgery.", + "Upon exploration, blood was found to be all over the abdomen.", + "There were ruptured bleeding cysts in the spleen.", + "Ligation of splenic vessels was done.", + "The spleen was removed.", + "Omentoplasty in the cyst space was performed.", + "A drain was inserted in the pelvis.", + "The dissected spleen was sent for pathological examination.", + "The spleen weighed 900 g.", + "The spleen measured 18 cm × 4 cm × 6 cm.", + "The capsule was intact.", + "The surface was smooth with focal laceration.", + "The hilum was preserved.", + "The cut section of the spleen revealed dark brown homogeneous splenic tissue.", + "No nodules or masses were detected.", + "Microscopic examination showed marked congestion in cords.", + "Dilated sinusoids were packed with RBCs.", + "Numerous cystic lesions were lined by fibrous tissue.", + "The lesions contained blood and fibrinous debris.", + "Adjacent chronic inflammatory cell infiltrate was present.", + "Other foci showed proliferation of sinusoid-like channels.", + "The channels were lined with plump endothelial cells.", + "The channels were filled with blood.", + "The diagnosis was congestive splenomegaly.", + "The diagnosis included splenic peliosis.", + "The diagnosis included splenic vascular hamartoma.", + "The patient was discharged with amoxicillin/clavulanic acid 1 g BID for 1 week.", + "The patient was discharged with diclofenac 50 mg every 12 hours for 1 week.", + "The patient was discharged with paracetamol 1 g TID for 1 week.", + "The patient was discharged with pantoprazole 40 mg once daily for 1 week.", + "The patient was discharged with enoxaparin 40 mg subcutaneously once daily for 7 days.", + "There were no postsurgical complications.", + "On follow-up after 1 week, the patient was well.", + "On follow-up after 1 week, she displayed thrombocytosis with a platelet count of 1,000,000/μL.", + "She was prescribed low-dose aspirin of 81 mg." + ], + "summary": "We present a case of a 29-year-old Arab female who was admitted to the hospital with severe upper abdominal pain that started 1 week from the date of admission, associated with nausea, anorexia, low-grade fever, and vomiting, with no past medical history or comorbidities. A computerized tomography scan with contrast showed intraperitoneal free fluid along with multiple hypodense splenic cysts. Hence, an emergent exploratory laparotomy with splenectomy was performed. Splenic peliosis was confirmed by the histopathological examination.", + "summary_subclaims": [ + "The patient is a 29-year-old Arab female.", + "She was admitted to the hospital with severe upper abdominal pain.", + "The pain started 1 week from the date of admission.", + "The pain was associated with nausea.", + "The pain was associated with anorexia.", + "The pain was associated with low-grade fever.", + "The pain was associated with vomiting.", + "She had no past medical history.", + "She had no comorbidities.", + "A computerized tomography scan with contrast showed intraperitoneal free fluid.", + "A computerized tomography scan with contrast showed multiple hypodense splenic cysts.", + "An emergent exploratory laparotomy with splenectomy was performed.", + "Splenic peliosis was confirmed by the histopathological examination." + ] + }, + { + "id": "multiclinsum_test_1289_en.txt", + "fulltext": "A 7-month-old Chinese boy was referred to the pediatric nephrology and immunology department of our hospital with eyelid edema for more than 2 months and limb swelling for 1 week. In the medical history, there had been recurrent cough that continued for some days. He had a pale complexion, with periorbital and bilateral pitting pedal edema on clinical examination, but no jaundice, petechiae, purpura, or lymphadenopathy. There was no history of tachycardia or tachypnea. There was no hepatosplenomegaly. His blood pressure (81/62 mmHg) was in the normal range at admission. The child had a history of amniotic fluid contamination at birth and no history of asphyxia. Neither the boy nor his family had a significant history of conditions such as kidney-related diseases or autoimmune diseases. However, the grandmother died of hematological disease.\nInvestigations 3 days prior at clinics of another hospital showed a hemoglobin (Hb) level of 62 g/L without thrombocytopenia (platelet count 396 × 109/L). Serum lactate dehydrogenase (LDH) was elevated (579 U/L) (normal <382 U/L). An elevated serum cholesterol of 5.38 mmol/L was noted at that time, along with range proteinuria (1+) and hypoalbuminemia (serum albumin 28.8 g/L). There was no gross or microscopic hematuria. The serum C3 and C4 levels were normal. The laboratory values with reference values are shown in the . The boy was immediately referred to our hospital with a referral diagnosis of “nephrotic syndrome (NS)”.\nThe patient presented with likely NS with anemia for five days after admission but no proteinuria or hypoalbuminemia. The direct Coombs test was negative. On hospital day 6, the patient presented with “hemolytic uremic syndrome (HUS)” following episodes of vomiting and diarrhea with fever. There were systemic pitting pedal edema, oliguria, petechiae, and soy sauce-colored urine at that time, along with hypertension (129/89 mmHg). Laboratory workup revealed normocytic hemolytic anemia with an Hb level of 62 g/L, mean corpuscular volume (MCV) of 86 fL, elevated reticulocyte count of 9.3%, schistocytes count of 3% on the peripheral smear, thrombocytopenia (platelet count 23 × 109/L), a serum creatinine (SCr) level of 0.62 mg/dl, blood urea nitrogen (BUN) level of 5.66 mmol/L, cystine (C) level of 1.57 mg/L, C3 level of 0.89 g/L, C4 level of 0.21 g/L, a markedly increased lactate dehydrogenase (LDH) level of 585.1 U/L, hematuria (red blood cells 4,627.9/µl), and proteinuria (3+). Coagulation function, including prothrombin time (PT), activated partial thromboplastin time (APTT) and fibrinogen, was elevated (36.2 s, 58.6 s and 4.26 g/L, respectively). The serum bilirubin, AST, ALT, and serum electrolyte levels were within normal limits. The activity of a disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13 (ADAMTS13), was normal. The stool rotavirus test was positive. Stool culture grew Streptococcus and Escherichia coli (E. coli), and stool multiplex polymerase chain reaction (PCR) showed that Shigella, Salmonella, E. coli O157, and pathogenic Vibrio were not detected. The infectious workup was notable for a negative respiratory viral panel, negative special viral panel (human parvovirus B19, EB virus, cytomegalovirus, rubella virus, herpes simplex virus, hepatitis virus), negative Mycobacterium tuberculosis, and negative blood culture. Antinuclear antibodies were negative. The chest x-ray was negative. B-ultrasound showed a small amount of abdominal effusion . Abdominal computed tomography (CT) showed that the kidney, liver and spleen increased in volume with a low-density image . The echocardiogram showed a central atrial septal defect (2.3 mm) with a normal ejection fraction (EF 66%). The 24 h urine protein quantification was not performed due to the difficulty in collecting 24 h urine. Moreover, due to his uncontrolled hypertension and thrombocytopenia, the patient could not undergo a kidney biopsy.\nGiven the concern for HUS, broad-spectrum antibiotics and fresh frozen plasma infusions were given to treat his gastrointestinal infection and TMA. The following other treatments were employed: intravenous immunoglobulin (IVIg) infusions, human prothrombin complex infusions, albumin infusions (due to a decreased level of albumin), red blood cell infusions, platelet infusions, intramuscular injection of vitamin K1, low-dose methylprednisolone for anti-inflammatory treatment, antihypertensive treatment (nifedipine and metoprolol), and symptomatic treatment.\nThe patient was diagnosed further with aHUS, had been administered plasma infusions (PIs) discontinuously and had required plasma exchange (PE) 2 times during the PICU hospital stay. Given the trend of acute respiratory distress syndrome (ARDS) with worsening pneumonedema and pneumorrhagia, mechanical ventilation (MV) was given for 7 days. There was a transient remission of respiratory symptoms. However, given the trend of worsening renal function [elevated levels of blood urea nitrogen (BUN)], progressing edema, and worsening hypertension, continuous renal replacement therapy (CRRT) and hemodialysis (HD) on alternating days were given to treat his acute kidney injury (AKI) for 13 days and 15 days, respectively. The patient's renal function and hematologic parameters (stage 3 AKI with gross hematuria) worsened during the 6th–7th week of the hospital stay while HD and PI therapy was continued, as depicted in . Subsequently, the patient developed a hypertensive emergency with features of intracranial hypertension leading to right temporoparietal hematoma and subarachnoid hemorrhage, as depicted in . He required multiple drugs (furosemide, nitrate, glycerin fructose) for the control of hypertension and intracranial hypertension. Ultimately, he still had a recurrence of ARDS and deteriorated to a stage of involuntary respiration requiring high ventilatory settings with pulmonary hemorrhage, gastrointestinal hemorrhage, and multiorgan dysfunction. Chest CT displayed both lung pneumonia and partial atelectasis of the upper lobe of the right lung . Head CT showed that the subarachnoid hemorrhage was more extensive than before . The patient's parents decided to withdraw the patient from further management. The patient died during the 8th week of his hospital stay.\nWe obtained 2 ml of peripheral blood from the patient, his parents and older brother respectively. Whole exome sequencing was performed on the patient, his parents and brother. Sanger sequencing was used to verify the mutation site. CNVnator software was used for CNV analysis, and QPCR was used for family analysis. Two heterozygous variations in the DGKE exon region: NM_003647.2, c.610dup, p.Thr204Asnfs*4 and deletion of exons 4–6 were identified. The first variant was classified as de novo compared with the results obtained in the conventional in the Sanger sequencing of the parents and the older brother . The second variant was a deletion of DGKE exons 4–6, which was also detected in the asymptomatic father, but absent in both the mother and the older brother . The patient in this case had aHUS, consistent with recessive transmission with the 100% penetrance.", + "fulltext_subclaims": [ + "A 7-month-old Chinese boy was referred to the pediatric nephrology and immunology department of our hospital.", + "He had eyelid edema for more than 2 months.", + "He had limb swelling for 1 week.", + "In the medical history, there had been recurrent cough that continued for some days.", + "He had a pale complexion.", + "He had periorbital and bilateral pitting pedal edema on clinical examination.", + "There was no jaundice.", + "There were no petechiae.", + "There was no purpura.", + "There was no lymphadenopathy.", + "There was no history of tachycardia.", + "There was no hepatosplenomegaly.", + "His blood pressure (81/62 mmHg) was in the normal range at admission.", + "The child had a history of amniotic fluid contamination at birth.", + "Neither the boy nor his family had a significant history of conditions such as kidney-related diseases or autoimmune diseases.", + "The grandmother died of hematological disease.", + "Investigations 3 days prior at clinics of another hospital showed a hemoglobin (Hb) level of 62 g/L.", + "There was no thrombocytopenia (platelet count 396 × 109/L).", + "Serum lactate dehydrogenase (LDH) was elevated (579 U/L) (normal <382 U/L).", + "An elevated serum cholesterol of 5.38 mmol/L was noted at that time.", + "There was range proteinuria (1+).", + "There was hypoalbuminemia (serum albumin 28.8 g/L).", + "There was no gross or microscopic hematuria.", + "The serum C3 and C4 levels were normal.", + "The boy was immediately referred to our hospital with a referral diagnosis of “nephrotic syndrome (NS)”.", + "The patient presented with likely NS with anemia for five days after admission.", + "There was no proteinuria.", + "There was no hypoalbuminemia.", + "The direct Coombs test was negative.", + "On hospital day 6, the patient presented with “hemolytic uremic syndrome (HUS)”.", + "There were systemic pitting pedal edema.", + "There was oliguria.", + "There were petechiae.", + "There was soy sauce-colored urine.", + "There was hypertension (129/89 mmHg).", + "Laboratory workup revealed normocytic hemolytic anemia with an Hb level of 62 g/L.", + "The mean corpuscular volume (MCV) was 86 fL.", + "The reticulocyte count was 9.3%.", + "The schistocytes count was 3% on the peripheral smear.", + "There was thrombocytopenia (platelet count 23 × 109/L).", + "The serum creatinine (SCr) level was 0.62 mg/dl.", + "The blood urea nitrogen (BUN) level was 5.66 mmol/L.", + "The cystine (C) level was 1.57 mg/L.", + "The C3 level was 0.89 g/L.", + "The C4 level was 0.21 g/L.", + "The lactate dehydrogenase (LDH) level was 585.1 U/L.", + "There was hematuria (red blood cells 4,627.9/µl).", + "There was proteinuria (3+).", + "Coagulation function, including prothrombin time (PT), activated partial thromboplastin time (APTT) and fibrinogen, was elevated (36.2 s, 58.6 s and 4.26 g/L, respectively).", + "The serum bilirubin, AST, ALT, and serum electrolyte levels were within normal limits.", + "The activity of ADAMTS13 was normal.", + "The stool rotavirus test was positive.", + "Stool culture grew Streptococcus and Escherichia coli (E. coli).", + "Stool multiplex polymerase chain reaction (PCR) showed that Shigella, Salmonella, E. coli O157, and pathogenic Vibrio were not detected.", + "The infectious workup was notable for a negative respiratory viral panel.", + "The special viral panel was negative.", + "The Mycobacterium tuberculosis test was negative.", + "The blood culture was negative.", + "Antinuclear antibodies were negative.", + "The chest x-ray was negative.", + "B-ultrasound showed a small amount of abdominal effusion.", + "Abdominal computed tomography (CT) showed that the kidney, liver and spleen increased in volume with a low-density image.", + "The echocardiogram showed a central atrial septal defect (2.3 mm) with a normal ejection fraction (EF 66%).", + "The 24 h urine protein quantification was not performed due to the difficulty in collecting 24 h urine.", + "The patient could not undergo a kidney biopsy due to uncontrolled hypertension and thrombocytopenia.", + "Given the concern for HUS, broad-spectrum antibiotics and fresh frozen plasma infusions were given.", + "Intravenous immunoglobulin (IVIg) infusions were given.", + "Human prothrombin complex infusions were given.", + "Albumin infusions were given due to a decreased level of albumin.", + "Red blood cell infusions were given.", + "Platelet infusions were given.", + "An intramuscular injection of vitamin K1 was given.", + "Low-dose methylprednisolone was given for anti-inflammatory treatment.", + "Antihypertensive treatment (nifedipine and metoprolol) was given.", + "Symptomatic treatment was given.", + "The patient was diagnosed further with aHUS.", + "The patient had been administered plasma infusions (PIs) discontinuously.", + "The patient had required plasma exchange (PE) 2 times during the PICU hospital stay.", + "Given the trend of acute respiratory distress syndrome (ARDS) with worsening pneumonedema and pneumorrhagia, mechanical ventilation (MV) was given for 7 days.", + "There was a transient remission of respiratory symptoms.", + "The patient's renal function and hematologic parameters (stage 3 AKI with gross hematuria) worsened during the 6th–7th week of the hospital stay.", + "The patient developed a hypertensive emergency with features of intracranial hypertension leading to right temporoparietal hematoma and subarachnoid hemorrhage.", + "Multiple drugs (furosemide, nitrate, glycerin fructose) were given for the control of hypertension and intracranial hypertension.", + "The patient still had a recurrence of ARDS.", + "The patient deteriorated to a stage of involuntary respiration requiring high ventilatory settings with pulmonary hemorrhage, gastrointestinal hemorrhage, and multiorgan dysfunction.", + "Chest CT displayed both lung pneumonia and partial atelectasis of the upper lobe of the right lung.", + "Head CT showed that the subarachnoid hemorrhage was more extensive than before.", + "The patient's parents decided to withdraw the patient from further management.", + "The patient died during the 8th week of his hospital stay.", + "We obtained 2 ml of peripheral blood from the patient, his parents and older brother respectively.", + "Whole exome sequencing was performed on the patient, his parents and brother.", + "Sanger sequencing was used to verify the mutation site.", + "CNVnator software was used for CNV analysis.", + "QPCR was used for family analysis.", + "Two heterozygous variations in the DGKE exon region: NM_003647.2, c.610dup, p.Thr204Asnfs*4 and deletion of exons 4–6 were identified.", + "The first variant was classified as de novo compared with the results obtained in the conventional in the Sanger sequencing of the parents and the older brother.", + "The second variant was a deletion of DGKE exons 4–6, which was also detected in the asymptomatic father, but absent in both the mother and the older brother.", + "The patient in this case had aHUS, consistent with recessive transmission with the 100% penetrance." + ], + "summary": "The present work reports a 7-month-old boy with aHUS, possibly triggered by gastrointestinal infection, without complement activation, with little response to plasma therapy and nephroprotective measures. The patient died during the 8th week of his hospital stay. The causes of death were intracranial hemorrhage and multiorgan dysfunction. Comprehensive WES of peripheral blood-derived DNA revealed two heterozygous variations in the DGKE exon region: NM_003647.2, c.610dup, p.Thr204Asnfs*4 and deletion of exons 4-6.", + "summary_subclaims": [ + "The patient was a 7-month-old boy.", + "The patient had atypical hemolytic uremic syndrome (aHUS).", + "The aHUS was possibly triggered by gastrointestinal infection.", + "There was no complement activation.", + "The patient had little response to plasma therapy.", + "The patient received nephroprotective measures.", + "The patient died during the 8th week of his hospital stay.", + "The causes of death were intracranial hemorrhage and multiorgan dysfunction.", + "Comprehensive whole exome sequencing of peripheral blood-derived DNA was performed.", + "Two heterozygous variations were found in the DGKE exon region.", + "The first variation was NM_003647.2, c.610dup, p.Thr204Asnfs*4.", + "The second variation was a deletion of exons 4-6." + ] + }, + { + "id": "multiclinsum_test_131_en.txt", + "fulltext": "A 59-year-old male was admitted to our ward with abdominal pain in the right upper quadrant, nausea, and vomiting; the symptoms had started about 24 hours before. Physical examination showed tenderness of the abdomen, positive Murphy's sign, negative Blumberg's sign. On admission, blood test showed WBC count of 17.200/mm3, whereas liver function tests, lipase, and amylase levels all resulted as normal. Abdominal ultrasound showed a single gallstone impacted in the infundibulum of a dilated gallbladder, with a thick and inflamed wall. The patient underwent emergency laparoscopic cholecystectomy. A three-trocar technique was used inserting the cannulas in the umbilicus (10 mm), subxiphoid (5 mm), and right lateral subcostal margin (5 mm). Preliminary evacuation of empyematous gallbladder was performed by a percutaneous 21-gauge needle . A fundus first approach was elected because of the severe inflammation of tissues surrounding the gallbladder and its hilum. The procedure lasted 45 minutes with repeated use of bipolar energy to control bleeding from the gallbladder bed. After removal of the gallbladder, thorough inspection of the hepatic bed was made and a little bile leak was identified from a duct of Luschka 1 cm away from the gallbladder hilum . Direct suture with 5/0 PDS was attempted first but failed because of the poor quality of the inflamed hepatic tissue. In order to avoid any deeper suture that would involve major hepatic vessels due to the proximity with the hepatic hilum, an alternative technique was chosen. We inserted a QuickClip Pro® clip (Olympus Medical Systems Corp., Tokyo, Japan) through the subxiphoid trocar. This endoscopic device was directed by means of a Johann clamp inserted through the right subcostal trocar to securely close the duct of Luschka . An abdominal drainage was left in place for 24 hours, and the patient was discharged on the second postoperative day.", + "fulltext_subclaims": [ + "The patient was a 59-year-old male.", + "The patient was admitted to our ward.", + "The patient had abdominal pain in the right upper quadrant.", + "The patient had nausea.", + "The patient had vomiting.", + "The symptoms had started about 24 hours before admission.", + "Physical examination showed tenderness of the abdomen.", + "Murphy's sign was positive.", + "Blumberg's sign was negative.", + "On admission, WBC count was 17.200/mm3.", + "Liver function tests were normal.", + "Lipase levels were normal.", + "Amylase levels were normal.", + "Abdominal ultrasound showed a single gallstone.", + "The gallstone was impacted in the infundibulum of a dilated gallbladder.", + "The gallbladder wall was thick and inflamed.", + "The patient underwent emergency laparoscopic cholecystectomy.", + "A three-trocar technique was used.", + "A 10 mm cannula was inserted in the umbilicus.", + "A 5 mm cannula was inserted subxiphoid.", + "A 5 mm cannula was inserted in the right lateral subcostal margin.", + "Preliminary evacuation of empyematous gallbladder was performed by a percutaneous 21-gauge needle.", + "A fundus first approach was elected.", + "The tissues surrounding the gallbladder and its hilum were severely inflamed.", + "The procedure lasted 45 minutes.", + "Bipolar energy was repeatedly used to control bleeding from the gallbladder bed.", + "A little bile leak was identified from a duct of Luschka.", + "The duct of Luschka was 1 cm away from the gallbladder hilum.", + "Direct suture with 5/0 PDS was attempted.", + "Direct suture with 5/0 PDS failed.", + "The hepatic tissue was of poor quality.", + "An alternative technique was chosen.", + "A QuickClip Pro® clip was inserted through the subxiphoid trocar.", + "The clip was directed by a Johann clamp inserted through the right subcostal trocar.", + "An abdominal drainage was left in place for 24 hours.", + "The patient was discharged on the second postoperative day." + ], + "summary": "We present a unique case of a 59-year-old male patient with acute cholecystitis. After removal of the gallbladder, thorough inspection of the hepatic bed was made and a little bile leak was identified from a duct of Luschka 1 cm away from the gallbladder hilum. We report on the use of endoscopic QuickClip Pro® clips (Olympus Medical Systems Corp., Tokyo, Japan) to avoid further more invasive treatment.", + "summary_subclaims": [ + "The patient was a 59-year-old male.", + "The patient had acute cholecystitis.", + "The gallbladder was removed.", + "A little bile leak was identified from a duct of Luschka 1 cm away from the gallbladder hilum.", + "Endoscopic QuickClip Pro® clips were used.", + "The clips were used to avoid further more invasive treatment." + ] + }, + { + "id": "multiclinsum_test_686_en.txt", + "fulltext": "A 58-year-old Caucasian non-smoker male with a history of symptomatic paroxysmal and persistent AF from 6 months, arterial hypertension, and heart failure with preserved ejection fraction (HFpEF, NYHA Class 2), without previous ablation procedures, was admitted to our hospital for AF catheter ablation. At the time of admission, his vital signs were in the range of normality and he was in sinus rhythm after spontaneous conversion of AF. He was receiving a rate-control treatment with a beta-blocker (bisoprolol 2.5 mg qd) and digoxin (0.125 mg qd), both in therapeutic range, a direct oral anticoagulant for stroke prevention (CHA2DS2-Vasc = 2), and an antihypertensive combination therapy with an angiotensin converting enzyme inhibitor and diuretic. He was also unable to tolerate antiarrhythmic drugs in the past. His physical examination was unremarkable. A chest X-Ray obtained before the procedure was completely normal. Routine blood tests were normal at the time of admission except for mildly increased N-terminal prohormone B-type natriuretic peptide levels (630 pg/mL; reference range <125 pg/mL). Transthoracic echocardiography (TTE) showed normal left ventricular and right ventricular systolic function and the absence of significant valvular heart disease with an only mildly enlarged left atrium (LA) and left ventricular concentric remodelling. A transoesophageal echocardiography was performed 24 h before the procedure in order to rule out the presence of LA thrombosis. Catheter ablation was performed under general anaesthesia with orotracheal intubation. Induction of anaesthesia was obtained with propofol 2 mg/Kg, fentanyl 100 mcg, and rocuronium 1 mg/Kg, and it was completely regular. General anaesthesia was maintained with sevoflurane 1.2–1.4% in a 1:1 oxygen:air combination. Analgesia was maintained with remifentanil infusion 0.03–0.08 mcg/Kg/min. A five Fr pig-tail catheter was placed at the aortic valvular plane through the right common femoral artery and a decapolar steerable diagnostic catheter was placed in the coronary sinus through the right common femoral vein. Then a fluoroscopy-guided transseptal puncture was performed without complications (SL0™ Swartz sheath, Abbott; BRK™ transseptal needle, Abbott). An electroanatomical three-dimensional map (EnSite NavX, Abbott) of the LA was obtained using a high-density mapping catheter (Advisor™ HD Grid Mapping Catheter, Sensor Enabled™ (SE), Abbott). PVI with RF energy (standard energy, 30–35 W) was started with the use of a 4 mm tip bidirectional irrigated catheter (FlexAbility Ablation Catheter, Abbott). The activating clotting time was maintained between 250 and 350 s through unfractionated heparin iv infusion at standard dose. At the time of RF initiation, the patient vital signs were completely normal. The procedure was initiated targeting the left superior pulmonary vein (LSPV). After a few seconds, during the encircling of the LSPV and RF delivery at the site of posterior left pulmonary venous carina, the patient developed a reproducible asystolic reflex associated with hypotension, suggesting GP irritation with subsequent vagal activation . RF delivery was stopped for a few seconds and then resumed after recovery of electrical activity. About 2 min after the first RF delivery, a prominent and diffuse ST-segment elevation was noted and the patient developed a transient complete atrioventricular block with a junctional escape rhythm requiring temporary right ventricular pacing and i.v. administration of atropine 0.5 mg. Bedside TTE was performed in order to rule out pericardial involvement or mechanical complications and showed a mildly reduced left ventricular ejection fraction (LVEF) without clear regional wall motion abnormalities in the absence of pericardial effusion. An invasive coronary angiography (ICA) was immediately performed. Severe multivessel CAS in the absence of significant atherosclerotic disease or air embolism was detected . CAS resolution and subsequent flow normalization were obtained after intracoronary administration of nitroglycerin . The ST-segment promptly returned to isoelectric line . Repeated bedside TTE performed after spasm regression showed recovered LVEF and confirmed the absence of pericardial effusion. After complete resolution and stabilization of the patient clinical parameters, the procedure was resumed and PVI with encircling and adjunctive LA lesion lines (mitral isthmus and roof line) were completed without further complications . After the procedure, myocardial injury markers (high-sensitivity cardiac troponin I) resulted slightly elevated with a ‘rise and fall’ pattern (peak 1060 ng/L, normal range <14 ng/L). After 48 h of clinical monitoring, the patient was discharged with a non-dihydropyridine calcium channel blocker (verapamil, 40 mg tid) therapy. At 30 days, 3 and 6 months follow-up the patient was in sinus rhythm without left ventricular wall motion abnormalities.", + "fulltext_subclaims": [ + "The patient is a 58-year-old Caucasian non-smoker male.", + "He has a history of symptomatic paroxysmal and persistent atrial fibrillation from 6 months.", + "He has a history of arterial hypertension.", + "He has heart failure with preserved ejection fraction.", + "He was admitted for AF catheter ablation.", + "At the time of admission, he was in sinus rhythm after spontaneous conversion of AF.", + "He was receiving bisoprolol 2.5 mg qd.", + "He was receiving digoxin 0.125 mg qd.", + "He was receiving a direct oral anticoagulant.", + "His CHA2DS2-Vasc score was 2.", + "He was receiving an angiotensin converting enzyme inhibitor.", + "He was receiving a diuretic.", + "He was unable to tolerate antiarrhythmic drugs in the past.", + "A chest X-Ray obtained before the procedure was completely normal.", + "N-terminal prohormone B-type natriuretic peptide levels were 630 pg/mL.", + "Transthoracic echocardiography showed normal left ventricular systolic function.", + "Transthoracic echocardiography showed normal right ventricular systolic function.", + "Transthoracic echocardiography showed the absence of significant valvular heart disease.", + "Transthoracic echocardiography showed a mildly enlarged left atrium.", + "A transoesophageal echocardiography was performed 24 h before the procedure.", + "Catheter ablation was performed under general anaesthesia with orotracheal intubation.", + "Induction of anaesthesia was obtained with propofol 2 mg/Kg.", + "Induction of anaesthesia was obtained with fentanyl 100 mcg.", + "Induction of anaesthesia was obtained with rocuronium 1 mg/Kg.", + "General anaesthesia was maintained with sevoflurane 1.2–1.4%.", + "Analgesia was maintained with remifentanil infusion 0.03–0.08 mcg/Kg/min.", + "A five Fr pig-tail catheter was placed at the aortic valvular plane.", + "A fluoroscopy-guided transseptal puncture was performed without complications.", + "An electroanatomical three-dimensional map of the LA was obtained.", + "PVI with RF energy was started with a 4 mm tip bidirectional irrigated catheter.", + "The activating clotting time was maintained between 250 and 350 s.", + "The procedure was initiated targeting the left superior pulmonary vein.", + "During RF delivery at the site of posterior left pulmonary venous carina, the patient developed a reproducible asystolic reflex associated with hypotension.", + "RF delivery was stopped for a few seconds and then resumed after recovery of electrical activity.", + "About 2 min after the first RF delivery, the patient developed a transient complete atrioventricular block.", + "The patient required temporary right ventricular pacing.", + "The patient received atropine 0.5 mg.", + "Bedside TTE showed a mildly reduced left ventricular ejection fraction.", + "An invasive coronary angiography was immediately performed.", + "Severe multivessel coronary artery spasm was detected.", + "CAS resolution was obtained after intracoronary administration of nitroglycerin.", + "The ST-segment promptly returned to isoelectric line.", + "Recovery of left ventricular ejection fraction was observed after spasm regression.", + "The procedure was resumed and PVI with encircling and adjunctive LA lesion lines were completed.", + "Myocardial injury markers were slightly elevated with a ‘rise and fall’ pattern.", + "The patient was discharged with verapamil, 40 mg tid.", + "At 30 days, the patient was in sinus rhythm.", + "At 3 and 6 months follow-up, the patient was in sinus rhythm." + ], + "summary": "We report a case of severe multivessel CAS triggered by ganglionated plexi stimulation during pulmonary vein isolation with radiofrequency catheter ablation in a patient with persistent AF, promptly resolved after intracoronary nitrate administration.", + "summary_subclaims": [ + "The patient had persistent AF.", + "The patient underwent pulmonary vein isolation with radiofrequency catheter ablation.", + "Ganglionated plexi stimulation was performed during the procedure.", + "Severe multivessel coronary artery spasm was triggered by ganglionated plexi stimulation.", + "The coronary artery spasm was promptly resolved after intracoronary nitrate administration." + ] + }, + { + "id": "multiclinsum_test_2102_en.txt", + "fulltext": "A 29-year-old male Albanian patient presented to our clinic owing to recurrent episodes of hypoglycemia. He referred to an incident of DKA that led to hospitalization abroad 20 days ago. The discharge report from the hospital referred to the DKA incident, but mentioned no precipitating factors. The patient was newly diagnosed with T1DM at this time, and intensified treatment with insulin at home was commenced (25 units of basal and 4–8–6 units of preprandial insulin per day). He had been going through stressful times, as he had recently received news of an upcoming fatherhood. He has a body mass index (BMI) of 21.6 kg/m2 and an unremarkable personal and family health record. He mentioned a 5 kg weight loss during the past 2 months. Laboratory tests exhibited glycosylated hemoglobin (HbA1c) at 8.1%, C-peptide at 1.8 ng/ml (normal range 0.5–2 ng/ml), and fasting plasma glucose (FPG) at 120 mg/dl. Antibody tests for anti-tyrosine phosphatase-related islet antigen 2 (anti-IA2) were upper normal (7.3 IU/ml, normal range 0.0–7.4 IU/ml), positive for anti-GAD65 (5.5 IU/ml, normal range 0–5 IU/ml), and negative for anti-islet cell antibodies (ICA) and anti-insulin antibodies (IAA). Initial management included significant downtitration of preprandial insulin. Basal insulin dosage was decreased at about 20 IU daily (initial dosage was 0.2 times the patient’s body weight: 0.2 × 70 kg = 14 units of degludec). Differential diagnosis consisted of T1DM “honeymoon” period and possible misdiagnosis at the hospital. Prolonged T1DM honeymoon periods have been described in the world literature, but the age of the patient, along with hypoglycemic incidents after insulin administration, positive anti-GAD65, C-peptide levels, and positive anti-IA2 and negative T1DM antibodies (anti-ICA, anti-insulin), suggested a type of diabetes other than the initially diagnosed T1DM, most likely LADA, according to the 2020 American Diabetes Association criteria . On a follow-up visit, considering the persistent laboratory and clinical findings, we discontinued the administration of preprandial insulin, regulated the basal insulin dosage, and enhanced treatment with metformin. One month later, under treatment with 2 g of metformin daily and additional sitagliptin, basal insulin dosage decreased at about 8 units per day and was subsequently halted. Two years later, basal insulin needed to be reintroduced, along with metformin and a glucagon-like peptide-1 receptor agonist (GLP-1 RA). Insulin requirement after at least 6 months from original diagnosis confirmed our previous hypothesis of LADA, which first manifested with DKA. On a 6-year follow-up, according to laboratory findings and glucose measurements, diabetes progressed to T1DM and basal bolus insulin treatment (multidose insulin, MDI) with detemir and lispro was initiated. The patient remains adherent to the regimen, and it has not been modified since.\nIn addition, at the initial visit, the patient complained of excessive sweating and increased sensitivity to heat. A complete physical examination (PE) revealed upper limb tremor, lid lag, palpable thyroid gland, and heart rate of 110 beats per minute. Thyroid-stimulating hormone (TSH) levels were lower than 0.004 mIU/L (normal range 0.5–5 μIU/ml), total triiodothyronine (T3) at 2.19 nmol/L (normal range 0.9–2.8 nmol/L), total thyroxine (T4) at 14.60 μg/dl (normal range 5–12 μg/dl), free T3 (fT3) at 4.93 pmol/L (normal range 2–7 pmol/L), and free T4 (fT4) at 1.65 ng/dl (normal range 0.8–1.8 ng/dl). There were positive anti-thyroglobulin (anti-TG) (174 IU/ml, normal range < 116 IU/ml) and thyroid peroxidase antibodies (anti-TPO) (245 IU/ml, normal range < 16 IU/ml), while anti-TSH-R antibody was negative. An ultrasound scan of the thyroid gland was not indicative of pathology. Seven days later, a thyroid panel was conducted: TSH, 3.14 μIU/ml; T3, 1.57 nmol/L; T4, 87.19 μg/dl; fT3, 5.60 pmol/L; fT4, 15.26 ng/dl. TSH values decreased spontaneously with no treatment admitted. High levels of total and free thyroid hormones and presence of elevated anti-thyroid antibodies with negative anti-TSH-R navigated the diagnosis toward hashitoxicosis complicating Hashimoto’s disease and made Graves’ disease less likely. One month later, TSH was measured in a laboratory and found to be higher than normal (7.29 mIU/L), so levothyroxine treatment with maximal dosage of 88 μg was decided. On a 2-year follow-up, thyroxine was withdrawn as Hashimoto’s thyroiditis retreated, and the patient has remained euthyroid (TSH and thyroid hormone levels close to normal on blood test). On a 6-year follow-up, there were no identifiable changes in the patient’s thyroid state.", + "fulltext_subclaims": [ + "The patient is a 29-year-old male Albanian.", + "He presented with recurrent episodes of hypoglycemia.", + "He referred to an incident of DKA that led to hospitalization abroad 20 days ago.", + "The discharge report from the hospital referred to the DKA incident.", + "The discharge report mentioned no precipitating factors.", + "The patient was newly diagnosed with T1DM at this time.", + "He had been going through stressful times, as he had recently received news of an upcoming fatherhood.", + "He has a BMI of 21.6 kg/m2.", + "He mentioned a 5 kg weight loss during the past 2 months.", + "Laboratory tests exhibited HbA1c at 8.1%.", + "C-peptide was 1.8 ng/ml (normal range 0.5–2 ng/ml).", + "Fasting plasma glucose was 120 mg/dl.", + "Anti-IA2 were upper normal at 7.3 IU/ml (normal range 0.0–7.4 IU/ml).", + "Anti-GAD65 were positive at 5.5 IU/ml (normal range 0–5 IU/ml).", + "Anti-ICA and anti-insulin antibodies were negative.", + "Initial management included significant downtitration of preprandial insulin.", + "Basal insulin dosage was decreased at about 20 IU daily.", + "Differential diagnosis consisted of T1DM 'honeymoon' period and possible misdiagnosis at the hospital.", + "The age of the patient, along with hypoglycemic incidents after insulin administration, positive anti-GAD65, C-peptide levels, and positive anti-IA2 and negative T1DM antibodies suggested a type of diabetes other than the initially diagnosed T1DM.", + "The most likely diagnosis was LADA, according to the 2020 American Diabetes Association criteria.", + "On a follow-up visit, preprandial insulin was discontinued.", + "Basal insulin dosage was regulated.", + "Treatment with metformin was enhanced.", + "One month later, basal insulin dosage decreased at about 8 units per day and was subsequently halted.", + "Two years later, basal insulin needed to be reintroduced, along with metformin and a GLP-1 RA.", + "Insulin requirement after at least 6 months from original diagnosis confirmed the hypothesis of LADA.", + "On a 6-year follow-up, diabetes progressed to T1DM.", + "Basal bolus insulin treatment with detemir and lispro was initiated.", + "The patient remains adherent to the regimen.", + "The regimen has not been modified since.", + "At the initial visit, the patient complained of excessive sweating and increased sensitivity to heat.", + "A complete physical examination revealed upper limb tremor, lid lag, palpable thyroid gland, and heart rate of 110 beats per minute.", + "TSH levels were lower than 0.004 mIU/L.", + "Total T3 was 2.19 nmol/L.", + "Total T4 was 14.60 μg/dl.", + "Free T3 was 4.93 pmol/L.", + "Free T4 was 1.65 ng/dl.", + "Anti-TG were positive at 174 IU/ml.", + "Anti-TPO were positive at 245 IU/ml.", + "Anti-TSH-R antibody was negative.", + "An ultrasound scan of the thyroid gland was not indicative of pathology.", + "Seven days later, TSH was 3.14 μIU/ml.", + "T3 was 1.57 nmol/L.", + "T4 was 87.19 μg/dl.", + "fT3 was 5.60 pmol/L.", + "fT4 was 15.26 ng/dl.", + "TSH values decreased spontaneously with no treatment admitted.", + "High levels of total and free thyroid hormones and presence of elevated anti-thyroid antibodies with negative anti-TSH-R navigated the diagnosis toward hashitoxicosis complicating Hashimoto’s disease.", + "One month later, TSH was higher than normal at 7.29 mIU/L.", + "Levothyroxine treatment with maximal dosage of 88 μg was decided.", + "On a 2-year follow-up, thyroxine was withdrawn as Hashimoto’s thyroiditis retreated.", + "The patient has remained euthyroid.", + "On a 6-year follow-up, there were no identifiable changes in the patient’s thyroid state." + ], + "summary": "A 29-year-old male of Albanian descent presented after being hospitalized owing to diabetic ketoacidosis. The diagnosis of type 1 diabetes mellitus was placed, and intensified insulin therapy was initiated. Medical history was not of significance except a 5 kg weight loss within 2 months. The patient presented with recurrent episodes of hypoglycemia, and the doses of preprandial and basal insulin were reduced. The differential diagnosis included type 1 diabetes mellitus \"honeymoon\" period or another type of diabetes mellitus. His serological tests only revealed positive autoantibodies against glutamic acid decarboxylase 65 and C-peptide. The diagnosis leaned toward latent autoimmune diabetes in adults, and the therapeutic approach involved cessation of preprandial insulin therapy, regulation, and subsequent discontinuation of basal insulin and introduction of metformin. Two years later, basal insulin was reintroduced along with a glucagon-like peptide-receptor agonist and metformin. Further physical examination during the initial visit disclosed upper limb tremor, lid lag, excessive sweating, increased sensitivity to heat, and tachycardia. Laboratory tests were indicative of hashitoxicosis (suppressed level of thyroid-stimulating hormone, high levels of total and free thyroid hormones, positive anti-thyroglobulin and anti-thyroid peroxidase, and negative anti-thyroid-stimulating hormone receptor). Thyroid-stimulating hormone level was spontaneously restored, but an increase was observed during follow-up. Levothyroxine was administrated for 2 years until the patient had normal thyroid function.", + "summary_subclaims": [ + "The patient is a 29-year-old male of Albanian descent.", + "The patient was hospitalized owing to diabetic ketoacidosis.", + "The diagnosis of type 1 diabetes mellitus was placed.", + "Intensified insulin therapy was initiated.", + "Medical history was not of significance except a 5 kg weight loss within 2 months.", + "The patient presented with recurrent episodes of hypoglycemia.", + "The differential diagnosis included type 1 diabetes mellitus 'honeymoon' period or another type of diabetes mellitus.", + "Serological tests only revealed positive autoantibodies against glutamic acid decarboxylase 65 and C-peptide.", + "The diagnosis leaned toward latent autoimmune diabetes in adults.", + "The therapeutic approach involved cessation of preprandial insulin therapy.", + "The therapeutic approach involved regulation and subsequent discontinuation of basal insulin.", + "The therapeutic approach involved introduction of metformin.", + "Two years later, basal insulin was reintroduced along with a glucagon-like peptide-receptor agonist and metformin.", + "Further physical examination during the initial visit disclosed upper limb tremor.", + "Further physical examination during the initial visit disclosed lid lag.", + "Further physical examination during the initial visit disclosed excessive sweating.", + "Further physical examination during the initial visit disclosed increased sensitivity to heat.", + "Further physical examination during the initial visit disclosed tachycardia.", + "Laboratory tests were indicative of hashitoxicosis.", + "Thyroid-stimulating hormone level was spontaneously restored.", + "An increase in thyroid-stimulating hormone was observed during follow-up.", + "Levothyroxine was administrated for 2 years until the patient had normal thyroid function." + ] + }, + { + "id": "multiclinsum_test_2293_en.txt", + "fulltext": "This study was approved by our institutional review board (MOD18120143-003, approved 3/9/2020), and written consent was obtained.\nA 60-year-old male with history of nonischemic cardiomyopathy and left ventricular ejection fraction of 20% was admitted to the hospital with recurrent ventricular tachycardia. He had undergone three unsuccessful ablation procedures and had also failed multiple outpatient anti-arrhythmic pharmacotherapies. While inpatient, he was maintained on a continuous intravenous infusion of lidocaine. Initially, he was listed as Status 3E, and remained inpatient awaiting a heart offer for over four months. Eventually, he was upgraded to Status 2E due to increased burden of ventricular tachycardia. On post-upgrade day 16, he received a donor offer.\nThe donor was a 40-year-old male who underwent brain death pronouncement after sustaining blunt head trauma. On echocardiography, the heart had good biventricular function. Due to the donor’s age, left coronary catheterization was performed, which revealed an anomalous origin of the left coronary artery (LCA). The LCA and right coronary artery arose from a single ostium within the right sinus of Valsalva . Chest computed tomography demonstrated a retro-aortic course of the LCA . A discussion was held among the heart failure cardiology and cardiac surgery team. Because the LCA did not appear to have an inter-arterial or other malignant course, nor did it appear to have flow limitation or restriction on angiography, the decision was made to pursue transplantation. A heart team was sent to the donor facility, and the heart was accepted and later transplanted (Additional file : Video). Transplantation was performed using our usual implantation technique without modification, beginning with the left atrial cuff anastomosis followed by the aortic anastomosis. The single coronary ostium was widely patent upon inspection, and did not require unroofing.\nThe patient did well post-transplant. His hospital course was prolonged primarily due to pretransplant physical deconditioning, having been hospitalized for four months prior to transplant. On posttransplant day 36, he was discharged to a rehabilitation facility, and was discharged home 24 days later.", + "fulltext_subclaims": [ + "The study was approved by the institutional review board (MOD18120143-003, approved 3/9/2020).", + "Written consent was obtained.", + "The patient was a 60-year-old male.", + "The patient had a history of nonischemic cardiomyopathy.", + "The patient had a left ventricular ejection fraction of 20%.", + "The patient was admitted to the hospital with recurrent ventricular tachycardia.", + "The patient had undergone three unsuccessful ablation procedures.", + "The patient had failed multiple outpatient anti-arrhythmic pharmacotherapies.", + "While inpatient, the patient was maintained on a continuous intravenous infusion of lidocaine.", + "Initially, the patient was listed as Status 3E.", + "The patient remained inpatient awaiting a heart offer for over four months.", + "The patient was upgraded to Status 2E due to increased burden of ventricular tachycardia.", + "On post-upgrade day 16, the patient received a donor offer.", + "The donor was a 40-year-old male.", + "The donor underwent brain death pronouncement after sustaining blunt head trauma.", + "On echocardiography, the donor heart had good biventricular function.", + "Due to the donor’s age, left coronary catheterization was performed.", + "The left coronary catheterization revealed an anomalous origin of the left coronary artery (LCA).", + "The LCA and right coronary artery arose from a single ostium within the right sinus of Valsalva.", + "Chest computed tomography demonstrated a retro-aortic course of the LCA.", + "A discussion was held among the heart failure cardiology and cardiac surgery team.", + "The LCA did not appear to have an inter-arterial or other malignant course.", + "The LCA did not appear to have flow limitation or restriction on angiography.", + "The decision was made to pursue transplantation.", + "A heart team was sent to the donor facility.", + "The heart was accepted and later transplanted.", + "Transplantation was performed using the usual implantation technique without modification.", + "The implantation technique began with the left atrial cuff anastomosis followed by the aortic anastomosis.", + "The single coronary ostium was widely patent upon inspection.", + "The single coronary ostium did not require unroofing.", + "The patient did well post-transplant.", + "The patient’s hospital course was prolonged primarily due to pretransplant physical deconditioning.", + "The patient had been hospitalized for four months prior to transplant.", + "On posttransplant day 36, the patient was discharged to a rehabilitation facility.", + "The patient was discharged home 24 days after being discharged to the rehabilitation facility." + ], + "summary": "An anomalous single coronary artery with the left main coronary artery arising from the right coronary ostium was discovered in a 40-year old male evaluated for cardiac donation. After evaluation, this heart was successfully procured and utilized for orthotopic heart transplantation.", + "summary_subclaims": [ + "An anomalous single coronary artery with the left main coronary artery arising from the right coronary ostium was discovered in a 40-year old male evaluated for cardiac donation.", + "After evaluation, this heart was successfully procured and utilized for orthotopic heart transplantation." + ] + }, + { + "id": "multiclinsum_test_1795_en.txt", + "fulltext": "A 17-year-old Han Chinese female presented to the psychiatric outpatient clinic with a one-week history of dizziness and feeling sluggish. These symptoms were impairing her ability to attend school regularly. Her psychiatric history was significant for a recent hospitalization three months prior for bipolar disorder with psychotic features (auditory hallucinations). The patient met the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition criteria for bipolar I disorder based on the documented presentation of manic episode as well as prior major depressive episodes over the preceding three months. During admission, she was started on lithium carbonate 500 mg twice daily and paliperidone 9 mg (450 mg Chlorpromazine, equivalent dose) once daily for treatment. Two months later, the paliperidone was down titrated to 6 mg (300 mg Chlorpromazine, equivalent dose) once daily. However, one week before her outpatient visit, she started to experience frequent dizziness, chest tightness, and feeling sluggish. She denied any other personal or family medical conditions, smoking, alcohol use, or illicit drug use. However, it was noted these were based on self-report only, and additional clinical documentation was unavailable to confirm past medical conditions. Prior to the initiation of lithium and paliperidone, she had no history of thyroid disease, bradycardia, or other cardiac issues.\nOn physical examination, her heart rate was bradycardic at 41 beats per minute, and her blood pressure was 95/57 mmHg. An electrocardiogram (ECG) revealed sinus bradycardia and sinus arrest . Her serum electrolytes, including calcium, potassium, and myocardial enzymes, were within normal limits . However, thyroid function tests showed an elevated thyroid-stimulating hormone (TSH) of 9.08 mIU/L (reference range 0.51–4.94 mIU/L), decreased total thyroxine (TT4) of 45.05 nmol/L (reference range 58.1–140.6 nmol/L), and decreased free thyroxine (FT4) of 10.94 pmol/L (reference range 11.5–22.7 pmol/L) . Her thyroid abnormalities were considered subclinical in nature since overt symptomatic manifestations were not charted in the available history. She and her guardian denied any personal or family history of cardiac or thyroid diseases, and she was not taking any other medicines known to cause heart block. Although her serum lithium level was not measured due to unavailability of the assay at our hospital, her serum paliperidone level was within the therapeutic range . Based on her medication history and clinical presentation, the combination of lithium and paliperidone was suspected as the likely cause of her hypothyroidism, bradycardia, and sinus arrest.\nThis was further supported when her thyroid function normalized 20 days after stopping these medications, without levothyroxine replacement . Bradycardia and sinus dysfunction were documented to have resolved within the same timeframe as thyroid function stabilization, with a restoration of normal sinus rhythm to 64 beats per minute occurring 20 days after medication cessation. This aligned timing provides evidence that the cardiac issues were likely attributable to drug-induced sinus node effects rather than idiopathic pathology. The half-lives of lithium and paliperidone are 18 hours and 23 hours, respectively, which explains the timing of the resolution of her subclinical hypothyroidism and sinus node dysfunction 20 days after discontinuing these medicines. Then, she was switched to olanzapine 2.5 mg once daily for her psychiatric disorder. Pacemaker implantation was not pursued because her sinus rhythm recovered with drug withdrawal.", + "fulltext_subclaims": [ + "The patient is a 17-year-old Han Chinese female.", + "She presented to the psychiatric outpatient clinic with a one-week history of dizziness and feeling sluggish.", + "These symptoms were impairing her ability to attend school regularly.", + "Her psychiatric history was significant for a recent hospitalization three months prior for bipolar disorder with psychotic features.", + "The patient met the DSM-5 criteria for bipolar I disorder.", + "During admission, she was started on lithium carbonate 500 mg twice daily.", + "During admission, she was started on paliperidone 9 mg once daily.", + "Two months later, the paliperidone was down titrated to 6 mg once daily.", + "One week before her outpatient visit, she started to experience frequent dizziness, chest tightness, and feeling sluggish.", + "She denied any other personal or family medical conditions, smoking, alcohol use, or illicit drug use.", + "Additional clinical documentation was unavailable to confirm past medical conditions.", + "Prior to the initiation of lithium and paliperidone, she had no history of thyroid disease.", + "On physical examination, her heart rate was bradycardic at 41 beats per minute.", + "An ECG revealed sinus bradycardia and sinus arrest.", + "Her serum electrolytes, including calcium, potassium, and myocardial enzymes, were within normal limits.", + "Her TSH was 9.08 mIU/L.", + "Her TT4 was 45.05 nmol/L.", + "Her FT4 was 10.94 pmol/L.", + "Her thyroid abnormalities were considered subclinical in nature.", + "Her serum lithium level was not measured due to unavailability of the assay.", + "Her serum paliperidone level was within the therapeutic range.", + "The combination of lithium and paliperidone was suspected as the likely cause of her hypothyroidism, bradycardia, and sinus arrest.", + "Her thyroid function normalized 20 days after stopping these medications.", + "Bradycardia and sinus dysfunction were documented to have resolved within the same timeframe as thyroid function stabilization.", + "The half-lives of lithium and paliperidone are 18 hours and 23 hours, respectively.", + "She was switched to olanzapine 2.5 mg once daily for her psychiatric disorder.", + "Pacemaker implantation was not pursued because her sinus rhythm recovered with drug withdrawal." + ], + "summary": "Here, we reported a case of a 17-year-old Han Chinese female who developed symptomatic hypothyroidism, sinus bradycardia, and sinus arrest while being treated with lithium and paliperidone for bipolar disorder with psychotic features including auditory hallucinations. Her workup suggested that these adverse effects might be related to the combined lithium and paliperidone treatment, although other causes could not be ruled out. After discontinuing both medications, her thyroid function and heart rhythm normalized over 20 days.", + "summary_subclaims": [ + "The patient was a 17-year-old Han Chinese female.", + "The patient developed symptomatic hypothyroidism.", + "The patient had sinus bradycardia.", + "The patient had sinus arrest.", + "The patient was being treated with lithium.", + "The patient was being treated with paliperidone.", + "The patient had bipolar disorder with psychotic features.", + "The patient had auditory hallucinations.", + "The workup suggested that the adverse effects might be related to the combined lithium and paliperidone treatment.", + "Other causes could not be ruled out.", + "After discontinuing both medications, her thyroid function normalized over 20 days.", + "After discontinuing both medications, her heart rhythm normalized over 20 days." + ] + }, + { + "id": "multiclinsum_test_56_en.txt", + "fulltext": "A 60-year-old man presented to the hospital with back pain and was subsequently diagnosed with uncomplicated Stanford type B acute aortic dissection. He was hospitalized and given conservative treatment; however, a contrast-enhanced computed tomography (CT) scan at that time showed a 55-mm aortic root dilatation . Furthermore, transthoracic echocardiogram revealed severe aortic regurgitation (AR), and the patient was diagnosed with annuloaortic ectasia . Its vena contracta was 6 mm, and the pressure halt time was 430 ms. Holodiastolic flow reversal was also detected in the abdominal aorta. Cusp degeneration and mitral valve insufficiency were not observed. After discharge, false lumen stability was confirmed on follow-up CT; thus, elective surgery for the aortic root was scheduled. The patient’s other significant past medical history included hypertension, dyslipidemia, hyperuricemia, sleep apnea, and vasospastic angina, which developed 11 months before. He was 183-cm tall and weighed 83.0 kg and had no specific family history.\nDuring surgery, cardiopulmonary bypass (CPB) was established via cannulation to the ascending aorta and the right atrium using a 24 Fr curved-tip dispersion aortic cannula and a 34/46 Fr two-stage venous cannula, respectively. In addition, an antegrade cardioplegia (CP) cannula was cannulated to the proximal ascending aorta, and then cardiac arrest was induced with antegrade CP after cross-clamping of the ascending aorta. Aside from a small calcification at the nadir of the annulus of the right coronary cusp, aortic valve degeneration such as cusp size discrepancy, cusp thickening, or cusp fenestration was not observed; thus, the David procedure was initially performed. However, intraoperative transesophageal echocardiogram revealed eccentric AR jet due to right coronary cusp falling toward the left ventricle. Therefore, valve sparing was abandoned, and the Bentall procedure using a mechanical valve was selected. The antegrade CP cannulation site was resected and replaced with vascular prosthesis. Smooth CPB weaning was achieved, and the procedure was completed without any problems. The operation and CPB times were 416 and 308 min, respectively.\nThe postoperative course was not complicated, and the patient had never complained of chest pain after the operation. However, a routine contrast-enhanced CT scan at postoperative day (POD) 14 showed new Stanford type A aortic dissection . It was thought to be caused by intraoperative aortic cannulation for CPB as the entry was just below the felt pledget used for aortic cannulation site closure. The postoperative dissection was conservatively treated as the aortic root had already been replaced, and no symptoms, or malperfusion was observed. The patient was carefully observed with continuing hospitalization, and the resting level was gradually eased. Follow-up CT at POD 29 showed no enlargement of the ascending aorta, and the patient was discharged without other complications at POD 34.\nAlthough he had no family history of cardiovascular diseases, including aortic dissection, or aortic aneurysm, connective tissue disease was suspected due to his own history of aortic root dilatation and recurrent aortic dissection; thus, a genetic test was conducted (tested genes: FBN1, FBN2, TGFBR1, TGFBR2, TGFB2, TGFB3, SMAD2, SMAD3, ACTA2, COL3A1, EFEMP2, FLNA, MYH11, MYLK, SLC2A10). Among the tested genes, unreported heterozygous 8-base duplication mutation in the SMAD3 MH2 domain (c.742_749dup, p. Gln252ThrfsTer7) and likely benign heterozygous missense mutation in FBN2 (c.3518C > G, p. Thr1173Ser) were detected . The SMAD3 mutation seemed to be pathogenic because it causes frameshift, and premature termination codon can be formed. When the oropharynx was examined, a bifid uvula was found . Although the patient had no history of musculoskeletal disease, such as osteoarthritis, he was diagnosed with LDS type III based on the diagnostic criterion .\nThe aortic diameter was unchanged on follow-up CT at 6 months after surgery ; thus, observation was continued. If aortic arch enlargement is seen in the future, surgical treatment such as total arch replacement with frozen elephant trunk will be planned.", + "fulltext_subclaims": [ + "A 60-year-old man presented to the hospital with back pain.", + "He was diagnosed with uncomplicated Stanford type B acute aortic dissection.", + "He was hospitalized and given conservative treatment.", + "A contrast-enhanced computed tomography (CT) scan at that time showed a 55-mm aortic root dilatation.", + "Transthoracic echocardiogram revealed severe aortic regurgitation (AR).", + "The patient was diagnosed with annuloaortic ectasia.", + "Its vena contracta was 6 mm.", + "The pressure halt time was 430 ms.", + "Holodiastolic flow reversal was also detected in the abdominal aorta.", + "Cusp degeneration and mitral valve insufficiency were not observed.", + "False lumen stability was confirmed on follow-up CT.", + "Elective surgery for the aortic root was scheduled.", + "The patient’s other significant past medical history included hypertension.", + "The patient’s other significant past medical history included dyslipidemia.", + "The patient’s other significant past medical history included hyperuricemia.", + "The patient’s other significant past medical history included sleep apnea.", + "The patient’s other significant past medical history included vasospastic angina.", + "Vasospastic angina developed 11 months before.", + "He was 183-cm tall.", + "He weighed 83.0 kg.", + "He had no specific family history.", + "Cardiopulmonary bypass (CPB) was established via cannulation to the ascending aorta.", + "Cardiopulmonary bypass (CPB) was established via cannulation to the right atrium.", + "A 24 Fr curved-tip dispersion aortic cannula was used.", + "A 34/46 Fr two-stage venous cannula was used.", + "An antegrade cardioplegia (CP) cannula was cannulated to the proximal ascending aorta.", + "Cardiac arrest was induced with antegrade CP after cross-clamping of the ascending aorta.", + "A small calcification at the nadir of the annulus of the right coronary cusp was observed.", + "Aortic valve degeneration such as cusp size discrepancy, cusp thickening, or cusp fenestration was not observed.", + "The David procedure was initially performed.", + "Intraoperative transesophageal echocardiogram revealed eccentric AR jet due to right coronary cusp falling toward the left ventricle.", + "Valve sparing was abandoned.", + "The Bentall procedure using a mechanical valve was selected.", + "The antegrade CP cannulation site was resected and replaced with vascular prosthesis.", + "Smooth CPB weaning was achieved.", + "The procedure was completed without any problems.", + "The operation time was 416 min.", + "The CPB time was 308 min.", + "The postoperative course was not complicated.", + "The patient had never complained of chest pain after the operation.", + "A routine contrast-enhanced CT scan at postoperative day (POD) 14 showed new Stanford type A aortic dissection.", + "It was thought to be caused by intraoperative aortic cannulation for CPB.", + "The entry was just below the felt pledget used for aortic cannulation site closure.", + "The postoperative dissection was conservatively treated.", + "The aortic root had already been replaced.", + "No symptoms or malperfusion was observed.", + "The patient was carefully observed with continuing hospitalization.", + "The resting level was gradually eased.", + "Follow-up CT at POD 29 showed no enlargement of the ascending aorta.", + "The patient was discharged without other complications at POD 34.", + "Although he had no family history of cardiovascular diseases, including aortic dissection, or aortic aneurysm, connective tissue disease was suspected.", + "A genetic test was conducted.", + "Unreported heterozygous 8-base duplication mutation in the SMAD3 MH2 domain (c.742_749dup, p. Gln252ThrfsTer7) was detected.", + "Likely benign heterozygous missense mutation in FBN2 (c.3518C > G, p. Thr1173Ser) was detected.", + "The SMAD3 mutation seemed to be pathogenic because it causes frameshift.", + "Premature termination codon can be formed.", + "A bifid uvula was found.", + "Although the patient had no history of musculoskeletal disease, such as osteoarthritis, he was diagnosed with LDS type III.", + "The aortic diameter was unchanged on follow-up CT at 6 months after surgery.", + "Observation was continued.", + "If aortic arch enlargement is seen in the future, surgical treatment such as total arch replacement with frozen elephant trunk will be planned." + ], + "summary": "A 60-year-old man was admitted to the hospital for Stanford type B acute aortic dissection and given conservative treatment. He was found to have aortic root dilatation and severe aortic regurgitation. Thus, elective Bentall procedure was performed. Postoperative computed tomography showed new Stanford type A aortic dissection that may have developed due to aortic cannulation during surgery. The patient was given conservative treatment and successfully discharged to home at postoperative day 34. Although he had no family history of aortic disease, a genetic test revealed an unreported SMAD3 frameshift mutation (c.742_749dup, p. Gln252ThrfsTer7), and the patient was diagnosed with Loeys-Dietz syndrome type III.", + "summary_subclaims": [ + "The patient was a 60-year-old man.", + "He was admitted to the hospital for Stanford type B acute aortic dissection.", + "He was given conservative treatment.", + "He was found to have aortic root dilatation.", + "He was found to have severe aortic regurgitation.", + "An elective Bentall procedure was performed.", + "Postoperative computed tomography showed new Stanford type A aortic dissection.", + "The new Stanford type A aortic dissection may have developed due to aortic cannulation during surgery.", + "The patient was given conservative treatment.", + "The patient was successfully discharged to home at postoperative day 34.", + "He had no family history of aortic disease.", + "A genetic test revealed an unreported SMAD3 frameshift mutation (c.742_749dup, p. Gln252ThrfsTer7).", + "The patient was diagnosed with Loeys-Dietz syndrome type III." + ] + }, + { + "id": "multiclinsum_test_3159_en.txt", + "fulltext": "A 49-year-old male was referred for sudden onset of right-side weakness and aphasia for 55 minutes, with an initial National Institute of Health Stroke Scale (NIHSS) score of 23 [(3 +2+2)+1+0+0+(0+4)+(0+4)+0+2+3+2+0] and a modified Rankin Scale (mRS) score 3. He had a history of rheumatic heart disease with atrial fibrillation and had been on oral warfarin anticoagulant therapy. AIS was considered after no bleeding was observed on emergency head computed tomography. Considering that the specific value of the patient’s international normalized ratio was unknown and given the risk of intravenous thrombolytic bleeding, we decided to perform MT directly after obtaining the consent of the patient’s family. The patient was then taken to the catheter room and prepared for an endovascular thrombectomy and the door-to-puncture time was 36 minutes. Digital subtraction angiography (DSA) in the posterior–anterior projection showed the bilateral A2 segments ACAs originating from the left A1 segment, and both bilateral A2 segments ACAs were occluded. Consider this rare anatomical variation and the fact that the existing aspiration catheter hardly reaches the occlusive site, MT then was performed by using a 4×20 stent retriever (RECO; Minitech Medical, Wuxi, China) to revascularize the bilateral ACAs. After the respective first thrombectomy trial with the stent retriever, the bilateral ACAs were completely reperfused with modified thrombolysis in cerebral ischemia 3, but secondary thrombi were found in the MCA bifurcation. Most thrombi were removed in the MCA bifurcation after the use of direct aspiration technique. Imaging was performed within the following 24 h using magnetic resonance imaging. A recent infarction in the bilateral ACA territory and part of the left MCA territory was found. The patient achieved an NIHSS of 4 and a mRS of 1 at the 3-month follow-up.", + "fulltext_subclaims": [ + "The patient was a 49-year-old male.", + "He had sudden onset of right-side weakness and aphasia for 55 minutes.", + "The initial NIHSS score was 23.", + "The mRS score was 3.", + "He had a history of rheumatic heart disease with atrial fibrillation.", + "He had been on oral warfarin anticoagulant therapy.", + "AIS was considered after no bleeding was observed on emergency head computed tomography.", + "The specific value of the patient’s international normalized ratio was unknown.", + "The risk of intravenous thrombolytic bleeding was considered.", + "MT was performed directly after obtaining the consent of the patient’s family.", + "The door-to-puncture time was 36 minutes.", + "DSA in the posterior–anterior projection showed the bilateral A2 segments ACAs originating from the left A1 segment.", + "Both bilateral A2 segments ACAs were occluded.", + "MT was performed by using a 4×20 stent retriever (RECO; Minitech Medical, Wuxi, China).", + "After the first thrombectomy trial with the stent retriever, the bilateral ACAs were completely reperfused with modified thrombolysis in cerebral ischemia 3.", + "Secondary thrombi were found in the MCA bifurcation.", + "Most thrombi were removed in the MCA bifurcation after the use of direct aspiration technique.", + "Imaging was performed within the following 24 h using magnetic resonance imaging.", + "A recent infarction in the bilateral ACA territory and part of the left MCA territory was found.", + "The patient achieved an NIHSS of 4 at the 3-month follow-up.", + "The patient achieved an mRS of 1 at the 3-month follow-up." + ], + "summary": "A 49-year-old man was referred for sudden onset of right-side weakness and aphasia for almost 55 min. AIS was considered after no bleeding was observed on emergency head computed tomography. Digital subtraction angiography was performed, and bilateral ACAs were found to originate from the anterior communicating branch of the left internal carotid artery and were occluded in their A2 segment. After immediate emergency MT with a stent retriever, the symptoms obviously improved.", + "summary_subclaims": [ + "A 49-year-old man was referred for sudden onset of right-side weakness and aphasia for almost 55 min.", + "AIS was considered after no bleeding was observed on emergency head computed tomography.", + "Digital subtraction angiography was performed.", + "Bilateral ACAs were found to originate from the anterior communicating branch of the left internal carotid artery.", + "Bilateral ACAs were occluded in their A2 segment.", + "Immediate emergency MT with a stent retriever was performed.", + "The symptoms obviously improved." + ] + }, + { + "id": "multiclinsum_test_1979_en.txt", + "fulltext": "A 70-year-old woman presented with 5 months of progressive low back pain. She had a complex medical history including a remote splenectomy, anti-phospholipid syndrome, autoimmune hemolytic anemia requiring previous courses of cyclophosphamide, L3 laminectomy 2 years prior, and systemic lupus erythematosus (SLE) with ongoing therapy with hydroxychloroquine and prednisone 20 mg daily. Her low back pain initially manifested in the context of a herpes zoster infection and management of presumed neuropathic pain was pursued. In ensuing months, she had progression of low back pain despite conservative management. Magnetic Resonance Imaging (MRI) of the lumbar spine showed evidence of an epidural abscess at L2–3, L3–4 with vertebral osteomyelitis at L2-L3. Admission vitals showed a heart rate of 120 beats per minute, blood pressure of 121/59 mmHg, temperature of 36.9 °C, respiratory rate 16 breaths per minute, and SpO2 of 93% on room air. She had a mild leukocytosis with a white blood cell count of 12.18 k/uL. C-reactive protein and sedimentation rate were elevated at 2.8 mg/dL and 45 mm/h respectively. She underwent surgical evacuation of the epidural abscess and wound revision of L2-L3. Intra-operative findings included dark brown fluid that egressed from her epidural site, but no purulent fluid was visualized. Intraoperative cultures of vertebral bodies and discs showed no evidence of bacterial or fungal growth. Acid-fast bacterial (AFB) stains, cultures and QuantiFERON®-TB Gold In-Tube testing were also negative. Empiric treatment with vancomycin and cefepime was initiated with plans to complete a six-week course.\nThree weeks after surgical intervention, she re-presented with persistent low back pain and encephalopathy. Cefepime was considered as a possible etiology of her altered mental status and therefore was replaced by aztreonam. Admission vital signs were unremarkable. C-reactive protein and sedimentation rate were 4.9 mg/dL and 36 mm/h respectively, with notable increase in C-reactive protein from 2.8 mg/dL. Lumbar spinal computed tomography (CT) demonstrated severe lytic and sclerotic destructive changes centered on the disc space of L2-L3 and the vertebral body of L4. There were also findings consistent with a large paraspinal abscess anterior to the L3 vertebral body. A biopsy of the L3 vertebral body was obtained and showed no organisms on gram stain with no growth after 7 days. This prompted a repeat bone biopsy in attempts to define the causative pathogen and direct further antimicrobial therapy. Meanwhile, empiric antibiotics to cover typical pathogens were continued. Two weeks following the initial vertebral body biopsy there was growth of acid fast bacilli from the bony specimen, which was further identified as MAC by hybridization probe. In vitro susceptibility testing indicated a favorable resistance profile with susceptibility to clofazimine, rifabutin, clarithromycin, ethambutol, and rifampin. Treatment with ethambutol and azithromycin was initiated after receiving susceptibility results. Two-drug therapy was selected due to the favorable susceptibility of the MAC isolate, in addition to efforts to mitigate potential adverse drug effects and medication interactions. She had no evidence of MAC pulmonary involvement on chest CT and the etiology of her infection was uncertain. Two months later she was seen in follow-up with resolution of her symptoms. She will continue antibiotics to complete a 12-month course.", + "fulltext_subclaims": [ + "The patient is a 70-year-old woman.", + "She had a remote splenectomy.", + "She has anti-phospholipid syndrome.", + "She has a history of autoimmune hemolytic anemia.", + "She had a L3 laminectomy 2 years prior.", + "She has systemic lupus erythematosus.", + "She was on hydroxychloroquine and prednisone 20 mg daily.", + "She had 5 months of progressive low back pain.", + "Her low back pain initially manifested in the context of a herpes zoster infection.", + "She had progression of low back pain despite conservative management.", + "MRI of the lumbar spine showed an epidural abscess at L2–3, L3–4.", + "MRI showed vertebral osteomyelitis at L2-L3.", + "Admission heart rate was 120 beats per minute.", + "Admission blood pressure was 121/59 mmHg.", + "Admission temperature was 36.9 °C.", + "Admission SpO2 was 93% on room air.", + "She had a white blood cell count of 12.18 k/uL.", + "C-reactive protein was 2.8 mg/dL.", + "Sedimentation rate was 45 mm/h.", + "She underwent surgical evacuation of the epidural abscess.", + "Intra-operative findings included dark brown fluid from the epidural site.", + "Intraoperative cultures showed no bacterial or fungal growth.", + "AFB stains, cultures, and QuantiFERON®-TB Gold In-Tube testing were negative.", + "Empiric treatment with vancomycin and cefepime was initiated.", + "Three weeks after surgery, she re-presented with persistent low back pain and encephalopathy.", + "Cefepime was replaced by aztreonam.", + "C-reactive protein increased to 4.9 mg/dL.", + "Lumbar spinal CT showed severe lytic and sclerotic destructive changes.", + "A large paraspinal abscess was found anterior to the L3 vertebral body.", + "A biopsy of the L3 vertebral body showed no organisms on gram stain.", + "There was no growth after 7 days from the initial biopsy.", + "A repeat bone biopsy was obtained.", + "Acid fast bacilli were grown from the bony specimen.", + "The isolate was identified as MAC by hybridization probe.", + "Susceptibility testing showed susceptibility to clofazimine, rifabutin, clarithromycin, ethambutol, and rifampin.", + "Treatment with ethambutol and azithromycin was initiated.", + "Two-drug therapy was selected due to the favorable susceptibility profile.", + "She had no evidence of MAC pulmonary involvement on chest CT.", + "The etiology of her infection was uncertain.", + "Two months later, she had resolution of her symptoms.", + "She will continue antibiotics to complete a 12-month course." + ], + "summary": "We report a case of MAC osteomyelitis of the lumbar spine in a 70-year-old woman on extended duration corticosteroid therapy for systemic lupus erythematosus who presented with progressive back pain. Upon presentation, imaging revealed osteomyelitis of the lumbar spine with associated paraspinal abscess. Cultures from the surgical evacuation of the paraspinal abscess yielded no pathogen growth and she was therefore treated with empiric antibacterial therapy. Two weeks after her initial hospital discharge she represented with severe back pain and radiologic evidence of progressive disease in her lumbar spine. Two additional vertebral biopsies were required during her first 2 weeks of admission. MAC eventually grew from culture 14 days after collection. She was treated with ethambutol and rifampin and her symptoms resolved in 2 weeks, though therapy was continued for 12 months.", + "summary_subclaims": [ + "The patient was a 70-year-old woman.", + "The patient was on extended duration corticosteroid therapy.", + "The corticosteroid therapy was for systemic lupus erythematosus.", + "The patient had MAC osteomyelitis of the lumbar spine.", + "The patient presented with progressive back pain.", + "Imaging revealed osteomyelitis of the lumbar spine.", + "Imaging revealed an associated paraspinal abscess.", + "Cultures from the surgical evacuation of the paraspinal abscess yielded no pathogen growth.", + "She was treated with empiric antibacterial therapy.", + "Two weeks after her initial hospital discharge she represented with severe back pain.", + "Radiologic evidence showed progressive disease in her lumbar spine.", + "Two additional vertebral biopsies were required during her first 2 weeks of admission.", + "MAC eventually grew from culture 14 days after collection.", + "She was treated with ethambutol and rifampin.", + "Her symptoms resolved in 2 weeks.", + "Therapy was continued for 12 months." + ] + }, + { + "id": "multiclinsum_test_1599_en.txt", + "fulltext": "In October 2009, a four-year-old girl was referred to the Rare Disease Unit of Bambino Gesù Children Hospital, presenting with phthisis bulbi (atrophy of the ocular bulb) of the left eye. She was the second child of Caucasian, non-consanguineous parents. Since the age of two-year-old, she developed recurrent episodes of conjunctivitis with pseudomembranes on the eyelids. After the failure of medical treatments, topical antibiotics and steroids, the lesions were surgically excised, but after a few weeks, they recurred, and conjunctivitis persisted. The surgical procedure was repeated twice.\nAfter the third recurrence, she was referred to our unit with a suspected diagnosis of LC.\nAt first examination, the left eye presented a red, woody-like pseudomembrane (9 mm thick) that involved the edge of the upper lid and the upper tarsal conjunctiva, causing ectropion of the lid . Slit lamp examination revealed a yellow-white membrane affecting the bulbar conjunctiva, fornix, and cornea, hampering the evaluation of both anterior and posterior segments. Brain MRI with Optic Nerves study, showed severe involvement of the left eye .\nThe right eye examination showed a small area of corneal de-epithelialization with a paracentral stromal opacity, and a whitish-yellow soft pseudomembrane involving the upper tarsal conjunctiva. The bulbar conjunctiva was not involved, and the rest of the ocular examination was normal. .\nAfter approval of the local Ethical Committee, treatment was started with topical plasminogen drops prepared from fresh frozen plasma (Kedrion Industrie Farmaceutiche, Lucca, Italy) in sodium hyaluronate, according to the Watts formulation [, ]. An intensive treatment schedule was chosen, with two drops instilled every two hours in both eyes.\nA rapid and complete response was observed in the right eye after one week. . In the left eye, we observed a reduction of the pseudomembranes after one week of treatment . The therapy was further intensified three days before surgery to two drops every hour. After that the red woody-like membrane was surgically removed. The thickened subconjunctival tissue was debulked via a conjunctival approach but the ectropion and lid retraction was not corrected until the upper lid retractors were recessed. The debulked posterior surface of the tarsus was left bare to granulate and the debulked flaps of conjunctiva were approximated to the upper border of the tarsus. The eyelid margin was left intact. A prosthetic shell was inserted behind the eyelids to maintain the conjunctival sac. The plasminogen was restarted every two hours.\nThe eye drop schedule was prolonged from every two hours to every four hours, and there was no evidence of membrane reformation at the twelve-month follow-up evaluation up to the present twelve-year follow-up and the eye prosthesis is well tolerated .\nAfter three years of follow-up a nodular asymptomatic gingival hypertrophy with ulceration around the eruption site of tooth 36, was found. Non-surgical management of the lesion and strict follow-up was performed. The first molar erupted completely, with no signs of bone and periodontal pathology.\nGenomic DNA was extracted from peripheral blood by using NucleoSpin tissue, according to the manufacturer's protocol (Macherey–Nagel, Germany). Whole exome sequencing (WES) was conducted on the proband and his parents by using kit Twist Custom Panel (clinical exome—Twist Bioscience) on platform NovaSeq6000 (Illumina). The bioinformatics analysis was performed trough BWA Aligner or DRAGEN Germline Pipeline systems and the sequences were aligned to reference human genome GRCh37. The DNA sequence analysis showed the variants c.112A > G (p.Lys38Glu) and c.217 T > C (p.Cys73Arg) in compound heterozygosity of PLG gene. The first variant was inherited by the father and the second by the mother.", + "fulltext_subclaims": [ + "In October 2009, a four-year-old girl was referred to the Rare Disease Unit of Bambino Gesù Children Hospital.", + "She presented with phthisis bulbi of the left eye.", + "She was the second child of Caucasian, non-consanguineous parents.", + "Since the age of two, she developed recurrent episodes of conjunctivitis with pseudomembranes on the eyelids.", + "Medical treatments, including topical antibiotics and steroids, failed.", + "The lesions were surgically excised.", + "The lesions recurred after a few weeks.", + "The surgical procedure was repeated twice.", + "After the third recurrence, she was referred to the unit with a suspected diagnosis of LC.", + "At first examination, the left eye presented a red, woody-like pseudomembrane (9 mm thick) involving the edge of the upper lid and the upper tarsal conjunctiva.", + "Slit lamp examination revealed a yellow-white membrane affecting the bulbar conjunctiva, fornix, and cornea.", + "Brain MRI with Optic Nerves study showed severe involvement of the left eye.", + "The right eye examination showed a small area of corneal de-epithelialization with a paracentral stromal opacity.", + "The right eye showed a whitish-yellow soft pseudomembrane involving the upper tarsal conjunctiva.", + "The bulbar conjunctiva was not involved in the right eye.", + "The rest of the ocular examination was normal in the right eye.", + "Treatment was started with topical plasminogen drops prepared from fresh frozen plasma.", + "The plasminogen drops were prepared in sodium hyaluronate according to the Watts formulation.", + "An intensive treatment schedule was chosen, with two drops instilled every two hours in both eyes.", + "A rapid and complete response was observed in the right eye after one week.", + "In the left eye, a reduction of the pseudomembranes was observed after one week of treatment.", + "The therapy was further intensified three days before surgery to two drops every hour.", + "After that, the red woody-like membrane was surgically removed.", + "The thickened subconjunctival tissue was debulked via a conjunctival approach.", + "The ectropion and lid retraction were not corrected until the upper lid retractors were recessed.", + "The debulked posterior surface of the tarsus was left bare to granulate.", + "The debulked flaps of conjunctiva were approximated to the upper border of the tarsus.", + "The eyelid margin was left intact.", + "A prosthetic shell was inserted behind the eyelids to maintain the conjunctival sac.", + "The plasminogen was restarted every two hours.", + "The eye drop schedule was prolonged from every two hours to every four hours.", + "There was no evidence of membrane reformation at the twelve-month follow-up evaluation.", + "There was no evidence of membrane reformation up to the present twelve-year follow-up.", + "The eye prosthesis is well tolerated.", + "After three years of follow-up, a nodular asymptomatic gingival hypertrophy with ulceration around the eruption site of tooth 36 was found.", + "Non-surgical management of the lesion and strict follow-up was performed.", + "The first molar erupted completely.", + "There were no signs of bone and periodontal pathology.", + "Genomic DNA was extracted from peripheral blood using NucleoSpin tissue.", + "Whole exome sequencing (WES) was conducted on the proband and his parents.", + "The WES was performed using the Twist Custom Panel (clinical exome) on the NovaSeq6000 platform.", + "The bioinformatics analysis was performed using BWA Aligner or DRAGEN Germline Pipeline systems.", + "The sequences were aligned to the reference human genome GRCh37.", + "The DNA sequence analysis showed the variants c.112A > G (p.Lys38Glu) and c.217 T > C (p.Cys73Arg) in compound heterozygosity of the PLG gene.", + "The first variant was inherited by the father.", + "The second variant was inherited by the mother." + ], + "summary": "We present the case of a sixteen-year-old girl with LC with severe left eye involvement. We reported the clinical conditions of the patient before and after the use of topical plasminogen eye drops and described the treatment schedule allowing the surgical procedure for the pseudomembranes debulking and the subsequent use of ocular prosthesis for aesthetic rehabilitation.", + "summary_subclaims": [ + "The patient is a sixteen-year-old girl.", + "The patient has LC.", + "The patient had severe left eye involvement.", + "Topical plasminogen eye drops were used.", + "The clinical conditions before the use of topical plasminogen eye drops were reported.", + "The clinical conditions after the use of topical plasminogen eye drops were reported.", + "A treatment schedule allowing the surgical procedure for the pseudomembranes debulking was described.", + "An ocular prosthesis was used for aesthetic rehabilitation." + ] + }, + { + "id": "multiclinsum_test_2379_en.txt", + "fulltext": "A 57-year-old woman presented with a 6 month history of increasing pain in the right side of her groin radiating down to the medial thigh, to the anterior aspect of the knee and to the medial side of the lower leg and foot. The pain worsened when climbing stairs and walking and could not be relieved by non-steroidal medications. She became unable to climb stairs and walk long distances for the preceding 2 months, due to paresthesias and hypoesthesia of the medial side of the right lower leg and foot.\nPhysical examination revealed tenderness over the anterior hip, no palpable mass and there was no muscle atrophy. Neurological examination revealed an altered sensation to light touch in the medical side of the right lower leg and foot. Internal rotation, external rotation and extension of the right hip were painful and were markedly limited. Vascular examination of her lower limb was intact. The result of the straight-leg-raising test was negative.\nLaboratory investigation included blood sugar, serum electrolytes, erythrocyte sedimentation rate, C-reactive protein, corpuscular blood count with differential count, rheumatoid factor and antinuclear antibodies. The results were all normal. Radiographs of the hip and lumbar spine were also normal. Computer tomography (CT) scan and magnetic resonance imaging (MRI) of the right hip region revealed a cystic lesion of 2.6 × 1.4 cm in diameter, both in high-T2- and low-T1-weighted signal intensity, arising from the antero-medial aspect of the acetabulum, displacing the femoral nerve as well as the femoral vein and the artery . A colour duplex Doppler ultrasonography excluded the possibility of aneurismal lesion. Electromyography (EMG) revealed evidence of muscle denervation.\nAt the time of surgery, a cyst measuring 3.3 × 2.4 × 1.8 cm was identified which was adherent to the anterior surface of the hip joint capsule. No communication was found between the joint space and the cyst. The joint capsule appeared intact. The cyst was removed totally and the base of the cyst was cauterized. The cyst was opened in the operating room and was found to contain thick, lucent gelatinous material .\nHistological evaluation identified fragments of benign cyst wall composed of variably dense fibroconnective tissue with no lining cells, consistent with a ganglion cyst .\nPostoperatively, the patient was pain-free and showed almost normal strength and sensation in the right leg. On clinical and ultrasonographic examination, no recurrence has been observed up until the time of writing this report.", + "fulltext_subclaims": [ + "The patient is a 57-year-old woman.", + "She had a 6 month history of increasing pain in the right side of her groin.", + "The pain radiated down to the medial thigh.", + "The pain radiated to the anterior aspect of the knee.", + "The pain radiated to the medial side of the lower leg and foot.", + "The pain worsened when climbing stairs.", + "The pain worsened when walking.", + "The pain could not be relieved by non-steroidal medications.", + "She became unable to climb stairs for the preceding 2 months.", + "She became unable to walk long distances for the preceding 2 months.", + "She had paresthesias of the medial side of the right lower leg and foot.", + "She had hypoesthesia of the medial side of the right lower leg and foot.", + "Physical examination revealed tenderness over the anterior hip.", + "Physical examination found no palpable mass.", + "Physical examination found no muscle atrophy.", + "Neurological examination revealed an altered sensation to light touch in the medial side of the right lower leg and foot.", + "Internal rotation of the right hip was painful and markedly limited.", + "External rotation of the right hip was painful and markedly limited.", + "Extension of the right hip was painful and markedly limited.", + "The straight-leg-raising test was negative.", + "Blood sugar was normal.", + "Serum electrolytes were normal.", + "Erythrocyte sedimentation rate was normal.", + "C-reactive protein was normal.", + "Corpuscular blood count with differential count was normal.", + "Rheumatoid factor was normal.", + "Antinuclear antibodies were normal.", + "Radiographs of the hip were normal.", + "Radiographs of the lumbar spine were normal.", + "CT scan and MRI of the right hip region revealed a cystic lesion of 2.6 × 1.4 cm in diameter.", + "The cystic lesion was in high-T2- and low-T1-weighted signal intensity.", + "The cystic lesion arose from the antero-medial aspect of the acetabulum.", + "The cystic lesion displaced the femoral nerve.", + "The cystic lesion displaced the femoral vein.", + "The cystic lesion displaced the femoral artery.", + "Color duplex Doppler ultrasonography excluded the possibility of aneurismal lesion.", + "EMG revealed evidence of muscle denervation.", + "At the time of surgery, a cyst measuring 3.3 × 2.4 × 1.8 cm was identified.", + "The cyst was adherent to the anterior surface of the hip joint capsule.", + "No communication was found between the joint space and the cyst.", + "The joint capsule appeared intact.", + "The cyst was removed totally.", + "The base of the cyst was cauterized.", + "The cyst was opened in the operating room.", + "The cyst was found to contain thick, lucent gelatinous material.", + "Histological evaluation identified fragments of benign cyst wall composed of variably dense fibroconnective tissue.", + "The cyst wall had no lining cells.", + "The histological findings were consistent with a ganglion cyst.", + "Postoperatively, the patient was pain-free.", + "Postoperatively, the patient showed almost normal strength in the right leg.", + "Postoperatively, the patient showed almost normal sensation in the right leg.", + "No recurrence has been observed up until the time of writing this report." + ], + "summary": "We report the case of a 57-year-old woman with femoral nerve compression caused by a true ganglion cyst of the hip joint.", + "summary_subclaims": [ + "The patient was a 57-year-old woman.", + "The patient had femoral nerve compression.", + "The femoral nerve compression was caused by a true ganglion cyst of the hip joint." + ] + }, + { + "id": "multiclinsum_test_1425_en.txt", + "fulltext": "A 24-year old female presented with urinary incontinence and periodical headaches. She was born with an imperforate anus, absent rectum and colon, double bladder , and a dysgenetic sacrum defect . Soon after birth she was given an ileostomy, and later underwent an anorectal and bladder reconstructions. She now came to her pediatric urologist for urinary incontinence and mentioned severe headaches on the side, particularly when riding a bike. She solved her headache problem by stopping to ride her bicycle. Her parents then sold the bicycle since it became useless.\nRecently she expressed the wish to become dry and additional investigations were scheduled. On physical examination a normal looking woman presented herself with an ileostomy and urinary incontinence without further palpable abnormalities in the abdomen or back. Blood tests showed no abnormalities; particularly alpha foeto-protein and B-HCG were within normal ranges. MRI showed a large and previously not known anterior presacral meningocele as well as a tethered cord due to a tight filum terminale . She refused testing for defects on the HLXB9 gene on chromosome 7q36. She was referred to a neurosurgeon and treatment of the meningocele consisted of a laminectomy S1-S2, transection of the filum terminale and an intradural closure of the dura towards the meningocele. The meningocele regressed and is expected to further dissolve. Three months after surgery she has no complaints; she received a urinary diversion and bought a new bicycle again.\nThe Currarino syndrome is a familiar syndrome with the triad of sacral defects, hindgut malformations and presacral tumors. It has an autosomal dominant inheritance with variable expression and the mutation is on the HLXB9 gene located on chromosome 7q36 [,]. The sacral defects vary from a slightly dysplastic sacrum to a complete sacral agenesis (caudal regression). The embryology of the syndrome is still unclear and was initially thought to be a consequence of mal-communication of the endoderm and the neuronal ectoderm . More recently it is suggested that developmental errors in progenitor cells at the region of the caudal eminence are responsible for the abnormality [,].\nClinically, the presacral mass in the Currrarino syndrome is a teratoma in approximately 25% of the cases . The complete Currarino triad is rare; this syndrome should be considered even in the presence of a partial phenotype [,]. The sacral defects can be mild and go unnoticed. The anorectal malformation can be present but the Currarino syndrome has also been described without an anorectal malformation . Constipation, however, is present in over 95% of the cases, often with an early onset as an infant and often with an intractable character . The wide phenotypic variability requires combined pediatric, neurosurgical, and often urological assessments. The triad is associated with other spinal abnormalities in the majority of patients, including anterior meningoceles in 60% . Anterior meningoceles are congenital lesions of spinal fluid filled sacs communicating with the subarachnoid space . They can give clinical symptoms related to the pressure the cele gives to organs in the pelvic floor region (rectum, bladder, genitals) or to the sacral nerves with subsequent failure of these nerves. Also, pressure on the cele gives increased intracerebral pressure with subsequent headaches.\nAnterior meningoceles give symptoms in approximately two-third of the cases. These are abdominal in 70% of the cases, urogenital in 30% of the cases and neurological in 27% of the cases . Beside these effects it may give enteral fistulas resulting in severe infections with life-threatening meningitis . These symptoms appear usually in the second to third decade of life. Anterior meningoceles can further give constipation, abdominal pains, constipation, urinary retention, dysmenorrhea, low back pain, radiation to the legs as first symptoms. However, as in our case other atypical symptoms can be seen as well. Treatment of anterior meningoceles can be conservative if no symptoms are present. However, most anterior meningoceles give symptoms and need surgical treatment because there will be no spontaneous regression. Conservative management is furthermore associated with a 30% mortality rate mostly due to meningitis. Therefore, surgical closure is generally recommended [,]. A posterior approach, transsacral or sagittal, is the preferred one because of the lowest complication rate [,]. The anterior laparotomy approach still has a high morbidity and mortality (22%) due to infections and fistula formation. Transvaginal and transrectal punctures have also previously been suggested but have a similar high morbidity and mortality.", + "fulltext_subclaims": [ + "The patient is a 24-year old female.", + "She presented with urinary incontinence.", + "She had periodical headaches.", + "She was born with an imperforate anus.", + "She had an absent rectum and colon.", + "She had a double bladder.", + "She had a dysgenetic sacral defect.", + "Soon after birth she was given an ileostomy.", + "She later underwent an anorectal reconstruction.", + "She later underwent a bladder reconstruction.", + "She now came to her pediatric urologist for urinary incontinence.", + "She mentioned severe headaches on the side, particularly when riding a bike.", + "She solved her headache problem by stopping to ride her bicycle.", + "Her parents then sold the bicycle since it became useless.", + "Recently she expressed the wish to become dry.", + "Additional investigations were scheduled.", + "On physical examination she had an ileostomy.", + "She had urinary incontinence.", + "Blood tests showed no abnormalities.", + "Alpha foeto-protein was within normal ranges.", + "B-HCG was within normal ranges.", + "MRI showed a large and previously not known anterior presacral meningocele.", + "MRI showed a tethered cord due to a tight filum terminale.", + "She refused testing for defects on the HLXB9 gene on chromosome 7q36.", + "She was referred to a neurosurgeon.", + "Treatment of the meningocele consisted of a laminectomy S1-S2.", + "Treatment included transection of the filum terminale.", + "Treatment included an intradural closure of the dura towards the meningocele.", + "The meningocele regressed.", + "The meningocele is expected to further dissolve.", + "Three months after surgery she has no complaints.", + "She received a urinary diversion.", + "She bought a new bicycle again.", + "The Currarino syndrome is a familiar syndrome with the triad of sacral defects, hindgut malformations and presacral tumors.", + "It has an autosomal dominant inheritance.", + "The mutation is on the HLXB9 gene located on chromosome 7q36.", + "The sacral defects vary from a slightly dysplastic sacrum to a complete sacral agenesis.", + "The embryology of the syndrome is still unclear.", + "It was initially thought to be a consequence of mal-communication of the endoderm and the neuronal ectoderm.", + "It is suggested that developmental errors in progenitor cells at the region of the caudal eminence are responsible for the abnormality.", + "The presacral mass in the Currarino syndrome is a teratoma in approximately 25% of the cases.", + "The complete Currarino triad is rare.", + "The syndrome should be considered even in the presence of a partial phenotype.", + "The sacral defects can be mild and go unnoticed.", + "The anorectal malformation can be present.", + "The Currarino syndrome has also been described without an anorectal malformation.", + "Constipation is present in over 95% of the cases.", + "Constipation often has an early onset as an infant.", + "Constipation is often with an intractable character.", + "The wide phenotypic variability requires combined pediatric, neurosurgical, and often urological assessments.", + "The triad is associated with other spinal abnormalities in the majority of patients.", + "Anterior meningoceles are present in 60%.", + "Anterior meningoceles are congenital lesions of spinal fluid filled sacs communicating with the subarachnoid space.", + "They can give clinical symptoms related to the pressure the cele gives to organs in the pelvic floor region.", + "They can give clinical symptoms related to the pressure the cele gives to the sacral nerves.", + "Anterior meningoceles give symptoms in approximately two-third of the cases.", + "Symptoms are abdominal in 70% of the cases.", + "Symptoms are urogenital in 30% of the cases.", + "Symptoms are neurological in 27% of the cases.", + "They may give enteral fistulas resulting in severe infections with life-threatening meningitis.", + "These symptoms appear usually in the second to third decade of life.", + "Anterior meningoceles can give constipation.", + "Anterior meningoceles can give abdominal pains.", + "Anterior meningoceles can give urinary retention.", + "Anterior meningoceles can give dysmenorrhea.", + "Anterior meningoceles can give low back pain.", + "Anterior meningoceles can give radiation to the legs as first symptoms.", + "Treatment of anterior meningoceles can be conservative if no symptoms are present.", + "Most anterior meningoceles give symptoms and need surgical treatment.", + "Conservative management is associated with a 30% mortality rate, mostly due to meningitis.", + "Surgical closure is generally recommended.", + "A posterior approach, transsacral or sagittal, is the preferred one because of the lowest complication rate.", + "The anterior laparotomy approach still has a high morbidity and mortality (22%) due to infections and fistula formation.", + "Transvaginal and transrectal punctures have also previously been suggested.", + "Transvaginal and transrectal punctures have a similar high morbidity and mortality." + ], + "summary": "A 24-year old female presented with periodical headaches. She was born with an imperforate anus, absent rectum and colon, double bladder, and sacral defect. Soon after birth she underwent several surgical procedures for anorectal and bladder reconstructions. The patient now came to her pediatric urologist for urinary incontinence and mentioned severe headaches on the side, particularly when riding a bike. Finally, she solved her headache problem by stopping to ride her bicycle.On physical examination no abnormalities were found except the ileostomy that was present ever since soon after birth and her urinary incontinence. Blood tests showed no abnormalities. Additional MRI showed a large and previously not known anterior meningocele at the level of the sacrum. Surgical treatment consisted of closure of the dura by posterior approach.", + "summary_subclaims": [ + "The patient is a 24-year old female.", + "She presented with periodical headaches.", + "She was born with an imperforate anus.", + "She was born with absent rectum and colon.", + "She was born with a double bladder.", + "She was born with a sacral defect.", + "She underwent several surgical procedures for anorectal and bladder reconstructions soon after birth.", + "She came to her pediatric urologist for urinary incontinence.", + "She mentioned severe headaches on the side, particularly when riding a bike.", + "She solved her headache problem by stopping to ride her bicycle.", + "On physical examination, no abnormalities were found except the ileostomy.", + "The ileostomy was present ever since soon after birth.", + "Blood tests showed no abnormalities.", + "Additional MRI showed a large and previously not known anterior meningocele at the level of the sacrum.", + "Surgical treatment consisted of closure of the dura by posterior approach." + ] + }, + { + "id": "multiclinsum_test_1633_en.txt", + "fulltext": "A 37-year-old man, with a history of surgery for right cryptorchidism at age 8 and no other medical history, consulted our department for primary infertility for 3 years. Clinical examination revealed a hypotrophic right testicle with a left varicocele and minor pain in the left testis, Ultrasound showed a heterogenous zones on the right testicle measuring 16 mm. , and testicular tumor markers were: alpha fetoprotein (AFP) 5.52 ng/mL (N: 0–13.4), human chorionic gonadotropin (HCG) < 2.3 mIU/mL (N: 0–5), and lactate dehydrogenase (LDH) 215 U/ L (N: 125–243).\nCytological analysis of the sperm showed no abnormalities that could help us make a diagnosis.\nAn inguinal right testicular biopsy was performed for anatomopathological study. The photomicrograph showing multiple seminiferous tubules containing large atypical cells with abundant eosinophilic cytoplasm; nuclei are hyperchromatic and angular with prominent nucleoli (H&E, ×100), suggestive of intratubular germinal neoplasia .\nWe proposed surveillance for our patient because he has an infertility, but the patient wishes to have radiotherapy for his intratubular germinal neoplasia.\nThe patient received 20 Gy of irradiation in ten fractionated sessions by oncologists, with disappearance of the intratubular germinal neoplasia on control imaging, the patient was satisfied with the treatment, especially with the preservation of his testicle.", + "fulltext_subclaims": [ + "The patient is a 37-year-old man.", + "He has a history of surgery for right cryptorchidism at age 8.", + "He has no other medical history.", + "He consulted for primary infertility for 3 years.", + "Clinical examination revealed a hypotrophic right testicle.", + "Clinical examination revealed a left varicocele.", + "Ultrasound showed heterogeneous zones on the right testicle measuring 16 mm.", + "Testicular tumor markers were measured.", + "Alpha fetoprotein was 5.52 ng/mL.", + "Human chorionic gonadotropin was < 2.3 mIU/mL.", + "Lactate dehydrogenase was 215 U/L.", + "Cytological analysis of the sperm showed no abnormalities.", + "An inguinal right testicular biopsy was performed.", + "The photomicrograph showed multiple seminiferous tubules containing large atypical cells with abundant eosinophilic cytoplasm.", + "The nuclei were hyperchromatic and angular with prominent nucleoli.", + "The findings were suggestive of intratubular germinal neoplasia.", + "The patient wished to have radiotherapy for his intratubular germinal neoplasia.", + "The patient received 20 Gy of irradiation in ten fractionated sessions.", + "The intratubular germinal neoplasia disappeared on control imaging.", + "The patient was satisfied with the treatment." + ], + "summary": "We report the case of a 37-year-old man with intratubular Germinal Cell Neoplasia (ITGCN) on a testis already treated for cryptorchidism in a context of infertility. We proposed active surveillance, but the patient preferred radiotherapy.", + "summary_subclaims": [ + "The patient is a 37-year-old man.", + "The patient had intratubular Germinal Cell Neoplasia (ITGCN).", + "The ITGCN was on a testis already treated for cryptorchidism.", + "The patient had infertility.", + "Active surveillance was proposed.", + "The patient preferred radiotherapy." + ] + }, + { + "id": "multiclinsum_test_2480_en.txt", + "fulltext": "A 74-year-old male was admitted to the emergency department with a 3-day history of progressive painful proptosis of the left eye. His medical history included hypertension and hyperlipidemia with no history of trauma. Clinical examination revealed a left proptotic orbit with chemosis and scleral injection . Visual acuity of the left eye was 20/150. The right eye was unremarkable; the patient had no fever nor other infectious signs.\nComputed tomography (CT) scan showed an ovoid mass in the lateral intraconal space with surrounding infiltration and increased vascularity. CT angiogram revealed a well-circumscribed heterogeneously enhancing mass within the inferior intraconal space of the left orbit (measuring 1.8 × 1.7 cm round) with periorbital soft-tissue swelling, suggesting inflammation . Magnetic resonance imaging (MRI) angiogram confirmed the findings of past studies: orbital cellulitis was apparent, the left inferior ophthalmic vein was prominent as compared to the right, and there was a partly thrombosed venous varix of the inferior ophthalmic vein . Imaging did not show any evidence of arteriovenous fistula.\nAt this point, potential considerations included orbital cavernous malformation, metastatic tumor causing venous outflow stenosis, arteriovenous malformation, dural arteriovenous fistula, and thrombosed venous varix due to orbital cellulitis.\nA neurosurgical consult was requested by the ophthalmology team. To further delineate the nature of the lesion, a diagnostic cerebral angiogram was performed, which revealed an intraconal venous varix . Consideration was made for transvenous embolization or direct orbital puncture and embolization along with surgical removal. A mutual decision of conservative treatment without intervention was reached, with aggressive interventions reserved if the patient declined further. Intravenous methylprednisolone for 5 days was initiated, as well as a maintained course of oral corticosteroids, doxycycline, and levofloxacin thereafter.\nThe patient was seen in the clinic 2 weeks after discharge. His symptoms had significantly improved, and he denied any eye redness, diplopia, or pain. On examination, there was no chemosis or scleral injection, but there was a significantly improved mild, painless proptosis . A 2-week follow-up CT scan of the orbit with contrast demonstrated a stable soft-tissue intraconal mass in the left orbit with peripheral venous phase enhancement in addition to central enhancement, consistent with the previously diagnosed thrombosed orbital venous varix of the inferior ophthalmic vein . At this time, the patient had completed his oral antibiotic course and was tapering his prednisone course. A 1-year orbital MRI was conducted and showed a slight increase in the enhancing intraconal mass in the left orbit . The patient had no symptoms. Since the mass size had not significantly increase and the patient’s condition was stable, no additional imaging or clinical follow-up was required per standard of care.", + "fulltext_subclaims": [ + "The patient is a 74-year-old male.", + "He was admitted to the emergency department with a 3-day history of progressive painful proptosis of the left eye.", + "His medical history included hypertension.", + "His medical history included hyperlipidemia.", + "He had no history of trauma.", + "Clinical examination revealed a left proptotic orbit with chemosis and scleral injection.", + "Visual acuity of the left eye was 20/150.", + "The right eye was unremarkable.", + "The patient had no fever.", + "Computed tomography (CT) scan showed an ovoid mass in the lateral intraconal space with surrounding infiltration and increased vascularity.", + "CT angiogram revealed a well-circumscribed heterogeneously enhancing mass within the inferior intraconal space of the left orbit.", + "The mass measured 1.8 × 1.7 cm round.", + "Magnetic resonance imaging (MRI) angiogram confirmed the findings of past studies.", + "Orbital cellulitis was apparent.", + "The left inferior ophthalmic vein was prominent as compared to the right.", + "There was a partly thrombosed venous varix of the inferior ophthalmic vein.", + "Imaging did not show any evidence of arteriovenous fistula.", + "Potential considerations included orbital cavernous malformation.", + "Potential considerations included metastatic tumor causing venous outflow stenosis.", + "Potential considerations included arteriovenous malformation.", + "Potential considerations included dural arteriovenous fistula.", + "Potential considerations included thrombosed venous varix due to orbital cellulitis.", + "A diagnostic cerebral angiogram was performed.", + "The cerebral angiogram revealed an intraconal venous varix.", + "A mutual decision of conservative treatment without intervention was reached.", + "Intravenous methylprednisolone for 5 days was initiated.", + "A 2-week follow-up CT scan of the orbit with contrast demonstrated a stable soft-tissue intraconal mass in the left orbit.", + "The CT scan showed peripheral venous phase enhancement in addition to central enhancement.", + "The findings were consistent with the previously diagnosed thrombosed orbital venous varix of the inferior ophthalmic vein.", + "A 1-year orbital MRI showed a slight increase in the enhancing intraconal mass in the left orbit.", + "The patient had no symptoms.", + "No additional imaging or clinical follow-up was required per standard of care." + ], + "summary": "We report a case of a 74-year-old male with progressively painful unilateral proptosis. Imaging revealed the presence of an orbital mass compatible with a thrombosed orbital varix of the inferior ophthalmic vein in the left inferior intraconal space. The patient was medically managed. On a follow-up outpatient clinic visit, he demonstrated remarkable clinical recovery and denied experiencing any symptoms. Follow-up computed tomography scan showed a stable mass with decreased proptosis in the left orbit consistent with the previously diagnosed orbital varix. One-year follow-up orbital magnetic resonance imaging without contrast showed slight increase in the intraconal mass.", + "summary_subclaims": [ + "The patient is a 74-year-old male.", + "The patient had progressively painful unilateral proptosis.", + "Imaging revealed the presence of an orbital mass.", + "The orbital mass was compatible with a thrombosed orbital varix of the inferior ophthalmic vein.", + "The orbital mass was located in the left inferior intraconal space.", + "The patient was medically managed.", + "On a follow-up outpatient clinic visit, the patient demonstrated remarkable clinical recovery.", + "The patient denied experiencing any symptoms.", + "Follow-up computed tomography scan showed a stable mass.", + "Follow-up computed tomography scan showed decreased proptosis in the left orbit.", + "The computed tomography findings were consistent with the previously diagnosed orbital varix.", + "One-year follow-up orbital magnetic resonance imaging without contrast showed a slight increase in the intraconal mass." + ] + }, + { + "id": "multiclinsum_test_2458_en.txt", + "fulltext": "A 55-year-old Caucasian man presented with an episode of hemospermia. Our patient had a complex urological history with bilateral inguinal hernias and undescended testes as a child. At the age of 11 years he underwent a right orchidopexy; but the left intra-abdominal testis could not be located during the operation. At the age of 26 years, our patient presented with a large mass in his abdomen, which was removed surgically and confirmed as a testicular cancer arising within an intra-abdominal testis. Postoperative treatment with cisplatin-based combination chemotherapy was delivered and regular check-ups showed no evidence of disease relapse.\nOur initial investigations for hemospermia included a cystoscopy, which revealed a 9cm mass present within his bladder. The result of a biopsy of this mass was suggestive of adenocarcinoma of the seminal vesicle, because the tumor appeared to arise from the seminal vesicle epithelium. Computed tomography imaging revealed no evidence of metastatic spread. His serum prostate-specific antigen level was normal at presentation, but his serum CA-125 was 783kU/L. Following diagnosis, a referral was made to Charing Cross Hospital for specialist surgical input, resulting in a radical cystoprostatectomy and orchidectomy (required for local disease clearance) with the formation of an ileal conduit.\nHistopathology confirmed the diagnosis of adenocarcinoma of the seminal vesicle (Figure ) with immunohistochemical studies positive for CK-7 and CA-125, while staining for prostate-specific antigenand CK-20 was negative. The tumor was noted to be widely infiltrative, involving the bladder, perivesical fat, prostate, prostatic urethra and ductus deferens, with additional pelvic lymph node metastases and a positive biopsy from an inoperable peritoneal deposit.\nIn view of the biopsy-proven distant metastasis (the peritoneal deposit), adjuvant radiotherapy was considered inappropriate and the initial management was of expectant observation. After three months observation, updated imaging demonstrated disease progression with malignant lymphadenopathy in his pelvis and a recurrence of the intra-peritoneal nodule combined with a rising CA-125 level.\nAndrogen withdrawal was commenced using goserelin, but after an initial response of five months, the tumor demonstrated evidence of progression with rising CA-125 levels and enlarging lymphadenopathy. Despite the serological and radiological progression, our patient remained asymptomatic and a decision regarding the role of chemotherapy treatment in disease palliation was deferred. Approximately six weeks later, our patient presented as an emergency with a short history of nausea, vomiting and diarrhea. The admission investigations showed his previously normal creatinine levels to now be elevated at 537μmol/L and urine testing revealed proteinuria >300mg/dL and hematuria with red cell casts. Imaging did not demonstrate an obvious cause for this rise in creatinine: ultrasound showed no hydronephrosis or evidence of obstruction, and computed tomography continued to show enlarging abdominal lymphadenopathy but was not significantly altered from the imaging that took place six weeks earlier.\nA renal biopsy (Figure ) showed pauci-immune crescentic glomerulonephritis with a segmental glomerular necrosis suggestive of ANCA-associated disease. A serum ANCA screen was ANCA IIF positive with a cytoplasmic ANCA pattern, while proteinase 3 and myeloperoxidase antibodies were negative.\nRenal replacement therapy (hemodialysis) and immunosuppressive therapy was commenced with prednisolone, cyclophosphamide and rituximab but his renal function did not significantly recover. His glomerular filtration rate remained less than 10mL/min. A repeated renal biopsy performed in July 2011 after three months of therapy showed glomerular and tubulointerstitial scarring secondary to ANCA-mediated glomerulonephritis but no active ANCA-mediated disease.\nAn updated computed tomography scan performed at this point demonstrated significant tumor progression, with new sites of disease in his liver, bones and adrenal glands. In view of these findings and the challenges of delivering chemotherapy while on dialysis, attempts at disease palliation with chemotherapy were withheld. Our patient was referred to our community palliative care team for end-of-life care and died at home two months later.", + "fulltext_subclaims": [ + "The patient was a 55-year-old Caucasian man.", + "The patient presented with an episode of hemospermia.", + "The patient had bilateral inguinal hernias.", + "The patient had undescended testes as a child.", + "At the age of 11 years, the patient underwent a right orchidopexy.", + "The left intra-abdominal testis could not be located during the operation at age 11.", + "At the age of 26 years, the patient presented with a large abdominal mass.", + "The abdominal mass was surgically removed and confirmed as testicular cancer arising within an intra-abdominal testis.", + "Postoperative treatment with cisplatin-based combination chemotherapy was delivered.", + "Regular check-ups showed no evidence of disease relapse.", + "Initial investigations for hemospermia included a cystoscopy.", + "The cystoscopy revealed a 9cm mass present within the bladder.", + "The result of a biopsy of the bladder mass was suggestive of adenocarcinoma of the seminal vesicle.", + "Computed tomography imaging revealed no evidence of metastatic spread.", + "The patient's serum prostate-specific antigen level was normal at presentation.", + "The patient's serum CA-125 was 783kU/L.", + "A referral was made to Charing Cross Hospital for specialist surgical input.", + "The patient underwent a radical cystoprostatectomy and orchidectomy.", + "The patient had the formation of an ileal conduit.", + "Histopathology confirmed the diagnosis of adenocarcinoma of the seminal vesicle.", + "Immunohistochemical studies were positive for CK-7 and CA-125.", + "Staining for prostate-specific antigen and CK-20 was negative.", + "The tumor was noted to be widely infiltrative.", + "The tumor involved the bladder, perivesical fat, prostate, prostatic urethra and ductus deferens.", + "There were additional pelvic lymph node metastases.", + "There was a positive biopsy from an inoperable peritoneal deposit.", + "In view of the biopsy-proven distant metastasis, adjuvant radiotherapy was considered inappropriate.", + "The initial management was of expectant observation.", + "After three months observation, updated imaging demonstrated disease progression.", + "There was malignant lymphadenopathy in the pelvis.", + "There was a recurrence of the intra-peritoneal nodule.", + "There was a rising CA-125 level.", + "Androgen withdrawal was commenced using goserelin.", + "After an initial response of five months, the tumor demonstrated evidence of progression.", + "The tumor demonstrated rising CA-125 levels.", + "The tumor demonstrated enlarging lymphadenopathy.", + "Despite the serological and radiological progression, the patient remained asymptomatic.", + "The decision regarding the role of chemotherapy treatment in disease palliation was deferred.", + "Approximately six weeks later, the patient presented as an emergency with a short history of nausea, vomiting and diarrhea.", + "Admission investigations showed an elevated creatinine level of 537μmol/L.", + "Urine testing revealed proteinuria >300mg/dL.", + "Urine testing revealed hematuria with red cell casts.", + "Imaging did not demonstrate an obvious cause for the rise in creatinine.", + "A renal biopsy showed pauci-immune crescentic glomerulonephritis.", + "The renal biopsy showed segmental glomerular necrosis suggestive of ANCA-associated disease.", + "A serum ANCA screen was ANCA IIF positive with a cytoplasmic ANCA pattern.", + "Proteinase 3 and myeloperoxidase antibodies were negative.", + "Renal replacement therapy (hemodialysis) and immunosuppressive therapy was commenced with prednisolone, cyclophosphamide and rituximab.", + "The patient's renal function did not significantly recover.", + "The patient's glomerular filtration rate remained less than 10mL/min.", + "A repeated renal biopsy performed in July 2011 showed glomerular and tubulointerstitial scarring secondary to ANCA-mediated glomerulonephritis.", + "The repeated renal biopsy showed no active ANCA-mediated disease.", + "An updated computed tomography scan demonstrated significant tumor progression.", + "There were new sites of disease in the liver, bones and adrenal glands.", + "Attempts at disease palliation with chemotherapy were withheld.", + "The patient was referred to the community palliative care team for end-of-life care.", + "The patient died at home two months later." + ], + "summary": "In this report we describe the case of a 55-year-old Caucasian man with metastatic adenocarcinoma of the seminal vesicles. He previously had received chemotherapy treatment for advanced testicular cancer and later presented with hemospermia. He subsequently developed c-antineutrophil cytoplasmic antibody vasculitis requiring intensive immunosuppression and renal dialysis.", + "summary_subclaims": [ + "The patient is a 55-year-old Caucasian man.", + "The patient has metastatic adenocarcinoma of the seminal vesicles.", + "The patient previously had received chemotherapy treatment for advanced testicular cancer.", + "The patient later presented with hemospermia.", + "The patient subsequently developed c-antineutrophil cytoplasmic antibody vasculitis.", + "The vasculitis required intensive immunosuppression.", + "The vasculitis required renal dialysis." + ] + }, + { + "id": "multiclinsum_test_2408_en.txt", + "fulltext": "A 69-year-old woman was seen in follow-up at an outpatient orthopaedic clinic approximately 10 weeks after completing a 3-month course of antibiotic therapy for a right knee PJI due to Brucella suis, as reported previously . She completely recovered following treatment of her B. suis PJI, but noted onset of acutely worsening right knee pain, warmth, and overlying redness 1 day prior to her scheduled follow-up. She was afebrile and systemically well.\nAn original total arthroplasty of the right knee was performed 12 years prior and she was diagnosed with a B. suis PJI after multiple synovial fluid aspirates grew the organism in 2015. She underwent irrigation and debridement with removal of all prosthetic components and implantation of a gentamicin, vancomycin, and ceftazidime impregnated static cement spacer. She completed 10 days of intravenous aminoglycoside therapy (initially tobramycin and then gentamicin) combined with oral doxycycline and rifampin. Oral antibiotics were continued for a total of 12 weeks. On initial follow-up, she had improved knee pain, no fever, normalization of inflammatory markers and a healed surgical wound.\nThe patient’s past medical history was otherwise significant for obesity, hypertension, gastroesophageal reflux disease and osteoarthritis with chronic back pain. Her medications were hydrochlorothiazide, ramipril, and pantoprazole. She had no known allergies. The patient lives on a remote island in the Canadian Arctic and works as an artist. She would regularly butcher wild meat (including caribou, muskox, seal and fish) and often consumed the meat and fish raw.\nOn physical examination, she was non-toxic and afebrile. Her right knee was swollen and erythematous. She had a static cement spacer at the time of this assessment and was not able to perform range of motion. There was no apparent drainage or visible sinus tracts on the right knee. The remainder of her physical examination was unremarkable.\nRadiographs of the right knee revealed that the position of the intramedullary pins and large spacer was unchanged with no skeletal changes, however diffuse soft tissue swelling was evident. Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) had risen from normal levels 3 months earlier to 49 mm/h and 171.4 mg/L respectively. Complete blood count did not show leukocytosis or neutrophilia. Serum creatinine was 66 μmol/L. A repeat Brucella IgG plus IgM standard agglutination assay performed in the previous month was negative with a titre of < 1:40. Given the clinical suspicion for recurrent PJI, a right knee arthrocentesis was performed in the orthopaedic outpatient clinic, which revealed a synovial fluid white blood cell count of 25,330 × 106/L comprised of 87% polymorphonuclear cells. No organisms were seen on direct gram stain of the fluid.\nA gram-positive bacillus was reported to be growing from liquid media culture 2 days after collection. The patient was taken back to the operating room the following day where she had irrigation and debridement of the right knee with removal of the previous prosthetic components and reinsertion of a static cement spacer with 3.6 g of tobramycin per bag of polymethylmethacrylate bone cement. Three bags of cement were used. No preoperative antibiotics were given. Once intra-operative tissue specimens had been collected, 2 g of cefazolin IV were given.\nThe organism recovered from the pre-operative knee aspirate was confirmed as E. rhusiopathiae by 16S rRNA sequencing at the Provincial Laboratory for Public Health in Edmonton, Canada. This organism was also seen on direct gram stain and eventually isolated from all 5 intraoperative tissue specimens. Whole genome sequencing was performed on two of these isolates using the Illumina MiSeq platform. The 250 bp paired-end reads were assembled de novo using SPAdes (v3.10.1), and the assemblies compared to sequence data from previously isolated E. rhusiopathiae from various mammal carcasses from the Canadian Arctic, isolates from domestic swine and poultry as well as wild birds, mammals, and fish originating from various locations in North America and Europe . This was done by generating a core genome alignment and phylogenetic tree using parsnp (Harvest Tools v1.2) .\nThe isolate tested susceptible in vitro by E-test methods to ampicillin (minimum inhibitory concentration (MIC) 0.094 μg/mL), ciprofloxacin (MIC 0.047 μg/mL), and erythromycin (MIC 0.032 μg/mL) (interpreted according to the current M45 Clinical and Laboratory Standards Institute clinical breakpoints) and was reported resistant to vancomycin as this is an intrinsic characteristic. Four blood cultures, which were collected on the same day of this visit to the orthopedic outpatient clinic and prior to the administration of antibiotics, remained negative after 5 days of incubation. An echocardiogram was not performed as it was felt that the patient was unlikely to have endocarditis. She was initially treated with intravenous ceftriaxone 1 g daily but was switched to intravenous penicillin G once susceptibility results were available. She completed 6 weeks of intravenous antibiotic therapy and subsequently completed an additional 6 weeks of oral amoxicillin 1 g three times daily.\nOn the last day of her oral antibiotic therapy she was reviewed as an outpatient and was clinically well with no fever and resolution of knee pain. Her surgical wound had healed well with no evidence of recurrent infection on physical examination. Her CRP and ESR had normalized to 1.4 mg/L and 13 mm/h respectively. She was again seen in follow-up 4 months later (approximately 8 months after her last surgery) and remained well with no clinical evidence of relapse and CRP and ESR remaining within normal limits at 0.9 mg/L and 15 mm/h respectively. The patient declined a second stage revision procedure and remained clinically well 1 year after her last surgery.", + "fulltext_subclaims": [ + "The patient is a 69-year-old woman.", + "She was seen in follow-up at an outpatient orthopaedic clinic approximately 10 weeks after completing a 3-month course of antibiotic therapy.", + "The antibiotic therapy was for a right knee PJI due to Brucella suis.", + "She completely recovered following treatment of her B. suis PJI.", + "She noted onset of acutely worsening right knee pain, warmth, and overlying redness 1 day prior to her scheduled follow-up.", + "She was afebrile and systemically well.", + "An original total arthroplasty of the right knee was performed 12 years prior.", + "She was diagnosed with a B. suis PJI after multiple synovial fluid aspirates grew the organism in 2015.", + "She underwent irrigation and debridement with removal of all prosthetic components.", + "A gentamicin, vancomycin, and ceftazidime impregnated static cement spacer was implanted.", + "She completed 10 days of intravenous aminoglycoside therapy.", + "She received initially tobramycin and then gentamicin.", + "She also received oral doxycycline and rifampin.", + "Oral antibiotics were continued for a total of 12 weeks.", + "On initial follow-up, she had improved knee pain.", + "On initial follow-up, she had no fever.", + "Inflammatory markers normalized on initial follow-up.", + "The surgical wound was healed on initial follow-up.", + "She had past medical history significant for obesity.", + "She had past medical history significant for hypertension.", + "She had past medical history significant for gastroesophageal reflux disease.", + "She had past medical history significant for osteoarthritis with chronic back pain.", + "Her medications were hydrochlorothiazide, ramipril, and pantoprazole.", + "She had no known allergies.", + "She lives on a remote island in the Canadian Arctic.", + "She works as an artist.", + "She regularly butchered wild meat including caribou, muskox, seal, and fish.", + "She often consumed the meat and fish raw.", + "On physical examination, she was non-toxic and afebrile.", + "Her right knee was swollen and erythematous.", + "She had a static cement spacer at the time of this assessment.", + "She was not able to perform range of motion.", + "There was no apparent drainage or visible sinus tracts on the right knee.", + "Radiographs of the right knee showed the position of the intramedullary pins and large spacer was unchanged.", + "Radiographs showed no skeletal changes.", + "Radiographs showed diffuse soft tissue swelling.", + "ESR was 49 mm/h.", + "CRP was 171.4 mg/L.", + "Complete blood count did not show leukocytosis.", + "Complete blood count did not show neutrophilia.", + "Serum creatinine was 66 μmol/L.", + "A repeat Brucella IgG plus IgM standard agglutination assay was negative.", + "A right knee arthrocentesis was performed.", + "Synovial fluid white blood cell count was 25,330 × 106/L.", + "Synovial fluid was comprised of 87% polymorphonuclear cells.", + "No organisms were seen on direct gram stain.", + "A gram-positive bacillus was reported to be growing from liquid media culture 2 days after collection.", + "The patient was taken back to the operating room the following day.", + "She had irrigation and debridement of the right knee.", + "She had removal of the previous prosthetic components.", + "A static cement spacer with 3.6 g of tobramycin per bag was reinserted.", + "Three bags of cement were used.", + "No preoperative antibiotics were given.", + "Once intra-operative tissue specimens had been collected, 2 g of cefazolin IV were given.", + "The organism was confirmed as E. rhusiopathiae by 16S rRNA sequencing.", + "The organism was also seen on direct gram stain.", + "The organism was isolated from all 5 intraoperative tissue specimens.", + "Whole genome sequencing was performed on two isolates.", + "The 250 bp paired-end reads were assembled de novo using SPAdes (v3.10.1).", + "The assemblies were compared to sequence data from previously isolated E. rhusiopathiae.", + "A core genome alignment and phylogenetic tree were generated using parsnp (Harvest Tools v1.2).", + "The isolate was susceptible to ampicillin with an MIC of 0.094 μg/mL.", + "The isolate was susceptible to ciprofloxacin with an MIC of 0.047 μg/mL.", + "The isolate was susceptible to erythromycin with an MIC of 0.032 μg/mL.", + "The isolate was reported resistant to vancomycin.", + "Four blood cultures remained negative after 5 days of incubation.", + "An echocardiogram was not performed.", + "She was initially treated with intravenous ceftriaxone 1 g daily.", + "She was switched to intravenous penicillin G once susceptibility results were available.", + "She completed 6 weeks of intravenous antibiotic therapy.", + "She completed an additional 6 weeks of oral amoxicillin 1 g three times daily.", + "On the last day of her oral antibiotic therapy, she was reviewed as an outpatient.", + "She was clinically well with no fever.", + "Knee pain had resolved.", + "Her surgical wound had healed well.", + "CRP had normalized to 1.4 mg/L.", + "ESR had normalized to 13 mm/h.", + "She was seen in follow-up 4 months later.", + "She remained well with no clinical evidence of relapse.", + "CRP remained within normal limits at 0.9 mg/L.", + "ESR remained within normal limits at 15 mm/h.", + "She declined a second stage revision procedure.", + "She remained clinically well 1 year after her last surgery." + ], + "summary": "We describe a case of E. rhusiopathiae prosthetic joint infection in a woman with a history of exposure to wild animals in the Canadian Arctic. Patient management involved a 1-stage surgical revision exchange with an antibiotic impregnated cement spacer and 6 weeks of intravenous penicillin G followed by 6 weeks of oral amoxicillin. Ten previously reported cases of E. rhusiopathiae joint infection are reviewed. Recent increases in mortality due to infection with this organism among host animal populations in the Canadian Arctic have generated concern regarding a potential increase in human infections. However, whole genome sequencing (WGS) of the organism was unable to identify a zoonotic origin for this case.", + "summary_subclaims": [ + "The patient had a prosthetic joint infection caused by E. rhusiopathiae.", + "The patient had a history of exposure to wild animals in the Canadian Arctic.", + "Patient management involved a 1-stage surgical revision exchange.", + "An antibiotic impregnated cement spacer was used.", + "The patient received 6 weeks of intravenous penicillin G.", + "The patient received 6 weeks of oral amoxicillin.", + "Ten previously reported cases of E. rhusiopathiae joint infection are reviewed.", + "Recent increases in mortality due to infection with this organism among host animal populations in the Canadian Arctic have generated concern regarding a potential increase in human infections.", + "Whole genome sequencing (WGS) of the organism was unable to identify a zoonotic origin for this case." + ] + }, + { + "id": "multiclinsum_test_208_en.txt", + "fulltext": "A 27-year-old male patient, underwent renal transplantation when he was 15-year old due to renal hypoplasia, but, was ultimately introduced hemodialysis. Following AVF construction, he experienced the steal syndrome, resulting in amputation of his left third digit and multiple AVF reconstruction. His left forearm AVF was malfunction due to severe PAD: quantity of blood flow was 70–110 ml/min because of complete obliteration of the proximal radial artery. Angiography demonstrated that obstruction of the proximal radial artery and regurgitation from the palmar arch to the AVF. This AVF condition barely enabled to perform daily hemodialysis with low efficiency with Kt/V < 1.0 (Daugirdas equation) . Exertional symptoms, tingling, and frigid digits were noted mainly due to decreased blood flow to the hand. The left second digits SPP was 17 mmHg. In order to restore digital circulation and AVF, distal dual bypass was planned under general anesthesia. First, in order to secure arterial inflow, brachial arterial stricture was excised and anastomosed end-to-end*. Following arterioplasty, however, the AVF flow measured by the doppler US, was still too weak to maintain hemodialysis. Thus, subsequently, the patient was given 5 000 units of intravenous heparin totally and monitored by ACT testing: 150–200. Regarding proximal anastomosis of the first distal bypass, the left brachial artery (distal to the * anastomosis) and reversed GSV graft were anastomosed with interrupted 7-0 prolene suture. In terms of the distal side, the posterior wall was sutured by parachute anastomosis technique, and the anterior wall anastomosis with interrupted 8-0 prolene was performed. Next, because it is true that AVF in the distal forearm is generally recommended, to repair forearm AVF, the second distal bypass was performed. The proximal portion was created at the proximal radial artery, downstream from the first distal bypass in order to prevent secondary steal syndrome. The left radial artery and reversed GSV graft were anastomosed with interrupted 7-0 prolene suture. Regarding the distal end side, the GSV graft and cephalic vein were sutured by the parachute anastomosis technique with 7-0 prolene. Finally, regurgitation from the palmar arch was ligated. The first distal bypass graft blood flow was 36 ml/min, measured by VeriQ (Medistim, Oslo, Norway). Angiography demonstrated satisfied simultaneous palmar arch and AVF circulation . The left second digits SPP improved to 90 mmHg following reflow. Kt/V improved to1.53 (Daugirdas equation) with well-maintained AVF. The both graft patency was confirmed without any endovascular intervention at 12-month following distal bypass.", + "fulltext_subclaims": [ + "The patient is a 27-year-old male.", + "He underwent renal transplantation when he was 15 years old.", + "The renal transplantation was due to renal hypoplasia.", + "He was ultimately introduced to hemodialysis.", + "Following AVF construction, he experienced steal syndrome.", + "Steal syndrome resulted in amputation of his left third digit.", + "He had multiple AVF reconstructions.", + "His left forearm AVF was malfunctioning due to severe PAD.", + "The quantity of blood flow was 70–110 ml/min.", + "The proximal radial artery was completely obliterated.", + "Angiography demonstrated obstruction of the proximal radial artery.", + "Angiography showed regurgitation from the palmar arch to the AVF.", + "The AVF condition barely enabled daily hemodialysis.", + "The hemodialysis had low efficiency with Kt/V < 1.0.", + "Exertional symptoms were noted.", + "Tingling was noted.", + "Frigid digits were noted.", + "The left second digits SPP was 17 mmHg.", + "Distal dual bypass was planned under general anesthesia.", + "Brachial arterial stricture was excised.", + "The brachial artery was anastomosed end-to-end.", + "Following arterioplasty, the AVF flow was still too weak.", + "The patient was given 5 000 units of intravenous heparin.", + "ACT testing was monitored.", + "The ACT range was 150–200.", + "The proximal anastomosis of the first distal bypass was between the left brachial artery and reversed GSV graft.", + "The posterior wall was sutured by parachute anastomosis technique.", + "The anterior wall anastomosis was performed with interrupted 8-0 prolene.", + "The second distal bypass was performed.", + "The proximal portion was created at the proximal radial artery.", + "The proximal portion was downstream from the first distal bypass.", + "The left radial artery and reversed GSV graft were anastomosed.", + "The distal end side of the second distal bypass was sutured by the parachute anastomosis technique.", + "Regurgitation from the palmar arch was ligated.", + "The first distal bypass graft blood flow was 36 ml/min.", + "The blood flow was measured by VeriQ.", + "Angiography demonstrated satisfied simultaneous palmar arch and AVF circulation.", + "The left second digits SPP improved to 90 mmHg.", + "Kt/V improved to 1.53.", + "The graft patency was confirmed without any endovascular intervention.", + "The graft patency was confirmed at 12-month following distal bypass." + ], + "summary": "We present the case of 27-year-old man with severe steal syndrome complained of AVF malfunction. There was a condition where an upstream artery of AVF is occluded and AVF is maintained by regurgitation from the palmar arch with ischemic digits. The patient underwent distal dual bypass: proximal to peripheral artery arterioarterial and arteriovenous bypasses and brachial arterioplasty. His skin perfusion pressure improved from 17 to 90 mmHg with enough quantity of blood: 250 ml/min for hemodialysis.", + "summary_subclaims": [ + "The patient is a 27-year-old man.", + "The patient had severe steal syndrome.", + "The patient complained of AVF malfunction.", + "There was a condition where an upstream artery of AVF is occluded.", + "AVF is maintained by regurgitation from the palmar arch.", + "The patient had ischemic digits.", + "The patient underwent distal dual bypass.", + "The bypass included proximal to peripheral artery arterioarterial and arteriovenous bypasses.", + "The patient underwent brachial arterioplasty.", + "Skin perfusion pressure improved from 17 to 90 mmHg.", + "Blood quantity was 250 ml/min for hemodialysis." + ] + }, + { + "id": "multiclinsum_test_3124_en.txt", + "fulltext": "We report the case of a 52-year-old patient from Bangladesh, diabetic and hypertensive, referred for exertional angina Canadian Cardiovascular Society III. A stress myocardial scintigraphy was performed and revealed deep hypoperfusion in the antero-apical, septo-apical, and lateral walls with electric positivity on the stress test; resting left ventricle ejection fraction was 61%. His clinical examination revealed a blood pressure of 127/85 mmHg, a heart rate of 92 b.p.m., and a normal oxygen saturation. No murmurs were detected, and there were no signs of heart failure. His electrocardiogram showed a sinus rhythm without significant repolarization abnormalities.\n\nWe performed a diagnostic coronary angiogram in this context. Left injection revealed a stenosis on a third significant diagonal branch and a circumflex of very poor calibre. However, we were struck by the appearance of the LAD, which seemed to stop at its mid-segment without wrapping around the apex and did not present a stump that could suggest a chronic occlusion.\n\nThe injection of the right coronary sinus revealed a dominant RCA free of stenosis. At the end of the injection in right anterior oblique and left anterior oblique views, we noticed a vessel opening into the ostium of the RCA and following the classic path of an LAD. A non-selective injection into this artery with a diagnostic JR 4 catheter (Judkins Right) identified an ostial-proximal stenosis of this artery but did not allow complete opacification of the distality of the vessel. Percutaneous coronary intervention of the third diagonal was performed during this procedure.\n\nThe coronary CT scan performed for a better characterization of this AAOCA identified an artery whose course is compatible with a mid and distal LAD. This artery connects in the right coronary ostium and joins the interventricular groove to wrap around the apex of the heart.\n\n\nIntervention\nGiven the evidence of ischaemia on stress myocardial scintigraphy in the apical territory, we decided to perform angioplasty on this AAOCA. We used a 6F IM guiding catheter (Internal Mammary) through a right radial access to engage the ostium of the RCA. We first positioned a workhorse wire (RUNTHROUGH® NS Extra Floppy) in the right posterolateral artery to stabilize the guiding catheter, and then navigated within the AAOCA using a polymerjacket wire with a hydrophilic coating (ASAHI SION® black).\n\nSince the proximal injection did not allow the visualization of the distal part of the AAOCA, we performed a distal injection through a microcatheter, which revealed a severe stenosis in the mid LAD.\n\nWe treated the distal lesion with a drug-eluting stent (DES) 2.25 × 15 mm and the mid lesion with a drug-eluting balloon (DEB) 2.0 × 15 mm. The ostial-proximal segment was treated with a DES 2.5 × 15 mm.\n\n\nOutcome\nThe final angiographic result was satisfactory. At the end of the procedure, a contralateral injection was performed, confirming the discontinuity of the AAOCA with the native LAD. The post-procedural course was uneventful, and the patient was discharged the following day.", + "fulltext_subclaims": [ + "The patient is a 52-year-old man from Bangladesh.", + "The patient has diabetes.", + "The patient has hypertension.", + "The patient had exertional angina Canadian Cardiovascular Society III.", + "A stress myocardial scintigraphy was performed.", + "The stress myocardial scintigraphy revealed deep hypoperfusion in the antero-apical, septo-apical, and lateral walls.", + "The stress test showed electric positivity.", + "The resting left ventricle ejection fraction was 61%.", + "The patient's blood pressure was 127/85 mmHg.", + "The patient's heart rate was 92 b.p.m.", + "The patient's oxygen saturation was normal.", + "No murmurs were detected.", + "There were no signs of heart failure.", + "The electrocardiogram showed a sinus rhythm.", + "The electrocardiogram showed no significant repolarization abnormalities.", + "A diagnostic coronary angiogram was performed.", + "Left injection revealed a stenosis on a third significant diagonal branch.", + "The LAD appeared to stop at its mid-segment without wrapping around the apex.", + "The LAD did not present a stump that could suggest a chronic occlusion.", + "The right coronary sinus injection revealed a dominant RCA free of stenosis.", + "A vessel opening into the ostium of the RCA was noted.", + "A non-selective injection into this artery identified an ostial-proximal stenosis.", + "Percutaneous coronary intervention of the third diagonal was performed.", + "A coronary CT scan was performed.", + "The CT scan identified an artery whose course is compatible with a mid and distal LAD.", + "This artery connects in the right coronary ostium.", + "This artery joins the interventricular groove.", + "This artery wraps around the apex of the heart.", + "Angioplasty was performed on the AAOCA.", + "A 6F IM guiding catheter was used.", + "The guiding catheter was accessed through the right radial artery.", + "A workhorse wire was positioned in the right posterolateral artery.", + "A polymerjacket wire with a hydrophilic coating was used to navigate within the AAOCA.", + "A distal injection through a microcatheter revealed a severe stenosis in the mid LAD.", + "The distal lesion was treated with a drug-eluting stent 2.25 × 15 mm.", + "The mid lesion was treated with a drug-eluting balloon 2.0 × 15 mm.", + "The ostial-proximal segment was treated with a drug-eluting stent 2.5 × 15 mm.", + "The final angiographic result was satisfactory.", + "A contralateral injection confirmed the discontinuity of the AAOCA with the native LAD.", + "The post-procedural course was uneventful.", + "The patient was discharged the following day." + ], + "summary": "We report the case of a 52-year-old patient from Bangladesh with dual-origin LAD arising from both left and right sinus with a pre-pulmonary course, presenting with exertional angina and documented myocardial ischaemia. Computed tomography (CT) scan confirmed the anatomical course of the AAOCA. Percutaneous coronary intervention was successfully performed using tailored techniques to treat significant atherosclerotic lesions.", + "summary_subclaims": [ + "The patient is a 52-year-old from Bangladesh.", + "The patient has dual-origin LAD arising from both left and right sinus.", + "The LAD has a pre-pulmonary course.", + "The patient presented with exertional angina.", + "The patient had documented myocardial ischaemia.", + "Computed tomography (CT) scan confirmed the anatomical course of the AAOCA.", + "Percutaneous coronary intervention was successfully performed.", + "Tailored techniques were used to treat significant atherosclerotic lesions." + ] + }, + { + "id": "multiclinsum_test_440_en.txt", + "fulltext": "A 27-year-old Japanese man with mild mental developmental retardation presented with a 1-year history of bilateral visual impairment as well as a 3-month gradually progressive general fatigue. He had no history of epileptic seizures. Neurological examination revealed blindness of the left eye, half-blindness of the right eye on the ear side, and cognitive dysfunction according to the Mini Mental State Examination 21/30. Fundus examination revealed no papilledema. Magnetic resonance imaging (MRI) revealed a 77 × 63 × 85-mm tumor that arose from the pituitary and extended bilaterally through the anterior skull base, the clivus, and the cavernous sinus, with compression of the optic chiasm and the bilateral frontal and temporal lobes . The patient was administered antiepileptics, such as 1000 mg/day levetiracetam, for prevention of seizure attack. His hormone profile showed hyperprolactinemia 25,270.0 ng/ml (3.6–12.8 ng/ml) and dysfunction of the other pituitary hormones (testosterone, < 0.04 ng/ml [1.3–8.7 ng/ml]; follicle-stimulating hormone, 0.54 mIU/ml [2.0–8.3 mIU/ml]; luteinizing hormone, < 0.10 mIU/ml [0.79–5.7 mIU/ml]; thyroid-stimulating hormone, 4.94 μIU/ml [0.5–5.0 μIU/ml]; free thyroxine 4, 0.6 ng/dl [0.9–1.7 ng/dl]; growth hormone, 0.22 ng/ml [0.0–2.5 ng/ml]; and adrenocorticotropic hormone, 1.7 pg/ml [7.2–63.3 pg/ml]) . The patient received a diagnosis of a giant PRLoma with hypopituitarism. We started DA therapy with CAB 0.25 mg once per week, supplemented by daily oral hydrocortisone.\nEight days after starting DA therapy, the patient had a tonic-clonic seizure with loss of consciousness that developed into status epilepticus. Incubation and general anesthetic therapy were required. The patient was admitted to the intensive care unit. An electroencephalographic examination was continuously performed; however, no findings of epileptic changes were found after general anesthesia. There was no abnormality in the laboratory analysis that may have led to status epilepticus. The patient’s blood level of PRL markedly decreased from 25,270.0 to 948.2 ng/ml. MRI revealed significant reduction of the tumor in a short period without pituitary apoplexy, including hemorrhagic or ischemic change . According to the significant reduction of the tumor, the bilateral mesial temporal lobes returned to medial position. Further, a hyperintense area in left frontal lobe appeared on T2 -weighted images . Because of the possibility that the epileptic seizures were induced by the rapid shrinkage of the tumor, we suspended DA therapy until the seizures were under control with the antiepileptic drug levetiracetam 2000 mg/day. General anesthetic therapy was required for the control of seizures for 2 weeks. After 4 weeks, we resumed DA therapy with extremely low doses of CAB. Both the level of PRL and the tumor size were gradually reduced without further seizures. The patient was able to return to daily life with medication of antiepileptics and oral hydrocortisone and levothyroxine.", + "fulltext_subclaims": [ + "The patient is a 27-year-old Japanese man.", + "The patient has mild mental developmental retardation.", + "The patient had a 1-year history of bilateral visual impairment.", + "The patient had a 3-month history of gradually progressive general fatigue.", + "The patient had no history of epileptic seizures.", + "Neurological examination revealed blindness of the left eye.", + "Neurological examination revealed half-blindness of the right eye on the ear side.", + "The Mini Mental State Examination score was 21/30.", + "Fundus examination revealed no papilledema.", + "MRI revealed a 77 × 63 × 85-mm tumor that arose from the pituitary.", + "The tumor extended bilaterally through the anterior skull base, the clivus, and the cavernous sinus.", + "The tumor compressed the optic chiasm and the bilateral frontal and temporal lobes.", + "The patient was administered 1000 mg/day levetiracetam for prevention of seizure attack.", + "The patient's prolactin level was 25,270.0 ng/ml.", + "The patient's testosterone level was < 0.04 ng/ml.", + "The patient's follicle-stimulating hormone level was 0.54 mIU/ml.", + "The patient's luteinizing hormone level was < 0.10 mIU/ml.", + "The patient's thyroid-stimulating hormone level was 4.94 μIU/ml.", + "The patient's free thyroxine 4 level was 0.6 ng/dl.", + "The patient's growth hormone level was 0.22 ng/ml.", + "The patient's adrenocorticotropic hormone level was 1.7 pg/ml.", + "The patient received a diagnosis of a giant PRLoma with hypopituitarism.", + "DA therapy with CAB 0.25 mg once per week was started.", + "Daily oral hydrocortisone was started.", + "Eight days after starting DA therapy, the patient had a tonic-clonic seizure with loss of consciousness.", + "The seizure developed into status epilepticus.", + "Incubation and general anesthetic therapy were required.", + "The patient was admitted to the intensive care unit.", + "An electroencephalographic examination was continuously performed.", + "No findings of epileptic changes were found after general anesthesia.", + "There was no abnormality in the laboratory analysis that may have led to status epilepticus.", + "The patient’s blood level of PRL decreased from 25,270.0 to 948.2 ng/ml.", + "MRI revealed significant reduction of the tumor in a short period.", + "MRI showed no pituitary apoplexy, including hemorrhagic or ischemic change.", + "The bilateral mesial temporal lobes returned to medial position.", + "A hyperintense area in the left frontal lobe appeared on T2-weighted images.", + "DA therapy was suspended until the seizures were under control.", + "General anesthetic therapy was required for the control of seizures for 2 weeks.", + "After 4 weeks, DA therapy with extremely low doses of CAB was resumed.", + "The level of PRL and the tumor size were gradually reduced without further seizures.", + "The patient was able to return to daily life with medication of antiepileptics and oral hydrocortisone and levothyroxine." + ], + "summary": "A 27-year-old Japanese man presented to our institution with a history of visual disturbance for 1 year and general fatigue for 3 months. Magnetic resonance imaging showed a tumor that arose from the pituitary and extended to the bilateral anterior skull base, the clivus, and the cavernous sinus, with compression of the optic chiasm and the bilateral frontal and temporal lobes. On the basis of the patient's serum concentration of prolactin, we diagnosed a prolactinoma and started dopamine agonist therapy with cabergoline. The patient had a general seizure immediately after starting dopamine agonist therapy and required general anesthetic treatment following the rapid reduction of the tumor. We speculated that the rapid reduction of the tumor resulted in the retraction of the surrounding brain structure, and the epileptic seizure was then induced by dopamine agonist therapy.", + "summary_subclaims": [ + "The patient is a 27-year-old Japanese man.", + "The patient had a history of visual disturbance for 1 year.", + "The patient had general fatigue for 3 months.", + "Magnetic resonance imaging showed a tumor that arose from the pituitary.", + "The tumor extended to the bilateral anterior skull base.", + "The tumor extended to the clivus.", + "The tumor extended to the cavernous sinus.", + "The tumor compressed the optic chiasm.", + "The tumor compressed the bilateral frontal and temporal lobes.", + "The diagnosis was a prolactinoma based on the patient's serum concentration of prolactin.", + "Dopamine agonist therapy with cabergoline was started.", + "The patient had a general seizure immediately after starting dopamine agonist therapy.", + "The patient required general anesthetic treatment following the rapid reduction of the tumor.", + "We speculated that the rapid reduction of the tumor resulted in the retraction of the surrounding brain structure.", + "The epileptic seizure was then induced by dopamine agonist therapy." + ] + }, + { + "id": "multiclinsum_test_174_en.txt", + "fulltext": "An otherwise healthy 3 years and 10 months-old, 99 cm, 14 kg Hispanic boy presented to our Emergency Department after multiple visits to other facilities during the same week with a chief complaint of abdominal pain. The pain was described as postprandial and crampy, and the child’s mother endorsed his aversion to fatty foods and carbonated beverages. She denied emesis, jaundice, icterus, pruritus, or symptoms of altered mental status. Physical examination was unremarkable. Laboratory studies showed only borderline elevated total bilirubin. A plain abdominal x-ray was obtained, which revealed a radiodense mass in the right upper quadrant . The patient was diagnosed with calcified gallstone. This was confirmed with an abdominal ultrasound, which further showed that the 1.2 × 0.8 × 0.7 cm stone was impacted in the neck of the gallbladder . Elective cholecystectomy was performed using the standard four-port laparoscopic technique, with the finding of a large pigmented stone in the gallbladder neck.", + "fulltext_subclaims": [ + "The patient is a 3 years and 10 months-old Hispanic boy.", + "The patient's height is 99 cm.", + "The patient's weight is 14 kg.", + "The patient presented to the Emergency Department with abdominal pain.", + "The abdominal pain was described as postprandial and crampy.", + "The patient's mother endorsed his aversion to fatty foods.", + "The patient's mother endorsed his aversion to carbonated beverages.", + "The mother denied emesis.", + "The mother denied jaundice.", + "The mother denied icterus.", + "The mother denied pruritus.", + "The mother denied symptoms of altered mental status.", + "Physical examination was unremarkable.", + "Laboratory studies showed only borderline elevated total bilirubin.", + "A plain abdominal x-ray was obtained.", + "The abdominal x-ray revealed a radiodense mass in the right upper quadrant.", + "The patient was diagnosed with calcified gallstone.", + "An abdominal ultrasound confirmed the calcified gallstone.", + "The stone was 1.2 × 0.8 × 0.7 cm.", + "The stone was impacted in the neck of the gallbladder.", + "Elective cholecystectomy was performed.", + "The cholecystectomy was performed using the standard four-port laparoscopic technique.", + "A large pigmented stone was found in the gallbladder neck." + ], + "summary": "We present the uncommon but classic plain x-ray finding of a calcified gallstone in a 3 year-old Hispanic boy. He was treated with elective laparoscopic cholecystectomy.", + "summary_subclaims": [ + "The patient is a 3 year-old Hispanic boy.", + "The plain x-ray finding is a calcified gallstone.", + "The finding is described as uncommon but classic.", + "The patient was treated with elective laparoscopic cholecystectomy." + ] + }, + { + "id": "multiclinsum_test_2643_en.txt", + "fulltext": "A 12-year-old boy presented with a chief complaint of pain and swelling in the lower jaw on the right side. He reported a gradual increase in the size of the swelling which had persisted for 4 months. On examination, a diffuse swelling was noted extending anteroposteriorly from 34 to 36 tooth region on the left side and 44 to 46 region on the right side and superoinferiorly from the gingival margin to the lower border of the mandible . The swellings measured approximately 2 × 3 cm in size and were of the same color as the surrounding mucosa. On palpation, both swellings were soft in consistency, with smooth margins and were nontender. Panoramic radiographs showed unilocular, well-circumscribed radiolucent areas extending from 34 to 37 on the left side and 44 to 47 on the right side of the mandible and involving retained mandibular second premolars on both sides . Cone-beam computed tomography (CBCT) was used to obtain a three-dimensional image, enabling the exact location and extent of the lesions. Cone-beam computed tomography examination of the left mandibular region showed well-defined, well-corticated expansile osteolytic radiolucency measuring approximately 36.1 × 23.6 × 16.0 mm in its greatest anteroposterior, superoinferior, and transverse dimensions (A). The radiolucency on the right side was approximately 38.0 × 28.7 × 19.4 mm encroaching the inferior border of the mandible (B). Furthermore, the systemic evaluation of the patient for syndromic features, such as malocclusion, condylar defects, gingival hyperplasia, and maxillary micrognathia, was confirmed negative. Hence, based on the clinical and radiographic findings, a provisional diagnosis of a nonsyndromic benign odontogenic cyst was established for both lesions. The biopsy specimen consisted of four soft tissue bits with the largest one measuring approximately 2.5 × 2 × 1 cm and smallest measuring 0.5 × 0.5 × 0.4 cm in size, brown in color, and soft in consistency. Histopathological examination of the cystic lesion on the left side revealed a 4 to 5 cell layered nonkeratinized epithelium overlying an inflamed connective tissue capsule (A arrowhead). A proliferative hyperplastic epithelium in an arcading pattern was noted in many areas under the influence of an intense juxtaepithelial inflammatory infiltrate (A arrows and B). The lesion on the right side demonstrated a thin nonkeratinized stratified squamous epithelium with many hyperplastic areas and a connective tissue with chronic inflammatory cell infiltrate (C). The findings were suggestive of inflammatory follicular cyst on either side.", + "fulltext_subclaims": [ + "The patient is a 12-year-old boy.", + "The chief complaint was pain and swelling in the lower jaw on the right side.", + "The swelling had persisted for 4 months.", + "On examination, a diffuse swelling was noted extending anteroposteriorly from 34 to 36 tooth region on the left side.", + "The swelling extended anteroposteriorly from 44 to 46 region on the right side.", + "The swellings measured approximately 2 × 3 cm in size.", + "The swellings were of the same color as the surrounding mucosa.", + "On palpation, both swellings were soft in consistency.", + "The swellings had smooth margins.", + "The swellings were nontender.", + "Panoramic radiographs showed unilocular, well-circumscribed radiolucent areas extending from 34 to 37 on the left side.", + "The radiolucent areas on panoramic radiographs extended from 44 to 47 on the right side.", + "Cone-beam computed tomography was used to obtain a three-dimensional image.", + "The radiolucency on the left side measured approximately 36.1 × 23.6 × 16.0 mm.", + "The radiolucency on the right side was approximately 38.0 × 28.7 × 19.4 mm.", + "The systemic evaluation for syndromic features was confirmed negative.", + "A provisional diagnosis of a nonsyndromic benign odontogenic cyst was established.", + "The biopsy specimen consisted of four soft tissue bits.", + "The largest biopsy specimen measured approximately 2.5 × 2 × 1 cm.", + "The smallest biopsy specimen measured 0.5 × 0.5 × 0.4 cm.", + "The biopsy specimens were brown in color.", + "The biopsy specimens were soft in consistency.", + "Histopathological examination of the left lesion revealed a 4 to 5 cell layered nonkeratinized epithelium.", + "The left lesion showed an inflamed connective tissue capsule.", + "A proliferative hyperplastic epithelium in an arcading pattern was noted in many areas.", + "The right lesion demonstrated a thin nonkeratinized stratified squamous epithelium.", + "The right lesion showed many hyperplastic areas.", + "The findings were suggestive of inflammatory follicular cyst on either side." + ], + "summary": "Bilateral swellings in a 12-year-old patient presented with a chief complaint of pain in the lower jaw for 4 months. The radiographic picture exhibited unilocular, well-circumscribed radiolucent areas extending from 34 to 37 on the left side and from 44 to 47 on the right side of the mandible and involving retained mandibular second premolars on both sides.", + "summary_subclaims": [ + "The patient is a 12-year-old.", + "The patient presented with pain in the lower jaw.", + "The pain duration was 4 months.", + "Radiographic images showed unilocular, well-circumscribed radiolucent areas.", + "The radiolucent areas extended from 34 to 37 on the left side of the mandible.", + "The radiolucent areas extended from 44 to 47 on the right side of the mandible.", + "The radiolucent areas involved retained mandibular second premolars on both sides." + ] + }, + { + "id": "multiclinsum_test_972_en.txt", + "fulltext": "The currently reported case is of a 46-year-old nulligravid female patient, of Middle Eastern ethnicity, who presented to the outpatient Gynaecology Clinic of our hospital one year ago. Her complaints included mild pelvic pain requiring the intake of non-steroidal anti-inflammatory drugs once a day two days a week at most. She also complained of pelvic heaviness combined with a gastrointestinal bloating sensation that required the daily intake of antiflatulent medication, which was not helpful in soothing the complaint. She had a past medical history of primary infertility for 20 years. She also had an abdominal myomectomy through a low-transverse abdominal incision 17 years earlier. A clinical examination revealed a huge pelvi-abdominal mass extending up to the level of her xiphisternum. A combined abdominal and vaginal ultrasound (US) revealed the presence of multiple leiomyomata with a huge subserous leiomyoma showing evidence of degeneration and extending to the level of the left lobe of her liver . There was no evidence of ureteric obstruction or renal pelvic ectasia as shown by a renal US. For an abdominal US we used a curvilinear probe with a frequency of 5 MHz, while for the transvaginal US a 7.5 MHz probe was used. The long history of the mass and its slow growth rate constituted a low index of suspicion of a uterine sarcoma.\nNo further imaging investigations were requested due to the highly suggestive characteristics of the mass on US; accordingly the clinical diagnosis of a huge subserous uterine leiomyoma was made. An abdominal hysterectomy via a lower midline incision with left periumbilical extension was performed. Intraoperatively, the uterus was found to be of normal size with numerous variable sized pedunculated subserous leiomyomata diffusely attached to its surface .\nThe huge degenerated leiomyoma previously delineated on sonography turned out to be a retroperitoneal mass extending from the left side of her pelvis through the infundibulopelvic ligament upwards to the lower border of her spleen, with no connections with the leiomyomata-studded uterus. The mass displaced her mesosigmoid and her descending colon medially and even the root of the mesentry was displaced towards the midline. General surgeons were involved; they dissected the mass from its retroperitoneal vascular connections. The mass was in close proximity to her descending colon which was reflected medially in order to gain better access to the mass. The mass was crossing her left kidney anteriorly to the level of her spleen. Dissection in this area was very meticulous due to the proximity to the tail of her pancreas. The hysterectomy specimen and the huge retroperitoneal mass were sent for pathological examination. The postoperative course of our patient was very smooth and she was safely discharged on the fourth postoperative day. She returned ten days later for wound care which showed very good healing.\nThe histopathologic examination revealed a non infiltrative growth with scant mitotic activity (one mitotic figure per 10 high power field) with no atypia, thus confirming the benign leiomyomatous nature of this huge retroperitoneal growth, with evidence of hyaline degeneration", + "fulltext_subclaims": [ + "The patient is a 46-year-old nulligravid female.", + "She is of Middle Eastern ethnicity.", + "She presented to the outpatient Gynaecology Clinic.", + "She had mild pelvic pain requiring the intake of non-steroidal anti-inflammatory drugs once a day two days a week at most.", + "She had pelvic heaviness combined with a gastrointestinal bloating sensation.", + "She had a past medical history of primary infertility for 20 years.", + "She had an abdominal myomectomy through a low-transverse abdominal incision 17 years earlier.", + "A clinical examination revealed a huge pelvi-abdominal mass extending up to the level of her xiphisternum.", + "A combined abdominal and vaginal ultrasound revealed the presence of multiple leiomyomata.", + "There was a huge subserous leiomyoma showing evidence of degeneration.", + "The subserous leiomyoma extended to the level of the left lobe of her liver.", + "There was no evidence of ureteric obstruction.", + "There was no evidence of renal pelvic ectasia.", + "A renal ultrasound was performed.", + "For the abdominal ultrasound, a curvilinear probe with a frequency of 5 MHz was used.", + "For the transvaginal ultrasound, a 7.5 MHz probe was used.", + "The long history of the mass and its slow growth rate constituted a low index of suspicion of a uterine sarcoma.", + "No further imaging investigations were requested.", + "The clinical diagnosis was a huge subserous uterine leiomyoma.", + "An abdominal hysterectomy via a lower midline incision with left periumbilical extension was performed.", + "Intraoperatively, the uterus was found to be of normal size.", + "There were numerous variable sized pedunculated subserous leiomyomata diffusely attached to the surface of the uterus.", + "The huge degenerated leiomyoma previously delineated on sonography turned out to be a retroperitoneal mass.", + "The retroperitoneal mass extended from the left side of her pelvis through the infundibulopelvic ligament upwards to the lower border of her spleen.", + "The mass had no connections with the leiomyomata-studded uterus.", + "The mass displaced her mesosigmoid and descending colon medially.", + "The root of the mesentery was displaced towards the midline.", + "General surgeons were involved in the dissection.", + "The mass was in close proximity to her descending colon.", + "The descending colon was reflected medially to gain better access to the mass.", + "The mass crossed her left kidney anteriorly to the level of her spleen.", + "Dissection was very meticulous due to the proximity to the tail of her pancreas.", + "The hysterectomy specimen and the huge retroperitoneal mass were sent for pathological examination.", + "The postoperative course was very smooth.", + "She was discharged on the fourth postoperative day.", + "She returned ten days later for wound care.", + "The wound showed very good healing.", + "The histopathologic examination revealed a non infiltrative growth.", + "There was scant mitotic activity (one mitotic figure per 10 high power field).", + "There was no atypia.", + "The histopathologic examination confirmed the benign leiomyomatous nature of the retroperitoneal growth.", + "There was evidence of hyaline degeneration." + ], + "summary": "We report the case of a 46-year-old nulligravid female patient of Middle Eastern ethnicity who presented to our university hospital with lower abdominal as well as pelvic pain along with a bloated sensation. She also reported noticing an unusual increase in her abdominal girth. These symptoms developed over the previous two months. Preoperative investigation by means of an ultrasound suggested a degenerated subserous huge uterine leiomyoma. An abdominal hysterectomy was planned. Intraoperatively, a normal sized uterus was found, the surface of which was studded with multiple variable sized pedunculated subserous leiomyomata. Another huge retroperitoneal soft to firm mass was found extending from her left pelvic wall to the level of her spleen, with no connections to her uterus. The mass was excised and a histopathological examination revealed a degenerated leiomyoma.", + "summary_subclaims": [ + "The patient is a 46-year-old nulligravid female.", + "The patient is of Middle Eastern ethnicity.", + "The patient presented with lower abdominal and pelvic pain.", + "The patient reported a bloated sensation.", + "The patient noticed an unusual increase in her abdominal girth.", + "The symptoms developed over the previous two months.", + "An ultrasound suggested a degenerated subserous huge uterine leiomyoma.", + "An abdominal hysterectomy was planned.", + "Intraoperatively, a normal sized uterus was found.", + "The uterus surface was studded with multiple variable sized pedunculated subserous leiomyomata.", + "A huge retroperitoneal soft to firm mass was found.", + "The mass extended from the left pelvic wall to the level of the spleen.", + "The mass had no connections to the uterus.", + "The mass was excised.", + "Histopathological examination revealed a degenerated leiomyoma." + ] + }, + { + "id": "multiclinsum_test_1050_en.txt", + "fulltext": "A medically and surgically free 6-year-old boy, with a weight of 22 kg and height of 122 cm, was brought to the ED of our hospital by his teacher with severe shortness of breath. The patient was witnessed ingesting popcorn when he suddenly started to develop cough and shortness of breath.\nIn the ED, the patient was agitated, drowsy, and semi-conscious. There was no obvious upper airway obstruction, but auscultation revealed absent air entry in the left lung with subcutaneous emphysema in the right side of the neck. His oxygen saturation was acceptable on oxygen supplementation.\nShortly after, patient became severely distressed and was intubated using midazolam, ketamine and succinylcholine. Chest x-ray was done after intubation and showed Endotracheal Tube (ETT) in good position, hyperlucent left hemithorax, flatting of ipsilateral hemidiaphragm, mediastinal shift to the right, and a radiopaque areain the left main bronchus . Auscultation after intubation showed minimal flow in the left lung (improved compared to initial presentation) with some episodes of desaturation.\nOtolaryngology – Head and Neck Surgery were contacted for urgent Direct Laryngoscopy and Bronchoscopy (DLB). After the patient was stabilized, he was taken to the operating room for DLB and foreign body removal with consent of the possible complications of bleeding, infection, inability to remove the foreign body, pneumothorax and/or teeth injury.\nIn the operating room, patient was intubated on bag mask ventilation. Air entry was diminished bilaterally with scattered wheezing in both sides. There was difficulty in bag mask ventilation with obvious expansion in the left side of the chest. The patient was connected to standard monitors. Initial end tidal CO2 was 104 mm Hg, arterial blood gas showed pH of 6.87, PaCO2 181 mm Hg and PaO2 of 231 mm Hg.\nGeneral anesthesia was maintained with propofol infusion of 250 mcg/kg/min, and dexmedetomidine 1 mcg/kg/hr. One dose of dexamethasone 0.5 mg/kg was given to help in relieving the possible airway edema.\nThe patient was given succinylcholine during intubation in the ED followed by a dose of rocuronium, so the option of spontaneous ventilation was lost. The patient was maintaining his oxygen saturation (SaO2) on 100% O2 flow.\nThe decision was made to proceed with flexible fiberoptic scope through the ETT to delineate the anatomy.\nFirst look was an unusual view of the foreign body which was seen saddling in the carina. The patient was extubated during flexible fiberoptic scope, so we proceeded with rigid bronchoscopy after irrigation with 2% lidocaine.\nWhile maintaining ventilation through the side port of the rigid bronchoscope, a foreign body was seen stuck in the trachea at the level of the carina, and a large right accessory tracheal bronchus was noted above the level of the foreign body . The foreign body was successfully retrieved as one piece under vision using fiberoptic forceps . A second look at the airway was done to exclude any other injuries and revealed a clear airway with no remaining foreign body and confirmed the presence of a right tracheal bronchus .\nAfter successful foreign body removal, another ETT was inserted and irrigation was done using normal saline. Airway entry improved, and arterial blood gas showed a pH of 6.95, PaCO2 of 141, and PaO2 of 40.3. Portable chest x-ray confirmed the ETT position and the absence of pneumothorax . The patient was shifted from the operating room to the pediatric intensive care unit (PICU) fully sedated and intubated. The patient was monitored in PICU and was extubated the same day.\nThe patient was playful, tolerating orally, with no signs of respiratory distress and maintaining saturation on room air. He returned to his usual level of activity and was given dexamethasone 10 mg every 6 h (total of 4 doses). He was discharged home the following day in a good and stable condition with no need for further follow up.", + "fulltext_subclaims": [ + "The patient was a medically and surgically free 6-year-old boy.", + "The patient's weight was 22 kg.", + "The patient's height was 122 cm.", + "The patient was brought to the ED by his teacher.", + "The patient was witnessed ingesting popcorn.", + "The patient suddenly started to develop cough and shortness of breath.", + "In the ED, the patient was agitated, drowsy, and semi-conscious.", + "Auscultation revealed absent air entry in the left lung.", + "Chest x-ray after intubation showed Endotracheal Tube (ETT) in good position.", + "Chest x-ray showed hyperlucent left hemithorax.", + "Chest x-ray showed a radiopaque area in the left main bronchus.", + "Otolaryngology – Head and Neck Surgery were contacted for urgent Direct Laryngoscopy and Bronchoscopy.", + "The patient was taken to the operating room for DLB.", + "The patient was intubated on bag mask ventilation.", + "Initial end tidal CO2 was 104 mm Hg.", + "Arterial blood gas showed pH of 6.87.", + "General anesthesia was maintained with propofol infusion of 250 mcg/kg/min.", + "The patient was given succinylcholine during intubation in the ED.", + "The patient was given a dose of rocuronium.", + "The decision was made to proceed with flexible fiberoptic scope through the ETT.", + "The foreign body was seen saddling in the carina.", + "A large right accessory tracheal bronchus was noted above the level of the foreign body.", + "The foreign body was successfully retrieved as one piece under vision using fiberoptic forceps.", + "A second look at the airway revealed a clear airway with no remaining foreign body.", + "After successful foreign body removal, another ETT was inserted.", + "Portable chest x-ray confirmed the ETT position.", + "The patient was shifted to the pediatric intensive care unit (PICU) fully sedated and intubated.", + "The patient was extubated the same day.", + "The patient was playful and tolerating orally.", + "The patient was discharged home the following day." + ], + "summary": "A 6-year-old medically and surgically free boy presented to the Emergency Department with severe shortness of breath. The patient was initially saturating well, but then suddenly worsened and was rushed for intubation. The patient was taken to the operating room for direct laryngobronchoscopy to retrieve the foreign body obstructing the airway. The foreign body was successfully retrieved, and the presence of a tracheal bronchus was confirmed.", + "summary_subclaims": [ + "A 6-year-old medically and surgically free boy presented to the Emergency Department with severe shortness of breath.", + "The patient was initially saturating well.", + "The patient suddenly worsened and was rushed for intubation.", + "The patient was taken to the operating room for direct laryngobronchoscopy to retrieve the foreign body obstructing the airway.", + "The foreign body was successfully retrieved.", + "The presence of a tracheal bronchus was confirmed." + ] + }, + { + "id": "multiclinsum_test_1120_en.txt", + "fulltext": "A 44-year-old male patient, residing in a village of Yunnan Province, was admitted to Xiangyun County People's Hospital in March 2021. He had a history of working in coal transportation. He was diagnosed with tuberculosis, tuberculous bronchostenosis, and silicosis by the local disease control center and a hospital due to repeated coughing and phlegm for up to 6 years. When he was discharged from hospital, he accepted the advice of anti-tuberculosis treatment and the anti-tuberculosis HRZE scheme (H: isoniazid, R: rifampicin, Z: pyrazinamide, E: ethambutol). However, after discharge, the patient did not take medicine every day according to the doctor's advice, and still had cough and expectoration symptoms, without obvious regularity of time.After taking anti-tuberculosis drugs on his own for five days, he was admitted to the hospital because of headache and fever for two days with rash, and a high body temperature up to 39.4℃. Rashes were observed on the face, head, neck, chest and abdomen, and limbs, distributing in patches with size ranging from a pinpoint to a grain of rice, which led to pruritus and a red halo at the base without rupture, separated by normal skin. The lips and mouth were slightly cyanotic, and the breath sounds of both lungs were coarse, with scattered moist rales. The other examination results were unremarkable.\nBy laboratory examination, normal level of blood cells were observed as follows: white blood cells (7.3 × 109/L), hemoglobin (155 g/L), platelets (202 × 109/L), neutrophil percentage (90.6%) and lymphocyte count (7.8 × 109/L). Biochemical tests showed impaired liver function: elevated aspartate aminotransferase(AST) (50U/L), elevated gamma-glutamyl transferase(GGT) (64U/L), slightly lower prealbumin (145.5 mg/L), however normal alanine aminotransferase(ALT) (21U/L). Inflammatory biomarker tests showed procalcitonin at 0.63 ng/mL and C-reactive protein at 59 mg/L. Coagulation analysis showed a prolonged prothrombin time of 13.2 s. Plasma fibrinogen was elevated at 4.80 g/L. Routine urinalysis showed that the patient was positive for urine protein (+ , 0.2 g/L – 1.0 g/L), blood cells (+ , 5 -10 red blood cells observed in 400 × microscopic field), and urinary ketones (+ + , 1.5 mmol/L-3.5 mmol/L), suggesting the presence of impairment of renal function (Supplementary Table ).\nNo acid-fast bacilli were detected by pooling the patient's nocturnal sputum, immediate sputum and morning sputum for testing. According to the patient's chest computed tomography (CT) scan (bilateral lungs and mediastinum) findings, the scattered nodular and lamellar shadows in both lungs were considered as tuberculosis most likely, and the lesions in the lingual segment of the upper lobe of the left lung and the lower lobe of the left lung were probably infectious lesions . The patient was tested for the antibodies (IgM and IgG) against OHV due to the patient from the natural epidemic foci of HFRS, but the results were negative.\nOn the first day after admission, the patient suspended his anti- tuberculosis treatment and was given an acetaminophen oral suspension. Subsequently, his temperature decreased and anti-inflammatory treatments were provided with methylprednisolone sodium succinate. The blood gas analysis of the patient showed that the pH value was 7.48, the oxygen partial pressure was 53.2 mmHg, the oxygen saturation was 90.1%, and the potassium ion (K +) was 2.8 mmol/L. The presence of electrolyte disorders (hypokalemia, hyponatremia) was treated with sodium chloride and potassium chloride injections. On the second day after admission, the patient's temperature fluctuated between 38.1–38.7° C, and he still had headache, cough, expectoration and other uncomfortable symptoms. For the symptoms of headache and rash, he took rotundine and ebastine tablets for symptomatic treatment. Later examination showed that the rash on the patient's face, head, chest and neck, and limbs had subsided, and the patient felt relief from the headache. On the third day after admission, the patient continued with symptomatic treatment for anti-infection and cough suppression. The patient sometimes had fever, discomfort, cough and expectoration with little sputum, which was yellow-white sputum. On the Fourth day after admission, the patient was discharged after the rash and fever subsided at the request of the patient and his wife.\nIn cases where serological and clinical examinations could not identify the specific cause of infection, rash and fever, we performed retrospectively etiological testing of the whole blood and serum from the collected patent previously. TIANamp Virus DNA/RNA extraction kit (DP315, TIANGEN, China) was used to extract viral nucleic acid and DNA of OT which is an intracellular parasitic microorganism with some characteristics of a virus and can be extracted as soon as the OT is lysed and DNA is released from the patient whole blood and serum according to the instructions. Configure the Carrier RNA working solution (final concentration of 1 ug/ul) using Carrier RNA lyophilized powder, buffer GB neutralization, and RNase-Free ddH2O according to the reagents provided in the extraction kit. Add 20 μl Proteinase K and 200 μl Carrier RNA working solution to a 200 μl serum or whole blood sample. Close the lid and mix well by vortexing for 15 s. Incubate at 56° C for 15 min, briefly centrifuge, add 250 μl of anhydrous ethanol, and let stand at room temperature for 5 min. Transfer all the mixed solution to the adsorption column, centrifuge at 8000 rpm for 1 min, and discard the filtrate. Add 500 μl buffer GD, centrifuge at 8000 rpm for 1 min, and discard the waste liquid. Add another 600 μl of rinse solution PW, cover the tube cap, let stand for 2 min, centrifuge at 8000 rpm for 1 min, discard the waste liquid, and repeat this step once. Afterwards, 500 μl absolute ethanol was added, centrifuged at 8000 rpm for 1 min, centrifuged at 12,000 rpm for 3 min, discarded the filtrate, opened the lid and left at room temperature for 3 min. Drop 40 μl RNase-Free ddH2O in the middle of the adsorption membrane, leave at room temperature for 5 min, centrifuge at 12,000 rpm for 1 min, completely elute the DNA/RNA on the membrane, and store the nucleic acids in a -80 °C freezer.The gene sequence was amplified by one-step nested reverse transcription-polymerase chain reaction(Nested RT-PCR) method using universal primers of OHV according to reference. Nested RT-PCRs were performed using the OneStep RT-PCR kit (Qiagen) for OHV. In each outer reaction, generating an about 600-bp fragment, 2 μl RNA extract was mixed with 10-nmol dNTPs, 2 × reaction buffer, 30-pmol forward primer (HAN-L-F1:5´-ATGTAYGTBAGTGCWGATGC3´), 30-pmol reverse primer (HAN-L-R1: 5´- AACCADTCWGTYCCRTCATC3´), and 1 μl of the supplied.enzyme mix, in a total volume of 25 μl. Cycling conditions were as follows: 30 min at 50℃ and 15 min at 95℃, followed by 35 cycles of 30 s at 94℃, 30 s at 47℃ and 1 min at 72℃. A final elongation step was performed at 72℃ for 10 min. For the inner reaction, generating an about 370-bp fragment, 2 μl of the outer reaction product was used. All reaction and cycling conditions were identical to the ones used for the outer reaction, with the exception of the used primer set (HAN-L-F2: 5´-TGCWGATGCHACIAARTGGTC-3´ and HAN-L-R2: 5´-GCRTCRTCWGARTGRTGDGCAA-3´) and the omission of the reverse transcription step at 50℃.PCR amplification was performed using the 56-kDa TSA gene of OT according to references [, ]. The outside primer pair comprised 56KD-F1: 5´-TACATTAGCTGCGGGTATGACA-3´ and 56KD-R1: 5´-CCAGCATAATTCTTCAACCAAG3´. The nested primer pair comprised 56KD-F2: 5´-GAGCAGAGCTAGGTGTTATGTA 3´ and56KD-R2: 5´-TAGGCATTATAGTAGGCTGAGG3´. PCR products were 306 to339 bp for the outside primer pair and 150 to 168 bp for the nested primer pair. PCR conditions were the same for both primer pairs, with initial denaturation for 5 min at 94 °C, followed by 35 cycles of 30 s at 94 °C, 30 s at 50 °C, and 1 min at 72 °C, and a final extension of 5 min at 72 °C.The agarose gel electrophoresis experiment was carried out under the imager .The PCR products were purified by gel cutting and sent to a sequencing company (Shanghai Sangon Biotech) for sequencing. The 362 bp sequence of OHV(accession no.OP392989) and the 172 bp DNA sequence of OT were obtained from serum samples. Then primers (ICRA-F2:5 '- CCTCAGTATAATGCCC-3' and ICR8A-R: 5 '- TCCTGCATGACGCTGCAA-3') were designed to obtain 449 bp DNA sequence of tsutsugamushi (accession no.OP392990).\nNucleotide sequence similarity searches in the public databases were assessed by the Basic Local Alignment Search Tool, implemented in the National Center for Biotechnology Information website , using BLASTn, and BLASTn optimized for highly similar sequences (MEGABLAST) and BLASTp, algorithms. In BLAST, it was 92.54% and 97.69% that the highest identity of nucleotide(nt) and amino acid(aa) compared the OHV sequence(OP39298) in this study to SEOV L0199 strain(HQ992814) and SEOV Rn-SHY17 ( ADR32120.1). The highest nt and aa identity compared the obtained OT sequence(OP392990) to Gilliam genotype of HZ01034 strain (MT258795.1) and Orientia tsutsugamushi str. Gilliam (KJV51889.1) was 96.88%, 93.96% respectively (Supplementary Tables and ).\nPhylogenetic trees were analyzed for the obtained OHV sequences (362 bp) and OT sequences (449 bp), and the related sequences retrieved in the Genbank database. The each sequence set was aligned by Clustal-X, and phylogenetic relationships were reconstructed using MEGA X for the initial trees obtained by the maximum likelihood neighbor joining method. In the nucleotide substitution models, the K2 + I and T92 + G models were selected for Bootstrap analysis using 1000 replicates to improve the confidence level of the phylogenetic tree, respectively .The results showed that the patient had been infected with SEOV of Orthohantavirus and Gilliam genotype of O. tsutsugamushi.", + "fulltext_subclaims": [ + "The patient was a 44-year-old male.", + "The patient resided in a village of Yunnan Province.", + "The patient was admitted to Xiangyun County People's Hospital in March 2021.", + "The patient had a history of working in coal transportation.", + "The patient was diagnosed with tuberculosis, tuberculous bronchostenosis, and silicosis.", + "The diagnosis was made by the local disease control center and a hospital.", + "The patient had repeated coughing and phlegm for up to 6 years.", + "The patient was discharged from hospital after being advised to take anti-tuberculosis treatment.", + "The patient was advised to take the anti-tuberculosis HRZE scheme.", + "The patient did not take medicine every day according to the doctor's advice after discharge.", + "The patient still had cough and expectoration symptoms.", + "The patient's symptoms did not have obvious regularity of time.", + "After taking anti-tuberculosis drugs on his own for five days, the patient was admitted to the hospital.", + "The patient had headache and fever for two days with rash.", + "The patient's body temperature was up to 39.4℃.", + "Rashes were observed on the face, head, neck, chest and abdomen, and limbs.", + "The rashes were distributed in patches with size ranging from a pinpoint to a grain of rice.", + "The rashes led to pruritus and a red halo at the base.", + "The rashes did not rupture and were separated by normal skin.", + "The lips and mouth were slightly cyanotic.", + "The breath sounds of both lungs were coarse.", + "Scattered moist rales were heard.", + "The other examination results were unremarkable.", + "White blood cells were 7.3 × 109/L.", + "Hemoglobin was 155 g/L.", + "Platelets were 202 × 109/L.", + "Neutrophil percentage was 90.6%.", + "Lymphocyte count was 7.8 × 109/L.", + "Aspartate aminotransferase (AST) was 50U/L.", + "Gamma-glutamyl transferase (GGT) was 64U/L.", + "Prealbumin was 145.5 mg/L.", + "Alanine aminotransferase (ALT) was 21U/L.", + "Procalcitonin was 0.63 ng/mL.", + "C-reactive protein was 59 mg/L.", + "Prothrombin time was 13.2 s.", + "Plasma fibrinogen was 4.80 g/L.", + "Urine protein was positive (+, 0.2 g/L – 1.0 g/L).", + "Blood cells in urine were positive (+, 5 -10 red blood cells observed in 400 × microscopic field).", + "Urinary ketones were positive (++ , 1.5 mmol/L-3.5 mmol/L).", + "No acid-fast bacilli were detected in the patient's sputum.", + "The chest CT scan showed scattered nodular and lamellar shadows in both lungs.", + "The lesions in the lingual segment of the upper lobe of the left lung and the lower lobe of the left lung were probably infectious lesions.", + "The patient was tested for antibodies (IgM and IgG) against OHV.", + "The results of the OHV antibody tests were negative.", + "On the first day after admission, the patient suspended his anti-tuberculosis treatment.", + "The patient was given an acetaminophen oral suspension.", + "The patient's temperature decreased.", + "The patient was provided with anti-inflammatory treatments with methylprednisolone sodium succinate.", + "The blood gas analysis showed a pH value of 7.48.", + "The oxygen partial pressure was 53.2 mmHg.", + "The oxygen saturation was 90.1%.", + "Potassium ion (K +) was 2.8 mmol/L.", + "The patient was treated with sodium chloride and potassium chloride injections.", + "On the second day after admission, the patient's temperature fluctuated between 38.1–38.7° C.", + "The patient still had headache, cough, expectoration and other uncomfortable symptoms.", + "The patient took rotundine and ebastine tablets for symptomatic treatment.", + "The rash on the patient's face, head, chest and neck, and limbs had subsided.", + "The patient felt relief from the headache.", + "On the third day after admission, the patient continued with symptomatic treatment for anti-infection and cough suppression.", + "The patient sometimes had fever, discomfort, cough and expectoration with little sputum.", + "The sputum was yellow-white.", + "On the Fourth day after admission, the patient was discharged after the rash and fever subsided.", + "The discharge was at the request of the patient and his wife.", + "Serological and clinical examinations could not identify the specific cause of infection, rash and fever.", + "Retrospectively etiological testing of the whole blood and serum from the collected patient was performed.", + "TIANamp Virus DNA/RNA extraction kit was used to extract viral nucleic acid and DNA.", + "OT is an intracellular parasitic microorganism with some characteristics of a virus.", + "OT DNA can be extracted as soon as the OT is lysed and DNA is released.", + "The gene sequence was amplified by one-step nested reverse transcription-polymerase chain reaction (Nested RT-PCR) method.", + "Universal primers of OHV were used according to reference.", + "Nested RT-PCRs were performed using the OneStep RT-PCR kit (Qiagen) for OHV.", + "In each outer reaction, an about 600-bp fragment was generated.", + "The agarose gel electrophoresis experiment was carried out under the imager.", + "The PCR products were purified by gel cutting and sent to a sequencing company.", + "A 362 bp sequence of OHV (accession no.OP392989) was obtained from serum samples.", + "A 172 bp DNA sequence of OT was obtained.", + "Primers were designed to obtain 449 bp DNA sequence of tsutsugamushi (accession no.OP392990).", + "Nucleotide sequence similarity searches were assessed by BLASTn.", + "The highest identity of nucleotide compared the OHV sequence to SEOV L0199 strain was 92.54%.", + "The highest identity of amino acid compared the OHV sequence to SEOV Rn-SHY17 was 97.69%.", + "The highest identity of nucleotide compared the OT sequence to Gilliam genotype of HZ01034 strain was 96.88%.", + "The highest identity of amino acid compared the OT sequence to Orientia tsutsugamushi str. Gilliam was 93.96%.", + "Phylogenetic trees were analyzed for the obtained OHV sequences and OT sequences.", + "The patient had been infected with SEOV of Orthohantavirus.", + "The patient had been infected with Gilliam genotype of O. tsutsugamushi." + ], + "summary": "In this case, a 44-year-old male famer with pulmonary tuberculosis and a history of working in coal transportation was admitted to the hospital because of respiratory symptoms accompanied by fever, headache, and skin rashes on his body. Biochemical and urinalysis revealed the hepatic and renal injury. The subsequent molecular testing confirmed he suffered from HFRS and scrub typhus simultaneously that the serological and clinical diagnosis could not identify the cause of infection before. Such case has not been reported in Yunnan Province before.", + "summary_subclaims": [ + "The patient is a 44-year-old male farmer.", + "The patient has pulmonary tuberculosis.", + "The patient has a history of working in coal transportation.", + "The patient was admitted to the hospital because of respiratory symptoms.", + "The patient had fever.", + "The patient had headache.", + "The patient had skin rashes on his body.", + "Biochemical and urinalysis revealed hepatic injury.", + "Biochemical and urinalysis revealed renal injury.", + "Molecular testing confirmed the patient suffered from HFRS.", + "Molecular testing confirmed the patient suffered from scrub typhus.", + "Serological and clinical diagnosis could not identify the cause of infection before.", + "Such a case has not been reported in Yunnan Province before." + ] + }, + { + "id": "multiclinsum_test_2064_en.txt", + "fulltext": "A 44-year-old Chinese man, weight 55 kg and height 165 cm, presented to the neurosurgery department of our institution with an 11-month history of paroxysmal headache and weakness of the right limb without any other pertinent positive symptom. The patient had been diagnosed with NF1 for more than 30 years. His past surgical history included having undergone left parietal tumor resection in May 2016, the postoperative pathology of which indicated glial sarcoma (World Health Organization grade IV). In July 2017, the patient presented with paroxysmal headache with weakness of the right limb. Computed tomography (CT) of the head revealed recurrence of left parietal glioma, acute cerebral infarction in the left frontal lobe and around ventricle. As a result, the patient received conservative treatment in the neurology department.\nThe only pertinent positive physical examination finding was multiple cutaneous neurofibromas and numerous café-au-lait spots of different sizes dispersed over the trunk and limbs . The results of the patient’s cardiovascular, respiratory, and abdominal examinations were all unremarkable. His baseline blood pressure was in the range of 120–140 mmHg for systolic blood pressure and 65–85 mmHg for diastolic blood pressure. He denied any current medication, tobacco, or alcohol use, and a family history of NF was also excluded.\nThe results of the patient’s preoperative laboratory examination were unremarkable, including blood and urine analysis. His electrocardiographic examination showed normal sinus rhythm. His chest x-ray revealed multiple nodules in the two lung fields, the largest being located in the upper right quadrant of the lung field and having a diameter of about 29 mm. Magnetic resonance imaging of the head revealed the recurrence of glioma. The patient was scheduled for resection of the recurrent gliomas.\nDuring the preoperative examination, it was thought that general anesthesia application would be more appropriate for the patient. The patient was monitored with electrocardiography, heart rate (HR), invasive blood pressure, and pulse oximetry in the operating room. He was anesthetized with midazolam 3 mg, etomidate 14 mg, cisatracurium 20 mg, fentanyl 0.15 mg, and propofol 60 mg in sequence. When assisted respiration was started, the monitor showed a persistent increase in blood pressure. Within 40 seconds, it rose to about 310/140 mmHg, and the HR increased to about 140 beats per minute (bpm). We quickly eliminated the following possibilities: taking the wrong medicine, blood pressure monitoring equipment malfunction, or problem with venous access. To prevent the cardiovascular complications, we took measures to control the patient’s blood pressure and HR with phentolamine 2 mg, esmolol 30 mg, and remifentanil 80 μg when the blood pressure was about 310/140 mmHg and HR was about 140 bpm. The blood pressure values were stable during intubation, but the HR continued to be higher than 110 bpm.\nThe patient’s blood pressure was stable during the operation. However, there was a fluctuation of blood pressure during extubation with an increase to as high as 210/140 mmHg, which was aborted with phentolamine 1 mg. Nevertheless, the patient’s HR continued to be higher than 120 bpm, and he was not sensitive to β-adrenergic blockade.\nDuring postoperative follow-up, no headache, nausea, or blood pressure change (especially hypotension) was observed, and the patient’s tachycardia disappeared 3 days after the operation. To investigate the causes of severe hypertension during anesthesia induction, we initiated a biochemical workup of his adrenal hormone 3 days after the operation, which revealed elevated 24-hour blood laboratory test results: epinephrine 3.57 nmol/L (normal range, 0.01-0.34 nmol/L), metanephrine 8.99 nmol/L (0.01–0.42), normetanephrine 2.25 nmol/L (0.01–0.71), and vanillylmandelate 160.41 nmol/L (0.01–62). Subsequently, CT of the abdomen with contrast enhancement demonstrated a 7.7-cm × 6.7-cm heterogeneous mass in the left adrenal gland.", + "fulltext_subclaims": [ + "The patient is a 44-year-old Chinese man.", + "The patient's weight is 55 kg.", + "The patient's height is 165 cm.", + "The patient presented with an 11-month history of paroxysmal headache.", + "The patient had weakness of the right limb.", + "The patient had no other pertinent positive symptoms.", + "The patient had been diagnosed with NF1 for more than 30 years.", + "The patient had undergone left parietal tumor resection in May 2016.", + "The postoperative pathology indicated glial sarcoma.", + "The glial sarcoma was World Health Organization grade IV.", + "In July 2017, the patient presented with paroxysmal headache with weakness of the right limb.", + "Computed tomography of the head revealed recurrence of left parietal glioma.", + "Computed tomography of the head revealed acute cerebral infarction in the left frontal lobe.", + "Computed tomography of the head revealed acute cerebral infarction around the ventricle.", + "The patient received conservative treatment in the neurology department.", + "The only pertinent positive physical examination finding was multiple cutaneous neurofibromas.", + "The patient had numerous café-au-lait spots of different sizes dispersed over the trunk and limbs.", + "The results of the patient’s cardiovascular, respiratory, and abdominal examinations were all unremarkable.", + "The patient’s baseline blood pressure was in the range of 120–140 mmHg for systolic blood pressure.", + "The patient’s baseline blood pressure was in the range of 65–85 mmHg for diastolic blood pressure.", + "The patient denied any current medication.", + "The patient denied tobacco use.", + "The patient denied alcohol use.", + "A family history of NF was excluded.", + "The results of the patient’s preoperative laboratory examination were unremarkable.", + "The patient’s electrocardiographic examination showed normal sinus rhythm.", + "The patient’s chest x-ray revealed multiple nodules in the two lung fields.", + "The largest nodule was located in the upper right quadrant of the lung field.", + "The largest nodule had a diameter of about 29 mm.", + "Magnetic resonance imaging of the head revealed the recurrence of glioma.", + "The patient was scheduled for resection of the recurrent gliomas.", + "During the preoperative examination, it was thought that general anesthesia application would be more appropriate for the patient.", + "The patient was monitored with electrocardiography.", + "The patient was monitored with heart rate.", + "The patient was monitored with invasive blood pressure.", + "The patient was monitored with pulse oximetry.", + "The patient was anesthetized with midazolam 3 mg.", + "The patient was anesthetized with etomidate 14 mg.", + "The patient was anesthetized with cisatracurium 20 mg.", + "The patient was anesthetized with fentanyl 0.15 mg.", + "The patient was anesthetized with propofol 60 mg.", + "When assisted respiration was started, the monitor showed a persistent increase in blood pressure.", + "Within 40 seconds, the blood pressure rose to about 310/140 mmHg.", + "The heart rate increased to about 140 beats per minute.", + "The following possibilities were quickly eliminated: taking the wrong medicine, blood pressure monitoring equipment malfunction, or problem with venous access.", + "Phentolamine 2 mg was administered to control the patient’s blood pressure.", + "Esmolol 30 mg was administered to control the patient’s heart rate.", + "Remifentanil 80 μg was administered to control the patient’s blood pressure.", + "The blood pressure values were stable during intubation.", + "The heart rate continued to be higher than 110 bpm.", + "The patient’s blood pressure was stable during the operation.", + "There was a fluctuation of blood pressure during extubation.", + "The blood pressure increased to as high as 210/140 mmHg.", + "Phentolamine 1 mg was administered to abort the increase in blood pressure.", + "The patient’s heart rate continued to be higher than 120 bpm.", + "The patient was not sensitive to β-adrenergic blockade.", + "During postoperative follow-up, no headache was observed.", + "During postoperative follow-up, no nausea was observed.", + "During postoperative follow-up, no blood pressure change was observed.", + "The patient’s tachycardia disappeared 3 days after the operation.", + "A biochemical workup of adrenal hormone was initiated 3 days after the operation.", + "The 24-hour blood laboratory test results showed epinephrine 3.57 nmol/L.", + "The 24-hour blood laboratory test results showed metanephrine 8.99 nmol/L.", + "The 24-hour blood laboratory test results showed normetanephrine 2.25 nmol/L.", + "The 24-hour blood laboratory test results showed vanillylmandelate 160.41 nmol/L.", + "CT of the abdomen with contrast enhancement demonstrated a 7.7-cm × 6.7-cm heterogeneous mass in the left adrenal gland." + ], + "summary": "Severe hypertension developed during anesthesia induction in our patient, a 44-year-old Chinese man with neurofibromatosis type 1. We screened for catecholamine level after glioma resection, and the patient was diagnosed with combined pheochromocytoma and paraganglioma.", + "summary_subclaims": [ + "Severe hypertension developed during anesthesia induction.", + "The patient is a 44-year-old Chinese man.", + "The patient has neurofibromatosis type 1.", + "We screened for catecholamine level after glioma resection.", + "The patient was diagnosed with combined pheochromocytoma and paraganglioma." + ] + }, + { + "id": "multiclinsum_test_2855_en.txt", + "fulltext": "A 67-year-old Caucasian female with glipizide- and metformin-treated diabetes mellitus and enalapril-treated arterial hypertension presented for open reposition and Zuggurtung fixation of a fracture of the olecranon. The elbow was fractured in a bicycle accident and had been conservatively treated for 14 days prior to surgery. The patient had suffered from diarrhoea and signs of confusion in the period between the trauma and surgery, but had been free of gastrointestinal or neurological symptoms during the week before surgery. The patient had not sought professional medical advice for these symptoms. When the patient presented for surgery, she was lucid, without any gastrointestinal symptoms and otherwise physically well. The preoperative laboratory work-up tests were without pathological signs . At the operating ward, 1 g paracetamol, 100 mg diclofenac, 10 mg oxycodone and 25 mg meclizine were administered orally as premedication. The anaesthesia was induced with propofol and fentanyl. The airway was secured by orotracheal intubation after which the anaesthesia was maintained with sevoflurane. The time of surgery was 31 min and the total anaesthesia duration was 70 min. After uncomplicated surgery and anaesthesia, the patient was transferred to the postoperative unit from where the patient went home after 3 h accompanied by her next of kin. During the first postoperative evening and night, the patient’s next of kin observed that the patient had problems with articulating words followed by increasing anxiety and confusion. At the next morning, the patient only spoke unrecognizable words, and by the afternoon, she could not walk. Approximately 24 h after leaving the hospital, the patient presented at the emergency ward. Respiration and circulation were normal and the patient was afebrile. A computed tomography (CT) scan of the brain was performed as well as an analysis of the cerebrospinal fluid, with both indicating no pathological signs. A neurological consult ordered an electroencephalogram (EEG) and a magnetic resonance imaging (MRI) of the brain to be performed as soon as possible at a secondary hospital to which the patient was referred. At arrival to the secondary hospital on the second postoperative day, the patient did not respond verbally, could not open her eyes spontaneously and the best motor response was withdrawal of the limbs on pain stimulation (Glasgow Coma Scale, GCS 9). It was noted that plasma creatinine was elevated to 313 μmol × L-1. Except for an elevated C-reactive protein (CRP) at 76 mg × L-1, all blood analyses were in the normal range, including haemoglobin, leucocyte and platelet count. On the night between the second and third postoperative day, the patient suffered a generalised tonic-clonic seizure. The patient was transferred to the intensive care unit, where she, was orotracheally intubated and mechanically ventilated. A second CT scan of the brain showed no bleeding or ischaemic signs. The patient was respiratory and circulatory stable and did not require an increased oxygen fraction or vasoactive drugs. The patient was anuric, was not icteric and did not have any pathological signs on the skin. Blood cultures were drawn and an antibiotic was given based on a body temperature of 38.9°C and tachycardia. The patient was started at 4 g piperacillin-tazobactam 3 times per day intravenously (i.v.). The cultures did not show any bacterial growth. Because the patient had elevated serum potassium of 5.8 mmol × L-1 and hyponatraemia of 131 mmol × L-1, blood was analysed for serum cortisol on the suspicion of Addison’s disease. Accordingly, the patient was given 100 mg hydrocortisone i.v. Cortisol in serum was found to be 796 nmol × L-1 and thus the suspicion of Addison’s disease was refuted. The patient was now anaemic with a haemoglobin of 86 g × L-1 and thrombocytopenic with a platelet count of 31 × 109 × L-1. Lactate dehydrogenase was elevated to 21.5μkat × L-1 and haptoglobin low at 0.07 g × L-1, which indicate haemolysis. The blood film showed schistocytosis., On the third postoperative day, plasmapheresis was started on the indication of HUS/TTP. One plasma volume was replaced daily for four days and continuous veno-venous haemodiafiltration was performed between plasmapheresis treatments. The patient’s haemoglobin and platelet count improved during treatment . The same positive development was seen for creatinine. Neurological status improved slowly and on the seventh postoperative day, GCS was 6 with withdrawal of the limbs on pain stimulation. Polymerase chain reaction (PCR) revealed enterohaemorrhagic E. coli (EHEC) in faeces. The serotype was non-O157, produced verotoxin type 2 and was eae-gene negative. Blood analysis of Adamts-13 protein activity showed normal levels and antibodies against the protein were not observed. Signs of multiple small ischaemic fronto-temporal cortical lesions were noted on an MRI scan, as well as lesions in the circulus Willisi and the basilar artery with narrowing and more distal dilatations of the vessels. Analyses of anti-neutrophil antibodies and anti-neutrophil cytoplasmic antibodies were negative. The neurological consult assessed the clinical picture together with the MRI findings as thrombotic microangiopathy. The patient continued to show slow improvement in neurological status with spontaneous eye opening and the ability to move all limbs, although with substantial weakness. The patient could make eye contact on instructions on the 20th postoperative day but was still anuric and in need of intermittent haemodialysis and mechanical ventilatory support. On the 21st postoperative day, the patient suffered a generalised tonic-clonic seizure followed by deep coma (GCS 3). EEG showed generalised deeply suppressed activity. A joint decision was made with the next of kin to withdraw all treatment. The patient died 6 h later.", + "fulltext_subclaims": [ + "The patient was a 67-year-old Caucasian female.", + "The patient had glipizide- and metformin-treated diabetes mellitus.", + "The patient had enalapril-treated arterial hypertension.", + "The patient presented for open reposition and Zuggurtung fixation of a fracture of the olecranon.", + "The elbow was fractured in a bicycle accident.", + "The elbow had been conservatively treated for 14 days prior to surgery.", + "The patient had suffered from diarrhoea and signs of confusion in the period between the trauma and surgery.", + "The patient had been free of gastrointestinal or neurological symptoms during the week before surgery.", + "The patient had not sought professional medical advice for these symptoms.", + "When the patient presented for surgery, she was lucid.", + "When the patient presented for surgery, she was without any gastrointestinal symptoms.", + "When the patient presented for surgery, she was otherwise physically well.", + "The preoperative laboratory work-up tests were without pathological signs.", + "At the operating ward, 1 g paracetamol was administered orally as premedication.", + "At the operating ward, 100 mg diclofenac was administered orally as premedication.", + "At the operating ward, 10 mg oxycodone was administered orally as premedication.", + "At the operating ward, 25 mg meclizine was administered orally as premedication.", + "The anaesthesia was induced with propofol and fentanyl.", + "The airway was secured by orotracheal intubation.", + "The anaesthesia was maintained with sevoflurane.", + "The time of surgery was 31 min.", + "The total anaesthesia duration was 70 min.", + "After uncomplicated surgery and anaesthesia, the patient was transferred to the postoperative unit.", + "The patient went home after 3 h.", + "The patient was accompanied by her next of kin.", + "During the first postoperative evening and night, the patient’s next of kin observed that the patient had problems with articulating words.", + "During the first postoperative evening and night, the patient’s next of kin observed increasing anxiety and confusion.", + "At the next morning, the patient only spoke unrecognizable words.", + "By the afternoon, the patient could not walk.", + "Approximately 24 h after leaving the hospital, the patient presented at the emergency ward.", + "Respiration and circulation were normal.", + "The patient was afebrile.", + "A computed tomography (CT) scan of the brain was performed.", + "An analysis of the cerebrospinal fluid was performed.", + "Both the CT scan of the brain and the analysis of the cerebrospinal fluid indicated no pathological signs.", + "A neurological consult ordered an electroencephalogram (EEG) and a magnetic resonance imaging (MRI) of the brain.", + "The neurological consult ordered the EEG and MRI to be performed as soon as possible.", + "The patient was referred to a secondary hospital.", + "At arrival to the secondary hospital on the second postoperative day, the patient did not respond verbally.", + "At arrival to the secondary hospital on the second postoperative day, the patient could not open her eyes spontaneously.", + "At arrival to the secondary hospital on the second postoperative day, the best motor response was withdrawal of the limbs on pain stimulation.", + "The Glasgow Coma Scale (GCS) was 9.", + "Plasma creatinine was elevated to 313 μmol × L-1.", + "Except for an elevated C-reactive protein (CRP) at 76 mg × L-1, all blood analyses were in the normal range.", + "On the night between the second and third postoperative day, the patient suffered a generalised tonic-clonic seizure.", + "The patient was transferred to the intensive care unit.", + "The patient was orotracheally intubated.", + "The patient was mechanically ventilated.", + "A second CT scan of the brain showed no bleeding or ischaemic signs.", + "The patient was respiratory and circulatory stable.", + "The patient did not require an increased oxygen fraction.", + "The patient did not require vasoactive drugs.", + "The patient was anuric.", + "The patient was not icteric.", + "The patient did not have any pathological signs on the skin.", + "Blood cultures were drawn.", + "An antibiotic was given based on a body temperature of 38.9°C.", + "An antibiotic was given based on tachycardia.", + "The patient was started at 4 g piperacillin-tazobactam 3 times per day intravenously.", + "The cultures did not show any bacterial growth.", + "Because the patient had elevated serum potassium of 5.8 mmol × L-1, blood was analysed for serum cortisol.", + "Because the patient had hyponatraemia of 131 mmol × L-1, blood was analysed for serum cortisol.", + "The suspicion was Addison’s disease.", + "The patient was given 100 mg hydrocortisone intravenously.", + "Serum cortisol was found to be 796 nmol × L-1.", + "The suspicion of Addison’s disease was refuted.", + "The patient was anaemic with a haemoglobin of 86 g × L-1.", + "The patient was thrombocytopenic with a platelet count of 31 × 109 × L-1.", + "Lactate dehydrogenase was elevated to 21.5 μkat × L-1.", + "Haptoglobin was low at 0.07 g × L-1.", + "The blood film showed schistocytosis.", + "On the third postoperative day, plasmapheresis was started on the indication of HUS/TTP.", + "One plasma volume was replaced daily for four days.", + "Continuous veno-venous haemodiafiltration was performed between plasmapheresis treatments.", + "The patient’s haemoglobin and platelet count improved during treatment.", + "The same positive development was seen for creatinine.", + "Neurological status improved slowly.", + "On the seventh postoperative day, GCS was 6 with withdrawal of the limbs on pain stimulation.", + "Polymerase chain reaction (PCR) revealed enterohaemorrhagic E. coli (EHEC) in faeces.", + "The EHEC serotype was non-O157.", + "The EHEC produced verotoxin type 2.", + "The EHEC was eae-gene negative.", + "Blood analysis of Adamts-13 protein activity showed normal levels.", + "Antibodies against the Adamts-13 protein were not observed.", + "Signs of multiple small ischaemic fronto-temporal cortical lesions were noted on an MRI scan.", + "Signs of lesions in the circulus Willisi and the basilar artery with narrowing and more distal dilatations of the vessels were noted on an MRI scan.", + "Analyses of anti-neutrophil antibodies were negative.", + "Analyses of anti-neutrophil cytoplasmic antibodies were negative.", + "The neurological consult assessed the clinical picture together with the MRI findings as thrombotic microangiopathy.", + "The patient continued to show slow improvement in neurological status.", + "The patient could make eye contact on instructions on the 20th postoperative day.", + "The patient was still anuric.", + "The patient was in need of intermittent haemodialysis.", + "The patient was in need of mechanical ventilatory support.", + "On the 21st postoperative day, the patient suffered a generalised tonic-clonic seizure.", + "On the 21st postoperative day, the patient went into deep coma (GCS 3).", + "EEG showed generalised deeply suppressed activity.", + "A joint decision was made with the next of kin to withdraw all treatment.", + "The patient died 6 h later." + ], + "summary": "We present a case in which a 67-year-old Caucasian female developed fatal haemolytic uremic syndrome in the immediate postoperative period of uncomplicated day care surgery. The patient had suffered gastrointestinal symptoms followed by confusion approximately two weeks before surgery, but had been without any symptoms in the week before surgery. Haemolytic uremic syndrome with cerebral symptoms ranging from initial anxiety to subsequent seizures and coma developed within a few hours after the end of surgery. In addition, acute kidney failure and severe thrombocytopenia occurred about the same time. During intensive care, the patient was found to be positive for enterohaemorrhagic E. coli (EHEC) in faeces.", + "summary_subclaims": [ + "A 67-year-old Caucasian female developed fatal haemolytic uremic syndrome in the immediate postoperative period of uncomplicated day care surgery.", + "The patient had suffered gastrointestinal symptoms followed by confusion approximately two weeks before surgery.", + "The patient had been without any symptoms in the week before surgery.", + "Haemolytic uremic syndrome with cerebral symptoms ranging from initial anxiety to subsequent seizures and coma developed within a few hours after the end of surgery.", + "Acute kidney failure and severe thrombocytopenia occurred about the same time.", + "During intensive care, the patient was found to be positive for enterohaemorrhagic E. coli (EHEC) in faeces." + ] + }, + { + "id": "multiclinsum_test_161_en.txt", + "fulltext": "A 19-year-old woman noticed blurred vision with photopsia of the left eye. The patient had no notable medical or family history. Her best-corrected visual acuity (BCVA) was 1.0 OD and 0.9 OS with myopia of −9.0 diopters OU. Visual examination of the right eye showed no abnormality. Slit-lamp biomicroscopy revealed mild cells in the anterior vitreous OS. Funduscopic examination revealed multiple punctate yellow-white exudates at the level of the retinal pigment epithelium (RPE) in the posterior pole but not the midperiphery OS (Figure A). These exudates appeared as initial hyperfluorescence with late staining on fluorescein angiography (FA, Figure B) and hypofluorescence during the initial phase of ICGA (Figure C). SD-OCT images showed a loss of photoreceptor inner/outer segment junction (IS/OS) integrity corresponding to the nasal fovea (Figure D), accompanied by a moderately reflective, nodule-like lesion extending from the outer nuclear layer to the choroid, which corresponded to the exudates described above (Figure E). Humphrey threshold 30–2 perimetry showed an area of decreased sensitivity corresponding to the lesion area. Multifocal electroretinography (mfERG) showed decreased amplitudes at the posterior pole wider than the lesion area OS and normal amplitudes OD. The patient received a diagnosis of PIC OS. A regimen of oral prednisolone (30 mg/day) was initiated then gradually tapered for 4 months. Three months after treatment, BCVA increased to 1.2 OS. The areas of exudate scarred as IS/OS line integrity recovered. Twelve months after treatment, some of the scar lesions developed hyperpigmentation (Figure F), whereas BCVA and OCT findings remained stable.Twenty months after the initial visit, the patient complained again of central blurred vision in the left eye. Her BCVA was 1.2 OS. A punctate subretinal yellowish-white lesion nasal to the fovea OS (Figure A, F) appeared to have increased in size (Figure A, arrow), although the number of PIC lesions remained unchanged. The area of hyperfluorescence on late-phase FA (Figure B, arrow) or hypofluorescence on initial-phase ICGA (Figure C, arrow) corresponding to the lesion had expanded since the patient’s initial visit (Figure B, C). The patient was diagnosed with recurrent PIC. Treatment with oral prednisolone (30 mg/day) was restarted and continued for 3 months with tapering. Three months after this second round of treatment, BCVA remained unchanged, and the recurrent lesion had scarred with an associated improvement of the patient’s subjective symptoms.", + "fulltext_subclaims": [ + "The patient is a 19-year-old woman.", + "The patient noticed blurred vision with photopsia of the left eye.", + "The patient had no notable medical or family history.", + "Her best-corrected visual acuity (BCVA) was 1.0 OD.", + "Her best-corrected visual acuity (BCVA) was 0.9 OS.", + "She had myopia of −9.0 diopters OU.", + "Visual examination of the right eye showed no abnormality.", + "Slit-lamp biomicroscopy revealed mild cells in the anterior vitreous OS.", + "Funduscopic examination revealed multiple punctate yellow-white exudates at the level of the retinal pigment epithelium (RPE) in the posterior pole OS.", + "These exudates appeared as initial hyperfluorescence with late staining on fluorescein angiography (FA).", + "These exudates appeared as hypofluorescence during the initial phase of ICGA.", + "SD-OCT images showed a loss of photoreceptor inner/outer segment junction (IS/OS) integrity corresponding to the nasal fovea.", + "Humphrey threshold 30–2 perimetry showed an area of decreased sensitivity corresponding to the lesion area.", + "Multifocal electroretinography (mfERG) showed decreased amplitudes at the posterior pole wider than the lesion area OS.", + "Multifocal electroretinography (mfERG) showed normal amplitudes OD.", + "The patient received a diagnosis of PIC OS.", + "A regimen of oral prednisolone (30 mg/day) was initiated.", + "The regimen was gradually tapered for 4 months.", + "Three months after treatment, BCVA increased to 1.2 OS.", + "The areas of exudate scarred as IS/OS line integrity recovered.", + "Twelve months after treatment, some of the scar lesions developed hyperpigmentation.", + "Twenty months after the initial visit, the patient complained again of central blurred vision in the left eye.", + "Her BCVA was 1.2 OS.", + "A punctate subretinal yellowish-white lesion nasal to the fovea OS appeared to have increased in size.", + "The area of hyperfluorescence on late-phase FA corresponding to the lesion had expanded since the patient’s initial visit.", + "The area of hypofluorescence on initial-phase ICGA corresponding to the lesion had expanded since the patient’s initial visit.", + "The patient was diagnosed with recurrent PIC.", + "Treatment with oral prednisolone (30 mg/day) was restarted.", + "Treatment was continued for 3 months with tapering.", + "Three months after this second round of treatment, BCVA remained unchanged.", + "The recurrent lesion had scarred." + ], + "summary": "This PIC patient was initially treated with systemic corticosteroids for 4 months. LSFG measurements were taken 10 consecutive times before treatment and at 1, 3, 12, 20 and 23 months after the initiation of therapy. The mean blur rate (MBR), a quantitative index of relative blood flow velocity, was calculated using LSFG in three regions: Circles 1, 2 and 3 were set at the fovea, a lesion site, and an area of normal-appearing retina, respectively.The PIC lesions scarred after treatment along with improvements in visual function and outer retinal morphology. When the changing rate of macular flow over the 12-month follow-up period was compared with the MBR before treatment (100%), an increase of 16-37%, 24-49% and 15-18% was detected in Circles 1, 2 and 3, respectively. At the time of PIC recurrence after 20 months, the MBR decreased temporarily but subsequently increased after retreatment with systemic corticosteroids. This trend was accompanied by a decrease in choroidal thickness at the lesion site after retreatment.", + "summary_subclaims": [ + "This PIC patient was initially treated with systemic corticosteroids for 4 months.", + "LSFG measurements were taken 10 consecutive times before treatment and at 1, 3, 12, 20 and 23 months after the initiation of therapy.", + "The mean blur rate (MBR), a quantitative index of relative blood flow velocity, was calculated using LSFG in three regions.", + "Circles 1, 2 and 3 were set at the fovea, a lesion site, and an area of normal-appearing retina, respectively.", + "The PIC lesions scarred after treatment along with improvements in visual function and outer retinal morphology.", + "When the changing rate of macular flow over the 12-month follow-up period was compared with the MBR before treatment (100%), an increase of 16-37%, 24-49% and 15-18% was detected in Circles 1, 2 and 3, respectively.", + "At the time of PIC recurrence after 20 months, the MBR decreased temporarily but subsequently increased after retreatment with systemic corticosteroids.", + "This trend was accompanied by a decrease in choroidal thickness at the lesion site after retreatment." + ] + }, + { + "id": "multiclinsum_test_3152_en.txt", + "fulltext": "A 52-year-old woman was admitted with acute myocardial infarction due to a spontaneous right coronary artery dissection. Her medical history was notable for a conservatively managed left posterolateral branch myocardial infarction at the age of 39 with normal left ventricular (LV) function. At 51, she was treated for breast cancer with a curative intent.\n\nAt presentation, an emergency percutaneous coronary intervention of the right coronary artery was performed. The post-procedural course was complicated by ventricular tachycardia (VT) and fibrillation for which she was successfully resuscitated. During the following hours she developed cardiogenic shock due to failure of the right ventricle (RV) that was refractory to fluid resuscitation and inotropes. She was transferred to the intensive care unit of a tertiary heart failure referral centre and was stabilized using peripheral veno-arterial (VA) extracorporeal membrane oxygenation (ECMO). Echocardiography showed a dilated RV with severely impaired function, paradoxical septal motion with signs of RV volume overload and severe tricuspid regurgitation with elevated filling pressures. The LV function was slightly impaired.\n\nShe developed heparin-induced thrombocytopaenia (HIT) and was rejected for an urgent heart transplant listing due to the recent oncological history. The VA-ECMO was exchanged for percutaneous veno-pulmonary ECMO in order to allow for recovery of the RV. Five weeks after the start, weaning was initially successful.\n\nHowever, within days after discontinuation of the ECMO, she developed fast recurrent VTs that were haemodynamically poorly tolerated and resulted in hypotension and elevated lactate levels. Intravenous administration of amiodarone resulted in further progression of RV failure due to the negative inotropic effects and the development of a slow junctional rhythm that was poorly tolerated haemodynamically, limiting further pharmacological options.\n\nEscalation in the inotropic regimen in the days after ECMO weaning further contributed to the incessant VTs and resulted in a persistent decrease of organ perfusion (INTERMACS profile 2).\n\nAfter careful consideration and discussion with the electrophysiology team, an ablation procedure was deferred due to the proposed haemodynamic triggers of the VTs and the estimated low chance of a curative procedure. Invasive haemodynamic evaluation revealed a cardiac output of 3.05 L/min (CI 1.61 L/minute/m2) and low pulmonary pressures (mean pulmonary arterial pressure 9 mmHg, pulmonary vascular resistance 1.9 WU).\n\nBecause of persistent inotropic dependency and recurrent VTs in the setting of progressive RV failure, VA-ECMO was re-initiated, and both a right ventricular assist device (RVAD) and a bidirectional cavopulmonary anastomosis (BCPA) with TV repair were explored. In a BCPA, the superior vena cava (SVC) is disconnected from the right atrium and anastomosed end-to-side to the right pulmonary artery, redirecting a substantial proportion of the venous return directly to the lungs, bypassing the RV. Due to the recent HIT and the chance of recovery of RV function in the near future, a decision was made to perform a BCPA with a concomitant TV annuloplasty.\n\nTwo months after her initial presentation, the patient underwent BCPA and restrictive TV annuloplasty. She had an arterial oxygen saturation of 95% in ambient air and could be weaned off VA-ECMO and inotropes within 3 weeks after the operation. Echocardiography showed normalization of RV dimensions, moderate to severely impaired RV function and trivial TV regurgitation.\n\nBecause there was an indication for an implantable cardioverter-defibrillator (ICD) (secondary prevention), a subcutaneous ICD (S-ICD) seemed most appropriate because the BCPA now limited transvenous lead access. However, due to a sternal wound infection, implanting the device was postponed. One month after surgery, she was discharged home with guideline-dictated medical therapy and a LifeVest Wearable Defibrillator (Zoll Medical Corporation, Chelmsford, MA, USA) as a bridge to an S-ICD. The peripheral oxygen saturation at discharge was 99%, and she subsequently completed a cardiac rehabilitation program. Her New York Heart Association functional class IV improved to III (INTERMACS profile 2 to 7) at the 6-month follow-up examination, and there have not been any heart failure-related admissions.", + "fulltext_subclaims": [ + "The patient was a 52-year-old woman.", + "She was admitted with acute myocardial infarction due to a spontaneous right coronary artery dissection.", + "Her medical history included a conservatively managed left posterolateral branch myocardial infarction at the age of 39.", + "At 51, she was treated for breast cancer with a curative intent.", + "An emergency percutaneous coronary intervention of the right coronary artery was performed.", + "The post-procedural course was complicated by ventricular tachycardia and fibrillation.", + "She was successfully resuscitated.", + "She developed cardiogenic shock due to failure of the right ventricle.", + "The cardiogenic shock was refractory to fluid resuscitation and inotropes.", + "She was stabilized using peripheral veno-arterial extracorporeal membrane oxygenation.", + "Echocardiography showed a dilated right ventricle with severely impaired function.", + "Echocardiography showed paradoxical septal motion with signs of right ventricular volume overload.", + "Echocardiography showed severe tricuspid regurgitation with elevated filling pressures.", + "The left ventricular function was slightly impaired.", + "She developed heparin-induced thrombocytopaenia.", + "She was rejected for an urgent heart transplant listing due to the recent oncological history.", + "The veno-arterial extracorporeal membrane oxygenation was exchanged for percutaneous veno-pulmonary extracorporeal membrane oxygenation.", + "Weaning from extracorporeal membrane oxygenation was initially successful.", + "Within days after discontinuation of the extracorporeal membrane oxygenation, she developed fast recurrent ventricular tachycardias.", + "The ventricular tachycardias were haemodynamically poorly tolerated.", + "Intravenous administration of amiodarone resulted in further progression of right ventricular failure.", + "Amiodarone caused a slow junctional rhythm that was poorly tolerated haemodynamically.", + "Escalation in the inotropic regimen in the days after extracorporeal membrane oxygenation weaning further contributed to the incessant ventricular tachycardias.", + "A decision was made to perform a bidirectional cavopulmonary anastomosis with a concomitant tricuspid valve annuloplasty.", + "In a bidirectional cavopulmonary anastomosis, the superior vena cava is disconnected from the right atrium and anastomosed end-to-side to the right pulmonary artery.", + "The bidirectional cavopulmonary anastomosis redirects a substantial proportion of the venous return directly to the lungs, bypassing the right ventricle.", + "The patient underwent bidirectional cavopulmonary anastomosis and restrictive tricuspid valve annuloplasty.", + "She had an arterial oxygen saturation of 95% in ambient air.", + "She could be weaned off veno-arterial extracorporeal membrane oxygenation and inotropes within 3 weeks after the operation.", + "Echocardiography showed normalization of right ventricular dimensions.", + "Echocardiography showed moderate to severely impaired right ventricular function.", + "Echocardiography showed trivial tricuspid valve regurgitation.", + "A subcutaneous implantable cardioverter-defibrillator seemed most appropriate.", + "Implanting the subcutaneous implantable cardioverter-defibrillator was postponed due to a sternal wound infection.", + "She was discharged home with a LifeVest Wearable Defibrillator.", + "The peripheral oxygen saturation at discharge was 99%.", + "She completed a cardiac rehabilitation program.", + "Her New York Heart Association functional class IV improved to III at the 6-month follow-up examination.", + "There have not been any heart failure-related admissions." + ], + "summary": "We present the case of a 52-year-old woman with cardiogenic shock and refractory right ventricular failure due to spontaneous dissection of the right coronary artery. She remained dependent on mechanical support for several weeks. Both a right ventricular assist device implant and a bidirectional cavopulmonary anastomosis were explored as long-term support options. A history of malignancy and possible right ventricular functional recovery resulted in a decision in favour of the bidirectional cavopulmonary anastomosis and concomitant tricuspid valve annuloplasty. Postoperatively her clinical condition improved significantly, and she could be discharged home. Echocardiography showed normalization of right ventricular dimensions and slight improvement of right ventricular function.", + "summary_subclaims": [ + "The patient is a 52-year-old woman.", + "She had cardiogenic shock.", + "She had refractory right ventricular failure.", + "The cause was spontaneous dissection of the right coronary artery.", + "She remained dependent on mechanical support for several weeks.", + "A right ventricular assist device implant was explored as a long-term support option.", + "A bidirectional cavopulmonary anastomosis was explored as a long-term support option.", + "A history of malignancy was present.", + "Possible right ventricular functional recovery was considered.", + "A decision in favour of the bidirectional cavopulmonary anastomosis was made.", + "A concomitant tricuspid valve annuloplasty was performed.", + "Postoperatively, her clinical condition improved significantly.", + "She could be discharged home.", + "Echocardiography showed normalization of right ventricular dimensions.", + "Echocardiography showed slight improvement of right ventricular function." + ] + }, + { + "id": "multiclinsum_test_2503_en.txt", + "fulltext": "A 53-year-old previously healthy woman was diagnosed with a calvarial lesion on a brain checkup and was referred to the hospital. She had not undergone cranial radiotherapy in her life. Cerebral magnetic resonance imaging (MRI) revealed an intradiploic tumor in the right parietal bone protruding into the cranial cavity. It was a lobular mass 11 × 14 × 12 mm, presented isointensity on T1- and hyperintensity on T2-weighted sequences, and was inhomogeneously enhanced with intense enhancement of the surrounding dura mater. The inner table and dura underlying the tumor appeared intact. There was no identifiable peritumoral brain edema . On computed tomography (CT), the tumor was accompanied by a well-demarcated calvarial erosion at the site of the tumor, extending more predominantly into the inner side compared to the outer side. In addition, sclerotic changes were observed in the surrounding bone . The patient was requested to undergo a tumor resection. Intraoperatively, the tumor was reflected with the surrounding bone that presented sclerotic changes and removed en bloc. The inner table compressed by the tumor was partially defective and the underlying dura mater was erosive, which was circumferentially resected and replaced by an artificial substitute . Eventually, a Simpson Grade I resection was achieved. Adhesions between the tumor and surrounding dura mater were not found in the intact underlying cerebral cortex. Microscopically, the tumor comprised cells with oval-shaped nuclei and intervening vasculature of varying sizes. There were a few mitotic figures. Immunohistochemical examination showed positive staining for epithelial membrane antigen and progesterone receptor but negative staining for CD34. These findings are consistent with those of angiomatous meningiomas. In addition, tumor invasion into the adjacent bone and dura mater was observed . At present, the patient is planning to undergo periodic MRI surveillance in every 6 months.", + "fulltext_subclaims": [ + "A 53-year-old previously healthy woman was diagnosed with a calvarial lesion on a brain checkup.", + "She had not undergone cranial radiotherapy in her life.", + "Cerebral MRI revealed an intradiploic tumor in the right parietal bone protruding into the cranial cavity.", + "The tumor was a lobular mass 11 × 14 × 12 mm.", + "The tumor was isointense on T1-weighted sequences.", + "The tumor was hyperintense on T2-weighted sequences.", + "The tumor was inhomogeneously enhanced.", + "The surrounding dura mater showed intense enhancement.", + "The inner table and dura underlying the tumor appeared intact.", + "There was no identifiable peritumoral brain edema.", + "CT showed a well-demarcated calvarial erosion at the site of the tumor.", + "The calvarial erosion extended more predominantly into the inner side compared to the outer side.", + "Sclerotic changes were observed in the surrounding bone.", + "The patient was requested to undergo a tumor resection.", + "Intraoperatively, the tumor was reflected with the surrounding bone that presented sclerotic changes.", + "The tumor was removed en bloc.", + "The inner table compressed by the tumor was partially defective.", + "The underlying dura mater was erosive.", + "The erosive dura mater was circumferentially resected and replaced by an artificial substitute.", + "A Simpson Grade I resection was achieved.", + "Adhesions between the tumor and surrounding dura mater were not found in the intact underlying cerebral cortex.", + "Microscopically, the tumor comprised cells with oval-shaped nuclei.", + "The tumor had intervening vasculature of varying sizes.", + "There were a few mitotic figures.", + "Immunohistochemical examination showed positive staining for epithelial membrane antigen.", + "Immunohistochemical examination showed positive staining for progesterone receptor.", + "Immunohistochemical examination showed negative staining for CD34.", + "These findings are consistent with those of angiomatous meningiomas.", + "Tumor invasion into the adjacent bone was observed.", + "Tumor invasion into the adjacent dura mater was observed.", + "The patient is planning to undergo periodic MRI surveillance in every 6 months." + ], + "summary": "A 53-year-old previously healthy woman was diagnosed with a calvarial lesion during a brain checkup. Cerebral magnetic resonance imaging showed an intradiploic tumor, 11 × 14 × 12 mm, in the right parietal bone. It was an enhancing, lobular tumor presenting as isointensity on T1- and hyperintensity on T2-weighted sequences, with an intense enhancement of the adjacent dura mater. Computed tomography revealed bone erosion at the tumor site, extending predominantly into the inner side, and sclerotic changes in the surrounding bone. Total resection was performed. Microscopically, the tumor tissue comprised cells with low-grade meningioma and intervening prominent vasculatures, consistent with angiomatous meningioma.", + "summary_subclaims": [ + "The patient is a 53-year-old previously healthy woman.", + "The patient was diagnosed with a calvarial lesion during a brain checkup.", + "Cerebral magnetic resonance imaging showed an intradiploic tumor, 11 × 14 × 12 mm, in the right parietal bone.", + "The tumor was an enhancing, lobular tumor.", + "The tumor presented as isointensity on T1-weighted sequences.", + "The tumor presented as hyperintensity on T2-weighted sequences.", + "There was an intense enhancement of the adjacent dura mater.", + "Computed tomography revealed bone erosion at the tumor site.", + "The bone erosion extended predominantly into the inner side.", + "Sclerotic changes were present in the surrounding bone.", + "Total resection was performed.", + "Microscopically, the tumor tissue comprised cells with low-grade meningioma.", + "The tumor tissue showed intervening prominent vasculatures.", + "The tumor was consistent with angiomatous meningioma." + ] + }, + { + "id": "multiclinsum_test_872_en.txt", + "fulltext": "A 22-year-old woman, G3P1, was admitted in August 2021 after being referred from a local hospital for amenorrhea of 23 weeks and 5 days duration.\nBefore referral, an ultrasound scan in the seventh week of her pregnancy showed she had a congenital uterine malformation suspicious of a bicornuate uterus. The scan also revealed an intrauterine pregnancy in one cavity, a live embryo, a small amount of fluid around the pregnancy sac, and what appeared to be some fluid in the other uterus. Her previous pregnancy, five years earlier, culminated in an emergency cesarean section for intrauterine fetal distress. She claimed to have a bicornuate uterus.\nAfter admission, an ultrasound scan showed a live fetus in the abdominal cavity with the placenta on the right side of the abdominal cavity instead of in the endometrium. We diagnosed the woman with a case of abdominal pregnancy.\nIn September 2021, during the 29th week of her pregnancy, the patient experienced intermittent abdominal pain for 3 h. Magnetic resonance imaging (MRI) revealed an abdominal pregnancy and rupture of the fetal membranes. We performed an emergency laparotomy and found part of the omentum adherent to the anterior abdominal wall and a live fetus of the same gestational age on the left side of the abdominal cavity.\nDuring the surgery, we performed procedures such as transurethral ureteroscopy, double J-stent placement, transabdominal fetal removal, placentectomy , right uterine cornual repair, and pelvic adhesiolysis. We found that the amniotic membrane had ruptured, but there were no clear ascites or amniotic fluid in the abdominal and pelvic cavities. In the right pelvic cavity, an amniotic sac covered the placenta, which was attached to the right uterine horn. The placental implantation site was approximately 2 cm × 3 cm, the placental size was approximately 15 cm × 10 cm, and the fetal membrane was wrapped around it. The uterus was enlarged, equivalent to the size of a 60-day gestation, soft, and showed no abnormalities in the appearance of the bilateral appendages. The right fallopian tube and the ovarian ligament were approximately 1 cm from the implantation site. We separated the adhesions between the omentum and the anterior abdominal wall, carefully explored the pelvic and abdominal cavities, and found the placenta implanted in the right uterine horn with no evidence of pelvic, abdominal organ, or large vessel involvement.\nWe delivered a live male infant in the left sacro-anterior position (LSA) weighing 1200 g, with a body length of 38 cm and a head circumference of 27 cm. The APGAR scores at 1 min and 5 min after birth were 10 and 10, respectively. The placenta weighed approximately 500 g.\nThe placenta was attached to the right uterine horn, and the left uterine horn was normal. The fetus and placenta entered the abdominal cavity by rupturing the right uterine horn. The placenta was attached to the right uterine horn, sealing the rupture. The surgeon repaired the right uterine horn after delivering the placenta.\nThe patient had an uneventful recovery and was discharged eight days after surgery. The discharge diagnosis was rudimentary uterine horn pregnancy and secondary abdominal pregnancy. Immediately after birth, the newborn was transferred to the Neonatal Intensive Care Unit (NICU) for further management. He was diagnosed with bronchopulmonary dysplasia, neonatal respiratory distress syndrome, intrauterine infectious pneumonia, premature encephalopathy, jaundice of premature infants, anemia of premature infants (moderate), sclerema neonatorum (mild), hyperthermia, and fetal growth restriction. He also had hypoalbuminemia, hyperkalemia, and vitamin D deficiency. Eventually, he was discharged from the hospital after 41 days of NICU management. A follow-up was scheduled for this patient, but she did not have regular follow-up.", + "fulltext_subclaims": [ + "The patient is a 22-year-old woman, G3P1.", + "She was admitted in August 2021.", + "She was referred from a local hospital.", + "She had amenorrhea of 23 weeks and 5 days duration.", + "An ultrasound scan in the seventh week of her pregnancy showed a congenital uterine malformation suspicious of a bicornuate uterus.", + "The scan also revealed an intrauterine pregnancy in one cavity.", + "The scan showed a live embryo.", + "The scan showed a small amount of fluid around the pregnancy sac.", + "The scan showed some fluid in the other uterus.", + "Her previous pregnancy, five years earlier, culminated in an emergency cesarean section for intrauterine fetal distress.", + "She claimed to have a bicornuate uterus.", + "After admission, an ultrasound scan showed a live fetus in the abdominal cavity.", + "The placenta was on the right side of the abdominal cavity instead of in the endometrium.", + "We diagnosed the woman with a case of abdominal pregnancy.", + "In September 2021, during the 29th week of her pregnancy, the patient experienced intermittent abdominal pain for 3 h.", + "MRI revealed an abdominal pregnancy.", + "MRI revealed rupture of the fetal membranes.", + "We performed an emergency laparotomy.", + "We found part of the omentum adherent to the anterior abdominal wall.", + "We found a live fetus of the same gestational age on the left side of the abdominal cavity.", + "During the surgery, we performed transurethral ureteroscopy.", + "During the surgery, we performed double J-stent placement.", + "During the surgery, we performed transabdominal fetal removal.", + "During the surgery, we performed placentectomy.", + "During the surgery, we performed right uterine cornual repair.", + "During the surgery, we performed pelvic adhesiolysis.", + "We found that the amniotic membrane had ruptured.", + "There were no clear ascites or amniotic fluid in the abdominal and pelvic cavities.", + "In the right pelvic cavity, an amniotic sac covered the placenta.", + "The placenta was attached to the right uterine horn.", + "The placental implantation site was approximately 2 cm × 3 cm.", + "The placental size was approximately 15 cm × 10 cm.", + "The fetal membrane was wrapped around the placenta.", + "The uterus was enlarged, equivalent to the size of a 60-day gestation.", + "The uterus was soft.", + "There were no abnormalities in the appearance of the bilateral appendages.", + "The right fallopian tube and the ovarian ligament were approximately 1 cm from the implantation site.", + "We separated the adhesions between the omentum and the anterior abdominal wall.", + "We carefully explored the pelvic and abdominal cavities.", + "We found the placenta implanted in the right uterine horn.", + "There was no evidence of pelvic, abdominal organ, or large vessel involvement.", + "We delivered a live male infant in the left sacro-anterior position (LSA).", + "The infant weighed 1200 g.", + "The infant's body length was 38 cm.", + "The infant's head circumference was 27 cm.", + "The APGAR score at 1 min after birth was 10.", + "The APGAR score at 5 min after birth was 10.", + "The placenta weighed approximately 500 g.", + "The placenta was attached to the right uterine horn.", + "The left uterine horn was normal.", + "The fetus and placenta entered the abdominal cavity by rupturing the right uterine horn.", + "The placenta was attached to the right uterine horn, sealing the rupture.", + "The surgeon repaired the right uterine horn after delivering the placenta.", + "The patient had an uneventful recovery.", + "The patient was discharged eight days after surgery.", + "The discharge diagnosis was rudimentary uterine horn pregnancy.", + "The discharge diagnosis was secondary abdominal pregnancy.", + "The newborn was transferred to the Neonatal Intensive Care Unit (NICU) immediately after birth.", + "The newborn was diagnosed with bronchopulmonary dysplasia.", + "The newborn was diagnosed with neonatal respiratory distress syndrome.", + "The newborn was diagnosed with intrauterine infectious pneumonia.", + "The newborn was diagnosed with premature encephalopathy.", + "The newborn was diagnosed with jaundice of premature infants.", + "The newborn was diagnosed with anemia of premature infants (moderate).", + "The newborn was diagnosed with sclerema neonatorum (mild).", + "The newborn was diagnosed with hyperthermia.", + "The newborn was diagnosed with fetal growth restriction.", + "The newborn had hypoalbuminemia.", + "The newborn had hyperkalemia.", + "The newborn had vitamin D deficiency.", + "The newborn was discharged from the hospital after 41 days of NICU management.", + "A follow-up was scheduled for the patient.", + "She did not have regular follow-up." + ], + "summary": "We present a case of intraperitoneal ectopic pregnancy with fetal survival. Ultrasound and magnetic resonance imaging showed a right cornual pregnancy with a secondary abdominal pregnancy. In September 2021, we performed an emergency laparotomy, along with additional procedures such as transurethral ureteroscopy, double J-stent placement, abdominal fetal removal, placentectomy, repair of the right uterine horn, and pelvic adhesiolysis, in the 29th week of pregnancy. During laparotomy, we diagnosed abdominal pregnancy secondary to a rudimentary uterine horn. The mother and her baby were discharged eight days and 41 days, respectively, after surgery.", + "summary_subclaims": [ + "We present a case of intraperitoneal ectopic pregnancy with fetal survival.", + "Ultrasound and magnetic resonance imaging showed a right cornual pregnancy with a secondary abdominal pregnancy.", + "In September 2021, we performed an emergency laparotomy.", + "We performed transurethral ureteroscopy during the procedure.", + "We performed double J-stent placement during the procedure.", + "We performed abdominal fetal removal during the procedure.", + "We performed placentectomy during the procedure.", + "We performed repair of the right uterine horn during the procedure.", + "We performed pelvic adhesiolysis during the procedure.", + "The procedures were performed in the 29th week of pregnancy.", + "During laparotomy, we diagnosed abdominal pregnancy secondary to a rudimentary uterine horn.", + "The mother was discharged eight days after surgery.", + "The baby was discharged 41 days after surgery." + ] + }, + { + "id": "multiclinsum_test_1675_en.txt", + "fulltext": "A 29 year-old female, non-smoker, who was diagnosed with Polycystic Ovarian Disease (PCOD) presented with a history of cough and fever for 25 days. She had delivered a baby 4 months back after hormonal treatment. On examination she was obese with significant hirsuitism, and had bilateral corneal congestion. Ophthalmologic evaluation did not reveal uveitis. The lab tests including complete blood picture, renal and liver functions and autoimmune profile were within normal limits. The chest X-ray and HRCT showed bilateral nodular infiltrates, for which she underwent CT-guided biopsy. Histopathology of the lung showed non-caseating granuloma . The serum ACE level was 110 U/L. She was started on steroids with remarkable clinical and radiological improvement on subsequent clinic visits.", + "fulltext_subclaims": [ + "The patient is a 29 year-old female.", + "She is a non-smoker.", + "She was diagnosed with Polycystic Ovarian Disease.", + "She had a history of cough and fever for 25 days.", + "She had delivered a baby 4 months back after hormonal treatment.", + "On examination, she was obese.", + "She had significant hirsuitism.", + "She had bilateral corneal congestion.", + "Ophthalmologic evaluation did not reveal uveitis.", + "The lab tests including complete blood picture, renal and liver functions and autoimmune profile were within normal limits.", + "The chest X-ray showed bilateral nodular infiltrates.", + "The HRCT showed bilateral nodular infiltrates.", + "She underwent CT-guided biopsy.", + "Histopathology of the lung showed non-caseating granuloma.", + "The serum ACE level was 110 U/L.", + "She was started on steroids.", + "She had remarkable clinical and radiological improvement on subsequent clinic visits." + ], + "summary": "We report three cases of nodular sarcoidosis in young females of Asian origin who had initially presented with dry cough and worsening dyspnea non-responsive to initially administered antibiotics. Pulmonary nodules were discovered upon radiographic imaging in all three cases which raised concern for the possibility of neoplastic processes. Subsequent biopsies revealed granulomatous inflammation indicative of sarcoidosis. All cases responded very well to systemic corticosteroids.", + "summary_subclaims": [ + "We report three cases of nodular sarcoidosis in young females of Asian origin.", + "All three patients had initially presented with dry cough and worsening dyspnea.", + "The dyspnea was non-responsive to initially administered antibiotics.", + "Pulmonary nodules were discovered upon radiographic imaging in all three cases.", + "The pulmonary nodules raised concern for the possibility of neoplastic processes.", + "Subsequent biopsies revealed granulomatous inflammation indicative of sarcoidosis.", + "All cases responded very well to systemic corticosteroids." + ] + }, + { + "id": "multiclinsum_test_453_en.txt", + "fulltext": "The patient was a 70-year-old male with a history of glaucoma. There was no outstanding family medical history. He was diagnosed with esophageal cancer 3 years earlier, and had undergone surgical resection and chemotherapy. Best supportive care was initiated 1 year earlier. From 1 month before the last hospitalization, the patient had been in the terminal stage of cancer with an Eastern Cooperative Oncology Group performance status of 3 and decreased activities. At that point, he was told he had 1–2 months to live. Around the same time, the left supraclavicular lymph node was becoming progressively enlarged. Consequently, the patient developed repetitive syncope episodes lasting 2–3 min for which hospitalization was necessary.\nA single mass of 120 mm × 90 mm was detected in the supraclavicular area on palpation . No outstanding findings were detected with cardiac ultrasonography or cerebral magnetic resonance imaging. No blood biochemistry findings suggestive of anemia, dehydration, hypoglycemia, electrolyte abnormalities or thyroid disorder were observed.\nAfter admission, ADL decreased and the patient became bedridden because of his anticipatory anxiety for syncope onset. Subsequently, syncope episodes disappeared; however, the patients complained of prodromal symptoms such as dizziness, nausea, and ocular pain. These symptoms persisted for 20–30 min, spontaneously disappeared, and recurred three to four -times daily. When prodromal symptoms occurred, the heart rate ranged between 20 and 30 bpm and systolic blood pressure decreased by 50 mmHg. Holter electrocardiography performed on the day after admission revealed stable blood pressure and heart rate as long as no syncope occurred. During a syncope episode, however, abrupt bradycardia persisted for 1–2 min, initially with a non-sinus rate, then returning to a sinus rate . This cycle recurred five to six -times in 20–30 min. During this period, arrest for more than 2 s was frequently observed, and the recovery time in the sinus node was within 5 s. One of the factors contributing to the prodromal symptoms was cervical rotation toward the tumor side. Although the head-up tilt test could not be performed owing to the patient’s poor health condition, postural change with angles between 0° and 80° were performed using a motorized bed. The postural changes did not induce prodromal symptoms or changes in blood pressure or heart rate, which did not support a diagnosis of vasovagal syncope. Although the tilt table test with carotid sinus massage was avoided because of the patient’s poor health condition, the patient was diagnosed with a mixed-type secondary CSS based on the syncope episodes.\nThe patient understood his status well, including the poor prognosis. On admission, he expressed that he knew he might live a few weeks at best. His will was not to undergo life-prolonging treatment but to obtain symptom relief and respect for his autonomy. In particular, he wished for reduction of the severity of the prodromal symptoms and improvement of his autonomy by reducing anticipatory anxiety. He declined to receive palliative radiation therapy to the cervical tumor or implantation of a temporary or permanent pacemaker because of their invasive nature and his poor prognosis.\nPalliative radiation therapy to the cervical tumor was initially considered; however, it was not warranted based on the patient’s will and because the effects of this treatment could take some time to be reflected in the patient’s condition and because this treatment was associated with poor prognosis. Implantation of a temporary or permanent pacemaker was also initially considered; however, it was not warranted based on the patient’s will as well as the suspected vasoinhibitory-predominant mixed-type . Although treatment with α1 adrenergic agonist was initially considered, it was not warranted based on the patient’s history of swallowing disorder due to recurrent laryngeal nerve paralysis associated with the cervical tumor.\nOn the fourth day of hospitalization, the patient discovered that he could decrease the duration of prodromal symptoms by contracting the muscles in his hands and legs, by clenching his hands into fists and continuously stomping his feet on his bed while lying in it. In particular, symptoms that had previously persisted for 20–30 min were resolved in several tens of seconds by applying his coping method. When he tried to cope with the prodromal symptoms, his heart rate decreased up to 20–30 bpm; however, no change in blood pressure was observed. He hoped for improvement of his autonomy and discovered this coping method incidentally and with the support of medical staff. Based on his experience, he recognized these actions as effective coping and applied them whenever he experienced prodromal symptoms.\nBecause coping reduced the severity and duration of prodromal symptoms, the patient recognized amelioration of the prodromal symptoms. Subsequently, his anticipatory anxiety for syncope was reduced, resulting in enhanced self-efficacy. He had demonstrated improved ADL, including being able to elevate his head with the motorized bed, maintaining a sitting position and performing cervical rotation as early as 1 day after the initiation of coping. As ADL improved, the frequency of prodromal symptoms transiently increased up to seven or eight times a day during the early phase of coping. The frequency thereafter decreased and eventually the prodromal symptoms subsided after 4 days of coping. Nineteen days after admission, he developed sudden aspiration pneumonia secondary to recurrent laryngeal nerve paralysis associated with the cervical tumor and decreased awareness. He had not complained of prodromal symptoms and had maintained his ADL status for the 19 days after admission. On day 21 after admission, he died from respiratory failure.\nAs far as we know, this is the first report of a case of end-stage cancer that led to enhanced self-efficacy with self-control of prodromal symptoms of syncope associated with secondary CSS. There are two critical points in this case. First, prodromal symptoms of syncope associated with CSS were successfully self-controlled. Second, the frequency of prodromal symptoms of syncope decreased after self-control became effective.\nThe first critical point in this case was that prodromal symptoms of syncope associated with CSS were successfully self-controlled. The hypothesis that the tumor could induce depolarization in afferent and efferent nerve fibers was a possible underlying mechanism of CSS in this case of cervical tumor; however, details regarding this hypothesis have not yet been elucidated. Efferent nerve fibers involved in the carotid sinus reflex split into the cardiac vagal nerve, which is distributed to the sinus and the atrioventricular nodes. The sympathetic nerve is distributed to the ventricular myocardium and peripheral blood vessels . Depending on the abnormality of the regulating function, CSS is classified as cardio-inhibitory type when the stimulation of the vagal nerve inhibits the sinus node function or atrioventricular conduction, or a vasodepressor type when the inhibition of the synthetic nerve reduces blood pressure . In our case, we feel that the patient’s coping method, consisting of contracting the muscles in his hands and legs, induced is peripheral vasoconstriction followed by enhanced synthetic nerve function, which avoided an abrupt decrease in blood pressure. Indeed, based on the Holter electrocardiogram, we observed that an abrupt decrease in blood pressure by 50 mmHg or greater occurred within 66 s after the bradycardia emerged. In contrast, after his coping method was applied, there were no decreases in blood pressure although comparable bradycardia occurred. Based on these episodes, this patient was considered to present a vasoinhibitory-predominant mixed-type CSS. As this patient was not monitored with direct measurement of arterial pressure, no continuous blood pressure data were available. It was previously reported that blood pressure showed the lowest value 18 ± 3 s after the carotid sinus massage in a vasoinhibitory-type CSS . Similarly, blood pressure might have decreased rapidly in our patient after cervical rotation. Coping in our case was considered to have either avoided the abrupt decrease in blood pressure or contributed to rapid recovery from hypotension. Additionally, it was reported that interruption of cerebral circulation for 6–8 s or a decrease in systolic blood pressure to 60 mmHg can result in syncope . Thus, the recovery period in the sinus node might be within 5 s, thus, bradycardia alone was not considered to be a primary factor for the prodromal symptoms of syncope.\nThe second critical point from this case was that not only the severity of prodromal symptoms of syncope decreased but also the frequency of prodromal symptoms decreased gradually after self-control became effective. Although the frequency of prodromal symptoms transiently increased with improved ADL in the early phase, the symptoms had almost resolved 4 days after the initiation of coping. This amelioration was considered to be due to decreased subjective symptoms associated with increased threshold for the prodromal symptoms of syncope. It was reported that the preventive effects of pacemaker treatment against recurrence of syncope can be attributed to a placebo effect caused by pacemaker implantation . Namely, self-efficacy enhanced by self-control might contribute to a placebo effect that increased the threshold of symptoms. As for pain management, it was reported that a patient’s recognition of self-efficacy that can reduce pain enhances analgesic potency . Additionally, in an experimental study of end-stage cancer patients, the existence of stress associated with decreased ADL was observed . Coping in this case might have led to stress reduction caused by increased ADL, possibly resulting in an increased threshold of symptoms. Furthermore, tilt training was reported to prevent the recurrence of neurally mediated syncope . Coping in this case led to an increased duration of sitting due to improved ADL, which might possibly work as a preventive exercise against the recurrence of prodromal symptoms of syncope.", + "fulltext_subclaims": [ + "The patient was a 70-year-old male with a history of glaucoma.", + "There was no outstanding family medical history.", + "He was diagnosed with esophageal cancer 3 years earlier.", + "He had undergone surgical resection and chemotherapy.", + "Best supportive care was initiated 1 year earlier.", + "From 1 month before the last hospitalization, the patient had been in the terminal stage of cancer.", + "He had an Eastern Cooperative Oncology Group performance status of 3.", + "He was told he had 1–2 months to live.", + "The left supraclavicular lymph node was becoming progressively enlarged.", + "He developed repetitive syncope episodes lasting 2–3 min.", + "A single mass of 120 mm × 90 mm was detected in the supraclavicular area on palpation.", + "No outstanding findings were detected with cardiac ultrasonography.", + "No blood biochemistry findings suggestive of anemia were observed.", + "ADL decreased and the patient became bedridden because of anticipatory anxiety for syncope.", + "Syncope episodes disappeared after admission.", + "The patient complained of prodromal symptoms such as dizziness, nausea, and ocular pain.", + "These symptoms persisted for 20–30 min and recurred three to four times daily.", + "During prodromal symptoms, the heart rate ranged between 20 and 30 bpm.", + "Systolic blood pressure decreased by 50 mmHg during prodromal symptoms.", + "Holter electrocardiography revealed abrupt bradycardia during syncope episodes.", + "Arrest for more than 2 s was frequently observed during syncope episodes.", + "The patient understood his status well, including the poor prognosis.", + "He expressed that he knew he might live a few weeks at best.", + "He declined to receive palliative radiation therapy to the cervical tumor.", + "He declined implantation of a temporary or permanent pacemaker.", + "Palliative radiation therapy was not warranted based on the patient’s will.", + "Implantation of a pacemaker was not warranted based on the patient’s will.", + "The patient discovered that contracting the muscles in his hands and legs decreased the duration of prodromal symptoms.", + "Symptoms that had previously persisted for 20–30 min were resolved in several tens of seconds.", + "He recognized these actions as effective coping and applied them whenever he experienced prodromal symptoms.", + "Coping reduced the severity and duration of prodromal symptoms.", + "His anticipatory anxiety for syncope was reduced, resulting in enhanced self-efficacy.", + "He demonstrated improved ADL, including being able to elevate his head with the motorized bed.", + "The frequency of prodromal symptoms transiently increased up to seven or eight times a day during the early phase of coping.", + "The frequency of prodromal symptoms decreased and eventually subsided after 4 days of coping.", + "Nineteen days after admission, he developed sudden aspiration pneumonia.", + "He died from respiratory failure on day 21 after admission.", + "This is the first report of a case of end-stage cancer with enhanced self-efficacy through self-control of prodromal symptoms of syncope.", + "The first critical point was that prodromal symptoms of syncope associated with CSS were successfully self-controlled.", + "The hypothesis that the tumor could induce depolarization in afferent and efferent nerve fibers was a possible underlying mechanism.", + "CSS is classified as cardio-inhibitory type when vagal nerve stimulation inhibits the sinus node function.", + "CSS is classified as vasodepressor type when sympathetic nerve inhibition reduces blood pressure.", + "The patient’s coping method induced peripheral vasoconstriction followed by enhanced sympathetic nerve function.", + "An abrupt decrease in blood pressure by 50 mmHg or greater occurred within 66 s after bradycardia emerged.", + "After his coping method was applied, there were no decreases in blood pressure although comparable bradycardia occurred.", + "This patient was considered to present a vasoinhibitory-predominant mixed-type CSS.", + "The second critical point was that the frequency of prodromal symptoms decreased after self-control became effective.", + "The amelioration was considered due to decreased subjective symptoms associated with increased threshold for the prodromal symptoms.", + "Self-efficacy enhanced by self-control might contribute to a placebo effect that increased the threshold of symptoms.", + "Coping in this case might have led to stress reduction caused by increased ADL.", + "Coping in this case led to an increased duration of sitting due to improved ADL.", + "Tilt training was reported to prevent the recurrence of neurally mediated syncope." + ], + "summary": "A 70-year-old patient with end-stage esophageal cancer and enlarged supraclavicular lymph nodes developed CSS. The CSS was a mixed type with both bradycardia and decreased blood pressure, accompanied by prodromal symptoms prior to syncope episodes. The patient incidentally discovered that he could decrease the duration of symptoms by contracting the muscles in his hands and legs. By applying this coping method at the onset of prodromal symptoms, he was also able to reduce the severity and duration of symptoms, which resulted in enhanced self-efficacy. As a result, the frequency of prodromal symptoms also decreased even though ADL improved.", + "summary_subclaims": [ + "The patient is a 70-year-old man.", + "The patient has end-stage esophageal cancer.", + "The patient has enlarged supraclavicular lymph nodes.", + "The patient developed CSS.", + "The CSS was a mixed type.", + "The CSS included bradycardia.", + "The CSS included decreased blood pressure.", + "The patient had prodromal symptoms prior to syncope episodes.", + "The patient discovered that contracting muscles in his hands and legs could decrease the duration of symptoms.", + "Applying this coping method at the onset of prodromal symptoms reduced the severity and duration of symptoms.", + "This resulted in enhanced self-efficacy.", + "The frequency of prodromal symptoms decreased.", + "ADL improved." + ] + }, + { + "id": "multiclinsum_test_1283_en.txt", + "fulltext": "A 79-year-old male presented to the dermatology clinic with a new rash. He had a past medical history of chronic kidney disease stage 3, gout, and papillary and invasive urothelial carcinoma, extravesical high-grade invading into the lamina propria and muscularis propria Stage IVA (pT4b, pN0, cM0) diagnosed by transurethral resection of bladder tumor 05/2020 on pembrolizumab. Of note, his urothelial carcinoma biomarkers were programmed death-ligand 1 negative (immune cell 5%, tumor <1%), Tempus XF (liquid) = IDH1 GOF, xT = ERBB2, RB1, TP53, CDKN2A, GATA-3, MTAP, TMB 4.2 m/MB, MS-S. He was treated with neoadjuvant Gemcitabine/Cisplatin ×3 cycles complicated by sepsis. The patient underwent cystoprostatectomy 09/2020. In 07/2021, he was found to have metastasis to the rectum after sigmoidoscopy biopsies show rectal mucosa and submucosa containing rare foci of malignant cells in lymphatic spaces. GATA-3 immunostaining was positive in these cells, compatible with a spread from the patient's known urothelial primary carcinoma. Surgery was offered at this time, but the patient declined. He was then started on pembrolizumab. Recent CT and sigmoidoscopy were concerning for the progression of rectal mass. After receiving 15 cycles of pembrolizumab, the patient was started on enfortumab vedotin plus pembrolizumab. On cycle 3 day 1, he presented to dermatology with a rash of the right inguinal region for 5 weeks which was painful and pruritic. He had previously been treated with oral valacyclovir and topical clotrimazole cream with no improvement. The patient denied a history of fevers or night sweats.\nHis physical exam was notable for firm papulonodules, several of which formed confluent, hyperpigmented to violaceous plaques involving the right inguinal fold . Similar lesions also extended onto the proximal anterior thigh. A punch biopsy was performed which revealed a dermal proliferation of neoplastic cells in irregular nests with retraction artifact and focal glandular differentiation. The cells show high-grade nuclear features with background apoptosis. There was no involvement of the overlying epidermis. Immunohistochemistry revealed that the tumor cells were positive for CK20 and GATA3 and negative for CK7 . The presence of a glandular proliferation in the dermis, without overlying connection to the epidermis, and with a staining pattern consistent with the patient's known urothelial carcinoma, led to the diagnosis of cutaneous metastasis. Of note, the papillary dermis showed edema and perivascular inflammation that corroborated the clinical appearance of the rash and can be seen in metastatic lesions, adding to diagnostic challenge on clinical grounds. After confirmation of skin metastasis, the patient received one fraction of intensity-modulated radiation therapy to the right pelvis/groin. He was continued on enfortumanb vedotin plus pembrolizumab at that time. Significant decline in CA19-9 and ctDNA had stabilized. The newest CT imaging demonstrates a decrease in abdominal/pelvic lymphadenopathy with no new findings.", + "fulltext_subclaims": [ + "The patient is a 79-year-old male.", + "The patient presented to the dermatology clinic with a new rash.", + "The patient had a past medical history of chronic kidney disease stage 3.", + "The patient had a past medical history of gout.", + "The patient had a past medical history of papillary and invasive urothelial carcinoma.", + "The urothelial carcinoma was extravesical high-grade invading into the lamina propria and muscularis propria.", + "The urothelial carcinoma was Stage IVA (pT4b, pN0, cM0).", + "The urothelial carcinoma was diagnosed by transurethral resection of bladder tumor 05/2020.", + "The patient was treated with neoadjuvant Gemcitabine/Cisplatin ×3 cycles.", + "The patient's neoadjuvant therapy was complicated by sepsis.", + "The patient underwent cystoprostatectomy 09/2020.", + "In 07/2021, the patient was found to have metastasis to the rectum.", + "Sigmoidoscopy biopsies showed rectal mucosa and submucosa containing rare foci of malignant cells in lymphatic spaces.", + "GATA-3 immunostaining was positive in these cells.", + "The cells were compatible with a spread from the patient's known urothelial primary carcinoma.", + "The patient declined surgery.", + "The patient was then started on pembrolizumab.", + "Recent CT and sigmoidoscopy were concerning for the progression of rectal mass.", + "After receiving 15 cycles of pembrolizumab, the patient was started on enfortumab vedotin plus pembrolizumab.", + "On cycle 3 day 1, the patient presented to dermatology with a rash of the right inguinal region for 5 weeks.", + "The rash was painful and pruritic.", + "The patient had previously been treated with oral valacyclovir and topical clotrimazole cream with no improvement.", + "The patient denied a history of fevers or night sweats.", + "Physical exam was notable for firm papulonodules.", + "Several papulonodules formed confluent, hyperpigmented to violaceous plaques involving the right inguinal fold.", + "Similar lesions extended onto the proximal anterior thigh.", + "A punch biopsy was performed.", + "The biopsy revealed a dermal proliferation of neoplastic cells in irregular nests with retraction artifact and focal glandular differentiation.", + "The cells showed high-grade nuclear features with background apoptosis.", + "There was no involvement of the overlying epidermis.", + "Immunohistochemistry revealed that the tumor cells were positive for CK20 and GATA3.", + "Immunohistochemistry revealed that the tumor cells were negative for CK7.", + "The presence of a glandular proliferation in the dermis, without overlying connection to the epidermis, and with a staining pattern consistent with the patient's known urothelial carcinoma, led to the diagnosis of cutaneous metastasis.", + "The papillary dermis showed edema and perivascular inflammation.", + "The patient received one fraction of intensity-modulated radiation therapy to the right pelvis/groin.", + "The patient was continued on enfortumab vedotin plus pembrolizumab at that time.", + "Significant decline in CA19-9 and ctDNA had stabilized.", + "The newest CT imaging demonstrates a decrease in abdominal/pelvic lymphadenopathy with no new findings." + ], + "summary": "A 79-year-old male with a history of papillary urothelial carcinoma of the bladder and metastasis to the rectum presented with a painful and pruritic rash in the right inguinal region. Physical examination revealed firm papulonodules forming confluent, hyperpigmented to violaceous plaques. A punch biopsy confirmed the diagnosis of cutaneous metastasis of urothelial carcinoma based on histopathological and immunohistochemical findings.", + "summary_subclaims": [ + "The patient is a 79-year-old male.", + "The patient has a history of papillary urothelial carcinoma of the bladder.", + "The patient has metastasis to the rectum.", + "The patient presented with a painful and pruritic rash in the right inguinal region.", + "Physical examination revealed firm papulonodules forming confluent, hyperpigmented to violaceous plaques.", + "A punch biopsy confirmed the diagnosis of cutaneous metastasis of urothelial carcinoma.", + "The diagnosis was based on histopathological and immunohistochemical findings." + ] + }, + { + "id": "multiclinsum_test_2188_en.txt", + "fulltext": "A 37-year-old man presented with a 2-year history of painless swelling of the right arm with a gradual increase in size. A physical examination was normal except for a well circumscribed non-tender mass in the upper two-thirds of the right arm and multiple lymph nodes in the right axilla. Imaging revealed a 53 × 40 mm diameter soft tissue mass that was hyperintense on T2-weighted MRI in the posterior compartment of the right arm, with no bone or vascular invasion . Surgical biopsy of the mass and axillary lymph node excision were performed; the laboratory received two fragments with soft consistency, measuring 2 × 1 × 0.3 cm and 2.5 × 1 × 0.5 cm. Histopathological examination showed a desembryoplastic multitissular tumor, containing a sarcomatous component constituted by spindle cells and organized in bundles with rhabdomyoblastic differentiation. There was also an immature and malignant neuroglial component, and this tumor additionally showed epithelial structures with squamous or glandular differentiation; some cells were compatible with embryonal carcinoma. These various tissular structures were very confluent, without transition. Atypical immature cartilage and bone components were observed associated with necrosis. The axillary lymph node excised was metastatic. There was no need for immunohistochemical staining to confirm the diagnosis of malignant mixed GCT (teratocarcinoma variety) . Testicular palpation and ultrasonography results were normal. A computed tomography (CT) scan of the chest, abdomen and pelvis showed no abnormalities. Serum α-fetoprotein (AFP), β-human chorionic gonadotropin (β-HCG), and serum lactate dehydrogenase (LDH) levels were all within normal ranges. The patient received four courses of chemotherapy (bleomycin 30 units intravenous injection, days 1, 8, and 15; etoposide 100 mg/m2 intravenously, days 1 through 5; cisplatin 20 mg/m2 intravenously, days 1 through 5). A clinical evaluation of response at the end of chemotherapy showed a stable disease. Then, 1 month later, a wide excision with axillary dissection was performed; the excised tumor was partially well circumscribed and measured 57 × 42 × 38 mm and had a uniform, yellowish, solid, and partially nodular appearance on the cut surface. Final pathology revealed the same histological aspect as observed in the biopsy but did not revealed tumoral necrotic patterns. All surgical margins were free, and one of six lymph nodes identified was involved without extracapsular spread . Two further cycles of chemotherapy using the same protocol were added. At 18 months of close follow-up, no locoregional recurrence or distant metastases have been detected.", + "fulltext_subclaims": [ + "The patient is a 37-year-old man.", + "He had a 2-year history of painless swelling of the right arm.", + "The swelling gradually increased in size.", + "Physical examination was normal except for a well circumscribed non-tender mass in the upper two-thirds of the right arm.", + "Multiple lymph nodes were present in the right axilla.", + "Imaging showed a 53 × 40 mm diameter soft tissue mass.", + "The mass was hyperintense on T2-weighted MRI.", + "The mass was located in the posterior compartment of the right arm.", + "There was no bone invasion.", + "There was no vascular invasion.", + "Surgical biopsy of the mass was performed.", + "Axillary lymph node excision was performed.", + "The laboratory received two fragments with soft consistency.", + "The fragments measured 2 × 1 × 0.3 cm and 2.5 × 1 × 0.5 cm.", + "Histopathological examination showed a desembryoplastic multitissular tumor.", + "The tumor contained a sarcomatous component constituted by spindle cells.", + "The sarcomatous component was organized in bundles.", + "The sarcomatous component showed rhabdomyoblastic differentiation.", + "The tumor had an immature and malignant neuroglial component.", + "The tumor showed epithelial structures with squamous or glandular differentiation.", + "Some cells were compatible with embryonal carcinoma.", + "The various tissular structures were very confluent.", + "There was no transition between the tissular structures.", + "Atypical immature cartilage and bone components were observed.", + "Necrosis was observed.", + "The axillary lymph node excised was metastatic.", + "There was no need for immunohistochemical staining to confirm the diagnosis of malignant mixed GCT (teratocarcinoma variety).", + "Testicular palpation and ultrasonography results were normal.", + "A CT scan of the chest, abdomen, and pelvis showed no abnormalities.", + "Serum α-fetoprotein (AFP) levels were within normal ranges.", + "Serum β-human chorionic gonadotropin (β-HCG) levels were within normal ranges.", + "Serum lactate dehydrogenase (LDH) levels were within normal ranges.", + "The patient received four courses of chemotherapy.", + "Chemotherapy included bleomycin 30 units intravenous injection on days 1, 8, and 15.", + "Chemotherapy included etoposide 100 mg/m2 intravenously on days 1 through 5.", + "Chemotherapy included cisplatin 20 mg/m2 intravenously on days 1 through 5.", + "A clinical evaluation of response at the end of chemotherapy showed stable disease.", + "One month later, a wide excision with axillary dissection was performed.", + "The excised tumor was partially well circumscribed.", + "The excised tumor measured 57 × 42 × 38 mm.", + "The excised tumor had a uniform, yellowish, solid, and partially nodular appearance on the cut surface.", + "Final pathology revealed the same histological aspect as observed in the biopsy.", + "Final pathology did not reveal tumoral necrotic patterns.", + "All surgical margins were free.", + "One of six lymph nodes identified was involved.", + "There was no extracapsular spread.", + "Two further cycles of chemotherapy using the same protocol were added.", + "At 18 months of close follow-up, no locoregional recurrence was detected.", + "At 18 months of close follow-up, no distant metastases were detected." + ], + "summary": "We report the case of a 37-year-old man who presented with a primary malignant mixed non-seminomatous GCT (teratocarcinoma variety) in the right arm, treated by a combination of cisplatin-based chemotherapy and surgery. After 18 months of close follow-up, no locoregional recurrence or distant metastases have been detected.", + "summary_subclaims": [ + "The patient is a 37-year-old man.", + "He presented with a primary malignant mixed non-seminomatous GCT in the right arm.", + "The tumor was of the teratocarcinoma variety.", + "He was treated by a combination of cisplatin-based chemotherapy and surgery.", + "After 18 months of close follow-up, no locoregional recurrence has been detected.", + "After 18 months of close follow-up, no distant metastases have been detected." + ] + }, + { + "id": "multiclinsum_test_1969_en.txt", + "fulltext": "An asymptomatic 40-year-old woman presented with gastric wall thickening detected by screening with an upper gastrointestinal series and underwent contrast-enhanced computed tomography (CT), which also revealed an anterior mediastinal mass. She had been diagnosed with asymptomatic SjS at the age of 35, which was overlooked during the initial work-up. She had no medication or smoking history. She had a family history of breast cancer in her mother’s side and rheumatoid arthritis in her father’s side. The laboratory data showed nothing but hypergammaglobulinemia (IgG, 2750 mg/dL; IgA, 625 mg/dL; IgM, 241 mg/dL), and the serum soluble interleukin-2 receptor level was also within the normal limits (362 U/mL). A chest radiograph revealed no abnormalities. An abdominal CT revealed a localized wall thickness measuring 22 mm with enhancement in the middle part of the gastric body on the greater curvature. A well-circumscribed mass with a heterogenous concentration measuring 49 × 22 mm in the anterior mediastinum without any distant metastases and multiple cysts in both lungs were also demonstrated. Magnetic resonance imaging revealed a multilocular mediastinal mass without invasion to the surrounding parenchyma . 18Fluoro-2-deoxyglucose positron emission tomography (FDG-PET) was not performed before the surgery. Suspecting the gastric wall thickness suggested a gastrointestinal stromal tumor or MALT lymphoma, we performed an endoscopic incisional biopsy. The pathological findings showed lymphocytic infiltration without any atypical cells or a light chain restriction between the kappa and lambda chains on immunostaining, consistent with inflammatory changes. We successfully performed a total thymectomy, due to suspecting an anterior mediastinal mass as a thymoma, by a bilateral approach via video-assisted thoracoscopic surgery with carbon dioxide insufflation in a supine position. There were no adhesions around the mass, and it was removed from the surrounding organs without any surgical difficulty . We also performed a wedge resection of the right upper lobe of the lung as a surgical biopsy to rule out lymphangioleiomyomatosis (LAM). The operation time was 187 min with 2 g of total blood loss. The cut surface of the mediastinal tumor exhibited a grayish-white solid mass with multiple cysts. Histopathologically, there was an infiltration of numerous lymphoid cells with lymphoid follicles. Small- to medium-sized atypical lymphoid cells were observed, and some of them exhibited plasmacytoid differentiation . Cytokeratin immunostaining revealed a lymphoepithelial lesion, consistent with infiltration of lymphoid cells into the epithelium. These cells were positive for CD20 and negative for CD3, CD5, and CD10. A light chain restriction positive for kappa and negative for lambda chains was demonstrated. From these findings, we diagnosed the mediastinal mass as a MALT lymphoma. A lung cyst was found to be an emphysematous bulla without any specific histological findings suggesting LAM. The postoperative course was uneventful, and she was discharged home on postoperative day 2. FDG-PET revealed no abnormal FDG uptakes in any organs 1 month later, and she is currently disease-free at 9 months after surgery.", + "fulltext_subclaims": [ + "The patient is an asymptomatic 40-year-old woman.", + "She presented with gastric wall thickening detected by screening with an upper gastrointestinal series.", + "She underwent contrast-enhanced computed tomography (CT).", + "The CT revealed an anterior mediastinal mass.", + "She had been diagnosed with asymptomatic SjS at the age of 35.", + "The SjS diagnosis was overlooked during the initial work-up.", + "She had no medication or smoking history.", + "She had a family history of breast cancer in her mother’s side.", + "She had a family history of rheumatoid arthritis in her father’s side.", + "The laboratory data showed hypergammaglobulinemia (IgG, 2750 mg/dL; IgA, 625 mg/dL; IgM, 241 mg/dL).", + "The serum soluble interleukin-2 receptor level was within the normal limits (362 U/mL).", + "A chest radiograph revealed no abnormalities.", + "An abdominal CT revealed a localized wall thickness measuring 22 mm with enhancement in the middle part of the gastric body on the greater curvature.", + "A well-circumscribed mass with a heterogenous concentration measuring 49 × 22 mm in the anterior mediastinum was demonstrated.", + "There were multiple cysts in both lungs.", + "Magnetic resonance imaging revealed a multilocular mediastinal mass without invasion to the surrounding parenchyma.", + "18Fluoro-2-deoxyglucose positron emission tomography (FDG-PET) was not performed before the surgery.", + "Suspecting the gastric wall thickness suggested a gastrointestinal stromal tumor or MALT lymphoma, an endoscopic incisional biopsy was performed.", + "The pathological findings showed lymphocytic infiltration without any atypical cells.", + "There was no light chain restriction between the kappa and lambda chains on immunostaining.", + "The findings were consistent with inflammatory changes.", + "A total thymectomy was performed due to suspecting the anterior mediastinal mass as a thymoma.", + "The thymectomy was performed by a bilateral approach via video-assisted thoracoscopic surgery with carbon dioxide insufflation in a supine position.", + "There were no adhesions around the mass.", + "The mass was removed from the surrounding organs without any surgical difficulty.", + "A wedge resection of the right upper lobe of the lung was performed as a surgical biopsy to rule out lymphangioleiomyomatosis (LAM).", + "The operation time was 187 min with 2 g of total blood loss.", + "The cut surface of the mediastinal tumor exhibited a grayish-white solid mass with multiple cysts.", + "Histopathologically, there was an infiltration of numerous lymphoid cells with lymphoid follicles.", + "Small- to medium-sized atypical lymphoid cells were observed.", + "Some of the cells exhibited plasmacytoid differentiation.", + "Cytokeratin immunostaining revealed a lymphoepithelial lesion.", + "The lymphoepithelial lesion was consistent with infiltration of lymphoid cells into the epithelium.", + "The cells were positive for CD20 and negative for CD3, CD5, and CD10.", + "A light chain restriction positive for kappa and negative for lambda chains was demonstrated.", + "The mediastinal mass was diagnosed as a MALT lymphoma.", + "The lung cyst was found to be an emphysematous bulla.", + "There were no specific histological findings suggesting LAM.", + "The postoperative course was uneventful.", + "She was discharged home on postoperative day 2.", + "FDG-PET revealed no abnormal FDG uptakes in any organs 1 month later.", + "She is currently disease-free at 9 months after surgery." + ], + "summary": "A 40-year-old woman presented with an anterior mediastinal mass and multiple lung cysts on computed tomography. We suspected thymoma concomitant with lymphangioleiomyomatosis and performed a total thymectomy and wedge resection of the lung as a surgical biopsy. The histopathological diagnosis of the mediastinal mass was a MALT lymphoma, and there were no specific findings in the lung specimen. She had a history of SjS, which had been overlooked during the initial work-up.", + "summary_subclaims": [ + "The patient is a 40-year-old woman.", + "The patient had an anterior mediastinal mass on computed tomography.", + "The patient had multiple lung cysts on computed tomography.", + "We suspected thymoma concomitant with lymphangioleiomyomatosis.", + "We performed a total thymectomy.", + "We performed a wedge resection of the lung as a surgical biopsy.", + "The histopathological diagnosis of the mediastinal mass was a MALT lymphoma.", + "There were no specific findings in the lung specimen.", + "The patient had a history of SjS.", + "The patient's history of SjS had been overlooked during the initial work-up." + ] + }, + { + "id": "multiclinsum_test_1311_en.txt", + "fulltext": "A 4-year-old female Caucasian child was admitted to the emergency department with fever and acute respiratory failure. The personal and familial anamnestic recall brought no elements of suspicion for a past SARS-CoV-2 infection. The chest X-ray and subsequent computed tomography (CT) showed multiple and bilateral ground glass areas and patchy consolidations in the inferior lobes, pneumomediastinum with supraclavicular and cervical bilateral subcutaneous emphysema . The microbiological assessment on broncho-alveolar lavage (BAL) was positive for Pneumocystis jiroveci (PJ) and galactomannan, SARS-CoV-2 proved negative. As her respiratory dynamics progressively deteriorated, she was intubated and assisted through mechanical ventilation.\nAt the anamnestic recall the parents reported a history of recurrent respiratory infections since she was 3 years old, a previous episode of ocular HSV infection and recurrent oral thrush. Due to the patient’s medical history and the evidence of PJI and pulmonary aspergillosis, an immunological assessment was performed, and a severe CD4-penia emerged: CD4+ was 1.06% (6 cell/µl, normal value 500–1000). Soon after the diagnosis of HIV-positivity was finalised with a viral load of 83.429 copies/ml. She was classified as a stage 3, according to Centres for Disease Control (CDC) classification system for HIV infection . Combined ART was initiated at the diagnosis of HIV infection, with a lamivudine, zidovudine and lopinavir/ritonavir; alongside treatment for PJ and aspergillosis was started with Trimethoprim/Sulfamethoxazole, Caspofungin and Ambisome.\nThe microbiological assessment run to investigate possible coinfections proved positivity for CMV (31,446 copies/ml) and EBV (8542 copies/mL). Also, at the oral cavity inspection, the patient presented some vesicles positive for HSV. Acyclovir and Gancyclovir were then added to her therapeutic regimen. On the 51st day after she had started ART, she started presenting fever with a progressive worsening of clinical conditions: no other microbiological agents were isolated at the analysed samples (blood, stools and urine) and there was no improvement with broad-spectrum antibiotic therapy.\nHer laboratory assessment showed progressive trilinear cytopenia (lowest values: haemoglobin 7,7 g/dl, absolute neutrophil count 690 cells/mcl, platelet count 14.000 cells/mcl), progressive increase of C-reactive protein (up to 4,28 mg/dl), hyponatremia (serum sodium 129 mEq/l), hypoalbuminemia (3,1 g/dl) and hypofibrinogenemia (76 mg/dl ). Triglycerides were slightly increased (160 mg/dl) and ferritin levels were increased (up to > 12.000 ng/ml). Cardiac enzymes showed progressive elevation (high sensitivity troponin up to 40,9 pg/ml and proBNP 1548 pg/ml). At that time her HIV viral load was undetectable and CD4+ cell count was 35 cells/mcl (normal value 630–2110). We have always studied the expansion trend of expansion of CD4+ cell in relation to CD8+ cell, we also evaluating the expression of CD45 RA+RO− (naïve) and CD45RA−RO+ (memory) on the T cells: these analyses were compatible with the success of ART .\nIn order to assess the differential diagnosis between HLH and IRIS, T-cell activation was investigated through the HLA-DR+ and CD38+ evaluation on CD4+ lymphocytes, which resulted always less than 1/microliter . In the suspicion of HLH and in order to assess other causes of cytopenia, a bone marrow aspirate and biopsy were performed: evidence of bone marrow cytopenia with prevalence of T-cells and macrophages with signs of phagocytosis was found. The immune activation markers, HLA-DR + and CD38+, were present on the CD8+ lymphocytes , making the diagnosis of HLH even more suggestive . We could not assess soluble IL2-R at that time in our hospital.\nDue to the presence of six diagnostic criteria the diagnosis of HLH was made: persistent fever > 38,5 °C, cytopenia involving more than two lineages, hypertriglyceridemia and hypofibrinogenemia, splenomegaly, hyperferritinemia and hemophagocytosis in bone marrow. Furthermore, Patient’s NK showed a lower degranulation after stimulation with K562 cells than healthy donor . However due to an ongoing treatment with systemic corticosteroids such assay can only be partially considered reliable for degranulation.\nThen a glucocorticoid therapy with three pulses of methylprednisolone (30 mg/kg/day) was started. The patient returned upyretic after the first pulse of methylprednisolone. After the three pulses, she was started on dexamethasone (10 mg/m2/day) as maintenance therapy. The laboratory assessment showed a progressive improve of the inflammatory parameters with worsening cytopenia and coagulopathy.\nIn consideration of the insufficient response to glucocorticoid therapy, the treatment was implemented with intravenous interleukin-1 receptor antagonist (Anakinra, 100 mg twice a day = 14 mg/kg/day).\nAfter the treatment with anakinra was started, the patient’s clinical conditions and laboratory parameters showed a progressive improvement. Glucocorticoid therapy was progressively reduced and the interleukin-1 receptor antagonist was initially reduced to 7 mg/kg/dose (100 mg once per day) after 21 days of treatment. Anakinra was reduced by 25% after 5 days; after 3 days, the dose was reduced by 30% and eventually stopped after an additional 24 h of treatment. After the immunosuppressive therapy was stopped, the patient maintained good clinical condition and normalization of inflammatory markers.", + "fulltext_subclaims": [ + "The patient was a 4-year-old female Caucasian child.", + "She was admitted to the emergency department with fever and acute respiratory failure.", + "The personal and familial anamnestic recall brought no elements of suspicion for a past SARS-CoV-2 infection.", + "The chest X-ray and subsequent computed tomography showed multiple and bilateral ground glass areas.", + "The chest X-ray and subsequent computed tomography showed patchy consolidations in the inferior lobes.", + "The chest X-ray and subsequent computed tomography showed pneumomediastinum with supraclavicular and cervical bilateral subcutaneous emphysema.", + "The microbiological assessment on broncho-alveolar lavage was positive for Pneumocystis jiroveci.", + "The microbiological assessment on broncho-alveolar lavage was positive for galactomannan.", + "SARS-CoV-2 proved negative.", + "She was intubated and assisted through mechanical ventilation.", + "The parents reported a history of recurrent respiratory infections since she was 3 years old.", + "The parents reported a previous episode of ocular HSV infection.", + "The parents reported recurrent oral thrush.", + "An immunological assessment was performed.", + "A severe CD4-penia emerged.", + "CD4+ was 1.06% (6 cell/µl).", + "The diagnosis of HIV-positivity was finalised.", + "The HIV viral load was 83.429 copies/ml.", + "She was classified as stage 3 according to the CDC classification system for HIV infection.", + "Combined ART was initiated at the diagnosis of HIV infection.", + "The ART regimen included lamivudine, zidovudine, and lopinavir/ritonavir.", + "Treatment for Pneumocystis jiroveci was started with Trimethoprim/Sulfamethoxazole.", + "Treatment for pulmonary aspergillosis was started with Caspofungin and Ambisome.", + "The microbiological assessment proved positivity for CMV (31,446 copies/ml).", + "The microbiological assessment proved positivity for EBV (8,542 copies/mL).", + "The patient presented some vesicles positive for HSV.", + "Acyclovir and Gancyclovir were added to her therapeutic regimen.", + "On the 51st day after she had started ART, she started presenting fever.", + "No other microbiological agents were isolated at the analysed samples.", + "There was no improvement with broad-spectrum antibiotic therapy.", + "Her laboratory assessment showed progressive trilinear cytopenia.", + "C-reactive protein increased up to 4.28 mg/dl.", + "Serum sodium was 129 mEq/l.", + "Albumin was 3.1 g/dl.", + "Fibrinogen was 76 mg/dl.", + "Triglycerides were 160 mg/dl.", + "Ferritin levels were > 12,000 ng/ml.", + "High sensitivity troponin was 40.9 pg/ml.", + "ProBNP was 1,548 pg/ml.", + "HIV viral load was undetectable.", + "CD4+ cell count was 35 cells/mcl.", + "HLA-DR+ and CD38+ evaluation on CD4+ lymphocytes resulted always less than 1/microliter.", + "A bone marrow aspirate and biopsy were performed.", + "Bone marrow cytopenia with prevalence of T-cells and macrophages with signs of phagocytosis was found.", + "The immune activation markers, HLA-DR+ and CD38+, were present on the CD8+ lymphocytes.", + "The diagnosis of HLH was made.", + "The patient had six diagnostic criteria for HLH.", + "The patient had persistent fever > 38.5 °C.", + "The patient had cytopenia involving more than two lineages.", + "The patient had hypertriglyceridemia and hypofibrinogenemia.", + "The patient had splenomegaly.", + "The patient had hyperferritinemia.", + "The patient had hemophagocytosis in bone marrow.", + "Patient’s NK showed a lower degranulation after stimulation with K562 cells than healthy donor.", + "A glucocorticoid therapy with three pulses of methylprednisolone (30 mg/kg/day) was started.", + "The patient returned afebrile after the first pulse of methylprednisolone.", + "After the three pulses, she was started on dexamethasone (10 mg/m2/day) as maintenance therapy.", + "The laboratory assessment showed a progressive improvement of the inflammatory parameters.", + "The treatment was implemented with intravenous interleukin-1 receptor antagonist (Anakinra, 100 mg twice a day).", + "After the treatment with anakinra was started, the patient’s clinical conditions and laboratory parameters showed a progressive improvement.", + "Glucocorticoid therapy was progressively reduced.", + "The interleukin-1 receptor antagonist was initially reduced to 7 mg/kg/dose after 21 days of treatment.", + "Anakinra was reduced by 25% after 5 days.", + "After 3 days, the dose was reduced by 30%.", + "Anakinra was eventually stopped after an additional 24 h of treatment.", + "After the immunosuppressive therapy was stopped, the patient maintained good clinical condition.", + "After the immunosuppressive therapy was stopped, inflammatory markers normalized." + ], + "summary": "We here report the case of a 4-year-old child with a recent AIDS diagnosis who was admitted to the ER with acute respiratory failure due to Pneumocystis jiroveci infection and Aspergillosis; the following microbiological assessment also showed a CMV, HSV, EBV and HHV-7 coinfection. On the 51st day after she'd started antiretroviral therapy, 39th after she'd followed a course of Bactrim and Caspofungin for PJI and Ambisome for pulmonary Aspergillosis, she started presenting fever, unresponsive to broad-spectrum antibiotic therapy. She also presented worsening of her clinical conditions, with evidence at the laboratory assessments of progressive raise in inflammatory indexes, coagulopathy, trilinear cytopenia and hyperferritinemia. To perform the differential diagnosis between IRIS and HLH, HLA-DR on T cells was studied, turning out negative for IRIS. Therefore, in the suspicion of HLH, a bone marrow aspirate and biopsy were performed with evidence of trilinear cytopenia, prevalence of T-cells and macrophages with signs of phagocytosis. She was started on high-dose steroids and Anakinra for a total of 29 days, resulting in prompt apyrexia and progressive improvement of her clinical conditions and laboratory results.", + "summary_subclaims": [ + "The patient was a 4-year-old child with a recent AIDS diagnosis.", + "The patient was admitted to the ER with acute respiratory failure due to Pneumocystis jiroveci infection.", + "The patient had Aspergillosis.", + "The microbiological assessment showed a CMV coinfection.", + "The microbiological assessment showed an HSV coinfection.", + "The microbiological assessment showed an EBV coinfection.", + "The microbiological assessment showed an HHV-7 coinfection.", + "The patient started antiretroviral therapy.", + "The patient followed a course of Bactrim for PJI.", + "The patient followed a course of Caspofungin for PJI.", + "The patient received Ambisome for pulmonary Aspergillosis.", + "On the 51st day after starting antiretroviral therapy, the patient started presenting fever.", + "The fever was unresponsive to broad-spectrum antibiotic therapy.", + "The patient had progressive raise in inflammatory indexes.", + "The patient had coagulopathy.", + "The patient had trilinear cytopenia.", + "The patient had hyperferritinemia.", + "HLA-DR on T cells was studied.", + "HLA-DR on T cells was negative for IRIS.", + "A bone marrow aspirate and biopsy were performed.", + "The bone marrow aspirate showed trilinear cytopenia.", + "The bone marrow aspirate showed prevalence of T-cells.", + "The bone marrow aspirate showed macrophages with signs of phagocytosis.", + "The patient was started on high-dose steroids.", + "The patient received Anakinra for a total of 29 days.", + "The treatment resulted in prompt apyrexia.", + "The treatment resulted in progressive improvement of clinical conditions.", + "The treatment resulted in progressive improvement of laboratory results." + ] + }, + { + "id": "multiclinsum_test_53_en.txt", + "fulltext": "A 63-year-old male was admitted to our hospital with an uncontrolled itching sensation and whole body jaundice.\nSix months prior he had experienced intractable itching, which led to suspicion of obstructive cholangitis. Despite endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic retrograde biliary drainage, which ruled out malignancy, the itching became aggravated and obstructive-pattern jaundice developed.\nThe patient’s medical history was non-specific with the exception of hypertension and diabetes mellitus, which were well controlled by medication. He was ex-smoker of ten years and a social drinker.\nNo previous illnesses were reported and there was no family history of oncologic and rheumatic diseases.\nThe physical examination revealed icteric sclerae with multiple itching scratches on the skin.\nThe patient’s laboratory results were as follows: Hemoglobin 10 g/dL (normal, 13-17 g/dL), hematocrit 30.6% (normal 39%-52%), platelet count 348000/L (normal, 130000-450000/L), aspartate aminotransferase 71 U/L (normal, 0-40 U/L), alanine aminotransferase level 44 U/L (normal, 0-41 U/L), gamma-glutamyl transferase level 233 U/L (normal, 5-61 U/L), alkaline phosphatase level 315 U/L (normal, 35-130 U/L), total bilirubin level 8.6 mg/dL (normal, 0-1.2 mg/dL), BUN level 26.7 mg/dL (normal, 6-20 mg/dL), creatinine level 1.37 mg/dL (normal, 0.5-1.2 mg/dL), erythrocyte sedimentation rate 120 mm/h (normal, 0-20 mm/h), C reactive protein (CRP) level 1.81 mg/dL (normal, 0-0.5 mg/dL), antinuclear antibody titer 1:2560 (nucleolar pattern), IgG level 2416 mg/dL (normal, 700-1600 mg/dL), and serum IgG4 level 465 mg/dL (normal, 0-135 mg/dL).\nAbdominal computed tomography (CT) showed intrahepatic duct (IHD) dilatation with intraductal soft tissue attenuation and periductal enhancement . The common bile duct (CBD) was dilated with mild luminal narrowing but without findings of AIP . There was no definite obstructive lesion or suspected malignancy. CT also showed fibrotic enhancement around the infrarenal aorta.", + "fulltext_subclaims": [ + "The patient is a 63-year-old male.", + "The patient was admitted with an uncontrolled itching sensation.", + "The patient had whole body jaundice.", + "Six months prior, the patient had experienced intractable itching.", + "The patient had obstructive-pattern jaundice.", + "Endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic retrograde biliary drainage were performed.", + "ERCP and endoscopic retrograde biliary drainage ruled out malignancy.", + "The patient's medical history included hypertension.", + "The patient's medical history included diabetes mellitus.", + "The patient's hypertension and diabetes mellitus were well controlled by medication.", + "The patient was an ex-smoker of ten years.", + "The patient was a social drinker.", + "No previous illnesses were reported.", + "There was no family history of oncologic diseases.", + "There was no family history of rheumatic diseases.", + "The physical examination revealed icteric sclerae.", + "The physical examination revealed multiple itching scratches on the skin.", + "The patient’s hemoglobin was 10 g/dL.", + "The patient’s hematocrit was 30.6%.", + "The patient’s platelet count was 348000/L.", + "The patient’s aspartate aminotransferase was 71 U/L.", + "The patient’s alanine aminotransferase level was 44 U/L.", + "The patient’s gamma-glutamyl transferase level was 233 U/L.", + "The patient’s alkaline phosphatase level was 315 U/L.", + "The patient’s total bilirubin level was 8.6 mg/dL.", + "The patient’s BUN level was 26.7 mg/dL.", + "The patient’s creatinine level was 1.37 mg/dL.", + "The patient’s erythrocyte sedimentation rate was 120 mm/h.", + "The patient’s C reactive protein (CRP) level was 1.81 mg/dL.", + "The patient’s antinuclear antibody titer was 1:2560.", + "The patient’s antinuclear antibody titer had a nucleolar pattern.", + "The patient’s IgG level was 2416 mg/dL.", + "The patient’s serum IgG4 level was 465 mg/dL.", + "Abdominal computed tomography (CT) showed intrahepatic duct (IHD) dilatation.", + "Abdominal CT showed intraductal soft tissue attenuation.", + "Abdominal CT showed periductal enhancement.", + "The common bile duct (CBD) was dilated.", + "The CBD had mild luminal narrowing.", + "There were no findings of AIP.", + "There was no definite obstructive lesion.", + "There was no suspected malignancy.", + "CT showed fibrotic enhancement around the infrarenal aorta." + ], + "summary": "A 63-year-old male presented with a prominent itching sensation and wholebody jaundice. He showed obstructive-pattern jaundice, an elevated IgG4 level, and infiltration of a large number of IgG4-positive cells in the ampulla of Vater. The imaging findings of intrahepatic duct (IHD) and common bile duct dilation, an elevated serum IgG4 level, and characteristic histological findings led to diagnosis of IgG4-SC that compatible with the 2019 ACR/EULAR classification criteria. We planned to treat the patient with high-dose glucocorticoid (GC), followed by cyclophosphamide pulse therapy. After treatment with high-dose GC and an immunosuppressant, imaging studies showed that IHD dilatation had completely resolved.", + "summary_subclaims": [ + "The patient is a 63-year-old male.", + "The patient had a prominent itching sensation.", + "The patient had wholebody jaundice.", + "The patient showed obstructive-pattern jaundice.", + "The patient had an elevated IgG4 level.", + "The patient had infiltration of a large number of IgG4-positive cells in the ampulla of Vater.", + "The imaging findings included intrahepatic duct and common bile duct dilation.", + "The diagnosis was IgG4-SC compatible with the 2019 ACR/EULAR classification criteria.", + "The planned treatment was high-dose glucocorticoid followed by cyclophosphamide pulse therapy.", + "After treatment with high-dose GC and an immunosuppressant, imaging studies showed that intrahepatic duct dilatation had completely resolved." + ] + }, + { + "id": "multiclinsum_test_1861_en.txt", + "fulltext": "This study was conducted under the approval of the ethics committee of the Third Hospital of Hebei Medical University, and the protocol accorded with its standards.\nThis patient was a 52-year-old man who was admitted to our hospital due to low back pain 2 weeks ago. The symptom of low back pain did not improve after bed rest. He was a chronic smoker for the past 20 years and quit smoking for 5 years. Twenty-nine months previously, he underwent right radical nephrectomy not followed by local radiotherapy. Histopathology of the nephrectomy specimen revealed a CCRCC. No recurrence or distant conversion was found in intermittent reexamination. A routine physical examination revealed a body mass index = 19.27 kg/m2 (reference <25) with significant conjuctival pallor but no organomegaly. His blood pressure, pulse rate, respiratory rate, and body temperature were all in the normal range. He had no hypertension, heart disease, diabetes, any infectious disease, or drug allergy history.\nSix months ago, he fell down accidentally during work and later developed lumbar pain. He went to the local hospital for computed tomography (CT) examination, which showed lumbar compression fracture, and received local physical therapy. Later, he felt that his symptoms were better than before. However, he had low backache for the last 2 weeks without cause. At day 1 after admission, the lumbar CT revealed expansive bone destruction in the vertebrae and appendages of the 11th thoracic vertebra and the first lumbar vertebra, bone cortex thinning, and local continuity interruption, accompanied by soft tissue mass formation and vertebral canal compression . Multiple spotty abnormal signals were seen in the cervical vertebra, thoracic vertebra, lumbar vertebra, and sacrum by magnetic resonance imaging (MRI), which were both low signal on T1-weighted imaging and high signal on T2-weighted imaging, accompanied by mass formation in the 11th thoracic and first lumbar vertebrae and appendages . Diffusion weighted imaging (DWI) of vertebral showed scattered high signals, and they were low signals on the corresponding apparent diffusion coefficient (ADC) imaging . Pathological fractures were seen on multiple vertebrae suggestive of metastasis of bone or MM.\nA routine laboratory examination showed that red blood cells and hemoglobin were decreased. Leukocyte and platelet count were normal. Total protein and globulin increased, while albumin decreased. His serum β 2-microglobulin was 4.59 µg/mL (ref. 0.9–2.7), M protein was 45.79 g/L, and IL-6 was 28.871 pg/mL (ref. <10). Five items of myeloma detection showed that IgG (70 g/L, ref. 7.51–15.6) and immunoglobulin k light chain (KAPPA, 94 g/L, ref. 6.29–13.5) were increased, and immunoglobulin A (IgA; 0.515 g/L, ref. 0.82–4.53), immunoglobulin M (IgM, 0.253 g/L, ref. 0.4–2.74), and immunoglobulin M light chain (LAMBDA, 1.16 g/L, ref. 3.13–7.23) were decreased. Immunotyping of lymphoma (including plasma cell tumor) was abnormal. Serum-free light chain assay showed that elevated serum free kappa was 832.5 mg/L (ref. 3.3–19.4). Blood calcium was reduced, and blood phosphorus was normal. Bone marrow aspiration was MM. Alkaline phosphatase (ALP) was normal .\nThe patient had symptoms of lumbar nerve compression, and surgery was the first choice in clinical practice to relieve the symptoms of nerve compression, but he had anemia. Before surgery, anemia must be corrected and immunotherapy and targeted systemic therapy must be performed. According to the above results, bone marrow aspiration and CT-guided vertebral biopsy were performed to make a definite diagnosis. Pathological examination showed the coexistence of myeloma with CCRCC in hematoxylin and eosin (HE) staining . There were monomorphic cells with clear cytoplasm and an intricate network of capillary vasculature in the CCRCC site. The variegated areas of atypical plasma cells infiltrated in CCRCC. There was no clear distinction between the two components. The CCRCC cells were positive for carbonic anhydrase IX (CA-IX), cytokeratin-8, and paired box gene 8 (Pax8); however, the myeloma cells were positive for CD38, CD138, multiple myeloma oncogene 1 (MUM1), and kappa and negative for lambda.\nHe received radiotherapy and immunotherapy and acquired a satisfying outcome. The patient recovered well after treatment and was followed up for 12 months during the whole treatment course. The symptom of back pain was significantly relieved.", + "fulltext_subclaims": [ + "This study was conducted under the approval of the ethics committee of the Third Hospital of Hebei Medical University.", + "The protocol accorded with its standards.", + "This patient was a 52-year-old man.", + "He was admitted to our hospital due to low back pain 2 weeks ago.", + "The symptom of low back pain did not improve after bed rest.", + "He was a chronic smoker for the past 20 years.", + "He quit smoking for 5 years.", + "Twenty-nine months previously, he underwent right radical nephrectomy.", + "The nephrectomy was not followed by local radiotherapy.", + "Histopathology of the nephrectomy specimen revealed a CCRCC.", + "No recurrence or distant conversion was found in intermittent reexamination.", + "A routine physical examination revealed a body mass index = 19.27 kg/m2.", + "The reference body mass index is <25.", + "Significant conjunctival pallor was found.", + "No organomegaly was found.", + "His blood pressure, pulse rate, respiratory rate, and body temperature were all in the normal range.", + "He had no hypertension.", + "He had no heart disease.", + "He had no diabetes.", + "He had no any infectious disease.", + "He had no drug allergy history.", + "Six months ago, he fell down accidentally during work.", + "He later developed lumbar pain.", + "He went to the local hospital for computed tomography (CT) examination.", + "CT showed lumbar compression fracture.", + "He received local physical therapy.", + "He felt that his symptoms were better than before.", + "He had low backache for the last 2 weeks without cause.", + "At day 1 after admission, the lumbar CT revealed expansive bone destruction in the vertebrae and appendages of the 11th thoracic vertebra and the first lumbar vertebra.", + "Bone cortex thinning was seen.", + "Local continuity interruption was seen.", + "Soft tissue mass formation was seen.", + "Vertebral canal compression was seen.", + "Multiple spotty abnormal signals were seen in the cervical vertebra, thoracic vertebra, lumbar vertebra, and sacrum by magnetic resonance imaging (MRI).", + "The signals were both low signal on T1-weighted imaging and high signal on T2-weighted imaging.", + "Mass formation was seen in the 11th thoracic and first lumbar vertebrae and appendages.", + "Diffusion weighted imaging (DWI) of vertebral showed scattered high signals.", + "The corresponding apparent diffusion coefficient (ADC) imaging showed low signals.", + "Pathological fractures were seen on multiple vertebrae.", + "The fractures were suggestive of metastasis of bone or MM.", + "A routine laboratory examination showed that red blood cells and hemoglobin were decreased.", + "Leukocyte count was normal.", + "Platelet count was normal.", + "Total protein and globulin increased.", + "Albumin decreased.", + "Serum β 2-microglobulin was 4.59 µg/mL.", + "The reference range for β 2-microglobulin is 0.9–2.7 µg/mL.", + "M protein was 45.79 g/L.", + "IL-6 was 28.871 pg/mL.", + "The reference range for IL-6 is <10 pg/mL.", + "IgG was 70 g/L.", + "The reference range for IgG is 7.51–15.6 g/L.", + "Immunoglobulin k light chain (KAPPA) was 94 g/L.", + "The reference range for immunoglobulin k light chain is 6.29–13.5 g/L.", + "Immunoglobulin A (IgA) was 0.515 g/L.", + "The reference range for IgA is 0.82–4.53 g/L.", + "Immunoglobulin M (IgM) was 0.253 g/L.", + "The reference range for IgM is 0.4–2.74 g/L.", + "Immunoglobulin M light chain (LAMBDA) was 1.16 g/L.", + "The reference range for immunoglobulin M light chain is 3.13–7.23 g/L.", + "Immunotyping of lymphoma (including plasma cell tumor) was abnormal.", + "Serum-free light chain assay showed that elevated serum free kappa was 832.5 mg/L.", + "The reference range for serum free kappa is 3.3–19.4 mg/L.", + "Blood calcium was reduced.", + "Blood phosphorus was normal.", + "Bone marrow aspiration was MM.", + "Alkaline phosphatase (ALP) was normal.", + "The patient had symptoms of lumbar nerve compression.", + "Surgery was the first choice in clinical practice to relieve the symptoms of nerve compression.", + "He had anemia.", + "Before surgery, anemia must be corrected.", + "Immunotherapy and targeted systemic therapy must be performed.", + "Bone marrow aspiration and CT-guided vertebral biopsy were performed.", + "Pathological examination showed the coexistence of myeloma with CCRCC in hematoxylin and eosin (HE) staining.", + "There were monomorphic cells with clear cytoplasm and an intricate network of capillary vasculature in the CCRCC site.", + "The variegated areas of atypical plasma cells infiltrated in CCRCC.", + "There was no clear distinction between the two components.", + "The CCRCC cells were positive for carbonic anhydrase IX (CA-IX).", + "The CCRCC cells were positive for cytokeratin-8.", + "The CCRCC cells were positive for paired box gene 8 (Pax8).", + "The myeloma cells were positive for CD38.", + "The myeloma cells were positive for CD138.", + "The myeloma cells were positive for multiple myeloma oncogene 1 (MUM1).", + "The myeloma cells were positive for kappa.", + "The myeloma cells were negative for lambda.", + "He received radiotherapy and immunotherapy.", + "He acquired a satisfying outcome.", + "The patient recovered well after treatment.", + "He was followed up for 12 months during the whole treatment course.", + "The symptom of back pain was significantly relieved." + ], + "summary": "We reported a man with a unique case whose tumors were MM with bone metastatic tumor of clear cell renal cell carcinoma (CCRCC). Computed tomography (CT) showed multifocal osteolytic bone destruction, while magnetic resonance imaging (MRI) showed multifocal bone marrow infiltration with soft tissue mass. Pathology and immunohistochemistry established the diagnosis of the coexistence of myeloma with bone metastatic tumor of CCRCC in the spine. Immunotherapy and systemic chemotherapy were adopted in the clinic, and vertebral decompression was performed after anemia was corrected. This case with MM and bone metastatic tumor of CCRCC received radiotherapy and immunotherapy and acquired satisfying outcome after 1 year of follow-up.", + "summary_subclaims": [ + "The patient had tumors of multiple myeloma with bone metastatic tumor of clear cell renal cell carcinoma.", + "Computed tomography showed multifocal osteolytic bone destruction.", + "Magnetic resonance imaging showed multifocal bone marrow infiltration with soft tissue mass.", + "Pathology and immunohistochemistry established the diagnosis of the coexistence of myeloma with bone metastatic tumor of CCRCC in the spine.", + "Immunotherapy and systemic chemotherapy were adopted in the clinic.", + "Vertebral decompression was performed after anemia was corrected.", + "The case received radiotherapy.", + "The case received immunotherapy.", + "The case had a satisfying outcome after 1 year of follow-up." + ] + }, + { + "id": "multiclinsum_test_311_en.txt", + "fulltext": "This case study was approved by the Institutional Review Board of the ethical committee of Fudan University Shanghai Cancer Center.\nA 48-year-old woman presented with epigastric discomfort for several weeks, and the levels of serum tumor markers were normal. Computed tomography (CT) of the abdomen showed a mass (diameter 21.7 mm) confined to the neck of the pancreas with low density and two enlarged lymph nodes approximately 8 mm in size around the pancreas . Subsequently, she underwent positron emission tomography/computed tomography (PET/CT). A lytic bony lesion in the caput femoris was found besides the pancreatic mass , while there were no signs of metastasis in the axillary and supraclavicular lymph nodes, liver or lung. After consideration of imaging manifestations of malignancy, the patient underwent distal pancreatosplenectomy.\nMicroscopic analysis revealed that the tumor was composed of pleomorphic cells infiltrating the lobules of the pancreas . The malignant cells were arranged in the form of solid sheets and nests and as single files, with high nuclear to cytoplasmic ratio and loss of cohesion . The cell contours were round to polygonal. The cytoplasm of the cells was abundant and eosinophilic, with nuclei of increased size, frequent mitotic figures, and nucleolar prominence . There were no metastases in any of the ten lymph nodes removed around the pancreas.\nImmunohistochemical staining revealed that the tumor cells were positive for p120 (cytoplasmic) and GATA3 and negative for estrogen receptor (ER), progesterone receptor (PR), human epidermal growth factor receptor 2 (HER2), E-cadherin, gross cystic disease fluid protein 15 (GCDFP-15) and mammaglobin.\nPast medical history of this patient was significant for a modified radical mastectomy. Two years ago, a lump was found in her right breast without swelling or pain, and she chose to follow up. The patient presented to our outpatient clinic because of dragging pain in her right breast 10 months later. Physical examination revealed a breast mass (approximately 4 × 4 cm) in the internal inferior quadrant, and invasive carcinoma was confirmed by core needle biopsy. Ultrasonography showed no other metastases in the left breast, supraclavicular lymph nodes or abdomen. The patient was diagnosed with invasive PLC (4.5 × 3.5 × 2.0 cm in size) after modified radical mastectomy , with the absence of metastases in all 17 lymph nodes removed (pT2 N0 M0, stage IIA). By immunohistochemistry, the tumor showed a triple-negative breast cancer (TNBC) phenotype (ER−/PR−/HER2-), negative for E-cadherin , positive for GATA-3 , and the Ki-67 index was approximately 40%. After mastectomy, she received adjuvant chemotherapy with paclitaxel for 6 courses and then underwent regular follow up.\nThe profile of this case is in accordance with the diagnosis of metastatic pleomorphic lobular breast cancer in the pancreas. The patient was then treated with capecitabine, an orally administered chemotherapeutic agent used in the treatment of numerous cancers, including metastatic breast cancer.", + "fulltext_subclaims": [ + "This case study was approved by the Institutional Review Board of the ethical committee of Fudan University Shanghai Cancer Center.", + "A 48-year-old woman presented with epigastric discomfort for several weeks.", + "The levels of serum tumor markers were normal.", + "Computed tomography (CT) of the abdomen showed a mass (diameter 21.7 mm) confined to the neck of the pancreas with low density.", + "Computed tomography (CT) of the abdomen showed two enlarged lymph nodes approximately 8 mm in size around the pancreas.", + "She underwent positron emission tomography/computed tomography (PET/CT).", + "A lytic bony lesion in the caput femoris was found besides the pancreatic mass.", + "There were no signs of metastasis in the axillary and supraclavicular lymph nodes.", + "There were no signs of metastasis in the liver.", + "There were no signs of metastasis in the lung.", + "After consideration of imaging manifestations of malignancy, the patient underwent distal pancreatosplenectomy.", + "Microscopic analysis revealed that the tumor was composed of pleomorphic cells infiltrating the lobules of the pancreas.", + "The malignant cells were arranged in the form of solid sheets and nests.", + "The malignant cells were arranged as single files.", + "The malignant cells had a high nuclear to cytoplasmic ratio.", + "The malignant cells showed loss of cohesion.", + "The cell contours were round to polygonal.", + "The cytoplasm of the cells was abundant and eosinophilic.", + "The nuclei of the cells were increased in size.", + "There were frequent mitotic figures.", + "There were nucleolar prominences.", + "There were no metastases in any of the ten lymph nodes removed around the pancreas.", + "Immunohistochemical staining revealed that the tumor cells were positive for p120 (cytoplasmic).", + "Immunohistochemical staining revealed that the tumor cells were positive for GATA3.", + "Immunohistochemical staining revealed that the tumor cells were negative for estrogen receptor (ER).", + "Immunohistochemical staining revealed that the tumor cells were negative for progesterone receptor (PR).", + "Immunohistochemical staining revealed that the tumor cells were negative for human epidermal growth factor receptor 2 (HER2).", + "Immunohistochemical staining revealed that the tumor cells were negative for E-cadherin.", + "Immunohistochemical staining revealed that the tumor cells were negative for gross cystic disease fluid protein 15 (GCDFP-15).", + "Immunohistochemical staining revealed that the tumor cells were negative for mammaglobin.", + "The patient had a past medical history significant for a modified radical mastectomy.", + "Two years ago, a lump was found in her right breast without swelling or pain.", + "She chose to follow up.", + "The patient presented to our outpatient clinic because of dragging pain in her right breast 10 months later.", + "Physical examination revealed a breast mass (approximately 4 × 4 cm) in the internal inferior quadrant.", + "Invasive carcinoma was confirmed by core needle biopsy.", + "Ultrasonography showed no other metastases in the left breast.", + "Ultrasonography showed no other metastases in the supraclavicular lymph nodes.", + "Ultrasonography showed no other metastases in the abdomen.", + "The patient was diagnosed with invasive PLC (4.5 × 3.5 × 2.0 cm in size) after modified radical mastectomy.", + "There were no metastases in all 17 lymph nodes removed.", + "The tumor showed a triple-negative breast cancer (TNBC) phenotype (ER−/PR−/HER2-).", + "The tumor was negative for E-cadherin.", + "The tumor was positive for GATA-3.", + "The Ki-67 index was approximately 40%.", + "After mastectomy, she received adjuvant chemotherapy with paclitaxel for 6 courses.", + "The patient was then treated with capecitabine.", + "Capecitabine is an orally administered chemotherapeutic agent used in the treatment of numerous cancers, including metastatic breast cancer." + ], + "summary": "We report a rare case of a 48-year-old woman presenting with clinical gastrointestinal symptoms and pancreatic metastasis of PLC. The pancreatic tumor was composed of pleomorphic tumor cells arranged in the form of solid sheets and nests and as single files, with frequent mitotic figures, nucleolar prominence, high nuclear to cytoplasmic ratio and loss of cohesion. The malignant cells were positive for p120 (cytoplasmic) and GATA3 and negative for estrogen receptor, progesterone receptor, human epidermal growth factor receptor 2, E-cadherin, gross cystic disease fluid protein 15 and mammaglobin, which indicated a lobular carcinoma phenotype of the breast.", + "summary_subclaims": [ + "The patient was a 48-year-old woman.", + "The patient had clinical gastrointestinal symptoms.", + "The patient had pancreatic metastasis of PLC.", + "The pancreatic tumor was composed of pleomorphic tumor cells.", + "The tumor cells were arranged in the form of solid sheets and nests.", + "The tumor cells were arranged as single files.", + "The tumor cells had frequent mitotic figures.", + "The tumor cells had nucleolar prominence.", + "The tumor cells had a high nuclear to cytoplasmic ratio.", + "The tumor cells showed loss of cohesion.", + "The malignant cells were positive for p120 (cytoplasmic).", + "The malignant cells were positive for GATA3.", + "The malignant cells were negative for estrogen receptor.", + "The malignant cells were negative for progesterone receptor.", + "The malignant cells were negative for human epidermal growth factor receptor 2.", + "The malignant cells were negative for E-cadherin.", + "The malignant cells were negative for gross cystic disease fluid protein 15.", + "The malignant cells were negative for mammaglobin.", + "The immunohistochemical profile indicated a lobular carcinoma phenotype of the breast." + ] + }, + { + "id": "multiclinsum_test_1445_en.txt", + "fulltext": "A 21-year-old male Japanese student, an active member of an equestrian club, sustained a right toe injury during an accident in a club-related activity. The injury resulted in the severance of his right toe above the interphalangeal joint . Following initial wound treatment, he was directed to the rehabilitation department 2 weeks post-injury. He had no remarkable medical or family history. The patient agreed to provide the case report and consented to its publication, including any accompanying images. The ethics committee of our institution waived the need for ethical review, as the patient provided written consent for the case report.\nInitial assessments indicated pain localized to the injury site, primarily during walking. One month post-injury, the patient also reported pain in the right knee joint while engaging in riding or walking. The pain in the area of the hallux deficit hindered his ability to apply pressure on the thenars. Diagnostic tests, including walking cycle analysis, temporospatial gait parameters, foot pressure distribution, ground reaction force measurements, toe grip force, and one-leg standing tests, were conducted. The foot pressure during a comfortable walk were recorded using a Zebris plantar pressure platform (FDM; GmbH, Munich, Germany; number of sensors: 11,264; sampling rate: 100 Hz; sensor area: 149 cm × 54.2 cm) [–]. The center of pressure (COP) during a comfortable walking pace was captured using force plates (Kistler Japan Co., Ltd., Tokyo, Japan) at a sampling rate of 1000 Hz with a low-pass filter set at 20 Hz . A diminished foot pressure was observed not just in the hallux but also in the metatarsal head of toes two to five on the injured side . The left-foot COP shifted toward the left toe in the late stance phase, while the right-foot COP transitioned toward the second toe, exhibiting greater spatial variability . Assessing the walking cycle using a Zebris plantar pressure platform , the load response and single-support durations were reduced, while the pre-swing phase was extended .\nVertical ground reaction force during the second peak of walking was diminished on the right side (right 599.8 N, left 660.3 N). The patient was unable to maintain a one-leg stand for 10 seconds on the right foot. Pain levels for the toe and knee were rated 5 out of 10 on a numerical rating scale (NRS).\nOn the basis of these findings, a rehabilitation protocol was designed to enhance medial foot loading and improve foot pressure during walking and standing . The regimen included balance and trunk strength training. Starting from the fifth week, the focus shifted to lower limb strength training. From the ninth week, dynamic joint stability exercises were introduced to enhance neuromuscular coordination for movement stabilization . After 3 months, foot pressure and COP movement during walking improved, as did pressure distribution across toes two to five and the metatarsal head, with negligible discrepancies between the left and right sides in both the vertical and anterior–posterior directions . The pressure was consistently distributed from the second toe of the right foot . Notable enhancements were also observed in the pre-leg phase . The second peak of the vertical component of the ground reaction force increased (right 647.5 N, left 639.5 N). One-leg standing on the right foot became stable for 10 seconds, even on a balance mat. NRS scores for the toe and knee pain reduced to 0, indicating a return to pre-injury levels of activity.", + "fulltext_subclaims": [ + "The patient is a 21-year-old male Japanese student.", + "He is an active member of an equestrian club.", + "He sustained a right toe injury during an accident in a club-related activity.", + "The injury resulted in the severance of his right toe above the interphalangeal joint.", + "He was directed to the rehabilitation department 2 weeks post-injury.", + "He had no remarkable medical or family history.", + "The patient agreed to provide the case report and consented to its publication, including any accompanying images.", + "The ethics committee of our institution waived the need for ethical review, as the patient provided written consent for the case report.", + "Initial assessments indicated pain localized to the injury site, primarily during walking.", + "One month post-injury, the patient also reported pain in the right knee joint while engaging in riding or walking.", + "The pain in the area of the hallux deficit hindered his ability to apply pressure on the thenars.", + "Diagnostic tests, including walking cycle analysis, temporospatial gait parameters, foot pressure distribution, ground reaction force measurements, toe grip force, and one-leg standing tests, were conducted.", + "The foot pressure during a comfortable walk were recorded using a Zebris plantar pressure platform.", + "The center of pressure (COP) during a comfortable walking pace was captured using force plates.", + "A diminished foot pressure was observed not just in the hallux but also in the metatarsal head of toes two to five on the injured side.", + "The left-foot COP shifted toward the left toe in the late stance phase.", + "The right-foot COP transitioned toward the second toe, exhibiting greater spatial variability.", + "Assessing the walking cycle using a Zebris plantar pressure platform, the load response and single-support durations were reduced.", + "The pre-swing phase was extended.", + "Vertical ground reaction force during the second peak of walking was diminished on the right side.", + "The patient was unable to maintain a one-leg stand for 10 seconds on the right foot.", + "Pain levels for the toe and knee were rated 5 out of 10 on a numerical rating scale (NRS).", + "A rehabilitation protocol was designed to enhance medial foot loading and improve foot pressure during walking and standing.", + "The regimen included balance and trunk strength training.", + "Starting from the fifth week, the focus shifted to lower limb strength training.", + "From the ninth week, dynamic joint stability exercises were introduced to enhance neuromuscular coordination for movement stabilization.", + "After 3 months, foot pressure and COP movement during walking improved.", + "Pressure distribution across toes two to five and the metatarsal head improved.", + "There were negligible discrepancies between the left and right sides in both the vertical and anterior–posterior directions.", + "The pressure was consistently distributed from the second toe of the right foot.", + "Notable enhancements were also observed in the pre-leg phase.", + "The second peak of the vertical component of the ground reaction force increased.", + "One-leg standing on the right foot became stable for 10 seconds, even on a balance mat.", + "NRS scores for the toe and knee pain reduced to 0, indicating a return to pre-injury levels of activity." + ], + "summary": "A 21-year-old Japanese patient, suffering from a traumatic hallux deficit with only a portion of the basal phalanx intact, underwent rehabilitation treatment. The thenar area exhibited instability, leading to impaired balance and walking difficulties. Biomechanical assessment revealed the need for a rehabilitation strategy for the foot, as well as the knee, hip, and trunk. A rehabilitation protocol was designed to enhance medial foot loading during walking and standing, including balance and trunk strength training. After a 12-week rehabilitation period, the patient's gait showed significant improvement. Specifically, the load response and single-support phases of the gait cycle on the affected side increased from 46.9% to 49.3%, while the pre-swing phase decreased from 14.6% to 11.6%. The vertical component of the ground reaction force rose from 599.8 to 647.5 N. The enhanced stability from balance training and increased muscle strength contributed to the patient's improved walking and balance.", + "summary_subclaims": [ + "The patient is a 21-year-old Japanese individual.", + "The patient had a traumatic hallux deficit.", + "Only a portion of the basal phalanx was intact.", + "The thenar area exhibited instability.", + "The instability led to impaired balance.", + "The instability led to walking difficulties.", + "Biomechanical assessment revealed the need for a rehabilitation strategy for the foot.", + "Biomechanical assessment revealed the need for a rehabilitation strategy for the knee.", + "Biomechanical assessment revealed the need for a rehabilitation strategy for the hip.", + "Biomechanical assessment revealed the need for a rehabilitation strategy for the trunk.", + "A rehabilitation protocol was designed to enhance medial foot loading during walking.", + "A rehabilitation protocol was designed to enhance medial foot loading during standing.", + "The rehabilitation protocol included balance training.", + "The rehabilitation protocol included trunk strength training.", + "The rehabilitation period lasted 12 weeks.", + "The load response and single-support phases of the gait cycle on the affected side increased from 46.9% to 49.3%.", + "The pre-swing phase of the gait cycle on the affected side decreased from 14.6% to 11.6%.", + "The vertical component of the ground reaction force rose from 599.8 to 647.5 N.", + "Enhanced stability from balance training contributed to the patient's improved walking.", + "Enhanced stability from balance training contributed to the patient's improved balance.", + "Increased muscle strength contributed to the patient's improved walking.", + "Increased muscle strength contributed to the patient's improved balance." + ] + }, + { + "id": "multiclinsum_test_1729_en.txt", + "fulltext": "A 48-year-old man presented with lateral pain in his left elbow. A diagnosis of lateral epicondylitis was made and the patient was initially treated conservatively with physiotherapy, elbow straps, and corticosteroid injections at another institution. However, the pain did not improve and the patient was referred to our hospital. Physical examination revealed tenderness over the lateral epicondyle of the humerus and pain induced by resistance to the middle finger or on wrist extension. He also experienced discomfort and catching around the posterior radiocapitellar joints during extension and flexion of the elbow. Although there were no restriction of range of motion of the elbow, the patient’s grip strength had decreased to 45 kg on the left side compared with 52 kg on the right side. A radiograph of the elbow showed no abnormal findings. Magnetic resonance imaging (MRI) showed increased effusion in the humeroradial joint, but there was no marked signal change at the origin of the ECRB tendon . No obvious intra-articular abnormal tissue, except for posterior synovial plicas, was identified on pre-operative MRI. Arthroscopic surgery was planned for debridement of the ECRB tendon and to examine the cause of posterolateral discomfort and catching in the elbow.\nIntra-articular observation of the radiocapitellar joint was performed through the anteromedial portal. Degenerative changes in the lateral capsule with synovitis were observed, but there was no synovial plica interposed in the humeroradial joint . Debridement of the ECRB tendon and synovium was performed using a shaver inserted through the anterolateral portal . Subsequently, a posterior viewing portal was made 1 cm proximal to the midpoint of the line connecting the olecranon and the lateral epicondyle of the humerus. Posterior observation revealed a tendon-like abnormality running longitudinally along the articular surface from the humeroradial joint to the capitulum of the humerus . This structure was mobile during extension and flexion of the elbow. The abnormality was resected easily using a shaver inserted through the soft-spot portal .\nThe elbow joint was splinted at 90° of flexion for 1 week, after which active motion exercises were initiated. The discomfort and catching of the elbow disappeared immediately after cast removal. At 24-month postoperatively, the pre-operative visual analog scale and the patient-rated tennis elbow evaluation scores improved from 45 mm to 5 mm and from 48 points to 9 points, respectively. At 12 months postoperatively, MRI revealed decreased effusion in the lateral humeroradial joint compared with that on pre-operative MRI .", + "fulltext_subclaims": [ + "The patient is a 48-year-old man.", + "He presented with lateral pain in his left elbow.", + "A diagnosis of lateral epicondylitis was made.", + "The patient was initially treated with physiotherapy.", + "The patient was treated with elbow straps.", + "The patient received corticosteroid injections at another institution.", + "The pain did not improve.", + "The patient was referred to our hospital.", + "Physical examination revealed tenderness over the lateral epicondyle of the humerus.", + "Pain was induced by resistance to the middle finger.", + "Pain was induced by wrist extension.", + "The patient experienced discomfort and catching around the posterior radiocapitellar joints.", + "The patient’s grip strength had decreased to 45 kg on the left side.", + "A radiograph of the elbow showed no abnormal findings.", + "MRI showed increased effusion in the humeroradial joint.", + "There was no marked signal change at the origin of the ECRB tendon.", + "No obvious intra-articular abnormal tissue was identified on pre-operative MRI.", + "Arthroscopic surgery was planned.", + "Intra-articular observation of the radiocapitellar joint was performed through the anteromedial portal.", + "Degenerative changes in the lateral capsule with synovitis were observed.", + "There was no synovial plica interposed in the humeroradial joint.", + "Debridement of the ECRB tendon and synovium was performed using a shaver.", + "A posterior viewing portal was made 1 cm proximal to the midpoint of the line connecting the olecranon and the lateral epicondyle of the humerus.", + "Posterior observation revealed a tendon-like abnormality running longitudinally along the articular surface.", + "The abnormality was mobile during extension and flexion of the elbow.", + "The abnormality was resected easily using a shaver.", + "The elbow joint was splinted at 90° of flexion for 1 week.", + "Active motion exercises were initiated after 1 week.", + "The discomfort and catching of the elbow disappeared immediately after cast removal.", + "At 24 months postoperatively, the visual analog scale score improved from 45 mm to 5 mm.", + "At 24 months postoperatively, the patient-rated tennis elbow evaluation score improved from 48 points to 9 points.", + "At 12 months postoperatively, MRI revealed decreased effusion in the lateral humeroradial joint." + ], + "summary": "A 48-year-old man presented with posterolateral pain and discomfort in his left elbow. A diagnosis of lateral epicondylitis was made, and arthroscopic debridement of the ECRB tendon was performed. Posterior arthroscopic examination revealed a tendon-like abnormality running longitudinally along the articular surface of the capitulum of the humerus. The abnormality was resected using a shaver, and symptoms improved postoperatively.", + "summary_subclaims": [ + "The patient is a 48-year-old man.", + "He presented with posterolateral pain and discomfort in his left elbow.", + "A diagnosis of lateral epicondylitis was made.", + "Arthroscopic debridement of the ECRB tendon was performed.", + "Posterior arthroscopic examination revealed a tendon-like abnormality running longitudinally along the articular surface of the capitulum of the humerus.", + "The abnormality was resected using a shaver.", + "Symptoms improved postoperatively." + ] + }, + { + "id": "multiclinsum_test_3300_en.txt", + "fulltext": "A 36-year-old woman with no medical history was admitted to An-Najah National University Hospital in the West Bank, Palestine for fever and pancytopenia without a known source of infection. The lab findings indicated a neutrophil count of 300 cells per microliter and she received a diagnosis of non-M3 AML. On the eighth day of chemotherapy, she experienced neutropenic fever and received IV antibiotics following culture collection. One week later, her fever persisted and the antibiotics were switched to meropenem and vancomycin.\n\nOn the eighth day of neutropenic fever, a pan-computed tomography (CT) scan revealed bibasal pulmonary glass opacity, an enlarged spleen measuring 15 cm with several hypodense lesions. Because of inadequate vascular access, a catheter was placed in the right internal jugular vein. It was believed that this overall picture, combined with the positive galactomann test, indicated a widespread fungal infection, leading to the initiation of oral voriconazole. Severe thrombocytopenia prevented a biopsy from being performed, leading to an unclear diagnosis. Furthermore, there were no abnormalities detected during the ophthalmological examination and transthoracic echocardiogram.\n\nOn the ninth day of treatment, primary fungal growth was observed in the peripheral blood culture, leading to the initiation of a broader antifungal agent (IV caspofungin). Nonetheless, the final growth revealed growth of Saprochaete capitata; a fungi that exhibited varying appearances when grown on blood and chocolate agar, with dry white colonies on blood agar and cotton colonies with a frosted glass appearance on chocolate agar. Based on the susceptibility report, treatment started with amphotericin B (minimum inhibitory concentrations were: voriconazole < 2 mg/l, amphotericin B < 0.25 mg/l and caspofungin > 32 mg/l), leading to a decrease in inflammatory markers, fever frequency, and cell recovery count. Subsequent blood cultures revealed no signs of bacterial growth. A second bone marrow biopsy revealed no malignant cells, and she was prescribed voriconazole tablets for a six-week course upon leaving the hospital. She was admitted again for consolidation chemotherapy but experienced neutropenic fever. Even with antibiotics and voriconazole, her fever persisted, and the CT scan indicated the disappearance of the lung opacity, but revealed that the splenic hypodense lesions had grown in both size and number (4.5 × 5 cm, previously only subcentimeters). Furthermore, there were newly emerged small hypodense lesions in both kidneys, as well as numerous hypodense lesions in the liver. Amphotericin B IV was administered in combination with oral voriconazole, and a spleen biopsy guided by CT was conducted, however, the culture revealed no organism growth. Following a two-week course of dual antifungal treatment, her condition improved; however, she had to be readmitted due to the recurrence of fever. Despite receiving antifungals and steroids, no improvement was seen in her condition, with the spleen having the largest lesions. She had surgery involving resection of spleen removal, part of the stomach, and part of the pancreas due to extensive adhesions and to control source of infection. The histopathological analysis revealed fungal spores and septate hyphae branching at sharp angles, while the tissue culture did not indicate any growth. Voriconazole and amphotericin B were prescribed for another three weeks, and a CT scan showed marked improvement in the hypodense liver and kidney lesions.\n\n", + "fulltext_subclaims": [ + "The patient was a 36-year-old woman with no medical history.", + "She was admitted to An-Najah National University Hospital in the West Bank, Palestine.", + "She had fever and pancytopenia without a known source of infection.", + "The lab findings indicated a neutrophil count of 300 cells per microliter.", + "She received a diagnosis of non-M3 AML.", + "On the eighth day of chemotherapy, she experienced neutropenic fever.", + "She received IV antibiotics following culture collection.", + "One week later, her fever persisted.", + "The antibiotics were switched to meropenem and vancomycin.", + "On the eighth day of neutropenic fever, a pan-computed tomography (CT) scan revealed bibasal pulmonary glass opacity.", + "The CT scan showed an enlarged spleen measuring 15 cm with several hypodense lesions.", + "A catheter was placed in the right internal jugular vein.", + "It was believed that the overall picture, combined with the positive galactomann test, indicated a widespread fungal infection.", + "This led to the initiation of oral voriconazole.", + "Severe thrombocytopenia prevented a biopsy from being performed.", + "There were no abnormalities detected during the ophthalmological examination.", + "There were no abnormalities detected during the transthoracic echocardiogram.", + "On the ninth day of treatment, primary fungal growth was observed in the peripheral blood culture.", + "This led to the initiation of a broader antifungal agent (IV caspofungin).", + "The final growth revealed growth of Saprochaete capitata.", + "Saprochaete capitata exhibited varying appearances when grown on blood and chocolate agar.", + "It had dry white colonies on blood agar.", + "It had cotton colonies with a frosted glass appearance on chocolate agar.", + "Based on the susceptibility report, treatment started with amphotericin B.", + "The minimum inhibitory concentrations were: voriconazole < 2 mg/l, amphotericin B < 0.25 mg/l, and caspofungin > 32 mg/l.", + "Treatment with amphotericin B led to a decrease in inflammatory markers.", + "Treatment with amphotericin B led to a decrease in fever frequency.", + "Treatment with amphotericin B led to a decrease in cell recovery count.", + "Subsequent blood cultures revealed no signs of bacterial growth.", + "A second bone marrow biopsy revealed no malignant cells.", + "She was prescribed voriconazole tablets for a six-week course upon leaving the hospital.", + "She was admitted again for consolidation chemotherapy.", + "She experienced neutropenic fever.", + "Even with antibiotics and voriconazole, her fever persisted.", + "The CT scan indicated the disappearance of the lung opacity.", + "The CT scan revealed that the splenic hypodense lesions had grown in both size and number (4.5 × 5 cm, previously only subcentimeters).", + "There were newly emerged small hypodense lesions in both kidneys.", + "There were numerous hypodense lesions in the liver.", + "Amphotericin B IV was administered in combination with oral voriconazole.", + "A spleen biopsy guided by CT was conducted.", + "The culture revealed no organism growth.", + "Following a two-week course of dual antifungal treatment, her condition improved.", + "She had to be readmitted due to the recurrence of fever.", + "Despite receiving antifungals and steroids, no improvement was seen in her condition.", + "The spleen had the largest lesions.", + "She had surgery involving resection of spleen removal, part of the stomach, and part of the pancreas.", + "The histopathological analysis revealed fungal spores and septate hyphae branching at sharp angles.", + "The tissue culture did not indicate any growth.", + "Voriconazole and amphotericin B were prescribed for another three weeks.", + "A CT scan showed marked improvement in the hypodense liver and kidney lesions." + ], + "summary": "We report a 36-year-old woman who presented with fever and severe neutropenia and was found to have AML/Non M3. While receiving her initial chemotherapy treatment, she encountered a rare fungal infection (Saprochaete capitata) that spread throughout her lungs, stomach, spleen, liver, and kidneys, presenting difficulties in both diagnosing and treatment. In addition to being treated with both voriconazole and amphotericin B, the patient underwent surgery to remove the infection source, resulting in a cure.", + "summary_subclaims": [ + "The patient is a 36-year-old woman.", + "The patient presented with fever.", + "The patient had severe neutropenia.", + "The patient was found to have AML/Non M3.", + "The patient was receiving her initial chemotherapy treatment.", + "The patient encountered a rare fungal infection.", + "The fungal infection was caused by Saprochaete capitata.", + "The infection spread throughout the patient's lungs.", + "The infection spread throughout the patient's stomach.", + "The infection spread throughout the patient's spleen.", + "The infection spread throughout the patient's liver.", + "The infection spread throughout the patient's kidneys.", + "The infection presented difficulties in diagnosing.", + "The infection presented difficulties in treatment.", + "The patient was treated with voriconazole.", + "The patient was treated with amphotericin B.", + "The patient underwent surgery to remove the infection source.", + "The surgery resulted in a cure." + ] + }, + { + "id": "multiclinsum_test_2282_en.txt", + "fulltext": "The patient was a 19-year-old African American woman who underwent uncomplicated full-thickness-penetrating keratoplasty in her right eye (OD) for advanced keratoconus. One week after surgery, she sustained a blunt trauma to OD that resulted in graft dehiscence from 3 to 5 o'clock, which was repaired surgically. Postoperatively, she received a topical steroid (prednisolone) 4 times a day tapered to 3 times a day at 3 months. Four months after surgery, her uncorrected vision was 20/60 in OD, with 6 dpt of against-the-rule astigmatism. Two corneal sutures were removed with the guidance of topography. Four days later, the patient presented with redness, irritation, and sudden decrease in vision in OD to count fingers at 2 feet with intraocular pressure (IOP) of 11 mm Hg. Corneal examination showed diffuse haziness with stromal edema, Descemet membrane folds, and an incomplete Khodadoust line . A diagnosis of acute corneal rejection was made. Intravenous pulse methylprednisolone (Solu-Medrol), 1 g daily for 3 days, was initiated, in addition to an hourly topical steroid (prednisolone). At 3 days after initiation of treatment, the patient was seen to have progression of the Khodadoust line and no improvement in graft rejection. At that point, a 1-mL subtenon injection of 40 mg/mL of triamcinolone was placed in the superotemporal quadrant. The patient was asked to continue topical steroid drops and was started on oral prednisone, 60 mg/day. Seen a week later, she showed improvement in vision to 20/80 in OD, although it was fuzzy according to the patient. There was a remarkable clearance of corneal edema and improved clarity in the superior half of the graft, with the inferior half remaining hazy . IOP was 16 mm Hg. The patient was observed for another week with no further improvement. On the basis of the response to the initial subtenon triamcinolone injection, she received additional injections of 0.5 mL of triamcinolone (40 mg/mL) in the inferonasal and inferotemporal quadrants. Four days later, the corneal graft rejection had completely resolved, with no keratic precipitates and with complete resolution of corneal edema and haze . Her vision improved to 20/50, and IOP remained stable at 14 mm Hg. Topical prednisolone was decreased to 8 times a day for 2 weeks and subsequently to 4 times a day. Oral prednisone was tapered to stop. At her last follow-up, 5 months after the injections, the corneal graft remained clear.", + "fulltext_subclaims": [ + "The patient was a 19-year-old African American woman.", + "She underwent uncomplicated full-thickness-penetrating keratoplasty in her right eye (OD) for advanced keratoconus.", + "One week after surgery, she sustained a blunt trauma to OD that resulted in graft dehiscence from 3 to 5 o'clock.", + "The graft dehiscence was repaired surgically.", + "Postoperatively, she received a topical steroid (prednisolone) 4 times a day tapered to 3 times a day at 3 months.", + "Four months after surgery, her uncorrected vision was 20/60 in OD.", + "She had 6 dpt of against-the-rule astigmatism.", + "Two corneal sutures were removed with the guidance of topography.", + "Four days after suture removal, the patient presented with redness, irritation, and sudden decrease in vision in OD to count fingers at 2 feet.", + "Her intraocular pressure (IOP) was 11 mm Hg.", + "Corneal examination showed diffuse haziness with stromal edema.", + "Corneal examination showed Descemet membrane folds.", + "Corneal examination showed an incomplete Khodadoust line.", + "A diagnosis of acute corneal rejection was made.", + "Intravenous pulse methylprednisolone (Solu-Medrol), 1 g daily for 3 days, was initiated.", + "An hourly topical steroid (prednisolone) was initiated.", + "At 3 days after initiation of treatment, the patient was seen to have progression of the Khodadoust line.", + "At 3 days after initiation of treatment, there was no improvement in graft rejection.", + "A 1-mL subtenon injection of 40 mg/mL of triamcinolone was placed in the superotemporal quadrant.", + "The patient was asked to continue topical steroid drops.", + "The patient was started on oral prednisone, 60 mg/day.", + "Seen a week later, she showed improvement in vision to 20/80 in OD.", + "There was a remarkable clearance of corneal edema.", + "There was improved clarity in the superior half of the graft.", + "The inferior half of the graft remained hazy.", + "Her IOP was 16 mm Hg.", + "The patient was observed for another week with no further improvement.", + "On the basis of the response to the initial subtenon triamcinolone injection, she received additional injections of 0.5 mL of triamcinolone (40 mg/mL) in the inferonasal and inferotemporal quadrants.", + "Four days later, the corneal graft rejection had completely resolved.", + "There were no keratic precipitates.", + "There was complete resolution of corneal edema and haze.", + "Her vision improved to 20/50.", + "Her IOP remained stable at 14 mm Hg.", + "Topical prednisolone was decreased to 8 times a day for 2 weeks.", + "Topical prednisolone was subsequently decreased to 4 times a day.", + "Oral prednisone was tapered to stop.", + "At her last follow-up, 5 months after the injections, the corneal graft remained clear." + ], + "summary": "A 19-year-old woman who had acute corneal graft rejection failed to show resolution of the graft rejection after standard treatment with systemic, intravenous, and topical steroids. The graft rejection, however, responded to injection of triamcinolone in multiple subtenon quadrants.", + "summary_subclaims": [ + "The patient is a 19-year-old woman.", + "The patient had acute corneal graft rejection.", + "The graft rejection failed to show resolution after standard treatment with systemic, intravenous, and topical steroids.", + "The graft rejection responded to injection of triamcinolone in multiple subtenon quadrants." + ] + }, + { + "id": "multiclinsum_test_2436_en.txt", + "fulltext": "A 34-year old multigravida was found to have right adnexal mass on her routine gynecologic examination. Her previous medical history was uneventfull and Pap smear was normal. Transvaginal ultrasonography identified a cystic mass adjacent to the right ovary. Serum CA 125 was 5.1 U/ml (reference range: < 35 U/ml). At laparoscopy a dilated fallopian tube with bluish discoloration was found. The contralateral fallopian tube, ovaries and uterus were unremarkable. Exploration of the abdomino-pelvic cavity revealed smooth and shiny peritoneal surphace. Obtained peritoneal and pelvic washing were negative. Fine needle aspiration of dilated part of the fallopian tube revealed a 4 ml of bloody content. Cytological findings were consistent with hematosalpinx. Right salpingectomy was performed without using endoscopic bag. The patient was followed up by means of ultrasonography and serum CA 125 for 4.6 years. During this period she had no evidence of the disease.\nGrossly, a 7.0 cm long fallopian tube was irregularly dilated up to 4.4 cm in diameter at the ampulary region. The fimbriae were intact. The serosal surphace was smooth. Sections of the dilated part of the fallopian tube revealed a cystic tumor with focally yellow to tan, soft papillary excrescences protruding into the lumen and foci of intracystic hemorrhage. On microscopic examination the papillae were covered by serous type of epithelium, displaying stratification and budding with focal nuclear atypia . Three types of cells were recognised; ciliated cells, hob-nail cells and mesothelium-like cells. Small foci of tumor tissue necroses and hemorrhage were noted. There was no invasion of the supportive stroma of the papillae or into the fallopian tube wall. Focus of endosalpingiosis within the adjacent mesosalpinx was found. DNA analysis determined by flow cytometry paraffin technique revealed DNA diploid tumor with low S-phase fraction of 6.5 %.", + "fulltext_subclaims": [ + "A 34-year old multigravida was found to have right adnexal mass on her routine gynecologic examination.", + "Her previous medical history was uneventful.", + "Transvaginal ultrasonography identified a cystic mass adjacent to the right ovary.", + "Serum CA 125 was 5.1 U/ml.", + "At laparoscopy a dilated fallopian tube with bluish discoloration was found.", + "The contralateral fallopian tube, ovaries and uterus were unremarkable.", + "Exploration of the abdomino-pelvic cavity revealed smooth and shiny peritoneal surface.", + "Obtained peritoneal and pelvic washing were negative.", + "Fine needle aspiration of dilated part of the fallopian tube revealed a 4 ml of bloody content.", + "Cytological findings were consistent with hematosalpinx.", + "Right salpingectomy was performed without using endoscopic bag.", + "The patient was followed up by means of ultrasonography and serum CA 125 for 4.6 years.", + "During this period she had no evidence of the disease.", + "Grossly, a 7.0 cm long fallopian tube was irregularly dilated up to 4.4 cm in diameter at the ampulary region.", + "The fimbriae were intact.", + "The serosal surface was smooth.", + "Sections of the dilated part of the fallopian tube revealed a cystic tumor with focally yellow to tan, soft papillary excrescences protruding into the lumen and foci of intracystic hemorrhage.", + "On microscopic examination the papillae were covered by serous type of epithelium, displaying stratification and budding with focal nuclear atypia.", + "Three types of cells were recognised; ciliated cells, hob-nail cells and mesothelium-like cells.", + "Small foci of tumor tissue necroses and hemorrhage were noted.", + "There was no invasion of the supportive stroma of the papillae or into the fallopian tube wall.", + "Focus of endosalpingiosis within the adjacent mesosalpinx was found.", + "DNA analysis determined by flow cytometry paraffin technique revealed DNA diploid tumor with low S-phase fraction of 6.5 %." + ], + "summary": "A case of serous borderline tumor of the fallopian tube in a 34-year old patient is presented, incidentally found during routine gynecologic examination. At laparoscopy the tumor was unusually presented as hematosalpinx and was treated by salpingectomy. Cell-cycle analysis of the tumor tissue revealed a diploid DNA content and a low S-phase fraction. There was no evidence of the disease during the follow-up period of 4.6 years.", + "summary_subclaims": [ + "A case of serous borderline tumor of the fallopian tube in a 34-year old patient is presented.", + "The tumor was incidentally found during routine gynecologic examination.", + "At laparoscopy the tumor was unusually presented as hematosalpinx.", + "The tumor was treated by salpingectomy.", + "Cell-cycle analysis of the tumor tissue revealed a diploid DNA content.", + "Cell-cycle analysis of the tumor tissue revealed a low S-phase fraction.", + "There was no evidence of the disease during the follow-up period of 4.6 years." + ] + }, + { + "id": "multiclinsum_test_1407_en.txt", + "fulltext": "A 36-year-old man was referred to our clinic from his family dentist with a complaint of pain around the anterior maxillary region on the right side. The patient’s medical history was non-contributory. Intraoral examination identified a firm, non-fluctuant mass with no ulceration in the vestibular region between the right upper central incisor and canine . The right upper central and lateral incisors were missing. A computed tomography (CT) showed severe bony resorption between the right upper second premolar and the left upper lateral incisor . Incisional biopsy was performed via vestibular approach. The specimen of the tumor was extirpated with overlying mucosa. During the biopsy, an intact cortex was not observed. The histological diagnosis was moderately differentiated SCC. The connection between the tumor and the overlying mucosa was not observed. Contrast-enhanced computed tomography (CE-CT) revealed a destructive tumor with no cystic lesion, >50 mm in diameter. The tumor pressed the skin around the nasal ala and the nostril of the right side, but no direct connection between the skin and tumor was observed. Although the maxillary sinus and nasal cavity were deformed by the tumor, no abnormal findings were seen for the mucosa of the nasal cavity and maxillary sinus . One swollen and enhanced lymph node was recognized in the submandibular area of the right side. Positron emission tomography (PET) revealed the enhanced lesion in the maxilla and the right submandibular area. There was no evidence of metastatic disease on chest radiography, upper gastric endoscopy or PET. Based on these findings, solid type PIOSCC was diagnosed.\nThe patient underwent tumor ablative surgery. After bilateral supraomohyoid neck dissection, the primary tumor was radically excised. The surgical specimen comprised the anterior two-thirds of the hard palate and nasal septum, bilateral inferior nasal conchae and the skin around the nasal ala and nostril of the right side. The surgical defect was reconstructed using a partially double-folded free radial forearm flap and prefabricated denture-based surgical obturator. Microscopic examination of the surgical specimen revealed SCC without cystic component in the maxillary bone. The islands of the tumor cells extended into the bone with no dysplasia or carcinoma in the skin and mucosa of the nasal cavity and maxillary sinus. The dissected surgical specimen of the neck showed one lymph node metastasis of the ipsilateral submandibular region. Although adjuvant radiotherapy was recommended, the patient declined additional treatment. The postoperative course was quite good. Neither recurrence nor metastasis had been found as of 3 years and 1 month postoperatively.", + "fulltext_subclaims": [ + "A 36-year-old man was referred to our clinic from his family dentist.", + "The patient's complaint was pain around the anterior maxillary region on the right side.", + "The patient’s medical history was non-contributory.", + "Intraoral examination identified a firm, non-fluctuant mass with no ulceration in the vestibular region between the right upper central incisor and canine.", + "The right upper central and lateral incisors were missing.", + "Computed tomography showed severe bony resorption between the right upper second premolar and the left upper lateral incisor.", + "Incisional biopsy was performed via vestibular approach.", + "The specimen of the tumor was extirpated with overlying mucosa.", + "During the biopsy, an intact cortex was not observed.", + "The histological diagnosis was moderately differentiated SCC.", + "The connection between the tumor and the overlying mucosa was not observed.", + "Contrast-enhanced computed tomography revealed a destructive tumor with no cystic lesion, >50 mm in diameter.", + "The tumor pressed the skin around the nasal ala and the nostril of the right side.", + "No direct connection between the skin and tumor was observed.", + "The maxillary sinus and nasal cavity were deformed by the tumor.", + "No abnormal findings were seen for the mucosa of the nasal cavity and maxillary sinus.", + "One swollen and enhanced lymph node was recognized in the submandibular area of the right side.", + "Positron emission tomography revealed the enhanced lesion in the maxilla and the right submandibular area.", + "There was no evidence of metastatic disease on chest radiography.", + "There was no evidence of metastatic disease on upper gastric endoscopy.", + "There was no evidence of metastatic disease on PET.", + "Based on these findings, solid type PIOSCC was diagnosed.", + "The patient underwent tumor ablative surgery.", + "After bilateral supraomohyoid neck dissection, the primary tumor was radically excised.", + "The surgical specimen comprised the anterior two-thirds of the hard palate and nasal septum.", + "The surgical specimen comprised bilateral inferior nasal conchae.", + "The surgical specimen comprised the skin around the nasal ala and nostril of the right side.", + "The surgical defect was reconstructed using a partially double-folded free radial forearm flap.", + "The surgical defect was reconstructed using a prefabricated denture-based surgical obturator.", + "Microscopic examination of the surgical specimen revealed SCC without cystic component in the maxillary bone.", + "The islands of the tumor cells extended into the bone.", + "There was no dysplasia or carcinoma in the skin and mucosa of the nasal cavity and maxillary sinus.", + "The dissected surgical specimen of the neck showed one lymph node metastasis of the ipsilateral submandibular region.", + "Adjuvant radiotherapy was recommended.", + "The patient declined additional treatment.", + "The postoperative course was quite good.", + "Neither recurrence nor metastasis had been found as of 3 years and 1 month postoperatively." + ], + "summary": "A 36-year-old Japanese man was referred to our clinic with a complaint of pain around the anterior maxillary region on the right side. Intraoral examination identified a firm, non-fluctuant mass with no ulceration in the vestibular region of teeth #11-13. Incisional biopsy was performed, leading to histological diagnosis of moderately differentiated squamous cell carcinoma. Contrast-enhanced computed tomography revealed a destructive tumor with no cystic lesion, >50 mm in diameter. There was no evidence of metastatic disease on chest radiography, upper gastric endoscopy or positron emission tomography. Based on these findings, solid type primary intraosseous squamous cell carcinoma was diagnosed. The patient underwent tumor ablative surgery. The surgical defect was reconstructed using a partially double-folded free radial forearm flap and prefabricated denture-based surgical obturator. The postoperative course was quite good. Neither recurrence nor metastasis had been found as of 3 years and 1 month postoperatively.", + "summary_subclaims": [ + "A 36-year-old Japanese man was referred to our clinic with a complaint of pain around the anterior maxillary region on the right side.", + "Intraoral examination identified a firm, non-fluctuant mass with no ulceration in the vestibular region of teeth #11-13.", + "Incisional biopsy was performed, leading to histological diagnosis of moderately differentiated squamous cell carcinoma.", + "Contrast-enhanced computed tomography revealed a destructive tumor with no cystic lesion, >50 mm in diameter.", + "There was no evidence of metastatic disease on chest radiography.", + "There was no evidence of metastatic disease on upper gastric endoscopy.", + "There was no evidence of metastatic disease on positron emission tomography.", + "Based on these findings, solid type primary intraosseous squamous cell carcinoma was diagnosed.", + "The patient underwent tumor ablative surgery.", + "The surgical defect was reconstructed using a partially double-folded free radial forearm flap.", + "The surgical defect was reconstructed using a prefabricated denture-based surgical obturator.", + "The postoperative course was quite good.", + "Neither recurrence nor metastasis had been found as of 3 years and 1 month postoperatively." + ] + }, + { + "id": "multiclinsum_test_202_en.txt", + "fulltext": "A 76-year-old woman who had a past medical history of hypertension, atrial fibrillation, and right thalamic hemorrhage was admitted to the hospital because of fever and impaired balance. She suffered neck pain and dysarthria two days after admission and became somnolent. CSF examination showed pleocytosis (130 cells/mm3 [mononuclear cell: 130 cells/mm3], normal < 5 cells/mm3) and increased protein levels (113 mg/dL, normal < 50 mg/dL). She was treated with intravenous acyclovir on suspicion of viral meningoencephalitis. Her symptoms did not improve, and she was referred to our hospital for further investigation and treatment 22 days after onset. On admission, she was afebrile, and her consciousness level was E3V3M5 on the Glasgow Coma Scale. Her speech was slurred and barely comprehensible. She had left hemiparesis because of a past thalamic hemorrhage and flaccid muscle weakness in her right lower extremity. Tendon reflexes were hyperreflexia in both upper limbs and areflexia in both lower limbs. She had nuchal rigidity, but Kernig’s sign and Brudzinski’s sign were not observed.\nPeripheral blood cell counts showed mild thrombocytopenia (141 × 103 /µL, normal range: 158–348 × 103/µL). Biochemical examinations showed hypoalbuminemia (2.8 g/dL, normal range: 4.1–5.1 g/dL) and an elevated urea-nitrogen creatinine ratio suggestive of dehydration. C-reactive protein was within the normal limit. Serum thyroid stimulating hormone and free thyroxine levels were within normal limits. A mild elevated carbohydrate antigen 19 − 9 level was observed (39.2 U/mL, normal ≤ 37.0 U/mL). Serum anti-nuclear antibody and anti-aquaporin 4 antibody were negative. Anti-neuronal antibodies including anti-amphiphysin, CV2, Ma2, Ri, Yo, Hu, recoverin, SRY-related HMG-box gene 1, titin, zinc-finger protein of the cerebellum 4, Tr, and glutamic acid decarboxylase 65 antibodies were all negative results (Euroimmun, Lübeck, Germany). Mycobacterium tuberculosis specific interferon-gamma release assay and serum Candida, Aspergillus, and Cryptococcus antigens were negative.\nCSF examination showed normal opening pressure (105 mmH2O), pleocytosis (42 cells/mm3 [mononuclear cell: 41 cells/mm3]), increased protein levels (95 mg/dL), and mildly decreased glucose levels (40 mg/dL). Bacterial culture had a negative result. Herpes simplex virus and Mycobacterium tuberculosis polymerase chain reaction tests also gave negative results. CSF cytology showed no malignant cells. Later, CSF GFAP-IgG was detected by transfected cell-based assay and tissue-based immunofluorescence assay according to previous reports [, ] .\nBrain MRI scans showed abnormal signal changes caused by a past right thalamic hemorrhage and extended white matter hyperintensity lesions in the deep and periventricular white matter in the right frontal and parietal lobes on T2-weighted and FLAIR images . Gadolinium contrast-enhanced brain MRI scans showed heterogeneous thickening of the dura mater . Spinal MRI showed no abnormal signal changes in the spinal cord. Whole body computed tomography (CT) showed no findings of neoplasia. However, early-stage breast cancer was found in the left breast on mammography.\nBased on these results, the patient was diagnosed with GFAP-A. She was treated with an intravenous infusion of 1 gram per day methylprednisolone for 3 days starting on day 8 after admission. Her nuchal rigidity disappeared on day 10. Her consciousness level gradually improved starting on day 11 and became completely clear on day 32. She was also treated with intravenous immunoglobulin (0.4 gram per kilogram body weight for 5 days) on day 36 and again on day 60. She was temporarily transferred to the local hospital on day 91 for rehabilitation.\nA month later, the patient was re-admitted to our hospital and underwent a simple mastectomy for breast cancer. The pathological findings were invasive ductal carcinoma, tubule forming type . Immunohistochemical analysis showed that the restricted tumor expressed GFAP . The infiltration of CD3 + T cells were observed in the peritumoral and intratumoral areas . The most common infiltrating lymphocytes were CD8 + T cells . CD4 + T cells and CD20 + B cells were also observed in the predominant peritumoral area . Her condition did not deteriorate, and no relapse occurred thereafter.", + "fulltext_subclaims": [ + "The patient was a 76-year-old woman.", + "She had a past medical history of hypertension.", + "She had a past medical history of atrial fibrillation.", + "She had a past medical history of right thalamic hemorrhage.", + "She was admitted to the hospital because of fever.", + "She was admitted to the hospital because of impaired balance.", + "She suffered neck pain two days after admission.", + "She suffered dysarthria two days after admission.", + "She became somnolent.", + "CSF examination showed pleocytosis (130 cells/mm3).", + "CSF mononuclear cells were 130 cells/mm3.", + "CSF protein levels were 113 mg/dL.", + "She was treated with intravenous acyclovir.", + "Her symptoms did not improve.", + "She was referred to our hospital 22 days after onset.", + "On admission, her consciousness level was E3V3M5 on the Glasgow Coma Scale.", + "Her speech was slurred and barely comprehensible.", + "She had left hemiparesis because of a past thalamic hemorrhage.", + "She had flaccid muscle weakness in her right lower extremity.", + "Tendon reflexes were hyperreflexia in both upper limbs.", + "Tendon reflexes were areflexia in both lower limbs.", + "She had nuchal rigidity.", + "Kernig’s sign was not observed.", + "Brudzinski’s sign was not observed.", + "Peripheral blood cell counts showed mild thrombocytopenia (141 × 103 /µL).", + "Biochemical examinations showed hypoalbuminemia (2.8 g/dL).", + "An elevated urea-nitrogen creatinine ratio was observed.", + "C-reactive protein was within the normal limit.", + "Serum thyroid stimulating hormone was within normal limits.", + "Serum free thyroxine was within normal limits.", + "A mild elevated carbohydrate antigen 19 − 9 level was observed (39.2 U/mL).", + "Serum anti-nuclear antibody was negative.", + "Serum anti-aquaporin 4 antibody was negative.", + "Anti-neuronal antibodies including anti-amphiphysin, CV2, Ma2, Ri, Yo, Hu, recoverin, SRY-related HMG-box gene 1, titin, zinc-finger protein of the cerebellum 4, Tr, and glutamic acid decarboxylase 65 antibodies were all negative.", + "Mycobacterium tuberculosis specific interferon-gamma release assay was negative.", + "Serum Candida antigens were negative.", + "Serum Aspergillus antigens were negative.", + "Serum Cryptococcus antigens were negative.", + "CSF opening pressure was 105 mmH2O.", + "CSF pleocytosis was 42 cells/mm3.", + "CSF mononuclear cells were 41 cells/mm3.", + "CSF protein levels were 95 mg/dL.", + "CSF glucose levels were 40 mg/dL.", + "Bacterial culture had a negative result.", + "Herpes simplex virus polymerase chain reaction test was negative.", + "Mycobacterium tuberculosis polymerase chain reaction test was negative.", + "CSF cytology showed no malignant cells.", + "CSF GFAP-IgG was detected by transfected cell-based assay.", + "CSF GFAP-IgG was detected by tissue-based immunofluorescence assay.", + "Brain MRI showed abnormal signal changes caused by a past right thalamic hemorrhage.", + "Brain MRI showed extended white matter hyperintensity lesions in the deep and periventricular white matter in the right frontal and parietal lobes.", + "Gadolinium contrast-enhanced brain MRI showed heterogeneous thickening of the dura mater.", + "Spinal MRI showed no abnormal signal changes in the spinal cord.", + "Whole body CT showed no findings of neoplasia.", + "Early-stage breast cancer was found in the left breast on mammography.", + "The patient was diagnosed with GFAP-A.", + "She was treated with intravenous infusion of 1 gram per day methylprednisolone for 3 days.", + "Her nuchal rigidity disappeared on day 10.", + "Her consciousness level gradually improved starting on day 11.", + "Her consciousness level became completely clear on day 32.", + "She was treated with intravenous immunoglobulin (0.4 gram per kilogram body weight for 5 days) on day 36.", + "She was treated with intravenous immunoglobulin again on day 60.", + "She was temporarily transferred to the local hospital on day 91 for rehabilitation.", + "A month later, the patient was re-admitted to our hospital.", + "She underwent a simple mastectomy for breast cancer.", + "The pathological findings were invasive ductal carcinoma, tubule forming type.", + "Immunohistochemical analysis showed that the restricted tumor expressed GFAP.", + "The infiltration of CD3 + T cells was observed in the peritumoral and intratumoral areas.", + "The most common infiltrating lymphocytes were CD8 + T cells.", + "CD4 + T cells were observed in the predominant peritumoral area.", + "CD20 + B cells were observed in the predominant peritumoral area.", + "Her condition did not deteriorate.", + "No relapse occurred thereafter." + ], + "summary": "We report a case of 76-year-old female patient with GFAP-A complicated with breast cancer. She presented with altered consciousness, nuchal rigidity, speech disturbances, and weakness. Her clinical symptoms were improved by immunotherapy and cancer treatments. Immunohistochemical analysis showed that the restricted tumor expressed GFAP. The infiltration of CD3 + T cells were observed in the peritumoral and intratumoral areas. The most common infiltrating lymphocytes were CD8 + T cells. CD4 + T cells and CD20 + B cells were also observed in the predominant peritumoral area.", + "summary_subclaims": [ + "The patient was a 76-year-old female.", + "The patient had GFAP-A complicated with breast cancer.", + "She presented with altered consciousness.", + "She had nuchal rigidity.", + "She had speech disturbances.", + "She had weakness.", + "Her clinical symptoms were improved by immunotherapy.", + "Her clinical symptoms were improved by cancer treatments.", + "Immunohistochemical analysis showed that the restricted tumor expressed GFAP.", + "The infiltration of CD3 + T cells was observed in the peritumoral and intratumoral areas.", + "The most common infiltrating lymphocytes were CD8 + T cells.", + "CD4 + T cells were observed in the predominant peritumoral area.", + "CD20 + B cells were observed in the predominant peritumoral area." + ] + }, + { + "id": "multiclinsum_test_383_en.txt", + "fulltext": "A 46-year-old female patient presented at our department to undergo cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) with chief complaints of intra-abdominal recurrence and metastasis of a sigmoid colon tumor.\nIn the preoperative assessment, the patient’s vital signs were stable and complete blood test results were within the normal range. Further, chest X-ray findings were unremarkable, except for the presence of a chemoport through the right central vein. Meanwhile, electrocardiogram revealed a normal sinus rhythm of 60 beats per minute.\nThe patient reported that she had undergone laparoscopic anterior resection of the colon 3 years ago. She also reported having the same medical conditions and undergoing CRS and HIPEC 2 years ago.\nThe patient had no family or genetic history of the disease.\nGiven that the patient had a chemoport through the right central vein, during anesthesia in the operating room, we decided to insert a central venous catheter through the left internal jugular vein. The location of the left internal jugular vein was confirmed using ultrasound, and the needle was inserted after confirming the course of the vein.\nAlthough the internal jugular vein was distinctly visible on the ultrasound scan, blood reflux was noted when the needle tip was not within the ultrasound field of view. The guide wire was pushed through the needle, and we confirmed that it entered without resistance. Further, a 7-Fr 2-lumen central venous catheter was inserted along the guide wire without resistance. After inserting the catheter up to 15 cm, the guide wire was removed. Then, to remove the air, we regurgitated blood from the catheter and assessed blood reflux. However, after approximately 1 cc of blood was refluxed, we found that when blood reflux was induced, only clear fluid regurgitated from the 16-G distal port of the central venous catheter, but no blood regurgitated from the 18-G proximal port of central venous catheter. Because intravenous fluid administration was not started and no abnormal fluid collection was noted on preoperative chest X-ray, thoracic duct cannulation was suspected. Thus, we determined that central venous catheter could not be used as a central line. Accordingly, we reinserted the central venous catheter through the left subclavian vein under ultrasound guidance. Further, while carefully monitoring the needle tip and guide wire, we easily inserted the central venous catheter . The patient’s vital signs were stable. Meanwhile, the position of the tip of the internal jugular central venous catheter that was initially inserted was unclear. However, we determined that the catheter was unlikely to affect vital signs and that removing it without checking its position could cause problems. Therefore, we decided to leave it in the same position and checked its position after surgery.\nPostoperative complete blood test results were within the normal range.\nIn the recovery room, a chest X-ray was obtained , which revealed an appearance similar to that of the path of the thoracic duct.", + "fulltext_subclaims": [ + "The patient is a 46-year-old female.", + "The patient presented for cytoreductive surgery and hyperthermic intraperitoneal chemotherapy.", + "The patient had intra-abdominal recurrence and metastasis of a sigmoid colon tumor.", + "The patient’s vital signs were stable in the preoperative assessment.", + "Complete blood test results were within the normal range.", + "Chest X-ray findings were unremarkable, except for the presence of a chemoport through the right central vein.", + "Electrocardiogram revealed a normal sinus rhythm of 60 beats per minute.", + "The patient had undergone laparoscopic anterior resection of the colon 3 years ago.", + "The patient had undergone CRS and HIPEC 2 years ago.", + "The patient had no family or genetic history of the disease.", + "A central venous catheter was inserted through the left internal jugular vein.", + "The location of the left internal jugular vein was confirmed using ultrasound.", + "Blood reflux was noted when the needle tip was not within the ultrasound field of view.", + "A 7-Fr 2-lumen central venous catheter was inserted along the guide wire without resistance.", + "After inserting the catheter up to 15 cm, the guide wire was removed.", + "When blood reflux was induced, only clear fluid regurgitated from the 16-G distal port of the central venous catheter.", + "No blood regurgitated from the 18-G proximal port of the central venous catheter.", + "Thoracic duct cannulation was suspected.", + "The central venous catheter was reinserted through the left subclavian vein under ultrasound guidance.", + "The patient’s vital signs were stable.", + "The position of the tip of the initially inserted internal jugular central venous catheter was unclear.", + "The catheter was left in the same position.", + "A chest X-ray was obtained in the recovery room.", + "The chest X-ray revealed an appearance similar to that of the path of the thoracic duct." + ], + "summary": "A 46-year-old female patient presented at our department to undergo cytoreductive surgery and hyperthermic intraperitoneal chemotherapy. During anesthesia, we decided to insert a central venous catheter through the left internal jugular vein because the patient already had a chemoport through the right central vein. During the procedure, blood reflux was observed when the needle tip was not within the ultrasound field of view. We did not try to find the tip; however, a guide wire and a central venous catheter were inserted without any resistance. Subsequently, when inducing blood reflux from the distal port of the central venous catheter, only clear fluid, suspected to be lymphatic fluid, was regurgitated. Further, chest X-ray revealed an appearance similar to that of the path of the thoracic duct. Given that intravenous fluid administration was not started and no abnormal fluid collection was noted on preoperative chest X-ray, we suspected thoracic duct cannulation.", + "summary_subclaims": [ + "The patient was a 46-year-old female.", + "The patient presented to undergo cytoreductive surgery and hyperthermic intraperitoneal chemotherapy.", + "A central venous catheter was inserted through the left internal jugular vein.", + "The patient already had a chemoport through the right central vein.", + "Blood reflux was observed when the needle tip was not within the ultrasound field of view.", + "The needle tip was not located after blood reflux was observed.", + "A guide wire and central venous catheter were inserted without resistance.", + "Clear fluid, suspected to be lymphatic fluid, was regurgitated from the distal port.", + "Chest X-ray showed an appearance similar to the path of the thoracic duct.", + "Intravenous fluid administration was not started.", + "No abnormal fluid collection was noted on preoperative chest X-ray.", + "Thoracic duct cannulation was suspected." + ] + }, + { + "id": "multiclinsum_test_2690_en.txt", + "fulltext": "A 59-year-old male patient was diagnosed in 2003 with a smoldering multiple myeloma (IgG lambda) with bone marrow infiltration of 10 to 20% (negative CRAB criteria at that time). In 2004, he developed nephrotic syndrome and a histological diagnosis of focal segmental glomerulosclerosis was made. Immunofluorescence showed C3c deposition but dense deposits were absent on electron microscopy. Six months later, the patient developed progressive renal failure with nephritic syndrome. A subsequent kidney biopsy revealed crescentic membranoproliferative glomerulonephritis with dense deposits (dense deposit disease; DDD). Immunohistochemistry was negative for IgG, IgA, IgM and C1q. Despite treatment with cyclophosphamide, his kidney function rapidly decreased to end-stage renal disease (ESRD) in 2004. In the light of a stable remission of his multiple myeloma for 10 years (stage I Salmon/Durie; stage III ISS in 2014; positive CRAB-criteria: renal failure, anemia), a kidney transplantation was planned.\nAfter deceased donor kidney transplantation in October 2015, a kidney biopsy was performed at day seven because of delayed graft function. Immunosuppressive medication consisted of cyclosporine, mycophenolate mofetile and oral glucocorticoids without prior induction therapy. The biopsy revealed acute tubular necrosis, acute cellular rejection and an intracapillary proliferative glomerulonephritis (Banff IA; Fig. ). The biopsy result before receiving the additional immunohistochemical staining was compatible with mixed cellular and humoral rejection. The patient received four sessions of plasmapheresis and three doses of antithymocyte globuline (75 mg each) in combination with glucocorticoid pulse therapy. Cyclosporine was switched to tacrolimus. Additional immunohistochemical stainings revealed C3c deposition and on electron microscopy mesangial and dense intramembranous osmiophilic deposits were present, indicating an early recurrence of DDD in the allograft . Graft function improved to a stable creatinine of 2.6 mg/dl over several weeks .\nIn December 2015, creatinine increased to 3.2 mg/dl. Serum C3 was low (55 mg/dl) and the patient had active urine sediment. Tacrolimus trough levels were stable. A successive kidney biopsy confirmed C3G and minimal residual tubulitis diagnostic of borderline cellular rejection . CRAB criteria were positive for renal insufficiency and anemia. The concentration of free lambda light chain was 10.2 mg/l. Another course of high-dose corticosteroids was combined with five sessions of plasmapheresis and subsequent induction therapy with bortezomib and dexamethasone. Myeloma bone marrow infiltration was 20% at that time. After short-term stabilization (creatinine 3.2 mg/dl over 14 days), graft function rapidly deteriorated over several days . Despite four sessions of plasmapheresis, allograft function further declined and hemodialysis treatment was startet on 30th Dec 2015. Because of refractory MG-C3G, treatment was switched to eculizumab. The first infusion of 900 mg was given on 4th Jan 2016 followed by three infusions of 900 mg eculizumab weekly and one additional dose of 1200 mg 2 weeks thereafter. Graft function improved promptly and tapering of oral steroids was possible. Serum C3 increased from 55 mg/dl before treatment to 84 mg/dl after the induction course of eculizumab. Bortezomib had to be stopped after three cycles because of polyneuropathy.\nIn March 2016, creatinine increased and the patient developed nephrotic-range proteinuria . A graft biopsy showed active DDD without any sign of myeloma infiltration . The myeloma bone marrow infiltration at this time was 6% and free lambda light chain concentration was 10.4 mg/l. After restarting eculizumab 1200 mg every other week, creatinine and proteinuria improved quickly, indicating a rapid clinical response to complement inhibition. At the last follow-up in March 2018, the patient was well and had a stable allograft function (creatinine of 1.9 mg/dl) without proteinuria (230 mg/g creatinine). Serum C3 was decreased with 57 mg/dl, indicating persisting subclinical immunological activity of MG-C3G. Free lambda light chain concentration at last follow-up was 8.9 mg/l. No progression of myeloma occurred during a 28-months-follow-up after kidney transplantation and besides bortezomib-induced polyneuropathy, no adverse treatment effects were observed.", + "fulltext_subclaims": [ + "The patient was diagnosed in 2003 with smoldering multiple myeloma (IgG lambda).", + "Bone marrow infiltration was 10 to 20% at the time of diagnosis.", + "CRAB criteria were negative at the time of diagnosis.", + "In 2004, the patient developed nephrotic syndrome.", + "A histological diagnosis of focal segmental glomerulosclerosis was made.", + "Immunofluorescence showed C3c deposition.", + "Dense deposits were absent on electron microscopy.", + "Six months later, the patient developed progressive renal failure with nephritic syndrome.", + "A subsequent kidney biopsy revealed crescentic membranoproliferative glomerulonephritis with dense deposits.", + "The diagnosis was dense deposit disease (DDD).", + "Immunohistochemistry was negative for IgG, IgA, IgM, and C1q.", + "Despite treatment with cyclophosphamide, the patient's kidney function rapidly decreased to end-stage renal disease in 2004.", + "The patient had a stable remission of multiple myeloma for 10 years.", + "The myeloma stage was I Salmon/Durie in 2003.", + "The myeloma stage was III ISS in 2014.", + "CRAB criteria were positive for renal failure and anemia.", + "A kidney transplantation was planned.", + "A deceased donor kidney transplantation was performed in October 2015.", + "A kidney biopsy was performed at day seven because of delayed graft function.", + "Immunosuppressive medication consisted of cyclosporine, mycophenolate mofetile, and oral glucocorticoids.", + "The biopsy revealed acute tubular necrosis.", + "The biopsy revealed acute cellular rejection.", + "The biopsy revealed an intracapillary proliferative glomerulonephritis.", + "The biopsy result before additional immunohistochemical staining was compatible with mixed cellular and humoral rejection.", + "The patient received four sessions of plasmapheresis.", + "The patient received three doses of antithymocyte globuline (75 mg each).", + "The patient received glucocorticoid pulse therapy.", + "Cyclosporine was switched to tacrolimus.", + "Additional immunohistochemical stainings revealed C3c deposition.", + "Mesangial and dense intramembranous osmiophilic deposits were present on electron microscopy.", + "This indicated an early recurrence of DDD in the allograft.", + "Graft function improved to a stable creatinine of 2.6 mg/dl over several weeks.", + "In December 2015, creatinine increased to 3.2 mg/dl.", + "Serum C3 was low at 55 mg/dl.", + "The patient had active urine sediment.", + "Tacrolimus trough levels were stable.", + "A successive kidney biopsy confirmed C3G.", + "The biopsy showed minimal residual tubulitis diagnostic of borderline cellular rejection.", + "CRAB criteria were positive for renal insufficiency and anemia.", + "The concentration of free lambda light chain was 10.2 mg/l.", + "Another course of high-dose corticosteroids was combined with five sessions of plasmapheresis.", + "Subsequent induction therapy with bortezomib and dexamethasone was given.", + "Myeloma bone marrow infiltration was 20% at that time.", + "After short-term stabilization, graft function rapidly deteriorated over several days.", + "Despite four sessions of plasmapheresis, allograft function further declined.", + "Hemodialysis treatment was started on 30th Dec 2015.", + "Treatment was switched to eculizumab.", + "The first infusion of eculizumab was 900 mg on 4th Jan 2016.", + "Three infusions of 900 mg eculizumab were given weekly.", + "One additional dose of 1200 mg eculizumab was given 2 weeks after the first infusion.", + "Graft function improved promptly.", + "Tapering of oral steroids was possible.", + "Serum C3 increased from 55 mg/dl before treatment to 84 mg/dl after the induction course of eculizumab.", + "Bortezomib had to be stopped after three cycles because of polyneuropathy.", + "In March 2016, creatinine increased and the patient developed nephrotic-range proteinuria.", + "A graft biopsy showed active DDD.", + "There were no signs of myeloma infiltration.", + "The myeloma bone marrow infiltration at this time was 6%.", + "The free lambda light chain concentration was 10.4 mg/l.", + "After restarting eculizumab 1200 mg every other week, creatinine and proteinuria improved quickly.", + "This indicated a rapid clinical response to complement inhibition.", + "At the last follow-up in March 2018, the patient had a stable allograft function (creatinine of 1.9 mg/dl).", + "There was no proteinuria (230 mg/g creatinine).", + "Serum C3 was decreased with 57 mg/dl.", + "This indicated persisting subclinical immunological activity of MG-C3G.", + "The free lambda light chain concentration at last follow-up was 8.9 mg/l.", + "No progression of myeloma occurred during a 28-months-follow-up after kidney transplantation.", + "Besides bortezomib-induced polyneuropathy, no adverse treatment effects were observed." + ], + "summary": "We report a patient with recurrent MG-C3G in a renal allograft that was successfully treated with eculizumab in addition to standard immunosuppression. He had early recurrence of MG-C3G 2 months after transplantation. His graft function successively declined despite high dose steroids and plasmapheresis. Only after therapy with three cycles of bortezomib and continuous therapy with eculizumab, his graft function stabilized. He was still in clinical remission after 28 months of follow-up without having experienced major infectious complications.", + "summary_subclaims": [ + "The patient had recurrent MG-C3G in a renal allograft.", + "The patient was successfully treated with eculizumab in addition to standard immunosuppression.", + "He had early recurrence of MG-C3G 2 months after transplantation.", + "His graft function successively declined despite high dose steroids and plasmapheresis.", + "Only after therapy with three cycles of bortezomib and continuous therapy with eculizumab, his graft function stabilized.", + "He was still in clinical remission after 28 months of follow-up.", + "He did not experience major infectious complications." + ] + }, + { + "id": "multiclinsum_test_1918_en.txt", + "fulltext": "The patient, a 47-year-old male piano tuner, complained of weakness in his left hand, with no apparent traumatic causes of flexion or extension of the distal phalanges of his left thumb for two months.\nOver the past 2 mo, his condition has progressively deteriorated with weakness in his left hand, as well as ancient flexion weakness in the distal left thumb and significant restriction of movement.\nThe patient has no family history of alcohol or tobacco addiction and was in good overall mental condition.\nNo significant medical history.\nLeft thumb long flexor tendon strength grade 4, left index finger deep flexor tendon strength grade 0, left thumb short flexor strength grade 5, left index finger short flexor strength grade 5, no significant abnormalities of superficial skin sensation in the left hand and left forearm. The palmar aspect of the left wrist is flatter than that of the right wrist (anterior rotator muscle), and there are no significant abnormalities in finger movement or blood flow in the remaining fingers.\nNone.\nDigital radiography examination: The left ulnar radius is regular in shape with continuous bone cortex and clear bone trabeculae, with no obvious signs of bone destruction. The distal ulnar flexor and flexor carpal joint gaps were moderate and there were no obvious abnormalities in the surrounding soft tissues .\nColour ultrasonic Doppler examination: Widening of the median nerve cross-section over the left elbow, left side wide (0.48 cm × 0.29 cm), hypoechoic, star grid-like changes, the left side of the median nerve at the elbow is about 0.54 cm × 0.29 cm wide (right side is about 0.52 cm × 0.27 cm wide) locally hypoechoic, local nerve bundle thickness varies, one obvious narrowing is visible, local nerve bundle width is about 0.08 cm, proximal segment is 0.17 cm, the distal segment is 0.14 cm. The body surface was marked and the median nerve at the wrist was approximately 0.62 cm × 0.23 cm wide on the left (0.76 cm × 0.38 cm wide on the right).", + "fulltext_subclaims": [ + "The patient is a 47-year-old male piano tuner.", + "The patient complained of weakness in his left hand.", + "There was no apparent traumatic cause of flexion or extension of the distal phalanges of his left thumb.", + "The patient's condition has progressively deteriorated over the past 2 mo.", + "The patient has ancient flexion weakness in the distal left thumb.", + "The patient has significant restriction of movement.", + "The patient has no family history of alcohol or tobacco addiction.", + "The patient was in good overall mental condition.", + "Left thumb long flexor tendon strength grade 4.", + "Left index finger deep flexor tendon strength grade 0.", + "Left thumb short flexor strength grade 5.", + "Left index finger short flexor strength grade 5.", + "There are no significant abnormalities of superficial skin sensation in the left hand and left forearm.", + "The palmar aspect of the left wrist is flatter than that of the right wrist.", + "Digital radiography examination showed the left ulnar radius is regular in shape.", + "The distal ulnar flexor and flexor carpal joint gaps were moderate.", + "The median nerve cross-section over the left elbow was widened.", + "The left side of the median nerve at the elbow is about 0.54 cm × 0.29 cm wide.", + "The right side of the median nerve at the elbow is about 0.52 cm × 0.27 cm wide.", + "The median nerve at the wrist was approximately 0.62 cm × 0.23 cm wide on the left." + ], + "summary": "This report describes a rare hourglass constriction of the anterior interosseous nerve in the left forearm in a 47-year-old healthy male who was treated surgically and gradually recovered function over a 6-mo follow-up period.", + "summary_subclaims": [ + "This report describes a rare hourglass constriction of the anterior interosseous nerve in the left forearm.", + "The patient was a 47-year-old healthy male.", + "The patient was treated surgically.", + "The patient gradually recovered function over a 6-mo follow-up period." + ] + }, + { + "id": "multiclinsum_test_2636_en.txt", + "fulltext": "A 72-year-old male patient underwent D2 radical gastrectomy in October 2017 due to elevated carbohydrate antigen 199 (CA199, 902 U/mL) detected by routine examination and subsequently GC revealed by abdominal MRI and gastric adenocarcinoma by gastroscopy. Postoperative histopathological diagnosis was poorly differentiated from adenocarcinoma (Diffuse type) with HER2 positive (immunohistochemical), TNM staging (7th edition) was p-T4aN3aM0 (stage IIIC). After surgery, CA199 fell to 198 U/mL and the patient received six cycles of SOX (oxaliplatin 130 mg/m2, Tegafur Gimeracil Oteracil Potassium Capsule 60mg/d d1-14) regimens of adjuvant chemotherapy. In April 2018, Positron Emission Tomography-Computed Tomography (PET-CT) scan showed multiple larger lymph nodes in the right upper mesentery and abdominal aorta, the larger one was about 1.52×1.03 cm, and the maximum SUV was 3.84, indicating lymph node metastasis. According to the consensus, this postoperative adjuvant chemotherapy should be considered as a first-line treatment. – show the whole treatment process and the corresponding changes in PET-CT and computed tomography (CT) scan, as well as the changes in CA199 and carcinoembryonic antigen (CEA) levels.\nIn June 2018, CA199 (1239.0 U/mL) and CEA (18.7 ng/mL) were significantly elevated in this patient. We suggested that the patient should take trastuzumab combined with chemotherapy, but because trastuzumab was not covered by the medical insurance of Chinese residents at that time, the patient refused to use trastuzumab, so we gave the DP (docetaxel 75mg/m2, cisplatin 75mg/m2) chemotherapy to the patient. After two cycles of chemotherapy, a CT scan of the patient’s abdomen revealed a slight reduction in retroperitoneal lymph nodes. Until November 2018, new metastases were found on chest CT scan, accompanied by a significant increase in CA199 (8078.0 U/mL) and CEA (49.1 ng/mL). Subsequently, he underwent two cycles of third-line chemotherapy with irinotecan (250mg/m2). However, this regimen did not show therapeutic effect, accompanied by the continuous increase of CA199 (16644.0 U/mL) and CEA (65.6 ng/mL).\nIn January 2019, the patient developed back pain when a CT scan demonstrated progressive disease (PD) in the retroperitoneal lymph nodes. At this time, trastuzumab had been included in the medical insurance coverage of Chinese residents, so we treated the patient with trastuzumab (6mg/kg) combined with DCF (docetaxel 60mg/m2, cisplatin 60mg/m2, 5-fluorouracil 600mg/m2/d d1-5) regimen. After two cycles of therapy, the abdominal CT showed partial response (PR) of retroperitoneal lymph nodes, the back pain was significantly reduced. After four cycles of therapy, chest CT showed that pulmonary metastases disappeared, and abdominal CT showed PR of retroperitoneal lymph nodes. By August 2019, the patient received a total of 9 cycles of this regimen, during which CA199 was reduced to the lowest value of 206.0 U/mL and CEA to the lowest value of 9.3 ng/mL. In September 2019, PET-CT showed new nodules in left lung and right lung, and multiple enlarged lymph nodes in retroperitoneal. The largest lymph node had a length of about 2.4 cm, and the maximum SUV was 10.75. At the same time, CA199 (3988.0 U/mL) and CEA (30.2 ng/mL) increased significantly. Comprehensive consideration, the patient’s condition progress.\nAfter the fourth-line treatment of GC, there is no standard treatment. We suggested genetic testing, and the patient refused. After comprehensive consideration, the patient was treated with anti-angiogenesis (apatinib 250mg/d) combined with anti-PD-1 inhibitor (camrelizumab, SHR-1210, 200mg every 3 weeks). After two cycles of treatment, the abdominal CT scan showed no significant change in the size of the lesions. After that, we gave the patient two cycles of treatment again. In January 2020, CT scan showed that the retroperitoneal lymph nodes were enlarged, and CA199 (13725.0 U/mL) and CEA (48.3 ng/mL) were obviously increased.\nAfter the patient’s disease progresses, we recommend genetic testing again. Peripheral blood tests were performed because the patient’s pathological tissue was difficult to obtain. Next-generation sequencing (NGS) (543 genes; GeneCast Biotechnology Co. Ltd., Beijing, China) was performed. NGS results showed that the patient had an increased copy number of HER2 gene, no HER2 gene mutation, and a negative expression of programmed cell death ligand 1 (PD-L1). Detailed results are listed in . We conducted a multidisciplinary treatment discussion on the patient’s condition in our hospital, and found that there is no standard treatment plan for the six-line treatment of advanced GC, and no relevant clinical trial has been carried out in our hospital. According to the NGS results, the copy number of the HER2 gene was significantly increased in this patient. Pyrotinib, a novel HER2 inhibitor, has been approved in combination with capecitabine in China for patients with relapsed or metastatic breast cancer who had previously received trastuzumab. We hypothesized that pyrotinib combined with capecitabine might be effective in this patient. Therefore, with the patient’s informed consent, the patient was administered pyrotinib (400mg/d) plus capecitabine (1000 mg/m2, bid, d1-14, every 3 weeks) treatment in January 2020. After three cycles, abdominal CT scans showed PR in the retroperitoneal lymph node. After four cycles, chest CT scans showed that pulmonary nodules disappeared. At the same time, CA199 and CEA decreased steadily. In August 2020, abdominal CT still showed PR in retroperitoneal lymph nodes. The patient tolerated treatment with pyrotinib well. No adverse events were observed. Until the submission of the case draft, the patient has survived for over 30 months since postoperative recurrence and now continues to receive the combination treatment of pyrotinib plus capecitabine, and the PFS is over 8.5 months.", + "fulltext_subclaims": [ + "The patient is a 72-year-old male.", + "The patient underwent D2 radical gastrectomy in October 2017.", + "The patient had elevated carbohydrate antigen 199 (CA199) of 902 U/mL detected by routine examination.", + "Gastric cancer was revealed by abdominal MRI.", + "Gastric adenocarcinoma was confirmed by gastroscopy.", + "Postoperative histopathological diagnosis was poorly differentiated adenocarcinoma (Diffuse type).", + "HER2 was positive by immunohistochemical staining.", + "TNM staging (7th edition) was p-T4aN3aM0 (stage IIIC).", + "After surgery, CA199 fell to 198 U/mL.", + "The patient received six cycles of SOX adjuvant chemotherapy.", + "In April 2018, PET-CT showed multiple larger lymph nodes in the right upper mesentery and abdominal aorta.", + "The largest lymph node was about 1.52×1.03 cm.", + "The maximum SUV was 3.84.", + "This indicated lymph node metastasis.", + "In June 2018, CA199 was 1239.0 U/mL.", + "In June 2018, CEA was 18.7 ng/mL.", + "The patient was suggested to take trastuzumab combined with chemotherapy.", + "The patient refused trastuzumab due to lack of medical insurance coverage.", + "The patient received DP chemotherapy.", + "After two cycles of DP chemotherapy, CT scan showed a slight reduction in retroperitoneal lymph nodes.", + "In November 2018, new metastases were found on chest CT scan.", + "In November 2018, CA199 was 8078.0 U/mL.", + "In November 2018, CEA was 49.1 ng/mL.", + "The patient underwent two cycles of third-line chemotherapy with irinotecan.", + "This regimen did not show therapeutic effect.", + "CA199 increased to 16644.0 U/mL.", + "CEA increased to 65.6 ng/mL.", + "In January 2019, the patient developed back pain.", + "CT scan demonstrated progressive disease in retroperitoneal lymph nodes.", + "Trastuzumab had been included in medical insurance coverage.", + "The patient was treated with trastuzumab combined with DCF.", + "After two cycles of therapy, abdominal CT showed partial response of retroperitoneal lymph nodes.", + "Back pain was significantly reduced.", + "After four cycles of therapy, chest CT showed that pulmonary metastases disappeared.", + "Abdominal CT showed partial response of retroperitoneal lymph nodes.", + "By August 2019, the patient received a total of 9 cycles of this regimen.", + "CA199 was reduced to the lowest value of 206.0 U/mL.", + "CEA was reduced to the lowest value of 9.3 ng/mL.", + "In September 2019, PET-CT showed new nodules in left lung and right lung.", + "PET-CT showed multiple enlarged lymph nodes in retroperitoneal.", + "The largest lymph node had a length of about 2.4 cm.", + "The maximum SUV was 10.75.", + "CA199 increased to 3988.0 U/mL.", + "CEA increased to 30.2 ng/mL.", + "The patient’s condition was considered to have progressed.", + "After the fourth-line treatment of GC, there is no standard treatment.", + "The patient was suggested to undergo genetic testing.", + "The patient refused genetic testing.", + "The patient was treated with apatinib combined with camrelizumab.", + "After two cycles of treatment, abdominal CT scan showed no significant change in the size of the lesions.", + "In January 2020, CT scan showed that retroperitoneal lymph nodes were enlarged.", + "CA199 increased to 13725.0 U/mL.", + "CEA increased to 48.3 ng/mL.", + "Peripheral blood tests were performed because the patient’s pathological tissue was difficult to obtain.", + "Next-generation sequencing (NGS) was performed.", + "NGS results showed that the patient had an increased copy number of HER2 gene.", + "The patient had no HER2 gene mutation.", + "The patient had negative expression of PD-L1.", + "There is no standard treatment plan for the six-line treatment of advanced GC.", + "No relevant clinical trial has been carried out in the hospital.", + "The copy number of the HER2 gene was significantly increased in this patient.", + "Pyrotinib, a novel HER2 inhibitor, has been approved in combination with capecitabine in China for patients with relapsed or metastatic breast cancer who had previously received trastuzumab.", + "With the patient’s informed consent, the patient was administered pyrotinib plus capecitabine treatment in January 2020.", + "After three cycles, abdominal CT scans showed partial response in the retroperitoneal lymph node.", + "After four cycles, chest CT scans showed that pulmonary nodules disappeared.", + "CA199 and CEA decreased steadily.", + "In August 2020, abdominal CT still showed partial response in retroperitoneal lymph nodes.", + "The patient tolerated treatment with pyrotinib well.", + "No adverse events were observed.", + "Until the submission of the case draft, the patient has survived for over 30 months since postoperative recurrence.", + "The patient continues to receive the combination treatment of pyrotinib plus capecitabine.", + "The progression-free survival is over 8.5 months." + ], + "summary": "We report a 72-year-old male with HER2-positive gastric cancer. The patient had metastatic tumor during adjuvant chemotherapy after surgery, followed by second-line chemotherapy, and achieved a progression-free survival (PFS) of 4.5 months. Subsequent third-line chemotherapy treatment also failed. Fortunately, the patient had a significant tumor response and 8.5 months of PFS on trastuzumab combined with chemotherapy. After trastuzumab resistance, the patient was treated with programmed cell death protein-1 inhibitor combined with apatinib, which selectively inhibited VEGFR2, but the effect was not satisfactory. Finally, the patient was treated with capecitabine combined with pyrotinib, an irreversible TKI, acting on HER2. The tumor shrank significantly after this treatment.", + "summary_subclaims": [ + "The patient is a 72-year-old male.", + "The patient has HER2-positive gastric cancer.", + "The patient had metastatic tumor during adjuvant chemotherapy after surgery.", + "The patient received second-line chemotherapy.", + "The patient achieved a progression-free survival of 4.5 months.", + "The patient received third-line chemotherapy.", + "The patient had a significant tumor response on trastuzumab combined with chemotherapy.", + "The patient had 8.5 months of progression-free survival on trastuzumab combined with chemotherapy.", + "The patient was treated with a programmed cell death protein-1 inhibitor combined with apatinib.", + "Apatinib selectively inhibits VEGFR2.", + "The effect of the programmed cell death protein-1 inhibitor combined with apatinib was not satisfactory.", + "The patient was treated with capecitabine combined with pyrotinib.", + "Pyrotinib is an irreversible TKI acting on HER2.", + "The tumor shrank significantly after treatment with capecitabine combined with pyrotinib." + ] + }, + { + "id": "multiclinsum_test_2728_en.txt", + "fulltext": "A 64-year-old Caucasian male originally presented to his primary care physician due to gradually increasing right hip pain for more than two months. He denied any significant weight loss, night sweats, heart palpitations, or other systemic symptoms. His past medical history was significant for a parathyroidectomy with resection of a single parathyroid adenoma and well-controlled arterial hypertension. Family history included prostate cancer in his father. On exam, the patient had reproducible right hip pain with passive and active motion. Due to concerns for musculoskeletal pathology, magnetic resonance imaging (MRI) of the spine was obtained and had demonstrated mild degenerative changes in the spine and an 11.2 cm mid-abdominal retroperitoneal mass. Contrasted enhanced computed tomography (CT) of the abdomen and pelvis was obtained to characterize the mass; this showed an 11 cm ovoid, solid, enhancing mass in the right mid-abdominal mesentery with no associated lymphadenopathy . Given a low suspicion for a catecholamine-producing tumor (which would have necessitated further workup), the decision was made to proceed directly to an image-guided biopsy to establish a diagnosis and guide treatment. The biopsy demonstrated an atypical epithelioid and spindle cell neoplasm. The patient underwent an elective exploratory laparotomy for removal of the mass. Intraoperatively, the tumor was found to be adherent to the head of the pancreas and to the confluence of the superior mesenteric and portal veins. The tumor was resected en-bloc with a margin of pancreatic tissue and the portal vein defect was repaired primarily.\nHistologic evaluation of the tumor showed evidence of neoplastic cells arranged in nests and trabeculae within the tumor’s vasculature. Round to oval cells with moderate to abundant eosinophilic granular cytoplasm were found within the tumor bulk. Tumor was metastatic to one of the lymph nodes. The tumor immunohistochemistry demonstrated a Ki-67 index < 1%, positive succinate dehydrogenase subunit A (SDHA), SDHB, chromogranin A, and S-100 stains, and negative cytokeratin CAM 5.2 and human melanoma black-45 (HMB45) stains. These findings were consistent with a PGL with metastasis to the lymph node.\nOnce the diagnosis was obtained, urine catecholamines were immediately measured. The patient had elevated urine metanephrines 382 mcg/24 h (normal range 44 - 261 mcg/24 h) and urine normetanephrines 650 mcg/24 h (normal 138 - 521 mcg/24 h) demonstrating a functional PGL. Gallium-68 DOTATE scan showed no evidence of distant metastatic disease. Genetic analysis was performed on a peripheral blood sample using a hybridization-based protocol to enrich for regions of interest. Amplicons from the coding exons of 34 genes of interest were created using real time polymerase chain reaction, and subsequently sequenced using Illumina® technology. When compared to a reference sequence, a RET gene variant of unknown significance [c.731C>T (p.T244I)] was identified. Screening thyroid ultrasound did not demonstrate any suspicious thyroid nodules. At his three month follow up, our patient reported full recovery from the surgery with no further symptomatology and his metanephrines had normalized. At his one-year follow-up, he reported he was doing well. However, a suspicious left renal mass, concerning for renal cell carcinoma, was seen on his screening CT abdomen and pelvis. There was no evidence of recurrent disease from his metastatic PGL on imaging. At this time, patient is undergoing further work-up with urology.", + "fulltext_subclaims": [ + "The patient is a 64-year-old Caucasian male.", + "He had gradually increasing right hip pain for more than two months.", + "He denied significant weight loss, night sweats, heart palpitations, or other systemic symptoms.", + "His past medical history was significant for a parathyroidectomy with resection of a single parathyroid adenoma.", + "His past medical history was significant for well-controlled arterial hypertension.", + "Family history included prostate cancer in his father.", + "On exam, the patient had reproducible right hip pain with passive and active motion.", + "Magnetic resonance imaging (MRI) of the spine demonstrated an 11.2 cm mid-abdominal retroperitoneal mass.", + "Contrasted enhanced computed tomography (CT) of the abdomen and pelvis showed an 11 cm ovoid, solid, enhancing mass in the right mid-abdominal mesentery.", + "The CT showed no associated lymphadenopathy.", + "The decision was made to proceed directly to an image-guided biopsy.", + "The biopsy demonstrated an atypical epithelioid and spindle cell neoplasm.", + "The patient underwent an elective exploratory laparotomy for removal of the mass.", + "Intraoperatively, the tumor was found to be adherent to the head of the pancreas.", + "The tumor was resected en-bloc with a margin of pancreatic tissue.", + "The portal vein defect was repaired primarily.", + "Histologic evaluation showed neoplastic cells arranged in nests and trabeculae within the tumor’s vasculature.", + "Tumor was metastatic to one of the lymph nodes.", + "The tumor immunohistochemistry demonstrated a Ki-67 index < 1%.", + "The tumor immunohistochemistry showed positive SDHA, SDHB, chromogranin A, and S-100 stains.", + "The tumor immunohistochemistry showed negative cytokeratin CAM 5.2 and HMB45 stains.", + "These findings were consistent with a PGL with metastasis to the lymph node.", + "Urine metanephrines were 382 mcg/24 h.", + "Urine normetanephrines were 650 mcg/24 h.", + "Elevated urine metanephrines and normetanephrines demonstrated a functional PGL.", + "A RET gene variant of unknown significance [c.731C>T (p.T244I)] was identified.", + "Screening thyroid ultrasound did not demonstrate any suspicious thyroid nodules.", + "At his three month follow up, the patient reported full recovery from the surgery.", + "At his three month follow up, his metanephrines had normalized.", + "At his one-year follow-up, a suspicious left renal mass, concerning for renal cell carcinoma, was seen on CT.", + "There was no evidence of recurrent disease from his metastatic PGL on imaging.", + "The patient is undergoing further work-up with urology." + ], + "summary": "We report a case of a 64-year-old man with a history of parathyroid adenoma who developed a pancreatic retroperitoneal paraganglioma. Despite having laboratory evidence of excess circulating catecholamines, the patient's only presenting symptom was hip pain. The patient underwent resection, and histologic findings were consistent with paraganglioma with lymph node metastasis. Genetic testing revealed a variant of uncertain significance within the RET gene", + "summary_subclaims": [ + "The patient is a 64-year-old man.", + "The patient has a history of parathyroid adenoma.", + "The patient developed a pancreatic retroperitoneal paraganglioma.", + "The patient had laboratory evidence of excess circulating catecholamines.", + "The patient's only presenting symptom was hip pain.", + "The patient underwent resection.", + "Histologic findings were consistent with paraganglioma.", + "Histologic findings showed lymph node metastasis.", + "Genetic testing revealed a variant of uncertain significance within the RET gene." + ] + }, + { + "id": "multiclinsum_test_3077_en.txt", + "fulltext": "A 29-year-old right-handed Ethiopian male patient presented with a 10-year history of exercise intolerance that worsened with mild-to-moderate exertion. In addition, he reported bilateral ptosis (drooping eyelids) since childhood. He also had difficulty ambulating, with intermittent loss of balance, especially at night. A permanent pacemaker was inserted in 2018 after he was diagnosed with third-degree AV block with an electrocardiogram (ECG). Pacemaker implantation resulted in substantial improvement in exercise tolerance. However, the patient subsequently developed new neurological symptoms, including dysarthria (slurred speech) and intermittent attention deficits, particularly during listening tasks. Moreover, he reported a decline in hearing ability. Family history was negative for similar presentations. Physical examination revealed general muscle wasting and bilateral symmetrical ptosis. Limitation of ocular movements in all quadrants was found on examination of cranial nerves 3, 4, and 6. On examinations of cranial nerve 8, he could not hear finger rubbing sounds from 2 cm, but there was no lateralization on Rhine and Webber tests. The muscle bulk was comparable in all four extremities, and power and tone were normal. However, dysmetria on the finger-to-nose test was noted. He was also unable to perform tandem gait. He was referred to the otolaryngology department for audiometry evaluation and was found to have mild bilateral sensorineural hearing loss.\n\nLaboratory evaluations were within normal reference ranges, including a complete blood count (CBC), renal function tests (RFTs), serum electrolytes, and metabolic panels. Specifically, the CBC revealed white blood cells at 6500/μL, hemoglobin at 16.5 g/dL, and platelets at 193,000/μL. Fasting blood sugar was 95 mg/dL, and TSH level was 2.35 ng/dL.\n\nElectrophysiological studies yielded normal results, including electromyography (EMG) and nerve conduction studies (NCS).\n\nTreatment and outcomes\nThe patient underwent permanent pacemaker placement, resulting in a marked improvement in exertional dyspnea. A multidisciplinary team currently follows him, including the cardiology, neurology, and ophthalmology departments.", + "fulltext_subclaims": [ + "The patient is a 29-year-old right-handed Ethiopian male.", + "He has a 10-year history of exercise intolerance that worsened with mild-to-moderate exertion.", + "He reported bilateral ptosis since childhood.", + "He had difficulty ambulating with intermittent loss of balance, especially at night.", + "A permanent pacemaker was inserted in 2018 after he was diagnosed with third-degree AV block with an ECG.", + "Pacemaker implantation resulted in substantial improvement in exercise tolerance.", + "The patient subsequently developed new neurological symptoms, including dysarthria and intermittent attention deficits, particularly during listening tasks.", + "He reported a decline in hearing ability.", + "Family history was negative for similar presentations.", + "Physical examination revealed general muscle wasting and bilateral symmetrical ptosis.", + "Limitation of ocular movements in all quadrants was found on examination of cranial nerves 3, 4, and 6.", + "On examinations of cranial nerve 8, he could not hear finger rubbing sounds from 2 cm.", + "There was no lateralization on Rhine and Webber tests.", + "The muscle bulk was comparable in all four extremities.", + "Power and tone were normal.", + "Dysmetria on the finger-to-nose test was noted.", + "He was unable to perform tandem gait.", + "He was referred to the otolaryngology department for audiometry evaluation.", + "Audiometry evaluation found mild bilateral sensorineural hearing loss.", + "Laboratory evaluations were within normal reference ranges.", + "The CBC revealed white blood cells at 6500/μL.", + "The CBC revealed hemoglobin at 16.5 g/dL.", + "The CBC revealed platelets at 193,000/μL.", + "Fasting blood sugar was 95 mg/dL.", + "TSH level was 2.35 ng/dL.", + "Electrophysiological studies yielded normal results.", + "Electromyography and nerve conduction studies were normal.", + "The patient underwent permanent pacemaker placement, resulting in a marked improvement in exertional dyspnea.", + "A multidisciplinary team currently follows him, including the cardiology, neurology, and ophthalmology departments." + ], + "summary": "A 29-year-old right-handed Ethiopian male patient presented with progressive exercise intolerance for 10 years. He had had bilateral ptosis since childhood and experienced gait difficulty with intermittent balance problems, particularly at night. In 2018, he was diagnosed with a third-degree atrioventricular block with a resting electrocardiogram, and a permanent pacemaker was placed. Despite marked improvement in shortness of breath following pacemaker placement, the patient's progressive ptosis and gait ataxia prompted further workup, ultimately leading to the diagnosis of Kearns-Sayre syndrome. This case highlights the importance of comprehensive assessment in patients presenting with isolated organ manifestations, as exemplified by the delayed diagnosis of Kearns-Sayre syndrome following the initial recognition of a complete heart block.", + "summary_subclaims": [ + "The patient is a 29-year-old right-handed Ethiopian male.", + "He had progressive exercise intolerance for 10 years.", + "He had had bilateral ptosis since childhood.", + "He experienced gait difficulty with intermittent balance problems, particularly at night.", + "In 2018, he was diagnosed with a third-degree atrioventricular block with a resting electrocardiogram.", + "A permanent pacemaker was placed.", + "Shortness of breath improved markedly following pacemaker placement.", + "The patient's progressive ptosis and gait ataxia prompted further workup.", + "The diagnosis of Kearns-Sayre syndrome was ultimately made.", + "This case highlights the importance of comprehensive assessment in patients presenting with isolated organ manifestations.", + "The delayed diagnosis of Kearns-Sayre syndrome followed the initial recognition of a complete heart block." + ] + }, + { + "id": "multiclinsum_test_1854_en.txt", + "fulltext": "A healthy 18-year-old woman and thirty-nine-week pregnant woman suffered sudden onset of severe pain and was admitted to the obstetrics clinic. Myelomeningocele and breech presentation was previously diagnosed in fetus. In the ultrasonographic (USG) examination; fetal stress and hydrocephaly were determined and urgent cesarean was planned. A 2690 g. female baby was delivered with Apgar scores between seven to eight at an hour and five minutes. Swelling was determined on both her thighs in routine neonatal evaluation few minutes after the delivery. The neonate seemed irritated with the palpation of thighs. She was consulted to our department immediately. Antero-posterior and lateral radiographs of each femur were taken which revealed displaced femur shaft fractures on both sides . At first a pelvipedal cast was thought, however to avoid the lesion irritation on the lumbar skin, long leg splints were performed on both lower limbs for three weeks. The fractures healed uneventfully after three weeks . The follow-ups were continued at obstetric clinic during hospitalization. Myelomeningocele was repaired by plastic surgeons and neuro-surgeons ten days after her discharge from obstetric department.", + "fulltext_subclaims": [ + "A healthy 18-year-old woman and thirty-nine-week pregnant woman suffered sudden onset of severe pain.", + "Myelomeningocele and breech presentation was previously diagnosed in fetus.", + "In the ultrasonographic (USG) examination, fetal stress and hydrocephaly were determined.", + "Urgent cesarean was planned.", + "A 2690 g. female baby was delivered.", + "Apgar scores were between seven to eight at an hour and five minutes.", + "Swelling was determined on both her thighs in routine neonatal evaluation few minutes after the delivery.", + "The neonate seemed irritated with the palpation of thighs.", + "Antero-posterior and lateral radiographs of each femur were taken.", + "The radiographs revealed displaced femur shaft fractures on both sides.", + "A pelvipedal cast was thought.", + "Long leg splints were performed on both lower limbs for three weeks.", + "The fractures healed uneventfully after three weeks.", + "Myelomeningocele was repaired by plastic surgeons and neuro-surgeons ten days after her discharge from obstetric department." + ], + "summary": "A 2690 g female newborn with myelomeningocele sustained bilateral femoral shaft fractures during cesarean section. Complete healing was obtained without sequelae after 21 days ofimmobilization with long leg splints.", + "summary_subclaims": [ + "The newborn was a 2690 g female.", + "The newborn had myelomeningocele.", + "The newborn sustained bilateral femoral shaft fractures.", + "The fractures occurred during cesarean section.", + "Complete healing was obtained.", + "The healing occurred after 21 days of immobilization with long leg splints.", + "There were no sequelae." + ] + }, + { + "id": "multiclinsum_test_2964_en.txt", + "fulltext": "In January 2004 previously healthy 38-year-old man was admitted to hospital with fever (40°C) and arthralgia of upper and lower extremities. He was not addicted to drugs or alcohol. He smoked about 20 cigarettes per day. Physical examination revealed mild tachycardia with normal cardiac sounds and normal blood pressure. Oral cavity examination showed poor dentition. He presented generalized arthralgia and edema and redness of involved joints. Also there was a 3 day history of papulomacular haemorrhagic rash on his lower extremities. The patient had no symptoms of respiratory tract infection and X-ray examination showed no evidence of pneumonia. Laboratory evaluation revealed elevated white blood cell count (17,8 × 103/μl) with 34% of band neutrophils and 51% of granulocytes, decreased platelet count (29 × 103/μl), slightly elevated liver enzymes (AST 52 U/L, ALT 41 U/L, LDH 589 U/L, alkaline phosphate 150 U/L), hyperbilirubinemia (2,69 mg%), elevetad creatinine concentration (1,51 mg%), mild proteinuria, leucocyturia and erythrocyturia. The initial diagnosis was septicemia. Three blood samples were drawn during two first days of hospitalization for microbiological evaluation and empirical therapy with ceftazidime and teicoplanin was started.\nNontoxigenic C. diphtheriae biotype gravis was isolated from all blood cultures. On the third day of treatment the antibiotics were changed to amikacin and ciprofloxacin according to antibiogram. Despite resolution of most symptoms and negative blood and throat swab cultures after eight days of treatment the patient was still febrile. For that reason ciprofloxacin was changed to clindamycin.\nTransthoracic and transoesopharyngeal echocardiography performed on the 13th day of treatment showed two vegetations attached to the mitral and aortal valves. The patient underwent surgery for replacement of both valves. The cultures from vegetations were negative. After the operation the patient recovered. Although the cultures were negative we have supposed that the vegetations were caused by C. diphtheriae because the patient had no cardiac troubles before bacteremia.\nNontoxigenic C. diphtheriae biotype gravis isolated from blood cultures was identified and biotyped with use of morphological and biochemical methods as described elsewhere. Toxin production was examined in vitro by the conventional and modified Elek test . Polymerase chain reaction (PCR) was used for the detection of diphtheria toxin gene [,] and the PCR result was negative.\nThe susceptibility of isolates to 13 antibiotics was determined by the disk diffusion method accordingly to the National Committee for Clinical Laboratory Standards guidelines on Mueller-Hinton II blood agar (supplemented with 5% sheep blood). However NCCLS does not define breakpoints for Corynebacterium sp. For that reason interpretation was done comparatively as for Streptococcus spp. and Staphylococcus spp., because some breakpoints are different for that genera. The antimicrobial disks contained penicillin, cefaclor, cefuroxime axetil, cefazolin, ceftazidime, ceftriaxone, cefepime, amikacin, meropenem, azithromycin, trimethoprim-sulfamethoxazole, vancomycin and teicoplanin. Determination of MIC (results are shown in brackets) for ampicillin (0.5 mg/L), gentamicin (0.38 mg/L), ciprofloxacin (0.125 mg/L), clindamycin (0.25 mg/L), erythromycin (0.016 mg/L), chloramphenicol (2 mg/L) and tetracycline (0.5 mg/L) was done using E-test strips. Clindamycin and erythromycin MIC breakpoints for Streptococcus spp. are lower than for Staphylococcus spp. but both interpretations showed susceptibility of examined C. diphtheriae strain. Ampicillin MIC breakpoints pointed to investigated strain as ampicillin resistant. The strain was also resistant to penicillin and ceftazidime and intermediate to cefuroxime axetil and ceftriaxone.", + "fulltext_subclaims": [ + "In January 2004, a previously healthy 38-year-old man was admitted to hospital with fever (40°C) and arthralgia of upper and lower extremities.", + "He was not addicted to drugs or alcohol.", + "He smoked about 20 cigarettes per day.", + "Physical examination revealed mild tachycardia with normal cardiac sounds and normal blood pressure.", + "Oral cavity examination showed poor dentition.", + "He presented generalized arthralgia and edema and redness of involved joints.", + "There was a 3-day history of papulomacular haemorrhagic rash on his lower extremities.", + "The patient had no symptoms of respiratory tract infection.", + "X-ray examination showed no evidence of pneumonia.", + "Laboratory evaluation revealed elevated white blood cell count (17,8 × 103/μl) with 34% of band neutrophils and 51% of granulocytes.", + "Laboratory evaluation revealed decreased platelet count (29 × 103/μl).", + "Laboratory evaluation revealed slightly elevated liver enzymes (AST 52 U/L, ALT 41 U/L, LDH 589 U/L, alkaline phosphate 150 U/L).", + "Laboratory evaluation revealed hyperbilirubinemia (2,69 mg%).", + "Laboratory evaluation revealed elevated creatinine concentration (1,51 mg%).", + "Laboratory evaluation revealed mild proteinuria, leucocyturia and erythrocyturia.", + "The initial diagnosis was septicemia.", + "Three blood samples were drawn during the first two days of hospitalization for microbiological evaluation.", + "Empirical therapy with ceftazidime and teicoplanin was started.", + "Nontoxigenic C. diphtheriae biotype gravis was isolated from all blood cultures.", + "On the third day of treatment, antibiotics were changed to amikacin and ciprofloxacin according to antibiogram.", + "Despite resolution of most symptoms and negative blood and throat swab cultures after eight days of treatment, the patient was still febrile.", + "For that reason, ciprofloxacin was changed to clindamycin.", + "Transthoracic and transoesopharyngeal echocardiography performed on the 13th day of treatment showed two vegetations attached to the mitral and aortal valves.", + "The patient underwent surgery for replacement of both valves.", + "The cultures from vegetations were negative.", + "After the operation, the patient recovered.", + "Although the cultures were negative, we have supposed that the vegetations were caused by C. diphtheriae because the patient had no cardiac troubles before bacteremia.", + "Nontoxigenic C. diphtheriae biotype gravis isolated from blood cultures was identified and biotyped with use of morphological and biochemical methods.", + "Toxin production was examined in vitro by the conventional and modified Elek test.", + "Polymerase chain reaction (PCR) was used for the detection of diphtheria toxin gene.", + "The PCR result was negative.", + "The susceptibility of isolates to 13 antibiotics was determined by the disk diffusion method.", + "The antimicrobial disks contained penicillin, cefaclor, cefuroxime axetil, cefazolin, ceftazidime, ceftriaxone, cefepime, amikacin, meropenem, azithromycin, trimethoprim-sulfamethoxazole, vancomycin and teicoplanin.", + "Determination of MIC for ampicillin (0.5 mg/L), gentamicin (0.38 mg/L), ciprofloxacin (0.125 mg/L), clindamycin (0.25 mg/L), erythromycin (0.016 mg/L), chloramphenicol (2 mg/L) and tetracycline (0.5 mg/L) was done using E-test strips.", + "The strain was resistant to penicillin and ceftazidime.", + "The strain was intermediate to cefuroxime axetil and ceftriaxone.", + "Ampicillin MIC breakpoints pointed to the investigated strain as ampicillin resistant." + ], + "summary": "We have described the first case of septicemia and endocarditis due to nontoxigenic C. diphtheriae biotype gravis in Poland. The patient has not belonged to any group of risk such infection.", + "summary_subclaims": [ + "We have described the first case of septicemia and endocarditis due to nontoxigenic C. diphtheriae biotype gravis in Poland.", + "The patient has not belonged to any group of risk such infection." + ] + }, + { + "id": "multiclinsum_test_3149_en.txt", + "fulltext": "A 38-year-old female patient without a significant past medical history presented to the emergency department of our hospital in September 2019 with a history of exertional shortness of breath and regular palpitations since 1 month before admission. She had 2 attacks of syncope during this period. She also reported easy fatigability and 8-kg weight loss within the last 2 months.\n\nOn physical examination, at the time of admission, she looked healthy without shortness of breath or cyanosis. She was afebrile and normotensive. Her heart rate was 112 beats/min (bpm) and regular in rhythm. O2 saturation at room air was 93%. Heart examination revealed a pansystolic murmur at the lower left sternal edge that increased with inspiration concordant with tricuspid regurgitation (TR).\n\nHer chest was clear to auscultation. Abdominal examination revealed a firm and tender palpable liver edge 2 to 3 cm below the right costal margin. There was no raised jugular venous pressure or lower limb edema.\n\nElectrocardiography (ECG) showed sinus tachycardia, right bundle branch block, and frequent ventricular ectopic rhythm.\n\nHolter ECG monitoring (24-h) showed sinus tachycardia reaching 136–140 bpm and frequent ventricular premature complexes. Chest X-ray showed borderline cardiomegaly with clear lung fields.\n\nTransthoracic and transesophageal echocardiography (TTE and TEE respectively) revealed a large mass measuring 5.6×3.8 cm in the right atrium originating below the fossa ovalis, affecting the tricuspid valve, leading to severe TR and extending to the RV wall causing RV outflow obstruction and pulmonary hypertension.\n\nThe right side of the heart was dilated; RV dimension was 3.2 cm (N=1.2–2.3 cm), with TR grade 2–3 and RV systolic pressure (RVSP) of 50–55 mmHg (n=8–20 mmHg).\n\n\nLaboratory workup showed the following values: hemoglobin (Hb) 11.3 g/dL (n=12–14 g/dL); erythrocyte sedimentation rate (ESR) 53 mm/h (n=13–27 mm/h); C-reactive protein 145 mg/L (N=0–5); international normalized ratio 1.6 (n=0.9–1.2); alanine and aspartate transaminases 61 and 94 IU/L, respectively (n=35–38 IU/L), serum albumin 26 g/L (n=35–52 g/L), and brain-type natriuretic peptide 822 pg/mL (n<100 pg/mL).\n\nLiver ultrasound revealed a homogenously enlarged liver (18 cm) with no focal defects.\n\nThyroid function tests, fasting blood sugar, blood urea nitrogen, urinalysis, and serum lipids were within normal limits. Hepatitis markers hepatitis B surface antigen and hepatitis C virus antibodies were nonreactive. Also, human immunodeficiency virus antibodies were negative.\n\nAn initial diagnosis of cardiac myxoma was made and surgical resection of the mass was planned as soon as possible.\n\nThe patient underwent cardiac surgery after 4 days of admission. Intraoperatively, 400 mL of pericardial effusion was found and drained. The right atrium and right ventricle were enlarged. A 12×8-cm huge dark-red to gray color, vascularized, gelatinous mass filling both the right atrium and the right ventricle was found. It was attached to the interatrial septum below the fossa ovalis by a thin stalk. It was extending down through the tricuspid valve with part of the mass adherent to the interventricular septum. We delivered and freed the mass, identified and resected the stalk, and then cauterized the base of the stalk.\n\nThe patient came out of cardiopulmonary bypass without the need for direct-current shock. She was intubated for 12 h postoperatively and kept in the intensive care unit for 24 h, where she was given 1 unit of packed red blood cells and 5 units of fresh frozen plasma.\n\nThe mass was sent for histopathologic examination and showed macroscopically a gray-colored mass measuring 9×4.5×3 cm. Gross sectioning showed myxoid areas with other areas of hemorrhage and necrosis. Microscopic examination showed stellate myxoma cells with abundant eosinophilic cytoplasm in the background of abundant mucopolysaccharide (myxoid) ground and areas of hemorrhage and necrosis and no evidence of malignancy. The intrapericardial drain was removed on the third postoperative day and the patient was discharged without any complications.\n\nShe was seen in the clinic at 1-month, 2-month, 5-month, and 1-year intervals postoperatively. She was doing well without any complaint. Her liver transaminases returned to normal levels. Repeated TTE 5 months and nearly 1 year postoperatively was free of any cardiac masses. It showed grade 1 TR; the right atrium and right ventricle were still dilated, with RVSP of 35 mmHg.", + "fulltext_subclaims": [ + "The patient is a 38-year-old female.", + "She presented to the emergency department in September 2019.", + "She had a history of exertional shortness of breath since 1 month before admission.", + "She had 2 attacks of syncope during the 1 month before admission.", + "She reported 8-kg weight loss within the last 2 months.", + "On physical examination, her heart rate was 112 beats/min.", + "Heart examination revealed a pansystolic murmur at the lower left sternal edge.", + "The murmur increased with inspiration.", + "The murmur was concordant with tricuspid regurgitation.", + "Electrocardiography showed sinus tachycardia.", + "Electrocardiography showed right bundle branch block.", + "Electrocardiography showed frequent ventricular ectopic rhythm.", + "Holter ECG monitoring showed sinus tachycardia reaching 136–140 bpm.", + "Transthoracic and transesophageal echocardiography revealed a large mass in the right atrium.", + "The mass measured 5.6×3.8 cm.", + "The mass originated below the fossa ovalis.", + "The mass affected the tricuspid valve.", + "The mass extended to the RV wall.", + "The mass caused RV outflow obstruction.", + "The mass caused pulmonary hypertension.", + "The right side of the heart was dilated.", + "RV dimension was 3.2 cm.", + "RV systolic pressure was 50–55 mmHg.", + "Hemoglobin was 11.3 g/dL.", + "Erythrocyte sedimentation rate was 53 mm/h.", + "C-reactive protein was 145 mg/L.", + "International normalized ratio was 1.6.", + "Alanine transaminase was 61 IU/L.", + "Aspartate transaminase was 94 IU/L.", + "Serum albumin was 26 g/L.", + "Brain-type natriuretic peptide was 822 pg/mL.", + "An initial diagnosis of cardiac myxoma was made.", + "Surgical resection of the mass was planned.", + "The patient underwent cardiac surgery after 4 days of admission.", + "Intraoperatively, 400 mL of pericardial effusion was found.", + "The mass was attached to the interatrial septum below the fossa ovalis by a thin stalk.", + "The mass was resected.", + "The base of the stalk was cauterized.", + "The patient came out of cardiopulmonary bypass without the need for direct-current shock.", + "The patient was intubated for 12 h postoperatively.", + "The patient was kept in the intensive care unit for 24 h.", + "The mass was sent for histopathologic examination.", + "Macroscopic examination showed myxoid areas with other areas of hemorrhage and necrosis.", + "Microscopic examination showed stellate myxoma cells with abundant eosinophilic cytoplasm.", + "There was no evidence of malignancy.", + "The intrapericardial drain was removed on the third postoperative day.", + "The patient was discharged without any complications.", + "She was seen in the clinic at 1-month, 2-month, 5-month, and 1-year intervals postoperatively.", + "She was doing well without any complaint.", + "Her liver transaminases returned to normal levels.", + "Repeated TTE 5 months and nearly 1 year postoperatively was free of any cardiac masses.", + "Repeated TTE showed grade 1 TR.", + "The right atrium and right ventricle were still dilated.", + "RVSP was 35 mmHg." + ], + "summary": "A 38-year-old woman presented with shortness of breath and syncope. Upon investigation, she was found to have a right atrioventricular myxoma. It was associated with tricuspid regurgitation, right-sided heart failure, and pulmonary hypertension.\n\nThe syncopal attacks and shortness of breath resolved completely after tumor resection. Tricuspid regurgitation (grade 1) and mild pulmonary hypertension (right ventricular systolic pressure 35 mmHg) remained as sequelae of delayed presentation. These may be due to recurrent embolization of tumor fragments to segments of the pulmonary artery.", + "summary_subclaims": [ + "The patient is a 38-year-old woman.", + "She presented with shortness of breath.", + "She presented with syncope.", + "She was found to have a right atrioventricular myxoma.", + "The myxoma was associated with tricuspid regurgitation.", + "The myxoma was associated with right-sided heart failure.", + "The myxoma was associated with pulmonary hypertension.", + "The syncopal attacks resolved completely after tumor resection.", + "The shortness of breath resolved completely after tumor resection.", + "Tricuspid regurgitation (grade 1) remained as a sequela of delayed presentation.", + "Mild pulmonary hypertension (right ventricular systolic pressure 35 mmHg) remained as a sequela of delayed presentation.", + "These may be due to recurrent embolization of tumor fragments to segments of the pulmonary artery." + ] + }, + { + "id": "multiclinsum_test_1267_en.txt", + "fulltext": "A 35-year-old, well-built, right-hand dominant gentleman, a temple priest by profession and a known epileptic with a frequency of seizures of once every year, being treated with regular oral phenytoin, presented with pain and deformity in both shoulders since the previous day. He had an episode of generalized seizures the previous day and sustained a fall during the episode. He reported that his left arm got stuck between a wall and a cupboard during the fall while his right arm was free during the fall. However, the patient could not recollect clear details due to seizures. He was otherwise asymptomatic before the incident. There was no history of external injury or other associated injuries or history suggestive of instability.\nOn examination, both shoulders were swollen with bruising on the medial aspect of both arms. Both shoulders were tender and the arms were held in a neutral position. All attempted movements of the shoulders were painful. There was no distal neurological or vascular deficit in the upper limbs. There was no generalized ligament laxity on clinical examination.\nAnteroposterior and scapular Y-view radiographs of the right shoulder revealed an anteroinferior dislocation of the shoulder with a displaced fracture of the greater tuberosity and a large Hill–Sachs lesion.\nSimilar views of the left shoulder revealed a light bulb sign , suggesting posterior dislocation of the shoulder, along with a displaced fracture of the greater tuberosity.\nClosed reduction of both shoulders was performed with gentle traction under general anesthesia. The greater tuberosities were persistently displaced after the reduction. A lateral transdeltoid approach (deltoid splitting) was used to approach the fracture and transosseous suture fixation of the greater tuberosities with No. 2 Ethibond sutures was done by the technique suggested by Dimakopoulos et al. .\nAt 2 weeks post-fixation, both shoulders remained congruently reduced. While the right greater tuberosity fracture remained stable, the tuberosity fracture in the left shoulder had displaced . Resuturing was done under anesthesia and the fixation was reinforced with 4 mm cannulated cancellous screws . The greater tuberosity fracture had split into two fragments. Fixation was assessed under fluoroscopy and was found to be stable with movements of the shoulder. The patient was advised arm sling for both shoulders for 6 weeks, with an additional small abduction pillow on the left. Internal rotation was delayed for 4 weeks on the left shoulder. Pendulum exercises were started from 2 weeks postoperatively followed by active assisted and active exercises at 4 and 6 weeks, respectively. The patient recovered well. Fractures united at 8 weeks on the right shoulder and at 12 weeks on the left, and at last follow-up at 12 months, the greater tuberosity fractures had healed well and the glenohumeral joints were in situ . He had achieved full shoulder function by 16 weeks after first surgery .", + "fulltext_subclaims": [ + "The patient is a 35-year-old right-hand dominant gentleman.", + "The patient is a known epileptic with seizures occurring once every year.", + "The patient was being treated with regular oral phenytoin.", + "The patient presented with pain and deformity in both shoulders since the previous day.", + "He had an episode of generalized seizures the previous day.", + "He sustained a fall during the seizure episode.", + "He reported that his left arm got stuck between a wall and a cupboard during the fall.", + "He reported that his right arm was free during the fall.", + "The patient could not recollect clear details due to seizures.", + "There was no history of external injury.", + "There was no history of other associated injuries.", + "There was no history suggestive of instability.", + "Both shoulders were swollen.", + "There was bruising on the medial aspect of both arms.", + "Both shoulders were tender.", + "All attempted movements of the shoulders were painful.", + "There was no distal neurological deficit in the upper limbs.", + "There was no generalized ligament laxity on clinical examination.", + "Anteroposterior and scapular Y-view radiographs of the right shoulder revealed an anteroinferior dislocation of the shoulder.", + "Radiographs of the right shoulder showed a displaced fracture of the greater tuberosity.", + "Radiographs of the right shoulder showed a large Hill–Sachs lesion.", + "Radiographs of the left shoulder revealed a light bulb sign, suggesting posterior dislocation of the shoulder.", + "Radiographs of the left shoulder showed a displaced fracture of the greater tuberosity.", + "Closed reduction of both shoulders was performed with gentle traction under general anesthesia.", + "The greater tuberosities were persistently displaced after the reduction.", + "A lateral transdeltoid approach (deltoid splitting) was used to approach the fracture.", + "Transosseous suture fixation of the greater tuberosities with No. 2 Ethibond sutures was done by the technique suggested by Dimakopoulos et al.", + "At 2 weeks post-fixation, both shoulders remained congruently reduced.", + "The right greater tuberosity fracture remained stable.", + "The tuberosity fracture in the left shoulder had displaced.", + "Resuturing was done under anesthesia.", + "Fixation was reinforced with 4 mm cannulated cancellous screws.", + "The greater tuberosity fracture had split into two fragments.", + "Fixation was assessed under fluoroscopy and was found to be stable with movements of the shoulder.", + "The patient was advised arm sling for both shoulders for 6 weeks.", + "An additional small abduction pillow was advised on the left.", + "Internal rotation was delayed for 4 weeks on the left shoulder.", + "Pendulum exercises were started from 2 weeks postoperatively.", + "Active assisted exercises were started at 4 weeks.", + "Active exercises were started at 6 weeks.", + "Fractures united at 8 weeks on the right shoulder.", + "Fractures united at 12 weeks on the left.", + "At last follow-up at 12 months, the greater tuberosity fractures had healed well.", + "At last follow-up at 12 months, the glenohumeral joints were in situ.", + "The patient had achieved full shoulder function by 16 weeks after first surgery." + ], + "summary": "A 35-year-old, right-hand dominant male, a known epileptic presented with pain and deformity in both shoulders after an episode of generalized seizures. Radiographs revealed anterior dislocation on the right and posterior dislocation on the left shoulders along with bilateral displaced fractures of the greater tuberosities. The patient was treated with closed reduction of bilateral shoulder dislocations using gentle traction followed by open suture fixation of the greater tuberosity fractures. The greater tuberosity on the posterior dislocation side needed redo fixation with compression screws and sutures for failed fixation. The patient went on to heal well and achieve full function. The case is one of a very rare group of injuries.", + "summary_subclaims": [ + "The patient is a 35-year-old, right-hand dominant male.", + "The patient is a known epileptic.", + "The patient presented with pain and deformity in both shoulders after an episode of generalized seizures.", + "Radiographs revealed anterior dislocation on the right shoulder.", + "Radiographs revealed posterior dislocation on the left shoulder.", + "Radiographs revealed bilateral displaced fractures of the greater tuberosities.", + "The patient was treated with closed reduction of bilateral shoulder dislocations using gentle traction.", + "The patient was treated with open suture fixation of the greater tuberosity fractures.", + "The greater tuberosity on the posterior dislocation side needed redo fixation with compression screws and sutures for failed fixation.", + "The patient went on to heal well and achieve full function.", + "The case is one of a very rare group of injuries." + ] + }, + { + "id": "multiclinsum_test_1036_en.txt", + "fulltext": "A 46-year-old male was admitted with the chief complaints of nasal bleeding and nasal obstruction since 4 months. His blood profile for biochemistry and hematology was within normal limits. Tests for human immunodeficiency virus (HIV), hepatitis B surface antigen (HBsAg), and hepatitis C virus were negative.\nContrast-enhanced computed tomography scan (CECT) and contrast-enhanced magnetic resonance imaging (CEMRI) of the brain and paranasal sinuses were suggestive of a large heterogeneous mass in the left superior nasal cavity (causing its expansion) with intense heterogeneous post-contrast enhancement. The lesion was extending posteriorly into the nasopharynx, medially into the right nasal cavity and right maxillary antrum with deviation of the nasal septum to the right side, and laterally into the left maxillary sinus with blockage of the osteomeatal complex. Superiorly, the lesion was seen to erode the cribriform plate and extend into the anterior cranial fossa. There was evidence of peritumoral cysts at the tumor–brain interface with perilesional edema. The lesion involved bilateral ethmoidal and sphenoidal sinuses also . The patient underwent a combined bifrontal osteoplastic craniotomy and excision of the intracranial part of the tumor from above and transnasal endoscopic removal of the mass in the nasal cavities and paranasal sinuses from below. Postoperative CECT scan of the brain and paranasal sinuses was suggestive of gross complete excision of the mass .\nOn histopathological examination (HPE), the tumor was composed of lobules, sheets, and nest of primitive cells which were displaying high nuclear: cytoplasmic (N:C) ratio, pleomorphism, round hyperchromatic nuclei with inconspicuous nucleoli, and scanty cytoplasm. On immunohistochemistry (IHC), the tumor cells were positive for neuron-specific enolase (NSE), synaptophysin, chromogranin, CD56, and peripherally for S100 and were negative for CD99. True rosette formation was noted. Large areas of necrosis and brisk mitotic activity were seen. Neurofibrillary matrix was absent. The tumor cells were seen infiltrating the adjacent brain parenchyma. Some areas showed epithelial differentiation in the form of glandular, squamous, and respiratory epithelium. On IHC, these areas were positive for cytokeratin (CK) and epithelial membrane antigen (EMA). CK 5/6 was positive in the squamous morules and CK 7 focally in the glandular component. Intervening stroma was positive for vimentin. The final histopathological report was “mixed olfactory neuroblastoma-carcinoma (squamous and glandular differentiation) Hyams grade IV” .\nThe patient was discharged after removal of stitches on postoperative day 7. He was advised to take adjuvant radiotherapy, which the patient did not take due to personal reasons. Two months later, he presented to us again with nasal bleeding and nasal obstruction. CECT scan and CEMRI of the brain and paranasal sinuses were suggestive of a large recurrence of esthesioneuroblastoma with similar extensions as before . Metastatic work up of the patient was normal. The patient is now planned for salvage surgery followed by adjuvant chemoradiation.", + "fulltext_subclaims": [ + "The patient is a 46-year-old male.", + "The patient had nasal bleeding and nasal obstruction for 4 months.", + "Blood profile for biochemistry and hematology was within normal limits.", + "Tests for HIV, HBsAg, and hepatitis C virus were negative.", + "Contrast-enhanced computed tomography scan and contrast-enhanced magnetic resonance imaging of the brain and paranasal sinuses were suggestive of a large heterogeneous mass in the left superior nasal cavity.", + "The lesion was extending posteriorly into the nasopharynx.", + "The lesion was extending medially into the right nasal cavity and right maxillary antrum.", + "The lesion was extending laterally into the left maxillary sinus.", + "The lesion was seen to erode the cribriform plate and extend into the anterior cranial fossa.", + "There was evidence of peritumoral cysts at the tumor–brain interface.", + "There was perilesional edema.", + "The lesion involved bilateral ethmoidal and sphenoidal sinuses.", + "The patient underwent a combined bifrontal osteoplastic craniotomy.", + "The patient underwent excision of the intracranial part of the tumor from above.", + "The patient underwent transnasal endoscopic removal of the mass in the nasal cavities and paranasal sinuses from below.", + "Postoperative CECT scan of the brain and paranasal sinuses was suggestive of gross complete excision of the mass.", + "On histopathological examination, the tumor was composed of lobules, sheets, and nests of primitive cells.", + "The tumor cells displayed high nuclear: cytoplasmic ratio.", + "The tumor cells displayed pleomorphism.", + "The tumor cells had round hyperchromatic nuclei with inconspicuous nucleoli.", + "The tumor cells had scanty cytoplasm.", + "On immunohistochemistry, the tumor cells were positive for neuron-specific enolase.", + "On immunohistochemistry, the tumor cells were positive for synaptophysin.", + "On immunohistochemistry, the tumor cells were positive for chromogranin.", + "On immunohistochemistry, the tumor cells were positive for CD56.", + "On immunohistochemistry, the tumor cells were negative for CD99.", + "True rosette formation was noted.", + "Large areas of necrosis were seen.", + "Brisk mitotic activity was seen.", + "Neurofibrillary matrix was absent.", + "The tumor cells were seen infiltrating the adjacent brain parenchyma.", + "Some areas showed epithelial differentiation in the form of glandular, squamous, and respiratory epithelium.", + "On immunohistochemistry, these areas were positive for cytokeratin.", + "On immunohistochemistry, these areas were positive for epithelial membrane antigen.", + "CK 5/6 was positive in the squamous morules.", + "CK 7 was focally positive in the glandular component.", + "Intervening stroma was positive for vimentin.", + "The final histopathological report was 'mixed olfactory neuroblastoma-carcinoma (squamous and glandular differentiation) Hyams grade IV'.", + "The patient was discharged after removal of stitches on postoperative day 7.", + "The patient was advised to take adjuvant radiotherapy.", + "The patient did not take adjuvant radiotherapy due to personal reasons.", + "Two months later, the patient presented again with nasal bleeding and nasal obstruction.", + "Contrast-enhanced computed tomography scan and contrast-enhanced magnetic resonance imaging of the brain and paranasal sinuses were suggestive of a large recurrence of esthesioneuroblastoma.", + "The recurrence had similar extensions as before.", + "Metastatic work up of the patient was normal.", + "The patient is now planned for salvage surgery.", + "The patient is now planned for adjuvant chemoradiation." + ], + "summary": "We report the case of a 46-year-old male who presented with the chief complaints of nasal bleeding and nasal obstruction since 4 months. Radiological imaging was suggestive of a large heterogeneous mass in the left superior nasal cavity with extensions into bilateral maxillary, ethmoidal, and sphenoidal sinuses, as well as into the anterior cranial fossa. Bifrontal osteoplastic craniotomy and excision of the intracranial part of the tumor from above and transnasal endoscopic removal of the mass in the nasal cavities and paranasal sinuses from below was done. Postoperative radiological imaging was suggestive of gross complete excision of the mass. Histopathological diagnosis was \"mixed olfactory neuroblastoma-carcinoma (squamous and glandular differentiation) Hyams grade IV.\" On immunohistochemistry, the tumor cells were positive for neuron specific enolase (NSE), synaptophysin, chromogranin, and CD56 and peripherally for S100. Because of personal reasons, the patient did not take adjuvant radiotherapy. He presented again after 2 months with a full blown recurrence of esthesioneuroblastoma with similar extensions as before. The patient is now planned for salvage surgery followed by adjuvant chemoradiation.", + "summary_subclaims": [ + "The patient is a 46-year-old male.", + "The patient had nasal bleeding and nasal obstruction for 4 months.", + "Radiological imaging was suggestive of a large heterogeneous mass in the left superior nasal cavity.", + "The mass extended into bilateral maxillary, ethmoidal, and sphenoidal sinuses.", + "The mass extended into the anterior cranial fossa.", + "Bifrontal osteoplastic craniotomy was performed.", + "Excision of the intracranial part of the tumor from above was performed.", + "Transnasal endoscopic removal of the mass in the nasal cavities and paranasal sinuses from below was performed.", + "Postoperative radiological imaging was suggestive of gross complete excision of the mass.", + "The histopathological diagnosis was 'mixed olfactory neuroblastoma-carcinoma (squamous and glandular differentiation) Hyams grade IV.'", + "The tumor cells were positive for neuron specific enolase (NSE).", + "The tumor cells were positive for synaptophysin.", + "The tumor cells were positive for chromogranin.", + "The tumor cells were positive for CD56.", + "The tumor cells were positive for S100 peripherally.", + "The patient did not take adjuvant radiotherapy because of personal reasons.", + "The patient presented again after 2 months with a full blown recurrence of esthesioneuroblastoma.", + "The recurrence had similar extensions as before.", + "The patient is now planned for salvage surgery.", + "The patient is now planned for adjuvant chemoradiation." + ] + }, + { + "id": "multiclinsum_test_1573_en.txt", + "fulltext": "A 54-year-old Caucasian man with no known previous comorbidity developed sudden-onset severe right-sided calf pain. The pain occurred while he was taking a casual walk in the evening. The pain intensity gradually worsened over the next few hours. The patient also noted progressive swelling of the calf of the right leg, gradually extending to the ankle. He denied trauma and could not recall a history of animal or insect bite. There was also no recent history of immobility. He was on no medication, either prescription or over-the-counter. The symptom onset was spontaneous and unprecipitated. The patient sought initial pain relief and self-medicated with codeine-paracetamol 30/500 mg and ibuprofen 400 mg. Failure to achieve adequate pain relief, along with evolution of symptoms with the development of numbness on the same side below the knee, prompted the patient to seek medical assistance.\nOn clinical examination, the patient appeared to be in severe pain. He was afebrile with normal hemodynamic parameters, with a pulse rate of 85 beats per minute. Systolic and diastolic blood pressure measurements were 133 mmHg and 76 mmHg, respectively. Oxygen saturation was 97% on room air. His National Early Warning Score 2 (NEWS2) was 0 based on clinical assessment. Systemic clinical examination was normal. On examination of the lower limbs, the right calf measured 45 cm in circumference and the left calf measured 44 cm in circumference. On visual assessment there was no rubor or blisters. However, the skin appeared tense and stretched. The right leg and calf were tender to the touch. The right-sided dorsal and posterior tibial pulses were present and capillary refill time was < 2 seconds, which was normal. The anterior and peroneal compartment was visually tense, which was more evident with toe movement. A reduction in sensation to light touch was also noted.\nBedside venous blood gas analysis revealed a normal pH of 7.4 and a normal electrolyte profile, with blood glucose of 5.8 mmol/L (normal reference = 7–11.1). The serum lactate level was 1.6 mmol/L (normal < 1.8). Whole blood analysis revealed hemoglobin of 155 g/L (normal reference = 130–180), with a total white blood cell count of 9.9 × 109/L (normal reference = 3.7–11) and a normal differential count. Platelet count was 275 × 109/L (normal reference = 150–450). Renal and liver function and coagulation parameters were all normal. C-reactive protein was 4.3 mg/L (normal reference = < 5) and the D-dimer level was normal at 327 µg/L (normal reference = 0–500). Considering the clinical context and near normal biochemical parameters, the initial working clinical suspicion was compartment syndrome of the right leg despite the absence of an obvious etiology. This was based on the classical presentation, especially when D-dimers were negative, making deep vein thrombosis unlikely. Urgent magnetic resonance imaging of the lower limbs was done, which revealed gross edema and swelling of the right lateral leg compartment involving the peroneus and longus muscle, consistent with acute lateral compartment syndrome .\nThe patient received analgesia with intravenous administration of morphine 5 mg. The leg was kept in an elevated position. Urgent surgical consult was taken, and the patient underwent emergency anterior and peroneal compartment fasciotomy on the same evening of presentation. Subsequently he underwent a second-look washout and graft fasciotomy of the right lateral leg. He had an uncomplicated clinical course and underwent physiotherapy and recovered well, and was discharged 3 days after initial admission with a plan for review in 5 days to assess the graft and in 2 weeks to reassess the fasciotomy site. He was discharged on oral pain relief medication.", + "fulltext_subclaims": [ + "The patient is a 54-year-old Caucasian man.", + "The patient had no known previous comorbidity.", + "The patient developed sudden-onset severe right-sided calf pain.", + "The pain occurred while he was taking a casual walk in the evening.", + "The pain intensity gradually worsened over the next few hours.", + "The patient noted progressive swelling of the calf of the right leg.", + "The swelling gradually extended to the ankle.", + "The patient denied trauma.", + "The patient could not recall a history of animal or insect bite.", + "There was no recent history of immobility.", + "The patient was on no medication, either prescription or over-the-counter.", + "The symptom onset was spontaneous and unprecipitated.", + "The patient self-medicated with codeine-paracetamol 30/500 mg.", + "The patient self-medicated with ibuprofen 400 mg.", + "The patient developed numbness on the same side below the knee.", + "The patient sought medical assistance.", + "On clinical examination, the patient appeared to be in severe pain.", + "The patient was afebrile.", + "The pulse rate was 85 beats per minute.", + "Systolic blood pressure was 133 mmHg.", + "Diastolic blood pressure was 76 mmHg.", + "Oxygen saturation was 97% on room air.", + "The National Early Warning Score 2 (NEWS2) was 0.", + "Systemic clinical examination was normal.", + "The right calf measured 45 cm in circumference.", + "The left calf measured 44 cm in circumference.", + "There was no rubor or blisters.", + "The skin appeared tense and stretched.", + "The right leg and calf were tender to the touch.", + "The right-sided dorsal and posterior tibial pulses were present.", + "Capillary refill time was < 2 seconds.", + "The anterior and peroneal compartment was visually tense.", + "A reduction in sensation to light touch was noted.", + "Bedside venous blood gas analysis revealed a normal pH of 7.4.", + "The serum lactate level was 1.6 mmol/L.", + "The D-dimer level was normal at 327 µg/L.", + "The initial working clinical suspicion was compartment syndrome of the right leg.", + "Urgent magnetic resonance imaging of the lower limbs was done.", + "The MRI revealed gross edema and swelling of the right lateral leg compartment.", + "The MRI findings were consistent with acute lateral compartment syndrome.", + "The patient received analgesia with intravenous administration of morphine 5 mg.", + "The leg was kept in an elevated position.", + "The patient underwent emergency anterior and peroneal compartment fasciotomy.", + "The patient underwent a second-look washout and graft fasciotomy of the right lateral leg.", + "The patient had an uncomplicated clinical course.", + "The patient underwent physiotherapy.", + "The patient was discharged 3 days after initial admission.", + "The patient was discharged on oral pain relief medication." + ], + "summary": "A 54-year-old Caucasian man with no previous comorbidities presented with acute right-sided lower limb pain with classical symptoms showing gradual evolution. He had no other history of medical relevance and no preceding injury. Examination showed a marginally enlarged right lower limb with stretched skin and tenderness. Routine blood tests were normal including D-dimer levels. However, in the absence of any underlying risk factors, acute compartment syndrome was suspected on clinical merit and confirmed with magnetic resonance imaging. He underwent successful surgical intervention with fasciotomy and achieved good recovery.", + "summary_subclaims": [ + "The patient is a 54-year-old Caucasian man.", + "The patient had no previous comorbidities.", + "He presented with acute right-sided lower limb pain.", + "He had classical symptoms showing gradual evolution.", + "He had no other history of medical relevance.", + "He had no preceding injury.", + "Examination showed a marginally enlarged right lower limb.", + "Examination showed stretched skin.", + "Examination showed tenderness.", + "Routine blood tests were normal.", + "D-dimer levels were normal.", + "Acute compartment syndrome was suspected on clinical merit.", + "Acute compartment syndrome was confirmed with magnetic resonance imaging.", + "He underwent successful surgical intervention with fasciotomy.", + "He achieved good recovery." + ] + }, + { + "id": "multiclinsum_test_1920_en.txt", + "fulltext": "A 58-year-old man was receiving pembrolizumab as a 1st line treatment for NSCLC (showing differentiation into adenocarcinoma and squamous cell carcinoma) and multiple bone metastases for 9 months. The patient presented with anemia and bloody stools. Colonoscopy revealed a type 3 lesion at the transverse colon, and the biopsy showed an undifferentiated carcinoma. Computed tomography showed multiple swollen lymph nodes along the superior mesenteric artery. 18F-fluorodeoxyglucose positron emission tomography was performed for disease evaluation, and accumulation was observed in the right colon (maximum standardized uptake value of 22) . The preoperative diagnosis was cT3N1bM0 stage IIIB (union for international cancer control (UICC) 8th edition) locally advanced transverse colon cancer. We performed laparoscopic right hemicolectomy with lymphadenectomy. He was discharged on the 10 days after the surgery without postoperative complications. The resected specimen showed a tumor measuring 75 × 46 mm . Histologically, undifferentiated cancer cells and diffuse invasion of rhabdoid tumors were observed. Immunohistochemically, the tumor cells tested positive for AE1/AE3 and focally positive for CAM5.2 and epithelial membrane antigen. Programmed death-ligand 1 (PD-L1) tested positive . Synaptophysin, chromogranin A, thyroid transcription factor-1, surfactant protein A, cytokeratin 5/6, p40, S-100P, D2-40, leukocyte common antigen, α-smooth muscle actin, desmin, calponin, h-caldesmon, cytokeratin 20, and E-cadherin were all tested negative. The microsatellite instability (MSI) status was low. The final diagnosis was undifferentiated carcinoma with rhabdoid features and lymph node metastasis (pT3N2aM0 Stage IIIB, UICC 8th edition). He continued to be received pembrolizumab for NSCLC. There have been no signs of colon cancer recurrence and progression of NSCLC for 15 months.", + "fulltext_subclaims": [ + "The patient was receiving pembrolizumab as a 1st line treatment for NSCLC.", + "The NSCLC showed differentiation into adenocarcinoma and squamous cell carcinoma.", + "The patient had multiple bone metastases.", + "The patient presented with anemia and bloody stools.", + "Colonoscopy revealed a type 3 lesion at the transverse colon.", + "The biopsy showed an undifferentiated carcinoma.", + "Computed tomography showed multiple swollen lymph nodes along the superior mesenteric artery.", + "18F-fluorodeoxyglucose positron emission tomography was performed for disease evaluation.", + "Accumulation was observed in the right colon with a maximum standardized uptake value of 22.", + "The preoperative diagnosis was cT3N1bM0 stage IIIB (UICC 8th edition) locally advanced transverse colon cancer.", + "Laparoscopic right hemicolectomy with lymphadenectomy was performed.", + "The patient was discharged on the 10th day after the surgery without postoperative complications.", + "The resected specimen showed a tumor measuring 75 × 46 mm.", + "Histologically, undifferentiated cancer cells and diffuse invasion of rhabdoid tumors were observed.", + "The tumor cells tested positive for AE1/AE3.", + "The tumor cells were focally positive for CAM5.2.", + "The tumor cells were focally positive for epithelial membrane antigen.", + "Programmed death-ligand 1 (PD-L1) tested positive.", + "Synaptophysin was tested negative.", + "Chromogranin A was tested negative.", + "Thyroid transcription factor-1 was tested negative.", + "Surfactant protein A was tested negative.", + "Cytokeratin 5/6 was tested negative.", + "p40 was tested negative.", + "S-100P was tested negative.", + "D2-40 was tested negative.", + "Leukocyte common antigen was tested negative.", + "α-smooth muscle actin was tested negative.", + "Desmin was tested negative.", + "Calponin was tested negative.", + "h-caldesmon was tested negative.", + "Cytokeratin 20 was tested negative.", + "E-cadherin was tested negative.", + "The microsatellite instability (MSI) status was low.", + "The final diagnosis was undifferentiated carcinoma with rhabdoid features and lymph node metastasis (pT3N2aM0 Stage IIIB, UICC 8th edition).", + "The patient continued to receive pembrolizumab for NSCLC.", + "There have been no signs of colon cancer recurrence for 15 months.", + "There has been no progression of NSCLC for 15 months." + ], + "summary": "A 58-year-old man was diagnosed with transverse colon cancer during chemotherapy with pembrolizumab for NSCLC. Laparoscopic right hemicolectomy was performed. The histopathological diagnosis was undifferentiated carcinoma with rhabdoid features and lymph node metastasis. Immunohistochemically, programmed death ligand 1 (PD-L1) showed positivity. The microsatellite instability (MSI) status was low. He continued to receive pembrolizumab for NSCLC, and there have been no signs of colon cancer recurrence and progression of NSCLC for 15 months.", + "summary_subclaims": [ + "A 58-year-old man was diagnosed with transverse colon cancer during chemotherapy with pembrolizumab for NSCLC.", + "Laparoscopic right hemicolectomy was performed.", + "The histopathological diagnosis was undifferentiated carcinoma with rhabdoid features and lymph node metastasis.", + "Programmed death ligand 1 (PD-L1) showed positivity.", + "The microsatellite instability (MSI) status was low.", + "He continued to receive pembrolizumab for NSCLC.", + "There have been no signs of colon cancer recurrence and progression of NSCLC for 15 months." + ] + }, + { + "id": "multiclinsum_test_1299_en.txt", + "fulltext": "A 45-year-old male presented to the emergency department complaining of a cough for more than a week. This cough was not relieved by any medications. It was followed by dyspnoea for 2 days. From the patient's history, we found that he is a schoolteacher from a middle-class family. The living conditions of the family are at subpar levels. He is a non-smoker and an occasional alcohol consumer. There is no evidence of contact with domestic animals like dogs, sheep, or cows. The patient lives with his wife and two children in his home with no domestic animals as pets or livestock. Contamination of food and water are a few environmental risk factors that the patient has.\nOn physical examination, the patient had a normal heart rate, blood pressure, oxygen saturation, and temperature. His respiratory rate was significant for tachypnoea with 25 cycles per minute. On clinical examination, breath sounds were decreased on the left side, also vocal fremitus was found to be decreased, along with dullness on percussion on the left side of the chest. The right side of the chest showed normal clinical examination. Laboratory findings were significant for eosinophilia (12 %). A routine chest X-ray revealed rounded opacities and a large left-sided pleural effusion with a right-sided mediastinal shift. It did not reveal consolidation of the upper zone with ipsilateral hilar enlargement or any features suggestive of pulmonary tuberculosis.\nThe patient was hospitalized urgently and was referred to the Respiratory Medicine Department for further evaluation and management. The patient was scheduled for a pleural drainage procedure. A pleural drainage was inserted in the 5th intercostal space anterior to the mid-axillary line on the left side of the chest. 2600 ml of cloudy yellowish fluid was drained within 24 h. A differential diagnosis of tuberculosis, malignancy, and parapneumonia was considered based on the imaging which showed large left-sided pleural effusion and exudative pleural effusion on seeing the cloudy yellowish fluid on drainage. The fluid drained was sent for protein, lactate dehydrogenase, Gram stain, cytology, and microbiological culture. The pleural fluid analysis confirmed an exudative pleural effusion.\nComputed tomography was done to confirm the suspicion of hydatid disease. The CT revealed multiple small cysts which are round in shape filling up the entire left pleural cavity. Left-sided pleural effusion was associated with left lung atelectasis and right mediastinal shift. Abdominal CT was done which showed no lesion in the liver suggestive of the absence of a primary foci of hydatidosis in the liver. The patient was referred to the Surgery Department for further management of the case. Preoperative antihelminthic treatment with Albendazole 15 mg/kg/day for 6 days was completed. He completed the pre-anesthetic check-ups and was posted for surgery by the Chief Surgeon.\nThe patient was taken to the operation room for a left-sided posterolateral thoracotomy in the 5th intercostal space. The pleural space was then irrigated with hypertonic saline to kill the scolices. Multiple daughter cysts were removed, and a thorough inspection showed no other cysts in the pleural space, lung, diaphragm, or mediastinum .\nA pleurectomy and an empymectomy were done in view of infection-induced pleural effusion. After the procedure was done, the collapsed lung was expanded fully, and no air leakage was found. Additionally, there was no sign of parenchyma damage to the lung. It was followed by the closure of the thoracotomy. The patient was shifted to the Intensive Care Unit and was then discharged when he was hemodynamically stable and symptomatically better with 10 mg/kg/day of oral Albendazole for 1 year. The patient was asymptomatic and showed normal chest X-rays in the follow-up visits done monthly and yearly.", + "fulltext_subclaims": [ + "A 45-year-old male presented to the emergency department complaining of a cough for more than a week.", + "The cough was not relieved by any medications.", + "The cough was followed by dyspnoea for 2 days.", + "The patient is a schoolteacher from a middle-class family.", + "The living conditions of the family are at subpar levels.", + "There is no evidence of contact with domestic animals like dogs, sheep, or cows.", + "The patient lives with his wife and two children in his home with no domestic animals as pets or livestock.", + "On physical examination, the patient had a normal heart rate, blood pressure, oxygen saturation, and temperature.", + "The patient's respiratory rate was 25 cycles per minute.", + "Breath sounds were decreased on the left side.", + "Vocal fremitus was found to be decreased.", + "Dullness on percussion was found on the left side of the chest.", + "The right side of the chest showed normal clinical examination.", + "Laboratory findings were significant for eosinophilia (12 %).", + "A routine chest X-ray revealed rounded opacities.", + "A routine chest X-ray revealed a large left-sided pleural effusion.", + "A routine chest X-ray showed a right-sided mediastinal shift.", + "The chest X-ray did not reveal consolidation of the upper zone with ipsilateral hilar enlargement.", + "The chest X-ray did not reveal any features suggestive of pulmonary tuberculosis.", + "The patient was hospitalized urgently.", + "The patient was referred to the Respiratory Medicine Department for further evaluation and management.", + "A pleural drainage procedure was scheduled.", + "A pleural drainage was inserted in the 5th intercostal space anterior to the mid-axillary line on the left side of the chest.", + "2600 ml of cloudy yellowish fluid was drained within 24 h.", + "A differential diagnosis of tuberculosis, malignancy, and parapneumonia was considered.", + "The fluid drained was sent for protein, lactate dehydrogenase, Gram stain, cytology, and microbiological culture.", + "The pleural fluid analysis confirmed an exudative pleural effusion.", + "Computed tomography was done to confirm the suspicion of hydatid disease.", + "The CT revealed multiple small cysts which are round in shape filling up the entire left pleural cavity.", + "Left-sided pleural effusion was associated with left lung atelectasis.", + "Left-sided pleural effusion was associated with right mediastinal shift.", + "Abdominal CT showed no lesion in the liver.", + "The patient was referred to the Surgery Department for further management.", + "Preoperative antihelminthic treatment with Albendazole 15 mg/kg/day for 6 days was completed.", + "The patient was taken to the operation room for a left-sided posterolateral thoracotomy in the 5th intercostal space.", + "The pleural space was irrigated with hypertonic saline to kill the scolices.", + "Multiple daughter cysts were removed.", + "A thorough inspection showed no other cysts in the pleural space, lung, diaphragm, or mediastinum.", + "A pleurectomy and an empymectomy were done.", + "After the procedure, the collapsed lung was expanded fully.", + "No air leakage was found.", + "There was no sign of parenchyma damage to the lung.", + "The patient was shifted to the Intensive Care Unit.", + "The patient was discharged when he was hemodynamically stable and symptomatically better.", + "The patient was prescribed 10 mg/kg/day of oral Albendazole for 1 year.", + "The patient was asymptomatic in follow-up visits.", + "The patient showed normal chest X-rays in the follow-up visits." + ], + "summary": "We present a case of a 45-year-old who suffered from a cough for more than one week which did not subside after taking medications. This symptom was followed by dyspnoea for which an X-ray was done which showed left-sided pleural effusion, a complication of pleural hydatidosis. Computed tomography showed multiple cysts in the pleural cavity which confirmed the diagnosis of primary pleural hydatidosis as the cysts were not present in any other sites. Blood work revealed eosinophilia which is significant in parasitic diseases. A left posterolateral thoracotomy was performed, and the cysts were surgically removed. Additionally, empyemectomy and pleurectomy were done. The patient was then treated with anti-parasitic therapy and was advised to get X-rays during the follow-up visits. The X-rays were normal and indicated that there was no disease recurrence.", + "summary_subclaims": [ + "The patient was a 45-year-old.", + "The patient had a cough for more than one week.", + "The cough did not subside after taking medications.", + "The cough was followed by dyspnoea.", + "An X-ray showed left-sided pleural effusion.", + "The pleural effusion was a complication of pleural hydatidosis.", + "Computed tomography showed multiple cysts in the pleural cavity.", + "The diagnosis was confirmed as primary pleural hydatidosis.", + "The cysts were not present in any other sites.", + "Blood work revealed eosinophilia.", + "A left posterolateral thoracotomy was performed.", + "The cysts were surgically removed.", + "Empyemectomy and pleurectomy were done.", + "The patient was treated with anti-parasitic therapy.", + "The patient was advised to get X-rays during follow-up visits.", + "The X-rays were normal.", + "The X-rays indicated no disease recurrence." + ] + }, + { + "id": "multiclinsum_test_2385_en.txt", + "fulltext": "A 74-year-old male, known case of diabetes mellitus (DM), hypertension (HTN), bronchial asthma and hypothyroidism who was diagnosed with para-umbilical hernia. The defect size was 1 × 2 cm, after of which he underwent a laparoscopic hernia repair at our hospital using a 15 × 20 cm eTPES mesh Bard® Composix™ E/X Mesh (Warwick, RI) with no complications. The patient had uneventful admission period and was discharged home in good condition at day 2 post-op.\nPostoperatively day 10, he presented to the Emergency Room (ER) complaining of colicky abdominal pain in the right iliac fossa for 1 day associated with diarrhea (5 times/day). No other symptoms were reported by the patient. On physical examination, patient had normal vital signs and generalized mild abdominal tenderness. The maximum tenderness point was at the right iliac fossa. A Computed Tomography (CT) scan of the abdomen and pelvis was done which showed diffuse wall thickening of the cecum and terminal ileum with abnormal configuration of the cecum and ill definition of its anterior wall with small free air worrisome for perforation . The decision was made in the ER to discharge him home on antibiotics.\nTen weeks post-operation, the patient presented again to his primary surgeon at our institute with the same complains where CT scan was ordered again and showed the same findings. Colonoscopy was ordered which showed small polyp that was removed and revealed benign adenoma, also showed a small solid structure in the cecum . Biopsy of that solid structure showed granulating tissues.\nThree months after surgery, the patient returned back to his primary surgeon complaining of bleeding per rectum for which he underwent further investigations including second colonoscopy. The colonoscopy showed a polypoidal mass that was biopsied and showed granulating tissues . The patient was sent back to the surgeon’s clinic and reassured.\nTen months post operation, the patient was seen in the outpatient clinic complaining of persistent vague abdominal pain and bleeding per rectum. CT scan of abdomen and pelvis was repeated which demonstrated opacity at the level of the cecum with dense opacity medial to it of low attenuation and contains some air bubbles . Another colonoscopy was done which showed a small mass in the cecum that was biopsied and revealed to be granulating tissues, the patient was referred to the primary surgeon who reassured the patient and gave him a follow up appointment in one-year time.\nFollow up after more than 2 years of surgery indicated iron deficiency anemia and B12 deficiency. Thus, a colonoscopy was scheduled but the patient could not tolerate the bowel prep. A CT Colonography was ordered which showed a foreign object in the colon, possibly caused bleeding per rectum where the patient was referred back to the surgeon . A CT scan revealed recurrence of a periumbilical hernia and thickening of the medial wall of the cecum with mesh graft material that could suggest a complication of the previous ventral hernia repair with extension of the mesh graft through the cecal wall . Exploratory laparotomy was offered to the patient but he refused and was discharged against medical advice.\nTen months later, we received the patient in our service for the first time when he was complaining of persistent abdominal pain and bleeding per rectum. After reviewing his previous investigations, we told the patient about the mesh graft migration and we discussed with him the mandatory of exploratory laparotomy and mesh graft removal with bowel resection and the possibility of stoma creation at any point of surgery. The patient was informed that he would have higher rate of hernia recurrence and a mesh graft will not be used in this procedure to avoid further complications like wound/mesh infection due to the risk of bowel contents spillage in the surgical field on top of his other comorbidities like DM and bronchial asthma.\nThe patient then was taken to surgery by his primary surgeon, and intra-operative findings revealed migration of almost 50% of the mesh graft size to the cecum and part of the mesh graft was eroding the distal part of ileum just proximal to the ileocecal junction. Adhesolysis and limited right hemicolectomy with ileocolic anastomosis was done. Fascia closure was obtained primarily without mesh graft application. Skin closure completed with skin clips . The patient had an uneventful recovery after revisions surgery without any perioperative complications. He was discharged home on postoperative readmission day 5 and followed up at 2 weeks and 3 months without any delayed complications or subjective complaints.", + "fulltext_subclaims": [ + "The patient is a 74-year-old male.", + "The patient has diabetes mellitus.", + "The patient has hypertension.", + "The patient has bronchial asthma.", + "The patient has hypothyroidism.", + "The patient was diagnosed with para-umbilical hernia.", + "The hernia defect size was 1 × 2 cm.", + "The patient underwent laparoscopic hernia repair.", + "The repair used a 15 × 20 cm eTPES mesh Bard® Composix™ E/X Mesh.", + "The patient had no complications during the laparoscopic hernia repair.", + "The patient was discharged home at day 2 post-op.", + "Postoperatively day 10, the patient presented to the ER with colicky abdominal pain in the right iliac fossa.", + "The pain was associated with diarrhea (5 times/day).", + "The patient had generalized mild abdominal tenderness.", + "The maximum tenderness point was at the right iliac fossa.", + "A CT scan showed diffuse wall thickening of the cecum and terminal ileum.", + "The CT scan showed abnormal configuration of the cecum.", + "The CT scan showed ill definition of the cecal anterior wall.", + "The CT scan showed small free air worrisome for perforation.", + "The decision was made in the ER to discharge him home on antibiotics.", + "Ten weeks post-operation, the patient presented again with the same complaints.", + "A CT scan showed the same findings.", + "Colonoscopy showed a small polyp that was removed.", + "The polyp revealed benign adenoma.", + "Colonoscopy showed a small solid structure in the cecum.", + "Biopsy of the solid structure showed granulating tissues.", + "Three months after surgery, the patient returned with bleeding per rectum.", + "A second colonoscopy showed a polypoidal mass.", + "The mass was biopsied and showed granulating tissues.", + "Ten months post operation, the patient had persistent vague abdominal pain and bleeding per rectum.", + "A CT scan showed opacity at the level of the cecum.", + "The CT scan showed dense opacity medial to the cecum.", + "The CT scan showed low attenuation and air bubbles.", + "A colonoscopy showed a small mass in the cecum.", + "The mass was biopsied and revealed granulating tissues.", + "Follow up after more than 2 years of surgery indicated iron deficiency anemia.", + "Follow up after more than 2 years of surgery indicated B12 deficiency.", + "A CT Colonography showed a foreign object in the colon.", + "The foreign object was possibly caused by bleeding per rectum.", + "A CT scan showed recurrence of a periumbilical hernia.", + "A CT scan showed thickening of the medial wall of the cecum.", + "The CT scan showed mesh graft material.", + "The mesh graft material could suggest a complication of the previous ventral hernia repair.", + "The mesh graft material could suggest extension of the mesh graft through the cecal wall.", + "Exploratory laparotomy was offered to the patient.", + "The patient refused exploratory laparotomy.", + "The patient was discharged against medical advice.", + "Ten months later, the patient presented with persistent abdominal pain and bleeding per rectum.", + "The patient was informed about mesh graft migration.", + "The patient was informed about the mandatory exploratory laparotomy.", + "The patient was informed about mesh graft removal with bowel resection.", + "The patient was informed about the possibility of stoma creation.", + "The patient was informed about a higher rate of hernia recurrence.", + "The patient was informed that a mesh graft will not be used in the procedure.", + "The patient was informed about the risk of wound/mesh infection.", + "The patient was informed about the risk of bowel contents spillage.", + "The patient was informed about his comorbidities like DM and bronchial asthma.", + "The patient underwent exploratory laparotomy.", + "Intra-operative findings revealed migration of almost 50% of the mesh graft size to the cecum.", + "Part of the mesh graft was eroding the distal part of ileum just proximal to the ileocecal junction.", + "Adhesolysis and limited right hemicolectomy with ileocolic anastomosis was done.", + "Fascia closure was obtained primarily without mesh graft application.", + "Skin closure was completed with skin clips.", + "The patient had an uneventful recovery after revisions surgery.", + "The patient was discharged home on postoperative readmission day 5.", + "The patient was followed up at 2 weeks and 3 months.", + "The patient had no delayed complications.", + "The patient had no subjective complaints." + ], + "summary": "A 74-year-old gentleman with multiple medical comorbidities was diagnosed with a para-umbilical hernia after which he underwent a laparoscopic hernia repair at our hospital using a mesh graft with no complications. On postoperative day 10, he presented to the emergency room (ER) complaining of colicky abdominal pain in the right iliac fossa for 1 day associated with diarrhea. A Computed Tomography (CT) scan of the abdomen and pelvis showed diffuse wall thickening of the cecum and terminal ileum with small free air worrisome for perforation. The decision was made in the ER to discharge him home on antibiotics. The patient then returned back multiple times to the ER for the same complaint along with bleeding per rectum for which he underwent further investigations. Months later, the patient presented again with the same symptoms. A CT scan revealed recurrence of a periumbilical hernia and thickening of the medial wall of the cecum with mesh graft material. The patient was then taken to surgery and intra-operative findings revealed migration of almost 50% of the mesh graft size to the cecum and part of the mesh graft was eroding the distal part of ileum just proximal to the ileocecal junction. Adhesolysis and limited right hemicolectomy with ileocolic anastomosis was done. The patient had an uneventful recovery after revisions surgery without any perioperative complications. He was discharged home on postoperative readmission day 5 and followed up at 2 weeks and 3 months without any delayed complications or subjective complaints.", + "summary_subclaims": [ + "The patient is a 74-year-old gentleman with multiple medical comorbidities.", + "The patient was diagnosed with a para-umbilical hernia.", + "The patient underwent a laparoscopic hernia repair at our hospital using a mesh graft.", + "The laparoscopic hernia repair was performed with no complications.", + "On postoperative day 10, the patient presented to the emergency room with colicky abdominal pain in the right iliac fossa for 1 day.", + "The patient reported diarrhea.", + "A CT scan showed diffuse wall thickening of the cecum and terminal ileum.", + "The CT scan showed small free air worrisome for perforation.", + "The decision was made in the ER to discharge him home on antibiotics.", + "The patient returned multiple times to the ER for the same complaint.", + "The patient had bleeding per rectum.", + "Months later, the patient presented again with the same symptoms.", + "A CT scan revealed recurrence of a periumbilical hernia.", + "A CT scan showed thickening of the medial wall of the cecum.", + "A CT scan showed mesh graft material.", + "The patient was taken to surgery.", + "Intra-operative findings revealed migration of almost 50% of the mesh graft size to the cecum.", + "Part of the mesh graft was eroding the distal part of ileum just proximal to the ileocecal junction.", + "Adhesolysis and limited right hemicolectomy with ileocolic anastomosis was done.", + "The patient had an uneventful recovery after revisions surgery.", + "The patient had no perioperative complications.", + "The patient was discharged home on postoperative readmission day 5.", + "The patient was followed up at 2 weeks and 3 months.", + "The patient had no delayed complications.", + "The patient had no subjective complaints." + ] + }, + { + "id": "multiclinsum_test_261_en.txt", + "fulltext": "A 64-year-old Japanese woman was brought to the emergency department of our hospital in a deep coma. Six years before this admission, the patient presented at another hospital with transient right hemispatial neglect and, based on magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA), was diagnosed with left ICA obliteration immediately distal to the carotid bifurcation and unilateral moyamoya disease of the ipsilateral intracranial arteries, without any aneurysm formation or cerebral infarction . Quantitative 15O gas-inhalation positron emission tomography at the time showed no apparent misery perfusion, so the patient was initially treated medically with cilostazol for probable transient ischemic attack (TIA). However, cilostazol was subsequently stopped due to increasing microbleeds in the brain on follow-up MRI. No aneurysm was detected up until the last follow-up MRA evaluation 3 months before the event described in this report.\nComputed tomography (CT) of the head showed severe intraventricular hemorrhage with subarachnoid hemorrhage . CT angiography (CTA) showed obliteration of the left ICA with a hypoplastic carotid canal and foramen lacerum, suggesting congenital ICA agenesis rather than acquired ICA obliteration . The left posterior communicating artery (PComA) was not a single vessel, instead forming a vascular plexus . The peduncular, ambient, and quadrigeminal segments of the left PCA and the horizontal, infracallosal, and precallosal segments of the left ACA looked like a network of small tortuous vessels that replaced the main trunks of the left PCA and ACA, respectively. In the distal portion of the left PCA and ACA, these aberrant networks seemed to coalesce and formed hypoplastic but definite cortical branches of the PCA and supracallosal segment of the ACA. These anomalous arteries were located in the subarachnoid space, unlike moyamoya disease or arteriovenous malformation. From these findings, we diagnosed the anomaly as rete mirabile in the PComA, PCA, and ACA. Intriguingly, the appearance of the MCA was not rete-like in this patient . There was a saccular aneurysm (4.3 mm in size) arising from the inferior aspect of a perforating branch of the pericallosal artery and protruding into the left lateral ventricle that was presumed to be the source of the hemorrhage . Because of her critical condition (dilatation of pupils and hypothermia), the patient immediately underwent urgent bilateral external ventricular drainage to reduce the intracranial pressure, but soon deteriorated to brain death. Thus, we did not proceed with catheter angiography and further treatment of the ruptured aneurysm. The family refused an autopsy.", + "fulltext_subclaims": [ + "The patient was a 64-year-old Japanese woman.", + "She was brought to the emergency department in a deep coma.", + "Six years before this admission, the patient presented with transient right hemispatial neglect.", + "Based on MRI and MRA, she was diagnosed with left ICA obliteration immediately distal to the carotid bifurcation.", + "She was diagnosed with unilateral moyamoya disease of the ipsilateral intracranial arteries.", + "There was no aneurysm formation or cerebral infarction at the time of diagnosis.", + "Quantitative 15O gas-inhalation positron emission tomography showed no apparent misery perfusion.", + "The patient was initially treated medically with cilostazol for probable transient ischemic attack.", + "Cilostazol was subsequently stopped due to increasing microbleeds in the brain on follow-up MRI.", + "No aneurysm was detected up until the last follow-up MRA evaluation 3 months before the event.", + "CT of the head showed severe intraventricular hemorrhage with subarachnoid hemorrhage.", + "CTA showed obliteration of the left ICA with a hypoplastic carotid canal and foramen lacerum.", + "CTA findings suggested congenital ICA agenesis rather than acquired ICA obliteration.", + "The left posterior communicating artery was not a single vessel, instead forming a vascular plexus.", + "The left PCA and ACA segments looked like a network of small tortuous vessels.", + "These anomalous arteries were located in the subarachnoid space.", + "We diagnosed the anomaly as rete mirabile in the PComA, PCA, and ACA.", + "The appearance of the MCA was not rete-like in this patient.", + "There was a saccular aneurysm (4.3 mm in size) arising from the inferior aspect of a perforating branch of the pericallosal artery.", + "The aneurysm protruded into the left lateral ventricle.", + "The aneurysm was presumed to be the source of the hemorrhage.", + "The patient immediately underwent urgent bilateral external ventricular drainage.", + "The patient soon deteriorated to brain death.", + "We did not proceed with catheter angiography and further treatment of the ruptured aneurysm.", + "The family refused an autopsy." + ], + "summary": "A 64-year-old Japanese woman was brought to the emergency department of our hospital in a deep coma. Computed tomography of the head showed severe intraventricular hemorrhage with subarachnoid hemorrhage. Computed tomography angiography showed not only congenital left internal carotid artery agenesis, but also rete mirabile of the left posterior communicating artery, the left posterior cerebral artery, and the left anterior cerebral artery. This unilateral vessel anomaly complex may have contributed to the formation of a peripheral aneurysm arising from a perforating branch of the pericallosal artery, which ruptured. The patient underwent urgent bilateral external ventricular drainage, but deteriorated and was declared brain dead.", + "summary_subclaims": [ + "The patient was a 64-year-old Japanese woman.", + "She was brought to the emergency department in a deep coma.", + "Computed tomography of the head showed severe intraventricular hemorrhage with subarachnoid hemorrhage.", + "Computed tomography angiography showed congenital left internal carotid artery agenesis.", + "Computed tomography angiography showed rete mirabile of the left posterior communicating artery.", + "Computed tomography angiography showed rete mirabile of the left posterior cerebral artery.", + "Computed tomography angiography showed rete mirabile of the left anterior cerebral artery.", + "This unilateral vessel anomaly complex may have contributed to the formation of a peripheral aneurysm arising from a perforating branch of the pericallosal artery.", + "The aneurysm ruptured.", + "The patient underwent urgent bilateral external ventricular drainage.", + "The patient deteriorated and was declared brain dead." + ] + }, + { + "id": "multiclinsum_test_2569_en.txt", + "fulltext": "A 63-year-old woman with a history of ESRD was admitted to our hospital on June 3, 2015 after experiencing disorientation for 5 days. The patient had been receiving HD since December 2014 because of acute on chronic kidney disease due to pneumonia. She was also diagnosed with hepatitis B-related liver cirrhosis (Child-Pugh B with hepatic encephalopathy), Mycobacterium tuberculosis-related pleuritis, and IgGλ monoclonal gammopathy. Monoclonal gammapathy hadn’t been treated because she was permanently bedridden. She received maintenance HD through a tunneled-cuffed catheter inserted into the right subclavian vein since December 8th, 2014. She denied active intravenous drug use. We observed drowsy consciousness and splenomegaly during physical examination. No crackles were found in either lung field, and no track marks were present on her skin. Her white blood cell, absolute neutrophil, and platelet counts were 2.86 × 103/uL, 2116/mm3, and 14,000/uL, respectively. Her total bilirubin was 3.54 mg/dL. In addition, C-reactive protein was 2.31 mg/dL, and her serum glucose was 992 mg/dL, without metabolic acidosis. Because of the hyperglycemic hyperosmotic status of the patient, blood culture was drawn and empiric vancomycin and cefuroxime were prescribed. The initial blood culture grew Candida guilliermondii without other bacteria. Fluconazole 200 mg once per day was administered intravenously. The tunneled-cuffed catheter was removed on June 30 because of persistent fungemia. The culture of tunneled-cuffed catheter grew Candida guilliermondii.. Blood cultures on July 14 and August 10 and 28 still grew C. guilliermondii, even after replacement of caspofungin by fluconazole on July 28. No positive culture result was found in sputum or urine during the 8 weeks after admission. Transthoracic echocardiography on July 20 and August 21 revealed no vegetation or congenital abnormality. On August 25, repeated transthoracic echocardiograms showed a 1.2-cm mobile mass on the pulmonary valve extending from the right ventricular inflow tract across the pulmonary valve . No other vegetation was found. Surgical intervention was suggested, but the family of the patient declined because of her multiple comorbidities. Therefore, amphotericin B 40 mg was administered once daily from August 30 but was discontinued on September 1 because of allergic reactions (rash and fever). After 8 weeks of caspofungin, the C. guilliermondii septicemia was still present and the vegetation on the pulmonary valve had increased in size (3.73 × 2.70 cm). Computed tomography (CT) of the chest and abdomen revealed splenic infarction and right upper lung pneumonia with septic embolism . The patient and family requested hospice care, and we discharged the patient with a long-term prescription of fluconazole 200 mg/d. The patient died from hepatic encephalopathy and coma on September 26, 2015.", + "fulltext_subclaims": [ + "The patient was a 63-year-old woman with a history of ESRD.", + "She was admitted on June 3, 2015.", + "She had been receiving HD since December 2014.", + "She had acute on chronic kidney disease due to pneumonia.", + "She was diagnosed with hepatitis B-related liver cirrhosis.", + "She had Mycobacterium tuberculosis-related pleuritis.", + "She had IgGλ monoclonal gammopathy.", + "Monoclonal gammopathy hadn’t been treated.", + "She was permanently bedridden.", + "She received maintenance HD through a tunneled-cuffed catheter.", + "The catheter was inserted into the right subclavian vein on December 8th, 2014.", + "She denied active intravenous drug use.", + "She had drowsy consciousness.", + "She had splenomegaly.", + "No crackles were found in either lung field.", + "No track marks were present on her skin.", + "Her white blood cell count was 2.86 × 103/uL.", + "Her platelet count was 14,000/uL.", + "Her total bilirubin was 3.54 mg/dL.", + "Her serum glucose was 992 mg/dL.", + "Blood culture was drawn.", + "Empiric vancomycin and cefuroxime were prescribed.", + "The initial blood culture grew Candida guilliermondii.", + "Fluconazole 200 mg once per day was administered intravenously.", + "The tunneled-cuffed catheter was removed on June 30.", + "The culture of the tunneled-cuffed catheter grew Candida guilliermondii.", + "Blood cultures on July 14 and August 10 and 28 still grew C. guilliermondii.", + "No positive culture result was found in sputum.", + "No positive culture result was found in urine.", + "Transthoracic echocardiography on July 20 and August 21 revealed no vegetation.", + "On August 25, a 1.2-cm mobile mass was found on the pulmonary valve.", + "Surgical intervention was suggested.", + "The family declined surgical intervention.", + "Amphotericin B 40 mg was administered once daily from August 30.", + "Amphotericin B was discontinued on September 1.", + "After 8 weeks of caspofungin, C. guilliermondii septicemia was still present.", + "The vegetation on the pulmonary valve had increased in size.", + "CT of the chest and abdomen revealed splenic infarction.", + "CT of the chest and abdomen revealed right upper lung pneumonia with septic embolism.", + "The patient and family requested hospice care.", + "The patient was discharged with a long-term prescription of fluconazole 200 mg/d.", + "The patient died from hepatic encephalopathy and coma on September 26, 2015." + ], + "summary": "A 63-year-old woman with end-stage kidney disease was admitted to our hospital after experiencing disorientation for 5 days. The patient was permanently bedridden because of depression, and denied active intravenous drug use. She received maintenance hemodialysis through a tunneled-cuffed catheter. An initial blood culture grew Candida guilliermondii without other bacteria. Subsequent blood cultures and tip culture of tunneled-cuffed catheter also grew C. guilliermondii, even after caspofungin replaced fluconazole. A 1.2-cm mobile mass was observed on the pulmonary valve. Surgical intervention was suggested, but the family of the patient declined because of her multiple comorbidities. The patient was discharged with a prescription of fluconazole, but she died soon after.", + "summary_subclaims": [ + "The patient was a 63-year-old woman.", + "The patient had end-stage kidney disease.", + "The patient was admitted after experiencing disorientation for 5 days.", + "The patient was permanently bedridden because of depression.", + "The patient received maintenance hemodialysis through a tunneled-cuffed catheter.", + "An initial blood culture grew Candida guilliermondii.", + "Subsequent blood cultures grew C. guilliermondii.", + "The tip culture of the tunneled-cuffed catheter grew C. guilliermondii.", + "Caspofungin replaced fluconazole.", + "A 1.2-cm mobile mass was observed on the pulmonary valve.", + "Surgical intervention was suggested.", + "The family of the patient declined surgical intervention.", + "The patient was discharged with a prescription of fluconazole.", + "The patient died soon after discharge." + ] + }, + { + "id": "multiclinsum_test_253_en.txt", + "fulltext": "A 51-year-old white female who was referred from our outpatient pulmonary clinic to the ED (emergency department) for worsening respiratory distress and six weeks history of persistent dry cough. Prior to this admission, the patient was seen at an urgent care and was prescribed a 10 days course of oral antibiotic empirically without significant improvement. Subsequently, the patient was seen in our outpatient pulmonary clinic for a working diagnosis of pneumonia and a previous chest x-ray depicting bibasilar opacities. In the office, the patient complained of dyspnea with ambulation. She was tested negative for COVID-19. Therefore, patient was prescribed oral doxycycline 100 mg twice daily empirically for 14 days and 40 mg of oral prednisone for 5 days. The patient was advised to communicate her progress with the treating physician, so her treatment protocol can be adjusted if needed. However, attempts to wean her prednisone made her dyspnea worse with pulse oximetry reportedly in high 80 s% on ambulation. PFTs (pulmonary function tests) outpatient showed restrictive lung pattern with reduced FEV-1 (forced expiratory volume in 1 s) at 52%, and reduced FVC (Forced vital capacity) at 47%.\nPatient reported having associated generalized fatigue, but no weight loss. She denied any hemoptysis, chest pain, fever, chills, night sweats, epistaxis, dry eyes, dry mouth, vision changes, photosensitivity, oral ulcer, dysphagia, abdominal pain, nausea, vomiting, constipation, or diarrhea. She denied any urinary disturbances, myalgia, joint pain or swelling, blood in urine or stool, or any Raynaud's type symptoms. Patient reported a recent travel history to Florida, but no history of sick contacts. She endorsed a family history only significant for Crohn's disease in father and daughter. She reported no alcohol use and no smoking history. The patient did not have any occupational or pet exposure.\nIn the ED, the patients' vital signs were a temperature of 97.6 F, respiratory rate of 26 per minute, oxygen saturation of 88–90% on room air which improved to 94% with 3 L of oxygen on nasal cannula, and blood pressure of 102/53 mmHg. Patient’s body weight was 75.3 kg and her height was 157 cm. On physical exam, patient noticed to be dyspneic and tachypneic. She was alert and oriented to time, place and person. Head and neck examinations were unremarkable for lymphadenopathy, jugular venous distention (JVD), nasal/oral ulcerations, or any other lesions. On chest auscultation, reduced breath sounds were evident at the lower lung fields. Cardiology, gastrointestinal, and neurological examinations were unremarkable. No joint tenderness/swelling or muscle tenderness/weakness appreciated at the musculoskeletal examination. Skin examination revealed no rash or other lesions. The patient was admitted for further evaluation, beginning with retesting for COVID-19 and additional workup.\nInitial complete blood count, renal, and liver panel were all within normal limits except for normocytic anemia . Erythrocyte sedimentation rate (ESR) was 49 mm/h (0–15 mm/h), C-reactive protein (CRP) was 3.24 mg/dL (0.00–0.74 mg/dL), and anti-nuclear antibodies 2.09 (0.0–0.90). Urinalysis and complement levels were unremarkable. Creatine kinase (CK) and aldolase were 326 iu/L (22–232 iu/L), 39.5 u/L (1.5–8.1 u/L) respectively. The COVID-19 RT-PCR (Reverse transcription polymerase chain reaction) testing was negative twice as an inpatient.\nA chest x-ray showed persistent bibasilar infiltrates, finding similar to previous imaging. A Computed tomography angiography of the chest showed bilateral ground glass opacities, with shotty mediastinal lymph nodes, and no filling defects to suggest a pulmonary embolism. Echocardiogram showed normal left ventricular (LV) function, right ventricular function, and pulmonary pressures.\nThe patient underwent bronchoscopy with right lower lobe transbronchial biopsies which showed mild lung parenchymal inflammation, fibrosis, and reactive epithelial changes without any sign of malignancy. Gomori methenamine-silver (GMS) nitrate stain and acid-fast stains (also known as the Ziehl–Neelsen stain) were negative for Pneumocystis jiroveci and Mycobacterium species, respectively. Bacterial and fungal cultures from right lower lobe bronchoalveolar lavage remained negative.\nSubsequent autoimmune screening returned strongly positive for anti‑Jo‑1 antibody 191 au/mL (reference range 0–40). Other markers, including rheumatoid factor, anti‑cyclic citrullinated peptide antibodies, anti‑Ro/SSA, and antineutrophil cytoplasmic antibodies were negative.\nTherefore, ASS-associated ILD was considered in the setting of clinical and radiographic findings of nonspecific interstitial pneumonia (NSIP) associated with positive anti-Jo-1 antibody.\nPatient was started on intravenous methylprednisolone 40 mg every 12 h which failed to improve patient’s symptoms; therefore, she was given intravenous pulse methylprednisolone 1000 mg daily for 3 days. Patient reported some improvement of her symptoms after pulse steroids. She was discharged with 2 L home oxygen as needed and on high dose oral corticosteroids, prednisone 60 mg oral daily. She followed up with rheumatology outpatient two weeks after discharge and was started on oral mycophenolate 500 mg twice daily. However, tapering steroids was difficult and mycophenolate was titrated up to 1500 mg twice daily.\nAt her 3 months follow-up, the patient continued to have a gradual improvement of her symptoms and she was weaned off oxygen. Chest high-resolution computed tomography (HRCT) at that time showed 20% interval improvement particularly in the lower lobes with improvement of her laboratory markers such as ESR, CRP, CK, and aldolase demonstrated in . Favorably, her prednisone was tapered over six months to 10 mg daily while being on the same dose of mycophenolate.", + "fulltext_subclaims": [ + "The patient is a 51-year-old white female.", + "The patient was referred from the outpatient pulmonary clinic to the ED for worsening respiratory distress.", + "The patient had a six-week history of persistent dry cough.", + "The patient was seen at an urgent care and was prescribed a 10-day course of oral antibiotic.", + "The patient was seen in the outpatient pulmonary clinic for a working diagnosis of pneumonia.", + "A previous chest x-ray depicted bibasilar opacities.", + "The patient was tested negative for COVID-19.", + "The patient was prescribed oral doxycycline 100 mg twice daily empirically for 14 days.", + "The patient was prescribed 40 mg of oral prednisone for 5 days.", + "The patient was advised to communicate her progress with the treating physician.", + "Attempts to wean her prednisone made her dyspnea worse.", + "PFTs showed a restrictive lung pattern.", + "The patient reported generalized fatigue.", + "The patient denied weight loss.", + "The patient reported a recent travel history to Florida.", + "The patient had no history of sick contacts.", + "The patient's family history was significant for Crohn's disease in father and daughter.", + "The patient reported no alcohol use.", + "The patient had no smoking history.", + "The patient had no occupational or pet exposure.", + "In the ED, the patient's oxygen saturation was 88–90% on room air.", + "In the ED, the patient's oxygen saturation improved to 94% with 3 L of oxygen on nasal cannula.", + "On physical exam, the patient was noted to be dyspneic and tachypneic.", + "Chest auscultation revealed reduced breath sounds at the lower lung fields.", + "Initial complete blood count, renal, and liver panel were within normal limits except for normocytic anemia.", + "The ESR was 49 mm/h.", + "The CRP was 3.24 mg/dL.", + "Anti-nuclear antibodies were 2.09.", + "Creatine kinase was 326 iu/L.", + "Aldolase was 39.5 u/L.", + "The chest x-ray showed persistent bibasilar infiltrates.", + "The CT angiography showed bilateral ground glass opacities.", + "The CT angiography showed shotty mediastinal lymph nodes.", + "The CT angiography showed no filling defects to suggest a pulmonary embolism.", + "The echocardiogram showed normal left ventricular function.", + "The echocardiogram showed normal right ventricular function.", + "The echocardiogram showed normal pulmonary pressures.", + "The bronchoscopy showed mild lung parenchymal inflammation.", + "The bronchoscopy showed fibrosis.", + "The bronchoscopy showed reactive epithelial changes.", + "The GMS nitrate stain was negative for Pneumocystis jiroveci.", + "The acid-fast stain was negative for Mycobacterium species.", + "Bacterial and fungal cultures from bronchoalveolar lavage remained negative.", + "The anti-Jo-1 antibody was 191 au/mL.", + "Other markers, including rheumatoid factor, were negative.", + "Other markers, including anti-cyclic citrullinated peptide antibodies, were negative.", + "Other markers, including anti-Ro/SSA, were negative.", + "Other markers, including antineutrophil cytoplasmic antibodies, were negative.", + "ASS-associated ILD was considered.", + "The patient was started on intravenous methylprednisolone 40 mg every 12 h.", + "The patient was given intravenous pulse methylprednisolone 1000 mg daily for 3 days.", + "The patient reported some improvement of her symptoms after pulse steroids.", + "The patient was discharged with 2 L home oxygen as needed.", + "The patient was on high dose oral corticosteroids, prednisone 60 mg oral daily.", + "The patient followed up with rheumatology outpatient two weeks after discharge.", + "The patient was started on oral mycophenolate 500 mg twice daily.", + "Mycophenolate was titrated up to 1500 mg twice daily.", + "At her 3-month follow-up, the patient had a gradual improvement of her symptoms.", + "The patient was weaned off oxygen.", + "The chest HRCT showed 20% interval improvement particularly in the lower lobes.", + "Improvement of her laboratory markers such as ESR, CRP, CK, and aldolase was demonstrated.", + "Her prednisone was tapered over six months to 10 mg daily.", + "The patient was on the same dose of mycophenolate." + ], + "summary": "We present a challenging and rare case of ASS-associated ILD presenting with unexplained respiratory symptoms and bilateral infiltrates on chest imaging during the COVID-19 pandemic. High clinical suspicion for ASS with early appropriate therapy with corticosteroids and immunosuppressive agents led to marked clinical improvement.", + "summary_subclaims": [ + "This is a case of ASS-associated ILD.", + "The patient had unexplained respiratory symptoms.", + "The patient had bilateral infiltrates on chest imaging.", + "The case occurred during the COVID-19 pandemic.", + "High clinical suspicion for ASS was present.", + "Early appropriate therapy with corticosteroids was provided.", + "Early appropriate therapy with immunosuppressive agents was provided.", + "Marked clinical improvement occurred." + ] + }, + { + "id": "multiclinsum_test_289_en.txt", + "fulltext": "A 58-year-old woman was referred to the Endocrinology Unit in 2019 due to incidental findings of hypercalcaemia. Her medical history included hypertension, stage 3a chronic kidney disease (CKD), and carpal tunnel syndrome treated surgically. She had no family history of endocrine diseases or nephrolithiasis.\nA laboratory test revealed hypercalcaemia, hypercalciuria, and unsuppressed PTH levels (27 pg/mL, reference range, 15-65 pg/mL) .\nComputed tomography (CT) scans of the chest, abdomen and pelvis were conducted and showed no signs of malignancy or granulomatous disease.\nNeck ultrasonography and technetium 99m sestamibi (MIBI) scintigraphy revealed a mass in the upper pole of the left thyroid gland lobe, which was confirmed to be the parathyroid gland after biopsy via immunohistochemical staining .\nThere were no abnormalities in the densitometry results (T score of the lumbar spine 1.1; T score of the proximal femur -0.2; T score of the radius 0.5). However, an X-ray revealed advanced subperiosteal bone resorption in the fingers and bone loss in the thoracic spine and clavicles. There were no renal stones or fractures.\nThe patient underwent effective parathyroidectomy, after which the calcium level was normalized (2.45 mmol/L, reference range, 2.2-2.55 mmol/L). Histopathology confirmed parathyroid adenoma.\nTen months after the operation, postoperative assessment revealed a normal calcium concentration (2.48 mmol/L), but vitamin D deficiency (16.4 ng/mL, reference range, 30-50 ng/mL); thus, supplementation with cholecalciferol was administered (4000 IU/daily) . The patient did not attend her follow-up appointments for two years. In 2022, a laboratory test showed hypercalcaemia and hypercalciuria recurrence, which was initially identified as recurrent primary hyperparathyroidism. However, blood tests revealed PTH suppression with elevated 1,25(OH)2D3 concentrations .\nThe patient was screened for granulomatous disease and hypercalcaemia of malignancy again, and the results were negative.\nVitamin D metabolites were measured using LC–MS/MS, which revealed high 25(OH)D3 (72.62 ng/mL) and low 24,25(OH)2D3 (0.09 ng/mL) concentrations and an elevated 25(OH)D3/24,25(OH)2D3 ratio 806,9 (reference range, 7.0-23.6), suggesting a defect in vitamin D catabolism.\nThe genetic testing of the CYP24A1 gene was conducted using the NGS technique, and two pathogenic variants were identified NM_000782.5:c; 1186C>T(p.Arg396Trp, rs114368325) and NM_000782.5:c; 428_430del (p.Glu143del, rs777676129). Both variants are classified as pathogenic/likely pathogenic, and associated with hypercalcemia in the available databases, including ClinVar NIH (ClinVar archives, National Institutes of Health). Due to the unavailability of family members, it was impossible to assess whether the variants were located in the same of different alleles of CYP24A1, what would be a direct proof of their dominant or recessive involvement in development of the observed symptoms.\nThe recommendation was to discontinue vitamin D supplementation, maintain adequate hydration and avoid excessive sunlight exposure. Follow-up evaluation showed normalization of calcium and PTH concentrations .", + "fulltext_subclaims": [ + "The patient was referred to the Endocrinology Unit in 2019 due to incidental findings of hypercalcaemia.", + "Her medical history included hypertension, stage 3a chronic kidney disease, and carpal tunnel syndrome treated surgically.", + "She had no family history of endocrine diseases or nephrolithiasis.", + "A laboratory test revealed hypercalcaemia, hypercalciuria, and unsuppressed PTH levels (27 pg/mL, reference range, 15-65 pg/mL).", + "Computed tomography (CT) scans showed no signs of malignancy or granulomatous disease.", + "Neck ultrasonography and technetium 99m sestamibi scintigraphy revealed a mass in the upper pole of the left thyroid gland lobe.", + "The mass was confirmed to be the parathyroid gland after biopsy via immunohistochemical staining.", + "There were no abnormalities in the densitometry results (T score of the lumbar spine 1.1; T score of the proximal femur -0.2; T score of the radius 0.5).", + "An X-ray revealed advanced subperiosteal bone resorption in the fingers and bone loss in the thoracic spine and clavicles.", + "The patient underwent effective parathyroidectomy.", + "After parathyroidectomy, the calcium level was normalized (2.45 mmol/L, reference range, 2.2-2.55 mmol/L).", + "Histopathology confirmed parathyroid adenoma.", + "Ten months after the operation, postoperative assessment revealed a normal calcium concentration (2.48 mmol/L).", + "Postoperative assessment revealed vitamin D deficiency (16.4 ng/mL, reference range, 30-50 ng/mL).", + "Supplementation with cholecalciferol was administered (4000 IU/daily).", + "The patient did not attend her follow-up appointments for two years.", + "In 2022, a laboratory test showed hypercalcaemia and hypercalciuria recurrence.", + "The recurrence was initially identified as recurrent primary hyperparathyroidism.", + "Blood tests revealed PTH suppression with elevated 1,25(OH)2D3 concentrations.", + "The patient was screened for granulomatous disease and hypercalcaemia of malignancy again, and the results were negative.", + "Vitamin D metabolites were measured using LC–MS/MS.", + "LC–MS/MS revealed high 25(OH)D3 (72.62 ng/mL) and low 24,25(OH)2D3 (0.09 ng/mL) concentrations.", + "The 25(OH)D3/24,25(OH)2D3 ratio was 806.9 (reference range, 7.0-23.6).", + "The elevated 25(OH)D3/24,25(OH)2D3 ratio suggested a defect in vitamin D catabolism.", + "The genetic testing of the CYP24A1 gene was conducted using the NGS technique.", + "Two pathogenic variants were identified: NM_000782.5:c.1186C>T(p.Arg396Trp, rs114368325) and NM_000782.5:c.428_430del (p.Glu143del, rs777676129).", + "Both variants are classified as pathogenic/likely pathogenic.", + "The variants are associated with hypercalcemia in the available databases, including ClinVar NIH.", + "It was impossible to assess whether the variants were located in the same or different alleles of CYP24A1 due to the unavailability of family members.", + "The recommendation was to discontinue vitamin D supplementation.", + "The recommendation included maintaining adequate hydration and avoiding excessive sunlight exposure.", + "Follow-up evaluation showed normalization of calcium and PTH concentrations." + ], + "summary": "We report the case of a 58-year-old woman diagnosed initially with primary hyperparathyroidism. Preoperatively, the suspected mass adjoining the upper pole of the left lobe of the thyroid gland was found via ultrasonography and confirmed by 99mTc scintigraphy and biopsy as the parathyroid gland. The patient underwent parathyroidectomy (a histopathology report revealed parathyroid adenoma), which led to normocalcaemia. After 10 months, vitamin D supplementation was introduced due to deficiency, and the calcium level remained within the reference range. Two years later, biochemical tests showed recurrence of hypercalcaemia with suppressed parathyroid hormone levels and elevated 1,25(OH)2D3 concentrations. Further investigation excluded the most common causes of PTH-independent hypercalcaemia, such as granulomatous disease, malignancy, and vitamin D intoxication. Subsequently, vitamin D metabolites were measured using LC-MS/MS, which revealed high levels of 25(OH)D3, low levels of 24,25(OH)2D3 and elevated 25(OH)2D3/24,25(OH)2D3 ratios, suggesting a defect in vitamin D catabolism. Molecular analysis of the CYP24A1 gene using the NGS technique revealed two pathogenic variants: p.(Arg396Trp) and p.(Glu143del) (rs114368325 and rs777676129, respectively).", + "summary_subclaims": [ + "The patient was a 58-year-old woman.", + "The patient was diagnosed initially with primary hyperparathyroidism.", + "A suspected mass adjoining the upper pole of the left lobe of the thyroid gland was found via ultrasonography.", + "The suspected mass was confirmed by 99mTc scintigraphy and biopsy as the parathyroid gland.", + "The patient underwent parathyroidectomy.", + "A histopathology report revealed parathyroid adenoma.", + "The patient achieved normocalcaemia after parathyroidectomy.", + "After 10 months, vitamin D supplementation was introduced due to deficiency.", + "The calcium level remained within the reference range after vitamin D supplementation.", + "Two years later, biochemical tests showed recurrence of hypercalcaemia.", + "Parathyroid hormone levels were suppressed.", + "1,25(OH)2D3 concentrations were elevated.", + "Further investigation excluded granulomatous disease as a cause of PTH-independent hypercalcaemia.", + "Further investigation excluded malignancy as a cause of PTH-independent hypercalcaemia.", + "Further investigation excluded vitamin D intoxication as a cause of PTH-independent hypercalcaemia.", + "Vitamin D metabolites were measured using LC-MS/MS.", + "High levels of 25(OH)D3 were revealed.", + "Low levels of 24,25(OH)2D3 were revealed.", + "Elevated 25(OH)2D3/24,25(OH)2D3 ratios were revealed.", + "The findings suggested a defect in vitamin D catabolism.", + "Molecular analysis of the CYP24A1 gene was performed using the NGS technique.", + "Two pathogenic variants were found in the CYP24A1 gene.", + "The pathogenic variants were p.(Arg396Trp) and p.(Glu143del).", + "The pathogenic variants were rs114368325 and rs777676129, respectively." + ] + }, + { + "id": "multiclinsum_test_1923_en.txt", + "fulltext": "A 31-year-old man was admitted to our department because of acute abdominal pain, nausea, vomiting and anxiety of ten hours duration. On physical examination severe abdominal tenderness was marked, localized to the right lower abdomen aggravated on walking and coughing. His temperature was 37.8 degrees celcius and his pulse rate 92 bpm. Laboratory investigation disclosed a white blood count of 16,800/mm3, neutrofils 72% with left shift and elevated erythrocyte sedimentation rate (ESR) and C reactive protein (CRP).\nAll other hematological and biochemical parameters were within normal range. Clinical presentation and laboratory findings suggested acute appendicitis and laparotomy was performed. Through a right paramedian subumbilical incision the right iliac fossa was explored and a grossly inflamed omental mass was revealed and resected. .\nA small amount of fluid was seen. The appendix was macroscopically normal and no other cause of acute abdomen was identified. The pathology of the surgical specimen reported primary omentitis. The patient made an uneventful recovery.", + "fulltext_subclaims": [ + "A 31-year-old man was admitted to our department because of acute abdominal pain, nausea, vomiting and anxiety of ten hours duration.", + "On physical examination severe abdominal tenderness was marked, localized to the right lower abdomen aggravated on walking and coughing.", + "His temperature was 37.8 degrees celcius.", + "His pulse rate was 92 bpm.", + "Laboratory investigation disclosed a white blood count of 16,800/mm3.", + "Neutrophils were 72% with left shift.", + "Erythrocyte sedimentation rate was elevated.", + "C reactive protein was elevated.", + "All other hematological and biochemical parameters were within normal range.", + "Clinical presentation and laboratory findings suggested acute appendicitis.", + "Laparotomy was performed.", + "Through a right paramedian subumbilical incision the right iliac fossa was explored.", + "A grossly inflamed omental mass was revealed and resected.", + "A small amount of fluid was seen.", + "The appendix was macroscopically normal.", + "No other cause of acute abdomen was identified.", + "The pathology of the surgical specimen reported primary omentitis.", + "The patient made an uneventful recovery." + ], + "summary": "We report a case of ISIGO in a 31 year old patient, who presented with acute abdominal pain, nausea, vomiting and leukocytosis. Radiologic investigation was non-specific. The patient underwent surgical resection of the infracted omentum with compete recovery.", + "summary_subclaims": [ + "The patient is a 31 year old.", + "The patient had acute abdominal pain.", + "The patient had nausea.", + "The patient had vomiting.", + "The patient had leukocytosis.", + "Radiologic investigation was non-specific.", + "The patient underwent surgical resection of the infracted omentum.", + "The patient had complete recovery." + ] + }, + { + "id": "multiclinsum_test_2240_en.txt", + "fulltext": "A 44-year-old Chinese man presented with a 45-day history of diplopia. Before the onset of his condition, he reported no cold, nausea, dizziness, tinnitus, vomiting, headache, hearing impairment, or hair graying. Local hospital assessments previously identified panuveitis, choroidal detachment, DR, and bilateral macular edema. Macular OCT indicated both eyes had macular neuroepithelium thickening and elevation, along with intercystic low reflex and localized detachment of the neuroepithelium. Despite initiating treatment with corticosteroid eye drops and posterior subtenon injections of corticosteroids, his condition deteriorated progressively. The patient reported no prior trauma or eye surgery. He had managed type 2 diabetes for 15 years and received bilateral total retinal photocoagulation for DR two years earlier. Physical exam revealed BCVA: manual in both eyes, with intraocular pressure at 17 mmHg and 18 mmHg. Exam findings were bilateral conjunctival congestion, atrial flash (+), localized posterior iris synechiae, pupillary margin neovascularization, clear lens, grade II vitreous opacity, and white pompon-like opacities. Right eye fundus examination showed a disc-surrounding neovascular membrane, 360° peripheral retinal and choroidal bulges, dispersed old photocoagulation marks, neovascularization, and superior and inferonasal retinal hemorrhages, extending to the posterior pole. In both eyes, examination revealed the presence of circumferential peripheral retinal and choroidal protrusions. These were accompanied by scattered, pre-existing photocoagulation marks. UBM detected a detachment of the ciliary body in each eye. Utilizing B-mode ultrasonography, vitreous opacity, and detachments in the choroid, and retina were noted for both eyes. The axial length of the right eye is 22.68 mm, and that of the left eye is 22.50 mm.Furthermore, OCT identified a significant bulge in the peripheral retina and a lack of clarity in the macular area. FFA revealed twisted, enlarged retinal veins, pronounced dotted fluorescence, and hemorrhagic fluorescence shading in the retina, with patchy nonperfusion areas (refer to Fig. ). Orbital MRI and liver and kidney function tests were normal. Syphilis, HIV, and T-SPOT tests were negative. Intraocular fluid analysis ruled out microbial infection, with VEGF at 1614.3 pg/mL, BFGF at 478.3 pg/mL, IL-6 at 566 pg/mL, VCAM at 21845.2 pg/mL, and IL-8 at 135.7 pg/mL. HLA-DRB1 results indicated DRB1*04\nHe was therefore diagnosed with probable VKH. He was administered intravenous methylprednisolone at 0.5 g per day, gradually transitioning to oral corticosteroid therapy. Subsequently, the patient’s subretinal fluid resolved, and normal choroidal and retinal architecture was restored. Upon discharge, the BCVA was 20/250 in the right eye and 20/500 in the left eye (refer to Fig. ). Post-discharge, despite several adjustments, the patient’s blood glucose levels remained poorly controlled. Consequently, oral cyclosporine at 100 mg per day was added to his regimen. However, the patient experienced general weakness and dizziness, leading to the discontinuation of cyclosporine after 12 days. At the follow-up examination, there was an improvement in retinal and choroidal detachments, with a BCVA of 20/200 in both eyes. Nonetheless, fundus hemorrhage in the right eye had worsened (refer to Fig. ). The patient was then switched to cyclosporine from different manufacturers.", + "fulltext_subclaims": [ + "The patient is a 44-year-old Chinese man.", + "He had a 45-day history of diplopia.", + "Before the onset of his condition, he reported no cold.", + "Before the onset of his condition, he reported no nausea.", + "Before the onset of his condition, he reported no dizziness.", + "Before the onset of his condition, he reported no tinnitus.", + "Before the onset of his condition, he reported no vomiting.", + "Before the onset of his condition, he reported no headache.", + "Before the onset of his condition, he reported no hearing impairment.", + "Before the onset of his condition, he reported no hair graying.", + "Local hospital assessments identified panuveitis.", + "Local hospital assessments identified choroidal detachment.", + "Local hospital assessments identified diabetic retinopathy.", + "Local hospital assessments identified bilateral macular edema.", + "Macular OCT indicated both eyes had macular neuroepithelium thickening.", + "Macular OCT indicated both eyes had macular neuroepithelium elevation.", + "Macular OCT indicated both eyes had intercystic low reflex.", + "Macular OCT indicated both eyes had localized detachment of the neuroepithelium.", + "He was treated with corticosteroid eye drops.", + "He was treated with posterior subtenon injections of corticosteroids.", + "His condition deteriorated progressively.", + "He reported no prior trauma.", + "He reported no prior eye surgery.", + "He had managed type 2 diabetes for 15 years.", + "He received bilateral total retinal photocoagulation for diabetic retinopathy two years earlier.", + "Physical exam revealed best-corrected visual acuity: manual in both eyes.", + "Physical exam revealed intraocular pressure at 17 mmHg in the right eye.", + "Physical exam revealed intraocular pressure at 18 mmHg in the left eye.", + "Exam findings included bilateral conjunctival congestion.", + "Exam findings included atrial flash (+).", + "Exam findings included localized posterior iris synechiae.", + "Exam findings included pupillary margin neovascularization.", + "Exam findings included clear lens.", + "Exam findings included grade II vitreous opacity.", + "Exam findings included white pompon-like opacities.", + "Right eye fundus examination showed a disc-surrounding neovascular membrane.", + "Right eye fundus examination showed 360° peripheral retinal and choroidal bulges.", + "Right eye fundus examination showed dispersed old photocoagulation marks.", + "Right eye fundus examination showed neovascularization.", + "Right eye fundus examination showed superior and inferonasal retinal hemorrhages.", + "Right eye fundus examination showed retinal hemorrhages extending to the posterior pole.", + "In both eyes, examination revealed the presence of circumferential peripheral retinal and choroidal protrusions.", + "In both eyes, examination revealed scattered, pre-existing photocoagulation marks.", + "UBM detected a detachment of the ciliary body in each eye.", + "B-mode ultrasonography noted vitreous opacity in both eyes.", + "B-mode ultrasonography noted detachments in the choroid in both eyes.", + "B-mode ultrasonography noted detachments in the retina in both eyes.", + "The axial length of the right eye is 22.68 mm.", + "The axial length of the left eye is 22.50 mm.", + "OCT identified a significant bulge in the peripheral retina.", + "OCT identified a lack of clarity in the macular area.", + "FFA revealed twisted, enlarged retinal veins.", + "FFA revealed pronounced dotted fluorescence.", + "FFA revealed hemorrhagic fluorescence shading in the retina.", + "FFA revealed patchy nonperfusion areas.", + "Orbital MRI was normal.", + "Liver and kidney function tests were normal.", + "Syphilis test was negative.", + "HIV test was negative.", + "T-SPOT test was negative.", + "Intraocular fluid analysis ruled out microbial infection.", + "Intraocular fluid analysis showed VEGF at 1614.3 pg/mL.", + "Intraocular fluid analysis showed BFGF at 478.3 pg/mL.", + "Intraocular fluid analysis showed IL-6 at 566 pg/mL.", + "Intraocular fluid analysis showed VCAM at 21845.2 pg/mL.", + "Intraocular fluid analysis showed IL-8 at 135.7 pg/mL.", + "HLA-DRB1 results indicated DRB1*04.", + "He was diagnosed with probable VKH.", + "He was administered intravenous methylprednisolone at 0.5 g per day.", + "He was transitioned to oral corticosteroid therapy.", + "The patient’s subretinal fluid resolved.", + "Normal choroidal and retinal architecture was restored.", + "Upon discharge, the BCVA was 20/250 in the right eye.", + "Upon discharge, the BCVA was 20/500 in the left eye.", + "Post-discharge, the patient’s blood glucose levels remained poorly controlled.", + "Oral cyclosporine at 100 mg per day was added to his regimen.", + "The patient experienced general weakness.", + "The patient experienced dizziness.", + "Cyclosporine was discontinued after 12 days.", + "At the follow-up examination, there was an improvement in retinal and choroidal detachments.", + "At the follow-up examination, the BCVA was 20/200 in both eyes.", + "Fundus hemorrhage in the right eye had worsened.", + "The patient was switched to cyclosporine from different manufacturers." + ], + "summary": "In this study, we document a case of unconventional VKH. Manifestations in this patient included intense peripheral retinal detachment and choroidal detachment, along with vitreous opacities akin to cotton wool spots, concurrent with DR. The diagnosis was considered as probable VKH with DR. Treatment according to VKH protocols, including high-dose corticosteroids, yielded positive results.", + "summary_subclaims": [ + "The case documented is one of unconventional VKH.", + "Manifestations included intense peripheral retinal detachment.", + "Manifestations included choroidal detachment.", + "Manifestations included vitreous opacities akin to cotton wool spots.", + "The manifestations were concurrent with DR.", + "The diagnosis was considered as probable VKH with DR.", + "Treatment was according to VKH protocols.", + "Treatment included high-dose corticosteroids.", + "The treatment yielded positive results." + ] + }, + { + "id": "multiclinsum_test_2869_en.txt", + "fulltext": "A 29-years-old female experienced an episode of mild upper respiratory tract infection followed by a slowly developing dysphagia and dyspnea. This led to impaired exercise tolerance lasting several months, with recent subacute exacerbation. There was no significant history of travel or exposure to infectious agents. She had not suffered from fever or other acute or chronic infectious symptoms. Her palatine tonsils had been removed in childhood. She was diagnosed with epilepsy at age 17 and had been free of epileptic symptoms for over 5 years with levetiracetam (500 mg two times per day) and lamotrigine (150 mg two times per day). Her family history was unremarkable.\nShe spoke with hoarse voice, without signs or findings that would have suggested systemic involvement. There were no signs of generalized mucosal disease. Fiberoptic examination showed swelling of the lingual tonsil, epiglottic and arytenoid mucosa, causing airway obstruction . C-reactive protein concentration and blood sedimentation rate were low, and anti-nuclear, anti-neutrophil, anti-glomerular basement membrane, anti-myeloperoxidase, anti-proteinase 3, tissue transglutaminase and cyclic citrullinated peptide antibodies were negative. Thyroid function was normal and thyroid peroxidase antibodies were 34 IU/ml (normal value < 60 IU/ml). Plasma parathyroid hormone (39 ng/l; normal 18–80 ng/l) and serum vitamin D-25 (77 nmol/l; normal > 50 nmol/l) were normal. No evidence for acute or chronic viral, bacterial, mycobacterial or fungal infections, including hepatitis B and C, human immunodeficiency virus and tularemia, was found.\nDue to her swollen lingual tonsil and laryngeal mucosa causing airway obstruction, she was hospitalized and received empiric cefuroxime (1.5 g thrice daily) and methylprednisolone (75 mg once daily, height 173 cm, weight 63 kg, prednisolone dose 1.2 mg/kg) intravenously. After a transient positive response, she was discharged from the hospital after 6 days. Soon after, she was readmitted to due to a rapid reoccurrence of the symptoms. A modest positive response was seen after per oral clindamycin and oral prednisolone (60 mg/days) with dose reduction for 14 days. Lingual tonsil and epiglottis were biopsied. Histology showed granulomatous reaction in lingual tonsil with CD68+ (Kp-1) epithelioid histiocytes . The CD20+ B lymphocyte count was increased while Pax-5+ positive B lymphocyte count was normal. CD138+ plasma cells were scarce, and they showed polytypic kappa- and lambda light chain expression. The number of CD3+ T cells was normal, and most T cells were CD4+. Eosinophils were practically absent and well-formed follicles were not seen. Epstein–Barr virus in situ hybridization (EBER), p16, cytomegalovirus and mycobacteria were negative. Morphology, immunohistochemical staining, serum electrophoresis and bone marrow aspirate did not raise suspicion of lymphoid neoplasia, thus, no clonality studies were done.\nDue to granulomas, sarcoidosis was considered. However, chest X-ray, computerized tomography of chest and ultrasound of neck and abdomen were unremarkable. Positron emission tomography/computed tomography (PET/CT) showed increased fluorodeoxyglucose (FDG) uptake in the lingual tonsil, without evidence of widespread sarcoidosis . No other pathological FDG foci were found. Focal physiological FDG accumulation was seen in ureters on both sides of the spinal column. This is a common finding due to ureteral peristalsis and pooling of radiotracer in the recumbent patient. The patient had no neurological symptoms and brain magnetic resonance imaging was normal. Serum angiotensin converting enzyme (ACE) was within normal range (11–20 U/l; reference range 9–65 U/l) while daily urine calcium output was normal or slightly elevated (5.0–6.31 mmol; reference range 1.2–5.5 mmol).\nSubsequently, an unusual presentation of primary or secondary immunodeficiency was considered. There was no consanguinity; the patient or her family had no history of repeated infections or autoimmunity. White cell, lymphocyte, and B, T and NK lymphocyte subset counts were within normal limits. CD19+ B cell count was 153 × 109/l (normal range 80–616 × 109/l). Proportions of memory CD27+ B-cells (30.3%) and IgD−IgM−CD27+ switched memory B cells 7.2%; (normal range 6.5–29.2%) were normal and the percentage of activated CD21low B cells was high (6.6%; normal range 0.6–3.5%). Percentages of various CD3+CD4+ and CD3+CD8+ T cell subsets appeared normal. Serum total IgG (3.5 g/l; normal range 6.77–15.0 g/l) and all IgG subclass concentrations were low: IgG1 2.45 g/l (normal range 4.9–11.4 g/l), IgG2 0.91 g/l (normal range 1.5–6.4 g/l), IgG3 0.18 g/l (normal range 0.2–1.1 g/l) and IgG4 0.02 g/L (normal range 0.08–1.4 g/l). Anti-polysaccharide response to Pneumovax® were impaired, with only 3/10 serotypes reaching a level of 0.35 µg/ml after immunization. However, serum IgA (0.90 g/l; normal range 0.52–4.02 g/l) and IgM concentrations (0.57 g/l; normal range 0.47–2.84 g/l) were normal. Dihydrorhodamine test excluded chronic granulomatous disease. These findings were thus consistent with either granulomatous CVID or most likely secondary drug-induced hypogammaglobulinemia with a novel clinical presentation [–]. Genetic analysis (Blueprint Genetics, Primary Immunodeficiency Plus panel. ) did not find known mutations causative of CVID-like or other primary immunodeficiencies.\nDue to symptomatic upper airway obstruction, dysphagia, lack of evident infection and unsatisfactory response to prednisolone treatment and possible granulomatous CVID, the patient received immunoglobulin replacement and rituximab therapy (Mabthera® 100 mg, 200 mg and 500 mg on three consecutive days combined with 100 mg hydrocortisone and 1 g paracetamol), with a favorable response within 2 weeks accompanied by significant improvement in dysphagia and respiratory symptoms. Seven months later, her exercise capacity was good. She has remained asymptomatic for over 16 months after rituximab treatment. Her fiberoptic pharyngeal findings improved . She continues to receive subcutaneous immunoglobulin replacement with serum IgG levels in the range of 10 to 12 g/l.", + "fulltext_subclaims": [ + "The patient is a 29-years-old female.", + "She experienced an episode of mild upper respiratory tract infection.", + "This was followed by a slowly developing dysphagia and dyspnea.", + "The dysphagia and dyspnea led to impaired exercise tolerance lasting several months.", + "There was a recent subacute exacerbation.", + "There was no significant history of travel or exposure to infectious agents.", + "She had not suffered from fever or other acute or chronic infectious symptoms.", + "Her palatine tonsils had been removed in childhood.", + "She was diagnosed with epilepsy at age 17.", + "She had been free of epileptic symptoms for over 5 years.", + "She was taking levetiracetam (500 mg two times per day).", + "She was taking lamotrigine (150 mg two times per day).", + "Her family history was unremarkable.", + "She spoke with a hoarse voice.", + "There were no signs or findings that would have suggested systemic involvement.", + "There were no signs of generalized mucosal disease.", + "Fiberoptic examination showed swelling of the lingual tonsil.", + "Fiberoptic examination showed swelling of the epiglottic and arytenoid mucosa.", + "The swelling caused airway obstruction.", + "C-reactive protein concentration was low.", + "Blood sedimentation rate was low.", + "Anti-nuclear antibodies were negative.", + "Anti-neutrophil antibodies were negative.", + "Anti-glomerular basement membrane antibodies were negative.", + "Anti-myeloperoxidase antibodies were negative.", + "Anti-proteinase 3 antibodies were negative.", + "Tissue transglutaminase antibodies were negative.", + "Cyclic citrullinated peptide antibodies were negative.", + "Thyroid function was normal.", + "Thyroid peroxidase antibodies were 34 IU/ml.", + "Plasma parathyroid hormone was 39 ng/l.", + "Serum vitamin D-25 was 77 nmol/l.", + "No evidence for acute or chronic viral, bacterial, mycobacterial or fungal infections was found.", + "She was hospitalized due to her swollen lingual tonsil and laryngeal mucosa causing airway obstruction.", + "She received empiric cefuroxime (1.5 g thrice daily).", + "She received methylprednisolone (75 mg once daily).", + "She was discharged from the hospital after 6 days.", + "She was readmitted due to a rapid reoccurrence of the symptoms.", + "A modest positive response was seen after per oral clindamycin.", + "A modest positive response was seen after oral prednisolone (60 mg/days).", + "The prednisolone dose was reduced for 14 days.", + "Lingual tonsil and epiglottis were biopsied.", + "Histology showed granulomatous reaction in lingual tonsil.", + "The granulomatous reaction included CD68+ (Kp-1) epithelioid histiocytes.", + "The CD20+ B lymphocyte count was increased.", + "The Pax-5+ positive B lymphocyte count was normal.", + "CD138+ plasma cells were scarce.", + "CD138+ plasma cells showed polytypic kappa- and lambda light chain expression.", + "The number of CD3+ T cells was normal.", + "Most T cells were CD4+.", + "Eosinophils were practically absent.", + "Well-formed follicles were not seen.", + "Epstein–Barr virus in situ hybridization (EBER) was negative.", + "p16 was negative.", + "Cytomegalovirus was negative.", + "Mycobacteria were negative.", + "Morphology did not raise suspicion of lymphoid neoplasia.", + "Immunohistochemical staining did not raise suspicion of lymphoid neoplasia.", + "Serum electrophoresis did not raise suspicion of lymphoid neoplasia.", + "Bone marrow aspirate did not raise suspicion of lymphoid neoplasia.", + "No clonality studies were done.", + "Sarcoidosis was considered.", + "Chest X-ray was unremarkable.", + "Computerized tomography of chest was unremarkable.", + "Ultrasound of neck and abdomen was unremarkable.", + "PET/CT showed increased FDG uptake in the lingual tonsil.", + "PET/CT showed no evidence of widespread sarcoidosis.", + "Focal physiological FDG accumulation was seen in ureters on both sides of the spinal column.", + "The patient had no neurological symptoms.", + "Brain magnetic resonance imaging was normal.", + "Serum angiotensin converting enzyme (ACE) was within normal range.", + "Daily urine calcium output was normal or slightly elevated.", + "An unusual presentation of primary or secondary immunodeficiency was considered.", + "There was no consanguinity.", + "The patient or her family had no history of repeated infections or autoimmunity.", + "White cell, lymphocyte, and B, T and NK lymphocyte subset counts were within normal limits.", + "CD19+ B cell count was 153 × 109/l.", + "Proportions of memory CD27+ B-cells were normal.", + "IgD−IgM−CD27+ switched memory B cells proportion was 7.2%.", + "The percentage of activated CD21low B cells was high.", + "Percentages of various CD3+CD4+ and CD3+CD8+ T cell subsets appeared normal.", + "Serum total IgG was 3.5 g/l.", + "All IgG subclass concentrations were low.", + "Serum IgA was 0.90 g/l.", + "Serum IgM was 0.57 g/l.", + "Dihydrorhodamine test excluded chronic granulomatous disease.", + "The findings were consistent with either granulomatous CVID or most likely secondary drug-induced hypogammaglobulinemia.", + "Genetic analysis did not find known mutations causative of CVID-like or other primary immunodeficiencies.", + "The patient received immunoglobulin replacement and rituximab therapy.", + "She received Mabthera® 100 mg, 200 mg and 500 mg on three consecutive days.", + "She received 100 mg hydrocortisone.", + "She received 1 g paracetamol.", + "There was a favorable response within 2 weeks.", + "There was significant improvement in dysphagia.", + "There was significant improvement in respiratory symptoms.", + "Seven months later, her exercise capacity was good.", + "She has remained asymptomatic for over 16 months after rituximab treatment.", + "Fiberoptic pharyngeal findings improved.", + "She continues to receive subcutaneous immunoglobulin replacement.", + "Her serum IgG levels are in the range of 10 to 12 g/l." + ], + "summary": "A 29-year-old female with epilepsy developed dysphagia, dyspnea and impaired exercise tolerance. Obstruction caused by swollen lingual tonsil and edema in the epiglottis and arytenoid mucosa were found. Lingual tonsil and epiglottis biopsies displayed non-necrotizing granulomas. There was no evidence of viral, bacterial, mycobacterial or fungal infections. Chest X-ray, computerized tomography of chest and ultrasound of neck and abdomen remained unremarkable. Positron emission tomography/computed tomography (PET/CT) showed laryngeal enhancement. Empiric antimicrobials combined with prednisolone were insufficient to control her disease. In immunological evaluation, the patient had normal counts of B and T cells. Proportions of CD27+ memory B cells (30.3%) and IgD-IgM-CD27+ switched memory B cells (7.2%; normal range 6.5-29.2%) were normal. Percentage of activated CD21low B cells was high (6.6%; normal range 0.6-3.5%). IgG (3.5 g/L; normal range 6.77-15.0 g/l) and all IgG subclass concentrations were low. Anti-polysaccharide responses were impaired, with 3/10 serotypes reaching a level of 0.35 µg/ml after immunization with Pneumovax®. The findings were consistent with hypogammaglobulinemia resembling CVID, possibly secondary to antiepileptic medication. Her dyspnea and dysphagia responded favorably to subcutaneous IgG and rituximab.", + "summary_subclaims": [ + "The patient is a 29-year-old female with epilepsy.", + "The patient developed dysphagia.", + "The patient developed dyspnea.", + "The patient had impaired exercise tolerance.", + "Obstruction was caused by a swollen lingual tonsil.", + "Obstruction was caused by edema in the epiglottis.", + "Obstruction was caused by edema in the arytenoid mucosa.", + "Lingual tonsil biopsies displayed non-necrotizing granulomas.", + "Epiglottis biopsies displayed non-necrotizing granulomas.", + "There was no evidence of viral infection.", + "There was no evidence of bacterial infection.", + "There was no evidence of mycobacterial infection.", + "There was no evidence of fungal infection.", + "Chest X-ray remained unremarkable.", + "Computerized tomography of the chest remained unremarkable.", + "Ultrasound of the neck and abdomen remained unremarkable.", + "PET/CT showed laryngeal enhancement.", + "Empiric antimicrobials combined with prednisolone were insufficient to control her disease.", + "The patient had normal counts of B and T cells.", + "The proportion of CD27+ memory B cells was 30.3%.", + "The proportion of IgD-IgM-CD27+ switched memory B cells was 7.2%.", + "The normal range for IgD-IgM-CD27+ switched memory B cells is 6.5-29.2%.", + "The percentage of activated CD21low B cells was 6.6%.", + "The normal range for activated CD21low B cells is 0.6-3.5%.", + "IgG concentration was 3.5 g/L.", + "The normal range for IgG is 6.77-15.0 g/l.", + "All IgG subclass concentrations were low.", + "Anti-polysaccharide responses were impaired.", + "Three out of ten serotypes reached a level of 0.35 µg/ml after immunization with Pneumovax®.", + "The findings were consistent with hypogammaglobulinemia resembling CVID.", + "The hypogammaglobulinemia was possibly secondary to antiepileptic medication.", + "The patient's dyspnea responded favorably to subcutaneous IgG.", + "The patient's dysphagia responded favorably to subcutaneous IgG.", + "The patient's dyspnea responded favorably to rituximab.", + "The patient's dysphagia responded favorably to rituximab." + ] + }, + { + "id": "multiclinsum_test_677_en.txt", + "fulltext": "A 60-year-old Chinese male presented to our hospital complaining of pain, coldness and numbness in the right lower limb for one month. On physical examination, he was afebrile and had a pulsatile, firm subcutaneous mass with a diastolic and systolic murmur on the medial aspect of the right thigh. Peripheral pulsations could be palpated well at the right common femoral artery, but not the popliteal artery, dorsalis pedis artery and the tibialis posterior artery, indicating the occlusion of superficial femoral artery (SFA). Additional imaging, including the color Doppler ultrasonography (CDUS, Fig. ) and computed tomography angiography (CTA, Fig. ) conducted to evaluate the potential embolic sources, revealed the formation of two aneurysms in the middle and lower segment of the right SFA , accompanied by the presence of mural thrombus. The proximal aneurysm was located higher than the Hunter’s canal with the maximal diameter of 15 mm, while the distal aneurysm (which was ruptured, but only with localized hematoma, not progressive bleeding) was located within the Hunter’s canal with the maximal diameter of 26 mm. The normal neurological, cardiovascular systems examinations and no significant medical history of hypertension, heart diseases, diabetes mellitus, blood transfusion, genital ulcer and skin rash seemed to indicate our case was less possibly caused by the complications of these diseases. The popliteal lymph nodes were not palpated and clearly swollen in CDUS and CT examinations, excluding the lymph nodes origin. However, he recounted he had heterosexual extramarital unprotected sexual contacts twenty years ago, but denied any sexual activity since his wife died eighteen years ago. His wife had one previous abortion before death, but no syphilis testing was performed. These promoted us to perform the syphilis tests for this patient. As a result, the patient tested positive for Treponema pallidum hemagglutination antibody and rapid plasma regain (RPR, titer 1/16). The patient denied any recent inoculations, vaccinations or complementary treatments that may cause a false positive syphilis serology . Additional laboratory tests revealed the elevated levels of both the erythrocyte sedimentation rate (ESR, 58 mm/1 h) and the serum C-reactive protein (CRP, 15.4 mg/L), suggesting the inflammatory arteritis. A presumptive diagnosis of right femoral aneurysm secondary to the tertiary syphilis from unprotected sexual contacts was given.\nIn view of the active syphilis infection and the high vascular inflammatory reaction that may cause pseudoaneurysm and rupture of the artery anastomosis if surgery was performed, the patient was firstly treated with benzathine penicillin (2.4 MU, i.m) once a week. Four weeks later, the titer of RPR, the concentration of CRP and ESR were respectively reduced to 1:12, 12.5 mg/L and 42 mm/1 h, demonstrating the effectiveness of anti-syphilis therapy. However, the patient presented aggravated pain at the right thigh, which was considered to result from the hematoma enlargement due to the rupture and hemorrhage of the aneurysm. Thus, the operation treatment was prepared. In an effort to minimize the morbidity and mortality of femoral aneurysm repair, implantation of the Viabahn covered stent graft (Gore & Associates) was performed to isolate the aneurysm . Intraoperatively, a 90-cm, 6-F Flexor sheath (Cook) was advanced into the right common femoral artery in a retrograde fashion. Nevertheless, the distal occlusion of the right femoral artery was still displayed on the digital subtraction angiography (DSA, Fig. ), which may be attributed to the tortuous arterial wall compressed by the aneurysm and hematoma. Then a single 5-F, cobra-shaped catheter (Terumo) combined with a 0.035-inch smooth Radiofocus hydrophilic guidewire (Terumo) were inserted but they could also not pass through the distal end of the aneurysm. Subsequently, an incision was made below the right medial malleolus to expose the right tibialis posterior artery and the retrograde puncture was performed to place a 5-F dilator catheter (Cook). A 0.018-inch guide wire (Boston Scientific) was inserted through the dilator, however, the distal end of the aneurysm was still not opened. The routine open operation via a medial incision was eventually carried out to remove the right femoral aneurysm under the general anesthesia. Pathological examination of the resected aneurysm showed the proliferation of adventitial vasa vasorum, with sporadic infiltration of inflammatory cells ; the fibroplasia in the arterial wall accompanied by local calcification and mucoid degeneration . Accordingly, the patient was ultimately confirmed with right femoral aneurysm due to syphilis.\nPostoperatively, the anti-syphilis treatment continued. After three months, the laboratory findings indicated that RPR and Treponema pallidum hemagglutination antibody were negative. The CDUS demonstrated that the stenosis, occlusion and re-formation of aneurysm were all not found in the arteries of the right lower limb. The patient was also well and asymptomatic.", + "fulltext_subclaims": [ + "The patient was a 60-year-old Chinese male.", + "He had pain, coldness, and numbness in the right lower limb for one month.", + "On physical examination, he was afebrile.", + "He had a pulsatile, firm subcutaneous mass with a diastolic and systolic murmur on the medial aspect of the right thigh.", + "Peripheral pulsations could be palpated well at the right common femoral artery.", + "Peripheral pulsations could not be palpated at the popliteal artery.", + "Peripheral pulsations could not be palpated at the dorsalis pedis artery.", + "Peripheral pulsations could not be palpated at the tibialis posterior artery.", + "Color Doppler ultrasonography and computed tomography angiography were conducted.", + "Two aneurysms were found in the middle and lower segment of the right superficial femoral artery.", + "The proximal aneurysm was located higher than the Hunter’s canal with a maximal diameter of 15 mm.", + "The distal aneurysm was located within the Hunter’s canal with a maximal diameter of 26 mm.", + "The distal aneurysm was ruptured but only with localized hematoma, not progressive bleeding.", + "The patient had no significant medical history of hypertension.", + "The patient had no significant medical history of heart diseases.", + "The patient had no significant medical history of diabetes mellitus.", + "The patient had no significant medical history of blood transfusion.", + "The patient had no significant medical history of genital ulcer.", + "The patient had no significant medical history of skin rash.", + "The popliteal lymph nodes were not palpated.", + "The popliteal lymph nodes were not clearly swollen in CDUS and CT examinations.", + "The patient recounted he had heterosexual extramarital unprotected sexual contacts twenty years ago.", + "He denied any sexual activity since his wife died eighteen years ago.", + "His wife had one previous abortion before death.", + "No syphilis testing was performed on his wife.", + "The patient tested positive for Treponema pallidum hemagglutination antibody.", + "The patient tested positive for rapid plasma regain (RPR) with a titer of 1/16.", + "The patient denied any recent inoculations, vaccinations, or complementary treatments that may cause a false positive syphilis serology.", + "Erythrocyte sedimentation rate (ESR) was 58 mm/1 h.", + "Serum C-reactive protein (CRP) was 15.4 mg/L.", + "A presumptive diagnosis of right femoral aneurysm secondary to tertiary syphilis from unprotected sexual contacts was given.", + "The patient was treated with benzathine penicillin (2.4 MU, i.m) once a week.", + "After four weeks, the RPR titer was reduced to 1:12.", + "After four weeks, CRP was 12.5 mg/L.", + "After four weeks, ESR was 42 mm/1 h.", + "The patient presented aggravated pain at the right thigh.", + "The pain was considered to result from hematoma enlargement due to the rupture and hemorrhage of the aneurysm.", + "Implantation of the Viabahn covered stent graft was performed.", + "A 90-cm, 6-F Flexor sheath was advanced into the right common femoral artery in a retrograde fashion.", + "Digital subtraction angiography showed distal occlusion of the right femoral artery.", + "An incision was made below the right medial malleolus to expose the right tibialis posterior artery.", + "A 0.018-inch guide wire was inserted through the dilator.", + "The distal end of the aneurysm was still not opened.", + "A routine open operation via a medial incision was carried out.", + "The right femoral aneurysm was removed under general anesthesia.", + "Pathological examination showed proliferation of adventitial vasa vasorum.", + "Pathological examination showed sporadic infiltration of inflammatory cells.", + "Pathological examination showed fibroplasia in the arterial wall.", + "Pathological examination showed local calcification.", + "Pathological examination showed mucoid degeneration.", + "The patient was ultimately confirmed with right femoral aneurysm due to syphilis.", + "After three months, RPR and Treponema pallidum hemagglutination antibody were negative.", + "Color Doppler ultrasonography showed no stenosis, occlusion, or re-formation of aneurysm in the right lower limb arteries.", + "The patient was well and asymptomatic." + ], + "summary": "The present study described a 60-year-old Chinese male who presented with two aneurysms in the middle and lower segment of the right superficial femoral artery causing the symptoms of pain, coldness and numbness in the right lower limb. This case was diagnosed with syphilitic superficial femoral aneurysm because of positive syphilitic testing and the inflammatory cell infiltration around the adventitial vasa vasorum under the pathological examination. Anti-syphilis treatment, stent graft implantation and open surgery were attempted to eliminate the syphilis and aneurysm, which was ultimately successful, with no symptoms after a follow-up of 3 months.", + "summary_subclaims": [ + "The patient was a 60-year-old Chinese male.", + "The patient had two aneurysms in the middle and lower segment of the right superficial femoral artery.", + "The aneurysms caused pain, coldness, and numbness in the right lower limb.", + "The case was diagnosed with syphilitic superficial femoral aneurysm.", + "Syphilitic testing was positive.", + "Pathological examination showed inflammatory cell infiltration around the adventitial vasa vasorum.", + "Anti-syphilis treatment was attempted.", + "Stent graft implantation was attempted.", + "Open surgery was attempted.", + "The treatment was ultimately successful.", + "There were no symptoms after a follow-up of 3 months." + ] + }, + { + "id": "multiclinsum_test_1863_en.txt", + "fulltext": "A 32- day-old girl with fever and restlessness was admitted in the hospital. Parents reported fever and restlessness on the day before admission. There was no coryza or conjunctivitis. Left facial swelling was found during physical examination. Left sub-mandibular swelling was noted in physical examinations. Redness was observed in the face. Prenatal history was normal. Postnatal history was normal. Parents were close relatives. Cesarean section was used for the delivery because of breech presentation. Birth weight was 3500 g. Body weight, length, and head circumference were 4300 g (75 th percentile), 52 cm (50 th percentile), and 38 cm (75 th percentile), respectively. She was breastfed. Pulse and respiratory rates were 130/min and 50/min, respectively. Axillary temperature was 37.8°C. Head examination revealed normal sized fontanel (1.5×1.5 cm) without bulging. Facial examination revealed swelling and erythema over the parotid gland. The patient showed irritability during inspection of the area of swelling. Eye and ear were normal. Abdominal examination revealed no abnormal findings.\nChest examination revealed no abnormality. Red blood cell (RBC) and white blood cell (WBC) counts were 3.1 × 1012 cells/L and 12.6 × 109/L (neutrophil: 60%), respectively. Erythrocyte sedimentation rate and C-reactive protein were 20 mm/L and negative, respectively. Results of urine analysis and culture were normal. Blood urea nitrogen, sodium, potassium, and blood sugar were normal. Blood amylase was 10 U/L. Bilateral multiple reactive lymph node (size = 6×10 mm) at anterior cervical chain with a left facial swelling was observed in ultrasonography report. Chest roentgenogram was normal. Due to suspected neonatal parotitis, with gentle pressure on Stensen’s duct, pus was evacuated and transferred to the laboratory. Microscopic examinations of the smear revealed Gram-positive cocci. Culture showed coagulase positive S. aureus. Patient received vancomycin and amikacin for a seven-day period. She was discharged in a good condition.", + "fulltext_subclaims": [ + "A 32-day-old girl with fever and restlessness was admitted in the hospital.", + "Parents reported fever and restlessness on the day before admission.", + "There was no coryza or conjunctivitis.", + "Left facial swelling was found during physical examination.", + "Left sub-mandibular swelling was noted in physical examinations.", + "Redness was observed in the face.", + "Prenatal history was normal.", + "Postnatal history was normal.", + "Parents were close relatives.", + "Cesarean section was used for the delivery because of breech presentation.", + "Birth weight was 3500 g.", + "Body weight was 4300 g (75th percentile).", + "Length was 52 cm (50th percentile).", + "Head circumference was 38 cm (75th percentile).", + "She was breastfed.", + "Pulse was 130/min.", + "Respiratory rate was 50/min.", + "Axillary temperature was 37.8°C.", + "Head examination revealed normal sized fontanel (1.5×1.5 cm) without bulging.", + "Facial examination revealed swelling and erythema over the parotid gland.", + "The patient showed irritability during inspection of the area of swelling.", + "Eye and ear were normal.", + "Abdominal examination revealed no abnormal findings.", + "Chest examination revealed no abnormality.", + "RBC count was 3.1 × 10^12 cells/L.", + "WBC count was 12.6 × 10^9/L (neutrophil: 60%).", + "Erythrocyte sedimentation rate was 20 mm/L.", + "C-reactive protein was negative.", + "Results of urine analysis and culture were normal.", + "Blood urea nitrogen, sodium, potassium, and blood sugar were normal.", + "Blood amylase was 10 U/L.", + "Bilateral multiple reactive lymph node (size = 6×10 mm) at anterior cervical chain with a left facial swelling was observed in ultrasonography report.", + "Chest roentgenogram was normal.", + "Due to suspected neonatal parotitis, with gentle pressure on Stensen’s duct, pus was evacuated and transferred to the laboratory.", + "Microscopic examinations of the smear revealed Gram-positive cocci.", + "Culture showed coagulase positive S. aureus.", + "Patient received vancomycin and amikacin for a seven-day period.", + "She was discharged in a good condition." + ], + "summary": "A 32-day-old girl with fever and restlessness was admitted in the hospital. Left facial swelling was found during physical examination. Redness was observed in the face. Prenatal history was normal. Birth weight was 3500 g. Body weight, length, and head circumference were 4300 g (75 th percentile), 52 cm (50 th percentile), and 38 cm (75 th percentile), respectively. She was breastfed. Pulse and respiratory rates were 130/min and 50/min, respectively. Axillary temperature was 37.8°C. Head examination revealed normal sized fontanel (1.5 × 1.5 cm) without bulging. Eye and ear were normal. Abdominal examination revealed no abnormal findings. Results of urine analysis and culture were normal. Blood urea nitrogen, sodium, potassium, and blood sugar were normal. Blood amylase was 10 U/L. Bilateral multiple reactive lymph node (size = 6 × 10 mm) at anterior cervical chain with a left facial swelling was observed in ultrasonography report. Pus was obtained following gentle pressure on Stensen's duct. Staphylococcus aureus was detected in the microscopic and microbiological evaluations.The patient received a seven-day treatment course with vancomycin and amikacin. Neonate was discharged in a good condition.", + "summary_subclaims": [ + "A 32-day-old girl with fever and restlessness was admitted in the hospital.", + "Left facial swelling was found during physical examination.", + "Redness was observed in the face.", + "Prenatal history was normal.", + "Birth weight was 3500 g.", + "Body weight was 4300 g (75th percentile).", + "Length was 52 cm (50th percentile).", + "Head circumference was 38 cm (75th percentile).", + "She was breastfed.", + "Pulse was 130/min.", + "Respiratory rate was 50/min.", + "Axillary temperature was 37.8°C.", + "Head examination revealed normal sized fontanel (1.5 × 1.5 cm) without bulging.", + "Eye and ear were normal.", + "Abdominal examination revealed no abnormal findings.", + "Results of urine analysis and culture were normal.", + "Blood urea nitrogen, sodium, potassium, and blood sugar were normal.", + "Blood amylase was 10 U/L.", + "Bilateral multiple reactive lymph node (size = 6 × 10 mm) at anterior cervical chain with a left facial swelling was observed in ultrasonography report.", + "Pus was obtained following gentle pressure on Stensen's duct.", + "Staphylococcus aureus was detected in the microscopic and microbiological evaluations.", + "The patient received a seven-day treatment course with vancomycin and amikacin.", + "Neonate was discharged in a good condition." + ] + }, + { + "id": "multiclinsum_test_1715_en.txt", + "fulltext": "A 43 years old female of Han ethnic group from Northeast China, farmer by occupation, presented to the Department of Oral and Maxillofacial Surgery, Hospital of Stomatology, Jilin University, Changchun, China with an asymptomatic swelling in her anterior mandible. The swelling had started 1 year previously and since then, there had been a gradual increase to its present size. She denied experiencing any bleeding, pain or sensory changes. She also denied any history of trauma and the past medical, dental and family history was insignificant.\nOn physical examination, facial asymmetry due to swelling on the left side of the face was noticed. The swelling was oval in shape crossing the midline thereby obliterating the labiomental sulcus.\nThe swelling had smooth surface with normal overlying skin but stretched. It was non-tender on palpation.\nThe intra-oral examination revealed a large mass approximately 5 × 4 cm in size, extending from lower right canine to left 2nd premolar buccally. Buccal expansion of the mandibular left and right symphyseal and para-symphyseal region was evident. The overlying mucosa appeared normal. There was labial displacement of 32 .\nOn palpation, the swelling was found to be firm, bony hard in consistency, non-tender, non-fluctuant, irreducible, non-compressible and non-pulsatile. The teeth in the vicinity were non-tender to percussion; there was slight mobility of 32 and 33. On electric pulp vitality testing, all teeth in the affected area were vital except 32 and 33. No lymphadenopathy or fistulae were present.\nRadiographic examination of the mandible revealed a diffuse ill-defined mixed radiolucent radio-opaque lesion extending from mesial surface of lower right canine to the mesial surface of the lower left 2nd premolar with an approximate size of 5 × 4 cm . The lesion resulted in the displacement of the roots of 32 and 33 without any signs of root resorption. There was loss of periodontal ligament space on the involved teeth except lower right canine and lower left first premolar. There was loss of lamina dura around the involved teeth. Computerized tomography (CT) of the lesion showed a multiloculated lesion 5 cm mediolaterally, 4 cm superoinferiorly and 2.5 cm anteroposteriorly . Areas of calcifications were present within the lesion giving it a soap bubble appearance. The lesion almost involved the lower border of the mandible.\nA provisional diagnosis of a fibro-osseous lesion of the anterior mandible was made based on clinical and radiographic appearance. The lesion was non-productive on aspiration. Blood profile showed no abnormality except slightly raised levels of serum alkaline phosphatase, 148 IU/L, suggestive of a bone forming lesion. The final diagnosis was established through incisional biopsy performed under local anesthesia. The histologic features were corroborating with those of desmoplastic ameloblastoma.\nA segmental resection of mandible from 44 to 35 was done under general anesthesia with proposed incision as shown in Figs. and and temporarily reconstructed with 2.4 mm reconstruction plate. The surgical specimen consisted of a segment of mandible with the lesion and the associated teeth. The frozen sections were found to be free of tumors. The post-operative period was uneventful. The patient is advised for routine follow-up and has no signs of recurrence so far for a period of 10 months.", + "fulltext_subclaims": [ + "The patient is a 43 years old female of Han ethnic group from Northeast China.", + "She is a farmer by occupation.", + "She presented to the Department of Oral and Maxillofacial Surgery, Hospital of Stomatology, Jilin University, Changchun, China.", + "She had an asymptomatic swelling in her anterior mandible.", + "The swelling had started 1 year previously.", + "The swelling had gradually increased to its present size.", + "She denied experiencing any bleeding.", + "She denied experiencing any pain.", + "She denied experiencing any sensory changes.", + "She denied any history of trauma.", + "The past medical, dental and family history was insignificant.", + "On physical examination, facial asymmetry due to swelling on the left side of the face was noticed.", + "The swelling was oval in shape.", + "The swelling crossed the midline.", + "The swelling obliterated the labiomental sulcus.", + "The swelling had a smooth surface.", + "The overlying skin was normal but stretched.", + "The swelling was non-tender on palpation.", + "Intra-oral examination revealed a large mass approximately 5 × 4 cm in size.", + "The mass extended from lower right canine to left 2nd premolar buccally.", + "Buccal expansion of the mandibular left and right symphyseal and para-symphyseal region was evident.", + "The overlying mucosa appeared normal.", + "There was labial displacement of 32.", + "The swelling was firm in consistency.", + "The swelling was bony hard in consistency.", + "The swelling was non-tender.", + "The swelling was non-fluctuant.", + "The swelling was irreducible.", + "The swelling was non-compressible.", + "The swelling was non-pulsatile.", + "The teeth in the vicinity were non-tender to percussion.", + "There was slight mobility of 32 and 33.", + "On electric pulp vitality testing, all teeth in the affected area were vital except 32 and 33.", + "No lymphadenopathy was present.", + "No fistulae were present.", + "Radiographic examination of the mandible revealed a diffuse ill-defined mixed radiolucent radio-opaque lesion.", + "The lesion extended from mesial surface of lower right canine to the mesial surface of the lower left 2nd premolar.", + "The lesion had an approximate size of 5 × 4 cm.", + "The lesion resulted in the displacement of the roots of 32 and 33.", + "There were no signs of root resorption.", + "There was loss of periodontal ligament space on the involved teeth except lower right canine and lower left first premolar.", + "There was loss of lamina dura around the involved teeth.", + "Computerized tomography (CT) of the lesion showed a multiloculated lesion 5 cm mediolaterally.", + "The lesion was 4 cm superoinferiorly.", + "The lesion was 2.5 cm anteroposteriorly.", + "Areas of calcifications were present within the lesion.", + "The lesion gave a soap bubble appearance.", + "The lesion almost involved the lower border of the mandible.", + "A provisional diagnosis of a fibro-osseous lesion of the anterior mandible was made.", + "The lesion was non-productive on aspiration.", + "Blood profile showed no abnormality except slightly raised levels of serum alkaline phosphatase, 148 IU/L.", + "The final diagnosis was established through incisional biopsy performed under local anesthesia.", + "The histologic features were corroborating with those of desmoplastic ameloblastoma.", + "A segmental resection of mandible from 44 to 35 was done under general anesthesia.", + "The surgical specimen consisted of a segment of mandible with the lesion and the associated teeth.", + "The frozen sections were found to be free of tumors.", + "The post-operative period was uneventful.", + "The patient is advised for routine follow-up.", + "The patient has no signs of recurrence so far for a period of 10 months." + ], + "summary": "We present a case of DA in a 43-year-old female with a painless swelling in the anterior region of mandible. No fluid was evident on fine needle aspiration. A mixed lesion with multilocular appearance was evident on both panoramic radiographs as well as computed tomography scan. An incisional biopsy confirmed it to be a case of desmoplastic ameloblastoma. Segmental mandibulectomy was performed from teeth 35 to 44. The patient is on routine follow-up and is currently free of ailment.", + "summary_subclaims": [ + "The patient is a 43-year-old female.", + "The patient had a painless swelling in the anterior region of mandible.", + "No fluid was evident on fine needle aspiration.", + "A mixed lesion with multilocular appearance was evident on panoramic radiographs.", + "A mixed lesion with multilocular appearance was evident on computed tomography scan.", + "An incisional biopsy confirmed it to be a case of desmoplastic ameloblastoma.", + "Segmental mandibulectomy was performed from teeth 35 to 44.", + "The patient is on routine follow-up.", + "The patient is currently free of ailment." + ] + }, + { + "id": "multiclinsum_test_643_en.txt", + "fulltext": "A 68-year-old woman was brought to our hospital with repeated right upper abdominal pain lasting for 3 month and aggravation for 9 h. From February 2019 to May 2019, the patient experienced multiple episodes of dull epigastric pain and discomfort, which was often aggravated in the morning with paroxysmal colic. The patient had visited many hospitals without symptom control, but had improved after orally taking omeprazole and anti-inflammatory agents. She did not have black stools or similar symptoms before the symptoms appeared 3 months earlier.\nPhysical examination showed obvious tenderness in the lower right epigastric region of the xiphoid process, and there was no rebound pain or muscle tension. Blood examination only indicated slightly elevated levels of C-reactive protein, while other tests including routine blood tests were normal. Chest X-ray and B-ultrasound indicated no obvious abnormalities, as shown in Fig. . Gastroscopy revealed obvious hyperemia and edema in the anterior wall of the duodenal bulb, with superficial white pus coating on the surface, and semicircular swelling of the mucous membrane into the cavity, as shown in Fig. .\nA duodenal bulbous bulge with bulbous inflammation (possibly due to external pressure on the gall bladder abscess) and/or duodenal bulb ulcer were first considered to be responsible for the discomfort. Cefazoxime sodium was intravenously administered at 2 g and Q12h. Omeprazole was orally administered at 40 mg and Q12h. However, the effect of the anti-ulcer therapy was unremarkable as the symptoms were not significantly relieved and epigastric pain was still present. Additionally, the paroxysmal spasmolysis could not be controlled by intramuscular injection of anisodamine.\nComputed tomography (CT) was further performed, and the results suggested the gallbladder was slightly larger, the gastric cavity filling was poor, and the gastric antrum was thickened. After careful examination of the film, we found a streaky high-density shadow (approximately 3 cm in length) on the posterior wall of the gastric antrum extending outside the wall, as shown in Fig. . The possibility of FBs accompanied by perforation was then considered. Further abdominal X-ray also showed a dense shadow in the duodenal bulb with a length of about 2.7 cm, as shown in Fig. . Endoscopic ultrasonography showed that the anterior wall of the duodenal bulb obviously protruded into the cavity. A superficial ulcer was observed on the anterior wall and white moss was observed on the uplift. Hyperechoic space with a cross-section of approximately 0.1 × 0.1 cm was found in the deep submucosal layer of the local stomach, accompanied by an acoustic shadow in the rear as shown in Fig. , which led to the consideration of fishbone as the FB. Further questioning of the patient confirmed that she had a history of eating fish soup before she developed abdominal pain.\nAbdominal CT examination suggested abscessus and thus, the possibility of perforation was not excluded. It is more difficult to find lesions under laparoscopy and endoscopic treatment is associated with higher risks when perforation is suspected, thus the patient was recommended for exploratory laparotomy. However, the patient and her family refused open surgery and requested endoscopic investigation. However, certain difficulties and complications may arise with endoscopic treatment: 1) the FB stump may not be visible under the endoscope; 2) injury to the adjacent liver and pancreas can occur; 3) after removing the FB, the closed perforation cannot be treated under the endoscope; 4) massive upper gastrointestinal bleeding or perforation can occur during or after surgery. If any of the above conditions occurs, emergency surgery is required. During the operation, we attempted to find the end of the fishbone on the bulges of the ball using FB forceps (MTN-4GF-23, Nanjing minimally invasive), as the tail end could be seen faintly in the abscess. FB forceps were used to clamp the proximal end and a fishbone-like FB with a length of 5.5 cm was pulled out. The ulcer slightly oozed blood and two thrombins were sprayed to stop the bleeding. Fasting as well as acid inhibition and anti-infection medication were prescribed for the patient after surgery.\nAfter treatment, the patient’s abdominal pain disappeared. Endoscopy was performed 1 week later and showed that the ulcer healed well. The patient was discharged and subsequent follow-ups revealed no further abdominal discomfort.", + "fulltext_subclaims": [ + "The patient is a 68-year-old woman.", + "She had repeated right upper abdominal pain lasting for 3 months.", + "The pain was aggravated for 9 hours before presentation.", + "From February 2019 to May 2019, she experienced multiple episodes of dull epigastric pain and discomfort.", + "The pain was often aggravated in the morning with paroxysmal colic.", + "She had visited many hospitals without symptom control.", + "She improved after orally taking omeprazole and anti-inflammatory agents.", + "She did not have black stools before the symptoms appeared 3 months earlier.", + "Physical examination showed obvious tenderness in the lower right epigastric region of the xiphoid process.", + "Blood examination indicated slightly elevated levels of C-reactive protein.", + "Chest X-ray and B-ultrasound indicated no obvious abnormalities.", + "Gastroscopy revealed obvious hyperemia and edema in the anterior wall of the duodenal bulb.", + "Gastroscopy showed superficial white pus coating on the surface of the anterior wall of the duodenal bulb.", + "Gastroscopy showed semicircular swelling of the mucous membrane into the cavity.", + "A duodenal bulbous bulge with bulbous inflammation was first considered.", + "Cefazoxime sodium was intravenously administered at 2 g and Q12h.", + "Omeprazole was orally administered at 40 mg and Q12h.", + "The effect of the anti-ulcer therapy was unremarkable.", + "The symptoms were not significantly relieved.", + "Computed tomography showed the gallbladder was slightly larger.", + "Computed tomography showed poor gastric cavity filling.", + "Computed tomography showed thickening of the gastric antrum.", + "A streaky high-density shadow was found on the posterior wall of the gastric antrum.", + "Abdominal X-ray showed a dense shadow in the duodenal bulb with a length of about 2.7 cm.", + "Endoscopic ultrasonography showed the anterior wall of the duodenal bulb obviously protruded into the cavity.", + "A superficial ulcer was observed on the anterior wall of the duodenal bulb.", + "Hyperechoic space with a cross-section of approximately 0.1 × 0.1 cm was found in the deep submucosal layer.", + "The possibility of fishbone as the foreign body was considered.", + "The patient had a history of eating fish soup before she developed abdominal pain.", + "Abdominal CT suggested abscessus.", + "The patient and her family refused open surgery.", + "Endoscopic treatment was attempted.", + "FB forceps were used to clamp the proximal end of the fishbone.", + "A fishbone-like foreign body with a length of 5.5 cm was pulled out.", + "The ulcer slightly oozed blood.", + "Two thrombins were sprayed to stop the bleeding.", + "The patient’s abdominal pain disappeared after treatment.", + "Endoscopy 1 week later showed that the ulcer healed well.", + "The patient was discharged.", + "Subsequent follow-ups revealed no further abdominal discomfort." + ], + "summary": "A 68-year-old woman was brought to our hospital with repeated right upper abdominal pain lasting for 3 months and aggravation for 9 h. Computed tomography (CT) showed a streaky high-density shadow (approximately 3 cm in length) on the posterior wall of the gastric antrum extending outside the wall. Endoscopic ultrasonography showed hyperechoic space with a cross-section of approximately 0.1 × 0.1 cm in the deep submucosal layer of the local stomach, accompanied by an acoustic shadow in the rear. The possibility of a fishbone as well as perforation was considered and the object was removed using FB forceps. Fasting as well as acid inhibition and anti-infection medication were prescribed for the patient. She eventually recovered and was discharged from the hospital.", + "summary_subclaims": [ + "The patient was a 68-year-old woman.", + "She was brought to the hospital with repeated right upper abdominal pain lasting 3 months.", + "The pain had been aggravated for 9 h.", + "Computed tomography showed a streaky high-density shadow on the posterior wall of the gastric antrum.", + "The high-density shadow was approximately 3 cm in length.", + "The shadow extended outside the wall.", + "Endoscopic ultrasonography showed hyperechoic space in the deep submucosal layer of the local stomach.", + "The cross-section of the hyperechoic space was approximately 0.1 × 0.1 cm.", + "An acoustic shadow was present in the rear.", + "The possibility of a fishbone was considered.", + "The possibility of perforation was considered.", + "The object was removed using FB forceps.", + "Fasting was prescribed for the patient.", + "Acid inhibition medication was prescribed.", + "Anti-infection medication was prescribed.", + "The patient eventually recovered.", + "The patient was discharged from the hospital." + ] + }, + { + "id": "multiclinsum_test_699_en.txt", + "fulltext": "A 54-year-old woman (height, 145 cm; weight, 43 kg) diagnosed with mitochondrial encephalomyopathy with lactic acidosis and stroke-like episodes elected to undergo cochlear implantation to address her progressive bilateral sensorineural deafness. Preoperative electrocardiography showed no abnormalities. Transthoracic echocardiography showed circumferential thickening of the left ventricle and asymmetric hypertrophy of the septum, which was thicker than the posterior wall. Cardiac contractility was diffusely decreased and cardiac ejection fraction was 45%. Estimated glomerular filtration rate was low (27 mL/min) because of diabetic nephropathy. Although enhanced insulin therapy had been introduced, her HbA1c level was high (12.5%) immediately before surgery. Creatine kinase level was 162 IU/L (normal range, 41–153). Her medications included 5 mg oral imidapril daily and subcutaneous insulin (6 units in the morning, 8 units in the afternoon, and 6 units in the evening). She was not taking any antiepileptic drugs.\nNo premedication was administered. Intravenous remimazolam was administered as a 0.2 mg/kg bolus over 1 min, which resulted in loss of consciousness, followed by continuous infusion of remimazolam (1 mg/kg/h) and remifentanil (0.2 μg/kg/min). Neuromuscular monitoring of the left ulnar nerve was initiated using a train-of-four (TOF) stimulus (TOF watch SX®, MSD, Japan). Three minutes after administration of 30 mg of intravenous rocuronium, all four twitch responses disappeared and tracheal intubation was performed. During surgery, remimazolam was administered along with a continuous remifentanil infusion (0.2–0.25 μg/kg/min) to maintain the patient state index value between 25 and 50. Patient state index was measured using the SEDLine® monitor (Masimo Inc., Irvine, CA). A catheter was placed in the right radial artery for continuous arterial pressure monitoring. Intermittent blood gas analysis showed that the lactate concentration and pH ranged from 1.8 to 1.9 mmol/L and 7.41 to 7.45, respectively. Surgical time was 1 h and 34 min. Additional rocuronium administration was not needed throughout the surgery. After surgery was completed, the infusions were stopped and the TOF ratio was 0.91. The patient was extubated after stable spontaneous respirations with tidal volumes ≥ 8 mL/kg were confirmed (22 min after the end of surgery and 8 min after discontinuation of remimazolam). Thirteen minutes after extubation, her eyes remained closed; therefore, 200 μg of intravenous flumazenil was administered. Two minutes later, she opened her eyes, became verbally responsive, and was discharged from the operating room. After surgery, her only complaints were sore throat and nausea, which were treated with 1000 mg of acetaminophen and 10 mg of metoclopramide.", + "fulltext_subclaims": [ + "The patient is a 54-year-old woman.", + "The patient's height is 145 cm.", + "The patient's weight is 43 kg.", + "The patient has mitochondrial encephalomyopathy with lactic acidosis and stroke-like episodes.", + "The patient underwent cochlear implantation.", + "The patient had progressive bilateral sensorineural deafness.", + "Preoperative electrocardiography showed no abnormalities.", + "Transthoracic echocardiography showed circumferential thickening of the left ventricle.", + "Transthoracic echocardiography showed asymmetric hypertrophy of the septum.", + "The septum was thicker than the posterior wall.", + "Cardiac contractility was diffusely decreased.", + "Cardiac ejection fraction was 45%.", + "Estimated glomerular filtration rate was 27 mL/min.", + "The low estimated glomerular filtration rate was because of diabetic nephropathy.", + "Enhanced insulin therapy had been introduced.", + "HbA1c level was 12.5% immediately before surgery.", + "Creatine kinase level was 162 IU/L.", + "The normal range for creatine kinase is 41–153 IU/L.", + "The patient was taking 5 mg oral imidapril daily.", + "The patient was taking subcutaneous insulin.", + "The patient was not taking any antiepileptic drugs.", + "No premedication was administered.", + "Intravenous remimazolam was administered as a 0.2 mg/kg bolus over 1 min.", + "The bolus resulted in loss of consciousness.", + "A continuous infusion of remimazolam (1 mg/kg/h) was started.", + "A continuous infusion of remifentanil (0.2 μg/kg/min) was started.", + "Neuromuscular monitoring of the left ulnar nerve was initiated using a train-of-four (TOF) stimulus.", + "Three minutes after administration of 30 mg of intravenous rocuronium, all four twitch responses disappeared.", + "Tracheal intubation was performed.", + "During surgery, remimazolam was administered along with a continuous remifentanil infusion.", + "The patient state index value was maintained between 25 and 50.", + "A catheter was placed in the right radial artery for continuous arterial pressure monitoring.", + "Intermittent blood gas analysis showed that the lactate concentration ranged from 1.8 to 1.9 mmol/L.", + "Intermittent blood gas analysis showed that the pH ranged from 7.41 to 7.45.", + "Surgical time was 1 h and 34 min.", + "Additional rocuronium administration was not needed throughout the surgery.", + "After surgery was completed, the infusions were stopped.", + "The TOF ratio was 0.91.", + "The patient was extubated after stable spontaneous respirations with tidal volumes ≥ 8 mL/kg were confirmed.", + "Extubation occurred 22 min after the end of surgery.", + "Extubation occurred 8 min after discontinuation of remimazolam.", + "Thirteen minutes after extubation, her eyes remained closed.", + "200 μg of intravenous flumazenil was administered.", + "Two minutes after flumazenil administration, she opened her eyes.", + "Two minutes after flumazenil administration, she became verbally responsive.", + "The patient was discharged from the operating room.", + "After surgery, the patient had a sore throat.", + "After surgery, the patient had nausea.", + "1000 mg of acetaminophen was given.", + "10 mg of metoclopramide was given." + ], + "summary": "A 54-year-old woman (height, 145 cm; weight, 43 kg) diagnosed with mitochondrial encephalomyopathy with lactic acidosis and stroke-like episodes underwent elective cochlear implantation. Infusions of intravenous remimazolam and remifentanil guided by patient state index monitoring were used for anesthesia induction and maintenance. Neither lactic acidosis nor prolonged muscle relaxation occurred in the perioperative period. At the end of surgery, flumazenil was administered to antagonize sedation, which rapidly resulted in consciousness.", + "summary_subclaims": [ + "The patient was a 54-year-old woman.", + "The patient's height was 145 cm.", + "The patient's weight was 43 kg.", + "The patient was diagnosed with mitochondrial encephalomyopathy with lactic acidosis and stroke-like episodes.", + "The patient underwent elective cochlear implantation.", + "Intravenous remimazolam was used for anesthesia induction.", + "Intravenous remifentanil was used for anesthesia maintenance.", + "Anesthesia was guided by patient state index monitoring.", + "Lactic acidosis did not occur in the perioperative period.", + "Prolonged muscle relaxation did not occur in the perioperative period.", + "Flumazenil was administered to antagonize sedation.", + "Flumazenil rapidly resulted in consciousness." + ] + }, + { + "id": "multiclinsum_test_633_en.txt", + "fulltext": "A 60-year-old man with end-stage renal disease (ESRD) on hemodialysis via arteriovenous (AV) fistula presented to the emergency department (ED) from home on March 18, 2020, with a chief complaint of fever, cough, shortness of breath, and diarrhea. He has a history of IgA nephropathy and a failed kidney transplant due to rejection in 2013. He lives alone at home in western Iowa and had no recent travel history or visits to any healthcare facilities except for a local dialysis center for routine dialysis.\nThe patient receives hemodialysis three times a week (Monday, Wednesday, and Friday) at a local dialysis center. The symptoms started on Monday, March 16, 2020, while he was at his routine dialysis when he began to feel feverish and experience chills. His temperature taken at the dialysis center was 37.8 °C. After dialysis, he developed a headache, non-productive cough, sore throat, runny nose, poor appetite with nausea, vomiting, and abdominal pain, which progressively worsened over the next 2 days. On March 17, he started to have generalized myalgias, mild shortness of breath, and diarrhea with liquid green stool without visible blood. He missed his hemodialysis on Wednesday, March 18 and presented to the ED.\nOn arrival at the ED, the patient was provided a mask and placed in a private room in accordance with the ED screening protocol. He was ill-appearing with a fever of 38.6 °C. His respiratory rate was 23 per minute, and other vital signs were unremarkable. Physical examination was significant for diffuse rhonchi and bibasilar rales on auscultation. Chest X-ray showed right midlung consolidation, and patchy left lower lung opacities, concerning for multifocal pneumonia. Rapid influenza antigen test was positive for influenza A; viral subtypes were not specified. A nasopharyngeal swab specimen was sent for real-time reverse-transcriptase polymerase chain reaction (RT-PCR) test (NEcov19 assay) at the Nebraska Medical Center Clinical Lab to rule out COVID-19 infection. He was placed on contact and airborne isolation precautions with eye protection for concerns of probable COVID-19 as per the Centers for Disease Control and Prevention (CDC) recommendations.\nLab workup was significant for elevated procalcitonin and lymphopenia . The electrocardiogram showed normal sinus rhythm. Computed tomography (CT) of the chest demonstrated multifocal areas of consolidation and tree-in-bud opacities within multiple lobes of the lungs compatible with multifocal pneumonia, as well as small bilateral pleural effusions and extensive mediastinal and bilateral hilar adenopathy. CT abdomen and pelvis showed mildly dilated gas and fluid-filled loops of small bowel and bowel wall enhancement, reflecting possible partial distal obstruction or ileus and enteritis. Blood cultures were taken, and the patient was started on oseltamivir (30 mg, oral, once per day on Mon Wed Fri, given after hemodialysis) for influenza. He is anuric; therefore, we did not test urine streptococcal and legionella antigen. The patient was then admitted to a negative pressure room on an isolation ward while awaiting COVID-19 results.\nOn hospital day 2, his RT-PCR test was positive for SARS-CoV-2 E and/or N gene RNA, confirming the diagnosis of COVID-19. The local health department was notified to investigate the source of infection. The patient reported feeling extremely fatigued but was afebrile. His cough and shortness of breath improved. His primary complaint was severe liquid green diarrhea, although the Gastrointestinal (GI) pathogen panel and Clostridioides difficile (C. diff) toxin assay were negative. The repeated procalcitonin level was elevated on day 2, suggestive of potentially fivefold increased risk of severe disease of COVID-19 . The patient was continued on vancomycin and cefepime for possible superimposed bacterial pneumonia. Notably, he had multiple episodes of hypotension with systolic pressure in the high 80s (mmHg) to 90s with mean arterial pressure (MAP) in the low 60s. We administered 500 ml of lactated Ringer’s solution for volume resuscitation. However, aggressive fluid resuscitation was avoided to prevent volume overload. Oral fluids were encouraged to maintain normal volume status. For his COVID-19, as there were no proven specific therapeutic options, the treatment was mainly supportive. He was deemed not a candidate for the clinical trial with remdesivir due to his ESRD. Corticosteroids were not given at that time for concerns that they may delay viral clearance and prolong the disease course .\nHemodialysis resumed at the bedside as per the CDC guidelines on hospital day 3 . He remained afebrile, and his blood pressure improved with midodrine and albumin after the dialysis.\nSince hospital day 4, the patient started to feel better with increased appetite and improvement of diarrhea, cough, and shortness of breath. Blood cultures demonstrated no bacterial growth at 5 days. With a multidisciplinary approach and optimal medical management, he continues to show clinical improvement despite his comorbidities.\nTo optimize the use of personal protective equipment (PPE), the patient’s dialysis schedule was changed to Tuesday, Thursday, and Saturday to decrease the dialysis days during his hospitalization. His volume status was closely monitored, as inadequate oral fluid intake and diarrhea could lead to hypovolemia and delay dialysis.\nThe patient was discharged home on hospital day 9 based on a test-based strategy as per CDC guidelines because of his history of solid organ transplant . No outpatient dialysis precautions were recommended to the patient as he had two negative COVID-19 tests (≥24 h apart) .", + "fulltext_subclaims": [ + "The patient is a 60-year-old man with end-stage renal disease (ESRD) on hemodialysis via arteriovenous (AV) fistula.", + "He presented to the emergency department on March 18, 2020, with fever, cough, shortness of breath, and diarrhea.", + "He has a history of IgA nephropathy and a failed kidney transplant due to rejection in 2013.", + "He lives alone at home in western Iowa.", + "He had no recent travel history or visits to any healthcare facilities except for a local dialysis center for routine dialysis.", + "The patient receives hemodialysis three times a week (Monday, Wednesday, and Friday) at a local dialysis center.", + "The symptoms started on Monday, March 16, 2020, while he was at his routine dialysis.", + "His temperature taken at the dialysis center was 37.8 °C.", + "After dialysis, he developed headache, non-productive cough, sore throat, runny nose, poor appetite with nausea, vomiting, and abdominal pain.", + "On March 17, he started to have generalized myalgias, mild shortness of breath, and diarrhea with liquid green stool without visible blood.", + "He missed his hemodialysis on Wednesday, March 18 and presented to the ED.", + "On arrival at the ED, the patient was provided a mask and placed in a private room in accordance with the ED screening protocol.", + "He was ill-appearing with a fever of 38.6 °C.", + "Physical examination was significant for diffuse rhonchi and bibasilar rales on auscultation.", + "Chest X-ray showed right midlung consolidation and patchy left lower lung opacities, concerning for multifocal pneumonia.", + "Rapid influenza antigen test was positive for influenza A; viral subtypes were not specified.", + "A nasopharyngeal swab specimen was sent for real-time reverse-transcriptase polymerase chain reaction (RT-PCR) test (NEcov19 assay) at the Nebraska Medical Center Clinical Lab to rule out COVID-19 infection.", + "He was placed on contact and airborne isolation precautions with eye protection for concerns of probable COVID-19 as per the Centers for Disease Control and Prevention (CDC) recommendations.", + "Lab workup was significant for elevated procalcitonin and lymphopenia.", + "Computed tomography (CT) of the chest demonstrated multifocal areas of consolidation and tree-in-bud opacities within multiple lobes of the lungs compatible with multifocal pneumonia.", + "CT abdomen and pelvis showed mildly dilated gas and fluid-filled loops of small bowel and bowel wall enhancement, reflecting possible partial distal obstruction or ileus and enteritis.", + "Blood cultures were taken, and the patient was started on oseltamivir (30 mg, oral, once per day on Mon Wed Fri, given after hemodialysis) for influenza.", + "He is anuric; therefore, we did not test urine streptococcal and legionella antigen.", + "The patient was admitted to a negative pressure room on an isolation ward while awaiting COVID-19 results.", + "On hospital day 2, his RT-PCR test was positive for SARS-CoV-2 E and/or N gene RNA, confirming the diagnosis of COVID-19.", + "The local health department was notified to investigate the source of infection.", + "The patient reported feeling extremely fatigued but was afebrile.", + "His cough and shortness of breath improved.", + "His primary complaint was severe liquid green diarrhea.", + "The Gastrointestinal (GI) pathogen panel and Clostridioides difficile (C. diff) toxin assay were negative.", + "The repeated procalcitonin level was elevated on day 2, suggestive of potentially fivefold increased risk of severe disease of COVID-19.", + "The patient was continued on vancomycin and cefepime for possible superimposed bacterial pneumonia.", + "He had multiple episodes of hypotension with systolic pressure in the high 80s (mmHg) to 90s with mean arterial pressure (MAP) in the low 60s.", + "We administered 500 ml of lactated Ringer’s solution for volume resuscitation.", + "Aggressive fluid resuscitation was avoided to prevent volume overload.", + "Oral fluids were encouraged to maintain normal volume status.", + "For his COVID-19, as there were no proven specific therapeutic options, the treatment was mainly supportive.", + "He was deemed not a candidate for the clinical trial with remdesivir due to his ESRD.", + "Corticosteroids were not given at that time for concerns that they may delay viral clearance and prolong the disease course.", + "Hemodialysis resumed at the bedside as per the CDC guidelines on hospital day 3.", + "He remained afebrile, and his blood pressure improved with midodrine and albumin after the dialysis.", + "Since hospital day 4, the patient started to feel better with increased appetite and improvement of diarrhea, cough, and shortness of breath.", + "Blood cultures demonstrated no bacterial growth at 5 days.", + "With a multidisciplinary approach and optimal medical management, he continues to show clinical improvement despite his comorbidities.", + "The patient’s dialysis schedule was changed to Tuesday, Thursday, and Saturday to decrease the dialysis days during his hospitalization.", + "His volume status was closely monitored, as inadequate oral fluid intake and diarrhea could lead to hypovolemia and delay dialysis.", + "The patient was discharged home on hospital day 9 based on a test-based strategy as per CDC guidelines because of his history of solid organ transplant.", + "No outpatient dialysis precautions were recommended to the patient as he had two negative COVID-19 tests (≥24 h apart)." + ], + "summary": "A 60-year-old man with ESRD on hemodialysis presented for worsening cough, shortness of breath, and diarrhea. The patient first developed a mild fever (37.8 °C) during hemodialysis 3 days prior to presentation and has been experiencing worsening flu-like symptoms, including fever of up to 38.6 °C, non-productive cough, generalized abdominal pain, nausea, vomiting, and liquid green diarrhea. He lives alone at home with no known sick contacts and denies any recent travel or visits to healthcare facilities other than the local dialysis center. Rapid flu test was positive for influenza A. Procalcitonin was elevated at 5.21 ng/mL with a normal white blood cell (WBC) count. Computed tomography (CT) chest demonstrated multifocal areas of consolidation and extensive mediastinal and hilar adenopathy concerning for pneumonia. He was admitted to the biocontainment unit of Nebraska Medicine for concerns of possible COVID-19 and was started on oseltamivir for influenza and vancomycin/cefepime for the probable bacterial cause of his pneumonia and diarrhea. Gastrointestinal (GI) pathogen panel and Clostridioides difficile toxin assay were negative. On the second day of admission, initial nasopharyngeal swab came back positive for SARS-CoV-2 by real-time reverse-transcriptase polymerase chain reaction (RT-PCR). The patient received supportive care and resumed bedside hemodialysis in strict isolation, and eventually fully recovered from COVID-19.", + "summary_subclaims": [ + "The patient is a 60-year-old man with ESRD on hemodialysis.", + "He presented with worsening cough, shortness of breath, and diarrhea.", + "He first developed a mild fever (37.8 °C) during hemodialysis 3 days prior to presentation.", + "He has been experiencing worsening flu-like symptoms, including fever of up to 38.6 °C.", + "He has non-productive cough.", + "He has generalized abdominal pain.", + "He has nausea.", + "He has vomiting.", + "He has liquid green diarrhea.", + "He lives alone at home.", + "He denies any recent travel.", + "He denies any visits to healthcare facilities other than the local dialysis center.", + "Rapid flu test was positive for influenza A.", + "Procalcitonin was elevated at 5.21 ng/mL.", + "Computed tomography (CT) chest demonstrated multifocal areas of consolidation.", + "Computed tomography (CT) chest demonstrated extensive mediastinal and hilar adenopathy.", + "The CT findings were concerning for pneumonia.", + "He was admitted to the biocontainment unit of Nebraska Medicine.", + "He was started on oseltamivir for influenza.", + "He was started on vancomycin/cefepime for the probable bacterial cause of his pneumonia and diarrhea.", + "Gastrointestinal (GI) pathogen panel was negative.", + "Clostridioides difficile toxin assay was negative.", + "On the second day of admission, initial nasopharyngeal swab came back positive for SARS-CoV-2 by real-time reverse-transcriptase polymerase chain reaction (RT-PCR).", + "The patient received supportive care.", + "He resumed bedside hemodialysis in strict isolation.", + "He eventually fully recovered from COVID-19." + ] + }, + { + "id": "multiclinsum_test_1645_en.txt", + "fulltext": "A 63-year-old woman found a mass in the superior lateral quadrant of the left breast, with no obvious discomfort, and she paid no attention to it.\nDuring the next 2 years, the left breast mass gradually increased in size and was painful. She developed discomfort in the left upper limb and visited a local hospital many times (without an examination report). Surgical treatment was suggested, but the patient refused.\nThe patient had a free previous medical history.\nThe patient has a history of good health, and there is no similar patient in the family members.\nPhysical examination showed that the skin in the outer upper quadrant of the left mammary gland was obviously sunken, and a hard mass about 5 cm × 6 cm, with an unclear boundary, irregular shape, and poor activity was found on palpation. No obvious enlarged lymph nodes were found in the axilla.\nNo abnormalities were found in the patient's laboratory examinations.\nUltrasound showed a solid hypoechoic mass approximately 3.5 cm × 5.3 cm × 4.5 cm in size at the margin of the gland at 12-3 o'clock in the superior lateral quadrant of the left breast, and several hypoechoic lymph nodes of different sizes were detected in the left axilla. The largest lymph node was about 0.6 cm × 0.6 cm, and the lymphatic hilum structure had disappeared. No abnormalities were found in the right breast. Therefore, chest computed tomography (CT) scanning was performed, and the left breast mass was diagnosed as breast cancer, with no abnormalities in the lungs. Other results, including abdominal ultrasound, bone scan, and laboratory examinations, showed no abnormalities. There was no family history in genetic disorders.\nThe patient underwent core needle biopsy of the left breast mass under ultrasound guidance, and the histopathological diagnosis was apocrine carcinoma. Immunohistochemical analysis showed negative expression of ER and progesterone receptor (PR), but positive expression of HER2 and AR (approximately 60%); gross cystic disease fluid protein 15 (GCDFP-15) was also positive .", + "fulltext_subclaims": [ + "A 63-year-old woman found a mass in the superior lateral quadrant of the left breast.", + "The mass was in the superior lateral quadrant of the left breast.", + "The mass was not painful at the time of discovery.", + "The patient paid no attention to the mass.", + "During the next 2 years, the left breast mass gradually increased in size.", + "The left breast mass became painful.", + "The patient developed discomfort in the left upper limb.", + "The patient visited a local hospital many times.", + "The patient did not have an examination report.", + "Surgical treatment was suggested.", + "The patient refused surgical treatment.", + "The patient had a free previous medical history.", + "The patient has a history of good health.", + "There is no similar patient in the family members.", + "Physical examination showed that the skin in the outer upper quadrant of the left mammary gland was obviously sunken.", + "A hard mass about 5 cm × 6 cm was found on palpation.", + "The mass had an unclear boundary.", + "The mass had an irregular shape.", + "The mass had poor activity.", + "No obvious enlarged lymph nodes were found in the axilla.", + "No abnormalities were found in the patient's laboratory examinations.", + "Ultrasound showed a solid hypoechoic mass approximately 3.5 cm × 5.3 cm × 4.5 cm in size.", + "The mass was located at the margin of the gland at 12-3 o'clock in the superior lateral quadrant of the left breast.", + "Several hypoechoic lymph nodes of different sizes were detected in the left axilla.", + "The largest lymph node was about 0.6 cm × 0.6 cm.", + "The lymphatic hilum structure had disappeared.", + "No abnormalities were found in the right breast.", + "Chest computed tomography (CT) scanning was performed.", + "The left breast mass was diagnosed as breast cancer.", + "No abnormalities were found in the lungs.", + "Other results, including abdominal ultrasound, bone scan, and laboratory examinations, showed no abnormalities.", + "There was no family history in genetic disorders.", + "The patient underwent core needle biopsy of the left breast mass under ultrasound guidance.", + "The histopathological diagnosis was apocrine carcinoma.", + "Immunohistochemical analysis showed negative expression of ER.", + "Immunohistochemical analysis showed negative expression of PR.", + "Immunohistochemical analysis showed positive expression of HER2.", + "Immunohistochemical analysis showed positive expression of AR (approximately 60%).", + "GCDFP-15 was also positive." + ], + "summary": "A 63-year-old woman presented with apocrine carcinoma of the left breast underwent core needle biopsy. The patient was diagnosed with apocrine carcinoma by immunohistochemical staining and negative hormone status (estrogen receptor and progesterone receptor) but showed overexpression of human epidermal factor receptor 2 (HER-2). Moreover, positive expression of androgen receptor (approximately 60%) and gross cystic disease fluid protein 15 was observed. The patient was treated with neoadjuvant targeted therapy consisting of the TCH regimen (docetaxel, carboplatin area under curve 6 and trastuzumab) every 21 d. The mass in the left breast was significantly reduced, and pain in the breast and left upper arm also improved.", + "summary_subclaims": [ + "The patient was a 63-year-old woman.", + "The patient presented with apocrine carcinoma of the left breast.", + "The patient underwent core needle biopsy.", + "The patient was diagnosed with apocrine carcinoma by immunohistochemical staining.", + "The patient had negative estrogen receptor status.", + "The patient had negative progesterone receptor status.", + "The patient showed overexpression of human epidermal factor receptor 2.", + "The patient had positive expression of androgen receptor (approximately 60%).", + "The patient had positive expression of gross cystic disease fluid protein 15.", + "The patient was treated with neoadjuvant targeted therapy consisting of the TCH regimen.", + "The TCH regimen included docetaxel, carboplatin area under curve 6, and trastuzumab.", + "The TCH regimen was administered every 21 d.", + "The mass in the left breast was significantly reduced.", + "Pain in the breast improved.", + "Pain in the left upper arm improved." + ] + }, + { + "id": "multiclinsum_test_2820_en.txt", + "fulltext": "A 4-year-old white girl from Greece was attacked by a dog owned by her neighbour while playing unsupervised in front of her yard. The child was transported to the emergency department by the dog owner.\nOn admission, she was confused and lethargic, presenting findings compatible with hypovolemic shock (heart rate 130 beats per minute and hemoglobin level of 7.8 g/dl) secondary to traumatic blood volume loss. Hemodynamic compromise required an aggressive intravenous fluid administration and blood transfusion. Physical examination revealed multiple deep scalp lacerations. After rigorous disinfection, surgical repair was performed in the hospital's operating unit. Due to the extensive nature of the traumatic lesions and the subsequent high risk of infection, the healing process required two weeks of intravenous antibiotic therapy. Rabies prophylaxis was not administered due to the documented rabies vaccination status of the dog.\nOn the second day of hospitalization, the child was in a depressed mood and displayed mild withdrawal from contact with others. A psychiatric evaluation was performed. During consultation, the child was apparently agitated and refused to participate in any conversation. Non-verbal communication was used instead, including gestures and shaking of the head. The behaviour had not been present before the dog attack. On the sixth day of hospitalization, the child talked for the first time to her mother and asked her: \"Where were you when the dog attacked me?\".\nAfter a complete suture removal 15 days after the injury, she was discharged. Psychiatric monitoring was arranged after two months. During this interval, the child refused to speak to physicians and other children in the neighbourhood, and used only gestures to communicate while engaging in normal conversation in the home setting. Her memories of the dog attack remained remarkably clear. For six weeks as an outpatient, the child had recurrent traumatic memories when questioned about dogs. After this interval, the girl manifested a persistent avoidance of thoughts and conversations associated with the event. Remarkably, the parents reported that the child was avoiding the dog owner as well as the place where the dog attack occurred. Feelings of estrangement from her neighbours were also present. Hyperarousal occurred in the form of outbursts of anger and anxiety when left alone. She also had difficulty concentrating.\nA limited expression of emotions and a reluctance to play with toy dogs were observed during psychiatric consultation. This case fulfilled all diagnostic criteria for selective mutism and PTSD according to the Diagnostic and Statistical Manual of Mental Disorders, (4th edition) . Psychological treatment consisted of supportive psychotherapy for the child and consecutive sessions of counseling for her parents. On her six-month follow-up appointment a symptomatic improvement was evident, with decreased levels of anxiety and normal rates of social and verbal interaction. During consultation, the girl was clearly less anxious and able to communicate her needs verbally. According to her parents, she had become more comfortable speaking in environments out of the home setting and playing with other children in the place where the dog attack occurred.", + "fulltext_subclaims": [ + "A 4-year-old white girl from Greece was attacked by a dog owned by her neighbour while playing unsupervised in front of her yard.", + "The child was transported to the emergency department by the dog owner.", + "On admission, she was confused and lethargic.", + "Findings were compatible with hypovolemic shock.", + "The heart rate was 130 beats per minute.", + "The hemoglobin level was 7.8 g/dl.", + "Hemodynamic compromise required aggressive intravenous fluid administration.", + "Hemodynamic compromise required blood transfusion.", + "Physical examination revealed multiple deep scalp lacerations.", + "Surgical repair was performed in the hospital's operating unit.", + "The healing process required two weeks of intravenous antibiotic therapy.", + "Rabies prophylaxis was not administered.", + "The dog had a documented rabies vaccination status.", + "On the second day of hospitalization, the child was in a depressed mood.", + "On the second day of hospitalization, the child displayed mild withdrawal from contact with others.", + "A psychiatric evaluation was performed.", + "During consultation, the child was apparently agitated.", + "During consultation, the child refused to participate in any conversation.", + "Non-verbal communication was used instead.", + "The behaviour had not been present before the dog attack.", + "On the sixth day of hospitalization, the child talked for the first time to her mother.", + "After a complete suture removal 15 days after the injury, she was discharged.", + "Psychiatric monitoring was arranged after two months.", + "The child refused to speak to physicians.", + "The child used only gestures to communicate while engaging in normal conversation in the home setting.", + "Her memories of the dog attack remained remarkably clear.", + "For six weeks as an outpatient, the child had recurrent traumatic memories when questioned about dogs.", + "After this interval, the girl manifested a persistent avoidance of thoughts and conversations associated with the event.", + "The parents reported that the child was avoiding the dog owner.", + "The parents reported that the child was avoiding the place where the dog attack occurred.", + "Feelings of estrangement from her neighbours were also present.", + "Hyperarousal occurred in the form of outbursts of anger.", + "Hyperarousal occurred in the form of anxiety when left alone.", + "She also had difficulty concentrating.", + "A limited expression of emotions and a reluctance to play with toy dogs were observed during psychiatric consultation.", + "This case fulfilled all diagnostic criteria for selective mutism according to the Diagnostic and Statistical Manual of Mental Disorders, (4th edition).", + "This case fulfilled all diagnostic criteria for PTSD according to the Diagnostic and Statistical Manual of Mental Disorders, (4th edition).", + "Psychological treatment consisted of supportive psychotherapy for the child.", + "Psychological treatment consisted of consecutive sessions of counseling for her parents.", + "On her six-month follow-up appointment, a symptomatic improvement was evident.", + "Decreased levels of anxiety were evident.", + "Normal rates of social and verbal interaction were evident.", + "The girl was clearly less anxious.", + "The girl was able to communicate her needs verbally.", + "According to her parents, she had become more comfortable speaking in environments out of the home setting.", + "According to her parents, she had become more comfortable playing with other children in the place where the dog attack occurred." + ], + "summary": "A 4-year-old white girl of Greek origin, with a dog-bite related trauma was admitted to the University Hospital of Crete, Greece, for surgical repair and intravenous antibiotic therapy due to extensive lesions. Exposure to the traumatic event triggered the onset of an unusual psychological response, selective mutism and acute post-traumatic stress disorder.", + "summary_subclaims": [ + "The patient is a 4-year-old white girl of Greek origin.", + "The patient had a dog-bite related trauma.", + "The patient was admitted to the University Hospital of Crete, Greece.", + "The admission was for surgical repair.", + "The admission was for intravenous antibiotic therapy.", + "The patient had extensive lesions.", + "Exposure to the traumatic event triggered the onset of an unusual psychological response.", + "The patient had selective mutism.", + "The patient had acute post-traumatic stress disorder." + ] + }, + { + "id": "multiclinsum_test_114_en.txt", + "fulltext": "A 50-year-old man presented with positive fecal occult blood test results. He denied any previous medical or surgical history. On digital examination, a solid tumor 5 cm from the anal verge on the posterior side of the rectum was palpated, and there were no anal fistulas or abscesses. Colonoscopy revealed a rectal tumor below the peritoneal reflection, occupying three-quarters of the circumference . A pathological diagnosis of the biopsy specimen indicated a well-to-moderately differentiated tubular adenocarcinoma. Computed tomography (CT) and magnetic resonance imaging (MRI) showed no significant regional lymphadenopathy or distant metastasis. Therefore, the clinical diagnosis was rectal cancer cT3N0M0, cStage IIa (UICC TNM classification 8th edition) .\nWe indicated preoperative chemoradiation therapy (CRT), comprising 45 Gy in 25 fractions; tegafur/gimeracil/oteracil potassium (S-1), 80 mg/m2/day at days 1–14 and 21–35 (2 cycles). The patient did not experience any significant adverse events. Four weeks after completion of CRT, a follow-up CT and MRI showed that the primary tumor had shrunk with a partial response as defined by the Japanese Society for Cancer of the Colon and Rectum (JSCCR) , but a small liver mass highly indicative of metastasis was also detected. This was later diagnosed as cavernous hemangioma using gadolinium ethoxybenzyl-diethylenetriaminepentaacetic acid-enhanced MRI 3 months after CRT initiation. We then indicated consolidation chemotherapy, consisting of capecitabine combined with oxaliplatin (XELOX regimen: intravenous oxaliplatin 130 mg/m2 [day 1] followed by oral capecitabine 1000 mg/m2 twice daily [day 1, evening to day 15, morning]). His tolerance to chemotherapy gradually declined due to peripheral sensory neuropathy (CTCAE Grade 1 to 2 ) after three cycles. As such, we excluded oxaliplatin and continued consolidation chemotherapy with three cycles of capecitabine alone (1000 mg/m2 twice daily [day 1, evening to day 15, morning]). Four weeks after completing consolidation chemotherapy, follow-up colonoscopy showed that the primary tumor achieved a complete response based on the JSCCR guidelines . Since a follow-up CT simultaneously showed thickening of the edematous rectal wall, we planned to perform low anterior resection as a radical surgery after neoadjuvant therapy.\nHowever, he presented with persistent anal pain 2 weeks after the last chemotherapy session. Anorectal examination revealed tenderness and rigidity around the posterior side of the anus, which was distant from the primary tumor. MRI revealed a high-intensity mass behind the anus, suggestive of an anal fistula . We considered the differential diagnosis of a benign anal fistula or implantation metastasis into the anal fistula. Coring-out fistulectomy was performed, and the resected fistula was pathologically diagnosed as tubular adenocarcinoma, which has similar morphological characteristics to rectal cancer . The resection margin was deemed positive because of the cauterized margin of cancer cells. This result suggested an implantation metastasis to the anal fistula. Therefore, instead of low anterior resection, abdominoperineal resection was performed to resect the primary rectal tumor and metastatic lesion simultaneously.\nTwelve weeks after completing consolidation chemotherapy, we performed laparoscopic abdominoperineal resection. The postoperative course was complicated by a perineal abscess requiring percutaneous drainage. Otherwise, it was uneventful, and the patient was discharged on the 25th postoperative day. Histopathological examination revealed a well-differentiated adenocarcinoma, ypT2, INFb, Ly0, V0, Pn0, pPM0, pDM0, ypN0 . The therapeutic effect was grade 2 according to the definition of the JSCCR .\nSubsequently, we investigated the origin of the tubular adenocarcinoma from the resected anal fistula by immunohistochemistry and found that it was CDX-2-positive, CK20-positive, CK7-negative, and GCDFP-15-negative . These findings implied that the anal fistula adenocarcinoma was consistent with metastasis and intraluminally implanted rectal cancer. The patient declined to undergo postoperative adjuvant chemotherapy. No recurrence was detected until his last follow-up 21 months after the surgery.", + "fulltext_subclaims": [ + "A 50-year-old man presented with positive fecal occult blood test results.", + "He denied any previous medical or surgical history.", + "On digital examination, a solid tumor 5 cm from the anal verge on the posterior side of the rectum was palpated.", + "There were no anal fistulas or abscesses.", + "Colonoscopy revealed a rectal tumor below the peritoneal reflection, occupying three-quarters of the circumference.", + "A pathological diagnosis of the biopsy specimen indicated a well-to-moderately differentiated tubular adenocarcinoma.", + "Computed tomography (CT) and magnetic resonance imaging (MRI) showed no significant regional lymphadenopathy or distant metastasis.", + "The clinical diagnosis was rectal cancer cT3N0M0, cStage IIa (UICC TNM classification 8th edition).", + "We indicated preoperative chemoradiation therapy (CRT), comprising 45 Gy in 25 fractions.", + "The CRT regimen included tegafur/gimeracil/oteracil potassium (S-1), 80 mg/m2/day at days 1–14 and 21–35 (2 cycles).", + "The patient did not experience any significant adverse events.", + "Four weeks after completion of CRT, a follow-up CT and MRI showed that the primary tumor had shrunk with a partial response as defined by the Japanese Society for Cancer of the Colon and Rectum (JSCCR).", + "A small liver mass highly indicative of metastasis was also detected.", + "This was later diagnosed as cavernous hemangioma using gadolinium ethoxybenzyl-diethylenetriaminepentaacetic acid-enhanced MRI 3 months after CRT initiation.", + "We then indicated consolidation chemotherapy, consisting of capecitabine combined with oxaliplatin (XELOX regimen).", + "The XELOX regimen included intravenous oxaliplatin 130 mg/m2 on day 1.", + "The XELOX regimen included oral capecitabine 1000 mg/m2 twice daily from day 1, evening to day 15, morning.", + "His tolerance to chemotherapy gradually declined due to peripheral sensory neuropathy (CTCAE Grade 1 to 2) after three cycles.", + "We excluded oxaliplatin and continued consolidation chemotherapy with three cycles of capecitabine alone.", + "Four weeks after completing consolidation chemotherapy, follow-up colonoscopy showed that the primary tumor achieved a complete response based on the JSCCR guidelines.", + "A follow-up CT simultaneously showed thickening of the edematous rectal wall.", + "We planned to perform low anterior resection as a radical surgery after neoadjuvant therapy.", + "He presented with persistent anal pain 2 weeks after the last chemotherapy session.", + "Anorectal examination revealed tenderness and rigidity around the posterior side of the anus, which was distant from the primary tumor.", + "MRI revealed a high-intensity mass behind the anus, suggestive of an anal fistula.", + "We considered the differential diagnosis of a benign anal fistula or implantation metastasis into the anal fistula.", + "Coring-out fistulectomy was performed.", + "The resected fistula was pathologically diagnosed as tubular adenocarcinoma, which has similar morphological characteristics to rectal cancer.", + "The resection margin was deemed positive because of the cauterized margin of cancer cells.", + "This result suggested an implantation metastasis to the anal fistula.", + "Instead of low anterior resection, abdominoperineal resection was performed to resect the primary rectal tumor and metastatic lesion simultaneously.", + "Twelve weeks after completing consolidation chemotherapy, we performed laparoscopic abdominoperineal resection.", + "The postoperative course was complicated by a perineal abscess requiring percutaneous drainage.", + "Otherwise, it was uneventful, and the patient was discharged on the 25th postoperative day.", + "Histopathological examination revealed a well-differentiated adenocarcinoma, ypT2, INFb, Ly0, V0, Pn0, pPM0, pDM0, ypN0.", + "The therapeutic effect was grade 2 according to the definition of the JSCCR.", + "We investigated the origin of the tubular adenocarcinoma from the resected anal fistula by immunohistochemistry.", + "The anal fistula adenocarcinoma was CDX-2-positive.", + "The anal fistula adenocarcinoma was CK20-positive.", + "The anal fistula adenocarcinoma was CK7-negative.", + "The anal fistula adenocarcinoma was GCDFP-15-negative.", + "These findings implied that the anal fistula adenocarcinoma was consistent with metastasis and intraluminally implanted rectal cancer.", + "The patient declined to undergo postoperative adjuvant chemotherapy.", + "No recurrence was detected until his last follow-up 21 months after the surgery." + ], + "summary": "A 50-year-old man was diagnosed with rectal cancer located 5 cm from the anal verge, with a clinical stage of cT3N0M0. He denied any medical or surgical history, and physical examination revealed no perianal disease. He underwent preoperative chemoradiation therapy (CRT) consisting of a tegafur/gimeracil/oteracil potassium (S-1)-based regimen with 45 Gy of radiation. After completion of CRT, computed tomography (CT) revealed the primary tumor's partial response, but a liver mass highly suggestive of metastasis was detected. This mass was later diagnosed as cavernous hemangioma 3 months after CRT initiation. He then underwent and completed six cycles of consolidation chemotherapy with a capecitabine-based regimen. Subsequent colonoscopy revealed the complete response of the primary tumor, but CT showed thickening of the edematous rectal wall. Therefore, we planned to perform low anterior resection as a radical surgery. However, he presented with persistent anal pain after the last chemotherapy, and magnetic resonance imaging revealed a high-intensity mass behind the anus, suggestive of an anal fistula. We considered the differential diagnosis of a benign anal fistula or implantation metastasis into the anal fistula. Fistulectomy was performed, and a pathological diagnosis of tubular adenocarcinoma, suggestive of implantation metastasis, was made. Thereafter, we performed laparoscopic abdominoperineal resection. Histopathological examination revealed well-differentiated adenocarcinoma, ypT2N0, with a grade 2 therapeutic effect. Subsequent immunohistochemistry of the resected anal fistula showed a CDX-2-positive, CK20-positive, CK7-negative, and GCDFP-15 negative tumor, with implantation metastasis. There was no cancer recurrence 21 months after the radical surgery.", + "summary_subclaims": [ + "The patient was a 50-year-old man.", + "He was diagnosed with rectal cancer located 5 cm from the anal verge.", + "The clinical stage was cT3N0M0.", + "He denied any medical or surgical history.", + "Physical examination revealed no perianal disease.", + "He underwent preoperative chemoradiation therapy consisting of a tegafur/gimeracil/oteracil potassium (S-1)-based regimen with 45 Gy of radiation.", + "Computed tomography after CRT revealed the primary tumor's partial response.", + "A liver mass highly suggestive of metastasis was detected.", + "The liver mass was later diagnosed as cavernous hemangioma.", + "He underwent six cycles of consolidation chemotherapy with a capecitabine-based regimen.", + "Subsequent colonoscopy revealed the complete response of the primary tumor.", + "CT showed thickening of the edematous rectal wall.", + "We planned to perform low anterior resection as a radical surgery.", + "He presented with persistent anal pain after the last chemotherapy.", + "Magnetic resonance imaging revealed a high-intensity mass behind the anus, suggestive of an anal fistula.", + "We considered the differential diagnosis of a benign anal fistula or implantation metastasis into the anal fistula.", + "Fistulectomy was performed.", + "A pathological diagnosis of tubular adenocarcinoma, suggestive of implantation metastasis, was made.", + "We performed laparoscopic abdominoperineal resection.", + "Histopathological examination revealed well-differentiated adenocarcinoma, ypT2N0.", + "There was a grade 2 therapeutic effect.", + "Subsequent immunohistochemistry of the resected anal fistula showed a CDX-2-positive tumor.", + "The tumor was CK20-positive.", + "The tumor was CK7-negative.", + "The tumor was GCDFP-15 negative.", + "There was implantation metastasis.", + "There was no cancer recurrence 21 months after the radical surgery." + ] + }, + { + "id": "multiclinsum_test_3186_en.txt", + "fulltext": "M.C.L.M., 16 years old, reported a history of productive cough for 7 days, with fever and progressive respiratory discomfort for 4 days. She had a history of asthma without follow-up, with the last crisis 1 year ago. She denied other comorbidities, allergies, surgeries or previous hospitalizations. Her parents were healthy, and there were no sick contacts.\n\nShe sought emergency care at the beginning of the condition and was prescribed azithromycin. On the seventh day of symptoms, she went to emergency care again due to a significant worsening of dyspnea and a drop in saturation. Measures were taken for bronchospasm, and she was connected to non-invasive ventilation, without response, and required ventilatory support. A sepsis protocol was opened, and the patient received ceftriaxone (2g intravenous - IV - every 12 hours) and oseltamivir (75mg orally - VO - every 12 hours). A panel of respiratory viruses, polymerase chain reaction (PCR) for 2019 coronavirus disease (COVID-19), cultures and laboratory and imaging tests were collected. The patient was transferred on the same day to a paediatric intensive care unit.\n\nThe next day, she tested positive for Influenza B and negative for the other agents. She tolerated weaning from the ventilator and was extubated in 2 days. She required noradrenaline for 1 day due to hypotension and haemodynamic instability. On the third day of ceftriaxone, she had a fever, and oxacillin (2g EV every 4 hours) was associated to extend antibiotic coverage. On the eighth day of admission, despite progressing with improvement of the general state, she had a fever for 11 days, when she started laminar desquamation in hand, feet and inguinal region and raspberry tongue. She had bilateral conjunctivitis since admission, in addition to cervical lymph node on the left (5cm), closing criteria for DK. She received acetylsalicylic acid (AAS) 200mg once a day and gamma globulin 80g EV single dose, according to the protocol. Initial and control echocardiogram (ECO) was performed, without alteration of coronary arteries (initial ECO: right coronary artery: 2.9mm and z-score -0.57; left coronary artery: 3.3mm and z-score -0.49; descending anterior artery: 3.2mm and z-score +1.0).\n\nAs she had tachypnea with worsening of the chest radiograph image, in addition to the need for supplemental oxygen, an angiotomy was performed, showing pulmonary thromboembolism, small bilateral pleural effusion and pulmonary infiltrate compatible with the current pulmonary disease, and enoxaparin 40 mg subcutaneously was prescribed every 12 hours. Investigation for systemic lupus erythematosus and serologies (cytomegalovirus, toxoplasmosis and Epstein-Barr) were negative. On the 18th febrile day, prednisolone (60 mg, oral, once daily) was introduced due to the persistence of fever, which ceased 24 hours after the introduction of corticoid. Due to pulmonary thromboembolism, coagulopathies were investigated, with the presence of heterozygous mutation of factor V Leiden. She was discharged with the use of acetylsalicylic acid (AAS, 200 mg, oral, once daily) and warfarin (10 mg, oral, once daily) with ambulatory follow-up. During the follow-up, she collected serology for COVID-19, after more than 1 month from the onset of symptoms, presenting negative immunoglobulin G (IgG) and M (IgM).\n", + "fulltext_subclaims": [ + "M.C.L.M. is 16 years old.", + "She reported a productive cough for 7 days.", + "She had fever and progressive respiratory discomfort for 4 days.", + "She had a history of asthma without follow-up.", + "The last asthma crisis was 1 year ago.", + "She denied other comorbidities.", + "She denied allergies.", + "She denied surgeries.", + "She denied previous hospitalizations.", + "Her parents were healthy.", + "There were no sick contacts.", + "She sought emergency care at the beginning of the condition.", + "She was prescribed azithromycin.", + "On the seventh day of symptoms, she went to emergency care again due to a significant worsening of dyspnea and a drop in saturation.", + "Measures were taken for bronchospasm.", + "She was connected to non-invasive ventilation.", + "She required ventilatory support.", + "A sepsis protocol was opened.", + "She received ceftriaxone 2g intravenous every 12 hours.", + "She received oseltamivir 75mg orally every 12 hours.", + "A panel of respiratory viruses was collected.", + "A polymerase chain reaction for 2019 coronavirus disease was collected.", + "Cultures were collected.", + "Laboratory tests were collected.", + "Imaging tests were collected.", + "The patient was transferred to a paediatric intensive care unit on the same day.", + "The next day, she tested positive for Influenza B.", + "She tolerated weaning from the ventilator.", + "She was extubated in 2 days.", + "She required noradrenaline for 1 day due to hypotension and haemodynamic instability.", + "On the third day of ceftriaxone, she had a fever.", + "Oxacillin 2g intravenous every 4 hours was associated to extend antibiotic coverage.", + "On the eighth day of admission, she had a fever for 11 days.", + "She had laminar desquamation in hand, feet and inguinal region.", + "She had raspberry tongue.", + "She had bilateral conjunctivitis since admission.", + "She had cervical lymph node on the left (5cm).", + "She received acetylsalicylic acid 200mg once a day.", + "She received gamma globulin 80g intravenous single dose.", + "An initial echocardiogram was performed.", + "The initial echocardiogram showed no alteration of coronary arteries.", + "The initial echocardiogram showed right coronary artery 2.9mm and z-score -0.57.", + "The initial echocardiogram showed left coronary artery 3.3mm and z-score -0.49.", + "The initial echocardiogram showed descending anterior artery 3.2mm and z-score +1.0.", + "An angiotomy was performed.", + "The angiotomy showed pulmonary thromboembolism.", + "The angiotomy showed small bilateral pleural effusion.", + "The angiotomy showed pulmonary infiltrate compatible with the current pulmonary disease.", + "Enoxaparin 40 mg subcutaneously was prescribed every 12 hours.", + "Investigation for systemic lupus erythematosus was negative.", + "Serologies for cytomegalovirus, toxoplasmosis and Epstein-Barr were negative.", + "On the 18th febrile day, prednisolone 60 mg oral once daily was introduced.", + "Fever ceased 24 hours after the introduction of corticoid.", + "Coagulopathies were investigated.", + "Heterozygous mutation of factor V Leiden was present.", + "She was discharged with acetylsalicylic acid 200 mg oral once daily.", + "She was discharged with warfarin 10 mg oral once daily.", + "She collected serology for COVID-19 after more than 1 month from the onset of symptoms.", + "The serology for COVID-19 showed negative immunoglobulin G.", + "The serology for COVID-19 showed negative immunoglobulin M." + ], + "summary": "Presentation of a case of Influenza B infection and Kawasaki disease in an adolescent during the COVID-19 pandemic. An asthmatic adolescent developed a fever and influenza syndrome for 7 days and was admitted with a picture of acute respiratory failure, requiring orotracheal intubation. She also developed haemodynamic instability responding to the use of vasoactive drugs. Antibiotic therapy and supportive measures were introduced. She presented progressive haemodynamic and respiratory improvement, but she still had a fever and inflammatory tests were altered. During admission, she developed bilateral non-purulent conjunctivitis, hand and foot scaling, raspberry tongue and cervical lymphadenopathy, receiving a diagnosis of Kawasaki disease. She received gamma globulin and, due to a refractory clinical picture, corticoid was also administered, and she became afebrile 24 hours later. She did not have coronary artery changes. The only isolated agent was Influenza B, even though a viral panel and investigation for COVID-19 with polymerase chain reaction and serology were performed. During admission, she developed pulmonary thromboembolism, and, in a coagulopathy investigation, she was diagnosed with a heterozygous mutation of factor V Leiden.\n", + "summary_subclaims": [ + "The case involves an adolescent with Influenza B infection and Kawasaki disease.", + "The adolescent had asthma.", + "The adolescent had a fever and influenza syndrome for 7 days.", + "The adolescent was admitted with acute respiratory failure.", + "The adolescent required orotracheal intubation.", + "The adolescent developed haemodynamic instability.", + "The adolescent responded to vasoactive drugs.", + "Antibiotic therapy was introduced.", + "Supportive measures were introduced.", + "The adolescent had a fever during admission.", + "The adolescent's inflammatory tests were altered.", + "The adolescent developed bilateral non-purulent conjunctivitis.", + "The adolescent developed hand and foot scaling.", + "The adolescent developed raspberry tongue.", + "The adolescent developed cervical lymphadenopathy.", + "The diagnosis of Kawasaki disease was made.", + "The adolescent received gamma globulin.", + "The clinical picture was refractory.", + "The adolescent received corticoid.", + "The adolescent became afebrile 24 hours after corticoid administration.", + "The adolescent did not have coronary artery changes.", + "Influenza B was the only isolated agent.", + "A viral panel was performed.", + "An investigation for COVID-19 with polymerase chain reaction and serology was performed.", + "The adolescent developed pulmonary thromboembolism.", + "A coagulopathy investigation was performed.", + "The adolescent was diagnosed with a heterozygous mutation of factor V Leiden." + ] + }, + { + "id": "multiclinsum_test_2043_en.txt", + "fulltext": "A 16-year-old Persian man visited a referral hospital after his mother was diagnosed as having aggressive MTC. The 38-year-old woman, who had had a mass in the thyroid gland and cervical lymphadenopathy for six years, underwent thyroidectomy a year earlier after being diagnosed as having the disease. Her family members were then asked to visit a physician for further evaluation as the disease usually runs in the family.\nOur patient had no history of the main symptoms of the disease, namely lymphadenopathy (LAP), weight loss, fever, café au lait spots, ocular problems, gastrointestinal problems (failure to thrive (FTT), abdominal pain, dysphagia, projectile vomiting, diarrhea, constipation, flatulence), thyroid nodule, hoarseness, dyspnea and cough.\nOn physical examination, his face was symmetric and there was no sign of high arched palate, mandibular prognathism, and flat nasal bridge. He, however, had bumpy lips and several neuromas on his upper and lower eyelids, lips and tongue, all characteristic of MEN2B. His thyroid gland and abdomen were normal, and there were no other remarkable finding in the physical examination. He had a normal height with no signs of marfanoid habitus. He had increased calcitonin and carcinoembryonic antigen (CEA) levels but tests for RET proto-oncogene on exon 10, 11 and 16 were negative.\nThe results of an ophthalmology examination showed several mucosal neuromas on inner eyelids and conjunctivae, prominent perilimbal conjunctival blood vessels and enlarged corneal nerves. His intra-ocular pressure (IOP) was normal. His upper gastrointestinal and small bowel series were also normal.\nPheochromocytoma was ruled out based on the laboratory test results. Our patient thereafter underwent a thyroidectomy. The results of pathological tests revealed a small (0.5cm) medullary thyroid carcinoma in right lobe, with surgical margins free of tumor.\nPost-operative evaluation, including cervical ultrasound as well as cervical, thoracic and abdominal computed tomography, were normal. Our patient's calcitonin and CEA levels were then assessed periodically.\nIt should be noted that all the family members had signed an informed consent, providing the authors with an authorization to publish their information.", + "fulltext_subclaims": [ + "The patient is a 16-year-old Persian man.", + "The patient's mother was diagnosed with aggressive MTC.", + "The patient's mother had a mass in the thyroid gland and cervical lymphadenopathy for six years.", + "The patient's mother underwent thyroidectomy a year earlier.", + "The patient had no history of lymphadenopathy.", + "The patient had no history of weight loss.", + "The patient had no history of fever.", + "The patient had no history of café au lait spots.", + "The patient had no history of ocular problems.", + "The patient had no history of gastrointestinal problems.", + "The patient had no history of thyroid nodule.", + "The patient had no history of hoarseness.", + "The patient had no history of dyspnea.", + "The patient had no history of cough.", + "On physical examination, the patient's face was symmetric.", + "There was no sign of high arched palate.", + "There was no sign of mandibular prognathism.", + "There was no sign of flat nasal bridge.", + "The patient had bumpy lips.", + "The patient had several neuromas on his upper and lower eyelids, lips, and tongue.", + "The neuromas were characteristic of MEN2B.", + "The patient's thyroid gland was normal.", + "The patient's abdomen was normal.", + "There were no other remarkable findings in the physical examination.", + "The patient had a normal height.", + "There were no signs of marfanoid habitus.", + "The patient had increased calcitonin levels.", + "The patient had increased carcinoembryonic antigen (CEA) levels.", + "Tests for RET proto-oncogene on exon 10, 11, and 16 were negative.", + "The results of an ophthalmology examination showed several mucosal neuromas on inner eyelids and conjunctivae.", + "The ophthalmology examination showed prominent perilimbal conjunctival blood vessels.", + "The ophthalmology examination showed enlarged corneal nerves.", + "The patient's intra-ocular pressure (IOP) was normal.", + "The upper gastrointestinal and small bowel series were normal.", + "Pheochromocytoma was ruled out based on the laboratory test results.", + "The patient underwent a thyroidectomy.", + "The results of pathological tests revealed a small (0.5cm) medullary thyroid carcinoma in the right lobe.", + "The surgical margins were free of tumor.", + "Post-operative evaluation included cervical ultrasound.", + "Post-operative evaluation included cervical, thoracic, and abdominal computed tomography.", + "The post-operative evaluations were normal.", + "The patient's calcitonin and CEA levels were assessed periodically.", + "All the family members had signed an informed consent.", + "The family members provided the authors with an authorization to publish their information." + ], + "summary": "We present the case of a 16-year-old Persian man diagnosed as having a non-invasive form of multiple endocrine neoplasia 2B (medullary thyroid cancer, mucosal neuroma of the tongue, lips and inner eyelids). Our patient, who had a positive family history of medullary thyroid cancer, was of normal height with no signs of marfanoid habitus.", + "summary_subclaims": [ + "The patient is a 16-year-old Persian man.", + "The patient was diagnosed as having a non-invasive form of multiple endocrine neoplasia 2B.", + "The patient has medullary thyroid cancer.", + "The patient has mucosal neuroma of the tongue.", + "The patient has mucosal neuroma of the lips.", + "The patient has mucosal neuroma of the inner eyelids.", + "The patient had a positive family history of medullary thyroid cancer.", + "The patient was of normal height.", + "The patient had no signs of marfanoid habitus." + ] + }, + { + "id": "multiclinsum_test_863_en.txt", + "fulltext": "A 63-year-old female patient presented with postmenopausal intermittent vaginal bleeding for 2 months. She denied other urinary, rectal, and gynecological symptoms such as abnormal vaginal discharge, abnormal defecation, and abdominal pain. Transvaginal ultrasonography showed a small amount of hemorrhage in the uterine cavity, endometrial thickness of 0.68 cm, and no abnormal echo in the bilateral adnexal area. The levels of relevant tumor markers were all within normal ranges as follows: CA125:15.4 U/ml (reference value:<35 U/ml), CEA:2.21 ng/ml (reference value:<5 ng/ml) and CA19-9:13.6 U/ml (reference value:<37 U/ml). The endometrial cytology examination hint to possible endometrial adenocarcinoma. No other neoplasms, hereditary diseases, or related family histories were self-reported. The multimodal PET/MR examination was recommended to provide further information about the depth of myometrial invasion and the assessment of metastases in endometrial carcinoma.\nThe multimodal PET/MR imaging including the whole-body 18F-fluorodeoxyglucose (18F-FDG) PET and the multimodal MR images were performed with the hybrid PET/MR scanner (SIGNA TOF-PET/MR, GE Healthcare). The patient signed an informed consent form for the PET/MR examination and the publication of relevant images. On the pelvic sagittal MRI, there was no significant thickened endometrium and no high FDG uptake in the uterine corpus, but only a polypoid mass stretching from the lower segment of the uterine endometrium to the cervical canal . The polypoid lesion showed a slightly high intensity signal on non-contrast T1-weighted images (T1WI) and fat-suppressed T2-weighted images (fs T2WI), but no restricted diffusion signal in diffusion-weighted images (DWI) . Following gadolinium administration, a mild enhancement of the lesion was observed on contrast enhanced T1WI (T1WI+C) . The PET and PET/MR fusion images showed slight hypermetabolism in the lesion . Based on the pelvic PET/MR multimodal images and cytology examination, the polypoid mass in the cervical canal was suspected to be endometrial carcinoma.\nUnexpectedly, the maximum intensity projection (MIP) images of whole-body PET revealed an abnormal hypermetabolism in the left lower abdomen (SUVmax = 17.68 g/ml) . Thus, the coronal whole-body PET/MR images were reconstructed to evaluate the abnormal hypermetabolism. The coronal whole-body T2WI and PET/MR fusion images showed that the abnormal hypermetabolism on PET images was a mass in the intestinal wall of the descending colon . The thickened descending colon wall that showed markedly high signal intensity on either DWI (ADCmean = 0.75*10^-3 mm2/s) or T1WI+C and hypermetabolism on axial PET/MR fusion images was observed.\nSubsequent colonoscopy examination confirmed the presence of a descending colonic tumor on the corresponding location of PET/MR images. The patient underwent simultaneous laparoscopic radical hysterectomy and descending colectomy. Macroscopic analysis of the resected uterus confirmed that the polypoid mass stretching from the lower segment of the uterine endometrium to cervical canal. And the endometrial carcinoma (G2) categorized as superficial myometrial invasion and the poor-differentiated tubular adenocarcinoma invading the muscularis propria without serosa invasion were demonstrated by histologic analysis. Lynch syndrome was considered because the patient had both primary endometrial carcinoma and descending colon carcinoma, even though she had no relevant family history. Immunohistochemistry (IHC) analysis indicated that MLH1 and PMS2 proteins were negative expression in the resected tumor tissues derived from uterus . Molecular analysis identified no KRAS and BRAF mutations of primary colon tumor. Moreover, the gene analysis of both tumors was performed to identify microsatellite instability (MSI) for the diagnosis of Lynch syndrome. The results of endometrial carcinoma gene analysis included deletion mutations in exon 15 and exon 17 of MLH1 , replacement mutation in exon 16 of MSH-2 and duplication mutation in exon 5 of MSH-6 . And deletion mutation and replacement mutation of MLH-1 derived from the colon tumor were also confirmed . Therefore, post-operative adjuvant therapy and follow-up would be modified according to Lynch syndrome, and relevant genetic testing had been recommended for high-risk relatives.", + "fulltext_subclaims": [ + "The patient is a 63-year-old female.", + "She presented with postmenopausal intermittent vaginal bleeding for 2 months.", + "She denied other urinary, rectal, and gynecological symptoms.", + "Transvaginal ultrasonography showed a small amount of hemorrhage in the uterine cavity.", + "The endometrial thickness was 0.68 cm.", + "There was no abnormal echo in the bilateral adnexal area.", + "The levels of CA125, CEA, and CA19-9 were within normal ranges.", + "The endometrial cytology examination hinted to possible endometrial adenocarcinoma.", + "The multimodal PET/MR examination was recommended.", + "The patient signed an informed consent form for the PET/MR examination.", + "On the pelvic sagittal MRI, there was no significant thickened endometrium.", + "There was no high FDG uptake in the uterine corpus.", + "A polypoid mass was observed stretching from the lower segment of the uterine endometrium to the cervical canal.", + "The polypoid lesion showed a slightly high intensity signal on non-contrast T1WI.", + "The polypoid lesion showed a slightly high intensity signal on fat-suppressed T2WI.", + "No restricted diffusion signal was observed in diffusion-weighted images.", + "Following gadolinium administration, a mild enhancement of the lesion was observed on contrast-enhanced T1WI.", + "The PET and PET/MR fusion images showed slight hypermetabolism in the lesion.", + "The polypoid mass in the cervical canal was suspected to be endometrial carcinoma.", + "The maximum intensity projection images of whole-body PET revealed an abnormal hypermetabolism in the left lower abdomen.", + "The coronal whole-body PET/MR images showed that the abnormal hypermetabolism was a mass in the intestinal wall of the descending colon.", + "The thickened descending colon wall showed markedly high signal intensity on either DWI or T1WI+C.", + "Subsequent colonoscopy confirmed the presence of a descending colonic tumor.", + "The patient underwent simultaneous laparoscopic radical hysterectomy and descending colectomy.", + "Macroscopic analysis confirmed the polypoid mass stretching from the lower segment of the uterine endometrium to the cervical canal.", + "Histologic analysis demonstrated endometrial carcinoma (G2) with superficial myometrial invasion.", + "The endometrial carcinoma was categorized as poor-differentiated tubular adenocarcinoma invading the muscularis propria.", + "There was no serosa invasion.", + "Lynch syndrome was considered.", + "Immunohistochemistry analysis indicated that MLH1 and PMS2 proteins were negative.", + "Molecular analysis identified no KRAS and BRAF mutations of the primary colon tumor.", + "The results of endometrial carcinoma gene analysis included deletion mutations in exon 15 and exon 17 of MLH1.", + "The results of endometrial carcinoma gene analysis included a replacement mutation in exon 16 of MSH-2.", + "The results of endometrial carcinoma gene analysis included a duplication mutation in exon 5 of MSH-6.", + "Deletion mutation and replacement mutation of MLH-1 derived from the colon tumor were also confirmed.", + "Post-operative adjuvant therapy and follow-up would be modified according to Lynch syndrome.", + "Relevant genetic testing had been recommended for high-risk relatives." + ], + "summary": "A 63-year-old female patient presented with postmenopausal intermittent vaginal bleeding. Transvaginal ultrasonography showed a small amount of bleeding in the uterine cavity and no thickening of the endometrium. The levels of relevant tumor markers were all within normal ranges. The endometrial cytology examination hint to possible endometrial adenocarcinoma. The hybrid 18F-fluorodeoxyglucose (18F-FDG) positron emission tomography/magnetic resonance (PET/MR) images showed a polypoid mass in the lower uterine segment and unexpectedly found a mass in the descending colon. A colonoscopy confirmed that there was a colon adenocarcinoma in the same place as the PET/MR images. Thus, LS was suspected even though this patient did not match the clinical diagnostic criteria. The gene analysis of both tumors was performed to identify microsatellite instability (MSI) for the diagnosis of Lynch syndrome. Postoperative adjuvant therapy and follow-up protocol customized for patients with Lynch syndrome.", + "summary_subclaims": [ + "The patient is a 63-year-old female.", + "The patient had postmenopausal intermittent vaginal bleeding.", + "Transvaginal ultrasonography showed a small amount of bleeding in the uterine cavity.", + "Transvaginal ultrasonography showed no thickening of the endometrium.", + "The levels of relevant tumor markers were all within normal ranges.", + "The endometrial cytology examination hinted to possible endometrial adenocarcinoma.", + "The hybrid 18F-FDG PET/MR images showed a polypoid mass in the lower uterine segment.", + "The hybrid 18F-FDG PET/MR images unexpectedly found a mass in the descending colon.", + "A colonoscopy confirmed that there was a colon adenocarcinoma in the same place as the PET/MR images.", + "Lynch syndrome was suspected.", + "This patient did not match the clinical diagnostic criteria.", + "The gene analysis of both tumors was performed to identify microsatellite instability (MSI) for the diagnosis of Lynch syndrome.", + "Postoperative adjuvant therapy and follow-up protocol were customized for patients with Lynch syndrome." + ] + }, + { + "id": "multiclinsum_test_594_en.txt", + "fulltext": "A 46-year-old woman was hospitalized with a 2-year history of dull pain in the right upper abdomen. Her appetite was normal and she had no history of diarrhea, flushes or dyspnea. There was no pertinent past medical or surgical history. On examination, she was well nourished with stable vital signs, and no pallor, jaundice, or significant lymphadenopathy. Abdominal examination revealed no tenderness, organomegaly, or abnormal mass.\nLaboratory investigation revealed normal hematological findings and serum electrolyte levels. The laboratory data of Liver function were within normal limits. The results of assays for tumor-associated antigen revealed that the serum levels of CEA, CA-50, CA19-9 and CA125 were within normal limits. Urine and stool routine examinations proved normal. Because of no suspicion for the diagnosis of carcinoid tumor before treatment, we did not measure the levels of the urinary 5-hydroxyindoleacetic acid (5HIAA) and plasma serotonin. The chest X-ray revealed no unusual findings. Abdominal ultrasound showed a 4.5 cm protruding tissue mass in the body and fundus of the gallbladder lumen . This mass appeared to arise from the wall of the gallbladder. Contrast-enhance abdominal computed tomography was performed and revealed a high-density mass in the gallbladder on the atrial phase . Low-density lesions in the right hepatic lobe were not detected. No evidences of calcification in the mass and biliary dilatation were noted.\nWith a preoperative diagnosis of gallbladder carcinoma, the patient was referred for surgical opinion and laparotomy was subsequently performed. At laparotomy, a 4 × 5 cm mass was found within the gallbladder, located on the free surface of the body and fundus of the gallbladder. Neither metastases nor direct invasion to the liver was found. The entire mass and gallbladder were excised and intact. Pathological findings were as follows: On grass inspection of the operated material, the gallbladder measured 10 × 6 × 5 cm, and had a smooth external surface. On opening the specimen, an intramural tumor 5 cm in diameter located in the free wall of the body and fundus of the gallbladder . Histologically, the tumor was seen infiltrating into the mucosa extensively, and some penetrated the muscular layer but not through the serosa of the gallbladder into the liver. The gallbladder with tumor was completely excised with free resection margins. The tumor consisted of nests of small oval cells with round-to-oval neclei and these nests were separated from each other by thin fibrovascular bands. The tumor showed moderate pleomorphism with scattered mitotic figures, but no definite evidence of vascular permeation, perineural invasion or lymphatic permeation was seen . Immunohistochemical studies of paraffin sections revealed strong positivity for chromogranin A and neuron-specific enolase (NSE) . It was diagnosed as a classical carcinoid tumor of the gallbladder. After surgery, the patient had an uneventful recovery without incident. No recurrent lesion was found using abdominal ultrasound examination and CT scan 12 months after cholecystectomy.", + "fulltext_subclaims": [ + "The patient was a 46-year-old woman.", + "She had a 2-year history of dull pain in the right upper abdomen.", + "Her appetite was normal.", + "She had no history of diarrhea, flushes or dyspnea.", + "There was no pertinent past medical or surgical history.", + "On examination, she was well nourished with stable vital signs.", + "There was no pallor, jaundice, or significant lymphadenopathy.", + "Abdominal examination revealed no tenderness, organomegaly, or abnormal mass.", + "Laboratory investigation revealed normal hematological findings.", + "Serum electrolyte levels were within normal limits.", + "Liver function tests were within normal limits.", + "The serum levels of CEA, CA-50, CA19-9 and CA125 were within normal limits.", + "Urine and stool routine examinations proved normal.", + "We did not measure the levels of the urinary 5-hydroxyindoleacetic acid (5HIAA) and plasma serotonin.", + "The chest X-ray revealed no unusual findings.", + "Abdominal ultrasound showed a 4.5 cm protruding tissue mass in the body and fundus of the gallbladder lumen.", + "This mass appeared to arise from the wall of the gallbladder.", + "Contrast-enhance abdominal computed tomography was performed.", + "The CT scan revealed a high-density mass in the gallbladder on the atrial phase.", + "Low-density lesions in the right hepatic lobe were not detected.", + "No evidences of calcification in the mass and biliary dilatation were noted.", + "With a preoperative diagnosis of gallbladder carcinoma, the patient was referred for surgical opinion.", + "Laparotomy was subsequently performed.", + "At laparotomy, a 4 × 5 cm mass was found within the gallbladder.", + "The mass was located on the free surface of the body and fundus of the gallbladder.", + "Neither metastases nor direct invasion to the liver was found.", + "The entire mass and gallbladder were excised and intact.", + "On gross inspection of the operated material, the gallbladder measured 10 × 6 × 5 cm.", + "On opening the specimen, an intramural tumor 5 cm in diameter located in the free wall of the body and fundus of the gallbladder.", + "Histologically, the tumor was seen infiltrating into the mucosa extensively.", + "Some of the tumor penetrated the muscular layer but not through the serosa of the gallbladder into the liver.", + "The gallbladder with tumor was completely excised with free resection margins.", + "The tumor consisted of nests of small oval cells with round-to-oval nuclei.", + "These nests were separated from each other by thin fibrovascular bands.", + "The tumor showed moderate pleomorphism with scattered mitotic figures.", + "No definite evidence of vascular permeation, perineural invasion or lymphatic permeation was seen.", + "Immunohistochemical studies of paraffin sections revealed strong positivity for chromogranin A and neuron-specific enolase (NSE).", + "It was diagnosed as a classical carcinoid tumor of the gallbladder.", + "After surgery, the patient had an uneventful recovery without incident.", + "No recurrent lesion was found using abdominal ultrasound examination and CT scan 12 months after cholecystectomy." + ], + "summary": "A 46-year-old woman was hospitalized with a preoperative diagnosis of gallbladder carcinoma, The patient was referred for surgical opinion and laparotomy was subsequently performed. A 4 x 5 cm mass was found within the gallbladder, located on the free surface of the body and fundus of the gallbladder. Neither metastases nor direct invasion to the liver was found. The entire mass and gallbladder were excised and intact. Histologically, the tumor consisted of small oval cells with round-to-oval neclei and tumor cells formed small nodular, trabeculare and acinar structures. The tumor showed moderate pleomorphism with scattered mitotic figures, but no definite evidence of vascular permeation, perineural invasion or lymphatic permeation was seen. The tumor cells invaded the mucosa extensively, and some penetrated the muscular layer but not through the serosa of the gallbladder into the liver. Immunohistochemical studies revealed strong positive reaction for chromogranin A and NSE. This lesion was proved to be a primary carcinoid tumor of the gallbladder. A brief review of literature, clinical feature, pathology and treatment of this rare disease was discussed.", + "summary_subclaims": [ + "The patient was a 46-year-old woman.", + "The patient was hospitalized with a preoperative diagnosis of gallbladder carcinoma.", + "The patient was referred for surgical opinion.", + "Laparotomy was subsequently performed.", + "A 4 x 5 cm mass was found within the gallbladder.", + "The mass was located on the free surface of the body and fundus of the gallbladder.", + "Neither metastases nor direct invasion to the liver was found.", + "The entire mass and gallbladder were excised and intact.", + "Histologically, the tumor consisted of small oval cells with round-to-oval nuclei.", + "Tumor cells formed small nodular, trabecular and acinar structures.", + "The tumor showed moderate pleomorphism with scattered mitotic figures.", + "No definite evidence of vascular permeation was seen.", + "No definite evidence of perineural invasion was seen.", + "No definite evidence of lymphatic permeation was seen.", + "The tumor cells invaded the mucosa extensively.", + "Some tumor cells penetrated the muscular layer.", + "The tumor cells did not penetrate through the serosa of the gallbladder into the liver.", + "Immunohistochemical studies revealed strong positive reaction for chromogranin A.", + "Immunohistochemical studies revealed strong positive reaction for NSE.", + "This lesion was proved to be a primary carcinoid tumor of the gallbladder." + ] + }, + { + "id": "multiclinsum_test_1958_en.txt", + "fulltext": "A 39-year-old black male with known sickle cell trait presented to the emergency department with lower extremity swelling with blisters and odynophagia. He developed petechial lesions on both feet that progressed to ulcers on the bilateral lower extremities. The odynophagia started 2 weeks prior to presentation and was associated with a tongue ulcer. He had been evaluated by an infectious disease team during a previous visit and had an unrevealing workup. He was not on any treatment for lower extremity lesions. He denied fever, chills, nausea, vomiting, diarrhea, weight loss, night sweats, recent travel, and history of IV drug use.\nHis initial vital signs were BP 156/86, HR 114, temperature 102.2 F, and O2 saturation at 98% on room air. Physical exam was remarkable for oral thrush with right tongue ulceration and healing ulcers on the dorsal surface of his feet bilaterally. His complete blood count (CBC) and basic metabolic profile (BMP) were within normal limits. Urinalysis was positive for blood and 2+ proteinuria. His urine toxicology was positive for oxycodone. He was initially treated for Systemic Inflammatory Response System (SIRS). Blood cultures were drawn and he was started empirically on vancomycin and piperacillin and tazobactam. Bilateral venous duplex was negative for deep vein thrombosis. Computed tomography (CT) of the chest showed multiple irregular nodules with suspected infectious versus inflammatory etiology and septic emboli could not be excluded . Transthoracic echocardiogram was negative for infective endocarditis. Bilateral foot ulcers drained serosanguinous fluid with cultures positive for Enterococcus faecalis and Serratia but four sets of blood cultures remained negative. Magnetic resonance imaging (MRI) of the left foot was normal and MRI of the right foot showed metatarsal stress reaction versus early osteomyelitis. Skin biopsy showed extensively necrotic fibroadipose tissue with acute inflammation. Right lateral oral tongue ulcerative lesion biopsy showed predominantly hyperplastic squamous mucosa showing an ulcer site and abscess with fragments of necrotic squamous epithelium associated with cytologic atypia and colonies of bacteria, and one fragment of necrotic squamous epithelium displayed vague papillary architecture. The patient later developed right eye conjunctivitis. Appropriate consultations with nephrology, pulmonology, and podiatry were obtained.\nBased on the constellation of oral and cutaneous ulcers, CT chest findings, bilateral foot ulcers, and conjunctivitis, a rheumatologic process was suspected. The antinuclear antibody (ANA) was negative, rheumatoid factor was with 1 : 640 titer, C-ANCA (antineutrophil cytoplasmic antibody) was positive with 1 : 1280 titer, and the diagnosis of Wegner's granulomatosis was made. He was started on rituximab 375 mg weekly and methylprednisolone 250 mg every 6 hours for 3 days. He later had a renal biopsy which showed granulomatosis with polyangiitis and mild interstitial fibrosis with tubular atrophy and a pauci immune crescentic glomerulonephritis . He underwent debridement of his bilateral foot ulcers and received an additional dose of rituximab. Following the second dose of rituximab, the oral ulcers improved. Toward the end of his hospitalization, his hemoglobin decreased and he was noted to have blood streaked sputum. Repeat CT chest was ordered and was consistent with diffuse alveolar hemorrhage . Unfortunately, he left prior to pulmonology evaluation. He was called and encouraged to come back to the hospital but declined and ultimately sought further medical attention at another hospital where he was ultimately admitted to the intensive care unit (ICU). Nephrology was consulted and began plasmapheresis for a total of 7 treatments. He was given a one-time dose of cyclophosphamide on initial presentation and then an additional dose of rituximab following plasmapheresis. He gradually improved and was discharged home 8 days after admission.", + "fulltext_subclaims": [ + "The patient is a 39-year-old black male with known sickle cell trait.", + "He presented with lower extremity swelling with blisters and odynophagia.", + "He developed petechial lesions on both feet that progressed to ulcers on the bilateral lower extremities.", + "The odynophagia started 2 weeks prior to presentation.", + "He had a tongue ulcer.", + "He had been evaluated by an infectious disease team during a previous visit.", + "He had an unrevealing workup.", + "He was not on any treatment for lower extremity lesions.", + "He denied fever, chills, nausea, vomiting, diarrhea, weight loss, night sweats, recent travel, and history of IV drug use.", + "His initial temperature was 102.2 F.", + "Physical exam was remarkable for oral thrush with right tongue ulceration.", + "Physical exam showed healing ulcers on the dorsal surface of his feet bilaterally.", + "Urinalysis was positive for blood and 2+ proteinuria.", + "Urine toxicology was positive for oxycodone.", + "He was initially treated for Systemic Inflammatory Response System (SIRS).", + "Blood cultures were drawn.", + "He was started empirically on vancomycin and piperacillin and tazobactam.", + "Bilateral venous duplex was negative for deep vein thrombosis.", + "Computed tomography (CT) of the chest showed multiple irregular nodules with suspected infectious versus inflammatory etiology.", + "Transthoracic echocardiogram was negative for infective endocarditis.", + "Bilateral foot ulcers drained serosanguinous fluid.", + "Cultures from the foot ulcers were positive for Enterococcus faecalis and Serratia.", + "Four sets of blood cultures remained negative.", + "MRI of the right foot showed metatarsal stress reaction versus early osteomyelitis.", + "Skin biopsy showed extensively necrotic fibroadipose tissue with acute inflammation.", + "Right lateral oral tongue ulcerative lesion biopsy showed predominantly hyperplastic squamous mucosa showing an ulcer site and abscess with fragments of necrotic squamous epithelium associated with cytologic atypia and colonies of bacteria.", + "The patient later developed right eye conjunctivitis.", + "Appropriate consultations with nephrology, pulmonology, and podiatry were obtained.", + "The antinuclear antibody (ANA) was negative.", + "Rheumatoid factor was with 1 : 640 titer.", + "C-ANCA (antineutrophil cytoplasmic antibody) was positive with 1 : 1280 titer.", + "The diagnosis of Wegner's granulomatosis was made.", + "He was started on rituximab 375 mg weekly.", + "He was started on methylprednisolone 250 mg every 6 hours for 3 days.", + "He later had a renal biopsy which showed granulomatosis with polyangiitis and mild interstitial fibrosis with tubular atrophy and a pauci immune crescentic glomerulonephritis.", + "He underwent debridement of his bilateral foot ulcers.", + "He received an additional dose of rituximab.", + "Following the second dose of rituximab, the oral ulcers improved.", + "He was noted to have blood streaked sputum.", + "Repeat CT chest was ordered and was consistent with diffuse alveolar hemorrhage.", + "He left prior to pulmonology evaluation.", + "He was called and encouraged to come back to the hospital but declined.", + "He ultimately sought further medical attention at another hospital.", + "He was admitted to the intensive care unit (ICU).", + "Nephrology was consulted and began plasmapheresis for a total of 7 treatments.", + "He was given a one-time dose of cyclophosphamide on initial presentation.", + "He was given an additional dose of rituximab following plasmapheresis.", + "He gradually improved and was discharged home 8 days after admission." + ], + "summary": "A 39-year-old black male presented to the hospital with oral and skin ulcers and was diagnosed with GPA based on the biopsies of both cutaneous lesions and kidney. He was started on rituximab with minimal improvement. Later he was admitted to the ICU and had plasmapheresis, and he gradually improved and was discharged home 8 days after admission.", + "summary_subclaims": [ + "The patient is a 39-year-old black male.", + "The patient presented with oral and skin ulcers.", + "The patient was diagnosed with GPA based on biopsies of both cutaneous lesions and kidney.", + "The patient was started on rituximab.", + "The patient had minimal improvement with rituximab.", + "The patient was admitted to the ICU.", + "The patient had plasmapheresis.", + "The patient gradually improved.", + "The patient was discharged home 8 days after admission." + ] + }, + { + "id": "multiclinsum_test_2948_en.txt", + "fulltext": "The patient was a 69-year-old man referred to our department after a simple computed tomography (CT) scan revealed enlarged gastric lesser curvature lymph nodes and a mass lesion in the pancreatic head. A subsequent contrast-enhanced CT revealed wall thickening of the lower gastric body, multiple enlarged gastric lesser curvature lymph nodes, and an anterior superior common hepatic artery (CHA) lymph node involving the pancreatic head and CHA . Tumor markers showed elevated levels of carcinoembryonic antigen (CEA, 33.9 ng/ml) and carbohydrate antigen (CA19-9, 108.1 U/ml). Esophagogastroduodenoscopy (EGD) revealed a tumor with an ulcer on the lesser curvature of the lower body of the stomach . Histopathological examination of the biopsied specimen indicated moderately differentiated adenocarcinoma, which was HER2-negative, and MSI-high status was determined using an MSI test kit (FALCO biosystems, Kyoto, Japan). Based on these findings, a diagnosis of advanced gastric cancer of stage III (T3N2M0) was made (8th edition of the Union for International Cancer Control). The anterior superior lymph node of the CHA was considered unresectable due to its involvement with the pancreatic head and CHA, and chemotherapy was decided as the treatment plan. The patient had difficulty swallowing at the time of examination; therefore, he was treated with mFOLFOX6 therapy (leucovorin 200 mg/m2, oxaliplatin 85 mg/m2 in a 2-h infusion, bolus fluorouracil 400 mg/m2 on day 1, and a 46-h infusion of fluorouracil 2400 mg/m2 every 2 weeks). At the end of three courses, tumor markers were elevated (CEA, 35.3 ng/ml and CA19-9, 136.9 U/ml), and contrast-enhanced CT showed enlargement of the primary tumor, and lymph node of the lesser curvature and anterior superior CHA .\nThe patient was diagnosed with the progressive disease based on the Response Evaluation Criteria in Solid Tumors (RECIST) and was treated with ramucirumab plus paclitaxel as a second-line therapy. After a 4-week course of paclitaxel (80 mg/m2) intravenously on days 1, 8, and 15, with ramucirumab (8 mg/kg) intravenously on days 1 and 15, the patient developed a grade 3 fatigue, which necessitated a change of the therapeutic drugs. Hence, his second-line therapy was switched to pembrolizumab monotherapy (pembrolizumab 200 mg once every 3 weeks). Tumor markers decreased markedly to CEA 7.2 ng/ml and CA19-9 35.9 U/ml at the end of three courses, and contrast-enhanced CT showed that both the primary tumor and the lesser curvature lymph node had shrunk, and the anterior superior lymph nodes of the CHA showed improved findings of invasion into the pancreatic head and CHA . A diagnosis of partial response was made based on RECIST guidelines. EGD revealed a tumor in the primary lesion that almost disappeared after six courses of pembrolizumab . Tumor markers remained low with CEA 7.5 mg/ml and CA19-9 33.7 U/ml , and contrast-enhanced CT revealed that R0 resection was possible; therefore, a distal gastrectomy with D2 lymph node dissection was performed. Surgical findings showed no obvious liver metastasis or peritoneal dissemination, and the cytology was negative. The anterior superior lymph node of the CHA was safely dissected after resection of the primary tumor, as intraoperative ultrasonography confirmed that there was no invasion into the pancreatic head or CHA . Gastrectomy specimens showed an ulcerated scar on gross examination . The histopathological findings showed that the superficial layer of the gastric mucosa was covered by regenerating epithelium and that there was only mucus accumulation from the submucosa to the serosa with no residual tumor cells that could be considered viable, determined to be histological grade 3 . The histopathological findings of the resected lymph node revealed mucus accumulation only in the anterior superior lymph node of the CHA, which was diagnosed as metastasis of adenocarcinoma, although there were no residual tumor cells that could be classified as viable . The patient was discharged from the hospital 23 days after surgery without complications.\nThe patient commenced 6 months of adjuvant chemotherapy with pembrolizumab 3 months after surgery. Twenty months after surgery, the patient is alive and recurrence-free.", + "fulltext_subclaims": [ + "The patient was a 69-year-old man.", + "A simple computed tomography (CT) scan revealed enlarged gastric lesser curvature lymph nodes.", + "A simple CT scan revealed a mass lesion in the pancreatic head.", + "A contrast-enhanced CT revealed wall thickening of the lower gastric body.", + "A contrast-enhanced CT revealed multiple enlarged gastric lesser curvature lymph nodes.", + "A contrast-enhanced CT revealed an anterior superior common hepatic artery (CHA) lymph node involving the pancreatic head and CHA.", + "Tumor markers showed elevated levels of carcinoembryonic antigen (CEA, 33.9 ng/ml).", + "Tumor markers showed elevated levels of carbohydrate antigen (CA19-9, 108.1 U/ml).", + "Esophagogastroduodenoscopy (EGD) revealed a tumor with an ulcer on the lesser curvature of the lower body of the stomach.", + "Histopathological examination of the biopsied specimen indicated moderately differentiated adenocarcinoma.", + "The tumor was HER2-negative.", + "MSI-high status was determined using an MSI test kit (FALCO biosystems, Kyoto, Japan).", + "A diagnosis of advanced gastric cancer of stage III (T3N2M0) was made.", + "The anterior superior lymph node of the CHA was considered unresectable due to its involvement with the pancreatic head and CHA.", + "Chemotherapy was decided as the treatment plan.", + "The patient had difficulty swallowing at the time of examination.", + "He was treated with mFOLFOX6 therapy.", + "At the end of three courses, tumor markers were elevated (CEA, 35.3 ng/ml and CA19-9, 136.9 U/ml).", + "Contrast-enhanced CT showed enlargement of the primary tumor.", + "Contrast-enhanced CT showed enlargement of the lymph node of the lesser curvature.", + "Contrast-enhanced CT showed enlargement of the anterior superior CHA lymph node.", + "The patient was diagnosed with progressive disease based on the Response Evaluation Criteria in Solid Tumors (RECIST).", + "The patient was treated with ramucirumab plus paclitaxel as a second-line therapy.", + "After a 4-week course of paclitaxel (80 mg/m2) intravenously on days 1, 8, and 15, with ramucirumab (8 mg/kg) intravenously on days 1 and 15, the patient developed grade 3 fatigue.", + "His second-line therapy was switched to pembrolizumab monotherapy.", + "Tumor markers decreased markedly to CEA 7.2 ng/ml and CA19-9 35.9 U/ml at the end of three courses.", + "Contrast-enhanced CT showed that both the primary tumor and the lesser curvature lymph node had shrunk.", + "The anterior superior lymph nodes of the CHA showed improved findings of invasion into the pancreatic head and CHA.", + "A diagnosis of partial response was made based on RECIST guidelines.", + "EGD revealed a tumor in the primary lesion that almost disappeared after six courses of pembrolizumab.", + "Tumor markers remained low with CEA 7.5 ng/ml and CA19-9 33.7 U/ml.", + "Contrast-enhanced CT revealed that R0 resection was possible.", + "A distal gastrectomy with D2 lymph node dissection was performed.", + "Surgical findings showed no obvious liver metastasis.", + "Surgical findings showed no peritoneal dissemination.", + "The cytology was negative.", + "The anterior superior lymph node of the CHA was safely dissected after resection of the primary tumor.", + "Intraoperative ultrasonography confirmed that there was no invasion into the pancreatic head or CHA.", + "Gastrectomy specimens showed an ulcerated scar on gross examination.", + "The histopathological findings showed that the superficial layer of the gastric mucosa was covered by regenerating epithelium.", + "There was only mucus accumulation from the submucosa to the serosa with no residual tumor cells that could be considered viable.", + "The histopathological findings were determined to be histological grade 3.", + "The histopathological findings of the resected lymph node revealed mucus accumulation only in the anterior superior lymph node of the CHA.", + "The anterior superior lymph node of the CHA was diagnosed as metastasis of adenocarcinoma.", + "There were no residual tumor cells that could be classified as viable.", + "The patient was discharged from the hospital 23 days after surgery without complications.", + "The patient commenced 6 months of adjuvant chemotherapy with pembrolizumab 3 months after surgery.", + "Twenty months after surgery, the patient is alive and recurrence-free." + ], + "summary": "A 69-year-old man was diagnosed with stage III gastric cancer (T3N2M0) based on contrast-enhanced computed tomography, which revealed a neoplastic lesion and enlarged perigastric lymph nodes in the gastric lesser curvature. The anterior superior lymph node of the common hepatic artery (CHA) was determined to be unresectable due to invasion of the pancreatic head and CHA. Histopathologically, the biopsied tissue showed moderately differentiated adenocarcinoma, then determined to be MSI-high. After three courses of mFOLFOX6 therapy, the patient was diagnosed with progressive disease. Since one course of paclitaxel plus ramucirumab therapy caused grade 3 fatigue, his second-line therapy was switched to pembrolizumab monotherapy. After three courses, the primary tumor and perigastric lymph nodes had shrunk, and it was determined as a partial response. The anterior superior lymph node of the CHA became resectable based on the improvement of infiltration of the pancreatic head and CHA due to shrinkage of the lymph node. Tumor markers remained low; hence, distal gastrectomy plus D2 lymphadenectomy was performed at the end of six courses. Anterior superior lymph node of the CHA was confirmed by intraoperative ultrasonography, and the resection was completed safely. The gross examination of the resected specimen revealed an ulcer scar at the primary tumor site. The histopathological examination showed no viable tumor cell remnants in the primary tumor, which had a grade 3 histological response, and resection margins were negative. The lymph nodes showed mucus retention only in the anterior superior lymph node of the CHA, indicating the presence of metastasis, but no viable tumor cells remained. The patient commenced 6 months of adjuvant pembrolizumab monotherapy 3 months after surgery. Twenty months after surgery, there was no evidence of recurrence.", + "summary_subclaims": [ + "The patient was a 69-year-old man.", + "He was diagnosed with stage III gastric cancer (T3N2M0).", + "The diagnosis was based on contrast-enhanced computed tomography.", + "The imaging showed a neoplastic lesion in the gastric lesser curvature.", + "The imaging showed enlarged perigastric lymph nodes.", + "The anterior superior lymph node of the common hepatic artery was determined to be unresectable.", + "The unresectability was due to invasion of the pancreatic head and common hepatic artery.", + "Histopathologically, the biopsied tissue showed moderately differentiated adenocarcinoma.", + "The tumor was determined to be MSI-high.", + "After three courses of mFOLFOX6 therapy, the patient was diagnosed with progressive disease.", + "One course of paclitaxel plus ramucirumab therapy caused grade 3 fatigue.", + "The second-line therapy was switched to pembrolizumab monotherapy.", + "After three courses of pembrolizumab, the primary tumor and perigastric lymph nodes had shrunk.", + "It was determined as a partial response.", + "The anterior superior lymph node of the CHA became resectable.", + "The resectability was based on the improvement of infiltration of the pancreatic head and CHA.", + "The improvement was due to shrinkage of the lymph node.", + "Tumor markers remained low.", + "Distal gastrectomy plus D2 lymphadenectomy was performed at the end of six courses.", + "The anterior superior lymph node of the CHA was confirmed by intraoperative ultrasonography.", + "The resection was completed safely.", + "The gross examination revealed an ulcer scar at the primary tumor site.", + "The histopathological examination showed no viable tumor cell remnants in the primary tumor.", + "The primary tumor had a grade 3 histological response.", + "The resection margins were negative.", + "The lymph nodes showed mucus retention only in the anterior superior lymph node of the CHA.", + "The mucus retention indicated the presence of metastasis.", + "No viable tumor cells remained in the lymph nodes.", + "The patient commenced 6 months of adjuvant pembrolizumab monotherapy.", + "The adjuvant therapy started 3 months after surgery.", + "Twenty months after surgery, there was no evidence of recurrence." + ] + }, + { + "id": "multiclinsum_test_2167_en.txt", + "fulltext": "We report a case of a 46 year-old female patient, with a cataract on her right eye with a central corneal leukoma. Patient reported during one of the examination prior to the surgery that when she was 6 years old, patient had an eye injury with corn leaf. At the age of 10 year patient reported that she had another injury of the same eye with a glass. Patient also said that she wasn’t seeing quite well after that. Patient reported that she wasn’t under any medical therapy or that she was wearing contact lenses or glasses. Three years ago patient had a transplantation of amniotic membrane due ulcer on the same eye in different hospital then ours. Now she was admitted to hospital for a triple surgical procedure.\nOcular examination on admission day to hospital revealed patients best uncorrected distance visual acuity (UDVA) to be light perception on patient RE (right eye) and 1.0 with out any correction LE (left eye). Results on patient slit lamp revealed on the right eye corneal edema with a central leukoma, with a complicated cataract and partial seclusion of pupil and no pathological findings on left eye. Patients pupil size were equals. Patient ocular movements were normal in all gazes. Intraocular pressure (IOP) was also normal. Examination of the left eye was normal. The vitreous was quiet and retinal vessels were of normal caliber. Details on the founds of right eye were impossible to asses due the changes in anterior segment. We performed ultrasound examination and we performed intraocular lens calculation. Due pathological changes on the right eye we were unable to accurately measure the true corneal power values so we performed intraocular lens calculation for the left eye. Before the surgical procedure patient was treated with Prednisone 80 mg intravenous and as well systematic antibiotics with local corticosteroids and antibiotics . The pupil was dilated preoperatively with tropicamide 1% eye drops. Before surgical procedure a good quality donor cornea was retrieved from a cadaveric transplantation.\nAfter informed consent was obtained, operation was performed in general anesthesia. After excision of the opaque recipient cornea, a cataract was seen. Before the staining of anterior capsule, surgeon performed excision of pupillary membrane and synechiolysis. The anterior capsule was initially stained with VisionBlue (Dutch Ophthalmic, USA). Cataract extraction with IOL implantation (open sky) was performed under operating microscopes Operative Microscope OPMI Visu 150 Carl Zeiss Meditec Inc, Dublin, using Alcon Infiniti® Vision System Fort Worth Texas USA, sodium hyaluronate (Provisc® Alcon) as viscoelastic and surgical instruments Alcon and Geuder AG Heidelberg Germany. After placing four cardinal sutures, the donor button was fixed to the recipient using separate 10/0 nylon sutures. . Follow-up examinations were performed on days 1, 3, 7, and 30 days. Thirty days after surgery her UDVA was 0,5. The patients received topical antibiotic and corticosteroids. Postoperatively, if keratometric astigmatism exceeded 4.0 D, tension of the running sutures was adjusted after 1 to 2 months, and selective removal of separate sutures began after 2 months. Currently patients visual acuity is 0.6 without correction.", + "fulltext_subclaims": [ + "The patient is a 46 year-old female.", + "The patient has a cataract on her right eye.", + "The patient has a central corneal leukoma.", + "The patient reported an eye injury with corn leaf when she was 6 years old.", + "The patient reported another injury of the same eye with a glass at the age of 10.", + "The patient said she wasn’t seeing quite well after the injury at age 10.", + "The patient reported that she wasn’t under any medical therapy.", + "The patient reported that she wasn’t wearing contact lenses.", + "The patient reported that she wasn’t wearing glasses.", + "Three years ago, the patient had a transplantation of amniotic membrane due to an ulcer on the same eye.", + "The amniotic membrane transplantation was performed in a different hospital.", + "The patient was admitted to hospital for a triple surgical procedure.", + "On the day of admission, the patient’s best uncorrected distance visual acuity (UDVA) was light perception in the right eye.", + "On the day of admission, the patient’s best uncorrected distance visual acuity (UDVA) was 1.0 in the left eye.", + "Slit lamp examination revealed corneal edema with a central leukoma in the right eye.", + "Slit lamp examination revealed a complicated cataract in the right eye.", + "Slit lamp examination revealed partial seclusion of the pupil in the right eye.", + "The left eye showed no pathological findings.", + "The patient’s pupil size was equal.", + "The patient’s ocular movements were normal in all gazes.", + "The intraocular pressure (IOP) was normal.", + "The vitreous was quiet.", + "The retinal vessels were of normal caliber.", + "Details of the fundus of the right eye were impossible to assess due to changes in the anterior segment.", + "An ultrasound examination was performed.", + "Intraocular lens calculation was performed.", + "Due to pathological changes on the right eye, accurate measurement of true corneal power values was not possible.", + "Intraocular lens calculation was performed for the left eye.", + "Before the surgical procedure, the patient was treated with Prednisone 80 mg intravenous.", + "Before the surgical procedure, the patient was treated with systematic antibiotics.", + "Before the surgical procedure, the patient was treated with local corticosteroids.", + "Before the surgical procedure, the patient was treated with local antibiotics.", + "The pupil was dilated preoperatively with tropicamide 1% eye drops.", + "A good quality donor cornea was retrieved from a cadaveric transplantation.", + "Informed consent was obtained.", + "The operation was performed in general anesthesia.", + "The anterior capsule was initially stained with VisionBlue.", + "Cataract extraction with IOL implantation (open sky) was performed.", + "The operation was performed under operating microscopes.", + "The operation was performed using the Alcon Infiniti® Vision System.", + "Sodium hyaluronate (Provisc® Alcon) was used as viscoelastic.", + "Four cardinal sutures were placed.", + "The donor button was fixed to the recipient using separate 10/0 nylon sutures.", + "Follow-up examinations were performed on days 1, 3, 7, and 30.", + "Thirty days after surgery, the patient’s UDVA was 0.5.", + "The patient received topical antibiotic and corticosteroids.", + "Postoperatively, if keratometric astigmatism exceeded 4.0 D, tension of the running sutures was adjusted after 1 to 2 months.", + "Selective removal of separate sutures began after 2 months.", + "The patient’s current visual acuity is 0.6 without correction." + ], + "summary": "In this paper we report a case of a 46 year-old female patient, with a cataract on her right eye with a central corneal leukoma. She reported that when she was 6 years old, she had an eye injury with corn leaf. At the age of 10 year she reported that she had another injury of the same eye with a glass. She reported that she wasn't seeing quite good after that. Three years ago she had a transplantation of amniotic membrane due ulcer on the same eye. She reported also that even after this procedure she wasn't seeing quite good. Now she was admitted to hospital for a triple surgical procedure. At that moment patient has been ophthalmological examined (visual acuity testing, biomicroscopy, tonometry, ultrasound of both eyes with biometry and ophthalmoscopy). At the day of admission to the hospital on slit lamp we found central corneal leukoma, occlusion of pupil and complicated cataract. Before surgery her Uncorrected distance visual acuity (UDVA) on her left eye was light perception. A combined procedure of penetrating keratoplasty (PKP), open-sky cataract extraction, and intraocular lens (IOL) implantation was planned. Thirty days after surgery her visual acuity was 0,5 without correction. It is concluded that cataract surgery in patients after keratoplasty is more complicated.", + "summary_subclaims": [ + "The patient is a 46 year-old female.", + "The patient has a cataract on her right eye.", + "The patient has a central corneal leukoma.", + "When she was 6 years old, she had an eye injury with corn leaf.", + "At the age of 10 years, she had another injury of the same eye with a glass.", + "Three years ago, she had a transplantation of amniotic membrane due to ulcer on the same eye.", + "She was admitted to hospital for a triple surgical procedure.", + "At the day of admission to the hospital, slit lamp examination found central corneal leukoma.", + "At the day of admission to the hospital, slit lamp examination found occlusion of pupil.", + "At the day of admission to the hospital, slit lamp examination found complicated cataract.", + "Before surgery, her Uncorrected distance visual acuity (UDVA) on her left eye was light perception.", + "A combined procedure of penetrating keratoplasty (PKP), open-sky cataract extraction, and intraocular lens (IOL) implantation was planned.", + "Thirty days after surgery, her visual acuity was 0,5 without correction.", + "It is concluded that cataract surgery in patients after keratoplasty is more complicated." + ] + }, + { + "id": "multiclinsum_test_3235_en.txt", + "fulltext": "A 64-year-old woman was examined at a local clinic because of reduced vision in her right eye of three days duration. Her best-corrected visual acuity (BCVA) in the right eye was hand motion at 30 cm and she had no history of trauma. Her intraocular pressure (IOP) was 12 mmHg and the axial length was 23.52 mm in the right eye. Ophthalmoscopy revealed a dense vitreous hemorrhage (VH), and she underwent successful pars plana vitrectomy (PPV) combined with cataract surgery the following day. A retinal tear that caused the hemorrhage was detected during vitrectomy and was treated with photocoagulation and gas tamponade. The decimal BCVA in the right eye had improved to 1.2 one week later.\n\nEight months later, a MH developed in the vitrectomized right eye. OCT showed cyst-like changes in the retina and a thin hyperreflective membrane on the retinal surface. The patient complained of distorted vision even though her decimal BCVA was 1.2. PPV was planned, but was canceled 2 weeks later due to the spontaneous closure of the MH.\n\nFour months later, OCT showed a slight elevation of the ellipsoid zone and the interdigitation zone at the fovea but the patient reported that the distorted vision of her right eye was not present. Eleven months after the spontaneous closure of the MH, a LMH with EP was detected in the vitrectomized right eye. Nevertheless, her decimal BCVA was still 1.2. Two months later, the BCVA had decreased to 0.7, and OCT revealed a recurrence of the FTMH with cyst-like changes in the retina.\n\nA second PPV combined with the insertion of the peeled internal limiting membrane (ILM) flap into the MH was performed. The yellowish tissue was not large and was able to be inserted into the MH without trimming. The retina was then tamponaded with 20% SF6 gas. The MH was closed, and the decimal BCVA was restored to 1.2. No recurrence was found at the last visit 5 months after the second vitrectomy.", + "fulltext_subclaims": [ + "A 64-year-old woman was examined at a local clinic because of reduced vision in her right eye of three days duration.", + "Her best-corrected visual acuity (BCVA) in the right eye was hand motion at 30 cm.", + "She had no history of trauma.", + "Her intraocular pressure (IOP) was 12 mmHg.", + "The axial length was 23.52 mm in the right eye.", + "Ophthalmoscopy revealed a dense vitreous hemorrhage (VH).", + "She underwent successful pars plana vitrectomy (PPV) combined with cataract surgery the following day.", + "A retinal tear that caused the hemorrhage was detected during vitrectomy.", + "The retinal tear was treated with photocoagulation and gas tamponade.", + "The decimal BCVA in the right eye had improved to 1.2 one week later.", + "Eight months later, a macular hole (MH) developed in the vitrectomized right eye.", + "OCT showed cyst-like changes in the retina.", + "OCT showed a thin hyperreflective membrane on the retinal surface.", + "The patient complained of distorted vision.", + "Her decimal BCVA was 1.2.", + "PPV was planned.", + "PPV was canceled 2 weeks later due to the spontaneous closure of the MH.", + "Four months later, OCT showed a slight elevation of the ellipsoid zone at the fovea.", + "The patient reported that the distorted vision of her right eye was not present.", + "Eleven months after the spontaneous closure of the MH, a lamellar macular hole (LMH) with epiretinal membrane (EP) was detected in the vitrectomized right eye.", + "Her decimal BCVA was still 1.2.", + "Two months later, the BCVA had decreased to 0.7.", + "OCT revealed a recurrence of the full-thickness macular hole (FTMH) with cyst-like changes in the retina.", + "A second PPV combined with the insertion of the peeled internal limiting membrane (ILM) flap into the MH was performed.", + "The yellowish tissue was not large.", + "The yellowish tissue was able to be inserted into the MH without trimming.", + "The retina was then tamponaded with 20% SF6 gas.", + "The MH was closed.", + "The decimal BCVA was restored to 1.2.", + "No recurrence was found at the last visit 5 months after the second vitrectomy." + ], + "summary": "Patient: A 64-year-old woman visited an eye clinic with vision reduction in her right eye of 3 days duration. A VH was detected in the right eye and pars plana vitrectomy (PPV) was performed. A retinal tear was detected which was the origin of the VH. The vision was restored to a decimal visual acuity of 1.2. Eight months later, the patient noticed that her vision was distorted and was referred to our hospital.\n\nDiagnosis: Optical coherence tomographic (OCT) images showed a thin epiretinal membrane on the macula, cystoid changes in the macular area, and a full-thickness MH.\n\nInterventions: The MH closed spontaneously in two weeks, however a lamellar MH with an epiretinal proliferation (EP) developed 11 months later. Two months later, OCT showed cyst-like changes in the retina and a full-thickness MH. A second PPV was performed with the insertion of the ILM flap and EP into the MH to close the MH. Her visual acuity improved, and distorted vision was not present.", + "summary_subclaims": [ + "The patient is a 64-year-old woman.", + "She visited an eye clinic with vision reduction in her right eye of 3 days duration.", + "A vitreous hemorrhage (VH) was detected in the right eye.", + "A pars plana vitrectomy (PPV) was performed.", + "A retinal tear was detected which was the origin of the VH.", + "The vision was restored to a decimal visual acuity of 1.2.", + "Eight months later, the patient noticed that her vision was distorted.", + "Optical coherence tomographic (OCT) images showed a thin epiretinal membrane on the macula.", + "OCT images showed cystoid changes in the macular area.", + "OCT images showed a full-thickness macular hole (MH).", + "The MH closed spontaneously in two weeks.", + "A lamellar MH with an epiretinal proliferation (EP) developed 11 months later.", + "Two months later, OCT showed cyst-like changes in the retina.", + "Two months later, OCT showed a full-thickness MH.", + "A second PPV was performed with the insertion of the ILM flap and EP into the MH to close the MH.", + "Her visual acuity improved.", + "Distorted vision was not present." + ] + }, + { + "id": "multiclinsum_test_3253_en.txt", + "fulltext": "A 25-year old primigravid woman came to the University of Gondar Hospital fetal medicine outpatient clinic after she was referred for a fetal intraabdominal cystic mass seen on routine ultrasound scanning for a biophysical profile. Her medical and obstetric history was unremarkable. She had antenatal care and obstetric ultrasound was done at the fifth and seventh months and she was told that her fetus is in good condition. At 39 weeks of gestation, she came to us referred for advanced ultrasound scanning and we found an 80 × 60 × 40 mm retro vesical, oval, midline pelvic cystic mass with internal echoes. There was minimal calyceal dilation of both kidneys but the urinary bladder was seen and it was having a normal outline and volume. There was no abnormality in the anatomic scanning of the other systems. The amniotic fluid volume was normal and the biophysical profile was reassuring. The woman was counseled and induction of labor was done with oxytocin and she gave birth to a 3200-g female alive newborn. Immediately upon delivery the newborn was examined and there was an imperforate hymen that bulged forwards and the abdomen was distended, otherwise, the perineum, anus, and urethral orifice were normal. The baby passed urine and meconium. Grossly there was no dysmorphic feature in the newborn. Abdominopelvic ultrasound was done and showed a 100 × 70 × 40 mm oval cystic pelvic mass behind the bladder and there was also mild calyceal dilation of both kidneys, but there was no other abnormality. A renal function test was done for the newborn and found to be normal. Hymenectomy was done on the second day of delivery and around 200 mL of milky fluid was removed. The abdominal distention was relieved, and the renal calyceal dilation disappeared. Abdominal ultrasound after the procedure showed an empty uterus and vagina and the newborn was discharged improved. The newborn came back after 2 weeks for a checkup and she was doing well with normal hymen remnants and vaginal orifice.", + "fulltext_subclaims": [ + "The patient is a 25-year-old primigravid woman.", + "She was referred for a fetal intraabdominal cystic mass seen on routine ultrasound scanning.", + "Her medical and obstetric history was unremarkable.", + "She had antenatal care and obstetric ultrasound was done at the fifth and seventh months.", + "She was told that her fetus is in good condition.", + "At 39 weeks of gestation, she came to the hospital referred for advanced ultrasound scanning.", + "An 80 × 60 × 40 mm retro vesical, oval, midline pelvic cystic mass with internal echoes was found.", + "There was minimal calyceal dilation of both kidneys.", + "The urinary bladder was seen and it was having a normal outline and volume.", + "There was no abnormality in the anatomic scanning of the other systems.", + "The amniotic fluid volume was normal.", + "The biophysical profile was reassuring.", + "The woman was counseled and induction of labor was done with oxytocin.", + "She gave birth to a 3200-g female alive newborn.", + "Immediately upon delivery the newborn was examined.", + "There was an imperforate hymen that bulged forwards.", + "The abdomen was distended.", + "The perineum, anus, and urethral orifice were normal.", + "The baby passed urine and meconium.", + "Grossly there was no dysmorphic feature in the newborn.", + "Abdominopelvic ultrasound showed a 100 × 70 × 40 mm oval cystic pelvic mass behind the bladder.", + "There was also mild calyceal dilation of both kidneys.", + "A renal function test was done for the newborn and found to be normal.", + "Hymenectomy was done on the second day of delivery.", + "Around 200 mL of milky fluid was removed.", + "The abdominal distention was relieved.", + "The renal calyceal dilation disappeared.", + "Abdominal ultrasound after the procedure showed an empty uterus and vagina.", + "The newborn was discharged improved.", + "The newborn came back after 2 weeks for a checkup.", + "She was doing well with normal hymen remnants and vaginal orifice." + ], + "summary": "Here, we present a case diagnosed with congenital hydrometrocolpos at 39 weeks of gestation during routine third-trimester ultrasound scanning. The newborn was delivered vaginally and huge hydrometrocolpos secondary to imperforate hymen was diagnosed postnatally, and a hymenectomy was done and the newborn was discharged and improved from the hospital.", + "summary_subclaims": [ + "The case was diagnosed with congenital hydrometrocolpos at 39 weeks of gestation during routine third-trimester ultrasound scanning.", + "The newborn was delivered vaginally.", + "Huge hydrometrocolpos secondary to imperforate hymen was diagnosed postnatally.", + "A hymenectomy was done.", + "The newborn was discharged and improved from the hospital." + ] + }, + { + "id": "multiclinsum_test_2976_en.txt", + "fulltext": "A 62-year-old male with hypertension and hyperlipidaemia presented to an urgent care clinic with 7 days of dizziness, fatigue, nausea, and vomiting. He was transported to the emergency department, evaluated, and discharged home. Approximately 4 days later, emergency medical services were called after the patient experienced syncope. Electrocardiogram (ECG) obtained en route reported anterior ST-segment elevations. Before arrival at the hospital he developed ventricular fibrillation. Cardiac defibrillation was successful and endotracheal intubation was performed. Upon arrival at the emergency department, ventricular fibrillation recurred, and resuscitative efforts restored sinus rhythm and spontaneous circulation. Following return of spontaneous circulation, exam was notable for heart rate of 77 b.p.m., a regular rhythm, and hypotension (86 mmHg/48 mmHg). There were no appreciable murmurs. There was no lower extremity oedema. The extremities were cool to touch. On pulmonary exam, he required mechanical ventilation with a rate of 28, tidal volume 500 mL, FiO2 100%, and positive end-expiratory pressure of 8 cmH2O. Breath sounds were present bilaterally. The subsequent ECG showed wide complex rhythm consistent with slow ventricular tachycardia with right bundle branch block morphology and left axis deviation. .\nGiven the report of ST elevations prior to ventricular fibrillation, along with the ECG at presentation, there was high suspicion for acute coronary syndrome. He received aspirin, ticagrelor, and heparin for a presumed ST-segment elevation myocardial infarction. Epinephrine infusion was started due to bradycardia with hypotension. He was emergently taken to the catheterization lab, but coronary angiography did not reveal coronary stenosis. Right heart catheterization revealed elevated right-sided filling pressures with a right atrial pressure of 22 mmHg, pulmonary artery pressure 61/28 (39) mmHg, pulmonary capillary wedge pressure 15 mmHg, and Fick cardiac index 2.6 L/min/m2. Due to the unclear nature of his presentation, point-of-care echocardiogram was performed, and demonstrated a dilated right ventricle with severely reduced function. Based on point-of-care echocardiogram findings, there was concern for pulmonary embolism. Immediate pulmonary angiography was performed and revealed large, bilateral pulmonary emboli (, Video ). EkoSonic™ endovascular thrombolysis catheters were advanced into both main pulmonary arteries and 5 mg of tissue plasminogen activator was delivered through each catheter, followed by 2 mg/catheter/h for 2 h, then 1 mg/catheter/h for 16 h. Infusion was guided by fibrinogen monitoring as per institutional protocol.\nUpper and lower extremity Doppler ultrasounds were obtained but showed no evidence of venous thrombosis. Formal transthoracic echocardiogram confirmed depressed right ventricular function (, Video ). Computed tomography (CT) of the chest showed bilateral peripheral ground-glass opacities with wedge-shaped opacities in the right lung . These were thought to represent pulmonary infarctions, but, given refractory hypotension requiring vasopressors, he was started on broad-spectrum antibiotics for pneumonia. A viral respiratory panel was negative, but tracheal aspirate culture was positive for methicillin-resistant Staphylococcus aureus. Following completion of catheter-directed thrombolysis, repeat ECG showed sinus rhythm with first-degree atrioventricular (AV) block, left axis deviation, incomplete right bundle branch block, and prolonged QTc interval (498 ms) . Over the following 4 days, he developed anaemia, and CT of the chest, abdomen, and pelvis showed a mediastinal haematoma and persistent ground-glass opacities . Given his radiographic findings, and growing prevalence of COVID-19, he was tested for SARS-CoV-2 and found to be positive. He was transferred to a COVID-19-dedicated intensive care unit where he was placed under enhanced contact precautions and received supportive care. He was extubated 4 days later. Following extubation, he did well. He was admitted to an inpatient rehabilitation facility and discharged home on lifelong apixaban 5 mg twice daily. At 1 month follow-up, he described mild exertional dyspnoea that was improving. Transthoracic echocardiogram at that visit noted improvement of right ventricular dilation and systolic function (, Video ).", + "fulltext_subclaims": [ + "The patient is a 62-year-old male.", + "The patient has hypertension.", + "The patient has hyperlipidaemia.", + "The patient presented with 7 days of dizziness.", + "The patient presented with 7 days of fatigue.", + "The patient presented with 7 days of nausea.", + "The patient presented with 7 days of vomiting.", + "The patient was transported to the emergency department.", + "The patient was discharged home after initial evaluation.", + "Approximately 4 days after discharge, emergency medical services were called after the patient experienced syncope.", + "An ECG obtained en route reported anterior ST-segment elevations.", + "Before arrival at the hospital, the patient developed ventricular fibrillation.", + "Cardiac defibrillation was successful.", + "Endotracheal intubation was performed.", + "Upon arrival at the emergency department, ventricular fibrillation recurred.", + "Resuscitative efforts restored sinus rhythm and spontaneous circulation.", + "On arrival, the patient's heart rate was 77 b.p.m.", + "On arrival, the patient had a regular rhythm.", + "On arrival, the patient had hypotension (86 mmHg/48 mmHg).", + "There were no appreciable murmurs.", + "There was no lower extremity oedema.", + "The extremities were cool to touch.", + "The patient required mechanical ventilation with a rate of 28.", + "The patient required mechanical ventilation with a tidal volume of 500 mL.", + "The patient required mechanical ventilation with FiO2 100%.", + "The patient required mechanical ventilation with positive end-expiratory pressure of 8 cmH2O.", + "Breath sounds were present bilaterally.", + "The subsequent ECG showed wide complex rhythm consistent with slow ventricular tachycardia.", + "The subsequent ECG showed right bundle branch block morphology.", + "The subsequent ECG showed left axis deviation.", + "There was high suspicion for acute coronary syndrome.", + "The patient received aspirin.", + "The patient received ticagrelor.", + "The patient received heparin.", + "The patient was presumed to have an ST-segment elevation myocardial infarction.", + "Epinephrine infusion was started due to bradycardia with hypotension.", + "The patient was emergently taken to the catheterization lab.", + "Coronary angiography did not reveal coronary stenosis.", + "Right heart catheterization revealed elevated right-sided filling pressures.", + "Right atrial pressure was 22 mmHg.", + "Pulmonary artery pressure was 61/28 (39) mmHg.", + "Pulmonary capillary wedge pressure was 15 mmHg.", + "Fick cardiac index was 2.6 L/min/m2.", + "A point-of-care echocardiogram was performed.", + "The point-of-care echocardiogram demonstrated a dilated right ventricle.", + "The point-of-care echocardiogram demonstrated severely reduced right ventricular function.", + "There was concern for pulmonary embolism.", + "Immediate pulmonary angiography was performed.", + "Pulmonary angiography revealed large, bilateral pulmonary emboli.", + "EkoSonic™ endovascular thrombolysis catheters were advanced into both main pulmonary arteries.", + "5 mg of tissue plasminogen activator was delivered through each catheter.", + "2 mg/catheter/h of tissue plasminogen activator was delivered for 2 h.", + "1 mg/catheter/h of tissue plasminogen activator was delivered for 16 h.", + "Infusion was guided by fibrinogen monitoring.", + "Upper and lower extremity Doppler ultrasounds showed no evidence of venous thrombosis.", + "Formal transthoracic echocardiogram confirmed depressed right ventricular function.", + "Computed tomography of the chest showed bilateral peripheral ground-glass opacities.", + "Computed tomography of the chest showed wedge-shaped opacities in the right lung.", + "The wedge-shaped opacities were thought to represent pulmonary infarctions.", + "The patient was started on broad-spectrum antibiotics for pneumonia.", + "A viral respiratory panel was negative.", + "Tracheal aspirate culture was positive for methicillin-resistant Staphylococcus aureus.", + "Repeat ECG showed sinus rhythm.", + "Repeat ECG showed first-degree atrioventricular (AV) block.", + "Repeat ECG showed left axis deviation.", + "Repeat ECG showed incomplete right bundle branch block.", + "Repeat ECG showed a prolonged QTc interval (498 ms).", + "Over the following 4 days, the patient developed anaemia.", + "CT of the chest, abdomen, and pelvis showed a mediastinal haematoma.", + "CT of the chest, abdomen, and pelvis showed persistent ground-glass opacities.", + "The patient was tested for SARS-CoV-2.", + "The patient was found to be positive for SARS-CoV-2.", + "The patient was transferred to a COVID-19-dedicated intensive care unit.", + "The patient was placed under enhanced contact precautions.", + "The patient received supportive care.", + "The patient was extubated 4 days later.", + "Following extubation, the patient did well.", + "The patient was admitted to an inpatient rehabilitation facility.", + "The patient was discharged home.", + "The patient was prescribed lifelong apixaban 5 mg twice daily.", + "At 1 month follow-up, the patient described mild exertional dyspnoea.", + "Transthoracic echocardiogram at 1 month follow-up noted improvement of right ventricular dilation.", + "Transthoracic echocardiogram at 1 month follow-up noted improvement of right ventricular systolic function." + ], + "summary": "We present a case of 62-year-old male who presented after experiencing syncope and cardiac arrest. Given the clinical presentation and electrocardiographic findings, there was concern for acute coronary syndrome. However, coronary angiogram did not reveal significant coronary obstruction. Due to the unclear nature of his presentation, a bedside echocardiogram was rapidly performed and was indicative of right ventricular strain. Due to these findings, a pulmonary angiogram was performed that revealed massive pulmonary embolism. He successfully underwent catheter-directed thrombolysis and, after a prolonged hospital stay, was discharged home on lifelong anticoagulation.", + "summary_subclaims": [ + "The patient was a 62-year-old male.", + "He presented after experiencing syncope and cardiac arrest.", + "There was concern for acute coronary syndrome.", + "Coronary angiogram did not reveal significant coronary obstruction.", + "A bedside echocardiogram was rapidly performed.", + "The bedside echocardiogram was indicative of right ventricular strain.", + "A pulmonary angiogram was performed.", + "The pulmonary angiogram revealed massive pulmonary embolism.", + "He successfully underwent catheter-directed thrombolysis.", + "He was discharged home on lifelong anticoagulation." + ] + }, + { + "id": "multiclinsum_test_142_en.txt", + "fulltext": "A 42-year-old woman had a medical history of melanoma excised in 2002. Following the surgery, she was placed on active surveillance. In 2021, she developed a left inguinal lymph node and liver nodules, which were confirmed to be metastatic melanoma positive for the BRAF V600E mutation through biopsy. Initially, she received a combination of immune checkpoint inhibitors (ICI), specifically anti-PD-1 and anti-CTLA-4, for nearly three months, with the only side effect being hypothyroidism. Due to disease progression under ICI treatment, she was switched to encorafenib/binimetinib (E/B). On the fourth day of E/B treatment, she developed serous retinopathy, which resolved after a brief temporary discontinuation of the targeted therapy. This allowed the resumption of the E/B regimen at a reduced dose. One week later, she experienced severe acute pain in her left shoulder, scoring 8 on the Visual Analog Scale, without any traumatic context. During the medical examination, she displayed no motor deficits, no movement limitations, and her deep tendon reflexes remained intact. Both X-ray and ultrasound examinations of the shoulder were normal, but a C5-C6 discopathy was noted on cervical spine X-ray. The patient received treatment with analgesics and non-steroidal anti-inflammatory drugs (NSAIDs), which led to the resolution of pain within one month. However, this was followed by muscle weakness, prompting further investigations. An MRI of the cervical spine confirmed degeneration at the C5-C6 and C6-C7 levels, but without cervical radiculopathy. A lumbar puncture revealed no signs of inflammation, and serology testing for Lyme disease came back negative. Serum inflammatory markers remained within normal ranges, and the search for various autoantibodies, including antiganglioside antibodies, also yielded negative results. An electromyogram (EMG) was performed, revealing severe axonal denervation of the suprascapular nerve that did not respond to stimulation . The clinical presentation and EMG data led to the diagnosis of Parsonage-Turner syndrome. Given the temporal relationship with the oncological treatment and the absence of alternative triggers such as infection, vaccination, or mechanical events, the causality of the sequential use of ICI-targeted therapy was established. However, the E/B regimen was continued in the absence of an alternative treatment for her metastatic melanoma. The patient recovered and regained function in her arm through physical rehabilitation. No specific treatment was introduced, and corticoids were not administered because the diagnosis was made at a stage where the muscles were already atrophied, and the goal was to prevent the development of additional steroid-induced myopathy.\nRegular clinical evaluations and EMG assessments were conducted. At present, the patient is still undergoing treatment with E/B, with her oncological disease remaining stable. She is in good clinical condition, and there has been complete recovery of the suprascapular nerve.", + "fulltext_subclaims": [ + "The patient is a 42-year-old woman.", + "She had a medical history of melanoma excised in 2002.", + "Following the surgery, she was placed on active surveillance.", + "In 2021, she developed a left inguinal lymph node and liver nodules.", + "The left inguinal lymph node and liver nodules were confirmed to be metastatic melanoma positive for the BRAF V600E mutation through biopsy.", + "She initially received a combination of immune checkpoint inhibitors (ICI), specifically anti-PD-1 and anti-CTLA-4, for nearly three months.", + "The only side effect during ICI treatment was hypothyroidism.", + "Due to disease progression under ICI treatment, she was switched to encorafenib/binimetinib (E/B).", + "On the fourth day of E/B treatment, she developed serous retinopathy.", + "The serous retinopathy resolved after a brief temporary discontinuation of the targeted therapy.", + "The E/B regimen was resumed at a reduced dose.", + "One week after resuming E/B, she experienced severe acute pain in her left shoulder, scoring 8 on the Visual Analog Scale.", + "The shoulder pain occurred without any traumatic context.", + "During the medical examination, she displayed no motor deficits.", + "Her deep tendon reflexes remained intact.", + "Both X-ray and ultrasound examinations of the shoulder were normal.", + "A C5-C6 discopathy was noted on cervical spine X-ray.", + "She received treatment with analgesics and non-steroidal anti-inflammatory drugs (NSAIDs).", + "The shoulder pain resolved within one month.", + "This was followed by muscle weakness.", + "An MRI of the cervical spine confirmed degeneration at the C5-C6 and C6-C7 levels.", + "The MRI showed no cervical radiculopathy.", + "A lumbar puncture revealed no signs of inflammation.", + "Serology testing for Lyme disease came back negative.", + "Serum inflammatory markers remained within normal ranges.", + "The search for various autoantibodies, including antiganglioside antibodies, yielded negative results.", + "An electromyogram (EMG) revealed severe axonal denervation of the suprascapular nerve that did not respond to stimulation.", + "The clinical presentation and EMG data led to the diagnosis of Parsonage-Turner syndrome.", + "The causality of the sequential use of ICI-targeted therapy was established.", + "The E/B regimen was continued in the absence of an alternative treatment for her metastatic melanoma.", + "The patient recovered and regained function in her arm through physical rehabilitation.", + "No specific treatment was introduced.", + "Corticoids were not administered.", + "The diagnosis was made at a stage where the muscles were already atrophied.", + "The goal was to prevent the development of additional steroid-induced myopathy.", + "Regular clinical evaluations and EMG assessments were conducted.", + "The patient is still undergoing treatment with E/B.", + "Her oncological disease remains stable.", + "She is in good clinical condition.", + "There has been complete recovery of the suprascapular nerve." + ], + "summary": "A 42-year-old woman diagnosed with metastatic melanoma presented with an intense pain in the left shoulder 7 days after the beginning of encorafenib/binimetinib after immune checkpoint inhibitors (ICI) combination. No other triggering factors were identified. Electromyogram performed one month after the pain onset revealed a left brachial plexopathy suggestive of a Parsonage-Turner syndrome. The weakness slowly improved with intensive rehabilitation and targeted therapies were continued.", + "summary_subclaims": [ + "The patient is a 42-year-old woman.", + "The patient was diagnosed with metastatic melanoma.", + "The patient presented with an intense pain in the left shoulder.", + "The pain occurred 7 days after the beginning of encorafenib/binimetinib after immune checkpoint inhibitors.", + "No other triggering factors were identified.", + "An electromyogram was performed one month after the pain onset.", + "The electromyogram revealed a left brachial plexopathy.", + "The electromyogram findings were suggestive of a Parsonage-Turner syndrome.", + "The weakness slowly improved with intensive rehabilitation.", + "Targeted therapies were continued." + ] + }, + { + "id": "multiclinsum_test_1237_en.txt", + "fulltext": "A 47-year-old woman, non-smoker, with history of asthma and pollen allergy contacted the emergency services for subacute dyspnea, exercise intolerance and chest tightness. Her daily medication consisted of: desloratadine, a beclomethason/formoterol inhaler and an ethinylestradiol/levonorgestrel contraceptive, which she took on a continuous basis (without pill-free days) because of pre-menopausal menometrorrhagia. She had been feeling unwell for two days and thought her symptoms were due to an asthma attack. She had already tried increasing her inhaler, but without effect. Two days earlier she had returned from holiday after an 18-hour bus ride. She had taken the same bus on the outward journey 10 days earlier.\nOn arrival, the first responders team found her sitting on the ground in respiratory distress, tachypneic, tachycardic, hypoxic, hypotensive, and afebrile. Her vital signs were: respiratory rate 36 breaths per minute, heart rate 142 beats per minute (bpm), oxygen saturation 72% on room air, blood pressure 64/43 mmHg and temperature 35.8 °C. ECG showed sinus tachycardia, without Q waves or ischemic ST/T changes. The patient was given 12 L/m of oxygen via face mask and 500 mL of normal saline and was brought to the hospital. Repeat ECG showed similar findings, lab (results of which were only available later) showed hemoglobin of 14.0 g/dL, troponin 330 ng/L, d-dimers 7509 mcg/L, C-reactive protein 30.4 mg/L and creatinine of 1.31 mg/dL, corresponding to estimated glomerular filtration rate of 48 mL/min/1.73m2. Quick-look echocardiogram showed a nondilated and normocontractile left ventricle, a dilated right ventricle with leftward shift of the interventricular septum and pulmonary hypertension with an estimated right ventricular systolic pressure of 64 mmHg + central venous pressure . Inferior caval vein was plethoric without respiratory variation. There was no severe valvular pathology. At that moment, blood pressure was 142/95 mmHg, heart rate 139 bpm and oxygen saturation 97% while breathing 12 L/m oxygen via face mask.\nAcute pulmonary embolism was suspected. The patient was given 80 mg of enoxaparin (weight = 83 kg) and an urgent computerized tomography scan with intravenous contrast was performed, which confirmed the diagnosis of bilateral pulmonary embolism .\nThe Pulmonary Embolism Severity Index (PESI) score, calculated with the help of an online tool , was 167: very high risk. Based on hemodynamic compromise, right ventricular dysfunction on echocardiogram and a very high-risk PESI score, thrombolysis was administered. Alteplase was given as a 10 mg bolus and 90 mg infusion over 2 hours and the patient was admitted to the cardiac intensive care unit. Her condition gradually improved over the next few hours, with a decrease in heart rate from 130 bpm to 80 bpm and normalization of serum creatinine to 0.81 mg/dL (corresponding to eGFR of 85 mL/min/1.73 m2) by the second day. Repeat echocardiography showed a marked decrease in right ventricular dimensions and lowering of estimated right ventricular pressure to 27 mmHg + central venous pressure. In addition to the pulmonary embolism, the patient was found to have extensive deep venous thrombosis of the right femoral vein. Thrombophilia screening revealed a Factor V Leiden mutation. After two days of enoxaparin, 80 mg (1 mg/kg) twice daily, she was switched to rivaroxaban, 15 mg twice daily and at day 6 she was discharged with this therapy for a total of 21 days, after which she should decrease the dose to 20 mg once daily. She was instructed to discontinue her combined oral contraceptive pill indefinitely.\nFive days later, however, the patient was re-admitted to the hospital with pre-syncope. She was looking pale. During the few days between hospital admissions, she had had severe vaginal bleeding, with need for hygienic pad change every few hours. Vital signs were: blood pressure 102/74 mmHg, heart rate 114 beats per minute, respiratory rate 18 per minute, saturation 99% on room air, temperature 36.7 °C. There was no hematuria, melaena or hematochezia. Hemoglobin was 6.3 g/dL, ß-HCG negative, creatinine 0.96 mg/dL and C-reactive protein 2.1 mg/L. INR was 1.4 (12 h after last intake of rivaroxaban).\nFigure shows the evolution of anemia since the previous hospitalization. 500 mL of normal saline and two units of packed cells were infused. Rivaroxaban was withheld for 5 days and substituted for prophylactic dose enoxaparin, 40 mg once daily. Lynestrenol, an oral progestin, was administered at 5 mg twice daily for two weeks, and then switched to nomegestrol 5 mg once daily, to be taken continuously. An oral iron supplement was started to replete the iron stores. The patient was discharged on day 7.", + "fulltext_subclaims": [ + "The patient is a 47-year-old woman.", + "She is a non-smoker.", + "She has a history of asthma.", + "She has a history of pollen allergy.", + "She contacted emergency services for subacute dyspnea.", + "She had exercise intolerance.", + "She had chest tightness.", + "Her daily medication included desloratadine.", + "Her daily medication included a beclomethason/formoterol inhaler.", + "Her daily medication included an ethinylestradiol/levonorgestrel contraceptive.", + "She took the contraceptive on a continuous basis without pill-free days.", + "She had been feeling unwell for two days.", + "She thought her symptoms were due to an asthma attack.", + "She had already tried increasing her inhaler.", + "She had no effect from increasing her inhaler.", + "She had returned from a holiday after an 18-hour bus ride.", + "She had taken the same bus on the outward journey 10 days earlier.", + "On arrival, she was sitting on the ground in respiratory distress.", + "Her oxygen saturation was 72% on room air.", + "Her blood pressure was 64/43 mmHg.", + "ECG showed sinus tachycardia.", + "The patient was given 12 L/min of oxygen via face mask.", + "The patient was given 500 mL of normal saline.", + "Repeat ECG showed similar findings.", + "Lab results showed d-dimers 7509 mcg/L.", + "Quick-look echocardiogram showed a dilated right ventricle.", + "Acute pulmonary embolism was suspected.", + "The patient was given 80 mg of enoxaparin.", + "A computerized tomography scan confirmed the diagnosis of bilateral pulmonary embolism.", + "The Pulmonary Embolism Severity Index score was 167.", + "Thrombolysis was administered.", + "Alteplase was given as a 10 mg bolus and 90 mg infusion over 2 hours.", + "The patient was admitted to the cardiac intensive care unit.", + "Her condition gradually improved.", + "Repeat echocardiography showed a marked decrease in right ventricular dimensions.", + "The patient was found to have extensive deep venous thrombosis of the right femoral vein.", + "Thrombophilia screening revealed a Factor V Leiden mutation.", + "After two days of enoxaparin, she was switched to rivaroxaban.", + "She was discharged with rivaroxaban for a total of 21 days.", + "She was instructed to discontinue her combined oral contraceptive pill indefinitely.", + "Five days later, the patient was re-admitted to the hospital with pre-syncope.", + "She had severe vaginal bleeding.", + "Hemoglobin was 6.3 g/dL.", + "Rivaroxaban was withheld for 5 days.", + "Lynestrenol was administered at 5 mg twice daily for two weeks.", + "The patient was discharged on day 7." + ], + "summary": "We report a case of a 47-year-old female who presented to the emergency room with a two-day history of worsening shortness of breath and chest pain. Her chronic medication included a combined oral contraceptive pill. Transthoracic echocardiogram showed pulmonary hypertension and right ventricular dilatation. Computerized tomography scan revealed bilateral pulmonary embolism. She received thrombolysis with alteplase and was started on rivaroxaban. Five days after discharge, however, she was readmitted with severe vaginal bleeding.", + "summary_subclaims": [ + "The patient was a 47-year-old female.", + "She presented to the emergency room with a two-day history of worsening shortness of breath.", + "She had chest pain.", + "Her chronic medication included a combined oral contraceptive pill.", + "Transthoracic echocardiogram showed pulmonary hypertension.", + "Transthoracic echocardiogram showed right ventricular dilatation.", + "Computerized tomography scan revealed bilateral pulmonary embolism.", + "She received thrombolysis with alteplase.", + "She was started on rivaroxaban.", + "Five days after discharge, she was readmitted with severe vaginal bleeding." + ] + }, + { + "id": "multiclinsum_test_2713_en.txt", + "fulltext": "A 24-year-old man from Gondar town, North-West Ethiopia, presented to our medical out-patient clinic, University of Gondar Hospital in first week of June 2017. He presented with the chief complaint of recurrent episodes of nasal congestion with itching and paranasal discomfort, and productive cough for more than a decade. He had repeated clinic visits since then, and had been treated as having chronic sinusitis and recurrent pneumonia. He noticed frequent exacerbation of cough with copious purulent sputum in the last 3 years. He was treated for pulmonary tuberculosis 7 years back as smear-negative pulmonary tuberculosis, but there was no significant clinical improvement after completion of 6 months’ anti-tuberculosis therapy. He was seen by an ear, nose, and throat (ENT) specialist 3 months back and was told he had chronic sinusitis and nasal polyp, and was treated with antibiotics and intranasal steroid. He was a casual alcohol consumer, but never smoked cigarettes. There was no similar illness in his family.\nOn physical examination, he was nourished, conscious, and oriented. His blood pressure (BP) was 100/70 mmHg, pulse rate (PR) 90 beats per minute, respiratory rate (RR) 20 breaths per minute, and temperature (T°) 37.5 °C. His arterial oxygen saturation (SaO2) was 93% with room air. He had hyperemic conjunctivae. He had a deviated left nasal septum with 1 × 2 cm-sized nasal polyp, and hypertrophied inferior turbinate. There was no lymphadenopathy in accessible sites. A respiratory system examination revealed coarse crackles and scattered rhonchi on both basal lung fields. On cardiovascular examination, apex beat was felt on right fifth intercostal space along midclavicular line. Heart sounds were best audible on the right side of his chest. An abdominal examination revealed tympanitic note on percussion and no sign of fluid collection. He had grade 2 clubbing of fingers of both hands. A nervous system examination showed no abnormality.\nA laboratory examination revealed hemoglobin 18 gm/dl (normal, 12–18 gm/dl), total leukocyte count 12,500/μl (normal, 4000–11,000/μl; granulocyte 74%, lymphocyte 15%), and platelet count 350,000/μl (normal, 150,000–450,000/μl). Sputum for acid-fast bacilli (AFB) staining (three times) was negative for Mycobacterium tuberculosis. Serum chemistries were normal. A chest X-ray revealed cardiac apex and aortic arch on right side, and fibrotic bands and bronchiectasis on lower field of left lung . A chest computed tomography (CT) scan showed bronchiectatic changes prominent on both lower lung fields . Ultrasound examination of his abdomen showed liver and inferior vena cava on left side, and spleen on right side, suggestive of situs inversus . Then, a diagnosis of KS was made on the basis of clinical presentation and imaging features . He was treated with orally administered antibiotics, mucolytic, and chest physiotherapy. He was symptomatically better with the above therapy, and started on long-term low-dose prophylactic antibiotic. He was then referred to the medical chest clinic of our hospital for follow-up.", + "fulltext_subclaims": [ + "The patient is a 24-year-old man from Gondar town, North-West Ethiopia.", + "He presented to the medical out-patient clinic of University of Gondar Hospital in the first week of June 2017.", + "His chief complaint was recurrent episodes of nasal congestion with itching and paranasal discomfort.", + "He had productive cough for more than a decade.", + "He had been treated as having chronic sinusitis and recurrent pneumonia.", + "He noticed frequent exacerbation of cough with copious purulent sputum in the last 3 years.", + "He was treated for pulmonary tuberculosis 7 years back as smear-negative pulmonary tuberculosis.", + "There was no significant clinical improvement after completion of 6 months’ anti-tuberculosis therapy.", + "He was seen by an ear, nose, and throat (ENT) specialist 3 months back.", + "He was told he had chronic sinusitis and nasal polyp.", + "He was treated with antibiotics and intranasal steroid.", + "He was a casual alcohol consumer.", + "He never smoked cigarettes.", + "There was no similar illness in his family.", + "On physical examination, he was nourished, conscious, and oriented.", + "His blood pressure was 100/70 mmHg.", + "His arterial oxygen saturation was 93% with room air.", + "He had a deviated left nasal septum with 1 × 2 cm-sized nasal polyp.", + "A respiratory system examination revealed coarse crackles and scattered rhonchi on both basal lung fields.", + "A chest X-ray revealed cardiac apex and aortic arch on right side.", + "A chest computed tomography (CT) scan showed bronchiectatic changes prominent on both lower lung fields.", + "An ultrasound examination showed liver and inferior vena cava on left side, and spleen on right side.", + "A diagnosis of Kartagener syndrome (KS) was made on the basis of clinical presentation and imaging features.", + "He was treated with orally administered antibiotics, mucolytic, and chest physiotherapy.", + "He was symptomatically better with the above therapy.", + "He was started on long-term low-dose prophylactic antibiotic.", + "He was referred to the medical chest clinic of the hospital for follow-up." + ], + "summary": "A 24-year-old man from Gondar town, North-West Ethiopia, presented to University of Gondar Hospital with recurrent episodes of nasal congestion with itching and paranasal discomfort, and productive cough for more than a decade. Clinical and imaging findings revealed chronic sinusitis, bronchiectasis, dextrocardia, and situs inversus. He was treated with orally administered antibiotics, mucolytic, and chest physiotherapy. He was symptomatically better with the above therapy, and started on a long-term low-dose prophylactic antibiotic.", + "summary_subclaims": [ + "The patient is a 24-year-old man from Gondar town, North-West Ethiopia.", + "He presented with recurrent episodes of nasal congestion with itching and paranasal discomfort.", + "He had a productive cough for more than a decade.", + "Clinical and imaging findings revealed chronic sinusitis.", + "Clinical and imaging findings revealed bronchiectasis.", + "Clinical and imaging findings revealed dextrocardia.", + "Clinical and imaging findings revealed situs inversus.", + "He was treated with orally administered antibiotics.", + "He was treated with mucolytic.", + "He was treated with chest physiotherapy.", + "He was symptomatically better with the above therapy.", + "He started on a long-term low-dose prophylactic antibiotic." + ] + }, + { + "id": "multiclinsum_test_2377_en.txt", + "fulltext": "A 66-year-old man was admitted to our hospital for repeated hemoptysis accompanied by fever for 8 months. A large amount of bloody purulent sputum was coughed out at the beginning, followed by brown pus. The largest amount was about 100 ml. He denied chest pain or dyspnea. The patient took amoxicillin and oral hemostatic drug and the symptoms were relieved. However, the symptoms recurred and gradually worsened. He was admitted to another hospital and received antibiotic therapy with levofloxacin and imipenem. His relevant past medical history included cholecystectomy for gallstone 5 years ago.\nOn admission, he had a temperature of 37.0 °C, heart rate of 80 beats per minute, blood pressure of 120/70 mmHg, and an oxygen saturation of 95% on room air. Physical examination revealed no positive sign. Chest CT scan demonstrated a consolidative mass located in the right middle lobe, together with scattered inflammation in the bilateral lower lobes and mediastinal lymphadenopathy . The patient received ceftriaxone and moxifloxacin intravenously with no improvement. Bronchoscopy exhibited no evidence of tumor or tuberculosis . Percutaneous lung puncture found inflammatory and tissue cells, and puncture fluid grew Escherichia coli. Pulmonary abscess was diagnosed and the antobiotic was changed to biapenem according to the drug sensitivity result . The condition improved and the patient was discharged.\nHowever, the patient presented with hemoptysis again 2 months later but he refused surgery. So, he received right middle lobe arterial embolization. Digital substraction angiography showed a right bronchus common bronchial artery (canal-like expansion of right bronchial artery and right middle lobe pulmonary artery), a left and right common bronchial artery, and abnormal right inferior phrenic artery (tumor-like expansion at the traffic of right inferior phrenic artery and right middle lobe pulmonary artery).\nThree months later, the patient suffered from hemoptysis again with about 1000 ml a day. Since conservative treatment failed, the patient agreed to right middle and lower lobectomy by open surgery. During the operation, the middle lobe was found to adhere to the diaphragm. However, when the adhesion was removed, a hole was observed on the diaphragm and colonic perforation was seen. The colon and the diaphragm were closed by suturing separately. Pathology demonstrated bronchogenic cysts with epithelial squamous hyperplasia. In addition, intestinal epithelium was found on the adhesion of middle lobe with diaphragm . Three days after operation, turbid stool like fluid drained out from the chest tube , and the patient developed continuous fever and increased white blood cell. Enterogenic empyema was diagnosed and emergent surgery found the diaphragm repair ruptured. Considering the pus was derived from the colon, a jejunostomy and empyema drainage was performed. The pus in the chest cavity was removed and a drainage tube was put into the colon from the chest cavity . Blood culture grew Staphylococcus aureus, and he received imipenem and piperacillin/tazobartan alternately upon drug sensitive results . The right lung re-expanded after surgery and no drainage came out from the colon tube.\nThree weeks later, there was air leak from the chest tube again and CT scan showed bronchopleural fistula (BPF) at the bronchial stump . A rib bed drainage was performed since the visceral pleura was adhered to the lung tissue. Together with large amount of protein intake, the BPF closed in 3 months and all the chest tubes were removed.\nNine months after the first operation, enteroscopy demonstrated disuse colitis without other digestive tract pathology. The patient underwent right hemicolectomy and closure of ileostomy . The pathology reported chronic inflammation without evidence of Crohn’s disease. He was doing well when he was seen in clinic 2 months after the last surgery.", + "fulltext_subclaims": [ + "A 66-year-old man was admitted to our hospital for repeated hemoptysis accompanied by fever for 8 months.", + "A large amount of bloody purulent sputum was coughed out at the beginning, followed by brown pus.", + "The largest amount was about 100 ml.", + "He denied chest pain or dyspnea.", + "The patient took amoxicillin and oral hemostatic drug and the symptoms were relieved.", + "The symptoms recurred and gradually worsened.", + "He was admitted to another hospital and received antibiotic therapy with levofloxacin and imipenem.", + "The patient had a cholecystectomy for gallstone 5 years ago.", + "On admission, he had a temperature of 37.0 °C.", + "Chest CT scan demonstrated a consolidative mass located in the right middle lobe.", + "The patient received ceftriaxone and moxifloxacin intravenously with no improvement.", + "Bronchoscopy exhibited no evidence of tumor or tuberculosis.", + "Percutaneous lung puncture found inflammatory and tissue cells.", + "Puncture fluid grew Escherichia coli.", + "Pulmonary abscess was diagnosed.", + "The antibiotic was changed to biapenem according to the drug sensitivity result.", + "The condition improved and the patient was discharged.", + "The patient presented with hemoptysis again 2 months later.", + "He refused surgery.", + "He received right middle lobe arterial embolization.", + "Digital subtraction angiography showed a right bronchus common bronchial artery.", + "Digital subtraction angiography showed canal-like expansion of the right bronchial artery.", + "Digital subtraction angiography showed tumor-like expansion at the traffic of the right inferior phrenic artery and right middle lobe pulmonary artery.", + "Three months later, the patient suffered from hemoptysis again with about 1000 ml a day.", + "The patient agreed to right middle and lower lobectomy by open surgery.", + "During the operation, the middle lobe was found to adhere to the diaphragm.", + "When the adhesion was removed, a hole was observed on the diaphragm.", + "Colonic perforation was seen.", + "The colon and the diaphragm were closed by suturing separately.", + "Pathology demonstrated bronchogenic cysts with epithelial squamous hyperplasia.", + "Intestinal epithelium was found on the adhesion of the middle lobe with the diaphragm.", + "Three days after operation, turbid stool-like fluid drained out from the chest tube.", + "The patient developed continuous fever and increased white blood cell.", + "Enterogenic empyema was diagnosed.", + "Emergent surgery found the diaphragm repair ruptured.", + "A jejunostomy and empyema drainage was performed.", + "The pus in the chest cavity was removed.", + "A drainage tube was put into the colon from the chest cavity.", + "Blood culture grew Staphylococcus aureus.", + "He received imipenem and piperacillin/tazobactam alternately upon drug sensitive results.", + "The right lung re-expanded after surgery.", + "No drainage came out from the colon tube.", + "Three weeks later, there was air leak from the chest tube again.", + "CT scan showed bronchopleural fistula (BPF) at the bronchial stump.", + "A rib bed drainage was performed.", + "The BPF closed in 3 months.", + "All the chest tubes were removed.", + "Nine months after the first operation, enteroscopy demonstrated disuse colitis.", + "The patient underwent right hemicolectomy and closure of ileostomy.", + "The pathology reported chronic inflammation without evidence of Crohn’s disease.", + "He was doing well when he was seen in clinic 2 months after the last surgery." + ], + "summary": "A 66-year-old gentleman presented with persistent fever and repeated hemoptysis for 8 months. Computed tomography of the thorax confirmed the presence of a consolidation mass located in the right middle lobe and an air space near the right rib angle. During exploration, CBF was found. The patient underwent right middle and lower lobectomy together with closure of colonic and diaphragmatic perforation. The colon closure and diaphragm closure ruptured after surgery, leading to enterogenic empyema. Adequate drainage, sustained high protein diet, and antibiotic treatment eventually resulted in full recovery.", + "summary_subclaims": [ + "The patient is a 66-year-old gentleman.", + "The patient had persistent fever.", + "The patient had repeated hemoptysis for 8 months.", + "Computed tomography of the thorax confirmed the presence of a consolidation mass in the right middle lobe.", + "Computed tomography of the thorax showed an air space near the right rib angle.", + "During exploration, CBF was found.", + "The patient underwent right middle and lower lobectomy.", + "The patient had closure of colonic and diaphragmatic perforation.", + "The colon closure and diaphragm closure ruptured after surgery.", + "The ruptured closures led to enterogenic empyema.", + "Adequate drainage was provided.", + "Sustained high protein diet was provided.", + "Antibiotic treatment was provided.", + "The patient eventually had full recovery." + ] + }, + { + "id": "multiclinsum_test_3058_en.txt", + "fulltext": "A 52-year-old female with a history of repeat PKPs was referred to the glaucoma clinic due to uncontrolled IOP. The patient underwent PKP five times in the right eye from 1989 to 2019. She constantly experiences corneal rejection symptoms after several years of keratoplasty. The contralateral eye was diagnosed with myopic macular degeneration, and with appropriate treatment and uncomplicated cataract surgery, a best-corrected visual acuity (BCVA) of 1.00 logMAR was achieved. Therefore, treating the right eye was the immediate concern. There was no documented history of IOP elevation in the patient’s medical history prior to the fourth PKP. During that period, the IOP was adequately managed with topical antiglaucoma monotherapy, ranging from 12–14 mmHg. One week after the fifth PKP, the patient complained of pain, redness, and halos around lights. She was referred to the glaucoma service for further evaluation and management. The IOP was 42 mmHg by applanation tonometry, and the BCVA was 0.25 logMAR with a clear graft and no signs of rejection. The patient was treated with maximum topical antiglaucoma medications; however, the IOP was still 36 mmHg. We suggested tube implantation due to the uncontrolled IOP and history of repeat PKPs with a current viable graft. However, the patient was unable to attend our care due to socioeconomic factors and continued care in a tertiary clinic with no resources for glaucoma tube implantation. The patient underwent trabeculectomy with mitomycin C (MMC), and the IOP was well controlled after 22 months without antiglaucoma medications. In April 2022, she came to our clinic with complaints of irritation, redness, and decreased vision in the right eye. On examination, we found an incarcerated bleb with a positive Seidel test, 5 mmHg IOP, and BCVA hand movement. We treated this as a blebitis with broad-spectrum topical and oral antibiotics. After the infection subsided, we performed a bleb revision with scleral patch graft. One month after surgery, the IOP was 22 mmHg on maximum topical antiglaucoma medications, wound closure was good, and the corneal graft was clear. We decided to insert an Ahmed Glaucoma Valve (New World Medical, Inc., Rancho Cucamonga, California, USA) to lower the IOP. The tube was inserted in the posterior chamber to protect the corneal endothelium. Six months after surgery, the IOP was well controlled (11 mmHg) without antiglaucoma medications, BCVA was 0.2, and the graft remained clear.", + "fulltext_subclaims": [ + "The patient is a 52-year-old female.", + "The patient has a history of repeat PKPs.", + "The patient underwent PKP five times in the right eye from 1989 to 2019.", + "The patient constantly experiences corneal rejection symptoms after several years of keratoplasty.", + "The contralateral eye was diagnosed with myopic macular degeneration.", + "With appropriate treatment and uncomplicated cataract surgery, a best-corrected visual acuity (BCVA) of 1.00 logMAR was achieved in the contralateral eye.", + "The patient was referred to the glaucoma clinic due to uncontrolled IOP.", + "There was no documented history of IOP elevation in the patient’s medical history prior to the fourth PKP.", + "During the period prior to the fourth PKP, the IOP was adequately managed with topical antiglaucoma monotherapy, ranging from 12–14 mmHg.", + "One week after the fifth PKP, the patient complained of pain, redness, and halos around lights.", + "The IOP was 42 mmHg by applanation tonometry.", + "The BCVA was 0.25 logMAR.", + "The graft was clear.", + "There were no signs of rejection.", + "The patient was treated with maximum topical antiglaucoma medications.", + "The IOP was still 36 mmHg.", + "We suggested tube implantation due to the uncontrolled IOP and history of repeat PKPs with a current viable graft.", + "The patient was unable to attend our care due to socioeconomic factors.", + "The patient continued care in a tertiary clinic with no resources for glaucoma tube implantation.", + "The patient underwent trabeculectomy with mitomycin C (MMC).", + "The IOP was well controlled after 22 months without antiglaucoma medications.", + "In April 2022, the patient came to our clinic with complaints of irritation, redness, and decreased vision in the right eye.", + "An incarcerated bleb with a positive Seidel test was found.", + "The IOP was 5 mmHg.", + "The BCVA was hand movement.", + "We treated this as a blebitis with broad-spectrum topical and oral antibiotics.", + "After the infection subsided, we performed a bleb revision with scleral patch graft.", + "One month after surgery, the IOP was 22 mmHg on maximum topical antiglaucoma medications.", + "Wound closure was good.", + "The corneal graft was clear.", + "We decided to insert an Ahmed Glaucoma Valve.", + "The tube was inserted in the posterior chamber to protect the corneal endothelium.", + "Six months after surgery, the IOP was well controlled (11 mmHg) without antiglaucoma medications.", + "The BCVA was 0.2.", + "The graft remained clear." + ], + "summary": "A patient with a history of five repeat penetrating keratoplasties (PKPs) showed good intraocular pressure (IOP) control with trabeculectomy; however, blebitis occurred as an undesirable complication. Trabeculectomy was done rather than tube implantation due to socioeconomic factors, although it's not an ideal treatment. After the infection subsided, we performed a bleb revision with a scleral patch graft. Intraocular pressure was high in the follow-up period after the scleral patch, therefore we decided to do tube implantation. Following glaucoma tube implant surgery, the patient had good IOP control and a clear graft after six months of follow-up.", + "summary_subclaims": [ + "The patient had a history of five repeat penetrating keratoplasties.", + "The patient showed good intraocular pressure control with trabeculectomy.", + "Blebitis occurred as an undesirable complication.", + "Trabeculectomy was done rather than tube implantation.", + "Trabeculectomy was done due to socioeconomic factors.", + "Blebitis subsided after treatment.", + "A bleb revision with a scleral patch graft was performed.", + "Intraocular pressure was high in the follow-up period after the scleral patch.", + "Tube implantation was decided after the scleral patch.", + "Following glaucoma tube implant surgery, the patient had good intraocular pressure control.", + "Following glaucoma tube implant surgery, the patient had a clear graft after six months of follow-up." + ] + }, + { + "id": "multiclinsum_test_3146_en.txt", + "fulltext": "A previously healthy 6-year-old girl with no relevant family or consanguineous history presented with a history of hyporexia for 24 months, increased abdominal circumference and recurrent vomiting; in the last 2 months with chest pain and progressive decrease in functional class. She was found with hepatomegaly approximately 6 cm below the costal margin. The initial echocardiogram revealed marked dilatation of the suprahepatic veins and inferior vena cava, with marked biatrial dilatation, diastolic dysfunction with restrictive pattern and indirect signs of pulmonary hypertension. CMR was suspected and treatment with diuretics, carvedilol and enalapril was initiated, with improvement of the functional class.\n\nStudies were requested to clarify the etiology of CMR, cardiac magnetic resonance reported left ventricular hypertracheal with respect to non-compacted region/compacted region of 4:1, systolic dysfunction, significant ventricular cavity hypertracheal, right ventricular dilation with deterioration of systolic function. In addition, a 24-hour Holter ECG described right and left atrial changes and repolarization disorder in precordial leads. Based on the above, the patient was discussed in a cardiology meeting, considering the coexistence of restrictive cardiomyopathy and hypertracheal.\n\nAnti-insufficiency medical treatment was initiated and there was an improvement in the New York Heart Association (NYHA) functional classification from III to II. However, after a few months, the patient presented clinical worsening, requiring admission to an intensive care unit for refractory heart failure, and a diagnosis of cardiac tamponade was made, requiring a pericardial window, support with extracorporeal mechanical oxygenation and subsequent massive cerebral hemorrhage leading to her death.\n\nWritten informed consent was obtained from the minor's legal guardian/next of kin to publish any potentially identifiable images or data in this article. The ethics committee approved the conduct of the study.\n\nGenomics-based assessment\nDue to the diagnosis of early onset CMR, the genetic medical team was consulted. Physical examination was normal and there was no family history of cardiomyopathies or sudden cardiac death. After a careful review of the case, a full exome sequencing (WES) was performed.\n\nA new heterozygous missense variant in the FLNC gene (NM_001458.5) was identified: c.7559C>A, p.Thr2520Asn and confirmed by Sanger sequencing. This substitution converts the codon threonine at position 2520 to asparagine, located in the ROD2 domain in which there is a cluster of variants mainly associated with hypertrophic cardiomyopathy. This variant has not been reported in population databases or in the current medical literature and is classified as probably pathogenic.\n\nOther genetic variants identified in this case were: a heterozygous frameshift variant in the AGK gene (NM_018238.4): c.675delG, p.Trp225CysfsTer6, classified as pathogenic according to ACMG guidelines; and a heterozygous missense variant in the PKP2 gene (NM_004572.4): c.1163G>A, p.Arg388Gln, classified as a variant of uncertain significance (VSI).\n\nNo other genetic variants were identified in this case. The patient's mother (34 years old), father (38 years old), and paternal grandparents (55 and 62 years old) consented to genetic testing, and the father was found to carry the FLNC and AGK variants. He has a normal echocardiogram and is being evaluated by the cardiology team.\n", + "fulltext_subclaims": [ + "The patient was a previously healthy 6-year-old girl.", + "She had no relevant family or consanguineous history.", + "She had a history of hyporexia for 24 months.", + "She had increased abdominal circumference.", + "She had recurrent vomiting.", + "She had chest pain in the last 2 months.", + "She had a progressive decrease in functional class.", + "She was found with hepatomegaly approximately 6 cm below the costal margin.", + "The initial echocardiogram revealed marked dilatation of the suprahepatic veins.", + "The initial echocardiogram revealed marked dilatation of the inferior vena cava.", + "The initial echocardiogram revealed marked biatrial dilatation.", + "The initial echocardiogram revealed diastolic dysfunction with restrictive pattern.", + "The initial echocardiogram revealed indirect signs of pulmonary hypertension.", + "CMR was suspected.", + "Treatment with diuretics, carvedilol, and enalapril was initiated.", + "There was improvement of the functional class.", + "Studies were requested to clarify the etiology of CMR.", + "Cardiac magnetic resonance reported left ventricular hypertracheal with respect to non-compacted region/compacted region of 4:1.", + "Cardiac magnetic resonance reported systolic dysfunction.", + "Cardiac magnetic resonance reported significant ventricular cavity hypertracheal.", + "Cardiac magnetic resonance reported right ventricular dilation.", + "Cardiac magnetic resonance reported deterioration of right ventricular systolic function.", + "A 24-hour Holter ECG described right and left atrial changes.", + "A 24-hour Holter ECG described repolarization disorder in precordial leads.", + "The patient was discussed in a cardiology meeting.", + "The cardiology meeting considered the coexistence of restrictive cardiomyopathy and hypertracheal.", + "Anti-insufficiency medical treatment was initiated.", + "There was an improvement in the New York Heart Association (NYHA) functional classification from III to II.", + "After a few months, the patient presented clinical worsening.", + "The patient required admission to an intensive care unit for refractory heart failure.", + "A diagnosis of cardiac tamponade was made.", + "A pericardial window was performed.", + "Support with extracorporeal mechanical oxygenation was provided.", + "The patient had a subsequent massive cerebral hemorrhage.", + "The patient's death occurred.", + "Written informed consent was obtained from the minor's legal guardian/next of kin.", + "The ethics committee approved the conduct of the study.", + "Due to the diagnosis of early onset CMR, the genetic medical team was consulted.", + "Physical examination was normal.", + "There was no family history of cardiomyopathies.", + "There was no family history of sudden cardiac death.", + "A full exome sequencing (WES) was performed.", + "A new heterozygous missense variant in the FLNC gene was identified.", + "The variant was confirmed by Sanger sequencing.", + "The substitution converts the codon threonine at position 2520 to asparagine.", + "The variant is located in the ROD2 domain.", + "The variant has not been reported in population databases.", + "The variant has not been reported in the current medical literature.", + "The variant is classified as probably pathogenic.", + "A heterozygous frameshift variant in the AGK gene was identified.", + "The AGK variant was classified as pathogenic according to ACMG guidelines.", + "A heterozygous missense variant in the PKP2 gene was identified.", + "The PKP2 variant was classified as a variant of uncertain significance (VSI).", + "No other genetic variants were identified in this case.", + "The patient's mother, father, and paternal grandparents consented to genetic testing.", + "The father was found to carry the FLNC and AGK variants.", + "The father has a normal echocardiogram.", + "The father is being evaluated by the cardiology team." + ], + "summary": "6-year-old girl with restrictive cardiomyopathy and hypertracheal in which, due to early onset of the disease, a full exome sequencing was performed, revealing the presence of a new heterozygous missense variant in the FLNC gene. The same genetic variant was also identified in her father, who, as an adult, had normal imaging results and no symptoms.\n", + "summary_subclaims": [ + "The patient is a 6-year-old girl.", + "The patient has restrictive cardiomyopathy.", + "The patient has hypertracheal.", + "A full exome sequencing was performed.", + "A new heterozygous missense variant in the FLNC gene was revealed.", + "The FLNC gene variant was identified in the patient's father.", + "The father had normal imaging results as an adult.", + "The father had no symptoms." + ] + }, + { + "id": "multiclinsum_test_2664_en.txt", + "fulltext": "A 41-year-old young healthy male entered the retina clinic with complaints of seeing a black spot, blurred vision and metamorphopsia involving the right eye for the past 4 months. He was on treatment for androgenic alopecia with topical 5% Minoxidil application on scalp two times a day for a total time period of 10 months. He noticed the symptoms 8 months after starting the treatment. He was not seen by any other ophthalmologist previously and had stopped the medication on his own since the past 2 months. The patient denied using other medications or a history of previous treatment with corticosteroids. On examination, best-corrected visual acuity was 20/20 in both eyes. Intraocular pressure was 15 mmHg in both eyes. Anterior segment was unremarkable. Fundoscopic examination of the right eye with +78D lens on slit lamp revealed central swelling located over the macula with presence of subretinal fluid (SRF) and few focal spots of retinal pigment epithelial alterations. Left eye fundus was normal. Optical coherence tomography (OCT) scan evaluation showed the presence of SRF with an irregular retinal pigment epithelium. On enhanced depth imaging OCT, dilated pachy choroidal vessels compressing the overlying Sattler’s and choriocapillaris layer was noted nasal to the fovea. Subfoveal choroidal thickness measured was 425 μm. Fluorescein angiography did not show any classic smoke stack or ink-blot pattern of leaks. Indocyanine green angiography (ICGA) revealed dilated hyperpermeable choroidal vasculature on the nasal side of the fovea in the early and later phases of the angiogram corresponding to the pachy choroidal vessels seen on enhanced depth imaging OCT . The patient was diagnosed with CSCR as a possible consequence of his topical minoxidil solution. Patient was asked to avoid future use of Minoxidil and was started on oral eplerenone therapy 50 mg/day for 4 consecutive weeks. Serum electrolytes and renal profile were done prior to starting the therapy. Blood investigations were normal. One month later, he was found to have complete resolution of his symptoms. OCT examination revealed complete resolution of SRF and reduction in the subfoveal choroidal thickness (391 μm). Oral eplerenone was discontinued and patient was asked to follow up the next month. No side-effects were reported following the intake of oral eplerenone. At the final follow-up visit, 2 months after starting the therapy, there was no recurrence of SRF and the subfoveal choroidal thickness further decreased to 344 μm . Written informed consent was obtained from the patient for utilising his clinical details for this manuscript. Permission for using the patient data for this report was obtained from institutional review board and ethics committee (C/2019/06/03).", + "fulltext_subclaims": [ + "The patient is a 41-year-old young healthy male.", + "The patient had complaints of seeing a black spot, blurred vision, and metamorphopsia involving the right eye for the past 4 months.", + "The patient was on treatment for androgenic alopecia with topical 5% Minoxidil application on the scalp two times a day.", + "The patient noticed the symptoms 8 months after starting the Minoxidil treatment.", + "The patient had stopped the Minoxidil medication on his own since the past 2 months.", + "The patient denied using other medications or a history of previous treatment with corticosteroids.", + "Best-corrected visual acuity was 20/20 in both eyes.", + "Intraocular pressure was 15 mmHg in both eyes.", + "Fundoscopic examination of the right eye revealed central swelling located over the macula with presence of subretinal fluid (SRF) and few focal spots of retinal pigment epithelial alterations.", + "Left eye fundus was normal.", + "Optical coherence tomography (OCT) scan evaluation showed the presence of SRF with an irregular retinal pigment epithelium.", + "Enhanced depth imaging OCT showed dilated pachy choroidal vessels compressing the overlying Sattler’s and choriocapillaris layer nasal to the fovea.", + "Subfoveal choroidal thickness measured was 425 μm.", + "Fluorescein angiography did not show any classic smoke stack or ink-blot pattern of leaks.", + "Indocyanine green angiography (ICGA) revealed dilated hyperpermeable choroidal vasculature on the nasal side of the fovea in the early and later phases of the angiogram.", + "The patient was diagnosed with CSCR as a possible consequence of his topical minoxidil solution.", + "The patient was asked to avoid future use of Minoxidil.", + "The patient was started on oral eplerenone therapy 50 mg/day for 4 consecutive weeks.", + "Serum electrolytes and renal profile were done prior to starting the therapy.", + "Blood investigations were normal.", + "One month later, the patient had complete resolution of his symptoms.", + "OCT examination revealed complete resolution of SRF and reduction in the subfoveal choroidal thickness (391 μm).", + "Oral eplerenone was discontinued.", + "No side-effects were reported following the intake of oral eplerenone.", + "At the final follow-up visit, 2 months after starting the therapy, there was no recurrence of SRF.", + "The subfoveal choroidal thickness further decreased to 344 μm.", + "Written informed consent was obtained from the patient for utilising his clinical details for this manuscript.", + "Permission for using the patient data for this report was obtained from institutional review board and ethics committee (C/2019/06/03)." + ], + "summary": "A 41-year-old male presented to the retina clinic with complaints of seeing a black spot, blurred vision and metamorphopsia involving the right eye for the past 4 months. He was on treatment for androgenic alopecia with topical 5% Minoxidil application on scalp two times a day. He noticed the symptoms 8 months after starting the treatment and had stopped the medication since the past 2 months. On examination, best-corrected visual acuity was 20/20 in both eyes. Fundoscopic examination of the right eye with +78D lens on slit lamp revealed the presence of subretinal fluid and few focal spots of retinal pigment epithelial alterations. Optical coherence tomography scan evaluation showed the presence of subretinal fluid (SRF) and pachychoroid supporting the diagnosis of CSCR. Indocyanine green angiography revealed dilated hyperpermeable choroidal vasculature on the nasal side of the fovea in the early and later phases of the angiogram. The patient was diagnosed with CSCR as a possible consequence of the topical minoxidil solution. Patient was asked to avoid future use of Minoxidil and was started on oral eplerenone therapy 50 mg/day for 4 consecutive weeks. One month later, there was complete resolution of his symptoms and SRF. At the final follow-up visit, 2 months after starting the therapy, there was no recurrence of SRF.", + "summary_subclaims": [ + "The patient is a 41-year-old male.", + "He presented with complaints of seeing a black spot, blurred vision, and metamorphopsia involving the right eye for the past 4 months.", + "He was on treatment for androgenic alopecia with topical 5% Minoxidil application on scalp two times a day.", + "He noticed the symptoms 8 months after starting the treatment.", + "He had stopped the medication since the past 2 months.", + "Best-corrected visual acuity was 20/20 in both eyes.", + "Fundoscopic examination of the right eye with +78D lens on slit lamp revealed the presence of subretinal fluid and few focal spots of retinal pigment epithelial alterations.", + "Optical coherence tomography scan evaluation showed the presence of subretinal fluid.", + "Optical coherence tomography scan evaluation showed pachychoroid.", + "Indocyanine green angiography revealed dilated hyperpermeable choroidal vasculature on the nasal side of the fovea in the early and later phases of the angiogram.", + "The patient was diagnosed with CSCR as a possible consequence of the topical minoxidil solution.", + "Patient was asked to avoid future use of Minoxidil.", + "He was started on oral eplerenone therapy 50 mg/day for 4 consecutive weeks.", + "One month later, there was complete resolution of his symptoms and subretinal fluid.", + "At the final follow-up visit, 2 months after starting the therapy, there was no recurrence of subretinal fluid." + ] + }, + { + "id": "multiclinsum_test_1975_en.txt", + "fulltext": "The 46-year-old female patient was diagnosed with relapsing-remitting MS in 2005. She started on interferon-beta 1a in 2005 presenting a stable disease course in the following years. In 2010, severe idiopathic pulmonary arterial hypertension (IPAH) and one-vessel coronary artery disease were diagnosed after progressive exertional dyspnea, dizziness, marked restricted physical performance and mild stenocardia since 10 months, characterizing heart failure stage III of classification of the New York Heart Association (NYHA). Echocardiography showed right ventricular hypertrophy, moderate reduction of left ventricular and severe reduction of right ventricular function, paradox septum deviation and severe tricuspid valve insufficiency with an estimated systolic pressure of 90 mmHg . Routine echocardiography 12 months before was without abnormal results. Combined left and right heart catheterization demonstrated one-vessel coronary artery disease and severe pre-capillary pulmonary hypertension with a mean pulmonary arterial pressure of 66 mmHg (normal: 10–20 mmHg), left ventricular end-diastolic pressure of 12 mmHg (normal: 3–12 mmHg), cardiac index of 1.5 L/min/m2 (normal: 2.5-4.0 L/min/m2) and pulmonary vascular resistance of 14.1 wood units (normal: 0.25-1.6 wood units). The initial level of N-terminal pro-hormone of brain natriuretic peptide (NT-proBNP) presented with an increase up to 207 pmol/L (normal: ≤17 pmol/L). One week after placing a drug eluding stent in the left main coronary artery (LMCA) control echocardiography revealed an unchanged severe pulmonary hypertension with near normalized left ventricular function. Diagnosis of severe IPAH was established by exclusion of other causes of pulmonary hypertension according to the diagnostic criteria reported by Galie et al. . Compression of the LMCA by an enlarged pulmonary artery was excluded by CT-angiography of the pulmonary arteries. The patient started on the endothelin receptor antagonist ambrisentan and phosphodiesterase inhibitor tadalafil. By this treatment, the patient reported an improvement of physical performance, no more dizziness and stenocardia as well as a stable disease course corresponding to heart failure of stage NYHA II. In further evaluations, mild right ventricular hypertrophy and insufficiency, mild tricuspid valve insufficiency, decrease of right ventricular-systolic pressure in echocardiography, normal lung function, mild impairment in diffusion capacity of carbon monoxide and mild hypocapnia was detectable in the following years .\nIn 2013, she demonstrated with significant clinical disease activity of MS with two relapses and MRI activity with three gadolinium-enhancing lesions and an Expanded Disability Status Scale (EDSS) of 4.0. Because of positive JC-virus serology, fingolimod was selected as second line treatment. Before first dose application, extensive cardio-pulmonary testing demonstrated stable cardiovascular parameters as described above . The baseline electrocardiogram (ECG) showed a sinus rhythm with a right bundle branch block. During first dose, heart rate (HR) decreased at maximum by 13 bpm at 4 hours and reached baseline HR 6 hours after initial fingolimod administration. 12 lead ECG as well as Holter ECG did not demonstrate any significant abnormalities . Blood pressure (BP) in lying and tilted up position presented within normal range during the whole 6 hours monitoring . The patient did not complain any findings in the first 6 hours after fingolimod application. Cardio-pulmonary testing one week, one, three and nine months after first dose application demonstrated stable parameters in ECG, BP, echocardiography, body plethysmography and blood gas analysis . Especially relevant parameters of right ventricular and pulmonary circulation including right ventricular hypertrophy, right ventricular end-systolic pressure (RVESP), right-ventricular ejection fraction and tricuspid annular plane systolic excursion (TAPSE) kept stable on fingolimod treatment . Detailed testing of the autonomic nervous system demonstrated no change of the efferent sympathetic regulation and left ventricular function after orthostatic stress before, 2 hours, 4 hours, and 6 hours after fingolimod first dose application as well as in three and nine month follow up . Maximal heart rate variability measured by expiration/inspiration quotient (E/I) during deep metronomic breathing showed a decrease to 1.06, which stabilized over time back to 1.09 . There were no additional cardiac or pulmonary symptoms than known before fingolimod treatment.", + "fulltext_subclaims": [ + "The patient was diagnosed with relapsing-remitting MS in 2005.", + "She started on interferon-beta 1a in 2005.", + "In 2010, severe idiopathic pulmonary arterial hypertension and one-vessel coronary artery disease were diagnosed.", + "Echocardiography showed right ventricular hypertrophy.", + "Echocardiography showed moderate reduction of left ventricular function.", + "Echocardiography showed severe reduction of right ventricular function.", + "Echocardiography showed paradox septum deviation.", + "Echocardiography showed severe tricuspid valve insufficiency.", + "Echocardiography estimated systolic pressure of 90 mmHg.", + "Combined left and right heart catheterization demonstrated one-vessel coronary artery disease.", + "Combined left and right heart catheterization demonstrated severe pre-capillary pulmonary hypertension.", + "The initial level of NT-proBNP was 207 pmol/L.", + "The patient started on ambrisentan.", + "The patient started on tadalafil.", + "By this treatment, the patient reported improvement of physical performance.", + "By this treatment, the patient reported no more dizziness.", + "By this treatment, the patient reported no more stenocardia.", + "The patient demonstrated significant clinical disease activity of MS with two relapses.", + "MRI activity showed three gadolinium-enhancing lesions.", + "The EDSS was 4.0.", + "The patient had positive JC-virus serology.", + "Fingolimod was selected as second line treatment.", + "Baseline ECG showed a sinus rhythm with a right bundle branch block.", + "During first dose, heart rate decreased at maximum by 13 bpm at 4 hours.", + "12 lead ECG did not demonstrate any significant abnormalities.", + "Holter ECG did not demonstrate any significant abnormalities.", + "Blood pressure was within normal range during the whole 6 hours monitoring.", + "The patient did not complain any findings in the first 6 hours after fingolimod application.", + "Cardio-pulmonary testing one week after first dose application demonstrated stable parameters.", + "Cardio-pulmonary testing three months after first dose application demonstrated stable parameters.", + "Cardio-pulmonary testing nine months after first dose application demonstrated stable parameters.", + "Right ventricular hypertrophy kept stable on fingolimod treatment.", + "Right ventricular end-systolic pressure kept stable on fingolimod treatment.", + "Right-ventricular ejection fraction kept stable on fingolimod treatment.", + "TAPSE kept stable on fingolimod treatment.", + "Detailed testing of the autonomic nervous system demonstrated no change of the efferent sympathetic regulation.", + "Maximal heart rate variability measured by E/I decreased to 1.06.", + "There were no additional cardiac or pulmonary symptoms than known before fingolimod treatment." + ], + "summary": "We report the case of a 46-year-old woman presented with relapsing remitting multiple sclerosis and severe idiopathic pulmonary arterial hypertension. Fingolimod was initiated because of disease activity of multiple sclerosis with two relapses and gadolinium-enhancing lesions in MRI. The patient demonstrated stable disease course of idiopathic pulmonary arterial hypertension when fingolimod was started. Fingolimod therapy did not alter or even worsen the pulmonary or cardiovascular conditions during first dose application as well as follow up of nine months.", + "summary_subclaims": [ + "The patient is a 46-year-old woman.", + "The patient has relapsing remitting multiple sclerosis.", + "The patient has severe idiopathic pulmonary arterial hypertension.", + "Fingolimod was initiated because of disease activity of multiple sclerosis.", + "The patient had two relapses.", + "The patient had gadolinium-enhancing lesions in MRI.", + "The patient demonstrated stable disease course of idiopathic pulmonary arterial hypertension when fingolimod was started.", + "Fingolimod therapy did not alter or even worsen the pulmonary or cardiovascular conditions during first dose application.", + "Fingolimod therapy did not alter or even worsen the pulmonary or cardiovascular conditions during follow up of nine months." + ] + }, + { + "id": "multiclinsum_test_58_en.txt", + "fulltext": "A 32-year-old immunocompetent woman without any history of medical or surgical diseases, referred to our clinic, with unilateral edematous plaque on the left side of the face involving cheek, eyelids, nose and lips, with some ulcers which had purulent exudates on them .\nThe lesion had begun from 18 months ago. The lesion persisted till 5-6 months ago with no cure. Since then, the surrounded skin gradually became red, erythematous, and other ulcers appeared on the skin. On physical examination, the left side of the face was edematous and red and some ulcers with purulent exudates were seen. The lesion involved the nose and the lips but nasal and buccal mucosa was intact. CT-scanning of paranasal sinuses showed soft tissue thickness of the left cheek without involvement of the ipsilateral sinuses. Evaluations on exudate specimens revealed branched and aseptate hyphae, indicating mucormycosis. Punch biopsy and then surgical biopsy were done and both showed granulomatos dermatitis accompanying broad branched and aseptate hyphae that invaded the vascular endothelium. These findings confirmed the diagnosis of mucormycosis and therapy with Amphotricin-B deoxycholate was begun. After the patient became stable, extensive repetitive debridement of the involved area were performed. Therapy with amphotricine-B deoxycholate continued for a total dose of 2 g with good outcome and recovery of the lesion. The patient was then referred for plastic surgery.", + "fulltext_subclaims": [ + "The patient is a 32-year-old immunocompetent woman.", + "The patient had no history of medical or surgical diseases.", + "The patient had a unilateral edematous plaque on the left side of the face.", + "The lesion involved the cheek, eyelids, nose, and lips.", + "The lesion had begun 18 months ago.", + "The lesion persisted till 5-6 months ago with no cure.", + "Since 5-6 months ago, the surrounded skin gradually became red and erythematous.", + "Other ulcers appeared on the skin.", + "On physical examination, the left side of the face was edematous and red.", + "Some ulcers with purulent exudates were seen.", + "The lesion involved the nose and the lips.", + "The nasal and buccal mucosa was intact.", + "CT-scanning of paranasal sinuses showed soft tissue thickness of the left cheek.", + "The CT scan showed no involvement of the ipsilateral sinuses.", + "Evaluations on exudate specimens revealed branched and aseptate hyphae.", + "The findings indicated mucormycosis.", + "Punch biopsy showed granulomatous dermatitis accompanying broad branched and aseptate hyphae.", + "The hyphae invaded the vascular endothelium.", + "The diagnosis of mucormycosis was confirmed.", + "Therapy with Amphotericin-B deoxycholate was begun.", + "Extensive repetitive debridement of the involved area was performed after the patient became stable.", + "Therapy with amphotericin-B deoxycholate continued for a total dose of 2 g.", + "The patient had good outcome and recovery of the lesion.", + "The patient was referred for plastic surgery." + ], + "summary": "A 32-year-old immunocompetent woman presented with a large unilateral firm infiltrative plaque resembling cancer lesions, disfiguring the eyelids, nose and lips. The punch biopsy and then surgical debridement was done and the diagnosis of cutaneous mucormycosis was confirmed on histologic examinations with granulomatous reaction and characteristic broad, nonseptate, pale-staining hyphae.", + "summary_subclaims": [ + "The patient is a 32-year-old immunocompetent woman.", + "She presented with a large unilateral firm infiltrative plaque resembling cancer lesions.", + "The plaque disfigured the eyelids, nose, and lips.", + "A punch biopsy and surgical debridement were performed.", + "The diagnosis of cutaneous mucormycosis was confirmed.", + "Histologic examinations showed granulomatous reaction.", + "Histologic examinations showed characteristic broad, nonseptate, pale-staining hyphae." + ] + }, + { + "id": "multiclinsum_test_3303_en.txt", + "fulltext": "Patient, 29 years old, housewife, residing in Bamako, admitted to the department on 20 March 2023 for altered consciousness and fever. Her symptomatology would be of progressive onset, evolving for about fourteen days, marked by fever, headaches and vomiting, and then by a functional impairment of the right limbs. She had been treated for severe malaria confirmed by injection of artesunate in a private health facility for 6 days. She had given birth around 14 February 2023 after following prenatal consultations correctly. Her child was healthy. She had no known medical or surgical history, or use of immunosuppressive drugs. Physical examination revealed a fever of 38.8°C, a SOFA score of 6 (3 for the Glasgow score of 9/15 and 3 for a daily diuresis of 490 ml), a stiff neck, a pyramidal syndrome (hemiplegia and right-sided areflexia, left hemiplegia with a motor strength of 4/5 in the upper limb and 3/5 in the lower limb), and vaginal fingers stained with profuse discharge. The cranio-cerebral CT scan revealed several hypodensities enhanced by the contrast agent. One of these foci occupied almost the entire left hemisphere, with a mass effect on the homonymous ventricle and a deviation of the brain stem to the right, the other focus was right ventricular. The examination of the CSF showed a cloudy liquid, a mixed leukocytopaenia of 1080/mm3, hypoglycaemia of 0.5 g/l and hyperproteinaemia of 1.2 g/l. The CSF and vaginal swabs were positive for E. coli strains resistant to penicillin (amoxicillin, amoxicillin clavulanate), carboxypenicillin (ticarcillin), aminoglycoside (gentamycin), cephalosporins (cefotaxime, cefixime, cefotaxime, cefepime), quinolones (ciprofloxacin, norfloxacin), tetracycline, phenicols (chloramphenicol) and cotrimoxazole. They were sensitive to meropenem, amikacin, ceftazidine, colistine and cefepime. Creatinine clearance (CKD-EPI formula) was 61.35 ml/min with creatinemia of 110 µmol/l. The blood count showed moderate neutropenia of 1400/ml and moderate anaemia (haemoglobin of 9.1 g/dl), microcytic (VGM of 79 fl), hypochromic (CCMH of 30 g/dl). Two HIV serologies were negative. The diagnosis of genital sepsis with suppurative meningitis and acute renal failure was retained.\n\nThe patient was then given meropenem 1 g intravenously every eight hours for 21 days. She also received a hydro-electro-caloric intake of 3 litres per day, genital washing with chlorhexidine twice daily for five days, and physiotherapy from the 10th day of meropenem treatment. The patient's condition was favourable, with apyrexia and consciousness recovering on the 3rd and 6th day of meropenem treatment, respectively; the motor strength of the limbs was assessed as 2/5 on the right and 5/5 on the left upper limb, and 4/5 on the left lower limb on the 12th day of physiotherapy; renal function was good on the 10th day of meropenem treatment. Exeat was granted on 14 April 2023, with physiotherapy sessions in outpatient care and an appointment ten days later. At this appointment, the motor strength of the limbs was assessed as 5/5 on the left and 3/5 on the right.\n", + "fulltext_subclaims": [ + "The patient is a 29-year-old housewife.", + "The patient resides in Bamako.", + "The patient was admitted on 20 March 2023.", + "The patient had altered consciousness.", + "The patient had fever.", + "The patient's symptoms had a progressive onset.", + "The patient's symptoms had been evolving for about fourteen days.", + "The patient had fever, headaches, and vomiting.", + "The patient had functional impairment of the right limbs.", + "The patient had been treated for severe malaria.", + "The patient had received artesunate injections.", + "The treatment was in a private health facility.", + "The treatment lasted for 6 days.", + "The patient had given birth around 14 February 2023.", + "The patient had followed prenatal consultations correctly.", + "The patient's child was healthy.", + "The patient had no known medical or surgical history.", + "The patient had no use of immunosuppressive drugs.", + "Physical examination revealed a fever of 38.8°C.", + "The SOFA score was 6.", + "The Glasgow score was 9/15.", + "The daily diuresis was 490 ml.", + "The patient had a stiff neck.", + "The patient had a pyramidal syndrome.", + "The patient had hemiplegia and right-sided areflexia.", + "The patient had left hemiplegia with a motor strength of 4/5 in the upper limb.", + "The patient had left hemiplegia with a motor strength of 3/5 in the lower limb.", + "The cranio-cerebral CT scan revealed several hypodensities enhanced by the contrast agent.", + "One of the foci occupied almost the entire left hemisphere.", + "The CSF showed a cloudy liquid.", + "The CSF had a mixed leukocytopaenia of 1080/mm3.", + "The CSF had hypoglycaemia of 0.5 g/l.", + "The CSF had hyperproteinaemia of 1.2 g/l.", + "The CSF and vaginal swabs were positive for E. coli strains.", + "The E. coli strains were resistant to penicillin.", + "The E. coli strains were resistant to amoxicillin.", + "The E. coli strains were resistant to amoxicillin clavulanate.", + "The E. coli strains were resistant to ticarcillin.", + "The E. coli strains were resistant to gentamycin.", + "The E. coli strains were resistant to cefotaxime.", + "The E. coli strains were resistant to cefixime.", + "The E. coli strains were resistant to cefepime.", + "The E. coli strains were resistant to ciprofloxacin.", + "The E. coli strains were resistant to norfloxacin.", + "The E. coli strains were resistant to tetracycline.", + "The E. coli strains were resistant to chloramphenicol.", + "The E. coli strains were resistant to cotrimoxazole.", + "The E. coli strains were sensitive to meropenem.", + "The E. coli strains were sensitive to amikacin.", + "The E. coli strains were sensitive to ceftazidine.", + "The E. coli strains were sensitive to colistine.", + "The E. coli strains were sensitive to cefepime.", + "Creatinine clearance was 61.35 ml/min.", + "Creatinemia was 110 µmol/l.", + "The blood count showed moderate neutropenia of 1400/ml.", + "The blood count showed moderate anaemia with haemoglobin of 9.1 g/dl.", + "The anaemia was microcytic with VGM of 79 fl.", + "The anaemia was hypochromic with CCMH of 30 g/dl.", + "Two HIV serologies were negative.", + "The diagnosis was genital sepsis with suppurative meningitis.", + "The diagnosis included acute renal failure.", + "The patient was given meropenem 1 g intravenously every eight hours for 21 days.", + "The patient received a hydro-electro-caloric intake of 3 litres per day.", + "The patient had genital washing with chlorhexidine twice daily for five days.", + "The patient had physiotherapy from the 10th day of meropenem treatment.", + "The patient's condition was favourable.", + "The patient had apyrexia on the 3rd day of meropenem treatment.", + "The patient's consciousness recovered on the 6th day of meropenem treatment.", + "The motor strength of the limbs was assessed as 2/5 on the right and 5/5 on the left upper limb on the 12th day of physiotherapy.", + "The motor strength of the limbs was assessed as 4/5 on the left lower limb on the 12th day of physiotherapy.", + "Renal function was good on the 10th day of meropenem treatment.", + "Exeat was granted on 14 April 2023.", + "The patient had physiotherapy sessions in outpatient care.", + "The patient had an appointment ten days after exeat.", + "At the appointment, the motor strength of the limbs was assessed as 5/5 on the left and 3/5 on the right." + ], + "summary": "The second had given birth in the weeks prior to the onset of sepsis. She had meningitis and pyramidal syndrome with brain damage. Many antibiotic-resistant E. coli were isolated from the cerebrospinal fluid and genital swab. She recovered (with sequelae) with 21 days of meropenem treatment.\n", + "summary_subclaims": [ + "The second had given birth in the weeks prior to the onset of sepsis.", + "She had meningitis.", + "She had pyramidal syndrome.", + "She had brain damage.", + "Many antibiotic-resistant E. coli were isolated from the cerebrospinal fluid.", + "Many antibiotic-resistant E. coli were isolated from the genital swab.", + "She recovered with sequelae.", + "She received 21 days of meropenem treatment." + ] + }, + { + "id": "multiclinsum_test_2539_en.txt", + "fulltext": "A 45-year-old Japanese man visited our clinic in September 1996 complaining of decreased vision in his left eye. His vision was decreased to 20/200, and ophthalmoscopy showed a retinal detachment involving the macula and a retinoschisis that extended from the optic disc pit through the macula in the left eye . Glial tissue was seen at the optic disc pit but a retinal tear was not seen. Fluorescein angiography showed hypofluorescence of the optic disc pit, and multiple hyperfluorescent spots in the area of the macular lesion , but with no dye leakage. In the late phase, the optic disc pit and glial tissue became hyperfluorescent with mild dye leakage. He was diagnosed with optic disc pit maculopathy and vitrectomy was recommended.\nAfter obtaining informed consent, vitrectomy was performed. A posterior vitreous detachment (PVD) was created by suction with a vitreous cutter until the 'fish-strike sign' was no longer seen. However, the vitreous cortex remained firmly attached at the optic disc pit. Neither condensed vitreous strands nor a residual Cloquet's canal was observed. It was decided intra-operatively that the glial tissue at the edge of the optic pit should be removed in order to remove the vitreous traction completely. Tapered forceps with a fine tip were used to avoid contact with the neural tissue at the edges of the optic pit. During this procedure, it was noted that the glial tissue was firmly attached to the temporal wall of the optic pit. An excavated space at the bottom of the optic pit was then clearly observed after removal of the tissue.\nThe vitrectomy was completed with a 14% octafluoropropane (C3F8) gas tamponade, and the patient was instructed to maintain a face-down position for a week. Under these conditions, the retinal detachment and retinoschisis gradually decreased, and the retinal detachment and retinoschisis were absent six months postoperatively . Vision improved to 20/20 without any visual field defects (Goldmann perimetry).\nThe patient's vision deteriorated to 20/40 owing to a nuclear sclerosis cataract two years after the vitrectomy, and the lens was extracted. Vision has remained 20/20 for 10 years without any recurrence of the retinal detachment or retinoschisis. Optical coherence tomography (OCT) at this time did not detect a retinal detachment or retinoschisis, but two channels were seen running from the vitreous cavity to the longitudinal space of the optic nerve, possibly the subarachnoid space and the intraretinal space. The exit of these channels to the vitreous cavity was closed .", + "fulltext_subclaims": [ + "A 45-year-old Japanese man visited our clinic in September 1996.", + "He complained of decreased vision in his left eye.", + "His vision was decreased to 20/200.", + "Ophthalmoscopy showed a retinal detachment involving the macula.", + "Ophthalmoscopy showed a retinoschisis that extended from the optic disc pit through the macula in the left eye.", + "Glial tissue was seen at the optic disc pit.", + "A retinal tear was not seen.", + "Fluorescein angiography showed hypofluorescence of the optic disc pit.", + "Fluorescein angiography showed multiple hyperfluorescent spots in the area of the macular lesion.", + "There was no dye leakage in the early phase of fluorescein angiography.", + "In the late phase, the optic disc pit and glial tissue became hyperfluorescent with mild dye leakage.", + "He was diagnosed with optic disc pit maculopathy.", + "Vitrectomy was recommended.", + "After obtaining informed consent, vitrectomy was performed.", + "A posterior vitreous detachment (PVD) was created by suction with a vitreous cutter.", + "The 'fish-strike sign' was no longer seen after PVD creation.", + "The vitreous cortex remained firmly attached at the optic disc pit.", + "Neither condensed vitreous strands nor a residual Cloquet's canal was observed.", + "It was decided intra-operatively that the glial tissue at the edge of the optic pit should be removed.", + "Tapered forceps with a fine tip were used to avoid contact with the neural tissue at the edges of the optic pit.", + "The glial tissue was firmly attached to the temporal wall of the optic pit.", + "An excavated space at the bottom of the optic pit was then clearly observed after removal of the tissue.", + "The vitrectomy was completed with a 14% octafluoropropane (C3F8) gas tamponade.", + "The patient was instructed to maintain a face-down position for a week.", + "Under these conditions, the retinal detachment and retinoschisis gradually decreased.", + "The retinal detachment and retinoschisis were absent six months postoperatively.", + "Vision improved to 20/20.", + "There were no visual field defects.", + "The patient's vision deteriorated to 20/40 owing to a nuclear sclerosis cataract two years after the vitrectomy.", + "The lens was extracted.", + "Vision has remained 20/20 for 10 years.", + "There was no recurrence of the retinal detachment or retinoschisis.", + "Optical coherence tomography (OCT) at this time did not detect a retinal detachment or retinoschisis.", + "Two channels were seen running from the vitreous cavity to the longitudinal space of the optic nerve.", + "The exit of these channels to the vitreous cavity was closed." + ], + "summary": "A 45-year-old man complained of blurred vision, and ophthalmoscopy revealed a retinal detachment and retinoschisis extending from an optic disc pit through the macula in his left eye. He was diagnosed with optic disc pit maculopathy, and vitrectomy was performed. A posterior vitreous detachment was created, glial tissue at the optic pit was removed, and octafluoropropane (C3F8) was injected as a gas tamponade. The retinal detachment and retinoschisis disappeared after six months, and vision improved to 20/20 without any visual field defects (Goldmann perimetry). A cataractous lens was extracted 2 years after the vitrectomy, and vision has remained 20/20 for 10 years without any recurrence.", + "summary_subclaims": [ + "The patient is a 45-year-old man.", + "The patient complained of blurred vision.", + "Ophthalmoscopy revealed a retinal detachment.", + "Ophthalmoscopy revealed retinoschisis extending from an optic disc pit through the macula in his left eye.", + "He was diagnosed with optic disc pit maculopathy.", + "Vitrectomy was performed.", + "A posterior vitreous detachment was created.", + "Glial tissue at the optic pit was removed.", + "Octafluoropropane (C3F8) was injected as a gas tamponade.", + "The retinal detachment and retinoschisis disappeared after six months.", + "Vision improved to 20/20.", + "There were no visual field defects on Goldmann perimetry.", + "A cataractous lens was extracted 2 years after the vitrectomy.", + "Vision has remained 20/20 for 10 years.", + "There has been no recurrence." + ] + }, + { + "id": "multiclinsum_test_1061_en.txt", + "fulltext": "A 33-year-old Chinese man was admitted to our department for sustainable foamy urine for more than one year. He also complained of intermittent hair loss and recurrence of oral ulcers.\nApproximately one year prior, the patient was hospitalized at a local hospital for the same reason, and routine urine tests indicated microscopic hematuria and proteinuria. He did not pay much attention, and there was no further diagnosis or treatment because of a lack of conscious symptoms. One month prior, his blood pressure rose to 145/91 mmHg for unknown reasons; microscopic hematuria and heavy proteinuria were again detected.\nThe patient had no comorbidities.\nThe patient's father had asymptomatic microscopic hematuria and proteinuria, as detected in a routine physical examination approximately 2 years prior. The patient had a daughter and a son; the daughter (7 years old) had asymptomatic microscopic hematuria, and the son had microscopic hematuria and proteinuria. His son had ever been diagnosed with chronic nephritis at a local hospital.\nThe patient's appearance was normal, without edema. His systolic and diastolic blood pressures were 141 mmHg and 90 mmHg, respectively; his pulse rate was 81 beats per minute, and his respiratory rate was 19 breaths per minute. No obvious abnormality, including growth retardation, was detected during physical examination, and no specific nervous system symptoms were recognized. The patient was also subjected to audiologic assessments, but no hearing impairments were detected, even at high frequency. Furthermore, no symptoms were found in either eye by comprehensive ophthalmic examinations.\nMicroscopic hematuria and proteinuria were confirmed by urine tests. The results of other tests, including routine blood tests and serum immunology, are listed in Table .\nNo obvious abnormality was detected by abdominal ultrasound examination, X-ray diagnosis, or electrocardiographic examination. However, heart echocardiography showed a small amount of pericardial effusion.\nTo further analyze the renal presentation, a histopathology study of renal biopsy was performed. By light microscopy, a total of 13 glomeruli were observed, with one glomerulus being enlarged and lobulated. Para-aminosailcylic acid staining and Masson staining were positive, showing mild mesangial matrix proliferation. The basement membrane was thickened. Three glomerular fibroblastic crescents and pericystic fibrosis of glomeruli were observed . In addition, deposition of erythrotropin under the endothelium of the capillary loop was detected . Electron microscopy revealed obvious basement membrane lesions including variable thickness and reticulation of the glomerular basement membrane, as well as irregular subepithelial protrusion of the lamina densa. Fine particles and electron-dense bodies were detected in the stratified basement membrane . Immunological staining for IgG, IgA, IgM, C3, C4 C1q, К, and λ was positive in four glomeruli, with the signals being deposited in the vascular lumen and mesangial area in a granular or linear form .\nA considerable investigation of family history was performed. The patient’s father had asymptomatic microscopic hematuria and proteinuria, as detected in a routine physical examination approximately 2 years previously. As mentioned above, the patient had a daughter and a son: The former had asymptomatic microscopic hematuria, and the latter had microscopic hematuria and proteinuria; his son had been diagnosed with chronic nephritis at a local hospital. Thus, three relatives had microscopic hematuria. Therefore, a diagnosis of ATS was highly suspected . For a precise conclusive diagnosis, the patient and his children were recommended to undergo genetic testing, and WES was performed. Genomic DNA was extracted from blood samples; WES was performed as previously described. After sequencing, the coverage of the target sequence was over 99.12%, and the mean sequencing depth was approximately 147. The sequencing analysis revealed a heterozygous substitution, NM_000091 c.2657-1G>A (p. V294fs) in intron 22 of the COL4A3 gene, which was confirmed by Sanger sequencing . The mutation was excluded from the single nucleotide polymorphism database but was included in the ClinVar database. As this mutation is located at an evolutionarily conserved splice site, this splicing mutation is thought to lead to the skipping of exon 23. In addition, this variant is classified as “likely pathogenic” according to the American College of Medical Genetics and Genomics standards and guidelines .", + "fulltext_subclaims": [ + "The patient is a 33-year-old Chinese man.", + "He had sustainable foamy urine for more than one year.", + "He complained of intermittent hair loss.", + "He had recurrence of oral ulcers.", + "One year prior, he was hospitalized at a local hospital for the same reason.", + "Routine urine tests indicated microscopic hematuria and proteinuria.", + "He did not pay much attention.", + "There was no further diagnosis or treatment.", + "One month prior, his blood pressure rose to 145/91 mmHg.", + "Microscopic hematuria and heavy proteinuria were again detected.", + "The patient had no comorbidities.", + "The patient's father had asymptomatic microscopic hematuria and proteinuria.", + "The father's findings were detected in a routine physical examination approximately 2 years prior.", + "The patient had a daughter and a son.", + "The daughter had asymptomatic microscopic hematuria.", + "The son had microscopic hematuria and proteinuria.", + "The son had ever been diagnosed with chronic nephritis at a local hospital.", + "The patient's systolic blood pressure was 141 mmHg.", + "The patient's diastolic blood pressure was 90 mmHg.", + "No obvious abnormality was detected during physical examination.", + "No specific nervous system symptoms were recognized.", + "No hearing impairments were detected.", + "No symptoms were found in either eye.", + "Microscopic hematuria and proteinuria were confirmed by urine tests.", + "No obvious abnormality was detected by abdominal ultrasound.", + "No obvious abnormality was detected by X-ray diagnosis.", + "No obvious abnormality was detected by electrocardiographic examination.", + "Heart echocardiography showed a small amount of pericardial effusion.", + "A histopathology study of renal biopsy was performed.", + "A total of 13 glomeruli were observed.", + "One glomerulus was enlarged and lobulated.", + "Para-aminosailcylic acid staining and Masson staining were positive.", + "Mild mesangial matrix proliferation was observed.", + "The basement membrane was thickened.", + "Three glomerular fibroblastic crescents were observed.", + "Pericystic fibrosis of glomeruli was observed.", + "Deposition of erythrotropin under the endothelium of the capillary loop was detected.", + "Electron microscopy revealed variable thickness of the glomerular basement membrane.", + "Electron microscopy revealed reticulation of the glomerular basement membrane.", + "Electron microscopy revealed irregular subepithelial protrusion of the lamina densa.", + "Fine particles and electron-dense bodies were detected in the stratified basement membrane.", + "Immunological staining for IgG, IgA, IgM, C3, C4, C1q, К, and λ was positive in four glomeruli.", + "The signals were deposited in the vascular lumen and mesangial area in a granular or linear form.", + "Three relatives had microscopic hematuria.", + "A diagnosis of ATS was highly suspected.", + "The patient and his children were recommended to undergo genetic testing.", + "WES was performed.", + "Genomic DNA was extracted from blood samples.", + "The coverage of the target sequence was over 99.12%.", + "The mean sequencing depth was approximately 147.", + "A heterozygous substitution, NM_000091 c.2657-1G>A (p. V294fs), was found in intron 22 of the COL4A3 gene.", + "The mutation was confirmed by Sanger sequencing.", + "The mutation was excluded from the single nucleotide polymorphism database.", + "The mutation was included in the ClinVar database.", + "The mutation is located at an evolutionarily conserved splice site.", + "The splicing mutation is thought to lead to the skipping of exon 23.", + "The variant is classified as 'likely pathogenic' according to the American College of Medical Genetics and Genomics standards and guidelines." + ], + "summary": "A Chinese family with ATS was recruited for the current study. Clinical characteristics (including findings from renal biopsy) of ATS patients were collected from medical records, and potential causative genes were explored by whole-exome sequencing. A heterozygous substitution in intron 22 of COL4A3 (NM_000091 c.2657-1G>A) was found in the patients, which was further confirmed by quantitative polymerase chain reaction.", + "summary_subclaims": [ + "A Chinese family with ATS was recruited for the current study.", + "Clinical characteristics of ATS patients were collected from medical records.", + "Potential causative genes were explored by whole-exome sequencing.", + "A heterozygous substitution in intron 22 of COL4A3 (NM_000091 c.2657-1G>A) was found in the patients.", + "The heterozygous substitution in intron 22 of COL4A3 was further confirmed by quantitative polymerase chain reaction." + ] + }, + { + "id": "multiclinsum_test_2356_en.txt", + "fulltext": "The patient was a 27-year-old woman who first visited our hospital 4 years prior because of pain in the left femur. She was diagnosed with a left femoral synovial sarcoma with simultaneous multiple lung metastases. After chemotherapy, the primary lesion and lung metastasis decreased, and she underwent extensive resection of the primary lesion and lung metastases. During follow-up, abdominal computed tomography (CT) revealed a mass in the pancreatic tail. Before that time, only a chest CT was performed, and the abdomen was not evaluated. No notable hematology abnormalities were observed, and tumor markers (carcinoembryonic antigen: 0.7 ng/mL and carbohydrate antigen: 19–9: 7 U/mL) were within the normal ranges.\nContrast-enhanced thoracoabdominal CT revealed a large, 35-mm tumor in the pancreatic tail showing heterogeneous contrast enhancement without calcification or bleeding. Lymphadenopathy and distant metastases were not observed.\nAbdominal magnetic resonance imaging revealed that the tumor in the pancreatic tail was similar to that in the primary left femoral lesion, showing a low signal on the T1-weighted image, a slightly hyperintense tumor containing multiple cystic components on the T2-weighted image, and a high signal on the diffusion-weighted image. The inside of the pancreatic tail tumor was heterogeneous and partly showed a water signal that was indicative of necrosis. 18F-fluorodeoxyglucose positron emission tomography CT revealed abnormal fluorodeoxyglucose accumulation only in the tumor of the pancreatic tail, with no other metastatic findings .\nThe preoperative diagnosis was synovial sarcoma recurrence of pancreatic tail metastasis, and laparoscopic distal pancreatectomy was planned. However, 2 weeks after the outpatient consultation, she developed left upper quadrant abdominal pain at night after drinking a small amount of alcohol, and she visited our emergency department. Her vital signs were as follows: pulse, 66 beats/min; respiration, 18 breaths/min; blood pressure, 100/60 mmHg; and temperature, 36.8 °C. Physical examination revealed tenderness and rebound pain in the left upper quadrant of the abdomen. Hematology findings revealed leukocytosis (13,400 cells/mm3) and anemia (hemoglobin: 11.0 g/dL).\nContrast-enhanced abdominal CT performed in the emergency department revealed ascites with high CT values in the liver surface and pelvis , and leakage of contrast medium in the anterior of the pancreatic tail tumor to the omental bursa . The diagnosis was intra-abdominal hemorrhage due to a ruptured metastatic pancreatic tail tumor, and an urgent distal pancreatectomy was, therefore, performed.\nDuring the emergency surgery, approximately 1500 mL of hematoma was observed during laparotomy, and bleeding from the tumor of the pancreatic tail was identified after opening the omentum . The splenic artery and vein were isolated and individually ligated to control the bleeding. The pancreas was dissected with linear stapling devices for over 15 min, and distal pancreatectomy was performed . The operation time was 123 min, including the hematoma suctioning, and the amount of bleeding was 1530 mL; the patient required four units of concentrated red blood cell transfusion.\nAscites cytology was performed during the emergency surgery and after surgery, and the results were negative.\nAccording to the International Study Group of Pancreatic Fistula classification, a pancreatic fistula of the grade “biochemical leak” was observed, and she was discharged on postoperative day 18.\nAnalysis of the resected specimen showed that the capsule of the pancreas tail tumor was ruptured, and the tumor parenchyma was exposed . Upon histological examination, hematoxylin and eosin staining revealed the presence of monophasic spindle cells that grew solidly with stag horn-like vessels. Immunohistochemistry revealed that the tumor cells were positive for B-cell lymphoma 2 and CD99 but lacked expression of CD34, alpha-smooth muscle actin, desmin, and S100. Some of the tumor cells tested positive for epithelial membrane antigen. The MIB-1 proliferation index identified via MIB-1 staining was approximately 70%, indicating a high-grade sarcoma, and the tumor was compatible with synovial sarcoma metastasis to the pancreas . The resection margin of the pancreas was negative; however, tumor cells were exposed from the capsule owing to tumor rupture, and tumor cells were observed in the hematoma.\nRegarding the follow-up after discharge, the patient has been carefully monitored without chemotherapy, because the target lesion has been previously resected, and confirmed to be in relapse-free survival for 6 months.", + "fulltext_subclaims": [ + "The patient was a 27-year-old woman.", + "She first visited the hospital 4 years prior because of pain in the left femur.", + "She was diagnosed with a left femoral synovial sarcoma with simultaneous multiple lung metastases.", + "After chemotherapy, the primary lesion and lung metastasis decreased.", + "She underwent extensive resection of the primary lesion and lung metastases.", + "Abdominal computed tomography (CT) revealed a mass in the pancreatic tail.", + "Before that time, only a chest CT was performed, and the abdomen was not evaluated.", + "Tumor markers (carcinoembryonic antigen: 0.7 ng/mL and carbohydrate antigen 19–9: 7 U/mL) were within the normal ranges.", + "Contrast-enhanced thoracoabdominal CT revealed a large, 35-mm tumor in the pancreatic tail showing heterogeneous contrast enhancement without calcification or bleeding.", + "Lymphadenopathy and distant metastases were not observed.", + "Abdominal magnetic resonance imaging revealed that the tumor in the pancreatic tail was similar to that in the primary left femoral lesion.", + "The tumor showed a low signal on the T1-weighted image.", + "The tumor contained multiple cystic components on the T2-weighted image.", + "The tumor showed a high signal on the diffusion-weighted image.", + "The inside of the pancreatic tail tumor was heterogeneous and partly showed a water signal that was indicative of necrosis.", + "18F-fluorodeoxyglucose positron emission tomography CT revealed abnormal fluorodeoxyglucose accumulation only in the tumor of the pancreatic tail.", + "The preoperative diagnosis was synovial sarcoma recurrence of pancreatic tail metastasis.", + "Laparoscopic distal pancreatectomy was planned.", + "She developed left upper quadrant abdominal pain at night after drinking a small amount of alcohol.", + "Contrast-enhanced abdominal CT performed in the emergency department revealed ascites with high CT values in the liver surface and pelvis.", + "Contrast-enhanced abdominal CT revealed leakage of contrast medium in the anterior of the pancreatic tail tumor to the omental bursa.", + "The diagnosis was intra-abdominal hemorrhage due to a ruptured metastatic pancreatic tail tumor.", + "An urgent distal pancreatectomy was performed.", + "During the emergency surgery, approximately 1500 mL of hematoma was observed during laparotomy.", + "Bleeding from the tumor of the pancreatic tail was identified after opening the omentum.", + "The splenic artery and vein were isolated and individually ligated to control the bleeding.", + "The pancreas was dissected with linear stapling devices for over 15 min.", + "The operation time was 123 min, including the hematoma suctioning.", + "The amount of bleeding was 1530 mL.", + "The patient required four units of concentrated red blood cell transfusion.", + "Ascites cytology was performed during the emergency surgery and after surgery.", + "The results of ascites cytology were negative.", + "A pancreatic fistula of the grade 'biochemical leak' was observed.", + "She was discharged on postoperative day 18.", + "Analysis of the resected specimen showed that the capsule of the pancreas tail tumor was ruptured.", + "The tumor parenchyma was exposed.", + "Hematoxylin and eosin staining revealed the presence of monophasic spindle cells that grew solidly with stag horn-like vessels.", + "The tumor cells were positive for B-cell lymphoma 2 and CD99.", + "The tumor cells lacked expression of CD34, alpha-smooth muscle actin, desmin, and S100.", + "Some of the tumor cells tested positive for epithelial membrane antigen.", + "The MIB-1 proliferation index identified via MIB-1 staining was approximately 70%.", + "The tumor was compatible with synovial sarcoma metastasis to the pancreas.", + "The resection margin of the pancreas was negative.", + "Tumor cells were exposed from the capsule owing to tumor rupture.", + "Tumor cells were observed in the hematoma.", + "The patient has been carefully monitored without chemotherapy.", + "The target lesion has been previously resected.", + "The patient has been confirmed to be in relapse-free survival for 6 months." + ], + "summary": "A 27-year-old woman underwent extensive resection of the primary tumor and partial lung resection after chemotherapy for left femoral synovial sarcoma and multiple lung metastases 4 years prior. During the follow-up, a 35-mm tumor was noted in the pancreatic tail on abdominal computed tomography (CT), and no other distant metastases were detected via positron emission tomography CT. Laparoscopic distal pancreatectomy was scheduled for pancreatic metastasis of synovial sarcoma. However, before the scheduled pancreatectomy could be conducted, the patient visited the emergency department because of abdominal pain that occurred after consuming a small amount of alcohol, and CT showed ascites with high CT values and leakage of contrast media. She was diagnosed with intra-abdominal hemorrhage due to a ruptured metastatic pancreatic tumor, and an emergency operation was performed. In total, 1500 mL of blood was evacuated from the abdomen, and the bleeding pancreatic tail tumor was resected. Histopathological findings revealed synovial sarcoma metastasis and a ruptured tumor capsule, and tumor cells were observed in the hematoma. After discharge on postoperative day 18, the patient was carefully monitored and confirmed to be in relapse-free survival, without chemotherapy, at 6 months post-surgery.", + "summary_subclaims": [ + "The patient is a 27-year-old woman.", + "She underwent extensive resection of the primary tumor and partial lung resection.", + "The resection occurred after chemotherapy.", + "The primary tumor was a left femoral synovial sarcoma.", + "Multiple lung metastases were present.", + "The surgery was performed 4 years prior to the current follow-up.", + "A 35-mm tumor was noted in the pancreatic tail on abdominal CT.", + "No other distant metastases were detected via positron emission tomography CT.", + "Laparoscopic distal pancreatectomy was scheduled for pancreatic metastasis of synovial sarcoma.", + "The patient visited the emergency department due to abdominal pain after consuming a small amount of alcohol.", + "CT showed ascites with high CT values.", + "CT showed leakage of contrast media.", + "She was diagnosed with intra-abdominal hemorrhage due to a ruptured metastatic pancreatic tumor.", + "An emergency operation was performed.", + "A total of 1500 mL of blood was evacuated from the abdomen.", + "The bleeding pancreatic tail tumor was resected.", + "Histopathological findings revealed synovial sarcoma metastasis.", + "The tumor capsule was ruptured.", + "Tumor cells were observed in the hematoma.", + "The patient was discharged on postoperative day 18.", + "The patient was confirmed to be in relapse-free survival at 6 months post-surgery.", + "The patient was monitored without chemotherapy." + ] + }, + { + "id": "multiclinsum_test_2186_en.txt", + "fulltext": "On the 2nd of March 2013, a 26-year-old man resident of Rafsanjan (Kerman province, south-eastern, Iran) was admitted to Shahid Sadoughi Hospital of Yazd, Iran with symptoms of severe abdominal pain. The patient reported extensive biting on his left leg by a dog showing marked aggressiveness, on the 22nd of September 2012, eight months before symptomatic disease onset. The dog had bitten four people who had received rabies immune globulin (RIG) and vaccine while our study patient had not received this treatment. The dog died three days after the biting incident. On admission, our study patient stayed at the surgery unit for one day because of his severe abdominal pain followed by two days at the neurology unit because of behavioral changes. After consultation, he was transferred to the infectious diseases ward.\nOn the first day of hospital admission, the patient had malaise, diplopia, headache, depression, vomiting and severe abdominal pain in the hypogastria. He also had a five-year history of consumption of narcotic substances (opium) but had quit use since six months ago. Complete blood count revealed a normal count of leucocytes (9200/μL). Blood had a slight increase of glucose (111 mg/dL). Wright and Widal tests were negative. Cerebrospinal fluid (CSF) was analyzed and showed 100% lymphocytes, two white blood cells (WBC), 159 red blood cells (RBC) and protein 40 mg/dL.\nOn the 3rd and 4th of March 2013, the patient had a slight fever (38.1°C), malaise, headache, abdominal pain and abnormal behavior. Finally, the patient died on the 4th of March 2013. Cerebrospinal fluid sample was submitted to the Pasteur Institute of Tehran, Iran. The polymerase chain reaction (PCR) test was performed. This test was positive and proved rabies disease.", + "fulltext_subclaims": [ + "A 26-year-old man resident of Rafsanjan was admitted to Shahid Sadoughi Hospital of Yazd, Iran on the 2nd of March 2013.", + "The patient reported a dog bite on his left leg on the 22nd of September 2012.", + "The dog bite occurred eight months before the onset of symptoms.", + "The dog had bitten four people who had received rabies immune globulin and vaccine.", + "The study patient had not received rabies immune globulin or vaccine.", + "The dog died three days after the biting incident.", + "On admission, the patient stayed at the surgery unit for one day.", + "The patient was transferred to the neurology unit for two days due to behavioral changes.", + "The patient was transferred to the infectious diseases ward after consultation.", + "On the first day of hospital admission, the patient had malaise, diplopia, headache, depression, vomiting, and severe abdominal pain in the hypogastria.", + "The patient had a five-year history of opium use but had quit six months before admission.", + "Complete blood count showed a normal leucocyte count of 9200/μL.", + "Blood glucose was slightly increased at 111 mg/dL.", + "Wright and Widal tests were negative.", + "Cerebrospinal fluid analysis showed 100% lymphocytes, two white blood cells, 159 red blood cells, and protein 40 mg/dL.", + "On the 3rd and 4th of March 2013, the patient had a slight fever, malaise, headache, abdominal pain, and abnormal behavior.", + "The patient died on the 4th of March 2013.", + "A cerebrospinal fluid sample was submitted to the Pasteur Institute of Tehran, Iran.", + "A polymerase chain reaction test was performed.", + "The PCR test was positive and proved rabies disease." + ], + "summary": "During the years 2001-2011, there have been 73 reported rabies cases. About 50,000 reported human deaths are annually due to rabies. The actual number of human deaths due to rabies in Asia especially India, Pakistan and Bangladesh are more than these numbers, since there is no advanced surveillance system for disease control to determine the actual number of infected and fatal human cases. According to the World Health Organization (WHO) reports, more than 10 million people who are bitten by animals are annually treated by prophylactic treatment regimens for rabies, worldwide.", + "summary_subclaims": [ + "During the years 2001-2011, there have been 73 reported rabies cases.", + "About 50,000 reported human deaths are annually due to rabies.", + "The actual number of human deaths due to rabies in Asia especially India, Pakistan and Bangladesh are more than these numbers.", + "There is no advanced surveillance system for disease control to determine the actual number of infected and fatal human cases.", + "According to the World Health Organization (WHO) reports, more than 10 million people who are bitten by animals are annually treated by prophylactic treatment regimens for rabies, worldwide." + ] + }, + { + "id": "multiclinsum_test_3060_en.txt", + "fulltext": "A 13-year-old girl was referred to our hospital due to mild proteinuria which was detected at a school urinary screening. No urinary abnormalities had been detected previously. She was born at a gestational age of 23 weeks and 6 days because of maternal fever, with a very LBW of 630 g, equivalent in size to 23 weeks of pregnancy. She had chronic lung disease and premature infant retinitis. She required O2 until she was 1 year of age; however, her growth and development had reached the normal range by that time. Apart from retinopathy of prematurity, she had been generally healthy, both physically and mentally.\n\nPhysical examination showed the following: height 154 cm, weight 50 kg, body mass index 21.1, and blood pressure 115/73 mmHg. Dipstick urinalysis revealed grade (2+) proteinuria. Her serum creatinine level was 1.02 mg/dL, and she was diagnosed as having stage 2 CKD based on reference serum creatinine levels of Japanese male and female children aged 12 to 15 years. Her serum uric acid level was 7 mg/dL (normal level was less than 4.6 mg/dL based on reference serum levels of female children aged 12 to 14 years), she had hyperuricemia. Her mother and her 16-years old brother had hyperuricemia, too.\n\nA percutaneous renal biopsy demonstrated that 1 out of 8 glomeruli had segmental sclerosis with adhesion to the Bowman’s capsule (black arrow), and white arrow indicated partial focal interstitial fibrosis. The mean diameter of the glomeruli was 348.23 μm, which was much larger than that of normal glomeruli (168 ± 12 μm). Immunofluorescence analyses (IgG, IgA, IgM, C3, C1q and C4) were all negative. These biopsy findings supported a diagnosis of FSGS.\n\nAfter 3 years of treatment with an angiotensin receptor blocker (ARB), her proteinuria decreased. However, her serum creatinine level was 1.07 mg/dL, and she still had stage 2 CKD.", + "fulltext_subclaims": [ + "A 13-year-old girl was referred to our hospital due to mild proteinuria detected at a school urinary screening.", + "No urinary abnormalities had been detected previously.", + "She was born at a gestational age of 23 weeks and 6 days.", + "She had a very LBW of 630 g, equivalent in size to 23 weeks of pregnancy.", + "She had chronic lung disease.", + "She had premature infant retinitis.", + "She required O2 until she was 1 year of age.", + "Her growth and development had reached the normal range by the age of 1 year.", + "She had retinopathy of prematurity.", + "Her height was 154 cm.", + "Her weight was 50 kg.", + "Her body mass index was 21.1.", + "Her blood pressure was 115/73 mmHg.", + "Dipstick urinalysis revealed grade (2+) proteinuria.", + "Her serum creatinine level was 1.02 mg/dL.", + "She was diagnosed as having stage 2 CKD based on reference serum creatinine levels of Japanese male and female children aged 12 to 15 years.", + "Her serum uric acid level was 7 mg/dL.", + "The normal level of serum uric acid was less than 4.6 mg/dL based on reference serum levels of female children aged 12 to 14 years.", + "She had hyperuricemia.", + "Her mother had hyperuricemia.", + "Her 16-year-old brother had hyperuricemia.", + "A percutaneous renal biopsy demonstrated that 1 out of 8 glomeruli had segmental sclerosis with adhesion to the Bowman’s capsule.", + "White arrow indicated partial focal interstitial fibrosis.", + "The mean diameter of the glomeruli was 348.23 μm.", + "The mean diameter of the glomeruli was much larger than that of normal glomeruli (168 ± 12 μm).", + "Immunofluorescence analyses (IgG, IgA, IgM, C3, C1q and C4) were all negative.", + "These biopsy findings supported a diagnosis of FSGS.", + "After 3 years of treatment with an angiotensin receptor blocker (ARB), her proteinuria decreased.", + "Her serum creatinine level was 1.07 mg/dL.", + "She still had stage 2 CKD." + ], + "summary": "A 13-year-old girl was referred to our hospital owing to mild proteinuria, which was detected at a school urinary screening. She was born at a gestational age of 23 weeks, with a very LBW of 630 g. Dipstick urinalysis revealed grade (2+) proteinuria. Her serum creatinine level was 1.02 mg/dL, and she was diagnosed as having stage 2 chronic kidney disease (CKD). Her serum uric acid level was 7 mg/dL. Furthermore, her mother and 16-year old brother had hyperuricemia. A percutaneous renal biopsy leads to a diagnosis of FSGS. After 3 years of treatment with an angiotensin receptor blocker, her proteinuria decreased. However, her serum creatinine level was 1.07 mg/dL, and she still had stage 2 CKD. We considered that in this patient, the first hit was her LBW, and the second hit was hyperuricemia. The second hit might be associated with the development of CKD.", + "summary_subclaims": [ + "A 13-year-old girl was referred to our hospital owing to mild proteinuria.", + "The proteinuria was detected at a school urinary screening.", + "She was born at a gestational age of 23 weeks.", + "She had a very low birth weight of 630 g.", + "Dipstick urinalysis revealed grade (2+) proteinuria.", + "Her serum creatinine level was 1.02 mg/dL.", + "She was diagnosed as having stage 2 chronic kidney disease.", + "Her serum uric acid level was 7 mg/dL.", + "Her mother and 16-year-old brother had hyperuricemia.", + "A percutaneous renal biopsy leads to a diagnosis of FSGS.", + "After 3 years of treatment with an angiotensin receptor blocker, her proteinuria decreased.", + "Her serum creatinine level was 1.07 mg/dL.", + "She still had stage 2 CKD.", + "The first hit was her low birth weight.", + "The second hit was hyperuricemia.", + "The second hit might be associated with the development of CKD." + ] + }, + { + "id": "multiclinsum_test_335_en.txt", + "fulltext": "A 39 year-old white female presented to The Arthur G. James Cancer Hospital with worsening pain of the left breast and left chest wall region and a recurrent palpable mass within the inferior aspect of her left breast. She reports having had three separate left breast biopsies in the past (seven years, four years, and one year prior to her current presentation) for a recurring left breast palpable mass in this same location.\nSeven years prior to her current presentation, she presented to an outside community hospital with a palpable left breast mass in the inferior lateral aspect of her left breast. She underwent a left breast biopsy at that time that was reported as showing dense fibrous stroma with fibrocystic changes.\nThree years later (four years prior to her current presentation), she noticed a recurrent enlarging palpable left breast mass. She underwent a repeat left breast biopsy by the same surgeon and this showed hyperplastic fibrosis, consistent with fibromatosis of the breast. The pathology report clearly stated that the tumor involved the surgical margins. The patient reports that the surgeon told her that this was a benign tumor and that nothing further needed to be done.\nThree additional years later (one year prior to her current presentation), she again noticed a recurrent enlarging palpable left breast mass. She again underwent a repeat left breast biopsy by the same surgeon and this again showed findings consistent with fibromatosis of the breast. Again, the pathology report clearly stated that the tumor involved the surgical margins. The patient reports that the surgeon again told her that this was a benign tumor and that nothing further needed to be done.\nSince the time of her last left breast biopsy (one year prior to her current presentation), the patient reports persistent and worsening pain and palpable tenderness within the inferior aspect of her left breast and left chest wall region, with an associated increasing sized palpable mass within the same region.\nUpon presentation to The Arthur G. James Cancer Hospital, she was found on clinical examination to have volume loss along the entire inferior aspect of her left breast and slight downward tilting of her left nipple and areolar complex. She had three separate well-healed surgical scars along the inferior-lateral aspect of her left inframammary fold . Underneath these scars, she had a firm palpable mass, clinically measuring 6.5 × 3.0 × 2.5 cm in size and which clinically appeared to be adherent to the underlying left chest wall structures. She had no clinically apparent adenopathy in her left axilla.\nA mammogram showed scarring and tissue disorganization in the inferior left breast from prior multiple biopsies, but appeared unchanged since a prior mammogram done 13 months previously at an outside community hospital. Magnetic resonance imaging of the left breast showed an intensely enhancing lesion in the inferior-lateral aspect of the left breast, measuring 5.0 × 1.7 cm in size . This lesion appeared to abut the underlying chest wall musculature and appeared to efface the underlying fat plane. Computed tomography scan of the chest showed a 5.2 × 1.6 cm mass within the inferior-lateral aspect of the left chest wall that appeared to be in continuity with the left pectoralis major muscle and left serratus anterior muscle . A core biopsy was performed to the palpable left breast mass that confirmed the diagnosis of fibromatosis.\nThe patient was taken to the operating room at to The Arthur G. James Cancer Hospital and underwent a left total mastectomy, with en bloc resection of the underlying musculature (inferior lateral portion of the left pectoralis major muscle, superior portion of the left abdominal oblique musculature, and anterior portion of the left serratus anterior muscle) and en bloc resection of the underlying chest wall structures (fourth, fifth, and six ribs, intercostals muscles, and parietal pleura). The left chest wall defect was then closed with a 2-mm DualMesh Gore-Tex patch (W. L. Gore & Associates, Inc., Flagstaff, Arizona). The remaining portions of the left pectoralis major muscle was dissected off the underlying left chest wall and its lateral most attachments to the left humerus and superior attachments to the clavicle were divided, allowing it to rotate inferiorly to completely cover the Gore-Tex patch. The left mastectomy site was then closed in the standard fashion. No attempts at cosmetic breast reconstruction with autologous tissue transfer or expander/implant placement were considered at that time. The patient's post-operative course was uneventful and she was discharged to home on post-operative day eight.\nGross pathologic evaluation of the specimen, which overall measured 14.5 × 13.3 × 6.4 cm in size, revealed a 5.2 cm tumor that was grossly invading the underlying attached skeletal muscle to a depth of about 1.2 cm . It could not be definitively determined whether the invasion of the underlying skeletal muscle involved only the superficial muscles resected (consisting of the inferior lateral portion of the left pectoralis major muscle, superior portion of the left abdominal oblique musculature, and anterior portion of the left serratus anterior muscle) or whether skeletal muscle invasion was to the level of the underlying intercostal muscles resected. However, both grossly and microscopically, there was no evidence of invasion into the bony ribs or underlying parietal pleura. Microscopic evaluation revealed a proliferation of relatively evenly spaced plump spindle cells arranged in intersecting fascicles and associated with mild to moderate amounts of collagen and occasional mitotic figures and demonstrated that the spindle cell proliferations invaded into the adjacent skeletal muscle . All surgical margins were negative. On immunohistochemical staining, the spindle cells were negative for S-100 protein, muscle actin (HHF-35), and cytokeratin AE1/AE3. On immunohistochemical staining, less than 5% of the spindle cells were positive for Mib1 (Ki-67). The histology and immunohistochemical staining supported a diagnosis of fibromatosis (desmoid tumor).\nThe patient is now 22 months out from her previous aggressive operative management of her previous multiple recurrences of her fibromatosis of her left breast and she remains disease free.", + "fulltext_subclaims": [ + "The patient is a 39 year-old white female.", + "She presented with worsening pain of the left breast and left chest wall region.", + "She has a recurrent palpable mass within the inferior aspect of her left breast.", + "She reports having had three separate left breast biopsies in the past.", + "The biopsies were seven years, four years, and one year prior to her current presentation.", + "The biopsies were for a recurring left breast palpable mass in the same location.", + "Seven years prior, she had a left breast biopsy at an outside community hospital.", + "The biopsy showed dense fibrous stroma with fibrocystic changes.", + "Four years prior to her current presentation, she had a repeat left breast biopsy.", + "The biopsy showed hyperplastic fibrosis, consistent with fibromatosis of the breast.", + "The pathology report stated that the tumor involved the surgical margins.", + "The surgeon told her that this was a benign tumor and that nothing further needed to be done.", + "One year prior to her current presentation, she had another repeat left breast biopsy.", + "The biopsy again showed findings consistent with fibromatosis of the breast.", + "The pathology report again stated that the tumor involved the surgical margins.", + "The surgeon again told her that this was a benign tumor and that nothing further needed to be done.", + "Since her last biopsy, she reports persistent and worsening pain and palpable tenderness.", + "She reports an associated increasing sized palpable mass within the same region.", + "Clinical examination showed volume loss along the entire inferior aspect of her left breast.", + "There was slight downward tilting of her left nipple and areolar complex.", + "She had three separate well-healed surgical scars along the inferior-lateral aspect of her left inframammary fold.", + "Under these scars, there was a firm palpable mass, clinically measuring 6.5 × 3.0 × 2.5 cm.", + "The mass appeared to be adherent to the underlying left chest wall structures.", + "There was no clinically apparent adenopathy in her left axilla.", + "A mammogram showed scarring and tissue disorganization in the inferior left breast.", + "The mammogram appeared unchanged since a prior mammogram done 13 months previously.", + "Magnetic resonance imaging showed an intensely enhancing lesion in the inferior-lateral aspect of the left breast.", + "The lesion measured 5.0 × 1.7 cm in size.", + "The lesion appeared to abut the underlying chest wall musculature.", + "The lesion appeared to efface the underlying fat plane.", + "Computed tomography showed a 5.2 × 1.6 cm mass within the inferior-lateral aspect of the left chest wall.", + "The mass appeared to be in continuity with the left pectoralis major muscle and left serratus anterior muscle.", + "A core biopsy confirmed the diagnosis of fibromatosis.", + "The patient underwent a left total mastectomy.", + "The mastectomy included en bloc resection of the underlying musculature.", + "The musculature resected included the inferior lateral portion of the left pectoralis major muscle.", + "The musculature resected included the superior portion of the left abdominal oblique musculature.", + "The musculature resected included the anterior portion of the left serratus anterior muscle.", + "The resection included the fourth, fifth, and sixth ribs.", + "The resection included the intercostal muscles and parietal pleura.", + "The left chest wall defect was closed with a 2-mm DualMesh Gore-Tex patch.", + "The remaining portions of the left pectoralis major muscle were dissected off the underlying left chest wall.", + "The lateral most attachments to the left humerus and superior attachments to the clavicle were divided.", + "The muscle was allowed to rotate inferiorly to cover the Gore-Tex patch.", + "The left mastectomy site was closed in the standard fashion.", + "No attempts at cosmetic breast reconstruction were considered.", + "The patient was discharged to home on post-operative day eight.", + "Gross pathologic evaluation revealed a 5.2 cm tumor.", + "The tumor was invading the underlying attached skeletal muscle to a depth of about 1.2 cm.", + "It could not be definitively determined whether the invasion involved only the superficial muscles resected.", + "There was no evidence of invasion into the bony ribs or underlying parietal pleura.", + "Microscopic evaluation revealed a proliferation of relatively evenly spaced plump spindle cells.", + "The spindle cells were arranged in intersecting fascicles.", + "The spindle cells were associated with mild to moderate amounts of collagen.", + "The spindle cells showed occasional mitotic figures.", + "The spindle cell proliferations invaded into the adjacent skeletal muscle.", + "All surgical margins were negative.", + "The spindle cells were negative for S-100 protein.", + "The spindle cells were negative for muscle actin (HHF-35).", + "The spindle cells were negative for cytokeratin AE1/AE3.", + "Less than 5% of the spindle cells were positive for Mib1 (Ki-67).", + "The histology and immunohistochemical staining supported a diagnosis of fibromatosis (desmoid tumor).", + "The patient is now 22 months out from her previous aggressive operative management.", + "She remains disease free." + ], + "summary": "We report a patient with three post-surgical recurrences of fibromatosis of the breast over a seven year period. The fibromatosis was found to be involving the chest wall musculature and causing persistent and worsening pain. An aggressive operative strategy was undertaken, consisting of mastectomy with en bloc resection of the underlying chest wall musculature, ribs, and parietal pleura.", + "summary_subclaims": [ + "The patient had three post-surgical recurrences of fibromatosis of the breast over a seven year period.", + "The fibromatosis was involving the chest wall musculature.", + "The fibromatosis was causing persistent and worsening pain.", + "An aggressive operative strategy was undertaken.", + "The operative strategy consisted of mastectomy with en bloc resection of the underlying chest wall musculature, ribs, and parietal pleura." + ] + }, + { + "id": "multiclinsum_test_2579_en.txt", + "fulltext": "A 26-year-old Caucasian woman presented to cardiology polyclinics with heart palpitations and shortness of breath. The patient's mother had died when she was 35 years old as a result of sudden cardiac arrest (SCA), and her grandmother had died as a result of congestive heart failure (CHF). The patient's body mass index was 24 kg/m2. The 24-hour electrocardiographic (ECG) monitoring documented 2602 bi-geminal, tri-geminal and quadri-geminal ventricular extrasystoles per hour as well as ventricular tachycardia (VT) episodes. The duration of filtered QRS was more than 120 ms. Her echocardiogram was within the normal ranges. Cardiac non-contrast-enhanced magnetic resonance imaging (MRI) showed diffuse thinning of the right ventricle and local dilation in the right ventricular wall with segmental hypokinesia. The electrophysiological study revealed sustained non-inducible VT, low-amplitude areas in the right ventricular outflow tract and ventricular ectopic beats originating in the right ventricular outflow tract. Because VT was non-inducible, neither the use of an implanted cardioverter-defibrillator (ICD) nor ablation was considered. There was right ventricular dilation and apical mild hypokinesia. She had no signs of left ventricular dysfunction. On the basis of these results, the diagnosis of ARVD was made according to the original International Task Force diagnostic criteria. She was prescribed metoprolol and propafenone. She avoided physical stress and did very well with pharmacological treatment. After three years of follow-up, she wanted to conceive. She was counseled that only a few pregnancies have been reported in patients with ARVD and that the risk of transmission of the disease to the offspring is 50%. A mutation screening was offered, but she refused the mutation screening because of the high cost. She conceived and ceased her medications but did very well during her pregnancy until term.\nA fetal echocardiogram was performed at the 21st week of pregnancy, and after delivery no abnormality was detected. In the third trimester, she had heart palpitations and became symptomatic again. The 24-hour ECG monitoring at the 32nd week of pregnancy documented 16,251 ventricular extrasystoles.\nShe delivered at the 38th week of pregnancy by elective cesarean section while under general anesthesia. After three days of hospitalization, she was discharged without medications and continued breastfeeding for six months.", + "fulltext_subclaims": [ + "The patient is a 26-year-old Caucasian woman.", + "She presented to cardiology polyclinics with heart palpitations and shortness of breath.", + "Her mother had died at 35 years old from sudden cardiac arrest.", + "Her grandmother had died from congestive heart failure.", + "The 24-hour ECG monitoring documented 2602 bi-geminal, tri-geminal and quadri-geminal ventricular extrasystoles per hour.", + "The 24-hour ECG monitoring documented ventricular tachycardia episodes.", + "The duration of filtered QRS was more than 120 ms.", + "Her echocardiogram was within the normal ranges.", + "Cardiac non-contrast-enhanced MRI showed diffuse thinning of the right ventricle.", + "Cardiac non-contrast-enhanced MRI showed local dilation in the right ventricular wall.", + "Cardiac non-contrast-enhanced MRI showed segmental hypokinesia.", + "The electrophysiological study revealed sustained non-inducible VT.", + "The electrophysiological study revealed low-amplitude areas in the right ventricular outflow tract.", + "The electrophysiological study revealed ventricular ectopic beats originating in the right ventricular outflow tract.", + "Because VT was non-inducible, neither the use of an ICD nor ablation was considered.", + "There was right ventricular dilation.", + "There was apical mild hypokinesia.", + "She had no signs of left ventricular dysfunction.", + "The diagnosis of ARVD was made according to the original International Task Force diagnostic criteria.", + "She was prescribed metoprolol and propafenone.", + "She avoided physical stress.", + "She did very well with pharmacological treatment.", + "After three years of follow-up, she wanted to conceive.", + "She was counseled that only a few pregnancies have been reported in patients with ARVD.", + "The risk of transmission of the disease to the offspring is 50%.", + "A mutation screening was offered.", + "She refused the mutation screening because of the high cost.", + "She conceived.", + "She ceased her medications.", + "A fetal echocardiogram was performed at the 21st week of pregnancy.", + "After delivery, no abnormality was detected.", + "In the third trimester, she had heart palpitations and became symptomatic again.", + "The 24-hour ECG monitoring at the 32nd week of pregnancy documented 16,251 ventricular extrasystoles.", + "She delivered at the 38th week of pregnancy by elective cesarean section.", + "She was under general anesthesia during the cesarean section.", + "After three days of hospitalization, she was discharged without medications.", + "She continued breastfeeding for six months." + ], + "summary": "A 26-year-old Caucasian woman who presented to our hospital with heart palpitations was diagnosed with arrhythmogenic right ventricular dysplasia, and, after three years of follow up with anti-arrhythmic drugs, she wanted to conceive. During pregnancy, she ceased taking her medication. She tolerated pregnancy very well but her cardiac symptoms recurred after her 30th week of pregnancy. She delivered a baby via cesarean section under general anesthesia in her 38th week of pregnancy. She was discharged without any medications and continued lactation for six months.", + "summary_subclaims": [ + "The patient is a 26-year-old Caucasian woman.", + "She presented to our hospital with heart palpitations.", + "She was diagnosed with arrhythmogenic right ventricular dysplasia.", + "After three years of follow up with anti-arrhythmic drugs, she wanted to conceive.", + "During pregnancy, she ceased taking her medication.", + "She tolerated pregnancy very well.", + "Her cardiac symptoms recurred after her 30th week of pregnancy.", + "She delivered a baby via cesarean section under general anesthesia in her 38th week of pregnancy.", + "She was discharged without any medications.", + "She continued lactation for six months." + ] + }, + { + "id": "multiclinsum_test_2056_en.txt", + "fulltext": "An 82-year-old female patient with a history of coronary artery disease and coronary stenting, known to have gallstones, presented with a nausea vomiting and post prandial abdominal pain evolving for two weeks. Additionally, the patient presented with a pulse rate of 102 beats per minute, a weak pulse, blood pressure measuring 10/6, and indicators of extracellular dehydration, such as a persistent mucosal fold, clammy skin with decreased elasticity and sunken eyes. Laboratory tests revealed the presence of hypokalemia and hypochloremia. After putting the urinary catheter we noticed a reduced urinary output. We initiated resuscitation by inserting a nasogastric tube, which promptly drained 400 cc of gastric fluid. The fluid resuscitation was performed based on the input-output assessment, aiming to correct any hydro electrolytic imbalances. After stabilizing the patient an esophagogastroduodenoscopy revealed normal findings up to the second part of the duodenum , there was no duodenal dilatation and the EGD showed some retained bile. Regarding the symptomatology and signs of gastric outlet obstruction searching for ethiology we decided to perform a complementary abdominal computed tomography that showed a cholecystoduodenal fistula with a measured 4 cm stone lodged at the duodenojejunal jonction . Due to the absence of endoscopic treatment at that time, the decision was made to proceed with surgery.\nDuring laparotomy, a lodged stone was found at the duodenojejunal angle. The stone was successfully advanced to the second jejunal loop , where an enterotomy was performed, allowing for the extraction of the stone. After that we decided using this enterotomy, on the second jejunal loop, to proceed with a latero-lateral gastroenteroanastomosis Trans- and sub-mesocolic, without gastric resection. The cholecystoduodenal fistula was left untouched.\nPostoperative recovery was uneventful, and the patient was discharged on the 8th day post-surgery. 3 month follow up was uneventful.", + "fulltext_subclaims": [ + "The patient is an 82-year-old female.", + "The patient has a history of coronary artery disease.", + "The patient has a history of coronary stenting.", + "The patient has known gallstones.", + "The patient presented with nausea and vomiting.", + "The patient had postprandial abdominal pain evolving for two weeks.", + "The patient had a pulse rate of 102 beats per minute.", + "The patient had a weak pulse.", + "The patient's blood pressure measured 10/6.", + "The patient had indicators of extracellular dehydration.", + "Laboratory tests revealed hypokalemia.", + "Laboratory tests revealed hypochloremia.", + "After putting the urinary catheter, a reduced urinary output was noted.", + "A nasogastric tube was inserted and promptly drained 400 cc of gastric fluid.", + "Fluid resuscitation was performed based on input-output assessment.", + "The goal of fluid resuscitation was to correct hydroelectrolytic imbalances.", + "An esophagogastroduodenoscopy revealed normal findings up to the second part of the duodenum.", + "There was no duodenal dilatation.", + "The EGD showed some retained bile.", + "A complementary abdominal computed tomography was performed.", + "The abdominal CT showed a cholecystoduodenal fistula.", + "The abdominal CT showed a 4 cm stone lodged at the duodenojejunal junction.", + "Endoscopic treatment was not available at that time.", + "The decision was made to proceed with surgery.", + "During laparotomy, a lodged stone was found at the duodenojejunal angle.", + "The stone was successfully advanced to the second jejunal loop.", + "An enterotomy was performed on the second jejunal loop.", + "The stone was extracted through the enterotomy.", + "A latero-lateral gastroenteroanastomosis was performed through the enterotomy.", + "The cholecystoduodenal fistula was left untouched.", + "Postoperative recovery was uneventful.", + "The patient was discharged on the 8th day post-surgery.", + "Three-month follow-up was uneventful." + ], + "summary": "This article presents a case of an 82-year-old female with a history of coronary artery disease and untreated gallstones. The patient experienced nausea, vomiting, and abdominal pain for two weeks. Diagnostic procedures revealed a cholecystoduodenal fistula with a 4 cm stone lodged at the duodenojejunal angle. For our patient the gallstone was moved to the jejunum, followed by enterotomy and a latero_lateral gastroenteroanastomosis.", + "summary_subclaims": [ + "The patient is an 82-year-old female.", + "The patient has a history of coronary artery disease.", + "The patient had untreated gallstones.", + "The patient experienced nausea, vomiting, and abdominal pain for two weeks.", + "Diagnostic procedures revealed a cholecystoduodenal fistula.", + "A 4 cm stone was lodged at the duodenojejunal angle.", + "The gallstone was moved to the jejunum.", + "Enterotomy was performed.", + "A latero-lateral gastroenteroanastomosis was performed." + ] + }, + { + "id": "multiclinsum_test_272_en.txt", + "fulltext": "We present the case of a 60-year-old female patient of mixed race (Honduran) from an urban area of Honduras, with a pathological history of arterial hypertension and type 2 diabetes mellitus under control (metformin 500 mg and enalapril 10 mg). In December 2015, she presented to a local medical service with dysphonia that had progressed over 2 months; it was exacerbated by singing and accompanied by orthopnea that had progressed over a month. She denied odynophagia, weight loss, dysphagia, and hyporexia. She had no relevant family history.\nPhysical examination showed a good general condition, mesomorphic biotype, and stable vital signs. During the segmental physical examination, a soft mass was palpated within the anterior region of the neck; it was painless and mobile on swallowing and had irregular margins without inflammatory signs.\nUltrasound (US) of the neck showed a solid ovoid tumor located in the left thyroid lobe. It had well-defined borders, an approximate dimension of 37 × 24 × 37 mm, and a volume of 17 mL. The right thyroid lobe was normal with a dimension of 34 × 11 × 10 mm and a volume of 2 mL. The thyroid isthmus and adjacent vascular structures had no obvious abnormalities. One week later, fine needle aspiration (FNA) biopsy was performed on a single nodule. FNA was also performed for some lymph nodes suggestive of malignancy. The anatomopathological report confirmed ATC. Laboratory tests showed elevated thyroid stimulating hormone levels .\nComputed tomography of the neck performed a month later showed that the thyroid mass covered the entire left lobe, with predominant vascularity toward the periphery. The tumor extended to the isthmus and the right lobe, where the neoplasm replaced the inferior pole. There was also evidence of multiple adenopathies with loss of morphology, and all were larger than 8 mm. There were findings suggestive of infiltration of the perithyroid muscles and displacements of the trachea and carotid sheath; there was no infiltration of the other adjacent structures.\nA total thyroidectomy and bilateral central radical dissection were performed in February 2016 in a second-level care unit and sent for a pathological study. The macroscopic description of the right thyroid lobe measuring 25 × 10 mm is as follows: the external surface is rough partially covered by fibrous adhesions, at the cut of a soft consistency of gray color, with small areas of light brown color, separated by the isthmus where colored areas are observed light brown and left thyroid lobe measuring 55 × 30 × 20 mm, external surface is rough covered by fibrous adhesions, when cut with a mass that replaces the entire lobe, without viable thyroid tissue (see Fig. ). Microscopic study revealed an anaplastic thyroid carcinoma (stage IV B) with focal involvement of soft tissues and lymph nodes with macrometastasis (see Figs. , , , and ). There were no postoperative complications. No immunohistochemical study was performed.\nSubsequently, five cycles of chemotherapy with doxorubicin (60 mg/m2) were completed in 6 months. She did not receive any other form of therapy. Currently, the patient is under oncological surveillance (control appointments with imaging studies and hormonal tests every 6 months since her intervention). The most recent follow-up appointment was in February 2021; she showed no signs of recurrence. She has achieved 5 years of complete remission and has maintained optimal health.", + "fulltext_subclaims": [ + "The patient is a 60-year-old female.", + "She is of mixed race (Honduran).", + "She is from an urban area of Honduras.", + "She has a history of arterial hypertension.", + "She has a history of type 2 diabetes mellitus.", + "She is taking metformin 500 mg.", + "She is taking enalapril 10 mg.", + "In December 2015, she presented with dysphonia that had progressed over 2 months.", + "The dysphonia was exacerbated by singing.", + "She had orthopnea that had progressed over a month.", + "She denied odynophagia.", + "She denied weight loss.", + "She denied dysphagia.", + "She denied hyporexia.", + "She had no relevant family history.", + "Physical examination showed a soft mass palpated within the anterior region of the neck.", + "The mass was painless.", + "The mass was mobile on swallowing.", + "The mass had irregular margins.", + "Ultrasound showed a solid ovoid tumor located in the left thyroid lobe.", + "The tumor had well-defined borders.", + "The tumor had an approximate dimension of 37 × 24 × 37 mm.", + "The tumor had a volume of 17 mL.", + "The right thyroid lobe was normal with a dimension of 34 × 11 × 10 mm.", + "The right thyroid lobe had a volume of 2 mL.", + "The thyroid isthmus and adjacent vascular structures had no obvious abnormalities.", + "Fine needle aspiration (FNA) biopsy was performed on a single nodule.", + "FNA was also performed for some lymph nodes suggestive of malignancy.", + "The anatomopathological report confirmed anaplastic thyroid carcinoma (ATC).", + "Laboratory tests showed elevated thyroid stimulating hormone levels.", + "Computed tomography of the neck showed the thyroid mass covered the entire left lobe.", + "The tumor extended to the isthmus and the right lobe.", + "There was evidence of multiple adenopathies with loss of morphology.", + "All adenopathies were larger than 8 mm.", + "There were findings suggestive of infiltration of the perithyroid muscles.", + "There was displacement of the trachea.", + "There was displacement of the carotid sheath.", + "There was no infiltration of other adjacent structures.", + "A total thyroidectomy and bilateral central radical dissection were performed in February 2016.", + "The macroscopic description of the right thyroid lobe measured 25 × 10 mm.", + "The macroscopic description of the left thyroid lobe measured 55 × 30 × 20 mm.", + "Microscopic study revealed an anaplastic thyroid carcinoma (stage IV B).", + "There was focal involvement of soft tissues.", + "There were lymph nodes with macrometastasis.", + "There were no postoperative complications.", + "No immunohistochemical study was performed.", + "Five cycles of chemotherapy with doxorubicin (60 mg/m2) were completed in 6 months.", + "She did not receive any other form of therapy.", + "She is under oncological surveillance with control appointments every 6 months.", + "The most recent follow-up appointment was in February 2021.", + "She showed no signs of recurrence.", + "She has achieved 5 years of complete remission.", + "She has maintained optimal health." + ], + "summary": "A 60-year-old female patient of mixed race (Honduran) presented to the local medical service with dysphonia that had started approximately 2 months earlier, accompanied by orthopnea that had started 1 month earlier. On physical examination, a soft mass was palpated within the anterior neck region; it was approximately 4 cm in diameter, painless, and mobile on swallowing, and had irregular margins. Ultrasound and computed tomography of the neck were performed. Subsequently, fine needle aspiration biopsy was performed. The histological diagnosis was anaplastic thyroid carcinoma (stage IVB). She underwent total thyroidectomy and chemotherapy. She is currently in her fifth year of remission after diagnosis and remains under oncologic surveillance.", + "summary_subclaims": [ + "The patient is a 60-year-old female.", + "The patient is of mixed race (Honduran).", + "The patient presented with dysphonia that had started approximately 2 months earlier.", + "The patient had orthopnea that had started 1 month earlier.", + "A soft mass was palpated within the anterior neck region.", + "The mass was approximately 4 cm in diameter.", + "The mass was painless.", + "The mass was mobile on swallowing.", + "The mass had irregular margins.", + "Ultrasound and computed tomography of the neck were performed.", + "Fine needle aspiration biopsy was performed.", + "The histological diagnosis was anaplastic thyroid carcinoma.", + "The stage was IVB.", + "She underwent total thyroidectomy.", + "She underwent chemotherapy.", + "She is currently in her fifth year of remission after diagnosis.", + "She remains under oncologic surveillance." + ] + }, + { + "id": "multiclinsum_test_2241_en.txt", + "fulltext": "A 59-year-old male with a past medical history of hypertension presented to the ED for evaluation of a right-sided headache with an episode of palpitations and near syncope that developed while receiving an IANB for a tooth extraction at a dentist’s office. While his dentist was performing a dental block with lidocaine and epinephrine, he developed acute onset of severe right-sided headache accompanied by palpitations and near syncope with “trouble keeping his eyes open.” The dental extraction procedure was aborted and he was brought to the ED. By the time the patient had arrived to the ED, his palpitations and near syncopal episode had subsided, but his right-sided headache was persistent. The patient denied any other symptoms.\nVital signs at initial presentation included blood pressure of 190/80 millimeters of mercury; heart rate of 73 beats per minute; respiratory rate of 20 breaths per minute; pulse oximetry 96% on room air; and temperature of 98.4° Fahrenheit. Physical exam revealed a middle-aged man in moderate discomfort from pain. His head was normocephalic and atraumatic; no ecchymosis, erythema, or crepitus was noted on his jaw or neck. His pupils were 5 millimeters, equal, round, and reactive to light bilaterally, and without objective ptosis. Cranial nerves II-XII were intact and symmetrical bilaterally. He had 5/5 muscle strength in both the upper and lower extremities bilaterally and 2+ bilateral patella and Achilles deep tendon reflexes. The patient had no ataxia or pronator drift and had a normal finger to nose.\nInitial laboratory studies included a basic metabolic panel, complete blood count, coagulation panel, thyroid stimulating hormone level, and troponin. None of these labs demonstrated any significant abnormalities. Twelve-lead electrocardiogram was noted to be normal sinus rhythm with a rate of 63 beats per minute with left axis deviation with high lateral T wave inversion, nonspecific ST changes in anterior leads with no change from previous. A chest radiograph was obtained and was without infiltrates or evidence of cardiomegaly.\nComputed tomography (CT) of the head without intravenous (IV) contrast revealed multiple small foci of air predominantly in the expected region of the intracranial venous drainage system ( and ). Multiple small foci of air were also noted in the right temporalis muscle. Given the patient’s history of dental procedure the possibility of intravascular introduction of air and local anesthetic was raised . There was no evidence of hemorrhage or acute territorial infarction or mass.\nGiven the findings on the CT head, a dedicated CT neck with IV contrast was performed and showed residual punctate foci of gas in the left transverse sinus and posterior right cavernous sinus. Most of the previously seen bilateral cavernous sinus gas noted on CT of the head was not present on CT neck with IV contrast. The CT neck with IV contrast also reported that the patient was noted to have tortuosity of the extracranial internal carotid arteries with a short segment of the retropharyngeal course at the level of the hypopharynx.\nThe patient was admitted to the intensive care unit for continued neurologic and cardiovascular monitoring after discovering the findings of intracranial venous air embolism and air near the carotid sheath on CT from suspected intravascular injection of local anesthetic. While hospitalized, the patient’s headache completely resolved. The patient had a repeat CT of his head and neck 24 hours later with near-total resolution of the previously noted gas in the cavernous sinus region and no acute intracranial infarct or hemorrhage. Neurology evaluated the patient and recommended no additional imaging as repeat CT demonstrated resolution of previously noted venous gas foci, and recommended symptomatic treatment of headache if symptoms recurred. The patient was discharged that next day with completely resolved symptoms.", + "fulltext_subclaims": [ + "A 59-year-old male with a past medical history of hypertension presented to the ED.", + "He had a right-sided headache with an episode of palpitations and near syncope.", + "The symptoms developed while receiving an IANB for a tooth extraction.", + "The dental extraction procedure was aborted.", + "He was brought to the ED.", + "By the time he arrived to the ED, his palpitations and near syncopal episode had subsided.", + "His right-sided headache was persistent.", + "Vital signs at initial presentation included blood pressure of 190/80 millimeters of mercury.", + "Initial laboratory studies included a basic metabolic panel, complete blood count, coagulation panel, thyroid stimulating hormone level, and troponin.", + "None of these labs demonstrated any significant abnormalities.", + "Computed tomography (CT) of the head without intravenous (IV) contrast revealed multiple small foci of air predominantly in the expected region of the intracranial venous drainage system.", + "Multiple small foci of air were also noted in the right temporalis muscle.", + "Given the patient’s history of dental procedure, the possibility of intravascular introduction of air and local anesthetic was raised.", + "There was no evidence of hemorrhage or acute territorial infarction or mass.", + "A dedicated CT neck with IV contrast was performed.", + "The CT neck with IV contrast showed residual punctate foci of gas in the left transverse sinus and posterior right cavernous sinus.", + "Most of the previously seen bilateral cavernous sinus gas noted on CT of the head was not present on CT neck with IV contrast.", + "The CT neck with IV contrast also reported that the patient was noted to have tortuosity of the extracranial internal carotid arteries.", + "The patient was admitted to the intensive care unit.", + "The patient’s headache completely resolved.", + "The patient had a repeat CT of his head and neck 24 hours later.", + "Repeat CT demonstrated near-total resolution of the previously noted gas in the cavernous sinus region.", + "There was no acute intracranial infarct or hemorrhage.", + "Neurology evaluated the patient.", + "Neurology recommended no additional imaging.", + "Neurology recommended symptomatic treatment of headache if symptoms recurred.", + "The patient was discharged that next day.", + "The patient had completely resolved symptoms." + ], + "summary": "A 59-year-old male presented to the ED from a dentist's office for evaluation of a right-sided headache with an associated episode of palpitations and near syncope that developed while receiving an inferior alveolar nerve block. Computed tomography of the patient's head revealed multiple small foci of air in the right temporalis muscle and in the intracranial venous drainage system. Given the patient's history of dental procedure, the intravascular introduction of air and local anesthetic was suspected.", + "summary_subclaims": [ + "A 59-year-old male presented to the ED from a dentist's office.", + "The patient reported a right-sided headache.", + "The patient had an associated episode of palpitations.", + "The patient had an episode of near syncope.", + "The symptoms developed while receiving an inferior alveolar nerve block.", + "Computed tomography of the patient's head revealed multiple small foci of air in the right temporalis muscle.", + "Computed tomography revealed multiple small foci of air in the intracranial venous drainage system.", + "Given the patient's history of dental procedure, the intravascular introduction of air and local anesthetic was suspected." + ] + }, + { + "id": "multiclinsum_test_628_en.txt", + "fulltext": "A 59 year old male was admitted to the Department of Gastroenterology of our hospital on June 16, 2020 due to jaundice of the skin and sclera for more than 15 days and progressive weight loss about 5 kg. He had a history of brain stem infarction with left lower limb weakness and occasionally chokes on drinking water. He denied a history of hepatitis, tuberculosis or other infectious diseases. Physical examination showed that he had chronic disease appearance with jaundice of the skin and sclera, but no obvious enlargement of superficial lymph nodes and no obvious positive signs in the abdomen. Laboratory data on the day of admission were as follows: hemoglobin 101 g/L, glutamic-pyruvic transaminase 158 U/L, glutamic-oxaloacetic transaminase 150 U/L, total bilirubin 217.3 umo/L, direct bilirubin 152.4 umo/L, indirect bilirubin 64.9 umol/L, hypersensitive C-reactive protein 5.8 mg/L, procalcitonin 0.11 ng/ml, carcinoembryonic antigen (CEA) 6.19 μg/L, carbohydrate antigen 125 (CA125) 117.1 kU/L. On June 17 abdominal ultrasonography showed gallbladder enlargement, cholecystitis, cholestasis, and dilatation of intrahepatic and extrahepatic bile ducts. On June 18 magnetic resonance cholangiopancreatography (MRCP) and abdominal magnetic resonance (MRI) considered neoplastic lesions of the duodenal papilla, severe dilatation of intrahepatic and extrahepatic bile ducts, bile stasis in common bile duct, large gallbladder. On June 19 ultrasound gastroscopy revealed that a neoplasms of approximately 2.5 × 2.5 cm in size could be seen at the duodenal papilla, with ulceration on the surface, covered with yellow and white slough, and contact bleeding. Three biopsies were taken. The patient was transferred to our department from the Department of Gastroenterology on June 20. The results of abdominal enhanced computed tomography (CT) on June 23 were similar to MRI. On the same day cholangiograms of percutaneous transhepatic biliary drainage (PTBD) was performed for jaundice reduction. On June 29 we prepped the patient for pancreaticoduodenectomy after discussion and obtaining informed consent from the patient and his family. However, histopathological examination on June 30 showed severe chronic active inflammation with ulcers, infiltrated by large number of atypical lymphocytes. Mitotic figures were visible, and the cytoplasm of tumor cells was empty and bright. Immunohistochemical results were as follows: LCA ( +), CD34 (vascular +), Ki67 (Li80%), CD20 ( +), LCA ( +), CD34 (vascular +). Aggressive Non-Hodgkin’s B-cell lymphoma was diagnosed on the basis of this results. The surgical plan was cancelled after a consultation with a haematology, chemotherapy was indicated.", + "fulltext_subclaims": [ + "A 59 year old male was admitted to the Department of Gastroenterology of our hospital on June 16, 2020.", + "He had jaundice of the skin and sclera for more than 15 days.", + "He had progressive weight loss about 5 kg.", + "He had a history of brain stem infarction with left lower limb weakness.", + "He occasionally chokes on drinking water.", + "He denied a history of hepatitis.", + "He denied a history of tuberculosis.", + "He denied a history of other infectious diseases.", + "Physical examination showed chronic disease appearance with jaundice of the skin and sclera.", + "There was no obvious enlargement of superficial lymph nodes.", + "There were no obvious positive signs in the abdomen.", + "Hemoglobin was 101 g/L.", + "Glutamic-pyruvic transaminase was 158 U/L.", + "Glutamic-oxaloacetic transaminase was 150 U/L.", + "Total bilirubin was 217.3 umol/L.", + "Direct bilirubin was 152.4 umol/L.", + "Indirect bilirubin was 64.9 umol/L.", + "Hypersensitive C-reactive protein was 5.8 mg/L.", + "Procalcitonin was 0.11 ng/ml.", + "Carcinoembryonic antigen (CEA) was 6.19 μg/L.", + "Carbohydrate antigen 125 (CA125) was 117.1 kU/L.", + "Abdominal ultrasonography on June 17 showed gallbladder enlargement.", + "Abdominal ultrasonography on June 17 showed cholecystitis.", + "Abdominal ultrasonography on June 17 showed cholestasis.", + "Abdominal ultrasonography on June 17 showed dilatation of intrahepatic and extrahepatic bile ducts.", + "MRCP and abdominal MRI on June 18 considered neoplastic lesions of the duodenal papilla.", + "MRCP and abdominal MRI on June 18 showed severe dilatation of intrahepatic and extrahepatic bile ducts.", + "MRCP and abdominal MRI on June 18 showed bile stasis in common bile duct.", + "MRCP and abdominal MRI on June 18 showed large gallbladder.", + "Ultrasound gastroscopy on June 19 revealed a neoplasm of approximately 2.5 × 2.5 cm in size at the duodenal papilla.", + "The neoplasm had ulceration on the surface.", + "The neoplasm was covered with yellow and white slough.", + "Contact bleeding was observed.", + "Three biopsies were taken.", + "The patient was transferred to our department from the Department of Gastroenterology on June 20.", + "Abdominal enhanced CT on June 23 showed findings similar to MRI.", + "Percutaneous transhepatic biliary drainage (PTBD) was performed on June 23 for jaundice reduction.", + "The surgical plan was cancelled after a consultation with haematology.", + "Aggressive Non-Hodgkin’s B-cell lymphoma was diagnosed.", + "Chemotherapy was indicated." + ], + "summary": "We reported a 59-year-old man who underwent endoscopic ultrasonography for obstructive jaundice and found a duodenal papilla tumor. Light microscopy revealed a non-Hodgkin's lymphoma. Immunohistochemical staining showed that the tumor was aggressive B-cell lymphoma. We carried out molecular targeted therapy combined with CHOP regimen chemotherapy.", + "summary_subclaims": [ + "We reported a 59-year-old man who underwent endoscopic ultrasonography for obstructive jaundice and found a duodenal papilla tumor.", + "Light microscopy revealed a non-Hodgkin's lymphoma.", + "Immunohistochemical staining showed that the tumor was aggressive B-cell lymphoma.", + "We carried out molecular targeted therapy combined with CHOP regimen chemotherapy." + ] + }, + { + "id": "multiclinsum_test_1960_en.txt", + "fulltext": "A 33-year-old man developed diarrhoea 1 day after eating fried pork with chili and fever the next day, with a body temperature of 40 °C. The results of blood and faecal cultures were positive for Salmonella Dublin. Influenza A virus, influenza B virus, Mycoplasma pneumoniae, Chlamydia pneumoniae, respiratory syncytial virus, Haemophilus influenzae, varicella-zoster virus, Legionella, Campylobacter and SARS-CoV-2 tests were all negative. The patient developed drowsiness after 3 days, with gradual weakening of the limbs, dysarthria, binocular abduction paralysis, and ataxia. His brain MRI scan was normal. After 5 days, the patient could not raise his limbs. These symptoms were accompanied by liver function damage and myocardial damage. After 7 days, the patient still had weakness of the limbs and dysarthria. However, as other indicators improved, he was transferred from the Intensive Care Unit ward to the Neurology ward. Physical examination of the nervous system mainly showed flaccid paralysis of the limbs, disappearance of the bilateral tendon reflex, inability to speak, ataxia (bilateral limb paralysis limited the ability to assess gait), and positive bilateral Babinski signs. At that time, lumbar puncture results for intracranial pressure, CSF protein, and CSF cell number were normal, and the CSF was cultured for 3 days with no bacterial growth. On re-examination, the brain MRI and cervical MRI were normal. As BBE was suspected clinically, IVIg therapy (0.4 g/kg) was given for 5 days, but the patient’s symptoms did not improve significantly. Twenty days after admission, lumbar puncture examination showed that the protein content had increased by 0.86 g/L (the normal range is 0.08–0.43 g/L); the cell number was normal (the number of nucleated cells was 6, normal range 0–8; the red blood cell count was 0), CSF and serum anti-GQ1b antibody was negative, and CSF anti-MOG, anti-AQP4, and anti-MBP antibodies were all negative. The results of electrophysiological examination were normal (14 days and 60 days after onset). Considering no obvious improvement, at 21 days, he was given IVIg again at the same dose for 5 days. The patient’s symptoms gradually improved, and he was able to start walking on his own. His limb collateral movement was significantly better than before, his eye movement was normal, and his voice was low. The patient’s speech could be heard clearly, and he was given speech rehabilitation training. After 3 months, the patient could walk 10 m without assistance but was unable to run (the grade of the GBS disability scale was 2) . His speech also returned to normal.", + "fulltext_subclaims": [ + "The patient is a 33-year-old man.", + "He developed diarrhoea 1 day after eating fried pork with chili.", + "He had a fever the next day with a body temperature of 40 °C.", + "Blood and faecal cultures were positive for Salmonella Dublin.", + "Influenza A virus tests were negative.", + "Influenza B virus tests were negative.", + "Mycoplasma pneumoniae tests were negative.", + "Chlamydia pneumoniae tests were negative.", + "Respiratory syncytial virus tests were negative.", + "Haemophilus influenzae tests were negative.", + "Varicella-zoster virus tests were negative.", + "Legionella tests were negative.", + "Campylobacter tests were negative.", + "SARS-CoV-2 tests were negative.", + "The patient developed drowsiness after 3 days.", + "He had gradual weakening of the limbs.", + "He had dysarthria.", + "He had binocular abduction paralysis.", + "He had ataxia.", + "His brain MRI scan was normal.", + "After 5 days, the patient could not raise his limbs.", + "These symptoms were accompanied by liver function damage.", + "These symptoms were accompanied by myocardial damage.", + "After 7 days, the patient still had weakness of the limbs.", + "After 7 days, the patient still had dysarthria.", + "He was transferred from the Intensive Care Unit ward to the Neurology ward.", + "Physical examination showed flaccid paralysis of the limbs.", + "Bilateral tendon reflexes were absent.", + "The patient was unable to speak.", + "He had ataxia.", + "Bilateral Babinski signs were positive.", + "Lumbar puncture results for intracranial pressure were normal.", + "CSF protein was normal.", + "CSF cell number was normal.", + "CSF was cultured for 3 days with no bacterial growth.", + "Brain MRI was normal.", + "Cervical MRI was normal.", + "BBE was suspected clinically.", + "IVIg therapy (0.4 g/kg) was given for 5 days.", + "The patient’s symptoms did not improve significantly.", + "Twenty days after admission, lumbar puncture showed increased protein content by 0.86 g/L.", + "CSF cell number was normal.", + "CSF and serum anti-GQ1b antibody was negative.", + "CSF anti-MOG antibody was negative.", + "CSF anti-AQP4 antibody was negative.", + "CSF anti-MBP antibody was negative.", + "Electrophysiological examination was normal.", + "At 21 days, IVIg was given again at the same dose for 5 days.", + "The patient’s symptoms gradually improved.", + "He was able to start walking on his own.", + "Limb collateral movement was significantly better than before.", + "Eye movement was normal.", + "Voice was low.", + "Speech could be heard clearly.", + "Speech rehabilitation training was given.", + "After 3 months, the patient could walk 10 m without assistance.", + "The patient was unable to run.", + "The grade of the GBS disability scale was 2.", + "Speech returned to normal." + ], + "summary": "We report a suspected case of Bickerstaff's brainstem encephalitis caused by Salmonella Dublin. A young man presented with impaired consciousness, ataxia, dysarthria, limb weakness, and restricted eyeball abduction. His clinical symptoms were consistent with Bickerstaff's brainstem encephalitis.", + "summary_subclaims": [ + "We report a suspected case of Bickerstaff's brainstem encephalitis caused by Salmonella Dublin.", + "A young man presented with impaired consciousness.", + "A young man presented with ataxia.", + "A young man presented with dysarthria.", + "A young man presented with limb weakness.", + "A young man presented with restricted eyeball abduction.", + "His clinical symptoms were consistent with Bickerstaff's brainstem encephalitis." + ] + }, + { + "id": "multiclinsum_test_1286_en.txt", + "fulltext": "A 26-year-old black African male health care worker was admitted to the clinic on 21 July 2022, with a significant chief complaint of headache, loss of appetite, and watery diarrhea. The admitted patient presented with a 2-day history of hyperthermia, headache, loss of appetite, and watery diarrhea, as well as back pain, joint weakness, and insomnia. The patient traveled to Malarious area for his education 5 years ago; once upon a time, he bought overripe mangoes from a vegetable vendor on the street and ate them there. The patient ate mangoes at 4:00 a.m. and began experiencing diarrhea at noon, at 10:00 a.m. The patient had taken ciprofloxacillin at 11:00 a.m. from the student clinic without any clinical investigations based on his clinical manifestations due to the inaccessibility of laboratory investigations and diagnostic equipment, and he recovered totally from the illness after 2 days. No one in his family had previously been diagnosed with typhoid fever.\nRecently, the patient traveled to a desert environment and malarious area for work and stayed there for 1 year. When he returned home after 1 year, he bought pineapple from the vegetable seller on the street, ate it after 3 days without putting it in the refrigerator, and experienced the above clinical manifestations after 12 hours. The patient said, ‘I was suspecting typhoid fever because the pineapple I ate was overripe’, and then the physician decided to identify the disease type through laboratory investigations and diagnostic criteria and started undergoing it. First, the physician had performed a laboratory investigation to identify malarial parasites in peripheral blood via thin and thick smears, and no malarial parasites were detected in the patient.\nSecond, a physical examination was performed and revealed a high-grade fever (40.3°C/107.4°F) (normal value: 37°C/98.6°F), slight dehydration, tachycardia, or a heart rate of 114 beats per minute (normal value: 60–100 beats per minute), a respiratory rate of 15 breaths per minute (normal value: 12–16 breaths per minute), and a blood pressure of 112/71 mm Hg (normal value: 120/80 mm Hg).\nThird, laboratory investigations were performed and showed a white blood cell (WBC) count of 3160 cells /mm3 (normal value: 3200–9800 cells/mm3), neutrophils of 47% (normal value: 54–62%); eosinophils of 2.1% (normal value: 1–3%), monocytes of 4.8% (normal value: 3–7%), basophils of 0.3% (<1%), and lymphocytes of 43% (normal value: 25–33%), a platelet count of 125 000/mm3 (normal value: 130 000–400 000 cells/mm3), a serum creatinine level of 0.9 mg/dl (normal value: 0.6–1.2 mg/dl), an aspartate aminotransferase/serum glutamic oxaloacetic transaminase level of 68 units/l (normal value: 0–35 units/l), an (alanine aminotransferase/serum glutamic-pyruvic transaminase) alanine aminotransferase level of 95 units/l (normal value: 0–35 units/l), an erythrocyte sedimentation rate of 9 mm/h (normal value: 0–20 mm/h), 45% hematocrit (normal value: 39–49%), hemoglobin of 15.9 g/dl (normal value: 14–17.5 g/dl), mean corpuscular volume of 79.8 fl/cell (normal value: 80–97.6 fl/cell), mean corpuscular hemoglobin of 31 pg/cell (normal value: 27–33 pg/cell), and mean corpuscular hemoglobin concentration of 35 g/dl (normal value: 32–36 g/dl).\nFinally, the physician performed the Widal agglutination test to find that the patient had active or previous typhoid fever. According to the Widal test, the H antigen titer was 1 : 189 and the O antigen titer (TO) was 1 : 137 (normal value: 1 : 20–1 : 80). Herein, the admitted patient had a past history of S. typhi and no detection of active infection with S. typhi because the patient was discharged after 5 days from the onset of fever, and O agglutinins can usually be detected 6–8 days after the onset of fever. The H antigen titer was positive, which was 1 : 189 greater than the normal range and showed the past history of S. typhi infection. Because active typhoid fever infection is not detected until 6 days after the onset of fever, laboratory investigations are used to identify it. The above TO titer value detected was a false negative result because it was done before the 6-day onset of fever.\nOn admission, ciprofloxacillin 500 mg was given orally twice a day for 7 days to treat typhoid by inhibiting the deoxyribonucleic acid replication in S. typhi and preventing S. typhi deoxyribonucleic acid topoisomerase and deoxyribonucleic acid gyrase. On the same day, paracetamol 500 mg was given orally three times a day for 5 days to control the fever by inhibiting prostaglandin E2 secretion, which elevates heat secretion and lowers heat loss. The following day, 22 July 2022, the patient was free of all clinical manifestations except fever and sent home with ciprofloxacin and paracetamol.\nThe admitted patient recovered from a typhoid fever infection and was discharged back home with prescribed medications.", + "fulltext_subclaims": [ + "A 26-year-old black African male health care worker was admitted to the clinic on 21 July 2022.", + "The patient had a 2-day history of hyperthermia, headache, loss of appetite, and watery diarrhea.", + "The patient traveled to a malarious area for his education 5 years ago.", + "The patient ate overripe mangoes from a street vendor at 4:00 a.m.", + "The patient began experiencing diarrhea at 10:00 a.m.", + "The patient took ciprofloxacillin at 11:00 a.m. from the student clinic.", + "The patient recovered totally from the illness after 2 days.", + "No one in his family had previously been diagnosed with typhoid fever.", + "The patient recently traveled to a desert environment and malarious area for work and stayed there for 1 year.", + "The patient bought pineapple from a street vendor and ate it after 3 days without refrigeration.", + "The patient experienced clinical manifestations 12 hours after eating the pineapple.", + "The patient said, 'I was suspecting typhoid fever because the pineapple I ate was overripe'.", + "The physician performed a laboratory investigation to identify malarial parasites in peripheral blood via thin and thick smears.", + "No malarial parasites were detected in the patient.", + "The physical examination revealed a high-grade fever of 40.3°C.", + "The physical examination revealed a heart rate of 114 beats per minute.", + "The physical examination revealed a blood pressure of 112/71 mm Hg.", + "The WBC count was 3160 cells/mm3.", + "The physician performed the Widal agglutination test.", + "The H antigen titer was 1 : 189.", + "The O antigen titer (TO) was 1 : 137.", + "The patient had a past history of S. typhi.", + "The H antigen titer was positive, which was 1 : 189 greater than the normal range.", + "Active typhoid fever infection is not detected until 6 days after the onset of fever.", + "The TO titer value detected was a false negative result because it was done before the 6-day onset of fever.", + "On admission, ciprofloxacillin 500 mg was given orally twice a day for 7 days.", + "On the same day, paracetamol 500 mg was given orally three times a day for 5 days.", + "The patient was free of all clinical manifestations except fever on 22 July 2022.", + "The patient was sent home with ciprofloxacin and paracetamol.", + "The admitted patient recovered from a typhoid fever infection." + ], + "summary": "A 26-year-old black African male health care worker was admitted to the clinic on 21 July 2022, with a significant chief complaint of headache, loss of appetite, and watery diarrhea. The admitted patient presented with a 2-day history of hyperthermia, headache, loss of appetite, and watery diarrhea, as well as back pain, joint weakness, and insomnia. The H antigen titer was positive, which was 1 : 189 greater than the normal range and showed the past history of S. typhi infection. The O antigen titer value detected was a false negative result because it was done before the 7-day onset of fever. On admission, ciprofloxacillin 500 mg was given orally twice a day for 7 days to treat typhoid by inhibiting the deoxyribonucleic acid replication of S. typhi by preventing S. typhi deoxyribonucleic acid topoisomerase and deoxyribonucleic acid gyrase.", + "summary_subclaims": [ + "The patient is a 26-year-old black African male health care worker.", + "The patient was admitted to the clinic on 21 July 2022.", + "The patient's chief complaint was headache, loss of appetite, and watery diarrhea.", + "The patient had a 2-day history of hyperthermia.", + "The patient had a 2-day history of headache.", + "The patient had a 2-day history of loss of appetite.", + "The patient had a 2-day history of watery diarrhea.", + "The patient had back pain.", + "The patient had joint weakness.", + "The patient had insomnia.", + "The H antigen titer was positive.", + "The H antigen titer was 1:189.", + "The H antigen titer was greater than the normal range.", + "The H antigen titer suggested a past history of S. typhi infection.", + "The O antigen titer value was a false negative result.", + "The O antigen titer was done before the 7-day onset of fever.", + "Ciprofloxacillin 500 mg was given orally twice a day for 7 days.", + "Ciprofloxacillin was given to treat typhoid.", + "Ciprofloxacillin inhibits the deoxyribonucleic acid replication of S. typhi.", + "Ciprofloxacillin prevents S. typhi deoxyribonucleic acid topoisomerase.", + "Ciprofloxacillin prevents S. typhi deoxyribonucleic acid gyrase." + ] + }, + { + "id": "multiclinsum_test_912_en.txt", + "fulltext": "A 70-year-old woman presented to our outpatient clinic. She complained of motor weakness in the right hemisphere, which had appeared 4 months before. Magnetic resonance imaging was performed to rule out the presence of any intracranial lesions. Chronic lacunae infraction of the left corona radiata was detected on fluid-attenuated inversion recovery images. The lacunae infraction of the left corona radiata was considered a cause of her right motor weakness. No edematous changes were found in the infratentorial or supratentorial regions. However, magnetic resonance angiography revealed a vascular lesion . Vascular lesions were also found below the cerebellar tentorium on constructive interference in steady-state images . Cerebral angiography was performed as an arteriovenous shunt was suspected. A right external cerebral angiogram showed an arteriovenous shunt supplied by the mastoid branch of the occipital artery. A selective angiogram of the mastoid branch of the occipital artery revealed that the arteriovenous shunt was fed by the PMA. The arteriovenous shunt showed two draining patterns, travelling through the superior vermian vein to the petrosal vein and superior petrosal sinus and through the inferior hemispheric vein, inferior hemispheric vein, and tentorial sinus [ and ]. The left occipital angiogram showed an arteriovenous shunt fed by the left PMA [ and ]. On maximum intensity projection images, the shunting point was located beneath the cerebellar tentorium, and the drainer ran through the tentorial sinus into the transverse sinus . The internal carotid angiogram revealed no apparent feeders. The bilateral posterior cerebral arteries were of a fetal type. The straight sinus flow was anterograde. The left vertebral angiogram revealed no feeders. Venous congestion was suspected on the venous phase of the left vertebral angiogram. No retrograde flow of the basal vein of Rosenthal was observed [-]. Based on the findings of cerebral angiography, the arteriovenous shunt was diagnosed as TDAVF fed by the bilateral PMAs draining into the straight sinus with retrograde venous flow (Borden type III, Cognard type III). Transarterial endovascular surgery was planned to prevent hemorrhagic events associated with TDAVF.\nUnder general anesthesia, two Envoy 5F 90 cm MPD (Codman Neuro, Raynham, MA, USA) were introduced in the bilateral occipital artery. The mastoid branch of the left occipital artery was selected with a Masters HF 2.8-Fr/3.2-Fr 125 cm (ASAHI INTECC J-Sales, CO., LTD, Tokyo, Japan) and a Traxcess 14 0.012/0.014 200 cm (Terumo Corporation, Tokyo, Japan). The Masters HF 2.8-Fr/3.2-Fr 125 cm was placed at the mastoid foramen. Using an ASAHI CHIKAI 0.014 200 cm (ASAHI INTECC J-Sales, CO., LTD, Tokyo, Japan) and a Traxcess 14 0.012/0.014 200 cm, another Masters HF 2.8-Fr/3.2-Fr 125 cm was introduced through the mastoid branch of the right occipital artery to the right PMA. As the left PMA was quite tortuous compared to the right PMA, we considered that a transarterial embolization approached from the right PMA was the easiest course of action. From the right Masters HF 2.8-Fr/3.2-Fr 125 cm, a Carnelian MARVEL® 1.6/1.8-Fr 155 cm (Tokai Medical Products Inc.) was introduced near the shunting point with an ASAHI CHIKAI 0.008 200 cm (ASAHI INTECC J-Sales, CO., LTD, Tokyo, Japan) . A Carnelian MARVEL® 1.6/1.8-Fr 155 cm was also placed in the left PMA to inject the contrast medium intraoperatively. The inner lumen of the right Carnelian MARVEL® 1.6/1.8-Fr 155 cm was filled with 5% glucose solution, after which heated 20% n-butyl-2-cyanoacrylate (NBCA) was injected from the right Carnelian MARVEL® 1.6/1.8-Fr 155 cm. After NBCA reached the drainer with an injection volume of 0.3 mL, the right Carnelian MARVEL® 1.6/1.8-Fr 155 cm was removed. NBCA migrated partially to the left transverse sinus, left inferior hemispheric vein, and left petrosal vein [ and ]. The right and left occipital angiogram revealed the disappearance of the shunt [-], which was also confirmed by cone beam computed tomography using a half-diluted contrast agent. NBCA did not migrate to the arteries. The bilateral common carotid angiogram also revealed the disappearance of the shunt, and the venous flow was anterograde. A vertebral angiogram was finally acquired to ensure shunt disappearance. However, a residual arteriovenous shunt, which was not seen on preoperative angiography, was identified. Venous congestion also remained in the left cerebellar hemisphere [-]. On 3-dimensional reconstructed maximum intensity projection (3D-MIP) images, the residual arteriovenous shunt beneath the cerebellar tentorium was identified above the location of the NBCA along the cerebellar tentorium .\nOn the 3D-MIP images, a dural branch originating from the SCA was identified as the feeder of the residual shunt. The artery originated close to the bifurcation of the basilar artery and the SCA. The artery branched from the anterior pontomesencephalic segment of the SCA and was considered to be the AWW [ and ]. As the embolization of the main shunting point with NBCA was successfully achieved and the shunting flow was not remarkably strong, we considered that the residual arteriovenous shunt could be monitored under observation.\nThe patient’s postoperative course was uneventful. The residual arteriovenous fistula fed by the AWW disappeared spontaneously, as seen on follow-up vertebral angiography 1 week after the procedure [ and ]. No cerebellar ischemic lesion was observed postoperatively. The patient was discharged from the hospital without any neurological deficits. No apparent recurrence of the TDAVF was observed on the cerebral angiogram acquired 6 months after endovascular embolization.", + "fulltext_subclaims": [ + "A 70-year-old woman presented to our outpatient clinic.", + "She complained of motor weakness in the right hemisphere.", + "The motor weakness had appeared 4 months before.", + "Magnetic resonance imaging was performed to rule out the presence of any intracranial lesions.", + "Chronic lacunae infraction of the left corona radiata was detected on fluid-attenuated inversion recovery images.", + "The lacunae infraction of the left corona radiata was considered a cause of her right motor weakness.", + "No edematous changes were found in the infratentorial or supratentorial regions.", + "Magnetic resonance angiography revealed a vascular lesion.", + "Vascular lesions were also found below the cerebellar tentorium on constructive interference in steady-state images.", + "Cerebral angiography was performed as an arteriovenous shunt was suspected.", + "A right external cerebral angiogram showed an arteriovenous shunt supplied by the mastoid branch of the occipital artery.", + "A selective angiogram of the mastoid branch of the occipital artery revealed that the arteriovenous shunt was fed by the PMA.", + "The arteriovenous shunt showed two draining patterns, travelling through the superior vermian vein to the petrosal vein and superior petrosal sinus and through the inferior hemispheric vein, inferior hemispheric vein, and tentorial sinus.", + "The left occipital angiogram showed an arteriovenous shunt fed by the left PMA.", + "On maximum intensity projection images, the shunting point was located beneath the cerebellar tentorium, and the drainer ran through the tentorial sinus into the transverse sinus.", + "The internal carotid angiogram revealed no apparent feeders.", + "The bilateral posterior cerebral arteries were of a fetal type.", + "The straight sinus flow was anterograde.", + "The left vertebral angiogram revealed no feeders.", + "Venous congestion was suspected on the venous phase of the left vertebral angiogram.", + "No retrograde flow of the basal vein of Rosenthal was observed.", + "Based on the findings of cerebral angiography, the arteriovenous shunt was diagnosed as TDAVF fed by the bilateral PMAs draining into the straight sinus with retrograde venous flow (Borden type III, Cognard type III).", + "Transarterial endovascular surgery was planned to prevent hemorrhagic events associated with TDAVF.", + "Under general anesthesia, two Envoy 5F 90 cm MPD were introduced in the bilateral occipital artery.", + "The mastoid branch of the left occipital artery was selected with a Masters HF 2.8-Fr/3.2-Fr 125 cm and a Traxcess 14 0.012/0.014 200 cm.", + "The Masters HF 2.8-Fr/3.2-Fr 125 cm was placed at the mastoid foramen.", + "Using an ASAHI CHIKAI 0.014 200 cm and a Traxcess 14 0.012/0.014 200 cm, another Masters HF 2.8-Fr/3.2-Fr 125 cm was introduced through the mastoid branch of the right occipital artery to the right PMA.", + "As the left PMA was quite tortuous compared to the right PMA, we considered that a transarterial embolization approached from the right PMA was the easiest course of action.", + "From the right Masters HF 2.8-Fr/3.2-Fr 125 cm, a Carnelian MARVEL® 1.6/1.8-Fr 155 cm was introduced near the shunting point with an ASAHI CHIKAI 0.008 200 cm.", + "A Carnelian MARVEL® 1.6/1.8-Fr 155 cm was also placed in the left PMA to inject the contrast medium intraoperatively.", + "The inner lumen of the right Carnelian MARVEL® 1.6/1.8-Fr 155 cm was filled with 5% glucose solution, after which heated 20% n-butyl-2-cyanoacrylate (NBCA) was injected from the right Carnelian MARVEL® 1.6/1.8-Fr 155 cm.", + "After NBCA reached the drainer with an injection volume of 0.3 mL, the right Carnelian MARVEL® 1.6/1.8-Fr 155 cm was removed.", + "NBCA migrated partially to the left transverse sinus, left inferior hemispheric vein, and left petrosal vein.", + "The right and left occipital angiogram revealed the disappearance of the shunt.", + "This was also confirmed by cone beam computed tomography using a half-diluted contrast agent.", + "NBCA did not migrate to the arteries.", + "The bilateral common carotid angiogram also revealed the disappearance of the shunt, and the venous flow was anterograde.", + "A vertebral angiogram was finally acquired to ensure shunt disappearance.", + "However, a residual arteriovenous shunt, which was not seen on preoperative angiography, was identified.", + "Venous congestion also remained in the left cerebellar hemisphere.", + "On 3-dimensional reconstructed maximum intensity projection (3D-MIP) images, the residual arteriovenous shunt beneath the cerebellar tentorium was identified above the location of the NBCA along the cerebellar tentorium.", + "On the 3D-MIP images, a dural branch originating from the SCA was identified as the feeder of the residual shunt.", + "The artery originated close to the bifurcation of the basilar artery and the SCA.", + "The artery branched from the anterior pontomesencephalic segment of the SCA and was considered to be the AWW.", + "As the embolization of the main shunting point with NBCA was successfully achieved and the shunting flow was not remarkably strong, we considered that the residual arteriovenous shunt could be monitored under observation.", + "The patient’s postoperative course was uneventful.", + "The residual arteriovenous fistula fed by the AWW disappeared spontaneously, as seen on follow-up vertebral angiography 1 week after the procedure.", + "No cerebellar ischemic lesion was observed postoperatively.", + "The patient was discharged from the hospital without any neurological deficits.", + "No apparent recurrence of the TDAVF was observed on the cerebral angiogram acquired 6 months after endovascular embolization." + ], + "summary": "A 70-year-old woman complaining of the right motor weakness underwent magnetic resonance imaging. A vascular lesion beneath the cerebellar tentorium was incidentally found with chronic infarction of the left corona radiata. Angiographically, the vascular lesion was a TDAVF supplied by the bilateral posterior meningeal arteries. No other apparent feeders were detected. The TDAVF had a shunting point on the inferior surface of the cerebellar tentorium with venous retrograde flow (Borden type III, Cognard type III). To prevent vascular events, endovascular embolization was performed using n-butyl-2-cyanoacrylate. Following embolization of the shunting point, a residual shunt fed by the AWW was identified. The shunt supplied by the AWW was not observed preoperatively. Follow-up angiography performed 1 week later revealed spontaneous disappearance of the residual shunt. The patient was followed-up in our outpatient clinic, and no recurrence of the TDAVF was confirmed postoperatively.", + "summary_subclaims": [ + "A 70-year-old woman complaining of the right motor weakness underwent magnetic resonance imaging.", + "A vascular lesion beneath the cerebellar tentorium was incidentally found.", + "Chronic infarction of the left corona radiata was found.", + "The vascular lesion was a TDAVF supplied by the bilateral posterior meningeal arteries.", + "No other apparent feeders were detected.", + "The TDAVF had a shunting point on the inferior surface of the cerebellar tentorium with venous retrograde flow.", + "The TDAVF was classified as Borden type III and Cognard type III.", + "Endovascular embolization was performed using n-butyl-2-cyanoacrylate.", + "Following embolization of the shunting point, a residual shunt fed by the AWW was identified.", + "The shunt supplied by the AWW was not observed preoperatively.", + "Follow-up angiography performed 1 week later revealed spontaneous disappearance of the residual shunt.", + "The patient was followed-up in our outpatient clinic.", + "No recurrence of the TDAVF was confirmed postoperatively." + ] + }, + { + "id": "multiclinsum_test_2660_en.txt", + "fulltext": "A 55-year-old male patient was admitted to Shanghai Xuhui Central Hospital due to fever, cough, and expectoration for 3 days on 9 April 2021. The patient had a history of hypertension, long-term smoking, chronic bronchitis, and emphysema. On 17 March 2021, the patient visited a tertiary general hospital in Shanghai and received a radical resection of right lower lung cancer and right upper lobectomy, and the postoperative pathology changes were various. Invasive adenocarcinoma was identified in the right lower lung, with alveolar and adherent growth, not involving the visceral pleura. A large number of acute and chronic inflammatory cells were infiltrated the right upper lobe, and fungal hyphae were specifically visible, considering fungal infections (Candida infection was suspected, and mucormycosis and aspergillosis were ruled out). On 7 April 2021, the patient developed a high fever, with chest computed tomography (CT) in that hospital revealing possible empyema on the right side, postoperative changes in the right lung with scattered infection, multiple fractures of the right ribs with chest wall pneumatosis, and enlarged lymph nodes in the mediastinum. His vital signs upon admission to our hospital were as follows: temperature, 39.0°C; blood pressure, 134/70 mmHg; respiratory rate, 20 breaths/min; pulse, 112 beats/min; blood oxygen saturation level (SpO2), 92% (without oxygen inhalation); clear mind, stable breathing, no cyanosis of lips, the disappearance of breath sounds in the right lower lung, dullness to percussion in the right lower lung, and no dry or moist rales heard. As given above, the patient was diagnosed with right hydropneumothorax and empyema, pneumonia, postoperative malignant tumor of the right lower lobe (adenocarcinoma), and hypertension.\nAfter admission, the patient was given empirical anti-infective treatment with flucloxacillin (2 g Bid) plus levofloxacin (0.5 g Qd) injection. In addition, treatment for reducing phlegm, pleural effusion puncture and drainage, and other symptomatic treatments were given. On 10 April 2021, the patient had a sudden high fever without explained causes, accompanied by dyspnea, profuse sweating, and a large amount of purulent sputum. Physical examination revealed a heart rate of 108 bpm/min, an SpO2 of 75% (without oxygen inhalation), a blood pressure of 118/88 mmHg, a respiratory rate of 34 breaths/min, wheezing appearance, clear consciousness, coarse breath sounds, and a large number of palpable moist rales. Blood gas analysis showed a decreased pH of 7.237 and an elevated PCO2 and PO2 level (62.1 and 97.2 mmHg, respectively), indicating type II respiratory failure. The patient was given Bipap ventilator-assisted ventilation (A/C mode, inspired positive airway pressure (IPAP) 18 cm H2O, expired positive airway pressure (EPAP) 4 cm H2O, f = 24, O2 = 5 L/min) and transferred to the intensive care unit. Meropenem injection 0.5 g q8h and linezolid injection 0.6 g q12h were given immediately. The bedside chest x-ray showed infectious lesions and pleural effusion in the right lung (, ). The patient refused bronchoscopy. Sputum and blood samples were sent for mNGS (Vision medicals, Guangzhou, China), but both showed negative results. On 11 April 2021, the bedside chest x-ray was repeated, and the symptoms improved (, ). On 12 April 2021, the culture of pleural effusion in the microbiology laboratory reported Gram-negative bacteria, which was preliminarily considered as Eikenella corrodens based on morphology. Chest CT was performed on the same day, indicating a right lung abscess with cavitation (, ). The patient was given a meropenem injection of 0.5 g q8h alone for anti-infection. On 17 April 2021, the symptoms of cough, expectoration, chest distress, and shortness of breath were improved, without fever. The patient was transferred to the respiratory medicine ward. On 23 April 2021, the re-examination of chest CT showed that the lesion was continuously absorbed .\nThe patient was discharged on 25 April 2021. Amoxicillin 1.0 g q8h continued for 1 week. The conditions of the patient were stable. On 24 May 2021 and 9 July 2021 (, ), the re-examination of chest CT showed further absorption of the lesion. To date, the patient had no fever, dyspnea, or other symptoms.\nUnder aseptic operation, B ultrasound-guided thoracentesis was performed on 9 April 2021. A total of 15 ml of dark red pleural effusion was withdrawn and sent to the microbiology laboratory for aerobic and anaerobic culture. Direct smear staining showed elongated Gram-negative bacteria . The culture was transferred to a Columbia blood agar plate and incubated at 35°C under 5% CO2 for 72 h. We observed a typical straw cap colony on the plate, which was flat, with central convex and smooth round . A 16S rRNA gene sequencing was performed. The pathogen was detected as Eikenella at the genus level.\nTo further confirm the pathogen at the species level, a sputum sample collected on 11 April 2021 was sent for mNGS (Hugobiotech, Beijing, China), identifying the pathogens as E. halliae (82 specific reads, ,). Considering the rarity of the pathogen in this patient, the previously negative mNGS data were reanalyzed, and E. corrodens (91 unique reads, ,) were found in the background microorganisms. Interestingly, the pathogens detected by the two mNGS tests were different at the species level. So, high-throughput whole genome sequencing (WGS) was finally applied, of which the result showed that the isolate had the best concordance with E. halliae .\nDNA was extracted from sputum samples using the QIAamp DNA Micro Kit (QIAGEN, Hilden, Germany) according to its manual. DNA libraries were then constructed by QIAseqTM Ultralow Input Library Kit (Illumina, California, USA), and the quality of libraries was estimated using Qubit (Thermo Fisher, Massachusetts, USA) and Agilent 2100 Bioanalyzer (Agilent Technologies, Santa Clara, USA). The qualified libraries were finally sequenced on the Nextseq 550 platform (Illumina, California, USA). Reads of short length, low quality, and low complexity were removed from the raw data. Human DNA was also removed after mapping the human reference genome database (hg38). The remaining reads were finally aligned to the National Center for Biotechnology Information (NCBI) Microbial Genome Databases. The detailed method is shown in the .\nThe patient was initially treated with ß-amides and quinolones, but his conditions progressed, and respiratory failure occurred during treatment. According to the susceptibility protocol of rare bacteria and aerobic bacteria in the Clinical and Laboratory Standards Institute (CLSI) M45-A3 document, this bacterium was highly sensitive to amoxicillin/clavulanic acid. To further determine the sensitive drugs, the broth microdilution method was used for the susceptibility test in this case, and it was found that amoxicillin/clavulanic acid was the best antibiotic drug for the patient.", + "fulltext_subclaims": [ + "A 55-year-old male patient was admitted to Shanghai Xuhui Central Hospital due to fever, cough, and expectoration for 3 days on 9 April 2021.", + "The patient had a history of hypertension.", + "The patient had a history of chronic bronchitis.", + "The patient had a history of emphysema.", + "On 17 March 2021, the patient received a radical resection of right lower lung cancer and right upper lobectomy at a tertiary general hospital in Shanghai.", + "Postoperative pathology identified invasive adenocarcinoma in the right lower lung.", + "Fungal hyphae were specifically visible, considering fungal infections.", + "Candida infection was suspected.", + "Mucormycosis and aspergillosis were ruled out.", + "On 7 April 2021, chest CT revealed possible empyema on the right side.", + "On 7 April 2021, chest CT showed postoperative changes in the right lung with scattered infection.", + "On 7 April 2021, chest CT showed multiple fractures of the right ribs with chest wall pneumatosis.", + "On 7 April 2021, chest CT showed enlarged lymph nodes in the mediastinum.", + "Upon admission to Shanghai Xuhui Central Hospital, the patient's temperature was 39.0°C.", + "Upon admission to Shanghai Xuhui Central Hospital, the patient's blood oxygen saturation level (SpO2) was 92% without oxygen inhalation.", + "The patient was diagnosed with right hydropneumothorax and empyema.", + "The patient was diagnosed with pneumonia.", + "The patient was diagnosed with postoperative malignant tumor of the right lower lobe (adenocarcinoma).", + "The patient was diagnosed with hypertension.", + "The patient was given empirical anti-infective treatment with flucloxacillin (2 g Bid) plus levofloxacin (0.5 g Qd) injection.", + "The patient was given pleural effusion puncture and drainage.", + "On 10 April 2021, the patient had a sudden high fever without explained causes.", + "On 10 April 2021, the patient had dyspnea.", + "On 10 April 2021, the patient had profuse sweating.", + "On 10 April 2021, the patient had a large amount of purulent sputum.", + "On 10 April 2021, blood gas analysis showed a decreased pH of 7.237.", + "On 10 April 2021, blood gas analysis showed an elevated PCO2 level of 62.1 mmHg.", + "On 10 April 2021, blood gas analysis showed a PO2 level of 97.2 mmHg.", + "On 10 April 2021, the patient was given Bipap ventilator-assisted ventilation.", + "On 10 April 2021, the patient was transferred to the intensive care unit.", + "On 10 April 2021, meropenem injection 0.5 g q8h was given.", + "On 10 April 2021, linezolid injection 0.6 g q12h was given.", + "On 11 April 2021, the bedside chest x-ray showed infectious lesions and pleural effusion in the right lung.", + "On 12 April 2021, the culture of pleural effusion reported Gram-negative bacteria.", + "On 12 April 2021, the culture of pleural effusion was preliminarily considered as Eikenella corrodens based on morphology.", + "On 12 April 2021, chest CT indicated a right lung abscess with cavitation.", + "On 12 April 2021, the patient was given meropenem injection of 0.5 g q8h alone for anti-infection.", + "On 17 April 2021, the symptoms of cough, expectoration, chest distress, and shortness of breath were improved.", + "On 17 April 2021, the patient was transferred to the respiratory medicine ward.", + "On 23 April 2021, re-examination of chest CT showed that the lesion was continuously absorbed.", + "The patient was discharged on 25 April 2021.", + "Amoxicillin 1.0 g q8h continued for 1 week after discharge.", + "On 24 May 2021, re-examination of chest CT showed further absorption of the lesion.", + "On 9 April 2021, B ultrasound-guided thoracentesis was performed.", + "A total of 15 ml of dark red pleural effusion was withdrawn.", + "Direct smear staining showed elongated Gram-negative bacteria.", + "The culture was transferred to a Columbia blood agar plate and incubated at 35°C under 5% CO2 for 72 h.", + "A typical straw cap colony was observed on the plate.", + "16S rRNA gene sequencing detected the pathogen as Eikenella at the genus level.", + "A sputum sample collected on 11 April 2021 was sent for mNGS (Hugobiotech, Beijing, China).", + "mNGS identified the pathogens as E. halliae (82 specific reads).", + "The previously negative mNGS data were reanalyzed, and E. corrodens (91 unique reads) were found in the background microorganisms.", + "The pathogens detected by the two mNGS tests were different at the species level.", + "High-throughput whole genome sequencing (WGS) was finally applied.", + "The WGS result showed that the isolate had the best concordance with E. halliae.", + "DNA was extracted from sputum samples using the QIAamp DNA Micro Kit.", + "DNA libraries were constructed by QIAseqTM Ultralow Input Library Kit.", + "The libraries were sequenced on the Nextseq 550 platform.", + "The patient was initially treated with ß-amides and quinolones.", + "The patient's conditions progressed during treatment.", + "Respiratory failure occurred during treatment.", + "According to the CLSI M45-A3 document, this bacterium was highly sensitive to amoxicillin/clavulanic acid.", + "The broth microdilution method was used for the susceptibility test.", + "Amoxicillin/clavulanic acid was found to be the best antibiotic drug for the patient." + ], + "summary": "In this study, we report a clinical case of empyema caused by Eikenella halliae after pulmonary surgery in a 55-year-old man. He had a fever, cough, and expectoration for 3 days and was diagnosed with right hydropneumothorax and empyema, pneumonia, postoperative malignant tumor of the right lower lobe (adenocarcinoma), and hypertension. The microbiology laboratory reported Gram-negative bacteria in pleural effusion, which was preliminarily considered as Eikenella based on culture and 16S rRNA sequencing. Furthermore, metagenomic next-generation sequencing (mNGS) of sputum samples was performed two times and reported negative results and the presence of E. halliae, respectively. The pathogen was finally confirmed as E. halliae by whole genome sequencing, suggesting the high-resolution ability of mNGS in the clinical diagnosis of this case.", + "summary_subclaims": [ + "The patient was a 55-year-old man.", + "He had a fever, cough, and expectoration for 3 days.", + "He was diagnosed with right hydropneumothorax and empyema.", + "He was diagnosed with pneumonia.", + "He had a postoperative malignant tumor of the right lower lobe (adenocarcinoma).", + "The microbiology laboratory reported Gram-negative bacteria in pleural effusion.", + "The microbiology laboratory preliminarily considered the bacteria as Eikenella based on culture and 16S rRNA sequencing.", + "Metagenomic next-generation sequencing (mNGS) of sputum samples was performed two times.", + "The first mNGS of sputum samples reported negative results.", + "The second mNGS of sputum samples reported the presence of E. halliae.", + "The pathogen was finally confirmed as E. halliae by whole genome sequencing.", + "The case suggests the high-resolution ability of mNGS in the clinical diagnosis." + ] + }, + { + "id": "multiclinsum_test_2357_en.txt", + "fulltext": "A 61-year-old Caucasian man underwent a chest CT due to unclear right-sided thoracic pain. In addition our patient complained of abdominal cramps. Examination suggested a retroperitoneal mass seen on the most caudal CT slices. He was referred to our hospital for abdominal ultrasound, showing a 11 cm large retroperitoneal tumor located right and ventral to the abdominal aorta . The craniocaudal dimension extended from the head of pancreas to the aortic bifurcation. The tumor consisted of two different components: the cranial component was well delineated and heterogeneous with hyperechoic and anechoic compartments. The caudal tumor component was poorly delineated, homogeneous and hypo-echoic. The tumor led to a ventral displacement of the duodenum and a compression of the inferior vena cava. Due to an obstruction of the right ureter, there was a right-sided hydronephrosis.\nA subsequent abdominal CT confirmed these findings . As seen by ultrasound, the tumor consisted of two different parts: (1) a well-perfused heterogeneous part with cystic lesions and (2) a less-perfused, homogeneous part. The two parts were well delineated from each other. The tumor partially encased the inferior vena cava, the right common iliac artery and right ureter. In addition the pancreas and the duodenum could not be delineated from the tumor. Due to the obstruction of the right ureter, the right kidney showed delayed enhancement.\nLaboratory analyses found elevated levels of normetanephrin (4411 nmol; normal 570 to 1930 nmol) in a 24-hour urine test, clinically proving a neuroendocrine tumor of the pheochromocytoma/paraganglioma family. Unaware of this differential diagnosis, an endosonographic-guided transduodenal fine needle aspiration was performed confirming the diagnosis. Fortunately no hypertensive crisis occurred.\nIn addition, intra-hepatic metastases were seen on the initial CT scan and a subsequent octreoscan also revealed the presence of intra-osseous metastases. On contrast-enhanced CT the liver metastases had a slight early arterial enhancement with a reduced wash-out during the venous phase. On ultrasound the liver metastases were not well delineated, but appeared slightly hypo-echogenic compared with the surrounding liver tissue. Contrast-enhanced ultrasound was not performed. The CT findings, in particular, would be consistent with metastases from a neuroendocrine tumor.\nThe presence of metastatic disease precluded a curative resection. However, local resection of the tumor was undertaken for symptomatic relief.\nMacroscopically the partially resected tumor reflected the radiological results. The cranial component was well defined and encapsulated and displayed red, brown and black hemorrhagic and cystic areas consistent with the appearance of paragangliomas. Meanwhile the caudal part, corresponding to the neuroblastoma, was macroscopically less well demarcated with a white-gray-tan and solid cut surface.\nMicroscopically, the encapsulated paraganglioma showed the typical Zellballen growth pattern, an elevated mitotic activity (Ki-67) of up to 50%, necrosis and vascular invasion. The small blue round cells of the neuroblastoma component displayed a highly proliferative (around 90%) and broadly infiltrative growth pattern and lymphovascular invasion was seen . Immunohistochemically, both components were positive for synaptophysin and somatostatin receptor 2 with the latter one being consistent with the positive octreotid scan. In contrast to the neuroblastoma, the paraganglioma expressed the typical markers chromogranin A and vimentin.\nThere was no evidence for an amplification of the prognostic oncogene N-myc. Tumor metastasis of the neuroblastoma component was histologically confirmed by lymph node and skin biopsies.\nSubsequently, our patient was treated with palliative chemotherapy and radiotherapy beginning with three cycles of carboplatin aqueous solution and etoposide phosphate. On tumor progression palliative radiotherapy with 10 × 3 Gray at multiple locations followed. Subsequently chemotherapy with CHOP (cyclophoshamide, hydroxydaunorubicin, oncovin, prednisone) was started and finally (after two months) changed to a weekly dose of docetaxel with prednisone. Ten months after the initial diagnosis our patient died of cancer-related pulmonary embolism and pneumonia.", + "fulltext_subclaims": [ + "The patient is a 61-year-old Caucasian man.", + "The patient underwent a chest CT due to unclear right-sided thoracic pain.", + "The patient complained of abdominal cramps.", + "Examination suggested a retroperitoneal mass seen on the most caudal CT slices.", + "The patient was referred to the hospital for an abdominal ultrasound.", + "The ultrasound showed a 11 cm large retroperitoneal tumor located right and ventral to the abdominal aorta.", + "The tumor's craniocaudal dimension extended from the head of the pancreas to the aortic bifurcation.", + "The tumor consisted of two different components.", + "The cranial component was well delineated and heterogeneous with hyperechoic and anechoic compartments.", + "The caudal tumor component was poorly delineated, homogeneous, and hypo-echoic.", + "The tumor led to a ventral displacement of the duodenum.", + "The tumor caused compression of the inferior vena cava.", + "Due to an obstruction of the right ureter, there was a right-sided hydronephrosis.", + "A subsequent abdominal CT confirmed these findings.", + "The tumor consisted of two different parts: (1) a well-perfused heterogeneous part with cystic lesions and (2) a less-perfused, homogeneous part.", + "The two parts were well delineated from each other.", + "The tumor partially encased the inferior vena cava.", + "The tumor partially encased the right common iliac artery.", + "The tumor partially encased the right ureter.", + "The pancreas and the duodenum could not be delineated from the tumor.", + "Due to the obstruction of the right ureter, the right kidney showed delayed enhancement.", + "Laboratory analyses found elevated levels of normetanephrin (4411 nmol; normal 570 to 1930 nmol) in a 24-hour urine test.", + "This finding clinically proved a neuroendocrine tumor of the pheochromocytoma/paraganglioma family.", + "An endosonographic-guided transduodenal fine needle aspiration was performed.", + "The fine needle aspiration confirmed the diagnosis.", + "Intra-hepatic metastases were seen on the initial CT scan.", + "A subsequent octreoscan revealed the presence of intra-osseous metastases.", + "On contrast-enhanced CT, the liver metastases had a slight early arterial enhancement with a reduced wash-out during the venous phase.", + "On ultrasound, the liver metastases were not well delineated.", + "The liver metastases appeared slightly hypo-echogenic compared with the surrounding liver tissue.", + "Contrast-enhanced ultrasound was not performed.", + "The CT findings would be consistent with metastases from a neuroendocrine tumor.", + "The presence of metastatic disease precluded a curative resection.", + "A local resection of the tumor was undertaken for symptomatic relief.", + "Macroscopically, the partially resected tumor reflected the radiological results.", + "The cranial component was well defined and encapsulated.", + "The cranial component displayed red, brown, and black hemorrhagic and cystic areas consistent with the appearance of paragangliomas.", + "The caudal part corresponded to the neuroblastoma.", + "The caudal part was macroscopically less well demarcated with a white-gray-tan and solid cut surface.", + "Microscopically, the encapsulated paraganglioma showed the typical Zellballen growth pattern.", + "The paraganglioma component had an elevated mitotic activity (Ki-67) of up to 50%.", + "The paraganglioma component showed necrosis.", + "The paraganglioma component showed vascular invasion.", + "The small blue round cells of the neuroblastoma component displayed a highly proliferative (around 90%) and broadly infiltrative growth pattern.", + "Lymphovascular invasion was seen in the neuroblastoma component.", + "Both components were positive for synaptophysin.", + "Both components were positive for somatostatin receptor 2.", + "The paraganglioma expressed the typical markers chromogranin A and vimentin.", + "There was no evidence for an amplification of the prognostic oncogene N-myc.", + "Tumor metastasis of the neuroblastoma component was histologically confirmed by lymph node and skin biopsies.", + "The patient was treated with palliative chemotherapy and radiotherapy.", + "The patient received three cycles of carboplatin aqueous solution and etoposide phosphate.", + "On tumor progression, palliative radiotherapy with 10 × 3 Gray at multiple locations followed.", + "Chemotherapy with CHOP was started.", + "Chemotherapy was changed to a weekly dose of docetaxel with prednisone.", + "Ten months after the initial diagnosis, the patient died of cancer-related pulmonary embolism and pneumonia." + ], + "summary": "A 61-year-old Caucasian man was referred to our hospital due to a suspect lesion found on chest computed tomography carried out for unclear thoracic pain. An abdominal computed tomography scan and ultrasound examination detected a retroperitoneal tumor comprising two different tumor components. Twenty-four-hour urine revealed high levels of normetanephrine, characteristic of a neuroendocrine tumor. An octreoscan prior to surgical procedures revealed multiple osseous and intra-hepatic metastases. The final histopathological workup revealed a composite paraganglioma with neuroblastoma. Our patient died ten months after the initial diagnosis from tumor-associated complications.", + "summary_subclaims": [ + "The patient was a 61-year-old Caucasian man.", + "The patient was referred to the hospital due to a suspect lesion found on chest computed tomography.", + "The chest computed tomography was carried out for unclear thoracic pain.", + "An abdominal computed tomography scan and ultrasound examination detected a retroperitoneal tumor comprising two different tumor components.", + "Twenty-four-hour urine revealed high levels of normetanephrine.", + "High levels of normetanephrine are characteristic of a neuroendocrine tumor.", + "An octreoscan prior to surgical procedures revealed multiple osseous and intra-hepatic metastases.", + "The final histopathological workup revealed a composite paraganglioma with neuroblastoma.", + "The patient died ten months after the initial diagnosis from tumor-associated complications." + ] + }, + { + "id": "multiclinsum_test_148_en.txt", + "fulltext": "A 45-year-old female presented to the emergency with complaints of blood-stained stool for 1 day. The patient was apparently well until 7 days back when she developed pain over the right lower abdomen. The pain was colicky in nature, moderate intensity, and non-radiating, with no aggravating or relieving factors. The pain was associated with vomiting for 2 days which was non-bilious, occurred two to three times per day, and contained only food particles. On further inquiry, the patient reported having constipation for 6 months which occurred in an on-and-off pattern. She did not report any pain during defecation nor any protruding mass per rectum. There was no history of melena, anorexia, weight loss, or fever.\nNo significant past medical and surgical history.\nNo family history of similar presentations exists.\nNo significant drug and allergy history. The patient denied the use of tobacco or illicit drugs.", + "fulltext_subclaims": [ + "The patient is a 45-year-old female.", + "She presented with complaints of blood-stained stool for 1 day.", + "She developed pain over the right lower abdomen 7 days back.", + "The pain was colicky in nature.", + "The pain was moderate intensity.", + "The pain was non-radiating.", + "The pain was associated with vomiting for 2 days.", + "The vomiting was non-bilious.", + "The vomiting occurred two to three times per day.", + "The vomiting contained only food particles.", + "She reported having constipation for 6 months.", + "The constipation occurred in an on-and-off pattern.", + "She did not report any pain during defecation.", + "She did not report any protruding mass per rectum.", + "There was no history of melena.", + "There was no history of anorexia.", + "There was no history of weight loss.", + "There was no history of fever.", + "There was no significant past medical and surgical history.", + "There was no family history of similar presentations.", + "There was no significant drug and allergy history.", + "The patient denied the use of tobacco or illicit drugs." + ], + "summary": "A 45-year-old woman presented with hematochezia and abdominal pain. Abdominal ultrasound and Contrast enhanced computed tomography abdomen, both showed features of ileocolic intussusception. Intraoperatively, an intraluminal pedunculated polypoid growth extending up to the hepatic flexure of the colon was discovered. A right hemicolectomy was performed, removing the polypoid growth as well. After histopathological evaluation, a final diagnosis of colonic polypoid vascular ectasia was made.", + "summary_subclaims": [ + "The patient is a 45-year-old woman.", + "She presented with hematochezia.", + "She presented with abdominal pain.", + "Abdominal ultrasound showed features of ileocolic intussusception.", + "Contrast enhanced computed tomography abdomen showed features of ileocolic intussusception.", + "Intraoperatively, an intraluminal pedunculated polypoid growth extending up to the hepatic flexure of the colon was discovered.", + "A right hemicolectomy was performed.", + "The polypoid growth was removed.", + "Histopathological evaluation was performed.", + "The final diagnosis was colonic polypoid vascular ectasia." + ] + }, + { + "id": "multiclinsum_test_2289_en.txt", + "fulltext": "A previously healthy 35-year-old Sri Lankan man presented with high-grade intermittent fever for 3 days with constitutional symptoms. He had spontaneous gum bleeding with no other overt bleeding manifestations. He had associated intermittent frontal headache of moderate severity at presentation and subsequently developed gradually worsening drowsiness. Rest of the history including his past medical and family histories were unremarkable. In particular, he did not have diabetes mellitus, history of recurrent infections, unprotected sexual contact or recreational drug abuse.\nOn examination, his body temperature was 100 °F and his Glasgow coma scale score was 10/15. He was mildly pale. There was no neck stiffness. Fundoscopic examination was normal. There were no focal neurological signs. His pulse rate was 100 bpm and blood pressure was 130/80 mmHg, Rest of the cardiovascular, respiratory and abdominal examinations were normal.\nHis full blood count showed a white cell count of 9.2 × 103/dl (Normal Range (NR) 4–11 × 103) with neutrophil predominance (77%). Haemoglobin was 6.9 g/dl (NR 11–15) and platelet count on admission was 7 × 103 (NR150–400 × 103). His coagulation profile was normal with prothrombin time of 12.8 s (NR 10–13) and APTT 30 s (NR 26–40). Serum creatinine was slightly elevated at 137 mmol/l (NR 60–120 umol/L) and the electrolytes were normal. There was indirect hyperbilirubinaemia with total bilirubin of 44.7 μmol/l (NR 1.7–20.5) and direct bilirubin of 7.3 μmol/l (NR 1.7–5.1). The serum lactate dehydrogenase level was 3115 U/l (NR 160–450). Direct coombs test and dengue serology were negative. Non-contrast CT scan of the brain was normal. Blood picture showed evidence of severe thrombocytopenia with microangiopathic haemolytic anaemia (MAHA).\nA diagnosis of TTP was made and he was promptly commenced on therapeutic plasma exchange and 1 mg/kg of oral prednisolone. However, he developed two episodes of generalized tonic-clonic convulsions which progressed in to a non-convulsive status epilepticus on the fifth day of illness, which required elective ventilation in the intensive care unit. On day 18, he developed flaccid paraparesis with sphincter dysfunction. Magnetic resonance imaging showed haemorrhage at multiple spinal levels including cervical spine sub-arachnoid space, anterior epidural space and intra-thecal space from T10 to L3 vertebral levels, and in the the region of the conus medullaris.\nSurgical drainage of the spinal haematoma was considered hazardous. At this point his platelet count was 85 × 103 and remained < 100 × 103 with MAHA persisting despite 16 plasma exchanges and high dose steroids.\nInitially, the refractoriness of the TTP was attributed to ventilator associated pneumonia. However, since successful treatment of sepsis did not improve the MAHA, an alternative aetiology was investigated. Polymerase chain reaction of serum revealed 2100 IU/ml copies of CMV (Reference laboratory cutoff value more than 640 IU/ml was considered clinically significant). CMV DNA was quantitatively determined by RealStar® CMV PCR Kit 1.0 (Altona diagnostics). Screening tests for autoimmune diseases, other chronic infections and immunodeficiency, which included ANA, serum complement levels, serum immunoglobulin levels, HIV 1, HIV 2, VDRL, hepatitis screen and HbA1c were negative.\nThe patient was commenced on oral valganciclovir 450 mg/daily and continued for 21 days. After about 6 days of valganciclovir treatment his platelet count increased to 198 × 103/cumm and the MAHA resolved. After resolution of the TTP, the patient was transferred to a rehabilitation facility for further care. At three months’ review, he had normal haematological and biochemical parameters and a negative PCR quantification of CMV. He had regained ability to walk with support and had normal sphincter function.", + "fulltext_subclaims": [ + "A previously healthy 35-year-old Sri Lankan man presented with high-grade intermittent fever for 3 days with constitutional symptoms.", + "He had spontaneous gum bleeding with no other overt bleeding manifestations.", + "He had associated intermittent frontal headache of moderate severity at presentation.", + "He subsequently developed gradually worsening drowsiness.", + "He did not have diabetes mellitus.", + "He did not have a history of recurrent infections.", + "He did not have unprotected sexual contact.", + "He did not have recreational drug abuse.", + "On examination, his body temperature was 100 °F.", + "His Glasgow coma scale score was 10/15.", + "He was mildly pale.", + "There was no neck stiffness.", + "Fundoscopic examination was normal.", + "There were no focal neurological signs.", + "His pulse rate was 100 bpm.", + "His blood pressure was 130/80 mmHg.", + "His full blood count showed a white cell count of 9.2 × 103/dl.", + "Haemoglobin was 6.9 g/dl.", + "Platelet count on admission was 7 × 103.", + "Prothrombin time was 12.8 s.", + "APTT was 30 s.", + "Serum creatinine was 137 mmol/l.", + "Total bilirubin was 44.7 μmol/l.", + "Direct bilirubin was 7.3 μmol/l.", + "Serum lactate dehydrogenase level was 3115 U/l.", + "Direct coombs test was negative.", + "Dengue serology was negative.", + "Non-contrast CT scan of the brain was normal.", + "Blood picture showed evidence of severe thrombocytopenia.", + "Blood picture showed evidence of microangiopathic haemolytic anaemia.", + "A diagnosis of TTP was made.", + "He was promptly commenced on therapeutic plasma exchange.", + "He was commenced on 1 mg/kg of oral prednisolone.", + "He developed two episodes of generalized tonic-clonic convulsions.", + "He developed non-convulsive status epilepticus on the fifth day of illness.", + "He required elective ventilation in the intensive care unit.", + "On day 18, he developed flaccid paraparesis with sphincter dysfunction.", + "Magnetic resonance imaging showed haemorrhage at multiple spinal levels.", + "Surgical drainage of the spinal haematoma was considered hazardous.", + "At this point his platelet count was 85 × 103.", + "His platelet count remained < 100 × 103.", + "MAHA persisted despite 16 plasma exchanges.", + "MAHA persisted despite high dose steroids.", + "Initially, the refractoriness of the TTP was attributed to ventilator associated pneumonia.", + "Successful treatment of sepsis did not improve the MAHA.", + "Polymerase chain reaction of serum revealed 2100 IU/ml copies of CMV.", + "CMV DNA was quantitatively determined by RealStar® CMV PCR Kit 1.0.", + "The patient was commenced on oral valganciclovir 450 mg/daily.", + "Valganciclovir was continued for 21 days.", + "After about 6 days of valganciclovir treatment his platelet count increased to 198 × 103/cumm.", + "The MAHA resolved after valganciclovir treatment.", + "After resolution of the TTP, the patient was transferred to a rehabilitation facility.", + "At three months’ review, he had normal haematological and biochemical parameters.", + "At three months’ review, PCR quantification of CMV was negative.", + "He had regained ability to walk with support.", + "He had normal sphincter function." + ], + "summary": "A 35-year-old, previously healthy Sri Lankan man, presented with fever for 3 days with gum bleeding and progressive drowsiness. His Glasgow coma scale score was 10/15. He did not have papilloedema or neck stiffness. Laboratory evaluation showed a severe thrombocytopenia with microangiopathic haemolytic anaemia. There was marginal renal impairment and normal coagulation profile. Non-contrast CT scan of brain was normal. A diagnosis of thrombotic thrombocytopenic purpura was made. Despite daily plasma exchanges and high-dose steroids, he failed to achieve the expected therapeutic response, thus demonstrating refractory TTP. On exploring for possible causes of refractoriness to treatment, a clinically significant PCR titre of CMV was detected. Treatment of CMV infection lead to complete recovery of TTP. His disease course was further complicated with spontaneous spinal haemorrhage leading to neurological sequelae.", + "summary_subclaims": [ + "A 35-year-old, previously healthy Sri Lankan man presented with fever for 3 days.", + "The man had gum bleeding.", + "The man had progressive drowsiness.", + "His Glasgow coma scale score was 10/15.", + "He did not have papilloedema.", + "He did not have neck stiffness.", + "Laboratory evaluation showed severe thrombocytopenia.", + "There was microangiopathic haemolytic anaemia.", + "There was marginal renal impairment.", + "The coagulation profile was normal.", + "Non-contrast CT scan of brain was normal.", + "A diagnosis of thrombotic thrombocytopenic purpura was made.", + "Despite daily plasma exchanges and high-dose steroids, he failed to achieve the expected therapeutic response.", + "This demonstrated refractory TTP.", + "A clinically significant PCR titre of CMV was detected.", + "Treatment of CMV infection led to complete recovery of TTP.", + "The disease course was further complicated with spontaneous spinal haemorrhage.", + "Spontaneous spinal haemorrhage led to neurological sequelae." + ] + }, + { + "id": "multiclinsum_test_1059_en.txt", + "fulltext": "The subject of our study, a 56-year-old Caucasian Italian woman, presents with an occlusal open bite and a complete dental formula, with only the left superior second premolar missing, substituted by an implantoprosthetic rehabilitation . The patient, a medical doctor, has a normal blood pressure range, is not affected by any metabolic disease and is a non-cigarette smoker. For the evaluation of her occlusal muscle activity, a bilateral electromyography (EMG) of her masseter muscle was recorded using an evaluation system of mandibular movement (K6-I; Myotronics, Seattle, WA, USA) and Duo-trode surface Ag-AgCl electrodes (Duo-trode; interelectrode distance: 19.5mm, Myotronics). EMG data were recorded at a sampling rate of 240Hz and amplified at a time constant of 0.06 seconds. For the evaluation of her muscle activity, voluntary dental clenching was executed and recorded during swallowing. In accordance with the dental diagnostic protocol , a preliminary evaluation of the patient’s myoelectric activity in dental occlusion was performed through muscle EMG in order to assess their functional balance. Registered values showed a remarkable functional asymmetry of masseter muscles, 23mV for her left masseter and 103mV for her right masseter . According to the expressed electromyographic values, muscular activity was symmetrized by applying a 15 minutes transcutaneous stimulation of trigeminal motor branches at low frequency for elevator occlusal muscles and at medium frequency for submandibular antagonist muscles. This method allowed detection of the functional trajectory of occlusal elevator muscles and to record a symmetric craniomandibular relation, positioning a self-hardening material between the dental arches. The same material was used to make a cusp bite modeled on the inferior dental arch named orthotic-syntropic bite for its peculiar use of electrostimulation. When the orthotic was applied, electromyographic control was repeated to verify occlusal myoelectric balance. Registrations have documented substantially equal values: 57mV for left masseter muscle and 61mV for right masseter . Immediately after, the patient was submitted to pupillometric and hemodynamic examinations in habitual occlusion first and with the orthotic soon after.\nFor pupillary diameter measurement, we used a computerized corneal topographer MODI02 software 2005 LITE (CSO, Florence, Italy), made of a survey section by Placido disk 24 loops, camera sensor charge-coupled device (CCD) 1/3 inch and a claim support. The instrument presents, during the pupillar acquisition phases, a constant lighting of the disk and a 56mm distance of work. The points measured during data acquisition are 6.144, with a model elaboration higher than 100.000 points. Registered pupillometric analysis showed a remarkable right and left baseline asymmetry, respectively 4.98mm and 4.40mm , whereas in the occlusal rebalance condition an equivalent pupil diameter was registered, 4.13mm right pupil and 4.10mm left pupil . Indeed, pupillometric data analysis registered in occlusal rebalance shows a more suitable reduction of the basal diameter, with clear right side decrease, relating to higher occlusal myoelectric values.\nFor blood flow computerized examination, a GE HealthCare echograph, Voluson E8 Expert model, was used, with a 3D-4D-color-power Doppler volumetric probe. The duplex color scanner investigations were executed with an interval of 60 minutes, in habitual occlusion first, and with the orthotic after . The following evaluations were performed (see Table ).\nsystolic pulsatility and average flow velocity: (P.I. Index);\nsystolic and diastolic relationship-flow: (R.I. Index);\nsystolic peak in cm/second: (P.S. Index);\ndiastasis cordis in cm/second: (E.D. Index);\nsystole-diastole relationship: (S-D Index);\nCarotid artery: C.a.;\nVertebral artery: V.a.\nThe registrations reveal that the patient’s left V.a. hemodynamic is more influenced by trigeminal proprioception. In fact, the orthotic application reduces on the left the S-D index of 70.94 and equilibrates the values of both vertebral arteries, 3.40 (left) and 3.21 (right), respectively. Whereas, in the ED index, diastolic flow increase of 12.06 cm/second of the left V.a. makes the values of both arteries equal, 12.70 (left) and 12.16 (right) respectively. Moreover, in the PI index it is possible to observe that the different average flow between the right (1.0) and left (2.88) vertebral arteries is totally cancelled in occlusal rebalance, with perfectly equal values (1.23). Also the PS Index confirms the previous results because a general reduction of hemodynamic values is registered both in carotid and vertebral arteries after orthotic application. In fact, the systolic hematic peak, expressed in cm/second, shows decreases of 2.05 on the right and of 7.69 on the left in the carotid arteries, while in vertebral arteries the decreases are of 7.42 on the right and of 4.37 on the left. The RI index does not seem to be influenced by occlusal proprioception.", + "fulltext_subclaims": [ + "The subject of our study is a 56-year-old Caucasian Italian woman.", + "She presents with an occlusal open bite.", + "She has a complete dental formula.", + "The left superior second premolar is missing.", + "The missing left superior second premolar is substituted by an implantoprosthetic rehabilitation.", + "The patient is a medical doctor.", + "The patient has a normal blood pressure range.", + "The patient is not affected by any metabolic disease.", + "The patient is a non-cigarette smoker.", + "A bilateral electromyography (EMG) of her masseter muscle was recorded.", + "EMG data were recorded at a sampling rate of 240Hz.", + "EMG data were amplified at a time constant of 0.06 seconds.", + "Voluntary dental clenching was executed and recorded during swallowing.", + "A preliminary evaluation of the patient’s myoelectric activity in dental occlusion was performed.", + "Registered values showed a remarkable functional asymmetry of masseter muscles.", + "The left masseter muscle showed 23mV.", + "The right masseter muscle showed 103mV.", + "Muscular activity was symmetrized by applying 15 minutes transcutaneous stimulation of trigeminal motor branches.", + "The stimulation was at low frequency for elevator occlusal muscles.", + "The stimulation was at medium frequency for submandibular antagonist muscles.", + "A self-hardening material was positioned between the dental arches.", + "The same material was used to make a cusp bite modeled on the inferior dental arch.", + "The cusp bite was named orthotic-syntropic bite.", + "Electromyographic control was repeated to verify occlusal myoelectric balance.", + "Registrations documented 57mV for the left masseter muscle.", + "Registrations documented 61mV for the right masseter muscle.", + "The patient was submitted to pupillometric and hemodynamic examinations.", + "Pupillometric measurements were made using a computerized corneal topographer MODI02 software 2005 LITE.", + "The instrument uses a Placido disk with 24 loops.", + "The instrument uses a camera sensor charge-coupled device (CCD) 1/3 inch.", + "The work distance during pupillar acquisition phases is 56mm.", + "The points measured during data acquisition are 6.144.", + "The model elaboration is higher than 100.000 points.", + "Registered pupillometric analysis showed a right baseline asymmetry of 4.98mm.", + "Registered pupillometric analysis showed a left baseline asymmetry of 4.40mm.", + "In the occlusal rebalance condition, an equivalent pupil diameter was registered.", + "The right pupil diameter in occlusal rebalance was 4.13mm.", + "The left pupil diameter in occlusal rebalance was 4.10mm.", + "A GE HealthCare echograph, Voluson E8 Expert model, was used for blood flow computerized examination.", + "A 3D-4D-color-power Doppler volumetric probe was used.", + "Duplex color scanner investigations were executed with an interval of 60 minutes.", + "The evaluations were performed in habitual occlusion first, and with the orthotic after.", + "The left vertebral artery (V.a.) hemodynamic is more influenced by trigeminal proprioception.", + "The orthotic application reduces the left S-D index by 70.94.", + "The orthotic application equilibrates the values of both vertebral arteries.", + "The left vertebral artery S-D index after orthotic application is 3.40.", + "The right vertebral artery S-D index after orthotic application is 3.21.", + "In the ED index, the diastolic flow increase of 12.06 cm/second of the left V.a. makes the values of both arteries equal.", + "The left vertebral artery ED index after orthotic application is 12.70.", + "The right vertebral artery ED index after orthotic application is 12.16.", + "In the PI index, the different average flow between the right and left vertebral arteries is totally cancelled in occlusal rebalance.", + "The PI index after orthotic application shows perfectly equal values of 1.23.", + "The PS Index confirms a general reduction of hemodynamic values both in carotid and vertebral arteries after orthotic application.", + "The systolic hematic peak in carotid arteries shows decreases of 2.05 on the right and 7.69 on the left after orthotic application.", + "The systolic hematic peak in vertebral arteries shows decreases of 7.42 on the right and 4.37 on the left after orthotic application.", + "The RI index does not seem to be influenced by occlusal proprioception." + ], + "summary": "A 56-year-old Caucasian Italian woman affected by asymmetric blood flow of cerebro-afferent vessels underwent an electromyographic investigation of her occlusal muscles in order to assess their occlusal functional balance. The extreme asymmetry of myoelectric activity in dental occlusion evidenced by electromyographic values suggested the rebalancing of the functions of occlusal muscles through concurrent transcutaneous stimulation of the trigeminal nerve supra- and submandibular motor branches. The above-mentioned method allowed the detection of a symmetric craniomandibular muscular relation that can be kept constant through the use of a cusp bite modeled on the inferior dental arch: called orthotic-syntropic bite for its peculiar use of electrostimulation. A few days later, the patient underwent a duplex color scanner investigation and pupillometric video-oculographic examinations in occlusal unbalance and rebalance conditions.", + "summary_subclaims": [ + "The patient is a 56-year-old Caucasian Italian woman.", + "The patient is affected by asymmetric blood flow of cerebro-afferent vessels.", + "An electromyographic investigation of her occlusal muscles was performed.", + "The investigation aimed to assess the occlusal functional balance.", + "The extreme asymmetry of myoelectric activity in dental occlusion was evidenced by electromyographic values.", + "The method involved concurrent transcutaneous stimulation of the trigeminal nerve supra- and submandibular motor branches.", + "The method allowed the detection of a symmetric craniomandibular muscular relation.", + "The symmetric relation can be kept constant through the use of a cusp bite modeled on the inferior dental arch.", + "The cusp bite is called an orthotic-syntropic bite.", + "A few days later, the patient underwent a duplex color scanner investigation.", + "Pupillometric video-oculographic examinations were performed in occlusal unbalance and rebalance conditions." + ] + }, + { + "id": "multiclinsum_test_3322_en.txt", + "fulltext": "A 44-year-old female patient presented to the emergency department with a 3-week history of melena and abdominal pain. She was hemodynamically unstable with a mean arterial pressure of 60 mmHg and a heart rate of 95 bpm. In the laboratory, a baseline Hb of 4.8 g/dL was noted. Supportive measures were initiated and an upper gastrointestinal endoscopy was performed, which revealed a submucosal gastric tumor without active bleeding, but intractable by this means. The patient was hospitalized and the study was complemented with an abdominal CT scan, which reported a solid exophytic mass dependent on the gastric fundus of 11.3 cm in major diameter, of heterogeneous density and a 24 mm ulcer on the anterior face, suggestive of a gastric gastrointestinal stromal tumor (GIST).\n\nAfter the patient was stabilized, a surgical resection was planned. On examination, the tumor was a large exophytic lesion of the proximal third and posterior aspect of the stomach, 12 cm in diameter, with extensive adhesive and infiltrative process to the splenic hilum, including the pancreatic tail and part of the left Gerota's fascia; however, the adjacent pancreatic tissue was normal in appearance. There was no evidence of lymphatic, visceral, or peritoneal metastases.\n\nA vertical wedge gastrectomy was performed with a corporodistal pancreatectomy and a splenectomy en bloc. The histological study showed a tumour with a neoplastic, anaplastic, poorly differentiated, malignant proliferation with cells arranged in a solid pattern with increased nuclear-cytoplasmic ratio, hyperchromatic, pleomorphic, anisocaryotic nuclei with numerous mitoses and some multinucleated giant cells of osteoclastic type, circumferential surgical margins and a pancreatic margin of 0.5 cm. There was no evidence of perineural or lymphovascular invasion. Immunohistochemistry for vimentin, keratin and CD68 were positive. Immunohistochemistry for DOG, S100, CD34 and DOG1 was negative. These findings were consistent with an anaplastic cancer of the pancreas.\n\nThe patient evolved in the immediate postoperative period in a good way. The only notable complication was a pancreatic biochemical leakage (fistula type A) without clinical repercussions, so it was kept drained for 6 weeks and then removed without incident. She subsequently evolved in a favorable way, receiving chemotherapy effectively with Oxaliplatino, 5-Fluorouracil and Leucovorin, with a serial follow-up with PET/CT without metastases at 5 years, in good general condition and with a good quality of life.", + "fulltext_subclaims": [ + "The patient was a 44-year-old female.", + "She presented with a 3-week history of melena.", + "She had a 3-week history of abdominal pain.", + "She was hemodynamically unstable.", + "Her mean arterial pressure was 60 mmHg.", + "Her heart rate was 95 bpm.", + "A baseline hemoglobin of 4.8 g/dL was noted.", + "An upper gastrointestinal endoscopy was performed.", + "The endoscopy revealed a submucosal gastric tumor.", + "The tumor was without active bleeding.", + "The tumor was intractable by endoscopic means.", + "An abdominal CT scan was performed.", + "The CT scan reported a solid exophytic mass dependent on the gastric fundus.", + "The mass had a major diameter of 11.3 cm.", + "The mass was of heterogeneous density.", + "The mass had a 24 mm ulcer on the anterior face.", + "The findings were suggestive of a gastric gastrointestinal stromal tumor.", + "A surgical resection was planned.", + "The tumor was a large exophytic lesion of the proximal third and posterior aspect of the stomach.", + "The tumor was 12 cm in diameter.", + "There was an extensive adhesive and infiltrative process to the splenic hilum.", + "The process included the pancreatic tail.", + "The process included part of the left Gerota's fascia.", + "The adjacent pancreatic tissue was normal in appearance.", + "There was no evidence of lymphatic metastases.", + "There was no evidence of visceral metastases.", + "There was no evidence of peritoneal metastases.", + "A vertical wedge gastrectomy was performed.", + "A corporodistal pancreatectomy was performed.", + "A splenectomy en bloc was performed.", + "The histological study showed a neoplastic, anaplastic, poorly differentiated, malignant proliferation.", + "The cells were arranged in a solid pattern.", + "The cells had an increased nuclear-cytoplasmic ratio.", + "The nuclei were hyperchromatic.", + "The nuclei were pleomorphic.", + "The nuclei were anisocaryotic.", + "There were numerous mitoses.", + "There were some multinucleated giant cells of osteoclastic type.", + "The surgical margins were circumferential.", + "The pancreatic margin was 0.5 cm.", + "There was no evidence of perineural invasion.", + "There was no evidence of lymphovascular invasion.", + "Immunohistochemistry for vimentin was positive.", + "Immunohistochemistry for keratin was positive.", + "Immunohistochemistry for CD68 was positive.", + "Immunohistochemistry for DOG was negative.", + "Immunohistochemistry for S100 was negative.", + "Immunohistochemistry for CD34 was negative.", + "Immunohistochemistry for DOG1 was negative.", + "The findings were consistent with an anaplastic cancer of the pancreas.", + "The patient had a pancreatic biochemical leakage (fistula type A).", + "The fistula was without clinical repercussions.", + "The fistula was kept drained for 6 weeks.", + "The fistula was removed without incident.", + "The patient received chemotherapy with Oxaliplatino, 5-Fluorouracil, and Leucovorin.", + "She had a serial follow-up with PET/CT.", + "There were no metastases at 5 years.", + "She was in good general condition.", + "She had a good quality of life." + ], + "summary": "We present the case of a 44-year-old female patient with upper gastrointestinal bleeding, admitted in a hemodynamically unstable condition. CT revealed a mass of the gastric fundus with pancreatic infiltration, suggestive of a GIST. Endoscopy identified an intractable submucosal gastric lesion. Emergency surgical resection was performed; histology confirmed a CAP. The patient had a favorable outcome, with no recurrence at 5 years post chemotherapy. Treatment with surgery and adjuvant chemotherapy was effective.\n", + "summary_subclaims": [ + "The patient is a 44-year-old female.", + "The patient had upper gastrointestinal bleeding.", + "The patient was admitted in a hemodynamically unstable condition.", + "CT revealed a mass of the gastric fundus with pancreatic infiltration.", + "CT findings were suggestive of a GIST.", + "Endoscopy identified an intractable submucosal gastric lesion.", + "Emergency surgical resection was performed.", + "Histology confirmed a CAP.", + "The patient had no recurrence at 5 years post chemotherapy.", + "Treatment with surgery and adjuvant chemotherapy was effective." + ] + }, + { + "id": "multiclinsum_test_1253_en.txt", + "fulltext": "An immunocompetent 28-year-old male was empirically diagnosed with a primary tectal tumor at an outside hospital; his history was negative for intravenous drug use or significant systemic bacterial infection. He presented initially with progressive intermittent headache for more than 6 months. Initial magnetic resonance imaging (MRI) showed a 10 mm × 9 mm left midbrain tectum ring-enhancing lesion with associated surrounding edema and mild hydrocephalus . At the other hospital, he underwent placement of a ventriculoperitoneal shunt (VPS) for obstructive hydrocephalus.\nEight weeks later, he started to have worsening headache, nausea, and intermittent vomiting. He was readmitted with a VPS infection and an abdominal pseudocyst. He was transferred to our institution where the VPS was removed, an external ventriculostomy was placed, and he was started on intravenous ceftriaxone and vancomycin. Cerebrospinal fluid (CSF) profile showed elevated white blood cell (WBC) count of 482 with lymphocyte predominance, suggesting a chronic infection; CSF culture revealed A. aphrophilus. His other workup including blood cultures and transthoracic echocardiogram were negative for infectious etiologies. He slowly improved with antibiotic treatment and was weaned off the ventriculostomy after 14 days, without any subsequent recurrence of hydrocephalus. Vancomycin was stopped after 10 days when the culture finalized A. aphrophilus sensitive to ceftriaxone. The tectal lesion completely resolved after 15 weeks of intravenous ceftriaxone . At the 4-month follow-up, he had no headache or any other clinical sequelae.", + "fulltext_subclaims": [ + "The patient is an immunocompetent 28-year-old male.", + "He was empirically diagnosed with a primary tectal tumor at an outside hospital.", + "His history was negative for intravenous drug use.", + "He had progressive intermittent headache for more than 6 months.", + "Initial MRI showed a 10 mm × 9 mm left midbrain tectum ring-enhancing lesion.", + "The lesion had associated surrounding edema.", + "The lesion was associated with mild hydrocephalus.", + "He underwent placement of a ventriculoperitoneal shunt at the other hospital.", + "Eight weeks later, he started to have worsening headache, nausea, and intermittent vomiting.", + "He was readmitted with a VPS infection and an abdominal pseudocyst.", + "He was transferred to our institution.", + "The VPS was removed.", + "An external ventriculostomy was placed.", + "He was started on intravenous ceftriaxone and vancomycin.", + "CSF profile showed elevated white blood cell count of 482 with lymphocyte predominance.", + "CSF culture revealed A. aphrophilus.", + "Blood cultures were negative.", + "Transthoracic echocardiogram was negative.", + "He was weaned off the ventriculostomy after 14 days.", + "Vancomycin was stopped after 10 days.", + "The tectal lesion completely resolved after 15 weeks of intravenous ceftriaxone.", + "At the 4-month follow-up, he had no headache." + ], + "summary": "Here, we present a case of isolated solitary midbrain tectum abscess in an immunocompetent 28-year-old male who was empirically diagnosed as a primary tectal tumor at an outside hospital where he also underwent placement of a ventriculoperitoneal shunt (VPS) for obstructive hydrocephalus. Eight weeks later he was readmitted with a VPS infection. He was transferred to our institution where the VPS was removed and he was started on broad-spectrum antibiotics. Cerebrospinal fluid (CSF) culture revealed A. aphrophilus. All other workup was negative for infectious etiologies. The tectal lesion completely resolved after 15 weeks of intravenous ceftriaxone without surgical aspiration.", + "summary_subclaims": [ + "The patient was a 28-year-old immunocompetent male.", + "He had an isolated solitary midbrain tectum abscess.", + "He was empirically diagnosed as having a primary tectal tumor at an outside hospital.", + "He underwent placement of a ventriculoperitoneal shunt at the outside hospital.", + "The shunt was placed for obstructive hydrocephalus.", + "Eight weeks later, he was readmitted with a ventriculoperitoneal shunt infection.", + "He was transferred to the reporting institution.", + "The ventriculoperitoneal shunt was removed at the reporting institution.", + "He was started on broad-spectrum antibiotics.", + "Cerebrospinal fluid culture revealed A. aphrophilus.", + "All other workup was negative for infectious etiologies.", + "The tectal lesion completely resolved after 15 weeks of intravenous ceftriaxone.", + "The tectal lesion resolved without surgical aspiration." + ] + }, + { + "id": "multiclinsum_test_2217_en.txt", + "fulltext": "This was a 2.5 year-old girl admitted to the hospital with a 5 day history of high grade and persistent fever. The patient received amoxicillin (50mg/kg/day) for 3 days and acetaminophen (15mg/kg/dose every 4-6 h), but she no improvement was noted. After 3 days fever she developed generalized erythematous macular rash. On admission she was febrile (39.5°C) and restless. She had red lips, strawberry tongue, bilateral non suppurative conjunctival injection, and edema of extremities. No rash was noticed.\nLaboratory findings: white blood cell (WBC) 14×103/µl, hemoglobin 10.9 gr/dl, platelets 126×103/µl, C-reactive protein 192 mg/dl, erythrocyte sedimentation rate 80 mm/hr, albumin 2.8 gr/dl, Serum glutamic pyruvic transaminase (SGPT) 24 U/L, Serum glutamic oxaloacetic transaminase (SGOT) 25 U/L, alkaline phosphatase 451 U/L, Lactate dehydrogenase (LDH) 430 U/L, Creatine phosphokinase (CPK) 124 and total billirubin 8 mg/dl. Blood, throat, stool, and urine cultures were negative. Electrocardiogram and chest x-ray were normal. Echocardiography showed dilatation of right coronary artery. KD was diagnosed based on the presence of clinical criteria, and lesion of coronary artery. She was treated with aspirin (100mg/kg/day), and intravenous gamma globulin (2 gr/kg). On day 2 from admission she developed abdominal pain.\nUltrasound examination of abdomen revealed presence of multiple lymph nodes in paraaortic area distributed from below the pancreas to the bifurcation of the aorta; the largest was 6 mm ×12mm . After 36 hour from receiving of intravenous gamma globulin, the fever was not subsided, so another dose (2gr/kg) was given. One day later the fever stopped. Four days thereafter we reduced aspirin dose (4mg/kg/day) and discharged the patient in good condition.\nOne week later blood tests revealed platelet count 480×103/µl, WBC count 6.7×103/µl and plasma albumin 3/5 gr/dl. Ultrasonography was normal without signs of lymphadenopathy. CT scan of abdomen was also normal. A second echocardiography showed ectasia of the right coronary artery. On follow up 8 weeks later, erythrocyte sedimentation rate decreased to 13mm/hr and echocardiography showed disappearance of ectasia of the coronary artery, so aspirin was discontinued. The patient was followed by cardiologist for 1 year and the last echocardiography has been normal.", + "fulltext_subclaims": [ + "This was a 2.5 year-old girl admitted to the hospital with a 5 day history of high grade and persistent fever.", + "The patient received amoxicillin (50mg/kg/day) for 3 days.", + "The patient received acetaminophen (15mg/kg/dose every 4-6 h).", + "After 3 days fever she developed generalized erythematous macular rash.", + "On admission she was febrile (39.5°C) and restless.", + "She had red lips.", + "She had strawberry tongue.", + "She had bilateral non suppurative conjunctival injection.", + "She had edema of extremities.", + "No rash was noticed.", + "White blood cell (WBC) was 14×103/µl.", + "Hemoglobin was 10.9 gr/dl.", + "Platelets were 126×103/µl.", + "C-reactive protein was 192 mg/dl.", + "Erythrocyte sedimentation rate was 80 mm/hr.", + "Albumin was 2.8 gr/dl.", + "Serum glutamic pyruvic transaminase (SGPT) was 24 U/L.", + "Serum glutamic oxaloacetic transaminase (SGOT) was 25 U/L.", + "Alkaline phosphatase was 451 U/L.", + "Lactate dehydrogenase (LDH) was 430 U/L.", + "Creatine phosphokinase (CPK) was 124.", + "Total billirubin was 8 mg/dl.", + "Blood, throat, stool, and urine cultures were negative.", + "Electrocardiogram was normal.", + "Chest x-ray was normal.", + "Echocardiography showed dilatation of right coronary artery.", + "KD was diagnosed based on the presence of clinical criteria.", + "KD was diagnosed based on the lesion of coronary artery.", + "She was treated with aspirin (100mg/kg/day).", + "She was treated with intravenous gamma globulin (2 gr/kg).", + "On day 2 from admission she developed abdominal pain.", + "Ultrasound examination of abdomen revealed presence of multiple lymph nodes in paraaortic area.", + "The largest lymph node was 6 mm ×12mm.", + "After 36 hour from receiving of intravenous gamma globulin, the fever was not subsided.", + "Another dose (2gr/kg) was given.", + "One day later the fever stopped.", + "Four days thereafter aspirin dose was reduced (4mg/kg/day).", + "The patient was discharged in good condition.", + "One week later platelet count was 480×103/µl.", + "One week later WBC count was 6.7×103/µl.", + "One week later plasma albumin was 3.5 gr/dl.", + "Ultrasonography was normal without signs of lymphadenopathy.", + "CT scan of abdomen was also normal.", + "A second echocardiography showed ectasia of the right coronary artery.", + "On follow up 8 weeks later, erythrocyte sedimentation rate decreased to 13mm/hr.", + "On follow up 8 weeks later, echocardiography showed disappearance of ectasia of the coronary artery.", + "Aspirin was discontinued.", + "The patient was followed by cardiologist for 1 year.", + "The last echocardiography has been normal." + ], + "summary": "This 2.5 year old girl presented with persistent high grade fever, erythematous rash, bilateral non purulent conjunctivitis, red lips, and edema of extremities. Laboratory results included an elevated erythrocyte sedimentation rate, leukocytosis, anemia, and positive C-reactive protein. On second day after admission she developed abdominal pain. Ultrasonography of abdomen revealed multiple lymph nodes around para aortic area, the largest measuring 12mm×6mm. Treatment consisted of aspirin and high dose intravenous γ-globulin. Ultrasonography and CT scan of abdomen performed one week later showed disappearance of the lymph nodes.", + "summary_subclaims": [ + "The patient is a 2.5 year old girl.", + "She presented with persistent high grade fever.", + "She had an erythematous rash.", + "She had bilateral non purulent conjunctivitis.", + "She had red lips.", + "She had edema of extremities.", + "Laboratory results included an elevated erythrocyte sedimentation rate.", + "Laboratory results included leukocytosis.", + "Laboratory results included anemia.", + "C-reactive protein was positive.", + "On the second day after admission she developed abdominal pain.", + "Ultrasonography of the abdomen revealed multiple lymph nodes around the para aortic area.", + "The largest lymph node measured 12mm×6mm.", + "Treatment consisted of aspirin.", + "Treatment consisted of high dose intravenous γ-globulin.", + "Ultrasonography and CT scan of the abdomen performed one week later showed disappearance of the lymph nodes." + ] + }, + { + "id": "multiclinsum_test_758_en.txt", + "fulltext": "We present a 48-year-old patient, to whom a transrectal biopsy of the prostate gland was performed in 2005 due to increased level of prostate-specific antigen (PSA) to 597 ng/ml, and the pathohistological (PH) finding revealed an adenocarcinoma of the prostate with the Gleason score 7 (4A+3B) and 80% tumor volume. According to the digitorectal examination, the prostate gland was found to be heterogenous, rough, with the size of an average walnut. Ten days after the biopsy, due to the complete urine retention, a urinary catheter was inserted and then transurethral resection of the prostate was performed.\nThe patient had pre-surgical value of PSA 132 ng/ml and also elevated levels of: acid phosphatase at 10.74 U/L (up to 6.6), prostatic acid phosphatase 7.7 U/L (up to 3.5) and alcaline phosphatase 146 U/L (up to 136). Pathohistological analysis of the prostatic tissue sample, obtained by transurethral resection, confirmed the existence of prostate adenocarcinoma with the Gleason score 7 (4B+3B) and infiltration of bladder wall, pT4a. Bone scintigraphy showed a clear zone of asymmetrically increased accumulation of radiopharmaceuticals in the VIII right rib, less homogeneous binding in the spine and increased binding of radiopharmaceuticals in the projection of costovertebral joint, right, in level VI. According the decision of the Uro-oncology consilium, the patient was treated with a maximal androgen blockade, zolendronic acid in monthly intervals, as well as the radiotherapy, with dose of 65 Gy in 32 sessions, which was done because of the patient’s relatively young age. After 9 years of the initial diagnosis, within the period of 14 months, a gradual increase of PSA from 4.3 ng/ml to 23.09 ng/ml was registered, with inhomogenous, slightly enlarged and firmer in whole left testis.\nThe values of the tumor markers /AFP, beta HCG and LDH/were within referential values, and two echo-heterogenous oval zones were identified by the ultrasound examination of the left testis, 10 mm in diameter . Osteoclastic changes in the vertebral bodies TH 6, 8, 11 and L4 were detected by a multisliced computed tomography (MSCT), but bone scintigraphy had normal finding. Left inguinal orchectomy and right orchectomy were done, and the PH result of the left testis showed metastases of prostate adenocarcinoma. One month after the surgery, the PSA value fell to 2.76 ng/ml, and the treatment was continued with Bicadex (bicalutamid) tablets, 50 mg daily and with zolendronic acid per month. Two years after the bilateral orchectomy, the patient is symptom free and in good general condition with latest PSA value of 4.22 ng/ml.", + "fulltext_subclaims": [ + "A 48-year-old patient had a transrectal biopsy of the prostate gland in 2005.", + "The biopsy was performed due to an increased level of prostate-specific antigen (PSA) to 597 ng/ml.", + "The pathohistological finding revealed an adenocarcinoma of the prostate with the Gleason score 7 (4A+3B).", + "The tumor volume was 80%.", + "The prostate gland was found to be heterogeneous, rough, with the size of an average walnut.", + "Ten days after the biopsy, due to complete urine retention, a urinary catheter was inserted.", + "Transurethral resection of the prostate was performed.", + "The pre-surgical PSA value was 132 ng/ml.", + "Acid phosphatase was 10.74 U/L (up to 6.6).", + "Prostatic acid phosphatase was 7.7 U/L (up to 3.5).", + "Alkaline phosphatase was 146 U/L (up to 136).", + "Pathohistological analysis of the prostatic tissue sample confirmed the existence of prostate adenocarcinoma with the Gleason score 7 (4B+3B).", + "Infiltration of the bladder wall was noted, pT4a.", + "Bone scintigraphy showed a clear zone of asymmetrically increased accumulation of radiopharmaceuticals in the VIII right rib.", + "Less homogeneous binding was observed in the spine.", + "Increased binding of radiopharmaceuticals was noted in the projection of the costovertebral joint, right, in level VI.", + "The patient was treated with maximal androgen blockade.", + "Zolendronic acid was administered in monthly intervals.", + "Radiotherapy with a dose of 65 Gy in 32 sessions was performed.", + "After 9 years of the initial diagnosis, a gradual increase of PSA from 4.3 ng/ml to 23.09 ng/ml was registered.", + "The left testis was inhomogeneous, slightly enlarged, and firmer.", + "The values of tumor markers AFP, beta HCG, and LDH were within referential values.", + "Two echo-heterogeneous oval zones were identified by the ultrasound examination of the left testis, 10 mm in diameter.", + "Osteoclastic changes in the vertebral bodies TH 6, 8, 11, and L4 were detected by multisliced computed tomography.", + "Bone scintigraphy had normal findings.", + "Left inguinal orchectomy and right orchectomy were performed.", + "The pathohistological result of the left testis showed metastases of prostate adenocarcinoma.", + "One month after the surgery, the PSA value fell to 2.76 ng/ml.", + "The treatment was continued with Bicadex (bicalutamide) tablets, 50 mg daily.", + "Zolendronic acid was administered per month.", + "Two years after the bilateral orchectomy, the patient is symptom free.", + "The patient is in good general condition.", + "The latest PSA value was 4.22 ng/ml." + ], + "summary": "This work presents a 48-year-old patient, to whom an adenocarcinoma of the prostate has been proven by the pathohistological finding of transrectal biopsy, performed due to the elevated level of prostate-specific antigen (PSA). Nine years after the initial diagnosis, due to a gradual rise of PSA and tumorous enlargement of the left testis, left inguinal orchectomy and right orchectomy were performed. Metastatic dissemination of prostate adenocarcinoma into a testis was determined by a pathohistological analysis of the left testis.", + "summary_subclaims": [ + "The patient is a 48-year-old man.", + "An adenocarcinoma of the prostate was proven by the pathohistological finding of transrectal biopsy.", + "The transrectal biopsy was performed due to an elevated level of prostate-specific antigen (PSA).", + "Nine years after the initial diagnosis, a gradual rise of PSA was observed.", + "Nine years after the initial diagnosis, there was tumorous enlargement of the left testis.", + "Left inguinal orchectomy and right orchectomy were performed.", + "Metastatic dissemination of prostate adenocarcinoma into a testis was determined by a pathohistological analysis of the left testis." + ] + }, + { + "id": "multiclinsum_test_1144_en.txt", + "fulltext": "A 35-year-old Chinese female was referred to complete root canal treatment of the maxillary right molars using a DOM. She had repeated episodes of swelling in the upper right posterior maxilla for the past three months. The basis for the referral was the presence of a second root canal in the mesiobuccal root (MB2), as stated by the general dentist was suspected but not found. The pulp of 3 main root canals for the upper right first permanent molar (#16, Fédération Dentaire Internationale notation) and upper right second permanent molar (#17, Fédération Dentaire Internationale notation) were removed by the dentist. The medical history was non-contributory. The intraoral examination revealed profound disto-occlusal destruction in #16 and mesio-occlusal destruction in #17 . Teeth #16 and #17 were sensitive to palpation and percussion but were negative for thermal testing.\nBased on the preoperative radiographs of teeth #16 and #17, the pulp chamber was noted to be extended, the pulp floors exhibited apical displacement, and the roots were short. In addition, teeth #16 and #17 had periapical translucency .\nAccording to the radiographic images, teeth #16 and #17 were diagnosed as symptomatic apical periodontitis and mesotaurodonts.\nThe clinical condition was explained to the patient, and root canal therapy was proposed and conducted. After proper disinfection and rubber dam isolation, all the subsequent procedures were performed using a DOM (Leica, Germany). The residual decay was excavated, and the access opening was prepared. The pulp chamber was identified with three orifice openings (MB, DB, and P), and the dentist utilized the ProTaper F2 after discussion. A complex pattern of the dentinal map in teeth #16 and #17 was demonstrated. After removing the dentinal lips around the orifice of the three prepared canals with a DG-16 endodontic explorer, the second canals (MB2, DB2, and P2) of the tooth #16 were identified. In contrast, the extra root canal orifice was concealed approximately 2–3 mm under the prepared canal orifice of MB and P in the tooth #17.\nTwo experienced operators (He Wang and Na Cao) analyzed the data taken by CBCT using a Scanora ® 3D unit (SoredexOy, Tuusula, Finland). In this device, the mandible is stabilized with a cheek rest while the patient is seated, and two vertical plastic rods (one on each side) are used to support the head position. The settings (FOV and voxel resolution) were chosen for each patient based on the area to be examined and the diagnostic task in question. Considering the small FOV (6 × 6 cm, resolution 0.13-mm), the scan time was 23 s.\nThe results were further evaluated and verified by the CBCT . Together with the DOM, the ultrasonic tips maintained good visibility of the operative field. The ultrasonic tips were used for the removal of gross tissue and calculus. We prepared six canals in the tooth #16 with two canals in the mesiobuccl root (MB1 and MB2 canals), two in the distobuccal root (DB1 and DB2 canals), and two in the palatal root (P1 and P2 canals) . Also, we prepared seven canals in the tooth #17 with three in the mesiobuccal root (MB1, MB2, and MB3 canals), two in the distobuccal root (DB1 and DB2 canals), and two in the palatal root (P1 and P2 canals) . All of the extra canals were prepared using a stainless steel hand files (ISO size 8). During the root canal preparation, it was apparent that MB2 and MB3 in the tooth #17 were joined together in the apical third of the mesiobuccal root, but P1 and P2 in the same molar were separated in the middle third of the palatal root and joined together in the third apical. The working length was determined by both radiographs and an electronic apex locator (Raypex5; VDW, Germany). The instrumentation was completed using ProTaper sequence S1, S2, F1, and F2 rotary files (ProTaper Universal; Dentsply Maillefer, Switzerland) as per instructions from the manufacturer. Sodium hypochlorite (2.5%) was used as intracanal irrigat, and calcium hydroxide was used as a disinfectant. The access cavity was sealed with a temporary filling (IRM; Dentsply).\nOne week later, the two teeth were not associated with symptoms, and root canals were obturated using a continuous-wave condensation technique with thermoplasticized gutta-percha (E&Q Plus system; Meta, Korea) and AH Plus (Dentsply) as sealer cement . The access cavity was temporarily restored, and the patient was sent for coronal rehabilitation.", + "fulltext_subclaims": [ + "A 35-year-old Chinese female was referred for complete root canal treatment of the maxillary right molars using a DOM.", + "She had repeated episodes of swelling in the upper right posterior maxilla for the past three months.", + "The basis for the referral was the presence of a second root canal in the mesiobuccal root (MB2), as stated by the general dentist was suspected but not found.", + "The pulp of 3 main root canals for the upper right first permanent molar (#16) and upper right second permanent molar (#17) were removed by the dentist.", + "The medical history was non-contributory.", + "The intraoral examination revealed profound disto-occlusal destruction in #16 and mesio-occlusal destruction in #17.", + "Teeth #16 and #17 were sensitive to palpation and percussion but were negative for thermal testing.", + "Based on the preoperative radiographs, the pulp chamber was noted to be extended.", + "The pulp floors exhibited apical displacement.", + "The roots were short.", + "Teeth #16 and #17 had periapical translucency.", + "According to the radiographic images, teeth #16 and #17 were diagnosed as symptomatic apical periodontitis.", + "According to the radiographic images, teeth #16 and #17 were diagnosed as mesotaurodonts.", + "Root canal therapy was proposed and conducted.", + "All the subsequent procedures were performed using a DOM (Leica, Germany).", + "The pulp chamber was identified with three orifice openings (MB, DB, and P).", + "The dentist utilized the ProTaper F2 after discussion.", + "A complex pattern of the dentinal map in teeth #16 and #17 was demonstrated.", + "After removing the dentinal lips around the orifice of the three prepared canals with a DG-16 endodontic explorer, the second canals (MB2, DB2, and P2) of the tooth #16 were identified.", + "In contrast, the extra root canal orifice was concealed approximately 2–3 mm under the prepared canal orifice of MB and P in the tooth #17.", + "Two experienced operators (He Wang and Na Cao) analyzed the data taken by CBCT using a Scanora® 3D unit.", + "The settings (FOV and voxel resolution) were chosen for each patient based on the area to be examined and the diagnostic task in question.", + "Considering the small FOV (6 × 6 cm, resolution 0.13-mm), the scan time was 23 s.", + "The results were further evaluated and verified by the CBCT.", + "The ultrasonic tips were used for the removal of gross tissue and calculus.", + "We prepared six canals in the tooth #16 with two canals in the mesiobuccal root (MB1 and MB2 canals), two in the distobuccal root (DB1 and DB2 canals), and two in the palatal root (P1 and P2 canals).", + "We prepared seven canals in the tooth #17 with three in the mesiobuccal root (MB1, MB2, and MB3 canals), two in the distobuccal root (DB1 and DB2 canals), and two in the palatal root (P1 and P2 canals).", + "All of the extra canals were prepared using a stainless steel hand files (ISO size 8).", + "During the root canal preparation, it was apparent that MB2 and MB3 in the tooth #17 were joined together in the apical third of the mesiobuccal root.", + "P1 and P2 in the same molar were separated in the middle third of the palatal root and joined together in the third apical.", + "The working length was determined by both radiographs and an electronic apex locator (Raypex5; VDW, Germany).", + "The instrumentation was completed using ProTaper sequence S1, S2, F1, and F2 rotary files.", + "Sodium hypochlorite (2.5%) was used as intracanal irrigant.", + "Calcium hydroxide was used as a disinfectant.", + "The access cavity was sealed with a temporary filling (IRM; Dentsply).", + "One week later, the two teeth were not associated with symptoms.", + "Root canals were obturated using a continuous-wave condensation technique with thermoplasticized gutta-percha (E&Q Plus system; Meta, Korea) and AH Plus (Dentsply) as sealer cement.", + "The access cavity was temporarily restored.", + "The patient was sent for coronal rehabilitation." + ], + "summary": "A 35-year-old Chinese female had repeated swelling in the upper right posterior maxilla for 3 months and was referred to evaluate symptomatic apical periodontitis and mesotaurodonts for upper right first permanent molar and upper right second permanent molar. Root canal therapy was proposed and conducted with the use of DOM and CBCT.", + "summary_subclaims": [ + "The patient is a 35-year-old Chinese female.", + "She had repeated swelling in the upper right posterior maxilla for 3 months.", + "She was referred to evaluate symptomatic apical periodontitis.", + "She was referred to evaluate mesotaurodonts for upper right first permanent molar.", + "She was referred to evaluate mesotaurodonts for upper right second permanent molar.", + "Root canal therapy was proposed.", + "Root canal therapy was conducted.", + "DOM was used during the root canal therapy.", + "CBCT was used during the root canal therapy." + ] + }, + { + "id": "multiclinsum_test_1326_en.txt", + "fulltext": "A 13-year-old boy was admitted to Pediatric Intensive Care Unit (PICU) in a critical situation. After waking up in the morning, he complained of left-sided abdominal pain, nausea, and vomiting. Over the hours, the pain was intermittent and increasing in intensity.\nAt admission, the patient looked pale, in a forced sitting position. On physical examination, his abdomen was tender in all quadrants with left upper quadrant pain rated as 10 out of 10 in intensity. The pain was described as very strong and increased if he laid down, thus requiring intravenous opioids. Upon examination, heart rate was 92 bpm along with low blood pressure 82/42 mmHg. Diminished breath sounds at the lung bases were noted, most likely due to limited excursions of the chest due to pain. There was no fever (temperature 36.5 C). There was no rash, nor lymphadenopathy. No hematomas or bruises were observed. After intravenous opioids and liquid administration, blood pressure was normalized.\nThe patient and his father denied any history of trauma. They insisted the child had been totally healthy up until that morning. The child had no family history of coagulopathies, autoimmune diseases, or malignancies. According to his family, there were no bowel abnormalities; use of thrombolytic or anticoagulant drugs.\nSeveral laboratory and imaging examinations were performed immediately. Given the relatively large number of COVID-19 patients during this period, our main differential diagnoses were either a splenic rupture or a splenic artery thrombosis, due to COVID-19. Therefore, a nasopharyngeal swab specimen was collected for COVID-19 testing.\nThe upright abdominal radiograph showed no abnormalities. Abdominal ultrasound revealed free fluid in the abdomen, but without any clear suspicion, so an emergent Computed tomography (CT) with contrast of the chest and abdomen was carried out. The thoracic CT scan was normal. Abdominal CT revealed hemoperitoneum with splenic laceration.\nSince the hemoglobin, hematocrit, and patient’s blood pressure were normal, with no active bleeding on CT, the splenic injury was initially managed conservatively. Twelve hours after presentation, a decrease in hemoglobin (Hb = 8.1 g/dL) and hematocrit (HCT = 25.6%) was noted and the patient’s blood pressure started dropping. He received 1 Unit of blood and the decision to proceed to surgery was made. During the operation, it was observed that the patient had plenty of blood in the abdominal cavity. Laceration of the splenic hilum and a large perisplenic hematoma was noted and splenectomy was performed. Two additional Units of blood were transfused intraoperatively.\nHuman immunodeficiency virus (HIV) test, IgM and IgG antibodies for Epstein Barr virus (EBV) and cytomegalovirus (CMV) were negative. The polymerase chain reaction (PCR) was positive for COVID-19, making us think that the splenic rupture could be a consequence of COVID-19. The child’s clinical condition was stable after surgery. He was discharged, without further problems during the follow-up.", + "fulltext_subclaims": [ + "The patient was a 13-year-old boy.", + "He was admitted to the Pediatric Intensive Care Unit in a critical situation.", + "He complained of left-sided abdominal pain, nausea, and vomiting.", + "The pain was intermittent and increasing in intensity.", + "At admission, the patient looked pale.", + "The abdomen was tender in all quadrants.", + "Left upper quadrant pain was rated as 10 out of 10 in intensity.", + "The pain was described as very strong.", + "The pain increased if he laid down.", + "Intravenous opioids were required.", + "Heart rate was 92 bpm.", + "Blood pressure was 82/42 mmHg.", + "Diminished breath sounds at the lung bases were noted.", + "There was no fever.", + "There was no rash.", + "There was no lymphadenopathy.", + "There were no hematomas or bruises.", + "After intravenous opioids and liquid administration, blood pressure was normalized.", + "The patient and his father denied any history of trauma.", + "They insisted the child had been totally healthy up until that morning.", + "The child had no family history of coagulopathies.", + "The child had no family history of autoimmune diseases.", + "The child had no family history of malignancies.", + "There were no bowel abnormalities.", + "There was no use of thrombolytic or anticoagulant drugs.", + "The main differential diagnoses were either a splenic rupture or a splenic artery thrombosis, due to COVID-19.", + "A nasopharyngeal swab specimen was collected for COVID-19 testing.", + "The upright abdominal radiograph showed no abnormalities.", + "Abdominal ultrasound revealed free fluid in the abdomen.", + "An emergent CT with contrast of the chest and abdomen was carried out.", + "The thoracic CT scan was normal.", + "Abdominal CT revealed hemoperitoneum with splenic laceration.", + "The splenic injury was initially managed conservatively.", + "Twelve hours after presentation, a decrease in hemoglobin was noted.", + "Twelve hours after presentation, a decrease in hematocrit was noted.", + "The patient’s blood pressure started dropping.", + "He received 1 Unit of blood.", + "The decision to proceed to surgery was made.", + "During the operation, it was observed that the patient had plenty of blood in the abdominal cavity.", + "Laceration of the splenic hilum was noted.", + "A large perisplenic hematoma was noted.", + "Splenectomy was performed.", + "Two additional Units of blood were transfused intraoperatively.", + "The HIV test was negative.", + "The IgM and IgG antibodies for EBV were negative.", + "The IgM and IgG antibodies for CMV were negative.", + "The PCR was positive for COVID-19.", + "The splenic rupture could be a consequence of COVID-19.", + "The child’s clinical condition was stable after surgery.", + "He was discharged without further problems during the follow-up." + ], + "summary": "A 13-year-old boy with clinical signs of acute abdomen, left-sided abdominal pain, and hemodynamic instability was admitted to the PICU in critical condition. His parents denied any trauma had occurred. In addition to imaging tests, a nasopharyngeal swab was taken for COVID-19 testing, which was positive. The thoracic CT scan was normal, whereas the abdominal CT scan revealed hemoperitoneum, splenic rupture, and free fluid in the abdomen.", + "summary_subclaims": [ + "The patient is a 13-year-old boy.", + "The patient had clinical signs of acute abdomen.", + "The patient had left-sided abdominal pain.", + "The patient had hemodynamic instability.", + "The patient was admitted to the PICU in critical condition.", + "The parents denied any trauma had occurred.", + "A nasopharyngeal swab was taken for COVID-19 testing.", + "The COVID-19 test was positive.", + "The thoracic CT scan was normal.", + "The abdominal CT scan revealed hemoperitoneum.", + "The abdominal CT scan revealed splenic rupture.", + "The abdominal CT scan revealed free fluid in the abdomen." + ] + }, + { + "id": "multiclinsum_test_717_en.txt", + "fulltext": "A 15-year-old girl was admitted to our hospital complaining of severe headaches since the eighth month of pregnancy, which had worsened in the last five hours. The following information was observed in the prenatal card: G1P0A0; gestational age: 37 weeks (estimated by date of last menstrual period); type O+ blood and negative serology. On examination our patient presented an arterial blood pressure of 180/120 mmHg, her uterine cervix was 20% effaced, with impervious external orifice and cephalic presentation. The diagnostic hypothesis was pre-eclampsia and routine investigations were requested to diagnose the HSP. After the tests, the diagnostic hypothesis changed to gestational hypertension. As our patient continued with elevated blood pressure levels, she was submitted to a cesarean section on the fourth day in hospital, delivering a male live baby with no intercurrences. After the procedure, she was referred to our infirmary, presenting a blank distant look and with no interaction with the environment. On examination she presented with dyslalia, and labial and upper and lower right limb paresis. During an examination six days after hospital admission, our patient was confused and unable to speak, but responded to painful stimuli as she conveyed abdominal pain at superficial and deep palpation. Moreover, she had a hematoma on the upper region of the surgical wound and physiological lochia. The hypothesis of post-partum psychosis was suggested and a careful neurological evaluation requested. She was administered the following drugs in hospital: nifedipine 1 mg, methyldopa 500 mg, 750 mg paracetamol, betamethasone, oxytocin, tenoxicam, promethazine, diclofenac sodium, cephalexin, and haloperidol. She was then transferred to the teaching hospital on the same day, and admitted to our intensive care unit, maintaining an impassive attitude in bed but reacting to external stimuli. She also emitted incomprehensible sounds, presented a blank look, with upward conjugated deviation of the eyes and mydriatic pupils reactive to light. She had Glasgow Coma Scale (GCS) score of nine points (2 +5 +2). Our patient was then submitted to orotracheal intubation with mechanical ventilation and central venous access through her right internal jugular vein, in addition to continuous sedation. Computed tomography (CT) of her skull and pelvis were requested. Results revealed tomography findings consistent with ischemic infarction of the territory of her left middle cerebral artery, but no pelvic alterations were observed. Our patient showed progressive worsening of the neurological symptoms, hyperthermia, tonic-extensor crisis, difficulty in breathing and scored four points in the GCS. A repeat skull CT revealed ischemic lesions in the mean cerebral system affecting her basal ganglia and parietal lobe, with proper filling of venous sinuses and no signs of meningeal inflammation. During this period, her blood pressure levels remained elevated (MAP 140-150 mmHg) and refractory to medication. In addition, our patient presented with neuropsychomotor agitation and periods of tachycardia and systemic arterial hypertension alternating with bradycardia and normotension. An urgent selective cerebral arteriography was requested; this showed bilateral occlusion of her internal carotid artery in the intracranial position, pre-bifurcation and angiodysplasia in the cervical segments of the internal carotid artery. Sixteen days after hospital admission, there was a worsening of our patient's condition and she died. Brain death as a consequence of bilateral obstruction of the internal carotid was certified as the cause of death.", + "fulltext_subclaims": [ + "The patient was a 15-year-old girl.", + "She was admitted to the hospital complaining of severe headaches since the eighth month of pregnancy.", + "The headaches had worsened in the last five hours.", + "The prenatal card noted G1P0A0.", + "The gestational age was 37 weeks.", + "The estimated gestational age was based on the date of the last menstrual period.", + "The patient's blood type was O+.", + "Serology was negative.", + "On examination, the patient's arterial blood pressure was 180/120 mmHg.", + "The uterine cervix was 20% effaced.", + "The external orifice was impervious.", + "The presentation was cephalic.", + "The diagnostic hypothesis was pre-eclampsia.", + "Routine investigations were requested to diagnose HSP.", + "After the tests, the diagnostic hypothesis changed to gestational hypertension.", + "The patient continued with elevated blood pressure levels.", + "She was submitted to a cesarean section on the fourth day in hospital.", + "A male live baby was delivered with no intercurrences.", + "After the procedure, she was referred to the infirmary.", + "She presented a blank distant look and no interaction with the environment.", + "On examination, she had dyslalia.", + "She had labial and upper and lower right limb paresis.", + "Six days after hospital admission, she was confused and unable to speak.", + "She responded to painful stimuli.", + "She conveyed abdominal pain at superficial and deep palpation.", + "She had a hematoma on the upper region of the surgical wound.", + "She had physiological lochia.", + "The hypothesis of post-partum psychosis was suggested.", + "A careful neurological evaluation was requested.", + "She was administered nifedipine 1 mg.", + "She was administered methyldopa 500 mg.", + "She was administered 750 mg paracetamol.", + "She was administered betamethasone.", + "She was administered oxytocin.", + "She was administered tenoxicam.", + "She was administered promethazine.", + "She was administered diclofenac sodium.", + "She was administered cephalexin.", + "She was administered haloperidol.", + "She was transferred to the teaching hospital on the same day.", + "She was admitted to the intensive care unit.", + "She maintained an impassive attitude in bed.", + "She reacted to external stimuli.", + "She emitted incomprehensible sounds.", + "She had a blank look.", + "She had upward conjugated deviation of the eyes.", + "Her pupils were mydriatic and reactive to light.", + "Her Glasgow Coma Scale score was nine points (2 +5 +2).", + "She was submitted to orotracheal intubation with mechanical ventilation.", + "Central venous access was obtained through the right internal jugular vein.", + "Continuous sedation was provided.", + "Computed tomography of the skull and pelvis were requested.", + "CT findings were consistent with ischemic infarction of the territory of the left middle cerebral artery.", + "No pelvic alterations were observed.", + "The patient showed progressive worsening of neurological symptoms.", + "She had hyperthermia.", + "She had tonic-extensor crisis.", + "She had difficulty in breathing.", + "She scored four points in the GCS.", + "A repeat skull CT revealed ischemic lesions in the mean cerebral system affecting the basal ganglia and parietal lobe.", + "Venous sinuses were properly filled.", + "There were no signs of meningeal inflammation.", + "Her blood pressure levels remained elevated (MAP 140-150 mmHg).", + "Her blood pressure was refractory to medication.", + "She presented with neuropsychomotor agitation.", + "She had periods of tachycardia and systemic arterial hypertension alternating with bradycardia and normotension.", + "An urgent selective cerebral arteriography was requested.", + "The arteriography showed bilateral occlusion of the internal carotid artery in the intracranial position, pre-bifurcation.", + "Angiodysplasia was observed in the cervical segments of the internal carotid artery.", + "Sixteen days after hospital admission, there was a worsening of the patient's condition.", + "The patient died.", + "Brain death was certified as the cause of death.", + "Brain death was a consequence of bilateral obstruction of the internal carotid artery." + ], + "summary": "A 15-year-old girl was admitted to our hospital complaining of severe headaches since the eighth month of pregnancy, and presented with an arterial blood pressure of 180/120 mmHg. The diagnostic hypothesis was pre-eclampsia. Our patient's blood pressure levels remained elevated, and she was submitted to a cesarean section. After the procedure, she was referred to our infirmary, presenting with a blank distant look and with no interaction with the environment, dyslalia, and labial and upper and lower right limb paresis. She was confused and unable to speak, but responded to painful stimuli as she conveyed abdominal pain at superficial and deep palpation. The hypothesis of post-partum psychosis was suggested. She was then transferred to our intensive care unit, maintaining an impassive attitude in bed but reacting to external stimuli. Results of a computed tomography scan revealed ischemic infarction of the territory of her left middle cerebral artery. A selective cerebral arteriography showed bilateral occlusion of her internal carotid artery in the intracranial position, prebifurcation and angiodysplasia in the cervical segments of her internal carotid artery. Sixteen days after hospital admission, our patient died.", + "summary_subclaims": [ + "The patient was a 15-year-old girl.", + "She was admitted to the hospital complaining of severe headaches since the eighth month of pregnancy.", + "She presented with an arterial blood pressure of 180/120 mmHg.", + "The diagnostic hypothesis was pre-eclampsia.", + "The patient's blood pressure levels remained elevated.", + "She was submitted to a cesarean section.", + "After the procedure, she presented with a blank distant look and no interaction with the environment.", + "She had dyslalia.", + "She had labial and upper and lower right limb paresis.", + "She was confused and unable to speak.", + "She responded to painful stimuli by conveying abdominal pain at superficial and deep palpation.", + "The hypothesis of post-partum psychosis was suggested.", + "She was transferred to the intensive care unit.", + "She maintained an impassive attitude in bed but reacted to external stimuli.", + "Computed tomography revealed ischemic infarction of the territory of her left middle cerebral artery.", + "Selective cerebral arteriography showed bilateral occlusion of her internal carotid artery in the intracranial position, prebifurcation.", + "Selective cerebral arteriography showed angiodysplasia in the cervical segments of her internal carotid artery.", + "The patient died 16 days after hospital admission." + ] + }, + { + "id": "multiclinsum_test_842_en.txt", + "fulltext": "A 59-year-old postmenopausal female presented herself to our hospital with a mass on her right breast for 2 weeks. The patient had no history of hormonal treatment or family history of cancer. Clinical examination confirmed a nodule in the right breast, situated at 5 o’clock. Mammography revealed a spherical, well-defined nodule of 3.2*3*2.3 cm .\nCore needle biopsy (CNB) revealed multiple lesions lined with layered columnar cells and abundant mucous secretion, and the diagnosis of invasive breast cancer with abundant mucous secretion was made. Then, a right lumpectomy along with ipsilateral axillary lymph node dissection was performed. Under macroscopic observation, the tumor was a well-circumscribed mass 3*3*2 cm in size. The cross-section was grayish-white with a moderate myxoid appearance. Microscopically, the tumor consisted of mucus-filled cavities of varying sizes lined with columnar cells . Tall columnar cells were rich in mucous and had nuclei at the base of the cell. Cells in some areas appeared stratified, protruding into the lumen and even forming branched papillary structures. Nests or papillary cell masses floated in the intracavity mucous lake accompanied by necrosis and inflammatory cell infiltration . Microscopically, no distinct myoepithelial layer was observed, and subsequent immunohistochemical results also confirmed the absence of myoepithelium . The cells had mild atypia, and mitotic figures were rare. No common ductal carcinoma in situ (DCIS) existed, and ipsilateral axillary lymph nodes showed no metastasis. The Nottingham grade was 1 (tubule formation = 3, nuclear pleomorphism = 1, and mitotic count = 1), and the pathological stage was T2N0Mx.\nBased on these morphological features, a wide range of differential diagnoses included metastatic tumors from the ovaries or pancreas, mucinous carcinoma, mucoceloid lesions, encapsulated papillary carcinoma (EPC) and invasive papillary carcinoma. A broad immunohistochemical panel was performed to narrow the differential diagnosis. The neoplastic cells showed diffuse immunoreactivity for cytokeratin 7 (CK7) and a high Ki-67 index of up to 40% . There was no immunoreactivity for ER, PR, HER2, cytokeratin 20 (CK20), CA19-9, CDX-2, Villin, PAX8, GATA3, SOX10, GCDFP-15, mammaglobin, p63 or calponin. Positive immunoreactivity for CK7, negative immunoreactivity for CK20, CA19-9, CDX-2, and Villin, and metastasis from the ovary, pancreas or intestine were excluded. Positron emission tomography (PET)/computed tomography (CT) was performed on the patient, and no other lesions were found, confirming nonmetastatic lesions. A triple-negative immunophenotype and a relatively high Ki-67 index ruled out mucinous carcinoma and EPC, which typically express ER and PR. Mucoceloid lesions of the breast are benign lesions in which myoepithelium is present around the lumen. The absence of myoepithelium also ruled out this diagnosis . Invasive papillary carcinoma is composed of mildly dilated ducts and microcysts containing a papillary formation without intracellular and extracellular mucus. These cases are usually non-triple-negative phenotypes. Eventually, we favored the diagnosis of MCA based on the morphological and immunohistochemical findings.\nFurthermore, 425 genes were sequenced using formalin-fixed and paraffin-embedded (FFPE) tissues and next-generation sequencing (NGS) technology. Recurrent mutations in PIK3CA, KRAS, MAP2K4, RB1, KDR, PKHD1, TERT, and TP53 were identified and are summarized in Table . The tumor mutation burden (TMB) was 9.27, and microsatellite instability high (MSI-H) was not detected. P53, RB1 and PD-L1 protein were stained according to the sequencing results. Immunohistochemistry confirmed the overexpression of p53 protein and loss of RB1 protein expression. PD-L1 (sp142) was focally positive in immune cells, and the positive rate was approximately 7% . The patient received 6 cycles of adjuvant chemotherapy and was followed up for 108 months, with no signs of recurrence or metastasis.", + "fulltext_subclaims": [ + "The patient is a 59-year-old postmenopausal female.", + "She presented with a mass on her right breast for 2 weeks.", + "The patient had no history of hormonal treatment.", + "The patient had no family history of cancer.", + "Clinical examination confirmed a nodule in the right breast at 5 o'clock.", + "Mammography revealed a spherical, well-defined nodule measuring 3.2*3*2.3 cm.", + "Core needle biopsy revealed multiple lesions lined with layered columnar cells and abundant mucous secretion.", + "The diagnosis of invasive breast cancer with abundant mucous secretion was made.", + "A right lumpectomy along with ipsilateral axillary lymph node dissection was performed.", + "Under macroscopic observation, the tumor was a well-circumscribed mass 3*3*2 cm in size.", + "The cross-section was grayish-white with a moderate myxoid appearance.", + "Microscopically, the tumor consisted of mucus-filled cavities of varying sizes lined with columnar cells.", + "Tall columnar cells were rich in mucous and had nuclei at the base of the cell.", + "Cells in some areas appeared stratified, protruding into the lumen and even forming branched papillary structures.", + "Nests or papillary cell masses floated in the intracavity mucous lake accompanied by necrosis and inflammatory cell infiltration.", + "Microscopically, no distinct myoepithelial layer was observed.", + "Subsequent immunohistochemical results also confirmed the absence of myoepithelium.", + "The cells had mild atypia.", + "Mitotic figures were rare.", + "No common ductal carcinoma in situ (DCIS) existed.", + "Ipsilateral axillary lymph nodes showed no metastasis.", + "The Nottingham grade was 1 (tubule formation = 3, nuclear pleomorphism = 1, and mitotic count = 1).", + "The pathological stage was T2N0Mx.", + "A broad immunohistochemical panel was performed.", + "The neoplastic cells showed diffuse immunoreactivity for cytokeratin 7 (CK7).", + "The Ki-67 index was up to 40%.", + "There was no immunoreactivity for ER, PR, HER2, cytokeratin 20 (CK20), CA19-9, CDX-2, Villin, PAX8, GATA3, SOX10, GCDFP-15, mammaglobin, p63, or calponin.", + "Positive immunoreactivity for CK7, negative immunoreactivity for CK20, CA19-9, CDX-2, and Villin, and metastasis from the ovary, pancreas, or intestine were excluded.", + "Positron emission tomography (PET)/computed tomography (CT) was performed.", + "No other lesions were found, confirming nonmetastatic lesions.", + "A triple-negative immunophenotype and a relatively high Ki-67 index ruled out mucinous carcinoma and EPC.", + "Mucoceloid lesions of the breast are benign lesions in which myoepithelium is present around the lumen.", + "The absence of myoepithelium also ruled out this diagnosis.", + "Invasive papillary carcinoma is composed of mildly dilated ducts and microcysts containing a papillary formation without intracellular and extracellular mucus.", + "These cases are usually non-triple-negative phenotypes.", + "Eventually, we favored the diagnosis of MCA based on the morphological and immunohistochemical findings.", + "425 genes were sequenced using formalin-fixed and paraffin-embedded (FFPE) tissues and next-generation sequencing (NGS) technology.", + "Recurrent mutations in PIK3CA, KRAS, MAP2K4, RB1, KDR, PKHD1, TERT, and TP53 were identified.", + "The tumor mutation burden (TMB) was 9.27.", + "Microsatellite instability high (MSI-H) was not detected.", + "P53, RB1, and PD-L1 protein were stained according to the sequencing results.", + "Immunohistochemistry confirmed the overexpression of p53 protein.", + "Loss of RB1 protein expression was confirmed.", + "PD-L1 (sp142) was focally positive in immune cells.", + "The positive rate of PD-L1 was approximately 7%.", + "The patient received 6 cycles of adjuvant chemotherapy.", + "The patient was followed up for 108 months.", + "There were no signs of recurrence or metastasis." + ], + "summary": "A 59-year-old woman presented with a breast lump in which mammography showed a well-defined nodule. Core needle biopsy (CNB) revealed several lesions lined by tall columnar cells with stratification and abundant mucinous secretion; excision was recommended for final diagnosis. The resected specimens showed cavities of different sizes without surrounding myoepithelial cells. The cavities were rich in mucus, and the nuclei were located at the base of the cells, containing intracellular mucus. Immunohistochemical analysis revealed that it was triple-negative breast cancer (TNBC). Next-generation sequencing (NGS) revealed pathogenic mutations in the PIK3CA, KRAS, MAP2K4, RB1, KDR, PKHD1, TERT, and TP53 genes. A diagnosis of MCA was rendered. The patient has been followed up for 108 months to date and showed no signs of recurrence or metastasis.", + "summary_subclaims": [ + "A 59-year-old woman presented with a breast lump.", + "Mammography showed a well-defined nodule.", + "Core needle biopsy revealed several lesions lined by tall columnar cells with stratification and abundant mucinous secretion.", + "Excision was recommended for final diagnosis.", + "The resected specimens showed cavities of different sizes without surrounding myoepithelial cells.", + "The cavities were rich in mucus.", + "The nuclei were located at the base of the cells, containing intracellular mucus.", + "Immunohistochemical analysis revealed that it was triple-negative breast cancer.", + "Next-generation sequencing revealed pathogenic mutations in the PIK3CA, KRAS, MAP2K4, RB1, KDR, PKHD1, TERT, and TP53 genes.", + "A diagnosis of MCA was rendered.", + "The patient has been followed up for 108 months to date.", + "The patient showed no signs of recurrence or metastasis." + ] + }, + { + "id": "multiclinsum_test_1763_en.txt", + "fulltext": "A 42-year-old man (lowlander, Beijing, China, 43.5 m/142.7 ft. above mean sea level) presented with acute, painless visual loss and visual field loss in his left eye. The patient travelled to Tibet before the onset of symptoms when he took 1 day to ascend to the high altitude by car. He spent 1 week at high altitude before the descent back, which also took him 1 day by car. The complaints began at a low altitude after the end of his journey. The patient had type II diabetes, which was controlled by insulin for 10 years. He also used metformin for some time. The patient underwent binocular subtotal panretinal photocoagulation for the treatment of DR at 3 months before his journey. The patient did not have any other ocular treatments, such as intravitreal injections or intraocular surgery. According to the severity of DR from the description of the patient, the left eye was slightly worse than the right eye. Blood glucose was not monitored during the high-altitude journey. The patient had no history of smoking, hypertension, and hypercholesterolemia. Multiple carotid atherosclerotic plaques were shown by the Doppler examination. Increased blood cell counts for white blood cell (WBC), red blood cell (RBC), hemoglobin (HB) and packed cell volume (PCV) were revealed by hematologic examination. Decreased prothrombin time (PT) and increased prothrombin time activity were revealed by hematologic examination. All of the systemic examination parameters are shown in Table .\nThe best-corrected visual acuity (BCVA) in the right and the left eye were 20/25 and 20/40 (Snellen Chart), respectively. Non-contact intraocular pressure was 17 mmHg in the right eye and 18 mmHg in the left eye. Anterior segment examinations were normal in both eyes. Ophthalmoscopy revealed hemorrhages, cotton wool spots, and laser spots in both eyes. Superficial retinal whitening inferior to the fovea along the distribution of the inferotemporal branch retinal artery was revealed by color fundus photograph of the left eye . Delayed arterial filling corresponding to the area of retinal edema in the early phase and capillary nonperfusion around the optic disc, leakage at the posterior pole in the late phase were revealed by ultra-widefield fluorescein angiography (UWFA) . Hyper-reflective band in the inner plexiform and inner nuclear layers and thickening of the retinal layers were shown by spectral-domain optical coherence tomography (SD-OCT) . Central scotomas corresponding to the area of BRAO in the left eye were shown in the Humphrey visual field .\nThe HBO treatment, which included daily sessions lasting for 110 min at 2.0 absolute atmospheres, was performed for 10 days. The BCVA in the left eye on the fourth and sixth day of the HBO treatment were 20/33 and 20/25, respectively. On the first day after the end of the HBO treatment, the BCVA in the left eye was 20/20, and it remained unchanged at 1 month after the HBO treatment. Superficial retina whitening of the left eye disappeared, which was revealed by color fundus photograph . The narrowing of the hyper-reflective band and the thinning of the retinal layers were shown in SD-OCT . Central scotomas of the Humphrey visual field had become smaller in the left eye .", + "fulltext_subclaims": [ + "The patient is a 42-year-old man.", + "The patient is a lowlander from Beijing, China.", + "The patient presented with acute, painless visual loss in his left eye.", + "The patient had a 1-week stay at high altitude before descending.", + "The patient had type II diabetes controlled by insulin for 10 years.", + "The patient underwent binocular subtotal panretinal photocoagulation for the treatment of DR 3 months before his journey.", + "The patient did not have any other ocular treatments, such as intravitreal injections or intraocular surgery.", + "The best-corrected visual acuity in the left eye was 20/40.", + "Non-contact intraocular pressure was 18 mmHg in the left eye.", + "Ophthalmoscopy revealed hemorrhages in both eyes.", + "Color fundus photograph of the left eye revealed superficial retinal whitening inferior to the fovea.", + "Ultra-widefield fluorescein angiography revealed delayed arterial filling corresponding to the area of retinal edema in the early phase.", + "Spectral-domain optical coherence tomography showed hyper-reflective band in the inner plexiform and inner nuclear layers.", + "The HBO treatment included daily sessions lasting for 110 min at 2.0 absolute atmospheres.", + "The BCVA in the left eye on the fourth day of the HBO treatment was 20/33.", + "The BCVA in the left eye on the sixth day of the HBO treatment was 20/25.", + "On the first day after the end of the HBO treatment, the BCVA in the left eye was 20/20.", + "Color fundus photograph revealed that superficial retina whitening of the left eye disappeared.", + "Spectral-domain optical coherence tomography showed the narrowing of the hyper-reflective band.", + "Central scotomas of the Humphrey visual field had become smaller in the left eye." + ], + "summary": "We present a case of a 42-year-old man with DR who travelled to Tibet (in China, 3800 m/12467 ft. above mean sea level). The day after the end of his journey, the patient presented with acute, painless visual loss and visual field loss in his left eye. He was then diagnosed with BRAO, which is an acute blockage of blood flow. After HBO treatment, visual acuity and visual field were improved.", + "summary_subclaims": [ + "The patient is a 42-year-old man.", + "The patient has DR.", + "The patient travelled to Tibet.", + "Tibet is in China.", + "Tibet is 3800 m/12467 ft. above mean sea level.", + "The day after the end of his journey, the patient presented with acute, painless visual loss.", + "The day after the end of his journey, the patient presented with visual field loss in his left eye.", + "The patient was diagnosed with BRAO.", + "BRAO is an acute blockage of blood flow.", + "After HBO treatment, visual acuity was improved.", + "After HBO treatment, visual field was improved." + ] + }, + { + "id": "multiclinsum_test_3154_en.txt", + "fulltext": "A 59-year-old man presented to the emergency department with acute diffuse lower limb pain of recent onset with no history of trauma. His medical history included obesity, hypertension, type 2 diabetes, myocardial infarction, stroke, obesity, and long-term smoking. His treatment included bisoprolol 5 mg daily, furosemide 20 mg daily, metformin 1000 mg twice daily, sitagliptin 50 mg daily, atorvastatin 20 mg at night, and aspirin 75 mg daily. No relevant family history was noted. He had been smoking 10 cigarettes/day for 15 years. No allergies or history of alcohol abuse or illicit drug use. On clinical examination, the heart rate was 89 beats per minute, blood pressure 161/79 mmHg, temperature 36.9 C, and oxygen saturation 99%. The lower left limb was cold, peripheral pulses were not palpable with no edema. Cardiopulmonary and abdominal examinations were normal. The blood work showed a hemoglobin of 18 g/dL, leukocytosis (15 700/mm3), and C-reactive protein of 6 mg/L. Liver, thyroid, renal, and coagulation tests were normal. A lower limb angioscopy was performed that confirmed an occlusion of the left common femoral artery extending to the superficial femoral artery, as well as an occlusion of the left popliteal artery to the tripod. A right tibio-fibular trunk occlusion and moderate mixed atheromatous changes in the infrarenal aorta and iliac arteries were also described. The patient was then hospitalized and a thrombectomy of the left femoral artery was performed to revascularize the left lower limb. As part of the etiologic study, a cardiac ultrasound was performed that showed no abnormality and subsequently a thoracic angiotomography that described the presence of a floating thrombus in the distal third of the aortic arch downstream of the supra-aortic trunks. In the face of these findings, a positron emission tomography (PET) scan was performed to look for occult neoplastic disease, but this investigation did not show the presence of significant hypermetabolism in the segments examined.\n", + "fulltext_subclaims": [ + "A 59-year-old man presented to the emergency department with acute diffuse lower limb pain of recent onset.", + "He had no history of trauma.", + "His medical history included obesity.", + "His medical history included hypertension.", + "His medical history included type 2 diabetes.", + "His medical history included myocardial infarction.", + "His medical history included stroke.", + "His medical history included long-term smoking.", + "He had been smoking 10 cigarettes/day for 15 years.", + "On clinical examination, the lower left limb was cold.", + "Peripheral pulses were not palpable.", + "A lower limb angioscopy was performed.", + "The angioscopy confirmed an occlusion of the left common femoral artery extending to the superficial femoral artery.", + "The angioscopy confirmed an occlusion of the left popliteal artery to the tripod.", + "A right tibio-fibular trunk occlusion was described.", + "A thoracic angiotomography described the presence of a floating thrombus in the distal third of the aortic arch downstream of the supra-aortic trunks.", + "A positron emission tomography (PET) scan was performed.", + "The PET scan did not show the presence of significant hypermetabolism in the segments examined." + ], + "summary": "We present the case of a 59-year-old man who presented to the emergency department with a sharp, diffuse pain in the left lower limb caused by extensive obstructive clots in the arteries of the left lower limb. Since an atheromatous cause was unlikely after the lower limb angioscopy, a cardiac origin was suspected. Cardiac ultrasound did not show abnormalities, however, thoracic angiotomography revealed a free-floating thrombus in the aortic arch. The patient was treated surgically with a stent graft in the aorta without complications.\n", + "summary_subclaims": [ + "The patient was a 59-year-old man.", + "He presented to the emergency department with a sharp, diffuse pain in the left lower limb.", + "The pain was caused by extensive obstructive clots in the arteries of the left lower limb.", + "An atheromatous cause was unlikely after the lower limb angioscopy.", + "A cardiac origin was suspected.", + "Cardiac ultrasound did not show abnormalities.", + "Thoracic angiotomography revealed a free-floating thrombus in the aortic arch.", + "The patient was treated surgically with a stent graft in the aorta.", + "The surgical treatment was without complications." + ] + }, + { + "id": "multiclinsum_test_2670_en.txt", + "fulltext": "A 55-year-old male patient with a medical history of systemic arterial hypertension was admitted to the neuroemergency department, after being transferred from another service, with a report of sudden, intense thunderstorm headache, associated with the left eyelid ptosis and diplopia. During the neurological examination, the patient was awake, lucid, and oriented. He had complete palsy of the left oculomotor nerve, with no other focal neurological deficits. Neck stiffness was present.\nCranial CT performed on the day following the headache showed no SAH, but showed an expansive process in the sella turcica associated with sellar enlargement . SAH was then confirmed by lumbar puncture (Fisher I). A cranial angio-CT was made and revealed an intradural saccular aneurysm in the cavernous segment of the left internal carotid artery (ICA) .\nThe patient underwent cranial microsurgery for cerebral aneurysm clipping that confirmed the intradural location of the aneurysm, arising from a tortuous cavernous ICA .\nHe underwent control cerebral angiography on the 2nd postoperative day that demonstrated complete aneurysm occlusion , with no residual neck and no vasospasm and complemented the study with magnetic resonance imaging (MRI) of the sella turcica that was consistent of pituitary macroadenoma with apoplexy . He was discharged on the 21st day after the hemorrhage, maintaining complete left oculomotor nerve dysfunction, but with no other complaints and no neurological deficits.", + "fulltext_subclaims": [ + "The patient is a 55-year-old male.", + "The patient has a medical history of systemic arterial hypertension.", + "The patient was admitted to the neuroemergency department.", + "The patient was transferred from another service.", + "The patient reported a sudden, intense thunderstorm headache.", + "The headache was associated with left eyelid ptosis.", + "The headache was associated with diplopia.", + "During the neurological examination, the patient was awake.", + "During the neurological examination, the patient was lucid.", + "During the neurological examination, the patient was oriented.", + "The patient had complete palsy of the left oculomotor nerve.", + "The patient had no other focal neurological deficits.", + "Neck stiffness was present.", + "Cranial CT performed on the day following the headache showed no subarachnoid hemorrhage (SAH).", + "Cranial CT showed an expansive process in the sella turcica.", + "Cranial CT showed sellar enlargement.", + "SAH was confirmed by lumbar puncture.", + "The lumbar puncture showed Fisher I subarachnoid hemorrhage.", + "Cranial angio-CT revealed an intradural saccular aneurysm in the cavernous segment of the left internal carotid artery.", + "The patient underwent cranial microsurgery for cerebral aneurysm clipping.", + "The surgery confirmed the intradural location of the aneurysm.", + "The aneurysm arose from a tortuous cavernous ICA.", + "Control cerebral angiography on the 2nd postoperative day demonstrated complete aneurysm occlusion.", + "Control cerebral angiography showed no residual neck.", + "Control cerebral angiography showed no vasospasm.", + "Magnetic resonance imaging (MRI) of the sella turcica was consistent with pituitary macroadenoma with apoplexy.", + "The patient was discharged on the 21st day after the hemorrhage.", + "The patient maintained complete left oculomotor nerve dysfunction at discharge.", + "The patient had no other complaints at discharge.", + "The patient had no neurological deficits at discharge." + ], + "summary": "A 55-year-old male patient presented with sudden, intense thunderstorm headache, associated with complete palsy of the left oculomotor nerve and neck stiffness. Cranial computed tomography (CT) showed no SAH, but showed an expansive process in the sella turcica, consistent with a pituitary macroadenoma. After that, SAH was confirmed by lumbar puncture (Fisher I). Cranial angio-CT revealed an intradural saccular aneurysm in the cavernous segment of the left ICA. The patient underwent cranial microsurgery for cerebral aneurysm clipping. Unlike the normal anatomic pattern, the cavernous segment of the carotid artery in this patient was located in the intradural compartment.", + "summary_subclaims": [ + "The patient is a 55-year-old male.", + "The patient presented with sudden, intense thunderstorm headache.", + "The patient had complete palsy of the left oculomotor nerve.", + "The patient had neck stiffness.", + "Cranial CT showed no subarachnoid hemorrhage.", + "Cranial CT showed an expansive process in the sella turcica.", + "The expansive process in the sella turcica was consistent with a pituitary macroadenoma.", + "Subarachnoid hemorrhage was confirmed by lumbar puncture.", + "The subarachnoid hemorrhage was classified as Fisher I.", + "Cranial angio-CT revealed an intradural saccular aneurysm in the cavernous segment of the left internal carotid artery.", + "The patient underwent cranial microsurgery for cerebral aneurysm clipping.", + "The cavernous segment of the carotid artery in this patient was located in the intradural compartment." + ] + }, + { + "id": "multiclinsum_test_3396_en.txt", + "fulltext": "A 30-year-old female hospitalized patient was referred from the Internal Medicine clinic with chief complaints of multiple oral ulcers, a sore palate, and difficulty opening her mouth ten days prior. Initially, the ulcers appeared on the buccal mucosa and palate, progressing rapidly throughout the oral cavity. Doctors from the hospital beforehand have prescribed medication to relieve the pain complaints, but there has been no improvement. Since being hospitalized, the patient has had difficulty cleaning her mouth and can only consume milk through a straw. The patient has a habit of peeling off the scabs on the lips.\n\nThe patient experienced a body fever three days before being hospitalized. There were no complaints of coughing, runny noses, or altered taste. The patient has also complained of swollen legs and abdomen, pain in all joints, hair loss, and reddish skin once exposed to sunlight three months prior. Following a previous hospital diagnosis of nephrotic syndrome, the patient was prescribed furosemide 80 mg, albumin, and methylprednisolone 32 mg. The patient stopped the drugs after taking them for two weeks without consulting a doctor because she felt her condition was improving.\n\nExtra-oral examination at the first visit showed multiple hemorrhagic crusts and erosions in the bilateral frontal and zygoma regions passed through the bridge of the nose, an irregular shape with distinct borders, and hemorrhagic crusts on the upper and lower lips that bleed easily. Intra-oral examination revealed erythema throughout oral mucosa and multiple irregular white plaques with diffuse borders that vary in size, which can be partially scraped off to reveal patches of erythema on the palate. Based on the history and clinical findings, the suspected diagnosis in the first visit was oral lesions associated with SLE and acute pseudomembranous candidiasis, with the differential diagnoses were pemphigus vulgaris (PV), erythema major and Steven Johnson syndrome (SJS).\n\nThe internal medicine specialist made a provisional diagnosis of suspected SLE with mucocutaneous, musculoskeletal, renal, and serositis involvement. Suspected chronic cutaneous lupus erythematosus (CCLE) and suspected toxic epidermal necrolysis-like acute cutaneous lupus erythematosus (TEN-like ACLE) were established as differential diagnoses. An antinuclear-antibodies (ANA) test was performed in the second visit (third day) and showed reactive results with a homogeneous pattern (titer 1:3200). Complete blood cell count and other parameters in laboratory examination were performed to assess the patient’s general health status.\n\nDisease activity assessment was performed using the Mexican-Systemic Lupus Erythematosus Disease Activity Index (Mex-SLEDAI) and revealed a score of 7. Based on these examination results, the internal medicine specialist diagnosed SLE, and the oral medicine specialist diagnosed lupus cheilitis and palatal erythematous ulcer. Evaluation from the oral medicine department at the second visit showed no improvement in the oral lesions.\n\nThe patient complained of increasing crusts on her lips at her follow-up on the third visit (sixth day), while the pain in the oral cavity remained. Extra-oral examination reveals an improvement in the crust of the frontal region, bilateral zygomas, and nose bridge, but the hemorrhagic crust on the lips develops into the serosanguinolenta crust. Intra-oral examination showed multiple ulcers surrounded by diffusely bounded erythema areas on the buccal mucosa and palate. An anti-HSV-1 IgG examination was carried out, and positive results were obtained at a ratio of 1.57 times. Diagnosis of lupus cheilitis associated with HSV-1 infection, oral discoid lupus erythematosus (DLE), and palatal erythematous ulcer was established.\n\nThe patient felt that the complaints in the oral cavity had begun to improve on the fourth visit (thirteenth day), but there was still a slight stinging sensation on the lips, buccal mucosa, and palate. Extra-oral examination showed that the crusts on the lips had improved but still bled easily. Intra-oral examination revealed improvement, as indicated by a decrease in lesion size.\n\nOn the fifth visit (40th day), the patient no longer felt sore in the oral cavity, and all lesions had disappeared. The patient has been able to eat normally for the last 10 days, following a three-meal-A-day diet accompanied by routine consumption of vegetables and fruits. The patient was instructed to continue maintaining oral hygiene.\n\n\nCase Management\nComprehensive management, including pharmacological and non-pharmacological therapy, was given to the patient with a multidisciplinary approach from various fields, such as internal medicine, dermatology venereology, and oral medicine.\n\nPharmacological therapy from internal medicine was methylprednisolone 500 mg intravenously administered for three days and continued orally at a dose of 48 mg per day, while dermatology and venereology prescribed SPF 45 sunscreen and mometasone furoate 0.1% cream. These drugs were continued alongside therapy from the oral medicine clinic, such as 0.9% NaCl solution, 0.025% hyaluronic acid mouthwash, nystatin oral suspension 100.000 IU/mL, and a mixture of ointments containing dexamethasone. Acyclovir 200 mg as an antiviral agent was added on the sixth day after the anti-HSV-1 IgG test showed a positive result. Chlorhexidine gluconate 0.2% mouthwash was given on the thirteenth day to replace hyaluronic acid mouthwash, and nystatin oral suspension was stopped.\n\nNon-pharmacological therapy includes instructions for applying moist gauze moistened with 0.9% NaCl solution to compress lips at least three times daily. Education is given to the patient to stop the habit of peeling scabs on the lips, encouraging a healthy lifestyle and adequate hydration at least two liters per day. All lesions healed within 40 days, and the patient was still educated on maintaining oral hygiene.", + "fulltext_subclaims": [ + "The patient is a 30-year-old female.", + "The patient was hospitalized.", + "The patient was referred from the Internal Medicine clinic.", + "The patient's chief complaints were multiple oral ulcers, a sore palate, and difficulty opening her mouth ten days prior.", + "The ulcers initially appeared on the buccal mucosa and palate.", + "The ulcers progressed rapidly throughout the oral cavity.", + "Doctors from the hospital beforehand prescribed medication to relieve the pain complaints.", + "There has been no improvement in the patient's condition.", + "Since being hospitalized, the patient has had difficulty cleaning her mouth.", + "The patient can only consume milk through a straw.", + "The patient has a habit of peeling off the scabs on the lips.", + "The patient experienced a body fever three days before being hospitalized.", + "There were no complaints of coughing.", + "There were no complaints of runny nose.", + "There were no complaints of altered taste.", + "The patient has complained of swollen legs and abdomen.", + "The patient has complained of pain in all joints.", + "The patient has complained of hair loss.", + "The patient has complained of reddish skin once exposed to sunlight three months prior.", + "The patient was previously diagnosed with nephrotic syndrome.", + "The patient was prescribed furosemide 80 mg.", + "The patient was prescribed albumin.", + "The patient was prescribed methylprednisolone 32 mg.", + "The patient stopped the drugs after taking them for two weeks.", + "The patient stopped the drugs without consulting a doctor.", + "The patient felt her condition was improving.", + "Extra-oral examination showed multiple hemorrhagic crusts and erosions in the bilateral frontal and zygoma regions passed through the bridge of the nose.", + "Extra-oral examination showed an irregular shape with distinct borders.", + "Extra-oral examination showed hemorrhagic crusts on the upper and lower lips that bleed easily.", + "Intra-oral examination revealed erythema throughout oral mucosa.", + "Intra-oral examination revealed multiple irregular white plaques with diffuse borders that vary in size.", + "The white plaques can be partially scraped off to reveal patches of erythema on the palate.", + "The suspected diagnosis in the first visit was oral lesions associated with SLE.", + "The suspected diagnosis in the first visit was acute pseudomembranous candidiasis.", + "The differential diagnoses were pemphigus vulgaris (PV).", + "The differential diagnoses were erythema major.", + "The differential diagnoses were Steven Johnson syndrome (SJS).", + "The internal medicine specialist made a provisional diagnosis of suspected SLE with mucocutaneous involvement.", + "The internal medicine specialist made a provisional diagnosis of suspected SLE with musculoskeletal involvement.", + "The internal medicine specialist made a provisional diagnosis of suspected SLE with renal involvement.", + "The internal medicine specialist made a provisional diagnosis of suspected SLE with serositis involvement.", + "Suspected chronic cutaneous lupus erythematosus (CCLE) was established as a differential diagnosis.", + "Suspected toxic epidermal necrolysis-like acute cutaneous lupus erythematosus (TEN-like ACLE) was established as a differential diagnosis.", + "An antinuclear-antibodies (ANA) test was performed in the second visit.", + "The ANA test showed reactive results with a homogeneous pattern.", + "The ANA titer was 1:3200.", + "Complete blood cell count was performed.", + "Other parameters in laboratory examination were performed.", + "The laboratory examinations were performed to assess the patient’s general health status.", + "Disease activity assessment was performed using the Mexican-Systemic Lupus Erythematosus Disease Activity Index (Mex-SLEDAI).", + "The Mex-SLEDAI score was 7.", + "The internal medicine specialist diagnosed SLE.", + "The oral medicine specialist diagnosed lupus cheilitis.", + "The oral medicine specialist diagnosed palatal erythematous ulcer.", + "Evaluation from the oral medicine department at the second visit showed no improvement in the oral lesions.", + "The patient complained of increasing crusts on her lips at her follow-up on the third visit.", + "The pain in the oral cavity remained.", + "Extra-oral examination reveals an improvement in the crust of the frontal region.", + "Extra-oral examination reveals an improvement in the crust of the bilateral zygomas.", + "Extra-oral examination reveals an improvement in the crust of the nose bridge.", + "The hemorrhagic crust on the lips develops into the serosanguinolenta crust.", + "Intra-oral examination showed multiple ulcers surrounded by diffusely bounded erythema areas on the buccal mucosa.", + "An anti-HSV-1 IgG examination was carried out.", + "The anti-HSV-1 IgG test showed positive results.", + "The anti-HSV-1 IgG ratio was 1.57 times.", + "Diagnosis of lupus cheilitis associated with HSV-1 infection was established.", + "Diagnosis of oral discoid lupus erythematosus (DLE) was established.", + "Diagnosis of palatal erythematous ulcer was established.", + "The patient felt that the complaints in the oral cavity had begun to improve on the fourth visit.", + "There was still a slight stinging sensation on the lips, buccal mucosa, and palate.", + "Extra-oral examination showed that the crusts on the lips had improved.", + "The crusts on the lips still bled easily.", + "Intra-oral examination revealed improvement, as indicated by a decrease in lesion size.", + "On the fifth visit, the patient no longer felt sore in the oral cavity.", + "All lesions had disappeared.", + "The patient has been able to eat normally for the last 10 days.", + "The patient follows a three-meal-A-day diet.", + "The patient consumes vegetables and fruits routinely.", + "The patient was instructed to continue maintaining oral hygiene.", + "Comprehensive management, including pharmacological and non-pharmacological therapy, was given to the patient.", + "The management was given with a multidisciplinary approach.", + "The multidisciplinary approach included internal medicine, dermatology venereology, and oral medicine.", + "Pharmacological therapy from internal medicine was methylprednisolone 500 mg intravenously administered for three days.", + "Pharmacological therapy from internal medicine was continued orally at a dose of 48 mg per day.", + "Dermatology and venereology prescribed SPF 45 sunscreen.", + "Dermatology and venereology prescribed mometasone furoate 0.1% cream.", + "Oral medicine prescribed 0.9% NaCl solution.", + "Oral medicine prescribed 0.025% hyaluronic acid mouthwash.", + "Oral medicine prescribed nystatin oral suspension 100.000 IU/mL.", + "Oral medicine prescribed a mixture of ointments containing dexamethasone.", + "Acyclovir 200 mg was added on the sixth day.", + "Chlorhexidine gluconate 0.2% mouthwash was given on the thirteenth day.", + "Nystatin oral suspension was stopped.", + "Non-pharmacological therapy included instructions for applying moist gauze moistened with 0.9% NaCl solution to compress lips at least three times daily.", + "Education was given to the patient to stop the habit of peeling scabs on the lips.", + "Education encouraged a healthy lifestyle.", + "Education encouraged adequate hydration at least two liters per day.", + "All lesions healed within 40 days.", + "The patient was still educated on maintaining oral hygiene." + ], + "summary": "A 30-year-old woman complained of a sore mouth and mouth-opening difficulty ten days prior. Previously, the patient complained of swelling in the legs and stomach, joint pain, hair loss, and skin redness on exposure to sunlight. Extra-oral examination revealed multiple red-black erosions and crusts on the zygoma region bilaterally over the nasal bridge, well-demarcated with an irregular shape, while the lips bled easily with hemorrhagic crusts that developed into serosanguineous crusts. Intra-oral examination showed scrapable white plaques on the palate, leaving erythematous areas, pain, and ulcers throughout the oral mucosa. The antinuclear antibody (ANA) examination revealed reactive results, positive anti-HSV-1 IgG, and positive hyphal on KOH examination. Based on the examination results, the diagnosis was SLE with herpes virus-associated oral involvement and acute pseudomembranous candidiasis.\n\nCase Management\nComprehensive therapy, including non-pharmacological and pharmacological therapy, was involved. All oral lesions improved within one month.", + "summary_subclaims": [ + "The patient is a 30-year-old woman.", + "The patient complained of a sore mouth and mouth-opening difficulty ten days prior.", + "Previously, the patient complained of swelling in the legs and stomach.", + "Previously, the patient complained of joint pain.", + "Previously, the patient complained of hair loss.", + "Previously, the patient complained of skin redness on exposure to sunlight.", + "Extra-oral examination revealed multiple red-black erosions and crusts on the zygoma region bilaterally over the nasal bridge.", + "The red-black erosions and crusts were well-demarcated with an irregular shape.", + "The lips bled easily with hemorrhagic crusts that developed into serosanguineous crusts.", + "Intra-oral examination showed scrapable white plaques on the palate.", + "The white plaques left erythematous areas.", + "The intra-oral examination showed pain and ulcers throughout the oral mucosa.", + "The antinuclear antibody (ANA) examination revealed reactive results.", + "The patient had positive anti-HSV-1 IgG.", + "The patient had positive hyphal on KOH examination.", + "The diagnosis was SLE with herpes virus-associated oral involvement.", + "The diagnosis included acute pseudomembranous candidiasis.", + "Comprehensive therapy, including non-pharmacological and pharmacological therapy, was involved.", + "All oral lesions improved within one month." + ] + }, + { + "id": "multiclinsum_test_1522_en.txt", + "fulltext": "A 16-year-old Japanese primipara was urgently transported from a regional maternity clinic to our hospital because of threatened premature labor in the 25th week of pregnancy. There was no medical or family history of note. At that time, there had been extremely powerful earthquakes occurring in the Kumamoto area where she lived, and as a result, she had been forced to stay in an emergency shelter. When she arrived at our hospital, treatment with ritodrine hydrochloride, magnesium sulfate, betamethasone and hydroxyprogesterone was initiated, and her premature uterine contractions were successfully controlled.\nSoon after her admission, considerable polyuria (3000–6000 mL/day), nocturia (5–6 times a night) and polydipsia gradually became obvious . Because she was restricted to bedrest to prevent premature labor, precise diagnosis and treatment of polyuria was necessary. From the 27th to the 28th week of gestation, the amount of urine increased from 4000 to 6000 mL/day . Fasting plasma glucose levels during hospitalization were around 78–88 mg/dL and the results from a 75-g oral glucose tolerance test indicated that she was not diabetic . Although she developed polyuria, serum sodium levels were constant at around 137–140 mEq/L during the clinical course . Serum osmolality was maintained at around 260–265 mOsm/L, while urine osmolality (191–293 mOsm/L) showed below the levels of serum osmolality, indicating that her urine concentration ability had deteriorated . The serum level of AVP was 1.7 pg/mL (0.3–3.5; Table ), which is inconsistent with central DI. At the time of admission, hepatic dysfunction was not observed . A water deprivation test would have been unsuitable for diagnosis in this case because dehydration can deteriorate the maternal-fetus environment. Although a precise diagnosis of GDI was not made at that time, we decided to use oral 1-deamino-8-D-AVP (DDAVP) tablets for diagnostic treatment to determine whether her urine would respond to DDAVP and treat DI, as well as to rule out nephrogenic DI. Thus, the patient was first given 120 μg of oral DDAVP tablets, and then the dose of DDAVP was gradually increased to 360 μg until the amount of urine was less than 2000 mL/day with a urine osmolality of 305–365 mOsm/L . At the 32nd week of gestation, fetal maturation was confirmed and medical support to prevent premature contractions was ceased. Soon after this decision, a male fetus weighing 1660 g and 45 cm was delivered with a one-minute Apgar score of 8/9. Immediately after the normal delivery, DDAVP tablets were no longer necessary to control her polyuria. Daily urine amount decreased to 1300–1600 mL/day . At this point, s-Osm was 268 mOsm/L and u-Osm increased to 540 mOsm/L without DDAVP treatment . Pituitary magnetic resonance imaging (MRI) was performed and confirmed that the normal bright spot in the posterior pituitary on the T1 image was present . After these observations, clinical diagnosis of GDI was confirmed.\nAt 2 weeks post-partum, the patient’s sodium, serum and urine osmolality were within normal range. She remained clinically well, and is currently breast-feeding with no complications.\nAt 4 weeks post-partum, she developed postpartum destructive thyrotoxicosis with increases of free-T4 and free-T3, and suppressed thyroid stimulating hormone (TSH), with positive thyroglobulin antibody . After 8–12 weeks of follow up with no medications, she had completely recovered thyroid function.", + "fulltext_subclaims": [ + "A 16-year-old Japanese primipara was urgently transported from a regional maternity clinic to our hospital because of threatened premature labor in the 25th week of pregnancy.", + "There was no medical or family history of note.", + "Extremely powerful earthquakes were occurring in the Kumamoto area where she lived.", + "She had been forced to stay in an emergency shelter.", + "Treatment with ritodrine hydrochloride, magnesium sulfate, betamethasone and hydroxyprogesterone was initiated.", + "Her premature uterine contractions were successfully controlled.", + "Soon after her admission, considerable polyuria (3000–6000 mL/day), nocturia (5–6 times a night) and polydipsia gradually became obvious.", + "She was restricted to bedrest to prevent premature labor.", + "From the 27th to the 28th week of gestation, the amount of urine increased from 4000 to 6000 mL/day.", + "Fasting plasma glucose levels during hospitalization were around 78–88 mg/dL.", + "The results from a 75-g oral glucose tolerance test indicated that she was not diabetic.", + "Serum sodium levels were constant at around 137–140 mEq/L during the clinical course.", + "Serum osmolality was maintained at around 260–265 mOsm/L.", + "Urine osmolality (191–293 mOsm/L) showed below the levels of serum osmolality.", + "The serum level of AVP was 1.7 pg/mL.", + "A water deprivation test would have been unsuitable for diagnosis in this case.", + "We decided to use oral 1-deamino-8-D-AVP (DDAVP) tablets for diagnostic treatment.", + "The patient was first given 120 μg of oral DDAVP tablets.", + "The dose of DDAVP was gradually increased to 360 μg until the amount of urine was less than 2000 mL/day with a urine osmolality of 305–365 mOsm/L.", + "At the 32nd week of gestation, fetal maturation was confirmed.", + "Medical support to prevent premature contractions was ceased.", + "A male fetus weighing 1660 g and 45 cm was delivered.", + "The one-minute Apgar score was 8/9.", + "DDAVP tablets were no longer necessary to control her polyuria.", + "Daily urine amount decreased to 1300–1600 mL/day.", + "s-Osm was 268 mOsm/L.", + "u-Osm increased to 540 mOsm/L without DDAVP treatment.", + "Pituitary magnetic resonance imaging (MRI) was performed.", + "The normal bright spot in the posterior pituitary on the T1 image was present.", + "Clinical diagnosis of GDI was confirmed.", + "At 2 weeks post-partum, the patient’s sodium, serum and urine osmolality were within normal range.", + "She remained clinically well.", + "She is currently breast-feeding with no complications.", + "At 4 weeks post-partum, she developed postpartum destructive thyrotoxicosis.", + "Free-T4 and free-T3 increased.", + "Thyroid stimulating hormone (TSH) was suppressed.", + "Thyroglobulin antibody was positive.", + "After 8–12 weeks of follow up with no medications, she had completely recovered thyroid function." + ], + "summary": "A 16-year-old pregnant woman was urgently transferred to our hospital because of threatened premature labor when the Kumamoto earthquakes hit the area where she lived. During her hospitalization, she complained of gradually increasing symptoms of polyuria and polydipsia. The serum level of arginine vasopressin (AVP) was 1.7 pg/mL, which is inconsistent with central DI. The challenge of diagnostic treatment using oral 1-deamino-8-D-AVP (DDAVP) successfully controlled her urine and allowed for normal delivery. DDAVP tablets were not necessary to control her polyuria thereafter. Based on these observations, clinical diagnosis of GDI was confirmed. Pathophysiological analyses revealed that vasopressinase expression was more abundant in the GDI patient's syncytiotrophoblast in placenta compared with that in a control subject. Serum vasopressinase was also observed during gestation and disappeared soon after delivery. Vasopressinase is reportedly identical to oxytocinase or insulin regulated aminopeptidase (IRAP), which is an abundant cargo protein associated with the glucose transporter 4 (GLUT4) storage vesicle. Interestingly, the expression and subcellular localization of GLUT4 appeared to occur in a vasopressinase (IRAP)-dependent manner.", + "summary_subclaims": [ + "A 16-year-old pregnant woman was urgently transferred to our hospital because of threatened premature labor when the Kumamoto earthquakes hit the area where she lived.", + "During her hospitalization, she complained of gradually increasing symptoms of polyuria and polydipsia.", + "The serum level of arginine vasopressin (AVP) was 1.7 pg/mL.", + "The serum level of AVP was inconsistent with central DI.", + "The challenge of diagnostic treatment using oral 1-deamino-8-D-AVP (DDAVP) successfully controlled her urine.", + "DDAVP tablets were not necessary to control her polyuria thereafter.", + "Based on these observations, clinical diagnosis of GDI was confirmed.", + "Vasopressinase expression was more abundant in the GDI patient's syncytiotrophoblast in placenta compared with that in a control subject.", + "Serum vasopressinase was also observed during gestation.", + "Serum vasopressinase disappeared soon after delivery.", + "Vasopressinase is reportedly identical to oxytocinase or insulin regulated aminopeptidase (IRAP).", + "IRAP is an abundant cargo protein associated with the glucose transporter 4 (GLUT4) storage vesicle.", + "The expression and subcellular localization of GLUT4 appeared to occur in a vasopressinase (IRAP)-dependent manner." + ] + }, + { + "id": "multiclinsum_test_2572_en.txt", + "fulltext": "A 55-year-old Asian (Japanese) woman presented with low back pain and right leg radiating pain without any apparent cause. She received conservative treatment, such as pain killer administration and lumbar root block injection under the diagnosis of lumbar disc herniation at the right L5/S. However, her symptoms gradually worsened until she could not walk because of severe right leg pain and mild muscle weakness. She then referred to our hospital for surgical treatment.\nPhysical examination revealed a positive Lasègue sign and the range of the straight leg raising test was 20° on the right side. The right patellar tendon reflex was normal; however, the right ankle jerk reflex absent. On the manual muscle test (MMT), mild muscle weakness (4/5) was observed in the right tibialis anterior (TA), peroneal longus et brevis (PL et B), extensor hallucis longus (EHL), flexor hallucis longus (FHL), and triceps surae (TS). Although there was occasional mild numbness in the right lower leg, no obvious hypoesthesia was noted in the definitive area.\nOn plain radiograph, spina bifida occulta at the L5 neural arch was detected in the anteroposterior direction, and slight disc space narrowing at the L4/5 and L5/S intervertebral disc levels was seen in the lateral direction . Myelography and computed tomography (CT) following myelography (CTM) showed a defect in the right L5 and S1 nerve roots . Magnetic resonance (MR) images revealed a herniated nucleus pulposus (HNP) on the right side at the L5/S1 intervertebral disc level . Our preoperative diagnosis was right S1 radiculopathy originating from a usual HNP that compresses the right S1 nerve root in accordance with the findings of L5 radiculopathy suspected by muscle weakness of the TA, EHL, and PL et B.\nWe planned lumbar discectomy under a microscope. First, wide fenestration at the right L5/S interlaminar space was performed to identify the right S1 nerve root that was compressed by HNP. However, an anomaly of the conjoined right L5–S1 nerve root was observed. There was no adhesion between the yellow ligament and neural tissue. The epidural space was filled with sufficient adipose tissue. An HNP extruding from the right L5/S intervertebral disc space was confirmed beneath the conjoined right L5–S1 nerve root, which was severely compressed and shifted backward. Mild adhesion between the conjoined right L5–S1 nerve root and capsule of the HNP was observed. Next, to ensure safe discectomy, the area of the fenestration was enlarged while assuring that the facet joint was not disrupted. Although the conjoined right L5–S1 nerve root was very thick and less mobile, some pieces of HNP could be removed piece by piece from the axillary part of the conjoined right L5–S1 nerve root. After these decompressive procedures, the tightness of the conjoined right L5–S1 nerve root decreased, but its mobility did not improve much . The laterality of the thickness and exit angle of the conjoined right L5–S1 nerve root was retrospectively confirmed on preoperative T2 coronal MR images and MR neurography .\nPostoperatively, right leg pain was immediately alleviated and complete improvement of muscle weakness was achieved 1 week later (5/5). At 6 months after surgery, she complained of mild pain at the back and the bilateral thighs, similar to myalgia but was able to walk without any support .", + "fulltext_subclaims": [ + "The patient is a 55-year-old Asian (Japanese) woman.", + "She presented with low back pain and right leg radiating pain without any apparent cause.", + "She received conservative treatment, such as pain killer administration and lumbar root block injection.", + "The diagnosis was lumbar disc herniation at the right L5/S.", + "Her symptoms gradually worsened until she could not walk because of severe right leg pain and mild muscle weakness.", + "She was referred to the hospital for surgical treatment.", + "Physical examination revealed a positive Lasègue sign.", + "The range of the straight leg raising test was 20° on the right side.", + "The right patellar tendon reflex was normal.", + "The right ankle jerk reflex was absent.", + "Mild muscle weakness (4/5) was observed in the right tibialis anterior.", + "Mild muscle weakness (4/5) was observed in the right peroneal longus et brevis.", + "Mild muscle weakness (4/5) was observed in the right extensor hallucis longus.", + "Mild muscle weakness (4/5) was observed in the right flexor hallucis longus.", + "Mild muscle weakness (4/5) was observed in the right triceps surae.", + "There was occasional mild numbness in the right lower leg.", + "No obvious hypoesthesia was noted in the definitive area.", + "Plain radiograph showed spina bifida occulta at the L5 neural arch in the anteroposterior direction.", + "Plain radiograph showed slight disc space narrowing at the L4/5 and L5/S intervertebral disc levels in the lateral direction.", + "Myelography and CTM showed a defect in the right L5 and S1 nerve roots.", + "MR images revealed a herniated nucleus pulposus on the right side at the L5/S1 intervertebral disc level.", + "The preoperative diagnosis was right S1 radiculopathy originating from a usual HNP that compresses the right S1 nerve root.", + "The preoperative diagnosis was in accordance with the findings of L5 radiculopathy suspected by muscle weakness of the tibialis anterior, extensor hallucis longus, and peroneal longus et brevis.", + "Lumbar discectomy under a microscope was planned.", + "Wide fenestration at the right L5/S interlaminar space was performed.", + "An anomaly of the conjoined right L5–S1 nerve root was observed.", + "There was no adhesion between the yellow ligament and neural tissue.", + "The epidural space was filled with sufficient adipose tissue.", + "An HNP extruding from the right L5/S intervertebral disc space was confirmed beneath the conjoined right L5–S1 nerve root.", + "The HNP was severely compressed and shifted backward.", + "Mild adhesion between the conjoined right L5–S1 nerve root and capsule of the HNP was observed.", + "The area of the fenestration was enlarged while assuring that the facet joint was not disrupted.", + "The conjoined right L5–S1 nerve root was very thick and less mobile.", + "Some pieces of HNP could be removed piece by piece from the axillary part of the conjoined right L5–S1 nerve root.", + "After decompressive procedures, the tightness of the conjoined right L5–S1 nerve root decreased.", + "The mobility of the conjoined right L5–S1 nerve root did not improve much.", + "The laterality of the thickness and exit angle of the conjoined right L5–S1 nerve root was retrospectively confirmed on preoperative T2 coronal MR images.", + "The laterality of the thickness and exit angle of the conjoined right L5–S1 nerve root was retrospectively confirmed on MR neurography.", + "Postoperatively, right leg pain was immediately alleviated.", + "Complete improvement of muscle weakness was achieved 1 week later (5/5).", + "At 6 months after surgery, she complained of mild pain at the back and the bilateral thighs.", + "At 6 months after surgery, she was able to walk without any support." + ], + "summary": "A 55-year-old Asian (Japanese) woman presented with low back pain and right leg radiating pain due to lumbar disc herniation at the right L5/S1. Physical examination revealed a positive Lasègue sign and the range of the straight leg raising test was 20° on the right side. The right patellar tendon reflex was normal; however, the right ankle jerk reflex disappeared. Although no obvious hypoesthesia was noted, mild muscle weakness (4/5) was observed in the right leg on the manual muscle test. We planned the lumbar discectomy under a microscope. During surgery, the conjoined right L5-S1 nerve root, which was compressed by herniated nucleus pulposus, was encountered. Although it was very thick and less mobile, some pieces of herniated nucleus pulposus could be removed piece by piece from the axillary part. After sequential decompressive procedures, the tightness of the conjoined right L5-S1 nerve root decreased but its mobility did not improve much. The laterality of the thickness and exit angle of the conjoined right L5-S1 nerve root was retrospectively confirmed on T2 coronal magnetic resonance images and magnetic resonance neurography. Postoperatively, right leg pain was immediately alleviated and complete improvement of muscle weakness was achieved 1 week later (5/5).", + "summary_subclaims": [ + "The patient is a 55-year-old Asian (Japanese) woman.", + "She presented with low back pain and right leg radiating pain due to lumbar disc herniation at the right L5/S1.", + "Physical examination revealed a positive Lasègue sign.", + "The range of the straight leg raising test was 20° on the right side.", + "The right patellar tendon reflex was normal.", + "The right ankle jerk reflex disappeared.", + "Mild muscle weakness (4/5) was observed in the right leg on the manual muscle test.", + "We planned the lumbar discectomy under a microscope.", + "During surgery, the conjoined right L5-S1 nerve root, which was compressed by herniated nucleus pulposus, was encountered.", + "Some pieces of herniated nucleus pulposus could be removed piece by piece from the axillary part.", + "After sequential decompressive procedures, the tightness of the conjoined right L5-S1 nerve root decreased.", + "The laterality of the thickness and exit angle of the conjoined right L5-S1 nerve root was retrospectively confirmed on T2 coronal magnetic resonance images and magnetic resonance neurography.", + "Postoperatively, right leg pain was immediately alleviated.", + "Complete improvement of muscle weakness was achieved 1 week later (5/5)." + ] + }, + { + "id": "multiclinsum_test_1414_en.txt", + "fulltext": "A 19-year-old young lady presented to our cardiology clinic complaining of shortness of breath of 3 months duration. Her symptoms were progressive over time, and on presentation, she was short of breath on minimal effort. She also reported two attacks of hemoptysis, and each was about a cup of fresh blood. She denied any history of chest pain, palpitations, syncope, or lower limb swelling.\nSix years earlier, she was admitted with generalized anasarca, rapidly deteriorating renal functions, and nephrotic range of proteinuria. Renal biopsy showed focal segmental glomerulosclerosis. She had two sessions of hemodialysis and was kept on immune-suppressive medical therapy, and her renal functions were then stabilized. Furthermore, 2 years before presenting to us, she had a purpuric eruption and was found to have severe thrombocytopenia. Her platelets reached 10,000, and after exclusion of all other possible causes, she was diagnosed with immune thrombocytopenic purpura (ITP) and was kept on steroids. She also reported a history of previous right femoral deep venous thrombosis 1 year ago for which she was anticoagulated using warfarin for 6 months. The patient denied any history suggestive of an autoimmune disorder (e.g., arthralgia, skin rash, mouth ulcers, hair loss), and there was no family history of any similar conditions.\nAt the time of presentation, her blood pressure was 110/70 and her heart rate was 100/min. Her resting oxygen saturation was 88%. The rest of the physical examination was unremarkable apart from abdominal striae (steroids use). Her ECG showed normal sinus rhythm with no abnormalities . Echocardiography showed a huge right atrial mass (about 8 × 7 cm), filling the whole cavity of the right atrium and oscillating in and out of the right ventricle through the tricuspid valve . The left ventricle appeared of normal dimensions and systolic function. The right ventricle appeared dilated with impaired systolic function. Laboratory findings showed marked thrombocytopenia (30.000) and severe renal impairment (creatinine 6.1 mg/dl and urea 176 mg/dl). Troponin was positive. Anti-thrombin III, lupus anticoagulant (LA), anti-cardiolipin (IgG, IgM), compliments 3 and 4, and proteins C and S were in the normal range. There was a hypoalbuminemia (albumin 1.9 mg/dl). Lower limb venous Duplex showed old canalized femoral deep venous thrombosis (DVT) with no evidence of acute DVT. Trans-esophageal echocardiography confirmed a huge right atrial mass that was extending from the inferior vena cava (IVC) and appeared to occupy the whole atrium. A small patent foramen ovale was also noticed in the inter-atrial septum . Differential diagnosis of the right atrial mass included thrombus (pulmonary emboli-in-transit), primary and metastatic cardiac tumors (e.g., right atrial myxoma), and vegetations on the tricuspid valve and intracardiac electrodes. The huge size, extension of the mass, and clinical context suggested that it was most probably a huge thrombus. The patient was admitted, IV heparin was initiated, and a heart team discussion was held regarding the best way of management. Urgent cardiac surgery to remove the right atrial mass was proposed as the best option for the patient taking into consideration its large size and risk of distant embolization. However, concerns were raised for the risk of peri-operative bleeding due to thrombocytopenia, the risk of renal failure, and the risk of recurring thrombosis post-operatively.\nA few hours later, while the patient was in the intensive care unit (ICU), the patient arrested in asystole. Cardiopulmonary resuscitation (CPR) was immediately initiated, the patient was intubated, and she was resuscitated after two cycles of cardiopulmonary resuscitation. After the return of spontaneous circulation, she was vitally stable; the blood pressure was 140/90 and heart rate was 110/min. However, ECG showed ST-segment elevation in anterior chest leads and bedside echocardiography showed impaired left ventricle (EF of 40%) with akinetic mid and apical anterior septum and anterior wall, i.e., acute anterior STEMI, mostly due to paradoxical embolism. Recent updates were discussed, and a consensus was reached that surgery, despite the very high risk, will be the best management strategy.\nAs the patient was hemodynamically stable, we transferred her to the cath lab. Coronary angiography showed normal epicardial coronaries with mild haziness at mid segment of LAD artery with mild slow flow in the artery (canalized or dislodged embolus). The rest of the coronaries were normal (Additional file : Movie 3A, 3B). Multislice computed tomography (CT) pulmonary angiography was then performed (to exclude massive pulmonary embolism) and showed normal major pulmonary artery branches with occluded some peripheral pulmonary branches . The inferior vena cava was clear of thrombi. No suspicious abdominal masses were visualized.\nAfter a discussion with the family and explaining the high risk of mortality and morbidity, open-heart surgery was performed to excise the right atrial thrombus. Extra-corporeal membrane oxygenator (ECMO) was used as a support during surgery. At post-operative ICU, she was kept on IV steroids and had three sessions of hemodialysis. After 5 days, ECMO was disconnected and her vital signs stabilized. Two days later, she was extubated. A good urine output was maintained, the acid-base balance was normalized without the need for further dialysis, and creatinine and urea returned to the same levels as pre-operative. The platelets were stable at a level of 70,000. Oral anticoagulation using warfarin was initiated reaching an INR target of 2–3. Post-operative echocardiography showed borderline left ventricle (LV) contractility with regional wall motion abnormalities and mildly impaired right ventricle (RV) contractility with no evidence of mass residual . The patient was discharged on warfarin and oral steroids 3 weeks following surgery.\nShe returned to her daily activities with good functional capacity within 2 months after surgery. She was very happy and grateful to the whole team. She was referred to an immunologist and nephrologist to continue the treatment regimen of her underlying medical conditions.", + "fulltext_subclaims": [ + "The patient is a 19-year-old young lady.", + "She presented to the cardiology clinic with shortness of breath of 3 months duration.", + "Her symptoms were progressive over time.", + "On presentation, she was short of breath on minimal effort.", + "She reported two attacks of hemoptysis, each about a cup of fresh blood.", + "She denied any history of chest pain.", + "She denied any history of palpitations.", + "She denied any history of syncope.", + "She denied any history of lower limb swelling.", + "Six years earlier, she was admitted with generalized anasarca.", + "Six years earlier, she had rapidly deteriorating renal functions.", + "Six years earlier, she had nephrotic range of proteinuria.", + "A renal biopsy showed focal segmental glomerulosclerosis.", + "She had two sessions of hemodialysis.", + "She was kept on immune-suppressive medical therapy.", + "Her renal functions were then stabilized.", + "Two years before presenting to us, she had a purpuric eruption.", + "Two years before presenting to us, she was found to have severe thrombocytopenia.", + "Her platelets reached 10,000.", + "After exclusion of all other possible causes, she was diagnosed with immune thrombocytopenic purpura (ITP).", + "She was kept on steroids.", + "She had a history of previous right femoral deep venous thrombosis 1 year ago.", + "She was anticoagulated using warfarin for 6 months.", + "She denied any history suggestive of an autoimmune disorder.", + "There was no family history of any similar conditions.", + "At the time of presentation, her blood pressure was 110/70.", + "Her heart rate was 100/min.", + "Her resting oxygen saturation was 88%.", + "The rest of the physical examination was unremarkable apart from abdominal striae.", + "Her ECG showed normal sinus rhythm with no abnormalities.", + "Echocardiography showed a huge right atrial mass (about 8 × 7 cm).", + "The mass filled the whole cavity of the right atrium.", + "The mass oscillated in and out of the right ventricle through the tricuspid valve.", + "The left ventricle appeared of normal dimensions.", + "The left ventricle had normal systolic function.", + "The right ventricle appeared dilated.", + "The right ventricle had impaired systolic function.", + "Laboratory findings showed marked thrombocytopenia (30,000).", + "Laboratory findings showed severe renal impairment (creatinine 6.1 mg/dl and urea 176 mg/dl).", + "Troponin was positive.", + "Anti-thrombin III, lupus anticoagulant, anti-cardiolipin, compliments 3 and 4, and proteins C and S were in the normal range.", + "There was hypoalbuminemia (albumin 1.9 mg/dl).", + "Lower limb venous Duplex showed old canalized femoral deep venous thrombosis.", + "Trans-esophageal echocardiography confirmed a huge right atrial mass.", + "The mass extended from the inferior vena cava.", + "The mass occupied the whole atrium.", + "A small patent foramen ovale was noticed in the inter-atrial septum.", + "Differential diagnosis included thrombus (pulmonary emboli-in-transit).", + "Differential diagnosis included primary and metastatic cardiac tumors.", + "Differential diagnosis included right atrial myxoma.", + "Differential diagnosis included vegetations on the tricuspid valve.", + "Differential diagnosis included intracardiac electrodes.", + "The huge size, extension of the mass, and clinical context suggested it was most probably a huge thrombus.", + "The patient was admitted.", + "IV heparin was initiated.", + "A heart team discussion was held regarding the best way of management.", + "Urgent cardiac surgery to remove the right atrial mass was proposed.", + "Concerns were raised for the risk of peri-operative bleeding due to thrombocytopenia.", + "Concerns were raised for the risk of renal failure.", + "Concerns were raised for the risk of recurring thrombosis post-operatively.", + "A few hours later, the patient arrested in asystole.", + "Cardiopulmonary resuscitation was immediately initiated.", + "The patient was intubated.", + "She was resuscitated after two cycles of cardiopulmonary resuscitation.", + "After the return of spontaneous circulation, she was vitally stable.", + "ECG showed ST-segment elevation in anterior chest leads.", + "Bedside echocardiography showed impaired left ventricle (EF of 40%).", + "Bedside echocardiography showed akinetic mid and apical anterior septum and anterior wall.", + "This was acute anterior STEMI, mostly due to paradoxical embolism.", + "A consensus was reached that surgery, despite the very high risk, will be the best management strategy.", + "The patient was transferred to the cath lab.", + "Coronary angiography showed normal epicardial coronaries.", + "Coronary angiography showed mild haziness at mid segment of LAD artery.", + "Coronary angiography showed mild slow flow in the artery.", + "Multislice computed tomography pulmonary angiography showed normal major pulmonary artery branches.", + "Multislice computed tomography showed occluded some peripheral pulmonary branches.", + "The inferior vena cava was clear of thrombi.", + "No suspicious abdominal masses were visualized.", + "Open-heart surgery was performed to excise the right atrial thrombus.", + "Extra-corporeal membrane oxygenator was used as a support during surgery.", + "At post-operative ICU, she was kept on IV steroids.", + "She had three sessions of hemodialysis.", + "After 5 days, ECMO was disconnected.", + "Her vital signs stabilized.", + "Two days later, she was extubated.", + "A good urine output was maintained.", + "The acid-base balance was normalized without the need for further dialysis.", + "Creatinine and urea returned to the same levels as pre-operative.", + "The platelets were stable at a level of 70,000.", + "Oral anticoagulation using warfarin was initiated.", + "The INR target was 2–3.", + "Post-operative echocardiography showed borderline left ventricle contractility.", + "Post-operative echocardiography showed regional wall motion abnormalities.", + "Post-operative echocardiography showed mildly impaired right ventricle contractility.", + "There was no evidence of mass residual.", + "The patient was discharged on warfarin and oral steroids.", + "She returned to her daily activities with good functional capacity within 2 months after surgery.", + "She was referred to an immunologist and nephrologist to continue the treatment regimen of her underlying medical conditions." + ], + "summary": "A 19-year-old young lady presented with progressive shortness of breath, marked renal impairment, thrombocytopenia, and a highly oscillating huge right atrial mass. After she was admitted to the intensive care unit, she arrested in asystole and was resuscitated, and her electrocardiogram (ECG) showed evidence of acute anterior myocardial infarction. Urgent cardiac surgery to remove the right atrial mass was proposed by the heart team as the best option of management. Surgery was emergently performed with extra-corporeal membrane oxygenator (ECMO) as a support. Following surgery, mechanical support and vasopressors were successfully weaned and the patient achieved a good recovery.", + "summary_subclaims": [ + "The patient is a 19-year-old young lady.", + "The patient had progressive shortness of breath.", + "The patient had marked renal impairment.", + "The patient had thrombocytopenia.", + "The patient had a highly oscillating huge right atrial mass.", + "The patient was admitted to the intensive care unit.", + "The patient arrested in asystole.", + "The patient was resuscitated.", + "The electrocardiogram showed evidence of acute anterior myocardial infarction.", + "Urgent cardiac surgery to remove the right atrial mass was proposed by the heart team.", + "Surgery was emergently performed.", + "Extra-corporeal membrane oxygenator (ECMO) was used as a support.", + "Mechanical support and vasopressors were successfully weaned.", + "The patient achieved a good recovery." + ] + }, + { + "id": "multiclinsum_test_449_en.txt", + "fulltext": "A 23-year-old, nulliparous, Chinese woman at 35 weeks gestation, was admitted to the hospital complaining of hematuria accompanied by severe pain in the left abdomen and left subcostal area. She had no past history of urological difficulties until week 26 of pregnancy when she was diagnosed with a spontaneous renal rupture resulting in acute left loin pain and hematuria. She denied any accident or renal problems at that time. Magnetic resonance imaging (MRI) confirmed the diagnosis , and that the fluid around the ruptured left kidney had spread from the superior margin of the 10th thoracic vertebral body to the inferior margin of the second lumbar vertebral body. The patient was admitted to the hospital for observation. The hematuria resolved the day following admission, and she was discharged 1 week after admission when the loin pain decreased and her hemodynamic status was stabilized.\nAt 34 weeks gestation, she presented at the urology clinic with a growing mass in the left subcostal area. Ultrasound showed right renal hydronephrosis without hydroureter. In addition, a cyst was noted to surround the left kidney, and this was measured as 250 × 170 × 233 mm. The cyst was located under the left renal capsule, and the margins were 100 mm from the upper pole, and 60 mm from the lower pole of the left kidney. The medial margin of the cyst was 70 mm away from the medial edge of the left kidney, and 103 mm away from the lateral edge. It was suspected that she had a subcapsular hematoma following renal rupture. At the time, she was more than 33 weeks pregnant, and her laboratory values were normal for kidney function, hematocrit and hemoglobin. She declined further testing of the mass because she was concerned about the side effects on the fetus.\nThe patient came to the Obstetric Department requesting a cesarean section when she was 35 weeks pregnant because she could not bear the severe pain of the increasingly swollen left subcostal mass. She denied nausea, shortness of breath, fever or chills, and there was no vaginal bleeding or uterine contractions. After she was admitted to the obstetrics ward, the fetal heart non-stress test was determined to be reactive. The fetal bi-parietal diameter (BPD) measured by ultrasound was 86 mm, and femoral length. (FL) was 66 mm, which were both consistent with the gestational age. The amniotic fluid index was 95 mm and umbilical arterial S/D was 2.5. The biophysical profile score was 8. Additionally, ultrasound demonstrated signs of maternal hydronephrosis accompanied by a much larger cyst surrounding the left kidney than that observed in the previous ultrasound. Over the past few weeks, this sub-capsular cyst had increased to a size of 319 × 175 × 250 mm.\nPhysical examination revealed the gravid uterus, and obvious swelling over the left abdominal region. A large firm mass with undefined boundary was palpable over the left lumbar region extending to the side of uterus. The left flank and subcostal area had notable tenderness with significant hyperesthesia of the overlying skin. Laboratory evaluation demonstrated a normal white blood cell count and hemoglobin. The urinalysis and kidney function values showed no abnormalities.\nThe patient was known to have had a spontaneous renal rupture and a growing mass in the left subcostal area at week 26 of gestation. The first diagnosis was hematoma or abscess surrounding the left kidney. Because her hemodynamic status was stable without anemia or fever for more than 2 months after the renal rupture, she had been followed using repeat urine analyses, which showed no hematuria. The urologist diagnosed her current condition as perirenal urine extravasation, and it was decided to place a percutaneous nephrostomy tube (PCN) before delivery or during the surgery.\nThe patient requested Cesarean section because the gestational age was 35 weeks, and due to concerns about the progression of the subcostal mass, the surgery was performed. The patient agreed to receive the PCN placement along with the Cesarean section. A male newborn weighing 2580 g with an Apgar score 10/10 at 1 and 5 min was delivered. Following completion of the Cesarean section, the patient’s upper abdominal cavity was explored, and, on the left side, a large retroperitoneal bulging mass was noted with an estimated size of 300 × 200 × 300 mm. The consulting urologist suctioned 5 ml of light yellow fluid from the mass and the sample was sent for creatinine determination. The creatinine level of the sample was 2100 μmol/L and similar to the level in the patient’s urine. A left urinoma as a result of spontaneous renal rupture was then diagnosed, and a total of 4 L of fluid was drained via the PCN. PCN was left in the urinoma to allow for further drainage of urine. After 3 days, a computer tomography (CT) scan was performed to assess the effect of draining the urinoma. The CT revealed that the PCN was properly placed in the cyst, and that the urinoma had decreased in size. The patient was discharged 1 week after the surgery with the PCN in place. She was closely followed by a urologist, and the nephrostomy tube was to be removed when there was no further drainage. Two months postpartum, the CT scan showed the cyst had diminished in size to 50 mm . Six months later, an ultrasound scan was performed and revealed that no perirenal extravasation was present. The urine analysis and renal function tests at that time were normal.", + "fulltext_subclaims": [ + "The patient was a 23-year-old, nulliparous, Chinese woman at 35 weeks gestation.", + "She was admitted to the hospital complaining of hematuria accompanied by severe pain in the left abdomen and left subcostal area.", + "She had no past history of urological difficulties until week 26 of pregnancy.", + "At week 26 of pregnancy, she was diagnosed with a spontaneous renal rupture.", + "The diagnosis was confirmed by magnetic resonance imaging (MRI).", + "The fluid around the ruptured left kidney had spread from the superior margin of the 10th thoracic vertebral body to the inferior margin of the second lumbar vertebral body.", + "The patient was admitted to the hospital for observation.", + "The hematuria resolved the day following admission.", + "She was discharged 1 week after admission.", + "At 34 weeks gestation, she presented at the urology clinic with a growing mass in the left subcostal area.", + "Ultrasound showed right renal hydronephrosis without hydroureter.", + "A cyst was noted to surround the left kidney, measured as 250 × 170 × 233 mm.", + "The cyst was located under the left renal capsule.", + "The margins of the cyst were 100 mm from the upper pole and 60 mm from the lower pole of the left kidney.", + "The medial margin of the cyst was 70 mm away from the medial edge of the left kidney.", + "The lateral margin of the cyst was 103 mm away from the lateral edge of the left kidney.", + "It was suspected that she had a subcapsular hematoma following renal rupture.", + "She was more than 33 weeks pregnant at the time.", + "Her laboratory values were normal for kidney function, hematocrit, and hemoglobin.", + "She declined further testing of the mass because she was concerned about the side effects on the fetus.", + "The patient requested a cesarean section at 35 weeks gestation.", + "She could not bear the severe pain of the increasingly swollen left subcostal mass.", + "She denied nausea, shortness of breath, fever, or chills.", + "There was no vaginal bleeding or uterine contractions.", + "The fetal heart non-stress test was determined to be reactive.", + "The fetal bi-parietal diameter (BPD) measured by ultrasound was 86 mm.", + "The femoral length (FL) was 66 mm.", + "Both the BPD and FL were consistent with the gestational age.", + "The amniotic fluid index was 95 mm.", + "The umbilical arterial S/D was 2.5.", + "The biophysical profile score was 8.", + "Ultrasound demonstrated signs of maternal hydronephrosis.", + "A much larger cyst surrounding the left kidney was observed than that seen in the previous ultrasound.", + "The sub-capsular cyst had increased to a size of 319 × 175 × 250 mm.", + "Physical examination revealed the gravid uterus.", + "A large firm mass with undefined boundary was palpable over the left lumbar region extending to the side of the uterus.", + "The left flank and subcostal area had notable tenderness with significant hyperesthesia of the overlying skin.", + "Laboratory evaluation demonstrated a normal white blood cell count and hemoglobin.", + "The urinalysis and kidney function values showed no abnormalities.", + "The patient was known to have had a spontaneous renal rupture and a growing mass in the left subcostal area at week 26 of gestation.", + "The first diagnosis was hematoma or abscess surrounding the left kidney.", + "Her hemodynamic status was stable without anemia or fever for more than 2 months after the renal rupture.", + "She had been followed using repeat urine analyses, which showed no hematuria.", + "The urologist diagnosed her current condition as perirenal urine extravasation.", + "It was decided to place a percutaneous nephrostomy tube (PCN) before delivery or during the surgery.", + "The patient requested Cesarean section because the gestational age was 35 weeks.", + "The surgery was performed due to concerns about the progression of the subcostal mass.", + "The patient agreed to receive the PCN placement along with the Cesarean section.", + "A male newborn weighing 2580 g with an Apgar score 10/10 at 1 and 5 min was delivered.", + "Following completion of the Cesarean section, the patient’s upper abdominal cavity was explored.", + "On the left side, a large retroperitoneal bulging mass was noted with an estimated size of 300 × 200 × 300 mm.", + "The consulting urologist suctioned 5 ml of light yellow fluid from the mass.", + "The sample was sent for creatinine determination.", + "The creatinine level of the sample was 2100 μmol/L.", + "The level was similar to the level in the patient’s urine.", + "A left urinoma as a result of spontaneous renal rupture was then diagnosed.", + "A total of 4 L of fluid was drained via the PCN.", + "PCN was left in the urinoma to allow for further drainage of urine.", + "After 3 days, a computer tomography (CT) scan was performed to assess the effect of draining the urinoma.", + "The CT revealed that the PCN was properly placed in the cyst.", + "The urinoma had decreased in size.", + "The patient was discharged 1 week after the surgery with the PCN in place.", + "She was closely followed by a urologist.", + "The nephrostomy tube was to be removed when there was no further drainage.", + "Two months postpartum, the CT scan showed the cyst had diminished in size to 50 mm.", + "Six months later, an ultrasound scan was performed.", + "No perirenal extravasation was present.", + "The urine analysis and renal function tests at that time were normal." + ], + "summary": "A 23-year-old primagravida was diagnosed with a spontaneous renal rupture and acute left loin pain accompanied by hematuria when she was 35 weeks pregnant. A sub-capsular perinephric cyst then developed to a size of 319 × 175 × 253 mm, and because of discomfort to the patient, we performed Cesarean section. After a healthy male newborn was delivered, fluid was suctioned from a large perirenal cyst that had an estimated size of 300 × 200 × 300 mm. A percutaneous nephrostomy tube was left in the cyst until CT showed no remaining fluid. In the six-month follow-up, the patient showed no perirenal extravasation according to an ultrasound scan, and the urine analysis and renal function tests were normal.", + "summary_subclaims": [ + "A 23-year-old primagravida was diagnosed with a spontaneous renal rupture when she was 35 weeks pregnant.", + "She had acute left loin pain accompanied by hematuria.", + "A sub-capsular perinephric cyst developed to a size of 319 × 175 × 253 mm.", + "A Cesarean section was performed because of discomfort to the patient.", + "A healthy male newborn was delivered.", + "Fluid was suctioned from a large perirenal cyst estimated to be 300 × 200 × 300 mm.", + "A percutaneous nephrostomy tube was left in the cyst until CT showed no remaining fluid.", + "In the six-month follow-up, the patient showed no perirenal extravasation according to an ultrasound scan.", + "The urine analysis and renal function tests were normal." + ] + }, + { + "id": "multiclinsum_test_767_en.txt", + "fulltext": "A 6-year-old Chinese boy sustained a crush injury in a motor vehicle accident resulting in extensive damage to his right lower limb with comminuted fractures of his right femur and his right tibia-fibula. His right femur was a Gustilo type IIIC fracture with sciatic nerve and femoral artery tears associated with a 9cm bony fragment lost during the trauma . His right tibia-fibula also had severely comminuted, Gustilo type IIIC fractures . He was taken to the operation room 5 hours after injury. A right below-knee amputation was performed on the basis of the major neurovascular damage to the femoral artery, vein and sciatic nerve in his thigh along with the severe soft tissue injury and comminution of his distal tibia-fibula. The amputated specimen was prepared with normal saline irrigation. The distal tibia-fibular osteomuscular flap was then harvested to microsurgically reconstruct the femoral bony defect. Informed consent to perform this procedure and report the case was obtained from the patient and his parents. Due to segmental loss of the femoral artery and vein, the tibia-fibular osteocutaneous flap pedicle was anastomosed with a flow-through artery and vein graft. The posterior tibial artery was anastomosed to the torn femoral artery, and the posterior tibial vein was anastomosed to a superficial vein in the groin area. The femoral vein was grafted using the greater saphenous vein from the amputated specimen. The sciatic nerve was repaired directly using 9–0 nylon end-to-end perineurium repairs. Ankle joint cartilage was removed to increase the contact area for the incorporation of the distal femur-graft. A Hoffmann’s external fixation was applied to keep the same length as the opposite leg and immobilize the fracture . After meticulous debridement, the wound was sutured directly without any skin defect, because adequate skin and soft tissue were provided by the tibia-fibular composite graft. The operation took 6 hours and 40 minutes.\nPostoperatively, the patient was treated with intravenous antibiotics using cefazolin 500mg every 8 hours and gentamicin sulfate 20mg every 8 hours. No anticoagulants were used postoperatively in this patient. Subsequent wound cultures grew Escherichia coli and Streptococcus bovis. On the 7th postoperative day, bone scanning using technetium-labeled methylene diphosphonate was performed which demonstrated positive uptake on both ends of the donor tibia-fibular graft. Because the right leg was not stable enough, no specific physical therapy or temporary prosthesis was used. The wound at the medial and posterior aspect of the right thigh became erythematous and purulent discharge was noted 11 days after the initial operation. Debridement of the necrotic muscle and tissue was performed and the wound was then closed loosely. The antibiotics were changed to cefamandole 250mg every 8 hours and ampicillin 500mg every 6 hours, based on the culture data. The stump of the below-knee amputation also became necrotic and was debrided 26 days after the initial surgery. The skin and wound condition were stabilized thereafter.\nThe patient was discharged 6 weeks after the operation, with the wound clear and the infection under control. Non-weight-bearing crutch walking was started 5 weeks after the surgery and partial-weight-bearing was allowed 2 months later when the patient used 50% weight-bearing with the aid of a below-knee prosthesis. Unfortunately, delayed callous formation at the distal femoral-graft junction and pin tract infection in the distal femur were noted at 4 months after surgery . At that time, a change was made from the Hoffmann’s external skeletal fixation to an internal compression plate supplemented by an autogenous iliac crest bone graft. During the operation, the pin holes of the external fixation device were curetted and the iliac bone graft was put on the distal end of the host-donor bones. The transferred epiphyseal plate of the distal tibia and fibula were removed because there was no length discrepancy of the injured femur at 4 months. The pin tract infection healed 2 weeks after the removal of the Hoffmann’s external skeletal fixation. Over the subsequent 6 months, serial radiographs revealed complete incorporation and gradual remodeling of the vascularized tibia-fibular composite graft in the femur . Walking with full weight-bearing was allowed at 8 months after the surgery. Plate removal was performed 1.5 years after the operation due to chronic irritation from the loosened plate and screws, and for fear that the plate might hinder further remodeling and hypertrophy of the femur. Hypertrophy of the tibial graft, good remodeling of the femoral shaft, and atrophy of the unloaded fibular graft were noted at the 10-year follow up . On the standing scanogram, both the hip and the knee joints were at the same level, and the femurs were of equal length . Clinically, there were symmetrical alignments of both legs. The boy did well with his prosthesis, including all his daily activities. He was able to participate in outdoor activities such as basketball while wearing his prosthesis . The range of motion of the right knee was between 5 and 95 degrees in extension–flexion and that of the right hip was between 0 to 90 degrees in extension–flexion, 40 degrees in abduction, 15 degrees in adduction, 15 degrees in external rotation, and 10 degrees in internal rotation. The repaired sciatic nerve was functioning well, in that there was full strength of hip extension and knee flexion indicating good function of the hamstring muscles and normal sensation at the stump.", + "fulltext_subclaims": [ + "The patient was a 6-year-old Chinese boy.", + "He sustained a crush injury in a motor vehicle accident.", + "He had extensive damage to his right lower limb.", + "He had comminuted fractures of his right femur.", + "He had comminuted fractures of his right tibia-fibula.", + "His right femur was a Gustilo type IIIC fracture.", + "His right femur had sciatic nerve tears associated with a 9cm bony fragment lost during the trauma.", + "His right femur had femoral artery tears associated with a 9cm bony fragment lost during the trauma.", + "His right tibia-fibula had severely comminuted, Gustilo type IIIC fractures.", + "He was taken to the operation room 5 hours after injury.", + "A right below-knee amputation was performed.", + "The amputation was based on major neurovascular damage to the femoral artery, vein, and sciatic nerve in his thigh.", + "The amputation was based on severe soft tissue injury.", + "The amputation was based on comminution of his distal tibia-fibula.", + "The amputated specimen was prepared with normal saline irrigation.", + "The distal tibia-fibular osteomuscular flap was harvested to microsurgically reconstruct the femoral bony defect.", + "Informed consent to perform this procedure and report the case was obtained from the patient and his parents.", + "The tibia-fibular osteocutaneous flap pedicle was anastomosed with a flow-through artery and vein graft.", + "The posterior tibial artery was anastomosed to the torn femoral artery.", + "The posterior tibial vein was anastomosed to a superficial vein in the groin area.", + "The femoral vein was grafted using the greater saphenous vein from the amputated specimen.", + "The sciatic nerve was repaired directly using 9–0 nylon end-to-end perineurium repairs.", + "Ankle joint cartilage was removed to increase the contact area for the incorporation of the distal femur-graft.", + "A Hoffmann’s external fixation was applied to keep the same length as the opposite leg.", + "A Hoffmann’s external fixation was applied to immobilize the fracture.", + "After meticulous debridement, the wound was sutured directly without any skin defect.", + "Adequate skin and soft tissue were provided by the tibia-fibular composite graft.", + "The operation took 6 hours and 40 minutes.", + "Postoperatively, the patient was treated with intravenous antibiotics using cefazolin 500mg every 8 hours.", + "Postoperatively, the patient was treated with intravenous antibiotics using gentamicin sulfate 20mg every 8 hours.", + "No anticoagulants were used postoperatively in this patient.", + "Subsequent wound cultures grew Escherichia coli.", + "Subsequent wound cultures grew Streptococcus bovis.", + "Bone scanning using technetium-labeled methylene diphosphonate was performed on the 7th postoperative day.", + "Bone scanning demonstrated positive uptake on both ends of the donor tibia-fibular graft.", + "The right leg was not stable enough.", + "No specific physical therapy was used.", + "No temporary prosthesis was used.", + "The wound at the medial and posterior aspect of the right thigh became erythematous 11 days after the initial operation.", + "Purulent discharge was noted 11 days after the initial operation.", + "Debridement of the necrotic muscle and tissue was performed.", + "The wound was then closed loosely.", + "The antibiotics were changed to cefamandole 250mg every 8 hours.", + "The antibiotics were changed to ampicillin 500mg every 6 hours.", + "The stump of the below-knee amputation became necrotic.", + "The stump of the below-knee amputation was debrided 26 days after the initial surgery.", + "The skin and wound condition were stabilized thereafter.", + "The patient was discharged 6 weeks after the operation.", + "The wound was clear at discharge.", + "The infection was under control at discharge.", + "Non-weight-bearing crutch walking was started 5 weeks after the surgery.", + "Partial-weight-bearing was allowed 2 months after the surgery.", + "Partial-weight-bearing was allowed when the patient used 50% weight-bearing with the aid of a below-knee prosthesis.", + "Delayed callous formation at the distal femoral-graft junction was noted at 4 months after surgery.", + "Pin tract infection in the distal femur was noted at 4 months after surgery.", + "A change was made from the Hoffmann’s external skeletal fixation to an internal compression plate.", + "The change was supplemented by an autogenous iliac crest bone graft.", + "During the operation, the pin holes of the external fixation device were curetted.", + "The iliac bone graft was put on the distal end of the host-donor bones.", + "The transferred epiphyseal plate of the distal tibia and fibula were removed.", + "There was no length discrepancy of the injured femur at 4 months.", + "The pin tract infection healed 2 weeks after the removal of the Hoffmann’s external skeletal fixation.", + "Serial radiographs revealed complete incorporation and gradual remodeling of the vascularized tibia-fibular composite graft in the femur.", + "Walking with full weight-bearing was allowed at 8 months after the surgery.", + "Plate removal was performed 1.5 years after the operation.", + "Plate removal was due to chronic irritation from the loosened plate and screws.", + "Plate removal was due to fear that the plate might hinder further remodeling and hypertrophy of the femur.", + "Hypertrophy of the tibial graft was noted at the 10-year follow up.", + "Good remodeling of the femoral shaft was noted at the 10-year follow up.", + "Atrophy of the unloaded fibular graft was noted at the 10-year follow up.", + "On the standing scanogram, both the hip and the knee joints were at the same level.", + "On the standing scanogram, the femurs were of equal length.", + "Clinically, there were symmetrical alignments of both legs.", + "The boy did well with his prosthesis, including all his daily activities.", + "He was able to participate in outdoor activities such as basketball while wearing his prosthesis.", + "The range of motion of the right knee was between 5 and 95 degrees in extension–flexion.", + "The range of motion of the right hip was between 0 to 90 degrees in extension–flexion.", + "The range of motion of the right hip was 40 degrees in abduction.", + "The range of motion of the right hip was 15 degrees in adduction.", + "The range of motion of the right hip was 15 degrees in external rotation.", + "The range of motion of the right hip was 10 degrees in internal rotation.", + "The repaired sciatic nerve was functioning well.", + "There was full strength of hip extension indicating good function of the hamstring muscles.", + "There was full strength of knee flexion indicating good function of the hamstring muscles.", + "There was normal sensation at the stump." + ], + "summary": "We present a rare case of using a vascularized tibia-fibular composite graft taken from a 6-year-old Chinese boy's ipsilateral lower leg to reconstruct a large bony defect of his traumatic femur. Hypertrophy of the tibial graft, good remodeling of the femoral shaft, and atrophy of the unloaded fibular graft were noted at the 10-year follow up. He was able to participate in outdoor activities such as basketball while wearing his prosthesis.", + "summary_subclaims": [ + "A 6-year-old Chinese boy had a vascularized tibia-fibular composite graft taken from his ipsilateral lower leg.", + "The graft was used to reconstruct a large bony defect of his traumatic femur.", + "At the 10-year follow up, hypertrophy of the tibial graft was noted.", + "Good remodeling of the femoral shaft was noted at the 10-year follow up.", + "Atrophy of the unloaded fibular graft was noted at the 10-year follow up.", + "He was able to participate in outdoor activities such as basketball while wearing his prosthesis." + ] + }, + { + "id": "multiclinsum_test_622_en.txt", + "fulltext": "A 78-year-old male presented at our hospital in April 2005 with a history of bronchial asthma and pulmonary emphysema first diagnosed at age 66 years. He had been an office worker for 40 years and had never been involved in agriculture. He had therefore had no obvious opportunity for exposure to the citrus pathogen in his work environment or in and around his house. His asthma was of the non-atopic type and moderate, as defined by the Global Initiative for Asthma Guidelines 2002. The patient was an ex-smoker with a Brinkman Index of 1590. He was being treated with inhaled corticosteroids and theophylline. On first presentation in April 2005 to our hospital, he did not have asthma exacerbation or increased sputum production, but his dyspnoea on effort was graded 2 on the Hugh–Jones scale. In April 2005, when the patient was 78 years old, an abnormal shadow representing a cavity was found in the left upper lung on chest X ray at his yearly medical check-up. At the time the patient did not have increased sputum production, but chest computed tomography (CT) revealed a thin-walled cavity about 4 cm across and containing a fungus ball in the left upper lobe (S1 + 2); a CT scan taken 2 years previously had revealed only a small cavity indicative of emphysematous change (Figures a,\nb). There were no inflammatory changes in the peripheral blood (leukocyte count, 7950 cells/μL; C-reactive protein, 0.23 mg/dL; erythrocyte sedimentation rate, 10 mm/h; Aspergillus antigen, negative; β-D glucan, negative), but antigen-specific precipitating antibodies to Aspergillus flavus and P. digitatum were confirmed in the patient’s serum and pleural fluid by Ouchterlony double immunodiffusion testing\n. No A. flavus or P. digitatum and no bacteria or tubercle bacilli were detected in cultures of sputum or bronchial lavage fluids. We diagnosed the patient with lung aspergilloma and treated with itraconazole (100 mg/day) for 3 months. However, the cavity became larger and thicker-walled (Figure c, July 2005), and the patient developed back pain. He was admitted to our hospital on 25 July 2005 and was treated for 3 months with an increased dose of itraconazole (200 mg/day) with added micafungin (300 mg/day). The patient’s vital capacity (VC) of 2.64 L, percentage VC of 85.7%, forced expiratory volume in 1 s (FEV1) of 1.09 L, and percentage FEV1 of 50.9% in August 2005 was lower than his VC of 3.01 L,%VC of 95.6%, FEV1 of 1.12 L,%FEV1 of 49.6% in 2003. The patient was unable to undergo further lung function tests because of his progressive respiratory failure.\nThe cavity continued to enlarge further. Its fluid content increased, and consolidation appeared around it (Figure d, October 2005). The patient’s medication regimen was changed to voriconazole (400 mg/day), amphotericin B (10 mg/day), and fluconazole (400 mg/day), in addition to itraconazole (200 mg/day) and antibacterials. Treatment with this broad range of antimycotics and antibiotics did not slow the growth of the cavity: its fluid content continued to increase, and invasive consolidation and pleural effusion developed (Figure e, December 2005; 1f, January 2006). The pleural effusion increased, and the patient began producing purulent sputum. He died in February 2006 from progressive renal failure. Sputum samples yielded a single fungus, which was isolated repeatedly on potato-dextrose agar in large quantities. It was identified as P. digitatum and had the form of a spreading organism with a mealy, grey-green colour that turned olive green in culture. The abundance of the organism’s elliptical spores was greater in the patient’s sputum culture (Figure ) than in cultured reference colonies\n. This fungus was confirmed to be P. digitatum by molecular identification. Partial sequences of the β-tubulin gene determined by using the primers Bt2a and Bt2b underwent BLAST analysis at the National Centre for Biotechnology Information.\nWe found antigen-specific precipitating antibodies to A. flavus and P. digitatum in the patient’s serum (Figure a) at April 2005.and pleural effusion at November 2005 by using Ouchterlony double immunodiffusion testing with A. flavus and P. digitatum antigens (HollisterStier, Spokane, WA, USA). We confirmed the presence of antigen-specific precipitating antibodies to P digitatum by using antigen derived from the patient’s sputum culture fluid or extracted directly from his sputum (Figure b).\nTo extract the antigen from the sputum culture, we added 1.5 mL of Glass Beads (Biospec Product, OK, USA) to the patient’s sputum and crushed the mixture with a Mini-Beadbeater (Biospec Product, OK, USA). It was then incubated with 0.125 mol of NH4CO3 overnight at 4°C and the antigen extracted after freeze-drying of the filtrate. We diagnosed invasive pulmonary penicilliosis due to P. digitatum.", + "fulltext_subclaims": [ + "The patient was a 78-year-old male.", + "He had a history of bronchial asthma and pulmonary emphysema first diagnosed at age 66 years.", + "He had been an office worker for 40 years.", + "He had never been involved in agriculture.", + "He had no obvious opportunity for exposure to the citrus pathogen in his work environment.", + "His asthma was of the non-atopic type.", + "His asthma was moderate as defined by the Global Initiative for Asthma Guidelines 2002.", + "He was an ex-smoker with a Brinkman Index of 1590.", + "He was being treated with inhaled corticosteroids and theophylline.", + "On first presentation in April 2005, he did not have asthma exacerbation.", + "On first presentation in April 2005, he did not have increased sputum production.", + "His dyspnoea on effort was graded 2 on the Hugh–Jones scale.", + "An abnormal shadow representing a cavity was found in the left upper lung on chest X ray in April 2005.", + "Chest CT revealed a thin-walled cavity about 4 cm across and containing a fungus ball in the left upper lobe.", + "A CT scan taken 2 years previously had revealed only a small cavity indicative of emphysematous change.", + "There were no inflammatory changes in the peripheral blood.", + "Antigen-specific precipitating antibodies to Aspergillus flavus and P. digitatum were confirmed in the patient’s serum and pleural fluid by Ouchterlony double immunodiffusion testing.", + "No A. flavus or P. digitatum were detected in cultures of sputum or bronchial lavage fluids.", + "We diagnosed the patient with lung aspergilloma.", + "He was treated with itraconazole (100 mg/day) for 3 months.", + "The cavity became larger and thicker-walled.", + "The patient developed back pain.", + "He was admitted to our hospital on 25 July 2005.", + "He was treated for 3 months with an increased dose of itraconazole (200 mg/day) with added micafungin (300 mg/day).", + "The patient’s VC of 2.64 L, percentage VC of 85.7%, FEV1 of 1.09 L, and percentage FEV1 of 50.9% in August 2005 was lower than in 2003.", + "The patient was unable to undergo further lung function tests because of his progressive respiratory failure.", + "The cavity continued to enlarge further.", + "Its fluid content increased.", + "Consolidation appeared around it.", + "The patient’s medication regimen was changed to voriconazole (400 mg/day), amphotericin B (10 mg/day), and fluconazole (400 mg/day), in addition to itraconazole (200 mg/day) and antibacterials.", + "Treatment with this broad range of antimycotics and antibiotics did not slow the growth of the cavity.", + "Its fluid content continued to increase.", + "Invasive consolidation and pleural effusion developed.", + "The pleural effusion increased.", + "The patient began producing purulent sputum.", + "He died in February 2006 from progressive renal failure.", + "Sputum samples yielded a single fungus, which was isolated repeatedly on potato-dextrose agar in large quantities.", + "It was identified as P. digitatum.", + "It had the form of a spreading organism with a mealy, grey-green colour that turned olive green in culture.", + "The abundance of the organism’s elliptical spores was greater in the patient’s sputum culture than in cultured reference colonies.", + "This fungus was confirmed to be P. digitatum by molecular identification.", + "Partial sequences of the β-tubulin gene determined by using the primers Bt2a and Bt2b underwent BLAST analysis at the National Centre for Biotechnology Information.", + "We found antigen-specific precipitating antibodies to A. flavus and P. digitatum in the patient’s serum at April 2005.", + "We found antigen-specific precipitating antibodies to A. flavus and P. digitatum in the patient’s pleural effusion at November 2005.", + "We confirmed the presence of antigen-specific precipitating antibodies to P. digitatum by using antigen derived from the patient’s sputum culture fluid or extracted directly from his sputum.", + "To extract the antigen from the sputum culture, we added 1.5 mL of Glass Beads to the patient’s sputum and crushed the mixture with a Mini-Beadbeater.", + "It was then incubated with 0.125 mol of NH4CO3 overnight at 4°C.", + "The antigen was extracted after freeze-drying of the filtrate.", + "We diagnosed invasive pulmonary penicilliosis due to P. digitatum." + ], + "summary": "A cavity was found in the left upper lung on routine chest X-ray in a 78-year-old undernourished male who had been diagnosed at age 66 with bronchial asthma and pulmonary emphysema. No increased sputum production was present. The presence of antigen-specific precipitating antibodies to Aspergillus flavus and P. digitatum was confirmed in the patient's serum and also later pleural fluid by using Ouchterlony double immunodiffusion testing with A. flavus and P. digitatum antigens. The patient was treated over a period of months with itraconazole, micafungin, voriconazole, amphotericin B, and antibacterials. However, the cavity enlarged, the pleural effusion increased, and the patient began producing purulent sputum. He died from progressive renal failure. From sputum culture only one fungus was isolated repeatedly on potato-dextrose agar in large quantities. This fungus was confirmed to be P. digitatum by molecular identification. Partial sequences of the beta-tubulin gene were determined by using the primers Bt2a and Bt2b for PCR amplification and sequencing and underwent a BLAST search at the National Centre for Biotechnology Information, these results confirmed that the isolated fungus was P. digitatum.", + "summary_subclaims": [ + "A cavity was found in the left upper lung on routine chest X-ray in a 78-year-old undernourished male.", + "The patient had been diagnosed at age 66 with bronchial asthma and pulmonary emphysema.", + "No increased sputum production was present.", + "The presence of antigen-specific precipitating antibodies to Aspergillus flavus and P. digitatum was confirmed in the patient's serum.", + "The presence of antigen-specific precipitating antibodies to Aspergillus flavus and P. digitatum was confirmed in the pleural fluid.", + "The patient was treated over a period of months with itraconazole, micafungin, voriconazole, amphotericin B, and antibacterials.", + "The cavity enlarged.", + "The pleural effusion increased.", + "The patient began producing purulent sputum.", + "He died from progressive renal failure.", + "From sputum culture only one fungus was isolated repeatedly on potato-dextrose agar in large quantities.", + "This fungus was confirmed to be P. digitatum by molecular identification.", + "Partial sequences of the beta-tubulin gene were determined by using the primers Bt2a and Bt2b for PCR amplification and sequencing.", + "These results underwent a BLAST search at the National Centre for Biotechnology Information.", + "These results confirmed that the isolated fungus was P. digitatum." + ] + }, + { + "id": "multiclinsum_test_3324_en.txt", + "fulltext": "An 18-year-old Caucasian British male patient presented to the emergency department complaining of sharp, central, pleuritic chest pain that radiated up to the throat and was worse when lying down. At presentation, he was alert, responsive, speaking in full sentences, and without airway compromise or respiratory distress. His respiratory rate was 18 breaths/minute, heart rate 62 beats/minute, blood pressure 133/62 mmHg, temperature 35.7 °C, and saturation of 97% on room air. He occasionally smokes tobacco and vapes. On examination, palpable surgical emphysema was noted on the neck and on chest X-ray. Baseline investigations, including arterial blood gas analysis and electrocardiogram, did not reveal any abnormalities. Troponin levels were within the normal range (3.9 ng/L). A computed tomography of the neck and thorax was then performed, which revealed extensive pneumomediastinum tracking along the cervical, axillary, presternal, and anterior pericardial regions; the lungs were reported as clear, with no lymphadenopathy and no aggressive bony lesions. Following the diagnosis of a pneumomediastinum, the patient was admitted and the search for the cause commenced. On retrospective history-taking, he reported taking five balloons of nitrous oxide in the afternoon, along with other recreational drugs (cocaine and “ecstasy”). Then 6 hours later, he presented with this chest pain. After discussion with a tertiary center, a water-soluble contrast study was performed, which showed no evidence of esophageal perforation. He remained hemodynamically stable throughout his stay in the hospital. Despite awaiting further studies and ongoing medical care, the patient discharged himself against medical advice and was lost to follow-up.", + "fulltext_subclaims": [ + "The patient is an 18-year-old Caucasian British male.", + "He presented with sharp, central, pleuritic chest pain.", + "The chest pain radiated up to the throat.", + "The chest pain was worse when lying down.", + "He was alert and responsive.", + "He was speaking in full sentences.", + "He had no airway compromise.", + "He had no respiratory distress.", + "His respiratory rate was 18 breaths/minute.", + "His heart rate was 62 beats/minute.", + "His blood pressure was 133/62 mmHg.", + "His saturation was 97% on room air.", + "He occasionally smokes tobacco and vapes.", + "Palpable surgical emphysema was noted on the neck.", + "Palpable surgical emphysema was noted on chest X-ray.", + "Baseline arterial blood gas analysis did not reveal any abnormalities.", + "The electrocardiogram did not reveal any abnormalities.", + "Troponin levels were within the normal range.", + "A computed tomography of the neck and thorax was performed.", + "The CT scan revealed extensive pneumomediastinum.", + "The pneumomediastinum tracked along the cervical, axillary, presternal, and anterior pericardial regions.", + "The lungs were reported as clear.", + "There was no lymphadenopathy.", + "There were no aggressive bony lesions.", + "The patient was admitted following the diagnosis of pneumomediastinum.", + "The search for the cause of pneumomediastinum commenced.", + "On retrospective history-taking, he reported taking five balloons of nitrous oxide.", + "He reported taking cocaine and 'ecstasy'.", + "He presented with chest pain 6 hours after taking the drugs.", + "A water-soluble contrast study was performed.", + "The water-soluble contrast study showed no evidence of esophageal perforation.", + "He remained hemodynamically stable.", + "The patient discharged himself against medical advice.", + "The patient was lost to follow-up." + ], + "summary": "An 18-year-old Caucasian British male patient presented to the emergency department complaining of sharp, central, pleuritic chest pain that radiated up to the throat and was worse on lying down. On examination, palpable surgical emphysema was noted on the neck and was noted on chest X-ray. A computed tomography of neck and chest was then performed, which revealed extensive pneumomediastinum tracking along the cervical, axillary, presternal, and anterior pericardial regions. A water-soluble contrast study was performed, which showed no evidence of esophageal perforation.", + "summary_subclaims": [ + "The patient is an 18-year-old Caucasian British male.", + "The patient presented with sharp, central, pleuritic chest pain.", + "The chest pain radiated up to the throat.", + "The chest pain was worse on lying down.", + "Palpable surgical emphysema was noted on the neck.", + "A chest X-ray showed surgical emphysema.", + "A computed tomography of the neck and chest was performed.", + "The CT scan revealed extensive pneumomediastinum.", + "The pneumomediastinum tracked along the cervical, axillary, presternal, and anterior pericardial regions.", + "A water-soluble contrast study was performed.", + "The contrast study showed no evidence of esophageal perforation." + ] + }, + { + "id": "multiclinsum_test_1320_en.txt", + "fulltext": "A four-month-old previously well Sri Lankan male infant from an urban area presented with high grade fever of 102-103 °F of 2 days duration. He had conjunctival redness, bilateral pedal oedema, a scaly rash in the cheeks, and a sand-paper like papular erythematous rash on the trunk and bilateral upper and lower limbs. Both liver and spleen were palpable 2 cm below the costal margin. There was no redness in the tongue and no cervical lymphadenopathy. Other system examinations were normal, except for high blood pressure measured by both manual and electronic methods, which was above the 99th percentile.\nThe initial full blood count showed a total white cell count (WBC) of 18,000/uL with a neutrophil leukocytosis of 53%, a platelet count of 552,000/uL and a haemoglobin of 12 g/dL. C-reactive protein (CRP) was 130 mg/dL and the erythrocyte sedimentation rate (ESR) was 10 mm in the 1st hour. Serum sodium was 134 mmol/L and potassium 5.4 mmol/L. Renal and liver function tests were normal. Covid-19 rapid antigen and PCR tests were negative.\nHe was empirically initiated on intravenous cefotaxime and flucloxacillin based on the local sensitivity patterns, suspecting either a streptococcal or staphylococcal septicaemia. However, blood culture was sterile and high fever spikes continued despite continuous antibiotics. Ultrasound scan abdomen on day four was normal and 2D echocardiogram did not show any coronary artery dilatations. Atypical Kawasaki disease was suspected and intravenous immunoglobulin (IVIG) 2 g/kg was administered on day six, followed by aspirin 80 mg/kg/day in four divided doses. As the response was poor, investigations were repeated. CRP and ESR had risen to 143 mg/dL and 130 mm/1st hour respectively. Cerebrospinal fluid (CSF) showed polymorphs 10/mm3, lymphocytes 43/mm3, red cells 23/mm3 and protein 136 mg/dL. Antibiotics were escalated to intravenous meropenam and vancomycin. CSF culture showed no growth.\nFever spikes continued on day ten and the child developed periungual desquamation in fingers and toes. 2D echocardiogram was repeated which showed dilated coronary arteries (left main coronary artery 5.3 mm, left anterior descending artery 6.5 mm, right coronary artery 5 mm) and a thin pericardial effusion suggestive of KD. A second dose of IVIG 2 g/kg was given and Aspirin dose increased to 100 mg/kg/day. Intravenous Methylprednisolone 30 mg/kg pulse therapy was given for 3 days followed by oral prednisolone. Fever settled for 72 hours, only to recur again. Repeat 2D echocardiogram on day fifteen showed progressive worsening of the coronary dilatation (LMCA 5.7 mm, LAD 9 mm, RCA 6 mm). Electrocardiogram (ECG) showed ST elevations in inferior leads which were persistent on serial ECGs. Cardiac Troponin I levels and Creatine-kinase levels were normal. Clopidogrel and warfarin were added while Aspirin was continued. Oral prazosin and furosemide were added to control the hypertension. His serum electrolytes, renal functions and ultrasound abdomen and kidney-ureter-bladder and renal artery doppler were normal. Extensive investigations in view of aetiology for hypertension such as renal angiogram, urinary and plasma metanephrines, renin-aldosterone levels were not performed as the preliminary investigations were normal and due to limitation of resources in the local setting. His 2D-Echocardiogram did not reveal left ventricular hypertrophy and ophthalmic assessment did not reveal hypertensive retinopathy which confirmed the acute onset of hypertension with the current illness.\nOn day sixteen he developed a vesiculo-papular rash involving face, trunk and distal upper and lower limbs including the periungual regions and the perineum . It progressively evolved into bullous lesions. Biopsy of the rash revealed parakeratosis and neutrophils in the epidermis with broad papillae suggestive of guttate psoriasis . It did not show small or medium vessel vasculitis.\nIntravenous infliximab 5 mg/kg was administered on the 28th day of illness after screening for and excluding tuberculosis, followed by two more doses on the 2nd and 6th week after the initial dose. Fever responded to infliximab within 24 hours and the skin lesions showed gradual improvement. He developed a small joint arthritis involving proximal and middle inter-phalangeal joints of hands and feet on day 40 which showed a diurnal worsening . Oral Methotrexate was added. Repeat 2D echocardiogram on day 60 showed a reduction in the coronary artery diameters, finally indicating a therapeutic response (LMCA 5.3 mm, LAD 6.9 mm, RCA 5 mm). The infant was discharged on day 61 of illness on aspirin, warfarin and prazosin. Oral prednisolone, clopidogrel and methotrexate were gradually tailed off after discharge. Oral prednisolone 2 mg/kg dose was given for 6 weeks followed by gradual taper over a period of 3 months.\nOn follow up, his arthritis and skin rash resolved completely. The hypertension which was present from the beginning of illness settled completely four and a half months from disease onset, enabling discontinuation of anti-hypertensive medications.", + "fulltext_subclaims": [ + "The infant was a four-month-old previously well Sri Lankan male.", + "He had high grade fever of 102-103 °F for 2 days.", + "He had conjunctival redness.", + "He had bilateral pedal oedema.", + "He had a scaly rash in the cheeks.", + "He had a sand-paper like papular erythematous rash on the trunk.", + "He had a sand-paper like papular erythematous rash on the bilateral upper and lower limbs.", + "Both liver and spleen were palpable 2 cm below the costal margin.", + "There was no redness in the tongue.", + "There was no cervical lymphadenopathy.", + "Blood pressure was above the 99th percentile.", + "The initial full blood count showed a total white cell count of 18,000/uL.", + "The initial full blood count showed a neutrophil leukocytosis of 53%.", + "The initial platelet count was 552,000/uL.", + "The initial haemoglobin was 12 g/dL.", + "C-reactive protein was 130 mg/dL.", + "The erythrocyte sedimentation rate was 10 mm in the 1st hour.", + "Serum sodium was 134 mmol/L.", + "Serum potassium was 5.4 mmol/L.", + "Renal and liver function tests were normal.", + "Covid-19 rapid antigen and PCR tests were negative.", + "He was empirically initiated on intravenous cefotaxime.", + "He was empirically initiated on intravenous flucloxacillin.", + "Blood culture was sterile.", + "High fever spikes continued despite continuous antibiotics.", + "Atypical Kawasaki disease was suspected.", + "Intravenous immunoglobulin 2 g/kg was administered on day six.", + "Aspirin 80 mg/kg/day in four divided doses was administered.", + "CRP and ESR had risen to 143 mg/dL and 130 mm/1st hour respectively.", + "Cerebrospinal fluid showed polymorphs 10/mm3.", + "Cerebrospinal fluid showed lymphocytes 43/mm3.", + "Cerebrospinal fluid showed red cells 23/mm3.", + "Cerebrospinal fluid showed protein 136 mg/dL.", + "Antibiotics were escalated to intravenous meropenam.", + "Antibiotics were escalated to intravenous vancomycin.", + "CSF culture showed no growth.", + "The child developed periungual desquamation in fingers and toes.", + "2D echocardiogram showed dilated coronary arteries.", + "2D echocardiogram showed a thin pericardial effusion.", + "A second dose of IVIG 2 g/kg was given.", + "Aspirin dose was increased to 100 mg/kg/day.", + "Intravenous Methylprednisolone 30 mg/kg pulse therapy was given for 3 days.", + "Fever settled for 72 hours, only to recur again.", + "Repeat 2D echocardiogram on day fifteen showed progressive worsening of the coronary dilatation.", + "Electrocardiogram showed ST elevations in inferior leads.", + "Cardiac Troponin I levels were normal.", + "Creatine-kinase levels were normal.", + "Clopidogrel and warfarin were added.", + "Oral prazosin and furosemide were added.", + "Extensive investigations in view of aetiology for hypertension were not performed.", + "2D-Echocardiogram did not reveal left ventricular hypertrophy.", + "Ophthalmic assessment did not reveal hypertensive retinopathy.", + "The infant developed a vesiculo-papular rash involving face, trunk, distal upper and lower limbs, and the perineum.", + "Biopsy of the rash revealed parakeratosis and neutrophils in the epidermis.", + "Biopsy of the rash revealed broad papillae.", + "Biopsy did not show small or medium vessel vasculitis.", + "Intravenous infliximab 5 mg/kg was administered on the 28th day of illness.", + "Fever responded to infliximab within 24 hours.", + "The skin lesions showed gradual improvement.", + "He developed a small joint arthritis involving proximal and middle inter-phalangeal joints of hands and feet.", + "The arthritis showed a diurnal worsening.", + "Repeat 2D echocardiogram on day 60 showed a reduction in the coronary artery diameters.", + "The infant was discharged on day 61 of illness.", + "The infant was discharged on aspirin, warfarin, and prazosin.", + "Oral prednisolone, clopidogrel, and methotrexate were gradually tailed off after discharge.", + "Oral prednisolone 2 mg/kg dose was given for 6 weeks.", + "The hypertension which was present from the beginning of illness settled completely four and a half months from disease onset.", + "The hypertension enabled discontinuation of anti-hypertensive medications." + ], + "summary": "A four-month-old male infant from Sri Lanka presented with high fever, conjunctival redness, pedal oedema and skin rash. He was found to have hypertension since admission with a high white cell count and high inflammatory markers. There was poor response to intravenous antibiotics and subsequent 2D echocardiogram revealed coronary artery aneurysms suggestive of KD. In the third week of illness he developed a vesiculo-papular rash involving face, trunk and limbs - which on biopsy revealed features of guttate psoriasis. Fever spikes continued and the coronary arteries showed progressive dilatation despite timely intravenous immunoglobulin administered on day 6 and methylprednisolone administered on day 10-13. Therapeutic response by means of reduction of fever was seen only after initiation of intravenous infliximab on day 28 of illness for which the fever responded within 24 hours. He developed a small joint arthritis of hands and feet on day 40 of illness which responded only after initiating methotrexate therapy. The hypertension persisted for 4 months after the onset of the illness before complete resolution.", + "summary_subclaims": [ + "A four-month-old male infant from Sri Lanka presented with high fever.", + "The infant had conjunctival redness.", + "The infant had pedal oedema.", + "The infant had a skin rash.", + "The infant was found to have hypertension since admission.", + "The infant had a high white cell count.", + "The infant had high inflammatory markers.", + "The infant had poor response to intravenous antibiotics.", + "A 2D echocardiogram revealed coronary artery aneurysms suggestive of KD.", + "In the third week of illness, the infant developed a vesiculo-papular rash involving face, trunk and limbs.", + "A biopsy of the rash revealed features of guttate psoriasis.", + "Fever spikes continued.", + "The coronary arteries showed progressive dilatation.", + "Intravenous immunoglobulin was administered on day 6.", + "Methylprednisolone was administered on day 10-13.", + "Therapeutic response by means of reduction of fever was seen only after initiation of intravenous infliximab on day 28 of illness.", + "The fever responded within 24 hours after initiation of intravenous infliximab.", + "The infant developed small joint arthritis of hands and feet on day 40 of illness.", + "The arthritis responded only after initiating methotrexate therapy.", + "The hypertension persisted for 4 months after the onset of the illness before complete resolution." + ] + }, + { + "id": "multiclinsum_test_2859_en.txt", + "fulltext": "A 60-year-old Saudi man with a history of diabetes, hypertension, and chronic active hepatitis B, an entrepreneur, married with seven children, who denied tobacco smoking, alcohol consumption, and illicit drug use, was initially seen at our facility and was diagnosed as having Rai stage II CLL in December 2012. His physical examination at presentation revealed a moderately built man. His respiratory and cardiovascular examination was normal. His liver was normal in size but his spleen was palpable (8 cm below the costal margin). He had generalized lymphadenopathy involving his neck, axillae, and bilateral inguinal regions; however, the lymph nodes were 1–3 cm in size. A neurological examination revealed no focal neurological deficit. His serum creatinine at presentation was 72 umol/L, and his blood urea nitrogen (BUN) was 4.3 mmol/L. The results of his liver function test were: aspartate aminotransferase (AST) 22 unit/L, alanine transaminase (ALT) 27 unit/L, total bilirubin 12.1 umol/L, albumin 3.5 g/dL, and alkaline phosphatase of 68 unit/L. His blood count at presentation showed a white blood cell (WBC) count of 28.9 × 109/L, hemoglobin (Hb) level of 13.4 g/dl, a platelet count of 106 × 109/L, and an absolute lymphocyte count (ALC) of 25.1 × 109/L . Peripheral blood flow cytometry revealed 43% of total acquired events co-expressing CD5, CD19, CD23, CD79b, and cytoplasmic CD79a, but lacking surface immunoglobulin light chains, CD10, and CD38. Bone marrow aspirate and biopsy (BMAB) showed hypercellular bone marrow with diffuse intestinal and focal paratrabecular lymphocytic infiltrate. The lymphocytes were mature, small, and positive for CD20, CD79a, PAX-5, CD5, CD23, and BCL2, but negative for cyclin D1 and CD10 . Conventional cytogenetic tests and fluorescence in situ hybridization (FISH) revealed that 27% of analyzed cells displayed rearrangement of the CCND1 gene in chromosome 11 and 15% of cells had trisomy 12, but t(11;14) (q13;q32) was not detected .\nA computed tomography (CT) scan of his neck, chest, abdomen, and pelvis showed hepatomegaly with focal hypodense liver lesions and massive splenomegaly (20.9 × 7.3 cm) . A liver biopsy showed infiltration with small lymphocytic lymphoma (SLL; Fig. ). He remained under surveillance until January 2016, when he developed anemia, thrombocytopenia, and significant constitutional symptoms. He was started on chemoimmunotherapy with fludarabine 25 mg/m2 on days 1–3, cyclophosphamide 250 mg/m2 on days 1–3, and rituximab 375 mg/m2 on day 1 (FCR) for a total of six cycles, until 27 July 2016. His blood counts normalized . And an end-of-therapy CT scan showed resolution of the liver lesions, and significantly reduced lymphadenopathy and splenomegaly.\nOne month after completing FCR therapy, his leukocytosis (mostly neutrophilia) returned, with myeloid left shift. His spleen was palpable 10 cm below the costal margin. His WBC count reached 93 × 109/L, Hb 10.9 g/dl, platelet count 61 × 109/l, absolute neutrophil count 42 × 109/L, and eosinophil count 3 × 109/L. Peripheral blood blasts and basophils were 1% each . BMAB was suboptimal. Conventional cytogenetic analysis using bone marrow showed Philadelphia chromosomes in all examined cells with no other cytogenetic aberrations. FISH analysis revealed presence of the BCR-ABL fusion gene in 100% of cells examined, and quantitative reverse transcription polymerase chain reaction (RT-PCR) of peripheral blood showed a ratio of BCR-ABL/ABL of 21% .\nSince the morphologic findings of both the blood smear and the cytogenetics were compatible with chronic phase CML, he was started on first-generation tyrosine kinase inhibitor (TKI) imatinib at a dose of 400 mg daily. As a result, his complete blood count normalized and his spleen shrank. Although he achieved an appropriate hematologic response within 3 months of imatinib treatment, on 21 March 2017 he demonstrated a suboptimal molecular response with a BCR-ABL/ABL ratio of 17%. Subsequently, he was switched to 300 mg orally administered nilotinib (a second-generation TKI) twice daily. After 3 months of nilotinib treatment, the BCR-ABL/ABL ratio dropped to 0.093%.\nTo screen for hepatocellular carcinoma, an abdominal CT scan was done in March 2017 and it revealed multiple hypoechoic liver lesions . Magnetic resonance imaging of his liver confirmed the presence of at least nine hepatic lesions . Positron emission tomography (PET) showed multiple metabolically active liver lesions . A liver biopsy performed in May 2017 confirmed RT to high-grade B cell lymphoma. After negative tests for c-MYC, the final pathological diagnosis was confirmed as DLBCL . Staging BMAB was morphologically negative for CLL, CML, and DLBCL. FISH analysis on BMAB was negative for CCND1 gene rearrangement, trisomy 12, and BCR-ABL oncogene.\nWhile awaiting c-MYC in situ hybridization he received two cycles of chemoimmunotherapy by infusion consisting of rituximab 375 mg/m2 on day 1, etoposide 50 mg/m2 on days 1–4, prednisone 60 mg/m2 on days 1–5, doxorubicin 10 mg/m2 on days 1-4, Oncovin (vincristine) 0.5 mg/m2 on days 1–4, and cyclophosphamide (R-EPOCH). He was then switched to rituximab 375 mg/m2 on day 1, cyclophosphamide 750 mg/m2 on day 1, doxorubicin 50 mg/m2 on day 1, oncovin (vincristine) 50 mg/m2 on day 1, vincristine 1.4 mg/m2 on day 1, and prednisone 100 mg days 1–5 (R-CHOP); he completed four cycles. Radiological assessment with PET/CT at the end of chemotherapy was consistent with complete metabolic response.\nA donor had been identified in preparation for allogeneic hematopoietic stem cell transplantation, in case our patient’s CML proved resistant to second-line TKI treatment. He was last seen in January 2018, 8 months after his diagnosis with DLBCL with no evidence of lymphoma and his BCR-ABL/ABL ratio dropped to 0.01%.", + "fulltext_subclaims": [ + "The patient is a 60-year-old Saudi man.", + "He has a history of diabetes.", + "He has a history of hypertension.", + "He has chronic active hepatitis B.", + "He is an entrepreneur.", + "He is married with seven children.", + "He denied tobacco smoking.", + "He denied alcohol consumption.", + "He denied illicit drug use.", + "He was diagnosed with Rai stage II CLL in December 2012.", + "His spleen was palpable 8 cm below the costal margin.", + "He had generalized lymphadenopathy involving the neck, axillae, and bilateral inguinal regions.", + "The lymph nodes were 1–3 cm in size.", + "His serum creatinine at presentation was 72 umol/L.", + "His blood urea nitrogen (BUN) was 4.3 mmol/L.", + "His aspartate aminotransferase (AST) was 22 unit/L.", + "His alanine transaminase (ALT) was 27 unit/L.", + "His total bilirubin was 12.1 umol/L.", + "His albumin was 3.5 g/dL.", + "His alkaline phosphatase was 68 unit/L.", + "His white blood cell (WBC) count was 28.9 × 109/L.", + "His hemoglobin (Hb) level was 13.4 g/dl.", + "His platelet count was 106 × 109/L.", + "His absolute lymphocyte count (ALC) was 25.1 × 109/L.", + "Peripheral blood flow cytometry revealed 43% of total acquired events co-expressing CD5, CD19, CD23, CD79b, and cytoplasmic CD79a.", + "The lymphocytes lacked surface immunoglobulin light chains, CD10, and CD38.", + "Bone marrow aspirate and biopsy showed hypercellular bone marrow with diffuse intestinal and focal paratrabecular lymphocytic infiltrate.", + "The lymphocytes were positive for CD20, CD79a, PAX-5, CD5, CD23, and BCL2.", + "The lymphocytes were negative for cyclin D1 and CD10.", + "Conventional cytogenetic tests and FISH revealed 27% of cells with CCND1 gene rearrangement.", + "FISH revealed 15% of cells with trisomy 12.", + "t(11;14) (q13;q32) was not detected.", + "A CT scan showed hepatomegaly with focal hypodense liver lesions.", + "A CT scan showed massive splenomegaly (20.9 × 7.3 cm).", + "A liver biopsy showed infiltration with small lymphocytic lymphoma.", + "He remained under surveillance until January 2016.", + "He developed anemia, thrombocytopenia, and constitutional symptoms.", + "He was started on chemoimmunotherapy with fludarabine, cyclophosphamide, and rituximab (FCR).", + "He received six cycles of FCR until 27 July 2016.", + "His blood counts normalized.", + "An end-of-therapy CT scan showed resolution of the liver lesions.", + "An end-of-therapy CT scan showed significantly reduced lymphadenopathy.", + "An end-of-therapy CT scan showed significantly reduced splenomegaly.", + "One month after completing FCR therapy, his leukocytosis returned.", + "His spleen was palpable 10 cm below the costal margin.", + "His WBC count reached 93 × 109/L.", + "His hemoglobin was 10.9 g/dl.", + "His platelet count was 61 × 109/l.", + "His absolute neutrophil count was 42 × 109/L.", + "His eosinophil count was 3 × 109/L.", + "Peripheral blood blasts were 1%.", + "Peripheral blood basophils were 1%.", + "Bone marrow aspirate and biopsy were suboptimal.", + "Conventional cytogenetic analysis showed Philadelphia chromosomes in all examined cells.", + "FISH analysis revealed presence of the BCR-ABL fusion gene in 100% of cells examined.", + "Quantitative RT-PCR showed a BCR-ABL/ABL ratio of 21%.", + "The morphologic findings were compatible with chronic phase CML.", + "He was started on imatinib at 400 mg daily.", + "His complete blood count normalized.", + "His spleen shrank.", + "He achieved an appropriate hematologic response within 3 months of imatinib treatment.", + "On 21 March 2017, he demonstrated a suboptimal molecular response with a BCR-ABL/ABL ratio of 17%.", + "He was switched to nilotinib at 300 mg twice daily.", + "After 3 months of nilotinib treatment, the BCR-ABL/ABL ratio dropped to 0.093%.", + "An abdominal CT scan in March 2017 revealed multiple hypoechoic liver lesions.", + "Magnetic resonance imaging confirmed at least nine hepatic lesions.", + "PET showed multiple metabolically active liver lesions.", + "A liver biopsy confirmed RT to high-grade B cell lymphoma.", + "Tests for c-MYC were negative.", + "The final pathological diagnosis was DLBCL.", + "Staging BMAB was morphologically negative for CLL, CML, and DLBCL.", + "FISH analysis on BMAB was negative for CCND1 gene rearrangement.", + "FISH analysis on BMAB was negative for trisomy 12.", + "FISH analysis on BMAB was negative for BCR-ABL oncogene.", + "He received two cycles of R-EPOCH chemoimmunotherapy.", + "He received four cycles of R-CHOP chemoimmunotherapy.", + "A donor was identified for allogeneic hematopoietic stem cell transplantation.", + "He was last seen in January 2018.", + "He had no evidence of lymphoma.", + "His BCR-ABL/ABL ratio dropped to 0.01%." + ], + "summary": "A 60-year-old Saudi man known to have diabetes, hypertension, and chronic active hepatitis B was diagnosed as having Rai stage II chronic lymphocytic leukemia, with trisomy 12 and rearrangement of the CCND1 gene in December 2012. He required no therapy until January 2016 when he developed significant anemia, thrombocytopenia, and constitutional symptoms. He received six cycles of fludarabine, cyclophosphamide, and rituximab, after which he achieved complete remission. One month later, he presented with progressive leukocytosis (mostly neutrophilia) and splenomegaly. Fluorescence in situ hybridization from bone marrow aspirate was positive for translocation (9;22) and reverse transcription polymerase chain reaction detected BCR-ABL fusion gene consistent with chronic myeloid leukemia. He had no morphologic or immunophenotypic evidence of chronic lymphocytic leukemia at the time. Imatinib, a first-line tyrosine kinase inhibitor, was started. Eight months later, a screening imaging revealed new liver lesions, which were confirmed to be diffuse large B-cell lymphoma.", + "summary_subclaims": [ + "The patient is a 60-year-old Saudi man.", + "The patient has diabetes.", + "The patient has hypertension.", + "The patient has chronic active hepatitis B.", + "The patient was diagnosed with Rai stage II chronic lymphocytic leukemia.", + "The patient had trisomy 12.", + "The patient had rearrangement of the CCND1 gene.", + "The patient was diagnosed in December 2012.", + "The patient received six cycles of fludarabine, cyclophosphamide, and rituximab.", + "The patient achieved complete remission after the six cycles.", + "One month after remission, the patient presented with progressive leukocytosis.", + "The patient's leukocytosis was mostly neutrophilia.", + "The patient had splenomegaly.", + "Fluorescence in situ hybridization from bone marrow aspirate was positive for translocation (9;22).", + "Reverse transcription polymerase chain reaction detected BCR-ABL fusion gene.", + "The BCR-ABL fusion gene was consistent with chronic myeloid leukemia.", + "The patient had no morphologic evidence of chronic lymphocytic leukemia at the time.", + "The patient had no immunophenotypic evidence of chronic lymphocytic leukemia at the time.", + "Imatinib was started.", + "Imatinib is a first-line tyrosine kinase inhibitor.", + "Eight months after starting imatinib, a screening imaging revealed new liver lesions.", + "The new liver lesions were confirmed to be diffuse large B-cell lymphoma." + ] + }, + { + "id": "multiclinsum_test_1173_en.txt", + "fulltext": "In 2006, a 52-year old female patient was admitted to a neurological department due to sudden difficulties with swallowing and speech, ophthalmoparesis with a vertical and horizontal eye movement disorder, dysesthesia of the hands with a quality of “pins and needles” and a glove-like distribution, as well as generalized areflexia. Muscle strength was normal. A Miller Fisher syndrome was diagnosed. Under treatment with 150 g intravenous immunoglobulins the symptoms completely remitted within a few days. In the following years, the patient consulted the general practitioner and several gastroenterologists because of unspecific abdominal pain, from which she has been suffering since childhood. Diagnostics including computer tomography (CT), magnetic resonance imaging (MRI) and gastroscopy were normal.\nIn October 2017 the meanwhile 63-year old patient was hospitalized with generalized epileptic seizures with prolonged postictal confusion. Cerebral MRI showed no pathological findings, and therapy with levetiracetam was started.\nIn December 2017 the patient was admitted to our clinic for internal medicine because of persisting diarrhea, abdominal pain, renal failure and a reduced general state of health. Again, the patient had generalized epileptic seizures with postictal confusion and significantly reduced vigilance, accompanied from a lactic acidosis (serum-lactate 26.0 mmol/l (reference 0.55–2.2 mmol/l), pH 6.863), leading to admission to the neurological intensive care unit. Moreover, a slight, presumably residual ophthalmoparesis as vertical gaze palsy with conjugate, bilateral limitation of the eye movements in upgaze was evident. The anticonvulsive therapy with levetiracetam (3 g/day) was extended by lacosamide (400 mg/day). A mechanical ventilation was necessary due to the sudden and massive metabolic acidosis as well as a respiratory failure during an epileptic seizure (serum-lactat 14.7; 10.6; 16.0 mmol/l). In CSF, lactate (12.01 mmol/l (reference 1.12–2.47 mmol/l) and protein level (67 mg/dl (reference 15–45 mg/dl) were significantly increased. There were no signs for an infectious origin in CSF (polymerase chain reaction for neurotrophic germs, including Tropheryma whippelii). CT and MRI of the brain as well as abdominal- and thorax-CT were normal. The electroneurography revealed a slight mixed axonal-demyelinating polyneuropathy, the electromyography was normal. Besides a sinus-tachycardia with 140 bpm and a mild pericardial effusion, no signs of a Wolff–Parkinson–White syndrome, that would be common in mitochondriopathies, were present.\nAttempted extubation failed as another severe epileptic seizure occurred with life-threatening lactic acidosis and hyperkalemia (lactate 26.0 mmol/l; pH 6.925; potassium 7.8 mmol/l (referece 3.6–5.2 mmol/l). EEG showed an alpha rhythm, with intermittent slow waves and tendency to generalize. In cerebral follow-up MRI, multiple fat embolies were detected. CT-angiography of the lung revealed a pulmonary embolism. As a reason for the fat embolies, multiple vertebral fractures were verified in CT, presumably as a result of severe epileptic seizures. A surgical fixation of vertebral fractures was performed. Intensive care therapy including ventilation was necessary for more than eight weeks. Weaning was successful after dilatative tracheostomy and nutrition via percutaneous endoscopic gastrostomy (PEG) tube. Vitamin-B6 was supplemented. Subsequently, a rehabilitative therapy was performed. After five months, the patient returned to her normal life. Tracheostomy and PEG were removed.\nTaking into account all the symptoms (abdominal pain, relapsing remitting course, neurological deficits, epileptic seizures, peripheral neuropathy, lactic acidosis, cardiac disturbance), two main differential diagnosis were discussed: porphyria and a mitochondrial disease (MERRF syndrome). None of both diagnoses could be verified: Laboratory test revealed no hints of porphyria (Porphyria Specialist Center of the European Porphyria Network University Hospital Düsseldorf, Germany). A muscle biopsy gave no hint of a mitochondrial disease and revealed only a slight unspecific atrophy that was very likely due to immobility (Institute of Neuropathology of the University Hospital Essen, Germany). In terms of differential diagnosis, other metabolic diseases came into consideration. Comprehensive diagnostic for diseases of copper metabolism, lead poisoning or adrenoleukodystrophy remained inconspicuous. Finally, the analysis of the amino acids in the urine, CSF and serum showed a strong abnormality with ubiquitously increased amino acids, especially proline (proline in serum 3085 μmol/l (reference 90-342 μmol/l), in urine 46,531 μmol/g Crea (reference < 100 μmol/g Crea), in CSF 104 mg/dl (reference < 6 mg/dl), Hydroxyproline in urine 1395 μmol/g Crea (reference <100) Table ). Furthermore, vitamin-B6 was decreased with 3.3 μg/l (reference > 4.9 μg/l). We supplemented vitamin B6 with 200 mg/d.\nTherefore, a hyperprolinemia type I or type II was most likely. The targeted genetic analyses by Sanger sequencing revealed no pathogenic variant within the PRODH-gene (hyperprolinemia type I) but identified two novel variants within the ALDH4A1-gene . In combination, both heterozygous variants within the ALDH4A1 gene could lead to a compound heterozygosity (variants in trans), that would cause the described disease phenotype. Since the patient’s son had only one of the two heterozygous variants of his mother, the compound heterozygous state of both variants in our patient was proven.", + "fulltext_subclaims": [ + "In 2006, a 52-year old female patient was admitted to a neurological department due to sudden difficulties with swallowing and speech.", + "The patient had ophthalmoparesis with a vertical and horizontal eye movement disorder.", + "The patient had dysesthesia of the hands with a quality of 'pins and needles' and a glove-like distribution.", + "The patient had generalized areflexia.", + "Muscle strength was normal.", + "A Miller Fisher syndrome was diagnosed.", + "Under treatment with 150 g intravenous immunoglobulins the symptoms completely remitted within a few days.", + "In the following years, the patient consulted the general practitioner and several gastroenterologists because of unspecific abdominal pain.", + "Diagnostics including computer tomography (CT), magnetic resonance imaging (MRI) and gastroscopy were normal.", + "In October 2017 the meanwhile 63-year old patient was hospitalized with generalized epileptic seizures with prolonged postictal confusion.", + "Cerebral MRI showed no pathological findings.", + "Therapy with levetiracetam was started.", + "In December 2017 the patient was admitted to our clinic for internal medicine because of persisting diarrhea, abdominal pain, renal failure and a reduced general state of health.", + "The patient had generalized epileptic seizures with postictal confusion and significantly reduced vigilance.", + "The patient had a lactic acidosis (serum-lactate 26.0 mmol/l (reference 0.55–2.2 mmol/l), pH 6.863).", + "A mechanical ventilation was necessary due to the sudden and massive metabolic acidosis as well as a respiratory failure during an epileptic seizure.", + "In CSF, lactate (12.01 mmol/l (reference 1.12–2.47 mmol/l) and protein level (67 mg/dl (reference 15–45 mg/dl) were significantly increased.", + "There were no signs for an infectious origin in CSF.", + "CT and MRI of the brain as well as abdominal- and thorax-CT were normal.", + "The electroneurography revealed a slight mixed axonal-demyelinating polyneuropathy.", + "The electromyography was normal.", + "Besides a sinus-tachycardia with 140 bpm and a mild pericardial effusion, no signs of a Wolff–Parkinson–White syndrome were present.", + "Attempted extubation failed as another severe epileptic seizure occurred with life-threatening lactic acidosis and hyperkalemia.", + "EEG showed an alpha rhythm, with intermittent slow waves and tendency to generalize.", + "In cerebral follow-up MRI, multiple fat embolies were detected.", + "CT-angiography of the lung revealed a pulmonary embolism.", + "Multiple vertebral fractures were verified in CT, presumably as a result of severe epileptic seizures.", + "A surgical fixation of vertebral fractures was performed.", + "Intensive care therapy including ventilation was necessary for more than eight weeks.", + "Weaning was successful after dilatative tracheostomy and nutrition via percutaneous endoscopic gastrostomy (PEG) tube.", + "Vitamin-B6 was supplemented.", + "A rehabilitative therapy was performed.", + "After five months, the patient returned to her normal life.", + "Tracheostomy and PEG were removed.", + "Two main differential diagnosis were discussed: porphyria and a mitochondrial disease (MERRF syndrome).", + "None of both diagnoses could be verified.", + "Laboratory test revealed no hints of porphyria.", + "A muscle biopsy gave no hint of a mitochondrial disease.", + "Comprehensive diagnostic for diseases of copper metabolism, lead poisoning or adrenoleukodystrophy remained inconspicuous.", + "The analysis of the amino acids in the urine, CSF and serum showed a strong abnormality with ubiquitously increased amino acids, especially proline.", + "Vitamin-B6 was decreased with 3.3 μg/l.", + "We supplemented vitamin B6 with 200 mg/d.", + "A hyperprolinemia type I or type II was most likely.", + "The targeted genetic analyses by Sanger sequencing revealed no pathogenic variant within the PRODH-gene.", + "The targeted genetic analyses identified two novel variants within the ALDH4A1-gene.", + "In combination, both heterozygous variants within the ALDH4A1 gene could lead to a compound heterozygosity.", + "The compound heterozygous state of both variants in our patient was proven." + ], + "summary": "The 64-years female patient had a long history of abdominal pain, and episode of an acute neuritis. Ten years later she was admitted into the neurological intensive-care-unit with acute abdominal pain, multiple generalized epileptic seizures, a vertical gaze palsy accompanied by extensive lactic acidosis in serum 26.0 mmol/l (reference: 0.55-2.2 mmol/l) and CSF 12.01 mmol/l (reference: 1.12-2.47 mmol/l). Due to repeated epileptic seizures and secondary complications a long-term sedation with a ventilation therapy over 20 days was administered. A diagnostic work-up revealed up to 400-times increased prolin-level in urine CSF and blood. Furthermore, a low vitamin-B6 serum value was found, consistent with a HPII causing secondary pyridoxine deficiency and seizures. The ALDH4A1 gene sequencing confirmed two previously unknown compound heterozygous variants (ALDH4A1 gene (NM_003748.3) Intron 1: c.62 + 1G > A - heterozygous and ALDH4A1 gene (NM_003748.3) Exon 5 c.349G > C, p.(Asp117His) - heterozygous). Under high-dose vitamin-B6 therapy no further seizures occurred.", + "summary_subclaims": [ + "The patient was a 64-years female.", + "The patient had a long history of abdominal pain.", + "The patient had an episode of an acute neuritis.", + "Ten years later she was admitted into the neurological intensive-care-unit.", + "She had acute abdominal pain.", + "She had multiple generalized epileptic seizures.", + "She had a vertical gaze palsy.", + "She had extensive lactic acidosis in serum 26.0 mmol/l.", + "The reference range for serum lactic acid is 0.55-2.2 mmol/l.", + "She had lactic acidosis in CSF 12.01 mmol/l.", + "The reference range for CSF lactic acid is 1.12-2.47 mmol/l.", + "A long-term sedation with ventilation therapy over 20 days was administered.", + "A diagnostic work-up revealed up to 400-times increased prolin-level in urine.", + "A diagnostic work-up revealed up to 400-times increased prolin-level in CSF.", + "A diagnostic work-up revealed up to 400-times increased prolin-level in blood.", + "A low vitamin-B6 serum value was found.", + "The findings were consistent with a HPII causing secondary pyridoxine deficiency and seizures.", + "ALDH4A1 gene sequencing confirmed two previously unknown compound heterozygous variants.", + "The variants were ALDH4A1 gene (NM_003748.3) Intron 1: c.62 + 1G > A - heterozygous.", + "The variants were ALDH4A1 gene (NM_003748.3) Exon 5 c.349G > C, p.(Asp117His) - heterozygous.", + "Under high-dose vitamin-B6 therapy no further seizures occurred." + ] + }, + { + "id": "multiclinsum_test_2611_en.txt", + "fulltext": "Written informed consent for the publication of this article was obtained from the patient prior to submission of the manuscript.\nA 62-year-old female with a past ocular history of conjunctival melanoma in the left eye, which had been treated with topical excision and beta brachytherapy with ruthenium 10 years earlier, was referred to our department for the management of actinic keratopathy. Uncorrected distance visual acuity (UCVA) at presentation was Counting Fingers (CF) at 50 cm. The patient underwent uneventful penetrating keratoplasty, and the 1-month postoperative UCVA was CF at 1 m. Three months postoperatively she presented as an emergency to our department complaining of red painful eye and reduced visual acuity. UCVA had decreased to hand movement (HM). Slit-lamp examination revealed conjunctival injection and a diffuse corneal melting abscess infiltrating the corneal rim . Corneal scraping was performed and sent for microbiologic cultures and analysis. The patient reported professional exposure to plant material, making a fungal infection highly possible. Intensive antibiotic and antifungal therapy was introduced including voriconazole topical and per os, amphotericin B per os, topical moxifloxacine and doxycycline. Cultures confirmed fungal keratitis with Purpureocillium lilacinum (anc. Paecilomyces lilacinus), which was voriconazole-sensitive, and this treatment was subsequently pursued. Despite aggressive medical treatment, corneal melting progressed to the stage of graft perforation. We decided to proceed with a combined repeat PKP and PACK-CXL. The operation was performed under general anesthesia without any intraoperative complication. PACK-CXL was applied intraoperatively on the infected graft. A modified protocol was utilized with riboflavin instillation every 2 min for 15 min followed by UVA irradiation at 9 mW for 10 min. The irradiation zone was set from limbus to limbus to cover an area extending over the donor-recipient junction and the corneoscleral rim, as it seemed that the infection had spread to the recipient rim. PACK-CXL was repeated after placement of the new graft with the same irradiation zone and according to the same parameters for 10 min. Immediate postoperative UCVA was CF at 30 cm. The postoperative period was uneventful, and the graft remained clear thereafter. Nine months postoperatively the patient had regained a UCVA of CF at 1 m. No signs of infection or graft-related complications were noted .", + "fulltext_subclaims": [ + "Written informed consent for the publication of this article was obtained from the patient prior to submission of the manuscript.", + "The patient was a 62-year-old female.", + "The patient had a past ocular history of conjunctival melanoma in the left eye.", + "The conjunctival melanoma had been treated with topical excision and beta brachytherapy with ruthenium 10 years earlier.", + "The patient was referred to the department for the management of actinic keratopathy.", + "Uncorrected distance visual acuity at presentation was Counting Fingers at 50 cm.", + "The patient underwent uneventful penetrating keratoplasty.", + "The 1-month postoperative uncorrected distance visual acuity was Counting Fingers at 1 m.", + "Three months postoperatively, the patient presented as an emergency with a red painful eye and reduced visual acuity.", + "Uncorrected distance visual acuity had decreased to hand movement.", + "Slit-lamp examination revealed conjunctival injection.", + "Slit-lamp examination revealed a diffuse corneal melting abscess infiltrating the corneal rim.", + "Corneal scraping was performed and sent for microbiologic cultures and analysis.", + "The patient reported professional exposure to plant material.", + "A fungal infection was considered highly possible.", + "Intensive antibiotic and antifungal therapy was introduced.", + "The treatment included voriconazole topical and per os.", + "The treatment included amphotericin B per os.", + "The treatment included topical moxifloxacin and doxycycline.", + "Cultures confirmed fungal keratitis with Purpureocillium lilacinum.", + "The infection was voriconazole-sensitive.", + "Corneal melting progressed to the stage of graft perforation.", + "A combined repeat PKP and PACK-CXL was decided.", + "The operation was performed under general anesthesia.", + "The operation was performed without any intraoperative complication.", + "PACK-CXL was applied intraoperatively on the infected graft.", + "A modified protocol was utilized with riboflavin instillation every 2 min for 15 min.", + "UVA irradiation was performed at 9 mW for 10 min.", + "The irradiation zone was set from limbus to limbus.", + "The irradiation zone extended over the donor-recipient junction and the corneoscleral rim.", + "PACK-CXL was repeated after placement of the new graft.", + "The same irradiation zone and parameters were used for the second PACK-CXL.", + "Immediate postoperative uncorrected distance visual acuity was Counting Fingers at 30 cm.", + "The postoperative period was uneventful.", + "The graft remained clear after the operation.", + "Nine months postoperatively, the patient had regained a UCVA of Counting Fingers at 1 m.", + "No signs of infection were noted nine months postoperatively.", + "No signs of graft-related complications were noted nine months postoperatively." + ], + "summary": "A 62-year-old female underwent uneventful PKP for the management of post-irradiation actinic keratopathy. Three months postoperatively, she presented with a diffuse corneal melting abscess that was infiltrating the donor-recipient junction. Despite intensive antibiotic and antifungal therapy, corneal melting progressed to graft perforation. A repeat PKP combined with intraoperative PACK-CXL was performed. PACK-CXL was applied initially on the infected graft, involving the corneoscleral rim and then following placement of the donor button. No intra- or postoperative graft-related complications were encountered. No signs of infection were noted, and the graft remained clear during the 9-month follow-up period.", + "summary_subclaims": [ + "The patient was a 62-year-old female.", + "She underwent uneventful PKP for the management of post-irradiation actinic keratopathy.", + "Three months postoperatively, she presented with a diffuse corneal melting abscess.", + "The abscess was infiltrating the donor-recipient junction.", + "Despite intensive antibiotic and antifungal therapy, corneal melting progressed to graft perforation.", + "A repeat PKP combined with intraoperative PACK-CXL was performed.", + "PACK-CXL was applied initially on the infected graft.", + "PACK-CXL involved the corneoscleral rim.", + "PACK-CXL was applied following placement of the donor button.", + "No intra- or postoperative graft-related complications were encountered.", + "No signs of infection were noted.", + "The graft remained clear during the 9-month follow-up period." + ] + }, + { + "id": "multiclinsum_test_365_en.txt", + "fulltext": "A 60-year-old postmenopausal woman presented with lump in lower abdomen of 2 months duration. Abdominal examination revealed a large, irregular, firm supra-pubic mass. On pelvic examination, the same mass was felt in the vagina. Cervix and uterus were not felt separately from the mass. Computed tomography (CT) scan showed a large, well defined heterogeneous abdomino-pelvic mass. Serum CA-125 level was 52.3 U/mL. Exploratory laparotomy was performed, which revealed a large, bosselated mass arising from the cervix. Body of the uterus, bilateral ovaries, tubes and other abdomino-pelvic organs were within normal limits. Total abdominal hysterectomy with bilateral salpingo-oophorectomy with complete excision of the mass was done after identifying the ureters from pelvic brim to their entry into the urinary bladder. Her postoperative recovery was uneventful.\nThe patient was kept under close observation after initial treatment. Four months after surgery, on routine follow-up, vaginal cytology showed the malignant squamous component of MMMT. The recurrence was confirmed by colposcopy-guided biopsy from the vaginal vault. Physical examination and CT-scan did not reveal any evidence of disease elsewhere. This recurrence was treated with radical pelvic radiotherapy (RT) (external pelvic RT 60 Gy in 30 fractions plus 2 intracavitary applications of 6 Gy each). The patient is free of disease at eighteen months after the treatment of recurrence.\nGross examination of the surgical specimen revealed a 28 × 20 × 15 cm bosselated, mass arising from the cervix. The cervical canal was distorted because of the mass. On cut surface, the mass was fleshy, solid with cystic areas.\nOn hematomylin and eosin staining, the entire tumor showed cellular whorls dispersed amidst pale sarcomatous stroma. The cells in whorls were round to short spindle shaped and had moderate mitotic activity . Although no vessels were seen in the center of these whorls, the whorled appearance was reminiscent of an endometrial stromal sarcoma. Hence, the preliminary diagnosis of endometrial stromal sarcoma (ESS) was made. Additional sections however revealed that whorled areas had basaloid squamous carcinoma in the center . A panel of immunohistochemical tests was performed and whorled basaloid areas were positive for cytokeratin , epithelial membrane antigen and CD 10 but were negative for vimentin confirming their epithelial nature. The stromal component of the tumor was highlighted on vimentin stain . The stromal element was sarcomatous and showed diffuse vimentin and focal SMA positivity. SMA, S-100, calponin, inhibin, Mic-2, desmin and myoglobin were negative in the basaloid islands. No heterologous elements were seen. The final diagnosis was homologous malignant mixed mullerian tumor with basaloid squamous carcinoma.", + "fulltext_subclaims": [ + "The patient was a 60-year-old postmenopausal woman.", + "She presented with a lump in the lower abdomen of 2 months duration.", + "Abdominal examination revealed a large, irregular, firm supra-pubic mass.", + "On pelvic examination, the same mass was felt in the vagina.", + "Cervix and uterus were not felt separately from the mass.", + "Computed tomography (CT) scan showed a large, well defined heterogeneous abdomino-pelvic mass.", + "Serum CA-125 level was 52.3 U/mL.", + "Exploratory laparotomy was performed.", + "The mass was found to arise from the cervix.", + "The body of the uterus, bilateral ovaries, tubes, and other abdomino-pelvic organs were within normal limits.", + "Total abdominal hysterectomy with bilateral salpingo-oophorectomy with complete excision of the mass was done.", + "The ureters were identified from the pelvic brim to their entry into the urinary bladder.", + "Her postoperative recovery was uneventful.", + "Four months after surgery, vaginal cytology showed the malignant squamous component of MMMT.", + "The recurrence was confirmed by colposcopy-guided biopsy from the vaginal vault.", + "Physical examination and CT-scan did not reveal any evidence of disease elsewhere.", + "The recurrence was treated with radical pelvic radiotherapy.", + "The patient is free of disease at eighteen months after the treatment of recurrence.", + "Gross examination of the surgical specimen revealed a 28 × 20 × 15 cm bosselated mass arising from the cervix.", + "The cervical canal was distorted because of the mass.", + "On cut surface, the mass was fleshy, solid with cystic areas.", + "On hematoxylin and eosin staining, the entire tumor showed cellular whorls dispersed amidst pale sarcomatous stroma.", + "The cells in whorls were round to short spindle shaped and had moderate mitotic activity.", + "No vessels were seen in the center of these whorls.", + "The whorled appearance was reminiscent of an endometrial stromal sarcoma.", + "The preliminary diagnosis of endometrial stromal sarcoma (ESS) was made.", + "Additional sections revealed that whorled areas had basaloid squamous carcinoma in the center.", + "The whorled basaloid areas were positive for cytokeratin, epithelial membrane antigen, and CD 10.", + "The whorled basaloid areas were negative for vimentin.", + "The stromal component of the tumor was highlighted on vimentin stain.", + "The stromal element was sarcomatous and showed diffuse vimentin and focal SMA positivity.", + "SMA, S-100, calponin, inhibin, Mic-2, desmin, and myoglobin were negative in the basaloid islands.", + "No heterologous elements were seen.", + "The final diagnosis was homologous malignant mixed mullerian tumor with basaloid squamous carcinoma." + ], + "summary": "We report the clinical, pathological and immunohistochemical profile and diagnostic difficulties in a case of giant MMMT of the cervix in a postmenopausal woman who presented with a large cervical mass. On microscopic examination, initially tumor appeared to be endometrial stromal sarcoma, however, immunohistochemical examination revealed the biphasic nature of the tumor. The malignant epithelial component was basaloid squamous carcinoma with homologous sarcomatous component. The patient was treated with surgery. However, she experienced vaginal vault recurrence four months after the initial treatment, which was successfully treated with pelvic radiotherapy.", + "summary_subclaims": [ + "The patient was a postmenopausal woman.", + "The patient presented with a large cervical mass.", + "The tumor initially appeared to be endometrial stromal sarcoma on microscopic examination.", + "Immunohistochemical examination revealed the biphasic nature of the tumor.", + "The malignant epithelial component was basaloid squamous carcinoma.", + "The tumor had a homologous sarcomatous component.", + "The patient was treated with surgery.", + "The patient experienced vaginal vault recurrence four months after the initial treatment.", + "The recurrence was successfully treated with pelvic radiotherapy." + ] + }, + { + "id": "multiclinsum_test_1438_en.txt", + "fulltext": "A 44-year-old female presented with progressive abdominal distension especially after eating, accompanied by anorexia, fatigue and vomiting, was admitted to our hospital. MRI of the upper abdomen revealed an irregular huge cystic-solid mass which located in both Segments V-VI and VII-VIII of the liver. The largest size of each section was approximately 12 cm × 9 cm (S VII-VIII) and 11 cm × 8 cm (S V-VI). The mass consisted of dense calcification, fat and soft tissue, poorly demarcated from the adjacent peritoneum, suggesting the possibility of malignant teratoma. No abnormalities were found during the examination of the uterus and bilateral adnexa. For serum tumor markers, carcinoma embryonic antigen (CEA) and β-human chorionic gonadotropin (β-HCG) levels were normal, but AFP level was elevated to 476 ng/ml (the normal range: 0–20 ng/ml). Then, biopsy specimens were obtained and immature neuroectodermal-like structure was observed , which showed positive staining for spalt like transcription factor 4 (SALL4, Clone#6E3, ZSGB-BIO) and negative for glial fibrillary acidic protein (GFAP, Clone#GA5, Vision BiosytemsTM) . Also, Ki-67 (Clone#MRX002, MXB Biotechnologies) staining showed high proliferative index . Therefore, the tumor was diagnosed as immature teratoma, which was not further graded because of the limited tissues.\nAfter exclusion of chemotherapy contraindication, a systemic chemotherapy was delivered associating etoposide (75 mg/m2), with ifosfamide (1.2 g/m2) and cisplatin (20 mg/m2) each day, day 1 to day 4, every 3 weeks. After four cycles, MRI of the upper abdomen showed tumor survival and the size of tumor increased to 14 cm × 11 cm (S VII-VIII) and 13 cm × 12 cm (S V-VI) . However, the serum AFP level was nearly normal.\nFor further treatment, right hepatectomy, cholecystectomy and partial diaphragmectomy and diaphragmatic repair were performed. During the surgery, the tumor was found to protrude from the liver surface and adhere to the diaphragm, omentum, transverse colon, stomach and duodenum. The tumor size was about 28 cm × 17 cm × 15 cm, and it invaded the abdominal wall and part of the diaphragm. No metastatic tumor was detected in other parts of the abdominal cavity.\nMacroscopically, the resected liver measured 30 cm × 24 cm × 13 cm. Cut sections of the liver revealed a solitary, round and cystic-solid mass with grayish or grey-yellow color, which sized 28 cm × 14 cm × 13 cm. The tumor was well-circumscribed but unencapsulated, adjacent to the liver capsule and about 2.5 cm distant from surgical margin.\nThe section was cystic and solid, showing multiple cystic cavities with different sizes (about 2–10 cm in diameter). The inner wall of the cyst was smooth, and the cavity was filled with jelly-like viscous liquid. For the solid areas, hard bone-like tissues, tender brain-like tissues, and multitudes of fat were visible .\nOn histologic examination, the tumor contained multiple mature types of tissues derived from three germ layers. Ectodermal derivatives including squamous epithelium, sebaceous glands, eccrine glands and hair follicle could be seen . Also, abundant mature brain tissues such as glia and choroid can be observed . In some areas, these cells were sheet arranged, with layers and polarities, but without significant cellular atypia and neural tube formation . On immunohistochemical staining, those densely cellular regions demonstrated positive for GFAP but negative for SALL-4, and Ki-67 index was low . Moreover, intestinal epithelia and respiratory ciliated epithelium (endoderm), mature cartilage and adipose tissue (mesoderm) could also be observed . The tumor was cut open along its long axis and extensively sampled, and no immature component was found. GTS was diagnosed finally.\nThen the patient continued to receive 2 courses of chemotherapy, with the same type and dose of medications as before. However, after 2 months, a CT scan showed multiple small nodules in the bilateral adnexa, suggesting new-onset lesions . Subsequently, the patient underwent the second surgery to resect total uterus and bilateral adnexa. Multiple nodules (0.5-2 cm in diameter) were found on the surface of the ovary, the front of the rectum, and the pelvis on both sides at surgery. Histologically, a large amount of mature glial was observed, while no immature components such as neural tube existed with all tissues sampled. Based on clinical history, GP should be considered.\nA brief flow chart of clinical diagnosis and treatment was shown in Fig. . The patient was still in follow-up at the outpatient clinic and in good condition .", + "fulltext_subclaims": [ + "A 44-year-old female presented with progressive abdominal distension especially after eating.", + "The patient had anorexia, fatigue, and vomiting.", + "MRI of the upper abdomen revealed an irregular huge cystic-solid mass located in both Segments V-VI and VII-VIII of the liver.", + "The largest size of each section was approximately 12 cm × 9 cm (S VII-VIII) and 11 cm × 8 cm (S V-VI).", + "The mass consisted of dense calcification, fat, and soft tissue.", + "The mass was poorly demarcated from the adjacent peritoneum.", + "The mass suggested the possibility of malignant teratoma.", + "No abnormalities were found during the examination of the uterus and bilateral adnexa.", + "Carcinoma embryonic antigen (CEA) and β-human chorionic gonadotropin (β-HCG) levels were normal.", + "AFP level was elevated to 476 ng/ml.", + "Biopsy specimens showed immature neuroectodermal-like structure.", + "The immature neuroectodermal-like structure showed positive staining for spalt like transcription factor 4 (SALL4, Clone#6E3, ZSGB-BIO).", + "The immature neuroectodermal-like structure showed negative staining for glial fibrillary acidic protein (GFAP, Clone#GA5, Vision BiosytemsTM).", + "Ki-67 staining showed high proliferative index.", + "The tumor was diagnosed as immature teratoma.", + "The tumor was not further graded because of the limited tissues.", + "Systemic chemotherapy was delivered associating etoposide, ifosfamide, and cisplatin.", + "After four cycles of chemotherapy, MRI showed tumor survival.", + "The size of the tumor increased to 14 cm × 11 cm (S VII-VIII) and 13 cm × 12 cm (S V-VI).", + "The serum AFP level was nearly normal.", + "Right hepatectomy, cholecystectomy, and partial diaphragmectomy and diaphragmatic repair were performed.", + "The tumor was found to protrude from the liver surface and adhere to the diaphragm, omentum, transverse colon, stomach, and duodenum.", + "The tumor size was about 28 cm × 17 cm × 15 cm.", + "The tumor invaded the abdominal wall and part of the diaphragm.", + "No metastatic tumor was detected in other parts of the abdominal cavity.", + "The resected liver measured 30 cm × 24 cm × 13 cm.", + "Cut sections of the liver revealed a solitary, round and cystic-solid mass with grayish or grey-yellow color, which sized 28 cm × 14 cm × 13 cm.", + "The tumor was well-circumscribed but unencapsulated.", + "The tumor was about 2.5 cm distant from surgical margin.", + "The section was cystic and solid, showing multiple cystic cavities with different sizes.", + "The inner wall of the cyst was smooth, and the cavity was filled with jelly-like viscous liquid.", + "The solid areas showed hard bone-like tissues, tender brain-like tissues, and multitudes of fat.", + "The tumor contained multiple mature types of tissues derived from three germ layers.", + "Ectodermal derivatives including squamous epithelium, sebaceous glands, eccrine glands, and hair follicle could be seen.", + "Abundant mature brain tissues such as glia and choroid could be observed.", + "In some areas, these cells were sheet arranged, with layers and polarities, but without significant cellular atypia and neural tube formation.", + "On immunohistochemical staining, those densely cellular regions demonstrated positive for GFAP but negative for SALL-4.", + "Ki-67 index was low.", + "Intestinal epithelia and respiratory ciliated epithelium could also be observed.", + "Mature cartilage and adipose tissue could also be observed.", + "The tumor was cut open along its long axis and extensively sampled.", + "No immature component was found.", + "GTS was diagnosed finally.", + "The patient continued to receive 2 courses of chemotherapy.", + "A CT scan showed multiple small nodules in the bilateral adnexa, suggesting new-onset lesions.", + "The patient underwent the second surgery to resect total uterus and bilateral adnexa.", + "Multiple nodules (0.5-2 cm in diameter) were found on the surface of the ovary, the front of the rectum, and the pelvis on both sides.", + "Histologically, a large amount of mature glial was observed.", + "No immature components such as neural tube existed with all tissues sampled.", + "Based on clinical history, GP should be considered.", + "The patient was still in follow-up at the outpatient clinic.", + "The patient was in good condition." + ], + "summary": "Here, we report a case of a 44-year-old female presenting with progressive abdominal distension and elevated serum alpha fetal protein (AFP) level. CT/MRI scans revealed a large cystic-solid mass in the right lobe of the liver, accompanied with implant or metastasis in the abdominal cavity. Pathologic examination at biopsy suggested immature teratoma. After 4 cycles of chemotherapy, an MRI showed a slight increase in tumor size. Therefore, surgical resection of the right lobe of the liver was performed. The final histological diagnosis was a mature teratoma (tumor size 28 cm × 14 cm × 13 cm), with no residual immature component, and the diagnosis of GTS was considered. The patient continued to receive 2 courses of postoperative chemotherapy. An abdominal CT scan revealed innumerable miliary nodules in bilateral adnexal areas 2 months after surgery. Histologically, large numbers of mature glia were observed, supporting the diagnosis of GP.", + "summary_subclaims": [ + "The patient was a 44-year-old female.", + "She had progressive abdominal distension.", + "Her serum alpha fetal protein level was elevated.", + "CT/MRI scans revealed a large cystic-solid mass in the right lobe of the liver.", + "The scans showed implant or metastasis in the abdominal cavity.", + "Pathologic examination at biopsy suggested immature teratoma.", + "After 4 cycles of chemotherapy, an MRI showed a slight increase in tumor size.", + "Surgical resection of the right lobe of the liver was performed.", + "The final histological diagnosis was a mature teratoma.", + "The tumor size was 28 cm × 14 cm × 13 cm.", + "There was no residual immature component.", + "The diagnosis of GTS was considered.", + "The patient continued to receive 2 courses of postoperative chemotherapy.", + "An abdominal CT scan revealed innumerable miliary nodules in bilateral adnexal areas 2 months after surgery.", + "Histologically, large numbers of mature glia were observed.", + "The diagnosis of GP was supported." + ] + }, + { + "id": "multiclinsum_test_2698_en.txt", + "fulltext": "A 22-year-old Caucasian female with a remote history of transverse myelitis presented with 3 years of worsening midline low back pain. The episode of transverse myelitis occurred 8 years prior to presentation . At that time, she suffered paraplegia, bowel and bladder incontinence, complete sensory loss localized to the T8 level, diffuse pains and paresthesia in the upper extremities, and low back pain below the sensory level. One and a half years after the initial episode of TM, the patient reported a pain burden score (PBS) in her low back below the sensory level of 22/28. She also reported loss of function and inability to do transfers, indicating worsening quality of life.\nDue to worsening lower back pain, loss of function, and development of neuromuscular scoliosis secondary to TM, the patient decided to undergo posterior spinal fusion T3 through pelvis. Preoperatively, in addition to low back PBS score of 22/28, her lower extremity physical exam was notable for complete paraplegia with wheelchair bound status and inability to ambulate, atrophy and edema in all muscles in the lower extremities, a sensory level of T10 on the right and T8 on the left, with only some patchy sensation to pressure evident over her left thigh but otherwise no neuropathic pain or other sensation in the lower extremities bilaterally, and absence of lower extremity reflexes. She underwent surgery of posterior spinal fusion T3 through pelvis which was complicated by wound infection and subsequent incision and debridement. She was discharged following a 60-day hospital stay, and 6 months postoperative the patient reported improved low back pain with PBS 13/28 and unchanged motor and sensory exams in the lower extremities. At this time, she also reported improved mood and ability to conduct activities of daily living, indicating improved quality of life compared with prior to surgery. Unfortunately, at 1.5 years post spinal fusion T3-pelvis, the patient presented to clinic with worsening lumbar back pain and PBS increased to 22/28, worsened with prolonged sitting. Bilateral loosening of the pelvic fixation screws were demonstrated on imaging and deemed to be the cause of the patient’s pain as a result of increased load at the L4–S1 levels. She underwent revision of the pelvic fixation, which improved her PBS to 18/28. The postoperative course was complicated by a new MRSA infection at the incision site and recurrent wound dehiscence, leading to seven incision and drainage treatments over a 6-month duration. The patient then underwent removal of segmental instrumentation T3-pelvis, which initially improved back pain to PBS score 12/28. The patient’s quality of life had clearly increased, as she reported doing remarkably well with increased mobility. Additionally, her mother reported the patient was more functionally active than she had been in a year. Unfortunately, her low back pain continued to progressively worsen over the next 3 years, with lower back pain increasing to PBS score 15/28, at which point she approached our team to consider redo L4–S1 decompression and fusion.\nMagnetic resonance imagaing (MRI) of the lumbar spine demonstrated severe central spinal stenosis at L4–5 and L5–S1 due to facet and ligamentum flavum hypertrophy . Flexion–extension X-ray of the lumbar spine demonstrated axial distraction of the posterior edges of the vertebral bodies at L4–5 and L5–S1 on flexion with alignment improving on extension .\nGiven her worsening pain with evidence of lumbar spinal stenosis and instability, she underwent redo L4–S1 decompression and fusion. She underwent L4 and L5 laminectomies with bilateral L4–L5 medial facetectomies and foraminotomies and posterior lateral lumbosacral fusion with bilateral pedicle screws at L4, L5, and S1. She tolerated the procedure well and endorsed improved pain compared with prior to surgery. She was discharged to home on postoperative day 3.\nOn postoperative day 16, she presented with fever, chills, tachycardia, and return of her midline low back pain. MRI demonstrated a surgical site infection with severe compression of the lower lumbar thecal sac . Of note, the patient reported severe midline low back pain similar to what she experienced prior to surgery, identifying this as a separate pain from her postoperative soreness.\nThe patient underwent lumbar wound washout with significant improvement in low back pain. During her convalescence, she experienced incisional pain but reported significant improvement in her deeper, chronic pain, with an increased ability to perform transfers.\nAt 1 year postoperative, the patient’s chronic low back pain remained improved compared with preoperative baseline. The pain was described as “moderate” and “not as severe as preoperative back pain”. The patient reported doing well, with improved ability to bend and overall mobility. Follow-up MRI demonstrated decompression at L4–L5. Imaging also demonstrated increased spondylosis at L5–S1 . Repeat decompression at L5–S1 with revised fusion at this level was offered, but the patient ultimately decided not to proceed with surgery as her back pain was no longer severe.", + "fulltext_subclaims": [ + "The patient is a 22-year-old Caucasian female.", + "She has a remote history of transverse myelitis.", + "The episode of transverse myelitis occurred 8 years prior to presentation.", + "At that time, she suffered paraplegia.", + "At that time, she had bowel and bladder incontinence.", + "At that time, she had complete sensory loss localized to the T8 level.", + "At that time, she had diffuse pains and paresthesia in the upper extremities.", + "At that time, she had low back pain below the sensory level.", + "One and a half years after the initial episode of TM, the patient reported a pain burden score (PBS) in her low back below the sensory level of 22/28.", + "She reported loss of function and inability to do transfers.", + "She reported worsening quality of life.", + "The patient decided to undergo posterior spinal fusion T3 through pelvis.", + "Preoperatively, her lower extremity physical exam was notable for complete paraplegia with wheelchair bound status and inability to ambulate.", + "Preoperatively, she had atrophy and edema in all muscles in the lower extremities.", + "Preoperatively, she had a sensory level of T10 on the right and T8 on the left.", + "Preoperatively, she had only some patchy sensation to pressure evident over her left thigh.", + "Preoperatively, she had no neuropathic pain or other sensation in the lower extremities bilaterally.", + "Preoperatively, she had absence of lower extremity reflexes.", + "She underwent surgery of posterior spinal fusion T3 through pelvis.", + "The surgery was complicated by wound infection.", + "The surgery was complicated by incision and debridement.", + "She was discharged following a 60-day hospital stay.", + "Six months postoperative, the patient reported improved low back pain with PBS 13/28.", + "Six months postoperative, she reported unchanged motor and sensory exams in the lower extremities.", + "Six months postoperative, she reported improved mood.", + "Six months postoperative, she reported improved ability to conduct activities of daily living.", + "Six months postoperative, she reported improved quality of life compared with prior to surgery.", + "At 1.5 years post spinal fusion T3-pelvis, the patient presented to clinic with worsening lumbar back pain.", + "At 1.5 years post spinal fusion T3-pelvis, the patient had PBS increased to 22/28.", + "At 1.5 years post spinal fusion T3-pelvis, the patient had pain worsened with prolonged sitting.", + "Bilateral loosening of the pelvic fixation screws was demonstrated on imaging.", + "Bilateral loosening of the pelvic fixation screws was deemed to be the cause of the patient’s pain.", + "Bilateral loosening of the pelvic fixation screws was due to increased load at the L4–S1 levels.", + "She underwent revision of the pelvic fixation.", + "Revision of the pelvic fixation improved her PBS to 18/28.", + "The postoperative course was complicated by a new MRSA infection at the incision site.", + "The postoperative course was complicated by recurrent wound dehiscence.", + "The postoperative course had seven incision and drainage treatments over a 6-month duration.", + "She underwent removal of segmental instrumentation T3-pelvis.", + "Removal of segmental instrumentation T3-pelvis initially improved back pain to PBS score 12/28.", + "The patient’s quality of life had clearly increased.", + "The patient reported doing remarkably well with increased mobility.", + "Her mother reported the patient was more functionally active than she had been in a year.", + "Her low back pain continued to progressively worsen over the next 3 years.", + "Her lower back pain increased to PBS score 15/28.", + "She approached the team to consider redo L4–S1 decompression and fusion.", + "Magnetic resonance imaging (MRI) of the lumbar spine demonstrated severe central spinal stenosis at L4–5 and L5–S1 due to facet and ligamentum flavum hypertrophy.", + "Flexion–extension X-ray of the lumbar spine demonstrated axial distraction of the posterior edges of the vertebral bodies at L4–5 and L5–S1 on flexion.", + "Flexion–extension X-ray of the lumbar spine demonstrated alignment improving on extension.", + "Given her worsening pain with evidence of lumbar spinal stenosis and instability, she underwent redo L4–S1 decompression and fusion.", + "She underwent L4 and L5 laminectomies.", + "She underwent bilateral L4–L5 medial facetectomies.", + "She underwent bilateral L4–L5 foraminotomies.", + "She underwent posterior lateral lumbosacral fusion with bilateral pedicle screws at L4, L5, and S1.", + "She tolerated the procedure well.", + "She endorsed improved pain compared with prior to surgery.", + "She was discharged to home on postoperative day 3.", + "On postoperative day 16, she presented with fever.", + "On postoperative day 16, she presented with chills.", + "On postoperative day 16, she presented with tachycardia.", + "On postoperative day 16, she presented with return of her midline low back pain.", + "MRI demonstrated a surgical site infection with severe compression of the lower lumbar thecal sac.", + "The patient reported severe midline low back pain similar to what she experienced prior to surgery.", + "The patient identified this as a separate pain from her postoperative soreness.", + "The patient underwent lumbar wound washout.", + "The patient experienced significant improvement in low back pain.", + "During her convalescence, she experienced incisional pain.", + "During her convalescence, she reported significant improvement in her deeper, chronic pain.", + "During her convalescence, she reported increased ability to perform transfers.", + "At 1 year postoperative, the patient’s chronic low back pain remained improved compared with preoperative baseline.", + "The pain was described as “moderate”.", + "The pain was described as “not as severe as preoperative back pain”.", + "The patient reported doing well, with improved ability to bend and overall mobility.", + "Follow-up MRI demonstrated decompression at L4–L5.", + "Imaging also demonstrated increased spondylosis at L5–S1.", + "Repeat decompression at L5–S1 with revised fusion at this level was offered.", + "The patient ultimately decided not to proceed with surgery.", + "The patient decided not to proceed with surgery as her back pain was no longer severe." + ], + "summary": "In this report, we describe a 22-year-old Caucasian female who suffered from chronic lumbar back pain despite a complete thoracic sensory level secondary to prior transverse myelitis. Imaging demonstrated multilevel central stenosis below the sensory level, and her pain improved after surgical decompression. To our knowledge, this is the first reported case of symptomatic lumbar stenosis below a sensory level after transverse myelitis successfully treated with surgical decompression.", + "summary_subclaims": [ + "The patient was a 22-year-old Caucasian female.", + "She suffered from chronic lumbar back pain.", + "She had a complete thoracic sensory level secondary to prior transverse myelitis.", + "Imaging demonstrated multilevel central stenosis below the sensory level.", + "Her pain improved after surgical decompression.", + "To our knowledge, this is the first reported case of symptomatic lumbar stenosis below a sensory level after transverse myelitis successfully treated with surgical decompression." + ] + }, + { + "id": "multiclinsum_test_3230_en.txt", + "fulltext": "The patient was a 76-year-old woman. At the age of 70, when she was admitted to our hospital’s department of collagen medicine with polymyositis, she developed a depressive state for the first time and was subsequently treated by the department of psychiatry. She was diagnosed with major depressive disorder by diagnostic and statistical manual of mental disorders IV-TR and treated with mirtazapine 45 mg; however, her depressive state and anxiety agitation did not improve. Thereafter, she failed to respond to various drug therapies, including escitalopram, venlafaxine, vortioxetine, and augmentation with aripiprazole, and she underwent initial mECT at the age of 72. The depressive state improved immediately after mECT, but she relapsed several times, requiring mECT each time.\n\nAt the age of 76, she was admitted to our hospital to undergo mECT for the fifth time because of recurrent depressive symptoms such as decreased appetite, anxiety, and agitation. After admission, vortioxetine 10 mg and olanzapine 10 mg were tapered off. Quetiapine 50 mg, suvorexant 15 mg, and trazodone 25 mg were continued. Propofol (1.0 mg/kg) was administered intravenously, and rocuronium bromide (1.0 mg/kg) was given to avoid muscle contractions. After induction of anesthesia, suxamethonium chloride (4.0–5.0 mg/kg) was administered intravenously as a muscle relaxant. The mECT was bilateral and started at 35% stimulus intensity, and effective convulsions were obtained for the first time. However, during the 8th mECT at the same intensity (35% stimulus intensity), an unexpected prolonged seizure of 966 s (over 16 minutes) occurred. The seizure was abruptly stopped with diazepam 10 mg and midazolam 2 mg. There were no tardive seizures. The patient had used a range of antidepressants in the past with poor efficacy, therefore, we considered continuing mECT could be reasonable to improve her depressive symptoms.\n\nDuring the ninth mECT session, the stimulation intensity was increased to 50%, which resulted in effective seizures and no prolonged seizures. Subsequently, appropriate convulsions were obtained with the same stimulation intensity, and she completed 12 sessions. Her depressive symptoms improved both subjective and objective, and she was discharged on the 45th day of hospitalization.", + "fulltext_subclaims": [ + "The patient was a 76-year-old woman.", + "At the age of 70, she was admitted to the hospital’s department of collagen medicine with polymyositis.", + "She developed a depressive state for the first time at the age of 70.", + "She was diagnosed with major depressive disorder by the diagnostic and statistical manual of mental disorders IV-TR.", + "She was treated with mirtazapine 45 mg.", + "Her depressive state and anxiety agitation did not improve.", + "She failed to respond to various drug therapies, including escitalopram, venlafaxine, vortioxetine, and augmentation with aripiprazole.", + "She underwent initial mECT at the age of 72.", + "The depressive state improved immediately after mECT.", + "She relapsed several times, requiring mECT each time.", + "At the age of 76, she was admitted to the hospital to undergo mECT for the fifth time.", + "After admission, vortioxetine 10 mg and olanzapine 10 mg were tapered off.", + "Quetiapine 50 mg, suvorexant 15 mg, and trazodone 25 mg were continued.", + "Propofol (1.0 mg/kg) was administered intravenously.", + "Rocuronium bromide (1.0 mg/kg) was given to avoid muscle contractions.", + "Suxamethonium chloride (4.0–5.0 mg/kg) was administered intravenously as a muscle relaxant.", + "The mECT was bilateral and started at 35% stimulus intensity.", + "Effective convulsions were obtained for the first time.", + "During the 8th mECT at the same intensity (35% stimulus intensity), an unexpected prolonged seizure of 966 s occurred.", + "The seizure was abruptly stopped with diazepam 10 mg and midazolam 2 mg.", + "There were no tardive seizures.", + "The patient had used a range of antidepressants in the past with poor efficacy.", + "We considered continuing mECT could be reasonable to improve her depressive symptoms.", + "During the ninth mECT session, the stimulation intensity was increased to 50%.", + "This resulted in effective seizures and no prolonged seizures.", + "Appropriate convulsions were obtained with the same stimulation intensity.", + "She completed 12 sessions.", + "Her depressive symptoms improved both subjective and objective.", + "She was discharged on the 45th day of hospitalization." + ], + "summary": "The patient was a 76-year-old woman with major depressive disorder. She suffered from depressive symptoms such as decreased appetite, anxiety, and agitation. She was admitted to our hospital for mECT for the fifth time. The mECT was bilateral and started at 35% stimulus intensity, and effective convulsions were obtained for the first time. During the 8th mECT at the same intensity (35% stimulus intensity), an unexpected prolonged seizure of 966 s (over 16 minutes) occurred. The seizure was abruptly stopped with diazepam 10 mg and midazolam 2 mg. During the ninth mECT session, the stimulation intensity was increased to 50%, which resulted in effective seizures and no prolonged seizures. Subsequently, appropriate convulsions were obtained with the same stimulation intensity, and she completed 12 sessions. Her depressive symptoms improved, and she was discharged on the 45th day of hospitalization.", + "summary_subclaims": [ + "The patient was a 76-year-old woman with major depressive disorder.", + "She suffered from depressive symptoms such as decreased appetite, anxiety, and agitation.", + "She was admitted to our hospital for mECT for the fifth time.", + "The mECT was bilateral and started at 35% stimulus intensity.", + "Effective convulsions were obtained for the first time.", + "During the 8th mECT at the same intensity (35% stimulus intensity), an unexpected prolonged seizure of 966 s (over 16 minutes) occurred.", + "The seizure was abruptly stopped with diazepam 10 mg and midazolam 2 mg.", + "During the ninth mECT session, the stimulation intensity was increased to 50%.", + "The increased stimulation intensity resulted in effective seizures and no prolonged seizures.", + "Subsequently, appropriate convulsions were obtained with the same stimulation intensity.", + "She completed 12 sessions.", + "Her depressive symptoms improved.", + "She was discharged on the 45th day of hospitalization." + ] + }, + { + "id": "multiclinsum_test_1124_en.txt", + "fulltext": "A 79-year-old Japanese woman with a leg oedema visited her primary care physician, 3 months before being admitted to our hospital. Outpatient treatment with diuretics was initiated, but the oedema did not improve. Three days before admission, she experienced palpitations and fatigue, prompting her to again visit her primary care physician. Her laboratory data showed severe anaemia (haemoglobin [Hb], 58 g/L). Hence, she was subsequently admitted to our hospital.\nShe had no specific medical or any family history of renal disease. Physical examination revealed moderate leg oedema and kyphosis and no other indications of amyloidosis, such as numbness or signs consistent with polyneuropathy, gastrointestinal symptoms, macroglossia, orthostatic hypotension, purpura, or any changes to the skin. Laboratory data revealed microcytic anaemia (Hb, 50 g/L; mean corpuscular volume, 85.9 fL), hypoalbuminemia (albumin, 2.8 g/dL), and a possible slight decline in kidney function (serum creatinine, 0.64 mg/dL; estimated glomerular filtration rate, 66.9 mL/min/1.73 m2). Serum IgG, IgA, and IgM levels were 794 mg/dL, 1006 mg/dL, and 48 mg/dL, respectively. The serum free light chain (FLC) level for kappa and lambda was 77.4 mg/L and 15.2 mg/L, respectively, and the FLC ratio was 5.09. The brain natriuretic peptide level was 72.7 pg/mL. She also had iron and zinc deficiency. Serum and urine electrophoresis revealed the presence of IgA-kappa type M proteins (immunofixation method; Fig. ). Serum β2-microglobulin was 4.6 mg/L. Bone marrow aspiration revealed a slight proliferation of plasma cells (6.8%). Urinalysis revealed an occult haematuria (1 +) and moderate proteinuria (1.34 g/gCr). Electrocardiography and cardiac ultrasound did not show any changes consistent with cardiomyopathy associated with amyloidosis, such as low voltage, thickening of the ventricular wall, or granular sparkling appearance. The chest radiograph revealed a slight bilateral pleural effusion, and the cardiothoracic rate was deemed to be 56.5%. For treating severe anaemia, red blood cell transfusion was administered in conjunction with iron and zinc supplementation, resulting in an improvement in anaemia (Hb 95 g/L) and her subsequent discharge. After discharge, her urinary protein increased to 5.7 g/gCr, and serum albumin decreased to 2.8 g/dL. The patient was then diagnosed with nephrotic syndrome and a renal biopsy was performed.\nLight microscopy revealed methenamine-positive deposits in the mesangial and paramesangial regions . Some glomeruli were accompanied by segmental sclerosis caused by the deposits. Interstitial fibrosis and tubular atrophy were mild. Immunofluorescence staining was positive for IgA and kappa chains in the expanded mesangial area . The tubular basement membrane was partly granular and positive for kappa chains. Additional Congo red staining showed mild positivity in the glomerular deposits, but only faint birefringence. Immunohistochemical staining of the kappa chains was mildly positive . Furthermore, electron microscopy was conducted with formalin-fixed specimen to evaluate glomerular deposits, which revealed unbranched fibrils in glomerular deposits measuring 10–15 nm .\nLMD-LC–MS/MS revealed that the deposits consisted significant amounts of the kappa constant region of immunoglobulin. Additionally, a small amount of the alpha-1 constant region was also detected along with amyloid-associated proteins . Details of the detected protein and an illustration of globulin are presented in Fig. . The emPAI (exponentially modified protein abundance index) is often used as an index for estimating protein abundance during proteomic analyses using mass-spectrometry. The emPAI value represents the relative amount of each protein contained within the sample . Therefore, a higher value emPAI is indicative of a larger amount of protein, compared to the other proteins in the sample.\nBased on the above findings, the patient was diagnosed with LHCDD and focal amyloid deposition. Skin biopsy did not show amyloid deposition, while gastrointestinal biopsy revealed faint birefringence, suggesting that the patient had systemic amyloidosis. Bone marrow aspiration was repeated, which revealed an increase in the plasma cell population (14.4%). The increase in plasma cell population and a concurrent anaemia indicated multiple myeloma . She did not however present any other myeloma-defining events, such as hypercalcemia, decline in renal function, and bone legions. We started cyclophosphamide 300 mg/m2/day, bortezomib 1.3 mg/m2, and dexamethasone treatment 20 mg/week followed by weekly administration of daratumumab (1, 800 mg/week). After 9 months of treatment, proteinuria improved from 8.0 to approximately 5.0 g/gCr in the absence of decrease in eGFR, indicating a renal response . Serum albumin concentration also gradually increased, leading to a reduction in leg oedema. The reduction in serum M-protein (IgA 467 mg/dL) and the difference between involved and uninvolved FLC (dFLC; 20.8 mg/L) was greater than 50%, but less than 90% (haematological partial response ).", + "fulltext_subclaims": [ + "A 79-year-old Japanese woman with a leg oedema visited her primary care physician 3 months before being admitted to our hospital.", + "Outpatient treatment with diuretics was initiated, but the oedema did not improve.", + "Three days before admission, she experienced palpitations and fatigue, prompting her to again visit her primary care physician.", + "Her laboratory data showed severe anaemia (haemoglobin [Hb], 58 g/L).", + "She was subsequently admitted to our hospital.", + "She had no specific medical or any family history of renal disease.", + "Physical examination revealed moderate leg oedema and kyphosis.", + "No other indications of amyloidosis, such as numbness or signs consistent with polyneuropathy, gastrointestinal symptoms, macroglossia, orthostatic hypotension, purpura, or any changes to the skin, were found.", + "Laboratory data revealed microcytic anaemia (Hb, 50 g/L; mean corpuscular volume, 85.9 fL).", + "Serum IgG, IgA, and IgM levels were 794 mg/dL, 1006 mg/dL, and 48 mg/dL, respectively.", + "The serum free light chain (FLC) level for kappa and lambda was 77.4 mg/L and 15.2 mg/L, respectively, and the FLC ratio was 5.09.", + "The brain natriuretic peptide level was 72.7 pg/mL.", + "She also had iron and zinc deficiency.", + "Serum and urine electrophoresis revealed the presence of IgA-kappa type M proteins (immunofixation method).", + "Serum β2-microglobulin was 4.6 mg/L.", + "Bone marrow aspiration revealed a slight proliferation of plasma cells (6.8%).", + "Urinalysis revealed an occult haematuria (1 +) and moderate proteinuria (1.34 g/gCr).", + "Electrocardiography and cardiac ultrasound did not show any changes consistent with cardiomyopathy associated with amyloidosis.", + "The chest radiograph revealed a slight bilateral pleural effusion.", + "For treating severe anaemia, red blood cell transfusion was administered in conjunction with iron and zinc supplementation.", + "This resulted in an improvement in anaemia (Hb 95 g/L) and her subsequent discharge.", + "After discharge, her urinary protein increased to 5.7 g/gCr.", + "The patient was then diagnosed with nephrotic syndrome and a renal biopsy was performed.", + "Light microscopy revealed methenamine-positive deposits in the mesangial and paramesangial regions.", + "Some glomeruli were accompanied by segmental sclerosis caused by the deposits.", + "Interstial fibrosis and tubular atrophy were mild.", + "Immunofluorescence staining was positive for IgA and kappa chains in the expanded mesangial area.", + "The tubular basement membrane was partly granular and positive for kappa chains.", + "Additional Congo red staining showed mild positivity in the glomerular deposits, but only faint birefringence.", + "Immunohistochemical staining of the kappa chains was mildly positive.", + "Electron microscopy revealed unbranched fibrils in glomerular deposits measuring 10–15 nm.", + "LMD-LC–MS/MS revealed that the deposits consisted of significant amounts of the kappa constant region of immunoglobulin.", + "A small amount of the alpha-1 constant region was also detected along with amyloid-associated proteins.", + "The emPAI value represents the relative amount of each protein contained within the sample.", + "A higher value emPAI is indicative of a larger amount of protein, compared to the other proteins in the sample.", + "Based on the above findings, the patient was diagnosed with LHCDD and focal amyloid deposition.", + "Skin biopsy did not show amyloid deposition.", + "Gastrointestinal biopsy revealed faint birefringence, suggesting that the patient had systemic amyloidosis.", + "Bone marrow aspiration was repeated, which revealed an increase in the plasma cell population (14.4%).", + "The increase in plasma cell population and a concurrent anaemia indicated multiple myeloma.", + "She did not however present any other myeloma-defining events, such as hypercalcemia, decline in renal function, and bone lesions.", + "We started cyclophosphamide 300 mg/m2/day, bortezomib 1.3 mg/m2, and dexamethasone treatment 20 mg/week followed by weekly administration of daratumumab (1, 800 mg/week).", + "After 9 months of treatment, proteinuria improved from 8.0 to approximately 5.0 g/gCr in the absence of decrease in eGFR, indicating a renal response.", + "Serum albumin concentration also gradually increased, leading to a reduction in leg oedema.", + "The reduction in serum M-protein (IgA 467 mg/dL) and the difference between involved and uninvolved FLC (dFLC; 20.8 mg/L) was greater than 50%, but less than 90% (haematological partial response)." + ], + "summary": "We report a case of a 79-year-old Japanese woman with nephrotic syndrome. Bone marrow aspiration revealed a slight proliferation of plasma cells (under 10%). Immunofluorescence assessment of renal biopsy showed amyloid-like deposits in the glomerulus that were positive for IgA and kappa. Further, the Congo red staining of the deposits was faintly positive, and only a slight birefringence was detected. Electron microscopy confirmed fine fibrillar structures and non-amyloid deposits. Finally, mass spectrometry revealed that the deposits were composed of abundant amounts of light chain with small amounts of heavy chain. Therefore, the patient was diagnosed with LHCDD and focal amyloid deposition. Chemotherapy was subsequently initiated, which resulted in haematological and renal response. Under polarised light, faint birefringence with Congo red staining and periodic acid-methenamine silver positivity indicated that the deposits were mostly non-amyloid fibrils with a small component of amyloid fibrils. Generally, the diagnosis of heavy- and light-chain amyloidosis is defined by greater heavy chain deposition compared to the light chain. However, in our case, contrary to the definition, the light-chain deposition was far greater than that of the heavy-chain.", + "summary_subclaims": [ + "The patient was a 79-year-old Japanese woman.", + "The patient had nephrotic syndrome.", + "Bone marrow aspiration revealed a slight proliferation of plasma cells (under 10%).", + "Immunofluorescence assessment of renal biopsy showed amyloid-like deposits in the glomerulus that were positive for IgA and kappa.", + "Congo red staining of the deposits was faintly positive.", + "Only a slight birefringence was detected.", + "Electron microscopy confirmed fine fibrillar structures and non-amyloid deposits.", + "Mass spectrometry revealed that the deposits were composed of abundant amounts of light chain with small amounts of heavy chain.", + "The patient was diagnosed with LHCDD and focal amyloid deposition.", + "Chemotherapy was subsequently initiated.", + "Chemotherapy resulted in haematological and renal response.", + "Under polarised light, faint birefringence with Congo red staining indicated that the deposits were mostly non-amyloid fibrils with a small component of amyloid fibrils.", + "Periodic acid-methenamine silver positivity indicated that the deposits were mostly non-amyloid fibrils with a small component of amyloid fibrils.", + "The diagnosis of heavy- and light-chain amyloidosis is defined by greater heavy chain deposition compared to the light chain.", + "In our case, the light-chain deposition was far greater than that of the heavy-chain." + ] + }, + { + "id": "multiclinsum_test_985_en.txt", + "fulltext": "A 48-year-old caucasian male with an extensive psychiatric history of depression was admitted to the intensive care unit at a local hospital following intoxication of approximately 20 g venlafaxine, 450 mg zolpidem, and 250 mg propiomazine. His past history included intensive care hospitalization due to two suicidal attempts through pharmacological intoxication and self-harm with a knife. On admission, he was awake but drowsy and had a Glasgow Coma Scale (GCS) 13 of 15 (E3 + V4 + M6) but stable respiratory and circulatory status. His electrocardiography (ECG) was normal with a sinus rhythm of 57 beats per minute. Laboratory findings were within normal range . Admission occurred approximately 2 hours after intake of the pills. Activated charcoal suspension was administered via a nasogastric tube upon arrival at the intensive care unit.\nThe patient was stable during the first 5 hours at the intensive care unit (ICU), but then 7 hours post-intoxication he experienced tonic–clonic seizures. This was successfully treated with diazepam 10 mg intravenously, and he was subsequently intubated and sedated with propofol and remifentanil. Vasopressor support with low-dose norepinephrine was also initiated.\nNine hours after ingestion, his circulation began to slowly fail. Increased doses of norepinephrine were required, and the patient developed metabolic acidosis with lactate elevation. Fifteen hours after ingestion, the patient’s blood pressure fell rapidly despite high doses of norepinephrine. Prompt echocardiography revealed prominent hypokinesia with akinesia from the mid-left ventricle to the apex, as in TTC, with a left ventricle ejection fraction (EF) of 20%. The right ventricle was also affected with a tricuspid annular plane systolic excursion (TAPSE) measuring 10 mm. At this point, dobutamine was added to norepinephrine, but only a few micrograms were infused prior to cardiac arrest.\nShortly after the addition of dobutamine, his circulatory status deteriorated further, and the patient suffered a cardiac arrest with an initial rhythm of asystole. Advanced cardiac life support was initiated according to national guidelines including manual CPR and intravenous epinephrine. The patient was given three doses of epinephrine 1 mg intravenously, and after 5 minutes without return of spontaneous circulation, the ECMO center at a tertiary hospital was contacted. Fifteen minutes post cardiac arrest, the patient regained circulation temporarily for approximately 10 minutes before relapsing into cardiac arrest. The patient’s circulatory status and blood pressure were, however, inadequate during these 10 minutes. High-dose epinephrine infusion (1.0 µg/kg/minute) was initiated and manual CPR continued for another 30 minutes. The patient was then transported by helicopter to a tertiary hospital using mechanical CPR (AutoPulse Resuscitation System) and ongoing epinephrine infusion. Transportation time was approximately 30 minutes. One hour 15 minutes after the cardiac arrest, the patient was delivered to the tertiary hospital for ECMO initiation.\nUpon arrival at the tertiary hospital and prior to initiation of ECMO, the patient had a sinus rhythm but very low cardiac output. Blood pressure was 55/45 mmHg without cardiac arrest, and external compression was continued whilst ECMO system treatment was established. Short pauses were taken during specifically vulnerable periods of the cannulation procedure. Lactate peaked at 4.6 mmol/L. Two hours after the cardiac arrest, the patient was on ECMO.\nAfter ECMO initiation treatment with sedation and circulatory drugs continued, continuous renal replacement therapy (CRRT) was initiated. CRRT was initiated due to anuria and creatinine level of 265 µmol/L. Sedation was reinitiated using midazolam and morphine instead of propofol and remifentanil. The amount of epinephrine was significantly decreased during the initial hours of ECMO treatment, and norepinephrine and milrinone were used instead. Multiple plasma and red cell concentrate (RCC) transfusion were also required due to significant bleeding from the femoral artery catheter. The patient was successfully weaned after 32 hours of ECMO. Epinephrine infusion was terminated the same day, while milrinone continued until the following day.\nThe patient was transported back to the primary hospital with decreasing doses of norepinephrine the day after ECMO termination. Three days after the cardiac arrest, his cardiac function was echodynamically restored with an EF of above 55%. Values of the cardiac biomarker NT-proBNP decreased from 8360 ng/L the day after the cardiac arrest to 1190 ng/L 36 days after the intoxication. He was ventilated for 8 days and received CRRT for 3 weeks. Two days after extubation, the patient gradually regained consciousness. Thirty days after the intoxication, he had regained normal cardiac and cognitive function and left the hospital for further psychiatric treatment. The patient’s renal function was fully restored with normal creatinine level (82 µmol/L) 7 weeks after the intoxication. He was finally discharged in good health without his former prescribed psychiatric medications. Two years later, his cardiac and renal function were normal, although his psychiatric medication was reinstated.\nThe serum venlafaxine concentration 24 hours after ingestion was 12.6 mg/L, but this laboratory result was not received until 1 week after ingestion.", + "fulltext_subclaims": [ + "The patient was a 48-year-old caucasian male.", + "He had an extensive psychiatric history of depression.", + "He was admitted to the intensive care unit following intoxication of approximately 20 g venlafaxine, 450 mg zolpidem, and 250 mg propiomazine.", + "His past history included intensive care hospitalization due to two suicidal attempts through pharmacological intoxication.", + "On admission, he was awake but drowsy.", + "His Glasgow Coma Scale (GCS) was 13 of 15.", + "His electrocardiography (ECG) was normal with a sinus rhythm of 57 beats per minute.", + "Laboratory findings were within normal range.", + "Admission occurred approximately 2 hours after intake of the pills.", + "Activated charcoal suspension was administered via a nasogastric tube upon arrival at the intensive care unit.", + "The patient was stable during the first 5 hours at the intensive care unit.", + "Seven hours post-intoxication, he experienced tonic–clonic seizures.", + "This was successfully treated with diazepam 10 mg intravenously.", + "He was intubated and sedated with propofol and remifentanil.", + "Vasopressor support with low-dose norepinephrine was initiated.", + "Nine hours after ingestion, his circulation began to slowly fail.", + "Increased doses of norepinephrine were required.", + "The patient developed metabolic acidosis with lactate elevation.", + "Fifteen hours after ingestion, the patient’s blood pressure fell rapidly despite high doses of norepinephrine.", + "Prompt echocardiography revealed prominent hypokinesia with akinesia from the mid-left ventricle to the apex, as in TTC.", + "The left ventricle ejection fraction (EF) was 20%.", + "The right ventricle was also affected with a tricuspid annular plane systolic excursion (TAPSE) measuring 10 mm.", + "Dobutamine was added to norepinephrine.", + "Only a few micrograms of dobutamine were infused prior to cardiac arrest.", + "The patient suffered a cardiac arrest with an initial rhythm of asystole.", + "Advanced cardiac life support was initiated according to national guidelines.", + "The patient was given three doses of epinephrine 1 mg intravenously.", + "After 5 minutes without return of spontaneous circulation, the ECMO center at a tertiary hospital was contacted.", + "Fifteen minutes post cardiac arrest, the patient regained circulation temporarily for approximately 10 minutes.", + "The patient’s circulatory status and blood pressure were inadequate during these 10 minutes.", + "High-dose epinephrine infusion (1.0 µg/kg/minute) was initiated.", + "Manual CPR continued for another 30 minutes.", + "The patient was transported by helicopter to a tertiary hospital using mechanical CPR (AutoPulse Resuscitation System) and ongoing epinephrine infusion.", + "Transportation time was approximately 30 minutes.", + "One hour 15 minutes after the cardiac arrest, the patient was delivered to the tertiary hospital for ECMO initiation.", + "Upon arrival at the tertiary hospital, the patient had a sinus rhythm but very low cardiac output.", + "Blood pressure was 55/45 mmHg without cardiac arrest.", + "External compression was continued whilst ECMO system treatment was established.", + "Short pauses were taken during specifically vulnerable periods of the cannulation procedure.", + "Lactate peaked at 4.6 mmol/L.", + "Two hours after the cardiac arrest, the patient was on ECMO.", + "After ECMO initiation, treatment with sedation and circulatory drugs continued.", + "Continuous renal replacement therapy (CRRT) was initiated.", + "CRRT was initiated due to anuria and creatinine level of 265 µmol/L.", + "Sedation was reinitiated using midazolam and morphine instead of propofol and remifentanil.", + "The amount of epinephrine was significantly decreased during the initial hours of ECMO treatment.", + "Norepinephrine and milrinone were used instead.", + "Multiple plasma and red cell concentrate (RCC) transfusions were also required due to significant bleeding from the femoral artery catheter.", + "The patient was successfully weaned after 32 hours of ECMO.", + "Epinephrine infusion was terminated the same day.", + "Milrinone continued until the following day.", + "The patient was transported back to the primary hospital with decreasing doses of norepinephrine the day after ECMO termination.", + "Three days after the cardiac arrest, his cardiac function was echodynamically restored with an EF of above 55%.", + "Values of the cardiac biomarker NT-proBNP decreased from 8360 ng/L the day after the cardiac arrest to 1190 ng/L 36 days after the intoxication.", + "He was ventilated for 8 days.", + "He received CRRT for 3 weeks.", + "Two days after extubation, the patient gradually regained consciousness.", + "Thirty days after the intoxication, he had regained normal cardiac and cognitive function.", + "He left the hospital for further psychiatric treatment.", + "The patient’s renal function was fully restored with normal creatinine level (82 µmol/L) 7 weeks after the intoxication.", + "He was finally discharged in good health without his former prescribed psychiatric medications.", + "Two years later, his cardiac and renal function were normal.", + "His psychiatric medication was reinstated.", + "The serum venlafaxine concentration 24 hours after ingestion was 12.6 mg/L.", + "This laboratory result was not received until 1 week after ingestion." + ], + "summary": "A 48-year-old caucasian male with an extensive psychiatric history ingested a high dose of venlafaxine causing a serum venlafaxine concentration of 12.6 mg/L 24 hours after ingestion. Seven hours post-ingestion, he experienced tonic-clonic seizures, and 8 hours later, takotsubo cardiomyopathy was recognized followed by cardiac arrest. The patient was resuscitated with prolonged cardiopulmonary resuscitation including ongoing automatic external compressions during helicopter transportation to a tertiary hospital for extracorporeal membrane oxygenation treatment. Despite a cardiopulmonary resuscitation duration of 2 hours, 36 hours of extracorporeal membrane oxygenation, and a total of 30 days of intensive care, the patient made a full recovery.", + "summary_subclaims": [ + "The patient is a 48-year-old caucasian male.", + "The patient has an extensive psychiatric history.", + "The patient ingested a high dose of venlafaxine.", + "The serum venlafaxine concentration was 12.6 mg/L 24 hours after ingestion.", + "Seven hours post-ingestion, the patient experienced tonic-clonic seizures.", + "Eight hours post-ingestion, takotsubo cardiomyopathy was recognized.", + "The patient had a cardiac arrest.", + "The patient was resuscitated with prolonged cardiopulmonary resuscitation.", + "Ongoing automatic external compressions were used during helicopter transportation.", + "The patient was transported to a tertiary hospital for extracorporeal membrane oxygenation treatment.", + "The cardiopulmonary resuscitation duration was 2 hours.", + "The patient received 36 hours of extracorporeal membrane oxygenation.", + "The patient spent a total of 30 days in the intensive care unit.", + "The patient made a full recovery." + ] + }, + { + "id": "multiclinsum_test_1749_en.txt", + "fulltext": "We presented a 20-year-old male patient, who fell from a height of about 30 feet. He was initially managed at a nearby community hospital where he was diagnosed to have multiple rib fractures on both sides, with bilateral hemopneumothorax. The primary management of patient was performed with bilateral intercostal chest drains and positive pressure ventilation for lung contusion. The patient had no neurological deficit at initial presentation. He was then referred to our center after four weeks for further management.\nOn examination, there was tenderness over the tenth thoracic vertebrae with mild knuckle deformity. There was no motor or sensory deficit at any level. Superficial and deep tendon reflexes were normal. Radiographs and computerized tomography showed a fracture dislocation with spondyloptosis of the ninth thoracic vertebra (T9) over the tenth thoracic vertebra (T10) with vertebral body fracture of the eight vertebral body ( - ). The pedicles of both T9 and T10 vertebrae were fractured bilaterally, thus separating the posterior elements from their respective vertebral bodies. There was complete spondyloptosis of T9 over T10 vertebral body and both T9 and T10 vertebral bodies could be seen in a single transverse section of computerized tomography . The patient was scheduled for surgery after improvement in general and lung condition. The spine was approached through standard posterior midline incision. There was no significant kyphosis seen and the posterior elements of the eighth and ninth thoracic vertebrae were lying almost in place with undisplaced fractures in the lamina of respective vertebra. The pedicle screws were inserted in the fifth, sixth and seventh thoracic vertebrae proximally and the tenth, eleventh and twelfth vertebrae distally ( - ). An in-situ posterior instrumentation with laminectomy of T8 and T9 vertebrae and posterolateral fusion from the fifth to twelfth thoracic vertebrae was performed. No attempt was made to reduce spondyloptosis of T9 over the T10 vertebrae. The patient tolerated the operation well and there was no postoperative neurological deterioration. He was mobilized with the help of customized dorsolumbar rigid orthosis on fifth postoperative day. He was followed up at monthly intervals and radiographs along with computerized tomography showed satisfactory in situ fusion between T9 and T10 vertebral bodies . The patient returned to his previous occupation.", + "fulltext_subclaims": [ + "The patient was a 20-year-old male.", + "He fell from a height of about 30 feet.", + "He was initially managed at a nearby community hospital.", + "He was diagnosed to have multiple rib fractures on both sides.", + "He had bilateral hemopneumothorax.", + "The primary management was performed with bilateral intercostal chest drains.", + "Positive pressure ventilation was used for lung contusion.", + "The patient had no neurological deficit at initial presentation.", + "He was referred to our center after four weeks.", + "On examination, there was tenderness over the tenth thoracic vertebrae.", + "There was mild knuckle deformity.", + "There was no motor or sensory deficit at any level.", + "Superficial and deep tendon reflexes were normal.", + "Radiographs showed a fracture dislocation with spondyloptosis of the ninth thoracic vertebra (T9) over the tenth thoracic vertebra (T10).", + "The vertebral body of the eighth thoracic vertebra was fractured.", + "The pedicles of both T9 and T10 vertebrae were fractured bilaterally.", + "The posterior elements were separated from their respective vertebral bodies.", + "There was complete spondyloptosis of T9 over T10 vertebral body.", + "Both T9 and T10 vertebral bodies could be seen in a single transverse section of computerized tomography.", + "The patient was scheduled for surgery after improvement in general and lung condition.", + "The spine was approached through a standard posterior midline incision.", + "There was no significant kyphosis seen.", + "The posterior elements of the eighth and ninth thoracic vertebrae were lying almost in place.", + "The fractures in the lamina of the eighth and ninth thoracic vertebrae were undisplaced.", + "Pedicle screws were inserted in the fifth, sixth, and seventh thoracic vertebrae proximally.", + "Pedicle screws were inserted in the tenth, eleventh, and twelfth thoracic vertebrae distally.", + "An in-situ posterior instrumentation with laminectomy of T8 and T9 vertebrae was performed.", + "Posterolateral fusion from the fifth to twelfth thoracic vertebrae was performed.", + "No attempt was made to reduce spondyloptosis of T9 over the T10 vertebrae.", + "The patient tolerated the operation well.", + "There was no postoperative neurological deterioration.", + "He was mobilized with the help of a customized dorsolumbar rigid orthosis on the fifth postoperative day.", + "He was followed up at monthly intervals.", + "Radiographs showed satisfactory in situ fusion between T9 and T10 vertebral bodies.", + "Computerized tomography showed satisfactory in situ fusion between T9 and T10 vertebral bodies.", + "The patient returned to his previous occupation." + ], + "summary": "We reported a four-week spondyloptosis of the ninth thoracic vertebra over the tenth thoracic vertebra, in a 20-year-old male without any neurological deficit. The patient had associated chest injuries. The spine injury was managed surgically with in-situ posterior instrumentation and fusion. The patient tolerated the operation well and postoperatively there was no neurological deterioration or surgical complication.", + "summary_subclaims": [ + "We reported a four-week spondyloptosis of the ninth thoracic vertebra over the tenth thoracic vertebra.", + "The patient was a 20-year-old male.", + "The patient had no neurological deficit.", + "The patient had associated chest injuries.", + "The spine injury was managed surgically with in-situ posterior instrumentation and fusion.", + "The patient tolerated the operation well.", + "Postoperatively there was no neurological deterioration.", + "Postoperatively there was no surgical complication." + ] + }, + { + "id": "multiclinsum_test_1915_en.txt", + "fulltext": "A 40 year old, 83Kg female with developmental dysplasia of her left hip (DDH) was referred to us for consideration of left THA having suffered increasing left hip pain over the past three years. Her diagnosis of DDH was not made until adulthood despite her left leg being shorter than her right leg by 2.5 cm. She was diagnosed with BSS at the age of 18, and her haematology reports confirm 2 prior hospital admissions related to delayed bleeding following wisdom- teeth extraction at the age of 20 and cervical cone biopsy; the latter of which required transfusion with platelets and packed red blood cells (pRBC). Prior to this, she had been taking birth control pills from the age 14 for heavy menstruation.\nPre-operative cross-match and group and screen of blood was conducted confirming blood type A+. Blood work also confirmed that she was not Factor XIII deficit as initially suspected (FXIII activity, 1.04 U/mL). Her glycoprotein 1b level was 15% with an estimated platelet count of 12 (x109/L) and INR 0.9. Her euglobulin lysis time was also well within acceptable limits (4.5 h). We consulted our Thrombosis, Haemophilia and Internal Medicine teams for pre-operative optimization. Having a Clinical Nurse Specialist coordinate the patient care path was fundamental to this process.\nTranexamic acid (TA) 1g po TID was initiated 24 hours prior to surgery and continued until 14 days post-operatively. 20 mcg of DDAVP (desmopressin) diluted into 50 mL of normal saline was given intravenously over a period of 30 minutes, 1 hour prior to surgery. Immediately following this, she received 1 adult dose (4 units/318 mL) of pooled, buffy-coat platelets which elevated her platelets to 79 (x109/L) along with 1 unit of pRBC to bring her haemoglobin (Hb) to 135 . Intravenous antibiotics (Ancef, 2g) were given within 30 minutes of surgery. Arterial lines and additional peripheral lines were avoided to limit potential bleeding.\nInduction of general anaesthesia was conducted using a mixture of intravenous propofol (170 mg), sufentanil (20 mcg), versed (2 mg) and rocuronium (50 mcg). A glideScope® (Verathon Inc., Bothell, WA, USA) was used for placement of the endotracheal tube. Anaesthesia maintenance comprised isoflurane (1.8%) with 58% O2 at 1.2L/min and air at 1.3L/min.\nOnce sedate, our patient was positioned in a standard right lateral decubitus position, supported by a Stulberg frame (Innomed Inc., Savannah, GA, USA). A Hardinge approach was used to the left hip. Meticulous haemostasis was maintained using cautery throughout the case. Particular attention was taken to avoid undue tension through soft tissues during dislocation of the hip. Similarly, bone bleeding following transection of the femoral neck and reaming of the acetabulum and femoral canal was addressed immediately. Gauze soaked in tranexamic acid (Pfizer Inc., NY, USA, 2g in 10 mL sterile normal saline) was packed into the femoral canal and acetabulum for a period of 3-4 minutes prior to placement of implants.\nThe femoral component (Accolade II; Stryker Canada, Hamilton, ON, CA) was impacted into the femoral canal in the typical fashion. To optimize functional range, we used an anatomic dual mobility (ADM®), bearing hip system from Stryker . Bleeding was minimal following impaction of either the femoral or acetabular prostheses. Muscle and surrounding fascial layers were infiltrated with 0.5% Marcaine/epinephrine (1:1000; 40 mL). The incision was meticulously closed in multiple layers followed by steri- strips™ and mepore® dressings.\nSystolic blood pressure was maintained below 125 mmHg throughout the surgery. Total operative time was 85 minutes. Estimated blood loss was 450 mL. Patient received a 1L bolus of normal saline intra-operatively. Her vitals remained stable throughout the surgery.\nPost-operatively, daily transfusions of platelets were given up to post-operative day (POD) 14. Transfusions comprised 2 single donor (232 mL), 4 plateletpharesis (208 ±44 mL) and 8 pooled, buffy coated platelets (345 ±15mL). Minor crossmatch check was conducted daily. Platelet counts dropped by 40% post-operatively but recovered by POD 6 (see ). DDAVP (20 mcg, subcutaneous) was continued daily until POD 4. Serum sodium levels remained stable; the lowest reading was 128 mmol/L on POD 2, recovering to 136 mmol/L by POD 6. Systolic blood pressures were also stable at 103 ±14 mmHg, the lowest (98/59) occurring POD 1. Her blood work was recorded daily, a summary of which is shown in . She was weight bearing as tolerated from POD 1. Daily dressing checks confirmed no bleeding concerns at the incision site. DVT prophylaxis comprised moonboots starting POD 0. Her pain was controlled effectively with oral hydromorphone contin (6mg, BID) and Tylenol (975 mg, q4h). Patient entered into rehabilitation POD 7 and was discharged home on POD 19 following complete review by our Haematology and medicine teams.\nThe overall leg length discrepancy was improved from 2.5 cm to 1 cm without the need for additional soft tissue release.", + "fulltext_subclaims": [ + "The patient is a 40 year old, 83Kg female.", + "She has developmental dysplasia of her left hip.", + "She was referred for consideration of left THA.", + "She has had increasing left hip pain over the past three years.", + "Her diagnosis of DDH was not made until adulthood.", + "Her left leg is shorter than her right leg by 2.5 cm.", + "She was diagnosed with BSS at the age of 18.", + "She had two prior hospital admissions related to delayed bleeding.", + "The first admission was following wisdom-teeth extraction at the age of 20.", + "The second admission was following a cervical cone biopsy.", + "The latter admission required transfusion with platelets and packed red blood cells.", + "She had been taking birth control pills from the age of 14.", + "Pre-operative cross-match and group and screen of blood was conducted.", + "Blood type A+ was confirmed.", + "Blood work confirmed that she was not Factor XIII deficit.", + "FXIII activity was 1.04 U/mL.", + "Her glycoprotein 1b level was 15%.", + "Her platelet count was 12 (x109/L).", + "Her INR was 0.9.", + "Her euglobulin lysis time was 4.5 h.", + "Consultation with Thrombosis, Haemophilia and Internal Medicine teams was conducted.", + "A Clinical Nurse Specialist coordinated the patient care path.", + "Tranexamic acid 1g po TID was initiated 24 hours prior to surgery.", + "DDAVP 20 mcg was given intravenously over 30 minutes, 1 hour prior to surgery.", + "She received 1 adult dose of pooled, buffy-coat platelets.", + "She received 1 unit of packed red blood cells.", + "Intravenous antibiotics (Ancef, 2g) were given within 30 minutes of surgery.", + "Arterial lines and additional peripheral lines were avoided.", + "General anaesthesia was induced with propofol, sufentanil, versed, and rocuronium.", + "A glideScope® was used for endotracheal tube placement.", + "Anaesthesia maintenance comprised isoflurane with 58% O2 and air.", + "The patient was positioned in a standard right lateral decubitus position.", + "A Stulberg frame was used for support.", + "A Hardinge approach was used to the left hip.", + "Meticulous haemostasis was maintained using cautery.", + "Gauze soaked in tranexamic acid was packed into the femoral canal and acetabulum.", + "The femoral component was impacted into the femoral canal.", + "An anatomic dual mobility hip system was used.", + "Muscle and surrounding fascial layers were infiltrated with 0.5% Marcaine/epinephrine.", + "The incision was closed in multiple layers.", + "Systolic blood pressure was maintained below 125 mmHg.", + "Total operative time was 85 minutes.", + "Estimated blood loss was 450 mL.", + "A 1L bolus of normal saline was given intra-operatively.", + "Daily transfusions of platelets were given up to post-operative day 14.", + "Platelet counts dropped by 40% post-operatively.", + "DDAVP was continued daily until post-operative day 4.", + "Serum sodium levels remained stable.", + "The lowest serum sodium was 128 mmol/L on post-operative day 2.", + "Systolic blood pressures were stable at 103 ±14 mmHg.", + "The lowest systolic blood pressure was 98/59 on post-operative day 1.", + "She was weight bearing as tolerated from post-operative day 1.", + "DVT prophylaxis comprised moonboots starting post-operative day 0.", + "Pain was controlled with oral hydromorphone contin and Tylenol.", + "She entered rehabilitation on post-operative day 7.", + "She was discharged home on post-operative day 19.", + "The overall leg length discrepancy was improved from 2.5 cm to 1 cm." + ], + "summary": "A 40 year old, female with known BSS and developmental dysplasia of her left hip (DDH) was referred to us for consideration of left total hip arthroplasty (THA). Consultation with her Haematologist for pre-operative optimization of platelets and related clotting times together with detailed discussions of her intended anaesthesia protocol and surgery resulted in a successful operation with less than anticipated blood loss. She entered our rehabilitation program just one week after surgery.", + "summary_subclaims": [ + "The patient is a 40 year old female.", + "The patient has known BSS.", + "The patient has developmental dysplasia of her left hip.", + "The patient was referred for consideration of left total hip arthroplasty.", + "Consultation with her Haematologist occurred for pre-operative optimization.", + "Detailed discussions of her intended anaesthesia protocol and surgery occurred.", + "The operation was successful.", + "The operation resulted in less than anticipated blood loss.", + "She entered our rehabilitation program one week after surgery." + ] + }, + { + "id": "multiclinsum_test_2474_en.txt", + "fulltext": "A 19-year-old Saudi male was referred to the Department of ENT at our institution with the complaint of facial pain over the upper jaw area along with post-nasal discharge. This complaint has developed over a period of 6 months prior to his presentation. The patient gave a history of recurrent sinusitis but had no other systemic illness, no past surgical history and no history of trauma. No known drug history, no family history of any genetic disorder. The patient and both parents are non-smokers.\nEndoscopic examination was unremarkable except for a septal spur to the left side. Paranasal sinuses computed tomography (CT) scan showed bilateral cystic lesions and ectopic teeth in both maxillary sinuses .\nThe patient was booked for endonasal endoscopic enucleation of the cysts and extraction of the ectopic impacted teeth.\nIntra-operative, bilateral big cystic masses completely filling both maxillary sinuses were visualized along with a tooth impacted in the floor of the left maxillary sinus and another tooth identified within the right osteomeatal complex obstructing the right maxillary ostium.\nBilateral endoscopic wide middle meatal antrostomies were performed under general anesthesia. The cystic masses were dissected from the wall of both maxillary sinuses and removed by using different angel forceps and endoscopes. The right tooth was obstructing the maxillary sinus drainage removed with the cyst while the left was impacted in the left inferiolateral walls of left maxillary sinus removed completely with angled giraffe forceps . Homeostasis was achieved in both sinuses and no nasal packing was needed.\nThe specimen was sent for histopathologic examination which confirmed the diagnosis of dentigerous cysts.\nThe patient’s symptoms were resolved completely post-operatively and remained free of symptoms for 5 years follow up.", + "fulltext_subclaims": [ + "The patient is a 19-year-old Saudi male.", + "The patient was referred to the Department of ENT.", + "The patient had facial pain over the upper jaw area.", + "The patient had post-nasal discharge.", + "The complaint had developed over a period of 6 months.", + "The patient had a history of recurrent sinusitis.", + "The patient had no other systemic illness.", + "The patient had no past surgical history.", + "The patient had no history of trauma.", + "The patient had no known drug history.", + "The patient had no family history of any genetic disorder.", + "The patient and both parents are non-smokers.", + "Endoscopic examination was unremarkable except for a septal spur to the left side.", + "Paranasal sinuses CT scan showed bilateral cystic lesions.", + "Paranasal sinuses CT scan showed ectopic teeth in both maxillary sinuses.", + "The patient was booked for endonasal endoscopic enucleation of the cysts.", + "The patient was booked for extraction of the ectopic impacted teeth.", + "Intra-operatively, bilateral big cystic masses were visualized.", + "A tooth was impacted in the floor of the left maxillary sinus.", + "A tooth was identified within the right osteomeatal complex.", + "Bilateral endoscopic wide middle meatal antrostomies were performed under general anesthesia.", + "The cystic masses were dissected from the wall of both maxillary sinuses.", + "The cystic masses were removed using different angle forceps and endoscopes.", + "The right tooth was removed with the cyst.", + "The left tooth was impacted in the left inferiolateral walls of the left maxillary sinus.", + "The left tooth was removed completely with angled giraffe forceps.", + "Homeostasis was achieved in both sinuses.", + "No nasal packing was needed.", + "The specimen was sent for histopathologic examination.", + "The histopathologic examination confirmed the diagnosis of dentigerous cysts.", + "The patient’s symptoms were resolved completely post-operatively.", + "The patient remained free of symptoms for 5 years follow up." + ], + "summary": "This article presents a rare case report of bilateral dentigerous cysts associated with two ectopic teeth located atypically in the maxillary sinuses in a 19-year-old male manifesting as bilateral upper jaw pain, post-nasal discharge and recurrent sinusitis which was managed via the endonasal endoscopic approach by enucleation of the cysts and teeth removal.", + "summary_subclaims": [ + "This article presents a rare case report of bilateral dentigerous cysts associated with two ectopic teeth located atypically in the maxillary sinuses.", + "The patient was a 19-year-old male.", + "The patient manifested as bilateral upper jaw pain.", + "The patient had post-nasal discharge.", + "The patient had recurrent sinusitis.", + "The condition was managed via the endonasal endoscopic approach.", + "The cysts were enucleated.", + "The teeth were removed." + ] + }, + { + "id": "multiclinsum_test_3321_en.txt", + "fulltext": "70-year-old woman with a medical history of hypertension, diabetes, hyperlipidemia, ischemic heart disease, and degenerative joint disease who presented with progressive weakness of proximal muscles and myalgia over several months. The patient's current medication was tramadol/paracetamol 75 + 650 mg every eight hours, fluoxetine 20 mg/day, furosemide 40 mg/day, metformin 1,000 mg/day, linagliptin 2.5 mg/day, and simvastatin 20 mg/day (for the last seven years).\n\nShe began to have problems climbing steps and getting out of a chair. Her weakness progressed gradually until she was unable to walk unaided, comb her hair or bathe without support. She reported anorexia and weight loss of 15% in the past 10 months. She denied fever or associated chills, rash, oral ulcers, dyspnoea, chest pain, dysphagia or visual disturbances. There was no family history of neuromuscular disease.\n\nThe physical examination revealed significant proximal muscle weakness of the upper and lower extremities (shoulder abduction 3/5, elbow flexion 4/5, hip flexion 3/5, knee flexion 4/5 bilaterally, according to the Medical Research Council scale of muscle strength) and was unable to rise from a sitting position. Deep tendon reflexes, sensation and coordination were intact. Cardiac and pulmonary auscultation and abdominal examination revealed no abnormalities. Physical examination did not reveal cutaneous manifestations suggestive of dermatomyositis.\n\nLaboratory tests showed an elevation of creatine kinase (2,954 U/L, ref. 10-149), aldolase (45.6 U/L, ref. <7.6), aspartate transaminase (124 U/L, ref. 10-31) and alanine transaminase (95 U/L, ref. 10-31). Serologic tests for herpes simplex virus, Epstein-Barr virus, cytomegalovirus, varicella-zoster virus, human immunodeficiency virus and hepatitis C were negative. Serology for hepatitis B virus revealed a past infection (hepatitis B virus DNA was negative). Thyroid function was normal.\n\nNerve conduction studies and electromyography showed abnormal spontaneous muscle activity in proximal muscles of the upper and lower extremities, suggestive of irritable myopathy. A biopsy of the right deltoid muscle showed deep myopathic features with numerous necrotic fibers, some regenerating fibers, and perimysial infiltrate of inflammatory cells (predominantly composed of macrophages and T cells), combined with a diffuse overexpression of major histocompatibility complex class I. The test for antibodies to connective tissue diseases and myositis, including antinuclear antibodies, anti-dsDNA, anti-SSA, anti-SSB, anti-Sm, anti-RNP, anti-neutrophil cytoplasmic antibodies PR3, anti-neutrophil cytoplasmic antibodies MPO, and myositis panel for Mi2, Ku, SRP (signal recognition particle), PL7 (antithreonyl-tRNA synthetase), PL12 (antialanyl-tRNA synthetase), EJ (antiglycyl-tRNA synthetase), OJ (antiisoleucyl-tRNA synthetase), TIF1-γ (transcriptional intermediate factor 1 gamma), MDA5 (melanoma differentiation associated gene 5), SAE (small ubiquitin-like modifier activator enzyme), PM-Scl100, PM-Scl75, and Jo 1 (anti-histidyl-tRNA synthetase), was negative. Anti-3-hydroxy-3-methylglutaryl-coenzyme A (anti-HMG-CoA) reductase antibodies were positive (>200, ref. <20).\n\nGiven the association between inflammatory myopathies and malignancy, cancer screening was reviewed. Colonoscopy, mammography, and past cervical cancer screening did not show significant abnormalities. Chest and abdominal computed tomography, thyroid ultrasound, and positron emission tomography were negative for malignancy.\n\nSINAM was diagnosed and the statin was discontinued. He started with 1 g methylprednisolone/day for three days, followed by 60 mg prednisolone/day (0.75 mg/kg/day). Due to the lack of improvement in his symptoms, he was started on intravenous immunoglobulin therapy for five consecutive days (0.4 g/kg/day).\n\nThis combination of treatment allowed a significant improvement in muscle strength and myalgia, and a substantial reduction in the creatine kinase level, to 1,029 U/L. After 21 days of hospitalization, she was discharged with a decreasing dose of steroids and methotrexate was initiated. After three months of follow-up, the neurological examination was normal and the creatine kinase level returned to normal (15 U/L). At that time, the patient was medicated with methotrexate 10 mg/week and prednisolone 20 mg/day.\n", + "fulltext_subclaims": [ + "The patient is a 70-year-old woman.", + "The patient has a medical history of hypertension.", + "The patient has a medical history of diabetes.", + "The patient has a medical history of hyperlipidemia.", + "The patient has a medical history of ischemic heart disease.", + "The patient has a medical history of degenerative joint disease.", + "The patient presented with progressive weakness of proximal muscles.", + "The patient presented with myalgia over several months.", + "The patient's current medication included tramadol/paracetamol 75 + 650 mg every eight hours.", + "The patient's current medication included fluoxetine 20 mg/day.", + "The patient's current medication included furosemide 40 mg/day.", + "The patient's current medication included metformin 1,000 mg/day.", + "The patient's current medication included linagliptin 2.5 mg/day.", + "The patient's current medication included simvastatin 20 mg/day.", + "The patient had problems climbing steps.", + "The patient had problems getting out of a chair.", + "The patient had anorexia.", + "The patient had weight loss of 15% in the past 10 months.", + "The patient denied fever.", + "The patient denied rash.", + "The patient denied oral ulcers.", + "The patient denied dyspnoea.", + "The patient denied chest pain.", + "The patient denied dysphagia.", + "The patient denied visual disturbances.", + "There was no family history of neuromuscular disease.", + "Physical examination revealed significant proximal muscle weakness of the upper and lower extremities.", + "Shoulder abduction was 3/5.", + "Elbow flexion was 4/5.", + "Hip flexion was 3/5.", + "Knee flexion was 4/5 bilaterally.", + "The patient was unable to rise from a sitting position.", + "Deep tendon reflexes were intact.", + "Sensation was intact.", + "Coordination was intact.", + "Cardiac and pulmonary auscultation revealed no abnormalities.", + "Abdominal examination revealed no abnormalities.", + "Physical examination did not reveal cutaneous manifestations suggestive of dermatomyositis.", + "Creatine kinase was 2,954 U/L.", + "Aldolase was 45.6 U/L.", + "Aspartate transaminase was 124 U/L.", + "Alanine transaminase was 95 U/L.", + "Serologic tests for herpes simplex virus, Epstein-Barr virus, cytomegalovirus, varicella-zoster virus, human immunodeficiency virus, and hepatitis C were negative.", + "Serology for hepatitis B virus revealed a past infection.", + "Thyroid function was normal.", + "Nerve conduction studies and electromyography showed abnormal spontaneous muscle activity in proximal muscles of the upper and lower extremities.", + "The electromyography findings were suggestive of irritable myopathy.", + "A biopsy of the right deltoid muscle showed deep myopathic features.", + "The muscle biopsy showed numerous necrotic fibers.", + "The muscle biopsy showed some regenerating fibers.", + "The muscle biopsy showed a perimysial infiltrate of inflammatory cells.", + "The muscle biopsy showed a diffuse overexpression of major histocompatibility complex class I.", + "The test for antibodies to connective tissue diseases and myositis was negative.", + "Anti-3-hydroxy-3-methylglutaryl-coenzyme A reductase antibodies were positive.", + "Cancer screening was reviewed.", + "Colonoscopy did not show significant abnormalities.", + "Mammography did not show significant abnormalities.", + "Chest and abdominal computed tomography were negative for malignancy.", + "Thyroid ultrasound was negative for malignancy.", + "Positron emission tomography was negative for malignancy.", + "SINAM was diagnosed.", + "The statin was discontinued.", + "The patient started with 1 g methylprednisolone/day for three days.", + "The patient started with 60 mg prednisolone/day.", + "The patient was started on intravenous immunoglobulin therapy for five consecutive days.", + "The combination of treatment allowed a significant improvement in muscle strength.", + "The combination of treatment allowed a significant improvement in myalgia.", + "The creatine kinase level decreased to 1,029 U/L.", + "The patient was discharged after 21 days of hospitalization.", + "Methotrexate was initiated.", + "After three months of follow-up, the neurological examination was normal.", + "After three months of follow-up, the creatine kinase level returned to normal.", + "The patient was medicated with methotrexate 10 mg/week.", + "The patient was medicated with prednisolone 20 mg/day." + ], + "summary": "We present a patient who developed progressive muscle weakness after taking simvastatin for the last seven years. At initial presentation, his creatine kinase level was 2954 U/L and anti-HMG-CoA reductase antibodies were positive. The biopsy showed deep myopathic features with numerous necrotic fibers, some regenerating fibers, and perimysial inflammatory cell infiltrate, combined with a diffuse overexpression of the major histocompatibility complex class I. He was diagnosed with SINAM, the statin was discontinued, and high-dose systemic corticosteroids, intravenous immunoglobulin, and methotrexate were initiated. After three months of follow-up, he had a significant improvement in muscle strength and creatine kinase level returned to normal.\n", + "summary_subclaims": [ + "The patient had progressive muscle weakness after taking simvastatin for the last seven years.", + "The patient's creatine kinase level was 2954 U/L at initial presentation.", + "The patient's anti-HMG-CoA reductase antibodies were positive.", + "The biopsy showed deep myopathic features.", + "The biopsy showed numerous necrotic fibers.", + "The biopsy showed some regenerating fibers.", + "The biopsy showed a perimysial inflammatory cell infiltrate.", + "The biopsy showed diffuse overexpression of the major histocompatibility complex class I.", + "The patient was diagnosed with SINAM.", + "The statin was discontinued.", + "High-dose systemic corticosteroids were initiated.", + "Intravenous immunoglobulin was initiated.", + "Methotrexate was initiated.", + "After three months of follow-up, the patient had significant improvement in muscle strength.", + "After three months of follow-up, the patient's creatine kinase level returned to normal." + ] + }, + { + "id": "multiclinsum_test_3379_en.txt", + "fulltext": "A 62-year-old male with a history of 3 vessel coronary disease and prior coronary artery surgery was admitted with an inferior STEMI and cardiogenic shock, 6 hours after the onset of symptoms. Twelve months earlier, the patient had undergone a failed attempt of anterograde CTO RCA PCI, followed by an arterial bypass graft placement using a LITA graft to the left anterior descending artery (LAD) and a RITA graft sequentially to the obtuse marginal branch of the left circumflex and the RCA arteries.\n\nThe patient was diagnosed with an acute thrombotic occlusion of the RITA graft at its ostium and a patent LITA to the LAD artery. The posterior-descending artery (PDA) was also occluded. The patient was in refractory cardiogenic shock and was placed on ECMO. Concerns were raised that antegrade interventions through the RITA graft could result in distal thrombus embolization and acute revascularization was attempted using an antegrade approach from the native LCx into the RITA graft segment to the PDA and then a retrograde approach through the native RCA CTO.\n\nThe procedure was successful after the retrograde crossing of the remaining RITA graft (between the obtuse marginal and the PDA), retrograde dissection re-entry technique, externalization, rotational atherectomy of the lesion, and implantation of 3 drug-eluting stents.\n\nThe clinical evolution of the patient was favorable after the intervention and at 12 months follow-up.\n\nPast Medical History\nThe patient had a history of diabetes, dyslipidemia, mild renal insufficiency and left ventricular systolic dysfunction with a LVEF of 45%.\n\nAcute Presentation\nThe patient presented to the emergency department in cardiogenic shock with a blood pressure of 77/50 mm Hg and a pulse rate of 102 beats per minute. The patient was in a poor overall condition, the skin was pale, cool and diaphoretic.\n\nAn initial electrocardiogram (ECG) revealed 2 mm ST elevations in the inferior leads and ST segment depression in leads V1-2. These findings are consistent with inferior and posterior injury.\n\nAn echocardiogram obtained on initial presentation documented severe left ventricular systolic dysfunction with limited basal inferior akinesia, severe hypokinesia in the anterior and inferolateral wall, and an LVEF of 20%. There was evidence of moderate mitral regurgitation, right ventricular dilatation, and systolic dysfunction.\n\nUrgent coronary angiography was performed and the patient was started on ECMO immediately because of cardiogenic shock status despite pharmacological support. An intra-aortic balloon pump (IABP) was not preferred as a first choice regarding the stage D cardiogenic shock and the need for optimal perfusion in this acute coronary syndrome. A potential higher risk of mortality in acute settings could be related to the limited hemodynamic benefit of the IABP in comparison to other mechanical devices.7–9\n\nThe patient was documented to have a CTO of the RCA and an occluded proximal LAD after the origin of the first diagonal branch. The LITA graft to the LAD was patent, and there was an acute ostial occlusion of the RITA graft. The ostial circumflex showed 80% lesion and the segment of the RITA graft between the left circumflex and the PDA artery was widely patent but with an occlusion in the native PDA vessel related probably to thrombotic embolization.\n\n\nManagement\nFlow to the distal PDA and the posterolateral artery (PL) was absent and attempts were made to establish the reperfusion of these vessels.\n\nThe RCA was chronically occluded and revascularization was attempted by bilateral sheathless distal radial artery access with 7Fr guiding catheters. Knowing that the anterograde true to true lumen approach had previously failed we performed an anterograde knuckle with Fielder XTR (Asahi Intecc, Japan) supported by 7Fr TrapLiner (Teleflex Medical Incorporated, US) and Corsair Pro 135cm (Asahi Intecc, Japan). The retrograde Sion (Asahi Intecc, Japan) wire supported by a Corsair Pro 150 cm microcatheter was able to pass through the remaining anastomosis between the RITA and the obtuse marginal to the distal anastomosis with the PDA. The guideliner reverse CART was successful after the retrograde Gaia 3 wire crossed and the externalization was made using an RG3 wire (Asahi Intecc, Japan).\n\nDue to the severity and the extension of calcium the balloon failed to open and we performed a rotational atherectomy after crossing the CTO with an anterograde microcatheter on the RG3 and exchanging it with an extra support Rota Wire.\n\n\nThe procedure was successful after implantation of 3 drug-eluting stents. The first stent was placed from the distal RCA to PDA using a provisional technique. The second stent was placed on the mid part of the RCA by overlapping with the first one and the third one on the proximal part of the RCA. The intervention was completed within 2 hours and 40 minutes.\n\nFollow-Up\nAfter 12 months of clinical follow-up the patient had mild NYHA II (New York Heart Association) dyspnea without angina.\n\nThe echocardiography revealed an improvement of ventricular function (40% EF).", + "fulltext_subclaims": [ + "The patient is a 62-year-old male.", + "The patient has a history of 3 vessel coronary disease.", + "The patient had prior coronary artery surgery.", + "The patient was admitted with an inferior STEMI.", + "The patient was admitted with cardiogenic shock.", + "The patient had a failed attempt of anterograde CTO RCA PCI 12 months earlier.", + "The patient had an arterial bypass graft placement 12 months earlier.", + "The LITA graft was used to the left anterior descending artery.", + "The RITA graft was used sequentially to the obtuse marginal branch of the left circumflex and the RCA arteries.", + "The patient was diagnosed with an acute thrombotic occlusion of the RITA graft at its ostium.", + "The posterior-descending artery was occluded.", + "The patient was placed on ECMO.", + "Antegrade interventions through the RITA graft could result in distal thrombus embolization.", + "Acute revascularization was attempted using an antegrade approach from the native LCx into the RITA graft segment to the PDA.", + "Acute revascularization was attempted using a retrograde approach through the native RCA CTO.", + "The procedure was successful after the retrograde crossing of the remaining RITA graft.", + "The procedure was successful after a retrograde dissection re-entry technique.", + "The procedure was successful after externalization.", + "The procedure was successful after rotational atherectomy of the lesion.", + "The procedure was successful after implantation of 3 drug-eluting stents.", + "The clinical evolution of the patient was favorable after the intervention.", + "The patient had a history of diabetes.", + "The patient had a history of dyslipidemia.", + "The patient had mild renal insufficiency.", + "The patient had left ventricular systolic dysfunction with a LVEF of 45%.", + "The patient presented to the emergency department in cardiogenic shock.", + "The patient's blood pressure was 77/50 mm Hg.", + "The patient's pulse rate was 102 beats per minute.", + "The patient's skin was pale, cool, and diaphoretic.", + "An initial ECG revealed 2 mm ST elevations in the inferior leads.", + "An initial ECG revealed ST segment depression in leads V1-2.", + "An echocardiogram documented severe left ventricular systolic dysfunction.", + "An echocardiogram documented an LVEF of 20%.", + "An echocardiogram documented moderate mitral regurgitation.", + "An echocardiogram documented right ventricular dilatation.", + "An echocardiogram documented right ventricular systolic dysfunction.", + "Urgent coronary angiography was performed.", + "The patient was started on ECMO.", + "An intra-aortic balloon pump was not preferred as a first choice.", + "The patient had a CTO of the RCA.", + "The patient had an occluded proximal LAD after the origin of the first diagonal branch.", + "The LITA graft to the LAD was patent.", + "The ostial circumflex showed an 80% lesion.", + "The segment of the RITA graft between the left circumflex and the PDA artery was widely patent.", + "The native PDA vessel was occluded.", + "Flow to the distal PDA and the posterolateral artery was absent.", + "Reperfusion of these vessels was attempted.", + "The RCA was chronically occluded.", + "Revascularization was attempted by bilateral sheathless distal radial artery access.", + "The anterograde true to true lumen approach had previously failed.", + "An anterograde knuckle was performed with a Fielder XTR wire.", + "A retrograde Sion wire was used.", + "The retrograde Sion wire was supported by a Corsair Pro 150 cm microcatheter.", + "The guideliner reverse CART was successful.", + "Externalization was made using an RG3 wire.", + "The balloon failed to open due to the severity and extension of calcium.", + "A rotational atherectomy was performed.", + "The first stent was placed from the distal RCA to PDA using a provisional technique.", + "The second stent was placed on the mid part of the RCA by overlapping with the first one.", + "The third stent was placed on the proximal part of the RCA.", + "The intervention was completed within 2 hours and 40 minutes.", + "After 12 months of clinical follow-up, the patient had mild NYHA II dyspnea.", + "After 12 months of clinical follow-up, the patient had no angina.", + "Echocardiography revealed an improvement of ventricular function to 40% EF." + ], + "summary": "A patient with a history of multivessel coronary artery disease and a chronic total occlusion (CTO) of the right coronary artery (RCA) requiring arterial bypass surgery, presented with an acute inferior STEMI and cardiogenic shock. It was felt that shock was caused by the acute thrombotic occlusion of a right internal thoracic artery (RITA) bypass graft that had been sequentially anastomosed to the left circumflex (LCx) and right coronary arteries. Despite initiation of extracorporeal membrane oxygenation (ECMO), the patient remained in refractory shock and acute revascularization of the right coronary artery was performed through the RITA bypass segment using antegrade access to the graft through the LCx and then a retrograde approach to open a CTO of the RCA. After successful revascularization, the patient was successfully weaned from ECMO. Over 12 months of follow-up, the patient did well and was documented to have improved left ventricular systolic function.", + "summary_subclaims": [ + "The patient had a history of multivessel coronary artery disease.", + "The patient had a chronic total occlusion of the right coronary artery.", + "The patient presented with an acute inferior STEMI.", + "The patient had cardiogenic shock.", + "It was felt that shock was caused by the acute thrombotic occlusion of a right internal thoracic artery bypass graft.", + "The right internal thoracic artery bypass graft had been sequentially anastomosed to the left circumflex and right coronary arteries.", + "The patient remained in refractory shock despite initiation of extracorporeal membrane oxygenation.", + "Acute revascularization of the right coronary artery was performed through the right internal thoracic artery bypass segment.", + "Revascularization was performed using antegrade access to the graft through the left circumflex artery.", + "A retrograde approach was used to open a chronic total occlusion of the right coronary artery.", + "After successful revascularization, the patient was successfully weaned from extracorporeal membrane oxygenation.", + "Over 12 months of follow-up, the patient did well.", + "The patient was documented to have improved left ventricular systolic function." + ] + }, + { + "id": "multiclinsum_test_1460_en.txt", + "fulltext": "The patient is a 33-year-old female patient with personal history of NF1 (without any family history in the two previous generations) characterized by multiple Café au lait macules and multiple neurofibroma nodules in distinct regions of the skin which involve the scalp, neck, back, abdomen, and all the extremities.\nThe patient has a normal evolution of her disease with no incidents; she is an independent professional and refers no other symptomatology. Eventually, she complains of pain due to the mechanical compression of one of the neurofibromas. After considering the genetic counseling, the patient decides to get pregnant. During the second trimester of her pregnancy, she started to note gradual and progressive growth of one of the neurofibromas located in the anterolateral left portion of the neck, in the angle formed by the thyroid gland and the common carotid artery. Such growth gradually increased to the point where by the end of the pregnancy it had a diameter of approximately 10 cm × 15 cm, it made swallowing difficult, dysphonia, and generated local pain (nonneuropathic pain) . The consistency was smooth in the peripheral contours, but firm in the center, mobile, and no skin changes were noted. She has an uneventful full term pregnancy with a C-section delivery.\nAfter neuroimaging evaluation, a surgical approach is decided 3 months after the C-section using general anesthesia and microsurgical dissection. A tumor mass was identified, with a superficial wall, free from vascular or cervical major nerve structures, with a clear serous liquid content that after decompression, modifies the tumoral morphology immediately, allowing identification of the layers of the cystic lesion. The visceral portion of the capsule was found attached to the external plane of the thyroid gland and to the carotid artery adventitia, which was preserved. The postsurgical evolution was normal, without any complications. There were no alterations regarding phonation or deglutition, and there was a normal recovery of the external anatomy of the neck without any evidence of tumoral mass. The analysis of the fluid reported no cytological alterations and culture was negative for infection. The hematoxylin and eosin stain shows the presence of neoplastic cells, nuclear and diffuse cytoplasmic positivity to S-100 protein .", + "fulltext_subclaims": [ + "The patient is a 33-year-old female.", + "The patient has personal history of NF1.", + "There is no family history of NF1 in the two previous generations.", + "The patient has multiple Café au lait macules.", + "The patient has multiple neurofibroma nodules involving the scalp, neck, back, abdomen, and all the extremities.", + "The patient has a normal evolution of her disease with no incidents.", + "The patient is an independent professional.", + "The patient refers no other symptomatology.", + "The patient complains of pain due to mechanical compression of one of the neurofibromas.", + "The patient decides to get pregnant after considering genetic counseling.", + "During the second trimester of her pregnancy, the patient noted gradual and progressive growth of a neurofibroma located in the anterolateral left portion of the neck.", + "The neurofibroma was located in the angle formed by the thyroid gland and the common carotid artery.", + "By the end of the pregnancy, the neurofibroma had a diameter of approximately 10 cm × 15 cm.", + "The neurofibroma made swallowing difficult.", + "The neurofibroma generated local pain that was nonneuropathic.", + "The tumor mass had a superficial wall free from vascular or cervical major nerve structures.", + "The tumor mass had clear serous liquid content.", + "After decompression, the tumoral morphology immediately modified, allowing identification of the layers of the cystic lesion.", + "The visceral portion of the capsule was attached to the external plane of the thyroid gland.", + "The visceral portion of the capsule was attached to the carotid artery adventitia, which was preserved.", + "The postsurgical evolution was normal without any complications.", + "There were no alterations regarding phonation or deglutition.", + "There was normal recovery of the external anatomy of the neck without any evidence of tumoral mass.", + "The analysis of the fluid reported no cytological alterations.", + "The culture was negative for infection.", + "The hematoxylin and eosin stain shows the presence of neoplastic cells.", + "The neoplastic cells showed nuclear and diffuse cytoplasmic positivity to S-100 protein." + ], + "summary": "A 33-year-old female patient with a known personal history of NF1, with annual control of the peripheral neurofibromas and cerebral and spinal magnetic resonance imaging follow-ups. Under genetic counseling, she decides to get pregnant following all the medical advises. Once the pregnancy is confirmed, she starts to notice the growth of one of them adjacent to the left cervical region. Such neurofibroma presented with the progressive gradual increase and in the last month, she presented dysphagia, dysphonia, and postural pain localized by the mass effect. Once the pregnancy concluded, the microsurgical approach was scheduled for resection of the lesion, where a cystic mass was found within the walls of the neurofibroma. The resection was uneventful.", + "summary_subclaims": [ + "The patient is a 33-year-old female.", + "The patient has a known personal history of NF1.", + "The patient has annual control of the peripheral neurofibromas.", + "The patient has cerebral and spinal magnetic resonance imaging follow-ups.", + "The patient was under genetic counseling.", + "The patient decided to get pregnant following all the medical advises.", + "Once the pregnancy is confirmed, the patient starts to notice the growth of one of the neurofibromas adjacent to the left cervical region.", + "The neurofibroma presented with progressive gradual increase.", + "In the last month, the patient presented dysphagia.", + "In the last month, the patient presented dysphonia.", + "In the last month, the patient presented postural pain localized by the mass effect.", + "Once the pregnancy concluded, a microsurgical approach was scheduled for resection of the lesion.", + "A cystic mass was found within the walls of the neurofibroma.", + "The resection was uneventful." + ] + }, + { + "id": "multiclinsum_test_1546_en.txt", + "fulltext": "A 23-year-old male patient without past medical history presented to the emergency room with recent retrosternal chest tightness and pain. He reported recent gastro-intestinal (GI) symptoms of nausea, vomiting, 4-day watery diarrhea with transient episode of fever (38.7 °C). At admission, physical examination showed an impaired general status. He was afebrile (37.2 °C), respiratory rate 20 per min., cardiac assessment showed blood pressure of 140/70 mmHg, regular tachycardia of 100 beats per minute and normal cardiac murmur. Pulmonary examination showed a respiratory rate of 16 cycles per min, and auscultation was normal. He denied abdominal pain, and palpation showed no tenderness and no liver or spleen enlargement. He reported generalized myalgia but rheumatological evaluation did not show arthritis or productive myalgia. The electrocardiogram (ECG) showed left axis deviation with regular sinusal tachycardia. Routine laboratory showed leukocytosis 13 G/L (normal range < 10 G/L), neutrophilia 8.2 G/L (normal range 1.5–7 G/L) and lymphopenia 600/mm3 (normal range 1500 to 4000/mm3) on cell blood count, with elevated C-reactive protein of 130 mg/dL (normal range < 5 mg/dL), serum electrolytes, creatinine and liver enzymes within normal limits. Maximum Troponins and creatine kinase MB (CK-MB) were elevated to 678 ng/L (normal range < 14 ng/L) and 54 ng/mL (normal range < 7 ng/mL). The patient was admitted to the cardiac department for further workup. He was managed symptomatically with analgesics, anti-reflux and fluids. Transthoracic echocardiography (TTE) revealed a preserved ejection fraction (EF) of 55% with normal wall motions, no valvular dysfunction, normal pulmonary pressure and no pericardial effusion. His risk of coronary artery disease (CAD) was low; moreover, clinical, biological and echocardiographic presentation summed the hypothesis of an acute myocarditis. A large etiological workup, including repeated peripheral blood culture, Mycoplasma pneumoniae, Chlamydia pneumoniae, Coxiella burnetii, Borrelia burgdorferi, Leptospira spp., Rickettsia spp. and Brucella spp., was conducted. The serologies, such as urinary Legionella pneumophila antigen, were negative. Moreover, serologies of RNA viruses (coxsackieviruses A and B, hepatitis C virus, human immunodeficiency virus) and DNA viruses (adenoviruses, parvovirus B19, cytomegalovirus, human herpes virus-6, Epstein-Barr virus, varicella-zoster virus and herpes simplex virus) were negative. Autoimmune assessment, including antinuclear, anti-neutrophil cytoplasmic antibodies, systemic sclerosis and autoimmune myopathies specific antibodies and converting enzyme assay, were negative. The patient denied any recent drug intake. A Gram stain of specimen stool collected showed multiple curved and spiral Gram-negative rods. Biochemical tests indicated an oxidase, catalase and hippurate negative and indoxyl acetate-positive bacterial species, corresponding to C. jejuni. Stool cultures confirmed the diagnosis of C. jejuni sensitive to macrolides (Azithromycin/Roxithromycin/Clarythromycin) and flouroquinolones (Ciprofloxacin). Continuous telemetry monitoring showed some runs of non-sustained ventricular tachycardia (NSVT). Oral bisoprolol 2.5 mg twice daily was started for that, and oral 1 g of Azithromycin was administered. He remained clinically stable over the rest of the hospital course, and the diarrhea was progressively resolved. The patient remained stable, and we could perform cardiovascular magnetic resonance (CMR) imaging. Triple inversion-recovery black-blood T2-weighted STIR sequences showed focal areas of hypersignal in the subepicardium of the posterolateral left ventricular (LV) wall, indicative of myocardial edema . In addition, steady-state-free-precession (SSFP) cine CMR showed early hypersignal in the subepicardium of the posterolateral LV wall immediately after injection of 0.1 mM of Gadolinium chelates, indicating focal hyperemia . Inversion-recovery gradient-echo-based late Gadolinium enhancement techniques, acquired 10 min. after Gadolinium injection, revealed subepicardial nodular lesions of myocardial damage . The final diagnosis of C. jejuni-related acute myocarditis was supported by the Lake Louise criteria . The patient was discharged free of symptoms after one week in hospital. On close follow-up, his C-reactive protein and cardiac enzymes normalized after three weeks. Repeated TTE and 24-h ECG were normal, so bisoprolol was progressively discontinued after 6 months. Control CMR imaging at 3 months showed regression of the focal areas of hyper signal in the sub epicardium of the posterolateral left ventricular (LV) wall.", + "fulltext_subclaims": [ + "The patient is a 23-year-old male.", + "The patient had recent retrosternal chest tightness and pain.", + "The patient reported recent gastro-intestinal symptoms of nausea, vomiting, 4-day watery diarrhea, and a transient episode of fever.", + "At admission, the patient was afebrile with a temperature of 37.2 °C.", + "The patient had a respiratory rate of 20 per minute.", + "The patient had a blood pressure of 140/70 mmHg.", + "The patient had a regular tachycardia of 100 beats per minute.", + "The patient had a normal cardiac murmur.", + "The patient denied abdominal pain.", + "The electrocardiogram showed left axis deviation with regular sinusal tachycardia.", + "Routine laboratory showed leukocytosis 13 G/L.", + "Routine laboratory showed neutrophilia 8.2 G/L.", + "Routine laboratory showed lymphopenia 600/mm3.", + "The C-reactive protein was elevated to 130 mg/dL.", + "The maximum Troponins were elevated to 678 ng/L.", + "The creatine kinase MB was elevated to 54 ng/mL.", + "The patient was admitted to the cardiac department.", + "Transthoracic echocardiography revealed a preserved ejection fraction of 55%.", + "The risk of coronary artery disease was low.", + "The clinical, biological, and echocardiographic presentation summed the hypothesis of an acute myocarditis.", + "A large etiological workup was conducted.", + "The serologies of RNA viruses were negative.", + "The serologies of DNA viruses were negative.", + "The autoimmune assessment was negative.", + "A Gram stain of the stool specimen showed multiple curved and spiral Gram-negative rods.", + "Biochemical tests indicated an oxidase, catalase, and hippurate negative and indoxyl acetate-positive bacterial species, corresponding to C. jejuni.", + "Stool cultures confirmed the diagnosis of C. jejuni sensitive to macrolides and flouroquinolones.", + "Continuous telemetry monitoring showed some runs of non-sustained ventricular tachycardia.", + "Oral bisoprolol 2.5 mg twice daily was started.", + "Oral 1 g of Azithromycin was administered.", + "The patient remained clinically stable over the rest of the hospital course.", + "The diarrhea was progressively resolved.", + "Cardiovascular magnetic resonance imaging was performed.", + "Triple inversion-recovery black-blood T2-weighted STIR sequences showed focal areas of hypersignal in the subepicardium of the posterolateral left ventricular wall.", + "Steady-state-free-precession cine CMR showed early hypersignal in the subepicardium of the posterolateral left ventricular wall immediately after injection of 0.1 mM of Gadolinium chelates.", + "Inversion-recovery gradient-echo-based late Gadolinium enhancement techniques revealed subepicardial nodular lesions of myocardial damage.", + "The final diagnosis of C. jejuni-related acute myocarditis was supported by the Lake Louise criteria.", + "The patient was discharged free of symptoms after one week in hospital.", + "On close follow-up, the C-reactive protein and cardiac enzymes normalized after three weeks.", + "Repeated TTE and 24-h ECG were normal.", + "Bisoprolol was progressively discontinued after 6 months.", + "Control CMR imaging at 3 months showed regression of the focal areas of hypersignal in the subepicardium of the posterolateral left ventricular wall." + ], + "summary": "We report herein a case of myocarditis complicating gastroenteritis in a 23-year-old immunocompetent patient, caused by this bacterium with a favorable outcome. Cardiac magnetic resonance imagining was useful in establishing an early diagnosis.", + "summary_subclaims": [ + "The patient was a 23-year-old immunocompetent individual.", + "The patient had myocarditis.", + "The myocarditis complicated gastroenteritis.", + "The myocarditis was caused by this bacterium.", + "The outcome of the case was favorable.", + "Cardiac magnetic resonance imaging was useful in establishing an early diagnosis." + ] + }, + { + "id": "multiclinsum_test_3104_en.txt", + "fulltext": "The patient is a 24-year-old male with no relevant history, except for an appendectomy performed 12 days prior to admission. The patient reported that he had a two-day course of evolution until surgical treatment. He had nausea, vomiting and intense pain in the right iliac fossa, without fever. The examinations of that occasion revealed a mild leukocytosis of 13,200 mm3 and platelets of 64,000 mm3 as the only alterations. An appendectomy was performed, finding gangrenous appendicitis, without intra-abdominal collections. After the surgery, good evolution was observed, so he was discharged on the second day of hospital stay, prescribing cefuroxima (1 g) from admission until five days after discharge.\n\nOn his second admission, the patient presented with a fever of three previous days, not quantified, without predominance of time, self-limited. Subsequently, ictric skin and sclera dye was added, in addition to coluria. He did not manifest any pain, fever or others. In his initial laboratories, leukocytes of 8600/µl, platelets of 32,000/l, total bilirubin of 4.7 mg/dL, direct bilirubin of 3.9 mg/dL, TGP of 129 U/I, TGO of 63 U/I, alkaline phosphatase of 288 U/l and lipase of 744 U/l were observed.\n\nEmpirical treatment was initiated with piperacillin/tazobactam and with noreprinephrine, due to low blood pressure. An ultrasound was performed, which showed a tubular portal vein of 10 mm in diameter, with hypoechoic content and flow present. A blood culture was performed, with no bacterial development. Subsequently, an intravenous contrast medium tomography was performed, which revealed the presence of a thrombus in the portal vein and splenomesaraic trunk. After six days of established management, leukocytes of 7500/µl, platelets of 128,000/l, total bilirubin of 1.0 mg/dL, direct bilirubin of 0.6 mg/dL, ALT of 34 U/I, AST of 37 U/I and alkaline phosphatase of 189 U/l were observed. During the hospital stay, clinical improvement was observed, with normal blood pressure after the cessation of norepinephrine. The antibiotic was maintained for a week and he was discharged with rivaroxabán, 20 mg daily for three months, on the recommendation of the haematology department. The three-month review did not show any clinical alteration, in addition to normal or negative immunological profile and determination of protein C, S and antithrombin III.\n", + "fulltext_subclaims": [ + "The patient is a 24-year-old male.", + "The patient had an appendectomy performed 12 days prior to admission.", + "The patient reported a two-day course of evolution until surgical treatment.", + "The patient had nausea.", + "The patient had vomiting.", + "The patient had intense pain in the right iliac fossa.", + "The patient did not have fever.", + "The examinations revealed a mild leukocytosis of 13,200 mm3.", + "The examinations revealed platelets of 64,000 mm3.", + "An appendectomy was performed.", + "Gangrenous appendicitis was found.", + "There were no intra-abdominal collections.", + "The patient was discharged on the second day of hospital stay.", + "Cefuroxima (1 g) was prescribed from admission until five days after discharge.", + "On the second admission, the patient had a fever of three previous days.", + "The fever was not quantified.", + "Icteric skin and sclera were observed.", + "Coluria was observed.", + "The patient did not manifest any pain.", + "The patient did not manifest any fever.", + "Leukocytes were 8600/µl.", + "Platelets were 32,000/l.", + "Total bilirubin was 4.7 mg/dL.", + "Direct bilirubin was 3.9 mg/dL.", + "ALT was 129 U/I.", + "AST was 63 U/I.", + "Alkaline phosphatase was 288 U/l.", + "Lipase was 744 U/l.", + "Empirical treatment was initiated with piperacillin/tazobactam.", + "Norepinephrine was initiated due to low blood pressure.", + "An ultrasound showed a tubular portal vein of 10 mm in diameter.", + "The ultrasound showed hypoechoic content.", + "The ultrasound showed flow present.", + "A blood culture was performed.", + "No bacterial development was observed in the blood culture.", + "A tomography revealed the presence of a thrombus in the portal vein.", + "A tomography revealed the presence of a thrombus in the splenomesenteric trunk.", + "After six days of management, leukocytes were 7500/µl.", + "After six days of management, platelets were 128,000/l.", + "After six days of management, total bilirubin was 1.0 mg/dL.", + "After six days of management, direct bilirubin was 0.6 mg/dL.", + "After six days of management, ALT was 34 U/I.", + "After six days of management, AST was 37 U/I.", + "After six days of management, alkaline phosphatase was 189 U/l.", + "Clinical improvement was observed.", + "Blood pressure normalized after the cessation of norepinephrine.", + "The antibiotic was maintained for a week.", + "The patient was discharged with rivaroxaban, 20 mg daily for three months.", + "The haematology department recommended rivaroxaban.", + "The three-month review did not show any clinical alteration.", + "The immunological profile was normal or negative.", + "Protein C, S, and antithrombin III were determined." + ], + "summary": "24-year-old male patient, postoperative of appendicectomy 12 days ago. Re-admitted for three-day fever, jaundice and coluria, hyperbilirubinaemia. Intravenous contrast tomography was performed, showing thrombus in the portal-hepatic system. Pilephlebitis was diagnosed, and treatment was initiated with antibiotics and anticoagulation, with a favorable clinical evolution. Pilephlebitis has an estimated incidence of 2.7 cases per year, with a nonspecific clinical picture, ranging from an asymptomatic state to severe cases with septic shock and liver failure. Abdominal pain and fever may occur in more than 80% of cases, with leukocytosis and hyperbilirubinaemia in some cases. Intravenous contrast tomography is the study of choice. Treatment is based on four points: control of the septic focus, antibiotics, early anticoagulation and resolution of complications.\n", + "summary_subclaims": [ + "The patient is a 24-year-old male.", + "The patient had an appendicectomy 12 days ago.", + "The patient was re-admitted for a three-day fever.", + "The patient had jaundice and coluria.", + "The patient had hyperbilirubinaemia.", + "Intravenous contrast tomography showed a thrombus in the portal-hepatic system.", + "Pilephlebitis was diagnosed.", + "Treatment was initiated with antibiotics and anticoagulation.", + "The clinical evolution was favorable.", + "Pilephlebitis has an estimated incidence of 2.7 cases per year.", + "The clinical picture of pilephlebitis is nonspecific.", + "Intravenous contrast tomography is the study of choice.", + "Treatment is based on four points: control of the septic focus, antibiotics, early anticoagulation and resolution of complications." + ] + }, + { + "id": "multiclinsum_test_171_en.txt", + "fulltext": "A 44-year-old Asian man was admitted to our hospital complaining of sensory disturbances in his four extremities and trunk, as well as weakness of his upper extremities, and clumsy hand and gait disturbances. He had an unremarkable childhood, but developed tics and was diagnosed with Tourette’s syndrome at age 24. At the age of 33, he noticed numbness in his right hand, which gradually worsened. He visited a hospital for his symptoms and was diagnosed with compression myelopathy at the C3-C4 and C5-C6 levels. At the age of 38, he underwent anterior discectomy and spinal fusion with ceramics at the C3-C4 and C5-C6 levels. Two weeks later, our patient underwent an iliac bone graft at the C3-C4 and C5-C6 levels because of displacement of the ceramics. Postoperatively, he was immobilized in a halo vest for 2.5 months. After the second surgery, his spinal fusion was successful and his neurological symptoms improved. However, 5.5 years after the second surgery, he began experiencing numbness in his left leg after sustaining a fall. Subsequent to that, he presented with weakness of his right leg. He was once again diagnosed with compression myelopathy that developed at the sandwiched (C4-C5) disc level, and he underwent a C4-C5 anterior discectomy and spinal fusion at the same hospital. After the third surgery, his symptoms were temporarily relieved, but recurred 3.5 months later (one month prior to his visit to our clinic).\nOn admission to our hospital, our patient was able to walk independently but his gait was slow and unsteady. His muscle strength in the lower limbs was normal, but his deltoid, biceps and triceps muscles were somewhat weak bilaterally. His pinprick sensation was reduced up to the level of the C6 dermatome. Hyperreflexia was present at his bilateral patellar and Achilles tendons, and patellar and ankle clonus were transiently positive bilaterally. His Babinski sign was present, and his bladder function was slightly disturbed. A myelogram showed pseudoarthrosis of the C4-C5 fusion and anterior compression of the dural tube at the C4-C5 level . A computed tomographic (CT) myelogram and a magnetic resonance (MR) image showed spinal canal stenosis at the C4-C5 level .\nOur patient was prepared for surgical treatment, which was initially planned as a posterior fusion and an anterior decompression and interbody fusion with electrophysiological monitoring of spinal cord activity. We first performed posterior fusion of C3-C7 using Bohlman’s triple-wire technique, which was uneventful. Next, we performed anterior corpectomy of C4, C5 and C6, and spinal fusion at C3-C7 with a strut graft using autologous iliac bone .\nPostoperatively, our patient was fitted with a halo vest for the first three months and a cervical collar for another three months. After application of the halo vest his tics worsened, possibly due to the discomfort he felt by the immobilization of his neck, and the pins became loose several times. We had to regulate the torque of the pins every day, and replaced them four times. We treated his tics with haloperidol and his involuntary neck movements were slightly reduced. However, we could not increase the dose because of drowsiness. Botulinum toxin was not used for treating such a patient in our hospital at that time. A midsagittal CT reconstruction three months after surgery showed a mature fusion mass . A T2-weighted MR image one year after surgery revealed that his spinal cord was well decompressed . A lateral cervical radiogram taken six years after surgery showed successful interbody fusion, and a T2-weighted MR image taken at the same time detected only slight degeneration of the adjacent discs of the fusion site .\nOur patient’s neurological deficits gradually recovered after surgery. His clumsy hand movements disappeared four months after surgery, and at his last follow-up examination, 10 years after the surgery, he was able to perform all activities of daily living.", + "fulltext_subclaims": [ + "The patient is a 44-year-old Asian man.", + "He was admitted to the hospital complaining of sensory disturbances in his four extremities and trunk.", + "He had weakness of his upper extremities.", + "He had clumsy hand and gait disturbances.", + "He was diagnosed with Tourette’s syndrome at age 24.", + "At age 33, he noticed numbness in his right hand.", + "He was diagnosed with compression myelopathy at the C3-C4 and C5-C6 levels.", + "At age 38, he underwent anterior discectomy and spinal fusion with ceramics at the C3-C4 and C5-C6 levels.", + "Two weeks later, he underwent an iliac bone graft at the C3-C4 and C5-C6 levels because of displacement of the ceramics.", + "Postoperatively, he was immobilized in a halo vest for 2.5 months.", + "After the second surgery, his spinal fusion was successful.", + "His neurological symptoms improved after the second surgery.", + "Five and a half years after the second surgery, he began experiencing numbness in his left leg after a fall.", + "He was diagnosed with compression myelopathy at the sandwiched (C4-C5) disc level.", + "He underwent a C4-C5 anterior discectomy and spinal fusion at the same hospital.", + "After the third surgery, his symptoms were temporarily relieved.", + "His symptoms recurred 3.5 months after the third surgery.", + "On admission to our hospital, he was able to walk independently.", + "His gait was slow and unsteady.", + "His muscle strength in the lower limbs was normal.", + "His deltoid, biceps, and triceps muscles were somewhat weak bilaterally.", + "His pinprick sensation was reduced up to the level of the C6 dermatome.", + "Hyperreflexia was present at his bilateral patellar and Achilles tendons.", + "Patellar and ankle clonus were transiently positive bilaterally.", + "His Babinski sign was present.", + "His bladder function was slightly disturbed.", + "A myelogram showed pseudoarthrosis of the C4-C5 fusion.", + "A myelogram showed anterior compression of the dural tube at the C4-C5 level.", + "A computed tomographic myelogram showed spinal canal stenosis at the C4-C5 level.", + "A magnetic resonance image showed spinal canal stenosis at the C4-C5 level.", + "Surgical treatment was initially planned as a posterior fusion and an anterior decompression and interbody fusion with electrophysiological monitoring of spinal cord activity.", + "We first performed posterior fusion of C3-C7 using Bohlman’s triple-wire technique.", + "The posterior fusion was uneventful.", + "We performed anterior corpectomy of C4, C5, and C6.", + "We performed spinal fusion at C3-C7 with a strut graft using autologous iliac bone.", + "Postoperatively, the patient was fitted with a halo vest for the first three months.", + "Postoperatively, he was fitted with a cervical collar for another three months.", + "After application of the halo vest, his tics worsened.", + "The pins of the halo vest became loose several times.", + "We had to regulate the torque of the pins every day.", + "We replaced the pins four times.", + "We treated his tics with haloperidol.", + "His involuntary neck movements were slightly reduced.", + "We could not increase the dose of haloperidol because of drowsiness.", + "Botulinum toxin was not used for treating such a patient in our hospital at that time.", + "A midsagittal CT reconstruction three months after surgery showed a mature fusion mass.", + "A T2-weighted MR image one year after surgery revealed that his spinal cord was well decompressed.", + "A lateral cervical radiogram taken six years after surgery showed successful interbody fusion.", + "A T2-weighted MR image taken six years after surgery detected only slight degeneration of the adjacent discs of the fusion site.", + "Our patient’s neurological deficits gradually recovered after surgery.", + "His clumsy hand movements disappeared four months after surgery.", + "At his last follow-up examination, 10 years after the surgery, he was able to perform all activities of daily living." + ], + "summary": "A 44-year-old Asian man with severe motor tics due to Tourette's syndrome presented with cervical myelopathy. Previously, he had undergone an anterior discectomy and spinal fusion with ceramics at the C3-C4 and C5-C6 levels, but required further surgery because of displacement of the ceramics. After the second operation, he developed compression myelopathy at the sandwiched (C4-C5) disc level, and had to undergo a C4-C5 anterior discectomy and spinal fusion, which was unsuccessful.As a salvage operation, we performed a C3-C7 decompression and spinal fusion from both the anterior and posterior approaches. By thorough postoperative external immobilization of his neck, our patient's spinal fusion was successful and his neurological improvements were maintained for more than 10 years.", + "summary_subclaims": [ + "The patient is a 44-year-old Asian man.", + "He has severe motor tics due to Tourette's syndrome.", + "He presented with cervical myelopathy.", + "He had previously undergone an anterior discectomy and spinal fusion with ceramics at the C3-C4 and C5-C6 levels.", + "He required further surgery because of displacement of the ceramics.", + "After the second operation, he developed compression myelopathy at the sandwiched (C4-C5) disc level.", + "He had to undergo a C4-C5 anterior discectomy and spinal fusion.", + "The C4-C5 anterior discectomy and spinal fusion was unsuccessful.", + "A C3-C7 decompression and spinal fusion from both the anterior and posterior approaches was performed as a salvage operation.", + "By thorough postoperative external immobilization of his neck, the spinal fusion was successful.", + "Neurological improvements were maintained for more than 10 years." + ] + }, + { + "id": "multiclinsum_test_2904_en.txt", + "fulltext": "A 70-year-old man presented to a neurologist in February 2020 with complaints of aggressive behaviour, depressed mood, gait problems and general deterioration.\nThe patient’s medical history listed chronic axonal-demyelinating sensory-motoric polyneuropathy, peripheral arterial vascular disease, chronic kidney insufficiency, hypertension and diabetes mellitus. He also had a pacemaker, due to paroxysmal atrial fibrillation. He had quit smoking in 1995. Alcohol consumption was not clearly stated.\nClinical examination revealed general weakness and areflexia in the four limbs. Electroencephalography (EEG) was normal, as was a CT scan of the brain, according to the protocol. Nerve conduction studies and electromyography (ENMG) indicated the known polyneuropathy, most probably due to diabetes mellitus.\nA CT scan of the lumbar spine could not explain the impaired gait.\nA second contact with the same neurologist took place 4 months later. The gait problems had increased, accompanied by aggressive behaviour, loss of interest and problems with executive functioning.\nA second CT scan of the brain listed a ventriculomegaly, but not in the conclusion.\nAs treatment, the patient was advised to see a psychologist for the depressed mood and to visit a rehabilitation centre for the gait impairment. The latter recommendation was refused.\nIn November 2021, the patient went to the urologist because of urinary incontinence. A urodynamic study revealed an overactive bladder, which was treated with medication. There was no improvement at all.\nTwo months later, the patient was admitted to hospital because of generalised deterioration, acute renal insufficiency and dysregulated glycaemia. During this admission, the patient was confused and delirious. Gait problems were evident, with an increased risk of falling, as well as urinary incontinence. Rehabilitation was then started for the first time.\nLess than a few weeks after discharge, May 2022, the patient was readmitted to hospital, in the intensive care unit, after a fall with rib fractures and haemothorax. He was disoriented and developed hyperactive delirium, reported as being of multifactorial origin. At this time, ethyl abuse was mentioned. This could have explained the falls, cognitive dysfunction and delirium.\nOn admission to the rehabilitation unit (May 2022), the patient was seen for the first time by one of the authors. He had a cognitive deficit, an impaired gait with frequent falling and urinary incontinence. Upon clinical examination, cogwheel rigidity, gait impairments and ataxia were noticed. In the absence of a diagnosis, a PET scan was requested, and the imaging was reviewed by the radiologist. Heteroanamnesis with the patient’s spouse revealed that the symptoms were progressively increasing, but alcohol consumption was not mentioned. According to the spouse, the patient was no longer the same person she used to know. The triad of symptoms was recognised, and a retrograde review of imaging confirmed the suspicion of iNPH ( and ).\nFollowing the diagnosis, a diagnostic lumbar puncture was performed with drainage of 30 ml cerebrospinal fluid (CSF). Testing pre- and post-puncture indicated an increase in scores on the Mini Mental State Exam (MMSE) from 24 to 27/30. In addition, the Timed Up & Go test was significantly better. Clinical improvements were also observed in gait pattern and cognition.\nA ventriculoperitoneal shunt (VP shunt) was placed successfully: cognition improved, and both gait disturbances and urinary incontinence disappeared. Neurological examination normalised. Multidisciplinary rehabilitation was subsequently continued with favourable results, despite the long existence of the symptoms.\nUpon discharge from our ward, the patient was able to walk securely and independently. Further rehabilitation was provided at home. Vertigo and fatigue remained and were followed up by the neurologist. With the improvement of urinary incontinence, medication could be tapered off.", + "fulltext_subclaims": [ + "A 70-year-old man presented to a neurologist in February 2020 with complaints of aggressive behaviour, depressed mood, gait problems and general deterioration.", + "The patient’s medical history listed chronic axonal-demyelinating sensory-motoric polyneuropathy.", + "The patient’s medical history listed peripheral arterial vascular disease.", + "The patient’s medical history listed chronic kidney insufficiency.", + "The patient’s medical history listed hypertension.", + "The patient’s medical history listed diabetes mellitus.", + "The patient had a pacemaker due to paroxysmal atrial fibrillation.", + "He had quit smoking in 1995.", + "Alcohol consumption was not clearly stated.", + "Clinical examination revealed general weakness.", + "Clinical examination revealed areflexia in the four limbs.", + "Electroencephalography (EEG) was normal.", + "A CT scan of the brain was normal according to the protocol.", + "Nerve conduction studies and electromyography (ENMG) indicated the known polyneuropathy.", + "The polyneuropathy was most probably due to diabetes mellitus.", + "A CT scan of the lumbar spine could not explain the impaired gait.", + "A second contact with the same neurologist took place 4 months later.", + "The gait problems had increased.", + "The gait problems were accompanied by aggressive behaviour.", + "The gait problems were accompanied by loss of interest.", + "The gait problems were accompanied by problems with executive functioning.", + "A second CT scan of the brain listed a ventriculomegaly, but not in the conclusion.", + "The patient was advised to see a psychologist for the depressed mood.", + "The patient was advised to visit a rehabilitation centre for the gait impairment.", + "The recommendation to visit a rehabilitation centre was refused.", + "In November 2021, the patient went to the urologist because of urinary incontinence.", + "A urodynamic study revealed an overactive bladder.", + "The overactive bladder was treated with medication.", + "There was no improvement at all.", + "Two months later, the patient was admitted to hospital because of generalised deterioration.", + "Two months later, the patient was admitted to hospital because of acute renal insufficiency.", + "Two months later, the patient was admitted to hospital because of dysregulated glycaemia.", + "During this admission, the patient was confused and delirious.", + "Gait problems were evident, with an increased risk of falling.", + "Urinary incontinence was present.", + "Rehabilitation was then started for the first time.", + "Less than a few weeks after discharge, May 2022, the patient was readmitted to hospital.", + "The patient was readmitted to the intensive care unit after a fall with rib fractures and haemothorax.", + "He was disoriented.", + "He developed hyperactive delirium, reported as being of multifactorial origin.", + "At this time, ethyl abuse was mentioned.", + "This could have explained the falls, cognitive dysfunction and delirium.", + "On admission to the rehabilitation unit (May 2022), the patient was seen for the first time by one of the authors.", + "He had a cognitive deficit.", + "He had an impaired gait with frequent falling.", + "He had urinary incontinence.", + "Upon clinical examination, cogwheel rigidity was noticed.", + "Upon clinical examination, gait impairments were noticed.", + "Upon clinical examination, ataxia was noticed.", + "In the absence of a diagnosis, a PET scan was requested.", + "The imaging was reviewed by the radiologist.", + "Heteroanamnesis with the patient’s spouse revealed that the symptoms were progressively increasing.", + "Alcohol consumption was not mentioned.", + "The triad of symptoms was recognised.", + "A retrograde review of imaging confirmed the suspicion of iNPH.", + "A diagnostic lumbar puncture was performed with drainage of 30 ml cerebrospinal fluid (CSF).", + "Testing pre- and post-puncture indicated an increase in scores on the Mini Mental State Exam (MMSE) from 24 to 27/30.", + "The Timed Up & Go test was significantly better.", + "Clinical improvements were also observed in gait pattern and cognition.", + "A ventriculoperitoneal shunt (VP shunt) was placed successfully.", + "Cognition improved.", + "Both gait disturbances and urinary incontinence disappeared.", + "Neurological examination normalised.", + "Multidisciplinary rehabilitation was subsequently continued with favourable results.", + "Upon discharge from our ward, the patient was able to walk securely and independently.", + "Further rehabilitation was provided at home.", + "Vertigo and fatigue remained.", + "They were followed up by the neurologist.", + "With the improvement of urinary incontinence, medication could be tapered off." + ], + "summary": "This patient developed several symptoms over time. First, he presented with depressive mood and altered behaviour. He later developed gait difficulties and, finally, urinary incontinence. Multiple consultations and examinations failed to provide an exact explanation for all his symptoms. After 2 years, a new doctor at the hospital started from scratch and recognised the iNPH triad, and the diagnosis was confirmed by the radiologist.", + "summary_subclaims": [ + "The patient developed several symptoms over time.", + "He presented with depressive mood.", + "He had altered behaviour.", + "He later developed gait difficulties.", + "He finally developed urinary incontinence.", + "Multiple consultations and examinations failed to provide an exact explanation for all his symptoms.", + "After 2 years, a new doctor at the hospital started from scratch.", + "The new doctor recognised the iNPH triad.", + "The diagnosis was confirmed by the radiologist." + ] + }, + { + "id": "multiclinsum_test_276_en.txt", + "fulltext": "A 12-year-old girl was referred to our university hospital for short stature with a dysmorphic facies for evaluation. She was the second child of four siblings, of parents who were first-degree cousins. The maternal and neonatal history was uneventful. There was no history of similar illness in the family. The patient reported loss of teeth and nails at the age of 2 years and gave a history of multiple fractures of the long bones resulting after trivial fall: two of the right tibia and one of the left tibia. On physical examination, she had the following features: standing height at 117 cm (- 5 SDS), the cranial perimeter was 47.5 cm, sexual maturity rating showed pre-adolescent stage, presenting facial dysmorphia, limited mouth opening, short hands and feet with dysplastic nails ; frontal and occipital bossing; and hypoplasia of the maxilla and mandible . Examination of the mouth: grooved palate, caries of the teeth, impacted and malposed teeth, persistent deciduous teeth and missing teeth . Audiometry showed mild conductive hearing loss. Fundus examination was normal. Laboratory investigations such as complete blood count, serum calcium, phosphate, 25- hydroxy vitamin D, alkaline phosphatase, and hormonal balance (tetraiodothyronine, cortisol, and insulin growth factor 1) were normal. The radiographic examination showed a generalized increase in the bone density and horizontal fissure in the middle portion of the tibial shaft, but without obliteration of the medulary canals. . Radiography of the skull showed sutures and fontanelles closed, slight condensation of the skull base and a very open mandibular angle . X-rays showed tapered phalanges with acro-osteolysis of the distal phalanges of the 1st and 2nd row . The bone age was 11.5 years. These clinical and radiological characteristics are in favor of a pycnodysostosis. Since there is no specific treatment, and for the financial constraints of the patient (not allowing her a growth hormone therapy), a symptomatic treatment was proposed based: on fracture prevention, oral hygiene, frequent dental visits and psychiatric support.", + "fulltext_subclaims": [ + "The patient is a 12-year-old girl.", + "She was referred for short stature with a dysmorphic facies.", + "She is the second child of four siblings.", + "Her parents are first-degree cousins.", + "The maternal and neonatal history was uneventful.", + "There was no history of similar illness in the family.", + "The patient reported loss of teeth and nails at the age of 2 years.", + "She had multiple fractures of the long bones after trivial falls.", + "She had two fractures of the right tibia.", + "She had one fracture of the left tibia.", + "On physical examination, her standing height was 117 cm (-5 SDS).", + "She had facial dysmorphia.", + "She had limited mouth opening.", + "She had short hands and feet with dysplastic nails.", + "She had frontal and occipital bossing.", + "She had hypoplasia of the maxilla and mandible.", + "Examination of the mouth showed grooved palate.", + "Examination of the mouth showed caries of the teeth.", + "Examination of the mouth showed impacted and malposed teeth.", + "Examination of the mouth showed persistent deciduous teeth.", + "Examination of the mouth showed missing teeth.", + "Audiometry showed mild conductive hearing loss.", + "Fundus examination was normal.", + "Laboratory investigations showed normal complete blood count.", + "Laboratory investigations showed normal serum calcium.", + "Laboratory investigations showed normal phosphate.", + "Laboratory investigations showed normal 25-hydroxy vitamin D.", + "Laboratory investigations showed normal alkaline phosphatase.", + "Laboratory investigations showed normal tetraiodothyronine.", + "Laboratory investigations showed normal cortisol.", + "Laboratory investigations showed normal insulin growth factor 1.", + "Radiographic examination showed generalized increase in bone density.", + "Radiographic examination showed horizontal fissure in the middle portion of the tibial shaft.", + "Radiographic examination showed no obliteration of the medulary canals.", + "Radiography of the skull showed closed sutures and fontanelles.", + "Radiography of the skull showed slight condensation of the skull base.", + "Radiography of the skull showed a very open mandibular angle.", + "X-rays showed tapered phalanges with acro-osteolysis of the distal phalanges of the 1st and 2nd row.", + "The bone age was 11.5 years.", + "These clinical and radiological characteristics are in favor of pycnodysostosis.", + "There is no specific treatment.", + "The patient's financial constraints do not allow growth hormone therapy.", + "A symptomatic treatment was proposed.", + "The treatment included fracture prevention.", + "The treatment included oral hygiene.", + "The treatment included frequent dental visits.", + "The treatment included psychiatric support." + ], + "summary": "A 12-year-female was admitted in our institute for short stature with a dysmorphic facies for evaluation. The patient reported a history of multiple fractures of the long bones after a trivial fall. On physical examination, she had the following features: short stature, limited mouth opening, short hands and feet with dysplastic nails; frontal and occipital bossing; and hypoplasia of the maxilla and mandible. Examination of the mouth: grooved palate, caries of the teeth, impacted and malposed teeth, persistent deciduous teeth and missing teeth. Laboratory investigations were normal. The radiographic examination showed a generalized increase in the bone density, slight condensation of the skull base and a very open mandibular angle. X-rays showed tapered phalanges with acro-osteolysis of the distal phalanges. A symptomatic treatment was proposed based on fracture prevention, oral hygiene, frequent dental visits and psychiatric support.", + "summary_subclaims": [ + "A 12-year-old female was admitted for short stature with a dysmorphic facies for evaluation.", + "The patient reported a history of multiple fractures of the long bones after a trivial fall.", + "On physical examination, she had short stature.", + "On physical examination, she had limited mouth opening.", + "On physical examination, she had short hands and feet with dysplastic nails.", + "On physical examination, she had frontal and occipital bossing.", + "On physical examination, she had hypoplasia of the maxilla and mandible.", + "Examination of the mouth showed grooved palate.", + "Examination of the mouth showed caries of the teeth.", + "Examination of the mouth showed impacted and malposed teeth.", + "Examination of the mouth showed persistent deciduous teeth.", + "Examination of the mouth showed missing teeth.", + "Laboratory investigations were normal.", + "Radiographic examination showed a generalized increase in bone density.", + "Radiographic examination showed slight condensation of the skull base.", + "Radiographic examination showed a very open mandibular angle.", + "X-rays showed tapered phalanges with acro-osteolysis of the distal phalanges.", + "A symptomatic treatment was proposed based on fracture prevention.", + "A symptomatic treatment was proposed based on oral hygiene.", + "A symptomatic treatment was proposed based on frequent dental visits.", + "A symptomatic treatment was proposed based on psychiatric support." + ] + }, + { + "id": "multiclinsum_test_2625_en.txt", + "fulltext": "A previously healthy 16-year-old female presented with a four-day history of abdominal pain, vomiting, fever, headache, myalgias and cough. Her initial vital signs in the referring emergency department were temperature 39.4° Celsius, pulse 154, respiratory rate 16, blood pressure 115/61, and oxygen saturation 96 %. Physical examination was notable for pallor and right lower quadrant (RLQ) abdominal tenderness without guarding or rebound. Initial laboratory testing significant for white blood cell (WBC) count 5.8 10^3/uL (reference range 4-10.5) with 93 % neutrophils, hemoglobin 11.9 g/dL (12–15), platelets 102 10^3/uL (150–450), C-reactive protein 11 mg/dL (0–1.0), erythrocyte sedimentation rate 26 mm/hr (0–20), and procalcitonin 0.50 ng/mL (< 0.09). Urine hCG negative. Urinalysis showed trace leukocyte esterase (negative), negative nitrites, and 1–5 WBCs (0). Contrast-enhanced computed tomography (CT) of the abdomen/pelvis showed mesenteric edema, dilation of the appendix (8mm), and fat stranding throughout the lower abdomen and pelvis. She received two intravenous (IV) fluid boluses, anti-pyrectics and was transferred to our pediatric hospital.\nOn arrival she was evaluated by the pediatric surgery team who felt her presentation was not consistent with acute appendicitis. Further history and exam revealed that she had mild bilateral conjunctival injection and neck tenderness in addition to RLQ pain and had a positive SARS-CoV-2 polymerase chain reaction (PCR) test one month prior (she was asymptomatic but underwent testing due to several family members testing positive).\nAdditional labs were obtained with concern for MIS-C and were significant for a positive SARS-CoV-2 IgG antibody test and normal troponin and N-terminal Pro-Brain Natriuretic Peptide. Given fever, positive SARS-CoV-2 IgG, laboratory evidence of inflammation, and multisystem involvement she was hospitalized for further monitoring and treatment of MIS-C.\nOvernight, the patient was persistently febrile and tachycardic. She also reported increasing RLQ pain and exhibited new abdominal rebound tenderness. The attending pediatric radiologist’s review of the prior CT concluded that the imaging was consistent with acute appendicitis as there was dilation of the appendix, measuring 8 mm, mild appendiceal mucosal hyperenhancement and adjacent mesenteric fat stranding . The patient’s care was re-discussed with pediatric surgery and together the multidisciplinary team was unable to definitively rule out appendicitis as a concurrent pathology. While a diagnosis of MIS-C generally requires exclusion of other etiologies, it was felt that she could have appendicitis and MIS-C simultaneously. Empiric treatment for appendicitis was started with piperacillin-tazobactam. The surgical team reviewed the risks and benefits of non-operative management with continued antibiotics versus diagnostic laparoscopy and appendectomy. Surgical management was selected. Echocardiogram was obtained to assess for cardiac involvement and showed normal cardiac function and no dilation of the coronary arteries. She remained stable on the acute floor on hospital day two and therapy with intravenous immune globulin (IVIG) and aspirin were ordered for treatment of MIS-C. However, given the timing of when surgery could take her to the operating room, she underwent diagnostic laparoscopy and appendectomy first. She was found to have a grossly normal appendix with no inflammation to suggest appendicitis . As a surgeon’s intra-operative “eyeball” assessment of appendicitis is not perfect and the risk of appendectomy while undergoing laparoscopy is low the decision was made to complete appendectomy. Histologic findings revealed only mild chronic serosal inflammation and edematous mesothelium; it did not show the transmural acute inflammation diagnostic of appendicitis. Piperacillin-tazobactam was discontinued and the patient was returned to the acute care floor for post-surgical monitoring and MIS-C treatment with IVIG infusion (2 g/kg) and aspirin (81 mg).\nOn hospital day three she completed IVIG therapy, and her blood pressure and fever curve improved. Repeat labs showed worsening lymphocytopenia, anemia, and thrombocytopenia and hypoalbuminemia. She then developed tachycardia and hypotension refractory to fluid resuscitation and given concern for refractory MIS-C, she was started on corticosteroid therapy (2 mg/kg twice daily). She was transferred to the intensive care unit and started on norepinephrine (0.02 mcg/kg/min) for hemodynamic support, which she required for 24 hours. The patient stabilized and was then transferred back to the acute care floor with improvement of her pancytopenia over the next two days. She was discharged home in stable condition on day seven of hospitalization to complete a course of low dose aspirin and a steroid taper.\nAt her follow-up cardiology appointment four weeks after discharge, she was asymptomatic, but echocardiogram showed moderately dilated right and left coronary arteries with normal ventricular function. She remained on daily aspirin with close cardiology follow up to monitor progression of her coronary involvement.", + "fulltext_subclaims": [ + "The patient is a 16-year-old female.", + "She had a four-day history of abdominal pain, vomiting, fever, headache, myalgias, and cough.", + "Her initial temperature was 39.4° Celsius.", + "Her initial pulse was 154.", + "Her initial oxygen saturation was 96%.", + "Physical examination was notable for pallor and right lower quadrant abdominal tenderness without guarding or rebound.", + "Initial laboratory testing showed a white blood cell count of 5.8 10^3/uL.", + "Initial laboratory testing showed 93% neutrophils.", + "Initial laboratory testing showed hemoglobin 11.9 g/dL.", + "Initial laboratory testing showed platelets 102 10^3/uL.", + "Initial laboratory testing showed C-reactive protein 11 mg/dL.", + "Initial laboratory testing showed procalcitonin 0.50 ng/mL.", + "Urine hCG was negative.", + "Urinalysis showed trace leukocyte esterase.", + "Contrast-enhanced CT of the abdomen/pelvis showed mesenteric edema.", + "Contrast-enhanced CT showed dilation of the appendix measuring 8 mm.", + "Contrast-enhanced CT showed fat stranding throughout the lower abdomen and pelvis.", + "She received two intravenous fluid boluses.", + "She was transferred to a pediatric hospital.", + "The pediatric surgery team felt her presentation was not consistent with acute appendicitis.", + "She had a positive SARS-CoV-2 PCR test one month prior.", + "She was asymptomatic at the time of the positive SARS-CoV-2 PCR test.", + "Additional labs showed a positive SARS-CoV-2 IgG antibody test.", + "Additional labs showed normal troponin.", + "Additional labs showed normal N-terminal Pro-Brain Natriuretic Peptide.", + "She was hospitalized for further monitoring and treatment of MIS-C.", + "Overnight, the patient was persistently febrile and tachycardic.", + "The patient reported increasing RLQ pain.", + "The patient exhibited new abdominal rebound tenderness.", + "The attending pediatric radiologist’s review of the prior CT concluded that the imaging was consistent with acute appendicitis.", + "The multidisciplinary team was unable to definitively rule out appendicitis as a concurrent pathology.", + "Empiric treatment for appendicitis was started with piperacillin-tazobactam.", + "The surgical team reviewed the risks and benefits of non-operative management with continued antibiotics versus diagnostic laparoscopy and appendectomy.", + "Surgical management was selected.", + "Echocardiogram showed normal cardiac function.", + "Echocardiogram showed no dilation of the coronary arteries.", + "She underwent diagnostic laparoscopy and appendectomy.", + "The surgeon found a grossly normal appendix with no inflammation to suggest appendicitis.", + "Histologic findings revealed only mild chronic serosal inflammation and edematous mesothelium.", + "Histologic findings did not show transmural acute inflammation diagnostic of appendicitis.", + "Piperacillin-tazobactam was discontinued.", + "The patient was returned to the acute care floor for post-surgical monitoring.", + "Therapy with intravenous immune globulin and aspirin were ordered for treatment of MIS-C.", + "On hospital day three, she completed IVIG therapy.", + "Her blood pressure and fever curve improved.", + "Repeat labs showed worsening lymphocytopenia, anemia, and thrombocytopenia.", + "Repeat labs showed hypoalbuminemia.", + "She developed tachycardia and hypotension refractory to fluid resuscitation.", + "She was started on corticosteroid therapy.", + "She was transferred to the intensive care unit.", + "She was started on norepinephrine for hemodynamic support.", + "She required norepinephrine for 24 hours.", + "The patient stabilized and was transferred back to the acute care floor.", + "She was discharged home on day seven of hospitalization.", + "At her follow-up cardiology appointment four weeks after discharge, she was asymptomatic.", + "Echocardiogram showed moderately dilated right and left coronary arteries.", + "Echocardiogram showed normal ventricular function.", + "She remained on daily aspirin with close cardiology follow-up." + ], + "summary": "We describe the case of a 16-year-old female who presented with clinical symptoms suggestive of appendicitis and an abdominal computed tomography (CT) that revealed features concerning for appendicitis. After laparoscopic appendectomy, histopathology of the appendix demonstrated only mild serosal inflammation and was not consistent with acute appendicitis. Her overall clinical presentation was felt to be consistent with MIS-C and she subsequently improved with immunomodulatory and steroid treatment.", + "summary_subclaims": [ + "The patient was a 16-year-old female.", + "The patient presented with clinical symptoms suggestive of appendicitis.", + "An abdominal computed tomography (CT) revealed features concerning for appendicitis.", + "After laparoscopic appendectomy, histopathology of the appendix demonstrated only mild serosal inflammation.", + "The histopathology was not consistent with acute appendicitis.", + "Her overall clinical presentation was felt to be consistent with MIS-C.", + "She subsequently improved with immunomodulatory and steroid treatment." + ] + }, + { + "id": "multiclinsum_test_1118_en.txt", + "fulltext": "The patient is a 69-year-old female who underwent a right radical nephrectomy 10 years ago, in 2011 for a pT3b N1 M0 grade 3 clear cell carcinoma of the right kidney. Adjuvant sunitinib therapy was initiated and then discontinued after 2 months due to myelosuppression and rash. In February 2013, the patient was found to have recurrence in the right lung upon follow-up CT imaging. The patient was started on sunitinib and then switched to pazopanib February 2014 due to progression. Pazopanib was held briefly during radical radiotherapy to oligometastatic disease.\nThe patient developed hypertension a couple of months after starting pazopanib. This was effectively treated with amlodipine. After persistently stable disease, she made a joint decision with her oncologist to discontinue her pazopanib June 2019. She did not experience any other side effects while on pazopanib except for some moderate gastric reflux. Her past medical history is only significant for hypothyroidism and hiatal hernia. She has family history of a father who died in his 60s of a myocardial infarction and sisters with hypertension. She has a substance history of a remote 3 pack year smoking history and occasional alcohol use. Her most recent BMI was calculated to be 24.4.\nIn July 2020, CT imaging showed recurrence with enlargement of a left apical pulmonary nodule. She received radical intent radiotherapy with a dose of 60 Gray in 30 fractions, then she was started back on pazopanib. Due to severe reflux symptoms and the development of atrial fibrillation, pazopanib was briefly held January 2021 and restarted February 22, 2021. She was also placed on bisoprolol and warfarin by her cardiologist during this period. CT of her chest, abdomen, and pelvis on February 10, 2021 did not reveal any signs of disease progression and demonstrated normal splenic artery anatomy .\nOn March 5, 2021 at 10 pm, the patient suddenly developed excruciating, sharp left upper quadrant pain that radiated to her entire abdomen. She had associated nausea and loose bowel movements but no vomiting, fever, lightheadedness, rashes or petechiae. She activated emergency medical services and was brought to her local emergency department in Northern Ontario. Her pain improved with IV opioid analgesics, but her abdomen became continually distended and her hemoglobin dropped into the low 70s. A CT of her abdomen and pelvis was performed to reveal free fluid within the peritoneal cavity and contrast pooling noted adjacent the splenic hilum, related to the splenic artery . The splenic artery measured 1.5 cm representing either a ruptured aneurysm or pseudoaneurysm. The patient ultimately received Vitamin K, 6 units of red blood cells and was transferred to a tertiary center elsewhere in Ontario for definitive treatment of her ruptured splenic artery aneurysm.\nShe had coil embolization of the splenic artery by intervention radiology . Her recovery was complicated by a post-operative hematoma and elevated troponin, no intervention was required.\nAfter an extended stay in hospital, the patient was discharged home and pazopanib was discontinued. In a follow-up appointment, the patient does not disclose any complaints and states her home blood pressure has been stable. The patient remains in good health at the time of writing this case report.", + "fulltext_subclaims": [ + "The patient is a 69-year-old female.", + "She underwent a right radical nephrectomy 10 years ago, in 2011.", + "The nephrectomy was for a pT3b N1 M0 grade 3 clear cell carcinoma of the right kidney.", + "Adjuvant sunitinib therapy was initiated.", + "Sunitinib was discontinued after 2 months due to myelosuppression and rash.", + "In February 2013, the patient was found to have recurrence in the right lung upon follow-up CT imaging.", + "The patient was started on sunitinib.", + "The patient was switched to pazopanib in February 2014 due to progression.", + "Pazopanib was held briefly during radical radiotherapy to oligometastatic disease.", + "The patient developed hypertension a couple of months after starting pazopanib.", + "Hypertension was effectively treated with amlodipine.", + "She made a joint decision with her oncologist to discontinue pazopanib in June 2019.", + "She did not experience any other side effects while on pazopanib except for some moderate gastric reflux.", + "Her past medical history is only significant for hypothyroidism and hiatal hernia.", + "Her most recent BMI was calculated to be 24.4.", + "In July 2020, CT imaging showed recurrence with enlargement of a left apical pulmonary nodule.", + "She received radical intent radiotherapy with a dose of 60 Gray in 30 fractions.", + "She was started back on pazopanib.", + "Pazopanib was briefly held in January 2021 due to severe reflux symptoms and the development of atrial fibrillation.", + "Pazopanib was restarted on February 22, 2021.", + "She was placed on bisoprolol and warfarin by her cardiologist during this period.", + "CT of her chest, abdomen, and pelvis on February 10, 2021 did not reveal any signs of disease progression.", + "The CT demonstrated normal splenic artery anatomy.", + "On March 5, 2021 at 10 pm, the patient suddenly developed excruciating, sharp left upper quadrant pain that radiated to her entire abdomen.", + "She had associated nausea and loose bowel movements.", + "She had no vomiting, fever, lightheadedness, rashes, or petechiae.", + "She was brought to her local emergency department in Northern Ontario.", + "Her pain improved with IV opioid analgesics.", + "Her abdomen became continually distended.", + "Her hemoglobin dropped into the low 70s.", + "A CT of her abdomen and pelvis was performed.", + "The CT revealed free fluid within the peritoneal cavity.", + "The CT showed contrast pooling noted adjacent the splenic hilum, related to the splenic artery.", + "The splenic artery measured 1.5 cm representing either a ruptured aneurysm or pseudoaneurysm.", + "The patient received Vitamin K.", + "The patient received 6 units of red blood cells.", + "The patient was transferred to a tertiary center elsewhere in Ontario for definitive treatment of her ruptured splenic artery aneurysm.", + "She had coil embolization of the splenic artery by intervention radiology.", + "Her recovery was complicated by a post-operative hematoma.", + "Her recovery was complicated by elevated troponin.", + "No intervention was required.", + "After an extended stay in hospital, the patient was discharged home.", + "Pazopanib was discontinued.", + "In a follow-up appointment, the patient does not disclose any complaints.", + "The patient states her home blood pressure has been stable.", + "The patient remains in good health at the time of writing this case report." + ], + "summary": "Here we report a 69-year-old patient with minimal cardiovascular risk factors who developed a rupture of a splenic arterial aneurysm after more than 5 years of effective treatment with pazopanib for metastatic renal cell carcinoma.", + "summary_subclaims": [ + "The patient was 69 years old.", + "The patient had minimal cardiovascular risk factors.", + "The patient developed a rupture of a splenic arterial aneurysm.", + "The patient had been receiving pazopanib for more than 5 years.", + "The pazopanib treatment was effective.", + "The pazopanib was used for metastatic renal cell carcinoma." + ] + }, + { + "id": "multiclinsum_test_2607_en.txt", + "fulltext": "A 71-year-old Chinese man presented with urinary hesitancy, dribbling urination, and prolonged urination and was diagnosed as benign prostatic hyperplasia at out-patient one year ago. The serum creatinine was 101 μmol/L (normal range 53~140 μmol/L) at that moment. He was prescribed with epristeride and tamsulosin. Nine months ago, the patient stopped the oral medication because of loss of appetite. The symptoms of urinary hesitancy, dribbling and prolonged urination worsened gradually and therefore he was admitted to our hospital for surgery. On admission, the renal function test revealed a serum creatinine level of 291.0 μmol/L. The post-void residual was normal. The ultrasonic examination revealed that both kidneys were normal in structure and size (left 11.6 cm × 6.3 cm,right 10.7 cm × 4.4 cm). Obstructive nephropathy was thus excluded and the surgery was canceled for renal dysfunction. The patient was transferred to renal division of internal medicine department where additional tests were performed in order to establish the etiology of his documented renal failure. The results of routine peripheral blood test were as follows: hemoglobin 89 g/L (normal range 130~175 g/L), white blood cells 5.21 × 109/L (normal range 3.5~9.55.21 × 109/L), and platelets 204 × 109/L (normal range 100~300 × 109/L). Urinalysis was positive for 1+ protein. Red blood cells and white blood cells were negative in urine sediment microscopic examination. The 24 h urinary protein determination was 0.67 g. Fecal occult blood testing was positive. In addition, the serum creatinine level increased to 415 μmol/L. The immunology tests revealed the following: anti-nuclear antibody + 1:100, rheumatoid factor 149 IU/ml (normal range < 20 IU/ml), IgG 23 g/L (normal range 8~15.5 g/L), serum IgG4 13.9 g/L (normal range 0.035~1.5 g/L), IgE 288.7 IU/ml (normal range 0.1~150 IU/ml), C3 0.4310 g/L (normal range 0.785~1.520 g/L), C4 0.0362 g/L (normal range 0.145~0.360 g/L). The direct Coomb’s test was negative. The anti-neutrophil cytoplasmic antibodies and anti-glomerular basement membrane antibody were both negative. The abdominal ultrasonography revealed multiple solid nodules in the liver. Magnetic resonance imaging (MRI) confirmed multiple liver parenchymal round shaped long T1 and long T2 signal nodules, with a diameter of between 0.6 and 16 cm. The nodules revealed mild enhancement during arterial enhancement phase with some of them showed a decline of enhancement during portal enhancement period. Since the patient has gastrointestinal symptoms in combination with positive fecal occult blood test and moderate anemia, a gastrointestinal endoscopy was performed and It showed a circular cauliflower shaped, ulcerative mass at the middle section of the transverse colon. Biopsies of the mass revealed adenocarcinoma .\nFor evaluation of renal dysfunction, a renal biopsy was performed. The pathological findings in light microscopy demonstrated glomerular sclerosis in two of twelve glomeruli whereas the other glomeruli demonstrated only mild lesions. The periodic acid-silver metheramine and Masson’s trichrome stainings showed 75% interstitial fibrosis and tubular atrophy in the tubulointerstitial area. In the fibrotic interstitial compartment, collagen fibers exhibited a storiform pattern, with massive lymphocyte and plasma cells infiltration. Immunohistochemical staining showed more than 30 IgG4-positive plasma cells per high-power field . Immunofluorescence testing was negative for IgG, IgA, IgM, C3, C4, C1q, κ chain, and λ chains in glomeruli. A diagnosis of IgG4-related tubulointerstitial nephritis (IgG4-TIN) was thus made.\nAs previously established, both IgG4-related disease and metastasis of gastrointestinal tumor could cause hepatic occupying lesions. In that sense, liver nodules in the current case could be secondary to either IgG4-related tubulointerstitial nephritis or remote metastasis from colon adenocarcinoma. Prednisone of 1 mg/kg daily was initiated with the objective to treat IgG4-TIN. On the one hand, the treatment might improve renal function, the improvement of renal function would then create better conditions for chemotherapy or surgery of adenocarcinoma treatment. On the other hand, the imaging response of hepatic nodules to glucocorticoid administration might suggest whether the nodules were malignancy or IgG4-related pseudo-tumor. One and a half month later, the serum creatinine had decreased from 415 to 246 μmol/L, and the serum IgG4 level dropped from 13.9 g/L to 5.3 g/L. However, the repeat MRI revealed no diminution of hepatic nodules. A liver biopsy was performed and atypical glands were founded in the specimen . Based on the findings of immunohistochemistry of the specimen and clinical data, a diagnosis of adenocarcinoma with hepatic metastasis was made. Chemotherapy was recommended by the Oncology team although impaired renal function was a contraindication. Prednisone was continued to improve kidney function in order to propitiate conditions for chemotherapy administration. Prednisone was gradually tapered and 14 weeks later, the serum creatinine level was 207 μmol/L and the serum IgG4 level was 1.41 g/L . Unfortunately, five months later, the patient’s general condition deteriorated quickly. The patient suffered from anorexia and poor mental state. During the last follow-up, occurring half-year later, the patient experienced shortness of breath but refused to be admitted and died two days later. The last serum creatinine level tested was 176 μmol/L.", + "fulltext_subclaims": [ + "The patient is a 71-year-old Chinese man.", + "He presented with urinary hesitancy, dribbling urination, and prolonged urination.", + "He was diagnosed with benign prostatic hyperplasia at out-patient one year ago.", + "The serum creatinine was 101 μmol/L at that moment.", + "The normal range for serum creatinine is 53~140 μmol/L.", + "He was prescribed epristeride and tamsulosin.", + "Nine months ago, the patient stopped the oral medication because of loss of appetite.", + "The symptoms of urinary hesitancy, dribbling, and prolonged urination worsened gradually.", + "He was admitted to the hospital for surgery.", + "On admission, the renal function test revealed a serum creatinine level of 291.0 μmol/L.", + "The post-void residual was normal.", + "The ultrasonic examination revealed that both kidneys were normal in structure and size.", + "Obstructive nephropathy was thus excluded.", + "The surgery was canceled for renal dysfunction.", + "The patient was transferred to the renal division of the internal medicine department.", + "The hemoglobin was 89 g/L.", + "The normal range for hemoglobin is 130~175 g/L.", + "Urinalysis was positive for 1+ protein.", + "The 24 h urinary protein determination was 0.67 g.", + "Fecal occult blood testing was positive.", + "The serum creatinine level increased to 415 μmol/L.", + "The anti-nuclear antibody was positive at 1:100.", + "The rheumatoid factor was 149 IU/ml.", + "The normal range for rheumatoid factor is < 20 IU/ml.", + "The serum IgG4 was 13.9 g/L.", + "The normal range for serum IgG4 is 0.035~1.5 g/L.", + "The abdominal ultrasonography revealed multiple solid nodules in the liver.", + "Magnetic resonance imaging confirmed multiple liver parenchymal round shaped long T1 and long T2 signal nodules.", + "The nodules revealed mild enhancement during arterial enhancement phase.", + "A gastrointestinal endoscopy showed a circular cauliflower shaped, ulcerative mass at the middle section of the transverse colon.", + "Biopsies of the mass revealed adenocarcinoma.", + "The renal biopsy showed glomerular sclerosis in two of twelve glomeruli.", + "The periodic acid-silver metheramine and Masson’s trichrome stainings showed 75% interstitial fibrosis and tubular atrophy.", + "Immunohistochemical staining showed more than 30 IgG4-positive plasma cells per high-power field.", + "A diagnosis of IgG4-related tubulointerstitial nephritis (IgG4-TIN) was made.", + "Prednisone of 1 mg/kg daily was initiated.", + "One and a half month later, the serum creatinine had decreased from 415 to 246 μmol/L.", + "The serum IgG4 level dropped from 13.9 g/L to 5.3 g/L.", + "The repeat MRI revealed no diminution of hepatic nodules.", + "A liver biopsy was performed.", + "Atypical glands were found in the specimen.", + "A diagnosis of adenocarcinoma with hepatic metastasis was made.", + "Prednisone was continued to improve kidney function.", + "14 weeks later, the serum creatinine level was 207 μmol/L.", + "The serum IgG4 level was 1.41 g/L.", + "Five months later, the patient’s general condition deteriorated quickly.", + "The patient suffered from anorexia and poor mental state.", + "During the last follow-up, occurring half-year later, the patient experienced shortness of breath.", + "The patient refused to be admitted and died two days later.", + "The last serum creatinine level tested was 176 μmol/L." + ], + "summary": "A 71-year-old Chinese man presented with dysuria and was initially diagnosed as benign prostatic hyperplasia for one year. He was admitted to the hospital for surgery. After admission, the renal function tests revealed a rapid increase of serum creatinine from 291.0 μmol/L to 415 μmol/L. The hemoglobin level was 89 g/L. Fecal occult blood testing was positive. Urinalysis revealed mild proteinuria. The serum IgG4 level was 13.9 g/L. The abdominal imaging examination revealed multiple solid nodules in the liver. The gastrointestinal endoscopy combined with the biopsy revealed colon adenocarcinoma. Kidney biopsy showed massive IgG4-positive plasma cells and storiform fibrosis infiltration in the tubulointerstitial area, thus establishing the diagnosis of IgG4-related tubulointerstitial nephritis. Corticosteroid therapy was initiated, and subsequently, the renal function dramatically improved without the diminution of the liver nodules. The liver biopsy was performed and a diagnosis of metastatic colon adenocarcinoma was confirmed.", + "summary_subclaims": [ + "The patient is a 71-year-old Chinese man.", + "He presented with dysuria.", + "He was initially diagnosed with benign prostatic hyperplasia for one year.", + "He was admitted to the hospital for surgery.", + "After admission, the serum creatinine increased from 291.0 μmol/L to 415 μmol/L.", + "The hemoglobin level was 89 g/L.", + "Fecal occult blood testing was positive.", + "Urinalysis revealed mild proteinuria.", + "The serum IgG4 level was 13.9 g/L.", + "Abdominal imaging revealed multiple solid nodules in the liver.", + "Gastrointestinal endoscopy combined with biopsy revealed colon adenocarcinoma.", + "Kidney biopsy showed massive IgG4-positive plasma cells and storiform fibrosis infiltration in the tubulointerstitial area.", + "The diagnosis of IgG4-related tubulointerstitial nephritis was established.", + "Corticosteroid therapy was initiated.", + "The renal function dramatically improved.", + "The liver nodules did not diminish.", + "Liver biopsy confirmed a diagnosis of metastatic colon adenocarcinoma." + ] + }, + { + "id": "multiclinsum_test_735_en.txt", + "fulltext": "A 25-year-old Asian man presented to our department 2 days after a penile trauma with perineal pain and erectile dysfunction. The patient was injured during rolling over in bed and heard a “snap” sound just before pain. Physical examination showed swelling of the perineum with subcutaneous bleeding and tenderness. However, the appearance of the penis was normal. His laboratory data were within the normal limits, and hematuria was not detected on urinalysis. Ultrasonography revealed a hematoma in the perineum without any testicular injury. MRI showed a subcutaneous perineal hematoma and a 6-mm tear to the ventral tunica albuginea of the left crus penis near the bulbospongiosus muscle . He was diagnosed with PF associated with a penile crus injury. Six days after injury, repair of the tear at the left penile crus was performed. The transperineal approach was selected because the injured area was near the bulbospongiosus muscle. Subcutaneous bleeding expanded into his hip. However, a penis deformity was not found . Just before surgery, we were able to insert a 14-Fr Foley’s catheter smoothly through his urethra and no urethral injury was observed. We made a 4-cm incision in his perineum and identified the bulbospongiosus muscle after removing the hematoma. After dissecting the bulbospongiosus muscle, the corpus spongiosum of the penis was pulled to the right side using an 8-Fr flexible catheter. The trauma site of the left crus penis was revealed and repaired by interrupted sutures using 3-0 absorbable sutures . The day after surgery, Foley’s catheter was removed without complications. The patient had a good recovery and was discharged 6 days after surgery without postoperative complications. At the follow-up period of approximately 50 days, he did not face perineal pain, dysuria, or erectile dysfunction.", + "fulltext_subclaims": [ + "A 25-year-old Asian man presented to our department 2 days after a penile trauma with perineal pain and erectile dysfunction.", + "The patient was injured during rolling over in bed and heard a 'snap' sound just before pain.", + "Physical examination showed swelling of the perineum with subcutaneous bleeding and tenderness.", + "The appearance of the penis was normal.", + "His laboratory data were within the normal limits.", + "Hematuria was not detected on urinalysis.", + "Ultrasonography revealed a hematoma in the perineum without any testicular injury.", + "MRI showed a subcutaneous perineal hematoma.", + "MRI showed a 6-mm tear to the ventral tunica albuginea of the left crus penis near the bulbospongiosus muscle.", + "He was diagnosed with PF associated with a penile crus injury.", + "Six days after injury, repair of the tear at the left penile crus was performed.", + "The transperineal approach was selected because the injured area was near the bulbospongiosus muscle.", + "Subcutaneous bleeding expanded into his hip.", + "A penis deformity was not found.", + "We were able to insert a 14-Fr Foley’s catheter smoothly through his urethra.", + "No urethral injury was observed.", + "We made a 4-cm incision in his perineum.", + "The corpus spongiosum of the penis was pulled to the right side using an 8-Fr flexible catheter.", + "The trauma site of the left crus penis was revealed and repaired by interrupted sutures using 3-0 absorbable sutures.", + "The day after surgery, Foley’s catheter was removed without complications.", + "The patient had a good recovery and was discharged 6 days after surgery.", + "At the follow-up period of approximately 50 days, he did not face perineal pain, dysuria, or erectile dysfunction." + ], + "summary": "A 25-year-old Asian man was injured when rolling over in bed. Magnetic resonance imaging showed a tear in the left crus of the penis with a hematoma. Delayed surgery was successfully performed using the transperineal approach. He did not experience pain, dysuria, or erectile dysfunction postoperatively.", + "summary_subclaims": [ + "A 25-year-old Asian man was injured when rolling over in bed.", + "Magnetic resonance imaging showed a tear in the left crus of the penis with a hematoma.", + "Delayed surgery was successfully performed using the transperineal approach.", + "He did not experience pain, dysuria, or erectile dysfunction postoperatively." + ] + }, + { + "id": "multiclinsum_test_3326_en.txt", + "fulltext": "57-year-old woman, Laboratory Specialist Technician in the Microbiology Service with a personal history of polymyalgia rheumatica on chronic corticosteroid treatment. In 1996 she showed a Mantoux of 20 mm after accidental puncture with a sample from a patient with TBC and completed six months of TILT. In the controls carried out in 2017 and 2020 with QuantiFERON® TB Gold in-tube (QFT-GIT) she tested negative. In mid-March 2021 she suffered a work accident with biological risk after accidental puncture in the second finger of the right hand with a hollow needle used to puncture the vial of blood culture from a patient with TBC.\n\nFollowing exposure via the bloodstream, the immediate measures for the wound were applied as established in the protocol for action in the face of a biological risk. The worker then contacted the Occupational Risk Prevention Service (SPRL) where an initial assessment of the risk of infection was carried out. The patient initiated prophylactic treatment with emtricitabine, tenofovir and raltegravir (post-exposure prevention of HIV), which lasted five days until the source patient was located and a blood sample was obtained for serological analysis of human immunodeficiency virus (HIV), hepatitis B virus (HBV) and hepatitis C virus (HCV), the results of which were negative.\n\nThe biohazard accident was reported through the online form (Annex B) as established in the procedure for reporting and investigating events of the SPRL in compliance with the Occupational Risks Prevention Law 31/1995 of 8 November.\n\nHe was monitored with determination of QFT-GIT at the end of April 2021 with a positive result. He presented an erythematous area with a small erosion at the tip of the index finger of the right hand and a doubtful small superior adenopathy in the epitroclea of the right arm.\n\nHe was referred to the Dermatology Department for a punch biopsy, a large needle aspirate biopsy (LNAA), and a skin lesion tru-cut, which were sent to the Department of Pathology for examination of possible inoculation of tubercle bacilli. The diagnosis was a case of granulomatous necrotizing-caseous inflammation compatible with cutaneous tuberculosis. The PCR for tuberculosis performed at the request of the dermatologist was positive. DNA was extracted from the paraffin tissue of the biopsy using the QIAamp DNA FFPE tissue kit (Qiagen, Germany) for qualitative molecular detection of the M. tuberculosis complex (MTB) with the High-Resolution Melting technique using the FluoroType® MTB kit (Hain Lifescience, Nehren, Germany) in the FluoroCycler® 12 (Hain Lifescience). The sensitivity and specificity of the kit for qualitative detection of the MTB complex in paraffin tissue is 60.0% and 71.4%, respectively, and depends on the amount of bacilli present in the sample. A fragment of the biopsy was sent to the Microbiology Department for the isolation of the causative agent of the clinical picture by the corresponding cultures and antimicrobial susceptibility testing. The growth of M. tuberculosis was detected and no antimicrobial resistance was observed.\n\nIn mid-May 2021, treatment with rifampicin (R), isoniazid (I), pyrazinamide (P) and ethambutol hydrochloride (E) was initiated, manifesting cutaneous improvement. On the last day of the same month, treatment was suspended due to intolerance with generalized asthenia, nausea and vomiting, poor general condition with generalized arthralgias, non-specific skin lesions, without dysthermic sensation or analytical alteration of the hepatic profile.\n\nAt the end of July, the patient was evaluated in Internal Medicine, observing the normalization of the hepatic profile and the disappearance of the referred clinical. The determination of QFT-GIT was still positive, although quantitatively better than the previous one. At this same time, treatment with R/H and levofloxacin (Lfx) was initiated with good tolerance. In August, the patient reported a picture of asthenia that was related to her history of polymyalgia rheumatica, and prednisone was prescribed in a descending pattern. She continued with the triple TB therapy until mid-March 2022. The second treatment pattern was concluded after seven months, with complete recovery from the clinical point of view regarding the dermatological lesion.\n", + "fulltext_subclaims": [ + "The patient is a 57-year-old woman.", + "She works as a Laboratory Specialist Technician in the Microbiology Service.", + "She has a personal history of polymyalgia rheumatica.", + "She is on chronic corticosteroid treatment.", + "In 1996, she had a Mantoux of 20 mm after accidental puncture with a sample from a patient with TBC.", + "In 1996, she completed six months of TILT.", + "In 2017, she had a negative QuantiFERON® TB Gold in-tube (QFT-GIT) test.", + "In 2020, she had a negative QuantiFERON® TB Gold in-tube (QFT-GIT) test.", + "In mid-March 2021, she suffered a work accident with biological risk after accidental puncture in the second finger of the right hand with a hollow needle.", + "The needle was used to puncture the vial of blood culture from a patient with TBC.", + "Immediate measures for the wound were applied as established in the protocol for action in the face of a biological risk.", + "She contacted the Occupational Risk Prevention Service (SPRL).", + "An initial assessment of the risk of infection was carried out.", + "She initiated prophylactic treatment with emtricitabine, tenofovir and raltegravir.", + "The prophylactic treatment lasted five days.", + "The source patient was located and a blood sample was obtained for serological analysis.", + "The serological analysis was for human immunodeficiency virus (HIV), hepatitis B virus (HBV) and hepatitis C virus (HCV).", + "The results of the serological analysis were negative.", + "The biohazard accident was reported through the online form (Annex B).", + "The reporting was done in compliance with the Occupational Risks Prevention Law 31/1995 of 8 November.", + "She was monitored with determination of QFT-GIT at the end of April 2021.", + "The QFT-GIT test at the end of April 2021 had a positive result.", + "She presented an erythematous area with a small erosion at the tip of the index finger of the right hand.", + "She had a doubtful small superior adenopathy in the epitroclea of the right arm.", + "She was referred to the Dermatology Department for a punch biopsy.", + "She was referred to the Dermatology Department for a large needle aspirate biopsy (LNAA).", + "She was referred to the Dermatology Department for a skin lesion tru-cut.", + "The biopsies were sent to the Department of Pathology.", + "The diagnosis was a case of granulomatous necrotizing-caseous inflammation compatible with cutaneous tuberculosis.", + "The PCR for tuberculosis performed at the request of the dermatologist was positive.", + "DNA was extracted from the paraffin tissue of the biopsy using the QIAamp DNA FFPE tissue kit (Qiagen, Germany).", + "The High-Resolution Melting technique was used with the FluoroType® MTB kit (Hain Lifescience).", + "The FluoroCycler® 12 (Hain Lifescience) was used for the High-Resolution Melting technique.", + "The sensitivity of the kit for qualitative detection of the MTB complex in paraffin tissue is 60.0%.", + "The specificity of the kit for qualitative detection of the MTB complex in paraffin tissue is 71.4%.", + "The sensitivity and specificity depend on the amount of bacilli present in the sample.", + "A fragment of the biopsy was sent to the Microbiology Department.", + "The causative agent of the clinical picture was isolated by the corresponding cultures.", + "Antimicrobial susceptibility testing was performed.", + "The growth of M. tuberculosis was detected.", + "No antimicrobial resistance was observed.", + "In mid-May 2021, treatment with rifampicin, isoniazid, pyrazinamide and ethambutol hydrochloride was initiated.", + "The treatment manifested cutaneous improvement.", + "On the last day of May 2021, treatment was suspended due to intolerance.", + "The intolerance included generalized asthenia, nausea and vomiting.", + "The intolerance included poor general condition with generalized arthralgias.", + "The intolerance included non-specific skin lesions.", + "There was no dysthermic sensation.", + "There was no analytical alteration of the hepatic profile.", + "At the end of July, the patient was evaluated in Internal Medicine.", + "The hepatic profile was normalized.", + "The referred clinical symptoms disappeared.", + "The determination of QFT-GIT was still positive.", + "The QFT-GIT was quantitatively better than the previous one.", + "Treatment with R/H and levofloxacin was initiated.", + "The treatment with R/H and levofloxacin was well tolerated.", + "In August, the patient reported a picture of asthenia.", + "The asthenia was related to her history of polymyalgia rheumatica.", + "Prednisone was prescribed in a descending pattern.", + "She continued with the triple TB therapy until mid-March 2022.", + "The second treatment pattern was concluded after seven months.", + "There was complete recovery from the clinical point of view regarding the dermatological lesion." + ], + "summary": "A case of cutaneous tuberculosis was reported in a 57-year-old female employee, a laboratory specialist technician in the Microbiology Service, after she suffered a work-related accident due to an accidental puncture with a hollow needle. Shortly after, she developed a cutaneous lesion on her finger that was biopsied and reported as a case of necrotizing granulomatous inflammation (caseifying). She was started on a treatment with four drugs: isoniazid, rifampicin, pyrazinamide and ethambutol hydrochloride, with a cutaneous improvement and was suspended due to poor tolerance, changing the treatment to isoniazid, rifampicin and levofloxacin.\n", + "summary_subclaims": [ + "A case of cutaneous tuberculosis was reported in a 57-year-old female employee.", + "The patient was a laboratory specialist technician in the Microbiology Service.", + "She suffered a work-related accident due to an accidental puncture with a hollow needle.", + "She developed a cutaneous lesion on her finger.", + "The lesion was biopsied and reported as a case of necrotizing granulomatous inflammation (caseifying).", + "She was started on a treatment with four drugs: isoniazid, rifampicin, pyrazinamide and ethambutol hydrochloride.", + "She had cutaneous improvement.", + "The treatment was suspended due to poor tolerance.", + "The treatment was changed to isoniazid, rifampicin and levofloxacin." + ] + }, + { + "id": "multiclinsum_test_65_en.txt", + "fulltext": "A 74-year-old woman was referred to our hospital because of a nodule in the right lobe of the thyroid. The nodule had been found during a medical examination performed 3 years ago, but she did not undergo a detailed examination at the local hospital at that time. On physical examination, a palpable and hard nodule of approximately 2 cm in size was noted in the right side of her neck. Results of the blood examination were normal, except for mildly increased thyroglobulin (142 ng/mL) and antithyroglobulin antibody levels (59.7 IU/mL). Ultrasonography and computed tomography showed a right thyroid nodule with calcification. The nodule had no signs of extrathyroidal invasion and measured 21 mm in diameter. The lymph nodes of the neck were not swollen . The nodule was diagnosed as an indeterminate lesion by fine needle aspiration cytology. The fine needle aspiration smears showed spindle-shaped cells with prominent nucleoli and nuclear inclusion. The intercellular space was metachromatic on Giemsa staining . Taken together, these findings suggested a hyalinizing trabecular adenoma, granulomatous lesion, papillary carcinoma, or poorly differentiated carcinoma.\nWe decided to treat this nodule as thyroid cancer. Right thyroid lobectomy and central neck dissection were performed. Macroscopically, a well-circumscribed mass in the right lobe of the thyroid was observed. Histologic evaluation of the thyroid nodule showed multinodular proliferation of oval to polygonal-shaped epithelioid cells with oval nuclei and eosinophilic cytoplasm arranged in sheet- or cord-like patterns, accompanied by fibrous stroma and marked osseous metaplasia. Nuclear atypia was mild, and mitosis was not prominent. Results of the immunohistochemical staining showed that these areas were partially positive for cytokeratin, cluster of differentiation (CD)34, and factor VIII; diffusely positive for vimentin; and negative for thyroglobulin, thyroid transcription factor-1, smooth muscle actin, desmin, S100, CD31, CD68, and CD163 . These findings were suggestive of EHE.\nPostoperatively, the patient’s thyroglobulin level fluctuated inconsistently (range, 11–292 ng/mL), as did the antithyroglobulin antibody level, although it remained positive. The mild elevation of the preoperative and postoperative thyroglobulin levels might have been caused by chronic thyroiditis. The patient has been followed-up for 3 years and has had no signs of recurrence postoperatively.", + "fulltext_subclaims": [ + "The patient is a 74-year-old woman.", + "She was referred to the hospital because of a nodule in the right lobe of the thyroid.", + "The nodule had been found during a medical examination 3 years ago.", + "She did not undergo a detailed examination at the local hospital at that time.", + "On physical examination, a palpable and hard nodule of approximately 2 cm in size was noted in the right side of her neck.", + "Results of the blood examination were normal, except for mildly increased thyroglobulin (142 ng/mL) and antithyroglobulin antibody levels (59.7 IU/mL).", + "Ultrasonography and computed tomography showed a right thyroid nodule with calcification.", + "The nodule had no signs of extrathyroidal invasion.", + "The nodule measured 21 mm in diameter.", + "The lymph nodes of the neck were not swollen.", + "The nodule was diagnosed as an indeterminate lesion by fine needle aspiration cytology.", + "The fine needle aspiration smears showed spindle-shaped cells with prominent nucleoli and nuclear inclusion.", + "The intercellular space was metachromatic on Giemsa staining.", + "These findings suggested a hyalinizing trabecular adenoma, granulomatous lesion, papillary carcinoma, or poorly differentiated carcinoma.", + "We decided to treat this nodule as thyroid cancer.", + "Right thyroid lobectomy and central neck dissection were performed.", + "Macroscopically, a well-circumscribed mass in the right lobe of the thyroid was observed.", + "Histologic evaluation of the thyroid nodule showed multinodular proliferation of oval to polygonal-shaped epithelioid cells with oval nuclei and eosinophilic cytoplasm arranged in sheet- or cord-like patterns.", + "The histologic evaluation showed fibrous stroma and marked osseous metaplasia.", + "Nuclear atypia was mild.", + "Mitosis was not prominent.", + "Results of the immunohistochemical staining showed that these areas were partially positive for cytokeratin, cluster of differentiation (CD)34, and factor VIII.", + "Results of the immunohistochemical staining showed that these areas were diffusely positive for vimentin.", + "Results of the immunohistochemical staining showed that these areas were negative for thyroglobulin, thyroid transcription factor-1, smooth muscle actin, desmin, S100, CD31, CD68, and CD163.", + "These findings were suggestive of EHE.", + "Postoperatively, the patient’s thyroglobulin level fluctuated inconsistently (range, 11–292 ng/mL).", + "The mild elevation of the preoperative and postoperative thyroglobulin levels might have been caused by chronic thyroiditis.", + "The patient has been followed-up for 3 years.", + "The patient has had no signs of recurrence postoperatively." + ], + "summary": "A 74-year-old woman presented with a right thyroid mass. The nodule was approximately 2 cm in size and was diagnosed as an indeterminate lesion by fine needle aspiration cytology. She was treated with thyroid lobectomy. The histopathological and immunohistochemical findings indicated an EHE of the thyroid. At the latest follow-up, 3 years postoperatively, the patient showed no signs of recurrence.", + "summary_subclaims": [ + "The patient is a 74-year-old woman.", + "She presented with a right thyroid mass.", + "The nodule was approximately 2 cm in size.", + "The nodule was diagnosed as an indeterminate lesion by fine needle aspiration cytology.", + "She was treated with thyroid lobectomy.", + "The histopathological and immunohistochemical findings indicated an EHE of the thyroid.", + "At the latest follow-up, 3 years postoperatively, the patient showed no signs of recurrence." + ] + }, + { + "id": "multiclinsum_test_458_en.txt", + "fulltext": "A 15-year-old boy suffering from SWS was born from the third pregnancy of nonconsaguine young and healthy parents as a hypotrophic infant with a perinatal risk factor which included intrauterine growth retardation and asphyxia. Complex phenotypic dysmorphic features were observed at birth. The phenotype of our patient includes multiple facial and skeletal disorders: midface retrusion, prominent forehead, frontal bossing, shallow orbits, downslanted palpebral fissures, narrow nasal bridge, large filtrum, micrognathia, small hands with short metacarpal bones and short distal phalanges of fingers with consequent brachydactyly, knee flexion contracture, pseudoarthrosis, calcaneovalgus deformity, thoracic scoliosis, lumbar hyperlordosis, coxa valga, skeletal dysplasia, pectus carinatum, generalized hypotonia, global developmental delay, cognitive impairment, complete lack of adipose tissue with consequent pseudohypertrophy of muscles, bilateral cataracts and progeroid facial appearance ( and ). As a part of the syndrome, an extremely short stature, body weight of 15 kg and body height of 100 cm were observed.\nComputed tomography (CT) scan of cranio-cervical junction revealed bifid arch of the atlas as a part of skeletal disorders. Additional preoperative magnetic resonance imaging (MRI) revealed a critical stenosis of cranio-cervical junction with concomitant myelopathy .", + "fulltext_subclaims": [ + "The patient is a 15-year-old boy.", + "The patient suffers from SWS.", + "The patient was born from the third pregnancy of nonconsanguine young and healthy parents.", + "The patient was a hypotrophic infant.", + "The patient had intrauterine growth retardation.", + "The patient had asphyxia.", + "Complex phenotypic dysmorphic features were observed at birth.", + "The patient has midface retrusion.", + "The patient has a prominent forehead.", + "The patient has frontal bossing.", + "The patient has shallow orbits.", + "The patient has downslanted palpebral fissures.", + "The patient has a narrow nasal bridge.", + "The patient has a large filtrum.", + "The patient has micrognathia.", + "The patient has small hands with short metacarpal bones.", + "The patient has short distal phalanges of fingers with consequent brachydactyly.", + "The patient has knee flexion contracture.", + "The patient has pseudoarthrosis.", + "The patient has calcaneovalgus deformity.", + "The patient has thoracic scoliosis.", + "The patient has lumbar hyperlordosis.", + "The patient has coxa valga.", + "The patient has skeletal dysplasia.", + "The patient has pectus carinatum.", + "The patient has generalized hypotonia.", + "The patient has global developmental delay.", + "The patient has cognitive impairment.", + "The patient has a complete lack of adipose tissue with consequent pseudohypertrophy of muscles.", + "The patient has bilateral cataracts.", + "The patient has a progeroid facial appearance.", + "The patient has extremely short stature.", + "The patient's body weight is 15 kg.", + "The patient's body height is 100 cm.", + "Computed tomography (CT) scan of cranio-cervical junction revealed bifid arch of the atlas.", + "Magnetic resonance imaging (MRI) revealed a critical stenosis of cranio-cervical junction.", + "Magnetic resonance imaging (MRI) revealed concomitant myelopathy." + ], + "summary": "We present a case of a 15-years-old boy with clinical and radiological characteristics of SWS. Genetic examination identified a pathogenic heterozygous variant in the COG4 gene. Magnetic resonance imaging revealed a critical stenosis of the cranio-cervical junction (CCJ) which required surgical treatment to attempt sufficient neurological decompression. The patient underwent decompression of CCJ under general anesthesia. There was no significant radiological and clinical improvement during the postoperative period.", + "summary_subclaims": [ + "The patient is a 15-years-old boy.", + "The patient has clinical and radiological characteristics of SWS.", + "Genetic examination identified a pathogenic heterozygous variant in the COG4 gene.", + "Magnetic resonance imaging revealed a critical stenosis of the cranio-cervical junction.", + "The stenosis of the cranio-cervical junction required surgical treatment.", + "The surgical treatment aimed to achieve sufficient neurological decompression.", + "The patient underwent decompression of the cranio-cervical junction under general anesthesia.", + "There was no significant radiological improvement during the postoperative period.", + "There was no significant clinical improvement during the postoperative period." + ] + }, + { + "id": "multiclinsum_test_386_en.txt", + "fulltext": "In October 2019, a 54-year-old Arab male patient presented with 2 months history of fatigue, orthostatic hypotension followed by bruising on the lower right extremity, melena (present for one month only) and dyspnea II. Physical examination and computer tomographic scan showed hepatomegaly (4 cm). He had no familial history of malignancies and no social and environmental history of exposure to toxins or animals. Initial laboratory evaluation of peripheral blood (PB) revealed white blood cells count (WBC) of 26.3 × 109/l (10% were blasts). Pathologic examination of bone marrow (BM) aspirate characterized hybercellularity with 60% of blasts. Flow cytometric (FCM) analysis classified this case as AML-M2 according to world health organization (WHO) classification. The abnormal cell population (60%) was positive for CD45dim, CD34, HLADr, CD13, CD33 and expressed CD117 heterogeneously. Blasts cell population was negative for CD3, CD117, CD14, cCD3, cCD79a, CD14, CD11c, CD38, CD64, CD32, CD7, CD19, CD10, and CD5.\nThe 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). One month later, under treatment with 3 + 7 protocol, the patient relapsed, i.e. his PB showed a WBC of 107 × 109/l, anemia (hemoglobin level (Hgb) = 8.8 g/dl) and thrombocytopenia (Plt 93 × 109/l). The patient was given re-induction with 3 + 7 chemotherapy protocol (for more details see Table ). Less than one month after relapse, the patient acquired additional severe symptoms such as neutropenia, neutropenic enterocolitis, and diabetes insipidus, and the patient unfortunately passed away due to respiratory and cardiac arrest. No autopsy was performed. The patient’s brother agreed with the scientific evaluation of this case and the study was approved by the ethical committee of Pharmacy faculty at Damascus University, Ministry of High Education, Syria review Board, No. 2/2019.\nChromosome analysis using GTG-banding was performed on BM sample taken prior to chemotherapy according to standard protocols . A normal male karyotype was diagnosed. Fluorescence in situ hybridization (FISH) using specific probes to detect translocations t(8;21), t(15;17), t(16;16), t(12;21), and deletion del(13q), were applied to excluded chromosomal abnormalities, too, as previously reported .\nFor molecular analyses, whole genomic DNA was extracted from PB cells (EDTA-blood) prior to chemotherapy treatment. Polymerase chain reaction (PCR) amplification of genomic DNA and Sanger sequencing were used to screen for the presence of mutations of the following genes: FLT3/ITD (exons 11 and 12), FLT3-KTD and NPM1; using specific primers for each mutation previously reported . ITDs were confirmed by Sanger sequence analysis; the wild-type band of 330 bp length, and other differently sized PCR products were identified in our patient using the ABI Prism 310 genetic analyzer (Applied Biosystems, Foster City, CA, USA). Two novel frameshift mutations of the JMD in FLT3-ITD were identified in our patient (see also Fig. ):\nmutation 1: c.1779-1780insTTTCAGAGAATATGAATATGATCTCAAATGGGAGTTTCCAAGAGAAAATTTAGAGTTAGG (p.D593-F594insREYEYDLKWEFPRENLEF).\nmutation 2: homozygous substitution c.1836T>A (p.F612L).\nA D835 mutation was not detected by FLT3-KTD test in our patient. However, he had also NPM1 type A mutation (data not shown).", + "fulltext_subclaims": [ + "The patient was a 54-year-old Arab male.", + "The patient presented in October 2019.", + "The patient had a 2-month history of fatigue.", + "The patient had orthostatic hypotension.", + "The patient had bruising on the lower right extremity.", + "The patient had melena.", + "The patient had dyspnea II.", + "Physical examination showed hepatomegaly.", + "The hepatomegaly was 4 cm.", + "The patient had no familial history of malignancies.", + "The patient had no social and environmental history of exposure to toxins or animals.", + "Initial laboratory evaluation showed a WBC of 26.3 × 109/l.", + "10% of the WBC were blasts.", + "Bone marrow aspirate showed 60% blasts.", + "The case was classified as AML-M2 according to WHO classification.", + "The abnormal cell population was positive for CD45dim.", + "The abnormal cell population was positive for CD34.", + "The abnormal cell population was positive for HLADr.", + "The abnormal cell population was positive for CD13.", + "The abnormal cell population was positive for CD33.", + "The abnormal cell population expressed CD117 heterogeneously.", + "The blasts were negative for CD3.", + "The blasts were negative for CD117.", + "The blasts were negative for CD14.", + "The blasts were negative for cCD3.", + "The blasts were negative for cCD79a.", + "The blasts were negative for CD11c.", + "The blasts were negative for CD38.", + "The blasts were negative for CD64.", + "The blasts were negative for CD32.", + "The blasts were negative for CD7.", + "The blasts were negative for CD19.", + "The blasts were negative for CD10.", + "The blasts were negative for CD5.", + "The patient received 3 + 7 induction chemotherapy.", + "The patient relapsed one month later.", + "The patient's WBC was 107 × 109/l at relapse.", + "The patient had anemia at relapse.", + "The patient had thrombocytopenia at relapse.", + "The patient received re-induction with 3 + 7 chemotherapy.", + "The patient acquired neutropenia.", + "The patient acquired neutropenic enterocolitis.", + "The patient acquired diabetes insipidus.", + "The patient passed away due to respiratory and cardiac arrest.", + "No autopsy was performed.", + "The patient’s brother agreed with the scientific evaluation.", + "The study was approved by the ethical committee.", + "Chromosome analysis was performed using GTG-banding.", + "A normal male karyotype was diagnosed.", + "FISH was used to detect translocations t(8;21), t(15;17), t(16;16), t(12;21), and deletion del(13q).", + "Whole genomic DNA was extracted from PB cells.", + "PCR amplification and Sanger sequencing were used to screen for mutations.", + "Two novel frameshift mutations of the JMD in FLT3-ITD were identified.", + "Mutation 1 was c.1779-1780insTTTCAGAGAATATGAATATGATCTCAAATGGGAGTTTCCAAGAGAAAATTTAGAGTTAGG.", + "Mutation 2 was homozygous substitution c.1836T>A.", + "A D835 mutation was not detected.", + "The patient had an NPM1 type A mutation." + ], + "summary": "Here we report a 54-year-old Arab male diagnosed with AML who had two FLT3-ITD mutations in addition to NPM1 mutation. Cytogenetic approaches (banding cytogenetics) and fluorescence in situ hybridization (FISH) using specific probes to detect translocations t(8;21), t(15;17), t(16;16), t(12;21), and deletion del(13q)) were applied to exclude chromosomal abnormalities. Molecular genetic approaches (polymerase chain reaction (PCR) and the Sanger sequencing) identified a yet unreported combination of two new mutations in FLT3-ITDs. The first mutation induced a frameshift in JMD, and the second led to a homozygous substitution of c.1836T>A (p.F612L) also in JMD. Additionally a NPM1 type A mutation was detected. The first chemotherapeutic treatment was successful, but 1 month after the initial diagnosis, the patient experienced a relapse and unfortunately died.", + "summary_subclaims": [ + "The patient is a 54-year-old Arab male.", + "The patient was diagnosed with AML.", + "The patient had two FLT3-ITD mutations.", + "The patient had an NPM1 mutation.", + "Cytogenetic approaches were applied to exclude chromosomal abnormalities.", + "Fluorescence in situ hybridization (FISH) was used to detect translocations t(8;21), t(15;17), t(16;16), t(12;21), and deletion del(13q).", + "Molecular genetic approaches identified a yet unreported combination of two new mutations in FLT3-ITDs.", + "The first mutation induced a frameshift in JMD.", + "The second mutation led to a homozygous substitution of c.1836T>A (p.F612L) in JMD.", + "A NPM1 type A mutation was detected.", + "The first chemotherapeutic treatment was successful.", + "The patient experienced a relapse 1 month after the initial diagnosis.", + "The patient died." + ] + }, + { + "id": "multiclinsum_test_3369_en.txt", + "fulltext": "The clinical case of a 14-year-old male adolescent with no significant antecedents for the current condition is described. He presents to the outpatient department with lower back pain for four years, of insidious onset, intermittent, progressive, which exacerbated six months ago, with irradiation to lower extremities, accompanied by progressive paresthesia and paresis predominantly in the right lower extremity, reporting limitations for personal activities. Physical examination: patient with plantígrado, bipodálica, assisted with cane in the left hand, with claudicatio at the expense of the right lower extremity, with impossibility for heel-toe gait, presenting paravertebral muscular contracture in the lower back region predominantly in the right, without external lesions, or changes in colouration. Lower extremities present muscular hypotrophy in quadriceps and tibial anterior bilateral, with muscular strength 3/5 in the Daniels scale in the right L4, L5 and S1 myotomes, rest of myotomes with normal muscular strength, presenting hypesthesia in the right L5 dermatome, bilateral normal osteotendinous reflexes, L4, S1, right Legg-Perthes, positive right Bragard, positive right clonus.\n\nLaboratory studies with bone chemistry are performed with results within normal parameters according to the patient's age, which are presented in Table 1. A simple magnetic resonance imaging of the lumbosacral column is requested, where a heterogeneous, hyperintense mass is observed in the sagittal sections within the spinal canal, immediately posterior to the L5-S1 intervertebral disc with caudal extension to the underlying S1 vertebral body. An axial section in T1 and T2 shows a hyperintense mass in zone IV according to Weinstein, occupying approximately 30% of the spinal canal. Electromyography of the lower extremities with somatosensory evoked potentials and nerve conduction velocity is performed, which is reported as abnormal, with data of acute/active denervation in myotomes corresponding to the L5-S1 level on both sides and reduction of the bilateral voluntary contraction pattern in L5-S1 and S1 right.\n\nThe Oswestry disability scale is performed within the study protocol and found to have a disability limit of 71.1%, which is classified as a disabling disability.\n\n\nResults\n\nDue to the progressive symptoms and the patient's functional limitations, it was decided to operate, and a bilateral L4 and L5 laminotomy was performed, along with exploration and resection of the tumour and release of the nerve roots.\n\nA tumor with characteristics similar to adipose tissue was obtained, where a wide vascular network was observed inside, with an approximate size of 14 × 10 × 4 mm of an ovoid shape, flattened with a smooth and shiny surface. The tumor was sent for anatomopathological analysis, which reported \"adipose tissue with hypertrophic and enlarged blood vessels\". After hospital discharge, the patient presented immediate symptomatic improvement, with independent walking, although with limitations for heel-toe walking, reporting improvement in lower back pain. Manoeuvres were performed to assess neurotension, which were negative.\n\nOne month after the surgical treatment, the patient reported clinical improvement in gait, muscle strength and sensitivity, with improvement in the Oswestry scale of functional disability, reporting a functional limitation of 26.6%, which is classified as moderate functional limitation, finding considerable functional improvement after one month of the surgical treatment\n", + "fulltext_subclaims": [ + "The patient is a 14-year-old male adolescent.", + "The patient has no significant antecedents for the current condition.", + "The patient presents with lower back pain for four years.", + "The pain has an insidious onset.", + "The pain is intermittent.", + "The pain is progressive.", + "The pain exacerbated six months ago.", + "The pain irradiates to the lower extremities.", + "The patient reports progressive paresthesia.", + "The paresthesia is predominantly in the right lower extremity.", + "The patient reports progressive paresis.", + "The paresis is predominantly in the right lower extremity.", + "The patient reports limitations for personal activities.", + "The patient uses a cane in the left hand.", + "The patient has claudicatio at the expense of the right lower extremity.", + "The patient cannot perform heel-toe gait.", + "There is paravertebral muscular contracture in the lower back region.", + "The contracture is predominantly on the right.", + "There are no external lesions.", + "There are no changes in colouration.", + "The lower extremities show muscular hypotrophy in the quadriceps.", + "The lower extremities show muscular hypotrophy in the tibial anterior.", + "The hypotrophy is bilateral.", + "Muscular strength is 3/5 in the right L4 myotome.", + "Muscular strength is 3/5 in the right L5 myotome.", + "Muscular strength is 3/5 in the right S1 myotome.", + "The rest of the myotomes have normal muscular strength.", + "There is hypesthesia in the right L5 dermatome.", + "Bilateral osteotendinous reflexes are normal.", + "The right Legg-Perthes test is positive.", + "The right Bragard test is positive.", + "The right clonus is positive.", + "Bone chemistry laboratory studies are within normal parameters.", + "A magnetic resonance imaging of the lumbosacral column is requested.", + "A heterogeneous, hyperintense mass is observed in the sagittal sections.", + "The mass is within the spinal canal.", + "The mass is immediately posterior to the L5-S1 intervertebral disc.", + "The mass extends caudally to the underlying S1 vertebral body.", + "An axial section in T1 shows a hyperintense mass in zone IV according to Weinstein.", + "The mass occupies approximately 30% of the spinal canal.", + "Electromyography of the lower extremities is performed.", + "The electromyography is reported as abnormal.", + "There are data of acute/active denervation in myotomes corresponding to the L5-S1 level on both sides.", + "There is a reduction of the bilateral voluntary contraction pattern in L5-S1.", + "There is a reduction of the right S1 voluntary contraction pattern.", + "The Oswestry disability scale is performed.", + "The Oswestry disability scale reports a disability limit of 71.1%.", + "The disability is classified as disabling.", + "A bilateral L4 and L5 laminotomy is performed.", + "Exploration and resection of the tumour are performed.", + "Release of the nerve roots is performed.", + "The tumor has characteristics similar to adipose tissue.", + "The tumor has a wide vascular network inside.", + "The tumor has an approximate size of 14 × 10 × 4 mm.", + "The tumor is ovoid in shape.", + "The tumor is flattened.", + "The tumor has a smooth and shiny surface.", + "Anatomopathological analysis reports 'adipose tissue with hypertrophic and enlarged blood vessels'.", + "The patient presents immediate symptomatic improvement after surgery.", + "The patient can walk independently after surgery.", + "The patient has limitations for heel-toe walking after surgery.", + "The patient reports improvement in lower back pain after surgery.", + "Neurotension assessment manoeuvres are negative.", + "One month after surgery, the patient reports clinical improvement in gait.", + "One month after surgery, the patient reports improvement in muscle strength.", + "One month after surgery, the patient reports improvement in sensitivity.", + "The Oswestry scale reports a functional limitation of 26.6%.", + "The functional limitation is classified as moderate.", + "There is considerable functional improvement after one month of surgical treatment." + ], + "summary": "The clinical case of a 14-year-old male adolescent is described, with lower back pain for four years, insidious onset, intermittent, progressive, which exacerbated six months ago, with irradiation to lower extremities, accompanied by progressive paresthesia and paresis predominantly in the right lower extremity.\n\nResults: Laminotomy of L4 and L5 was performed bilaterally, and the tumour was explored and resected, and the nerve roots were released. The tumour had characteristics similar to adipose tissue, with a large vascular network inside, approximately 14 × 10 × 4 mm in size, oval in shape, flat with a smooth, shiny surface.\n", + "summary_subclaims": [ + "The patient is a 14-year-old male adolescent.", + "The patient has had lower back pain for four years.", + "The back pain had an insidious onset.", + "The back pain is intermittent.", + "The back pain is progressive.", + "The back pain exacerbated six months ago.", + "The pain irradiates to the lower extremities.", + "The pain is accompanied by progressive paresthesia.", + "The paresthesia is predominantly in the right lower extremity.", + "The pain is accompanied by paresis.", + "The paresis is predominantly in the right lower extremity.", + "Laminotomy of L4 and L5 was performed bilaterally.", + "The tumour was explored and resected.", + "The nerve roots were released.", + "The tumour had characteristics similar to adipose tissue.", + "The tumour had a large vascular network inside.", + "The tumour was approximately 14 × 10 × 4 mm in size.", + "The tumour was oval in shape.", + "The tumour was flat with a smooth, shiny surface." + ] + }, + { + "id": "multiclinsum_test_1662_en.txt", + "fulltext": "A 66-year-old man with hypertension and coronary artery disease as underlying diseases had pain in both lower extremities. His symptoms occurred after walking for approximately 100 m. He received acupuncture at an oriental clinic. However, his symptoms did not improve. According to the patient's description, his symptoms rose from the feet to the top. On a physical examination, the straight leg raise test was negative and the motor grade for both lower extremities was grade V. He also complained of a tingling sensation in the L5 dermatome of the right leg and L4 dermatome of the left leg. Conservative treatment was performed using non-steroidal anti-inflammatory drugs.\nOne month later, his pain in the left leg was improved, but the pain in the right leg had worsened. Therefore, lumbar spine magnetic resonance imaging (MRI) was performed, which showed central stenosis at the L4–5 and L5–S1 levels, and lateral recess stenosis at the L5–S1 level was observed . The patient’s symptoms were ambiguous with mixed neurological claudication and vascular claudication. We performed a Doppler test for both lower extremities. No pulsations in the right dorsalis pedis or posterior tibialis artery were detected. Under the suspicion of a problem in a vessel, computed tomography (CT) scans for the lower extremity arteries were taken. CT scans showed complete occlusion in the right external iliac artery . The patient was referred to the General Surgery Department. The ankle–brachial pressure index (ABI) was 0.1 to 0.2 (normal range: 1.0–1.4). Conservative treatment with 75 mg of clopidogrel/day and 20 mcg of beraprost sodium every 8 hours was initially performed for external iliac artery occlusion in the right leg. We obtained consent for this treatment from the patient. After the treatment, his symptoms were improved by 30% to 35% at 1 month after the diagnosis, 60% to 70% after 3 months, and 80% to 85% after 6 months. The patient refused further surgery for the spinal stenosis because he was satisfied with the clinical results.\nClopidogrel and beraprost sodium were continued for 4 years. The ABI was continuously measured during the follow-up period, and it continued to rise to 0.56 after 1 year, 0.69 after 2 years, and 0.73 after 4 years. A follow-up CT scan performed 4 years later showed recanalization of the right external iliac artery occlusion .\nWritten informed consent was obtained from the patient for the publication of this case report and accompanying images. All consent procedures and details of this study were approved by the Institutional Review Board of the Catholic University of Korea (approval number: SC16ZISE0080). The reporting of this study conforms to the CARE guidelines.", + "fulltext_subclaims": [ + "The patient is a 66-year-old man.", + "The patient has hypertension.", + "The patient has coronary artery disease.", + "The patient had pain in both lower extremities.", + "The patient's symptoms occurred after walking for approximately 100 m.", + "The patient received acupuncture at an oriental clinic.", + "The patient's symptoms did not improve.", + "The patient described symptoms rising from the feet to the top.", + "The straight leg raise test was negative.", + "The motor grade for both lower extremities was grade V.", + "The patient complained of a tingling sensation in the L5 dermatome of the right leg.", + "The patient complained of a tingling sensation in the L4 dermatome of the left leg.", + "Conservative treatment was performed using non-steroidal anti-inflammatory drugs.", + "One month later, the patient's pain in the left leg was improved.", + "One month later, the patient's pain in the right leg had worsened.", + "Lumbar spine MRI showed central stenosis at the L4–5 and L5–S1 levels.", + "Lumbar spine MRI showed lateral recess stenosis at the L5–S1 level.", + "The patient’s symptoms were ambiguous with mixed neurological claudication and vascular claudication.", + "A Doppler test was performed for both lower extremities.", + "No pulsations in the right dorsalis pedis artery were detected.", + "No pulsations in the right posterior tibialis artery were detected.", + "CT scans showed complete occlusion in the right external iliac artery.", + "The patient was referred to the General Surgery Department.", + "The ABI was 0.1 to 0.2.", + "Conservative treatment with 75 mg of clopidogrel/day was performed.", + "Conservative treatment with 20 mcg of beraprost sodium every 8 hours was performed.", + "The patient was satisfied with the clinical results.", + "The patient refused further surgery for the spinal stenosis.", + "Clopidogrel and beraprost sodium were continued for 4 years.", + "The ABI was 0.56 after 1 year.", + "The ABI was 0.69 after 2 years.", + "The ABI was 0.73 after 4 years.", + "A follow-up CT scan performed 4 years later showed recanalization of the right external iliac artery occlusion.", + "Written informed consent was obtained from the patient.", + "All consent procedures and details of this study were approved by the Institutional Review Board of the Catholic University of Korea.", + "The reporting of this study conforms to the CARE guidelines." + ], + "summary": "A 66-year-old man with lower extremity pain and claudication visited the outpatient spine clinic. He complained of a tingling sensation in the L5 dermatome of the right leg and L4 dermatome of the left leg. Magnetic resonance imaging showed central stenosis in at the L4-5 and L5-S1 levels, and lateral recess stenosis at the L5-S1 level. The patient's symptoms were ambiguous with mixed neurological claudication and vascular claudication. Computed tomography of the lower extremity artery showed complete occlusion in the right external iliac artery. Conservative treatment with clopidogrel and beraprost sodium was performed. After treatment, his symptoms gradually improved. Clopidogrel and beraprost sodium were continued for 4 years. Follow-up computed tomography at 4 years showed recanalization of the right external iliac artery occlusion.", + "summary_subclaims": [ + "The patient is a 66-year-old man.", + "He has lower extremity pain and claudication.", + "He visited the outpatient spine clinic.", + "He complained of a tingling sensation in the L5 dermatome of the right leg.", + "He complained of a tingling sensation in the L4 dermatome of the left leg.", + "Magnetic resonance imaging showed central stenosis at the L4-5 and L5-S1 levels.", + "Magnetic resonance imaging showed lateral recess stenosis at the L5-S1 level.", + "The patient's symptoms were ambiguous with mixed neurological claudication and vascular claudication.", + "Computed tomography of the lower extremity artery showed complete occlusion in the right external iliac artery.", + "Conservative treatment with clopidogrel and beraprost sodium was performed.", + "After treatment, his symptoms gradually improved.", + "Clopidogrel and beraprost sodium were continued for 4 years.", + "Follow-up computed tomography at 4 years showed recanalization of the right external iliac artery occlusion." + ] + }, + { + "id": "multiclinsum_test_3273_en.txt", + "fulltext": "54-year-old male patient with pain and stiffness in the dorsal and medial aspect of the hallux metatarsophalangeal joint of the right hallux that started four years ago. Pain worsens with walking and decreases with rest. No history of trauma to that foot. His personal medical history is hypothyroidism and dyslipidemia and his surgical history is a release of the trigger finger of the right and left hand and a resection of the synovial cyst of the left wrist. After the physical examination of the right foot, he has pain on the dorsal and medial aspect of the hallux metatarsophalangeal joint, skin without alterations. His range of motion of the hallux metatarsophalangeal joint is dorsiflexion of 25° with pain and plantar flexion of 20°, distal neurovascular examination without alterations with a two-second distal capillary refill. Physical examination of the rest of the foot was normal. Dorsal and lateral radiographs were taken with support of the right foot, which showed a decreased joint space of the hallux metatarsophalangeal joint predominantly of the lateral aspect, subchondral sclerosis and cysts with a dorsal osteophyte on the head of the first metatarsal, as well as the presence of small osteophytes on the head of the first metatarsal and the base of the proximal phalanx of the hallux. Based on the radiographic findings, the diagnosis of hallux rigidus Coughlin and Shurnas stage 3 was made. The patient tried conservative treatment with non-steroidal anti-inflammatory drugs and modifications in the type of footwear for six months with no improvement, so surgical treatment was proposed. Under general anaesthesia and using a tourniquet, a 4 cm incision was made on the dorsal aspect of the hallux metatarsophalangeal joint. Dissection was performed and the hallucis longus extensor was identified and retracted. A dorsal capsulotomy was performed and the joint was exposed. A large dorsal osteophyte was observed on the head of the metatarsal. A dorsal exostectomy was performed with a saw and a gouge. In addition, a cheilectomy and a medial buniectomy were performed with a saw. The sesamoids were exposed and released. There was no articular cartilage on the lateral aspect of the head of the first metatarsal. The cartilage on the medial aspect was intact. The hallucis longus extensor (EHB) was located and released from its insertion. A transosseous perforation was performed in the head of the metatarsal, the EHB was interposed in the medial aspect of the hallux metatarsophalangeal joint and fixed with vicryl. The wound was washed, capsulorrhapy was performed and the wound was closed in layers. The skin was covered with gauze, elastic bandage and a rehabilitation shoe was placed.\n\nThe preoperative Foot Function Index was 27% and the postoperative was 8%; the preoperative American Orthopaedic Foot and Ankle Society Hallux Metatarsophalangeal-Interphalangeal Rating System (AOFAS-HMI) was 77% and the postoperative was 90%; the preoperative subscale of activities of daily living Foot and Ankle Ability Measure (FAAM) was 76% and postoperative 95% and the preoperative sports subscale was 75% and postoperative 97%.\n\nAt 1.7 years after surgery, his postoperative range of motion was 60° active dorsiflexion and 40° active plantar flexion. The patient denied pain, discomfort or weakness in the metatarsophalangeal joint. He performed his daily activities without limitations and was satisfied with the postoperative results.\n", + "fulltext_subclaims": [ + "The patient is a 54-year-old male.", + "He has pain and stiffness in the dorsal and medial aspect of the hallux metatarsophalangeal joint of the right hallux.", + "The pain started four years ago.", + "The pain worsens with walking.", + "The pain decreases with rest.", + "There is no history of trauma to that foot.", + "His personal medical history includes hypothyroidism.", + "His personal medical history includes dyslipidemia.", + "His surgical history includes a release of the trigger finger of the right and left hand.", + "His surgical history includes a resection of the synovial cyst of the left wrist.", + "Physical examination of the right foot shows pain on the dorsal and medial aspect of the hallux metatarsophalangeal joint.", + "The skin is without alterations.", + "The range of motion of the hallux metatarsophalangeal joint is dorsiflexion of 25° with pain.", + "The range of motion of the hallux metatarsophalangeal joint is plantar flexion of 20°.", + "The distal neurovascular examination is without alterations.", + "The distal capillary refill is two seconds.", + "Dorsal and lateral radiographs were taken with support of the right foot.", + "The radiographs showed a decreased joint space of the hallux metatarsophalangeal joint predominantly of the lateral aspect.", + "The radiographs showed subchondral sclerosis and cysts.", + "The radiographs showed a dorsal osteophyte on the head of the first metatarsal.", + "The radiographs showed the presence of small osteophytes on the head of the first metatarsal and the base of the proximal phalanx of the hallux.", + "The diagnosis was hallux rigidus Coughlin and Shurnas stage 3.", + "The patient tried conservative treatment with non-steroidal anti-inflammatory drugs.", + "The patient tried modifications in the type of footwear.", + "The conservative treatment lasted six months.", + "The conservative treatment did not improve the condition.", + "Surgical treatment was proposed.", + "The surgery was performed under general anaesthesia.", + "A tourniquet was used.", + "A 4 cm incision was made on the dorsal aspect of the hallux metatarsophalangeal joint.", + "Dissection was performed.", + "The hallucis longus extensor was identified and retracted.", + "A dorsal capsulotomy was performed.", + "The joint was exposed.", + "A large dorsal osteophyte was observed on the head of the metatarsal.", + "A dorsal exostectomy was performed with a saw and a gouge.", + "A cheilectomy was performed with a saw.", + "A medial buniectomy was performed with a saw.", + "The sesamoids were exposed and released.", + "There was no articular cartilage on the lateral aspect of the head of the first metatarsal.", + "The cartilage on the medial aspect was intact.", + "The hallucis longus extensor (EHB) was located and released from its insertion.", + "A transosseous perforation was performed in the head of the metatarsal.", + "The EHB was interposed in the medial aspect of the hallux metatarsophalangeal joint.", + "The EHB was fixed with vicryl.", + "The wound was washed.", + "Capsulorrhapy was performed.", + "The wound was closed in layers.", + "The skin was covered with gauze.", + "An elastic bandage was applied.", + "A rehabilitation shoe was placed.", + "The preoperative Foot Function Index was 27%.", + "The postoperative Foot Function Index was 8%.", + "The preoperative AOFAS-HMI was 77%.", + "The postoperative AOFAS-HMI was 90%.", + "The preoperative subscale of activities of daily living FAAM was 76%.", + "The postoperative subscale of activities of daily living FAAM was 95%.", + "The preoperative sports subscale FAAM was 75%.", + "The postoperative sports subscale FAAM was 97%.", + "At 1.7 years after surgery, the postoperative range of motion was 60° active dorsiflexion.", + "At 1.7 years after surgery, the postoperative range of motion was 40° active plantar flexion.", + "The patient denied pain, discomfort or weakness in the metatarsophalangeal joint.", + "He performed his daily activities without limitations.", + "He was satisfied with the postoperative results." + ], + "summary": "We present the case of a 54-year-old patient with the diagnosis of hallux rigidus who had involvement of only the lateral aspect of the head of the metatarsal. This patient was treated with a novel surgical procedure, a hemiartroplasty of interposition was performed using the hallucis brevis extensor associated with a cheilectomy and exostectomy. The patient had a favorable clinical evolution with improvement evidenced by clinical scales, with resolution of the symptomatology and without complications.\n", + "summary_subclaims": [ + "The patient was a 54-year-old individual.", + "The patient had the diagnosis of hallux rigidus.", + "The involvement was of only the lateral aspect of the head of the metatarsal.", + "The patient was treated with a novel surgical procedure.", + "A hemiartroplasty of interposition was performed.", + "The interposition used the hallucis brevis extensor.", + "A cheilectomy was performed.", + "An exostectomy was performed.", + "The patient had a favorable clinical evolution.", + "Improvement was evidenced by clinical scales.", + "Resolution of the symptomatology was observed.", + "There were no complications." + ] + }, + { + "id": "multiclinsum_test_1539_en.txt", + "fulltext": "A 74-year-old woman was referred to our hospital and admitted for progressive speech and language difficulties. The patient was unable to recall the names of things or persons and was unable to communicate with others for about 1 year prior to admission, though she was able to shop and do housework without difficulty. She had no significant medical history; however, regarding her family history, her elder brother had developed word-finding difficulty with verbal paraphasia and right-hand limb-kinetic apraxia at the age of 62 years of age, and was diagnosed with CBS at 69 years of age. He had frontal lobe signs such as forced grasping, total aphasia, and right-limb kinetic apraxia; moreover, brain magnetic resonance imaging (MRI) demonstrated frontal and temporal lobar atrophy dominantly affecting the left side . The patient’s brother and parents had passed away; therefore, we could not obtain their detailed clinical information.\nNeurological findings indicated that our patient was lucid, but showed thought laziness. The cranial nerves, including those related to eye movement, were normal. The patient had normal muscle tonus and did not show muscle weakness or involuntary movement, but all extremity tendon reflexes were slightly increased. There was no evidence of sensory impairment or cerebellar ataxia. It was noted that speech required significant effort, was slow and non-fluent, and showed anarthria and aphasia. The patient’s Mini-Mental Scale Examination score was 4/30.\nLanguage function was assessed using the Western Aphasia Battery (WAB) Japanese edition once and SLTA (standard language test of aphasia) two times within 2 months. The scores of WAB subtests were as follows: spontaneous speech, 13 points; auditory verbal comprehension, 5.5 points; repetition, 0 points; naming, 0 points; reading, 4.3 points; writing, 2.2 points; praxis, 6.8 points; and construction, drawing, block design & calculation, 6.6 points. Raven’s score was 25/37 (average ± standard deviation: 26.9 ± 5.4). Aphasia quotient was 36.8. The results of SLTA were similar to those of WAB. Naming, writing, and repetition were impaired. However, auditory verbal comprehension and reading concerning words and short sentences were relatively preserved. Spatial perception and visual perception were also normal. Verbal comprehension via visual perception was approximately normal. Therefore, it is likely that auditory verbal comprehension was complemented by visual perception. Constructional dysfunction, limb-kinetic apraxia, ideational apraxia, and motor apraxia were not observed. Laboratory blood examinations did not reveal any particular abnormalities that could have caused cognitive dysfunction. Cell counts and protein concentrations in the patient’s cerebrospinal fluid were within normal ranges, and concentrations of tau protein (282 pg/mL) and phosphorylated tau protein (31.3 pg/mL or lower) were also normal. Brain MRI demonstrated cerebral atrophy dominantly affecting the left frontotemporal lobes .\nClinically, the main patient symptoms were difficulty in verbal expression and non-fluent aphasia in the absence of visual memory impairment or behavioral abnormalities. On this premise, the patient was diagnosed with PPA according to Mesulam’s criteria . Furthermore, the aphasia was classified as non-fluent progressive aphasia because, while speech itself required effort, the patient retained knowledge about objects and the ability to understand words. Brain MRI demonstrated cerebral cortical atrophy dominantly affecting the left frontal and temporal lobes, consistent with previous reports of non-fluent aphasia [, ]. Thus, FTLD was diagnosed according to the patient’s clinical symptoms. Since the patient’s elder brother had been diagnosed with CBS, and similar familial cases of FTLD due to GRN and microtubule-associated protein tau gene (MAPT) mutations had been reported , we performed genetic analyses on the patient.\nGenomic deoxyribonucleic acid (DNA) was extracted from peripheral leukocytes isolated from the patient. The exon/intron boundary of GRN was amplified by polymerase chain reaction (PCR) according to a previously reported method and the PCR products were sequenced in both directions. Briefly, blood was collected into a PAXgene® RNA tube, total ribonucleic acid (RNA) was extracted from the sample, and cDNA was prepared from total RNA by a reverse transcriptase reaction. cDNA was then amplified by reverse transcriptase–polymerase chain reaction (RT-PCR) (forward primer: 5′-ACCCAGGCTGTGTGCTG-3′; reverse primer: 5′-GACAGCCTCTGGGATTGGAC-3′) and the gene expression of GRN was analyzed. Then, the amplified PCR product was extracted and its sequence was analyzed.\nThe genetic examination identified a novel mutation (c.1118_1119delCCinsG) in exon10 of GRN, which was thought to cause a frameshift mutation (p.Pro373ArgX38). No pathological mutations of MAPT were identified. The GRN mRNA sequence was analyzed by RT-PCR; however, a mutant allele product was not detected, suggesting degradation of the mutant allele by the nonsense-mediated RNA decay system. Accordingly, haploinsufficiency due to reduced expression of progranulin was considered to be a possible pathogenic mechanism of FTLD in these cases .", + "fulltext_subclaims": [ + "The patient was a 74-year-old woman.", + "She was admitted for progressive speech and language difficulties.", + "The patient was unable to recall the names of things or persons.", + "She was unable to communicate with others for about 1 year prior to admission.", + "She was able to shop and do housework without difficulty.", + "She had no significant medical history.", + "Her elder brother had developed word-finding difficulty with verbal paraphasia and right-hand limb-kinetic apraxia at the age of 62.", + "Her brother was diagnosed with CBS at 69 years of age.", + "Her brother had frontal lobe signs such as forced grasping, total aphasia, and right-limb kinetic apraxia.", + "Brain MRI demonstrated frontal and temporal lobar atrophy dominantly affecting the left side.", + "The patient’s brother and parents had passed away.", + "The patient was lucid.", + "She showed thought laziness.", + "The cranial nerves, including those related to eye movement, were normal.", + "The patient had normal muscle tonus.", + "All extremity tendon reflexes were slightly increased.", + "Speech required significant effort, was slow and non-fluent, and showed anarthria and aphasia.", + "The patient’s Mini-Mental Scale Examination score was 4/30.", + "Language function was assessed using the Western Aphasia Battery (WAB) Japanese edition once.", + "Language function was assessed using SLTA two times within 2 months.", + "The WAB subtest score for spontaneous speech was 13 points.", + "The WAB subtest score for auditory verbal comprehension was 5.5 points.", + "The WAB subtest score for repetition was 0 points.", + "The WAB subtest score for naming was 0 points.", + "The WAB subtest score for reading was 4.3 points.", + "The WAB subtest score for writing was 2.2 points.", + "The WAB subtest score for praxis was 6.8 points.", + "The WAB subtest score for construction, drawing, block design & calculation was 6.6 points.", + "Raven’s score was 25/37.", + "Aphasia quotient was 36.8.", + "The results of SLTA were similar to those of WAB.", + "Naming, writing, and repetition were impaired.", + "Auditory verbal comprehension and reading concerning words and short sentences were relatively preserved.", + "Spatial perception and visual perception were also normal.", + "Verbal comprehension via visual perception was approximately normal.", + "Constructional dysfunction, limb-kinetic apraxia, ideational apraxia, and motor apraxia were not observed.", + "Cell counts and protein concentrations in the patient’s cerebrospinal fluid were within normal ranges.", + "Concentrations of tau protein were 282 pg/mL.", + "Concentrations of phosphorylated tau protein were 31.3 pg/mL or lower.", + "Brain MRI demonstrated cerebral atrophy dominantly affecting the left frontotemporal lobes.", + "The main patient symptoms were difficulty in verbal expression and non-fluent aphasia.", + "The patient was diagnosed with PPA according to Mesulam’s criteria.", + "The aphasia was classified as non-fluent progressive aphasia.", + "Brain MRI demonstrated cerebral cortical atrophy dominantly affecting the left frontal and temporal lobes.", + "FTLD was diagnosed according to the patient’s clinical symptoms.", + "The patient’s elder brother had been diagnosed with CBS.", + "Genomic DNA was extracted from peripheral leukocytes isolated from the patient.", + "The exon/intron boundary of GRN was amplified by PCR.", + "The genetic examination identified a novel mutation (c.1118_1119delCCinsG) in exon10 of GRN.", + "The mutation was thought to cause a frameshift mutation (p.Pro373ArgX38).", + "No pathological mutations of MAPT were identified.", + "A mutant allele product was not detected in the GRN mRNA sequence.", + "Haploinsufficiency due to reduced expression of progranulin was considered to be a possible pathogenic mechanism of FTLD in these cases." + ], + "summary": "We describe the case of a 74-year-old woman with left frontotemporal lobe atrophy who presented with progressive anarthria and non-fluent aphasia. Her brother had been diagnosed with corticobasal syndrome (CBS) with right-hand limb-kinetic apraxia, aphasia, and a similar pattern of brain atrophy. Laboratory blood examinations did not reveal abnormalities that could have caused cognitive dysfunction. In the cerebrospinal fluid, cell counts and protein concentrations were within normal ranges, and concentrations of tau protein and phosphorylated tau protein were also normal. Since similar familial cases due to mutation of GRN and microtubule-associated protein tau gene (MAPT) were reported, we performed genetic analysis. No pathological mutations of MAPT were identified, but we identified a novel GRN frameshift mutation (c.1118_1119delCCinsG: p.Pro373ArgX37) that resulted in progranulin haploinsufficiency.", + "summary_subclaims": [ + "The patient was a 74-year-old woman.", + "The patient had left frontotemporal lobe atrophy.", + "The patient presented with progressive anarthria.", + "The patient had non-fluent aphasia.", + "The patient's brother had been diagnosed with corticobasal syndrome.", + "The patient's brother had right-hand limb-kinetic apraxia.", + "The patient's brother had aphasia.", + "The patient's brother had a similar pattern of brain atrophy.", + "Laboratory blood examinations did not reveal abnormalities that could have caused cognitive dysfunction.", + "Cerebrospinal fluid cell counts were within normal ranges.", + "Cerebrospinal fluid protein concentrations were within normal ranges.", + "Cerebrospinal fluid concentrations of tau protein were normal.", + "Cerebrospinal fluid concentrations of phosphorylated tau protein were normal.", + "We performed genetic analysis.", + "No pathological mutations of MAPT were identified.", + "We identified a novel GRN frameshift mutation (c.1118_1119delCCinsG: p.Pro373ArgX37).", + "The GRN frameshift mutation resulted in progranulin haploinsufficiency." + ] + }, + { + "id": "multiclinsum_test_535_en.txt", + "fulltext": "A 56-year-old woman with staghorn calculi with 43 mm as long diameter in the abdominal X-ray was referred to our hospital. She had the comorbidities of hypertension, diabetes mellitus, obesity (Body Mass Index was 33), and without coagulopathy.\nThe surgical procedure was as following. The patient was set in the Galdakao-modified-Valdivia-position under general anesthesia. We planned to puncture into the dorsal-middle calix along the anterior line to avoid the renal cyst . 0.035-inch guidewire was successfully inserted into the urinary collecting system at the first puncture of the 18 gauge needle guided by ultrasound and fluoroscopy. The 24Fr Amplatz sheath was inserted through the tract which was enlarged by metallic telescopic serial dilator. The stone was crushed by Holmium laser (Lumenis VersaPulse PowerSuite 30W: 0.5–0.6 J/ 5–15 Hz) and removed by forceps visualized by the rigid and flexible nephroscope. There was no bleeding which prevent the endoscopic view during the surgery. The 20Fr nephrostomy tube with the 5Fr ureteral catheter to prevent slip-out was indwelled at the end. The operation time was 97 min. The dust and multiple fragments smaller than 3 mm diameter were seen in abdominal X-ray on the next day of PNL , and hemoglobin drop was not seen (11.9 g/dl).\nSuddenly, massive bleeding was seen around the nephrostomy tube on the 2nd day after PNL. CECT was examined after 37 min from onset of the bleeding. The extravasation of contrast agents was seen in the abdominal wall . It could not be controlled by finger pressure and suturing around the nephrostomy. Then, the patient had got into the hemorrhagic shock status (the blood pressure was 76/44 mmHg and hemoglobin dropped to 9.1 g/dl).\nEmergently, TAE was performed by the interventional radiologist after 123 min from onset of the bleeding. The 4Fr sheath was inserted into the right femoral artery by the Seldinger technique under local anesthesia. The injuries of the distal branches of the 9th and 10th intercostal arteries were identified and embolized by gelatin sponges cut into 1 mm size through the micro-catheter involving the communicating branch of the circumflex iliac artery . The blood pressure had been recovered to 97/65 mmHg as soon as closing TAE. A lot of infusion (normal saline, 3000 ml, and albuminous preparations, 5% 500 ml) were intravenously dripped to stabilize hemodynamics. On the next day of TAE, the hemoglobin dropped down to 7.2 g/dl and the transfusion of red blood cells (560 ml) was needed.\nOn the 7th day after PNL, the patient got a high fever. Pseudomonas aeruginosa was detected in her blood and urine sample. Ceftriaxion and ceftazidime were intravenously administered for 7 days. The 2nd PNL by flexible nephroscope and basket retrieval device was performed on the 19th day (operation time was 51 min), and she could discharge without residual fragments on the 30th day from the first PNL .", + "fulltext_subclaims": [ + "A 56-year-old woman with staghorn calculi with 43 mm as long diameter in the abdominal X-ray was referred to our hospital.", + "She had the comorbidities of hypertension, diabetes mellitus, obesity (Body Mass Index was 33), and without coolopathy.", + "The surgical procedure was as following.", + "The patient was set in the Galdakao-modified-Valdivia-position under general anesthesia.", + "We planned to puncture into the dorsal-middle calix along the anterior line to avoid the renal cyst.", + "0.035-inch guidewire was successfully inserted into the urinary collecting system at the first puncture of the 18 gauge needle guided by ultrasound and fluoroscopy.", + "The 24Fr Amplatz sheath was inserted through the tract which was enlarged by metallic telescopic serial dilator.", + "The stone was crushed by Holmium laser (Lumenis VersaPulse PowerSuite 30W: 0.5–0.6 J/ 5–15 Hz) and removed by forceps visualized by the rigid and flexible nephroscope.", + "There was no bleeding which prevent the endoscopic view during the surgery.", + "The 20Fr nephrostomy tube with the 5Fr ureteral catheter to prevent slip-out was indwelled at the end.", + "The operation time was 97 min.", + "The dust and multiple fragments smaller than 3 mm diameter were seen in abdominal X-ray on the next day of PNL.", + "Hemoglobin drop was not seen (11.9 g/dl).", + "Suddenly, massive bleeding was seen around the nephrostomy tube on the 2nd day after PNL.", + "CECT was examined after 37 min from onset of the bleeding.", + "The extravasation of contrast agents was seen in the abdominal wall.", + "It could not be controlled by finger pressure and suturing around the nephrostomy.", + "The patient had got into the hemorrhagic shock status (the blood pressure was 76/44 mmHg and hemoglobin dropped to 9.1 g/dl).", + "Emergently, TAE was performed by the interventional radiologist after 123 min from onset of the bleeding.", + "The 4Fr sheath was inserted into the right femoral artery by the Seldinger technique under local anesthesia.", + "The injuries of the distal branches of the 9th and 10th intercostal arteries were identified and embolized by gelatin sponges cut into 1 mm size through the micro-catheter involving the communicating branch of the circumflex iliac artery.", + "The blood pressure had been recovered to 97/65 mmHg as soon as closing TAE.", + "A lot of infusion (normal saline, 3000 ml, and albuminous preparations, 5% 500 ml) were intravenously dripped to stabilize hemodynamics.", + "On the next day of TAE, the hemoglobin dropped down to 7.2 g/dl and the transfusion of red blood cells (560 ml) was needed.", + "On the 7th day after PNL, the patient got a high fever.", + "Pseudomonas aeruginosa was detected in her blood and urine sample.", + "Ceftriaxion and ceftazidime were intravenously administered for 7 days.", + "The 2nd PNL by flexible nephroscope and basket retrieval device was performed on the 19th day (operation time was 51 min).", + "She could discharge without residual fragments on the 30th day from the first PNL." + ], + "summary": "A 56-year-old woman had been in the bleeding shock status on the 2nd day after percutaneous nephrolithotoripsy. Emergently, contrast-enhanced computed tomography was performed and extravasation of contrast agents was seen in the abdominal wall. Injuries of the intercostal artery were identified in the angiography and controlled by transcatheter arterial embolization.", + "summary_subclaims": [ + "The patient was a 56-year-old woman.", + "She had been in the bleeding shock status on the 2nd day after percutaneous nephrolithotomy.", + "Contrast-enhanced computed tomography was performed emergently.", + "Extravasation of contrast agents was seen in the abdominal wall.", + "Injuries of the intercostal artery were identified in the angiography.", + "The injuries were controlled by transcatheter arterial embolization." + ] + }, + { + "id": "multiclinsum_test_1032_en.txt", + "fulltext": "A 54-year-old right-handed male patient known for RA treated with Methotrexate and anti-TNF-α was referred to a specialized shoulder and elbow clinic for right chronic elbow pain refractory to conservative management, consisting in intra-articular cortisone injection and physical therapy. He complained about posterior joint pain, swelling, and a deficit in extension, causing severe disability in his daily life and professional activities as a firefighter. Pain Visual Analogic Scale (pVAS) was 8/10,[ elbow Single Assessment Numeric Evaluation (SANE) score 25/100,[ Mayo Elbow Performance Score (MEPS) 35/100.[ Physical examination showed joint effusion with tenderness on palpation of the olecranon fossa, painful restricted range of motion (ROM) with 140–20–0° in flexion-extension compared to 150–0–0° on the contralateral side, pronosupination was unrestricted. There were no signs of ulnar nerve entrapment. Preoperative magnetic resonance imaging (MRI) showed a large intra-articular multilobulated pseudo-tumoral mass causing posterior humeroulnar impingement , with mixed components including lipomatous and synovial fringes , characteristic of LA. Due to the severity and duration of his disease with failed nonoperative measures, the patient underwent arthroscopic synovectomy and posterior humeroulnar decompression.", + "fulltext_subclaims": [ + "The patient is a 54-year-old right-handed male.", + "The patient has rheumatoid arthritis.", + "The patient was treated with Methotrexate.", + "The patient was treated with anti-TNF-α.", + "The patient was referred to a specialized shoulder and elbow clinic.", + "The patient had right chronic elbow pain.", + "The patient's elbow pain was refractory to conservative management.", + "Conservative management included intra-articular cortisone injection.", + "Conservative management included physical therapy.", + "The patient complained about posterior joint pain.", + "The patient had swelling.", + "The patient had a deficit in extension.", + "The patient's pain Visual Analogic Scale was 8/10.", + "The patient's elbow Single Assessment Numeric Evaluation score was 25/100.", + "The patient's Mayo Elbow Performance Score was 35/100.", + "Physical examination showed joint effusion.", + "Physical examination showed tenderness on palpation of the olecranon fossa.", + "Preoperative magnetic resonance imaging showed a large intra-articular multilobulated pseudo-tumoral mass.", + "The MRI findings were characteristic of lipoma arborescens.", + "The patient underwent arthroscopic synovectomy.", + "The patient underwent posterior humeroulnar decompression." + ], + "summary": "We describe the case of a 54-year-old patient known for rheumatoid arthritis, who consulted for chronic elbow pain associated with swelling and limited extension.", + "summary_subclaims": [ + "The patient is a 54-year-old.", + "The patient is known for rheumatoid arthritis.", + "The patient consulted for chronic elbow pain.", + "The patient had swelling.", + "The patient had limited extension." + ] + }, + { + "id": "multiclinsum_test_1939_en.txt", + "fulltext": "We report the case of a 52-year-old woman, autonomous and professionally active, without family or social support, with an Eastern Cooperative Oncology Group Performance Status (ECOG-PS) of 1. She noted a lump in her right breast and was diagnosed with breast cancer in 2019: invasive carcinoma of the breast, of no special type, G2, estrogen receptor (ER)-positive (90%), progesterone receptor-negative, HER2 3+, Ki67 60%, staged as cT3(m)N3M0—prognostic stage group IIIB.\nHer medical family history included maternal breast cancer at 68 years old and paternal CKD. The patient had multiple comorbidities, namely, CKD. When she was 9 years old, she was diagnosed with Fanconi syndrome. She has been on hemodialysis three times a week (medium 3.7 hours per session) since 1998. From 1982 to 1990, the patient was on hemodialysis as well, having received a transplant in 1990 that failed in 1998. At the time of the first oncology consultation, the patient presented a left arm aneurysm of the arteriovenous fistula, secondary hyperparathyroidism, secondary hypertension, severe pulmonary hypertension, uremic neuropathy, malnutrition, chronic hepatitis C virus infection genotype 2, prior acute colonic diverticulitis complicated with abscess with surgical management and colostomy, major depression, and status post-thyroidectomy and right neck dissection (May 2017) for papillary thyroid carcinoma.\nThe patient was asthenic, and her physical exam denoted malnutrition, a right breast lesion measuring 10 × 7 cm, right axilla and right supra- and infraclavicular lymphadenopathies, and right arm lymphedema. The remaining physical exam found no evidence of breast cancer metastatic disease (cM0).\nGiven the diagnosis of locally advanced HER2-positive, ER-positive breast cancer, along with the patient’s comorbidities and preferences (prioritizing tolerability and flatly refusing chemotherapy), neoadjuvant therapy with subcutaneous trastuzumab and oral tamoxifen was started in January 2020. The best response was a partial response with good tolerance and no cardiac toxicity. After 6 months of therapy, and repeatedly thereafter, curative surgery was proposed, which the patient refused, maintaining trastuzumab and hormonal therapy up until July 2022, when after 30 months of therapy, locoregional, skin, pleural, peritoneal, and lymph node progression was confirmed . During this period (until July 2022), the case was rediscussed in the tumor board, and alternatives such as radiotherapy were discussed and dismissed considering it would not be curative by itself nor effective palliating the lymphedema—the only local symptom the patient presented at that point.\nAt the tumor board and considering the advice of the patient’s nephrologist, first-line treatment with paclitaxel, trastuzumab, and pertuzumab was recommended.\nThe patient refused chemotherapy, so she was started on Phesgo® combined with exemestane in August 2022 (by then, the patient was postmenopausal). Phesgo® was administered every 21 days, 24 hours after the last hemodialysis session and 24 hours before the next.\nThree weeks after starting Phesgo® and exemestane, a reduction in the dimensions of the breast and skin lesions was already noted .\nIn the first response evaluation by positron emission tomography (PET) with fluorine-18 fluorodeoxyglucose (FDG), a partial metabolic response was documented with a clear decrease in the uptake in the breast lesion, the lymph nodes, and the pleural nodules, in addition to a decrease in the pleural effusion volume . In January 2023, all the skin lesions had disappeared.\nNo adverse events were noted, and the left ventricle ejection fraction and strain remained within the normal range .\nThe patient completed 10 cycles of Phesgo® until April 2023, when some of the skin lesions reappeared, the breast lesion increased in size, and new left axillary lymph nodes were identified . FDG-PET in April 2023 documented disease progression in the breast, pleura, peritoneum, and lymph nodes . The patient maintained an ECOG-PS of 1 and started a second-line anti-HER2 therapy recommended by the tumor board.\nOur report is, to our best knowledge, the first published case report of Phesgo® treatment in a patient on hemodialysis. The choice of Phesgo®, a subcutaneous fixed-dose formulation of pertuzumab and trastuzumab, instead of the intravenous formulation was justified by the right arm lymphedema, the left arm aneurysm of the arteriovenous fistula, and the limited vascular access options. Also, according to PHranceSCa trial results, most patients prefer the subcutaneous formulation, with the most common reasons being “less time in the clinic” and “more comfortable during administration”, which were very important to this professionally active patient, already spending much time in the hemodialysis center . In the absence of dose and schedule recommendations, we chose to administer Phesgo® on a different day from dialysis, which was conducted at another institution. Due to pertuzumab’s high molecular weight (148 kDa), removal of Phesgo® by hemodialysis was not expected . Despite prior reports suggesting that a lower glomerular filtration rate could be associated with an increased risk of cardiotoxicity for both trastuzumab and pertuzumab, our patient did not experience cardiac toxicity. Considering the limited safety and dosage data for aromatase inhibitors (AI) in patients with a glomerular filtration rate under 30 mL/min, we chose exemestane due to its minimal renal elimination (<1%) compared to other options (anastrozole 11%, letrozole 90%, and fulvestrant 8%) . In the case presented, Phesgo progression-free survival (PFS) was 8 months, lower than reported in the phase II PERTAIN trial, which compared the combination of trastuzumab plus pertuzumab plus an AI with trastuzumab plus an AI, with a median PFS of 20.6 vs. 15.8 months [hazard ratio (HR) 0.67, p = 0.006]. While these results are encouraging for a chemotherapy-free regimen, it must be noted that one-half of patients received induction chemotherapy with a taxane prior to switching to maintenance exemestane. Furthermore, patients with CKD or other comorbidities and patients with disease progression on prior trastuzumab were excluded from the trial, which may explain the lower PFS observed in this case (–). One limitation of this report is the absence of pharmacokinetic data, which were not collected considering that they would not lead to therapy modification (in the absence of guidance for that) but would add morbidity and costs to the patient’s care.\nTo conclude, our report demonstrates the safe and effective use of the association of trastuzumab plus pertuzumab in a patient with end-stage renal disease undergoing RRT and raises no red flags to the administration of the subcutaneous fixed-dose formulation in this setting. More studies are needed to assess the PK of anticancer drugs in patients on RRT and its efficacy and security in a real-world population. Meanwhile, some important lessons can be taken from this case, such as the importance of a multidisciplinary approach including medical subspecialties, in this case, nephrology. This was key to allowing the patient access to innovative oncological treatment despite her comorbidities and in accordance with her preferences. Raising awareness and special recommendations are needed for this patient’s subgroup not only to guide drug use and dosing but also to preclude undertreatment, especially in the curative setting.", + "fulltext_subclaims": [ + "The patient is a 52-year-old woman.", + "She is autonomous and professionally active.", + "She has no family or social support.", + "Her ECOG-PS is 1.", + "She noted a lump in her right breast.", + "She was diagnosed with breast cancer in 2019.", + "The breast cancer was invasive carcinoma of the breast, of no special type, G2.", + "The breast cancer was estrogen receptor (ER)-positive (90%).", + "The breast cancer was progesterone receptor-negative.", + "The breast cancer was HER2 3+.", + "The breast cancer was Ki67 60%.", + "The breast cancer was staged as cT3(m)N3M0—prognostic stage group IIIB.", + "Her medical family history included maternal breast cancer at 68 years old.", + "Her medical family history included paternal CKD.", + "She had multiple comorbidities, namely, CKD.", + "When she was 9 years old, she was diagnosed with Fanconi syndrome.", + "She has been on hemodialysis three times a week since 1998.", + "She received a transplant in 1990 that failed in 1998.", + "At the time of the first oncology consultation, the patient presented a left arm aneurysm of the arteriovenous fistula.", + "At the time of the first oncology consultation, the patient presented secondary hyperparathyroidism.", + "At the time of the first oncology consultation, the patient presented secondary hypertension.", + "At the time of the first oncology consultation, the patient presented severe pulmonary hypertension.", + "At the time of the first oncology consultation, the patient presented uremic neuropathy.", + "At the time of the first oncology consultation, the patient presented malnutrition.", + "At the time of the first oncology consultation, the patient had chronic hepatitis C virus infection genotype 2.", + "At the time of the first oncology consultation, the patient had prior acute colonic diverticulitis complicated with abscess with surgical management and colostomy.", + "At the time of the first oncology consultation, the patient had major depression.", + "At the time of the first oncology consultation, the patient was status post-thyroidectomy and right neck dissection (May 2017) for papillary thyroid carcinoma.", + "The patient was asthenic.", + "The physical exam denoted malnutrition.", + "The physical exam noted a right breast lesion measuring 10 × 7 cm.", + "The physical exam noted right axilla and right supra- and infraclavicular lymphadenopathies.", + "The physical exam noted right arm lymphedema.", + "The physical exam found no evidence of breast cancer metastatic disease (cM0).", + "The diagnosis was locally advanced HER2-positive, ER-positive breast cancer.", + "The patient prioritized tolerability and flatly refused chemotherapy.", + "Neoadjuvant therapy with subcutaneous trastuzumab and oral tamoxifen was started in January 2020.", + "The best response was a partial response with good tolerance and no cardiac toxicity.", + "After 6 months of therapy, curative surgery was proposed.", + "The patient refused curative surgery.", + "The patient maintained trastuzumab and hormonal therapy up until July 2022.", + "In July 2022, locoregional, skin, pleural, peritoneal, and lymph node progression was confirmed.", + "During this period, the case was rediscussed in the tumor board.", + "Alternatives such as radiotherapy were discussed and dismissed.", + "First-line treatment with paclitaxel, trastuzumab, and pertuzumab was recommended.", + "The patient refused chemotherapy.", + "She was started on Phesgo® combined with exemestane in August 2022.", + "Phesgo® was administered every 21 days, 24 hours after the last hemodialysis session and 24 hours before the next.", + "Three weeks after starting Phesgo® and exemestane, a reduction in the dimensions of the breast and skin lesions was already noted.", + "In the first response evaluation by PET with FDG, a partial metabolic response was documented.", + "In January 2023, all the skin lesions had disappeared.", + "No adverse events were noted.", + "The left ventricle ejection fraction and strain remained within the normal range.", + "The patient completed 10 cycles of Phesgo® until April 2023.", + "In April 2023, some of the skin lesions reappeared.", + "In April 2023, the breast lesion increased in size.", + "In April 2023, new left axillary lymph nodes were identified.", + "FDG-PET in April 2023 documented disease progression in the breast, pleura, peritoneum, and lymph nodes.", + "The patient maintained an ECOG-PS of 1.", + "The patient started a second-line anti-HER2 therapy recommended by the tumor board.", + "Our report is, to our best knowledge, the first published case report of Phesgo® treatment in a patient on hemodialysis.", + "The choice of Phesgo® was justified by the right arm lymphedema.", + "The choice of Phesgo® was justified by the left arm aneurysm of the arteriovenous fistula.", + "The choice of Phesgo® was justified by the limited vascular access options.", + "According to PHranceSCa trial results, most patients prefer the subcutaneous formulation.", + "The most common reason for preferring the subcutaneous formulation was 'less time in the clinic'.", + "The most common reason for preferring the subcutaneous formulation was 'more comfortable during administration'.", + "Phesgo® was administered on a different day from dialysis.", + "Pertuzumab has a high molecular weight (148 kDa).", + "Removal of Phesgo® by hemodialysis was not expected.", + "Prior reports suggested that a lower glomerular filtration rate could be associated with an increased risk of cardiotoxicity for both trastuzumab and pertuzumab.", + "Our patient did not experience cardiac toxicity.", + "Exemestane was chosen due to its minimal renal elimination (<1%).", + "Anastrozole has 11% renal elimination.", + "Letrozole has 90% renal elimination.", + "Fulvestrant has 8% renal elimination.", + "Phesgo progression-free survival (PFS) was 8 months.", + "The phase II PERTAIN trial reported a median PFS of 20.6 months for the combination of trastuzumab plus pertuzumab plus an AI.", + "The phase II PERTAIN trial reported a median PFS of 15.8 months for trastuzumab plus an AI.", + "One-half of patients in the PERTAIN trial received induction chemotherapy with a taxane prior to switching to maintenance exemestane.", + "Patients with CKD or other comorbidities were excluded from the PERTAIN trial.", + "Patients with disease progression on prior trastuzumab were excluded from the PERTAIN trial.", + "Pharmacokinetic data were not collected in this case.", + "Our report demonstrates the safe and effective use of the association of trastuzumab plus pertuzumab in a patient with end-stage renal disease undergoing RRT.", + "More studies are needed to assess the PK of anticancer drugs in patients on RRT.", + "A multidisciplinary approach including medical subspecialties was key to allowing the patient access to innovative oncological treatment.", + "Raising awareness and special recommendations are needed for patients with CKD and other comorbidities." + ], + "summary": "We report the use of Phesgo® (subcutaneous fixed-dose combination of trastuzumab and pertuzumab) combined with exemestane as a first-line treatment of metastatic HER2-positive breast cancer in a hemodialysis patient with multiple comorbidities. Partial response was attained, with disease progression after 8 months without evidence of significant toxicity.", + "summary_subclaims": [ + "Phesgo® is a subcutaneous fixed-dose combination of trastuzumab and pertuzumab.", + "Phesgo® was combined with exemestane as a first-line treatment.", + "The treatment was used for metastatic HER2-positive breast cancer.", + "The patient was undergoing hemodialysis.", + "The patient had multiple comorbidities.", + "Partial response was attained.", + "Disease progression occurred after 8 months.", + "There was no evidence of significant toxicity." + ] + }, + { + "id": "multiclinsum_test_319_en.txt", + "fulltext": "On 30 Jun 2016, a 16-year-old male patient without any known medical background presented with a 1 month history of fatigue and fever without sweating. He had no familial history of malignancies and no social and environmental history or exposure to toxins and animals. Initial laboratory evaluation of peripheral blood (PB) revealed white blood cells (WBC) of 52.2 × 109/l (88% were blasts). He was treated with Predlon 60 mg/day per 10 days. Afterwards, physical examination and ultrasound at our hospital showed no splenomegaly, however, several lymphadenopathies (sternocleidomastoidal (1 cm) and right of subaxilla (1 cm)), normal heart rate (90/min) and his blood pressure was 12/6. His PB showed: WBC 3.5 × 109/l (neutrophils 33%, lymphocytes 64%), Hb = 7.5 g/dl, and platelets = 49.4 × 109/l. Serum biochemistry analyses were: Calcium (Ca+ 2) 9.9 mmol/l (normal value 8.5–10.3); LDH 229 U/l (normal level < 460); β2-microglbulin 3.32 mg/l (normal value 0.61–3.7); alanine aminotransferase level was 24 U/l (normal up to 40 U/l); aspartate aminotransferase level 17 U/l (normal up to 40 U/l); creatinine was 0.57 μmol/l (normal 45–120); Urea 38 mmol/l (normal 10–50); Sodium (Na+) 137 mmol/l (normal 135–148), Potasium (K+) 4.7 mmol/l (3.5–5.2), total protein 6.2 g/dl (normal 6.6–8.7), albumin 4.2 g/dl (normal 3.8–5.4). Bone marrow (BM) aspiration revealed hypercellularity with 90% of lymphoblasts. In cerebrospinal fluid aspiration no cells were found.\nHe was diagnosed as having pre-B-ALL according to the World Health Organization (WHO) classification. Thus, the patient was treated further according to GRALL 2003 chemotherapy protocol. Two days after initiating GRALL 2003 chemotherapy, the patient developed neutropenia, was given Neupogen and restarted chemotherapy protocol. The patient suffered from neutropenia and fever many times during chemotherapy. All chromosomal aberrations were vanishing during the chemotherapeutic treatment. After 17 months of treatment the patient relapsed. BM aspiration revealed 10% of lymphoblasts and PB showed: WBC 1.7 × 109/l (neutrophils 60.5%, lymphocytes 32.2%, and immature cells 7.3%); Hb = 13.6 g/dl; and platelets = 216 × 109/l. The patient received cytosar 3.5 g (twice per day for 4 days) and doxorubcin 50 mg/m2 for 3 days and a wide spectrum of antibodies.\nApproximately 2 months after relapse patient died due to respiratory and heart arrest, as well as neutropenia. No autopsy was performed. Patient’s father agreed with scientific evaluation of his case and the study was approved by the ethical committee of the Atomic Energy Commission, Damascus, Syria.", + "fulltext_subclaims": [ + "The patient was a 16-year-old male.", + "He had no known medical background.", + "He had no familial history of malignancies.", + "He had no social and environmental history or exposure to toxins and animals.", + "He had a 1 month history of fatigue.", + "He had a 1 month history of fever without sweating.", + "Initial laboratory evaluation of peripheral blood revealed white blood cells of 52.2 × 109/l.", + "Initial laboratory evaluation of peripheral blood revealed 88% blasts.", + "He was treated with Predlon 60 mg/day for 10 days.", + "Physical examination showed no splenomegaly.", + "Ultrasound showed several lymphadenopathies.", + "Ultrasound showed a sternocleidomastoidal lymphadenopathy of 1 cm.", + "Ultrasound showed a right subaxillary lymphadenopathy of 1 cm.", + "His heart rate was 90/min.", + "His blood pressure was 12/6.", + "Peripheral blood showed WBC 3.5 × 109/l.", + "Peripheral blood showed neutrophils 33%.", + "Peripheral blood showed lymphocytes 64%.", + "Hemoglobin was 7.5 g/dl.", + "Platelets were 49.4 × 109/l.", + "Calcium was 9.9 mmol/l.", + "LDH was 229 U/l.", + "β2-microglobulin was 3.32 mg/l.", + "Alanine aminotransferase was 24 U/l.", + "Aspartate aminotransferase was 17 U/l.", + "Creatinine was 0.57 μmol/l.", + "Urea was 38 mmol/l.", + "Sodium was 137 mmol/l.", + "Potassium was 4.7 mmol/l.", + "Total protein was 6.2 g/dl.", + "Albumin was 4.2 g/dl.", + "Bone marrow aspiration revealed hypercellularity with 90% lymphoblasts.", + "Cerebrospinal fluid aspiration found no cells.", + "He was diagnosed as having pre-B-ALL according to the WHO classification.", + "He was treated according to the GRALL 2003 chemotherapy protocol.", + "Two days after initiating GRALL 2003 chemotherapy, the patient developed neutropenia.", + "He was given Neupogen.", + "He was restarted on the chemotherapy protocol.", + "The patient suffered from neutropenia and fever many times during chemotherapy.", + "All chromosomal aberrations were vanishing during the chemotherapeutic treatment.", + "After 17 months of treatment, the patient relapsed.", + "Bone marrow aspiration revealed 10% lymphoblasts.", + "Peripheral blood showed WBC 1.7 × 109/l.", + "Peripheral blood showed neutrophils 60.5%.", + "Peripheral blood showed lymphocytes 32.2%.", + "Peripheral blood showed immature cells 7.3%.", + "Hemoglobin was 13.6 g/dl.", + "Platelets were 216 × 109/l.", + "The patient received cytosar 3.5 g twice per day for 4 days.", + "The patient received doxorubicin 50 mg/m2 for 3 days.", + "The patient received a wide spectrum of antibodies.", + "Approximately 2 months after relapse, the patient died due to respiratory and heart arrest.", + "The patient died due to neutropenia.", + "No autopsy was performed.", + "The patient’s father agreed with scientific evaluation of his case.", + "The study was approved by the ethical committee of the Atomic Energy Commission, Damascus, Syria." + ], + "summary": "Here we report a case of 16-year-old male diagnosed with a de novo pre-B-ALL. Molecular approaches (array-based multicolor banding (aMCB) and array comparative genomic hybridization (aCGH)) were applied, and a unique complex karyotype involving six chromosomes was identified. It included three previously unreported chromosomal aberrations: dicentric dic(9;20;X), deletion del(7)(p22.2p15.2) and dicentric dic(7;13). The dicentric dic(9;20;X) also led to monoallelic loss of tumor suppressor gene CDKN2A. After successful chemotherapeutic treatment the patient experienced a relapse with a secondary ALL without complex karyotype but a deletion del(19)(p13). Unfortunately, the patient died after 17 months of the initial diagnosis.", + "summary_subclaims": [ + "The patient was a 16-year-old male.", + "The patient was diagnosed with a de novo pre-B-ALL.", + "Molecular approaches (array-based multicolor banding (aMCB) and array comparative genomic hybridization (aCGH)) were applied.", + "A unique complex karyotype involving six chromosomes was identified.", + "The complex karyotype included three previously unreported chromosomal aberrations.", + "The chromosomal aberrations were dicentric dic(9;20;X), deletion del(7)(p22.2p15.2), and dicentric dic(7;13).", + "The dicentric dic(9;20;X) led to monoallelic loss of tumor suppressor gene CDKN2A.", + "The patient experienced a relapse with a secondary ALL.", + "The relapse ALL did not have a complex karyotype.", + "The relapse ALL had a deletion del(19)(p13).", + "The patient died after 17 months of the initial diagnosis." + ] + }, + { + "id": "multiclinsum_test_101_en.txt", + "fulltext": "A 32-year-old man presented to the emergency room with repetitive episodes of syncope and intermittent dyspnea within 7 d.\nThe patient complained of chest distress on February 15, 2019. Then he had a transient, self-limited loss of consciousness lasting for 3-5 min, followed by prompt recovery. The syncope happened four times. The trigger of the attacks included physical exertion or inhaling cold air. There is no prodromal or accompanied symptom. He went to our hospital by himself on February 22, 2019 because of another onset of syncope.\nThe patient had no medical history nor family history of blood clotting disorders, but he had a sedentary lifestyle due to his job as a news editor.\nHis vital signs were stable at the time of the first medical contact. Physical examination results were as follows: Pulse rate: 96 beats/min; respiratory rate: 20 breaths/min; blood pressure: 15.5/10.1 kPa; body mass index: 23.1 kg/m2; pupils: Symmetric and responsive to light; prominent P2; symmetrical breath sounds without rales or wheezing; and warm extremities without edema. The neurological examination was negative.\nInitial laboratory test showed elevated serum D-dimer at 4150 ng/mL (reference < 500 ng/mL). Arterial blood gas analysis showed PaO2 of 79 mmHg while he was breathing ambient air. N-terminal pro-B-type natriuretic peptide was 4460 pg/mL (reference < 450 pg/mL). The levels of serum cardiac enzyme series were normal.\nThe electrocardiogram showed sinus tachycardia. Doppler ultrasound revealed a deep venous thrombosis in the right popliteal vein . Transthoracic echocardiography showed a mass thrombus straddling a PFO concomitant dilated right atrium and moderate pulmonary hypertension . The size of the thrombus was 3 mm × 20 mm in the left atrium, 8 mm × 25 mm in the right atrium. Computed tomography angiography confirmed bilateral peripheral PE . The brain computed tomography scan was normal.", + "fulltext_subclaims": [ + "A 32-year-old man presented to the emergency room with repetitive episodes of syncope and intermittent dyspnea within 7 d.", + "The patient complained of chest distress on February 15, 2019.", + "He had a transient, self-limited loss of consciousness lasting for 3-5 min, followed by prompt recovery.", + "The syncope happened four times.", + "The trigger of the attacks included physical exertion or inhaling cold air.", + "There is no prodromal or accompanied symptom.", + "He went to our hospital by himself on February 22, 2019 because of another onset of syncope.", + "The patient had no medical history nor family history of blood clotting disorders.", + "He had a sedentary lifestyle due to his job as a news editor.", + "His vital signs were stable at the time of the first medical contact.", + "Pulse rate was 96 beats/min.", + "Respiratory rate was 20 breaths/min.", + "Blood pressure was 15.5/10.1 kPa.", + "Body mass index was 23.1 kg/m2.", + "Pupils were symmetric and responsive to light.", + "Prominent P2 was noted.", + "Symmetrical breath sounds without rales or wheezing were noted.", + "Warm extremities without edema were noted.", + "The neurological examination was negative.", + "Initial laboratory test showed elevated serum D-dimer at 4150 ng/mL.", + "Arterial blood gas analysis showed PaO2 of 79 mmHg while he was breathing ambient air.", + "N-terminal pro-B-type natriuretic peptide was 4460 pg/mL.", + "The levels of serum cardiac enzyme series were normal.", + "The electrocardiogram showed sinus tachycardia.", + "Doppler ultrasound revealed a deep venous thrombosis in the right popliteal vein.", + "Transthoracic echocardiography showed a mass thrombus straddling a PFO concomitant dilated right atrium and moderate pulmonary hypertension.", + "The size of the thrombus was 3 mm × 20 mm in the left atrium.", + "The size of the thrombus was 8 mm × 25 mm in the right atrium.", + "Computed tomography angiography confirmed bilateral peripheral PE.", + "The brain computed tomography scan was normal." + ], + "summary": "A 32-year-old man suffered from recurrent syncope and intermittent dyspnea for 1 wk. Transthoracic echocardiography confirmed a thrombus straddling the patent foramen ovale, and thrombi were also found in the bilateral pulmonary artery by computed tomography. The man underwent inferior vena cava filter placement and thrombolysis with alteplase. Echocardiography showed the absence of thrombi in both the right atrium and left atrium 2 d after hospitalization. The man was discharged to home on warfarin without any complications 2 wk later.", + "summary_subclaims": [ + "The patient is a 32-year-old man.", + "The patient suffered from recurrent syncope.", + "The patient had intermittent dyspnea for 1 wk.", + "Transthoracic echocardiography confirmed a thrombus straddling the patent foramen ovale.", + "Computed tomography found thrombi in the bilateral pulmonary artery.", + "The man underwent inferior vena cava filter placement.", + "The man underwent thrombolysis with alteplase.", + "Echocardiography showed the absence of thrombi in both the right atrium and left atrium 2 d after hospitalization.", + "The man was discharged to home on warfarin.", + "The man was discharged 2 wk after hospitalization.", + "The man had no complications at discharge." + ] + }, + { + "id": "multiclinsum_test_1663_en.txt", + "fulltext": "A 23-year-old man presented with nausea, imbalance, occasional urinary and fecal incontinence and a severe headache for 1 month. The patient was a farmer with an unremarkable past experience for his relatives. Neurological examination was completely normal. Magnetic resonance imaging (MRI) demonstrated a left cerebellar mass lesion of 3×2×1.5 cm in size with marked peripheral contrast enhancement . Computed tomography (CT) examination of the chest and abdomen were performed for a primary origin. Multiple calcified mass lesions with lobulated contours were shown in the right upper lobe of lung, right liver and another solid tumor between right kidney and liver. Suboccipital craniotomy was performed and a left intracerebellar pale yellow mass was excised grossly as total. The tumor was almost avascular and it was easily dissected from the surrounding cerebellar tissues. Postoperative course was unremarkable without any neurological deficit. Histopathological examination revealed PAS (+) cuticular membrane with wide areas of necrosis and inflammation which were typical for EM . Serological tests at the postoperative period confirmed the presence of EM with indirect hemagglutination test.\nAlbendazole (800 mg, bid, 3 cure, 28-day cycle followed by a 14-day albendazole-free interval) and cephotaxime (4 g, bid) were prescribed for postoperative treatment. A further operation was performed to resect the lesion in the lung a month after intracranial surgery. Postoperative early CT examination and MRI performed 6 months after surgery showed no recurrence.", + "fulltext_subclaims": [ + "A 23-year-old man presented with nausea, imbalance, occasional urinary and fecal incontinence and a severe headache for 1 month.", + "The patient was a farmer.", + "Neurological examination was completely normal.", + "MRI demonstrated a left cerebellar mass lesion of 3×2×1.5 cm in size with marked peripheral contrast enhancement.", + "CT examination of the chest and abdomen were performed for a primary origin.", + "Multiple calcified mass lesions with lobulated contours were shown in the right upper lobe of lung, right liver and another solid tumor between right kidney and liver.", + "Suboccipital craniotomy was performed and a left intracerebellar pale yellow mass was excised grossly as total.", + "The tumor was almost avascular and it was easily dissected from the surrounding cerebellar tissues.", + "Postoperative course was unremarkable without any neurological deficit.", + "Histopathological examination revealed PAS (+) cuticular membrane with wide areas of necrosis and inflammation which were typical for EM.", + "Serological tests at the postoperative period confirmed the presence of EM with indirect hemagglutination test.", + "Albendazole (800 mg, bid, 3 cure, 28-day cycle followed by a 14-day albendazole-free interval) and cephotaxime (4 g, bid) were prescribed for postoperative treatment.", + "A further operation was performed to resect the lesion in the lung a month after intracranial surgery.", + "Postoperative early CT examination and MRI performed 6 months after surgery showed no recurrence." + ], + "summary": "We report a 23-year-old man with a cerebellar Echinococcosis multilocularis mimicking a metastatic cerebellar tumor. Suboccipital craniotomy was performed for gross total removal of the tumor. Histopathological specimens confirmed the diagnosis of Echinococcosis multilocularis.", + "summary_subclaims": [ + "The patient is a 23-year-old man.", + "The patient had a cerebellar Echinococcosis multilocularis.", + "The Echinococcosis multilocularis mimicked a metastatic cerebellar tumor.", + "Suboccipital craniotomy was performed.", + "The tumor was grossly totally removed.", + "Histopathological specimens confirmed the diagnosis of Echinococcosis multilocularis." + ] + }, + { + "id": "multiclinsum_test_3107_en.txt", + "fulltext": "A 62-year-old individual with obesity (BMI 37.1 kg/m2) was admitted to the authors’ spinal surgery unit due to the presence of severe pain in the lumbosacral region, which radiated to the lower extremities (Visual Analog Scale [VAS] score of 6 out of 10). Additionally, the patient experienced severe neurogenic claudication (14 points on the N-CLASS scale) and exhibited weakness in the lower limbs (MRC scale: 4). No reports of bowel or bladder control loss were noted. The Oswestry Disability Index (ODI) score was 48%, indicating a state of severe disability.\n\nThe magnetic resonance imaging (MRI) examination performed on the patient revealed findings consistent with complete spondylolisthesis (spondyloptosis) at the L5/S1 level. The MRI showed distortion of the vertebral bodies, with the L5 vertebral body displaced anteriorly to the S1 vertebral body. Additionally, critical stenosis of the spinal canal and intervertebral foramina was observed. Prior to the surgery, a preoperative computed tomography (CT) scan was conducted, providing further information. In addition to the previously mentioned findings, the CT scan revealed a significant degree of bone fusion (union) in the L5/S1 region. Furthermore, the transverse dimension of the dural sac at the L4/L5 level was measured to be 15×9 [mm].\n\nThe surgical intervention consisted of decompression of the dural sac through laminectomy at the L3-S1 levels and stabilization of L3, L4, and L5-S1. Transpedicular screws were routinely inserted at the L3 and L4 levels. However, due to the significant bone fusion between L5 and S1, which hindered the reduction of spondyloptosis at this level, transpedicular screws were inserted using Grob’s technique, passing through the fused L5 and S1 vertebrae. Following stabilization, spinal canal decompression was performed, and the screws were connected to a connecting rod for further support and stability.\n\nThe postoperative course was uneventful, without any complications. A CT scan conducted 24 hours after the surgery confirmed the accurate positioning and secure anchorage of the screws. This imaging assessment provided reassurance regarding the stability and integrity of the surgical construct.\n\nTo enhance the comprehensibility of the case report, we compiled tomographic images that illustrate the placement of the screws. By consolidating these images, we aimed to provide a clearer visual representation of the precise positioning and alignment of the screws within the spinal structure.\n\nWithin 24 hours of the procedure, the patient regained the ability to walk. The previously experienced weakness in the lower extremities and neurogenic claudication were resolved. Following a favorable recovery, the patient was discharged in good overall condition after 72 hours. A digital radiograph obtained four weeks post-surgery revealed the accurate positioning of the screws, indicating successful alignment and stability. At the four-month postoperative assessment, the patient’s Oswestry Disability Index (ODI) improved to 34%, indicating a significant reduction in disability. Prior to the surgery, the patient experienced nighttime pain disturbances, but after the procedure, he achieved uninterrupted sleep. The patient’s mobility has notably improved, enabling him to walk distances of up to 4 km without significant difficulties. However, he does report occasional paresthesias in his toes. Overall, the patient’s functional outcomes have significantly improved, demonstrating the positive impact of the surgical intervention.", + "fulltext_subclaims": [ + "The patient was a 62-year-old individual with obesity (BMI 37.1 kg/m2).", + "The patient was admitted to the authors’ spinal surgery unit.", + "The patient had severe pain in the lumbosacral region that radiated to the lower extremities.", + "The patient’s VAS score was 6 out of 10.", + "The patient had severe neurogenic claudication.", + "The patient’s N-CLASS score was 14.", + "The patient had weakness in the lower limbs.", + "The patient’s MRC scale score was 4.", + "The patient did not report bowel or bladder control loss.", + "The patient’s ODI score was 48%.", + "MRI showed findings consistent with complete spondylolisthesis (spondyloptosis) at the L5/S1 level.", + "MRI showed the L5 vertebral body displaced anteriorly to the S1 vertebral body.", + "MRI showed critical stenosis of the spinal canal and intervertebral foramina.", + "A preoperative CT scan was conducted.", + "The CT scan revealed significant bone fusion in the L5/S1 region.", + "The transverse dimension of the dural sac at the L4/L5 level was measured to be 15×9 mm.", + "The surgical intervention included decompression of the dural sac through laminectomy at the L3-S1 levels.", + "The surgical intervention included stabilization of L3, L4, and L5-S1.", + "Transpedicular screws were inserted at the L3 and L4 levels.", + "Due to significant bone fusion between L5 and S1, transpedicular screws were inserted using Grob’s technique.", + "Spinal canal decompression was performed.", + "The screws were connected to a connecting rod.", + "The postoperative course was uneventful.", + "A CT scan 24 hours after surgery confirmed accurate positioning and secure anchorage of the screws.", + "Tomographic images were compiled to illustrate the placement of the screws.", + "The patient regained the ability to walk within 24 hours of the procedure.", + "The patient’s weakness in the lower extremities resolved.", + "The patient’s neurogenic claudication resolved.", + "The patient was discharged after 72 hours.", + "A digital radiograph four weeks post-surgery showed accurate positioning of the screws.", + "At four months postoperatively, the patient’s ODI improved to 34%.", + "The patient achieved uninterrupted sleep after the procedure.", + "The patient can walk distances of up to 4 km without significant difficulties.", + "The patient reports occasional paresthesias in his toes.", + "The patient’s functional outcomes have significantly improved." + ], + "summary": "In this case report, we describe the case of a 62-year-old man who experienced a lumbosacral injury from a fall twenty years prior to seeking treatment. The patient had multiple comorbidities, including obesity and internal medicine conditions. He presented with severe back pain radiating to the lower extremities, accompanied by significant neurogenic chroma and lower extremity weakness. Imaging studies revealed spondyloptosis at the L5/S1 level, along with bony fusion and spinal canal stenosis at the L3/L4 level.", + "summary_subclaims": [ + "The patient is a 62-year-old man.", + "The patient experienced a lumbosacral injury from a fall twenty years prior to seeking treatment.", + "The patient had multiple comorbidities.", + "The patient had obesity.", + "The patient had internal medicine conditions.", + "The patient presented with severe back pain radiating to the lower extremities.", + "The patient had significant neurogenic chroma.", + "The patient had lower extremity weakness.", + "Imaging studies revealed spondyloptosis at the L5/S1 level.", + "Imaging studies revealed bony fusion at the L3/L4 level.", + "Imaging studies revealed spinal canal stenosis at the L3/L4 level." + ] + }, + { + "id": "multiclinsum_test_2004_en.txt", + "fulltext": "A 31-year-old woman was admitted to our hospital emergencies referred from the Medical Center of Santorini Island with a preliminary diagnosis of acute abdomen, after a penetrating trauma in the upper right abdomen by a swordfish. Whilst she was swimming close to the seacoast, only three meters away from the beach yet in waist-deep water, she felt a stab to her right hypochondrial area. After the first shock, she realized it was a fish that had attacked her and she pulled it out of her body. Neither she nor any other bather swimming nearby saw any fish approaching her. However, after her injury, some of the bathers dived and saw the fish running away towards deeper water. The patient was withdrawn from the sea and, having received first aid by the local lifeguard, she was immediately transferred to the island's Medical Center by her companions. Witnesses' testimony, which was enforced by a part of the fish bill, measured to be 20 cm, found at the bottom of the sea in the area of the incident by the Coast Guard of Santorini Island led ichthyologists to identify the fish as a billfish, Xiphias gladius (swordfish).\nHer vital signs on presentation to our hospital were: blood pressure 113/71 mm Hg, heart rate 81 beats/minute, arterial blood oxygen saturation 100% and temperature 38.6°C. Physical examination was remarkable only in the abdomen which was scaphoid, tender to palpation with diminished bowel sounds and a 4 cm trauma at the mid-axillary line below the right costal margin. The patient received a broad-spectrum antibiotic and a prophylactic tetanus toxoid injection. Laboratory tests showed a haematocrit of 28.5%, haemoglobin levels of 9.7 g/dL, white blood cell count of 25 × 109/L (with 94.10% polymorphonuclear cell type), and platelet count of 152 × 109/L. The coagulation profile was within normal limits. Thoracic and abdominal X-rays performed at the island's Medical Center did not reveal any pathology whilst F.A.S.T (Focused Assessment Sonography in Trauma) performed there marked out free intraperitoneal fluid at the right circumrenal and Duglas areas. An abdominal Computed Tomography (CT) scan in our hospital revealed: laceration of right liver lobe, distension of inferior vena cava, distension of right renal vein and a hyperdense bone-type foreign body (swordfish bill tip) retroperitoneally. The latter had entered the spinal canal through the body of the second lumbar vertebra (L2) after crossing the abdominal cavity . CT reconstruction images demonstrating the tip of the swordfish bill lodged within the spinal canal were produced . The magnetic resonance imaging (MRI) scan of the lumbar region indicated a longitudinal foreign body, which had reached the interspinous space of the second and third lumbar spinous processes, through the body of the L2 and the spinal canal . Myelography showed that the foreign body penetrated tabular roots and spinal canal at the area mentioned above and further neurological examination was recommended. The neurological (sensory and mobility) examination of both legs, as well as the sensory examination of the perineum did not reveal any neurological deficit.\nAfter all diagnostic tests had been completed and interpreted, the patient was transfused with one unit of blood and assigned to surgery for intra-abdominal bleeding. Penetration of the abdomen was present at the mid-axillary line, below the right costal margin. The abdomen was explored through bilateral subcostal incision. Approximately 1 litre of blood was aspirated from the abdominal cavity and a large right retroperitoneal hematoma was identified. The right liver lobe was mobilized and the portal triad was controlled with a sling. Liver had been penetrated from segment IVa posteriorly and the inferior vena cava (IVC) had been lacerated medially. The duodenum was mobilized and the retroperitoneum was opened. Blood and clots were evacuated from the retroperitoneal space and the IVC was repaired with proline 4-0. Cholecystectomy was performed at this stage because of laceration of the cystic duct. The gastrocolic ligament was subsequently divided and the pancreas and aorta were explored. An unsuccessful effort was done in order to find the foreign body (sword fish bill tip) at the level of L2 vertebra, which was revealed at the CT and MRI scan. A penrose drainage was placed below the liver and the wound was closed.\nAfter the completion of the surgery, the patient was transferred to the Intensive Care Unit for monitoring and planning of the foreign body removal in future. She was hospitalized there for three days. The patient's clinical state and laboratory parameters were evaluated from orthopedics of our hospital who recommended the patient's mobilization. After that she was transferred to the Third Surgical department for further medical attendance and laboratory tests. On the third postoperative day, she exhibited fever up to 38.5°C which was resistant to antibiotic therapy. Blood cultures were taken and lumbar puncture was performed; the collected sample of cerebrospinal fluid was sent for biochemical and microbiological analysis. Both examinations were negative for bacterium growth. The new thoracic and abdominal computed tomography (CT) scan did not show significant changes compared with CT on her admission to the emergency with the exception of subcapsular fluid collection of increased density at left liver lobe, which was found increased in new CT examination 4 days later. CT- guided drainage of that fluid, which was a biloma, was performed and drainage tube was left at the collection's area. The Magnetic resonance cholangiopancreatography (MRCP), that was performed three days later, did not reveal any pathology of bile ducts or bile leak. The new MRI scan of lumbar region indicated L2 inflammation and arachnoiditis of some tabular roots (Arrow; Figure ). The patient then was transferred to the Neurosurgical department of our hospital and underwent an operation in order to remove the swordfish bill tip by approaching it from the spinal canal (posteriore approach). Laminectomy of the second and third lumbar vertebra was accomplished and the foreign body was removed intact easily . There was L2 vertebral decomposition as a result of local osteomyelitis. Osteomyelitis of these vertebras was the result of bone infection by bacteria of the epithelium of swordfish bill which invaded the bone directly after the swordfish attack. Consequently, when the cause of osteomyelitis - tip of swordfish bill - removed surgically, patient's fever declined since the first postoperative day and the overall condition improved significantly. Patient was mobilized on the third postoperative day. However, she was hospitalized further in order to receive intravenous antibiotic therapy. She left the hospital on the thirty fifth postoperative day, fourteen days after the abdominal drainage was taken out. Antibiotics were continued for further four more weeks.\nWritten informed consent was obtained from the patient for the publication of the case report.", + "fulltext_subclaims": [ + "A 31-year-old woman was admitted to the hospital emergencies with a preliminary diagnosis of acute abdomen.", + "She had a penetrating trauma in the upper right abdomen by a swordfish.", + "The injury occurred while she was swimming close to the seacoast, three meters away from the beach, in waist-deep water.", + "She felt a stab to her right hypochondrial area.", + "She pulled the fish out of her body after the initial shock.", + "Neither she nor any other bather saw any fish approaching her.", + "After her injury, some bathers dived and saw the fish running away towards deeper water.", + "She was withdrawn from the sea and received first aid by the local lifeguard.", + "She was transferred to the island's Medical Center by her companions.", + "Witnesses' testimony, enforced by a 20 cm part of the fish bill found by the Coast Guard, led to the identification of the fish as a swordfish.", + "Her blood pressure on presentation was 113/71 mm Hg.", + "Her heart rate was 81 beats/minute.", + "Her arterial blood oxygen saturation was 100%.", + "Her temperature was 38.6°C.", + "Physical examination showed a 4 cm trauma at the mid-axillary line below the right costal margin.", + "She received a broad-spectrum antibiotic and a prophylactic tetanus toxoid injection.", + "Laboratory tests showed a haematocrit of 28.5%.", + "Her haemoglobin level was 9.7 g/dL.", + "Her white blood cell count was 25 × 109/L.", + "The polymorphonuclear cell type was 94.10%.", + "Her platelet count was 152 × 109/L.", + "The coagulation profile was within normal limits.", + "Thoracic and abdominal X-rays did not reveal any pathology.", + "F.A.S.T. performed at the island's Medical Center showed free intraperitoneal fluid at the right circumrenal and Duglas areas.", + "An abdominal CT scan showed laceration of the right liver lobe.", + "The CT scan showed distension of the inferior vena cava.", + "The CT scan showed distension of the right renal vein.", + "A hyperdense bone-type foreign body (swordfish bill tip) was found retroperitoneally.", + "The foreign body had entered the spinal canal through the body of the second lumbar vertebra.", + "CT reconstruction images showed the tip of the swordfish bill lodged within the spinal canal.", + "MRI of the lumbar region showed a longitudinal foreign body reaching the interspinous space of the second and third lumbar spinous processes.", + "Myelography showed the foreign body penetrating tabular roots and the spinal canal at the area mentioned.", + "Neurological examination did not reveal any deficit.", + "The patient was transfused with one unit of blood.", + "She was assigned to surgery for intra-abdominal bleeding.", + "Penetration of the abdomen was at the mid-axillary line, below the right costal margin.", + "The abdomen was explored through bilateral subcostal incision.", + "Approximately 1 litre of blood was aspirated from the abdominal cavity.", + "A large right retroperitoneal hematoma was identified.", + "The right liver lobe was mobilized and the portal triad was controlled with a sling.", + "The liver had been penetrated from segment IVa posteriorly.", + "The inferior vena cava had been lacerated medially.", + "The duodenum was mobilized and the retroperitoneum was opened.", + "Blood and clots were evacuated from the retroperitoneal space.", + "The inferior vena cava was repaired with proline 4-0.", + "Cholecystectomy was performed because of laceration of the cystic duct.", + "An unsuccessful effort was made to find the foreign body at the level of L2 vertebra.", + "A penrose drainage was placed below the liver.", + "The wound was closed.", + "The patient was transferred to the Intensive Care Unit.", + "She was hospitalized there for three days.", + "The patient's clinical state and laboratory parameters were evaluated by orthopedics.", + "She was transferred to the Third Surgical department.", + "On the third postoperative day, she exhibited fever up to 38.5°C.", + "The fever was resistant to antibiotic therapy.", + "Blood cultures were taken.", + "Lumbar puncture was performed.", + "Cerebrospinal fluid was sent for biochemical and microbiological analysis.", + "Both examinations were negative for bacterium growth.", + "A new thoracic and abdominal CT scan did not show significant changes.", + "A subcapsular fluid collection of increased density at the left liver lobe was found.", + "CT-guided drainage of the fluid, a biloma, was performed.", + "A drainage tube was left at the collection's area.", + "MRCP did not reveal any pathology of bile ducts or bile leak.", + "A new MRI scan of the lumbar region showed L2 inflammation and arachnoiditis.", + "The patient was transferred to the Neurosurgical department.", + "She underwent an operation to remove the swordfish bill tip from the spinal canal.", + "Laminectomy of the second and third lumbar vertebra was accomplished.", + "The foreign body was removed intact easily.", + "There was L2 vertebral decomposition as a result of local osteomyelitis.", + "Osteomyelitis was the result of bone infection by bacteria of the swordfish bill epithelium.", + "When the cause of osteomyelitis was removed, the patient's fever declined.", + "The patient's overall condition improved significantly.", + "She was mobilized on the third postoperative day.", + "She was hospitalized further to receive intravenous antibiotic therapy.", + "She left the hospital on the thirty-fifth postoperative day.", + "Antibiotics were continued for four more weeks.", + "Written informed consent was obtained from the patient for the publication of the case report." + ], + "summary": "In this case report we present the unique, as far as the literature is concerned, unprovoked woman's injury to the abdomen by a swordfish. There are only four cases of swordfish attacks on humans in the literature - one resulted to thoracic trauma, two to head trauma and one to knee trauma, one of which was fatal - none of which were unprovoked. Three victims were professional or amateur fishermen whereas in the last reported case the victim was a bather as in our case. Our case is the only case where organic debris of animal's origin remained in the spinal canal after penetrating trauma.", + "summary_subclaims": [ + "This case report presents a unique, as far as the literature is concerned, unprovoked woman's injury to the abdomen by a swordfish.", + "There are only four cases of swordfish attacks on humans in the literature.", + "One swordfish attack resulted in thoracic trauma.", + "Two swordfish attacks resulted in head trauma.", + "One swordfish attack resulted in knee trauma.", + "One of the swordfish attacks was fatal.", + "None of the four swordfish attack cases were unprovoked.", + "Three victims of swordfish attacks were professional or amateur fishermen.", + "In the last reported swordfish attack case, the victim was a bather.", + "In this case, organic debris of animal's origin remained in the spinal canal after penetrating trauma." + ] + }, + { + "id": "multiclinsum_test_2808_en.txt", + "fulltext": "A 32-year-old woman was admitted to our hospital with a progressively enlarged mass in the rectovaginal space for 9 years.\nThe mass was found during a routine examination 9 years ago and no obvious progression was seen in following annual examinations until a year ago. The maximum diameter of the mass had significantly grown from 4.0 cm to 9.7 cm in a year, with dents in stools, which was caused by tumor compression. The patient had a submucosal protrusion demonstrated by endoscopy in a local hospital. However, no absolute tumor tissue but only inflammation was found after several times of endoscopic biopsies in the latest 2 years, which was not consistent with clinical estimation. Therefore, she came to our hospital for further diagnosis .\nThe patient had no previous medical history.\nThe patient and family had no history of previous similar illness.\nThe patient’s mental status, appetite, sleep, and weight were normal without any obvious symptoms of abdominal distension, tenesmus, prolapse, diarrhea, or constipation. The anterior rectum wall was plump during digital rectal examination without tenderness or blood stain on the fingertip.\nLaboratory examinations were normal, including routine blood analysis, carcinoembryonic antigen, α-fetoprotein, carbohydrate antigen (CA) 19-9, and CA125.\nContrast-enhanced CT (CECT) showed a mass with liquefaction necrosis (low density area) inside the rectovaginal space, with an obscure margin . Transabdominal US was performed. A heterogeneous hypoechoic mass with a maximum diameter of 9.7 cm was also seen in the rectovaginal space , which was suspected to be a rectal GIST or exophytic uterine fibroid.\nTransabdominal CNB (MG1522 BARD MAGNUM Biopsy Instrument; Tempe, AZ, United States; disposable core tissue biopsy needle, gauge size and needle length: 16 G and 16 cm) was performed to make a definite diagnosis . Before the operation, written informed consent was obtained from the patient, and her preoperative regular laboratory examinations were normal, including routine blood test, coagulation function, and blood transfusion set. Some hemorrhage occurred from the vagina, causing premature end of the biopsy, and spontaneously relieved several days later. Strips of greyish shattered tissue were obtained, with the largest diameter smaller than 0.3 cm. Pathology indicated inadequate biopsy tissue for diagnosis. Another biopsy after ERUS assessment was recommended by multiple disciplinary treatment (MDT).\nFirst, ERUS was performed with the MyLab Twice US system (Esaote, Genoa, Italy) equipped with a biplane endoscopic probe (TRT33, linear frequency of 4–13 MHz, convex frequency of 3-9 MHz), recording the location, size, stratification, adjacence, and echogenicity of the tumor. Then CEUS was performed with a bolus injection through the elbow vein of 2.4 mL SonoVue (Bracco, Milan, Italy) . Because of the heterogeneity of the tumor, it was difficult to recognize the necrotic from non-necrotic part in B mode, which can be clearly depicted by CEUS as nonenhanced vs enhanced area. As previous CECT has pointed out necrosis, CEUS was performed right before puncture to confirm the substantial part of the tumor for biopsy guidance for the second time, avoiding the failed samples inside presumptive solid area, which turned to be non-enhanced after CEUS. This guarantees the precision and efficiency of biopsy samples.\nThe probe was switched to linear mode. The transperineal puncture site and path were decided, and disinfection as well as drape were also completed. After local anesthesia, a freehand biopsy of the lesion was performed with the guidance of in-plane needle. The needle tip and its movements were continuously monitored in real time by ERUS during the whole puncture procedure to procure the tissue of lesion from enhanced area of the tumor on CEUS . Several strips of greyish tissue were obtained with a length of 0.3-1.2 cm . No complications occurred.", + "fulltext_subclaims": [ + "The patient is a 32-year-old woman.", + "She was admitted with a progressively enlarged mass in the rectovaginal space for 9 years.", + "The mass was found during a routine examination 9 years ago.", + "No obvious progression was seen in following annual examinations until a year ago.", + "The maximum diameter of the mass had significantly grown from 4.0 cm to 9.7 cm in a year.", + "Dents in stools were caused by tumor compression.", + "Endoscopy in a local hospital showed a submucosal protrusion.", + "No absolute tumor tissue but only inflammation was found after several times of endoscopic biopsies in the latest 2 years.", + "The patient had no previous medical history.", + "The patient and family had no history of previous similar illness.", + "The anterior rectum wall was plump during digital rectal examination.", + "Contrast-enhanced CT showed a mass with liquefaction necrosis inside the rectovaginal space.", + "Transabdominal US showed a heterogeneous hypoechoic mass with a maximum diameter of 9.7 cm in the rectovaginal space.", + "The mass was suspected to be a rectal GIST or exophytic uterine fibroid.", + "Transabdominal CNB was performed to make a definite diagnosis.", + "Written informed consent was obtained from the patient before the operation.", + "Some hemorrhage occurred from the vagina, causing premature end of the biopsy.", + "The hemorrhage spontaneously relieved several days later.", + "Strips of greyish shattered tissue were obtained, with the largest diameter smaller than 0.3 cm.", + "Pathology indicated inadequate biopsy tissue for diagnosis.", + "Another biopsy after ERUS assessment was recommended by multiple disciplinary treatment.", + "ERUS was performed with the MyLab Twice US system.", + "CEUS was performed with a bolus injection of 2.4 mL SonoVue.", + "CEUS was performed right before puncture to confirm the substantial part of the tumor for biopsy guidance.", + "The probe was switched to linear mode.", + "The transperineal puncture site and path were decided.", + "A freehand biopsy of the lesion was performed with the guidance of in-plane needle.", + "The needle tip and its movements were continuously monitored in real time by ERUS during the whole puncture procedure.", + "Several strips of greyish tissue were obtained with a length of 0.3-1.2 cm.", + "No complications occurred." + ], + "summary": "A 32-year-old woman complained of a mass inside the rectovaginal space for 9 years, which became enlarged within 1 year. A rectal SEL detected by endoscopy was suspected to be a gastrointestinal stromal tumor or exophytic uterine fibroid. Pathological diagnosis was difficult because of unsuccessful transabdominal core needle biopsy with insufficient tissues, as well as vaginal hemorrhage. A second biopsy was suggested after multiple disciplinary treatment discussion, which referred to a transperineal core needle biopsy (CNB) guided by ERUS combined with CEUS. Adequate samples were procured and rectal gastrointestinal stromal tumor was proved to be the pathological diagnosis. Imatinib was recommended for first-line therapy by multiple disciplinary treatment discussion. After the tumor shrunk, resection of the rectal gastrointestinal stromal tumor was performed through the posterior vaginal wall. Adjuvant therapy was applied and no recurrence or metastasis has been found by the last follow-up on December 13, 2019.", + "summary_subclaims": [ + "The patient is a 32-year-old woman.", + "She complained of a mass inside the rectovaginal space for 9 years.", + "The mass became enlarged within 1 year.", + "A rectal SEL was detected by endoscopy.", + "The rectal SEL was suspected to be a gastrointestinal stromal tumor.", + "The rectal SEL was suspected to be an exophytic uterine fibroid.", + "A transabdominal core needle biopsy was unsuccessful.", + "The transabdominal core needle biopsy resulted in insufficient tissues.", + "Vaginal hemorrhage occurred.", + "A second biopsy was suggested after multiple disciplinary treatment discussion.", + "A transperineal core needle biopsy was guided by ERUS combined with CEUS.", + "Adequate samples were procured.", + "The pathological diagnosis was rectal gastrointestinal stromal tumor.", + "Imatinib was recommended for first-line therapy.", + "The tumor shrank after treatment.", + "Resection of the rectal gastrointestinal stromal tumor was performed through the posterior vaginal wall.", + "Adjuvant therapy was applied.", + "No recurrence or metastasis has been found by the last follow-up on December 13, 2019." + ] + }, + { + "id": "multiclinsum_test_982_en.txt", + "fulltext": "A 76-year-old male patient presented to the Department of Orthopedics of our hospital complaining of worsening progressive right hip pain, a limp when walking and weakness of the right hip. He was admitted to our hospital.\nThe patient’s symptoms started four years ago with recurrent swelling of the right hip with mild pain, which had worsened in the last 48 h.\nThe patient initially presented with neck pain and weakness in all four limbs 16 years ago and was diagnosed with cervical spondylosis, which was treated conservatively.\nThe patient had an unremarkable personal and family history.\nThe patient reported mild pain with flexion and extension of the cervical spine and activity limitation. Apparent swelling was observed in the left hip, and more than 110 mL of clear yellowish joint fluid was extracted. The active range of motion of the right hip was recorded as follows: flexion 90°, abduction 30°, internal rotation 20°, and external rotation 35°, with pain in all directions. The visual analog score was 6/10 points, and the Harris hip score (HHS) was 56 points. Neurologically, the sensation of pain and temperature in the upper and lower extremities was decreased, and proprioception and position sensation were normal. A pathologic reflex was not elicited. Both upper limbs and the right lower limb exhibited weakness with a muscle strength of 4/5, the muscle strength of the left lower limb was normal at 5/5, the right abductor had a muscle strength score of 5/5, and the modified Japanese Orthopedic Association score for CSM was 9/17 points. The bone mineral density (BMD) of the hip was 0.45 g/cm2, and the T score was -2.9. Laboratory results were nonspecific.\nBlood biochemistry and urine analyses were normal. Electrocardiogram, chest X-ray and arterial blood gases were also normal. The BMD of the hip was 0.45 g/cm2, and the T score was -2.9.\nMagnetic resonance imaging (MRI) of the cervical spine showed cervical syringomyelia at C4, cervical disc herniation and spinal canal stenosis from the C3 to the C7 levels . Cervical computed tomography (CT) revealed destruction of the vertebral body at C4 and C5–7 vertebral body assimilation . Three-dimensional CT reconstruction, CT scans, and X-rays of the right hip joint showed joint space loss, articular surface collapse, and destructive changes in the acetabulum and femoral head . T2W1 MRI of the right hip showed articular cartilage loss, degeneration of the joint, disordered soft tissue, and apparent joint fluid .", + "fulltext_subclaims": [ + "A 76-year-old male patient presented to the Department of Orthopedics of our hospital complaining of worsening progressive right hip pain.", + "The patient was admitted to our hospital.", + "The patient’s symptoms started four years ago with recurrent swelling of the right hip with mild pain.", + "The patient initially presented with neck pain and weakness in all four limbs 16 years ago.", + "The patient was diagnosed with cervical spondylosis.", + "The patient had an unremarkable personal and family history.", + "Apparent swelling was observed in the left hip.", + "More than 110 mL of clear yellowish joint fluid was extracted.", + "The active range of motion of the right hip was recorded as follows: flexion 90°, abduction 30°, internal rotation 20°, and external rotation 35°.", + "The visual analog score was 6/10 points.", + "The Harris hip score (HHS) was 56 points.", + "The sensation of pain and temperature in the upper and lower extremities was decreased.", + "Proprioception and position sensation were normal.", + "A pathologic reflex was not elicited.", + "Both upper limbs and the right lower limb exhibited weakness with a muscle strength of 4/5.", + "The muscle strength of the left lower limb was normal at 5/5.", + "The right abductor had a muscle strength score of 5/5.", + "The modified Japanese Orthopedic Association score for CSM was 9/17 points.", + "The bone mineral density (BMD) of the hip was 0.45 g/cm2.", + "The T score was -2.9.", + "Blood biochemistry and urine analyses were normal.", + "Electrocardiogram, chest X-ray and arterial blood gases were also normal.", + "Magnetic resonance imaging (MRI) of the cervical spine showed cervical syringomyelia at C4.", + "Cervical computed tomography (CT) revealed destruction of the vertebral body at C4.", + "Three-dimensional CT reconstruction showed joint space loss.", + "T2W1 MRI of the right hip showed articular cartilage loss." + ], + "summary": "We describe a 76-year-old male patient who was diagnosed with CSM due to neck pain and weakness of limbs 16 years ago. Four years ago, he noticed recurrent swelling of the right hip with pain and was diagnosed with degenerative arthritis. Recently, however, his symptoms gradually worsened, and because of progressive pain, destabilization and weakness of the right hip, he was admitted to our hospital. Through systematic physical, radiographic and laboratory examinations, we finally reached a diagnosis: CN of the right hip associated with syringomyelia secondary to CSM. After comprehensive evaluation of the patient's condition, we performed right total hip arthroplasty. During the follow-up, the patient felt well clinically and could walk independently with a knee brace.", + "summary_subclaims": [ + "The patient is a 76-year-old male.", + "The patient was diagnosed with CSM due to neck pain and weakness of limbs 16 years ago.", + "Four years ago, the patient noticed recurrent swelling of the right hip with pain.", + "The patient was diagnosed with degenerative arthritis.", + "Recently, the patient's symptoms gradually worsened.", + "The patient was admitted to the hospital due to progressive pain, destabilization, and weakness of the right hip.", + "The diagnosis was CN of the right hip associated with syringomyelia secondary to CSM.", + "The patient underwent right total hip arthroplasty.", + "During follow-up, the patient felt well clinically.", + "The patient could walk independently with a knee brace." + ] + }, + { + "id": "multiclinsum_test_2483_en.txt", + "fulltext": "A 50-year-old female presented with three years of metatarsophalangeal (MTP) joint pain. She has no family history of RA. She visited our hospital with a chief complaint of foot pain and swelling 3 years ago. Morton's disease was initially suspected. She stopped visiting our hospital because pain did not get better. 3 years after, she was referred from clinic to our hospital because of the foot deformity, subcutaneous hemorrhage, and bone erosion image on the X-ray. On physical examination, she had pain and swelling on MTP joint of forth toe . The MTP joint had 0° of extension and 30° of flexion. Pain on motion was observed at that time. Laboratory tests revealed low levels of inflammatory markers and positive serological markers for RA: C-reactive protein (CRP) was negative, rheumatoid factor (RF) was 29.3 IU/mL, and anti-cyclic citrullinated peptide (ACPA) was 496.6 IU/mL. She scored 6 points according to the 2010 American College of Rheumatology/European League Against Rheumatism (ACR/EULAR) classification criteria and was classified with RA. X-ray showed bone erosion of metatarsal (a and b). MRI showed synovial proliferation and fluid around 3rd and 4th metatarsals (c). Because of difficulties in diagnosis, disease-modifying anti-rheumatic drugs were not administered prior to surgery, only non-steroidal anti-inflammatory drugs were administered, but there was no improvement in pain. She had pain due to lateral dislocation of proximal phalanx of foot and was performed synovectomy for diagnosis and treatment. Enlarged MTP joint capsule was observed (a). Incision through the joint capsule revealed synovial proliferation (b). After synovectomy, we found destruction of articular cartilage and subchondral bone (c). Joint instability due to periarticular tissue destruction was observed, so MTP joint was fixed by using Kirschner-wire (d). On pathological examination, there was infiltration by inflammatory cells including plasma cells with blood vessel proliferation (a and c) and formation of lymphoid follicle (b). CD138 immuno-staining was positive (d). CD138 is a member of the syndecan family of type I transmembrane proteoglycans. CD138 is highly expressed on plasma cells which is characteristic for RA . Pathological findings were consistent with chronic synovitis consistent with rheumatoid arthritis. Surgical wound had healed in two weeks. K-wire was removed one month after surgery, and she could walk with a little pain. The MTP joint had 20° of extension and 40° of flexion postoperatively. Postoperative figure is shown . After that, she was administered methotrexate at 4 mg per week. The pain has been getting better after administering methotrexate. 8 mg per week of methotrexate is still being administered to inhibit the progression of RA.", + "fulltext_subclaims": [ + "The patient is a 50-year-old female.", + "She had three years of metatarsophalangeal (MTP) joint pain.", + "She has no family history of rheumatoid arthritis (RA).", + "She visited the hospital with a chief complaint of foot pain and swelling 3 years ago.", + "Morton's disease was initially suspected.", + "She stopped visiting the hospital because the pain did not get better.", + "Three years after the initial visit, she was referred to the hospital due to foot deformity, subcutaneous hemorrhage, and bone erosion on X-ray.", + "On physical examination, she had pain and swelling on the MTP joint of the fourth toe.", + "The MTP joint had 0° of extension and 30° of flexion.", + "Pain on motion was observed.", + "Laboratory tests showed low levels of inflammatory markers.", + "Rheumatoid factor (RF) was 29.3 IU/mL.", + "Anti-cyclic citrullinated peptide (ACPA) was 496.6 IU/mL.", + "She scored 6 points according to the 2010 ACR/EULAR classification criteria.", + "She was classified with rheumatoid arthritis.", + "X-ray showed bone erosion of the metatarsal.", + "MRI showed synovial proliferation and fluid around the 3rd and 4th metatarsals.", + "Disease-modifying anti-rheumatic drugs were not administered prior to surgery.", + "Non-steroidal anti-inflammatory drugs were administered, but there was no improvement in pain.", + "She had pain due to lateral dislocation of the proximal phalanx of the foot.", + "Synovectomy was performed for diagnosis and treatment.", + "Enlarged MTP joint capsule was observed.", + "Incision through the joint capsule revealed synovial proliferation.", + "Destruction of articular cartilage and subchondral bone was found after synovectomy.", + "Joint instability due to periarticular tissue destruction was observed.", + "The MTP joint was fixed using a Kirschner-wire.", + "Pathological examination showed infiltration by inflammatory cells including plasma cells with blood vessel proliferation.", + "Formation of lymphoid follicle was observed.", + "CD138 immuno-staining was positive.", + "CD138 is a member of the syndecan family of type I transmembrane proteoglycans.", + "CD138 is highly expressed on plasma cells, which is characteristic for RA.", + "Pathological findings were consistent with chronic synovitis consistent with rheumatoid arthritis.", + "The surgical wound had healed in two weeks.", + "The K-wire was removed one month after surgery.", + "She could walk with a little pain after the K-wire was removed.", + "The MTP joint had 20° of extension and 40° of flexion postoperatively.", + "She was administered methotrexate at 4 mg per week.", + "The pain has been getting better after administering methotrexate.", + "8 mg per week of methotrexate is still being administered to inhibit the progression of RA." + ], + "summary": "A 50-year-old female presented with three years of metatarsophalangeal joint pain and deformity. MRI showed bursitis and synovial proliferation around the joint. Synovectomy reduced pain and foot deformity. After surgery, the patient was administered methotrexate.", + "summary_subclaims": [ + "The patient is a 50-year-old female.", + "The patient had three years of metatarsophalangeal joint pain and deformity.", + "MRI showed bursitis and synovial proliferation around the joint.", + "Synovectomy reduced pain and foot deformity.", + "After surgery, the patient was administered methotrexate." + ] + }, + { + "id": "multiclinsum_test_1301_en.txt", + "fulltext": "Our patient is a 73-year-old male with a past medical history of polymyositis, hypertension, constipation, and insomnia, who presented to the emergency department with dyspnea. He had been experiencing weakness and changes in mental status since his last intravenous immunoglobulin (IVIg) treatment. Initial assessment revealed hypothermia, bradycardia, and hypoxia, prompting admission for acute hypercapnic respiratory failure secondary to a possible polymyositis flare.\nUpon admission, he received supportive care including fluid resuscitation, oxygen therapy, and antibiotic coverage. Patient was started on corticosteroids, bronchodilators, and bilevel positive airway pressure (BiPAP) for respiratory support. Investigations were undertaken to identify the cause of his respiratory distress, including blood cultures, urine analysis, and imaging studies, which were largely unremarkable.\nHis clinical condition improved temporarily, but not soon after, he developed altered mental status owing to hypercapnia. An arterial blood gas analysis revealed respiratory acidosis with a compensatory increase in bicarbonate levels. A comprehensive plan was devised for continued management, including transitioning to home non-invasive ventilation (NIV). Shortly thereafter, he developed shingles and further complications arose, such as dysphagia confirmed on modified barium swallow study, thrombocytopenia, and debility requiring full assistance for activities of daily living.\nConsultations with neurology and rheumatology raised questions about the primary diagnosis of polymyositis, with a strong clinical suspicion for inclusion body myositis. In addition, the pattern of weakness and atrophy was more suggestive of inclusion body myositis than polymyositis. Further discussions with the patient's previous neurologist shed light on his extensive medical history, muscle biopsy report and IVIg therapy.\nDespite initial stabilization, his respiratory status deteriorated, necessitating transfer to the intensive care unit for closer monitoring and adjustment of his respiratory support. He tolerated BiPAP well during his ICU stay.\nThroughout his hospitalization, efforts were made to address his thrombocytopenia, constipation, and dysphagia. Oncology consultation was sought for further evaluation of his thrombocytopenia, while palliative care discussions were initiated given the complexity of his medical condition and declining respiratory status. Possible intubation, tracheostomy, and code status were elaborately discussed with the patient and family, following which the patient expressed a preference for a DNR/DNI order.\nDespite challenges with BiPAP adherence, patient showed improvement with consistent use of the device, leading to discussions on discharge planning. Physical therapy recommended a transfer to a subacute rehabilitation facility, but the patient wished to be discharged home. Arrangements were made for home health services, including physical therapy, and visiting nurse support.\nPrior to discharge, the patient's medication regimen was adjusted. Dietary modifications were recommended to address his dysphagia, and precautions were advised to prevent aspiration. Also, a tyrosine rich diet was recommended, which has been proven beneficial in patients with nemaline myopathy . Patient's discharge plan emphasized the importance of continued respiratory support with BiPAP, along with close follow-up with his primary care provider and neurologist. Home equipment, including cough assistance and suction devices, were provided to aid in airway clearance and ensure a safe transition to home care.", + "fulltext_subclaims": [ + "The patient is a 73-year-old male.", + "The patient has a past medical history of polymyositis.", + "The patient has a past medical history of hypertension.", + "The patient has a past medical history of constipation.", + "The patient has a past medical history of insomnia.", + "The patient presented to the emergency department with dyspnea.", + "The patient had been experiencing weakness since his last intravenous immunoglobulin (IVIg) treatment.", + "The patient had been experiencing changes in mental status since his last intravenous immunoglobulin (IVIg) treatment.", + "Initial assessment revealed hypothermia.", + "Initial assessment revealed bradycardia.", + "Initial assessment revealed hypoxia.", + "The patient was admitted for acute hypercapnic respiratory failure.", + "The acute hypercapnic respiratory failure was secondary to a possible polymyositis flare.", + "Upon admission, the patient received fluid resuscitation.", + "Upon admission, the patient received oxygen therapy.", + "Upon admission, the patient received antibiotic coverage.", + "The patient was started on corticosteroids.", + "The patient was started on bronchodilators.", + "The patient was started on bilevel positive airway pressure (BiPAP) for respiratory support.", + "Investigations included blood cultures.", + "Investigations included urine analysis.", + "Investigations included imaging studies.", + "The patient developed altered mental status owing to hypercapnia.", + "An arterial blood gas analysis revealed respiratory acidosis.", + "An arterial blood gas analysis revealed a compensatory increase in bicarbonate levels.", + "A comprehensive plan was devised for continued management.", + "The patient was transitioned to home non-invasive ventilation (NIV).", + "The patient developed shingles.", + "Dysphagia was confirmed on modified barium swallow study.", + "The patient had thrombocytopenia.", + "The patient had debility requiring full assistance for activities of daily living.", + "Consultations with neurology and rheumatology raised questions about the primary diagnosis of polymyositis.", + "There was a strong clinical suspicion for inclusion body myositis.", + "The pattern of weakness and atrophy was more suggestive of inclusion body myositis than polymyositis.", + "Further discussions with the patient's previous neurologist shed light on his extensive medical history.", + "Further discussions with the patient's previous neurologist included the muscle biopsy report.", + "Further discussions with the patient's previous neurologist included IVIg therapy.", + "The patient's respiratory status deteriorated.", + "The patient was transferred to the intensive care unit.", + "The patient tolerated BiPAP well during his ICU stay.", + "Efforts were made to address thrombocytopenia.", + "Efforts were made to address constipation.", + "Efforts were made to address dysphagia.", + "Oncology consultation was sought for further evaluation of thrombocytopenia.", + "Palliative care discussions were initiated.", + "Possible intubation, tracheostomy, and code status were discussed with the patient and family.", + "The patient expressed a preference for a DNR/DNI order.", + "The patient showed improvement with consistent use of BiPAP.", + "Discussions on discharge planning were initiated.", + "Physical therapy recommended a transfer to a subacute rehabilitation facility.", + "The patient wished to be discharged home.", + "Arrangements were made for home health services, including physical therapy.", + "Arrangements were made for visiting nurse support.", + "The patient's medication regimen was adjusted prior to discharge.", + "Dietary modifications were recommended to address dysphagia.", + "Precautions were advised to prevent aspiration.", + "A tyrosine rich diet was recommended.", + "A tyrosine rich diet has been proven beneficial in patients with nemaline myopathy.", + "The discharge plan emphasized the importance of continued respiratory support with BiPAP.", + "The discharge plan included close follow-up with the primary care provider.", + "The discharge plan included close follow-up with the neurologist.", + "Home equipment, including cough assistance and suction devices, were provided." + ], + "summary": "Our patient is a 73-year-old male with a history of polymyositis, who presented with acute hypercapnic respiratory failure secondary to a suspected polymyositis flare. Despite initial management, the patient experienced complications, including dysphagia, thrombocytopenia, and altered mental status. Neurological consultations revealed conflicting opinions regarding the primary diagnosis, suggesting inclusion body myositis. The patient's condition continued to deteriorate, prompting discussions about prognosis and palliative care options. This case highlights the challenges in managing respiratory failure in patients with late-onset nemaline myopathy and the importance of multidisciplinary care in addressing complex medical needs.", + "summary_subclaims": [ + "The patient is a 73-year-old male.", + "The patient has a history of polymyositis.", + "The patient presented with acute hypercapnic respiratory failure.", + "The acute hypercapnic respiratory failure is secondary to a suspected polymyositis flare.", + "The patient experienced dysphagia.", + "The patient experienced thrombocytopenia.", + "The patient experienced altered mental status.", + "Neurological consultations revealed conflicting opinions regarding the primary diagnosis.", + "The consultations suggested inclusion body myositis.", + "The patient's condition continued to deteriorate.", + "Discussions about prognosis and palliative care options occurred.", + "The case highlights the challenges in managing respiratory failure in patients with late-onset nemaline myopathy.", + "The case highlights the importance of multidisciplinary care in addressing complex medical needs." + ] + }, + { + "id": "multiclinsum_test_2084_en.txt", + "fulltext": "In July 2013, a 53-year-old man presented to our hospital with a chief complaint of colic pain in the left lower limb while walking. The patient was 175 cm tall, weighed 87.1 kg, and had a BMI of 28.4. The patient’s past medical history was significant for left indirect inguinal hernia; Gilbert/ Rutkow& Robbins classification was type 2 and Nyhus classification was type 2 [-]. The patient had undergone left inguinal hernia repair (mesh plug method) at our hospital just 10 years earlier and reported no pain after the operation. In addition, the patient’s postoperative course was uneventful. We used the visual analog scale (VAS) pain scales; 100 mm vertical lines anchored with “no pain” at the bottom and “worst imaginable pain” at the top. In this scale, 0 mm is “no pain” and 100 mm is “worst imaginable pain”. Physical examination revealed a colic pain exacerbated by left thigh movement; VAS 80–100 mm, especially during flexion; however, the patient was pain free at rest; VAS 0–20 mm and had no sensory deficits. The patient also had no signs of inguinal hernia recurrence. The results of routine blood tests were all within normal limits. We considered radicular symptoms, orthopedic disease, and urological disease as a differential diagnosis, but all were refuted by specialists in the respective departments.\nAbdominal ultrasonography was normal. Computed tomography (CT) revealed a low-density structure in the left inguinal region with no evidence of infection . This structure showed low signal intensity on T1-weighted magnetic resonance imaging (MRI) and high intensity on T2-weighted MRI . CT and MRI also showed the plug bulging outward into the peritoneal cavity, with axial images showing the inward-projecting plug extremely close to the femoral nerve .\nFollowing neurosurgical, orthopedic, and urologic consultations, we strongly suspected that his neuralgia was associated with the hernia operation 10 years earlier. However, we could not provide a definitive diagnosis preoperatively. Therefore, an exploratory laparoscopy was decided. The first port was inserted through the navel to observe the abdominal cavity. We found that the plug bulged outward into the abdominal cavity and that the tip of the plug had become firmly calcified . There were no signs of recurrence. The exposed plug was compressing the femoral nerve, which lay just beneath the plug when the patient moved, especially during flexion. We inserted left and right lateral ports and removed the plug laparoscopically. We then carefully broke up adhesions between the plug and peritonea, fat, nerve, and vessels using an ultrasonically activated scalpel . The abdominal wall after plug removal is shown in Fig. . We removed only plug causing leg pain and did not remove onlay mesh. We restored the peritoneal defect after plug removal to prevent future recurrence and adhesions. Once the pre-peritoneal space was prepared, a 12 × 8 cm composite mesh (VentrioTM Hernia Patch, BIRD Inc.) was positioned to cover the hernia orifice because the peritoneal defect was large and we were not able to unite the peritoneum. The mesh was fixed to the pubic ramus and Cooper’s ligament using endoscopic tackers (Protack®, Covidien Inc.). The superior margins of the mesh were then fixed to the abdominal wall, deliberately avoiding the inferior epigastric vessels. Finally, we sewed the peritoneum to the mesh .\nThe patient reported that the sharp pain in his leg disappeared after the procedure; VAS 0–10 mm, and the patient started walking the following day. The postoperative course was uneventful, and the patient was discharged from the hospital 3 days postoperatively. The patient has remained pain-free for 20 months.", + "fulltext_subclaims": [ + "A 53-year-old man presented to the hospital in July 2013.", + "The patient's chief complaint was colic pain in the left lower limb while walking.", + "The patient's height was 175 cm.", + "The patient's weight was 87.1 kg.", + "The patient's BMI was 28.4.", + "The patient had a past medical history of left indirect inguinal hernia.", + "The patient had undergone left inguinal hernia repair (mesh plug method) at the hospital 10 years earlier.", + "The patient reported no pain after the hernia operation.", + "The patient's postoperative course was uneventful.", + "The visual analog scale (VAS) pain scale was used.", + "The VAS scale ranges from 0 mm (no pain) to 100 mm (worst imaginable pain).", + "Physical examination revealed colic pain exacerbated by left thigh movement.", + "The VAS score during movement was 80–100 mm.", + "The patient was pain free at rest.", + "The VAS score at rest was 0–20 mm.", + "The patient had no sensory deficits.", + "The patient had no signs of inguinal hernia recurrence.", + "Routine blood tests were within normal limits.", + "Abdominal ultrasonography was normal.", + "Computed tomography (CT) revealed a low-density structure in the left inguinal region.", + "CT showed no evidence of infection.", + "MRI showed low signal intensity on T1-weighted images.", + "MRI showed high signal intensity on T2-weighted images.", + "CT and MRI showed the plug bulging outward into the peritoneal cavity.", + "Axial images showed the inward-projecting plug extremely close to the femoral nerve.", + "Following consultations, we strongly suspected that the neuralgia was associated with the hernia operation 10 years earlier.", + "We could not provide a definitive diagnosis preoperatively.", + "An exploratory laparoscopy was decided.", + "The first port was inserted through the navel to observe the abdominal cavity.", + "The plug was found to bulge outward into the abdominal cavity.", + "The tip of the plug had become firmly calcified.", + "There were no signs of recurrence.", + "The exposed plug was compressing the femoral nerve.", + "The femoral nerve lay just beneath the plug when the patient moved, especially during flexion.", + "The plug was removed laparoscopically.", + "Adhesions between the plug and peritonea, fat, nerve, and vessels were broken up using an ultrasonically activated scalpel.", + "Only the plug causing leg pain was removed.", + "The onlay mesh was not removed.", + "The peritoneal defect was restored after plug removal.", + "A 12 × 8 cm composite mesh (VentrioTM Hernia Patch, BIRD Inc.) was positioned to cover the hernia orifice.", + "The mesh was fixed to the pubic ramus and Cooper’s ligament using endoscopic tackers (Protack®, Covidien Inc.).", + "The superior margins of the mesh were fixed to the abdominal wall.", + "The inferior epigastric vessels were deliberately avoided.", + "The peritoneum was sewed to the mesh.", + "The patient reported that the sharp pain in his leg disappeared after the procedure.", + "The VAS score after the procedure was 0–10 mm.", + "The patient started walking the following day.", + "The postoperative course was uneventful.", + "The patient was discharged from the hospital 3 days postoperatively.", + "The patient has remained pain-free for 20 months." + ], + "summary": "In July 2013, a 53-year-old man presented to our hospital with a chief complaint of colic pain in the left lower limb while walking. The patient had undergone left inguinal hernia repair about 10 years earlier and reported no chronic pain after the operation. Physical examination revealed a colic pain exacerbated by left thigh movement, especially during flexion, but the patient was pain-free at rest and had no sensory loss. Axial computed tomography and magnetic resonance imaging showed that the inward-projecting plug was extremely close to the femoral nerve. Because of the radicular symptoms and the absence of orthopedic and urological disease, we strongly suspected that the neuralgia was associated with the previous hernia operation and advised exploratory laparotomy, which revealed the plug bulging inward into the abdominal cavity. Moreover, the tip of the plug was firmly calcified and compressing the femoral nerve, which lay just beneath the plug, especially during hip flexion. We explanted the plug and his pain resolved after the operation. The patient remains pain free after 20 months of follow up.", + "summary_subclaims": [ + "A 53-year-old man presented to the hospital in July 2013.", + "The patient's chief complaint was colic pain in the left lower limb while walking.", + "The patient had undergone left inguinal hernia repair about 10 years earlier.", + "The patient reported no chronic pain after the hernia operation.", + "Physical examination revealed colic pain exacerbated by left thigh movement.", + "The patient was pain-free at rest.", + "Axial computed tomography showed the inward-projecting plug was extremely close to the femoral nerve.", + "Magnetic resonance imaging showed the inward-projecting plug was extremely close to the femoral nerve.", + "We strongly suspected that the neuralgia was associated with the previous hernia operation.", + "We advised exploratory laparotomy.", + "Exploratory laparotomy revealed the plug bulging inward into the abdominal cavity.", + "The tip of the plug was firmly calcified.", + "The calcified tip of the plug was compressing the femoral nerve.", + "The femoral nerve lay just beneath the plug.", + "The plug was explanted.", + "The patient's pain resolved after the operation.", + "The patient remains pain free after 20 months of follow up." + ] + }, + { + "id": "multiclinsum_test_1039_en.txt", + "fulltext": "A 31-year-old woman, gravidity three, parity zero, was admitted because of a suspected intramural pregnancy after IVF-ET.\nThe patient was completely asymptomatic. She had regular menstruation, a moderate amount of menstruation and no dysmenorrhea. Her last menstrual period was November 17, 2020. The endometrium was prepared using hormone replacement therapy following 1.875 mg of subcutaneous gonadotropin-releasing hormone agonist (Leuprorelin Acetate, Livzon Pharmaceuticals, China) on day 3 of the menstrual cycle. In addition, 90 mg of vaginal progesterone (Crinone, Merck Serono, United Kingdom) once a day and 10 mg of dydrogesterone three times daily were administered (P + 0). A frozen day 6 embryo which had undergone preimplantation genetic screening was transferred on the 7th day of progesterone exposure (P + 6) under sonographic guidance.\nShe received laparoscopic salpingotomy in 2014 due to a right tubal pregnancy. She had suffered secondary infertility since December 2015 and her hysterosalpingography results showed an obstruction in the right fallopian tube and adhesion of the distal end of the left fallopian tube in June 2016. As spontaneous pregnancy did not subsequently occur, she was referred to the reproductive center of our hospital for IVF-ET in June 2018. The patient underwent laparoscopic bilateral salpingectomy for bilateral tubal pregnancy after two frozen day 3 embryos were transferred in December 2018. Of the other three frozen-thawed embryo transfer cycles, a total of 5 embryos were transferred, but pregnancy was not achieved. In addition, the patient had a history of hysteroscopy three times to remove endometrial polyps and separate uterine adhesions.\nHer personal history and family history were unremarkable.\nThe patient’s vital signs were normal. Physical examination revealed a 7-week sized uterus with no tenderness and no abnormalities in the uterine cervix and abdomen. There was no vaginal bleeding or fluid.\nAt day 14 after ET, her serum β-human chorionic gonadotropin (β-hCG) level was 111.54 mIU/mL and then increased from 290 mIU/mL to 1759 mIU/mL. On day 32 after ET, her serum β-hCG level was 3819 mIU/mL.\nA transvaginal ultrasound examination revealed a suspected intramural pregnancy. When admitted on day 33 after ET, three-dimensional transvaginal ultrasound indicated a heterogeneous echogenic area measuring 1.40 cm × 1.26 cm in size arising from the uterine fundus which had a 0.48 cm × 0.37 cm anechoic region inside and was surrounded by myometrium . Color Doppler ultrasound showed abundant blood flow. This region seemed to have a slender and extremely hypoechoic area stretching to the uterine cavity . In addition, a hypoechoic structure with an indistinct boundary measuring 2.74 cm × 1.61 cm in size was observed in the anterior myometrium near the uterine fundus, which was thought to be a uterine adenomyoma.", + "fulltext_subclaims": [ + "The patient is a 31-year-old woman, gravidity three, parity zero.", + "She was admitted because of a suspected intramural pregnancy after IVF-ET.", + "The patient was completely asymptomatic.", + "Her last menstrual period was November 17, 2020.", + "The endometrium was prepared using hormone replacement therapy.", + "She received 1.875 mg of subcutaneous gonadotropin-releasing hormone agonist (Leuprorelin Acetate, Livzon Pharmaceuticals, China) on day 3 of the menstrual cycle.", + "She received 90 mg of vaginal progesterone (Crinone, Merck Serono, United Kingdom) once a day.", + "She received 10 mg of dydrogesterone three times daily.", + "A frozen day 6 embryo which had undergone preimplantation genetic screening was transferred on the 7th day of progesterone exposure.", + "The embryo transfer was performed under sonographic guidance.", + "She received laparoscopic salpingotomy in 2014 due to a right tubal pregnancy.", + "Her hysterosalpingography results showed an obstruction in the right fallopian tube and adhesion of the distal end of the left fallopian tube in June 2016.", + "She was referred to the reproductive center of our hospital for IVF-ET in June 2018.", + "She underwent laparoscopic bilateral salpingectomy for bilateral tubal pregnancy after two frozen day 3 embryos were transferred in December 2018.", + "Of the other three frozen-thawed embryo transfer cycles, a total of 5 embryos were transferred, but pregnancy was not achieved.", + "The patient had a history of hysteroscopy three times to remove endometrial polyps and separate uterine adhesions.", + "The patient’s vital signs were normal.", + "Physical examination revealed a 7-week sized uterus with no tenderness.", + "There was no vaginal bleeding or fluid.", + "At day 14 after ET, her serum β-human chorionic gonadotropin (β-hCG) level was 111.54 mIU/mL.", + "On day 32 after ET, her serum β-hCG level was 3819 mIU/mL.", + "A transvaginal ultrasound examination revealed a suspected intramural pregnancy.", + "Three-dimensional transvaginal ultrasound indicated a heterogeneous echogenic area measuring 1.40 cm × 1.26 cm in size arising from the uterine fundus.", + "This region had a 0.48 cm × 0.37 cm anechoic region inside.", + "Color Doppler ultrasound showed abundant blood flow.", + "This region seemed to have a slender and extremely hypoechoic area stretching to the uterine cavity.", + "A hypoechoic structure with an indistinct boundary measuring 2.74 cm × 1.61 cm in size was observed in the anterior myometrium near the uterine fundus.", + "This hypoechoic structure was thought to be a uterine adenomyoma." + ], + "summary": "We present a case of intramural pregnancy after in vitro fertilization and elective single embryo transfer following salpingectomy. The patient was completely asymptomatic and her serum β-human chorionic gonadotropin level increased from 290 mIU/mL to 1759 mIU/mL. Three-dimensional transvaginal ultrasound indicated a heterogeneous echogenic mass arising from the uterine fundus which was surrounded by myometrium and a slender and extremely hypoechoic area stretching to the uterine cavity which was thought to be a fistulous tract. Therefore, we considered a diagnosis of intramural pregnancy and laparoscopic surgery was conducted at 7 wk gestation.", + "summary_subclaims": [ + "The patient had an intramural pregnancy after in vitro fertilization and elective single embryo transfer.", + "The patient had a salpingectomy prior to the pregnancy.", + "The patient was completely asymptomatic.", + "The serum β-human chorionic gonadotropin level increased from 290 mIU/mL to 1759 mIU/mL.", + "Three-dimensional transvaginal ultrasound showed a heterogeneous echogenic mass arising from the uterine fundus.", + "The mass was surrounded by myometrium.", + "A slender and extremely hypoechoic area was seen stretching to the uterine cavity.", + "The hypoechoic area was thought to be a fistulous tract.", + "The diagnosis considered was intramural pregnancy.", + "Laparoscopic surgery was conducted at 7 wk gestation." + ] + }, + { + "id": "multiclinsum_test_1968_en.txt", + "fulltext": "A 10-year-old boy referred to the pediatric cardiology clinic of Chamran Hospital, Isfahan University of Medical Sciences, Isfahan, Iran on 1-May-2012 with a chief complaint of recurrent chest pain from two weeks ago. He had an atypical chest pain in the 4th and 5th left intercostals areas without any radiation which lasted for several minutes. He had no other symptoms though.\nIn physical examination, the pulses of left upper limb and left carotid artery were not detected; however, the other pulses were normal. He had no cyanosis or clubbing in his extremities. In heart auscultation, the S1 and S2 sounds were normal and a grade I-II/VI systolic ejection-type murmur was heard on the left sternal border. The other examinations were normal.\nNo abnormal findings were revealed in electrocardiography.\nThe cardiothoracic ratio was in upper normal range and the pulmonary vascular markings were normal in chest X-ray (CXR). The right sided aortic arch was observed in .\nThe main abnormal findings in echocardiography included mild mitral valve prolapse (MVP) and tricuspid regurgitation (TR) with a pressure gradient of 25 mmHg. Besides, the right sided aortic arch was observed.\nIn CT angiogram, the left carotid artery was significantly narrower than the right one which seemed to be dilated for enough cerebral circulation. Moreover, as a rare anomalous finding, the left subclavian artery aroused from this narrow carotid artery and the left vertebral artery originated from this subclavian artery (.A and .B).\nThereafter, the patient underwent the left heart catheterization. The arterial catheter passed from the femoral artery into descending aorta (DAO), ascending aorta (AAO), and left ventricle (LV), respectively. It entered into the right and left coronary arteries (RCA and LCA) normally.\nSystemic sample was saturated. In addition, it entered into the right subclavian and right carotid arteries, but it could not enter into the left brachiocephalic artery.\nLV, coronary arteries and aortic root injections revealed no pathologic findings. The right sided aortic arch was observed again. Aortic arch injection in the right anterior oblique view showed normal right subclavian and right carotid arteries and also showed with no connection of the left subclavian artery to the aortic arch.\nSelective right carotid artery injection showed opacified left subclavian artery. The left subclavian and left vertebral arteries supplied from the circle of Willis (right vertebral artery). Selective right subclavian artery showed no anomaly (.A, .B, and .C).\nFollowing the whole procedures, the patient was discharged and was advised to refer periodically for clinical follow-up.", + "fulltext_subclaims": [ + "The patient is a 10-year-old boy.", + "He was referred to the pediatric cardiology clinic of Chamran Hospital, Isfahan University of Medical Sciences, Isfahan, Iran.", + "The referral date was 1-May-2012.", + "His chief complaint was recurrent chest pain from two weeks ago.", + "He had atypical chest pain in the 4th and 5th left intercostal areas.", + "The chest pain lasted for several minutes.", + "The chest pain did not radiate.", + "He had no other symptoms.", + "In physical examination, the pulses of the left upper limb and left carotid artery were not detected.", + "The other pulses were normal.", + "He had no cyanosis in his extremities.", + "He had no clubbing in his extremities.", + "In heart auscultation, the S1 and S2 sounds were normal.", + "A grade I-II/VI systolic ejection-type murmur was heard on the left sternal border.", + "The other examinations were normal.", + "No abnormal findings were revealed in electrocardiography.", + "The cardiothoracic ratio was in the upper normal range in chest X-ray.", + "The pulmonary vascular markings were normal in chest X-ray.", + "A right-sided aortic arch was observed in chest X-ray.", + "Echocardiography showed mild mitral valve prolapse.", + "Echocardiography showed tricuspid regurgitation with a pressure gradient of 25 mmHg.", + "A right-sided aortic arch was observed in echocardiography.", + "In CT angiogram, the left carotid artery was significantly narrower than the right one.", + "The right carotid artery was dilated.", + "The left subclavian artery arose from the narrow left carotid artery.", + "The left vertebral artery originated from the left subclavian artery.", + "The patient underwent left heart catheterization.", + "The arterial catheter passed from the femoral artery into the descending aorta.", + "The arterial catheter passed into the ascending aorta.", + "The arterial catheter passed into the left ventricle.", + "The catheter entered the right and left coronary arteries normally.", + "Systemic sample was saturated.", + "The catheter entered the right subclavian artery.", + "The catheter entered the right carotid artery.", + "The catheter could not enter the left brachiocephalic artery.", + "LV, coronary arteries, and aortic root injections revealed no pathologic findings.", + "A right-sided aortic arch was observed again.", + "Aortic arch injection in the right anterior oblique view showed normal right subclavian and right carotid arteries.", + "Aortic arch injection showed no connection of the left subclavian artery to the aortic arch.", + "Selective right carotid artery injection showed opacified left subclavian artery.", + "The left subclavian and left vertebral arteries supplied from the circle of Willis.", + "Selective right subclavian artery showed no anomaly.", + "Following the procedures, the patient was discharged.", + "The patient was advised to refer periodically for clinical follow-up." + ], + "summary": "In this study, a case of a right-sided aortic arch with anomalous left subclavian artery origin from the cerebral arteries is presented which was diagnosed in Computed tomography angiogram (CT angiogram) and angiography of a 10-year-old boy referred due to recurrent chest pains during two weeks before admission and pulselessness of his left upper limb and left carotid artery.", + "summary_subclaims": [ + "A case of a right-sided aortic arch with anomalous left subclavian artery origin from the cerebral arteries is presented.", + "The diagnosis was made in Computed tomography angiogram (CT angiogram) and angiography.", + "The patient was a 10-year-old boy.", + "The boy was referred due to recurrent chest pains during two weeks before admission.", + "The boy had pulselessness of his left upper limb.", + "The boy had pulselessness of the left carotid artery." + ] + }, + { + "id": "multiclinsum_test_938_en.txt", + "fulltext": "A 46-year-old male presented with a chief complaint of progressively worsening right hip pain over the past decade. The patient denied antecedent trauma or any hip injuries since childhood. The patient did note that he was previously very active and went running and cycling on a regular basis. However, he became limited due to pain in his groin, buttock, and thigh, which were all exacerbated by weight-bearing activities. On a day-to-day basis, the patient reported difficulty with stairs, limping while ambulating, and significant trouble getting in and out of a car. The patient’s medical history was significant for a lumbar disc herniation 8 years prior, for which he underwent a microdiscectomy at L5-S1. Past medical, family and social history were otherwise unremarkable. Conservative management, including nonsteroidal anti-inflammatory medications, activity modification, and physical therapy, only provided minimal relief.\nInitial orthopedic examination revealed the patient walking with a coxalgic gait and abductor lurch to the right. To test for anterior impingement, while lying supine, the patient’s hip was internally rotated and adducted during passive flexion to 90°, which reproduced the patient’s symptom of groin pain. The hip was able to internally rotate to neutral and externally rotate to 30°. On range of motion testing, abduction was 30°and the patient had 0°of adduction. Patrick’s test (flexion, abduction, and external rotation) was also positive and associated with severe groin pain and restricted sacroiliac joints. There were groin and buttock pain with passive hip motion in all directions. Lower limb neurologic and vascular examination was unremarkable. Plain film radiographs revealed severe right hip osteoarthritis with bone-on-bone apposition, subchondral cysts and sclerosis . A rounded focus of ossification adjacent to the acetabulum was found, which may have reflected os acetabuli or ossified labrum. Cam-type configurations were seen bilaterally. The left hip also demonstrated moderate-to-severe joint space narrowing. Degenerative changes of bilateral sacroiliac joints were also identified. A lengthy discussion was had regarding hip resurfacing versus hip replacement; however, based on the patient’s age and activity level, conservative hip resurfacing with metal-on-metal (MoM) parts was deemed an appropriate option. The patient agreed, given his desire to run at least 5 miles twice per week, competed in triathlons, and work. Risks and benefits were discussed in detail with the patient. We discussed surgical approaches to the hip joint and the rationale for a posterior approach.\nThe patient was brought to the operating room and was placed on the hip table in the lateral decubitus position. The patient’s surgical area was prepped and draped in the standard, sterile fashion. Two threaded pins for a minioptical navigation tool (Intellijoint HIP®, Intellijoint Surgical Inc., Waterloo, ON, Canada; off-label use) were placed into the iliac crest, approximately 2 cm posterior to the ASIS. The navigation system camera was then attached, and registration was performed. Next, a standard posterolateral incision was made through the skin and dissection was carried down through subcutaneous tissue to the underlying fascia achieving hemostasis where necessary. The posterior short external rotators were identified, and the piriformis, conjoined tendons, and quadratus femoris were detached and tagged. Following elevation of the gluteus minimus, a 360° circumferential capsulotomy was performed. The femoral disc for navigational leg length measurements was impacted onto the greater trochanter, and registration of the hip center of rotation was performed. Once the hip was dislocated, the femoral head and neck were exposed. Osteophytes from the anterior superior aspect of the femoral neck were now removed, restoring the anterior head-neck offset. The femoral head was then measured as to its diameter. The head-neck templates were placed along the posterior aspect of the femoral neck to measure the sizing. Lines were marked along the midpoint of the femoral neck in both the coronal and sagittal planes. At this point, attention was turned toward the acetabulum. The labrum, as well as the tissues from the acetabular fossa, was removed. Reaming was begun, with the plan for a 1 mm press-fit. Reaming was first directed medially and then in the desired alignment of the acetabular implant. A trial implant was impacted into place and marked as to its depth of insertion using electrocautery. The actual implant (58mm M2a-Magnum cup; Biomet Inc., Warsaw, IN, USA) was then placed on its insertion handle and impacted into place. The alignment was checked using external alignment guides, bony landmarks, and corroboration with pre-operative templating. The navigation unit was then used to confirm final acetabular component position, measuring 14° of anteversion and 39° of inclination as selected by the surgeon intraoperatively. Following femoral preparation, the trial femoral implant was passed around the prepared bone to ensure adequate bone preparation and contact. With the trial femoral implant in place, the hip was reduced and the navigation device used to confirm the restoration of leg lengths, measuring 4 mm of lengthening . The hip was again dislocated and the trial head removed. It was then decided that the bone was sufficiently supportive to allow for uncemented fixation and the actual implant was impacted. The head was relocated into the acetabulum, after ensuring that there was no debris or soft tissue interposed. The capsule and short external rotators were reattached through a bony bridge in the greater trochanter. The quadratus femoris and gluteus maximus tendon insertion were also repaired. The navigation hardware was then removed. We returned the patient to the supine position. We verified that all lower extremity compartments were soft and compressible and that we had intact distal pulses. The patient was then transferred to the recovery room in stable condition.\nStandard, pre- and post-operative AP pelvic radiographs were obtained and analyzed using TraumaCad (Brainlab, Chicago, USA). Final values for cup position and leg length were measured in triplicate and averaged. Radiographic analysis revealed a final post-operative cup position of 14.3° anteversion and 38.3° inclination on the post-operative radiograph , as well as a lengthened operative leg of 5 mm between pre- and post-operative images.\nAt 1-year post-operative, the patient was doing extremely well, demonstrating range of motion in the operative hip of 0°–120° flexion, 40° external rotation, 10° internal rotation, 40° abduction, and 10° adduction. Harris Hip Score was 91.8, with no instability in the joint and both neuromuscular and vascular examinations normal. The patient was able to walk unlimited distances, run, cycle and swim with no physical limitations.", + "fulltext_subclaims": [ + "The patient is a 46-year-old male.", + "The patient presented with progressively worsening right hip pain over the past decade.", + "The patient denied antecedent trauma or any hip injuries since childhood.", + "The patient reported pain in the groin, buttock, and thigh exacerbated by weight-bearing activities.", + "The patient had difficulty with stairs, limping while ambulating, and trouble getting in and out of a car.", + "The patient had a history of lumbar disc hernation 8 years prior.", + "The patient underwent a microdiscectomy at L5-S1.", + "Past medical, family, and social history were otherwise unremarkable.", + "Conservative management provided minimal relief.", + "Initial orthopedic examination revealed a coxalgic gait and abductor lurch to the right.", + "Testing for anterior impingement reproduced the patient’s symptom of groin pain.", + "The hip was able to internally rotate to neutral and externally rotate to 30°.", + "Patrick’s test was positive and associated with severe groin pain and restricted sacroiliac joints.", + "Plain film radiographs revealed severe right hip osteoarthritis with bone-on-bone apposition.", + "A rounded focus of ossification adjacent to the acetabulum was found.", + "Cam-type configurations were seen bilaterally.", + "The left hip demonstrated moderate-to-severe joint space narrowing.", + "Degenerative changes of bilateral sacroiliac joints were identified.", + "A discussion was had regarding hip resurfacing versus hip replacement.", + "Conservative hip resurfacing with metal-on-metal parts was deemed an appropriate option.", + "The patient agreed to the procedure.", + "The patient was placed on the hip table in the lateral decubitus position.", + "Two threaded pins were placed into the iliac crest for a minioptical navigation tool.", + "A standard posterolateral incision was made.", + "The posterior short external rotators were identified and detached.", + "A 360° circumferential capsulotomy was performed.", + "The femoral disc for navigational leg length measurements was impacted onto the greater trochanter.", + "Osteophytes from the anterior superior aspect of the femoral neck were removed.", + "The femoral head was measured for diameter.", + "The labrum and tissues from the acetabular fossa were removed.", + "Reaming was begun with the plan for a 1 mm press-fit.", + "A trial implant was impacted into place and marked with electrocautery.", + "The actual implant was placed and impacted into the acetabulum.", + "The navigation unit confirmed final acetabular component position.", + "The hip was reduced and the navigation device used to confirm leg length restoration.", + "The hip was dislocated and the trial head removed.", + "The actual implant was impacted into place.", + "The capsule and short external rotators were reattached.", + "The navigation hardware was removed.", + "The patient was transferred to the recovery room in stable condition.", + "Standard pre- and post-operative AP pelvic radiographs were obtained.", + "Radiographic analysis revealed a final post-operative cup position of 14.3° anteversion and 38.3° inclination.", + "Radiographic analysis showed a lengthened operative leg of 5 mm.", + "At 1-year post-operative, the patient demonstrated range of motion in the operative hip of 0°–120° flexion.", + "At 1-year post-operative, the patient had 40° external rotation.", + "At 1-year post-operative, the patient had 10° internal rotation.", + "At 1-year post-operative, the patient had 40° abduction.", + "At 1-year post-operative, the patient had 10° adduction.", + "The Harris Hip Score was 91.8.", + "There was no instability in the joint.", + "Neuromuscular and vascular examinations were normal.", + "The patient was able to walk unlimited distances.", + "The patient was able to run, cycle, and swim with no physical limitations." + ], + "summary": "The present case describes an active 46-year-old male presenting with severe osteoarthritis of the right hip who elected to undergo a ReCap resurfacing arthroplasty with navigation. Results demonstrated accurate acetabular component position and leg length measurements to within <1° and 1mm of standard radiographic measurements.", + "summary_subclaims": [ + "The patient is a 46-year-old male.", + "The patient had severe osteoarthritis of the right hip.", + "The patient elected to undergo a ReCap resurfacing arthroplasty with navigation.", + "Results demonstrated accurate acetabular component position.", + "Leg length measurements were within <1° of standard radiographic measurements.", + "Leg length measurements were within 1mm of standard radiographic measurements." + ] + }, + { + "id": "multiclinsum_test_237_en.txt", + "fulltext": "A 72-year-old man, who had been suffering from right hip pain for 7 years when walking, was referred to our institute. Roentogenography of the right pelvic bone showed an expansion of the cortical contour and a soft-tissue mass with punctate calcification . Magnetic resonance imaging (MRI) showed a lobulated lesion expanding over the entire right pelvic bone with low-intensity on T1-weighted imaging and iso- to high-intensity on T2-weighted imaging, with the tumor protuberant to the pelvic cavity . Right hemipelvectomy was carried out. Histological sections showed a conventional chondrosarcoma having atypical chondrocytes with hyaline cartilage matrix or myxoid matrix . In a small section, dedifferentiated components were also identified, and these dedifferentiated components consisted of atypical spindle cells arranged in short fascicles or a storiform pattern showing MFH-like features, plus some pleomorphic cells with lace-like osteoid formation showing osteosarcoma-like features . Therefore, the final diagnosis was dedifferentiated chondrosarcoma because of the coexistence of conventional chondrosarcoma and dedifferentiated components.\nPreoperative laboratory data were not remarkable. After surgery, the laboratory data also showed leukocytosis predominantly in the neutrophils with an elevated level of C-reactive protein . The serum level of G-CSF was also elevated (330 pg/ml [normal, <8 pg/ml]). Magnetic resonance imaging (MRI) and computed tomography (CT) revealed evidence of local recurrence and metastatic lesions in the lungs. Flow-cytometry indicated no evidence of leukemia and serological studies showed no evidence of specific infections, such as candidiasis or tuberculosis. Despite the administration of several antibiotics, the leukocytosis did not disappear. Two months after the surgery, the patient died of multiple organ failure. An autopsy was carried out, and in addition to the lung metastasis, metastasis was also found in the liver, thyroid, diaphragm, adrenal gland, digestive tract and skin. The histology of the recurrent and metastatic lesions was not conventional chondrosarcoma but only dedifferentiated components. Immunoexpression of G-CSF (anti-G-CSF [Ab1], Calbiochem, San Diego CA, USA) was seen in the dedifferentiated components, but not in the conventional chondrosarcoma components .", + "fulltext_subclaims": [ + "The patient was a 72-year-old man.", + "The patient had right hip pain for 7 years when walking.", + "Roentogenography of the right pelvic bone showed an expansion of the cortical contour.", + "Roentogenography showed a soft-tissue mass with punctate calcification.", + "MRI showed a lobulated lesion expanding over the entire right pelvic bone.", + "The lesion had low-intensity on T1-weighted imaging.", + "The lesion had iso- to high-intensity on T2-weighted imaging.", + "The tumor was protuberant to the pelvic cavity.", + "Right hemipelvectomy was carried out.", + "Histological sections showed a conventional chondrosarcoma having atypical chondrocytes with hyaline cartilage matrix or myxoid matrix.", + "In a small section, dedifferentiated components were also identified.", + "The dedifferentiated components consisted of atypical spindle cells arranged in short fascicles or a storiform pattern showing MFH-like features.", + "The dedifferentiated components included some pleomorphic cells with lace-like osteoid formation showing osteosarcoma-like features.", + "The final diagnosis was dedifferentiated chondrosarcoma because of the coexistence of conventional chondrosarcoma and dedifferentiated components.", + "Preoperative laboratory data were not remarkable.", + "After surgery, the laboratory data showed leukocytosis predominantly in the neutrophils.", + "After surgery, the laboratory data showed an elevated level of C-reactive protein.", + "The serum level of G-CSF was 330 pg/ml.", + "MRI and CT revealed evidence of local recurrence.", + "MRI and CT revealed metastatic lesions in the lungs.", + "Flow-cytometry indicated no evidence of leukemia.", + "Serological studies showed no evidence of specific infections, such as candidiasis or tuberculosis.", + "Despite the administration of several antibiotics, the leukocytosis did not disappear.", + "Two months after the surgery, the patient died of multiple organ failure.", + "An autopsy showed metastasis in the liver.", + "An autopsy showed metastasis in the thyroid.", + "An autopsy showed metastasis in the diaphragm.", + "An autopsy showed metastasis in the adrenal gland.", + "An autopsy showed metastasis in the digestive tract.", + "An autopsy showed metastasis in the skin.", + "The histology of the recurrent and metastatic lesions was not conventional chondrosarcoma but only dedifferentiated components.", + "Immunoexpression of G-CSF was seen in the dedifferentiated components.", + "Immunoexpression of G-CSF was not seen in the conventional chondrosarcoma components." + ], + "summary": "We report the case of a 72-year-old man with dedifferentiated chondrosarcoma characterized by dedifferentiated components of malignant fibrous histiocytoma- or osteosarcoma-like features in addition to conventional chondrosarcoma, arising from his pelvic bone. After hemipelvectomy, when local recurrence and metastasis were identified, leukocytosis appeared and an elevated level of serum granulocyte-colony-stimulating factor (G-CSF) was also recognized. The patient died of multiple organ failure 2 months after surgery. Autopsy specimens showed that the histological specimens of the recurrence and metastasis were dedifferentiated components, without any conventional chondrosarcoma components. G-CSF was expressed only in the dedifferentiated components, not in the chondrosarcoma components, immunohistochemically.", + "summary_subclaims": [ + "The patient was a 72-year-old man.", + "The patient had dedifferentiated chondrosarcoma.", + "The dedifferentiated components had malignant fibrous histiocytoma- or osteosarcoma-like features.", + "The tumor arose from the pelvic bone.", + "The patient underwent hemipelvectomy.", + "Local recurrence and metastasis were identified after surgery.", + "Leukocytosis appeared after surgery.", + "An elevated level of serum granulocyte-colony-stimulating factor (G-CSF) was recognized.", + "The patient died of multiple organ failure 2 months after surgery.", + "Autopsy specimens showed that the histological specimens of the recurrence and metastasis were dedifferentiated components.", + "The recurrence and metastasis did not contain conventional chondrosarcoma components.", + "G-CSF was expressed only in the dedifferentiated components.", + "G-CSF was not expressed in the chondrosarcoma components." + ] + }, + { + "id": "multiclinsum_test_1198_en.txt", + "fulltext": "A solitary pulmonary nodule on the left upper lobe was detected as an incidental finding in a 58-year-old Caucasian woman who was a former smoker with a cumulative exposure of 50 pack-years. She had no other significant history and there was no reason to suspect that she could be immunocompromised. Lung cancer was suspected and an upper left lobe resection was performed two months later and the stumps were sutured with synthetic thread. The pathologic diagnosis was small cell lung carcinoma.\nPostoperative chemotherapy and whole-brain radiation therapy were administered and the clinical course was uneventful for two years until a slight rise in serum carcinoembryonic antigen (CEA) and CA 125 levels was detected. A PET-CT scan revealed two foci of increased FDG activity adjacent to left hilar lymph nodes (maximum standardized uptake values [SUVmax] of 10.3 and 8.3, respectively; Figure ) and local recurrence was suspected. A necrotic lesion at the left upper lobe bronchial stump was identified at bronchoscopy and an endobronchial biopsy was obtained. Pathologic examination revealed chronic inflammation and granulation tissue and numerous hyphae with the appearance of Aspergillus species but no sign of malignancy. Cultures were positive for Aspergillus fumigatus and antifungal therapy with itraconazole was started and continued for three months. Improvement was remarkable both on a follow-up PET-CT performed two months later (SUVmax of 4.3 and 3.2, respectively; Figure ) and a subsequent bronchoscopy, during which fragments of suture were recovered along with biopsy material. Cultures of the material obtained after this bronchoscopy were negative. The patient was followed up once a month for one year after treatment was stopped and there were no signs of recurrence of either the infection or the cancer.", + "fulltext_subclaims": [ + "A solitary pulmonary nodule on the left upper lobe was detected as an incidental finding in a 58-year-old Caucasian woman.", + "She was a former smoker with a cumulative exposure of 50 pack-years.", + "She had no other significant history.", + "There was no reason to suspect that she could be immunocompromised.", + "Lung cancer was suspected.", + "An upper left lobe resection was performed two months later.", + "The stumps were sutured with synthetic thread.", + "The pathologic diagnosis was small cell lung carcinoma.", + "Postoperative chemotherapy and whole-brain radiation therapy were administered.", + "The clinical course was uneventful for two years.", + "A slight rise in serum carcinoembryonic antigen (CEA) and CA 125 levels was detected.", + "A PET-CT scan revealed two foci of increased FDG activity adjacent to left hilar lymph nodes.", + "The maximum standardized uptake values (SUVmax) were 10.3 and 8.3, respectively.", + "Local recurrence was suspected.", + "A necrotic lesion at the left upper lobe bronchial stump was identified at bronchoscopy.", + "An endobronchial biopsy was obtained.", + "Pathologic examination revealed chronic inflammation and granulation tissue.", + "Numerous hyphae with the appearance of Aspergillus species were found.", + "No sign of malignancy was found.", + "Cultures were positive for Aspergillus fumigatus.", + "Antifungal therapy with itraconazole was started.", + "Antifungal therapy was continued for three months.", + "Improvement was remarkable on a follow-up PET-CT performed two months later.", + "The SUVmax were 4.3 and 3.2, respectively.", + "Fragments of suture were recovered during a subsequent bronchoscopy.", + "Cultures of the material obtained after this bronchoscopy were negative.", + "The patient was followed up once a month for one year after treatment was stopped.", + "There were no signs of recurrence of either the infection or the cancer." + ], + "summary": "We report the case of a 58-year-old Caucasian woman who developed bronchial stump aspergillosis two years after a left upper lobe resection for lung cancer. Bronchial stump aspergillosis was diagnosed as a result of a focus of increased fluorodeoxyglucose activity in a follow-up positron emission tomography and computed tomography scan. She was treated with oral antifungal therapy and presented with good evolution after three months of treatment.", + "summary_subclaims": [ + "The patient was a 58-year-old Caucasian woman.", + "She developed bronchial stump aspergillosis two years after a left upper lobe resection for lung cancer.", + "Bronchial stump aspergillosis was diagnosed as a result of a focus of increased fluorodeoxyglucose activity in a follow-up positron emission tomography and computed tomography scan.", + "She was treated with oral antifungal therapy.", + "She presented with good evolution after three months of treatment." + ] + }, + { + "id": "multiclinsum_test_1054_en.txt", + "fulltext": "A 10-year-old white girl presented to our emergency room in January 2015 with a 1-month history of headache and morning vomiting. On examination, she appeared slightly pale, with body temperature of 36.5 °C, heart rate of 90 beats per minute, blood pressure of 106/62 mmHg, respiratory rate of 18 breaths per minute, and oxygen saturation of 100% in ambient air. Her neurological status was normal. Laboratory test results are shown in Table . A chest X-ray was within limits. An urgent non-enhanced brain computed tomography (CT) scan showed a focal lesion in the left frontal subcortical region with prominent surrounding edema and mass effect . She was therefore admitted to our hospital. Magnetic resonance imaging (MRI) demonstrated ring enhancement on post-contrast T1-weighted (T1W) sequences; fluid-attenuated inversion recovery (FLAIR) sequences confirmed extensive vasogenic edema . She lived with her parents and siblings in Southern Italy. Before the onset of the current illness, at 5 years of age she had undergone surgical excision of a pleomorphic adenoma of the parotid gland. No evidence of a pre-existing congenital airway malformation was referred. She was not sexually active, and she did not smoke cigarettes, drink alcohol, or use illicit drugs. Her father, a heavy tobacco smoker, was a merchant. Her mother, a housewife, reported three miscarriages. Her maternal grandfather had died from colon cancer at 40 years. Her paternal aunt was affected by , and a second-degree cousin presented ovarian immature teratoma. After multidisciplinary discussion, neuronavigation and left frontal craniotomy with tumor resection with direct cortical and subcortical stimulation was done under general anesthesia. She received preoperative steroid medication which was tapered post-surgery. MRI scanning within 72 hours after surgery documented total resection .\nMicroscopy on tissue sections showed malignant neoplasms with extensive necrosis, composed of atypical columnar and cuboidal cells, which had vesicular nucleolated nuclei and eosinophilic cytoplasm. Tumor cells covered papillary structures with fibrovascular cores or formed small glands and micropapillae lacking stroma. The surrounding brain parenchyma showed evidence of reactive gliosis and lymphohistiocytic infiltrate . On immunohistochemical examination, neoplastic cells were positive for cytokeratin 7, thyroid transcription factor 1 (TTF-1) , cytokeratin AE1/AE3, and epithelial membrane antigen (EMA), whereas all other markers tested were negative: cytokeratin 20, carcinoembryonic antigen (CEA), thyroglobulin, vimentin, cluster of differentiation (CD) 10, WT1, calretinin, inhibin, CD117, CD30, S100 protein, melan-A, actin, chromogranin, synaptophysin, and glial fibrillary acidic protein (GFAP). INI1 expression was retained. Thus, a diagnosis of metastatic lung adenocarcinoma was proposed. A chest CT scan showed a parenchymal nodular lesion in the lower lateral basal segment of the right lobe, measuring 32 mm × 18 mm × 17 mm, thought to be the primary lung cancer with mediastinal nodal metastasis. Tumor spread was confirmed by positron emission tomography (PET)/CT showing a primary lung tumor and with high fluorodeoxyglucose (FDG) uptake: maximum standardized uptake value (SUVmax) of 8.5 and 8, respectively .\nAt fluorescence in situ hybridization (FISH) analysis, no rearrangements of anaplastic lymphoma kinase (ALK), c-ros oncogene 1, receptor tyrosine kinase (ROS1), and rearranged during transfection (RET) genes were found. ROS1 gene was found deleted in 57% of neoplastic cells. Next generation sequencing (NGS) analysis was applied to genomic deoxyribonucleic acid (DNA) extracted from formalin-fixed paraffin-embedded tissue. Both the “Cancer Hotspot Panel” (50 genes) and the “Comprehensive Cancer Panel” (444 genes) through the Personal Genome Machine with Ion Torrent™ technology (Life Technologies, Applied Biosystems) were applied. NGS analyses with Comprehensive Cancer Panel highlighted the presence of multiple non-targetable mutations in fms-related tyrosine kinase 4 (FLT4), ubiquitin-protein ligase E3 component N-recognin 5 (UBR5), ataxia telangiectasia mutated (ATM), and TATA-box binding protein associated factor 1 (TAF1). Epidermal growth factor receptor (EGFR) mutation status was negative.\nOne month after admission our patient started chemotherapy treatment for NSCLC with cisplatin and vinorelbine for six cycles over a 5-month period. Two months later, an MRI 3 months after diagnosis revealed cerebral recurrence; therefore, she underwent a second surgical resection, followed by radiosurgery (CyberKnife). A brain MRI and PET/CT scan after completion of her last dose of chemotherapy showed absence of cerebral metastasis and partial regression of the lesion of the lower lobe of her right lung (RLL); thus, between 7 and 8 months after admission she received adjuvant thoracic radiation therapy. Unfortunately, 1 month later surveillance imaging revealed lung tumor progression and multiple brain metastases. She subsequently started whole brain radiotherapy (WBRT) and three cycles of docetaxel. One year after admission a rapid lung tumor progression was documented. One month later she developed headache and vomiting due to increased cerebral edema and growth of brain metastases. Therefore, she started corticotherapy and third-line pemetrexed treatment (five cycles), but 5 months later a PET/CT scan revealed further worsening of intracranial lesions and skeletal metastases. She underwent radiosurgery by CyberKnife technique on brain metastases and the following month she received nivolumab at 3 mg/kg intravenously every 2 weeks compassionately. Due to worsening of clinical conditions, a month later PET/CT was performed, revealing disseminated (skeletal, pulmonary, cerebral, lymphonodal) disease. She continued nivolumab, receiving a total of five cycles without adverse events. Given the ongoing clinical and imaging deterioration, palliative treatment was initiated and she died of respiratory failure 23 months after diagnosis of metastatic lung adenocarcinoma . Autopsy was declined by parents.", + "fulltext_subclaims": [ + "The patient was a 10-year-old white girl.", + "She presented with a 1-month history of headache and morning vomiting.", + "On examination, she appeared slightly pale.", + "Her body temperature was 36.5 °C.", + "Her heart rate was 90 beats per minute.", + "Her blood pressure was 106/62 mmHg.", + "Her oxygen saturation was 100% in ambient air.", + "Her neurological status was normal.", + "An urgent non-enhanced brain CT scan showed a focal lesion in the left frontal subcortical region.", + "The CT scan showed prominent surrounding edema.", + "The CT scan showed mass effect.", + "She was admitted to the hospital.", + "MRI demonstrated ring enhancement on post-contrast T1-weighted sequences.", + "FLAIR sequences confirmed extensive vasogenic edema.", + "She lived in Southern Italy.", + "She had undergone surgical excision of a pleomorphic adenoma of the parotid gland at 5 years of age.", + "No evidence of a pre-existing congenital airway malformation was referred.", + "She was not sexually active.", + "She did not smoke cigarettes, drink alcohol, or use illicit drugs.", + "Her father was a heavy tobacco smoker.", + "Her mother reported three miscarriages.", + "Her maternal grandfather had died from colon cancer at 40 years.", + "Her paternal aunt was affected by [not specified].", + "A second-degree cousin presented ovarian immature teratoma.", + "Neuronavigation and left frontal craniotomy with tumor resection was done under general anesthesia.", + "She received preoperative steroid medication.", + "The steroids were tapered post-surgery.", + "MRI within 72 hours after surgery documented total resection.", + "Microscopy showed malignant neoplasms with extensive necrosis.", + "The tumor cells had vesicular nucleolated nuclei.", + "The tumor cells had eosinophilic cytoplasm.", + "Tumor cells formed small glands and micropapillae.", + "The surrounding brain parenchyma showed reactive gliosis.", + "The surrounding brain parenchyma showed lymphohistiocytic infiltrate.", + "Neoplastic cells were positive for cytokeratin 7.", + "Neoplastic cells were positive for TTF-1.", + "Neoplastic cells were positive for cytokeratin AE1/AE3.", + "Neoplastic cells were positive for EMA.", + "Neoplastic cells were negative for cytokeratin 20.", + "Neoplastic cells were negative for CEA.", + "Neoplastic cells were negative for thyroglobulin.", + "Neoplastic cells were negative for vimentin.", + "Neoplastic cells were negative for CD10.", + "Neoplastic cells were negative for WT1.", + "Neoplastic cells were negative for calretinin.", + "Neoplastic cells were negative for inhibin.", + "Neoplastic cells were negative for CD117.", + "Neoplastic cells were negative for CD30.", + "Neoplastic cells were negative for S100 protein.", + "Neoplastic cells were negative for melan-A.", + "Neoplastic cells were negative for actin.", + "Neoplastic cells were negative for chromogranin.", + "Neoplastic cells were negative for synaptophysin.", + "Neoplastic cells were negative for GFAP.", + "INI1 expression was retained.", + "A diagnosis of metastatic lung adenocarcinoma was proposed.", + "A chest CT scan showed a parenchymal nodular lesion in the lower lateral basal segment of the right lobe.", + "The lesion measured 32 mm × 18 mm × 17 mm.", + "PET/CT showed a primary lung tumor with high FDG uptake.", + "The primary tumor had an SUVmax of 8.5.", + "Mediastinal nodal metastasis had an SUVmax of 8.", + "FISH analysis showed no ALK rearrangements.", + "FISH analysis showed no ROS1 rearrangements.", + "FISH analysis showed no RET rearrangements.", + "ROS1 gene was found deleted in 57% of neoplastic cells.", + "NGS analysis was applied to DNA extracted from formalin-fixed paraffin-embedded tissue.", + "The Cancer Hotspot Panel and Comprehensive Cancer Panel were used.", + "NGS highlighted multiple non-targetable mutations in FLT4, UBR5, ATM, and TAF1.", + "EGFR mutation status was negative.", + "One month after admission, she started chemotherapy with cisplatin and vinorelbine.", + "She received six cycles of chemotherapy over 5 months.", + "Two months later, an MRI showed cerebral recurrence.", + "She underwent a second surgical resection.", + "She underwent radiosurgery (CyberKnife).", + "After chemotherapy, brain MRI and PET/CT showed absence of cerebral metastasis.", + "PET/CT showed partial regression of the right lung lesion.", + "She received adjuvant thoracic radiation therapy.", + "Surveillance imaging revealed lung tumor progression.", + "She developed multiple brain metastases.", + "She started whole brain radiotherapy.", + "She received three cycles of docetaxel.", + "One year after admission, rapid lung tumor progression was documented.", + "She developed headache and vomiting due to increased cerebral edema.", + "She started corticotherapy.", + "She started third-line pemetrexed treatment.", + "She received five cycles of pemetrexed.", + "PET/CT revealed worsening of intracranial lesions.", + "PET/CT revealed skeletal metastases.", + "She underwent radiosurgery on brain metastases.", + "She received nivolumab at 3 mg/kg intravenously every 2 weeks.", + "She received a total of five cycles of nivolumab.", + "PET/CT revealed disseminated disease.", + "Palliative treatment was initiated.", + "She died of respiratory failure 23 months after diagnosis.", + "Autopsy was declined by parents." + ], + "summary": "A 10-year-old white girl presented with brain metastases due to primary pulmonary adenocarcinoma. Next generation sequencing analysis with \"Comprehensive Cancer Panel\" highlighted the presence of multiple non-targetable mutations in the FLT4, UBR5, ATM, TAF1, and GUCY1A2 genes. She was treated aggressively with chemotherapy, surgery, and radiation therapy for local and distant recurrence. Eventually, therapy with nivolumab was started compassionately, and she died 23 months after diagnosis.", + "summary_subclaims": [ + "The patient is a 10-year-old white girl.", + "She presented with brain metastases due to primary pulmonary adenocarcinoma.", + "Next generation sequencing analysis with 'Comprehensive Cancer Panel' was performed.", + "Multiple non-targetable mutations were found in the FLT4, UBR5, ATM, TAF1, and GUCY1A2 genes.", + "She was treated with chemotherapy, surgery, and radiation therapy for local and distant recurrence.", + "Therapy with nivolumab was started compassionately.", + "She died 23 months after diagnosis." + ] + }, + { + "id": "multiclinsum_test_2097_en.txt", + "fulltext": "The patient was a 5-month-old boy, delivered through cesarean section on March 7, 2017. He was brought to our department on April 24, 2017, and was diagnosed as having a right transverse facial cleft with an incomplete cleft palate. Further, we delivered the Hotz appliance. Figure shows the right transverse facial cleft. The patient had Goldenhar syndrome as a systemic disease. And on our clinical examination, the patient had a cleft in the right corner of the mouth, macrostomia, malposition of the orbicularis oris muscle, and right oral commissure, which was pulled laterally and downwards.\nOrbicularis oris muscle reconstruction and cheiloplasty using a mucocutaneous flap and Z-plasty were performed. Figure shows the operative technique for reconstruction of the transverse facial cleft. The general operation technique was conducted following the method performed by Dr. Akita for reconstruction of a transverse facial cleft . First, an incision was made using the healthy side as reference. To raise a mucocutaneous flap, incisions were made both extraorally and intraorally . Extraoral primary closure was performed for the newly formed oral orifice. To avoid dysfunctions, such as those of mouth opening, pronunciation, and mastication, an additional incision was made on the intraoral mucosal flap, and the bucco-mucosal cleft was closed . The muscle layer and exposed orbicularis oris muscle were dissected. To reconstruct the modiolus region, the inferior part of the orbicularis oris muscle was overlapped with its superior part, and muscle closure was performed. Subsequently, the mucosa was closed with the Z-plasty technique to prevent wound contraction and obtain a good facial profile in the patient .\nFigure shows the photographs acquired before and 3 months after the surgery. At 3 postoperative months, symmetry was observed between both the oral commissures with satisfactory esthetic reconstruction, and there were no functional postoperative complications.", + "fulltext_subclaims": [ + "The patient was a 5-month-old boy.", + "He was delivered through cesarean section on March 7, 2017.", + "He was brought to the department on April 24, 2017.", + "He was diagnosed as having a right transverse facial cleft.", + "He had an incomplete cleft palate.", + "The Hotz appliance was delivered.", + "The patient had Goldenhar syndrome as a systemic disease.", + "The patient had a cleft in the right corner of the mouth.", + "The patient had macrostomia.", + "The patient had malposition of the orbicularis oris muscle.", + "The right oral commissure was pulled laterally and downwards.", + "Orbicularis oris muscle reconstruction and cheiloplasty were performed.", + "A mucocutaneous flap and Z-plasty were used.", + "The general operation technique was conducted following the method performed by Dr. Akita.", + "An incision was made using the healthy side as reference.", + "Incisions were made both extraorally and intraorally to raise a mucocutaneous flap.", + "Extraoral primary closure was performed for the newly formed oral orifice.", + "An additional incision was made on the intraoral mucosal flap.", + "The bucco-mucosal cleft was closed.", + "The muscle layer and exposed orbicularis oris muscle were dissected.", + "The inferior part of the orbicularis oris muscle was overlapped with its superior part.", + "Muscle closure was performed.", + "The mucosa was closed with the Z-plasty technique.", + "Photographs were acquired before and 3 months after the surgery.", + "At 3 postoperative months, symmetry was observed between both oral commissures.", + "There were no functional postoperative complications." + ], + "summary": "In a patient with a transverse facial cleft, to functionally arrange the orbicularis oris muscle and form the oral commissure naturally, we performed a surgical procedure including orbicularis oris muscle reconstruction and cheiloplasty with Z-plasty.", + "summary_subclaims": [ + "In a patient with a transverse facial cleft, we performed a surgical procedure including orbicularis oris muscle reconstruction and cheiloplasty with Z-plasty.", + "The surgical procedure aimed to functionally arrange the orbicularis oris muscle.", + "The surgical procedure aimed to form the oral commissure naturally." + ] + }, + { + "id": "multiclinsum_test_3309_en.txt", + "fulltext": "Twin children aged 2 years and 8 months, born to a gravida 3, para 2 mother, presented to the Orthopedic department at CURE Children’s Hospital, Ethiopia. The presenting complaint was a bilateral decrease in size and poor thumb function in both children. The children were born at a local health center. The antenatal history was unremarkable, and the mother did not recall the birth weight. Apart from the decreased thumb size, they were born without any anomalies, and their parents had no consanguinity. There was no family history of twin pregnancies on either parent’s side.\n\nOn physical examination, both children had bilaterally decreased size of their thumbs with other normal-appearing digits, the wrist in a neutral position, and no limb length discrepancy. They had well-formed skin creases and thenar folds. The children were observed to use their index and long fingers of both hands for pinching. During a passive range of motion, the first web space was tight with excessive adduction at the metacarpophalangeal (MCP) and carpometacarpal (CMC) joints of the thumb. The wrist, elbow, and shoulder ranges of motion were normal. On auscultation, heart sounds were well heard with clear bilateral air entry, no swelling, and no mass over the abdomen. No visible abnormalities were observed in their back or lower limbs.\n\nX-ray images were taken and showed a significantly decreased thumb size with abnormally developed basal metacarpal bone and deficient first CMC joint, and no radial deviation of the wrist joint. To rule out other associated anomalies, abdominal ultrasonography and echocardiography were performed in both patients, and the results were unremarkable. On complete blood cell count, twin A had hemoglobin of 12.5 g/dl and the platelet count was 356, whereas twin B’s hemoglobin and platelet count were 13.0 g/dl and 429, respectively. Based on the above findings, a diagnosis of type IIIB bilateral thumb hypoplasia was made for both twin children according to the modified Blauth classification,5 and pollicization was performed using the Buck-Gramcko technique, as described by Ezaki et al.\n\nSurgical Procedure\nAfter obtaining informed consent from the family, the infants were taken to the operating theater. General anesthesia was administered with endotracheal intubation and the skin prepared with povidone-iodine and draped. The limb was exsanguinated and an Esmarch’s tourniquet was applied.8 Similar skin incisions were utilized for all four hands, which were designed with a fish mouth appearance over the radial aspect of the index finger, and the palmar incision was more distal than dorsal so that the glabrous skin would be placed over the palmar aspect of the index finger, which in turn would improve the appearance of the index finger in the thumb position.\n\n\nThe volar skin incision started from the radial aspect of the index finger and continued to the thumb, looking for a vessel within the hypoplastic digit to trace the radial neurovascular bundle of the index finger. After localizing the radial neurovascular bundle of the index finger, dissection proceeded further to the ulna to identify the proper digital artery on the ulnar side of the index finger and common digital arteries in the second web space. To allow tension-free index finger pollicization, the radial proper digital artery of the middle finger was ligated and labeled with a stay suture. The common digital nerve to the second web space was divided along the proper digital nerve to the ulnar side of the index finger and the radial side of the middle finger. No variation was observed during dissection.\n\nThe intervolar plate ligament and fascia between the index and middle fingers were divided. The A1 and A2 pulleys of the index finger were opened to avoid flexor tendon buckling when the digit was shortened. The palmar digital arteries were protected with vessel loops, and dissection proceeded gently over the dorsal side. The dorsal flap was carefully raised to preserve the dorsal vein of the index finger. The extensor digitorum communis (EDC) and the extensor index proprius (EIP) were identified. The tendon of the EDC was severed at the level of the metacarpophalangeal joint for subsequent suturing to the base of the proximal phalanx. The suture was placed over the tendons of the palmar and dorsal interphalangeal muscles before dividing them for later transfer to the proximal interphalangeal joint extensor hood.\n\nAbout 2 cm of the index finger metacarpal was removed with a distal cut through the physis, where physeodesis was performed to prevent growth of the pollicized index finger. Hence, a 1.0 mm K-wire was inserted retrogradely from the metacarpal head to the proximal phalanx hyperextending into the MCP joint. Using the K-wire as a joystick, the digit was positioned at 35° palmar, 20° radial abduction, and 80° pronation and was secured with the same K-wire (1.0 m). The EDC tendon was sutured to the base of the new thumb to act as the new abductor pollicis longus. The tendons of the first dorsal and palmar interosseous muscles were transferred to the radial and ulnar aspects, respectively, to act as the abductor pollicis brevis and adductor pollicis, respectively. The extensor index proprius acts as the extensor pollicis longus. The tourniquet time was 2 hrs and the vascularity of the new thumb was checked. Any redundant skin was trimmed and the wound was closed in an interrupted fashion.\n\nAfter releasing the tourniquet, arterial circulation returned within a few seconds in three of the four pollicizations. However, in one case the arterial circulation was delayed beyond the expected time despite the application of warm saline-soaked gauze and release of some suture knots. Subsequently, we removed the K-wire from the proximal segment, after which the circulation returned immediately, which may be explained by inadvertent kinking of the arteries. The digit was then repositioned and fixed with the same K-wire and perfused well postoperatively. The skin was then closed with a 5.0 plain gut and covered with xeroform, fluffs of gauze and cotton, and a long-arm cast was applied.\n\nFollow-Up and Outcomes\nWe removed the cast and K-wires after 6 weeks of immobilization and the pollicized index fingers were well-maintained in the thumbs position. The incisions healed adequately and no wound complications were observed. Hand physiotherapy was started to increase ranges-of-motion exercises, such as playing with different toys and encouraging them to hold a pencil. They were able to pinch at 12 weeks and grabbing at 6 months.", + "fulltext_subclaims": [ + "The children were born at a local health center.", + "The antenatal history was unremarkable.", + "The mother did not recall the birth weight.", + "The children were born without any anomalies.", + "There was no family history of twin pregnancies on either parent’s side.", + "Both children had bilaterally decreased size of their thumbs.", + "The wrist was in a neutral position.", + "There was no limb length discrepancy.", + "The children used their index and long fingers of both hands for pinching.", + "During passive range of motion, the first web space was tight with excessive adduction at the metacarpophalangeal (MCP) and carpometacarpal (CMC) joints of the thumb.", + "The wrist, elbow, and shoulder ranges of motion were normal.", + "X-ray images showed a significantly decreased thumb size.", + "X-ray images showed abnormally developed basal metacarpal bone.", + "X-ray images showed deficient first CMC joint.", + "X-ray images showed no radial deviation of the wrist joint.", + "Abdominal ultrasonography and echocardiography were performed in both patients.", + "The results of abdominal ultrasonography and echocardiography were unremarkable.", + "Twin A had hemoglobin of 12.5 g/dl.", + "Twin A had a platelet count of 356.", + "Twin B had hemoglobin of 13.0 g/dl.", + "Twin B had a platelet count of 429.", + "A diagnosis of type IIIB bilateral thumb hypoplasia was made for both twin children.", + "The diagnosis was based on the modified Blauth classification.", + "Pollicization was performed using the Buck-Gramcko technique.", + "The surgical procedure was described by Ezaki et al.", + "General anesthesia was administered with endotracheal intubation.", + "The skin was prepared with povidone-iodine and draped.", + "An Esmarch’s tourniquet was applied.", + "Similar skin incisions were utilized for all four hands.", + "The skin incisions were designed with a fish mouth appearance over the radial aspect of the index finger.", + "The palmar incision was more distal than dorsal.", + "The volar skin incision started from the radial aspect of the index finger.", + "The volar skin incision continued to the thumb.", + "The radial neurovascular bundle of the index finger was localized.", + "The radial proper digital artery of the middle finger was ligated.", + "The radial proper digital artery of the middle finger was labeled with a stay suture.", + "The common digital nerve to the second web space was divided.", + "The intervolar plate ligament and fascia between the index and middle fingers were divided.", + "The A1 and A2 pulleys of the index finger were opened.", + "The palmar digital arteries were protected with vessel loops.", + "The dorsal flap was carefully raised.", + "The extensor digitorum communis (EDC) and the extensor index proprius (EIP) were identified.", + "The tendon of the EDC was severed at the level of the metacarpophalangeal joint.", + "The tendon of the EDC was sutured to the base of the new thumb.", + "The tendons of the first dorsal and palmar interosseous muscles were transferred.", + "The extensor index proprius acts as the extensor pollicis longus.", + "About 2 cm of the index finger metacarpal was removed.", + "A 1.0 mm K-wire was inserted retrogradely from the metacarpal head to the proximal phalanx.", + "The digit was positioned at 35° palmar, 20° radial abduction, and 80° pronation.", + "The tourniquet time was 2 hrs.", + "Arterial circulation returned within a few seconds in three of the four pollicizations.", + "In one case, arterial circulation was delayed beyond the expected time.", + "Warm saline-soaked gauze and release of some suture knots were applied.", + "The K-wire from the proximal segment was removed.", + "After removing the K-wire, circulation returned immediately.", + "The digit was repositioned and fixed with the same K-wire.", + "The skin was closed with a 5.0 plain gut.", + "A long-arm cast was applied.", + "The cast and K-wires were removed after 6 weeks of immobilization.", + "The pollicized index fingers were well-maintained in the thumbs position.", + "The incisions healed adequately.", + "No wound complications were observed.", + "Hand physiotherapy was started.", + "They were able to pinch at 12 weeks.", + "They were able to grab at 6 months." + ], + "summary": "Twin girls aged two years and eight months, born to a 42-year-old para III mother, presented with bilateral thumb hypoplasia. There was no family history of similar complaints, and no consanguinity was identified between their parents. After excluding other associated anomalies, index finger pollicization was performed for all four hands of the children according to modified Buck-Gramcko techniques, with modifications from Ezaki et al.", + "summary_subclaims": [ + "The children are twin girls.", + "The twins are aged two years and eight months.", + "The mother is 42 years old.", + "The mother is para III.", + "The children presented with bilateral thumb hypoplasia.", + "There was no family history of similar complaints.", + "There was no consanguinity between the parents.", + "Other associated anomalies were excluded.", + "Index finger pollicization was performed for all four hands of the children.", + "The procedure was performed according to modified Buck-Gramcko techniques.", + "Modifications from Ezaki et al. were used." + ] + }, + { + "id": "multiclinsum_test_2358_en.txt", + "fulltext": "A 14-year-old Greek male, born to healthy non-consanguineous parents, at term and without perinatal complications, was evaluated for uncontrolled epilepsy. He displayed generalized motor seizures at 3.5 months of age, eventually controlled by anticonvulsants. He showed developmental delay with head control at 4.5 months and ambulation at 19 months with a broad-based unsteady gait. He was diagnosed with ataxic cerebral palsy. In addition, he displayed a delay in speech and generalized learning difficulties at school. Tubulopathy was identified at the age of 8 years. Bartter syndrome was erroneously diagnosed at first. The patient received treatment with potassium gluconate, magnesium, spironolactone and indomethacin. At the same age, sensorineural deafness was detected and a hearing aid was used. At the start of his teenage years, this young man had infrequent secondarily generalized focal motor seizures unresponsive to several medication changes. At 14 years of age, he was a pleasant, cooperative teenager with mild intellectual disability and normal cranial nerve examination (II–XII), normal muscle strength in the upper and lower extremities, mild spastic hypertonia in the lower limbs, increased deep tendon reflexes and bilateral Babinski signs. There was mildly decreased superficial sensation in the lower extremities and no disturbance of position sensation or vibration. Romberg sign was absent. His gait was broad based and slow and he was unable to walk in tandem. Examination for cerebellar signs revealed the absence of tremor and dysmetria, while rapid alternating movements were slow and uncoordinated, resulting in dysdiadochokinesis.\nWakefulness and sleep electroencephalogram (EEG) showed slow background rhythms and no epileptiform activity. Brain computed tomography (CT) and MRI were normal. Nerve conduction studies revealed mild abnormalities on two occasions without important differences between the two tests. The motor conduction velocities on the second measurement were 41.3 m/s for the right median nerve, 38.2 m/s for the right peroneal nerve and 40.8 m/s for the left peroneal nerve. The sensory conduction velocities were 38.6 m/s for the right median nerve, 42.9 m/s for the right ulnar nerve and 42.3 m/s for the right sural nerve. There were no other abnormalities in these electrophysiological studies. Laboratory tests showed normal serum vitamin E, B12, folic acid and plasma very-long-chain fatty acid (VLCFA).\nThe patient’s epilepsy was fully controlled with topiramate and carbamazepine. At F/U, the ataxia remained stable, as was the spasticity, with independent home ambulation and need for support in the community. Episodic weakness appeared on many occasions, without evidence of electrolyte disturbance or clinically overt seizures, and this responded to adjustment of the anticonvulsants. Overall status was consistent with a static disorder of movement, with activity limitations, also associated with intellectual disability and epilepsy. Nevertheless, the unremarkable neuroimaging, the renal tubulopathy and sensorineural deafness, led us to obtain consent from the family to search for a neurogenetic syndrome, specifically for KCNJ10 mutations associated with EAST syndrome. The patient was heterozygous for two KCNJ10 mutations: a missense mutation (p.R65C) that is already published and a not yet published duplication (p.F119GfsX25) that creates a premature truncation of the protein . Both mutations are likely damaging. The missense mutation p.R65C has been also listed as disease causing in various databases including OMIM (Online Mendelian Inheritance in Man). In addition, prediction software agrees. As for the truncating frameshift mutation p.F119GfsX25, it is noted that truncating mutations in particular when occurring at the beginning of the protein are most likely damaging. Prediction software agrees here too.\nParental testing has not been performed, and therefore, we do not know for certain whether the mutations are in different alleles, but this also seems quite likely as the missense mutation has already been described in a patient not harboring the additional duplication (and that the same mutation occurred twice is not impossible but very unlikely). This patient’s static clinical course has been ascertained for the following 10 years.", + "fulltext_subclaims": [ + "The patient is a 14-year-old Greek male.", + "He was born to healthy non-consanguineous parents.", + "He was born at term without perinatal complications.", + "He was evaluated for uncontrolled epilepsy.", + "He displayed generalized motor seizures at 3.5 months of age.", + "The seizures were eventually controlled by anticonvulsants.", + "He showed developmental delay with head control at 4.5 months.", + "He ambulated at 19 months with a broad-based unsteady gait.", + "He was diagnosed with ataxic cerebral palsy.", + "He displayed a delay in speech.", + "He had generalized learning difficulties at school.", + "Tubulopathy was identified at the age of 8 years.", + "Bartter syndrome was erroneously diagnosed at first.", + "He received treatment with potassium gluconate.", + "He received treatment with magnesium.", + "He received treatment with spironolactone.", + "He received treatment with indomethacin.", + "Sensorineural deafness was detected at the age of 8 years.", + "A hearing aid was used.", + "At 14 years of age, he had infrequent secondarily generalized focal motor seizures.", + "The seizures were unresponsive to several medication changes.", + "He was a pleasant, cooperative teenager.", + "He had mild intellectual disability.", + "The cranial nerve examination was normal.", + "Muscle strength in the upper and lower extremities was normal.", + "Mild spastic hypertonia was present in the lower limbs.", + "Deep tendon reflexes were increased.", + "Bilateral Babinski signs were present.", + "Mildly decreased superficial sensation was present in the lower extremities.", + "There was no disturbance of position sensation.", + "There was no disturbance of vibration.", + "Romberg sign was absent.", + "His gait was broad based and slow.", + "He was unable to walk in tandem.", + "Examination for cerebellar signs revealed the absence of tremor.", + "Examination for cerebellar signs revealed the absence of dysmetria.", + "Rapid alternating movements were slow and uncoordinated.", + "Wakefulness and sleep electroencephalogram showed slow background rhythms.", + "There was no epileptiform activity.", + "Brain computed tomography was normal.", + "Brain MRI was normal.", + "Nerve conduction studies revealed mild abnormalities on two occasions.", + "Motor conduction velocities on the second measurement were 41.3 m/s for the right median nerve.", + "Motor conduction velocities on the second measurement were 38.2 m/s for the right peroneal nerve.", + "Motor conduction velocities on the second measurement were 40.8 m/s for the left peroneal nerve.", + "Sensory conduction velocities were 38.6 m/s for the right median nerve.", + "Sensory conduction velocities were 42.9 m/s for the right ulnar nerve.", + "Sensory conduction velocities were 42.3 m/s for the right sural nerve.", + "There were no other abnormalities in the electrophysiological studies.", + "Serum vitamin E was normal.", + "Serum B12 was normal.", + "Serum folic acid was normal.", + "Plasma very-long-chain fatty acid was normal.", + "The patient’s epilepsy was fully controlled with topiramate and carbamazepine.", + "At follow-up, the ataxia remained stable.", + "The spasticity remained stable.", + "He was able to ambulate independently at home.", + "He needed support in the community.", + "Episodic weakness appeared on many occasions.", + "There was no evidence of electrolyte disturbance.", + "There was no evidence of clinically overt seizures.", + "The weakness responded to adjustment of the anticonvulsants.", + "The overall status was consistent with a static disorder of movement.", + "The disorder was associated with intellectual disability.", + "The disorder was associated with epilepsy.", + "The unremarkable neuroimaging led to the search for a neurogenetic syndrome.", + "The renal tubulopathy led to the search for a neurogenetic syndrome.", + "The sensorineural deafness led to the search for a neurogenetic syndrome.", + "The search was specifically for KCNJ10 mutations associated with EAST syndrome.", + "The patient was heterozygous for two KCNJ10 mutations.", + "The first mutation was a missense mutation (p.R65C).", + "The second mutation was a duplication (p.F119GfsX25).", + "The duplication creates a premature truncation of the protein.", + "Both mutations are likely damaging.", + "The missense mutation p.R65C has been listed as disease causing in various databases.", + "Prediction software agrees that the missense mutation is damaging.", + "The truncating frameshift mutation p.F119GfsX25 is noted to be likely damaging.", + "Prediction software agrees that the truncating mutation is damaging.", + "Parental testing has not been performed.", + "It is not known for certain whether the mutations are in different alleles.", + "The missense mutation has already been described in a patient not harboring the additional duplication.", + "The static clinical course has been ascertained for the following 10 years." + ], + "summary": "A European male of non-consanguineous birth, with early-onset, static ataxic motor disorder, intellectual disability and epilepsy, imitating cerebral palsy, presented with additional findings of renal tubulopathy, sensorineural deafness and normal neuroimaging leading to the diagnosis of epilepsy, ataxia, sensorineural deafness, tubulopathy syndrome. The patient was heterozygous for two KCNJ10 mutations: a missense mutation (p.R65C) that is already published and a not yet published duplication (p.F119GfsX25) that creates a premature truncation of the protein. Both mutations are likely damaging. Parental testing has not been performed, and therefore, we do not know for certain whether the mutations are on different alleles. This young man presents some clinical and laboratory features that differ from previously reported patients with epilepsy, ataxia, sensorineural deafness, tubulopathy syndrome.", + "summary_subclaims": [ + "The patient is a European male of non-consanguineous birth.", + "The patient has early-onset, static ataxic motor disorder.", + "The patient has intellectual disability.", + "The patient has epilepsy.", + "The patient's condition imitates cerebral palsy.", + "The patient has renal tubulopathy.", + "The patient has sensorineural deafness.", + "The patient's neuroimaging is normal.", + "The diagnosis is epilepsy, ataxia, sensorineural deafness, tubulopathy syndrome.", + "The patient is heterozygous for two KCNJ10 mutations.", + "One mutation is a missense mutation (p.R65C).", + "The missense mutation (p.R65C) is already published.", + "The other mutation is a duplication (p.F119GfsX25).", + "The duplication (p.F119GfsX25) is not yet published.", + "The duplication (p.F119GfsX25) creates a premature truncation of the protein.", + "Both mutations are likely damaging.", + "Parental testing has not been performed.", + "It is not known for certain whether the mutations are on different alleles.", + "The patient presents some clinical and laboratory features that differ from previously reported patients with epilepsy, ataxia, sensorineural deafness, tubulopathy syndrome." + ] + }, + { + "id": "multiclinsum_test_2668_en.txt", + "fulltext": "It is a case report of a 13-year-old girl appeared to the outpatient department with the history of swelling over her right hand for 5 months. It was gradually progressive in nature and situated over the dorsum and medial aspect of the hand. There was no history of trauma or such type of lesion elsewhere in the body or the in the family. There were no any associated features, i.e. pain, fever, or any sign or symptoms influencing her general health. On examination, there was a swelling, which was firm in consistency and occupying the dorsal and inner side of the fifth metacarpal. Local temperature was not raised and the skin was mobile and there was no any feature suggestive of inflammatory pathology. On deep palpation, it was tender and the range of movement was restricted.\nThe routine hematological examination was within normal limit. The radiology revealed that there was an osteolytic fusiform expansible lesion involving to the whole distal 2/3rd of the fifth metacarpal and the articular surface too. The cortical is was paper thin, breached, inflated, and without the periosteal reaction and the tumor radiograph had “soap bubble” appearance. Hence, the provisional (clinicoradiological) diagnosis of aneurysmal bone cyst and GCT was conceded. The chest X-ray was also sought and it was within the normal limit. The core-cut biopsy sent and it conferred the diagnosis of GCT .\nOur technique is free osteoarticular metatarsal transfer, described by the Maini etal. The dorsal approach was used for the enbloc resection. Incision also included the previous biopsy track. The fifth metatarsal was removed except the base of it along with the partial resection of surrounding muscles . While removing the mass in enbloc, the capsule and collateral ligament of the fifth metacarpophalangeal joint left. The fourth metatarsal (same side) was harvested from the foot along with its capsule and collateral ligament of the metatarsal-phalangeal joint. The required length of the metatarsal was measured preoperatively, and it was osteotomized out from the base , and the capsuloligamentous of the metatarsal sutured to the counter capsuloligamentous structure at the recipient site to reconstruct the metacarpal-phalangeal joint. The metatarsal was fixed with the leftover base of the metacarpal by the K-wires and the volar slab applied . At the 14thpost-operative day, the sutures removed and the exercise started gradually.\nAt each follow-up, the clinical and radiological assessment was done. The Union at the junction of the metatarsal and the base of the leftover metacarpal occurred in the 6weeks and no obvious changes noticed at the transferred metatarsal. Initially, the movements had both extension and flexion lag, so the meanwhile electric stimulation given. At the end of the 6months of follow-up, the movements are painless and almost up to normal except the terminally restricted at the flexion. It ranges from 0° to75° flexion at the metacarpophalangeal joint ( and ). The patient was able to grasp any object and has pretty good grip strength.\nAfter the 2years of follow-up, after the surgery, the procedure is fulfilling our expectations and corroborates the reliability of this method. During the initial follow-up, the patient had the mild-to-moderate pain over his foot while walking and unable to dorsiflex his fourth toe. However, now, she is free from pain or any complaint such asdeformity or difficulty in walking. However, there is still slight weakness of fourth toe’s dorsiflexor. Finally, she is happy and has no any complaints.", + "fulltext_subclaims": [ + "It is a case report of a 13-year-old girl.", + "She had swelling over her right hand for 5 months.", + "The swelling was gradually progressive.", + "The swelling was situated over the dorsum and medial aspect of the hand.", + "There was no history of trauma.", + "There was no lesion elsewhere in the body.", + "There was no lesion in the family.", + "There were no associated features such as pain, fever, or signs influencing general health.", + "On examination, the swelling was firm in consistency.", + "The swelling occupied the dorsal and inner side of the fifth metacarpal.", + "Local temperature was not raised.", + "The skin was mobile.", + "There was no feature suggestive of inflammatory pathology.", + "On deep palpation, the swelling was tender.", + "The range of movement was restricted.", + "Routine hematological examination was within normal limits.", + "Radiology revealed an osteolytic fusiform expansible lesion involving the distal 2/3rd of the fifth metacarpal.", + "The lesion involved the articular surface.", + "The cortical was paper thin, breached, inflated, and without periosteal reaction.", + "The tumor radiograph had a 'soap bubble' appearance.", + "The provisional diagnosis was aneurysmal bone cyst and GCT.", + "The chest X-ray was within normal limits.", + "A core-cut biopsy was sent.", + "The biopsy conferred the diagnosis of GCT.", + "The technique used was free osteoarticular metatarsal transfer, described by Maini et al.", + "A dorsal approach was used for the enbloc resection.", + "The incision included the previous biopsy track.", + "The fifth metatarsal was removed except the base.", + "Partial resection of surrounding muscles was performed.", + "The capsule and collateral ligament of the fifth metacarpophalangeal joint were left.", + "The fourth metatarsal was harvested from the foot.", + "The capsuloligamentous of the metatarsal was sutured to the counter capsuloligamentous structure at the recipient site.", + "The metatarsal was fixed with the leftover base of the metacarpal by K-wires.", + "A volar slab was applied.", + "At the 14th post-operative day, the sutures were removed.", + "Exercise was started gradually.", + "Union at the junction occurred in 6 weeks.", + "No obvious changes were noticed at the transferred metatarsal.", + "Initially, the movements had both extension and flexion lag.", + "Electric stimulation was given.", + "At the end of 6 months of follow-up, the movements were painless and almost up to normal.", + "Flexion was restricted terminally at the metacarpophalangeal joint.", + "The patient was able to grasp any object.", + "The patient had pretty good grip strength.", + "After 2 years of follow-up, the procedure was fulfilling expectations.", + "The procedure corroborates the reliability of this method.", + "During the initial follow-up, the patient had mild-to-moderate pain over the foot while walking.", + "The patient was unable to dorsiflex the fourth toe.", + "She is now free from pain or any complaint such as deformity or difficulty in walking.", + "There is still slight weakness of the fourth toe’s dorsiflexor.", + "She is happy and has no complaints." + ], + "summary": "It is a case report of a 13-year-old girl with the history of swelling over her right hand for 5 months. X-ray revealed that there was an osteolytic fusiform expansible lesion. The biopsy sent and it conferred the diagnosis of GCT. Dorsal approach used for the enbloc resection of the fifth metacarpals (except at the base) and partial excision of the surrounding muscles done. The capsule and collateral ligament of the fifth metacarpophalangeal joint were left. The fourth metatarsal was harvested from the foot along with its capsule and collateral ligament of the metatarsophalangeal joint and sutured to the counter capsuloligamentous structure at the recipient site.", + "summary_subclaims": [ + "It is a case report of a 13-year-old girl.", + "She had a history of swelling over her right hand for 5 months.", + "X-ray revealed an osteolytic fusiform expansible lesion.", + "The biopsy conferred the diagnosis of GCT.", + "A dorsal approach was used for the enbloc resection of the fifth metacarpals (except at the base).", + "Partial excision of the surrounding muscles was done.", + "The capsule and collateral ligament of the fifth metacarpophalangeal joint were left.", + "The fourth metatarsal was harvested from the foot along with its capsule and collateral ligament of the metatarsophalangeal joint.", + "The harvested fourth metatarsal was sutured to the counter capsuloligamentous structure at the recipient site." + ] + }, + { + "id": "multiclinsum_test_457_en.txt", + "fulltext": "A patient, 35-year-old female, came to our clinic because of severe vertigo and paroxysmal headaches for about 2 years. She mostly suffered from vertigo at night with multiple vomiting spells and bilateral tinnitus, which would last the entire night. During the period of vertigo, she also had a headache at the right temporal site, which was present a kind of pulsatile pain and could last several hours; this caused nausea and the inability to fall asleep. Prior to the onset of the vertigo and headache, she also had a visual aura with wave sight that lasted 10 min. Approximately 10 of these attacks were trigged by loud noises or bright lights, accompanied with symptoms such as chest tightness, tachypnea, and blushing. The migraine attacks were mostly accompanied by vertigo, becoming more severe during vestibular episodes. Those symptoms continued to worsen over the next week from the initial onset. During this time, the patient suffered from vertigo for several hours daily, and also suffered from repeated vomiting, numbness on the right side of the face, and tinnitus in the ear. The attacks of vertigo had no connection to changing body position. The headache occurred on the right side with visual aura expressing as fortification spectrum during vertigo. Physical examination found dysesthesia around the right side of the forehead and unsteady gait.\nThe patient’s clinical history revealed a more frequent occurrence of migraines during the period of pregnancy. The headache was usually a throbbing, unilateral temporal pain for 20 min each time. It would result in nausea and vomiting, which led to functional limitation in daily activities and led to bed rest to alleviate her symptoms. Meanwhile, the patient also had a visual aura with waves of light that lasting approximately 10 min. She had no family history regarding her illness, history of drug use, allergy, smoking, or drinking.\nA neurological examination showed clockwise rotary nystagmus when she gazed to the left side, and an abnormal finger-to-nose test at the right side. The patient had normal muscle tone and muscle strength, and no appearance of the Babinski Sign. Vestibular system tests including Dix-hallpike, Roll-test as well as a head thrust test were all negative as well.\nLaboratory test showed the HbA1C was 5.1%, and plasma homocysteine was 9.5 μmol/L. The autoimmune antibodies including pANCA、cANCA(−)、MPO、PR3、ENA、ACA-IgA、ACA-IgG、ACA-IgM、ANA、ds-DNA、DNP were negative except for the AECA(++). Thrombophilia markers were also tested, including protein C activity (130%)、von Willebrand factor activity (109%) 、free protein S activity (76%) as well as antithrombin III activity (109%). Other tumor markers regarding lung cancer and colon carcinoma were all negative and thyroid gland function was also normal. The routine test of cerebrospinal fluid (CSF) was normal, while the aquaporin (AQP) 4 antibodies were negative in both plasma and CSF.\nThe electro-audiometry test revealed a mild hearing impairment in the right ear. Other Neuro-electrophysiology tests, including brainstem auditory evoked potential (BAEP)、visual evoked potential (VEP)、electromyogram (EMG) as well as nerve conductive velocity (NCV) were all normal. The cardiac and carotid ultrasound exams were both negative. The diffusive weighted imaging showed subacute infarction in the right lateral medullar on January 8th . The digital subtraction cerebral angiography (DSA) indicated a left intracranial aneurysm on the next day . The infarction and intracranial aneurysm were located on separate sides of the brain, which suggested that the Wallenberg syndrome might not be caused by the intracranial aneurysm. DSA imaging showed that the communicating artery between anterior and posterior circulation of cerebral arteries was not open, and ipsilateral posterior inferior cerebella artery could be seen clearly . We administrated antiplatelet treatment as well as Flunarizine immediately. The patient’s vertigo symptoms diminished just in a few days, with the patient being discharged three weeks later with oral medication, including Betahistine Mesilate 6 mg tid, Dihydroergotoxine 2.5 mg bid, Aspirin 100 mg qd and Flunarizine 5 mg qn. At the patient’s 3-month follow-up, she said she had only once been affected by vertigo and the migraines were less common and less intense than she was previously experiencing.", + "fulltext_subclaims": [ + "The patient is a 35-year-old female.", + "She had severe vertigo and paroxysmal headaches for about 2 years.", + "She mostly suffered from vertigo at night with multiple vomiting spells and bilateral tinnitus, which would last the entire night.", + "During the period of vertigo, she had a headache at the right temporal site.", + "The headache was present as a kind of pulsatile pain and could last several hours.", + "The headache caused nausea and the inability to fall asleep.", + "Prior to the onset of the vertigo and headache, she had a visual aura with wave sight that lasted 10 min.", + "Approximately 10 of these attacks were triggered by loud noises or bright lights.", + "The attacks were accompanied with symptoms such as chest tightness, tachypnea, and blushing.", + "The migraine attacks were mostly accompanied by vertigo.", + "The symptoms continued to worsen over the next week from the initial onset.", + "During this time, the patient suffered from vertigo for several hours daily.", + "She also suffered from repeated vomiting, numbness on the right side of the face, and tinnitus in the ear.", + "The attacks of vertigo had no connection to changing body position.", + "The headache occurred on the right side with visual aura expressing as fortification spectrum during vertigo.", + "Physical examination found dysesthesia around the right side of the forehead.", + "The patient’s clinical history revealed a more frequent occurrence of migraines during the period of pregnancy.", + "The headache was usually a throbbing, unilateral temporal pain for 20 min each time.", + "It would result in nausea and vomiting.", + "The patient had a visual aura with waves of light that lasted approximately 10 min.", + "She had no family history regarding her illness.", + "She had no history of drug use, allergy, smoking, or drinking.", + "A neurological examination showed clockwise rotary nystagmus when she gazed to the left side.", + "The vestibular system tests including Dix-hallpike, Roll-test, and head thrust test were all negative.", + "Laboratory test showed the HbA1C was 5.1%.", + "Plasma homocysteine was 9.5 μmol/L.", + "The autoimmune antibodies including pANCA, cANCA, MPO, PR3, ENA, ACA-IgA, ACA-IgG, ACA-IgM, ANA, ds-DNA, DNP were negative except for the AECA (++).", + "Thrombophilia markers were tested, including protein C activity (130%), von Willebrand factor activity (109%), free protein S activity (76%), and antithrombin III activity (109%).", + "The routine test of cerebrospinal fluid (CSF) was normal.", + "The aquaporin (AQP) 4 antibodies were negative in both plasma and CSF.", + "The electro-audiometry test revealed a mild hearing impairment in the right ear.", + "The diffusive weighted imaging showed subacute infarction in the right lateral medullar on January 8th.", + "The digital subtraction cerebral angiography (DSA) indicated a left intracranial aneurysm on the next day.", + "The infarction and intracranial aneurysm were located on separate sides of the brain.", + "DSA imaging showed that the communicating artery between anterior and posterior circulation of cerebral arteries was not open.", + "We administrated antiplatelet treatment as well as Flunarizine immediately.", + "The patient’s vertigo symptoms diminished just in a few days.", + "The patient was discharged three weeks later with oral medication, including Betahistine Mesilate 6 mg tid, Dihydroergotoxine 2.5 mg bid, Aspirin 100 mg qd, and Flunarizine 5 mg qn.", + "At the patient’s 3-month follow-up, she said she had only once been affected by vertigo.", + "The migraines were less common and less intense than she was previously experiencing." + ], + "summary": "The patient, a 35-year-old lady, came to our department with severe vertigo and headaches for approximately two years. She suffered from migraines which attacked about twice yearly for nearly a decade. The diffusive weighted imaging showed a subacute infarction in the right lateral medullar. The clinical characteristics and MRI findings supported the diagnosis of vestibular migraine with Wallenberg syndrome. Along with the normal routine medication for vestibular migraine with Wallenberg syndrome, we also prescribed migraine therapy at the same time. In a 3-month follow-up, the patient had suffered only one vertigo attack and she reported that the migraines were less common and less intense than she was previously experiencing.", + "summary_subclaims": [ + "The patient is a 35-year-old lady.", + "She came to the department with severe vertigo and headaches for approximately two years.", + "She suffered from migraines which attacked about twice yearly for nearly a decade.", + "The diffusive weighted imaging showed a subacute infarction in the right lateral medullar.", + "The clinical characteristics and MRI findings supported the diagnosis of vestibular migraine with Wallenberg syndrome.", + "Along with the normal routine medication for vestibular migraine with Wallenberg syndrome, migraine therapy was prescribed at the same time.", + "In a 3-month follow-up, the patient had suffered only one vertigo attack.", + "She reported that the migraines were less common and less intense than she was previously experiencing." + ] + }, + { + "id": "multiclinsum_test_752_en.txt", + "fulltext": "The patient is a 65-year-old Chinese woman with a 4-year history of hypertension, and a 14 months history of proteinuria and microscopic hematuria. The patient had been in her baseline renal condition until January 9, 2020. As shown in Table , her baseline estimated glomerular filtration rate (eGFR) in the past year range from 64.2 ml/min/1.73m2 to 72.6 ml/min/1.73m2. Baseline urine sediment examination showed 36.61 cells/μl − 74.43 cells/μl in erythrocyte count and baseline proteinuria excretion was up to 510 mg/day. Three days prior to her admission, she got flu-like symptoms including headache, myalgia and fatigue, which were resolved in 1 to 2 days. However, she developed dark-colored urine and flank pain a day later and presented to the out-patient clinic. Urine sediment investigation showed significant worsening in urine erythrocyte count (2518.03/μL) and she was admitted to the hospital on January 10, 2020. On admission, vital signs were normal with a body temperature of 36.8 °C, blood pressure of 149/104 mmHg, heart rate of 80 beats per minute, and a respiratory rate of 16 breaths per minute. Both lungs were clear to auscultation. The rest of the physical examination was also unremarkable.\nLaboratory results from the time of admission are summarized in Table . She got decreased eGFR (53.6 ml/min/1.73m2) and deteriorated proteinuria (1.07 g/day, of which, albuminuria was 839 mg/day) when compared to her baseline level. Notably, the patient had mild lymphopenia of 0.86*109/L and increased C reaction protein (CRP) level of 19.6 mg/L. Serologic examinations for hepatitis B virus (HBV), hepatitis C virus (HCV) and human immunodeficiency virus (HIV) were negative. Anti-nuclear antibody, anti-extractable nuclear antigen antibodies, anti-neutrophil cytoplasm antibodies and anti-glomerular basement membrane antibody were negative. Serum immunoglobulin (Ig) A level was slightly increased at 4.71 g/L (reference range: 0.82 g/L-4.53 g/L), whereas IgG, IgM, complement C3 and C4 levels were within the normal range. An ultrasound and a Computed Tomography (CT) examinations for the urinary system were unremarkable. A chest CT scan revealed scattered ground glass opacity (GGO) .\nOn admission day 5, a renal biopsy was performed. A total of 16 glomeruli were identified in the tissue submitted for evaluation, 5 of which were completely sclerosed. One glomerulus showed segmental sclerosis and one showed a fibrocellular crescent . Focal mild mesangial hypercellularity was identified in rare glomeruli. There was no evidence of significant glomerular inflammation or necrosis. The tubular parenchyma showed moderate interstitial fibrosis associated with nonspecific mononuclear cell inflammatory. Intact tubules showed focal acute tubular injurious changes characterized by attenuation of the brush borders and cytoplasmic vacuolization as well as luminal cellular debris . By immunofluorescence microscopy, the glomeruli showed 2+ granular mesangial staining for IgA , C3, kappa and lambda light chains. IgG, IgM and C1q were negative. Electron microscopy (EM) examination revealed mesangial electron dense immune-type deposits. There was no evidence of definitive viral particles . A diagnosis of IgA nephropathy with an Oxford score of M0E0S1T1C1 was rendered.\nWith the diagnosis of IgA nephropathy, she received valsartan, an angiotensin II receptor blocker (ARB), with an initial dosage of 20 mg per day. She experienced dry cough without fever, dyspnea, diarrhea, myalgia or sore throat on admission day 12. Consequently, we repeated a chest CT scan for her out of caution due to COVID-19. The CT images showed a significant interval progression with a viral pneumonia pattern . She had progressive chest imaging, however, she had only mild symptoms and her oxygen saturation maintained between 97 and 99%. Her CRP level increased to 36.6 mg/L. A panel of infectious disease screening was initiated including IgM antibodies against nine respiratory pathogens: influenza virus A, influenza virus B, parainfluenza virus, adenovirus, respiratory syncytial virus, pneumonophagous legionella, Q fever rickettsia, mycoplasma pneumoniae and chlamydia pneumoniae, which were all negative. A throat swab specimen tested positive for SARS-CoV-2 later. The frozen renal tissue from biopsy specimens was submitted for reverse transcription-polymerase chain reaction, however, which was tested negative for SARS-CoV-2. Immunohistochemical (IHC) evaluation for the spike protein (40150-R007, Sino Biological, Beijing, China) of SARS-CoV-2 in the kidney was negative as well . According to the guideline for COVID-19 issued by the National Health Commission of China , she received methylprednisolone (40 mg per day for 3 days) to alleviate her pulmonary inflammation and empirical anti-virus medication (oseltamivir at 75 mg, twice a day for 5 days).\nOn admission day 17, a follow-up chest CT scan showed a significant improvement . Laboratory investigations showed stable renal function , restored lymphocyte count (1.05*109/L) and decreased CRP level (4.6 mg/L). A repeated throat swab specimen tested negative for SARS-CoV-2. The patient was discharged.\nThree months later, the patient remains asymptomatic clinically. A follow-up investigation revealed positive IgG and the IgM antibody against SARS-CoV-2. Her eGFR and UACR were 74.69 ml/min/1.73m2 and 33.61 mg/g respectively; her urine erythrocyte was 28.3 cells/μl (her baseline level). The valsartan dosage was titrated to 40 mg OD for optimizing her blood pressure control.", + "fulltext_subclaims": [ + "The patient is a 65-year-old Chinese woman.", + "She has a 4-year history of hypertension.", + "She has a 14 months history of proteinuria.", + "She has a 14 months history of microscopic hematuria.", + "Her baseline estimated glomerular filtration rate (eGFR) in the past year ranged from 64.2 ml/min/1.73m2 to 72.6 ml/min/1.73m2.", + "Baseline urine sediment examination showed 36.61 cells/μl − 74.43 cells/μl in erythrocyte count.", + "Baseline proteinuria excretion was up to 510 mg/day.", + "Three days prior to admission, she had flu-like symptoms including headache, myalgia and fatigue.", + "She developed dark-colored urine and flank pain a day later.", + "Urine sediment investigation showed significant worsening in urine erythrocyte count (2518.03/μL).", + "She was admitted to the hospital on January 10, 2020.", + "On admission, her blood pressure was 149/104 mmHg.", + "On admission, her eGFR was 53.6 ml/min/1.73m2.", + "On admission, proteinuria was 1.07 g/day.", + "On admission, albuminuria was 839 mg/day.", + "She had mild lymphopenia of 0.86*109/L.", + "She had increased C reaction protein (CRP) level of 19.6 mg/L.", + "Serologic examinations for hepatitis B virus (HBV), hepatitis C virus (HCV) and human immunodeficiency virus (HIV) were negative.", + "Anti-nuclear antibody, anti-extractable nuclear antigen antibodies, anti-neutrophil cytoplasm antibodies and anti-glomerular basement membrane antibody were negative.", + "Serum immunoglobulin (Ig) A level was slightly increased at 4.71 g/L.", + "An ultrasound and a Computed Tomography (CT) examinations for the urinary system were unremarkable.", + "A chest CT scan revealed scattered ground glass opacity (GGO).", + "A renal biopsy was performed on admission day 5.", + "A total of 16 glomeruli were identified in the tissue submitted for evaluation.", + "Five glomeruli were completely sclerosed.", + "One glomerulus showed segmental sclerosis.", + "One glomerulus showed a fibrocellular crescent.", + "There was no evidence of significant glomerular inflammation or necrosis.", + "The tubular parenchyma showed moderate interstitial fibrosis associated with nonspecific mononuclear cell inflammatory.", + "Intact tubules showed focal acute tubular injurious changes characterized by attenuation of the brush borders and cytoplasmic vacuolization as well as luminal cellular debris.", + "By immunofluorescence microscopy, the glomeruli showed 2+ granular mesangial staining for IgA.", + "By immunofluorescence microscopy, the glomeruli showed 2+ granular mesangial staining for C3.", + "By immunofluorescence microscopy, the glomeruli showed 2+ granular mesangial staining for kappa and lambda light chains.", + "IgG, IgM and C1q were negative.", + "Electron microscopy (EM) examination revealed mesangial electron dense immune-type deposits.", + "There was no evidence of definitive viral particles.", + "A diagnosis of IgA nephropathy with an Oxford score of M0E0S1T1C1 was rendered.", + "She received valsartan, an angiotensin II receptor blocker (ARB), with an initial dosage of 20 mg per day.", + "On admission day 12, she experienced dry cough without fever, dyspnea, diarrhea, myalgia or sore throat.", + "A chest CT scan was repeated due to caution regarding COVID-19.", + "The CT images showed a significant interval progression with a viral pneumonia pattern.", + "Her oxygen saturation maintained between 97 and 99%.", + "Her CRP level increased to 36.6 mg/L.", + "A panel of IgM antibodies against nine respiratory pathogens was negative.", + "A throat swab specimen tested positive for SARS-CoV-2.", + "Frozen renal tissue from biopsy specimens was submitted for reverse transcription-polymerase chain reaction.", + "The frozen renal tissue tested negative for SARS-CoV-2.", + "Immunohistochemical (IHC) evaluation for the spike protein of SARS-CoV-2 in the kidney was negative.", + "She received methylprednisolone (40 mg per day for 3 days).", + "She received oseltamivir at 75 mg, twice a day for 5 days.", + "On admission day 17, a follow-up chest CT scan showed a significant improvement.", + "Laboratory investigations showed stable renal function.", + "Laboratory investigations showed restored lymphocyte count (1.05*109/L).", + "Laboratory investigations showed decreased CRP level (4.6 mg/L).", + "A repeated throat swab specimen tested negative for SARS-CoV-2.", + "The patient was discharged.", + "Three months later, the patient remains asymptomatic clinically.", + "A follow-up investigation revealed positive IgG antibody against SARS-CoV-2.", + "A follow-up investigation revealed positive IgM antibody against SARS-CoV-2.", + "Her eGFR was 74.69 ml/min/1.73m2.", + "Her urine albumin-to-creatinine ratio (UACR) was 33.61 mg/g.", + "Her urine erythrocyte count was 28.3 cells/μl.", + "The valsartan dosage was titrated to 40 mg OD." + ], + "summary": "In the present case, we report a 65-year old Chinese woman who presented with dark-colored urine, worsening proteinuria and decreased renal function after COVID-19 infection. She received a renal biopsy during COVID-19 infection. The renal biopsy revealed IgA nephropathy without any evidence for SARS-Cov-2. The findings suggest that the renal abnormalities were a consequence of exacerbation of this patient's underlying glomerular disease after COVID-19 infection. After a regimen of 3-day course of glucocorticoid and angiotensin II receptor blocker therapy, the patient recovered and remained stable upon follow-up.", + "summary_subclaims": [ + "The patient was a 65-year old Chinese woman.", + "She presented with dark-colored urine.", + "She had worsening proteinuria.", + "She had decreased renal function after a COVID-19 infection.", + "She received a renal biopsy during the COVID-19 infection.", + "The renal biopsy revealed IgA nephropathy.", + "There was no evidence for SARS-Cov-2 in the renal biopsy.", + "The findings suggest that the renal abnormalities were a consequence of exacerbation of this patient's underlying glomerular disease after the COVID-19 infection.", + "The patient received a 3-day course of glucocorticoid.", + "The patient received angiotensin II receptor blocker therapy.", + "The patient recovered.", + "The patient remained stable upon follow-up." + ] + }, + { + "id": "multiclinsum_test_324_en.txt", + "fulltext": "The patient was an 89-year-old woman who visited a neighborhood hospital 4 h after developing abdominal pain and vomiting of sudden onset. She was referred to our hospital 2 h later with the diagnosis of intestinal obstruction. She had a history of undergoing cesarean sections. On arrival at our hospital, her vital signs were stable; examination revealed that she was 145 cm tall and weighed 36.9 kg (calculated body mass index [BMI], 17.5). She had severe tenderness in the lower abdomen, but no signs of peritoneal irritation. Blood tests showed an elevated white blood cell count, although the serum C-reactive protein (CRP) was normal. Blood gas analysis showed mild acidosis, with a pH of 7.383, and a base excess (BE) of − 3.7. Contrast-enhanced computed tomography (CT) revealed a small bowel forming a closed loop, with poor contrast effect, and dilatation of the oral side of the small bowel . Ascites was also identified . The patient was diagnosed as having strangulated bowel obstruction, and emergency surgery was performed.\nAt laparotomy, bloody ascites was observed. Two segments of the ileum were tied together forming a knot, and both segments were necrotic due to impaired blood flow . There was a band formation between a nearby segment of the small bowel and the abdominal wall, probably attributable in part to the previous cesarean sections, but there was no evidence of intestinal obstruction. Although it was necessary to release the strangulated small bowel, we did not immediately release the knot, but first proceeded with ligation of the mesenteric vessels draining the strangulated small bowel, to prevent dissemination of toxic substances from the necrotic bowel to the systemic circulation. Ligation of the mesenteric vessels was followed by resection of a 100-cm segment of the knotted necrotic ileum, 10 cm from the ileal end. Hand-sewn anastomosis was performed with the Albert-Lembert suture. The volume of blood loss was 282 ml, and the operation time was 1 h 41 min.\nThe resected specimen showed the two intestinal segments wrapped together forming a knot, as indicated by the intraoperative diagnosis, and the strangulation was released by untying the knot . There were no abnormalities on the mucosal surface other than signs of necrosis. Histopathological examination of the resected ileum showed that the resected small bowel was remarkably devoid of crypt epithelium, and there was severe congestion and hemorrhage extending from the intrinsic mucosal layer to the submucosa, which was considered to represent an ischemic change.\nThe postoperative course was uneventful, and the patient was discharged on the 13th postoperative day.", + "fulltext_subclaims": [ + "The patient was an 89-year-old woman.", + "She visited a neighborhood hospital 4 h after developing abdominal pain and vomiting of sudden onset.", + "She was referred to our hospital 2 h later with the diagnosis of intestinal obstruction.", + "She had a history of undergoing cesarean sections.", + "On arrival at our hospital, her vital signs were stable.", + "She was 145 cm tall and weighed 36.9 kg.", + "She had severe tenderness in the lower abdomen.", + "Blood tests showed an elevated white blood cell count.", + "The serum C-reactive protein (CRP) was normal.", + "Blood gas analysis showed mild acidosis, with a pH of 7.383.", + "Contrast-enhanced computed tomography (CT) revealed a small bowel forming a closed loop.", + "Contrast-enhanced CT showed poor contrast effect.", + "Contrast-enhanced CT showed dilatation of the oral side of the small bowel.", + "Ascites was also identified.", + "The patient was diagnosed as having strangulated bowel obstruction.", + "Emergency surgery was performed.", + "At laparotomy, bloody ascites was observed.", + "Two segments of the ileum were tied together forming a knot.", + "Both segments were necrotic due to impaired blood flow.", + "There was a band formation between a nearby segment of the small bowel and the abdominal wall.", + "There was no evidence of intestinal obstruction.", + "Ligation of the mesenteric vessels draining the strangulated small bowel was performed.", + "A 100-cm segment of the knotted necrotic ileum was resected.", + "Hand-sewn anastomosis was performed with the Albert-Lembert suture.", + "The volume of blood loss was 282 ml.", + "The operation time was 1 h 41 min.", + "The resected specimen showed the two intestinal segments wrapped together forming a knot.", + "The strangulation was released by untying the knot.", + "Histopathological examination showed the resected small bowel was remarkably devoid of crypt epithelium.", + "There was severe congestion and hemorrhage extending from the intrinsic mucosal layer to the submucosa.", + "The postoperative course was uneventful.", + "The patient was discharged on the 13th postoperative day." + ], + "summary": "An 89-year-old woman was referred to our hospital with the diagnosis of intestinal obstruction. Contrast-enhanced computed tomography revealed the small bowel forming a closed loop, with poor contrast effect. Based on the findings, the patient was diagnosed as having strangulated bowel obstruction, and emergency surgery was performed. At laparotomy, two segments of the ileum were found to be tied together forming a knot, and both segments were necrotic. Although it was necessary to release the strangulated small bowel, we did not immediately release the knot, but first proceeded with ligation of the mesenteric vessels to the strangulated small bowel to prevent dissemination of toxic substances from the necrotic bowel into the systemic circulation. The surgery was completed with resection of the necrotic ileum and anastomosis of the small intestine. The postoperative course was uneventful, and the patient was discharged home.", + "summary_subclaims": [ + "An 89-year-old woman was referred to our hospital with the diagnosis of intestinal obstruction.", + "Contrast-enhanced computed tomography revealed the small bowel forming a closed loop.", + "Contrast-enhanced computed tomography showed poor contrast effect.", + "Based on the findings, the patient was diagnosed as having strangulated bowel obstruction.", + "Emergency surgery was performed.", + "At laparotomy, two segments of the ileum were found to be tied together forming a knot.", + "Both segments were necrotic.", + "It was necessary to release the strangulated small bowel.", + "We did not immediately release the knot.", + "We first proceeded with ligation of the mesenteric vessels to the strangulated small bowel.", + "The surgery was completed with resection of the necrotic ileum.", + "The surgery was completed with anastomosis of the small intestine.", + "The postoperative course was uneventful.", + "The patient was discharged home." + ] + }, + { + "id": "multiclinsum_test_952_en.txt", + "fulltext": "The patient in this case was an 11-year-old male who fell while running and injured his left wrist(We have obtained the consent of the patients and their families regarding sharing information associated with the patient). An X-ray examination at the local hospital revealed a fracture of the distal radius and dislocation of the distal ulnar radial joint. The doctor at the hospital administered the patient 2 manipulations and plaster fixation. Two months later, the patient presented to our hospital due to local swelling and pain. An initial examination of the injury site found no signs of neurovascular damage, but there was pain at the left upper ulnar radial joint, dorsal ulnar bony projection of the left wrist with slight local swelling and significant tenderness. The left wrist joint had nearly unrestricted extension and flexion, but its rotational ability, particularly supination, was limited .\nWe performed an X-ray of the injured site and found that the distal left ulna was split and a new ulna was growing. With the consent of the patient’s family, we performed a CT examination of the area which clearly revealed the deformity was more clearly . The new ulna grew inwards, was slightly smaller than the original ulna and did not have a complete articular surface, while the normal original ulna protrudes dorsally and laterally with an intact articular surface and a “Y” shaped distal ulna. The patient exhibited normal wrist flexion and extension, but had limited rotation. Following a discussion, the patient’s parents declined surgical treatment. Consequently, we recommended functional exercise and regular follow-up to manage the condition. After a period of seven months, the patient returned to us as a result of experiencing pain. Examination showed that the showed that the pain in the left upper ulnar radius had almost disappeared and the rotation of the left wrist had improved, but there was still pain on extreme supination. The x-ray showed that the distal ulnar bifurcation was still visible, but the two bifurcated ulnae were close to each other and the base was decreased compared with that at 2 months after injury .\nThe patient presented to our hospital at 3 years and 7 years after the injury. At the last follow-up, the patient’s status was that of a university student, not yet in the workforce. The patient’s left wrist function recovered satisfactorily and did not interfere with his daily life or physical activity, including playing basketball, push-ups and lifting heavy objects. A physical examination revealed that the length of the forearms were equal, the left elbow joint was normal, the left wrist deformity was minimal, the left ulnar styloid process was not prominent, there was no obvious local tenderness, the left wrist extension and flexion and rotation range of activities were normal. However, there was mild pain around the ulnar styloid process on extreme posterior rotation of the left wrist. The X-ray showed that the distal ulna was shortened and bifurcated, but the ulnar bifurcation was atrophied and smaller than previously, the ulnar styloid process was deformed and enlarged, the inferior ulnar radial joint was dislocated, the distal ulna did not participate in the composition of the radial carpal joint, and there was no obvious deformity of the radius.\nWhen performing activities of daily living (ADLs), the normal functional range of wrist motion is 5 degrees of flexion, 30 degrees of extension, 10 degrees of radial deviation and 15 degrees of ulnar deviation [, ]. During the follow-up visits, we recorded the patient’s range of motion including wrist flexion and extension, ulnar and radial deviation of the wrist, and anterior/posterior rotation of the forearm . The wrist function was rated following the criteria proposed by Krimmer et al. .", + "fulltext_subclaims": [ + "The patient was an 11-year-old male.", + "The patient fell while running and injured his left wrist.", + "An X-ray examination at the local hospital revealed a fracture of the distal radius.", + "An X-ray examination at the local hospital revealed dislocation of the distal ulnar radial joint.", + "The doctor at the hospital administered the patient 2 manipulations.", + "The doctor at the hospital administered plaster fixation.", + "Two months later, the patient presented to our hospital due to local swelling and pain.", + "An initial examination of the injury site found no signs of neurovascular damage.", + "There was pain at the left upper ulnar radial joint.", + "There was dorsal ulnar bony projection of the left wrist.", + "There was slight local swelling.", + "There was significant tenderness.", + "The left wrist joint had nearly unrestricted extension and flexion.", + "The left wrist joint had limited rotational ability, particularly supination.", + "We performed an X-ray of the injured site.", + "The X-ray found that the distal left ulna was split.", + "The X-ray found that a new ulna was growing.", + "We performed a CT examination of the area.", + "The CT examination revealed the deformity was more clearly.", + "The new ulna grew inwards.", + "The new ulna was slightly smaller than the original ulna.", + "The new ulna did not have a complete articular surface.", + "The normal original ulna protrudes dorsally and laterally.", + "The normal original ulna has an intact articular surface.", + "The normal original ulna has a “Y” shaped distal ulna.", + "The patient exhibited normal wrist flexion and extension.", + "The patient had limited rotation.", + "The patient’s parents declined surgical treatment.", + "We recommended functional exercise.", + "We recommended regular follow-up.", + "After a period of seven months, the patient returned.", + "The pain in the left upper ulnar radius had almost disappeared.", + "The rotation of the left wrist had improved.", + "There was still pain on extreme supination.", + "The X-ray showed that the distal ulnar bifurcation was still visible.", + "The two bifurcated ulnae were close to each other.", + "The base was decreased compared with that at 2 months after injury.", + "The patient presented to our hospital at 3 years after the injury.", + "The patient presented to our hospital at 7 years after the injury.", + "At the last follow-up, the patient’s status was that of a university student.", + "The patient’s left wrist function recovered satisfactorily.", + "The left wrist function did not interfere with daily life.", + "The left wrist function did not interfere with physical activity.", + "The patient could play basketball.", + "The patient could perform push-ups.", + "The patient could lift heavy objects.", + "A physical examination revealed that the length of the forearms were equal.", + "The left elbow joint was normal.", + "The left wrist deformity was minimal.", + "The left ulnar styloid process was not prominent.", + "There was no obvious local tenderness.", + "The left wrist extension and flexion and rotation range of activities were normal.", + "There was mild pain around the ulnar styloid process on extreme posterior rotation of the left wrist.", + "The X-ray showed that the distal ulna was shortened and bifurcated.", + "The ulnar bifurcation was atrophied and smaller than previously.", + "The ulnar styloid process was deformed and enlarged.", + "The inferior ulnar radial joint was dislocated.", + "The distal ulna did not participate in the composition of the radial carpal joint.", + "There was no obvious deformity of the radius.", + "During follow-up visits, we recorded the patient’s range of motion including wrist flexion and extension.", + "During follow-up visits, we recorded the patient’s range of motion including ulnar and radial deviation of the wrist.", + "During follow-up visits, we recorded the patient’s range of motion including anterior/posterior rotation of the forearm.", + "The wrist function was rated following the criteria proposed by Krimmer et al." + ], + "summary": "In this case report, we describe an 11-year-old male child who presented with an ulnar bifida following trauma to the hand, and was treated with manipulation and conservative treatment without surgery. A follow-up performed over the years demonstrated that the patient recovered well, and had normal wrist movements without significant pain, and the patient expressed great satisfaction.", + "summary_subclaims": [ + "The patient is an 11-year-old male child.", + "The patient presented with an ulnar bifida following trauma to the hand.", + "The patient was treated with manipulation and conservative treatment without surgery.", + "A follow-up performed over the years demonstrated that the patient recovered well.", + "The patient had normal wrist movements without significant pain.", + "The patient expressed great satisfaction." + ] + }, + { + "id": "multiclinsum_test_907_en.txt", + "fulltext": "An 80-year-old man presented with a progressive decrease in hearing on the right side accompanied by dizziness and disturbance of balance 10 months prior to admission. The neurological examination revealed right hypoglossal nerve palsy. Audiometry documented complete sensorineural hearing loss on the right side.\nSkull x-ray and cranial computed tomography (CT) scans showed a large osteolytic lesion with bone destruction, including the temporal bone, occipital bone, clivus, jugular foramen, and hypoglossal canal . Magnetic resonance imaging (MRI) revealed an 8 × 7 cm homogeneous enhancing mass in the right posterior fossa related to the petrous part of the temporal bone, with extension to the cervical region . The cerebellum was displaced, and definite brain invasion was not seen. The preoperative diagnosis was a temporal bone origin malignancy such as squamous cell carcinoma or meningioma with invasion of the petrous bone.\nThe patient underwent surgery to obtain a pathological diagnosis and for complete removal of the mass. A C-shaped postauricular skin incision was made that extended to the neck. The scalp was reflected anteriorly, and the mass infiltrating the subcutaneous tissue was exposed. The lesion appeared as a firm gray mass that had destroyed the temporal and occipital bones. The dura was intact with no invasion, and the lesion was easily peeled off. For the cervical part of the tumor, the major vessels were secured inferiorly, and the mass was removed up to the skull base. The tumor was removed entirely, except for a small portion around the jugular foramen to avoid lower cranial nerve injury. Finally, the large empty space was filled with a sternocleidomastoid muscle flap . There were no neurological deficits after surgery.\nHistopathological studies confirmed a WHO (World Health Organization) grade II atypical meningioma with up to 6 mitoses per 10 high-power fields . The Ki-67 proliferation index was 15%. The results of immunohistochemical staining are provided in Additional file : Figure S1.", + "fulltext_subclaims": [ + "An 80-year-old man presented with a progressive decrease in hearing on the right side.", + "The decrease in hearing was accompanied by dizziness and disturbance of balance.", + "The symptoms began 10 months prior to admission.", + "The neurological examination revealed right hypoglossal nerve palsy.", + "Audiometry documented complete sensorineural hearing loss on the right side.", + "Skull x-ray showed a large osteolytic lesion with bone destruction.", + "Cranial CT scans showed bone destruction, including the temporal bone, occipital bone, clivus, jugular foramen, and hypoglossal canal.", + "MRI revealed an 8 × 7 cm homogeneous enhancing mass in the right posterior fossa.", + "The mass was related to the petrous part of the temporal bone.", + "The mass extended to the cervical region.", + "The cerebellum was displaced.", + "Definite brain invasion was not seen.", + "The preoperative diagnosis was a temporal bone origin malignancy such as squamous cell carcinoma or meningioma.", + "The patient underwent surgery to obtain a pathological diagnosis.", + "A C-shaped postauricular skin incision was made that extended to the neck.", + "The scalp was reflected anteriorly.", + "The mass infiltrating the subcutaneous tissue was exposed.", + "The lesion appeared as a firm gray mass that had destroyed the temporal and occipital bones.", + "The dura was intact with no invasion.", + "The lesion was easily peeled off.", + "For the cervical part of the tumor, the major vessels were secured inferiorly.", + "The mass was removed up to the skull base.", + "The tumor was removed entirely, except for a small portion around the jugular foramen.", + "The large empty space was filled with a sternocleidomastoid muscle flap.", + "There were no neurological deficits after surgery.", + "Histopathological studies confirmed a WHO grade II atypical meningioma.", + "The tumor showed up to 6 mitoses per 10 high-power fields.", + "The Ki-67 proliferation index was 15%." + ], + "summary": "An 80-year-old man presented with decreased hearing on the right side accompanied by a disturbance of balance 10 months prior to admission. Magnetic resonance imaging revealed an 8 × 7 cm osteolytic mass in the right posterior fossa related to the petrous bone, with extension to the cervical region. During surgery, the tumor was found to be located extradurally, with no invasion of the dura. The tumor was removed entirely, apart from a small portion around the jugular foramen to avoid lower cranial nerve injury.", + "summary_subclaims": [ + "An 80-year-old man presented with decreased hearing on the right side.", + "The decreased hearing was accompanied by a disturbance of balance.", + "The disturbance of balance had been present for 10 months prior to admission.", + "Magnetic resonance imaging revealed an 8 × 7 cm osteolytic mass in the right posterior fossa.", + "The mass was related to the petrous bone.", + "The mass extended to the cervical region.", + "During surgery, the tumor was found to be located extradurally.", + "The tumor was found to be located extradurally, with no invasion of the dura.", + "The tumor was removed entirely, apart from a small portion around the jugular foramen.", + "The small portion around the jugular foramen was not removed to avoid lower cranial nerve injury." + ] + }, + { + "id": "multiclinsum_test_2977_en.txt", + "fulltext": "Our patient was a 37-year-old, 48 kg Yoruba woman, who developed impaired visual function while on treatment for pulmonary tuberculosis. She was diagnosed as having pulmonary tuberculosis based on a history of chronic cough, weight loss, positive acid- and alcohol-fast bacilli sputum examinations and reticulonodular chest features of pulmonary tuberculosis evident on radiology .\nShe successfully completed a two-month intensive treatment course on a daily four-drug combination comprising ethambutol 825 mg, isoniazid 225 mg, rifampicin 450 mg, and pyrazinamide 1200 mg. Our patient's weight improved to 52 kg. This two-month course was followed by a continuous phase of treatment. This comprised a daily two-drug combination including ethambutol 825 mg and isoniazid 450 mg. The two-drug combination was, however, substituted with only rifampicin about 11 weeks into the continuous phase when our patient reported blurred vision at the chest clinic where she was being managed. There was total withdrawal of the antituberculosis drug about two weeks later on account of persistent impaired visual function. By then, our patient had been receiving antituberculosis therapy for a period of five months, including the two-month intensive and three-month continuous phases.\nShe presented to our eye clinic about nine days after her antituberculosis drugs had been discontinued on account of her progressive painless diminishing vision of approximately one month's duration. Our patient also complained of a tingling sensation in her lower limbs. There was no record of a visual assessment before and during her therapy, however, our patient stated she had had normal vision previously. She had no family history of significant blinding ocular conditions and did not wear glasses. Furthermore, our patient had no history suggestive of diabetes mellitus, hypertension, sickle cell disease or HIV and/or AIDS.\nA physical examination on presentation showed a wasted and concerned patient, however her vital signs were normal. Her visual acuity (VA) was 6/60 in her right eye and 1/60 in her left eye. She had red-green dyschromatopsia using Ishihara color plates and her pupils were sluggish in their response to light. Her optic discs were hyperemic. Her intraocular pressure was 14 mmHg in both eyes. She had central visual field (CVF) defects . Biochemical tests to assess kidney and liver function were essentially normal except for elevated alkaline phosphatase . A screening for HIV was not reactive.\nExcept for multivitamins (Dolo-Neurobion® taken orally daily) taken by our patient for three weeks, our patient was not on any other medication. She was counseled and reassured of a high chance of visual recovery over time. Our patient was monitored in our eye clinic at two-weekly intervals. At each visit, aside from our patient's briefings on visual function, her VA, color vision, pupillary activities and funduscopy were checked and documented. Her VA initially got worse, declining to 1/60 in both eyes two weeks after initial presentation, but later improved steadily following the discontinuation of the antituberculosis therapy. Our patient was last reviewed by our eye clinic nine months after her initial presentation, and her VA was recorded as unaided VA right eye 6/24-1, left eye 6/12+2 and aided (using correction with lenses; right eye -2.75DS, left eye -1.00DS) VA right eye 6/9-2, left eye 6/6-3. A repeat CVF test performed eight months after her initial CVF showed that the CVF defects had disappeared.", + "fulltext_subclaims": [ + "The patient was a 37-year-old, 48 kg Yoruba woman.", + "She developed impaired visual function while on treatment for pulmonary tuberculosis.", + "She was diagnosed as having pulmonary tuberculosis based on a history of chronic cough.", + "She had weight loss.", + "Acid- and alcohol-fast bacilli sputum examinations were positive.", + "Reticulonodular chest features of pulmonary tuberculosis were evident on radiology.", + "She successfully completed a two-month intensive treatment course on a daily four-drug combination comprising ethambutol 825 mg, isoniazid 225 mg, rifampicin 450 mg, and pyrazinamide 1200 mg.", + "Her weight improved to 52 kg.", + "This two-month course was followed by a continuous phase of treatment.", + "The continuous phase comprised a daily two-drug combination including ethambutol 825 mg and isoniazid 450 mg.", + "The two-drug combination was substituted with only rifampicin about 11 weeks into the continuous phase.", + "The substitution occurred when the patient reported blurred vision at the chest clinic.", + "There was total withdrawal of the antituberculosis drug about two weeks later.", + "The withdrawal occurred on account of persistent impaired visual function.", + "By then, the patient had been receiving antituberculosis therapy for a period of five months.", + "She presented to the eye clinic about nine days after her antituberculosis drugs had been discontinued.", + "She had progressive painless diminishing vision of approximately one month's duration.", + "She complained of a tingling sensation in her lower limbs.", + "There was no record of a visual assessment before and during her therapy.", + "The patient stated she had had normal vision previously.", + "She had no family history of significant blinding ocular conditions.", + "She did not wear glasses.", + "She had no history suggestive of diabetes mellitus.", + "She had no history suggestive of hypertension.", + "She had no history suggestive of sickle cell disease.", + "She had no history suggestive of HIV and/or AIDS.", + "A physical examination on presentation showed a wasted and concerned patient.", + "Her vital signs were normal.", + "Her visual acuity was 6/60 in her right eye and 1/60 in her left eye.", + "She had red-green dyschromatopsia using Ishihara color plates.", + "Her pupils were sluggish in their response to light.", + "Her optic discs were hyperemic.", + "Her intraocular pressure was 14 mmHg in both eyes.", + "She had central visual field defects.", + "Biochemical tests to assess kidney and liver function were essentially normal.", + "Alkaline phosphatase was elevated.", + "A screening for HIV was not reactive.", + "Except for multivitamins (Dolo-Neurobion® taken orally daily), the patient was not on any other medication.", + "The patient was counseled and reassured of a high chance of visual recovery over time.", + "The patient was monitored in the eye clinic at two-weekly intervals.", + "At each visit, her VA, color vision, pupillary activities, and funduscopy were checked and documented.", + "Her VA initially got worse, declining to 1/60 in both eyes two weeks after initial presentation.", + "Her VA later improved steadily following the discontinuation of the antituberculosis therapy.", + "The patient was last reviewed by the eye clinic nine months after her initial presentation.", + "Her unaided VA was right eye 6/24-1 and left eye 6/12+2.", + "Her aided VA was right eye 6/9-2 and left eye 6/6-3.", + "A repeat CVF test performed eight months after her initial CVF showed that the CVF defects had disappeared." + ], + "summary": "A 37-year-old Yoruba woman, weighing 48 kg, presented to our facility with impaired visual functions and mild sensory polyneuropathy in about the fourth month of antituberculosis treatment. Her therapy comprised ethambutol 825 mg, isoniazid 225 mg, rifampicin 450 mg, and pyrazinamide 1200 mg. Her visual acuity was 6/60 in her right eye and 1/60 in her left eye. She had sluggish pupils, red-green dyschromatopsia, hyperemic optic discs and central visual field defects. Her intraocular pressure was 14 mmHg. Her liver and kidney functions were essentially normal. Screening for human immunodeficiency virus was not reactive. Her impaired visual function improved following prompt diagnosis and attention, including the discontinuation of medication.", + "summary_subclaims": [ + "The patient is a 37-year-old Yoruba woman.", + "She weighs 48 kg.", + "She presented with impaired visual functions.", + "She had mild sensory polyneuropathy.", + "The polyneuropathy occurred in about the fourth month of antituberculosis treatment.", + "Her therapy comprised ethambutol 825 mg.", + "Her therapy comprised isoniazid 225 mg.", + "Her therapy comprised rifampicin 450 mg.", + "Her therapy comprised pyrazinamide 1200 mg.", + "Her visual acuity was 6/60 in her right eye.", + "Her visual acuity was 1/60 in her left eye.", + "She had red-green dyschromatopsia.", + "She had central visual field defects.", + "Her intraocular pressure was 14 mmHg.", + "Her liver and kidney functions were essentially normal.", + "Screening for human immunodeficiency virus was not reactive.", + "Her impaired visual function improved following prompt diagnosis and attention.", + "The improvement included the discontinuation of medication." + ] + }, + { + "id": "multiclinsum_test_3133_en.txt", + "fulltext": "54-year-old male who presented with acute coronary syndrome, requiring advanced airway management on arrival in the emergency department with tenecteplase 0.5 mg/kg given with an ischaemic time of 1 hour 40 minutes, without reperfusion.\n\nThe patient had two episodes of pulseless tachyarrhythmias that required three defibrillation events of 200 J, advanced cardiopulmonary resuscitation, and intravenous amiodarone 300 mg for return of spontaneous circulation. The total time of cardiac arrest was approximately 11 minutes. In the rescue coronary angiography, a medicated stent was placed in the anterior descending artery and an unmedicated stent in the first diagonal artery, final flow TIMI 3, Blush 3. The patient was admitted to the coronary care unit (CCU) with deep sedation, mechanical ventilation, cardiogenic shock, and a SOFA score of 7 points.\n\nThe patient was extubated 6 days after admission, but developed post-extubation delirium, stridor and iatrogenic pneumothorax, which required endotracheal tube placement and reintubation 48 hours later. During this period, he received drugs associated with myositis, such as haloperidol 5 mg intravenous in intermittent doses (accumulated 30 mg), olanzapine (accumulated 20 mg) and hydrocortisone (200 mg). After reintubation, the patient developed septic shock, so he was given supportive treatment and started with vancomycin and meropenem at full doses (with subsequent adjustment to renal function) for six days as treatment for nosocomial pneumonia. Atorvastatin was continued enterally at a dose of 80 mg every 24 hours and an elevation of the serum level of creatine phosphokinase (CPK) was detected that exceeded 10 times its upper normal limit two days after reintubation (10 days after admission to the CCU), reaching its maximum peak five days later (at which time atorvastatin was discontinued) and having a plateau for three more days. The total time of use of atorvastatin (80 mg every 24 hours) was 15 days.\n\nThe oliguric LRA KDIGO 3 reached its maximum level of azoates eight days after re-intubation.\n\nA catheter for haemodialysis was placed, two intermittent sessions were given and extubation was successful six days after the start of renal replacement therapy. A biopsy of the right deltoid muscle was performed at the peak of the elevation of muscle enzymes and, finally, the patient was discharged three days later to the general hospital room.\n", + "fulltext_subclaims": [ + "The patient was a 54-year-old male.", + "The patient presented with acute coronary syndrome.", + "Advanced airway management was required on arrival in the emergency department.", + "Tenecteplase 0.5 mg/kg was given.", + "The ischaemic time was 1 hour 40 minutes.", + "There was no reperfusion.", + "The patient had two episodes of pulseless tachyarrhythmias.", + "Three defibrillation events of 200 J were performed.", + "Advanced cardiopulmonary resuscitation was provided.", + "Intravenous amiodarone 300 mg was administered.", + "The total time of cardiac arrest was approximately 11 minutes.", + "A medicated stent was placed in the anterior descending artery.", + "An unmedicated stent was placed in the first diagonal artery.", + "Final flow TIMI 3 was achieved.", + "Blush 3 was observed.", + "The patient was admitted to the coronary care unit.", + "The patient had deep sedation.", + "The patient was on mechanical ventilation.", + "The patient had cardiogenic shock.", + "The patient's SOFA score was 7 points.", + "The patient was extubated 6 days after admission.", + "Post-extubation delirium was observed.", + "Stridor was observed.", + "Iatrogenic pneumothorax was observed.", + "Endotracheal tube placement was performed.", + "Reintubation occurred 48 hours after extubation.", + "The patient received haloperidol 5 mg intravenous in intermittent doses.", + "The accumulated dose of haloperidol was 30 mg.", + "The patient received olanzapine.", + "The accumulated dose of olanzapine was 20 mg.", + "The patient received hydrocortisone.", + "The accumulated dose of hydrocortisone was 200 mg.", + "The patient developed septic shock.", + "Vancomycin was started at full doses.", + "Meropenem was started at full doses.", + "Vancomycin and meropenem were given for six days.", + "Atorvastatin was continued enterally at a dose of 80 mg every 24 hours.", + "An elevation of the serum level of creatine phosphokinase (CPK) was detected.", + "The CPK level exceeded 10 times its upper normal limit two days after reintubation.", + "The CPK maximum peak was five days after reintubation.", + "Atorvastatin was discontinued at the peak of CPK.", + "The total time of use of atorvastatin was 15 days.", + "The oliguric LRA KDIGO 3 reached its maximum level of azoates eight days after re-intubation.", + "A catheter for haemodialysis was placed.", + "Two intermittent haemodialysis sessions were given.", + "Extubation was successful six days after the start of renal replacement therapy.", + "A biopsy of the right deltoid muscle was performed.", + "The patient was discharged to the general hospital room three days after the muscle biopsy." + ], + "summary": "54-year-old male with AMI, cardiogenic shock and cardiac arrest requiring cardiopulmonary resuscitation, fibrinolysis and successful coronary angiography. However, he developed severe rhabdomyolysis associated with atorvastatin that required drug discontinuation and multi-organ support in a coronary care unit.\n", + "summary_subclaims": [ + "The patient is a 54-year-old male.", + "The patient had an acute myocardial infarction.", + "The patient had cardiogenic shock.", + "The patient had cardiac arrest requiring cardiopulmonary resuscitation.", + "The patient received fibrinolysis.", + "The patient had a successful coronary angiography.", + "The patient developed severe rhabdomyolysis.", + "The rhabdomyolysis was associated with atorvastatin.", + "The atorvastatin was discontinued.", + "The patient required multi-organ support in a coronary care unit." + ] + }, + { + "id": "multiclinsum_test_525_en.txt", + "fulltext": "A 29-year-old female, gravida 3 para 2, was referred to our hospital at 13 weeks of gestation for suspected fetal abdominal wall anomaly. Ultrasound scanning revealed cauliflower-like intestinal loops floating freely in the amniotic fluid, suggesting gastroschisis. There was neither polyhydramnios nor bowel dilatation of the fetus. At 36 weeks’ gestation, a premature male baby weighing 1600 g was born by vaginal delivery with an Apgar score of 8 and 8 at 1 and 5 min, respectively. The baby was immediately referred to our neonatal intensive care unit due to evisceration of the stomach and small bowel through a paramedian full-thickness abdominal wall defect . As severe intestinal edema prohibited primary abdominal wall closure, the baby underwent a staged closure of the abdomen using a silo. Then, the Applied Alexis wound protector and retractor system (Applied Medical Resources Corp, USA) was used for wrapping and reducing the eviscerated bowel .\nOn the 10th postnatal day, the silo was removed and definitive fascial closure was completed by suturing after placing the eviscerated organs into the abdominal cavity.\nAfter abdominal closure, mechanical ventilation was ceased the following day, and enteral feeding was started on the 7th postoperative day. The pace of enteral feeding increase appeared slow, and the baby showed frequent vomiting with increases in feeding dosage. Upper gastrointestinal series performed on day 51 revealed a sliding hiatal hernia, accompanied by marked GER , and hiatal sliding hernia was also confirmed by computed tomography . The baby was managed by gradual increase in oral intake and postcibal positional therapy, and anti-acid drugs. On the 81st postnatal day, the baby was discharged, with a weight of 3040 g, and the ability to tolerate an oral diet.\nIn spite of continuous conservative management, he began to show frequent vomiting, a failure to thrive, and hematemesis at the age of 8 months. Esophageal pH monitoring of the distal esophagus revealed frequent GER. The percentage of total time with pH less than 4 was 58.2%. A laparoscopic fundoplication was done on the 290th postnatal day, when patient’s body weight was 6500 g.\nThe first trocar was inserted in the left upper abdomen using Hasson’s method. A laparoscopic view showed a moderate space in the upper abdominal cavity with dozens of fibrous bands connecting the stomach, bowels, liver, and abdominal wall to each other . No adhesion was seen beneath the umbilicus. The second trocar was inserted at the umbilicus, and 3 other ports were added in the usual manner by dissecting several adhesive bands. The herniated upper portion of the stomach and abdominal esophagus could be easily reduced back into the abdomen using forceps with no remarkable tension. After the dissection of the moderately thickened phrenoesophageal ligament, the right and left crus of the diaphragm were cleared. The large hiatal opening, about 3 cm in diameter , was closed around the esophagus with 3 interrupted 3–0 braided polyester sutures . Thereafter, a short and floppy 360° fundic wrap was constructed . The wrap on the stomach was hitched to the bilateral cupolas of the diaphragm. The operation time was 308 min including umbilical reconstruction, and there was little blood loss. The patient’s postoperative recovery was uneventful, and he was discharged without incident on postoperative day 7. Postoperatively, vomiting ceased and an upper gatrointestinal examination revealed no signs of GER. He is now 8 years old and has remained asymptomatic.", + "fulltext_subclaims": [ + "The patient was a 29-year-old female, gravida 3 para 2.", + "She was referred to the hospital at 13 weeks of gestation for suspected fetal abdominal wall anomaly.", + "Ultrasound scanning revealed cauliflower-like intestinal loops floating freely in the amniotic fluid.", + "The ultrasound findings suggested gastroschisis.", + "There was neither polyhydramnios nor bowel dilatation of the fetus.", + "A premature male baby weighing 1600 g was born at 36 weeks’ gestation.", + "The baby was born by vaginal delivery.", + "The Apgar score was 8 at 1 minute and 8 at 5 minutes.", + "The baby was immediately referred to the neonatal intensive care unit due to evisceration of the stomach and small bowel.", + "The evisceration was through a paramedian full-thickness abdominal wall defect.", + "Severe intestinal edema prohibited primary abdominal wall closure.", + "The baby underwent a staged closure of the abdomen using a silo.", + "The Applied Alexis wound protector and retractor system was used for wrapping and reducing the eviscerated bowel.", + "On the 10th postnatal day, the silo was removed.", + "Definitive fascial closure was completed by suturing after placing the eviscerated organs into the abdominal cavity.", + "Mechanical ventilation was ceased the day after abdominal closure.", + "Enteral feeding was started on the 7th postoperative day.", + "The pace of enteral feeding increase appeared slow.", + "The baby showed frequent vomiting with increases in feeding dosage.", + "An upper gastrointestinal series performed on day 51 revealed a sliding hiatal hernia.", + "The upper gastrointestinal series showed marked GER.", + "Hiatal sliding hernia was confirmed by computed tomography.", + "The baby was managed by gradual increase in oral intake.", + "Postcibal positional therapy was used.", + "Anti-acid drugs were used.", + "The baby was discharged on the 81st postnatal day.", + "The baby’s weight at discharge was 3040 g.", + "The baby was able to tolerate an oral diet at discharge.", + "At 8 months of age, the baby began to show frequent vomiting.", + "The baby showed failure to thrive at 8 months.", + "The baby had hematemesis at 8 months.", + "Esophageal pH monitoring of the distal esophagus revealed frequent GER.", + "The percentage of total time with pH less than 4 was 58.2%.", + "A laparoscopic fundoplication was done on the 290th postnatal day.", + "The patient’s body weight at the time of surgery was 6500 g.", + "The first trocar was inserted in the left upper abdomen using Hasson’s method.", + "A laparoscopic view showed a moderate space in the upper abdominal cavity.", + "Dozens of fibrous bands connected the stomach, bowels, liver, and abdominal wall.", + "No adhesion was seen beneath the umbilicus.", + "The second trocar was inserted at the umbilicus.", + "Three other ports were added in the usual manner by dissecting several adhesive bands.", + "The herniated upper portion of the stomach and abdominal esophagus could be easily reduced back into the abdomen.", + "The right and left crus of the diaphragm were cleared.", + "The large hiatal opening, about 3 cm in diameter, was closed around the esophagus with 3 interrupted 3–0 braided polyester sutures.", + "A short and floppy 360° fundic wrap was constructed.", + "The wrap on the stomach was hitched to the bilateral cupolas of the diaphragm.", + "The operation time was 308 min including umbilical reconstruction.", + "There was little blood loss.", + "The patient’s postoperative recovery was uneventful.", + "The patient was discharged without incident on postoperative day 7.", + "Postoperatively, vomiting ceased.", + "An upper gastrointestinal examination revealed no signs of GER.", + "The patient is now 8 years old.", + "The patient has remained asymptomatic." + ], + "summary": "A male infant who showed a severe gastroesophageal reflux due to hiatal hernia after staged abdominal fascial closure of gastroschisis. In spite of continuous conservative management, frequent vomiting and hematemesis had become progressively worse at the age of 8 months. Laparoscopic Nissen fundoplication was attempted and completed with no adverse events.", + "summary_subclaims": [ + "A male infant showed a severe gastroesophageal reflux due to hiatal hernia after staged abdominal fascial closure of gastroschisis.", + "In spite of continuous conservative management, frequent vomiting and hematemesis had become progressively worse at the age of 8 months.", + "Laparoscopic Nissen fundoplication was attempted.", + "Laparoscopic Nissen fundoplication was completed with no adverse events." + ] + }, + { + "id": "multiclinsum_test_854_en.txt", + "fulltext": "A 53-year-old female patient who had been suffering for ten years from atypical facial pain combined with a partial facial spasm was referred to our outpatient clinic.\nShe presented with continuous distorsions of the mimic musculature in the region of the lower left lip, which had appeared following severe osteomyelitis of the left side of the mandible that had been treated surgically. For several weeks following the operation the patient experienced hypesthesia in the left mandibular region and skin. Thereafter, constant, disturbing spasms of the mimic musculature occurred combined with dyskinesia and deep spasmodic pain attacks located in her lower left lip region. In addition, a distinct cutaneous erythema appeared in the region of the dyskinesia .\nThe patient reported that pain attacks occurred daily immediately after awakening in the morning, continued during the day without any improvement and subsided only at bedtime.\nThere had been no satisfactory response to various neurological or dental therapy attempts nor to acupuncture. Only therapy with carbamazepine had brought a slight and transient relief of her symptoms.\nThe patient felt herself immensely restricted by her symptoms and was socially and professionally disabled. She had had to retire because of the intolerable pain attacks, and reported having suicidal thoughts from time to time.\nDuring the following years she detected alleviation points in her left hand and behind the left ear with which she was able to stop the convulsions and the pain as long as pressure was applied to the points .\nThe patient had had no history of movement disorders such as hemifacial spasms nor of allergy, smoking or alcoholism. She had no history of medication except for carbamazepine.\nOn physical examination, no anatomic disorders, infections or tumors were found except for a discrete septum deviation. We observed continuous spasms in the region of her left lower lip, accompanied by an intense eczema in this region. She was able to stop the spasms and the pain by pressing the points on her hand or behind the ear.\nAfter the patient had given informed consent, BTX-A-treatment was begun. She was treated over a period of 67 weeks with seven different injections of BTX-A at different time points.\nThe dose of BTX-A was increased from initially 5 units to 25 units at the seventh treatment. We also augmented the number of injection points from 2 points to 10 points in the affected area. Injections were made with 2.5 units per site (Botox®, Allergan Inc, Irvine, California; 0.1 ml = 2.5 units BTX-A). The time between the treatment sessions varied from 3 weeks to 24 weeks up to the last treatment. For details see table .\nBTX-A was injected into the inferior depressor labii muscle in the left lower lip region. The seventh injection with 25 units injected into 10 points was the most effective with an effect lasting 24 weeks .\nThe patient was immediately pain-free after the injections and experienced other positive effects such as relief of spasms and eczema. The symptoms improved already after the first injection of botulinum toxin type A. At the check-up, three weeks after the first injection, the patient was free of symptoms and was very satisfied.\nAs agreed upon with the patient, she returned to our outpatient clinic for further treatment whenever any symptoms reappeared.\nThe BTX-A injection was repeated after 5 weeks with a total dose of 10 units at 4 injection points (4 injections à 2.5 units) because of mild spasms.\nAfter the second injection, the patient again experienced a reduction in pain, spasms and eczema for a period of 7 weeks, at which time we injected 15 units into 6 injection points.\nIn the further course, the patient returned four more times after 3, 11, 17 and 24 weeks for further injections with 20 to 25 units BTX-A into 8 to 10 injection sites. Fourteen weeks after the last series, she reported in a telephone interview that the excellent positive effects were long lasting and that she was not suffering from pain, spasms or eczema.\nThe patient was able to reduce the dose of carbamazepine considerably.\nIn the course of the treatment period, the duration of the symptom-free period increased from a minimum of 3 weeks to 24 weeks. The longest positive effect was seen after the injection of 25 units BTX-A into 10 injection points in the lower left lip region.\nThe patient did not note any side effects except for a slight leakage at the corner of her mouth lasting a few days, which she did not find very irritating as the positive benefits were much more important for her. A total follow-up period of 62 weeks was observed in this patient.\nIn summary, the patient expressed great satisfaction and stated: \"A completely new period in my life began\" after the first injection.", + "fulltext_subclaims": [ + "The patient was a 53-year-old female.", + "She had been suffering for ten years from atypical facial pain combined with a partial facial spasm.", + "She was referred to the outpatient clinic.", + "She had continuous distorsions of the mimic musculature in the region of the lower left lip.", + "The distorsions had appeared following severe osteomyelitis of the left side of the mandible.", + "The osteomyelitis had been treated surgically.", + "For several weeks following the operation, the patient experienced hypesthesia in the left mandibular region and skin.", + "Thereafter, constant, disturbing spasms of the mimic musculature occurred.", + "The spasms were combined with dyskinesia and deep spasmodic pain attacks located in her lower left lip region.", + "A distinct cutaneous erythema appeared in the region of the dyskinesia.", + "The patient reported that pain attacks occurred daily immediately after awakening in the morning.", + "The pain attacks continued during the day without any improvement.", + "The pain attacks subsided only at bedtime.", + "There had been no satisfactory response to various neurological or dental therapy attempts.", + "There had been no satisfactory response to acupuncture.", + "Only therapy with carbamazepine had brought a slight and transient relief of her symptoms.", + "The patient had had to retire because of the intolerable pain attacks.", + "She reported having suicidal thoughts from time to time.", + "During the following years, she detected alleviation points in her left hand and behind the left ear.", + "She was able to stop the convulsions and the pain as long as pressure was applied to the points.", + "The patient had no history of movement disorders such as hemifacial spasms.", + "She had no history of allergy, smoking or alcoholism.", + "She had no history of medication except for carbamazepine.", + "On physical examination, no anatomic disorders, infections or tumors were found except for a discrete septum deviation.", + "Continuous spasms in the region of her left lower lip were observed.", + "An intense eczema was observed in this region.", + "She was able to stop the spasms and the pain by pressing the points on her hand or behind the ear.", + "BTX-A-treatment was begun after the patient had given informed consent.", + "She was treated over a period of 67 weeks with seven different injections of BTX-A at different time points.", + "The dose of BTX-A was increased from initially 5 units to 25 units at the seventh treatment.", + "The number of injection points was increased from 2 points to 10 points in the affected area.", + "Injections were made with 2.5 units per site.", + "The time between the treatment sessions varied from 3 weeks to 24 weeks up to the last treatment.", + "BTX-A was injected into the inferior depressor labii muscle in the left lower lip region.", + "The seventh injection with 25 units injected into 10 points was the most effective with an effect lasting 24 weeks.", + "The patient was immediately pain-free after the injections.", + "She experienced other positive effects such as relief of spasms and eczema.", + "The symptoms improved already after the first injection of botulinum toxin type A.", + "At the check-up, three weeks after the first injection, the patient was free of symptoms.", + "She was very satisfied.", + "She returned to the outpatient clinic for further treatment whenever any symptoms reappeared.", + "The BTX-A injection was repeated after 5 weeks with a total dose of 10 units at 4 injection points.", + "After the second injection, the patient again experienced a reduction in pain, spasms and eczema for a period of 7 weeks.", + "At that time, we injected 15 units into 6 injection points.", + "In the further course, the patient returned four more times after 3, 11, 17 and 24 weeks for further injections.", + "The injections included 20 to 25 units BTX-A into 8 to 10 injection sites.", + "Fourteen weeks after the last series, she reported in a telephone interview that the excellent positive effects were long lasting.", + "She was not suffering from pain, spasms or eczema.", + "The patient was able to reduce the dose of carbamazepine considerably.", + "The duration of the symptom-free period increased from a minimum of 3 weeks to 24 weeks.", + "The longest positive effect was seen after the injection of 25 units BTX-A into 10 injection points in the lower left lip region.", + "The patient did not note any side effects except for a slight leakage at the corner of her mouth lasting a few days.", + "A total follow-up period of 62 weeks was observed in this patient.", + "The patient expressed great satisfaction.", + "She stated: 'A completely new period in my life began' after the first injection." + ], + "summary": "In this patient, persistent intense pain arose in the lower part of her face following a dental operation. The patient also exhibited dyskinesia of her caudal mimic musculature that was triggered by specific movements. Several attempts at therapy had been unsuccessful. We performed local injections of botulinum toxin type A (BTX-A) into the affected region of the patient's face. Pain relief was immediate following each set of botulinum toxin injections. The follow up time amounts 62 weeks.", + "summary_subclaims": [ + "Persistent intense pain arose in the lower part of her face following a dental operation.", + "The patient also exhibited dyskinesia of her caudal mimic musculature that was triggered by specific movements.", + "Several attempts at therapy had been unsuccessful.", + "We performed local injections of botulinum toxin type A (BTX-A) into the affected region of the patient's face.", + "Pain relief was immediate following each set of botulinum toxin injections.", + "The follow up time amounts 62 weeks." + ] + }, + { + "id": "multiclinsum_test_514_en.txt", + "fulltext": "The subject was a 26-year-old male Air Force pilot and a foreign state officer. The pilot had some individual flight experience, with a flight time of 120 h in the last 2 years on a L-39 Albatros, aircraft type designation. He reported no health problems before the training, nor in his medical history. He is a non-smoker and denies drug abuse. A clinical examination before the incident showed normal findings and the beginning of the practical training was normal. Problems arose the moment after the explosive decompression – the pressure inside the chamber was already stable. The pilot signaled to stop by waving his arm, than he crouched down in the seat, holding his head. Then, he produced a few grunts or cough-like sounds. He did not respond to questions about what had happened or what the problem was. After 7–8 s, an emergency descent was ordered to access the pilot. During the descent, the pilot started to respond normally. This emergency descent was likely the reason for the mild iatrogenic barotrauma of the middle ear. This issue was resolved in the next few days and is not connected to the purpose of this report.\nOnce on the ground, the pilot did not report any major symptoms at first. He said the main problem was sinus pain, that he did not feel any chest pain or have trouble with breathing. He described the coughing sounds as a verbalization of his pain and remembers us talking to him. In other words, he did not understand our concern in regards to lung trauma and did not seem anxious or worried. He also clearly stated that he did not hold his breath during the decompression. After finishing, he was eupneic, with normal hemodynamic parameters and a normal chest examination. After a few minutes, he developed retrosternal pain during deep inspiration and his tolerance of being in a horizontal position was reduced. These symptoms did not worsen, however, he was sent to our emergency department on suspicion of lung barotrauma.\nThe first chest X-ray and CT showed diffuse emphysema of the superficial and deep parts of the neck, continuing to the proximal section of the ventral chest wall . Diffuse pneumomediastinum signs are apparent paratracheal right, around right pulmonary artery, junction of left pulmonary veins and left atrium further are present signs in right cardiophrenic angle . A small bilateral pneumothorax was found apically and basally with pneumoperitoneum. The pneumoperitoneum was concluded to have been caused by passing gas through the hiatus in the diaphragm. There was no evidence of free fluid in the chest, no dislocations of mediastinal structures, no traumatic skeletal changes. A bronchoscopy was recommended for suspected airway injuries, but the patient refused. Conservative protocol without thoracic drainage was followed during his hospital stay. A two-day interval chest CT scan showed regression of the bilateral pneumothorax, regression of soft tissue emphysema, as well as pneumomediastinum regression. The patient stated he felt well and did not exhibit any additional symptoms, so he was discharged. After the discharge, follow-up examinations were recommended and a 2 month no-fly period was ordered. However, after 3 days, the patient left to his homeland and a contact at required medical level was lost. Pilot reported that he is doing well, without any problems and will be fit-to-fly soon.\nA report done by the technical staff ruled out technical malfunction. A breathing mask was used before and after the incident without problem. All of the equipment used had required official certifications. There were not any suggestions of problems with the used equipment.", + "fulltext_subclaims": [ + "The subject was a 26-year-old male Air Force pilot and a foreign state officer.", + "The pilot had some individual flight experience, with a flight time of 120 h in the last 2 years on a L-39 Albatros, aircraft type designation.", + "He reported no health problems before the training, nor in his medical history.", + "He is a non-smoker and denies drug abuse.", + "A clinical examination before the incident showed normal findings.", + "The beginning of the practical training was normal.", + "Problems arose the moment after the explosive decompression.", + "The pressure inside the chamber was already stable.", + "The pilot signaled to stop by waving his arm.", + "The pilot crouched down in the seat, holding his head.", + "The pilot produced a few grunts or cough-like sounds.", + "He did not respond to questions about what had happened or what the problem was.", + "After 7–8 s, an emergency descent was ordered to access the pilot.", + "During the descent, the pilot started to respond normally.", + "This emergency descent was likely the reason for the mild iatrogenic barotrauma of the middle ear.", + "This issue was resolved in the next few days.", + "This issue is not connected to the purpose of this report.", + "Once on the ground, the pilot did not report any major symptoms at first.", + "He said the main problem was sinus pain.", + "He did not feel any chest pain or have trouble with breathing.", + "He described the coughing sounds as a verbalization of his pain.", + "He remembers us talking to him.", + "He did not understand our concern in regards to lung trauma.", + "He did not seem anxious or worried.", + "He clearly stated that he did not hold his breath during the decompression.", + "After finishing, he was eupneic.", + "After finishing, he had normal hemodynamic parameters.", + "After finishing, he had a normal chest examination.", + "After a few minutes, he developed retrosternal pain during deep inspiration.", + "His tolerance of being in a horizontal position was reduced.", + "These symptoms did not worsen.", + "He was sent to our emergency department on suspicion of lung barotrauma.", + "The first chest X-ray and CT showed diffuse emphysema of the superficial and deep parts of the neck, continuing to the proximal section of the ventral chest wall.", + "Diffuse pneumomediastinum signs are apparent paratracheal right, around right pulmonary artery, junction of left pulmonary veins and left atrium further are present signs in right cardiophrenic angle.", + "A small bilateral pneumothorax was found apically and basally with pneumoperitoneum.", + "The pneumoperitoneum was concluded to have been caused by passing gas through the hiatus in the diaphragm.", + "There was no evidence of free fluid in the chest.", + "There were no dislocations of mediastinal structures.", + "There were no traumatic skeletal changes.", + "A bronchoscopy was recommended for suspected airway injuries.", + "The patient refused the bronchoscopy.", + "A conservative protocol without thoracic drainage was followed during his hospital stay.", + "A two-day interval chest CT scan showed regression of the bilateral pneumothorax.", + "A two-day interval chest CT scan showed regression of soft tissue emphysema.", + "A two-day interval chest CT scan showed pneumomediastinum regression.", + "The patient stated he felt well and did not exhibit any additional symptoms.", + "He was discharged.", + "After the discharge, follow-up examinations were recommended.", + "A 2 month no-fly period was ordered.", + "After 3 days, the patient left to his homeland.", + "A contact at required medical level was lost.", + "Pilot reported that he is doing well, without any problems.", + "Pilot reported that he will be fit-to-fly soon.", + "A report done by the technical staff ruled out technical malfunction.", + "A breathing mask was used before and after the incident without problem.", + "All of the equipment used had required official certifications.", + "There were not any suggestions of problems with the used equipment." + ], + "summary": "A 26-year-old active duty Air Force pilot was performing an explosive decompression simulation from 8000 ft. (2438.4 m) to 25,000 ft. (7620 m) in a 1.5 s interval. The training was interrupted due to the pilot's apparent health complications. After transfer to the emergency department, a CT scan showed bilateral lung barotrauma with emphysema.", + "summary_subclaims": [ + "The patient is a 26-year-old active duty Air Force pilot.", + "The pilot was performing an explosive decompression simulation.", + "The simulation involved a descent from 8000 ft. (2438.4 m) to 25,000 ft. (7620 m).", + "The simulation occurred in a 1.5 s interval.", + "The training was interrupted due to the pilot's apparent health complications.", + "After transfer to the emergency department, a CT scan showed bilateral lung barotrauma.", + "The CT scan showed emphysema." + ] + }, + { + "id": "multiclinsum_test_349_en.txt", + "fulltext": "A 61-year-old Chinese male presented with a progressive painful swelling in the right parotid gland for one month prior to attending our hospital. The patient had a history of heavy smoking, but did not complain of hemoptysis or other symptoms related to lung cancer. A clinical examination showed the size of the mass to be approximately 1 × 1 cm, with a good activity and a moderate texture. An ultrasound showed there to be a hypoechoic nodule with a size of 1.3× 1.3 × 0.9 cm. Therefore our initial diagnosis was that of a primary parotid tumor and we recommended surgical treatment. However, in preoperative routine examinations, a chest X-ray showed there to be a high density shadow in the right hilar. At this stage we highly suspected that the mass was metastases and required further examination. A lung computational tomography (CT) scan revealed a shadow in the right upper lobe, with a size of approximately 5.4 × 6.3 cm. The CT value was 40HU, and the enhanced CT value was 60HU, with multiple lymph nodes in the mediastinum appearing enlarged. After consulting with the patient, we performed an operation constituting of a partial parotidectomy and facial nerve dissection. Postoperative pathology reported a small-cell lung cancer metastases to parotid . Immunohistochemistry showed TTF(thyroid transcription factor)-1(+), Syn (Synaptophysin) (+), actin (-), S-100(-), P63 (-), EMA (epithelial membrane antigen) (-), ck(cytokeratin)20 (-). Therefore, we recommended that the patient receive postoperative radiation and chemotherapy.", + "fulltext_subclaims": [ + "The patient was a 61-year-old Chinese male.", + "He had a progressive painful swelling in the right parotid gland for one month.", + "The patient had a history of heavy smoking.", + "The patient did not complain of hemoptysis.", + "The mass was approximately 1 × 1 cm in size.", + "An ultrasound showed a hypoechoic nodule with a size of 1.3 × 1.3 × 0.9 cm.", + "The initial diagnosis was a primary parotid tumor.", + "A chest X-ray showed a high density shadow in the right hilar.", + "A lung CT scan revealed a shadow in the right upper lobe with a size of approximately 5.4 × 6.3 cm.", + "The CT value was 40HU.", + "The enhanced CT value was 60HU.", + "Multiple lymph nodes in the mediastinum appeared enlarged.", + "A partial parotidectomy and facial nerve dissection were performed.", + "Postoperative pathology reported small-cell lung cancer metastases to the parotid.", + "Immunohistochemistry showed TTF-1(+).", + "Immunohistochemistry showed Syn(+).", + "Immunohistochemistry showed actin(-).", + "Immunohistochemistry showed S-100(-).", + "Immunohistochemistry showed P63(-).", + "Immunohistochemistry showed EMA(-).", + "Immunohistochemistry showed CK20(-).", + "The patient was recommended to receive postoperative radiation and chemotherapy." + ], + "summary": "We report on the case of a 61-year-old Chinese male patient who presented with parotid swelling metastasizing from advanced lung cancer. We therefore performed an operation of partial parotidectomy with preservation of the facial nerve and advised the patient receive chemotherapy, however, the patient died four months later.", + "summary_subclaims": [ + "The patient was a 61-year-old Chinese male.", + "The patient had parotid swelling metastasizing from advanced lung cancer.", + "We performed an operation of partial parotidectomy.", + "We preserved the facial nerve during the operation.", + "We advised the patient receive chemotherapy.", + "The patient died four months later." + ] + }, + { + "id": "multiclinsum_test_1474_en.txt", + "fulltext": "The patient was 76-year-old male, right-handed, living by himself, and fully able to walk independently. His chief complaint was right shoulder pain, limited range of motion (ROM) in the right shoulder. He fell on his right shoulder while walking and injured it. He visited another hospital 3 days after the injury where he was diagnosed with dislocation of the right shoulder and received manual reduction followed by immobilization with a sling. Due to persistent pain and limited ROM of the right shoulder, plain magnetic resonance imaging (MRI)was performed and revealed a massive rotator cuff tear. He was then referred to our hospital 2 months after the injury. Physical findings on initial examination were markedly limited ROM and decreased abductor/external rotator muscle strength were observed, with an active flexion angle of 10°, active abduction angle of 10°, active external rotation angle of 0°, and manual muscle test (MMT) for abductor and lateral rotator (at a hanging position) muscle strength of 2 . Visually discernible atrophy of the deltoid, supraspinatus and infraspinatus muscles and hypoesthesia (5/10) in the axillary nerve region were also observed. At this point, the patient was given an American shoulder and elbow surgeons (ASES) scoring system of 10/100, University of California at Los Angeles (UCLA) shoulder scaling system of 4/35, and Japanese Orthopaedic Association (JOA) scoring system of 37/100. The plain X-ray findings were irregular glenohumeral joint surface and subacromial osteophytes, diagnosed as Grade 3 on the Hamada classification , were observed. The plain MRI findings were massive tear of the supraspinatus and infraspinatus muscles, which were withdrawn back to the glenoid fossa, diagnosed as Stage4 atrophy of supraspinatus muscle and Stage3 atrophy of infraspinatus muscle on the Goutallier classification was observed. The subscapular muscle was completely torn with bone fragment formation and diagnosed as Grade 3 on the ide classification . Electromyography was performed at the neurology department of our hospital to evaluate the degree of axillary nerve palsy. A motor nerve conduction study of the axillary nerve showed a marked decrease in compound muscle action potential in the deltoid muscle. An electromyogram showed a denervation potential suggestive of neurogenic changes in muscles innervated by the axillary nerve, leading to a diagnosis of axillary nerve palsy, leading to a diagnosis of neuropraxia in axillary nerve. However, muscle contraction was maintained in the axillary nerve region, suggesting the possibility of restoration. Therefore, a treatment plan was developed to conduct an outpatient rehabilitation program to improve the ROM and enhance the muscle strength of the shoulder until the palsy is improved, and then perform the surgical treatment. Hypoesthesia improved to 7—/10 with a reduced affected area. Furthermore, noted was an improved ROM, with active flexion, abduction, and external rotation angles of 20°, 20°, and 40°, respectively, and gradual improvement in muscle strength, with an abductor and external rotator (at a hanging position) muscle strength of 2 and 3 by MMT, respectively ( and ). Given these findings, ASCR was performed 6 months after injury.\nThe operation was started with the patient placed in a beach chair position under general anesthesia. Two portals were made in the posterior and lateral aspects of the shoulder, and the posterior portal was used to perform intra-articular locking. Arthroscopy revealed no injury in the tendon of the long head of the biceps brachii muscle, but its origin was detached along with the labrum. The rotator cuff was extensively torn, involving the tendons of the subscapular, supraspinatus, and infraspinatus muscles, with the stumps withdrawn back to the glenoid fossa. Osteoarthritic changes were observed in the joint surface but were mild in severity. Mild injury of the glenoid labrum was observed, but it was not associated with joint dislocation under anesthesia. The subscapular muscle tear was repaired as it was considered reparable. In contrast, the supra/infraspinatus muscle tear was considered irreparable; therefore, the contralateral fascia lata was collected, folded in half and used as a graft for ASCR. Although it was initially planned to repair the humeral head side of the graft using a bridging suture, it was difficult to place four anchors due to poor bone quality. Therefore, the graft was fixed using single-row interrupted sutures. Finally, to complete the operation, the graft was attached to the residual teres minor muscle by interrupted sutures . After surgery, the patient wore a shoulder abduction pillow for 3 weeks, followed by immobilization with a sling for 2 weeks. On the day after the operation, the patient started shoulder girdle relaxation, passive ROM, and periscapular muscle training. An ultrasonography performed 4 weeks after operation showed coverage of the torn portion by the graft. External fixation was removed 5 weeks after the operation, and active ROM training was started. Hypoesthesia in the axillary nerve region was almost completely resolvedat 3 months after operation, with no bilateral difference. Pain and deltoid muscle atrophy were resolved by 4.5 months after operation. During the first 2 years after operation, improvements were observed in both the ROM and muscle strength of the shoulder, with an ASES shoulder score of 96, UCLA shoulder rating scale of 34, and JOA score of 95. An MRI performed 2 years after operation also showed adequate coverage of the torn portion by the graft ( and ).", + "fulltext_subclaims": [ + "The patient was a 76-year-old male.", + "He was right-handed.", + "He lived by himself.", + "He was fully able to walk independently.", + "His chief complaint was right shoulder pain.", + "He had limited range of motion in the right shoulder.", + "He fell on his right shoulder while walking and injured it.", + "He visited another hospital 3 days after the injury.", + "He was diagnosed with dislocation of the right shoulder.", + "He received manual reduction.", + "He received immobilization with a sling.", + "Plain MRI revealed a massive rotator cuff tear.", + "He was referred to our hospital 2 months after the injury.", + "Physical findings on initial examination showed markedly limited ROM.", + "Physical findings showed decreased abductor/external rotator muscle strength.", + "Active flexion angle was 10°.", + "Active abduction angle was 10°.", + "Active external rotation angle was 0°.", + "MMT for abductor and lateral rotator muscle strength was 2.", + "Visually discernible atrophy of the deltoid, supraspinatus, and infraspinatus muscles was observed.", + "Hypoesthesia (5/10) in the axillary nerve region was observed.", + "The ASES scoring system was 10/100.", + "The UCLA shoulder scaling system was 4/35.", + "The JOA scoring system was 37/100.", + "Plain X-ray showed irregular glenohumeral joint surface.", + "Plain X-ray showed subacromial osteophytes.", + "The Hamada classification diagnosed the X-ray findings as Grade 3.", + "Plain MRI showed a massive tear of the supraspinatus and infraspinatus muscles.", + "The supraspinatus muscle tear was diagnosed as Stage4 atrophy on the Goutallier classification.", + "The infraspinatus muscle tear was diagnosed as Stage3 atrophy on the Goutallier classification.", + "The subscapular muscle was completely torn with bone fragment formation.", + "The subscapular muscle tear was diagnosed as Grade 3 on the Ide classification.", + "Electromyography was performed at the neurology department.", + "A motor nerve conduction study showed a marked decrease in compound muscle action potential in the deltoid muscle.", + "An electromyogram showed denervation potential suggestive of neurogenic changes.", + "The diagnosis was axillary nerve palsy.", + "The diagnosis was neuropraxia in the axillary nerve.", + "Muscle contraction was maintained in the axillary nerve region.", + "A treatment plan was developed to conduct an outpatient rehabilitation program.", + "The rehabilitation program aimed to improve ROM and enhance muscle strength.", + "Hypoesthesia improved to 7—/10.", + "Active flexion, abduction, and external rotation angles improved to 20°, 20°, and 40°, respectively.", + "Abductor and external rotator muscle strength improved to 2 and 3 by MMT.", + "ASCR was performed 6 months after injury.", + "The operation was started with the patient in a beach chair position under general anesthesia.", + "Two portals were made in the posterior and lateral aspects of the shoulder.", + "The posterior portal was used to perform intra-articular locking.", + "Arthroscopy revealed no injury in the tendon of the long head of the biceps brachii muscle.", + "The origin of the long head of the biceps brachii muscle was detached along with the labrum.", + "The rotator cuff was extensively torn, involving the subscapular, supraspinatus, and infraspinatus muscle tendons.", + "The stumps were withdrawn back to the glenoid fossa.", + "Osteoarthritic changes were observed in the joint surface.", + "The osteoarthritic changes were mild in severity.", + "Mild injury of the glenoid labrum was observed.", + "The glenoid labrum injury was not associated with joint dislocation under anesthesia.", + "The subscapular muscle tear was repaired.", + "The supraspinatus/infraspinatus muscle tear was considered irreparable.", + "The contralateral fascia lata was collected, folded in half, and used as a graft for ASCR.", + "It was initially planned to repair the humeral head side of the graft using a bridging suture.", + "It was difficult to place four anchors due to poor bone quality.", + "The graft was fixed using single-row interrupted sutures.", + "The graft was attached to the residual teres minor muscle by interrupted sutures.", + "After surgery, the patient wore a shoulder abduction pillow for 3 weeks.", + "After surgery, the patient wore a sling for 2 weeks.", + "On the day after the operation, the patient started shoulder girdle relaxation.", + "On the day after the operation, the patient started passive ROM.", + "On the day after the operation, the patient started periscapular muscle training.", + "Ultrasonography 4 weeks after operation showed coverage of the torn portion by the graft.", + "External fixation was removed 5 weeks after the operation.", + "Active ROM training was started after external fixation was removed.", + "Hypoesthesia in the axillary nerve region was almost completely resolved at 3 months after operation.", + "There was no bilateral difference in hypoesthesia at 3 months after operation.", + "Pain and deltoid muscle atrophy were resolved by 4.5 months after operation.", + "Improvements were observed in both ROM and muscle strength during the first 2 years after operation.", + "The ASES shoulder score was 96 at 2 years after operation.", + "The UCLA shoulder rating scale was 34 at 2 years after operation.", + "The JOA score was 95 at 2 years after operation.", + "An MRI performed 2 years after operation showed adequate coverage of the torn portion by the graft." + ], + "summary": "A 76-year-old man, injured from a fall while walking, presented to another hospital with right shoulder pain and a limited range of motion (ROM) 3 days after the injury. Given a diagnosis of right shoulder dislocation, he received manual reduction followed by immobilization with a sling. He continued to experience difficulty in performing active ROM exercises of the shoulder and underwent magnetic resonance imaging, which revealed an irreparable extensive rotator cuff tear involving the supraspinatus and infraspinatus muscles. He was then referred to our hospital 2 months after the injury. Examination revealed atrophy of the supraspinatus and infraspinatus muscles, atrophy of the deltoid muscle and hypoesthesia, likely due to axillary nerve palsy, and a marked limitation of active ROM with flexion, abduction and lateral rotation angles of 10°each. ASCR was considered for treating the irreparable rotator cuff tear. Since the technique is not indicated for patients with deltoid paralysis, the operation was delayed until signs of improved axillary nerve palsy were observed at 6 months after the injury. The patient started passive ROM training the day after the operation while wearing a shoulder abduction orthosis for 3 weeks, followed by immobilization with a sling for 2 weeks. Thereafter, he started active exercise. The axillary nerve palsy was almost completely resolved 3 months after the operation. He achieved a ROM comparable to that of the unaffected side at 1 year after operation. He has had an uneventful post-operative course for 2 years after operation.", + "summary_subclaims": [ + "The patient is a 76-year-old man.", + "He was injured from a fall while walking.", + "He presented to another hospital with right shoulder pain.", + "He had a limited range of motion 3 days after the injury.", + "He was diagnosed with right shoulder dislocation.", + "He received manual reduction.", + "He was immobilized with a sling.", + "He continued to experience difficulty in performing active ROM exercises.", + "Magnetic resonance imaging revealed an irreparable extensive rotator cuff tear.", + "The tear involved the supraspinatus and infraspinatus muscles.", + "He was referred to our hospital 2 months after the injury.", + "Examination revealed atrophy of the supraspinatus and infraspinatus muscles.", + "Examination revealed atrophy of the deltoid muscle.", + "Hypoesthesia was likely due to axillary nerve palsy.", + "Active ROM was markedly limited.", + "Flexion, abduction, and lateral rotation angles were 10° each.", + "ASCR was considered for treating the irreparable rotator cuff tear.", + "ASCR is not indicated for patients with deltoid paralysis.", + "The operation was delayed until signs of improved axillary nerve palsy were observed.", + "Signs of improved axillary nerve palsy were observed at 6 months after the injury.", + "The patient started passive ROM training the day after the operation.", + "He wore a shoulder abduction orthosis for 3 weeks.", + "He was immobilized with a sling for 2 weeks.", + "He started active exercise after the immobilization.", + "The axillary nerve palsy was almost completely resolved 3 months after the operation.", + "He achieved a ROM comparable to that of the unaffected side at 1 year after operation.", + "He has had an uneventful post-operative course for 2 years after operation." + ] + }, + { + "id": "multiclinsum_test_46_en.txt", + "fulltext": "A 58-year-old female presented with a one-week history of blurred vision associated with photophobia and redness. The episode started when she tapered her loteprednol from twice a day to once a day. The patient underwent DSAEK regrafting 1 year before her presentation. Her first DSAEK procedure had been performed 4 years prior for a decompensated cornea secondary to an iris-fixated anterior chamber lens. Her best corrected visual acuity in the right eye was 20/200, and the intraocular pressure was 9 mmHg. Slit-lamp examination showed a mildly injected conjunctiva with 1+ corneal oedema . On the posterior surface of the cornea, there was an endothelial rejection line (Khodadoust line) with KPs extending from 4 to 8 o’clock . Additionally, there were multiple areas of anterior synechia. The pupil was irregular and oval in shape, and the anterior chamber was deep with occasional cells. Examination of the left eye was unremarkable. The patient had a central corneal thickness of 659 μm (measured by anterior segment optical coherence tomography) on initial presentation . The diagnosis of graft rejection was made, and the patient was started on prednisolone acetate 1% drops every 1 h. After 1 month of follow-up, the patient’s vision improved from 20/200 to 20/60, and the corneal oedema also improved .", + "fulltext_subclaims": [ + "The patient is a 58-year-old female.", + "She had a one-week history of blurred vision.", + "The episode started when she tapered her loteprednol from twice a day to once a day.", + "The patient underwent DSAEK regrafting 1 year before her presentation.", + "Her first DSAEK procedure had been performed 4 years prior.", + "The first DSAEK was performed for a decompensated cornea secondary to an iris-fixated anterior chamber lens.", + "Her best corrected visual acuity in the right eye was 20/200.", + "The intraocular pressure was 9 mmHg.", + "Slit-lamp examination showed a mildly injected conjunctiva with 1+ corneal oedema.", + "There was an endothelial rejection line (Khodadoust line) with KPs extending from 4 to 8 o’clock.", + "There were multiple areas of anterior synechia.", + "The pupil was irregular and oval in shape.", + "The anterior chamber was deep with occasional cells.", + "Examination of the left eye was unremarkable.", + "The patient had a central corneal thickness of 659 μm on initial presentation.", + "The diagnosis of graft rejection was made.", + "The patient was started on prednisolone acetate 1% drops every 1 h.", + "After 1 month of follow-up, the patient’s vision improved from 20/200 to 20/60.", + "The corneal oedema also improved." + ], + "summary": "A 58-year-old female presented with graft rejection 1 year following a DSAEK procedure. The episode started when she tapered down her loteprednol to once a day. Slit-lamp examination showed a mildly injected conjunctiva with 1+ corneal oedema. On the posterior surface of the cornea, there was an endothelial rejection line (Khodadoust line) with keratic precipitates and multiple areas of anterior synechia.", + "summary_subclaims": [ + "The patient is a 58-year-old female.", + "She had graft rejection 1 year following a DSAEK procedure.", + "The episode started when she tapered down her loteprednol to once a day.", + "Slit-lamp examination showed a mildly injected conjunctiva.", + "There was 1+ corneal oedema.", + "On the posterior surface of the cornea, there was an endothelial rejection line (Khodadoust line).", + "There were keratic precipitates.", + "There were multiple areas of anterior synechia." + ] + }, + { + "id": "multiclinsum_test_2519_en.txt", + "fulltext": "A 7-d history of fever and cough.\nA ten-year old girl presented to our hospital with a fever and cough of 7 days’ duration. Her temperature peaked at 39.2 °C. She had been initially admitted to a local hospital, where she was diagnosed with community-acquired pneumonia and treated with intravenous antibiotics that did not resolve her fever and cough. Due to lingering symptoms, she sought further treatment at our hospital.\nHer medical history was unremarkable.\nThe patient had no relevant personal or family history.\nAt admission, the patient’s weight was 34.0 kg and her vital signs were as follows: Body temperature, 37.0 °C; blood pressure, 90/62 mmHg; heart rate, 130 beats/min; respiratory rate, 20 breaths/min; oxygen saturation, 98% in room air. At the time of admission, moderate and fine moist rales were heard in both lungs with no wheezing observed.\nInfection index white blood cell count, 17.52 × 109/L; platelet count, 256 × 109/L; erythrocyte sedimentation rate, 30 mm/h; C-reactive protein, 60.65 mg/L (0.00-5.00 mg/L) (December 16, 2021). Immune function was normal. Liver function: Alanine aminotransferase, 29 U/L (0-40 U/L); aspartate aminotransferase, 33U/L (0-40 U/L). A positive culture result for Streptococcus parasanguiniswas obtained, with no fungal growth detected.\nDuring her first stay at our hospital, the patient underwent electronic lung bronchoscopy, which detected endobronchial inflammation in the left upper lobe proper segment and left lower lobe basal segment . Results of CT retesting obtained 7 d later revealed growing, dense masses within lung tissues, as evidenced by darker shadows on the scan coinciding with the position of the outer basal segment of the lower lobe of the left lung that indicated the presence of multiple cystic translucent lesions. Moreover, various lesions of different sizes, multilocular thin-walled air-filled cavities, and patchy and highly dense shadows were observed that lacked clear boundaries and had approximate dimensions of 72 mm × 60 mm × 42 mm. The child was subsequently discharged with oral amoxicillin clavulanate potassium and advised to undergo an enhanced pulmonary CT scan 2 wk after discharge. The CT results revealed that the previously noted multiple cystic lesions within the lower left lung lobe and the dense mass within the basal segment outside that lobe remained unchanged in appearance. In contrast, the inflammatory lesions within the middle and lower lobes of the right lung were larger than before . Due to the fact that the pathological nature of the peripheral lung lesion could not be determined from these findings, the patient underwent a TBLB procedure to ensure that appropriate treatment would be administered to treat the disorder.\nThe entire procedure was conducted using the following steps. Prior to TBLB, inspiratory and expiratory CT images were uploaded to the Lungpro system (LungPoint VBN, version 3,4, Broncus Medical Inc, CA, United States), which was used to construct a virtual airway leading to the above-mentioned peripheral lesions. Next, picture archiving and communication system-based integration was conducted to build a virtual three-dimensional image of the patient’s lungs. Then, a bronchial centerline was used as a frame of reference to help the bronchoscope operator plan a path to the airway wall puncture point or focus point.\nAfter the patient was prepared for the procedure, she was administered local anesthesia and intravenous midazolam, a mild sedative. Endobronchial occlusion was then performed using a bronchoscope (BF-P260, Olympus Ltd.). The patient was placed in the supine position and was administered oxygen through a nasal catheter. Using a nasal point of entry, the optimal navigational path to pulmonary lesions was selected, and the reconstructed three-dimensional image was superimposed onto the image as viewed under the bronchoscope. During real-time navigation, the position of the bronchoscope and the distance from the pleura and the focus were displayed.\nFinally, Lungpro-guided TBLB was performed using a bronchoscope with a working channel diameter of 2.8 mm . Biopsy samples taken from the posterior basal segment of the left lower lobe were sent to the hospital pathology department for microscopic examination . The patient experienced no complications after the procedure.", + "fulltext_subclaims": [ + "The patient was a ten-year old girl.", + "She had a fever and cough of 7 days’ duration.", + "Her temperature peaked at 39.2 °C.", + "She had been initially admitted to a local hospital.", + "She was diagnosed with community-acquired pneumonia at the local hospital.", + "She was treated with intravenous antibiotics at the local hospital.", + "The intravenous antibiotics did not resolve her fever and cough.", + "She sought further treatment at our hospital.", + "Her medical history was unremarkable.", + "The patient had no relevant personal or family history.", + "At admission, the patient’s weight was 34.0 kg.", + "At admission, body temperature was 37.0 °C.", + "At admission, blood pressure was 90/62 mmHg.", + "At admission, heart rate was 130 beats/min.", + "At admission, oxygen saturation was 98% in room air.", + "Moderate and fine moist rales were heard in both lungs at admission.", + "Infection index white blood cell count was 17.52 × 109/L.", + "C-reactive protein was 60.65 mg/L.", + "A positive culture result for Streptococcus parasanguinis was obtained.", + "No fungal growth was detected.", + "During her first stay at our hospital, the patient underwent electronic lung bronchoscopy.", + "Electronic lung bronchoscopy detected endobronchial inflammation in the left upper lobe proper segment.", + "Electronic lung bronchoscopy detected endobronchial inflammation in the left lower lobe basal segment.", + "CT retesting 7 d later revealed growing, dense masses within lung tissues.", + "The CT scan showed multiple cystic translucent lesions in the lower left lung lobe.", + "The CT scan showed a dense mass within the basal segment outside the lower left lung lobe.", + "The child was discharged with oral amoxicillin clavulanate potassium.", + "The child was advised to undergo an enhanced pulmonary CT scan 2 wk after discharge.", + "The CT results showed the previously noted multiple cystic lesions within the lower left lung lobe remained unchanged.", + "The CT results showed the previously noted dense mass within the basal segment outside the lower left lung lobe remained unchanged.", + "The inflammatory lesions within the middle and lower lobes of the right lung were larger than before.", + "The pathological nature of the peripheral lung lesion could not be determined from these findings.", + "The patient underwent a TBLB procedure.", + "Prior to TBLB, inspiratory and expiratory CT images were uploaded to the Lungpro system.", + "A virtual airway was constructed using the Lungpro system.", + "Picture archiving and communication system-based integration was conducted to build a virtual three-dimensional image of the patient’s lungs.", + "A bronchial centerline was used as a frame of reference to plan a path to the airway wall puncture point.", + "The patient was administered local anesthesia and intravenous midazolam.", + "Endobronchial occlusion was performed using a bronchoscope.", + "The patient was placed in the supine position.", + "The patient was administered oxygen through a nasal catheter.", + "The optimal navigational path to pulmonary lesions was selected.", + "The reconstructed three-dimensional image was superimposed onto the bronchoscope image.", + "During real-time navigation, the position of the bronchoscope and the distance from the pleura and the focus were displayed.", + "Lungpro-guided TBLB was performed using a bronchoscope with a working channel diameter of 2.8 mm.", + "Biopsy samples were taken from the posterior basal segment of the left lower lobe.", + "The patient experienced no complications after the procedure." + ], + "summary": "A 10-year-old girl presented with constitutional symptoms of cough and fever of 7 days' duration. Chest CT scans detected peripheral lung lesions and no endobronchial lesions. TBLB performed under the guidance of an ENB Lungpro navigation system was safe, well-tolerated, and effective for biopsying peripheral lung lesions. Examination of biopsied samples indicated the patient had a pulmonary Streptococcus parasanguinis infection, which was treated with antibiotics instead of more invasive treatment interventions. The patient's symptoms resolved after she received a 3-wk course of oral linezolid. Comparisons of pre-treatment and post-treatment CT scans revealed absorption of some lung lesions within 7 mo of hospital discharge.", + "summary_subclaims": [ + "A 10-year-old girl presented with constitutional symptoms of cough and fever of 7 days' duration.", + "Chest CT scans detected peripheral lung lesions.", + "Chest CT scans detected no endobronchial lesions.", + "TBLB performed under the guidance of an ENB Lungpro navigation system was safe.", + "TBLB performed under the guidance of an ENB Lungpro navigation system was well-tolerated.", + "TBLB performed under the guidance of an ENB Lungpro navigation system was effective for biopsying peripheral lung lesions.", + "Examination of biopsied samples indicated the patient had a pulmonary Streptococcus parasanguinis infection.", + "The patient was treated with antibiotics instead of more invasive treatment interventions.", + "The patient received a 3-wk course of oral linezolid.", + "The patient's symptoms resolved after she received a 3-wk course of oral linezolid.", + "Comparisons of pre-treatment and post-treatment CT scans revealed absorption of some lung lesions.", + "Absorption of some lung lesions occurred within 7 mo of hospital discharge." + ] + }, + { + "id": "multiclinsum_test_1284_en.txt", + "fulltext": "A 21-year-old man was diagnosed with B-ALL 5 years ago (August 2015) and received chemotherapy consisting of one cycle of VCDLP (CTX, vindesine, daunorubicin, prednisone, PEG-aspargase) for induction ), and one cycle of MTX plus PEG-aspargase for consolidate . After these two cycles of therapy, minimal residue disease (MRD) was still positive. Therefore, he underwent a second-line therapy with MA (MTX and Arac) , and reached MRD-negative complete remission (CR). In March 2016, he received allo-HSCT (allogenic hematopoietic stem cell transplantation) from an HLA-matched unrelated donor, and all went well with no occurrence of CMV reactivation. Four months later, a disease relapse was suspected, and the patient was admitted to our hospital for further treatment, where he underwent bone marrow (BM) examination. Flow cytometry revealed 18.5% abnormal B lymphoblasts, and immunohistochemistry showed significant hyperplasia of abnormal lymphoblasts with CD34+ TdT+ CD79a+ CD10+ CD19+ CD22+ CD3- BCL2+ MPO- and Ki-67 Li 90%. Gene examination revealed a missense mutation in the NOTCH2 gene and a splice variant of the IKZF1 gene. No evidence of central nervous system (CNS) invasion or any other extramedullary diseases were identified. Serological tests were negative for HBV antigens/antibodies except for HBsAb, but they were not performed for CMV antibodies. No CMV DNA or HBV DNA was detected in the blood. The chest CT scan and hematobiochemical results were consistently normal. He was allergic to ofloxacin and had no history of exposure to HBV, HIV, tuberculosis, or any other infectious diseases. No other clinical history, familiar or psycho-social history of importance.\nGiven the relapse after HSCT, we treated the patient with the sequential infusion of anti-CD19 and anti-CD22 CAR-T cells (ChiCTR-OPN-16008526). It took two weeks to manufacture the patient’s own anti-CD19 and anti-CD22 CAR-T cells from collected peripheral blood mononuclear cells (PBMCs). The transfection rates of CD19 CAR and CD22 CAR were 35.6% and 40.9%, respectively . The patient was treated with 3-day conditioning chemotherapy consisting of fludarabine 25 mg/m2 and cyclophosphamide 20 mg/kg per day, and was sequentially transfused with CD19 CAR-T cells and CD22 CAR-T cells at doses of 1.5x106 cells/kg and 1x106 cells/kg, respectively. As shown in , CAR-T cells expanded well in vivo with CD19 and CD22 CAR copy numbers of 1,034,286 and 52,857.14 per µg genomic DNA, respectively, on day 6. Meanwhile, after the infusion of CAR-T cells, the patient developed grade 3 CRS manifested as high fever (max temperature of 41°C), hypotension (lowest at 88/42 mmHg, responsive to fluids therapy), hypoxia (requiring high-flow nasal cannula oxygen), coagulopathy (requiring fresh frozen plasma), pulmonary edema characterized by extensive rales among both lower lobes of the lung, and grade 3 immune effector cell-associated neurotoxicity syndrome (ICANS) with two-side blurred vision. Eye examinations found patchy bleeding around the infratemporal branch of the central retinal vein and scattered exudation in the other parts of the right retina (suspected to be associated with coagulopathy and severe thrombocytopenia), and mild retinal edema (no hemorrhage was observed) in the left eye. Laboratory testing revealed markedly increased levels of IL-6 and ferritin after CAR-T cell infusion, as shown in , with peak values of 1,260 pg/mL and 30,014 µg/L on day 6 and day 8, respectively. The serum levels of aspartate aminotransferase (AST), alanine aminotransferase (ALT), N-terminal B-type natriuretic peptide (NT-proBNP), and hypersensitive troponin were also abnormally elevated. After one session of plasma exchanges [to selectively eliminate inflammatory cytokines ], two 40-mg doses of methylprednisolone, and other supportive treatments, the inflammatory cytokine storm was gradually controlled, with both the levels of IL-6 and ferritin falling to baseline levels 2 weeks after the infusion as well as the levels of AST, ALT, NT-proBNP, and hypersensitive troponin. The blurred vision disappeared spontaneously two days later. In addition, the patient experienced severe myelosuppression but recovered two weeks later, as depicted in . The patient received prophylactic anti-infective treatment (excluding antiviral therapy) after CAR-T cell infusion, and no severe infection was observed during treatment. BM aspiration was performed on day 14, indicative of complete remission by flow cytometry.\nOn December 3, three months after CAR-T cell treatment, the patient was hospitalized with a 10-day history of low fever (37-38 °C) and cough, and a 3-day history of palpitations, chest tightness and dyspnea. The primary disease was well controlled, and B cells were still absent . The findings on chest X-ray suggested pulmonary infection and interstitial infiltration . CMV DNA, rather than bacterial DNA or fungal DNA, was detected in the peripheral blood by next-generation sequencing (NGS) sequencing. Given the patient’s previous medical history, clinical manifestations, and laboratory and radiographic evidence, he was diagnosed with suspectable CMV pneumonia (fiberoptic bronchoscopy was contraindicated as the patient was oxygen dependent, and therefore, no pneumonia tissue was available to confirm CMV infection). On December 4, the patient received antiviral (ganciclovir 5mg/kg q12h) therapy, as well as preventive anti-bacteria (tigecycline 50mg q12h, and sequential use of cefoperazone/sulbactam 3g q8h, meropenem 0.5g q6h and imipenem/cilastatin 1g q8h) and anti-fungi (sequential use of voriconazole 0.2g q12h and caspofungin 50mg qd) therapy (all intravenously). However, the symptoms worsened rather than alleviated, with the occurrence of diarrhea (yellow watery stool) and an SpO2 of 90% despite using oxygen mask on December 7. Therefore, we introduced intravenous gamma globulin 20 g/day, methylprednisolone 40 mg/day and bilevel positive airway pressure (BiPAP) ventilation on December 8, after which his pulmonary symptoms gradually improved. Ganciclovir was changed to penciclovir (5mg/kg q12h, intravenous drip) due to the side effects of limb numbness, chills and pain at the infusion site. During treatment with these two antiviral drugs, the patient’s WBC count and platelet count decreased progressively . We stopped penciclovir on December 18 when the clinical symptoms had improved. Meanwhile, CMV DNA was negative in the blood, and a chest X-ray showed reduced inflammatory filtration. However, the side effects of myelosuppression aggravated, and three days after treatment discontinuation with penciclovir, the patient again reported chest tightness and shortness of breath. We reintroduced penciclovir on December 21, but the patient’s symptoms gradually worsened. He died on December 25 from respiratory failure. The key events in this case are summarized in .", + "fulltext_subclaims": [ + "The patient was a 21-year-old man.", + "He was diagnosed with B-ALL 5 years ago.", + "The diagnosis was in August 2015.", + "He received chemotherapy consisting of one cycle of VCDLP.", + "VCDLP included CTX, vindesine, daunorubicin, prednisone, and PEG-aspargase.", + "He received one cycle of MTX plus PEG-aspargase for consolidation.", + "After these two cycles of therapy, MRD was still positive.", + "He underwent second-line therapy with MA (MTX and Arac).", + "He reached MRD-negative complete remission.", + "In March 2016, he received allo-HSCT from an HLA-matched unrelated donor.", + "There was no occurrence of CMV reactivation.", + "Four months after allo-HSCT, a disease relapse was suspected.", + "He was admitted to the hospital for further treatment.", + "Bone marrow examination was performed.", + "Flow cytometry revealed 18.5% abnormal B lymphoblasts.", + "Immunohistochemistry showed significant hyperplasia of abnormal lymphoblasts.", + "The lymphoblasts were CD34+ TdT+ CD79a+ CD10+ CD19+ CD22+ CD3- BCL2+ MPO-.", + "Ki-67 labeling index was 90%.", + "A missense mutation in the NOTCH2 gene was detected.", + "A splice variant of the IKZF1 gene was detected.", + "No evidence of CNS invasion was identified.", + "No evidence of extramedullary disease was identified.", + "Serological tests were negative for HBV antigens/antibodies except for HBsAb.", + "No CMV DNA was detected in the blood.", + "No HBV DNA was detected in the blood.", + "Chest CT scan results were normal.", + "Hematobiochemical results were normal.", + "He was allergic to ofloxacin.", + "He had no history of exposure to HBV.", + "He had no history of exposure to HIV.", + "He had no history of exposure to tuberculosis.", + "He had no history of other infectious diseases.", + "He received sequential infusion of anti-CD19 and anti-CD22 CAR-T cells.", + "The CAR-T cell trial was registered as ChiCTR-OPN-16008526.", + "It took two weeks to manufacture the patient’s own CAR-T cells.", + "The transfection rate of CD19 CAR was 35.6%.", + "The transfection rate of CD22 CAR was 40.9%.", + "The patient received 3-day conditioning chemotherapy.", + "The conditioning chemotherapy included fludarabine 25 mg/m2.", + "The conditioning chemotherapy included cyclophosphamide 20 mg/kg per day.", + "He was transfused with CD19 CAR-T cells at a dose of 1.5x106 cells/kg.", + "He was transfused with CD22 CAR-T cells at a dose of 1x106 cells/kg.", + "CAR-T cells expanded well in vivo.", + "CD19 CAR copy number was 1,034,286 per µg genomic DNA on day 6.", + "CD22 CAR copy number was 52,857.14 per µg genomic DNA on day 6.", + "The patient developed grade 3 CRS.", + "CRS was manifested as high fever with a maximum temperature of 41°C.", + "CRS was manifested as hypotension with the lowest at 88/42 mmHg.", + "CRS was manifested as hypoxia requiring high-flow nasal cannula oxygen.", + "CRS was manifested as coagulopathy requiring fresh frozen plasma.", + "CRS was manifested as pulmonary edema with extensive rales.", + "CRS was manifested as grade 3 ICANS with two-side blurred vision.", + "Eye examinations found patchy bleeding around the infratemporal branch of the central retinal vein.", + "Eye examinations found scattered exudation in the right retina.", + "Eye examinations found mild retinal edema in the left eye.", + "IL-6 levels were markedly increased after CAR-T cell infusion.", + "Ferritin levels were markedly increased after CAR-T cell infusion.", + "The peak IL-6 level was 1,260 pg/mL on day 6.", + "The peak ferritin level was 30,014 µg/L on day 8.", + "AST levels were abnormally elevated.", + "ALT levels were abnormally elevated.", + "NT-proBNP levels were abnormally elevated.", + "Hypersensitive troponin levels were abnormally elevated.", + "The patient received one session of plasma exchanges.", + "The patient received two 40-mg doses of methylprednisolone.", + "The inflammatory cytokine storm was gradually controlled.", + "IL-6 levels fell to baseline 2 weeks after infusion.", + "Ferritin levels fell to baseline 2 weeks after infusion.", + "AST levels fell to baseline 2 weeks after infusion.", + "ALT levels fell to baseline 2 weeks after infusion.", + "NT-proBNP levels fell to baseline 2 weeks after infusion.", + "Hypersensitive troponin levels fell to baseline 2 weeks after infusion.", + "Blurred vision disappeared spontaneously two days after infusion.", + "The patient experienced severe myelosuppression.", + "The patient recovered from myelosuppression two weeks later.", + "The patient received prophylactic anti-infective treatment.", + "No severe infection was observed during treatment.", + "BM aspiration on day 14 indicated complete remission.", + "Three months after CAR-T cell treatment, the patient was hospitalized.", + "He had a 10-day history of low fever.", + "He had a 10-day history of cough.", + "He had a 3-day history of palpitations.", + "He had a 3-day history of chest tightness.", + "He had a 3-day history of dyspnea.", + "Chest X-ray findings suggested pulmonary infection.", + "Chest X-ray findings suggested interstitial infiltration.", + "CMV DNA was detected in the peripheral blood by NGS sequencing.", + "Bacterial DNA was not detected in the peripheral blood.", + "Fungal DNA was not detected in the peripheral blood.", + "The patient was diagnosed with suspectable CMV pneumonia.", + "Fiberoptic bronchoscopy was contraindicated.", + "The patient received ganciclovir 5mg/kg q12h.", + "The patient received tigecycline 50mg q12h.", + "The patient received cefoperazone/sulbactam 3g q8h.", + "The patient received meropenem 0.5g q6h.", + "The patient received imipenem/cilastatin 1g q8h.", + "The patient received voriconazole 0.2g q12h.", + "The patient received caspofungin 50mg qd.", + "The patient's symptoms worsened.", + "The patient experienced diarrhea.", + "The patient's SpO2 was 90% despite using an oxygen mask.", + "The patient received intravenous gamma globulin 20 g/day.", + "The patient received methylprednisolone 40 mg/day.", + "The patient received BiPAP ventilation.", + "Ganciclovir was changed to penciclovir.", + "Penciclovir was 5mg/kg q12h.", + "The patient’s WBC count decreased progressively.", + "The patient’s platelet count decreased progressively.", + "Penciclovir was stopped on December 18.", + "CMV DNA was negative in the blood.", + "Chest X-ray showed reduced inflammatory filtration.", + "The patient again reported chest tightness.", + "The patient again reported shortness of breath.", + "Penciclovir was reintroduced on December 21.", + "The patient’s symptoms gradually worsened.", + "The patient died on December 25 from respiratory failure." + ], + "summary": "A 21-year old male patient with relapsed B-ALL received anti-CD19/22 CAR-T cell therapy, and achieved complete remission 2 weeks after the infusion. However, three months later, the patient was hospitalized again with a 10-day history of fever and cough and a 3-day history of palpitations and chest tightness. He was diagnosed with possible CMV pneumonia. Under treatment with antiviral medicine (ganciclovir/penciclovir), intravenous gamma globulin and methylprednisolone and the use of BiPAP ventilator, his symptoms improved, but after removing penciclovir his symptoms went out of control, and the patient died of respiratory failure 22 days after admission.", + "summary_subclaims": [ + "The patient was a 21-year-old male.", + "The patient had relapsed B-ALL.", + "The patient received anti-CD19/22 CAR-T cell therapy.", + "The patient achieved complete remission 2 weeks after the infusion.", + "Three months later, the patient was hospitalized.", + "The patient had a 10-day history of fever and cough.", + "The patient had a 3-day history of palpitations and chest tightness.", + "The patient was diagnosed with possible CMV pneumonia.", + "The patient received treatment with antiviral medicine (ganciclovir/penciclovir).", + "The patient received intravenous gamma globulin.", + "The patient received methylprednisolone.", + "The patient used a BiPAP ventilator.", + "The patient's symptoms improved.", + "After removing penciclovir, the patient's symptoms went out of control.", + "The patient died of respiratory failure.", + "The patient died 22 days after admission." + ] + }, + { + "id": "multiclinsum_test_1258_en.txt", + "fulltext": "A 4-year-old female was hospitalized in the Republican Center of Pediatric Surgery (Minsk, Belarus) in 2017 with the signs of chronic GI bleeding, iron deficiency anemia, episodes of melena, and a rapid deterioration in her general condition.\nDuring the first year of observation in our clinic, the child underwent seven procedures of blood transfusions due to low hemoglobin levels before the first sclerotherapy was performed.\nThe patient’s birth (per via naturalis) had resulted from the mother’s first pregnancy, which was also full-term. Her birth weight was 3760 g and length was 51 cm. The patient’s mother noticed a roundish dark blue, soft-elastic formation on the skin of the child’s thigh at 8 d after the birth. A few months later, new formations appeared on the skin of the child’s head (at the border of the forehead and parietal ridge) and lumbar, perianal and plantar areas.\nAnamnesis vitae yielded report of venous malformations involving the gluteo-femoral region, which had been partly excised at the age of 3 mo. Several complaints of melena were also disclosed. In addition, the parents reported that, at the age of 2 years, the child had developed periodic lethargy, drowsiness, and pallor of the skin; clinical assessment at that time yielded the first detection of a significant decrease in hemoglobin levels. Thus, iron supplements were prescribed. Several other episodes of a critical decrease in hemoglobin reportedly occurred over the next few years, all of which required a blood transfusion.\nThe patient has no family history of BRBNS.\nThe patient’s skin showed an overall paleness and several vascular skin lesions were found in the lumbar region, the inner part of the left thigh, the lower leg, the forearm , and on the sole of the right foot. The formations were of various sizes but all had a soft, elastic-like consistency and showed a cyanotic coloration.\nThe patient’s blood parameters were low, with hemoglobin of 95 g/L (normal range: 110-140 g/L), mean corpuscular hemoglobin concentration of 32.8 (normal range: 31.9-35.6 g/dL), erythrocytes of 4.4 × 1012/L (normal range: 3.9-5.3 × 1012/L), and hematocrit of 29% (normal range: 34%-40%).\nUltrasound showed vascular malformations in the left lobe of the liver, pancreas, bladder, and left ovary. Magnetic resonance imaging of the soft tissues of the lower extremities showed vascular malformations in the upper third of the left thigh. Although gastroscopy and colonoscopy were unsuccessful in detecting the source of GI bleeding, capsule enteroscopy revealed multiple (-10) vascular formations in the wall of the small intestine . All formations appeared round in shape and bluish-purple in color; the largest reached 2 cm in diameter.", + "fulltext_subclaims": [ + "A 4-year-old female was hospitalized in the Republican Center of Pediatric Surgery (Minsk, Belarus) in 2017.", + "The child had signs of chronic GI bleeding.", + "The child had iron deficiency anemia.", + "The child had episodes of melena.", + "The child had a rapid deterioration in her general condition.", + "During the first year of observation in our clinic, the child underwent seven procedures of blood transfusions.", + "The blood transfusions were due to low hemoglobin levels before the first sclerotherapy was performed.", + "The patient was born via natural delivery.", + "The patient’s birth was the mother’s first pregnancy.", + "The patient’s birth was full-term.", + "The patient’s birth weight was 3760 g.", + "The patient’s birth length was 51 cm.", + "The patient’s mother noticed a roundish dark blue, soft-elastic formation on the skin of the child’s thigh at 8 d after the birth.", + "New formations appeared on the skin of the child’s head at the border of the forehead and parietal ridge.", + "New formations appeared on the skin of the child’s lumbar, perianal, and plantar areas.", + "Anamnesis vitae yielded report of venous malformations involving the gluteo-femoral region.", + "The venous malformations had been partly excised at the age of 3 mo.", + "The parents reported several complaints of melena.", + "At the age of 2 years, the child had developed periodic lethargy.", + "At the age of 2 years, the child had developed drowsiness.", + "At the age of 2 years, the child had developed pallor of the skin.", + "Clinical assessment at that time yielded the first detection of a significant decrease in hemoglobin levels.", + "Iron supplements were prescribed.", + "Several other episodes of a critical decrease in hemoglobin reportedly occurred over the next few years.", + "All episodes of critical decrease in hemoglobin required a blood transfusion.", + "The patient has no family history of BRBNS.", + "The patient’s skin showed an overall paleness.", + "Several vascular skin lesions were found in the lumbar region.", + "Several vascular skin lesions were found in the inner part of the left thigh.", + "Several vascular skin lesions were found on the lower leg.", + "Several vascular skin lesions were found on the forearm.", + "Several vascular skin lesions were found on the sole of the right foot.", + "The formations were of various sizes.", + "The formations had a soft, elastic-like consistency.", + "The formations showed a cyanotic coloration.", + "The patient’s hemoglobin was 95 g/L.", + "The patient’s mean corpuscular hemoglobin concentration was 32.8.", + "The patient’s erythrocytes were 4.4 × 1012/L.", + "The patient’s hematocrit was 29%.", + "Ultrasound showed vascular malformations in the left lobe of the liver.", + "Ultrasound showed vascular malformations in the pancreas.", + "Ultrasound showed vascular malformations in the bladder.", + "Ultrasound showed vascular malformations in the left ovary.", + "Magnetic resonance imaging of the soft tissues of the lower extremities showed vascular malformations in the upper third of the left thigh.", + "Gastroscopy and colonoscopy were unsuccessful in detecting the source of GI bleeding.", + "Capsule enteroscopy revealed multiple (-10) vascular formations in the wall of the small intestine.", + "All vascular formations in the small intestine appeared round in shape.", + "All vascular formations in the small intestine were bluish-purple in color.", + "The largest vascular formation in the small intestine reached 2 cm in diameter." + ], + "summary": "We present here a case of BRBNS involving a 4-year-old female, whose intestinal venous lesions were successfully treated by endoscopic sclerotherapy and aethoxysklerol foam. Skin lesions, typical for BRBNS, appeared on the 8th d of the child's life and their number increased over the next several months. The child also experienced episodes of critical decrease in hemoglobin level (by as much as 52 g/L) for several years, requiring iron supplementation and several blood transfusions. Video capsule endoscopy revealed numerous vascular formations in the small bowel. The combined findings of gastrointestinal venous formations and skin lesions prompted BRBNS diagnosis. Single-balloon enteroscopy was used to perform sclerotherapy, with aethoxysklerol foam. A positive effect was observed within 19 mo of follow-up. We continue to monitor the patient's hemoglobin level, every 2 wk, and it has remained satisfactory (> 120 g/L).", + "summary_subclaims": [ + "The patient is a 4-year-old female.", + "The patient had intestinal venous lesions.", + "The intestinal venous lesions were successfully treated by endoscopic sclerotherapy and aethoxysklerol foam.", + "Skin lesions, typical for BRBNS, appeared on the 8th d of the child's life.", + "The number of skin lesions increased over the next several months.", + "The child experienced episodes of critical decrease in hemoglobin level.", + "The decrease in hemoglobin level was by as much as 52 g/L.", + "The episodes of critical decrease in hemoglobin level occurred for several years.", + "The child required iron supplementation.", + "The child received several blood transfusions.", + "Video capsule endoscopy revealed numerous vascular formations in the small bowel.", + "The combined findings of gastrointestinal venous formations and skin lesions prompted BRBNS diagnosis.", + "Single-balloon enteroscopy was used to perform sclerotherapy.", + "Aethoxysklerol foam was used during the sclerotherapy.", + "A positive effect was observed within 19 mo of follow-up.", + "The patient's hemoglobin level is monitored every 2 wk.", + "The patient's hemoglobin level has remained satisfactory (> 120 g/L)." + ] + }, + { + "id": "multiclinsum_test_969_en.txt", + "fulltext": "A 35-year-old female was diagnosed with type I DM at the age of 9 years. During childhood her DM was poorly controlled and the patient gained significant weight. At the age of 25 years her weight was 105 kg with a body mass index (BMI) of 40 kg/m2 and her renal function started to deteriorate with progression to requiring hemodialysis by age 30. With development of renal failure, secondary hyperparathyroidism was noted. Due to her obesity, she was not eligible for a renal transplant or a SPK. At this point it was decided to offer her bariatric surgery, and, after extensive discussion, it was felt that a RYGBP was the best option for her in terms of weight loss. At the age of 32 years, she underwent uneventful robotic-assisted surgery; the stomach remnant was attached to the abdominal wall for potential future access.\nOver the next 2 years she lost 60 kg and underwent SPK during which the donor duodenal segment was diverted to a bowel loop distal to her Roux loop implant site into the common channel. Induction immunosuppression with alemtuzumab was followed by maintenance with tacrolimus (trough levels 5-7 ng/mL), mycophenolate-mofetil (2 g daily), and a steroid taper. She was CMV seronegative and received a graft from a CMV positive donor and received standard prophylaxis with oral ganciclovir (GCV) for 100 days. Within 100 days posttransplant, she was readmitted to the hospital with acute CMV disease, which was successfully treated with intravenous ganciclovir.\nShortly after this episode the patient was found to have skin lesions on her right leg, which were diagnosed as calciphylaxis. Her serum calcium at that time was 14 mg/dl and the diagnosis of tertiary hyperparathyroidism was made. A three-and-a-half-gland resection together with subtotal thymectomy was done without any complications; the left lower parathyroid gland was the only normal appearing and half of it was preserved taking care that blood supply remained intact. Intraoperative parathyroid hormone levels dropped from >1500 to 150. Calcium serum levels within 24 hours postoperatively were 9 mg/dl with ionized calcium of 3.5 mg/dl. She was discharged in good condition within 24 hours postoperatively with daily calcium supplementation of 4.5 g/day divided into three doses.\nDuring the following week her calcium levels started to drop and on day 10 postoperatively at an outside hospital serum calcium was found to be critically low at 5.5 mg/dl with an ionized fraction of 2.1 mg/dl. However, the patient had remained clinically symptom free. She was admitted for intravenous calcium replacement. Pushes of calcium were unable to appropriately raise her calcium levels and, therefore, a calcium drip (85 mg/h) was started. Her calcium levels came up to 7.1 mg/dl. Oral calcium dose was raised to 15 g/day and hydrochlorothiazide was started. The calcium drip was stopped and the patient was discharged home in good condition.\nIntense calcium supplementation was continued. Gradually the patient's gastrointestinal tract started to adapt and after two years her calcium levels started to stabilize. She has not experienced any additional complications from her transplant or gastric bypass. She is currently alive with excellent function of both grafts, normal calcium levels, stable weight, and an excellent quality of life almost five years after her last surgery.", + "fulltext_subclaims": [ + "The patient was diagnosed with type I DM at the age of 9 years.", + "During childhood her DM was poorly controlled.", + "The patient gained significant weight.", + "At the age of 25 years her weight was 105 kg.", + "Her body mass index (BMI) was 40 kg/m2.", + "Her renal function started to deteriorate.", + "She required hemodialysis by age 30.", + "Secondary hyperparathyroidism was noted.", + "Due to her obesity, she was not eligible for a renal transplant.", + "Due to her obesity, she was not eligible for a SPK.", + "It was decided to offer her bariatric surgery.", + "It was felt that a RYGBP was the best option for her in terms of weight loss.", + "At the age of 32 years, she underwent uneventful robotic-assisted surgery.", + "The stomach remnant was attached to the abdominal wall for potential future access.", + "Over the next 2 years she lost 60 kg.", + "She underwent SPK during which the donor duodenal segment was diverted to a bowel loop distal to her Roux loop implant site into the common channel.", + "Induction immunosuppression with alemtuzumab was followed by maintenance with tacrolimus (trough levels 5-7 ng/mL).", + "Maintenance immunosuppression included mycophenolate-mofetil (2 g daily).", + "A steroid taper was used.", + "She was CMV seronegative.", + "She received a graft from a CMV positive donor.", + "She received standard prophylaxis with oral ganciclovir (GCV) for 100 days.", + "Within 100 days posttransplant, she was readmitted to the hospital with acute CMV disease.", + "The acute CMV disease was successfully treated with intravenous ganciclovir.", + "Skin lesions on her right leg were diagnosed as calciphylaxis.", + "Her serum calcium at that time was 14 mg/dl.", + "The diagnosis of tertiary hyperparathyroidism was made.", + "A three-and-a-half-gland resection together with subtotal thymectomy was done.", + "The left lower parathyroid gland was the only normal appearing.", + "Half of the left lower parathyroid gland was preserved.", + "Intraoperative parathyroid hormone levels dropped from >1500 to 150.", + "Calcium serum levels within 24 hours postoperatively were 9 mg/dl.", + "Ionized calcium was 3.5 mg/dl.", + "She was discharged in good condition within 24 hours postoperatively.", + "She was discharged with daily calcium supplementation of 4.5 g/day divided into three doses.", + "During the following week her calcium levels started to drop.", + "On day 10 postoperatively at an outside hospital serum calcium was found to be 5.5 mg/dl.", + "The ionized calcium fraction was 2.1 mg/dl.", + "The patient had remained clinically symptom free.", + "She was admitted for intravenous calcium replacement.", + "Pushes of calcium were unable to appropriately raise her calcium levels.", + "A calcium drip (85 mg/h) was started.", + "Her calcium levels came up to 7.1 mg/dl.", + "Oral calcium dose was raised to 15 g/day.", + "Hydrochlorothiazide was started.", + "The calcium drip was stopped.", + "The patient was discharged home in good condition.", + "Intense calcium supplementation was continued.", + "Gradually the patient's gastrointestinal tract started to adapt.", + "After two years her calcium levels started to stabilize.", + "She has not experienced any additional complications from her transplant or gastric bypass.", + "She is currently alive with excellent function of both grafts.", + "She has normal calcium levels.", + "She has stable weight.", + "She has an excellent quality of life almost five years after her last surgery." + ], + "summary": "A 41-old-year morbidly obese female with c-peptide negative diabetes mellitus and renal failure had RYGBP. Following significant weight loss she underwent simultaneous pancreas-kidney transplantation. She had excellent transplant graft function but developed tertiary hyperparathyroidism with calciphylaxis. She underwent resection of 3.5 glands leaving a small, physiologic remnant remaining in situ at the left inferior position. She was discharged on postoperative day one in good condition, asymptomatic with serum calcium of 7.6 mg/dL and intact PTH of 12 pg/mL. The patient had to be readmitted on postoperative day #14 for severe hypocalcemia of 5.0 mg/dl and ionized calcium 2.4 mg/dl. She required intravenous calcium infusion to achieve calcium levels of >6.5 mg/dl. Long-term treatment includes 5 g of elemental oral calcium TID, vitamin D, and hydrochlorothiazide. She remains in the long term on high-dose medical therapy with normal serum calcium levels and PTH levels around 100 pg/mL.", + "summary_subclaims": [ + "The patient is a 41-year-old morbidly obese female.", + "She has c-peptide negative diabetes mellitus.", + "She has renal failure.", + "She had RYGBP.", + "Following significant weight loss, she underwent simultaneous pancreas-kidney transplantation.", + "She had excellent transplant graft function.", + "She developed tertiary hyperparathyroidism.", + "She developed calciphylaxis.", + "She underwent resection of 3.5 glands.", + "A small, physiologic remnant was left in situ at the left inferior position.", + "She was discharged on postoperative day one.", + "She was asymptomatic at discharge.", + "Her serum calcium at discharge was 7.6 mg/dL.", + "Her intact PTH at discharge was 12 pg/mL.", + "She was readmitted on postoperative day #14.", + "She had severe hypocalcemia of 5.0 mg/dl.", + "Her ionized calcium was 2.4 mg/dl.", + "She required intravenous calcium infusion.", + "She was treated to achieve calcium levels of >6.5 mg/dl.", + "Long-term treatment includes 5 g of elemental oral calcium TID.", + "Long-term treatment includes vitamin D.", + "Long-term treatment includes hydrochlorothiazide.", + "She remains on high-dose medical therapy.", + "She has normal serum calcium levels long-term.", + "Her PTH levels are around 100 pg/mL long-term." + ] + }, + { + "id": "multiclinsum_test_2415_en.txt", + "fulltext": "In February 2017, a 56-year old woman was transferred from a peripheral hospital to the department of Urology (University of Bonn) due to left sided flank pain and elevated serum infection parameters. An abdominal computed tomography scan showed an obstruction of the renal pelvis caused by an amorphous mass .\nThe patient had neither relevant urologic medical history nor hematuria but she reported intermittent shivering since one week. The physical examination showed severe left sided flank pain on palpation. Extensive laboratory examination revealed leucocytosis (22.53 G/l), elevated C-reactive protein (253 mg/dl) and creatinin (1.4 mg/dl) as well as significant leucocyturia. A calculated antibiotic therapy with ceftriaxone and tobramycin was initiated and a double-J-stent was inserted into the left ureter. The urine culture of the admission day did not reveal bacterial growth.\nDue to missing clinical recovery with persistent fever and elevated serum infection parameters, the antibiotic treatment was changed to meropenem after four days.\nEventually, repeated urine culture and blood cultures revealed fungaemia with Candida glabrata. Therefore, intravenous antifungal therapy with caspofungin was started. Due to an allergic reaction with exanthema the therapy was shifted to amphotericin B. Blood tests ruled out HIV infection and Diabetes and there was no evidence for other immune deficiencies.\nCerebral and thoracoabdominal computed tomography scan excluded an extrarenal focus of infection and echocardiography did not show any intracardial fungal vegetations. Although the patient did not suffer from any visual impairment we initiated ophthalmoscopic examination as recommended in literature in case of fungaemia . Funduscopy revealed fungal parapapillary chorioretinal infiltrates . Under the antimycotic treatment, the inflammatory parameters were regressive and the patient’s clinical condition improved significantly. Ureterorenoscopic examination revealed a tough yellowish-gray mass in the renal pelvis.\nDue to insufficient ureterorenoscopic removal of the mass, it was decided to perform percutaneous “nephrolitholapaxy”. Thus the material could be extracted completely . Microbiological and histological work-up revealed fungal bezoar colonized with Candida glabrata. Seven days after intervention urine culture control proved the absence of fungal colonization.\nFinally, after 22 days of amphotericin B therapy, ophthalmologic re-examination showed a complete regression of the chorioretinal candida infiltrates and the patient was discharged in good general condition with normalized infection parameters.\nAfter a follow up of two months the patient felt well and urine culture was sterile.", + "fulltext_subclaims": [ + "The patient was a 56-year old woman.", + "She was transferred to the department of Urology at the University of Bonn in February 2017.", + "She had left sided flank pain.", + "She had elevated serum infection parameters.", + "An abdominal computed tomography scan showed an obstruction of the renal pelvis caused by an amorphous mass.", + "The patient had no relevant urologic medical history.", + "The patient had no hematuria.", + "The patient reported intermittent shivering since one week.", + "The physical examination showed severe left sided flank pain on palpation.", + "Extensive laboratory examination revealed leucocytosis (22.53 G/l).", + "Extensive laboratory examination revealed elevated C-reactive protein (253 mg/dl).", + "Extensive laboratory examination revealed creatinin (1.4 mg/dl).", + "Extensive laboratory examination revealed significant leucocyturia.", + "A calculated antibiotic therapy with ceftriaxone and tobramycin was initiated.", + "A double-J-stent was inserted into the left ureter.", + "The urine culture of the admission day did not reveal bacterial growth.", + "Due to missing clinical recovery with persistent fever and elevated serum infection parameters, the antibiotic treatment was changed to meropenem after four days.", + "Repeated urine culture and blood cultures revealed fungaemia with Candida glabrata.", + "Intravenous antifungal therapy with caspofungin was started.", + "Due to an allergic reaction with exanthema, the therapy was shifted to amphotericin B.", + "Blood tests ruled out HIV infection.", + "Blood tests ruled out Diabetes.", + "There was no evidence for other immune deficiencies.", + "Cerebral and thoracoabdominal computed tomography scan excluded an extrarenal focus of infection.", + "Echocardiography did not show any intracardial fungal vegetations.", + "Although the patient did not suffer from any visual impairment, we initiated ophthalmoscopic examination as recommended in literature in case of fungaemia.", + "Funduscopy revealed fungal parapapillary chorioretinal infiltrates.", + "Under the antimycotic treatment, the inflammatory parameters were regressive.", + "The patient’s clinical condition improved significantly.", + "Ureterorenoscopic examination revealed a tough yellowish-gray mass in the renal pelvis.", + "Due to insufficient ureterorenoscopic removal of the mass, it was decided to perform percutaneous nephrolitholapaxy.", + "The material could be extracted completely.", + "Microbiological and histological work-up revealed fungal bezoar colonized with Candida glabrata.", + "Seven days after intervention, urine culture control proved the absence of fungal colonization.", + "After 22 days of amphotericin B therapy, ophthalmologic re-examination showed a complete regression of the chorioretinal candida infiltrates.", + "The patient was discharged in good general condition with normalized infection parameters.", + "After a follow up of two months, the patient felt well.", + "After a follow up of two months, urine culture was sterile." + ], + "summary": "Hereinafter we describe a case of an immunocompetent 56 years old woman, presenting with flank pain and shivering. The diagnosis turned out to be difficult due to initially negative urine culture. The fungaemia caused by obstructive nephropathy led to bilateral candida chorioretinitis. The patient was treated with intravenous amphotericin b and the bezoar was removed by percutaneous \"nephrolitholapaxy\". After two months, a follow up revealed the patient felt well, chorioretinal lesions regressed and urine culture did not show any fungal growth.", + "summary_subclaims": [ + "The patient is an immunocompetent 56 years old woman.", + "The patient presented with flank pain and shivering.", + "The diagnosis was difficult due to initially negative urine culture.", + "The fungaemia was caused by obstructive nephropathy.", + "The patient developed bilateral candida chorioretinitis.", + "The patient was treated with intravenous amphotericin b.", + "The bezoar was removed by percutaneous nephrolitholapaxy.", + "After two months, the patient felt well.", + "Chorioretinal lesions regressed after two months.", + "Urine culture did not show any fungal growth after two months." + ] + }, + { + "id": "multiclinsum_test_523_en.txt", + "fulltext": "A 5 year old girl of Indo-Aryan origin presented with one and a half month old neglected trauma left leg, managed by a local bone setter (quack). Examination revealed swelling from knee to ankle, 5cm×5cm ulceration over proximal part of shin, purulent discharging sinus and deformity. X-ray revealed non-union with exuberant callus at the fracture site.\nAt the age of 2 years patient developed ulcers of multiple fingers and toes followed by their self amputation (, ). Finger and toe tips showed multiple healed scars. Radiographs revealed osteoacrolysis . In the same year, patient had trauma to left thumb which healed with a deformity . There had been trauma to left forearm in childhood; X-ray revealed healed fracture of shaft of ulna. Parents mentioned all the above traumatic events were not associated with pain.\nAround the age of 2 and half years patient developed blisters over right lower extremity, which healed leaving scar marks .\nThere is history of recurrent episodes of high grade fever since childhood. There was one such episode in the hospital lasting 4 days. There is history of lack of sweating since birth. Physical and laboratory tests revealed anhidrosis. Patient feels very uncomfortable during hot weather and comforts herself by taking a cold water bath which gives temporary relief.\nShe is born of non-consanguineous marriage. Family history was insignificant. Motor and mental milestones were delayed. Intelligence is low as compared to other siblings. There is history of repeated respiratory tract infections in childhood.\nNeurological examination was normal except inability to perceive painful stimuli. No pain was perceived even at the time of intravenous and intramuscular injections. Nerve conduction study revealed normal median nerve conduction velocity. There is history of several episodes of biting of tongue. The patient had normal eruption of teeth but had lost most of them; all the incisors and canines were absent.\nCRP was elevated. Culture of pus from discharging sinus cultured S. aureus. Serum calcium, serum phosphorus, renal function parameters, thyroid function tests, parathormone levels, serum uric acid were in normal range. Infected non-union was managed by curettage and debridement. Reduction was achieved and fixed using biplanar external fixator . At 3 months follow up pus discharge had subsided with abundant granulation tissue at wound site. There was callus formation at fracture site and features of union on radiograph.", + "fulltext_subclaims": [ + "The patient is a 5 year old girl of Indo-Aryan origin.", + "The patient had a one and a half month old neglected trauma to the left leg.", + "The trauma was managed by a local bone setter.", + "Examination revealed swelling from knee to ankle.", + "Examination revealed a 5cm×5cm ulceration over the proximal part of the shin.", + "Examination revealed a purulent discharging sinus.", + "Examination revealed deformity.", + "X-ray revealed non-union with exuberant callus at the fracture site.", + "At the age of 2 years, the patient developed ulcers of multiple fingers and toes.", + "At the age of 2 years, the ulcers were followed by self amputation.", + "Finger and toe tips showed multiple healed scars.", + "Radiographs revealed osteoacrolysis.", + "In the same year, the patient had trauma to the left thumb.", + "The trauma to the left thumb healed with a deformity.", + "There had been trauma to the left forearm in childhood.", + "X-ray revealed a healed fracture of the shaft of the ulna.", + "Parents mentioned all the traumatic events were not associated with pain.", + "Around the age of 2 and a half years, the patient developed blisters over the right lower extremity.", + "The blisters healed leaving scar marks.", + "There is a history of recurrent episodes of high grade fever since childhood.", + "There was one episode of high grade fever in the hospital lasting 4 days.", + "There is a history of lack of sweating since birth.", + "Physical and laboratory tests revealed anhidrosis.", + "The patient feels very uncomfortable during hot weather.", + "The patient comforts herself by taking a cold water bath.", + "The cold water bath gives temporary relief.", + "The patient is born of a non-consanguineous marriage.", + "Family history was insignificant.", + "Motor and mental milestones were delayed.", + "Intelligence is low as compared to other siblings.", + "There is a history of repeated respiratory tract infections in childhood.", + "Neurological examination was normal except inability to perceive painful stimuli.", + "No pain was perceived even at the time of intravenous and intramuscular injections.", + "Nerve conduction study revealed normal median nerve conduction velocity.", + "There is a history of several episodes of biting of the tongue.", + "The patient had normal eruption of teeth.", + "The patient had lost most of her teeth.", + "All the incisors and canines were absent.", + "CRP was elevated.", + "Culture of pus from the discharging sinus cultured S. aureus.", + "Serum calcium, serum phosphorus, renal function parameters, thyroid function tests, parathormone levels, serum uric acid were in normal range.", + "Infected non-union was managed by curettage and debridement.", + "Reduction was achieved and fixed using a biplanar external fixator.", + "At 3 months follow up, pus discharge had subsided.", + "At 3 months follow up, there was abundant granulation tissue at the wound site.", + "At 3 months follow up, there was callus formation at the fracture site.", + "At 3 months follow up, features of union were seen on radiograph." + ], + "summary": "We present a 5 year old girl child, who was brought to us as a case of one and a half month old neglected trauma left leg and was diagnosed to be suffering from congenital insensitivity to pain with anhidrosis (HSAN Type IV).", + "summary_subclaims": [ + "The patient is a 5 year old girl child.", + "She was brought as a case of one and a half month old neglected trauma left leg.", + "She was diagnosed to be suffering from congenital insensitivity to pain with anhidrosis.", + "The diagnosis is HSAN Type IV." + ] + }, + { + "id": "multiclinsum_test_1710_en.txt", + "fulltext": "A 19-year-old girl was seen in the outpatient department with a diffuse, dull aching right heel pain that was the insidious onset and gradually progressive in nature. There was no history of any injury or surgery. The right heel pain was associated with a limp and did not respond to analgesics. There was no diurnal variation of pain. She had been experiencing difficulty in walking and carrying out daily activities for the past 6 months due to this heel pain. A local examination revealed mild swelling but no overt inflammatory signs, such as erythema or the local rise of temperature, and there was no tenderness. Considering her age of presentation, the character of pain, and no signs of inflammation or infections, further investigations were undertaken.\nA plain X-ray of the foot showed an ill-defined sclerotic area in the calcaneum with radiating spicules, thinned overlying cortex, and soft-tissue edema over the heel . Contrastenhanced magnetic resonance imaging (MRI) of the left ankle confirmed the sclerotic lesion in the calcaneum with extraosseous component and enhancement with contrast. Alkaline phosphatase and lactate dehydrogenase were within the normal range and renal functions were also normal. An ultrasound-guided tru-cut biopsy was undertaken from the lesion, which on microscopy showed abundant osteoid matrix interspersed by pleomorphic cells with elongated oval to spindle hyperchromatic nuclei with increased areas of fibrous tissue, which was the hallmark of osteogenic sarcoma . Fluorodeoxyglucose positron emission tomography-computed tomography scans (FDG PET-CT) showed no distant metastasis.\nTreatment: The patient was given 3 cycles of chemotherapy (cisplatin+adriamycin) at 3-week intervals. After the chemotherapy, a repeat contrast MRI and FDG-PET-CT were undertaken to determine the size and extent of the disease and micrometastasis, which revealed a decrease in the standardized uptake values in the primary lesion and also the extent of the disease.\nA limb salvage surgery was undertaken, which involved a posteromedial incision extending 5 cm from above the ankle to the base of first metatarsal along the watershed line . The biopsy scar was excised, and the neurovascular bundle was isolated and separated. The flexor retinaculum was released, and the lateral plantar vessels had to be sacrificed because of their adherence to the tumor. The medial plantar vessels and nerves were isolated and separated . The capsule was incised all around the subtalar joint and removed from the navicular and cuneiform bone. The tendon Achilles was resected 1 169 cm from its insertion, and the plantar fascia was resected 1 cm from its margins. After thorough dissection, a wide en bloc resection of the calcaneum was taken . The procedure was uneventful. The sample was sent for histopathology, which confirmed osteosarcoma.\nAfter the surgery, a below-knee splint was applied for 3 months,and the patient was advised non-weight-bearing ambulation. Sutures were removed at 2 weeks, and then three cycles of adjuvant chemotherapy were given. At 3 months of follow-up, partial weight bearing was allowed with elbow crutches and an ankle-foot orthosis. The patient was followed up every 6 weeks. At a 1-year follow-up, a customized silicon heel cup and shoes were given for full weight-bearing ambulation. At the end of 1 year, a PET-CT revealed no evidence of metabolically active disease.", + "fulltext_subclaims": [ + "The patient was a 19-year-old girl.", + "She had a diffuse, dull aching right heel pain.", + "The pain had an insidious onset.", + "The pain was gradually progressive in nature.", + "There was no history of any injury.", + "There was no history of any surgery.", + "The right heel pain was associated with a limp.", + "The right heel pain did not respond to analgesics.", + "There was no diurnal variation of pain.", + "She had difficulty in walking for the past 6 months.", + "A local examination revealed mild swelling.", + "There were no overt inflammatory signs.", + "There was no tenderness.", + "A plain X-ray showed an ill-defined sclerotic area in the calcaneum.", + "The X-ray showed radiating spicules.", + "The X-ray showed a thinned overlying cortex.", + "The X-ray showed soft-tissue edema over the heel.", + "Contrast-enhanced MRI confirmed the sclerotic lesion in the calcaneum.", + "The MRI showed an extraosseous component.", + "The MRI showed enhancement with contrast.", + "Alkaline phosphatase was within the normal range.", + "Lactate dehydrogenase was within the normal range.", + "Renal functions were normal.", + "An ultrasound-guided tru-cut biopsy was undertaken.", + "The biopsy showed abundant osteoid matrix.", + "The biopsy showed pleomorphic cells with elongated oval to spindle hyperchromatic nuclei.", + "The biopsy showed increased areas of fibrous tissue.", + "The biopsy was the hallmark of osteogenic sarcoma.", + "FDG PET-CT showed no distant metastasis.", + "The patient was given 3 cycles of chemotherapy.", + "The chemotherapy regimen was cisplatin+adriamycin.", + "The chemotherapy cycles were at 3-week intervals.", + "A repeat contrast MRI was undertaken.", + "A repeat FDG-PET-CT was undertaken.", + "The scans revealed a decrease in the standardized uptake values in the primary lesion.", + "The scans revealed a decrease in the extent of the disease.", + "A limb salvage surgery was undertaken.", + "The surgery involved a posteromedial incision.", + "The incision extended 5 cm from above the ankle to the base of first metatarsal.", + "The incision was along the watershed line.", + "The biopsy scar was excised.", + "The neurovascular bundle was isolated and separated.", + "The flexor retinaculum was released.", + "The lateral plantar vessels were sacrificed.", + "The medial plantar vessels and nerves were isolated and separated.", + "The capsule was incised all around the subtalar joint.", + "The capsule was removed from the navicular and cuneiform bone.", + "The tendon Achilles was resected 1 169 cm from its insertion.", + "The plantar fascia was resected 1 cm from its margins.", + "A wide en bloc resection of the calcaneum was taken.", + "The procedure was uneventful.", + "The sample was sent for histopathology.", + "The histopathology confirmed osteosarcoma.", + "A below-knee splint was applied for 3 months.", + "The patient was advised non-weight-bearing ambulation.", + "Sutures were removed at 2 weeks.", + "Three cycles of adjuvant chemotherapy were given.", + "At 3 months of follow-up, partial weight bearing was allowed.", + "Partial weight bearing was allowed with elbow crutches.", + "Partial weight bearing was allowed with an ankle-foot orthosis.", + "The patient was followed up every 6 weeks.", + "At a 1-year follow-up, a customized silicon heel cup and shoes were given.", + "At the end of 1 year, a PET-CT revealed no evidence of metabolically active disease." + ], + "summary": "We report a case of a 19-year-old girl with calcaneal osteosarcoma who initially complained of heel pain that was refractory to analgesic medications over a period of 4 months.", + "summary_subclaims": [ + "The patient is a 19-year-old girl.", + "The patient had calcaneal osteosarcoma.", + "The patient initially complained of heel pain.", + "The heel pain was refractory to analgesic medications.", + "The heel pain occurred over a period of 4 months." + ] + }, + { + "id": "multiclinsum_test_3054_en.txt", + "fulltext": "A 60-year-old white female was referred to the nephrology clinic for further evaluation for unexplained rise in the creatinine (Cr) level to 1.4 mg/dL during her routine hematology visit from the baseline of 0.9 mg/dL. She was diagnosed with Polyneuropathy, Organomegaly, Endocrinopathy, Monoclonal plasma cell disorder, Skin changes (POEMS) syndrome approximately 1 year prior due to the presence of sciatica, hypothyroidism, monoclonal gammopathy of undetermined significance (MGUS), and onychomycosis, with regular hematology visits afterwards. Her serum protein electrophoresis around 2 years prior showed m-spike of 1.0 g/dL with immunofixation electrophoresis demonstrated the presence of monoclonal IgG having kappa light chain restriction (kappa free light chain: 2.12 mg/dL, lambda free light chain: 2.01 mg/dL, kappa/lambda free light chain ratio: 1.05). Complementary bone marrow biopsy indicated mildly increased plasma cell (5%-7%) with kappa light chain predominance, in favor of MGUS.\n\nShe was diagnosed with HTN approximately 3 years before her referral. Despite having few episodes of high blood pressure, her HTN status was well controlled. Patient has been receiving allopurinol, aspirin, losartan, hydrochlorothiazide, levothyroxine, metoprolol, and prednisone (20 mg daily). The latter was prescribed by the patient’s hematologist due to suspected vasculitis approximately 1 year after the nephrology visit, and the patient continues to take it. She did not report long-standing use of nonsteroidal anti-inflammatory drugs; however, she mentioned intermittent consumption (approximately 500 mg weekly) over the past couple of years, with normal Cr levels. She had no family or personal history of kidney diseases. The patient denied any active smoking. However, she reported long-standing exposure to passive cigarette smoking because of living with a heavy smoking family member and working as a bartender for more than 30 years. At her first nephrology visit, her blood pressure, pulse rate, and body mass index were 97/64 mm Hg, 59 beats/minute, and 19.32 kg/m2, respectively, and there was no rash on physical examination. She was not diabetic (hemoglobin A1c [HbA1c]: 5.4%). At the time of the nephrology consultation request, her Cr level was 1.4 mg/dL (blood pressure: 101/65 mm Hg), a value that had also been observed 2 months earlier. Therefore, the patient was diagnosed with chronic kidney disease stage 3B at the nephrology visit (estimated glomerular filtration rate [eGFR]: 43 mL/min/1.73 m2), with the increase in serum Cr to 1.8 mg/dL 1 week after her first nephrology visit. One month later, complementary tests showed a similar Cr value (1.8 mg/dL), and urinalysis results were in favor of nephritic range proteinuria, hematuria, and pyuria with moderate bacteriuria and negative nitrite without any urinary symptoms. Autoimmune and infectious markers (antinuclear Ab, anti-ds DNA Ab, anti-smith Ab, anti-SSA and SSB Abs, anti-SCL70 Ab, anti-Jo1 Ab, anti-centromere Ab, cytoplasmic antineutrophil cytoplasmic Ab [C-ANCA], perinuclear ANCA [P-ANCA], hepatitis B virus [HBV]) were negative. Kidney ultrasound was unremarkable.\n\nThe patient underwent kidney biopsy, and the results of hematoxylin and eosin, periodic acid-Schiff, Jones silver, and Masson trichrome staining revealed diffuse and focal nodular mesangial expansion without hypercellularity and moderate arteriosclerosis. Out of 49 glomeruli, 18 (37%) showed signs of diffuse glomerulosclerosis and 3 (10%) showed segmental sclerosis. DNAJB9 immunohistochemical staining and immunofluorescent studies (IgA, IgG, IgM, C1q, kappa, and lambda light chains) as well as Congo red staining were negative. On electron microscopy, mesangial matrix expansion was confirmed with the additional finding of scattered embedded distinct curved fibrils ranging from 7 to 12 nm in diameter. The patient was finally diagnosed with ING in the context of HTN and passive smoking. During follow-up and after kidney biopsy, the patient’s blood pressure became uncontrolled, reaching a peak of 183/93 mm Hg. Several first-line antihypertensive regimens failed to control her blood pressure, and she was subsequently prescribed carvedilol, clonidine, and hydralazine. A duplex kidney ultrasound revealed left renal artery stenosis, and she was referred for appropriate management. Regarding her hematological condition, her most recent serum protein electrophoresis showed an M-spike of 0.8 g/dL, with immunofixation electrophoresis confirming the presence of monoclonal IgG with kappa light chain restriction (kappa free light chain: 4.51 mg/dL, lambda free light chain: 2.86 mg/dL, kappa/lambda free light chain ratio: 1.58). The patient remains under regular follow-up with a stable condition. At her most recent nephrology visit, 12 months later, the patient reported no symptoms, and her blood pressure reduced to 144/78 mm Hg. Table 1 shows the most recent patient’s laboratory data approximately 12 months after her first nephrology visit.", + "fulltext_subclaims": [ + "The patient is a 60-year-old white female.", + "She was referred to the nephrology clinic for an unexplained rise in creatinine to 1.4 mg/dL.", + "Her baseline creatinine was 0.9 mg/dL.", + "She was diagnosed with POEMS syndrome approximately 1 year prior.", + "Her serum protein electrophoresis around 2 years prior showed an m-spike of 1.0 g/dL.", + "Immunofixation electrophoresis demonstrated the presence of monoclonal IgG with kappa light chain restriction.", + "Complementary bone marrow biopsy indicated mildly increased plasma cells (5%-7%) with kappa light chain predominance.", + "She was diagnosed with hypertension approximately 3 years before her referral.", + "She was taking prednisone 20 mg daily, prescribed by her hematologist due to suspected vasculitis.", + "She reported intermittent consumption of nonsteroidal anti-inflammatory drugs (approximately 500 mg weekly) over the past couple of years.", + "At her first nephrology visit, her creatinine level was 1.4 mg/dL.", + "She was diagnosed with chronic kidney disease stage 3B at the nephrology visit.", + "Her estimated glomerular filtration rate was 43 mL/min/1.73 m2.", + "Her creatinine increased to 1.8 mg/dL 1 week after her first nephrology visit.", + "Urinalysis results showed nephritic range proteinuria, hematuria, and pyuria with moderate bacteriuria.", + "Autoimmune and infectious markers were negative.", + "Kidney ultrasound was unremarkable.", + "The kidney biopsy showed diffuse and focal nodular mesangial expansion without hypercellularity.", + "DNAJB9 immunohistochemical staining and immunofluorescent studies were negative.", + "Electron microscopy showed mesangial matrix expansion with scattered embedded distinct curved fibrils ranging from 7 to 12 nm in diameter.", + "The patient was diagnosed with immunotactoid glomerulopathy in the context of hypertension and passive smoking.", + "Her blood pressure became uncontrolled after the kidney biopsy, reaching a peak of 183/93 mm Hg.", + "A duplex kidney ultrasound revealed left renal artery stenosis.", + "She was referred for appropriate management of renal artery stenosis.", + "Her most recent serum protein electrophoresis showed an M-spike of 0.8 g/dL.", + "Immunofixation electrophoresis confirmed the presence of monoclonal IgG with kappa light chain restriction.", + "At her most recent nephrology visit, 12 months later, her blood pressure was 144/78 mm Hg." + ], + "summary": "A 60-year-old white female with Polyneuropathy, Organomegaly, Endocrinopathy, Monoclonal plasma cell disorder, Skin changes (POEMS) syndrome and newly diagnosed HTN was referred because of an elevated creatinine level. She denied being an active smoker but reported long-term exposure to cigarette smoke due to living with a heavy smoking family and working as a bartender. Further investigations revealed microscopic hematuria and nephritic range proteinuria. Kidney biopsy revealed diffuse and focal nodular mesangial expansion without hypercellularity, with negative staining for amyloid, fibrillary glomerulonephritis, and immunoglobulins, leading to a diagnosis of ING.", + "summary_subclaims": [ + "The patient is a 60-year-old white female.", + "She has POEMS syndrome.", + "She has newly diagnosed HTN.", + "She was referred because of an elevated creatinine level.", + "She denied being an active smoker.", + "She reported long-term exposure to cigarette smoke.", + "Further investigations revealed microscopic hematuria.", + "Further investigations revealed nephritic range proteinuria.", + "Kidney biopsy revealed diffuse and focal nodular mesangial expansion without hypercellularity.", + "Staining for amyloid was negative.", + "Staining for fibrillary glomerulonephritis was negative.", + "Staining for immunoglobulins was negative.", + "The diagnosis was ING." + ] + }, + { + "id": "multiclinsum_test_2735_en.txt", + "fulltext": "A 41-year-old man (height 171.5 cm, body weight 67 kg) was transferred to the regional medical center due to right hemiplegia and aphagia. Cerebral magnetic resonance imaging revealed cerebral infarction caused by occlusion of the left middle cerebral artery, while cerebral magnetic resonance angiography showed the development of a network of abnormal collateral vessels. Hence, the patient was diagnosed with MMD.\nBefore cerebral revascularization surgery, severe MR (III/IV) due to the prolapse of the P2 leaflet in the mitral valve was indicated by transthoracic echocardiography. Cardiac catheterization indicated elevated pulmonary arterial pressure (PAP) (systolic/diastolic/mean: 86/33/60 mmHg) and pulmonary capillary wedge pressure (32 mmHg) at the systemic arterial pressure of 120/83/102 mmHg. Hence, the patient was admitted to our university center for the surgical treatment of MR.\nPreoperative single-photon emission computed tomography revealed reduced cerebral blood flow in the left cerebral hemisphere (especially in the external left frontal cortex; Fig. ). Neurosurgeons at our center judged that the patient did not have an indication for cerebral revascularization surgery, which is used to prevent ischemic complications during the perioperative period of mitral valve plasty. This was because his left frontal lobe showed extensive cerebral infarction and no cerebral infarction symptoms were observed in the right cerebral hemisphere. Therefore, mitral valve plasty without cerebral revascularization was chosen.\nIn the operation room, the patient’s monitoring of electrocardiogram, oxygen saturation, systemic arterial pressure via right radial artery catheter, bispectral index, and regional cerebral oxygen saturation (rSO2) at the right and left forehead (INVOS™ 5100C, Somanetics, USA) was initiated before the administration of general anesthesia. The rSO2 values for the left and right forehead were 72 and 81 %, respectively.\nGeneral anesthesia was induced by intravenous administration of 3 mg of midazolam, 0.4 mg of fentanyl, and 50 mg of rocuronium. After tracheal intubation, a transesophageal echocardiography (TEE) probe was inserted. Then, a central venous catheter and right heart catheter were inserted via the right internal jugular vein, and central venous pressure, PAP, cardiac output, and mixed venous oxygen saturation were measured. The nasopharyngeal temperature and urinary bladder temperature were also measured.\nBefore CPB, general anesthesia was maintained by inhalation of sevoflurane (1–1.5 % of end-tidal concentration). The patient’s PaCO2 was maintained between 38 and 42 mmHg. Intra-aortic balloon pumping (IABP) was placed at the start of surgery and the augmented pressure was maintained. The mean arterial pressure was constantly above 70 mmHg. Before CPB, rSO2 values were almost above 80 % on both sides .\nDuring CPB, administration of sevoflurane via the oxygenator was also continued because of its cerebrovascular dilatation activity and potential preconditioning effect against focal cerebral ischemia. PaCO2 was maintained between 45 and 50 mmHg, and alpha-stat management of pH was performed. Hypothermia was induced; the temperature at the bottom of the nasopharyngeal temprature was 28 °C. We used pulsatile perfusion assist to maintain cerebral circulation during CPB with IABP. A decrease in rSO2 was observed 162 min after the initiation of CPB. Our perfusionist increased the CPB pump flow from 2.2 L/min/m2 to 2.8 L/min/m2 in order to increase cerebral blood flow. Moreover, the concentration of sevoflurane was increased to 2 %. Yet, rSO2 desaturation (15 % reduction from baseline) was not improved. We decided to increase the depth-of-anesthesia with another dose of midazolam. After administration of 3 mg of midazolam, the rSO2 values increased from 67 to 73 % on the right side and from 71 to 74 % on the left side. During CPB, the lowest values (and variation) of rSO2 in the left and right forehead were 71 % (−2 %) and 67 % (−17 %), respectively. Mitral valve plasty was performed as planned.\nAt the weaning from the CPB, the disappearance of MR was confirmed by TEE; the weaning was not difficult. Pulmonary hypertension also improved (PAP was 26/12 mmHg, while systemic arterial pressure was 105/56 mmHg). After CPB, inhalation of sevoflurane (1–1.5 % of end-tidal concentration) was also continued. The rSO2 values were almost above 75 % on both sides and not below the awake rSO2 values . CPB and aortic cross-clamping lasted 352 min and 289 min, respectively. On the completion of the surgery, the IABP was discontinued and sevoflurane administration was stopped. The patient was transferred to the intensive care unit with ventilator support under propofol sedation.\nOn the 1st postoperative day (POD), the patient was weaned from the ventilator, and the patient did not complain about any new neurological deficits. We monitored the rSO2 of his forehead until the 2nd POD and no significant decrease (−20 %) of the rSO2 values was confirmed. The postoperative course was uneventful. On the 15th POD, single-photon emission computed tomography revealed that the low cerebral blood flow lesions had not changed , and the patient was discharged from our hospital on the 16th POD.", + "fulltext_subclaims": [ + "The patient was a 41-year-old man.", + "The patient's height was 171.5 cm.", + "The patient's body weight was 67 kg.", + "The patient was transferred to the regional medical center due to right hemiplegia and aphagia.", + "Cerebral magnetic resonance imaging revealed cerebral infarction caused by occlusion of the left middle cerebral artery.", + "Cerebral magnetic resonance angiography showed the development of a network of abnormal collateral vessels.", + "The patient was diagnosed with MMD.", + "Before cerebral revascularization surgery, severe MR (III/IV) due to the prolapse of the P2 leaflet in the mitral valve was indicated by transthoracic echocardiography.", + "Cardiac catheterization indicated elevated pulmonary arterial pressure (PAP) (systolic/diastolic/mean: 86/33/60 mmHg).", + "Cardiac catheterization indicated elevated pulmonary capillary wedge pressure (32 mmHg).", + "The patient was admitted to our university center for the surgical treatment of MR.", + "Preoperative single-photon emission computed tomography revealed reduced cerebral blood flow in the left cerebral hemisphere.", + "Neurosurgeons at our center judged that the patient did not have an indication for cerebral revascularization surgery.", + "The patient's left frontal lobe showed extensive cerebral infarction.", + "No cerebral infarction symptoms were observed in the right cerebral hemisphere.", + "Mitral valve plasty without cerebral revascularization was chosen.", + "The rSO2 values for the left and right forehead were 72 and 81 %, respectively.", + "General anesthesia was induced by intravenous administration of 3 mg of midazolam, 0.4 mg of fentanyl, and 50 mg of rocuronium.", + "A transesophageal echocardiography (TEE) probe was inserted after tracheal intubation.", + "A central venous catheter and right heart catheter were inserted via the right internal jugular vein.", + "Before CPB, general anesthesia was maintained by inhalation of sevoflurane (1–1.5 % of end-tidal concentration).", + "The patient’s PaCO2 was maintained between 38 and 42 mmHg before CPB.", + "Intra-aortic balloon pumping (IABP) was placed at the start of surgery.", + "The mean arterial pressure was constantly above 70 mmHg before CPB.", + "Before CPB, rSO2 values were almost above 80 % on both sides.", + "During CPB, administration of sevoflurane via the oxygenator was also continued.", + "PaCO2 was maintained between 45 and 50 mmHg during CPB.", + "Alpha-stat management of pH was performed during CPB.", + "Hypothermia was induced; the temperature at the bottom of the nasopharyngeal temperature was 28 °C.", + "Pulsatile perfusion assist was used to maintain cerebral circulation during CPB with IABP.", + "A decrease in rSO2 was observed 162 min after the initiation of CPB.", + "The perfusionist increased the CPB pump flow from 2.2 L/min/m2 to 2.8 L/min/m2.", + "The concentration of sevoflurane was increased to 2 %.", + "rSO2 desaturation (15 % reduction from baseline) was not improved.", + "After administration of 3 mg of midazolam, the rSO2 values increased from 67 to 73 % on the right side.", + "After administration of 3 mg of midazolam, the rSO2 values increased from 71 to 74 % on the left side.", + "During CPB, the lowest values (and variation) of rSO2 in the left and right forehead were 71 % (−2 %) and 67 % (−17 %), respectively.", + "Mitral valve plasty was performed as planned.", + "At the weaning from the CPB, the disappearance of MR was confirmed by TEE.", + "Pulmonary hypertension improved (PAP was 26/12 mmHg, while systemic arterial pressure was 105/56 mmHg).", + "After CPB, inhalation of sevoflurane (1–1.5 % of end-tidal concentration) was also continued.", + "The rSO2 values were almost above 75 % on both sides after CPB.", + "CPB and aortic cross-clamping lasted 352 min and 289 min, respectively.", + "On the 1st postoperative day (POD), the patient was weaned from the ventilator.", + "The patient did not complain about any new neurological deficits on the 1st POD.", + "We monitored the rSO2 of his forehead until the 2nd POD.", + "No significant decrease (−20 %) of the rSO2 values was confirmed.", + "The postoperative course was uneventful.", + "On the 15th POD, single-photon emission computed tomography revealed that the low cerebral blood flow lesions had not changed.", + "The patient was discharged from our hospital on the 16th POD." + ], + "summary": "Herein, we report the case of a 42-year-old man who was scheduled to undergo mitral valve plasty for severe mitral regurgitation. He had been diagnosed with moyamoya disease on the onset of cerebral ischemia at 41 years of age. During the cardiac surgical procedure, the patient was maintained on inhalation anesthesia with 1 to 1.5 % sevoflurane. Sevoflurane causes cerebral vasodilation followed by increased cerebral blood flow, and moreover we expected a sevoflurane preconditioning-induced neuroprotective effect. In addition, we used pulsatile perfusion support to maintain cerebral circulation with intra-aortic balloon pumping during the cardiopulmonary bypass. We aimed to keep the mean arterial pressure constantly above 70 mmHg. We were able to maintain regional cerebral oxygen saturation at 80 % of the baseline value, and could not detect the progression of neurological deficits using follow-up brain single photon emission computed tomography. The patient was discharged 16 days after admission.", + "summary_subclaims": [ + "The patient was a 42-year-old man.", + "He was scheduled to undergo mitral valve plasty for severe mitral regurgitation.", + "He had been diagnosed with moyamoya disease on the onset of cerebral ischemia at 41 years of age.", + "During the cardiac surgical procedure, the patient was maintained on inhalation anesthesia with 1 to 1.5 % sevoflurane.", + "Sevoflurane causes cerebral vasodilation followed by increased cerebral blood flow.", + "We expected a sevoflurane preconditioning-induced neuroprotective effect.", + "We used pulsatile perfusion support to maintain cerebral circulation with intra-aortic balloon pumping during the cardiopulmonary bypass.", + "We aimed to keep the mean arterial pressure constantly above 70 mmHg.", + "We were able to maintain regional cerebral oxygen saturation at 80 % of the baseline value.", + "We could not detect the progression of neurological deficits using follow-up brain single photon emission computed tomography.", + "The patient was discharged 16 days after admission." + ] + }, + { + "id": "multiclinsum_test_1631_en.txt", + "fulltext": "A 43-year-old male presented to the outpatient Department of Urology of West China Hospital in March 2012 with severe paralytic attacks characterised by palpitations and muscle weakness starting in the right thigh and spreading to all limbs. A significant reduction in the serum potassium concentration (1.89 mmol/L, reference value 3.5–5.0 mmol/L) was found during laboratory examination, and an ECG indicated severe potassium deficiency. Symptoms remitted after taking oral potassium (50 ml of 10% potassium chloride was administered immediately followed by an additional 50 ml over 24 h for a total dose of 10 g). After the paralytic attack, a CT scan of the abdomen was performed, which revealed left UAH characterised by a nodular mass on the left adrenal gland. Laboratory examination showed a slight elevation in norepinephrine (602 ng/L, reference value, 272–559 ng/L) and a reduction in adrenaline (< 25 ng/L, reference value 54–122 ng/L) in the serum. Other data, including the serum concentrations of potassium (3.71 mmol/L), aldosterone (11.41 ng/dL, reference value 9.8–27.5 ng/dl), cortisol (7.3 μg/dL, reference value 7.2–18.2 μg/dL), renin (2.22 ng/mL, reference value 0.56–2.79 ng/ml), calcium (2.27 mmol/L, reference value 2.1–2.7 mmol/L), creatine kinase (58 IU/L, reference value 19–226 IU/L), lactate dehydrogenase (167 IU/L, reference value 110–220 IU/L), alanine aminotransferase (19 IU/L, reference value <55 IU/L), aspartate transaminase (15 IU/L, reference value <46 IU/L), creatinine (74.5 μmol/L, reference value 53–140 μmol/L), blood urea nitrogen (7.69 mmol/L, reference value 3.30–8.22 mmol/L), thyroid-stimulating hormone (6.3 mU/L, reference value 2–10 mU/L), total-triiodothyronine (2.14 nmol/L, reference value 1.8–2.9 nmol/L), and total thyroxine (87 nmol/L, reference value 65156 nmol/L), were normal. The patient did not have hypertension (117/83 mm Hg).\nPatient history showed that the paralytic attacks were usually triggered by physical labour or stress and were periodic. Attack frequency varied from weekly during the summer to bimonthly in the winter; each attack lasted 4–6 hours. This attack was the most severe of the attacks he had experienced during the past decade. Although these paralytic attacks were associated with hypokalaemia, the aetiology had not been previously established, and the patient had not received any treatment, including potassium supplement, between attacks. Two years before this attack, serum potassium had been measured several times between attacks; the results of three of these tests were available and were 3.74, 3.69 and 3.63 mmol/L.\nBecause of the presence of severe hypokalaemic periodic paralysis, the patient underwent a left adrenalectomy after admission. Examination of the adrenal gland revealed a 1.1-cm benign nodule at the periphery of the gland with multiple cortical nodular hyperplasias. The patient did not have any complications during the perioperative period and laboratory results were normal (serum potassium .87 mmol/L, serum sodium 143.9 mmol/L, norepinephrine 452 ng/L, adrenaline 60 ng/L, aldosterone 12.24 ng/dL, cortisol 8.1 μg/dL, renin 2.13 ng/mL, creatine kinase 60 IU/L, lactate dehydrogenase 168 IU/L, alanine aminotransferase 20 IU/L, aspartate transaminase 16 IU/L, creatinine 81.3 μmol/L, blood urea nitrogen 8.01 mmol/L). He was discharged 4 days after surgery. During the next 3 months, while recovering at home, no paralytic attacks occurred. The patient then returned to work, and the acute paralytic crises soon recurred. A colour Doppler ultrasound examination did not show any abnormality of the right adrenal gland. The patient then asked for help from the Department of Medical Genetics. His serum potassium was monitored three times with a frequency of once per month with results of 4.12, 3.97, and 4.27 mmol/L, respectively. As shown in Figure , in addition to the patient (II2), four other adult male family members, including two uncles (I5 and I6), one brother (II3), and one nephew (III1), also had a history of paralytic attacks, although their attacks were milder and less frequent (yearly to decadal). These members refused examination to determine the presence or absence of UAH.\nBecause of the positive family history of periodic paralysis with potential autosomal dominant inheritance, the diagnosis of HOKPP was considered, and genetic testing of the CACNA1S and SCN4A genes was performed using Sanger sequencing of all exons and their splice sites. Consequently, the patient was identified as a heterozygote carrying a novel missense mutation, c.1582C > T, in CACNA1S (p.Arg528Cys) . In his family, the mutation was also detected in three other adult males with periodic paralysis (I6, II3, and III1) and in two asymptomatic females (II1 and III2). This mutation was absent in two male family members who did not have a history of symptoms (III3 and III4). Furthermore, the targeted Sanger sequencing did not detect the mutation in 130 adult male controls.\nDuring the following 2 years, the patient maintained the same diet as before surgery. He did not receive any potassium supplement treatment and suffered 12 paralytic attacks. However, there were considerably fewer attacks (monthly in the summer and no attacks in the winter), and the attacks were shorter in duration (2–3 hours) than the attacks before adrenalectomy.", + "fulltext_subclaims": [ + "The patient was a 43-year-old male.", + "He presented to the outpatient Department of Urology of West China Hospital in March 2012.", + "He had severe paralytic attacks characterised by palpitations and muscle weakness.", + "The muscle weakness started in the right thigh and spread to all limbs.", + "The serum potassium concentration was 1.89 mmol/L.", + "An ECG indicated severe potassium deficiency.", + "Symptoms remitted after taking oral potassium.", + "A CT scan of the abdomen revealed left UAH characterised by a nodular mass on the left adrenal gland.", + "Serum norepinephrine was 602 ng/L.", + "Serum adrenaline was < 25 ng/L.", + "The patient did not have hypertension (117/83 mm Hg).", + "The paralytic attacks were usually triggered by physical labour or stress.", + "Each attack lasted 4–6 hours.", + "This attack was the most severe of the attacks he had experienced during the past decade.", + "The patient had not received any treatment, including potassium supplement, between attacks.", + "Two years before this attack, serum potassium had been measured several times between attacks.", + "The results of three of these tests were 3.74, 3.69 and 3.63 mmol/L.", + "The patient underwent a left adrenalectomy after admission.", + "Examination of the adrenal gland revealed a 1.1-cm benign nodule at the periphery of the gland.", + "The patient did not have any complications during the perioperative period.", + "He was discharged 4 days after surgery.", + "During the next 3 months, while recovering at home, no paralytic attacks occurred.", + "The patient then returned to work, and the acute paralytic crises soon recurred.", + "A colour Doppler ultrasound examination did not show any abnormality of the right adrenal gland.", + "The patient asked for help from the Department of Medical Genetics.", + "His serum potassium was monitored three times with a frequency of once per month.", + "The results were 4.12, 3.97, and 4.27 mmol/L.", + "Four other adult male family members had a history of paralytic attacks.", + "These members refused examination to determine the presence or absence of UAH.", + "The diagnosis of HOKPP was considered.", + "Genetic testing of the CACNA1S and SCN4A genes was performed using Sanger sequencing.", + "The patient was identified as a heterozygote carrying a novel missense mutation, c.1582C > T, in CACNA1S (p.Arg528Cys).", + "This mutation was also detected in three other adult males with periodic paralysis.", + "This mutation was absent in two male family members who did not have a history of symptoms.", + "The targeted Sanger sequencing did not detect the mutation in 130 adult male controls.", + "During the following 2 years, the patient maintained the same diet as before surgery.", + "He did not receive any potassium supplement treatment.", + "He suffered 12 paralytic attacks.", + "There were considerably fewer attacks (monthly in the summer and no attacks in the winter).", + "The attacks were shorter in duration (2–3 hours) than the attacks before adrenalectomy." + ], + "summary": "A 43-year-old Han Chinese male presented with severe hypokalaemic paralysis that remitted after taking oral potassium. The patient had suffered from periodic attacks of hypokalaemic paralysis for more than 20 years. A computed tomography (CT) scan of the abdomen showed a nodular mass on the left adrenal gland, although laboratory examination revealed the patient had not developed primary aldosteronism. The patient underwent a left adrenalectomy 4 days after admission, and the pathological examination further confirmed a 1.1 cm benign nodule at the periphery of the adrenal gland. Three months after the adrenalectomy, a paralytic attack recurred and the patient asked for assistance from the Department of Medical Genetics. His family history showed that two uncles, one brother, and a nephew also had a history of periodic paralysis, although their symptoms were milder. The patient's CACNA1S and SCN4A genes were sequenced, and a novel missense mutation, c.1582C > T (p.Arg528Cys), in CACNA1S was detected. Detection of the mutation in five adult male family members, including three with periodic paralysis and two with no history of the disease, indicated that this mutation caused hypokalaemic periodic paralysis type I in his family. Follow-up 2 years after adrenalectomy showed that the serum potassium concentration was increased between paralyses and the number and severity of paralytic attacks were significantly decreased.", + "summary_subclaims": [ + "The patient is a 43-year-old Han Chinese male.", + "The patient presented with severe hypokalaemic paralysis.", + "The hypokalaemic paralysis remitted after taking oral potassium.", + "The patient had suffered from periodic attacks of hypokalaemic paralysis for more than 20 years.", + "A CT scan of the abdomen showed a nodular mass on the left adrenal gland.", + "Laboratory examination revealed the patient had not developed primary aldosteronism.", + "The patient underwent a left adrenalectomy 4 days after admission.", + "Pathological examination confirmed a 1.1 cm benign nodule at the periphery of the adrenal gland.", + "Three months after the adrenalectomy, a paralytic attack recurred.", + "The patient asked for assistance from the Department of Medical Genetics.", + "The patient's family history showed that two uncles, one brother, and a nephew also had a history of periodic paralysis.", + "The symptoms of the family members were milder.", + "The patient's CACNA1S and SCN4A genes were sequenced.", + "A novel missense mutation, c.1582C > T (p.Arg528Cys), in CACNA1S was detected.", + "Detection of the mutation in five adult male family members, including three with periodic paralysis and two with no history of the disease, indicated that this mutation caused hypokalaemic periodic paralysis type I in his family.", + "Follow-up 2 years after adrenalectomy showed that the serum potassium concentration was increased between paralyses.", + "The number and severity of paralytic attacks were significantly decreased." + ] + }, + { + "id": "multiclinsum_test_1149_en.txt", + "fulltext": "A 43-year-old male was implanted with a dual-chamber implantable cardioverter-defibrillator (ICD) for primary prevention. The patient presented with dyspnoea and had a family history of sudden cardiac death (SCD), hypertrophic cardiomyopathy, and mild LV systolic impairment (Class IIB recommendation for an ICD with a 5% risk of SCD at 5 years). No other abnormalities were detected. The underlying rhythm was sinus with first-degree AV Block (PR interval 340 ms) and a QRS duration of 90 ms. The ICD (AUTOGEN EL, Boston Scientific) was programmed to DDDR mode with rates of 70–120 b.p.m., and sensed and paced AV delays of 80 ms and 110 ms, respectively. Subsequent device follow-ups demonstrated normal device function and measurements, >95% atrial and ventricular pacing, and patient was symptomatically improving.\nSeven years after the initial presentation, patient presented with symptoms of progressive dyspnoea and a follow-up echocardiogram demonstrated moderate LV systolic impairment . As a result, RYTHMIQ™ and AV Search+ device features were enabled to minimize RV pacing. A device check 7 months later verified normal device and lead parameters . Atrial and ventricular pacing were 100% and 1%, respectively. As patient’s symptoms were improving, no changes to the device settings were made. The following day, the patient experienced a single episode of appropriate device (shock) therapy for ventricular fibrillation. Interrogation of device electrograms demonstrated initiation of ventricular arrhythmia due to R on T pacing.\nThe alert demonstrated an episode of shock delivered for ventricular arrhythmia. The trace begins with atrial pacing and ventricular sensing (VS) at the sensor indicated rate (SIR) (120 ppm) (1,2). As the RYTHMIQ™’s criteria were met (VS within A-A + 150 ms), the device remained in AAIR mode. In the presence of AV block and subsequent ventricular beats falling in the atrial blanking period , the device failed to detect the intrinsic ventricular events: [VS] (3). This initiated mode switch to backup VVI pacing [lower rate limit (LRL) set at 70 ppm, therefore, VVI backup is 55 ppm (1090 ms)], with ventricular paced beats on the 3rd, 6th, and 9th beats (4). We believe the closely coupled V-V timing resulted in R on T pacing (5), initiating ventricular fibrillation.", + "fulltext_subclaims": [ + "A 43-year-old male was implanted with a dual-chamber implantable cardioverter-defibrillator (ICD) for primary prevention.", + "The patient had a family history of sudden cardiac death.", + "The patient had hypertrophic cardiomyopathy.", + "The patient had mild LV systolic impairment.", + "The patient had a Class IIB recommendation for an ICD.", + "The patient had a 5% risk of sudden cardiac death at 5 years.", + "The underlying rhythm was sinus.", + "The patient had first-degree AV Block with a PR interval of 340 ms.", + "The QRS duration was 90 ms.", + "The ICD was programmed to DDDR mode.", + "The ICD had sensed and paced AV delays of 80 ms and 110 ms, respectively.", + "Subsequent device follow-ups demonstrated normal device function.", + "Subsequent device follow-ups demonstrated >95% atrial and ventricular pacing.", + "The patient was symptomatically improving.", + "Seven years after the initial presentation, the patient experienced progressive dyspnoea.", + "A follow-up echocardiogram demonstrated moderate LV systolic impairment.", + "RYTHMIQ™ and AV Search+ device features were enabled.", + "A device check 7 months later verified normal device and lead parameters.", + "Atrial pacing was 100%.", + "Ventricular pacing was 1%.", + "The patient experienced a single episode of appropriate device (shock) therapy for ventricular fibrillation.", + "Device interrogation demonstrated initiation of ventricular arrhythmia due to R on T pacing.", + "The alert demonstrated an episode of shock delivered for ventricular arrhythmia.", + "The trace began with atrial pacing and ventricular sensing at the sensor indicated rate (120 ppm).", + "RYTHMIQ™’s criteria were met (VS within A-A + 150 ms).", + "The device remained in AAIR mode.", + "The device failed to detect the intrinsic ventricular events.", + "This initiated mode switch to backup VVI pacing.", + "The lower rate limit was set at 70 ppm.", + "The VVI backup was 55 ppm.", + "Ventricular paced beats occurred on the 3rd, 6th, and 9th beats.", + "The closely coupled V-V timing resulted in R on T pacing.", + "R on T pacing initiated ventricular fibrillation." + ], + "summary": "We present a case of a 43-year-old male implanted with a dual-chamber primary prevention implantable cardioverter-defibrillator (AUTOGEN EL, Boston Scientific) for sudden cardiac death. At the time of implant, the patient had hypertrophic cardiomyopathy with mild left ventricular (LV) systolic impairment, and sinus rhythm with intact atrioventricular (AV) conduction. The patient developed progression of his disease with symptoms (dyspnoea) and LV impairment. This led to a decision to activate the minimal RV pacing algorithm (RYTHMIQ™). A deterioration in AV conduction caused intrinsic ventricular beats to fall in the atrial blanking period, and subsequent VVI backup pacing resulted in R on T pacing. This induced ventricular arrhythmia. RYTHMIQ™ was subsequently deactivated, and the patient has had no further device-induced arrhythmias.", + "summary_subclaims": [ + "The patient is a 43-year-old male.", + "The patient was implanted with a dual-chamber primary prevention implantable cardioverter-defibrillator.", + "The implantable cardioverter-defibrillator model is AUTOGEN EL.", + "The manufacturer of the implantable cardioverter-defibrillator is Boston Scientific.", + "The implant was for sudden cardiac death.", + "At the time of implant, the patient had hypertrophic cardiomyopathy.", + "At the time of implant, the patient had mild left ventricular systolic impairment.", + "At the time of implant, the patient had sinus rhythm.", + "At the time of implant, the patient had intact atrioventricular conduction.", + "The patient developed progression of his disease.", + "The patient developed symptoms of dyspnoea.", + "The patient developed left ventricular impairment.", + "The decision was made to activate the minimal RV pacing algorithm.", + "The minimal RV pacing algorithm is RYTHMIQ™.", + "A deterioration in AV conduction occurred.", + "Intrinsic ventricular beats fell in the atrial blanking period.", + "VVI backup pacing resulted in R on T pacing.", + "R on T pacing induced ventricular arrhythmia.", + "RYTHMIQ™ was subsequently deactivated.", + "The patient has had no further device-induced arrhythmias." + ] + }, + { + "id": "multiclinsum_test_802_en.txt", + "fulltext": "A 60-year-old female experienced an acute onset headache that was temporarily relieved with ibuprofen but presented to the emergency department 3 days later due to headache persistence. It was noted that she had a medical history of triple-negative breast cancer (TNBC) and ST-segment elevation myocardial infarction, as well as a family history of lung cancer and thyroid cancer. Head computed tomography (CT) revealed a small volume subarachnoid hemorrhage within the sulci overlying the posterior left cerebral convexity . Digital subtraction angiography (DSA) revealed a 3.9 × 3.5 × 4.2 mm aneurysm or pseudoaneurysm involving a bifurcation point of a distal M4 segment of the left MCA [ and ]. Mild stenosis of the distal parent vessel and branch vessel origins was also noted.\nEmbolization through distal navigation was attempted with a Headway® DUO microcatheter over a Synchro2® Soft microwire. However, due to the distal location, navigation was ultimately unsuccessful. Surgical clipping with intraoperative DSA guidance was then performed. The aneurysm was successfully clipped and resected, and the sample was sent for histopathology [ and ]. A postoperative CT scan of the head demonstrated expected postoperative changes involving the parietal lobe . Histopathological examination of the aneurysm sample confirmed triple-negative invasive ductal breast carcinoma . After surgery, the patient remained neurologically intact. Six weeks after surgery, she underwent CyberKnife stereotactic radiosurgery to the region of the resected aneurysm and began treatment with chemotherapy.\nFour months later, the patient presented once again with acute severe headache. Magnetic resonance imaging revealed multiple small lesions within the brain parenchyma, compatible with new metastatic deposits. Catheter angiography showed bilateral cerebral aneurysms, including a new mixed fusiform and saccular pseudoaneurysm arising from a distal M3 posterior division branch of the right MCA. In addition, there was a mixed fusiform and saccular pseudoaneurysm arising from a distal branch of the left callosomarginal artery with a saccular component measuring up to 2 mm in maximum dimension [ and ], as well as a 1 mm saccular outpouching arising from a distal M2 anterior division branch of the right MCA, suspicious for an additional small pseudoaneurysm .\nGiven the patient’s medical condition, these aneurysms were not felt to be amenable to open surgical repair, and endovascular therapy would have required parent artery sacrifice with associated risk of stroke. The patient was seen by an oncologist and radiation oncologist, and it was suggested by the team that there was a chance the aneurysms would be responsive to radiation therapy. The patient was subsequently treated with whole-brain radiation therapy and chemotherapy with capecitabine (Xeloda®). Radiation was well-tolerated other than headaches and fatigue, although the patient was capable of limited self-care and confined to a bed or chair >50% of waking hours. A short-term follow-up DSA was recommended to be sure that there was no unexpected, dramatic enlargement or change in configuration of the lesions. Although a nonsurgical course had been chosen, given the paucity of data regarding these unusual aneurysms, we felt that it was important to be able to modify our recommendations to the family if a significant change had occurred, potentially indicating a very high risk of imminent bleeding. Follow-up cerebral angiography 6 days after initiation of radiation therapy demonstrated interval decreased size of the right MCA posterior division distal M3 segment aneurysm.\nOver the ensuing 4 months, CT revealed progression of malignancy in the chest, abdomen, and pelvis. Termination of chemotherapy and radiation therapy was decided, and the patient was offered palliative care. She was placed on a tapering schedule of dexamethasone (Decadron®) to control inflammation and the anticonvulsant medication levetiracetam (Keppra®). The patient died 6 months later while receiving palliative treatment.", + "fulltext_subclaims": [ + "The patient was a 60-year-old female.", + "She experienced an acute onset headache.", + "The headache was temporarily relieved with ibuprofen.", + "She presented to the emergency department 3 days later due to headache persistence.", + "She had a medical history of triple-negative breast cancer.", + "She had a medical history of ST-segment elevation myocardial infarction.", + "Head CT revealed a small volume subarachnoid hemorrhage within the sulci overlying the posterior left cerebral convexity.", + "DSA revealed a 3.9 × 3.5 × 4.2 mm aneurysm or pseudoaneurysm involving a bifurcation point of a distal M4 segment of the left MCA.", + "Mild stenosis of the distal parent vessel and branch vessel origins was noted.", + "Embolization through distal navigation was attempted with a Headway® DUO microcatheter over a Synchro2® Soft microwire.", + "Navigation was ultimately unsuccessful.", + "Surgical clipping with intraoperative DSA guidance was performed.", + "The aneurysm was successfully clipped and resected.", + "The sample was sent for histopathology.", + "A postoperative CT scan of the head demonstrated expected postoperative changes involving the parietal lobe.", + "Histopathological examination of the aneurysm sample confirmed triple-negative invasive ductal breast carcinoma.", + "The patient remained neurologically intact after surgery.", + "Six weeks after surgery, she underwent CyberKnife stereotactic radiosurgery to the region of the resected aneurysm.", + "She began treatment with chemotherapy.", + "Four months later, she presented with acute severe headache.", + "MRI revealed multiple small lesions within the brain parenchyma, compatible with new metastatic deposits.", + "Catheter angiography showed bilateral cerebral aneurysms.", + "There was a new mixed fusiform and saccular pseudoaneurysm arising from a distal M3 posterior division branch of the right MCA.", + "There was a mixed fusiform and saccular pseudoaneurysm arising from a distal branch of the left callosomarginal artery with a saccular component measuring up to 2 mm in maximum dimension.", + "There was a 1 mm saccular outpouching arising from a distal M2 anterior division branch of the right MCA, suspicious for an additional small pseudoaneurysm.", + "The aneurysms were not felt to be amenable to open surgical repair.", + "Endovascular therapy would have required parent artery sacrifice with associated risk of stroke.", + "The patient was seen by an oncologist and radiation oncologist.", + "It was suggested by the team that there was a chance the aneurysms would be responsive to radiation therapy.", + "The patient was treated with whole-brain radiation therapy.", + "The patient was treated with chemotherapy with capecitabine.", + "Radiation was well-tolerated other than headaches and fatigue.", + "The patient was capable of limited self-care.", + "The patient was confined to a bed or chair >50% of waking hours.", + "A short-term follow-up DSA was recommended.", + "Follow-up cerebral angiography 6 days after initiation of radiation therapy demonstrated interval decreased size of the right MCA posterior division distal M3 segment aneurysm.", + "CT over the ensuing 4 months revealed progression of malignancy in the chest, abdomen, and pelvis.", + "Termination of chemotherapy and radiation therapy was decided.", + "The patient was offered palliative care.", + "She was placed on a tapering schedule of dexamethasone.", + "She was placed on the anticonvulsant medication levetiracetam.", + "The patient died 6 months later while receiving palliative treatment." + ], + "summary": "Head computed tomography (CT) revealed a small volume subarachnoid hemorrhage and digital subtraction angiography revealed a 3.9 x 3.5 x 4.2 mm aneurysm or pseudoaneurysm involving the left middle cerebral artery. The aneurysm was successfully clipped and resected, and histopathological examination confirmed triple-negative invasive ductal breast carcinoma within the aneurysm. Six weeks after surgery, she underwent stereotactic radiosurgery and began treatment with chemotherapy. Four months later, the patient presented once again with acute severe headache, and magnetic resonance imaging revealed multiple small lesions within the brain parenchyma, compatible with new metastatic deposits. The patient was subsequently treated with whole-brain radiation therapy and chemotherapy. Over the ensuing 4 months, CT revealed progression of malignancy in the chest, abdomen, and pelvis. Chemotherapy and radiation therapy were terminated, and the patient unfortunately succumbed to her disease 6 months later.", + "summary_subclaims": [ + "Head computed tomography (CT) revealed a small volume subarachnoid hemorrhage.", + "Digital subtraction angiography revealed a 3.9 x 3.5 x 4.2 mm aneurysm or pseudoaneurysm involving the left middle cerebral artery.", + "The aneurysm was successfully clipped and resected.", + "Histopathological examination confirmed triple-negative invasive ductal breast carcinoma within the aneurysm.", + "Six weeks after surgery, she underwent stereotactic radiosurgery.", + "She began treatment with chemotherapy.", + "Four months later, the patient presented once again with acute severe headache.", + "Magnetic resonance imaging revealed multiple small lesions within the brain parenchyma.", + "The lesions were compatible with new metastatic deposits.", + "The patient was subsequently treated with whole-brain radiation therapy.", + "The patient was treated with chemotherapy.", + "Over the ensuing 4 months, CT revealed progression of malignancy in the chest, abdomen, and pelvis.", + "Chemotherapy and radiation therapy were terminated.", + "The patient succumbed to her disease 6 months later." + ] + }, + { + "id": "multiclinsum_test_2920_en.txt", + "fulltext": "This 54-year-old Malay woman, an insurance agent, was seen at a primary care clinic in February 2021 when she was 52 years old for a routine follow-up of hypercholesterolaemia. She had been on treatment for hypercholesterolaemia since the age of 25. Initially, atorvastatin 40 mg nocte was commenced, and the dose was gradually increased to 80 mg nocte at the time of presentation. There was no history of chronic kidney disease, diabetes, or hypothyroidism to suggest a secondary cause for hypercholesterolaemia. She was a non-smoker and did not drink alcohol. She had no history of hypertension or cerebrovascular disease. The Edinburgh Claudication Questionnaire was negative for peripheral vascular disease (PVD). However, the WHO Rose Angina Questionnaire was positive. She had retrosternal chest pain during exertion, relieved within 5 min of taking glyceryl trinitrate 0.5 mg. It occurred once or twice a month. There was no radiation, shortness of breath, or any other associated symptoms. Her resting electrocardiogram was normal.\nThis patient was diagnosed with PCAD in 1998 at 29 years of age when she presented to a cardiology clinic complaining of exertional angina and reduced effort tolerance. She subsequently underwent percutaneous coronary intervention (PCI) of the left anterior descending artery. After the intervention, she received follow-up care at a primary care clinic. Unfortunately, she developed another episode of chest pain in 2015 at the age of 46. An angiogram revealed an 80% blocked left circumflex artery and obtuse marginal arteries. She was initially treated with medical therapy due to financial constraints but eventually underwent another PCI in 2018 at the age of 49 years. She then continued her follow-up concurrently in the cardiology and primary care clinics.\nThis patient had a strong family history of hypercholesterolaemia and PCAD. Both of her parents were treated for hypercholesterolaemia. Her father passed away at 63 due to a major adverse cardiovascular event (MACE). Her mother had coronary artery bypass grafting at 72 years old. Among her eight siblings, seven were treated for hypercholesterolaemia and had either MACE or sudden cardiac death between the ages of 43 and 56 at the time of diagnosis. She has three children who are being investigated for high cholesterol. None of her family members have had genetic testing for suspected FH. Her family pedigree chart is shown in .\nOn examination, she was obese, with a body mass index of 38.4 kg/m2. Her blood pressure was 104/74 mmHg. Other vital signs were normal. Bilateral grade 2 corneal arcus were observed , but the patient only noticed them at 52 years old. There was no tendon xanthoma.\nThe SBC, DLCN score, and FAMCAT relative risk score for this patient were deduced based on the clinical history and laboratory investigations that were extracted from her electronic medical record. The highest LDL-c level was 8.0 mmol/L, and the highest total cholesterol (TC) level was 10.7 mmol/L, recorded in October 2020. Therefore, this patient fulfilled the SBC (possible FH), DLCN (score of 8 – probable FH), and FAMCAT (relative risk score of 9.51) criteria. She was then offered and counselled for genetic testing, the gold standard for diagnosing FH. Targeted next-generation sequencing of the three FH candidate genes (LDLR, APOB, and PCSK9) was conducted. Subsequently, she was confirmed to carry a heterozygous pathogenic variant in the LDLR gene (rs769446356) located in intron 2 (noncoding area), in keeping with the American College of Medical Genetics and Genomics (ACMG) recommendation. This patient was then counselled by the primary care physician regarding the genetic diagnosis, the need to intensify her lipid-lowering medication (LLM), and to screen her first-degree relatives. The importance of adherence to lifestyle modification and pharmacotherapy was also emphasized.\nThis patient received long-term follow-up care from a multidisciplinary team of primary care physician, cardiologist, and lipid specialist. Despite being on atorvastatin 80 mg nocte, her LDL-c level was still high at 8.0 mmol/L, and her TC level was also high at 10.7 mmol/L. The cardiology team changed the LLM regime to a combination therapy of rosuvastatin 20 mg nocte and ezetimibe 10 mg daily. The lower rosuvastatin dose of 20 mg was chosen instead of 40 mg to minimize the potential side effects of high-intensity statin in this patient. She responded well to the combination treatment, where her LDL-c level decreased to 5.0 mmol/L, and her TC level decreased to 7.6 mmol/L. However, she still failed to achieve the ≥50% reduction in LDL-c or the target LDL-c of <1.8 mmol/L as recommended by the international guidelines. Her LLM will be further intensified by the lipid specialist in the subsequent follow-ups to achieve the recommended LDL-c target of <1.8 mmol/L by maximizing rosuvastatin from 20 to 40 mg nocte before adding an injectable LLM, such as the PCSK9 inhibitors. The possibility that lipoprotein apheresis may be needed in the future was also discussed with the patient if there is an inadequate response to the maximum tolerated dose of LLM. The cost of treatment with PCSK9 inhibitors and lipoprotein apheresis was also discussed, as these treatments are not currently reimbursed by the government health financing system in Malaysia.\nThe primary care physician conducted a cascade screening of her first-degree relatives. All three of her children were found to have elevated LDL-c levels and were clinically diagnosed with FH. They were started on statin monotherapy by the primary care physician and were referred to the lipid specialist for further management and intensification of LLM. The cardiology team was informed of the FH diagnosis in these children. summarizes the important key features of this case, and summarizes the clinical histories of her three children.", + "fulltext_subclaims": [ + "The patient is a 54-year-old Malay woman.", + "She was seen at a primary care clinic in February 2021.", + "She had been on treatment for hypercholesterolaemia since the age of 25.", + "Atorvastatin 40 mg nocte was initially commenced.", + "The dose was gradually increased to 80 mg nocte at the time of presentation.", + "There was no history of chronic kidney disease.", + "There was no history of diabetes.", + "There was no history of hypothyroidism.", + "She was a non-smoker.", + "She did not drink alcohol.", + "She had no history of hypertension.", + "She had no history of cerebrovascular disease.", + "The Edinburgh Claudication Questionnaire was negative for peripheral vascular disease.", + "The WHO Rose Angina Questionnaire was positive.", + "She had retrosternal chest pain during exertion.", + "The chest pain was relieved within 5 min of taking glyceryl trinitrate 0.5 mg.", + "The chest pain occurred once or twice a month.", + "There was no radiation of the chest pain.", + "There was no shortness of breath.", + "There were no other associated symptoms.", + "Her resting electrocardiogram was normal.", + "She was diagnosed with PCAD in 1998 at 29 years of age.", + "She underwent percutaneous coronary intervention of the left anterior descending artery.", + "She developed another episode of chest pain in 2015 at the age of 46.", + "An angiogram revealed an 80% blocked left circumflex artery.", + "An angiogram revealed an 80% blocked obtuse marginal arteries.", + "She was initially treated with medical therapy due to financial constraints.", + "She eventually underwent another PCI in 2018 at the age of 49 years.", + "She continued follow-up concurrently in the cardiology and primary care clinics.", + "Both of her parents were treated for hypercholesterolaemia.", + "Her father passed away at 63 due to a major adverse cardiovascular event.", + "Her mother had coronary artery bypass grafting at 72 years old.", + "Seven of her eight siblings were treated for hypercholesterolaemia.", + "Seven of her siblings had either MACE or sudden cardiac death between the ages of 43 and 56.", + "She has three children who are being investigated for high cholesterol.", + "None of her family members have had genetic testing for suspected FH.", + "On examination, she was obese with a body mass index of 38.4 kg/m2.", + "Bilateral grade 2 corneal arcus were observed.", + "The patient only noticed the corneal arcus at 52 years old.", + "There was no tendon xanthoma.", + "The highest LDL-c level was 8.0 mmol/L.", + "The highest total cholesterol level was 10.7 mmol/L.", + "The highest total cholesterol level was recorded in October 2020.", + "This patient fulfilled the SBC (possible FH) criteria.", + "This patient fulfilled the DLCN (score of 8 – probable FH) criteria.", + "This patient fulfilled the FAMCAT (relative risk score of 9.51) criteria.", + "She was offered and counselled for genetic testing.", + "Targeted next-generation sequencing of the three FH candidate genes was conducted.", + "She was confirmed to carry a heterozygous pathogenic variant in the LDLR gene.", + "The variant was located in intron 2 (noncoding area).", + "The variant was in keeping with the American College of Medical Genetics and Genomics recommendation.", + "She was counselled regarding the genetic diagnosis.", + "She was counselled regarding the need to intensify her lipid-lowering medication.", + "She was counselled regarding the need to screen her first-degree relatives.", + "The importance of adherence to lifestyle modification was emphasized.", + "The importance of adherence to pharmacotherapy was emphasized.", + "She received long-term follow-up care from a multidisciplinary team.", + "Despite being on atorvastatin 80 mg nocte, her LDL-c level was still high at 8.0 mmol/L.", + "Despite being on atorvastatin 80 mg nocte, her TC level was still high at 10.7 mmol/L.", + "The LLM regime was changed to a combination therapy of rosuvastatin 20 mg nocte and ezetimibe 10 mg daily.", + "The lower rosuvastatin dose of 20 mg was chosen to minimize potential side effects.", + "Her LDL-c level decreased to 5.0 mmol/L.", + "Her TC level decreased to 7.6 mmol/L.", + "She still failed to achieve the ≥50% reduction in LDL-c.", + "She still failed to achieve the target LDL-c of <1.8 mmol/L.", + "Her LLM will be further intensified by the lipid specialist.", + "The recommended LDL-c target is <1.8 mmol/L.", + "The possibility of adding an injectable LLM, such as PCSK9 inhibitors, was discussed.", + "The possibility of lipoprotein apheresis was discussed.", + "The cost of treatment with PCSK9 inhibitors and lipoprotein apheresis was discussed.", + "These treatments are not currently reimbursed by the government health financing system in Malaysia.", + "The primary care physician conducted a cascade screening of her first-degree relatives.", + "All three of her children were found to have elevated LDL-c levels.", + "All three of her children were clinically diagnosed with FH.", + "They were started on statin monotherapy by the primary care physician.", + "They were referred to the lipid specialist for further management.", + "The cardiology team was informed of the FH diagnosis in these children." + ], + "summary": "This is the case of a 54-year-old Malay woman with genetically confirmed FH complicated by premature coronary artery disease (PCAD). She was clinically diagnosed in primary care at 52 years old, fulfilling the Simon Broome Criteria (possible FH), Dutch Lipid Clinic Criteria (score of 8: probable FH), and Familial Hypercholesterolaemia Case Ascertainment Tool (relative risk score of 9.51). Subsequently, she was confirmed to have a heterozygous LDLR c.190+4A>T intron 2 pathogenic variant at the age of 53 years. She was known to have hypercholesterolaemia and was treated with statin since the age of 25. However, the lipid-lowering agent was not intensified to achieve the recommended treatment target. The delayed FH diagnosis has caused this patient to have PCAD and percutaneous coronary intervention (PCI) at the age of 29 years and a second PCI at the age of 49 years. She also has a very strong family history of hypercholesterolaemia and PCAD, where seven out of eight of her siblings were affected. Despite this, FH was not diagnosed early, and cascade screening of family members was not conducted, resulting in a missed opportunity to prevent PCAD.", + "summary_subclaims": [ + "The patient is a 54-year-old Malay woman.", + "She has genetically confirmed familial hypercholesterolaemia (FH).", + "She has premature coronary artery disease (PCAD).", + "She was clinically diagnosed in primary care at 52 years old.", + "She fulfilled the Simon Broome Criteria for possible FH.", + "She fulfilled the Dutch Lipid Clinic Criteria with a score of 8, indicating probable FH.", + "She had a Familial Hypercholesterolaemia Case Ascertainment Tool relative risk score of 9.51.", + "She was confirmed to have a heterozygous LDLR c.190+4A>T intron 2 pathogenic variant at age 53.", + "She was known to have hypercholesterolaemia.", + "She was treated with statin since age 25.", + "The lipid-lowering agent was not intensified to achieve the recommended treatment target.", + "The delayed FH diagnosis caused PCAD.", + "She had a percutaneous coronary intervention (PCI) at age 29.", + "She had a second PCI at age 49.", + "She has a very strong family history of hypercholesterolaemia and PCAD.", + "Seven out of eight of her siblings were affected.", + "FH was not diagnosed early.", + "Cascade screening of family members was not conducted.", + "There was a missed opportunity to prevent PCAD." + ] + }, + { + "id": "multiclinsum_test_2942_en.txt", + "fulltext": "An 18 year old female patient presented with acute symptoms of abdominal and flank pain, nausea, dark red urine, fevers and chills. One month prior to presentation, she had experienced a few days of rhinorrhea and headaches, suggestive of a viral upper respiratory tract infection. Upon presentation, she was found to be pregnant by serum hCG and ultrasound, with an estimated gestational age of 6 weeks. Laboratory evaluation showed hemoglobin 11.2 g/dL, haptoglobin <20 mg/dL, total bilirubin 6.8 mg/dL, direct bilirubin 0.7 mg/dL, lactic acid dehydrogenase (LDH) 735 U/L, and absolute reticulocyte count 49.3 K/μL. Urine analysis demonstrated 3+ blood and the microscopic examination was negative for red blood cells. A direct antiglobulin test was positive for anti-C3d and negative for IgG. The cold agglutinin titer was negative (<2). Donath Landsteiner antibody testing was performed using a blood sample that was immediately immersed into an insulated container filled with water at 37°C, and directly delivered to the testing laboratory. A Donath Landsteiner antibody test was positive , confirming the diagnosis of PCH. Over the next 48 hours, the patient’s hemoglobin declined to 7.3 g/dL . She was managed supportively with a prenatal vitamin supplement and encouraged to keep warm. Her hemoglobin and LDH normalized by day 42 . A Donath Landsteiner test on day 77 was negative. Her hemoglobin declined during the third trimester of pregnancy, to 11.0 g/dL on the day of delivery, without any laboratory evidence of recurrent hemolysis. She delivered a healthy female child by Cesarian section at 39 weeks of gestation. The neonate did not have anemia or hemolysis after birth.", + "fulltext_subclaims": [ + "The patient is an 18 year old female.", + "She presented with acute symptoms of abdominal and flank pain, nausea, dark red urine, fevers, and chills.", + "One month prior to presentation, she had experienced a few days of rhinorrhea and headaches.", + "The symptoms were suggestive of a viral upper respiratory tract infection.", + "Upon presentation, she was found to be pregnant by serum hCG and ultrasound.", + "The estimated gestational age was 6 weeks.", + "Laboratory evaluation showed hemoglobin 11.2 g/dL.", + "Haptoglobin was <20 mg/dL.", + "Total bilirubin was 6.8 mg/dL.", + "Direct bilirubin was 0.7 mg/dL.", + "Lactic acid dehydrogenase (LDH) was 735 U/L.", + "The absolute reticulocyte count was 49.3 K/μL.", + "Urine analysis demonstrated 3+ blood.", + "Microscopic examination was negative for red blood cells.", + "A direct antiglobulin test was positive for anti-C3d.", + "A direct antiglobulin test was negative for IgG.", + "The cold agglutinin titer was negative (<2).", + "A Donath Landsteiner antibody test was performed using a blood sample that was immediately immersed into an insulated container filled with water at 37°C.", + "The blood sample was directly delivered to the testing laboratory.", + "A Donath Landsteiner antibody test was positive.", + "The diagnosis of PCH was confirmed.", + "Over the next 48 hours, the patient’s hemoglobin declined to 7.3 g/dL.", + "She was managed supportively with a prenatal vitamin supplement.", + "She was encouraged to keep warm.", + "Her hemoglobin and LDH normalized by day 42.", + "A Donath Landsteiner test on day 77 was negative.", + "Her hemoglobin declined during the third trimester of pregnancy.", + "Her hemoglobin was 11.0 g/dL on the day of delivery.", + "There was no laboratory evidence of recurrent hemolysis.", + "She delivered a healthy female child by Cesarian section at 39 weeks of gestation.", + "The neonate did not have anemia or hemolysis after birth." + ], + "summary": "We report a case of an 18 year old female who presented in early pregnancy with acute hemolytic anemia and a positive Donath-Landsteiner antibody test. She was diagnosed with paroxysmal cold hemoglobinuria and treated supportively. Her hemolysis resolved within 6 weeks. Because maternal IgG autoantibodies can cross the placenta, the patient was monitored closely throughout her pregnancy for recurrence. The outcome of the pregnancy was successful, with no evidence of neonatal anemia or hemolysis.", + "summary_subclaims": [ + "The patient was an 18 year old female.", + "She presented in early pregnancy.", + "She had acute hemolytic anemia.", + "Her Donath-Landsteiner antibody test was positive.", + "She was diagnosed with paroxysmal cold hemoglobinuria.", + "She was treated supportively.", + "Her hemolysis resolved within 6 weeks.", + "Maternal IgG autoantibodies can cross the placenta.", + "The patient was monitored closely throughout her pregnancy for recurrence.", + "The outcome of the pregnancy was successful.", + "There was no evidence of neonatal anemia or hemolysis." + ] + }, + { + "id": "multiclinsum_test_3070_en.txt", + "fulltext": "15-year-old overweight female adolescent (BMI/E z-score + 1.3 SD), with no other medical or family history, presented to the emergency department with a two-week history of non-quantified fever, anorexia, and diffuse abdominal pain. Initial laboratory tests included a lipid profile with TG levels of 17,580 mg/dL, total cholesterol (TC) 1,633 mg/dL, high-density lipoprotein cholesterol (HDL-C) 1.8 mg/dL, low-density lipoprotein cholesterol (LDL-C) 1,573 mg/dL, blood glucose 200 mg/dL, lipase 723 U/L, and unprocessed amylase per lipemic sample.\n\nAn abdominal computed tomography (CT) scan showed an enlarged and edematous pancreas without peri-pancreatic collections. The patient was hospitalized with a diagnosis of severe PA and HTG and was started on continuous intravenous infusion of insulin. On the third day, a new abdominal CT scan showed signs of necrohemorrhagic pancreatitis.\n\nHe was transferred to the Paediatric Intensive Care Unit of the UC-Christus Health Network Hospital to continue his management, where he arrived in good general condition, haemodynamically stable, afebrile and with mild abdominal pain. The physical examination did not reveal xanthomas, xanthelasma, acanthosis nigricans or hepatomegaly. Control laboratory tests were performed: TG 3,222 mg/dL, CT 887 mg/dL, C-HDL 12 mg/dL, C-LDL 231 mg/dL, glycaemia 150 mg/dL, amylase 161 U/L and lipase 643 U/L.\n\nGiven the persistence of TGs above 1000 mg/dL (> 11.2 mmol/L), it was decided to maintain the continuous intravenous infusion of insulin at 0.05 U/kg/hour, with a glucose load of 2.27 mg/kg/min and gemfibrozil was initiated at a dose of 900 mg/day. On day 6, the TGs dropped to 500 mg/dL (5.6 mmol/L), so the continuous intravenous infusion of insulin was discontinued. However, the patient developed persistent metabolic acidosis, a fasting blood glucose of 206 mg/dL and a capillary blood glucose of 326 mg/dL. Because of suspicion of DM and in search of the classic triad of this disease, the patient's medical history was investigated, highlighting a history of polydipsia, polyuria and unobjectified weight loss during the last 3 months. A glycated hemoglobin A1c (HbA1c) was requested, which resulted in 14.7% (ref value < 5.7%), along with anti-TPO antibodies < 1, which determined a DM of pre-PA onset. Treatment with insulin (Lantus®) was initiated\n\n11 IU/day.\n\nOn day 10, an abdominal MRI and cholangiography were performed, which showed images consistent with PA with a right anterior parrenal acute hemorrhagic necrosis collection and another in the transverse mesocolon, without signs of pancreatic necrosis or gallstones.\n\nSubsequently, insulin therapy was adjusted with improvement of metabolic parameters, stabilisation of glycaemia and reduction of TG. After 15 days of favourable clinical evolution, without fever or abdominal pain and with good oral tolerance, control laboratory tests were performed that showed TG 244 mg/dL, glycaemia 175 mg/dL, lipase 73 U/L and amylase 26 U/L. Given the improvement of the clinical, laboratory and imaging picture, hospital discharge was decided.\n\nOne month after discharge, outpatient examinations showed normal levels of TG and CT, along with good metabolic control as a result of insulin treatment. Gemfibrozil was discontinued and continued on controls for DM1. A control CT of the abdomen and pelvis showed a decrease in the size of the anterior pararenal collection and resolution of the collection in the transverse mesocolon. Two months after discharge, a follow-up MRI showed findings similar to the CT, with a decrease in the size of the anterior right pararenal collection. Abdominal ultrasound performed one year after discharge showed a complete anatomical resolution of the pancreatic anomalies.\n", + "fulltext_subclaims": [ + "The patient is a 15-year-old overweight female adolescent.", + "The patient's BMI/E z-score is +1.3 SD.", + "The patient had no other medical or family history.", + "The patient presented with a two-week history of non-quantified fever.", + "The patient had anorexia.", + "The patient had diffuse abdominal pain.", + "Initial laboratory tests showed triglyceride (TG) levels of 17,580 mg/dL.", + "Initial laboratory tests showed total cholesterol (TC) of 1,633 mg/dL.", + "Initial laboratory tests showed high-density lipoprotein cholesterol (HDL-C) of 1.8 mg/dL.", + "Initial laboratory tests showed low-density lipoprotein cholesterol (LDL-C) of 1,573 mg/dL.", + "Initial laboratory tests showed blood glucose of 200 mg/dL.", + "Initial laboratory tests showed lipase of 723 U/L.", + "Initial laboratory tests showed unprocessed amylase per lipemic sample.", + "An abdominal CT scan showed an enlarged and edematous pancreas.", + "The abdominal CT scan showed no peri-pancreatic collections.", + "The patient was hospitalized with a diagnosis of severe PA and HTG.", + "The patient was started on continuous intravenous infusion of insulin.", + "On the third day, a new abdominal CT scan showed signs of necrohemorrhagic pancreatitis.", + "The patient was transferred to the Paediatric Intensive Care Unit of the UC-Christus Health Network Hospital.", + "The patient arrived in good general condition.", + "The patient was haemodynamically stable.", + "The patient was afebrile.", + "The patient had mild abdominal pain.", + "The physical examination did not reveal xanthomas.", + "The physical examination did not reveal xanthelasma.", + "The physical examination did not reveal acanthosis nigricans.", + "The physical examination did not reveal hepatomegaly.", + "Control laboratory tests showed TG of 3,222 mg/dL.", + "Control laboratory tests showed TC of 887 mg/dL.", + "Control laboratory tests showed C-HDL of 12 mg/dL.", + "Control laboratory tests showed C-LDL of 231 mg/dL.", + "Control laboratory tests showed glycaemia of 150 mg/dL.", + "Control laboratory tests showed amylase of 161 U/L.", + "Control laboratory tests showed lipase of 643 U/L.", + "Given the persistence of TGs above 1000 mg/dL, it was decided to maintain the continuous intravenous infusion of insulin.", + "The continuous intravenous infusion of insulin was at 0.05 U/kg/hour.", + "The glucose load was 2.27 mg/kg/min.", + "Gemfibrozil was initiated at a dose of 900 mg/day.", + "On day 6, the TGs dropped to 500 mg/dL.", + "On day 6, the continuous intravenous infusion of insulin was discontinued.", + "The patient developed persistent metabolic acidosis.", + "The patient had a fasting blood glucose of 206 mg/dL.", + "The patient had a capillary blood glucose of 326 mg/dL.", + "The patient's medical history included polydipsia.", + "The patient's medical history included polyuria.", + "The patient's medical history included unobjectified weight loss during the last 3 months.", + "A glycated hemoglobin A1c (HbA1c) was requested.", + "The HbA1c result was 14.7%.", + "The HbA1c reference value is < 5.7%.", + "Anti-TPO antibodies were < 1.", + "The diagnosis was DM of pre-PA onset.", + "Treatment with insulin (Lantus®) was initiated at 11 IU/day.", + "On day 10, an abdominal MRI and cholangiography were performed.", + "The MRI showed images consistent with PA.", + "The MRI showed a right anterior parrenal acute hemorrhagic necrosis collection.", + "The MRI showed another collection in the transverse mesocolon.", + "The MRI showed no signs of pancreatic necrosis.", + "The MRI showed no signs of gallstones.", + "Insulin therapy was adjusted.", + "There was improvement of metabolic parameters.", + "There was stabilisation of glycaemia.", + "There was reduction of TG.", + "After 15 days, the patient had no fever.", + "After 15 days, the patient had no abdominal pain.", + "After 15 days, the patient had good oral tolerance.", + "Control laboratory tests showed TG of 244 mg/dL.", + "Control laboratory tests showed glycaemia of 175 mg/dL.", + "Control laboratory tests showed lipase of 73 U/L.", + "Control laboratory tests showed amylase of 26 U/L.", + "Hospital discharge was decided.", + "One month after discharge, outpatient examinations showed normal levels of TG.", + "One month after discharge, outpatient examinations showed normal levels of CT.", + "One month after discharge, there was good metabolic control as a result of insulin treatment.", + "Gemfibrozil was discontinued.", + "The patient continued on controls for DM1.", + "A control CT of the abdomen and pelvis showed a decrease in the size of the anterior pararenal collection.", + "A control CT showed resolution of the collection in the transverse mesocolon.", + "Two months after discharge, a follow-up MRI showed findings similar to the CT.", + "Two months after discharge, the MRI showed a decrease in the size of the anterior right pararenal collection.", + "An abdominal ultrasound performed one year after discharge showed complete anatomical resolution of the pancreatic anomalies." + ], + "summary": "15-year-old overweight female adolescent, consulted for fever, anorexia and diffuse abdominal pain of two weeks evolution. Laboratory tests highlighted HTG 17,580 mg/dL, lipase 723 U/L, glycemia 200 mg/dL. Abdominal computed tomography showed enlarged and edematous pancreas. She was hospitalized with a diagnosis of PA and severe HTG, which evolved with PA necro-hemorrhagic. She was treated with continuous intravenous insulin infusion until the triglyceride levels decreased. When insulin was discontinued, she presented again with increased fasting glycemia (206 mg/dL) and metabolic acidosis, so DM was suspected. When asked directly, she highlighted a history of polydipsia, polyuria and weight loss during the last 3 months. Glycated hemoglobin (HbA1c) was very high (14.7%). Insulin treatment was optimized, achieving, 15 days after treatment, stabilization of laboratory parameters and complete anatomical resolution of the pancreatic compromise after one year of follow-up.\n", + "summary_subclaims": [ + "The patient is a 15-year-old overweight female adolescent.", + "She consulted for fever, anorexia, and diffuse abdominal pain of two weeks evolution.", + "Laboratory tests showed triglycerides of 17,580 mg/dL.", + "Lipase was 723 U/L.", + "Glycemia was 200 mg/dL.", + "Abdominal computed tomography showed an enlarged and edematous pancreas.", + "She was hospitalized with a diagnosis of pancreatitis and severe hypertriglyceridemia.", + "The condition evolved with necro-hemorrhagic pancreatitis.", + "She was treated with continuous intravenous insulin infusion until triglyceride levels decreased.", + "After insulin was discontinued, she presented with increased fasting glycemia of 206 mg/dL.", + "She had metabolic acidosis.", + "Diabetes mellitus was suspected.", + "She reported a history of polydipsia, polyuria, and weight loss during the last 3 months.", + "Glycated hemoglobin was 14.7%.", + "Insulin treatment was optimized.", + "Laboratory parameters stabilized 15 days after treatment.", + "There was complete anatomical resolution of the pancreatic compromise after one year of follow-up." + ] + }, + { + "id": "multiclinsum_test_2993_en.txt", + "fulltext": "A 63-year-old male with no personal or family history of psychiatric illness was admitted to the inpatient psychiatric ward at a teaching hospital in September 2018 because of sudden-onset manic-like symptoms including irritable mood, increased talkativeness, decreased need for sleep, and hyperactivity that began 2 weeks previously. Concurrently, he was convinced of the existence of a plot by his family members to murder him. He had received a kidney transplant for kidney disease due to diabetes in July 2016. Upon admission, a Mini-Mental State Examination (MMSE) was performed and his score (24/30) indicated impairments in orientation to time and concentration, but no abnormalities were found upon physical and neurological examination. Other than anti-diabetic medications, including gliclazide (60 mg/day) and linagliptin (5 mg/day), the patient was also being treated with the following immunosuppressants: tacrolimus (2 mg/day), methylprednisolone (4 mg/day), and sirolimus (2 mg/day). His tacrolimus levels (6.1 µg/mL) were within the therapeutic range (5–10 µg/mL). The consulted nephrologist recommended continued use of immunosuppressive drugs. On the first day of admission, blonanserin (8 mg/day), an atypical antipsychotic drug, was administered to alleviate psychotic symptoms.\nOn the second day, all laboratory results including a drug screen were normal, except increased serum glucose (220 mg/dL) and hemoglobin A1c (9.7%) levels. However, a cerebral magnetic resonance imaging (MRI) study revealed a tuberculum sellae mass measuring 15 × 8 × 13 mm. The lesion was typical of a meningioma displaying homogenous enhancement with gadolinium and a dural tail . Hyperintense white matter lesions with possible tacrolimus neurotoxicity were also seen on fluid-attenuated inversion recovery (FLAIR) images . Since the patient did not show any visual field defects, neurosurgical consultation recommended regular follow-up without surgery. On the tenth day of admission, manic symptoms and impaired cognitive functions significantly improved (MMSE score: 29/30), whereas persecutory delusions remained unchanged. Accordingly, the patient’s blonanserin dosage was increased to 16 mg/day. Seventeen days after admission, delusions disappeared completely, which was supported by his statement of gaining insight into illness. After 3 weeks of hospitalization, most of the symptoms resolved. He was discharged and kept on the triple immunosuppressive regimen without any change in their doses and a reduced dose of blonanserin (8 mg/day).", + "fulltext_subclaims": [ + "The patient was a 63-year-old male.", + "He had no personal or family history of psychiatric illness.", + "He was admitted to the inpatient psychiatric ward at a teaching hospital in September 2018.", + "He had sudden-onset manic-like symptoms including irritable mood, increased talkativeness, decreased need for sleep, and hyperactivity.", + "The symptoms began 2 weeks before admission.", + "He was convinced of the existence of a plot by his family members to murder him.", + "He had received a kidney transplant for kidney disease due to diabetes in July 2016.", + "Upon admission, a Mini-Mental State Examination (MMSE) was performed.", + "His MMSE score was 24/30.", + "The MMSE indicated impairments in orientation to time and concentration.", + "No abnormalities were found upon physical and neurological examination.", + "He was being treated with gliclazide (60 mg/day) and linagliptin (5 mg/day).", + "He was also being treated with tacrolimus (2 mg/day), methylprednisolone (4 mg/day), and sirolimus (2 mg/day).", + "His tacrolimus level was 6.1 µg/mL.", + "The tacrolimus level was within the therapeutic range (5–10 µg/mL).", + "The consulted nephrologist recommended continued use of immunosuppressive drugs.", + "On the first day of admission, blonanserin (8 mg/day) was administered to alleviate psychotic symptoms.", + "On the second day, all laboratory results including a drug screen were normal, except increased serum glucose (220 mg/dL) and hemoglobin A1c (9.7%) levels.", + "A cerebral MRI study revealed a tuberculum sellae mass measuring 15 × 8 × 13 mm.", + "The lesion was typical of a meningioma displaying homogenous enhancement with gadolinium and a dural tail.", + "Hyperintense white matter lesions with possible tacrolimus neurotoxicity were also seen on FLAIR images.", + "The patient did not show any visual field defects.", + "Neurosurgical consultation recommended regular follow-up without surgery.", + "On the tenth day of admission, manic symptoms and impaired cognitive functions significantly improved.", + "The patient’s MMSE score on the tenth day was 29/30.", + "Persecutory delusions remained unchanged on the tenth day.", + "The patient’s blonanserin dosage was increased to 16 mg/day.", + "Seventeen days after admission, delusions disappeared completely.", + "The patient’s statement of gaining insight into illness supported the disappearance of delusions.", + "After 3 weeks of hospitalization, most of the symptoms resolved.", + "He was discharged and kept on the triple immunosuppressive regimen without any change in their doses.", + "He was discharged on a reduced dose of blonanserin (8 mg/day)." + ], + "summary": "A 63-year-old male presenting with acute psychotic mania was admitted to a psychiatric ward approximately 2 years after kidney transplantation. On brain magnetic resonance imaging, a tuberculum sellae meningioma was found, and hyperintense white matter lesions with possible tacrolimus-induced neurotoxicity were seen on fluid-attenuated inversion recovery images. Interestingly, the patient showed no visual field defects, and his blood tacrolimus concentration was within therapeutic ranges. After 3 weeks of adjunctive treatment with blonanserin, most of the symptoms had abated.", + "summary_subclaims": [ + "The patient is a 63-year-old male.", + "The patient presented with acute psychotic mania.", + "The patient was admitted to a psychiatric ward.", + "The admission occurred approximately 2 years after kidney transplantation.", + "A tuberculum sellae meningioma was found on brain magnetic resonance imaging.", + "Hyperintense white matter lesions were seen on fluid-attenuated inversion recovery images.", + "The white matter lesions were possibly due to tacrolimus-induced neurotoxicity.", + "The patient showed no visual field defects.", + "The patient's blood tacrolimus concentration was within therapeutic ranges.", + "The patient received 3 weeks of adjunctive treatment with blonanserin.", + "Most of the symptoms had abated after 3 weeks of treatment." + ] + }, + { + "id": "multiclinsum_test_384_en.txt", + "fulltext": "A 79-year-old lady with a background of multiple spinal fractures resulting in chronic back pain, poor mobility and falls, osteoporosis and mild cognitive impairment was admitted to the Queen Elizabeth University Hospital, Glasgow, during August 2015. She was found unconscious in the garden by a neighbour and the paramedics were called to the scene. She was unable to mobilise and had been positioned in the one location unnoticed for a minimum of 2 days. On admission to the local hospital’s Accident and Emergency (A&E) department, the patient was confused, dehydrated, septic and sunburnt. She had abrasions over her thoracic and sacral area with cellulitis. When her trousers were removed, it was noted that a fly flew out. Further investigations revealed maggots embedded in her vagina labia. A fracture to the right neck of her femur, rhabdomyolysis and a urinary tract infection were also noted.\nThe maggots, six in total, were removed from the labia using tweezers and sent to the Scottish Parasite Diagnostic and Reference Laboratory (SPDRL), Glasgow Royal Infirmary. On arrival at the SPDRL, the live maggots were killed by immersing in boiling water for 60 s before being submerged in 90 % ethanol. The final segment containing the posterior spiracles of the segmented body was dissected using a sterile blade before being submerged into 5 % potassium hydroxide. This was gently heated to 100 °C for 5 min. Once cooled, the segment was rinsed in distilled water then transferred to a glass slide and examined under both the dissecting microscope and a light microscope using ×10 magnification.\nThe second instar larvae showing the spiracles were identified as those from the Protophormia species northern blowfly of the family Calliphoridae .\nThe patient’s condition improved after complete removal of the larvae followed by cleansing of the infected area, intravenous fluids and antibiotics. She remained well enough to go to theatre for a dynamic hip screw 10 days post admission.\nThe patient was reviewed by the Gynaecology Team 4 days later, and there was no evidence of an ongoing vaginal infestation. The patient was transferred to a local rehabilitation centre and made good progress. She was discharged home late November 2015.", + "fulltext_subclaims": [ + "The patient was a 79-year-old lady.", + "She had a background of multiple spinal fractures.", + "She had chronic back pain.", + "She had poor mobility.", + "She had falls.", + "She had osteoporosis.", + "She had mild cognitive impairment.", + "She was admitted to the Queen Elizabeth University Hospital, Glasgow, during August 2015.", + "She was found unconscious in the garden by a neighbour.", + "The paramedics were called to the scene.", + "She had been positioned in the one location unnoticed for a minimum of 2 days.", + "On admission to the local hospital’s Accident and Emergency department, the patient was confused.", + "On admission to the local hospital’s Accident and Emergency department, the patient was dehydrated.", + "On admission to the local hospital’s Accident and Emergency department, the patient was septic.", + "On admission to the local hospital’s Accident and Emergency department, the patient was sunburnt.", + "She had abrasions over her thoracic and sacral area with cellulitis.", + "When her trousers were removed, it was noted that a fly flew out.", + "Further investigations revealed maggots embedded in her vagina labia.", + "A fracture to the right neck of her femur was noted.", + "Rhabdomyolysis was noted.", + "A urinary tract infection was noted.", + "The maggots, six in total, were removed from the labia using tweezers.", + "The maggots were sent to the Scottish Parasite Diagnostic and Reference Laboratory, Glasgow Royal Infirmary.", + "On arrival at the SPDRL, the live maggots were killed by immersing in boiling water for 60 s.", + "The maggots were then submerged in 90 % ethanol.", + "The final segment containing the posterior spiracles of the segmented body was dissected using a sterile blade.", + "The segment was submerged into 5 % potassium hydroxide.", + "The segment was gently heated to 100 °C for 5 min.", + "Once cooled, the segment was rinsed in distilled water.", + "The segment was transferred to a glass slide.", + "The segment was examined under both the dissecting microscope and a light microscope using ×10 magnification.", + "The second instar larvae showing the spiracles were identified as those from the Protophormia species northern blowfly of the family Calliphoridae.", + "The patient’s condition improved after complete removal of the larvae.", + "The patient received cleansing of the infected area.", + "The patient received intravenous fluids.", + "The patient received antibiotics.", + "She remained well enough to go to theatre for a dynamic hip screw 10 days post admission.", + "The patient was reviewed by the Gynaecology Team 4 days later.", + "There was no evidence of an ongoing vaginal infestation.", + "The patient was transferred to a local rehabilitation centre.", + "She made good progress.", + "She was discharged home late November 2015." + ], + "summary": "We describe an unusual case of a 79-year-old female who collapsed in her garden and lay there for several days before presenting to her local hospital Accident and Emergency department with an infestation of larvae in her vagina labia, identified as those from the Protophormia species northern blowfly. After complete removal of the larvae using tweezers followed by cleansing of the affected area and a course of antibiotics, the patient's condition improved. A follow-up review by the local gynaecology team revealed no evidence of further infestation.", + "summary_subclaims": [ + "The patient was a 79-year-old female.", + "She collapsed in her garden.", + "She lay there for several days before presenting to her local hospital Accident and Emergency department.", + "She had an infestation of larvae in her vagina labia.", + "The larvae were identified as those from the Protophormia species northern blowfly.", + "The larvae were completely removed using tweezers.", + "The affected area was cleansed.", + "The patient received a course of antibiotics.", + "The patient's condition improved.", + "A follow-up review by the local gynaecology team revealed no evidence of further infestation." + ] + }, + { + "id": "multiclinsum_test_2774_en.txt", + "fulltext": "A 27-year-old Caucasian man presented to the emergency department (ED) following the acute onset of severe, sharp chest and abdominal pain radiating to his shoulder blades and testicles. These symptoms began acutely five hours earlier, waking him from sleep and were associated with nausea and generalized weakness. He was initially able to return to sleep although he clearly stated that the pain was exacerbated in the supine position. On presentation to the ED, his initial vital signs included a blood pressure of 80/60 mm Hg and a heart rate of 60 beats/minute described as 'thready.' His respiratory rate was 26 per minute and he was afebrile. His blood pressure while supine prior to fluid resuscitation was 98/60 mm Hg. The patient had a single episode of emesis in the ED. The initial abdominal examination demonstrated both guarding and rebound tenderness with normal bowel sounds but the remainder of the physical examination, including the testicles, was unremarkable. Fluid resuscitation was initiated and blood pressure stabilised at 110/60.\nHis past medical history and review of systems were unremarkable including no peptic ulcer disease and no travel history. Family history did not include any bleeding diathesis, connective tissue or rheumatologic condition. His only medication was ranitidine recently taken for heartburn as needed.\nInitial blood work demonstrated a hemoglobin level of 115 g/L without any obvious history of bleeding and a white blood cell count of 13.8 g/L. Liver enzymes, electrolytes, blood glucose, blood urea nitrogen, creatinine, and amylase were essentially normal, and an electrocardiogram was unremarkable. Both the ED physician and consultant radiologist reported erect and supine views of the abdomen and postero-anterior and lateral views of the chest were normal. In particular, no rib fractures were evident on the chest X-ray, and the left hemi-diaphragm appeared normal. The point of care ultrasound machine was out-of-service at the time this patient presented.\nIntense pain persisted after a total of 20 mg of morphine, 50 mg of dimenhydrinate and 20 mg of hyoscine. He was sent for a contrast enhanced computed tomography (CT) scan of the chest, abdomen and pelvis which demonstrated a macerated spleen with rupture resulting in a significant hemoperitoneum . Only after this revelation and with repeated specific questioning did the patient recall an apparently trivial injury to his left side about one week prior to presentation while playfully wrestling with his partner. He did not present for assessment of the injury at that time.\nSplenectomy and post-operative recovery were uneventful and he was discharged home one week after presentation. The pathology report of our patient's spleen later documented an organ weighing 235 grams and measuring 14.0 × 9.5 × 5.5 cm. This weight is within the reported range of normal . Approximately 30% of the splenic parenchyma contained dilated hemorrhage filled vascular areas but the uninvolved parenchyma appeared grossly and histologically normal.", + "fulltext_subclaims": [ + "A 27-year-old Caucasian man presented to the emergency department following the acute onset of severe, sharp chest and abdominal pain radiating to his shoulder blades and testicles.", + "These symptoms began acutely five hours earlier, waking him from sleep.", + "The symptoms were associated with nausea and generalized weakness.", + "He was initially able to return to sleep.", + "He clearly stated that the pain was exacerbated in the supine position.", + "On presentation to the ED, his initial blood pressure was 80/60 mm Hg.", + "His heart rate was 60 beats/minute described as 'thready.'", + "His respiratory rate was 26 per minute.", + "He was afebrile.", + "His blood pressure while supine prior to fluid resuscitation was 98/60 mm Hg.", + "The patient had a single episode of emesis in the ED.", + "The initial abdominal examination demonstrated both guarding and rebound tenderness.", + "The remainder of the physical examination, including the testicles, was unremarkable.", + "Fluid resuscitation was initiated.", + "Blood pressure stabilised at 110/60.", + "His past medical history and review of systems were unremarkable.", + "Family history did not include any bleeding diathesis, connective tissue or rheumatologic condition.", + "His only medication was ranitidine recently taken for heartburn as needed.", + "Initial blood work demonstrated a hemoglobin level of 115 g/L.", + "There was no obvious history of bleeding.", + "The white blood cell count was 13.8 g/L.", + "Liver enzymes, electrolytes, blood glucose, blood urea nitrogen, creatinine, and amylase were essentially normal.", + "An electrocardiogram was unremarkable.", + "Both the ED physician and consultant radiologist reported erect and supine views of the abdomen and postero-anterior and lateral views of the chest were normal.", + "No rib fractures were evident on the chest X-ray.", + "The left hemi-diaphragm appeared normal.", + "The point of care ultrasound machine was out-of-service at the time this patient presented.", + "Intense pain persisted after a total of 20 mg of morphine, 50 mg of dimenhydrinate and 20 mg of hyoscine.", + "He was sent for a contrast enhanced computed tomography (CT) scan of the chest, abdomen and pelvis.", + "The CT scan demonstrated a macerated spleen with rupture resulting in a significant hemoperitoneum.", + "Only after this revelation and with repeated specific questioning did the patient recall an apparently trivial injury to his left side about one week prior to presentation.", + "He did not present for assessment of the injury at that time.", + "Splenectomy and post-operative recovery were uneventful.", + "He was discharged home one week after presentation.", + "The pathology report of the patient's spleen documented an organ weighing 235 grams.", + "The spleen measured 14.0 × 9.5 × 5.5 cm.", + "This weight is within the reported range of normal.", + "Approximately 30% of the splenic parenchyma contained dilated hemorrhage filled vascular areas.", + "The uninvolved parenchyma appeared grossly and histologically normal." + ], + "summary": "A 27-year-old Caucasian man with no underlying splenic pathology presented with splenic rupture one week after playfully wrestling with his partner. The patient did not present at the time of the injury and only recalled it upon repeated questioning after computed tomography diagnosis.", + "summary_subclaims": [ + "The patient is a 27-year-old Caucasian man.", + "The patient had no underlying splenic pathology.", + "The patient presented with splenic rupture.", + "The splenic rupture occurred one week after playfully wrestling with his partner.", + "The patient did not present at the time of the injury.", + "The patient only recalled the injury upon repeated questioning after computed tomography diagnosis." + ] + }, + { + "id": "multiclinsum_test_1873_en.txt", + "fulltext": "A 42 year-old, right hand dominant male presented with 10 years of atraumatic right shoulder pain, exacerbated by overhead activity and weightlifting. He denied any history of trauma or instability. Physical examination revealed no gross deformities and no tenderness at the acromioclavicular joint or along the bicipital tunnel. Internal rotation was slightly limited compared to his contralateral side. The rotator cuff (RC) demonstrated mild weakness and was easily fatigued. Neer and Hawkins impingement tests were markedly positive. The active compression test (O’Brien Sign) was also positive as indicated by reproduction of the patient’s symptoms - pain deep within the glenohumeral joint - during phase one (thumb down) that were alleviated in phase two (thumb up). Cross-body adduction, speeds, and Yergason tests were all negative, and there was no evidence of shoulder instability. Magnetic resonance imaging demonstrated a partial-thickness articular-sided tearing of the supraspinatus (SS) and degenerative labrum tearing The biceps tendon was noted to have an accessory slip originating from the anterior aspect of the SS. Conservative efforts including oral anti-inflammatories, activity modification, corticosteroid injection, and physical therapy failed to provide longstanding relief. The patient elected to undergo definitive surgical intervention to include labral debridement, subacromial decompression, and biceps tenodesis. During diagnostic arthroscopy, the origin of the LHBT was found to be trifurcate, with origins arising from the SS tendon, superior labrum, and rotator interval (RI). At the articular margin, the LHBT was bifurcate . The more anterior of these two structures (2.8 cm) attached to the RI with its fibers blending such that the tendon was grossly indistinguishable from the interval tissue itself and separate from the leading edge of the SS. The more posterior bifurcate portion of the LHBT (3.8 cm) itself bifurcated with one portion attaching directly to the undersurface of the SS, while the remaining band attached to the superior labrum/supraglenoid tubercle . No fraying or gross inflammatory changes of the LHBT were appreciated . Tenotomy of all three origins was carried out using a radiofrequency ablation wand with care to avoid damaging either the SS or the RI tissue. Subpectoral biceps tenodesis was selected for definitive management to enable fixation of a single tendon. Postoperatively, the patient was started on early range of motion with limitations of active elbow flexion to less than 1 pound for the first 6 weeks followed by progressive strengthening. By 3 months postoperatively, the patient maintained normal biceps contour, regained full shoulder motion, and was progressing his activities without limitation.", + "fulltext_subclaims": [ + "The patient is a 42 year-old, right hand dominant male.", + "He had 10 years of atraumatic right shoulder pain.", + "The pain was exacerbated by overhead activity and weightlifting.", + "He denied any history of trauma or instability.", + "Physical examination revealed no gross deformities.", + "There was no tenderness at the acromioclavicular joint.", + "There was no tenderness along the bicipital tunnel.", + "Internal rotation was slightly limited compared to his contralateral side.", + "The rotator cuff demonstrated mild weakness.", + "The rotator cuff was easily fatigued.", + "Neer and Hawkins impingement tests were markedly positive.", + "The active compression test (O’Brien Sign) was positive.", + "Pain deep within the glenohumeral joint was reproduced during phase one (thumb down) of the active compression test.", + "Pain was alleviated in phase two (thumb up) of the active compression test.", + "Cross-body adduction, speeds, and Yergason tests were all negative.", + "There was no evidence of shoulder instability.", + "Magnetic resonance imaging demonstrated a partial-thickness articular-sided tearing of the supraspinatus.", + "Degenerative labrum tearing was noted.", + "The biceps tendon was noted to have an accessory slip originating from the anterior aspect of the supraspinatus.", + "Conservative efforts including oral anti-inflammatories, activity modification, corticosteroid injection, and physical therapy failed to provide longstanding relief.", + "The patient elected to undergo definitive surgical intervention.", + "Surgical intervention included labral debridement.", + "Surgical intervention included subacromial decompression.", + "Surgical intervention included biceps tenodesis.", + "During diagnostic arthroscopy, the origin of the LHBT was found to be trifurcate.", + "The LHBT had origins arising from the supraspinatus tendon.", + "The LHBT had origins arising from the superior labrum.", + "The LHBT had origins arising from the rotator interval.", + "At the articular margin, the LHBT was bifurcate.", + "The more anterior of the two structures at the articular margin attached to the rotator interval.", + "The more posterior bifurcate portion of the LHBT itself bifurcated.", + "One portion of the posterior bifurcate portion attached directly to the undersurface of the supraspinatus.", + "The remaining band of the posterior bifurcate portion attached to the superior labrum/supraglenoid tubercle.", + "No fraying or gross inflammatory changes of the LHBT were appreciated.", + "Tenotomy of all three origins was carried out using a radiofrequency ablation wand.", + "Care was taken to avoid damaging either the supraspinatus or the rotator interval tissue.", + "Subpectoral biceps tenodesis was selected for definitive management.", + "Postoperatively, the patient was started on early range of motion.", + "Active elbow flexion was limited to less than 1 pound for the first 6 weeks.", + "By 3 months postoperatively, the patient maintained normal biceps contour.", + "By 3 months postoperatively, the patient regained full shoulder motion.", + "By 3 months postoperatively, the patient was progressing his activities without limitation." + ], + "summary": "We report a case of a trifurcate intra-articular LHBT, a variation which, to our knowledge, has not been previously described. The patient was an adult male presenting with chronic atraumatic shoulder pain that worsened with overhead activity. On arthroscopy, the LHBT was found to have three origins from the (1) supraspinatus tendon, (2) superior labrum, and (3) rotator interval that joined together distally within the biceps tunnel. We believe the split tendon may have caused impingement the biceps tunnel; therefore, the patient was treated with subpectoral tenodesis. He also underwent subacromial decompression and rotator cuff debridement.", + "summary_subclaims": [ + "We report a case of a trifurcate intra-articular LHBT.", + "To our knowledge, this variation has not been previously described.", + "The patient was an adult male.", + "The patient presented with chronic atraumatic shoulder pain.", + "The shoulder pain worsened with overhead activity.", + "On arthroscopy, the LHBT was found to have three origins.", + "The first origin was from the supraspinatus tendon.", + "The second origin was from the superior labrum.", + "The third origin was from the rotator interval.", + "The three origins joined together distally within the biceps tunnel.", + "We believe the split tendon may have caused impingement in the biceps tunnel.", + "The patient was treated with subpectoral tenodesis.", + "The patient also underwent subacromial decompression.", + "The patient also underwent rotator cuff debridement." + ] + }, + { + "id": "multiclinsum_test_695_en.txt", + "fulltext": "Our patient is a 31-year-old Sudanese female from Sudan who came to Canada in July of 2017 as a refugee. She is recognized as a Government-Assisted Refugee (GAR) which is defined as “a person who is outside Canada and has been determined to be a Convention refugee and who receives financial and other support” .\nUpon arrival in Canada with her 5 children - aged 5 to 16 years - she underwent medical evaluation and was put in contact with a “Welcome Clinic” which specializes in medical evaluation of refugees. After undergoing routine medical evaluation, she was diagnosed with HIV and severe dental caries in August 2017. When she was tested 1 year prior to arriving in Canada, she was negative for HIV.\nAfter being diagnosed with HIV she was put into contact with an HIV specialist with whom she is currently following up with. The patient is on government assistance and is receiving financial aid for herself and her children. The cost of living is automatically deducted from her bank account. The government assistance will expire in a year and then she must provide for herself or resettle [, ]. The patient does not understand how the financial aid system works and reports that she constantly worries about what will happen to her and her children after the year of assistance have expired.\nShe reports that she has not told anyone about her diagnosis; she has only told those that are involved in her medical care. She is embarrassed and afraid of what people will think about her after learning about her diagnosis. Her only support system is her children and she refuses to tell them about her diagnosis.\nIn her refugee camp in Sudan, she was given education regarding HIV including how HIV is transmitted, the risk factors associated with it, and practices regarding HIV risk reduction. When discussing her diagnosis, however, she did not know that treatment was lifelong and she was under the impression that after one course of treatment, she would be cured.\nWhen discussing if she has any other concerns with her diagnosis or her transition to Canada, she explains that her teeth are still sore, and her dental carries have not been resolved yet (almost 5 months after visiting the dentist). According to the patient’s record, the dentist was unable to provide any care due to administrative issues. She also goes on to state that transportation is a very big issue for her here as she does not understand how the transport system works here -she relies on a social worker from the Welcome Clinic to assist her in her transportation. Similarly, language has been a concern for her as her dialect of Arabic is different than those in her medical care team and therefore, she expressed that she has difficulty in speaking with medical staff.\nCurrently, the patient is stable on her antiretroviral’s (ARVs) and is following up with her infectious diseases specialist.", + "fulltext_subclaims": [ + "The patient is a 31-year-old Sudanese female.", + "She came to Canada in July of 2017 as a refugee.", + "She is recognized as a Government-Assisted Refugee.", + "A Government-Assisted Refugee is defined as “a person who is outside Canada and has been determined to be a Convention refugee and who receives financial and other support.”", + "She arrived in Canada with five children aged 5 to 16 years.", + "She underwent medical evaluation upon arrival.", + "She was put in contact with a “Welcome Clinic” which specializes in medical evaluation of refugees.", + "She was diagnosed with HIV in August 2017.", + "She was tested for HIV one year prior to arriving in Canada and was negative.", + "She was diagnosed with severe dental caries in August 2017.", + "She was put into contact with an HIV specialist.", + "She is currently following up with an HIV specialist.", + "She is on government assistance.", + "She is receiving financial aid for herself and her children.", + "The cost of living is automatically deducted from her bank account.", + "The government assistance will expire in a year.", + "She does not understand how the financial aid system works.", + "She reports that she constantly worries about what will happen to her and her children after the year of assistance has expired.", + "She has not told anyone about her HIV diagnosis.", + "She has only told those involved in her medical care about her diagnosis.", + "She is embarrassed about her diagnosis.", + "She is afraid of what people will think about her after learning about her diagnosis.", + "Her only support system is her children.", + "She refuses to tell her children about her diagnosis.", + "In her refugee camp in Sudan, she was given education regarding HIV.", + "She did not know that treatment for HIV is lifelong.", + "She was under the impression that after one course of treatment, she would be cured.", + "Her teeth are still sore.", + "Her dental caries have not been resolved yet.", + "The dentist was unable to provide any care due to administrative issues.", + "Transportation is a very big issue for her.", + "She does not understand how the transport system works.", + "She relies on a social worker from the Welcome Clinic to assist her with transportation.", + "Her dialect of Arabic is different than those in her medical care team.", + "She has difficulty speaking with medical staff.", + "She is stable on her antiretroviral’s (ARVs).", + "She is following up with her infectious diseases specialist." + ], + "summary": "31-year-old female arrived in Canada as a refugee from Sudan with her 5 children in July of 2017. She was diagnosed with HIV and severe dental carries during her initial medical evaluation and referred to our centre. A lack of social support has resulted in severe psychological stress. The first being stigmatization which has led to her not disclosing the diagnosis to anyone outside her medical care team. Her level of knowledge about HIV is consistent with literature reporting that despite HIV prevention programs in refugee camps, compliance with risk reduction behaviors, especially in females, is low. Lastly, her major concern relates to the cost of living and supporting her children.", + "summary_subclaims": [ + "The patient is a 31-year-old female.", + "She arrived in Canada as a refugee from Sudan.", + "She arrived with her 5 children in July of 2017.", + "She was diagnosed with HIV during her initial medical evaluation.", + "She was diagnosed with severe dental carries during her initial medical evaluation.", + "A lack of social support has resulted in severe psychological stress.", + "Stigmatization has led to her not disclosing the diagnosis to anyone outside her medical care team.", + "Her level of knowledge about HIV is consistent with literature reporting that despite HIV prevention programs in refugee camps, compliance with risk reduction behaviors, especially in females, is low.", + "Her major concern relates to the cost of living and supporting her children." + ] + }, + { + "id": "multiclinsum_test_2401_en.txt", + "fulltext": "A 32-year-old asymptomatic woman with a mediastinal mass found by CT scan 2 years ago was admitted to our hospital. Physical examination and laboratory tests showed no significant abnormalities. Contrast-enhanced chest CT scan revealed a sharply marginated mass, 24 × 33 mm in size, in the right superior mediastinum . A right-sided video-assisted thoracoscopic thoracotomy was performed, a 3 cm uniport through the 4th intercostal at midaxillary line was made to perform the procedure. Intraoperatively, a 4 × 3 cm mass was found in the right superior mediastinum, which was originated from the right vagus nerve. The boundary of the tumor was clear, and the tumor was excised completely . Grossly, the tumor was encapsulated by a complete envelope, with yellow-colored solid component inside . Histologic examination revealed that the tumor was formed by spindle cells and loose myxoid tissue, which clarified the diagnosis as schwannoma . The patient recovered uneventfully after the surgery, and was discharged on the 3rd postoperative day.", + "fulltext_subclaims": [ + "A 32-year-old asymptomatic woman with a mediastinal mass found by CT scan 2 years ago was admitted to our hospital.", + "Physical examination and laboratory tests showed no significant abnormalities.", + "Contrast-enhanced chest CT scan revealed a sharply marginated mass, 24 × 33 mm in size, in the right superior mediastinum.", + "A right-sided video-assisted thoracoscopic thoracotomy was performed.", + "A 3 cm uniport through the 4th intercostal at midaxillary line was made to perform the procedure.", + "Intraoperatively, a 4 × 3 cm mass was found in the right superior mediastinum.", + "The tumor was originated from the right vagus nerve.", + "The boundary of the tumor was clear.", + "The tumor was excised completely.", + "Grossly, the tumor was encapsulated by a complete envelope.", + "The tumor had a yellow-colored solid component inside.", + "Histologic examination revealed that the tumor was formed by spindle cells and loose myxoid tissue.", + "The diagnosis was clarified as schwannoma.", + "The patient recovered uneventfully after the surgery.", + "The patient was discharged on the 3rd postoperative day." + ], + "summary": "This article reported one case of schwannoma originating from vagus nerve in the right superior mediastinum. The mediastinal schwannoma was completely resected through a right-sided video-assisted thoracoscopic thoracotomy. Histologic examination clarified the diagnosis as schwannoma.", + "summary_subclaims": [ + "This article reported one case of schwannoma originating from vagus nerve in the right superior mediastinum.", + "The mediastinal schwannoma was completely resected through a right-sided video-assisted thoracoscopic thoracotomy.", + "Histologic examination clarified the diagnosis as schwannoma." + ] + }, + { + "id": "multiclinsum_test_1349_en.txt", + "fulltext": "A 65-year-old white male was referred to our Vitreo-Retinal Surgery Service for a retinal detachment (RD) in his right eye. On examination, his best-corrected visual acuity (BCVA) was 20/63 in the right eye (RE) and 20/20 in the left eye (LE), with a small refractive error. Intraocular pressure was 15 mmHg OU. Slitlamp examination revealed quiet anterior chambers and slight nuclear sclerosis in both eyes. Dilated fundus examination of the right eye showed an inferior bullous RD involving the macula with no evidence of retinal breaks, while a large RPE tear was detected in the temporal quadrant . There was no sign of uveitis or vitreitis. Fundus examination of the LE was unremarkable, except for slight RPE distrophic alterations at the posterior pole with RPE mottling. Enhanced depth imaging optical coherence tomography (EDI-OCT) revealed a pachychoroid pattern in both eyes . Moreover, OCT scans of the right eye showed sub-retinal fluid (SRF) reaching the macular area from the inferior quadrants. No SRF was detected in the LE. Ocular ultrasound showed no mass lesion . Upon questioning his medical history, the patient referred a history of central serous chorioretinopathy (CSC) in the RE and the recent use of intravenous corticosteroids for bronchitis. Fluorescein angiography (FA) and Indocyanine green angiography (ICGA) were performed, revealing hyperpermeable and dilated choroidal vessels and multifocal and diffuse leakage in the late angiograms of the RE . No disc leak or vasculitis were detected. Swept-Source OCT angiography (SS-OCT-A) confirmed the pachychoroid pattern and clearly demonstrated the mid-pheripheral RPE tear in the inferotemporal quadrant . Axial lengths were 23.63 mm (RE) and 23.35 mm (LE).\nBased on the clinical features, a diagnosis of bullous variant of CSC with RPE tear was made. Oral therapy with eplerenone at a dose of 50 mg/day was initiated. However, no improvement was detected. In fact, two months later, the exudative RD increased with a worsening of the BCVA to 20/80 , despite the continuing therapy with eplerenone. To prevent irreversible photoreceptor damage, management with observation or eplerenone treatment continuation were excluded, and alternative therapeutic procedures were discussed. Laser therapy was deemed inappropriate because the leakage was multifocal and diffuse, with multiple “ink blot” focal areas of leakage at the superior margin of the detached retina and other poorly defined leakage areas in the attached retina. Photodynamic therapy (PDT) was not applicable because of the extension and elevation of the RD. Therefore, the opportunity for surgical treatment was considered.\nWritten informed consent was given by the patient, after a comprehensive explanation of the procedures. Under general anesthesia, the patient’s eye was prepared with povidone-iodine and draped. After 180° inferior conjunctival peritomy, bridle suture was passed under the inferior, medial and lateral rectus muscles with 3–0 ticron, and the sclera was exposed. Two 4 × 4 mm almost full scleral thickness sclerectomies were done in the inferior quadrants, taking care to avoid the areas close to exit sites of the vortex veins. Finally, the conjunctiva was approximated with 8–0 Vicryl suture. The treatment resulted in complete RD resolution as of the first day after surgery. Upon follow-up six months after surgery- complete SRF resolution was confirmed and BCVA was stable at 20/80 .", + "fulltext_subclaims": [ + "The patient is a 65-year-old white male.", + "He was referred to the Vitreo-Retinal Surgery Service for a retinal detachment in his right eye.", + "His best-corrected visual acuity was 20/63 in the right eye.", + "His best-corrected visual acuity was 20/20 in the left eye.", + "Intraocular pressure was 15 mmHg in both eyes.", + "Dilated fundus examination of the right eye showed an inferior bullous retinal detachment involving the macula.", + "There was no evidence of retinal breaks.", + "A large RPE tear was detected in the temporal quadrant.", + "There was no sign of uveitis or vitreitis.", + "Fundus examination of the left eye was unremarkable, except for slight RPE distrophic alterations at the posterior pole.", + "Enhanced depth imaging optical coherence tomography revealed a pachychoroid pattern in both eyes.", + "OCT scans of the right eye showed sub-retinal fluid reaching the macular area from the inferior quadrants.", + "No sub-retinal fluid was detected in the left eye.", + "Ocular ultrasound showed no mass lesion.", + "The patient reported a history of central serous chorioretinopathy in the right eye.", + "The patient reported recent use of intravenous corticosteroids for bronchitis.", + "Fluorescein angiography revealed hyperpermeable and dilated choroidal vessels.", + "Fluorescein angiography showed multifocal and diffuse leakage in the late angiograms of the right eye.", + "No disc leak or vasculitis were detected.", + "Swept-Source OCT angiography confirmed the pachychoroid pattern.", + "Swept-Source OCT angiography demonstrated the mid-peripheral RPE tear in the inferotemporal quadrant.", + "Axial length was 23.63 mm in the right eye.", + "Axial length was 23.35 mm in the left eye.", + "A diagnosis of bullous variant of central serous chorioretinopathy with RPE tear was made.", + "Oral therapy with eplerenone at a dose of 50 mg/day was initiated.", + "Two months later, the exudative retinal detachment increased.", + "The best-corrected visual acuity worsened to 20/80.", + "Laser therapy was deemed inappropriate because the leakage was multifocal and diffuse.", + "Photodynamic therapy was not applicable because of the extension and elevation of the retinal detachment.", + "The opportunity for surgical treatment was considered.", + "Written informed consent was given by the patient.", + "The treatment resulted in complete retinal detachment resolution as of the first day after surgery.", + "Six months after surgery, complete sub-retinal fluid resolution was confirmed.", + "Best-corrected visual acuity was stable at 20/80 six months after surgery." + ], + "summary": "A 65-year-old male was referred for vitreo-retinal surgery with a provisional diagnosis of rhegmatogenous RD in his right eye. Dilated fundus examination showed an inferior bullous RD with no evidence of retinal breaks, while a large RPE tear was detected in the temporal quadrant. Ocular ultrasound showed no mass lesion. The axial length was 23.63 mm. Enhanced depth imaging optical coherence tomography (EDI-OCT) revealed a pachychoroid pattern in both eyes. The patient referred a history of CSC in the right eye and the recent use of intravenous corticosteroids for bronchitis. Laser therapy and photodynamic therapy were not applicable due to the extension and elevation of the RD. Two months after oral treatment with eplerenone, the subretinal fluid increased significantly. The patient underwent two 4 × 4 mm deep lamellar sclerectomies in the inferior quadrants. The surgical treatment resulted in complete RD resolution.", + "summary_subclaims": [ + "The patient is a 65-year-old male.", + "The patient was referred for vitreo-retinal surgery.", + "The provisional diagnosis was rhegmatogenous RD in the right eye.", + "Dilated fundus examination showed an inferior bullous RD.", + "There was no evidence of retinal breaks.", + "A large RPE tear was detected in the temporal quadrant.", + "Ocular ultrasound showed no mass lesion.", + "The axial length was 23.63 mm.", + "EDI-OCT revealed a pachychoroid pattern in both eyes.", + "The patient referred a history of CSC in the right eye.", + "The patient reported recent use of intravenous corticosteroids for bronchitis.", + "Laser therapy and photodynamic therapy were not applicable due to the extension and elevation of the RD.", + "Two months after oral treatment with eplerenone, the subretinal fluid increased significantly.", + "The patient underwent two 4 × 4 mm deep lamellar sclerectomies in the inferior quadrants.", + "The surgical treatment resulted in complete RD resolution." + ] + }, + { + "id": "multiclinsum_test_3281_en.txt", + "fulltext": "We present the case of a 54-year-old woman, who attended a general ophthalmology clinic complaining of painless epiphora in the left eye while speaking or eating, with 6 months of evolution. The patient had been diagnosed with Bell’s palsy on the left side one year earlier but recovered from the motor deficit with physical therapy. She had no other relevant medical history.\n\nThe ophthalmological evaluation revealed mild weakening of the left orbicularis oculi and frontal muscles without lagophthalmos. No other abnormalities were found, including inflammation of the ocular surface, ectropion, or obstruction of the tear outlet system.\n\nA Schirmer test was performed under topical anesthesia for 5 minutes and the result was 12 mm for the left eye. The same test was then repeated while the patient was chewing, and the result was 23 mm.\n\nAll these clues led to the diagnosis of Bogorad syndrome and treatment with botulinum toxin injection in the lacrimal gland was proposed.\n\nTwo weeks after the transconjunctival injection of 6 units of botulinum toxin in the palpebral lobe of the left lacrimal gland, the patient reported a decrease in perceived tearing, and 1 month after the treatment there was an almost complete resolution of the complaints.\n\nSchirmer test was repeated under the same previous conditions, and the result was 5 and 12 mm, respectively.\n\nMunk scale was used for epiphora grading and the patient noted a reduction of the symptoms from a score of 4 to 1 with treatment.\n\nThe social impact was also assessed using the lacrimal symptom questionnaire (Lac-Q) and a score of 12 and 4 was reported by the patient before and 1 month after treatment, respectively.\n\nRecurrence of the symptoms was detected 6 months after botulinum toxin treatment, and a new injection was performed with similar reported results.", + "fulltext_subclaims": [ + "The patient is a 54-year-old woman.", + "She complained of painless epiphora in the left eye while speaking or eating.", + "The epiphora had been present for 6 months.", + "She had been diagnosed with Bell’s palsy on the left side one year earlier.", + "She recovered from the motor deficit with physical therapy.", + "The ophthalmological evaluation revealed mild weakening of the left orbicularis oculi and frontal muscles.", + "No lagophthalmos was found.", + "No inflammation of the ocular surface was found.", + "No ectropion was found.", + "No obstruction of the tear outlet system was found.", + "A Schirmer test was performed under topical anesthesia for 5 minutes.", + "The result of the Schirmer test under topical anesthesia was 12 mm for the left eye.", + "The Schirmer test was repeated while the patient was chewing.", + "The result of the Schirmer test while chewing was 23 mm.", + "The diagnosis was Bogorad syndrome.", + "Treatment with botulinum toxin injection in the lacrimal gland was proposed.", + "A transconjunctival injection of 6 units of botulinum toxin was performed in the palpebral lobe of the left lacrimal gland.", + "Two weeks after the injection, the patient reported a decrease in perceived tearing.", + "One month after the treatment, there was an almost complete resolution of the complaints.", + "The Schirmer test was repeated under the same previous conditions.", + "The result of the repeated Schirmer test was 5 and 12 mm, respectively.", + "The Munk scale was used for epiphora grading.", + "The patient noted a reduction of the symptoms from a score of 4 to 1 with treatment.", + "The lacrimal symptom questionnaire (Lac-Q) was used to assess social impact.", + "The patient reported a Lac-Q score of 12 before treatment.", + "The patient reported a Lac-Q score of 4 one month after treatment.", + "Recurrence of the symptoms was detected 6 months after botulinum toxin treatment.", + "A new injection was performed.", + "Similar reported results were obtained after the new injection." + ], + "summary": "We report the case of a 54-year-old woman, with a history of left Bell's palsy, who attended our ophthalmology clinic due to epiphora of the left eye while eating or speaking, for 6 months.\n\nResults: The ophthalmologic evaluation revealed a mild weakening of the frontal and left orbicularis oculi muscles without lagophthalmos. No other abnormalities were found, namely ocular surface swelling, ectropion, or obstruction of the lacrimal outflow system. Schirmer test II in the left eye increased from 12 to 23 mm while the patient was chewing. All these clues led to the diagnosis of crocodile tears syndrome and treatment with botulinum toxin A injection was proposed. One month after the injection of the palpebral lobe of the left lacrimal gland with 6 units of botulinum toxin A, the patient reported an almost complete resolution of the complaints, stated by a decrease in Munk scale and Lac-Q scores. Six months after injection, the patient conveyed recurrence of symptoms and a new treatment session was performed with comparable results.", + "summary_subclaims": [ + "The patient is a 54-year-old woman.", + "The patient has a history of left Bell's palsy.", + "The patient attended the ophthalmology clinic due to epiphora of the left eye while eating or speaking.", + "The epiphora had been present for 6 months.", + "The ophthalmologic evaluation revealed a mild weakening of the frontal and left orbicularis oculi muscles.", + "No lagophthalmos was found.", + "No ocular surface swelling was found.", + "No ectropion was found.", + "No obstruction of the lacrimal outflow system was found.", + "The Schirmer test II in the left eye increased from 12 to 23 mm while the patient was chewing.", + "The diagnosis was crocodile tears syndrome.", + "Treatment with botulinum toxin A injection was proposed.", + "One month after the injection of the palpebral lobe of the left lacrimal gland with 6 units of botulinum toxin A, the patient reported an almost complete resolution of the complaints.", + "The resolution was stated by a decrease in Munk scale and Lac-Q scores.", + "Six months after injection, the patient conveyed recurrence of symptoms.", + "A new treatment session was performed.", + "The new treatment session had comparable results." + ] + }, + { + "id": "multiclinsum_test_2589_en.txt", + "fulltext": "A 17-year-old male was referred to our hospital with progressive headache and nausea. Neurological examination showed papilledema, and MRI [Figure –] revealed hydrocephalus and a bilateral multicystic lesion in the midbrain and thalamus that caused aqueduct stenosis. The signal intensity of the lesion on T1- and T2-weighted images was identical to that of cerebrospinal fluid (CSF). There was no enhancement with contrast media, no evidence of perifocal edema on FLAIR, and no evidence of calcification on computed tomography (CT). He underwent neuroendoscopic surgery for obstructive hydrocephalus caused by the lesion. A cyst with a transparent membrane continuous with the ependyma was responsible for the blockade of the aqueduct. Two stomas were made on the cyst wall by electrocoagulation, and the cyst shrunk. Third ventriculostomy was then performed. Biopsy of the cyst membrane was initially attempted by grasping it with forceps, but this was discontinued because of hemorrhage. Considering the imaging and surgical findings, the multicystic lesion was considered to be PVS dilation. Postoperative MRI revealed a marked improvement in hydrocephalus, but no change was observed in the size or number of the multicystic lesion. Headache and nausea improved. After discharge, the patient stopped visiting our hospital based on his own judgment.\nFourteen years later, at age 31, the patient was readmitted to our hospital with progressive double vision and nausea. Neurological examination revealed anisocoria (right pupil: 3 mm, left pupil: 5 mm), and the light reflex was dull in both pupils. Left eye exotropia in the primary position was present. When the patient tilted his head to the right, double vision worsened, while titling to the left resolved the double vision (Bielshowsky sign positive). Eye movement during tracking of moving objects was normal. These findings indicated left oculomotor and right trochlear nerve palsies. MRI [Figure and ] revealed that a multicystic lesion in the midbrain and thalamus had increased in number and size compared with the initial examination at age 17, but hydrocephalus was not present. Radiological appearance was not typical of a tumor, and inflammatory or infectious disease was unlikely in view of the clinical course. Progression of giant tumefactive PVSs was considered the differential diagnosis.\nWe speculated that compression of the midbrain was the most probable cause of symptoms and performed neuroendoscopic surgery. Two frontal precoronal burr holes were drilled. Through the left burr hole, we inserted the rigid endoscope with an operating sheath (Karl Storz Inc., Germany) and a neuronavigational guidance probe (Medtronic Inc., USA) into the third ventricle. Through the right burr hole, we inserted the flexible endoscope VEF-IV (Olympus, INC. Japan) with EMF System Pal-1 (Japan Medical Dynamic Marketing Inc., Japan) into the third ventricle. Thin-walled cysts were observed in the third ventricle . We fenestrated the cyst walls from rostral to caudal along the midline under the guidance of the navigation system. The interior of the cysts appeared to be traversed by small arteries that were surrounded by enlarged PVSs . Specimens of the cyst membrane were retrieved for biopsy.\nAfter surgery, the symptoms and neurological disorder improved. Postsurgical MRI [Figure and ] revealed a slight reduction in the size of the multicystic lesion. Histopathological staining for glial fibrillary acid protein (GFAP) [Figure –] demonstrated extensive gliosis in the cyst wall. Epithelial cells on the outer aspects appeared to be ependymal cells compressed by the cystic lesion. Based on MRI, surgical, and histological findings, we diagnosed the patient with a multicystic lesion, which was caused by giant tumefactive PVSs. MRI performed at 6 months after surgery showed a slight reduction in the number and average size of the cysts, and the patient remained free of symptoms.", + "fulltext_subclaims": [ + "A 17-year-old male was referred to our hospital with progressive headache and nausea.", + "Neurological examination showed papilledema.", + "MRI revealed hydrocephalus and a bilateral multicystic lesion in the midbrain and thalamus that caused aqueduct stenosis.", + "The signal intensity of the lesion on T1- and T2-weighted images was identical to that of cerebrospinal fluid.", + "There was no enhancement with contrast media.", + "There was no evidence of perifocal edema on FLAIR.", + "There was no evidence of calcification on computed tomography.", + "He underwent neuroendoscopic surgery for obstructive hydrocephalus caused by the lesion.", + "A cyst with a transparent membrane continuous with the ependyma was responsible for the blockade of the aqueduct.", + "Two stomas were made on the cyst wall by electrocoagulation, and the cyst shrunk.", + "Third ventriculostomy was then performed.", + "Biopsy of the cyst membrane was initially attempted by grasping it with forceps, but this was discontinued because of hemorrhage.", + "Considering the imaging and surgical findings, the multicystic lesion was considered to be PVS dilation.", + "Postoperative MRI revealed a marked improvement in hydrocephalus.", + "No change was observed in the size or number of the multicystic lesion.", + "Headache and nausea improved.", + "After discharge, the patient stopped visiting our hospital based on his own judgment.", + "Fourteen years later, at age 31, the patient was readmitted to our hospital with progressive double vision and nausea.", + "Neurological examination revealed anisocoria (right pupil: 3 mm, left pupil: 5 mm).", + "The light reflex was dull in both pupils.", + "Left eye exotropia in the primary position was present.", + "When the patient tilted his head to the right, double vision worsened, while tilting to the left resolved the double vision.", + "Eye movement during tracking of moving objects was normal.", + "These findings indicated left oculomotor and right trochlear nerve palsies.", + "MRI revealed that a multicystic lesion in the midbrain and thalamus had increased in number and size compared with the initial examination at age 17.", + "Hydrocephalus was not present.", + "Radiological appearance was not typical of a tumor.", + "Inflammatory or infectious disease was unlikely in view of the clinical course.", + "Progression of giant tumefactive PVSs was considered the differential diagnosis.", + "We speculated that compression of the midbrain was the most probable cause of symptoms and performed neuroendoscopic surgery.", + "Two frontal precoronal burr holes were drilled.", + "Through the left burr hole, we inserted the rigid endoscope with an operating sheath into the third ventricle.", + "Through the right burr hole, we inserted the flexible endoscope VEF-IV into the third ventricle.", + "Thin-walled cysts were observed in the third ventricle.", + "We fenestrated the cyst walls from rostral to caudal along the midline under the guidance of the navigation system.", + "The interior of the cysts appeared to be traversed by small arteries that were surrounded by enlarged PVSs.", + "Specimens of the cyst membrane were retrieved for biopsy.", + "After surgery, the symptoms and neurological disorder improved.", + "Postsurgical MRI revealed a slight reduction in the size of the multicystic lesion.", + "Histopathological staining for glial fibrillary acid protein demonstrated extensive gliosis in the cyst wall.", + "Epithelial cells on the outer aspects appeared to be ependymal cells compressed by the cystic lesion.", + "Based on MRI, surgical, and histological findings, we diagnosed the patient with a multicystic lesion, which was caused by giant tumefactive PVSs.", + "MRI performed at 6 months after surgery showed a slight reduction in the number and average size of the cysts.", + "The patient remained free of symptoms." + ], + "summary": "On first admission at age 17, endoscopic ventriculocystostomy and third ventriculostomy were performed to relieve hydrocephalus caused by cysts compressing the cerebral aqueduct. Fourteen years later, the multicystic lesion reappeared with an increase in both cyst number and size. The patient showed no hydrocephalus but presented with oculomotor and trochlear nerve palsies, which were caused by a mass effect on the midbrain. Endoscopic ventriculocystostomy was performed and symptoms improved.", + "summary_subclaims": [ + "Endoscopic ventriculocystostomy and third ventriculostomy were performed to relieve hydrocephalus caused by cysts compressing the cerebral aqueduct.", + "Fourteen years later, the multicystic lesion reappeared with an increase in both cyst number and size.", + "The patient showed no hydrocephalus.", + "The patient presented with oculomotor and trochlear nerve palsies.", + "The oculomotor and trochlear nerve palsies were caused by a mass effect on the midbrain.", + "Endoscopic ventriculocystostomy was performed.", + "Symptoms improved." + ] + }, + { + "id": "multiclinsum_test_1757_en.txt", + "fulltext": "A 37-year-old G9P0171 (seven spontaneous abortions reported) with a history of chronic hypertension, type 2 diabetes mellitus, chronic kidney disease, neuropathy with Charcot foot, class III obesity with a BMI 52, and prior preterm delivery for superimposed preeclampsia transferred her care to our high-risk practice at 24w2d. During her initial prenatal visit, she also disclosed a history of multiple MRSA containing skin abscesses on her chest that she reported had originated from spider bites.\nPrior to transferring her care, she first presented to the Emergency Department with shooting left upper back and flank pain at 18 weeks. At that time at the outside institution, a CT scan without contrast was ordered to evaluate for nephrolithiasis, but the abdomen visualized inferiorly from the diaphragm was largely unremarkable. She presented to the Emergency Department six more times from 18 through 34 weeks gestation with complaints of ongoing pain, occasionally describing the pain shooting down her legs and causing lower extremity numbness. Throughout her visits no motor or sensory deficits were elicited on exam, and she was repeatedly afebrile with no pain on spine palpation. She was treated with acetaminophen and cyclobenzaprine for possible paraspinal muscle spasm. During one of these visits at 33 weeks a urine drug screen was obtained by the triage provider due to their concerns about the patient’s poor compliance with prenatal care appointments, as she had not presented to scheduled visits for over eight weeks. This screen resulted positive for fentanyl and was negative for all other substances included in the basic toxicology screen. She adamantly denied any opioid use, presenting a diagnostic challenge, and requested repeat testing the following day as well as five days later. Both subsequent tests were positive. The patient continued to deny any opioid use, however the placement and number of infected skin lesions on her chest raised suspicion for injection drug use. At a much later date, she disclosed she had been a restrained passenger in a motor vehicle collision during the first trimester of her pregnancy and stated this was the first time she noticed the back pain.\nAt 36w1d, she was directed to the Obstetrics Emergency Department for evaluation after a biophysical profile score of 2/8 and amniotic fluid index of 0.7 was noted during routine antenatal testing. At this time, she also reported that her back pain had been significantly exacerbated by a fall en route to the hospital. Due to reactive non-stress test upon arrival, decision was made for observation until delivery via repeat cesarean section at the next available scheduled OR slot. Anesthesia attempted to place a combined spinal and epidural block at L2-L3, as was the standard of care for obese patients. Following the initial spinal dose, placement of the epidural catheter was abandoned after the patient experienced pressure and pain with local anesthetic infusion. The procedure continued under single-shot spinal anesthesia. Her mean arterial pressure (MAP) dropped to 75 mmHg for a few minutes following the spinal, and then corrected to her baseline MAP of 115–125 mmHg with fluid resuscitation prior to the procedure. The repeat cesarean section was then completed and was overall uncomplicated. Final quantitative blood loss was 910 mL. Her neonate had 1 and 5 min APGAR scores of 3 and 7, respectively, initially requiring some positive pressure ventilation but with an overall uncomplicated neonatal course.\nWhile in the post anesthesia care unit, she developed severe range blood pressures (systolic pressures persisting in the 170 s over fifteen minutes apart) requiring acute treatment with labetalol and hydralazine. Complete blood count, complete metabolic panel, lactate dehydrogenase, urine protein to creatine ratio (U P:C) were obtained which were unremarkable aside from a significant increase from baseline in her U P:C. Superimposed pre-eclampsia with severe features was diagnosed and intravenous magnesium sulfate was initiated for seizure prophylaxis and continued over the next 24 h. Her MAP nadired at 68 mmHg during this 24 h period, and she did not require further acute treatment of severe range blood pressures. Throughout treatment she continued to complain of back pain at a similar severity to the antepartum period. Since reflexes in the bilateral lower extremities were poorly elicited and this was thought to be her baseline, reflexes in her upper extremities were used for her serial examinations while receiving magnesium. She was noted to have full voluntary motor function in all four extremities during this time.\nOn post-operative day one, after completion of magnesium treatment, the patient complained of inability to move her legs. Physical examination demonstrated impaired pain and light touch sensation below the umbilicus, no voluntary strength in bilateral lower extremities, no Babinski or ankle jerk reflex, and the patient was unable to void after Foley catheter removal. MRI of the spine showed discitis osteomyelitis at T9-T10 with phlegmonous change in the soft tissues anterior to the vertebral column. This phlegmonous area extended into the ventral and dorsal epidural space resulting in severe spinal cord narrowing at T9-T10. There was also focal kyphosis in this region, indicating chronicity of some of these changes. MRI images are displayed in Figs. and . Orthopedic surgery was consulted and the patient was taken for emergent T9-T10 laminectomy, wound debridement, and T7-T12 fusion for suspected spinal cord infarction secondary to arterial disruption in the setting of infection. Intra-operatively, a “thick phlegmon” was noted overlying the dura which was dissected away to decompress the cord. She received 4 units of packed red blood cells and 2 units of fresh frozen plasma intraoperatively due to neurogenic shock. Cultures collected during surgery grew Methicillin-sensitive Staphylococcus aureus. Postoperatively, she had persistent bilateral lower extremity motor and sensory deficit and was admitted to inpatient rehabilitation. Her lower extremity function and sensation improved over months of physical therapy. As of four months following the initial injury, the patient had been discharged from the hospital and was undergoing home physical therapy. She was not ambulatory but could stand with support equipment. Please refer to Fig. for a visual of the clinical timeline.", + "fulltext_subclaims": [ + "The patient is a 37-year-old G9P0171 with seven spontaneous abortions reported.", + "She has a history of chronic hypertension.", + "She has a history of type 2 diabetes mellitus.", + "She has a history of chronic kidney disease.", + "She has a history of neuropathy with Charcot foot.", + "She has class III obesity with a BMI of 52.", + "She has a history of prior preterm delivery for superimposed preeclampsia.", + "She transferred her care to a high-risk practice at 24w2d.", + "She disclosed a history of multiple MRSA-containing skin abscesses on her chest.", + "She reported the skin abscesses originated from spider bites.", + "At 18 weeks, she presented to the Emergency Department with shooting left upper back and flank pain.", + "A CT scan without contrast was ordered to evaluate for nephrolithiasis.", + "The CT scan visualized inferiorly from the diaphragm and was largely unremarkable.", + "She presented to the Emergency Department six more times from 18 through 34 weeks gestation.", + "She described the pain shooting down her legs and causing lower extremity numbness.", + "No motor or sensory deficits were elicited on exam.", + "She was repeatedly afebrile.", + "She was treated with acetaminophen and cyclobenzaprine for possible paraspinal muscle spasm.", + "At 33 weeks, a urine drug screen was obtained due to concerns about poor compliance with prenatal care.", + "The urine drug screen was positive for fentanyl.", + "The urine drug screen was negative for all other substances included in the basic toxicology screen.", + "She adamantly denied any opioid use.", + "She requested repeat testing the following day and five days later.", + "Both subsequent urine drug screens were positive.", + "The placement and number of infected skin lesions on her chest raised suspicion for injection drug use.", + "She disclosed she had been a restrained passenger in a motor vehicle collision during the first trimester.", + "She stated this was the first time she noticed the back pain.", + "At 36w1d, she was directed to the Obstetrics Emergency Department after a biophysical profile score of 2/8.", + "An amniotic fluid index of 0.7 was noted.", + "She reported that her back pain had been significantly exacerbated by a fall en route to the hospital.", + "A reactive non-stress test was noted upon arrival.", + "The decision was made for observation until delivery via repeat cesarean section.", + "Anesthesia attempted to place a combined spinal and epidural block at L2-L3.", + "The epidural catheter placement was abandoned after the patient experienced pressure and pain with local anesthetic infusion.", + "The procedure continued under single-shot spinal anesthesia.", + "Her mean arterial pressure dropped to 75 mmHg for a few minutes following the spinal.", + "Her mean arterial pressure corrected to her baseline of 115–125 mmHg with fluid resuscitation.", + "The repeat cesarean section was completed and was overall uncomplicated.", + "Final quantitative blood loss was 910 mL.", + "The neonate had 1 and 5 min APGAR scores of 3 and 7, respectively.", + "The neonate initially required some positive pressure ventilation.", + "The neonate had an overall uncomplicated course.", + "In the post anesthesia care unit, she developed severe range blood pressures with systolic pressures persisting in the 170s.", + "Acute treatment with labetalol and hydralazine was required.", + "A complete blood count, complete metabolic panel, lactate dehydrogenase, and urine protein to creatine ratio were obtained.", + "The urine protein to creatine ratio showed a significant increase from baseline.", + "Superimposed pre-eclampsia with severe features was diagnosed.", + "Intravenous magnesium sulfate was initiated for seizure prophylaxis.", + "Magnesium sulfate was continued over the next 24 h.", + "Her mean arterial pressure nadired at 68 mmHg during this 24 h period.", + "She did not require further acute treatment of severe range blood pressures.", + "She continued to complain of back pain at a similar severity to the antepartum period.", + "Reflexes in the bilateral lower extremities were poorly elicited and thought to be her baseline.", + "Reflexes in her upper extremities were used for serial examinations while receiving magnesium.", + "She was noted to have full voluntary motor function in all four extremities during this time.", + "On post-operative day one, after completion of magnesium treatment, the patient complained of inability to move her legs.", + "Physical examination demonstrated impaired pain and light touch sensation below the umbilicus.", + "There was no voluntary strength in bilateral lower extremities.", + "There was no Babinski or ankle jerk reflex.", + "The patient was unable to void after Foley catheter removal.", + "MRI of the spine showed discitis osteomyelitis at T9-T10.", + "The MRI showed phlegmonous change in the soft tissues anterior to the vertebral column.", + "The phlegmonous area extended into the ventral and dorsal epidural space resulting in severe spinal cord narrowing at T9-T10.", + "There was focal kyphosis in this region, indicating chronicity of some of these changes.", + "Orthopedic surgery was consulted.", + "The patient was taken for emergent T9-T10 laminectomy, wound debridement, and T7-T12 fusion.", + "The procedure was for suspected spinal cord infarction secondary to arterial disruption in the setting of infection.", + "Intra-operatively, a “thick phlegmon” was noted overlying the dura.", + "The phlegmon was dissected away to decompress the cord.", + "She received 4 units of packed red blood cells and 2 units of fresh frozen plasma intraoperatively.", + "Cultures collected during surgery grew Methicillin-sensitive Staphylococcus aureus.", + "Postoperatively, she had persistent bilateral lower extremity motor and sensory deficit.", + "She was admitted to inpatient rehabilitation.", + "Her lower extremity function and sensation improved over months of physical therapy.", + "As of four months following the initial injury, she had been discharged from the hospital.", + "She was undergoing home physical therapy.", + "She was not ambulatory but could stand with support equipment." + ], + "summary": "A 38 year old G9P0171 at 24 weeks gestation with a complex past medical history, and a suspected history of IVDU, presented repeatedly with back pain. Following cesarean delivery at 36w2d, she developed signs and symptoms of an anterior spinal artery syndrome (ASAS) and had evidence of chronic osteomyelitis at T9-T10 on imaging. This required emergent decompressive laminectomy and ultimately resulted in paraplegia.", + "summary_subclaims": [ + "The patient is a 38 year old G9P0171 at 24 weeks gestation.", + "The patient had a complex past medical history.", + "The patient had a suspected history of IVDU.", + "The patient presented repeatedly with back pain.", + "The patient had a cesarean delivery at 36w2d.", + "The patient developed signs and symptoms of an anterior spinal artery syndrome.", + "The patient had evidence of chronic osteomyelitis at T9-T10 on imaging.", + "The patient required emergent decompressive laminectomy.", + "The patient ultimately resulted in paraplegia." + ] + }, + { + "id": "multiclinsum_test_662_en.txt", + "fulltext": "A 74-year-old indigenous Malaysian man, an ex-smoker of tobacco, with underlying severe aortic stenosis, atrial fibrillation, hypertension, and chronic kidney disease presented to us with a 6-month history of lethargy, subjective loss of weight, loss of appetite, and night sweats associated with a sharp, persistent right-sided headache and left hip pain. He denied any pruritus. He denied chronic cough, and had no significant travel history or high risk behavior. He had no family history of malignancy. He had no baseline ultrasound of the genitourinary tract, having refused investigation of his chronic kidney disease previously.\nPrior to this current admission, he had been admitted two times over the past 4 months for hyponatremia and normochromic normocytic anemia, with initial serum sodium measuring 120 mmol/L and 124 mmol/L, respectively. Peripheral blood film showed features suggestive of iron deficiency anemia; concurrent with a serum iron level of 9.7 umol/L with calculated transferrin saturation of 21.2%. Ferritin and B12 levels were normal while a fecal occult blood test was negative. On both occasions, he received intravenously administered saline and subsequently was discharged with orally administered sodium supplements. Tests for thyroid function and cortisol levels from a previous admission were normal.\nOn admission, he was afebrile with a blood pressure of 130/70 and pulse rate of 70. An examination revealed a mildly cachexic man with generalized disuse atrophy of all limbs. Functionally, he was unable to ambulate due to left hip pain. There was tenderness at his left hip with reduced passive and active movement due to pain, and a bony protuberance at the posterolateral aspect of the right side of his scalp. There were no neurological deficits, and respiratory and abdominal examinations were unremarkable.\nOn examination of the skin, there were diffuse brown well-circumscribed pigmented lesions of undetermined onset over his face and trunk suggestive of multiple seborrheic keratoses. The lesions over his posterior trunk were distributed in a symmetrical “Christmas-tree” pattern .\nAn electrolyte investigation showed low serum sodium of 119 mmol/L. All other electrolytes were within normal range, and there was no derangement of liver enzymes. A chest X-ray on admission showed bilateral multiple irregular nodules and prominent hilar opacities . In view of long-standing headache, we proceeded with non-contrasted computed tomography of his brain, which revealed a well-defined round hyperdense lesion at the right high frontal cortex measuring 0.7 × 0.7 cm, associated with perilesional edema . There was a lytic lesion at the right parietal bone with expansile soft tissue component . Resource limitations precluded a follow-on magnetic resonance imaging (MRI). Computed tomography of his thorax, abdomen, and pelvis revealed a heterogeneously enhancing soft tissue mass at the right kidney measuring 3.8 × 4.4 × 3.7 cm, with no evidence of obstruction or hydronephrosis . There was evidence of bilateral metastatic lung nodules, and multiple hilar and paratracheal nodes . There was no evidence of aortic aneurysm. There was also a 5 × 5cm lytic lesion at the left ilium, consistent with his left hip pain .\nFurther biochemical investigation showed increased urine osmolarity of 303 mOsmol/kg and urine sodium of 48 mmol/L; in view of prior normal thyroid function, cortisol level, and clinical euvolemia, we diagnosed him as having syndrome of inappropriate antidiuretic hormone secretion (SIADH). Fluid restriction was commenced and his sodium levels recovered to 131 mmol/L over 5 days. He was referred to the Dermatology team; in view of the findings of metastatic renal carcinoma, the skin lesions were attributed to Leser–Trélat syndrome.\nHaving been thoroughly counselled on his condition, he refused renal and skin biopsy and was not keen for further intervention. Despite the absence of a histopathological diagnosis, the constellation of clinical and radiological features was suggestive of a renal malignancy with metastasis, and he was referred to the Palliative Care team for further management.", + "fulltext_subclaims": [ + "The patient is a 74-year-old indigenous Malaysian man.", + "He is an ex-smoker of tobacco.", + "He has underlying severe aortic stenosis.", + "He has atrial fibrillation.", + "He has hypertension.", + "He has chronic kidney disease.", + "He had a 6-month history of lethargy.", + "He had a subjective loss of weight.", + "He had loss of appetite.", + "He had night sweats.", + "He had a sharp, persistent right-sided headache.", + "He had left hip pain.", + "He denied any pruritus.", + "He had no significant travel history.", + "He had no high-risk behavior.", + "He had no family history of malignancy.", + "He had no baseline ultrasound of the genitourinary tract.", + "He had been admitted two times over the past 4 months for hyponatremia.", + "He had been admitted two times over the past 4 months for normochromic normocytic anemia.", + "Initial serum sodium measured 120 mmol/L.", + "Initial serum sodium measured 124 mmol/L.", + "Peripheral blood film showed features suggestive of iron deficiency anemia.", + "Serum iron level was 9.7 umol/L.", + "Calculated transferrin saturation was 21.2%.", + "Ferritin and B12 levels were normal.", + "Fecal occult blood test was negative.", + "He received intravenously administered saline.", + "He was discharged with orally administered sodium supplements.", + "Tests for thyroid function and cortisol levels from a previous admission were normal.", + "On admission, he was afebrile.", + "Blood pressure was 130/70.", + "Pulse rate was 70.", + "Examination revealed a mildly cachexic man.", + "There was generalized disuse atrophy of all limbs.", + "He was unable to ambulate due to left hip pain.", + "There was tenderness at his left hip.", + "There was reduced passive and active movement due to pain.", + "There was a bony protuberance at the posterolateral aspect of the right side of his scalp.", + "There were no neurological deficits.", + "Respiratory and abdominal examinations were unremarkable.", + "There were diffuse brown well-circumscribed pigmented lesions over his face and trunk.", + "The lesions over his posterior trunk were distributed in a symmetrical “Christmas-tree” pattern.", + "An electrolyte investigation showed low serum sodium of 119 mmol/L.", + "A chest X-ray showed bilateral multiple irregular nodules.", + "A chest X-ray showed prominent hilar opacities.", + "Non-contrasted computed tomography of the brain revealed a well-defined round hyperdense lesion at the right high frontal cortex measuring 0.7 × 0.7 cm.", + "There was perilesional edema.", + "There was a lytic lesion at the right parietal bone with expansile soft tissue component.", + "Resource limitations precluded a follow-on magnetic resonance imaging (MRI).", + "Computed tomography of the thorax, abdomen, and pelvis revealed a heterogeneously enhancing soft tissue mass at the right kidney measuring 3.8 × 4.4 × 3.7 cm.", + "There was no evidence of obstruction or hydronephrosis.", + "There was evidence of bilateral metastatic lung nodules.", + "There were multiple hilar and paratracheal nodes.", + "There was no evidence of aortic aneurysm.", + "There was a 5 × 5 cm lytic lesion at the left ilium.", + "Further biochemical investigation showed increased urine osmolarity of 303 mOsmol/kg.", + "Urine sodium was 48 mmol/L.", + "He was diagnosed as having syndrome of inappropriate antidiuretic hormone secretion (SIADH).", + "Fluid restriction was commenced.", + "His sodium levels recovered to 131 mmol/L over 5 days.", + "The skin lesions were attributed to Leser–Trélat syndrome.", + "He refused renal and skin biopsy.", + "He was not keen for further intervention.", + "The constellation of clinical and radiological features was suggestive of a renal malignancy with metastasis.", + "He was referred to the Palliative Care team for further management." + ], + "summary": "A 74-year-old indigenous Malaysian man with underlying chronic kidney disease presented with recurrent admissions for hyponatremia with parameters indicative of syndrome of inappropriate antidiuretic hormone secretion, constitutional symptoms, and diffuse skin lesions suggestive of multiple seborrheic keratoses. A radiological workup revealed metastatic renal cell carcinoma with evidence of metastasis to the brain, adrenal glands, bone, and lungs.", + "summary_subclaims": [ + "The patient is a 74-year-old indigenous Malaysian man.", + "The patient has underlying chronic kidney disease.", + "The patient had recurrent admissions for hyponatremia.", + "The hyponatremia parameters were indicative of syndrome of inappropriate antidiuretic hormone secretion.", + "The patient had constitutional symptoms.", + "The patient had diffuse skin lesions suggestive of multiple seborrheic keratoses.", + "A radiological workup revealed metastatic renal cell carcinoma.", + "There was evidence of metastasis to the brain.", + "There was evidence of metastasis to the adrenal glands.", + "There was evidence of metastasis to the bone.", + "There was evidence of metastasis to the lungs." + ] + }, + { + "id": "multiclinsum_test_2387_en.txt", + "fulltext": "A 24-year-old female with no significant past medical history initially presented to an outside hospital with severe abdominal pain and scantly bloody stools. She was transferred to a tertiary care center for further work-up and management. Contrast-enhanced CT of the abdomen and pelvis showed findings of colitis extending from the splenic flexure to the rectum . The patient was empirically treated for infectious and inflammatory etiologies of colitis without improvement. Flexible sigmoidoscopy demonstrated inflammatory changes in the descending colon and rectum with biopsy samples suggestive of ischemic colitis. A small external hemorrhoid was noted. Differential diagnosis for possible ischemic colitis included thrombosis and vasculitis, but there were no definitive imaging findings of either on CT imaging. Hematologic and rheumatologic work-up were nonspecific but notable for elevated rheumatoid factor and positive antinuclear antibodies.\nInterventional radiology was consulted for further angiographic evaluation of the mesenteric vessels given the ischemic findings on pathology. IMA angiography was performed, and prompt filling of the IMA and paralleling mesenteric venous branches was observed . A few abnormal-appearing, tortuous distal IMA branches were noted. Hepatofugal flow was observed in the IMV.\nGiven these findings, the patient was empirically treated with steroids and anticoagulation. She showed marginal improvement and had persistent severe abdominal pain. Based on the prompt venous filling seen on conventional angiography, it was hypothesized that the presence of an arteriovenous connection may be causing mesenteric venous congestion. After a multidisciplinary team discussion, it was decided to pursue further angiographic investigation and attempt endovascular embolization of a suspected arteriovenous connection.\nThe patient returned to interventional radiology for further diagnostic imaging and potential intervention. The right common femoral artery was accessed using standard micropuncture technique with a 5 French micropuncture set (Merit Medical, South Jordan, UT). Digital subtraction angiography of the IMA was performed using a 5 French catheter. Using a microcatheter, further selective angiography of the IMA branches was performed. Filling of the venous system was again seen along with a tangle of small vessels compatible with a nidus connecting small arterial feeders to the venous system . Glue embolization of this nidus was performed using n-butyl cyanoacrylate (n-BCA) (TruFill, Codman and Shurtleff Inc., Raynham, MA) diluted in a 3:1 lipiodol to n-BCA concentration. Post-embolization imaging demonstrated decreased venous filling, although there was persistent venous filling from several smaller IMA feeding branches, which were small and not amenable to embolization .\nThe patient’s pain significantly improved the day after embolization, and she was discharged 5 days post-embolization. Unfortunately, her pain returned in 11 days and rose to pre-embolization levels approximately 26 days post-embolization. She was readmitted for pain management, and her deteriorating condition resulted in a multidisciplinary medicine, interventional radiology, and surgery team decision to proceed with colonic resection. Extended left colectomy with partial proctectomy, end transverse colostomy, and rectal stump was performed. The patient tolerated the procedure well, and her pain completely resolved. Pathological analysis of resection specimens was consistent with venous insufficiency, as it indicated prominent concentric intimal smooth muscle hyperplasia with colonic perforation. Dilated capillaries, thickened hyaline walls, and ischemic changes were visualized without evidence of malignancy or thrombosis. Van Gieson’s stain along with venous presence of lymphocytic phlebitis, fat necrosis, and organizing thrombi confirmed IMHMV diagnosis (Genta and Haggitt ).", + "fulltext_subclaims": [ + "The patient is a 24-year-old female.", + "She had no significant past medical history.", + "She initially presented with severe abdominal pain.", + "She had scantly bloody stools.", + "She was transferred to a tertiary care center.", + "Contrast-enhanced CT showed findings of colitis extending from the splenic flexure to the rectum.", + "The patient was empirically treated for infectious and inflammatory etiologies of colitis.", + "There was no improvement with the empirical treatment.", + "Flexible sigmoidoscopy demonstrated inflammatory changes in the descending colon and rectum.", + "Biopsy samples were suggestive of ischemic colitis.", + "A small external hemorrhoid was noted.", + "Differential diagnosis included thrombosis and vasculitis.", + "There were no definitive imaging findings of thrombosis or vasculitis on CT imaging.", + "Hematologic and rheumatologic work-up were nonspecific.", + "Elevated rheumatoid factor was noted.", + "Positive antinuclear antibodies were noted.", + "Interventional radiology was consulted for further angiographic evaluation.", + "IMA angiography was performed.", + "Prompt filling of the IMA and paralleling mesenteric venous branches was observed.", + "A few abnormal-appearing, tortuous distal IMA branches were noted.", + "Hepatofugal flow was observed in the IMV.", + "The patient was empirically treated with steroids and anticoagulation.", + "She showed marginal improvement.", + "She had persistent severe abdominal pain.", + "It was hypothesized that the presence of an arteriovenous connection may be causing mesenteric venous congestion.", + "A multidisciplinary team decided to pursue further angiographic investigation.", + "The team decided to attempt endovascular embolization of a suspected arteriovenous connection.", + "The right common femoral artery was accessed using a 5 French micropuncture set.", + "Digital subtraction angiography of the IMA was performed using a 5 French catheter.", + "Selective angiography of the IMA branches was performed using a microcatheter.", + "Filling of the venous system was again seen.", + "A tangle of small vessels compatible with a nidus connecting small arterial feeders to the venous system was noted.", + "Glue embolization of this nidus was performed using n-butyl cyanoacrylate diluted in a 3:1 lipiodol to n-BCA concentration.", + "Post-embolization imaging demonstrated decreased venous filling.", + "There was persistent venous filling from several smaller IMA feeding branches.", + "The patient’s pain significantly improved the day after embolization.", + "She was discharged 5 days post-embolization.", + "Her pain returned in 11 days.", + "Her pain rose to pre-embolization levels approximately 26 days post-embolization.", + "She was readmitted for pain management.", + "A multidisciplinary team decided to proceed with colonic resection.", + "Extended left colectomy with partial proctectomy, end transverse colostomy, and rectal stump was performed.", + "The patient tolerated the procedure well.", + "Her pain completely resolved.", + "Pathological analysis of resection specimens was consistent with venous insufficiency.", + "Prominent concentric intimal smooth muscle hyperplasia with colonic perforation was indicated.", + "Dilated capillaries, thickened hyaline walls, and ischemic changes were visualized.", + "There was no evidence of malignancy.", + "There was no evidence of thrombosis.", + "Van Gieson’s stain showed venous presence of lymphocytic phlebitis, fat necrosis, and organizing thrombi.", + "IMHMV diagnosis was confirmed." + ], + "summary": "This report describes a 24-year-old female patient with findings of colitis and an abnormal arteriovenous connection of the inferior mesenteric arterial and venous systems. Partial embolization of this arteriovenous connection temporarily improved the patient's condition, but her symptoms ultimately returned due to the presence of multiple smaller feeder vessels not amenable to embolization, necessitating colonic resection for definitive treatment. Although prior reports have hypothesized that arterial pressurization of the veins may precipitate myointimal hyperplasia, to the authors' knowledge, this is the first report of IMHMV with an associated abnormal arteriovenous connection.", + "summary_subclaims": [ + "The patient is a 24-year-old female.", + "The patient had findings of colitis.", + "The patient had an abnormal arteriovenous connection of the inferior mesenteric arterial and venous systems.", + "Partial embolization of the arteriovenous connection temporarily improved the patient's condition.", + "The patient's symptoms ultimately returned.", + "The return of symptoms was due to the presence of multiple smaller feeder vessels not amenable to embolization.", + "Colonic resection was performed for definitive treatment.", + "Prior reports have hypothesized that arterial pressurization of the veins may precipitate myointimal hyperplasia.", + "To the authors' knowledge, this is the first report of IMHMV with an associated abnormal arteriovenous connection." + ] + }, + { + "id": "multiclinsum_test_2024_en.txt", + "fulltext": "A 37-year-old woman (height, 158 cm; body weight, 50 kg; ASA physical status class II; no systemic complications other than VLCAD exist) with VLCAD deficiency was diagnosed with an ovarian cyst and was scheduled for laparoscopic ovarian cystectomy. Rhabdomyolysis due to VLCAD deficiency first appeared at age 6 with skeletal muscle pain and myoglobinuria after swimming. Since then, she has exhibited similar symptoms several times a year during fasting, exercise, and mental stress. At the age of 31, VLCAD deficiency was diagnosed by acylcarnitine profile analysis. At the same time, genetic mutations c.1349G>A (p.R450H) and c.1639G>A (p.V547M) were identified in her ACADVL gene.\nGlucose was administered at 2 mg−1 kg−1 h−1 intravenously to prevent hypoglycemia with the start of fasting at 9 p.m. on the night before the surgery. On the day of surgery, when the patient entered the operating room, her blood glucose level was 108 mg dL−1 . Glucose administration was increased to 4 mg−1 kg−1 h−1. Anesthesia was induced with 0.5 μg−1 kg−1 min−1 of remifentanil, 3 mg of midazolam, and 200 mg of thiamylal, and muscle relaxation was achieved by 30 mg of rocuronium. After intubation with a cuffed tracheal tube, mechanical ventilation was started, and anesthesia was maintained with 40% oxygen and 5% desflurane in combination with the continuous infusion of 0.25–0.3 μg−1 kg−1 min−1 of remifentanil. Routine monitoring of vital signs and invasive radial artery pressure was performed. Blood glucose, creatine kinase, myoglobinuria, and lactate were monitored during anesthesia . To avoid postoperative shivering, body temperature was maintained at 36.2–36.7 °C . Acetaminophen (1000 mg) and buprenorphine (0.1 mg) were administered for postoperative analgesia. At the end of the surgery, administration of desflurane and remifentanil was stopped, and rocuronium was antagonized by 200 mg of sugammadex. Surgery time was 53 min, and anesthesia time was 1 h 59 min. No shivering was observed after extubation. Glucose was administered at 2–4 mg−1 kg−1 h−1 until oral intake was started. The blood glucose level of the patient was 142 mg dL−1 about 1 h after the surgery. The patient was discharged 2 days after the surgery.", + "fulltext_subclaims": [ + "The patient is a 37-year-old woman.", + "The patient's height is 158 cm.", + "The patient's body weight is 50 kg.", + "The patient has no systemic complications other than VLCAD.", + "The patient was diagnosed with an ovarian cyst.", + "The patient was scheduled for laparoscopic ovarian cystectomy.", + "Rhabdomyolysis due to VLCAD deficiency first appeared at age 6.", + "The patient experienced skeletal muscle pain and myoglobinuria after swimming at age 6.", + "The patient has exhibited similar symptoms several times a year during fasting.", + "The patient has exhibited similar symptoms several times a year during exercise.", + "The patient has exhibited similar symptoms several times a year during mental stress.", + "VLCAD deficiency was diagnosed at the age of 31.", + "VLCAD deficiency was diagnosed by acylcarnitine profile analysis.", + "Genetic mutations c.1349G>A (p.R450H) and c.1639G>A (p.V547M) were identified in her ACADVL gene.", + "Glucose was administered at 2 mg−1 kg−1 h−1 intravenously to prevent hypoglycemia.", + "Glucose administration was increased to 4 mg−1 kg−1 h−1 on the day of surgery.", + "Anesthesia was induced with 0.5 μg−1 kg−1 min−1 of remifentanil.", + "Anesthesia was induced with 3 mg of midazolam.", + "Anesthesia was induced with 200 mg of thiamylal.", + "Muscle relaxation was achieved by 30 mg of rocuronium.", + "Anesthesia was maintained with 40% oxygen and 5% desflurane.", + "Anesthesia was maintained with the continuous infusion of 0.25–0.3 μg−1 kg−1 min−1 of remifentanil.", + "Routine monitoring of vital signs and invasive radial artery pressure was performed.", + "Blood glucose, creatine kinase, myoglobinuria, and lactate were monitored during anesthesia.", + "Body temperature was maintained at 36.2–36.7 °C to avoid postoperative shivering.", + "Acetaminophen (1000 mg) was administered for postoperative analgesia.", + "Buprenorphine (0.1 mg) was administered for postoperative analgesia.", + "Rocuronium was antagonized by 200 mg of sugammadex.", + "Surgery time was 53 min.", + "Anesthesia time was 1 h 59 min.", + "No shivering was observed after extubation.", + "Glucose was administered at 2–4 mg−1 kg−1 h−1 until oral intake was started.", + "The blood glucose level of the patient was 142 mg dL−1 about 1 h after the surgery.", + "The patient was discharged 2 days after the surgery." + ], + "summary": "A 37-year-old woman with VLCAD deficiency was diagnosed with an ovarian cyst and was scheduled for laparoscopic ovarian cystectomy. Glucose was administered intravenously with the start of fasting. Anesthesia was induced with remifentanil, midazolam, and thiamylal, maintained with desflurane and remifentanil. Body temperature was maintained at 36.2-36.7 °C. During anesthesia, hypoglycemia did not occur, creatine kinase levels were in the normal range, and myoglobinuria was not detected. No shivering was observed after extubation.", + "summary_subclaims": [ + "The patient is a 37-year-old woman.", + "The patient has VLCAD deficiency.", + "The patient was diagnosed with an ovarian cyst.", + "The patient was scheduled for laparoscopic ovarian cystectomy.", + "Glucose was administered intravenously with the start of fasting.", + "Anesthesia was induced with remifentanil, midazolam, and thiamylal.", + "Anesthesia was maintained with desflurane and remifentanil.", + "Body temperature was maintained at 36.2-36.7 °C.", + "During anesthesia, hypoglycemia did not occur.", + "Creatine kinase levels were in the normal range.", + "Myoglobinuria was not detected.", + "No shivering was observed after extubation." + ] + }, + { + "id": "multiclinsum_test_2017_en.txt", + "fulltext": "A nine-month-old male infant, was admitted with an 8-day history of watery, non-bloody diarrhea, vomiting and decreased oral intake. The baby was previously healthy and had a negative medical history.\nOn physical examination, the patient was pale and irritable with generalized body edema, tachypnea (rate 36/min) and tachycardia (HR140/min) but no rales or murmurs were heard. No other abnormalities were noted.\nInitial investigations revealed leukocytosis (19 × 103), anemia (hemoglobin 7.7 g/L, hematocrit 22%) and thrombocytopenia (platelets 62× 103). Serum creatinine was 2.5, BUN, 57 uric acid, 7.6 mg/dl respectively, LDH 2293 IU/L. (reference value 265 I U/L). Peripheral blood smear revealed evidence of microangiopathic hemolysis with schistocytes and helmet cells. Abdominal ultrasound showed echogenic but normal sized kidneys. The patient was admitted to the pediatric intensive care with the diagnosis of hemolytic uremic syndrome for possible dialysis.\nDuring his stay, the patient had persistent diarrhea, decreased oral intake, oligoanuria and generalized body edema and hypertension. There was no response to high doses of intravenous furosemide (urine output less than 0.5 ml/kg/hour). Because of progressive deterioration in kidney function (creatinine reaching 5.2 mg/dl, blood urea nitrogen 88 mg/dl), persistent oligoanuria and worsening microangiopathic hemolysis and thrombocytopenia (hemoglobin of 5.4 g/dl and platelets of 23× 103) peritoneal dialysis was started after 48 h of hospitalization. The patient also received one unit of packed RBC transfusion.\nStool studies with Multiplex Qualitative reverse transcriptase PCR were negative for Salmonella, Shigella, Campylobacter, Yersinia, enterohemorrhagic E coli; enteropathogenic E coli (EPEC), enterotoxigenic E coli (ETEC), enteroinvasive E coli (EIEC) and Shiga-like toxin-producing E.coli (STEC) stx1/stx2, Rotavirus A, Adenovirus, Astrovirus, but were positive for Norovirus GI/G II.\nAdditional relevant laboratory studies included massive albuminuria with an Ualb/Cr 97 mg/mg (ref value < 0.2), low C3 and C4 complement of 0.56 g/L (ref value 0.9–1.8 g/L) and 0.07 g/L (reference value 0.1–0.4 g/L) respectively.\nAfter 48 h of continuous peritoneal dialysis, the patient improved clinically with progressive decrease in edema and gradual increase in urine output. Peritoneal dialysis was continued for 5 more days and his kidney function improved steadily and normalized by the 10th day when his serum creatinine was 0.3 mg/dl, and albuminuria was down to 0.13 mg/mg creatinine. Three weeks after the onset of the disease, C3 and C4 had returned to normal levels at 1.16 g/L and 0.31 g/L respectively. The patient’s hospital course and laboratory data are depicted in Figs. a and b. The patient has been followed for 11 months since the onset of his illness and shows no evidence of residual damage with normal renal, hematologic and complement profile. He is normotensive and has no microalbuminuria.", + "fulltext_subclaims": [ + "The patient was a nine-month-old male infant.", + "The patient had an 8-day history of watery, non-bloody diarrhea.", + "The patient had vomiting.", + "The patient had decreased oral intake.", + "The patient was previously healthy.", + "The patient had a negative medical history.", + "On physical examination, the patient was pale.", + "On physical examination, the patient was irritable.", + "On physical examination, generalized body edema was noted.", + "Tachypnea with a rate of 36/min was noted.", + "Tachycardia with a heart rate of 140/min was noted.", + "No rales were heard.", + "No murmurs were heard.", + "No other abnormalities were noted.", + "Initial investigations revealed leukocytosis of 19 × 103.", + "Initial investigations revealed anemia with hemoglobin of 7.7 g/L.", + "Initial investigations revealed thrombocytopenia of 62 × 103.", + "Serum creatinine was 2.5 mg/dl.", + "Blood urea nitrogen was 57 mg/dl.", + "Uric acid was 7.6 mg/dl.", + "LDH was 2293 IU/L.", + "Peripheral blood smear showed microangiopathic hemolysis.", + "Abdominal ultrasound showed echogenic but normal sized kidneys.", + "The patient was admitted to the pediatric intensive care.", + "The diagnosis was hemolytic uremic syndrome.", + "The patient had persistent diarrhea.", + "The patient had decreased oral intake.", + "The patient had oligoanuria.", + "The patient had generalized body edema.", + "The patient had hypertension.", + "There was no response to high doses of intravenous furosemide.", + "Urine output was less than 0.5 ml/kg/hour.", + "Serum creatinine reached 5.2 mg/dl.", + "Blood urea nitrogen was 88 mg/dl.", + "Hemoglobin was 5.4 g/dl.", + "Platelets were 23 × 103.", + "Peritoneal dialysis was started after 48 h of hospitalization.", + "The patient received one unit of packed RBC transfusion.", + "Stool studies were negative for Salmonella.", + "Stool studies were negative for Shigella.", + "Stool studies were negative for Campylobacter.", + "Stool studies were negative for Yersinia.", + "Stool studies were negative for enterohemorrhagic E. coli.", + "Stool studies were negative for enteropathogenic E. coli.", + "Stool studies were negative for enterotoxigenic E. coli.", + "Stool studies were negative for enteroinvasive E. coli.", + "Stool studies were negative for Shiga-like toxin-producing E. coli.", + "Stool studies were negative for Rotavirus A.", + "Stool studies were negative for Adenovirus.", + "Stool studies were negative for Astrovirus.", + "Stool studies were positive for Norovirus GI/G II.", + "Massive albuminuria was noted with Ualb/Cr of 97 mg/mg.", + "C3 complement was 0.56 g/L.", + "C4 complement was 0.07 g/L.", + "After 48 h of continuous peritoneal dialysis, the patient improved clinically.", + "Edema decreased progressively.", + "Urine output increased gradually.", + "Peritoneal dialysis was continued for 5 more days.", + "Kidney function improved steadily.", + "Serum creatinine normalized by the 10th day at 0.3 mg/dl.", + "Albuminuria was down to 0.13 mg/mg creatinine.", + "Three weeks after the onset, C3 was 1.16 g/L.", + "Three weeks after the onset, C4 was 0.31 g/L.", + "The patient has been followed for 11 months.", + "There is no evidence of residual damage.", + "The patient has a normal renal profile.", + "The patient has a normal hematologic profile.", + "The patient has a normal complement profile.", + "The patient is normotensive.", + "The patient has no microalbuminuria." + ], + "summary": "A nine-month-old male infant, was admitted with an 8-day history of watery, non-bloody diarrhea, vomiting and decreased oral intake. Physical exam revealed normal blood pressure, pallor and generalized edema. Laboratory findings were significant for microangiopathic hemolytic anemia, thrombocytopenia and azotemia. Stool studies with Multiplex Qualitative reverse transcriptase PCR were positive for Norovirus GI/G II. His clinical course was unusually severe, complicated by oligoanuria and worsening uremia requiring peritoneal dialysis but with eventual complete recovery.", + "summary_subclaims": [ + "The patient is a nine-month-old male infant.", + "The patient had an 8-day history of watery, non-bloody diarrhea.", + "The patient had vomiting.", + "The patient had decreased oral intake.", + "Physical exam revealed normal blood pressure.", + "Physical exam revealed pallor.", + "Physical exam revealed generalized edema.", + "Laboratory findings were significant for microangiopathic hemolytic anemia.", + "Laboratory findings were significant for thrombocytopenia.", + "Laboratory findings were significant for azotemia.", + "Stool studies with Multiplex Qualitative reverse transcriptase PCR were positive for Norovirus GI/G II.", + "The patient's clinical course was unusually severe.", + "The patient had oligoanuria.", + "The patient had worsening uremia.", + "The patient required peritoneal dialysis.", + "The patient had eventual complete recovery." + ] + }, + { + "id": "multiclinsum_test_226_en.txt", + "fulltext": "A 12-year-old boy presented with complains of swelling over the right side of neck for last 1 year. The swelling was insidious in onset, gradually progressive, and painless. On clinical examination, a solitary 3 cm × 3 cm × 2 cm spherical bony hard swelling with well-defined margins was palpable in the right supraclavicular region . The swelling was nontender and immobile. Neck movements were terminally restricted. Adson’s test was positive. Roos and Wright’s tests were negative. There was no distal neurovascular deficit.\nPlain radiographs of cervical spine revealed a bony mass over right side of neck . Computerized tomographic (CT) scans showed a well-defined broad-based lobulated bony outgrowth measuring 2.8 cm × 2.4 cm arising from the right pedicle and encroaching onto lamina and transverse process of C6 vertebra. The cortex and medulla of the lesion was in continuity with the host bone . Magnetic resonance imaging (MRI) was done to evaluate the degree of soft tissue involvement. It revealed altered signal intensity of 11 mm thickness which was hyperintense on T2W and short tau inversion recovery (STIR) images. After gadolinium administration, there was peripheral enhancement surrounding the bony outgrowth which was suggestive of a cartilage cap. The scalene muscles showed no signs of infiltration; however, the roots and trunks of the brachial plexus were hyperintense on STIR which was suggestive of some compression .\nThe bony swelling arising from the right pedicle and encroaching onto lamina and transverse process of C6 vertebra was excised extraperiosteally through an anterior spinal approach .\nHistopathological examination showed thick cartilage cap overlying endochondral ossification and lamellar bony trabeculae encasing fatty and cellular marrow which was consistent with osteochondroma . At 4-year follow-up, the patient was asymptomatic, and CT scan did not show recurrence .", + "fulltext_subclaims": [ + "A 12-year-old boy presented with complains of swelling over the right side of neck for last 1 year.", + "The swelling was insidious in onset, gradually progressive, and painless.", + "On clinical examination, a solitary 3 cm × 3 cm × 2 cm spherical bony hard swelling with well-defined margins was palpable in the right supraclavicular region.", + "The swelling was nontender and immobile.", + "Neck movements were terminally restricted.", + "Adson’s test was positive.", + "Roos and Wright’s tests were negative.", + "There was no distal neurovascular deficit.", + "Plain radiographs of cervical spine revealed a bony mass over right side of neck.", + "Computerized tomographic (CT) scans showed a well-defined broad-based lobulated bony outgrowth measuring 2.8 cm × 2.4 cm arising from the right pedicle and encroaching onto lamina and transverse process of C6 vertebra.", + "The cortex and medulla of the lesion was in continuity with the host bone.", + "Magnetic resonance imaging (MRI) was done to evaluate the degree of soft tissue involvement.", + "It revealed altered signal intensity of 11 mm thickness which was hyperintense on T2W and short tau inversion recovery (STIR) images.", + "After gadolinium administration, there was peripheral enhancement surrounding the bony outgrowth which was suggestive of a cartilage cap.", + "The scalene muscles showed no signs of infiltration.", + "The roots and trunks of the brachial plexus were hyperintense on STIR which was suggestive of some compression.", + "The bony swelling arising from the right pedicle and encroaching onto lamina and transverse process of C6 vertebra was excised extraperiosteally through an anterior spinal approach.", + "Histopathological examination showed thick cartilage cap overlying endochondral ossification and lamellar bony trabeculae encasing fatty and cellular marrow.", + "The histopathological findings were consistent with osteochondroma.", + "At 4-year follow-up, the patient was asymptomatic.", + "CT scan did not show recurrence." + ], + "summary": "A 12-year-old boy presented with right sided supraclavicular swelling. Plain radiographs revealed a bony mass. Computerized tomography (CT) and magnetic resonance imaging scans of the cervical region showed a bony mass arising from pedicle and encroaching onto lamina of C6 vertebra. He underwent excision biopsy of the mass through an anterior approach. The histopathological diagnosis was osteochondroma. At 4-year follow-up, he was asymptomatic and CT scan revealed no recurrence.", + "summary_subclaims": [ + "A 12-year-old boy presented with right sided supraclavicular swelling.", + "Plain radiographs revealed a bony mass.", + "Computerized tomography (CT) and magnetic resonance imaging scans of the cervical region showed a bony mass arising from pedicle and encroaching onto lamina of C6 vertebra.", + "He underwent excision biopsy of the mass through an anterior approach.", + "The histopathological diagnosis was osteochondroma.", + "At 4-year follow-up, he was asymptomatic.", + "CT scan revealed no recurrence." + ] + }, + { + "id": "multiclinsum_test_3331_en.txt", + "fulltext": "67-year-old female patient who consulted the emergency department for palpitations. As a clinical history, she presented mitral prolapse and loss of vision in the right eye secondary to an ophthalmic artery embolism. She began 7 days earlier with sporadic palpitations, not associated with the functional class, which subsided spontaneously, and which persisted permanently for 2 hours on the day of the consultation. The patient reported progressive dyspnoea up to functional class III of 6 months of evolution. On admission, she presented the following vital signs: arterial tension of 110/60 mmHg, heart rate of 140 beats per minute, oxygen saturation of 95% of ambient air, respiratory rate of 20 beats per minute, jugular engorgement, oedema 3/6 and hepatalgia. On the admission electrocardiogram, a rhythm of atrial fibrillation was observed at 140 beats per minute, axis at 60°, qrs 0.14 with an image of incomplete left branch block, without alterations of the ST-T segment. Laboratory: haematocrit of 42, no leukocytosis, creatinine 0.92, sodium of 136, potassium of 4.3, magnesium of 1.9, NT proBnp of 12 000 pg/dL, and troponins of 1900 ng/dL. It was interpreted as heart failure in a patient with atrial fibrillation with high ventricular response. During the admission, the etiological diagnosis was deepened. An echocardiogram was performed, where increased left ventricular diameters with severe impairment of function, severe left atrial enlargement, redundant mitral valve with bivalve prolapse were observed, with a predominance of p, with mild reflux and mild tricuspid insufficiency with pulmonary systolic pressure of 28 mmHg. Due to severe impairment of function not known and positive troponins, a cinecoronaryography was performed, which did not evidence angiographically significant lesions. Differential diagnoses were proposed: myocarditis and tachycardiomyopathy. They were ruled out, given that the patient did not present echocardiographic characteristics of myocarditis and in the rhythm without sinus there was no recovery of function, which also did not correspond with a syndrome of tachycardiomyopathy. It was interpreted as severe impairment of ventricular function in a patient with Barlow's disease. An electrocardiogram of the rhythm without sinus was performed, and a transesophageal cardioversion was performed successfully. In the transesophageal electrocardiogram, the mitral valve was reevaluated again and the patient presented mild insufficiency with a prolapse similar to that observed in the transtoracic electrocardiogram. Electrocardioversion was performed successfully. In the subsequent electrocardiograms of the rhythm without sinus, the severe impairment of ventricular function persisted. At 24 hours of admission, the patient intercurred with an episode of cardiorespiratory arrest, secondary to polymorphic ventricular tachycardia. She repeated two similar events at 48 and 72 hours, all of which were reversed with advanced cardiopulmonary resuscitation. For this reason, the placement of an implantable cardiodesfibrilator (CDI) was decided as secondary prevention. The patient was discharged.\n", + "fulltext_subclaims": [ + "The patient is a 67-year-old female.", + "She consulted the emergency department for palpitations.", + "She has a clinical history of mitral prolapse.", + "She has a clinical history of loss of vision in the right eye secondary to an ophthalmic artery embolism.", + "She began 7 days earlier with sporadic palpitations.", + "The palpitations were not associated with the functional class.", + "The palpitations subsided spontaneously.", + "The palpitations persisted permanently for 2 hours on the day of the consultation.", + "The patient reported progressive dyspnoea up to functional class III.", + "The dyspnoea had an evolution of 6 months.", + "On admission, the arterial tension was 110/60 mmHg.", + "On admission, the heart rate was 140 beats per minute.", + "On admission, the oxygen saturation was 95% of ambient air.", + "On admission, the respiratory rate was 20 beats per minute.", + "On admission, there was jugular engorgement.", + "On admission, there was oedema 3/6.", + "On admission, there was hepatalgia.", + "On the admission electrocardiogram, a rhythm of atrial fibrillation was observed.", + "On the admission electrocardiogram, the heart rate was 140 beats per minute.", + "On the admission electrocardiogram, the axis was at 60°.", + "On the admission electrocardiogram, the qrs was 0.14.", + "On the admission electrocardiogram, there was an image of incomplete left branch block.", + "On the admission electrocardiogram, there were no alterations of the ST-T segment.", + "The haematocrit was 42.", + "There was no leukocytosis.", + "The creatinine was 0.92.", + "The sodium was 136.", + "The potassium was 4.3.", + "The magnesium was 1.9.", + "The NT proBnp was 12 000 pg/dL.", + "The troponins were 1900 ng/dL.", + "It was interpreted as heart failure in a patient with atrial fibrillation with high ventricular response.", + "An echocardiogram was performed.", + "The echocardiogram showed increased left ventricular diameters with severe impairment of function.", + "The echocardiogram showed severe left atrial enlargement.", + "The echocardiogram showed redundant mitral valve with bivalve prolapse.", + "The echocardiogram showed a predominance of p.", + "The echocardiogram showed mild reflux.", + "The echocardiogram showed mild tricuspid insufficiency.", + "The echocardiogram showed pulmonary systolic pressure of 28 mmHg.", + "A cinecoronaryography was performed.", + "The cinecoronaryography did not evidence angiographically significant lesions.", + "Differential diagnoses were proposed: myocarditis and tachycardiomyopathy.", + "Myocarditis was ruled out.", + "Tachycardiomyopathy was ruled out.", + "It was interpreted as severe impairment of ventricular function in a patient with Barlow's disease.", + "An electrocardiogram of the rhythm without sinus was performed.", + "A transesophageal cardioversion was performed successfully.", + "In the transesophageal electrocardiogram, the mitral valve was reevaluated.", + "The patient presented mild insufficiency with a prolapse similar to that observed in the transtoracic electrocardiogram.", + "Electrocardioversion was performed successfully.", + "In the subsequent electrocardiograms of the rhythm without sinus, the severe impairment of ventricular function persisted.", + "At 24 hours of admission, the patient intercurred with an episode of cardiorespiratory arrest.", + "The cardiorespiratory arrest was secondary to polymorphic ventricular tachycardia.", + "The patient repeated two similar events at 48 and 72 hours.", + "All events were reversed with advanced cardiopulmonary resuscitation.", + "The placement of an implantable cardiodesfibrilator (CDI) was decided as secondary prevention.", + "The patient was discharged." + ], + "summary": "A 60-year-old woman with a history of mitral valve prolapse presented with dyspnoea and palpitations of 2 weeks' evolution to functional class IV. The admission electrocardiogram showed a moderate response atrial fibrillation rhythm with frequent ventricular extrasystoles. A transthoracic echocardiogram was performed where mitral valve prolapse was observed with severe deterioration of ventricular function. Barlow syndrome was diagnosed. The patient had three episodes of cardiorespiratory arrest during the hospital stay that were reversed with advanced cardiopulmonary resuscitation maneuvers. During the hospital stay, a negative balance was performed, the rhythm was reversed to sinus rhythm and an implantable cardiodesfibrilator was placed for secondary prevention. In the follow-up, there is a persistence of severe deterioration of ventricular function.\n", + "summary_subclaims": [ + "The patient is a 60-year-old woman.", + "She has a history of mitral valve prolapse.", + "She presented with dyspnoea and palpitations of 2 weeks' evolution.", + "The admission electrocardiogram showed a moderate response atrial fibrillation rhythm.", + "The admission electrocardiogram showed frequent ventricular extrasystoles.", + "A transthoracic echocardiogram was performed.", + "Mitral valve prolapse was observed on the echocardiogram.", + "Severe deterioration of ventricular function was observed on the echocardiogram.", + "Barlow syndrome was diagnosed.", + "The patient had three episodes of cardiorespiratory arrest during the hospital stay.", + "The episodes of cardiorespiratory arrest were reversed with advanced cardiopulmonary resuscitation maneuvers.", + "A negative balance was performed during the hospital stay.", + "The rhythm was reversed to sinus rhythm during the hospital stay.", + "An implantable cardiodesfibrilator was placed for secondary prevention.", + "In the follow-up, there is a persistence of severe deterioration of ventricular function." + ] + }, + { + "id": "multiclinsum_test_2238_en.txt", + "fulltext": "A 2 years old Javanese boy came with complaints of recurrent fever and urinary tract symptoms such as dysuria and straining. The patient was born via cesarean section at 34 weeks of gestation, with birth weight of 2250 g and considered as low birth weight. In his growth and development, this patient experienced numerous clinical problems in the form of abnormalities in his organs, such as atresia ani and unilateral undescended testicles. During the first year of his life, this patient underwent several definitive surgeries such as colostomy, anoplasty and orchidopexy. Right now this patient came with complaints of recurrent fever and urinary tract symptoms such as dysuria and straining. From a computerized tomography (CT) scan of the abdomen, the results showed there was an abnormality in the urinary tract . Cystourethrography examination was done and showed grade 5 voiding and grade 1 vesicoureteral reflux on both the left and right side Fig. .\nRetrograde pyelography is a necessary examination to confirm the diagnosis of unilateral renal agenesis. From this examination, it was found that there was a duplication in the left ureter and the absence of a collecting system on the left side. This patient also underwent a lumbosacral magnetic resonance imaging (MRI) examination to confirm whether this patient suffered from spina bifida or not . A laparoscopic left ureterectomy examination was carried to see how the patient's urinary tract functions Fig. .\nIn the end, laparoscopic left transperitoneal ureterectomy was done because of the presence of recurrent infections and visible vesicoureteral reflux (VUR) grade 5. The procedure began with the insertion of three 3 mm ports in the left abdominal hemi. Followed by opening the white line to access the ureter. Blunt dissection and hemodynamic control were performed afterward. The left ureter was cut at a height to reach the vesicoureteral junction and macroscopically no kidney image remained at all in the resected tissue . After that, the specimens were taken to the pathology laboratory for histopathological investigation Fig. .\nThe results of the pathological examination concluded several things. Most of the primitive kidney tissue with parenchyma had been replaced with fibrotic tissue. In several places such as atrophic dilated kidney tubules and a small part of the glomerulus, colloid-like material (thyroidization) can be seen. This pathological examination does not identify the cortex and medulla of the kidney because it is quite difficult to process. However, foci of ureteral tissue with monomorphic urothelial cells were identified. Apart from that, the fibrous stroma is edematous and fibrotic with chronic inflammatory cells, mostly lymphocytes. The blastema component also cannot be seen, but metaplastic cartilage islands could be seen in our case Fig. .\nFurther examination immunostaining using CD10, CK7 and p63 which aims to check the presence of renal glomeruli and tubules, urothelial cells and urothelial basal cells. The examination results of each immunostaining test included, the CD10 test gave positive staining results in the glomerulus and remaining renal tubular cells, as well as very positive CK7 staining in urothelial cells and positive p63 expression in urothelial basal cells. The conclusion that can be drawn is that after the initial examination was carried out and the diagnosis was established in the form of unilateral renal agenesis, the diagnosis changed because the results of histopathological and immunohistochemical examinations were more likely to lead to a diagnosis of severe dysplasia or aplastic kidney Fig. .\nAfter the surgical management was carried out, the condition of the patient showed positive results because there was a complete resolution of the condition of fever and dysuria which had been the main complaint so far. Video urodynamic studies were performed two months after surgery. The results show that the patient's bladder capacity is 120 cc. From the examination, it was concluded that this patient was already experiencing a normal condition because there were no abnormalities found when the filling phase had reached 120 cc, grade I right ureteral reflux, detrussor overactivity, normal bladder compliance and bladder capacity. When it was time to urinate, the patient was able to void 75 cc of urine and 75 cc of post-voiding volume. For now, the condition of spina bifida experienced by patients is still the responsibility of the neurosurgeon for follow-up and management.", + "fulltext_subclaims": [ + "The patient is a 2 years old Javanese boy.", + "The patient had complaints of recurrent fever.", + "The patient had urinary tract symptoms such as dysuria and straining.", + "The patient was born via cesarean section at 34 weeks of gestation.", + "The patient's birth weight was 2250 g.", + "The patient was considered as low birth weight.", + "The patient experienced numerous clinical problems in the form of abnormalities in his organs.", + "The patient had atresia ani.", + "The patient had unilateral undescended testicles.", + "During the first year of his life, the patient underwent several definitive surgeries.", + "The patient had a colostomy.", + "The patient had an anoplasty.", + "The patient had an orchidopexy.", + "A CT scan of the abdomen showed an abnormality in the urinary tract.", + "Cystourethrography showed grade 5 voiding.", + "Cystourethrography showed grade 1 vesicoureteral reflux on both the left and right side.", + "Retrograde pyelography is a necessary examination to confirm the diagnosis of unilateral renal agenesis.", + "The retrograde pyelography showed a duplication in the left ureter.", + "The retrograde pyelography showed the absence of a collecting system on the left side.", + "A lumbosacral MRI was done to confirm whether the patient suffered from spina bifida.", + "A laparoscopic left ureterectomy was carried out.", + "The procedure began with the insertion of three 3 mm ports in the left abdominal hemi.", + "Blunt dissection and hemodynamic control were performed.", + "The left ureter was cut at a height to reach the vesicoureteral junction.", + "Macroscopically, no kidney image remained at all in the resected tissue.", + "The specimens were taken to the pathology laboratory for histopathological investigation.", + "The pathological examination concluded that most of the primitive kidney tissue with parenchyma had been replaced with fibrotic tissue.", + "In several places, colloid-like material (thyroidization) can be seen.", + "The pathological examination does not identify the cortex and medulla of the kidney.", + "Foci of ureteral tissue with monomorphic urothelial cells were identified.", + "The fibrous stroma is edematous and fibrotic with chronic inflammatory cells, mostly lymphocytes.", + "The blastema component also cannot be seen.", + "Metaplastic cartilage islands could be seen in our case.", + "Further examination immunostaining using CD10, CK7 and p63 was performed.", + "The CD10 test gave positive staining results in the glomerulus and remaining renal tubular cells.", + "The CK7 staining was very positive in urothelial cells.", + "The p63 expression was positive in urothelial basal cells.", + "The conclusion was that the diagnosis changed to severe dysplasia or aplastic kidney.", + "After the surgical management, the condition of the patient showed positive results.", + "There was a complete resolution of the condition of fever.", + "There was a complete resolution of the condition of dysuria.", + "Video urodynamic studies were performed two months after surgery.", + "The patient's bladder capacity was 120 cc.", + "The patient had grade I right ureteral reflux.", + "The patient had detrussor overactivity.", + "The patient had normal bladder compliance.", + "The patient had normal bladder capacity.", + "The patient was able to void 75 cc of urine.", + "The patient had 75 cc of post-voiding volume.", + "The condition of spina bifida is still the responsibility of the neurosurgeon for follow-up and management." + ], + "summary": "A 2 year old Javanese boy came to the health facility with complaints of recurrent fever and urinary tract symptoms such as dysuria and straining. Computerized Tomography (CT) scan of the abdomen and urography showed agenesis of the left kidney and a probable spina bifida. Cystourethrography examination was done and showed grade 5 voiding, then retrograde pyelography was performed with the diagnosis of unilateral renal agenesis was made because there was no visible left side collecting system even though there was a duplication in the left ureter. The next examination was carried out by histopathology and immunohistochemistry after resection of the left side of the ureter and the diagnosis increasingly pointed towards renal aplasia after primitive renal structures were found.", + "summary_subclaims": [ + "The patient is a 2 year old Javanese boy.", + "The patient had complaints of recurrent fever.", + "The patient had urinary tract symptoms such as dysuria and straining.", + "Computerized Tomography (CT) scan of the abdomen and urography showed agenesis of the left kidney.", + "Computerized Tomography (CT) scan of the abdomen and urography showed a probable spina bifida.", + "Cystourethrography examination showed grade 5 voiding.", + "Retrograde pyelography was performed.", + "The diagnosis of unilateral renal agenesis was made.", + "There was no visible left side collecting system.", + "There was a duplication in the left ureter.", + "Histopathology and immunohistochemistry were carried out after resection of the left side of the ureter.", + "The diagnosis increasingly pointed towards renal aplasia.", + "Primitive renal structures were found." + ] + }, + { + "id": "multiclinsum_test_182_en.txt", + "fulltext": "A 72-year-old man was admitted with shortness of breath for more than 1 year after the activity and then had hemoptysis for 1 week. The patient has a history of dermatophytosis for 4 years and never-treated, smoking more than 20 years cigarettes 3 per day and quitting smoking for 6 months, drinking for more than 10 years. On physical examination, her bilateral zygomatic and lips had cyanosis, hepatic jugular venous reflux sign was positive. Mild systolic murmur of grade 2/6 could be heard in the auscultation area of pulmonary valve and peripheral oxygen saturation was 97% while breathing ambient air. Two-dimensional transthoracic echocardiography showed a solid mass was detected at the pulmonary valve orifice, showing moderate-to-strong echo. Its outline was clear, and the internal echo was uniform, with the size of about 57mm × 36mm. It was attached to the pulmonary valve orifice, part of which was located in the right ventricular outflow tract, and part in the main pulmonary artery. There was no obvious motion, causing obvious stenosis of the pulmonary valve orifice . The right atrium and right ventricle were enlarged, and the interventricular septum shifted to the left ventricle, showing “D” sign . Color Doppler flow imaging showed moderate regurgitation in tricuspid valve with regurgitation area of 8.8cm2 , regurgitation velocity of 420 cm/s and PG of 70 mmHg . Computed tomography angiography (CTA) findings of superior vena cava: right ventricular and the root of pulmonary artery has low-density imaging, considering that it is thrombosis, neoplastic lesions are not excluded . The patient underwent surgery, which showed pulmonary valve has solid occupying lesions, pale yellow, soft, nonenveloped, wrapping of the pulmonary valve leaflet, adhesion of the posterior wall of pulmonary valve, clipping the mass along the posterior wall of the pulmonary valve, the size of the mass is about 6.0cm × 4.5 cm . Cardiac surgeons explored that the posterior wall is very thin, fresh autologous pericardium to reconstruct the pulmonary valve. Continuous observation intraoperative by transoesophageal echocardiography. Postoperative transoesophageal echocardiography demonstrated no obvious abnormalities in the pulmonary arteries. Doppler examination showed a maximum flow velocity of 110 cm/s; color Doppler flow imaging (CDFI) displayed there was no stenosis in the pulmonary arteries. The final pathological diagnosis is Pulmonary artery endometrial sarcoma . The lesions presented three regions under the microscope: including necrotic regions, sparse region and intensive areas. Tumor cells grow in solid neoplasm, invade from pulmonary artery intima to adventitia, most of the tumor cells are spindle cells, it is very obvious in heteromorphism. Collagen presents predominantly in the interstitial matrix, also bone matrix visible, nuclear compartmentalization and necroptosis is frequent. An immunohistochemical analysis showed that CD vimentin-positive and α-smooth muscle actin-positive, desmin-negative, CD34-negative, CD31-negative, F8-negative, Stat6-negative, Ki67(+ 10%), S100-negative, SOX10-negative, TLE1-negative, CK-negative, EMA-negative. A further treatment for this patient after cardiac surgery was carried on in the cardiac intensive care. Persistent hypoxemia could not correct after giving various intravenous drugs. The patient died in the fifth day after cardiac surgery.", + "fulltext_subclaims": [ + "The patient is a 72-year-old man.", + "The patient had shortness of breath for more than 1 year after activity.", + "The patient had hemoptysis for 1 week.", + "The patient has a history of dermatophytosis for 4 years.", + "The patient had never-treated dermatophytosis.", + "The patient smoked more than 20 years, 3 cigarettes per day.", + "The patient quit smoking 6 months before admission.", + "The patient had cyanosis of bilateral zygomatic and lips.", + "The hepatic jugular venous reflux sign was positive.", + "A mild systolic murmur of grade 2/6 was heard in the pulmonary valve auscultation area.", + "The peripheral oxygen saturation was 97% while breathing ambient air.", + "A solid mass was detected at the pulmonary valve orifice on two-dimensional transthoracic echocardiography.", + "The mass showed moderate-to-strong echo with clear outline and uniform internal echo.", + "The mass size was about 57mm × 36mm.", + "The mass was attached to the pulmonary valve orifice.", + "Part of the mass was located in the right ventricular outflow tract.", + "Part of the mass was located in the main pulmonary artery.", + "The mass caused obvious stenosis of the pulmonary valve orifice.", + "The right atrium and right ventricle were enlarged.", + "The interventricular septum shifted to the left ventricle, showing 'D' sign.", + "Color Doppler flow imaging showed moderate tricuspid regurgitation.", + "The tricuspid regurgitation area was 8.8cm2.", + "The tricuspid regurgitation velocity was 420 cm/s.", + "The tricuspid regurgitation PG was 70 mmHg.", + "Computed tomography angiography showed low-density imaging in the right ventricular and pulmonary artery root.", + "Computed tomography angiography considered thrombosis.", + "Computed tomography angiography did not exclude neoplastic lesions.", + "The patient underwent surgery.", + "The mass was pale yellow, soft, nonenveloped, and wrapped the pulmonary valve leaflet.", + "The mass size was about 6.0cm × 4.5 cm.", + "The posterior wall of the pulmonary valve was very thin.", + "Fresh autologous pericardium was used to reconstruct the pulmonary valve.", + "Transoesophageal echocardiography was used intraoperatively.", + "Postoperative transoesophageal echocardiography showed no obvious abnormalities in the pulmonary arteries.", + "Doppler examination showed a maximum flow velocity of 110 cm/s.", + "Color Doppler flow imaging showed no stenosis in the pulmonary arteries.", + "The final pathological diagnosis was pulmonary artery endometrial sarcoma.", + "The lesions included necrotic regions, sparse regions, and intensive areas.", + "Tumor cells grew in solid neoplasm and invaded from pulmonary artery intima to adventitia.", + "Most tumor cells were spindle cells with obvious heteromorphism.", + "Collagen was predominant in the interstitial matrix.", + "Bone matrix was visible.", + "Nuclear compartmentalization and necroptosis were frequent.", + "Immunohistochemical analysis showed CD vimentin-positive.", + "Immunohistochemical analysis showed α-smooth muscle actin-positive.", + "Immunohistochemical analysis showed desmin-negative.", + "Immunohistochemical analysis showed CD34-negative.", + "Immunohistochemical analysis showed CD31-negative.", + "Immunohistochemical analysis showed F8-negative.", + "Immunohistochemical analysis showed Stat6-negative.", + "Immunohistochemical analysis showed Ki67(+10%).", + "Immunohistochemical analysis showed S100-negative.", + "Immunohistochemical analysis showed SOX10-negative.", + "Immunohistochemical analysis showed TLE1-negative.", + "Immunohistochemical analysis showed CK-negative.", + "Immunohistochemical analysis showed EMA-negative.", + "The patient received further treatment in the cardiac intensive care after cardiac surgery.", + "Persistent hypoxemia could not be corrected after various intravenous drugs.", + "The patient died on the fifth day after cardiac surgery." + ], + "summary": "Here, we report a case in a Chinese male where the symptom presentation was episodes of shortness of breath. Transthoracic echocardiography showed a solid mass in the pulmonary valve orifice, which was demonstrated to be a pulmonary artery intimal sarcoma diagnosed by histopathology. In this case, the initial differential diagnosis included pulmonary embolism. Because the initial symptom of primary pulmonary artery sarcoma is extremely similar to the pulmonary embolism, half of them may be misdiagnosed as pulmonary embolism. Imaging studies are very helpful. Ultrasound and CT are the best due to their resolution and ability to assess the relationship of the mass with the surrounding structures. The final diagnosis is mostly made after surgical excision and this is the most effective treatment. At the same time, radiotherapy and chemotherapy after surgery is also an adjuvant treatment.", + "summary_subclaims": [ + "The patient was a Chinese male.", + "The symptom presentation was episodes of shortness of breath.", + "Transthoracic echocardiography showed a solid mass in the pulmonary valve orifice.", + "The mass was diagnosed as a pulmonary artery intimal sarcoma by histopathology.", + "The initial differential diagnosis included pulmonary embolism.", + "The initial symptom of primary pulmonary artery sarcoma is extremely similar to pulmonary embolism.", + "Half of them may be misdiagnosed as pulmonary embolism.", + "Imaging studies are very helpful.", + "Ultrasound and CT are the best due to their resolution and ability to assess the relationship of the mass with the surrounding structures.", + "The final diagnosis is mostly made after surgical excision.", + "Surgical excision is the most effective treatment.", + "Radiotherapy and chemotherapy after surgery is also an adjuvant treatment." + ] + }, + { + "id": "multiclinsum_test_3194_en.txt", + "fulltext": "The patient, an Ivorian of 37 years of age, was admitted to the emergency department with a rapidly progressive tetraparesis that was detected on his awakening on March 30, 2024. The day before, the patient reported diffuse myalgia. The patient has a history of hyperthyroidism diagnosed in November 2023, for which treatment with neomercazole was initiated. The patient's history reveals a episode of tetraparesis without ascending character in November 2023 that lasted approximately 30 minutes, and was followed by a progressive spontaneous regression of the motor deficit in an apyretic context. On March 29, 2024, the patient presented a motor deficit of the four limbs detected on his awakening and of progressive aggravation. The patient indicated a therapeutic interruption of one week before the onset of symptoms. This motor deficit was preceded the day before by diffuse myalgia. The examination on his admission to hospital noted a flaccid tetraparesis with a motor strength of 3/5 affecting mainly the lower limbs. The biological balance found a hypokalaemia of 2.6 mEq/l. The natremia and chloremia as well as the renal functions were normal. The ultrasensitive TSH was low (less than 0.005 µl/ml) with an elevation of T3 and T4 respectively to 24.42 µl/ml and 79.68 µl/ml. We retained the diagnosis of a hypokalemic thyrotoxic periodic paralysis. The management consisted of an infusion of 3 g of potassium chloride. The clinical evolution after 24 hours was marked by an improvement of the motor strength. The biological balance found a normal potassium level of 3.9 mEq/l. The patient was discharged 48 hours later, in the context of satisfactory clinical follow-up with endocrinology.\n", + "fulltext_subclaims": [ + "The patient is an Ivorian of 37 years of age.", + "The patient was admitted to the emergency department with a rapidly progressive tetraparesis detected on awakening on March 30, 2024.", + "The patient reported diffuse myalgia the day before admission.", + "The patient has a history of hyperthyroidism diagnosed in November 2023.", + "The patient was treated with neomercazole for hyperthyroidism.", + "The patient had an episode of tetraparesis without ascending character in November 2023.", + "The November 2023 tetraparesis lasted approximately 30 minutes.", + "The November 2023 tetraparesis was followed by progressive spontaneous regression of the motor deficit.", + "The November 2023 tetraparesis occurred in an apyretic context.", + "On March 29, 2024, the patient had a motor deficit of the four limbs detected on awakening.", + "The March 29, 2024 motor deficit was of progressive aggravation.", + "The patient indicated a therapeutic interruption of one week before the onset of symptoms.", + "The motor deficit was preceded the day before by diffuse myalgia.", + "On admission, the examination noted a flaccid tetraparesis with motor strength of 3/5.", + "The flaccid tetraparesis mainly affected the lower limbs.", + "The biological balance found a hypokalaemia of 2.6 mEq/l.", + "The natremia and chloremia were normal.", + "The renal functions were normal.", + "The ultrasensitive TSH was less than 0.005 µl/ml.", + "The T3 level was elevated to 24.42 µl/ml.", + "The T4 level was elevated to 79.68 µl/ml.", + "The diagnosis retained was hypokalemic thyrotoxic periodic paralysis.", + "The management consisted of an infusion of 3 g of potassium chloride.", + "After 24 hours, the clinical evolution was marked by improvement of motor strength.", + "The biological balance after 24 hours found a normal potassium level of 3.9 mEq/l.", + "The patient was discharged 48 hours later.", + "The discharge occurred in the context of satisfactory clinical follow-up with endocrinology." + ], + "summary": "Mr. NK, aged 37, was hospitalised for a rapidly progressive quadriplegia. The patient has hyperthyroidism treated with neomercazole. His history reveals a first regressive episode in 30 minutes and a more marked relapse 4 months later in a context of therapeutic withdrawal. The clinical examination noted a flaccid tetraplegia mainly affecting the lower limbs. The biological assessment found a hypokalaemia of 2.6 mEq/L, ultrasensitive TSH was low (less than 0.005 µl/ml) with an elevation of T3 and T4 to 24.42 µl/ml and 79.68 µl/ml respectively. We retained the diagnosis of PPHT. The clinical evolution was satisfactory after the correction of the kaliemia and a readaptation of the hyperthyroidism treatment.\n", + "summary_subclaims": [ + "Mr. NK is aged 37.", + "Mr. NK was hospitalised for a rapidly progressive quadriplegia.", + "The patient has hyperthyroidism treated with neomercazole.", + "The patient had a first regressive episode in 30 minutes.", + "The patient had a more marked relapse 4 months later in a context of therapeutic withdrawal.", + "The clinical examination noted a flaccid tetraplegia mainly affecting the lower limbs.", + "The biological assessment found a hypokalaemia of 2.6 mEq/L.", + "Ultrasensitive TSH was less than 0.005 µl/ml.", + "T3 was elevated to 24.42 µl/ml.", + "T4 was elevated to 79.68 µl/ml.", + "The diagnosis retained was PPHT.", + "The clinical evolution was satisfactory after the correction of the kaliemia.", + "The clinical evolution was satisfactory after a readaptation of the hyperthyroidism treatment." + ] + }, + { + "id": "multiclinsum_test_2116_en.txt", + "fulltext": "We report a 26-year-old female and her 28-year-old healthy male partner, who experienced difficulties in becoming pregnant since 2015. Female patient had a regular menstrual cycle, but was previously diagnosed with endometriosis in 2012 following laparoscopy, for which she received treatment with goserelin acetate implant (Zoladex®). In January and October 2016, the couple experienced two first trimester miscarriages after natural conception at 5/6 weeks (gestational sac and yolk sac were visible by obstetric ultrasonography) and at 4/5 weeks (only gestational sac was visible) of gestation, respectively. The couple then turned to assisted reproduction in 2017 due to fertility issues. Because of history of endometriosis, the female patient underwent laparoscopy again in April 2017, but no endometriotic lesions were found and fallopian tubes were patent. The female patient was then followed up for multiple cycles for the presence of a dominant follicle. In addition, she was administered with alpha chorionic gonadotropin (Ovitrelle®) and dihydrogesterone (Duphaston®) but failed to conceive. In September 2017, the couple enrolled into IVF/PGT-A program at fertility clinic at West-Tallinn Central Hospital for elective embryo transfer to assist in achieving a successful pregnancy. An informed consent was also obtained, allowing to use supernumerary/affected embryos for research purposes.\nControlled ovarian stimulation was performed using recombinant follicle-stimulating hormone, followed by a gonadotropin-releasing hormone (GnRH) antagonist protocol. Final oocyte maturation was triggered by human chorionic gonadotropin administration 36–38 h prior to oocyte retrieval. In total 19 oocytes have been retrieved and all of them were fertilized by conventional IVF. The presumed zygotes were then cultured in a SAGE-1 single step media (Origio, Denmark) until day 5 blastocyst stage. Subsequent embryo morphological evaluation was performed according to the criteria set by Gardner and Schoolcraft . Trophectoderm (TE) biopsy was performed on four embryos that reached the blastocyst stage using RI Saturn 5 Active™ Laser and on average 5–10 cells were aspirated per embryo. Following TE biopsy, all blastocysts were vitrified using MediCult Vitrification Cooling medias (Origio).\nFor PGT-A, commercially available VeriSeq PGS kit (Illumina Inc., USA) was used for next-generation sequencing (NGS)-based aneuploidy screening. Briefly, TE biopsies were whole-genome amplified (WGA) according to ligation-mediated PCR-based SurePlex protocol (Illumina Inc., USA). The quality of WGA products was controlled on 1.5% agarose gel and the amount of amplified material was quantified by Qubit dsDNA HS Assay kit (Thermo Fisher Scientific, USA). Next, successfully amplified samples were used for library preparation, according to the manufacturer’s VeriSeq PGS kit protocol, and were sequenced on the Illumina MiSeq system. Subsequent CCS was performed using Illumina BlueFuse Multi v4.3 software with an embedded aneuploidy calling algorithm. Based on TE biopsy results, embryo classification was performed according to Preimplantation Genetic Diagnosis International Society (PGDIS) guidelines and recommendations for embryo prioritization (PGDIS, 2016).\nFor blood cell karyotyping, conventional GTG-banding technique (G-bands by trypsin using Giemsa; band level 550) was used for staining metaphase chromosomes from peripheral blood lymphocytes. Chromosome aberrations were classified according to the International System for Human Cytogenetic Nomenclature (ISCN2016).", + "fulltext_subclaims": [ + "The patient is a 26-year-old female.", + "The patient's partner is a 28-year-old healthy male.", + "The couple experienced difficulties in becoming pregnant since 2015.", + "The female patient had a regular menstrual cycle.", + "The female patient was previously diagnosed with endometriosis in 2012 following laparoscopy.", + "The female patient received treatment with goserelin acetate implant (Zoladex®).", + "In January 2016, the couple experienced a first trimester miscarriage after natural conception at 5/6 weeks.", + "In January 2016, obstetric ultrasonography showed a gestational sac and yolk sac.", + "In October 2016, the couple experienced a first trimester miscarriage after natural conception at 4/5 weeks.", + "In October 2016, obstetric ultrasonography showed only a gestational sac.", + "The couple turned to assisted reproduction in 2017 due to fertility issues.", + "In April 2017, the female patient underwent laparoscopy.", + "In April 2017, no endometriotic lesions were found.", + "In April 2017, the fallopian tubes were patent.", + "The female patient was followed up for multiple cycles for the presence of a dominant follicle.", + "The female patient was administered alpha chorionic gonadotropin (Ovitrelle®).", + "The female patient was administered dihydrogesterone (Duphaston®).", + "The female patient failed to conceive.", + "In September 2017, the couple enrolled into an IVF/PGT-A program.", + "An informed consent was obtained allowing the use of supernumerary/affected embryos for research purposes.", + "Controlled ovarian stimulation was performed using recombinant follicle-stimulating hormone.", + "A gonadotropin-releasing hormone (GnRH) antagonist protocol was used.", + "Final oocyte maturation was triggered by human chorionic gonadotropin administration 36–38 h prior to oocyte retrieval.", + "In total, 19 oocytes were retrieved.", + "All retrieved oocytes were fertilized by conventional IVF.", + "The presumed zygotes were cultured in SAGE-1 single step media until day 5 blastocyst stage.", + "Embryo morphological evaluation was performed according to Gardner and Schoolcraft criteria.", + "Trophectoderm (TE) biopsy was performed on four embryos that reached the blastocyst stage.", + "TE biopsy was performed using RI Saturn 5 Active™ Laser.", + "On average, 5–10 cells were aspirated per embryo during TE biopsy.", + "All blastocysts were vitrified using MediCult Vitrification Cooling medias.", + "For PGT-A, the VeriSeq PGS kit was used.", + "TE biopsies were whole-genome amplified using SurePlex protocol.", + "The quality of WGA products was controlled on 1.5% agarose gel.", + "The amount of amplified material was quantified by Qubit dsDNA HS Assay kit.", + "Successfully amplified samples were used for library preparation.", + "Libraries were sequenced on the Illumina MiSeq system.", + "CCS was performed using Illumina BlueFuse Multi v4.3 software.", + "Embryo classification was performed according to PGDIS guidelines.", + "Blood cell karyotyping was performed using conventional GTG-banding technique.", + "Chromosome aberrations were classified according to ISCN2016." + ], + "summary": "We describe a female patient, who pursued in vitro fertilization (IVF) treatment coupled with PGT-A following two consecutive miscarriages, unaware of her genetic condition. PGT-A was performed on blastocyst-stage embryos and the results of comprehensive chromosome screening from a first IVF cycle demonstrated reciprocal segmental aberrations on chromosome 7 and chromosome 10 in two out of four embryos. Due to distinct embryo profiles, the couple was then referred for genetic counselling and subsequent parental karyotyping revealed the presence of a previously undetected balanced translocation in the mother.", + "summary_subclaims": [ + "The patient is a female.", + "The patient pursued in vitro fertilization (IVF) treatment coupled with PGT-A.", + "The patient had two consecutive miscarriages.", + "The patient was unaware of her genetic condition.", + "PGT-A was performed on blastocyst-stage embryos.", + "The results of comprehensive chromosome screening from a first IVF cycle demonstrated reciprocal segmental aberrations on chromosome 7 and chromosome 10 in two out of four embryos.", + "The couple was referred for genetic counselling.", + "Subsequent parental karyotyping revealed the presence of a previously undetected balanced translocation in the mother." + ] + }, + { + "id": "multiclinsum_test_219_en.txt", + "fulltext": "A 23-year-old male sedentary worker sustained road traffic accident 1 year back, fall on outstretched hand, while he was driving two-wheeler. Immediately, he noticed inability to adduct the arm, bony mass below the collar bone. He was taken to nearby local hospital manipulated to reduce dislocation. He was immobilized in adducted position. He was asymptomatic till last 2 months when he experienced one more episode of dislocation which he reduced himself, following which seven episode of dislocation following daily routine activities each reduced by patient himself. Pain aggravated in last few days which made him to visit our hospital. On examination, coracoid tenderness present, Neer apprehension test positive, load and shift test positive, anterior draw test was grade 2, with no hyperlaxity. Routine radiographs revealed coracoid fracture. Computed tomography was done to assess glenoid bone loss and avulsion fracture of coracoid . Coracoid fracture belongs to Ogava et al., type II, magnetic resonance imaging confirmed the same . Labrum was deficient anteriorly and there was no associated rotator cuff tear.\nAfter a discussion with patient, open Laterjet procedure using fractured coracoid process in beach chair position under general anesthesia was decided. An incision of 5 cm made over apparent coracoid made standard deltopectoral approach performed. Clavipectoral fascia incised. Fractured coracoid process identified with its partial coracoacromial ligament and pectoralis minor attachment which was separated. Fractured fragment with conjoint tendon attachment separated from underlying structures . Graft was prepared of size length of 2 cm width of 0.8 mm with good amount of cancellous bed. Two drill holes were made over graft centimeter apart using 3.2 mm drill bit with special graft holding device. Graft recipient site was approached using upper two-third and lower one-third subscapular split and shoulder capsule incised vertically. Humeral head retracted using fakuda retractor. After adequate exposure and preparation of recipient site offset jig used to place graft parallel to glenoid anterior surface. Bi-cortical drilling performed over glenoid for adequate purchase of screws. After confirming the offset of graft two cannulated cancellous titanium screws of size 36 mm were inserted . Adequate stability of graft and tenodesis effect of lowed third subscapularis confirmed. To provide triple tenodesis effect, lateral leaf of capsule was sutured over glenoid lateral surface with double loaded 3.5 mm metal suture anchor as adequate amount of coracohumeral ligament was not present with fractured coracoid process.\nPost-operative rehabilitation includes shoulder immobilizer with chest binder to maintain arm in adducted position. Active elbow wrist exercises, Codman pendular exercises for 2 weeks, following suture removal isometric rotation exercises and shoulder range of motion exercises, were advised as permitted by pain. The patient called for follow-up at 6-week, 4-month, and 6 months for assessment of pain, range . At three and 6 month follow-up, CT scan was performed to assess union of graft and allowed to return to sport activity .", + "fulltext_subclaims": [ + "The patient is a 23-year-old male sedentary worker.", + "He sustained a road traffic accident 1 year back.", + "He had a fall on outstretched hand while driving a two-wheeler.", + "He noticed inability to adduct the arm immediately.", + "He noticed a bony mass below the collar bone.", + "He was taken to a nearby local hospital.", + "The dislocation was manipulated to reduce.", + "He was immobilized in an adducted position.", + "He was asymptomatic for 2 months before another episode of dislocation.", + "He experienced seven episodes of dislocation following daily routine activities.", + "Each dislocation was reduced by the patient himself.", + "Pain aggravated in the last few days.", + "Coracoid tenderness was present on examination.", + "Neer apprehension test was positive.", + "Load and shift test was positive.", + "Anterior draw test was grade 2.", + "Routine radiographs revealed coracoid fracture.", + "Computed tomography was done to assess glenoid bone loss.", + "Computed tomography was done to assess avulsion fracture of coracoid.", + "The coracoid fracture belongs to Ogava et al., type II.", + "MRI confirmed the coracoid fracture type.", + "The labrum was deficient anteriorly.", + "There was no associated rotator cuff tear.", + "An open Latarjet procedure using the fractured coracoid process was decided.", + "The procedure was performed in beach chair position under general anesthesia.", + "A 5 cm incision was made over the apparent coracoid.", + "A standard deltopectoral approach was performed.", + "Clavipectoral fascia was incised.", + "The fractured coracoid process was identified with partial coracoacromial ligament and pectoralis minor attachment.", + "The fractured fragment with conjoint tendon attachment was separated from underlying structures.", + "The graft was prepared with a length of 2 cm and width of 0.8 mm.", + "The graft had a good amount of cancellous bed.", + "Two drill holes were made over the graft centimeter apart using a 3.2 mm drill bit.", + "A special graft holding device was used.", + "The graft recipient site was approached using upper two-third and lower one-third subscapular split.", + "The shoulder capsule was incised vertically.", + "The humeral head was retracted using a Fakuda retractor.", + "An offset jig was used to place the graft parallel to the glenoid anterior surface.", + "Bi-cortical drilling was performed over the glenoid for adequate purchase of screws.", + "Two cannulated cancellous titanium screws of size 36 mm were inserted.", + "Adequate stability of the graft and tenodesis effect of the lower third subscapularis were confirmed.", + "To provide triple tenodesis effect, the lateral leaf of the capsule was sutured over the glenoid lateral surface.", + "A double loaded 3.5 mm metal suture anchor was used.", + "Post-operative rehabilitation included a shoulder immobilizer with chest binder.", + "Active elbow and wrist exercises were advised.", + "Codman pendular exercises were advised for 2 weeks.", + "Suture removal and isometric rotation exercises were advised.", + "Shoulder range of motion exercises were advised as permitted by pain.", + "Follow-up was scheduled at 6 weeks, 4 months, and 6 months.", + "CT scan was performed at 3 and 6 month follow-up.", + "CT scan was performed to assess union of the graft.", + "The patient was allowed to return to sport activity." + ], + "summary": "A 23-year-old male suffering from recurrent shoulder dislocation sustained coracoid fracture. Further evaluation showed glenoid defect of 25%. Magnetic resonance study showed on track lesion with Hill-Sach lesion of 9 mm, labral defect anteriorly with no associated rotator cuff tear. The patient was managed with open Latarjet procedure with fracture coracoid fragment with conjoint tendon as graft.", + "summary_subclaims": [ + "The patient is a 23-year-old male.", + "The patient has recurrent shoulder dislocation.", + "The patient sustained coracoid fracture.", + "Further evaluation showed a glenoid defect of 25%.", + "Magnetic resonance study showed an on track lesion.", + "Magnetic resonance study showed a Hill-Sach lesion of 9 mm.", + "Magnetic resonance study showed a labral defect anteriorly.", + "There was no associated rotator cuff tear.", + "The patient was managed with open Latarjet procedure.", + "The open Latarjet procedure used the fracture coracoid fragment with conjoint tendon as graft." + ] + }, + { + "id": "multiclinsum_test_2003_en.txt", + "fulltext": "A 74-year-old woman was admitted to our hospital department due to a right atrium mass. Three months earlier, she consulted a haematologist due to persistent fever and lymphadenopathy. A diagnosis of metastatic non-small cell lung carcinoma was made. Cardiovascular assessment before cancer treatment by transthoracic echocardiography (TTE) revealed the presence of a mass in the right atrium. A transoesophageal echocardiography (TEE) and a cardiac magnetic resonance were performed to further evaluate this mass, revealing a filamentous formation of 15 × 15 × 19 mm, originating from the inferior vena cava and extending to the interatrial septum, without gadolinium enhancement (; see ). This mass was interpreted as a Chiari’s network, and no specific treatment was proposed at the time. Immunotherapy with pembrolizumab was initiated. One month prior admission, she was hospitalized for fatigue. Physical examination revealed peripheral oedema and elevated jugular venous pressure. Laboratory investigation revealed cholestasis. Due to this right-sided acute heart failure, a computed tomography angiography of the chest was performed and showed a bilateral pulmonary embolism . The TTE showed the same previously known mass in the right atrium. Rivaroxaban, a non-vitamin K antagonist oral anticoagulant (NOAC), was started and patient was discharged. One day prior to admission, the follow-up TTE showed an increased size of the right atrium mass, as well as two new masses on the mitral valve . The patient was referred to our department.\nAt presentation, she was still febrile with a body temperature of 38.1°C. She presented persistent dyspnoea for several weeks and reported amaurosis fugax as well as transient diplopia. Except for pulmonary cancer, the patient’s medical history was only relevant for arterial hypertension. Her usual treatment included perindopril. Her blood pressure was 120/60 mm Hg, heart rate was 90 beats/min, and oxygen saturation was 96% on room air. The physical examination was irrelevant, and there were no signs of heart failure or neurological deficit. Routine laboratory investigations showed a C-reactive protein at 195 mg/L (normal range < 10.0). Blood cultures were negative multiple times. Immunological assays for anti-phospholipid syndrome were negative. Coagulation factor VIII was 419% (normal range: 60–150%). TEE showed two masses on the mitral valve: the first one on the A2 portion of the anterior leaflet, and the second one on the posterior leaflet (; see , ). These two masses had the same echogenicity as the one in the right atrium. The valve had neither stenotic nor regurgitant complications. A cerebral magnetic resonance was performed and showed multiple bilateral lesions compatible with ischaemic embolism.\nA NBTE involving Chiari’s network and mitral valve in the setting of a procoagulant state related to the active cancer was suspected, and intravenous heparin was started. To achieve the target range of activated partial thromboplastin time and anti-Xa level, the patient required a high dose of heparin (50.000 units per day for a weight of 50 kg). TTE and TEE realized 2 weeks after heparin initiation, showed a favourable regression of the right atrium mass, as well as the two lesions on the mitral valve. After multidisciplinary discussion, 3 weeks of intravenous heparin was decided with bridging therapy to vitamin K antagonist (VKA) for life (international normalized ratio target range 2.0–3.0). Follow-up TTE and TEE at 6 weeks showed a persistent filamentous structure coming from the inferior vena cava, which is consistent with the Chiari’s network . The mitral valve was free from vegetations. On the oncologic level, the patient did not respond to immunotherapy and is undergoing chemotherapy.", + "fulltext_subclaims": [ + "The patient is a 74-year-old woman.", + "She was admitted due to a right atrium mass.", + "Three months earlier, she consulted a haematologist due to persistent fever and lymphadenopathy.", + "A diagnosis of metastatic non-small cell lung carcinoma was made.", + "A transoesophageal echocardiography and a cardiac magnetic resonance were performed.", + "The mass was interpreted as a Chiari’s network.", + "No specific treatment was proposed at the time.", + "Immunotherapy with pembrolizumab was initiated.", + "One month prior to admission, she was hospitalized for fatigue.", + "Physical examination revealed peripheral oedema and elevated jugular venous pressure.", + "Laboratory investigation revealed cholestasis.", + "A computed tomography angiography showed a bilateral pulmonary embolism.", + "Rivaroxaban was started.", + "One day prior to admission, the follow-up TTE showed an increased size of the right atrium mass.", + "The patient was referred to the department.", + "At presentation, she was still febrile with a body temperature of 38.1°C.", + "She reported amaurosis fugax and transient diplopia.", + "Her usual treatment included perindopril.", + "The C-reactive protein was 195 mg/L.", + "Blood cultures were negative multiple times.", + "Immunological assays for anti-phospholipid syndrome were negative.", + "Coagulation factor VIII was 419%.", + "TEE showed two masses on the mitral valve.", + "The masses had the same echogenicity as the one in the right atrium.", + "A cerebral magnetic resonance showed multiple bilateral lesions compatible with ischaemic embolism.", + "A NBTE involving Chiari’s network and mitral valve was suspected.", + "Intravenous heparin was started.", + "The patient required a high dose of heparin.", + "TTE and TEE showed a favourable regression of the right atrium mass.", + "After multidisciplinary discussion, 3 weeks of intravenous heparin was decided.", + "Bridging therapy to vitamin K antagonist was planned.", + "Follow-up TTE and TEE at 6 weeks showed a persistent filamentous structure coming from the inferior vena cava.", + "The mitral valve was free from vegetations.", + "The patient did not respond to immunotherapy.", + "She is undergoing chemotherapy." + ], + "summary": "A 74-year-old patient with metastatic pulmonary cancer was diagnosed with a right atrium mass during pre-treatment cardiovascular check-up. Transoesophageal echocardiography and cardiac magnetic resonance concluded that the mass was a Chiari's network. Two months later, the patient was admitted for a pulmonary embolism and started rivaroxaban. At 1-month follow-up, the patient underwent a new echocardiography, which showed an increased size of the right atrium mass and the presence of two new masses on the mitral valve. She suffered an ischaemic stroke. Infectious work-up was negative. Coagulation factor VIII was 419%. A NBTE with Chiari's network thrombosis and mitral valve involvement was suspected in the setting of a hypercoagulable state related to the active cancer, and intravenous heparin was started, bridged to vitamin K antagonist (VKA) after 3 weeks. All the lesions were fully resolved on follow-up echocardiography at 6 weeks.", + "summary_subclaims": [ + "A 74-year-old patient with metastatic pulmonary cancer was diagnosed with a right atrium mass during pre-treatment cardiovascular check-up.", + "Transoesophageal echocardiography and cardiac magnetic resonance concluded that the mass was a Chiari's network.", + "Two months later, the patient was admitted for a pulmonary embolism and started rivaroxaban.", + "At 1-month follow-up, the patient underwent a new echocardiography, which showed an increased size of the right atrium mass.", + "At 1-month follow-up, the patient underwent a new echocardiography, which showed the presence of two new masses on the mitral valve.", + "She suffered an ischaemic stroke.", + "Infectious work-up was negative.", + "Coagulation factor VIII was 419%.", + "A NBTE with Chiari's network thrombosis and mitral valve involvement was suspected in the setting of a hypercoagulable state related to the active cancer.", + "Intravenous heparin was started, bridged to vitamin K antagonist (VKA) after 3 weeks.", + "All the lesions were fully resolved on follow-up echocardiography at 6 weeks." + ] + }, + { + "id": "multiclinsum_test_1272_en.txt", + "fulltext": "In May 2005, a 43-year-old man was admitted to the hospital with mitral regurgitation. In 1981, he had been in a car crash and developed a destructive nosocomial Staphylococcus aureus endocarditis of the mitral valve. A bioprosthesis was inserted which failed in 1988 and was replaced. In May 2005, regurgitation through the valve was once again detected and the patient was hospitalized for a further valve replacement. The patient was afebrile and had a systolic murmur over the mitral area. He had no leukocytosis (leukocyte count was 3.63 × 109/l with 50.2% neutrophils). The low neutrophil count corrected itself spontaneously. The erythrocyte sedimentation rate (16/43 mm) and C-reactive protein (<5 mg/l) was normal and hepatic enzymes were elevated (ALT: 69 IU/L; normal ≤ 40 IU/L). Three routine blood cultures were negative (Bactec, Becton Dickinson, Sparus, Maryland) and no rheumatoid factor was detected. Transthoracic echocardiography revealed mitral insufficiency but there were no vegetations and IE was not considered as a possible diagnosis. However, no transesophageal echocardiography was performed. Histology of the prosthetic valve removed at surgery using reported methods [,], revealed an IE with a vegetation containing micro-organisms that stained with Warthin-Starry and Giemsa . Standard cultures of cardiac valve tissue remained sterile, but with cell-cultures (human endothelial cell) a strain of B. henselae was isolated in 3 weeks . Also, DNA of B. henselae was demonstrated to be present in the valve by PCR and sequencing with primers for the eubacterial 16S rRNA gene and Bartonella ITS region Genotyping of the B. henselae strain was carried out using the multi-spacer typing (MST) method as previously described . Sequences obtained from the nine studied spacers classified the strain within MST genotype five, previously described to contain cat isolates from various countries including France, Germany and USA . Serum tested retrospectively was found to contain antibodies to B. henselae and B. quintana at an IgG titer of 1:200 , which is not suggestive of IE. However, western blotting was positive for antibodies to B. henselae and B. quintana and showed a reactivity pattern typical for endocarditis . Immunoblotting with a serum sample adsorbed with B. henselae confirmed the diagnosis of B. henselae IE.\nThe diagnosis of IE was made retrospectively based on the combination of histology of the cardiac valve lesions, culture of Bartonella from the valve, presence of a predisposing heart condition, and serological evidence of Bartonella infection. Without the histology of the valve the patient would not have had a positive score using the Duke criteria; he would only have had 2 minor criteria. After surgery, the patient recovered rapidly with routine post-surgical amoxicillin administration for 4 days, followed by gentamycin for 15 days and doxycycline for 1 month .\nRetrospectively, it was found that six months before the patient had had suspected lymphoma of an inguinal lymph node. Histology of the node, however, showed a necrotizing lymphadenitis suggested of CSD. Numerous microabscesses containing fragmented neutrophils were observed in homogenous necrotic areas. These necrotic regions were surrounded by a ring of macrophages and epithelioid histiocytes to form stellate inflammatory granulomas . No bacteria were detected by immunohistochemical examination or Warthin-Starry staining. Unfortunately, the lymph node sample was not available for PCR analysis to confirm the diagnosis of CSD.\nThe patient did not own a cat but reported a single contact with a stray cat that scratched him one month before the enlargement of the inguinal lymph node. We report the development of IE after a likely episode of CSD in a patient with a mechanical mitral cardiac valve. In previous studies , B. henselae was described in patients who have regular contact with cats and with pre-existing valvulopathies [,], but to the best of our knowledge the progression of CSD to IE has not previously been reported.", + "fulltext_subclaims": [ + "In May 2005, a 43-year-old man was admitted to the hospital with mitral regurgitation.", + "In 1981, he had been in a car crash and developed a destructive nosocomial Staphylococcus aureus endocarditis of the mitral valve.", + "A bioprosthesis was inserted which failed in 1988 and was replaced.", + "In May 2005, regurgitation through the valve was once again detected and the patient was hospitalized for a further valve replacement.", + "The patient was afebrile and had a systolic murmur over the mitral area.", + "He had no leukocytosis (leukocyte count was 3.63 × 109/l with 50.2% neutrophils).", + "The low neutrophil count corrected itself spontaneously.", + "The erythrocyte sedimentation rate (16/43 mm) and C-reactive protein (<5 mg/l) was normal.", + "Hepatic enzymes were elevated (ALT: 69 IU/L; normal ≤ 40 IU/L).", + "Three routine blood cultures were negative (Bactec, Becton Dickinson, Sparus, Maryland).", + "No rheumatoid factor was detected.", + "Transthoracic echocardiography revealed mitral insufficiency.", + "There were no vegetations and IE was not considered as a possible diagnosis.", + "No transesophageal echocardiography was performed.", + "Histology of the prosthetic valve removed at surgery revealed an IE with a vegetation containing micro-organisms that stained with Warthin-Starry and Giemsa.", + "Standard cultures of cardiac valve tissue remained sterile.", + "With cell-cultures (human endothelial cell), a strain of B. henselae was isolated in 3 weeks.", + "DNA of B. henselae was demonstrated to be present in the valve by PCR and sequencing with primers for the eubacterial 16S rRNA gene and Bartonella ITS region.", + "Genotyping of the B. henselae strain was carried out using the multi-spacer typing (MST) method.", + "Sequences obtained from the nine studied spacers classified the strain within MST genotype five.", + "MST genotype five was previously described to contain cat isolates from various countries including France, Germany and USA.", + "Serum tested retrospectively was found to contain antibodies to B. henselae and B. quintana at an IgG titer of 1:200.", + "The IgG titer of 1:200 is not suggestive of IE.", + "Western blotting was positive for antibodies to B. henselae and B. quintana.", + "Western blotting showed a reactivity pattern typical for endocarditis.", + "Immunoblotting with a serum sample adsorbed with B. henselae confirmed the diagnosis of B. henselae IE.", + "The diagnosis of IE was made retrospectively based on the combination of histology of the cardiac valve lesions, culture of Bartonella from the valve, presence of a predisposing heart condition, and serological evidence of Bartonella infection.", + "Without the histology of the valve the patient would not have had a positive score using the Duke criteria.", + "He would only have had 2 minor criteria.", + "After surgery, the patient recovered rapidly with routine post-surgical amoxicillin administration for 4 days.", + "Gentamycin was administered for 15 days.", + "Doxycycline was administered for 1 month.", + "Retrospectively, it was found that six months before the patient had had suspected lymphoma of an inguinal lymph node.", + "Histology of the node showed a necrotizing lymphadenitis suggested of CSD.", + "Numerous microabscesses containing fragmented neutrophils were observed in homogenous necrotic areas.", + "These necrotic regions were surrounded by a ring of macrophages and epithelioid histiocytes to form stellate inflammatory granulomas.", + "No bacteria were detected by immunohistochemical examination or Warthin-Starry staining.", + "The lymph node sample was not available for PCR analysis to confirm the diagnosis of CSD.", + "The patient did not own a cat.", + "The patient reported a single contact with a stray cat that scratched him one month before the enlargement of the inguinal lymph node.", + "We report the development of IE after a likely episode of CSD in a patient with a mechanical mitral cardiac valve.", + "In previous studies, B. henselae was described in patients who have regular contact with cats and with pre-existing valvulopathies.", + "To the best of our knowledge, the progression of CSD to IE has not previously been reported." + ], + "summary": "Here we report the case of a patient who had CSD and six months later developed IE of the mitral valve caused by B. henselae.", + "summary_subclaims": [ + "The patient had CSD.", + "Six months later, the patient developed IE of the mitral valve.", + "The IE was caused by B. henselae." + ] + }, + { + "id": "multiclinsum_test_939_en.txt", + "fulltext": "A 49-year-old healthy Greek man without any prior significant medical history, working as a cook on a merchant ship, drank accidentally a glass of 70% methanol rubbing solution, while he was on board. One day later he complained for blurred vision and painful eye movement in both eyes. The second day he woke up blind. He remained on board since the ship was heading to Australia and so treatment was impossible. When the ship reached Australia, he was hospitalized for a week. On arrival his vital signs were within normal limits and his examination tests revealed normal muscle tone. His initial laboratory evaluation included a complete blood count, electrolytes, blood urea nitrogen, creatinine, and serum glucose. All test results were within the normal range for the patient’s age. A urine drug test was negative for benzodiazepines, opiates, cocaine, amphetamines, phencyclidine, salicylates, and barbiturates. The blood methyl alcohol and formic acid values could not be determined. No treatment was given due to patient’s late arrival. He then was transferred to the University Eye Clinic of Athens. At presentation he underwent a complete ophthalmological examination. Visual acuity was no light perception in both eyes. The pupils were semi-dilated and unreactive to light. Fundus examination revealed an unremarkable retina in both eyes with the exception of pronounced pale, atrophic optic discs with “pseudoglaucomatous” thinning of the neuroretinal rim area. Electroretinogram (ERG) was normal in both eyes (Figure ). Visual evoked potentials (VEPs) were nearly extinguished (Figure ). Multifocal-visual evoked potential (mf-VEP) recording was also pathological in area 0 (right eye: 169 nV/deg2 and left eye: 186 nV/deg2) (Figure ). Optical coherence tomography (OCT) of the optic nerve head demonstrated abnormally low values of the retinal nerve fiber layer (RNFL) thickness equal to 128 μm in the superior, 39 in the nasal, 108 in the inferior, and 72 in the temporal quadrant of the right eye (OD), and 134, 99, 92, and 58 correspondingly of the left eye (OS) (Figure ).\nNeurological examination with the patient awake revealed no extrapyramidal motor disturbances and computed tomography (CT) scans showed no abnormalities. Anion gap was less than 30 mg/dL and no treatment was deemed necessary to initiate. The patient was discharged on the fourth day. He was reexamined one month later. The situation remained unchanged.", + "fulltext_subclaims": [ + "The patient is a 49-year-old healthy Greek man.", + "The patient had no prior significant medical history.", + "The patient drank a glass of 70% methanol rubbing solution.", + "One day after the ingestion, he complained of blurred vision and painful eye movement in both eyes.", + "The second day he woke up blind.", + "The patient remained on board the ship since it was heading to Australia.", + "Treatment was impossible while the ship was at sea.", + "The patient was hospitalized in Australia for a week.", + "On arrival, his vital signs were within normal limits.", + "The patient's muscle tone was normal.", + "The initial laboratory evaluation included a complete blood count, electrolytes, blood urea nitrogen, creatinine, and serum glucose.", + "All test results were within the normal range for the patient’s age.", + "The urine drug test was negative for benzodiazepines, opiates, cocaine, amphetamines, phencyclidine, salicylates, and barbiturates.", + "The blood methyl alcohol and formic acid values could not be determined.", + "No treatment was given due to the patient’s late arrival.", + "The patient was transferred to the University Eye Clinic of Athens.", + "At presentation, visual acuity was no light perception in both eyes.", + "The pupils were semi-dilated and unreactive to light.", + "Fundus examination revealed pronounced pale, atrophic optic discs with “pseudoglaucomatous” thinning of the neuroretinal rim area.", + "Electroretinogram (ERG) was normal in both eyes.", + "Visual evoked potentials (VEPs) were nearly extinguished.", + "Multifocal-visual evoked potential (mf-VEP) recording was pathological in area 0.", + "Optical coherence tomography (OCT) of the optic nerve head demonstrated abnormally low values of the retinal nerve fiber layer (RNFL) thickness.", + "Neurological examination revealed no extrapyramidal motor disturbances.", + "Computed tomography (CT) scans showed no abnormalities.", + "The anion gap was less than 30 mg/dL.", + "No treatment was deemed necessary to initiate.", + "The patient was discharged on the fourth day.", + "The patient was reexamined one month later.", + "The situation remained unchanged." + ], + "summary": "A 49-year-old Greek man developed bilateral irreversible blindness after accidental methanol intoxication. He underwent complete ophthalmological examination, including electroretinogram, visual evoked potentials, multifocal-visual evoked potentials, and optical coherence tomography scan of the optic nerve. Complete laboratory evaluation, urine drug testing, neurological examination, and computed tomography scans were also performed. Visual acuity demonstrated no light perception bilaterally, pupils were semi-dilated and unreactive to light, while the retina was normal in both eyes. Electroretinogram was normal, while visual evoked potentials, multifocal-visual evoked potentials recording, and optical coherence tomography scanning of both optic nerve heads were pathological in both eyes. The neurological examination and the computed tomography scans did not reveal any abnormalities. The laboratory evaluation was normal and the urine drug test was negative for benzodiazepines, opiates, cocaine, amphetamines, salicylates, barbiturates, and phencyclidine.", + "summary_subclaims": [ + "A 49-year-old Greek man developed bilateral irreversible blindness after accidental methanol intoxication.", + "He underwent complete ophthalmological examination, including electroretinogram, visual evoked potentials, multifocal-visual evoked potentials, and optical coherence tomography scan of the optic nerve.", + "Complete laboratory evaluation, urine drug testing, neurological examination, and computed tomography scans were also performed.", + "Visual acuity demonstrated no light perception bilaterally.", + "Pupils were semi-dilated and unreactive to light.", + "The retina was normal in both eyes.", + "Electroretinogram was normal.", + "Visual evoked potentials were pathological in both eyes.", + "Multifocal-visual evoked potentials recording was pathological in both eyes.", + "Optical coherence tomography scanning of both optic nerve heads was pathological.", + "The neurological examination did not reveal any abnormalities.", + "The computed tomography scans did not reveal any abnormalities.", + "The laboratory evaluation was normal.", + "The urine drug test was negative for benzodiazepines.", + "The urine drug test was negative for opiates.", + "The urine drug test was negative for cocaine.", + "The urine drug test was negative for amphetamines.", + "The urine drug test was negative for salicylates.", + "The urine drug test was negative for barbiturates.", + "The urine drug test was negative for phencyclidine." + ] + }, + { + "id": "multiclinsum_test_960_en.txt", + "fulltext": "A 40-year-old man with unstable Type I diabetes mellitus (with positive anti-insulin antibodies) was followed-up in the diabetology department of Strasbourg University Hospital. The duration of his diabetes was 35 years, during which he had normal renal function, no hematuria, stable microalbuminuria, and no other diabetic complications. Pre-transplant tests revealed neither HLA antibodies nor positive EBV serology, with negative CMV serology, normal cardiovascular exploration, and hepatic morphology. Since he did experience recurrent severe hypoglycemic episodes, the patient was included in the TRIMECO trial . In this trial, the patient received two pancreatic islet allografts using a percutaneous transhepatic portal approach over a 3-month period, without any immediate complications. Immunosuppressive induction for the first procedure included anti-thymocyte globulin (Thymoglobulin®, Sanofi Genzyme) at 0.5–1.5 mg/Kg/day for the first 3 days and anti-TNF-alpha etanercept (Enbrel®, AMGEN) on Day 0, which was decreased to 25 mg on Days 3, 7, and 10. Maintenance immunosuppression was conducted using 1000 mg of mycophenolate mofetil (Cellcept®, Genentech) twice a day and a CNI, tacrolimus (Prograf®, Astellas), twice a day, depending on the residual plasma levels (objectives: 9–13 μg/L for the first 3 months, then 6–9 μg/L thereafter). Induction for the second procedure consisted of 20 mg of the interleukin 2-receptor antagonist basiliximab (Simulect®, Novartis) on Days 0 and 4, along with etanercept. The total number of islets that were injected was 950,000 IEQ (islet equivalents to 150 pancreatic islet diameter). Two months after the second procedure, the patient became insulin-independent with a fasting C-peptide level of 2.3 μg/L (0.77 nmol/L), fasting glycemia of 5.7 mmol/L, and HbA1c of 5.1% (32 mmol/mol). This resulted in the disappearance of his hypoglycemic episodes. About 4 and 8 months after the second procedure, the patient was hospitalized due to recurrent watery diarrhea with Stage 1 acute kidney injury (AKI) , without any signs of hematological TMA. All microbiological explorations (bacterial, virologic, and parasitological in blood and feces) were negative, and kidney function returned to the normal range after intravenous hydration. This digestive episode was possibly linked to an undesirable effect of either mycophenolate mofetil or tacrolimus. However, these drugs were not discontinued.\nAbout 15 months after the second procedure, the patient was readmitted to hospital for Stage 3 AKI and high blood pressure (200/100 mmHg). All blood and urine analysis results are presented in Table . The renal ultrasonography was normal, and the association of mechanical hemolytic anemia–thrombocytopenia and acute renal failure led us to suspect aHUS . A hemodialysis session was initiated, along with plasma exchange (PEX; 60 mL/Kg) for 11 days. At this time, the first hypothesis established was direct endothelial toxicity due to overdosing of tacrolimus, in the context of dehydration from recurrent watery diarrhea, given that the trough tacrolimus level was at the upper limit of recommended targets. Since the suspicion was AKI/HUS induced by tacrolimus, the patient was first switched to ciclosporin (Neoral®, Novartis). He was subsequently switched to everolimus (Certican®, Novartis, anti m-TOR) after histological analysis of the renal biopsy results favored a typical TMA process . The poor response to PEX and low C3 level led us to suspect aHUS, so eculizumab (Soliris®, ALEXION) was initiated. Eculizumab was started 18 days after AKI was diagnosed, at a weekly dose of 900 mg for the first 4 weeks. Thereafter, therapy was maintained at 1200 mg per week for a further 2 months . At the same time, everolimus was similarly switched to cyclosporine. Although the thrombocytopenia resolved after 8 days of PEX, eculizumab administration was not followed by a recovery of renal function. During AKI, the islet graft remained functional. Despite the patient’s C-peptide level remaining uninterpretable in AKI, external insulin therapy was not deemed necessary to maintain normoglycemia.\nAfter receiving the patient’s written informed consent, blood samples were taken to screen for the six genes associated with aHUS. A rare nucleotide change (c.1775G > A) was detected in exon 14 of the C3 gene, resulting in an arginine-to-glutamine substitution in the C3 protein at position 570 (p.R592Q). This heterozygous variant, which has already been reported in patients diagnosed with aHUS , is an exposed amino acid located near the membrane cofactor protein (MCP) binding site. Functional analysis using a recombinant protein demonstrated decreased binding of the C3 variant with MCP, compared to the wild type, as well as a reduced rate of C3 cleavage by Factor I with MCP as the cofactor. This variant led to an indirect function gain, relative to complement activation, which explains the permanently low level of C3 in the patient’s plasma that was observed . Genetic evaluations that were conducted on two sisters revealed the same C3 gene mutation, which contraindicated a related living kidney donation.\nThe 40-year-old male patient eventually spent 1 year on hemodialysis treatment before undergoing brain-dead-donor kidney transplantation. There was no evidence for HLA immunization prior to transplantation, and preoperative HLA scoring identified four mismatches in HLA Class I, with none in HLA Class II. Cold ischemia time was 16 h. Immunosuppressive induction included basiliximab (Simulect®, Novartis), and eculizumab was continued at a dosage of 900 mg on Days 0, 1, 8, and 15, and then every other week at a dosage of 1200 mg to prevent aHUS relapse. Evidence of hematological TMA was absent in the immediate kidney transplantation follow-up. After kidney transplantation, the immunosuppressive regimen was modified to cyclosporine and mycophenolic acid (Myfortic®, Novartis). Three months after kidney transplantation, renal and pancreatic islet functions were considered excellent, with plasma creatinine levels at 94 μmol/L (1.06 mg/dL) and an HbA1c level of 5.5% (36.5 mmol/mol), without insulin therapy. Kidney function remained satisfactory 12 months after renal transplantation, with a plasma creatinine level of 87 μmol/L (1.0 mg/dL) without TMA lesions at the per-protocol kidney biopsy. Four years after renal transplantation, the patient is still treated with eculizumab, his plasma creatinine is 99 μmol/L, his low C3 level persists, and his pancreatic islet function is satisfactory. He has been insulin free for 5 years. The laboratory results pertaining to the 4-year follow-up are detailed in Fig. .", + "fulltext_subclaims": [ + "The patient is a 40-year-old man with unstable Type I diabetes mellitus.", + "The patient has positive anti-insulin antibodies.", + "The patient was followed-up in the diabetology department of Strasbourg University Hospital.", + "The duration of his diabetes was 35 years.", + "During the 35 years of diabetes, he had normal renal function.", + "During the 35 years of diabetes, he had no hematuria.", + "During the 35 years of diabetes, he had stable microalbuminuria.", + "During the 35 years of diabetes, he had no other diabetic complications.", + "Pre-transplant tests revealed neither HLA antibodies nor positive EBV serology.", + "Pre-transplant tests revealed negative CMV serology.", + "Pre-transplant tests revealed normal cardiovascular exploration.", + "Pre-transplant tests revealed normal hepatic morphology.", + "The patient experienced recurrent severe hypoglycemic episodes.", + "The patient was included in the TRIMECO trial.", + "In the TRIMECO trial, the patient received two pancreatic islet allografts.", + "The islet allografts were administered using a percutaneous transhepatic portal approach.", + "The islet allografts were administered over a 3-month period.", + "The islet allografts were administered without any immediate complications.", + "Immunosuppressive induction for the first procedure included anti-thymocyte globulin (Thymoglobulin®).", + "Immunosuppressive induction for the first procedure included anti-TNF-alpha etanercept (Enbrel®).", + "Maintenance immunosuppression included mycophenolate mofetil (Cellcept®).", + "Maintenance immunosuppression included tacrolimus (Prograf®).", + "Induction for the second procedure consisted of basiliximab (Simulect®).", + "Induction for the second procedure included etanercept.", + "The total number of islets injected was 950,000 IEQ.", + "Two months after the second procedure, the patient became insulin-independent.", + "Two months after the second procedure, the patient had a fasting C-peptide level of 2.3 μg/L.", + "Two months after the second procedure, the patient had a fasting glycemia of 5.7 mmol/L.", + "Two months after the second procedure, the patient had an HbA1c of 5.1%.", + "About 4 and 8 months after the second procedure, the patient was hospitalized due to recurrent watery diarrhea.", + "About 4 and 8 months after the second procedure, the patient had Stage 1 acute kidney injury.", + "About 4 and 8 months after the second procedure, there were no signs of hematological TMA.", + "All microbiological explorations were negative.", + "Kidney function returned to the normal range after intravenous hydration.", + "This digestive episode was possibly linked to an undesirable effect of either mycophenolate mofetil or tacrolimus.", + "These drugs were not discontinued.", + "About 15 months after the second procedure, the patient was readmitted for Stage 3 AKI.", + "About 15 months after the second procedure, the patient had high blood pressure (200/100 mmHg).", + "The association of mechanical hemolytic anemia–thrombocytopenia and acute renal failure led to suspicion of aHUS.", + "A hemodialysis session was initiated.", + "Plasma exchange (PEX) was performed for 11 days.", + "The first hypothesis was direct endothelial toxicity due to overdosing of tacrolimus.", + "The suspicion was AKI/HUS induced by tacrolimus.", + "The patient was switched to ciclosporin.", + "The patient was subsequently switched to everolimus after histological analysis favored a typical TMA process.", + "The poor response to PEX and low C3 level led to suspicion of aHUS.", + "Eculizumab was initiated 18 days after AKI was diagnosed.", + "Eculizumab was started at a weekly dose of 900 mg for the first 4 weeks.", + "Eculizumab was maintained at 1200 mg per week for a further 2 months.", + "Everolimus was switched to cyclosporine.", + "Eculizumab administration was not followed by a recovery of renal function.", + "During AKI, the islet graft remained functional.", + "External insulin therapy was not deemed necessary to maintain normoglycemia.", + "Blood samples were taken to screen for the six genes associated with aHUS.", + "A rare nucleotide change (c.1775G > A) was detected in exon 14 of the C3 gene.", + "This variant resulted in an arginine-to-glutamine substitution in the C3 protein at position 570 (p.R592Q).", + "This variant is heterozygous.", + "This variant has been reported in patients diagnosed with aHUS.", + "Functional analysis demonstrated decreased binding of the C3 variant with MCP.", + "Functional analysis demonstrated a reduced rate of C3 cleavage by Factor I with MCP as the cofactor.", + "This variant led to an indirect function gain, relative to complement activation.", + "This explains the permanently low level of C3 in the patient’s plasma.", + "Genetic evaluations on two sisters revealed the same C3 gene mutation.", + "This contraindicated a related living kidney donation.", + "The patient spent 1 year on hemodialysis treatment.", + "The patient underwent brain-dead-donor kidney transplantation.", + "There was no evidence for HLA immunization prior to transplantation.", + "Preoperative HLA scoring identified four mismatches in HLA Class I.", + "Cold ischemia time was 16 h.", + "Immunosuppressive induction included basiliximab.", + "Eculizumab was continued at a dosage of 900 mg on Days 0, 1, 8, and 15.", + "Eculizumab was continued at 1200 mg every other week.", + "Evidence of hematological TMA was absent in the immediate kidney transplantation follow-up.", + "After kidney transplantation, the immunosuppressive regimen was modified to cyclosporine and mycophenolic acid.", + "Three months after kidney transplantation, renal function was excellent.", + "Three months after kidney transplantation, plasma creatinine levels were 94 μmol/L.", + "Three months after kidney transplantation, HbA1c was 5.5%.", + "Three months after kidney transplantation, the patient was without insulin therapy.", + "Kidney function remained satisfactory 12 months after renal transplantation.", + "Plasma creatinine was 87 μmol/L 12 months after renal transplantation.", + "There were no TMA lesions at the per-protocol kidney biopsy.", + "Four years after renal transplantation, the patient is still treated with eculizumab.", + "Four years after renal transplantation, plasma creatinine is 99 μmol/L.", + "Four years after renal transplantation, the patient’s low C3 level persists.", + "Four years after renal transplantation, pancreatic islet function is satisfactory.", + "The patient has been insulin free for 5 years." + ], + "summary": "A 40-year-old man with brittle diabetes, who was included in the TRIMECO trial, became insulin-independent 2 months after pancreatic islet transplantation. About 15 months after islet transplantation, the patient exhibited acute kidney injury due to aHUS. Despite plasma exchange and eculizumab treatment, the patient developed end-stage renal disease. A genetic workup identified a missense variant (p.R592Q) in the C3 gene. In vitro, this C3 variant had defective Factor I proteolytic activity with membrane proteins as cofactor proteins, which was thus classified as pathogenic. About 1 year after the aHUS episode, kidney transplantation was carried out under the protection of the specific anti-C5 monoclonal antibody eculizumab. The patient had normal kidney function, with preserved pancreatic islet function 4 years later.", + "summary_subclaims": [ + "The patient was included in the TRIMECO trial.", + "The patient became insulin-independent 2 months after pancreatic islet transplantation.", + "About 15 months after islet transplantation, the patient exhibited acute kidney injury due to aHUS.", + "Despite plasma exchange and eculizumab treatment, the patient developed end-stage renal disease.", + "A genetic workup identified a missense variant (p.R592Q) in the C3 gene.", + "In vitro, this C3 variant had defective Factor I proteolytic activity with membrane proteins as cofactor proteins.", + "The C3 variant was classified as pathogenic.", + "About 1 year after the aHUS episode, kidney transplantation was carried out under the protection of eculizumab.", + "The patient had normal kidney function 4 years later.", + "The patient had preserved pancreatic islet function 4 years later." + ] + }, + { + "id": "multiclinsum_test_848_en.txt", + "fulltext": "An 81-year-old man presented with epigastric pain lasting for a month.\nHis pain increased after eating. He had undergone esophagogastroduodenoscopy (EGD) at the previous hospital, which showed findings suggesting GLP. He was therefore admitted to our hospital for further examinations.\nThe patient had a history of postoperative benign prostatic hyperplasia and eradication of Helicobacter pylori.\nHe had no specific personal and family history.\nHis vital signs were normal, and the abdomen examination revealed mild epigastric tenderness and no guarding or rebound tenderness. He had no swollen Virchow's lymph nodes or parotid or lacrimal glands.\nA blood examination showed that inflammatory markers, serum pancreatic enzymes, and total and direct bilirubin levels were normal . The levels of serum carbohydrate antigen 19-9 (CA19-9) and IgG4 were elevated (2556 U/mL and 280.5 mg/dL, respectively).\nEndoscopy: EGD showed giant gastric folds and reddish mucosa; however, no epithelial changes were observed. The gastric lumen was not distensible by air inflation, making duodenoscopy impossible to perform . We suspected GLP, so seven specimens were obtained by a gastric mucosal biopsy, none of which showed malignancy .\nComputed tomography and fluorodeoxyglucose-positron emission tomography/computed tomography: Contrast-enhanced computed tomography (CT) showed thickening of the wall of the gastric body . Incidentally, CT showed diffuse enlargement of the pancreas and peripancreatic rim, suggesting the coexistence of AIP . No evidence of bile duct obstruction or dilation was observed. After fluorodeoxyglucose-positron emission tomography/CT (FDG-PET/CT), the accumulation of FDG was found in both the gastric wall [maximum standardized uptake value (SUVmax: 19.2) and pancreas (SUVmax: 4.9)] . No other organ involvement complicating AIP and no obvious metastasis of GLP nor swollen nodules in which FDG had accumulated were observed.\nEUS and EUS-FNB findings: An EUS-FNB was performed for the histopathological diagnosis. With a linear array echoendoscope and a universal ultrasonography processor (EG-580UT and SU-1; Fujifilm, Tokyo, Japan), the thickened third layer of the gastric wall (representing the submucosa) and the fourth layer (representing the muscularis propria) were observed , which was consistent with the findings of GLP. The thickness of the gastric wall as measured by EUS was up to 18.5 mm. The thickened fourth layer of the gastric wall was punctured a total of three times using a 19-gauge needle (SharkCore; Medtronics, Minneapolis, MN, United States) . EUS also revealed hyperechoic spots in the diffuse hypoechoic pancreatic parenchymal and duct-penetrating sign . These findings were consistent with AIP, and no obvious pancreatic tumor was observed. Puncturing the pancreas to obtain pancreatic tissue seemed undesirable because a transgastric puncture might cause seeding of cancer, and transduodenal puncture was impossible due to difficulty reaching the duodenum with the scope. No adverse event related to an EUS-FNB occurred.\nHistopathology: The histopathological findings of the gastric wall showed poorly differentiated adenocarcinoma within the muscularis propria and the deeper site of the mucosa . No cancer cells were found in the shallow site of the mucosa. In the muscularis mucosae, fibroblasts had proliferated and were considered to be the cause of gastric wall thickening.", + "fulltext_subclaims": [ + "An 81-year-old man presented with epigastric pain lasting for a month.", + "His pain increased after eating.", + "He had undergone esophagogastroduodenoscopy (EGD) at the previous hospital, which showed findings suggesting GLP.", + "He was admitted to our hospital for further examinations.", + "The patient had a history of postoperative benign prostatic hyperplasia.", + "The patient had a history of eradication of Helicobacter pylori.", + "The abdomen examination revealed mild epigastric tenderness.", + "A blood examination showed that inflammatory markers were normal.", + "Serum pancreatic enzymes were normal.", + "Total and direct bilirubin levels were normal.", + "The levels of serum carbohydrate antigen 19-9 (CA19-9) were elevated (2556 U/mL).", + "The level of IgG4 was elevated (280.5 mg/dL).", + "EGD showed giant gastric folds.", + "EGD showed reddish mucosa.", + "No epithelial changes were observed.", + "The gastric lumen was not distensible by air inflation.", + "Duodenoscopy was impossible to perform.", + "Seven specimens were obtained by a gastric mucosal biopsy.", + "None of the specimens showed malignancy.", + "Contrast-enhanced computed tomography (CT) showed thickening of the wall of the gastric body.", + "CT showed diffuse enlargement of the pancreas.", + "CT showed peripancreatic rim, suggesting the coexistence of AIP.", + "No evidence of bile duct obstruction or dilation was observed.", + "FDG-PET/CT showed accumulation of FDG in the gastric wall (SUVmax: 19.2).", + "FDG-PET/CT showed accumulation of FDG in the pancreas (SUVmax: 4.9).", + "No other organ involvement complicating AIP was observed.", + "No obvious metastasis of GLP was observed.", + "No swollen nodules in which FDG had accumulated were observed.", + "EUS showed thickened third layer of the gastric wall.", + "EUS showed thickened fourth layer of the gastric wall.", + "The thickness of the gastric wall as measured by EUS was up to 18.5 mm.", + "EUS revealed hyperechoic spots in the diffuse hypoechoic pancreatic parenchymal.", + "EUS revealed duct-penetrating sign.", + "The histopathological findings of the gastric wall showed poorly differentiated adenocarcinoma within the muscularis propria.", + "The histopathological findings showed poorly differentiated adenocarcinoma in the deeper site of the mucosa.", + "No cancer cells were found in the shallow site of the mucosa.", + "Fibroblasts had proliferated in the muscularis mucosae.", + "The proliferated fibroblasts were considered to be the cause of gastric wall thickening." + ], + "summary": "An 81-year-old man was admitted to our hospital for a 1-mo history of epigastric pain that increased after eating. His laboratory data revealed high levels of serum carbohydrate antigen 19-9 and immunoglobulin-G4. Endoscopic examinations showed giant gastric folds and reddish mucosa; however, no epithelial changes were observed. The gastric lumen was not distensible by air inflation, suggesting GLP. Computed tomography showed the thickened gastric wall, the diffuse enlargement of the pancreas, and the peripancreatic rim, which suggested autoimmune pancreatitis (AIP) coexisting with GLP. Because the pathological findings of the endoscopic biopsy showed no malignancy, he underwent an EUS-FNB and was diagnosed with GLP. He received chemotherapy for unresectable gastric cancer due to peritoneal metastasis, after which both the gastric wall thickening and diffuse enlargement of the pancreas were improved.", + "summary_subclaims": [ + "The patient was an 81-year-old man.", + "He was admitted for a 1-mo history of epigastric pain that increased after eating.", + "His laboratory data revealed high levels of serum carbohydrate antigen 19-9.", + "His laboratory data revealed high levels of immunoglobulin-G4.", + "Endoscopic examinations showed giant gastric folds.", + "Endoscopic examinations showed reddish mucosa.", + "No epithelial changes were observed.", + "The gastric lumen was not distensible by air inflation.", + "Computed tomography showed the thickened gastric wall.", + "Computed tomography showed the diffuse enlargement of the pancreas.", + "Computed tomography showed the peripancreatic rim.", + "The pathological findings of the endoscopic biopsy showed no malignancy.", + "He underwent an EUS-FNB.", + "He was diagnosed with GLP.", + "He received chemotherapy for unresectable gastric cancer.", + "The gastric wall thickening was improved after chemotherapy.", + "The diffuse enlargement of the pancreas was improved after chemotherapy." + ] + }, + { + "id": "multiclinsum_test_1420_en.txt", + "fulltext": "A 38-year-old female nursing technician presented a prior history of three episodes of anaphylaxis within one year, all in the workplace. She had a personal history of mild intermittent allergic rhinitis from childhood, for which antihistamines and nasal corticosteroid had been used only during exacerbated episodes. She had a family history of atopy and presented a positive prick test for aeroallergens (Dermatophagoides pteronyssinus and Blomia tropicalis). She tested negative for serum-specific immunoglobulin E (IgE) for latex.\nBecause of her recurrent pattern of anaphylaxis and risk factor for latex allergy, a latex prick test using a standard commercial extract (500 mcg/ml; ALK Abelló, Spain) was performed. Five minutes after the puncturing, the patient developed a generalized rash, itchy skin, hoarseness, dyspnea, dry cough and a sensation of a foreign body in the oropharynx. Her vital signs were: blood pressure of 134 x 84 mmHg, heart rate of 130 bpm and peripheral oxygen saturation of 94%. The patient was placed in dorsal decubitus, with elevation of the lower limbs and 0.5 mg of adrenaline was applied intramuscularly in the upper third of the vastus lateralis muscle of the thigh, in addition to 200 mg of hydrocortisone and 50 mg of diphenhydramine intravenously, and inhalation of short-acting ß2-agonist. The patient presented progressive improvement of the condition without presentation of the late-phase reaction.\nThe patient was evaluated in the context of another major study that was ongoing, and signed a free and informed consent statement for that study, which had been approved by the institution’s ethics committee, under the number 0538/10 on September 22, 2010.", + "fulltext_subclaims": [ + "The patient is a 38-year-old female nursing technician.", + "She had a prior history of three episodes of anaphylaxis within one year.", + "All anaphylaxis episodes occurred in the workplace.", + "She had a personal history of mild intermittent allergic rhinitis from childhood.", + "Antihistamines and nasal corticosteroid had been used only during exacerbated episodes.", + "She had a family history of atopy.", + "She had a positive prick test for aeroallergens.", + "The prick test was positive for Dermatophagoides pteronyssinus.", + "The prick test was positive for Blomia tropicalis.", + "She tested negative for serum-specific immunoglobulin E (IgE) for latex.", + "A latex prick test using a standard commercial extract was performed.", + "The latex prick test extract was 500 mcg/ml.", + "The latex prick test extract was from ALK Abelló, Spain.", + "Five minutes after the puncturing, the patient developed a generalized rash.", + "Five minutes after the puncturing, the patient developed itchy skin.", + "Five minutes after the puncturing, the patient developed hoarseness.", + "Five minutes after the puncturing, the patient developed dyspnea.", + "Five minutes after the puncturing, the patient developed a dry cough.", + "Five minutes after the puncturing, the patient had a sensation of a foreign body in the oropharynx.", + "Her blood pressure was 134 x 84 mmHg.", + "Her heart rate was 130 bpm.", + "Her peripheral oxygen saturation was 94%.", + "The patient was placed in dorsal decubitus.", + "The patient’s lower limbs were elevated.", + "0.5 mg of adrenaline was applied intramuscularly.", + "The adrenaline was applied in the upper third of the vastus lateralis muscle of the thigh.", + "200 mg of hydrocortisone was administered intravenously.", + "50 mg of diphenhydramine was administered intravenously.", + "Short-acting ß2-agonist was inhaled.", + "The patient presented progressive improvement of the condition.", + "There was no presentation of the late-phase reaction.", + "The patient was evaluated in the context of another major study.", + "The patient signed a free and informed consent statement.", + "The study had been approved by the institution’s ethics committee.", + "The study approval number was 0538/10.", + "The study approval was on September 22, 2010." + ], + "summary": "A 38-year-old female nursing technician complained of three episodes of anaphylaxis in one year, all in the workplace. To investigate latex allergy, the patient underwent the prick test with latex, and immediately developed a rash, itchy skin, hoarseness, dyspnea and dry cough. Her condition improved promptly after appropriate measures were established for controlling her anaphylaxis.", + "summary_subclaims": [ + "The patient is a 38-year-old female nursing technician.", + "She complained of three episodes of anaphylaxis in one year.", + "All episodes occurred in the workplace.", + "The patient underwent the prick test with latex.", + "She immediately developed a rash.", + "She had itchy skin.", + "She experienced hoarseness.", + "She had dyspnea.", + "She had a dry cough.", + "Her condition improved promptly after appropriate measures were established." + ] + }, + { + "id": "multiclinsum_test_2550_en.txt", + "fulltext": "A 55-year-old male patient, who present to our hospital in August 2021, because of repeated infection at multiple incisions for more than 1 year after laparoscopic cholecystectomy surgery done for gallstone complicated with cholangitis. On examination, the incisions under the xiphoid process were red and swollen, the incisions were dehiscent, local tenderness, high skin temperature and a little suppuration .\nThe patient had multiple incisions infections and repeated purulent exudates after surgery, with an average recurrence about 25 days, but the blood routine results shown no abnormality. According to the B-ultrasound results , considering the formation of sinus tract under xiphoid process. In September 2021, laparoscopic re-surgery and abdominal exploration were performed, the sinus trace was cut and drainage of abscess. Then given piperacillin sodium and tazobactam sodium anti-infection treatment, but the effect was still poor after a period of time. We discovered the surgical incisions still were not healing, the skin surrounding the incisions was red, swollen and painful, and suppuration was present .\nSince admission, the patient's body temperature and blood routine results were normal . Additionally, regular bacterial culture and acid-fast bacillus (AFB) staining were negative, but blood samples for the tubercle bacillus antibody (TB-Ab) test were positive. Combined with the patient's chest CT , tuberculosis related examination and the patient's clinical symptoms, they did not support tuberculosis-related diseases. In order to further resolve the question and determine the pathogens, the mategenomic sequencing technology covering the pathogen is used to accurately identify pathogens.\nOn November 29, 2021, the tissue from the incisions of the patient was sampled for DNA metagenomic next-generation sequencing (mNGS) (KingMed Diagnostics, Changsha, China). It detected 53 sequences that could be mapped to M. senegalense in a total of 113 sequences, and the coverage was 0.09%, making up 58.76% of the total microbe sequences . Targeted PCR of M. senegalense using two pairs of primers was applied: 16S RNA forward 5′-AGCGGCGGAGCATGTGGATTA-3′, reverse 5′-GCTGATCTGCGATTACTAGCGACTC-3′ (GenBank: ); rpoB forward 5′-TGCGTGCCATCTTCGGTGAGA-3′, reverse 5′-GTCGATGTTCCAGCCTGCCTTG-3′ (GenBank: ). The primers were designed and verified using Primer-BLAST based on the reference genome sequence of M. senegalense in NCBI. Subsequently, the capillary electrophoresis technique (Qsep 100TM; Bioptic) also curtained the M. senegalense infection .\nAccording to the results, the patient was initiated with oral clarithromycin (500 mg, twice daily), moxifloxacin (400 mg, once daily), rifampicin (450 mg, once daily) and doxycycline (100 mg, once every 12 hours). Then the swelling gradually subsided and there was no obvious purulent exudation. After 20 days, the patient's incisions healed well, and there was no sign of recurrence in the 60th day after quadruple therapy .", + "fulltext_subclaims": [ + "The patient is a 55-year-old male.", + "The patient presented to the hospital in August 2021.", + "The patient had repeated infection at multiple incisions for more than 1 year after laparoscopic cholecystectomy.", + "The laparoscopic cholecystectomy was done for gallstone complicated with cholangitis.", + "On examination, the incisions under the xiphoid process were red and swollen.", + "The incisions were dehiscent.", + "There was local tenderness.", + "There was high skin temperature.", + "There was a little suppuration.", + "The patient had multiple incisions infections.", + "The patient had repeated purulent exudates after surgery.", + "The average recurrence was about 25 days.", + "The blood routine results showed no abnormality.", + "B-ultrasound results considered the formation of a sinus tract under the xiphoid process.", + "In September 2021, laparoscopic re-surgery and abdominal exploration were performed.", + "The sinus trace was cut.", + "Abscess drainage was performed.", + "Piperacillin sodium and tazobactam sodium were given for anti-infection treatment.", + "The effect of the treatment was still poor after a period of time.", + "The surgical incisions were still not healing.", + "The skin surrounding the incisions was red, swollen, and painful.", + "Suppuration was present.", + "The patient's body temperature and blood routine results were normal since admission.", + "Regular bacterial culture and acid-fast bacillus (AFB) staining were negative.", + "Blood samples for the tubercle bacillus antibody (TB-Ab) test were positive.", + "Combined with the patient's chest CT, tuberculosis-related examination, and clinical symptoms, they did not support tuberculosis-related diseases.", + "DNA metagenomic next-generation sequencing (mNGS) was used to accurately identify pathogens.", + "On November 29, 2021, tissue from the incisions was sampled for mNGS.", + "The mNGS detected 53 sequences that could be mapped to M. senegalense in a total of 113 sequences.", + "The coverage was 0.09%.", + "The M. senegalense sequences made up 58.76% of the total microbe sequences.", + "Targeted PCR of M. senegalense using two pairs of primers was applied.", + "The primers were designed and verified using Primer-BLAST based on the reference genome sequence of M. senegalense in NCBI.", + "The capillary electrophoresis technique also confirmed the M. senegalense infection.", + "The patient was initiated with oral clarithromycin (500 mg, twice daily).", + "The patient was initiated with moxifloxacin (400 mg, once daily).", + "The patient was initiated with rifampicin (450 mg, once daily).", + "The patient was initiated with doxycycline (100 mg, once every 12 hours).", + "The swelling gradually subsided.", + "There was no obvious purulent exudation.", + "After 20 days, the patient's incisions healed well.", + "There was no sign of recurrence in the 60th day after quadruple therapy." + ], + "summary": "A 55-year-old man was admitted because of repeated infections at multiple incision sites for more than 1 year. Although routine diagnostic test results were negative, metagenomic next-generation sequencing (mNGS) identified DNA sequences of M. senegalense in tissue samples from incision sites. The presence of M. senegalense was further confirmed by polymerase chain reaction and capillary electrophoresis. After 60 days of quadruple therapy with clarithromycin, moxifloxacin, rifampicin, and oxycycline, the patient's wound healed.", + "summary_subclaims": [ + "A 55-year-old man was admitted because of repeated infections at multiple incision sites for more than 1 year.", + "Routine diagnostic test results were negative.", + "Metagenomic next-generation sequencing identified DNA sequences of M. senegalense in tissue samples from incision sites.", + "The presence of M. senegalense was further confirmed by polymerase chain reaction and capillary electrophoresis.", + "After 60 days of quadruple therapy with clarithromycin, moxifloxacin, rifampicin, and oxycycline, the patient's wound healed." + ] + }, + { + "id": "multiclinsum_test_1748_en.txt", + "fulltext": "A 22-year-old Persian man was referred to our outpatient SLE clinic for regular follow-up on 27 December 2018. He complained of severe and progressive generalized bone pain that he had begun experiencing 2 weeks before his admission. He did not report any clinical symptoms in favor of SLE flare-up. His physical examination revealed generalized bone tenderness over the sternum, vertebra, and pelvis. His joints were normal without any sign of arthritis. He weighed 69 kg and was 170 cm tall (body mass index, 23.87 kg/m2). The results of the rest of his examinations were unremarkable. The patient’s vital signs were within the normal range, and the results of examinations of his mucocutaneous, cardiopulmonary, and neurologic systems were normal.\nHowever, the laboratory examinations showed an exceedingly elevated level of serum alkaline phosphatase (ALP) of 3609 U/L (reference range, 40–130). The rest of the tests consisted of a complete blood count, erythrocyte sedimentation rate, C-reactive protein, liver function, glucose and lipid profiles, serum creatinine, urinalysis, and anti-double-stranded deoxyribonucleic acid (DNA); all of these were within the normal ranges. The last laboratory examination was performed on 15 November 2018 and indicated a normal serum ALP level of 141 U/L.\nThe patient’s medical history was significant for an antecedent of SLE from 2 years earlier, which was diagnosed with the primary manifestations of oral ulcers, polyarthritis, hematuria, and proteinuria, along with positive antinuclear antibody and diminished complement level. A renal biopsy was performed at the time of diagnosis; this biopsy was compatible with mesangial proliferative lupus nephritis (class II). At this time, hydroxychloroquine (400 mg/day), prednisolone (15 mg/day), azathioprine (2.5 mg/kg/day), and calcium vitamin D supplementation began being administered. According to the patient’s gastrointestinal side effects and persistent dysmorphic hematuria, azathioprine was replaced with mycophenolate mofetil (2 g/day), and prednisolone was tapered to 5 mg/day from 1 year prior.\nThe patient’s bone mineral densitometry (BMD) was assessed at the time of the diagnosis and again one year later using the same instrument (Hologic, Marlborough, MA, USA) . At the time of diagnosis, the patient had osteopenia (lumbar spine Z-score, − 2.2), which was unjustifiable on the basis of his age. The results of laboratory examinations, including serum electrolytes and endocrine panel evaluations, were normal . However, the patient’s serum ALP level was lower than normal at 175 U/L (normal range, 245–768). Supplemental calcium vitamin D was administered, and the patient was referred to a sports medicine specialist.\nA detailed investigation of the patient’s past medical history revealed instances of idiopathic kyphoscoliosis, mitral valve prolapse, and a bilateral congenital inguinal hernia that was operated on in the infantile period. The patient’s physical examination was compatible with hypermobility of the joints (Beighton score, 4). There was no evidence to suggest delayed or absent puberty. The results of the rest of the investigations, including a complete endocrine panel and ocular evaluation, were normal. It was speculated that the patient had an occult connective tissue disease such as Ehlers-Danlos syndrome. However, due to the unavailability of genetic studies and the lack of full-blown manifestations of inherited collagen disease, this diagnosis remained unidentified.\nAccording to the very low bone mass of the patient and diminished bone density at the hip and the lumbar spine , subcutaneous injection of teriparatide (Forteo® 20 μg/day; Eli Lilly, Indianapolis, IN, USA) was started on 2 May 2018. Additionally, he was receiving hydroxychloroquine 200 mg/day, prednisolone 5 mg/day, mycophenolate mofetil 500 mg/day, and calcium vitamin D supplementation. He denied any use of other medications, even over-the-counter medicines and herbal remedies. He tolerated the teriparatide well without any adverse drug reactions and was strictly adherent to his medications and physical activities. His family history was remarkable for SLE in his mother. His history was negative for cigarette smoking and any drug abuse.\nThe workup began for this patient according to his generalized bone pain and tenderness and extremely elevated level of serum ALP. The results of laboratory examinations done on 31 December 2018 are shown in Table . The serum and urinary bone turnover marker measurement kits were unavailable at that moment, and the patient did not consent to undergo bone biopsy. His whole-body bone scan showed a superscan pattern with diffusely increased osseous uptake in the calvarium, supraorbital crests, and mandible (Lincoln sign), as well as all the costochondral joints, both sacroiliac joints (butterfly sign), and the pubic symphysis . Most of the epiphyseal plates also showed a significant diffuse and symmetric uptake. The pattern of the scan was compatible with metabolic bone disease (MBD) associated with a diffuse bone formation state without any evidence for fracture, bone metastasis, or Paget disease. Abdominopelvic ultrasonography and skull and pelvic x-ray results were entirely normal .\nBriefly, we had a patient complaining of recent-onset generalized bone pain and tenderness in addition to a newly raised serum ALP level. The patient’s γ-glutamyltransferase level, liver function test, and biliary system ultrasonography were normal. His whole-body bone scan was in favor of MBD without any evidence of bone tumors. Neither the patient’s clinical manifestations nor his laboratory test results were compatible with SLE flare-up. Taken together, all of these manifestations were probably related to teriparatide use, and the medication was discontinued on 31 December 2018. The patient’s serum ALP level began to decline with the level of 6423 U/L (normal range, 80–306) on 10 January 2019, to 3492 U/L (80–306) on 18 January 2019, 598 U/L (40–130) on 24 January 2019, 151 U/L (40–130) on 10 February 2019, 40 U/L (40–130) on 18 June 2019, and 42 U/L (40–130) on 2 March 2020. The calcium supplement dosage was augmented to prevent probable hungry bone syndrome. However, the serum calcium and phosphorus levels were strictly normal during this period. Most of the laboratory examinations were performed in a single laboratory, whereas the abnormal findings were also rechecked in another medical center. This could justify the enormously different ALP levels in a short time interval. The clinical manifestations completely resolved, and the patient did not experience any SLE relapse. The third BMD was performed on 8 April 2019 with a similar machine, revealing a significant increase of bone density . After 7 months of treatment with teriparatide, the bone density of the lumbar spine, femoral neck, total hip, and one-third distal radius was increased 4.5%, 4.8%, 23%, and 6.1%, respectively. To the best of our knowledge, this is the highest rate of increased bone density in such a short period of time reported in the literature.", + "fulltext_subclaims": [ + "A 22-year-old Persian man was referred to the outpatient SLE clinic for regular follow-up on 27 December 2018.", + "He complained of severe and progressive generalized bone pain that he had begun experiencing 2 weeks before his admission.", + "He did not report any clinical symptoms in favor of SLE flare-up.", + "Physical examination revealed generalized bone tenderness over the sternum, vertebra, and pelvis.", + "The patient weighed 69 kg and was 170 cm tall.", + "The results of the rest of his examinations were unremarkable.", + "The patient’s vital signs were within the normal range.", + "The results of examinations of his mucocutaneous, cardiopulmonary, and neurologic systems were normal.", + "The laboratory examinations showed an exceedingly elevated level of serum alkaline phosphatase (ALP) of 3609 U/L.", + "The rest of the tests, including complete blood count, erythrocyte sedimentation rate, C-reactive protein, liver function, glucose and lipid profiles, serum creatinine, urinalysis, and anti-double-stranded DNA, were within the normal ranges.", + "The last laboratory examination on 15 November 2018 indicated a normal serum ALP level of 141 U/L.", + "The patient had a medical history of SLE diagnosed 2 years earlier.", + "At the time of SLE diagnosis, the patient had oral ulcers, polyarthritis, hematuria, and proteinuria.", + "A renal biopsy at the time of SLE diagnosis was compatible with mesangial proliferative lupus nephritis (class II).", + "At the time of SLE diagnosis, hydroxychloroquine, prednisolone, azathioprine, and calcium vitamin D supplementation were started.", + "Azathioprine was replaced with mycophenolate mofetil due to gastrointestinal side effects and persistent dysmorphic hematuria.", + "Prednisolone was tapered to 5 mg/day from 1 year prior.", + "The patient’s bone mineral densitometry at the time of SLE diagnosis showed osteopenia (lumbar spine Z-score, −2.2).", + "The patient’s serum ALP level at the time of SLE diagnosis was lower than normal at 175 U/L.", + "The patient was referred to a sports medicine specialist.", + "The patient had a history of idiopathic kyphoscoliosis.", + "The patient had a history of mitral valve prolapse.", + "The patient had a history of bilateral congenital inguinal hernia operated on in the infantile period.", + "The patient’s physical examination was compatible with hypermobility of the joints (Beighton score, 4).", + "There was no evidence to suggest delayed or absent puberty.", + "The results of the rest of the investigations, including a complete endocrine panel and ocular evaluation, were normal.", + "It was speculated that the patient had an occult connective tissue disease such as Ehlers-Danlos syndrome.", + "Due to the unavailability of genetic studies and the lack of full-blown manifestations of inherited collagen disease, this diagnosis remained unidentified.", + "Subcutaneous injection of teriparatide was started on 2 May 2018.", + "The patient was receiving hydroxychloroquine 200 mg/day, prednisolone 5 mg/day, mycophenolate mofetil 500 mg/day, and calcium vitamin D supplementation.", + "The patient denied any use of other medications, even over-the-counter medicines and herbal remedies.", + "The patient tolerated teriparatide well without any adverse drug reactions.", + "The patient was strictly adherent to his medications and physical activities.", + "The patient’s family history was remarkable for SLE in his mother.", + "The patient’s history was negative for cigarette smoking and any drug abuse.", + "The workup began for the patient according to his generalized bone pain and tenderness and extremely elevated level of serum ALP.", + "The results of laboratory examinations done on 31 December 2018 are shown in Table.", + "The serum and urinary bone turnover marker measurement kits were unavailable at that moment.", + "The patient did not consent to undergo bone biopsy.", + "The whole-body bone scan showed a superscan pattern with diffusely increased osseous uptake in the calvarium, supraorbital crests, and mandible.", + "The whole-body bone scan showed diffusely increased osseous uptake in all the costochondral joints, both sacroiliac joints, and the pubic symphysis.", + "Most of the epiphyseal plates also showed a significant diffuse and symmetric uptake.", + "The pattern of the scan was compatible with metabolic bone disease (MBD) associated with a diffuse bone formation state.", + "There was no evidence for fracture, bone metastasis, or Paget disease.", + "Abdominopelvic ultrasonography and skull and pelvic x-ray results were entirely normal.", + "The patient’s clinical manifestations and laboratory test results were not compatible with SLE flare-up.", + "All of these manifestations were probably related to teriparatide use.", + "The medication was discontinued on 31 December 2018.", + "The patient’s serum ALP level began to decline.", + "The patient’s serum ALP level was 6423 U/L on 10 January 2019.", + "The patient’s serum ALP level was 3492 U/L on 18 January 2019.", + "The patient’s serum ALP level was 598 U/L on 24 January 2019.", + "The patient’s serum ALP level was 151 U/L on 10 February 2019.", + "The patient’s serum ALP level was 40 U/L on 18 June 2019.", + "The patient’s serum ALP level was 42 U/L on 2 March 2020.", + "The calcium supplement dosage was augmented to prevent probable hungry bone syndrome.", + "The serum calcium and phosphorus levels were strictly normal during this period.", + "Most of the laboratory examinations were performed in a single laboratory.", + "The abnormal findings were also rechecked in another medical center.", + "This could justify the enormously different ALP levels in a short time interval.", + "The clinical manifestations completely resolved.", + "The patient did not experience any SLE relapse.", + "The third BMD was performed on 8 April 2019 with a similar machine.", + "The third BMD revealed a significant increase of bone density.", + "After 7 months of treatment with teriparatide, the bone density of the lumbar spine, femoral neck, total hip, and one-third distal radius was increased 4.5%, 4.8%, 23%, and 6.1%, respectively.", + "To the best of our knowledge, this is the highest rate of increased bone density in such a short period of time reported in the literature." + ], + "summary": "We present a case of a 22-year-old Persian man with a previous history of systemic lupus erythematosus and glucocorticoid-induced osteoporosis. He had a previous history of joint hypermobility, idiopathic kyphoscoliosis, mitral valve prolapse, and bilateral congenital inguinal hernia, which were probably compatible with an inherited connective tissue disease. He was treated with teriparatide for 7 months because of glucocorticoid-induced osteoporosis. He was referred with a complaint of generalized bone pain and an extremely elevated serum alkaline phosphatase concentration of 6480 U/L (normal range, 80-306). A whole-body bone scan revealed a diffuse increased osseous uptake. Furthermore, the patient's systemic lupus erythematosus was clinically inactive on the basis of laboratory findings during this period. The medication was discontinued, and the patient's serum alkaline phosphatase level began to decline.", + "summary_subclaims": [ + "The patient is a 22-year-old Persian man.", + "The patient had a previous history of systemic lupus erythematosus.", + "The patient had a previous history of glucocorticoid-induced osteoporosis.", + "The patient had a previous history of joint hypermobility.", + "The patient had a previous history of idiopathic kyphoscoliosis.", + "The patient had a previous history of mitral valve prolapse.", + "The patient had a previous history of bilateral congenital inguinal hernia.", + "The patient's previous medical history was probably compatible with an inherited connective tissue disease.", + "The patient was treated with teriparatide for 7 months because of glucocorticoid-induced osteoporosis.", + "The patient was referred with a complaint of generalized bone pain.", + "The patient had an extremely elevated serum alkaline phosphatase concentration of 6480 U/L.", + "A whole-body bone scan revealed a diffuse increased osseous uptake.", + "The patient's systemic lupus erythematosus was clinically inactive on the basis of laboratory findings during this period.", + "The medication was discontinued.", + "The patient's serum alkaline phosphatase level began to decline." + ] + }, + { + "id": "multiclinsum_test_2727_en.txt", + "fulltext": "A 25-year-old man residing in the hilly district of Nepal presented with a 10-year history of pain and swelling in both hands and feet of insidious onset, progressive in nature without radiation but exacerbated during long travel and dangling of limbs associated with profuse sweating (hyperhidrosis) and progressive enlargement of hands and feet. He also gives a history of easy fatigability, heat intolerance and skin changes like acne, scalp dandruff and thickened eyelids. He had visited multiple health care centres for this concern for the past 10 years as the suspected diagnosis could not be confirmed by any laboratory results. None of the family members had a similar history.\nThe patient was moderately built with marked thickening of skin folds in his forehead and evident swelling of bilateral ankle joints along with grade IV clubbing on both upper and lower limbs . Systemic examinations were otherwise normal. A clinical diagnosis of PDP, a rare genetic disease characterised by pachyderma, digital clubbing and periostosis was made. Normal serum insulin-like growth factor-1 (IGF-1) level and thyroid function tests ruled out our other differentials such as acromegaly and hyperthyroidism. Routine blood investigations including blood counts, liver function tests and renal function tests were also normal. Psoriatic arthritis was ruled out on the basis of the clinical history, which is generally limited to the extremities with psoriatic nail involvement and tests for rheumatoid factor and anti-cyclic citrullinated peptide were normal, ruling out suspicion of rheumatoid arthritis.\nRadiography of the ankle joint showed symmetric, shaggy subperiosteal new bone formation and cortical thickening leading to the characteristic dripping candle wax appearance of the fibula; coarse periosteal new bone formation in the distal tibia and fibula leading to distortion of the medial malleolus and periarticular osteopenia with preserved articular surface along with hyperostosis of the metatarsal bones .\nHyperostosis of the metacarpal bones, proximal and middle phalanx with unaffected articular surfaces along with increased soft tissue shadow showing characteristic sausage finger appearance was also seen in the radiograph, which was supported by the clinical picture . Hair on the end appearance of the parietal bone along with hyperostosis of the skull bones and normal appearing Sella turcica was witnessed .\nAfter the diagnosis of PDP was made, he was prescribed with selective COX-2 inhibitor (etoricoxib 90 mg oral once a day) and he showed partial improvement in joint pain and swelling along with a gradual reduction of pachyderma making his daily life easier with treatment thereafter. Additionally, retinoid ointment was also used during this course, which might have improved symptoms of facial acne and skin changes whereas physical therapy also helped to improve joint mobility. Radiological follow-up after 6 months showed improvement in soft tissue thickening near the occiput and supraorbital ridge of the skull as well as in soft tissue swelling of the lower limb .\nContinuous pain and change in his physical appearance affected his personal and social life. Ambiguous diagnosis and deteriorating symptoms made the process of seeking medical help overwhelming. Over the course of treatment, the physical and mental well-being is now improving. For follow-up, he visits our outpatient clinic or communicates via telephone with the consultant. The patient experienced no complications from the condition or the medications.", + "fulltext_subclaims": [ + "The patient is a 25-year-old man.", + "He resides in the hilly district of Nepal.", + "He has a 10-year history of pain and swelling in both hands and feet.", + "The pain and swelling have an insidious onset.", + "The pain and swelling are progressive in nature.", + "The pain and swelling are not radiating.", + "The pain and swelling are exacerbated during long travel.", + "The pain and swelling are exacerbated by dangling of limbs.", + "The pain and swelling are associated with profuse sweating.", + "The pain and swelling are associated with progressive enlargement of hands and feet.", + "He has a history of easy fatigability.", + "He has a history of heat intolerance.", + "He has skin changes like acne.", + "He has skin changes like scalp dandruff.", + "He has thickened eyelids.", + "He had visited multiple health care centres for this concern.", + "The suspected diagnosis could not be confirmed by any laboratory results.", + "None of the family members had a similar history.", + "The patient had marked thickening of skin folds in his forehead.", + "There was evident swelling of bilateral ankle joints.", + "There was grade IV clubbing on both upper and lower limbs.", + "Systemic examinations were otherwise normal.", + "A clinical diagnosis of PDP was made.", + "PDP is a rare genetic disease.", + "PDP is characterised by pachyderma.", + "PDP is characterised by digital clubbing.", + "PDP is characterised by periostosis.", + "Normal serum IGF-1 level ruled out acromegaly.", + "Normal thyroid function tests ruled out hyperthyroidism.", + "Routine blood investigations were normal.", + "Tests for rheumatoid factor were normal.", + "Tests for anti-cyclic citrullinated peptide were normal.", + "Radiography of the ankle joint showed symmetric, shaggy subperiosteal new bone formation.", + "Radiography showed cortical thickening leading to the characteristic dripping candle wax appearance of the fibula.", + "Radiography showed coarse periosteal new bone formation in the distal tibia and fibula.", + "Radiography showed distortion of the medial malleolus.", + "Radiography showed periarticular osteopenia with preserved articular surface.", + "Radiography showed hyperostosis of the metatarsal bones.", + "Hyperostosis of the metacarpal bones was seen.", + "Hyperostosis of the proximal and middle phalanx was seen.", + "Increased soft tissue shadow showing characteristic sausage finger appearance was seen.", + "The radiographic findings were supported by the clinical picture.", + "The patient was prescribed etoricoxib 90 mg oral once a day.", + "He showed partial improvement in joint pain and swelling.", + "He showed a gradual reduction of pachyderma.", + "Retinoid ointment was used during this course.", + "Physical therapy helped to improve joint mobility.", + "Radiological follow-up after 6 months showed improvement in soft tissue thickening near the occiput.", + "Radiological follow-up after 6 months showed improvement in soft tissue thickening of the supraorbital ridge of the skull.", + "Radiological follow-up after 6 months showed improvement in soft tissue swelling of the lower limb.", + "The patient experienced no complications from the condition or the medications." + ], + "summary": "A 25-year-old man with no comorbidities presented to OPD with a 10-year history of bilateral pain and swelling of the hands and feets associated with hyperhidrosis, grade IV clubbing and marked skin thickening on his forehead. X-rays revealed hyperostosis of the metacarpals, proximal and middle phalanges and periosteal bone formation with cortical thickening of the ankle joint. Tests done to rule out differentials such as thyroid acropachy, acromegaly, psoriatic arthritis were normal and a clinical diagnosis of PDP, a rare genetic disease characterised by pachyderma, digital clubbing and periostosis was made.", + "summary_subclaims": [ + "The patient is a 25-year-old man.", + "The patient has no comorbidities.", + "He presented with a 10-year history of bilateral pain and swelling of the hands and feets.", + "He had hyperhidrosis.", + "He had grade IV clubbing.", + "He had marked skin thickening on his forehead.", + "X-rays revealed hyperostosis of the metacarpals.", + "X-rays revealed hyperostosis of the proximal and middle phalanges.", + "X-rays showed periosteal bone formation.", + "X-rays showed cortical thickening of the ankle joint.", + "Tests to rule out thyroid acropachy were normal.", + "Tests to rule out acromegaly were normal.", + "Tests to rule out psoriatic arthritis were normal.", + "A clinical diagnosis of PDP was made.", + "PDP is a rare genetic disease.", + "PDP is characterised by pachyderma.", + "PDP is characterised by digital clubbing.", + "PDP is characterised by periostosis." + ] + }, + { + "id": "multiclinsum_test_2185_en.txt", + "fulltext": "A 32-year-old healthy male presented to the outpatient clinic with a history of pain and swelling in the Right foot for 10 months after alleged history of sustaining a grinder (heavy machine) injury to the medial aspect of the right foot 10 months ago. At the time of injury, the patient sustained a contused lacerated wound approximately 3 × 0.5 × 0.5 cm in size over the medial aspect of the right foot and visited the emergency department at a local hospital. Anteroposterior and oblique radiographs of the right foot and anteroposterior, lateral, and mortise radiographs of the right ankle suggested no fractures or skeletal abnormalities.\nThe CLW was sutured, and dressing was done, and the patient was managed conservatively with analgesic, anti-inflammatory, and compression bandaging. One month following the injury, the patient started experiencing a dull aching persistent, non-radiating pain in the right foot which was insidious in onset; aggravated on weight bearing, and relieved on taking rest.\nA magnetic resource imaging (MRI) of the right foot was advised after no relief of symptoms with conservative management. The MRI showed a high-grade tear of the distal TPT from the level of medial malleolus to its insertion and was planned for operative management of TPT tear.\nAfter anesthetic workup, patient was posted for surgery and operated with open repair of TPT using suture anchor.\nAfter administration of spinal anesthesia, a 5 cm incision was taken over the right foot beginning from the tip of the medial malleolus extending distally and curved anteriorly till the navicular bone.\nSuperficial dissection was carried out and the fibers of TP were identified , alternate sliding tenotomy, and lengthening carried out for the proximal end of the TPT.\nA 2.5 mm suture anchor was fixed in the navicular bone and fibers of TPT were sutured using a running whip stitch . There were no complications in the intraoperative or post-operative period. Patient was given a below knee slab with the foot in inversion postoperatively.\nAfter removal of sutures, the slab was revised into a below knee cast with the foot in inversion for 6 weeks.\nThe patient’s assessment was carried out based on Modified Olerud and Molander Score.\nSix-week post-operative follow-up, cast was removed, and physiotherapy was started for the patient that included active ankle ROM and gait training, patient had a Modified Olerud and Molander Score of 45/100 at 6 weeks.\nAt 6-month post-operative follow-up, patient was relieved of chronic pain and was able walk and stand on his toes without pain and showed significant improvement in gait with Modified Olerud and Molander Score 90/100 .", + "fulltext_subclaims": [ + "The patient is a 32-year-old healthy male.", + "The patient presented with pain and swelling in the right foot for 10 months.", + "The patient had an alleged history of sustaining a grinder injury to the medial aspect of the right foot 10 months ago.", + "At the time of injury, the patient sustained a contused lacerated wound approximately 3 × 0.5 × 0.5 cm in size over the medial aspect of the right foot.", + "The patient visited the emergency department at a local hospital.", + "Anteroposterior and oblique radiographs of the right foot suggested no fractures or skeletal abnormalities.", + "Anteroposterior, lateral, and mortise radiographs of the right ankle suggested no fractures or skeletal abnormalities.", + "The wound was sutured, and dressing was done.", + "The patient was managed conservatively with analgesic, anti-inflammatory, and compression bandaging.", + "One month following the injury, the patient started experiencing a dull aching persistent, non-radiating pain in the right foot.", + "The pain was insidious in onset.", + "The pain was aggravated on weight bearing.", + "The pain was relieved on taking rest.", + "A magnetic resource imaging (MRI) of the right foot was advised.", + "The MRI showed a high-grade tear of the distal TPT from the level of medial malleolus to its insertion.", + "Operative management of TPT tear was planned.", + "After anesthetic workup, the patient was posted for surgery.", + "The patient was operated with open repair of TPT using suture anchor.", + "A 5 cm incision was taken over the right foot beginning from the tip of the medial malleolus extending distally and curved anteriorly till the navicular bone.", + "Superficial dissection was carried out and the fibers of TP were identified.", + "Alternate sliding tenotomy and lengthening were carried out for the proximal end of the TPT.", + "A 2.5 mm suture anchor was fixed in the navicular bone.", + "Fibers of TPT were sutured using a running whip stitch.", + "There were no complications in the intraoperative period.", + "There were no complications in the post-operative period.", + "The patient was given a below knee slab with the foot in inversion postoperatively.", + "After removal of sutures, the slab was revised into a below knee cast with the foot in inversion for 6 weeks.", + "The patient’s assessment was carried out based on Modified Olerud and Molander Score.", + "At 6 weeks post-operative, the cast was removed.", + "Physiotherapy was started for the patient.", + "Physiotherapy included active ankle ROM and gait training.", + "The patient had a Modified Olerud and Molander Score of 45/100 at 6 weeks.", + "At 6-month post-operative follow-up, the patient was relieved of chronic pain.", + "The patient was able to walk and stand on his toes without pain.", + "The patient showed significant improvement in gait.", + "The patient had a Modified Olerud and Molander Score of 90/100 at 6 months." + ], + "summary": "A 32-year-old healthy male presented to the outpatient clinic with a history of pain and swelling in the right foot for 10 months after alleged history of sustaining a grinder (heavy machine) injury to the medial aspect of the right foot 10 months ago. Anteroposterior and oblique radiographs of the right foot suggestive of no skeletal pathology and patient was managed conservatively with analgesic, anti-inflammatory, and compression bandaging. A magnetic resource imaging of the right foot was advised after no relief of symptoms and was suggestive of high-grade tear of the distal tibialis posterior tendon from the level of medial malleolus to its insertion. Surgical repair of the TPT was planned with a suture anchor placed in the navicular bone. The procedure was carried out under spinal anesthesia and there were no complications in the intraoperative or post-operative period. Patient was given a below knee slab with the foot in inversion postoperatively which was revised into a below knee cast with foot in inversion. Six-week post-operative follow-up, cast was removed and physiotherapy was started for the patient that included Active Ankle ROM and Gait Training, patient had a Modified Olerud and Molander Score of 45/100. Six-month post-operative follow-up, patient was relieved of chronic pain and was able walk and stand on his toes without pain and showed significant improvement in gait with Modified Olerud and Molander Score 90/100.", + "summary_subclaims": [ + "The patient is a 32-year-old healthy male.", + "The patient had pain and swelling in the right foot for 10 months.", + "The patient had an alleged history of sustaining a grinder injury to the medial aspect of the right foot 10 months ago.", + "Anteroposterior and oblique radiographs of the right foot were suggestive of no skeletal pathology.", + "The patient was managed conservatively with analgesic, anti-inflammatory, and compression bandaging.", + "A magnetic resonance imaging of the right foot was advised after no relief of symptoms.", + "The magnetic resonance imaging was suggestive of a high-grade tear of the distal tibialis posterior tendon from the level of the medial malleolus to its insertion.", + "Surgical repair of the TPT was planned with a suture anchor placed in the navicular bone.", + "The procedure was carried out under spinal anesthesia.", + "There were no complications in the intraoperative or post-operative period.", + "The patient was given a below knee slab with the foot in inversion postoperatively.", + "The below knee slab was revised into a below knee cast with foot in inversion.", + "At six-week post-operative follow-up, the cast was removed.", + "Physiotherapy was started for the patient that included Active Ankle ROM and Gait Training.", + "At six-week post-operative follow-up, the patient had a Modified Olerud and Molander Score of 45/100.", + "At six-month post-operative follow-up, the patient was relieved of chronic pain.", + "At six-month post-operative follow-up, the patient was able to walk and stand on his toes without pain.", + "At six-month post-operative follow-up, the patient showed significant improvement in gait.", + "At six-month post-operative follow-up, the patient had a Modified Olerud and Molander Score of 90/100." + ] + }, + { + "id": "multiclinsum_test_2205_en.txt", + "fulltext": "A 33-year-old woman was referred to our department with unstable angina. At the age of six, she underwent CABG to the second diagonal branch using the left internal thoracic artery (LITA) and to the obtuse marginal branch using a saphenous vein graft (SVG), as well as mitral annuloplasty for congenital LMCA and moderate mitral regurgitation. After the initial operation, 18 years passed without any signs of angina. However, at the age of 24, she started to experience occasional chest pain on exertion, which had become more frequent by the age of 32. Although her electrocardiogram and echocardiogram showed no abnormal findings, exercise stress myocardial perfusion scintigraphy revealed an extensive ischemic lesion on the left ventricular anterior wall . Although a coronary angiogram showed a patent LITA to the second diagonal branch and a patent SVG to the obtuse marginal branch , the LAD was not perfused by the LITA, and was mainly supplied by collateral flow from the right coronary artery . Multidetector-row computed tomography demonstrated a disruption of blood flow to the LAD from the LITA due to an occlusion of the proximal part of the second diagonal branch. Therefore, to improve the ischemia of the LAD lesion, we performed a redo CABG using the right internal thoracic artery (RITA). In the current case, because the distal LAD was too small to be grafted, and the proximal LAD was deep in the myocardium, we bypassed to the first diagonal branch, which was connected to the LAD. Postoperative coronary angiogram showed that all bypass grafts, including the RITA, were patent and there was blood flow communication between the first diagonal branch and the LAD . Pharmacologic stress perfusion scintigraphy revealed an improvement in the ischemia, especially in the left intraventricular septum . The patient’s symptoms also improved and she was discharged 10 days after surgery. She has been in good health for over 3 years without recurrence of chest symptoms.", + "fulltext_subclaims": [ + "The patient is a 33-year-old woman.", + "She was referred to the department with unstable angina.", + "At the age of six, she underwent CABG to the second diagonal branch using the left internal thoracic artery.", + "At the age of six, she underwent CABG to the obtuse marginal branch using a saphenous vein graft.", + "At the age of six, she underwent mitral annuloplasty.", + "The initial CABG was performed for congenital LMCA.", + "The initial CABG was performed for moderate mitral regurgitation.", + "After the initial operation, 18 years passed without any signs of angina.", + "At the age of 24, she started to experience occasional chest pain on exertion.", + "By the age of 32, the chest pain had become more frequent.", + "Exercise stress myocardial perfusion scintigraphy revealed an extensive ischemic lesion on the left ventricular anterior wall.", + "A coronary angiogram showed a patent LITA to the second diagonal branch.", + "A coronary angiogram showed a patent SVG to the obtuse marginal branch.", + "The LAD was not perfused by the LITA.", + "The LAD was mainly supplied by collateral flow from the right coronary artery.", + "Multidetector-row computed tomography demonstrated a disruption of blood flow to the LAD from the LITA.", + "The disruption of blood flow to the LAD was due to an occlusion of the proximal part of the second diagonal branch.", + "To improve the ischemia of the LAD lesion, a redo CABG using the right internal thoracic artery was performed.", + "The distal LAD was too small to be grafted.", + "The proximal LAD was deep in the myocardium.", + "A bypass was performed to the first diagonal branch, which was connected to the LAD.", + "Postoperative coronary angiogram showed that all bypass grafts, including the RITA, were patent.", + "Postoperative coronary angiogram showed blood flow communication between the first diagonal branch and the LAD.", + "Pharmacologic stress perfusion scintigraphy revealed an improvement in the ischemia, especially in the left intraventricular septum.", + "The patient’s symptoms improved.", + "She was discharged 10 days after surgery.", + "She has been in good health for over 3 years without recurrence of chest symptoms." + ], + "summary": "A 33-year-old woman was referred to our department with unstable angina. At the age of 6, she had undergone coronary artery bypass grafting of the second diagonal branch using the left internal thoracic artery and the obtuse marginal branch using saphenous vein grafting for left main coronary atresia. Although a coronary angiogram showed a patent left internal thoracic artery graft to the second diagonal branch and a patent saphenous vein graft to the obtuse marginal branch, the left anterior descending artery was not being perfused by the grafts because of a disruption of blood flow to the left anterior descending artery from the left internal thoracic artery. Therefore, we performed a redo coronary artery bypass grafting using the in situ right internal thoracic artery to the first diagonal branch, which was to be connected to the left anterior descending artery, resulting in amelioration of the ischemia of the left anterior wall. The patient was discharged 10 days after the operation and has been in good health for over 3 years without recurrence of chest symptoms.", + "summary_subclaims": [ + "The patient is a 33-year-old woman.", + "She was referred to the department with unstable angina.", + "At the age of 6, she had undergone coronary artery bypass grafting of the second diagonal branch using the left internal thoracic artery.", + "At the age of 6, she had undergone coronary artery bypass grafting of the obtuse marginal branch using saphenous vein grafting.", + "The bypass grafting at age 6 was performed for left main coronary atresia.", + "A coronary angiogram showed a patent left internal thoracic artery graft to the second diagonal branch.", + "A coronary angiogram showed a patent saphenous vein graft to the obtuse marginal branch.", + "The left anterior descending artery was not being perfused by the grafts.", + "The disruption of blood flow to the left anterior descending artery was from the left internal thoracic artery.", + "We performed a redo coronary artery bypass grafting using the in situ right internal thoracic artery to the first diagonal branch.", + "The graft was to be connected to the left anterior descending artery.", + "The redo bypass grafting resulted in amelioration of the ischemia of the left anterior wall.", + "The patient was discharged 10 days after the operation.", + "The patient has been in good health for over 3 years without recurrence of chest symptoms." + ] + }, + { + "id": "multiclinsum_test_1154_en.txt", + "fulltext": "A 37-year-old african-american male was referred to the endocrinology department of the Federal Hospital of Lagoa for evaluation of adrenal insufficiency due to chronic and irregular use of steroids (Prednisone 20 to 40 mg/day) for 10 years. He had history of use of anabolic drugs and intramuscular mineral oil (hydrogel) injections in the upper and lower limbs for 15 years for muscle hypertrophy. Three months prior to the referral he developed intense headache, fever, night sweats, weight loss and limb pain. No other systemic comorbidities.\nDuring hospitalization, intramuscular purulent collections were diagnosed by imaging tests and he presented daily fever (maximum of 38 °C or 100 °F). Treatment with piperacillin/tazobactam 2.25 g IV q6hr and vancomycin 500 mg IV q6hr was initiated and laboratory tests collected. The blood tests showed 11,900 leukocytes (90% neutrophils), high level of C reactive protein, negative blood culture, culture of the intramuscular purulent material negative, negative serology for HIV and syphilis. Chest and cranial computed tomography scans were normal. The cerebrospinal fluid showed the presence of 330 cells (60% mononuclear), 239 mg/dL proteins, 49 mg/dL glucose, negative Nanquin test, negative latex fixation test, negative bacterioscopy, negative cytomegalovirus serology. The polymerase chain reaction (PCR) result for Koch’s bacillus was in process at this time. Drainage of right thigh abscess was performed and material sent to culture.\nOphthalmology Service was then requested for evaluation. Visual acuity was 20/20 in both eyes, anterior biomicroscopy and intra-ocular pressure were normal. Fundus examination revealed subretinal, elevated, rounded, yellowish lesions in the nasal region in the right eye and superior to the macula in the left eye .\nOn fluorescein angiography (FA), these lesions showed punctate leakage . The optical coherence tomography (OCT) revealed choroidal lesions causing elevation of the retinal pigment epithelium (RPE) and subretinal fluid .\nConsidering systemic symptoms, suggestive laboratory and retinal lesions, the hypothesis of systemic tuberculosis with choroidal granuloma was assumed. After 14 days of treatment with piperacillin/tazobactam and vancomycin without clinical or laboratory response, the therapy was switched to rifampicin, isoniazid, pyrazinamide and ethambutol. At this point, several cultures of the material drained from the abscess were negative.\nAfter 4 weeks of treatment for tuberculosis, the patient maintained the symptoms and no improvement of laboratory tests. The possibility of fast growing atypical mycobacteria was considered and the empirical treatment for mycobacteria with amikacin and clarithromycin was added to previous tuberculosis treatment.\nPosteriorly to the change on the treatment, the patient presented clinical improvement and leukocytes progressively reduced from 16,500 to 7800 after 2 days. Then, one of the cultures collected from the left thigh confirmed the growth of non-tuberculous mycobacteria and the agent Mycobacterium Fortuitum was isolated. It was susceptible to the following antibiotics: amikacin, ciprofloxacin, doxycycline and moxifloxacin. At this time, the antibiotic therapy was replaced by doxycycline 200 mg/day and ciprofloxacin 1 g/day, oral administration.\nAfter 6 months of targeted treatment, the fundus exam revealed a significant regression of the lesions . The FA still showed discrete leakage and the OCT demonstrated regression of the choroidal lesion and subretinal fluid, which were replaced by areas of retinal atrophy .", + "fulltext_subclaims": [ + "The patient is a 37-year-old African-American male.", + "He was referred to the endocrinology department of the Federal Hospital of Lagoa.", + "The referral was for evaluation of adrenal insufficiency.", + "The adrenal insufficiency was due to chronic and irregular use of steroids.", + "He used Prednisone 20 to 40 mg/day for 10 years.", + "He had a history of use of anabolic drugs.", + "He had a history of intramuscular mineral oil (hydrogel) injections in the upper and lower limbs.", + "The injections were for muscle hypertrophy.", + "He used the injections for 15 years.", + "Three months prior to the referral, he developed intense headache.", + "Three months prior to the referral, he developed fever.", + "Three months prior to the referral, he developed night sweats.", + "Three months prior to the referral, he developed weight loss.", + "Three months prior to the referral, he developed limb pain.", + "No other systemic comorbidities were reported.", + "During hospitalization, intramuscular purulent collections were diagnosed by imaging tests.", + "He presented daily fever with a maximum of 38 °C.", + "Treatment with piperacillin/tazobactam 2.25 g IV q6hr was initiated.", + "Treatment with vancomycin 500 mg IV q6hr was initiated.", + "Blood tests showed 11,900 leukocytes.", + "The leukocytes were 90% neutrophils.", + "The blood tests showed high level of C reactive protein.", + "Blood culture was negative.", + "Culture of the intramuscular purulent material was negative.", + "Serology for HIV was negative.", + "Serology for syphilis was negative.", + "Chest computed tomography scan was normal.", + "Cranial computed tomography scan was normal.", + "Cerebrospinal fluid showed the presence of 330 cells.", + "The cerebrospinal fluid cells were 60% mononuclear.", + "Cerebrospinal fluid protein was 239 mg/dL.", + "Cerebrospinal fluid glucose was 49 mg/dL.", + "Nanquin test was negative.", + "Latex fixation test was negative.", + "Bacterioscopy was negative.", + "Cytomegalovirus serology was negative.", + "The PCR result for Koch’s bacillus was in process.", + "Drainage of right thigh abscess was performed.", + "Material from the abscess was sent to culture.", + "Ophthalmology Service was requested for evaluation.", + "Visual acuity was 20/20 in both eyes.", + "Anterior biomicroscopy was normal.", + "Intra-ocular pressure was normal.", + "Fundus examination revealed subretinal, elevated, rounded, yellowish lesions in the nasal region in the right eye.", + "Fundus examination revealed subretinal, elevated, rounded, yellowish lesions superior to the macula in the left eye.", + "On fluorescein angiography, the lesions showed punctate leakage.", + "Optical coherence tomography revealed choroidal lesions causing elevation of the retinal pigment epithelium.", + "Optical coherence tomography revealed subretinal fluid.", + "The hypothesis of systemic tuberculosis with choroidal granuloma was assumed.", + "After 14 days of treatment with piperacillin/tazobactam and vancomycin, there was no clinical or laboratory response.", + "The therapy was switched to rifampicin, isoniazid, pyrazinamide, and ethambutol.", + "At this point, several cultures of the material drained from the abscess were negative.", + "After 4 weeks of treatment for tuberculosis, the patient maintained the symptoms.", + "After 4 weeks of treatment for tuberculosis, there was no improvement of laboratory tests.", + "The possibility of fast growing atypical mycobacteria was considered.", + "Empirical treatment for mycobacteria with amikacin and clarithromycin was added.", + "After the change in treatment, the patient presented clinical improvement.", + "Leukocytes progressively reduced from 16,500 to 7800 after 2 days.", + "One of the cultures collected from the left thigh confirmed the growth of non-tuberculous mycobacteria.", + "Mycobacterium Fortuitum was isolated.", + "Mycobacterium Fortuitum was susceptible to amikacin.", + "Mycobacterium Fortuitum was susceptible to ciprofloxacin.", + "Mycobacterium Fortuitum was susceptible to doxycycline.", + "Mycobacterium Fortuitum was susceptible to moxifloxacin.", + "Antibiotic therapy was replaced by doxycycline 200 mg/day.", + "Antibiotic therapy was replaced by ciprofloxacin 1 g/day.", + "The antibiotics were administered orally.", + "After 6 months of targeted treatment, the fundus exam revealed a significant regression of the lesions.", + "Fluorescein angiography still showed discrete leakage.", + "Optical coherence tomography demonstrated regression of the choroidal lesion.", + "Optical coherence tomography demonstrated regression of subretinal fluid.", + "The regression of subretinal fluid was replaced by areas of retinal atrophy." + ], + "summary": "A 37-year-old african-american male with history of use of anabolic drugs and intramuscular mineral oil injections in the upper and lower limbs for 15 years for muscular hypertrophy. He developed intramuscular abscesses with systemic infection, sub-retinal lesions in both eyes and alterations in cerebrospinal fluid suggestive of mycobacteria. Considering these findings, empirical treatment for tuberculosis was started, without success. After several negative cultures of the material drained from the abscesses, finally one of the cultures isolated the agent Mycobacterium Fortuitum. Proper treatment for atypical mycobacteria was initiated with clinical and laboratory improvement. After 6 months the sub-retinal lesions regressed.", + "summary_subclaims": [ + "The patient is a 37-year-old african-american male.", + "He has a history of use of anabolic drugs.", + "He has a history of intramuscular mineral oil injections in the upper and lower limbs.", + "The injections were used for muscular hypertrophy.", + "The injections were used for 15 years.", + "He developed intramuscular abscesses.", + "He had systemic infection.", + "He had sub-retinal lesions in both eyes.", + "He had alterations in cerebrospinal fluid suggestive of mycobacteria.", + "Empirical treatment for tuberculosis was started.", + "The empirical treatment for tuberculosis was without success.", + "Several negative cultures of the material drained from the abscesses were obtained.", + "One of the cultures isolated the agent Mycobacterium Fortuitum.", + "Proper treatment for atypical mycobacteria was initiated.", + "There was clinical and laboratory improvement.", + "After 6 months the sub-retinal lesions regressed." + ] + }, + { + "id": "multiclinsum_test_2865_en.txt", + "fulltext": "A 34-year-old Caucasian woman was admitted complaining of a 10-day history of acute thoracic pain, progressive weakness of both lower extremities, worse on the right side, a ‘pins and needles’ sensation in the abdominal region, and bladder dysfunction. A neurological examination revealed spastic paraparesis, symmetrically decreased lower-extremity reflexes in her legs, a bilateral positive Babinski sign and decreased pinprick sensation below D6 level.Our patient underwent an MRI scan of the spine, which revealed an intramedullary lesion at D5 level with high-intensity signal relative to the spinal cord on T1-weighted images, spindle-like shaped and 1.5cm in diameter . An MRI scan with angiographic sequences and selective spinal angiography did not show vascular blush or abnormal vascularity.Our patient underwent D4-D5-D6 laminectomy. At the operation, the dura appeared intact. Once exposed, the spinal cord appeared normal on the surface although it was swollen at D5 level. A midline cordotomy was performed and a well-circumscribed dark-bluish lesion, measuring 1.5×0.5cm in diameter, was revealed deep within the spinal cord . The lesion was carefully dissected out and totally removed in one piece . A histological examination revealed the typical features of a cavernous angioma.The immediate postoperative course was uneventful. The paraparesis and sensory deficits gradually improved and our patient was discharged on the 18th postoperative day. A one-month follow-up spine MRI scan revealed no residual lesion . One-year post-operatively, our patient was able to walk again.", + "fulltext_subclaims": [ + "The patient is a 34-year-old Caucasian woman.", + "She had a 10-day history of acute thoracic pain.", + "She reported progressive weakness of both lower extremities, worse on the right side.", + "She had a 'pins and needles' sensation in the abdominal region.", + "She had bladder dysfunction.", + "A neurological examination revealed spastic paraparesis.", + "There was symmetrically decreased lower-extremity reflexes in her legs.", + "There was a bilateral positive Babinski sign.", + "There was decreased pinprick sensation below D6 level.", + "An MRI scan of the spine revealed an intramedullary lesion at D5 level.", + "The lesion had high-intensity signal relative to the spinal cord on T1-weighted images.", + "The lesion was spindle-like shaped and 1.5cm in diameter.", + "An MRI scan with angiographic sequences did not show vascular blush or abnormal vascularity.", + "Selective spinal angiography did not show vascular blush or abnormal vascularity.", + "The patient underwent D4-D5-D6 laminectomy.", + "At the operation, the dura appeared intact.", + "The spinal cord appeared normal on the surface.", + "The spinal cord was swollen at D5 level.", + "A midline cordotomy was performed.", + "A well-circumscribed dark-bluish lesion, measuring 1.5×0.5cm in diameter, was revealed deep within the spinal cord.", + "The lesion was carefully dissected out and totally removed in one piece.", + "A histological examination revealed the typical features of a cavernous angioma.", + "The immediate postoperative course was uneventful.", + "The paraparesis and sensory deficits gradually improved.", + "The patient was discharged on the 18th postoperative day.", + "A one-month follow-up spine MRI scan revealed no residual lesion.", + "One-year post-operatively, the patient was able to walk again." + ], + "summary": "We report the case of a 34-year-old Caucasian woman affected by a thoracic intramedullary cavernous angioma. Our patient complained of 10-day history of acute dorsal pain, progressive weakness of both lower extremities, worse on the right side, a 'pins and needles' sensation in the abdominal region and bladder dysfunction. Magnetic resonance imaging showed, at D5 level, a vascular malformation, which was not documented at spinal angiography. Our patient underwent surgical treatment with total removal of the lesion and her symptoms gradually improved. A histological examination revealed the typical features of a cavernous angioma.", + "summary_subclaims": [ + "The patient is a 34-year-old Caucasian woman.", + "The patient has a thoracic intramedullary cavernous angioma.", + "The patient had a 10-day history of acute dorsal pain.", + "The patient had progressive weakness of both lower extremities.", + "The weakness was worse on the right side.", + "The patient had a 'pins and needles' sensation in the abdominal region.", + "The patient had bladder dysfunction.", + "Magnetic resonance imaging showed a vascular malformation at D5 level.", + "The vascular malformation was not documented at spinal angiography.", + "The patient underwent surgical treatment with total removal of the lesion.", + "The patient's symptoms gradually improved.", + "A histological examination revealed the typical features of a cavernous angioma." + ] + }, + { + "id": "multiclinsum_test_2959_en.txt", + "fulltext": "Four years ago, a healthy 64-year-old Caucasian woman began to experience pain in the lower abdomen, only partially relieved by analgesics. Her past medical history was unremarkable. Magnetic resonance imaging (MRI) of the pelvis demonstrated a pelvic solid mass.\nA total abdominal hysterectomy with bilateral salpingo-oophorectomy was performed. The surgical procedure also included pelvic lymphadenectomy, partial colectomy, and cystectomy. Histopathologic staging revealed a high-grade endometrial carcinosarcoma measuring 14 cm in its greatest dimension. Tumor infiltration included the uterine serosa, rectosigmoid serosa, surrounding adipose tissue, cecal appendix, right fallopian tube, and ovaries. No lymphatic or vascular invasion and no involved lymph nodes were present. Peritoneal fluid was collected and was found to be positive for malignant tumor cells. Her immunohistochemistry result was positive for CD10, vimentin, AE1/3, endomysial, and S100 antibodies and negative for actin, desmin, estrogen and progesterone receptor. The patient was given adjuvant systemic chemotherapy with six cycles of carboplatin and paclitaxel.\nThe patient developed local recurrence 8 months after the end of her chemotherapy and was referred for surgery. An exploratory laparotomy revealed a high-grade endometrial sarcoma involving the terminal ileum and visceral peritoneum. The patient underwent a secondary cytoreductive surgery with no residual disease. After surgery, she received two cycles of ifosfamide at 2 g/m2 D1-3 combined with epirubicin at 50 mg/m2 D1-2 every 21 days. Treatment was interrupted due to encephalopathy and hematologic toxicity. Hematologic toxicity included grade 4 neutropenia according to the National Cancer Institute (NCI) Common Terminology Criteria for Adverse Events (CTCAE) version 4.0. The patient developed symptoms of agitation, confusion, and seizure due to ifosfamide-related encephalopathy. Her neurologic symptoms were totally reversed after chemotherapy interruption.\nThe patient was followed for 8 months, when fluorodeoxyglucose positron emission tomography–computed tomography (FDG-PET/CT) revealed two major perihepatic peritoneal nodules near segment VI, along with several other, smaller peritoneal implants. She had a complete tertiary cytoreduction that included resection of hepatic implants near segment VI, mesentery, and peritoneal bladder. Her pathology results confirmed carcinosarcoma, with a predominant high-grade, undifferentiated stromal component. Following surgery, she received carboplatin at a target carboplatin area under the time–concentration curve of 5, combined with docetaxel at 60 mg/m2; however, after the third cycle, she developed grade 3 NCI CTCAE version 4.0 infusion-related allergy to carboplatin, and the fourth cycle included docetaxel monotherapy at 60 mg/m2.\nFive months later, MRI and FDG-PET/CT demonstrated a peritoneal recurrence near hepatic segments VIII and VI, as well as the precaval lymph node and hepatic hilum with extension to the retropancreatic space. Nevertheless, a new attempt at cytoreductive surgery was ruled out. She was started on topotecan at 1.25 mg/m2 D1-5 every 21 days, but she developed progressive disease shortly after the fourth cycle. Her clinical condition included jaundice, malaise, and a great deterioration of PS.\nBiliary stents were placed. The procedure was successful, and the patient experienced considerable clinical improvement. The physician team decided to initiate metronomic chemotherapy. Oral cyclophosphamide at an empiric dose of 50 mg/day, given continuously, was started. The patient tolerated this regimen quite well, started to feel better, and recovered her performance status. Abdominal MRI was performed to evaluate treatment efficacy, and the patient was found to have a partial response according to Response Evaluation Criteria in Solid Tumors (RECIST) 1.1 criteria. Figure displays MRI scans obtained before and after metronomic therapy.\nThree months later, the patient complained of a new abdominal pain, and MRI demonstrated a new liver mass that was interpreted as progressive disease. Metronomic therapy was switched to a standard vinorelbine dosing schedule, namely 25 mg/m2 D1 and D8 every 21 days. After three cycles, the patient was experiencing worsening of her abdominal pain as well as daily fever. Chemotherapy was discontinued. A new abdominal MRI scan demonstrated that the liver lesion was bigger, with a central necrotic aspect. Percutaneous drainage of the lesion confirmed that there was a hepatic abscess. After the procedure and antibiotic treatment, the patient’s condition improved. This suggested that the medical team had misinterpreted computed tomographic (CT) scans and that the new liver lesion which had developed while the patient was on metronomic chemotherapy was a liver abscess. Earlier this year, cyclophosphamide was reinitiated, and a new MRI performed 3 months after treatment initiation revealed a partial response based on RECIST 1.1. The patient has continued with oral cyclophosphamide therapy through the time of this report. Tomographic evaluation was performed in December 2015, and the images demonstrated a partial response in comparison to the initial CT scans performed before cyclophosphamide treatment. The patient’s progression-free survival is 22 months at the time of this report.", + "fulltext_subclaims": [ + "Four years ago, a healthy 64-year-old Caucasian woman began to experience pain in the lower abdomen.", + "The pain was only partially relieved by analgesics.", + "Her past medical history was unremarkable.", + "Magnetic resonance imaging (MRI) of the pelvis demonstrated a pelvic solid mass.", + "A total abdominal hysterectomy with bilateral salpingo-oophorectomy was performed.", + "The surgical procedure also included pelvic lymphadenectomy.", + "The surgical procedure also included partial colectomy.", + "The surgical procedure also included cystectomy.", + "Histopathologic staging revealed a high-grade endometrial carcinosarcoma measuring 14 cm in its greatest dimension.", + "Tumor infiltration included the uterine serosa.", + "Tumor infiltration included the rectosigmoid serosa.", + "Tumor infiltration included surrounding adipose tissue.", + "Tumor infiltration included the cecal appendix.", + "Tumor infiltration included the right fallopian tube.", + "Tumor infiltration included the ovaries.", + "No lymphatic or vascular invasion was present.", + "No involved lymph nodes were present.", + "Peritoneal fluid was collected and was found to be positive for malignant tumor cells.", + "Her immunohistochemistry result was positive for CD10.", + "Her immunohistochemistry result was positive for vimentin.", + "Her immunohistochemistry result was positive for AE1/3.", + "Her immunohistochemistry result was positive for endomysial.", + "Her immunohistochemistry result was positive for S100 antibodies.", + "Her immunohistochemistry result was negative for actin.", + "Her immunohistochemistry result was negative for desmin.", + "Her immunohistochemistry result was negative for estrogen and progesterone receptor.", + "The patient was given adjuvant systemic chemotherapy with six cycles of carboplatin and paclitaxel.", + "The patient developed local recurrence 8 months after the end of her chemotherapy.", + "An exploratory laparotomy revealed a high-grade endometrial sarcoma involving the terminal ileum and visceral peritoneum.", + "The patient underwent a secondary cytoreductive surgery with no residual disease.", + "After surgery, she received two cycles of ifosfamide at 2 g/m2 D1-3 combined with epirubicin at 50 mg/m2 D1-2 every 21 days.", + "Treatment was interrupted due to encephalopathy and hematologic toxicity.", + "Hematologic toxicity included grade 4 neutropenia according to the National Cancer Institute (NCI) Common Terminology Criteria for Adverse Events (CTCAE) version 4.0.", + "The patient developed symptoms of agitation, confusion, and seizure due to ifosfamide-related encephalopathy.", + "Her neurologic symptoms were totally reversed after chemotherapy interruption.", + "The patient was followed for 8 months.", + "Fluorodeoxyglucose positron emission tomography–computed tomography (FDG-PET/CT) revealed two major perihepatic peritoneal nodules near segment VI.", + "She had a complete tertiary cytoreduction that included resection of hepatic implants near segment VI.", + "Her pathology results confirmed carcinosarcoma, with a predominant high-grade, undifferentiated stromal component.", + "Following surgery, she received carboplatin at a target carboplatin area under the time–concentration curve of 5, combined with docetaxel at 60 mg/m2.", + "After the third cycle, she developed grade 3 NCI CTCAE version 4.0 infusion-related allergy to carboplatin.", + "The fourth cycle included docetaxel monotherapy at 60 mg/m2.", + "Five months later, MRI and FDG-PET/CT demonstrated a peritoneal recurrence near hepatic segments VIII and VI.", + "A new attempt at cytoreductive surgery was ruled out.", + "She was started on topotecan at 1.25 mg/m2 D1-5 every 21 days.", + "She developed progressive disease shortly after the fourth cycle.", + "Her clinical condition included jaundice.", + "Her clinical condition included malaise.", + "Her clinical condition included a great deterioration of performance status.", + "Biliary stents were placed.", + "The procedure was successful, and the patient experienced considerable clinical improvement.", + "The physician team decided to initiate metronomic chemotherapy.", + "Oral cyclophosphamide at an empiric dose of 50 mg/day, given continuously, was started.", + "The patient tolerated this regimen quite well.", + "The patient started to feel better.", + "The patient recovered her performance status.", + "Abdominal MRI was performed to evaluate treatment efficacy.", + "The patient was found to have a partial response according to Response Evaluation Criteria in Solid Tumors (RECIST) 1.1 criteria.", + "Three months later, the patient complained of a new abdominal pain.", + "MRI demonstrated a new liver mass that was interpreted as progressive disease.", + "Metronomic therapy was switched to a standard vinorelbine dosing schedule, namely 25 mg/m2 D1 and D8 every 21 days.", + "After three cycles, the patient was experiencing worsening of her abdominal pain as well as daily fever.", + "Chemotherapy was discontinued.", + "A new abdominal MRI scan demonstrated that the liver lesion was bigger, with a central necrotic aspect.", + "Percutaneous drainage of the lesion confirmed that there was a hepatic abscess.", + "After the procedure and antibiotic treatment, the patient’s condition improved.", + "This suggested that the medical team had misinterpreted computed tomographic (CT) scans.", + "The new liver lesion which had developed while the patient was on metronomic chemotherapy was a liver abscess.", + "Cyclophosphamide was reinitiated earlier this year.", + "A new MRI performed 3 months after treatment initiation revealed a partial response based on RECIST 1.1.", + "The patient has continued with oral cyclophosphamide therapy through the time of this report.", + "Tomographic evaluation was performed in December 2015.", + "The images demonstrated a partial response in comparison to the initial CT scans performed before cyclophosphamide treatment.", + "The patient’s progression-free survival is 22 months at the time of this report." + ], + "summary": "We describe a case of a Caucasian woman diagnosed with metastatic carcinosarcoma that had already been treated with multiple lines of conventional chemotherapy, with progressive disease. This patient had a surprising clinical and imaging response when treated with oral metronomic cyclophosphamide.", + "summary_subclaims": [ + "The patient was a Caucasian woman.", + "The patient was diagnosed with metastatic carcinosarcoma.", + "The patient had already been treated with multiple lines of conventional chemotherapy.", + "The patient had progressive disease.", + "The patient had a surprising clinical response when treated with oral metronomic cyclophosphamide.", + "The patient had a surprising imaging response when treated with oral metronomic cyclophosphamide." + ] + }, + { + "id": "multiclinsum_test_2016_en.txt", + "fulltext": "A 6-year-old female child was diagnosed with acquired aplastic anemia in December 2019. Cytogenetic studies showed 46XX karyotype, chromosomal breakage study was normal, paroxysmal nocturnal hemoglobinuria clone was absent and clinical exome did not show any genetic mutation for inherited bone marrow failure syndrome. She did not have any significant infection during the pre-transplant course, except for the SARS-CoV-2 infection in June 2020. As she had no matched sibling or matched unrelated donor, she received a haploidentical stem cell transplant in July 2020.\nThe conditioning regimen was Rabbit ATG from Day-9 to Day-7 (0.5 mg/kg for 1 day and 2 mg/kg for 2 days), Fludarabine 40 mg/m2 for 4 days (Day-6 to Day-3), Cyclophosphamide 14.5 mg/kg for 2 days (Day − 6 and Day-5) and single fraction TBI (400 cGy) on Day − 1. On the day of transplantation, she received a peripheral blood stem cell graft from the father with 10 million CD34+ cells/kg and 2.41 × 108 CD3+ T cells/kg. Post-transplant Cyclophosphamide (50 mg/kg) was given on Day+ 3 and Day+ 4 followed by Ciclosporin and Mycophenolate mofetil on Day+ 5 as graft-versus-host disease (GvHD) prophylaxis.\nOn Day+ 9, she developed high-grade fever with the onset of engraftment. Her ferritin was raised at 65000 ng/mL and her bone marrow had haemophagocytosis. Blood cultures were negative. On day+ 13, a diagnosis of Candida tropicalis-driven macrophage activation syndrome was established on blood PCR and radio imaging of the abdomen. She was treated with antifungals (caspofungin and posaconazole), intravenous immunoglobulin (1 g/kg for 5 days), and intravenous Methylprednisolone (2 mg/kg). She continued to have high-grade fever and ferritin peaked at 190,000 ng/ml on Day+ 13. Hence, one dose of intravenous Alemtuzumab (0.1 mg/kg) was administered following which her fever subsided.\nThe patient developed hypertension from Day+ 13 requiring three antihypertensive medications. On Day+ 14, she had loose motions with abdominal pain. Abdominal pain persisted with frequent loose motions and significant hematochezia. An ultrasound scan of the abdomen was suggestive of pan-colitis. Oral Budesonide was started for possible gut GvHD, and intravenous Methylprednisolone was continued considering the possibility of stage 4 gut GvHD. The patient had neutrophil engraftment on day+ 16 and the neutrophils continued to increase. However, hemoglobin and platelet count gradually decreased. TA-TMA was suspected because of anemia, thrombocytopenia, hypertension, gastrointestinal bleeding, decreased serum albumin, and raised lactate dehydrogenase. On Day+ 20, the blood smear showed 1 fragmented RBC per high power field, and on Day+ 37 fragmented RBCs peaked at 5 per high power field. Urine protein:creatinine ratio was 0.47 on Day+ 20, and the ratio peaked at 2.88 on Day+ 34. Serum haptoglobin level was very low (< 5 mg/dl), but the direct antiglobulin test was negative. Soluble C5b-9 assay is not available nationally and hence was not performed. ADAMTS-13 activity was normal. Based on the Overall-TMA criteria the diagnosis of TA-TMA was confirmed.\nCiclosporin was discontinued, and the patient was given Inj Defibrotide from Day+ 21. There was no evidence of pathogenic variation in TMA-associated genes on clinical exome. She continued to have laboratory and clinical parameters of TMA after 10 days of treatment with Defibrotide. Eculizumab, a terminal complement inhibitor was considered. Eculizumab is exorbitantly expensive and hence it was not possible to treat with Eculizumab. Narsoplimab was available through an expanded access program for compassionate use. Narsoplimab was therefore accessed and commenced at a dose of 4 mg/kg twice a week on Day+ 30.\nThe patient’s stool pattern changed from frequent small-volume stools to large-volume stools with ongoing hematochezia. Severe colitis with inflammatory thickening measuring 5.5 mm extending up to the caecum and base of the appendix was seen on an ultrasound scan. Since gut GvHD and TA-TMA are known to coexist, she was also started on a TNF-α inhibitor (Etanercept). She developed pneumatosis coli after two doses of Etanercept on Day+ 40 and Day+ 43, and hence Etanercept was stopped. She continued to have significant intestinal bleeding requiring 86 mls/kg of packed red cell transfusion for 7 days. Intestinal mucosa appeared friable on a serial ultrasound scan with a risk of perforation. Therefore, endoscopic biopsies were not attempted, and monitoring of intestines was done with serial ultrasonography.\nNarsoplimab was increased from twice a week to thrice a week on Day+ 45 because of significant intestinal bleeding. Her lactate dehydrogenase improved dramatically after starting Narsoplimab and her haptoglobin normalized on Day+ 48 . Her hypertension improved and her antihypertensive requirement was reduced to a single antihypertensive medication from Day+ 59 . Her intestinal bleeding reduced from Day+ 50 and completely stopped on Day+ 82. Inj Methyprednisolone was gradually tapered from Day+ 72 and stopped on Day+ 92 because of improvement in gut symptoms. There were no schistocytes in the peripheral blood smear after Day+ 70. The patient received the last packed cell transfusion on Day+ 70 and the last platelet transfusion on Day+ 77 . Narsoplimab was reduced to twice a week regimen on Day+ 109, a once-a-week regimen on Day+ 133, and stopped on Day+ 195 .\nDuring this period, the patient had CMV reactivation on Day+ 59 with CMV copy numbers of 16,500/ml. She received Inj Foscarnet for 2 weeks, and CMV viremia resolved on Day+ 73. She had a herpes zoster skin infection on Day+ 111, which resolved with Acyclovir.\nThe patient developed liver GvHD from Day+ 217. Therefore, Tacrolimus was started from Day+ 217, and Ruxolitinib was added from Day+ 237. She had severe reticulocytopenia secondary to parvovirus infection on Day+ 246. Parvovirus infection was managed with immunoglobulin infusion. Concurrent with parvoviremia, she developed a second episode of TA-TMA manifested by circulating schistocytes, anemia, thrombocytopenia, low albumin, and an increase in lactate dehydrogenase and creatinine . Urine protein:creatinine ratio increased to 0.89. Hence, Tacrolimus was stopped, steroids were started, and Ruxolitinib was continued. She was started on Narsoplimab from Day+ 254, initially twice a week for 3 weeks. Narsoplimab was escalated to thrice a week from Day+ 274 because of persistent TA-TMA, and then tapered to twice weekly from Day+ 290 and stopped on Day+ 357.\nLiver GvHD resolved with steroids and Ruxolitinib. The patient is alive and well and had no features of TA-TMA on the last follow-up of D + 650.", + "fulltext_subclaims": [ + "The patient was diagnosed with acquired aplastic anemia in December 2019.", + "Cytogenetic studies showed 46XX karyotype.", + "Chromosomal breakage study was normal.", + "Paroxysmal nocturnal hemoglobinuria clone was absent.", + "Clinical exome did not show any genetic mutation for inherited bone marrow failure syndrome.", + "The patient had no matched sibling or matched unrelated donor.", + "She received a haploidentical stem cell transplant in July 2020.", + "The conditioning regimen included Rabbit ATG from Day-9 to Day-7.", + "Fludarabine was given at 40 mg/m2 for 4 days (Day-6 to Day-3).", + "Cyclophosphamide was given at 14.5 mg/kg for 2 days (Day-6 and Day-5).", + "A single fraction TBI (400 cGy) was given on Day-1.", + "On the day of transplantation, she received a peripheral blood stem cell graft from the father.", + "The graft contained 10 million CD34+ cells/kg.", + "The graft contained 2.41 × 108 CD3+ T cells/kg.", + "Post-transplant Cyclophosphamide (50 mg/kg) was given on Day+3 and Day+4.", + "Ciclosporin and Mycophenolate mofetil were started on Day+5 as GvHD prophylaxis.", + "On Day+9, she developed high-grade fever with the onset of engraftment.", + "Bone marrow showed haemophagocytosis.", + "A diagnosis of Candida tropicalis-driven macrophage activation syndrome was established on Day+13.", + "She was treated with caspofungin and posaconazole.", + "She received intravenous immunoglobulin (1 g/kg for 5 days).", + "She received intravenous Methylprednisolone (2 mg/kg).", + "One dose of intravenous Alemtuzumab (0.1 mg/kg) was administered.", + "The patient developed hypertension from Day+13.", + "On Day+14, she had loose motions with abdominal pain.", + "An ultrasound scan was suggestive of pan-colitis.", + "Oral Budesonide was started for possible gut GvHD.", + "The patient had neutrophil engraftment on Day+16.", + "TA-TMA was suspected based on anemia, thrombocytopenia, hypertension, gastrointestinal bleeding, decreased serum albumin, and raised lactate dehydrogenase.", + "Blood smear showed 1 fragmented RBC per high power field on Day+20.", + "Urine protein:creatinine ratio was 0.47 on Day+20.", + "Soluble C5b-9 assay is not available nationally.", + "ADAMTS-13 activity was normal.", + "The diagnosis of TA-TMA was confirmed based on the Overall-TMA criteria.", + "Ciclosporin was discontinued.", + "Inj Defibrotide was given from Day+21.", + "There was no evidence of pathogenic variation in TMA-associated genes on clinical exome.", + "Eculizumab was considered but not used due to cost.", + "Narsoplimab was accessed through an expanded access program.", + "Narsoplimab was commenced at a dose of 4 mg/kg twice a week on Day+30.", + "Severe colitis with inflammatory thickening measuring 5.5 mm extending up to the caecum and base of the appendix was seen on ultrasound.", + "She was started on a TNF-α inhibitor (Etanercept).", + "She developed pneumatosis coli after two doses of Etanercept.", + "Etanercept was stopped.", + "She continued to have significant intestinal bleeding.", + "Narsoplimab was increased to thrice a week on Day+45.", + "Her lactate dehydrogenase improved dramatically after starting Narsoplimab.", + "Her haptoglobin normalized on Day+48.", + "Her hypertension improved and antihypertensive requirement was reduced to a single medication from Day+59.", + "Intestinal bleeding reduced from Day+50 and completely stopped on Day+82.", + "Inj Methylprednisolone was tapered and stopped on Day+92.", + "There were no schistocytes in the peripheral blood smear after Day+70.", + "The patient received the last packed cell transfusion on Day+70.", + "The patient received the last platelet transfusion on Day+77.", + "Narsoplimab was reduced to twice a week on Day+109.", + "Narsoplimab was reduced to once a week on Day+133.", + "Narsoplimab was stopped on Day+195.", + "The patient had CMV reactivation on Day+59 with CMV copy numbers of 16,500/ml.", + "She received Inj Foscarnet for 2 weeks.", + "CMV viremia resolved on Day+73.", + "She had a herpes zoster skin infection on Day+111.", + "The infection resolved with Acyclovir.", + "The patient developed liver GvHD from Day+217.", + "Tacrolimus was started from Day+217.", + "Ruxolitinib was added from Day+237.", + "She had severe reticulocytopenia secondary to parvovirus infection on Day+246.", + "Parvovirus infection was managed with immunoglobulin infusion.", + "She developed a second episode of TA-TMA.", + "The second episode was manifested by circulating schistocytes, anemia, thrombocytopenia, low albumin, and an increase in lactate dehydrogenase and creatinine.", + "Urine protein:creatinine ratio increased to 0.89.", + "Tacrolimus was stopped.", + "Steroids were started.", + "Ruxolitinib was continued.", + "Narsoplimab was started from Day+254.", + "Narsoplimab was given twice a week for 3 weeks.", + "Narsoplimab was escalated to thrice a week from Day+274.", + "Narsoplimab was tapered to twice weekly from Day+290.", + "Narsoplimab was stopped on Day+357.", + "Liver GvHD resolved with steroids and Ruxolitinib.", + "The patient is alive and well.", + "The patient had no features of TA-TMA on the last follow-up of Day+650." + ], + "summary": "The six-year-old girl underwent a human leucocyte antigen (HLA) haploidentical hematopoietic stem cell transplant using post-transplant Cyclophosphamide for severe aplastic anemia. In the second week of the transplant, the patient developed macrophage activation syndrome necessitating treatment with steroids and intravenous immunoglobulin. Subsequently, USG abdomen and blood fungal PCR revealed the diagnosis of hepatosplenic candidiasis. Candida-triggered macrophage activation syndrome responded to antifungals, steroids, intravenous immunoglobulin, and alemtuzumab. However, the subsequent clinical course was complicated by thrombotic microangiopathy. The patient developed hypertension in the 2nd week, followed by high lactate dehydrogenase (1010 U/L), schistocytes (5 per hpf), low haptoglobin (< 5 mg/dl), thrombocytopenia, and anemia in the 3rd week. Ciclosporin was stopped, and the patient was treated with 10 days of defibrotide without response. The course was further complicated by the involvement of the gastrointestinal tract and kidneys. She had per rectal bleeding with frequent but low-volume stools, severe abdominal pain, and hypoalbuminemia with a rising urine protein:creatinine ratio. Narsoplimab was started in the 5th week of the transplant. A fall in lactate dehydrogenase was observed after starting Narsoplimab. This was followed by the resolution of gastrointestinal symptoms, proteinuria, and recovery of cytopenia. The second episode of TA-TMA occurred with parvoviraemia and was also successfully treated with Narsoplimab.", + "summary_subclaims": [ + "The six-year-old girl underwent a human leucocyte antigen (HLA) haploidentical hematopoietic stem cell transplant using post-transplant Cyclophosphamide for severe aplastic anemia.", + "In the second week of the transplant, the patient developed macrophage activation syndrome.", + "The diagnosis of hepatosplenic candidiasis was made based on USG abdomen and blood fungal PCR.", + "Candida-triggered macrophage activation syndrome responded to antifungals, steroids, intravenous immunoglobulin, and alemtuzumab.", + "The patient developed hypertension in the 2nd week.", + "The patient had high lactate dehydrogenase (1010 U/L), schistocytes (5 per hpf), low haptoglobin (< 5 mg/dl), thrombocytopenia, and anemia in the 3rd week.", + "Ciclosporin was stopped.", + "The patient was treated with 10 days of defibrotide without response.", + "The course was further complicated by the involvement of the gastrointestinal tract and kidneys.", + "Narsoplimab was started in the 5th week of the transplant.", + "A fall in lactate dehydrogenase was observed after starting Narsoplimab.", + "The resolution of gastrointestinal symptoms, proteinuria, and recovery of cytopenia followed starting Narsoplimab.", + "The second episode of TA-TMA occurred with parvoviraemia.", + "The second episode of TA-TMA was successfully treated with Narsoplimab." + ] + }, + { + "id": "multiclinsum_test_3218_en.txt", + "fulltext": "A 69-year-old female had received antihypertensive drugs (azilsartan [20 mg/day] and amlodipine [10 mg/day]) for over 15 years. The patient previously had non-Hodgkin’s lymphoma (stage IV) and underwent repeated courses of chemotherapy for each relapse between the ages of 35–49 years, resulting in complete remission (chemotherapy drug/cumulative dose [mg/m2]: doxorubicin [DOX]/218; pirarubicin/830; mitoxantrone/33; cyclophosphamide/23,758; vincristine/72; etoposide/333; and carboplatin/85; and rituximab/1,358; the equivalent DOX dose to assess ATC cardiotoxicity was 691 mg/m2). Furthermore, the patient received endoscopic submucosal dissection for early-stage rectal cancer and a right hemicolectomy for colon cancer at the age of 65 years.\n\nThe patient subsequently presented with exertional dyspnea and abdominal distention and was hospitalized for acute HF in August X, 1.5 months after symptom onset (this admission date was considered the reference date). Upon admission, the patient was in clinical scenario 2, with chest X-ray (CXR) findings of a pleural effusion, cardiac enlargement, and moderate pulmonary congestion (CXR2). An electrocardiogram (ECG) revealed sinus tachycardia (E2). A systolic murmur was heard, suggesting aortic stenosis (AS). Initial oxygen and intravenous diuretic therapies relieved the HF symptoms. Azilsartan was titrated to 40 mg/day, and azosemide (30 mg/day) and carvedilol (5 mg/day) were added early in the treatment course. A two-dimensional echocardiogram (2DE) revealed left ventricular (LV) and left atrial (LA) enlargement, reduced left ventricular wall motion (LVWM) with an 18% left ventricular ejection fraction (LVEF), and an elevated tricuspid regurgitant maximum pressure gradient (TRmaxPG) of 41 mmHg. All three calcified aortic valve leaflets had restricted openings, with a 30-mmHg aortic valve pressure gradient (AVPG) (#1 in Table 1). Dobutamine Stress 2DE ruled out severe AS. Computed tomography (CT) revealed an aortic valve calcium score of 1,189 Agatston units (AU). Coronary angiography (CAG) demonstrated no significant stenosis. Cardiac catheterization revealed increased pulmonary artery wedge pressure, increased LV end-diastolic pressure, pulmonary hypertension (PH), decreased cardiac output index, and low AVPG. Brain natriuretic peptide (BNP) levels declined from 1,183 pg/mL at admission to 710 pg/mL at discharge. In January X + 1, five months after reference date and four months post-discharge, weight gain was observed, and the BNP level increased to 2,986 pg/mL, indicating WHF. Azosemide was titrated to 45 mg/day, slow-release nifedipine at 20 mg/day was added to control blood pressure below 120 mmHg, and carvedilol was titrated to 7.5 mg/day. The patient remained stable at New York Heart Association (NYHA) class 2, with BNP levels of 1,100–1,900 pg/mL over the following year.\n\nIn March X + 2, one year and seven months after the reference date, the patient was suspected of having WHF with possible progression toward severe AS. This suspicion was based on an ECG in February X + 2 (one year and six months after the reference date) demonstrating LV strain (E4) and a CXR in March X + 2 (one year and seven months after the reference date) demonstrating cardiac enlargement (CXR4). Azilsartan was substituted with empagliflozin at 10 mg/day and sacubitril/valsartan at 200 mg/day (titrated to 400 mg/day over four weeks). Approximately three months later (one year and 11 months after the reference date), the patient rapidly experienced WHF symptoms, including dyspnea and abdominal distention, classified as NYHA class III. The symptom progression coincided with physical exertion, as the patient’s partner had undergone surgery and required care. Ivabradine was added to achieve heart rate control between 50–60 bpm, and a diuretic was used as needed to achieve target morning weight maintenance. Cardiac status subsequently improved to NYHA class II moderate limitation of physical activity (NYHA class IIm). The 2DE in October (two years and two months after the reference date) revealed a slight decrease in LV systolic dimension, slight LVEF improvement to 29%, and AS progression. Therefore, spironolactone at 25 mg/day was started as quadruple therapy. BNP levels decreased to 2,902 pg/mL in early February X + 3 (two years and six months after the reference date). Vericiguat was started in late February after receiving quadruple therapy and ivabradine treatment, without a 2DE evaluation. HF symptoms improved with weight loss owing to increased urine output, and the BNP level decreased below 650 pg/dL. The 2DE in March X + 3 (two years and seven months after the reference date) revealed the same LVEF and AVPG as in October X + 2 (two years and two months after the reference date), in addition to decreasing LV dimensions and a normalized TRmaxPG. Paroxysmal supraventricular tachycardia with hypotension frequently occurred, and the patient was readmitted in June (two years and 10 months after the reference date) for an electrophysiological study and right heart catheterization (RHC). RHC revealed mild PH, and right ventricular myocardial biopsies demonstrated drug-induced myocardial damage: the cardiomyocyte diameter was mildly enlarged, with noticeable anisokaryosis of the cardiomyocyte nuclei, some cardiomyocytes exhibited giant nuclei, and cytoplasmic vacuolar degeneration was observed. Mallory staining revealed fibrosis unrelated to the vascular structure between the cardiomyocytes, with the replacement of the myocardium by fibrous tissue. The 2DE in June (two years and 10 months after the reference date) revealed normalized LV diameter, a moderate reduction in LA enlargement, improved LVWM (52% LVEF), and a normalized TRmaxPG; however, the AVPG increased to 77 mmHg, with a Vmax of 4.4 m/s and aortic valve orifice area of 0.55 cm2, which was diagnosed as severe AS. The restricted openings of all calcified aortic valve leaflets were unchanged; however, all leaflets appeared slightly thickened and brightened. CT revealed that the aortic valve calcium score increased to 2,468 AU. Amlodipine was discontinued, and sacubitril/valsartan was tapered to mid-dose owing to persistent hypotensive symptoms. Spironolactone was discontinued due to hyperkalemia. The patient was stable at NYHA class II with a slight limitation of physical activity (NYHA class IIs) on sacubitril/valsartan at 200 mg/day, empagliflozin at 10 mg/day, carvedilol at 7.5 mg/day, azosemide at 30 mg/day, ivabradine at 15 mg/day, and vericiguat at 10 mg/day. An aortic valve replacement (AVR) for severe AS was successfully performed in September (three years and one month after the reference date), with good subsequent clinical outcomes.", + "fulltext_subclaims": [ + "The patient is a 69-year-old female.", + "She had received antihypertensive drugs (azilsartan [20 mg/day] and amlodipine [10 mg/day]) for over 15 years.", + "She previously had non-Hodgkin’s lymphoma (stage IV).", + "She underwent repeated courses of chemotherapy for each relapse between the ages of 35–49 years.", + "The chemotherapy resulted in complete remission.", + "The cumulative doxorubicin equivalent dose was 691 mg/m2.", + "She received endoscopic submucosal dissection for early-stage rectal cancer.", + "She had a right hemicolectomy for colon cancer at the age of 65 years.", + "She was hospitalized for acute HF in August X.", + "The admission date was considered the reference date.", + "Upon admission, she was in clinical scenario 2.", + "Chest X-ray findings included a pleural effusion, cardiac enlargement, and moderate pulmonary congestion.", + "An electrocardiogram revealed sinus tachycardia.", + "A systolic murmur was heard, suggesting aortic stenosis.", + "Initial oxygen and intravenous diuretic therapies relieved the HF symptoms.", + "Azilsartan was titrated to 40 mg/day.", + "Azosemide (30 mg/day) and carvedilol (5 mg/day) were added early in the treatment course.", + "A two-dimensional echocardiogram revealed left ventricular and left atrial enlargement.", + "The left ventricular ejection fraction was 18%.", + "The tricuspid regurgitant maximum pressure gradient was 41 mmHg.", + "All three calcified aortic valve leaflets had restricted openings.", + "The aortic valve pressure gradient was 30 mmHg.", + "Dobutamine Stress 2DE ruled out severe aortic stenosis.", + "Computed tomography revealed an aortic valve calcium score of 1,189 Agatston units.", + "Coronary angiography demonstrated no significant stenosis.", + "Cardiac catheterization revealed increased pulmonary artery wedge pressure.", + "Cardiac catheterization revealed increased LV end-diastolic pressure.", + "Cardiac catheterization revealed pulmonary hypertension.", + "Cardiac catheterization revealed decreased cardiac output index.", + "Cardiac catheterization revealed low aortic valve pressure gradient.", + "BNP levels declined from 1,183 pg/mL at admission to 710 pg/mL at discharge.", + "In January X + 1, five months after reference date, weight gain was observed.", + "In January X + 1, BNP levels increased to 2,986 pg/mL.", + "Azosemide was titrated to 45 mg/day.", + "Slow-release nifedipine at 20 mg/day was added to control blood pressure below 120 mmHg.", + "Carvedilol was titrated to 7.5 mg/day.", + "The patient remained stable at NYHA class 2.", + "BNP levels were 1,100–1,900 pg/mL over the following year.", + "In March X + 2, the patient was suspected of having worsening heart failure with possible progression toward severe aortic stenosis.", + "An ECG in February X + 2 demonstrated LV strain.", + "A CXR in March X + 2 demonstrated cardiac enlargement.", + "Azilsartan was substituted with empagliflozin at 10 mg/day.", + "Sacubitril/valsartan at 200 mg/day was added.", + "Sacubitril/valsartan was titrated to 400 mg/day over four weeks.", + "Approximately three months later, the patient rapidly experienced worsening heart failure symptoms.", + "The symptoms were classified as NYHA class III.", + "The symptom progression coincided with physical exertion.", + "Ivabradine was added to achieve heart rate control between 50–60 bpm.", + "A diuretic was used as needed to achieve target morning weight maintenance.", + "Cardiac status improved to NYHA class II moderate limitation of physical activity.", + "A 2DE in October revealed a slight decrease in LV systolic dimension.", + "A 2DE in October revealed slight LVEF improvement to 29%.", + "A 2DE in October revealed AS progression.", + "Spironolactone at 25 mg/day was started as quadruple therapy.", + "BNP levels decreased to 2,902 pg/mL in early February X + 3.", + "Vericiguat was started in late February after receiving quadruple therapy and ivabradine treatment.", + "HF symptoms improved with weight loss owing to increased urine output.", + "BNP levels decreased below 650 pg/dL.", + "A 2DE in March X + 3 revealed the same LVEF and AVPG as in October X + 2.", + "A 2DE in March X + 3 revealed decreasing LV dimensions.", + "A 2DE in March X + 3 revealed a normalized TRmaxPG.", + "The patient was readmitted in June for an electrophysiological study and right heart catheterization.", + "Right heart catheterization revealed mild PH.", + "Right ventricular myocardial biopsies demonstrated drug-induced myocardial damage.", + "The 2DE in June revealed normalized LV diameter.", + "The 2DE in June revealed a moderate reduction in LA enlargement.", + "The 2DE in June revealed improved LVWM (52% LVEF).", + "The 2DE in June revealed a normalized TRmaxPG.", + "The AVPG increased to 77 mmHg.", + "The Vmax was 4.4 m/s.", + "The aortic valve orifice area was 0.55 cm2.", + "This was diagnosed as severe AS.", + "CT revealed that the aortic valve calcium score increased to 2,468 AU.", + "Amlodipine was discontinued.", + "Sacubitril/valsartan was tapered to mid-dose owing to persistent hypotensive symptoms.", + "Spironolactone was discontinued due to hyperkalemia.", + "The patient was stable at NYHA class II with a slight limitation of physical activity.", + "An aortic valve replacement was successfully performed in September.", + "Aortic valve replacement was performed three years and one month after the reference date.", + "The patient had good subsequent clinical outcomes." + ], + "summary": "A survivor of cancer as a young adult who received high-dose anthracycline chemotherapy presented with acute decompensated heart failure 20 years post-chemotherapy and worsening heart failure 1.5 years after discharge. The patient showed signs of improvement after a step-wise introduction of carvedilol, empagliflozin, sacubitril/valsartan, ivabradine, and spironolactone for worsening heart failure. Vericiguat was accelerated owing to the risk of more severe cardiovascular events associated with ongoing aortic stenosis and the poor prognosis of anthracycline-induced cardiomyopathy. Heart failure symptoms continued to improve, with significant cardiac reverse remodeling, and the patient successfully underwent aortic valve replacement for severe aortic stenosis.", + "summary_subclaims": [ + "The patient is a survivor of cancer as a young adult.", + "The patient received high-dose anthracycline chemotherapy.", + "The patient presented with acute decompensated heart failure 20 years post-chemotherapy.", + "The patient had worsening heart failure 1.5 years after discharge.", + "The patient showed signs of improvement after a step-wise introduction of carvedilol, empagliflozin, sacubitril/valsartan, ivabradine, and spironolactone.", + "Vericiguat was accelerated owing to the risk of more severe cardiovascular events.", + "Vericiguat was accelerated owing to the poor prognosis of anthracycline-induced cardiomyopathy.", + "Heart failure symptoms continued to improve.", + "There was significant cardiac reverse remodeling.", + "The patient successfully underwent aortic valve replacement for severe aortic stenosis." + ] + }, + { + "id": "multiclinsum_test_1180_en.txt", + "fulltext": "A 6-year-old boy presented to the neuro-ophthalmic clinic with swelling over the lateral aspect of his left eye for 15 days. The swelling was not painful, but had been progressive and associated with lacrimation and drooping of the eyelid. Concurrently, an asymptomatic midline swelling was evident over the patient’s neck which had been present for 2 months. A history of occasional low-grade fever and a decrease in appetite were also reported. There was no history of bleeding tendency or similar swellings elsewhere, neither of cough or hemoptysis.\nOn examination, visual acuity was 6/6 in the right eye and 6/24 (6/6 with pinhole) in the left. The left upper eyelid demonstrated fullness over its lateral aspect with erythema of the overlying skin. A minimally mobile, non-pulsatile, non-compressible, diffuse and firm mass with mild tenderness was palpable in the lateral upper lid. There was mild ptosis and the eyeball was displaced inferomedially. Both the palpebral and bulbar conjunctivae were congested. Anterior and posterior segments in both eyes were normal. The pupils were 4 mm in diameter, with brisk direct and consensual light reactions and no relative afferent defect. The neck swelling was soft, fluctuant, non-tender and moved on deglutition.\nUltrasonography (US) of the orbital lesion showed low reflectivity, while contrast-enhanced computed tomography demonstrated a ring-enhancing, low density lesion in the lateral extraconal space with medial displacement of the globe and lateral rectus . The lacrimal gland could not be separately visualized. Sections obtained from the brain were normal.\nLaboratory investigations revealed hemoglobin level of 9.3 g/dL, leukocyte count of 15,000 cells/mm3, and erythrocyte sedimentation rate of 48 mm in the first hour. Thyroid function tests demonstrated high levels of thyroid stimulating hormone (TSH), 25.75 milliunits per liter (normal, 0.3 to 5.0 mU/L), with T3 and T4 within standard limits. US of the neck revealed a cystic swelling measuring 3 × 2 cm in the left lobe of the thyroid gland. A technetium-99 scan was performed which revealed a hypofunctioning nodule involving the lower third of the left lobe, extending to the isthmus.\nUS-guided fine needle aspiration of the orbital lesion was performed and the specimen underwent microscopic examination, and culture for bacteria, mycobacteria and fungi. Cytology demonstrated lymphocytes and a few giant cells, but no micro-organisms. Cultures remained sterile after 2 weeks. Fine needle aspiration from the neck mass revealed acid-fast bacilli, together with lymphocytes, and epitheloid and giant cells . Mycobacteria grew on the culture media incubated with the thyroid specimen. Chest X-ray and abdominal US were normal.\nEventually, a diagnosis of thyroid gland TB with coexisting tuberculous orbital abscess was made and the patient received a 3-drug antitubercular regimen. The orbital and neck swelling resolved after 6 months of therapy and the child remained asymptomatic up to one year .", + "fulltext_subclaims": [ + "A 6-year-old boy presented to the neuro-ophthalmic clinic with swelling over the lateral aspect of his left eye for 15 days.", + "The swelling was not painful.", + "The swelling had been progressive.", + "The swelling was associated with lacrimation.", + "The swelling was associated with drooping of the eyelid.", + "An asymptomatic midline swelling was evident over the patient’s neck.", + "The neck swelling had been present for 2 months.", + "A history of occasional low-grade fever was reported.", + "A history of a decrease in appetite was reported.", + "There was no history of bleeding tendency.", + "There was no history of similar swellings elsewhere.", + "There was no history of cough.", + "There was no history of hemoptysis.", + "Visual acuity was 6/6 in the right eye.", + "Visual acuity was 6/24 (6/6 with pinhole) in the left eye.", + "The left upper eyelid demonstrated fullness over its lateral aspect.", + "The overlying skin of the left upper eyelid was erythematous.", + "A minimally mobile mass was palpable in the lateral upper lid.", + "The mass was non-pulsatile.", + "The mass was non-compressible.", + "The mass was diffuse and firm.", + "The mass had mild tenderness.", + "There was mild ptosis.", + "The eyeball was displaced inferomedially.", + "Both the palpebral and bulbar conjunctivae were congested.", + "Anterior and posterior segments in both eyes were normal.", + "The pupils were 4 mm in diameter.", + "The pupils had brisk direct and consensual light reactions.", + "There was no relative afferent defect.", + "The neck swelling was soft.", + "The neck swelling was fluctuant.", + "The neck swelling was non-tender.", + "The neck swelling moved on deglutition.", + "Ultrasonography of the orbital lesion showed low reflectivity.", + "Contrast-enhanced computed tomography demonstrated a ring-enhancing, low density lesion in the lateral extraconal space.", + "The lesion caused medial displacement of the globe.", + "The lesion caused lateral rectus displacement.", + "The lacrimal gland could not be separately visualized.", + "Sections obtained from the brain were normal.", + "Hemoglobin level was 9.3 g/dL.", + "Leukocyte count was 15,000 cells/mm3.", + "Erythrocyte sedimentation rate was 48 mm in the first hour.", + "Thyroid stimulating hormone (TSH) was 25.75 milliunits per liter.", + "T3 and T4 were within standard limits.", + "US of the neck revealed a cystic swelling measuring 3 × 2 cm in the left lobe of the thyroid gland.", + "A technetium-99 scan revealed a hypofunctioning nodule involving the lower third of the left lobe.", + "The nodule extended to the isthmus.", + "US-guided fine needle aspiration of the orbital lesion was performed.", + "The specimen underwent microscopic examination.", + "Cytology demonstrated lymphocytes.", + "Cytology demonstrated a few giant cells.", + "Cultures remained sterile after 2 weeks.", + "Fine needle aspiration from the neck mass revealed acid-fast bacilli.", + "Fine needle aspiration from the neck mass revealed lymphocytes.", + "Fine needle aspiration from the neck mass revealed epitheloid cells.", + "Fine needle aspiration from the neck mass revealed giant cells.", + "Mycobacteria grew on the culture media incubated with the thyroid specimen.", + "Chest X-ray was normal.", + "Abdominal US was normal.", + "A diagnosis of thyroid gland TB with coexisting tuberculous orbital abscess was made.", + "The patient received a 3-drug antitubercular regimen.", + "The orbital and neck swelling resolved after 6 months of therapy.", + "The child remained asymptomatic up to one year." + ], + "summary": "A six-year old boy presented with left upper lid swelling of 15 days' duration and an asymptomatic midline neck mass from 2 months ago. Imaging studies, and microbiologic tests which demonstrated acid-fast bacilli in the fine needle aspirate of the thyroid mass, both confirmed a diagnosis of cold tuberculous thyroid abscess with presumed hematogenous spread to the orbit. The patient demonstrated marked improvement of both lesions with antitubercular drugs.", + "summary_subclaims": [ + "A six-year old boy presented with left upper lid swelling of 15 days' duration.", + "He had an asymptomatic midline neck mass from 2 months ago.", + "Microbiologic tests demonstrated acid-fast bacilli in the fine needle aspirate of the thyroid mass.", + "The diagnosis was cold tuberculous thyroid abscess with presumed hematogenous spread to the orbit.", + "The patient demonstrated marked improvement of both lesions with antitubercular drugs." + ] + }, + { + "id": "multiclinsum_test_2923_en.txt", + "fulltext": "An 85-year-old man who had a history of advanced lung adenocarcinoma for 1 year was admitted to our hospital with complaints of exacerbating cough and chest distress for 1 month on October 24, 2018. In September 2017, the patient visited our hospital due to cough, chest distress and fatigue. Chest CT: space-occupying lesions in the left upper lung, which was considered to be the lung cancer with obstructive pneumonia in the left upper lung; accompanied by left pleural effusion. Brain MRI: a left occipital lobe nodule, which was considered to be a metastatic tumor. PETCT: Partial rib and thoracic vertebra had higher levels of glucose metabolism, which might be the lung cancer bone metastasis. Then cytological examination of exfoliated cells in hydrothorax confirmed lung adenocarcinoma. The stage after assessment was T4N1M1c, stage IVB. Genetic testing showed that exon 21 L861Q of EGFR gene was positive, mutation frequency: 3.23%. The patient was given gefitinib (Iressa) 250 mg qd for targeted therapy. In February 2018, re-examination of chest CT showed progression of tumor lesions. In April 2018, a second genetic testing: exon 20 T790M of EGFR gene was positive. The treatment was adjusted to osimertinib (Teresa) 80 mg qd. Meanwhile, echocardiography was performed and showed the left ventricular ejection fraction (LVEF): 73%. Half a month after administration of osimertinib, the patient experienced alternating diarrhea and constipation, mainly diarrhea, the initial diarrhea was assessed as NCI-CTCAE V5.0 grade 1–2, and electrolyte imbalance was also observed: mild hypokalemia (potassium 3.0–3.5 mmol/L). The patient visited the outpatient for antidiarrheal and maintenance electrolyte therapy several times. During this period, the follow-up chest CT indicated that osimertinib treatment was effective, which was evaluated as partial response. When the patient was admitted to our hospital on October 24, 2018, the diarrhea was severe, which was assessed as NCI-CTCAE V5.0 grade 3.\nThe vital signs were T 36.0 °C, BP 99/64 mmHg, heart rate 86 beats per minute, and respiratory rate 20 breaths per minute during the initial examination. Chest CT on admission showed left upper lung tumor enlarged compared with that a month ago, with pleural effusion; the outcome of clinical efficacy evaluation was progressive disease; electrolytes: potassium 2.94 mmol/L; blood routine: white blood cells 1.16 × 109/L, neutrophils 0.56 × 109/L, hemoglobin 78 g/L, platelets 82 × 109/L; NT-proBNP: 5221 pg/mL; echocardiography: LVEF: 41%; Electrocardiogram (ECG): sinus rhythm, left anterior fascicular block, QTc interval 484 ms . Then thoracentesis was performed for pleural effusion, biapenem preventive anti-infection, recombinant human granulocyte colony-stimulating factor (rhG-CSF) to stimulate hematopoietic system, antidiarrheal, potassium supplement and other treatments. Electrolytes after potassium supplementation: potassium 3.75 mmol/L. In addition, considering severe diarrhea, neutropenia and other adverse reactions, the administration of osimertinib was temporarily stopped. On the 3rd day after admission, the patient had a fever with a peak temperature of 39.1 °C, and was given Moxifloxacin Hydrochloride and Sodium Chloride Injection (Avelox, specification: 250 ml: 0.4 g) ivgtt. The infusion time was about 100 min. Twenty minutes after the end of infusion, ECG monitoring showed TdP , and the patient had transient syncope. ECG: QTc interval 647 ms. Magnesium supplementation, potassium supplementation, and the antiarrhythmic drug lidocaine were given for emergency treatment. The patient did not have recurrent TdP afterwards. ECG after 7 h: QTc interval 631 ms; ECG after 10 h: QTc interval 578 ms; ECG after 43 h: QTc interval 531 ms; ECG after 91 h: QTc interval 496 ms. On October 30, 2018, the patient experienced decreased blood pressure and pulse oxygen, and was unconscious. In order to relieve the patient’s pain, the family did not consider the tracheal intubation, chest compression or other invasive rescue measures, and the patient was discharged.", + "fulltext_subclaims": [ + "An 85-year-old man who had a history of advanced lung adenocarcinoma for 1 year was admitted to our hospital with complaints of exacerbating cough and chest distress for 1 month on October 24, 2018.", + "Chest CT showed space-occupying lesions in the left upper lung, which was considered to be the lung cancer with obstructive pneumonia in the left upper lung.", + "Brain MRI showed a left occipital lobe nodule, which was considered to be a metastatic tumor.", + "PETCT showed partial rib and thoracic vertebra had higher levels of glucose metabolism, which might be the lung cancer bone metastasis.", + "Cytological examination of exfoliated cells in hydrothorax confirmed lung adenocarcinoma.", + "The stage after assessment was T4N1M1c, stage IVB.", + "Genetic testing showed that exon 21 L861Q of EGFR gene was positive, mutation frequency: 3.23%.", + "The patient was given gefitinib (Iressa) 250 mg qd for targeted therapy.", + "In February 2018, re-examination of chest CT showed progression of tumor lesions.", + "In April 2018, a second genetic testing showed exon 20 T790M of EGFR gene was positive.", + "The treatment was adjusted to osimertinib (Teresa) 80 mg qd.", + "Echocardiography showed the left ventricular ejection fraction (LVEF): 73%.", + "Half a month after administration of osimertinib, the patient experienced alternating diarrhea and constipation, mainly diarrhea.", + "The initial diarrhea was assessed as NCI-CTCAE V5.0 grade 1–2.", + "Electrolyte imbalance was also observed: mild hypokalemia (potassium 3.0–3.5 mmol/L).", + "The patient visited the outpatient for antidiarrheal and maintenance electrolyte therapy several times.", + "During this period, the follow-up chest CT indicated that osimertinib treatment was effective, which was evaluated as partial response.", + "When the patient was admitted to our hospital on October 24, 2018, the diarrhea was severe, which was assessed as NCI-CTCAE V5.0 grade 3.", + "Chest CT on admission showed left upper lung tumor enlarged compared with that a month ago, with pleural effusion.", + "The outcome of clinical efficacy evaluation was progressive disease.", + "Electrolytes: potassium 2.94 mmol/L.", + "Blood routine: white blood cells 1.16 × 109/L, neutrophils 0.56 × 109/L, hemoglobin 78 g/L, platelets 82 × 109/L.", + "NT-proBNP: 5221 pg/mL.", + "Echocardiography: LVEF: 41%.", + "Electrocardiogram (ECG): sinus rhythm, left anterior fascicular block, QTc interval 484 ms.", + "Thoracentesis was performed for pleural effusion.", + "Biapenem preventive anti-infection was given.", + "Recombinant human granulocyte colony-stimulating factor (rhG-CSF) was given to stimulate hematopoietic system.", + "Antidiarrheal, potassium supplement and other treatments were given.", + "Electrolytes after potassium supplementation: potassium 3.75 mmol/L.", + "Considering severe diarrhea, neutropenia and other adverse reactions, the administration of osimertinib was temporarily stopped.", + "On the 3rd day after admission, the patient had a fever with a peak temperature of 39.1 °C.", + "Moxifloxacin Hydrochloride and Sodium Chloride Injection (Avelox, specification: 250 ml: 0.4 g) was given ivgtt.", + "The infusion time was about 100 min.", + "Twenty minutes after the end of infusion, ECG monitoring showed TdP.", + "The patient had transient syncope.", + "ECG showed QTc interval 647 ms.", + "Magnesium supplementation, potassium supplementation, and the antiarrhythmic drug lidocaine were given for emergency treatment.", + "The patient did not have recurrent TdP afterwards.", + "ECG after 7 h showed QTc interval 631 ms.", + "ECG after 10 h showed QTc interval 578 ms.", + "ECG after 43 h showed QTc interval 531 ms.", + "ECG after 91 h showed QTc interval 496 ms.", + "On October 30, 2018, the patient experienced decreased blood pressure and pulse oxygen, and was unconscious.", + "The family did not consider the tracheal intubation, chest compression or other invasive rescue measures.", + "The patient was discharged." + ], + "summary": "An 85-year-old man with advanced NSCLC with brain andbone metastasis was initially treated with gefitinib targeted therapy. After 4 months treatment, the patient developed drug resistance and a second genetic testing revealed that the T790M mutation was positive. And the patient was then changed to targeted therapy with osimertinib, followed by adverse reactions of varying severity such as diarrhea, electrolyte imbalance, decreased cardiac function, leukopenia, and prolonged QTc interval. Six months after the administration of osimertinib, the patient was admitted to the hospital, chest CT showed the lesion progressed again, and during which hospital-acquired infection occurred. After concomitant use of moxifloxacin, the patient had sudden TdP, and finally died of this cardiac event.", + "summary_subclaims": [ + "An 85-year-old man with advanced NSCLC with brain and bone metastasis was initially treated with gefitinib targeted therapy.", + "After 4 months treatment, the patient developed drug resistance.", + "A second genetic testing revealed that the T790M mutation was positive.", + "The patient was then changed to targeted therapy with osimertinib.", + "The patient had adverse reactions such as diarrhea.", + "The patient had adverse reactions such as electrolyte imbalance.", + "The patient had adverse reactions such as decreased cardiac function.", + "The patient had adverse reactions such as leukopenia.", + "The patient had adverse reactions such as prolonged QTc interval.", + "Six months after the administration of osimertinib, the patient was admitted to the hospital.", + "Chest CT showed the lesion progressed again.", + "During the hospitalization, hospital-acquired infection occurred.", + "After concomitant use of moxifloxacin, the patient had sudden TdP.", + "The patient finally died of this cardiac event." + ] + }, + { + "id": "multiclinsum_test_3043_en.txt", + "fulltext": "We present the case of a 40-year-old Caucasian female nurse who presented with complaints of blurred vision that had developed over the preceding two weeks. The patient denied experiencing other symptoms, including pain, ocular redness or scotoma. Notably, she reported flu-like illness one week prior to the onset of her visual symptoms, during which she self-initiated treatment with oral prednisolone (20 mg/day, during 3 days) and bilastine (10 mg/day, during 3 days).\n\nHer medical history is significant for vitiligo and hypertension, which has been well-controlled with telmisartan (40mg/day) since diagnosis, 3 years earlier. The patient has no known allergies and no relevant family medical history. Her visual acuity was assessed at 20/20 with a refractive error of −0.25 in both eyes at baseline.\n\nBiomicroscopy of the anterior segment was unremarkable, and intraocular pressure (IOP) was recorded at 14 mmHg in the right eye (OD) and left eye (OS). Pupillary reflexes were normal, with equal and reactive pupils. Extraocular movements were intact.\n\nFundoscopic examination under mydriasis revealed the absence of the foveal reflex, along with a suspected subfoveal serous retinal detachment and multiple small serous retinal detachments in the posterior pole, but no other abnormalities. The retinal vessels appeared normal without signs of vasculitis, and no vitreous opacities or chorioretinal lesions were identified.\n\nInfrared and spectral-domain optical coherence tomography (SD-OCT) in OD and OS revealed bilateral, multiple, bleb-like small serous retinal detachments in the macula and along the vascular arcades, with varying sizes. A large confluent detachment was present in both eyes, temporal to the fovea. Fundus autofluorescence (FAF) appeared normal, showing no significant alterations at this stage. Fluorescein angiography (FA) and indocyanine green angiography (ICG) presented a normal aspect without any leakage or pooling.\n\nA survey for possible infectious causes was carried out and the patient lived in an apartment in an urban area with good sanitary conditions but had contact with a dog and cows/goats once a week, cleaning them. There is no history of international travel within the past five years, nor any recent hair coloring. There was no recent tick bite, no contact with patients with known pulmonary tuberculosis, nor any recent work accident, such as a needle stick. No recent or past consumption of intravenous drugs and no recent or previous use of topiramate or any MEK inhibitor. No recent or past risky sexual relations and no consumption of unpasteurized milk and its derivatives or consumption of undercooked meat.\n\nRegarding vaccination, the patient’s immunization status is in accordance with the national vaccination schedule, including the COVID-19 vaccination. Two initial doses of the Pfizer-BioNTech COVID-19 vaccine were administered at the beginning of 2021, followed by a booster dose later in the same year. An annual booster has been received since then, with the most recent dose administered 6 months prior to the onset of symptoms.\n\nA comprehensive laboratory workup was conducted to investigate potential infectious, autoimmune, and systemic etiologies for the serous retinal detachments. Hematological evaluation, including a complete blood count and platelet levels, returned within normal limits. Liver function tests, including aspartate aminotransferase (AST), alanine aminotransferase (ALT), and gamma-glutamyl transferase (GGT), as well as kidney function markers (creatinine and urea), erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) were all normal. Electrolyte levels were also within normal ranges, and thyroid function tests, including thyroid-stimulating hormone (TSH) and free thyroxine (T4), revealed no abnormalities. Angiotensin-converting enzyme (ACE) levels and ionized calcium were likewise normal.\n\nTo explore autoimmune causes, tests for antinuclear antibodies (ANA), antineutrophil cytoplasmic antibodies (ANCA), anti-double-stranded DNA (anti-dsDNA), anti-extractable nuclear antigen (anti-ENA), anti–Sjögren’s-syndrome-related antigens A and B (anti-SSA and anti-SSB) and anti-Smith antibodies (anti-SM) were all negative. Rheumatoid factor testing was also negative. Syphilis serology (TPPA) was unremarkable.\n\nInfectious serologies showed that IgG antibodies for cytomegalovirus (CMV), herpes simplex virus 1 (HSV1), Epstein-Barr virus (EBV), and parvovirus were positive, while IgM antibodies for these infections were negative, suggesting past infections. Serologies for herpes simplex virus 2 (HSV2), varicella-zoster virus, Toxoplasma gondii, Borrelia, Coxsackie B virus, Coxiella burnetii, and Rickettsia were negative for both IgG and IgM antibodies. Bartonella DNA/PCR testing was negative, as was the Wright reaction for brucellosis. Serological tests for HIV, hepatitis B, and hepatitis C were also negative. Tuberculosis screening with an interferon-gamma release assay (IGRA) and a Mantoux test yielded negative results, with 0 mm of induration. Urine test revealed no hematuria or proteinuria.\n\nAdditional imaging and systemic evaluations were conducted. A brain and orbit magnetic resonance imaging (MRI) and thoraco-abdominopelvic computerized tomography (CT) scan were both normal. Further assessments, including upper gastrointestinal endoscopy, colonoscopy, breast CT, breast ultrasound, cervical cytology, transvaginal ultrasound, and dermatological screening, revealed no significant abnormalities.\n\nThree months after the onset of the visual symptoms, in a follow-up consultation, her best corrected visual acuity (BCVA) remained 20/20 in OD but decreased to 20/25 in OS. Biomicroscopy of the anterior segment was unremarkable, and IOP was 14 mmHg in both eyes. Fundoscopic examination revealed multifocal yellowish subretinal polymorphous material scattered throughout the macula and seemed to gravitate along the lower margin of the serous retinal detachment, forming a curvilinear meniscus along temporal inferior vascular arcade. The previously observed bilateral multiple small serous retinal detachments have coalesced into a single larger detachment, while an accumulation of hyperreflective material in the subretinal space is observed, which translates the fundoscopic vitelliform deposits, as seen on SD-OCT. Additionally, FAF demonstrated the characteristic hyperautofluorescence of the polymorphous deposits, that corresponded to the yellow spots observed during fundoscopic examination. The same lesions showed hyperfluorescence on FA in all phases of the angiogram and ICG showed mild hypofluorescence in all phases of the angiogram.\n\nIn both eyes, full field electroretinogram was normal, as electrooculogram (Arden ratio was 2.39 in OD and 2.51 in OS) and pattern visually evoked potentials. Pattern Electroretinogram was normal in OD but showed a mild macular dysfunction in OS (reduction of P50-wave amplitude).\n\nBased on the clinical presentation, multimodal imaging findings, evolving retinal changes, and comprehensive systemic screening to rule out autoimmune, infectious, and neoplastic etiologies, a diagnosis of idiopathic AEPVM was established. The patient is being monitored for visual recovery and the potential need for further interventions.", + "fulltext_subclaims": [ + "The patient is a 40-year-old Caucasian female nurse.", + "The patient presented with blurred vision that had developed over the preceding two weeks.", + "The patient denied experiencing pain, ocular redness, or scotoma.", + "The patient reported flu-like illness one week prior to the onset of her visual symptoms.", + "The patient self-initiated treatment with oral prednisolone (20 mg/day, during 3 days).", + "The patient self-initiated treatment with bilastine (10 mg/day, during 3 days).", + "The patient has a medical history of vitiligo.", + "The patient has a medical history of hypertension, which has been well-controlled with telmisartan (40mg/day) since diagnosis 3 years earlier.", + "The patient has no known allergies.", + "The patient has no relevant family medical history.", + "Visual acuity was assessed at 20/20 with a refractive error of −0.25 in both eyes at baseline.", + "Biomicroscopy of the anterior segment was unremarkable.", + "Intraocular pressure was recorded at 14 mmHg in the right eye.", + "Intraocular pressure was recorded at 14 mmHg in the left eye.", + "Pupillary reflexes were normal, with equal and reactive pupils.", + "Extraocular movements were intact.", + "Fundoscopic examination under mydriasis revealed the absence of the foveal reflex.", + "Fundoscopic examination revealed a suspected subfoveal serous retinal detachment.", + "Fundoscopic examination revealed multiple small serous retinal detachments in the posterior pole.", + "The retinal vessels appeared normal without signs of vasculitis.", + "No vitreous opacities were identified.", + "No chorioretinal lesions were identified.", + "Infrared and spectral-domain optical coherence tomography revealed bilateral, multiple, bleb-like small serous retinal detachments in the macula.", + "A large confluent detachment was present in both eyes, temporal to the fovea.", + "Fundus autofluorescence appeared normal, showing no significant alterations at this stage.", + "Fluorescein angiography presented a normal aspect without any leakage or pooling.", + "Indocyanine green angiography presented a normal aspect without any leakage or pooling.", + "The patient lived in an apartment in an urban area with good sanitary conditions.", + "The patient had contact with a dog and cows/goats once a week, cleaning them.", + "The patient had no history of international travel within the past five years.", + "The patient had no recent tick bite.", + "The patient had no contact with patients with known pulmonary tuberculosis.", + "The patient had no recent work accident, such as a needle stick.", + "The patient had no recent or past consumption of intravenous drugs.", + "The patient had no recent or previous use of topiramate or any MEK inhibitor.", + "The patient had no recent or past risky sexual relations.", + "The patient had no consumption of unpasteurized milk and its derivatives.", + "The patient had no consumption of undercooked meat.", + "The patient’s immunization status is in accordance with the national vaccination schedule, including the COVID-19 vaccination.", + "The patient received two initial doses of the Pfizer-BioNTech COVID-19 vaccine at the beginning of 2021.", + "The patient received a booster dose of the Pfizer-BioNTech vaccine later in 2021.", + "The patient received an annual booster dose of the Pfizer-BioNTech vaccine since 2021.", + "The most recent dose of the Pfizer-BioNTech vaccine was administered 6 months prior to the onset of symptoms.", + "A comprehensive laboratory workup was conducted.", + "Hematological evaluation, including a complete blood count and platelet levels, returned within normal limits.", + "Liver function tests, including AST, ALT, and GGT, were within normal limits.", + "Kidney function markers, including creatinine and urea, were within normal limits.", + "ESR and CRP were within normal limits.", + "Electrolyte levels were within normal ranges.", + "Thyroid function tests, including TSH and free thyroxine, revealed no abnormalities.", + "ACE levels were normal.", + "Ionized calcium was normal.", + "Tests for ANA, ANCA, anti-dsDNA, anti-ENA, anti-SSA, anti-SSB, and anti-SM were all negative.", + "Rheumatoid factor testing was negative.", + "Syphilis serology (TPPA) was unremarkable.", + "IgG antibodies for CMV, HSV1, EBV, and parvovirus were positive.", + "IgM antibodies for CMV, HSV1, EBV, and parvovirus were negative.", + "Serologies for HSV2, varicella-zoster virus, Toxoplasma gondii, Borrelia, Coxsackie B virus, Coxiella burnetii, and Rickettsia were negative for both IgG and IgM antibodies.", + "Bartonella DNA/PCR testing was negative.", + "The Wright reaction for brucellosis was negative.", + "Serological tests for HIV, hepatitis B, and hepatitis C were negative.", + "Tuberculosis screening with IGRA and Mantoux test yielded negative results.", + "The Mantoux test showed 0 mm of induration.", + "Urine test revealed no hematuria or proteinuria.", + "A brain and orbit MRI was normal.", + "A thoraco-abdominopelvic CT scan was normal.", + "Upper gastrointestinal endoscopy revealed no significant abnormalities.", + "Colonoscopy revealed no significant abnormalities.", + "Breast CT revealed no significant abnormalities.", + "Breast ultrasound revealed no significant abnormalities.", + "Cervical cytology revealed no significant abnormalities.", + "Transvaginal ultrasound revealed no significant abnormalities.", + "Dermatological screening revealed no significant abnormalities.", + "Three months after the onset of the visual symptoms, best corrected visual acuity remained 20/20 in the right eye.", + "Three months after the onset of the visual symptoms, best corrected visual acuity decreased to 20/25 in the left eye.", + "Fundoscopic examination revealed multifocal yellowish subretinal polymorphous material scattered throughout the macula.", + "The previously observed bilateral multiple small serous retinal detachments have coalesced into a single larger detachment.", + "An accumulation of hyperreflective material in the subretinal space was observed, translating the fundoscopic vitelliform deposits.", + "FAF demonstrated the characteristic hyperautofluorescence of the polymorphous deposits.", + "The same lesions showed hyperfluorescence on FA in all phases of the angiogram.", + "ICG showed mild hypofluorescence in all phases of the angiogram.", + "Full field electroretinogram was normal.", + "Electrooculogram showed an Arden ratio of 2.39 in the right eye.", + "Electrooculogram showed an Arden ratio of 2.51 in the left eye.", + "Pattern visually evoked potentials were normal.", + "Pattern electroretinogram was normal in the right eye.", + "Pattern electroretinogram showed a mild macular dysfunction in the left eye.", + "A diagnosis of idiopathic AEPVM was established.", + "The patient is being monitored for visual recovery and the potential need for further interventions." + ], + "summary": "We report the case of a 40-year-old Caucasian female presenting with blurred vision for two weeks, with a best corrected visual acuity of 20/20 in both eyes, preceded by flu-like symptoms. Initial clinical evaluation, including fundus examination and spectral-domain optical coherence tomography (SD-OCT), revealed multiple small serous retinal detachments bilaterally. Multimodal imaging (fundus autofluorescence, fluorescein angiography, and indocyanine green angiography) appeared normal initially. A comprehensive systemic workup excluded autoimmune, infectious, and neoplastic etiologies. Upon follow-up, yellowish retinal lesions and hyperautofluorescence emerged, leading to the diagnosis of idiopathic AEPVM. The patient continues to be monitored for visual recovery and potential complications.", + "summary_subclaims": [ + "The patient is a 40-year-old Caucasian female.", + "She had blurred vision for two weeks.", + "Her best corrected visual acuity was 20/20 in both eyes.", + "She had flu-like symptoms before the onset of blurred vision.", + "Fundus examination and SD-OCT revealed multiple small serous retinal detachments bilaterally.", + "Multimodal imaging initially appeared normal.", + "A comprehensive systemic workup excluded autoimmune, infectious, and neoplastic etiologies.", + "Yellowish retinal lesions and hyperautofluorescence emerged upon follow-up.", + "The diagnosis was idiopathic AEPVM.", + "The patient continues to be monitored for visual recovery and potential complications." + ] + }, + { + "id": "multiclinsum_test_1871_en.txt", + "fulltext": "The 6-year-old boy complained of nausea, vomiting and headache for one week. He received medical treatment at local medical clinics initially, but his condition still persisted without improvement. Progressed symptoms and fever were also noted after initial medical treatment, and, he was transferred to our emergency department (ED) for further evaluation. At the ED, the previous history of the patient was obtained from his family. This boy had experienced one earlier episode of AOM in his young-infant stage and experienced a single episode of acute sinusitis about 2 months prior to admission. Moreover, no any history of skull trauma was noted before admission. However, the physical examinations revealed general appearance as lethargy and neck stiffness with positive meningitis signs (Brudzinski’s sign and Kerning sign). After admission, blood was sampled for complete blood count (CBC) with differential count (DC) analysis, biochemistry, glucose levels, and blood culture. Immediately lumbar puncture with CSF survey (CSF analysis, bacterial culture, virus culture and CSF biochemistry test) was also performed. The blood laboratory tests showed leukocytosis with shift to the left (white blood cell (WBC) count: 29190/mm3, and bands: 4 %), and the results of CSF analysis revealed WBC count as 3240/uL with predominant neutrophils as 91 %, glucose levels as 55 mg/dL, and total protein levels as 160.5 mg/dL. Moreover, the gram stain of CSF showed Sptreptococcus Pneumoniae , and antibiotics with vancomycin and cefotaxime were given immediately. The cultures of CSF and blood both showed Sptreptococcus Pneumoniae 23 F. Based on the report of the sensitivity to antibiotics in the strain of 23 F, vancomycin was useful and given continuously for 14 days. To trace back his past history, about 6 months ago, this pediatric patient suffered from bacterial meningitis, and was admitted for survey and treatments. The CSF gram stain showed Sptreptococcus Pneumoniae. Both CSF and blood cultures also showed Sptreptococcus Pneumoniae 23 F. After complete antimicrobial treatment with vancomycin for 14 days, he was discharged home without complication.\nTo further survey the cause of recurrent bacteria meningitis in such short period, we analyzed immunological functions of this boy, including complements and various immunoglobulins. However, the results showed normal immunity. According to the previous history of recurrent sinusitis for several weeks, we suspected that recurrent meningitis may be due to a bony defect caused by chronic sinusitis. Sinus computed tomography (CT) was performed but only right side maxillary sinusitis was noted without any bony defect. Moreover, nuclear scan was arranged and performed for studying CSF leakage. Notably, the results showed CSF leaked originating from the right petrooccpital region into the middle ear . Subsequent high resolution CT (HRCT) and magnetic resonance imaging (MRI) of bilateral ears were both carried out. The HRCT reports showed focal enlargement of the right facial nerve canal, erosion of the bony canal at geniculate ganglion and tympanic segment with tiny high-density spots and the reconstruction HRCT showed multiple bony defect at petrous part of temporal bone . The MRI reports revealed multifocal bony destruction with CSF collection in the right petrous ridge (near the Meckel cave and facial nerve canal at geniculate body ganglion region), carotid canal and jugular foramen . Eventually, CSF leakage to the right middle ear was confirmed and this may explain the cause of the recurrent bacteria meningitis in this boy. Further surgical approach for bony defect was suggested, but his family refused and asked for medical treatments. Therefore, after complete antimicrobial treatments with vancomycin for 14 days, this patient was discharged home, and received conjugated streptococcus pneumoniae vaccination (Prevenar 7) by self-payment, which is not included in the program of our national schedule vaccination at that time.", + "fulltext_subclaims": [ + "The 6-year-old boy complained of nausea, vomiting and headache for one week.", + "He received medical treatment at local medical clinics initially.", + "His condition still persisted without improvement.", + "Progressed symptoms and fever were also noted after initial medical treatment.", + "He was transferred to our emergency department for further evaluation.", + "The previous history of the patient was obtained from his family.", + "This boy had experienced one earlier episode of AOM in his young-infant stage.", + "He experienced a single episode of acute sinusitis about 2 months prior to admission.", + "No history of skull trauma was noted before admission.", + "The physical examinations revealed general appearance as lethargy.", + "Neck stiffness with positive meningitis signs (Brudzinski’s sign and Kerning sign) was noted.", + "Blood was sampled for complete blood count (CBC) with differential count (DC) analysis.", + "Blood culture was performed.", + "Lumbar puncture with CSF survey was also performed.", + "The blood laboratory tests showed leukocytosis with shift to the left.", + "The CSF analysis revealed WBC count as 3240/uL with predominant neutrophils as 91 %.", + "The gram stain of CSF showed Sptreptococcus Pneumoniae.", + "Antibiotics with vancomycin and cefotaxime were given immediately.", + "The cultures of CSF and blood both showed Sptreptococcus Pneumoniae 23 F.", + "Vancomycin was given continuously for 14 days.", + "About 6 months ago, this pediatric patient suffered from bacterial meningitis.", + "The CSF gram stain showed Sptreptococcus Pneumoniae.", + "Both CSF and blood cultures also showed Sptreptococcus Pneumoniae 23 F.", + "After complete antimicrobial treatment with vancomycin for 14 days, he was discharged home without complication.", + "Immunological functions of this boy, including complements and various immunoglobulins, were analyzed.", + "The results showed normal immunity.", + "Sinus computed tomography (CT) was performed.", + "Sinus CT showed right side maxillary sinusitis without any bony defect.", + "Nuclear scan was arranged and performed for studying CSF leakage.", + "The nuclear scan showed CSF leaked originating from the right petrooccpital region into the middle ear.", + "High resolution CT (HRCT) and magnetic resonance imaging (MRI) of bilateral ears were both carried out.", + "The HRCT reports showed focal enlargement of the right facial nerve canal.", + "The MRI reports revealed multifocal bony destruction with CSF collection in the right petrous ridge.", + "CSF leakage to the right middle ear was confirmed.", + "This may explain the cause of the recurrent bacteria meningitis in this boy.", + "Further surgical approach for bony defect was suggested.", + "His family refused and asked for medical treatments.", + "After complete antimicrobial treatments with vancomycin for 14 days, this patient was discharged home.", + "He received conjugated streptococcus pneumoniae vaccination (Prevenar 7) by self-payment.", + "Prevenar 7 was not included in the program of our national schedule vaccination at that time." + ], + "summary": "A 6-year-old boy was diagnosed with recurrent bacterial meningitis caused by Streptococcus Pneumonia 23 F. He had received serial imaging studies for identifying the cause. The initial sinus computed tomography (CT) also showed sinusitis without bony defect of sinus. However, after performing nuclear scan, the results showed cerebrospinal fluid (CSF) leaked originating from the right petrooccpital region into the middle ear. Subsequent high resolution CT (HRCT) reports showed focal enlargement of the right facial nerve canal, erosion of the bony canal at geniculate ganglion and tympanic segment with tiny high-density spots. The reconstruction HRCT showed multiple bony defects at temporal bone. The magnetic resonance imaging revealed multifocal bony destruction with CSF collection in the right petrous ridge, carotid canal and jugular foramen. Eventually, CSF leakage to the right middle ear was confirmed and this could be the cause of the recurrent bacteria meningitis in this patient.", + "summary_subclaims": [ + "A 6-year-old boy was diagnosed with recurrent bacterial meningitis caused by Streptococcus Pneumonia 23 F.", + "He had received serial imaging studies for identifying the cause.", + "The initial sinus computed tomography (CT) also showed sinusitis without bony defect of sinus.", + "After performing nuclear scan, the results showed cerebrospinal fluid (CSF) leaked originating from the right petrooccpital region into the middle ear.", + "Subsequent high resolution CT (HRCT) reports showed focal enlargement of the right facial nerve canal.", + "HRCT reports showed erosion of the bony canal at geniculate ganglion and tympanic segment with tiny high-density spots.", + "The reconstruction HRCT showed multiple bony defects at temporal bone.", + "The magnetic resonance imaging revealed multifocal bony destruction with CSF collection in the right petrous ridge, carotid canal and jugular foramen.", + "CSF leakage to the right middle ear was confirmed.", + "This could be the cause of the recurrent bacteria meningitis in this patient." + ] + }, + { + "id": "multiclinsum_test_1604_en.txt", + "fulltext": "A 51-year-old man had previously undergone a vertebral body resection, bone grafting and internal fixation surgery due to eosinophilic granuloma of the 9th thoracic vertebra in Dec 2014. In June 2015, the patient presented to our hospital with symptoms of chest tightness and lower back discomfort. Computed tomography (CT) scan revealed a pseudoaneurysm of the thoracic aorta and recommended surgical intervention. However, the patient declined the surgery because he considered the risk, especially paraplegia, to be high. Six months later, follow-up CT examination revealed no improvement in the condition of the pseudoaneurysm, leading to the decision to seek further treatment at our hospital in Jan 2016.\nPreoperative X-rays showed an abnormal bulging shadow in the descending aorta and a slightly enlarged aortic arch. CT scans revealed that a screw used in spinal surgery penetrated the wall of the descending aorta and locally formed a pseudoaneurysm, with the size of 27*42 mm, in the mid-segment of the descending aorta, with a significant amount of intraluminal thrombus and shell-like calcifications. The proximal landing diameter is approximately 23 mm, and the distal landing diameter is approximately 22 mm.\nUnder general anesthesia, the right femoral artery was accessed, and angiography confirmed the pseudoaneurysm in the mid-segment of the descending aorta, just located at the level of the spinal column fixation instruments. No significant AKA was identified during the procedure, and several pairs of intercostal arteries of similar sizes were visible. A 28–80 mm stent graft (Lifetech, Shenzhen, China) was placed via the right common femoral artery to seal the lesion. Subsequent angiography showed slight type Ia endoleak. Considering the risk of endoleak and the potential durability problems caused by friction between the stent graft and the screw, we decided to implant a second stent graft. Subsequently, a 28–140 mm stent graft (COOK, Bloomington, USA) was deployed just inside the first one. The second stent graft lengthened the proximal landing zone and strengthened the local abrasion resistance. The final angiography revealed complete exclusion of the pseudoaneurysm with no endoleak . Due to the orthopedic consultation determining that the removal would pose significant risks and the patient’s refusal of further open surgery, the screws were not extracted. Extubation was carried out in the operating room under general anesthesia, and assessment of lower limb function was performed. The operation was successful, the patient recovered well and was discharged from hospital 5 days later. There were no complications such as paraplegia, paresis or infection. Postoperative CT scans showed excellent apposition of the two stent grafts with no evidence of endoleak.\nDuring a follow-up period of nearly 8 years, CT scans indicated that the descending aortic stent grafts keep patency, and the lesion became smaller year by year and gradually absorbed. He recovered well and remained asymptomatic. The quality of life has not been affected in any way.", + "fulltext_subclaims": [ + "The patient is a 51-year-old man.", + "He had previously undergone a vertebral body resection, bone grafting and internal fixation surgery due to eosinophilic granuloma of the 9th thoracic vertebra in Dec 2014.", + "In June 2015, the patient presented with symptoms of chest tightness and lower back discomfort.", + "Computed tomography (CT) scan revealed a pseudoaneurysm of the thoracic aorta.", + "The patient declined the surgery because he considered the risk, especially paraplegia, to be high.", + "Six months later, follow-up CT examination revealed no improvement in the condition of the pseudoaneurysm.", + "Preoperative X-rays showed an abnormal bulging shadow in the descending aorta and a slightly enlarged aortic arch.", + "CT scans revealed that a screw used in spinal surgery penetrated the wall of the descending aorta and locally formed a pseudoaneurysm.", + "The size of the pseudoaneurysm was 27*42 mm.", + "The proximal landing diameter is approximately 23 mm.", + "The distal landing diameter is approximately 22 mm.", + "Under general anesthesia, the right femoral artery was accessed.", + "Angiography confirmed the pseudoaneurysm in the mid-segment of the descending aorta.", + "A 28–80 mm stent graft (Lifetech, Shenzhen, China) was placed via the right common femoral artery.", + "Subsequent angiography showed slight type Ia endoleak.", + "A second stent graft was implanted.", + "A 28–140 mm stent graft (COOK, Bloomington, USA) was deployed just inside the first one.", + "The final angiography revealed complete exclusion of the pseudoaneurysm with no endoleak.", + "The screws were not extracted.", + "Extubation was carried out in the operating room under general anesthesia.", + "The operation was successful.", + "The patient recovered well and was discharged from hospital 5 days later.", + "There were no complications such as paraplegia, paresis or infection.", + "Postoperative CT scans showed excellent apposition of the two stent grafts with no evidence of endoleak.", + "During a follow-up period of nearly 8 years, CT scans indicated that the descending aortic stent grafts keep patency.", + "The lesion became smaller year by year and gradually absorbed.", + "He recovered well and remained asymptomatic.", + "The quality of life has not been affected in any way." + ], + "summary": "We herein report a patient who underwent endovascular repair for the pseudoaneurysm of the descending thoracic aorta following thoracic vertebral fixation surgery. A 28-80 mm covered stent was initially inserted through the right femoral artery, and intraoperative aortography revealed a minor extravasation of contrast material. Subsequently, an additional 28-140 mm covered stent was implanted. The patient recovered well during the 8-year follow-up period.", + "summary_subclaims": [ + "The patient underwent endovascular repair for the pseudoaneurysm of the descending thoracic aorta.", + "The pseudoaneurysm occurred following thoracic vertebral fixation surgery.", + "A 28-80 mm covered stent was initially inserted through the right femoral artery.", + "Intraoperative aortography revealed a minor extravasation of contrast material.", + "An additional 28-140 mm covered stent was implanted.", + "The patient recovered well during the 8-year follow-up period." + ] + }, + { + "id": "multiclinsum_test_2172_en.txt", + "fulltext": "A 28-year-old man presented to the emergency room complaining of sudden-onset dyspnea, with no predisposing factors. The dyspnea lasted less than two hours and had almost resolved upon arrival at the emergency room, and there were no accompanying symptoms. He revealed no medical history other than two operations related to trauma, namely, a right anterior cruciate ligament reconstruction four years earlier, and nasal fracture reduction 13 years earlier. He denied any history of medication, and underlying diseases including connective tissue disease. The patient had never smoked, and drank a bottle of beer with 4.5% alcohol twice a week.\nOn admission, he did not complain of fever, cold sensation, diarrhea, or abdominal pain. His vital signs on presentation demonstrated a temperature of 36.2°C, a heart rate of 72 beats per minute, a respiratory rate of 19 breaths per minute, a blood pressure of 120/80 mm Hg, and an oxygen saturation of 97% on room air. He presented with a soft abdomen with normoactive bowel sounds, and no abdominal tenderness to palpation on physical examination. A plain chest and abdominal film showed subphrenic free air and an unremarkable bowel gas pattern . The laboratory tests presented the following results: serum total bilirubin, 1.67 mg/dL (normal, 0.3–1.2 mg/dL); alanine aminotransferase, 24 IU/L (normal, <50 U/L); aspartate aminotransferase, 25 IU/L (normal, <50 U/L); amylase, 47 U/L (normal, 28–100 U/L); and C-reactive protein, 0.48 mg/dL (normal, < 0.5 mg/dL). Given the free air finding on the chest X-ray, we were highly suspicious of bowel perforation. We therefore performed contrast-enhanced computed tomography (CT) of the abdomen.\nA CT scan revealed a pneumoperitoneum in the right upper quadrant, pneumoretroperitoneum, and gas in the entire portal venous system, without bowel wall thickening, bowel dilatation, bowel perforation, intramural gas, or any abnormal findings in the mesenteric arteries . The diagnosis of HPVG accompanied by free air was made by CT scan; however, no underlying etiology was identified. The patient denied a recent history of trauma, endoscopic procedures, asphyxia, or heavy lifting activity, or any symptoms suggestive of an infectious disease.\nConsidering the stable vital signs and the lack of physical findings suggesting a surgical acute abdomen, the patient was conservatively managed with fluid resuscitation and antibiotics, including cefotaxime 2 g every 8 hours and metronidazole 500 mg every 8 hours, and was kept nil-per-os. On admission day 3, the follow-up simple erect abdominal X-ray revealed resolving free air , and no new symptoms appeared. Oral feeding was initiated, after confirming that there were no abnormalities on esophagogastroduodenoscopic examination . The patient was able to tolerate oral food intake without any complications, and was later discharged.\nThe follow-up CT scan, performed two weeks after discharge, showed that the diffuse air density in the portal venous system, the pneumoperitoneum, and the pneumoretroperitoneum had resolved, and the colonoscopy and the colonography protocol CT scan revealed no significant abnormalities . The patient has been on follow-up observation at an outpatient clinic for four years, and has experienced no recurrence of symptoms.", + "fulltext_subclaims": [ + "A 28-year-old man presented to the emergency room complaining of sudden-onset dyspnea.", + "The dyspnea lasted less than two hours.", + "The dyspnea had almost resolved upon arrival at the emergency room.", + "There were no accompanying symptoms.", + "He revealed no medical history other than two operations related to trauma.", + "He had a right anterior cruciate ligament reconstruction four years earlier.", + "He had nasal fracture reduction 13 years earlier.", + "He denied any history of medication.", + "He denied underlying diseases including connective tissue disease.", + "He had never smoked.", + "He drank a bottle of beer with 4.5% alcohol twice a week.", + "On admission, he did not complain of fever.", + "On admission, he did not complain of cold sensation.", + "On admission, he did not complain of diarrhea.", + "On admission, he did not complain of abdominal pain.", + "His temperature on presentation was 36.2°C.", + "His heart rate on presentation was 72 beats per minute.", + "His respiratory rate on presentation was 19 breaths per minute.", + "His blood pressure on presentation was 120/80 mm Hg.", + "His oxygen saturation on presentation was 97% on room air.", + "He presented with a soft abdomen with normoactive bowel sounds.", + "There was no abdominal tenderness to palpation on physical examination.", + "A plain chest and abdominal film showed subphrenic free air.", + "A plain chest and abdominal film showed an unremarkable bowel gas pattern.", + "The serum total bilirubin was 1.67 mg/dL.", + "The normal range for serum total bilirubin is 0.3–1.2 mg/dL.", + "The alanine aminotransferase was 24 IU/L.", + "The normal range for alanine aminotransferase is <50 U/L.", + "The aspartate aminotransferase was 25 IU/L.", + "The normal range for aspartate aminotransferase is <50 U/L.", + "The amylase was 47 U/L.", + "The normal range for amylase is 28–100 U/L.", + "The C-reactive protein was 0.48 mg/dL.", + "The normal range for C-reactive protein is <0.5 mg/dL.", + "Given the free air finding on the chest X-ray, we were highly suspicious of bowel perforation.", + "We performed contrast-enhanced computed tomography (CT) of the abdomen.", + "The CT scan revealed a pneumoperitoneum in the right upper quadrant.", + "The CT scan revealed pneumoretroperitoneum.", + "The CT scan revealed gas in the entire portal venous system.", + "The CT scan showed no bowel wall thickening.", + "The CT scan showed no bowel dilatation.", + "The CT scan showed no bowel perforation.", + "The CT scan showed no intramural gas.", + "The CT scan showed no abnormal findings in the mesenteric arteries.", + "The diagnosis of HPVG accompanied by free air was made by CT scan.", + "No underlying etiology was identified.", + "The patient denied a recent history of trauma.", + "The patient denied recent endoscopic procedures.", + "The patient denied recent asphyxia.", + "The patient denied recent heavy lifting activity.", + "The patient denied any symptoms suggestive of an infectious disease.", + "The patient was conservatively managed with fluid resuscitation.", + "The patient was given cefotaxime 2 g every 8 hours.", + "The patient was given metronidazole 500 mg every 8 hours.", + "The patient was kept nil-per-os.", + "On admission day 3, the follow-up simple erect abdominal X-ray revealed resolving free air.", + "No new symptoms appeared.", + "Oral feeding was initiated after confirming no abnormalities on esophagogastroduodenoscopic examination.", + "The patient was able to tolerate oral food intake without any complications.", + "The patient was later discharged.", + "The follow-up CT scan, performed two weeks after discharge, showed that the diffuse air density in the portal venous system had resolved.", + "The follow-up CT scan showed that the pneumoperitoneum had resolved.", + "The follow-up CT scan showed that the pneumoretroperitoneum had resolved.", + "The colonoscopy revealed no significant abnormalities.", + "The colonography protocol CT scan revealed no significant abnormalities.", + "The patient has been on follow-up observation at an outpatient clinic for four years.", + "The patient has experienced no recurrence of symptoms." + ], + "summary": "A 28-year-old man without any specific medical history complained of sudden-onset dyspnea. On admission, his vital signs were stable, and the laboratory tests and physical examinations were within normal range. A plain chest and abdominal film revealed subphrenic free air and HPVG. Contrast-enhanced computed tomography (CT) showed extensive portal venous gas throughout the liver; however, there were no abnormal findings indicative of the etiology. Considering the stable vital signs and the lack of physical findings suggesting a surgical acute abdomen, the patient was managed conservatively. On admission day 3, the subphrenic free air and HPVG shown in the initial study had almost resolved, with no new symptoms. He was discharged on the fourth day after admission without any complications. Esophagogastroduodenoscopy, colonoscopy, and colonography protocol CT scan showed no significant abnormalities.", + "summary_subclaims": [ + "The patient is a 28-year-old man.", + "The patient had no specific medical history.", + "The patient complained of sudden-onset dyspnea.", + "On admission, his vital signs were stable.", + "The laboratory tests were within normal range.", + "The physical examinations were within normal range.", + "A plain chest and abdominal film revealed subphrenic free air.", + "A plain chest and abdominal film revealed HPVG.", + "Contrast-enhanced CT showed extensive portal venous gas throughout the liver.", + "There were no abnormal findings indicative of the etiology.", + "The patient was managed conservatively.", + "On admission day 3, the subphrenic free air had almost resolved.", + "On admission day 3, the HPVG had almost resolved.", + "The patient was discharged on the fourth day after admission.", + "Esophagogastroduodenoscopy showed no significant abnormalities.", + "Colonoscopy showed no significant abnormalities.", + "Colonography protocol CT scan showed no significant abnormalities." + ] + }, + { + "id": "multiclinsum_test_1954_en.txt", + "fulltext": "A 13 year old female living in a remote rural area came to our clinic with an 8 year history of deformities in the extremities which had gradually became worse till she was unable to walk. The patient over the years had developed recurrent fractures in her legs and arms after minor falls. The family was poor and lived in a remote area far away from proper medical facilities. She was treated by local healers for her fractures which resulted in bowing of legs and arms. There were no gastrointestinal symptoms of abdominal pain or diarrhea. She was brought to the clinic carried by her father. The patient used her arms to drag herself around the house and developed fractures followed by severe bowing of her arms. She had been diagnosed with rickets and iron deficiency anemia by doctors in community hospitals and had received Vitamin D and iron supplements many times without improvement. She had never had a complete workup to find out the cause of her rickets. The patient also had failure to thrive. On examination the patient was pale, weight was 11 kg and height 97 cm (below the 3rd percentile for her age) . She had severe bowing of her arms and legs.\nDue to the presence of anemia, failure to thrive and rickets the initial impression was malabsorption probably due to celiac disease and the laboratory work up was done accordingly.\nInitial laboratory investigations that were done are mentioned in Additional file : Table S1. X-rays of her upper and lower limbs showed diffuse osteopenia and bowing of both legs and forearms with blurring of the metaphyseal lines. It also showed dense transverse lines in tibia and ulna suggestive of looser’s zones indicative of severe rickets .Anti- endomysial antibodies titer was 80 (normal is negative), anti-tissue transglutaminase IgA was positive 75 U/ml (normal <2.5 U/ml) and anti-tissue transglutaminase IgG was negative. Upper endoscopy was done with small intestinal biopsy. The duodenum showed scalloping and fissuring of the small bowel suggestive of celiac disease. The histopathology report of the small intestine showed severe villous atrophy grade IV with crypt hyperplasia consistent with celiac disease. Old Marsh-Oberhuber classification: Type 3c: Total villous atrophy with completely flat mucosa and increased intraepithelial lymphocytes .\nThe patient was started on a gluten free diet. She also was started on Vitamin D supplements, calcium and iron replacement. The patient returned for follow-up 5 months later, she was feeling better, her weight had increased to 14 kg and her height had increased to 97 cm. She had taken iron and calcium supplements for a very short period but she did continue on a gluten free diet. The family was very poor and on further questioning on their dietary habit, it lacked many of the main constituents and was very low in vitamin D for most of her life but she did live in a very sunny area and before becoming crippled she had adequate sun exposure. Her diet before diagnosis was found to consist mainly of grains and breads with little protein and after being diagnosed and receiving instructions on a gluten free diet it was changed to rice and potatoes. Laboratory investigations showed some improvement from 5 months earlier these are shown in Additional file : Table S1. The patient was seen by an orthopedic surgeon who wanted the general condition of the patient to improve before considering any surgery.\nThe patient and her family were further instructed again on a gluten free diet emphasizing the available options. She was given further iron, calcium and Vitamin D replacement, the patient was not able to come back for follow up but 4 months later the family phoned and said she had markedly improved and had started walking.", + "fulltext_subclaims": [ + "The patient is a 13 year old female.", + "She has an 8 year history of deformities in the extremities.", + "The deformities had gradually become worse until she was unable to walk.", + "She had developed recurrent fractures in her legs and arms after minor falls.", + "The family lived in a remote area far away from proper medical facilities.", + "She was treated by local healers for her fractures.", + "This resulted in bowing of legs and arms.", + "There were no gastrointestinal symptoms of abdominal pain or diarrhea.", + "She was brought to the clinic carried by her father.", + "She used her arms to drag herself around the house.", + "She had been diagnosed with rickets and iron deficiency anemia by doctors in community hospitals.", + "She had received Vitamin D and iron supplements many times without improvement.", + "She had never had a complete workup to find out the cause of her rickets.", + "She had failure to thrive.", + "On examination, the patient was pale.", + "Her weight was 11 kg.", + "Her height was 97 cm.", + "Her height was below the 3rd percentile for her age.", + "She had severe bowing of her arms and legs.", + "The initial impression was malabsorption probably due to celiac disease.", + "X-rays showed diffuse osteopenia and bowing of both legs and forearms.", + "X-rays showed blurring of the metaphyseal lines.", + "X-rays showed dense transverse lines in tibia and ulna suggestive of looser’s zones indicative of severe rickets.", + "Anti-endomysial antibodies titer was 80 (normal is negative).", + "Anti-tissue transglutaminase IgA was positive 75 U/ml (normal <2.5 U/ml).", + "Anti-tissue transglutaminase IgG was negative.", + "Upper endoscopy was done with small intestinal biopsy.", + "The duodenum showed scalloping and fissuring of the small bowel suggestive of celiac disease.", + "The histopathology report showed severe villous atrophy grade IV with crypt hyperplasia consistent with celiac disease.", + "The histopathology report showed Old Marsh-Oberhuber classification: Type 3c.", + "The patient was started on a gluten free diet.", + "She was started on Vitamin D supplements.", + "She was started on calcium and iron replacement.", + "She returned for follow-up 5 months later.", + "Her weight had increased to 14 kg.", + "Her height had increased to 97 cm.", + "She had taken iron and calcium supplements for a very short period.", + "She did continue on a gluten free diet.", + "The family was very poor.", + "Her diet before diagnosis was found to consist mainly of grains and breads with little protein.", + "After diagnosis, her diet was changed to rice and potatoes.", + "Laboratory investigations showed some improvement from 5 months earlier.", + "The patient was seen by an orthopedic surgeon.", + "The orthopedic surgeon wanted the general condition of the patient to improve before considering any surgery.", + "The patient and her family were further instructed again on a gluten free diet.", + "She was given further iron, calcium and Vitamin D replacement.", + "The patient was not able to come back for follow up.", + "Four months later, the family phoned and said she had markedly improved.", + "She had started walking." + ], + "summary": "We present a 13 year old female from the middle east with an 8 year history of severe rickets causing multiple bone deformities leaving the child crippled with bowing of both of her arms and legs. The patient was also found to have growth failure, anemia and on further workup she was found to have celiac disease.", + "summary_subclaims": [ + "The patient is a 13 year old female.", + "The patient is from the middle east.", + "The patient has an 8 year history of severe rickets.", + "The rickets caused multiple bone deformities.", + "The bone deformities left the child crippled.", + "The child has bowing of both of her arms and legs.", + "The patient has growth failure.", + "The patient has anemia.", + "The patient was found to have celiac disease." + ] + }, + { + "id": "multiclinsum_test_2099_en.txt", + "fulltext": "A 69-year-old woman was diagnosed with suspected GBC and peritoneal carcinomatosis and was referred to our hospital. She had no remarkable medical history, but hepatitis C virus antibody was incidentally detected on a laboratory test and a suspected GBC lesion was found in a subsequent imaging examination. The levels of carcinoembryonic antigen (CEA) and carbohydrate antigen 19–9 (CA19-9) were 1.8 ng/mL and 144.5 U/mL, respectively. Contrast-enhanced CT showed 20-mm thickening of the fundus of the gallbladder and multiple nodules of approximately 100-mm maximum diameter in the peritoneal cavity . Contrast-enhanced MRI indicated similar findings to those in CT, and diffusion impairment at the primary tumor was apparent in diffusion-weighted imaging . The gallbladder tumor and the other nodules had high maximum standardized uptake values on PET-CT. The value for the primary tumor was 6.5.\nGemcitabine (GEM) plus cisplatin (CDDP) combination therapy (GC therapy) was started under a diagnosis of unresectable GBC with peritoneal carcinomatosis. After 12 courses of therapy over 9 months, the CEA and CA19-9 levels were similar to their initial values, after each had elevated once . The CA19-9 level remained high, but stable, and the primary tumor had enlarged slightly . However, the peritoneal nodules had disappeared in some areas and had not increased in number, and no new lesions, including distant metastasis, were visible on CT . Thus, we decided that complete resection was possible macroscopically.\nExtended cholecystectomy with partial liver resection with surgical margins of approximately 1.5 cm from the primary tumor, resection of the extrahepatic bile duct with regional lymph node dissection, and total omentectomy were performed. The primary tumor at the fundus of the gallbladder had a macroscopic appearance of the nodular-infiltrating type . Multiple cancerous nodules were found in the omentum , but disseminated nodules in the peritoneum and liver metastasis were not apparent. Carcinoma cells were detected in intraoperative peritoneal lavage cytology, but ascites was not noted. The final stage was ypT3N0M1 (PER), ypStage IVB in the TNM clinical classification .\nThe primary GBC was biliary-type adenocarcinoma with squamous differentiation . Lymphatic invasion was seen , but lymph node metastasis was not detected. Degenerative features such as atrophic changes of tumor cells and prominent fibrosis and calcification of the surrounding stroma were partly present . The disseminated omentum nodules had similar degenerative features to those of the primary tumor . Overall, these findings suggested that preoperative chemotherapy had been effective.\nOn postoperative day 14, GC therapy was switched to GEM and S-1 therapy (GS therapy). We made this decision because of the apparent gradual weakening of the effect of GC therapy, based on the lack of shrinkage of the primary tumor; the small decline in the CA19-9 level; and the limited effect in histopathological findings. After 8 courses of GS therapy over 5 months, the regimen was changed to S-1 monotherapy because of the patient’s tolerance for GS therapy. This treatment has continued to date (i.e., 31 months from the initial diagnosis) without any apparent recurrence for 19 months postoperatively.", + "fulltext_subclaims": [ + "A 69-year-old woman was diagnosed with suspected gallbladder cancer and peritoneal carcinomatosis.", + "She had no remarkable medical history.", + "Hepatitis C virus antibody was incidentally detected on a laboratory test.", + "A suspected gallbladder cancer lesion was found in a subsequent imaging examination.", + "The levels of carcinoembryonic antigen were 1.8 ng/mL.", + "The levels of carbohydrate antigen 19–9 were 144.5 U/mL.", + "Contrast-enhanced CT showed 20-mm thickening of the fundus of the gallbladder.", + "Contrast-enhanced CT showed multiple nodules of approximately 100-mm maximum diameter in the peritoneal cavity.", + "Contrast-enhanced MRI indicated similar findings to those in CT.", + "Diffusion impairment at the primary tumor was apparent in diffusion-weighted imaging.", + "The gallbladder tumor had high maximum standardized uptake values on PET-CT.", + "The value for the primary tumor on PET-CT was 6.5.", + "Gemcitabine plus cisplatin combination therapy was started under a diagnosis of unresectable gallbladder cancer with peritoneal carcinomatosis.", + "After 12 courses of therapy over 9 months, the CEA and CA19-9 levels were similar to their initial values.", + "The CA19-9 level remained high, but stable.", + "The primary tumor had enlarged slightly.", + "The peritoneal nodules had disappeared in some areas.", + "The peritoneal nodules had not increased in number.", + "No new lesions, including distant metastasis, were visible on CT.", + "We decided that complete resection was possible macroscopically.", + "Extended cholecystectomy with partial liver resection with surgical margins of approximately 1.5 cm from the primary tumor was performed.", + "Resection of the extrahepatic bile duct with regional lymph node dissection was performed.", + "Total omentectomy was performed.", + "The primary tumor at the fundus of the gallbladder had a macroscopic appearance of the nodular-infiltrating type.", + "Multiple cancerous nodules were found in the omentum.", + "Disseminated nodules in the peritoneum were not apparent.", + "Liver metastasis was not apparent.", + "Carcinoma cells were detected in intraoperative peritoneal lavage cytology.", + "Ascites was not noted.", + "The final stage was ypT3N0M1 (PER), ypStage IVB in the TNM clinical classification.", + "The primary gallbladder cancer was biliary-type adenocarcinoma with squamous differentiation.", + "Lymphatic invasion was seen.", + "Lymph node metastasis was not detected.", + "Degenerative features such as atrophic changes of tumor cells were partly present.", + "Prominent fibrosis and calcification of the surrounding stroma were partly present.", + "The disseminated omentum nodules had similar degenerative features to those of the primary tumor.", + "Overall, these findings suggested that preoperative chemotherapy had been effective.", + "On postoperative day 14, GC therapy was switched to GEM and S-1 therapy.", + "This decision was based on the apparent gradual weakening of the effect of GC therapy.", + "After 8 courses of GS therapy over 5 months, the regimen was changed to S-1 monotherapy.", + "This treatment has continued to date.", + "There has been no apparent recurrence for 19 months postoperatively." + ], + "summary": "A 69-year-old woman was referred to our hospital with initially unresectable gallbladder cancer with peritoneal carcinomatosis. She underwent gemcitabine plus cisplatin therapy for 9 months. Extended cholecystectomy, resection of the extrahepatic bile duct with regional lymph node dissection, and total omentectomy were then performed as conversion surgery. The patient has survived without recurrence for 19 months postoperatively (31 months after the initial diagnosis) while continuing chemotherapy.", + "summary_subclaims": [ + "The patient is a 69-year-old woman.", + "She was referred to the hospital with initially unresectable gallbladder cancer.", + "She had peritoneal carcinomatosis.", + "She underwent gemcitabine plus cisplatin therapy for 9 months.", + "Extended cholecystectomy was performed.", + "Resection of the extrahepatic bile duct with regional lymph node dissection was performed.", + "Total omentectomy was performed.", + "The surgeries were performed as conversion surgery.", + "The patient has survived without recurrence for 19 months postoperatively.", + "The patient has survived 31 months after the initial diagnosis.", + "The patient was continuing chemotherapy." + ] + }, + { + "id": "multiclinsum_test_979_en.txt", + "fulltext": "A 48-year-old Japanese woman fell down stairs that had a height of approximately 4 m. Her family called 119 (a direct-dial emergency number that connects the caller to the fire and emergency medical services) and the fire station simultaneously dispatched a “doctor-helicopter” from our hospital. She had past medical history including cholecystectomy and schizophrenia, and no remarkable family history. Her respiratory rate was 30 breaths/minute and blood oxygen saturation (SpO2) was 90% with oxygen at 10 L/minute. Her breath sound in her right chest was diminished. Her pulse rate was 130 beats/minute and her blood pressure was 88/55 mmHg. Her extremities were cold with sweat present, suggesting she was in a shock status. A focused assessment sonography for trauma (FAST) revealed hemoperitoneum in the pelvic space and a hemothorax in the right side of her chest. Her consciousness levels were 12 points (E3, V4, M5) according to the Glasgow Coma Scale at first contact and no coarse paralysis of limbs was observed. She was brought to our hospital by a doctor-helicopter, undergoing initial fluid resuscitation and respiratory assist with a bag valve mask (BVM).\nHer hemodynamics deteriorated remarkably with a pulse rate of 120 beats per minute and 50 mmHg systolic blood pressure on arrival. SpO2 was below 90% under respiratory assist with BVM. She was given 6 units of type O Rh plus red blood cells (RBC). A 7-French aortic occlusion catheter (Rescue Balloon®, Tokai Medical Products, Aichi, Japan) was inserted from her right femoral artery and was inflated with 20 ml distilled water to maintain her systolic blood pressure above 90 mmHg. A chest X-ray showed pneumothorax and pulmonary contusion in her right lung . A pelvis X-ray revealed an unstable fracture . The FAST showed a moderate hemothorax in the right side of her chest and a small amount of hemoperitoneum in Morison’s pouch and Douglas pouch. A 28-French chest drain was inserted, and preperitoneal pelvic packing (PPP) was performed to control bleeding from the unstable pelvic fracture, followed by application of a pelvic binder. A whole-body contrast-enhanced computed tomography (CT) scan was performed. The chest CT scan revealed massive lung contusion with major active extravasation of contrast media in the lower lobe of her right lung and moderate lung contusion in the lower lobe of her left lung . The abdominal CT revealed liver injuries with extravasation of contrast media, as well as massive hematoma in an erector spinae muscle with extravasation of contrast media and fractures of transverse process of lumbar vertebra . The pelvic CT confirmed multiple pelvic fractures involving moderate hematoma with extravasation of contrast media in retroperitoneal pelvic space .\nThe laboratory data on initial arrival are shown in Table . The Injury Severity Score (ISS) in this case was 48 and the probability of survival was calculated as 29.1%. We first decided to perform damage control thoracotomy since the right severe pulmonary contusion was thought to be a main bleeding source based on CT. Hemorrhage influx into the lumen of our patient’s trachea from the right pulmonary contusion was observed in a tracheal tube when she returned to the operation room (OR) in our emergency department (ED) from the CT room. A double lumen tracheal tube was replaced with a single lumen tracheal tube to prevent blood influx into healthy lung areas before emergency thoracotomy in a supine position. The amount of bleeding in the right thoracic cavity was approximately 1500 ml. The main sources of bleeding in her chest were the lung contusion area of the lower lobe of her right lung and multiple rib fractures. Intrathoracic packing with surgical gauze was performed as a temporary hemostasis to control bleeding from the sites of fractures of ribs. Since the right lung contusion had extended to near the hilum of lung , the hilum of lung was clamped for temporary hemostasis of the lung. At that time, her body temperature was 35.2 °C, base excess and pH of arterial blood gas analysis (BGA) were 10.5 mmol/L and 7.099, respectively, and a persistent oozing of blood from a non-surgical site was recognized. Therefore, we decided to perform wide wedge resection of the lung using a surgical stapling device as a DCS instead of an anatomical lobectomy. We converted the hilum clamp to a limited clamp to the injured lobe with two Satinsky blood vessel clamps. The vessel clamps were left in the right thoracic cavity, clamping proximal to suture lines. Then, therapeutic intrathoracic packing for hemorrhage from multiple rib fractures was performed. Surgical packing gauzes were mainly put in the dorsal and lower side in right thoracic cavity in order to maintain respiratory function of the upper and middle lobes of her right lung, and the vessel clamps were stabilized with additional surgical towels. After the placement of a chest drain, a temporary vacuum packing chest closure was performed and DCS was finished (total surgical time was 55 minutes).\nAfter the DCS for the chest, TAE was performed for severe liver injuries including medial segment and right lobe with gelatin sponge. Furthermore, her left subcostal artery, left first and fourth lumbar arteries, right first to fourth lumbar arteries, right superior gluteal artery, bilateral iliolumbar arteries, right obturator artery, and left lateral sacral artery were embolized in the same fashion (total procedure time was 118 minutes). Meanwhile, her respiratory status worsened including decreased partial pressure of oxygen in arterial blood (PaO2)/fraction of inspired oxygen (FiO2) (P/F) ratio and elevation of partial pressure of carbon dioxide (pCO2) on arterial blood gas. In the intensive care unit (ICU), her respiratory functions deteriorated with a P/F ratio below 50: pCO2 on BGA over 70 mmHg, pH of 7.099, and base deficit of − 12 mmol/L. Since a ventilator was no longer sufficient to maintain her respiratory condition, VV-ECMO was initiated as a lung assist: FiO2 1.0, oxygen flow 2.0 L/minute, and veno-venous (VV) blood flow 4.5〜5.0 L/minute . A bronchial block balloon was inserted into her right lower bronchus to reduce pressure to the suture lines of the lung. Blood and clots in the other side of the trachea and bronchus were toileted with a bronchoscope. Her hemodynamics and respiratory function improved gradually with these treatments. A blood transfusion continued to maintain the following: hemoglobin (Hb) > 9.0 g/dl, fibrinogen > 150 mg/dl, and platelet > 10 × 104/μl. The total blood transfusion for 24 hours included 82 units of RBC, 136 units of fresh frozen plasma (FFP), and 70 units of platelet concentrate (PC).\nThe planned reoperation for her chest and pelvis under VV-ECMO was performed on day 2 . When Satinsky blood vessel clamps were cautiously removed, there was a slight oozing of blood from the suture line at the resection site of the lower lobe of her right lung. The vessel forceps were reclamped and the stump was interruptedly sutured with two pairs of Teflon pledgets for hemostasis. We closed her chest with two chest drains placed following additional suture for hemorrhage from the multiple rib fractures area . Since slight bleeding continued from the right side of her pelvic retroperitoneal space after removal of PPP gauze, repacking and external fixation for pelvic fracture were also performed. On day 3, RBC and PC were appropriately transfused as our patient’s Hb and platelets were decreased due to VV-ECMO. Her respiratory function was completely dependent on VV-ECMO. Fluid infusion was restricted and a diuretic was administered to make her run on the dry side and her bloody and mucinous phlegm was deliberately removed by a bronchoscope. On day 5, the PPP gauze was removed and the wound was definitively closed. Her respiratory condition improved gradually, and P/F ratio became over 250, and her pCO2 level was within the normal limit when FiO2 and blood flow of VV-ECMO were decreased. The VV-ECMO circuit was withdrawn and the bronchial block balloon was removed on day 7. Our patient’s clinical course with intervention and examination and the change in lactate levels and P/F ratio until day 8 are shown in Fig. . On day 15, her respiratory condition was improved to the desired extent with no need for a ventilator . Pneumonia and right intrathoracic infection subsequently occurred and were treated by antibiotics. She needed another 45 days of rehabilitation to be able to walk independently, and was transferred to the psychiatric ward of our hospital on day 75.", + "fulltext_subclaims": [ + "The patient was a 48-year-old Japanese woman.", + "She fell down stairs that had a height of approximately 4 m.", + "Her family called 119.", + "A doctor-helicopter was dispatched from the hospital.", + "She had a past medical history including cholecystectomy.", + "She had a past medical history including schizophrenia.", + "Her respiratory rate was 30 breaths/minute.", + "Her blood oxygen saturation (SpO2) was 90% with oxygen at 10 L/minute.", + "Her breath sound in her right chest was diminished.", + "Her pulse rate was 130 beats/minute.", + "Her blood pressure was 88/55 mmHg.", + "Her extremities were cold with sweat present.", + "A focused assessment sonography for trauma (FAST) revealed hemoperitoneum in the pelvic space.", + "A FAST revealed a hemothorax in the right side of her chest.", + "Her Glasgow Coma Scale score was 12 points (E3, V4, M5).", + "No coarse paralysis of limbs was observed.", + "She was brought to the hospital by a doctor-helicopter.", + "She underwent initial fluid resuscitation.", + "She received respiratory assist with a bag valve mask (BVM).", + "Her hemodynamics deteriorated remarkably on arrival.", + "Her pulse rate was 120 beats per minute on arrival.", + "Her systolic blood pressure was 50 mmHg on arrival.", + "SpO2 was below 90% under respiratory assist with BVM.", + "She was given 6 units of type O Rh plus red blood cells.", + "A 7-French aortic occlusion catheter was inserted from her right femoral artery.", + "The catheter was inflated with 20 ml distilled water.", + "A chest X-ray showed pneumothorax in her right lung.", + "A chest X-ray showed pulmonary contusion in her right lung.", + "A pelvis X-ray revealed an unstable fracture.", + "The FAST showed a moderate hemothorax in the right side of her chest.", + "The FAST showed a small amount of hemoperitoneum in Morison’s pouch.", + "A 28-French chest drain was inserted.", + "Preperitoneal pelvic packing (PPP) was performed.", + "A whole-body contrast-enhanced CT scan was performed.", + "The chest CT scan revealed massive lung contusion with major active extravasation of contrast media in the lower lobe of her right lung.", + "The chest CT scan revealed moderate lung contusion in the lower lobe of her left lung.", + "The abdominal CT revealed liver injuries with extravasation of contrast media.", + "The abdominal CT revealed massive hematoma in an erector spinae muscle with extravasation of contrast media.", + "The abdominal CT revealed fractures of transverse process of lumbar vertebra.", + "The pelvic CT confirmed multiple pelvic fractures involving moderate hematoma with extravasation of contrast media in retroperitoneal pelvic space.", + "The Injury Severity Score (ISS) in this case was 48.", + "The probability of survival was calculated as 29.1%.", + "Damage control thoracotomy was decided to be performed.", + "The right severe pulmonary contusion was thought to be a main bleeding source based on CT.", + "Hemorrhage influx into the trachea from the right pulmonary contusion was observed.", + "A double lumen tracheal tube was replaced with a single lumen tracheal tube.", + "The amount of bleeding in the right thoracic cavity was approximately 1500 ml.", + "The main sources of bleeding in her chest were the lung contusion area of the lower lobe of her right lung and multiple rib fractures.", + "Intrathoracic packing with surgical gauze was performed.", + "The right lung contusion had extended to near the hilum of lung.", + "The hilum of lung was clamped for temporary hemostasis.", + "Her body temperature was 35.2 °C.", + "The base excess of arterial blood gas analysis was 10.5 mmol/L.", + "The pH of arterial blood gas analysis was 7.099.", + "Persistent oozing of blood from a non-surgical site was recognized.", + "Wide wedge resection of the lung using a surgical stapling device was decided.", + "The hilum clamp was converted to a limited clamp to the injured lobe with two Satinsky blood vessel clamps.", + "The vessel clamps were left in the right thoracic cavity.", + "Therapeutic intrathoracic packing for hemorrhage from multiple rib fractures was performed.", + "Surgical packing gauzes were mainly put in the dorsal and lower side in right thoracic cavity.", + "A chest drain was placed.", + "A temporary vacuum packing chest closure was performed.", + "Damage control surgery was finished in 55 minutes.", + "TAE was performed for severe liver injuries including medial segment and right lobe with gelatin sponge.", + "Her left subcostal artery was embolized.", + "Her left first and fourth lumbar arteries were embolized.", + "Her right first to fourth lumbar arteries were embolized.", + "Her right superior gluteal artery was embolized.", + "Bilateral iliolumbar arteries were embolized.", + "Her right obturator artery was embolized.", + "Her left lateral sacral artery was embolized.", + "The total procedure time for TAE was 118 minutes.", + "Her respiratory status worsened including decreased PaO2/FiO2 ratio.", + "Her pCO2 on arterial blood gas was elevated.", + "VV-ECMO was initiated as a lung assist.", + "A bronchial block balloon was inserted into her right lower bronchus.", + "Blood and clots in the other side of the trachea and bronchus were toileted with a bronchoscope.", + "The total blood transfusion for 24 hours included 82 units of RBC.", + "The total blood transfusion for 24 hours included 136 units of fresh frozen plasma.", + "The total blood transfusion for 24 hours included 70 units of platelet concentrate.", + "The planned reoperation for her chest and pelvis under VV-ECMO was performed on day 2.", + "There was a slight oozing of blood from the suture line at the resection site of the lower lobe of her right lung.", + "The vessel forceps were reclamped and the stump was interruptedly sutured.", + "Her chest was closed with two chest drains.", + "Slight bleeding continued from the right side of her pelvic retroperitoneal space after removal of PPP gauze.", + "Repacking and external fixation for pelvic fracture were performed.", + "RBC and PC were appropriately transfused on day 3.", + "Her respiratory condition was completely dependent on VV-ECMO.", + "Fluid infusion was restricted and a diuretic was administered.", + "Bloody and mucinous phlegm was deliberately removed by a bronchoscope.", + "The PPP gauze was removed on day 5.", + "The wound was definitively closed on day 5.", + "Her respiratory condition improved gradually.", + "The P/F ratio became over 250.", + "The VV-ECMO circuit was withdrawn on day 7.", + "The bronchial block balloon was removed on day 7.", + "Her respiratory condition was improved to the desired extent with no need for a ventilator on day 15.", + "Pneumonia and right intrathoracic infection occurred.", + "She needed another 45 days of rehabilitation to be able to walk independently.", + "She was transferred to the psychiatric ward on day 75." + ], + "summary": "A 48-year-old Japanese woman fell down stairs that had a height of approximately 4 m. An X-ray showed pneumothorax, pulmonary contusion in her right lung, and an unstable pelvic fracture. A chest drain was inserted and preperitoneal pelvic packing was performed to control bleeding, performing resuscitative endovascular balloon occlusion of the aorta. A computed tomography scan revealed massive lung contusion in the lower lobe of her right lung, pelvic fractures, and multiple fractures and hematoma in other areas. An emergency thoracotomy was performed, and then we performed wide wedge resection of the injured lung, clamping proximal to suture lines with two Satinsky blood vessel clamps. The vessel clamps were left in the right thoracic cavity. The other hemorrhagic areas were embolized by transcatheter arterial embolization. However, since her respiratory functions deteriorated in the intensive care unit, veno-venous extracorporeal membrane oxygenation was used for lung assist. Planned reoperation under veno-venous extracorporeal membrane oxygenation was performed on day 2. Since her respiratory condition improved gradually, the veno-venous extracorporeal membrane oxygenation circuit was withdrawn on day 7. She was transferred to the psychiatric ward of our hospital on day 75.", + "summary_subclaims": [ + "The patient is a 48-year-old Japanese woman.", + "She fell down stairs that had a height of approximately 4 m.", + "An X-ray showed pneumothorax.", + "An X-ray showed pulmonary contusion in her right lung.", + "An X-ray showed an unstable pelvic fracture.", + "A chest drain was inserted.", + "Preperitoneal pelvic packing was performed.", + "Resuscitative endovascular balloon occlusion of the aorta was performed.", + "A computed tomography scan revealed massive lung contusion in the lower lobe of her right lung.", + "A computed tomography scan revealed pelvic fractures.", + "A computed tomography scan revealed multiple fractures and hematoma in other areas.", + "An emergency thoracotomy was performed.", + "Wide wedge resection of the injured lung was performed.", + "Two Satinsky blood vessel clamps were used, clamping proximal to suture lines.", + "The vessel clamps were left in the right thoracic cavity.", + "The other hemorrhagic areas were embolized by transcatheter arterial embolization.", + "Veno-venous extracorporeal membrane oxygenation was used for lung assist.", + "Planned reoperation under veno-venous extracorporeal membrane oxygenation was performed on day 2.", + "The veno-venous extracorporeal membrane oxygenation circuit was withdrawn on day 7.", + "She was transferred to the psychiatric ward of our hospital on day 75." + ] + }, + { + "id": "multiclinsum_test_2819_en.txt", + "fulltext": "A female in her late 20s was initially diagnosed with neurofibromatosis type 1 in childhood. There was a known inheritance pattern in the patient’s family, and she carried a pathogenic germline heterozygous NF1-mutation at c.6494 C > G, p.(Ser2165*). Clinically, she presented with café au-lait spots, fold lentiges, and multiple subcutaneous tumors. Besides the classical presentation of neurofibromatosis and menstrual pain attributed to the two uterine leiomyomas, the patient was previously healthy. She had been clinically followed up for NF1 up to the age of 18 years, but these follow-ups had ceased.\nThe patient was referred to our hospital for multiple painful subcutaneous tumors, the largest of which was in the inner thigh, measuring up to 4 cm. Surgery was scheduled for the removal of the lesions. During the surgery, while under general anesthesia, she experienced a high systolic blood pressure of up to 200 mmHg and wide-complex tachycardia of up to 150 beats per minute. Skin erythema was also observed. Anesthesia was intensified and the symptoms subsided. Surgery was completed as planned, and 12 tumors were subjected to pathological examination. These were diagnosed as benign conventional neurofibromas according to World Health Organization (WHO) criteria .\nAfter the surgery, she underwent cardiac MRI, where no structural abnormalities were found. However, there was a large heterogeneous mass, which in the subsequent abdominal MRI was confirmed to be a left adrenal mass measuring 7.4 × 6.3 × 4.4 centimeters. Hormonal testing revealed elevated metanephrine (1.2 nmol/L) and normetanephrine (18.0 nmol/L) levels, raising suspicion of pheochromocytoma. The patient was started on phenoxybenzamine and surgery was scheduled. Preoperative abdominal computed tomography revealed a 6 × 3 × 2.7 cm cystic and solid tumor within the right gluteus minimus muscle. Retrospectively, according to abdominal CT, this tumor had existed already 7 months before, with no growth in this time. Open surgery for the adrenal tumor was commenced, and the left adrenal gland containing the tumor was removed. The tumor was interpreted by a pathologist as a pheochromocytoma according to the WHO criteria .\nOtherwise uneventful post-surgery recovery was hindered by the Covid-19-infection, during which thoracic radiography was performed. This revealed a 1,4 cm diameter left upper lobe tumor, which was confirmed by pulmonary CT. These findings were followed by 68Ga-DOTANOC PET-CT, which showed above-background uptake in both lung (SUVmax 6,2) and gluteal (SUVmax 5,0) tumors. The gluteal tumor was radiologically suspected to be a neurofibroma or malignant peripheral nerve sheath tumor, and core needle biopsy was performed. Core needle biopsy was difficult to interpret, but the pathologist suspected a high-grade sarcoma. The final diagnosis was not obtained from the biopsy. Biopsy findings prompted clinicians to suspect lung metastasis. Subsequently, the gluteal tumor was surgically resected, and a right upper lung lobectomy was performed separately. Postoperative recovery was uneventful, and the patient underwent hysterectomy for histopathologically confirmed leiomyomas. The patient is disease-free after 15 months after diagnosis.\nThe cut surface of the adrenal tumor showed a well-circumscribed hemorrhagic tumor. The adrenal tumor is composed of plump epithelioid cells with an abundant eosinophilic cytoplasm and nested “Zellballen” growth pattern. The nuclei showed moderate variation in size, clumped chromatin, and small conspicuous nucleoli. Marked intratumoral hemorrhage was observed. The tumor cells stained positive for chromogranin and synaptophysin and weakly and heterogeneously stained with S100. In addition, occasional S100 positive sustentacular cells were identified, rimming the tumor cell nests .\nThe intragluteal tumor was well circumscribed and had a fibrous pseudocapsule. The cut surface revealed a gray-tan tumor with small cystic spaces. Histological examination revealed a predominantly solid tumor with frequent cystic growth. The tumor was composed of partly spindly hyperchromatic mononuclear cells with abundant eosinophilic cytoplasms. Large pleomorphic and multinucleated cells rimmed cystic spaces. Variable numbers of lymphocytes and histiocytic cells were observed intermixed with the tumor cells, and focal aggregates of foam cell histiocytes were also observed at the edge of the tumor. No tumor necrosis was observed. The tumor was completely resected with < 0,1 cm marginal resection margins without the accompanying fascia .\nTumor cells were strongly and diffusely positive for desmin and patchy positivity for SMA was seen. The core needle biopsy sample showed weak MyoD1 positivity in scattered cells; however, the surgical sample was completely negative for MyoD1 despite repeated staining from another block. This discrepancy may be due to inadequate fixation. The large multinucleated cells palisading around the cystic spaces were strongly and diffusely positive for p53, whereas the cells in the solid areas showed a wild-type expression pattern. CD68 and CD163 showed an abundant population of histiocytic cells intermixed with tumor cells . Ki-67 was low at 5%. Mitotic figures were inconspicuous in 2/50 high-power fields (11,8 mm2) at 40x magnification. All other markers, including S100, pancytokeratin, caldesmon, pancytokeratin AE1/AE3, ALK-1, SMMHC, calponin, MUC4, GFAP, SOX10, Melan A, and HMB45, were negative. H3K27me3 showed normal nuclear expression. Thus, an inflammatory rhabdoid tumor was diagnosed according to WHO criteria .\nThe IRMT was subjected to further diagnostic analyses. RNA was extracted from paraffin slides, and a sequencing library was constructed using the Archer FusionPlex Sarcoma v2 and Archer FusionPlex CTL panels. The panels identified both novel and unknown fusions with 63 and 17 predetermined genes, respectively. The final libraries were sequenced using Ion Torrent semiconductor sequencing. The Archer Analysis software was used to interpret the results. No gene fusions were detected.\nComparative genomic hybridization was performed using the OGT Consortium Cancer + SNP 180k microarray. The relative copy number changes were read using a laser scanner and analyzed using Cytosure Interpret-software (Hg 19). This result showed 30–40% of the cells had a hyperhaploid karyotype, with chromosomes 5, 20, and 22 having a relatively higher copy number corresponding to a normal disomic karyotype .\nThe lung tumor was well-circumscribed and histologically composed of nodular aggregates of epithelioid to stellated cells within the basophilic myxoid stroma. Entrapped non-atypical respiratory epithelial cells were frequently observed between the nodules. Occasional intermixed mature adipocytes were also observed. No mature terminally differentiated chondroid component was observed in this case. Immunohistochemical findings showed that the stellate cells were strongly and diffusely S100-positive, supporting their chondroid background. Pancytokeratin AE1/AE3, CD34, and EMA were negative. Occasional scattered cells showing smooth muscle differentiation (SMA + and desmin+) were observed among the stellate cells. Ki67 proliferation was very low < 1–2%. The entrapped epithelial strands showed strong positivity for TTF1 and scattered p63-positivity. Pulmonary hamartoma was diagnosed according to the WHO criteria .", + "fulltext_subclaims": [ + "The patient was a female in her late 20s.", + "She was initially diagnosed with neurofibromatosis type 1 in childhood.", + "She carried a pathogenic germline heterozygous NF1-mutation at c.6494 C > G, p.(Ser2165*).", + "Clinically, she presented with café au-lait spots.", + "She had multiple subcutaneous tumors.", + "She had two uterine leiomyomas.", + "She had ceased clinical follow-ups for NF1 after the age of 18 years.", + "She was referred for multiple painful subcutaneous tumors.", + "The largest subcutaneous tumor was in the inner thigh, measuring up to 4 cm.", + "Surgery was scheduled for the removal of the lesions.", + "During surgery, she experienced a high systolic blood pressure of up to 200 mmHg.", + "She had wide-complex tachycardia of up to 150 beats per minute.", + "Skin erythema was observed.", + "Anesthesia was intensified and the symptoms subsided.", + "Surgery was completed as planned.", + "Twelve tumors were subjected to pathological examination.", + "The tumors were diagnosed as benign conventional neurofibromas according to WHO criteria.", + "After surgery, she underwent cardiac MRI.", + "No structural abnormalities were found on cardiac MRI.", + "A large heterogeneous mass was found on abdominal MRI.", + "The mass was confirmed to be a left adrenal mass measuring 7.4 × 6.3 × 4.4 centimeters.", + "Hormonal testing revealed elevated metanephrine (1.2 nmol/L) and normetanephrine (18.0 nmol/L) levels.", + "The adrenal mass raised suspicion of pheochromocytoma.", + "The patient was started on phenoxybenzamine.", + "Preoperative abdominal CT revealed a 6 × 3 × 2.7 cm cystic and solid tumor within the right gluteus minimus muscle.", + "The gluteal tumor had existed already 7 months before, with no growth in this time.", + "The left adrenal gland containing the tumor was removed.", + "The adrenal tumor was interpreted as a pheochromocytoma according to WHO criteria.", + "Thoracic radiography revealed a 1.4 cm diameter left upper lobe tumor.", + "The lung tumor was confirmed by pulmonary CT.", + "68Ga-DOTANOC PET-CT showed above-background uptake in both lung (SUVmax 6.2) and gluteal (SUVmax 5.0) tumors.", + "The gluteal tumor was radiologically suspected to be a neurofibroma or malignant peripheral nerve sheath tumor.", + "Core needle biopsy was performed.", + "The core needle biopsy was difficult to interpret.", + "The pathologist suspected a high-grade sarcoma.", + "The final diagnosis was not obtained from the biopsy.", + "Biopsy findings prompted clinicians to suspect lung metastasis.", + "The gluteal tumor was surgically resected.", + "A right upper lung lobectomy was performed separately.", + "The patient underwent hysterectomy for histopathologically confirmed leiomyomas.", + "The patient is disease-free after 15 months after diagnosis.", + "The cut surface of the adrenal tumor showed a well-circumscribed hemorrhagic tumor.", + "The adrenal tumor is composed of plump epithelioid cells with an abundant eosinophilic cytoplasm.", + "The tumor cells showed a nested “Zellballen” growth pattern.", + "The nuclei showed moderate variation in size, clumped chromatin, and small conspicuous nucleoli.", + "Marked intratumoral hemorrhage was observed.", + "The tumor cells stained positive for chromogranin and synaptophysin.", + "The tumor cells weakly and heterogeneously stained with S100.", + "Occasional S100 positive sustentacular cells were identified, rimming the tumor cell nests.", + "The intragluteal tumor was well circumscribed and had a fibrous pseudocapsule.", + "The cut surface revealed a gray-tan tumor with small cystic spaces.", + "Histological examination revealed a predominantly solid tumor with frequent cystic growth.", + "The tumor was composed of partly spindly hyperchromatic mononuclear cells with abundant eosinophilic cytoplasms.", + "Large pleomorphic and multinucleated cells rimmed cystic spaces.", + "Variable numbers of lymphocytes and histiocytic cells were observed intermixed with the tumor cells.", + "Focal aggregates of foam cell histiocytes were also observed at the edge of the tumor.", + "No tumor necrosis was observed.", + "The tumor was completely resected with < 0.1 cm marginal resection margins.", + "Tumor cells were strongly and diffusely positive for desmin.", + "Patchy positivity for SMA was seen.", + "The core needle biopsy sample showed weak MyoD1 positivity in scattered cells.", + "The surgical sample was completely negative for MyoD1 despite repeated staining from another block.", + "This discrepancy may be due to inadequate fixation.", + "The large multinucleated cells palisading around the cystic spaces were strongly and diffusely positive for p53.", + "The cells in the solid areas showed a wild-type expression pattern.", + "CD68 and CD163 showed an abundant population of histiocytic cells intermixed with tumor cells.", + "Ki-67 was low at 5%.", + "Mitotic figures were inconspicuous in 2/50 high-power fields.", + "All other markers, including S100, pancytokeratin, caldesmon, pancytokeratin AE1/AE3, ALK-1, SMMHC, calponin, MUC4, GFAP, SOX10, Melan A, and HMB45, were negative.", + "H3K27me3 showed normal nuclear expression.", + "An inflammatory rhabdoid tumor was diagnosed according to WHO criteria.", + "RNA was extracted from paraffin slides.", + "A sequencing library was constructed using the Archer FusionPlex Sarcoma v2 and Archer FusionPlex CTL panels.", + "The panels identified both novel and unknown fusions with 63 and 17 predetermined genes, respectively.", + "The final libraries were sequenced using Ion Torrent semiconductor sequencing.", + "The Archer Analysis software was used to interpret the results.", + "No gene fusions were detected.", + "Comparative genomic hybridization was performed using the OGT Consortium Cancer + SNP 180k microarray.", + "The relative copy number changes were read using a laser scanner.", + "The result showed 30–40% of the cells had a hyperhaploid karyotype.", + "Chromosomes 5, 20, and 22 had a relatively higher copy number corresponding to a normal disomic karyotype.", + "The lung tumor was well-circumscribed.", + "The lung tumor was histologically composed of nodular aggregates of epithelioid to stellated cells within the basophilic myxoid stroma.", + "Entrapped non-atypical respiratory epithelial cells were frequently observed between the nodules.", + "Occasional intermixed mature adipocytes were also observed.", + "No mature terminally differentiated chondroid component was observed.", + "Immunohistochemical findings showed that the stellate cells were strongly and diffusely S100-positive.", + "Pancytokeratin AE1/AE3, CD34, and EMA were negative.", + "Occasional scattered cells showing smooth muscle differentiation (SMA + and desmin+) were observed among the stellate cells.", + "Ki67 proliferation was very low < 1–2%.", + "The entrapped epithelial strands showed strong positivity for TTF1.", + "Pulmonary hamartoma was diagnosed according to WHO criteria." + ], + "summary": "A female patient in her late 20s with known NF1 was diagnosed with an inflammatory rhabdomyoblastic tumor, pheochromocytoma, and pulmonary hamartoma in a short succession. IRMT was found to harbor a near-haploid genome and displayed a typical immunohistochemical profile as well as a focal aberrant p53 expression pattern.", + "summary_subclaims": [ + "The patient is a female in her late 20s.", + "The patient has known NF1.", + "The patient was diagnosed with an inflammatory rhabdomyoblastic tumor.", + "The patient was diagnosed with pheochromocytoma.", + "The patient was diagnosed with pulmonary hamartoma.", + "The diagnoses occurred in a short succession.", + "The IRMT was found to harbor a near-haploid genome.", + "The IRMT displayed a typical immunohistochemical profile.", + "The IRMT displayed a focal aberrant p53 expression pattern." + ] + }, + { + "id": "multiclinsum_test_2996_en.txt", + "fulltext": "An 84-year-old male patient (163 cm in height, 41 kg in weight) presenting with esophageal cancer was administered with radiotherapy and chemotherapy 11 years prior, after which he got better.\nIn December 2020, the patient was diagnosed with advanced esophageal squamous cell carcinoma with liver metastasis, classified as stage TxN1M1. Based on the 2020 Chinese Society of Clinical Oncology guidelines, the patient was administered the first immunotherapeutic (camrelizumab 200 mg/each time + 0.9% NS 100 mL, intravenous infusion, q3w) and did not exhibit any adverse reactions. On January 12, 2021, the patient was admitted to the hospital for the second time to be administered the same therapy. On January 19, 2021, the patient was introduced to intravenous infusions of camrelizumab. However, 10 min after initiating intravenous camrelizumab, he suddenly developed a generalized rash in the chest and upper limbs. He also experienced chest tightness without chest pain, palpitations, and breathing difficulties with a sense of dying.\nThe patient had a previous medical history free of allergy.\nThe patient had no significant personal or family history.\nElectrocardiograph (ECG) monitoring revealed a pulse rate of 70 beats/min, blood pressure of 69/24 mmHg, a respiratory rate of 28 breaths/min, and a pulse oximetry of 86% in room air (no other medication was administered concomitantly). The patient presented with drowsiness and weakened cardiac sounds as well as a weak major arterial pulse.\nBlood analysis revealed white blood cell count of 7.04 × 109/L, neutrophil count of 2.81 × 109/L (normal range: 2.0-7.5 × 109/L), neutrophil percentage of 39.90%, red blood cell count of 2.35 × 1012/L, hemoglobin level of 66.00 g/L (normal range: 110-160 g/L), platelet count of 219.00 × 109/L (normal range: 100-300 × 109/L), C-reactive protein level of 31.61 mg/L (normal range: < 0.5 mg/L), potassium level of 2.12 mmol/L (normal range: 3.5-5.0 mmol/L), chloride level of 117.80 mmol/L (normal range: 96-108 mmol/L), and calcium level of 1.41 mmol/L (normal range: 2.0-2.6 mmol/L). Markers of renal function and levels of cardiac enzyme and troponin were normal.\nECG revealed a sinus rhythm. Enhanced computed tomography scan revealed chronic inflammation of the right lower lobe with left-side pleural slight effusion .", + "fulltext_subclaims": [ + "The patient is an 84-year-old male.", + "The patient's height is 163 cm.", + "The patient's weight is 41 kg.", + "The patient was diagnosed with esophageal cancer.", + "The patient was administered radiotherapy and chemotherapy 11 years prior.", + "The patient got better after radiotherapy and chemotherapy.", + "In December 2020, the patient was diagnosed with advanced esophageal squamous cell carcinoma with liver metastasis.", + "The patient's cancer was classified as stage TxN1M1.", + "Based on the 2020 Chinese Society of Clinical Oncology guidelines, the patient was administered the first immunotherapeutic.", + "The first immunotherapeutic was camrelizumab 200 mg/each time + 0.9% NS 100 mL, intravenous infusion, q3w.", + "The patient did not exhibit any adverse reactions to the first immunotherapeutic.", + "On January 12, 2021, the patient was admitted to the hospital for the second time to be administered the same therapy.", + "On January 19, 2021, the patient was introduced to intravenous infusions of camrelizumab.", + "10 min after initiating intravenous camrelizumab, the patient suddenly developed a generalized rash in the chest and upper limbs.", + "The patient experienced chest tightness without chest pain.", + "The patient experienced palpitations.", + "The patient experienced breathing difficulties with a sense of dying.", + "The patient had a previous medical history free of allergy.", + "The patient had no significant personal or family history.", + "ECG monitoring revealed a pulse rate of 70 beats/min.", + "ECG monitoring revealed a blood pressure of 69/24 mmHg.", + "ECG monitoring revealed a respiratory rate of 28 breaths/min.", + "ECG monitoring revealed a pulse oximetry of 86% in room air.", + "The patient presented with drowsiness.", + "The patient presented with weakened cardiac sounds.", + "The patient presented with a weak major arterial pulse.", + "Blood analysis revealed white blood cell count of 7.04 × 109/L.", + "Blood analysis revealed neutrophil count of 2.81 × 109/L.", + "Blood analysis revealed neutrophil percentage of 39.90%.", + "Blood analysis revealed red blood cell count of 2.35 × 1012/L.", + "Blood analysis revealed hemoglobin level of 66.00 g/L.", + "Blood analysis revealed platelet count of 219.00 × 109/L.", + "Blood analysis revealed C-reactive protein level of 31.61 mg/L.", + "Blood analysis revealed potassium level of 2.12 mmol/L.", + "Blood analysis revealed chloride level of 117.80 mmol/L.", + "Blood analysis revealed calcium level of 1.41 mmol/L.", + "ECG revealed a sinus rhythm.", + "Enhanced computed tomography scan revealed chronic inflammation of the right lower lobe.", + "Enhanced computed tomography scan revealed left-side pleural slight effusion." + ], + "summary": "An 84-year-old male esophageal cancer patient received radiotherapy and chemotherapy 11 years ago. He was diagnosed with advanced esophageal squamous cell carcinoma with liver metastasis (TxN1M1) and received the first immunotherapy (camrelizumab 200 mg/each time, once every 3 wk) dose in December 2020, with no adverse reactions. Three weeks later, a generalized rash was noted on the chest and upper limbs; palpitations and breathing difficulties with a sense of dying occurred 10 min after the patient had been administered with the second camrelizumab therapy. Electrocardiograph monitoring revealed a 70 beats/min pulse rate, 69/24 mmHg (1 mmHg = 0.133 kPa) blood pressure, 28 breaths/min respiratory rate, and 86% pulse oximetry in room air. The patient was diagnosed with anaphylactic shock and was managed with intravenous fluid, adrenaline, dexamethasone sodium phosphate, calcium glucosate, and noradrenaline. Approximately 2 h after treatment, the patient's anaphylactic shock symptoms had been completely relieved.", + "summary_subclaims": [ + "The patient is an 84-year-old male.", + "The patient has esophageal cancer.", + "The patient received radiotherapy and chemotherapy 11 years ago.", + "The patient was diagnosed with advanced esophageal squamous cell carcinoma.", + "The patient had liver metastasis.", + "The patient's cancer stage was TxN1M1.", + "The patient received the first immunotherapy dose in December 2020.", + "The first immunotherapy was camrelizumab 200 mg.", + "The first immunotherapy was administered once every 3 wk.", + "The patient had no adverse reactions after the first immunotherapy dose.", + "A generalized rash was noted on the chest and upper limbs after the second camrelizumab therapy.", + "Palpitations occurred 10 min after the second camrelizumab therapy.", + "Breathing difficulties occurred 10 min after the second camrelizumab therapy.", + "The patient had a sense of dying 10 min after the second camrelizumab therapy.", + "Electrocardiograph monitoring showed a 70 beats/min pulse rate.", + "Electrocardiograph monitoring showed 69/24 mmHg blood pressure.", + "Electrocardiograph monitoring showed 28 breaths/min respiratory rate.", + "Electrocardiograph monitoring showed 86% pulse oximetry in room air.", + "The patient was diagnosed with anaphylactic shock.", + "The patient was managed with intravenous fluid.", + "The patient was managed with adrenaline.", + "The patient was managed with dexamethasone sodium phosphate.", + "The patient was managed with calcium glucosate.", + "The patient was managed with noradrenaline.", + "Approximately 2 h after treatment, the patient's anaphylactic shock symptoms had been completely relieved." + ] + }, + { + "id": "multiclinsum_test_563_en.txt", + "fulltext": "The patient was a 55-year-old and was referred to our practice for anal cancer screening.\nThe patient had no known history of present illness.\nThe patient has been living with human immunodeficiency virus (HIV) for 17 years.\nHe had no gastrointestinal or anorectal symptoms and his physical examination was positive only for a three millimeter, smooth, flesh colored papule at the anal margin .\nHis cluster of differentiation 4 (CD4) count was 2200 cells/mm3, with a nadir of 1300 cells/mm3. His HIV viral load was undetectable. Anal cytology collected at this visit was benign.\nDigital anorectal examination and high resolution anoscopy (HRA) were otherwise normal.\nThe differential diagnosis included molluscum contagiosum, anal condyloma, and basal cell carcinoma. To obtain a definitive diagnosis, the anal margin lesion was excised in the office, using local anesthetic.\nUpon examination of the specimen, the lab determined the patient had EA.", + "fulltext_subclaims": [ + "The patient was a 55-year-old and was referred to our practice for anal cancer screening.", + "The patient had no known history of present illness.", + "The patient has been living with human immunodeficiency virus (HIV) for 17 years.", + "He had no gastrointestinal or anorectal symptoms.", + "His physical examination was positive only for a three millimeter, smooth, flesh colored papule at the anal margin.", + "His cluster of differentiation 4 (CD4) count was 2200 cells/mm3.", + "His HIV viral load was undetectable.", + "Anal cytology collected at this visit was benign.", + "Digital anorectal examination and high resolution anoscopy (HRA) were otherwise normal.", + "The differential diagnosis included molluscum contagiosum, anal condyloma, and basal cell carcinoma.", + "The anal margin lesion was excised in the office, using local anesthetic.", + "Upon examination of the specimen, the lab determined the patient had EA." + ], + "summary": "A 55-year-old man living with human immunodeficiency virus presented for anal cancer screening. His physical examination revealed a flesh colored papule at the anal margin. The initial differential diagnosis included molluscum contagiosum, anal condyloma, and basal cell carcinoma. The lesion was excised to obtain a definitive diagnosis and was discovered to be EA.", + "summary_subclaims": [ + "The patient is a 55-year-old man.", + "The patient lives with human immunodeficiency virus.", + "The patient presented for anal cancer screening.", + "The physical examination revealed a flesh colored papule at the anal margin.", + "The initial differential diagnosis included molluscum contagiosum.", + "The initial differential diagnosis included anal condyloma.", + "The initial differential diagnosis included basal cell carcinoma.", + "The lesion was excised to obtain a definitive diagnosis.", + "The lesion was discovered to be EA." + ] + }, + { + "id": "multiclinsum_test_2209_en.txt", + "fulltext": "We present the case of a female patient, 60 years old, which was admitted in May 2019, in the Dermatological Clinic of Emergency Hospital of Craiova after the onset of a new episode, consisting in the appearance of violaceous erythematous-oedematous infiltrated plaques, located on the face, neck, upper limbs , trunk and knees .\nThe onset of the cutaneous manifestations had occurred 2 months prior this presentation, accompanied by pain, chills, flares of fever and arthralgia.\nA written informed consent of the patient was obtained, agreeing with publishing these data.\nPersonal medical history: Umbilical hernia, treated by surgery 2 months prior.\nRelevant behavior: does not smoke, does not drink alcohol.\nAnalysis of the case history revealed that the patient was first diagnosed with Sweet syndrome in 2014, during the hospitalization in another clinic. Based on the case history available from the patient, the results of the histopathological examination of the skin lesions at the time of initial diagnosis described:\n-polymorphous inflammatory infiltrate, relatively dense, located at the level of the superficial and middle reticular dermis, comprised of neutrophils and neutrophilic nuclear dust, intricated with mononuclear cells with immature appearance, lymphocytes, and some eosinophils;\n-inflammatory infiltrate with lymphocytes and some eosinophils with superficial perivascular location;\n-important oedema at the level of the papillary dermis.\nAt that moment, in 2014, immunohistochemistry was also performed on the surgical specimen, resulting data showing: CD3-positive frequent small lymphocytes, CD20-positive rare small lymphocytes, CD30-negative infiltrate, CD-68 positive histiocytes and mononuclear histiocytoid cells, MPO-positive segmented granulocytes and mononuclear histiocytoid cells (immature granulocytes), and CD33-positive segmented and immature granulocytes.\nBased on the clinical, histopathological, and immunohistochemical profile, the diagnosis of histiocytoid Sweet syndrome was made.\nShe followed a treatment with 32mg/day methylprednisolone, with positive response, but had many relapses after the discontinuation of the treatment.\nIn 2017, due to a new episode, the histopathological examination was repeated and revealed the following features: tegument fragment showing minimal surface parakeratosis, marked inflammatory lymphoplasmacytic infiltrate with a large number of perivascular neutrophils and areas of leukocytoclasis with periadnexal and interstitial location in the reticular and deep dermis, dilated blood vessels lined by endothelial cells with intraluminal bulging.\nShe received treatment with Disulone (which she did not tolerate) and Colchicine. She had not been administered any treatment throughout the previous year.\nThe onset of the current episode (2019) occurred following the treatment she received for umbilical hernia.\nAt clinical examination, we noticed a phototype II, normal weight female patient, having pains and crackling in the joints of knees and fingers on both hands.\nLaboratory blood tests showed: leukocytes 12.5x1000/microL, neutrophils 72,5%, ESR (erythrocyte sedimentation rate) 32mm/1h, HBsAg negative, Anti-HCV antibodies-negativ, anti-Ro and anti-La antibodies-normal; complements C3 1.55g/L normal and C4 57mg/dl (10-40) elevated, anti-DNA antibody 5.4UI/ml (<25), CIC (circulating immune complexes) <2U/ml (2-20), glycaemia 111mg/dL (65-110), GOT 12UI/l, GPT 17UI/L, GGT 34UI/L (7-32), CK (creatin kinase) 38U/L (<145U/L), FR (rheumatoid factor) 8.2IU/ml (<14IU/ml).\nUrinalysis findings: relatively frequent flat epithelial cells, relatively frequent leukocytes.\nFaecal parasitology findings: normal.\nChest X-ray: heart within limits, without progressing pleural-pulmonary lesions.\nUltrasound examination of the abdomen and pelvis regions revealed liver with steatosis, left lobe measuring 71mm, right lobe 152mm.\nGallbladder reduces in size, two hyperechogenic images measuring 9 and 6mm respectively, suggesting the presence of stones, VP 7mm, main biliary duct 3mm, pancreas with infiltrate. Homogenous spleen, measuring 100mm along the long axis. Kidneys with normal size, without dilatations. Urinary bladder with soft walls. Uterus measuring approximately 46/38mm, homogenous structure, without fluid in the peritoneal cavity.\nUnder local anesthesia induces by 1% Lidocaine biopsies were performed from representative lesions located on the forearm and right arm.\nThe surgical specimen was fixed in 10% buffered formalin, processed for routinely paraffin embedding, sectioning and Hematoxylin-Eosin (HE) staining) in the Pathology Department of the same hospital.\nThe histopathological examination showed:\n-abundant lymphoid cells, rare eosinophils and PMN with leukocytoclasis ,\n-inflammatory infiltrate in the dermis around the capillaries with turgescent endothelial cells .\n-tegument with orthokeratosis and inflammatory infiltrate in the dermis .\nBased on the case history, on the objective clinical examination, and on the histopathological and immunohistochemical findings the diagnosis of was supported.\nWe initiated the treatment with 32mg methylprednisolone 1 tablet/day in the morning, topical Clobetasol ointment, 10mg Rupatadine-1 tablet/morning, 1mg Ketotifen-1 tablet/evening, with positive response.", + "fulltext_subclaims": [ + "The patient is a 60-year-old female.", + "She was admitted in May 2019 to the Dermatological Clinic of Emergency Hospital of Craiova.", + "She had violaceous erythematous-oedematous infiltrated plaques on the face, neck, upper limbs, trunk, and knees.", + "The onset of the cutaneous manifestations had occurred 2 months prior to this presentation.", + "The cutaneous manifestations were accompanied by pain, chills, flares of fever, and arthralgia.", + "A written informed consent of the patient was obtained, agreeing with publishing these data.", + "Personal medical history included umbilical hernia, treated by surgery 2 months prior.", + "She does not smoke.", + "She does not drink alcohol.", + "In 2014, she was diagnosed with Sweet syndrome.", + "The histopathological examination in 2014 showed polymorphous inflammatory infiltrate in the superficial and middle reticular dermis.", + "The infiltrate was comprised of neutrophils and neutrophilic nuclear dust, intricated with mononuclear cells with immature appearance, lymphocytes, and some eosinophils.", + "The histopathological examination in 2014 showed important oedema at the level of the papillary dermis.", + "Immunohistochemistry in 2014 showed CD3-positive frequent small lymphocytes.", + "Immunohistochemistry in 2014 showed CD20-positive rare small lymphocytes.", + "Immunohistochemistry in 2014 showed CD30-negative infiltrate.", + "Immunohistochemistry in 2014 showed CD-68 positive histiocytes and mononuclear histiocytoid cells.", + "Immunohistochemistry in 2014 showed MPO-positive segmented granulocytes and mononuclear histiocytoid cells.", + "Immunohistochemistry in 2014 showed CD33-positive segmented and immature granulocytes.", + "The diagnosis of histiocytoid Sweet syndrome was made.", + "She received treatment with 32mg/day methylprednisolone.", + "She had many relapses after the discontinuation of the treatment.", + "In 2017, due to a new episode, the histopathological examination was repeated.", + "The histopathological examination in 2017 revealed a tegument fragment showing minimal surface parakeratosis.", + "The histopathological examination in 2017 showed marked inflammatory lymphoplasmacytic infiltrate with a large number of perivascular neutrophils.", + "The histopathological examination in 2017 showed areas of leukocytoclasis with periadnexal and interstitial location in the reticular and deep dermis.", + "The histopathological examination in 2017 showed dilated blood vessels lined by endothelial cells with intraluminal bulging.", + "She received treatment with Disulone.", + "She did not tolerate Disulone.", + "She received treatment with Colchicine.", + "She had not been administered any treatment throughout the previous year.", + "The onset of the current episode occurred following the treatment she received for umbilical hernia.", + "At clinical examination, she had pains and crackling in the joints of knees and fingers on both hands.", + "Laboratory blood tests showed leukocytes 12.5x1000/microL.", + "Laboratory blood tests showed neutrophils 72.5%.", + "Laboratory blood tests showed ESR 32mm/1h.", + "Laboratory blood tests showed HBsAg negative.", + "Laboratory blood tests showed Anti-HCV antibodies negative.", + "Laboratory blood tests showed anti-Ro and anti-La antibodies normal.", + "Laboratory blood tests showed complements C3 1.55g/L normal.", + "Laboratory blood tests showed complements C4 57mg/dl elevated.", + "Laboratory blood tests showed anti-DNA antibody 5.4UI/ml.", + "Laboratory blood tests showed CIC <2U/ml.", + "Laboratory blood tests showed glycaemia 111mg/dL.", + "Laboratory blood tests showed GOT 12UI/l.", + "Laboratory blood tests showed GPT 17UI/L.", + "Laboratory blood tests showed GGT 34UI/L.", + "Laboratory blood tests showed CK 38U/L.", + "Laboratory blood tests showed FR 8.2IU/ml.", + "Urinalysis findings showed relatively frequent flat epithelial cells.", + "Urinalysis findings showed relatively frequent leukocytes.", + "Faecal parasitology findings were normal.", + "Chest X-ray showed heart within limits.", + "Chest X-ray showed no progressing pleural-pulmonary lesions.", + "Ultrasound examination showed liver with steatosis.", + "Ultrasound examination showed left lobe measuring 71mm.", + "Ultrasound examination showed right lobe 152mm.", + "Ultrasound examination showed gallbladder reducing in size.", + "Ultrasound examination showed two hyperechogenic images measuring 9 and 6mm, suggesting the presence of stones.", + "Ultrasound examination showed VP 7mm.", + "Ultrasound examination showed main biliary duct 3mm.", + "Ultrasound examination showed pancreas with infiltrate.", + "Ultrasound examination showed homogenous spleen measuring 100mm along the long axis.", + "Ultrasound examination showed kidneys with normal size.", + "Ultrasound examination showed no dilatations.", + "Ultrasound examination showed urinary bladder with soft walls.", + "Ultrasound examination showed uterus measuring approximately 46/38mm.", + "Ultrasound examination showed homogenous structure.", + "Ultrasound examination showed no fluid in the peritoneal cavity.", + "Biopsies were performed from representative lesions located on the forearm and right arm.", + "The surgical specimen was fixed in 10% buffered formalin.", + "The surgical specimen was processed for routinely paraffin embedding.", + "The surgical specimen was sectioned and stained with Hematoxylin-Eosin (HE).", + "The histopathological examination showed abundant lymphoid cells.", + "The histopathological examination showed rare eosinophils.", + "The histopathological examination showed PMN with leukocytoclasis.", + "The histopathological examination showed inflammatory infiltrate in the dermis around the capillaries.", + "The histopathological examination showed turgescent endothelial cells.", + "The histopathological examination showed tegument with orthokeratosis.", + "The histopathological examination showed inflammatory infiltrate in the dermis.", + "The diagnosis was supported based on the case history, objective clinical examination, and histopathological and immunohistochemical findings.", + "Treatment was initiated with 32mg methylprednisolone 1 tablet/day in the morning.", + "Treatment included topical Clobetasol ointment.", + "Treatment included 10mg Rupatadine-1 tablet/morning.", + "Treatment included 1mg Ketotifen-1 tablet/evening.", + "The treatment had a positive response." + ], + "summary": "A female patient, 60 years old, attended the Dermatology Clinic due to the appearance of violaceous erythematous-oedematous infiltrated plaques, located on the face, neck, upper limbs, trunk and knees. The onset of the cutaneous manifestation had occurred 2 months prior, accompanied by pain, chills, flares of fever and arthralgia. The onset coincided with the surgical treatment of an umbilical hernia. From the medical history we note that the patient was diagnosed in 2014 with histiocytoid SS. She followed a treatment with methylprednisolone, with positive response, but had many relapses after the discontinuation of treatment. In 2017, due to a new episode, the histopathological examination was repeated, which revealed classical SS. She received treatment with Disulone and Colchicine. She had not been administered any treatment throughout the previous year. Laboratory tests revealed leukocytosis with neutrophils, increased ESR, elevated C4, hyperglycemia. The current histopathological examination revealed lymphocytic SS. Under treatment with methylprednisolone 32mg/day, the evolution was favorable.", + "summary_subclaims": [ + "A female patient, 60 years old, attended the Dermatology Clinic.", + "The patient had violaceous erythematous-oedematous infiltrated plaques located on the face, neck, upper limbs, trunk and knees.", + "The onset of the cutaneous manifestation had occurred 2 months prior.", + "The onset coincided with the surgical treatment of an umbilical hernia.", + "The patient was diagnosed in 2014 with histiocytoid SS.", + "She followed a treatment with methylprednisolone.", + "The histopathological examination in 2017 revealed classical SS.", + "She received treatment with Disulone and Colchicine.", + "She had not been administered any treatment throughout the previous year.", + "Laboratory tests revealed leukocytosis with neutrophils.", + "The ESR was increased.", + "C4 was elevated.", + "The current histopathological examination revealed lymphocytic SS.", + "Under treatment with methylprednisolone 32mg/day, the evolution was favorable." + ] + }, + { + "id": "multiclinsum_test_1397_en.txt", + "fulltext": "A 61-year-old man was injured when his penis slipped out of his wife's vagina during penovaginal intercourse with penetration from behind (“doggy style”). His physician treated the penile swelling with hemostatic agents, but his symptoms worsened. When he presented to our institution, 13 hours had passed. Physical examination showed a swollen penis with an “eggplant” deformity caused by a hematoma on the distal ventral surface of the penis; he also had gross hematuria visible at the external urethral orifice . His past medical history was significant for benign prostatic hyperplasia, for which he was taking tadalafil.\nWe ordered an immediate MRI; T2-weighted imaging revealed an isolated tear of the ventral tunica albuginea of the CS . We diagnosed a rupture of the CS with urethral injury and proceeded to the operating room. A 5-cm transverse incision of the epidermis just above the subcutaneous hematoma allowed us to remove as much blood and clot as possible. A 2-cm longitudinal injury of the tunica albuginea of the CS was visible, and the anterior urethra was ruptured; a 14-Fr urethral catheter was visible through the defect in the urethra . We repaired the tunica albuginea of the CS and the urethral mucosa using interrupted 3–0 and 4–0 absorbable sutures, respectively.\nThe patient's postoperative course was unremarkable. We removed the urinary catheter on postoperative day 8, and the patient was discharged home. On postoperative day 17, he returned for follow-up. There was no discoloration or swelling of the penile shaft, and his erectile function had returned to his pre-injury status. Cystoscopy showed no obvious urethral stenosis or injury except for residual edema .", + "fulltext_subclaims": [ + "A 61-year-old man was injured when his penis slipped out of his wife's vagina during penovaginal intercourse with penetration from behind.", + "His physician treated the penile swelling with hemostatic agents.", + "When he presented to our institution, 13 hours had passed.", + "Physical examination showed a swollen penis with an 'eggplant' deformity caused by a hematoma on the distal ventral surface of the penis.", + "He also had gross hematuria visible at the external urethral orifice.", + "His past medical history was significant for benign prostatic hyperplasia.", + "He was taking tadalafil.", + "We ordered an immediate MRI.", + "T2-weighted imaging revealed an isolated tear of the ventral tunica albuginea of the CS.", + "We diagnosed a rupture of the CS with urethral injury.", + "A 5-cm transverse incision of the epidermis just above the subcutaneous hematoma allowed us to remove as much blood and clot as possible.", + "A 2-cm longitudinal injury of the tunica albuginea of the CS was visible.", + "The anterior urethra was ruptured.", + "A 14-Fr urethral catheter was visible through the defect in the urethra.", + "We repaired the tunica albuginea of the CS and the urethral mucosa using interrupted 3–0 and 4–0 absorbable sutures, respectively.", + "The patient's postoperative course was unremarkable.", + "We removed the urinary catheter on postoperative day 8.", + "The patient was discharged home.", + "On postoperative day 17, he returned for follow-up.", + "There was no discoloration or swelling of the penile shaft.", + "His erectile function had returned to his pre-injury status.", + "Cystoscopy showed no obvious urethral stenosis or injury except for residual edema." + ], + "summary": "A 61-year-old man presented with swelling, pain, and bruising of his penis, along with gross hematuria. He reported that he sustained this injury while having sex with his wife. We suspected a penile fracture and obtained magnetic resonance imaging, which showed a rupture of the ventral corpus spongiosum and clarified the appropriate approach for repair. We used a direct transverse incision to repair both the urethral injury and the corpus spongiosum. Surgery went well, without any significant intraoperative or postoperative complications. We removed the urinary catheter on postoperative day 8, and cystoscopy showed no urethral stenosis on postoperative day 17. The patient's postoperative erectile function was the same as before his injury.", + "summary_subclaims": [ + "The patient is a 61-year-old man.", + "He presented with swelling, pain, and bruising of his penis.", + "He had gross hematuria.", + "He reported that he sustained the injury while having sex with his wife.", + "Magnetic resonance imaging showed a rupture of the ventral corpus spongiosum.", + "A direct transverse incision was used to repair both the urethral injury and the corpus spongiosum.", + "Surgery went well, without any significant intraoperative complications.", + "Surgery went well, without any significant postoperative complications.", + "The urinary catheter was removed on postoperative day 8.", + "Cystoscopy showed no urethral stenosis on postoperative day 17.", + "The patient's postoperative erectile function was the same as before his injury." + ] + }, + { + "id": "multiclinsum_test_1255_en.txt", + "fulltext": "A 30-year-old female had a 2 years history of left frontal headache unresponsive to drug therapy with common analgesics. The intensity of this symptom increased over time. Her neurological examination was normal. The magnetic resonance imaging (MRI) showed a dural-based lesion in the left frontal region; the lesion size was 1.5 cm × 3.5 cm. It was hyperintense on T2-weighted images and isointense on T1-weighted images showing intense contrast enhancement. This small mass appeared to be adherent to the dura mater with a dural tail sign . The appearance suggested a convexity meningioma.\nInitially, the patient refused surgery.\nAfter 1-year, brain control MRI showed no changes of the lesion.\nFinally, the patient decided to undergo surgery because the episodes of headaches had become more and more frequent and intense.\nA left frontal craniotomy was performed. After opening the dura, an encapsulated, red-colored tumor was exposed. The base of the implant was coagulated and the lesion was removed en-bloc without significant intraoperative bleeding.\nThe histopathological diagnosis deposed for a cavernous hemangioma of the dura mater .\nThe postoperative MRI showed no residual hemangioma .\nAt 1-year follow-up, the patient was asymptomatic without any neurologic deficit.", + "fulltext_subclaims": [ + "The patient is a 30-year-old female.", + "She had a 2 years history of left frontal headache.", + "The headache was unresponsive to drug therapy with common analgesics.", + "The intensity of the headache increased over time.", + "Her neurological examination was normal.", + "The MRI showed a dural-based lesion in the left frontal region.", + "The lesion size was 1.5 cm × 3.5 cm.", + "The lesion was hyperintense on T2-weighted images.", + "The lesion was isointense on T1-weighted images.", + "The lesion showed intense contrast enhancement.", + "The mass appeared to be adherent to the dura mater.", + "The dural tail sign was present.", + "The appearance suggested a convexity meningioma.", + "Initially, the patient refused surgery.", + "After 1-year, brain control MRI showed no changes of the lesion.", + "The patient decided to undergo surgery because the episodes of headaches had become more and more frequent and intense.", + "A left frontal craniotomy was performed.", + "After opening the dura, an encapsulated, red-colored tumor was exposed.", + "The base of the implant was coagulated.", + "The lesion was removed en-bloc without significant intraoperative bleeding.", + "The histopathological diagnosis was a cavernous hemangioma of the dura mater.", + "The postoperative MRI showed no residual hemangioma.", + "At 1-year follow-up, the patient was asymptomatic.", + "At 1-year follow-up, the patient had no neurologic deficit." + ], + "summary": "We report a case of a 30-year-old female presenting with a 2 years history of headache unresponsive to drug therapy. The magnetic resonance imaging showed a dural-based lesion in the left frontal region; the lesion size was: 1.5 cm × 3.5 cm. The appearance suggested a convexity meningioma. A left frontal craniotomy was performed, and the histopathological diagnosis deposed for a cavernous hemangioma of the dura mater. The follow-up at 1-year was good without any neurologic deficit.", + "summary_subclaims": [ + "The patient is a 30-year-old female.", + "The patient had a 2 years history of headache.", + "The headache was unresponsive to drug therapy.", + "Magnetic resonance imaging showed a dural-based lesion in the left frontal region.", + "The lesion size was 1.5 cm × 3.5 cm.", + "The appearance suggested a convexity meningioma.", + "A left frontal craniotomy was performed.", + "The histopathological diagnosis was a cavernous hemangioma of the dura mater.", + "The follow-up at 1-year was good.", + "There were no neurologic deficits at 1-year follow-up." + ] + }, + { + "id": "multiclinsum_test_2623_en.txt", + "fulltext": "A 35-year old Caucasian female with a history of multiple sclerosis and atopic diathesis (including bronchial asthma) presented for chronic respiratory discomfort to obtain a second opinion on her treatment. Furthermore, she had noted recurrent coughing that deteriorated in autumn. Prednisolone prescribed due to her allergic asthma had only insufficiently relieved symptoms. Previously, she had completed a specific immunotherapy addressing her allergy towards certain phytocomponents, and quit smoking after accumulation of 2 pack years in total. With seasonal fluctuation of symptoms, spirometry revealed stable static and dynamic respiratory flow values with slight obstruction. Asthma control testing (ACT), a patient-based questionnaire , revealed eight points at initial presentation (target range ≥ 19 points), indicating poorly controlled asthma. There were no signs of acute infection and an influenza immunization had recently been implemented.\nNext to oral contraception and seasonal antihistamines, her medication included inhalative steroids in combination with a long-acting betamimetic agent and a short-acting betamimetic nebulizer on demand. Therapy with montelukast had to be discontinued due to gastrointestinal adverse effects. Her relapsing–remitting multiple sclerosis was kept in a steady state by dimethyl fumarate (Tecfidera) and glatiramer acetate. She experienced two episodes in the past 9 years and was left with residual mild hypoesthesia, gait disturbances, and chronic fatigue.\nPhysical examination detected no pathologies in the patient, a medium-build [body mass index (BMI) 21 kg/m2] woman in good condition. Auscultation revealed vesicular respiratory sounds without rales. No cardiac murmur was audible. Her fingers did not show clubbing. Cardiac natriuretic peptides presented within normal limits. Besides hypereosinophilia (0.27 GPL/L), laboratory testing revealed a hypoxemia with an adequate response to oxygen (initial: 67 mmHg, with 3 L O2: 72 mmHg), that persisted in rest and exertion.\nDue to this blood gas analysis presenting relevant hypoxemia, further investigations were undertaken. In the meantime, daily self-assessment of peak flow values for continuous monitoring of dynamic respiratory function was recommended.\nScintigraphy was performed to rule out a ventilation perfusion deficiency. For the subjacent computed tomographic (CT) scan, contrast media was injected into the left brachial veins. Secondarily to the exclusion of pulmonary embolism, venous contrast filling suspected an additional left superior cava vein connected to the left atrium.\nThe diagnosis was confirmed by echocardiography: following the attestation of a normal biventricular function with regular sized atria and no evidence of dilatation of the coronary sinus , contrast media was applied via the left brachial veins. Recordings of the apical four chamber view demonstrated an instant and complete opacification solely of the left-sided cardiac cavities . The right atrium and ventricle were unaffected and septal structures were intact. Contrast media inflow originated from the lateral base of the left atrium . On transesophageal echocardiography (TEE), contrast enhancement commenced at the junction of the left atrial appendage and the left pulmonary veins as depicted in midesophageal pulmonary vein view . As the CT scan reconstruction visualizes , the drainage location site could be specified as being the left atrial appendage. Herein, the persistent left vena cava superior complied with type IIIb of Schummer’s classification of PLVCS, with an atypical draining into the left atrial appendage .\nFollowing the imaging modalities, cardiac catheterization was performed to assess the effect of the PLVCS on the patient’s hemodynamics. Pulmonary circulation showed normal proportions of pressure and resistance. The composition of intracardiac blood gas analyses revealed a Qp/Qs of 1.2, reflecting a hemodynamically nonrelevant right-to-left shunt, with an oxygen saturation of 69% in the PLVCS not altering the saturation of the left atrium (95%). To assess its functional impact, we complemented a spiroergometry. The patient completed the testing with a peak oxygen uptake of 23 mL/min/kg, rated as an unrestricted exercise capacity.\nFurthermore, the cerebral condition was—on account of her multiple sclerosis—frequently appraised by magnetic resonance imaging. T2-weighted sequences revealed multiple lesions of varying sizes in various cerebral compartments, mainly in white matter (frontal, mesencephalic, occipital) and cerebellar.\nThe main diagnostic concerns in the present case of an atypical draining PLVCS into the left atrial appendage were to distinguish the hypoxemia and neurologic disorders from the known bronchial asthma and multiple sclerosis.\nThe initial complaints about dyspnoea on exertion and coughing were accompanied by mild hypoxemia. After imaging revealed a PLVCS draining atypically into the left atrial appendage, further testing was implemented. The resulting right-to-left-shunt that led to an opacification of the left atrium during echocardiography could have been the etiology. Invasive testing revealed an oxymetrically nonrelevant shunt, which later allowed unrestricted exercise testing. In the meantime, the patient received bronchial asthma treatment according to guidelines. She especially stated a relief of her symptoms using inhalative tiotropium bromide in addition to betamimetics and physical conditioning. The frequency of her coughing attacks declined using steam inhalation with brine. Thereupon her asthma control testing increased from 8 to 19 points (the latter being within physiological limits), indicative of a correlation between symptoms and asthma rather than the incidental finding of PLVCS.\nRegarding her cerebral lesion, a differentiation between injuries from her known multiple sclerosis and paradoxical embolic insults from her right-to-left-shunt was essential. The patient had developed symptoms suspicious of multiple sclerosis for 9 years at the time of presentation: chronic fatigue, mild hypoesthesia, gait disturbances, and voiding dysfunction, but no focal deficiency. These symptoms resided from two episodes of her relapsing–remitting disease progress analogous to temporal dissemination. Magnetic resonance imaging (MRI) revealed a demyelination mainly of white matter and cerebellar structures, as represented in the reviewed McDonald criteria. Responsive to immunomodulating treatment with dimethyl fumarate and glatiramer acetate, clinical and imaging follow-ups over the past 5 years have not shown disease progression, with a constant disability score (EDSS) of 3.5. Though T2-hyperintense, the lesions showed no relevant signs of infarction (cortical location, diffusion deficiency, contrast enhancement). Typical symptoms, time course, imaging, and response to specific treatment assigned her neurologic disorders to multiple sclerosis rather than embolic strokes resulting from right-to-left-shunting caused by PLVCS.\nProposed treatment options of a persistent left vena cava superior with drainage into the left atrium include percutaneous closure with an Amplatzer device and surgical intervention, with the latter usually being subject to complex operations of coexisting cardiovascular defects . These interventions are reserved for symptomatic patients.\nThe presented case of an atypical drainage into the left atrial appendage resulted in a minor right-to-left-shunt. Its subordination correlated well with adequate oxygen utilization, quantified by spiroergometry. The left atrium showed no evidence of volume overload. Substantiated with a small shunt volume and no evidence of embolization, no specific treatment was required for the venous anomaly. This restraining approach is subject to constant reevaluation in case of an aggravation.\nThe respiratory symptoms were allocated to a known and lately aggravated bronchial asthma that was successfully treated with inhalatives according to current guidelines.\nSince no specific treatment was required, further therapy of the coexisting medical conditions will reside with the respective practitioners. Nonetheless the patient will remain in cardiologic control for periodic surveillance at regular intervals.", + "fulltext_subclaims": [ + "The patient is a 35-year old Caucasian female.", + "She has a history of multiple sclerosis.", + "She has a history of atopic diathesis.", + "She has bronchial asthma.", + "She presented for chronic respiratory discomfort.", + "She sought a second opinion on her treatment.", + "She had noted recurrent coughing that deteriorated in autumn.", + "Prednisolone prescribed due to her allergic asthma had only insufficiently relieved symptoms.", + "She had completed a specific immunotherapy addressing her allergy towards certain phytocomponents.", + "She quit smoking after accumulation of 2 pack years in total.", + "Spirometry revealed stable static and dynamic respiratory flow values with slight obstruction.", + "Asthma control testing (ACT) revealed eight points at initial presentation.", + "The ACT score of eight points indicated poorly controlled asthma.", + "There were no signs of acute infection.", + "An influenza immunization had recently been implemented.", + "Her medication included inhalative steroids in combination with a long-acting betamimetic agent.", + "Her medication included a short-acting betamimetic nebulizer on demand.", + "Therapy with montelukast had to be discontinued due to gastrointestinal adverse effects.", + "Her relapsing–remitting multiple sclerosis was kept in a steady state by dimethyl fumarate and glatiramer acetate.", + "She experienced two episodes in the past 9 years.", + "She had residual mild hypoesthesia.", + "She had gait disturbances.", + "She had chronic fatigue.", + "Physical examination detected no pathologies.", + "She is a medium-build woman with a BMI of 21 kg/m2.", + "Auscultation revealed vesicular respiratory sounds without rales.", + "No cardiac murmur was audible.", + "Her fingers did not show clubbing.", + "Cardiac natriuretic peptides presented within normal limits.", + "Laboratory testing revealed hypereosinophilia.", + "Laboratory testing revealed hypoxemia with an adequate response to oxygen.", + "Due to the blood gas analysis presenting relevant hypoxemia, further investigations were undertaken.", + "Daily self-assessment of peak flow values for continuous monitoring of dynamic respiratory function was recommended.", + "Scintigraphy was performed to rule out a ventilation perfusion deficiency.", + "For the CT scan, contrast media was injected into the left brachial veins.", + "Venous contrast filling suspected an additional left superior cava vein connected to the left atrium.", + "The diagnosis was confirmed by echocardiography.", + "Contrast media was applied via the left brachial veins.", + "Recordings of the apical four chamber view demonstrated an instant and complete opacification solely of the left-sided cardiac cavities.", + "The right atrium and ventricle were unaffected.", + "Contrast media inflow originated from the lateral base of the left atrium.", + "On transesophageal echocardiography, contrast enhancement commenced at the junction of the left atrial appendage and the left pulmonary veins.", + "The drainage location site was specified as being the left atrial appendage.", + "The persistent left vena cava superior complied with type IIIb of Schummer’s classification of PLVCS.", + "The drainage was into the left atrial appendage.", + "Cardiac catheterization was performed to assess the effect of the PLVCS on the patient’s hemodynamics.", + "Pulmonary circulation showed normal proportions of pressure and resistance.", + "The composition of intracardiac blood gas analyses revealed a Qp/Qs of 1.2.", + "The Qp/Qs of 1.2 reflected a hemodynamically nonrelevant right-to-left shunt.", + "The oxygen saturation of 69% in the PLVCS did not alter the saturation of the left atrium.", + "The patient completed spiroergometry with a peak oxygen uptake of 23 mL/min/kg.", + "The peak oxygen uptake of 23 mL/min/kg was rated as an unrestricted exercise capacity.", + "T2-weighted sequences revealed multiple lesions of varying sizes in various cerebral compartments.", + "The lesions were mainly in white matter (frontal, mesencephalic, occipital) and cerebellar.", + "The main diagnostic concerns were to distinguish hypoxemia and neurologic disorders from bronchial asthma and multiple sclerosis.", + "The initial complaints included dyspnoea on exertion and coughing.", + "The initial complaints were accompanied by mild hypoxemia.", + "Imaging revealed a PLVCS draining atypically into the left atrial appendage.", + "Further testing was implemented.", + "The resulting right-to-left-shunt could have been the etiology.", + "Invasive testing revealed an oxymetrically nonrelevant shunt.", + "The patient received bronchial asthma treatment according to guidelines.", + "The patient stated relief of symptoms using inhalative tiotropium bromide.", + "The frequency of coughing attacks declined using steam inhalation with brine.", + "Asthma control testing increased from 8 to 19 points.", + "The increase in ACT score was within physiological limits.", + "The increase in ACT score was indicative of a correlation between symptoms and asthma.", + "The patient had developed symptoms suspicious of multiple sclerosis for 9 years.", + "MRI revealed demyelination mainly of white matter and cerebellar structures.", + "The lesions showed no relevant signs of infarction.", + "The lesions showed no cortical location, diffusion deficiency, or contrast enhancement.", + "The neurologic disorders were assigned to multiple sclerosis rather than embolic strokes.", + "Proposed treatment options for a persistent left vena cava superior include percutaneous closure with an Amplatzer device.", + "Proposed treatment options include surgical intervention.", + "The subordination of the PLVCS correlated well with adequate oxygen utilization.", + "The left atrium showed no evidence of volume overload.", + "No specific treatment was required for the venous anomaly.", + "The respiratory symptoms were allocated to bronchial asthma.", + "The respiratory symptoms were successfully treated with inhalatives according to current guidelines.", + "The patient will remain in cardiologic control for periodic surveillance.", + "The patient will not receive specific treatment for the venous anomaly.", + "The patient will continue therapy of coexisting medical conditions with respective practitioners." + ], + "summary": "Here we report a 35-year-old Caucasian female patient with drainage into the left atrial appendage who presented with shortness of breath accompanied by mild hypoxemia. Venous contrast filling in the context of pulmonary scintigraphy suspected an additional superior caval vein connected to the left atrial appendage. Diagnosis was confirmed by transesophageal echocardiography. Cardiac catheterization revealed a minor right-to-left shunt. The symptoms could be allocated to a bronchial asthma and treated according to guidelines. Cerebral lesions detected in the patient were due to a coincident multiple sclerosis rather than cerebral embolisms. Thus, the venous anomaly was classified as an incidental finding currently requiring no treatment.", + "summary_subclaims": [ + "The patient is a 35-year-old Caucasian female.", + "The patient had drainage into the left atrial appendage.", + "The patient presented with shortness of breath.", + "The patient had mild hypoxemia.", + "Venous contrast filling in pulmonary scintigraphy suggested an additional superior caval vein connected to the left atrial appendage.", + "Diagnosis was confirmed by transesophageal echocardiography.", + "Cardiac catheterization revealed a minor right-to-left shunt.", + "The symptoms were allocated to bronchial asthma.", + "The symptoms were treated according to guidelines.", + "Cerebral lesions detected were due to multiple sclerosis.", + "The cerebral lesions were not due to cerebral embolisms.", + "The venous anomaly was classified as an incidental finding.", + "The venous anomaly currently requires no treatment." + ] + }, + { + "id": "multiclinsum_test_1498_en.txt", + "fulltext": "A 29-year-old man visited our urology clinic for a premarital medical examination, with complaints of occasional scrotal pain.\nFor the previous month, the patient had experienced occasional minor pain in the testicles.\nThe patient had no notable previous medical history.\nHe denied any family history and had no specific past history.\nHis height was 167 cm, and his weight was 57.9 kg. After physical examination, we found that he had no dysmorphisms and had a normal distribution of pubic hair and body hair. His external urethral meatus was in a normal position, and his penis had a normal appearance and size (5.7 cm, non-erectile).\nThe results of the patient's serum test revealed that the luteinizing hormone (LH) concentration was elevated at 15.73 IU/L (normal range: 1.7-8.6 IU/L), and the follicle-stimulating hormone (FSH) concentration was elevated at 14.13 IU/L (normal range: 1.5-12.4 IU/L). However, the serum testosterone hormone concentration was 3.22 μg/L, which was in the normal range for adult males of 2.49-8.36 μg/L. Azoospermia was determined after repeated seminal analysis. Chromosomal analysis was performed twice on samples collected at different times, and 100 metaphases were analyzed in each analysis. Two different cell lines with the karyotype 45,X[93%] /46,X,+mar(Y)[7%] were observed by GTG banding. Fluorescence in situ hybridization analysis with screening of metaphase and interphase lymphocytes was carried out to confirm the result of the karyotype analysis. Two cell lines, one with one green signal for Xcen (182/200) and the other with one green signal and one red signal for Xcen and Ycen (18/200), respectively, were observed according to fluorescence in situ hybridization . All the metaphase and interphase lymphocytes showed one signal for Xcen but no SRY signal, except for cell lines containing SRY . Polymerase chain reaction amplification of 16 Y-STS gene loci (SRY, ZFY, sY86, sY84, CDY2, SMCY, sY127, sY134, sY1161, sY1191, sY254, sY255, DAZ, sY157, CDY1, ZFX, SMCX, DAZL) using a Y-chromosome microdeletion detection kit (Microread Gene; Beijing, China) demonstrated the presence of Y chromosome-derived sequences. The SRY and ZFY genes were not amplified in the AZF region . The negative amplification of SRY further confirmed the partial absence of the Y-chromosome sequence.\nUltrasound scanning of the scrotum showed that both testicles were located in the scrotum, but the volumes (6.6 mL and 6.8 mL, respectively) were significantly smaller than the normal adult male testicle size (range: 15-23 mL). In addition, a normal-sized prostate and seminal vesicles were observed by internal genitalia ultrasound analysis.", + "fulltext_subclaims": [ + "A 29-year-old man visited our urology clinic for a premarital medical examination.", + "The patient had occasional scrotal pain.", + "The patient had experienced occasional minor pain in the testicles for the previous month.", + "The patient had no notable previous medical history.", + "The patient denied any family history.", + "The patient had no specific past history.", + "The patient's height was 167 cm.", + "The patient's weight was 57.9 kg.", + "The patient had no dysmorphisms.", + "The patient had a normal distribution of pubic hair and body hair.", + "The external urethral meatus was in a normal position.", + "The penis had a normal appearance and size (5.7 cm, non-erectile).", + "The luteinizing hormone (LH) concentration was elevated at 15.73 IU/L.", + "The follicle-stimulating hormone (FSH) concentration was elevated at 14.13 IU/L.", + "The serum testosterone hormone concentration was 3.22 μg/L.", + "The serum testosterone hormone concentration was in the normal range for adult males.", + "Azoospermia was determined after repeated seminal analysis.", + "Chromosomal analysis was performed twice on samples collected at different times.", + "100 metaphases were analyzed in each analysis.", + "Two different cell lines with the karyotype 45,X[93%] /46,X,+mar(Y)[7%] were observed by GTG banding.", + "Fluorescence in situ hybridization analysis with screening of metaphase and interphase lymphocytes was carried out.", + "Two cell lines, one with one green signal for Xcen (182/200) and the other with one green signal and one red signal for Xcen and Ycen (18/200), respectively, were observed.", + "All the metaphase and interphase lymphocytes showed one signal for Xcen but no SRY signal, except for cell lines containing SRY.", + "Polymerase chain reaction amplification of 16 Y-STS gene loci was performed.", + "The SRY and ZFY genes were not amplified in the AZF region.", + "The negative amplification of SRY further confirmed the partial absence of the Y-chromosome sequence.", + "Ultrasound scanning of the scrotum showed that both testicles were located in the scrotum.", + "The volumes of the testicles were 6.6 mL and 6.8 mL, respectively.", + "The testicle volumes were significantly smaller than the normal adult male testicle size.", + "A normal-sized prostate and seminal vesicles were observed by internal genitalia ultrasound analysis." + ], + "summary": "In this study, a 29-year-old male patient with complete azoospermia is reported. Chromosomal analyses of his lymphocytes revealed the karyotype 45,X", + "summary_subclaims": [ + "A 29-year-old male patient with complete azoospermia is reported.", + "Chromosomal analyses of his lymphocytes revealed the karyotype 45,X." + ] + }, + { + "id": "multiclinsum_test_2447_en.txt", + "fulltext": "A 54-year-old man presented with a history of epigastric pain and melena over the last few days. The patient did not have hormone-related symptoms. He had received treatment for a myocardial infarction at the age of 51 with an antiplatelet therapy; therefore, we considered that there was a possibility of tumor bleeding by antiplatelet therapy. Blood biochemical examinations indicated slight anemia. Serum carbohydrate antigen 19-9 and carcinoembryonic antigen (CEA) levels were not elevated. The 24-h urinary 5-hydroxyindoleacetic acid (5-HIAA) level was 3.2 mg. Upper gastrointestinal endoscopy showed a bulging papilla with bleeding . A biopsy was not performed at that time because of the active bleeding. Endoscopic examination on day 7 revealed an approximately 10-mm mass of the ampulla of Vater with a superficial ulcer . Pathological findings of the endoscopic biopsy of the ampulla revealed a well-differentiated NET. Immunohistochemically, the tumor stained positive for CD56, chromogranin A, and synaptophysin. An upper gastrointestinal series showed an ampullary mass without any obvious lesions of the jejunum . An enhanced abdominal computed tomography (CT) scan revealed a 10-mm hypervascular tumor at the ampulla of Vater and a 41-mm multilocular cyst adjacent to the wall of the jejunum near the ligament of Treitz . The wall of the multilocular cyst showed the same enhancement patterns with the tumor. The patient underwent magnetic resonance imaging that was negative for visceral metastasis. About the cyst, the preoperative definitive diagnosis was not provided.\nThe patient was referred to our hospital for treatment of the NET. We performed a pylorus-preserving pancreaticoduodenectomy with regional lymph node dissection. The operative time was 497 min, and the volume of blood loss during the surgery was 1220 ml. The resected specimen was macroscopically a 9-mm white solid tumor . Tumor cells confined to duodenal mucosal layer. There was a 52-mm cyst in the superior mesentery adjacent to the wall of the jejunum . Microscopically, the tumor consisted of small-sized round cell proliferations with a solid nest pattern . The cyst preserved the structure of the lymph node and was the superior mesenteric lymph node metastasis of the tumor . We performed D2 lymph node dissection, and there was no metastatic lymph node except for the superior mesenteric lymph node. Immunohistochemically, the resected specimen revealed that the tumor and the lymph node metastasis were positive for chromogranin A and CD56 and negative for synaptophysin. The Ki-67-labeling index of the tumor cells determined with MIB-1 was 2.0 %. The final diagnosis was sporadic non-functional NET G1 of the ampulla of Vater (pT1N1M0 stage IIIB). The patient was discharged 36 days after the operation. He has had no recurrence for 4 years after surgery. No further treatment was administered.\nNETs of the ampulla of Vater are rare and difficult to diagnose [, ]. Jaundice (60 %) and abdominal pain (40 %) are the most frequent symptoms. Upper gastrointestinal bleeding is a rare presentation (<3 %) [, ]. In our case, the patient presented with abdominal pain and melena. On admission, upper gastrointestinal endoscopy revealed a bulging papilla with active bleeding. When we performed gastric endoscopy again 7 days later, we found a 10-mm mass of the ampulla of Vater with a superficial ulcer.\nDiagnosis of NETs is established by histological and immunohistochemical analysis of endoscopic biopsy specimens . NETs of the ampulla of Vater usually appear as submucosal masses that are small and spherical with a smooth surface and an intact duodenal mucosa. Consequently, superficial biopsies are negative and deeper biopsies are required for a diagnosis [, ]. In our present case, we could get the biopsy specimen from the mass because it had an ulcerated surface. Thus, the correct diagnosis of a NET was established preoperatively. However, we could not diagnose the cyst adjacent to the wall of the jejunum as a lymph node metastasis at the time of resection.\nPrevious reports have suggested that the biological behavior of ampullary NETs is distinct from that of duodenal NETs and they are more aggressive . Randle and colleagues reported that ampullary NETs were larger, higher grade, and higher stage and had a higher rate of lymph node metastasis than duodenal NETs . The incidence of lymph node metastases in patients with resected ampullary NETs and duodenal NETs was 72.9 and 48.4 %, respectively.\nIn the case of ampullary NETs, even in tumors smaller than 2 cm, a high percentage have lymph node metastases [, –]. Nikou et al. reported that lymph node metastases were found in two cases of ampullary NET with tumor sizes of 1.0 and 1.2 cm, respectively . In the present case, the histologic examination revealed metastasis to distant lymph nodes despite the tumor only being 9 mm in diameter and within duodenal mucosal layer. These findings suggest that there is no correlation between tumor size and metastatic potential in ampullary NETs. We consider that an anatomical reason is one of the reasons why NETs at the ampulla of Vater have high incidence of metastasis. Ampullary carcinoma with perisphincteric or duodenal submucosal invasion showed more frequent lymph node metastasis and a greater tumor recurrence rate than tumor limited within the sphincter of Oddi muscle . Moreover, the perisphincteric and duodenal submucosal space is relatively small and closer to the next layering of duodenal proper muscle and the pancreas. Thus, the malignant potential of perisphincteric and/or duodenal submucosal invasion may be greater than that of other gastrointestinal tract tumors. Moreover, previous studies have reported that lymph node metastasis is difficult to detect on preoperative imaging [, ]. Although some authors report the existence of lymph node metastasis of NETs is not correlated with patient prognosis, this could be due to metastasis to the liver or some other organ, which is an important prognostic factor for NETs. Therefore, radical resection with lymph node dissection is recommended as a treatment of ampullary NETs regardless of tumor size [, , , , ].\nWe performed a pylorus-preserving pancreaticoduodenectomy with regional lymph node resection and also resected a 52-mm lymphatic metastasis adjacent to the wall of the jejunum. Despite the lymph node involvement, the Ki-67-labeling index was low (2 %) and the patient has had no evidence of recurrence for 4 years after surgery.\nRandle et al. indicated that tumor size was correlated with poor prognosis, but the presence of positive lymph nodes was not a predictive outcome in resected ampullary NETs . Untch et al. reported that only tumor size and tumor grade were associated with recurrence . Thus, we can perform radical resection and completely remove the tumor with good clinical outcomes.", + "fulltext_subclaims": [ + "The patient was a 54-year-old man.", + "The patient had epigastric pain and melena over the last few days.", + "The patient did not have hormone-related symptoms.", + "The patient had received treatment for a myocardial infarction at the age of 51.", + "The patient was on antiplatelet therapy.", + "We considered that there was a possibility of tumor bleeding by antiplatelet therapy.", + "Blood biochemical examinations indicated slight anemia.", + "Serum carbohydrate antigen 19-9 and carcinoembryonic antigen (CEA) levels were not elevated.", + "The 24-h urinary 5-hydroxyindoleacetic acid (5-HIAA) level was 3.2 mg.", + "Upper gastrointestinal endoscopy showed a bulging papilla with bleeding.", + "A biopsy was not performed at that time because of the active bleeding.", + "Endoscopic examination on day 7 revealed an approximately 10-mm mass of the ampulla of Vater with a superficial ulcer.", + "Pathological findings of the endoscopic biopsy of the ampulla revealed a well-differentiated NET.", + "Immunohistochemically, the tumor stained positive for CD56, chromogranin A, and synaptophysin.", + "An upper gastrointestinal series showed an ampullary mass without any obvious lesions of the jejunum.", + "An enhanced abdominal computed tomography (CT) scan revealed a 10-mm hypervascular tumor at the ampulla of Vater.", + "An enhanced abdominal CT scan revealed a 41-mm multilocular cyst adjacent to the wall of the jejunum near the ligament of Treitz.", + "The wall of the multilocular cyst showed the same enhancement patterns with the tumor.", + "Magnetic resonance imaging was negative for visceral metastasis.", + "The preoperative definitive diagnosis of the cyst was not provided.", + "The patient underwent pylorus-preserving pancreaticoduodenectomy with regional lymph node dissection.", + "The operative time was 497 min.", + "The volume of blood loss during the surgery was 1220 ml.", + "The resected specimen was macroscopically a 9-mm white solid tumor.", + "Tumor cells were confined to the duodenal mucosal layer.", + "There was a 52-mm cyst in the superior mesentery adjacent to the wall of the jejunum.", + "Microscopically, the tumor consisted of small-sized round cell proliferations with a solid nest pattern.", + "The cyst preserved the structure of the lymph node and was the superior mesenteric lymph node metastasis of the tumor.", + "We performed D2 lymph node dissection.", + "There was no metastatic lymph node except for the superior mesenteric lymph node.", + "Immunohistochemically, the resected specimen revealed that the tumor and the lymph node metastasis were positive for chromogranin A and CD56.", + "Immunohistochemically, the resected specimen revealed that the tumor and the lymph node metastasis were negative for synaptophysin.", + "The Ki-67-labeling index of the tumor cells determined with MIB-1 was 2.0 %.", + "The final diagnosis was sporadic non-functional NET G1 of the ampulla of Vater (pT1N1M0 stage IIIB).", + "The patient was discharged 36 days after the operation.", + "The patient has had no recurrence for 4 years after surgery.", + "No further treatment was administered.", + "NETs of the ampulla of Vater are rare and difficult to diagnose.", + "Jaundice is the most frequent symptom in 60 % of cases.", + "Abdominal pain is the most frequent symptom in 40 % of cases.", + "Upper gastrointestinal bleeding is a rare presentation (<3 %).", + "In our case, the patient presented with abdominal pain and melena.", + "On admission, upper gastrointestinal endoscopy revealed a bulging papilla with active bleeding.", + "When we performed gastric endoscopy again 7 days later, we found a 10-mm mass of the ampulla of Vater with a superficial ulcer.", + "Diagnosis of NETs is established by histological and immunohistochemical analysis of endoscopic biopsy specimens.", + "NETs of the ampulla of Vater usually appear as submucosal masses that are small and spherical with a smooth surface and an intact duodenal mucosa.", + "Superficial biopsies are negative and deeper biopsies are required for a diagnosis.", + "In our present case, we could get the biopsy specimen from the mass because it had an ulcerated surface.", + "The correct diagnosis of a NET was established preoperatively.", + "We could not diagnose the cyst adjacent to the wall of the jejunum as a lymph node metastasis at the time of resection.", + "Previous reports have suggested that the biological behavior of ampullary NETs is distinct from that of duodenal NETs and they are more aggressive.", + "Randle and colleagues reported that ampullary NETs were larger, higher grade, and higher stage and had a higher rate of lymph node metastasis than duodenal NETs.", + "The incidence of lymph node metastases in patients with resected ampullary NETs and duodenal NETs was 72.9 and 48.4 %, respectively.", + "In the case of ampullary NETs, even in tumors smaller than 2 cm, a high percentage have lymph node metastases.", + "Nikou et al. reported that lymph node metastases were found in two cases of ampullary NET with tumor sizes of 1.0 and 1.2 cm, respectively.", + "In the present case, the histologic examination revealed metastasis to distant lymph nodes despite the tumor only being 9 mm in diameter and within duodenal mucosal layer.", + "These findings suggest that there is no correlation between tumor size and metastatic potential in ampullary NETs.", + "We consider that an anatomical reason is one of the reasons why NETs at the ampulla of Vater have high incidence of metastasis.", + "Ampullary carcinoma with perisphincteric or duodenal submucosal invasion showed more frequent lymph node metastasis and a greater tumor recurrence rate than tumor limited within the sphincter of Oddi muscle.", + "The perisphincteric and duodenal submucosal space is relatively small and closer to the next layering of duodenal proper muscle and the pancreas.", + "The malignant potential of perisphincteric and/or duodenal submucosal invasion may be greater than that of other gastrointestinal tract tumors.", + "Previous studies have reported that lymph node metastasis is difficult to detect on preoperative imaging.", + "Radical resection with lymph node dissection is recommended as a treatment of ampullary NETs regardless of tumor size.", + "We performed a pylorus-preserving pancreaticoduodenectomy with regional lymph node resection and also resected a 52-mm lymphatic metastasis adjacent to the wall of the jejunum.", + "Despite the lymph node involvement, the Ki-67-labeling index was low (2 %) and the patient has had no evidence of recurrence for 4 years after surgery.", + "Randle et al. indicated that tumor size was correlated with poor prognosis, but the presence of positive lymph nodes was not a predictive outcome in resected ampullary NETs.", + "Untch et al. reported that only tumor size and tumor grade were associated with recurrence.", + "We can perform radical resection and completely remove the tumor with good clinical outcomes." + ], + "summary": "The patient was a 54-year-old man complaining of epigastric pain and melena. Upper gastrointestinal endoscopy revealed a bulging papilla with active bleeding, which was diagnosed as a well-differentiated NET of the ampulla of Vater. An approximately 10-mm hypervascular tumor at the ampulla of Vater and a 41-mm cyst adjacent to the wall of the jejunum were revealed by abdominal computed tomography. We performed pylorus-preserving pancreaticoduodenectomy with lymph node dissection. Macroscopic examination revealed a 9-mm tumor of the ampulla of Vater and a 52-mm cyst adjacent to the wall of the jejunum. Histological examination revealed that the cyst was a lymph node metastasis. The final diagnosis was non-functional NET G1 of the ampulla of Vater, designated T1N1M0 stage IIIB. Postoperatively, the patient underwent no treatment and has had no recurrence for 4 years.", + "summary_subclaims": [ + "The patient was a 54-year-old man.", + "The patient was complaining of epigastric pain.", + "The patient was complaining of melena.", + "Upper gastrointestinal endoscopy revealed a bulging papilla with active bleeding.", + "The bulging papilla with active bleeding was diagnosed as a well-differentiated NET of the ampulla of Vater.", + "Abdominal computed tomography revealed an approximately 10-mm hypervascular tumor at the ampulla of Vater.", + "Abdominal computed tomography revealed a 41-mm cyst adjacent to the wall of the jejunum.", + "We performed pylorus-preserving pancreaticoduodenectomy with lymph node dissection.", + "Macroscopic examination revealed a 9-mm tumor of the ampulla of Vater.", + "Macroscopic examination revealed a 52-mm cyst adjacent to the wall of the jejunum.", + "Histological examination revealed that the cyst was a lymph node metastasis.", + "The final diagnosis was non-functional NET G1 of the ampulla of Vater.", + "The final diagnosis was designated T1N1M0 stage IIIB.", + "Postoperatively, the patient underwent no treatment.", + "The patient has had no recurrence for 4 years." + ] + }, + { + "id": "multiclinsum_test_1029_en.txt", + "fulltext": "Our patient is a 66-year-old Eritrean gentleman, who presented to our emergency department with severe epigastric pain and a history of a growing abdominal wall mass. On systematic review, he reported anorexia and weight loss, with no history of alteration in bowel habits. The patient had no significant past medical history apart from this presentation.\nTen days prior to his presentation to our institution, he underwent an incision and drainage procedure of an abdominal wall abscess at an outside institution. The patient was discharged with outpatient dressing protocol and oral antibiotics.\nOn examination, the patient was thin and cachectic, with a large tender warm swelling occupying the supraumbilical and epigastric regions. It measured about 10 × 15 cm in greatest dimension. There were two ulcerations on the surface of the swelling draining purulent discharge corresponding to the incisions done previously . There was no evidence of peritonitis or other significant physical findings.\nLaboratory results revealed a hemoglobin level of 5.7 g/dl (normal range: 14–18), white blood count level of 13.3 K/µL (normal range: 4.5–11.5), and carcinoembryonic antigen (CEA) level of 12.99 ng/ml (normal range: 0–3.4). Coagulation profile and liver function tests were within normal ranges. Wound culture showed mixed bacterial growth of Escherichia coli and Klebsiella pneumoniae.", + "fulltext_subclaims": [ + "The patient is a 66-year-old Eritrean gentleman.", + "He presented to the emergency department with severe epigastric pain.", + "He has a history of a growing abdominal wall mass.", + "He reported anorexia.", + "He reported weight loss.", + "He had no history of alteration in bowel habits.", + "Ten days prior to presentation, he underwent an incision and drainage procedure of an abdominal wall abscess at an outside institution.", + "He was discharged with outpatient dressing protocol and oral antibiotics.", + "On examination, the patient was thin and cachectic.", + "There was a large tender warm swelling occupying the supraumbilical and epigastric regions.", + "The swelling measured about 10 × 15 cm in greatest dimension.", + "There were two ulcerations on the surface of the swelling draining purulent discharge.", + "The ulcerations corresponded to the incisions done previously.", + "There was no evidence of peritonitis.", + "The hemoglobin level was 5.7 g/dl.", + "The white blood count level was 13.3 K/µL.", + "The carcinoembryonic antigen (CEA) level was 12.99 ng/ml.", + "Coagulation profile was within normal ranges.", + "Liver function tests were within normal ranges.", + "Wound culture showed mixed bacterial growth of Escherichia coli and Klebsiella pneumoniae." + ], + "summary": "In this case report, we present a case of a 66-year-old male presenting with abdominal wall abscess that was refractory to treatment. The patient later was found to have an abdominal wall invasion by an underlying colonic carcinoma.", + "summary_subclaims": [ + "The patient is a 66-year-old male.", + "The patient presented with an abdominal wall abscess.", + "The abscess was refractory to treatment.", + "The patient was found to have an abdominal wall invasion.", + "The abdominal wall invasion was by an underlying colonic carcinoma." + ] + }, + { + "id": "multiclinsum_test_2876_en.txt", + "fulltext": "A 76-year-old man of Caucasian ethnicity was hospitalized for syncope 2 years before index hospitalization. Comorbidities included liver cirrhosis (Child-Pugh A) due to non-alcoholic fatty liver disease, type-2 diabetes, hypertension, and suspected Alzheimer-type dementia. Etiologically unclear transitory ischemic attacks had been diagnosed before. Holter electrocardiogram (ECG) showed a first-degree atrioventricular block and three episodes of bradycardia with minimal cardiac frequencies of 37bpm that were deemed unlikely as a cause for syncope. Schellong test revealed a hypodynamic cardiac response, that is, his heart rate stayed at 50bpm after change from supine to upright position. Hypoglycemia (under insulin therapy) was not detected prior, during or after hospitalization. A concomitant AKI (AKIN 2, maximum creatinine: 297μmol/L) was regarded as pre-renal, and syncope was attributed to arterial hypotension and hypovolemia. Following intravenous rehydration, he was discharged with spironolactone 150mg/day and propranolol 100mg/day for liver cirrhosis, donepezil 10mg/day for suspected dementia, amlodipine 10mg/day, and insulin subcutaneous injection (average: 50IU/day).\nAt index hospitalization, he (body mass index: 35.2) was admitted with nausea and vomiting for 3 days, as well as dizziness due to a presumed hepatic encephalopathy. On admission, vital parameters including blood pressure (150/80mmHg), heart rate (62bpm), and temperature and physical examination including cardiopulmonary state were unrevealing. Specifically, ascites and peripheral edema were absent. He was oriented to person, place, and time. Physical reactions were slowed though. Compared to baseline values prior to hospitalization (serum creatinine: 139μmol/L, estimated glomerular filtration rate\n: 43.2μmol/L/1.73m2), serum creatinine was elevated on admission (Table ). Glutamate-oxaloacetate transaminase (0.64), gamma-glutamyltransferase (2.46), and international normalized ratio (1.13) were slightly elevated; serum albumin (31g/L) was decreased. Other laboratory values including inflammation parameters (leukocyte count, C-reactive protein), total serum protein, bilirubin, glutamate-pyruvate transaminase, and alkaline phosphatase were within normal range. Partial respiratory insufficiency and metabolic acidosis (pH: 7.326, oxygen partial pressure: 55.8mmHg, carbon dioxide partial pressure: 29.0mmHg, bicarbonate: 14.7mmol/L, base excess: -9.7) were found on admission. His urine test showed microalbuminuria (<300mg/day), microscopic hematuria, and leukocyturia consistent with urinary tract infection. Concomitant medication largely remained unchanged since discharge 2 years ago. ECG showing sinus rhythm and the known first-degree atrioventricular block was without change since the last ambulatory cardiology check 1 year before. During hospitalization, he was bed-bound. Gastroscopy proved helicobacter-negative gastritis. An intravenous fluid challenge using sterile saline was performed for suspected, however clinically inapparent, hypovolemia. Despite fluid challenge, oliguria suddenly developed shortly after admission, serum creatinine remained high (Table ). A pre- and post-renal cause of AKI was excluded. Myocardial infarction as a possible cause of hemodynamic instability was ruled out in repeat laboratory and ECG examinations. Echocardiography showed a normal systolic left-ventricular function, yet left-ventricular hypertrophy and diastolic dysfunction accompanied by a mild mitral regurgitation and an enlarged left atrium. Nephrotoxins and/or nephrotoxic medications were not applied. Euglycemia was verified during the whole index hospitalization. Kidney sonography revealed normal-sized kidneys with a centralized arterial perfusion (Figure ), and an increased renal resistive index (1.0 on both sides) reflecting a diastolic no-flow condition. Of importance, a bradycardia (less than 50bpm) was present during ultrasound. Propranolol was discontinued at once, thereafter urine output improved (Table ). In a Holter ECG 3 days following propranolol cessation, an intermittent third-degree atrioventricular block with pauses for less than 3 seconds was found (Figure ). He was subjected to pacemaker insertion on day 11 after admission. Thereafter, renal function in terms of urine output and serum creatinine remained stable. Beta-blocker therapy was reinstituted. By discharge to a rehabilitation facility 14 days after pacemaker insertion, renal function in terms of serum creatinine further improved (Table ), body weight remained constant in comparison to admission, and peripheral edema was absent.\nAt discharge, spironolactone 50mg daily, propranolol 25mg thrice daily, amlodipine (5mg daily), donezepil (10mg daily), and antidiabetic medication including sitagliptin and insulin were maintained. Ramipril (5mg daily), torasemide (20mg daily), acetylsalicylic acid (100mg daily), simvastatin (20mg daily), and pantoprazole (20mg daily) were prescribed.\nRenal recovery continued after discharge, the prehospitalization level of creatinine was reached within 1 month following discharge.During the 4 months following discharge, amlodipine and ramipril were discontinued. Otherwise, medication has not changed. Syncope has not occurred again. His overall condition improved considerably. He was not bed-bound; he was alert and he could walk short distances with walking aid. Symptoms consistent with hepatic encephalopathy or progressive dementia were not present. Four weeks after discharge, his mini-mental state examination yielded 22 (out of 30) points. A neurologic reassessment was recommended regarding the ongoing donepezil treatment. At 4-months follow-up, sonography of his kidneys showed persistent renal resistive index of 1.0 on both sides (Figure ).", + "fulltext_subclaims": [ + "The patient is a 76-year-old man of Caucasian ethnicity.", + "He was hospitalized for syncope 2 years before index hospitalization.", + "Comorbidities included liver cirrhosis (Child-Pugh A) due to non-alcoholic fatty liver disease.", + "Comorbidities included type-2 diabetes.", + "Comorbidities included hypertension.", + "Comorbidities included suspected Alzheimer-type dementia.", + "Etiologically unclear transitory ischemic attacks had been diagnosed before.", + "Holter ECG showed a first-degree atrioventricular block.", + "Holter ECG showed three episodes of bradycardia with minimal cardiac frequencies of 37bpm.", + "The bradycardia episodes were deemed unlikely as a cause for syncope.", + "Schellong test revealed a hypodynamic cardiac response.", + "His heart rate stayed at 50bpm after change from supine to upright position.", + "Hypoglycemia was not detected prior, during, or after hospitalization.", + "A concomitant AKI (AKIN 2) was regarded as pre-renal.", + "Syncope was attributed to arterial hypotension and hypovolemia.", + "Following intravenous rehydration, he was discharged with spironolactone 150mg/day.", + "Following intravenous rehydration, he was discharged with propranolol 100mg/day.", + "Following intravenous rehydration, he was discharged with donepezil 10mg/day.", + "Following intravenous rehydration, he was discharged with amlodipine 10mg/day.", + "Following intravenous rehydration, he was discharged with insulin subcutaneous injection (average: 50IU/day).", + "At index hospitalization, he had a body mass index of 35.2.", + "He was admitted with nausea and vomiting for 3 days.", + "He was admitted with dizziness due to a presumed hepatic encephalopathy.", + "On admission, vital parameters including blood pressure (150/80mmHg), heart rate (62bpm), and temperature were unrevealing.", + "On admission, physical examination including cardiopulmonary state was unrevealing.", + "Ascites and peripheral edema were absent.", + "He was oriented to person, place, and time.", + "Physical reactions were slowed.", + "Serum creatinine was elevated on admission compared to baseline values.", + "Glutamate-oxaloacetate transaminase was slightly elevated.", + "Gamma-glutamyltransferase was slightly elevated.", + "International normalized ratio was slightly elevated.", + "Serum albumin was decreased.", + "Partial respiratory insufficiency and metabolic acidosis were found on admission.", + "His urine test showed microalbuminuria (<300mg/day).", + "His urine test showed microscopic hematuria.", + "His urine test showed leukocyturia consistent with urinary tract infection.", + "Concomitant medication largely remained unchanged since discharge 2 years ago.", + "ECG showed sinus rhythm and the known first-degree atrioventricular block.", + "ECG was without change since the last ambulatory cardiology check 1 year before.", + "During hospitalization, he was bed-bound.", + "Gastroscopy proved helicobacter-negative gastritis.", + "An intravenous fluid challenge using sterile saline was performed.", + "Oliguria suddenly developed shortly after admission.", + "Serum creatinine remained high.", + "A pre-renal cause of AKI was excluded.", + "A post-renal cause of AKI was excluded.", + "Myocardial infarction as a possible cause of hemodynamic instability was ruled out.", + "Echocardiography showed a normal systolic left-ventricular function.", + "Echocardiography showed left-ventricular hypertrophy.", + "Echocardiography showed diastolic dysfunction.", + "Echocardiography showed mild mitral regurgitation.", + "Echocardiography showed an enlarged left atrium.", + "Nephrotoxins and/or nephrotoxic medications were not applied.", + "Euglycemia was verified during the whole index hospitalization.", + "Kidney sonography revealed normal-sized kidneys with centralized arterial perfusion.", + "Kidney sonography showed an increased renal resistive index (1.0 on both sides).", + "A bradycardia (less than 50bpm) was present during ultrasound.", + "Propranolol was discontinued at once.", + "After propranolol discontinuation, urine output improved.", + "In a Holter ECG 3 days following propranolol cessation, an intermittent third-degree atrioventricular block with pauses for less than 3 seconds was found.", + "He was subjected to pacemaker insertion on day 11 after admission.", + "After pacemaker insertion, renal function in terms of urine output and serum creatinine remained stable.", + "Beta-blocker therapy was reinstituted.", + "By discharge to a rehabilitation facility 14 days after pacemaker insertion, renal function in terms of serum creatinine further improved.", + "Body weight remained constant in comparison to admission.", + "Peripheral edema was absent.", + "At discharge, spironolactone 50mg daily was maintained.", + "At discharge, propranolol 25mg thrice daily was maintained.", + "At discharge, amlodipine 5mg daily was maintained.", + "At discharge, donepezil 10mg daily was maintained.", + "At discharge, antidiabetic medication including sitagliptin and insulin was maintained.", + "Ramipril 5mg daily was prescribed.", + "Torasemide 20mg daily was prescribed.", + "Acetylsalicylic acid 100mg daily was prescribed.", + "Simvastatin 20mg daily was prescribed.", + "Pantoprazole 20mg daily was prescribed.", + "Renal recovery continued after discharge.", + "The prehospitalization level of creatinine was reached within 1 month following discharge.", + "During the 4 months following discharge, amlodipine was discontinued.", + "During the 4 months following discharge, ramipril was discontinued.", + "Otherwise, medication has not changed.", + "Syncope has not occurred again.", + "He was not bed-bound.", + "He was alert.", + "He could walk short distances with walking aid.", + "Symptoms consistent with hepatic encephalopathy or progressive dementia were not present.", + "Four weeks after discharge, his mini-mental state examination yielded 22 (out of 30) points.", + "A neurologic reassessment was recommended regarding the ongoing donepezil treatment.", + "At 4-months follow-up, sonography of his kidneys showed persistent renal resistive index of 1.0 on both sides." + ], + "summary": "A 76-year-old Caucasian man with liver cirrhosis due to non-alcoholic fatty liver disease, and type-2 diabetes was cognitively impaired and had reduced vigilance presumably caused by hepatic encephalopathy and/or Alzheimer dementia. Within 2 years, two hospitalizations occurred for syncope attributed to orthostatic failure and hypovolemia. During the last hospitalization, oliguric acute kidney injury occurred. Sonography ruled out a post-renal cause. His renal resistive index was 1.0; his heart rate was below 50 beats per minute. After cessation of beta-blocker therapy, Holter electrocardiogram showed a new intermittent third-degree atrioventricular block with pauses for less than 3 seconds. Pacemaker insertion resolved his acute kidney injury, despite resumption of beta-blocker therapy. During four months of follow-up, syncope has not occurred, and vigilance was stable. However, his renal resistive index of 1.0 remained.", + "summary_subclaims": [ + "The patient is a 76-year-old Caucasian man.", + "The patient has liver cirrhosis due to non-alcoholic fatty liver disease.", + "The patient has type-2 diabetes.", + "The patient was cognitively impaired.", + "The patient had reduced vigilance.", + "The reduced vigilance was presumably caused by hepatic encephalopathy and/or Alzheimer dementia.", + "Within 2 years, two hospitalizations occurred for syncope.", + "The syncope was attributed to orthostatic failure and hypovolemia.", + "During the last hospitalization, oliguric acute kidney injury occurred.", + "Sonography ruled out a post-renal cause.", + "The patient's renal resistive index was 1.0.", + "The patient's heart rate was below 50 beats per minute.", + "After cessation of beta-blocker therapy, Holter electrocardiogram showed a new intermittent third-degree atrioventricular block with pauses for less than 3 seconds.", + "Pacemaker insertion resolved his acute kidney injury.", + "Beta-blocker therapy was resumed.", + "During four months of follow-up, syncope has not occurred.", + "Vigilance was stable.", + "The patient's renal resistive index of 1.0 remained." + ] + }, + { + "id": "multiclinsum_test_1315_en.txt", + "fulltext": "A 49-year-old woman with a 1-month history of dyspnea was admitted to our hospital. Her medical history included hypertension, hyperlipidemia, and uterine fibroids. Chest computed tomography (CT) and echocardiography revealed a large epicardial effusion (A). The patient underwent pericardiocentesis to remove 1.2 L of hemorrhagic pericardial fluid. Cytology of the fluid was negative for malignant cells. Contrast-enhanced CT after pericardiocentesis showed a tumor measuring 24 × 33 mm in the right atrium (B). Following pericardiocentesis, the patient's symptoms were alleviated, and she was discharged. Two weeks later, transthoracic echocardiography and cardiac magnetic resonance imaging (MRI) showed progression of the epicardial effusion. Since there were no severe symptoms, we did not intervene. MRI showed a 25 × 28-mm mass in the right atrium exhibiting high signal intensity on T2-weighted images (C). Blood test results for tumor markers were negative. Coronary artery angiography revealed a feeding artery from the sinus node branch to the tumor. We investigated for embolization of the feeding artery, although we could not find any previous report of such embolization treatment of the feeding artery in the case of a cardiac tumor. These examinations were insufficient to make a definitive diagnosis. However, the tumor was resected to alleviate the persistent tamponade.\nPreoperative transesophageal echocardiography, performed under general anesthesia, showed a mass measuring 28 × 41 mm originating from the free wall of the right atrium. It was not adherent to the tricuspid valve or septum and was thus resectable. Upon pericardiotomy, the tumor was visualized in the right atrium, adherent to the pericardium. The tumor was highly vascularized and had rough borders . Cardiopulmonary bypass was established between the ascending aorta and superior vena cava. A venous cannula was subsequently inserted into the right femoral artery, through the inferior vena cava, and into the front of the right atrium so as not to interfere with the tumor. We made an incision on the right atrium near the tumor and observed the presence of endocardium on the smooth surface of the mass. We biopsied a part of the tumor surface to obtain an intraoperative frozen section, which revealed the presence of a sarcoma. The tumor and adherent right atrial wall were removed with adequate margins to the greatest extent possible. The resected right atrial wall was reconstructed using a bovine pericardial patch. Pathological examination of the resected tumor revealed fusiform tumor cells in frequent mitosis and a rich blood supply with intraluminal red blood cells. Immunological staining was positive for CD34 expression . A pathological diagnosis of angiosarcoma was made; the resected end of the superior vena cava was tumor-free. The patient was discharged on postoperative day 12. Postoperative CT and echocardiography showed no residual tumor, while positron emission tomography revealed normal findings. Two months later, the patient received radiotherapy (heavy ion therapy) to the right atrium for a month at a dose of 64 Gy in 16 Fr. There was no local recurrence 6 months after surgery. However, metastasis to the lungs was identified. Although the patient received chemotherapy (paclitaxel and cisplatin), lung and liver metastases progressed . Unfortunately, the patient died of multiorgan failure due to multiple metastases 17 and 18 months after surgery and diagnosis, respectively.", + "fulltext_subclaims": [ + "The patient was a 49-year-old woman.", + "She had a 1-month history of dyspnea.", + "Chest computed tomography and echocardiography revealed a large epicardial effusion.", + "The patient underwent pericardiocentesis to remove 1.2 L of hemorrhagic pericardial fluid.", + "Cytology of the fluid was negative for malignant cells.", + "Contrast-enhanced CT after pericardiocentesis showed a tumor measuring 24 × 33 mm in the right atrium.", + "Following pericardiocentesis, the patient's symptoms were alleviated.", + "Two weeks later, transthoracic echocardiography and cardiac MRI showed progression of the epicardial effusion.", + "MRI showed a 25 × 28-mm mass in the right atrium exhibiting high signal intensity on T2-weighted images.", + "Blood test results for tumor markers were negative.", + "Coronary artery angiography revealed a feeding artery from the sinus node branch to the tumor.", + "We investigated for embolization of the feeding artery.", + "We could not find any previous report of such embolization treatment of the feeding artery in the case of a cardiac tumor.", + "These examinations were insufficient to make a definitive diagnosis.", + "The tumor was resected to alleviate the persistent tamponade.", + "Preoperative transesophageal echocardiography showed a mass measuring 28 × 41 mm originating from the free wall of the right atrium.", + "The tumor was not adherent to the tricuspid valve or septum.", + "Upon pericardiotomy, the tumor was visualized in the right atrium, adherent to the pericardium.", + "The tumor was highly vascularized and had rough borders.", + "A venous cannula was inserted into the right femoral artery, through the inferior vena cava, and into the front of the right atrium.", + "An incision was made on the right atrium near the tumor.", + "The intraoperative frozen section revealed the presence of a sarcoma.", + "The tumor and adherent right atrial wall were removed with adequate margins.", + "The resected right atrial wall was reconstructed using a bovine pericardial patch.", + "Pathological examination revealed fusiform tumor cells in frequent mitosis and a rich blood supply with intraluminal red blood cells.", + "Immunological staining was positive for CD34 expression.", + "A pathological diagnosis of angiosarcoma was made.", + "The resected end of the superior vena cava was tumor-free.", + "The patient was discharged on postoperative day 12.", + "Postoperative CT and echocardiography showed no residual tumor.", + "Positron emission tomography revealed normal findings.", + "Two months later, the patient received radiotherapy (heavy ion therapy) to the right atrium for a month at a dose of 64 Gy in 16 Fr.", + "There was no local recurrence 6 months after surgery.", + "Metastasis to the lungs was identified.", + "The patient received chemotherapy (paclitaxel and cisplatin).", + "Lung and liver metastases progressed.", + "The patient died of multiorgan failure due to multiple metastases 17 and 18 months after surgery and diagnosis, respectively." + ], + "summary": "A 49-year-old Japanese woman with a month-long history of dyspnea was admitted to our hospital for pericardial effusion. Chest computed tomography and cardiac magnetic resonance imaging showed a mass in the right atrium. The patient underwent surgical resection of the tumor, and the pathological diagnosis was angiosarcoma. The patient received radiotherapy after surgery. Six months following surgery, she underwent chemotherapy following the diagnosis of lung metastasis. The patient died 18 months after the initial diagnosis.", + "summary_subclaims": [ + "The patient is a 49-year-old Japanese woman.", + "She had a month-long history of dyspnea.", + "She was admitted to our hospital for pericardial effusion.", + "Chest computed tomography showed a mass in the right atrium.", + "Cardiac magnetic resonance imaging showed a mass in the right atrium.", + "The patient underwent surgical resection of the tumor.", + "The pathological diagnosis was angiosarcoma.", + "The patient received radiotherapy after surgery.", + "Six months following surgery, she underwent chemotherapy.", + "The diagnosis of lung metastasis occurred six months following surgery.", + "The patient died 18 months after the initial diagnosis." + ] + }, + { + "id": "multiclinsum_test_3190_en.txt", + "fulltext": "In December 2017, a 50-day-old female Caucasian infant was admitted to the neonatal intensive care unit due to acute bronchiolitis with severe respiratory distress. Multiplex real-time reverse transcription polymerase chain reaction (RT-PCR) analysis on a nasal swab sample for the qualitative detection of RNA was positive for respiratory syncytial virus. Simultaneously, influenza A virus (flu A) and influenza B virus (flu B) infection were excluded with the same method. The girl was the firstborn of unrelated healthy parents who did not suffer from any respiratory illnesses and denied exposure to sick people. The infant was delivered by uneventful vaginal delivery at 37 weeks and three days. The birth weight was 2980 gr (0.29 SDS, 61st percentile). She did not present any health problems in the first days of life, and showed regular physical growth during the first weeks of life.\n\nTwo days before hospitalization, the infant presented with a cough, rhinitis, and inappetence. Upon later appearance of respiratory distress, she was conducted to the emergency department. On admission, the girl was afebrile. Physical examination demonstrated severely compromised general conditions, with wheezing, dyspnea, and decreased breathing sounds on auscultation of lungs. Blood tests showed a clinical picture of severe hypercapnic respiratory failure (on capillary blood sample: pH 7.25, PaCO2 71.4 mmHg, HCO3 -31.3 mg/dL, excess base 3.9). Sepsis was excluded. A chest X-ray showed signs of severe respiratory distress. Echocardiography excluded congenital heart defects. The infant was immediately intubated, and conventional mechanical ventilation with synchronous intermittent positive pressure ventilation (SIPPV) was started, with constant monitoring of vital parameters. After placing a central venous line and a nasogastric tube, adequate sedation was provided and total parenteral nutrition was initiated. Simultaneously, inotropic agents (dopamine and dobutamine) were administered to offer support to the cardiovascular system; this strategy was not adopted with the support of targeted neonatal echocardiography (TnEcho), which was unavailable in the neonatal intensive care unit. Antibiotic prophylaxis with cephalosporine and macrolides (ceftriaxone and clarithromycin, respectively) was started. Despite the ongoing invasive ventilatory strategy, the patient’s general conditions worsened with increased O2 demand. After approximately 20 h of conventional mechanical ventilation, high-frequency oscillatory ventilation was started. Nevertheless, blood gas monitoring showed a progressive increase in CO2 level.\n\nOn the third day of hospitalization, exogenous surfactant (poractant alfa; Curosurf, Chiesi Farmaceutici, Parma, Italy) was administered via intratracheal instillation, followed by a bronchoalveolar lavage with exogenous surfactant during the next day. Despite the ongoing medical and ventilator strategies, hypercapnia progressively worsened, reaching a capillary PaCO2 level of 123 mmHg. At this point, rescue treatment with whole-body hypothermia (34.0 °C) was started in an attempt to reduce CO2 production. Of note, the infant showed gradual respiratory improvement with a decrease in CO2 level. To further enhance gas exchanges by increasing lung vasodilatation, nitric oxide by inhalation was started. Overall, whole-body hypothermia was maintained for 48 h, with further lowering of capillary PaCO2 level and no side effects. Afterwards, the baby was gradually warmed up by increasing the core temperature by 0.25 °C/h, without detecting a subsequent CO2 increase. High-frequency oscillatory ventilation was maintained for five days, after which SIPPV was started. The need for O2 therapy progressively reduced. Overall, nitric oxide was provided for 10 days. Extubation was performed after 10 days of hospitalization, with a switch to non-invasive mechanical ventilation (high-flow nasal cannula) for two days. Hemodynamic support lasted six days, while antibiotic prophylaxis was discontinued on day nine. During hospitalization, no neurological deficits were observed. To exclude the injury to the central nervous system caused by severe hypercapnia, the infant underwent a brain ultrasound, electroencephalography, and magnetic resonance imaging, the results of which were normal. Overall, after 20 days spent in the hospital, the patient was discharged due to her good general condition. The infant was followed over the next few months without showing any growth or nervous/cognitive disorders.", + "fulltext_subclaims": [ + "A 50-day-old female Caucasian infant was admitted to the neonatal intensive care unit in December 2017.", + "The infant was admitted due to acute bronchiolitis with severe respiratory distress.", + "Multiplex real-time reverse transcription polymerase chain reaction (RT-PCR) analysis on a nasal swab sample was positive for respiratory syncytial virus.", + "Influenza A virus and influenza B virus infection were excluded with the same method.", + "The infant was the firstborn of unrelated healthy parents.", + "The parents did not suffer from any respiratory illnesses.", + "The parents denied exposure to sick people.", + "The infant was delivered by uneventful vaginal delivery at 37 weeks and three days.", + "The birth weight was 2980 gr.", + "The infant did not present any health problems in the first days of life.", + "The infant showed regular physical growth during the first weeks of life.", + "Two days before hospitalization, the infant presented with a cough, rhinitis, and inappetence.", + "The infant was conducted to the emergency department upon later appearance of respiratory distress.", + "On admission, the girl was afebrile.", + "Physical examination demonstrated severely compromised general conditions.", + "Blood tests showed a clinical picture of severe hypercapnic respiratory failure.", + "Sepsis was excluded.", + "A chest X-ray showed signs of severe respiratory distress.", + "Echocardiography excluded congenital heart defects.", + "The infant was immediately intubated.", + "Conventional mechanical ventilation with synchronous intermittent positive pressure ventilation (SIPPV) was started.", + "A central venous line and a nasogastric tube were placed.", + "Adequate sedation was provided.", + "Total parenteral nutrition was initiated.", + "Inotropic agents (dopamine and dobutamine) were administered.", + "This strategy was not adopted with the support of targeted neonatal echocardiography (TnEcho), which was unavailable in the neonatal intensive care unit.", + "Antibiotic prophylaxis with cephalosporine and macrolides (ceftriaxone and clarithromycin, respectively) was started.", + "Despite the ongoing invasive ventilatory strategy, the patient’s general conditions worsened with increased O2 demand.", + "After approximately 20 h of conventional mechanical ventilation, high-frequency oscillatory ventilation was started.", + "Blood gas monitoring showed a progressive increase in CO2 level.", + "On the third day of hospitalization, exogenous surfactant (poractant alfa; Curosurf, Chiesi Farmaceutici, Parma, Italy) was administered via intratracheal instillation.", + "A bronchoalveolar lavage with exogenous surfactant was performed during the next day.", + "Despite the ongoing medical and ventilator strategies, hypercapnia progressively worsened, reaching a capillary PaCO2 level of 123 mmHg.", + "Rescue treatment with whole-body hypothermia (34.0 °C) was started.", + "The infant showed gradual respiratory improvement with a decrease in CO2 level.", + "Nitric oxide by inhalation was started.", + "Whole-body hypothermia was maintained for 48 h.", + "The baby was gradually warmed up by increasing the core temperature by 0.25 °C/h.", + "High-frequency oscillatory ventilation was maintained for five days.", + "SIPPV was started after high-frequency oscillatory ventilation.", + "The need for O2 therapy progressively reduced.", + "Nitric oxide was provided for 10 days.", + "Extubation was performed after 10 days of hospitalization.", + "Non-invasive mechanical ventilation (high-flow nasal cannula) was used for two days.", + "Hemodynamic support lasted six days.", + "Antibiotic prophylaxis was discontinued on day nine.", + "No neurological deficits were observed during hospitalization.", + "The infant underwent a brain ultrasound, electroencephalography, and magnetic resonance imaging.", + "The results of the brain ultrasound, electroencephalography, and magnetic resonance imaging were normal.", + "The patient was discharged after 20 days spent in the hospital.", + "The infant was followed over the next few months without showing any growth or nervous/cognitive disorders." + ], + "summary": "We report the case of a 50-day-old girl hospitalized with severe bronchiolitis caused by respiratory syncytial virus. On admission, the girl presented severe hypercapnic respiratory failure, requiring intubation and ventilatory support with conventional and non-conventional systems. However, the patient’s general conditions worsened with elevated O2 demand, thus whole-body hypothermia was attempted and performed for 48 h, with a gradual improvement in the respiratory function. No adverse effects were detected.", + "summary_subclaims": [ + "The patient was a 50-day-old girl.", + "The patient was hospitalized with severe bronchiolitis.", + "The bronchiolitis was caused by respiratory syncytial virus.", + "On admission, the girl presented severe hypercapnic respiratory failure.", + "The patient required intubation.", + "The patient required ventilatory support with conventional and non-conventional systems.", + "The patient’s general conditions worsened with elevated O2 demand.", + "Whole-body hypothermia was attempted.", + "Whole-body hypothermia was performed for 48 h.", + "There was a gradual improvement in the respiratory function.", + "No adverse effects were detected." + ] + }, + { + "id": "multiclinsum_test_2901_en.txt", + "fulltext": "A 55-year-old Caucasian obese woman (body mass index = 35) was admitted to Surgical Department of our institution for acute abdominal pain. Her past medical history was negative for previous gastrointestinal disease or surgery. She was on medical therapy for hypertension, type II diabetes, and minor depression. Glasgow coma scale was 15. She referred an increasing acute abdominal pain risen 5 hours ago after a fish-based dinner. She has showed an acute diffuse peritonitis. White blood cell count was 32.000 U/μL, with neutrophilia (90%); other blood tests were in normal range. Body temperature was 39.2°C. Electrocardiogram showed sinus rhythm with 92 heart rate. Chest X-ray was normal. Abdominal X-ray showed free subdiaphragmatic air. CT scan confirmed the suspicion of small bowel perforation because of the finding of free fluid in the abdomen and an inhomogeneous mass in the small bowel. A nasogastric tube was placed, and it drained 50 mL of biliogastric material. Because of her status, she was immediately ran to the theater for exploratory laparotomy under general anesthesia and oral intubation. Although each clinical finding suggested a colonic or caecum perforation, during the systematic exploration of the bowel loops, surgeons found free intestinal fluid in the abdomen, fecal peritonitis, and (at 60–70 from ileocaecal valve) a 3 cm linear tear of the ileum which was caused by the curve edge of a shell mussel . The foreign body was completely extracted from the lumen through the hole , and the breach was sutured with simple double-strand stitches of polyglactin 3/0 parallel to the bowel tearing. Abdominal cavity washing was carried out with 2 liters of saline. Two drains were placed on suction for 24 hours. Antibiotic therapy (ciprofloxacin, meropenem, and metronidazole) and nil by mouth regimen were started. Patient was admitted in Intensive Care Unit for 12 hours, the weaning from the ventilator, and she was discharged at home in healthy status from the ward on the sixth postoperative day. At the 30-day follow-up, the patient was in good clinical condition, surgical wounds were completely sealed, blood tests were normal, and bowel function was recovered.", + "fulltext_subclaims": [ + "The patient was a 55-year-old Caucasian obese woman.", + "The patient was admitted to the Surgical Department for acute abdominal pain.", + "Her past medical history was negative for previous gastrointestinal disease or surgery.", + "She was on medical therapy for hypertension.", + "She was on medical therapy for type II diabetes.", + "She was on medical therapy for minor depression.", + "The Glasgow coma scale was 15.", + "She referred an increasing acute abdominal pain that arose 5 hours ago after a fish-based dinner.", + "She showed an acute diffuse peritonitis.", + "White blood cell count was 32.000 U/μL.", + "Neutrophilia was 90%.", + "Other blood tests were in normal range.", + "Body temperature was 39.2°C.", + "Electrocardiogram showed sinus rhythm with 92 heart rate.", + "Chest X-ray was normal.", + "Abdominal X-ray showed free subdiaphragmatic air.", + "CT scan confirmed the suspicion of small bowel perforation.", + "A nasogastric tube was placed and it drained 50 mL of biliogastric material.", + "The patient was immediately taken to the theater for exploratory laparotomy under general anesthesia and oral intubation.", + "During the systematic exploration of the bowel loops, surgeons found free intestinal fluid in the abdomen.", + "During the systematic exploration of the bowel loops, surgeons found fecal peritonitis.", + "During the systematic exploration of the bowel loops, surgeons found a 3 cm linear tear of the ileum.", + "The tear was caused by the curve edge of a shell mussel.", + "The foreign body was completely extracted from the lumen through the hole.", + "The breach was sutured with simple double-strand stitches of polyglactin 3/0 parallel to the bowel tearing.", + "Abdominal cavity washing was carried out with 2 liters of saline.", + "Two drains were placed on suction for 24 hours.", + "Antibiotic therapy (ciprofloxacin, meropenem, and metronidazole) was started.", + "Nil by mouth regimen was started.", + "The patient was admitted in Intensive Care Unit for 12 hours.", + "The patient was discharged at home on the sixth postoperative day.", + "At the 30-day follow-up, the patient was in good clinical condition.", + "At the 30-day follow-up, surgical wounds were completely sealed.", + "At the 30-day follow-up, blood tests were normal.", + "At the 30-day follow-up, bowel function was recovered." + ], + "summary": "We present the first hitherto reported case of mussel shell ingestion, which caused acute abdominal pain in a 55-year-old woman. The shell pierced ileal loops, and it was found in the abdominal cavity.", + "summary_subclaims": [ + "This is the first hitherto reported case of mussel shell ingestion.", + "A 55-year-old woman had acute abdominal pain.", + "The mussel shell pierced ileal loops.", + "The mussel shell was found in the abdominal cavity." + ] + }, + { + "id": "multiclinsum_test_911_en.txt", + "fulltext": "A 36-year-old male patient was hospitalized due to complaints of a gradually aggravated pain on the lateral side of the left scapula for 6 months. Imaging examination showed that the neoplastic lesions on the left side of C7-T2 invaded the vertebral body of T1, T2, and caput costae of the second rib . Tumor metastasis in the left ilium was suspected . A computed tomography (CT)-guided core needle biopsy was performed to obtain the tissue samples of the paravertebral lesion in T2 and the lesion in the left ilium. The pathological results confirmed the diagnosis of FDCS. Diffuse small spindle cells were found in the hematoxylin and eosin (H&E) staining of both paravertebral and iliac lesions. Immunohistochemical staining of the paravertebral sample was positive for cytokeratin (CK){pan} and vimentin; partially positive for cluster of differentiation 68 (CD68){KP1} and epithelial membrane antigen (EMA); slightly positive for S100 and CD34; and negative for SRY-box transcription factor 10 (Sox10), Langerin, thyroid transcription factor 1 (TTF-1), and prostatic specific acid phosphatase (PSAP) . Immunohistochemical staining of the iliac sample was positive for CK{pan}, vimentin, CD68{KP1}, and epidermal growth factor receptor (EGFR); partially positive for Clusterin; slightly positive for S100, CD35, and CD20; and negative for CD21, Sox10, Langerin, and CXC chemokine ligand 13 (CXCL13) .\nTumor resection and nerve root decompression were performed as treatment for thoracic disease. A midline incision was made, and the lamina and facet joints of T1–T3 were exposed. Four pedicle screws were implanted in T1 and T3 . The left lamina and facet joint of T1 and T2 were resected . The left second costovertebral joint and the second rib head were also resected. Transpedicular curettage was performed to ensure sufficient neural decompression of the tumor, providing a safe target volume for radiation.\nThe body gamma knife was used as a radical treatment for iliac tumor and as an adjuvant treatment for thoracic disease. Body gamma knife planning and delivery were similar to those reported in previous studies (, , ). The patient was placed in a supine position and immobilized using a vacuum negative pressure bag and a body frame bed, allowing to breathe naturally. Markings were made on the four areas of the body that will receive the radiation to ensure reproducible body position. The CT images were transferred to the OPEN body gamma knife treatment planning system. A local bone destruction lesion was found at the posterior lower edge of the left ilium (near the sacroiliac joint) with clear boundaries and soft tissue density. The treatment target area was determined in the bone window on the CT image using the body gamma knife treatment planning system (window width, 1,000 HU; window level, 300 HU). The gross target volume (GTV) was delineated according to the lesion identified in the bone window. The clinical target volume (CTV) was generated by extending the GTV by 5 mm in all directions. The planning target volume (PTV) was generated by extending the CTV by 5 mm in all directions. The 50% radiation dose covered 100% of the PTV, the 60% dose covered 100% of the CTV, and the 70% dose covered 100% of the GTV. For the iliac lesion, the prescription dose for the PTV, CTV, and GTV margins were 40, 48, and 56 Gy in 10 fractions, respectively. The highest physical dose delivered at the center of the target area was 80 Gy. The biological effective dose (BED) of the RT was calculated using a linear quadratic (LQ) model, assuming an α/β ratio of 10. The BEDs at the margins of PTV, CTV, and GTV were 56, 71.04, and 87.36 Gy, respectively, and the highest BED delivered at the center of the target area was 144 Gy. For the thoracic lesion, the prescription doses for PTV, CTV, and GTV margins were 36, 43.2, and 50.4 Gy in 12 fractions, respectively. The highest physical dose delivered at the center of the target area was 72 Gy. The BEDs delivered to the margins of the PTV, CTV, and GTV were 46.8, 58.752, and 71.568 Gy, respectively, and the highest BED delivered at the center of the target area was 115.2 Gy. Radiotherapy target planning of thoracic and iliac lesions was presented in . The treatment process proceeded smoothly, the patient had no complaints, and no abnormal findings were found on blood tests after RT.\nThe patient did not receive systemic treatment or other local control treatments after the body gamma knife treatment. CT examination of the iliac bone showed that the lesion size was slightly larger than that before the 2-month postoperative follow-up . Thus, iliac bone lesion resection was performed 10 weeks after RT. The pathological examination of the left iliac bone tumor suggested a small amount of bone tissue, fibrous tissue hyperplasia and hemorrhage, myofibroblast reaction, lymphocyte and plasma cell infiltration, a small amount of necrosis, and tissue cell deposition, while no tumor tissue was observed . Thus, the body gamma knife treatment resulted in PCR. The patient was followed up for 1 year, and the VAS score for back pain reduced from 8 at preoperatively to 1 at the last follow-up. Thoracic and pelvic magnetic resonance imaging (MRI) examinations showed no significant enlargement or recurrence of the tumors after 15 months of follow-up . The timeline of major clinical events during treatment and follow-up is shown in .", + "fulltext_subclaims": [ + "A 36-year-old male patient was hospitalized due to complaints of a gradually aggravated pain on the lateral side of the left scapula for 6 months.", + "Imaging examination showed that the neoplastic lesions on the left side of C7-T2 invaded the vertebral body of T1, T2, and caput costae of the second rib.", + "Tumor metastasis in the left ilium was suspected.", + "A computed tomography (CT)-guided core needle biopsy was performed to obtain the tissue samples of the paravertebral lesion in T2 and the lesion in the left ilium.", + "The pathological results confirmed the diagnosis of FDCS.", + "Diffuse small spindle cells were found in the hematoxylin and eosin (H&E) staining of both paravertebral and iliac lesions.", + "Immunohistochemical staining of the paravertebral sample was positive for cytokeratin (CK){pan} and vimentin.", + "Immunohistochemical staining of the paravertebral sample was partially positive for cluster of differentiation 68 (CD68){KP1} and epithelial membrane antigen (EMA).", + "Immunohistochemical staining of the paravertebral sample was slightly positive for S100 and CD34.", + "Immunohistochemical staining of the paravertebral sample was negative for SRY-box transcription factor 10 (Sox10), Langerin, thyroid transcription factor 1 (TTF-1), and prostatic specific acid phosphatase (PSAP).", + "Immunohistochemical staining of the iliac sample was positive for CK{pan}, vimentin, CD68{KP1}, and epidermal growth factor receptor (EGFR).", + "Immunohistochemical staining of the iliac sample was partially positive for Clusterin.", + "Immunohistochemical staining of the iliac sample was slightly positive for S100, CD35, and CD20.", + "Immunohistochemical staining of the iliac sample was negative for CD21, Sox10, Langerin, and CXC chemokine ligand 13 (CXCL13).", + "Tumor resection and nerve root decompression were performed as treatment for thoracic disease.", + "A midline incision was made, and the lamina and facet joints of T1–T3 were exposed.", + "Four pedicle screws were implanted in T1 and T3.", + "The left lamina and facet joint of T1 and T2 were resected.", + "The left second costovertebral joint and the second rib head were also resected.", + "Transpedicular curettage was performed to ensure sufficient neural decompression of the tumor, providing a safe target volume for radiation.", + "The body gamma knife was used as a radical treatment for iliac tumor and as an adjuvant treatment for thoracic disease.", + "The patient was placed in a supine position and immobilized using a vacuum negative pressure bag and a body frame bed, allowing to breathe naturally.", + "Markings were made on the four areas of the body that will receive the radiation to ensure reproducible body position.", + "The CT images were transferred to the OPEN body gamma knife treatment planning system.", + "A local bone destruction lesion was found at the posterior lower edge of the left ilium (near the sacroiliac joint) with clear boundaries and soft tissue density.", + "The treatment target area was determined in the bone window on the CT image using the body gamma knife treatment planning system (window width, 1,000 HU; window level, 300 HU).", + "The gross target volume (GTV) was delineated according to the lesion identified in the bone window.", + "The clinical target volume (CTV) was generated by extending the GTV by 5 mm in all directions.", + "The planning target volume (PTV) was generated by extending the CTV by 5 mm in all directions.", + "The 50% radiation dose covered 100% of the PTV, the 60% dose covered 100% of the CTV, and the 70% dose covered 100% of the GTV.", + "For the iliac lesion, the prescription dose for the PTV, CTV, and GTV margins were 40, 48, and 56 Gy in 10 fractions, respectively.", + "The highest physical dose delivered at the center of the target area was 80 Gy.", + "The biological effective dose (BED) of the RT was calculated using a linear quadratic (LQ) model, assuming an α/β ratio of 10.", + "The BEDs at the margins of PTV, CTV, and GTV were 56, 71.04, and 87.36 Gy, respectively, and the highest BED delivered at the center of the target area was 144 Gy.", + "For the thoracic lesion, the prescription doses for PTV, CTV, and GTV margins were 36, 43.2, and 50.4 Gy in 12 fractions, respectively.", + "The highest physical dose delivered at the center of the target area was 72 Gy.", + "The BEDs delivered to the margins of the PTV, CTV, and GTV were 46.8, 58.752, and 71.568 Gy, respectively, and the highest BED delivered at the center of the target area was 115.2 Gy.", + "Radiotherapy target planning of thoracic and iliac lesions was presented.", + "The treatment process proceeded smoothly, the patient had no complaints, and no abnormal findings were found on blood tests after RT.", + "The patient did not receive systemic treatment or other local control treatments after the body gamma knife treatment.", + "CT examination of the iliac bone showed that the lesion size was slightly larger than that before the 2-month postoperative follow-up.", + "Iliac bone lesion resection was performed 10 weeks after RT.", + "The pathological examination of the left iliac bone tumor suggested a small amount of bone tissue, fibrous tissue hyperplasia and hemorrhage, myofibroblast reaction, lymphocyte and plasma cell infiltration, a small amount of necrosis, and tissue cell deposition, while no tumor tissue was observed.", + "Thus, the body gamma knife treatment resulted in PCR.", + "The patient was followed up for 1 year, and the VAS score for back pain reduced from 8 at preoperatively to 1 at the last follow-up.", + "Thoracic and pelvic magnetic resonance imaging (MRI) examinations showed no significant enlargement or recurrence of the tumors after 15 months of follow-up." + ], + "summary": "A 36-year-old male patient was hospitalized at Zhongshan Hospital, Fudan University, due to a gradually aggravated pain on the lateral side of the left scapula for 6 months. Imaging examination showed neoplastic lesions on the left side of C7-T2 invading the vertebral body of T1, T2, and caput costae of the second rib and suspected metastasis in the left ilium. FDCS was diagnosed after performing a computed tomography (CT)-guided core needle biopsy, and the thoracic lesion was surgically resected. The body gamma knife was used as an adjuvant radiotherapy for the thoracic lesion and a primary therapy for the left ilium lesion. Iliac bone lesion resection was performed at Zhongshan Hospital, Fudan University, 10 weeks after RT. Compared with the biopsy report, the body gamma knife treatment resulted in a pathological complete response (PCR). The magnetic resonance imaging (MRI) examinations showed stable disease of the thoracic lesion after body gamma knife radiosurgery.", + "summary_subclaims": [ + "A 36-year-old male patient was hospitalized at Zhongshan Hospital, Fudan University.", + "The patient had a gradually aggravated pain on the lateral side of the left scapula for 6 months.", + "Imaging examination showed neoplastic lesions on the left side of C7-T2.", + "The lesions invaded the vertebral body of T1, T2, and caput costae of the second rib.", + "The imaging suggested suspected metastasis in the left ilium.", + "FDCS was diagnosed after performing a computed tomography (CT)-guided core needle biopsy.", + "The thoracic lesion was surgically resected.", + "The body gamma knife was used as an adjuvant radiotherapy for the thoracic lesion.", + "The body gamma knife was used as a primary therapy for the left ilium lesion.", + "Iliac bone lesion resection was performed at Zhongshan Hospital, Fudan University, 10 weeks after RT.", + "Compared with the biopsy report, the body gamma knife treatment resulted in a pathological complete response (PCR).", + "Magnetic resonance imaging (MRI) examinations showed stable disease of the thoracic lesion after body gamma knife radiosurgery." + ] + }, + { + "id": "multiclinsum_test_2374_en.txt", + "fulltext": "A 50-year-old housewife was diagnosed to have end-stage renal disease of uncertain etiology. After being on hemodialysis for one year, she underwent living unrelated renal transplantation at another centre with basiliximab induction followed by triple drug immunosuppression with tacrolimus (trough level 6.7-8.8 ng/mL), mycophenolate mofetil (1 gm twice daily) and prednisolone (5 mg daily). The pretransplant CMV sero-status of the donor and recipient was not known and she was not on prophylaxis for CMV. Three months post transplant, she was admitted with fever, headache, oral ulcers and dysphagia of one week duration and soon after admission she developed slurring of speech with drowsiness and weakness of left upper and lower limbs. During the preceding three months, she had maintained normal graft function and did not receive any anti-rejection therapy. There was no history of contact with pets or occupational exposure. At presentation, she was hemodynamically stable, febrile, had multiple oral ulcers with left hemiparesis and right upper motor neuron facial palsy. Her hemoglobin was 112 gm/L, total leukocyte count 7.8 × 109/L, platelet count 145 × 109/L and serum creatinine 78 μmol/L. Noncontrast computerized tomography (CT) followed by magnetic resonance imaging of brain revealed a 3 × 3 cm hypodense lesion in right temporo-parietal region with significant peri-lesional edema . An endoscopic examination for dysphagia revealed multiple esophageal ulcers, biopsy from which was positive for cytomegalovirus inclusions. Whole blood quantitative polymerase chain reaction (PCR) for CMV was positive with 17500 copies/mL. Simultaneously, a stereotactic biopsy from the brain lesion was performed. Fungal staining of the material showed septate hyphae, while fungal cultures grew melanin producing filamentous fungi with brown-black colonies. A lactophenol cotton blue mount demonstrated numerous single-celled, broadly clavate to ovoid conidia, 4–9 × 6–10 mm in size, rounded above with truncate bases, borne singly or in small groups on elongated, simple or branched conidiophores or on hyphae. These features confirmed the diagnosis of Scedosporium apiospermum . Mycophenolate mofetil and tacrolimus were stopped and she was started on intravenous (i.v.) ganciclovir and i.v. voriconazole. After one week of therapy, she became afebrile with improvement of power in the left upper limb. A repeat CT scan of the head done after one week showed reduction in size of the lesion . After 3 weeks of therapy, the patient showed significant improvement in the slurred speech and she became ambulatory with support. There was significant reduction in size in repeat CT scan. Repeat CMV PCR done after three weeks was negative and patient was started on valganciclovir prophylaxis and oral voriconazole. The levels of voriconazole were monitored and maintained between 1–5.0 μg/mL for initial 3 months. At the end of two months, she was readmitted with fever and dry cough. Chest radiograph and high resolution CT chest showed thin smooth walled cavitary lesion with surrounding consolidation. A fine-needle aspiration demonstrated acid-fast bacilli, which were confirmed to be Mycobacterium tuberculosis on culture. A CT chest was not obtained during the first hospitalization, thus we cannot exclude the possibility of either Scedosporium or tuberculosis in the lung at that time. She responded well with rifampicin based four drug antituberculous therapy. During the first month of rifampicin therapy, the median dose of voriconazole needed to be increased to 600 mg per day to maintain its levels in the therapeutic range, while subsequently voriconazole was given at a fixed dose of 200 mg once a day as secondary chemoprophylaxis. At six months of follow-up, she had recovered completely. She was maintaining normal graft function with prednisolone 10 mg once a day with a plan to introduce azathioprine. She continues to take 200 mg of voriconazole, while her antituberculous therapy and valganciclovir have been stopped. She was evaluated for an occult primary immunosuppressive disorder with defective cell mediated immunity, in view of the repeated life threatening infections. There was no hypogammaglobulinemia or CD4 cytopenia and her human immunodeficiency virus (HIV) status was negative.", + "fulltext_subclaims": [ + "The patient was diagnosed to have end-stage renal disease of uncertain etiology.", + "She underwent living unrelated renal transplantation at another centre.", + "The pretransplant CMV sero-status of the donor and recipient was not known.", + "She was not on prophylaxis for CMV.", + "Three months post transplant, she was admitted with fever, headache, oral ulcers and dysphagia of one week duration.", + "She developed slurring of speech with drowsiness and weakness of left upper and lower limbs.", + "During the preceding three months, she had maintained normal graft function.", + "Noncontrast computerized tomography followed by magnetic resonance imaging of brain revealed a 3 × 3 cm hypodense lesion in right temporo-parietal region with significant peri-lesional edema.", + "An endoscopic examination for dysphagia revealed multiple esophageal ulcers.", + "Biopsy from the esophageal ulcers was positive for cytomegalovirus inclusions.", + "Whole blood quantitative polymerase chain reaction for CMV was positive with 17500 copies/mL.", + "A stereotactic biopsy from the brain lesion was performed.", + "Fungal staining of the material showed septate hyphae.", + "Fungal cultures grew melanin producing filamentous fungi with brown-black colonies.", + "A lactophenol cotton blue mount demonstrated numerous single-celled, broadly clavate to ovoid conidia, 4–9 × 6–10 mm in size, rounded above with truncate bases, borne singly or in small groups on elongated, simple or branched conidiophores or on hyphae.", + "These features confirmed the diagnosis of Scedosporium apiospermum.", + "Mycophenolate mofetil and tacrolimus were stopped.", + "She was started on intravenous ganciclovir and intravenous voriconazole.", + "After one week of therapy, she became afebrile with improvement of power in the left upper limb.", + "A repeat CT scan of the head done after one week showed reduction in size of the lesion.", + "After 3 weeks of therapy, the patient showed significant improvement in the slurred speech.", + "She became ambulatory with support.", + "There was significant reduction in size in repeat CT scan.", + "Repeat CMV PCR done after three weeks was negative.", + "The patient was started on valganciclovir prophylaxis and oral voriconazole.", + "The levels of voriconazole were monitored and maintained between 1–5.0 μg/mL for initial 3 months.", + "At the end of two months, she was readmitted with fever and dry cough.", + "Chest radiograph and high resolution CT chest showed thin smooth walled cavitary lesion with surrounding consolidation.", + "A fine-needle aspiration demonstrated acid-fast bacilli.", + "These were confirmed to be Mycobacterium tuberculosis on culture.", + "A CT chest was not obtained during the first hospitalization.", + "We cannot exclude the possibility of either Scedosporium or tuberculosis in the lung at that time.", + "She responded well with rifampicin based four drug antituberculous therapy.", + "During the first month of rifampicin therapy, the median dose of voriconazole needed to be increased to 600 mg per day to maintain its levels in the therapeutic range.", + "Subsequently voriconazole was given at a fixed dose of 200 mg once a day as secondary chemoprophylaxis.", + "At six months of follow-up, she had recovered completely.", + "She was maintaining normal graft function with prednisolone 10 mg once a day with a plan to introduce azathioprine.", + "She continues to take 200 mg of voriconazole.", + "Her antituberculous therapy and valganciclovir have been stopped.", + "She was evaluated for an occult primary immunosuppressive disorder with defective cell mediated immunity.", + "There was no hypogammaglobulinemia or CD4 cytopenia.", + "Her human immunodeficiency virus status was negative." + ], + "summary": "We report a 50-year-old female, a renal allograft recipient who presented with left hemiplegia, esophageal ulcers and fever 3 months after her transplant. Esophageal biopsy revealed Cytomegalovirus (CMV) inclusions and the whole blood quantitative CMV polymerase chain reaction (PCR) was positive. Neuroimaging showed a brain abscess, stereotactic biopsy from which revealed Scedosporium apiospermum on fungal culture. Her tacrolimus and mycophenolate were stopped and she was managed with intravenous ganciclovir and voriconazole. With these measures, she showed marked improvement in her general and neurological condition. Two months later, she developed recurrence of fever with dry cough. Radiological investigation revealed a cavitating lung lesion, a needle aspiration from which demonstrated acid-fast bacilli. She was started on antituberculous treatment. With these measures, she recovered completely and maintained good graft function despite being on only prednisolone 10 mg once a day.", + "summary_subclaims": [ + "The patient is a 50-year-old female.", + "She is a renal allograft recipient.", + "She presented with left hemiplegia.", + "She presented with esophageal ulcers.", + "She presented with fever.", + "The presentation occurred 3 months after her transplant.", + "Esophageal biopsy revealed Cytomegalovirus (CMV) inclusions.", + "The whole blood quantitative CMV polymerase chain reaction (PCR) was positive.", + "Neuroimaging showed a brain abscess.", + "Stereotactic biopsy of the brain abscess revealed Scedosporium apiospermum on fungal culture.", + "Her tacrolimus and mycophenolate were stopped.", + "She was managed with intravenous ganciclovir.", + "She was managed with voriconazole.", + "She showed marked improvement in her general and neurological condition.", + "Two months later, she developed recurrence of fever.", + "She developed dry cough.", + "Radiological investigation revealed a cavitating lung lesion.", + "Needle aspiration of the lung lesion demonstrated acid-fast bacilli.", + "She was started on antituberculous treatment.", + "With these measures, she recovered completely.", + "She maintained good graft function.", + "She was on only prednisolone 10 mg once a day." + ] + }, + { + "id": "multiclinsum_test_1517_en.txt", + "fulltext": "A 21-year-old African-American male basketball player presented after a positive COVID-19 PCR test 1 month earlier for an RTP assessment. His COVID-19 symptoms included diarrhoea, cough, shortness of breath, and nasal congestion for 9 days. No intervention or hospitalization was needed, and he felt he was fully recovered and was asymptomatic. His vital signs and physical examination were normal. His cardiac exam was within normal limits, including no abnormal heart sounds, regular pulse and rhythm, and equal strong peripheral pulses. His respiratory exam showed no abnormal breath sounds with equal inspiratory effort. His resting electrocardiography (ECG) is shown in . He had no significant past family history of cardiomyopathies or sudden cardiac arrest before the age of 50 years. He denied any persistent dyspnoea, chest pain, palpitations, lightheadedness, dizziness, near syncope, or syncope. At that time, as per published guidance, an echocardiogram revealed normal left ventricular (LV) size and function (normal wall motion, diastolic function, and LV ejection fraction = 58%) (see , ). Troponin was undetectable. As the player was currently without symptoms, he returned to activity with a ramp-up of exercise.\nHe returned to exercise as per the recommendations and noted symptoms of shortness of breath and chest tightness, which began within a week of return to basketball practice. This prompted a halt in exercise and additional testing. Cardiac magnetic resonance (CMR) imaging revealed normal size and function with an ejection fraction of 55% with mild apical lateral hypokinesis and subepicardial late gadolinium enhancement involving the apical lateral segment. No active oedema was present. This finding was consistent with myocardial fibrosis/scar related to myocarditis . He was held from exercise as per the ACC/AHA recommendations for return to sport. After 2 months, he was symptom-free; we decided to proceed with a stress test that was positive for inferolateral repolarization abnormalities at rest and positive for a significant burden of premature ventricular complexes (PVCs) (right bundle superior axis) likely originating from the LV inferolateral at the base and non-sustained ventricular tachycardia (VT) with exercise during the recovery phase . He was again held from the activity for an additional 3 months. A repeat CMR and echocardiography showed the resolution of scar/fibrosis and the prior mild apical lateral hypokinesis . A repeat stress test found rare, isolated PVCs (right bundle superior axis) initially at rest that did not escalate with exercise and the absence of non-sustained VT at peak heart rate. Moreover, the patient had a normal exercise tolerance, normal hazard ratio, and blood pressure response without sustained arrhythmias.\nMoreover, on follow-up ECG at 3 and 6 months, the PVC morphology remained unchanged. At this point, he began a slow RTP by ramping up his activities. Of note, the patient did not receive any medical therapy for myocarditis throughout the observation period, as his cardiac function was preserved. After 1 month of exercise, he wore an ambulatory monitor for 1 week, inclusive of a graded return to an exercise regimen, which did not demonstrate any significant arrhythmias with exercise.", + "fulltext_subclaims": [ + "The patient is a 21-year-old African-American male basketball player.", + "He had a positive COVID-19 PCR test 1 month earlier.", + "He presented for an RTP assessment.", + "His symptoms included diarrhoea, cough, shortness of breath, and nasal congestion.", + "He had symptoms for 9 days.", + "No intervention or hospitalization was needed.", + "He felt he was fully recovered.", + "He was asymptomatic.", + "His vital signs and physical examination were normal.", + "His cardiac exam was within normal limits.", + "His resting electrocardiography (ECG) is shown.", + "He had no significant past family history of cardiomyopathies.", + "He had no significant past family history of sudden cardiac arrest before the age of 50 years.", + "He denied any persistent dyspnoea.", + "He denied any chest pain.", + "He denied any palpitations.", + "He denied any lightheadedness.", + "He denied any dizziness.", + "He denied any near syncope.", + "He denied any syncope.", + "An echocardiogram revealed normal left ventricular size.", + "An echocardiogram revealed normal left ventricular function.", + "The echocardiogram showed normal wall motion.", + "The echocardiogram showed normal diastolic function.", + "The echocardiogram showed an LV ejection fraction of 58%.", + "Troponin was undetectable.", + "He returned to activity with a ramp-up of exercise.", + "He returned to basketball practice.", + "He noted symptoms of shortness of breath.", + "He noted symptoms of chest tightness.", + "These symptoms began within a week of return to basketball practice.", + "This prompted a halt in exercise.", + "Cardiac magnetic resonance imaging revealed normal size.", + "Cardiac magnetic resonance imaging revealed normal function.", + "The ejection fraction was 55%.", + "There was mild apical lateral hypokinesis.", + "There was subepicardial late gadolinium enhancement involving the apical lateral segment.", + "No active oedema was present.", + "This finding was consistent with myocardial fibrosis/scar related to myocarditis.", + "He was held from exercise as per the ACC/AHA recommendations for return to sport.", + "After 2 months, he was symptom-free.", + "A stress test was positive for inferolateral repolarization abnormalities at rest.", + "A stress test was positive for a significant burden of premature ventricular complexes.", + "The PVCs were likely originating from the LV inferolateral at the base.", + "There was non-sustained ventricular tachycardia with exercise during the recovery phase.", + "He was again held from the activity for an additional 3 months.", + "A repeat CMR showed resolution of scar/fibrosis.", + "A repeat echocardiography showed resolution of the prior mild apical lateral hypokinesis.", + "A repeat stress test found rare, isolated PVCs.", + "The PVC morphology remained unchanged on follow-up ECG at 3 and 6 months.", + "He began a slow RTP by ramping up his activities.", + "The patient did not receive any medical therapy for myocarditis.", + "After 1 month of exercise, he wore an ambulatory monitor for 1 week.", + "The ambulatory monitor included a graded return to an exercise regimen.", + "The ambulatory monitor did not demonstrate any significant arrhythmias with exercise." + ], + "summary": "An elite-level basketball player presented after a positive COVID-19 test with findings consistent with ventricular tachycardia related to myocardial fibrosis/scar from a COVID-19-related myocarditis. Although rare, COVID-19 myocarditis can occur. This case illustrates how the consensus guidelines for return-to-play correctly identified the player as high risk with appropriate downstream evaluation by cardiac magnetic resonance (CMR) imaging. The stepwise approach is illustrated in this case and highlights the utility and success of the algorithm when approaching athletes with COVID-19-related myocarditis risk and determining a return to exercise.", + "summary_subclaims": [ + "An elite-level basketball player presented after a positive COVID-19 test with findings consistent with ventricular tachycardia related to myocardial fibrosis/scar from a COVID-19-related myocarditis.", + "This case illustrates how the consensus guidelines for return-to-play correctly identified the player as high risk.", + "The stepwise approach is illustrated in this case and highlights the utility and success of the algorithm when approaching athletes with COVID-19-related myocarditis risk and determining a return to exercise." + ] + }, + { + "id": "multiclinsum_test_761_en.txt", + "fulltext": "A 53-year-old Caucasian man was referred to our centre for absolute dysphagia. This, initiated 4 months before for both solids and liquids, had an insidious onset and was accompanied by a slight cough and persistent fever for which initial antibiotic therapy was prescribed. Fever, usually mild and constantly measured, peaked twice over 40°C.\nThe initial radiological assessment consisted of a chest X-ray showing a large right paratracheal mass. A computed tomography (CT) scan confirmed, at the level of the thorax, the presence of a large (7.5 cm) lobulated mass of heterogeneous density located below the carina. This was clearly compressing the oesophagus. . No evident signs of direct infiltration were found. No other abnormalities were found at the level of the brain, abdomen or pelvis.\nA subsequent orogastric endoscopic ultrasonography revealed a hypoechogenic lesion 5 cm in maximum diameter and 25 cm from the incisor teeth, with regular margins, directly compressing the oesophagus. Fine needle aspiration cytology, with double sampling by CT guided transthoracic and ultrasound guided transparietal endoscopic procedures in two different regions of the mass, revealed a loosely dispersed population of rare epithelioid atypical cells with prominent nucleoli and abundant eosinophilic cytoplasm. No lesions or compressions were detected at fibro-tracheo-bronchoscopic examination.\nBecause of the rapid worsening of symptomatology, the patient underwent surgical intervention with a minimally invasive approach, initially with diagnostic intent. Should resectability have been confirmed, a radical procedure was planned. A right video-assisted thoracoscopic biopsy was performed. The frozen section demonstrated a malignant epithelioid lesion. Lung origin was excluded and further thoracoscopic exploration confirmed the feasibility of a radical resection.\nThe lesion was radically resected via an open thoracotomy. No signs of direct infiltration of the mass were confirmed at the level of surrounding organs. In particular, the surface of contact with the oesophagus, the right atrium, the main right bronchus and the pulmonary artery was carefully explored. The vagus nerve was identified. A single chest drainage tube was left in situ. The postoperative period was uneventful. The patient started oral intake of fluids on the first postoperative day.\nGross pathologic examination of the posterior mediastinal mass showed a grey lobulated mass measuring 8 × 9 × 7 cm . Routine histologic studies showed large sheets of epithelioid cells with abundant eosinophilic to clear cytoplasm. Focal spindle cell features and brown pigment were also present. The mass showed peripheral compressed nodal tissue with anthracotic pigment. The nuclei showed frequent inclusions and prominent nucleoli . A Fontana-Masson stain confirmed the presence of melanin pigment in the cytoplasm of neoplastic cells. Immunohistochemical positivity for S-100, Melan A and HMB 45 confirmed the melanomatous nature.\nThe final diagnosis was malignant metastatic melanoma of a lymph node. No evidence of a primary tumour or superficial nodal involvement was detected outside the mediastinum. The patient is alive and well one year after the operation with no signs of recurrent disease in the mediastinum or appearance of other signs of disease elsewhere. Standard adjuvant immunotherapy has been administered.", + "fulltext_subclaims": [ + "The patient is a 53-year-old Caucasian man.", + "He was referred for absolute dysphagia.", + "The dysphagia had an insidious onset.", + "The dysphagia was for both solids and liquids.", + "The dysphagia had been present for 4 months.", + "The dysphagia was accompanied by a slight cough.", + "The dysphagia was accompanied by persistent fever.", + "Initial antibiotic therapy was prescribed.", + "Fever usually was mild and constantly measured.", + "Fever peaked twice over 40°C.", + "A chest X-ray showed a large right paratracheal mass.", + "A CT scan confirmed a large (7.5 cm) lobulated mass of heterogeneous density.", + "The mass was located below the carina.", + "The mass was compressing the oesophagus.", + "No evident signs of direct infiltration were found.", + "No other abnormalities were found at the level of the brain, abdomen, or pelvis.", + "Orogastric endoscopic ultrasonography revealed a hypoechogenic lesion 5 cm in maximum diameter.", + "The lesion was 25 cm from the incisor teeth.", + "The lesion had regular margins.", + "The lesion directly compressed the oesophagus.", + "Fine needle aspiration cytology was performed.", + "Double sampling was done by CT guided transthoracic and ultrasound guided transparietal endoscopic procedures.", + "The cytology revealed a loosely dispersed population of rare epithelioid atypical cells.", + "The cells had prominent nucleoli.", + "The cells had abundant eosinophilic cytoplasm.", + "No lesions or compressions were detected at fibro-tracheo-bronchoscopic examination.", + "The patient underwent surgical intervention with a minimally invasive approach.", + "A right video-assisted thoracoscopic biopsy was performed.", + "The frozen section demonstrated a malignant epithelioid lesion.", + "Lung origin was excluded.", + "The lesion was radically resected via an open thoracotomy.", + "No signs of direct infiltration of the mass were confirmed at the level of surrounding organs.", + "The surface of contact with the oesophagus was explored.", + "The surface of contact with the right atrium was explored.", + "The surface of contact with the main right bronchus was explored.", + "The surface of contact with the pulmonary artery was explored.", + "The vagus nerve was identified.", + "A single chest drainage tube was left in situ.", + "The postoperative period was uneventful.", + "The patient started oral intake of fluids on the first postoperative day.", + "Gross pathologic examination showed a grey lobulated mass measuring 8 × 9 × 7 cm.", + "Routine histologic studies showed large sheets of epithelioid cells.", + "The cells had abundant eosinophilic to clear cytoplasm.", + "Focal spindle cell features were present.", + "Brown pigment was present.", + "The mass showed peripheral compressed nodal tissue with anthracotic pigment.", + "The nuclei showed frequent inclusions.", + "The nuclei showed prominent nucleoli.", + "A Fontana-Masson stain confirmed the presence of melanin pigment in the cytoplasm of neoplastic cells.", + "Immunohistochemical positivity for S-100, Melan A, and HMB 45 confirmed the melanomatous nature.", + "The final diagnosis was malignant metastatic melanoma of a lymph node.", + "No evidence of a primary tumour was detected outside the mediastinum.", + "No evidence of superficial nodal involvement was detected elsewhere.", + "The patient is alive and well one year after the operation.", + "There are no signs of recurrent disease in the mediastinum.", + "There is no appearance of other signs of disease elsewhere.", + "Standard adjuvant immunotherapy has been administered." + ], + "summary": "A progressive severe dysphagia case is reported induced by a melanoma of unknown origin (metastatic to a posterior mediastinal lymph node). At the time of diagnosis, the lesion appeared as a large posterior mediastinal mass mimicking a neurogenic tumour with oesophageal involvement. After complete resection, pathological assessment of the tumour by immunohistochemistry was consistent with nodal metastatic melanoma.", + "summary_subclaims": [ + "A progressive severe dysphagia case is reported.", + "The dysphagia was induced by a melanoma of unknown origin.", + "The melanoma was metastatic to a posterior mediastinal lymph node.", + "At the time of diagnosis, the lesion appeared as a large posterior mediastinal mass.", + "The lesion mimicked a neurogenic tumour.", + "The lesion had oesophageal involvement.", + "After complete resection, pathological assessment of the tumour was performed.", + "The tumour was assessed by immunohistochemistry.", + "The immunohistochemistry was consistent with nodal metastatic melanoma." + ] + }, + { + "id": "multiclinsum_test_2578_en.txt", + "fulltext": "A 45-year-old male presented with cough for more than two months without obvious cause in August 2022. He claimed no other notable symptoms, and no evident abnormality was found in the laboratory blood test. Thus, infectious diseases were preliminarily excluded. For further examination, a chest CT scan showed that there were multiple nodules in both lungs with enlarged hilar lymph nodes, and multiple filling defects in both pulmonary arteries, consistent with pulmonary thromboembolism It was considered as tumor metastasis. An abdominal CT was performed for further evaluation. It showed an enlarged heterogeneous left renal mass almost completely replacing the left kidney (size 12.2 cm*9.7 cm), with mild perirenal fluid and fat stranding. There was associated tumor thrombus present in the left renal vein, along with enlarged metastatic retroperitoneal lymph nodes. The patient had a history of hypertension and diabetes, which were under well control with regular medication, and had no history of other diseases or surgery.\nThe patient underwent lung and kidney percutaneous core needle biopsy and the histological manifestations and immunochemistry (IHC) findings of the two samples are similar. Microscopically, the tumor cells were small to medium sized round or oval cells with poor adhesion. The cytoplasm was eosinophilic but scant, and the nucleoli were prominent with rough chromatin. The mitotic rate was high (> 10 mitotic figures per 10 high power field). Most of the tumor cells were organized in a solid sheets pattern. Large aeras of necrosis and partial myxoid stromal changes were observed . And in some aeras, the tumor cells were distributed around the open thin-walled vessels. Immunohistochemically, the tumor cells were focal positive for CD99 ; multifocal positive for WT1 with unequal strength, BRG1, focal weak positive for AE1/AE3 and diffuse positive for GATA3 , whereas S-100, Synaptophysin, Vimentin, CK7, PAX8 and TTF-1 were negative. The Ki67 proliferation index was high (> 80%). The fluorescence in situ hybridization (FISH) assay showed separated red and green signals or single red signals seen in the nuclei of 30% of tumor cells, suggesting the existence of CIC gene translocation . Moreover, the next generation sequencing (NGS) assay confirmed the existence of a fusion of CIC-LEUTX genes. The breakpoints were at chr19: 42799274 and chr19: 40276608 for CIC and LEUTX, respectively .\nThe patient received chemotherapy (paclitaxel + carboplatin) and immunotherapy(pabolizumab). However, brain metastases were found 2 months after diagnosis. Due to the rapid progression, a new chemotherapy regimen (Doxorubicin + vincristine + cyclophosphamide) and radiotherapy was applied. Unfortunately, treatment was not effective enough and the patient passed away 7 months after diagnosis.", + "fulltext_subclaims": [ + "A 45-year-old male presented with cough for more than two months without obvious cause in August 2022.", + "He claimed no other notable symptoms.", + "No evident abnormality was found in the laboratory blood test.", + "Infectious diseases were preliminarily excluded.", + "A chest CT scan showed multiple nodules in both lungs with enlarged hilar lymph nodes.", + "Multiple filling defects in both pulmonary arteries were observed.", + "The findings were considered as tumor metastasis.", + "An abdominal CT showed an enlarged heterogeneous left renal mass almost completely replacing the left kidney.", + "The left renal mass was 12.2 cm*9.7 cm in size.", + "There was mild perirenal fluid and fat stranding.", + "Tumor thrombus was present in the left renal vein.", + "Enlarged metastatic retroperitoneal lymph nodes were observed.", + "The patient had a history of hypertension.", + "The patient had a history of diabetes.", + "The patient's hypertension and diabetes were under well control with regular medication.", + "The patient had no history of other diseases or surgery.", + "The patient underwent lung and kidney percutaneous core needle biopsy.", + "The histological manifestations and immunochemistry findings of the two samples are similar.", + "Microscopically, the tumor cells were small to medium sized round or oval cells with poor adhesion.", + "The cytoplasm was eosinophilic but scant.", + "The nucleoli were prominent with rough chromatin.", + "The mitotic rate was high (> 10 mitotic figures per 10 high power field).", + "Most of the tumor cells were organized in a solid sheets pattern.", + "Large areas of necrosis and partial myxoid stromal changes were observed.", + "In some areas, the tumor cells were distributed around the open thin-walled vessels.", + "The tumor cells were focal positive for CD99.", + "The tumor cells were multifocal positive for WT1 with unequal strength.", + "The tumor cells were focal weak positive for AE1/AE3.", + "The tumor cells were diffuse positive for GATA3.", + "S-100, Synaptophysin, Vimentin, CK7, PAX8, and TTF-1 were negative.", + "The Ki67 proliferation index was high (> 80%).", + "The FISH assay showed separated red and green signals or single red signals seen in the nuclei of 30% of tumor cells.", + "The FISH assay suggested the existence of CIC gene translocation.", + "The NGS assay confirmed the existence of a fusion of CIC-LEUTX genes.", + "The breakpoints were at chr19: 42799274 and chr19: 40276608 for CIC and LEUTX, respectively.", + "The patient received chemotherapy (paclitaxel + carboplatin) and immunotherapy (pabolizumab).", + "Brain metastases were found 2 months after diagnosis.", + "A new chemotherapy regimen (Doxorubicin + vincristine + cyclophosphamide) and radiotherapy was applied.", + "Treatment was not effective enough.", + "The patient passed away 7 months after diagnosis." + ], + "summary": "A 45-year-old male was admitted to hospital with a dry cough for more than two months without obvious cause. Physical examination and laboratory tests revealed no notable abnormality. The CT scan demonstrated a mass in the left kidney and multiple nodules in both lungs. The percutaneous core needle biopsy showed similar histomorphology and immunophenotype of small round cell malignant tumors. Genetic test revealed a CIC-LEUTX gene fusion.", + "summary_subclaims": [ + "A 45-year-old male was admitted to hospital with a dry cough for more than two months without obvious cause.", + "Physical examination and laboratory tests revealed no notable abnormality.", + "The CT scan demonstrated a mass in the left kidney.", + "The CT scan demonstrated multiple nodules in both lungs.", + "The percutaneous core needle biopsy showed similar histomorphology and immunophenotype of small round cell malignant tumors.", + "Genetic test revealed a CIC-LEUTX gene fusion." + ] + }, + { + "id": "multiclinsum_test_913_en.txt", + "fulltext": "A 29-year-old black Cameroonian of Bamileke ethnicity, gravida 5, para 3 with a past obstetric history of two consecutive caesarean sections done 9 and 5 years ago. Also noted was a successful trial of scar 2 years after the second caesarean section and a uterine evacuation following a miscarriage at 8 weeks of gestation.\nThe patient before consultation in our facility had been hospitalised twice in an integrated health centre for mild pelvic discomfort and two episodes of bleeding per vaginum, for which she was managed with injectable progesterone and discharged with favourable evolution.\nThe client was then received in our emergency department at 20 weeks gestation with mild to moderate intermittent lower abdominal pains associated to mild epigastralgia. The client however had a history of fever 24 h before consultation but no urgency, frequency nor mictalgia were reported. The parameters at entry had as temperature 37 °C, blood pressure of 110/60 mmHg, Pulse rate of 94 beats per minute. Other physical examination findings included mild generalised abdominal tenderness on superficial and deep palpation which was worse at the pelvic region. The provisional diagnosis of threatened abortion (due to malaria or asymptomatic bacteriuria was considered) with acute appendicitis in pregnancy as differential. A rapid diagnostic test for malaria was done which was negative. The team on duty directly went into management with Omeprazole 20 mg tablets (1 tablet 12 hourly), phloroglucinol 80 mg injectable (1 ampoule 8 hourly) and Ampicilline injectable (1 g 8 hourly) while thick blood smears, urinalysis, obstetric ultrasound, and full blood count were requested for the next morning.\nHer evolution 4 h later was marked by an increase in the intensity of the abdominal pain which became generalised with altered general condition. The blood pressure was unmeasurable and the pulse feeble. Immediate paracentesis revealed 10 cc of fresh non coagulating blood. The diagnosis of ruptured ectopic pregnancy with abundant hemoperitoneum was considered and because of hemodynamic instability, the patient was immediately prepared for an emergency laparotomy with fluid and blood resuscitation.\nA midline subumbilical laparotomy was carried under general anaesthesia. The perioperative findings included: an abundant hemoperitoneum estimated to two litres; intact membranes containing the foetus in the abdominal cavity; rupture line along the old caesarean scar at the isthmic uterine region, detached placental tissue most of which was still inserted and covering the internal cervical os (see Figs. and ). The uterus and the intact membranes were carefully exteriorised. The hemoperitoneum was reduced with the help of sterile abdominal towels. Careful detachment of the placenta and repair of the opening with vicryl 1 suture was done. The patient was placed on antibioprophylaxis with Ampicilline injectable (1 g 8 hourly for 2 days) and analgesics (1000 mg of injectable paracetamol 8 hourly for 3 days). The postoperative recovery was uneventful and the patient was discharged 7 days following surgery. Follow-up of the patient to 1 year after surgery was uneventful.", + "fulltext_subclaims": [ + "The patient is a 29-year-old black Cameroonian of Bamileke ethnicity.", + "She is gravida 5, para 3.", + "She had two consecutive caesarean sections 9 and 5 years ago.", + "She had a successful trial of scar 2 years after the second caesarean section.", + "She had a uterine evacuation following a miscarriage at 8 weeks of gestation.", + "Before consultation in our facility, she had been hospitalised twice in an integrated health centre.", + "She had mild pelvic discomfort and two episodes of bleeding per vaginum.", + "She was managed with injectable progesterone and discharged with favourable evolution.", + "She was received in the emergency department at 20 weeks gestation.", + "She had mild to moderate intermittent lower abdominal pains.", + "She had mild epigastralgia.", + "She had a history of fever 24 h before consultation.", + "The temperature at entry was 37 °C.", + "The blood pressure at entry was 110/60 mmHg.", + "The pulse rate at entry was 94 beats per minute.", + "The provisional diagnosis was threatened abortion.", + "A rapid diagnostic test for malaria was done.", + "The malaria test was negative.", + "Omeprazole 20 mg tablets were given 12 hourly.", + "Phloroglucinol 80 mg injectable was given 8 hourly.", + "Ampicilline injectable 1 g was given 8 hourly.", + "Thick blood smears, urinalysis, obstetric ultrasound, and full blood count were requested.", + "Four hours later, the abdominal pain became generalised.", + "The blood pressure was unmeasurable.", + "Immediate paracentesis revealed 10 cc of fresh non coagulating blood.", + "The diagnosis of ruptured ectopic pregnancy with abundant hemoperitoneum was considered.", + "The patient was immediately prepared for an emergency laparotomy.", + "A midline subumbilical laparotomy was carried under general anaesthesia.", + "The hemoperitoneum was estimated to two litres.", + "The rupture line was along the old caesarean scar at the isthmic uterine region.", + "The placental tissue was detached and most of it was still inserted.", + "The placenta was carefully detached and the opening repaired with vicryl 1 suture.", + "The patient was placed on Ampicilline injectable 1 g 8 hourly for 2 days.", + "The patient was placed on injectable paracetamol 1000 mg 8 hourly for 3 days.", + "The postoperative recovery was uneventful.", + "The patient was discharged 7 days following surgery.", + "Follow-up of the patient to 1 year after surgery was uneventful." + ], + "summary": "We report a case of a ruptured caesarean scar pregnancy in a 29 year-old gravida 5, para 3 with a past obstetric history of two consecutive caesarean sections done 9 and 5 years ago respectively. The patient presented with intermittent lower abdominal pains on a 20 weeks gestation associated with mild epigastralgia and 2 previous episodes of mild pervaginal bleeding (2 and 1 months ago respectively before consultation) managed with injectable progesterone. Her evolution 4 h later was marked by an increase in the intensity of the abdominal pain, an unmeasurable blood pressure and a feeble pulse. Immediate paracentesis revealed 10 cc of fresh non coagulating blood. The diagnosis of ruptured ectopic pregnancy with abundant hemoperitoneum was considered and an emergency laparotomy with fluid and blood resuscitation was carried out. A midline laparotomy revealed a ruptured caesarean scar ectopic pregnancy with an abundant hemoperitoneum. Careful resection of the placenta and repair of the ruptured isthmic region of the uterus was carried out. Recovery after surgery was without complications and the patient was discharged on the 6th day following surgery.", + "summary_subclaims": [ + "The patient was a 29 year-old gravida 5, para 3.", + "The patient had two consecutive caesarean sections 9 and 5 years ago.", + "The patient presented with intermittent lower abdominal pains at 20 weeks gestation.", + "The patient had mild epigastralgia.", + "The patient had two previous episodes of mild pervaginal bleeding 2 and 1 months before consultation.", + "The episodes of mild pervaginal bleeding were managed with injectable progesterone.", + "Four hours after presentation, the patient had an increase in the intensity of the abdominal pain.", + "Four hours after presentation, the patient had unmeasurable blood pressure.", + "Four hours after presentation, the patient had a feeble pulse.", + "Immediate paracentesis revealed 10 cc of fresh non coagulating blood.", + "The diagnosis of ruptured ectopic pregnancy with abundant hemoperitoneum was considered.", + "An emergency laparotomy with fluid and blood resuscitation was carried out.", + "A midline laparotomy revealed a ruptured caesarean scar ectopic pregnancy with an abundant hemoperitoneum.", + "Careful resection of the placenta was carried out.", + "The ruptured isthmic region of the uterus was repaired.", + "Recovery after surgery was without complications.", + "The patient was discharged on the 6th day following surgery." + ] + }, + { + "id": "multiclinsum_test_2207_en.txt", + "fulltext": "A 78-year-old man was hospitalized to our hospital for a week owing to memory loss and poor responsiveness without obvious precipitating factors. Since the onset, he was in poor appetite and spirit, and occasionally unstable gait. The patient denied headache, dizziness, nausea, or vomiting, but he responded with intermittent headaches in the hospital. He had no ataxia, dystonia, speech disorder, and abnormal immunocompetence. There was also no history of cognitive decline, personality changes, seizures, radiation exposure, systemic infection, or other autoimmune diseases. His family history was unremarkable. Neurological examination did not show focal neurological signs. The patient was diagnosed with prostate cancer 3 years ago and got symptomatic treatment. On further evaluation, a routine blood investigation including HIV was done which was nonreactive.\nThe brain computed tomography (CT) disclosed three solid masses with slight hyper-attenuation, non-calcification, and non-cystic components. The biggest one was located in the third ventricle and the others were located in the body and posterior horn of the left lateral ventricle , MRI showed multifocal solid lesions in the same regions. They were slightly hypointense on T1WI and isointense to slightly hypointense on T2WI and T2WI dark-fluid images. While on diffusion-weighted imaging (DWI), the third ventricular lesion was hypointense, and the lateral ventricular lesion was slightly hyperintense, both of them with low apparent diffusion coefficient (ADC) values, all suggesting diffusion restricted. Post-enhanced, the ventricular lesions were significantly enhanced. Furthermore, parenchyma around the third ventricle displayed swelling and hyperintense on T2WI. It did not cause ventricular expansion and hydrocephalus above the lesions . He was diagnosed with intraventricular malignancy and based on his history of prostate cancer, the possibility of metastasis was considered clinically.\nIn order to determine the nature of the lesion and ensure smooth cerebrospinal fluid circulation in the third ventricle, the patient underwent a subtotal resection of the third ventricle tumor by transcallosal approach. Analysis of a frozen section was consistent with uncertain PCNSL. Immunohistochemistry revealed the tumor cells were positive for CD10, CD20, Bcl-6, MUM-1, C-MYC(10%), Bcl-2(90%), and Ki-67(80%), and negative for CD3, CD30, cyclin D1, ALK, and EBER in situ hybridization . The P53 was wild-type. Thus, the final diagnosis of the third ventricular tumor was DLBCL with a germinal center subtype. Postoperatively, the patient was in a shallow coma, and in poor overall condition. On day 17, he became critically unwell due to respiratory and circulatory failure and arrhythmia. But the families gave up continued resuscitation and requested to be discharged.", + "fulltext_subclaims": [ + "The patient was hospitalized for a week.", + "The patient had memory loss and poor responsiveness.", + "There were no obvious precipitating factors.", + "The patient had poor appetite and spirit since the onset.", + "The patient had occasionally unstable gait.", + "The patient denied headache, dizziness, nausea, or vomiting.", + "The patient responded with intermittent headaches in the hospital.", + "The patient had no ataxia.", + "The patient had no dystonia.", + "The patient had no speech disorder.", + "The patient had no abnormal immunocompetence.", + "There was no history of cognitive decline.", + "There was no history of personality changes.", + "There was no history of seizures.", + "There was no history of radiation exposure.", + "There was no history of systemic infection.", + "There was no history of other autoimmune diseases.", + "The family history was unremarkable.", + "Neurological examination did not show focal neurological signs.", + "The patient was diagnosed with prostate cancer 3 years ago.", + "The patient got symptomatic treatment.", + "A routine blood investigation including HIV was done.", + "The HIV test was nonreactive.", + "The brain CT disclosed three solid masses.", + "The masses had slight hyper-attenuation.", + "The masses were non-calcified.", + "The masses were non-cystic.", + "The biggest mass was located in the third ventricle.", + "MRI showed multifocal solid lesions in the same regions.", + "The lesions were slightly hypointense on T1WI.", + "The lesions were isointense to slightly hypointense on T2WI.", + "The lesions were isointense to slightly hypointense on T2WI dark-fluid images.", + "The third ventricular lesion was hypointense on DWI.", + "The lateral ventricular lesion was slightly hyperintense on DWI.", + "Both lesions had low ADC values.", + "The lesions suggested diffusion restricted.", + "Post-enhanced, the ventricular lesions were significantly enhanced.", + "The parenchyma around the third ventricle displayed swelling.", + "The parenchyma was hyperintense on T2WI.", + "There was no ventricular expansion.", + "There was no hydrocephalus above the lesions.", + "The patient was diagnosed with intraventricular malignancy.", + "The possibility of metastasis was considered clinically.", + "The patient underwent subtotal resection of the third ventricle tumor.", + "The resection was done by transcallosal approach.", + "The frozen section was consistent with uncertain PCNSL.", + "The tumor cells were positive for CD10.", + "The tumor cells were positive for CD20.", + "The tumor cells were positive for Bcl-6.", + "The tumor cells were positive for MUM-1.", + "The tumor cells were positive for C-MYC(10%).", + "The tumor cells were positive for Bcl-2(90%).", + "The tumor cells were positive for Ki-67(80%).", + "The tumor cells were negative for CD3.", + "The tumor cells were negative for CD30.", + "The tumor cells were negative for cyclin D1.", + "The tumor cells were negative for ALK.", + "The tumor cells were negative for EBER in situ hybridization.", + "The P53 was wild-type.", + "The final diagnosis of the third ventricular tumor was DLBCL with a germinal center subtype.", + "Postoperatively, the patient was in a shallow coma.", + "The patient was in poor overall condition.", + "On day 17, the patient became critically unwell.", + "The patient had respiratory failure.", + "The patient had circulatory failure.", + "The patient had arrhythmia.", + "The families gave up continued resuscitation.", + "The families requested to be discharged." + ], + "summary": "A 78-year-old man presented with memory loss and poor responsiveness for one week without obvious precipitating factors. Magnetic resonance imaging (MRI) showed lesions in the third ventricle and left lateral ventricles, which were slightly hypointense on T1-weighted imaging (T1WI), and isointense to slightly hypointense on T2-weighted imaging (T2WI). On DWI, the left lateral ventricular lesion was hyperintense, while the third ventricular lesion was hypointense. After the surgical procedure, the pathology and immunohistochemistry revealed diffuse large B-cell lymphoma (DLBCL).", + "summary_subclaims": [ + "The patient is a 78-year-old man.", + "He presented with memory loss and poor responsiveness for one week.", + "There were no obvious precipitating factors.", + "MRI showed lesions in the third ventricle and left lateral ventricles.", + "The lesions were slightly hypointense on T1-weighted imaging.", + "The lesions were isointense to slightly hypointense on T2-weighted imaging.", + "On DWI, the left lateral ventricular lesion was hyperintense.", + "On DWI, the third ventricular lesion was hypointense.", + "After the surgical procedure, the pathology and immunohistochemistry revealed diffuse large B-cell lymphoma." + ] + }, + { + "id": "multiclinsum_test_1492_en.txt", + "fulltext": "A 70-year-old man was diagnosed with lung adenocarcinoma (clinical T4N0M0) involving a right upper lobe mass of 4.0 cm in diameter and a metastatic nodule in the middle lobe. He underwent right upper and middle bilobectomy and systematic lymph node dissection through a posterolateral thoracotomy. On the second postoperative day, 1750 mL of white turbid fluid was drained through the chest tube and the effusion was diagnosed as chylothorax. During the first 24 h following implementation of a fat-free dietary regimen, the color of the discharge became transparent, but another 630 mL of discharge was observed. Although the amount of discharge reduced gradually, it was persistent. Chemical pleurodesis was performed on the sixth postoperative day for which 5 KE of OK-432 (Picibanil; Chugai Pharmaceutical, Tokyo, Japan) and 300 mg of minocycline were administered into the thoracic cavity. The discharge began to progressively diminish. Three days thereafter, the amount of discharge had decreased to 150 mL/day, and on the ninth postoperative day, the chest tube was removed. On the 14th postoperative day, the patient complained of dyspnea and dysphagia, and an upper mediastinal mass was detected on chest radiogram . Chest computed tomography revealed a large mediastinal fluid collection 6 cm in diameter surrounded by a thick capsule that was compressing the trachea and esophagus . The mass was suspected to be a mediastinal chyloma. Since the patient’s symptoms were gradually progressing, we performed surgery on the 15th postoperative day. Thirty minutes before the surgery, ice cream was given to the patient to help confirm the leakage point in the thoracic duct. Thoracoscopy revealed a small amount of chylous effusion in the thoracic cavity and an elastic mass in the upper mediastinum. When the thick capsule was incised, chyle began to spill out . Once the chyle had drained completely, we confirmed the point of leakage and repaired it using a Z-suture with 4–0 Prolene (Ethicon, Somerville, NJ) . The postoperative course was uneventful and the patient was free of any symptoms. He remained asymptomatic 12 months after discharge from the hospital.", + "fulltext_subclaims": [ + "The patient was a 70-year-old man.", + "He was diagnosed with lung adenocarcinoma.", + "The tumor was clinical T4N0M0.", + "The right upper lobe mass was 4.0 cm in diameter.", + "A metastatic nodule was present in the middle lobe.", + "He underwent right upper and middle bilobectomy.", + "Systematic lymph node dissection was performed.", + "The procedure was done through a posterolateral thoracotomy.", + "On the second postoperative day, 1750 mL of white turbid fluid was drained.", + "The effusion was diagnosed as chylothorax.", + "A fat-free dietary regimen was implemented.", + "During the first 24 h, the discharge became transparent.", + "Another 630 mL of discharge was observed.", + "The amount of discharge reduced gradually.", + "The discharge was persistent.", + "Chemical pleurodesis was performed on the sixth postoperative day.", + "5 KE of OK-432 was administered into the thoracic cavity.", + "300 mg of minocycline was administered into the thoracic cavity.", + "The discharge began to progressively diminish.", + "Three days after pleurodesis, the amount of discharge had decreased to 150 mL/day.", + "The chest tube was removed on the ninth postoperative day.", + "On the 14th postoperative day, the patient complained of dyspnea.", + "On the 14th postoperative day, the patient complained of dysphagia.", + "An upper mediastinal mass was detected on chest radiogram.", + "Chest computed tomography revealed a large mediastinal fluid collection 6 cm in diameter.", + "The mass was surrounded by a thick capsule.", + "The mass was compressing the trachea.", + "The mass was compressing the esophagus.", + "The mass was suspected to be a mediastinal chyloma.", + "Surgery was performed on the 15th postoperative day.", + "Ice cream was given to the patient 30 minutes before surgery.", + "Thoracoscopy revealed a small amount of chylous effusion in the thoracic cavity.", + "Thoracoscopy revealed an elastic mass in the upper mediastinum.", + "When the thick capsule was incised, chyle began to spill out.", + "The point of leakage was confirmed.", + "The leakage point was repaired using a Z-suture with 4–0 Prolene.", + "The postoperative course was uneventful.", + "The patient was free of any symptoms.", + "He remained asymptomatic 12 months after discharge." + ], + "summary": "A 70-year-old man underwent right upper and middle bilobectomy and systematic lymph node dissection through a posterolateral thoracotomy for lung cancer. On the second postoperative day, he developed chylothorax that was treated with dietary management and pleurodesis. The discharge diminished and his chest tube was removed on the ninth postoperative day. On the 14(th) postoperative day, the patient complained of dyspnea and dysphagia, and imaging studies revealed mediastinal chyloma. Thoracoscopic surgical drainage was performed and the site of chyle leakage was sutured.", + "summary_subclaims": [ + "The patient was a 70-year-old man.", + "The patient underwent right upper and middle bilobectomy.", + "The patient underwent systematic lymph node dissection.", + "The procedure was performed through a posterolateral thoracotomy.", + "The procedure was for lung cancer.", + "On the second postoperative day, the patient developed chylothorax.", + "The chylothorax was treated with dietary management.", + "The chylothorax was treated with pleurodesis.", + "The discharge diminished.", + "The chest tube was removed on the ninth postoperative day.", + "On the 14th postoperative day, the patient complained of dyspnea.", + "On the 14th postoperative day, the patient complained of dysphagia.", + "Imaging studies revealed mediastinal chyloma.", + "Thoracoscopic surgical drainage was performed.", + "The site of chyle leakage was sutured." + ] + }, + { + "id": "multiclinsum_test_1254_en.txt", + "fulltext": "A 63-year-old man having received a heart transplant due to dilated cardiomyopathy (May 2012) was hospitalized at the Department of Internal Medicine in Ilava hospital, Slovakia (December 2012). The patient had dyspnoea, left-sided bronchopneumonia and fevers. He was treated with amoxicillin/clavulanate and ciprofloxacin. The left-sided hemiparesis becoming hemiplegia evolved during the hospitalization. The CT (computed tomography) of the brain revealed numerous focal changes in the brain parenchyma, and suspected infra- and supratentorial metastatic lesions.\nThe patient was transferred to the ICU (Intensive Care Unit) of the Clinic of Infectology and Geographic Medicine (January 2013). His pulse was 75 BPM and blood pressure was 125/70 mm mercury. The patient had a headache, cough and he was afebrile, with hemiparesis on the left lower limb. Anti-oedemotous and switched antibiotic therapy by third-generation cephalosporin and metronidazole was initiated. The investigations were complemented by MRI (magnetic resonance imaging) of the brain, which did not prove metastases and showed numerous abscesses with a strong oedema supra- and infratentorially in the posterior cranial fossa. In the quest for the brain abscess etiology, biological materials were collected for serological and microbiological tests. Blood culture was sterile. The cerebrospinal fluid was negative for any bacteria and bacterial antigens (Neisseria meningitidis serotypes a, b, c, y, w135; Streptococcus group B; Haemophilus influenzae serotype b; Streptococcus pneumoniae; Escherichia coli K1). The mycological serology, antigens of Cryptococcus neoformans, Aspergillus spp. and Candida spp., was negative as well. The pus from the skin lesion was examined by the Gram staining technique, showing the presence of Gram-positive hyphae. Native preparation and Lactophenol Cotton Blue staining of the material from the skin biopsy revealed the same observation – numerous darkly pigmented fungal elements with septa. As a bacteriological examination was negative, the samples were further cultured on Sabouraud dextrose agar (SDA) (HPL SERVIS Ltd. Nesvady, Slovak Republic) or Sabouraud dextrose broth (SDB) (HPL SERVIS Ltd. Nesvady, Slovak Republic) with antibiotics. The SDA and SDB were incubated at both 25 °C and 37 °C. The growth rate was moderate and it took about 4–5 days of incubation. After that time, velvety, olivaceous, grey colonies with olivaceous, black reverse could be observed . Colonies did not produce any diffusible pigment. The slide culture of the mould was incubated at 25 °C and after 5–7 days showed dark-walled, septate hyphae with poor branching. The one-celled oval conidia (7.5–11 µm×2.5–4 µm) were smooth-walled and pale brown without pigmented hila. They formed long, coherent, sessile, lateral or terminal chains on undifferentiated hyphae . The fungus grew on SDA and malt agar at 42 °C, with the optimal growth temperature between 35 and 37 °C. The mould was urease positive, growth on 10% NaCl agar was negative and colonies could grow on media containing cycloheximide. Based on these results, the isolate was identified in our laboratory as C. bantiana. To confirm this observation, we performed DNA sequencing-based identification. DNA was extracted using a Qiagen kit according to the manufacturer’s protocol and used for PCR with a specific set of primers for the internal transcribed spacer (ITS) regions of the fungal rRNA gene ITS1 (5′-TCCGTAGGTGAACCTGCG-3′) and ITS4 (5′-TCCTCCGCTTATTGATATGC-3′) (Invitrogen) according to . The PCR products were sequenced twice in both directions and the consensus sequence (596 nt) was used for subsequent blastn analysis against the nucleotide database with standard blast settings. The consensus obtained was aligned with the sequence of the ITS1 and ITS2 region of C. bantiana strain 1394 (sequence ID GQ258793), which had the highest score (1037 bits). Over 578 nt of the alignment, 99% identity, 2 gaps and 8 mismatching nucleotides were observed. Other C. bantiana strain ITS sequences represented all 13 highest-scoring blast matches. Finally, the isolate was identified as C. bantiana based on morphological and physiological features, and on the DNA sequence analysis. The sequence obtained was registered in the genetic sequence database GenBank under accession number KM525668.\nSusceptibility testing to selected antimycotics was performed on RPMI medium by quantitative assay for determining the MIC (MIC Test Strip; Liofilchem). After 48–72 h of cultivation at 30 °C, the MICs of 0.006 mg posaconazole l−1, 0.125 mg voriconazole l−1, 0.016 mg itraconazole l−1 and 0.75 mg amphotericin B l−1, were evaluated. There are no standard guidelines for antifungal therapy and until now, it has not been confirmed that therapy alone can improve survival . The current recommendation for eradication of disease associated with dematiaceous fungi is a combination of total surgical excision followed by systemic antifungal therapy . Our patient received an intravenous administration of amphotericin B and intense anti-oedematous therapy. The status of the patient was not improved, retrograded neurological complications and accelerated respiratory insufficiency resulted in the patient’s death one month later (February 2013). As the death of the patient was classified as being due to systemic fungal infection, a pathological-anatomic autopsy was recommended. Finally, C. bantiana was isolated from autopsy material taken from the lung, brain and skin.", + "fulltext_subclaims": [ + "The patient was a 63-year-old man.", + "The patient received a heart transplant due to dilated cardiomyopathy in May 2012.", + "The patient was hospitalized at the Department of Internal Medicine in Ilava hospital, Slovakia in December 2012.", + "The patient had dyspnoea.", + "The patient had left-sided bronchopneumonia.", + "The patient had fevers.", + "The patient was treated with amoxicillin/clavulanate.", + "The patient was treated with ciprofloxacin.", + "The patient developed left-sided hemiparesis that became hemiplegia during hospitalization.", + "The CT of the brain revealed numerous focal changes in the brain parenchyma.", + "The CT of the brain showed suspected infra- and supratentorial metastatic lesions.", + "The patient was transferred to the ICU of the Clinic of Infectology and Geographic Medicine in January 2013.", + "The patient's pulse was 75 BPM.", + "The patient's blood pressure was 125/70 mm mercury.", + "The patient had a headache.", + "The patient had a cough.", + "The patient was afebrile.", + "The patient had hemiparesis on the left lower limb.", + "Anti-oedemotous therapy was initiated.", + "Antibiotic therapy was switched to a third-generation cephalosporin and metronidazole.", + "MRI of the brain did not prove metastases.", + "MRI of the brain showed numerous abscesses with strong oedema in the posterior cranial fossa.", + "Blood culture was sterile.", + "Cerebrospinal fluid was negative for any bacteria and bacterial antigens.", + "Mycological serology for Cryptococcus neoformans, Aspergillus spp., and Candida spp. was negative.", + "Gram staining of pus from the skin lesion showed the presence of Gram-positive hyphae.", + "Native preparation and Lactophenol Cotton Blue staining of the skin biopsy material revealed numerous darkly pigmented fungal elements with septa.", + "The isolate was identified in the laboratory as C. bantiana.", + "DNA sequencing-based identification was performed.", + "DNA was extracted using a Qiagen kit.", + "PCR was performed with specific primers for the ITS regions of the fungal rRNA gene.", + "The consensus sequence was aligned with the sequence of C. bantiana strain 1394.", + "The isolate was identified as C. bantiana based on morphological and physiological features and DNA sequence analysis.", + "The sequence obtained was registered in GenBank under accession number KM525668.", + "Susceptibility testing to selected antimycotics was performed.", + "The MIC of posaconazole was 0.006 mg l−1.", + "The MIC of voriconazole was 0.125 mg l−1.", + "The MIC of itraconazole was 0.016 mg l−1.", + "The MIC of amphotericin B was 0.75 mg l−1.", + "There are no standard guidelines for antifungal therapy.", + "The current recommendation for eradication of disease associated with dematiaceous fungi is a combination of total surgical excision followed by systemic antifungal therapy.", + "The patient received intravenous administration of amphotericin B.", + "The patient received intense anti-oedematous therapy.", + "The patient's status did not improve.", + "Retrograded neurological complications occurred.", + "Accelerated respiratory insufficiency occurred.", + "The patient died one month later in February 2013.", + "The patient's death was classified as being due to systemic fungal infection.", + "A pathological-anatomic autopsy was recommended.", + "C. bantiana was isolated from autopsy material taken from the lung, brain, and skin." + ], + "summary": "We report a new case of phaeohyphomycosis brain abscesses caused by C. bantiana in Slovakia. The patient was a 63-year-old man having undergone heart transplantation, with dyspnoea, left-sided bronchopneumonia and fevers. CT (computed tomography) and MRI (magnetic resonance imaging) of the brain revealed numerous abscesses. Bacterial infection was proven by neither the growth of bacteria in culture nor the presence of bacterial antigens. Direct microscopy of the pus from the brain abscess showed Gram-positive hyphae. The isolate was finally identified as C. bantiana based on morphological and physiological features, and on DNA sequence analysis.", + "summary_subclaims": [ + "We report a new case of phaeohyphomycosis brain abscesses caused by C. bantiana in Slovakia.", + "The patient was a 63-year-old man.", + "The patient had undergone heart transplantation.", + "The patient had dyspnoea.", + "The patient had left-sided bronchopneumonia.", + "The patient had fevers.", + "CT and MRI of the brain revealed numerous abscesses.", + "Bacterial infection was proven by neither the growth of bacteria in culture nor the presence of bacterial antigens.", + "Direct microscopy of the pus from the brain abscess showed Gram-positive hyphae.", + "The isolate was finally identified as C. bantiana based on morphological and physiological features.", + "The isolate was finally identified as C. bantiana based on DNA sequence analysis." + ] + }, + { + "id": "multiclinsum_test_2504_en.txt", + "fulltext": "A 56-year-old Caucasian woman was referred for treatment of a local recurrence of endometrial cancer with infiltration of her sacral bone and nerve plexus. After initial diagnosis of endometrial cancer in 2005 (pT1B N0 MX G1 L0 V0), a Wertheim-Meigs operation was performed with subsequent radiotherapy with the initial result of complete tumor remission. In 2009 the patient presented with histologically confirmed pulmonary metastases. Under anti-hormonal therapy (medroxyprogesterone acetate), again complete remission was achieved. At the start of 2012, 7 years after the initial diagnosis, the patient was admitted to our hospital due to a presacral recurrence of the endometrial cancer with infiltration and widespread destruction of the os sacrum.\nThe patient complained of severe back pain and a marked pain spreading out to her right leg, suggestive of nerve infiltration. Magnetic resonance imaging (MRI) showed infiltration of the os sacrum and the sacral plexus. The tumor size was 11.9 × 11.6cm in axial section and 14.9cm in craniocaudal direction .\nThe patient’s case was discussed at the multidisciplinary tumor board for therapy options: due to the immediate proximity to the sacral plexus the patient could neither undergo surgical therapy nor a second radiation therapy because of the high risk of neural destruction potentially resulting in paralysis. Due to its ablation mechanism IRE was deemed to be the best therapy option for the patient as palliative disease control.\nIRE uses a series of electrical pulses of microseconds to generate irreversible permeabilization of cell membranes and thereby induces cell death in the treated region. IRE seems to be highly effective in tissues with a high density of cell wall structures and less effective in tissues with a high concentration of collagenous and elastic fibers [,]. This – in contrast to thermal ablation techniques like radiofrequency ablation (RFA) or microwave ablation – potentially allows tumor cell ablation without concomitant destruction of connective tissue, blood vessels and nerves . Due to this potentially selective cell ablation technique, IRE was offered as a palliative therapy option because it provided the opportunity of tumor mass reduction and decrease of tumor burden with reduced risk of impairment of the sacral plexus and surrounding blood vessels. The procedure with risks and benefits was discussed with the patient and informed consent was obtained.\nThe patient was put under general anesthesia and neuromuscular blocking to prevent arrhythmia . The procedure was performed using a commercially available IRE system. Due to the large tumor volume (941cm3) a total of six needles were placed into the target area . The percutaneous placement of the electrodes was guided by computed tomography (CT) fluoroscopy as well as ultrasound using a multifrequency probe (1 to 5MHz). As recommended by the manufacturer and recorded by the IRE generator the following parameters were used: number of electrodes: six; type of electrodes: monopolar; distance of electrodes: 0.7cm (minimum), 1.2cm (maximum); impulses per electrode: 70; voltage: 1100V (minimum), 3000V (maximum). A stepwise ablation procedure with multiple replacements of the electrodes was performed, starting from a caudal position and moving to cranial. The first ablation procedure covered about 40% of the tumor mass and was stopped after 8 hours. Follow-up imaging showed good response to treatment in the caudal parts of the tumor with remaining viable tumor tissue in the cranial parts . The patient was scheduled for a second ablation procedure after 14 weeks to cover the formally not treated areas.\nDuring the two IRE procedures the patient did not have any cardiovascular events, in particular no supraventricular tachycardia and no atrial fibrillation. Complications, especially postinterventional paralysis or bleeding, were not observed. After the first ablation procedure the patient did not complain about aggravated back pain; neither sensory deficit, nor loss of strength in her legs, nor paresthesia were observed. A neurological examination after the second ablation session revealed a mild 4+ paresis of the right extensor hallucis longus (L4 to S1) with complete resolution after 4 weeks. No sensory loss or impairment of bladder function occurred. After the second intervention opiate medication could be withdrawn. Using carbamazepine (200mg twice a day) and Polamidone (levomethadone) (5mg three times a day) pain control was achieved. The patient’s 24 hour follow-up imaging after the second ablation as well as follow-up imaging after 8 weeks (consisting of contrast-enhanced ultrasound, MRI and a CT scan) showed wide ablation of the tumor with necrosis of most portions of the tumor and reduction of tumor volume to 791cm3.", + "fulltext_subclaims": [ + "A 56-year-old Caucasian woman was referred for treatment of a local recurrence of endometrial cancer with infiltration of her sacral bone and nerve plexus.", + "After initial diagnosis of endometrial cancer in 2005 (pT1B N0 MX G1 L0 V0), a Wertheim-Meigs operation was performed.", + "Subsequent radiotherapy was performed with the initial result of complete tumor remission.", + "In 2009 the patient presented with histologically confirmed pulmonary metastases.", + "Under anti-hormonal therapy (medroxyprogesterone acetate), again complete remission was achieved.", + "At the start of 2012, 7 years after the initial diagnosis, the patient was admitted to our hospital due to a presacral recurrence of the endometrial cancer with infiltration and widespread destruction of the os sacrum.", + "The patient complained of severe back pain and a marked pain spreading out to her right leg, suggestive of nerve infiltration.", + "Magnetic resonance imaging (MRI) showed infiltration of the os sacrum and the sacral plexus.", + "The tumor size was 11.9 × 11.6cm in axial section and 14.9cm in craniocaudal direction.", + "The patient’s case was discussed at the multidisciplinary tumor board for therapy options.", + "Due to the immediate proximity to the sacral plexus the patient could neither undergo surgical therapy nor a second radiation therapy because of the high risk of neural destruction potentially resulting in paralysis.", + "Due to its ablation mechanism IRE was deemed to be the best therapy option for the patient as palliative disease control.", + "IRE uses a series of electrical pulses of microseconds to generate irreversible permeabilization of cell membranes and thereby induces cell death in the treated region.", + "IRE seems to be highly effective in tissues with a high density of cell wall structures and less effective in tissues with a high concentration of collagenous and elastic fibers.", + "This – in contrast to thermal ablation techniques like radiofrequency ablation (RFA) or microwave ablation – potentially allows tumor cell ablation without concomitant destruction of connective tissue, blood vessels and nerves.", + "Due to this potentially selective cell ablation technique, IRE was offered as a palliative therapy option because it provided the opportunity of tumor mass reduction and decrease of tumor burden with reduced risk of impairment of the sacral plexus and surrounding blood vessels.", + "The procedure with risks and benefits was discussed with the patient and informed consent was obtained.", + "The patient was put under general anesthesia and neuromuscular blocking to prevent arrhythmia.", + "The procedure was performed using a commercially available IRE system.", + "Due to the large tumor volume (941cm3) a total of six needles were placed into the target area.", + "The percutaneous placement of the electrodes was guided by computed tomography (CT) fluoroscopy as well as ultrasound using a multifrequency probe (1 to 5MHz).", + "The following parameters were used: number of electrodes: six; type of electrodes: monopolar; distance of electrodes: 0.7cm (minimum), 1.2cm (maximum); impulses per electrode: 70; voltage: 1100V (minimum), 3000V (maximum).", + "A stepwise ablation procedure with multiple replacements of the electrodes was performed, starting from a caudal position and moving to cranial.", + "The first ablation procedure covered about 40% of the tumor mass and was stopped after 8 hours.", + "Follow-up imaging showed good response to treatment in the caudal parts of the tumor with remaining viable tumor tissue in the cranial parts.", + "The patient was scheduled for a second ablation procedure after 14 weeks to cover the formally not treated areas.", + "During the two IRE procedures the patient did not have any cardiovascular events, in particular no supraventricular tachycardia and no atrial fibrillation.", + "Complications, especially postinterventional paralysis or bleeding, were not observed.", + "After the first ablation procedure the patient did not complain about aggravated back pain; neither sensory deficit, nor loss of strength in her legs, nor paresthesia were observed.", + "A neurological examination after the second ablation session revealed a mild 4+ paresis of the right extensor hallucis longus (L4 to S1) with complete resolution after 4 weeks.", + "No sensory loss or impairment of bladder function occurred.", + "After the second intervention opiate medication could be withdrawn.", + "Using carbamazepine (200mg twice a day) and Polamidone (levomethadone) (5mg three times a day) pain control was achieved.", + "The patient’s 24 hour follow-up imaging after the second ablation as well as follow-up imaging after 8 weeks showed wide ablation of the tumor with necrosis of most portions of the tumor and reduction of tumor volume to 791cm3." + ], + "summary": "A 56-year-old Caucasian woman was referred for interventional treatment of an advanced local recurrence of endometrial cancer (11.9 × 11.6 × 14.9cm) with infiltration of the sacral bone and nerve plexus. Due to the immediate proximity to the sacral plexus, the patient could neither undergo surgical therapy nor a second radiation therapy. Due to its ablation mechanism irreversible electroporation was deemed to be the best therapy option.", + "summary_subclaims": [ + "The patient is a 56-year-old Caucasian woman.", + "The patient was referred for interventional treatment of an advanced local recurrence of endometrial cancer.", + "The tumor size is 11.9 × 11.6 × 14.9cm.", + "The tumor has infiltration of the sacral bone and nerve plexus.", + "Due to the immediate proximity to the sacral plexus, the patient could neither undergo surgical therapy nor a second radiation therapy.", + "Due to its ablation mechanism, irreversible electroporation was deemed to be the best therapy option." + ] + }, + { + "id": "multiclinsum_test_2252_en.txt", + "fulltext": "A 20-month-old Japanese boy presented with pectus carinatum with no relevant past or family medical history (including no history of metabolic/storage disorders) and as the second child in the family. He had presented to his family physician at 6 months of age with left rib protrusion, and at 18 months of age with left torticollis. At this time, chest X-ray showed deformity and protrusion of ribs (pectus carinatum), but there were no other symptoms suggestive of Morquio A syndrome; for example, joint contracture and peculiar facies were not present and there were no problems with sleep or respiration. The patient was referred to our department (Department of Pediatrics, Jikei University School of Medicine, Tokyo, Japan).\nAt the time of initial consultation in our department, the patient presented with normal growth for his age (height 83.3 cm, body weight 11.0 kg; 0.4 and 0.2 standard deviations, respectively, relative to growth standards for Japanese children ). On physical examination, we observed genu valgum, kyphosis, and pectus carinatum. Clear contracture of the elbow and knee joints was not observed. As part of our differential diagnosis based on these physical findings, and to rule out possible storage/metabolic diseases, we initiated a workup and measured urine GAG levels. We performed a quantitative urine mucopolysaccharide test and detected an elevation in GAGs: 97.7 µg/mL compared with a normal range of 5.3–34.0 µg/mL. The patient was admitted to the hospital for further examination.\nOn admission at 22 months of age, the patient presented with similar height and body weight and normal vital signs (body temperature 36.6 °C, blood pressure 94/- mmHg, heart rate 90 beats per minute, respiratory rate 35 breaths/minute). As at the initial consultation, genu valgum, kyphosis, and pectus carinatum were present . Detailed clinical examination did not reveal adventitious lung sounds or heart murmur, hepatosplenomegaly, neurological abnormalities, coarse facial features, macroglossia, tonsillar hypertrophy, or umbilical hernia. Ophthalmic examination did not reveal any corneal opacity. Blood tests did not reveal any abnormalities. Chest X-ray showed the flattening of ribs , thoracolumbar X-ray showed kyphoscoliosis and ovalization of the thoracolumbar vertebral body , and carpus X-ray showed short and stubby phalangeal bones with mild metaphyseal cupping and strikingly short metacarpals with proximal coning . Echocardiography revealed very slight tricuspid, pulmonary, and mitral valve regurgitation. Brain magnetic resonance imaging (MRI) did not reveal any clear abnormalities in the parenchyma.\nGiven these findings, blood enzyme activity for MPS I, MPS II, MPS IVA, and MPS VI was measured (Advanced Clinical Research Centre & Asian LSD Centre, Institute of Neurological Disorders, Tokyo, Japan). GALNS enzyme activity, indicative of MPS IVA, was found to be at very low levels (0.05 pmol/punch/hour) compared with normal levels (1.21–1.87 pmol/punch/hour). The enzyme activity levels for MPS I, MPS II, and MPS VI were within the normal range.\nGiven the low levels of GALNS enzyme activity in the blood, we strongly suspected a diagnosis of MPS IVA disease. To definitively diagnose, we measured GALNS enzyme activity in dermal fibroblasts; this assay showed a clinically significant low level (0.01 nmol/hour/mg protein) compared with normal levels (7.48–9.52 nmol/hour/mg protein). This finding established a definitive diagnosis of MPS IVA , also known as Morquio A syndrome.\nAt 30 months of age, treatment with elosulfase alfa enzyme replacement therapy (ERT) at 2 mg/kg/week was initiated and continued throughout the reported follow-up period (36 months after the start of treatment). Treatment did not begin before this date because ERT in Japan had not been approved. Both acetaminophen (10 mg/kg) and loratadine (5 mg) were given 30 minutes prior to ERT administration to reduce pain, fever, and allergic reaction.\nFor this report, the progress of the patient was followed for 36 months, during which time he was adherent to treatment and assessed yearly.\nUrine KS levels at the start of ERT were high (71.05 µg/mg creatinine) compared with the reference range (1.75–6.81 µg/mg creatinine) and decreased over time: 69.5%, 36.8%, and 47.1% of the pre-ERT level at 12 months, 24 months, and 36 months of treatment, respectively.\nThe patient grew 14.5 cm during the 36-month treatment period. To assess spinal deformity, a thoracolumbar MRI after 24 months of treatment showed deformity and hypoplasia of the vertebral body, hypoplasia of the odontoid process, and spinal canal stenosis at C2–C4 and Th2–Th4 (which worsened at 36 months). However, no neurological abnormalities were observed.\nTo assess physical endurance and exercise performance, a 6-minute walk test and a 3-minute stair climb test were conducted. The initial 6-minute walk test was conducted 12 months after the start of treatment; at 36 months the walking distance had increased by 68 m. The 3-minute stair climb test was conducted 24 months after the start of treatment; at 36 months the number of steps taken had decreased by 31.", + "fulltext_subclaims": [ + "A 20-month-old Japanese boy presented with pectus carinatum.", + "He had no relevant past or family medical history, including no history of metabolic/storage disorders.", + "He was the second child in the family.", + "He had presented to his family physician at 6 months of age with left rib protrusion.", + "At 18 months of age, he had left torticollis.", + "Chest X-ray showed deformity and protrusion of ribs (pectus carinatum).", + "There were no other symptoms suggestive of Morquio A syndrome.", + "Joint contracture and peculiar facies were not present.", + "There were no problems with sleep or respiration.", + "The patient was referred to the Department of Pediatrics, Jikei University School of Medicine, Tokyo, Japan.", + "At the time of initial consultation, the patient had normal growth for his age.", + "On physical examination, genu valgum, kyphosis, and pectus carinatum were observed.", + "Clear contracture of the elbow and knee joints was not observed.", + "A quantitative urine mucopolysaccharide test was performed.", + "Urine GAG levels were elevated at 97.7 µg/mL compared with a normal range of 5.3–34.0 µg/mL.", + "The patient was admitted to the hospital for further examination.", + "On admission at 22 months of age, the patient had normal vital signs.", + "Carpus X-ray showed short and stubby phalangeal bones with mild metaphyseal cupping and strikingly short metacarpals with proximal coning.", + "Echocardiography revealed very slight tricuspid, pulmonary, and mitral valve regurgitation.", + "Brain MRI did not reveal any clear abnormalities in the parenchyma.", + "GALNS enzyme activity was found to be at very low levels (0.05 pmol/punch/hour) compared with normal levels (1.21–1.87 pmol/punch/hour).", + "The enzyme activity levels for MPS I, MPS II, and MPS VI were within the normal range.", + "GALNS enzyme activity in dermal fibroblasts was at a clinically significant low level (0.01 nmol/hour/mg protein) compared with normal levels (7.48–9.52 nmol/hour/mg protein).", + "This finding established a definitive diagnosis of MPS IVA, also known as Morquio A syndrome.", + "Treatment with elosulfase alfa ERT at 2 mg/kg/week was initiated at 30 months of age.", + "ERT in Japan had not been approved before this date.", + "Acetaminophen (10 mg/kg) and loratadine (5 mg) were given 30 minutes prior to ERT administration.", + "The patient was followed for 36 months.", + "Urine KS levels at the start of ERT were high (71.05 µg/mg creatinine) compared with the reference range (1.75–6.81 µg/mg creatinine).", + "Urine KS levels decreased over time: 69.5%, 36.8%, and 47.1% of the pre-ERT level at 12 months, 24 months, and 36 months of treatment, respectively.", + "The patient grew 14.5 cm during the 36-month treatment period.", + "A thoracolumbar MRI after 24 months of treatment showed deformity and hypoplasia of the vertebral body, hypoplasia of the odontoid process, and spinal canal stenosis at C2–C4 and Th2–Th4.", + "No neurological abnormalities were observed.", + "The 6-minute walk test was conducted 12 months after the start of treatment.", + "At 36 months, the walking distance had increased by 68 m.", + "The 3-minute stair climb test was conducted 24 months after the start of treatment.", + "At 36 months, the number of steps taken had decreased by 31." + ], + "summary": "As part of our differential diagnosis we found elevated urine glycosaminoglycans, which triggered further investigation. Detailed examination showed flattening of the ribs, kyphoscoliosis and ovalization of the thoracolumbar vertebral body, strikingly short metacarpals, and very slight cardiac regurgitation. N-Acetylgalactosamine-6-sulfatase levels in the blood and dermal fibroblasts were very low, thus confirming diagnosis of Morquio A within 2 months of presentation. The patient was placed on elosulfase alfa enzyme replacement therapy and followed for 3 years.", + "summary_subclaims": [ + "Elevated urine glycosaminoglycans were found.", + "Further investigation was triggered.", + "Detailed examination showed flattening of the ribs.", + "Detailed examination showed kyphoscoliosis.", + "Detailed examination showed ovalization of the thoracolumbar vertebral body.", + "Detailed examination showed strikingly short metacarpals.", + "Detailed examination showed very slight cardiac regurgitation.", + "N-Acetylgalactosamine-6-sulfatase levels in the blood were very low.", + "N-Acetylgalactosamine-6-sulfatase levels in dermal fibroblasts were very low.", + "The diagnosis of Morquio A was confirmed within 2 months of presentation.", + "The patient was placed on elosulfase alfa enzyme replacement therapy.", + "The patient was followed for 3 years." + ] + }, + { + "id": "multiclinsum_test_1224_en.txt", + "fulltext": "A 35-day-old girl was admitted to Kunming Children’s Hospital in October 2019 due to a lesion in the right frontotemporal region.\nThe lesion was found at birth, as a subcutaneous mass with granular and papillary surface. The patient was firstly diagnosed with “cavernous hemangioma”, without treatment. The skin lesion easily bled upon touch, and showed repeated ulceration, erosion, and scab formation. There was no obvious enlargement of the lesion and subcutaneous mass from birth until now.\nThe patient was born at 38 wk of pregnancy, with a birth weight of 3.1 kg and no perinatal infection or suffocation.\nThe patient had no specific personal and family history.\nPhysical examination revealed good general condition. The vital signs were stable, and no other abnormality was found. Dermatological examination showed a red lesion in the right frontotemporal region, with thick brown scab on the surface. After cleaning the scab, the surface of the skin lesion was bright red, appearing like granulation tissue. The lesion was granular and papillary and easily bled upon touch, with about 1.5 cm × 4 cm in size. A small amount of pale yellow thin secretion was observed on the lesion surface. There was a pedicle at the base of the skin lesion. A subcutaneous mass was felt at the base of the lesion, with slightly hard texture and a clear boundary. The mass expanded beyond the red area, with a size of about 3 cm × 5 cm. The surrounding skin had no redness or swelling, and the mass showed no tenderness .\nBlood routine test showed lymphocyte count at 4.51 × 109/L (1.0-3.0 × 109/L), lymphocyte percentage at 60.60% (20%-40%), neutrophil percentage at 30.80% (50%-70%), platelet count at 528 × 109/L (100-300 × 109/L), platelet hematocrit at 0.52% (0.108%-0.282%), and platelet distribution width at 10.0 fL (15.5-18.1 fL). The remaining indicators were unremarkable. Surface secretions were cultured for 48 h, and three plasma coagulase tests were negative; meanwhile, mixed growth of Staphylococcus was detected, with no Haemophilus isolated. Stool routine, urine routine, liver function, and kidney function tests were normal. These laboratory findings did not point to any specific diagnosis.\nSkull plain computed tomography (CT) and enhanced scans showed slightly thickened subcutaneous soft tissue of the right temporal region, and the stripes showed a high-density shadow, with a CT value of about 31 HU. Enhanced CT showed enhancement, with a CT value of about 61 HU. No obvious signs of damage were seen in the adjacent skull. There were no lesions with definite abnormal density in the brain parenchyma (no obvious abnormal enhancement). There was no enlargement, stenosis, or occlusion in the ventricular system; no widening of subarachnoid space of each ventricle or displacement of the midline structure was found.\nDermatoscopy showed that the skin lesion was lobular and crumby. The lesion center was reddish or white, while the edges were white or yellowish band-like. There were polymorphic vascular structures and white radial streaks in the lesion, with some vascular clusters scattered .\nPathological examination showed papilloma-like hyperplasia of the epidermis, with the epidermis partly sinking into the dermis to form several cystic depressions, lined with stratified squamous epithelium. Glandular cavity-like structures were seen in the dermis, with some opened into the epidermis. A large number of lymphocytes, neutrophils, and plasma cells infiltrated in the interstitial area was observed, as well as splinter hemorrhage. The cavity wall and villous epidermis of the glandular cavity were composed of two layers of epithelial cells; the inner layer included columnar cells, with oval and eosinophilic nuclei and abundant cytoplasm; apocrine secretion was observed .", + "fulltext_subclaims": [ + "A 35-day-old girl was admitted to Kunming Children’s Hospital in October 2019 due to a lesion in the right frontotemporal region.", + "The lesion was found at birth, as a subcutaneous mass with granular and papillary surface.", + "The patient was firstly diagnosed with “cavernous hemangioma”, without treatment.", + "The skin lesion easily bled upon touch, and showed repeated ulceration, erosion, and scab formation.", + "There was no obvious enlargement of the lesion and subcutaneous mass from birth until now.", + "The patient was born at 38 wk of pregnancy, with a birth weight of 3.1 kg and no perinatal infection or suffocation.", + "The patient had no specific personal and family history.", + "Physical examination revealed good general condition.", + "The vital signs were stable, and no other abnormality was found.", + "Dermatological examination showed a red lesion in the right frontotemporal region, with thick brown scab on the surface.", + "After cleaning the scab, the surface of the skin lesion was bright red, appearing like granulation tissue.", + "The lesion was granular and papillary and easily bled upon touch, with about 1.5 cm × 4 cm in size.", + "A small amount of pale yellow thin secretion was observed on the lesion surface.", + "There was a pedicle at the base of the skin lesion.", + "A subcutaneous mass was felt at the base of the lesion, with slightly hard texture and a clear boundary.", + "The mass expanded beyond the red area, with a size of about 3 cm × 5 cm.", + "The surrounding skin had no redness or swelling, and the mass showed no tenderness.", + "Blood routine test showed lymphocyte count at 4.51 × 109/L (1.0-3.0 × 109/L).", + "Blood routine test showed lymphocyte percentage at 60.60% (20%-40%).", + "Blood routine test showed neutrophil percentage at 30.80% (50%-70%).", + "Blood routine test showed platelet count at 528 × 109/L (100-300 × 109/L).", + "Blood routine test showed platelet hematocrit at 0.52% (0.108%-0.282%).", + "Blood routine test showed platelet distribution width at 10.0 fL (15.5-18.1 fL).", + "Surface secretions were cultured for 48 h, and three plasma coagulase tests were negative.", + "Mixed growth of Staphylococcus was detected, with no Haemophilus isolated.", + "Stool routine, urine routine, liver function, and kidney function tests were normal.", + "These laboratory findings did not point to any specific diagnosis.", + "Skull plain computed tomography (CT) and enhanced scans showed slightly thickened subcutaneous soft tissue of the right temporal region.", + "The stripes showed a high-density shadow, with a CT value of about 31 HU.", + "Enhanced CT showed enhancement, with a CT value of about 61 HU.", + "No obvious signs of damage were seen in the adjacent skull.", + "There were no lesions with definite abnormal density in the brain parenchyma (no obvious abnormal enhancement).", + "There was no enlargement, stenosis, or occlusion in the ventricular system.", + "No widening of subarachnoid space of each ventricle or displacement of the midline structure was found.", + "Dermatoscopy showed that the skin lesion was lobular and crumby.", + "The lesion center was reddish or white, while the edges were white or yellowish band-like.", + "There were polymorphic vascular structures and white radial streaks in the lesion, with some vascular clusters scattered.", + "Pathological examination showed papilloma-like hyperplasia of the epidermis.", + "The epidermis partly sank into the dermis to form several cystic depressions, lined with stratified squamous epithelium.", + "Glandular cavity-like structures were seen in the dermis, with some opened into the epidermis.", + "A large number of lymphocytes, neutrophils, and plasma cells infiltrated in the interstitial area was observed, as well as splinter hemorrhage.", + "The cavity wall and villous epidermis of the glandular cavity were composed of two layers of epithelial cells.", + "The inner layer included columnar cells, with oval and eosinophilic nuclei and abundant cytoplasm.", + "Apocrine secretion was observed." + ], + "summary": "In this study, a 35-day-old girl was admitted to Kunming Children's Hospital in October 2019 due to a lesion in the right frontotemporal region since birth. The surface of the lesion was bright red, granular, and papillary and easily bled upon touch, with about 1.5 cm × 4 cm in size. A subcutaneous mass was felt at the base of the lesion, with a size of about 3 cm × 5 cm. Dermatoscopy showed that the skin lesion was lobular and crumby. The lesion center was reddish or white, while the edges were white or yellowish band-like. There were polymorphic vascular structures and white radial streaks in the lesion, with some vascular clusters scattered. Pathological examination showed papilloma-like hyperplasia of the epidermis, with the epidermis partly sinking into the dermis to form several cystic depressions. Combining clinical and histopathological features, the child was diagnosed with SCAP. Follow-up is ongoing, and surgical resection will be performed.", + "summary_subclaims": [ + "A 35-day-old girl was admitted to Kunming Children's Hospital in October 2019.", + "The lesion was in the right frontotemporal region since birth.", + "The surface of the lesion was bright red, granular, and papillary.", + "The lesion easily bled upon touch.", + "The lesion size was about 1.5 cm × 4 cm.", + "A subcutaneous mass was felt at the base of the lesion.", + "The subcutaneous mass size was about 3 cm × 5 cm.", + "Dermatoscopy showed the skin lesion was lobular and crumby.", + "The lesion center was reddish or white.", + "The edges of the lesion were white or yellowish band-like.", + "There were polymorphic vascular structures in the lesion.", + "There were white radial streaks in the lesion.", + "Some vascular clusters were scattered in the lesion.", + "Pathological examination showed papilloma-like hyperplasia of the epidermis.", + "The epidermis partly sank into the dermis to form several cystic depressions.", + "The child was diagnosed with SCAP.", + "Follow-up is ongoing.", + "Surgical resection will be performed." + ] + }, + { + "id": "multiclinsum_test_2113_en.txt", + "fulltext": "A forty year-old male was brought to the Queen Elizabeth Hospital, Kota Kinabalu, Sabah (8.30 am) in a state of collapse. He was unable to give a history himself or to stand. On examination his blood pressure was unrecordable and oxygen saturations were recorded as low.\nThe patient had no past medical history. He had spent two weeks in the jungles of Borneo before leaving for an urban setting. Ten days after leaving the jungle he experienced the onset of fever and body aches. Two days later, he sought treatment at a government outpatient clinic continuing to complain of fever and myalgia. A specific diagnosis was not made and he was able to work although he developed rashes the next day. He remained unwell for the next two days, when he presented in a state of collapse and had developed abdominal pain.\nResuscitation measures were begun and the patient was immediately intubated, given adrenaline/atropine and sodium bicarbonate. On examination and after resuscitation measures his vital signs were: symmetrical air entry into lungs, BP 58/44 mm Hg, pulse rate 40-50 per minute with poor peripheral perfusion and cyanosis. Heart sounds were normal. He had generalized petechiae and his abdomen was tense and distended.\nResuscitation measures continued for one hour, during which time \"coffee grounds\" were observed in the nasogastric aspirate. The patient became asystolic after one hour and although cardiopulmonary resuscitation was given for a further 20 minutes, there was no response. The patient was pronounced dead two hours after admission.\nDengue haemorrhagic shock was suspected and a post-mortem examination was performed approximately 24 hours later.\nLaboratory results are summarized in Table . The patient was not anemic, but was thrombocytopenic and had an eosinophilia. He was also hyponatraemic and had elevated blood urea, potassium, lactate dehydrogenase and amino transferase values. Serum creatinine was not available. A blood sample taken 24 hours post-mortem showed >10% of erythrocytes infected with predominantly pigmented parasites . Heavily pigmented monocytes were also present . Plasmodium knowlesi, as a single species infection, was confirmed by nested-PCR . Post-mortem dengue serology was negative and dengue, respiratory syncytial virus and enterovirus were not isolated in organ samples.\nExternal examination showed a well-nourished adult male. The conjunctivae showed tinges of jaundice and the right eye had subconjunctival haemorrhages. There were multiple petechial haemorrhages on the body and venepuncture sites were associated with marked bruising. Coffee ground material was noted in the mouth. Internal examination revealed no tissue oedema or excess fluid in the body cavities.\nThe external surfaces of the cerebrum were dusky. The cut sections showed multiple petechial haemorrhages. The cerebellum also showed petechial haemorrhages externally and on multiple cut sections . The brain stem and upper spinal chord were grossly normal. Both lungs were heavy (weighing on the right 720 g and left 690 g) and cut sections were congested and 'beefy' in appearance. Petechial haemorrhages were present on the endocardium with extensive subendocardial haemorrhages involving the left ventricular wall. The haemorrhages were most prominent at the apex of the heart. The liver (2640 g) and spleen (340 g) were markedly enlarged. The cut surfaces of the spleen were soft and friable. The gallbladder, pancreas and kidneys were grossly normal.\nHaematoxylin and eosin stained sections from various organs were available for examination. Parasitized red blood cells (PRBC) were abundant although parasite bodies were obscured by haemozoin (malaria) pigment. Chemical removal of pigment and oil immersion (×1,000) magnification revealed trophozoites that were discernibly bigger than those of P. falciparum. Immunohistochemistry stained sections from the brain were Plasmodium anti-aldolase positive and negative for P. falciparum- specific staining .\nMany petechial haemorrhages (up to 600 μm diameter) arising from the rupture of the small vessels of the cerebrum and cerebellum were observed Sequestration of PRBC was evident within small blood vessels . Congested larger vessels and areas of haemorrhage showed considerable amounts of malaria pigment . Clumps of platelets or evidence of thrombi in vessels were not seen. There was no evidence of vasculitis or perivascular chronic inflammatory reaction in the brain or any other organ examined (heart, kidney, liver, adrenal gland and spleen). There was no evidence of perivascular or diffuse parenchymal oedema in the brain. Diffuse astrocytosis or microgliosis was not observed, nor was there evidence for acute gliotic reactions about the haemorrhages. There was no aggregation of polymorphs in the vessels, no perivascular inflammation, nor generalized encephalitis. There was no diffuse thrombotic microangiopathy, but within one haemorrhage there was probably some fibrin at the site of the vessel. Immunohistochemistry of sections from the brain was negative for CD54 (which stains intercellular adhesion molecule-1, ICAM-1).\nAlthough sections from the spleen showed some autolysis, expansion of the red pulp and atrophy of the white pulp was noted. Germinal centers were not observed. Abundant pigment-containing macrophages and some haemophaghocytosis was evident in the red pulp and parasitized red cells were plentiful . There was no necrosis or fibrin deposition in the spleen.\nThere were many PRBC's in the liver sinusoids with haemozoin pigment in Kupffer cells and evidence of haemophagocytosis. The portal tracts and sinusoids had moderate chronic lymphoplasmacytic inflammation. Overall the liver was non-cirrhotic but with severe macrovesicular steatosis. No cholestasis, regional necrosis or thrombotic microangiopathy was observed .\nThe renal cortex showed dilated and congested blood vessels. Many PRBC were observed within glomerular capillaries with pigment deposition in the mesangium. There was no evidence of thrombotic microangiopathy (disseminated intravascular coagulation, DIC). The tubules showed acute tubular necrosis and regeneration. There were a small number of eosinophilic intra-tubular casts .\nSequestration of PRBC's was evident in the small vessels of the heart . Endothelial cells were prominent as sometimes observed in patients with sepsis whose cells are responding to generalized stimuli . There was no evidence of myocarditis and the heart muscle fibers appeared normal. There was focal petechial haemorrhage in the subendocardium, which may relate to resuscitation, or be secondary to malaria.\nThe adrenal gland appeared active with eosinophilic cytoplasm in the fasciculata layer with no evidence of PRBC sequestration or of parenchymal haemorrhage. Samples of lung, intestine or bone marrow were not available for histopathology examination.\nThe overall picture was one of systemic malaria infection with multi-organ damage, particularly in the brain where there was much vascular rupture and petechial haemorrhaging.", + "fulltext_subclaims": [ + "The patient was a forty year-old male.", + "He was brought to the Queen Elizabeth Hospital, Kota Kinabalu, Sabah at 8.30 am.", + "He was in a state of collapse.", + "He was unable to give a history himself.", + "He was unable to stand.", + "On examination his blood pressure was unrecordable.", + "Oxygen saturations were recorded as low.", + "The patient had no past medical history.", + "He had spent two weeks in the jungles of Borneo before leaving for an urban setting.", + "Ten days after leaving the jungle he experienced the onset of fever and body aches.", + "Two days later, he sought treatment at a government outpatient clinic.", + "He continued to complain of fever and myalgia.", + "A specific diagnosis was not made.", + "He was able to work.", + "He developed rashes the next day.", + "He remained unwell for the next two days.", + "He presented in a state of collapse.", + "He had developed abdominal pain.", + "Resuscitation measures were begun.", + "The patient was immediately intubated.", + "He was given adrenaline/atropine.", + "He was given sodium bicarbonate.", + "After resuscitation measures, his blood pressure was 58/44 mm Hg.", + "His pulse rate was 40-50 per minute.", + "He had poor peripheral perfusion.", + "He had cyanosis.", + "He had generalized petechiae.", + "His abdomen was tense and distended.", + "Resuscitation measures continued for one hour.", + "Coffee grounds were observed in the nasogastric aspirate.", + "The patient became asystolic after one hour.", + "Cardiopulmonary resuscitation was given for a further 20 minutes.", + "There was no response.", + "The patient was pronounced dead two hours after admission.", + "Dengue haemorrhagic shock was suspected.", + "A post-mortem examination was performed approximately 24 hours later.", + "The patient was not anemic.", + "He was thrombocytopenic.", + "He had an eosinophilia.", + "He was hyponatraemic.", + "He had elevated blood urea.", + "He had elevated potassium.", + "He had elevated lactate dehydrogenase.", + "He had elevated amino transferase values.", + "Serum creatinine was not available.", + "A blood sample taken 24 hours post-mortem showed >10% of erythrocytes infected with predominantly pigmented parasites.", + "Heavily pigmented monocytes were also present.", + "Plasmodium knowlesi, as a single species infection, was confirmed by nested-PCR.", + "Post-mortem dengue serology was negative.", + "Dengue, respiratory syncytial virus and enterovirus were not isolated in organ samples.", + "External examination showed a well-nourished adult male.", + "The conjunctivae showed tinges of jaundice.", + "The right eye had subconjunctival haemorrhages.", + "There were multiple petechial haemorrhages on the body.", + "Venepuncture sites were associated with marked bruising.", + "Coffee ground material was noted in the mouth.", + "The external surfaces of the cerebrum were dusky.", + "The cut sections showed multiple petechial haemorrhages.", + "The cerebellum also showed petechial haemorrhages externally and on multiple cut sections.", + "The brain stem and upper spinal chord were grossly normal.", + "Both lungs were heavy.", + "The right lung weighed 720 g.", + "The left lung weighed 690 g.", + "The cut sections were congested and 'beefy' in appearance.", + "Petechial haemorrhages were present on the endocardium.", + "There were extensive subendocardial haemorrhages involving the left ventricular wall.", + "The haemorrhages were most prominent at the apex of the heart.", + "The liver weighed 2640 g.", + "The spleen weighed 340 g.", + "The cut surfaces of the spleen were soft and friable.", + "The gallbladder, pancreas and kidneys were grossly normal.", + "Haematoxylin and eosin stained sections from various organs were available for examination.", + "Parasitized red blood cells were abundant.", + "Parasite bodies were obscured by haemozoin pigment.", + "Chemical removal of pigment and oil immersion (×1,000) magnification revealed trophozoites that were discernibly bigger than those of P. falciparum.", + "Immunohistochemistry stained sections from the brain were Plasmodium anti-aldolase positive.", + "Immunohistochemistry stained sections from the brain were negative for P. falciparum-specific staining.", + "Many petechial haemorrhages (up to 600 μm diameter) arising from the rupture of the small vessels of the cerebrum and cerebellum were observed.", + "Sequestration of PRBC was evident within small blood vessels.", + "Congested larger vessels and areas of haemorrhage showed considerable amounts of malaria pigment.", + "Clumps of platelets or evidence of thrombi in vessels were not seen.", + "There was no evidence of vasculitis or perivascular chronic inflammatory reaction in the brain.", + "There was no evidence of perivascular or diffuse parenchymal oedema in the brain.", + "Diffuse astrocytosis or microgliosis was not observed.", + "There was no evidence for acute gliotic reactions about the haemorrhages.", + "There was no aggregation of polymorphs in the vessels.", + "There was no perivascular inflammation.", + "There was no generalized encephalitis.", + "There was no diffuse thrombotic microangiopathy.", + "Within one haemorrhage there was probably some fibrin at the site of the vessel.", + "Immunohistochemistry of sections from the brain was negative for CD54.", + "Sections from the spleen showed some autolysis.", + "Expansion of the red pulp and atrophy of the white pulp was noted.", + "Germinal centers were not observed.", + "Abundant pigment-containing macrophages and some haemophagocytosis was evident in the red pulp.", + "Parasitized red cells were plentiful.", + "There was no necrosis or fibrin deposition in the spleen.", + "There were many PRBC's in the liver sinusoids.", + "Haemozoin pigment was in Kupffer cells.", + "Evidence of haemophagocytosis was present.", + "The portal tracts and sinusoids had moderate chronic lymphoplasmacytic inflammation.", + "The liver was non-cirrhotic.", + "The liver had severe macrovesicular steatosis.", + "There was no cholestasis.", + "There was no regional necrosis.", + "There was no thrombotic microangiopathy.", + "The renal cortex showed dilated and congested blood vessels.", + "Many PRBC were observed within glomerular capillaries.", + "Pigment deposition was in the mesangium.", + "There was no evidence of thrombotic microangiopathy.", + "The tubules showed acute tubular necrosis and regeneration.", + "There were a small number of eosinophilic intra-tubular casts.", + "Sequestration of PRBC's was evident in the small vessels of the heart.", + "Endothelial cells were prominent.", + "There was no evidence of myocarditis.", + "The heart muscle fibers appeared normal.", + "There was focal petechial haemorrhage in the subendocardium.", + "The focal petechial haemorrhage may relate to resuscitation.", + "The focal petechial haemorrhage may be secondary to malaria.", + "The adrenal gland appeared active.", + "There was eosinophilic cytoplasm in the fasciculata layer.", + "There was no evidence of PRBC sequestration.", + "There was no parenchymal haemorrhage.", + "Samples of lung, intestine or bone marrow were not available for histopathology examination.", + "The overall picture was one of systemic malaria infection with multi-organ damage.", + "There was much vascular rupture and petechial haemorrhaging in the brain." + ], + "summary": "A formerly healthy 40 year-old male became symptomatic 10 days after spending time in the jungle of North Borneo. Four days later, he presented to hospital in a state of collapse and died within two hours. He was hyponatraemic and had elevated blood urea, potassium, lactate dehydrogenase and amino transferase values; he was also thrombocytopenic and eosinophilic. Dengue haemorrhagic shock was suspected and a post-mortem examination performed. Investigations for dengue virus were negative. Blood for malaria parasites indicated hyperparasitaemia and single species P. knowlesi infection was confirmed by nested-PCR. Macroscopic pathology of the brain and endocardium showed multiple petechial haemorrhages, the liver and spleen were enlarged and lungs had features consistent with ARDS. Microscopic pathology showed sequestration of pigmented parasitized red blood cells in the vessels of the cerebrum, cerebellum, heart and kidney without evidence of chronic inflammatory reaction in the brain or any other organ examined. Brain sections were negative for intracellular adhesion molecule-1. The spleen and liver had abundant pigment containing macrophages and parasitized red blood cells. The kidney had evidence of acute tubular necrosis and endothelial cells in heart sections were prominent.", + "summary_subclaims": [ + "A formerly healthy 40 year-old male became symptomatic 10 days after spending time in the jungle of North Borneo.", + "He presented to hospital in a state of collapse and died within two hours.", + "He was hyponatraemic.", + "He had elevated blood urea.", + "He had elevated potassium.", + "He had elevated lactate dehydrogenase.", + "He had elevated amino transferase values.", + "He was thrombocytopenic.", + "He was eosinophilic.", + "Dengue haemorrhagic shock was suspected.", + "A post-mortem examination was performed.", + "Investigations for dengue virus were negative.", + "Blood for malaria parasites indicated hyperparasitaemia.", + "Single species P. knowlesi infection was confirmed by nested-PCR.", + "Macroscopic pathology of the brain and endocardium showed multiple petechial haemorrhages.", + "The liver and spleen were enlarged.", + "The lungs had features consistent with ARDS.", + "Microscopic pathology showed sequestration of pigmented parasitized red blood cells in the vessels of the cerebrum, cerebellum, heart and kidney.", + "There was no evidence of chronic inflammatory reaction in the brain or any other organ examined.", + "Brain sections were negative for intracellular adhesion molecule-1.", + "The spleen and liver had abundant pigment containing macrophages and parasitized red blood cells.", + "The kidney had evidence of acute tubular necrosis.", + "Endothelial cells in heart sections were prominent." + ] + }, + { + "id": "multiclinsum_test_488_en.txt", + "fulltext": "The 44-year-old male acute myeloid leukemia (AML) patient received an unmanipulated graft from an unrelated donor (CMV D−/R+) after conditioning with the FLAMSA protocol. The patient received acyclovir (ACV, 400 mg twice per day) continuously, except between days + 43 to + 70 and day + 110 to + 145 (summarized in Fig. ). For maintenance of immunosuppression, the patient received cyclosporine A per os (measured blood concentrations 180–220 μg/L), mycophenolate (360 mg twice daily), and prednisolone.\nIt was planned to start LMV prophylaxis directly after the transplantation. However, due to a delay in delivery, administration of LMV could only be initiated at day + 34, under the assumption that CMV viral load was still below detection limit (50 IU/ml in serum). The compound was given at 240 mg once per day per os, along with cyclosporine. In retrospect, it turned out that the virus DNA load at the last check on day + 28 was 190 IU/ml in serum. Over the next 8 days, increasing CMV loads were measured up to 39.600 IU/ml. Therefore, letermovir treatment was discontinued and the patient was switched to valganciclovir (valGCV, 900 mg twice per day) at day + 42. Treatment was maintained for 4 weeks until CMV DNA was negative. At this time, the patient suffered from an intestinal graft-versus-host disease (GvHD) and a mucositis. Therefore, prednisolone was administered at day + 46 for 7 days with 10 mg and then was reduced to 1 mg until discontinuation at day + 82.\nAs neutropenia occurred during valGCV therapy, stimulation with G-CSF was necessary. After discontinuation of valGCV, neutropenia was resolved and LMV secondary prophylaxis was started at day + 70 with 240 mg once per day. At this time point CMV DNA was not detectable. At day + 80, mycophenolate was discontinued. For 4 weeks, CMV DNA remained undetectable or at the limit of quantitation of 125 IU/ml. At day + 97, tapering of cyclosporine A was initiated. However, several days later, the patient failed to maintain virologic suppression. CMV viral loads rapidly increased to 236.400 IU/ml in serum samples, between days + 104 and + 110. In order to avoid neutropenia, valGCV treatment with a reduced dosage of 450 mg twice per day was initiated at day + 110. Concomitantly, LMV dosage was increased to 480 mg per day. During the next 4 weeks, CMV viral loads decreased to 1.200 IU/ml. ValGCV treatment, which meanwhile necessitated daily stimulation with G-CSF, was discontinued.\nHowever, CMV DNA levels increased up to 33.000 IU/ml during the following 2 weeks. Therefore, genotyping of the CMV terminase UL56 as well as the other relevant genes (UL97 kinase, viral polymerase UL54, and UL89) was initiated. Thereby, a mutation corresponding to amino acid 325 (C325Y, cytosine at amino acid 325 to tyrosine) of UL56 was detected (see Fig. ). This mutation is associated with a high resistance to LMV in vitro . Therefore, LMV was discontinued at day + 167.\nNo further mutation was detected. Retrospective analysis revealed that the UL56 mutation C325Y was already present at day + 117, within 6 weeks after the start of the second letermovir administration. Unfortunately, no other patient specimens were available in order to further elucidate the time point of emergence of the mutation.\nSince then CMV DNA loads remained at a low level of 1300 to 2500 IU/ml. Due to the lack of clinical symptoms and increasing CD4 T-cells since day + 145, no further anti-CMV therapy was carried out.\nUntil today, the patient is clinically stable and participates in a professional reintegration.", + "fulltext_subclaims": [ + "The patient received an unmanipulated graft from an unrelated donor.", + "The donor was CMV D−/R+.", + "The patient received acyclovir 400 mg twice per day.", + "Acyclovir was not administered between days + 43 to + 70.", + "Acyclovir was not administered between days + 110 to + 145.", + "The patient received cyclosporine A per os.", + "Cyclosporine A blood concentrations were measured at 180–220 μg/L.", + "The patient received mycophenolate 360 mg twice daily.", + "The patient received prednisolone.", + "It was planned to start LMV prophylaxis directly after the transplantation.", + "LMV could only be initiated at day + 34.", + "CMV viral load was assumed to be below detection limit at the start of LMV.", + "LMV was given at 240 mg once per day per os.", + "The patient's CMV DNA load at day + 28 was 190 IU/ml.", + "CMV loads increased up to 39.600 IU/ml over the next 8 days.", + "Letermovir treatment was discontinued at day + 42.", + "The patient was switched to valganciclovir 900 mg twice per day at day + 42.", + "Treatment was maintained for 4 weeks until CMV DNA was negative.", + "The patient suffered from intestinal graft-versus-host disease.", + "The patient had mucositis.", + "Prednisolone was administered at day + 46 for 7 days with 10 mg.", + "Prednisolone was reduced to 1 mg until discontinuation at day + 82.", + "Neutropenia occurred during valganciclovir therapy.", + "Stimulation with G-CSF was necessary.", + "LMV secondary prophylaxis was started at day + 70.", + "CMV DNA was not detectable at day + 70.", + "LMV was given at 240 mg once per day.", + "Mycophenolate was discontinued at day + 80.", + "CMV DNA remained undetectable or at the limit of quantitation for 4 weeks.", + "Tapering of cyclosporine A was initiated at day + 97.", + "CMV viral loads rapidly increased to 236.400 IU/ml between days + 104 and + 110.", + "Valganciclovir treatment with a reduced dosage of 450 mg twice per day was initiated at day + 110.", + "Letermovir dosage was increased to 480 mg per day.", + "CMV viral loads decreased to 1.200 IU/ml during the next 4 weeks.", + "Valganciclovir treatment necessitated daily stimulation with G-CSF.", + "CMV DNA levels increased up to 33.000 IU/ml during the following 2 weeks.", + "Genotyping of the CMV terminase UL56 was initiated.", + "A mutation corresponding to amino acid 325 (C325Y) of UL56 was detected.", + "The mutation C325Y is associated with high resistance to LMV in vitro.", + "Letermovir was discontinued at day + 167.", + "The UL56 mutation C325Y was already present at day + 117.", + "No other patient specimens were available to further elucidate the time point of emergence of the mutation.", + "CMV DNA loads remained at a low level of 1300 to 2500 IU/ml.", + "No further anti-CMV therapy was carried out.", + "The patient is clinically stable.", + "The patient participates in a professional reintegration." + ], + "summary": "A 44-year-old male patient with acute myeloid leukemia (AML) experienced a CMV-reactivation within the first 4 weeks of allogeneic hematopoietic-cell transplantation. Administration of LMV was initiated at day + 34. Due to increasing viral loads, LMV treatment was discontinued after 8 days. The patient was then administered with valganciclovir (valGCV) until viral DNA was undetectable. Due to neutropenia, valGCV treatment was switched to LMV secondary prophylaxis. For 4 weeks, the patient maintain virologic suppression. Then, CMV viral loads increased with a fast kinetic. Genotypic testing of the viral polymerase UL54, the kinase UL97 as well as the viral terminase UL56 and UL89 revealed the mutation C325Y in UL56, which is associated with the high level LMV resistance.", + "summary_subclaims": [ + "The patient is a 44-year-old male.", + "The patient has acute myeloid leukemia.", + "The patient experienced a CMV-reactivation within the first 4 weeks of allogeneic hematopoietic-cell transplantation.", + "LMV was initiated at day + 34.", + "LMV treatment was discontinued after 8 days.", + "The patient was administered valganciclovir until viral DNA was undetectable.", + "Valganciclovir treatment was switched to LMV secondary prophylaxis due to neutropenia.", + "The patient maintained virologic suppression for 4 weeks.", + "CMV viral loads increased with a fast kinetic.", + "Genotypic testing revealed the mutation C325Y in UL56.", + "The mutation C325Y in UL56 is associated with high level LMV resistance." + ] + }, + { + "id": "multiclinsum_test_213_en.txt", + "fulltext": "A 53-year-old man with a long-lasting history of objective vertigo and neck pain accessed to emergency care because of a severe headache, disabling vertiginous crisis with falls, increasing neck pain also in lateral head movements and decline in health-related quality of life. Clinical examination showed hyperreflexia in lower limbs, diffuse burning paresthesia of the four limbs, bilateral Babinski sign, and downbeat nystagmus. Magnetic resonance imaging (MRI) and computed tomography (CT) scans showed a complex CVJ malformation with the basilar impression and radiological signs of myelopathy at the C2 level . Furthermore, a dynamic cervical spine X-ray proved that there was no instability in flexion and extension movements of the CVJ .\nThe patient underwent a transnasal image-guided fully 3D endoscopic approach . Intraoperative neurophysiological monitoring was used: Somatosensory evoked potentials of the four limbs and motor evoked potentials. The technique to reach the CVJ has been described elsewhere.\nThe lowest part of the clivus and the upper-medial portion of the C1 anterior arch were removed. After subperiosteal preparation of the C1 anterior arch, every effort was made to preserve the anterior arch integrity, drilling only its anterior–superior portion in the midline but keeping its continuity. At this stage, the partial drilling of the uppermost part of the odontoid peg was safely performed. After image guidance confirmation of the odontoid, a 3 mm coarse diamond burr was used to enter its anterior cortex. An ultrasonic bone curette was used to remove the tip of the odontoid, the base and the interface between the posterior cortex of the dens and the soft tissues covering the spinal dura. The decompression of the medulla and spinal cord was performed by using the neuronavigation system.\nFurthermore, pulsatility of the dura during surgery confirmed the achievement of sufficient decompression.\nAfter the procedure, the reverse U mucosal nasopharingeal flap harvested at the beginning of surgery was reapproximated and fixed with fibrin glue. A Foley catheter was held in place for 2 days to compress the mucosal flap. No tracheostomy was needed, and the patient received food orally the day after surgery\nImmediately after surgery, a dynamic X-ray scan was performed: The anterior atlas-dens interval (AADI), posterior atlas-dens interval (PADI), and C1–C2 total lateral overhang were measured as morphological criteria to determine the upper cervical spine stability. AADI and PADI remained stable after surgery, and the total C1–C2 overhang was no more than 7 mm, thus demonstrating no difference in CVJ motility compared with the preoperative radiographic pictures . Therefore, we did not proceed to posterior cervical stabilization, postponing the eventual decision in light of the clinical status in the follow-up.\nThe postoperative course was uneventful, and the patient was discharged showing a significant improvement in paresthesia and the disappearance of nystagmus.\nPostoperative dynamic CT and MRI confirmed complete CVJ decompression, and the patient underwent a nasal endoscopic follow-up 1 month after surgery and another one 6 months after surgery .\nAfter an 18-month follow-up, the patient reported neither other vertiginous episodes, nor neck pain. Clinical examination showed normoreflexia in lower limbs, the absence of paresthesia of the four limbs, normal motor functions, bilateral negative cutaneous plantar reflex, and mild downbeat nystagmus.\nAt the 18-month re-evaluation, a new dynamic X-ray scan showed no difference in CVJ motility in comparison with the preoperative and immediately postoperative ones .", + "fulltext_subclaims": [ + "The patient is a 53-year-old man.", + "The patient had a long-lasting history of objective vertigo.", + "The patient had a long-lasting history of neck pain.", + "The patient accessed emergency care because of a severe headache.", + "The patient had a disabling vertiginous crisis with falls.", + "The patient had increasing neck pain also in lateral head movements.", + "The patient had a decline in health-related quality of life.", + "Clinical examination showed hyperreflexia in lower limbs.", + "Clinical examination showed diffuse burning paresthesia of the four limbs.", + "Clinical examination showed bilateral Babinski sign.", + "Clinical examination showed downbeat nystagmus.", + "Magnetic resonance imaging showed a complex CVJ malformation.", + "Computed tomography showed radiological signs of myelopathy at the C2 level.", + "A dynamic cervical spine X-ray proved that there was no instability in flexion and extension movements of the CVJ.", + "The patient underwent a transnasal image-guided fully 3D endoscopic approach.", + "Intraoperative neurophysiological monitoring was used.", + "The lowest part of the clivus was removed.", + "The upper-medial portion of the C1 anterior arch was removed.", + "Every effort was made to preserve the anterior arch integrity.", + "The partial drilling of the uppermost part of the odontoid peg was safely performed.", + "A 3 mm coarse diamond burr was used to enter the anterior cortex of the odontoid.", + "An ultrasonic bone curette was used to remove the tip of the odontoid.", + "The decompression of the medulla and spinal cord was performed by using the neuronavigation system.", + "Pulsatility of the dura during surgery confirmed the achievement of sufficient decompression.", + "A reverse U mucosal nasopharingeal flap was reapproximated and fixed with fibrin glue.", + "A Foley catheter was held in place for 2 days to compress the mucosal flap.", + "No tracheostomy was needed.", + "The patient received food orally the day after surgery.", + "A dynamic X-ray scan was performed immediately after surgery.", + "AADI and PADI remained stable after surgery.", + "The total C1–C2 overhang was no more than 7 mm.", + "We did not proceed to posterior cervical stabilization.", + "The postoperative course was uneventful.", + "The patient was discharged showing a significant improvement in paresthesia.", + "The patient showed the disappearance of nystagmus.", + "Postoperative dynamic CT confirmed complete CVJ decompression.", + "Postoperative MRI confirmed complete CVJ decompression.", + "The patient underwent a nasal endoscopic follow-up 1 month after surgery.", + "The patient underwent a nasal endoscopic follow-up 6 months after surgery.", + "After an 18-month follow-up, the patient reported no other vertiginous episodes.", + "After an 18-month follow-up, the patient reported no neck pain.", + "Clinical examination showed normoreflexia in lower limbs.", + "Clinical examination showed the absence of paresthesia of the four limbs.", + "Clinical examination showed normal motor functions.", + "Clinical examination showed bilateral negative cutaneous plantar reflex.", + "Clinical examination showed mild downbeat nystagmus.", + "A new dynamic X-ray scan showed no difference in CVJ motility in comparison with the preoperative and immediately postoperative ones." + ], + "summary": "This is the first report in which the technique to remove the tip of the odontoid while preserving the C1 anterior arch is described by means of a three-dimensional (3D) endoscope. A 53-year-old man underwent a transnasal 3D endoscopic approach because of a complex CVJ malformation. The upper-medial portion of the C1 anterior arch was removed preserving its continuity, and the odontoidectomy was performed. After surgery, a dynamic X-ray scan showed no difference in CVJ motility in comparison with the preoperative one.", + "summary_subclaims": [ + "This is the first report in which the technique to remove the tip of the odontoid while preserving the C1 anterior arch is described by means of a three-dimensional (3D) endoscope.", + "A 53-year-old man underwent a transnasal 3D endoscopic approach because of a complex CVJ malformation.", + "The upper-medial portion of the C1 anterior arch was removed preserving its continuity.", + "The odontoidectomy was performed.", + "After surgery, a dynamic X-ray scan showed no difference in CVJ motility in comparison with the preoperative one." + ] + }, + { + "id": "multiclinsum_test_610_en.txt", + "fulltext": "A 35-year-old Caucasian female patient was referred to our hospital because of an incidental finding of a large right ventricular mass during sonography of her upper abdominal organs performed for the evaluation of transient and moderate abdominal pain. Our patient did not have any specific cardiac symptoms like chest pain, dizziness, nausea, palpitations, syncope, or signs of congestive heart failure. Cardiovascular risk factors involved current smoking and obesity (body mass index 32.8 kg/m2). Her medical history included bronchial asthma, previous gestational diabetes, and minor depression. She was taking beclometasondipropionat, fluticason-17-propionat and formoterol-fumarate-dihydrate for the bronchial asthma, and fluoxetine for the depression. A cardiac murmur was not detected during a routine physical examination. Laboratory parameters were unremarkable, with no elevation in her levels of high-sensitive cardiac troponin T (7 pg/ml, reference <14 pg/ml), n-terminal pro-brain natriuretic peptide (75 ng/l, reference <125 ng/l), or C-reactive protein (4.5 mg/l, reference <5 mg/l). A 12-lead electrocardiogram showed T-wave inversion in the inferior and precordial leads . Holter monitoring showed a normofrequent sinus rhythm without any supraventricular or ventricular ectopic beat. An exercise test revealed a good exercise capacity without chest pain, shortness of breath, or any other symptoms upon reaching a maximal heart rate of 163 beats per minute (93 % of the target heart rate). Her blood pressure and heart rate profile during exercise testing were normal and no ectopic beats were detected. Transthoracic echocardiography revealed a large homogenous mass in her slightly dilated right ventricle, suggesting the involvement of her intraventricular septum and left ventricular apex. Her cardiac valves were normal without stenosis or regurgitation, and the size and function of her left ventricle were normal. A small, not significant pericardial effusion was also detected . Our patient then underwent cardiovascular magnetic resonance (CMR) imaging, which revealed a 104 × 62 mm right ventricular mass infiltrating her intraventricular septum and left ventricular apex. T1-weighted images showed isointensity and T2-weighted images showed clear hyperintensity of the relatively homogenous tumor . Late gadolinium enhancement depicted the dimensions of the tumor . Online supplemental video files show good systolic left ventricular function, slightly reduced right ventricular longitudinal function, and an intensive perfusion of the tumor (Additional files , and ).\nA transvenous right ventricular biopsy was performed to gain tissue material for histological analysis; however, the obtained material was insufficient for a definitive diagnosis. Our patient was then referred for an open myocardial biopsy via a partial inferior sternotomy . Previously, a coronary angiography was performed to identify the feeding arteries of the large tumor. Coronary angiography revealed ectatic coronary arteries without any stenosis. A biventricular tumor was visualized on angiography with connection to both her right coronary artery and her left circumflex artery, showing a characteristic tumor blush . Histopathological analysis led to the diagnosis of a benign vascular tumor. Examination of the tumor revealed numerous capillaries, arterioles, and venules embedded in a collagen-rich matrix . Some vital heart muscle cells within the tumor mass could also be observed . Cells showed strong positive staining with antibodies against CD31 and CD34, which supported the vascular origin of this tumor . Histological findings were consistent with a benign intracardiac angioma. The first imaging follow-up was performed 2 weeks later by CMR, and showed an unchanged result. Because our patient was asymptomatic without signs of heart failure or arrhythmia, and the large tumor proved to be surgically unresectable, we decided on conservative management with regular clinical and imaging controls. Nine months later our patient presented to our department for her regular follow-up appointment without any major complications. Echocardiography showed no significant progress of the tumor.", + "fulltext_subclaims": [ + "A 35-year-old Caucasian female patient was referred to our hospital because of an incidental finding of a large right ventricular mass during sonography of her upper abdominal organs.", + "The sonography was performed for the evaluation of transient and moderate abdominal pain.", + "Our patient did not have any specific cardiac symptoms like chest pain, dizziness, nausea, palpitations, syncope, or signs of congestive heart failure.", + "Cardiovascular risk factors involved current smoking and obesity (body mass index 32.8 kg/m2).", + "Her medical history included bronchial asthma, previous gestational diabetes, and minor depression.", + "She was taking beclometasondipropionat, fluticason-17-propionat and formoterol-fumarate-dihydrate for the bronchial asthma.", + "She was taking fluoxetine for the depression.", + "A cardiac murmur was not detected during a routine physical examination.", + "Laboratory parameters were unremarkable.", + "High-sensitive cardiac troponin T was 7 pg/ml.", + "N-terminal pro-brain natriuretic peptide was 75 ng/l.", + "C-reactive protein was 4.5 mg/l.", + "A 12-lead electrocardiogram showed T-wave inversion in the inferior and precordial leads.", + "Holter monitoring showed a normofrequent sinus rhythm without any supraventricular or ventricular ectopic beat.", + "An exercise test revealed a good exercise capacity without chest pain, shortness of breath, or any other symptoms upon reaching a maximal heart rate of 163 beats per minute.", + "Transthoracic echocardiography revealed a large homogenous mass in her slightly dilated right ventricle.", + "The mass suggested the involvement of her intraventricular septum and left ventricular apex.", + "A small, not significant pericardial effusion was also detected.", + "Cardiovascular magnetic resonance imaging revealed a 104 × 62 mm right ventricular mass infiltrating her intraventricular septum and left ventricular apex.", + "T1-weighted images showed isointensity of the relatively homogenous tumor.", + "T2-weighted images showed clear hyperintensity of the relatively homogenous tumor.", + "Late gadolinium enhancement depicted the dimensions of the tumor.", + "A transvenous right ventricular biopsy was performed to gain tissue material for histological analysis.", + "The obtained material was insufficient for a definitive diagnosis.", + "Our patient was then referred for an open myocardial biopsy via a partial inferior sternotomy.", + "A coronary angiography was performed to identify the feeding arteries of the large tumor.", + "Coronary angiography revealed ectatic coronary arteries without any stenosis.", + "A biventricular tumor was visualized on angiography with connection to both her right coronary artery and her left circumflex artery.", + "Histopathological analysis led to the diagnosis of a benign vascular tumor.", + "Examination of the tumor revealed numerous capillaries, arterioles, and venules embedded in a collagen-rich matrix.", + "Cells showed strong positive staining with antibodies against CD31 and CD34.", + "Histological findings were consistent with a benign intracardiac angioma.", + "The first imaging follow-up was performed 2 weeks later by CMR, and showed an unchanged result.", + "Because our patient was asymptomatic without signs of heart failure or arrhythmia, and the large tumor proved to be surgically unresectable, we decided on conservative management with regular clinical and imaging controls.", + "Nine months later our patient presented to our department for her regular follow-up appointment without any major complications.", + "Echocardiography showed no significant progress of the tumor." + ], + "summary": "A 35-year-old Caucasian female patient presented to our department with an asymptomatic giant intracardiac angioma infiltrating both ventricles. Evaluation of this tumor involved electrocardiography, echocardiography, cardiac magnetic resonance imaging, coronary angiography, an open myocardial biopsy, and histological examination of the resected specimen. Because our patient was asymptomatic, she was managed conservatively with regular follow-up. We discuss the treatment options available in comparison with similar cases.", + "summary_subclaims": [ + "The patient is a 35-year-old Caucasian female.", + "The patient had an asymptomatic giant intracardiac angioma.", + "The tumor infiltrated both ventricles.", + "Evaluation included electrocardiography.", + "Evaluation included echocardiography.", + "Evaluation included cardiac magnetic resonance imaging.", + "Evaluation included coronary angiography.", + "Evaluation included an open myocardial biopsy.", + "Evaluation included histological examination of the resected specimen.", + "The patient was asymptomatic.", + "The patient was managed conservatively with regular follow-up.", + "Treatment options were discussed in comparison with similar cases." + ] + }, + { + "id": "multiclinsum_test_2620_en.txt", + "fulltext": "A 67-year-old man with permanent AF and haemophilia was referred for further evaluation to our cardiology clinic by his primary haematologist. His past medical history included hypertension and heart failure. Recombinant factor VIII infusion was prescribed regularly and his baseline factor VIII activity level was kept around 10% by his primary haematologist. The CHA2DS2-VASc score was estimated to be 3 and the HAS-BLED score was 3. Due to the high risk of bleeding, we decided to perform percutaneous LAA closure. Pre-procedural cardiac computerized tomography angiography and TOE were performed for measurements of LAA dimensions and exclude LAA thrombus . The procedure was performed under mild anaesthesia, with the aid of TOE and fluoroscopy guidance. Additional recombinant factor VIII was administered according to the recommendations of haematologist before catheterization. Based on measurements, a 28-mm AmplatzerTM AmuletTM device was chosen for occlusion. Initially, trans-septal puncture was performed at the posteroinferior interatrial septum using the right femoral vein as the access site, and then 5000 IU of intravenous heparin was administered. The trans-septal sheath was exchanged for the 12-Fr delivery catheter which was subsequently loaded with the 28-mm AmplatzerTM AmuletTM device. The delivery catheter was advanced up to the LAA ostium and under TOE guidance the lobe of the device was carefully pushed to the landing zone and deployed at that level. The deployment of the proximal disc was then achieved by advancing the delivery cable while unsheathing the disc . The final result was excellent without significant residual leak, pericardial effusion, and embolic complication .The remaining hospital stay was uneventful and he was discharged on the following day. Clopidogrel 75 mg/day and aspirin 81 mg/day for 1 month with adequate FVIII prophylaxis and then only aspirin 81 mg/day for 2 months were recommended. No antithrombotic was given after 3 months. The patient did not report any thrombotic or haemorrhagic adverse events and there were no complications related to implanted device after 1 year of follow-up.", + "fulltext_subclaims": [ + "The patient is a 67-year-old man.", + "The patient has permanent AF.", + "The patient has haemophilia.", + "The patient was referred to the cardiology clinic by his primary haematologist.", + "The patient's past medical history includes hypertension.", + "The patient's past medical history includes heart failure.", + "Recombinant factor VIII infusion was prescribed regularly.", + "The baseline factor VIII activity level was kept around 10%.", + "The CHA2DS2-VASc score was estimated to be 3.", + "The HAS-BLED score was 3.", + "Percutaneous LAA closure was decided due to the high risk of bleeding.", + "Pre-procedural cardiac computerized tomography angiography was performed.", + "Pre-procedural TOE was performed.", + "The procedure was performed under mild anaesthesia.", + "TOE guidance was used during the procedure.", + "Fluoroscopy guidance was used during the procedure.", + "Additional recombinant factor VIII was administered before catheterization.", + "A 28-mm AmplatzerTM AmuletTM device was chosen for occlusion.", + "Trans-septal puncture was performed at the posteroinferior interatrial septum.", + "The right femoral vein was used as the access site.", + "5000 IU of intravenous heparin was administered.", + "The trans-septal sheath was exchanged for the 12-Fr delivery catheter.", + "The delivery catheter was advanced up to the LAA ostium.", + "The lobe of the device was pushed to the landing zone under TOE guidance.", + "The deployment of the proximal disc was achieved by advancing the delivery cable while unsheathing the disc.", + "The final result was excellent without significant residual leak.", + "There was no pericardial effusion.", + "There was no embolic complication.", + "The patient was discharged on the following day.", + "Clopidogrel 75 mg/day and aspirin 81 mg/day were recommended for 1 month.", + "Adequate FVIII prophylaxis was recommended.", + "Aspirin 81 mg/day was recommended for 2 months.", + "No antithrombotic was given after 3 months.", + "The patient did not report any thrombotic adverse events after 1 year of follow-up.", + "The patient did not report any haemorrhagic adverse events after 1 year of follow-up.", + "There were no complications related to the implanted device after 1 year of follow-up." + ], + "summary": "A 67-year-old man with permanent AF and haemophilia was referred for further evaluation of our cardiology clinic by his primary haematologist. The CHA2DS2-VASc score was estimated to be 3 and the HAS-BLED score was 3. Due to high risk of bleeding, we decided to perform percutaneous LAA closure instead of oral anticoagulation. Pre-procedural cardiac computerized tomography angiography and transoesophageal echocardiography were performed for measurements of LAA dimensions and exclude LAA thrombus. Percutaneous LAA occlusion was performed using a 28-mm AmplatzerTM AmuletTM device. The final result was excellent without significant residual leak, pericardial effusion, and embolic complication. Clopidogrel 75 mg/day and aspirin 81 mg/day for 1 month with adequate FVIII prophylaxis and then only aspirin 81 mg/day for 2 months were recommended. No antiplatelet was given after 3 months. The patient did not report any thrombotic or haemorrhagic adverse events and there were no complications related to implanted device after 1 year of follow-up.", + "summary_subclaims": [ + "The patient is a 67-year-old man.", + "The patient has permanent AF.", + "The patient has haemophilia.", + "The patient was referred to the cardiology clinic.", + "The referral was made by his primary haematologist.", + "The CHA2DS2-VASc score was estimated to be 3.", + "The HAS-BLED score was 3.", + "Percutaneous LAA closure was decided upon.", + "The decision was due to high risk of bleeding.", + "Pre-procedural cardiac computerized tomography angiography was performed.", + "Transoesophageal echocardiography was performed.", + "The purpose of the imaging was to measure LAA dimensions.", + "The purpose of the imaging was to exclude LAA thrombus.", + "Percutaneous LAA occlusion was performed using a 28-mm AmplatzerTM AmuletTM device.", + "The final result was excellent.", + "There was no significant residual leak.", + "There was no pericardial effusion.", + "There was no embolic complication.", + "Clopidogrel 75 mg/day and aspirin 81 mg/day were recommended for 1 month.", + "Adequate FVIII prophylaxis was recommended.", + "After 1 month, only aspirin 81 mg/day was recommended for 2 months.", + "No antiplatelet was given after 3 months.", + "The patient did not report any thrombotic adverse events.", + "The patient did not report any haemorrhagic adverse events.", + "There were no complications related to the implanted device after 1 year of follow-up." + ] + }, + { + "id": "multiclinsum_test_3051_en.txt", + "fulltext": "Clinical finding\nA 28-year-old male presented with right preauricular, painless swelling for 9 months. The swelling was gradually increasing in size. On examination, superficial swelling was found, which measured 4.8 cm × 4.0 cm in size, firm in consistency, mobile, smooth surface, regular border, and nontender. There was no sign of facial nerve deficit. He did not have any family history of cancer or history of radiation exposure.\n\nManagement\nThe patient was advised for head-and-neck ultrasound and FNAC of the preauricular swelling. USG showed a heterogeneous, hypoechoic mass with well-defined border on the right side of the superficial lobe of the parotid gland. These radiological findings suggest the diagnosis of a benign tumor in the parotid gland.\n\nA FNAC was performed in the preauricular or parotid swelling. According to the Milan system for reporting salivary gland cytology, the FNAC of the parotid gland was categorized as IV – neoplasm. After that, a superficial parotidectomy with facial nerve preservation was performed under general anesthesia. Then, the parotidectomy specimen was sent to the pathology department for histopathological examination.\n\nHistopathology\nA parotidectomy specimen was received grossly as a multiple nodular mass measuring 6.2 cm × 4.3 cm × 2.0 cm. It cuts firm. The cut surface showed multiple small nodular solid yellowish-to-whitish areas. Microscopic examination of hematoxylin and eosin stained section showed malignant tumor islands that composed of an admixture of different types of malignant tumor cells, including malignant acinar cells, clear/vacuolated cells, intercalated duct-like cells, and nonspecific glandular cells. These tumor cells are arranged in solid and microcystic patterns that infiltrate into the sclerotic stroma. Malignant acinar cells are large polygonal cells with abundant basophilic granular cytoplasm and eccentrically placed small hyperchromatic nuclei. Intercalated duct-like cells are cuboidal cells with amphophilic cytoplasm with centrally placed dark nuclei. Nonspecific glandular cells have vesicular nuclei with eosinophilic cytoplasm. Sheets of malignant tumor cells are also traversed by very delicate blood vessels. There is no evidence of necrosis. The morphological diagnosis was hence, as the differential diagnosis of ACC and secretory carcinoma (SC). After that, we performed a special stain PAS-D, which showed abundant PAS-positive diastase-resistant cytoplasmic granules in the malignant acinar cells. On further IHC, DOG-1 was positive with cytoplasmic expression in tumor cells, while mammaglobin was not expressed in tumor cells. This special stain and IHC almost confirmed the diagnosis of ACC in the parotid gland. Currently, the patient has remained disease-free with no signs of recurrence.\n", + "fulltext_subclaims": [ + "The patient is a 28-year-old male.", + "He had right preauricular, painless swelling for 9 months.", + "The swelling was gradually increasing in size.", + "On examination, the superficial swelling measured 4.8 cm × 4.0 cm.", + "The swelling was firm in consistency.", + "The swelling was mobile.", + "The swelling had a smooth surface.", + "The swelling had a regular border.", + "The swelling was nontender.", + "There was no sign of facial nerve deficit.", + "He did not have any family history of cancer.", + "He did not have a history of radiation exposure.", + "The patient was advised for head-and-neck ultrasound.", + "The patient was advised for FNAC of the preauricular swelling.", + "USG showed a heterogeneous, hypoechoic mass with well-defined border on the right side of the superficial lobe of the parotid gland.", + "These radiological findings suggest the diagnosis of a benign tumor in the parotid gland.", + "A FNAC was performed in the preauricular or parotid swelling.", + "According to the Milan system for reporting salivary gland cytology, the FNAC of the parotid gland was categorized as IV – neoplasm.", + "A superficial parotidectomy with facial nerve preservation was performed under general anesthesia.", + "The parotidectomy specimen was sent to the pathology department for histopathological examination.", + "A parotidectomy specimen was received grossly as a multiple nodular mass measuring 6.2 cm × 4.3 cm × 2.0 cm.", + "The cut surface showed multiple small nodular solid yellowish-to-whitish areas.", + "Microscopic examination showed malignant tumor islands composed of an admixture of different types of malignant tumor cells.", + "The tumor cells were arranged in solid and microcystic patterns that infiltrate into the sclerotic stroma.", + "Malignant acinar cells were large polygonal cells with abundant basophilic granular cytoplasm and eccentrically placed small hyperchromatic nuclei.", + "Intercalated duct-like cells were cuboidal cells with amphophilic cytoplasm with centrally placed dark nuclei.", + "Nonspecific glandular cells had vesicular nuclei with eosinophilic cytoplasm.", + "Sheets of malignant tumor cells were traversed by very delicate blood vessels.", + "There was no evidence of necrosis.", + "The morphological diagnosis was the differential diagnosis of ACC and secretory carcinoma (SC).", + "A special stain PAS-D showed abundant PAS-positive diastase-resistant cytoplasmic granules in the malignant acinar cells.", + "On further IHC, DOG-1 was positive with cytoplasmic expression in tumor cells.", + "Mammaglobin was not expressed in tumor cells.", + "This special stain and IHC almost confirmed the diagnosis of ACC in the parotid gland.", + "The patient has remained disease-free with no signs of recurrence." + ], + "summary": "Here, a 28-year-old man presented with a right preauricular swelling for 9 months. Ultrasound of the head region - and of the peak and fine cytology aspirate Diagnosis of neoplasm in the parotid gland, most likely a benign tumour. After that, a total parotidectomy with preservation of the facial nerve was performed. On the histopathological and immunohistochemical study, was consistent with the diagnosis of ACC in the parotid gland.\n", + "summary_subclaims": [ + "A 28-year-old man presented with a right preauricular swelling for 9 months.", + "Ultrasound of the head region was performed.", + "Fine cytology aspirate was performed.", + "The diagnosis was neoplasm in the parotid gland, most likely a benign tumour.", + "A total parotidectomy with preservation of the facial nerve was performed.", + "Histopathological and immunohistochemical study was consistent with the diagnosis of ACC in the parotid gland." + ] + }, + { + "id": "multiclinsum_test_1402_en.txt", + "fulltext": "A 66-year-old man underwent high anterior resection for rectal cancer 11 years ago. He had also been diagnosed with an esophageal tumor 15 cm in size at the same time, based on the symptom of mild dysphagia, but had left the tumor untreated. Recently, he presented to our hospital with progressive dysphagia and appetite loss, which had gradually worsened over the course of the previous year. He had no history of smoking or drinking alcohol. His tumor markers were not increased (carcinoembryonic antigen: 2.0 ng/mL, squamous cell cancer antigen: 0.9 ng/mL). Upper gastrointestinal imaging (UGI) and esophagogastroduodenoscopy (EGD) showed a large tumor with a thick stalk arising from the esophageal entrance, extending to the gastroesophageal junction, with a normal surface mucosa . Since we could not identify details of this submucosal tumor (SMT), we considered it a so-called fibrovascular polyp. Furthermore, a localized erythematous lesion and type B1 vessels according to the Japan Esophageal Society classification were identified on the tumor surface, 30 cm from the incisor teeth . Contrast-enhanced computed tomography (CT) showed a large tumor hanging from the cervical esophagus, extending to the gastroesophageal junction . The inside of the tumor was heterogeneously contrasted with a mixture of fatty, fibrous and vascular components. The length of the tumor was about 30 cm, indicating that it had doubled in size over the last 10 years. There were no findings suggesting lymph node or distant metastasis. Three-dimensional CT (3D-CT) revealed that the tumor was an intraluminal polypoid tumor . Our preoperative diagnosis was a so-called giant fibrovascular polyp with superficial carcinoma of the esophagus. From the above findings, we determined that it was possible to achieve radical en bloc resection of the tumor through the cervical approach as a minimally invasive procedure, without lymph node dissection. With the patient under general anesthesia, we made a 7-cm skin incision on the left side of the neck. We cut the lateral side of the anterior cervical muscles, but preserved the sternocleidomastoid muscle and entered the inner side of the common carotid artery. After that, we reached the wall of the esophagus and taped it. After directly incising the esophageal wall at the opposite side of tumor peduncle and encircling the stalk of the tumor, the giant tumor was directly grasped and could be carefully pulled out of the esophageal lumen . We transected the stalk of the tumor arising from the posterior wall and extracted it . The basal mucosal layer of the esophagus was closed using continuous 4–0 absorbable sutures, and the muscle layer was closed with nodal sutures using 3–0 absorbable sutures. The surgical duration was 2 h and 22 min, and blood loss was minimal. The patient had an uneventful postoperative course without any complications, and was discharged on postoperative day 14 without dysphagia.\nThe excised specimen consisted of a 23.0 × 8.5 cm polypoid mass and superficial esophageal carcinoma located on it . Histological examination showed proliferation of squamous cell carcinoma in the epithelium and invasion of the stroma in some areas, although there was no lamina muscularis mucosa. The depth of invasion was 930 μm from the surface of mucosa , and there was no vascular or lymphatic invasion. On the other hand, most of the submucosal tumor was composed of adipocytes and spindle cells with atypical nuclei . Immunohistochemical analysis showed that the adipocytes were weakly positive for murine double minute-2 (MDM2) and positive for cyclin-dependent kinase 4 (CDK4) and p16 . The final pathological diagnosis was well-differentiated esophageal liposarcoma together with squamous cell carcinoma. The surgical margin of the tumor was microscopically negative. The patient did not undergo any postoperative adjuvant therapy and gained 10 kg in weight within 3 months postoperatively.", + "fulltext_subclaims": [ + "The patient is a 66-year-old man.", + "He underwent high anterior resection for rectal cancer 11 years ago.", + "He had also been diagnosed with an esophageal tumor 15 cm in size at the same time.", + "The esophageal tumor diagnosis was based on the symptom of mild dysphagia.", + "He had left the tumor untreated.", + "He recently presented with progressive dysphagia and appetite loss.", + "The dysphagia and appetite loss had gradually worsened over the previous year.", + "He had no history of smoking.", + "He had no history of drinking alcohol.", + "His tumor markers were not increased.", + "Carcinoembryonic antigen was 2.0 ng/mL.", + "Squamous cell cancer antigen was 0.9 ng/mL.", + "Upper gastrointestinal imaging showed a large tumor with a thick stalk arising from the esophageal entrance.", + "The tumor extended to the gastroesophageal junction.", + "The surface mucosa was normal.", + "A localized erythematous lesion was identified on the tumor surface.", + "The lesion was 30 cm from the incisor teeth.", + "Contrast-enhanced computed tomography showed a large tumor hanging from the cervical esophagus.", + "The tumor extended to the gastroesophageal junction.", + "The tumor was heterogeneously contrasted with a mixture of fatty, fibrous, and vascular components.", + "The length of the tumor was about 30 cm.", + "There were no findings suggesting lymph node metastasis.", + "There were no findings suggesting distant metastasis.", + "Three-dimensional CT revealed that the tumor was an intraluminal polypoid tumor.", + "The preoperative diagnosis was a so-called giant fibrovascular polyp with superficial carcinoma of the esophagus.", + "Radical en bloc resection of the tumor was planned through the cervical approach.", + "The procedure was planned as a minimally invasive procedure.", + "A 7-cm skin incision was made on the left side of the neck.", + "The lateral side of the anterior cervical muscles was cut.", + "The sternocleidomastoid muscle was preserved.", + "The inner side of the common carotid artery was entered.", + "The wall of the esophagus was reached and taped.", + "The esophageal wall was directly incised at the opposite side of the tumor peduncle.", + "The stalk of the tumor was encircled.", + "The giant tumor was directly grasped and carefully pulled out of the esophageal lumen.", + "The stalk of the tumor was transected.", + "The basal mucosal layer of the esophagus was closed using continuous 4–0 absorbable sutures.", + "The muscle layer was closed with nodal sutures using 3–0 absorbable sutures.", + "The surgical duration was 2 h and 22 min.", + "Blood loss was minimal.", + "The patient had an uneventful postoperative course.", + "The patient was discharged on postoperative day 14.", + "The excised specimen consisted of a 23.0 × 8.5 cm polypoid mass.", + "Superficial esophageal carcinoma was located on the mass.", + "Histological examination showed proliferation of squamous cell carcinoma in the epithelium.", + "There was invasion of the stroma in some areas.", + "There was no lamina muscularis mucosa.", + "The depth of invasion was 930 μm from the surface of the mucosa.", + "There was no vascular invasion.", + "There was no lymphatic invasion.", + "Most of the submucosal tumor was composed of adipocytes and spindle cells with atypical nuclei.", + "Immunohistochemical analysis showed that the adipocytes were weakly positive for MDM2.", + "The adipocytes were positive for CDK4.", + "The adipocytes were positive for p16.", + "The final pathological diagnosis was well-differentiated esophageal liposarcoma together with squamous cell carcinoma.", + "The surgical margin of the tumor was microscopically negative.", + "The patient did not undergo any postoperative adjuvant therapy.", + "The patient gained 10 kg in weight within 3 months postoperatively." + ], + "summary": "A 66-year-old man was diagnosed with an esophageal tumor 11 years ago, but he left it untreated. He presented to our hospital with progressive dysphagia and appetite loss since the previous year. Esophagogastroduodenoscopy (EGD) showed a large pedunculated submucosal tumor (SMT) originating at the esophageal entrance, extending to the gastroesophageal junction. Additionally, there was a superficial carcinoma on the surface of the SMT, 30 cm from the incisor teeth. Three-dimensional computed tomography (3D-CT) showed a giant elongated intraluminal tumor extending downwards from the cervical esophagus. We diagnosed a giant esophageal polyp accompanied by a superficial carcinoma and performed tumor resection via a cervical approach. The excised specimen consisted of a 23.0 × 8.5 cm polypoid mass. The final diagnosis by histopathological and immunohistochemical examination was well-differentiated liposarcoma and esophageal squamous cell carcinoma. He was discharged on postoperative day 14 with drastic improvement in his swallowing ability.", + "summary_subclaims": [ + "The patient is a 66-year-old man.", + "He was diagnosed with an esophageal tumor 11 years ago.", + "He left the tumor untreated.", + "He presented with progressive dysphagia and appetite loss since the previous year.", + "Esophagogastroduodenoscopy showed a large pedunculated submucosal tumor originating at the esophageal entrance.", + "The submucosal tumor extended to the gastroesophageal junction.", + "There was a superficial carcinoma on the surface of the submucosal tumor.", + "The superficial carcinoma was 30 cm from the incisor teeth.", + "Three-dimensional computed tomography showed a giant elongated intraluminal tumor extending downwards from the cervical esophagus.", + "The diagnosis was a giant esophageal polyp accompanied by a superficial carcinoma.", + "Tumor resection was performed via a cervical approach.", + "The excised specimen was a 23.0 × 8.5 cm polypoid mass.", + "The final diagnosis was well-differentiated liposarcoma and esophageal squamous cell carcinoma.", + "He was discharged on postoperative day 14.", + "He had drastic improvement in his swallowing ability." + ] + }, + { + "id": "multiclinsum_test_2412_en.txt", + "fulltext": "A 52-year-old Albanian woman from Kosovo presented to our hospital with dyspnea, tachycardia, and jugular distension. On admission she was in New York Heart Association class III, with normal blood pressure and absence of aortic murmur. She was in sinus rhythm and a chest X-ray demonstrated cardiomegaly with right atrium enlargement. A transthoracic echocardiography demonstrated increased pericardial effusion of almost 35 mm and a giant mass above her left atrium communicating with the ascending aorta. A transesophageal echocardiogram showed a large unruptured aneurysm/pseudoaneurysm 61×77 mm of the noncoronary sinus of Valsalva, without thrombosis or shunts, above her left atrium . Her aortic valve was competent, without annular enlargement. A cardiac contrast-enhanced angio-computed tomography (CT) scan confirmed the presence of a giant unruptured aneurysm of the noncoronary sinus of Valsalva of 74×60 mm diameter free from thrombotic lining, which was compressing her right atrium . The presence of a significant amount of pericardial effusion indicated a possible rupture of the aneurysm of the sinus of Valsalva or the presence of a pseudoaneurysm; therefore, we recommended urgent surgical repair.\nShe underwent femoral artery and vein cannulation and on cardiopulmonary bypass a sternotomy was performed. Her pericardium was then opened. An unruptured aneurysm of the noncoronary sinus of Valsalva was identified . On intraoperative examination, a thin-walled unruptured aneurysm of the noncoronary sinus of Valsalva expanding above the roof of her left atrium, compressing and partially gaining adhesions with her right atrium was identified. Her aorta was clamped and her heart was arrested with anterograde cardioplegic infusion. An anterior oblique aortotomy was performed. The orifice of the unruptured aneurysm of the noncoronary sinus of Valsalva was identified . The aneurysm was opened and carefully inspected for any possible communication. A Dacron patch was prepared to remodel the noncoronary sinus, which then was sutured with a continuous Prolene 4/0 suture . Then the aneurysmatic sac was closed from outside above the orifice of the aneurysm. A pathological examination of the resected unruptured aneurysm of the noncoronary sinus of Valsalva revealed conspicuous mucoid deposits, loss of elastic fibers and eosinophilic infiltration. Her postoperative course was uneventful. At 1 month after surgery, a contrast-enhanced angio-CT demonstrated a totally thrombosed cavity of the previous aneurysm which had non-communication with her aorta or any other cardiac chamber . At 1 year after surgery, she was doing well and an echocardiographic examination revealed mild aortic insufficiency.", + "fulltext_subclaims": [ + "The patient was a 52-year-old Albanian woman from Kosovo.", + "She presented with dyspnea, tachycardia, and jugular distension.", + "On admission, she was in New York Heart Association class III.", + "She was in sinus rhythm.", + "A chest X-ray demonstrated cardiomegaly with right atrium enlargement.", + "A transthoracic echocardiography demonstrated increased pericardial effusion of almost 35 mm.", + "A transthoracic echocardiography demonstrated a giant mass above her left atrium communicating with the ascending aorta.", + "A transesophageal echocardiogram showed a large unruptured aneurysm/pseudoaneurysm 61×77 mm of the noncoronary sinus of Valsalva.", + "The aneurysm/pseudoaneurysm was above her left atrium.", + "The aneurysm/pseudoaneurysm showed no thrombosis or shunts.", + "Her aortic valve was competent, without annular enlargement.", + "A cardiac contrast-enhanced angio-computed tomography scan confirmed the presence of a giant unruptured aneurysm of the noncoronary sinus of Valsalva.", + "The aneurysm was 74×60 mm in diameter.", + "The aneurysm was free from thrombotic lining.", + "The aneurysm was compressing her right atrium.", + "The presence of a significant amount of pericardial effusion indicated a possible rupture of the aneurysm of the sinus of Valsalva or the presence of a pseudoaneurysm.", + "We recommended urgent surgical repair.", + "She underwent femoral artery and vein cannulation.", + "On cardiopulmonary bypass, a sternotomy was performed.", + "Her pericardium was opened.", + "An unruptured aneurysm of the noncoronary sinus of Valsalva was identified.", + "On intraoperative examination, a thin-walled unruptured aneurysm of the noncoronary sinus of Valsalva expanding above the roof of her left atrium was identified.", + "The aneurysm was compressing and partially gaining adhesions with her right atrium.", + "Her aorta was clamped and her heart was arrested with anterograde cardioplegic infusion.", + "An anterior oblique aortotomy was performed.", + "The orifice of the unruptured aneurysm of the noncoronary sinus of Valsalva was identified.", + "The aneurysm was opened and carefully inspected for any possible communication.", + "A Dacron patch was prepared to remodel the noncoronary sinus.", + "The patch was sutured with a continuous Prolene 4/0 suture.", + "Then the aneurysmatic sac was closed from outside above the orifice of the aneurysm.", + "A pathological examination of the resected aneurysm revealed conspicuous mucoid deposits.", + "The pathological examination showed loss of elastic fibers.", + "The pathological examination showed eosinophilic infiltration.", + "Her postoperative course was uneventful.", + "At 1 month after surgery, a contrast-enhanced angio-CT demonstrated a totally thrombosed cavity of the previous aneurysm.", + "The thrombosed cavity had no communication with her aorta or any other cardiac chamber.", + "At 1 year after surgery, she was doing well.", + "An echocardiographic examination revealed mild aortic insufficiency." + ], + "summary": "In this report we describe a 52-year-old Albanian woman from Kosovo with an unruptured aneurysm of 74×60 mm of the noncoronary sinus of Valsalva presenting dyspnea, jugular distension, and tachycardia due to cardiac compression. She underwent successful closure of the orifice and sinus remodeling with a Dacron patch.", + "summary_subclaims": [ + "The patient is a 52-year-old Albanian woman from Kosovo.", + "She has an unruptured aneurysm of 74×60 mm of the noncoronary sinus of Valsalva.", + "She presented with dyspnea.", + "She presented with jugular distension.", + "She presented with tachycardia due to cardiac compression.", + "She underwent successful closure of the orifice.", + "She underwent sinus remodeling with a Dacron patch." + ] + }, + { + "id": "multiclinsum_test_1251_en.txt", + "fulltext": "A 67-year-old man with a history of intrinsic asthma, but who otherwise had very good health condition, was admitted to our intensive care unit with an acute asthma attack. Peripheral oxygenation saturation had been 80–89% without oxygen, and he then received supplemental oxygen, combined with inhalative salbutamol, as well as intravenous prednisolone, dimetindene, and ranitidine by an emergency physician at his home.\nOn admission to the intensive care unit, the patient was still awake, but severely tachy- and orthopnoic. Oxygen, 4 l min−1, resulted in 95% SpO2, but blood gas analysis showed a respiratory acidosis (pH 7.29, pCO2 55 mmHg, pO2 84 mmHg, HCO3−26.4, BE −1.6). Chest X-ray was normal, but severe expiratory wheezing could be heard on both lungs. The patient was on theophylline and formoterole/budesonide. Other relevant comorbidities were diabetes type 2 treated with metformin and coronary heart disease (1-vessel disease). He repeatedly inhaled salbutamol, ipatropiumbromide, and budesonide and received intravenous prednisolone, reproterole (bolus plus continuous), and magnesium. The patient was directly put on non-invasive ventilation (NIV; EVITA-4, Draeger®), facilitated with a cumulative dose of 4 mg morphine. While at first sight, the therapeutic regimen seemed to work and an ongoing deterioration with increasing pCO2-levels and signs of respiratory exhaustion were recognized. The patient’s vigilance became more and more impaired, and respiratory acidosis was later accompanied by a slight metabolic acidosis (blood gas analysis before ECCO2R: pH 7.24, pCO2 61 mmHg, pO2 289 mmHg, HCO3−26.1, BE −3.0). Meanwhile, other possible contributing causes, like pneumonia, lung embolism, and cardiac attack, were ruled out.\nAfter careful consideration, and with the consent of the patient and his family, a ECCO2R system was prepared. Under non-invasive ventilation conditions and local anesthesia, a 22 French double lumen cannula (Twinport®, Novalung, Heilbronn, Germany) was placed in the right upper jugular vein under sonographic guidance. The system was started with a blood flow of 1 l min−1 and a sweep gas flow of 1 l min−1 oxygen, (ILA-activve®, Xenios, Heilbronn, Germany). Due to the respiratory effort of the patient along with hypovolemia, blood flow initially fluctuated between 0.6 and 1.5 l min−1. Fluid repletion was therefore conducted with balanced crystalloids combined with albumin to achieve a better intravascular effect. With the circuit running, a rapid improvement in almost all former deranged qualities was noticed: breath rate decreased from 40 to 16 per minute, SpO2 rose to 100%, and pCO2 was intentionally lowered very slowly (with 2 l min−1 sweep gas flow). Due to the sudden relief, the patient fell asleep for a few hours and NIV was down-graded to nasal oxygen (4 l min−1). Three hours after starting the ECCO2R circuit, blood gas analysis was normal (pH 7.39, pCO2 44 mmHg, pO2 93 mmHg, SpO2 97%, BE 1.2). On day two, the patient was put on oral prednisolone (50 mg day−1). There was no more dyspnea or wheezing and both, nasal oxygen and sweep gas flow, could be reduced. Early mobilization and physiotherapy was started the very same day. Thirty-four hours after initiating the ECCO2R system, the patient was completely weaned, and the cannula could be removed without any complication. On day 4, the patient could be discharged from the ICU without need for supplemental oxygen and 6 days later, he left the hospital without any impairment.", + "fulltext_subclaims": [ + "The patient was a 67-year-old man.", + "He had a history of intrinsic asthma.", + "He was admitted to the intensive care unit with an acute asthma attack.", + "Peripheral oxygenation saturation had been 80–89% without oxygen.", + "He received supplemental oxygen, combined with inhalative salbutamol.", + "He received intravenous prednisolone, dimetindene, and ranitidine.", + "On admission to the intensive care unit, the patient was still awake.", + "Oxygen at 4 l min−1 resulted in 95% SpO2.", + "Blood gas analysis showed a respiratory acidosis (pH 7.29, pCO2 55 mmHg).", + "Chest X-ray was normal.", + "Severe expiratory wheezing could be heard on both lungs.", + "The patient was on theophylline and formoterole/budesonide.", + "He repeatedly inhaled salbutamol, ipatropiumbromide, and budesonide.", + "He received intravenous prednisolone, reproterole (bolus plus continuous), and magnesium.", + "The patient was directly put on non-invasive ventilation (NIV).", + "A cumulative dose of 4 mg morphine was administered.", + "The patient’s vigilance became more and more impaired.", + "Blood gas analysis before ECCO2R showed pH 7.24, pCO2 61 mmHg.", + "Other possible contributing causes like pneumonia, lung embolism, and cardiac attack were ruled out.", + "A ECCO2R system was prepared.", + "A 22 French double lumen cannula was placed in the right upper jugular vein.", + "The system was started with a blood flow of 1 l min−1 and a sweep gas flow of 1 l min−1 oxygen.", + "Blood flow initially fluctuated between 0.6 and 1.5 l min−1.", + "Fluid repletion was conducted with balanced crystalloids combined with albumin.", + "With the circuit running, breath rate decreased from 40 to 16 per minute.", + "SpO2 rose to 100%.", + "pCO2 was intentionally lowered very slowly.", + "The patient fell asleep for a few hours.", + "NIV was down-graded to nasal oxygen (4 l min−1).", + "Three hours after starting the ECCO2R circuit, blood gas analysis was normal.", + "On day two, the patient was put on oral prednisolone (50 mg day−1).", + "There was no more dyspnea or wheezing.", + "Nasal oxygen and sweep gas flow could be reduced.", + "Early mobilization and physiotherapy was started the very same day.", + "Thirty-four hours after initiating the ECCO2R system, the patient was completely weaned.", + "The cannula could be removed without any complication.", + "On day 4, the patient could be discharged from the ICU without need for supplemental oxygen.", + "He left the hospital 6 days later without any impairment." + ], + "summary": "A 67-year-old man with a near-fatal asthma attack deteriorated under non-invasive ventilation conditions. Beside pharmacological treatment, the intensivists decided to use an extracorporeal carbon dioxide removal system (ECCO2R) to avoid sedation and intubation. Within only a few hours, there was a breakthrough and the patient's status improved continuously. One and a half days later, weaning from ECCO2R was already completed.", + "summary_subclaims": [ + "The patient is a 67-year-old man.", + "The patient had a near-fatal asthma attack.", + "The patient deteriorated under non-invasive ventilation conditions.", + "The intensivists decided to use an extracorporeal carbon dioxide removal system (ECCO2R).", + "The ECCO2R was used to avoid sedation and intubation.", + "Within only a few hours, there was a breakthrough.", + "The patient's status improved continuously.", + "Weaning from ECCO2R was completed one and a half days later." + ] + }, + { + "id": "multiclinsum_test_1747_en.txt", + "fulltext": "The patient was a 43-year-old man with a fecal specimen that was positive for occult blood during a routine check-up. He underwent a colonoscopy, which revealed a type I serrated polyp (SP) in the sigmoid colon 20 cm from the anal verge. He was referred to our hospital for an endoscopic mucosal resection (EMR). The histopathologic assessment of the resected specimen showed infiltration into the submucosal layer and he was referred to the Department of Digestive Surgery for an additional resection.\nThe medical history included hypertension, hyperlipidemia, and elevated hepatobiliary enzymes. He was 158 cm tall and weighed 53.2 kg. Blood tests showed elevated liver enzymes, but no other abnormalities, and tumor markers were within the normal ranges. A preoperative CT scan was negative for distant metastases and enlarged lymph nodes, and colonoscopy revealed a scar at the site of the EMR in the sigmoid colon 20 cm from the anal verge.\nSurgery was performed under general anesthesia in the lithotomy position. A laparoscopic sigmoidectomy was performed. The sigmoid colon was transected 10 cm from the anal side of the tumor, and after a small laparotomy, the sigmoid colon was extracted from the abdominal cavity. ICG (Diagnogreen; Dai-Ichi Pharm, Tokyo, Japan) was injected as a 12.5-mg bolus (0.25 mg/kg) from a peripheral vein, and ICG /TG was used to evaluate blood flow. We used a T530 thermal camera (FLIR Systems, Tokyo, Japan) and analysis software (ResearchIRMAX; FLIR Systems, Tokyo, Japan).\nAfter confirmation of the boundary between ischemic and non-ischemic colon tissues at the level of the mesenteric processing site, the colon was resected; however, a diverticulum was noted at the anastomotic site when the anvil head of the circular stapler was inserted and attached to the oral side of the colon when performing the anastomosis. Because there was a risk of suture failure if the anastomosis had been performed using a double stapling technique (DST), additional resection (2 cm of colon on the oral side) was needed. After further manipulation of the mesentery, ICG was administered again, and fluorescence due to the remaining ICG from the previous administration was observed in the colon that was thought to have interrupted blood flow . Blood flow in the colon was confirmed by TG, and a transitional zone of serosal surface temperature was observed at the mesentery processing site, which corresponded to both the tissue where blood flow had been preserved and the ischemic tissue. Therefore, additional colon resection was performed along the boundary between the ischemic and non-ischemic tissues.\nAfter the anvil head was re-attached and the colon returned to the abdominal cavity, a DST anastomosis was performed between the oral side of the colon and the rectum. A leak test performed immediately after the anastomosis was negative, and the anastomosis appeared to have been performed successfully without any problems. A closed-suction drain was placed on the back side of the anastomotic site and the wound was closed. The postoperative course was uneventful and the patient was discharged to home 5 days after the surgery.", + "fulltext_subclaims": [ + "The patient was a 43-year-old man.", + "The fecal specimen was positive for occult blood.", + "The colonoscopy revealed a type I serrated polyp in the sigmoid colon 20 cm from the anal verge.", + "The patient was referred for an endoscopic mucosal resection.", + "The histopathologic assessment showed infiltration into the submucosal layer.", + "The patient was referred to the Department of Digestive Surgery for an additional resection.", + "The medical history included hypertension.", + "The medical history included hyperlipidemia.", + "The medical history included elevated hepatobiliary enzymes.", + "The patient was 158 cm tall.", + "The patient weighed 53.2 kg.", + "Blood tests showed elevated liver enzymes.", + "Tumor markers were within the normal ranges.", + "A preoperative CT scan was negative for distant metastases.", + "A preoperative CT scan was negative for enlarged lymph nodes.", + "Colonoscopy revealed a scar at the site of the EMR in the sigmoid colon 20 cm from the anal verge.", + "Surgery was performed under general anesthesia.", + "A laparoscopic sigmoidectomy was performed.", + "The sigmoid colon was transected 10 cm from the anal side of the tumor.", + "A small laparotomy was performed.", + "The sigmoid colon was extracted from the abdominal cavity.", + "ICG was injected as a 12.5-mg bolus.", + "ICG was used to evaluate blood flow.", + "A T530 thermal camera was used.", + "A diverticulum was noted at the anastomotic site.", + "Additional resection (2 cm of colon on the oral side) was needed.", + "ICG fluorescence due to the remaining ICG from the previous administration was observed.", + "Blood flow in the colon was confirmed by TG.", + "A transitional zone of serosal surface temperature was observed at the mesentery processing site.", + "Additional colon resection was performed along the boundary between the ischemic and non-ischemic tissues.", + "A DST anastomosis was performed between the oral side of the colon and the rectum.", + "A leak test performed immediately after the anastomosis was negative.", + "The anastomosis appeared to have been performed successfully without any problems.", + "A closed-suction drain was placed on the back side of the anastomotic site.", + "The wound was closed.", + "The postoperative course was uneventful.", + "The patient was discharged to home 5 days after the surgery." + ], + "summary": "The patient is 43-year-old man who underwent laparoscopic resection of the sigmoid colon for colon cancer. After vascular treatment of the colonic mesentery, ICG/TG identified the boundary between ischemic and non-ischemic colon tissues. An additional 2 cm of colonic mesentery was resected because of the presence of a diverticulum noted at the intended site of oral anastomosis when attaching the anvil head. After additional vascular treatment of the colonic mesentery and administration of ICG, fluorescence was observed in the colon; however, TG identified the zone of the temperature transition on the surface of the colonic mesentery, even after additional colonic mesentery resection in the same region as previously observed. This zone was used as the cut-off line. There were no complications, such as anastomotic leakage, after the surgery.", + "summary_subclaims": [ + "The patient is a 43-year-old man.", + "The patient underwent laparoscopic resection of the sigmoid colon for colon cancer.", + "After vascular treatment of the colonic mesentery, ICG/TG identified the boundary between ischemic and non-ischemic colon tissues.", + "An additional 2 cm of colonic mesentery was resected because of the presence of a diverticulum noted at the intended site of oral anastomosis when attaching the anvil head.", + "After additional vascular treatment of the colonic mesentery and administration of ICG, fluorescence was observed in the colon.", + "TG identified the zone of the temperature transition on the surface of the colonic mesentery, even after additional colonic mesentery resection in the same region as previously observed.", + "This zone was used as the cut-off line.", + "There were no complications, such as anastomotic leakage, after the surgery." + ] + }, + { + "id": "multiclinsum_test_569_en.txt", + "fulltext": "A 74-year-old woman presented with abdominal pain of 1 mo duration and was referred to Sun Yat-Sen Memorial Hospital, in March 2018.\nShe presented with abdominal pain of 1 mo duration.\nShe mentioned a loss of 8 kg over the previous 6 mo and had anemia. Hypertension was confirmed for many years.\nThe patient denied any family history of malignant tumors.\nUpon physical examination, no peripheral lymphadenopathy or hepatosplenomegaly was found. A mass was noted in the right lower quadrant.\nBlood examination showed an increase in carbohydrate antigen 125, carbohydrate antigen 19-9 level, and a decrease in lymphocyte proportion and count, hemoglobin, and total protein . Serum lactate dehydrogenase was elevated (538 U/L, normal 108-252 U/L). Blood detection for syphilis, hepatitis B virus, hepatitis C virus and human immunodeficiency virus was negative or normal.\nHypertensive heart disease was diagnosed by color sonography. Chest radiography showed no evidence of metastasis in the lung. Contrast-enhanced computed tomography revealed bowel wall thickening with contrast enhancement at the cecum, but no lymph node or organ metastasis and a negative scan of the liver and spleen. Colonoscopy revealed a tumor of the ascending colon, which was confirmed as adenocarcinoma on biopsy.", + "fulltext_subclaims": [ + "The patient is a 74-year-old woman.", + "She presented with abdominal pain of 1 mo duration.", + "She mentioned a loss of 8 kg over the previous 6 mo.", + "She had anemia.", + "Hypertension was confirmed for many years.", + "The patient denied any family history of malignant tumors.", + "Upon physical examination, no peripheral lymphadenopathy was found.", + "A mass was noted in the right lower quadrant.", + "Blood examination showed an increase in carbohydrate antigen 125.", + "Blood examination showed an increase in carbohydrate antigen 19-9 level.", + "Blood examination showed a decrease in lymphocyte proportion and count.", + "Blood examination showed a decrease in hemoglobin.", + "Blood examination showed a decrease in total protein.", + "Serum lactate dehydrogenase was elevated (538 U/L, normal 108-252 U/L).", + "Blood detection for syphilis was negative or normal.", + "Blood detection for hepatitis B virus was negative or normal.", + "Blood detection for hepatitis C virus was negative or normal.", + "Blood detection for human immunodeficiency virus was negative or normal.", + "Hypertensive heart disease was diagnosed by color sonography.", + "Chest radiography showed no evidence of metastasis in the lung.", + "Contrast-enhanced computed tomography revealed bowel wall thickening with contrast enhancement at the cecum.", + "Colonoscopy revealed a tumor of the ascending colon.", + "The tumor was confirmed as adenocarcinoma on biopsy." + ], + "summary": "A 74-year-old woman presented with abdominal pain of 1 mo duration. Biopsy under colonoscopy revealed adenocarcinoma of the ascending colon. Subsequently, the patient underwent laparoscopic radical resection of right colon cancer with lymph node dissection. A collision tumor was found incidentally through postoperative pathological sampling. Genetic analysis showed a collision tumor of DLBCL with germinal center B-cell subtype and TP53 mutation, and adenocarcinoma arising in a tubulovillous adenoma in the colon, with BRAF mutation and mutL homolog 1 promoter methylation. The patient died 3 mo after surgery. To our knowledge, this is the 23rd reported case of collision tumor of colorectal adenocarcinoma and lymphoma. The mean age of the 23 patients was 73 years. The most common site was the cecum. There were 15 cases with follow-up data including 11 living and four dead with a 3-year overall survival rate of 71.5%.", + "summary_subclaims": [ + "A 74-year-old woman presented with abdominal pain of 1 mo duration.", + "Biopsy under colonoscopy revealed adenocarcinoma of the ascending colon.", + "The patient underwent laparoscopic radical resection of right colon cancer with lymph node dissection.", + "A collision tumor was found incidentally through postoperative pathological sampling.", + "Genetic analysis showed a collision tumor of DLBCL with germinal center B-cell subtype and TP53 mutation.", + "Genetic analysis showed adenocarcinoma arising in a tubulovillous adenoma in the colon.", + "Genetic analysis showed BRAF mutation.", + "Genetic analysis showed mutL homolog 1 promoter methylation.", + "The patient died 3 mo after surgery.", + "To our knowledge, this is the 23rd reported case of collision tumor of colorectal adenocarcinoma and lymphoma.", + "The mean age of the 23 patients was 73 years.", + "The most common site was the cecum.", + "There were 15 cases with follow-up data.", + "There were 11 living patients among the 15 with follow-up data.", + "There were four dead patients among the 15 with follow-up data.", + "The 3-year overall survival rate was 71.5%." + ] + }, + { + "id": "multiclinsum_test_1693_en.txt", + "fulltext": "Our patient, a 71-year-old man, was admitted to our emergency department. He initially presented to his general practitioner with dizziness and palpitations, and was urgently transferred to hospital when his Holter electrocardiogram (ECG) demonstrated hundreds of episodes of nsVT. The patient's past medical history demonstrated a high cardiovascular risk profile, and included diabetes mellitus and hypertension. He had also previously been diagnosed with blue toe syndrome and peripheral arterial occlusive disease, for which he had previously been administered prostavasin therapy. No cardiac disease was known so far. A clinical examination, including a cardiovascular examination, was performed and was unremarkable. No relevant laboratory abnormalities were present. Continuous ECG monitoring and a 12 channel Holter ECG were performed, to detect the origin of the arrhythmia (, ). Multiple monomorphic, nsVTs were documented. The origin of the triggering ventricular extrasystole (VES) was septal. Based on the hospital’s own localization algorithm (adapted from), the left ventricular outflow tract (LVOT) aortic cusp region was the most likely origin of the nsVT. In a first step an echocardiography was performed. During this exam, an episode of an nsVT was recorded, including the triggering VES. All other values during sinus rhythm (SR) were normal (except a borderline left ventricular global longitudinal peak systolic strain and an aortic sclerosis) (see , ). During coronary angiography, one-vessel disease was revealed with a 70% obstruction of the left anterior descending artery and a 90% obstruction of the first diagonal branch. Both lesions were treated using in total three drug-eluting stents. After this procedure, no residual obstruction was left. Antiarrhythmic medication was optimized by intensifying the existing bisoprolol therapy and adding magnesium. During the three-channel 24 h Holter ECG after intervention only one further nsVT was documented. After a short monitoring period, the patient was supplied with a LifeVest® and was discharged. In the follow-up, the nsVTs reappeared after 6 weeks and the patient had to be sent to a specialized centre. In total, three electrophysiological studies were performed. Two endocardial approaches failed to terminate the arrhythmia. Finally, the arrhythmogenic LVOT area was treated by an epicardial ablation and an antiarrhythmic medication with sotalol instead of bisoprolol.", + "fulltext_subclaims": [ + "The patient is a 71-year-old man.", + "He was admitted to the emergency department.", + "He initially presented to his general practitioner with dizziness and palpitations.", + "His Holter ECG demonstrated hundreds of episodes of nsVT.", + "He was urgently transferred to hospital.", + "The patient's past medical history included diabetes mellitus.", + "The patient's past medical history included hypertension.", + "He had previously been diagnosed with blue toe syndrome.", + "He had previously been diagnosed with peripheral arterial occlusive disease.", + "He had previously been administered prostavasin therapy.", + "No cardiac disease was known so far.", + "A clinical examination was performed.", + "The cardiovascular examination was unremarkable.", + "No relevant laboratory abnormalities were present.", + "Continuous ECG monitoring was performed.", + "A 12 channel Holter ECG was performed.", + "Multiple monomorphic, nsVTs were documented.", + "The origin of the triggering ventricular extrasystole was septal.", + "The left ventricular outflow tract aortic cusp region was the most likely origin of the nsVT.", + "An echocardiography was performed.", + "An episode of an nsVT was recorded during the echocardiography.", + "All other values during sinus rhythm were normal.", + "A borderline left ventricular global longitudinal peak systolic strain was noted.", + "Aortic sclerosis was noted.", + "Coronary angiography revealed one-vessel disease.", + "A 70% obstruction of the left anterior descending artery was present.", + "A 90% obstruction of the first diagonal branch was present.", + "Both lesions were treated using three drug-eluting stents.", + "No residual obstruction was left after the procedure.", + "Antiarrhythmic medication was optimized.", + "Bisoprolol therapy was intensified.", + "Magnesium was added.", + "A three-channel 24 h Holter ECG was performed after intervention.", + "Only one further nsVT was documented.", + "The patient was supplied with a LifeVest®.", + "The patient was discharged.", + "The nsVTs reappeared after 6 weeks.", + "The patient was sent to a specialized centre.", + "Three electrophysiological studies were performed.", + "Two endocardial approaches failed to terminate the arrhythmia.", + "The arrhythmogenic LVOT area was treated by an epicardial ablation.", + "Antiarrhythmic medication was changed to sotalol instead of bisoprolol." + ], + "summary": "We report on a 71-year-old male patient with a distinct cardiovascular risk profile, recurrent incidences of dizziness and palpitations. A Holter electrocardiogram was performed showing multiple episodes of ventricular tachycardia. He was immediately transferred to our hospital for further monitoring and diagnostics. During echocardiography, one of these episodes could be recorded with a four-dimensional (4D) probe in triplane acquisition mode and strain analysis was done. Afterwards, a heart catheter examination was performed. A one-vessel coronary heart disease was diagnosed and treated with three drug-eluting stents. The burden of non-sustained ventricular tachycardia (nsVT) significantly reduced post-procedure. During the follow-up, new episodes of nsVT occurred after 6 weeks, which were treated by electrophysiological examinations.", + "summary_subclaims": [ + "The patient is a 71-year-old male.", + "The patient has a distinct cardiovascular risk profile.", + "The patient has recurrent incidences of dizziness and palpitations.", + "A Holter electrocardiogram was performed.", + "The Holter electrocardiogram showed multiple episodes of ventricular tachycardia.", + "The patient was immediately transferred to the hospital.", + "During echocardiography, one of these episodes could be recorded with a four-dimensional (4D) probe in triplane acquisition mode.", + "Strain analysis was done during echocardiography.", + "A heart catheter examination was performed.", + "A one-vessel coronary heart disease was diagnosed.", + "The one-vessel coronary heart disease was treated with three drug-eluting stents.", + "The burden of non-sustained ventricular tachycardia (nsVT) significantly reduced post-procedure.", + "New episodes of nsVT occurred after 6 weeks.", + "The new episodes of nsVT were treated by electrophysiological examinations." + ] + }, + { + "id": "multiclinsum_test_2632_en.txt", + "fulltext": "A 56-year-old gentleman (65 kg, 160 cm, BMI 25.4 kg/sq.m and ASA-IV E) presented to our emergency department with a two-day history of right lower abdominal pain, fever, and vomiting. His medical history was significant for long-standing type 2 diabetes mellitus (DM), hypertension, dyslipidemia, and dilated cardiomyopathy. Examination revealed tenderness in the right iliac fossa and bilateral fine basal crepitation. CT abdomen revealed acute gangrenous appendicitis, and an urgent open appendectomy was scheduled.\nWe assessed him preoperatively and consulted with a cardiologist. He was admitted to the Emergency Department, and our focus was on the patient’s cardiorespiratory system and ability to tolerate a general anesthetic procedure.\nOn examination, he was stable enough to verbalize his medical history. He also had a history of hospital admission for decompensated heart failure in 2019. At that time, transthoracic echocardiography (TTE) revealed a dilated left ventricle (LV), severely reduced systolic LV function (EF 18%), severe global hypokinesis of LV, and Grade 3 diastolic dysfunction. The patient was treated with anti-heart failure medications and discharged home a week later. He was prescribed aspirin, bisoprolol, ramipril, dapagliflozin, rosuvastatin, isosorbide dinitrate, and insulin.\nIn this visit, he had poorly controlled DM (HbA1C 13%). Laboratory tests revealed an NT pro-BNP level of 1122 pg/mL, troponin T level of 28 ng/l, CRP level of 158 mg/l, WBC 16000/mcl. TTE revealed a moderately dilated left ventricle, severely reduced LV systolic function, biplane LVEF of approximately 25%, severe global hypokinesis of the LV, and Grade 3 diastolic dysfunction. His medications on admission included bisoprolol, rosuvastatin, and insulin.\nThe patient had a revised cardiac risk index (RCRI) of 4, with 15% risk of major adverse cardiac events (MACE) and high risk for both general anesthesia and neuraxial blockade.\nHe was admitted to the SICU for preoperative optimization, arterial and central venous line insertion, Pulse index Continuous Cardiac Output (PiCCO)-guided fluid resuscitation, and antibiotic prophylaxis.\nOwing to the patient’s high risk, we held a multidisciplinary team meeting. The team decided that the patient would undergo an open appendectomy with QLB combined with monitored anesthesia care (MAC). As the patient had gangrenous appendicitis, there was a further risk of deterioration.\nThe patient was counselled regarding the urgent need for surgery, perioperative risk of cardiac complications, and specific anesthesia management, and written consent for anesthesia was obtained. He was brought to the operating room, and standard monitors were applied, along with an invasive arterial line monitor and supplemental oxygen administered via face mask at 5L/min. Inotropes (dobutamine and adrenaline infusions) were prepared in case he developed hemodynamic instability.\nIn the left lateral decubitus position, 2 mg of midazolam and 50 µg of fentanyl were administered intravenously as anxiolytics. An ultrasound probe (curvilinear low-frequency) was placed in a transverse orientation at the midaxillary line at the L2-L4 level to visualize the three expected abdominal layers (transversus abdominis, external oblique, and internal oblique). The probe was then moved posteriorly until quadratus lumborum muscle (QLM) was confirmed. Under aseptic techniques and ultrasound guidance, the needle was inserted and advanced into the anterior aspect of the QLM. Proper positioning of the needle tip was confirmed by hydrodissection, and 20 mL of 0.33% levobupivacaine was injected into the fascia between the right QL muscle and psoas muscles .\nSurgery was performed 15 min after the block, with supplemental local infiltration and intravenous fentanyl at titrated doses of up to 50 µg. Intraoperative sedation was achieved with 2 mg of midazolam intravenously at titrated doses of up to 4 mg. A minimal dose of noradrenaline 0.03–0.05mcg/kg/min infusion was continued to maintain normal hemodynamics. An additional dose of intravenous fentanyl (50 µg) was administered to blunt the effects of deep peritoneal stimulation. The patient maintained the airway and vital signs around baseline throughout the procedure.\nThe patient was transferred to the SICU for hemodynamic monitoring and organ support. The numerical rating of pain score was 0/10 at rest and 2/10 with movement at 24 h and reached a maximum of 4/10 with movement at 48 h postoperatively. His pain was managed with paracetamol, and he was discharged on the fourth day postoperatively. A summary of the clinical care pathways for our patient is shown in .", + "fulltext_subclaims": [ + "The patient is a 56-year-old gentleman.", + "The patient's BMI is 25.4 kg/sq.m.", + "The patient's ASA classification is IV E.", + "The patient presented with a two-day history of right lower abdominal pain.", + "The patient had fever.", + "The patient had vomiting.", + "The patient has type 2 diabetes mellitus.", + "The patient has hypertension.", + "The patient has dyslipidemia.", + "The patient has dilated cardiomyopathy.", + "CT abdomen revealed acute gangrenous appendicitis.", + "An urgent open appendectomy was scheduled.", + "The patient had a history of hospital admission for decompensated heart failure in 2019.", + "Transthoracic echocardiography in 2019 revealed a dilated left ventricle.", + "Transthoracic echocardiography in 2019 showed severely reduced systolic LV function with an ejection fraction of 18%.", + "Transthoracic echocardiography in 2019 showed severe global hypokinesis of the LV.", + "Transthoracic echocardiography in 2019 showed Grade 3 diastolic dysfunction.", + "The patient was prescribed aspirin.", + "The patient was prescribed bisoprolol.", + "The patient was prescribed ramipril.", + "The patient was prescribed dapagliflozin.", + "The patient was prescribed rosuvastatin.", + "The patient was prescribed isosorbide dinitrate.", + "The patient was prescribed insulin.", + "The patient had an HbA1C of 13%.", + "The patient's NT pro-BNP level was 1122 pg/mL.", + "The patient's troponin T level was 28 ng/l.", + "The patient's CRP level was 158 mg/l.", + "The patient's WBC was 16000/mcl.", + "TTE revealed a moderately dilated left ventricle.", + "TTE showed severely reduced LV systolic function.", + "TTE showed a biplane LVEF of approximately 25%.", + "TTE showed severe global hypokinesis of the LV.", + "TTE showed Grade 3 diastolic dysfunction.", + "The patient's medications on admission included bisoprolol.", + "The patient's medications on admission included rosuvastatin.", + "The patient's medications on admission included insulin.", + "The patient had a revised cardiac risk index (RCRI) of 4.", + "The patient had a 15% risk of major adverse cardiac events.", + "The patient was admitted to the SICU for preoperative optimization.", + "The patient underwent arterial and central venous line insertion.", + "The patient received PiCCO-guided fluid resuscitation.", + "The patient received antibiotic prophylaxis.", + "The team decided the patient would undergo an open appendectomy with QLB combined with monitored anesthesia care.", + "The patient had gangrenous appendicitis.", + "The patient was counselled regarding the urgent need for surgery.", + "The patient was counselled regarding the perioperative risk of cardiac complications.", + "The patient was counselled regarding specific anesthesia management.", + "Written consent for anesthesia was obtained.", + "An ultrasound probe was placed in a transverse orientation at the midaxillary line at the L2-L4 level.", + "The probe was moved posteriorly until the quadratus lumborum muscle was confirmed.", + "The needle was inserted and advanced into the anterior aspect of the QLM under ultrasound guidance.", + "Proper positioning of the needle tip was confirmed by hydrodissection.", + "20 mL of 0.33% levobupivacaine was injected into the fascia between the right QL muscle and psoas muscles.", + "Surgery was performed 15 min after the block.", + "Intraoperative sedation was achieved with 2 mg of midazolam intravenously at titrated doses of up to 4 mg.", + "A minimal dose of noradrenaline 0.03–0.05mcg/kg/min infusion was continued.", + "The patient maintained the airway and vital signs around baseline throughout the procedure.", + "The patient's pain score was 0/10 at rest at 24 h.", + "The patient's pain score was 2/10 with movement at 24 h.", + "The patient's pain score reached a maximum of 4/10 with movement at 48 h postoperatively.", + "The patient was discharged on the fourth day postoperatively." + ], + "summary": "We describe the case of an adult patient in mid-50s, with a history of ischemic dilated cardiomyopathy with reduced Ejection Fraction (about 25%) who presented with acute gangrenous appendicitis and was scheduled for an open appendectomy. It was deemed to be a high-risk patient for general and spinal anesthesia. With the guidance of a multidisciplinary team, surgery was successfully performed using a quadratus lumborum block with standard monitoring. The patient was comfortable and hemodynamically stable throughout the procedure. The postoperative course was uneventful.", + "summary_subclaims": [ + "The patient was an adult in mid-50s.", + "The patient had a history of ischemic dilated cardiomyopathy.", + "The patient had reduced Ejection Fraction.", + "The Ejection Fraction was about 25%.", + "The patient presented with acute gangrenous appendicitis.", + "The patient was scheduled for an open appendectomy.", + "It was deemed to be a high-risk patient for general and spinal anesthesia.", + "Surgery was performed using a quadratus lumborum block.", + "The surgery was performed with standard monitoring.", + "The patient was comfortable throughout the procedure.", + "The patient was hemodynamically stable throughout the procedure.", + "The postoperative course was uneventful." + ] + }, + { + "id": "multiclinsum_test_2608_en.txt", + "fulltext": "A 64-year-old woman, with medical history of hypertension that was treated with amlozin (5 mg, Sumitomo Pharma, Japan) and azilsartan (20 mg, Towa, Japan), was initially admitted to another institution due to temporary back and abdominal pain. Her abdominal ultrasonography raised suspicion of CAA. Consequently, she was referred to our institution for further evaluation and treatment of CAA.\nAt the time of presentation at our institution, she was asymptomatic, and her laboratory results were within the normal range (Additional file ). Enhanced computed tomography (CT) revealed that the CA and SMA converged into the aorta via the CMT. The CAA was a saccular aneurysm and located approximately at the median of the CA, with a diameter of 26 × 28 mm . Notably, no significant stenosis was present on the CMT. The patient was diagnosed with CAA, complicated by CMT. She was a good candidate for surgery since her CAA was > 20 mm .\nSelective visceral angiography was performed to evaluate the visceral circulation of each branch, especially that of the CA and SMA. Angiography revealed that the branches from the CA were only the common hepatic artery (CHA) and splenic artery (SA). We found no discernible microbranches originating directly from the primary CA duct . The left gastric artery (LGA) originated from the aorta. Angiography of the LGA with balloon occlusion of the CMT revealed collateral circulation to the proper hepatic artery (PHA) via the right gastric artery (RGA) and to the SA via the short gastric artery (SGA) , suggesting that hepatic circulation could be maintained even after occlusion of the CHA.\nBased on these anatomical findings, we determined that the safety landing zone for stenting of the CA was not sufficient. In addition, coil embolization of the CAA itself posed a potential risk of coil migration, which could lead to severe complications. Because of the patient's relatively young age, preserving the anatomical antegrade visceral circulation was considered more important than pursuing a less invasive approach through endovascular therapy (EVT). Regarding open surgical procedures, several options are available, such as aneurysmectomy, aneurysmorrhaphy, aortoceliac bypass, aortohepatic bypass, or ligation [, ]. Based on CT and angiography findings, simple CAA resection would suffice and be a less invasive surgical procedure for open surgery; therefore, direct CAA resection was performed.\nAfter the induction of general anesthesia, the abdomen was opened through a midline incision. The pancreas was exposed through an incision in the omentum. Since the CAA was located behind the pancreas on preoperative CT, the CAA was approached with caution to separate it from the pancreas. The portal vein, CMT, CHA, and SA were eventually exposed . Following systemic heparinization, direct resection of the CAA and subsequent reconstruction of the CA were performed after clamping the CHA, SA, and proximal CA . The total operative time was 249 min, and blood transfusion was not required.\nOn postoperative enhanced CT, the visceral circulation of the CA and SMA was preserved . Histological analysis of the CAA revealed degenerative true aneurysm, with no evidence of abnormalities, such as lack of elastic fibers or cystic medial necrosis . The patient was discharged uneventfully on postoperative day 10. A follow-up CT one year later demonstrated no sign of recurrence of the CA or the development of new visceral aneurysms.", + "fulltext_subclaims": [ + "The patient was a 64-year-old woman.", + "She had medical history of hypertension.", + "She was treated with amlozin (5 mg, Sumitomo Pharma, Japan).", + "She was treated with azilsartan (20 mg, Towa, Japan).", + "She was admitted to another institution due to temporary back and abdominal pain.", + "Her abdominal ultrasonography raised suspicion of CAA.", + "She was referred to our institution for further evaluation and treatment of CAA.", + "At the time of presentation at our institution, she was asymptomatic.", + "Her laboratory results were within the normal range.", + "Enhanced computed tomography (CT) revealed that the CA and SMA converged into the aorta via the CMT.", + "The CAA was a saccular aneurysm.", + "The CAA was located approximately at the median of the CA.", + "The CAA had a diameter of 26 × 28 mm.", + "No significant stenosis was present on the CMT.", + "The patient was diagnosed with CAA, complicated by CMT.", + "The patient was a good candidate for surgery since her CAA was > 20 mm.", + "Selective visceral angiography was performed.", + "Angiography revealed that the branches from the CA were only the common hepatic artery (CHA) and splenic artery (SA).", + "No discernible microbranches originating directly from the primary CA duct were found.", + "The left gastric artery (LGA) originated from the aorta.", + "Angiography of the LGA with balloon occlusion of the CMT revealed collateral circulation to the proper hepatic artery (PHA) via the right gastric artery (RGA).", + "Angiography of the LGA with balloon occlusion of the CMT revealed collateral circulation to the SA via the short gastric artery (SGA).", + "Hepatic circulation could be maintained even after occlusion of the CHA.", + "The safety landing zone for stenting of the CA was not sufficient.", + "Coil embolization of the CAA itself posed a potential risk of coil migration.", + "Coil migration could lead to severe complications.", + "The patient's relatively young age was considered.", + "Preserving the anatomical antegrade visceral circulation was considered more important than pursuing a less invasive approach through endovascular therapy (EVT).", + "Several open surgical procedures were available, such as aneurysmectomy, aneurysmorrhaphy, aortoceliac bypass, aortohepatic bypass, or ligation.", + "Direct CAA resection was performed.", + "The abdomen was opened through a midline incision.", + "The pancreas was exposed through an incision in the omentum.", + "The CAA was located behind the pancreas on preoperative CT.", + "The CAA was approached with caution to separate it from the pancreas.", + "The portal vein, CMT, CHA, and SA were eventually exposed.", + "Direct resection of the CAA and subsequent reconstruction of the CA were performed after clamping the CHA, SA, and proximal CA.", + "The total operative time was 249 min.", + "Blood transfusion was not required.", + "On postoperative enhanced CT, the visceral circulation of the CA and SMA was preserved.", + "Histological analysis of the CAA revealed degenerative true aneurysm.", + "No evidence of abnormalities, such as lack of elastic fibers or cystic medial necrosis, was found.", + "The patient was discharged uneventfully on postoperative day 10.", + "A follow-up CT one year later demonstrated no sign of recurrence of the CA.", + "A follow-up CT one year later demonstrated no development of new visceral aneurysms." + ], + "summary": "A 64-year-old woman was diagnosed with a CA aneurysm in the CMT. Aneurysmectomy of the aneurysm was performed successfully. On preoperative selective visceral angiography, the CA was seen to bifurcate into the common hepatic and splenic artery. The left gastric artery was directly isolated from the aorta and perfused to the common hepatic and splenic artery through collateral circulation. These findings showed that celiac artery embolization is anatomically feasible, even in cases of celiac artery aneurysm rupture.", + "summary_subclaims": [ + "A 64-year-old woman was diagnosed with a CA aneurysm in the CMT.", + "Aneurysmectomy of the aneurysm was performed successfully.", + "On preoperative selective visceral angiography, the CA was seen to bifurcate into the common hepatic and splenic artery.", + "The left gastric artery was directly isolated from the aorta.", + "The left gastric artery was perfused to the common hepatic and splenic artery through collateral circulation.", + "These findings showed that celiac artery embolization is anatomically feasible, even in cases of celiac artery aneurysm rupture." + ] + }, + { + "id": "multiclinsum_test_1499_en.txt", + "fulltext": "We evaluated a 28-year-old African-American woman with a history of myoclonus and epilepsy. She was born at term from an uncomplicated vaginal delivery, with initial normal development. A teacher noticed “hand tremors” at the age of 4 years. She had normal socialization and a mild learning disability but was able to finish high school and start college. At the age of 13, she developed her first generalized myoclonic seizure, followed by multiple episodes of early morning focal onset seizure with secondary generalization and additional episodes of generalized myoclonic seizures. She was treated with zonisamide and then topiramate with good control of the seizures. A previous EEG showed diffuse excessive fast activity. Brain MRI showed mild cerebellar atrophy .\nThe “hand tremor” was later identified as myoclonus and worsened during her high school years, with prominent involvement of her upper limbs. She was treated with clonazepam with moderate benefit. At her last evaluation, she displayed multifocal myoclonus at rest, mostly involving her face and distal upper limbs, mild action myoclonus at target, and no clear stimulus sensitivity. There were only very mild cerebellar signs (including mild saccadic pursuits, dysdiadochokinesia, and appendicular dysmetria) with no significant gait impairment . Patient’s cognitive profile was not formally assessed but she presented a decline over the years affecting her school career. Her parents were both from Antigua. There was no consanguinity in the family and no family history of seizures or other neurological conditions. Written authorization for the acquisition of the video for publication for scientific purposes was signed by the patient.\nPrevious genetic testing, including 21 genes of progressive myoclonic epilepsy and Dentatorubro-Pallidoluysian Atrophy (DRPLA) expansion, were negative. Targeted gene testing of NUS1 revealed a novel missense mutation of the NUS1 gene, c.868C>T (p.Arg290Cys), initially classified as a variant of unknown significance (VUS). The variant was not found in large population datasets and was absent in her parents (de novo). Therefore, the p.Arg290Cys was re-classified as likely pathogenic (ACMG criteria: PM1, PM2, PM5, PM6, PP3). This variant affects the same residues reported in previous cases of CDG with recessive mode of inheritance (p.R290H). We hypothesize that the different aminoacidic change in our case (p.R290C) may have a more profound impact on an important domain of the NUS1 protein due to the biochemical differences between Arginine and Cysteine, compared to Arginine and Histidine.\nTo the best of authors’ knowledge and as per Genetic Testing Registry (GTR, ) there are no gene panels for the myoclonic epilepsy in the US that include NUS1.", + "fulltext_subclaims": [ + "The patient is a 28-year-old African-American woman.", + "She has a history of myoclonus and epilepsy.", + "She was born at term from an uncomplicated vaginal delivery.", + "A teacher noticed “hand tremors” at the age of 4 years.", + "She had normal socialization.", + "She had a mild learning disability.", + "She was able to finish high school and start college.", + "At the age of 13, she developed her first generalized myoclonic seizure.", + "She had multiple episodes of early morning focal onset seizure with secondary generalization.", + "She had additional episodes of generalized myoclonic seizures.", + "She was treated with zonisamide.", + "She was treated with topiramate.", + "The seizures were well controlled with zonisamide and then topiramate.", + "A previous EEG showed diffuse excessive fast activity.", + "Brain MRI showed mild cerebellar atrophy.", + "The “hand tremor” was later identified as myoclonus.", + "The myoclonus worsened during her high school years.", + "The myoclonus involved her upper limbs.", + "She was treated with clonazepam.", + "Clonazepam provided moderate benefit.", + "At her last evaluation, she displayed multifocal myoclonus at rest.", + "The myoclonus at rest mostly involved her face and distal upper limbs.", + "She had mild action myoclonus at target.", + "There was no clear stimulus sensitivity.", + "There were only very mild cerebellar signs.", + "The cerebellar signs included mild saccadic pursuits.", + "The cerebellar signs included dysdiadochokinesia.", + "The cerebellar signs included appendicular dysmetria.", + "There was no significant gait impairment.", + "The patient’s cognitive profile was not formally assessed.", + "She presented a decline over the years affecting her school career.", + "Her parents were both from Antigua.", + "There was no consanguinity in the family.", + "There was no family history of seizures.", + "There was no family history of other neurological conditions.", + "Written authorization for the acquisition of the video for publication for scientific purposes was signed by the patient.", + "Previous genetic testing, including 21 genes of progressive myoclonic epilepsy and DRPLA expansion, were negative.", + "Targeted gene testing of NUS1 revealed a novel missense mutation of the NUS1 gene, c.868C>T (p.Arg290Cys).", + "The variant was initially classified as a variant of unknown significance (VUS).", + "The variant was not found in large population datasets.", + "The variant was absent in her parents.", + "The variant was de novo.", + "The p.Arg290Cys was re-classified as likely pathogenic.", + "The ACMG criteria used were PM1, PM2, PM5, PM6, PP3.", + "The variant affects the same residues reported in previous cases of CDG with recessive mode of inheritance.", + "The different aminoacidic change in our case (p.R290C) may have a more profound impact on an important domain of the NUS1 protein.", + "The biochemical differences between Arginine and Cysteine are compared to Arginine and Histidine.", + "To the best of authors’ knowledge, there are no gene panels for the myoclonic epilepsy in the US that include NUS1." + ], + "summary": "We report a case of myoclonus epilepsy, mild cerebellar ataxia, and ID due to a new de-novo NUS1 missense variant (c.868C>T, p.R290C), and review the current literature of NUS1-associated clinical phenotypes.", + "summary_subclaims": [ + "The patient had myoclonus epilepsy.", + "The patient had mild cerebellar ataxia.", + "The patient had ID.", + "The patient had a new de-novo NUS1 missense variant (c.868C>T, p.R290C).", + "The authors reviewed the current literature of NUS1-associated clinical phenotypes." + ] + }, + { + "id": "multiclinsum_test_2665_en.txt", + "fulltext": "We report a 70-year-old male patient who presented to our emergency room with fever and altered mental status for 24 hours before presentation. The patient was also complaining of increasing left flank pain, nausea, and emesis. There was no history of trauma. On physical examination, the patient appeared to be in distress and minimally responsive. Initial vital signs revealed a temperature of 103.3°F, tachycardia, but stable blood pressure. Abdominal examination revealed distended abdomen and left flank tenderness to palpation. He was found to have severe leukopenia with white blood cell count of 0.7 K/μL and a serum creatinine (sCr) of 1.64 mg/dL with a normal coagulation profile. A computed tomography (CT) scan of the abdomen/pelvis with intravenous contrast showed a large intracapsular hematoma (13.3 × 10.0 cm), which deformed and compressed the kidney anteriorly ( and ). There were multiple areas of curvilinear hyperdense material within the hematoma, indicating vascular extravasation consistent with active bleeding. Marked left perinephric stranding with extension of the extracapsular hematoma to the distal aorta, iliac vessels, presacral space, and along the left prerenal space was seen . A 1.1 cm stone was identified within the proximal left ureter, and a 6 mm stone was identified within the inferior pole of the left kidney. The proximal left ureter was dilated ( and ).\nDespite ongoing resuscitative measures with intravenous fluid boluses and intravenous antibiotics, the patient became hemodynamically unstable 1 hour after presentation to the emergency room. His blood pressure decreased to 70/40 mmHg and Hgb dropped to 9.5 g/dL (from 11.3) that required initiation of blood transfusion and infusion of vasoactive pressor medications. The patient remained critically ill, tachycardic, and hypotensive with a blood pressure of 80/60 mmHg despite 8 L of intravenous crystalloid fluid, 4 U of blood, and pressure support. Interventional radiology was consulted. If managed nonoperatively, it appeared the patient would need both a nephrostomy tube and selective arterial embolization. Given the large hematoma with minimal hydronephrosis combined with the patient's rapid clinical deterioration, interventional radiology did not think they would be able to help with both of these problems. Because of the complicated nature of the combined issues of active renal hemorrhage with hemorrhagic/septic shock, the patient was subsequently taken for emergent exploratory laparotomy and left nephrectomy. During the exploration, active bleeding was encountered with a (2.4 × 2.0 cm) shaggy defect at the interpolar lateral aspect of the kidney . Vascular control of the renal pedicle was obtained and a nephrectomy was performed. Postoperatively, the patient made a steady progress until he was discharged with sCr 1.38 mg/dL, estimated glomerular filtration rate 51 mL/min/1.73 sqM, and stable Hgb 9.6 g/dL. The initial blood and urine cultures revealed growth of Escherichia coli that was treated with appropriate antibiotics. Histopathologic examination of the kidney showed acute and chronic interstitial and intratubular inflammatory infiltrate with acute hemorrhage with no evidence of malignancy .", + "fulltext_subclaims": [ + "The patient was a 70-year-old male.", + "The patient presented with fever and altered mental status for 24 hours before presentation.", + "The patient was complaining of increasing left flank pain.", + "The patient had no history of trauma.", + "On physical examination, the patient appeared to be in distress and minimally responsive.", + "Initial vital signs revealed a temperature of 103.3°F.", + "The patient had tachycardia.", + "The patient had a serum creatinine of 1.64 mg/dL.", + "A CT scan showed a large intracapsular hematoma (13.3 × 10.0 cm).", + "The CT scan showed multiple areas of curvilinear hyperdense material within the hematoma.", + "The CT scan showed marked left perinephric stranding.", + "A 1.1 cm stone was identified within the proximal left ureter.", + "The proximal left ureter was dilated.", + "The patient became hemodynamically unstable 1 hour after presentation.", + "The patient's blood pressure decreased to 70/40 mmHg.", + "The patient's hemoglobin dropped to 9.5 g/dL.", + "The patient received 4 units of blood.", + "The patient was taken for emergent exploratory laparotomy and left nephrectomy.", + "During the exploration, active bleeding was encountered.", + "Vascular control of the renal pedicle was obtained.", + "A nephrectomy was performed.", + "Postoperatively, the patient's serum creatinine was 1.38 mg/dL.", + "The initial blood and urine cultures revealed growth of Escherichia coli.", + "Histopathologic examination showed acute and chronic interstitial and intratubular inflammatory infiltrate.", + "Histopathologic examination showed acute hemorrhage.", + "Histopathologic examination showed no evidence of malignancy." + ], + "summary": "We report a 70-year-old Caucasian male patient who presented to our emergency room with fever, altered mental status, and left flank pain. He had a temperature of 103.3°F, tachycardia, but stable blood pressure. He had left flank tenderness. A computed tomography scan of the abdomen/pelvis with intravenous contrast revealed an intracapsular hematoma (13.3 × 10.0 × 6.4 cm) with an active bleeding and a 1.1 cm left proximal ureteral stone. The patient became quickly hemodynamically unstable and was taken for emergent exploratory laparotomy and left nephrectomy. An active bleeding was encountered secondary to a (2.4 × 2.0 cm) lateral capsular defect in the kidney.", + "summary_subclaims": [ + "The patient is a 70-year-old Caucasian male.", + "The patient presented with fever.", + "The patient had altered mental status.", + "The patient had left flank pain.", + "The patient had a temperature of 103.3°F.", + "The patient had tachycardia.", + "The patient had stable blood pressure.", + "The patient had left flank tenderness.", + "A computed tomography scan of the abdomen/pelvis with intravenous contrast was performed.", + "The CT scan showed an intracapsular hematoma measuring 13.3 × 10.0 × 6.4 cm.", + "The CT scan showed active bleeding.", + "The CT scan showed a 1.1 cm left proximal ureteral stone.", + "The patient became hemodynamically unstable.", + "The patient was taken for emergent exploratory laparotomy and left nephrectomy.", + "An active bleeding was encountered during surgery.", + "The bleeding was secondary to a 2.4 × 2.0 cm lateral capsular defect in the kidney." + ] + }, + { + "id": "multiclinsum_test_873_en.txt", + "fulltext": "A 56-year-old woman, of Moroccan nationality, a chronic cigarette smoker consuming an average of one pack a day for 38 years, was hospitalized for a large right-sided hemifacial swelling. Her early symptoms dated from 4 months previously, by the appearance of straight facial neuralgia, treated as dental neuralgia without any improvement. The evolution was marked by rapid aggravation of the pain, which then became disabling, and the emergence of a right-sided maxillary swelling rapidly increasing in size and accompanied by a limitation of mouth opening, and a nasal obstruction with episodes of epistaxis.\nA clinical examination determined a painful and inflammatory right-sided hemifacial swelling, right exophthalmus without notion of decreased visual acuity, and hypoesthesia at the second and third trigeminal nerve areas. An endonasal examination detected a tumor mass in her right nasal cavity, friable and bleeding at contact. An oral examination, very difficult because of the limited mouth opening, showed an erosion of the hard palate. Cervical lymph node areas were free and an endoscopy examination of the upper aerodigestive tract did not show any lesions. Otoscopy and audiometry test results were normal. Our patient was hospitalized and placed immediately on morphine.\nA computed tomography (CT) scan revealed the presence of a large heterogeneous mass occupying her infratemporal fossa as well as the masticator space and right maxillary sinus, lysing the walls of the maxillary sinus, the ascending branch of the mandible and the orbital floor with ethmoidonasal, parapharyngeal and intraorbital extension.\nA magnetic resonance imaging (MRI) scan showed an aggressive and invasive tumor occupying her right infratemporal fossa and maxillary sinus with irregular boundaries, heterogeneous intermediary signal at T1 and T2 weight, with sphenoidal, ethmoidonasal, nasopharyngeal and intraorbital extension. This process infiltrated the jugal and temporozygomatic soft parts, with heterogeneous contrast enhancement and areas of necrosis .\nA nasal endoscopic biopsy was performed. A pathological examination was in favor of a malignant process, poorly differentiated and invasive . An immunohistochemical examination demonstrated a total cytoplasmic positivity to anti-S100 protein antibody, concluding in a diagnosis of malignant schwannoma . The staging, including a cervico-thoraco-abdominal CT scan, did not find any distant metastasis. According to the clinical and radiological data obtained, palliative radiotherapy was decided, delivered by a linear electron accelerator, at a total dose of 30Gy, 10Gy by fraction, over 3 days, with one field including the tumor mass. The outcome was favorable with improvement of symptoms. Unfortunately, our patient died 10 days later after severe respiratory distress.", + "fulltext_subclaims": [ + "The patient is a 56-year-old woman.", + "She is of Moroccan nationality.", + "She is a chronic cigarette smoker.", + "She consumes an average of one pack a day.", + "She has smoked for 38 years.", + "She was hospitalized for a large right-sided hemifacial swelling.", + "Her early symptoms dated from 4 months previously.", + "She had straight facial neuralgia.", + "The facial neuralgia was treated as dental neuralgia.", + "The treatment did not result in improvement.", + "The pain became disabling.", + "A right-sided maxillary swelling emerged.", + "The maxillary swelling rapidly increased in size.", + "She had episodes of epistaxis.", + "A clinical examination determined a painful and inflammatory right-sided hemifacial swelling.", + "Right exophthalmus was noted.", + "Hypoesthesia at the second and third trigeminal nerve areas was noted.", + "An endonasal examination detected a tumor mass in her right nasal cavity.", + "The tumor mass was friable and bleeding at contact.", + "An oral examination showed an erosion of the hard palate.", + "Cervical lymph node areas were free.", + "An endoscopy examination of the upper aerodigestive tract did not show any lesions.", + "Otoscopy and audiometry test results were normal.", + "The patient was hospitalized and placed immediately on morphine.", + "A CT scan revealed a large heterogeneous mass occupying her infratemporal fossa.", + "The mass occupied the masticator space and right maxillary sinus.", + "The mass lysed the walls of the maxillary sinus.", + "The mass lysed the ascending branch of the mandible.", + "The mass lysed the orbital floor.", + "The process had ethmoidonasal extension.", + "The process had parapharyngeal extension.", + "The process had intraorbital extension.", + "An MRI scan showed an aggressive and invasive tumor.", + "The tumor occupied the right infratemporal fossa.", + "The tumor occupied the maxillary sinus.", + "The tumor had irregular boundaries.", + "The tumor had heterogeneous intermediary signal at T1 and T2 weight.", + "The process had sphenoidal extension.", + "The process had nasopharyngeal extension.", + "The process had intraorbital extension.", + "The process infiltrated the jugal and temporozygomatic soft parts.", + "The tumor had heterogeneous contrast enhancement.", + "The tumor had areas of necrosis.", + "A nasal endoscopic biopsy was performed.", + "A pathological examination was in favor of a malignant process.", + "The malignant process was poorly differentiated.", + "The malignant process was invasive.", + "An immunohistochemical examination demonstrated total cytoplasmic positivity to anti-S100 protein antibody.", + "The diagnosis was malignant schwannoma.", + "The staging did not find any distant metastasis.", + "Palliative radiotherapy was decided.", + "The radiotherapy was delivered by a linear electron accelerator.", + "The total dose was 30Gy.", + "The dose was 10Gy by fraction.", + "The radiotherapy was delivered over 3 days.", + "The outcome was favorable with improvement of symptoms.", + "The patient died 10 days later after severe respiratory distress." + ], + "summary": "A 56-year-old woman, of Moroccan nationality, presented to our hospital in 2013 with a large right-sided hemifacial swelling that had evolved over the previous 4 months, with a limitation of mouth opening, nasal obstruction and episodes of epistaxis. A CT scan and MRI showed a large and invasive tumor occupying her right infratemporal fossa and maxillary sinus, with sphenoidal, ethmoidonasal, nasopharyngeal and intraorbital extension. A nasal endoscopic biopsy was performed. Immunohistochemical examination concluded a diagnosis of malignant schwannoma, and a palliative radiotherapy was decided; however, our patient died 10 days later.", + "summary_subclaims": [ + "The patient is a 56-year-old woman.", + "The patient is of Moroccan nationality.", + "She presented to the hospital in 2013.", + "She had a large right-sided hemifacial swelling.", + "The swelling had evolved over the previous 4 months.", + "She had limitation of mouth opening.", + "She had nasal obstruction.", + "She had episodes of epistaxis.", + "A CT scan and MRI showed a large and invasive tumor.", + "The tumor occupied her right infratemporal fossa and maxillary sinus.", + "The tumor had sphenoidal extension.", + "The tumor had ethmoidonasal extension.", + "The tumor had nasopharyngeal extension.", + "The tumor had intraorbital extension.", + "A nasal endoscopic biopsy was performed.", + "Immunohistochemical examination concluded a diagnosis of malignant schwannoma.", + "A palliative radiotherapy was decided.", + "The patient died 10 days later." + ] + }, + { + "id": "multiclinsum_test_505_en.txt", + "fulltext": "We present the case of a 7 year old boy who presented with effort intolerance and no cyanosis. Clinical examination was unremarkable. Doppler echocardiography revealed left sided pulmonary veins opening into left innominate vein. Right pulmonary veins were seen draining normally into the left atrium. There was no ASD and right atrium and right ventricle were dilated. CTPA ( & ) aided in defining the anatomy. Left pulmonary veins were shown to be joining to form a common channel and draining into superior vena cava via left brachiocephalic vein suggestive of left supracardiac PAPVC thus confirming the preliminary diagnosis of isolated left sided PAPVC.\nPt. was successfully surgically managed. Median sternotomy approach was chosen.\nInnominate vein and superior vena cava were found to be dilated. Also, the right atrium and the right ventricle were dilated . Vertical vein was seen opening into innominate vein. Left Pulmonary veins were seen opening into the vertical vein. Patient was operated without cardiopulmonary bypass (CPB) support. A 15 mm opening was made in the common chamber horizontally after applying a Cooley’s clamp. Another opening of similar dimension made over LA appendage. Vertical vein was anastomosed to left atrial appendage posteriorly with 6-0 prolene in side-to-side fashion. The vertical vein-innominate confluence was ligated at the end of the procedure. Chest was closed in standard fashion. Mechanical ventilation was required for 12 h. Patient recovered uneventfully and was discharged on Day 10.", + "fulltext_subclaims": [ + "The patient is a 7 year old boy.", + "The patient presented with effort intolerance.", + "The patient had no cyanosis.", + "Clinical examination was unremarkable.", + "Doppler echocardiography revealed left sided pulmonary veins opening into left innominate vein.", + "Right pulmonary veins were seen draining normally into the left atrium.", + "There was no ASD.", + "Right atrium and right ventricle were dilated.", + "CTPA aided in defining the anatomy.", + "Left pulmonary veins were shown to be joining to form a common channel.", + "The common channel drained into superior vena cava via left brachiocephalic vein.", + "The diagnosis was isolated left sided PAPVC.", + "The patient was successfully surgically managed.", + "Median sternotomy approach was chosen.", + "Innominate vein and superior vena cava were found to be dilated.", + "The right atrium and the right ventricle were dilated.", + "Vertical vein was seen opening into innominate vein.", + "Left pulmonary veins were seen opening into the vertical vein.", + "The patient was operated without cardiopulmonary bypass support.", + "A 15 mm opening was made in the common chamber horizontally after applying a Cooley’s clamp.", + "Another opening of similar dimension was made over LA appendage.", + "Vertical vein was anastomosed to left atrial appendage posteriorly with 6-0 prolene in side-to-side fashion.", + "The vertical vein-innominate confluence was ligated at the end of the procedure.", + "Chest was closed in standard fashion.", + "Mechanical ventilation was required for 12 h.", + "The patient recovered uneventfully.", + "The patient was discharged on Day 10." + ], + "summary": "We present a case of left sided PAPVC with no atrial septal defect (ASD), who presented with effort intolerance and an unremarkable physical examination. Computed tomography pulmonary angiography (CTPA) confirmed the primary diagnosis as suggested by an initial 2-D echocardiography, and aided in better understanding of the anatomy.", + "summary_subclaims": [ + "The patient had left sided PAPVC.", + "The patient had no atrial septal defect.", + "The patient presented with effort intolerance.", + "The patient's physical examination was unremarkable.", + "Computed tomography pulmonary angiography confirmed the primary diagnosis.", + "Computed tomography pulmonary angiography aided in better understanding of the anatomy." + ] + }, + { + "id": "multiclinsum_test_85_en.txt", + "fulltext": "A 14-year-old Chinese Malaysian boy presented to University Malaya Medical Centre, Kuala Lumpur in September 2013 with history of recurrent pneumonia, poor growth and steatorrhoea since childhood. He had finger clubbing and bronchiectasis. Later, he was diagnosed with CF and Pseudomonas aeruginosa was isolated from his sputum. He received 3 weeks of intravenous ceftazidime (50 mg/kg/dose, QDS) and gentamicin (5 mg/kg/dose, OD). He was discharged with azithromycin (5 mg/kg EOD), nebulised gentamicin (80 mg BD) amongst other CF-related medications. In November 2013, he was readmitted with a pulmonary exacerbation and his sputum sample grew methicillin-resistant Staphylococcus aureus (MRSA) and he received intravenous vancomycin, oral rifampicin (300 mg BD) and sodium fusidate (500 mg TDS) with significant clinical improvement. During a follow-up visit in December 2013, he had a productive cough but was apyrexic. He was empirically treated with oral ciprofloxacin (750 mg BD) and the sputum sample later isolated B.pseudomallei. As he clinically improved, the treatment regimen remained unchanged. Subsequently, the repeat sputum samples were negative for B.pseudomallei and he continued to remain active with good exercise tolerance and relatively stable lung function. It is noteworthy that he had been residing in an urban area of non-endemicity for melioidosis and there were no other known risk factors identified.\nIn August 2014, he was admitted with another pulmonary exacerbation and his cultured sputum grew B.pseudomallei and Pseudomonas spp. His chest radiograph showed diffused interstitial changes with bronchiectasis throughout both lungs with minimal pleural effusions. He received 2 weeks of intravenous ceftazidime (2 g; 6hourly) and amikacin (720 mg; 15 mg/kg/OD). Upon completion of antibiotics, he remained afebrile and the chest auscultatory findings improved. He was discharged with 6 months of oral doxycycline, and co-trimoxazole to treat the B.pseudomallei and 3 months of nebulized amikacin for chronic P.aeruginosa. He still continued on his alternate day of azithromycin (250 mg).\nA detailed travel history revealed that in June 2014, he visited recreational parks in Sabah, Malaysia. During the visit, he went jungle trekking, snorkeling and dipped in a hot-water spring. It is noteworthy that melioidosis is endemic in Sabah, one of the two East Malaysian states on the island of Borneo, where B.pseudomallei prominently occurs in soil and water. Later then, he was admitted 3 monthly for antibiotic tuning and his sputum culture had no specific bacterial growth.\nIn August 2015, there was a decline in his lung function tests with deterioriorating cough. A bronchoscopy was performed and Burkholderia cepacia was isolated from his bronchoalveoloar lavage specimen, while acid-fast bacillus (AFB) smear was weakly positive. Initially, the patient was treated with intravenous imipenem and ceftazidime for 3 weeks but had recurrence of fever. However, the sputum AFB smears remained positive although the suspected nontuberculous mycobacterium could not be isolated despite various culturing techniques. Therefore, the antibiotics were changed to intravenous meropenem, doxycycline, amikacin and oral clarithromycin to treat both the B.cepacia and the suspected nontuberculous mycobacterium.\nUpon discharge, he had been continuing with amoxicillin-clavulanate and doxycycline for 6 months, which helped with weight gain and secretion reduction. Repeat AFB smear remained negative for the subsequent 5 months. However, in January 2016, further decline in his lung function was observed with worsening respiratory symptoms. A chest computed tomography showed worsening bronchiectasis, tree in bud appearance in the lung peripheries, patchy consolidation and several enlarged lymph nodes at the right paratracheal region . His sputum sample grew P.aeruginosa and was also strongly positive for AFB. Intravenous meropenem and ceftazidime (for P.aeruginosa) and combination therapy of rifampicin, ethambutol, azithromycin and nebulized amikacin (for nontuberculous mycobacterium) was started. He improved clinically and was discharged with the above oral medications for 6 months.\nB.pseudomallei was isolated once again in April 2016 and he was treated with intravenous amoxicillin-clavulanate and ceftazidime for 3 weeks. He was then discharged with 6 months of oral amoxicillin-clavulanate. However, in May 2016, his antibiotics were changed to levofloxacin (750 mg) and clarithromycin (500 mg). Following that, for the next 8 months, his sputum sample continued to grow B.pseudomallei but was negative for AFB. Despite many admissions for intravenous antibiotics against B.pseudomallei, the patient passed away from end stage respiratory failure in February 2017. Bacteriological reports were reviewed, and over the 3 years, the patient had several infective exacerbations and his sputum samples grew Gram-negative organisms that were later identified to be B.pseudomallei, Pseudomonas spp., P.aeruginosa, or B.cepacia .\nAll the isolates were found to have different susceptibility patterns (resistant to co-trimoxazole; intermediate to doxycycline and susceptible to all other antibiotics). The B.pseudomallei isolated in 2013, 2014 and 2016 (UMC083, UMC 082 and UMC114, respectively), were also further confirmed as B.pseudomallei using API 20NE (Biomerieux, France), Ashdown agar and also an in-house polymerase chain reaction (PCR) using specific primers . However, we were not able to obtain the B.pseudomallei isolated in 2017.\nThe isolates were characterized by multilocus sequence typing (MLST), a method of molecular subtyping that compares sequences of seven housekeeping genes , and repetitive-element PCR (rep-PCR). It appeared that these isolates were of two different sequence type (ST); ST51 (UMC083 and UMC114), which is a common ST found widely in Malaysia, Thailand, Singapore, Hong Kong and China, and ST1644, (UMC082) a new ST. The STs were deposited in the B.pseudomallei MLST database .", + "fulltext_subclaims": [ + "The patient was a 14-year-old Chinese Malaysian boy.", + "He presented to University Malaya Medical Centre, Kuala Lumpur in September 2013.", + "He had a history of recurrent pneumonia since childhood.", + "He had steatorrhoea.", + "He had finger clubbing.", + "He had bronchiectasis.", + "He was diagnosed with CF.", + "Pseudomonas aeruginosa was isolated from his sputum.", + "He received 3 weeks of intravenous ceftazidime (50 mg/kg/dose, QDS).", + "He received 3 weeks of intravenous gentamicin (5 mg/kg/dose, OD).", + "He was discharged with azithromycin (5 mg/kg EOD).", + "He was discharged with nebulised gentamicin (80 mg BD).", + "In November 2013, he was readmitted with a pulmonary exacerbation.", + "His sputum sample grew methicillin-resistant Staphylococcus aureus (MRSA).", + "He received intravenous vancomycin.", + "He received oral rifampicin (300 mg BD).", + "He received sodium fusidate (500 mg TDS).", + "He had significant clinical improvement.", + "During a follow-up visit in December 2013, he had a productive cough.", + "He was empirically treated with oral ciprofloxacin (750 mg BD).", + "The sputum sample later isolated B.pseudomallei.", + "The repeat sputum samples were negative for B.pseudomallei.", + "He continued to remain active with good exercise tolerance.", + "He had relatively stable lung function.", + "He had been residing in an urban area of non-endemicity for melioidosis.", + "No other known risk factors were identified.", + "In August 2014, he was admitted with another pulmonary exacerbation.", + "His cultured sputum grew B.pseudomallei and Pseudomonas spp.", + "His chest radiograph showed diffused interstitial changes with bronchiectasis throughout both lungs.", + "He received 2 weeks of intravenous ceftazidime (2 g; 6hourly).", + "He received 2 weeks of intravenous amikacin (720 mg; 15 mg/kg/OD).", + "He was discharged with 6 months of oral doxycycline.", + "He was discharged with 6 months of co-trimoxazole.", + "He was discharged with 3 months of nebulized amikacin.", + "He continued on his alternate day of azithromycin (250 mg).", + "In June 2014, he visited recreational parks in Sabah, Malaysia.", + "Melioidosis is endemic in Sabah.", + "B.pseudomallei prominently occurs in soil and water in Sabah.", + "He went jungle trekking.", + "He went snorkeling.", + "He dipped in a hot-water spring.", + "He was admitted 3 monthly for antibiotic tuning.", + "His sputum culture had no specific bacterial growth.", + "In August 2015, there was a decline in his lung function tests.", + "A bronchoscopy was performed.", + "Burkholderia cepacia was isolated from his bronchoalveolar lavage specimen.", + "The AFB smear was weakly positive.", + "He was treated with intravenous imipenem and ceftazidime for 3 weeks.", + "He had recurrence of fever.", + "The sputum AFB smears remained positive.", + "The suspected nontuberculous mycobacterium could not be isolated.", + "The antibiotics were changed to intravenous meropenem, doxycycline, amikacin and oral clarithromycin.", + "He was continuing with amoxicillin-clavulanate and doxycycline for 6 months.", + "The repeat AFB smear remained negative for the subsequent 5 months.", + "In January 2016, further decline in his lung function was observed.", + "A chest computed tomography showed worsening bronchiectasis.", + "A chest computed tomography showed tree in bud appearance in the lung peripheries.", + "A chest computed tomography showed patchy consolidation.", + "A chest computed tomography showed several enlarged lymph nodes at the right paratracheal region.", + "His sputum sample grew P.aeruginosa.", + "His sputum sample was strongly positive for AFB.", + "Intravenous meropenem and ceftazidime were started.", + "Combination therapy of rifampicin, ethambutol, azithromycin and nebulized amikacin was started.", + "He improved clinically.", + "He was discharged with the above oral medications for 6 months.", + "B.pseudomallei was isolated once again in April 2016.", + "He was treated with intravenous amoxicillin-clavulanate and ceftazidime for 3 weeks.", + "He was discharged with 6 months of oral amoxicillin-clavulanate.", + "In May 2016, his antibiotics were changed to levofloxacin (750 mg) and clarithromycin (500 mg).", + "For the next 8 months, his sputum sample continued to grow B.pseudomallei.", + "His sputum sample was negative for AFB.", + "Despite many admissions for intravenous antibiotics against B.pseudomallei, the patient passed away from end stage respiratory failure in February 2017.", + "Bacteriological reports were reviewed.", + "Over the 3 years, the patient had several infective exacerbations.", + "His sputum samples grew Gram-negative organisms that were later identified to be B.pseudomallei, Pseudomonas spp., P.aeruginosa, or B.cepacia.", + "All the isolates were found to have different susceptibility patterns.", + "The isolates were resistant to co-trimoxazole.", + "The isolates were intermediate to doxycycline.", + "The isolates were susceptible to all other antibiotics.", + "The B.pseudomallei isolated in 2013, 2014 and 2016 were further confirmed as B.pseudomallei.", + "The B.pseudomallei isolates were confirmed using API 20NE.", + "The B.pseudomallei isolates were confirmed using Ashdown agar.", + "The B.pseudomallei isolates were confirmed using an in-house polymerase chain reaction (PCR) using specific primers.", + "We were not able to obtain the B.pseudomallei isolated in 2017.", + "The isolates were characterized by multilocus sequence typing (MLST).", + "MLST is a method of molecular subtyping that compares sequences of seven housekeeping genes.", + "The isolates were characterized by repetitive-element PCR (rep-PCR).", + "These isolates were of two different sequence types (ST).", + "ST51 (UMC083 and UMC114) is a common ST found widely in Malaysia, Thailand, Singapore, Hong Kong and China.", + "ST1644 (UMC082) is a new ST.", + "The STs were deposited in the B.pseudomallei MLST database." + ], + "summary": "A 14-year-old Chinese Malaysian boy presented with a history of recurrent pneumonia, poor growth and steatorrhoea since childhood, and was diagnosed with CF. B. pseudomallei was cultured from his sputum during three different admissions between 2013 and 2016. However, the patient succumbed to end stage of respiratory failure in 2017 despite antibiotics treatment against B.pseudomallei. The isolates were compared using multilocus-sequence typing and repetitive-element polymerase chain reaction (PCR), and confirmed that two of the isolates were of same sequence type, which may indicate relapse.", + "summary_subclaims": [ + "The patient was a 14-year-old Chinese Malaysian boy.", + "The patient had a history of recurrent pneumonia.", + "The patient had poor growth.", + "The patient had steatorrhoea.", + "The patient was diagnosed with CF.", + "B. pseudomallei was cultured from his sputum during three different admissions between 2013 and 2016.", + "The patient succumbed to end stage of respiratory failure in 2017.", + "The patient received antibiotics treatment against B. pseudomallei.", + "The isolates were compared using multilocus-sequence typing.", + "The isolates were compared using repetitive-element polymerase chain reaction (PCR).", + "Two of the isolates were of same sequence type.", + "Two of the isolates may indicate relapse." + ] + }, + { + "id": "multiclinsum_test_1926_en.txt", + "fulltext": "A 71-year-old man presented with a lengthy history of benign prostatic hypertrophy.\nHe was asymptomatic without any hematuria, pain, or other urinary symptoms. The ECOG performance status was 1.\nHe had a lengthy history of benign prostatic hypertrophy.\nHeight: 6 feet (1.83 m); Weight: 225 lbs (102 kg); Body mass index: 30.5 kg/m2.\nA computed tomography (CT) scan of the abdomen and pelvis showed a 1.8 cm left retroperitoneal lymph node which was concerning for malignancy . There was no evidence of renal pathology. A positron emission tomography/CT revealed intense fluorine-18-deoxyglucose activity in the left retroperitoneal soft tissue nodule adjacent to the medial limb of the left adrenal gland . The standard uptake volume was 12.4.\nA core biopsy was performed under CT guidance of the left para-aortic lymph node. The immunohistochemical stains were strong and diffusely positive for PAX8 and cytokeratin (CK) AE1 and AE3 and negative for prostate-specific antigen (PSA), prostate specific acid phosphatase, Inhibin, and melanocyte antigen related to T-cells-1. Although the primary tumor site was unknown, the morphological and immunohistochemical features were most consistent with CCRCC.\nRestaging studies by bone scan 6 wk later were negative for skeletal metastasis. An abdominal and pelvic CT scan with and without Gadolinium contrast demonstrated a significant increase in size of the hypoenhancing retroperitoneal lymph node (4.3 cm × 4.4 cm compared to 1.8 cm × 2.8 cm 8 mo earlier). A primary lesion in the renal collecting system or ureters was not observed, although the prostate was markedly enlarged and there was diffuse bladder wall thickening.", + "fulltext_subclaims": [ + "The patient is a 71-year-old man.", + "He had a lengthy history of benign prostatic hypertrophy.", + "He was asymptomatic without any hematuria, pain, or other urinary symptoms.", + "The ECOG performance status was 1.", + "A CT scan of the abdomen and pelvis showed a 1.8 cm left retroperitoneal lymph node.", + "The CT scan showed the lymph node was concerning for malignancy.", + "There was no evidence of renal pathology.", + "A positron emission tomography/CT revealed intense fluorine-18-deoxyglucose activity in the left retroperitoneal soft tissue nodule.", + "The standard uptake volume was 12.4.", + "A core biopsy was performed under CT guidance of the left para-aortic lymph node.", + "The immunohistochemical stains were strong and diffusely positive for PAX8.", + "The immunohistochemical stains were strong and diffusely positive for cytokeratin AE1 and AE3.", + "The immunohistochemical stains were negative for prostate-specific antigen.", + "The immunohistochemical stains were negative for prostate specific acid phosphatase.", + "The immunohistochemical stains were negative for Inhibin.", + "The immunohistochemical stains were negative for melanocyte antigen related to T-cells-1.", + "The primary tumor site was unknown.", + "The morphological and immunohistochemical features were most consistent with CCRCC.", + "Restaging studies by bone scan 6 wk later were negative for skeletal metastasis.", + "An abdominal and pelvic CT scan with and without Gadolinium contrast demonstrated a significant increase in size of the hypoenhancing retroperitoneal lymph node.", + "The retroperitoneal lymph node measured 4.3 cm × 4.4 cm compared to 1.8 cm × 2.8 cm 8 mo earlier.", + "A primary lesion in the renal collecting system or ureters was not observed.", + "The prostate was markedly enlarged.", + "There was diffuse bladder wall thickening." + ], + "summary": "A 71-year-old man presented with a history of benign prostatic hypertrophy. He was asymptomatic without any hematuria, pain, or other urinary symptoms. A computed tomography (CT) scan of the abdomen and pelvis showed a 1.8 cm left retroperitoneal lymph node. There was no evidence of renal pathology. A core biopsy was performed of the left para-aortic lymph node. Although the primary tumor site was unknown, the morphological and immunohistochemical features were most consistent with CCRCC. A RPLND was performed which revealed a single mass 5.5 cm in greatest dimension with extensive necrosis. The retroperitoneal lymph node was most compatible with CCRCC. A nephrectomy was not conducted as a renal mass had not been detected on any prior imaging studies. The patient did not receive any type of adjuvant therapy. The patient underwent surveillance with serial CT scans with contrast of the chest, abdomen, and pelvis for the next 5 years, all of which demonstrated no recurrent or metastatic disease and no evidence of retroperitoneal adenopathy.", + "summary_subclaims": [ + "The patient is a 71-year-old man.", + "The patient has a history of benign prostatic hypertrophy.", + "The patient was asymptomatic.", + "The patient had no hematuria.", + "The patient had no pain.", + "The patient had no other urinary symptoms.", + "A computed tomography (CT) scan of the abdomen and pelvis showed a 1.8 cm left retroperitoneal lymph node.", + "There was no evidence of renal pathology.", + "A core biopsy was performed of the left para-aortic lymph node.", + "The primary tumor site was unknown.", + "The morphological and immunohistochemical features were most consistent with CCRCC.", + "A RPLND was performed.", + "The RPLND revealed a single mass 5.5 cm in greatest dimension.", + "The mass had extensive necrosis.", + "The retroperitoneal lymph node was most compatible with CCRCC.", + "A nephrectomy was not conducted.", + "A renal mass had not been detected on any prior imaging studies.", + "The patient did not receive any type of adjuvant therapy.", + "The patient underwent surveillance with serial CT scans with contrast of the chest, abdomen, and pelvis for the next 5 years.", + "All surveillance CT scans demonstrated no recurrent or metastatic disease.", + "All surveillance CT scans demonstrated no evidence of retroperitoneal adenopathy." + ] + }, + { + "id": "multiclinsum_test_1667_en.txt", + "fulltext": "A 25-year-old previously well white woman presented with two generalized tonic–clonic seizures, which were preceded by a 2-week history of prodromal flu-like symptoms and nonspecific headache. She was agitated in the emergency department for which she required midazolam.\nHer routine bloods were unremarkable. A computed tomography (CT) scan of her brain showed mild generalized cerebral edema and a magnetic resonance imaging (MRI) showed bilateral temporal lobe lesions involving her hippocampi and amygdala, which were more extensive on the right; this is an appearance in keeping with limbic encephalitis. An electroencephalogram (EEG) showed periodic lateralized epileptiform discharges and slow wave changes, which were maximal in the frontal and temporal regions.\nShe was initially treated with acyclovir for possible HSV encephalitis. She also received levetiracetam to prevent seizures. However, she deteriorated over the next week with behavioral changes, memory impairment, hypoventilation, and coma. She was admitted to ICU 9 days after admission for airway support.\nInvestigations revealed that her cerebrospinal fluids (CSF) had an elevated lymphocyte count and anti-NMDAR antibodies were strongly positive. Anti-NMDAR antibodies were also detected in her serum. The diagnosis of anti-NMDAR encephalitis was made 11 days after admission. She was commenced on a 5-day course of methylprednisolone, 5 days of plasmapheresis, and 5 days of immunoglobulin administered intravenously. She continued to have features of orofacial dyskinesia (that is, jaw opening and closing, chewing, facial grimacing, lip pouting) and tongue protrusion, which are characteristic features of this illness with autonomic instability; she remained intubated.\nDuring the search for an ovarian teratoma, an MRI of her abdomen and pelvis showed a left ovarian 2.6 cm simple cyst and a right ovarian 19 mm hemorrhagic cyst with no evidence of a teratoma. A whole body positron emission tomography (PET) scan was negative for malignancy. The serum tumor markers carcinoembryonic antigen (CEA) and CA-125 were also negative.\nA multidisciplinary team discussed with her family the risks and benefits of bilateral oophorectomy including premature menopause, the need for hormone replacement therapy (HRT), and fertility issues balanced with the chances of neurological recovery. A decision was made to proceed with laparoscopic bilateral salpingo-oophorectomy and harvesting of ovarian tissue for cryopreservation, despite no convincing radiological evidence of an ovarian teratoma; the procedure was performed 29 days after admission. Histopathology of her left ovary revealed a mature cystic teratoma/dermoid cyst with mature neuroglial elements resembling a cerebral ventricle . The ovarian teratoma had a prominent inflammatory response associated with the neural/glial elements: cytotoxic T lymphocytes (CD8-positive cells) were prominent; CD4-positive T helper cells and CD20-positive B lymphocytes were also found. This inflammatory response is unusual for teratomas, and points to the cellular immune response involved in our patient’s encephalitis.\nPostoperatively she continued to receive rituximab followed by cyclophosphamide. She started to show signs of improvement with fluctuating level of consciousness: intermittently obeying commands, spontaneous eye opening, mouthing words, and smiling. She suddenly improved and a repeat CT of her head showed some volume loss of her right hippocampus.\nOne month later she was oriented with a Glasgow Coma Scale of 15/15 and was transferred to our medical ward where she remained seizure free on levetiracetam. A cognitive screen showed no deficits with a Mini–Mental State Examination (MMSE) score of 26/30, a repeat EEG showed a major reduction in the severity of the slow wave change and the disappearance of epileptogenic activity. A follow-up brain MRI showed developing hippocampal atrophy on the right.\nAt 3 months, our patient maintained an excellent recovery, apart from mild short-term memory impairment. She regained strength and was mobilizing independently with no further involuntary movements or seizures. She remained well at 7 months post-diagnosis and was fully independent in all acts of daily living, with some symptomatic improvement in memory, such that her MMSE was 30/30 and her Addenbrooke’s Cognitive Examination score was 98/100. Her EEG had normalized and MRI revealed persistent involutional change to the right hippocampal head. The NMDAR antibodies remained positive in her blood, one year after recovery.", + "fulltext_subclaims": [ + "A 25-year-old previously well white woman presented with two generalized tonic–clonic seizures.", + "The seizures were preceded by a 2-week history of prodromal flu-like symptoms and nonspecific headache.", + "She was agitated in the emergency department and required midazolam.", + "Her routine bloods were unremarkable.", + "A CT scan of her brain showed mild generalized cerebral edema.", + "An MRI showed bilateral temporal lobe lesions involving her hippocampi and amygdala, which were more extensive on the right.", + "The MRI appearance is in keeping with limbic encephalitis.", + "An EEG showed periodic lateralized epileptiform discharges and slow wave changes, maximal in the frontal and temporal regions.", + "She was initially treated with acyclovir for possible HSV encephalitis.", + "She also received levetiracetam to prevent seizures.", + "She deteriorated over the next week with behavioral changes, memory impairment, hypoventilation, and coma.", + "She was admitted to ICU 9 days after admission for airway support.", + "Her cerebrospinal fluid had an elevated lymphocyte count.", + "Anti-NMDAR antibodies were strongly positive in her cerebrospinal fluid.", + "Anti-NMDAR antibodies were also detected in her serum.", + "The diagnosis of anti-NMDAR encephalitis was made 11 days after admission.", + "She was commenced on a 5-day course of methylprednisolone.", + "She received 5 days of plasmapheresis.", + "She received 5 days of intravenous immunoglobulin.", + "She continued to have orofacial dyskinesia, including jaw opening and closing, chewing, facial grimacing, and lip pouting.", + "She also had tongue protrusion, which are characteristic features of this illness.", + "An MRI of her abdomen and pelvis showed a left ovarian 2.6 cm simple cyst.", + "An MRI showed a right ovarian 19 mm hemorrhagic cyst with no evidence of a teratoma.", + "A whole body PET scan was negative for malignancy.", + "The serum tumor markers carcinoembryonic antigen and CA-125 were also negative.", + "A multidisciplinary team discussed the risks and benefits of bilateral oophorectomy with her family.", + "A decision was made to proceed with laparoscopic bilateral salpingo-oophorectomy and harvesting of ovarian tissue for cryopreservation.", + "The procedure was performed 29 days after admission.", + "Histopathology of her left ovary revealed a mature cystic teratoma/dermoid cyst with mature neuroglial elements resembling a cerebral ventricle.", + "The ovarian teratoma had a prominent inflammatory response associated with the neural/glial elements.", + "Cytotoxic T lymphocytes (CD8-positive cells) were prominent in the inflammatory response.", + "CD4-positive T helper cells and CD20-positive B lymphocytes were also found.", + "This inflammatory response is unusual for teratomas.", + "This inflammatory response points to the cellular immune response involved in our patient’s encephalitis.", + "Postoperatively she continued to receive rituximab followed by cyclophosphamide.", + "She started to show signs of improvement with fluctuating level of consciousness.", + "A repeat CT of her head showed some volume loss of her right hippocampus.", + "One month later she was oriented with a Glasgow Coma Scale of 15/15.", + "She was transferred to the medical ward where she remained seizure free on levetiracetam.", + "A cognitive screen showed no deficits with a Mini–Mental State Examination score of 26/30.", + "A repeat EEG showed a major reduction in the severity of the slow wave change and the disappearance of epileptogenic activity.", + "A follow-up brain MRI showed developing hippocampal atrophy on the right.", + "At 3 months, our patient maintained an excellent recovery, apart from mild short-term memory impairment.", + "She regained strength and was mobilizing independently with no further involuntary movements or seizures.", + "She remained well at 7 months post-diagnosis and was fully independent in all acts of daily living.", + "Her MMSE was 30/30 at 7 months post-diagnosis.", + "Her Addenbrooke’s Cognitive Examination score was 98/100 at 7 months post-diagnosis.", + "Her EEG had normalized at 7 months post-diagnosis.", + "Her MRI revealed persistent involutional change to the right hippocampal head.", + "The NMDAR antibodies remained positive in her blood one year after recovery." + ], + "summary": "A 25-year-old white woman with anti-N-methyl-D-aspartate receptor encephalitis presented with behavioral changes and seizures that were confirmed to be secondary to anti-N-methyl-D-aspartate receptor encephalitis. She required an admission to our intensive care unit for ventilator support and received a number of immunological therapies. Multiple imaging investigations showed no evidence of an ovarian teratoma; she had a bilateral oophorectomy 29 days after admission. Ovarian histology confirmed the presence of a teratoma with neuronal cells. A few days after the operation she began to show signs of improvement and, apart from mild short-term memory loss, she returned to normal function.", + "summary_subclaims": [ + "The patient is a 25-year-old white woman.", + "She has anti-N-methyl-D-aspartate receptor encephalitis.", + "She presented with behavioral changes.", + "She presented with seizures.", + "The seizures were confirmed to be secondary to anti-N-methyl-D-aspartate receptor encephalitis.", + "She required admission to the intensive care unit.", + "She received ventilator support.", + "She received immunological therapies.", + "Multiple imaging investigations showed no evidence of an ovarian teratoma.", + "She had a bilateral oophorectomy 29 days after admission.", + "Ovarian histology confirmed the presence of a teratoma with neuronal cells.", + "A few days after the operation she began to show signs of improvement.", + "She returned to normal function apart from mild short-term memory loss." + ] + }, + { + "id": "multiclinsum_test_2843_en.txt", + "fulltext": "An 84-year-old woman was admitted to our institution because of rapidly progressive dyspnoea and orthopnoea over the past month despite aggressive dehydration during outpatient dialysis.\nShe had a history of ESRD due to diabetic nephropathy and had been on haemodialysis for two and a half years. Additionally, she had a history of dyslipidaemia and hypertension. One and a half years prior, she began experiencing chest discomfort and shortness of breath on exertion. A Levine three-sixths degree systolic ejection murmur and a coarse crackle were heard from her. Electrocardiogram showed sinus rhythm, high voltage, and strain T pattern in chest leads suggesting left ventricular hypertrophy. Chest X-ray revealed cardiomegaly and pulmonary congestion, and serum brain natriuretic peptide level was 1290 pg/mL (normal range ≦ 18.4 pg/mL). Echocardiography revealed severe AS with a mean aortic valve pressure gradient (mAVPG) of 41 mmHg and an aortic valve area of 0.72 mm2. She underwent TAVI with a 23 mm SAPIEN3 (Edwards Lifesciences) a year and a half prior to this admission. Following the procedure, the patient’s recovery was uneventful, and echocardiography showed no paravalvular leak, a mAVPG of 17 mmHg, and an effective orifice area (EOA) of 1.92 cm2 at discharge (see ). She had been receiving antiplatelet therapy with clopidogrel 75 mg after TAVI. Echocardiography at the one-year follow-up revealed no evidence of prosthetic valve dysfunction, with a mAVPG of 18 mmHg and an EOA of 1.82 cm2 (see ).\nThe patient underwent transthoracic echocardiography at admission, which revealed stiffening and complete loss of mobility of the aortic prosthetic valves (see ). This resulted in severe AS with a mAVPG of 68 mmHg and an EOA of 0.65 cm2. Contrast-enhanced computed tomography (CT) showed severe calcification and thickening of all three prosthetic valve leaflets .\nThe CT findings suggested a high risk of coronary artery occlusion if TAV in TAV was selected. Even in the case of a repeated SAVR with a bioprosthetic valve, there remained a concern about high surgical risk, with an STS score of 13.8% and a significant likelihood of early SVD. Following a rapid multidisciplinary team discussion, we performed an emergency SAVR with a 19 mm On-X valve (CryoLife). Pathological observation of the explanted SAPIEN 3 valves demonstrated severely degenerated bioprosthetic pericardial leaflets with severe intrinsic and extrinsic calcifications that could cause limitation of the leaflet motion . The patient did well post-operatively, and there were no other major complications. Post-operative echocardiography showed improvement in AV peak flow [2.6 m/s, mAVPG (14 mmHg], and EOA (1.84 cm2). No heart failure exacerbations, warfarin-induced bleeding events or prosthetic valve dysfunction were observed in the first year after SAVR.", + "fulltext_subclaims": [ + "An 84-year-old woman was admitted because of rapidly progressive dyspnoea and orthopnoea over the past month.", + "She had a history of ESRD due to diabetic nephropathy.", + "She had been on haemodialysis for two and a half years.", + "She had a history of dyslipidaemia.", + "She had a history of hypertension.", + "One and a half years prior, she began experiencing chest discomfort and shortness of breath on exertion.", + "A Levine three-sixths degree systolic ejection murmur was heard.", + "A coarse crackle was heard.", + "Electrocardiogram showed sinus rhythm.", + "Electrocardiogram showed high voltage.", + "Electrocardiogram showed strain T pattern in chest leads.", + "Electrocardiogram findings suggested left ventricular hypertrophy.", + "Chest X-ray revealed cardiomegaly.", + "Chest X-ray revealed pulmonary congestion.", + "Serum brain natriuretic peptide level was 1290 pg/mL.", + "Echocardiography revealed severe AS with a mean aortic valve pressure gradient of 41 mmHg.", + "Echocardiography revealed an aortic valve area of 0.72 mm2.", + "She underwent TAVI with a 23 mm SAPIEN3 a year and a half prior to this admission.", + "Following the procedure, the patient’s recovery was uneventful.", + "Echocardiography at discharge showed no paravalvular leak.", + "Echocardiography at discharge showed a mean aortic valve pressure gradient of 17 mmHg.", + "Echocardiography at discharge showed an effective orifice area of 1.92 cm2.", + "She had been receiving antiplatelet therapy with clopidogrel 75 mg after TAVI.", + "Echocardiography at the one-year follow-up revealed no evidence of prosthetic valve dysfunction.", + "Echocardiography at the one-year follow-up showed a mean aortic valve pressure gradient of 18 mmHg.", + "Echocardiography at the one-year follow-up showed an effective orifice area of 1.82 cm2.", + "The patient underwent transthoracic echocardiography at admission.", + "Transthoracic echocardiography at admission revealed stiffening and complete loss of mobility of the aortic prosthetic valves.", + "Transthoracic echocardiography at admission revealed severe AS with a mean aortic valve pressure gradient of 68 mmHg.", + "Transthoracic echocardiography at admission revealed an effective orifice area of 0.65 cm2.", + "Contrast-enhanced computed tomography showed severe calcification of all three prosthetic valve leaflets.", + "Contrast-enhanced computed tomography showed thickening of all three prosthetic valve leaflets.", + "The CT findings suggested a high risk of coronary artery occlusion if TAV in TAV was selected.", + "Even in the case of a repeated SAVR with a bioprosthetic valve, there remained a concern about high surgical risk.", + "The STS score was 13.8%.", + "There was a significant likelihood of early SVD.", + "Following a rapid multidisciplinary team discussion, we performed an emergency SAVR with a 19 mm On-X valve.", + "Pathological observation of the explanted SAPIEN 3 valves demonstrated severely degenerated bioprosthetic pericardial leaflets.", + "Pathological observation demonstrated severe intrinsic calcifications.", + "Pathological observation demonstrated severe extrinsic calcifications.", + "Severe intrinsic and extrinsic calcifications could cause limitation of the leaflet motion.", + "The patient did well post-operatively.", + "There were no other major complications.", + "Post-operative echocardiography showed improvement in AV peak flow to 2.6 m/s.", + "Post-operative echocardiography showed a mean aortic valve pressure gradient of 14 mmHg.", + "Post-operative echocardiography showed an effective orifice area of 1.84 cm2.", + "No heart failure exacerbations were observed in the first year after SAVR.", + "No warfarin-induced bleeding events were observed in the first year after SAVR.", + "No prosthetic valve dysfunction was observed in the first year after SAVR." + ], + "summary": "We present a case of rapidly progressive bioprosthetic aortic valve stenosis in a patient with end-stage renal disease secondary to diabetic nephropathy in an 83-year-old female admitted due to progressive dyspnoea and orthopnoea. A 23 mm sized SAPIEN3 bioprosthetic aortic valve showed normal function for the first year after transcatheter aortic valve implantation (TAVI), but then rapidly developed stenosis and required acute hospitalization for heart failure a year and a half after surgery. Emergent surgical aortic valve replacement with a 19 mm On-X valve (CryoLife, Kennesaw, GA, USA) was performed. Pathological examination of the explanted SAPIEN 3 valve demonstrated severely degenerated bioprosthetic pericardial leaflets with severe intrinsic and extrinsic nodular calcifications, which could limit the leaflet motion.", + "summary_subclaims": [ + "The patient is an 83-year-old female.", + "The patient had end-stage renal disease.", + "The patient's end-stage renal disease was secondary to diabetic nephropathy.", + "The patient was admitted due to progressive dyspnoea and orthopnoea.", + "A 23 mm sized SAPIEN3 bioprosthetic aortic valve was implanted via transcatheter aortic valve implantation.", + "The SAPIEN3 bioprosthetic aortic valve showed normal function for the first year.", + "The valve rapidly developed stenosis.", + "The patient required acute hospitalization for heart failure a year and a half after surgery.", + "Emergent surgical aortic valve replacement with a 19 mm On-X valve was performed.", + "Pathological examination of the explanted SAPIEN 3 valve demonstrated severely degenerated bioprosthetic pericardial leaflets.", + "The explanted valve showed severe intrinsic and extrinsic nodular calcifications.", + "The calcifications could limit the leaflet motion." + ] + }, + { + "id": "multiclinsum_test_2847_en.txt", + "fulltext": "A 34-year-old Iranian man presented to the clinic with redness and impaired vision in the right eye for many months, despite topical corticosteroid treatment. His prior medical history was unremarkable. His best-corrected visual acuity (BCVA) in the right eye was 4/10 (+5.00 sphere) and 10/10 (−0.50 sphere) in the left eye at the time of presentation. The examination of the left eye was normal. During a slit-lamp examination, the right eye revealed chemosis as well as a nodular salmon patch in the bulbar conjunctiva and 1+ vitritis. The fundus examination of the right eye revealed near-total shallow serous retinal detachment, multifocal yellow choroidal infiltrates, and widespread mid-peripheral retinal pigment epithelium (RPE) changes .\nEnhanced-depth-imaging optical coherence tomography (EDI-OCT) showed macular retinal folds and a “seasick” appearance on the choroidal surface with compression of the choriocapillaris. OCT images also revealed intraretinal and subretinal fluid, as well as clumps of optically dense material at the level of the RPE .\nFluorescein angiography (FA) disclosed diffuse patches of choroidal hyperfluorescence. In the posterior pole, blue autofluorescence (BAF) and FA imaging exhibited a nonspecific “leopard-spot” appearance .\nIncisional biopsy of the conjunctival lesion was performed; histological and immunohistochemistry studies revealed a dense infiltrate of small lymphocytes with positive staining for CD20 and CD79, with coexpression of BCL2. The diagnosis was atypical monoclonal lymphoid infiltration suggestive of low-grade extranodal marginal zone B-cell lymphoma.\nMagnetic resonance imaging (MRI) of the orbit was negative for extrascleral extension; his systemic workup for extraocular involvement including laboratory data, chest and abdomen computed tomography (CT) scans, and bone marrow aspiration results were all negative.\nUltra-low-dose radiation, termed “boom-boom radiotherapy” (4 Gy delivered in two fractions over two consecutive days) was used in conjunction with intravitreal injections of methotrexate and rituximab. To reduce radiation scatter to periocular tissue, orbital rim bones, and midfacial soft tissues, the beam was delivered through a bolus shell of 42-mm water-equivalent thickness placed 3 cm from the patient.\nIntravitreal methotrexate injections were started at a dosage of 400 µg in 0.1 ml per week for 6 weeks, then monthly for 6 months. Rituximab was administered intravitreally once a month for 3 months at a dosage of 1 mg in 0.1 ml. The intravitreal injections were started just 1 week after the last radiotherapy session.\nSerous retinal detachment was resolved 2 months following ultra-low-dose radiation, and subretinal fibrosis and widespread RPE alterations were observed at the location of the detachment. On EDI-OCT, the lymphoid infiltration, flattening of the macular fold, and resolution of subretinal and intraretinal fluid were all observed. Hyperreflective deposits were observed under the retina that correlated to fibrosis. The RPE–choroidal interface changed to a “calm sea” appearance. At 1-year follow-up, the results remained consistent, the subconjunctival lesions were regressed, and the BCVA improved to 6/10. During this time, there was no recurrence or radiation-associated complications. The patient was scheduled for regular follow-up visits.", + "fulltext_subclaims": [ + "A 34-year-old Iranian man presented to the clinic with redness and impaired vision in the right eye for many months.", + "The patient had used topical corticosteroid treatment.", + "His best-corrected visual acuity in the right eye was 4/10 (+5.00 sphere) at the time of presentation.", + "The left eye examination was normal.", + "Slit-lamp examination of the right eye revealed chemosis.", + "Slit-lamp examination of the right eye revealed a nodular salmon patch in the bulbar conjunctiva.", + "Slit-lamp examination of the right eye revealed 1+ vitritis.", + "Fundus examination of the right eye revealed near-total shallow serous retinal detachment.", + "Fundus examination of the right eye revealed multifocal yellow choroidal infiltrates.", + "Fundus examination of the right eye revealed widespread mid-peripheral retinal pigment epithelium changes.", + "Enhanced-depth-imaging optical coherence tomography showed macular retinal folds.", + "Enhanced-depth-imaging optical coherence tomography showed a 'seasick' appearance on the choroidal surface.", + "Enhanced-depth-imaging optical coherence tomography showed compression of the choriocapillaris.", + "OCT images revealed intraretinal fluid.", + "OCT images revealed subretinal fluid.", + "OCT images revealed clumps of optically dense material at the level of the RPE.", + "Fluorescein angiography disclosed diffuse patches of choroidal hyperfluorescence.", + "Blue autofluorescence and FA imaging exhibited a nonspecific 'leopard-spot' appearance.", + "Incisional biopsy of the conjunctival lesion was performed.", + "Histological and immunohistochemistry studies revealed a dense infiltrate of small lymphocytes.", + "The lymphocytes showed positive staining for CD20.", + "The lymphocytes showed positive staining for CD79.", + "The lymphocytes showed coexpression of BCL2.", + "The diagnosis was atypical monoclonal lymphoid infiltration suggestive of low-grade extranodal marginal zone B-cell lymphoma.", + "MRI of the orbit was negative for extrascleral extension.", + "The systemic workup for extraocular involvement was negative.", + "Ultra-low-dose radiation, termed 'boom-boom radiotherapy,' was used.", + "The radiation was delivered in two fractions of 4 Gy over two consecutive days.", + "The beam was delivered through a bolus shell of 42-mm water-equivalent thickness.", + "Intravitreal injections of methotrexate and rituximab were used.", + "Intravitreal methotrexate injections were started at a dosage of 400 µg in 0.1 ml per week for 6 weeks.", + "Intravitreal methotrexate injections were then given monthly for 6 months.", + "Rituximab was administered intravitreally once a month for 3 months at a dosage of 1 mg in 0.1 ml.", + "The intravitreal injections were started just 1 week after the last radiotherapy session.", + "Serous retinal detachment was resolved 2 months following ultra-low-dose radiation.", + "Subretinal fibrosis was observed at the location of the detachment.", + "EDI-OCT showed lymphoid infiltration.", + "EDI-OCT showed flattening of the macular fold.", + "EDI-OCT showed resolution of subretinal and intraretinal fluid.", + "Hyperreflective deposits were observed under the retina.", + "The RPE–choroidal interface changed to a 'calm sea' appearance.", + "At 1-year follow-up, the results remained consistent.", + "The subconjunctival lesions were regressed.", + "The best-corrected visual acuity improved to 6/10.", + "There was no recurrence during the 1-year follow-up.", + "There were no radiation-associated complications.", + "The patient was scheduled for regular follow-up visits." + ], + "summary": "A 34-year-old Iranian man presented with a nodular patch of bulbar conjunctiva in the right eye, and 1+ vitritis. A nearly complete shallow serous retinal detachment, retinal folds, and multifocal yellow choroidal infiltrates were seen during a fundus examination of the right eye. Enhanced depth imaging optical coherence tomography revealed macular retinal folds and an uneven, undulating, \"seasick\" appearance of the choroidal surface with choriocapillaris compression, intraretinal and subretinal fluid, and clusters of optically dense material at the outer retinal level. An incisional biopsy of the conjunctival lesion confirmed the diagnosis of primary choroidal lymphoma with epibulbar involvement. The patient was treated with ultra-low-dose \"boom-boom\" radiation (4 Gy delivered in two fractions over two consecutive days) as well as intravitreal methotrexate and rituximab injections. After a year, the lesions had completely disappeared, with no adverse effects or recurrence.", + "summary_subclaims": [ + "The patient is a 34-year-old Iranian man.", + "The patient had a nodular patch of bulbar conjunctiva in the right eye.", + "The patient had 1+ vitritis.", + "A nearly complete shallow serous retinal detachment was seen during a fundus examination of the right eye.", + "Retinal folds were seen during a fundus examination of the right eye.", + "Multifocal yellow choroidal infiltrates were seen during a fundus examination of the right eye.", + "Enhanced depth imaging optical coherence tomography revealed macular retinal folds.", + "Enhanced depth imaging optical coherence tomography showed an uneven, undulating, 'seasick' appearance of the choroidal surface.", + "Enhanced depth imaging optical coherence tomography showed choriocapillaris compression.", + "Enhanced depth imaging optical coherence tomography showed intraretinal and subretinal fluid.", + "Enhanced depth imaging optical coherence tomography showed clusters of optically dense material at the outer retinal level.", + "An incisional biopsy of the conjunctival lesion confirmed the diagnosis of primary choroidal lymphoma with epibulbar involvement.", + "The patient was treated with ultra-low-dose 'boom-boom' radiation (4 Gy delivered in two fractions over two consecutive days).", + "The patient received intravitreal methotrexate injections.", + "The patient received intravitreal rituximab injections.", + "After a year, the lesions had completely disappeared.", + "After a year, there were no adverse effects.", + "After a year, there was no recurrence." + ] + }, + { + "id": "multiclinsum_test_2413_en.txt", + "fulltext": "The patient was a 34-year-old Korean man who visited our emergency department complaining of intractable insomnia and progressive dementia. The patient suffered from intractable insomnia and irregular, coarse breathing during sleep, which began 9 months before admission. He consequently developed excessive sweating, bilateral action tremors, and restlessness. Memory disturbance and poor executive function were noticed 2 months before admission. Delusions of persecution and social withdrawal were also present. Three days before admission, the patient began to show gait disturbance with mild postural instability.\nThe patient had been in good health before disease onset. He had 16 years of education, majored in law, and worked as a civil servant at the district court until he lost his job due to memory disturbance.\nHis vital signs showed a marked fluctuation in blood pressure, tachycardia, and tachypnea. His initial body temperature was 38.0°C, which was stabilized after controlling his pneumonia.\nNeurologic examination revealed disorientation and anomic aphasia with paraphasia. The Korean version of the Mini-Mental State Examination score was 17 out of 30. Hypophonia, dysarthria, both resting and action tremors, and akathisia were present. His gait was ataxic with a tendency of tilting backwards. Otherwise, cranial nerve functions, muscle volume, tone, and power as well as sensory functions were normal. Extrapyramidal signs such as rigidity or bradykinesia were absent. Deep tendon reflexes were normoactive without pathologic reflexes.\nRoutine blood labs showed no abnormalities. Both plasma and urine catecholamine levels were elevated. Cerebrospinal fluid analysis was unremarkable and the patient was negative for 14-3-3 protein.\nThe patient's four-generation pedigree is presented in fig. . The patient's mother (III:7), who was a physically and mentally healthy 70-year-old woman, had the same mutation. An asymptomatic brother of the proband (IV:12) was negative for the PRNP gene mutation. The son of the patient's great-aunt (II:1) had gradually developed hypersomnia, gait disturbance, ataxia, and dysarthria. His cerebrospinal fluid study was positive for 14-3-3 protein. The genetic analysis of subject II:1 revealed a PRNP gene mutation at codon 178 (D178N) and homozygosity for methionine at codon 129. Total disease duration was 27 months.\nMagnetic resonance imaging and electroencephalography findings were unremarkable. Polysomnography revealed reduced total sleep time, absence of slow-wave and REM stages of sleep, severe periodic limb movement, and heavy snoring.\nNeuropsychological tests were performed using the Seoul Neuropsychological Screening Battery . The results are summarized in table . Forward and backward digit span were markedly reduced. The Boston Naming Test showed severely impaired confrontational naming ability. Other language functions were intact. Gerstmann syndrome, buccofacial and ideomotor apraxia were observed. The Rey-Osterrieth Complex Figure Test revealed visuoconstructive dysfunction. The Seoul Verbal Learning Test and the Rey-Osterrieth Complex Figure Test showed that both verbal and visual memory functions were severely impaired. Frontal surveys revealed poor frontal executive function, generative naming abilities, and inhibitory control.\nGenomic DNA isolated from peripheral blood leukocytes was used for analysis. Direct sequencing of the PRNP gene identified a heterozygous p. Asp179Asn mutation homozygous for methionine at codon 129 and for glutamate at codon 219.\nThe patient's FDG-PET scan showed mild hypometabolism in the bilateral frontal cortices and bilateral thalamus . Using SPM analysis, the patient's PET scan was compared with those of 7 healthy male controls . The results of the SPM analysis showed marked hypometabolism in the patient's deep cerebral nuclei including the bilateral thalami, caudate nuclei, and hypothalamus. In addition, the hypometabolism affected association cortices including the frontal, lateral temporal, inferior parietal lobule, and posterior cingulate gyri; among these, frontal association areas including the dorsolateral, medial and orbitofrontal areas were more dominantly affected than the other lobes. Lastly, in addition to cerebral lesions, the midbrain was also affected.", + "fulltext_subclaims": [ + "The patient was a 34-year-old Korean man.", + "The patient visited the emergency department complaining of intractable insomnia and progressive dementia.", + "The patient suffered from intractable insomnia and irregular, coarse breathing during sleep, which began 9 months before admission.", + "He developed excessive sweating, bilateral action tremors, and restlessness.", + "Memory disturbance and poor executive function were noticed 2 months before admission.", + "Delusions of persecution and social withdrawal were also present.", + "Three days before admission, the patient began to show gait disturbance with mild postural instability.", + "The patient had been in good health before disease onset.", + "He had 16 years of education.", + "He majored in law.", + "He worked as a civil servant at the district court.", + "He lost his job due to memory disturbance.", + "His vital signs showed marked fluctuation in blood pressure, tachycardia, and tachypnea.", + "His initial body temperature was 38.0°C.", + "His body temperature was stabilized after controlling his pneumonia.", + "Neurologic examination revealed disorientation and anomic aphasia with paraphasia.", + "The Korean version of the Mini-Mental State Examination score was 17 out of 30.", + "Hypophonia, dysarthria, both resting and action tremors, and akathisia were present.", + "His gait was ataxic with a tendency of tilting backwards.", + "Cranial nerve functions, muscle volume, tone, and power as well as sensory functions were normal.", + "Extrapyramidal signs such as rigidity or bradykinesia were absent.", + "Deep tendon reflexes were normoactive without pathologic reflexes.", + "Routine blood labs showed no abnormalities.", + "Both plasma and urine catecholamine levels were elevated.", + "Cerebrospinal fluid analysis was unremarkable.", + "The patient was negative for 14-3-3 protein.", + "The patient's four-generation pedigree is presented in fig.", + "The patient's mother (III:7) had the same mutation.", + "An asymptomatic brother of the proband (IV:12) was negative for the PRNP gene mutation.", + "The son of the patient's great-aunt (II:1) had gradually developed hypersomnia, gait disturbance, ataxia, and dysarthria.", + "The son of the patient's great-aunt (II:1) had a cerebrospinal fluid study positive for 14-3-3 protein.", + "Genetic analysis of subject II:1 revealed a PRNP gene mutation at codon 178 (D178N) and homozygosity for methionine at codon 129.", + "Total disease duration was 27 months.", + "Magnetic resonance imaging and electroencephalography findings were unremarkable.", + "Polysomnography revealed reduced total sleep time.", + "Polysomnography revealed absence of slow-wave and REM stages of sleep.", + "Polysomnography revealed severe periodic limb movement.", + "Polysomnography revealed heavy snoring.", + "Neuropsychological tests were performed using the Seoul Neuropsychological Screening Battery.", + "Forward and backward digit span were markedly reduced.", + "The Boston Naming Test showed severely impaired confrontational naming ability.", + "Other language functions were intact.", + "Gerstmann syndrome was observed.", + "Buccofacial and ideomotor apraxia were observed.", + "The Rey-Osterrieth Complex Figure Test revealed visuoconstructive dysfunction.", + "The Seoul Verbal Learning Test showed that verbal memory functions were severely impaired.", + "The Rey-Osterrieth Complex Figure Test showed that visual memory functions were severely impaired.", + "Frontal surveys revealed poor frontal executive function.", + "Frontal surveys revealed poor generative naming abilities.", + "Frontal surveys revealed poor inhibitory control.", + "Genomic DNA isolated from peripheral blood leukocytes was used for analysis.", + "Direct sequencing of the PRNP gene identified a heterozygous p. Asp179Asn mutation.", + "The mutation was homozygous for methionine at codon 129.", + "The mutation was homozygous for glutamate at codon 219.", + "The patient's FDG-PET scan showed mild hypometabolism in the bilateral frontal cortices and bilateral thalamus.", + "The patient's PET scan was compared with those of 7 healthy male controls.", + "The results of the SPM analysis showed marked hypometabolism in the patient's deep cerebral nuclei including the bilateral thalami, caudate nuclei, and hypothalamus.", + "The results of the SPM analysis showed hypometabolism affecting association cortices including the frontal, lateral temporal, inferior parietal lobule, and posterior cingulate gyri.", + "Frontal association areas including the dorsolateral, medial and orbitofrontal areas were more dominantly affected than the other lobes.", + "In addition to cerebral lesions, the midbrain was also affected." + ], + "summary": "The patient was a 34-year-old Korean man. He presented with intractable insomnia, rapidly progressive dementia and autonomic disturbances. A comprehensive clinical investigation was conducted, including brain MRI, electroencephalography, polysomnography, neuropsychological tests, FDG-PET and genomic tests. SPM analysis was performed using 7 healthy controls. Direct sequencing of the PRNP gene identified a heterozygous p. Asp179Asn mutation homozygous for methionine at codon 129 and for glutamate at codon 219. The results of the SPM analysis showed marked hypometabolism in the deep cerebral nuclei (including the bilateral thalami, caudate nuclei, and hypothalamus), association cortices (including the frontal, lateral temporal, inferior parietal lobule and posterior cingulate gyri), and midbrain.", + "summary_subclaims": [ + "The patient was a 34-year-old Korean man.", + "He presented with intractable insomnia.", + "He presented with rapidly progressive dementia.", + "He presented with autonomic disturbances.", + "A comprehensive clinical investigation was conducted.", + "Brain MRI was performed.", + "Electroencephalography was performed.", + "Polysomnography was performed.", + "Neuropsychological tests were performed.", + "FDG-PET was performed.", + "Genomic tests were performed.", + "SPM analysis was performed using 7 healthy controls.", + "Direct sequencing of the PRNP gene identified a heterozygous p. Asp179Asn mutation.", + "The patient was homozygous for methionine at codon 129.", + "The patient was homozygous for glutamate at codon 219.", + "The results of the SPM analysis showed marked hypometabolism in the deep cerebral nuclei.", + "The deep cerebral nuclei included the bilateral thalami, caudate nuclei, and hypothalamus.", + "The results of the SPM analysis showed marked hypometabolism in the association cortices.", + "The association cortices included the frontal, lateral temporal, inferior parietal lobule and posterior cingulate gyri.", + "The results of the SPM analysis showed marked hypometabolism in the midbrain." + ] + }, + { + "id": "multiclinsum_test_13_en.txt", + "fulltext": "A 56-year-old male patient presented with a pancreatic cyst identified by abdominal ultrasonography on a comprehensive medical examination and was admitted to our hospital. He had a past medical history of type 2 diabetes, hyperlipidemia, and chronic hepatitis C for which he received interferon therapy for chronic hepatitis C more than 20 years previously. He had no family history of cancer. Laboratory tests revealed normal levels of carcinoembryonic antigen (CEA) and carbohydrate antigen 19–9, and alpha-fetoprotein (AFP) and protein induced by vitamin K absence or antagonist-II (PIVKA-II) were absent. Endoscopic ultrasound (EUS) showed a cystic mass measuring 13 mm in size in the pancreatic head and a low-density mass measuring 16 mm in size in the pancreatic tail , which was partially enhanced on the contrast-enhanced ultrasound image . Contrast-enhanced computed tomography (CT) revealed branch duct type intraductal papillary mucinous neoplasms in the pancreatic head and an early enhanced nodule measuring approximately 10 mm in size in the pancreatic tail . An enhancement of the nodule lasted until the late phase, although its density was gradually attenuated. Magnetic resonance imaging (MRI) did not detect the corresponding nodule in the pancreatic tail.\nBased on the above features, our initial differential was that of a neuroendocrine tumor or a solid pseudopapillary neoplasm (SPN). Endoscopic ultrasound-guided fine-needle aspiration (FNA) was performed to make a definitive diagnosis. FNA cytology showed that the tumor cells exhibited an acidophilic cytoplasm with small, round nuclei. Immunohistochemistry was performed to differentiate between a neuroendocrine tumor, SPN, and acinar cell carcinoma. The tumor cells were positive for cytokeratin, nuclear/membranous β-catenin, CD10, and CD56 and were negative for chromogranin A, synaptophysin, progesterone receptor, vimentin, and Bcl-10. Therefore, we suspected that the hypervascular tumor in the pancreatic tail was suspected to be SPN, but the results were not convincing. Laparoscopic spleen-preserving distal pancreatectomy was performed. Macroscopically, a well-circumscribed whitish-yellow solid mass, measuring 7 mm in the greatest dimension, was found in the pancreatic tail . Histologically, polygonal tumor cells with round nuclei and abundant eosinophilic cytoplasm formed thick trabeculae. The differentiation was moderate . Immunohistochemically, the tumor cells were positive for hepatocyte paraffin 1, AE1/AE3, and CD10 and negative for AFP, progesterone receptor, vimentin, chromogranin A, and synaptophysin . A canalicular pattern was confirmed on the polyclonal CEA staining . HC is characteristically hepatocyte paraffin 1 (HepPar1)-positive and has a canalicular pattern on polyclonal CEA staining. Finally, a diagnosis of moderately differentiated pancreatic HC was made. The patient’s postoperative course was uneventful, and he was discharged in good health 10 days after the operation. The patient did not receive adjuvant chemotherapy and remained recurrence-free at 6 months after the surgery. The serum levels of AFP (3 ng/mL) and PIVKA-II (28 mAU/mL) were normal at 1 month after the surgery. The latest serum levels of AFP (2 ng/mL) and PIVKA-II (25 mAU/mL) were normal at 6 months after the surgery.", + "fulltext_subclaims": [ + "A 56-year-old male patient presented with a pancreatic cyst identified by abdominal ultrasonography.", + "The patient had a past medical history of type 2 diabetes.", + "The patient had a past medical history of hyperlipidemia.", + "The patient had a past medical history of chronic hepatitis C.", + "The patient received interferon therapy for chronic hepatitis C more than 20 years previously.", + "The patient had no family history of cancer.", + "Laboratory tests revealed normal levels of carcinoembryonic antigen (CEA).", + "Laboratory tests revealed normal levels of carbohydrate antigen 19–9.", + "Alpha-fetoprotein (AFP) was absent.", + "Protein induced by vitamin K absence or antagonist-II (PIVKA-II) was absent.", + "Endoscopic ultrasound (EUS) showed a cystic mass measuring 13 mm in size in the pancreatic head.", + "EUS showed a low-density mass measuring 16 mm in size in the pancreatic tail.", + "The mass in the pancreatic tail was partially enhanced on the contrast-enhanced ultrasound image.", + "Contrast-enhanced computed tomography (CT) revealed branch duct type intraductal papillary mucinous neoplasms in the pancreatic head.", + "CT revealed an early enhanced nodule measuring approximately 10 mm in size in the pancreatic tail.", + "The enhancement of the nodule lasted until the late phase.", + "The density of the nodule was gradually attenuated.", + "Magnetic resonance imaging (MRI) did not detect the corresponding nodule in the pancreatic tail.", + "The initial differential was that of a neuroendocrine tumor or a solid pseudopapillary neoplasm (SPN).", + "Endoscopic ultrasound-guided fine-needle aspiration (FNA) was performed.", + "FNA cytology showed tumor cells with acidophilic cytoplasm and small, round nuclei.", + "Immunohistochemistry was performed to differentiate between a neuroendocrine tumor, SPN, and acinar cell carcinoma.", + "The tumor cells were positive for cytokeratin.", + "The tumor cells were positive for nuclear/membranous β-catenin.", + "The tumor cells were positive for CD10.", + "The tumor cells were positive for CD56.", + "The tumor cells were negative for chromogranin A.", + "The tumor cells were negative for synaptophysin.", + "The tumor cells were negative for progesterone receptor.", + "The tumor cells were negative for vimentin.", + "The tumor cells were negative for Bcl-10.", + "We suspected that the hypervascular tumor in the pancreatic tail was suspected to be SPN.", + "The results of the immunohistochemistry were not convincing.", + "Laparoscopic spleen-preserving distal pancreatectomy was performed.", + "Macroscopically, a well-circumscribed whitish-yellow solid mass, measuring 7 mm in the greatest dimension, was found in the pancreatic tail.", + "Histologically, polygonal tumor cells with round nuclei and abundant eosinophilic cytoplasm formed thick trabeculae.", + "The differentiation was moderate.", + "Immunohistochemically, the tumor cells were positive for hepatocyte paraffin 1.", + "The tumor cells were positive for AE1/AE3.", + "The tumor cells were positive for CD10.", + "The tumor cells were negative for AFP.", + "The tumor cells were negative for progesterone receptor.", + "The tumor cells were negative for vimentin.", + "The tumor cells were negative for chromogranin A.", + "The tumor cells were negative for synaptophysin.", + "A canalicular pattern was confirmed on the polyclonal CEA staining.", + "HC is characteristically hepatocyte paraffin 1 (HepPar1)-positive.", + "HC has a canalicular pattern on polyclonal CEA staining.", + "A diagnosis of moderately differentiated pancreatic HC was made.", + "The patient’s postoperative course was uneventful.", + "The patient was discharged in good health 10 days after the operation.", + "The patient did not receive adjuvant chemotherapy.", + "The patient remained recurrence-free at 6 months after the surgery.", + "The serum levels of AFP (3 ng/mL) and PIVKA-II (28 mAU/mL) were normal at 1 month after the surgery.", + "The latest serum levels of AFP (2 ng/mL) and PIVKA-II (25 mAU/mL) were normal at 6 months after the surgery." + ], + "summary": "A 56-year-old male patient was admitted to our hospital after a pancreatic cyst was identified by abdominal ultrasonography on a comprehensive medical examination. Endoscopic ultrasound revealed a cystic mass measuring 13 mm in size in the pancreatic head and a low-density mass measuring 16 mm in size in the pancreatic tail, which was partially enhanced on contrast-enhanced ultrasound. Contrast-enhanced computed tomography (CT) revealed a branch duct type intraductal papillary mucinous neoplasm in the pancreatic head and an early enhanced nodule measuring approximately 10 mm in size in the pancreatic tail. Endoscopic ultrasound-guided fine-needle aspiration of the hypervascular tumor was performed. The hypervascular tumor was suspected to be a solid pseudopapillary neoplasm. Laparoscopic spleen-preserving distal pancreatectomy was performed. Histology was identical to hepatocellular carcinoma of the liver. Immunohistochemically, the tumor cells were positive for hepatocyte paraffin 1, and a canalicular pattern was confirmed on the polyclonal carcinoembryonic antigen staining. The patient was diagnosed with a moderately differentiated pancreatic HC. The patient was followed up without adjuvant chemotherapy, and there was no evidence of recurrence at 6 months post-operatively.", + "summary_subclaims": [ + "A 56-year-old male patient was admitted to our hospital after a pancreatic cyst was identified by abdominal ultrasonography on a comprehensive medical examination.", + "Endoscopic ultrasound revealed a cystic mass measuring 13 mm in size in the pancreatic head.", + "Endoscopic ultrasound revealed a low-density mass measuring 16 mm in size in the pancreatic tail.", + "The low-density mass in the pancreatic tail was partially enhanced on contrast-enhanced ultrasound.", + "Contrast-enhanced computed tomography (CT) revealed a branch duct type intraductal papillary mucinous neoplasm in the pancreatic head.", + "Contrast-enhanced CT revealed an early enhanced nodule measuring approximately 10 mm in size in the pancreatic tail.", + "Endoscopic ultrasound-guided fine-needle aspiration of the hypervascular tumor was performed.", + "The hypervascular tumor was suspected to be a solid pseudopapillary neoplasm.", + "Laparoscopic spleen-preserving distal pancreatectomy was performed.", + "Histology was identical to hepatocellular carcinoma of the liver.", + "The tumor cells were positive for hepatocyte paraffin 1.", + "A canalicular pattern was confirmed on the polyclonal carcinoembryonic antigen staining.", + "The patient was diagnosed with a moderately differentiated pancreatic HC.", + "The patient was followed up without adjuvant chemotherapy.", + "There was no evidence of recurrence at 6 months post-operatively." + ] + }, + { + "id": "multiclinsum_test_2573_en.txt", + "fulltext": "An 87-year-old female patient with no history of diabetes or other conditions causing blood glucose abnormalities was brought to our emergency department due to an acutely altered mental state after a few-week course of headaches and decreased left vision. Notably, 2 months before admission, she was incidentally found to have a sellar mass . Initial workup revealed severe hypoglycemia (17 mg/dL), and the administration of glucose restored consciousness. Given the mild hyponatremia (131 mEq/L), relatively low levels of serum cortisol (13.3 μg/dL) and adrenocorticotropic hormone (39.7 pg/mL) despite the acute sick condition, as well as a known history of sellar mass, central adrenal insufficiency was suspected, and the patient was initiated on hydrocortisone. Further, the endocrinological evaluation revealed hypothyroidism (thyroid-stimulating hormone level, 0.36 μIU/mL; free T4 level, 0.58 ng/dL; and free T3 level, 1.5 pg/mL). Her visual field was significantly narrowed, with mildly decreased visual acuity (20/200) on the left side, although these deteriorations were deemed to be attributable to glaucoma rather than the mass, considering the mild compression of the optic apparatus as well as the atypical pattern of visual field disturbance. Given her senility, she and her family initially refused surgical intervention and imaging surveillance with cortisol replacement was initiated. Two months later, however, she complained of rapid deterioration of her left eye vision and loss of light perception. Repeat magnetic resonance imaging (MRI) revealed rapid mass growth [ and ]. Imaging studies demonstrated a T1-isointense, T2-hyperintense, heterogeneously enhanced, and irregularly shaped mass with restricted diffusion in the sellar and suprasellar regions [-]. Marked bony erosion of the posterior clinoid process and dorsum sellae was noted . On 18fluorodeoxyglucose positron-emission tomography, the mass exhibited a maximum standardized uptake value of 6.2 . After a thorough discussion with the patient and her family, we decided to proceed with the surgery.\nDuring surgery, a transnasal corridor was created using endoscopic visualization. The mass had destroyed the sellar floor. After opening the dura in a U-shaped fashion, the mass was piecemeal removed. It was soft, grayish, and gelatinous, compressing the normal pituitary gland to the left and invading the right cavernous sinus . Notably, the bony dorsum sellae was absent, and the sellar side of the dural membrane was almost completely torn by the mass . A bony prominence was observed on the left side of the sellar floor , which also lost its covering dura. The bony prominence was removed using a high-speed drill to access the tumor behind it. Finally, the suprasellar mass was removed while preserving the surrounding dural membrane and diaphragm. Although intraoperative cerebrospinal fluid leakage was not apparent, we decided to reinforce the diaphragm in a multilayered fashion since the diaphragm was already thin, and we were considering postoperative radiotherapy for this patient. The sellar defects were reconstructed using in- and on-lay fascial grafts with abdominal fat pieces. The dura covering the dorsum sellae was sutured with a 4–0 STRATAFIX Spiral (Ethicon, Johnson and Johnson, NJ, US) in a non-watertight fashion and was covered with pedicled sphenoid mucosa.\nPostoperative imaging revealed no residual masses [ and b]. Her visual acuity improved significantly (20/40). Histological examination revealed the presence of physaliphorous cells with a background of myxoid stroma and positive immunostaining for brachyury , leading to a diagnosis of conventional chordoma. Although the Ki-67 index was not extremely high (3%), the patient was treated with upfront adjuvant stereotactic radiosurgery (20 Gy in a single fraction), given the previous rapid progression and possible minor tumor remnants around the right carotid artery. She has been free from tumor progression for 12 months.", + "fulltext_subclaims": [ + "The patient was an 87-year-old female.", + "She had no history of diabetes.", + "She had no other conditions causing blood glucose abnormalities.", + "She was brought to the emergency department due to an acutely altered mental state.", + "She had a few-week course of headaches.", + "She had decreased left vision.", + "Two months before admission, she was incidentally found to have a sellar mass.", + "Initial workup revealed severe hypoglycemia (17 mg/dL).", + "The administration of glucose restored consciousness.", + "She had mild hyponatremia (131 mEq/L).", + "She had relatively low levels of serum cortisol (13.3 μg/dL).", + "She had relatively low levels of adrenocorticotropic hormone (39.7 pg/mL).", + "Central adrenal insufficiency was suspected.", + "The patient was initiated on hydrocortisone.", + "The endocrinological evaluation revealed hypothyroidism.", + "Her visual field was significantly narrowed.", + "Her visual acuity was 20/200 on the left side.", + "The deteriorations were deemed attributable to glaucoma.", + "She and her family initially refused surgical intervention.", + "Imaging surveillance with cortisol replacement was initiated.", + "Two months later, she complained of rapid deterioration of her left eye vision.", + "She had loss of light perception.", + "Repeat MRI revealed rapid mass growth.", + "The mass was T1-isointense.", + "The mass was T2-hyperintense.", + "The mass was heterogeneously enhanced.", + "The mass was irregularly shaped.", + "The mass showed restricted diffusion.", + "Marked bony erosion of the posterior clinoid process was noted.", + "Marked bony erosion of the dorsum sellae was noted.", + "The mass exhibited a maximum standardized uptake value of 6.2.", + "A transnasal corridor was created using endoscopic visualization.", + "The mass had destroyed the sellar floor.", + "The dura was opened in a U-shaped fashion.", + "The mass was piecemeal removed.", + "The mass was soft, grayish, and gelatinous.", + "The mass compressed the normal pituitary gland to the left.", + "The mass invaded the right cavernous sinus.", + "The bony dorsum sellae was absent.", + "The sellar side of the dural membrane was almost completely torn by the mass.", + "A bony prominence was observed on the left side of the sellar floor.", + "The bony prominence was removed using a high-speed drill.", + "The suprasellar mass was removed while preserving the surrounding dural membrane and diaphragm.", + "The sellar defects were reconstructed using in- and on-lay fascial grafts with abdominal fat pieces.", + "The dura covering the dorsum sellae was sutured with a 4–0 STRATAFIX Spiral.", + "Postoperative imaging revealed no residual masses.", + "Her visual acuity improved significantly (20/40).", + "Histological examination revealed the presence of physaliphorous cells with a background of myxoid stroma.", + "The tumor was positive for brachyury immunostaining.", + "The diagnosis was conventional chordoma.", + "The Ki-67 index was 3%.", + "The patient was treated with upfront adjuvant stereotactic radiosurgery (20 Gy in a single fraction).", + "The patient was free from tumor progression for 12 months." + ], + "summary": "An 87-year-old female presented with an acutely altered mental state after a few-week course of headaches and decreased left vision. Adrenal insufficiency was evident, and magnetic resonance imaging revealed an intrasellar lesion with heterogeneous contrast enhancement and marked T2 hyperintensity. Central adrenal insufficiency due to an intrasellar lesion was suspected. Cortisol replacement was initiated, and transsphenoidal surgery was performed. Anterosuperior displacement of the normal pituitary gland and the absence of the bony dorsum sellae were notable during the procedure. Histological examination led to a diagnosis of conventional chordoma, and upfront adjuvant stereotactic radiosurgery was executed. She has been free from tumor progression for 12 months.", + "summary_subclaims": [ + "An 87-year-old female presented with an acutely altered mental state.", + "She had a few-week course of headaches.", + "She had decreased left vision.", + "Adrenal insufficiency was evident.", + "Magnetic resonance imaging revealed an intrasellar lesion.", + "The lesion showed heterogeneous contrast enhancement.", + "The lesion showed marked T2 hyperintensity.", + "Central adrenal insufficiency due to an intrasellar lesion was suspected.", + "Cortisol replacement was initiated.", + "Transsphenoidal surgery was performed.", + "Anterosuperior displacement of the normal pituitary gland was noted.", + "The bony dorsum sellae was absent.", + "Histological examination led to a diagnosis of conventional chordoma.", + "Upfront adjuvant stereotactic radiosurgery was executed.", + "She has been free from tumor progression for 12 months." + ] + }, + { + "id": "multiclinsum_test_1956_en.txt", + "fulltext": "A 56-year-old Caucasian man with a history of severe aortic insufficiency presented to the emergency department with twelve hours of continuous, crushing substernal chest pain. An inferior myocardial infarction was diagnosed by the electrocardiogram and serologic markers. Aspirin, clopidogrel, a statin and a beta-blocker were administered. At cardiac catheterization, the left ventricular end diastolic pressure (LVEDP) was 20 mmHg, and there was a complete occlusion of the right coronary artery (RCA) as well as a 50-75% stenosis of the left anterior descending artery. Angioplasty of the RCA was performed, but immediate re-occlusion occurred. The subsequent course was complicated by hypotension and severe hypoxemia that persisted despite intubation and mechanical ventilation with 100% oxygen. In an effort to lessen the risk of oxygen toxicity, the lowest FiO2 that maintained the oxygen saturation at least 90% was used. An FiO2 of 0.60 was thus chosen. A PEEP of 10 mmHg was required to maintain oxygenation due to the marked pulmonary congestion caused by severe aortic insufficiency. Transesophageal echocardiography with intravenous microbubbles demonstrated a significant right-to-left shunt through a patent foramen ovale . The right ventricle was dilated, and the free wall was akinetic. The patient was taken to the operating room for coronary artery bypass grafting, aortic valve replacement and closure of the atrial defect. Immediately following closure of the PFO the patient’s oxygen saturation rapidly improved to 100%. There was a slight decrease in the patient’s cardiac output post-operatively (from 5.4 to 5.0 L/min) following surgery. He was successfully weaned from the ventilator on post-operative day four and the remainder of the hospital course was uneventful.", + "fulltext_subclaims": [ + "The patient is a 56-year-old Caucasian man.", + "The patient has a history of severe aortic insufficiency.", + "The patient presented with twelve hours of continuous, crushing substernal chest pain.", + "An inferior myocardial infarction was diagnosed by the electrocardiogram and serologic markers.", + "Aspirin, clopidogrel, a statin, and a beta-blocker were administered.", + "At cardiac catheterization, the left ventricular end diastolic pressure was 20 mmHg.", + "There was a complete occlusion of the right coronary artery.", + "There was a 50-75% stenosis of the left anterior descending artery.", + "Angioplasty of the right coronary artery was performed.", + "Immediate re-occlusion occurred after the angioplasty.", + "The patient developed hypotension.", + "The patient developed severe hypoxemia.", + "The hypoxemia persisted despite intubation and mechanical ventilation with 100% oxygen.", + "An FiO2 of 0.60 was chosen.", + "A PEEP of 10 mmHg was required to maintain oxygenation.", + "Transesophageal echocardiography with intravenous microbubbles demonstrated a significant right-to-left shunt through a patent foramen ovale.", + "The right ventricle was dilated.", + "The right ventricular free wall was akinetic.", + "The patient was taken to the operating room for coronary artery bypass grafting.", + "The patient was taken to the operating room for aortic valve replacement.", + "The patient was taken to the operating room for closure of the atrial defect.", + "Immediately following closure of the PFO, the patient’s oxygen saturation rapidly improved to 100%.", + "There was a slight decrease in the patient’s cardiac output post-operatively (from 5.4 to 5.0 L/min).", + "The patient was successfully weaned from the ventilator on post-operative day four.", + "The remainder of the hospital course was uneventful." + ], + "summary": "A 56-year-old Caucasian man with severe aortic insufficiency presented to the emergency department for evaluation of substernal chest pain. An inferior myocardial infarction was diagnosed by the electrocardiogram and serologic markers. Cardiac catheterization revealed complete occlusion of the right coronary artery as well as a 50-75% stenosis of the left anterior descending artery. Angioplasty of the right coronary artery was performed, but immediate re-occlusion occurred. Subsequently, hypotension and severe hypoxemia developed and persisted despite intubation and mechanical ventilation with 100% oxygen. A significant right-to-left shunt through a patent foramen ovale was diagnosed by contrast transesophageal echocardiogram. Surgical intervention was required and included coronary artery bypass grafting, aortic valve replacement as well as closure of his atrial septal defect.", + "summary_subclaims": [ + "The patient is a 56-year-old Caucasian man.", + "The patient has severe aortic insufficiency.", + "The patient presented with substernal chest pain.", + "An inferior myocardial infarction was diagnosed by electrocardiogram.", + "An inferior myocardial infarction was diagnosed by serologic markers.", + "Cardiac catheterization revealed complete occlusion of the right coronary artery.", + "Cardiac catheterization revealed 50-75% stenosis of the left anterior descending artery.", + "Angioplasty of the right coronary artery was performed.", + "Immediate re-occlusion occurred after angioplasty.", + "Hypotension and severe hypoxemia developed.", + "Hypotension and severe hypoxemia persisted despite intubation.", + "A contrast transesophageal echocardiogram was performed.", + "A significant right-to-left shunt through a patent foramen ovale was diagnosed.", + "Surgical intervention included coronary artery bypass grafting.", + "Surgical intervention included aortic valve replacement.", + "Surgical intervention included closure of the atrial septal defect." + ] + }, + { + "id": "multiclinsum_test_240_en.txt", + "fulltext": "A 66-year-old man was admitted to our clinic two years ago complaining abdominal discomfort associated with distension, pain, and symptoms related to small intestine bowel obstruction (vomiting and obstipation). On physical examination a palpable mass in the lower right abdomen was found. CT scan of the abdomen and pelvis demonstrated a large (9 × 6.5 × 7 cm) low-density, well circumscribed mass in the right lower abdomen, without evidence of tumor infiltration of adjacent structures and without free fluid. No metastatic nodules were found in the liver and the lung.\nLaparotomy revealed a pedunculated, ulcerative and friable large mass (a small bowel mass greater than 10 cm) with the features of gastroimtestinal stromal tumor: the surrounding organs (sigmoid colon, rectum, ureters and bladder) were pushed but not involved by the tumor. Furthermore, remarkable intraabdominal metastatic spread consisted of multiple small nodular lesions – less than 2 cm in size – all over the peritoneal surface and between bowel loops, was encountered. No evidence of liver metastasis or lymphadenopathy was found. The patient underwent an en-block resection of the tumor along with all visible disease in order to avoid capsule rupture and intraabdominal spillage, as is recommended . A small bowel resection with an end to end primary anastomosis was performed. Numerous peritoneal nodal metastases were excised and sent for histological analysis.\nHistopathological examination of the resected specimens revealed a stromal cell neoplasm with necrotic and hemorrhagic areas and a high index of mitotic count: 8–10 mitoses per high-power fields (HPF). Immunohistochemical analysis revealed C-kit (strongly positive), SMA(strongly positive), focal S-100(+) and CD34(-). The result of histological examination confirmed also the existence of intraabdominal metastatic spread.\nFollowing the histopathological confirmation, immediate treatment with imatinib was initiated. The imatinib was introduced in dose of 400 mg/day without interruption (in order to minimize the risk of relapse associated with the drug interruption) . Postoperatively, patient was followed up with CT scan. According to the clinical, surgical and histopathological features, our patient was included in the high risk group for recurrence. The patient underwent a CT scan of the abdomen and the pelvis in regular 4–6 months intervals [,].\nThe CT scan performed 2 years after surgical excision and treatment commencement, revealed metastatic liver disease. Dose escalation (400 mg of imatinib mesylate twice a day) was decided and initiated. Six months later, liver lesion was presented with a characteristic size increase . Furthermore, a small soft tissue mass (3,3 × 2,8 × 3 cm) in the right lower abdomen was revealed in the abdominal CT scan. The mass was localized at the anatomic area of the previous excision and was considered either as another metastatic lesion or as a possible local recurrence .\nLaparotomy confirmed the presence of liver metastasis, localized between the Segment V & Segment VI as well as intra-abdominal metastatic spread (multiple small nodular lesions – less than 1 cm in size – all over the peritoneal surface and between bowel loops). An intestinal mass was also found 60 cm proximal to the ileocecal valve. Surprisingly, during the thorough exploration of the peritoneal cavity, another mass with completely different macroscopic features was discovered. It was a palpable cecal mass, without extracanalicular growth or infiltration into other organs, associated with local lymph-node enlargement.\nIntra-abdominal ultrasound (IOUS) was performed in order to assist in liver resection planning (mainly to enable detection of additional tumors, missed in preoperative CT scan imaging and to evaluate the relationship between metastatic lesions and major vascular structures).\nRFA (Radio Frequency Ablation)-assisted liver resection of segments V, VI was performed and a segmental small-bowel resection along with excision of all gross visible peritoneal nodular lesions followed. Finally, a right hemicolectomy was decided in order to treat the \"unexpected\" cecal lesion.\nAt this point is important to underline that surgery remains the mainstay therapy for both (GIST and colorectal cancer) although the operative strategies and extent of resection are fairly different. Given the rarity of lymph-node involvement, routine lymphadenectomy is not currently recommended in GIST cases. [,] At the present case because of local lymph-node enlargement a curative resection was performed (included the resection of the lymphatic station), aiming to obtain microscopic disease-free radial and distal margins.\nGross examination of the 29 cm specimen disclosed a 7 × 4 cm tumor originating from the cecum and two polyps located about 7 cm from the cecum. The liver specimen (8.5 × 6.5 × 3.7 cm, segments V, VI) weighted 90 gr and contained the 5 cm metastatic lesion.\nHistopathological examination of the resected specimen revealed a recurrent intestinal GIST with malignant biological behavior and a moderately differentiated stage Dukes C (T3, N3, M0 according the TNM staging classification of colorectal cancer) cecal adenocarcinoma .\nThe specimen had the following characteristics: a) metastatic liver tumor with mesenhymal origin characterized by necrotic and bleeding areas and a mitotic count of <5/50 HPF. Immunohistochemical staining revealed a strongly (+) reaction for c-kit, slight (+) for S-100, and no specific staining for CD34 and desmin. The surgical margins of the resected hepatic specimen were free from invasion, b) moderately differentiated adenocarcinoma with a slight extracellular, mucus production. The tumor invaded the muscularis propria and the pericolonic adipose tissue. The neoplastic tissue extended and infiltrated the small bowel wall but the proximal and distant surgical margins were free.\nFour of the examined lymph nodes presented metastatic invasion from GIST and 12 from colorectal adenocarcinoma. The above mentioned morphologic and immunochistochemical findings are diagnostic for coexistence of GIST and colorectal adenocarcinoma", + "fulltext_subclaims": [ + "A 66-year-old man was admitted to our clinic two years ago.", + "He complained of abdominal discomfort associated with distension, pain, and symptoms related to small intestine bowel obstruction.", + "On physical examination, a palpable mass in the lower right abdomen was found.", + "CT scan of the abdomen and pelvis demonstrated a large (9 × 6.5 × 7 cm) low-density, well circumscribed mass in the right lower abdomen.", + "There was no evidence of tumor infiltration of adjacent structures.", + "No free fluid was found.", + "No metastatic nodules were found in the liver.", + "No metastatic nodules were found in the lung.", + "Laparotomy revealed a pedunculated, ulcerative and friable large mass (a small bowel mass greater than 10 cm).", + "The tumor had the features of gastrointestinal stromal tumor.", + "The surrounding organs (sigmoid colon, rectum, ureters and bladder) were pushed but not involved by the tumor.", + "Remarkable intraabdominal metastatic spread consisted of multiple small nodular lesions – less than 2 cm in size – all over the peritoneal surface and between bowel loops.", + "No evidence of liver metastasis or lymphadenopathy was found.", + "The patient underwent an en-block resection of the tumor along with all visible disease.", + "A small bowel resection with an end to end primary anastomosis was performed.", + "Numerous peritoneal nodal metastases were excised and sent for histological analysis.", + "Histopathological examination of the resected specimens revealed a stromal cell neoplasm with necrotic and hemorrhagic areas.", + "The mitotic count was 8–10 per high-power fields.", + "Immunohistochemical analysis revealed C-kit (strongly positive).", + "Immunohistochemical analysis revealed SMA (strongly positive).", + "Immunohistochemical analysis revealed focal S-100(+).", + "Immunohistochemical analysis revealed CD34(-).", + "The result of histological examination confirmed the existence of intraabdominal metastatic spread.", + "Following the histopathological confirmation, immediate treatment with imatinib was initiated.", + "Imatinib was introduced in a dose of 400 mg/day without interruption.", + "The patient was included in the high risk group for recurrence.", + "The patient underwent a CT scan of the abdomen and the pelvis in regular 4–6 months intervals.", + "The CT scan performed 2 years after surgical excision and treatment commencement revealed metastatic liver disease.", + "Dose escalation (400 mg of imatinib mesylate twice a day) was decided and initiated.", + "Six months later, liver lesion was presented with a characteristic size increase.", + "A small soft tissue mass (3.3 × 2.8 × 3 cm) in the right lower abdomen was revealed in the abdominal CT scan.", + "The mass was localized at the anatomic area of the previous excision.", + "The mass was considered either as another metastatic lesion or as a possible local recurrence.", + "Laparotomy confirmed the presence of liver metastasis, localized between Segment V & Segment VI.", + "Intra-abdominal metastatic spread (multiple small nodular lesions – less than 1 cm in size – all over the peritoneal surface and between bowel loops) was found.", + "An intestinal mass was also found 60 cm proximal to the ileocecal valve.", + "During the thorough exploration of the peritoneal cavity, another mass with completely different macroscopic features was discovered.", + "It was a palpable cecal mass, without extracanalicular growth or infiltration into other organs.", + "Intra-abdominal ultrasound (IOUS) was performed in order to assist in liver resection planning.", + "RFA-assisted liver resection of segments V, VI was performed.", + "A segmental small-bowel resection along with excision of all gross visible peritoneal nodular lesions followed.", + "A right hemicolectomy was decided in order to treat the 'unexpected' cecal lesion.", + "Gross examination of the 29 cm specimen disclosed a 7 × 4 cm tumor originating from the cecum.", + "The liver specimen (8.5 × 6.5 × 3.7 cm, segments V, VI) contained the 5 cm metastatic lesion.", + "Histopathological examination of the resected specimen revealed a recurrent intestinal GIST with malignant biological behavior.", + "Histopathological examination revealed a moderately differentiated stage Dukes C (T3, N3, M0) cecal adenocarcinoma.", + "The metastatic liver tumor had mesenchymal origin characterized by necrotic and bleeding areas.", + "The mitotic count of the metastatic liver tumor was <5/50 HPF.", + "Immunohistochemical staining of the metastatic liver tumor revealed a strongly (+) reaction for c-kit.", + "Immunohistochemical staining of the metastatic liver tumor revealed a slight (+) for S-100.", + "The surgical margins of the resected hepatic specimen were free from invasion.", + "The moderately differentiated adenocarcinoma had slight extracellular mucus production.", + "The tumor invaded the muscularis propria and the pericolonic adipose tissue.", + "The neoplastic tissue extended and infiltrated the small bowel wall.", + "The proximal and distant surgical margins were free.", + "Four of the examined lymph nodes presented metastatic invasion from GIST.", + "Twelve of the examined lymph nodes presented metastatic invasion from colorectal adenocarcinoma.", + "The above mentioned morphologic and immunohistochemical findings are diagnostic for coexistence of GIST and colorectal adenocarcinoma." + ], + "summary": "We present here, a case of a 66-year-old patient with intestinal GIST and a synchronous colorectal adenocarcinoma discovered incidentally during surgical treatment of the recurrent GIST. Immunohistochemical examination revealed the concurrence of histologically proved GIST (strongly positive staining for c-kit, vimentin, SMA, and focal positive in S-100, while CD-34 was negative) and Dukes Stage C, (T3, N3, M0 according the TNM staging classification of colorectal cancer).", + "summary_subclaims": [ + "The patient is a 66-year-old individual.", + "The patient has intestinal GIST.", + "The patient has a synchronous colorectal adenocarcinoma.", + "The colorectal adenocarcinoma was discovered incidentally during surgical treatment of the recurrent GIST.", + "Immunohistochemical examination was performed.", + "The GIST was histologically proved.", + "The GIST showed strongly positive staining for c-kit.", + "The GIST showed strongly positive staining for vimentin.", + "The GIST showed strongly positive staining for SMA.", + "The GIST showed focal positive staining in S-100.", + "The GIST showed negative staining for CD-34.", + "The colorectal adenocarcinoma was classified as Dukes Stage C.", + "The colorectal adenocarcinoma was classified as T3 according to the TNM staging classification.", + "The colorectal adenocarcinoma was classified as N3 according to the TNM staging classification.", + "The colorectal adenocarcinoma was classified as M0 according to the TNM staging classification." + ] + }, + { + "id": "multiclinsum_test_2161_en.txt", + "fulltext": "A 34-year-old G4P3 Caucasian woman was followed up antenatally because of a stillbirth in her previous pregnancy. She had had mild pre-eclampsia in her first pregnancy and a Caesarean section was carried out after unsuccessful induction of labor. Her second pregnancy and delivery were uneventful. The reason for the stillbirth in her third pregnancy was found to be an umbilical cord knot.\nIn the pregnancy reported here, our patient had polymorphic eruption of pregnancy (PEP) from 26 weeks' gestation and had three separate courses of oral steroids. Anti-D-antibodies were also found to be increased but in quantitative analyses their concentration, however, remained low. She was hospitalized once for a short period in late pregnancy because of an abnormal fetal heart rate recording.\nAt 36 weeks' gestation, a hypoechoic, 3.6 × 4.2 cm rounded mass was noted within the placenta on ultrasound examination . An ultrasound scan with umbilical artery Doppler measurement after 28 weeks' gestation was normal and it is likely that the leiomyoma had gone unnoticed probably because no special attention had been paid to the placenta on that occasion. Another explanation could be that the leiomyoma grew very rapidly in the third trimester of pregnancy and it was too small to draw appropriate attention in earlier scans.\nShe had induction of labor due to worsening of PEP at 38 weeks' gestation. A viable male infant weighing 3330 g was delivered with Apgar scores of 9 at one minute and 9 at five minutes. The placenta was removed without difficulty.\nA round-shaped nodule was noted on the maternal surface of the otherwise normal placenta. The size of the nodule was 4 × 4 × 3 cm. It had a pale cut surface without hemorrhage, necrosis or calcification .\nHistologically, the nodule was composed of bundles of smooth muscle cells. Nuclei were round or oval shaped and there were no atypical features or mitotic activity . No attached myometrium was identified.\nImmunohistochemistry was positive for the smooth muscle actin antigen (Neomarkers, 1:500). Factor VIII related antigen (Dako, 1:750) and CD34 (Becton-Dickinson 1:20) marked only the endothelial cells, whereas cytokeratin of low molecular weight (Becton-Dickinson, 1:20), placental alkaline phosphatase (Dako 1:20) and desmin (Biogenex, 1:50) were negative. The method used for labeling was streptavidin-biotin. The tumor cells were positive for progesterone receptors but negative for estrogen receptors which is typical for leiomyomas during pregnancy .\nChromosomes of the tumor were studied from paraffin sections by the fluorescence in situ hybridization technique with X- and Y-chromosome-specific probes and the tumor was found to carry XX chromosomes.", + "fulltext_subclaims": [ + "The patient is a 34-year-old G4P3 Caucasian woman.", + "She had a stillbirth in her previous pregnancy.", + "The reason for the stillbirth in her third pregnancy was found to be an umbilical cord knot.", + "In the pregnancy reported here, our patient had polymorphic eruption of pregnancy (PEP) from 26 weeks' gestation.", + "She had three separate courses of oral steroids.", + "Anti-D-antibodies were also found to be increased.", + "In quantitative analyses, their concentration remained low.", + "She was hospitalized once for a short period in late pregnancy because of an abnormal fetal heart rate recording.", + "At 36 weeks' gestation, a hypoechoic, 3.6 × 4.2 cm rounded mass was noted within the placenta on ultrasound examination.", + "An ultrasound scan with umbilical artery Doppler measurement after 28 weeks' gestation was normal.", + "It is likely that the leiomyoma had gone unnoticed probably because no special attention had been paid to the placenta on that occasion.", + "Another explanation could be that the leiomyoma grew very rapidly in the third trimester of pregnancy.", + "She had induction of labor due to worsening of PEP at 38 weeks' gestation.", + "A viable male infant weighing 3330 g was delivered.", + "The placenta was removed without difficulty.", + "A round-shaped nodule was noted on the maternal surface of the otherwise normal placenta.", + "The size of the nodule was 4 × 4 × 3 cm.", + "It had a pale cut surface without hemorrhage, necrosis or calcification.", + "Histologically, the nodule was composed of bundles of smooth muscle cells.", + "Nuclei were round or oval shaped.", + "There were no atypical features or mitotic activity.", + "No attached myometrium was identified.", + "Immunohistochemistry was positive for the smooth muscle actin antigen (Neomarkers, 1:500).", + "Factor VIII related antigen (Dako, 1:750) and CD34 (Becton-Dickinson 1:20) marked only the endothelial cells.", + "Cytokeratin of low molecular weight (Becton-Dickinson, 1:20), placental alkaline phosphatase (Dako 1:20) and desmin (Biogenex, 1:50) were negative.", + "The method used for labeling was streptavidin-biotin.", + "The tumor cells were positive for progesterone receptors.", + "The tumor cells were negative for estrogen receptors.", + "The tumor was found to carry XX chromosomes." + ], + "summary": "A 34-year-old G4P3 Caucasian woman was followed up antenatally because of a stillbirth in her previous pregnancy. At 36 weeks' gestation, a hypoechoic, 3.6 x 4.2 cm rounded mass was noted within the placenta on ultrasound examination. Histologically, the tumor was a benign leiomyoma and this finding was supported by immunohistochemistry. The newborn infant was male. Chromosomes of the neoplasm were studied by the fluorescence in situ hybridization technique and the tumor was found to carry XX chromosomes.", + "summary_subclaims": [ + "The patient is a 34-year-old G4P3 Caucasian woman.", + "The patient was followed up antenatally because of a stillbirth in her previous pregnancy.", + "At 36 weeks' gestation, a hypoechoic, 3.6 x 4.2 cm rounded mass was noted within the placenta on ultrasound examination.", + "Histologically, the tumor was a benign leiomyoma.", + "This finding was supported by immunohistochemistry.", + "The newborn infant was male.", + "Chromosomes of the neoplasm were studied by the fluorescence in situ hybridization technique.", + "The tumor was found to carry XX chromosomes." + ] + }, + { + "id": "multiclinsum_test_1801_en.txt", + "fulltext": "A 17-year-old Vietnamese female presented to the emergency department with chest pain, several weeks of fatigue, decreased appetite, a dry cough, and unintentional weight loss over 2 months. Her vital signs were normal and the physical exam was without virilization or cushingoid features. Physical exam was notable for clubbing and right flank tenderness. Initial laboratories obtained showed a normocytic anemia and normal electrolytes. CT-angiography of the chest revealed a 9.2 × 8 × 7.4 cm large heterogeneous hypervascular mass in the right lower lung, a similar-appearing 7.1 × 5.4 × 6.9 cm heterogeneous mass in the left adrenal gland, and a 3.4 cm hypodense mass in the right adrenal gland (shown in , ). CT abdomen and pelvis also showed a 1 cm lesion abutting the dorsal pancreas and a right adnexal enhancing mass.\nFurther laboratory testing showed normal tumor markers: CA 19-9, AFP, beta-Hcg, CA 125, and CEA. Dopamine, epinephrine and norepinephrine levels were normal. Urine metanephrine to creatinine ratio, free metanephrines, and normetanephrines were normal. HVA and VMA were done for neuroblastoma screening and were in normal ranges. Testing for Echinococcus, tuberculosis, and Coccidioides was negative. Endocrine workup was normal with 17-hydroxyprogesterone at 81 ng/dL, aldosterone 2.0 ng/dL, renin 1.5 ng/mL/h, DHEAS 37 μg/dL, testosterone 14 ng/dL, progesterone less than 10 ng/dL, ACTH 29 pg/mL, and AM cortisol 18.2 μg/dL (shown in ). She underwent interventional radiology-guided biopsy of the left adrenal mass and was discharged.\nShe was readmitted for chemotherapy after preliminary pathology from the adrenal mass returned ALK positive. Ancillary staining of the mass showed it was positive for ALK-1, WT1, and D240 , and it was sent to Mayo laboratory for consultation. MRI brain showed abnormal clival signal consistent with metastatic disease but no evidence of metastasis. MRI spine did show evidence of spinal metastasis. PET scan showed diffuse bony lesions. Due to evidence of metastasis and acute onset of hypoglossal nerve deficit, she received a 2-day course of palliative radiation therapy (8 Gy) to clival region and C4–C7. She was started on crizotinib, an ALK/ROS1 inhibitor, in December 2021. During her hospital stay, she endorsed persistent cough, headaches and also developed blurry vision after starting crizotinib, possibly a side effect of the medication. During this hospitalization, the final pathology from Mayo laboratory was received and was confirmed as a malignant ALK-positive neoplasm harboring DCTN1-ALK fusion transcript, likely representing ALK-positive histiocytosis. Immunohistochemistry performed showed CD163-positive cells, as well as scattered WT-1 positivity. Next-generation sequencing demonstrated the DCTN1-ALK fusion transcript . Follow-up CT abdomen and pelvis obtained 1 week after starting crizotinib showed a decrease in the size of lung and adrenal masses (shown in , ), with lung mass now 7.9 × 7.5 cm (previously 8.2 × 8), left adrenal mass now 7.6 × 5.6 (previously 8.2 × 6.2), and right adrenal mass 1.1 × 1.0 cm (previously 3 × 2 cm). She was discharged on crizotinib 400 mg BID.\nALK-positive histiocytosis was originally reported in infants but more recently has been reported in older children and young adults, particularly of Asian origin. Most of these cases have been reported to have a KIF5B-ALK fusion mutation; however, there are a few reports of DCTN1-ALK fusion that was seen in our patient. DCTN1-ALK fusion mutations have also been rarely reported in non-small cell lung cancer, inflammatory myofibroblastic tumor, spindle cell variant of epithelioid cell histiocytoma, and juvenile myelomonocytic leukemia. Tumors with ALK fusions have been shown to respond to ALK-inhibitor therapy.\nShe was seen a week later in oncology clinic, and the final pathology report showed the rare diagnosis of metastatic DCTN1-ALK fusion-positive histiocytosis. After 3 weeks on crizotinib, her hypoglossal nerve deficit resolved and headaches and cough had significantly improved. Follow-up PET scan 2 months later showed resolution of lesion in left occipital condyle and decreased avidity of the other bony lesions. The right lung mass and left adrenal mass had further decreased in size, and the right adrenal lesion was no longer seen. She continued on the same dose of crizotinib with good response. She had significant improvement in extracranial lesions on crizotinib, but May 2022 scans showed a small CNS lesion despite improved intracranial disease, suggesting sanctuary site disease on crizotinib. She was switched to lorlatinib, which has documented superior CNS penetration. Follow-up MRI brain 2 months later showed resolution of the left frontal lobe lesion. The most recent scan done in August 2022 demonstrated continued improvement while on lorlatinib, with right lower lobe mass and left adrenal mass continuing to decrease in size.", + "fulltext_subclaims": [ + "The patient is a 17-year-old Vietnamese female.", + "She presented with chest pain.", + "She had several weeks of fatigue.", + "She had decreased appetite.", + "She had a dry cough.", + "She had unintentional weight loss over 2 months.", + "Her vital signs were normal.", + "The physical exam was without virilization.", + "The physical exam was without cushingoid features.", + "Physical exam was notable for clubbing.", + "Physical exam was notable for right flank tenderness.", + "Initial laboratories showed a normocytic anemia.", + "Initial laboratories showed normal electrolytes.", + "CT-angiography of the chest revealed a 9.2 × 8 × 7.4 cm large heterogeneous hypervascular mass in the right lower lung.", + "CT-angiography of the chest revealed a 7.1 × 5.4 × 6.9 cm heterogeneous mass in the left adrenal gland.", + "CT-angiography of the chest revealed a 3.4 cm hypodense mass in the right adrenal gland.", + "CT abdomen and pelvis showed a 1 cm lesion abutting the dorsal pancreas.", + "CT abdomen and pelvis showed a right adnexal enhancing mass.", + "Further laboratory testing showed normal tumor markers: CA 19-9, AFP, beta-Hcg, CA 125, and CEA.", + "Dopamine, epinephrine, and norepinephrine levels were normal.", + "Urine metanephrine to creatinine ratio, free metanephrines, and normetanephrines were normal.", + "HVA and VMA were done for neuroblastoma screening.", + "HVA and VMA were in normal ranges.", + "Testing for Echinococcus, tuberculosis, and Coccidioides was negative.", + "Endocrine workup was normal.", + "17-hydroxyprogesterone was 81 ng/dL.", + "Aldosterone was 2.0 ng/dL.", + "Renin was 1.5 ng/mL/h.", + "DHEAS was 37 μg/dL.", + "Testosterone was 14 ng/dL.", + "Progesterone was less than 10 ng/dL.", + "ACTH was 29 pg/mL.", + "AM cortisol was 18.2 μg/dL.", + "She underwent interventional radiology-guided biopsy of the left adrenal mass.", + "She was discharged.", + "She was readmitted for chemotherapy.", + "Preliminary pathology from the adrenal mass returned ALK positive.", + "Ancillary staining showed the mass was positive for ALK-1.", + "Ancillary staining showed the mass was positive for WT1.", + "Ancillary staining showed the mass was positive for D240.", + "The mass was sent to Mayo laboratory for consultation.", + "MRI brain showed abnormal clival signal consistent with metastatic disease.", + "MRI brain showed no evidence of metastasis.", + "MRI spine showed evidence of spinal metastasis.", + "PET scan showed diffuse bony lesions.", + "Due to evidence of metastasis and acute onset of hypoglossal nerve deficit, she received a 2-day course of palliative radiation therapy (8 Gy) to clival region and C4–C7.", + "She was started on crizotinib, an ALK/ROS1 inhibitor, in December 2021.", + "During her hospital stay, she endorsed persistent cough.", + "During her hospital stay, she endorsed headaches.", + "During her hospital stay, she developed blurry vision after starting crizotinib, possibly a side effect of the medication.", + "The final pathology from Mayo laboratory was received.", + "The final pathology was confirmed as a malignant ALK-positive neoplasm harboring DCTN1-ALK fusion transcript.", + "The final pathology was likely representing ALK-positive histiocytosis.", + "Immunohistochemistry showed CD163-positive cells.", + "Immunohistochemistry showed scattered WT-1 positivity.", + "Next-generation sequencing demonstrated the DCTN1-ALK fusion transcript.", + "Follow-up CT abdomen and pelvis obtained 1 week after starting crizotinib showed a decrease in the size of lung and adrenal masses.", + "The lung mass was now 7.9 × 7.5 cm (previously 8.2 × 8).", + "The left adrenal mass was now 7.6 × 5.6 cm (previously 8.2 × 6.2).", + "The right adrenal mass was 1.1 × 1.0 cm (previously 3 × 2 cm).", + "She was discharged on crizotinib 400 mg BID.", + "ALK-positive histiocytosis was originally reported in infants.", + "ALK-positive histiocytosis has more recently been reported in older children and young adults, particularly of Asian origin.", + "Most cases of ALK-positive histiocytosis have been reported to have a KIF5B-ALK fusion mutation.", + "There are a few reports of DCTN1-ALK fusion that was seen in our patient.", + "DCTN1-ALK fusion mutations have also been rarely reported in non-small cell lung cancer.", + "DCTN1-ALK fusion mutations have also been rarely reported in inflammatory myofibroblastic tumor.", + "DCTN1-ALK fusion mutations have also been rarely reported in spindle cell variant of epithelioid cell histiocytoma.", + "DCTN1-ALK fusion mutations have also been rarely reported in juvenile myelomonocytic leukemia.", + "Tumors with ALK fusions have been shown to respond to ALK-inhibitor therapy.", + "The final pathology report showed the rare diagnosis of metastatic DCTN1-ALK fusion-positive histiocytosis.", + "After 3 weeks on crizotinib, her hypoglossal nerve deficit resolved.", + "After 3 weeks on crizotinib, her headaches had significantly improved.", + "After 3 weeks on crizotinib, her cough had significantly improved.", + "Follow-up PET scan 2 months later showed resolution of lesion in left occipital condyle.", + "Follow-up PET scan 2 months later showed decreased avidity of the other bony lesions.", + "The right lung mass and left adrenal mass had further decreased in size.", + "The right adrenal lesion was no longer seen.", + "She continued on the same dose of crizotinib with good response.", + "May 2022 scans showed a small CNS lesion despite improved intracranial disease, suggesting sanctuary site disease on crizotinib.", + "She was switched to lorlatinib, which has documented superior CNS penetration.", + "Follow-up MRI brain 2 months later showed resolution of the left frontal lobe lesion.", + "The most recent scan done in August 2022 demonstrated continued improvement while on lorlatinib.", + "The right lower lobe mass and left adrenal mass continued to decrease in size." + ], + "summary": "We present a recent case of bilateral adrenal masses in a pediatric patient at our institution, with an unusual diagnosis of histiocytosis.", + "summary_subclaims": [ + "We present a recent case of bilateral adrenal masses in a pediatric patient at our institution.", + "The diagnosis was histiocytosis." + ] + }, + { + "id": "multiclinsum_test_3272_en.txt", + "fulltext": "This was a 67-year-old female patient with a history of non-Hodgkin lymphoma in remission for 3 years who presented to her oncologist for worsening night sweats and 2 weeks of progressive shortness of breath with exertion. A positron emission tomography (PET) scan and a computed tomography scan (CT) scan were ordered 6 months prior, but the patient was lost to follow-up, and she did not complete the study at that time. The non-Hodgkin lymphoma the patient was previously diagnosed with was a stage IV double-hit DLBCL, the tumor was c-Myc and B-cell lymphoma 6-positive and was treated with 6 cycles of rituximab, etoposide phosphate, prednisone, vincristine sulfate, cyclophosphamide, doxorubicin hydrochloride (R-EPOCH), completed in October 2019. Since that time, she was in remission, based on the results of a follow-up confirmed on PET/CT scan in March 2021 that showed no evidence of malignancy.\n\nOn further questioning, the patient was found to have had a concomitant 4.5-kg weight gain over 2 weeks, along with bilateral leg swelling. The patient used to walk 90 min daily but over the prior 2 weeks was unable to complete even half of her usual exercise route. The patient had no cardiac history, such as heart failure, prior to this presentation. Nuclear medicine PET/CT, was obtained and completed 1 week later, revealing hypermetabolic activity localizing to a large, ill-defined right lower anterior mediastinal mass that appeared to extend into the right ventricular myocardium as well as the entire cardiac base, most consistent with malignancy. Additionally, it revealed cardiophrenic adenopathy and mildly active bilateral distal retroperitoneal lymph nodes that were highly worrisome for additional low volume disease. The patient was urged to present to the Emergency Department. Her blood pressure was 106/65 mmHg and heart rate was regular and bradycardic, at 56 bpm. Her vital signs were otherwise unremarkable. On physical examination, the patient’s cardiac and pulmonary examination was unremarkable, but the patient was found to have 2+ pitting edema in the bilateral lower extremities, without skin changes consistent with chronic edema or venous stasis. A complete blood count and comprehensive metabolic panel values were within normal limits. Troponins were trended, and all were negative. Brain natriuretic peptide was found to be elevated at 710 pq/mL (≤100 pq/mL). Lactate dehydrogenase was elevated at 458 u/L (140–271 u/L). Electrocardiogram (EKG) on admission was notable for a complete heart block, with a normal heart rate maintained by a junctional escape rhythm. Chest X-ray on admission was notable only for moderate right pleural effusion. Bedside transthoracic echocardiogram was attempted in the Emergency Department but was not able to visualize the right ventricle well.\n\nOncology and cardiac electrophysiology teams were consulted for management. The patient was determined to have International Prognostic Index of 4. Transcutaneous pacing was discussed but was not indicated, due to the stability of the patient’s junctional escape rhythm. Intravenous furosemide 40 mg twice daily was started. Coronary CT angiogram was obtained and redemonstrated the large mass in the anterior mediastinum, extending along the entire right ventricular free wall and invading the right ventricular myocardium, with impingement into the cavity as well as extension in to the right atrium, interatrial septum, and interventricular groove.\n\nBiopsies of the anterior mediastinal mass and the patient’s bone marrow were obtained. Biopsy results showed double-hit high-grade B-cell lymphoma. Epstein-Barr encoding region in situ hybridization was negative. The patient was started on rituximab, ifosfamide, carboplatin, and etoposide (RICE) chemotherapy after the pathology was confirmed. The patient was observed inpatient during the first cycle to monitor hemodynamic stability during lymphoma retreat and was discharged with improvement in her heart failure symptoms and close cardiology and oncology follow-up. Abnormal EKG findings resolved following her chemotherapy treatment, and atrioventricular block did not recur. Follow-up PET/CT obtained 7 months later revealed complete resolution of the mediastinal mass and adenopathy, with no remaining evidence of malignancy.", + "fulltext_subclaims": [ + "The patient was a 67-year-old female.", + "The patient had a history of non-Hodgkin lymphoma in remission for 3 years.", + "The patient presented with worsening night sweats.", + "The patient had 2 weeks of progressive shortness of breath with exertion.", + "A PET scan and a CT scan were ordered 6 months prior.", + "The patient was lost to follow-up and did not complete the study.", + "The non-Hodgkin lymphoma was stage IV double-hit DLBCL.", + "The tumor was c-Myc and B-cell lymphoma 6-positive.", + "The patient was treated with 6 cycles of R-EPOCH.", + "The R-EPOCH treatment was completed in October 2019.", + "The patient was in remission based on a PET/CT scan in March 2021.", + "The PET/CT scan showed no evidence of malignancy.", + "The patient had a 4.5-kg weight gain over 2 weeks.", + "The patient had bilateral leg swelling.", + "The patient was unable to complete half of her usual exercise route.", + "The patient had no prior cardiac history of heart failure.", + "A nuclear medicine PET/CT was obtained 1 week later.", + "The PET/CT revealed hypermetabolic activity localizing to a large, ill-defined right lower anterior mediastinal mass.", + "The mass appeared to extend into the right ventricular myocardium.", + "The mass extended into the entire cardiac base.", + "The findings were most consistent with malignancy.", + "The PET/CT revealed cardiophrenic adenopathy.", + "The PET/CT revealed mildly active bilateral distal retroperitoneal lymph nodes.", + "The lymph nodes were highly worrisome for additional low volume disease.", + "The patient was urged to present to the Emergency Department.", + "The patient's blood pressure was 106/65 mmHg.", + "The patient's heart rate was 56 bpm.", + "The patient's vital signs were otherwise unremarkable.", + "The patient had 2+ pitting edema in the bilateral lower extremities.", + "The patient did not have skin changes consistent with chronic edema.", + "The patient did not have skin changes consistent with venous stasis.", + "Troponins were trended and all were negative.", + "Brain natriuretic peptide was 710 pq/mL.", + "Lactate dehydrogenase was 458 u/L.", + "The EKG was notable for a complete heart block.", + "The heart block was maintained by a junctional escape rhythm.", + "The chest X-ray showed moderate right pleural effusion.", + "A bedside transthoracic echocardiogram was attempted.", + "The echocardiogram did not visualize the right ventricle well.", + "The International Prognostic Index was 4.", + "Transcutaneous pacing was discussed.", + "Transcutaneous pacing was not indicated due to the stability of the junctional escape rhythm.", + "Intravenous furosemide 40 mg twice daily was started.", + "A coronary CT angiogram was obtained.", + "The CT angiogram redemonstrated the large mass in the anterior mediastinum.", + "The mass extended along the entire right ventricular free wall.", + "The mass invaded the right ventricular myocardium.", + "The mass impinged into the cavity.", + "The mass extended into the right atrium.", + "The mass extended into the interatrial septum.", + "The mass extended into the interventricular groove.", + "Biopsies of the anterior mediastinal mass were obtained.", + "Biopsy results showed double-hit high-grade B-cell lymphoma.", + "Epstein-Barr encoding region in situ hybridization was negative.", + "The patient was started on RICE chemotherapy after pathology confirmation.", + "The patient was observed inpatient during the first cycle.", + "The patient was discharged with improvement in heart failure symptoms.", + "The patient had close cardiology and oncology follow-up.", + "Abnormal EKG findings resolved following chemotherapy.", + "Atrioventricular block did not recur.", + "A follow-up PET/CT obtained 7 months later revealed complete resolution of the mediastinal mass.", + "The follow-up PET/CT showed no remaining evidence of malignancy." + ], + "summary": "A 67-year-old female patient with a history of stage IV double-hit DLBCL in remission for 3 years presented with acute-onset heart failure. Nuclear medicine PET/CT revealed a massive poorly defined right lower anterior mediastinal mass extending into the entire cardiac base and right ventricular myocardium, with cardiophrenic and retroperitoneal adenopathy. Vital signs and laboratory test results were significant for a heart rate of 56 beats per min (bpm) and elevated brain natriuretic peptide. Electrocardiogram was significant for a complete heart block, maintained by a junctional escape rhythm. Biopsies of the mass revealed recurrence of DLBCL. The patient was treated with diuretics and later started on RICE chemotherapy.", + "summary_subclaims": [ + "The patient is a 67-year-old female.", + "The patient has a history of stage IV double-hit DLBCL in remission for 3 years.", + "The patient presented with acute-onset heart failure.", + "Nuclear medicine PET/CT revealed a massive poorly defined right lower anterior mediastinal mass.", + "The mediastinal mass extended into the entire cardiac base.", + "The mediastinal mass extended into the right ventricular myocardium.", + "The mediastinal mass was associated with cardiophrenic and retroperitoneal adenopathy.", + "The patient's heart rate was 56 beats per min.", + "The patient had elevated brain natriuretic peptide.", + "The electrocardiogram showed a complete heart block.", + "The electrocardiogram showed a junctional escape rhythm.", + "Biopsies of the mass revealed recurrence of DLBCL.", + "The patient was treated with diuretics.", + "The patient was later started on RICE chemotherapy." + ] + }, + { + "id": "multiclinsum_test_21_en.txt", + "fulltext": "A male, 71 years old, a retired teacher, did not have previous history of diseases, including hypertension, diabetes, coronary heart disease, chronic lung disease, kidney disease, and liver disease. He had a long history of smoking with 20 cigarettes per day. On August 24 2018, he got a fever with the heat peak at 40.0 °C without known causes and heat type, accompanied by chills, dizziness, abdominal pain, cough, and by a lot of yellow purulent sputum which was occasionally bloody. These symptoms appeared mainly in the morning and night, accompanied by right chest pain, aggravating when coughing, and difficulty in breathing. After an ineffective antibiotic treatment in the local hospital, he was then transferred to our hospital on September 2nd, 2018. The Computed Tomography (CT) results showed a large consolidation, grinding glass shadow, honeycomb changes, lung balloon formation in the right lung, and a newly-discovered solid patch and grinding glass shadow in the left, as well as bilateral pleural effusion . These indicate: 1. Double lung infection, interstitial pneumonia (mainly right lung), left emphysema, pneumatocele in the upper lobe of left lung; 2. Bilateral pleural effusion, mainly in the right lung; Laboratory analysis and display: Blood analysis: white blood cells 17.34 × 109 / L, neutrophil count 15.52 × 109 / L, neutrophil ratio 89.5%, lymphocyte count 0.83 × 109 / L, lymphocyte ratio 4.8%, platelets 102 × 109 / L. Abnormal test results in liver function: Alanine aminotransferase (ALT) 709 U/L, Aspartate aminotransferase (AST) 474 U/L, Cholinesterase (CHE) 2789 U/L, Total bilirubin (TB) 25.6umol/L, Direct Bilirubin (DB) 23.3umol/L, Lactate dehydrogenase (LDH) 758 U / L; Abnormal test results in renal function: Blood urine nitrogen (BUN) 10.10 mmol / L, Creatinine (Cr) 122umol / L; Hypersensitivity C reactive protein (Hs-CRP) 17.49 mg / dl. Abnormal test results in coagulation function: Prothrombin time (PT) 17.40, international normalized ratio (PT-INR) 1.52, D-dimer (DD) 2.37 mg/L; sputum anti-acid staining (−), T-SPOT (−), HIV antibody (HIV-Ab) (−); The patient was diagnosed to be severe pneumonia with multiple organ dysfunction. According to the initial experience, caspofungin (CAS) combined with imipenem, moxifloxacin and oseltamivir were given to resist infection; At 7 days later, the re-examination of chest CT plain scan showed that the pulmonary lesion did not change much in comparison with the previous symptom, showing that the treatment was ineffective, and the clinical symptoms did not improve.\nMycelia and spores were found frequently in the sputum samples of the lower respiratory tract by Gram staining and methylenol lactate microscopic examination. Colonies could be observed in fungal culture: the Sabourauds Agar (SDA) and Potato Dextrose Agar (PDA) showed rapid growth at 25 °C, 35 °C and 42 °C, especially on the SDA, with colonies of a gray front and a black reversed. It was dark grayish brown on the PDA. The characteristics of colonies on various substrate were shown in Fig. . Microscope: the hyphae was light brown, 1.5–3.5 μm wide, straight, separated, and unbranched. Erected or slightly curved conidiophores stretch out from the top or side of the hyphae. The tip was tapered; the base was slightly enlarged with a bottle-shaped stalk; the long and narrow neck was similar to the tubular of the Paecilomyces, appearing transparent, and smooth. An array of oval or round conidium was produced from the top of or directly from the end or side of conidiophores arranged in chain. Elliptical conidial was a unicellular microorgnism, which was straight or slightly curved, tapered to the top, transparent, smooth, 4–9 μm long, 2–6 wide micron with a smooth fine spiral strip pattern. The various staining and morphological features under microscopy were shown in Fig. .\nFor further identification, a single colony on the SDA purification plate was selected, and the general primers for ITS1 and ITS4 of fungi were used. By amplying the region of the internal transcriptional interval region, the sequencing results were analyzed by BLAST comparison. The homology to the Acrophialophora levis sequence in the gene bank was 99%, and the NCBI number referenced was KM995879. We have also submitted the sequence data to GenBank (Accession number is MN461541).\nAfter that, sensitivity to antifungal drugs was further tested by colorimetric microdilution method recommended by CLSI M61 version 2018. The tested antifungal drugs were amphotericin B (AMB), 5-flucytosine (5-FC), anidulafungin (AND), CAS, micafungin (MF), fluconazole (FLU), itraconazole (ITR), posaconazole (PSC), and voriconazole (VRC). Until now, the in vitro sensitivity information of Acrophialophora had not been reported. Among them, AMB (≤0.12 μg/ml) had the best anti-fungal activity against A. levis in vitro, following by the activity of VRC (0.12 μg/ml), ITR (0.12 μg/ml), and PSC (0.25 μg/ml) in vitro. The activity of 5-FC (≥64 μg/ml), AND (≥8 μg/ml), CAS (≥8 μg/ml), MF (≥8 μg/ml), and FLU (16 μg/ml) were poor. Drug sensitivity results confirmed that the original drug, CAS, was not effective. Then liposomal amphotericin B was used for suppressing infection. After that, the fever of patient declined with fluctuations from 36.5 to 37.8 °C. He had reduced sputum volume, cough, sputum blood in phlegm, but still had the white phlegm, with oxygen 5 L/min and blood oxygen saturation by more than 95%. The re-examination of chest CT plain scan at 17 days after the change of anti-infection program indicated that the upper left pneumonia sites were more reduced than before, and the pleural effusion was less severe than before. The next day, the patient was asked to go back to the local hospital for treatment. The treatment was discontinued because liposomal amphotericin B was not available in the local hospital, and this patient died of respiratory failure at 2 days later. The imaging data were shown in Fig. .", + "fulltext_subclaims": [ + "The patient is a 71-year-old male.", + "The patient did not have previous history of diseases, including hypertension, diabetes, coronary heart disease, chronic lung disease, kidney disease, and liver disease.", + "He had a long history of smoking with 20 cigarettes per day.", + "On August 24 2018, he got a fever with the heat peak at 40.0 °C without known causes.", + "The fever was accompanied by chills, dizziness, abdominal pain, cough, and a lot of yellow purulent sputum which was occasionally bloody.", + "These symptoms appeared mainly in the morning and night.", + "He had right chest pain, aggravating when coughing.", + "He had difficulty in breathing.", + "After an ineffective antibiotic treatment in the local hospital, he was transferred to our hospital on September 2nd, 2018.", + "Computed Tomography (CT) results showed a large consolidation, grinding glass shadow, honeycomb changes, lung balloon formation in the right lung.", + "CT results showed a newly-discovered solid patch and grinding glass shadow in the left lung.", + "CT results showed bilateral pleural effusion.", + "Blood analysis showed white blood cells 17.34 × 109 / L.", + "Blood analysis showed neutrophil count 15.52 × 109 / L.", + "Blood analysis showed neutrophil ratio 89.5%.", + "Blood analysis showed lymphocyte count 0.83 × 109 / L.", + "Blood analysis showed lymphocyte ratio 4.8%.", + "Blood analysis showed platelets 102 × 109 / L.", + "Alanine aminotransferase (ALT) was 709 U/L.", + "Aspartate aminotransferase (AST) was 474 U/L.", + "Cholinesterase (CHE) was 2789 U/L.", + "Total bilirubin (TB) was 25.6umol/L.", + "Direct Bilirubin (DB) was 23.3umol/L.", + "Lactate dehydrogenase (LDH) was 758 U / L.", + "Blood urine nitrogen (BUN) was 10.10 mmol / L.", + "Creatinine (Cr) was 122umol / L.", + "Hypersensitivity C reactive protein (Hs-CRP) was 17.49 mg / dl.", + "Prothrombin time (PT) was 17.40.", + "International normalized ratio (PT-INR) was 1.52.", + "D-dimer (DD) was 2.37 mg/L.", + "The patient was diagnosed to be severe pneumonia with multiple organ dysfunction.", + "Caspofungin (CAS) combined with imipenem, moxifloxacin and oseltamivir were given to resist infection.", + "At 7 days later, the re-examination of chest CT plain scan showed that the pulmonary lesion did not change much in comparison with the previous symptom.", + "The clinical symptoms did not improve.", + "Mycelia and spores were found frequently in the sputum samples of the lower respiratory tract by Gram staining and methylenol lactate microscopic examination.", + "Colonies could be observed in fungal culture.", + "The Sabourauds Agar (SDA) showed rapid growth at 25 °C, 35 °C and 42 °C.", + "The colonies on SDA were gray front and black reversed.", + "The colonies on PDA were dark grayish brown.", + "The hyphae was light brown, 1.5–3.5 μm wide, straight, separated, and unbranched.", + "Erected or slightly curved conidiophores stretch out from the top or side of the hyphae.", + "The tip of the conidiophores was tapered; the base was slightly enlarged with a bottle-shaped stalk.", + "An array of oval or round conidium was produced from the top of or directly from the end or side of conidiophores arranged in chain.", + "The elliptical conidial was a unicellular microorgnism, which was straight or slightly curved, tapered to the top, transparent, smooth, 4–9 μm long, 2–6 wide micron with a smooth fine spiral strip pattern.", + "The sequencing results were analyzed by BLAST comparison.", + "The homology to the Acrophialophora levis sequence in the gene bank was 99%.", + "The NCBI number referenced was KM995879.", + "The sequence data were submitted to GenBank with Accession number MN461541.", + "The tested antifungal drugs were amphotericin B (AMB), 5-flucytosine (5-FC), anidulafungin (AND), CAS, micafungin (MF), fluconazole (FLU), itraconazole (ITR), posaconazole (PSC), and voriconazole (VRC).", + "The in vitro sensitivity information of Acrophialophora had not been reported.", + "AMB (≤0.12 μg/ml) had the best anti-fungal activity against A. levis in vitro.", + "VRC (0.12 μg/ml) had good anti-fungal activity against A. levis in vitro.", + "ITR (0.12 μg/ml) had good anti-fungal activity against A. levis in vitro.", + "PSC (0.25 μg/ml) had good anti-fungal activity against A. levis in vitro.", + "5-FC (≥64 μg/ml) had poor anti-fungal activity against A. levis in vitro.", + "AND (≥8 μg/ml) had poor anti-fungal activity against A. levis in vitro.", + "CAS (≥8 μg/ml) had poor anti-fungal activity against A. levis in vitro.", + "MF (≥8 μg/ml) had poor anti-fungal activity against A. levis in vitro.", + "FLU (16 μg/ml) had poor anti-fungal activity against A. levis in vitro.", + "Drug sensitivity results confirmed that the original drug, CAS, was not effective.", + "Liposomal amphotericin B was used for suppressing infection.", + "After that, the fever of patient declined with fluctuations from 36.5 to 37.8 °C.", + "He had reduced sputum volume.", + "He had reduced cough.", + "He had sputum blood in phlegm.", + "He had white phlegm.", + "He had oxygen 5 L/min.", + "He had blood oxygen saturation by more than 95%.", + "The re-examination of chest CT plain scan at 17 days after the change of anti-infection program indicated that the upper left pneumonia sites were more reduced than before.", + "The pleural effusion was less severe than before.", + "The patient was asked to go back to the local hospital for treatment.", + "The treatment was discontinued because liposomal amphotericin B was not available in the local hospital.", + "The patient died of respiratory failure at 2 days later." + ], + "summary": "A 71-year-old male patient with severe pneumonia complicated with multiple organ dysfunction caused by A. levis infection. The fungal identification was based on micromorphology and sequence analysis of the internal transcriptional spacer (ITS) of ribosomal RNA genes recovered from lower respiratory tract secretions. The microbial characteristics, sensitivity to antifungal drugs of this isolated A. levis were studied. Anti-infective regimen, liposomal amphotericin B combined with tegacycline, was used to prevent infection. The next day, the fever decreased, body temperature fluctuated between 36.5 and 37.8 degree, cough and sputum decreased, and sputum volume decreased, with oxygen uptake for 5 L/min, blood oxygen saturation over 95%. After 17 days of treatment, CT reexamination showed that the lesions in the right lung and left upper lung were absorbed and pleural effusion was reduced. The next 8 days, the patient asked to return to the local hospital for treatment. The local hospital stopped using liposomal amphotericin B because of the absence of liposomal amphotericin B, and died of respiratory failure 2 days later.", + "summary_subclaims": [ + "The patient was a 71-year-old male.", + "The patient had severe pneumonia.", + "The pneumonia was complicated with multiple organ dysfunction.", + "The infection was caused by A. levis.", + "The fungal identification was based on micromorphology.", + "The fungal identification was based on sequence analysis of the internal transcriptional spacer (ITS) of ribosomal RNA genes.", + "The ITS was recovered from lower respiratory tract secretions.", + "The microbial characteristics of the isolated A. levis were studied.", + "The sensitivity to antifungal drugs of the isolated A. levis was studied.", + "An anti-infective regimen of liposomal amphotericin B combined with tegacycline was used.", + "The regimen was used to prevent infection.", + "The next day, the fever decreased.", + "Body temperature fluctuated between 36.5 and 37.8 degree.", + "Cough and sputum decreased.", + "Sputum volume decreased.", + "Oxygen uptake was 5 L/min.", + "Blood oxygen saturation was over 95%.", + "After 17 days of treatment, CT reexamination showed that the lesions in the right lung and left upper lung were absorbed.", + "Pleural effusion was reduced.", + "The next 8 days, the patient asked to return to the local hospital for treatment.", + "The local hospital stopped using liposomal amphotericin B because of the absence of liposomal amphotericin B.", + "The patient died of respiratory failure 2 days later." + ] + }, + { + "id": "multiclinsum_test_2058_en.txt", + "fulltext": "A 66-year-old man with multiple cardiovascular risk factors; such as diabetes, hypertension, smoking and STEMI 6 years ago, who did not receive a reperfusion therapy. He consulted the ER referring atypical chest pain that began 8 days prior to his visit. He showed normal vital signs with the following relevant findings in the cardiovascular physical examination: visible and palpable double systolic apical impulse with a wide apical impulse area (4,5 cm in diameter), located in the fifth intercostal space of the left mid-clavicular line. On auscultation, an audible fourth heart sound (S4) was present. The cardiac biomarkers were negative.\nNormal sinus rhythm, Q-wave in inferior leads and T-wave inversion in lateral leads. .\nMild cardiomegaly, of note, a homogeneous opacity was observed adjacent to the LV. .\nRevealed a saccular image in the LV posterolateral wall, which, due to its characteristics, suggested a thrombosed PSA in the LV free -wall. .\nShowed a spherical-shaped left ventricular cavity with segmental wall-motion abnormalities, a LV ejection fraction of 40% by 3D method, PSA involving the basal and mid segments of both, inferolateral and anterolateral wall; with a narrow neck (38 mm), a shunt of LV to PSA was observed in color Doppler. .\nA viability protocol rest imaging/4-h redistribution imaging/24-h redistribution imaging was performed and showed a myocardial infarction located in the inferolateral wall, which involved the inferoseptal region; non-transmural in the apical segment and transmural in basal and mid segment, without signs of viability in the delayed redistribution imaging. .\nMulti-vessel coronary artery disease, with involvement of the left main coronary artery and high SYNTAX score [40 pts.]. Left ventriculography was not performed due to elevated end diastolic pressure and because of the previously reported left ventricular mural thrombus.\nThe case was discussed by the heart team. Due to the high SINTAX score and the mechanical complication, a coronary artery bypass grafting (CABG) plus aneurysmectomy with geometric reconstruction was considered. On-pump CABG was performed with internal thoracic artery anastomosis to the left anterior descendent coronary artery. A giant posterolateral wall LV PSA of approximately 7 cm was observed; described with a “petrous” consistency and adhered to the posterior pericardium. Due to the previously mentioned findings, it was not possible to perform the aneurysmectomy, as the cardiovascular surgical team considered the benefit was not worth compared to the risk of performing the procedure, so the surgery was concluded. The patient was discharged five days after CABG and he is currently asymptomatic, in NYHA functional class II and is followed up as an outpatient in our hospital.", + "fulltext_subclaims": [ + "The patient is a 66-year-old man.", + "The patient has multiple cardiovascular risk factors.", + "The patient had a STEMI 6 years ago.", + "The patient did not receive reperfusion therapy.", + "The patient consulted the ER with atypical chest pain.", + "The chest pain began 8 days prior to the ER visit.", + "The patient had a visible and palpable double systolic apical impulse.", + "The apical impulse area was 4.5 cm in diameter.", + "An audible fourth heart sound (S4) was present on auscultation.", + "The cardiac biomarkers were negative.", + "The ECG showed normal sinus rhythm.", + "The ECG showed Q-waves in inferior leads.", + "The ECG showed T-wave inversions in lateral leads.", + "Mild cardiomegaly was observed.", + "A homogeneous opacity was observed adjacent to the LV.", + "A saccular image in the LV posterolateral wall was observed.", + "The saccular image suggested a thrombosed PSA in the LV free wall.", + "The LV cavity was spherical-shaped.", + "Segmental wall-motion abnormalities were present.", + "The LV ejection fraction was 40% by 3D method.", + "The PSA involved the basal and mid segments of both inferolateral and anterolateral walls.", + "The PSA had a narrow neck of 38 mm.", + "A shunt from LV to PSA was observed in color Doppler.", + "A myocardial infarction was located in the inferolateral wall.", + "The myocardial infarction involved the inferoseptal region.", + "The myocardial infarction was non-transmural in the apical segment.", + "The myocardial infarction was transmural in the basal and mid segments.", + "There were no signs of viability in the delayed redistribution imaging.", + "The patient had multi-vessel coronary artery disease.", + "The patient had involvement of the left main coronary artery.", + "The SYNTAX score was 40 points.", + "Left ventriculography was not performed.", + "The decision not to perform left ventriculography was due to elevated end diastolic pressure.", + "The decision not to perform left ventriculography was due to the previously reported left ventricular mural thrombus.", + "The case was discussed by the heart team.", + "A coronary artery bypass grafting (CABG) plus aneurysmectomy with geometric reconstruction was considered.", + "An on-pump CABG was performed.", + "An internal thoracic artery anastomosis was performed to the left anterior descending coronary artery.", + "A giant posterolateral wall LV PSA of approximately 7 cm was observed.", + "The PSA had a 'petrous' consistency.", + "The PSA was adhered to the posterior pericardium.", + "An aneurysmectomy was not performed.", + "The surgical team considered the benefit was not worth the risk of performing the aneurysmectomy.", + "The patient was discharged five days after CABG.", + "The patient is currently asymptomatic.", + "The patient is in NYHA functional class II.", + "The patient is followed up as an outpatient in the hospital." + ], + "summary": "We report a case of a 66-year-old man with multiple cardiovascular risk factors and previous ST elevation myocardial infarction, complaining of atypical chest pain. His electrocardiogram was in normal sinus rhythm, with the presence of Q wave in inferior leads and T-wave inversion in lateral leads. A transthoracic echocardiogram showed a left ventricular pseudoaneurysm. In the coronary angiography, multi-vessel disease was found. On-pump CABG was performed and a posterolateral left ventricular giant pseudoaneurysm were observed. Due its \"petrous\" consistency it was impossible to perform an aneurysmectomy.", + "summary_subclaims": [ + "The patient is a 66-year-old man.", + "The patient has multiple cardiovascular risk factors.", + "The patient had a previous ST elevation myocardial infarction.", + "The patient complained of atypical chest pain.", + "The electrocardiogram was in normal sinus rhythm.", + "A Q wave was present in inferior leads.", + "T-wave inversion was present in lateral leads.", + "A transthoracic echocardiogram showed a left ventricular pseudoaneurysm.", + "Coronary angiography showed multi-vessel disease.", + "On-pump CABG was performed.", + "A posterolateral left ventricular giant pseudoaneurysm was observed.", + "The pseudoaneurysm had a 'petrous' consistency.", + "It was impossible to perform an aneurysmectomy." + ] + }, + { + "id": "multiclinsum_test_538_en.txt", + "fulltext": "A 50-year-old Iranian housewife with a total replacement of the left knee joint presented to our department. On the primary examination, fever (38 °C), blood pressure (BP) of 125/75 mmHg, pulse rate (PR) of 75 beats per minute, and respiratory rate (RR) of 15 breaths per minute, along with chilling, nausea, swelling, and pain in the left knee that had started 3 days ago, were recorded. Except for decreased ability to move the joint, other predominant physical and neurological symptoms were not observed.\nIn the past medical history (PMH), the patient had a history of diabetes mellitus with insulin therapy and a left knee joint replacement 1.5 years ago. Except for these cases, she had no other significant past medical history or notable family or hereditary history of specific disease and medication use. She had given birth to three children and denied alcohol consumption and smoking. For controlling diabetes, she used neutral protamine Hagedorn (NPH) insulin [20 units every 12 hours, subcutaneous injection (SQ)] and regular insulin (12 units in the morning and 8 units at night, SQ).\nFor diagnosis, a peripheral blood sample and aspirated synovial fluid were taken and were subjected to biochemical, hematological, and microbiological testing.\nA peripheral blood sample of 10 ml was obtained and inoculated into a blood culture bottle aseptically; it was negative after a 72-hour period of incubation at 37 °C. A synovial aspiration sample of 2 ml was taken from the patient and was dropped into collection tubes containing liquid ethylenediaminetertraacetic acid (EDTA) aseptically. The specimen was cultured into selective media including blood agar (for isolating aerobic bacteria), chocolate agar (incubated in a candle jar for isolating aerobic capnophilic bacteria), thioglycollate broth (for recovering anaerobic bacteria), eosin methylene blue agar (EMB; for recovering gram-negative bacteria), and subro dextrose agar (for isolating fungi). Also, two sets of slides were prepared and stained with gram and acid-fast staining. Polymerase chain reaction (PCR) and acid-fast staining were employed for identification of acid-fast bacilli, which were negative. Susceptibility to sulfamethoxazole-trimethoprim (SXT), neomycin, and bacitracin discs was used for the differentiation of α-hemolytic Streptococcus species (spp.) from other Streptococcus spp.\nLab biomarkers of blood and synovial specimens at the time of admission are presented in Table . In synovial cell counting examination, many WBC in which neutrophils accounted for 80% of whole cells were reported.\nAt the time of admission, since the causative agent was unknown, on the first day, empirical therapy including vancomycin (1 g every 12 hours, intravenous injection for 2 days) and meropenem (1 g every 8 hours, intravenous injection for 2 days) were initiated to target suspicious invasive agents like Staphylococcus spp. and gram-negative bacilli. On the second day, edema, warmness, and redness declined but fever remained. The results of the blood and synovial culture were revealed on the third day. Only the α-hemolytic Streptococcus spp. was isolated from the synovial specimen, which was subjected to antibiogram testing. Based on the results of antimicrobial susceptibility testing on the third day, antibiotic medication was changed to cefepime (2 g every 8 hours, intravenous injection) for 14 days. Transthoracic echocardiogram (TTE) and transesophageal echocardiogram (TEE) tests were recommended by an infectious disease (ID) specialist and were performed by an echocardiography cardiologist, who indicated that there was no sign of endocarditis. In orthopedic consultation, according to radiographic results, the exchange of removable components of the implant was not recommended; the antibiotic therapy was continued. The patient was treated with intravenous antibiotics for 14 days and was discharged after partial recovery. At the time of discharge, the patient's symptoms were entirely resolved, there was no movement disorder, and there was only slight swelling in her left knee. Oral medication with cephalexin was prescribed for her for 2 weeks. One month after discharge, the patient did not have any specific complaints and joint restrictions, and the test results of erythrocyte sedimentation rate (ESR) of 25 and C-reactive protein (CRP) of 8 were in normal range.", + "fulltext_subclaims": [ + "The patient is a 50-year-old Iranian housewife.", + "The patient had a total replacement of the left knee joint.", + "On the primary examination, fever of 38 °C was recorded.", + "On the primary examination, blood pressure was 125/75 mmHg.", + "On the primary examination, pulse rate was 75 beats per minute.", + "On the primary examination, respiratory rate was 15 breaths per minute.", + "The patient reported chilling, nausea, swelling, and pain in the left knee that had started 3 days ago.", + "The patient had a history of diabetes mellitus with insulin therapy.", + "The patient had a left knee joint replacement 1.5 years ago.", + "The patient had no other significant past medical history.", + "The patient had no notable family or hereditary history of specific disease.", + "The patient used neutral protamine Hagedorn (NPH) insulin 20 units every 12 hours, subcutaneous injection.", + "The patient used regular insulin 12 units in the morning and 8 units at night, subcutaneous injection.", + "A peripheral blood sample and aspirated synovial fluid were taken for testing.", + "The blood culture was negative after 72 hours of incubation.", + "A synovial aspiration sample of 2 ml was taken.", + "The synovial specimen was cultured into selective media including blood agar, chocolate agar, thioglycollate broth, eosin methylene blue agar, and subro dextrose agar.", + "Polymerase chain reaction and acid-fast staining were employed for identification of acid-fast bacilli, which were negative.", + "In synovial cell counting, many WBC were reported, with neutrophils accounting for 80% of whole cells.", + "Empirical therapy including vancomycin 1 g every 12 hours intravenous injection for 2 days was initiated.", + "Empirical therapy including meropenem 1 g every 8 hours intravenous injection for 2 days was initiated.", + "On the second day, edema, warmness, and redness declined but fever remained.", + "On the third day, α-hemolytic Streptococcus spp. was isolated from the synovial specimen.", + "Antibiotic medication was changed to cefepime 2 g every 8 hours intravenous injection for 14 days.", + "Transthoracic and transesophageal echocardiograms were performed.", + "There was no sign of endocarditis.", + "The exchange of removable components of the implant was not recommended.", + "The patient was treated with intravenous antibiotics for 14 days.", + "At the time of discharge, the patient's symptoms were entirely resolved.", + "At the time of discharge, there was only slight swelling in the left knee.", + "Oral medication with cephalexin was prescribed for 2 weeks.", + "One month after discharge, the patient did not have any specific complaints.", + "One month after discharge, the patient did not have joint restrictions.", + "One month after discharge, the erythrocyte sedimentation rate was 25.", + "One month after discharge, the C-reactive protein was 8." + ], + "summary": "In this report, a 50-year-old Iranian woman was diagnosed with prosthetic knee joint infection based on clinical, radiological, and laboratory findings. She was diabetic and had undergone a left total knee arthroplasty, which, 18 months after the surgery, presented pain, erythema, and edema in that knee. The primary culture of knee aspirate was positive for α-hemolytic Streptococcus species, but following antibiotic medication, culture was negative. The primary antibiotic regime was vancomycin and meropenem, which was changed to cefepime for the management of the infection based on the results of antimicrobial susceptibility testing.", + "summary_subclaims": [ + "A 50-year-old Iranian woman was diagnosed with prosthetic knee joint infection.", + "The diagnosis was based on clinical, radiological, and laboratory findings.", + "She was diabetic.", + "She had undergone a left total knee arthroplasty.", + "Eighteen months after the surgery, she presented with pain, erythema, and edema in that knee.", + "The primary culture of knee aspirate was positive for α-hemolytic Streptococcus species.", + "Following antibiotic medication, culture was negative.", + "The primary antibiotic regime was vancomycin and meropenem.", + "The antibiotic regime was changed to cefepime.", + "The change was based on the results of antimicrobial susceptibility testing." + ] + }, + { + "id": "multiclinsum_test_1252_en.txt", + "fulltext": "A 64-year-old male patient was admitted to the hospital because of upper abdominal pain lasting for 1 year.\nThe patient had upper abdominal distension and discomfort for more than 1 year, accompanied by poor appetite. After eating, the patient felt upper abdominal fullness and painful discomfort, which could be relieved slightly by resting or taking acid-inhibiting drugs orally. The symptoms were slightly aggravated 3 mo ago, accompanied by weight loss.\nThe patient denied any history of hypertension, diabetes, and coronary heart disease; hepatitis, tuberculosis, typhoid fever, malaria, and other infectious diseases; and major trauma, surgery, and drug or food allergies. Vaccination history is unknown. He had a history of smoking and drinking for more than 40 years.\nNo significant family history.\nThe patient’s weight was 56 kg and his height was 170 cm, with a calculated body mass index of 19.3 kg/cm2. His Karnofsky Performance Scale score was 100. No enlarged superficial lymph nodes were palpable. His abdomen was flat, and there was no gastrointestinal or peristaltic waves. There was mild tenderness in the upper abdomen, but there was no rebound pain. The shifting dullness was negative, and the frequency of borborygmus sounds was 4 times/min.\nTumor marker levels [carcinoembryonic antigen, cancer antigen (CA)-199, and CA125] and routine laboratory blood test results were within normal ranges.\nComputer tomography examination showed thickening of the gastric angle. Gastroscopic examination was performed, and an ulcer at the gastric horn was found. Then pathological biopsy findings confirmed that the ulcer was a gastric adenocarcinoma (clinical stage: cT1bN0M0).", + "fulltext_subclaims": [ + "The patient is a 64-year-old male.", + "The patient had upper abdominal pain lasting for 1 year.", + "The patient had upper abdominal distension and discomfort for more than 1 year.", + "The patient had poor appetite.", + "After eating, the patient felt upper abdominal fullness and painful discomfort.", + "The symptoms could be relieved slightly by resting.", + "The symptoms could be relieved slightly by taking acid-inhibiting drugs orally.", + "The symptoms were slightly aggravated 3 mo ago.", + "The patient had weight loss.", + "The patient denied any history of hypertension.", + "The patient denied any history of diabetes.", + "The patient denied any history of coronary heart disease.", + "The patient denied any history of hepatitis.", + "The patient denied any history of tuberculosis.", + "The patient denied any history of typhoid fever.", + "The patient denied any history of malaria.", + "The patient denied any history of major trauma.", + "The patient denied any history of surgery.", + "The patient denied any history of drug or food allergies.", + "Vaccination history is unknown.", + "The patient had a history of smoking for more than 40 years.", + "The patient had a history of drinking for more than 40 years.", + "No significant family history.", + "The patient’s weight was 56 kg.", + "The patient’s height was 170 cm.", + "The patient’s body mass index was 19.3 kg/cm2.", + "The patient’s Karnofsky Performance Scale score was 100.", + "No enlarged superficial lymph nodes were palpable.", + "The abdomen was flat.", + "There were no gastrointestinal or peristaltic waves.", + "There was mild tenderness in the upper abdomen.", + "There was no rebound pain.", + "The shifting dullness was negative.", + "The frequency of borborygmus sounds was 4 times/min.", + "Tumor marker levels [carcinoembryonic antigen, cancer antigen (CA)-199, and CA125] were within normal ranges.", + "Routine laboratory blood test results were within normal ranges.", + "Computer tomography examination showed thickening of the gastric angle.", + "Gastroscopic examination was performed.", + "An ulcer at the gastric horn was found.", + "Pathological biopsy findings confirmed that the ulcer was a gastric adenocarcinoma.", + "The clinical stage was cT1bN0M0." + ], + "summary": "We performed NOSE gastrectomy in a male patient. Tumor resection, digestive tract reconstruction, and lymph node dissection were performed totally laparoscopically; the specimen was extracted from the natural orifice of the rectum-anus. This procedure reduced damage to the abdominal wall and decreased postoperative pain. We successfully performed radical gastrectomy without conversion and complications. Total operative time and blood loss were 176 min and 50 mL, respectively. The patient resumed normal activities of daily living on day 1 without pain, and passed flatus within 48 h. Postoperative hospital stay was 10 d. The number of resected lymph nodes was 0/43. During the follow-up, no stricture or anastomotic leakage was detected. Three months postoperatively, colonoscopy showed full recovery of the rectum without stricture or scar contracture. Computed tomography and laboratory test results showed no signs of tumor recurrence. There was no visible scar on the abdominal wall.", + "summary_subclaims": [ + "The patient was male.", + "NOSE gastrectomy was performed.", + "Tumor resection, digestive tract reconstruction, and lymph node dissection were performed totally laparoscopically.", + "The specimen was extracted from the natural orifice of the rectum-anus.", + "This procedure reduced damage to the abdominal wall.", + "This procedure decreased postoperative pain.", + "Radical gastrectomy was performed without conversion.", + "There were no complications.", + "Total operative time was 176 min.", + "Total blood loss was 50 mL.", + "The patient resumed normal activities of daily living on day 1 without pain.", + "The patient passed flatus within 48 h.", + "Postoperative hospital stay was 10 d.", + "The number of resected lymph nodes was 0/43.", + "No stricture or anastomotic leakage was detected during follow-up.", + "Three months postoperatively, colonoscopy showed full recovery of the rectum without stricture or scar contracture.", + "Computed tomography showed no signs of tumor recurrence.", + "Laboratory test results showed no signs of tumor recurrence.", + "There was no visible scar on the abdominal wall." + ] + }, + { + "id": "multiclinsum_test_93_en.txt", + "fulltext": "A 79-year-old female experiencing gait disturbance, cognitive impairment, and urinary incontinence for about a year presented at our hospital. CT head scanning showed enlarged ventricles (Evan’s index 0.31) and no other remarkable signs . A lumbar tap test showed slight improvement of gait and memory function. After a diagnosis of probable normal-pressure hydrocephalus, a ventriculoperitoneal shunt operation was completed without complications. However, symptoms did not greatly improve and the patient demanded a shunt removal. Before removal, gait instability and mild cognitive impairment were present without any paralysis, sensory dysfunction, or cranial nerve palsy.\nDuring the operation, propofol (60 mg), rocuronium (35 mg), and remifentanil (0.7 mg/h) were used as general anesthesia with 5% desflurane and remifentanil (0.6 mg/h) continuously infused for maintenance. We injected 10 ml of 0.5% lidocaine with epinephrine into the chest skin incision site and cut the skin to expose the shunt valve; cranial and rostral shunt tubes were removed without resistance. A clip anchor was left at the scalp so we injected 7 ml of 0.5% lidocaine with epinephrine into the previous skin incision site around the burr hole and removed it. The skin was closed after 10 ml of 0.75% bupivacaine was added into the subcutaneous layer to reduce postoperative pain. The total operation and anesthetic times were 22 and 58 min, respectively.\nAnesthesia was reversed by Sugammadex and train of four stimulation showed diminishment of muscle relaxants, but spontaneous respiration was still not observed. At this time, vital signs were blood pressure 90/50 mmHg, pulse 80 bpm, SpO2 98%, and body temperature 35.8°C with a Japan Coma Scale score of 300 even after naloxone administration. Pupils were dilated bilaterally and light, cough, and vestibuloocular reflexes were lost. Emergent head CT showed no abnormal lesions such as hemorrhages, infarctions, or cerebral herniations . Under suspicion of brainstem anesthesia, systemic management in an intensive care unit was conducted and, within an hour, pupil size, respiration, and consciousness gradually recovered to normal and extubation occurred 1.5 h after the operation. The postoperative course was uncomplicated and discharge occurred at postoperative day 9.", + "fulltext_subclaims": [ + "The patient was a 79-year-old female.", + "She had gait disturbance, cognitive impairment, and urinary incontinence for about a year.", + "CT head scanning showed enlarged ventricles with an Evan’s index of 0.31.", + "A lumbar tap test showed slight improvement of gait and memory function.", + "The diagnosis was probable normal-pressure hydrocephalus.", + "A ventriculoperitoneal shunt operation was completed without complications.", + "Symptoms did not greatly improve after the shunt operation.", + "The patient demanded a shunt removal.", + "Gait instability and mild cognitive impairment were present before shunt removal.", + "There was no paralysis, sensory dysfunction, or cranial nerve palsy before shunt removal.", + "Propofol (60 mg) was used as general anesthesia.", + "Rocuronium (35 mg) was used as general anesthesia.", + "Remifentanil (0.7 mg/h) was used as general anesthesia.", + "5% desflurane and remifentanil (0.6 mg/h) were continuously infused for maintenance.", + "10 ml of 0.5% lidocaine with epinephrine was injected into the chest skin incision site.", + "The cranial and rostral shunt tubes were removed without resistance.", + "A clip anchor was left at the scalp.", + "7 ml of 0.5% lidocaine with epinephrine was injected into the previous skin incision site around the burr hole.", + "10 ml of 0.75% bupivacaine was added into the subcutaneous layer.", + "The total operation time was 22 minutes.", + "The total anesthetic time was 58 minutes.", + "Anesthesia was reversed by Sugammadex.", + "Train of four stimulation showed diminishment of muscle relaxants.", + "Spontaneous respiration was still not observed after Sugammadex.", + "Blood pressure was 90/50 mmHg at the time.", + "SpO2 was 98% at the time.", + "Body temperature was 35.8°C at the time.", + "The Japan Coma Scale score was 300 at the time.", + "Pupils were dilated bilaterally.", + "Emergent head CT showed no abnormal lesions such as hemorrhages, infarctions, or cerebral herniations.", + "Under suspicion of brainstem anesthesia, systemic management in an intensive care unit was conducted.", + "Pupil size, respiration, and consciousness gradually recovered to normal.", + "Extubation occurred 1.5 h after the operation.", + "The postoperative course was uncomplicated.", + "Discharge occurred at postoperative day 9." + ], + "summary": "Here, we report a case of brainstem anesthesia during shunt revision operation in a 79-year-old woman. Local anesthesia administered at the end of surgery was thought to have infiltrated the subarachnoid space through a burr hole, causing prolonged unconsciousness and cranial nerves' impairment. Spontaneous resolution occurred during systemic support.", + "summary_subclaims": [ + "The patient was a 79-year-old woman.", + "The case involved brainstem anesthesia during a shunt revision operation.", + "Local anesthesia was administered at the end of surgery.", + "The local anesthesia was thought to have infiltrated the subarachnoid space through a burr hole.", + "Prolonged unconsciousness occurred.", + "Cranial nerves' impairment occurred.", + "Spontaneous resolution occurred during systemic support." + ] + }, + { + "id": "multiclinsum_test_2109_en.txt", + "fulltext": "A 19-year-old man with no medical history or relevant family history was referred to our hospital because of elevated liver enzyme levels and abdominal distention. An abdominal computed tomography (CT) scan showed that his three main hepatic veins were completely obstructed and that the suprahepatic IVC had stenosis involving a membranous-like structure . Moreover, the CT scan revealed severe ascites and esophagogastric varices. Magnetic resonance imaging (MRI) showed a lack of patency and scarring in the main hepatic veins . The patient’s laboratory findings before transplantation showed elevated total bilirubin and decreased platelet and prothrombin time (total bilirubin, platelet, and prothrombin time was 3.8 mg/dl, 150 × 103/ml, 56.2%, respectively). His Child–Pugh score was 11 (grade C), and his Model for End-stage Liver Disease score was 14. He was considered to have no blood disorders that could cause coagulation abnormalities, such as abnormal protein C and S activities. Accordingly, he was diagnosed with primary BCS and decompensated liver failure. Endovascular treatment for the main hepatic veins was considered; however, we recognized that it could be impossible to restore the patency of the hepatic vessels, and we did not perform the preoperative angiography. In addition, his esophagogastric varices were severe. For these reasons, we decided to perform LDLT 5 months after referral.\nDonor candidates for LDLT were limited in this case. The eventual donor was his 46-year-old mother, who had no notable medical history and whose blood type was O Rh (+), identical to that of the patient. Based on preoperative CT investigation, we calculated that her estimated whole liver volume was 1047 ml. Her estimated left-lobe graft volume, estimated graft-to-recipient weight ratio (GRWR), and estimated ratio of liver remnant were 303 ml, 0.49, and 71.0%, respectively, which indicated that the size of the left-lobe graft was insufficient for the patient. On the other hand, in the right-lobe graft without the middle hepatic vein, the estimated graft volume was 734.2 ml, and the estimated GRWR was 1.19, which were sufficient for the patient. However, the estimated liver remnant was only 285.7 ml (31%), which was not applicable for our donor selection criteria. Under these mismatches, neither left-lobe graft nor right-lobe graft could be selected. For these reasons, we considered her RPSG, which could provide sufficient liver volume for the patient (estimated graft volume was 609 ml and GRWR was 0.99), and a safe residual liver volume for the donor (estimated ratio of liver remnant was 38.1%). There were no identified abnormalities of the portal vein, hepatic artery, bile duct, or hepatic vein in preoperative CT and MRI.\nDonor hepatectomy was performed with a mid-line incision, and liver mobilization was performed using a laparoscopy-assisted technique. During mobilization, the root of the middle hepatic vein and the right hepatic vein (RHV) were identified. Then, anterior and posterior branches of the hepatic artery and portal vein were skeletonized. The transection line was marked on the liver surface according to the RHV and to the demarcation line when the posterior branch of the portal vein was temporarily clamped. Following a hanging maneuver, parenchymal transection was performed using a cavitron ultrasonic surgical aspiration system without occlusion of portal vein inflow. After transection of the liver parenchyma was completely finished, the biliary duct and portal vein of the right posterior branches were cut. Because the right posterior branch of the hepatic artery was thin and it was considered that anastomosis of this artery with recipient hepatic artery increased risks of artery-related complications, the donor’s right anterior branch of the hepatic artery was sacrificed after the artery blood flow in the anterior liver segment was detected by Doppler ultrasound with temporary clamping of the right hepatic artery, and then the right hepatic artery was cut at the root. Finally, the inferior right hepatic vein (IRHV) and RHV were cut, and the liver graft was harvested. The RPSG was flushed with 1000 ml of University of Wisconsin solution from the portal vein. The actual RPSG weight was 570 g.\nRecipient surgery was started simultaneously with donor surgery. Prior to the abdominal incision, 16 cm of the SFV was harvested from his left leg for reconstruction of the IVC and hepatic vein. During the operation, there were approximately 3500 ml of ascites, and dense adhesions were seen around the IVC. The native liver was dark and hardened because of the liver congestion. The common bile duct, right and left hepatic arteries, and portal veins were cut, and then all three major hepatic veins, which were thickened and scarred, were cut while preserving the recipient IVC. Explantation of native, diseased liver was completed. The diseased liver weight was 1765 g, and the roots of three major hepatic veins were completely occluded.\nAt bench surgery, a longitudinal incision was made from the caudal side of the SFV graft, followed by ligation of the cranial side of the SFV graft. The graft RHV and IRHV was anastomosed to the sidewall of the SFV graft for patch plasty of the IVC .\nFor graft implantation, the infrahepatic IVC was mobilized and exposed, and then cross-clamping was performed. Venoveno bypass was not used during graft implantation because the collaterals were well developed, and the hemodynamic parameters were stable after IVC clamping. The thickened anterior suprahepatic IVC was longitudinally cut and opened, and the stenotic lesion of the IVC was identified . There were only a few patent millimeters in the IVC due to the membranous web-like obstruction, and there was no IVC thrombosis. The stenotic and thickened wall of the IVC was resected, and then an anastomotic orifice was created . As the caliber of IVC orifice did not coincide with the RHV–IRHV–SFV graft, the SFV graft was cut between RHV and IRHV before anastomosis. The RPSG was placed into the recipient, and then patch cavoplasty procedures were performed. The RHV‒SFV graft patch was anastomosed to the IVC orifice using continuous 5-0 prolene sutures. After the graft portal vein was anastomosed to the patient’s main portal vein trunk and portal reperfusion started, Doppler ultrasonography showed satisfactory hepatic venous outflow, without any venous graft congestion. The IRHV with SFV patch was directly anastomosed to the IVC using side-clamping of the IVC after portal reperfusion started. Thereafter, the graft right hepatic artery was anastomosed to the patient’s right hepatic artery. Finally, bile duct reconstruction, involving a choledochojejunostomy, was performed. The surgical time, cold ischemia time, and warm ischemia time were 1028, 235, and 80 min, respectively. The blood loss during surgery was 8486 ml.\nThe donor had no complications and recovered rapidly, and was discharged at postoperative day (POD) 9. The recipient’s postoperative course was also uneventful. Daily Doppler ultrasound revealed patency of the RHV‒SFV graft without venous congestion of the liver, and postoperative CT imaging clearly showed the graft RHV and IRHV with no stenosis in the IVC . At 13 days after transplantation, the laboratory data showed a slight increase in liver transaminase, and angiography was performed to rule out the hepatic venous outflow block. The postoperative angiography showed no occlusion of the IVC and RHV, and the mean blood pressure of the peripheral RHV, the root of the RHV, IVC, and right atrium were 7 mmHg, 8 mmHg, 7 mmHg, and 4 mmHg, respectively. These findings revealed that the IVC and the graft RHV had sufficient patency, and there was no liver congestion. The increased liver transaminase then normalized spontaneously with no specific treatment. The patient was discharged at POD 28. He has continued to take edoxaban, a direct FXa inhibitor, as a prophylaxis for venous thrombosis. The patient’s condition was good at his last follow-up, 9 months after transplantation.", + "fulltext_subclaims": [ + "A 19-year-old man with no medical history or relevant family history was referred to our hospital because of elevated liver enzyme levels and abdominal distention.", + "An abdominal computed tomography (CT) scan showed that his three main hepatic veins were completely obstructed.", + "The CT scan revealed severe ascites.", + "The CT scan revealed esophagogastric varices.", + "Magnetic resonance imaging (MRI) showed a lack of patency and scarring in the main hepatic veins.", + "The patient’s total bilirubin was 3.8 mg/dl.", + "The patient’s platelet count was 150 × 103/ml.", + "The patient’s prothrombin time was 56.2%.", + "The patient’s Child–Pugh score was 11 (grade C).", + "The patient’s Model for End-stage Liver Disease score was 14.", + "He was considered to have no blood disorders that could cause coagulation abnormalities.", + "He was diagnosed with primary BCS.", + "He was diagnosed with decompensated liver failure.", + "Endovascular treatment for the main hepatic veins was considered.", + "We recognized that it could be impossible to restore the patency of the hepatic vessels.", + "We did not perform the preoperative angiography.", + "His esophagogastric varices were severe.", + "We decided to perform LDLT 5 months after referral.", + "The eventual donor was his 46-year-old mother.", + "Her blood type was O Rh (+), identical to that of the patient.", + "Her estimated whole liver volume was 1047 ml.", + "Her estimated left-lobe graft volume was 303 ml.", + "Her estimated graft-to-recipient weight ratio (GRWR) was 0.49.", + "Her estimated ratio of liver remnant was 71.0%.", + "The size of the left-lobe graft was insufficient for the patient.", + "The estimated graft volume of the right-lobe graft without the middle hepatic vein was 734.2 ml.", + "The estimated GRWR of the right-lobe graft was 1.19.", + "The estimated liver remnant of the right-lobe graft was 285.7 ml (31%).", + "The estimated liver remnant of the right-lobe graft was not applicable for our donor selection criteria.", + "We considered her RPSG, which could provide sufficient liver volume for the patient.", + "The estimated graft volume of the RPSG was 609 ml.", + "The estimated GRWR of the RPSG was 0.99.", + "The estimated ratio of liver remnant of the RPSG was 38.1%.", + "There were no identified abnormalities of the portal vein.", + "There were no identified abnormalities of the hepatic artery.", + "There were no identified abnormalities of the bile duct.", + "There were no identified abnormalities of the hepatic vein.", + "Donor hepatectomy was performed with a mid-line incision.", + "Liver mobilization was performed using a laparoscopy-assisted technique.", + "The root of the middle hepatic vein and the right hepatic vein (RHV) were identified.", + "The anterior and posterior branches of the hepatic artery and portal vein were skeletonized.", + "The transection line was marked on the liver surface according to the RHV and to the demarcation line when the posterior branch of the portal vein was temporarily clamped.", + "Parenchymal transection was performed using a cavitron ultrasonic surgical aspiration system without occlusion of portal vein inflow.", + "After transection of the liver parenchyma was completely finished, the biliary duct and portal vein of the right posterior branches were cut.", + "The right posterior branch of the hepatic artery was thin.", + "It was considered that anastomosis of this artery with recipient hepatic artery increased risks of artery-related complications.", + "The donor’s right anterior branch of the hepatic artery was sacrificed after the artery blood flow in the anterior liver segment was detected by Doppler ultrasound with temporary clamping of the right hepatic artery.", + "The right hepatic artery was cut at the root.", + "The inferior right hepatic vein (IRHV) and RHV were cut.", + "The liver graft was harvested.", + "The RPSG was flushed with 1000 ml of University of Wisconsin solution from the portal vein.", + "The actual RPSG weight was 570 g.", + "Recipient surgery was started simultaneously with donor surgery.", + "Prior to the abdominal incision, 16 cm of the SFV was harvested from his left leg for reconstruction of the IVC and hepatic vein.", + "During the operation, there were approximately 3500 ml of ascites.", + "Dense adhesions were seen around the IVC.", + "The native liver was dark and hardened because of the liver congestion.", + "The common bile duct, right and left hepatic arteries, and portal veins were cut.", + "All three major hepatic veins were cut while preserving the recipient IVC.", + "Explantation of native, diseased liver was completed.", + "The diseased liver weight was 1765 g.", + "The roots of three major hepatic veins were completely occluded.", + "At bench surgery, a longitudinal incision was made from the caudal side of the SFV graft.", + "The cranial side of the SFV graft was ligated.", + "The graft RHV and IRHV was anastomosed to the sidewall of the SFV graft for patch plasty of the IVC.", + "For graft implantation, the infrahepatic IVC was mobilized and exposed.", + "Cross-clamping was performed.", + "Venoveno bypass was not used during graft implantation.", + "The thickened anterior suprahepatic IVC was longitudinally cut and opened.", + "The stenotic lesion of the IVC was identified.", + "There were only a few patent millimeters in the IVC due to the membranous web-like obstruction.", + "There was no IVC thrombosis.", + "The stenotic and thickened wall of the IVC was resected.", + "An anastomotic orifice was created.", + "The SFV graft was cut between RHV and IRHV before anastomosis.", + "The RPSG was placed into the recipient.", + "Patch cavoplasty procedures were performed.", + "The RHV‒SFV graft patch was anastomosed to the IVC orifice using continuous 5-0 prolene sutures.", + "After the graft portal vein was anastomosed to the patient’s main portal vein trunk and portal reperfusion started, Doppler ultrasonography showed satisfactory hepatic venous outflow, without any venous graft congestion.", + "The IRHV with SFV patch was directly anastomosed to the IVC using side-clamping of the IVC after portal reperfusion started.", + "The graft right hepatic artery was anastomosed to the patient’s right hepatic artery.", + "Bile duct reconstruction, involving a choledochojejunostomy, was performed.", + "The surgical time was 1028 minutes.", + "The cold ischemia time was 235 minutes.", + "The warm ischemia time was 80 minutes.", + "The blood loss during surgery was 8486 ml.", + "The donor had no complications and recovered rapidly.", + "The donor was discharged at postoperative day (POD) 9.", + "The recipient’s postoperative course was also uneventful.", + "Daily Doppler ultrasound revealed patency of the RHV‒SFV graft without venous congestion of the liver.", + "Postoperative CT imaging clearly showed the graft RHV and IRHV with no stenosis in the IVC.", + "At 13 days after transplantation, the laboratory data showed a slight increase in liver transaminase.", + "Angiography was performed to rule out the hepatic venous outflow block.", + "The postoperative angiography showed no occlusion of the IVC and RHV.", + "The mean blood pressure of the peripheral RHV was 7 mmHg.", + "The mean blood pressure of the root of the RHV was 8 mmHg.", + "The mean blood pressure of the IVC was 7 mmHg.", + "The mean blood pressure of the right atrium was 4 mmHg.", + "These findings revealed that the IVC and the graft RHV had sufficient patency.", + "There was no liver congestion.", + "The increased liver transaminase then normalized spontaneously with no specific treatment.", + "The patient was discharged at POD 28.", + "He has continued to take edoxaban, a direct FXa inhibitor, as a prophylaxis for venous thrombosis.", + "The patient’s condition was good at his last follow-up, 9 months after transplantation." + ], + "summary": "A 19-year-old man, who was diagnosed with primary BCS, underwent LDLT. His main hepatic veins were totally obstructed, and membranous stenosis was seen in the IVC. The LDLT donor was his mother; however, liver volumetric analysis showed that only her RPSG was appropriate. In the recipient surgery, 16 cm of the left SFV was harvested and was cut longitudinally and opened. The right hepatic vein (RHV) of the RPSG was anastomosed to the sidewall of the SFV graft. After explantation of native diseased liver was completed, the stenotic and thickened wall of the IVC was widely resected, and a large anastomotic orifice was created. Patch cavoplasty was performed with the RHV‒SFV graft patch. After portal reperfusion started, hepatic venous outflow was satisfactory, and there was no venous graft congestion. Both his postoperative course and his long-term course after discharge were uneventful.", + "summary_subclaims": [ + "The patient was diagnosed with primary BCS.", + "The patient underwent LDLT.", + "The patient's main hepatic veins were totally obstructed.", + "Membranous stenosis was seen in the IVC.", + "The LDLT donor was the patient's mother.", + "Liver volumetric analysis showed that only the donor's RPSG was appropriate.", + "16 cm of the left SFV was harvested.", + "The SFV was cut longitudinally and opened.", + "The RHV of the RPSG was anastomosed to the sidewall of the SFV graft.", + "The stenotic and thickened wall of the IVC was widely resected.", + "A large anastomotic orifice was created.", + "Patch cavoplasty was performed with the RHV‒SFV graft patch.", + "After portal reperfusion started, hepatic venous outflow was satisfactory.", + "There was no venous graft congestion.", + "The patient's postoperative course was uneventful.", + "The patient's long-term course after discharge was uneventful." + ] + }, + { + "id": "multiclinsum_test_1200_en.txt", + "fulltext": "A 16-year-old male presented with a painless swelling on the posteromedial aspect of the lower one-third of the right tibia. The swelling had been present since he was 8 years old and had slowly progressed to the size of 8 × 5 cm. The overlying skin had numerous folds giving an elephantiasis-like appearance .\nX-ray of the affected limb showed a deforming mass arising from the posteromedial aspect of the ankle and foot ( and ). Magnetic resonance imaging revealed the deforming mass arising from the posteromedial aspect of the tibia After taking due consent, the patient was examined, revealing multiple, hyper-pigmented, flat, well-circumscribed macular lesions on the trunk and right arm which were subsequently identified as café au lait spots (-). Axillary freckling was also evident. The patient did not give any family history suggestive of a similar disorder.\nA final diagnosis of NF-1 was made, on the basis of the criteria given by the National Institute of Health (NIH), and surgical excision of the dysplastic lesion was done to correct the deformity.", + "fulltext_subclaims": [ + "The patient is a 16-year-old male.", + "He presented with a painless swelling on the posteromedial aspect of the lower one-third of the right tibia.", + "The swelling had been present since he was 8 years old.", + "The swelling had slowly progressed to the size of 8 × 5 cm.", + "The overlying skin had numerous folds giving an elephantiasis-like appearance.", + "X-ray of the affected limb showed a deforming mass arising from the posteromedial aspect of the ankle and foot.", + "Magnetic resonance imaging revealed the deforming mass arising from the posteromedial aspect of the tibia.", + "The patient was examined, revealing multiple, hyper-pigmented, flat, well-circumscribed macular lesions on the trunk and right arm.", + "The macular lesions were subsequently identified as café au lait spots.", + "Axillary freckling was also evident.", + "The patient did not give any family history suggestive of a similar disorder.", + "A final diagnosis of NF-1 was made.", + "The diagnosis was based on the criteria given by the National Institute of Health (NIH).", + "Surgical excision of the dysplastic lesion was done to correct the deformity." + ], + "summary": "A 16-year-old male presented with painless swelling on the posteromedial aspect of the lower right tibia, which was confirmed to be a dysplastic mass on biopsy. Physical examination also revealed cafe au lait macules and axillary freckling, leading to a diagnosis of NF-1.", + "summary_subclaims": [ + "The patient is a 16-year-old male.", + "The patient had painless swelling on the posteromedial aspect of the lower right tibia.", + "The swelling was confirmed to be a dysplastic mass on biopsy.", + "Physical examination revealed cafe au lait macules.", + "Physical examination also revealed axillary freckling.", + "The diagnosis was NF-1." + ] + }, + { + "id": "multiclinsum_test_3211_en.txt", + "fulltext": "A 39-year-old man, a drug addict in treatment with methadone, suffered an accident with a fracture dislocation of Monteggia, open grade II of Gustilo and multifragmentary of the right cubitus. There was no nerve deficit. A closed reduction of the radial head and provisional fixation with two percutaneous Kirschner needles, wound closure, immobilization with a brachial plaster splint and antibiotic prophylaxis with cephalosporin were performed urgently. Six days later, the definitive stabilization of the fracture was performed by a reconstruction plate of titanium in the cubitus and fixation of the coronoid process with a screw. The patient did not return to the evaluation after eight months postoperatively. Two years postoperatively, the patient returned to the consultation for having elbow pain and large defects of skin coverage with exposure of the osteosynthesis material. Some of the screws of the cubitus plate had been removed by the patient himself. He was advised to remove the plate, due to the risk of infection, but the patient refused and did not return for revision. Four years later, the patient was admitted to the emergency department for having suffered a new accident, he had a fracture intertrocantérea of the right hip. In addition, he presented a complete exposure of 20 cm long of the forearm plate, without signs of infection after six years of evolution since the surgery. In the same intervention, an internal fixation of the fracture of the hip and extraction of the cubitus plate were performed. Under the forearm, skin growth was observed below the plate. Radiologically, there was consolidation with malalignment of the proximal cubitus and proximal radiocubital synostosis. Clinically, the patient had a great limitation of pronosupination, 100o elbow flexion and a deficit of 50o extension. The patient evolved favorably, without presenting infection and with complete reepithelisation of the forearm.\n", + "fulltext_subclaims": [ + "The patient is a 39-year-old man.", + "The patient is a drug addict in treatment with methadone.", + "The patient suffered an accident with a fracture dislocation of Monteggia.", + "The fracture dislocation was open grade II of Gustilo.", + "The fracture dislocation was multifragmentary of the right cubitus.", + "There was no nerve deficit.", + "A closed reduction of the radial head was performed urgently.", + "Provisional fixation with two percutaneous Kirschner needles was performed.", + "Wound closure was performed.", + "Immobilization with a brachial plaster splint was performed.", + "Antibiotic prophylaxis with cephalosporin was performed.", + "Six days later, definitive stabilization of the fracture was performed.", + "Definitive stabilization was performed by a reconstruction plate of titanium in the cubitus.", + "Fixation of the coronoid process with a screw was performed.", + "The patient did not return to the evaluation after eight months postoperatively.", + "Two years postoperatively, the patient returned to the consultation.", + "The patient had elbow pain.", + "The patient had large defects of skin coverage.", + "There was exposure of the osteosynthesis material.", + "Some of the screws of the cubitus plate had been removed by the patient himself.", + "He was advised to remove the plate.", + "The patient refused to remove the plate.", + "The patient did not return for revision.", + "Four years later, the patient was admitted to the emergency department.", + "The patient had a fracture intertrocantérea of the right hip.", + "The patient presented a complete exposure of 20 cm long of the forearm plate.", + "There were no signs of infection after six years of evolution since the surgery.", + "In the same intervention, internal fixation of the fracture of the hip was performed.", + "Extraction of the cubitus plate was performed.", + "Skin growth was observed below the plate under the forearm.", + "Radiologically, there was consolidation with malalignment of the proximal cubitus.", + "Radiologically, there was proximal radiocubital synostosis.", + "Clinically, the patient had a great limitation of pronosupination.", + "The patient had 100o elbow flexion.", + "The patient had a deficit of 50o extension.", + "The patient evolved favorably.", + "The patient did not present infection.", + "The patient had complete reepithelisation of the forearm." + ], + "summary": "39-year-old male with a grade II, open, multifragmentary Monteggia fracture-dislocation. The patient had a history of drug addiction and was on methadone. He was treated with internal fixation of the ulna with a long reconstruction plate. After surgery, the patient stopped coming for evaluation. Six years after surgery, the patient had a complete exposure of the plate (20 cm in length), with no signs of infection and consolidation with malalignment of the fracture. After the plate was removed, spontaneous epithelization adhered to the ulnar bone bed. The skin coverage was complete after two months.\n", + "summary_subclaims": [ + "The patient is a 39-year-old male.", + "The patient had a grade II, open, multifragmentary Monteggia fracture-dislocation.", + "The patient had a history of drug addiction.", + "The patient was on methadone.", + "The patient was treated with internal fixation of the ulna with a long reconstruction plate.", + "After surgery, the patient stopped coming for evaluation.", + "Six years after surgery, the patient had a complete exposure of the plate.", + "The plate was 20 cm in length.", + "There were no signs of infection.", + "There was consolidation with malalignment of the fracture.", + "After the plate was removed, spontaneous epithelization adhered to the ulnar bone bed.", + "The skin coverage was complete after two months." + ] + }, + { + "id": "multiclinsum_test_528_en.txt", + "fulltext": "A four-month-old female child presented with five day's history of non-projectile vomiting, three episodes of food contents vomitus per day, aggravated by feeding. This condition was accompanied by on and off lower grade fever and one episode of passing black tarry stool. She was prescribed ampiclox syrup 5mls po 8hrly for five days and paracetamol syrup 3mls po 8hrly for five days, at a nearby hospital as an outpatient. The child's health was reported to be in good progress for about three days. Over the course of the illness, the mother noted a protruding, self-reducing mass per anal, non-painful, not bleeding, no vomiting, and no abdominal distention associated with passing a normal soft stool, rectal prolapse diagnosis was reached, and she was referred to our center for father management.\nOn physical examination; the child was alert and active, not pale, not dehydrated and afebrile.\nVital signs; blood pressure = 95/45, pulse pate = 110bmn, respiratory rate = 45 cpm Spo2 = 98 % on room air and body temperature = 36 °C.\nPer-Abdominal Examination; not distended, soft abdomen, no tenderness, palpable mobile, free mass on the left lower quadrant which was mobile and non-tender.\nDigital Rectal Examination; an obvious circumferential protruding mass per anal on straining, which reduces spontaneously; no other lesion is seen. .\nPlane abdominal x ray done shows nothing significant.\nAbd ultrasound findings were specific to features of intussusception, including the “target sign,” with a remarkable end and suggestive features of edematous bowel.\nElectrolyte results revealed mild hyponatremia of 133.01 mmol/l, with normal chlorine and potassium levels, CBC was essentially normal paramitas, with Hb 11.3 g/dl.\nThe diagnosis of intussusception was based on the history, clinical examination, laboratory, and radiological results. Plan for emergency laparotomy procedure reached, in which intraoperative finding was ilea caecum intussusception, which advanced to the anus with edematous bowel , milking was managed only up to the level of transverse colon, then it was impossible to progress up to the caecum due to oedema, hence right hemicolectomy was done and ilea transverse end-end anastomosis performed. The child was admitted to the pediatric ICU, whereby on the 2nd day, the child was doing well and transferred to a general ward, started to feed and pass stool normally. On the 4th day the patient was discharged home, and with a follow up on surgical outpatients' clinic for six weeks, with no complications were reported.", + "fulltext_subclaims": [ + "A four-month-old female child presented with five day's history of non-projectile vomiting.", + "The vomiting occurred three episodes per day.", + "The vomiting was aggravated by feeding.", + "The condition was accompanied by on and off lower grade fever.", + "There was one episode of passing black tarry stool.", + "The child was prescribed ampiclox syrup 5mls po 8hrly for five days.", + "The child was prescribed paracetamol syrup 3mls po 8hrly for five days.", + "The child's health was reported to be in good progress for about three days.", + "The mother noted a protruding, self-reducing mass per anal.", + "The mass was non-painful.", + "The mass was not bleeding.", + "There was no vomiting associated with the mass.", + "There was no abdominal distention associated with passing a normal soft stool.", + "A rectal prolapse diagnosis was reached.", + "The child was referred to our center for further management.", + "On physical examination, the child was alert and active.", + "The child was not pale.", + "The child was not dehydrated.", + "The child was afebrile.", + "Blood pressure was 95/45.", + "Pulse rate was 110bmn.", + "Respiratory rate was 45 cpm.", + "SpO2 was 98% on room air.", + "Body temperature was 36 °C.", + "Per-Abdominal Examination showed a soft abdomen.", + "A palpable mobile, free mass was noted on the left lower quadrant.", + "Digital Rectal Examination showed an obvious circumferential protruding mass per anal on straining.", + "The mass reduced spontaneously.", + "Plane abdominal x ray showed nothing significant.", + "Abd ultrasound findings were specific to features of intussusception.", + "The ultrasound showed the “target sign.”", + "The diagnosis of intussusception was based on the history, clinical examination, laboratory, and radiological results.", + "Intraoperative finding was ilea caecum intussusception.", + "The intussusception advanced to the anus with edematous bowel.", + "Milking was managed only up to the level of transverse colon.", + "It was impossible to progress up to the caecum due to oedema.", + "A right hemicolectomy was done.", + "An ilea transverse end-end anastomosis was performed.", + "The child was admitted to the pediatric ICU.", + "On the 2nd day, the child was doing well and transferred to a general ward.", + "The child started to feed and pass stool normally.", + "On the 4th day the patient was discharged home.", + "The patient was to follow up on surgical outpatients' clinic for six weeks.", + "No complications were reported." + ], + "summary": "A four-month-old infant presented with a one-day history of non-projectile vomiting, three episodes, food contents, worsened by feeding, accompanied by intermittent low-grade fever, and one instance of passing black tarry stool. After outpatient treatment, the infant showed improvement for three days, but later the mother noticed a protruding, self-reducing anal mass, hence the suspected rectal prolapse, which was then Referred for further management.", + "summary_subclaims": [ + "The infant is four months old.", + "The infant had a one-day history of non-projectile vomiting.", + "The infant had three episodes of vomiting.", + "The vomitus was food contents.", + "The vomiting was worsened by feeding.", + "The infant had intermittent low-grade fever.", + "The infant had one instance of passing black tarry stool.", + "Outpatient treatment was provided.", + "The infant showed improvement for three days.", + "The mother noticed a protruding, self-reducing anal mass.", + "The suspected diagnosis was rectal prolapse.", + "The infant was referred for further management." + ] + }, + { + "id": "multiclinsum_test_1609_en.txt", + "fulltext": "A 49-year-old man was admitted to our emergency department after severe trauma to the chest wall by a steering wheel in a traffic accident. When he was sent to our hospital, his vital signs were as follows: respiratory rate 39 breaths/minute; heart rate 142 beats/minute; blood pressure 127/76 mmHg; blood gas pH 7.235; pCO2 64.2 mmHg; and pO2 56.5 mmHg. Chest computed tomography (CT) revealed multiple sternal fractures, bilateral multiple rib fractures from the first to the seventh ribs , and bilateral hemopneumothorax. The anterior chest wall was depressed due to multiple fractures . Closed thoracic drainage was performed bilaterally in the intensive care unit (ICU). The paradoxical movement gradually worsened, and respiratory failure emerged (Video S).\nThe patient had been consistently administrated with ventilator-assisted ventilation for over 1 week, however, no improvement of paradoxical respiration was observed. More importantly, the patient suffered from a more severe lung infection and the blood oxygen saturation decreased obviously. Therefore, a multidisciplinary discussion including experts from departments of thoracic surgery, ICU, respiration, radiology, as well as anaesthesiology was organized. The physicians from the respiratory department and ICU insisted that the patient still required ventilator-assisted ventilation although it could not ameliorate severe abnormal breathing, extra antibiotic usage with effective lung care might be useful to suppress lung inflammation, the most important treatment was to perform chest wall fixation. With the three-dimensional bone reconstruction images of chest wall provided by the radiology department, the chief physician from the thoracic surgery department indicated that it was not suitable to perform conventional rib and sternum fixation in this case as the images clearly showed too many fracture sites in ribs (including costal cartilage), sternum, anterior as well as lateral chest wall , thus this method could not establish a stable chest wall, and time-consuming, traumatic, more bleeding and costly. We noticed the use of Nuss procedure in trauma had been previously reported [–]. It was a new effective treatment for severe flail chest patients who couldn’t survive without prolonged mechanical ventilation. The most important advantages for the Nuss procedure were minimally invasive and much less time-consuming. However, it was not suitable when there were combined fractures in both the anterior and lateral chest walls as the Nuss bar required a stable lateral chest wall to guarantee the physical support, which the patient lacked. Therefore, neither the Nuss procedure nor rib fixation could completely fix the chest wall and eliminate abnormal breathing. We then proposed a strategy to combine the Nuss procedure with rib fixation. First, the rib fixation rebuilt a stable lateral chest wall, then the Nuss procedure stabilized the front chest wall. This strategy was also supported by the physicians from the anaesthesiology department as he mentioned that the conventional rib and sternum fixation could severely influence the patient’s respiratory and circulatory system during the operation. Finally, combining the use of the Nuss procedure and rib fixation was determined after the multidisciplinary discussion.\nFirst, the right third and fourth and the left fifth fractured lateral ribs were stabilized using rib fixation plates (Seemine SMA Co., LTD, Gansu, China) to stabilize both lateral chest walls . Then the thoracoscopy-assisted Nuss procedure was performed. Two Nuss bars (GRINM Advanced Materials Co., LTD, Beijing, China) were inserted into the third and fifth intercostal spaces of both sides for elevating and stabilizing the depressed mid sternum and fractured ribs at the anterior chest wall respectively to avoid the fractured sites of the ribs . The Nuss procedure process was as follows: one 40 cm Nuss bar was bent into a symmetric arc shape. Two skin incisions (1.5 cm) were made on both lateral chest walls in the mid-axillary line at the third intercostal space. Submuscular tunnels were made the outside pleural entry and exit points. The right entry point was punctured with an introducer, and a 1 cm thoracoscope was placed into the pleural cavity. The mediastinum was dissected under direct vision. The exit point at the left side was punctured under direct visual guidance as well, and a 32F chest tube passed through the tunnel created by the introducer. The bar was positioned by following the guidance of the chest tube. The Nuss bar was rotated, and the depressed anterior upper chest wall was elevated. However, the shape of the anterior lower chest wall still had depression resulting from the large fractured areas, and paradoxical movement existed too. Therefore, another 40 cm Nuss bar was inserted at the fifth intercostal space with the same method. Two bars finally were fixed on the stable lateral ribs with steel wires. Finally, two Nuss bars and three rib fixation plates simultaneously exert sustained support, and the shape of the chest wall was nearly perfect .\nNo complications occurred during the procedure (surgical time 85 min, bleeding volume 50 mL). Paradoxical respiration was eliminated immediately postoperation. The patient was weaned from mechanical ventilation on the third postoperative day. He recovered smoothly and was discharged 2 weeks after the operation. No short-term complications were found except pain and activity limitations, and the pain was blocked using epidural anaesthesia after the operation. Three months later, the patient had no pain and activity limitations, but only complained numbness at the surgical incisions. One year later, the patient lived a normal life without any adverse events. We have scheduled a completed examination including chest CT scan and three-dimensional bone reconstruction for this patient, the Nuss bars and rib fixation plates will be removed immediately once the chest wall fully recovered.", + "fulltext_subclaims": [ + "A 49-year-old man was admitted to our emergency department after severe trauma to the chest wall by a steering wheel in a traffic accident.", + "When he was sent to our hospital, his vital signs were as follows: respiratory rate 39 breaths/minute; heart rate 142 beats/minute; blood pressure 127/76 mmHg; blood gas pH 7.235; pCO2 64.2 mmHg; and pO2 56.5 mmHg.", + "Chest computed tomography (CT) revealed multiple sternal fractures.", + "Chest computed tomography (CT) revealed bilateral multiple rib fractures from the first to the seventh ribs.", + "Chest computed tomography (CT) revealed bilateral hemopneumothorax.", + "The anterior chest wall was depressed due to multiple fractures.", + "Closed thoracic drainage was performed bilaterally in the intensive care unit (ICU).", + "The paradoxical movement gradually worsened, and respiratory failure emerged.", + "The patient had been consistently administrated with ventilator-assisted ventilation for over 1 week.", + "No improvement of paradoxical respiration was observed.", + "The patient suffered from a more severe lung infection.", + "The blood oxygen saturation decreased obviously.", + "A multidisciplinary discussion including experts from departments of thoracic surgery, ICU, respiration, radiology, as well as anaesthesiology was organized.", + "The physicians from the respiratory department and ICU insisted that the patient still required ventilator-assisted ventilation.", + "The physicians from the respiratory department and ICU suggested that extra antibiotic usage with effective lung care might be useful to suppress lung inflammation.", + "The most important treatment was to perform chest wall fixation.", + "The chief physician from the thoracic surgery department indicated that it was not suitable to perform conventional rib and sternum fixation in this case.", + "The images clearly showed too many fracture sites in ribs (including costal cartilage), sternum, anterior as well as lateral chest wall.", + "The use of Nuss procedure in trauma had been previously reported.", + "The Nuss procedure was a new effective treatment for severe flail chest patients who couldn’t survive without prolonged mechanical ventilation.", + "The most important advantages for the Nuss procedure were minimally invasive and much less time-consuming.", + "It was not suitable when there were combined fractures in both the anterior and lateral chest walls.", + "Neither the Nuss procedure nor rib fixation could completely fix the chest wall and eliminate abnormal breathing.", + "A strategy to combine the Nuss procedure with rib fixation was proposed.", + "The rib fixation rebuilt a stable lateral chest wall.", + "The Nuss procedure stabilized the front chest wall.", + "The strategy was also supported by the physicians from the anaesthesiology department.", + "Combining the use of the Nuss procedure and rib fixation was determined after the multidisciplinary discussion.", + "The right third and fourth and the left fifth fractured lateral ribs were stabilized using rib fixation plates.", + "Two Nuss bars were inserted into the third and fifth intercostal spaces of both sides.", + "The Nuss bars were inserted to avoid the fractured sites of the ribs.", + "The Nuss bar was rotated, and the depressed anterior upper chest wall was elevated.", + "The shape of the anterior lower chest wall still had depression resulting from the large fractured areas.", + "Paradoxical movement existed too.", + "Another 40 cm Nuss bar was inserted at the fifth intercostal space with the same method.", + "Two bars finally were fixed on the stable lateral ribs with steel wires.", + "Two Nuss bars and three rib fixation plates simultaneously exert sustained support.", + "The shape of the chest wall was nearly perfect.", + "No complications occurred during the procedure.", + "The surgical time was 85 minutes.", + "The bleeding volume was 50 mL.", + "Paradoxical respiration was eliminated immediately postoperation.", + "The patient was weaned from mechanical ventilation on the third postoperative day.", + "He recovered smoothly and was discharged 2 weeks after the operation.", + "No short-term complications were found except pain and activity limitations.", + "The pain was blocked using epidural anaesthesia after the operation.", + "Three months later, the patient had no pain and activity limitations.", + "Three months later, the patient only complained numbness at the surgical incisions.", + "One year later, the patient lived a normal life without any adverse events.", + "We have scheduled a completed examination including chest CT scan and three-dimensional bone reconstruction for this patient.", + "The Nuss bars and rib fixation plates will be removed immediately once the chest wall fully recovered." + ], + "summary": "A 49-year-old patient suffered severe flail chest by a steering wheel in a traffic accident with multiple fractures in both the anterior and lateral chest walls. In the beginning, the patient was administrated with mechanical ventilation because of acute respiratory distress syndrome (ARDS) for more than 1 week. Then the patient suffered from a severe lung infection and decreased blood oxygen saturation. After a multidiscipline discussion (MDT), three rib fixation plates were first used to rebuild the stability of lateral chest walls, then two Nuss bars were inserted to eliminate paradoxical movement in the anterior chest wall. Finally, the patient recovered smoothly after the combining procedure.", + "summary_subclaims": [ + "The patient suffered severe flail chest by a steering wheel in a traffic accident.", + "The patient had multiple fractures in both the anterior and lateral chest walls.", + "The patient was administrated with mechanical ventilation because of acute respiratory distress syndrome (ARDS) for more than 1 week.", + "The patient suffered from a severe lung infection.", + "The patient had decreased blood oxygen saturation.", + "Three rib fixation plates were first used to rebuild the stability of lateral chest walls.", + "Two Nuss bars were inserted to eliminate paradoxical movement in the anterior chest wall.", + "The patient recovered smoothly after the combining procedure." + ] + }, + { + "id": "multiclinsum_test_831_en.txt", + "fulltext": "In April 2007, a 56-year-old Caucasian woman with a painful, right-sided neck mass presented to a private practitioner. Ultrasound (US) suggested a clinical diagnosis of subacute thyroiditis, which was not supported by subsequent laboratory tests (C-reactive protein 1.9 mg/L; leukocytes 9700/μL; thyroid hormones within normal range; antithyroid auto-antibodies negative). Two days later, the patient had an exacerbation of the latero-cervical pain which prompted a repeat US of the neck, which revealed an iso-echoic lesion (51.3 mm in size), apparently included within an enlarged right thyroid lobe (83.5 mm). The lesion was interpreted as an intrathyroid hematoma and the opinion of a neck surgeon (MRP) was requested. The patient's medical history was collected at this time and included a severely diminished bone mass treated with bisphosphonate, though no information on bone metabolism was provided. History ruled out any regional traumatic event. The patient seemed quite anxious and dysphonetic but not dyspnoeic. Physical examination revealed a tender right-sided cervical mass, extending from the right mandibular arch to the thoracic inlet.\nThe patient was referred to the Special Surgical Pathology Department at Padova University Hospital, where computed tomography (CT) showed a laterocervical hemorrhagic lesion, extending from the lateral neck to the right prevertebral/paratracheal spaces ; a distinct midline shift and compression of both the hypopharynx and the trachea were also documented. During the CT procedure, the patient suffered from severe respiratory distress with dyspnea and she was immediately referred for surgical treatment, where an ovoid, hemorrhagic mass (4.0 × 2.4 × 1.3 cm, weight 8.1 g) was revealed posterior to the right thyroid lobe. Laboratory tests (conducted during the surgical procedure) demonstrated severe hypercalcemia (3.18 mmol/L; normal range: 2.10 to 2.55 mmol/L) with a decrease in hemoglobin level (12.0 g/dL). Surgery consisted of hematoma evacuation, parathyroidectomy and \"en bloc\" right thyroid lobectomy . There was no evidence of regional lymph node involvement. The surgery was curative and both serum calcium and parathyroid hormone (PTH) levels quickly dropped to within the normal range (at discharge: calcium 2.29 mg/dL; PTH 52 pg/mL).\nGross section of the surgical specimen revealed a three-layered lesion consisting of peripheral areas of (partially fluid) hemorrhagic material, invading a more internal, compact (partially organized) zone around the core of the specimen, which consisted of necrotic parathyroid remnants . Multiple gross samples were obtained for histological assessment, which showed an extensively hemorrhagic chief cell parathyroid adenoma surrounded by a loosely organized hemorrhagic and fibrous reaction, which became frankly hemorrhagic in the tissue samples obtained from the periphery of the resected mass.\nA 9-month follow-up including clinical evaluation, serology and US, revealed no clinical abnormalities.", + "fulltext_subclaims": [ + "In April 2007, a 56-year-old Caucasian woman with a painful, right-sided neck mass presented to a private practitioner.", + "Ultrasound suggested a clinical diagnosis of subacute thyroiditis.", + "Subsequent laboratory tests showed C-reactive protein 1.9 mg/L.", + "Subsequent laboratory tests showed leukocytes 9700/μL.", + "Subsequent laboratory tests showed thyroid hormones within normal range.", + "Subsequent laboratory tests showed antithyroid auto-antibodies negative.", + "Two days later, the patient had an exacerbation of the latero-cervical pain.", + "A repeat US of the neck revealed an iso-echoic lesion (51.3 mm in size).", + "The lesion was interpreted as an intrathyroid hematoma.", + "The opinion of a neck surgeon (MRP) was requested.", + "The patient's medical history included a severely diminished bone mass treated with bisphosphonate.", + "History ruled out any regional traumatic event.", + "Physical examination revealed a tender right-sided cervical mass.", + "Computed tomography showed a laterocervical hemorrhagic lesion.", + "The CT showed a distinct midline shift and compression of both the hypopharynx and the trachea.", + "During the CT procedure, the patient suffered from severe respiratory distress with dyspnea.", + "An ovoid, hemorrhagic mass (4.0 × 2.4 × 1.3 cm, weight 8.1 g) was revealed posterior to the right thyroid lobe.", + "Laboratory tests demonstrated severe hypercalcemia (3.18 mmol/L).", + "Laboratory tests showed a decrease in hemoglobin level (12.0 g/dL).", + "Surgery consisted of hematoma evacuation, parathyroidectomy, and 'en bloc' right thyroid lobectomy.", + "There was no evidence of regional lymph node involvement.", + "The surgery was curative.", + "Serum calcium levels quickly dropped to within the normal range.", + "Serum parathyroid hormone (PTH) levels quickly dropped to within the normal range.", + "Gross section of the surgical specimen revealed a three-layered lesion.", + "The core of the specimen consisted of necrotic parathyroid remnants.", + "Histological assessment showed an extensively hemorrhagic chief cell parathyroid adenoma.", + "A 9-month follow-up including clinical evaluation, serology, and US, revealed no clinical abnormalities." + ], + "summary": "This report describes an atypical two-step spontaneous rupture of an asymptomatic parathyroid adenoma in a 56-year-old Caucasian woman who presented with a painful mass in the right side of her neck.", + "summary_subclaims": [ + "The report describes an atypical two-step spontaneous rupture of an asymptomatic parathyroid adenoma.", + "The patient was a 56-year-old Caucasian woman.", + "The patient presented with a painful mass in the right side of her neck." + ] + }, + { + "id": "multiclinsum_test_1785_en.txt", + "fulltext": "A 16-year-old male with acute lymphoblastic leukemia (ALL) was admitted to our hospital because an echocardiographic examination revealed a ring-like structure in the right atrium that had been present for 6 months and there was no change of the ring-like structure after 6-month aspirin anti-coagulation therapy. Two years previously, the child had been diagnosed with ALL and a PICC had been placed for intravenous access during treatment in the general medical ward for chemotherapy and parenteral nutrition in a children’s hospital. The PICC remained intact and was successfully retrieved after 18 months of chemotherapy. A regular transthoracic echocardiography (TTE) examination revealed a large, mobile, ring-like mass originating from the free wall of the right atrium that measured 15 × 20 mm . The child was asymptomatic and the physical examination was also negative. When he presented to our hospital for a definite diagnosis, cardiac CT and radiography was performed to confirm the diagnosis.\nCardiac computed tomography revealed a calcified mass with a diameter of about 15 mm in the right atrium close to the inferior vena cava . Radiography confirmed the diagnosis and showed the absence of a PICC distal catheter in the right atrium and also that the mass was mobile . Given the large size of the mass, interventional radiology was used as part of a multidisciplinary approach to determine the optimal removal strategy. It was finally decided to remove the mass surgically.\nThe patient was operated on using cardiopulmonary bypass, with aortic and bicaval cannulation performed in the standard manner. The right atrium was opened and a large, solid, ring-like mass was found to be eroding into the orifice of the inferior vena cava (IVC) . After the mass was removed, it was cut open, showing a 2 mm pinhole in the middle, indicating that it had formed by initial calcification around the tip of the PICC which progressed after the retrieval of the PICC.", + "fulltext_subclaims": [ + "A 16-year-old male with acute lymphoblastic leukemia was admitted to our hospital.", + "An echocardiographic examination revealed a ring-like structure in the right atrium.", + "The ring-like structure had been present for 6 months.", + "There was no change of the ring-like structure after 6-month aspirin anti-coagulation therapy.", + "Two years previously, the child had been diagnosed with ALL.", + "A PICC had been placed for intravenous access during treatment in the general medical ward.", + "The PICC remained intact and was successfully retrieved after 18 months of chemotherapy.", + "A regular transthoracic echocardiography examination revealed a large, mobile, ring-like mass originating from the free wall of the right atrium.", + "The mass measured 15 × 20 mm.", + "The child was asymptomatic.", + "The physical examination was also negative.", + "Cardiac CT revealed a calcified mass with a diameter of about 15 mm in the right atrium close to the inferior vena cava.", + "Radiography confirmed the diagnosis and showed the absence of a PICC distal catheter in the right atrium.", + "Radiography showed that the mass was mobile.", + "It was finally decided to remove the mass surgically.", + "The patient was operated on using cardiopulmonary bypass.", + "The right atrium was opened and a large, solid, ring-like mass was found to be eroding into the orifice of the inferior vena cava.", + "After the mass was removed, it was cut open, showing a 2 mm pinhole in the middle.", + "The pinhole indicated that it had formed by initial calcification around the tip of the PICC." + ], + "summary": "A 16-year-old male with acute lymphoblastic leukemia (ALL) was admitted to our hospital after an echocardiographic examination revealed a ring-like structure in the right atrium that was still present after 6 months' anticoagulation treatment with aspirin. The boy had had a PICC inserted 2 years previously for chemotherapy; the PICC was intact and successfully removed 18 months after insertion when chemotherapy is finished. Subsequent computer tomography and radiography differentiated right atrial ring-shaped mass with a diameter of approximately 15 mm. Cardiac surgery was performed to remove the mass which was found to be a calcified thrombus.", + "summary_subclaims": [ + "The patient is a 16-year-old male.", + "The patient has acute lymphoblastic leukemia.", + "An echocardiographic examination revealed a ring-like structure in the right atrium.", + "The ring-like structure was still present after 6 months' anticoagulation treatment with aspirin.", + "The patient had had a PICC inserted 2 years previously for chemotherapy.", + "The PICC was intact and successfully removed 18 months after insertion.", + "Subsequent computer tomography and radiography differentiated a right atrial ring-shaped mass.", + "The right atrial ring-shaped mass had a diameter of approximately 15 mm.", + "Cardiac surgery was performed to remove the mass.", + "The mass was found to be a calcified thrombus." + ] + }, + { + "id": "multiclinsum_test_749_en.txt", + "fulltext": "This patient was a 71-year-old man with a history of grade 2 hypertension for 30 years, and he presented with dizziness for a week. As sudden urinary incontinence, weakness in right lower limb, and trouble speaking, he underwent an emergency non-enhanced head computed tomography (CT) examination. The CT examination showed a slightly low-density area in the left frontal lobe and the left temporal lobe, which raised a suspicion for acute infarctions. The following contrast-enhanced head CT and magnetic resonance imaging (MRI) examinations showed no infarction, but a 1.7 × 1.4 × 1.3 cm sellar occupied lesion with heterogeneous enhancement . The patient had normal levels of pituitary hormones. Physical examinations showed the mouth drawn to the left side, the right nasolabial fold blunting, and the deviation of the protruded tongue toward the right side, which indicated a right facial paralysis. The symptoms were effectively relieved after the patient underwent the drug treatment including aspirin and atorvastatin for secondary prevention of stroke and ginkgo biloba extract for symptomatic treatment. The patient subsequently underwent transsphenoidal resection of pituitary mass on October 22, 2019.\nThe greyish-white colour resected specimen was about 1.5 cm in diameter. Histologically, this tumour contained hypocellular and hypercellular areas that showed apparent geographical separation . The hypocellular area showed elongated spindle cells arranged in a fascicular pattern around small vessels and scattered Herring bodies. The spindle cell had blunted-ended to irregular nuclei with abundant, palely eosinophilic, fibrillary cytoplasm . The hypercellular area was characterised by pseudorosettes in which the tumour cells showed crowding, overlapping the nucleus with speckled nuclear chromatin . Mitoses were not seen in the tumour. Immunohistochemistrically, the tumour cells showed diffuse nuclear expression of TTF1 . S100 and neuron-specific enolase (NSE) expressed in the tumour cells and Herring bodies. Neurofilament (NF) was completely negative in the hypercellular area but had a little positive in the hypocellular area . Silver impregnation was only noted in a perivascular distribution . Ki-67 showed extremely low proliferative index in the tumour. The other markers were negative, including glial fibrillary acidic protein, Olig2, SOX10, CD68, adrenocorticotropic hormone, thyroid stimulating hormone, growth hormone, prolactin, luteinizing hormone, follicle-stimulating hormone, SF1, PIT1, TPIT, cytokeratin, epithelial membrane antigen, CD68, and Galectin-3, neither was periodic acid–Schiff. The final diagnosis was pituicytoma with a biphasic pattern and admixed with scattered Herring bodies. The patient made a good postoperative recovery and had no recurrence at 4 months of MRI follow-up.", + "fulltext_subclaims": [ + "The patient was a 71-year-old man.", + "He had a history of grade 2 hypertension for 30 years.", + "He presented with dizziness for a week.", + "He had sudden urinary incontinence.", + "He had weakness in the right lower limb.", + "He had trouble speaking.", + "He underwent an emergency non-enhanced head CT examination.", + "The CT showed a slightly low-density area in the left frontal lobe.", + "The CT showed a slightly low-density area in the left temporal lobe.", + "The CT raised a suspicion for acute infarctions.", + "Contrast-enhanced head CT and MRI showed no infarction.", + "There was a 1.7 × 1.4 × 1.3 cm sellar occupied lesion with heterogeneous enhancement.", + "The patient had normal levels of pituitary hormones.", + "Physical examination showed the mouth drawn to the left side.", + "Physical examination showed the right nasolabial fold blunting.", + "Physical examination showed the deviation of the protruded tongue toward the right side.", + "The symptoms were effectively relieved after drug treatment.", + "The drug treatment included aspirin.", + "The drug treatment included atorvastatin.", + "The drug treatment included ginkgo biloba extract.", + "The patient underwent transsphenoidal resection of the pituitary mass on October 22, 2019.", + "The resected specimen was about 1.5 cm in diameter.", + "The tumour contained hypocellular and hypercellular areas with apparent geographical separation.", + "The hypocellular area showed elongated spindle cells arranged in a fascicular pattern around small vessels.", + "The hypocellular area had scattered Herring bodies.", + "The spindle cells had blunted-ended to irregular nuclei with abundant, palely eosinophilic, fibrillary cytoplasm.", + "The hypercellular area was characterised by pseudorosettes.", + "The tumour cells showed crowding and overlapping nuclei in the hypercellular area.", + "The nuclei showed speckled nuclear chromatin in the hypercellular area.", + "Mitoses were not seen in the tumour.", + "The tumour cells showed diffuse nuclear expression of TTF1.", + "S100 and NSE expressed in the tumour cells and Herring bodies.", + "NF was completely negative in the hypercellular area.", + "NF had a little positive in the hypocellular area.", + "Silver impregnation was only noted in a perivascular distribution.", + "Ki-67 showed an extremely low proliferative index in the tumour.", + "The other markers were negative, including glial fibrillary acidic protein.", + "The other markers were negative, including Olig2.", + "The other markers were negative, including SOX10.", + "The other markers were negative, including CD68.", + "The other markers were negative, including adrenocorticotropic hormone.", + "The other markers were negative, including thyroid stimulating hormone.", + "The other markers were negative, including growth hormone.", + "The other markers were negative, including prolactin.", + "The other markers were negative, including luteinizing hormone.", + "The other markers were negative, including follicle-stimulating hormone.", + "The other markers were negative, including SF1.", + "The other markers were negative, including PIT1.", + "The other markers were negative, including TPIT.", + "The other markers were negative, including cytokeratin.", + "The other markers were negative, including epithelial membrane antigen.", + "The other markers were negative, including Galectin-3.", + "Periodic acid–Schiff was negative.", + "The final diagnosis was pituicytoma with a biphasic pattern.", + "The tumour was admixed with scattered Herring bodies.", + "The patient made a good postoperative recovery.", + "There was no recurrence at 4 months of MRI follow-up." + ], + "summary": "A 71-year-old man presented with sudden symptoms of stroke including urinary incontinence, weakness in right lower limb, and trouble speaking. Physical examinations showed a right facial paralysis. The radiological examinations eventually found a 1.7 × 1.4 × 1.3 cm sellar occupied lesion. After symptomatic treatment improved the symptoms, the patient underwent transsphenoidal resection of the pituitary mass. Histologically, the tumour contained hypocellular area and hypercellular area. The hypocellular area showed elongated spindle cells arranged in a fascicular pattern around small vessels and scattered Herring bodies; the hypercellular area showed a large number of pseudorosettes. Immunohistochemistrically, the tumour cells were positive for thyroid transcription factor-1, S100, and neuron-specific enolase. Neurofilament only showed a little positive in the hypocellular area, and silver impregnation was only noted in a perivascular distribution. The patient had no recurrence 4 months after the surgery.", + "summary_subclaims": [ + "A 71-year-old man presented with sudden symptoms of stroke.", + "The symptoms included urinary incontinence.", + "The symptoms included weakness in right lower limb.", + "The symptoms included trouble speaking.", + "Physical examinations showed a right facial paralysis.", + "Radiological examinations found a 1.7 × 1.4 × 1.3 cm sellar occupied lesion.", + "After symptomatic treatment improved the symptoms, the patient underwent transsphenoidal resection of the pituitary mass.", + "Histologically, the tumour contained hypocellular area and hypercellular area.", + "The hypocellular area showed elongated spindle cells arranged in a fascicular pattern around small vessels.", + "The hypocellular area showed scattered Herring bodies.", + "The hypercellular area showed a large number of pseudorosettes.", + "The tumour cells were positive for thyroid transcription factor-1.", + "The tumour cells were positive for S100.", + "The tumour cells were positive for neuron-specific enolase.", + "Neurofilament only showed a little positive in the hypocellular area.", + "Silver impregnation was only noted in a perivascular distribution.", + "The patient had no recurrence 4 months after the surgery." + ] + }, + { + "id": "multiclinsum_test_830_en.txt", + "fulltext": "The reported patient was a 33-year-old man complaining of decreased urine volume, urine color change, and lower abdominal pain. He was admitted to the emergency department of a general university hospital in one of the northern cities of Iran in winter, 2016. After preliminary examinations, he was transferred to the department of nephrology for dialysis and other treatments because of high levels of urea and creatinine as well as ARF. Because of a history of drug dependence, a request for psychiatric consultation was submitted to psychiatric service department of the hospital. During clinical diagnostic interviews, the patient was determined as suffering from substance-related disorder and borderline personality disorder on the basis of the Axes I and II dimensions, respectively, of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5).\nHe had a history of hospitalization for methamphetamine rehabilitation, after which the patient turned to methadone, tramadol, and opium. To prevent the weight loss caused by these drugs, he arbitrarily used oxymetholone for two months. The patient was observed for the onset of urinary symptoms for four days prior to admission. The first laboratory findings for ARF included a urea level of 238 mg/dL and a creatinine level of 11 mg/dL. Muscle injury and rhabdomyolysis were confirmed through the analysis of experimental data (myoglobinuria, CPK: 10726 IU/L and LDH: 4383 U/L). Concentrations of electrolytes, such as potassium and sodium (Na: 130 mEq/L and K: 4.9 mEq/L), and serum levels of liver enzymes (alanine transaminase and aspartate transaminase) and coagulation factors were normal. Liver and kidney ultrasonography was performed shortly after hospitalization.\nLiver size and echogenicity were normal. The right kidney was 136 mm in size, with a cortical echo and increased corticomedullary differentiation. A small amount of perinephric fluid was evident around the kidney. The left kidney was 102 mm in size, with a normal paranshyal echo and reduced focal thickness. Based upon physical examination of the patient, the heart, lungs, and nervous system showed normal functioning. After diagnostic confirmation, the primary therapeutic purpose was to prevent ARF risk factors, including the reduction of fluid volume, the blocking of tubules, release of free radicals, and aciduria. The patient underwent seven rounds of hemodialysis and hydration. Eight days after the first day of hospitalization, his CPK and LDH levels declined rapidly (CPK: 365 IU/L and LDH: 855 U/L). When ARF was settled and the values were normal, the patient was discharged.", + "fulltext_subclaims": [ + "The patient was a 33-year-old man.", + "He complained of decreased urine volume.", + "He complained of urine color change.", + "He complained of lower abdominal pain.", + "He was admitted to the emergency department of a general university hospital in one of the northern cities of Iran in winter, 2016.", + "He was transferred to the department of nephrology for dialysis and other treatments.", + "He had high levels of urea and creatinine.", + "He had ARF.", + "A request for psychiatric consultation was submitted to the psychiatric service department of the hospital.", + "The patient was determined as suffering from substance-related disorder.", + "The patient was determined as suffering from borderline personality disorder.", + "The determination was based on the Axes I and II dimensions of the DSM-5.", + "He had a history of hospitalization for methamphetamine rehabilitation.", + "After methamphetamine rehabilitation, the patient turned to methadone, tramadol, and opium.", + "He arbitrarily used oxymetholone for two months.", + "The patient was observed for the onset of urinary symptoms for four days prior to admission.", + "The first laboratory findings for ARF included a urea level of 238 mg/dL.", + "The first laboratory findings for ARF included a creatinine level of 11 mg/dL.", + "Muscle injury and rhabdomyolysis were confirmed through the analysis of experimental data.", + "The experimental data included myoglobinuria.", + "The experimental data included a CPK level of 10726 IU/L.", + "The experimental data included an LDH level of 4383 U/L.", + "Concentrations of potassium and sodium were normal.", + "Serum levels of liver enzymes and coagulation factors were normal.", + "Liver and kidney ultrasonography was performed shortly after hospitalization.", + "Liver size and echogenicity were normal.", + "The right kidney was 136 mm in size.", + "The right kidney had a cortical echo and increased corticomedullary differentiation.", + "A small amount of perinephric fluid was evident around the right kidney.", + "The left kidney was 102 mm in size.", + "The left kidney had a normal paranshyal echo and reduced focal thickness.", + "The heart, lungs, and nervous system showed normal functioning.", + "The primary therapeutic purpose was to prevent ARF risk factors.", + "The patient underwent seven rounds of hemodialysis.", + "The patient received hydration.", + "Eight days after the first day of hospitalization, his CPK and LDH levels declined rapidly.", + "When ARF was settled and the values were normal, the patient was discharged." + ], + "summary": "We present one 33-year-old man complaining of decreased urine volume, urine color change, and lower abdominal pain. He is engaged with a rare side effect of oxymetholone abuse. During assessments of potential medical issues associated with the intake of anabolic steroids, known side effects are known to be transient, but the need for appropriate interventions remains essential.", + "summary_subclaims": [ + "A 33-year-old man is complaining of decreased urine volume.", + "The man is complaining of urine color change.", + "The man is complaining of lower abdominal pain.", + "The man is engaged with a rare side effect of oxymetholone abuse.", + "Known side effects of anabolic steroids are known to be transient.", + "The need for appropriate interventions remains essential." + ] + }, + { + "id": "multiclinsum_test_608_en.txt", + "fulltext": "A 50-year-old diabetic female patient, who has been on oral hypoglycemics for seven years. She had never been treated for tuberculosis and had no recent history of a tuberculosis contact. She reported the appearance of bilateral cervical lymphadenopathy two months before her admission, without any other associated respiratory or extra-respiratory signs, all evolving in a context of fever, night sweats, and preservation of her general condition. The physical examination revealed a patient in a good general condition (PS 1) with multiple lymphadenopathies of different sizes, painless and without any inflammatory signs, located in the cervical, axillary, epitrochlear, and inguinal regions. The rest of the physical examination was unremarkable.\nThe chest X-ray showed a left hilar opacity and a right paracardiac opacity . The complete blood count was normal. The C-reactive protein was slightly elevated at 40 mg/l, blood ionogram, kidney function test, liver function test, and the viral serologies including HIV were normal. The search for acid-fast bacilli (AFB) in sputum was negative, and the tuberculin skin test (TST) was positive at 15 mm. The biopsy of the cervical adenopathy showed the presence of an epithelioid and giant cellular granuloma without caseous necrosis. Unfortunately, the culture of the biopsy specimen was not performed.\nThe patient was put on anti-tuberculosis as tuberculosis was highly suspected due to the epidemiological context, the clinical symptomatology and the strong positivity of the tuberculin test. On the fifteenth day, she developed a generalized pruritic erythematous rash that required the interruption of the treatment. A thoracic CT scan was performed, which revealed mediastinal hilar and axillary adenopathy without parenchymal involvement and a right breast lump (a, b).\nBronchoscopy showed thickening of the left upper lobar spur, bronchoalveolar lavage was predominantly lymphocytic (42%), staged bronchial biopsies were negative as well as the search for AFB in the bronchial aspiration fluid.\nBilateral mammography and mammary ultrasound showed a right and left breast lump which is classified respectively BI-RADS V and BI-RADS IV (a, b). The breast biopsy was in favor of a granulomatous inflammatory process without caseous necrosis.\nThe phosphocalcic balance, the electrocardiogram, and the ophthalmic exam were without abnormalities. The biopsy of the accessory salivary glands showed the presence of a giant cellular epithelioid granuloma without caseous necrosis compatible with sarcoidosis. The pulmonary function test showed a correct total lung capacity (TLC). Beta microglobulinemia, serum protein electrophoresis, and abdominal ultrasound were without abnormalities.\nThe diagnosis of sarcoidosis was based on clinical, radiological, biological, and histological criteria (presence of granuloma without caseous necrosis in 3 different organs: lymph node, salivary glands, and mammary glands).\nTherapeutic abstention was recommended with clinical and radiological surveillance. The evolution was marked over two years by the disappearance of arthralgias, hilar adenopathies and peripheral adenopathies.", + "fulltext_subclaims": [ + "The patient is a 50-year-old diabetic female.", + "She has been on oral hypoglycemics for seven years.", + "She had never been treated for tuberculosis.", + "She had no recent history of a tuberculosis contact.", + "She reported the appearance of bilateral cervical lymphadenopathy two months before admission.", + "The physical examination revealed multiple lymphadenopathies located in the cervical, axillary, epitrochlear, and inguinal regions.", + "The chest X-ray showed a left hilar opacity and a right paracardiac opacity.", + "The complete blood count was normal.", + "The C-reactive protein was slightly elevated at 40 mg/l.", + "The search for acid-fast bacilli in sputum was negative.", + "The tuberculin skin test was positive at 15 mm.", + "The biopsy of the cervical adenopathy showed the presence of an epithelioid and giant cellular granuloma without caseous necrosis.", + "The culture of the biopsy specimen was not performed.", + "The patient was put on anti-tuberculosis treatment.", + "On the fifteenth day, she developed a generalized pruritic erythematous rash.", + "A thoracic CT scan revealed mediastinal hilar and axillary adenopathy without parenchymal involvement.", + "A right breast lump was noted.", + "Bronchoscopy showed thickening of the left upper lobar spur.", + "Bronchoalveolar lavage was predominantly lymphocytic (42%).", + "Staged bronchial biopsies were negative.", + "The search for AFB in the bronchial aspiration fluid was negative.", + "Bilateral mammography and mammary ultrasound showed a right and left breast lump classified respectively BI-RADS V and BI-RADS IV.", + "The breast biopsy was in favor of a granulomatous inflammatory process without caseous necrosis.", + "The biopsy of the accessory salivary glands showed the presence of a giant cellular epithelioid granuloma without caseous necrosis.", + "The diagnosis of sarcoidosis was based on clinical, radiological, biological, and histological criteria.", + "Therapeutic abstention was recommended.", + "Clinical and radiological surveillance was recommended.", + "The evolution was marked over two years by the disappearance of arthralgias.", + "The evolution was marked over two years by the disappearance of hilar adenopathies.", + "The evolution was marked over two years by the disappearance of peripheral adenopathies." + ], + "summary": "We report the case of a 50-year-old, diagnosed with mediastinal and mammary sarcoidosis. Therapeutic abstention with clinical and radiological surveillance was recommended. The evolution was marked by a clear improvement (clinical and radiological).", + "summary_subclaims": [ + "The patient was a 50-year-old.", + "The patient was diagnosed with mediastinal and mammary sarcoidosis.", + "Therapeutic abstention with clinical and radiological surveillance was recommended.", + "The evolution was marked by a clear improvement.", + "The improvement was clinical and radiological." + ] + }, + { + "id": "multiclinsum_test_1802_en.txt", + "fulltext": "The patient is a 2-year-old boy, the second child in the family. His elder brother and parents are healthy. Ophthalmological, neurological, and ultrasonographic examination of the patient showed complete aniridia, cataract, optic disc hypoplasia and partial atrophy of the optic nerves, foveal hypoplasia, nystagmus, hypotalamia (shallow anterior chamber), high hypermetropia, and strabismus; , as well as early organic CNS damage, hydrocephalus, brain vascular plexus cysts, developmental delay, myotonic syndrome, pes valgus, ataxia, and emotional lability. In addition, short stature, gallbladder dysfunction, reactive pancreatitis, iodine deficiency, anemia, celiac disease, atopic dermatitis, open oval window, and umbilical hernia were observed.\nInitial cytogenetic study revealed the normal karyotype 46,XY and pericentric inversion of chromosome 11, inv(11)(p13q14) . The best resolution of the karyotyping was about 10 Mb. Inversion was not identified in the healthy parents of the proband with normal karyotype (data not shown) thus it was assumed to occur de novo. Such an inversion could lead to the patient’s phenotype with aniridia in two ways: either through the so-called position effect earlier described for AN , or through the loss of genomic material at the rearrangement break points. In the latter case the refinement of the deletion boundaries is crucial due to the vicinity of the WT1 gene.\nTo determine a possible chromosome disbalance in the 11p13 region, multiplex ligase-dependent probe amplification (MLPA) analysis was applied using the SALSA MLPA of P219-B2 PAX6 probes (MRC-Holland, Amsterdam, the Netherlands). The MLPA analysis showed a deletion stretched for at least 668 kb in 11p13 region (hg19::chr11:g.(30255690_31671656)_(32339851_32410037)del) and removed loci of the ELP4, PAX6, and RCN1 genes, and it did not affect the WT1 gene . This was confirmed by normal fluorescence in situ hybridization (FISH) pattern with a specific probe for the WT1 gene locus (FA0275, Abnova, Taiwan) and 11p region (CEN11p, FC0096, Abnova). . Further high-resolution chromosomal microarray analysis (CMA) with CytoScan HD array (2.67 M probes, ThermoFisher Scientific, MA USA) specified the deletion region to be 977.065 kb (arr [GRCh37] 11p13(31400114_32377179)×1) . The CMA revealed no meaningful disbalance of more than 10 kb in the 11q14 region at the other side of the inversion.", + "fulltext_subclaims": [ + "The patient is a 2-year-old boy.", + "The patient is the second child in the family.", + "The patient's elder brother and parents are healthy.", + "Ophthalmological examination showed complete aniridia.", + "Ophthalmological examination showed cataract.", + "Ophthalmological examination showed optic disc hypoplasia.", + "Ophthalmological examination showed partial atrophy of the optic nerves.", + "Ophthalmological examination showed foveal hypoplasia.", + "Ophthalmological examination showed nystagmus.", + "Ophthalmological examination showed hypotalamia.", + "Ophthalmological examination showed high hypermetropia.", + "Ophthalmological examination showed strabismus.", + "Neurological examination showed early organic CNS damage.", + "Neurological examination showed hydrocephalus.", + "Neurological examination showed brain vascular plexus cysts.", + "Neurological examination showed developmental delay.", + "Neurological examination showed myotonic syndrome.", + "Neurological examination showed pes valgus.", + "Neurological examination showed ataxia.", + "Neurological examination showed emotional lability.", + "Ultrasonographic examination showed early organic CNS damage.", + "Ultrasonographic examination showed hydrocephalus.", + "Ultrasonographic examination showed brain vascular plexus cysts.", + "Ultrasonographic examination showed developmental delay.", + "Ultrasonographic examination showed myotonic syndrome.", + "Ultrasonographic examination showed pes valgus.", + "Ultrasonographic examination showed ataxia.", + "Ultrasonographic examination showed emotional lability.", + "Short stature was observed.", + "Gallbladder dysfunction was observed.", + "Reactive pancreatitis was observed.", + "Iodine deficiency was observed.", + "Anemia was observed.", + "Celiac disease was observed.", + "Atopic dermatitis was observed.", + "An open oval window was observed.", + "An umbilical hernia was observed.", + "Initial cytogenetic study revealed the normal karyotype 46,XY.", + "Initial cytogenetic study revealed pericentric inversion of chromosome 11, inv(11)(p13q14).", + "The best resolution of the karyotyping was about 10 Mb.", + "The inversion was not identified in the healthy parents of the proband.", + "The inversion was assumed to occur de novo.", + "Such an inversion could lead to the patient’s phenotype with aniridia through the so-called position effect.", + "Such an inversion could lead to the patient’s phenotype with aniridia through the loss of genomic material at the rearrangement break points.", + "MLPA analysis showed a deletion stretched for at least 668 kb in 11p13 region.", + "The deletion removed loci of the ELP4, PAX6, and RCN1 genes.", + "The deletion did not affect the WT1 gene.", + "Normal fluorescence in situ hybridization (FISH) pattern with a specific probe for the WT1 gene locus was observed.", + "Normal fluorescence in situ hybridization (FISH) pattern with a specific probe for the 11p region was observed.", + "CMA specified the deletion region to be 977.065 kb.", + "CMA revealed no meaningful disbalance of more than 10 kb in the 11q14 region." + ], + "summary": "DNA samples were obtained from the proband (a 2-year-old boy) and his two healthy parents. Molecular analysis revealed a 977.065 kb deletion that removed loci of the ELP4, PAX6, and RCN1 genes but did not affect the coding sequence of the WT1 gene. The deletion occurred de novo on the paternal allele. The patient had normal karyotype 46,XY and a de novo pericentric inversion of chromosome 11, inv(11)(p13q14).", + "summary_subclaims": [ + "DNA samples were obtained from the proband (a 2-year-old boy) and his two healthy parents.", + "Molecular analysis revealed a 977.065 kb deletion that removed loci of the ELP4, PAX6, and RCN1 genes.", + "The deletion did not affect the coding sequence of the WT1 gene.", + "The deletion occurred de novo on the paternal allele.", + "The patient had normal karyotype 46,XY.", + "The patient had a de novo pericentric inversion of chromosome 11, inv(11)(p13q14)." + ] + }, + { + "id": "multiclinsum_test_2707_en.txt", + "fulltext": "A 57-year-old man previously known for type 2 diabetes (T2D) for 3 years, asthma and obstructive sleep apnea was admitted for an aggravation of his dyspnea. Bodyweight was 99 kg, height was 172 cm and body mass index was 33.5 kg/m2.\nHis T2D was treated only with metformin 500 mg twice daily and his latest Hb1Ac was 6.1%. The patient was not on other regular treatment. In the past 3 weeks, he presented a dry cough that was initially managed with amoxicillin/clavulanic acid and clarithromycin for 5 days. At admission, he presented a normal leucocyte count at 4.3 G/l with lymphopenia at 0.39 G/l count and an elevated CRP at 58 mg/l [, ]. Chest CT SCAN showed a bilateral multilobar ground-glass opacification. A nasopharyngeal swab test of SARS-CoV-2 by RT-qPCR was performed the same day in another medical facility and the result was pending.\nTwenty-four hours after his admission he presented a worsening of dyspnea, with tachypnea and severe hypoxemia requiring a transfer to the intensive care unit rapidly followed by oro-tracheal intubation for mechanical ventilation support. A vasopressor infusion (norepinephrine) was started. A bronchoalveolar lavage was performed and test of SARS-CoV-2 by RT-qPCR assay was positive. At day 3, he presented a rapidly progressive insulin requirement at a rate of up to 50 units/hour iv of insulin aspart . Despite the high insulin doses, he maintained an elevated plasma glucose level at 270 mg/dL on average.\nHis extremely high-dose insulin requirement “resolved” at day 9, and the insulin infusion rate was rapidly reduced, avoiding hypoglycemia . He was extubated at day 13 and discharged to an intermediate care unit as a step down approach to pursue a close monitoring and regular respiratory care including continuous positive airway pressure (CPAP), and 2 days later he was transferred to regular hospital room due a positive clinical evolution. His insulin treatment was switched to subcutaneous neutral protamine Hagedorn (NPH) insulin at a total dose of 60 UI per day.", + "fulltext_subclaims": [ + "The patient is a 57-year-old man.", + "He has type 2 diabetes.", + "He has asthma.", + "He has obstructive sleep apnea.", + "He was admitted for an aggravation of dyspnea.", + "His bodyweight was 99 kg.", + "His height was 172 cm.", + "His body mass index was 33.5 kg/m2.", + "His type 2 diabetes was treated only with metformin 500 mg twice daily.", + "His latest HbA1c was 6.1%.", + "He was not on other regular treatment.", + "In the past 3 weeks, he presented a dry cough.", + "He was managed with amoxicillin/clavulanic acid for 5 days.", + "He was managed with clarithromycin for 5 days.", + "At admission, his leucocyte count was 4.3 G/l.", + "At admission, he had lymphopenia at 0.39 G/l.", + "At admission, his CRP was 58 mg/l.", + "Chest CT scan showed bilateral multilobar ground-glass opacification.", + "A nasopharyngeal swab test of SARS-CoV-2 by RT-qPCR was performed the same day in another medical facility.", + "The SARS-CoV-2 test result was pending.", + "Twenty-four hours after admission, he presented worsening of dyspnea.", + "He had tachypnea.", + "He had severe hypoxemia.", + "He required transfer to the intensive care unit.", + "He was rapidly followed by oro-tracheal intubation for mechanical ventilation support.", + "A vasopressor infusion (norepinephrine) was started.", + "A bronchoalveolar lavage was performed.", + "A SARS-CoV-2 test by RT-qPCR assay was positive.", + "At day 3, he had a rapidly progressive insulin requirement at a rate of up to 50 units/hour iv of insulin aspart.", + "Despite the high insulin doses, he maintained an elevated plasma glucose level at 270 mg/dL on average.", + "His extremely high-dose insulin requirement resolved at day 9.", + "The insulin infusion rate was rapidly reduced.", + "He was extubated at day 13.", + "He was discharged to an intermediate care unit.", + "He was transferred to a regular hospital room 2 days later.", + "His insulin treatment was switched to subcutaneous neutral protamine Hagedorn (NPH) insulin at a total dose of 60 UI per day." + ], + "summary": "A 57-year-old man resident in Geneva, Switzerland, previously known for type 2 diabetes for 3 years was admitted for an aggravation of his dyspnea. His type 2 diabetes was treated only with metformin and his latest Hb1Ac was 6.1%. Chest CT SCAN showed a bilateral multilobar ground-glass opacification. Twenty-four hours after his admission he presented a worsening of dyspnea and severe hypoxemia requiring a transfer to the intensive care unit rapidly followed by oro-tracheal intubation for mechanical ventilation support. A bronchoalveolar lavage was performed and test of SARS-CoV-2 by RT-qPCR assay was positive. At day 3, he presented a rapidly progressive insulin requirement at a rate of up to 50 units/hour intravenous insulin aspart. Despite the high insulin doses, he maintained an elevated plasma glucose level at 270 mg/dL on average. His extremely high-dose insulin requirement \"resolved\" at day 9, and the insulin infusion rate was rapidly reduced.", + "summary_subclaims": [ + "The patient is a 57-year-old man.", + "The patient is a resident in Geneva, Switzerland.", + "The patient had type 2 diabetes for 3 years.", + "The patient was admitted for an aggravation of his dyspnea.", + "The patient's type 2 diabetes was treated only with metformin.", + "The patient's latest Hb1Ac was 6.1%.", + "Chest CT scan showed bilateral multilobar ground-glass opacification.", + "Twenty-four hours after admission, the patient presented a worsening of dyspnea.", + "Twenty-four hours after admission, the patient had severe hypoxemia.", + "The patient was transferred to the intensive care unit.", + "The patient was rapidly followed by oro-tracheal intubation for mechanical ventilation support.", + "A bronchoalveolar lavage was performed.", + "The test of SARS-CoV-2 by RT-qPCR assay was positive.", + "At day 3, the patient had a rapidly progressive insulin requirement at a rate of up to 50 units/hour intravenous insulin aspart.", + "Despite the high insulin doses, the patient maintained an elevated plasma glucose level at 270 mg/dL on average.", + "The patient's extremely high-dose insulin requirement 'resolved' at day 9.", + "The insulin infusion rate was rapidly reduced." + ] + }, + { + "id": "multiclinsum_test_218_en.txt", + "fulltext": "A 94-year-old male with a past ocular history of age-related macular degeneration (AMD) in both eyes presented to the ophthalmology clinic for a routine dilated fundus exam (DFE). On exam his Snellen visual acuity was 20/100 OD and count fingers (CF) OS. Exam findings were significant for end-stage AMD in the left eye and subretinal hemorrhage in the right eye. He was referred for ocular ultrasound and found to have subretinal hemorrhage secondary to progression of his exudative macular degeneration. Anti-VEGF treatment was initiated and continued for several months. The patient was then found to have a choroidal lesion that measured 14.5 × 14.6 mm in basal dimension with a thickness of 6.4 mm. There was low to medium reflectivity, moderate irregularity and trace spontaneous vascularity. These findings were consistent with a clinical diagnosis of choroidal melanoma.\nThe patient was referred for a liver ultrasound, which showed questionable focal lesions within the liver, and further evaluation with CT abdomen and pelvis was recommended. Given the liver ultrasound findings the patient was re-evaluated with ocular ultrasound, which did not show evidence of extrascleral extension . The patient underwent staging CT chest, abdomen and pelvis that were negative for metastatic disease. An MRI of the orbits with contrast showed a subcentimeter region of abnormal contrast enhancement extending into the immediately adjacent retro-bulbar fat, suspicious for scleral invasion and small extrascleral lesional extension .\nThe patient presented to the ophthalmology walk-in clinic several days after the MRI with complaints of right eye pain that he described as “monotonous friction” like pain. Exam findings were significant for visual acuity no light perception (NLP) OD, an intraocular pressure of 28 OD, diffuse hemorrhage in the anterior chamber and no view into the posterior pole secondary to vitreous hemorrhage. B-scan ocular ultrasound performed during that visit was consistent with hemorrhagic choroidal detachments with diffuse vitreous hemorrhage. Given the presence of a choroidal melanoma, questionable extrascleral extension and a painful eye, patient and providers decided to pursue enucleation. The patient underwent enucleation OD and the specimen was sent for analysis. Final pathology revealed malignant melanoma of the choroid (spindle B-type) with intact sclera and no obvious extrascleral extension posteriorly .", + "fulltext_subclaims": [ + "The patient is a 94-year-old male.", + "The patient has a past ocular history of age-related macular degeneration in both eyes.", + "The patient presented for a routine dilated fundus exam.", + "On exam, his Snellen visual acuity was 20/100 OD.", + "On exam, his Snellen visual acuity was count fingers OS.", + "Exam findings were significant for end-stage AMD in the left eye.", + "Exam findings were significant for subretinal hemorrhage in the right eye.", + "He was referred for ocular ultrasound.", + "Ocular ultrasound found subretinal hemorrhage secondary to progression of his exudative macular degeneration.", + "Anti-VEGF treatment was initiated.", + "Anti-VEGF treatment was continued for several months.", + "The patient was found to have a choroidal lesion that measured 14.5 × 14.6 mm in basal dimension.", + "The choroidal lesion had a thickness of 6.4 mm.", + "The choroidal lesion had low to medium reflectivity.", + "The choroidal lesion had moderate irregularity.", + "The choroidal lesion had trace spontaneous vascularity.", + "These findings were consistent with a clinical diagnosis of choroidal melanoma.", + "The patient was referred for a liver ultrasound.", + "The liver ultrasound showed questionable focal lesions within the liver.", + "Further evaluation with CT abdomen and pelvis was recommended.", + "The patient was re-evaluated with ocular ultrasound.", + "Ocular ultrasound did not show evidence of extrascleral extension.", + "The patient underwent staging CT chest, abdomen, and pelvis.", + "The staging CT was negative for metastatic disease.", + "An MRI of the orbits with contrast showed a subcentimeter region of abnormal contrast enhancement extending into the immediately adjacent retro-bulbar fat.", + "The MRI findings were suspicious for scleral invasion.", + "The MRI findings were suspicious for small extrascleral lesional extension.", + "The patient presented to the ophthalmology walk-in clinic several days after the MRI.", + "The patient complained of right eye pain described as “monotonous friction” like pain.", + "Exam findings were significant for visual acuity no light perception OD.", + "Exam findings were significant for an intraocular pressure of 28 OD.", + "Exam findings were significant for diffuse hemorrhage in the anterior chamber.", + "Exam findings were significant for no view into the posterior pole secondary to vitreous hemorrhage.", + "B-scan ocular ultrasound performed during that visit was consistent with hemorrhagic choroidal detachments.", + "B-scan ocular ultrasound performed during that visit was consistent with diffuse vitreous hemorrhage.", + "Given the presence of a choroidal melanoma, questionable extrascleral extension, and a painful eye, the patient and providers decided to pursue enucleation.", + "The patient underwent enucleation OD.", + "The specimen was sent for analysis.", + "Final pathology revealed malignant melanoma of the choroid (spindle B-type).", + "Final pathology showed intact sclera.", + "Final pathology showed no obvious extrascleral extension posteriorly." + ], + "summary": "We present a case of a 94-year-old male with choroidal melanoma of the right eye imaged with MRI and ocular ultrasound to aid in the detection of extrascleral extension.", + "summary_subclaims": [ + "The patient is a 94-year-old male.", + "The patient has choroidal melanoma of the right eye.", + "MRI was used to image the right eye.", + "Ocular ultrasound was used to image the right eye.", + "The imaging was performed to aid in the detection of extrascleral extension." + ] + }, + { + "id": "multiclinsum_test_1826_en.txt", + "fulltext": "A 33-year-old man complained of multisite pain for 6 h following waist trauma and was admitted to the hospital. He suffered multiple injuries from severe impact on the right rear of his waist after driving an out of control forklift truck. The patient presented with excruciating pain in the back, chest, and abdomen, and the muscle strength of both lower limbs was decreased (3/5 strength in the left lower limb and 2/5 strength in the right lower limb); both lower limb extremity paresthesias and urinary retention was observed. Immediately after the injury, the patient was sent to our hospital by ambulance for treatment and underwent x-ray and computed tomography (CT) scan ; the imaging examinations revealed the left 10th and 11th rib, bilateral transverse processes (L2–L5 levels), sacrum, and coccyx and right ilium fractures, and L5 vertebra and S1 vertebra dislocation and separation. A lumbosacral vertebra magnetic resonance imaging (MRI) revealed a complete rupture of the L5–S1 intervertebral disc; tear in anterior longitudinal ligament, posterior longitudinal ligament, ligamentum flavum, interspinous ligament, supraspinous ligament, and dural sac; and cerebrospinal fluid (CSF) seepage into the tissue space behind the lumbar spine . The patient was healthy previously and had no other diseases or syndromes. Traumatic lumbosacral spondyloptosis diagnosis was established. On admission, the patient was conscious, the blood pressure (BP) was 85/60 mmHg, and heart rate was 78 beats/min; intravenous rehydration therapy was immediately started because of a low BP and then the BP gradually returned to the normal level. The severity of the spinal injury was graded according to the American Spinal Injury Association (ASIA) grading scale, and the patient was classified as grade C. The visual analog scale (VAS) score was 9.\nThe patient was sent to the operating room for surgical treatment 10 days after admission. During the operation, we found that the subcutaneous soft tissue and muscle behind the lumbar spine were seriously injured, the L5 vertebra were severely dislocated to the front-left side, the L5–S1 facet joint was fractured and dislocated, the bilateral inferior articular processes of L5 were locked and located anterior to the S1 vertebra , severe dural sac tear had occurred at the L5–S1 level, and only part of cauda equina and filum terminale are continuous; the L5–S1 intervertebral disc had ruptured and prolapsed into the spinal canal. Specific procedures were performed as follows. After successful anesthesia, the patient was placed in the prone position. In the surgical area, routine disinfection was carried out and laid with sterile sheets. A 20–25 cm incision was made at the midline of the back using the L4 spinous process as the center. The skin was cut parallel to the spine, then the lumbodorsal fascia was stripped and the paravertebral muscle was bluntly stripped to completely expose the spinous process and bilateral vertebral plate of L3–S2 vertebrae, and the spinous process of L5–S1 vertebrae was removed. Pilot holes for pedicle screws placement from L3 through S1 and also for the S2 alar-iliac (S2AI) screws entry site were marked; bilateral L3, L4, L5, and S1 pedicle screws of appropriate length were then inserted, and dual S2AI screws placement bilaterally were performed. A pre-bent short titanium rod was temporarily installed to distract L5–S1 intervertebral space. We found that the bilateral inferior articular processes of L5 was still dislocated in front of the S1 vertebra after C-arm fluoroscopy, and it is particularly difficult to perform the reduction with a screw distractor; so we decided to resect bilateral inferior articular processes of L5 with the assistance of the ultrasonic bone scalpel . Reduction was attempted again, and the spinal column getting back into normal alignment was observed after C-arm fluoroscopy . Then, bilateral laminectomies, facetectomies, decompression of the cauda equina, and discectomy of L5–S1 were performed. Interbody bone graft fusion was performed by implanting an interbody fusion cage filled with bone morphogenetic protein (BMP) and local bone at the L5/S1 level. Finally, the dura with artificial dura mater were repaired. Bilateral lumbar drainage tubes were placed at the end of procedures. The operative procedure was about 3 h and intraoperative blood loss was about 800 ml.\nAfter the surgical operation was completed, the patient was transferred to the postanesthesia care unit and then to the orthopedics wards. We found the patient had CSF leakage on the first postoperative day and presented with mild headaches and light-headedness. The patient's low back pain and numbness of both lower limbs were effectively improved; however, the muscle strength of both lower limbs did not significantly improve. The VAS back pain decreased from 9 preoperatively to 4 postoperatively. The ASIA grade remained in grade C after surgery. The right lumbar drainage tube and the Foley catheter were removed on the third postoperative day, and then the left lumbar drainage tube was removed and the skin was closed using 2–0 nylon sutures on postoperative day 7. The patient was then transferred to the rehabilitation hospital for hyperbaric oxygen and rehabilitation treatment on postoperative day 10. At 1-month follow-up, the patient's muscle strength of bilateral hip flexors and knee extensors improved gradually, but the muscle strength of right foot dorsiflexion and plantar flexion did not show significant improvement. The lumbar x-ray, CT scan, and MRI showed that the internal fixation and lumbar interbody cages were in good position, and there was a small amount of fluid behind the lumbar spine . At the 6-month postoperative follow-up, the patient had no numbness of both lower limbs, and the symptom of urinary retention was significantly improved. The patient exhibited 4/5 strength in the left lower limb, 2/5 strength in right foot dorsiflexion and plantar flexion, and 4/5 strength in right hip flexor and knee extensor. The ASIA grade improved from grade C preoperatively to grade D postoperatively.", + "fulltext_subclaims": [ + "The patient was a 33-year-old man.", + "He complained of multisite pain for 6 h following waist trauma.", + "He was admitted to the hospital.", + "He suffered multiple injuries from severe impact on the right rear of his waist after driving an out of control forklift truck.", + "The patient presented with excruciating pain in the back, chest, and abdomen.", + "The muscle strength of both lower limbs was decreased.", + "The patient had 3/5 strength in the left lower limb.", + "The patient had 2/5 strength in the right lower limb.", + "Both lower limb extremity paresthesias were observed.", + "Urinary retention was observed.", + "The patient was sent to the hospital by ambulance for treatment.", + "The patient underwent x-ray and computed tomography (CT) scan.", + "The imaging examinations revealed the left 10th and 11th rib fractures.", + "The imaging examinations revealed bilateral transverse processes (L2–L5 levels) fractures.", + "The imaging examinations revealed sacrum fractures.", + "The imaging examinations revealed coccyx fractures.", + "The imaging examinations revealed right ilium fractures.", + "The imaging examinations revealed L5 vertebra dislocation and separation.", + "The imaging examinations revealed S1 vertebra dislocation and separation.", + "A lumbosacral vertebra magnetic resonance imaging (MRI) revealed a complete rupture of the L5–S1 intervertebral disc.", + "A lumbosacral vertebra MRI revealed tear in anterior longitudinal ligament.", + "A lumbosacral vertebra MRI revealed tear in posterior longitudinal ligament.", + "A lumbosacral vertebra MRI revealed tear in ligamentum flavum.", + "A lumbosacral vertebra MRI revealed tear in interspinous ligament.", + "A lumbosacral vertebra MRI revealed tear in supraspinous ligament.", + "A lumbosacral vertebra MRI revealed tear in dural sac.", + "A lumbosacral vertebra MRI revealed cerebrospinal fluid (CSF) seepage into the tissue space behind the lumbar spine.", + "Traumatic lumbosacral spondyloptosis diagnosis was established.", + "On admission, the patient was conscious.", + "The blood pressure (BP) was 85/60 mmHg.", + "The heart rate was 78 beats/min.", + "Intravenous rehydration therapy was immediately started because of a low BP.", + "The BP gradually returned to the normal level.", + "The severity of the spinal injury was graded according to the American Spinal Injury Association (ASIA) grading scale.", + "The patient was classified as grade C.", + "The visual analog scale (VAS) score was 9.", + "The patient was sent to the operating room for surgical treatment 10 days after admission.", + "During the operation, subcutaneous soft tissue and muscle behind the lumbar spine were seriously injured.", + "The L5 vertebra were severely dislocated to the front-left side.", + "The L5–S1 facet joint was fractured and dislocated.", + "The bilateral inferior articular processes of L5 were locked and located anterior to the S1 vertebra.", + "Severe dural sac tear had occurred at the L5–S1 level.", + "Only part of cauda equina and filum terminale are continuous.", + "The L5–S1 intervertebral disc had ruptured and prolapsed into the spinal canal.", + "The patient was placed in the prone position.", + "A 20–25 cm incision was made at the midline of the back using the L4 spinous process as the center.", + "The skin was cut parallel to the spine.", + "The lumbodorsal fascia was stripped.", + "The paravertebral muscle was bluntly stripped to completely expose the spinous process and bilateral vertebral plate of L3–S2 vertebrae.", + "The spinous process of L5–S1 vertebrae was removed.", + "Pilot holes for pedicle screws placement from L3 through S1 and also for the S2 alar-iliac (S2AI) screws entry site were marked.", + "Bilateral L3, L4, L5, and S1 pedicle screws of appropriate length were then inserted.", + "Dual S2AI screws placement bilaterally were performed.", + "A pre-bent short titanium rod was temporarily installed to distract L5–S1 intervertebral space.", + "The bilateral inferior articular processes of L5 were still dislocated in front of the S1 vertebra after C-arm fluoroscopy.", + "It is particularly difficult to perform the reduction with a screw distractor.", + "Bilateral inferior articular processes of L5 were resected with the assistance of the ultrasonic bone scalpel.", + "Reduction was attempted again.", + "The spinal column getting back into normal alignment was observed after C-arm fluoroscopy.", + "Bilateral laminectomies, facetectomies, decompression of the cauda equina, and discectomy of L5–S1 were performed.", + "Interbody bone graft fusion was performed by implanting an interbody fusion cage filled with bone morphogenetic protein (BMP) and local bone at the L5/S1 level.", + "The dura with artificial dura mater were repaired.", + "Bilateral lumbar drainage tubes were placed at the end of procedures.", + "The operative procedure was about 3 h.", + "Intraoperative blood loss was about 800 ml.", + "After the surgical operation was completed, the patient was transferred to the postanesthesia care unit.", + "The patient was transferred to the orthopedics wards.", + "The patient had CSF leakage on the first postoperative day.", + "The patient presented with mild headaches and light-headedness.", + "The patient's low back pain and numbness of both lower limbs were effectively improved.", + "The muscle strength of both lower limbs did not significantly improve.", + "The VAS back pain decreased from 9 preoperatively to 4 postoperatively.", + "The ASIA grade remained in grade C after surgery.", + "The right lumbar drainage tube and the Foley catheter were removed on the third postoperative day.", + "The left lumbar drainage tube was removed and the skin was closed using 2–0 nylon sutures on postoperative day 7.", + "The patient was transferred to the rehabilitation hospital for hyperbaric oxygen and rehabilitation treatment on postoperative day 10.", + "At 1-month follow-up, the patient's muscle strength of bilateral hip flexors and knee extensors improved gradually.", + "The muscle strength of right foot dorsiflexion and plantar flexion did not show significant improvement.", + "The lumbar x-ray, CT scan, and MRI showed that the internal fixation and lumbar interbody cages were in good position.", + "There was a small amount of fluid behind the lumbar spine.", + "At the 6-month postoperative follow-up, the patient had no numbness of both lower limbs.", + "The symptom of urinary retention was significantly improved.", + "The patient exhibited 4/5 strength in the left lower limb.", + "The patient exhibited 2/5 strength in right foot dorsiflexion and plantar flexion.", + "The patient exhibited 4/5 strength in right hip flexor and knee extensor.", + "The ASIA grade improved from grade C preoperatively to grade D postoperatively." + ], + "summary": "A 33-year-old man presented with multisite pain for 6 h following waist trauma and was admitted to the hospital. He suffered multiple injuries from severe impact on the waist after driving an out of control forklift truck. Preoperative imaging examinations revealed that the patient was diagnosed with traumatic lumbosacral spondyloptosis and the L5 inferior articular process was locked into the anterior margin of the S1 vertebra. A posterior instrumentation, decompression of the cauda equina, and interbody fusion procedure was performed. The patient received hyperbaric oxygen and rehabilitation treatment 10 days after the surgery. At the 6-month postoperative follow-up, the muscle strength of the lower limbs was improved, the patient had no numbness of both lower limbs, and the urinary retention symptom was significantly improved. The American Spinal Injury Association grade improved from grade C preoperatively to grade D postoperatively. As far as we know, there have been no relevant reports on traumatic lumbosacral spondyloptosis with locked L5 inferior articular process yet.", + "summary_subclaims": [ + "A 33-year-old man presented with multisite pain for 6 h following waist trauma.", + "He was admitted to the hospital.", + "He suffered multiple injuries from severe impact on the waist after driving an out of control forklift truck.", + "Preoperative imaging examinations revealed that the patient was diagnosed with traumatic lumbosacral spondyloptosis.", + "The L5 inferior articular process was locked into the anterior margin of the S1 vertebra.", + "A posterior instrumentation, decompression of the cauda equina, and interbody fusion procedure was performed.", + "The patient received hyperbaric oxygen and rehabilitation treatment 10 days after the surgery.", + "At the 6-month postoperative follow-up, the muscle strength of the lower limbs was improved.", + "The patient had no numbness of both lower limbs.", + "The urinary retention symptom was significantly improved.", + "The American Spinal Injury Association grade improved from grade C preoperatively to grade D postoperatively.", + "As far as we know, there have been no relevant reports on traumatic lumbosacral spondyloptosis with locked L5 inferior articular process yet." + ] + }, + { + "id": "multiclinsum_test_2637_en.txt", + "fulltext": "A woman in her 40s presented to the emergency department following 4 h of acute chest pain. The pain was described as severe pressure on the chest and radiated to the left arm.\nThe patient was 2 weeks following the birth of a healthy daughter (gravity 6, parity 3, caesarean section 3, spontaneous abortion 3).\nThe pregnancy was uncomplicated. She had an elective caesarean section due to previous caesarean section with her first pregnancy (breech presentation). This was performed at week 38 + 3. However, during admission following the caesarean section, the patient was noted to have elevated blood pressure and proteinuria and was treated with magnesium intravenously for pre-eclampsia. She was discharged with no further medication and was currently breastfeeding her child.\nShe was not on any other chronic medications, no past medical history, with no known allergies. She did not smoke, and her lipid profile 4 years prior revealed LDL blood level of 78 mg/dL.\nHer initial vital signs were blood pressure 145/80 mmHg, heart rate 95 b.p.m., normal oxygen saturation, and no fever. She was not in haemodynamic compromise or respiratory distress. The heart and lung examination were without abnormal findings.\nThe electrocardiogram showed sinus rhythm, normal axis, narrow QRS complex with T waves inversion in the anterior leads, and Type 2 Wellens sign in leads V4–V5 with QTC 462 ms (Bazett formula). There was no recording or symptoms of an arrhythmia on telemetry monitoring in the emergency room.\nA focused echocardiogram in the emergency department showed reduced left ventricular dysfunction (ejection fraction estimated to be 40%) with hypokinesia of the mid and apical segments mostly of the anterior wall in the four-chamber and two-chamber views, with no valvular lesions and no pericardial effusion (see , )\nBlood results reported an elevated troponin T 1633 ng/L (normal value < 13 ng/L), NT ProBNP 1046 pg/mL (normal value < 125 pg/mL), creatinine kinase 1451 U/L, creatinine of 0.6���mg/dL (glomerular filtration rate according to MDRD 133.5 mL/min/1.73m2) (normal value: 0.51–0.95 mg/dL), AST 116 U/L (normal values < 31 U/L), no electrolyte abnormalities, haemoglobin 14 g/dL (normal values: 12–16 g/dL), and platelets 431 K/mcL (normal values: 150–450 K/μL).\nDue to ongoing chest pain, the patient was taken urgently to the catheterization laboratory. Angiography showed critical stenosis of 99% of the middle left anterior descending artery with TIMI flow score of 3 ( and and , ). This lesion was tapered and indicative of spontaneous Type 2 coronary artery dissection (SCAD). No other coronary lesions were noted with smooth contour of the coronary arteries otherwise. Due to the clinical presentation of ongoing chest pain, abnormal electrocardiogram, and reduced left ventricular function, percutaneous coronary intervention was pursued. This was done with a 5 French 3.0 EBU engagement catheter, careful wiring of the coronary artery using a floppy wire (RUNTHROUGH NS Floppy, Terumo, Japan) and direct stenting with a single long EluNIR™ ridaforolimus drug eluting stent (Medinol, Tel Aviv, Israel, 2.75 mm diameter × 28 mm length) with a good angiographic result and optimal distal angiographic flow . The patient had immediate clinical improvement and was transferred for observation in the coronary care unit. She was given a loading dose of aspirin (300 mg) and clopidogrel (600 mg).\nHer echocardiogram the following day showed a reduced ejection fraction of 40% with anterior-apical dyskinesia and no valvular abnormalities. She was found to be hypertensive during her admission with 24 h albuminuria of 838 md/day and was started on Enalapril 5MG BD following a nephrology and gynaecology consultation. Bisoprolol 2.5MG QD was added due to her left ventricular dysfunction. LDL results were 144 mg/dL, and a statin (atorvastatin 80 mg) was initiated.\nA shared decision-making discussion was done with the patient about the recommendations and relative lack of data on antiplatelet drugs and effects of drugs from drug eluting stents (DESs) in breastmilk. The patient decided to avoid the potential risk on her child from the drugs and to stop breastfeeding. Her antiplatelet regimen was then changed to dual antiplatelet with ticagrelor (90 mg twice daily) and aspirin (100 mg once daily).", + "fulltext_subclaims": [ + "The patient was a woman in her 40s.", + "She presented to the emergency department following 4 h of acute chest pain.", + "The pain was described as severe pressure on the chest.", + "The pain radiated to the left arm.", + "The patient was 2 weeks following the birth of a healthy daughter.", + "The pregnancy was uncomplicated.", + "She had an elective caesarean section due to previous caesarean section with her first pregnancy.", + "The caesarean section was performed at week 38 + 3.", + "During admission following the caesarean section, the patient was noted to have elevated blood pressure and proteinuria.", + "She was treated with magnesium intravenously for pre-eclampsia.", + "She was discharged with no further medication.", + "She was currently breastfeeding her child.", + "She was not on any other chronic medications.", + "She had no past medical history.", + "She had no known allergies.", + "She did not smoke.", + "Her lipid profile 4 years prior revealed LDL blood level of 78 mg/dL.", + "Her initial vital signs were blood pressure 145/80 mmHg.", + "Her initial heart rate was 95 b.p.m.", + "She was not in haemodynamic compromise.", + "The electrocardiogram showed T waves inversion in the anterior leads.", + "The electrocardiogram showed Type 2 Wellens sign in leads V4–V5.", + "The QTC was 462 ms (Bazett formula).", + "There was no recording or symptoms of an arrhythmia on telemetry monitoring.", + "A focused echocardiogram showed reduced left ventricular dysfunction.", + "The estimated ejection fraction was 40%.", + "There was hypokinesia of the mid and apical segments.", + "Blood results reported an elevated troponin T 1633 ng/L.", + "Blood results reported an elevated NT ProBNP 1046 pg/mL.", + "Blood results reported an elevated creatinine kinase 1451 U/L.", + "Blood results reported an elevated AST 116 U/L.", + "The patient was taken urgently to the catheterization laboratory.", + "Angiography showed critical stenosis of 99% of the middle left anterior descending artery.", + "The lesion was tapered and indicative of spontaneous Type 2 coronary artery dissection.", + "No other coronary lesions were noted.", + "Percutaneous coronary intervention was pursued.", + "The patient had immediate clinical improvement.", + "She was given a loading dose of aspirin (300 mg).", + "She was given a loading dose of clopidogrel (600 mg).", + "Her echocardiogram the following day showed a reduced ejection fraction of 40%.", + "She was found to be hypertensive during her admission.", + "She was started on Enalapril 5MG BD.", + "Bisoprolol 2.5MG QD was added.", + "LDL results were 144 mg/dL.", + "A statin (atorvastatin 80 mg) was initiated.", + "A shared decision-making discussion was done with the patient.", + "The patient decided to avoid the potential risk on her child from the drugs.", + "The patient decided to stop breastfeeding.", + "Her antiplatelet regimen was changed to dual antiplatelet with ticagrelor (90 mg twice daily) and aspirin (100 mg once daily)." + ], + "summary": "We report a case of a young women presenting with chest pain in the post-partum period. Her clinical appearance was that of a myocardial infarction, and angiography was indicative of a Type 2 SCAD. The patients had persistent chest pain, reduced left ventricular function, and critical left anterior descending artery stenosis. Percutaneous coronary intervention was done with caution. Shared decision-making with the patient helped guide the medical treatment plan and follow-up.", + "summary_subclaims": [ + "We report a case of a young women presenting with chest pain in the post-partum period.", + "Her clinical appearance was that of a myocardial infarction.", + "Angiography was indicative of a Type 2 SCAD.", + "The patients had persistent chest pain.", + "The patients had reduced left ventricular function.", + "The patients had critical left anterior descending artery stenosis.", + "Percutaneous coronary intervention was done with caution.", + "Shared decision-making with the patient helped guide the medical treatment plan and follow-up." + ] + }, + { + "id": "multiclinsum_test_2716_en.txt", + "fulltext": "A 14-year-old girl had one episode of seizure five months prior to admission. She was diagnosed to be having multiple intracranial neurocysticercosis lesions and started on carbamazepine therapy. After three months of treatment, she noticed intermittent distortion of vision (metamorphopsia), seeing black spots and floaters in both the eyes. Subsequently, she developed progressive painless vision loss from both the eyes. There was no history of diabetes mellitus, hypertension or tuberculosis. Ophthalmological examination did not show orbital swelling, redness of eye, excessive lacrimation and other signs of ocular or orbital inflammation. There was no evidence of adnexal, orbital or extraocular muscle involvement. Intraocular pressure was normal on both sides. Though, the pupils were slightly dilated, reaction to light and accommodation was normal. Visual acuity was limited to perception of light in both the eyes. Bilateral detailed indirect ophthalmoscopic examination revealed evidence of subretinal cysts, retinal hemorrhage and retinal detachment. Surprisingly vitreous hemorrhage was also detected in both the eyes. Rest of the neurological examination was unremarkable.\nHemogram, serum biochemistry and x-ray chest were normal. Human immunodeficiency virus (HIV) was negative. Enzyme linked immunosorbent assay (ELISA) was strongly positive for Taenia solium. Ocular B-scan ultrasonography (USG) revealed septations and debris in vitreous in both eyes. It also showed cystic lesion with small peripheral solid nodular area in subretinal space in both eyes [Figure (a)]. Orbital computed tomography also depicted the vitreous hemorrhage with retinal detachment in both the eyes. Magnetic resonance imaging (MRI) of orbits showed heterogeneous hyperintensity in posterior chamber of eyes [Figure (c), (d)]. Ocular B-scan USG, orbital computed tomography and MRI orbit were consistent with vitreous hemorrhage and retinal detachment in both the eyes (right more than left). Subretinal cyst was located at the posterior pole of both the eyes. MRI brain revealed multiple small cystic intraparenchymal lesions in bilateral cerebral and cerebellar hemispheres, basal ganglia, thalami and brainstem. MRI T1-weighted image showed isointense to hypointense lesions. Fluid attenuated inversion recovery (FLAIR) and T2-weighted images showed hyperintense lesions with surrounding edema. Postcontrast T1-weighted image showed multiple ring enhancing lesions [Figure (a-f)].\nA clinical diagnosis of vitreous hemorrhage due to ocular cysticercosis was made and it was further supported by various imaging modalities. The patient underwent retinal surgery for cyst extraction. A complete cyst excision was possible from right eye, but on left side, cyst got ruptured during intra-operative procedure. Gross examination of pathological specimen revealed a thin walled, transparent, globular cyst with eccentrically placed small scolex [Figure (b)]. Histopathological examination (stained with hematoxylin and eosin) showed the invaginated scolex with suckers, spiral canal and hooks thereby confirming the cysticercus cellulosae. A short course of oral steroid was given to the patient after cyst excision. At the time of discharge from hospital, she was able to count finger at one foot from right eye, but still had only perception of light from left eye. She was continued on carbamazepine (200 mg thrice a day) for seizures. At one-year follow up, seizures are well controlled. Visual acuity (Snellen chart) is 6/60 in right eye and complete loss of vision in left eye. Ophthalmoscopic examination shows partial retinal re-attachment and optic disc pallor in the right eye, whereas optic disc atrophy is present in left eye.", + "fulltext_subclaims": [ + "The patient is a 14-year-old girl.", + "She had one episode of seizure five months prior to admission.", + "She was diagnosed to be having multiple intracranial neurocysticercosis lesions.", + "She was started on carbamazepine therapy.", + "After three months of treatment, she noticed intermittent distortion of vision.", + "She saw black spots and floaters in both the eyes.", + "She developed progressive painless vision loss from both the eyes.", + "There was no history of diabetes mellitus.", + "There was no history of hypertension.", + "There was no history of tuberculosis.", + "Ophthalmological examination did not show orbital swelling.", + "Ophthalmological examination did not show redness of eye.", + "Ophthalmological examination did not show excessive lacrimation.", + "There was no evidence of adnexal involvement.", + "There was no evidence of orbital involvement.", + "There was no evidence of extraocular muscle involvement.", + "Intraocular pressure was normal on both sides.", + "The pupils were slightly dilated.", + "Reaction to light was normal.", + "Accommodation was normal.", + "Visual acuity was limited to perception of light in both the eyes.", + "Bilateral detailed indirect ophthalmoscopic examination revealed subretinal cysts.", + "Bilateral detailed indirect ophthalmoscopic examination revealed retinal hemorrhage.", + "Bilateral detailed indirect ophthalmoscopic examination revealed retinal detachment.", + "Vitreous hemorrhage was also detected in both the eyes.", + "Hemogram was normal.", + "Serum biochemistry was normal.", + "X-ray chest was normal.", + "HIV was negative.", + "ELISA was strongly positive for Taenia solium.", + "Ocular B-scan USG revealed septations and debris in vitreous in both eyes.", + "Ocular B-scan USG showed cystic lesion with small peripheral solid nodular area in subretinal space in both eyes.", + "Orbital computed tomography depicted vitreous hemorrhage with retinal detachment in both the eyes.", + "MRI of orbits showed heterogeneous hyperintensity in posterior chamber of eyes.", + "MRI brain revealed multiple small cystic intraparenchymal lesions in bilateral cerebral and cerebellar hemispheres.", + "MRI brain showed multiple small cystic intraparenchymal lesions in basal ganglia.", + "MRI brain showed multiple small cystic intraparenchymal lesions in thalami.", + "MRI brain showed multiple small cystic intraparenchymal lesions in brainstem.", + "MRI T1-weighted image showed isointense to hypointense lesions.", + "FLAIR and T2-weighted images showed hyperintense lesions with surrounding edema.", + "Postcontrast T1-weighted image showed multiple ring enhancing lesions.", + "A clinical diagnosis of vitreous hemorrhage due to ocular cysticercosis was made.", + "The patient underwent retinal surgery for cyst extraction.", + "A complete cyst excision was possible from right eye.", + "On left side, cyst got ruptured during intra-operative procedure.", + "Gross examination of pathological specimen revealed a thin walled, transparent, globular cyst with eccentrically placed small scolex.", + "Histopathological examination showed the invaginated scolex with suckers, spiral canal and hooks.", + "Histopathological examination confirmed the cysticercus cellulosae.", + "A short course of oral steroid was given to the patient after cyst excision.", + "At the time of discharge from hospital, she was able to count finger at one foot from right eye.", + "At the time of discharge from hospital, she had only perception of light from left eye.", + "She was continued on carbamazepine (200 mg thrice a day) for seizures.", + "At one-year follow up, seizures are well controlled.", + "Visual acuity (Snellen chart) is 6/60 in right eye.", + "There is complete loss of vision in left eye.", + "Ophthalmoscopic examination shows partial retinal re-attachment and optic disc pallor in the right eye.", + "Ophthalmoscopic examination shows optic disc atrophy in left eye." + ], + "summary": "We report a case of young girl who was diagnosed with multiple intracranial neurocysticercosis lesions and was on antiepileptic drugs, following which she presented with progressive painless vision loss from both the eyes. Indirect ophthalmoscopic examination showed evidence of subretinal cysts, retinal hemorrhage and retinal detachment in both the eyes. Surprisingly, bilateral vitreous hemorrhage was also detected. Ocular B-scan ultrasonography, orbital MRI and computed tomography revealed retinal detachment with vitreous hemorrhage in both the eyes. Magnetic resonance imaging (MRI) of brain showed multiple intraparenchymal small cystic lesions in bilateral cerebral and cerebellar hemispheres, basal ganglia, thalami and brainstem.", + "summary_subclaims": [ + "The patient was a young girl.", + "The patient was diagnosed with multiple intracranial neurocysticercosis lesions.", + "The patient was on antiepileptic drugs.", + "The patient presented with progressive painless vision loss from both the eyes.", + "Indirect ophthalmoscopic examination showed evidence of subretinal cysts.", + "Indirect ophthalmoscopic examination showed retinal hemorrhage.", + "Indirect ophthalmoscopic examination showed retinal detachment in both the eyes.", + "Bilateral vitreous hemorrhage was detected.", + "Ocular B-scan ultrasonography revealed retinal detachment with vitreous hemorrhage in both the eyes.", + "Orbital MRI revealed retinal detachment with vitreous hemorrhage in both the eyes.", + "Computed tomography revealed retinal detachment with vitreous hemorrhage in both the eyes.", + "Magnetic resonance imaging (MRI) of the brain showed multiple intraparenchymal small cystic lesions.", + "The multiple intraparenchymal small cystic lesions were in bilateral cerebral and cerebellar hemispheres.", + "The multiple intraparenchymal small cystic lesions were in the basal ganglia.", + "The multiple intraparenchymal small cystic lesions were in the thalami.", + "The multiple intraparenchymal small cystic lesions were in the brainstem." + ] + }, + { + "id": "multiclinsum_test_2253_en.txt", + "fulltext": "A 82-year-old man living on the French Riviera presented at the emergency department for fever and chills lasting for 5 days. He complained of severe asthenia. He came back two weeks ago from a travel in New York city, USA with a two days stay on the Long Island countryside. He did not note any insect bite during his travel. Jaundice was noticed on examination as well as slightly enlarged spleen and liver. Blood test showed an abnormal blood cell count with neutropenia (0·5 G/L), lymphopenia (0·3 G/L), thrombocytopenia (30×109/L) and anemia (haemoglobin of 91 g/L) with a low reticulocyte count (45 G/L). Blood test also showed increased C reactive protein (154 mg/L), raised ferritin (5953 ng/ml) and liver enzymes were elevated (ALT 56 UI/L (N<40), AST 68 UI/L (N<53), Alkaline phosphatase 213 UI/L (N<129), total bilirubin 48·9 μmol/L). Haptoglobin was undetectable, LDH levels increased 620 UI/L (N<225) and coagulation tests were in normal range. Routine blood cultures were negative. Bone marrow aspiration was performed because of the severe cytopenias associated with a low reticulocyte count and showed typical hemophagocytosis . Microscopic examination of the blood smear and the bone marrow stained with Giemsa showed intra-eryhtrocytic parasites . The parasitemia was evaluated about 3% of red blood cells. Rapid testing for Plasmodium falciparum by PCR revealed negative. Intravenous treatment for babesiosis with clindamycin and quinine was started. Patient’s clinical status improved with the resolution of the fever after 3 days of treatment. Blood analysis improved after the 10 days treatment course (haemoglobin 104 g/L, platelets 220×109/L, neutrophils 3 G/L, C reactive protein 16 mg/L). PCR testing on blood for babesia was positive . Babesia microti was confirmed by PCR with specific primers (LDH gene amplification) as shown on Figure B. Serology for Borrelia burgdorferi, the agent of Lyme disease, was negative.", + "fulltext_subclaims": [ + "The patient is an 82-year-old man.", + "He presented at the emergency department for fever and chills lasting for 5 days.", + "He complained of severe asthenia.", + "He returned two weeks ago from a travel in New York city, USA.", + "He had a two days stay on the Long Island countryside.", + "He did not note any insect bite during his travel.", + "Jaundice was noticed on examination.", + "Slightly enlarged spleen and liver were noted.", + "Blood test showed neutropenia (0·5 G/L).", + "Blood test showed lymphopenia (0·3 G/L).", + "Blood test showed thrombocytopenia (30×109/L).", + "Blood test showed anemia (haemoglobin of 91 g/L).", + "Blood test showed a low reticulocyte count (45 G/L).", + "C reactive protein was increased to 154 mg/L.", + "Ferritin was raised to 5953 ng/ml.", + "ALT was 56 UI/L.", + "AST was 68 UI/L.", + "Alkaline phosphatase was 213 UI/L.", + "Total bilirubin was 48·9 μmol/L.", + "Haptoglobin was undetectable.", + "LDH levels were increased to 620 UI/L.", + "Coagulation tests were in normal range.", + "Routine blood cultures were negative.", + "Bone marrow aspiration showed typical hemophagocytosis.", + "Microscopic examination of the blood smear showed intra-eryhtrocytic parasites.", + "The parasitemia was evaluated about 3% of red blood cells.", + "Rapid testing for Plasmodium falciparum by PCR revealed negative.", + "Intravenous treatment for babesiosis with clindamycin and quinine was started.", + "The patient’s clinical status improved with the resolution of the fever after 3 days of treatment.", + "Blood analysis improved after the 10 days treatment course.", + "PCR testing on blood for babesia was positive.", + "Babesia microti was confirmed by PCR with specific primers (LDH gene amplification).", + "Serology for Borrelia burgdorferi was negative." + ], + "summary": "We report a European patient with severe pancytopenia and reactive hemophagocytosis related to a Babesia microti infection. Babesia infection was acquired during a travel in the USA.", + "summary_subclaims": [ + "The patient is from Europe.", + "The patient had severe pancytopenia.", + "The patient had reactive hemophagocytosis.", + "The reactive hemophagocytosis was related to a Babesia microti infection.", + "The Babesia infection was acquired during a travel in the USA." + ] + }, + { + "id": "multiclinsum_test_1441_en.txt", + "fulltext": "A 65-year-old male Caucasian patient was admitted with respiratory distress and suspected non-Hodgkin's lymphoma. His medical history revealed arterial hypertension, diabetes mellitus type 2 and cholecystolithiasis.\nOn clinical examination our obese patient (body mass index 41.5) suffered from dyspnea at rest. He presented with enlarged cervical and axillary lymph nodes, hepatosplenomegaly and diminished breath sounds over his right lung. A blood count revealed a leukocytosis of 35,000 leukocytes/μL of blood, with 80% partially atypical small lymphocytes and Gumprecht's shadow cells. Hemoglobin concentration and thrombocytes were within normal range. Immunophenotyping revealed that 67% of leukocytes were CD19+ B-lymphocytes, with co-expression of CD5, CD20, CD23 and a clonal restriction for the lambda light chain. This established the diagnosis of CLL. Bone marrow puncture demonstrated a medium degree of infiltration, with monoclonal B-cells beginning to replace the normal hematopoiesis.\nA chest X-ray was performed and showed a right-sided complete opacity suggesting a pleural effusion . Thoracentesis produced a milky pleural fluid . The cellular content consisted of 80% lymphocytes, two thirds of which expressed the B-CLL phenotype. Further analysis of the pleural fluid revealed triglyceride levels over 700 mg/dL and cholesterol levels below 70 mg/dL, establishing the diagnosis of chylothorax. Our patient received a pleural drainage, which initially produced nearly 3 liters of chyle per 24 hours. A computed tomography (CT) scan depicted enlarged lymph nodes in the cervical, axillary and mediastinal region, and suspected splenic involvement with several hypodense lesions. Taking the findings into account, our patient was diagnosed with a right-sided chylothorax caused by a concomitantly diagnosed CLL, stage Binet B or Rai II.\nThe chylothorax represented a major complication of the CLL, and so immunochemotherapy consisting of fludarabine (25 mg/m2 on days one to three), cyclophosphamide (250 mg/m2 on days one to three) and rituximab (375 mg/m2 on day one) was initiated. Our patient received four courses, repeated every four weeks. Since the therapeutic effect of reduced dietary intake on chylothorax had been described previously, our patient received total parenteral nutrition for two weeks, starting with the first cycle of the immunochemotherapy. The chylous effusion disappeared nearly completely, and the chest drain could be removed after 10 days. After two weeks an enteral low-fat diet enriched with medium-chain triglycerides was started, to continue therapy on an out-patient basis. Unfortunately the chylothorax relapsed and thoracentesis of a volume of 1 L to 1.5 L once to twice a week became necessary. Due to the low-fat intake the appearance of the pleural effusion had changed from milky-white to clear amber-colored .\nOur patient received four cycles of immunochemotherapy and regular thoracentesis on an out-patient basis. Since patients with protracted chylothorax are at risk of malnutrition and immunosuppression, our patient received antifungal and antiviral prophylaxis in addition to vitamin supplementation. However, the chylothorax persisted, despite a good clinical response of the CLL, with normalized blood counts and complete regression of the lymphadenopathy .\nIn light of this, percutaneous radiotherapy of his mediastinum and thoracic duct, with an overall dose of 24 Gy, was initiated. Radiation induces an inflammatory response which can result in an obliteration of the disrupted thoracic duct . However, up to eight weeks after completion of the radiotherapy the chylothorax still persisted with continued requirement for regular pleural tapping.\nFinally our patient agreed to a surgical intervention. A supradiaphragmal ligation of the thoracic duct via a right muscle sparing thoracotomy was carried out. In addition, a decortication of his right lung was necessary because, during his surgery, a pleural fibrosis was diagnosed. The pleural fibrosis was most likely caused by the long-term chylothorax with repetitive thoracenteses. Our patient quickly recovered and the pleural effusions ceased completely. The time from the first diagnosis of chylothorax until the final surgical intervention was six months. Our patient is still in complete remission after 24 months of follow-up.", + "fulltext_subclaims": [ + "The patient was a 65-year-old male Caucasian.", + "The patient was admitted with respiratory distress.", + "The patient had suspected non-Hodgkin's lymphoma.", + "The patient's medical history included arterial hypertension.", + "The patient's medical history included diabetes mellitus type 2.", + "The patient's medical history included cholecystolithiasis.", + "On clinical examination, the patient was obese with a body mass index of 41.5.", + "The patient had dyspnea at rest.", + "The patient had enlarged cervical and axillary lymph nodes.", + "The patient had hepatosplenomegaly.", + "The patient had diminished breath sounds over the right lung.", + "A blood count revealed a leukocytosis of 35,000 leukocytes/μL of blood.", + "The leukocytosis included 80% partially atypical small lymphocytes.", + "The leukocytosis included Gumprecht's shadow cells.", + "Hemoglobin concentration was within normal range.", + "Thrombocytes were within normal range.", + "Immunophenotyping showed 67% of leukocytes were CD19+ B-lymphocytes.", + "The CD19+ B-lymphocytes co-expressed CD5, CD20, CD23.", + "The CD19+ B-lymphocytes had a clonal restriction for the lambda light chain.", + "This established the diagnosis of CLL.", + "Bone marrow puncture showed a medium degree of infiltration.", + "The bone marrow infiltration was due to monoclonal B-cells.", + "The monoclonal B-cells were beginning to replace normal hematopoiesis.", + "A chest X-ray showed a right-sided complete opacity.", + "The opacity suggested a pleural effusion.", + "Thoracentesis produced a milky pleural fluid.", + "The pleural fluid had 80% lymphocytes.", + "Two thirds of the lymphocytes expressed the B-CLL phenotype.", + "The pleural fluid had triglyceride levels over 700 mg/dL.", + "The pleural fluid had cholesterol levels below 70 mg/dL.", + "This established the diagnosis of chylothorax.", + "The patient received a pleural drainage.", + "The drainage initially produced nearly 3 liters of chyle per 24 hours.", + "A CT scan showed enlarged lymph nodes in the cervical, axillary, and mediastinal regions.", + "The CT scan showed suspected splenic involvement with several hypodense lesions.", + "The patient was diagnosed with a right-sided chylothorax.", + "The chylothorax was caused by a concomitantly diagnosed CLL.", + "The stage of the CLL was Binet B or Rai II.", + "The chylothorax was a major complication of the CLL.", + "Immunochemotherapy was initiated.", + "The immunochemotherapy included fludarabine (25 mg/m2 on days one to three).", + "The immunochemotherapy included cyclophosphamide (250 mg/m2 on days one to three).", + "The immunochemotherapy included rituximab (375 mg/m2 on day one).", + "The patient received four courses of immunochemotherapy.", + "The courses were repeated every four weeks.", + "The patient received total parenteral nutrition for two weeks.", + "The total parenteral nutrition started with the first cycle of immunochemotherapy.", + "The chylous effusion disappeared nearly completely.", + "The chest drain could be removed after 10 days.", + "An enteral low-fat diet enriched with medium-chain triglycerides was started after two weeks.", + "The chylothorax relapsed.", + "Thoracentesis of 1 L to 1.5 L once to twice a week became necessary.", + "The pleural effusion changed from milky-white to clear amber-colored due to low-fat intake.", + "The patient received four cycles of immunochemotherapy.", + "The patient received regular thoracentesis on an out-patient basis.", + "The patient received antifungal and antiviral prophylaxis.", + "The patient received vitamin supplementation.", + "The chylothorax persisted despite a good clinical response of the CLL.", + "The blood counts normalized.", + "The lymphadenopathy completely regressed.", + "Percutaneous radiotherapy of the mediastinum and thoracic duct was initiated.", + "The radiotherapy had an overall dose of 24 Gy.", + "Radiation induces an inflammatory response.", + "The inflammatory response can result in an obliteration of the disrupted thoracic duct.", + "Up to eight weeks after completion of radiotherapy, the chylothorax still persisted.", + "The patient agreed to a surgical intervention.", + "A supradiaphragmal ligation of the thoracic duct via a right muscle sparing thoracotomy was carried out.", + "A decortication of the right lung was necessary.", + "A pleural fibrosis was diagnosed during surgery.", + "The pleural fibrosis was most likely caused by the long-term chylothorax.", + "The pleural fibrosis was most likely caused by repetitive thoracenteses.", + "The patient quickly recovered.", + "The pleural effusions ceased completely.", + "The time from the first diagnosis of chylothorax until the final surgical intervention was six months.", + "The patient is still in complete remission after 24 months of follow-up." + ], + "summary": "We present the case of a 65-year-old male Caucasian patient with right-sided chylothorax caused by a concomitantly diagnosed chronic lymphocytic leukemia. As first-line treatment four cycles of an immunochemotherapy, consisting of fludarabine, cyclophosphamide and rituximab were administered. In addition, our patient received total parenteral nutrition for the first two weeks of treatment. Despite the very good clinical response of the lymphoma to treatment, the chylothorax persisted and percutaneous radiotherapy of the thoracic duct was applied. However, eight weeks after the radiotherapy the chylothorax still persisted and our patient agreed to a surgical intervention. A ligation of the thoracic duct via a muscle sparing thoracotomy was performed, resulting in a complete cessation of the pleural effusion. Apart from the first two weeks our patient was treated on an out-patient basis for nearly six months.", + "summary_subclaims": [ + "The patient is a 65-year-old male Caucasian.", + "The patient had right-sided chylothorax.", + "The chylothorax was caused by chronic lymphocytic leukemia.", + "The patient received four cycles of immunochemotherapy.", + "The immunochemotherapy consisted of fludarabine, cyclophosphamide, and rituximab.", + "The patient received total parenteral nutrition for the first two weeks of treatment.", + "The lymphoma had a very good clinical response to treatment.", + "The chylothorax persisted despite the very good clinical response of the lymphoma.", + "Percutaneous radiotherapy of the thoracic duct was applied.", + "Eight weeks after radiotherapy, the chylothorax still persisted.", + "A ligation of the thoracic duct via a muscle sparing thoracotomy was performed.", + "The ligation resulted in a complete cessation of the pleural effusion." + ] + }, + { + "id": "multiclinsum_test_3315_en.txt", + "fulltext": "A 29-year-old male patient was admitted to our department on December 29th, 2020 with complaints of moderate pain and chronic subcutaneous abscess with purulent flow from his old surgical scar on the lower back.\n\nThirty-four months before admission, the patient underwent a traditional open bilateral L4 laminotomy without discectomy and intraspine device insertion for the treatment of L4-5 central lumbar spinal stenosis at another hospital. The patient was discharged 4 days after surgery without radiating pain, and the surgical wound was well healed. He gradually returned to his normal activity and work. However, he had moderate pain, redness and swelling of his old surgical scar approximately one month before coming to our hospital, but he did not receive any treatment. One month later, he had a mass at his old surgical scar site with purulent discharge, and he visited our hospital.\n\nA chronic subcutaneous abscess and normal neurological findings were found by physical examination. The erythrocyte sedimentation rate (ESR) was 2 mm/h, and the white blood cell (WBC) count was 6.550/mm3. Magnetic resonance imaging (MRI) of the lumbar spine was performed on the day of the visit and showed a chronic subcutaneous abscess connected to the artificial device. No evidence of lumbar discitis or epidural abscess was detected on MRI.\n\nStaphylococcus aureus was found in cultures of purulent flow from the chronic subcutaneous abscess, and cefoxitin 4 gr/day was initiated according to the sensitivity tests. The artificial implant was removed, debridement of the soft tissue and L4 and L5 spinous processes was performed, and closed drainage and wound closure were achieved. Pathological examination of the surgical material was consistent with chronic nonspecific infection, and Staphylococcus aureus was detected again in cultures.\n\nThe wound healed satisfactorily, and the patient was discharged on the 10th postoperative day. He had no complaints more than 2 years later.", + "fulltext_subclaims": [ + "A 29-year-old male patient was admitted to our department on December 29th, 2020.", + "The patient had moderate pain and chronic subcutaneous abscess with purulent flow from his old surgical scar on the lower back.", + "Thirty-four months before admission, the patient underwent a traditional open bilateral L4 laminotomy without discectomy and intraspine device insertion.", + "The surgery was performed for the treatment of L4-5 central lumbar spinal stenosis at another hospital.", + "The patient was discharged 4 days after surgery without radiating pain.", + "The surgical wound was well healed after the surgery.", + "He gradually returned to his normal activity and work.", + "He had moderate pain, redness and swelling of his old surgical scar approximately one month before coming to our hospital.", + "He did not receive any treatment for the redness and swelling.", + "One month later, he had a mass at his old surgical scar site with purulent discharge.", + "A chronic subcutaneous abscess was found by physical examination.", + "The erythrocyte sedimentation rate (ESR) was 2 mm/h.", + "The white blood cell (WBC) count was 6.550/mm3.", + "Magnetic resonance imaging (MRI) of the lumbar spine was performed on the day of the visit.", + "MRI showed a chronic subcutaneous abscess connected to the artificial device.", + "No evidence of lumbar discitis or epidural abscess was detected on MRI.", + "Staphylococcus aureus was found in cultures of purulent flow from the chronic subcutaneous abscess.", + "Cefoxitin 4 gr/day was initiated according to the sensitivity tests.", + "The artificial implant was removed.", + "Debridement of the soft tissue and L4 and L5 spinous processes was performed.", + "Closed drainage and wound closure were achieved.", + "Pathological examination of the surgical material was consistent with chronic nonspecific infection.", + "Staphylococcus aureus was detected again in cultures.", + "The wound healed satisfactorily.", + "The patient was discharged on the 10th postoperative day.", + "He had no complaints more than 2 years later." + ], + "summary": "A 29-year-old male patient was admitted to our department with complaints of moderate pain and chronic subcutaneous abscess with purulent flow from his old surgical scar. Thirty-four months ago, he underwent a traditional open bilateral L4 laminotomy without discectomy and intraspine insertion for the treatment of L4-5 central lumbar spinal stenosis at another hospital. The patient was discharged 4 days after surgery without radiating pain, and the surgical wound was well healed. He gradually returned to his normal activity and work. However, he experienced moderate pain, redness and swelling of his old surgical scar approximately one month before coming to our hospital, but he did not receive any treatment. One month later, he had a mass with purulent discharge at the surgical scar site, and he visited our hospital on December 29th, 2020. Based on the physical examination and MRI findings, delayed -SSI was diagnosed. The patient underwent removal of the intraspine device, debridement and wound closure with closed drainage. The wound healed satisfactorily, and the patient had no complaints more than 2 years later.\n\nConclusion: A delayed surgical site infection following intraspine insertion may have occurred.", + "summary_subclaims": [ + "The patient is a 29-year-old male.", + "The patient had moderate pain and chronic subcutaneous abscess with purulent flow from his old surgical scar.", + "Thirty-four months ago, he underwent a traditional open bilateral L4 laminotomy without discectomy and intraspine insertion.", + "The surgery was performed for the treatment of L4-5 central lumbar spinal stenosis.", + "The patient was discharged 4 days after surgery.", + "The surgical wound was well healed at discharge.", + "He gradually returned to his normal activity and work.", + "Approximately one month before coming to our hospital, he experienced moderate pain, redness, and swelling of his old surgical scar.", + "He did not receive any treatment for the pain, redness, and swelling.", + "One month later, he had a mass with purulent discharge at the surgical scar site.", + "He visited our hospital on December 29th, 2020.", + "Based on the physical examination and MRI findings, delayed -SSI was diagnosed.", + "The patient underwent removal of the intraspine device.", + "The patient underwent debridement and wound closure with closed drainage.", + "The wound healed satisfactorily.", + "The patient had no complaints more than 2 years later.", + "A delayed surgical site infection following intraspine insertion may have occurred." + ] + }, + { + "id": "multiclinsum_test_3_en.txt", + "fulltext": "A 50-year-old Caucasian male collapsed unexpectedly whilst playing football. He was brought to hospital following successful resuscitation for an out-of-hospital ventricular tachycardia (VT) arrest. He had no significant past medical or family history of cardiac disease and was a keen recreational athlete, playing 5-a-side football regularly and cycling 60–100 miles per week. In the months leading up to his cardiac arrest, he recalled three brief episodes of exertional pre-syncope whilst playing sports. On admission, coronary angiography showed unobstructed epicardial vessels and echocardiography revealed mild LV impairment with normal heart valves. An FDG PET–computed tomography scan was negative for active myocardial inflammation. However, cardiovascular magnetic resonance imaging (CMRI) demonstrated a mildly dilated and moderately impaired LV [left ventricular ejection fraction (LVEF) 41%] with epicardial late gadolinium enhancement of the lateral wall and subendocardial enhancement of the septum. The RV was non-dilated with no regional wall motion abnormalities (Videos 1–3).\nA diagnosis of ACM was suspected, and he received an implantable cardiac defibrillator (ICD) for secondary prevention. Post-implantation, his 12-lead electrocardiogram (ECG) showed an atrial paced rhythm with normal ventricular conduction . The limb lead complexes were of low voltage and demonstrated fractionated QRS complexes. There were flattened inferolateral T waves and his signal-averaged ECG was negative for late potentials. He was discharged on Bisoprolol 5 mg daily, lifestyle advice to limit his exercise intensity, and referred for genetic testing along with a recommendation for clinical screening of his family members. He was asymptomatic for a significant period, but at 26 months follow-up device interrogation demonstrated three runs of non-sustained ventricular tachycardia (NSVT) and he received one shock for sustained fast VT. He was then trialled on Nadolol therapy. Genetic testing for pathogenic Lamin A variants and subsequent testing against a panel of 77 cardiomyopathy and arrhythmia-related genes were negative.\nAt 41 months, an echocardiogram demonstrated a mildly dilated LV with mild-moderate systolic impairment (LVEF 45%). Interrogation of his ICD revealed two episodes of NSVT and one fast sustained VT treated by antitachycardia pacing. He was switched to Sotalol for its Class III antiarrhythmic properties and started Ramipril 1.25 mg once daily. Given his electrical and structural phenotype, genetic testing was extended to include FLNC. Subsequently, he tested positive for a likely pathogenic FLNC frameshift variant [c.8107del; p.(Asp2703ThrfsTer69)], thus confirming the diagnosis of ALVC. Predictive testing also uncovered the variant in his three children, all of whom had variable clinical expression of the disease.\nAt 52 months he was climbing a ski slope and experienced an episode of fast VT requiring an ICD shock . Following urgent electrophysiology outpatient review, he was referred for VT ablation utilizing a combined endocardial and epicardial approach. During the procedure, two types of VT arising from the LV were readily induced and radiofrequency ablation was targeted to abnormal local potentials and the region surrounding epicardial and endocardial scar. At 6 months post-ablation, he was asymptomatic and arrhythmia free on Sotalol 80 mg twice daily, and echocardiography showed some improvement in LV systolic function (LVEF 50–54%).", + "fulltext_subclaims": [ + "A 50-year-old Caucasian male collapsed unexpectedly whilst playing football.", + "He was brought to hospital following successful resuscitation for an out-of-hospital ventricular tachycardia (VT) arrest.", + "He had no significant past medical or family history of cardiac disease.", + "In the months leading up to his cardiac arrest, he recalled three brief episodes of exertional pre-syncope whilst playing sports.", + "Coronary angiography showed unobstructed epicardial vessels.", + "Echocardiography revealed mild LV impairment with normal heart valves.", + "An FDG PET–computed tomography scan was negative for active myocardial inflammation.", + "Cardiovascular magnetic resonance imaging (CMRI) demonstrated a mildly dilated and moderately impaired LV with LVEF 41%.", + "CMRI showed epicardial late gadolinium enhancement of the lateral wall.", + "CMRI showed subendocardial enhancement of the septum.", + "The RV was non-dilated with no regional wall motion abnormalities.", + "A diagnosis of ACM was suspected.", + "He received an implantable cardiac defibrillator (ICD) for secondary prevention.", + "Post-implantation, his 12-lead ECG showed an atrial paced rhythm with normal ventricular conduction.", + "The limb lead complexes were of low voltage.", + "The limb lead complexes demonstrated fractionated QRS complexes.", + "There were flattened inferolateral T waves.", + "His signal-averaged ECG was negative for late potentials.", + "He was discharged on Bisoprolol 5 mg daily.", + "He was advised to limit his exercise intensity.", + "He was referred for genetic testing.", + "He was recommended for clinical screening of his family members.", + "At 26 months follow-up device interrogation demonstrated three runs of non-sustained ventricular tachycardia (NSVT).", + "He received one shock for sustained fast VT.", + "He was trialled on Nadolol therapy.", + "Genetic testing for pathogenic Lamin A variants was negative.", + "Subsequent testing against a panel of 77 cardiomyopathy and arrhythmia-related genes was negative.", + "At 41 months, an echocardiogram demonstrated a mildly dilated LV with mild-moderate systolic impairment (LVEF 45%).", + "Interrogation of his ICD revealed two episodes of NSVT.", + "Interrogation of his ICD revealed one fast sustained VT treated by antitachycardia pacing.", + "He was switched to Sotalol for its Class III antiarrhythmic properties.", + "He was started on Ramipril 1.25 mg once daily.", + "Given his electrical and structural phenotype, genetic testing was extended to include FLNC.", + "He tested positive for a likely pathogenic FLNC frameshift variant [c.8107del; p.(Asp2703ThrfsTer69)].", + "This confirmed the diagnosis of ALVC.", + "Predictive testing also uncovered the variant in his three children.", + "At 52 months he was climbing a ski slope and experienced an episode of fast VT requiring an ICD shock.", + "He was referred for VT ablation utilizing a combined endocardial and epicardial approach.", + "During the procedure, two types of VT arising from the LV were readily induced.", + "Radiofrequency ablation was targeted to abnormal local potentials.", + "Radiofrequency ablation was targeted to the region surrounding epicardial and endocardial scar.", + "At 6 months post-ablation, he was asymptomatic and arrhythmia free on Sotalol 80 mg twice daily.", + "Echocardiography at 6 months post-ablation showed some improvement in LV systolic function (LVEF 50–54%)." + ], + "summary": "A 50-year-old athletic male was admitted following an out-of-hospital cardiac arrest due to ventricular tachycardia (VT) whilst playing football. Coronary angiography revealed unobstructed epicardial vessels and the diagnosis of ALVC was suggested by cardiovascular magnetic resonance imaging, which demonstrated a mildly dilated and moderately impaired left ventricle with epicardial late gadolinium enhancement in the basal to mid-lateral walls and subendocardial septum. Initial testing with a cardiomyopathy and arrhythmia gene panel was negative but extended testing uncovered a likely pathogenic variant in FLNC. Subsequently, the patient experienced a recurrence of sustained VT necessitating implantable cardioverter-defibrillator (ICD) therapies, ultimately undergoing a combined epicardial and endocardial VT ablation 4 years after presentation. Six months post-ablation, he was asymptomatic and his arrhythmia rendered quiescent.", + "summary_subclaims": [ + "The patient was a 50-year-old athletic male.", + "The patient was admitted following an out-of-hospital cardiac arrest.", + "The cardiac arrest was due to ventricular tachycardia.", + "The cardiac arrest occurred while the patient was playing football.", + "Coronary angiography revealed unobstructed epicardial vessels.", + "The diagnosis of ALVC was suggested by cardiovascular magnetic resonance imaging.", + "Cardiovascular magnetic resonance imaging demonstrated a mildly dilated and moderately impaired left ventricle.", + "Cardiovascular magnetic resonance imaging showed epicardial late gadolinium enhancement in the basal to mid-lateral walls.", + "Cardiovascular magnetic resonance imaging showed subendocardial septum enhancement.", + "Initial testing with a cardiomyopathy and arrhythmia gene panel was negative.", + "Extended testing uncovered a likely pathogenic variant in FLNC.", + "The patient experienced a recurrence of sustained VT.", + "The recurrence necessitated implantable cardioverter-defibrillator therapies.", + "The patient underwent a combined epicardial and endocardial VT ablation.", + "The ablation occurred 4 years after presentation.", + "Six months post-ablation, the patient was asymptomatic.", + "The arrhythmia rendered quiescent six months post-ablation." + ] + }, + { + "id": "multiclinsum_test_431_en.txt", + "fulltext": "A 53-year-old Japanese man affected by NF-1 presented with a three-week history of jaundice, upper abdominal discomfort, dysphagia and loss of appetite . His mother had a history of neurofibromatosis. Upon physical examination, a smooth mass, with its largest dimension measuring 20 cm, was palpated in his right upper abdomen. On admission, laboratory findings revealed leukocytosis, with a white blood cell count of 12,200/mm3; aspartate aminotransferase, 75 U/L; alanine aminotransferase, 75 U/L; alkaline phosphates 1913 U/L; γ-glutamyl transferase, 960 U/L; total protein, 7.4 g/dL; and total bilirubin, 4.4 mg/dL. His C-reactive protein level was 9.3 mg/mL (normal range, 0.5 mg/mL to 0.8 mg/mL). His serum level of carcinoembryonic antigen (CEA) was extremely high at 3050 ng/mL (cutoff, 2.5 ng/mL), and his α-fetoprotein (AFP) level was 812 ng/mL (cutoff, 10 ng/mL). The carbohydrate antigen (CA) 72-4 was also high at 180 U/mL (cutoff, 8.0 U/mL); CA 19-9 was normal at 16 U/mL (cutoff, 37 U/mL). An upper GI barium study showed a 5.0 cm filling defect on his cardia that extended to his lower esophagus. An abdominal computerized tomography (CT) scan showed multiple liver lesions and ascites, but no lymph node enlargement was identified . Gastroendoscopic examination revealed a tumor with a 6 cm diameter on the esophagogastric junction, which was spreading to his esophagus . Multiple biopsies showed moderately differentiated tubular adenocarcinoma of the stomach at stage IV . An immunohistochemical study showed that CEA-positive and AFP-negative cells were present in the tumor . Our patient was administered palliative chemotherapy and treated with TS-1 (tegafur, gimeracil, oteracil potassium). Our patient died due to liver failure a month after initial admission. A pathological review of necropsy specimens of his liver lesions showed moderately differentiated tubular adenocarcinoma . An immunohistochemical study showed that CEA-positive and AFP-negative cells were present in the metastatic liver tumor resembling the gastric lesion .", + "fulltext_subclaims": [ + "The patient is a 53-year-old Japanese man.", + "The patient is affected by NF-1.", + "The patient had a three-week history of jaundice.", + "The patient had a three-week history of upper abdominal discomfort.", + "The patient had a three-week history of dysphagia.", + "The patient had a three-week history of loss of appetite.", + "His mother had a history of neurofibromatosis.", + "A smooth mass, with its largest dimension measuring 20 cm, was palpated in his right upper abdomen.", + "On admission, the white blood cell count was 12,200/mm3.", + "On admission, aspartate aminotransferase was 75 U/L.", + "On admission, alanine aminotransferase was 75 U/L.", + "On admission, alkaline phosphatase was 1913 U/L.", + "On admission, γ-glutamyl transferase was 960 U/L.", + "On admission, total bilirubin was 4.4 mg/dL.", + "His C-reactive protein level was 9.3 mg/mL.", + "His serum level of carcinoembryonic antigen (CEA) was 3050 ng/mL.", + "His α-fetoprotein (AFP) level was 812 ng/mL.", + "The carbohydrate antigen (CA) 72-4 was 180 U/mL.", + "An upper GI barium study showed a 5.0 cm filling defect on his cardia that extended to his lower esophagus.", + "An abdominal CT scan showed multiple liver lesions.", + "An abdominal CT scan showed ascites.", + "Gastroendoscopic examination revealed a tumor with a 6 cm diameter on the esophagogastric junction.", + "Multiple biopsies showed moderately differentiated tubular adenocarcinoma of the stomach at stage IV.", + "An immunohistochemical study showed that CEA-positive and AFP-negative cells were present in the tumor.", + "The patient was administered palliative chemotherapy.", + "The patient was treated with TS-1.", + "The patient died due to liver failure a month after initial admission.", + "A pathological review of necropsy specimens of his liver lesions showed moderately differentiated tubular adenocarcinoma.", + "An immunohistochemical study showed that CEA-positive and AFP-negative cells were present in the metastatic liver tumor resembling the gastric lesion." + ], + "summary": "We report a case of an adenocarcinoma of the stomach in a 53-year-old Japanese man with neurofibromatosis type 1. An abdominal computed tomography scan and ultrasonography showed tumors in his liver. Gastric fibroscopy revealed a Borrmann type III tumor on his cardia that had spread to his esophagus and was highly suspicious for malignancy. Multiple biopsies showed an adenocarcinoma of the stomach, which was evaluated as gastric cancer, stage IV. Chemotherapy with TS-1 was performed. Our patient died four weeks after initial admission. Histological examination of a liver needle biopsy showed metastatic adenocarcinoma in his liver.", + "summary_subclaims": [ + "The patient is a 53-year-old Japanese man.", + "The patient has neurofibromatosis type 1.", + "An abdominal computed tomography scan showed tumors in his liver.", + "Ultrasonography showed tumors in his liver.", + "Gastric fibroscopy revealed a Borrmann type III tumor on his cardia.", + "The tumor had spread to his esophagus.", + "The tumor was highly suspicious for malignancy.", + "Multiple biopsies showed an adenocarcinoma of the stomach.", + "The cancer was evaluated as gastric cancer, stage IV.", + "Chemotherapy with TS-1 was performed.", + "The patient died four weeks after initial admission.", + "Histological examination of a liver needle biopsy showed metastatic adenocarcinoma in his liver." + ] + }, + { + "id": "multiclinsum_test_867_en.txt", + "fulltext": "A 56-year-old male patient was admitted to our hospital on 2022-09-19 with “chest tightness and chest pain for more than 2 months, aggravated for 20 days”, The patient have mild cough and expectoration, and had a weight loss of 10 kilogram (KG) in the past 2 months. The patient had a history of afternoon low fever before 1 week and the Physical examination revealed body temperature 36.5 °C, respiratory rate 25/min, pulse rate 96 beats/min, oxygen saturation 93%, 24-hour urine output about 600 mL, Performance status (PS) 3 points, he had a clear consciousness, poor mental health, anemia, enlarged superficial lymph nodes, barrel-shaped chest, swollen skin on the right side of the chest and the right side of the upper abdomen, solid percussion sounds on the right side of the chest with mixed turbid sounds, enlarged liver on the right side, no edema in the extremities, and deep yellow urine. Past medical history: mitral valvuloplasty and aortic valve replacement for mitral valve and aortic valve insufficiency at the Second Affiliated Hospital of Nanchang University under general anesthesia on 2021-08-11, long-term oral treatment with warfarin anticoagulation and metoprolol. Personal history: smoker for 40 years, 10 cigarettes per day, and no alcoholic habits, have no history of contact with a chronically coughing person suspected of or treated for TB.\nAdmission biochemical examination: neuronal enolase 35.97 ng/mL, fibrin degradation products 10.86 mg/L, prothrombin time 141.2 seconds, prothrombin normalized ratio 11.87 INR, activated partial thromboplastin time 121.7 seconds, fibrinogen 4.72 g/L, leukocytes 11.94×109/L, hemoglobin 36 g/L, albumin 22.3 g/L, white/sphere 0.5, glutamate transaminase 114 IU/L, glutathione transaminase 288 IU/L, glutamyl transferase 92 IU/L, lactate dehydrogenase 492 IU/L, coagulation factor VIII activity 239.2%, coagulation factor IX activity 10.1%, coagulation factor XII activity 34.4%, Procalcitonin (PCT) 0.43 ng/mL, ultrasensitive C-reactive protein (gold standard) 124.00 mg/L, TSPOT negative, sputum negative for antacid bacilli, anti-TB antibody Weakly positive, fecal occult blood negative, EBV test was negative, and HIV was negative. The CT examination report : multiple wall nodules in the right pleura, right pleural encapsulated effusion with limited swelling insufficiency in the middle and lower lobes of the right lung, enlarged lymph nodes in the right hilar and mediastinal diaphragm groups, bone destruction in the 2nd thoracic vertebra, multiple slightly hypodense nodules in the liver. The possibility of multiple metastases of right lung cancer with malignant pleural fluid and possible infection in the upper lobes of both lungs was considered. Finally, a Ultrasonic guided needle biopsy of the lymph node, pleural, liver was performed and the histopathology showed coagulative necrosis combining with granulomatous inflammation (acid-fast bacilli staining was positive). Research shows Tuberculosis (TB) in humans is characterized by formation of immune-rich granulomas in infected tissues, And confirmative diagnosis is based on liver biopsy where demonstration of acid-fast bacilli on acid-fast bacilli staining and caseous necrosis is a very useful histopathological sign. Thus, the diag-nosis of TB infection was definite.", + "fulltext_subclaims": [ + "The patient is a 56-year-old male.", + "The patient was admitted on 2022-09-19.", + "The patient had chest tightness and chest pain for more than 2 months.", + "The patient had a weight loss of 10 kilogram in the past 2 months.", + "The patient had a history of afternoon low fever before 1 week.", + "The patient had a clear consciousness.", + "The patient had anemia.", + "The patient had enlarged superficial lymph nodes.", + "The patient had barrel-shaped chest.", + "The patient had swollen skin on the right side of the chest.", + "The patient had solid percussion sounds on the right side of the chest.", + "The patient had enlarged liver on the right side.", + "The patient had deep yellow urine.", + "The patient had a history of mitral valvuloplasty and aortic valve replacement at the Second Affiliated Hospital of Nanchang University on 2021-08-11.", + "The patient had long-term oral treatment with warfarin anticoagulation.", + "The patient had long-term oral treatment with metoprolol.", + "The patient was a smoker for 40 years, 10 cigarettes per day.", + "The patient had no history of contact with a chronically coughing person suspected of or treated for TB.", + "The CT examination showed multiple wall nodules in the right pleura.", + "The CT examination showed right pleural encapsulated effusion.", + "The CT examination showed bone destruction in the 2nd thoracic vertebra.", + "The CT examination showed multiple slightly hypodense nodules in the liver.", + "The possibility of multiple metastases of right lung cancer with malignant pleural fluid was considered.", + "The histopathology showed coagulative necrosis combining with granulomatous inflammation.", + "Acid-fast bacilli staining was positive.", + "The diagnosis of TB infection was definite." + ], + "summary": "A HIV-negative 56-year-old male was hospitalized for chest disease with main symptoms of chest tightness, chest pain, fatigue, anorexia, and weight loss. Heart rate 109 times/min, the computed tomography (CT) scans of the neck, chest, and abdomen revealed multiple nodules in the right pleura, right pleural encapsulated effusion, and limited, incomplete expansion of the middle and lower lobes of the right lung, enlarged lymph nodes in the right hilar and mediastinal and diaphragm groups, and multiple slightly low-density nodules in the liver, bone destruction in the 2nd thoracic vertebra, raising the possibility of multiple liver metastases of right lung cancer and malignant pleural fluid. The lymph nodes in the neck, mediastinum, abdomen, and pelvis were enlarged bilaterally. After comprehensive analysis, the patient was diagnosed with atypical systemic HDTB. After three months of conventional anti-TB treatment, the patient refused our hospital follow-up, and his symptoms improved significantly during the telephone follow-up.", + "summary_subclaims": [ + "The patient is a 56-year-old male.", + "The patient is HIV-negative.", + "The patient was hospitalized for chest disease.", + "The patient's main symptoms included chest tightness.", + "The patient's main symptoms included chest pain.", + "The patient's main symptoms included fatigue.", + "The patient's main symptoms included anorexia.", + "The patient's main symptoms included weight loss.", + "The patient's heart rate was 109 times/min.", + "CT scans of the neck, chest, and abdomen revealed multiple nodules in the right pleura.", + "CT scans revealed right pleural encapsulated effusion.", + "CT scans showed limited, incomplete expansion of the middle and lower lobes of the right lung.", + "CT scans showed enlarged lymph nodes in the right hilar and mediastinal and diaphragm groups.", + "CT scans showed multiple slightly low-density nodules in the liver.", + "CT scans showed bone destruction in the 2nd thoracic vertebra.", + "The findings raised the possibility of multiple liver metastases of right lung cancer.", + "The findings raised the possibility of malignant pleural fluid.", + "The lymph nodes in the neck, mediastinum, abdomen, and pelvis were enlarged bilaterally.", + "The patient was diagnosed with atypical systemic HDTB.", + "The patient received three months of conventional anti-TB treatment.", + "The patient refused follow-up at our hospital.", + "The patient's symptoms improved significantly during telephone follow-up." + ] + }, + { + "id": "multiclinsum_test_3391_en.txt", + "fulltext": "A 28 year-old male was found to have a slightly increased serum creatinine (1.7 mg/dl) during the admission to ER because of abdominal pain. Since both his past medical history and an abdominal ultrasound performed on admission were unremarkable he was discharged with the indication to see a Nephrologist. At the Nephrology outpatient clinic, because of the reduced eGFR and of the presence of proteinuria (300 mg/24 h), an hospitalization for further investigations was planned.\n\nWhile waiting for the admission, a couple of weeks later, the patient was admitted to the emergency room in another hospital for abdominal pain and dyspnea. On admittance the ECG tracing performed showed sinus rhythm with diffuse repolarization abnormalities. Further exams revealed an increase of troponin (54 ng/ml) and transaminases levels (GOT 50 U/L; GPT 125 U/L) and a cardiac ultrasound showed a severe left ventricular dysfunction with right heart failure. Patient was thus admitted to the coronary intensive care unit. During his hospital stay the possibility of acute myocarditis was excluded because of the absence of a recent viral syndrome and the negativity of IgM antibodies against the viruses most commonly affecting the cardiovascular system and because of the low inflammatory indexes. An abdominal ultrasound demonstrated abdominal and pleural effusions, regular size and morphology of spleen and liver, no pancreatic changes; both kidneys had normal size but showed irregular margins and a reduced thickness of the cortex, no hydronephrosis nor stones were observed. A magnetic resonance demonstrated an increased volume of the cardiac chambers with a severe reduction of the function of both ventricles (EF20%), however no signs of reduced myocardial perfusion, valvular defects or other tissue changes such as inflammation, fibrosis or edema could be demonstrated. A chest CT scan confirmed the presence of pleural effusion and showed parenchymal atelectasias mainly involving the lower lobes of the lungs. The patient was discharged after 11 days on diuretics (furosemide 100 mg/daily), B-blocker (carvedilol 37.5 mg/daily), acetyl salicylic acid (Aspirin 100 mg/day) and an Ace inhibitor (Ramipril 5 mg/day) with a diagnosis of dilated cardiomyopathy and severe left ventricular dysfunction complicated with cardiogenic shock and anasarca. Few days later an EKG ergometric test revealed no areas of inducible ischemia. A further admission to the Cardiology Unit to define the effect of treatment was performed a week later. Cardiac ultrasound confirmed the left ventricular dysfunction (EF 23%), a coronary angiography was negative and a right chamber catheterism and endomyocardic biopsy demonstrated no specific lesion nor inflammatory infiltrate. The patient was then admitted to our Nephrology Unit, as planned, to evaluate the cause of the chronic kidney disease. On admission the patient appeared healthy and well oriented, his blood pressure was 110/60 mmHg, heart rate 56 bpm, physical examination was unremarkable except for a 1/6 intensity systolic heart murmur better audible on mitral valve area. ECG tracing showed sinus bradycardia. Laboratory studies revealed an increased serum creatinine (1.87 mg/dl), eGFR 48 ml/min/1.73 m2, hypercalcemia (serum calcium 11.5 mg/dl), hemoglobin 15.1 g/dl, sodium 135 mEq/L, potassium 4.37 mEq/L, phosphate 3.1 mg/dl, serum albumin 4.07 g/dl. The patient denied use of vitamin D analogs thus in consideration of the unexplained hypercalcemia other exams were performed. Thyroid hormones, calcitonin, vitamin D, serum ACE, phosphate and calcium urinary excretion rate were all within the normal range. PTH was lower than 3 pg/ml. To rule out multiple myeloma serum protein electrophoresis, serum and urine immunofixation, and spine and skull x-ray were performed and did not show any pathological changes.\n\nRenal biopsy was finally performed without complications and the patient was discharged after 24 h. While waiting for the renal biopsy pathology report, medications were not modified, but for an increase of the dose of furosemide because of the hypercalcemia. The renal biopsy contained eight glomeruli none of which was globally or partially sclerotic and no pathological changes were observed at glomerular level, vessels were also unremarkable. Tubulointerstitium was the only affected compartment with a moderate to severe inflammatory infiltrate, some calcium crystals in the tubular lumen and two granulomas with multinucleated giant cells. No necrosis could be observed within the granulomas. A diagnosis of granulomatous interstitial nephritis due to sarcoidosis was made.\n\nWhen the patient was called to discuss his kidney biopsy, his serum creatinine had further increased (3.5 mg /dl), eGFR 22 ml/min/1.73 m2 and so had his serum calcium (13.3 mg/dl), serum albumin 4.06 g/dl. For this reason, he was hospitalized again and treated with pulse methylprednisolone (250 mg/day for three days) and then with maintenance dose prednisone (50 mg/day). Serum creatinine decreased in a few days and so did his serum calcium. Since the episode of acute kidney injury the patient has been followed at our unit and at the unit of Cardiology. Renal function returned to normal (serum creatinine 1.1 mg/dl, eGFR 91 ml/min/1.73 m2) and heart function markedly improved over the following two years (EF 49% vs 37% vs 32% vs 23%). The diuretic and cardiologic therapy was significantly reduced to only 25 mg of furosemide and a small dose of beta blocker. The steroid was gradually tapered to 5 mg/day of prednisone for one year and then stopped.", + "fulltext_subclaims": [ + "A 28 year-old male was found to have a slightly increased serum creatinine (1.7 mg/dl) during the admission to ER because of abdominal pain.", + "Both his past medical history and an abdominal ultrasound performed on admission were unremarkable.", + "He was discharged with the indication to see a Nephrologist.", + "At the Nephrology outpatient clinic, because of the reduced eGFR and of the presence of proteinuria (300 mg/24 h), an hospitalization for further investigations was planned.", + "A couple of weeks later, the patient was admitted to the emergency room in another hospital for abdominal pain and dyspnea.", + "On admittance the ECG tracing performed showed sinus rhythm with diffuse repolarization abnormalities.", + "Further exams revealed an increase of troponin (54 ng/ml) and transaminases levels (GOT 50 U/L; GPT 125 U/L).", + "A cardiac ultrasound showed a severe left ventricular dysfunction with right heart failure.", + "The possibility of acute myocarditis was excluded because of the absence of a recent viral syndrome.", + "The negativity of IgM antibodies against the viruses most commonly affecting the cardiovascular system was noted.", + "The low inflammatory indexes were noted.", + "An abdominal ultrasound demonstrated abdominal and pleural effusions.", + "Both kidneys had normal size but showed irregular margins and a reduced thickness of the cortex.", + "A magnetic resonance demonstrated an increased volume of the cardiac chambers with a severe reduction of the function of both ventricles (EF20%).", + "No signs of reduced myocardial perfusion, valvular defects or other tissue changes such as inflammation, fibrosis or edema could be demonstrated.", + "A chest CT scan confirmed the presence of pleural effusion.", + "A chest CT scan showed parenchymal atelectasias mainly involving the lower lobes of the lungs.", + "The patient was discharged after 11 days on diuretics (furosemide 100 mg/daily), B-blocker (carvedilol 37.5 mg/daily), acetyl salicylic acid (Aspirin 100 mg/day) and an Ace inhibitor (Ramipril 5 mg/day).", + "The diagnosis was dilated cardiomyopathy and severe left ventricular dysfunction complicated with cardiogenic shock and anasarca.", + "A further admission to the Cardiology Unit to define the effect of treatment was performed a week later.", + "Cardiac ultrasound confirmed the left ventricular dysfunction (EF 23%).", + "A coronary angiography was negative.", + "A right chamber catheterism and endomyocardic biopsy demonstrated no specific lesion nor inflammatory infiltrate.", + "The patient was admitted to our Nephrology Unit to evaluate the cause of the chronic kidney disease.", + "On admission the patient appeared healthy and well oriented.", + "His blood pressure was 110/60 mmHg.", + "His heart rate was 56 bpm.", + "Physical examination was unremarkable except for a 1/6 intensity systolic heart murmur better audible on mitral valve area.", + "ECG tracing showed sinus bradycardia.", + "Laboratory studies revealed an increased serum creatinine (1.87 mg/dl).", + "eGFR was 48 ml/min/1.73 m2.", + "Serum calcium was 11.5 mg/dl.", + "The patient denied use of vitamin D analogs.", + "Thyroid hormones, calcitonin, vitamin D, serum ACE, phosphate and calcium urinary excretion rate were all within the normal range.", + "PTH was lower than 3 pg/ml.", + "To rule out multiple myeloma serum protein electrophoresis, serum and urine immunofixation, and spine and skull x-ray were performed and did not show any pathological changes.", + "Renal biopsy was finally performed without complications.", + "The patient was discharged after 24 h.", + "Medications were not modified, but for an increase of the dose of furosemide because of the hypercalcemia.", + "The renal biopsy contained eight glomeruli none of which was globally or partially sclerotic.", + "No pathological changes were observed at glomerular level.", + "Tubulointerstitium was the only affected compartment with a moderate to severe inflammatory infiltrate.", + "Some calcium crystals in the tubular lumen were observed.", + "Two granulomas with multinucleated giant cells were observed.", + "No necrosis could be observed within the granulomas.", + "A diagnosis of granulomatous interstitial nephritis due to sarcoidosis was made.", + "When the patient was called to discuss his kidney biopsy, his serum creatinine had further increased (3.5 mg /dl).", + "eGFR was 22 ml/min/1.73 m2.", + "His serum calcium had increased to 13.3 mg/dl.", + "He was hospitalized again and treated with pulse methylprednisolone (250 mg/day for three days) and then with maintenance dose prednisone (50 mg/day).", + "Serum creatinine decreased in a few days.", + "Serum calcium decreased in a few days.", + "Renal function returned to normal (serum creatinine 1.1 mg/dl, eGFR 91 ml/min/1.73 m2).", + "Heart function markedly improved over the following two years (EF 49% vs 37% vs 32% vs 23%).", + "The diuretic and cardiologic therapy was significantly reduced to only 25 mg of furosemide and a small dose of beta blocker.", + "The steroid was gradually tapered to 5 mg/day of prednisone for one year and then stopped." + ], + "summary": "We present the case of a 28 year-old man who, while waiting to undergo assessment for a mild chronic kidney disease, was diagnosed with decompensated dilated cardiomyopathy and placed on diuretics and β-blockers. After few weeks he developed a non oligoanuric acute renal failure with a slight elevation of serum calcium. Renal biopsy proved suggestive for renal sarcoidosis; thus the hypothesis of systemic sarcoidosis with cardiac and renal involvement was possible avoiding further delay in initiation of therapy.", + "summary_subclaims": [ + "The patient was a 28 year-old man.", + "The patient was waiting to undergo assessment for a mild chronic kidney disease.", + "The patient was diagnosed with decompensated dilated cardiomyopathy.", + "The patient was placed on diuretics and β-blockers.", + "After few weeks, the patient developed a non oligoanuric acute renal failure.", + "The patient had a slight elevation of serum calcium.", + "Renal biopsy proved suggestive for renal sarcoidosis.", + "The hypothesis of systemic sarcoidosis with cardiac and renal involvement was possible.", + "The hypothesis of systemic sarcoidosis with cardiac and renal involvement was possible avoiding further delay in initiation of therapy." + ] + }, + { + "id": "multiclinsum_test_2328_en.txt", + "fulltext": "We present a case of acute angle closure due to spontaneous suprachoroidal haemorrhage secondary to loss of anti-coagulation control.\nA 67-year-old man, who recently returned from a holiday abroad, presented with a one-day history of worsening right visual acuity and 4 day history of increasing right retro-bulbar pain not relieved with simple analgesia.\nHe had a past medical history of essential tremor managed with Propranolol, Atrial Fibrillation on anticoagulation with Warfarin 4 mg daily – target International Normalised Ratio (INR) 2.5. Possible confusion with his tablets in the week leading up to the start of his symptoms.\nOur patient was also known to have normal tension glaucoma (NTG) managed with Latanoprost. He had Selective Laser Trabeculoplasty (SLT) to the right eye 12 months before to improve his intraocular pressure control. His last recorded visual acuity (VA) was 6/6 in both eyes.\nOn examination the patient was found to have reduced VA in the right eye 6/12 with an injected conjunctiva, cloudy cornea and a mid-dilated pupil with a very shallow anterior chamber (AC) and closed irido-corneal angle on gonioscopy . Fundus exam revealed a large supero-nasal suprachoroidal haemorrhage not involving the macula. His right intra-ocular pressure (IOP) was 42 mmHg. The left eye had a VA of 6/6 with a deep AC and IOP of 12 mmHg . He was therefore diagnosed with acute angle closure secondary to spontaneous suprachoroidal haemorrhage. His INR measured at > 8. The patient was given 1 mg of Vitamin K to reverse his INR, which quickly came down to 5.1. Advice was taken from the general physicians’ team and no further Vitamin K doses were given.\nHe was started on maximal topical and systemic IOP lowering treatment including G. Apraclonidine 1% TDS, G. Latanoprost 0.005% ON, G. Brinzolamide/Timolol (Azarga®) and Oral Acetaolamide 250 mg QDS as well as cycloplegia with G. Atropine 1% OD.\nAfter 12 h the IOP was 27 mmHg and INR 3.1. But unfortunately, in the following 12 h, the patient had a second bleed, and his IOP went up to 42 mmHg and VA was down to finger counting. There was no view of the fundus due to corneal edema. B-Scan Ultrasound showed an extension of the suprachoroidal haemorrhage, covering 360 degrees and involving the fovea .\nFor the next 7 days the patient’s remained on the same medical treatment and his IOP was stable in the high 20s. A decision was taken to perform a combined phacoemulsification and lens implant, pars-plana vitrectomy and suprachoroidal haematoma drainage under general anesthesia. (Additional file 1).\nSix weeks post operatively the patient had a wide-open angle with a central IOL and a flat retina . Intraocular Pressure without IOP lowering treatment was recorded at 20 mmHg with VA 6/24. He was restarted on IOP lowering topical treatment (G Brinzolamide/Timolol BD).", + "fulltext_subclaims": [ + "We present a case of acute angle closure due to spontaneous suprachoroidal haemorrhage secondary to loss of anti-coagulation control.", + "A 67-year-old man, who recently returned from a holiday abroad, presented with a one-day history of worsening right visual acuity.", + "He had a 4 day history of increasing right retro-bulbar pain not relieved with simple analgesia.", + "He had a past medical history of essential tremor managed with Propranolol.", + "He had Atrial Fibrillation on anticoagulation with Warfarin 4 mg daily – target International Normalised Ratio (INR) 2.5.", + "Possible confusion with his tablets in the week leading up to the start of his symptoms.", + "He had normal tension glaucoma (NTG) managed with Latanoprost.", + "He had Selective Laser Trabeculoplasty (SLT) to the right eye 12 months before.", + "His last recorded visual acuity (VA) was 6/6 in both eyes.", + "On examination the patient was found to have reduced VA in the right eye 6/12.", + "Fundus exam revealed a large supero-nasal suprachoroidal haemorrhage not involving the macula.", + "His right intra-ocular pressure (IOP) was 42 mmHg.", + "The left eye had a VA of 6/6 with a deep AC and IOP of 12 mmHg.", + "He was therefore diagnosed with acute angle closure secondary to spontaneous suprachoroidal haemorrhage.", + "His INR measured at > 8.", + "The patient was given 1 mg of Vitamin K to reverse his INR, which quickly came down to 5.1.", + "Advice was taken from the general physicians’ team and no further Vitamin K doses were given.", + "He was started on maximal topical and systemic IOP lowering treatment including G. Apraclonidine 1% TDS, G. Latanoprost 0.005% ON, G. Brinzolamide/Timolol (Azarga®) and Oral Acetaolamide 250 mg QDS as well as cycloplegia with G. Atropine 1% OD.", + "After 12 h the IOP was 27 mmHg and INR 3.1.", + "In the following 12 h, the patient had a second bleed, and his IOP went up to 42 mmHg and VA was down to finger counting.", + "B-Scan Ultrasound showed an extension of the suprachoroidal haemorrhage, covering 360 degrees and involving the fovea.", + "For the next 7 days the patient’s remained on the same medical treatment and his IOP was stable in the high 20s.", + "A decision was taken to perform a combined phacoemulsification and lens implant, pars-plana vitrectomy and suprachoroidal haematoma drainage under general anesthesia.", + "Six weeks post operatively the patient had a wide-open angle with a central IOL and a flat retina.", + "Intraocular Pressure without IOP lowering treatment was recorded at 20 mmHg with VA 6/24.", + "He was restarted on IOP lowering topical treatment (G Brinzolamide/Timolol BD)." + ], + "summary": "A patient with known Open Angle Glaucoma and Atrial Fibrillation on warfarin presents symptoms and signs suggestive acute angle closure. Examination reveals the underlying cause is a large, macula involving, spontaneous suprachoroidal haemorrhage secondary to loss of anti-coagulation control. Following aggressive medical treatment and surgical intervention, including drainage combined cataract extraction with intraocular lens implant, pars-plana vitrectomy, and external drainage of suprachoroidal haematoma, we managed to preserve the patient's eye and some of its function.", + "summary_subclaims": [ + "The patient has known Open Angle Glaucoma.", + "The patient has Atrial Fibrillation.", + "The patient is on warfarin.", + "The patient presents symptoms and signs suggestive of acute angle closure.", + "The underlying cause is a large, macula involving, spontaneous suprachoroidal haemorrhage.", + "The suprachoroidal haemorrhage is secondary to loss of anti-coagulation control.", + "Aggressive medical treatment was provided.", + "Surgical intervention was provided.", + "Drainage combined cataract extraction with intraocular lens implant was performed.", + "Pars-plana vitrectomy was performed.", + "External drainage of suprachoroidal haematoma was performed.", + "The patient's eye was preserved.", + "Some of the patient's eye function was preserved." + ] + }, + { + "id": "multiclinsum_test_2799_en.txt", + "fulltext": "A 30 year old woman was diagnosed with end stage renal disease which was suspected to be a complication of previous malarial illness. Haemodialysis was initiated in 2000 and a deceased donor kidney transplant was performed in 2005. Immunosuppression was by cyclosporin, azathioprine and prednisone, without induction therapy. The post-transplant course was stable with good renal function. The patient developed diabetes mellitus in 2010 and was placed on insulin. Parathyroidectomy was performed in 2011 for hyperparathyroidism. She was treated in hospital once in 2012 for a urinary tract infection.\nRenal function deteriorated over a period of 6 months in 2014, serum creatinine increasing from a baseline of less than 100 to more than 300 μmol/l. This prompted the performance of a transplant biopsy. Chronic allograft nephropathy was diagnosed and immunosuppression changed to tacrolimus (target serum trough level 5-7 ng/ml), mycophenolate mofetil (1 g twice daily) and prednisone (10 mg/day). Renal function remained stable until rapid deterioration occurred early in 2015 due to suspected non-adherence to immune suppressants during a foreign visit. Three steroid pulses (methylprednisolone 250 mg daily) were administered, and a repeat transplant biopsy was performed. The histological appearance was essentially unchanged. Renal function improved somewhat with serum creatine decreasing from an initial value of 640 μmol/l to 395 μmol/l, and then stabilising at a new baseline of about 380 μmol/l after one further dose of methylprednisone 500 mg. Subsequently viral infection due to cytomegalo-, and BK-virus occurred at different times. The virus infections were diagnosed by quantitative serum PCR for CMV and by urine PCR for BK virus. CMV infection, which presented as a febrile illness, was treated because of a sustained viral load of 250–671 copies/ml. Treatment was by induction with intravenous gancyclovir and maintenance with oral valgancyclovir. The BK viral load in the urine was 269,000 copies/ml. Immunosupression was progressively reduced to a tacrolimus target trough level of 5 ng/ml, mycophenolate mofetil 500 mg twice daily and prednisone 5 mg daily and viral disease remained quiescent. Late in 2014 and during 2015 the patient developed recurrent episodes of severe bacterial urinary tract infection which were accompanied by SIRS response. She was admitted to hospital on five occasions with intervals of one to 2 months. The infections responded each time to empiric (usually amoxicillin/clavulanic acid) and/or directed (on occasion switched to a carbapenem) antibiotic therapy for 10–14 days. Initially Klebsiella pneumoniae was cultured from urine and blood, but on the last 3 occasions Escherichia coli (E. coli) was cultured, each time with similar antibiotic sensitivity. Ultrasound of the transplant, vesicocystourography and cystoscopy were non-contributory to the causation of recurrent infection apart from grade 2 reflux into the transplant ureter. Various prophylactic antibacterials were prescribed without success. On each occasion of admission for sepsis the graft was tender and it was decided to perform an FDG-PET/CT scan. This revealed a metabolically active lesion in the upper pole of the transplanted kidney, suggestive of an abscess . Attempted aspiration of the lesion did not yield pus after several passes, and was followed by a core needle biopsy. The biopsy yielded poor non-diagnostic tissue, but a positive culture of an E. coli with the same antibiotic sensitivity spectrum as that cultivated from urine and blood. The biopsy was repeated and this time yielded diagnosable material. Routine histological sections were stained with haematoxylin and eosin and revealed renal tissue with a prominent infiltrate of cryptococcus round yeast bodies. The fungal elements were organised into groups in a myxoid and inflammatory background in most of the tissue. Alcian blue staining demonstrated a thick mucinous fungal capsule. The microscopy confirmed the presence of chronic allograft nephropathy. There were areas of prominent interstitial fibrosis with atrophic tubuli and occasional sclerotic glomeruli. There were no specific features of BK virus nephropathy present. The biopsies had not been specifically cultured for fungal pathogens as the finding was unexpected. At the time of discarding the plates at 48 h, there had been no fungal growth.\nOn the basis of the radiological and histological appearances, a diagnosis of cryptococcoma of the transplanted kidney was made. Investigation for systemic cryptococcosis was commenced. An uncontrasted brain and lung CT scan was normal. Cerebrospinal fluid examination yielded the following: glucose 3.6 mmol/l, protein 0.29 g/l and adenosine deaminase 1.5 u/l. There were no cells present. India ink staining and cryptococcus latex antigen test (CLAT) of the fluid were negative. Bacterial and fungal culture were negative. The lungs were examined clinically, and radiographically by plain X-ray and CT scan. They were found to be normal. The serum cryptococcus latex antigen test (s-CLAT) was negative. Multiple subsequent blood and urine specimens were negative for fungal culture.\nThe patient was treated with fluconazole 400 mg daily with the intention of continuing for 6 to 12 months. During this time the patient remained chronically ill with nausea, anorexia and loss of weight, as well as the recurrent urinary tract infections. On follow-up FDG-PET/CT scan after 2 months the cryptococcoma showed a significant increase in size and intensity . A gastroscopy was performed for the upper gastro-intestinal symptoms. A mucosal mass was seen, biopsy of which revealed Kaposi sarcoma.\nThroughout her protracted illness the patient remained unwilling to accept any reduction of the immunosuppression for fear of losing the kidney. Eventually, in light of poor renal function and life-threatening infections, she acceded to reduction and cessation of immunosuppressants, and was started on haemodialysis. Treatment for the cryptococcosis was escalated by adding 200 mg of fluconazole after each dialysis session. The lesion in the kidney which had become detectable on ultrasound was apparently unchanged. The patient died soon after initiation of dialysis during admission to hospital for an episode of severe sepsis.", + "fulltext_subclaims": [ + "A 30 year old woman was diagnosed with end stage renal disease.", + "End stage renal disease was suspected to be a complication of previous malarial illness.", + "Haemodialysis was initiated in 2000.", + "A deceased donor kidney transplant was performed in 2005.", + "Immunosuppression was by cyclosporin, azathioprine and prednisone.", + "Immunosuppression did not include induction therapy.", + "The post-transplant course was stable with good renal function.", + "The patient developed diabetes mellitus in 2010.", + "Diabetes mellitus was treated with insulin.", + "Parathyroidectomy was performed in 2011 for hyperparathyroidism.", + "She was treated in hospital once in 2012 for a urinary tract infection.", + "Renal function deteriorated over a period of 6 months in 2014.", + "Serum creatinine increased from a baseline of less than 100 to more than 300 μmol/l.", + "A transplant biopsy was performed.", + "Chronic allograft nephropathy was diagnosed.", + "Immunosuppression was changed to tacrolimus, mycophenolate mofetil and prednisone.", + "Renal function remained stable until rapid deterioration occurred early in 2015.", + "Rapid deterioration was due to suspected non-adherence to immune suppressants during a foreign visit.", + "Three steroid pulses (methylprednisolone 250 mg daily) were administered.", + "A repeat transplant biopsy was performed.", + "The histological appearance was essentially unchanged.", + "Renal function improved somewhat with serum creatinine decreasing from 640 μmol/l to 395 μmol/l.", + "Renal function stabilised at a new baseline of about 380 μmol/l after one further dose of methylprednisone 500 mg.", + "Viral infection due to cytomegalovirus occurred.", + "Viral infection due to BK-virus occurred.", + "CMV infection was diagnosed by quantitative serum PCR.", + "BK viral load was diagnosed by urine PCR.", + "CMV infection presented as a febrile illness.", + "CMV infection was treated because of a sustained viral load of 250–671 copies/ml.", + "Treatment was by induction with intravenous gancyclovir and maintenance with oral valgancyclovir.", + "The BK viral load in the urine was 269,000 copies/ml.", + "Immunosuppression was progressively reduced.", + "The patient developed recurrent episodes of severe bacterial urinary tract infection.", + "She was admitted to hospital on five occasions with intervals of one to 2 months.", + "The infections responded to empiric and/or directed antibiotic therapy.", + "Initially Klebsiella pneumoniae was cultured from urine and blood.", + "On the last 3 occasions Escherichia coli was cultured.", + "Ultrasound of the transplant, vesicocystourography and cystoscopy were non-contributory.", + "FDG-PET/CT scan revealed a metabolically active lesion in the upper pole of the transplanted kidney.", + "The lesion was suggestive of an abscess.", + "Attempted aspiration of the lesion did not yield pus.", + "A core needle biopsy was performed.", + "The biopsy yielded poor non-diagnostic tissue.", + "A positive culture of an E. coli with the same antibiotic sensitivity spectrum as that cultivated from urine and blood was obtained.", + "The biopsy was repeated and this time yielded diagnosable material.", + "Routine histological sections were stained with haematoxylin and eosin.", + "The histological sections revealed renal tissue with a prominent infiltrate of cryptococcus round yeast bodies.", + "The fungal elements were organised into groups in a myxoid and inflammatory background.", + "Alcian blue staining demonstrated a thick mucinous fungal capsule.", + "The microscopy confirmed the presence of chronic allograft nephropathy.", + "There were areas of prominent interstitial fibrosis with atrophic tubuli.", + "There were occasional sclerotic glomeruli.", + "There were no specific features of BK virus nephropathy present.", + "The biopsies had not been specifically cultured for fungal pathogens.", + "At the time of discarding the plates at 48 h, there had been no fungal growth.", + "A diagnosis of cryptococcoma of the transplanted kidney was made.", + "Investigation for systemic cryptococcosis was commenced.", + "An uncontrasted brain and lung CT scan was normal.", + "Cerebrospinal fluid examination yielded glucose 3.6 mmol/l, protein 0.29 g/l and adenosine deaminase 1.5 u/l.", + "India ink staining and cryptococcus latex antigen test of the fluid were negative.", + "Bacterial and fungal culture were negative.", + "The lungs were found to be normal.", + "The serum cryptococcus latex antigen test was negative.", + "Multiple subsequent blood and urine specimens were negative for fungal culture.", + "The patient was treated with fluconazole 400 mg daily.", + "The patient remained chronically ill with nausea, anorexia and loss of weight.", + "On follow-up FDG-PET/CT scan after 2 months the cryptococcoma showed a significant increase in size and intensity.", + "A gastroscopy was performed.", + "A mucosal mass was seen.", + "Biopsy of the mass revealed Kaposi sarcoma.", + "The patient remained unwilling to accept any reduction of the immunosuppression.", + "In light of poor renal function and life-threatening infections, she acceded to reduction and cessation of immunosuppressants.", + "She was started on haemodialysis.", + "Treatment for the cryptococcosis was escalated by adding 200 mg of fluconazole after each dialysis session.", + "The lesion in the kidney which had become detectable on ultrasound was apparently unchanged.", + "The patient died soon after initiation of dialysis during admission to hospital for an episode of severe sepsis." + ], + "summary": "A 30 year old woman received a deceased donor kidney transplant in 2005. Due to chronic allograft nephropathy in 2014, cyclosporine and azathioprine immunosuppression was changed to tacrolimus and mycophenolate. After rapid deterioration of renal function in 2015 due to suspected non-adherence to immunosuppressants, steroid pulses were administered. The patient developed severe recurrent bacterial urinary tract infections and demonstrated several features of severe immunosuppression. She was treated for cytomegalovirus infection and BK virus was demonstrated in the urine. In addition, Kaposi sarcoma of the stomach was diagnosed on endoscopic biopsy. A metabolically-active lesion of the kidney transplant was imaged on FDG-PET/CT scan. Biopsy of the lesion demonstrated infection with cryptococcus. Escherichia coli with the same antibiotic sensitivity spectrum as that in the urine was cultured from the biopsy. Cryptococcus was not cultured from urine at that time or from several subsequent specimens. The lesion was not detected by conventional imaging. The patient manifested no other evidence of cryptococcosis. The lesion responded poorly to treatment with fluconazole.", + "summary_subclaims": [ + "A 30 year old woman received a deceased donor kidney transplant in 2005.", + "Due to chronic allograft nephropathy in 2014, cyclosporine and azathioprine immunosuppression was changed to tacrolimus and mycophenolate.", + "After rapid deterioration of renal function in 2015 due to suspected non-adherence to immunosuppressants, steroid pulses were administered.", + "The patient developed severe recurrent bacterial urinary tract infections.", + "She was treated for cytomegalovirus infection.", + "BK virus was demonstrated in the urine.", + "Kaposi sarcoma of the stomach was diagnosed on endoscopic biopsy.", + "A metabolically-active lesion of the kidney transplant was imaged on FDG-PET/CT scan.", + "Biopsy of the lesion demonstrated infection with cryptococcus.", + "Escherichia coli with the same antibiotic sensitivity spectrum as that in the urine was cultured from the biopsy.", + "Cryptococcus was not cultured from urine at that time or from several subsequent specimens.", + "The lesion was not detected by conventional imaging.", + "The patient manifested no other evidence of cryptococcosis.", + "The lesion responded poorly to treatment with fluconazole." + ] + }, + { + "id": "multiclinsum_test_843_en.txt", + "fulltext": "A 49-year-old Sri Lankan man with a history of long standing type 2 diabetes mellitus and hypertension, presented with fever, loss of appetite and generalised body aches for 1 week duration. He had a past history of right medial malleolar screw fixation 10 years ago following a traumatic uncomplicated closed fracture. He was diagnosed with type 2 diabetes mellitus 20 years ago; however, he was lost to follow-up with poor glycaemic control demonstrated by a HbA1c on admission of 8.5%. He was a non-smoker and consumed alcohol occasionally. He did not have any history of chronic lung disease or steroid use. There was no recent history of trauma or break in skin integrity and there were no cutaneous lesions or ulcers evident on examination. However, he was a tractor driver and had a history of exposure to mud in paddy fields. Due to the presence of fever with considerable myalgia and exposure to mud in paddy fields, he was initially suspected to have leptospirosis and was started on intravenous ceftriaxone at the local hospital. Four days later, he developed right ankle swelling and discolouration and was transferred to the tertiary care centre for further management.\nOn admission, he was febrile (103 °F) and tachycardic with a pulse rate of 104 / min. His other haemodynamic parameters were normal with a blood pressure of 140/80 mmHg and was mildly dehydrated with a urine output of 0.5 ml/kg/hour. He was not haemodynamically compromised due to sepsis and his urine output improved with fluid resuscitation. He had a white blood cell count of 15 × 103/uL with a neutrophil leucocytosis; C-reactive protein was 190 mg/dl and erythrocyte sedimentation rate was 86 mm/hour. His platelet count was 148 × 103/uL. His liver enzymes were mildly elevated and rest of the basic biochemistry was unremarkable (alanine transaminase: 252 U/L, aspartate transaminase: 222 U/L, serum creatine: 0.46 mg/dl). The X-ray of the right ankle revealed a healed fracture with two screws which were in position. There was no evidence of osteomyelitis .\nHe underwent a wound debridement of the right ankle and the necrotic skin and subcutaneous tissue were excised. The pus collection in the subcutaneous tissue plane was removed. Aspiration of the ankle joint revealed purulent fluid. Therefore, an arthrotomy and washout was done. One loosely fitted screw was removed and the wound was left open. Removal of the second screw was considered but this procedure was abandoned due to technical difficulties and concern about iatrogenically causing a fracture in the process.\nThe pus culture and the peripheral blood culture was positive for Burkholderia pseudomallei sensitive to meropenem and co-trimoxazole. Direct smear showed gram-negative bacilli with bipolar appearance. Non-lactose fermenting colonies with a metallic sheen were isolated on blood and MacConkey agar, and Burkholderia pseudomallei species were isolated using the latex agglutination test . The BD PHOENIX (Becton Dickinson Diagnostic Systems, Sparks, Md.) automated microbiology system for direct identification also confirmed the presence of Burkholderia pseudomallei.\nHis melioidosis antibody titre using the indirect haemagglutination assay was > 10,240. He was empirically managed with intravenous ceftriaxone 1 g 12 hourly and metronidazole 500 mg 8 hourly for 7 days. This was because Leptospirosis or anaerobic infection of the lower limb was thought possible given his environmental exposure history. Following the bacterial culture reports and the antibiotic sensitivity patterns, a diagnosis of melioidosis was made and the antibiotics were changed to intravenous Meropenem 1 g 8 hourly and Metronidazole 500 mg 8 hourly. Metronidazole was continued due to the presence of necrotic tissue and suspicion of superadded anaerobic infection. However, after 1 week he clinically deteriorated with worsening wound infection, fever and septic shock. He was resuscitated with fluids and commenced on noradrenaline. He required inotropic support for 4 days. He underwent another wound debridement and the dose of intravenous Meropenem was escalated to 2 g 8 hourly while continuing intravenous Metronidazole 500 mg 8 hourly and oral Co-trimoxazole 1920 mg 12 hourly was also added. He improved after a few days following the second wound debridement and supportive management. Fortunately, he did not develop any other organ dysfunction. All three antibiotics were continued for a period of 8 weeks.\nHe was screened for other foci for infection with chest radiograph, transthoracic and trans-oesophageal echocardiogram, abdominal ultrasonography and urine culture and all were negative. A computed tomography of the chest and abdomen was not performed as he did not have any clinical features to suggest a chest or abdominal foci of infection and the basic imaging were negative.\nHis temperature normalised 4 days after the second wound debridement and escalation of antibiotic therapy. However, he further required repeated wound debridement and removal of necrotic and infected tissue. His inflammatory markers became normal after 5 weeks of antibiotics (C-reactive protein of 2.6 mg/dl). Wound healing with secondary intention was achieved after 6 weeks . He was given a total course of intravenous antibiotics for 8 weeks and was discharged on oral co-trimoxazole 1920 mg 12 hourly. Repeat X-rays at 2 months showed features of chronic osteomyelitis . Due to the high risk of recurrence, the eradication phase was continued for a period of 6 months.\nAt 6 months follow up, he had satisfactory functional outcome with acceptable range of motion. There was no clinical evidence of relapse. However, the plain radiographic changes were persistent without any worsening.", + "fulltext_subclaims": [ + "The patient is a 49-year-old Sri Lankan man.", + "He has a history of long standing type 2 diabetes mellitus.", + "He has a history of hypertension.", + "He presented with fever, loss of appetite, and generalised body aches for 1 week.", + "He had a past history of right medial malleolar screw fixation 10 years ago following a traumatic uncomplicated closed fracture.", + "He was diagnosed with type 2 diabetes mellitus 20 years ago.", + "He was lost to follow-up.", + "He had poor glycaemic control demonstrated by a HbA1c on admission of 8.5%.", + "He was a non-smoker.", + "He consumed alcohol occasionally.", + "He did not have any history of chronic lung disease.", + "He did not have any history of steroid use.", + "There was no recent history of trauma.", + "There was no break in skin integrity.", + "There were no cutaneous lesions or ulcers evident on examination.", + "He was a tractor driver.", + "He had a history of exposure to mud in paddy fields.", + "He was initially suspected to have leptospirosis.", + "He was started on intravenous ceftriaxone at the local hospital.", + "Four days later, he developed right ankle swelling and discolouration.", + "He was transferred to the tertiary care centre for further management.", + "On admission, he was febrile (103 °F).", + "His pulse rate was 104 / min.", + "His blood pressure was 140/80 mmHg.", + "He was mildly dehydrated with a urine output of 0.5 ml/kg/hour.", + "He was not haemodynamically compromised due to sepsis.", + "His urine output improved with fluid resuscitation.", + "He had a white blood cell count of 15 × 103/uL with a neutrophil leucocytosis.", + "His C-reactive protein was 190 mg/dl.", + "His erythrocyte sedimentation rate was 86 mm/hour.", + "His platelet count was 148 × 103/uL.", + "His liver enzymes were mildly elevated.", + "The X-ray of the right ankle revealed a healed fracture with two screws which were in position.", + "There was no evidence of osteomyelitis.", + "He underwent a wound debridement of the right ankle.", + "The pus collection in the subcutaneous tissue plane was removed.", + "Aspiration of the ankle joint revealed purulent fluid.", + "An arthrotomy and washout was done.", + "One loosely fitted screw was removed and the wound was left open.", + "Removal of the second screw was considered but this procedure was abandoned due to technical difficulties and concern about iatrogenically causing a fracture.", + "The pus culture and the peripheral blood culture was positive for Burkholderia pseudomallei.", + "The BD PHOENIX automated microbiology system for direct identification also confirmed the presence of Burkholderia pseudomallei.", + "His melioidosis antibody titre using the indirect haemagglutination assay was > 10,240.", + "He was empirically managed with intravenous ceftriaxone 1 g 12 hourly and metronidazole 500 mg 8 hourly for 7 days.", + "Following the bacterial culture reports and the antibiotic sensitivity patterns, a diagnosis of melioidosis was made.", + "The antibiotics were changed to intravenous Meropenem 1 g 8 hourly and Metronidazole 500 mg 8 hourly.", + "After 1 week he clinically deteriorated with worsening wound infection, fever and septic shock.", + "He was resuscitated with fluids and commenced on noradrenaline.", + "He required inotropic support for 4 days.", + "He underwent another wound debridement.", + "The dose of intravenous Meropenem was escalated to 2 g 8 hourly.", + "He improved after a few days following the second wound debridement and supportive management.", + "He did not develop any other organ dysfunction.", + "All three antibiotics were continued for a period of 8 weeks.", + "He was screened for other foci for infection with chest radiograph, transthoracic and trans-oesophageal echocardiogram, abdominal ultrasonography and urine culture and all were negative.", + "A computed tomography of the chest and abdomen was not performed.", + "His temperature normalised 4 days after the second wound debridement and escalation of antibiotic therapy.", + "He further required repeated wound debridement and removal of necrotic and infected tissue.", + "His inflammatory markers became normal after 5 weeks of antibiotics.", + "Wound healing with secondary intention was achieved after 6 weeks.", + "He was given a total course of intravenous antibiotics for 8 weeks.", + "He was discharged on oral co-trimoxazole 1920 mg 12 hourly.", + "Repeat X-rays at 2 months showed features of chronic osteomyelitis.", + "The eradication phase was continued for a period of 6 months.", + "At 6 months follow up, he had satisfactory functional outcome with acceptable range of motion.", + "There was no clinical evidence of relapse.", + "The plain radiographic changes were persistent without any worsening." + ], + "summary": "We describe a 49-year-old male with a history of long standing diabetes who presented with fever, constitutional symptoms and right ankle pain for 1 week. Ten years ago, he underwent a medial malleolar screw fixation following a traumatic closed fracture. His initial right ankle radiographs showed no evidence of osteomyelitis. He underwent a wound debridement and washout of the right ankle joint. The peripheral blood and pus from the ankle joint was culture positive for Burkholderia pseudomallei with very high antibody titres. His subsequent radiographs showed features of chronic osteomyelitis. He was treated with a prolonged course of antibiotics and repeated wound debridement. At follow up after 6 months, he had no clinical features of recurrent infection.", + "summary_subclaims": [ + "The patient is a 49-year-old male.", + "He has a history of long standing diabetes.", + "He presented with fever, constitutional symptoms and right ankle pain for 1 week.", + "Ten years ago, he underwent a medial malleolar screw fixation following a traumatic closed fracture.", + "His initial right ankle radiographs showed no evidence of osteomyelitis.", + "He underwent a wound debridement and washout of the right ankle joint.", + "The peripheral blood and pus from the ankle joint was culture positive for Burkholderia pseudomallei.", + "The peripheral blood and pus from the ankle joint showed very high antibody titres.", + "His subsequent radiographs showed features of chronic osteomyelitis.", + "He was treated with a prolonged course of antibiotics.", + "He had repeated wound debridement.", + "At follow up after 6 months, he had no clinical features of recurrent infection." + ] + }, + { + "id": "multiclinsum_test_1928_en.txt", + "fulltext": "A 30 year-old man was referred to our trauma center with impaired wound healing and infection after multiple surgeries for bilateral intra-articular calcaneal fractures. Six months ago, he had jumped from a fire protection staircase at a height of about 2.5 m on a concrete surface while doing parkour sports. Initial fracture treatment consisted of bilateral open reduction and interlocking plate fixation via extensile lateral approaches. In the subsequent course, a deep infection developed on both sides necessitating multiple revisions with complete hardware removal, serial debridements and lavage until 4 months postoperatively. As part of this procedure, resorbable bone cement had been implanted. Because wound drainage and infection persisted, the patient had been offered bilateral partial calcanectomy. He therefore presented to our Foot & Ankle Center for a second opinion.\nFor initial examination at our center, 6 months after the initial injury, the patient appeared in a wheelchair. The scars of the extensive lateral approaches over both heels displayed a fistula formation of almost 2 cm in the wound angles on both sides . With continuous effusion that was more pronounced on the right side than on the left side. Bone could be probed from the fistula on both sides. The peripheral blood circulation was intact. A hypesthesia was noted on the lateral aspect of both feet distal to the scar area and interpreted as sural nerve affection. The total range of motion of both feet displayed 30 degrees of plantarflexion and no dorsiflexion in the sagittal plane. Hindfoot motion was severely restricted with no eversion and inversion of 15° bilaterally. The subtalar joint appeared stiff on both sides. Lab results upon presentation included a leukocyte count of 6.87 GPt/L s and a C reactive protein (CRP) level of 30 mg/L. CT scans on admission revealed a heled calcaneal fracture with minimal residual step-off in the subtalar joint on both sides and a central osseous defect in both calcanei. On the right side, amorphous hydroxyapatite bone cement was in place that seemed encapsulated by a fibrous membrane (see ).\nThe patient was admitted to our hospital and after a detailed discussion of all possible treatment options.\nAn extended reconstructive therapy after infected ORIF of calcaneus fractures was established: we decided for a radical irrigation and debridement of all necrotic and infected bone and soft tissues, removal of the bone cement and insertion of a polymethylmethacrylate (PMMA) cement spacer with gentamycin (Palacos-G, Heraeus Inc., Hanau, Germany) and with vacuum assisted closure (3 M™ V.A.C., Germany) dressing to eradicate infection. There were in total seven debridements accomplished. Intraoperative swabs revealed multibacterial infection with Staphylococcus epidermidis, Staphylococcus saprophyticus, Staphylococcus equorum, Enterococcus. avium and Enterococcus. faecalis. The wound debridement’s were repeated until negative swabs were obtained.\nAdditionally, an intravenous antibiotic first with Vancomycin for 10 days and then, matching the antibiogram, Amoxicillin was administered for 6 weeks intravenously. Following complete resection of all necrotic tissue, a bone defect remained measuring 20 × 19 × 14 mm on the right side and 57 × 25 × 14 mm on the left side . Furthermore, a full thickness soft tissue defect in the lateral hindfoot region 140 × 50 mm on the left and 150 × 70 mm right resulted, necessitating flap coverage .\nFollowing negative cultures from multiple bone biopsies, reconstruction of the bone and soft tissue defect was performed 8 weeks following admission and first debridement. The osseous defects were filled with resorbable bone cement containing gentamicin sulfate (Cerament G, Bonesupport Inc., Lund, Sweden).\nAn abductor digiti minimi flap was raised on both feet to cover the soft tissue defects. The incision was carried out from the distal insertion of the abductor digitus quintus muscle at proximal phalanx of the fifth toe to the lateral aspect of the calcaneus at the transition from the glabrous to the hairy skin of the heel. The abductor digiti minimi muscle and tendon were identified and gently separated from the flexor digiti minimi muscle, technique also described in Wie Mardini, Flaps and Reconstructive Surgery (2nd Edition, pg. 818–823, 2009). The tendon was detached from the proximal phalanx of the fifth toe and held with a PDS suture for atraumatic handling. Dissection from the fifth metatarsal bone was continued proximally until the first perforators were reached. The wound edges were mobilized towards the lateral calcaneal wall. After mobilizing the muscle flap, it was pivoted around the perforators into the defect zone on the lateral calcaneus . Finally, the abductor digiti minimi muscle flap was covered with meshed split thickness skin graft from the thigh and sealed with a V. A. C. dressing that was removed after 4 days.\nThe patient was kept nonweight-bearing for 4 weeks and on partial weight-bearing for another 8 weeks in hindfoot-offloading Donjoy boots using two crutches. He returned to full weight-bearing after three months after prolonged clear drainage with particles of the bone substitute (“white washout”) for 10 weeks, the soft tissues healed on both sides.\nThe patient was seen for a follow-up examination 9 months after defect filling and flap coverage. He was ambulating freely without crutches in sports shoes with insoles. He did not report pain when walking on even ground. The soft tissues had healed uneventfully without residual drainage on both feet . Range of motion was 45 degrees of dorsiflexion/plantarflexion in the sagittal plane and 20 degrees of eversion/inversion in the frontal plane. Except for the pre-existing hypesthesia, there were no neurovascular deficits. Standing radiographs including hindfoot alignment views revealed correct position of the hind foot and no signs of arthritis at the ankle, subtalar and calcaneocuboid joints. There was slight loss of heel height bilaterally. The bone cement was for the most part resorbed and replaced by cancellous bone.", + "fulltext_subclaims": [ + "The patient is a 30 year-old man.", + "He was referred to a trauma center with impaired wound healing and infection after multiple surgeries for bilateral intra-articular calcaneal fractures.", + "Six months prior, he had jumped from a fire protection staircase at a height of about 2.5 m on a concrete surface.", + "Initial fracture treatment consisted of bilateral open reduction and interlocking plate fixation via extensile lateral approaches.", + "A deep infection developed on both sides necessitating multiple revisions.", + "Resorbable bone cement had been implanted.", + "The patient had been offered bilateral partial calcanectomy.", + "He presented to the Foot & Ankle Center for a second opinion.", + "The scars of the extensive lateral approaches over both heels displayed a fistula formation of almost 2 cm in the wound angles on both sides.", + "Bone could be probed from the fistula on both sides.", + "A hypesthesia was noted on the lateral aspect of both feet distal to the scar area.", + "The total range of motion of both feet displayed 30 degrees of plantarflexion and no dorsiflexion in the sagittal plane.", + "Hindfoot motion was severely restricted with no eversion and inversion of 15° bilaterally.", + "The subtalar joint appeared stiff on both sides.", + "Lab results upon presentation included a leukocyte count of 6.87 GPt/L and a C reactive protein (CRP) level of 30 mg/L.", + "CT scans on admission revealed a healed calcaneal fracture with minimal residual step-off in the subtalar joint on both sides.", + "A central osseous defect in both calcanei was noted.", + "On the right side, amorphous hydroxyapatite bone cement was in place that seemed encapsulated by a fibrous membrane.", + "An extended reconstructive therapy after infected ORIF of calcaneus fractures was established.", + "A radical irrigation and debridement of all necrotic and infected bone and soft tissues was performed.", + "A polymethylmethacrylate (PMMA) cement spacer with gentamycin was inserted.", + "A vacuum assisted closure dressing was used.", + "There were in total seven debridements accomplished.", + "Intraoperative swabs revealed multibacterial infection with Staphylococcus epidermidis, Staphylococcus saprophyticus, Staphylococcus equorum, Enterococcus avium, and Enterococcus faecalis.", + "The wound debridements were repeated until negative swabs were obtained.", + "An intravenous antibiotic first with Vancomycin for 10 days and then Amoxicillin was administered for 6 weeks intravenously.", + "A bone defect remained measuring 20 × 19 × 14 mm on the right side and 57 × 25 × 14 mm on the left side.", + "A full thickness soft tissue defect in the lateral hindfoot region 140 × 50 mm on the left and 150 × 70 mm right resulted.", + "Following negative cultures from multiple bone biopsies, reconstruction of the bone and soft tissue defect was performed 8 weeks following admission and first debridement.", + "The osseous defects were filled with resorbable bone cement containing gentamicin sulfate.", + "An abductor digiti minimi flap was raised on both feet to cover the soft tissue defects.", + "The incision was carried out from the distal insertion of the abductor digitus quintus muscle at proximal phalanx of the fifth toe to the lateral aspect of the calcaneus.", + "The abductor digiti minimi muscle and tendon were identified and gently separated from the flexor digiti minimi muscle.", + "The tendon was detached from the proximal phalanx of the fifth toe and held with a PDS suture.", + "Dissection from the fifth metatarsal bone was continued proximally until the first perforators were reached.", + "The wound edges were mobilized towards the lateral calcaneal wall.", + "After mobilizing the muscle flap, it was pivoted around the perforators into the defect zone on the lateral calcaneus.", + "The abductor digiti minimi muscle flap was covered with meshed split thickness skin graft from the thigh.", + "A V. A. C. dressing was used that was removed after 4 days.", + "The patient was kept nonweight-bearing for 4 weeks.", + "He was on partial weight-bearing for another 8 weeks in hindfoot-offloading Donjoy boots.", + "He returned to full weight-bearing after three months.", + "The patient was seen for a follow-up examination 9 months after defect filling and flap coverage.", + "He was ambulating freely without crutches in sports shoes with insoles.", + "He did not report pain when walking on even ground.", + "The soft tissues had healed uneventfully without residual drainage on both feet.", + "Range of motion was 45 degrees of dorsiflexion/plantarflexion in the sagittal plane.", + "There were 20 degrees of eversion/inversion in the frontal plane.", + "Standing radiographs including hindfoot alignment views revealed correct position of the hind foot.", + "There were no signs of arthritis at the ankle, subtalar and calcaneocuboid joints.", + "There was slight loss of heel height bilaterally.", + "The bone cement was for the most part resorbed and replaced by cancellous bone." + ], + "summary": "Here we report a rare case of bilateral calcaneal osteomyelitis with fistula formation following open reduction and plate fixation via an extensile lateral approach that could be salvaged with an interdisciplinary approach including orthopedic and plastic surgeons. We are not aware of a similar case in the literature. Abductor digit minimi flaps is a well-established procedure in plastic and reconstructive surgery with a minimal functional defect and morbidity at the donor site. This treatment protocol resulted in minimal donor-site morbidity and good bone remodeling in the further course. We believe that it may be of use for complicated courses even with limited resources.", + "summary_subclaims": [ + "Here we report a rare case of bilateral calcaneal osteomyelitis with fistula formation following open reduction and plate fixation via an extensile lateral approach that could be salvaged with an interdisciplinary approach including orthopedic and plastic surgeons.", + "We are not aware of a similar case in the literature.", + "Abductor digit minimi flaps is a well-established procedure in plastic and reconstructive surgery with a minimal functional defect and morbidity at the donor site.", + "This treatment protocol resulted in minimal donor-site morbidity and good bone remodeling in the further course.", + "We believe that it may be of use for complicated courses even with limited resources." + ] + }, + { + "id": "multiclinsum_test_2806_en.txt", + "fulltext": "A healthy 41-year-old woman was referred to our center after the 22-week gestational ultrasound revealed short ribs and a possible craniosynostosis in the fetus on the second trimester ultrasound. After detailed genetic counselling, an amniocentesis was performed at 24 weeks to investigate the etiology. Array CGH was normal without any unbalanced chromosomal rearrangement, and so were FGFR2 and FGFR3 recurrent variant screening (to rule out FGFR related craniosynostosis syndromes), and the 7-dehydrocholesterol level (to rule out Smith-Lemli-Opitz syndrome). At 26 weeks, computed tomography confirmed short ribs with irregular ends but no craniosynostosis and overall renal cortex echogenicity was noted on ultrasound . The association of bone and renal abnormalities led to an initial diagnosis of a skeletal ciliopathy spectrum disorder such as Jeune syndrome (asphyxiating thoracic dystrophy). Pregnancy was then complicated by hydramnios requiring amniotic fluid drainage at 33 weeks, which triggered fetal bradycardia and the need for a caesarean delivery. At birth, the new-born male measured in the low normal range for gestational age with a weight of 1800 g (32nd centile), length of 43 cm (39th centile), and an occipitofrontal circumference of 30 cm (26th centile) without craniosynostosis. Soon after birth, he developed hypotonia and respiratory distress requiring oxygen and non-invasive ventilation. Except for a bell-shaped chest, the rest of his clinical examination was unremarkable. A chest X-ray showed a narrowed thoracic cage with short ribs and multiple rib fractures. Subsequently, a skeletal survey revealed diffuse osteopenia with coarse trabecular markings, subperiosteal bone resorption, cortical dualization and metaphyseal corner fractures . The initial laboratory evaluation revealed severe hypercalcemia (ionized calcemia: 1.66 mmol/l; reference range: 1.17–1.27), a slightly low phosphate level (1 mmol/l; reference range: 1–1.95), normal alkaline phosphatase levels (387 IU/l; reference range: 122–469), abnormal urinary calcium (calcium-to-creatinine ratio: 0.78 mmol/l; reference range: 0.2–2.0), and an increased PTH level (325 pg/ml; reference range: 15–65). The diagnosis of NSHPT was then suspected and confirmed by a phosphocalcic NGS panel which revealed the pathogenic heterozygous (PM1, PM2, PM5, PP2, PP3, PP5) variant c.554G>A p.(Arg185Gln) in the CASR gene (NM_000388.3).\nCalcium metabolism tests and genetic screening were then requested from both asymptomatic parents. These analyses revealed hypercalcemia (total serum calcium: 3.32 mmol/l, reference range: 2.2–2.6 mmol/l), low phosphate levels (0.59 mmol/l, reference range: 0.84–1.4 mmol/l), low calcium-to-creatinine ratio (0.16 mmol/mmol, reference range: 0.2–0.6 mmol/mmol) and hyperparathyroidism (PTH: 42 pg/ml, reference range: 15–65) in the father who harbored the same heterozygous CASR variant. Mineral homeostasis (25-hydroxyvitamin D level: 24 ng/ml) and CASR sequencing were normal in the mother. The family history revealed that the paternal grandmother also had FHH discovered as a result of recurrent urinary lithiasis . Similarly, FHH affected various members of the paternal branch.\nInitial therapy included hyperhydration, phosphate supplementation and a low-calcium milk formula. Hypercalcemia did not improve. Therefore, treatment with pamidronate (0.5 mg/kg intravenous on days 9 and 14) was started. After a moderate transient response to pamidronate, serum calcium levels subsequently increased and were associated with very high PTH levels (1671 pg/ml). Clinically, the patient had persistent restrictive lung disease caused by significant rib fractures requiring oxygen and analgesics. Therefore, after confirmation of the genetic diagnosis of NSHPT treatment with calcimimetics (cinacalcet) was initiated on day 22 at 0.5 mg/kg PO daily and progressively increased to 3 mg/kg in 2 doses. The cinacalcet dose titration normalized the PTH in 25 days but serum calcium remained at approximately 3 mmol/l .\nHyperparathyroidism control provided significant improvement in clinical signs. The patient was discharged on day 73, and oxygen therapy could be discontinued at 6 months of age. Psychomotor development and growth were normal. At 6 months of age, X-rays showed complete normalization of bone abnormalities and ultrasound revealed nephrocalcinosis. At 11 months of age, parathyroid gland ultrasound showed no abnormality.", + "fulltext_subclaims": [ + "A healthy 41-year-old woman was referred to our center after the 22-week gestational ultrasound revealed short ribs and a possible craniosynostosis in the fetus.", + "After detailed genetic counselling, an amniocentesis was performed at 24 weeks.", + "Array CGH was normal without any unbalanced chromosomal rearrangement.", + "FGFR2 and FGFR3 recurrent variant screening were normal.", + "The 7-dehydrocholesterol level was normal.", + "Computed tomography at 26 weeks confirmed short ribs with irregular ends.", + "No craniosynostosis was found on computed tomography.", + "Overall renal cortex echogenicity was noted on ultrasound.", + "The association of bone and renal abnormalities led to an initial diagnosis of a skeletal ciliopathy spectrum disorder such as Jeune syndrome.", + "Pregnancy was complicated by hydramnios requiring amniotic fluid drainage at 33 weeks.", + "Amniotic fluid drainage at 33 weeks triggered fetal bradycardia.", + "A caesarean delivery was performed.", + "The new-born male measured in the low normal range for gestational age.", + "The new-born male had a weight of 1800 g (32nd centile).", + "The new-born male had a length of 43 cm (39th centile).", + "The new-born male had an occipitofrontal circumference of 30 cm (26th centile).", + "There was no craniosynostosis at birth.", + "Soon after birth, the new-born developed hypotonia.", + "Soon after birth, the new-born developed respiratory distress requiring oxygen and non-invasive ventilation.", + "A chest X-ray showed a narrowed thoracic cage with short ribs.", + "A skeletal survey revealed diffuse osteopenia with coarse trabecular markings.", + "A skeletal survey revealed subperiosteal bone resorption.", + "A skeletal survey revealed cortical dualization.", + "A skeletal survey revealed metaphyseal corner fractures.", + "The initial laboratory evaluation revealed severe hypercalcemia (ionized calcemia: 1.66 mmol/l).", + "The initial laboratory evaluation revealed a slightly low phosphate level (1 mmol/l).", + "The initial laboratory evaluation revealed normal alkaline phosphatase levels (387 IU/l).", + "The initial laboratory evaluation revealed abnormal urinary calcium (calcium-to-creatinine ratio: 0.78 mmol/l).", + "The initial laboratory evaluation revealed an increased PTH level (325 pg/ml).", + "The diagnosis of NSHPT was suspected.", + "The diagnosis of NSHPT was confirmed by a phosphocalcic NGS panel.", + "The phosphocalcic NGS panel revealed the pathogenic heterozygous variant c.554G>A p.(Arg185Gln) in the CASR gene.", + "Calcium metabolism tests and genetic screening were requested from both asymptomatic parents.", + "The father had hypercalcemia (total serum calcium: 3.32 mmol/l).", + "The father had low phosphate levels (0.59 mmol/l).", + "The father had low calcium-to-creatinine ratio (0.16 mmol/mmol).", + "The father had hyperparathyroidism (PTH: 42 pg/ml).", + "The father harbored the same heterozygous CASR variant.", + "The mother had normal mineral homeostasis (25-hydroxyvitamin D level: 24 ng/ml).", + "The mother had normal CASR sequencing.", + "The family history revealed that the paternal grandmother also had FHH.", + "FHH affected various members of the paternal branch.", + "Initial therapy included hyperhydration, phosphate supplementation, and a low-calcium milk formula.", + "Hypercalcemia did not improve.", + "Treatment with pamidronate (0.5 mg/kg intravenous on days 9 and 14) was started.", + "After a moderate transient response to pamidronate, serum calcium levels subsequently increased.", + "Serum calcium levels were associated with very high PTH levels (1671 pg/ml).", + "The patient had persistent restrictive lung disease caused by significant rib fractures.", + "Treatment with calcimimetics (cinacalcet) was initiated on day 22.", + "Cinacalcet was initiated at 0.5 mg/kg PO daily.", + "The cinacalcet dose was progressively increased to 3 mg/kg in 2 doses.", + "The cinacalcet dose titration normalized the PTH in 25 days.", + "Serum calcium remained at approximately 3 mmol/l.", + "Hyperparathyroidism control provided significant improvement in clinical signs.", + "The patient was discharged on day 73.", + "Oxygen therapy could be discontinued at 6 months of age.", + "Psychomotor development and growth were normal.", + "At 6 months of age, X-rays showed complete normalization of bone abnormalities.", + "At 6 months of age, ultrasound revealed nephrocalcinosis.", + "At 11 months of age, parathyroid gland ultrasound showed no abnormality." + ], + "summary": "We describe the antenatal presentation of a male with short ribs, initially suspected having skeletal ciliopathy. At birth, he presented with NSHPT linked to the pathogenic heterozygous CASR variant, Arg185Gln, inherited from his father who had FHH. Postnatal therapy with cinacalcet was successful.", + "summary_subclaims": [ + "The patient was a male.", + "The patient had short ribs.", + "The patient was initially suspected of having skeletal ciliopathy.", + "At birth, the patient presented with NSHPT.", + "The NSHPT was linked to the pathogenic heterozygous CASR variant, Arg185Gln.", + "The CASR variant was inherited from his father.", + "The father had FHH.", + "Postnatal therapy with cinacalcet was successful." + ] + }, + { + "id": "multiclinsum_test_2489_en.txt", + "fulltext": "A 26-year-old pregnant woman with a gestational age of 25 + 2 weeks was admitted to hospital for more than 2 months after the discovery of pancytopenia and increased creatinine. She was admitted to the hospital for further diagnosis and treatment and categorized as “acute kidney injury, pancytopenia, and pregnancy” by the outpatient clinic.\nThe patient reported that her gums bled when she brushed her teeth; she had large, long-lasting bruises when she collided with hard objects; and she experienced no lower limb edema or backache. In terms of previous medical history, the patient was healthy, with no history of surgery, food or drug allergies, substance abuse, or exposure to toxins, dust, or harmful substances.\nThe patient did not undergo genetic testing before pregnancy, and the disease was not discovered until the second-trimester. Concerning menstrual history, the patient had normal menstrual volume, no dysmenorrhea, and a regular menstrual period. She had no fertility problems, had not experienced menopause, and currently had no children. Furthermore, her family had no history of malignant tumors.\nThe patient’s physical examination results were as follows. Her body temperature was 36.5 °C, pulse was 76 beats/min, respiration was 20 breaths/min, and blood pressure was 140/88 mmHg. She was conscious with satisfactory mental wellbeing. She had a centered trachea and clear respiratory sounds with no abnormal sounds in either lung. Her heart rate was normal with no abnormal sounds. Abdominal distension; consistent with gestational age; no tenderness; rebound tenderness. Her liver was not palpable under the ribs, but her spleen was palpable 1 cm under the ribs and hard with no tenderness. No tenderness or percussion pain were noted in either kidney, and no tenderness was noted in either ureter.\nThe patient’s laboratory examination results were as follows: white blood cells: 2.32*109/L; hemoglobin: 65 g/L; red blood cells: 2.65*1012/L; platelets: 31*109/L; serum ferritin: 7.1 μg/L; and creatinine 246 μmol/L. CA19–9, CA-125 alpha-fetoprotein, and carcinoembryonic antigen were in the normal range. Blood electrolytes were normal. A bone marrow examination was performed on July 17, 2020, and the results were as follows. The bone marrow morphological description revealed active nucleated cell proliferation; active granulocyte hyperplasia, mainly in the myelocyte and metamyelocyte stages; active erythrocyte hyperplasia, mainly in the immediate and late erythroblast stages; and reduced nucleoplasm in some early erythroblasts. Her bone marrow morphology revealed iron-deficiency anemia.\nThe patient underwent ultrasonography, magnetic resonance imaging (MRI), and magnetic resonance cholangiopancreatography (MRCP) examinations. Ultrasonic examination revealed an enlarged left liver lobe and a moderately sized and abnormally shaped right liver lobe. The width of the main vein of the porta hepatis was approximately 1.7 cm with local tortuous dilatation in a “vermis” shape . Color Doppler flow imaging (CDFI) indicated that the main portal vein was the signal of blood flowing into the liver, and its peak flow velocity measured by pulse-Doppler was approximately 35.8 cm/s; the accompanying dilated vein near the portal trunk was the signal of hepatic outflow, and its peak flow velocity measured by pulse-Doppler was approximately 21.4 cm. The spleen was approximately 5.3 cm thick; it was plump with a smooth outline, a strong echo in essence, and a dilated splenic vein, which was approximately 1.5 cm wide at the hilum of the spleen . Both kidneys were obviously enlarged, abnormally shaped, and covered with anechoic dark areas of different sizes ; no abnormal blood flow signal was detected by CDFI.\nRegarding the fetus, the gestational age was approximately 25 weeks, which was consistent with the actual fetal age. No significant abnormalities were observed except for polyhydramnios. The limb structure and face of the fetus were normal. In addition, no abnormalities were observed in the fetal spine, intracranial pressure, heart, lungs, kidneys, gastric vesicles, intestines, gallbladder, or bladder. The amniotic fluid index was 24–25 cm (reference value is 8–18 cm) with a maximum depth was 10.2 cm.\nMaternal MRI revealed that the liver was plump with disproportionate liver lobes. Furthermore, it revealed hepatomegaly as well as multiple tortuous dilated bile duct shadows near the liver surface, among which polycystic liver disease was identified near the top of the diaphragm. The T1 weighted image (WI) was the low signal, the T2WI was the high signal, and no dilation was observed in the common bile duct ; furthermore, the portal vein was widened and the spleen volume was enlarged. The volume of the kidneys had increased to an abnormal shape, with multiple, long, roundish T1 and T2 abnormal signals were observed . MRCP revealed that the intrahepatic cystic lesions were connected to the intrahepatic bile ducts . In conclusion, CD, polycystic kidney disease, cirrhosis, portal hypertension, and splenomegaly were revealed.\nThe patient’s venous blood samples were taken in July 2020 for genetic testing (whole exome sequencing, WES). The results revealed that the patient carried two heterozygous mutations in PKHD1: c.2854G > A, causing a change in amino acid P.(Gly952Arg), and in c.4682G > A, causing a change in amino acid P.(Cys1561Tyr).\nAccording to the imaging examinations and genetic testing, the patient was finally diagnosed with CD with concomitant ARPKD. In this state, the ongoing pregnancy would lead to higher risks for both the mother and fetus. Iron sucrose was infused to correct the iron-deficiency anemia. In addition, methylprednisolone succinate (20 mg) was prescribed to increase platelets, supplemented by stomach protection and calcium supplement supportive treatments. Cesarean section was performed after 36 weeks of pregnancy, the baby is normal after examination. Three months later in October 2020, the baby underwent a genetic test (WES), the result showed that the patient carried one heterozygous mutations in PKHD1: c.2854G > A, causing a change in amino acid P.(Gly952Arg), which indicated the baby was a PKHD1 carrier.", + "fulltext_subclaims": [ + "The patient was a 26-year-old pregnant woman with a gestational age of 25 + 2 weeks.", + "She was admitted to hospital more than 2 months after the discovery of pancytopenia and increased creatinine.", + "She was admitted for further diagnosis and treatment.", + "She was categorized as 'acute kidney injury, pancytopenia, and pregnancy' by the outpatient clinic.", + "The patient reported that her gums bled when she brushed her teeth.", + "She had large, long-lasting bruises when she collided with hard objects.", + "She experienced no lower limb edema or backache.", + "The patient was healthy with no history of surgery.", + "She had no history of food or drug allergies.", + "She had no history of substance abuse.", + "She had no exposure to toxins, dust, or harmful substances.", + "The patient did not undergo genetic testing before pregnancy.", + "The disease was not discovered until the second-trimester.", + "The patient had normal menstrual volume.", + "She had no dysmenorrhea.", + "Her menstrual period was regular.", + "She had no fertility problems.", + "She had not experienced menopause.", + "She currently had no children.", + "Her family had no history of malignant tumors.", + "Her body temperature was 36.5 °C.", + "Her pulse was 76 beats/min.", + "Her respiration was 20 breaths/min.", + "Her blood pressure was 140/88 mmHg.", + "She was conscious with satisfactory mental wellbeing.", + "Her trachea was centered.", + "She had clear respiratory sounds with no abnormal sounds in either lung.", + "Her heart rate was normal with no abnormal sounds.", + "Her abdominal distension was consistent with gestational age.", + "There was no tenderness or rebound tenderness.", + "Her liver was not palpable under the ribs.", + "Her spleen was palpable 1 cm under the ribs and hard with no tenderness.", + "No tenderness or percussion pain were noted in either kidney.", + "No tenderness was noted in either ureter.", + "Her white blood cells were 2.32*109/L.", + "Her hemoglobin was 65 g/L.", + "Her red blood cells were 2.65*1012/L.", + "Her platelets were 31*109/L.", + "Her serum ferritin was 7.1 μg/L.", + "Her creatinine was 246 μmol/L.", + "CA19–9, CA-125, alpha-fetoprotein, and carcinoembryonic antigen were in the normal range.", + "Blood electrolytes were normal.", + "A bone marrow examination was performed on July 17, 2020.", + "The bone marrow morphological description revealed active nucleated cell proliferation.", + "The bone marrow showed active granulocyte hyperplasia, mainly in the myelocyte and metamyelocyte stages.", + "The bone marrow showed active erythrocyte hyperplasia, mainly in the immediate and late erythroblast stages.", + "Some early erythroblasts had reduced nucleoplasm.", + "Her bone marrow morphology revealed iron-deficiency anemia.", + "Ultrasonic examination revealed an enlarged left liver lobe.", + "The right liver lobe was moderately sized and abnormally shaped.", + "The width of the main vein of the porta hepatis was approximately 1.7 cm with local tortuous dilatation in a 'vermis' shape.", + "Color Doppler flow imaging indicated that the main portal vein had a signal of blood flowing into the liver.", + "The peak flow velocity of the main portal vein measured by pulse-Doppler was approximately 35.8 cm/s.", + "The accompanying dilated vein near the portal trunk had a signal of hepatic outflow.", + "The peak flow velocity of the accompanying dilated vein measured by pulse-Doppler was approximately 21.4 cm.", + "The spleen was approximately 5.3 cm thick.", + "The spleen was plump with a smooth outline.", + "The spleen had a strong echo in essence.", + "The splenic vein was dilated, approximately 1.5 cm wide at the hilum of the spleen.", + "Both kidneys were obviously enlarged and abnormally shaped.", + "The kidneys were covered with anechoic dark areas of different sizes.", + "No abnormal blood flow signal was detected by CDFI.", + "The gestational age was approximately 25 weeks.", + "The gestational age was consistent with the actual fetal age.", + "No significant abnormalities were observed in the fetus except for polyhydramnios.", + "The limb structure and face of the fetus were normal.", + "No abnormalities were observed in the fetal spine.", + "No abnormalities were observed in the fetal intracranial pressure.", + "No abnormalities were observed in the fetal heart.", + "No abnormalities were observed in the fetal lungs.", + "No abnormalities were observed in the fetal kidneys.", + "No abnormalities were observed in the fetal gastric vesicles.", + "No abnormalities were observed in the fetal intestines.", + "No abnormalities were observed in the fetal gallbladder.", + "No abnormalities were observed in the fetal bladder.", + "The amniotic fluid index was 24–25 cm.", + "The maximum depth of the amniotic fluid was 10.2 cm.", + "Maternal MRI revealed that the liver was plump with disproportionate liver lobes.", + "Maternal MRI revealed hepatomegaly.", + "Maternal MRI revealed multiple tortuous dilated bile duct shadows near the liver surface.", + "Polycystic liver disease was identified near the top of the diaphragm.", + "The T1 weighted image was the low signal.", + "The T2 weighted image was the high signal.", + "No dilation was observed in the common bile duct.", + "The portal vein was widened.", + "The spleen volume was enlarged.", + "The volume of the kidneys had increased to an abnormal shape.", + "Multiple, long, roundish T1 and T2 abnormal signals were observed in the kidneys.", + "MRCP revealed that the intrahepatic cystic lesions were connected to the intrahepatic bile ducts.", + "The patient’s venous blood samples were taken in July 2020 for genetic testing.", + "The genetic testing was whole exome sequencing.", + "The results revealed that the patient carried two heterozygous mutations in PKHD1.", + "One mutation was c.2854G > A, causing a change in amino acid P.(Gly952Arg).", + "The other mutation was c.4682G > A, causing a change in amino acid P.(Cys1561Tyr).", + "According to the imaging examinations and genetic testing, the patient was finally diagnosed with CD with concomitant ARPKD.", + "The ongoing pregnancy would lead to higher risks for both the mother and fetus.", + "Iron sucrose was infused to correct the iron-deficiency anemia.", + "Methylprednisolone succinate (20 mg) was prescribed to increase platelets.", + "Stomach protection and calcium supplement supportive treatments were provided.", + "Cesarean section was performed after 36 weeks of pregnancy.", + "The baby was normal after examination.", + "Three months later in October 2020, the baby underwent a genetic test.", + "The baby’s genetic test was whole exome sequencing.", + "The baby’s genetic test result showed one heterozygous mutation in PKHD1.", + "The baby’s mutation was c.2854G > A, causing a change in amino acid P.(Gly952Arg).", + "The baby was a PKHD1 carrier." + ], + "summary": "A 26-year-old pregnant woman was admitted to our hospital for more than 2 months following the discovery of pancytopenia and increased creatinine. Ultrasonography detected an enlarged left liver lobe, widened hepatic portal vein, splenomegaly, and dilated splenic vein. In addition, both kidneys were obviously enlarged and sonolucent areas of varying sizes were visible, but color Doppler flow imaging revealed no abnormal blood flow signals. The gestational age was approximately 25 weeks, which was consistent with the actual fetal age. Polyhydramnios was detected but no other abnormalities were identified. Magnetic resonance imaging revealed that the liver was plump, and polycystic liver disease was observed near the top of the diaphragm. The T1 and T2 weighted images were the low and high signals, respectively. The bile duct was slightly dilated; the portal vein was widened; and the spleen volume was enlarged. Moreover, the volume of both kidneys had increased to an abnormal shape, with multiple, long, roundish T1 and T2 abnormal signals being observed. Magnetic resonance cholangiopancreatography revealed that intrahepatic cystic lesions were connected with intrahepatic bile ducts. The patient underwent a genetic testing, the result showed she carried two heterozygous mutations in PKHD1. The patient was finally diagnosed with CD with concomitant ARPKD. The baby underwent a genetic test three months after birth, the result showed that the patient carried one heterozygous mutations in PKHD1, which indicated the baby was a PKHD1 carrier.", + "summary_subclaims": [ + "The patient was a 26-year-old pregnant woman.", + "She was admitted to the hospital for more than 2 months.", + "The admission followed the discovery of pancytopenia and increased creatinine.", + "Ultrasonography detected an enlarged left liver lobe.", + "Ultrasonography showed a widened hepatic portal vein.", + "Ultrasonography revealed splenomegaly.", + "Ultrasonography showed a dilated splenic vein.", + "Both kidneys were obviously enlarged.", + "Sonolucent areas of varying sizes were visible in the kidneys.", + "Color Doppler flow imaging revealed no abnormal blood flow signals.", + "The gestational age was approximately 25 weeks.", + "The gestational age was consistent with the actual fetal age.", + "Polyhydramnios was detected.", + "Magnetic resonance imaging revealed a plump liver.", + "Polycystic liver disease was observed near the top of the diaphragm.", + "The T1 weighted images showed low signals.", + "The T2 weighted images showed high signals.", + "The bile duct was slightly dilated.", + "The portal vein was widened.", + "The spleen volume was enlarged.", + "The volume of both kidneys had increased to an abnormal shape.", + "Multiple, long, roundish T1 and T2 abnormal signals were observed.", + "Magnetic resonance cholangiopancreatography revealed that intrahepatic cystic lesions were connected with intrahepatic bile ducts.", + "The patient underwent genetic testing.", + "The genetic test result showed she carried two heterozygous mutations in PKHD1.", + "The patient was finally diagnosed with CD with concomitant ARPKD.", + "The baby underwent a genetic test three months after birth.", + "The baby's genetic test result showed one heterozygous mutation in PKHD1.", + "The baby was a PKHD1 carrier." + ] + } +] \ No newline at end of file