diff --git "a/data/data_annotator_data/new_v1/crowdsourcing_input_en_shard_2_v1.json" "b/data/data_annotator_data/new_v1/crowdsourcing_input_en_shard_2_v1.json" new file mode 100644--- /dev/null +++ "b/data/data_annotator_data/new_v1/crowdsourcing_input_en_shard_2_v1.json" @@ -0,0 +1,662 @@ +[ + { + "index": 0, + "label": "low_health_literacy", + "original_doc": "This is about a 20-year-old woman. She had a kidney problem since age eight that made protein leak into her urine. The problem first showed up when a big blood clot blocked veins in her brain, and a clot also went to her lungs. She took blood thinners and steroid pills. Later she took a medicine that calms the immune system to help her use fewer steroids. Tests showed no inherited blood-clotting problem. She had several flare-ups of the kidney problem. Steroid pills controlled them until 2017. After that she had no relapses. Her doctors stopped the blood thinner and the immune-calming medicine. One year later she had sudden, very bad belly pain all over. She threw up after eating. Both legs were swollen. Tests showed the kidney problem was back. A special X-ray picture (CT scan) showed a new clot in the main artery that feeds the small intestine. It was like a plug in a pipe that stops water. Blood could not reach the intestines. In surgery, most of her small intestine was dead. Taking out that much bowel would not allow life. She died 48 hours later.", + "wiki_anchor": "Causes are usually related to conditions that give rise to malabsorption of vitamin B12 particularly autoimmune gastritis in pernicious anemia.\nOther conditions giving rise to malabsorption include surgical removal of the stomach, chronic inflammation of the pancreas, intestinal parasites, certain medications such as long-term use of proton pump inhibitors, H2-receptor blockers, and metformin, and some genetic disorders. Deficiency can also be caused by inadequate dietary intake such as with the diets of vegetarians, and vegans, and in the malnourished. Deficiency may be caused by increased needs of the body for example in those with HIV/AIDS, and shortened red blood cell lifespan. Diagnosis is typically based on blood levels of vitamin B12 below 148\u2013185 pmol/L (200 to 250 pg/mL) in adults. Serum may give a false normal or even false high results. Elevated methylmalonic acid levels may also indicate a deficiency. A late finding type of anemia known as megaloblastic anemia is often but not always present. Individuals with low or marginal values of vitamin B12 in the range of 148\u2013221 pmol/L (200\u2013300 pg/mL) may not have classic neurological or hematological signs or symptoms.", + "doc_fkgl": 4.138157894736846, + "wiki_fkgl": 13.941092896174865, + "doc_tree_depth": 4.5, + "wiki_tree_depth": 7.777777777777778, + "fkgl_delta": -9.80293500143802 + }, + { + "index": 0, + "label": "intermediate_health_literacy", + "original_doc": "A 20\u2011year\u2011old woman had a 12\u2011year history of idiopathic nephrotic syndrome that initially presented with extensive cerebral venous thrombosis and pulmonary embolism. She was treated with anticoagulation and oral corticosteroids, then mycophenolate mofetil as a steroid\u2011sparing agent. A comprehensive thrombophilia work\u2011up was negative. She experienced multiple relapses controlled with steroids until 2017, then remained in remission; anticoagulation and MMF were discontinued. One year later, she developed sudden diffuse abdominal pain with postprandial vomiting and bilateral leg edema. Laboratory tests confirmed a relapse of nephrotic syndrome. Abdominal CT showed acute superior mesenteric artery thrombosis causing acute mesenteric ischemia. At surgery, there was extensive small\u2011bowel necrosis not compatible with survival. She died 48 hours later.", + "wiki_anchor": "Between 1998 and 2007, 33 serious adverse drug or device reactions have been reported by RADAR investigators. The toxicities involved multiple biological system and included thrombotic thrombocytopenic purpura (TTP) (ticlopidine and clopidogrel), thromboembolism (thalidomide and lenalidomide), liver failure (gemtuzumab and nevirapine), hypersensitivity (drug eluting coronary arterial stents), pure red-cell aplasia (PRCA) (epoetin), vision changes (amiodarone, sildenafil, and tadalafil), late thrombotic events (drug eluting cardiac stents), leukemia (G-CSF), and interstitial pneumonitis (gemcitabine). For each individual ADR, the number of unique event reports collected by RADAR ranged from 0 to 96. Twenty-seven sADRs were associated with drugs and four were associated with a device.", + "doc_fkgl": 15.20401179941003, + "wiki_fkgl": 18.996176470588242, + "doc_tree_depth": 4.888888888888889, + "wiki_tree_depth": 6.25, + "fkgl_delta": -3.792164671178213 + }, + { + "index": 0, + "label": "proficient_health_literacy", + "original_doc": "A 20\u2011year\u2011old woman had been followed since age eight for idiopathic nephrotic syndrome (NS) inaugurated by cerebral venous thrombosis extended to the right jugular vein with a massive pulmonary embolism, without sequelae and without personal or family thrombotic history. Kidney biopsy was deferred because there was no kidney failure, gross hematuria, hypertension, or extra\u2011renal signs suggestive of secondary NS at presentation. She was treated with an oral vitamin K antagonist and oral corticosteroids with good evolution. Subsequently, she had multiple steroid\u2011dependent relapses and was started on mycophenolate mofetil (MMF) as background therapy to spare corticosteroids and ensure normal growth. An exhaustive thrombophilia assessment was negative: homocysteine, fibrinogen, protein C, protein S, antithrombin III, factor V Leiden, JAK\u20112, cryoglobulins, anticardiolipin antibodies, lupus anticoagulant, and anti\u2011\u03b22\u2011glycoprotein I antibodies were all normal. Anticoagulation was stopped after nine years. Several relapses occurred but were controlled with oral corticosteroids. NS remission was documented from 2017; MMF was gradually discontinued in 2019, and she remained asymptomatic without relapse.\n\nOne year later, she presented to the emergency department with acute intense diffuse abdominal pain without irradiation, associated with postprandial vomiting and bilateral lower\u2011limb edema for six hours. Examination showed intense epigastric tenderness with normal vital signs (BP 120/70 mm Hg, HR 83 bpm, SpO2 100% on room air) and no fever or neurological impairment. Urinalysis detected proteinuria. Hemogasanalysis showed metabolic acidosis with respiratory compensation. Labs revealed hypoalbuminemia, hypercholesterolemia, prothrombin time 90%, elevated D\u2011dimer, LDH, and creatine phosphokinase, with inflammatory markers (CRP 37 mg/L) and leukocytosis (26.4 \u00d7 10^3/\u00b5L); renal and liver function were normal. Urgent abdominal ultrasound showed a low\u2011to\u2011moderate intra\u2011abdominal effusion. Contrast\u2011enhanced CT demonstrated acute thrombosis of the superior mesenteric artery with acute mesenteric ischemia. She underwent emergency laparotomy: intraoperative exploration confirmed mesenteric ischemia with extensive necrosis of almost the entire small bowel, rendering resection incompatible with life. She died 48 hours later.\n\nThis case illustrates catastrophic arterial thrombosis in the setting of NS despite a negative thrombophilia work\u2011up. NS is a hypercoagulable state with multifactorial mechanisms, including urinary loss of anticoagulant proteins (e.g., antithrombin III, protein S), increased fibrinogen, hemoconcentration, dyslipidemia, and systemic inflammation. While venous thromboembolism is more common in NS, superior mesenteric artery thrombosis is rare but often fatal, underscoring the need for high clinical suspicion and rapid imaging when severe acute abdominal pain occurs in patients with active or relapsing NS.", + "wiki_anchor": "Dehydroepiandrosterone (DHEA) \nDehydroepiandrosterone (DHEA) is a steroid hormone produced by the adrenal glands (and by the testes in men), which can be converted in the body to male and female sex hormones, including estrogen and testosterone. DHEA is used to treat a variety of conditions (without FDA approval) including aging, Alzheimer's disease, schizophrenia, erectile dysfunction, systemic lupus erythematosus, and for aiding in weight loss. There is insufficient data to support DHEA\u2019s efficacy for weight loss. The DHEA content in the daily recommended dose of Dexatrim Max ranges from 100\u2013200\u00a0mg per day. Side effects at this dose can include acne, hair loss, facial hair growth and deeper voice in women, stomach upset, and high blood pressure, particularly if the supplement is used for a longer period of time. There are many conditions in which DHEA use has special precautions and warnings. These include pregnancy and breast-feeding, hormone-sensitive conditions and cancers, liver problems, diabetes, and cholesterol problems. DHEA use is banned by the National Collegiate Athletic Association (NCAA).", + "doc_fkgl": 17.108284910965327, + "wiki_fkgl": 13.042267964071858, + "doc_tree_depth": 6.0, + "wiki_tree_depth": 6.625, + "fkgl_delta": 4.06601694689347 + }, + { + "index": 1, + "label": "low_health_literacy", + "original_doc": "She is 34 years old and pregnant. She had a seizure and trouble speaking clearly. She was sent right away for a head MRI scan. The scan showed a pattern doctors call the \u201cMedusa head.\u201d This means the veins in her brain are arranged in an unusual way that she was born with. There is a small blood clot at the outer part of this vein pattern. The blood is also moving slowly closer to the main vein.", + "wiki_anchor": "The girls are joined at the head (craniopagus), with Rose carrying her physically weaker and smaller sister on her right hip. According to the description of the condition at the start of the book, the girls are estimated to share 100 veins as well as skull bones. However, while their cerebral tissues are meshed, they have distinctly separate brains and so have different personalities.", + "doc_fkgl": 3.5813553113553134, + "wiki_fkgl": 10.798750000000002, + "doc_tree_depth": 5.142857142857143, + "wiki_tree_depth": 6.333333333333333, + "fkgl_delta": -7.2173946886446885 + }, + { + "index": 1, + "label": "intermediate_health_literacy", + "original_doc": "A 34-year-old woman who is 8 weeks pregnant had a first-time generalized seizure with temporary slurred speech. Because she is pregnant and this was her first seizure, doctors obtained an urgent brain MRI. The MRI showed the classic \u201cMedusa head\u201d sign, which indicates a developmental venous anomaly (DVA)\u2014a vein pattern you are born with. Imaging also suggested a partial clot along the peripheral portion of the draining system and slower blood flow closer to the main draining vein. These findings support the diagnosis: a developmental venous anomaly with peripheral partial thrombosis and proximal slow flow.", + "wiki_anchor": "Congenital dysfibrinogenemia is the commonest of these three disorders. Some 100 different genetic mutations occurring in more than 400 families have been found to cause it. All of these mutations as well as those causing hereditary fibrinogen A\u03b1-Chain amyloidosis exhibit partial penetrance, i.e. only some family members with one of these mutant genes develop dysfibrinogenemia-related symptoms. While both of these congenital disorders as well as acquired dysfibrinogenemia are considered very rare, it is estimated that ~0.8% of individuals with venous thrombosis have either a congenital or acquired dysfibrinogenemia. Hence, the dysfibrinogenemia disorders may be highly under-diagnosed conditions due to isolated thrombotic events that are not appreciated as reflecting an underlying fibrinogen disorder.", + "doc_fkgl": 11.942105263157895, + "wiki_fkgl": 15.408928571428572, + "doc_tree_depth": 6.4, + "wiki_tree_depth": 7.4, + "fkgl_delta": -3.4668233082706763 + }, + { + "index": 1, + "label": "proficient_health_literacy", + "original_doc": "A 34-year-old woman, 8 weeks pregnant and without other relevant history, presented with generalized convulsions and postictal dysarthria that resolved within two hours. On examination she was alert, oriented, and without focal language, motor, or sensory deficits; a right lateral tongue bite was noted. Laboratory tests and ECG were unremarkable. Given a first epileptic seizure in pregnancy, an urgent cranial MRI was performed. The protocol included 3D T1 pre- and post-contrast (axial, coronal, sagittal), axial FLAIR, axial T2, VEN BOLD and magnetic susceptibility sequences, as well as axial diffusion and ADC mapping. MRI demonstrated multiple venous cortico-medullary vascular structures converging centripetally to a large central draining vein that emptied via the inferior anastomotic vein into the left transverse sinus, forming the classic \u201cMedusa head\u201d sign. On T1 post-contrast, the drainage vein showed increased signal with central hyphocaptation, suggesting partial thrombosis versus slow flow. On T2 and FLAIR, the parenchyma surrounding the drainage vein was hyperintense, without diffusion restriction, compatible with edema. Overall, the findings are diagnostic of a developmental venous anomaly with signs of partial peripheral thrombosis and more proximal slow flow, causing perilesional edema. Management was initiated with clexane 60 mg every 12 hours and levetiracetam 500 mg every 12 hours, with symptomatic improvement and stability after one week. Contextually, DVAs are typically benign venous variants; however, pregnancy-associated hypercoagulability may predispose to thrombosis. Partial thrombosis and impaired outflow in a DVA can lead to venous congestion and edema, manifesting clinically with seizures.", + "wiki_anchor": "Symptoms\nIn affected children studied, the first signs of Pretzel syndrome begin during gestation: 80% of mothers have polyhydramnios, extra amniotic fluid around the affected baby.\nThe majority of mothers also have preterm labor starting anywhere from 25\u201338 weeks gestation. The brain is large and malformed in all affected children.\nMRI studies show extra fluid around the brain, or \u201chydrocephalus.\u201d\nThe nerve cells are not positioned properly and probably do not make normal connections with other nerve cells. As a result, seizures begin early in life and are often difficult to treat.\nMental development is severely delayed.\nThe muscles are thin and weaker than normal. The combination of low muscle tone and abnormal connective tissue results in very flexible joints and allows children to twist themselves into unusual \u201cpretzel-like\u201d postures.\nLike other muscles of the body, those that control the eyes are also weak, and about 40% of affected children have strabismus or \u201clazy eye.\u201d\nApproximately one third of the affected children have anatomical heart defects. The most common is atrial septal defect--a hole between the two upper chambers of the heart. This defect typically does not cause symptoms of heart failure early in life, but can become problematic later in childhood.\nIn 20-30% of affected children, there is a buildup of calcium deposits in the kidneys, which then lose the ability to conserve water for the body. This condition, called diabetes insipidus, causes children to urinate frequently.", + "doc_fkgl": 16.247417695473253, + "wiki_fkgl": 10.677831932773113, + "doc_tree_depth": 6.083333333333333, + "wiki_tree_depth": 6.333333333333333, + "fkgl_delta": 5.5695857627001395 + }, + { + "index": 2, + "label": "low_health_literacy", + "original_doc": "A 22-year-old woman had painful mouth sores. The sores made eating and drinking hard. The problem started after a fever. Small pimples showed up on her lips. She had been vaping for about one year. The checkup found no spots on the rest of her body. Her lips had crusts with a little blood. The corners of her mouth were raw and bled easily. Inside her mouth there were white sores with yellow edges. The sores were different shapes and sizes and were in several places. A test for the cold-sore virus was negative. The doctor said this was a mouth reaction called oral erythema multiforme. She was treated with salt-water compresses on the lips. She used a mouth rinse with an anti-swelling medicine (dexamethasone) mixed with a coating gel (hyaluronic acid). She put 2% miconazole cream on the sores at the mouth corners. She used petroleum jelly on her dry lips. She was told to stop vaping. Her mouth got better after one week of treatment.", + "wiki_anchor": "Viliuisk encephalomyelitis (VE) is a fatal progressive neurological disorder found only in the Sakha (Iakut/Yakut) population of central Siberia. About 15 new cases are reported each year. VE is a very rare disease and little research has been conducted. The causative agents, origin of the disease, and involved candidate genes are currently unknown, but much research has been done in pursuit of the answers.\nThose inflicted with the disease survive for a period of only a few months to several years. VE follows three main courses of infection: an acute form, a sub-acute form subsiding into a progressive form, and a chronic form. Initially, the infected patients experience symptoms such as: severe headaches, delirium, lethargy, meningism, bradykinesia, and incoordination. A small percentage of patients die during the acute phase as result of a severe coma. In all cases the disease is fatal.", + "doc_fkgl": 4.63312375249501, + "wiki_fkgl": 10.756291079812211, + "doc_tree_depth": 5.277777777777778, + "wiki_tree_depth": 6.555555555555555, + "fkgl_delta": -6.123167327317201 + }, + { + "index": 2, + "label": "intermediate_health_literacy", + "original_doc": "A 22-year-old woman presented with a month of painful stomatitis that made eating and drinking difficult. The illness began with a fever and pimple-like lesions on the lips. She had been vaping regularly for about one year. Examination showed no skin lesions elsewhere. The lips had serosanguineous crusts and erosions at the labial commissures that tended to bleed. Intraorally, there were multiple irregular white ulcers with yellowish borders on several sites of the oral mucosa. Anti\u2013HSV-1 IgG was non-reactive. The diagnosis was oral erythema multiforme, likely related to vaping. Management included normal saline compresses to the lips, a dexamethasone mouth rinse mixed with hyaluronic acid, 2% miconazole cream applied to the lip corner, petroleum jelly for dry lips, and stopping vaping. Her oral condition improved within one week.", + "wiki_anchor": "Epidermodysplasia verruciformis (EV) is a skin condition characterised by warty skin lesions. It results from an abnormal susceptibility to HPV infection (HPV) and is associated with a high lifetime risk of squamous cell carcinomas in skin. It generally presents with scaly spots and small bumps particularly on the hands, feet, face and neck; typically beginning in childhood or in a young adult. The bumps tend to be flat, grow in number and then merge to form plaques. On the trunk, it typically appears like pityriasis versicolor; lesions there being slightly scaly and tan, brown, red or looking pale. On the elbows, it may appear like psoriasis. On the forehead, neck and trunk, the lesions may appear like seborrheic keratosis.", + "doc_fkgl": 10.328562500000004, + "wiki_fkgl": 10.078655462184873, + "doc_tree_depth": 5.5, + "wiki_tree_depth": 6.0, + "fkgl_delta": 0.2499070378151309 + }, + { + "index": 2, + "label": "proficient_health_literacy", + "original_doc": "A 22-year-old woman presented to Oral Medicine with a 1-month history of painful oral ulcers causing difficulty eating and drinking. The episode began with fever followed by pimple-like lesions on the lips. She had used pod-type vapes for approximately one year, often trying different e-liquid flavors; she had never smoked conventional cigarettes. She reported no medication exposure prior to onset (no antibiotics, analgesics, anticonvulsants, NSAIDs, or antifungals), no drug or food allergies, and unhealthy eating habits. Extraorally, there were no lesions elsewhere on the body. The lips exhibited serosanguineous crusts with an erosive area at the right labial commissure that tended to bleed. Intraoral examination showed multiple painful white ulcers with yellowish edges, irregular and variable in size, on the labial and buccal mucosa, lateral and ventral tongue, and floor of mouth. Anti-HSV-1 IgG was non-reactive. Based on isolated oral mucosal involvement, absence of cutaneous lesions, and negative HSV serology, a diagnosis of vaping-related oral erythema multiforme, minor type, was established. Management comprised 0.9% NaCl\u2013moistened gauze compresses to the lips three times daily; a dexamethasone mouthrinse (1 mg in 10 mL hyaluronic acid) three times daily with a 30-minute post-rinse fasting period; 2% miconazole cream applied to the wound at the right labial commissure twice daily; and vaseline album (petrolatum) for dry lips. Adjunctive advice included brushing teeth and tongue twice daily (after breakfast and before bed), cessation of vaping, and avoidance of foods containing monosodium glutamate. At 1-week follow-up, the oral condition had improved. Ethical considerations: written informed consent was obtained; the case conformed to the Helsinki Declaration and had institutional approval. Context: Erythema multiforme is a mucocutaneous hypersensitivity reaction classically triggered by infections (e.g., HSV) or drugs; in this case, vaping exposure and frequent e-liquid flavor changes were considered plausible triggers in the absence of medication exposure and with non-reactive anti-HSV-1 serology.", + "wiki_anchor": "Causes\nIf a specific cause for pruritus ani is found it is classified as \"secondary pruritus ani\". If a specific cause is not found it is classified as \"idiopathic pruritus ani\". The irritation can be caused by intestinal parasites, anal perspiration, frequent liquid stools, diarrhea, residual stool deposits, or the escape of small amounts of stool as a result of incontinence or flatulence. Another cause is yeast infection or candidiasis. Some diseases increase the possibility of yeast infections, such as diabetes mellitus or HIV infection. Treatment with antibiotics can bring about a disturbance of the natural balance of intestinal flora, and lead to perianal thrush, a yeast infection affecting the anus. Psoriasis also can be present in the anal area and cause irritation. Abnormal passageways (fistulas) from the small intestine or colon to the skin surrounding the anus can form as a result of disease (such as Crohn's disease), acting as channels which may allow leakage of irritating fluids to the anal area. Other problems that can contribute to anal itching include pinworms, hemorrhoids, tears of the anal skin near the mucocutaneous junction (fissures), and skin tags (abnormal local growth of anal skin). Aside from diseases relative to the condition, a common view suggests that the initial cause of the itch may have passed, and that the illness is in fact prolonged by what is known as an itch-scratch-itch cycle. It states that scratching the itch encourages the release of inflammatory chemicals, which worsen redness, intensifies itchiness and increases the area covered by dry skin, thereby causing a snowball effect.", + "doc_fkgl": 14.527236842105264, + "wiki_fkgl": 14.36895104895105, + "doc_tree_depth": 7.214285714285714, + "wiki_tree_depth": 7.909090909090909, + "fkgl_delta": 0.15828579315421365 + }, + { + "index": 3, + "label": "low_health_literacy", + "original_doc": "At 32 weeks of pregnancy, a routine scan found one small lump inside the baby\u2019s heart. It caused no symptoms. This was the only problem seen. Doctors watched it with clinic visits until 39 weeks plus 1 day. Then the baby was delivered by C-section (a surgery to deliver the baby). After birth, the child had checkups on day 1, day 7, day 30, month 7, and month 12. At each visit, the child\u2019s growth and behavior were healthy for age. The heart lump stayed the same size; it did not grow or shrink. By 1 year old, there were no signs of a related condition called tuberous sclerosis complex.", + "wiki_anchor": "Children\nIn normal Bochdalek hernia cases, the symptoms are often observable simultaneously with the baby's birth. A few of the symptoms of a Bochdalek Hernia include difficulty breathing, fast respiration and increased heart rate. If the baby appears to have cyanosis (blue-tinted skin) this can also be a sign. Another way to identify a baby with Bochdalek hernia, is to look at the chest immediately after birth. If the baby has a Bochdalek hernia it may appear that one side of the chest cavity is larger than the other and/or the abdomen seems to be caved in.", + "doc_fkgl": 4.623939393939395, + "wiki_fkgl": 10.710020618556701, + "doc_tree_depth": 4.777777777777778, + "wiki_tree_depth": 6.4, + "fkgl_delta": -6.086081224617306 + }, + { + "index": 3, + "label": "intermediate_health_literacy", + "original_doc": "This case describes an isolated, asymptomatic fetal cardiac rhabdomyoma first detected at 32 weeks\u2019 gestation. The pregnancy was monitored as an outpatient until 39 weeks plus one day, when delivery occurred by cesarean section. Postnatal follow-up at day 1, day 7, day 30, 7 months, and 12 months showed normal growth and neurodevelopment. The intracardiac mass remained stable in size across all visits. Up to one year of age, the child did not meet any clinical diagnostic criteria for tuberous sclerosis complex (TSC).", + "wiki_anchor": "Diagnosis\nFor most cases the diagnosis for congenital amputation is not made until the infant is born. One procedure that is helpful in determining this condition in an infant is an ultrasound examination of a fetus when still in the mother's abdomen as it can reveal the absence of a limb. However, since ultrasounds are routine they may not pick up all the signs of some of the more subtle birth defects.", + "doc_fkgl": 11.214120481927715, + "wiki_fkgl": 12.617222222222225, + "doc_tree_depth": 5.4, + "wiki_tree_depth": 7.333333333333333, + "fkgl_delta": -1.4031017402945096 + }, + { + "index": 3, + "label": "proficient_health_literacy", + "original_doc": "A 29-year-old gravida V para IV (3 spontaneous vaginal deliveries, prior cesarean for failed induction 4 years earlier) presented for ANC at 32 weeks by LNMP. Maternal labs: VDRL, HBsAg, and urinalysis negative; CBC within normal limits; blood group A Rh-positive. Obstetric ultrasound revealed normal fetal anatomy except the heart. Fetal echocardiography showed normal situs; atria of comparable size; normally positioned atrioventricular and semilunar valves with normal motion; ventricles comparable in size and contractility; left ventricle forming the apex; no ventricular septal defect. Two circumscribed, round, echogenic masses were noted on the left ventricular papillary muscles, measuring 18.2 \u00d7 8.3 mm and 13.5 \u00d7 8.3 mm. LVOT and RVOT anatomy and function were normal on 2D and color flow. Impression: cardiac rhabdomyoma. Given the association with tuberous sclerosis complex (TSC), detailed neurosonography and systemic evaluation were performed and were unremarkable. She continued routine ANC without complications to 39 weeks. At 39 weeks + 1 day, a cesarean section (repeat on request at term) delivered a 3200 g female, Apgar 10 and 10 at 1 and 5 minutes. Postoperative courses for mother and neonate were uneventful; discharge occurred on postoperative day 3. The neonate was evaluated on days 1, 7, and 30: physical examinations were normal; no seizure activity or new cutaneous lesions; mass dimensions were similar to the antenatal findings. At 7 months, development was age-appropriate; pediatric echocardiography showed well-circumscribed hyperechoic masses on both left ventricular papillary muscles measuring 21.8 \u00d7 9.2 mm and 14.7 \u00d7 8.5 mm, without left ventricular inflow obstruction. At 12 months, anthropometric and neurobehavioral development remained normal. Echocardiography again demonstrated well-circumscribed hyperechoic masses on both left ventricular papillary muscles with no size increment and no left ventricular inflow obstruction. Up to one year of age, apart from the persistent intracardiac rhabdomyomas, the child met none of the clinical diagnostic criteria for TSC. Notably, while cardiac rhabdomyomas often regress spontaneously in infancy, these lesions were stable through 12 months.", + "wiki_anchor": "Ankyloglossia (tongue tie)\nFormula feeding\nDistractions or interruptions during feeds\nLong separations from the mother\nTachypnea (rapid breathing) such as in transient tachypnea of the newborn, surfactant deficiency, respiratory distress syndrome or other infant medical conditions\nPresence of an actual physical barrier between mother and infant\nSwallowing difficulties such as with prematurity and coordination of sucking, swallowing and breathing, or gastro-intestinal tract abnormalities like tracheo-oesophageal fistula.\nPain resulting from surgical procedures like circumcision, blood tests, or vaccinations.\nLatching onto the breast\nHypoplastic breasts/insufficient glandular tissue\nGalactorrhea\nLactation failure\nPolycystic ovarian syndrome\nDiabetes\nMaternal stress\nInsufficient rest/support of the mother during the first 6 weeks post-partum\nEarly return to work due to lack of financial support/maternity leave of mother\nCleft palate\nThrush\nHypoglycemia or hyperglycemia\nHypotonia, or \"low-tone\" infant disorder\nHyperlactation syndrome\nOveractive let-down\nPremature babies can have difficulties coordinating their sucking reflex with breathing. They may need to be fed more frequently because their stomachs tend to be smaller, and they may get sleepier during feedings. Premature infants unable to take enough calories by mouth may need enteral or gavage feeding - inserting a feeding tube into the stomach to provide enough breast milk or a substitute. This is often done together with Kangaroo care (prolonged skin-to-skin contact with the mother) which makes later breastfeeding easier. For some suckling difficulties, such as may happen with cleft lip/palate, the baby can be fed with a Haberman Feeder.\nDysphoric milk ejection reflex (D-MER) is a newly recognized condition affecting lactating women that is characterized by an abrupt dysphoria, or negative emotions that occur just before milk release and continuing not more than a few minutes. Preliminary testing tells us that D-MER is treatable and preliminary research tells us that inappropriate dopamine activity at the time of the milk ejection reflex is the cause of D-MER.", + "doc_fkgl": 13.580182389937107, + "wiki_fkgl": 20.354282560706405, + "doc_tree_depth": 5.529411764705882, + "wiki_tree_depth": 8.7, + "fkgl_delta": -6.774100170769298 + }, + { + "index": 4, + "label": "low_health_literacy", + "original_doc": "This is about a 13-year-old boy. He has had small growths in his throat since he was two years old. The growths were in his voice box and windpipe. They narrowed his breathing tube, so he had trouble breathing. It was like trying to breathe through a pinched straw. A chest scan showed several small cysts in his lungs. Doctors removed the throat growths. They also placed a breathing tube through a small hole in his neck to help him breathe. He got one dose of a medicine called bevacizumab (400 mg) through a vein. He also had breathing therapy. He got better. The problem has not come back during follow-up.", + "wiki_anchor": "Selected writings \n Laryngoscopische Mittheilungen, Vienna, (1863) - Laryngoscopic communications. \n Laryngoscopische Operationen, ib. 1870 (second edition in 1872) - Laryngoscopic operations.\n Beitr\u00e4ge zur Heilung des Parenchym und Cystenkropfes, Erlangen, 1874 - Contributions to healing of the parenchyma and cystic goiters.\n Mittheilungen \u00fcber Asthma Bronchiale und die Mechanische Lungenbehandlung, Stuttgart, (1875) - Communications on bronchial asthma, etc.\n Klinik der Krankheiten des Kehlkopfes, der Nase und des Rachens, ib. 1876-80 - Clinic of diseases of the larynx, nose and throat.\n Sprechen und Singen, Vienna, (1881) - Speaking and singing \n Die Erkrankungen der Nase, des Rachens und des Kehlkopfes, ib. 1895-97 - Diseases of the nose, pharynx and larynx.", + "doc_fkgl": 2.581463963963966, + "wiki_fkgl": 9.968911564625849, + "doc_tree_depth": 4.583333333333333, + "wiki_tree_depth": 5.375, + "fkgl_delta": -7.387447600661883 + }, + { + "index": 4, + "label": "intermediate_health_literacy", + "original_doc": "A 13-year-old boy with recurrent respiratory papillomatosis since age two presented with breathing difficulty, noisy breathing (stridor), and hoarseness. Airway evaluation showed multiple nodules narrowing the larynx and trachea. Chest CT revealed several pulmonary cysts. He underwent surgical removal of the papillomatosis lesions and a tracheostomy. He received a single 400 mg intravenous dose of bevacizumab and respiratory therapy. He recovered well, and there has been no recurrence on follow-up.", + "wiki_anchor": "A. haemolyticum infection is most common in 15- to 25-year-old persons and manifests as exudative pharyngitis and/or tonsillitis accompanied by cervical lymphadenopathy. Symptoms look like those of \u03b2-hemolytic streptococci or viral infection. A rash of the chest and of the abdomen, neck, or extremities is seen in 20% to 25% of cases, enhancing the risk of diagnostic error as streptococcal infection or penicillin allergy, when \u03b2-lactam therapy is initiated without exact diagnosis.", + "doc_fkgl": 12.728571428571431, + "wiki_fkgl": 16.550555555555558, + "doc_tree_depth": 5.166666666666667, + "wiki_tree_depth": 7.0, + "fkgl_delta": -3.821984126984127 + }, + { + "index": 4, + "label": "proficient_health_literacy", + "original_doc": "A 13-year-old male from Cusco with recurrent respiratory papillomatosis (RRP) since age two (tracheostomy at age three) and a maternal history of genital papilloma presented after 16 days of predominantly nocturnal respiratory difficulty, inspiratory laryngeal stridor, and moderate dysphonia. He had previously received azithromycin and supplemental oxygen without improvement. On exam, there was mild subcostal retraction, decreased vesicular breath sounds over the left hemithorax, and scant wheezes predominating on the right; he required 4 L/min oxygen via binasal cannula. Laboratory studies showed WBC 8.03 \u00d7 10^3/\u03bcL, platelets 209 \u00d7 10^3/\u03bcL, hemoglobin 13.2 g/dL, and CRP 36.6 mg/L. Imaging included a chest study and head and neck tomography; chest tomography visualized several pulmonary cysts. Forty-eight hours after admission, he developed worsening stridor and respiratory distress, prompting emergent OR transfer for tracheostomy, microlaryngoscopy, and excision of papillomatous lesions. Intraoperative findings demonstrated extensive papillomatous disease with appendicular tumor-like lesions and ventricular bands involving the epiglottis, glottic surface, vocal cords, subglottis, and trachea to ring 5. Histopathology showed koilocytotic atypia consistent with HPV and mild focal dysplasia. Postoperatively, he was managed in the PICU with respiratory monitoring and was weaned off oxygen within 48 hours. He received a single intravenous dose of bevacizumab 400 mg and showed prompt clinical improvement. He completed a seven-day hospitalization with normalization of oxygen saturation and progressive oxygen weaning, then was transferred for ongoing care. He also received respiratory therapy. On telemonitoring at eight months, there was no evidence of recurrence or intercurrent events. Clinical context: RRP is typically HPV-related (often low-risk types) and can cause multifocal papillomas leading to airway stenosis; anti-VEGF therapy such as bevacizumab is used off-label to reduce angiogenesis and disease recurrence, and in this case was associated with a favorable short- to mid-term outcome.", + "wiki_anchor": "Aspiration (defined as entry of material into the airway [trachea] thus passing below the vocal folds) and airway penetration (defined as entry of material into the laryngeal vestibule but not below the level of the vocal folds) (Figure 2) are believed to be the most significant adverse clinical outcomes of misdirected bolus flow. In older adults, penetration of the bolus into the airway occurs more often and to a deeper and more severe level than in younger adults. When the swallowing mechanism is functionally altered or perturbed in older people, such as with the placement of a nasogastric tube, airway penetration can be even more pronounced. A study examining this issue found that liquid penetrated the airway significantly more frequently when a nasogastric tube was in place in men and women older than 70 years. That study and additional evidence indicates that under stressful conditions or system perturbations, older individuals are less able to compensate due to the age-related reduction in reserve capacity (add Pendergast reference) and are more at risk to experience airway penetration or aspiration.", + "doc_fkgl": 15.644583333333337, + "wiki_fkgl": 20.016000000000002, + "doc_tree_depth": 6.769230769230769, + "wiki_tree_depth": 8.8, + "fkgl_delta": -4.371416666666665 + }, + { + "index": 5, + "label": "low_health_literacy", + "original_doc": "This 54-year-old man had long-term kidney disease. He took steroids and other medicines that weaken the body\u2019s defenses for a long time. He came to the lung department with fever, cough with mucus, and trouble breathing. A scan showed many cloudy spots in both lungs, like frosted glass. Blood tests showed a lot of inflammation. This suggested an infection from germs such as bacteria, a virus, or a fungus. A blood test was positive for RSV antibodies. Tests for other germs were not positive. His immune system was weak. His antibody level (IgG) was low. His infection-fighting T cells (CD4 and CD8) were also low. Doctors gave strong medicines for infection and support to help his breathing. His illness got worse quickly. He died from breathing failure.", + "wiki_anchor": "Patients presenting with no symptoms, and not affected by the syndrome may not require treatment. Corticosteroids have been reported to be of benefit in select patients. Bronchodilators may assist with breathing issues. Resolution may occur with the use of highly active anti-retroviral therapy used in patients with HIV, which suggests that the virus alone may cause immune cells to proliferate, or immunosuppression caused by HIV may lead to other viruses that induce the proliferation of immune cells, leading to LIP. There has been a decreased association of HIV and LIP since the introduction of antiretroviral therapy. However, responses to different treatments are widely varied, and no single first line treatment represents the default treatment for lymphocytic interstitial pneumonia.", + "doc_fkgl": 5.415573678290215, + "wiki_fkgl": 13.280000000000005, + "doc_tree_depth": 4.785714285714286, + "wiki_tree_depth": 7.5, + "fkgl_delta": -7.864426321709789 + }, + { + "index": 5, + "label": "intermediate_health_literacy", + "original_doc": "A 54-year-old man with chronic kidney disease on long-term corticosteroids and immunosuppressants was admitted to respiratory medicine with fever, cough with sputum, and shortness of breath. Chest CT showed multiple bilateral ground-glass opacities. Laboratory studies showed elevated inflammatory markers, indicating possible bacterial, viral, or fungal infection. RSV antibodies were positive, while tests for other pathogens were negative. He was immunocompromised from prolonged corticosteroid and immunosuppressant use, with low total IgG and reduced CD4 and CD8 T-lymphocyte counts. Despite intensive anti-infective therapy and escalating respiratory support, his condition deteriorated rapidly, and he died from respiratory failure.", + "wiki_anchor": "Most infections result in bacteraemia in patients that are extremely sick or peritonitis in individuals that undergo ambulatory peritoneal dialysis consistently. Several reports of infections these bacteria cause are correlated with patients who have AIDS. P. oryzihabitans is increasingly identified as a cause of opportunistic infections, taking advantage of weak immune systems in people. However, it is rare for the infection to escalate into sepsis, but there have been cases where patients have acquired the disease. Although these bacteria are able to cause infections, its role as a pathogen is questionable since this does not happen very often.", + "doc_fkgl": 16.420789473684213, + "wiki_fkgl": 14.329510204081636, + "doc_tree_depth": 6.166666666666667, + "wiki_tree_depth": 7.2, + "fkgl_delta": 2.091279269602577 + }, + { + "index": 5, + "label": "proficient_health_literacy", + "original_doc": "A 54-year-old male with membranous nephropathy II and nephrotic syndrome on long-term oral glucocorticoids and immunosuppressants (immunocompromised) presented to the Department of Respiratory Medicine with 5 days of fever, cough, expectoration, and progressive dyspnea. He had a 20 pack-year smoking history and no family history of hereditary disease. A chest x-ray one month prior was normal. On admission (August 8, 2016): BMI 24.5 kg/m2, T 39.0\u00b0C, tachypnea 35 breaths/min, severe hypoxemia (SaO2 86%). Auscultation revealed good bilateral air entry with scattered diffuse crackles and rhonchi. Chest CT demonstrated multiple bilateral ground-glass opacities. Initial labs showed a normal WBC count with elevated neutrophils and increased inflammatory markers (CRP, ESR) and elevated (1\u21923)-\u03b2-D-glucan. Serology was positive for RSV antibodies on hospital day 4; other pathogen testing was negative. He had laboratory evidence of immunosuppression with decreased total IgG and reduced CD4 and CD8 T-lymphocyte counts, consistent with chronic exposure to corticosteroids and immunosuppressants.\n\nManagement: Immediate respiratory monitoring and supplemental oxygen were initiated. Empiric anti-infective therapy included antibiotics (moxifloxacin for 4 days, then cefminoxine for 8 days) and antifungal therapy (voriconazole for 10 days). The glucocorticoid and immunosuppressant doses were largely unchanged. After 10 days, clinical status and oxygenation worsened with radiographic progression. He was transferred to the Emergency ICU for noninvasive mechanical ventilation, broad-spectrum antibiotics (i.v. meropenem, oral moxifloxacin, cotrimoxazole), antifungal therapy (micafungin), systemic corticosteroids (methylprednisolone 40 mg bid i.v.), and supportive care. Ganciclovir was added for possible viral coinfection (e.g., CMV). Five days later, chest x-ray showed further aggravation. Despite escalation to invasive ventilator-assisted ventilation, higher-dose methylprednisolone (80 mg bid), additional antibacterials (cefoperazone-sulbactam, tigecycline, cotrimoxazole), and continued micafungin, he developed rapid progression culminating in respiratory failure and death two days later.\n\nInterpretation: The presentation is consistent with severe viral pneumonia due to RSV in an immunocompromised host, with imaging showing multifocal ground-glass opacities and laboratory evidence of systemic inflammation. Elevated (1\u21923)-\u03b2-D-glucan prompted antifungal coverage, while broad-spectrum antibacterial and antiviral regimens addressed possible coinfections. Profound immunosuppression (low IgG, reduced CD4/CD8 T cells) likely contributed to rapid deterioration and refractory hypoxemic respiratory failure despite intensive anti-infective therapy and advanced respiratory support.", + "wiki_anchor": "The majority of cases of limbic encephalitis are associated with a tumor (diagnosed or undiagnosed). In cases caused by tumor, recovery can only occur following complete removal of the tumor, which is not always possible. Limbic encephalitis is classified according to the auto-antibody that causes the disease. The most common types are:\n Anti-Hu, which is associated with small-cell carcinoma of the lungs.\n Anti-Ma2, associated with germ-cell tumours of the testis.\n Anti-NMDAR, associated with tumors of the ovaries, commonly teratomata.\nSince 1999, following the publication of a case report of a 15-year-old teenager of Indian descent from South Africa who developed subacute memory loss subsequent to herpes simplex type 1 encephalitis, similar cases of non-paraneoplastic LE have been described, as has its association with auto-antibodies and response to steroid. Limbic encephalitis associated with voltage-gated potassium channel antibodies (VGKC-Abs) may frequently be non-paraneoplastic. A recent study of 15 cases of limbic encephalitis found raised VGKC-Abs associated with non-paraneoplastic disorders and remission following immunosuppressive treatment.", + "doc_fkgl": 16.479367816091955, + "wiki_fkgl": 16.486790123456796, + "doc_tree_depth": 6.15, + "wiki_tree_depth": 8.666666666666666, + "fkgl_delta": -0.007422307364841174 + }, + { + "index": 6, + "label": "low_health_literacy", + "original_doc": "A 34-year-old woman had new lower back pain. She saw blood in her urine. She also had a big bruise under the skin on her right buttock. She had never had bleeding problems before. Because these bleeding signs were serious, she was sent to the emergency room. Doctors did blood-clotting tests. One test mixed her blood with normal blood to see how it clotted. Another test looked for a blocker against a clotting protein called factor eight. These tests confirmed the diagnosis.", + "wiki_anchor": "Signs and symptoms\nHematometra typically presents as cyclic, cramping pain in the midline of the pelvis or lower abdomen. Patients may also report urinary frequency and urinary retention. Premenopausal women with hematometra often experience abnormal vaginal bleeding, including dysmenorrhea (pain during menstruation) or amenorrhea (lack of menstruation), while postmenopausal women are more likely to be asymptomatic. Due to the accumulation of blood in the uterus, patients may develop low blood pressure or a vasovagal response. When palpated, the uterus will typically feel firm and enlarged.", + "doc_fkgl": 4.512113821138211, + "wiki_fkgl": 13.668235294117647, + "doc_tree_depth": 4.444444444444445, + "wiki_tree_depth": 6.4, + "fkgl_delta": -9.156121472979436 + }, + { + "index": 6, + "label": "intermediate_health_literacy", + "original_doc": "A 34-year-old woman with no prior bleeding history developed lower back pain, passed a kidney stone, and then had three days of haematuria. She later developed painful thigh and right gluteal bruising after an intramuscular injection. Because the bleeding was extensive, she was transferred to the emergency department. Her coagulation work-up showed a markedly prolonged aPTT. A mixing study only partially corrected the aPTT, and factor VIII activity was very low with a measurable factor VIII inhibitor (8.64 BU/mL), confirming acquired haemophilia A, likely postpartum. She was treated with prednisone and cyclophosphamide, and received bypassing therapy (initially FEIBA, then switched to recombinant factor VIIa due to side effects). Her bleeding improved and she was discharged.", + "wiki_anchor": "Adverse effects \nHES can cause anaphylactoid reactions: hypersensitivity, mild influenza-like symptoms, slow heart rate, fast heart rate, spasms of the airways, and non-cardiogenic pulmonary edema. It is also linked to a decrease in hematocrit and disturbances in blood clotting. One liter of 6% solution (Hespan) reduces factor VIII level by 50% and will prolong the aPTT and will also decrease vWF. A coagulation effect of hetastarch administration is direct movement into fibrin clots and a dilutional effect on serum. Hetastarch may lead to platelet dysfunction by causing a reduction in the availability of glycoprotein IIb-IIIa on platelets.", + "doc_fkgl": 11.051032608695653, + "wiki_fkgl": 13.994556701030927, + "doc_tree_depth": 5.0, + "wiki_tree_depth": 7.2, + "fkgl_delta": -2.9435240923352737 + }, + { + "index": 6, + "label": "proficient_health_literacy", + "original_doc": "A 34-year-old female, 2 months post\u2013cesarean section (37 weeks) with persistent postoperative wound bleeding and no childhood/adolescent bleeding history, presented with a 4-week illness. The clinical course began with lower back pain attributed to bilateral renal lithiasis; after spontaneous passage of a stone she had 3 days of haematuria and was given tranexamic acid q12h. Three weeks later she developed progressive pain and induration of the left distal thigh. Following intramuscular diclofenac for persistent pain, she developed ecchymosis and ongoing bleeding in the gluteal area despite compression. An outside \u201cparticular Doppler ultrasound\u201d reportedly showed deep venous thrombosis (left lower limb), and she was started on enoxaparin 30 mg SC q24h plus morphine and hospitalized. The next day she developed epigastralgia, blurred vision, HR 117 bpm, BP 113/85 mmHg, and SpO2 93%; enoxaparin was discontinued. Hemoglobin fell from 10.4 g/dL (day prior to admission) to 6.4 g/dL, prompting 2 units of packed red cells. With a working diagnosis of vasculitis, methylprednisolone was started and she was referred for further evaluation.\n\nOn admission she had severe pallor, extensive ecchymosis of the left thigh and lateral knee, and a right thigh haematoma. Hemogram: Hb 9.8 g/dL, normocytic, normochromic. Chemistry notable for glucose 160 mg/dL; AST 52 U/L, ALT 86 U/L. Coagulation profile showed isolated prolongation of the activated partial thromboplastin time (aPTT) to 91.2 s; the remainder of hemogram, biochemistry, electrolytes, liver profile, and coagulation parameters were within reference limits. Soft-tissue ultrasound of the right gluteal region revealed a subcutaneous collection (TCSC) with oedema extending to the upper third of the thigh. Repeat Doppler ultrasound of the left lower limb showed normal flow without thrombosis in the common femoral, superficial, or deep venous systems. Blood and urine cultures were negative. ANA, C3, C4, and ferritin were within reference ranges.\n\nGiven suspected acquired haemophilia, a mixing test demonstrated partial correction of the aPTT. Factor VIII activity was <1.0 U/dL, and a factor VIII inhibitor was detected at 8.64 Bethesda units/mL, confirming acquired haemophilia A, likely postpartum in onset. Therapy included prednisone 50 mg PO at breakfast plus 10 mg at lunch, cyclophosphamide 50 mg (2 tablets) PO q24h, and FEIBA for haemostasis. After 5 days, FEIBA was discontinued due to chest tightness, dyspnoea, and nausea (suspected adverse drug reaction) and replaced with activated recombinant factor VII (rFVIIa; NovoSeven). Clinical evolution was favourable, with decreasing ecchymoses and no new symptoms, and she was discharged.\n\nContext: Postpartum acquired haemophilia A is mediated by autoantibodies to factor VIII and typically presents with isolated aPTT prolongation, low FVIII activity, and an inhibitor measured in Bethesda units. Partial correction on mixing supports an inhibitor pattern. First-line immunosuppression (e.g., prednisone with or without cyclophosphamide) and bypassing agents (FEIBA or rFVIIa) are standard to control bleeding while eradicating the inhibitor.", + "wiki_anchor": "Pathophysiology\nPreterm infants are often anemic and typically experience heavy blood losses from frequent laboratory testing in the first few weeks of life. Although their anemia is multifactorial, repeated blood sampling and reduced erythropoiesis with extremely low serum levels of erythropoietin (EPO) are major causative factors. Blood sampling done for laboratory testing can easily remove enough blood to produce anemia. Obladen, Sachsenweger and Stahnke (1987) studied 60 very low birth weight infants during the first 28 days of life. Infants were divided into 3 groups, group 1 (no ventilator support, 24 ml/kg blood loss), group 2(minor ventilated support, 60 ml/kg blood loss), and group 3(ventilated support for respiratory distress syndrome, 67 ml/kg blood loss). Infants were checked for clinical symptoms and laboratory signs of anemia 24 hours before and after the blood transfusion. The study found that groups 2 and 3 who had significant amount of blood loss, showed poor weight gain, pallor and distended abdomen. These reactions are the most frequent symptoms of anemia in very low birth weight infants.", + "doc_fkgl": 11.779287370862324, + "wiki_fkgl": 13.171980994152047, + "doc_tree_depth": 6.208333333333333, + "wiki_tree_depth": 6.875, + "fkgl_delta": -1.3926936232897233 + }, + { + "index": 7, + "label": "low_health_literacy", + "original_doc": "This is about a 2-day-old newborn boy. He was born at full term by C-section at a private hospital. He came to the children\u2019s hospital because the right side of his scrotum (the sack that holds the testicles) was swollen since birth. In the emergency room, he looked well. His skin was pink and warm. His blood flow looked good. On exam, the right testicle was big and tight. It was not sore when touched. The skin was red and looked rubbed. A light test did not shine through the right side. The light did shine through the left side. There were no signs of a hernia. An urgent ultrasound scan was done. The scan showed the right testicle was larger and looked uneven inside. No blood was flowing to it. The doctors took him quickly to surgery to look inside the scrotum. In surgery, the right testicle was dead because it had twisted, like a kinked hose that stops flow. There was a small amount of fluid. They removed the right testicle. They fixed the left testicle in place to help prevent twisting.", + "wiki_anchor": "A pelvic examination is the physical examination of the external and internal female pelvic organs. It is frequently used in gynecology for the evaluation of symptoms affecting the female reproductive and urinary tract, such as pain, bleeding, discharge, urinary incontinence, or trauma (e.g. sexual assault). It can also be used to assess a woman's anatomy in preparation for procedures. The exam can be done awake in the clinic and emergency department, or under anesthesia in the operating room. The most commonly performed components of the exam are 1) the external exam, to evaluate the external genitalia 2) the internal exam with palpation (commonly called the bimanual exam) to examine the uterus, ovaries, and fallopian tubes, and 3) the internal exam using the speculum to visualize the vaginal walls and cervix. During the pelvic exam, sample of cells and fluids may be collected to screen for sexually transmitted infections or cancer.", + "doc_fkgl": 3.26104347826087, + "wiki_fkgl": 16.816, + "doc_tree_depth": 4.0, + "wiki_tree_depth": 7.833333333333333, + "fkgl_delta": -13.554956521739129 + }, + { + "index": 7, + "label": "intermediate_health_literacy", + "original_doc": "A full\u2011term male newborn, 2 days old and delivered by cesarean section, presented with a congenital right scrotal swelling. On arrival he appeared well perfused and stable. Examination showed the right testis was enlarged, tense, non\u2011tender, and visibly reddish with excoriated overlying skin. Transillumination was negative on the right and positive on the left; both hernia openings were normal. Doppler ultrasound showed the right testis was enlarged with a heterogeneous, darker appearance and no detectable blood flow; the left testis looked normal, with only a small amount of fluid. He was taken urgently to surgery. Intra\u2011operatively, the right testis was frankly nonviable due to intravaginal torsion, with minimal hydrocele. Surgeons removed the right testis (orchidectomy) and fixed the left testis in place (contralateral orchidopexy) to reduce the risk of future twisting.", + "wiki_anchor": "Diagnosis\nWhile a full testing of tubal functions in patients with infertility is not possible, testing of tubal patency is feasible. A hysterosalpingogram will demonstrate that tubes are open when the radioopaque dye spills into the abdominal cavity. Sonography can demonstrate tubal abnormalities such as a hydrosalpinx indicative of tubal occlusion. During surgery, typically laparoscopy, the status of the tubes can be inspected and a dye such as methylene blue can be injected in a process termed chromotubation into the uterus and shown to pass through the tubes when the cervix is occluded. Laparoscopic chromotubation has been described as the gold standard of tubal evaluation. As tubal disease is often related to Chlamydia infection, testing for Chlamydia antibodies has become a cost-effective screening device for tubal pathology.", + "doc_fkgl": 11.784036259541985, + "wiki_fkgl": 15.52169291338583, + "doc_tree_depth": 5.375, + "wiki_tree_depth": 6.666666666666667, + "fkgl_delta": -3.737656653843846 + }, + { + "index": 7, + "label": "proficient_health_literacy", + "original_doc": "A 2\u2011day\u2011old term male neonate, delivered by cesarean section at a private hospital, was referred for a congenital right scrotal swelling and presented to our children\u2019s hospital one day later. On ED arrival he was well hydrated, pink on room air with good perfusion. Physical exam: right hemiscrotum with an enlarged, tense, non\u2011tender, visibly reddish testis and overlying skin excoriation; transillumination negative on the right and positive contralaterally; both hernial orifices normal. Laboratory studies were obtained, and urgent inguinoscrotal Doppler ultrasonography demonstrated an enlarged right testis measuring 15.6 \u00d7 9.4 mm with heterogeneous hypoechoic echotexture, prominent rete testis, and absent intratesticular color Doppler flow. The left testis was normal in size, shape, and echotexture; there was minimal hydrocele. The patient underwent urgent scrotal exploration. Intra\u2011operatively there was frank necrosis of the right testis secondary to intravaginal testicular torsion, with minimal hydrocele. A right orchidectomy and contralateral orchidopexy were performed. Contextually, perinatal testicular torsion often presents at or shortly after birth and Doppler evidence of absent flow with heterogeneous hypoechoic parenchyma correlates with nonviability; salvage rates are low when presentation is delayed. Contralateral orchidopexy is commonly performed to mitigate future torsion risk.", + "wiki_anchor": "Description\nAdult males measure and adult females in snout\u2013vent length. The canthus rostralis is rounded and not distinct. The tympanum is barely visible. The fingers and the toes have well-developed terminal disks. The fingers have no webbing whereas the toes have sparse webbing. The dorsum is dark gray to gray-brown; there is a more or less distinct dark, W-like mark in the scapular region. A rusty hourglass-shaped marking, an inter-ocular bar, and a dark mark in the postocular-supratympanic region may be present. Black lumbar ocelli with white anterior edging are usually present. The groin and the thighs are yellow, sometimes with light gray mottling. The chin, chest, and abdomen are gray, sometimes almost black, with the chin darker than posteriorly, with tiny white flecks. The iris is grayish gold to dark gray-brown.", + "doc_fkgl": 15.11899521531101, + "wiki_fkgl": 7.236969696969698, + "doc_tree_depth": 6.5, + "wiki_tree_depth": 4.909090909090909, + "fkgl_delta": 7.882025518341312 + }, + { + "index": 8, + "label": "low_health_literacy", + "original_doc": "A 4-year-old boy had blood in his pee and swelling for 5 days. He then had headaches, nausea, and vomiting. He came to the hospital with seizures and very high blood pressure. Blood tests showed a low level of a protein called C3 and signs of a recent strep infection. This meant his kidney filters were inflamed after strep. His brain was affected by the very high blood pressure. Doctors suspected a problem called PRES, which is brain swelling from high pressure. A brain MRI confirmed this. His immune system also attacked his red blood cells. This made his blood level drop very low, to 5 g/dL. He was treated with medicines to lower his blood pressure, steps to protect his brain, and steroid medicines. He left the hospital after 31 days. Six months later, he had no symptoms.", + "wiki_anchor": "Causes \nSerum sickness is a type III hypersensitivity reaction, caused by immune complexes. When an antiserum is given, the human immune system can mistake the proteins present for harmful antigens. The body produces antibodies, which combine with these proteins to form immune complexes. These complexes precipitate, enter the walls of blood vessels, and activate the complement cascade, initiating an inflammatory response and consuming much of the available complement component 3 (C3). They can be found circulating in the blood, which differentiates serum sickness from serum sickness-like reaction. The result is a leukocytoclastic vasculitis. This results in hypocomplementemia, a low C3 level in serum. They can also cause more reactions, causing the typical symptoms of serum sickness. This is similar to a generalised Arthus reaction.", + "doc_fkgl": 4.794388489208632, + "wiki_fkgl": 11.955913978494628, + "doc_tree_depth": 4.923076923076923, + "wiki_tree_depth": 6.222222222222222, + "fkgl_delta": -7.161525489285996 + }, + { + "index": 8, + "label": "intermediate_health_literacy", + "original_doc": "A 4-year-old boy presented after 5 days of visible blood in the urine and leg swelling, plus new headaches, nausea, and vomiting. He developed seizures with a hypertensive emergency. Labs showed low complement C3 and a high anti-streptolysin O (ASO) titer, consistent with acute post-streptococcal glomerulonephritis. He developed encephalopathy, and MRI confirmed posterior reversible encephalopathy syndrome (PRES) secondary to the hypertensive crisis. He also developed autoimmune hemolytic anemia, with hemoglobin falling to 5 g/dL. Treatment included antihypertensive therapy, neuroprotective measures, and corticosteroids. He was discharged after 31 days and remained asymptomatic at 6-month follow-up.", + "wiki_anchor": "Although the cause is unknown, the underlying mechanism involves an autoimmune disorder in which the body's immune system mistakenly attacks the peripheral nerves and damages their myelin insulation. Sometimes this immune dysfunction is triggered by an infection or, less commonly, by surgery, and rarely, by vaccination. The diagnosis is usually based on the signs and symptoms through the exclusion of alternative causes and supported by tests such as nerve conduction studies and examination of the cerebrospinal fluid. There are a number of subtypes based on the areas of weakness, results of nerve conduction studies, and the presence of certain antibodies. It is classified as an acute polyneuropathy.", + "doc_fkgl": 14.753525835866263, + "wiki_fkgl": 14.260672897196265, + "doc_tree_depth": 6.333333333333333, + "wiki_tree_depth": 6.6, + "fkgl_delta": 0.4928529386699978 + }, + { + "index": 8, + "label": "proficient_health_literacy", + "original_doc": "A 4-year-old male, two weeks post nasal impetigo treated with topical mupirocin and oral cefadroxil (dose/duration/adherence unknown), presented with 5 days of macroscopic glomerular haematuria and lower-extremity oedema, followed by 12 hours of headache, nausea, and vomiting, and arrived to the ED in convulsive status after 20 minutes of generalized tonic\u2013clonic seizures. On ED arrival he was afebrile, with non-evaluable BP, depressed consciousness, generalized hypertonia, and bilateral pretibial oedema. He was intubated and loaded with phenobarbital 10 mg/kg. In the ICU, BP was 134/94 mmHg (p95 for age 108/66; p95+12 120/78), consistent with hypertensive emergency. Initial labs: urinalysis with haematuria (>100 RBC/hpf), proteinuria 3+, leucocyturia 10\u201325/hpf; creatinine 0.3 mg/dL; anaemia Hct 21%, Hb 7 g/dL with normocytic, normochromic indices; leukocytosis 23,900/mm3; thrombocytosis 756,000/mm3; no elevation of acute-phase reactants; hypocomplementemia with C3 25 mg/dL (VN 80\u2013150) and normal C4. Throat rapid antigen for group A Streptococcus was positive and ASO positive. Non-contrast head CT was unremarkable. Renal ultrasound showed bilateral nephromegaly with increased cortical echogenicity and decreased corticomedullary differentiation. The working diagnosis was nephritic syndrome due to complicated GNAPE with hypertensive emergency and status epilepticus. He required mechanical ventilation and phenobarbital; EEG the next day was normal; CSF was normal. Cefotaxime was started for Streptococcus pyogenes eradication and furosemide for diuresis. By day 2 he developed AKI (creatinine 0.99 mg/dL), hypertension, and 24-hour proteinuria 36.6 mg/m2/h without oliguria. Antihypertensive therapy included amlodipine and IV labetalol with initial control. After extubation at 48 hours, he deteriorated neurologically within 24 hours (GCS 8) with BP > p95+12 despite labetalol infusion up to 3 mg/kg/h, amlodipine 10 mg/day, and furosemide, necessitating reintubation and sodium nitroprusside infusion up to 3 mcg/kg/min with a planned gradual BP reduction of 25% per day to mitigate secondary neurologic injury. Given acute neurologic deficits with severe HTN in GN, PRES was suspected and confirmed by brain MRI on day 5 showing increased subcortical T2/FLAIR signal in bilateral symmetric occipital regions without diffusion restriction, consistent with vasogenic edema. Ophthalmologic exam was normal; repeat EEG showed occasional generalized voltage depression. Enalapril was added. Over 10 days, BP normalized with slow pharmacologic weaning; follow-up MRI on day 12 showed radiologic regression, and he was successfully extubated after 5 days. During the ICU course, Hb fell to 5 g/dL with normocytic, normochromic indices and no thrombocytopenia; hemolytic anemia was diagnosed given a positive direct Coombs test and hemoglobinuria. He required two packed RBC transfusions. Methylprednisolone 1 mg/kg/day was given for 72 hours. Stool culture and urinary antigen for Streptococcus pneumoniae were negative. Serologies for EBV and Parvovirus B19, ENA profile, ANCA, anti-dsDNA, anti-\u03b22 glycoprotein I, anticardiolipin, and lupus anticoagulant were all negative; all cultures (blood, urine, endotracheal aspirate, pharyngeal) were negative. ANA was positive at 1:160. Clinical status improved with BP control, rising complement levels, and resolution of proteinuria and haematuria; the direct Coombs remained positive on hospital day 9. He was discharged on day 31 normotensive, non-anaemic, with preserved renal function, no proteinuria or haematuria, normalized C3, and asymptomatic neurologically. Discharge medications: prednisone, amlodipine, enalapril, and folic acid. He remained asymptomatic with no recurrence at 6 months. Overall, the case represents GNAPE with hypocomplementemia (low C3) and elevated ASO complicated by hypertensive emergency causing encephalopathy and secondary PRES, plus autoimmune hemolytic anemia with Hb nadir 5 g/dL, successfully managed with antihypertensives, neuroprotective measures, and corticosteroids, with full clinical and radiologic recovery.", + "wiki_anchor": "Adverse effects \nGenerally, studies in chemotherapy-induced nausea and vomiting suggest that doses of metopimazine higher than approved for common nausea and vomiting conditions tend to be more efficacious while remaining safe and well tolerated. \nNumerous open-label and randomized, placebo-controlled efficacy studies involving oral administration (ranging from 7.5 mg/day for 4 days, to up to 45 mg/day for ~7-30 days, to 120 mg/day for 4 days) or IV administration (10 mg to 40 mg) of metopimazine have concluded that metopimazine is safe and well tolerated with no report of severe adverse events. \nIn a dose-ranging, open-label study in patients undergoing chemotherapy, metopimazine administered orally at 20, 30, 40, 50, or 60 mg every 4 hours (q4h) for 48 hours was used to determine its safety and tolerability. Metopimazine was determined to be safe at a dose of 30 mg administered 6 times daily (180 mg/day). The dose-limiting toxicity to metopimazine was moderate-to-severe dizziness caused by orthostatic hypotension, which was observed beginning at 40 mg every 4 hours for 48 hours. Other side effects were few and mild in severity. A single possibly drug-related extrapyramidal adverse event was observed in a patient in the 60 mg q4h or 360 mg daily dose group.\nIn a randomized, double-blind comparison of ondansetron versus ondansetron plus metopimazine as an antiemetic prophylaxis during platinum-based chemotherapy, metopimazine was administered by IV (24-hour continuous infusion) at 35 mg/m2 followed by 30 mg per orally (PO) 4 times a day (120 mg/day) for 4 days. Metopimazine plus ondansetron was more efficacious than ondansetron alone, and adverse reactions were mild and without significant differences between the two treatment groups. However, there was an asymptomatic decrease in standing blood pressure when patients received the combination antiemetic therapy.\nIn a randomized, double-blind study assessing the efficacy and safety of sublingual metopimazine compared to ondansetron in chemotherapy-induced delayed emesis, patients received either 45 mg/day of metopimazine (7.5 mg x 2 every 8 hours) or 16 mg/day of ondansetron (8 mg every 12 hours). Results showed that metopimazine was comparable in efficacy to ondansetron; however, the incidence of gastrointestinal disorders was significantly lower in the metopimazine group, particularly abdominal pain and constipation.", + "doc_fkgl": 14.958653673835126, + "wiki_fkgl": 16.00520351157223, + "doc_tree_depth": 5.866666666666666, + "wiki_tree_depth": 8.083333333333334, + "fkgl_delta": -1.0465498377371034 + }, + { + "index": 9, + "label": "low_health_literacy", + "original_doc": "This 69-year-old man had heart bypass surgery in the past. For 2 months, he got very short of breath with light activity. Tests\u2014a heart tracing, a blood test, and an X-ray movie with dye of the heart arteries\u2014showed heart failure from poor blood flow after a bypass vein to the right heart artery failed. Doctors first opened a totally blocked artery on the left side of his heart. Then they used tiny natural detours between heart arteries to reach the right heart artery from the far end and open it. His breathing was better when he left the hospital. Six months later, his shortness of breath had not come back.", + "wiki_anchor": "On July 3, 2021, Gower nearly died after he suffered a massive heart attack while playing tennis with a friend. Gower needed a pacemaker installed in his heart. \"my right coronary artery ended up being 100 percent blocked with a giant blood clot... Apparently, according to the people that worked on me and the excellent cath lab team, we got here with about 10 minutes to spare\" Gower said in a Facebook video filmed from his hospital bed. A GoFundMe was set up to help pay for Gower's medical bills.", + "doc_fkgl": 6.522207792207791, + "wiki_fkgl": 8.867777777777778, + "doc_tree_depth": 5.571428571428571, + "wiki_tree_depth": 7.4, + "fkgl_delta": -2.3455699855699876 + }, + { + "index": 9, + "label": "intermediate_health_literacy", + "original_doc": "A 69-year-old man with prior coronary bypass surgery presented with two months of severe shortness of breath with mild activity (NYHA class III). He was diagnosed with heart failure due to ischemia after failure of a saphenous vein graft to the right coronary artery. This was supported by an abnormal ECG, elevated NT-proBNP, and a coronary angiogram; echocardiography also showed reduced pumping function. The team reopened a chronic total occlusion in the native right coronary artery using a retrograde approach through septal channels (septal surfing). To enable that route, they first re-opened the totally occluded left coronary artery. After the procedure, his dyspnea improved before discharge, and at 6 months he had no recurrence of shortness of breath.", + "wiki_anchor": "Off-pump coronary artery bypass or \"beating heart\" surgery is a form of coronary artery bypass graft (CABG) surgery performed without cardiopulmonary bypass (heart-lung machine) as a treatment for coronary heart disease. It was primarily developed in the early 1990s by Dr. Amano Atsushi. Historically, during bypass surgeries, the heart is stopped and a heart-lung machine takes over the work of the heart and lungs. When a cardiac surgeon chooses to perform the CABG procedure off-pump, also known as OPCAB (Off-pump Coronary Artery Bypass), the heart is still beating while the graft attachments are made to bypass a blockage.", + "doc_fkgl": 13.480000000000004, + "wiki_fkgl": 14.79561224489796, + "doc_tree_depth": 7.166666666666667, + "wiki_tree_depth": 7.5, + "fkgl_delta": -1.315612244897956 + }, + { + "index": 9, + "label": "proficient_health_literacy", + "original_doc": "A 69-year-old male with prior CABG presented with 2 months of severe dyspnea on mild exertion (NYHA III). ECG showed ST depression in II, III, aVF, and V4\u20136; NT-proBNP was 2640 pg/mL. Echocardiography demonstrated LV systolic dysfunction with LVEF 30%. His history included an inferior STEMI in 2009 with severe 3-vessel disease (proximal LAD CTO, 90% mid/distal LCx stenoses, 95% mid RCA stenosis) treated with CABG (LIMA\u2013LAD; sequential SVG to OM1, OM2, and PL). Current angiography via 6 Fr left radial access showed patent LIMA\u2013LAD and SVG\u2013OM1/OM2, but complete occlusion of the sequential SVG to PL. The native LM was occluded at the ostium and the native RCA was occluded in the mid segment with bridging collaterals. The strategy was to treat the native RCA CTO. Dual arterial access was obtained with an additional 6 Fr right femoral sheath. The right and left coronaries were engaged with 6 Fr AL 0.75 (Launcher; Medtronic) and 6 Fr EBU 3.5 (Launcher; Medtronic) guide catheters, respectively. An antegrade approach from the left radial artery failed: neither a Fielder XTR nor a Gaia 3 with a Finecross microcatheter could enter the distal true lumen. A parallel wire technique with a Crusade microcatheter and two Gaia 3 wires also failed. The team then switched to a retrograde approach via septal channels from the LAD through the occluded left coronary system. A Gaia 3 crossed the occluded LM and LAD to reach the distal LAD true lumen. A Sion wire was exchanged via a Finecross into the distal LAD, followed by dilation of the LM and proximal LAD with a 2.0 \u00d7 15 mm balloon. Septal surfing technique (SST) was then used to identify a viable septal channel. A Sion wire, supported by a 150-cm Finecross, was advanced retrogradely through a distal septal branch into the distal RCA. A Gaia 3 traversed the RCA CTO retrogradely into the proximal RCA true lumen and was advanced into a Guidezilla guide extension catheter positioned in the antegrade guide. The Finecross was delivered to the antegrade guide and an RG3 wire was externalized. The CTO segment was predilated with a 2.0 \u00d7 15 mm balloon and stented with two overlapping DES (2.5 \u00d7 38 mm and 3.0 \u00d7 38 mm), achieving an excellent angiographic result with TIMI 3 flow in all distal branches. Dyspnea was relieved at discharge, and at 6-month follow-up there was no recurrence of dyspnea.", + "wiki_anchor": "Selected publications\n Diastolic properties predict short-term postoperative risk and duration of pleural effusions after the fontan operation. Garofalo CA, Cabreriza SE, Quinn TA, Weinberg AD, Quaegebeur JM, Spotnitz HM, Mosca RS. Circulation. 114(1 Suppl):I56-61. 4 July 2006.\n Left ventricular pacing site-timing optimization during biventricular pacing using a multielectrode patch. Berberian G, Cabreriza SE, Quinn TA, Garofalo CA, Spotnitz HM. Ann. Th. Surg. 82(6):2292-4. Dec 2006.\n Surgical Considerations of Pacemakers and Automatic Defibrillators, in Cohn L, Cardiac Surgery in the Adult. Spotnitz HM. 2nd Ed., McGraw-Hill, 2003.\n Booth JH, Quinn TA, Richmond ME, Cabreriza SE, Weinberg AD, Johnston T, Spotnitz HM. Cardiac output measurement by arterial pressure waveform analysis during optimization of biventricular pacing after cardiac surgery. ASAIO J 2009 Nov-Dec;55(6):587-91.\nQuinn TA, Cabreriza SE, Richmond ME, Weinberg AD, Holmes JW, Spotnitz HM. Simultaneous variation of ventricular pacing site and timing with biventricular pacing in acute ventricular failure improves function by interventricular assist. Am J Physiol Heart Circ Physiol 2009 Dec; 297(6): H2220-6. \nSpotnitz HM. Ventricular function in surgery for congenital Heart Disease. World J of Surg [Epub ahead of print 2009 Nov 17].\nRusanov A, Spotnitz HM. 15-year experience with permanent pacemaker and defibrillator lead and patch extractions. Ann Thorac Surg 2010;89:44-50.\nBonney WJ, Spotnitz HM, Liberman L, Silver ES, Ceresnak SR, Hordof AJ, Pass RH. Survival of transvenous ICD leads in young patients. Pacing Clin Electrophysiol 2010;33:186-91.\nGeorge E, Cabreriza SE, Quinn TA, Rusanov A, Gerrah R, Broyles JM, Weinberg AD, Spotnitz HM. Validation of automated monitoring of cardiac output for biventricular pacing optimization. ASAIO J. Abstract. 2010; 56:265\u2013269.\nGray RG, Cabreriza SE, Quinn TA, Weinberg AD, Spotnitz HM. Feasibility of in vivo pressure measurement using a pressure-tip catheter via transventricular puncture. 2010; 56:194\u2013199.\nSpotnitz ME, Richmond ME, Quinn TA, Cabreriza SE, Wang DY, Albright CM, Weinberg AD, Dizon JM, Spotnitz HM. Relation of cardiac output to QRS duration during temporary resynchronization therapy after cardiac surgery. ASAIO J. 2010; Epub ahead of print", + "doc_fkgl": 9.065632911392406, + "wiki_fkgl": 11.051111111111112, + "doc_tree_depth": 6.684210526315789, + "wiki_tree_depth": 4.972222222222222, + "fkgl_delta": -1.985478199718706 + }, + { + "index": 10, + "label": "low_health_literacy", + "original_doc": "A 51-year-old man came to us with sudden, painful vision loss in his left eye for three days. His right eye could see clearly (20/20). His left eye could only see hand movements. The back of his left eye showed swelling of the seeing nerve, a bulge in the layer under the retina, several patches of fluid under the retina, and wrinkles in the thin lining there. An MRI scan with contrast dye of the eyes and brain showed a small lump behind the eye where the eye nerve meets the white part of the eye. Tests for cancer and immune diseases were normal. The doctors diagnosed inflammation in the back part of the eye\u2019s white coat that forms a small lump (nodular posterior scleritis). They started high-dose steroid pills by mouth (prednisolone).", + "wiki_anchor": "Signs and symptoms \nThe onset of ocular symptoms are usually preceded by episode of viral or flu-like symptoms such as fever, cough or sore throat (however this is not always the case). Patients can typically present erythema nodosum, livido reticularus, bilateral uveitis, and sudden onset of marked visual loss associated with the appearance of multiple lesions in the retina. These lesions may be colored from grey-white to cream-shaded yellow.\nOther symptoms include scotomata and photopsia. In weeks to a month times the lesions begin to clear and disappear (with prednisone) leaving behind areas of retinal pigment epithelial atrophy and diffuse fine pigmentation (scarring). Rarely choroidal neovascularization occur as a late onset complication.", + "doc_fkgl": 6.597509398496243, + "wiki_fkgl": 13.182857142857145, + "doc_tree_depth": 5.875, + "wiki_tree_depth": 7.5, + "fkgl_delta": -6.585347744360902 + }, + { + "index": 10, + "label": "intermediate_health_literacy", + "original_doc": "A 51-year-old man presented with 3 days of sudden, painful vision loss in the left eye. Visual acuity was 20/20 in the right eye and hand motion in the left eye. Left fundus findings included optic nerve head swelling, choroidal bulging, multiple areas of subretinal fluid, and RPE corrugations. Orbital/brain MRI with gadolinium showed a retrobulbar nodular mass enhancing at the junction of the optic nerve and sclera. Oncology and rheumatology evaluations were unremarkable. The clinical diagnosis was nodular posterior scleritis, and oral prednisolone was started.", + "wiki_anchor": "Central retinal artery occlusion is characterized by painless, acute vision loss in one eye. Upon fundoscopic exam, one would expect to find: cherry-red spot (90%) (a morphologic description in which the normally red background of the choroid is sharply outlined by the swollen opaque retina in the central retina), retinal opacity in the posterior pole (58%), pallor (39%), retinal arterial attenuation (32%), and optic disk edema (22%). During later stages of onset, one may also find plaques, emboli, and optic atrophy.", + "doc_fkgl": 11.54186046511628, + "wiki_fkgl": 16.500493827160494, + "doc_tree_depth": 6.0, + "wiki_tree_depth": 5.75, + "fkgl_delta": -4.958633362044214 + }, + { + "index": 10, + "label": "proficient_health_literacy", + "original_doc": "A 51-year-old male presented with acute, painful visual loss of the left eye (LE) for 3 days. Best-corrected distance visual acuity (BCDVA) was 20/20 OD and hand motion (HM) OS. Ocular motility and anterior segment were unremarkable OU. Fundus OS showed optic nerve head (ONH) swelling, choroidal bulging, multiple patches of subretinal fluid (SRF), and retinal pigment epithelial (RPE) corrugations; OD fundus was unremarkable.\n\nMultimodal imaging was obtained: OCT (OptoVue, Inc., Fremont, CA, USA; software version 2018.0.0.18) demonstrated mild RPE and choroidal bulging, RPE hyper-reflectivity with back shadowing, subretinal and intraretinal fluid, and mild retinal thickening. Indocyanine green angiography (ICGA) showed a geographic macular hypocyanescent area OS. Blue-autofluorescence (BAF) revealed a geographic macular area with speckled autofluorescence. B-scan ultrasonography showed optic nerve enlargement. Fluorescein angiography (FA) demonstrated vascular leakage at the ONH (hot disc) and a geographic patchy hypofluorescent area with speckled hyperfluorescent margins measuring approximately three disc diameters. Orbital and brain MRI with gadolinium revealed a retrobulbar nodular enhancing mass at the optic nerve\u2013sclera junction. Oncology consultation was unremarkable.\n\nGiven concern for malignancy and the enhancing orbital nodule, the patient underwent transconjunctival lateral orbitotomy one week after presentation. Intraoperatively, a pink localized scleral nodule with edematous Tenon was identified. With a clinical diagnosis of nodular posterior scleritis, sub-Tenon triamcinolone acetonide was administered. The patient declined admission and intravenous corticosteroids; oral prednisolone 50 mg/Kg was initiated. Rheumatologic and infectious work-up, including PPD (tuberculosis), chest X-ray, serum ACE (sarcoidosis), and C-ANCA (Wegener granulomatosis), was unremarkable.\n\nAt the one-week postoperative follow-up, BCDVA was 20/20 OD and counting fingers at 2 meters OS. SRF had resolved, and the macula was atrophic. Oral prednisolone was tapered over three months.", + "wiki_anchor": "The eyespot rasbora is an elongate fish, with a pointed snout, whose base colour is a reflective, metallic silver, though under some lighting conditions, the fish can take on a yellowish hue, with a slight pink flush present in the ventral area of the body between the operculum and the pelvic fins (corresponding roughly to the sac enclosing the alimentary canal). Under conditions of reflected light, the fish sometimes displays a fine lateral band from the operculum to the end of the caudal peduncle (Walker, 1971, p.\u00a098) this being an olive-gold hue. The fins, with the exception of the dorsal fin, are hyaline, the relation of the pectoral and pelvic fins being typical of the ostariophysans (fishes possessing an auxiliary mechanism for detecting sound consisting of a set of internal bones called the Weberian Ossicles). In such fishes, the pectoral fins are located immediately behind the operculum, whilst the pelvic fins are located further back upon the ventral side of the body - in the case of Brevibora dorsiocellata, their position is to be found vertically beneath the dorsal fin. The dorsal fin is positioned approximately equidistant between the operculum and the caudal fin, and it is the marking upon this fin that gives rise to the common names of the fish: the base colour is white, with a large rounded black oval overlaid upon the base colour, in appearance fancifully likened to an eye.", + "doc_fkgl": 14.661870129870131, + "wiki_fkgl": 19.21776595744681, + "doc_tree_depth": 5.473684210526316, + "wiki_tree_depth": 12.2, + "fkgl_delta": -4.5558958275766805 + }, + { + "index": 11, + "label": "low_health_literacy", + "original_doc": "A 78-year-old man from the Amhara region of Ethiopia had a permanent heart pacemaker because of a complete heart block. He was scheduled for prostate surgery. Before surgery, the anesthesia and heart doctors advised switching his pacemaker to a steady, fixed beat to lower the chance of problems. He could not afford that change. He chose to go ahead with the operation. He signed consent for the plan. After surgery, he also gave permission to share his case. For anesthesia, he got a numbing injection in the lower back (a combined spinal\u2013epidural). The team used 2.5 ml of strong numbing medicine (0.5% bupivacaine) and a tiny dose of fentanyl (50 micrograms). Standard monitors were used, and his heart was watched closely. His vital signs stayed steady, with only small changes. His blood pressure stayed good with IV salt water. After surgery, he went to the recovery room. He got pain medicine after 4 hours and an extra dose through the epidural. Six hours after surgery, he moved to the ward in stable condition. The epidural pain control continued for 72 hours. He went home in stable condition about 88 hours after surgery.", + "wiki_anchor": "Clinical Significance\nBecause the lumbar sympathetic nerve fibers control the muscle of the lower extremities during \u201cfight or flight\u201d response, treatment targeting this region can help relieve chronic leg pain. One common procedure is the lumbar sympathetic nerve block. This procedure involves an injection of an anesthetic in the sympathetic nerve tissue to block the sympathetic nerves ipsilaterally and test for any damage to the sympathetic nerve chain. By disrupting the nerve supply from the sympathetic chain to the lower extremities, monitoring the decrease of pain and swelling in these regions can help locate the origin of pain in the patient. Because the blocking procedure is safe and minimally invasive, this treatment is used for a multitude of sympathetic mediated pain disorders, including complex regional pain syndrome (CRPS) that causes dysregulation of the central and autonomic nervous system. This causes an upregulation of pain and temperature control to the extremity that is affected. However, the patient could experience an allergic reaction to the medications given during the procedure if the patient has uncontrolled diabetes, poorly controlled heart problems, or is under other medications.", + "doc_fkgl": 6.542719298245618, + "wiki_fkgl": 16.59369242779079, + "doc_tree_depth": 4.823529411764706, + "wiki_tree_depth": 7.571428571428571, + "fkgl_delta": -10.05097312954517 + }, + { + "index": 11, + "label": "intermediate_health_literacy", + "original_doc": "A 78-year-old man from the Amhara region, Ethiopia, with a permanent pacemaker placed for complete heart block was scheduled for retropubic prostatectomy. The anesthesia and cardiology teams recommended switching his dual-chamber, rate\u2011modulated pacemaker to an asynchronous mode perioperatively to reduce the risk of electromagnetic interference during surgery. He could not afford reprogramming and chose to proceed with the existing plan after informed consent; permission to publish the case was obtained after the operation. He received combined spinal\u2013epidural anesthesia at L3\u2013L4 using 0.5% isobaric bupivacaine 2.5 ml (12.5 mg) plus fentanyl 50 \u00b5g. Standard ASA monitoring was applied with special attention to cardiac stability. Intraoperatively, he remained stable with minimal changes in vital signs; blood pressure was supported with isotonic saline as needed. Postoperatively, he was monitored in the PACU, received analgesia at 4 hours with an epidural top\u2011up, and was transferred to the ward about 6 hours after surgery in stable condition. Epidural analgesia was continued for 72 hours. He was discharged at the 88th postoperative hour in good condition.", + "wiki_anchor": "Alcohol septal ablation is performed in the cardiac catheterization laboratory, and should only be performed by interventional cardiologists with specific training in the procedure. (Current guidelines suggest at least 20 successful procedures to demonstrate competence.) As such, it is only available in a few institutions. The technique is similar to coronary angioplasty, and utilizes similar equipment. Using wires and balloons to localize the septal artery feeding the diseased muscle under both fluoroscopic (X-ray) and echocardiographic (ultrasound) guidance, a small amount of pure alcohol is infused into the artery to produce a small heart attack. Patients typically experience mild chest discomfort during the procedure, which takes approximately 60\u201390 minutes to complete. Analgesics and mild sedatives are administered as needed. Patients typically are maintained in the hospital for three to four days to monitor for any complications, including the need for a permanent pacemaker in 5\u201310%. Complications are reduced in high volume centers, defined as a center that has performed more than 50 procedures, or an operator who has performed more than 20.", + "doc_fkgl": 12.910294117647059, + "wiki_fkgl": 14.177894736842106, + "doc_tree_depth": 6.444444444444445, + "wiki_tree_depth": 7.111111111111111, + "fkgl_delta": -1.267600619195047 + }, + { + "index": 11, + "label": "proficient_health_literacy", + "original_doc": "A 78-year-old male from the Amhara region of Ethiopia with a 7-year history of a permanent pacemaker for complete heart block was scheduled for retropubic prostatectomy for BPH after prior TURP 3 months earlier. Comorbidities included long-standing hypertension (amlodipine 5 mg daily, enalapril 10 mg BID, atorvastatin 10 mg daily) and type 2 diabetes mellitus (metformin 500 mg BID; NPH insulin 20 IU AM/10 IU PM). Preoperative evaluation showed complete bundle branch block on ECG; electrophysiology assessment demonstrated LVH due to hypertensive heart disease with mild diastolic dysfunction and an EF of 62%. Abdominal ultrasound showed an 82-ml prostate; AP chest X-ray was normal with a left-sided pacemaker in situ; electrolytes and troponin were normal. He had a frailty score of 5.5, METs 3.4, and an RCRI class III, indicating an estimated 10.1% risk of major adverse cardiac events within 30 days and intermediate surgical risk. Multidisciplinary planning recommended reprogramming the dual-chamber, rate\u2011modulated pacemaker to an asynchronous mode to mitigate intraoperative electromagnetic interference risk. Due to financial and logistical constraints, reprogramming was not performed; risks were disclosed, and he consented to proceed. Preoperatively, usual medications were continued (with a lower morning NPH dose at two\u2011thirds); diazepam 5 mg PO was given at midnight for anxiolysis. On the day of surgery, random blood glucose was checked and managed with a sliding scale. Team communication emphasized CIED precautions (electrosurgery pad positioned away from the device; emergency drugs and defibrillator immediately available). Dexamethasone was given for PONV prophylaxis and paracetamol for preemptive analgesia. ASA standard monitoring was applied and baselines recorded. An L3\u2013L4 combined epidural\u2013spinal anesthetic was performed using 0.5% isobaric bupivacaine 12.5 mg (2.5 ml) plus fentanyl 50 \u00b5g, achieving a sensory level to T7. The procedure used a midline infraumbilical incision; monopolar cautery at low voltage (20 mA) with bipolar low\u2011voltage cautery for hemostasis. Intraoperative hemodynamics remained within 10% of baseline without cardiorespiratory events; blood pressure was maintained with isotonic saline. Postoperatively, he was transferred to PACU with vigilant monitoring; analgesia was administered at 4 hours with an epidural top\u2011up, and he was transferred to the ward approximately 6 hours after surgery in stable condition. Epidural analgesia was continued for 72 hours. He was discharged at the 88th postoperative hour in stable condition, with cardiology follow\u2011up advised. Informed consent was obtained, and permission for case report publication was granted after the operation.", + "wiki_anchor": "Selected publications\n Diastolic properties predict short-term postoperative risk and duration of pleural effusions after the fontan operation. Garofalo CA, Cabreriza SE, Quinn TA, Weinberg AD, Quaegebeur JM, Spotnitz HM, Mosca RS. Circulation. 114(1 Suppl):I56-61. 4 July 2006.\n Left ventricular pacing site-timing optimization during biventricular pacing using a multielectrode patch. Berberian G, Cabreriza SE, Quinn TA, Garofalo CA, Spotnitz HM. Ann. Th. Surg. 82(6):2292-4. Dec 2006.\n Surgical Considerations of Pacemakers and Automatic Defibrillators, in Cohn L, Cardiac Surgery in the Adult. Spotnitz HM. 2nd Ed., McGraw-Hill, 2003.\n Booth JH, Quinn TA, Richmond ME, Cabreriza SE, Weinberg AD, Johnston T, Spotnitz HM. Cardiac output measurement by arterial pressure waveform analysis during optimization of biventricular pacing after cardiac surgery. ASAIO J 2009 Nov-Dec;55(6):587-91.\nQuinn TA, Cabreriza SE, Richmond ME, Weinberg AD, Holmes JW, Spotnitz HM. Simultaneous variation of ventricular pacing site and timing with biventricular pacing in acute ventricular failure improves function by interventricular assist. Am J Physiol Heart Circ Physiol 2009 Dec; 297(6): H2220-6. \nSpotnitz HM. Ventricular function in surgery for congenital Heart Disease. World J of Surg [Epub ahead of print 2009 Nov 17].\nRusanov A, Spotnitz HM. 15-year experience with permanent pacemaker and defibrillator lead and patch extractions. Ann Thorac Surg 2010;89:44-50.\nBonney WJ, Spotnitz HM, Liberman L, Silver ES, Ceresnak SR, Hordof AJ, Pass RH. Survival of transvenous ICD leads in young patients. Pacing Clin Electrophysiol 2010;33:186-91.\nGeorge E, Cabreriza SE, Quinn TA, Rusanov A, Gerrah R, Broyles JM, Weinberg AD, Spotnitz HM. Validation of automated monitoring of cardiac output for biventricular pacing optimization. ASAIO J. Abstract. 2010; 56:265\u2013269.\nGray RG, Cabreriza SE, Quinn TA, Weinberg AD, Spotnitz HM. Feasibility of in vivo pressure measurement using a pressure-tip catheter via transventricular puncture. 2010; 56:194\u2013199.\nSpotnitz ME, Richmond ME, Quinn TA, Cabreriza SE, Wang DY, Albright CM, Weinberg AD, Dizon JM, Spotnitz HM. Relation of cardiac output to QRS duration during temporary resynchronization therapy after cardiac surgery. ASAIO J. 2010; Epub ahead of print", + "doc_fkgl": 13.475840409207162, + "wiki_fkgl": 11.051111111111112, + "doc_tree_depth": 6.2631578947368425, + "wiki_tree_depth": 4.972222222222222, + "fkgl_delta": 2.42472929809605 + }, + { + "index": 12, + "label": "low_health_literacy", + "original_doc": "A 52-year-old woman had burning when she peed and had to pee very often for a long time. She tried many treatments for bladder infections, but the problem did not go away. Regular scans and lab tests looked normal. A camera test that looked inside her bladder showed the lining was red and irritated, with tiny bits floating in the urine. Later, the lab saw a live larva (a baby insect) in her urine under the microscope. That finding explained her symptoms. She was told to keep very clean. She was also told to drink plenty of water every day.", + "wiki_anchor": "Dioctophyme renale, commonly referred to as the giant kidney worm, is a parasitic nematode (roundworm) whose mature form is found in the kidneys of mammals. D. renale is distributed worldwide, but is less common in Africa and Oceania. It affects fish eating mammals, particularly mink and dogs. Human infestation is rare, but results in kidney destruction, usually of one kidney and hence not fatal. A 2019 review listed a total of 37 known human cases of dioctophymiasis in 10 countries with the highest number (22) in China. Upon diagnosis through tissue sampling, the only treatment is surgical excision.", + "doc_fkgl": 6.041, + "wiki_fkgl": 11.369795918367348, + "doc_tree_depth": 5.125, + "wiki_tree_depth": 5.833333333333333, + "fkgl_delta": -5.328795918367348 + }, + { + "index": 12, + "label": "intermediate_health_literacy", + "original_doc": "A 52-year-old woman had ongoing dysuria and urinary frequency despite multiple treatments for presumed infections. Cystoscopy showed bladder redness and debris, while imaging and routine lab tests were unremarkable. Eventually, a live larva was identified in the urine, confirming the cause of her symptoms. Management focused on better personal hygiene and increased fluid intake.", + "wiki_anchor": "Chyluria, also called chylous urine, is a medical condition involving the presence of chyle in the urine stream, which results in urine appearing milky white. The condition is usually classified as being either parasitic or non parasitic. It is a condition that is more prevalent among people of Africa and the Indian subcontinent.", + "doc_fkgl": 12.18240740740741, + "wiki_fkgl": 13.118867924528303, + "doc_tree_depth": 5.5, + "wiki_tree_depth": 8.333333333333334, + "fkgl_delta": -0.9364605171208922 + }, + { + "index": 12, + "label": "proficient_health_literacy", + "original_doc": "A 52-year-old woman presented with a three-year history of urinary frequency, dysuria, and dribbling, along with intermittent passage of red and black thread-like material in the urine. Episodes with these discharges were associated with headache, fever, and chills, and she reported intermittent periurethral and genital pruritus. She had been repeatedly treated for recurrent urinary tract infections without clinical improvement. She denied recent travel, camping, hiking, farming, swimming, or insect bites. Past surgical history included pilonidal sinus surgery (8 years prior) and hysterectomy (7 years prior). Two years before the current visit, she was hospitalized for evaluation. Examination revealed a well-appearing patient with normal vital signs. Laboratory testing, including complete blood count, urinalysis, and serum chemistries, was within normal limits. Abdominopelvic CT was unremarkable. Cystoscopy demonstrated erythema and hyperemia of the bladder mucosa, suspended intravesical debris, and dilatation of the left ureteral orifice. Schistosomiasis was suspected and she received praziquantel at appropriate dose and duration, without improvement. A second infectious diseases consultation raised suspicion for urinary myiasis, and ivermectin was prescribed, again without benefit. She underwent bladder irrigation with polyethylene glycol; no visible larvae were recovered from the washings, and she experienced self-limited hematuria for two days post-procedure. A subsequent random urinalysis was normal. However, a 24-hour urine collection demonstrated a live larva on light microscopy. The specimen was isolated and identified morphologically by an entomologist as Sarcophaga spp. Final management emphasized personal hygiene measures and liberal oral hydration.", + "wiki_anchor": "Most published studies have reported that between 50% and 80% of individuals mono-infected with Blastocystis will show symptoms. Factors influencing presentation of symptoms have been listed as the patient's age, with younger patients less likely to show symptoms, as well as genetic changes that influence the production of cytokines. Some studies have suggested that pathogenicity may be linked to specific subtypes of Blastocystis and experimental infection of animals has reported varying degrees of illness depending on the subtype used. While some subtypes appear to be less likely to result in symptomatic infection, those subtypes are also found in symptomatic individuals who have no other infection found. Symptoms associated with the infection are diarrhea, constipation, nausea, abdominal cramps, bloating, excessive gas, and anal itching. Most cases of the infection appear to become diagnosed as irritable bowel syndrome, according to studies from Denmark, Pakistan, the United Kingdom, and Italy. The timescale of infection with the parasite can range from weeks to years. In the early 2000s, Egyptian physicians identified 84 patients with diarrhea and enteritis apparently caused by Blastocystis hominis. After three days of nitazoxanide treatment, symptoms cleared and no fecal organisms were detectable in 36 (86%) of 42 treated patients and in 16 (38%) of 42 people who received placebo (P < .0001). The investigators concluded that either B hominis is pathogenic and can often be effectively treated with nitazoxanide, or that nitazoxanide (a drug approved by the FDA for the treatment of giardia and cryptosporidia) eradicated an unidentifiable organism.", + "doc_fkgl": 14.957394957983198, + "wiki_fkgl": 16.15941935483871, + "doc_tree_depth": 5.411764705882353, + "wiki_tree_depth": 7.4, + "fkgl_delta": -1.2020243968555135 + }, + { + "index": 13, + "label": "low_health_literacy", + "original_doc": "A 36-year-old woman had a long-term bowel disease (ulcerative colitis). She came in with chest pain that kept getting worse. She also had shortness of breath, sweating, and felt sick to her stomach. For months she had felt very tired and had night sweats. Her heart test (EKG) showed signs of a heart attack in the lower part of the heart. Doctors did a dye X-ray to look at the heart arteries. It showed bad blockages in two heart pipes. They opened the most blocked pipe right away with a balloon and a tiny mesh tube (stent). While looking, the team worried the main body artery (aorta) was swollen. Blood tests showed mild inflammation. A special CT scan showed the aorta wall looked thick and scarred, with tight narrow spots in several arteries. This pointed to a rare illness that causes swollen big arteries, called Takayasu arteritis. She started strong anti-inflammatory and immune medicines (prednisone and methotrexate). Later she had heart bypass surgery to improve blood flow. She did well after treatment.", + "wiki_anchor": "Signs and symptoms\nSigns and symptoms of alcoholic cardiomyopathy are indistinguishable from those seen in other forms of cardiomyopathy. These symptoms can include the following:\n Ankle, feet, and leg swelling (edema)\n This occurs because of a phenomenon known as third spacing. Third spacing occurs because the heart is unable to pump the blood throughout the body, and thus the fluid pools up in your veins. The fluid then eventually leaves your veins and enters the interstitial space, causing swelling. Doctors will sometimes test for pitting edema by pressing their fingers against the swelling to see if any \"pitting\" occurs. \u00a0\n Overall swelling\n Loss of appetite\n Shortness of breath (dyspnea), especially with activity\n Breathing difficulty while lying down\n This medical term for this symptoms is orthopnea, it occurs because fluid builds up in the posterior portion of both lungs, making it difficult to breathe.\n Fatigue, weakness, faintness\n Decreased alertness or concentration\n Cough containing mucus, or pink, frothy material\n Decreased urine output (oliguria)\n Need to urinate at night (nocturia)\n Heart palpitations (irregular heart beat)\n Rapid pulse (tachycardia)", + "doc_fkgl": 5.827348837209307, + "wiki_fkgl": 14.516929392446631, + "doc_tree_depth": 5.066666666666666, + "wiki_tree_depth": 7.25, + "fkgl_delta": -8.689580555237324 + }, + { + "index": 13, + "label": "intermediate_health_literacy", + "original_doc": "A 36-year-old woman with ulcerative colitis developed a week of worsening chest pressure with autonomic symptoms (such as sweating and nausea). Her electrocardiogram showed ST-segment elevation in the inferior leads, consistent with an inferior-wall heart attack. She also reported several months of fatigue and night sweats.\n\nUrgent coronary angiography found severe two-vessel coronary artery disease. The right coronary artery was the culprit lesion and was opened successfully with a stent. Because the interventional team suspected inflammation of the aorta (aortitis), additional workup was done. Inflammatory markers were mildly elevated, and CT angiography showed fibrotic thickening around the aorta with significant narrowing in multiple arteries, pointing to Takayasu arteritis.\n\nShe started treatment with prednisone and methotrexate. After stabilization, she underwent delayed coronary bypass surgery and did well.", + "wiki_anchor": "Selected publications\nShe authored or co-authored the following:\n 'Clinical outcome of older patients with acute coronary syndrome over the last three decades' Age Ageing 2006 35: 280\u2013285; \n'Use of evidence-based management for acute coronary syndrome.' N Z Med J. 2005 Oct 7;118(1223):U1678. PMID: 16224502.\n'Audit of a collaborative care model suggests patients with acute myocardial infarction are not disadvantaged by treatment in a rural hospital.' N Z Med J. 2002 Nov 8;115(1165):U239. PMID: 12552285.\n'Differences in easily recognised coronary risk factors by age at first myocardial infarction.' N Z Med J. 1997 Sep 12;110(1051):339-40. PMID: 9323375.\n'IDL Composition and Angiographically Determined Progression of Atherosclerotic Lesions During Simvastatin Therapy.' Arterioscler Thromb Vasc Biol. 1998 Apr;18(4):577-83. doi: 10.1161/01.atv.18.4.577. PMID: 9555863.", + "doc_fkgl": 14.593809523809526, + "wiki_fkgl": 10.193636363636365, + "doc_tree_depth": 5.888888888888889, + "wiki_tree_depth": 3.7333333333333334, + "fkgl_delta": 4.400173160173161 + }, + { + "index": 13, + "label": "proficient_health_literacy", + "original_doc": "A 36-year-old female with ulcerative colitis (well controlled on sulfasalazine, ferrous fumarate, and intermittent prednisone for flares) presented with 1 week of progressive oppressive precordial pain associated with dyspnea and neurovegetative symptoms. On admission, the ECG was in sinus rhythm with ST-segment elevation in the inferior wall. She endorsed a 6-month history of general malaise, fatigue, and night sweats, and had experienced exertional precordial pain that progressed to occur at rest. Physical examination revealed no murmurs or peripheral pulse abnormalities.\n\nEmergency coronary angiography demonstrated severe 2-vessel coronary disease: a severe 90% ostial lesion in the left coronary trunk (left main) and a severe 99\u2013100% subocclusive ostial lesion in the right coronary artery (culprit vessel). Primary angioplasty of the right coronary artery was performed with successful placement of a drug-eluting stent. The hemodynamicist noted possible aortitis given arch involvement and vessel friability during balloon advancement and recommended an inflammatory/etiologic evaluation prior to definitive management of the left main lesion.\n\nLaboratory testing showed mild anemia (hemoglobin 11.6 g/dL), mild leukocytosis (13,800/mm3), elevated ESR 42 mm/h, CRP 4.9 mg/L (normal <1), and elevated high-sensitivity troponin. Autoimmunity panel: normal complement C3/C4, negative ANA, anti-DNA, and ENA profile; non-reactive VDRL. Cardiac MRI with contrast demonstrated acute non-transmural infarction of the left ventricular inferior wall and subendocardial ischemia in the anteroseptoapical region at rest, with mild aortic and mitral insufficiency and preserved biventricular systolic function.\n\nComputed tomographic angiography of the chest/abdomen/pelvis showed periaortic fibrotic wall thickening involving the aortic root, arch, and abdominal aorta, with severe left coronary trunk stenosis, mild left subclavian and left vertebral artery stenoses, and severe inferior mesenteric artery stenosis. The differential included IgG4-related disease versus Takayasu arteritis. Total IgG was 1,600 mg/dL (ref 700\u20131,600) with IgG1 1,024 mg/dL (elevated) and normal IgG2 456 mg/dL, IgG3 98.8 mg/dL, and IgG4 13.6 mg/dL, findings not supportive of IgG4-related aortitis. Takayasu arteritis was diagnosed clinically and by imaging.\n\nImmunosuppression was initiated with prednisone 60 mg daily and methotrexate 20 mg weekly (parenteral) with folic acid 1 mg daily. After 3 weeks of therapy, she underwent myocardial revascularization surgery using the left internal mammary artery graft to the descending anterior artery (LAD) and an aortocoronary bypass to the circumflex artery. Intraoperatively, the aortic root and ascending aorta appeared healthy. She was discharged home in good general condition and remains under ambulatory follow-up.\n\nContext: Takayasu arteritis is a large-vessel granulomatous vasculitis affecting the aorta and its major branches that can produce aorto-ostial coronary lesions (as in this case, involving the left main and right coronary ostia), leading to myocardial ischemia/infarction. The mildly elevated inflammatory indices, periaortic fibrotic thickening, and multifocal arterial stenoses on CTA are characteristic, and the lack of IgG4 elevation argues against IgG4-related aortitis. The staged approach\u2014urgent culprit-vessel PCI followed by immunosuppression and delayed CABG\u2014is consistent with management principles aiming to control vascular inflammation before definitive surgical revascularization.", + "wiki_anchor": "Symptoms and signs\nAs Lutembacher's syndrome is known for ASD and MS, most of the symptoms experienced will be associated with ASD and MS. For most people, they will remain asymptomatic (experience no symptoms) but when symptoms are shown, they are due mainly to ASD and will vary depending on the size of the hole in the atria. If the patient has a large ASD, pulmonary congestion (blood or fluid buildup in the lungs) will happen later but if the patient has a small ASD, symptoms will appear early in the disorder. In general, unless the ASD and mitral stenosis causing Lutembacher's syndrome is severe, symptoms may not appear until the second and third decade of the patient's life. As many of the patients are asymptomatic and symptoms may not appear until later in life, the duration or frequency of the symptoms varies. For symptoms such as palpitations, ventricular overload, heart failure, and pulmonary congestion, these symptoms may be sudden and not that frequent as they are very severe symptoms. For symptoms such as loud mitral S1, pulmonary S2, mid-diastolic murmur, fatigue, reduced exercise tolerance, weight gain, ankle edema, and right upper quadrant pain, and ascities, these symptoms may be less frequent and severe; their duration may be only a few seconds, minutes, or even months.", + "doc_fkgl": 16.972754430379748, + "wiki_fkgl": 15.23687830687831, + "doc_tree_depth": 6.380952380952381, + "wiki_tree_depth": 8.714285714285714, + "fkgl_delta": 1.7358761235014377 + }, + { + "index": 14, + "label": "low_health_literacy", + "original_doc": "A 36-year-old woman had trouble swallowing. Tests found she was born with an unusual shape of the main body artery in her chest. The artery curves to the right in a mirror-image pattern. It wraps around a main branch of the airway. The side branches of the artery come off in the reverse order from normal. Most people with this have no symptoms. Problems happen only if the artery squeezes the space in the middle of the chest. This can press on the food pipe or the windpipe. Surgery may be needed if there is strong pressure on these tubes, a bulge or a tear in the chest artery, or a pouch on the artery bigger than 2 cm. There is no one-size-fits-all treatment. Care is tailored to the person\u2019s symptoms and body anatomy. This patient did not receive any treatment.", + "wiki_anchor": "It is performed by asking the patient to exhale and hold it. The doctor then percusses down their back in the intercostal margins (bone will be dull), starting below the scapula, until sounds change from resonant to dull (lungs are resonant, solid organs should be dull). That is where the provider marks the spot. Then the patient takes a deep breath in and holds it as the provider percusses down again, marking the spot where the sound changes from resonant to dull again. Then the provider will measure the distance between the two spots. Repeat on the other side, is usually higher up on the right side. If it is less than 3\u20135\u00a0cm the patient may have a pneumonia or a pneumothorax in which a chest x-ray is diagnostic for either.", + "doc_fkgl": 5.730088652482269, + "wiki_fkgl": 8.480952380952385, + "doc_tree_depth": 6.0, + "wiki_tree_depth": 6.0, + "fkgl_delta": -2.750863728470115 + }, + { + "index": 14, + "label": "intermediate_health_literacy", + "original_doc": "A 36-year-old woman had dysphagia due to a congenital right aortic arch with mirror-image branching.\nIn this rare pattern, the aorta runs to the right, wraps around the right main bronchus, and the head-and-arm arteries branch in the reverse order of normal.\nMost people have no symptoms unless the aorta or an associated bulge compresses the esophagus or trachea.\nSurgery is considered for major airway or esophageal compression, aneurysmal disease, thoracic aortic dissection, or a Kommerell diverticulum larger than 2 cm.\nThere is no standard operation; treatment is tailored to the person\u2019s anatomy and symptoms.\nIn this case, imaging showed external compression of the upper esophagus with a small Kommerell diverticulum (about 1.3 cm), so no intervention was performed and her symptoms improved.", + "wiki_anchor": "Physical factors may cause ischuria, constipation, as well as numerous spleen-related diseases such as hypersplenism, thrombocytopenia, and lymphoma. Blocking of the arteries and torsion (twisting that interrupts the blood supply to that organ) in the spleen can also result in abdominal pain or swelling. However, lack of visible symptoms \u2014 except in incidents of abdominal pain \u2014 makes the disease difficult for doctors to diagnose, though medical imaging techniques such as medical ultrasonography, magnetic resonance imaging, or computed tomography can be used to confirm its occurrence. Characteristics of the disorder include the loss, weakening, or malformation of the ligaments that help to keep the spleen located in the upper left part of the abdomen.", + "doc_fkgl": 11.984808362369339, + "wiki_fkgl": 17.455000000000002, + "doc_tree_depth": 6.666666666666667, + "wiki_tree_depth": 9.0, + "fkgl_delta": -5.470191637630663 + }, + { + "index": 14, + "label": "proficient_health_literacy", + "original_doc": "A 36-year-old female presented with dysphagia and longstanding cervical and upper thoracic pain; she also had a multinodular goiter with no other significant history. Esophagogastroduodenal transit after barium ingestion showed a posterior and lateral right impression on the proximal esophagus extending 3.5 cm craniocaudally, with an estimated maximal esophageal stenosis of 60%. Cervical and thoracic CT revealed a congenital anomaly of the aortic arch: a right aortic arch with mirror-image branching. The arch originated from the aortic root, coursed above the right stem bronchus, and gave rise to the three supra-aortic trunks as follows: (1) left brachiocephalic artery (giving rise to the left common carotid artery and the left subclavian artery), (2) right common carotid artery, and (3) right subclavian artery. The aortic arch then passed posterior to the esophagus and exhibited a small anterior saccule measuring 1.3 cm, consistent with a Kommerell diverticulum. This configuration formed a vascular ring around the tracheo-esophageal pair, bounded posterolaterally on the right by the aortic arch, posterolaterally on the left by the Kommerell diverticulum, laterally on the left by the arteriosum ligamentum (or arterial ligament), and anteriorly by the left brachiocephalic artery. Gastroscopy confirmed endoluminal impact of extrinsic compression. Given minimal clinical repercussions and absence of nutritional disorders, no surgical cure was performed. The evolution was favorable with patient-reported spontaneous amelioration of symptoms.\n\nContext: Right aortic arch with mirror-image branching is a rare anomaly of embryologic development. The vast majority of patients are asymptomatic unless mediastinal structures are compressed. Indications for surgery include major compression of the esophagus or trachea, aneurysmal disease, thoracic aortic dissection, or a Kommerell diverticulum larger than 2 cm. There is no standardized treatment; management is individualized according to clinical presentation and anatomic configuration.", + "wiki_anchor": "Skull\nIn Mahajangasuchus the skull is noticeably platyrostral, being flat and wide. The premaxilla possesses 1 to 4, potentially 5, tooth positions on each side, with the 3rd premaxillary tooth being the largest. The maxilla of Mahajangasuchus are very low in lateral view, appearing almost flat, and are heavily sculpted. They are roughly as long as they are wide with 11 to 12 alveoli on each side. The first 4 maxillary teeth were closely spaced with the 3rd being the largest. The 5th to 9th were smaller than the previous 4, but roughly evenly sized amongst themselves before the 10th and 11th (and potentially 12th) would have marked a further decrease in size. There is a notable diastema located between the 4th and 5th maxillary alveoli, most likely to make space for a large dentary tooth. Medially to the antorbital fenestra the maxilla forms a prominent ridge that runs laterally to the maxillary nasal contact. The nasals are fused, however it is uncertain if they reached up to the external nares. The nasals did not contact the lacrimal, which is anteriorly bifurcated and forms most of the posterior edge of the antorbital fenestra, a condition also seen in Stolokrosuchus, in which the antorbital fenestra is almost entirely located within the lacrimal. Along the contact with the prefrontals the lacrimals swell to form the posterolateral portion of the prominent rostral ridge. The posteromedial portion is formed by the elongated prefrontals. The frontal is broad between the orbits and narrows significantly between the prefrontals before making contact with the nasals. It only extends slightly between the supratemporal fenestrae. The medial wall and floor of the supratemporal fenestrae is made up by the parietal. In specimen FMNH PR 2448 the lateral edges of the fenestrae are strongly everted, creating a narrow medial groove. This feature however seems to vary between specimen, as FMNH PR 2389 is flat in comparison. A thin lamina of the parietal overhangs the posterior and medial edge of the supratemporals. The dentary has 14 alveoli on each half, the biggest of which being the 4th and the 9th. The first dentary tooth is elevated above the others.", + "doc_fkgl": 16.455087719298245, + "wiki_fkgl": 10.772005586592176, + "doc_tree_depth": 7.0, + "wiki_tree_depth": 5.75, + "fkgl_delta": 5.683082132706069 + }, + { + "index": 15, + "label": "low_health_literacy", + "original_doc": "This story is about a 62-year-old white North African woman. She was diagnosed in 2021 with a rare condition called Von Hippel\u2013Lindau disease. This condition caused growths in several parts of her body. She had a tumor in a bone near her left ear. She had a tumor in the left adrenal gland, which sits above the kidney. She had cancer in her left kidney. Her right kidney had many cysts. She also had growths in her pancreas. She received several treatments. She had radiation treatment. She had surgery to remove the left adrenal gland. She had surgery to remove the left kidney. She had major surgery on the pancreas and nearby small intestine. Later, ultrasound and MRI scans showed a lump with both fluid and solid parts near the left ovary and tube. Keyhole surgery looked inside the pelvis. It found cyst-type tumors in the thin support tissue next to both fallopian tubes. Doctors then removed the uterus and both ovaries and tubes. The lab checked the tissue. It showed tumors of the same type on both sides in the thin support tissue around the tubes and the uterus. These findings fit with Von Hippel\u2013Lindau disease.", + "wiki_anchor": "Aesophageal cancer \u2013 there are two types of aesophageal cancer. The squamous cell cancer from the squamous cells of the tongue or the adenocarcinoma from glandular cells present at the junction of the esophagus and stomach. This leads to a local tumour growth with spreading later. This spreading may lead to larger tumors that would result in the inability to swallow.\n Aesophageal webs \u2013 thin membranes located in the esophagus. Abnormalities can cause constrictions within the esophagus.\n Globus pharyngis \u2013 commonly referred to as lumps in ones throat\n Myasthenia gravis \u2013 the thymus gland is thought to be necessary for the deletion of auto-reactive T cells, and seems to have an important role in the pathogenesis of myasthenia gravis. In patients the thymus is typically enlarged, and contains many germinal centres with T and B cell areas very similar to those seen in lymph nodes. The tumour in thymoma associated disease is typically epithelial in nature.\n Facioscapulohumeral muscular dystrophy \u2013 even though there is not a clear correlation between the facioscapulohumeral muscular dystrophy and the pharyngeal and upper aesophageal striated muscle. Minor, and nonspecific, primary aesophageal dysmotility was present as seen in the 2008 study by Joerg-patrick St\u00fcbgen.\n Multiple sclerosis \u2013 may lead to aesophageal dysmotility", + "doc_fkgl": 5.262667512690356, + "wiki_fkgl": 11.737000000000002, + "doc_tree_depth": 5.15, + "wiki_tree_depth": 7.25, + "fkgl_delta": -6.4743324873096455 + }, + { + "index": 15, + "label": "intermediate_health_literacy", + "original_doc": "A 62-year-old white North African woman with Von Hippel\u2013Lindau (VHL) disease diagnosed in 2021 developed several VHL-related tumors: a left petrous bone tumor, a left pheochromocytoma, left renal cell carcinoma, a multicystic right kidney, and pancreatic masses. She was treated with radiotherapy to the petrous bone lesion, left adrenalectomy, left nephrectomy, and cephalic duodenopancreatectomy for the pancreatic tumors. During surveillance, ultrasound and MRI showed a solid\u2013cystic mass in the left adnexal (ovary/tube) region. Laparoscopy then identified cystic tumors in the mesosalpinx on both the right and left sides. She underwent hysterectomy with removal of both adnexa. Pathology confirmed bilateral clear-cell papillary cystadenomas of the mesosalpinx and broad ligament, a pattern consistent with VHL.", + "wiki_anchor": "An initial clinical report of this syndrome describes a 6-month-old boy with rhizomelic shortening, particularly in the arms, and protuberances over the lateral aspects of the clavicles. On radiographs the lateral third of the clavicles had a bifid appearance resulting from an abnormal process or protuberance arising from the fusion center. His 22-year-old mother also had a height of 142\u00a0cm with an arm span of 136\u00a0cm and rhizomelic shortness of the limbs, maximal in the arms, and abnormalities of the acromioclavicular joints. Both the mother and the son had marked bilateral clinodactyly of the fifth fingers associated with hypoplastic middle phalanx.", + "doc_fkgl": 13.893053097345135, + "wiki_fkgl": 15.073859223300971, + "doc_tree_depth": 6.666666666666667, + "wiki_tree_depth": 7.75, + "fkgl_delta": -1.1808061259558364 + }, + { + "index": 15, + "label": "proficient_health_literacy", + "original_doc": "A 62-year-old Tunisian Arab postmenopausal woman with Von Hippel\u2013Lindau (VHL) disease (diagnosed 2021) had multisystem involvement. In 2021 she had a 6 cm left petrous bone endolymphatic sac tumor managed with radiotherapy; a 6 cm left pheochromocytoma treated with left adrenalectomy (pathology: pheochromocytoma); and a ruptured left renal mass treated with left nephrectomy (microscopy: multifocal clear-cell renal cell carcinoma, nuclear grade 2). In 2022 she underwent cephalic duodenopancreatectomy for a pancreatic mass; histology showed three serous cystadenomas and two well-differentiated neuroendocrine tumors. In January 2021, surveillance abdominal\u2013pelvic CT incidentally identified a 4 cm solid\u2013cystic left adnexal mass suspected to be malignant; this was confirmed on transvaginal ultrasound and pelvic MRI and classified O-RADS 5. Gynecologic exam was unremarkable. At laparotomy via a midline infraumbilical incision, a well-defined solid\u2013cystic mass was found in the left adnexa. There was no ascites, no peritoneal carcinomatosis, and the right adnexa appeared grossly normal without exocystic vegetations. Peritoneal cytology was obtained. Left adnexectomy was performed and the specimen sent for frozen section, which was inconclusive, raising the differential of a borderline tumor versus a VHL-associated tumor. Given her postmenopausal status, total hysterectomy with right adnexectomy was completed. Final histology demonstrated bilateral clear-cell papillary cystadenomas of the Fallopian tubes and broad ligament, measuring 0.5 cm on the right and 4 cm on the left. The tumors were composed of tightly packed papillae with fibrous cores lined by monolayered epithelium, consistent with VHL-associated mesosalpinx/broad ligament lesions. The postoperative course was uneventful; 1-month postoperative evaluation was normal. She has been followed every 4 months with normal pelvic ultrasound for 2 years, and was recently readmitted to neurosurgery for recurrence of a brain tumor.", + "wiki_anchor": "The 33 NCCN Member Institutions are:\n Abramson Cancer Center at the University of Pennsylvania\n Alvin J. Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine\n Case Comprehensive Cancer Center/University Hospitals Seidman Cancer Center and Cleveland Clinic Taussig Cancer Institute\n City of Hope National Medical Center\n Dana-Farber/Brigham and Women's Cancer Center | Mass General Cancer Center\n Duke Cancer Institute\n Fox Chase Cancer Center\n Fred & Pamela Buffett Cancer Center at the University of Nebraska Medical Center\n Fred Hutchinson Cancer Center\n Huntsman Cancer Institute at the University of Utah\n Indiana University Melvin and Bren Simon Comprehensive Cancer Center\n Mayo Clinic Comprehensive Cancer Center\n Memorial Sloan Kettering Cancer Center\n Moffitt Cancer Center\n O'Neal Comprehensive Cancer Center at University of Alabama at Birmingham\n Robert H. Lurie Comprehensive Cancer Center\n Roswell Park Comprehensive Cancer Center\n St. Jude Children's Research Hospital/The University of Tennessee Health Science Center\n Stanford Cancer Institute\n The Ohio State University Comprehensive Cancer Center - James Cancer Hospital and Solove Research Institute\n The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins\n The UChicago Medicine Comprehensive Cancer Center\n University of Texas MD Anderson Cancer Center\n UC Davis Comprehensive Cancer Center\n UC San Diego Moores Cancer Center\n UCLA Jonsson Comprehensive Cancer Center\n UCSF Helen Diller Family Comprehensive Cancer Center\n University of Colorado Cancer Center\n University of Michigan Rogel Cancer Center\n University of Wisconsin Carbone Cancer Center\n University of Texas Southwestern Medical Center\n Vanderbilt-Ingram Cancer Center\n Yale Cancer Center/Smilow Cancer Hospital", + "doc_fkgl": 15.117090909090908, + "wiki_fkgl": 33.73441489361703, + "doc_tree_depth": 6.071428571428571, + "wiki_tree_depth": 14.5, + "fkgl_delta": -18.61732398452612 + }, + { + "index": 16, + "label": "low_health_literacy", + "original_doc": "A 59-year-old man with type 1 diabetes came to the hospital with heart failure. A heart ultrasound showed big clumps of germs stuck to two heart valves, the mitral and the aortic valves. His blood test grew a germ called Staphylococcus warneri. This is a kind of staph that usually lives on the skin and is normally harmless. Doctors found he had an infection on his own heart valves (native valve endocarditis). He later had surgery to replace both the mitral and the aortic valves. Looking back, small lab changes and weight loss that began about four months earlier may have been early warning signs. He had not been on immune-weakening medicines and did not have any implanted medical devices.", + "wiki_anchor": "Drawing severe criticism in the 1930s, focal infection theory\u2014whose popularity zealously exceeded consensus evidence\u2014was discredited in the 1940s by research attacks that drew overwhelming consensus of this sweeping theory's falsity. Thereupon, dental restorations and endodontic therapy became again favored. Untreated endodontic disease retained mainstream recognition as fostering systemic disease. But only alternative medicine and later biological dentistry continued highlighting sites of dental treatment\u2014still endodontic therapy, but, more recently, also dental implant, and even tooth extraction, too\u2014as foci of infection causing chronic and systemic diseases. In mainstream dentistry and medicine, the primary recognition of focal infection is endocarditis, if oral bacteria enter blood and infect the heart, perhaps its valves.", + "doc_fkgl": 7.468333333333334, + "wiki_fkgl": 18.6771376146789, + "doc_tree_depth": 6.125, + "wiki_tree_depth": 6.8, + "fkgl_delta": -11.208804281345568 + }, + { + "index": 16, + "label": "intermediate_health_literacy", + "original_doc": "A 59-year-old man with long-standing type 1 diabetes presented with acute heart failure. An echocardiogram showed large vegetations on the mitral and aortic valves. Blood cultures were positive for Staphylococcus warneri, a coagulase\u2011negative staphylococcus commonly found on the skin. He was diagnosed with native valve endocarditis. After medical stabilization, he ultimately underwent replacement of both the mitral and aortic valves. In retrospect, mild laboratory abnormalities and several months of weight loss beginning about four months earlier were likely early signs of endocarditis. He had no history of immunosuppressive therapy and no implanted medical devices.", + "wiki_anchor": "Mechanism\nAlthough the specific form of pathogenesis is still a subject of ongoing research, the bacteria has been observed to result in morphological symptoms that are atypical of bacterial infection. Autopsy of the victims vividly exhibit erythrophagocytosis, hepatosplenomegaly, interstitial pneumonia, and lymph node sinus hyperplasia. In addition, Myocarditis and Endocarditis have also been demonstrated in such patients. Synovial and serosal surfaces may be more suited for the growth of the bacteria within the body. Furthermore, leukocytoclastic vasculitis has been observed in the skin lesions.", + "doc_fkgl": 12.996079027355623, + "wiki_fkgl": 14.562000000000001, + "doc_tree_depth": 5.714285714285714, + "wiki_tree_depth": 6.2, + "fkgl_delta": -1.5659209726443777 + }, + { + "index": 16, + "label": "proficient_health_literacy", + "original_doc": "A 59-year-old Japanese man with a 28-year history of type 1 diabetes on intensive multiple-dose insulin therapy (BMI 18.4 kg/m2, undetectable C\u2011peptide, HbA1c ~9.0%) and remote, asymptomatic chronic severe (grade III) aortic regurgitation (diagnosed 16 years earlier without subsequent follow\u2011up) presented with acute decompensated heart failure. He had never undergone surgery or prosthetic device implantation and had no history of immunosuppressive therapies.\n\nEight days after a routine visit, he developed dyspnea and fever >38\u2103. On arrival: BP 192/82 mmHg, HR 118/min, orthopnea, SpO2 80%. Exam: Levine 3/6 systolic murmur; no Osler nodes, Janeway lesions, or conjunctival petechiae. Labs: WBC 20,800/\u03bcL, CRP 6.06 mg/dL, CK\u2011MB 6.0 IU/L, troponin T negative. CXR showed pulmonary congestion with cardiomegaly (CTR 55%). ECG had ST elevation in V1\u2013V4, but emergent echocardiography showed no systolic dysfunction. He was diagnosed with acute heart failure due to valvular disease and treated with non\u2011invasive positive pressure ventilation and nitrates.\n\nTransthoracic echocardiography demonstrated severe aortic regurgitation and severe mitral regurgitation with a mobile mitral vegetation. Transesophageal echocardiography identified a 16.5\u00d76\u2011mm mobile vegetation on the anterior leaflet of the mitral valve and an 11.2\u00d75\u2011mm nonmobile vegetation on the noncoronary cusp of the aortic valve, raising strong suspicion for native valve endocarditis (NVE). Head CT and MRI showed no cerebral infarction or hemorrhage.\n\nRetrospective review revealed subtle abnormalities starting four months pre\u2011admission: mildly elevated WBC, albumin decreased to 3.0 g/dL the following month, and gradual hemoglobin decline over two months, with a 4\u2011kg weight loss. EGD and whole\u2011body CT were unrevealing. He partially regained weight and labs nearly normalized except for a CRP of 0.54 mg/dL. At the last pre\u2011admission visit (8 days prior), WBC was 9,300/\u03bcL, Hb 13.1 g/dL, Alb 3.0 g/dL, CRP 4.18 mg/dL, and diastolic BP had fallen; he remained afebrile and asymptomatic aside from weight loss.\n\nEmpiric antibiotics were initiated with ampicillin\u2013sulbactam 12 g/day plus gentamicin 120 mg/day. Three admission blood culture sets all grew Staphylococcus warneri, a coagulase\u2011negative staphylococcus (CoNS) and resident skin flora (MICs: ABPC/S \u22648 \u03bcg/mL; GM \u22641 \u03bcg/mL; CEZ \u22642 \u03bcg/mL), confirming S. warneri IE. Per Japanese Circulation Society guidance, emergency surgery is generally recommended for NYHA III\u2013IV heart failure or urgent surgery for NVE with mobile vegetation >10 mm and severe valve dysfunction. Because heart failure improved rapidly and appropriate antibiotics were started (reducing embolic risk), and given poorly controlled type 1 diabetes increasing operative risk, elective surgery was planned after stabilization of infection and glycemia. Antibiotics were narrowed to cefazolin 6 g/day; dental evaluation showed no periodontitis.\n\nAfter four weeks of antibiotics, surgery revealed a bicuspid aortic valve with intact aortic and mitral annuli and no abscess. Large vegetations were exenterated, and both valves were replaced with mechanical prostheses. The postoperative course was uneventful; he was discharged on postoperative day 22 without apparent embolism and has remained recurrence\u2011free for over two years. This case represents NVE due to the resident CoNS S. warneri in a patient without prosthetic material or immunosuppression, with prodromal laboratory abnormalities and weight loss evident up to four months before presentation.", + "wiki_anchor": "Selected publications\n Diastolic properties predict short-term postoperative risk and duration of pleural effusions after the fontan operation. Garofalo CA, Cabreriza SE, Quinn TA, Weinberg AD, Quaegebeur JM, Spotnitz HM, Mosca RS. Circulation. 114(1 Suppl):I56-61. 4 July 2006.\n Left ventricular pacing site-timing optimization during biventricular pacing using a multielectrode patch. Berberian G, Cabreriza SE, Quinn TA, Garofalo CA, Spotnitz HM. Ann. Th. Surg. 82(6):2292-4. Dec 2006.\n Surgical Considerations of Pacemakers and Automatic Defibrillators, in Cohn L, Cardiac Surgery in the Adult. Spotnitz HM. 2nd Ed., McGraw-Hill, 2003.\n Booth JH, Quinn TA, Richmond ME, Cabreriza SE, Weinberg AD, Johnston T, Spotnitz HM. Cardiac output measurement by arterial pressure waveform analysis during optimization of biventricular pacing after cardiac surgery. ASAIO J 2009 Nov-Dec;55(6):587-91.\nQuinn TA, Cabreriza SE, Richmond ME, Weinberg AD, Holmes JW, Spotnitz HM. Simultaneous variation of ventricular pacing site and timing with biventricular pacing in acute ventricular failure improves function by interventricular assist. Am J Physiol Heart Circ Physiol 2009 Dec; 297(6): H2220-6. \nSpotnitz HM. Ventricular function in surgery for congenital Heart Disease. World J of Surg [Epub ahead of print 2009 Nov 17].\nRusanov A, Spotnitz HM. 15-year experience with permanent pacemaker and defibrillator lead and patch extractions. Ann Thorac Surg 2010;89:44-50.\nBonney WJ, Spotnitz HM, Liberman L, Silver ES, Ceresnak SR, Hordof AJ, Pass RH. Survival of transvenous ICD leads in young patients. Pacing Clin Electrophysiol 2010;33:186-91.\nGeorge E, Cabreriza SE, Quinn TA, Rusanov A, Gerrah R, Broyles JM, Weinberg AD, Spotnitz HM. Validation of automated monitoring of cardiac output for biventricular pacing optimization. ASAIO J. Abstract. 2010; 56:265\u2013269.\nGray RG, Cabreriza SE, Quinn TA, Weinberg AD, Spotnitz HM. Feasibility of in vivo pressure measurement using a pressure-tip catheter via transventricular puncture. 2010; 56:194\u2013199.\nSpotnitz ME, Richmond ME, Quinn TA, Cabreriza SE, Wang DY, Albright CM, Weinberg AD, Dizon JM, Spotnitz HM. Relation of cardiac output to QRS duration during temporary resynchronization therapy after cardiac surgery. ASAIO J. 2010; Epub ahead of print", + "doc_fkgl": 12.497337640821737, + "wiki_fkgl": 11.051111111111112, + "doc_tree_depth": 5.96, + "wiki_tree_depth": 4.972222222222222, + "fkgl_delta": 1.446226529710625 + }, + { + "index": 17, + "label": "low_health_literacy", + "original_doc": "A 27-year-old woman had many cancers in her large intestine and rectum. She also had an inherited condition that causes many polyps.\n\nShe had robot-assisted surgery to remove the entire colon and rectum. The team also removed lymph nodes from the whole area. They used a surgical robot called Hugo RAS.\n\nThe robot work had three steps.\n\nStep 1: Her head was tilted down. The team removed the right side of the colon with its nearby tissue, up to the bend near the liver.\n\nStep 2: They removed the left side of the colon with its nearby tissue. They also removed the rectum with the tissue around it. They took deeper lymph nodes.\n\nStep 3: Her body was kept flat. The team tied off the main blood vessels along the main artery that feeds the intestines.\n\nAfter the robot part was finished, they took the removed bowel out through the anus. Through a small cut at the belly button, they made a pouch from the small intestine. They connected this pouch to the anus.\n\nThe surgery took about 10 and a half hours. Blood loss was very small. Recovery after surgery went smoothly.", + "wiki_anchor": "Treatment of micrometastases\nIn breast cancer patients, if micrometastases are present in the SLN, removal of these nodes is often the next step in treatment. Axillary lymph node dissection involves the excision of the nodes from the armpit, or axilla, region. Depending on the progression of the cells, the surgeon will determine the level of dissection that is required. Level one is the least invasive, as it involves just the removal of tissue around the axillary vein, while level three is the most aggressive as it removes all of the nodal tissue from the axilla. It may be necessary to remove other lymph nodes in addition to the SLN. Each woman has a different number of lymph nodes in her body, so determining how many nodes to remove is based on location, rather than number. The lymph nodes serve as a filtering system for the lymphatic system, so it is important to preserve as many as possible, while also ridding the body of all cancer cells.", + "doc_fkgl": 5.185050449959093, + "wiki_fkgl": 11.785077452667817, + "doc_tree_depth": 4.526315789473684, + "wiki_tree_depth": 7.428571428571429, + "fkgl_delta": -6.600027002708725 + }, + { + "index": 17, + "label": "intermediate_health_literacy", + "original_doc": "A 27-year-old woman with familial adenomatous polyposis and multiple colorectal cancers underwent robot-assisted total proctocolectomy with complete lymph node dissection using the Hugo RAS system. The robotic work was organized into three steps: 1) in Trendelenburg position, ascending colon complete mesocolic excision up to the hepatic flexure; 2) descending colon complete mesocolic excision and total mesorectal excision with D3 lymph node dissection; and 3) in a flat position, central vessel ligation along the superior mesenteric artery. After undocking, the specimen was removed transanally. An ileal pouch was created through a small umbilical incision and then connected to the anus (ileal pouch\u2013anal anastomosis). The operation lasted 632 minutes with minimal blood loss, and the postoperative course was uneventful.", + "wiki_anchor": "Surgical resection specimens are obtained by the therapeutic surgical removal of an entire diseased area or organ (and occasionally multiple organs). These procedures are often intended as definitive surgical treatment of a disease in which the diagnosis is already known or strongly suspected. However, pathological analysis of these specimens is critically important in confirming the previous diagnosis, staging the extent of malignant disease, establishing whether or not the entire diseased area was removed (a process called \"determination of the surgical margin\", often using frozen section), identifying the presence of unsuspected concurrent diseases, and providing information for postoperative treatment, such as adjuvant chemotherapy in the case of cancer.", + "doc_fkgl": 16.9342905982906, + "wiki_fkgl": 24.01532710280374, + "doc_tree_depth": 5.8, + "wiki_tree_depth": 10.333333333333334, + "fkgl_delta": -7.081036504513143 + }, + { + "index": 17, + "label": "proficient_health_literacy", + "original_doc": "A 27-year-old woman with multiple colorectal cancers on a background of familial adenomatous polyposis (FAP) underwent robot-assisted total proctocolectomy (TPC) with lymph node dissection of the entire colorectal region using the Hugo RAS system. Preoperative CT showed multiple nodal swellings along the inferior mesenteric artery (IMA) and middle colic artery without distant metastases. After multidisciplinary review, robot-assisted TPC was performed under approvals from the Evaluating Committee for Highly Difficult New Medical Technologies (H-0051) and the Kyoto University IRB.\n\nUnder general anesthesia in lithotomy with arms tucked, a 5-cm vertical umbilical incision was made and a wound protector placed. After pneumoperitoneum, 4 robotic and 2 assistant trocars were inserted. Instruments included a camera, monopolar curved shears (right hand), bipolar fenestrated forceps (left hand), and Cadiere/double-fenestrated forceps (reserve arm). Two table positions (Trendelenburg and flat) were used with specific docking tilts; arm cart angles were unchanged. The robotic procedure comprised three steps, followed by transanal specimen extraction, ileal pouch construction via a small umbilical laparotomy, and ileal pouch\u2013anal anastomosis (IPAA).\n\nStep 1: Ascending colon complete mesocolic excision (CME) from a caudal approach, completed through hepatic flexure mobilization.\n\nStep 2: Central vessel ligation (CVL) of the IMA, descending colon CME to completion of splenic flexure mobilization, and total mesorectal excision (TME) to full exposure of the intersphincteric space. This corresponds to a D3 lymph node dissection of the left colon/rectum.\n\nStep 3: After undocking and repositioning the patient flat, CVL along the superior mesenteric artery (SMA) was performed, ligating the ileocolic, right colic, and middle colic vessels; the inferior mesenteric vein (IMV) was ligated at its root (exposed in Step 2).\n\nTransanal and small laparotomy procedures: After transection of the terminal ileum, a transanal specimen extraction was performed with complete rectal mucosectomy from just below the dentate line due to multiple adenomas in the anal canal. An ileal pouch was constructed via the small umbilical incision, its reach to the anal canal confirmed, and a transanal hand-sewn IPAA was completed. No diverting ileostomy was created.\n\nAll three steps were completed without conversion. Following undocking after Step 3, laparoscopy confirmed hemostasis, specimen extraction, and anastomotic integrity. Total operative time was 632 minutes (Step 1: 36 min; Step 2: 160 min; Step 3: 188 min; positioning/docking/specimen extraction/anastomosis: 248 min). Estimated blood loss was 20 mL. Postoperatively, the course was uneventful: flatus and initiation of liquids on POD 1, advancement to a solid diet on POD 3, with a functional ileal pouch and satisfactory anal function.\n\nFinal pathology identified two sigmoid cancers (S1: Type 0-Ip, 55 \u00d7 50 mm, tub1, T1b, ly0, v0; S2: Type 0-Isp, 55 \u00d7 50 mm, tub1, Tis, ly0, v0) and one rectal cancer (R1: Type 0-Ip, 40 \u00d7 35 mm, tub1, Tis, ly0, v0). Lymph node status: 18/89 positive, all in sigmoid/rectosigmoid stations (#241, #242, #251), yielding UICC pT1bN2b stage.", + "wiki_anchor": "The most common type of lobectomy is known as a thoracotomy. When this type of surgery is done the chest is opened up. An incision will be made on the side of the chest where the affected area of the lung is located. The incision will be in between the two ribs located in that area. The surgeon will then be able to have access to the chest cavity once the two involved ribs have been pried open. The surgeon will then be able to remove the lobe where the problem is contained.\nAnother less invasive lobectomy procedure can be performed through a video assisted surgery, where the surgeon does not need to pry the two ribs open in order to get access. A few small incisions are made and surgical tools are inserted into the chest cavity aided by a small video camera. The video images will be projected onto a screen that the surgeon can see. Once the problem area is located the small tools that were previously inserted will be utilized to perform the surgery. Once the surgery is complete, the patient will remain in the intensive care unit of the hospital for a day. They will then remain in a regular hospital room for about 4 to 7 days.", + "doc_fkgl": 14.549020678891925, + "wiki_fkgl": 9.170997652582162, + "doc_tree_depth": 6.681818181818182, + "wiki_tree_depth": 6.583333333333333, + "fkgl_delta": 5.378023026309762 + }, + { + "index": 18, + "label": "low_health_literacy", + "original_doc": "A 65-year-old man had a swollen right middle finger after a motorcycle crash 6 months earlier. The middle joint stayed bent, and the fingertip bent backward. He could not fully straighten the finger. An X-ray showed no broken bones. The problem was in the soft tissues and tendon on top of the finger. Before surgery, the middle joint could bend from 45 to 110 degrees but could not straighten. The doctors repaired the top tendon using a small strip from another tendon in the same finger. They put the middle joint in a straight splint for 2 weeks. After 2 weeks, he started gentle bending and straightening exercises for that joint. One month after surgery, the middle joint moved from 0 to 90 degrees. Two months after surgery, movement went back to normal. His hand function score (DASH) improved from 50 to 4.2.", + "wiki_anchor": "Ulnar tunnel syndrome, also known as Guyon's canal syndrome or Handlebar palsy, is ulnar neuropathy at the wrist where it passes through the Guyon canal. Symptoms usually begin with a feeling of pins and needles in the ring and little fingers before progressing to a loss of sensation and/or impaired motor function of the intrinsic muscles of the hand which are innervated by the ulnar nerve. Ulnar tunnel syndrome is commonly seen in regular cyclists due to prolonged pressure of the Guyon's canal against bicycle handlebars. Another very common cause of sensory loss in the ring and pink finger is due to ulnar nerve entrapment at the cubital tunnel near the elbow, which is known as cubital tunnel syndrome, although it can uncommonly be due to compression at the wrist.", + "doc_fkgl": 5.560996503496504, + "wiki_fkgl": 16.328076923076924, + "doc_tree_depth": 4.916666666666667, + "wiki_tree_depth": 11.75, + "fkgl_delta": -10.76708041958042 + }, + { + "index": 18, + "label": "intermediate_health_literacy", + "original_doc": "A 65-year-old man developed persistent swelling and a boutonniere deformity of the right middle finger after a motorcycle fall six months earlier. He could not fully extend the finger. On exam, the finger showed edema with flexion at the proximal interphalangeal (PIP) joint and hyperextension at the distal interphalangeal (DIP) joint. Active PIP range of motion (ROM) was 45\u2013110 degrees. X\u2011rays of the right hand (AP/oblique) showed no bone injury, indicating a soft-tissue problem consistent with a central slip injury. The patient underwent reconstruction of the central slip using a partial ulnar slip of the flexor digitorum superficialis (FDS) tendon. A PIP extension splint was used for 2 weeks. Active and passive PIP ROM exercises began after 2 weeks. One month after surgery, PIP ROM improved to 0\u201390 degrees, and by 2 months it returned to normal. Hand function, measured by the DASH score, improved markedly from 50 to 4.2.", + "wiki_anchor": "Ulnar tunnel syndrome, also known as Guyon's canal syndrome or Handlebar palsy, is ulnar neuropathy at the wrist where it passes through the Guyon canal. Symptoms usually begin with a feeling of pins and needles in the ring and little fingers before progressing to a loss of sensation and/or impaired motor function of the intrinsic muscles of the hand which are innervated by the ulnar nerve. Ulnar tunnel syndrome is commonly seen in regular cyclists due to prolonged pressure of the Guyon's canal against bicycle handlebars. Another very common cause of sensory loss in the ring and pink finger is due to ulnar nerve entrapment at the cubital tunnel near the elbow, which is known as cubital tunnel syndrome, although it can uncommonly be due to compression at the wrist.", + "doc_fkgl": 9.454666666666668, + "wiki_fkgl": 16.328076923076924, + "doc_tree_depth": 5.454545454545454, + "wiki_tree_depth": 11.75, + "fkgl_delta": -6.873410256410256 + }, + { + "index": 18, + "label": "proficient_health_literacy", + "original_doc": "A 65-year-old male presented with six months of swelling and boutonniere deformity of the right digit III following a motorcycle accident on January 1, 2023. He initially self-managed with analgesics and did not seek care. He reported inability to fully extend the right middle finger. Examination demonstrated edema and a boutonniere posture (PIP flexion, DIP hyperextension). Active PIP ROM was 45\u2013110 degrees, with passive PIP ROM within normal limits. Radiographs of the right hand (AP/lateral) revealed no osseous pathology, supporting a soft-tissue etiology consistent with a central slip injury. \n\nSurgical technique: Central slip defect reconstruction was performed using the partial ulnar slip of the flexor digitorum superficialis (FDS) tendon. Under anesthesia and tourniquet control in the supine position, a midlateral incision was made on the ulnar aspect of the middle phalanx centered at the PIP joint with dorsal oblique extension, and a transverse incision was made over the MCP flexion crease proximal to the A1 pulley. The ulnar digital neurovascular bundle was identified and protected. Full-thickness dorsal flaps were elevated to expose the central slip and extensor mechanism to the PIPJ. Scar and pseudotendinous tissue were excised. The central slip was not amenable to primary repair; therefore, the ulnar slip of the FDS was selected for reconstruction. The ulnar neurovascular bundle was mobilized to visualize the periosteal insertion of the A3 pulley. The extensor tendon was mobilized and tenolyzed; the dorsal PIP capsule was incised with removal of interposed tissue. The A3 pulley periosteal insertion and the volar capsule of the PIP joint were incised longitudinally. A 2\u20130 non-absorbable monofilament suture was placed around the ulnar FDS slip at the PIP level. Through the proximal incision, the flexor sheath and A1 pulley were incised longitudinally to expose the FDS; the ulnar slip was isolated and transected, preserving the radial slip. The previously placed 2\u20130 suture facilitated delivery of the distally based ulnar FDS slip distally. A 2.8\u2011mm dorsal-to-volar bone tunnel was drilled at the base of the middle phalanx; an elevator protected the FDP, volar plate, and volar structures. With the PIP reduced in full extension, the FDS slip was passed through the tunnel and routed through the intact proximal segment of the central slip/extensor tendon. A tendon weaver completed a Pulvertaft weave under appropriate tension with the PIP in full extension and reduction, secured with 3\u20130 non-absorbable suture. The capsule and central slip reconstruction margins were approximated; adhesions were released and lateral bands mobilized. Tenodesis effect, posture, stability, and motion were assessed. Wounds were irrigated, the tourniquet deflated, hemostasis obtained, and capillary refill confirmed. Skin was closed with horizontal mattress sutures. A sterile dressing and a well-padded PIP extension splint were applied to allow early DIP and MCP motion.\n\nPostoperative course: First wound check at postoperative day 4; the patient received meloxicam 7.5 mg PO BID and doxycycline 100 mg PO BID for 3 days. A second wound visit occurred 3 days later. At 2 weeks, the back slab and external sutures were removed, and active and passive PIP ROM exercises were initiated. By 3 weeks, the wound had healed and PIP ROM was 0\u201390 degrees. At 1 month, PIP ROM improved to 0\u2013100 degrees, with continued functional gains. After 7 weeks of rehabilitation, he returned to work with PIP ROM 0\u2013110 degrees. Overall function improved substantially, with the DASH score decreasing from 50 to 4.2.\n\nInterpretation: Clinical and radiographic findings were concordant with a chronic central slip injury producing boutonniere deformity (PIP flexion, DIP hyperextension due to dorsal apparatus disruption and volar migration of lateral bands). Reconstruction using an ulnar FDS slip via bone tunnel and Pulvertaft weave restored PIP extension and yielded progressive ROM gains and marked functional recovery.", + "wiki_anchor": "Common digital extensor: the common digital extensor muscle becomes tendon in the bottom third of the radius and continues down the front of the leg. The tendon pulls upward to extend the carpal, pastern, and coffin joints. It is the major extensor tendon of the leg. However, unlike the flexor tendons, a horse with a damaged or non-functional \"extensor unit\" (i.e. tendon and musculature) is not lame, but rapidly learns to compensate by \"flicking\" the lower limb using the carpal or tarsal extensor units.\nLateral digital extensor: the lateral digital extensor muscle becomes the lateral digital extensor tendon at the proximal portion of the metacarpus. The tendon continues down the front of the leg and inserts into the proximal portion of the first phalanx. Important in the treatment of stringhalt in the hind limb. Extends the carpal, pastern, and coffin joints\nDeep digital flexor: 3 tendons of the deep digital flexor muscle travel distally and join at the carpus, where they pass through the carpal canal, and travel distally along the back of the leg, finally inserting into the palmar side of the third phalanx. Below the knee/hock, the tendon is superficial to the suspensory ligament, but deep to the SDFT. Fairly commonly injured by horses doing fast work, the DDFT is round in cross section.\nSuperficial digital flexor: Runs down the back of the leg, behind the carpus and cannon, branches below the fetlock and inserts into the distal side of the 1st phalanx and proximal side of the 2nd phalanx. Flexes the elbow, carpus and lower joints. Additionally, the superior check ligament inserts into this tendon from the caudal side of the radius. The SDFT is the most commonly injured tendon, and appears oval or flattened in cross section.", + "doc_fkgl": 11.863529411764706, + "wiki_fkgl": 11.237168384879727, + "doc_tree_depth": 5.75, + "wiki_tree_depth": 6.928571428571429, + "fkgl_delta": 0.6263610268849789 + }, + { + "index": 19, + "label": "low_health_literacy", + "original_doc": "A 23-year-old man came to the emergency room with a sudden, very bad headache. He also felt sick, threw up, and felt heavy pressure in his chest. His blood pressure was high and he was breathing fast. A quick heart test looked like a major heart attack. He was rushed for a procedure to check and open the heart arteries. The heart arteries looked normal. A head CT scan then showed bleeding in the space around his brain. A team of specialists cared for him, but he got worse quickly. He went into cardiac arrest and died.", + "wiki_anchor": "As he lay dying in the streets, police officers stood on the sidelines and watched. His friends ran to the police and asked for assistance. The police were instructed they could not enter the riot zone, so they did not intervene. Off-duty fire department workers and his friends carried Kris out of the zone onto a nearby street. He was placed in a police vehicle, driven to Harborview Medical Center, and placed on life support. He died later the following night. The cause of death was listed as resulting from a fractured skull and subdural hematoma.", + "doc_fkgl": 4.0628178694158095, + "wiki_fkgl": 6.721071428571431, + "doc_tree_depth": 4.777777777777778, + "wiki_tree_depth": 5.142857142857143, + "fkgl_delta": -2.6582535591556216 + }, + { + "index": 19, + "label": "intermediate_health_literacy", + "original_doc": "A 23-year-old man came to the emergency department with a sudden severe headache, nausea, vomiting, and chest heaviness. His initial vital signs showed high blood pressure and a fast breathing rate. An emergency ECG showed a heart attack pattern (STEMI), so he was urgently sent for percutaneous coronary intervention; the angiogram revealed normal coronary arteries. Further evaluation with a brain CT identified a cisternal subarachnoid hemorrhage (bleeding around the brain). Despite coordinated care by multiple teams, his condition rapidly worsened, leading to cardiac arrest and death.", + "wiki_anchor": "30% of intraventricular hemorrhage (IVH) are primary, confined to the ventricular system and typically caused by intraventricular trauma, aneurysm, vascular malformations, or tumors, particularly of the choroid plexus. However 70% of IVH are secondary in nature, resulting from an expansion of an existing intraparenchymal or subarachnoid hemorrhage. Intraventricular hemorrhage has been found to occur in 35% of moderate to severe traumatic brain injuries. Thus the hemorrhage usually does not occur without extensive associated damage, and so the outcome is rarely good.", + "doc_fkgl": 13.757534883720933, + "wiki_fkgl": 16.19885802469136, + "doc_tree_depth": 6.0, + "wiki_tree_depth": 7.5, + "fkgl_delta": -2.441323140970429 + }, + { + "index": 19, + "label": "proficient_health_literacy", + "original_doc": "A 23-year-old male with a 23 pack-year smoking history, no alcohol use, and no illicit drug use presented with 2 hours of sudden severe frontal headache, nausea, vomiting, and chest heaviness. He was distressed but alert and oriented. Vitals: BP 178/103 mmHg, RR 26/min, T 38.9\u00b0C, HR 87/min, SpO2 94%. Exam: normal vesicular breath sounds; cardiovascular and abdominal exams inconclusive; neurological exam notable for neck stiffness, dilated but light-reactive pupils, normal plantar reflexes, and no focal deficits. ECG showed ST-segment elevation >2 mm in V2\u2013V5, consistent with STEMI; he received a 300 mg aspirin load and was urgently transferred for PCI. Troponin was elevated at 1.48 mg/dl (normal <0.16 mg/dl). Femoral-access coronary angiography demonstrated normal coronary arteries with TIMI 3 flow. Post-angiography ECG showed normal sinus rhythm with LVH; echocardiography revealed normal ventricular function without RWMA. Subsequent workup found lymphocytosis and mildly elevated CRP. Non-contrast CT brain demonstrated a cisternal subarachnoid haemorrhage with extension anterior to the right temporal lobe. Abdominal ultrasound was negative for polycystic kidney disease; cerebral CT angiography was planned to exclude aneurysm. Nimodipine 60 mg q4h was initiated with a BP target of 160/100 mmHg. On day 2, he acutely deteriorated with cardiac arrest; after CPR, GCS was 6, and he was intubated and mechanically ventilated in the ICU. Owing to instability, repeat CT brain and planned cerebral CTA were not performed. He received multidisciplinary ICU care with NG feeding, IV fluids, antibiotics, a proton pump inhibitor, and nimodipine. On day 8, he developed ventricular fibrillation and, despite CPR and more than five defibrillation attempts, could not be resuscitated and died.", + "wiki_anchor": "Coronary CT angiography (CCTA) is the use of CT angiography to assess the arteries of the heart. The patient receives an intravenous injection of contrast and then the heart is scanned using a high speed CT scanner. With the advances in CT technology, patients are typically able to be scanned without needing medicines by simply holding their breath during the scan. CTA is used to assess heart or vessel irregularities, location of stents and whether they are still open, and occasionally to check for atherosclerotic disease. This method displays the anatomical detail of blood vessels more precisely than magnetic resonance imaging (MRI) or ultrasound. Today, many patients can undergo CTA in place of a conventional catheter angiogram, a minor procedure during which a catheter is passed through the blood vessels all the way to the heart. However, CCTA has not fully replaced this procedure. CCTA is able to detect narrowing of blood vessels in time for corrective therapy to be done. CCTA is a useful way of screening for arterial disease because it is safer, much less time-consuming than catheter angiography, and is also a cost-effective procedure.", + "doc_fkgl": 12.237704402515725, + "wiki_fkgl": 12.83204991087344, + "doc_tree_depth": 5.529411764705882, + "wiki_tree_depth": 7.111111111111111, + "fkgl_delta": -0.5943455083577156 + } +] \ No newline at end of file