diff --git "a/data/data_annotator_data/new_v1/crowdsourcing_input_en_shard_4_v1.json" "b/data/data_annotator_data/new_v1/crowdsourcing_input_en_shard_4_v1.json" new file mode 100644--- /dev/null +++ "b/data/data_annotator_data/new_v1/crowdsourcing_input_en_shard_4_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": "The Canadiens went from last to first in the Canadian Division. Morenz was just hitting his stride in January 1937, when tragedy struck. On one of his hurtling rushes, he was being checked by Earl Seibert of Chicago when his left skate got caught in the dasher of the end boards, and Morenz suffered a badly fractured leg. After suffering a nervous breakdown worrying about if he'd be able to come back, more bad luck occurred. On March 8, 1937, X-rays revealed that Howie had blood clots in his healing leg. An operation was scheduled for the next day, but when Howie ate a light supper and told the nurse he wanted to rest, in falling asleep his pallor suddenly changed and the nurse knew something was wrong. A blood clot had stopped his heart, and attempts to revive Howie failed. News of Morenz's death shocked the hockey world, and thousands filed past his bier, many in tears, to pay their last respects.", + "doc_fkgl": 4.138157894736846, + "wiki_fkgl": 8.282630368098161, + "doc_tree_depth": 4.5, + "wiki_tree_depth": 6.0, + "fkgl_delta": -4.144472473361315 + }, + { + "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": "Signs and symptoms\nThe symptoms experienced in cholesterol embolism depend largely on the organ involved. Non-specific symptoms often described are fever, muscle ache and weight loss. Embolism to the legs causes a mottled appearance and purple discoloration of the toes, small infarcts and areas of gangrene due to tissue death that usually appear black, and areas of the skin that assume a marbled pattern known as livedo reticularis. The pain is usually severe and requires opiates. If the ulcerated plaque is below the renal arteries the manifestations appear in both lower extremities. Very rarely the ulcerated plaque is below the aortic bifurcation and those cases the changes occur only in one lower extremity.", + "doc_fkgl": 15.20401179941003, + "wiki_fkgl": 13.475353982300884, + "doc_tree_depth": 4.888888888888889, + "wiki_tree_depth": 6.0, + "fkgl_delta": 1.728657817109145 + }, + { + "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": "Sarcoidosis is a systemic disease of unknown cause that results in the formation of non-caseating granulomas in multiple organs. The prevalence is higher among black males than white males by a ratio of 20:1. Usually the disease is localized to the chest, but urogenital involvement is found in 0.2% of clinically diagnosed cases and 5% of those diagnosed at necropsy. The kidney is the most frequently affected urogenital organ, followed in men by the epididymis. Testicular sarcoidosis can present as a diffuse painless scrotal mass or can mimic acute epididymo-orchitis. Usually it appears with systemic manifestations of the disease. Since it causes occlusion and fibrosis of the ductus epididymis, fertility may be affected. On ultrasound, the hypoechogenicity and \u2018infiltrative\u2019 pattern seen in the present case are recognized features. Opinions differ on the need for histological proof, with reports of limited biopsy and frozen section, radical orchiectomy in unilateral disease and unilateral orchiectomy in bilateral disease. The peak incidence of sarcoidosis and testicular neoplasia coincide at 20\u201340 years and this is why most patients end up having an orchiectomy. However, testicular tumours are much more common in white men, less than 3.5% of all testicular tumours being found in black men. These racial variations justify a more conservative approach in patients of Afro-Caribbean descent with proven sarcoidosis elsewhere. Careful follow-up and ultrasonic surveillance may be preferable in certain clinical settings to biopsy and surgery, especially in patients with bilateral testicular disease.", + "doc_fkgl": 17.108284910965327, + "wiki_fkgl": 13.020833333333332, + "doc_tree_depth": 6.0, + "wiki_tree_depth": 6.846153846153846, + "fkgl_delta": 4.087451577631995 + }, + { + "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": "Investigations such as magnetic resonance imaging or CT scanning and electroencephalograms (EEGs) may be worthwhile, but will rarely show any serious pathology. It is believed that because this kind of phenomenon is usually heterogenous in causation, a wide variety of factors need to be considered, which could give possible explanation for why MES is seen as under diagnosed. Some of these factors may include significant trauma to the head or any side-effects from substances such as antidepressants, marijuana, alcohol, procaine, or general anesthesia.", + "doc_fkgl": 3.5813553113553134, + "wiki_fkgl": 17.520481927710843, + "doc_tree_depth": 5.142857142857143, + "wiki_tree_depth": 9.333333333333334, + "fkgl_delta": -13.93912661635553 + }, + { + "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": "Type I: infantile form, infants will develop normally until about a year old. At this time, the affected infant will begin to lose previously acquired skills involving the coordination of physical and mental behaviors. Additional neurological and neuromuscular symptoms such as diminished muscle tone, weakness, involuntary rapid eye movements, vision loss, and seizures may become present. With time, the symptoms worsen and children affected with this disorder will experience a decreased ability to move certain muscles due to muscle rigidity. The ability to respond to external stimuli will also decrease. Other symptoms include neuroaxonal dystrophy from birth, discoloration of skin, and telangiectasia or widening of blood vessels.", + "doc_fkgl": 11.942105263157895, + "wiki_fkgl": 14.523878504672897, + "doc_tree_depth": 6.4, + "wiki_tree_depth": 7.833333333333333, + "fkgl_delta": -2.581773241515002 + }, + { + "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": "The braincase\nSharing similarities with other procolophonids, the braincase of Leptopleuron consists of a relatively long basisphenoid that covers the front part of the basioccipital. Other apomorphies include a tripartite occipital condyle and a metotic foramen exposed anteriorly and unwalled by bone. Taking up the bottom half of the tripartite occipital condyle, the basioccipital is easily identified for having a large anterior portion. On the other hand, the exoccipitals are at the dorsolateral portion of the condyle and its arch-like supraoccipital forms the most dorsal edge of the foramen magnum as it is integrated with the prootic located anterolaterally. On the supraoccipital, a slight groove can be seen at each anteroventral extremity, particularly at the dorsolateral side. Leptopleuron is also characterized by its opisthotic having no foramen on the ventral ramus, specifically for nerve IX. The opisthotic is identified by a short transverse ridge that flanks a relatively deep and crescent moon-like notch ventrally. As for the prootic, the anteroventral process extends out into a free-standing distal plate rounded at the anterior. Characteristic of Leptopleuron as well is its extremely tiny stapes with a cone-like and obtusely sub-triangular footplate in lateral view. It was also known that its opisthotic and basioccipital did not come into contact with each other.", + "doc_fkgl": 16.247417695473253, + "wiki_fkgl": 14.41076076555024, + "doc_tree_depth": 6.083333333333333, + "wiki_tree_depth": 6.9, + "fkgl_delta": 1.8366569299230129 + }, + { + "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": "The herpes simplex virus comes in two different strains, though only one is spread among wrestlers. Type 1 (HSV-1) can be transmitted through contact with an infected individual, and usually associated with sores on the lips, mouth, and face. HSV-1 can also cause infection of the eye, or even infection of the lining of the brain, known as meningoencephalitis. The lesions will heal on their own in 7 to 10 days, unless the infected individual has a condition that weakens the immune system. Once an infection occurs, the virus will spread to nerve cells, where it remains for the rest of the person's life. Occasionally, the virus will suddenly display recurring symptoms, or flares. There is no complete treatment for Herpes Simplex 1 but there is prescription medication to help ease and relieve the symptoms of the virus. Antiviral oral medication and topic medication can be prescribed to relieve the pain and soreness of the herpes virus.", + "doc_fkgl": 4.63312375249501, + "wiki_fkgl": 10.778399681528665, + "doc_tree_depth": 5.277777777777778, + "wiki_tree_depth": 6.875, + "fkgl_delta": -6.145275929033655 + }, + { + "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": "The early (prodromal) symptoms in adolescents and adults are nausea, loss of appetite, aching muscles, and headache. This is followed by the characteristic rash or oral sores, malaise, and a low-grade fever that signal the presence of the disease. Oral manifestations of the disease (enanthem) not uncommonly may precede the external rash (exanthem). In children the illness is not usually preceded by prodromal symptoms, and the first sign is the rash or the spots in the oral cavity. The rash begins as small red dots on the face, scalp, torso, upper arms and legs; progressing over 10\u201312 hours to small bumps, blisters and pustules; followed by umbilication and the formation of scabs.", + "doc_fkgl": 10.328562500000004, + "wiki_fkgl": 12.426357142857146, + "doc_tree_depth": 5.5, + "wiki_tree_depth": 7.4, + "fkgl_delta": -2.097794642857142 + }, + { + "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": "Signs and symptoms\nWhile the presence of lesions is the denominator among patients with PNP, the characteristics of the lesions differ. The five clinical presentations of lesions associated with PNP include:\n \"Pemphigus-like\": Flaccid blister (discrete), crusts over the raw exuding skin lesions\n \"Pemphigoid-like\": Tense blister(s) on brick red erythema\n \"Erythema multiforme-like\": Severe polymorphic skin and/or mucous membrane lesions\n \"Graft-vs.-host disease-like\": Widespread lichenoid eruption with severe mucous membrane involvement\n \"Lichen planus-like\": Small red flat-topped scaly papules\nIt is most common that mucous membrane lesions of the oral cavity are presented first. They can involve the oropharynx, nasopharynx, tongue, and vermilion (red portion) of the lips. They are also known to develop in the conjunctiva of the eye, anogenital (perineum) region, and esophagus. Cutaneous lesions tend to follow the onset of mucosal lesions. The blisters often erupt in waves, usually affecting the upper trunk, head, neck, and proximal extremities. Pemphigoid-like lesions are seen more often on the extremities. Lichenoid lesions are more common among children, presenting on the trunk and limbs, ranging from small red scaly papules to extensive violet to brown papules extending to the face and neck. Within the spectrum of lichenoid presentations are wounds that have features of erythema multiforme and graft-vs.-host disease. Scaly lesions on the palms of the hand and soles of the feet have been noted to coincide with the lichenoid lesions. Lesions of varying morphology may present simultaneously and transform from one type to another as the disease progresses.", + "doc_fkgl": 14.527236842105264, + "wiki_fkgl": 12.506393442622954, + "doc_tree_depth": 7.214285714285714, + "wiki_tree_depth": 7.454545454545454, + "fkgl_delta": 2.0208433994823096 + }, + { + "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": "Type I: infantile form, infants will develop normally until about a year old. At this time, the affected infant will begin to lose previously acquired skills involving the coordination of physical and mental behaviors. Additional neurological and neuromuscular symptoms such as diminished muscle tone, weakness, involuntary rapid eye movements, vision loss, and seizures may become present. With time, the symptoms worsen and children affected with this disorder will experience a decreased ability to move certain muscles due to muscle rigidity. The ability to respond to external stimuli will also decrease. Other symptoms include neuroaxonal dystrophy from birth, discoloration of skin, and telangiectasia or widening of blood vessels.", + "doc_fkgl": 4.623939393939395, + "wiki_fkgl": 14.523878504672897, + "doc_tree_depth": 4.777777777777778, + "wiki_tree_depth": 7.833333333333333, + "fkgl_delta": -9.899939110733502 + }, + { + "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": "Neonatal lupus erythematosus is an autoimmune disease in an infant born to a mother with anti-Ro/SSA and with or without anti-La/SSB antibodies. The disease most commonly presents with a rash resembling subacute cutaneous lupus erythematosus and can have systemic abnormalities such as complete heart block or hepatosplenomegaly. Neonatal lupus is usually benign and self-limited. Many of the clinical manifestations are transient, but certain heart problems can be permanent. Diagnosis is based on maternal antibodies and clinical manifestations. Treatment and management is mainly supportive and focused on preventing complete heart block if possible.", + "doc_fkgl": 11.214120481927715, + "wiki_fkgl": 13.861739130434785, + "doc_tree_depth": 5.4, + "wiki_tree_depth": 6.333333333333333, + "fkgl_delta": -2.64761864850707 + }, + { + "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": "Pathophysiology\nTypically, a fetus experiences pulmonary hypertension in utero since it is relying on the placenta for oxygen rather than its lungs. When the fetus is born, it is no longer attached to the placenta and must use the lungs to receive oxygen. To facilitate this change from fetus to newborn, the baby must change from a state of high PVR to low PVR, allowing for increased blood flow to circulate throughout the body. This inability of the newborn to adapt to these changes is caused by various processes, such as:\n Normal vascular anatomy with functional vasoconstriction: This has a good prognosis, as it is reversible. Causes include hypoxia, meconium aspiration, and respiratory distress syndrome. Left untreated, this can lead to hypoxic respiratory failure (HRF).\n Decreased diameter of pulmonary vessels with hypertrophy of vessel walls: This has a poor prognosis, as it is a fixed abnormality. Causes include post-term pregnancy, placental insufficiency, and NSAID use by the mother.\n Decreased size of pulmonary vascular bed: This has a poor prognosis, as it is a fixed abnormality. It is caused by space occupying lesions such as pleural effusions and diaphragmatic hernias.\n Functional obstruction of pulmonary blood flow: This has a good prognosis if it is reversible. Causes include polycythemia and hyperfibrinogenemia.", + "doc_fkgl": 13.580182389937107, + "wiki_fkgl": 12.826423444976076, + "doc_tree_depth": 5.529411764705882, + "wiki_tree_depth": 5.666666666666667, + "fkgl_delta": 0.7537589449610316 + }, + { + "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": "Bronchomalacia is a term for weak cartilage in the walls of the bronchial tubes, often occurring in children under a day. Bronchomalacia means 'floppiness' of some part of the bronchi. Patients present with noisy breathing and/or wheezing. There is collapse of a main stem bronchus on exhalation. If the trachea is also involved the term tracheobronchomalacia (TBM) is used. If only the upper airway the trachea is involved it is called tracheomalacia (TM). There are two types of bronchomalacia. Primary bronchomalacia is due to a deficiency in the cartilaginous rings. Secondary bronchomalacia may occur by extrinsic compression from an enlarged vessel, a vascular ring or a bronchogenic cyst. Though uncommon, idiopathic (of unknown cause) tracheobronchomalacia has been described in older adults.", + "doc_fkgl": 2.581463963963966, + "wiki_fkgl": 9.803380165289258, + "doc_tree_depth": 4.583333333333333, + "wiki_tree_depth": 5.9, + "fkgl_delta": -7.221916201325293 + }, + { + "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": "Diagnosis \nDiagnosis can be made using chest X-ray; the lesion shows up as a small, round area filled with air. Computed tomography can give a more detailed understanding of the lesion. Differential diagnoses \u2013 other conditions that could cause similar symptoms as pneumatocele include lung cancer, tuberculosis, and a lung abscess in the setting of hyper IgE syndrome (aka Job's syndrome), as a complication of COVID-19 pneumonitis, or on its own, often caused by Staphylococcus aureus infection during cystic fibrosis.", + "doc_fkgl": 12.728571428571431, + "wiki_fkgl": 16.039493670886078, + "doc_tree_depth": 5.166666666666667, + "wiki_tree_depth": 8.333333333333334, + "fkgl_delta": -3.3109222423146463 + }, + { + "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": "Dermatological \nAlthough symptoms can vary greatly between affected individuals, even those within the same family, symptoms normally begin in infancy and are typically a result of thickening skin and mucous membranes. The first symptom is often a weak cry or a hoarse voice due to a thickening of the vocal cords. The hoarse voice can be one of the most striking clinical manifestations of the disease. Lesions and scars also appear on the skin, usually the face and the distal parts of the limbs. This is often the result of poor wound healing and the scarring continues to increase as the patient ages, leaving the skin with a waxy appearance. Skin may be easily damaged as a result of only a minor trauma or injury, leaving many blisters and additional scars. The skin is also usually very dry and wrinkly. White or yellow infiltrates form on the lips, buccal mucosa, tonsils, uvula, epiglottis and frenulum of the tongue. This can lead to upper respiratory tract infection and sometimes requires tracheostomy to relieve the symptom. Too much thickening of the frenulum can restrict tongue movement and may result in speech impediments. Beading of the papules around the eyelids is a very common symptom and is often used as part of a diagnosis of the disease. Some other dermatological symptoms that are sometimes seen but less common include hair loss, parotitis and other dental abnormalities, corneal ulceration, and focal degeneration of the macula.", + "doc_fkgl": 15.644583333333337, + "wiki_fkgl": 11.876524896265561, + "doc_tree_depth": 6.769230769230769, + "wiki_tree_depth": 6.3076923076923075, + "fkgl_delta": 3.7680584370677757 + }, + { + "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": "Shunt nephritis is a rare disease of the kidney that can occur in patients being treated for hydrocephalus with a cerebral shunt. It usually results from an infected shunt that produces a long-standing blood infection, particularly by the bacterium Staphylococcus epidermidis. Kidney disease results from an immune response that deposits immune complexes in the kidney. The most common signs and symptoms of the condition are blood and protein in the urine, anemia, and high blood pressure. Diagnosis is based on these findings in the context of characteristic laboratory values. Treatment includes antibiotics and the prompt removal of the infected shunt. Over half of individuals with shunt nephritis recover completely; most of the remainder have some degree of persistent kidney disease.", + "doc_fkgl": 5.415573678290215, + "wiki_fkgl": 12.434047619047622, + "doc_tree_depth": 4.785714285714286, + "wiki_tree_depth": 7.285714285714286, + "fkgl_delta": -7.018473940757406 + }, + { + "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": "Diagnosis \nDiagnosis can be made using chest X-ray; the lesion shows up as a small, round area filled with air. Computed tomography can give a more detailed understanding of the lesion. Differential diagnoses \u2013 other conditions that could cause similar symptoms as pneumatocele include lung cancer, tuberculosis, and a lung abscess in the setting of hyper IgE syndrome (aka Job's syndrome), as a complication of COVID-19 pneumonitis, or on its own, often caused by Staphylococcus aureus infection during cystic fibrosis.", + "doc_fkgl": 16.420789473684213, + "wiki_fkgl": 16.039493670886078, + "doc_tree_depth": 6.166666666666667, + "wiki_tree_depth": 8.333333333333334, + "fkgl_delta": 0.38129580279813524 + }, + { + "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": "After the 2006 death from respiratory disease of James Zadroga, a New York City Police Department Detective who had spent 450 hours as a rescue worker at Ground Zero, the Ocean County, New Jersey medical examiner's office, conducted an autopsy in April 2006 and reported that \"It is felt with a reasonable degree of medical certainty that the cause of death in this case was directly related to the 9/11 incident\" making Zadroga, 34 years old at the time of his death, the first 9/11 responder whose death was directly linked with toxic Ground Zero substances. An autopsy conducted by Hirsch in October 2007 found that Zadroga's death was not related to his time at Ground Zero, with Hirsch and another medical examiner signing a statement that \"It is our unequivocal opinion, with certainty beyond doubt, that the foreign material in your son\u2019s lungs did not get there as the result of inhaling dust at the World Trade Center or elsewhere.\" Hirsch concluded that Zadroga died from self-injection of prescription drugs, with Hirsch finding severe scarring in his lungs that he determined was caused by cellulose and talc granulomas and stating (through a spokesperson) that \"The lung disease he had was a consequence of injecting prescription drugs\". Officials from the Chief Medical Examiner's office met with the Zadroga family to present his findings. A third opinion obtained by Zadroga's family later that month from Dr. Michael Baden, chief forensic pathologist of the New York State Police (and former New York City Medical Examiner), backed the original claim of WTC dust responsibility, citing the presence of glass fibers in Zadroga's lungs that could not be related to injecting drugs. The Daily News criticized Hirsch in a November 2007 editorial, stating that the results blaming the death on drug use \"libeled the memory of Detective James Zadroga\" and that Hirsch had \"committed a gross injustice that no apology can ever set right\".", + "doc_fkgl": 16.479367816091955, + "wiki_fkgl": 21.413571428571434, + "doc_tree_depth": 6.15, + "wiki_tree_depth": 11.166666666666666, + "fkgl_delta": -4.934203612479479 + }, + { + "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": "Diagnosis \nTo aid with determining the underlying cause of the normocytic anemia, a lab test is done on reticulocyte count. A reticulocyte count that is high, normal or low will aid with the classification process. A high reticulocyte count signifies that bone marrow processes are normal. A low reticulocyte count would signify there is a problem at the level of the bone marrow, which produce the stem cells. Acute blood loss would result in a high reticulocyte count, as bone marrow processes are normal and the bone marrow responds accordingly to the body's need for blood.", + "doc_fkgl": 4.512113821138211, + "wiki_fkgl": 11.073, + "doc_tree_depth": 4.444444444444445, + "wiki_tree_depth": 7.4, + "fkgl_delta": -6.560886178861789 + }, + { + "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": "In intravascular hemolysis, hemoglobin is released and binds with haptoglobin. This causes haptoglobin levels to decrease.\nOnce haptoglobin is saturated, free hemoglobin readily distributes to tissues where it might be exposed to oxidative conditions. In such conditions, heme can be released from ferric hemoglobin. The free heme can then accelerate tissue damage by promoting peroxidative reactions and activation of inflammatory cascades. Hemopexin (Hx) is another plasma glycoprotein able to bind heme with high affinity. Hx sequesters heme in an inert, non-toxic form and transports it to the liver for catabolism and excretion. As long as both haptoglobin and hemopexin are saturated, the remaining free hemoglobins are filtered in the kidney and some of them will be reabsorbed by way of proximal tubules.", + "doc_fkgl": 11.051032608695653, + "wiki_fkgl": 10.959139344262294, + "doc_tree_depth": 5.0, + "wiki_tree_depth": 5.875, + "fkgl_delta": 0.09189326443335943 + }, + { + "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": "Blood loss, suppressed production of RBCs or hemolysis represent most cases of normocytic anemia. In blood loss, morphologic findings are generally unremarkable, except after 12 to 24 hrs where polychromasia appears. For reduced production of RBCs, like with low erythropoietin, the RBC morphology is unremarkable. Patients with disordered RBC production, e.g. myelodysplastic syndrome, may have a dual population of elliptocytes, teardrop cells, or other poikilocytes as well as a nucleated RBCs. Hemolysis will often demonstrate poikilocytes specific to a cause or mechanism, e.g. bite cells and/or blister cells for oxidative hemolysis, acanthocytes for pyruvate kinase deficiency or McLeod phenotype, sickle cells for sickle cell anemia, spherocytes for immune-mediated hemolysis or hereditary spherocytosis, elliptocytosis for iron deficiency or hereditary elliptocytosis and schistocytes for intravascular hemolysis. Many hemolytic anemias show multiple poikilocytes such as G6PD deficiency, which may show blister and bites cells as well as shistocytes. Neonatal hemolysis may not follow the classic patterns as in adults.", + "doc_fkgl": 11.779287370862324, + "wiki_fkgl": 15.602051282051288, + "doc_tree_depth": 6.208333333333333, + "wiki_tree_depth": 7.142857142857143, + "fkgl_delta": -3.8227639111889644 + }, + { + "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": "The scrotum (: scrotums or scrota; possibly from Latin scortum, meaning \"hide\" or \"skin\") or scrotal sac is an anatomical male reproductive structure located at the base of the penis that consists of a suspended dual-chambered sac of skin and smooth muscle. It is present in most terrestrial male mammals. The scrotum contains the external spermatic fascia, testicles, epididymis, and ductus deferens. It is a distention of the perineum and carries some abdominal tissues into its cavity including the testicular artery, testicular vein, and pampiniform plexus. The perineal raphe is a small, vertical, slightly raised ridge of scrotal skin under which is found the scrotal septum. It appears as a thin longitudinal line that runs front to back over the entire scrotum. In humans and some other mammals, the scrotum becomes covered with pubic hair at puberty. The scrotum will usually tighten during penile erection and when exposed to cold temperatures. One testis is typically lower than the other to avoid compression in the event of an impact.", + "doc_fkgl": 3.26104347826087, + "wiki_fkgl": 11.50175648702595, + "doc_tree_depth": 4.0, + "wiki_tree_depth": 6.777777777777778, + "fkgl_delta": -8.24071300876508 + }, + { + "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": "Mechanism\nNormally, the ovarian vein crosses over the ureter at the level of the fourth or fifth lumbar vertebra. The ureter itself courses over the external iliac artery and vein. Thus, these vessels can impinge on the ureter causing obstruction. The left ovarian vein ends in the renal vein whereas the right ovarian vein normally enters into the inferior vena cava. In the case of right ovarian vein syndrome, the vein often ends in the renal vein. This is thought to contribute to venous engorgement, in analogy to what is seen in varicoceles, which arise more commonly on the left side. The straight angle between the ovarian vein (or testicular vein in males in the case of varicocoele) and the renal vein has been proposed as a cause of decreased blood return.", + "doc_fkgl": 11.784036259541985, + "wiki_fkgl": 10.62640692640693, + "doc_tree_depth": 5.375, + "wiki_tree_depth": 6.285714285714286, + "fkgl_delta": 1.1576293331350556 + }, + { + "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": "The scrotum (: scrotums or scrota; possibly from Latin scortum, meaning \"hide\" or \"skin\") or scrotal sac is an anatomical male reproductive structure located at the base of the penis that consists of a suspended dual-chambered sac of skin and smooth muscle. It is present in most terrestrial male mammals. The scrotum contains the external spermatic fascia, testicles, epididymis, and ductus deferens. It is a distention of the perineum and carries some abdominal tissues into its cavity including the testicular artery, testicular vein, and pampiniform plexus. The perineal raphe is a small, vertical, slightly raised ridge of scrotal skin under which is found the scrotal septum. It appears as a thin longitudinal line that runs front to back over the entire scrotum. In humans and some other mammals, the scrotum becomes covered with pubic hair at puberty. The scrotum will usually tighten during penile erection and when exposed to cold temperatures. One testis is typically lower than the other to avoid compression in the event of an impact.", + "doc_fkgl": 15.11899521531101, + "wiki_fkgl": 11.50175648702595, + "doc_tree_depth": 6.5, + "wiki_tree_depth": 6.777777777777778, + "fkgl_delta": 3.6172387282850593 + }, + { + "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": "Shunt nephritis is a rare disease of the kidney that can occur in patients being treated for hydrocephalus with a cerebral shunt. It usually results from an infected shunt that produces a long-standing blood infection, particularly by the bacterium Staphylococcus epidermidis. Kidney disease results from an immune response that deposits immune complexes in the kidney. The most common signs and symptoms of the condition are blood and protein in the urine, anemia, and high blood pressure. Diagnosis is based on these findings in the context of characteristic laboratory values. Treatment includes antibiotics and the prompt removal of the infected shunt. Over half of individuals with shunt nephritis recover completely; most of the remainder have some degree of persistent kidney disease.", + "doc_fkgl": 4.794388489208632, + "wiki_fkgl": 12.434047619047622, + "doc_tree_depth": 4.923076923076923, + "wiki_tree_depth": 7.285714285714286, + "fkgl_delta": -7.639659129838989 + }, + { + "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": "Kidney involvement leads to the symptoms of kidney failure, which are non-specific but usually cause nausea, reduced appetite (anorexia), raised blood pressure (hypertension), and occasionally the various symptoms of electrolyte disturbance such as an irregular heartbeat. Some patients report hematuria (bloody urine) but this may only be detectable on microscopic examination of the urine. Increased amounts of protein in the urine may cause edema (swelling) of the skin (a combination of symptoms known as nephrotic syndrome).", + "doc_fkgl": 14.753525835866263, + "wiki_fkgl": 16.803157894736845, + "doc_tree_depth": 6.333333333333333, + "wiki_tree_depth": 9.333333333333334, + "fkgl_delta": -2.049632058870582 + }, + { + "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": "Medical uses \nThe medical justification for these combination drugs was that the CNS stimulant elevates mood and suppresses appetite, while the CNS depressant mitigates many of the adverse effects of the CNS stimulant without simultaneously reducing its therapeutic benefits. Some psychiatrists will attempt to duplicate this effect, albeit only partially, using stimulants in conjunction with benzodiazepines such as clonazepam in patients with certain forms of refractory depression where monoamine oxidase inhibitors such as nardil or parnate would be indicated, but lacking the dangers associated with that class of medication, as maois are extremely toxic in cases of overdose or deliberate or accidental ingestion of tyramine. This combination is regarded as extremely effective by patients and practitioners alike, and retains efficacy over time when used as directed, but both drugs do carry risks of abuse and dependency. Typically the CNS stimulant within these older combination drugs was racemic amphetamine, dextroamphetamine, or methamphetamine as various single or mixed salts, and phenmetrazine hydrochloride (Preludin) was also marketed albeit less frequently. Typically the CNS depressant within these combination drugs was a single barbiturate salt, especially pentobarbital sodium and sodium amobarbital (Amytal), although meprobamate (Miltown), a minor tranquilizer, and methaqualone hydrochloride (Quaalude), a non-barbiturate sedative were also sometimes used. Some less common combination drug formulations included a CNS stimulant combined with multiple vitamins and minerals, a first generation antipsychotic (Eskatrol was popular), or a first generation antihistamine (Obocell-TF). Other formulations utilized amphetamines, barbiturates, and meprobamate for their ability to potentiate analgesia by combining them with analgesics such as phenacetin and aspirin.", + "doc_fkgl": 14.958653673835126, + "wiki_fkgl": 22.77988839285715, + "doc_tree_depth": 5.866666666666666, + "wiki_tree_depth": 9.285714285714286, + "fkgl_delta": -7.821234719022023 + }, + { + "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": "Obesity \nAt one point, Deuel had not left his house (in Valentine) for five years. He stood at 180.34\u00a0cm (5\u00a0ft\u00a011\u00a0in), and weighed , at his peak. He was so large that half the house had to be cut out to extract him from his home. He was rushed to a hospital at Sioux Falls, South Dakota in an ambulance with extra-wide doors and a ramp-and-winch system that had to be dispatched from Denver. Despite being morbidly obese, Deuel was also malnourished because many of the calories he had consumed were from junk food. However, assisted by a gastric bypass surgery which followed his hospitalization, Deuel proceeded to lose more than .", + "doc_fkgl": 6.522207792207791, + "wiki_fkgl": 7.831378002528446, + "doc_tree_depth": 5.571428571428571, + "wiki_tree_depth": 7.833333333333333, + "fkgl_delta": -1.309170210320655 + }, + { + "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": "Coronary artery disease (CAD) is the most common cause of coronary ischemia. Coronary ischemia and coronary artery disease are contributors to the development of heart failure over time. Diagnosis of coronary ischemia is achieved by an attaining a medical history and physical examination in addition to other tests such as electrocardiography (ECG), stress testing, and coronary angiography. Treatment is aimed toward preventing future adverse events and relieving symptoms. Beneficial lifestyle modifications include smoking cessation, a heart healthy diet, and regular exercise. Medications such as nitrates and beta-blockers may be useful for reducing the symptoms of coronary ischemia. In refractory cases, invasive procedures such as percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG) may be performed to relieve coronary ischemia.", + "doc_fkgl": 13.480000000000004, + "wiki_fkgl": 17.189445100354195, + "doc_tree_depth": 7.166666666666667, + "wiki_tree_depth": 6.571428571428571, + "fkgl_delta": -3.7094451003541913 + }, + { + "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": "Etz CD, Plestis KA, Kari FA, Luehr M, Bodian CA, Spielvogel D, Griepp RB. Staged repair of thoracic and thoracoabdominal aortic aneurysms using the elephant trunk technique: a consecutive series of 215 first stage and 120 complete repairs. European Journal of Cardiothoracic Surgery 2008 Jun 12;. \nEtz CD, Homann TM, Silovitz D, Spielvogel D, Bodian CA, Luehr M, Di Luozzo G, Plestis KA, Griepp RB. Long-term survival after the Bentall procedure in 206 patients with bicuspid aortic valve. Annals of Thoracic Surgery. 2007 October; 84(4): 1189-1193. \nEtz CD, Homann TM, Rane N, Bodian CA, Di Luozzo G, Plestis KA, Spielvogel D, Griepp RB. Aortic root reconstruction with a bioprosthetic valved conduit: a consecutive series of 275 procedures. Journal of Thoracic and Cardiovascular Surgery. 2007 June; 133(6): 1455-1463. \nSpielvogel D, Etz CD, Silovitz D, Lansman SL, Griepp RB. Aortic arch replacement with a trifurcated graft. Annals of Thoracic Surgery. 2007 Feb; 83(2): 3791-3795. \nEtz CD, Halstead JC, Spielvogel D, Shahani R, Lazala R, Homann TM, Weisz DJ, Plestis K, Griepp RB. Thoracic and thoracoabdominal aneurysm repair: is reimplantation of spinal cord arteries a waste of time? Annals of Thoracic Surgery. 2006 November; 82(5): 1670-1677. \nCarroccio A, Spielvogel D, Ellozy SH, Lookstein RA, Chin IY, Minor ME, Sheahan CM, Teodorescu VJ, Griepp RB, Marin ML. Aortic arch and descending thoracic aortic aneurysms: experience with stent grafting for second-stage. Vascular. 2005 January\u2013February; 13(1): 5-10. \nHagl C, Strauch JT, Spielvogel D, Galla JD, Lansman SL, Squitieri R, Bodian CA, Griepp RB. Is the Bentall procedure for ascending aorta or aortic valve replacement the best approach for long-term event-free survival? Annals of Thoracic Surgery. 2003 September; 76(3): 698-702. \nGriepp RB, Ergin MA, Galla JD, Lansman S, Khan N, Quintana C, McCollough J, Bodian C. Looking for the artery of Adamkiewicz: a quest to minimize paraplegia after operations for aneurysms of the descending thoracic and thoracoabdominal aorta. Journal of Thoracic Cardiovascular Surgery. 1996 November; 112(5): 1202-1213. \nGriepp RB, Stinson EB, Bieber CP, Reitz BA, Copeland JG, Oyer PE, Shumway NE. Human heart transplantation: current status. Annals of Thoracic Surgery. 1976 August; 22(2): 171-175. \nGriepp RB, Stinson EB, Hollingsworth JF, Buehler D. Prosthetic replacement of the aortic arch. Journal of Thoracic Cardiovascular Surgery. 1975 December; 70(6): 1051-1063.", + "doc_fkgl": 9.065632911392406, + "wiki_fkgl": 9.511152204836417, + "doc_tree_depth": 6.684210526315789, + "wiki_tree_depth": 5.512820512820513, + "fkgl_delta": -0.4455192934440113 + }, + { + "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": "Vision impairment is an early symptom of Jansky\u2013Bielschowsky disease, and so an eye exam is another common diagnostic tool. During the eye exam, loss of cells within the eye would indicate the presence of the disease however more tests are needed for a complete diagnosis.\nOther common diagnostic tests include:\n Blood or urine test: elevated levels of the chemical dolichol found in the urine is typical of individuals with the disease, as well as the presence of vacuolated lymphocytes in the blood.\n Skin or tissue sampling: microscopy of skin could be used to observe lipopigment aggregation.\n CT scan or MRI: visualization of the brain would be able to detect areas of cerebral atrophy.", + "doc_fkgl": 6.597509398496243, + "wiki_fkgl": 13.169132743362834, + "doc_tree_depth": 5.875, + "wiki_tree_depth": 6.8, + "fkgl_delta": -6.571623344866591 + }, + { + "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": "Unlike Marfan syndrome, the cardiovascular system and the lens of the eye are unaffected. Mucosal neuromas are the most consistent and distinctive feature, appearing in 100% of patients. Usually there are numerous yellowish-white, sessile, painless nodules on the lips or tongue, with deeper lesions having normal coloration. There may be enough neuromas in the body of the lips to produce enlargement and a \"blubbery lip\" appearance. Similar nodules may be seen on the sclera and eyelids.", + "doc_fkgl": 11.54186046511628, + "wiki_fkgl": 10.988000000000003, + "doc_tree_depth": 6.0, + "wiki_tree_depth": 6.0, + "fkgl_delta": 0.5538604651162764 + }, + { + "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": "Signs and symptoms\nOA1 is recognized by many different symptoms. Reduced visual acuity is accompanied by involuntary movements of the eye termed as nystagmus. Astigmatism is a condition wherein there occurs significant refractive error. Moreover, ocular albino eyes become crossed, a condition called 'lazy eyes' or strabismus. Since very little pigment is present the iris becomes translucent and reflects light back. It appears green to violet. However, the most important part of the eye, the fovea which is responsible for acute vision, does not develop properly, probably indicating the role of melanin in the development stages of the eye. Some affected individuals may also develop photophobia/photodysphoria. All these symptoms are due to lack of pigmentation of the retina. Moreover, in an ocular albino eye, nerves from back of the eye to the brain may not follow the usual pattern of routing. In an ocular albino eye, more nerves cross from back of the eye to the opposite side of the brain instead of going to both sides of the brain as in a normal eye. An ocular albino eye appears blueish pink in color with no pigmentation at all unlike a normal eye. Carrier women have regions of hypo- and hyper-pigmentation due to X-inactivation and partial iris transillumination and do not show any other symptoms exhibited by those affected by OA1.", + "doc_fkgl": 14.661870129870131, + "wiki_fkgl": 11.863529411764706, + "doc_tree_depth": 5.473684210526316, + "wiki_tree_depth": 6.076923076923077, + "fkgl_delta": 2.7983407181054254 + }, + { + "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": "The ladder \nThe WHO guidelines recommend prompt oral administration of drugs (\"by the mouth\") when pain occurs, starting, if the patient is not in severe pain, with non-opioid drugs such as paracetamol (acetaminophen) or aspirin, with or without \"adjuvants\" such as non-steroidal anti-inflammatory drugs (NSAIDs) including COX-2 inhibitors. Then, if complete pain relief is not achieved or disease progression necessitates more aggressive treatment, a weak opioid such as codeine, dihydrocodeine or tramadol is added to the existing non-opioid regime. If this is or becomes insufficient, a weak opioid is replaced by a strong opioid, such as morphine, diamorphine, fentanyl, buprenorphine, oxymorphone, oxycodone, or hydromorphone, while continuing the non-opioid therapy, escalating opioid dose until the patient is pain free or at the maximum possible relief without intolerable side effects. If the initial presentation is severe pain, this stepping process should be skipped and a strong opioid should be started immediately in combination with a non-opioid analgesic.", + "doc_fkgl": 6.542719298245618, + "wiki_fkgl": 20.99088709677419, + "doc_tree_depth": 4.823529411764706, + "wiki_tree_depth": 9.75, + "fkgl_delta": -14.448167798528573 + }, + { + "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": "Graduate medical education in the United States is regulated by the Accreditation Council for Graduate Medical Education (ACGME) and the American Osteopathic Association Bureau of Osteopathic Specialists (AOABOS). Each program must provide \u201cappropriate didactic instruction and sufficient clinical experience in managing problems of the geriatric population.\u201d The published joint ASA/American Board of Anesthesiology content outline for in-training examinations also includes a section on \u201cGeriatric Anesthesia/Aging: The Pharmacological Implications, MAC Changes and the Physiological Implications on Major Organ Systems.\u201d These mandates make geriatric education a requirement for any program in anesthesiology. This is not the rule in all graduate medical education programs. A recent survey by the Association of Directors of Geriatric Academic Programs reviewed ACGME policies required by 100 nonpediatric programs. They found that only 27 of these programs had specific requirements for geriatric training; anesthesiology and pain management were two of these.", + "doc_fkgl": 12.910294117647059, + "wiki_fkgl": 19.19532467532468, + "doc_tree_depth": 6.444444444444445, + "wiki_tree_depth": 7.0, + "fkgl_delta": -6.285030557677622 + }, + { + "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": "Signs and symptoms\nOne particularity of diabetic cardiomyopathy is the long latent phase, during which the disease progresses but is completely asymptomatic. In most cases, diabetic cardiomyopathy is detected with concomitant hypertension or coronary artery disease. One of the earliest signs is mild left ventricular diastolic dysfunction with little effect on ventricular filling. Also, the diabetic patient may show subtle signs of diabetic cardiomyopathy related to decreased left ventricular compliance or left ventricular hypertrophy or a combination of both. A prominent \"a\" wave can also be noted in the jugular venous pulse, and the cardiac apical impulse may be overactive or sustained throughout systole. After the development of systolic dysfunction, left ventricular dilation and symptomatic heart failure, the jugular venous pressure may become elevated, the apical impulse would be displaced downward and to the left. Systolic mitral murmur is not uncommon in these cases. These changes are accompanied by a variety of electrocardiographic changes that\nmay be associated with diabetic cardiomyopathy in 60% of patients without structural heart disease, although usually not in the early asymptomatic phase. Later in the progression, a prolonged QT interval may be indicative of fibrosis. Given that diabetic cardiomyopathy's definition excludes concomitant atherosclerosis or hypertension, there are no changes in perfusion or in atrial natriuretic peptide levels up until the very late stages of the disease, when the hypertrophy and fibrosis become very pronounced.", + "doc_fkgl": 13.475840409207162, + "wiki_fkgl": 17.04405676855895, + "doc_tree_depth": 6.2631578947368425, + "wiki_tree_depth": 6.3, + "fkgl_delta": -3.568216359351787 + }, + { + "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": "The Pee Fah needs to possess a host in order to live, and only leaves the host's body when the host is asleep. Before the host dies, the Pee Fah must find a new host in which it can reside, and that is achieved by inducing the new victim to consume saliva from the old host. These ghosts are powerful and fearful, and if one succeeds in entering someone, it will possess them for life, feeding on the intestines and blood of human victims.", + "doc_fkgl": 6.041, + "wiki_fkgl": 10.922857142857143, + "doc_tree_depth": 5.125, + "wiki_tree_depth": 7.333333333333333, + "fkgl_delta": -4.881857142857143 + }, + { + "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": "Urinary bladder disease includes urinary bladder inflammation such as cystitis, bladder rupture and bladder obstruction (tamponade). Cystitis is common, sometimes referred to as urinary tract infection (UTI) caused by bacteria, bladder rupture occurs when the bladder is overfilled and not emptied while bladder tamponade is a result of blood clot formation near the bladder outlet.", + "doc_fkgl": 12.18240740740741, + "wiki_fkgl": 17.447727272727274, + "doc_tree_depth": 5.5, + "wiki_tree_depth": 8.5, + "fkgl_delta": -5.265319865319864 + }, + { + "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": "Works\nPractical observations on the nature and cure of Strictures in the Urethra London, 1809, 8vo: 2nd ed. 1811; reissued 1812; 3rd ed. 1826.\nCursory Remarks on Corpulence London, 1810, 8vo, issued anonymously; 3rd ed. 1816;\nreissued in an enlarged form as: Comments on Corpulency, Lineaments of Leanness, Mems on Diet and Dietetics London, 1829, 8vo. The etchings in this volume remind one of George Cruikshank.\n Cases of Diseased Bladder and Testicle London, 1815, 4to, with twenty-one plates; reissued 1817.\nCases of Diseased Prepuce and Scrotum London, 1817, 4to, with twelve plates.\nOn Malformations and Diseases of the Head London, 1819, 4to, with eleven plates.\nIllustrations of Morbid Anatomy London, 1824, fol. with seventy-eight plates.\nThe original drawings are in the Royal College of Surgeons of England. There is no letterpress attacked to the work beyond the title-page.\n Nug\u00e6 Chirurgic\u00e6, or a Biographical Miscellany illustrative of a Collection of Professional Portraits London, 1824, 8vo.\nThis is the work by which Wadd\u2019s name is best known. The nucleus of the collection of portraits was presented to him about 1814 by Henry Fauntleroy, the banker, who was hanged for forgery. The catalogue is arranged under two alphabets \u2014 one of anecdoted biographies, the other of memorabilia. The work is excellent reading, but it is full of inaccuracies both of dates and names.\nNug\u00e6 Canor\u00e6, or Epitaphian Mementoes (in stone-cutters\u2019 verse) of the Medici Family, by Unus Quorum London, 1827, 8vo.\nMems, Maxims, and Memoirs London, 1827, 8vo.\nBoth volumes contain a miscellany of things medical, and to the history of medicine and surgery in England. Many have utilised them, but few have acknowledged their indebtedness. They show a wide reading, but are thoroughly uncritical.", + "doc_fkgl": 14.957394957983198, + "wiki_fkgl": 8.960046910384989, + "doc_tree_depth": 5.411764705882353, + "wiki_tree_depth": 6.526315789473684, + "fkgl_delta": 5.997348047598209 + }, + { + "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": "A myocardial infarction (MI), commonly known as a heart attack, occurs when blood flow decreases or stops in one of the coronary arteries of the heart, causing infarction (tissue death) to the heart muscle. The most common symptom is chest pain or discomfort which may travel into the shoulder, arm, back, neck or jaw. Often it occurs in the center or left side of the chest and lasts for more than a few minutes. The discomfort may occasionally feel like heartburn. Other symptoms may include shortness of breath, nausea, feeling faint, a cold sweat, feeling tired, and decreased level of consciousness. About 30% of people have atypical symptoms. Women more often present without chest pain and instead have neck pain, arm pain or feel tired. Among those over 75 years old, about 5% have had an MI with little or no history of symptoms. An MI may cause heart failure, an irregular heartbeat, cardiogenic shock or cardiac arrest.", + "doc_fkgl": 5.827348837209307, + "wiki_fkgl": 9.180717299578063, + "doc_tree_depth": 5.066666666666666, + "wiki_tree_depth": 6.111111111111111, + "fkgl_delta": -3.3533684623687563 + }, + { + "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": "Coronary artery disease (CAD) is the most common cause of coronary ischemia. Coronary ischemia and coronary artery disease are contributors to the development of heart failure over time. Diagnosis of coronary ischemia is achieved by an attaining a medical history and physical examination in addition to other tests such as electrocardiography (ECG), stress testing, and coronary angiography. Treatment is aimed toward preventing future adverse events and relieving symptoms. Beneficial lifestyle modifications include smoking cessation, a heart healthy diet, and regular exercise. Medications such as nitrates and beta-blockers may be useful for reducing the symptoms of coronary ischemia. In refractory cases, invasive procedures such as percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG) may be performed to relieve coronary ischemia.", + "doc_fkgl": 14.593809523809526, + "wiki_fkgl": 17.189445100354195, + "doc_tree_depth": 5.888888888888889, + "wiki_tree_depth": 6.571428571428571, + "fkgl_delta": -2.5956355765446695 + }, + { + "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": "Although the reflex was originally described in response to Veratrum alkaloids, it can be stimulated by many biologically active chemicals, including nicotine, capsaicin, bradykinin, atrial natriuretic peptide, prostanoids, nitrovasodilators, angiotensin II type 1 receptor (AT1) antagonists and serotonin agonists. It may also contribute to various pathophysiological responses, such as:\n Severe hemorrhage and hypovolemia: During severe hemorrhage or profound hypovolemia the ventricle can become relatively empty and trigger cardiac vagal afferent fibers to elicit the Bezold\u2013Jarisch reflex resulting in paradoxical bradycardia, vasodilation, and hypotension.\n Myocardial ischemia: Chemoreceptors located in the ventricles respond to myocardial ischemia, resulting in an increase in blood flow to the myocardium and a decrease in the work of the heart. This appears to be a cardioprotective reflex, as coronary vasodilation occurs. The pathway for this cardioprotective reflex begins with receptors in the ventricles of the heart, which detect mechanical and chemical stimuli. Afferent unmyelinated C-fibers travel through the vagus to enhance the baroreceptor reflex mechanisms, inhibit sympathetic output, and inhibit vasomotor tone, leading to peripheral vasodilation. The Bezold\u2013Jarisch reflex is thought to be responsible for the sinus bradycardia that commonly occurs within the first hour following a myocardial infarction, and may explain the frequent occurrence of atrio-ventricular (AV) node block in acute posterior or inferior myocardial infarction. Bradycardia in this setting may be treated with atropine.\n Hypotension during coronary reperfusion\n Hypotension following injection of contrast media during coronary angiography\n Exertional syncope in aortic stenosis: in severe aortic stenosis exercise may cause a rise in left\u00a0ventricular\u00a0pressure which stimulates\u00a0the Bezold\u2013Jarisch reflex and results in reflex vasodilation and syncope.\n Spinal anesthesia: The Bezold\u2013Jarisch reflex has been suggested as a possible cause of profound bradycardia and circulatory collapse after spinal anesthesia and interscalene brachial plexus block.\n Vaso-vagal syncope: the role of the Bezold\u2013Jarisch reflex in vaso-vagal syncope is unclear. Upright posture results in pooling of blood in the lower extremities that diminishes venous return and results in a reduced cardiac output. The resultant lowering of blood pressure is sensed by carotid sinus baroreceptors, and stimulates the baroreflex to inhibit vagal activity and stimulate the sympathetic nervous system \u2013 this increases heart rate and contractility, induces vasoconstriction, and tends to restore blood pressure. However, if the Bezold\u2013Jarisch reflex is activated due to the reduced ventricular volume this may trigger paradoxical bradycardia and arterial hypotension resulting in syncope. The importance of this mechanism is unclear since vaso-vagal syncope can be observed in cardiac transplant patients who are presumed to lack cardiac innervation. If it operates this phenomenon would be expected to be exacerbated if the individual is dehydrated. It has also been proposed that this mechanism accounts for the increased susceptibility to orthostatic syncope of astronauts after space flights.", + "doc_fkgl": 16.972754430379748, + "wiki_fkgl": 19.709968487394963, + "doc_tree_depth": 6.380952380952381, + "wiki_tree_depth": 8.176470588235293, + "fkgl_delta": -2.7372140570152155 + }, + { + "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": "A subpulmonic effusion is excess fluid that collects at the base of the lung, in the space between the pleura and diaphragm. It is a type of pleural effusion in which the fluid collects in this particular space but can be \"layered out\" with decubitus chest radiographs. There is minimal nature of costophrenic angle blunting usually found with larger pleural effusions. The occult nature of the effusion can be suspected indirectly on radiograph by elevation of the right diaphragmatic border with a lateral peak and medial flattening. The presence of the gastric bubble on the left with an abnormalagm of more than 2\u00a0cm can also suggest the diagnosis. Lateral decubitus views, with the patient lying on their side, can confirm the effusion as it will layer along the lateral chest wall.", + "doc_fkgl": 5.730088652482269, + "wiki_fkgl": 12.388484848484854, + "doc_tree_depth": 6.0, + "wiki_tree_depth": 7.5, + "fkgl_delta": -6.658396196002585 + }, + { + "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": "A subpulmonic effusion is excess fluid that collects at the base of the lung, in the space between the pleura and diaphragm. It is a type of pleural effusion in which the fluid collects in this particular space but can be \"layered out\" with decubitus chest radiographs. There is minimal nature of costophrenic angle blunting usually found with larger pleural effusions. The occult nature of the effusion can be suspected indirectly on radiograph by elevation of the right diaphragmatic border with a lateral peak and medial flattening. The presence of the gastric bubble on the left with an abnormalagm of more than 2\u00a0cm can also suggest the diagnosis. Lateral decubitus views, with the patient lying on their side, can confirm the effusion as it will layer along the lateral chest wall.", + "doc_fkgl": 11.984808362369339, + "wiki_fkgl": 12.388484848484854, + "doc_tree_depth": 6.666666666666667, + "wiki_tree_depth": 7.5, + "fkgl_delta": -0.4036764861155149 + }, + { + "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": "The skulls of megalichthyids had a rather low and broad shape. Like the scales, the dermal bones of the skull bore a layer of cosmine. The nostrils were somewhat elongated, slit-like holes that were bordered in the front by the lateral rostral bone and in the back by the posterior tectal bone. The premaxilla (one of the bones of the upper jaw) had a well-developed posterior process, and bore a large tusk that either interrupted the main tooth row or was located further inside the mouth, depending on the species. The maxilla (another bone of the upper jaw, located behind the premaxilla) was rather tall, especially towards the rear end. The vomers (a pair of bones in the palate) were short and broad, with a well-developed mesial process in some cases. The lacrimal bone had a prominent notch. The front end of the parietal bone had a concave shape where it contacted the posterior nasal bone. The pineal foramen (a hole located at the top of the skull in some vertebrates, containing the parietal eye) was absent. The supratemporal bone had a forwards-pointing process that lacked a covering of cosmine. The squamosal bone was nearly equal in height and width. The preopercular was a fairly short, vertically aligned bone. The opercular series (a set of bones protecting the gills) consisted of three bones, the opercular and two suboperculars. The opercular was large and almost square-shaped. The suboperculars were in contact with the last or second-last of the submandibular bones (a group of bones lying beneath the dentary bone of the lower jaw). The pectoral fins were large and had a fan-like shape.", + "doc_fkgl": 16.455087719298245, + "wiki_fkgl": 9.043676470588235, + "doc_tree_depth": 7.0, + "wiki_tree_depth": 6.25, + "fkgl_delta": 7.41141124871001 + }, + { + "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": "Track list\n \"Intro: The Act of Intestinal Regurgitation\" \u2013 1:13\n \"Disgorging Foetus\" \u2013 1:21\n \"Confluent Macular Drug Eruption\" \u2013 0:23\n \"Bullous Impetigo\" \u2013 1:22\n \"Fleshfeast\" \u2013 1:05\n \"Anorectal Ulceration\" \u2013 0:55\n \"Vulva Fermentation\" \u2013 0:33\n \"Multicystic Kidney\" \u2013 1:33\n \"Mucupurulent Offal Grinder\" \u2013 0:18\n \"Total Dismemberment of a Female Corpse\" \u2013 1:07\n \"Carnal Cacophony\" \u2013 0:47\n \"Vomit Breath\" \u2013 0:20\n \"Complete Rectal Prolapse\" \u2013 1:00\n \"Testicular Trauma\" \u2013 1:11\n \"Genital Cancer\" \u2013 1:53\n \"Malignant Tumor\" \u2013 1:20\n \"Diffuse Systemic Scerosis\" \u2013 0:19\n \"Owner of a Necrotic Intestine\" \u2013 0:37\n \"Newborn Regurgitation\" \u2013 0:51\n \"Torsion of the Testicle\" \u2013 0:32\n \"Worm Eaten Rectum\" \u2013 0:50\n \"Chronic Lymphatic Leukemie\" \u2013 1:23\n \"Metal Ulcer\" \u2013 0:34\n \"Purulent Discharge from the Urethra\" \u2013 1:10\n \"Vaginal Obstriction\" \u2013 1:14\n \"Cloudy, Grayish Vomitus\" \u2013 0:22\n \"Fleshmangler\" \u2013 1:08\n \"Splattered Brains\" (Agathocles cover) \u2013 1:00\n \"Bulging Vaginal Septum\" \u2013 0:39\n \"Acute Urinary Infection\" \u2013 1:08\n \"Severe Necroses of the Face\" \u2013 0:22\n \"Bleeding Peptic Ulcer\" \u2013 0:43\n \"Face Mutilation\" \u2013 0:35\n \"Extensive Ulcerative Tumor\" \u2013 0:41\n \"Tumecent Foetal Fluids to Expurgate\" \u2013 0:55\n \"Carbonized Bowels \u2013 0:43\n \"Effortless Regurgitation of Bright Red Blood\" \u2013 1:18", + "doc_fkgl": 5.262667512690356, + "wiki_fkgl": 65.96225165562913, + "doc_tree_depth": 5.15, + "wiki_tree_depth": 12.0, + "fkgl_delta": -60.699584142938775 + }, + { + "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": "Prognosis \nAlthough it is a benign tumour and does not invade neighbouring tissues, it has a tendency to recur after surgical excision so it is termed \"aggressive\". Recurrence can occur as early as six months from initial resection. Patients frequently present at tertiary medical centers with a history of labial mass (sometimes misdiagnosed as Gartner's cyst), with multiple surgical excisions from several surgeons. There is no standard medical therapy; agents reported to be effective in case reports include systemic hormonal therapy with SERMs such as tamoxifen or LHRH agonists (leuprolide), and cytotoxic (\"traditional\") chemotherapy, as well as radiation therapy especially for recurrent disease.", + "doc_fkgl": 13.893053097345135, + "wiki_fkgl": 17.3651213592233, + "doc_tree_depth": 6.666666666666667, + "wiki_tree_depth": 6.0, + "fkgl_delta": -3.4720682618781638 + }, + { + "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": "Sarcoidosis is a systemic disease of unknown cause that results in the formation of non-caseating granulomas in multiple organs. The prevalence is higher among black males than white males by a ratio of 20:1. Usually the disease is localized to the chest, but urogenital involvement is found in 0.2% of clinically diagnosed cases and 5% of those diagnosed at necropsy. The kidney is the most frequently affected urogenital organ, followed in men by the epididymis. Testicular sarcoidosis can present as a diffuse painless scrotal mass or can mimic acute epididymo-orchitis. Usually it appears with systemic manifestations of the disease. Since it causes occlusion and fibrosis of the ductus epididymis, fertility may be affected. On ultrasound, the hypoechogenicity and \u2018infiltrative\u2019 pattern seen in the present case are recognized features. Opinions differ on the need for histological proof, with reports of limited biopsy and frozen section, radical orchiectomy in unilateral disease and unilateral orchiectomy in bilateral disease. The peak incidence of sarcoidosis and testicular neoplasia coincide at 20\u201340 years and this is why most patients end up having an orchiectomy. However, testicular tumours are much more common in white men, less than 3.5% of all testicular tumours being found in black men. These racial variations justify a more conservative approach in patients of Afro-Caribbean descent with proven sarcoidosis elsewhere. Careful follow-up and ultrasonic surveillance may be preferable in certain clinical settings to biopsy and surgery, especially in patients with bilateral testicular disease.", + "doc_fkgl": 15.117090909090908, + "wiki_fkgl": 13.020833333333332, + "doc_tree_depth": 6.071428571428571, + "wiki_tree_depth": 6.846153846153846, + "fkgl_delta": 2.0962575757575763 + }, + { + "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": "Immediate surgery was required to address Pai's aggressive bacterial infection. A conventional surgical procedurearresting the heart during the operation, using a heart-and-lung machine, and following up with a regime of anti-clotting drugswould have terminated the actress's pregnancy. With an incision across Pai's breast bone, Adams drained blood from her heart into a reservoir where it could be oxygenated before being returned to the aorta. In the meantime, he replaced two valves, both too badly damaged to attempt reconstruction with time limited by lack of a heart-and-lung machine, with compatible organic tissuethereby eliminating the need for pregnancy-prohibiting anti-clotting drugs post-surgery.", + "doc_fkgl": 7.468333333333334, + "wiki_fkgl": 16.828156565656567, + "doc_tree_depth": 6.125, + "wiki_tree_depth": 9.0, + "fkgl_delta": -9.359823232323233 + }, + { + "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": "Diabetic cardiomyopathy is a disorder of the heart muscle in people with diabetes. It can lead to inability of the heart to circulate blood through the body effectively, a state known as heart failure(HF), with accumulation of fluid in the lungs (pulmonary edema) or legs (peripheral edema). Most heart failure in people with diabetes results from coronary artery disease, and diabetic cardiomyopathy is only said to exist if there is no coronary artery disease to explain the heart muscle disorder.", + "doc_fkgl": 12.996079027355623, + "wiki_fkgl": 16.935, + "doc_tree_depth": 5.714285714285714, + "wiki_tree_depth": 8.333333333333334, + "fkgl_delta": -3.9389209726443752 + }, + { + "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": "Etz CD, Plestis KA, Kari FA, Luehr M, Bodian CA, Spielvogel D, Griepp RB. Staged repair of thoracic and thoracoabdominal aortic aneurysms using the elephant trunk technique: a consecutive series of 215 first stage and 120 complete repairs. European Journal of Cardiothoracic Surgery 2008 Jun 12;. \nEtz CD, Homann TM, Silovitz D, Spielvogel D, Bodian CA, Luehr M, Di Luozzo G, Plestis KA, Griepp RB. Long-term survival after the Bentall procedure in 206 patients with bicuspid aortic valve. Annals of Thoracic Surgery. 2007 October; 84(4): 1189-1193. \nEtz CD, Homann TM, Rane N, Bodian CA, Di Luozzo G, Plestis KA, Spielvogel D, Griepp RB. Aortic root reconstruction with a bioprosthetic valved conduit: a consecutive series of 275 procedures. Journal of Thoracic and Cardiovascular Surgery. 2007 June; 133(6): 1455-1463. \nSpielvogel D, Etz CD, Silovitz D, Lansman SL, Griepp RB. Aortic arch replacement with a trifurcated graft. Annals of Thoracic Surgery. 2007 Feb; 83(2): 3791-3795. \nEtz CD, Halstead JC, Spielvogel D, Shahani R, Lazala R, Homann TM, Weisz DJ, Plestis K, Griepp RB. Thoracic and thoracoabdominal aneurysm repair: is reimplantation of spinal cord arteries a waste of time? Annals of Thoracic Surgery. 2006 November; 82(5): 1670-1677. \nCarroccio A, Spielvogel D, Ellozy SH, Lookstein RA, Chin IY, Minor ME, Sheahan CM, Teodorescu VJ, Griepp RB, Marin ML. Aortic arch and descending thoracic aortic aneurysms: experience with stent grafting for second-stage. Vascular. 2005 January\u2013February; 13(1): 5-10. \nHagl C, Strauch JT, Spielvogel D, Galla JD, Lansman SL, Squitieri R, Bodian CA, Griepp RB. Is the Bentall procedure for ascending aorta or aortic valve replacement the best approach for long-term event-free survival? Annals of Thoracic Surgery. 2003 September; 76(3): 698-702. \nGriepp RB, Ergin MA, Galla JD, Lansman S, Khan N, Quintana C, McCollough J, Bodian C. Looking for the artery of Adamkiewicz: a quest to minimize paraplegia after operations for aneurysms of the descending thoracic and thoracoabdominal aorta. Journal of Thoracic Cardiovascular Surgery. 1996 November; 112(5): 1202-1213. \nGriepp RB, Stinson EB, Bieber CP, Reitz BA, Copeland JG, Oyer PE, Shumway NE. Human heart transplantation: current status. Annals of Thoracic Surgery. 1976 August; 22(2): 171-175. \nGriepp RB, Stinson EB, Hollingsworth JF, Buehler D. Prosthetic replacement of the aortic arch. Journal of Thoracic Cardiovascular Surgery. 1975 December; 70(6): 1051-1063.", + "doc_fkgl": 12.497337640821737, + "wiki_fkgl": 9.511152204836417, + "doc_tree_depth": 5.96, + "wiki_tree_depth": 5.512820512820513, + "fkgl_delta": 2.9861854359853197 + }, + { + "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": "Robotic prostatectomy \nWith the introduction of the da Vinci Surgical System, the advent of robotic surgery using a laparoscopic approach has significantly changed the way prostate cancer surgery and prostatectomy procedures in general are performed as compared to the traditional 'open' methodology. Much of Tewari's research projects serve to promote robotic surgery as opposed to open procedures. For example, Tewari has shown that the operating field has become more visible to the surgeon, unobscured by the copious amounts of blood encountered in traditional surgery and is thus able to view the urological structures under three-dimensional, enlarged magnification. Patients reap even greater benefits. Due to the minimally invasive nature of the procedure, they experience minimized pain, minimized blood loss, less scarring and fewer complications. Post-surgery recovery is accelerated and patients experience quicker return to urinary continence and sexual function. Some of Tewari's current research is focused on comparing the benefits of robot-assisted surgery with traditional open prostatic surgery.", + "doc_fkgl": 5.185050449959093, + "wiki_fkgl": 17.508735213830757, + "doc_tree_depth": 4.526315789473684, + "wiki_tree_depth": 7.571428571428571, + "fkgl_delta": -12.323684763871665 + }, + { + "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": "The rectum is a part of the lower gastrointestinal tract. The rectum is a continuation of the sigmoid colon, and connects to the anus. The rectum follows the shape of the sacrum and ends in an expanded section called an ampulla where feces is stored before its release via the anal canal. An ampulla () is a cavity, or the dilated end of a duct, shaped like a Roman ampulla. The rectum joins with the sigmoid colon at the level of S3, and joins with the anal canal as it passes through the pelvic floor muscles.", + "doc_fkgl": 16.9342905982906, + "wiki_fkgl": 9.457894736842107, + "doc_tree_depth": 5.8, + "wiki_tree_depth": 6.8, + "fkgl_delta": 7.476395861448491 + }, + { + "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": "Before his regular appearances on the show, Owen Hunt was a United States Army surgeon, specializing in trauma surgery. He held the rank of Major. The character makes a dramatic first appearance when he performs a tracheotomy on a man with a pen, winning the admiration of resident Cristina Yang (Sandra Oh). He is offered a job by former chief of surgery Richard Webber (James Pickens, Jr.), but declines, explaining that he has not completed his tour in Iraq. His appointment as the new head of trauma surgery at Seattle Grace Hospital was not well-received initially. By his first week he manages to irk both Derek Shepherd (Patrick Dempsey) and Mark Sloan (Eric Dane), head of neurosurgery and plastic surgery, respectively, who view his treatment of some of the patients as crude, and also rebuffed by resident Izzie Stevens (Katherine Heigl) when he stabs a set of pigs and then orders the residents and interns to save their lives, in order to teach them medicine on \"live tissue.\" Hunt eventually embarks on a relationship with Yang, but it comes to a sudden close when his PTSD gets the best of him, and he unconsciously strangles her. Soon after the breakup, he begins therapy with the hospital psychiatrist, Dr. Wyatt. Some time later, a soldier visits the hospital for treatment, and his presence influences Owen to contemplate returning to the US Army. When he shares this with Cristina, she disagrees with his decision, stating that she doesn't want him to die, and the two eventually rekindle their relationship. Owen brings in Teddy Altman (Kim Raver), his best friend and colleague from when he was in the army, as the new head of cardiothoracic surgery. When it is revealed that Hunt and Altman may be potential lovers, Hunt and Yang's relationship is challenged, and eventually concluded by Yang.", + "doc_fkgl": 14.549020678891925, + "wiki_fkgl": 12.408300653594775, + "doc_tree_depth": 6.681818181818182, + "wiki_tree_depth": 6.916666666666667, + "fkgl_delta": 2.140720025297149 + }, + { + "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": "Arthritis mutilans is a rare medical condition involving severe inflammation damaging the joints of the hands and feet, and resulting in deformation and problems with moving the affected areas; it can also affect the spine. As an uncommon arthropathy, arthritis mutilans was originally described as affecting the hands, feet, fingers, and/or toes, but can refer in general to severe derangement of any joint damaged by arthropathy. First described in modern medical literature by Marie and Leri in 1913, in the hands, arthritis mutilans is also known as opera glass hand (la main en lorgnette in French), or chronic absorptive arthritis. Sometimes there is foot involvement in which toes shorten and on which painful calluses develop in a condition known as opera glass foot, or pied en lorgnette.", + "doc_fkgl": 5.560996503496504, + "wiki_fkgl": 16.675964566929135, + "doc_tree_depth": 4.916666666666667, + "wiki_tree_depth": 9.0, + "fkgl_delta": -11.11496806343263 + }, + { + "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": "Structure \nThe extensor digitorum brevis manus usually originates from the dorsal aspect (backside) of the wrist, either from the joint capsule, the distal end (the most distant end) of the radius, the metacarpal, or from the radiocarpal ligament in the area of the fourth extensor compartment. Many variations of the muscle have been described in the literature. It could have up to four tendons with a single tendon inserting to the index or the middle finger being the two most common variations. At the insertion the tendon of the extensor digitorum brevis manus often joins the extensor indicis proprius, although it also occurs when the extensor indicis proprius is absent. It was also reported to coexist with the extensor medii proprius, another anatomical variation in the extensor compartment of the hand. The muscle is supplied the posterior interosseous nerve and posterior branch of the anterior interosseous artery.", + "doc_fkgl": 9.454666666666668, + "wiki_fkgl": 15.317380952380955, + "doc_tree_depth": 5.454545454545454, + "wiki_tree_depth": 7.833333333333333, + "fkgl_delta": -5.862714285714286 + }, + { + "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": "Compression of the median nerve in the region of the elbow or proximal part of the forearm can cause pain and/or numbness in the distribution of the distal median nerve, and weakness of the muscles innervated by the anterior interosseous nerve: the flexor pollicis longus (\"FPL\"), the flexor digitorum profundus of the index finger (\"FDP IF\"), and the pronator quadratus (\"PQ\").\nThe pain tends to be at the wrist joint, in the distribution of the terminal branch of the anterior interosseous nerve, and is exacerbated by sustained pronation (i.e., wrist down).\nThe weakness of the FPL and FDP IF is painless, but causes people to \"drop things\" and have a sense of loss of dexterity. Pinching with the wrist flexed magnifies the expression of this weakness, by reducing resting tension on the muscles of pinch. For instance, \"child-proof\" prescription pill bottles may be difficult to open. People easily adapt to this weakness without conscious effort or self-awareness, by using 1) the next muscles down, which are innervated by a different nerve, or 2) using ligaments to give resistance, pinching laterally against the index finger or against the side of the end of the thumb, or 3) by what is called \"tenodesis,\" which in this case is extension of the wrist joint, which tightens the muscles on the palm side of the hand. These adaptations on a moment-to-moment basis do not cause problems, but over time in loose-jointed patients, such as many women and people with collagen disorders such as Ehlers Danlos Syndrome, the adaptations can cause soft tissue failures that can become painful, particularly at the base of the thumb and in the proximal forearm (i.e., \"Tennis Elbow\" in a non-tennis player).", + "doc_fkgl": 11.863529411764706, + "wiki_fkgl": 16.5688475177305, + "doc_tree_depth": 5.75, + "wiki_tree_depth": 9.714285714285714, + "fkgl_delta": -4.7053181059657945 + }, + { + "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": "A man has a mysterious car accident, and falls into a coma. He is taken to a hospital by paramedics. The man, in his comatose state, dreams he is in a place called Mercy Falls. A few years after the accident, his wife comes to visit him (as she apparently has been doing constantly ever since that night). She comments that the doctors are still trying to wake him. She leaves his side, but turns the radio on to comfort her husband.", + "doc_fkgl": 4.0628178694158095, + "wiki_fkgl": 6.432682926829269, + "doc_tree_depth": 4.777777777777778, + "wiki_tree_depth": 5.0, + "fkgl_delta": -2.3698650574134597 + }, + { + "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": "Focal injuries include the following:\n Cerebral contusion is a bruise of brain tissue that commonly results from contact of the brain with the inside of the skull.\n Cerebral laceration is a brain injury in which the pia-arachnoid is torn.\n Epidural hemorrhage is bleeding between the dura mater and the skull. It is commonly associated with damage to the middle meningeal artery, often resulting from a skull fracture.\n Subdural hemorrhage is bleeding between the dura mater and the arachnoid.\n Intracerebral hemorrhage is bleeding within the brain tissue itself.\n Intraventricular hemorrhage is bleeding within the ventricles of the brain.", + "doc_fkgl": 13.757534883720933, + "wiki_fkgl": 10.981296023564067, + "doc_tree_depth": 6.0, + "wiki_tree_depth": 6.428571428571429, + "fkgl_delta": 2.776238860156866 + }, + { + "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": "Signs and symptoms\nOne particularity of diabetic cardiomyopathy is the long latent phase, during which the disease progresses but is completely asymptomatic. In most cases, diabetic cardiomyopathy is detected with concomitant hypertension or coronary artery disease. One of the earliest signs is mild left ventricular diastolic dysfunction with little effect on ventricular filling. Also, the diabetic patient may show subtle signs of diabetic cardiomyopathy related to decreased left ventricular compliance or left ventricular hypertrophy or a combination of both. A prominent \"a\" wave can also be noted in the jugular venous pulse, and the cardiac apical impulse may be overactive or sustained throughout systole. After the development of systolic dysfunction, left ventricular dilation and symptomatic heart failure, the jugular venous pressure may become elevated, the apical impulse would be displaced downward and to the left. Systolic mitral murmur is not uncommon in these cases. These changes are accompanied by a variety of electrocardiographic changes that\nmay be associated with diabetic cardiomyopathy in 60% of patients without structural heart disease, although usually not in the early asymptomatic phase. Later in the progression, a prolonged QT interval may be indicative of fibrosis. Given that diabetic cardiomyopathy's definition excludes concomitant atherosclerosis or hypertension, there are no changes in perfusion or in atrial natriuretic peptide levels up until the very late stages of the disease, when the hypertrophy and fibrosis become very pronounced.", + "doc_fkgl": 12.237704402515725, + "wiki_fkgl": 17.04405676855895, + "doc_tree_depth": 5.529411764705882, + "wiki_tree_depth": 6.3, + "fkgl_delta": -4.806352366043225 + } +] \ No newline at end of file